yl^ropical
THE JOURNAL OF
etifine atiti
With which is incorporated "CLIMATE"
AND
ons fpom THE COL.ONIAI:. miEDICA.X^ REPORTS.
^ BI-MONTHLY JOURNAL DEVOTED TO MEDICAL, SURGICAL AND
SANITARY WORK IN THE TROPICS
Edited by
SiK JAMES CANTLIE, K.B.E., M.B., P.R.C.S. ; and ALDO CASTELLANI, C.M.G., M.D., M.R.C.P.;
In Collabomation with W. J. R. SIMPSON, C.M.G., M.D., F.R.C.P.;
C. M. WENYON, C.M.G., C.B.E., M.B., B.S., B.Sc. ; and T. P. BEDDOES, MB., B,Ch„ F.R.C.S.
SiK RONALD ROSS, K.C.B., K.C.M.G., F.R.S., Colonel A.M.S. (Homrary Adviser to tJie Editorial Staff)
VOLUME 23
JANUARY 1 TO DECEMBER 15
1920
SWETS & ZEITLINGER N.V.
AMSTERDAM - 1967
1970
Reprinted bg arrangement with Staples & Staples Ltd., London
INDEX TO VOL. XXIII.
a Atixj ATtv I to i>E:cx:m^E: EC is,
INDEX OF AUTHORS.
Anigstein, Ludwik, M.D., Ph.D. — Some observations on
Vihriothrij- Zeijlunica (C;iatellaiii), 7
Archibald, Major K. G., D.S.O., M.U., U.A.M.C, and
CnALMERS, Albert J., M.D., F.K.C.S., D.P.H.— The
teniie
3f IHasmodhim
(Grassi
Feletti 1890), 33
Balfour, Andrew, C.B., C.M.G., M.D., F.K.C.P.E,, D.P.H.,
and Daukes, S. H., O.B.E., M.B., D.P.H., D.T.M. and
H. — The graphic method of demonstrating tropical
medicine and hygiene, 213
Bass, C. C, M.D. — An attempt to explain the greater
pathogenicity of Plasniodiiun falciparum, as compared
with other .specie.s, 237
Bassett-Sjiith, p. W., C.B., C.M.G., F.Ii.C.S., F.K.C.P.,
K.lN. — A case of undulant fever with unusual nerve
sequelae, 201
Browne, C. L., L.R.C.P., L.B.C.S. — Broncho-spirochaetosis
(Ca«tellani's bronchitis), 226
Castellani, Aldo, C.M.G., M.D., M.R.C.P.— The etiology
of thrush, 17
Castellani, Aldo, C.M.G. , M.D., M.R.C.P.— Milroy lec-
tures on the higher fungi in relation to human patho-
logy, 101, 119, 133
Cawston, F. G., M.D.Cantab. -Colloidal drugs in the treat-
ment of bilharzia disease.s in young |>eople, 180
Cawston, F. G., M.D.Cantab. — Four interesting cases of
bilharzia disease treated by tartar emetic, 69
Cawston, F. G., M.D.Cantab. — Some infections due to
freshwater snails and their eradication, 274
Chalmers, Albert J., M.D., F.R.C.S.. D.P.H., and
Archibald, Major B. G., D.S.O., M.D., R.A.M.C—
The " tenue " phase of Plasmodium vivax (Grassi and
Feletti 1890), 33
Chalmers, Albert J., M.D., F.R.C.S., D.P.H., and Joseph,
A. F., D.Sc, F.I.C— Sadd dermatitis, 57
Chalmers, Albert J., M.D., F.R.C.S., D.P.H.. and Kamah.
Saoh f Major), A., M.D. — Toxui>lusmu pyrogi'tifs Castel-
lani 1913, 45
Chalmers, Albert ,T., Ml), F.R.C S . DIM! , and
Macdonald, Norman. — Broncluinionilinsis in the Angln-
Egy,,tian Sudan and Egypt, 1
(Jhalmers, Albert .1 , M.D, F R (' S . I) I'll . ;mi<I
Macdonali. Norm an. Some cosmopolitan Sudan skin
affections, 150
Chalmers, Albert J., M.D., F.R.C.S., D.P.H., and
Macdonald, Nohman.— Some Soudanese diphtheroids. 85
Chhtstophehson, .1. B., C.B.E., M.A., M.D.. F.li C.P.,
F.R.C.S.— Bilharzia disease; the sterilization of the
ova dnring the course of cure by antimony (tartrate),
165
Crichlow, Nathaniel. M.B.. Ch. B.Glasgow. — Case of ap]K'n-
dicitis in a native of the Solomon Islands, Western
Ckichlow, Nathaniel, M.B., Ch.B Glasgow.— The treatment
of ulcus tropicum, 227
Daukes, S. H., O.B.E., MB., D.P.H., D.T.M. and H., and
Balfouk, Andrew, C.B., C.M.G. , M.D., F.R.C. P. E..
D.P.H. — The graphic method of demon.strating tropical
medicine and hygiene, 213
DriKwoHTH. Sir Dyce, Bart., M.D., LL 1) , F.R.C. P.—
Diagnosis and treatment of tropical hepatic ab.scess,
149
Fholich, Theodob, M.D., and Holst, Axel.— On the pre-
servation of the anti-scorbutic properties of cabbage
by drying, 261
Harper, P., M.R.C.S., L.R.C.P.— Preliminary note on the
treatment of nodular leprosy by intravenous injections
of chaulmoogra oil, 285
Uenry, T. a., D.Sc. — Chaulmoogra oil in leprosy, 249
HoLST, Axel and Fbolich, Theodor, M.D. — On the pre-
servation of the anti-scorbutic projierties of cabbage
by drying, 261
Hoops, A. L,, M.D., D.P.H., B.A., T.C.D.Lond.— Experi-
ences of medical and prison work in a new country
(Kedah, Malay Peninsula), 189
Howard, Robert, M.D., B.Ch.Oxon. — A note on the use of
the tourniquet in operations for elephantiasis scroti,
183
[acono, I., M.D.-
chitis," 70
-Notes on a case of " Castella
Jacono, I., M.D. — Notes on some cases of Castellani's
broncho-moniliasis, 250
Joseph, A. F., D.Sc., F.I.C, and Chalmers, Albert J.,
M.D., F.R.C.S., D.P.H.— Sadd dermatitis, 57
Kamah, Saoh (Major), A., M.D., and Chalmers, Albert J.
M.D., F.R.C.S., D.P.H.— Toxojjiasma pyrogenes Castel
McDonaoh, J. E. R., F.R.C.S.— The treatment of billn
ziosis with antimony, 165
Macdonald, W. M., M.R.C.S., L.R.C.P.Lond.— Quinine |.
phylaxis, 182
Macdonald, Norman, and Chalmers, Albert J.,
F.R.C. S., D.P.H.— Bronchomoniliasis in the
Egyptian Sudan and Egypt, 1
Macdonald, Nohman, and Chalmers, Albert J.,
M.D.,
Anglo-
M.D.,
usmojx
Sudan
kin
F.R.C.S., D.P.H. Some
iiffections. 150
Macdonald. Nok.man. and Chalmers, .Vlbeht J., M.D.,
F.K.C.S., D.P.H.— Some Soudanese diphtheroids, 85
Macfie, J. W. S.— Three cases of filariasis in which intra-
venous injections of tartar emetic were given, 36
Mackie, J. W.'S. -The occurrence of lateral-spined billiarzia
eggs (Schistoxoinu inuiisDni) in urine, 45
MacGreoob, Malcolm E. -Locality differences in the feed-
ing habits of mosquitoes, 226
Manoenie, E. — Leprosy at Rodrigues, 238
Mayer, T. J. G., M.R.C.S.— A new vehicle for emetine
bisniuthous iodide, 110
Mei, a., M.D. —Ulcus tropicum treated with tartar emetic,
MiNETT, E. P., M.D., D.P.H., D.T.M. and H.-Use of town
refuse for mosquito work, 297
Arthur, MB., B.S.Lond., M.R.C.S., L.R C.
Some notes on fifteen years' ex]x>rience of malari;
the Upper Congo, 177
Seidelin, Harold. — Notes on the pr
Df (|ninine.
Stammers, G. E. F. — Hsemogregarines in black rats, 298 Viswalingam, A., L.M.S. — Some further observations on
SwELLENGBEBEL, N. H., Ph.D., and SwELLENGREBEL-DE- the aetiology of " pellagra," 16
Graaf, J. M. H. — Observations on the larvae-destroying
action of small fish in the Malay Archipelago, 77
Welch, T. B., M.B.Lond.^Observations on a caee of
Toll, J. C, M.D., M.H.C.P.Lond.— Notes on an outbreak onyalai in the East African Protectorate, 138
of Asiatic cholera in Syriam municipality, Burma, in Wenyon, C. M.— Histological observations on the possible
June-July, 1920, 274 pathogenicity of Trichomonas intestinalis and Chilo-
mastix mesnili, with a note on Emiolimax nana, 125
Veale, Capt. P. J., I. M.S.— Three cases of malignant Wood, Edward J., B.Sc, M.D., D.T.M.Eng.— Sprue in
tertian malaria with special treatment, 59 America. 201
GENERAL INDEX
AllSTKACTS :
AiNplieiiamin reactions, 222
Axi'iiris lumhricuulex ivs the cause of iirsfciit symptoms
ill disease amongst children, 242
Betanaphthol poisoning in the treatment of hookworm
disease, 243
Biological cjassil'icitimi of influenza bacilli, 1G4
Botulism |>r..t.rti\-c iricusures and cautions, 212
Charactrr of tlir i.rrvalt-nt typhus in Poland and its
associafinii with relapsing fever, 53
Chronic cholecystitis complicating cardiac lesions,
diagnosis of, 54
Chronic indigestion in childhood, the treatment of, 26'J
Clinical method of determining the type of the in-
fecting meningococcus in cases of cerebrospinal
meningitis, 235
Diagnosis of lethargic encephalitis, hitherto unde-
scribed sign in, 232
Etiology of yellow fever : summary and conclusions,
99
Experimental determination, the, of the vertebrate
hosts of some South African cercariie from the
molluscs, I'hysopsis njricnnn and Limnma natalvn-
sis, 171
Exiierimental pellagra in white male convicts, 207
Fatal mouse typhus in a human being, 235
" Froghoppor," a, as a blood-sucking insect, 212
Uuinea-worm in the inguinal canal, 186
Haemoglobinuric bilious fever, 29
Intestinal protozoal infections among officers and men
of the Royal Navy and Marines, dealt with at the
Royal Naval Hospital, Ilaslar, during 1916 to
1918, 259
Int stinal tract, changing the flora cf the, 55
Le|)rosy, treatment of, with esj)ecial reference to some
now (li.iulmoogra oil derivatives, 290
Iji'tliaif,'!. . IK i[ili:ilitis ; history, pathology ami clinical
fiMdiM, .iimI . pilemiology" in brief, 244
Mpiinii .1 rM,it.d «ith chronic nephritis, 221
Methoil ..I ,|p.|.i,, diagnosis, 282
Metlii>cl lit ( (.111 .■ntr.ition of parasitic eggs in faeces, 303
Milk |.r.,<ln,,a in S„uthern China, 75
Mixed H jinnil iiphihius A and B inoculations with
seruin-ti.Mt il li.ieilli, 15(i
Notes on nn.ilfli -p^is, 157
()l)-,prv,it I. n-. Mil (.i-r, of seasonal hay fever diagnosi-cl
.111.1 Inated vvitli pollen extracts, 206
Operative treatment, the, of ulcerated colitis, 162
I'apulo-iirtiearial rashes caused by the hairlets of
caterpillars of the moth (K up rod is edwnriisi
Newm., 148
I'ellagra, prevalence of, among Turkish prisoners of
wlir, 209
Protein therapy of typhus, 22
Protein shock reaction in leprosy, 296
Pyrexia not yet diagnosed of dental origin, 210
Question of natural enemies, 145
Kelapsing fever in East Persia, 271
Uepiirl on the gynocardate and morrhuate treatment
of lepro-y based on forty cases treated in the
Kaslu.iii- State Ucpcr Hospital, 234
Seuivy ill tile Itoyal Navy, preliminary report of
experiiiu'iital investigation of, 233
Simple iiietliotl, a, of cultivating the micro-organisni
of aitiiiomycosis, 281
Some experieaces in the commoner tropical diseases
in (late) German New Guinea, 160
Specific ooinplement-fixation test for bilharziasis, note
on a, 272
Spread of the spirochaete of infectious jaundice, 74
Statistical remarks on the tiealmenf of bilharzi;:-is
bv tartar emetic, 175
Successful treatment of giardiasis in man with neo-
arsphenamin, 220 .
Surgery in chronic diarrhoea, 211
Surgical problems and -difficulties in the tropics, 31
Swarming, the, of anophcline mosquitoes, 146
Toxic reactions which follow the intravenous injection
of "914," treatment of the, 233
Typhoid and paratyphoid, incidence and deaths in the
American Expeditionary Force, 209
Vitamines, the, 254
Wood alcohol poisoning, the le<-;ioiis in, 200
Yaws : with a report of a case which developed in a
temperate climate, 280
Acetonuria from fatigue, 96
Action of various lower cryptogams other than bacteria in
the soil, 144
Acidosis; its mechanism, recognition and clinical mani-
festations, 183
Acute and chronic bacillary dvsentery, vaccine therapy in,
25
jEtiology of dengue fever, 290
.^t:tiology, the, of beriberi, 115
Alkali reserve in pellagra, the, 218
Amoebic dysentery, benzyl benzoate in. .39
An attempt to explain the greater pathogenicity of Plas-
modium falciparum a , compared with other species, 237
Anglo-Egyptian Sudan and Egypt, bronchomoniliasis in
the (illustrated), 1
Animal diseases in I'anama, some notes on, with special
referenc-e to blood and muscle parasites, 266
Acetonuria from fatigue, 96
Acidosis : its mechanism, recognition and clinical
manifestati.ins, 183
Action of radium on yeast, 82
Action of various lower cryjitoganis other than bacteria
i . the soil, 144
Adren.ilin, injections of, in the diagnosis of latent
malaria, 218
histiology of dengue fever, 290
-l^ltiology, the, of beriberi, 115
Alkali reserve in pellagra, the, 218
Anuebiasis cutis, 50
Animal diseases in Panama, some notes on, with
special reference to blood and muscle parasites,
266
Antagonism between epinephrin and (piiniiie, 97
Anthrax : comparison of surgical and non-surgical
methods of treatment, 169
Antihelminthic treatment of intestinal strongylosis of
the horse. 113
Anti-typhus work in Belgrade, 218
Atypical dysentery bacilli, 152
Bacteria, the fate of, introduced into the upjier air
passages, 65
Benzyl benzoatc in amirbie dysentery, .30
Beriberi and vitamine deficiency, 115
Blackwater fever, 278
Blood cultures in bubonic iilaguc, 115
Blood pressure in yell<.>v fever, 49
Botulism from eating canned ripe olives, 65
Botulism, preliminary report of a study of tiic anti-
toxin of Itucilhis hiitu'inus, 1.55
Bubonic plague. 51
Buried tube ili.iiiii'e m ,i rise of elephantiasis, .50
Ca.sc of chroiiir ,il. i ■ • " . .1 by a nocardia, .50
Ca,se of inulti|.l, ..In .i , eyst, 2.39
Case of non-pai.i ilK lia in.itucliyluria, 65
Castellani's Ihihk Im-pii oelia'tosis and its treatment,
1.30
INDEX
Annotations — continued .
Chronic diarrhoea due to syphilis, 65
Combined quinine and methylenc-blue treatment of
malaria, 130
Concerning a case of tetanus : use of dried serum and
large doses, 116
Contribution, a, to the helminthology of French Upper
Guinea, 114
Contribution to the arsenical treatment of leprosy, 155
Cultivation, the, of a trypanosome from the blood of
Panamanian cattle, 252
Cultural studies in a case of sprue, 50
Cutaneous reaction and desensitization in quinine idio-
syncrasy, 25
Defects of deficient dietaries in monkeys, 228
Delousing the American Army in France, 267
Diabetes, some experimental studies in, 167
Drugless therapy of diabetes, 185
Dysentery in Palestine, 41
Early use of convalescent serum in influenza, 254
Effect of therapeutic doses of mercury on the kidneys
and the duration of its excretion, 276
Egyptian bilharziasis, 41
Emergency measure and foresight in malaria control,
267
Emetine urticaria, 96
Encystment of a cercaria of the Cercaria armata type
in a freshwater turbellaria, 115
Entamoeba serpentis, 169
Epidemic encephalitis, 113
Etiology and treatment of seborrhoeic eruptions, 82
Fat-soluble vitamine content of green plant tissues, 97
Filarial periodicity, 11
Filariasis, 97
Flagellate character and reclassification of the para-
site producing " blackhead " in turkeys, 290
Further case of amoebic dysentery in a dog, 116
trametes of Plasmodium proecox and the variable pro-
portion of male and female elements, 115
Gastric polyposis (papillomatosis), 266
Granuloma inguinale in the United States, 170
Hcemogregarina in a Macacus monkey, 116
Hereditary diabetes, a case of, 241
How mange in domestic animals should be dealt with
in the French colonies, 115
Human synophthalmia, a case of, 267
Hydatid vesicles obstruct bile duct, 51
Hypodermic injeotions of milk in the treatment of
intolerance of milk in nurselings, 289
Ill-effects following novarsenobillon, 144
Influence, the, of vitamines in the course of pellagra,
267 1 e .
Influenza as observed in the Sambhu Nath Pundit
Hospital, Calcutta, 113
Intestinal animal parasites, the, found in one hundred
sick Filipino children, 279
Kala-azar in Europeans in the N^wgong district of
Assam, 113
Latent infection in experimental spirochaetosis, 239
Leprosy in Uruguay, 11
Malaria hemiplegia in an infant, 96
Manufacture and uses of essence of niaouli, 116
Mouse oxyuride, syphacia onvelata in man, 97
New methylene eosinate, a, 114
Note on a case of kala-azar in a child at Gabon, 115
Note on arrested development and infantilism of
malarial origin in Algeria, 12
Nutritional oedema and " war dropsy," 140
Observations on the cerebrospinal fluid of acute '
disease, 65
Occurrence of Bacillus botulinus in nature, 51
Ocular symptoms in encephalitis lethargica, 242
CEdema as a symptom in food-deficiency diseases, 228
Oil fuel refuse destruction, 114
On the results obtained by the Weil-Felix reaction for
typhus fever at the garrison of Baku, 230
On the Spirnbacillus zeylanicus, 50
Annotations — continued.
Operation for pruritus ani and vulvae, 289
Optic neuritis following typhus fever, 129
Oxygen, the therapeutic use of, 289
Oxyuris appendicitis, 130
Pandemic influenza, experimental study of, 170
Pathology and pathogenesis of pneumococcus loiiar
pneumonia in monkeys, 155
Penetration of the intestine by Endamaeba histolytica,
241
Plasmodium falcipai^m infection and novarsenobenzol,
115
Poisoning by castor oil seeds, 143
Polyvalent vaccine, a, in the treatment of bacillary
dysentery in East Africa, 96
Practical contribution to the therapeutics of epizootic
lymphangitis in the horse, 155
Preliminary note on an investigation as to the actual
weight of the cataractous lens, 113
Preliminary note on the apparent transmission of
leprosy to a Macaque monkey, 50
Prevention of simple goitre in man, 242
Production of pneumococcus lobar pneumonia in
monkeys, 155
Questions of salubrity and sanitary by-laws in French
Guinea, 115
Rancidity of edible coconut oil, 183
Harity of phlyctenular conjunctivitis in the Algerian
aborigines, 11
Kat-bite fever : report of a case, 130
Rats as agents in transmitting ringworm to the horse,
113
Reaction of the saliva, 185
Recent work on tropical diseases, 73
Relapsing fever : its occurrence in Panama, 266
Remarks on some cases of paratyphoid B, 241
Remote manifestations of focal dental infections with
case reports, 267
Results of prophylactic vaccination against pneumo-
coccus pneumonia in monkeys, 156
Rocky Mountain spotted fever, 82
Routine treatment, the, of malaria in Uganda, 49
Sanitary victory over yellow fever, 97
Secondary malaria, 39
Simple method of preparing an eosinate of Borrel's
blue for blood examinations, 114
Skin diseases among the Porto Rican troops, 11
Slow evolution of peritonitis following perforation of
typhoid ulcer, 129
Sodium citrate in the treatment of pneumonia, 50
Some experiments bearing upon the intravenous v.nc-
cine treatment of typhoid fever, 242
Sores analogous to veld sores and barcoo rot appearing
among soldier? working in blue clay and in chnlk,
143
Spider venom, 113
Spirochmta recurrentis : a filter passer, 241
Splenectomy in malaria, 63
Spontaneous pneumonia in monkeys, 154
Studies on the effect of light on vitiligo, 156
Study of new elements in the treatment of syphilis, 143
Study on the diffusibility of the virus of rabies, 94
Syphilis, incidence of, as manifested by routine
Wa*sermann reactions on 2,925 hospital and dis-
pensary medical cases, 65
Tardy post-arsenical jaundice, 127
Tetany in a case of sprue, 97
Thermostability of fat-soluble vitnmines in plant
materials, 97
Tick fever in East Persia, 266
Toxic jaundice in patients under antisyphilitic treat-
ment, 230
loxins and antitoxins of B. dysrnterice, 50
Transmission of typhus by lice stools, 41
Treatment of influenza pneumonia by serum from con-
valescent patients, 96
Treatment of malaria, report of the sub-committee of
Medical Research of the N:itiona! Malnria Coni-
ttee.
110
INDEX
Annotations — continued.
Treatment of sea-sickness, 25
Treatment of surra in camels by intravenous injec-
tions of tartar emetic, 268
Treatment of threadworms with carbonate of bismuth,
289
Trench fever, 49
Trench nephritis, 143
Trypanosome, a, associated with a fatal disease in
Carabao, 267
Trypanosomiasis americana, 73
Tuberculosis in animals, some intere,sting instances
of, 167
Types and treatment of pellagra, 267
Typhus fever, 98
Ulcerating granuloma of pudenda, 97
Ulcus tropicum of the genitals in Cyrenaica, 73
Underlying causes of the narcotic habit, 65
Unusual forms of dysentery, 96
Vaccinotherapy in acute and chronic bacillary dysen-
tery, 25
Value of complement fixation test in tuberculosis, 289
Work, the, of a vaccine depot, Meiktila, 113
Year's experience of a severe epidemic of malaria in
Mitidja (Algeria), 11
Yellow fever, 72
Yellow fever in New Orleans, 51
Anopheline mosquitoes, the swarming of, 146
Antagonism between epinephrin and quiuine, 97
Anthrax : comparison of surgical and non-surgical methods
of treatment, 169
Antihelminthic treatment of intestinal strongylosis of the
horse, 113
Anti-scorbutic properties of cabbage by drying, on the
preservation of the, 261
Anti-typhus work in Belgrade, 218
An X-ray motor-ambulance wagon for use at home and in
tropical countries, 264
Apparent transmission of leprosy to a macaque monkey,
preliminary note on the, 50
Appendicitis, case of, in a native of the Solomon Islands,
Western Pacific, 22
Arrested development and infantilism of malarial origin in
Algeria, note on, 12
Arsenical treatment of leprosy, contribution to the, 155
Arsphenamin reactions, 222
Ascuris lumbricoides as the cause of urgent symptoms in
disease amongst children, 242
Association of the bacillus of Hofmann with diphtheria in
India, 305
Atypical dysentery bacilli, 152
Bacteria, fate of, introduced into the upi)er air passages, 65
Beriberi and vitamine deficiency, 115
Betanapthol poisoning in the treatment of hookworm
disease, 24i3
Bilharzia disease treated by tartar emetic, four interesting
eases of, 69
Bilharzia eggs (Schistosoma mansoni) in urine, the occur-
rence of lateral-spined, 45
Biological classification of influenza bacilli, 164
Blackwater fever, 278
Blood cultures for bubonic plague, 115
Bodily powers as tested by the Olympic games, 216
Body temperature determined by temperature of urine, 302
Botulism from eating canned rii)e olives, 65
Botulism, preliminary report of a study of the antitoxin
of Bucilhis h,,ti,l,,n,s. 155
Botulism: |jro1.ctiv. iii.;i,ures and cautions, 212
British appl irajit , ti.r frvicc in the Crown colonies and
protecU>r;.t<'s. scan ity of, 63
Bronchomoniliasis in the "Anglo-Egyptian Sudan and Egypt
(illustrated), 1
Broncho-spirochaetosis (Caatellani's), 226
Bubonic plague, 51
" Castellani's bronchitis," notes on a case of (illustrated).
70
CaMellani's bronchospirochaetosis and its treatment, 130
Castor oil seeds, poisoning by, 143
Chalmers, Dr. Albert John, death of, 94
Chaulmoogra oil in leprosy, 249
Chronic abscesses, case of, caused by a nocardia, 50
Chronic diarrhoea di^e to syphilis, 65
Chronic indigestion in childhood, the treatment of, 269
Circular, a, being issued by the Tropical Diseases Preven-
tion Committte, 47 '
Clinical method of determining the type ot the infecting
meningococcus in cases' of cerebrospinal meningitis, 235
Clinical significance and therapeutic indications of abnor-
mal blood pressure, 302
Colloidal drugs in the treatment of bilharzia disea.se in
young people, 180
Coma as a cause of death in diabetes, 303
Combined quinine and methylene-blue treatment of
malaria, 130
Concerning a case of tetanus, use of dried serum and large
doses, 116
Contribution, a, to the helminthology of French Upjier
Guinea, 114
Coffee and the vitamines, 302
Cream cakes and paratyphus B., 299
COREESPONDENCE, 68, 224, 272
W^hen should a patient invalided to England for
malaria be considered fit to return to the tropics?
Cultivation, the, of a trypanasome from the blood of
Panamanian cattle, 252
CUBBENT LlTERATTJRE : —
A plea to ligate the hydrocele sac with living tis.sue,
248
Acute necrotic parotitis, 74
etiology of yellow fever : comparative immunological
studies on Leptospira icteroides and L. ictero-
hoemorrhagioe, 84
American leishmaniasis in Venezuela, 186
Amoebic dysentery carrier, 131
An anti-malarial mi.ssion in the eighteenth region of
Prance (1917-1918), 43
Anaphylaxis from quinine : anti-anaphylaxis and desen-
sitization, 284
An attempt at medical prophylaxis against sleeping
sickness in Oubangui-Chari, 205
An autocthonous malarial centre in the Seine-et-Oise
department of France, 28
Ankylostoma ceylanicum in the cat in Durban, 12
Ankylostomiasis and beriberi in French Guiana, 283
Anopheles centres in the Ardennes, 68
Anthrax in Morocco, a few facts concerning vaccinal
prophylaxis against, 67
Anti-malari.. <aiii|>aign in Palestine, 74, 98
Anti-mosquito iijoasures in Palestine during the cam-
paigns of 1917-1918, 41
Arsenobenzol treatment for dracontiasis, 42
Bacterial investigation of normal and disea.sed eyes.
tigation of influenza, 231
the Palesti
Bacteriologic
Beriberi, 131
Bilharziasis and mal
paign, 52
Bionomics of hou-se-flies, 231
Bionomics of Stegomyia fasciata, note on the, 12
Blackwater fever, cyanide of mercury in, 67
Blackwater fever in Macedonia, notes on, 219
Bovidae, 187
Bronchial spirochaetosis in Brazil, a case of, 283
Capsulated mucoid forms of paratyphoid and dysentery
bacilli, 98
Casablanca, climatology and demography of, an essay
on the, 14
Case, a, of red grain mycetoma (madura foot), 14
Ciuse of ophitoxsemia, 12
Cerebrospinal meningitis in goats, two caaes of, 284
" Charlatans and p»eudo-para«it<« " and "eye warms,"
187
Chemotherapy of trypanosome and spirochsete infcc-
INDEX
Cholera prophylactio vaccination ; ai
village during an epidemic, 12
Chronic plague in a rat without ai
present, note on a case of, 14
Cinchonidine in malaria, (JG
Cobra poisoning, 74
Coincident malaria and enteric fevei
Coleoptera in the human intestine, i
of, 232
Contribution, a, to the study of bov
27
the occurrence
Contribution to the study of flagellata of lulicidse,
niuscidse, phlebotomi and Blattu orientalis, 83
(Contribution to the study of the ixodidae : biologictil
adaptatiou of the ambulacra of the first pair of
legs, 83
Contribution to the study of osteoporosis or " big
hea-d " in horses as it occurs in New Caledonia, 187
Contribution to the study of the scro-reaction and the
fixation of complement with /{. protevs in exanthe-
matic typhus, 82
Contribution to the study of Trypanosoma venezuc-
lense Mesnil 1910, 283
Correlation between the chemical composition of
anthelmintics and their therapeutic values, 232
Correlation between the chemical composition of
anthelmintics and their therapeutic values iu con-
nection with the hookworm inquiry iu the Madras
presidency, 171
Course run by the leucocyte count and of the blood
changes in the clinical diagnosis of relapsing
fever, importance of the, 67
Craw-craw, or filarial itch, and its origin in sub-
cutaneus Onchocerca volvulus cysts, 187
Crescentic bodies in sestivo-autumnal malaria, 84
Crossocephalus zebras N. sp., 220
Cupric salvarsau and its sodium salt in the treatment
of human trypanosomiasis, 27
Culicidae collected by the anti-malaria commission
attached to the Armee d'Orient in 1918, 83
Cultivation of duckweed as a means of combating
malaria, 43
Cystolithiasis among Filipinos in association with
dietetic deficiency, 53
Deficiency disease, the pathogenesis of, 232
Description of the male genital armatures of the
British auopheline mos(|uitoes, 99
Determination of incubation periods from maritime
statistics with particular reference to the incuba-
tion period of influenza, 171
Diabetes, further notfs on the treatment of, 66
Diabetes in Madras, 12
Diagno-sis on a large scale in hookworm infections, 131
Dromedaries, on the heredity of infection and im-
munity iu the trypanosomiasis of, 284
Dysenteries at Salonica in 1918, 83
Dysentery and enteric disease in Mesopotamia from
the laboratory standpoint, 98
East Persia, typhus and typhus-like fevers in, 231
Economic value, the, of anticholera vaccination, 12
Eflects of injection. of ((uinine into the tissues of man
Endemic tsutsugamushi disease of Formosa 12
Enteric carriers, 131
Epidemic of fifty-four cases of relapsing fever observed
m Birjand, East Persia, 66
Estimation of erythrocytes and haemoglobin contents
Evidenc
jf blood, 231
reg:arding the
mmunity conferred by an
th a study of three local
attack of infin
epidemics, 171
Evolution of anaplasma in the blood of bovidse,
Existence of bovine spirochaetosis in Brazil
^■,^i„,. of the disease by the M„r<,arop,n „
Hxpc:
lis tick (-Fuller), 44
stence of distoma disease in
ital diagnosis of dour
CnHKRNT Tjiteratuhk — continued .
Ex]jerimental infection of the dromedary with Tnipnno-
soma berberin of Debab, 284*
Experimental infection in England of Anopheles
plvmbeus Stephens and A. bifurcatus L. with
J'lusmodiiim vivax, 99
Experimental infections of dogs and guinea-pigs with
cultures of lierpetemonas of insects, 283
Exi>erimental researches in the role of the gecko
^Tnren1ola maiiritanicu) in the etiology of oriental
sore, 284
Experimental study, an, on the life-history of Spar-
gunum mansuni , 2b
Ex|)eriments in the auto-hoemotherapic treatment of
blackwater fever, 20G
Experiments on the nasal route of infection in polio-
myelitis, 84
Fever, notes on certain cases of, 248
Filarial itch as a manifestation of volvulus. 284
First riTcirdi-d appearance of I'estis bnvimi in Italian
14
Indi
132
Kl.ivin.' ill .iphthalmic practice, 248
Fiiiiiigatinii cabin for native infirmaries, 14
Further case of black-grain mycetoma (madura fo<il)
iu Tunisia, 43
Further experiments in the aetiology of dengue fever,
26
Further observations on kala-azar, 73
Further observations on tetanus, 42
General vaccinia in Burma, 42
German medical organization in the Cainorooiis. IT)
Glioma of the brain in a negro, 67
Granules, the, of Spiruchwta duttoni, 28
Hazaribagh : a popular health resort, 269
Health conditions and depopulation in the Congo, 83
Heat and Stegomyia fasciata, 219
Heat stroke, 52
Hcrpetoinonas, the, and Spirnchasta of the Blalta
orientalis, 205
History of the guinea-worm, a further contribution
to the, 187
Human bites, 248
Human trypanosomiasis exists in thi> ea,stern forests of
Peru, 42
Human trypanosomiasis iu Peru, 99
Hydrocyanic acid gas as an insecticide, 131
Hydrophobia, note on a case of, 268
Hypertrophic osteitis and yaws, 188
Hypopus, the, of Carpoglyphtis anonymus Haller. 90
Identification of three strains of trypanosomes from
cases of sleeping sickness contracted in Portuguese
East Africa with Trypanosoma rhodesiense, 170
Importance of the cervical papillae or ankylostomes,
284
Infection by a fusospirillary organism, 47
Influenza, 66
influenza, notes on, 231
Intestinal bilharziosis showing Schistosomuni hcemato-
hium, and the geopraphical distribution of the
disease in the Belgian Congo and East Africa, 68
Intestinal parasitism in Annam, 283
lodosalyl in trypanosomiasis and yaws, 186
lonoid of arsenic in the treatment of paludism, 283
Is human bilharziosis likely to spread in India? 131
Isolation of and search for anaplasma by inoculation
of suspecte I blood into sheep or goats, 42
Juxta-articular nodosities in the Annamites : treatment
by novarsenobenzol, 283
Kashmir, note regarding malaria in, 232
Laboratory diagnosis of typhus fever, studies on the
Weil-Felix serulorrical test for the, 52
Laboratory methods in the diagnosis of sprue, 205
Larvicides, 74
Latradectus mactuns or " Lucacha " in Peru, 27
T-#prosy in the Cumeroous. 27
Ijeprasy, the treatment of, 145
Lethargic encephalitis in Karachi during «rii epidemic
of influenza, 231
INDEX
Current Literature — continued.
Ltvitiition method, technique of the, 52
id decrease of
opiiils in
human spirochaetnsi:
Leucocyte
iiig fever. 27
Leucocytic fornnilii
Middle Congo, Ja
Tif ucocytogreg;iiiiie, the, of the wilil
Lcncocytozoon, a, of the litle owl of Brazil, 283
M;icedoiiia, notes on blackwater fever in, 52
Malaria and rainfall, relationship of, 232
Malaria at Casablanca, 206
Malaria, treatment of, 12
Malarial blood, a, 153
Malarial infection and novarsenobenzol, 187
Malarial parasites in the peripheral blood, method of
search for scanty, 67
Mange in dromedaries by tarry extract of colocynthis,
treatment of, 68
Measurement of bacterial content in fluid sus|>ension,
171
Mechanism of the spontaneous elimination of yellow
fever from endemic centres, 99
Melancholic stupor, a case of, 268
Metabolism of white races living in the tropics, 99
Metabolism of white races livini? In tlic Iropics: com-
position of the urine, 12
Meteorological conditions in Mesopotamia affecting the
occurrence of heatstroke, 131
Mycosis of the bovine fa;tal membranes due to a mould
of the genus Mucor, 84
Naval medical conditions, retrospective view of, 52
Nomenclature of the parts of the male hypopygium of
Diptera nematocera, with special reference to
mosquitoes, 219
Note on a small outbreak of lobar pneumonia in
Baghdad due to a bacillus of the Gaertner para-
typhoid group, 132
Note on the relative proportions of amoebic and bacil-
lary dysentery among the troops of the Egyptian
Expeditionary Force, 74
Notes on a case of " hypospadias pcrincalis " (pseudo-
hermaphroditus mascullinus externus), 145
Notes on a monkey plasmodium and on some experi-
ments in malaria, 52
Notes on the protozoal iatestinal parasites of man and
animals, 26
Note on the etiology of oriental sore in Mesopotamia,
13
Observations on the cultivation of typhoid and para-
typhoid bacilli from the stools, 26
Observation on the effect of malaria in leukaemia, 99
Observations on the pa-steurelloses in Morocco, 284
Observations on the treatment of hookworm disease.
the norma
of liaeillus influ,
1 the island of Sal (Cape Verd Archi
Occurrence, the
throat, 13
Ocular myiasis ;
pelago), 43
On the results obtained from surveys for breeding-
places of tree-hole mosquitoes in Liverpool and
neighbourhood, 220
Oral administration of quinine or quinine and arsenic
for short periods to young native children infected
with malignant tertian malaria, 219
Organo-therajieutic treatment of malaria, 268
Oriental sore, a new treatment for (cretan), by local
injections of emetine hydrochloride, 187
Ornithodorus inouhata in the north-eaKtern districts of
Belgian Congo, 13
Paka oil in mustard oil iiM an adulterant, 12
I'aludisni and novarsenobenzol, 284
Parasitic flagellata harboured by some insects and the
infections they may produce in mice, 26
Parasitic Ixodes infesting domestic animals collected
at Mitylene between February and June, note on
the, 187
Pasteurellosis in rabbits following the intravenous in-
jection of influenza bacilli. 171
Pathogenic action of a fungus parasite on bamboos iri
Central Africa, 283
CtJRKENT LiTEBATDRE — Continued.
Pathogenesis of deficiency disease, 52, 170
Phagedenic complications noted after vaccination, 14
I'harmaoo-dynamics of quinine, the, 51
Plague, treatment of, by the solution of iodine and
camphor, 248
Plasmodium relictuin gives no fatal disease to the
mosquito which tranrfhiits it, 28
Porocephalus in a hernial sac, 74
inary
note
a fever of unknown origin'
observed in Cochin China,
Preliminary notes on a method of utilizing the natural
amboceptor in hsemolytic sera in the Wassermann
reaction, 231
Preparation of a culture medium suitable for the
growth of organisms used as vaccines, 231
Presence of acid-fast bacilli in the blood of lepers, 52
Prevalence, the. of ankylostomiasis in the Madras
presidency, 170
Prevalence, the, of Leptospira ictero-hcBmorrhagiae in
the wild rats of Sao Paulo, Brazil, 283
Probable syphilitic origin of juxta-articular nodosities.
Production of indole by Pfeiffer's bacillus, 231
Prophylaxis of dracontiasis, 132
Pulmonary manifestations in malaria, 12
Pulmonary manifestations of malaria, 74
Purpura haemorrhagica, treatment of, 248
Quickest method, on the, of diagnosing sleeping sick-
ness when on travelling practice in the bush, 42
Quinine prophylaxis, 52
Quinine prophylaxis and the treatment of malaria in
a coolie population, 66
Quinine tabellae and quinine salts, 52
[{abies in Senegal, a further case of, 67
Kat and plague conditions in hutted camps, 131
]{at-bite fever Spirochaete, 26
Kat problem in India, the, 131
Recent researches of hookworm infection in Indonesia,
42
Records of the occurrence of intestinal protozoa in
British and Indian troops in Mesopotamia, 51
llelapsing fever in the province of Se-chuen (Western
China), a clinical study of, 67
Relapsing fever in Turkey, an outbreak of, 231
Relationship of Onchocerca vohnthis and filarial itch,
on the, 284
Remarks on the haematological and clinical aspects of
Bancroft's filariasis in French Guinea, 186
Report on an epizootic disease among calves at the
Amara dairy farm, 170
Report on bilharziasis in Mesopotamia, 51
Report on the anti-beriberi vitamine content and
anti-scorbutic property of sun-dried vegetables, 131
lleport on the gynocardate and morrhuatc treatment of
leprosy based on forty cases treated in the
Kashmir State Leper Hospital, 145
Reservoir of the virus of oriental sore, 284
Resistance to desiccation of the intermediate host of
Schistosoma japonicum Katsurada, 66
R"sult, the, of trials of sodium hydnocarpate and
sodium morrhuatc in thirteen Indian leper
asylums, 145
Results of a mosquito survey of Indore City, on the,
1.30
nho'lnius prolirus, a new flagellum of, Trypanosoma
(or Crithidia) rangeli n. sp., 284
Roumanian epidemic, the, of exanthematic typhus
during the late war, 188.
Sarcospnridiosis in an East Indian, 66
Schistosomiasis in India, on the possible spread of, .')2
Scorbutic diet on the adrenal glands, influence of a, .52
Scurvy, 131
Second Hcries of twenty-five cases of malaria treated
by hypodermic injection of cinchnnine bihydro-
chloride, 74
Serum, treatment of animals infected with Leptospira
icteroides, 84
Sleeping sickness in North Katanga (Belgian Congo),
INDEX
CuREENT LiTKBATTTBE — Continued.
Sleeping sickness in the Middle Kwilu (District of
Kwango, Belgian Congo) in 1918, 43
Sodium morrhuate and sodium hydnocarpate in leprosy.
Sodium morrhuate in the treatment of tuberculosis, 132
Sodium morrhuate in tuberculosis, 145
Some bacteriological phases of the cholera-carrier pro-
blem. 53
Sphenoidal empyema and epidemic cerebrospinal fever,
98
Stallions clinically cured of dourine as healthy
carriers of pathogenic germs, 284
Standard diets, 230
Steam disinfections in destroying lioe in clothing, 66
Sterilization of lipovaccines, 84
Strongyloides intestinalis Bavay 1877 in the intestine
of man in Senegal, 283
Studies in ankylostomiasis, 171
Studies on the value of the Wassermann test, 170
Studies on the varioiis types of malarial infection and
the effect of quinine treatment thereon among the
native population of the Malay archipelago, 219
Study, the, of tuberculous infection among the native
population of Ouargla Saharian by the tuberculin
skin reaction test, 29
Subtertian malaria, intravenous injection of eusol in,
53
Surgical problems and difScultiee in the tropics, 41
Symptomatic anthrax in Annam, 82
Xabanus, secrttion and epithelial regeneration in the
mid-intestine of, 232
Three cases of oriental sore, with remarks concerning
the method of contamination, 28
The haemic basophile, 84
Therapeutic action, the, of N-phenylglycine-amide-p-
arsonic acid in experimental trypanosomiasis of
rats and guinea-pigs, 13
ista-ument for measuring tint
French dogs by
Tinturometer, the,
and turbidity, 171
Transmission of piropla
Dermacentor reticulattis , 27
Transmission of Tunisian canine piroplasmosis by
Rhipicephalus sanguinetis, 42
Treatment of leprosy by intravenous injections and by
ingestion of emulsions of chaulmoogra oil, 284
Treatment of phagedenic ulcers, remarks on the, 14
Treatment of sleeping sickness with coUobiase d'anti-
moine, experiments in the, 67
Tropical Australia and its settlements, 99
Trypanosoma dimorphon infection in horses and mules,
Trypanosoma marocanum, case of spontaneous infec-
tion of a dog by, 67
Trypanosomiases of animals in Venezuela, 187
Trypanosomiasis prophylactic sector in the French
Congo, on the working of a, 206
Tuberculosis of the skull wall in a Soudanese negro.
Two cases of milk-i
alastrim observed at
Spain and
irriga-
zaville (Middle Congo), 14
Two cases of oriental sore, contracted
France, respectively, 186
Typhoid and antitypho'id record for 1918-1919, 52
lyphus and typhus-like fevers in Birjand, East Persia,
73
Use of birds as laboratory animals, 231
Use of mouochloride of iodine for contii
tions, 42
Vaccination against cattle plague, 206
Vaccination, experiments in, against Pestis bovina by
the " sero-infection " method of Schein, 14
Vaccination of bovidae against anaplasmosis, 44
Vaccine therapy in typhoid and paratyphoid fever, a
note on, 268
Weil-Felix reaction in exanthematic typhus. Low
agglutinating power of spinal fluid, 28
Xenophthalmia in a native of the Gold Coast, 99
Death, the, of Gorgas, 184
Defects of deficient dietaries in monkeys, 228
Delousing the American Army in France, 267
Dermatitis, Sadd (illustrated), 57
Diabetes, drugless therapy of, 185
Diabetes, some experimental studies in, 167
Diagnosis of chronic cholecystitis complicating cardiac
lesions, 54
Diagnosis of lethargic encephalitis, hitherto undescribcd
Diphtheroids, some Soudanese (illustrated), 85
Dysentery in Palestine. 41
Early use of convalescent serum iu influenza, 254
Edible coconut oil, rancidity of, 183
Effect of therapeutic doses of mexcury on the kidneys and
the duration of its excretion, 276
Egyptian b'lharziasis, 41
Elephantiasis, buried tube drainage in a case of, 50
Emergency measures and foresight in malaria control, 267
Emetine urticaria, 96
Entamoeba serper^tis, 169
Epidemic encephalitis, 113
Etiology of thrush, the (illustrated), 18
Etiology of yellow fever : summary and conclusions, 99
Expense, the, of overseas travelling within the Empire and
some of its consequences. 111
Experiences of medical and prison work in a new country
(Kedah, Malay Peninsula), 189
Experimental determination, the, of the vertebrate hosts
of some African ceicariae from the molluscs, Physopsie
africana and Limntea natalensis, 171
Experimental pellagra in white male convicts, 207
Experimental studies in diabetes, 167
Extra-pharmacopoeia of Martindale and Westcott, the, 239
Fatal mouse typhus in a human being, 235
Fat-soluble vitamine content of green plant tissues, 97
Fifteen years' experience of malaria in the Upper Congo,
some notes on, 177
Filarial periodicity, 11
Filariasis, 97
Filariasis, three cases of, in which intravenous injections
of tartar emetic were given (illustrated), 36
Flagellate character and reclassification of the parasite
producing "blackhead" in turkeys, 290
Four interesting cases of bilharzia disease treated by tartar
emetic, 69
Freshwater snails and their eradication, some infections
due to, 274
" Froghopper " as a blood-sucking insect, a, 212
Fruits and their salts, 228
Further case of amoebic dysentery in a dog, 116
Gametes of plasmodium prsecox and the variable propor-
tion of male and female elements, 115
Gastric polyposis (papillomatosis), 266
Gorgas, the death of, 184
Granuloma inguinale in the United States, 170
Graphic method, the, of demonstrating tropical medicine
and hygiene (illustrated), 213
Haemoglobinuric bilious fever, 29
Ha-mogregarina in a Macaeus monkey, 116
Hereditary diabetes, a case of, 241
Higher fungi iu re'ation to human pathology, Milrov
lectures on the (illustrated), 101
Histological observations on the possible pathogenicity nf
Trichomonas intestinalis and Chilomastix mesnili, with
a note on Endolimax nana (illustrated), 125
Housing at home and abroad, 168
How mange in domestic animals should l>o dealt with in
the French colonies, 115
INDEX
Human synophthalmia, a case of, 267
Hydatid vessels obstruct bile duct, 51
Hypodermic injections of milk in the treatment of intoler-
ance of milk in nurselings, 289
I
Illustrations : —
Bronchomoniliasis in the Anglo-Egyptian Sudan and
Egypt, 6
Graphic method, the, of demonstrating tropical medi-
cine and hygiene, 213
Hsemogregarines in black rats, 299
Histological observations ou the possible pathogenicity
of Trichomonas intestinalis and Chilomastix mes-
nili, with a note on Endolimax nana, 125
I/ondon School of Tropical Medicine, 124
Milroy lectures on the higher fungi in relation to
human pathology, 101, 119, 133
Notes on a case of " Castellani's bronchitis," 70
Sadd dermatitis, 57
Some cosmopolitan Sudan skin affections, 150
Some observations on Vibriothrix zeylanica (Castel-
lani), 7
" Tenue " phase, the, of Plasmodium vivax (Grassi
and Feletti 1890), 33
Three cases of filariasis in which intravenous injec-
tious of tartar emetic were given, 36
Three cases of malignant tertian malaria, with special
treatment, 59
Thrush, the etiology of, 18
Toxoplasma pyrogenes Castellani 1913, 45
Use of town refuse for mosquito work, 297-8
Incidence of syphilis as manifested by routine Wasser-
mann reactions on 2,925 hospital and dispensary
medical cases, 65
Influence, the, of vitamines in the course of pellagra, 267
Influenza as observed in the Sambhu Nath Pundit Hospital,
Calcutta, 113
Inguinal canal, guinea-worm in the, 186
Injections of adrenalin in the diagnosis of latent malaria,
218
Intestinal animal parasites, the, found in one hundred
sick Filipino children, 279
Intestinal protozoal infections among officers and men of
the Royal Navy and Marines, dealt with at the Royal
Naval Hospital, Haslar, during 1916 to 1918, 259
Intestinal tract, changing the flora of the, 55
Kala-azar in Europeai
113
the Nougong district of Assam,
Latent infection in experimental spirochaetosis, 239
Lateral-spined bilharzia eggs (Schistosoma mansoni) in
urine, the occurrence of, 45
1 1 Leading Articles : —
A circular being issued by the Tropical Diseases Pre-
vention Committee, 47
A malarial blood, 153
An X-ray raotor-ambulance wagon for use at home and
in tropical countries, 264
Bodily powers as tested by the Olympic Games, 216
Death of Dr. Albert .lohn Chalmers, 94
Death, the, of Oorgas, 184
Expense, the, of overseas travelling within the Empire
and some of its con
sequences.
Extra-pharmacopo-ia of Martindale and Wcstoott, the.
Fruits and their salts, 228
Housing at home and abroad, 168
.TouRNAL OP Tropical Medicine and Hygiene twenty-
first birthday, 9
London School of Tropical Medicine, the, 276
Reflections on some ailments in their temperate and
tropical environment, 203
Royal Society, the, of Tropical Medicine and Hygiene,
198, 300
Leading Abticles — continued.
Scarcity of British applicants for aervioe in the Crown
colonies and protectorates; 63
Some aspects of poisoning in the tropics and some of
the more common vegetable poisons met with in
the tropics, 252
Special Indian Science Congress Number, 1919, 80
Sprue, 287
Tobacco smokers classified, 71
Tropical Disease Prevention Committee, 39
Typhus, 140
Universal national alliance to fight preventaVile
diseases (tropical), 23
When tropical residents cannot take quinine, 127
I leprosy, treatment of, with especial reference to some
new chaulmoogra oil derivatives, 290
Lesions, the, in wood alcohol poisoning, 200
Lethargic encephalitis, history, pathologic and clinical
features and epidemiology in brief, 244
Lipuria associated with chronic nephritis, 221
Locality differences in the. feeding habits of mosquitoes.
examination result.
London School of Tropical Med:
203
London School of Tropical Medicine, the, 276
Malaria at home and abroad, 188
Malaria hemiplegia in an infant, 96
Malaria in England, on the relation of temperature to, 218
Malaria in Uganda, routine treatment of, 49
Malaria in the Upper Congo, some notes on fifteen years'
experience of, 177
Malay Archipelago, observations on the larvae-destroying
action of small fish in the, 77
Manufacture and uses of essence of niaouli, 116
Method of cholera diagnosis, 282
Method of concentration of parasitic eggs in faeces, 303
Milk produced in Southern China, 75
Milroy lectures on the higher fungi in relation to human
pathology (illustrated), 101, 119, 133
Mixed B. paratyphosus A and B inoculations with serum-
treated bacilli, 156
Mouae oxyuride, syphacia onvelata in man, 97
Multiple echinoooccus cyst, a case of, 239
Narcotic habit, underlying causes of the, 65
Natural enemies, the question of, 145
Nephritis, trench, 143
New methylene eosinate, a, 114
New vehicle, a, for emetine bismuthous iodide, 110
Non-parasitic haematochyluria, 65
Note, a, on the use of the tourniquet in operations for
elephantiasis scroti, 183
Note on a case of kala-azar in a child at Gabon, 115
Note on the presence of acii-fast bacilli in the blood of
lepers, 305
Notes and News, 9, 32. 44, 68, 100, 112, 164, 198, 216, 296
Deer fly fever, or Pahvant Valley plague, 32
Diploma in radiology and electrologfy , 84
London School of Tropical Medicine, 127
Prevention and treatment of malaria by means of
mercurial preparations. 205
Notes on a monkey Plasmodium and on some experiments
in malaria 304
Notes on a case of " Castellani's bronchitis " (illustrated),
70
Notes on mouth sepsis, 157
Notes on some cases of Castellani's broncho-moniliasis
(illustrated), 250
Novar.senobillon, ill-effects following, 144
0
Obituary : —
Babtie, Lieut.-General, V.C, K.C.M.G., 248
Observations on a case of onyalai in the East African
Protectorate, 138
Observations on cases of seasonal hay fever diagnosed an4
treated with pollen extracts, 206
INDEX
Observations on the cerebrospinal fluid of acute diseasie, 65
Observations on the cultural methods of gonococcus, 303
Observations on the larvse-destroyiug action of small tisli
in the Malay Archijielago, 77
Occurrence of Huc'Uux holiilinus in nature, 51
Ocular symptoms in viiceplialitis lethargica, 24L'
(Edema as a sym[itnni in food-deficiency diseases, '22ti
Oil fuel refuse lUstructinn, 114
On the possible spread of schistosomiasis in India, 305
On the results obtained by the Weil-Pelix reaction for
typhus fever at the garrison of Baku, 230
Operation for pruritus ani and vulvae, 289
Operative treatment, the, of ulcerative colitis, 162
Optic neuritis foUovfing typhus fever, 129
Original Communications : —
attempt to explain the greater pathogenicity of
Pla
nodium falctpanim
compared
ith oth<
species. By C. C. Ba.-vs, M.D.,
Api>endicitis in a native of the Solomon Islands,
Western Pacific, a case of. By Nathaniel Crichlow,
MB., Oh.B.Gla.sgow, 22
Billiarzia disea.se : the sterilization of the ova during
the course of cure by antimony (tartrate). By
J. B. Christopher.son, C.B.E., M.A., M.D ,
F.R.C.P., F.U.C.S., 165
Bilharziasis, the treatment of, with antimony. By
J. E. R. McDonagh, F.R.C.S., 165
Bronchomonilia.sis in the Anglo-Egyptian Sudan and
Egypt Bv \ r f'li.ilmers, M.D., F.R.C S.,
D.r.H , .r.'vA X.'iin-ii Mulonald (illustrated), 1
Broncho-spiiM, iKit.i-i, , ( ...t. Il;iin-s). By C. L. Browne,
L.R.C.l'.. LIIC.S . ■.'■_•(;
Chaulmoogra oil in leprosy. By T. A. Henry, D.Sc,
249
Colloidal drugs in the treatment of bilharzia diseases
in young jwople. By F. G. Caw.ston, M.D.Cantab.,
180
Etioloo-y of thrush, the. By Aldo Ca.stellani, C.M.G..
MJ)., M.R.C.P. (illustrated), 18
Experiences of medical and prison work in a new
country (Kedah, Malay Peninsula) By A. L
Hoops, M.D., D.P.H . B.A., ICD Lond., 189
Four interesting cases cif bilharzia disoa.se treated by
tartar emetic. By F. G. Caw.ston, M.D Cantab, 69
Freshwater snails and their eradication, sonic infec-
tions due to. By F. G. Cawston, M D.Cantab, 274
Graphic method, the, of demonstrating tropical medi-
cine and hygiene. By Andrew Balfour, C.B.,
C.M.G., M.D., F.R.C. P., D.P.H. , and S. H.
Daukes, O.B.E., MB., D.P.H., D.T.M. and H.
(illustrated), 213
Ha>mogregarines in black rats. By G. E. F. Stammers,
298
Histological observations on the i>ossible pathog; nicity
of Trichomonas intestinalis and Chilomastix mes-
nili, with a note on Endolimax nana. By C. M.
Wenyon (illustrated), 125
Lepro.^y at Rodrigues. By E. Mangenie, 238
Locality differences in the fe.-ling habits of m- .-
i|uitoes. l!y Malcolm E, MacGregor, 226
Milroy lectures on the higher fungi in relation to
human pathologv. By -Aldo CasUdlani, C.M.G..
M.D., M.K.C.P. (illustrated). 101. 119, 133
New vehicle, a, for emetine bismuthous iodide. By
T. J. G. Mayer, M.R.C S.Gambia. 110
Note on the use of the tourni(|uet in operations for
<'lephantiasis scroti. By liobert Howard, M.D.,
B.Ch.Oxon, 183
Notes on a case of " Cadellani's bronchitis." Bv
1. lac-mo, M.D. (illustrated), 70
Notes on some cases of Castellani's broncho-moniliasis.
By 1. .lacono. M 11 , (illustrated), 250
Oh-xTvations on a case of onval.ii in the Ea.st African
protectorate. By T. R \V.I, 1,. *1 B Lniid , 138
DbservatioHs on the larva^- I I . mv ii,- .i.tion of small
lish in the Malay An Inp. I.i-i liv \ II. Sudl.-ii-
grebel, M.D., and .1. M 11 Sxv<ll,'ni;nl,el-de-(iraaf,
77
OniGiNAL Communications — covfinnnl
Occurrence, the, of later.il-^pi
(Schistosoma inaiisutii) in n
Maclie, 45
Burmi
inicipality.
By J. C.
I'relimiuary note mi tlir Ir.Mlniriit of nodular leprosy
by intravenous injections of chaulmoogra oil. By
P. H.-ir]>er, M.R.C.S., L.li.C.P., 285
Preservation of the anti-scorbutic jjroiierties of cab-
bage by drying. By Prof. Axel Hoist and Theodor
Frolich, M.D., 261
IJuininc, notes on the preventive use of. By Dr.
Harold Seidelin, 285
Quinine prophylaxis. By W. M. Macdonald, M.R.C.S..
L.R.C.P.Lond., 182
Sadd dermatitis. By Albert .J. Chalmers, M.D.,
F.H.C.S., D.P.H., and A. F. Joseph, D.Sc, F.I.C.
(illustrated), 57
Some cosmojwlitan Sudan skin affections. By A. J.
Chalmers, M.D., F.R.C.S., D.P.H., and Norman
Macdonald (illu.strated), 150
Some further observations on the aetiology of
'■ ])ellagra." By A. Viswaliiigam, L.M.S., 46
Some notes on fifteen years' cxjwrience of malaria in
the Upper Congo. By Arthur Pearson, M.B.,
B.S.Lond., M.R.C.S., L.R.C.P., 177
Some observations on ]'ihriothri.r zeylanica (Castel-
lani). By laidwik Anigstein, M.D., Ph.D. (illus-
trated), 7
Some Soudaiiesp diphtheroids Bv A .T. Chalmers,
M.D., F.R.C.S., D.P.H., and Norman Macdonald
(illustrated), 85
Sprue in America. By Edward J. Wood, B.Sc, M.D.,
D.T.M.Eng., 201
Surgical treatment, the, of ulcus tropiciiin. By Robert
Howard, M.D., B.Ch.Oxon, 215
" Tcnuc " phase, the, of I'lasmodium vivax (Grassi
and Feletti 1.S90). By Albert J. Chalmers, M.D..
FR.C.S., D.P.H., and Major R. G. Archibald,
DS.O., M.D.. U.A.M.C. (illustrated), 33
Three cases nf tiliariasis in which intravenous injec-
tions of t.nt:iv emetic were given. By J. W. S.
Macfio (illustr.ited), 36
Three cases of malignant tertian malaria with special
treatment. By P. J. Veale, I. M.S. (illustrated), 59
7'-.r„,,(u,s,„„ pi,rogcncs Ca.stellani 1913. Bv Albert J.
Chalmers. M.D., F.R.C S. D.P.H., and S.agh
(M..]-.!-) A K.imar, M.D. (illustrated), 45
Treat n, .■,,(. 11, ■, ,.f ulcus tropicuni. Bv \ itliaiiiol
Cm. Iil.iu, \\ H . Ch B.(;i isgow, 227
Ulcu-, tinpieuiii treated v,-ith tartar emetic. By A.
Mei, M.D., .38
Undulant fever with unusual nerve sc<|uela', a case of.
Bv P. W. Bassett-Smith, CB , CMC., F.U.C.S.,
FTi.C.P., R.N., 201
Use of town refus* for mos(|uito work. By E. P
Minett, M.D., D.P.H. and M., 297
Outbreak of Asiatic cholera, in Syrian municipality, Burma
in June-.Tuly, 1920, notes on an. 273
Oxygen, the therapeutic usc of, 289
Oxyuris appendicitis, 130
Pandemic influenza, experimental study of, 170
Papulo-urticarial rashes caused by the hairlcts of cater-
pillars of the moth (Kdpn.cli.v'c./w./i./.vi Newni.). 148
Pathologv and ,.ath..o-eiie-is „f inicnnincceiis |„l,ar |nieu.
monia in mnnkev,, l.V,
Pathology of ex|,eniiuiit.il r.il.U's, .(04
Pathogenesis of detieieiuv di,,e.ises. :!{I4
Pellagra, |.rcvaUnue of, among liirki-h pr
me further oli-
lie ietiology of,
hislaliilici, 241
., ((irassi and
l'hlyct<'iiuiar conjunctivitis, rarity of, in the Algerian
aborigines, 11
I'laxmodium falciparum infection and novarsenobenzol, 115
Pneumonia, sodium citrate in the treatment of, 50
Poland, character of the prevalent typhus in, and its
association with relap.sing fever, 53
Polyval?nt vaccine, a, in the treatment of bacillary dysen-
tiry in East Africa, <M
Porto Rican troops, skin diseases among the, 11
Pr.ictical contribution to the therapeutics of epizootic
lymphangitis in the horse, 155
Preliminary note on an investigation as to the actual
weight of the cataractous lens, 113
Preliminary note on the treatment of nodular leprosy by
intravenous injections of chaulmoogra oil, 285
Prevention coiiiniittee, tropical disease, 39
Prevention of simple goitre in man, 242
Production of pneumocoecus lobar pneumonia in monkeys.
155
Protein shock reaction in leprosy, 296
Pyrexia not yet diagnosed, of dental origin, 210
tjuestioiis of salubrity and sanitarv by-la
Guinea, 115
Quinine, notes on the preventive use of, 285
Quinfne prophylaxis, 182
Hat-bite fever : reiwrt of a case, 130
Kats as agents in transmitting ringworm to the hors<-. 113
Reaction, cutaneous, and de«ensitization in ijuinine idio-
syncra-sy, 25
Recent work on tropical diseases, 73
Records of the occurrence of intestinal protozoa in British
and Indian troops in Mesopotamia, 303
Reflections on some ailments in their tenii>erate an I
tropical environment, 203
Relapsing fever, its occurrence in Panama, 266
Relapsing fever in East Persia, 271
Remarks on some cases of paratyphoid B, 241
Remote manifestations of focal dental infections with
case reports, 267
Report on bilharzia.sis in Mesoixitamia, 303
Report on the gynocardate and morrhuate treatn);nt of
leprosy, based on forty cases treated in the Kashmir
State Leper Hospital, 234
Reports of Societiks : —
Medical Society of London : Treatment of malaria, 15
Hkpohts and Repkints, 116, 296, 305
Results of prophylactic vaccination against pneumocoecus
pneumonia in monkeys, 150
Reviews : —
Atlas of the primary and cutaneous lesions of ac(iuired
)racti
176
i-tric
it, 76
Essentials of trojiical medicine, 176
Handbook for tuberculosis workers, 278
Malaria at honu> and abroad, 188
Manual of tropical diseases, a, .55
Marine hygiene and sanitation : a manual for ships'
surgeons and port health officers, 132
Personal hygiene, 132
Primer of tropical hygiene, 132
■ inzy-s handbook of the diseases of the eye and their
itnient, 44
Rod
Roy
ign.^s, leprosy at, 238
1 Snciety, the, of Tropical Medici
s
Sad(
Sali
dermatitis lillustraU-d), 57
a, reaction of the, 185
ary victory over yellow fever, 97
Hygieii
Scarcity of British applicants for service in the Crown
colonies and protectorates, 63
Scurvy in the Royal Navy, preliminary report of experi-
mental investigation of, 233
Secondary malaria, 39
Severe epidemic of malaria in the Mitidja (Algeria), year's
ex]>erieuce of a, 11
Simple method, a, of cultivating the micro-organism of
actinomycosis, 281
Sim])le method of preparing all eosiiiate of Knrrel's blue
for blood examinations, 114
Slow evolution of jicritonitis following jjerforation of
typhoid ulcer, 129
Solomon IslancUi, Western Pacific, case of appendicitis in
a native of the, 22
Some aspects of poisoning iu the tropics and some of the
more common vegetable poisons met with in the tropics,
252
Some experiences in the commoner tropical diseases in
(lute) German New Guinea, 160
Some experiments bearing upon the intravenous vaccine
treatment of typhoid fever, 242
Some further observations on the aetiology of " pellagra,"
46
Some interesting instances of tuberculosis in animals, 167
Some observations on Viliriothri.r zeyliinica (Castellani)
^illustrated), 7
Sores analogous to veld sores and barcoo rot appearing
among soldiers worki
blue clay and in chalk, 143
Soudanese diphtheroides, some (illustrated).
Special ludian Service Congress Number, 1919, 80
Specific complement-fixation test for bilharziasis, note on
a, 272
Spider venom, 113
Spontaneous pneumonia in monkeys, 154
Spirobacillus zeylanicus, on the, 50
Spiruc.ha>tn recurrentis : a filter passer, 241
Splenectomy in malaria, 63
Spread of the spirochsete of infectious jaundice, 74
Sprue, 287
Sprue, cultural studies in a case of, 50
Sprue in America, 201
Statistical remarks on the treatment of bilharziasis by
tartar emetic, 175
Studies on the effect of light on vitiligo, 156
Study of the diffusibility of the virus of rabies, 94
Successful treatment of giardiasis in man with neo-
arsphenamin, 220
Sudan skin affections, some cosmopolitan (illustrated), 150
Surgery in chronic diarrhoea, 211
Surgical treatment, the, of ulcus tropicum, 215
Surgical problems and difficulties in the tropics, 31
'lardy post-arsenical jaundice, 127
"Tciim" phase, the, of I'laxmoilium vivax (Grassi and
Feletti 1890) (illustrated), 33
Tetany in a case of sprue, 97
Thermostability of fat-soluble vitamines in plant
materials, 97
Three cases of filariasis in which intravenous injections of
tartar emetic were given (illustrated), 36
Three cases of malignant tertian malaria with special
treatment (illustrated), 59
Thrush, the etiology of (illustrated), 18
Tick fever in Eiust Persia^ 266
Tobacco smokers classified, 71
Tourni(|uet in op«'rations for elephantiasis scroti, a note
on the, ia3
jaundice in pat
23(
idcr antisyi
treatment,
Toxic reactions which follow the intravenous injection of
" 914," treatment of the, 233
Toxins and antitoxins of II. ili/senterice, 50
Toxoplaxmu pyrugenes Castellani 1913 (illustrated), 45
TransmiKsion of typhus by lice stools, 41
Treatment of hilharzia disease in young people, colloidal
drugs ill the, 180
Treat uifiit of dial)et«s in India, the, 304
treat-
being
Treatmeut of typhus fever, 299
Treatment of threadworms with carbonate of bismuth, 289
Treatment of influenza pneumonia by serum from con-
valescent patients, 96
Treatment of malaria, report of the sub-committee of
medical research of the National Malaria Committee.
110
Treatmeut of surra in camels by intravenous iujectious of
tartar emetic, 268
Treatmeut of syphilis, study of new elements
ment of, 143
Trench fever, 49
Tropical Diseases Prevention Committee, 39
Tropical Diseases Prevention Committee, a c
issued by the, 47
Tropicum, ulcus, treated with tartar emetic, 38
Trypauosome, a, associated with a fatal disease in Carabao,
267
Trypanosoniiasui avtericana, 73
Tuberculosis in animals, some intere-,tiug instances of, 167
Twenty-first birthday of Journal of Tropical Medicine
AND Hygiene, 9 ,
Tyjjes and treatment of jiellagra, 267
Typhoid and paratyjjhoid incidence and deaths in the
American Ex])editionary Force, 209
Typhus, 140
Typhus fever, 98
Typhus, protein therapy of, 22
Ulcerating granuloma of pudenda, 97
Ileus tropicum of the geuitals in Cyreuaica, 73
Ulcus tropicum, the treatment of, 227
Ulcus tropicum treated with tartar emetic, 38
Undulant fever with uuusual nerve sequelae, a case of, 201
Universal national alliance to fight preventable diseases
(tropical), 23
Uuusual forms of dysentery, 96
Uruguay, leprosy in, 11
Value of complement-fixation test in tuberculosis, 289
]'ibriijikrix zeylanicu, some observations on (Castellani)
(illus-trated), 7
Vitamines, the, 254
" War dropsy," nutritional oedema aud, 140
When tropical residents cannot take quiniue, 127
Work, the, of a vaccine dejwt, Meiktila, 113
Yaws : with a report of a case which developed
perate climate, 280
Yellow fever, blood pressure in, 49
Yellow fever in New Orleans, 51
INDEX
LIST OF PLATES.
Bronchomoniliasis in the Anglo-Egyptian Sudan and Egypt, 1
Histological observations on the possible pathogenicity of
Trichomonas intestinalis and Chilomastix viesnili, with a
note ou Endolimax nana, 125
Sadd dermatitis, 57
Some cosmopolitan Sudan sliin affections: I.— Herpestris, 150
Some observations on Yibriolhrix zeylanica (Castellani), 7
Some Sudanese diphtheroids, 85
The etiology of thrush, 17
The graphic method of demonstrating tropical medicine and
hygiene, 213
The higher fungi in relation to human pathology, 117, 133
The " tentie " phase of Plasmodium wuoa;* (Grassi and Feletti,
1890), 33
Toxoplasma pyrogents (Castellani, 1913), 40
INDEX OF SELECTIONS FROM COLONIAL MEDICAL REPORTS.^
GENERAL INDEX.
(104) Ceylon, 1, 5
(105) Calcutta, 5, 9. 13
(106) Colombo, 15, 17, 21
(107) Hongkong, 21, 25
(108) Agra and Oudh, 28, 29
(109) New South Wales, 32, 33, 37, 41, 45, 49, 53
(110) Trinidad and Tobago, 56, 57, 61
(111) Cairo, 63, 65, 69, 73
(112) Jamaica, 74, 77, 81, 85, 89
(113) Shanghai, 91
'Note to Binder— These are to be bound to follow the lust number
Medicine akd Hyoiene.
the volume of the Joohnal of Tropical
1
Jan. J, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 1, Vol. XXIII.
(Sriginai CommnnuaUons.
BRONCHOMONILIASIS IN THE ANGLO-
EGYPTIAN SUDAN AND EGYPT.
By Albert J. Chalmers, M.D., F.E.C.S., D.P.H.,
DirtctoT, Wellcome Tropical Research Laboratories,
AND
NOBMAN MaCDONALD,
Bacteriological Laboratory Assistant, Khartoum.
Contents. — Introductory — Historical — Two Sudan
Cases — Egyptian and Sudan Cases — Fourth Sudan
Case — Summary — Acnowledgements- — References —
lUustratiotis.
Introductory. — Some years ago one of us, in con-
junction with Captain O'FarreU, R.A.M.C., demon-
strated the presence of Castellani's Bronchial spiro-
chcetosis in the Anglo-Egyptian Sudan, and these
observations were extended considerably from a
morphological point of view by Fantham working
on our Sudan cases. Since then this form of
bronchitis has become recognized as one of the
diseases of the Sudan.
Further studies during the last few years have
demonstrated the presence of Castellani's Broncho-
moniliasis and other forms of bronchomycosis in
the Sudan, and by the kindness of Dr. Farah, of
Alexandria, we have been able to establish its
presence in Egypt.
We think that some record of this disease as
seen in the Sudan and Egypt may be of interest,
and therefore we bring forward the following notes.
Historical. — Previous to Castellani's researches,
which began as far back as 1905 in Ceylon, the
subject of bronchitis received little or no study in
the Tropics, and it is entirely due to his initiative
that a number of causal agents have been recog-
nized and that the various diseases called Bronchial
Spirochsetosis, Bronchial Moniliasis, Bronchial
Oidiomycosis, &c., have been established as tropical
diseases. The last named disease has been fully
considered by Magalhaes in 1918. Restricting our
attention in this communication to Broncho-
moniliasis, as mentioned above, the history begins
with Castellani's observations in 1905.
In 1910 he pointed out that during six years'
residence in Ceylon he had met with twenty cases
of subchronic and chronic bronchitis which, on
superficial examination, might 1x3. thought to be
tubercular in nature, but iu which there wasi a con-
stant absence of the tubercle bacilli and negative
results with the ophthalmic and cuti-reactions. In
these, cases the spirochcetes of Bronchial spiro-
vhcetosis were also absent.
He divided the cases of primary infection into
those with a mild and those with a graver form of
the disease, while he also recognized a secondary
infection occurring in association with other ill-
nesses.
In the Primary Mild Type the patient complains
of cough and expectorates a muco-purulent sputum.
There is no fever and the general condition is good,
but examination of the chest may reveal the pre-
sence of a few moist rales.. In this type spon-
taneous cure may take place or the patient may
pass into the severe form.
In the Primary Graver Type the symptoms are
not unlike phthisis. -There is hectic fever, muco-
purulent and haemorrhagic expectoration, patches
of dullness, fine crepitations and pleuritic rubs.
This fonn is often fatal.
The treatment of both types is based upon the
fact that potassium iodide, in some form, kills
these fungi. Castellani advises that it be given
in 15 gr. doses in milk or water three times a day.
This treatment requires about 3 to 4 weeks to
effect a cure in mild cases, while Saiodin may also
be employed, being administered in cachets.
In 1913 Castellani drew attention to the possi-
bility of infection from man to man and from fungi
growing saprophytically in nature. Among these
latter he cites the monilia-like fungi which he found
in tea-dust in Ceylon. He also reports the suc-
cessful infection of a guinea-pig by regularly applied
insufflations of monilia cultures through the nose.
In March, 1917, Pijper published a valuable
communication upon the disease as seen in the
Transvaal, and continued this work in 1918 by
describing M. bethaliensis, which produces acid and
gas in glucose and maltose.
Castellani's latest remarks will be found on pages
1886 to 1889 of the third edition of the " Manual
of Tropical Medicine," written by himself and one
of us, and published this year.
Iu October, 1919, Farah, writing upon Broncho-
spirochffitosis as seen in Egypt, mentions the exist-
ence of broncho-moniliasis in that country.
So far as our literature in Khartoum goes this
completes a summary of the published communica-
tions on this subject, and in the references at the
end of this note we have put down all those with
which we are aequainknl. It will be observed that
we cannot quote any post-mortem observations.
Turning now to the botanical aspect of the his-
tory, we have asked ourselves the exact origin and
definition of the word Monilia.
We have expended a certain amount of time on
this inquiry, and we may definitely state with
regard to these fungi that, in our opinion, it is
useless to go further back than Saccardo's Sylloge
Fungorum, nevertheless we will give in small print
the results of our inquiries in case anyone be
interested therein.
The history of the genus Monilia begins in Micheli's Nova
Plantarum Genera which appeared in 1720. when he published
under the term Aspergillus two fungi, which he illustrated on
plate 91 in figures 3 and i. He describes the first as ;—
" Aspergillus albus, tenuisaimus, graminis dactyloidis facie,
aeminibus rotundis. In dimidiato et semiputrido Malo
Limonio dumtaxat cum vidimus."
The aecnnd he describes as : —
" Aspergillus terre^tris, cespitosus ac ramosus albus, Junio
mense, in Regio viridario supramemorato."
In the 12th edition of Linnaus' Systema Nalurce. of which
Vol. II appeared in 1767, these two fungi are named Mvcor
cespitosus on p. 727. In Gmelin's so-called IStli edition of
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 1, 1920.
Lintueus' Systema, of which Vol. II appeared in Leipsio in 1791,
these futigi together with Mucor crustaceus, Mucor glaucus and
Mucor leprosus, are made into a genus Monilia, and are joined
by other fungi described by Scopoli, by Haller, and in
BuUiard's Herbier -Htstoire des Champignons.
Now the first-mentioned form, and hence presumably the
type, is M. Crustacea, which was first described in 1757 in
Holm'a Flora Danica, and published in Vol. V, Aincenitates
Academics, which appeared in 1760, but this is not procurable
in Khartoum.
It will be noted that Micheli's genus Aspergillus was not
recognized by Linnaeus or by Gmelin.
We now come to Persoon's Tenlamen dispositionis methodicce,
which was published in Leipsic in 1797, and in which, on
page 40, Moniha is defined. This is the usually accepted
starting point for the genus {vide Saccardo and other authors).
We do not possess this work, but we have Persocm's Synopsis
ileOwdica Fangorum, published in 1801, where, on page 691,
he defines the geniis as " Stipitata, aut effusa byssoidea. Fila
moniliformia seu articulata." He divides the genera into
three groups, " Capitulum Rotundum," "Aspergillus," and
"Torula."
It is possible that all the forms mentioned above may be
ruled out of the genus as we know it except, perhaps, those
mentioned under Persoon's "Torula Subgroup," which is
defined as " Torula : effusa, acaulis, fills articulatis, indeter-
minate, efiusis mucidis," of which three species are recognized,
Monilia fructigena, Monilia herbarum, and Monilia aniennata.
The last named came under "Torula" when it was raised to
the level of a genus. Monilia is left, therefore, with two
forms, and as they are recognized as belonging to the genus
Monilia by Saccardo, M. herbarum might perhaps be accepted
as the type of Persoon's, but not of Gmelin's, Monilia as it
appears on page 25 of his " Observationes Mycologicse,"
published in Leipsic in 1796, as Torulo monilia, while M.
fructigena is placed on page 26, but neither have been studied
by modern methods, and therefore it may be advisable to take
a well known species as the type.
Now it is obvious that if the laws of botanical nomenclature
are pressed the name Monilia should disappear, as Gmelin's
species are probably either Aspergillus or Peuicillium, while
strictly speaking "T'orula" should apply to Monilia Jructigena
and M. lierbarum, but this will cause much confusion. Also,
perhaps, the genus as known to-day is neither Persoon's nor
Gmelin's.
We now come to Link's " Observationes in Ordines plantarum
naturales (Pungos tantum) Dissertation, I.," which appeared
in 1809 in the Magazin der Gesellschaft Naturforscliender
Freunde, 3 Jahrgang, Seite 1. We have been unable to refer
to this publication, hut we have in front of us Link's 1824
writing;, and we find that on page 16 of the " Observations "
he created the genus Oidium for his Oidium aureum, and that
his Oidium fructigena is marked with a note of interrogation
as being possibly Persoon's M. fructigena and Torula
fructigena, while he keeps Monilia antennata as his type of
Mmiilia, and later he uses Persoon's M. lierbarum as the type
of the genus Torula.
The next complication ^s introduced by Fries in 1829 when
he recognized Hill's Monilia, and quotes "Hill, ess p. 396,"
but this publication we have failed to trace. Be this as it
may, there is a consensus of opinion that the three species so
defined are not Persoon's Monilia. Bonorden accepts the Hill-
Pries genus.
If more modern works are searched the confusion outlined
above will be clearly noted. We have been unable to refer to
" Streinz (1862) Nomenclator Fungorum. Vindobona>," and
therefore cannot say whether this publication will throw any
light on the question at issue.
Gedcelst in 1902 recognized Hill's genus, but in 1911 went
back to Persoon's genus, of which in 1904 Gueguen gave a
good definition which is as follows :
" Conidiophores dresses simples ou subsimples souvent
denseraent rapprocb^s, rarementepars, emettant k leur sommet
une chainnette de conidies grosses, limoniformes. douvent
munies d'un appareil de disjonction."
From 1905 onwards there come the publications
of Castellani ah-eady referred to above.
In 1915 Chalmers and Archibald reviewed the
genus in their publication, " Fungi Imperfecti in
Tropical Medicine."
From the above it will be aeen that the greatest
confusion has arisen as to the meaning of the term
"Monilia "; in fact the words of Liunseus, in his
" Philosophia Botanic;i, 1751," page 241 —
"Fungorum ordo in opprobrium artis etianinum Chaos est,
ne.scientibus botanicis in his quid species, quid varietas sit."
may be quoted as referring to the monilia of to-day.
\Ve thei-efore follow Castellani and Chalmers in
tile third edition of their Manual where, on page
008, they are in accord with Vuillemin, who says
that Saccardo 's nomenclature should be the basis
for all fungi, and therefore we adopt Monilia Persoon
1797 as the name for present use, but we also adopt
the definition given on page 1079 of Castellani and
Chahners' third edition, viz. : —
"Monilia Persoon, 1797: — Oosporacea, possessing in situ
budding forms and mycelial threads, which later are often long
and branched, in nature with sporophores simple or subsimple,
producing by constriction at their extremity a chain of large
lemon-shaped spores, often provided with a disjunction
apparatus, in cultures producing mostly budding forms, but
sometimes filaments, in which thallospores of the blastospore
type are found and fermenting glucose, and often other
carbohydrate media with the production of gas."
The type species is most difficult to decide and
Monilia albicans (Ch. Eobin 1853) would be the
suitable form because it is well known and can
easily be studied, but according to Magalhaes,
Vuillemin has found asci in old cultures of this
parasite. If this is correct it will belong to the
-\.scomycetes, but Castellani has shown that there
are a number of formsi grouped under this name,
and therefore if it is taken to be the type it must
be used in the restricted sense defined by Castellani,
i.e., without asci, liquefying gelatine and clotting
milk, and forms which do not agree with this must
be considered as belonging to other genera.
Having now cleared the position of the fungus
and one of the diseases with which some of its
species are associated, we may turn to consider
the cases in the Sudan and Egypt from which we
obtained the fungi we are about to describe.
Sudan Cases. — The primary infections which we
have met with in the Sudan have, so far, belonged
to the mild type of the disease. The yeast-hke
organisms may, or may not, be found with ease
in the sputum, and figure 1 depicts their appearance
therein. We will now give a short account of the
common type which we have found in Omdurman
and Khartoum.
Omdurman Type. — The following case occurred I
in the practice of Dr. Haddad in Omdurman. The '
patient, a native of the Sudan, was taken ill on
■June 28 of this year, suffering from fever : tempera-
ture 103° F., severe cough, and profuse greenish,
foetid expectoration. On examination of the chest
moist rales were heard all over the lungs on both
sides. On the right side between the angle of
the scapula and the base there was some dullness,
iind crepitant rales were present, 'fh* sputum was
Jan. 1, 1920.] THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
sent to us for examination. No tubercle bacilli,
spirochaetes, or pneumococci could be found, but a
yeast-like organism was present which when grown
was found to be a monilia, as will be described
below.
The patient was treated with a mixture contain-
ing potassium iodide, and in the course of some
fifteen days became convalescent. ,
Organism. — With regard to the organism, it was
easily obtained in pure culture by inoculating a
tube of Sabouraud's maltose agar, picking oS a
surface portion of the resulting twenty-four hours'
growth and subinoculating on to another tube of
maltose agar.
The pure growth was diffuse, and white in colour
(fig. 3), and this could be obtained by aerobic and
anaerobic methods of cultivation.
When examined under the microscope it showed
typical yeast-like forms (fig. 2), which measured
from 5'6 to 8"4 microns in length and about
2'8 microns in breath, as well as longer or shorter,
straight or branched hyphae, usually about 2'1
microns in breadth, as depicted in fig. 4. Older
cultures, even up to eight weeks, never showed
any formation of asci.
This organism was Gram-positive but not acid-
fast.
It grew well on most solid laboratory media, in-
cluding potato, but preferred those with an acid
reaction or containing a sugar, and in all produced
diffuse whitish growths similar to fig. 3.
It grew on gelatine and inspissated ox-blood
serum, which it did not liquefy or discolour. When
grown in liquids, such as broth or peptone water,
the media remained clear with a deposit, while a
pellicle was produced in peptone water.
Its qualitative biochemical reactions may be
tabulated as follows : —
(1) Monosaccharide!' : —
(o) Hexoses. — Acid and gas in Glucose and
Lccvulose (Fructose), but no acid or gas
in Galactose.
(b) Pentose. — No acid or gas in Rhamnose
(Isodulcite).
(2) Disaccharides : —
No acid or gas in Maltose, Lactose or Sac-
charose.
(3) Trisaccharide :—
No acid or gas in Raffinosc.
(4) Polysaccharides: —
No acid or gas in Dextrin, Iniilin or A>nyltn)i
(starch).
(5) Alcohols: —
(o) Trihydric. — No acid or gas in Glycerol,
(h) Tetrahydric. — No acid or gas in Erythrol.
(c) Pentahydric. — No acid or gas in Adonitol.
(d) Hexahydric. — No acid or gas in Dulcitol
or Mannitol.
The acidity was tested quantitatively in all the
media mentioned above, but the only acid pre-
sent was that found in glucoco nnd lipvulose, when
the aninuiit o\pi"esspcl in cubic cciitiiuetres of
NjO KOH, after deducting any found in the
trols, was: —
Glucose
Lsevulose
2-1 c.c.
1-3 c.c.
It was, however, observed that if kept for any
length of time in liquid carbohydrate media, this
fungus was apt to produce aUtalinity, which of
course diminished the acidity found in the glucose
and laevulose media in proportion to the age of the
culture.
It produced neither acidity nor clot in milk,
which in the long run became alkaline. It did not
reduce nitrates, nor produce indol, while the Voges-
Proskauer reaction was negative.
It was insufflated into the nose of a guinea-pig
and a broncho-pneumonia produced,, from which the
animal died.
Classification. — It is obvious that the organism
which we are considering belongs to the subdivision
Fungacese Linnaeus 1737, because it has a vegetal
cellular structure without much differentiation, re-
produces by spore formation, and is without chromi-
diophores or chlorophyll.
As the vegetative body contains yeast-like cells
and filaments (figs. 2 and 4), it belongs to that
section of the Fungacese which is called Eumycetes
Schroeter 1892.
As the hyphse are not continuous in the vegetative
stage (fig. 4), and as the spores are neither enclosed
in asci nor in basidia, it belongs to the class Fungi
imperfecti Fuckcl 1869.
As its sporophores are not found in closed or open
receptacles it is placed in the subclass Hyphales
Vuillemin 1910.
As the mycelium is not composed of fine bacilli-
form hyphae (fig. 4), and as the spores are thallo-
spores, i.e., are in certain stages only portions of
the thallus secorxlarily adapted for reproduction
(fig. 2), it belongs to the order Thallosporales
Vuillemin 1910.
As the particular form of thallospore present is
developed from the summit (fig. 7) or sides of a
hypha by budding, it is classified in the suborder
Blastosporincic Vuillemin 1911.
As the hyphaj in certain stages are not manifestly
different from the spores, i.e., in the yeast-like
stage (fig. 2), while n carbohydrate-like glucose is
fermented, it belongs to the family Oosporacese
Saccardo 1886.
As there are numerous budding forms in cultures
(fig. 2), and as glucose is completely fermented
with the production of acid and gas, it is placed
in the genus Monilii l*ersoon 1797.
As gas is produced only in glucose and lievulose
it comes under the second group of the species of
Monilia, called the Kriisei group, and as it produces
neither acidity nor clot in milk it is recognized to
be Monilia krusei (Castellani 1909), synonyms
Saccharomyces krusei Castellani 1909, Endomyces
krusei (Castellani 1909).
It was first found by Castellani in the sputum
of cases of bronchornvcosis in Ceylon. In sputum
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
LJan. 1, 1920.
it has a yeast-like appearance (like fig. 1), but iu
cultures hyphae appear (fig. 4). Castellani hae
found that its characters remain constant after ten
years of subculturing.
The characters of the original strain resemble
those given above except that our variety, cultured
for several days, produced a small amount of
alkalinity, as mentioned above, in carbohydrate
media and formed a pellicle on peptone water,
which, however, are only minor points.
Khartoum Case. — This case is representative of
the mild type as seen in Khartoum. It occurred
in the practice of Dr. Malouf. The patient is a
native of the Sudan, aged about 25 years, and by
occupation a servant. He seems to have been
indisposed at times during the last three years.
An attack begins with fever (temperature about
103° F. and pulse rate about 120), associated with
a very persistent cough and a whitish frothy expec-
toration which becomes greenish on the second day.
When examined during such an attack moist rales
can be heard all over the chest. He was treated
with potassium iodide, with highly satisfactory
results.
When the sputum was examined during an attack
it was found to contain a fungus agreeing in all
particulars with that found in the Omdurman case.
Even the amount of acidity formed in glucose and
IfBvulose was comparable, being respectively 2'1 c.c.
and 0-9 c.c. in terms of N^O KOH.
The causal organism is therefore Monilia krusei
(Castellani 1909).
First Egyptian Case. — The case in question well
exemplifies the graver type of the disease. It
occurred in the practice of Dr. Farah, of Alexandria,
and as he intends to publish a full statement of the
case we will content ourselves with a mere outline
of the valuable and careful clinical and pathological
history which he has sent to us.
The patient is a well-to-do manufacturer, aged
about 57 years, who seems to have had hsemoptysis
for three days only when a young man and to have
remained free from chest symptoms until August,
1917, but since that date has suffered from a series
of attacks of fever associated with haemoptysis or
rusty sputum. During an attack the cough
becomes severe and is at first dry and associated
with fever, but after a few days the temperature
drops and an attack of hemoptysis occurs followed
by abundant rusty sputum, which, when carefully
examined by Dr. Crindiropoulo, of Alexandria, was
found to contain neither tubercle bacilli, pneumo-
cocci, streptococci, Castellani 's spirochaetes or
Paragonimus rinycri, b\it in which a yeast-like
organism of the Monilia type could readily be seen.
During an attack the patient, strange to say, does,
not feel very ill.
In the intervals between an attack and prior to
treatment the temperature seldom became quite
normal. These repeated attacks appear to have
caused some anaemia, as his erythrocytes numbered
4,500,000 per cubic millimetrp, while his haemo-
f,'lobin is only 5.5 per cent.
His leucocytes numbered 11,600, and were
divisible into polymorphonuclear leucocytes 73-5
per cent., mononuclear leucocytes 3-1 per cent.,
eosinophile leucocytes 2-0 per cent., lymphocytes
17'3 per cent., and transitional cells 4'1 per cent.
As regards physical signs, the left lung exhibited
a considerable area of dullness, with diminished
vocal fremitus in its upper part and aboUtion thereof
at the base. Subcrepitant rales could be heard
only in the axillary region. No friction sounds,
however, were noticed. The right lung does not
appear to have been affected at any time.
The patient was markedly improved by injections
of Lafay's Lipiodol, which was given in series of
daily injections of 2 c.c. for four consecutive days,
repeated after longer or shorter intervals. The
Monilia disappeared from the sputum under this
treatment and the patient was considerably bene-
fited, but the fungus reappeared after cessation of
the drug for some time and was followed by a slight
return of the symptoms, which are being ener-
getically treated on the above lines.
This is a very severe case and it is too early to
say what the result will be, but there can be no
doubt that Dr. Farah 's treatment has greatly re-
lieved the patient's symptoms, and probably pro-
longed his life.
Organism. — Culture* from the sputum were so
earefuDy sent to these laboratories that we had no
difficulty in obtaining pure growths on which the
following observations are based: —
The fungus grew well at 37° C. on acid and sugar
media giving rise to diffuse white growths (fig. 5).
At first we only observed yeast-hke fonns (fig. 6),
many of which were more or lees circular, while
others measured from 2'5 to 10-5 microns in length
by some 2"8 to 7 microns in breadth, but after a
time shorter or longer hyphae (fig. 7), measuring
about 1"75 microns in breadth, appeared but we
never observed ascal formation. The fungus is
Gram-positive but not acid-fast.
It grows well aerobically and anaerobically on
.solid and liquid media, but it does not liquefy gela-
tine or inspissated ox-blood serum, while broth and
peptone water remain clear with a deposit at the
bottom of the tube. No pellicle was formed on
IK-ptone water. It produces a thick white growth
u|)on potato (fig. 9).
Its qualitative biochemical reactions may be
tal)ulated as follows: —
/. Monosaccharides: —
(a) Hexoses. — Acid and gas in Ulucose and
Lsevulose (Fructose) but no acid or gas in
Galactose.
(/>) Pentose. — No acid or gas in Hhamnose
(Isodulcite).
//. Disaccharides : —
.^cid and gas in Maltose but no acid or gas in
Jjactose and Saccharose (for quantitative
determination in this sugar see below).
///. Trisaccharide : —
No .Tcid or rrfiR in BafJiiWKr,.
Jan. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
IV. Polysaccharides: —
No acid or gas in Dextrin (for quantitative
determination see below), Inulin or Amy-
lum (starch).
V. Glucose: —
No acid or gas in Salicin.
VI. Alcohols:—
(a) Trihydric. No acid or gas in Glycerol.
(b) Tetrahydric. No acid or gas in Erythrol.
(c) Pentahydric. No acid or gas in Adonitol.
(d) Hexahydric. No acid or gas in Dulcitol or
Mannitol.
The acidity was tested quantitatively in all the
media mentioned above and in tenns of N,0 KOH
was found to be as follows: —
Glucose 0'8 c.c.
Laevulose 0'6 c.c.
Maltose 0-9 c.c.
With regard to saccharose and dextrin only
0"1 c.c. was obtained and thie was considered to be
negligible as it would not appear in ordinary
methods of determining acidity.
The fungus did not reduce nitrates, produce
indol, or give the Voges-Proskauer reaction, while
it produced no acidity and no clot in milk.
Twice we have attempted to infect monkeys ;,{'
the species Lasiopyga callitrichus (I. Geoffroy 1851)
without success by repeated insufflations through
the nose and mouth.
The causal relationship to the disease seems to
be supported by Dr. Crindiropoulo's observations on
the positive agglutination and complement devia-
tion produced by the patient's eerum.
Classification. — By the process detailed above
under the Sudan cases it is possible to determine
that the organism in question belongs to the genus
Monilia Persoon 1797.
As it produces acid and gas in glucose, la&vulose
and maltose it belongs to the third group of the
species, viz., the pinoyi group, and as it does not
produce acid and clot in millk it is Monilia pinoyi
(Castellani 1910), synonym Endomyces pinoyi Cas-
tellani 1910.
This fungus was first found in the sputum of
cases of Bronchomycosis by Castellani in Ceylon in
1910.
Our variety agrees with Castellani 's original
organism in all details except the slight amount of
acidity obtained by quantitative methods in sac-
charose and dextrin, and therefore we conclude
that it is the same organism as Castellani 's Monilia
pinoyi.
Second Egyptian Case. — We have found exactly
the same organism in another Egyptian case of a
similar nature.
Third Sudan Case. — We have also met with M.
pinoyi in the Sudan in a milder case.
The quantitative sugar reactions of the pinoyi
strains may be of interest: —
Present
Present
Present
Sugar
Ca»e I
Case I
Glncose
0-8
0-8
Lsevuloae .
0-6
0-3
Maltose
0-9
10
All the other carbohydrate-alcohol reactions were
negative. In regard to saccharose and dextrin
only the firat strain produced traces of acidity not
exceeding O'l, and as the other two did not the
suggestion to treat this as negligible is supported.
None of the three strains produced acidity in
litmus milk, on the contrary all three strains even-
tually produced alkalinity. We may therefore con-
clude that we have demonstrated the presence of
Monilia pinoyi in the Anglo-Egyptian Sudan and in
Egypt.
Fonrtli Sudan Case. — The patient is a Sudanese
in the practice of Dr. Haddad, of Omdurman. Dur-
ing the last six months he has suffered from fever
at intervals and from profuse expectoration during
three months, but there has never been any haemo-
ptysis. Musical rales can be heard on both sides
of the chest and some crepitant rales about the
right apex. Repeated attempts to find the tubercle
bacillus by digestive and microscopical methods as
well as by animal inoculations have so far proved
negative, but there is a non-acidfast fungus, be-
longing to the Microsphonales, always present,
which so far has resisted all attempts at cultivation,
so that the Monilia infection may be secondary and
not primary.
Organism.- — Microscopical preparations naade from
the sputum and stained in the ordinary way showed
typical yeast-like bodies (fig. 1). Cultures were
made on maltose agar and from these pure growths
were in due course obtained.
The organism grew well both aerobically and
anaerobically at 37° C. as weU as at 22° C.
On maltose agar at 37° C, a circumscribed
raised white growth appeared (fig. 12). When
examined microscopically these cultures showed
numerous yeast-like bodies measuring from 5'6 to
9'8 microns in length and about 3"5 microns in
greatest breadth. Many filaments (fig. 11) were
also to be seen measuring about 2'8 microns in
breadth. The fungus is Gram-positive but not acid-
fast and grows well on solid and liquid laboratory
media, but prefers those with an acid reaction or
containing a carbohydrate.
It grows on gelatine at 22° C. and on inspissated
ox-blood serum at 37° C, but it does not liquefy
or discolour these media. When cultivated in broth
or peptone water it does not form a pellicle. Its
qualitative biochemical reactions are as follows: —
/. Monosaccharides : — •
(a) Hexoses. — Acid and gas are produced in
Glucose and L«Bvulose, but not in Galac-
tose.
((») Pentose. — No change is made in Rhamnose
(Isodulcite).
II. Disaccharides : —
There is no change in Maltose or Lactose, but
acid and gas are produced in Saccharose.
III. Trisaccharide : —
There is no change in Raffinose.
IV. Polysaccharides: —
No change is produced in Dextrin. Innbn or
Amylum.
THE JOUKNAL OF TEOPICAL MEDICINE AND HYGIENE. [Jan. 1. 1920.
Y. Glucoside: —
Salicin undergoes no fermentation.
T-7. Alcohols: —
No change is produced in Glycerol, Erythrol,
Adonitol, Dulcitol or Manuitol.
The quantitative amount of the acidity produced,
represented in the usual terms, was: —
Glucose 2-0 c.c.
Lasvulose 0-6 c.c.
Saccharose ... ... ... 2'0 c.c.
Compared with the quantitative results given by
other Monilias at the same time in the same batch
of reagents the amounts in glucose and saccharose
are high.
With regard to the biochemical reactions the fun-
gus produced acid and clot in milk and reduced
nitrates, but did not form indol or give the Voges-
Proskauer reaction.
Classification. — It is sufficiently obvious that the
organism belongs to the genus Monilia and as it
produces acid and gas in Glucose, LaevuJose and
Saccharose and in no other such reagent it is to
be placed in Group VI. The Guillermondi Group,
which contains only two species, M. guillermondi
and M. pseudoguillermondi.
They are distinguished from one another by their
reactions in milk in which M. guillermondi produces
either no change or aUcalinity and M. pseudo-
guillermondi gives rise to acidity and clotting.
As our organism produces acid and clot it is M.
pseudoguillermondi, and this is supported by the
fact that it does not produce slight acidity in mal-
tose or acidity in g.ilactose which M. guillermondi
does.
Summary. — The point which we have endeavoured
to demonstrate in this note is that Bronchomycosis
in the form of Bronchomoniliasis exists in the
Anglo-Egyptian Sudan and in Egypt as a primary
infection in its mild and severe forms and also a
secondary infection. Further, we have demon-
strated the presence of Monilia krusei (Castellani
1909), Monilia pinoyi (Castellani 1910), and Monilia
pseudoguillermondi (Castellani 1916), in cases of
disease in these countries, and we are of the opinion
that further researches in these and other tropical
and sub-tropical, and even perhaps temperate,
climates may reveal that Bronchomycosis in some
form is not rare.
With this idea in front of us it may perhaps be
admissible to invite especial attention to the method
of diagnosis which we adopt.
Diagnostic Methods. — The first essential is to
obtain the sputum as fresh as possible from patients
who have washed their mouths thoroughly with
boiled or sterilized water.
This fresh sputum is first examined for Castel-
lani's Bronchial Spirochcetes by means of dark
ground illumination, or in the case of out-stationsi
by dried films of the fresh sputum being forwarded
to the laboratories, where they are stained by Tri-
bondeau's modification of Fontana's silver method
of demonstrating spiroclisetes. The sputum is also
submitted to simple microscopical examination with
a view to the exclusion of lung parasites, such as
Paragonimus ringeri (Cobbold 1880).
The sputum (preferably the twenty-four hours'
collection) is digested in 3 per cent, solution of
caustic soda at the temperature of the laboratory
90° to 100° F.) for twelve hours and then centri-
fuged. Films are then prepared from the deposit
and stained by one of the usual methods of demon-
strating acid-fast bacilli. By this procedure the
tuberele bacillus and the acid-fast species of Nocar-
dia may be distinguished. In place of this method
a similar procedure described by Greenfield and
Anderson in the Lancet of September 6, 1919, may
be adopted. In special cases we always inoculate
a guinea-pig so as to definitely exclude tuberculosis.
Cultures are also made for the purpose of diScren-
tiating the tubercle bacillus and the Nocardias.
Other films of the fresh sputum are coloured by
Leishman's and by Gram's methods with the intent
of reveaUng the presence of the non-acidfast species
of Nocardia and of yeast-like fungi.
In the meanwhile cultures of the fresh sputum
are made upon Sabouraud's maltose agar and the
twenty-four hours old growth examined for yeast-
like organisms which, if present, are subinoculated
on to other slants of maltose agar in order to obtain
pure cultures. It is easy to define a Monilia when
isolated by this method.
Causal Agency. — That the organism is related to
the disease may at times be supported by agglutina-
tion, and complement deviation experiments with
the patient's serum and by animal infections, but
not always. Secondary infections also occur.
Treatment. — The sheet anchor of the treatment
is potassium iodide by the mouth or its equivalent
in the form of intramuscular injections of which
Lipiodol as used by Dr. Farah certainly deserves
an extended trial in severe cases.
Post-mortem Examination. — Post-mortem obser-
vations are still required to complete the history of
the disease.
Acknotvledgments. — -We beg to acknowledge
gratefully the kind assistance given to us in this
work by Dr. Farah of Alexandria and by Drs.
^lalouf and Haddad of the Anglo-Egyptian Sudan.
REFERENCES.
Ca&tfllani (1905 and 1911). "Ceylon Medical Reports.'
Colombo. (1910.) British Medical Journal, ii, p. 818. London.
(1910.) Philipinve Journal of Science, B. V, 197. Manila.
(1911.) Centralblalt fur Bakteriologie.l, O, Iviii, 230. Jena.
(1911.) "Report of the Advisory Committe- for Tropical
Diseases for 1910," pp. 76 and 93. London. (1912.) British
Medical Journal, ii, p. 1208. London. (1913.) JoUBNAr, of
Tropical Medicine and Hygiene, xvi, p. 102. London.
(1917) Ibid., XX, pp. 211-213. London.
Ca TELLANi and Chai MERS (1919). " Manual of Tropical
Medicine," third edition, pp. 1079-1092 and 1886-1889.
London.
Chalmers and Archibald (1915). "Fungi Imperfect! in
Tropical Medicine," pp. 18-23. Loudon.
Farah (1919). Lniiccr ii, p. 608. October 4. London.
PijPF.B (1917). Medical Journal of South Africa, xii, p. 129.
Johannesburg.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
January 1, 1920.
To illustrate paper on " Bronchoraoniliasis in the Anglo-Egyptian Sudan and Egypt," by Ai.iir.BT
M.D., P.K.C.S., D.P.H., and Nobman Macdonald.
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
Januaby 1, 1920.
9)
f 9 h
Fig. 2.
X
r
v^
To illustrate paper on " Some Observations on Vibriothrix zeylanica, (Castellani)," ty Ludwik Aniostein, M.D., Ph.D.
Jan. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Illdstratioks.
Fio. 1.— Yeast like forms of Monilia pseudoguillermondi as
seen in sputum after staining with thionin blue. Photomicro-
graph X 400 diameters.
t'lQ. 2. — Mtmilia krusei. Yeast like forms from a twenty-
four hours old culture on Sabouraud's maltose agar at 37° C.
Photomicrograph x by 400 diameters.
FlQ. 3. — Monilia krusei. Culture on Sabouraud's maltose
agar at 37° 0. for four days. Photograph about natural size.
Fio. 4. — Monilia krusei. Hyphie and spores from a seven
days' culture in peptone water. Photomicrograph x 400
diameters.
Fio. 5.—Mo}iilia pinoyi. Culture on Sabouraud's maltose
agar at 37" C. for four days. Photograph about natural size.
Pio. 6. — Monilia pinoyi. Yeast-like forms from a twenty-
four hours old culture on Sabouraud's maltose agar at 37° C.
Photomicrograph x 400 diameters.
FiQ. 7. — Monilia pinoyi. Yeast-like forms with commencing
hyphae from a twenty-four hours old culture on Sabour.iud's
maltose agar. Photomicrograph x 400 diameters.
FiG. 8. — Monilia pinoyi. Hyphae from culture on Sabouraud's
maltose agar after three and a half months' growth at 37° C.
Photomicrograph x 1,000 diameters.
Fig. 9. — Monilia pinoyi. Culture on potato at 37° C. for
seven days. Photograph natural size.
Fig. ih. — Monilia pinoyi. Hyphae and spores from a seven
days old culture in peptone water at 37° C. Photomicrograph
X 400 diameters.
Fio. 11. Monilia pseudoguillermondi. Hyphae and spores
from four days old culture in peptone water. Photomicrograph
X 400 diameters.
Fio. 12. — Monilia pseudoguillermondi. Culture on Sabou-
raud's maltose agar at 37" C. for four days. Photograph about
natural size.
OBSERVATIONS OX VIBBIOTHRIX
ZEYL.^Nir.A (CWSTELLAXI)
By LuDwiK Anigstein, M.D., Ph.I>.
Thk opportunity of investigating a strain of
Vihriotlirix zcylaiiica was given to me by Professoi-
-\lflo Castt'llani, who some time ago kindly offered
to the Central State Epidemdological Institute in
Warsav,- a collection of very interesting cultures of
bacteria prevalent in tropical countries. Castellani
isolated " Vibrinfhrix xpylanicn " from dysenterii'
faeces in 1904.
The several synonyms of this organism {Spiro-
bacillus xeylanicua, Spirillum zeylanicum, Vibrio
zeylanictis, Vibriothrix zeijlanica) tend to show that
it has not yet found a definite place in the classi-
fication of vegetal organisms. Its classification is
difHcult owing to its peomorphism as well as to tiie
fact that important morj)hological oharacteristifs
\ have not been defined clearly until now.
I The organism, which is very motile, gives an
I abundant growth on ordinary agar, in dextrose
agar, in broth and in 1 per cent, peptone water.
- In liquid media a pellicle is formed on the surfaco,
while the liquid ifcseli becames turbid after twenty-
four hours at 37° C. A precipitate consisting of
the Ijacteria is formed at the bottom of the tubes.
On agar plates round, transparent, bluish colonies
{appear, which closely resemble colonies of B. sliiga
— a faet to which attention was drawn by Castel-
lan: in 1910. The larger colomeB lose in time their
transparency and become greyish in tint.
Under a magnification of 28 diameters a diversity
in shape of the colonies can be noted. The surface
of the small semicircular ones is smooth, the edges
are usually straight, sharply indented. Some of
the smaller colonies present wavy edges. The
larger colonies assume a crater-like shape (fig. la),
while some of them are flattened or even concave
(fig. lb). The shape of the colony can best be
observed by reducing the lighting of the microscopic
field under a magnification of 28 diameters, in re-
flected but not in transmitted light. From the
standpoint of structure the colonies may be
described as small-granular uniform with darkened
centre and clearer edges. On gelatine plates the
.smaller colonies appear as transparent droplets
with la bluish tint; but in general the colonies
formed on gelatine after six days at 22° C. seem
smaller than on agar. They are uniform in appear-
ance in so far as they are all semicircular with a
regular sharp edge and a smooth surface.
Biochemical Properties.
On Endo plates colonies of the vibriothrix do not
differ from those of B. sliiga and B. typhosus in
so fai- as there is no change in colour. The fer-
mentative properties of this strain have been
described already by Castellani (1909). I can only
confirm the fact that neither gas nor acid is formed
in either mannito, maltose, dextrose, lactose or
saccharose. In fact, the contrary action, i.e., the
pi'oduction of alkali can be noted. Indol is not
produced (Kitasato-Salkowski method). Gelatine is
not li(]ue<fied after seventy-two honrs.
Morphology.
The examination in a hanging drop shows a very
actively motile organism. One notes a forward
movement comliined with a rotation round the axis
of the organism.
When observed in dark field examination (Zeiss
ajxK-hr. immersion, 1-5 mm., oc. 12) the rods show
the presence of an intracellular very retractile polar
granule. At times I succeeded in observing ultra-
microscopically a fairly rapid rotation round the
transversal axis of the rod. The above described
somewhat complex active movements suggested the
presence of definite organs of motility in the shape
of cilia or flagella, though the dark field examination
<lid not show the presence of any such organs.
In dried smears fixed by heat .or methylated spint
and stained by either gentian-violet, crystal-violet
or carbol-fuchsin, the organisms appear as uni-
foi-mly stained slender bacilli, at times somewhat
curved. They are stained best by crystal-violet
(Benda) or by fuchsin. Side by side with the
slender bacilli there may be noticed shorter forms
considerably thicker and more deeply taking the
stain. The first impression Ls that the culture
might be impure. Any such doubt is however dui_
jielled by using the classical method of Koch ot
THE JOURNAL OF TKOl'ICAL MEDICINE AND HYGIENE. [Jan. i, J920.
fractdonated plating. Castellani himseli has drawn
attention already to the fact of this pleomorphy.
He has also mentioned the appearance on forty-
eight hours' slant agar cultures, and particularly on
the surface of broth-cultures, of long threads which
resemble spirilla by their slow wavy movements.
We shall learn presently that these threads consist
each of a number of bacilli. In the older culturesi
the pleomorphy is most accentuated and globoid
bodies can be observed (" formes coccoides " Cas-
tellani, figs. 5, 6). These cannot be spores, for
they are all destroyed by the temperature of 60° C.
three minutes.
Ill tile selection of a technique for the study of
the iiiiirpliMl,,,'y of this strain I was guided by a
fuiiilanieiital a^:sumption, that the vibriothrix must
be endowed with organs of motihty. By fixing the
organisms while still alive I tried not to -damage
those assumed delicate formations. My technique
consisted in the following: I took a minute par-
ticle of the growth on a slant agar tube with a
platinum needle and I emulsified the material in
one loopful of tap-water on a slide. I then mixed
this emulsion with a drop of wat-er containing 2 per
cent, asmic acid in a proportion of 3 to 1. After
some ten seconds the emulsion was snieari-d on
cover-slips which had previously been tlaimil All
further procedures were carried out scnipulonsly
according to the silver-impregnation method of
Zettnow, as described in the " Lehrbuch der Bak-
teriologie," by Lurhvig Heim, 1918, Stuttgai't,
p. 184.
The first trials were crowned with results which
entirely supported the fundamental assumption.
The majority of the bacilli were shown to possess
one polar flagellum, while others exhibited one or
two ciha at each pole (fig. 3). Only a few organ-
isms did not show these formations. A great manj'
cilia appeared free in the microscopic field, detached
from the bacterial bodies. As regards the threads
resejnbling spu'illa or spirochaetes (figs. 3, 5), in
some of them there was at one end a darkly stained
granule (basal body). One can notice in well-
stained slides (Zeiss apochrorn. 2 mm., oc. 12)
that the fi'ee cilia consist of a number of minute
granules in the form of beads. It has been men-
tioned that individual organisms with two cilia at
each end may be met with. In particularly suc-
cessful shdes I was satisfied that I could see at
every pole three to four cilia in one bunch (fig. 6).
It is difficult however to find out their correct num-
ber owing to their extreme fragility and of the ease
with which they become detached from the bac-
terial bodies. It is possible that the number ex-
ceeds four.
The cilia are also present round the globoid
bodies. I have noted some of these with two cilia
on a joint basis (fig. 6). Such bodies, though not
ciliated, were described by Almquist (2) in the
course of his studies on B. shiqa. He designated
them by the name of " Conidia," assuming that
they represented foi-ms of evolution which appeared
in vitro under imusiial conditions. It is obvious
that the motility of previously mentioned threaded
rod formations is due to the presence of the cilia.
Amongst those elongated forms one can notice in
silver-stained preparations also some relatively short
ones with uniform contents, while others appear
considerably longer and consist of a series of bacilli,
touching each other pole to pole. These threads
are surrounded by a membrane which appears as
a dark contour and figs. 4 and 5 show such fonns
consisting of several bacilli with a gap in their
continuity, just as if these threads were empty at
places. Other threads (fig. 6) consist of a series
of bacilli sohdly filling up the whole thread. One
may assume that these threads are either forms of
evolution or involution. In the latter instance one
should expect their plentiful presence, particularly
in old cultures, yet I have seen no elongated forms
in ten weeks' old dried up slant agar cultures.
Obviously it is difl^cult to settle this question on
the ground of the above incomplete observations,
but one may suggest that the threads represent
one of the forms of evolution of this organism.
The xnability of vibx'iothrix at the room tempera-
ture (10-14° C.) is fairly long, for abundant gi'owth
may be obtained on slant agar after eighteen hours'
incubation when inoculated from a ten weeks' old
dry agar culture. In fresh cultures the bacilli
have a normal appearance, all of them showing the
presence of cilia. On the other hand, in the ten
weeks' old cultures there are numerous deeply
stained polar bodies, the protoplasm of the majority
of the baciUi being somewhat contracted. Prac-
tically all the bacillary foi-ms were provided with
cilia. In old cultures I have not observed any
elongated forms.
To summarize the morphological characters, the
vibriothrix may be described as a pleomorphic
highly motile organism, provided wdth a membrane,
with a bunch of cilia at each pole. There are' no
true spores and the organism has a tendency of
growing into long bacillary forms or into threads
consisting of a series of rods. It is Gram-negative.
The following table showTS at a g'lance the princi-
pal morphological and biochemical characters: —
Length in ;i 1-5— T'O
Cilia +
Gram
Growth :
Aerobic -f
Anaerobic -
Liquefaction in gelatine -
Growth in broth :
Turbidity -f
Pellicle -f
Spores ... ... ... ~
Indol
Fermentative action on sugars and other carbo-
hydrates -
With regard to the toxicity and pathogenicity of
the strain, it did not prove toxic in any way to
laboratory animals and so far all experimental evid-
ence as to its deleterious effects on man is lacking.
This confirms the results obtained by Castellani.
There remains to be investigated whether or not
vibriothrix plays any role in secondary changes in
Jan. 1, li>20.] THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
dysentery as, for example, in the formation of the
ulcers. This germ should be looked for, particu-
larly at the present moment, when lai'ge bodies of
allied troops are returning from tropical or sub-
tropical countries. The practical bacteriologist
should bear in mind that the colonies of vibriothrix
on superficial examination may be mistaken for
those of B. dysenterix Shiga.
The. two organisms however can be easily dis-
tinguished by the vibriothrix not fermenting any
sugar, being very polymorphic and by being motile,
and final proof may be obtained by using the silver
staining method of Zettnow. It must be em-
phasized that the cilia to which the motility of
vibriothrix is due are so extremely delicate that
dark groun<l examination does not bring them into
evidence.
BIBLIOGRAPHY.
1. — A. Castellani. Journal Ceylon Branch British Medica/
j Association, 1909 ; Philippine Journal of Science, vol. v. No. 2,
I Section Medical Sciences, Julv, 1910 (p. 206).
2. —A. Castellani. V. Spagnolo et C. Rosso. " Quelques
I observations sur le Spirobacillus zeylanicus Cast." Bulletin
I de la Societede la Patlwloqie exotique. T. xi. 1918. Nr. 4.
3 — Kolle-Wassermann. " Handbuch der pathogenen Mik-
roorganismen," 1913. Bd. iii, p. 915.
i. — LuDwiG Heim. "Lehrbuch der Bacteriologie," Stutt-
gart, 1918.
5.— F. E. Tatlob. "On the Spirobacillus zeylanicus"
(Castellani). Journal of Pathology and Bacteriology, vol. xxii,
jj(1919).
[I EXPLAKATION OP THE PlATE.
!Fig. 1 (a, b, c, d.)— Various colonies of Vibriothrix on agar-
I plate after twenty-four hours' incubation. Magnification 28
,diam.
Fig. 2 (e, f,g, h.) -Colonies of Vibriothrix on Endo-Agar plate
after twenty four hours' incubation. Magnification 28 diam.
Fig. 3. — Vibriothrix Z. silver impregnation method (Zettnow).
Isolated cilia, one with a polar (basal) body. Bacillary forms
on slant agar culture after twenty-four hours' incubation.
Pig. 4. — Elongated bacillary form. Thread forms and
bacillary form with polar bodies. Bacillary forms on slant
agar culture after forty-eight hours' incubation (Zettnow
method).
Fig. 5.— Globoid forms. Next to them isolated cilia. Long
thread forms (Zettnow technique).
Fig. 6. Bacillary and globoid forms with cilia. " Thread "
consisting of a series of bacilli. In some places cilia between
the rod like forms (Zettnow technique).
Magnification of figs. 3, 4, 5, 6; 1,500 diameters (Ze
iimers.-apochrom., 2 mm., Comp.-Ooul. 12).
flotircs.
Protein Therapy of Typhus (F. Opazo, Hevista
Medica de Chile, August). — This method was ap-
plied in twenty-seven cases of typhus, with four-
teen recoveries, four in convalescence and seven
still under treatment; two of the patients died, but
the disease in their cases had reached a stage
wlifn reaction was no longer possible. Protein
therapy induced a favourable reaction which modi-
fied the disease and all the symptoms. The reaction
was prompter and more effectual in children than
in adults. Protein therapy is the routine treatment
ill rill cases of typhus.
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THE JOURNAL OP
Cropf cal S^thitint and I^pgiene
.lANIIAKV 1, 1920.
Thk Journal ok Tropical Medicine and Hygiene
enters its twenty-first year to-day. It was con-
ceived, statute*!, and edited and financed by Mr.
(now Sir) James Cantlie in 1890; curiously enough,
the same year as the London School of Tropical
Medicine was opened, preceding that important
10
THE JOURNAL OF TllOPICAL MEDICINE AND HYGIENE. [Jan. 1, 1920.
event by a few months only. It was the first
journal of the kind ever instituted, and has had
many imitators. Sir James carried the idea to
many markets before he took upon himself the
issue and the financial responsibility. He went to
several publishers asking them to take the proposal
up, but one and all said it was too great a risk,
and that the subject was too limited in its scope
to justify or require a journal of its own. He then
went to the two leading medical journals in Britain
and got the same answer, and was told that the
best that they could do would be to publish an
occasional Tropical Supplement to their issues con-
sisting of four pages. Other medical journals
were approached, but they also declined, chiefly
on the score of finance. Disappointed in his
endeavours, he revisited each of the pubLishei's and
proprietors of the journals to whom he had given
the opportunity, and announced that as he could
not find a publisher he meant to publish the
Journal himself, and hoped that they would not
denounce the idea because it might tread upon
their preserves. Some of them indeed gave
fi-iendly advice in the matter, and he was warned
that he would certainly incur a serious financial
loss to begin with at any rate, which perhaps might
prove ruinous in course of time. But, as Sir James
himself put it, " Fools step in where, &c.," and
without further ado proceeded to bring out the >
first number. It was, to begin with, a monthly
Journal, and for some two years it remained at
that. John Bale, Sons and Danielsson were en-
trusted with the printing and publishing, but they
bore no monetary risk. Sir James paying all the ex-
penses in launching, printing, and carrying on the
production. It was altogether a bold undertaking
and a grave financial burden that the founder
shouldered, but those who know him ai-e well
aware that it was not the first, nor yet the last,
scheme of the kind he has brought forward,
cherished, established and carried to a successful
issue; and in which financial matters were the last
thing thought of or considered. His argument has
always been, " It is a national duty that so-and-so
be done, it i'. somebody's duty to do it, and if
nobody will take it up, I will do it myself."
During the early days of the Journal Dr. W. J. R.
Simpson, C.M.G., was an active help; in fact, Sir
James waited for several months until Dr. Simpson
came home from Calcutta, where he had been
Editor of the hidian Medical Gazette for some
years, and as the literature produced in that journal
was akin to that hkely to occupy the pages of the
proposed Journal of Tropical Medicine, Sir James
believed that he would be a most efiicient help
to liim. Nor was he mistaken ; for Dr. Simpson —
now Professor Simpson, C.M.G., of King's College,
London, and Lectiurer in Tropical Hygiene and
Sanitation in the London School of Tropical ^ledi-
cine — proved a standby of incalculable value. The
Journal proved fairly successful, but tropical medi-
cine was not so appreciated nor so " fashionable "
as it now is, and the circulation was limited to a
degree. The number of copies after a time failed to
show an increase; the advertisements by which, as
we well know, most medical journals practically
exist, were few; and it was difficult to persuade
business men to come forward, as the number of
copies i&ejit out had to be guaranteed, and the small
number in circulation was a serious detriment. The
future of the Joimial at one time seemefl so hopeless
that the friends of the founder advised him to give
it up altogether before worse befell him. I\Iost men
would have listened to their evidently kind and
honest advice; not so Sir James. The threatened
ruin had the opposite effect, for instead of giving
it up he proceeded to double the output, and
in place of bringing out the Journal once monthly,
he decided to publish it twice monthly : taking
a gambler's chance, it may be said — neck or
nothing. But the founder had had a long experi-
ence of inen and matters, and what seemed reck-
lessness to othei"s is but in accordance with the
experience of many men who, when the venture
succeeds, are credited with foresight, perspicuity
and all the attributes associated with ventures of
successful men. This venture came under this
category, and the Journal flourished from thence
gradually and assuredly.
Yet another scheme brought forward by Sir
James Cantlie enters into the tale of this Journal
and its future. It was none other than the forma-
tion of a Society of Tropical Medicine and Hygiene
for Bj-itain and the Empire, to be a centre of
information and a focal point at which men
engaged in tropical practice might bring forward
their ideas, reports of their doings, and afford a
channel of discussion to all interested. Sir James
drew up the constitution, this being the usual
rules appertaining to societies of the kind, and
named the first officers of the Society. With his
usual magnanimity he left out his own name, and
was content, as was his wont, to set the thing
a-going. The officers appointed set to work to
draw up new rules, so-called, which when com-
pleted were but facsimiles of the initial scheme in
every detail, even to the names of the men who
occupied the posts of the officers of the Society.
The expenses of the newly formed Society were a
serious question to begin with, until Sir James
came forward and offered to publish the Trans-
actions of the Society free of charge in the Journal
OF Tropical Medicine, and for twelve months this
was done. At the end of that period, however, the
Society published its own doings, and any possible
benefit that might have accrued to his Journal
was annulled and lost. It became evident to
Sir James that it was hopeless to conduct a " one-
man journal," as the Tropical Journal was styled,
any longer. That the usual feelings, natural to
mankind, would arise and interfere was certain,
and they were soon forthcoming. Well aware
of the feeling, Sir James determined for the sake of
the Journal to part with the cherished child of his
creation. He disposed of the proprietorship of the
Journal to Messrs. John Bale, Sons and Danielsson,
1, lb20.] THE JOUKNAL OF TKOPICAL MEDICINE AND HYGIENE.
of Oxford House, Great Titchfield Street, London.
They had been kindly helpers and publishers
from the first beginnings of the Journal, and he
parted with it to them, knowing that it was pass-
ing into the hands of a firm of honest men, and
one likely to carry on the furtherance of the subject
he had at heart. The terms were simple. He
invited Messrs. Bale to take it over, if they chose,
at whatever price they thought was likely to be
advantageous to them, that he was willing to
accept their own valuation, and, as they alone
knew what the Journal was worth, that the trans-
action be wholly left to them, and any sum
they offered would be right. The only remon-
strance Sir James made was that he thought hia
kind friends, Messrs. Bale, were too generous to
him, and that their friendly feelings had outrun
their commercial mstincts. By this time other
publishers were nibbling at tropical publications of
a similar nature and threatening to swamp Sir
James's effort, which, of course, was not without
its detractors. He offered to withdraw his name
from the title-page in the hopes that the " one-man
journal " idea might be stifled and allayed. This,
however, the new proprietors demurred to, and
persuaded him to continue in his editorship. By-
and-by other names began to creep into the
group of the editorial staff as well as that of Pro-
fessor Simpson, whose magnanimous help in early
days remained. Sir Patrick Manson found it
necessary, on taking up his appointment at the
Colonial Office, to remove his. Dr. G. C. Low
came on to the staff and afforded ready and most
efficient help ; and the heading on the front page
of the Journal shows that several others of the
great names in tropical medicine lent their active
aid or their important names to the Journal.
The words " akd Hygiene " were added to the
original title of the Journal really to meet the name
given to the newly raised Society of Tropical
' Medicine and Hygiene, and for other reasons which
can be readily guessed at. The readers of the
I Journal will no doubt appreciate the interesting
1 account here set forth ; given before the tale is
j altogether forgotten or those concerned in it have
left but a memory behind them. It seems expedient
therefore, on this the twenty-first year of publica-
tion, to recount the early days of the Journal, which
will flourish whilst tropical medicine attracts and
exists as a vital part of the world's scientific work.
Two important names have been ranged along-
side of the original founder with the issue of
January 1, 1920— namely, Dr. Aldo Castellani and
J)i. Albert J. Chalmers. This is as it should be,
.showing that younger men of world-wide reputation
are taking up the cause of the tropical journal, and
with the accumulated knowledge daily accruing
alons new lines of extended investirration the staff
I should be made more virile and varied.
M. B. C.
Annotations.
Filarial Periodicity.— In the Journal of the Amer.
Med. Assoc, of September 6, 1919, Lynch gives
the results of some interesting experiments which
in his opinion tend to confirm Rivas' mechanical
theory of filarial periodicity. Rivas, as is well
known, believes that the presence in large numbers
of Microfilaria bancrofti in the cutaneous capillaries
at night, principally from midnight to 8 a.m., is due
to the gradual resumption of capillary tone, delay-
ing the microfilariae at the periphery, where they
accumulate until they finally get through and are
held up again in the pulmonary capillaries. Lynch
has noticed that the administration of a dilator,
such as nitroglycerine, causes a decrease in the
number of microfilariae in the peripheral capillaries
during the period of prevalence, while the adminis-
tration of a constrictor, such as epinephrin, has the
opposite effect.
Leprosy in Uruguay (J. Brito Foresti, Revista
Medica del Uruguay, January, 1919). — Leprosy is
comparatively common in all South American coun-
tries except Chile. In Uruguay there are nearly
200 lepers in a population of a little over 1,300,000.
In the author's experience chalmoogra oil and
ichthyol are very beneficial, but in the acute febrile
periods salicylate of soda should be administered.
Skin Diseases among the Porto Rican Troops
(Herman Goodman, New Orleans Medical and Sur-
gical Journal, vol. 72, No. 6, December, 1919).—
The author has examined 7,000 men among the
troops stationed in Porto Rico for presence of skin
diseases. He) has observed two typical cases of
yaws, in which Treponema pertenue Castellani was
found. Tinea flava, vitiligo, nevi, pyodermia and
Tinea cruris were common affections. Alopecia
areata was found once. Keloids were not frequent,
and of psoriasis he sav? only one case.
A Year's Experience of a Severe Epidemic of
Malaria in the Mitidja (Algeria) (I nne Sergent,
Bull, de la Soc. de Path. Exotique, vJ. x, No. 7,
1917). — Quinine has been systematically adminis-
tered to the natives since 1906. Four or even two
8-gr. doses weekly give good results imder normal
conditions; but, during a severe epidemic, a daily
course is more effective.
On the Rarity of Phlyctenular Conjunctivitis in
the Algerian Aborigines (L. Parrot, Bull, de la
Soc. de Path. Exotique, vol. xi. No. 7, 1918).—
During ten years in Algeria the author only twice
saw conjunctival vesicles, though pediculosis of the
scalp, " scrofula," and impetigo are rife among the
juvenile population. His experience and that Jof
other writers fails to confirm P. de Font R^aulx's
hypothesis that Pediculua capitis is the" causal agent
of phlyctenular conjunctivitis.
12
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. ,Dec. 1. 1920.
Note on Arrested Development and Infantilism
of Malarial Origin in Algeria (H. Foley and L.
Parrot, Bulletin de la Soc. de Path. Exotique,
vol. xi. No. 10, 1918). — Though malaria causes
few deaths among the native children, the dys-
trophic effects of the infection are strongly manifest.
Latest investigations show that wherever malaria
prevails in Algeria pseudorachitic and temporary or
permanent infantilism are found. In earliest in-
fancy the dystrophy is shown in general backward-
ness and enormous development of the abdomen in
contrast to the emaciation of other jiarts : the
typical symptoms of true rachitis are absent. In
later childhood the same characteristics prevail and
growth is much below normal. As puberty (often
considerably delayed) approaches, the general con-
dition improves, the symptoms of infantilism
disappear, and the splenic hypertrophy abates;
growth is rapidly resumed in many cases, in others
it is long retarded, while in some the arrested
development is permanent.
€uxunt •Citfrntnrf.
Annals of Tropical Mkdicine and Parasitology.
Vol, XII 1, No. 3, December 19, 1919.
Coincident Malaria and Enteric Fever (Henry
Harold Scott). — The author calls attention to cer-
tain peculiarities which he has noticed in cases of
coincident enteric fever and malaria. In his ex-
perience such cases generally run a mild course, and
recovery is more rapid than in the case of either
affection separately.
The Metabolism of White Races living in the
Tropics: Composition of the Urine (William John
Young). — According to the author's researches in
North Queensland the daily volume of urine ex-
creted is nnich less than in Europe, the specific
gravity higher, while the freezing point is approxi-
mately the same. The quantity of sodium chloride
excreted in the urine is very low. The total nitro-
gen also shows a lower figure than that found in
Europe, and this cannot be explained by loss of
nitrogen from the skin, which amounts only to 1
or 2 grm. daily. A trace of albumin is frequently
present, especially in men.
On the Endemic Tsutsugamushi Disease of For-
mosa (Juro Hatori). — The disease as met with in
Formosa seems to be cHnically very eimilar or
identical with the type observed in Japan. It is
transmitted by the same red mite, the larva of
Trombic.ula [Leptus) akamushi Brumpt, and certain
species of monkeys can be infected experimentally.
With regard to prophylaxis the author recommends
as the most important measure to bring the lands
infested with the mites under cultivation. People
entering the infected areas should wear mite-proof
suits. Sulphur lotions are occasionaly useful.
Notes on the Bionomics of Stegomyia fasciata,
Fahr.- (J. W. Fielding).— A complete investigation
of the bionomics of this mosquito in Australia.
Among many other interesting observations, the
author has noted that batches of mosquitoes which
were given food other than blood never laid eggs
except when fed on concentrated peptone and sugar
solution.
Ankylostoryia ceylanicum in the Cat in Durbati
(B. Blacklock). — Several ankylostoma worms were
collected by Dr. I. G. Canston from the gut of a
cat in Durban and sent to the author, who describes
them as female specimens of A. ceylanicum Loos.
Indian Medical Gazette.
Vol. I.IV, No. 10, November, 1919.
Cholera Prophylactic Vaccination : An Experiment
in a Village during an Epidemic (Ashtosh Roy). —
The author succeeded in arresting a severe epidemic
in a village by inoculating with cholera vaccine
practically all the inhabitants, including children.
The Economic Value of Anticholera Inoculation
(T. C. McCombie Young). — The author, who is
Sanitary Commissioner, Assam, suggested to the
authorities that all labour recruits for Assam should
be inoculated with cholera vaccine before their
despatch from the recruiting agencies. The result
was very satisfactory, the incidence of cholera
among the emigrants on the transit routes became
very small and it was not found necessary to restrict
emigration, a step which would have had a very
serious economical effect on the tea industry of the
country.
Diabetes in Madras (S. Krishnamurti Aiyer). —
The author emphasizes the necessity of further
investigation of diabetes in South India.
A Case of Ophitoxxmia (D. J. Asaua). — A native
woman, 50 years of age, bitten bj" a poisonous snake
{Echis carinata), was successfully treated with cal-
cium chloride internally and hypodermic injectione
of emetine hydrochloride.
Paha Oil in Mustard Oil as an Adulterant (Rai
Chunilal Bose and Satyendra Nath Sen). — Several
cases of poisoning due to the admixture of paka
oil with edible mustard oil have recently occurred
in Bengal. The authors have found out that hydro-
cyanic acid, probably derived from some form of
cyanide glucosides, is present in paka oil.
Quakterly Journal of Medicine, Oxford.
No. 49, October, 1919.
Treatment of Malaria (J. Cowan and R. H.
Strong). — The authors believe that certain cases of
so-called chronic malaria are in reahty cases of
chronic quinine poisoning. In their opinion, in a
number of cases, quinine, even given in large doses,
does not cure the disease. They recommend the
use of arsenical pi-eparations.
Pulmonary Manifestations in Malaria {.\. W. Fal-
coner).—Malaria, as already noted by previouH
oliservers, mav affect the respiratory system, and
Jan, 1, 1920.J
THE JOUKNAL OF TiiOPlGAL MEDICINE AND HYGIENE.
13
thex'e may be present physical signs of bronchitis,
partial oonsolidatiou or massive coUapse of the
lung, without any evidence of superadded pneumo-
coccus infection.
The Jt)URNAL OF E.xperimental Medicine,
Vol. XXX, No. 5, November 1, 1919.
(Uiemotherapy of Trypanosome and Spiro-
ciuete Infections (N-phenylglycineamide-p-arsonic
Acid), by Walter A. Jacobs and Michael Heidel-
berger. — -This paper deals with the substance
N-phenylglycineamide-])-arsouic acid purely from a
chemical aspect.
Chemotherapy of Trypanosome and Spiro-
chete Infections; The Toxic Action of 'N-phenyl-
glycineamide-p-arsonic Acid, by Wade H. Brown
and Louise Pearce. — According to the authors'
experiments, the drug lends itself to almost any
method of administration and can be given to the
lower animals in very large doses. The reaction
of the animals to toxic doses of the drug is of
favourable character, the recovery of the animals
from sublethal intoxication being remarkably rapid
and complete. Very large doses can therefore be
given at short intervals, and such a degree of toler-
ance is developed in the animals that the dose can
be progressively increased to a point well over what
is fatal to a normal animal. This is a feature of
the gi-eatest significance as regards the use of the
drug for therapeutic purposes.
The Therapeutic Action of N-phenylyly cine-
amide- p-arsonic Acid in Experimental Trypano-
somiasis of Mice, Rats and Guinea-pigs, by Louise
Pearce and Wade H. Brown. — The authors give
accounts of the same substance as u&ed in curative
treatment on mice, rats and guinea-pigs. The
results were highly satisfactory, it being especially
noted that the animals appear to benefit in their
general health from the injections.
Chemotherapy of Trypanosom.e and Spiro-
chete Infections. The Therapeutic Action of N-
phenylglycinea7nide-p-arsonic Acid in Experimental
Trypanosomiasis of Rabbits, by lyouise Pearce and
Wade H. Brown. — Tlie authors give a detailed
description, accompanied by i)lates, of their experi-
ments in the treatment of experimental trypano-
somiasis of rabbits. The authors again note that
the injections are followed by a marked immediate
improvement in the animal's general condition.
Chemotherapy of Trypanosome and Sjiiro-
hcete Infections: The Action of N-phenyl(/lyrinr-
mide-p-arsonic Acid upon Spirochtetic Infections,
by Wade H. Brown and Louise Pearce. —
The authors conclude that N-jvhenylglycineamide-
p-arsonic acid is capable of exercising a very definite
effect upon the course of infections produced by
spirochsetes of the recurreus group and by Tre-
ponema pallidum (Schaudinn). With either group
of organisms N-phenylglycineamide-p-arsonio acid
appears to act in a manner somewhat different from
that of the usual spirocheeticidal agents. While it
rub
of ^pirochieticidal
action its chief effect is seen in the pecuUar manner
in which it modifies or controls the course of these
infections.
The Occurrence of Bacillus infiuenzx in the
Normal Throat, by Agnes I. Winchell and Ernest
G. Stillmau, M.D. — The authors have made further
investigation into the -Dccurrence of Bacillus in-
fiuenzic in throats and saliva. They conclude that
B. infiuenzx Pfeiffer may persist in the throats of
healthy carriers both during and after an epidemic
of influenza. The bacillus has been found in the
tlu'oats of a considerable number of individuals not
exposed during the epidemiic. The bacillus can best
be cultivated on oleate haemoglobin agar medium.
Bulli;tin de la Souiete de Pathologie Exotique,
Vol. XII, No. 8, November, 1919.
The Leucocijtic Formula in the Human Spiro-
chsetosis of the Middle Congo (A. Leboeuf and A.
Gambier). — The twenty-two patients from whom
the material was taken were all suffei'ing from
spiroehaetosis with presence of the organism in the
blood. The only abnormahty observed in the
counts was the disappearance of the eosinophils,
the average percentage being 0-94 (as against an
average of 8'43 in the apparently healthy native,
though all of thejn harbour intestinal worms), while
in ten cases there were none at all. Complete dis-
appearance of eosinophils in an aborigine of the
Middle Congo suffering from fever of obscure origin
may, therefore, in the authors' opinion, be regarded
as symptomatic of spiroehaetosis.
Ornithodorus Moubata in the North Eastern Dis-
tricts of Belgian Congo (J. Bequaert, Bull, de la
Soc. de Path. Exotique, October 8, 1919).— Though
this tick has not been identified in the villages and
encampments situated on the banks of the Arou-
wimi and Itouri rivers and their tributaries, it is
very common in the villages of the Walendou
plateau. It is present at Beni and infests Kasindi,
an important frontier station north of Ijakc Albert
Edward, and is probably to be found in all the
forest-free regions between the two. Its advent in
tlie latter district is recent and apparently dates
back to 1902-4, but the immunity of the aborigines
of the Walendou plateau to the infection it conveys
(relapsing fever) indicates its presence there for
very many years. The Walendou may, indeed, be
considered as f)ne of the original points of habitation
of the tick.
Note on the /Etiology of Oriental Sore in Meso-
potamia (Major W. S." Patton, M.B.Edin., F.E.S.,
I. M.S., Bull, de la Soc. Path. Exotique, October 8,
1919). — The author believes that Oriental sore is
acquired by rubbing Herpetomonas phlebotomi into
the skin when crushing an infected sand-fly in the
act of biting, but he failed to prove this in his own
case, perhaps because he had previously been in-
fected. He suggests that others on the spot should
try the experiment of dissecting out the alimentary
tracts of sand-flies, selecting an infected hind gut
and rubbing this into the skin at a marked spot ;
at tbc snmo time it should 1m- noted wlirtlipr the
14
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
[Jan. 1. 1920
specimen has ingested the blood of the gecko, for
the theory has been advanced that this lizard is the
natural reservoir of the parasit* of Oriental sore.
Two Cases of Milk-pox or Alastrim observed at
Brazzaville {Middle Congo) (A. Leboeuf and A.
Gambler, Bull, de la Soc. de Path. Exotique,
October 8, 1919). — -The second case was admitted
to hospital nine days after the first, and both ran
an identical course. The condition differed from
chicken-pox in the appearance of the vesicles and
scabs, and from small-pox in the mild character of
the general symptoms, as weO as the nature of the
pustules. The authors believe the condition to be
the same as that described under the name of vario-
loid varicella by Anderson in Jamaica and Dickson
and Lassalle at Trinity ; and also that the epidemic
which raged in Sydney in 1913 and caused so few
deaths (1 per 1,000) was miUc-pox and not small-
pox. They are of the opinion that vaccination is
effective protection against the disease, and con-
sider its rarity in Brazzaville to be due to the fact
that most of the inhabitants are inoculated annually
against smaU-pox.
A Case of Red Grain Mycetoma (Madura Foot)
(H. Griewank and M. Laveau, Bull, de la Soc. de
Path. Exotique, October 8, 1919). — Microscopic
examination of the red grains, after amputation of
the foot, sihowed the case to be due to an arthro-
sporing hyphomyoete which the authors classify in
the family Oosporaceae. Accepting Verdun's classi-
fication dividing the Oosporaceae into three genera
(Mycoderma, Nocardia and Sclerothrix), they con-
sider their hyphomycete should belong to the genus
Mycoderma, as having a septate mycelium exceed-
ing 1 micron in calibre and free, rounded, budding,
yeast-like elemejits.
Remarks on the Treatment of Phagedenic Ulcers
(Louis RfOusseau, Bull, de la Soc. de Path.
Exotique, October 8, 1919). — ^Comparative tests
with Dakin's solution, and salvarsan externally and
intravenously, showed the latter to give the best
results. After two or three injections of 0'30 grm.
pain ceases, the general condition rapidly improves,
and fusiform bacilh and spirochsetes disappear.
Phagedenic Complications noted after Vaccination
(M. Blanchard, Bull, de la Soc. de Path. Exotique,
October 8, 1919). — Numerous cases of phagedenism
havmg followed vaccination in different parts of
the colony, and the vaccine used faiUng to show
anything abnormal when tested, scrapings fi'om the
lesions were examined microscopically in the labora-
tories at Grand Bassam and found to contain ati
association of fusiform bacilli and spirochsetes in a
pure state. Though flies may be responsible for
the dissemination of the infection, the author con-
siders such an explanation doubtful in view of the
facts that cases occurred in widely separated dis-
tricts and that the complications appeared this year
for the first time.
Note on a Case of Chronic Plague in a Rat without
an Epizootic being Present (M. Laveau, Bull, de la
Snr. de Path. Exotique, October 8, 1919).— Plague
was introduced into Senegal some years ago and
may now be considered to be endemic in that
country. Recently there has been no epizootic
among rats. The authorities have examined 354
rats and found infected only one, caught ahve and
showing no sign of acute plague.
A Fumigation Cabin for Native Infirmaries (L.
Parrot, Bull, de la Soc. de Path. Exotique, October
8, 1919). — This is an exceedingly simple and in-
expensive apparatus designed for native hospitals
in the rural districts of Algeria. It consists of a
brick cabin with a hearth let into the floor for a
sulphur pot and a chimney in the roof which may
be opened or closed from the outside. The clothes
to be disinfected are introduced through a small
door, hung on cords inside, and removed through
another door. Both doors can be hermetically
sealed with strips of gummed paper. The cost of
each fumigation, including sulphur and gummed
paper, should not exceed 50 centimes (about five-
pence).
An Essay on the Climatology and Demography
of Casablanca (L. d'AnfreviUe, Bull, de la Soc. de
Path. Exotique, October 8, 1919).— The statistics
given show a heavy though decreasing mortality.
The climate is both hot and damp in the summer ;
there are violent winds part of the year and rainy
seasons in spring and autumn. The active measures
taken have practically suppressed small-pox except
in newly arrived natives and Spaniards. Typhus
(which is endemic in Morocco) and plague are being
successfull3' dealt with, wliilst malaria, which was
formerly exceedingly pi-evalent, even among the
natives, is gradually diminishing. Housing and
drainage pmblems are being energetically handled
by the authorities, and the town is rapidly becoming
healthier as a place of residence for Europeans.
First Recorded Appearance of Pestis Bovina in
Italian Somaliland (Paolo Croveri, Bull, de la Soc.
de Path. Exotique, October 8, 1919).— The disease,
hitherto unknown in Itahan Somaliland, made its
appearance with the first rains of 1917 among the
mules at an outpost station on the confines of
Abyssinia, having probably been imported from the
latter country. Clinically, the form seen was
oedematoue and differed from the classical type
described by Theiler in that it ran a much more
rapid coiirse and that the oedema did not always
begin in the temporal fossae ; in some instances the
abdomen was first affected. The speedy applica-
tion of energetic measures effectively quelled the
outbreak. A daily dose of 0'5 gi-. of arsenious
anhydride, contrinued for a month, would seem to
be a useful prophylactic measure if it can be given
to all the horses in the district.
Experiments in Vaccination against Pestis
Bovina by the " Sero-Infection " Method of Schein
(Paolo Croveri, Bull, de la Soc. de Path. Exotique,
October 8, 1919). — The experiments undertaken
failed to show that any real immunity against
Pestis bovina was conferred on cows in Italian
Somaliland by Schein 's " sero-infection " method.
The results obtained suggest that sero-vaccination
is a more \iseful method of projihylaxis against the
Jan. 1, 1910.] THE JOUliNAL OF TEOPICAL MEDICINE AND HYGIENE.
15
disease, for if care be taken not to vaccinate calvesi
before or immediately after weaning a positive re-
action is obtained in 100 per cent, of cases, whereas
the percentage of animals reacting to Schein's
method is very low.
The German Medical Unjanixatiun hi the
Cameroons (Gustave Martin, Bull, de la Soc. do
Path. Exotiqtie, October 8, 1919).— According to
the Author, under Gemian administration very
thorough measures were in force for fighting tlie
numerous endemic and epidemic diseases prevalent
in the Cameroons. Large sums of money were
spent and a large staff maintained. Besides hos-
jjitals, sanatoria and dispensaries, the system in-
cluded medical stations in the interior of the country
fully equipped with surgical, chemical, bacterio-
logical, meteorological apparatus, &c., and stocks of
quinine, mercury, arsenic and other drugs which
were liberally dealt out to the jjopulation. Small-pox
vaccine was obtained from cows kept in special
parks and distributed regularly by travelling medical
units. There were segregation camps for lepers
and the study of sleeping sickness was methodically
and assiduously carried on. The various depart-
ment* worked hand in hand, and the senior military
medical officer was ultimately responsible for all.
fejorls of ^ocictifs.
-MEDICAL SOCIETY OF LONDON.
Treatment of Malaria.
At a meeting of the Medical Society of Loudon,
held on November 24, Dr. V. Warren Low, C.B.,
President, in the chair, Lieut. -Colonel S. P. James
opened a di»cussiou on tlie Treatment of Malaria.
After sonii', inti i<-sting remarks on the increased
number of iuiliK' hmh;, cases of malaria in England,
he expressed ins idrus on the subject of treatment,
calling attenlidii to the very inadequate doses of
quinine so often given by medical men with do
tropical e.xperience. Such procedure had caused in
several cases disastrous results. At the invitation
of the Ministry of Health he and Sir Ronald Ross
had jointly drawn up a pamphlet in which a simple
and inexpensive routine treatment had been de-
scribed in detail.
Dr. G. Newton said that he recommended the
administration of quinine by intravenous injection.
The proceeding was simple, and thrombosis of the
vein was of rare occurrence.
Dr. Aldo Castellani said that one word sum-
marized the whole treatment of malaria — quinine.
The drug should be given by the mouth in ordinary
cases, by intramuscular injection in severe cases,
and both intramuscularly and intravenously in
pernicious cases. For oral administration he gene-
rally used the bisulphate, 30 to 45 gr. during the
twenty-four houns. Quinine was the only specific,
but occasionally arsenic, tartar emetic and phos-
phorus were usefid, as they seemed to reinforce
the action of (|niinnc in certain eases.
Dr. Andrew Balfour said that the quinine treat-
ment must be started as soon as possible during
the acute stage of the malady. Oral administration
suffices in ordinary cases, in severe cases intra-
muscular injections are very useful. Intravenous
injections are successful, but they are chiefly useful
for hospital practice. ' The practitioner should also
rememiber that the patient should be treated and
not the disease.
Dr. Gordon Ward said that he often gave small
doses of opium in conjunction with the quinine
treatment, as opium, being an antispasmodic, might
tend to mitigate the severity of the rigors. He
gave also, at times, small doses of aspirin; this drug
being probably a vaso-dilator might hasten the
sweating stage.
Major H. W. Acton recommended in relapsing
cases due to the benign tertian parasite a cinchona
febrifuge, which contains quinine, quinidine, cin-
chonine and cinchonidine.
^lajor J. Pratt Johnson said that in debilitated
individuals quinine had very little effect on the para-
sites, and that more attention should be paid to
the patient's own defensive mechanism. Salvarsan
seemed to be successful in cases of benign tertian,
liut not in mahgnant tertian.
Dr. ]\Ianson-Bahr called attention to the abuse
of intramuscular iitjections and the careless way in
which they were not rarely performed, with the
result that al)scesses and even gangrenous processes
developed.
Dr. W. H. WiLLCOX said that the possibility of
idiosyncrasy should always be borne in mind when
giving large doses of quinine. He had seen almost
complete amaurosis developing after the adminis-
tration of 15 gr. of quinine.
Carr^sponbfiicf.
WHEN SHOULD A PATIENT, INVALIDED
TO ENGLAND FOR MALARIA, BE CON-
SIDERED FIT TO RETURN TO THE
TROPICS :>
To the KditoiK of the Journal ok Troimcal Medicine
and Hygiene.
Sir, — Sir James Cantlie, K.B.E., asks the above
(piestion in a leading article in the Journal of
Tropical Medicine and Hygiene of 1st November
and invites suggestions from his readers as to the
best test that the i)atient is cured of his malaria and
fit to return to the Tropics or not. The microscope,
as he points out, does not provide a satisfactory test.
Indeed the verdict of the microscope, as Masterman
says, upsets all ordinary ideas of clinical experience.
It sometimes reveals Laveran's bodies in ewarms in
the blood of persons, especially children, who
exhibit no rise of body temperature and who are
in perfect health, whilst in others suffering from
clinical malarial fever it fails to reveal even one
parasite after repeated microscopic search by ex-
lurts. These two fac-ts are sometimes quoted as
16
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE.
[Jan, 1, 1920
proof that Laveran's bodies are not the cause of
malaria. They may also be quoted to show that
the microscope does not provide a reliable test of
whether a patient is cured of his malaria and fit to
return to the Tropics or not.
With much diffidence I suggest that the specific
gravity of the patient's blood supplies a more
reliable test of whether he is cured of his malaria
and fit to return to the Tropics or not. One advan-
tage of it is that it enables an answer to be given
to the question quickly. When the specific gravity
of the patient's blood is equal to or, within physio-
logical limits, higher than the average specific
gravity of healthy blood he is cured of his malaria
and fit to return to the Tropics. This of course
does not mean that he is absolutely immune from
again contracting the disease when he returns to a
climate where it is prevalent. But it means that
he is possessed of the same degree of immunity as
the average healthy man proceeding to the Tropics
for the first time. When the specific gravity of a
man's blood is below the average of healthy blood
he is not cured of his malaria nor fit to return to
the Tropics until it has, by suitable treatment,
been raised to the average specific gravity of healthy
blood. It also supplies a reliable test whether, as
regards malaria, those proceeding to the Tropics
for the first time are fit to go there or not.
I will now try to explain why I make this
suggestion. Long before instruments of research,
such as the microscope, had reached their present
state of perfection it was known that there is a re-
tention of water in the blood and tissues of those
who suffer from malaria. In the early paroxysms
of primary cases it escapes observation, but as the
paroxysms recur it becomes more evident and if
the disease is prolonged it is considerable. Sir
John Maccullooh refers to it in his work on malaria
published in 1827. Liebermeister said that in
exceptional cases it is sufficient to explain an
increase of body-weight by as much as 10 lb.
(4 kilo.), although beyond the increase of body-
weight there may be nothing to indicate it except
a slight CEdema of the eyelids or of the ankles. In
many cases of malaria it is sufficient not only to
mask any emaciation resulting from the febrile
process but even to give rise to a deceptive appear-
ance of obesity.
In a paper on malaria, in the French Supplement
to the Lancet of 3rd May, 1919, M. Paisseau also
refers to this retention of water in the blood and
tissues in malaria and says that malarial cachexia
corresponds with the condition described by Kelsch
as hydra'mic cachexia. In the exceptional circum-
stances in Macedonia it was found after primary
attacks as well as after more prolonged attacks.
It is evident then that there is a retention of water
in the blood in malaria and this would lead us to
expect that the specific gravity of malarial blood
must be lower than the average specific gravity
of healthy blood. Many, including Acton and
Knowles, have shown that it is lower than that of
liealthy blood. Hence the suggestion that the
specific gravity of a patient's blood provides a
reliable test as to whether he is cured of his malaria
and fit to return to the Tropics or not.
Whilst this retention of water in the blood and
tissues in malaria has long been recognized no
attention seems to have been directed to tlie way in
which it is produced, or to the important share it
takes in the explanation of the rigor, intermittent
pyrexia, grave anaemia and enlargement of the
spleen. It is obviously produced by the atmo-
spheric conditions under which malaria becomes
prevalent. Their chief characteristic is the very
large proportion of water vapour which, for its
temperature, the air contains.
Ordinarily, as atmospheric temperature rises
excretion of water through the kidneys is reduced.
This, of itself, would lead to a retention of water
in the blood and tissues of those who breathe and
are immersed in the atmosphere, but that, as the
temperature rises, the capacity of the air for taking
up water as vapour increases, producing a com-
pensating increased evaporation of water from the
skin and lungs which keeps the amount of water
in the blood and tissues within physiological limits.
Conversely, as atmospheric temperature falls, the
capacity of the air for taking up water as vapour
is reduced and this, by reducing evaporation from
the skin and lungs would, of itself, lead to a reten-
tion of water in the blood and tissues, but that the
fall of the atmospheric temperature produces at
the same time a compensating increased excretion
of water through the kidneys which keeps the
amount of water in the blood and tissues within
physiological limits.
Owing to the very large amount of water vapour
in the atmosphere under which malaria becomes
prevalent its drying power, for the temperature of
the air, is very small. Hence evaporation of water
from the skin and lungs of those immersed in such
an atmosphere is much impeded during the
daily rise of atmospheric temperature but more
markedly during its nocturnal fall. The result is
that the increased evaporation of water from the
skin and lungs does not fully compensate for the
reduced excretion of water through the kidney as
the atmospheric temperature rises throughout the
day. Neither does the increased excretion of water
through the kidneys, caused by the nocturnal fall
of atmospheric temperature, compensate for the
reduced evaporation from skin and lungs produced
by the low-drying power of the night air. There-
fore water is retained in the blood and tissues, pro-
ducing the hydraemia which i!3 found in those who
suffer from malaria.
The way in which the retention of water in the
blood and tissues in malaria assists in the produc-
tion of the characteristic rigor, intermittent pyrexia,
grave anaemia and enlargement of the spleen, is
not given in this paper, which is only an attempt
to answer Sir James Cantlie's question.
Mathew D. O'Connell, M.D.
Jan. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 2, Vol. XXIII.
6rt{inai Comntnmattons.
THE ETIOLOGY OF THRUSH.
By Aldo Castellani, C.M.G., M.D., M.R.C.P.
Lecturer at tJie London School of Tropical Medicine.
Physician, Tropical Hospital (Ministry of Pensions).
It is generally stated that thrush is due to th«
fungus Oidium albicans Robin. Since 1906, in a
series of researches carried out in tropical countries
and in the temperate zone, I have endeavoured
to demonstrate that the etiology of thrush is far
from being so simple, and that the condition is not
caused by one fungus only, but by a number of
different fungi, and that in reality the term thrush
does not cover one affection only, but a group of
clinically similar conditions due to different fungi.
Fungi Found in Thrush. — The fungi I have so
far isolated from cases of thrush, in the Tropics
and in temperate climates, may be classified as
follows : —
different authore. For instance, some observers
state that the organism "liquefies gelatine, others
deny that it possesses such action. Certain authori-
ties describe it as coagulating milk, others as not
having any action on this medium, &c.
The more important Monilia fungi I have found
in thrush belong to the following types: —
Monilia halcanica Cast. — type. This group con-
tains M. balcanica Cast., M. parabalcanica Cast.
M. krusei Cast. — type. This group contains: —
M. krusei Cast., M. parakrusei Cast.
M. pinoyi Cast. — type. This group contains: —
M. pinoyi Cast., M. nabarroi Cast.
M. 7netalondinenHis Cast. — type. This group
contains: M. albicans Robin sensu stricto, M.
metalondinensis Cast., M. alba Cast., M. pseudo-
metalondinensis Cast.
M. tropicalis Cast. — type. This group con-
tains: M. tropicalis Cast., M. metatropicalis Cast.,
M. paratropicalis Cast., M. pulmonalis Cast., M.
nivea Cast., M. insolita Cast., M. enterica Cast.
Most of these species are, in reality, merely varie-
ties of M. tropicalis.
Class: Fungi. Imperfecti-
Subclass : Hyphales
Class: Ascomycetes— Subclass; Protoascomycctes—
Order Saccharomycetales
(Genus Monilia Persoon— Several species,
f Order Thallosporales — Family Oosporaceae Saccardo \
! I GenuB Oidium Link— Three species.
I Order Hemisporales— Genus Hemispora Vuillemin — One species.
Family Endomycetaceae Rees— Genus Endomyces Rees— One species
Genus Saccharomyces Meyen— One species.
.Family Saccharomycetaceae Rees \
I do not propose entering into any botanical
details of these fungi as such details may be found
in Castellani and Chalmers' " Manual of Tropical
Medicine," Third Edition, p. 1079.
Fungi of Oenus Monilia Persoon. — These are the
fungi most connnonly found in thrush. The
botanical description of these fungi has been given
in my previous papers as well as in the " Manual
of Tropical Medicine " by Chalmers and myself.
It suffices to say, from a practical point of view,
that the fungi of the genus Monilia are charac-
terized principally by the following features. In
the lesions the vegetable body (thallus) is composed
of mycelial threads of rather large size often show-
ing arthrospores, and numerous free oval or roundish
budding yeast-like fonns — in cultures, especially
on solid media, mostly roundish or oval budding
elements are seen while mycelial filaments are
very scarce or absent. These fungi, as a rule,
ferment with j)i-oduc'tion of gas, glucose, and often
other sugars. The only Monilias I know of which
do not attack any sugar or other carbohydrates are
Monilia xcylaaica Cast, and M. xcyla7ioides Cast.
There is little doubt that the original fungus
Oidium albicans C. Robin 1853 belongs in reality
to this genus, and its correct name is therefore
Monilia albicans (C. Robin 1853). The term
Oidium or Monilia albicans has been used in the
past to cover a number of different fungi, as proved
by the widely different descriptions of it given by
(Genus Willia Hansen— One species.
M. giiillermondi Cast. — type. (Rare.) This
group contains: M. guillermondi Cast., M. pseudo-
guillermondi Cast.
M. chalmersi Cast. — type. (Hare.) This group
contains: — M. chalmersi Cast., M. parachalmersi
Cast., M. rnaccdonicnsis Cast. Only M. para-
chalmersi has so far been found in thrush.
M. pseudo-tropicalis. — type. (Very rare). This
group contains: M. pseudo-tropicalis Cast., M.
pseudo-tropicaloides Cast.
M. pseudo-londinensis. — type. This group con-
tains: M. pseudo-londinensis Cast., M. pseudo-
londinoides Cast.
M. zeylanica Cast. — type. This group contains
the following species: M. zeylanica Cast., M.
zeylanoides Cast.
M. albicans Robin sensu stricto belongs to the
metalondinensis type, and I have vei-y seldom
isolated it.
The various types can be easily differentiated by
their action on the following carbohydrates :
glucose, levulose, maltose, galactose, lactose,
saccharose, inulin and dextrin.
Fungi of the 1st group (M. halcanica type) pro-
duce gas in glucose only.
Fungi of the 2nd group (A/, krusei type) produce
gas in glucose and levulose only.
Fungi of the 3rd group (M. pinoyi type) produce
gas in glucose, levulose and maltose.
Fungi of the 4th group (M . metalondinnisis and
18
THE JOUKNAL OF TEOPIGAL MEDICINE AND HYGIENE. [Jan. 16, 1920.
albicans seneu strioto) produce gas in glucose,
levulose, maltose and galactose.
Fungi of the 5th group (M. tiopicalis) produce
gas iu glucose, levulose, maltose, galactose and
saccharose.
Fungi of the 6th group (M. guillermondi) produce
gas in glucose, levulose and saccharose.
Fungi of the 7th group (M. guiUermondi) produce
gas in glucose, levulose, galactose and inulin.
Fungi of the 8th group (M. psetido-tropicalin)
produce gas in lactose in addition to other carbo-
hydrates.
Fungi of the 9th group (M. pgeudo-tropicalis)
produce gas in dextrin in addition to other sugars.
Fungi of the 10th group (M. zeylanica type) do
not produce gas in any carbohydrate.
When a Monilia has been placed in one of the
above groups, it is easy to make the specific classi-
fication by means of the annexed table.
Further details on the classification of the various
species of the genus Monilia may be found in the
" Manual of Tropical Medicine " (C'astellani and
Chalmers— 3rd Edition, pp. 1070-1092). It 7nust be
remembered that a certain number of fungi of the
genus Monilia have not permanent sugar reactions
and can be trained to ferment sugars ivhich they do
not ferment when recently isolated, and therefore
for purposes of classification and comparison such
fungi should be investigated using only recently
isolated strains.
Fungi of genus Oidiuni Link emendavit Pinoy. —
This genus is morphologically closely allied to
Monilia, but mycelial threads are very abundant
both in the lesions and in cultures, and budding,
yeast-like cells are rare. Fungi of this genus may
occasionally induce an acid fermentation, but do
not produce gas in any carbohydrate.
I have found fungi of this genus in certain cases
of thrush in the Tropics and in the Balkans, but
so far not in England. I have isolated three
species; Oidium matalense Cast., 0. asteroides
Cast., and 0. rotundatum Cast. It is interesting
to note that I have found the same species in
cases of mycotic tonsillitis, and in the expectora-
tion of certain cases of bronchitis, while I have
observed 0. rotundatum and 0. asteroides also in
the stools of certain cases of enteritis. The descrip-
tion of these fungi may be found in previous papers
by me, as well as in Castellani and Chalmers'
'■ Manual," 3rd Edition, pp. 1093-1096.
Fungi of genus Hemispora Vuillemin. — These
fungi are characterized by the presence of abundant
mycelial hypli*, some of which are conidiophores.
Each conidiophore terminates into an ampulliform
or sausage-like structure, which is called protoconi-
dium. The protoconidium later divides into a
number of spore-like segments which are called
deuteroconidia.
So far only one species of this genus has been
found in cases of thrush; Hemispora rugosa Cast.
Tliis fungus was first isolated by me from a case of
iriyci.tic tonsillitis in 1910, and observed in a .!aso
of thrush by Pijper in 1915. Two varieties e:ui
be distinguished : one liquefying gelatine, the other
having no such action on the medium. Botanical
details of this fungus have been given in various
papers by me and by Pijper, and may be found
also in Castellani and Chalmers' " Manual "
(p. 1108 and p. 1743).
Fungi of the genus Willia Hansen. — These fungi
are characterized by the peculiar bowler-hat shape
of their ascospores. I isolated a fungus belonging
to this genus in Macedonia from a case of thrush
in a gypsy. In sugar broths it formed a thick
pellicle containing air-bubbles. It produced gas in
glucose and levulose only. Cultures on solid media
contained asci with 2-4 spores of the peculiar hat-
like api)earance. The fungus seemed to be some-
what similar to Willia anomala Hansen, but the
investigation of it is not yet complete.
Fungi of genus Endomyces Link. — These fungi
are in supei-ficial examination extremely similar
to those of the genus Monilia, budding elements
and mycelial threads being found in the lesions,
and mostly budding elements in cultures. There
is, however, a very important character which
differentiates these fungi : In old cultures of
Endo7nyces asci are present. Only once have I
come across a case of thi-ush due to a true endo-
myces, in Macedonia in 1917. I considered it to
be E. vuillemini Landrieu.
Fungi of genus Saccharomyces Meyen. In the
Balkans I found a case of thrush due to a typical
saccharomyces, which I have only recently studied.
Fungi of this genus are characterized by the
vegetative body consisting only of budding
elements, and by the presence of asci in cultures.
The sac<;liaromyces isolated by me ferments with
production of gas, glucose, levulose, galactose,
maltose and saccharose. It does not clot milk,
which, however, may occasionally become acid.
Celatine and serum are liquefied.
Clinical varieties of Thrush caused by above
Fungi. — I have always endeavoured to study the
c-Mses of thrush I have observed both mycologically
and clinically, to see whether different groups of
fungi are causing different types of thrush. In my
experience two principal varieties of thrush may
be distinguished: —
(1) The white, or white -greyish type. — By far
the most common. Characterized by the cream-
white colour of the patches.
(2) The yellow, or yellow-brownish type. —
Characterized by the yellowish, occasionally
brownish colour of the i)atches.
The first type may he caused by any species of
till' oiiius Mdiiilia (except M. zrylnnica Cast, and
M. .:cylaiuii(lcs Cast.), by Oidiuni matalense Cast..
by Endomyces vuillemini Landrieu, and by fungi
of the geims Saccharomyces Meyen and Williu
Hansen.
The second type is caused by M. zeylanica Cast.,
M. zeylanoides Cast., Oidium rotundatum, Cast.,
and Hemispora rugosa Cast.
Conclusion. — Thrush is not caused by one species
of fungus only, the so-called thrush-fungus or
Jan. 15, 1920.J THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
(?) ^^
^o
11?
Monilia tropicalis Cast.
(Preparation from a glucose-agar
culture.)
'81®
Willia ascospores.
S^ ^^v
Oidium rotundatum. Cast, (from a culture).
■~-^^^^^i:§)
.W^®
MonUia tropicalis Cast, (from thellesioDx).
Oidium aiteroidts Cast, (from a glucose-agar culture).
To illustrate paper on ' The Ktiology of Thrush," by Aldo Castki.i.ani, C.M.G , M.I)., M.R.C.P.
THE JGUENAL OF TEOPICAL MEDICINE AND HYGIENE.
[Jan. 15, 1920.
Oidium aateroldes Cast.
(Glucose-agar culture.)
IlcniiapoTarugo^a Cast.
(Oliicose-agar culture.)
1. gr
Monilia tropicalis Cast.
(Glueose-agar culture. )
Uemispora riujosa Cast.
(Glucose-agar culture.)
To illustr
: paper on " The Etiology of Thrush," by Albo Castei
, C.M.Ci,, M.I)., M.K.C.P.
Jan. 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENB.
FoNGi OP Gbnus Monilia.
1
J
1
1
1
1
2
1
t
s
1
1
1
1
i
1
1
5
Monilia alba CsLsteUnni 1911
M. albicans Robin, 1853
M. ftakanica Cast. 1916
M. bethaliensis Piipev 191S
AG
AG
AG
AG
AG
AGs
As
AG
AG
0
0
AG
AGs
0
AG
0
0
0
0
A
Avs
0
0
0
0
o
o
0
0
0
0
AC
AC
0
0
"o"
+
0
0
0
+ 8
0
o
White
M. blancliardi Cast. 1912
AGs
A
A
A
0
A
Avs
0
Avg
0
0
M. bronchialis Cast. 1910
AG
AG
0
AG
0
AGs
0
A
0
0
0
if. 6Mr<7essi Cast. 1912
AGs
A
A
AGs
0
AGs
0
0
0
Alk
0
0
„
M. chalmersi C&st. 1912
AG
AG
AGs
As
0
AG
AGs
0
As
AiF
0
0
M. decolorans Cast, and Low, 1913 ...
AG
AG
A
AG
0
A
0
A
DC.
0
o
if. en<crica Cast. 1911
AG
AG
AG
AG
0
AG
0
As
0
Aik
0
0
if. f«co/ts Cast. 1911
AG
AG
AGs
AG
0
AGs
0
0
A
DP?
0
0
M.guillermondi Ca.it. 1910
AG
AG
A
AG
0
AG
0
0
0
AlT
0
0
„
if. ijMoiito Cast. 1911
AG
AG
AG
AG
0
AG
o
0
As
Aik
ADs
0
AC
0
0
„
M. intestinalis Ca.st. 1911
af. fcntsei Cast. 1909
M. Icmdinensis C&st. 191&
AG
AG
AG
AG
AG
AG
A
AG
Oor As
A
0
0
A
A
0
0
0
0
0
0
0
0
0
0
0
0
"
M. hcstigi G&st. 1911
A
AGs
A
Avs
0
AGs
0
A
As
0
0
M. macedoniensis. Cast. 1917
M. meialondinesis Cast. 1916
M. metatropicalis Cast. 1916
Af. Mrtdarroi Cast. 1917
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
0
AorO
AG
AG
AG
o
0
o
0
AG
0
AG
0
AG
0
0
0
0
0
0
0
AC
0
AC
AC
o
0
0
o
0
0
0
0
Af. nejWi Cast. 1911
AG
AG
AGs
As
0
AG
0
0
Avs
Aiir
0
0
M. ni«da Cast. 1910
AG
AG
A
A
A
A
0
Avs
A
DC"
0
0
3f. niuea Cast. 1910
AG
AG
AG
AG
0
AGs
0
0
0
0
0
M. parabalcanica C&st. 1916
M. parachalmersi Cskst. 1911
M. parakrusei Cast. 1912
AG
AG
AG
As
AG
AG
0
AG
0
O
O
0
0
0
0
0
AG
0
0
AG
0
8
0
AC
AC
AC
0
0
0
0
M. paratropicalis Cast. 1909
AG
AG
AG
AG
0
AG
0
Avs
As
AiF
0
0
Jf. yerri/i Cast. 1912
A
AGs
A
A
0
AGs
Avs
O
As
D Aik
0
0
„
af. 2nnO!/i Cast. 1910
M. pseudo-bronchialis Ca.st. 191G
M. paeudo-giiillermondi Cast. 19 IG
M. pseudolnndinensis Cast. 191(i
M. pseudo-londijwides Cast. 191G
M. pseudo-metalondinejisls C&st. 191G
M. pseitdo-troincalis Cast. 1910
M. pseudo-tropicaloides Cast. 1919
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
O
O
0
AG
AG
AG
AGs
AG
AG
AG
O
AG
AG
AG
0
Oor A
0
0
0
0
0
0
AG
AG
0
AG
AG
0
0
0
AG
AG
O
0
0
0
0
AG
0
0
0
0
0
AG
AG
0
0
0
0
AC
ACorP
0
AG
AC
ACs
0
8
0
o
0
0
0
0
0
0
o
0
0
0
0
0
M. pulmo7ialis Cast. 1911
AG
AG
AGs
AG
0
AG
0
0
0
Alk.D
0
0
„
if. Wioi Cast. 1909
AG
AG
AGs
Avs
0
AG
0
0
As
Aik
0
0
M. rosea zeTumi 1910
Jlf. «roi)ica;is Cast. 1909
M. zeylanica Cast. 1910
M. teylanoides Cast. 19n
a'g
A
A
AG
A
A
AGs
A
A
AG
A
A
0
As
Oor As
AGs
A
A
0
Avs
Oor As
0
A
A
A
ACs
AO
0
0
0
0
o
0
0
0
Pink
White
Yellowish
Abbreviations used in the Table:
A = acid. G = ga3. C = clot (milk), clear (broth and peptone water) ; CTP = clear at first, then thin pellicle present. D = decolourized.
P = peptonized (milk) pellicle (broth). Alk = alkaline. ryr = acid, then alkaline. S = 3light. vs = very slight. 0 = negative
result- viz., neither acid nor clot in milk ; neither acid nor gas in sugar media ; non production of indol ; non-lique(action of gelatine
or serum, as the case may be. + -^positive result, liquefaction of medium.
22
THE JOURNAX, OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15. 1920.
Oidium albicans Robin, as generally stated. It is
caused by a number of difierent fungi, some of
which are botanically very far apart from each
other, and belong to separate specie^ genera and
families. The term Thrush covers in reality a
group of clinically similar conditions, rather than
one only; two principal types may be clinically
distinguished, the white or grey-white type, ex-
tremely common, and the yellow or yellow-
brownish type, of rarer occurrence.
rectal injection of saline solution three times daily
for a week.
The patient made an uneventful recovery and
was discharged apparently well and free from her
former abdominal pains.
With regard to the above case, I cannot help
feeling that the European foodstuffs and her life in
civilization played some part in the development
of her attack of appendicitis, as appendicitis is
unknown here among natives living solely upon
native foodstuffs.
A CASE OF APPENDICITIS IN A NATIVE
OF THE SOLOMON ISLANDS,
WESTERN PACIFIC.
By Nathaniel Cbichlow, M.B., Ch. B.Glasgow.
Oovemment Medical Officer.
Appendicitis is a rare disease among the natives
of the Solomon Islands, and during my five years'
experience among these natives I have only come
across one case.
The case in question was a young missionary
girl, aged twenty-one years. She was " Chris-
tianized " and " Europeanized " and spent some
time in civilization with her Missionary teacher,
with whom she was evidently a favourite.
After being " Christianized " and " Euro-
peanized ' ' she left off eating native foodstuffs and
used to eat European foodstuffs.
Her first attack of pain in the appendix region
was felt about two months before admission, and
this pain recurred at intervals of ten days.
She was first seen by the Mission Medical Officer,
who advised that she be brought into hospital to
be operated upon.
When I first saw the case, I had some doubts
whether it was a ca^e of appendicitis or not. The
patient had a temperature, but on palpation in
the appendix region there was little or no
tenderness.
I decided to "wait and see." About a week
later, the patient's temperature shot up to 103° F.
and there was intense abdominal pain. On exam-
ination, tenderness was now present in the
appendix region. On making a vaginal examina-
tion, I could not feel the appendix. The ovaries
were apparently unaffected. I then made a rectal
examination and felt the appendix as a hard
finger-like protuberance. I decided thereupon to
operate the following day.
On opening the abdomen, the intestines showed
signs of peritonitis. I found the appendix acutely
inflamed and bound down by many adhesions. It
was about three and a half inches long, and there
were three blocks of faecal matter, one at the
mouth, one at the tip and one in about the middle.
I removed the appendix, inserted a rubber
drainage tube, and closed up the abdomen. The
drainage tube was removed on the fourth day.
The after-operation treatment adopted was the
Protein Therapy of Typhus (Prado Tagle, Revista
Mddica de Chile, August). — Intravenous injections
of peptone were apphed in fifty-nine cases of typhus.
Aside from one patient that died in less than forty-
eight hours, the mortality was about 5 per cent.
The absence of by-effects confirms the harmless-
ness of the method for all ages. The acidity of
the solution of peptone in physiologic serum was
reduced to 4-3 per thousand, and the remedy was
put up in 5 c.c. ampoules. About 10 c.c. was
given as the first dose, to robust adults, otherwise
from 4 or 5 c.c. for older children, up to 6 or 8 c.c,
giving afterward only about half of the initial dose,
and allowing an interval of forty-eight hours to
elapse. In almost all the cases a second injection
was given and, exceptionally, a third, with only 1
or 2 c.c. A subcutaneous injection of 2 or 3 c.c.
of 20 or 25 per cent, camphorated oil was given
every six hours day and night, with 0-25 c.c. per
thousand epinephrin in each syringe. The patient
must be kept in repose. The blood pressure falls
during and immediately after the intravenous in-
jection of peptone, but if it is made slowly (1 c.c.
per minute) and if epinephrin has been given, the
drop is slight. The coagulation time of the blood
is much retarded. Analysis of the blood showed
that the urea content could be disregarded with this
protein therapy as the latter only slightly aug-
mented it, and it soon dropped below its previous'
figure from the rapid reaction to the injection,
while the dietetic restrictions in typhus aid in its
being speedily cast off. Analysis of the urine like-
wise showed that the injections of peptone had no
detrimental influence on the kidney and hence
there were no contra-indications on the part of the
kidneys, except of course with grave nephritis.
There are no characteristic findings in the urine in
typhus. Temperature charts show the attenuating
and abbreviating influence of the protein therapy
better than anything else. An interesting feature
of the cases was that when the temperature had
gone down under the injections, a further injection
did not induce any appreciable reaction. The pro-
duction of antitoxins can then be regarded as
sufficient and the case as cured. In every case
improvement in the general condition wag
unmistakeable.
Jan. 15, iy20.J THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
23
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THE JOURNAL OP
Cropf cal S&thitint ant) l^pgtene
January 15, 1920.
UNIVERSAL NATIONAL ALLIANCE TO FIGHT
PREVENTABLE DISEASES (TROPICAL).
Europe in the throes of post-bellum chaoe, as
evidenced by revolutiona, political intrigues, pira-
cies, strikes, foul murders, religious turmoil, pro-
moted by so-called lovers and agents of freedom, has
but little time for literary or scientific work, he it
medical or other. Hunger reigns and all else is
forgotten in the scramble for food. For five years
the study of everything of the nature of science
has been devoted to producing engines of destruc-
tion and to practising the art of medicine in
alleviating the human- ailments caused by them.
The science of medicine as regards research and
the advance of sanitation has had to be dropped,
for the laboratories have been emptied of their
workers, and investigations set aside for the art of
war. Nor is there' likely to be, nor can there be,
a speedy recovery from this calamity to scientific
advancement. In few countries is the machinery
available whereby regeneration can be for the
moment accomplished. The foul-stained epidemic
of Bolshevism has brought into being peoples who
despise and would destroy absolutely all advance-
ment in science.
In Britain and in the United States of America
has it been alone possible to carry on even a
semblance of investigation and practical work, apart
from observations in the field; and now that the
great fight is finished both countries are setting
earnestly to work in the sphere of tropical medicine
to " make good."
The subject chiefly to the fore is the application
of knowledge, accumulated during the past twenty
years, to the eradication of disease in tropical lands.
The pursuit of the subject has assumed an economic
interest far beyond anything heretofore in existence.
Labour in tropical countries has recently assumed
a new aspect. The coolie is of more value to-day
than even five years ago. His wages have had to
be increaised in some cases to double and treble
the pre-war scale. Food and fibre of all kinds
coming from wai-m climates is produced at an en-
hanced price and therefore costs the consumer more.
Uncontrolled disease due to deficient hygienic and
sanitary measures will foster still higher wages; for
the labour market of the world is not inexhaustible,
as at one time it was thought to be. Disease
lessens the labour available, it curtails the in-
dividual power of production, thereby requiring an
extra number of labourers to reach a desired end
in a given time, involving a greater, perhaps a
ruinous, expense in the accomplishment.
The French found labour the crucial point in their
attempt to finish the Panama Canal. Disease was
so rife in the sphere of the canal that it exhausted
the available labour supply of the world so that the
work could not be finished. For the same reason
in every military or exploratory mission in a tropical
country that has been undertaken, the excess of
labourers required, owing to the ravage of disease,
has from time immemorial required a retinue of
" camp followers " largely outnumbering the active
elements of the force. As an example, it is well
known that on the West .\frican coast military
expeditionary forces have always to engage three
times the number of non-combatants actually re-
quired for work and baggage carrying, owing to
the incapacity arising from infection by guinea-
24
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15, 1920.
worm alone. And, as in military, so in economic
work the number of labourers employed have to be
kept owing to disease at a higher level than would
otherwise be required were preventable ailments
eliminated, or even lessened, amongst the work-
men's ranks.
Hitherto replenishing the labour supply has been
comparatively easy ; human hfe was cheap and
labour cost little, but recently all has changed. In
Europe the labour supply may be plentiful enough
but it costs more. The hours have shortened from
twelve to eight; the word has gone forth that " ca'
cannie " is the rule of the hour, that is, that a
man must work at a minimum rate and lessen
production to the utmost. This calamitous com-
bination generates a vicious circle which it wOl take
some time to obviate and to bring home to all
concerned that in this directaon lies moral degrada-
tion and dishonest manhood. These so-called ad-
vanced Eurx)pean ideas are spreading to the peoples
of other continents where, disease to a degree un-
known in Europe prevails, so that a third element
is added to the questions of shorter hours and " ca'
cannie " work during these hours, an added element
which will remain until preventable diseases are
really prevented. It is in this the third factor that
medical science can assist in counteracting the
poisonous teaching of to-day.
Let us have increased pay by all means ;
Mhortened hours of labour sufficient to allow of a
man or woman working without exhaustion is a
great national physical asset; but to compel a man
to become dishonest by purposely diminishing his
IKissible outcome to spite his employer is progress-
ing along a road which is soul destroying. The
consequence upon a race of men following such a
regime will be a moral degradation, for the labourer
is not worthy of more than his hire.
The prevention of disease in the Tropic® is there-
fore a great economic factor to-day, with the
European teaching penetrating other continents,
increased pay, " ca' cannie " work plus the ravages
of disease demanding as it does double or treble
the number of men employed, presents a world-wide
problem which must appal the most optimistic.
Granted therefore that the question is focused
to the problem of the prevention of disease in
tropical lands, how and by whom is that to be
accomplisihed ? As stateil above, Europe, indeed
the' world, is in a state of mental chaos and
economic tui-moil. Few countries have the
machinery, the men, or the money to tackle the
all-important problem at present. The United
States of America and Britain are the only two
available countries and both are ready and willing
to take up the white man's burden. During the
war even scientific missions have been sent out
from both countries to investigate, to report, and
to deal scientifically with various questions of
epidemiology, but only to a limited degree owing to
the circumstances of war. Both are, however, now
contemplating extended efforts in the prevention of
disease. The United States are doing excellent
practical work in the Weat Indies. They have
well-nigh eradicated yellow fever from the shores
and islands of the Gulf of Mexico and they are at
present concentrating upon the eradication of
ankylostomiasis or hookworm disease, the scourge
of plantations in almost every tropical clime.
This scourge in the West Indies is rife, no island
or shore is free from it and the call for extra
labourers due to this ailment alone is such that
local impoverishment is engendered and the waste
of capital is ruinous. Other preventable diseases
there are, such as malaria, filariasis, yaws, leprosy,
but let us take ankylostomiasis as an example to
begin with. This intestinal infection by a worm,
either the Ancylostoma duodenale Dubini or the
Necator americanus Stiles, is widely met with
throughout the Antilles. The ova of the worm as
they leave the body with the feeces are usually de-
posited not in latrines but anywhere broadcast over
the plantation, for coolies defecate in the squatting
position in the open. In the moist soil the larvae
develop, and feeding on the vegetables or grasses
attain maturity and gain access to the body by way
of the skin or by way of the alimentary canal in
the footl. The evils they cause and how they cause
them are well known and the economic loss, infec-
tion by them entails, is fully recognized by every-
one who is cognizant with the matter at all. The
pollution of the soil is the matter to be dealt with.
This can be prevented in several ways, either by
killing the worms by drugs — thymol, eucalyptus,
chloroform, &c. — or by treating the soil by disin-
fectants, by burning, &c. In fact, the worm in one
or other stage of its being can be readily dealt with
and local immunity for a time can be obtained.
But sanitary restrictions in a plantation or a farm
here and there will not eradicate the ailment, for
until all the soil of, say. a whole island is cleansed
and further pollution prevented, local treatment by
drugs or by incineration is mere waste of time. We
have the same problem at home with rats; for
destroying rats on one isolated farm is useless in
attaining a permanent benefit; just as the cleansing
of a single farm of thistles, dandelions, &c., is use-
less so long as the down from uneleansed neighbour-
ing land is allowed to float over and deposit on the
cleansed fields. Co-operation is necessary to bring
about a permanent benefit in cases of this nature..
But the machinery for co-operation is not to hand,'
otherwise it would have been put into force long
ago. The puiification of the soil of one parish,
county, island or even nation is, if not futile, at
least an imperfect and consequently an inefficient
method of exterminating any ailment. The parish, I
county or national boundary applies only to human,
legislature ; but neither bird nor beast, nor bac-i
terium, and far less the air, knows any sucl'
limitation, and for scientific purposes such divi-
sions are directly detrimental to rooting out disease
Even a natural boundary is useless ; the islanc
would seem to have a hopeful and ideal setting
for the extermination of any given disease ; but
islands have neighbouring islands, and although th(
Jan. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
distance may be too far for the mosquito and other
insects to fly, and thereby naturally thwart the
spread of certain ailments, birds can do bo; ships
carry insects and vermin, and passengers are landed
from them that carry other things besides portman-
teaux, in the form of l)lood parasites of many sorts.
There is but one method if we hope to attain
tlie highest sanitation, namely, co-operation and
international co-operation and again co-operation.
This sche^me of international co-operation, it is
satisfactory to know, is not without a foundation of
hopeifulneisis, for within the past few months a body
of earnest men have formed themselves into a
Tropical Disease Prevention Committee, having for
its object the encouragement of International
Medical Research and the Prevention of D:se.ase in
Tropical Countries. This is as it should be ; the
Committee hais evidently grasped the broad princi-
ples that must obtain if permanent good is to be
done. It is to l>e hoped that co-operaton, complete
and limitless, will attend the work of this body.
Expeditions here and there to settle some obscure
or unsettled bacteriological or epidemiological point
have their purpose and do great scientific good ; but
the practical application of our knowledge to the
eradication of a disease or group of diseases can be
accomplished only by co-operation, international co-
operation of the most intimate nature. An entente
is not siufficient, but an alliance of heads and hearts,
a brotherhood of effort fighting against a common
enemy. The army by which this enemy, the most
deadly with which mankind has ever waged war,
must be organized. A general staff must be
formed, headquarters established and divisions
equipped; an army spirit and moral engendered
and encouraged; all jealousies crushed and a real
crusade of nations; launched, having hut a common
objeet, namely, the ruthless extermination of pre-
ventable disease. All the people must be enlisted
in this fight—" the laird, the tenant and the
cotter"; no slackers nor conscientious objectors
tolerated, for one defaulting nation may cause a
hecatomb of deaths. We wish this newly formed
Tropical Disease Prevention Committee well. It is
an association of scientific and commercial men in
Britain, pledged to accomplish a great work, free
and untrammelled in its scope and earnest in itf»
purpose. It is the first of its kind in the world
and with a horizon which is boundless for good,
scientifically and economically. A world alliance
against disease; nothing else will suffice to defeat
this universal enemy ; so secretive in its methods,
so foul in its purpose, so cruel to its victims, and
uncompromising in the destruction it causes. A
lead is being given by the British, and that the
enemy can be defeated, crushed and exterminated,
never to raise its head again, is as sure as that the
"earth is the Lord's and the fulness thereof."
J. Cantlie.
Annotations.
Treatment of Sea-sickness (P. Cazamian, Archives
de Med. et Pharm. Nav., vol. cviii, pp. 241-284,
1919). — The author has found atropine very useful.
In most cases all the symptoms disappear after one
hypodermic injection of 1/50 to 1/30 gr. of the drug.
In a late stage of the complaint, with great pros-
tration and low blood-pressure, adrenalin may be
associated with atropine.
Vaccinotherapy in Acute and Chronic Bacillary
Dysentery (P. Nolf, Journ. of the Amer. Med.
Assoc, October 18, 1919). — The author, who during
the war had to treat a large number of dysenteric
patients (Flexner type), did not see any good result
from serotherapy. He recommends vaccinotherapy,
a method of treatment first used in India in chronic
cases by Castellani and Greig in 1905.
Cutaneous Reaction and Desensitization in
Quinine Idiosyncrasy (John J. O'Malley and De
Wayne G. Richey, Archives of Internal Medicine,
October, 19i9, vol. xxiv, pp. 378-382).— The
author® have studied two cases of idiosyncrasy to
quinine. They find that the skin test described
by Baerner is a good index to hypersensitiveness.
This method is carried out by making two super-
ficial abrasions with a sterile needle on the flexor
surface of the forearm, about three inches apart,
after cleaning the parts with 95 per cent, ethyl
alcohol. To one a solution of quinine bihydro-
chloride (1 in 20) is applied, while the other is left
untouched, functioning as a control. In both
individuals the scarification to which the quinine
antigen had been applied showed a marked re-
action, while the control scarification merely
exhibited the results of traumatism. The reaction
consisted in an itching i)urning sensation followed
by an area of cedema on both sides of the needle
scratch. The oedematous patch was suiTonnded by
a ibright red halo of erythema. Control tests
carried out, using solutions of salicylic acid, caffeine
citrate, potassium iodide, atropin sulphate and
epinephrin did not produce any definite reaction.
The authors made then an attempt to desensitize
the patients to quinine, using Heran and Saint
Girons' method which consists in giving daily a
•' desensitizing dose " of grm. 0-005 quinine with
gmi. 0-5 sodium bicarbonate, followed after one
hour and thirty minutes by grm. O'l quinine bi-
sulph. and 0'5 grm. of sodium bicarbonate the first
day, and increasingly larger doses the following
days.
In one of the cases the authors had very good
results and succeeded in giving the patient 2 grm.
daily without provoking any discomfort. In the
other case the result was not so good. The authors
observed that in the two cases the intensity of the
cutaneous reaction was in inverse ratio to the
degree of desensitization obtained.
26
THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE. LJa,,. 15. 1920.
dinrrent ^ittnlnx!.
The Journal of Hygiene.
Vol. XVIII, No. 3.
Further Experiments in the /Etiology of Dengue
Fever (J. B. Cleland, B. Bradley and W. Mac-
Donald). — In this interesting paper the authors
show that it is possible to transmit the disease to
a healthy non-immune by the subcutaneous injec-
tion of blood derived from a dengue patient; that
the virus may be passed through a Pasteur-
Chamberland F. filter; that the virus is present in
washed corpuscles, in citrated plasma, and serum
free from corpuscles ; that the virus is resistant to
conditions outside the body for several days; that
the incubation period is usually six to eight days,
but may be as long as fifteen days; that immunity
iWiay be present to injection 229 days after a pre-
vious attack of dengue, that in one experiment
made no evidence could be found that Culex
futigans is the transmitter of the virus; that no
i-esult followed inoculation of guinea-pigs and
rabbits.
Observatiotis on the Cultivation of Typhoid and
Paratyphoid Bacilli from the Stools (T. W.
McLeod). — The author has obtained good results
by using Browning, Gilmour and McKie's brilliant
green enrichment method.
On the Effects of Injection of Quinine'into the
Tissues of Man and Animals (Leonard S. Dudgeon).
— Necrosis of the tissues always follows subcutane-
ous or intramuscular injections of quinine. The
had effects are not avoided by the addition of oUve
oil or fat, or by dissolving the drug in alcohol or
ether. In an addendum Captain F. S. Hele states
that quinine is not fixed in the tissues to any
appreciable extent.
The Kitasato Archives of Experimental Medicine.
Vol. Ill, No. 2.
The Leucocytogregarine of the Wild Rat (Shigeru
Kusama, Katsuya Kasai and Rokuzo Kobayashi).
— The authors describe their parasite as having
certain chai-acters in common with heucocytozoon
viuris Balfour, Leucocytozoon ratti Adie, and
Hepatozoon pemiciosum Miller. It undergoes
sporogony in the rate-mite, Lxlaps echidninvs.
The Rat-bite Fever Spiroclicete (Shigeru Kusama,
Eokuzo Kobayashi and Katsuya Kasai). — The
authors come to the conclusion that the human
and the wild rat strains belong to the same species,
and they believe that Spirochceta morsus-muris
Futaki is very similar or identical with Spirochata.
minor Carter (Spirillum minor Carter, Spirochceta
laverani Breinl, Spirochceta nniris Wenyon).
An Experimental Study on the Life-history of
Sparganum mansoni Cobbold (T. Okumura). —
.\ccording to the author's investigation S. mansoni
is identical with the larval cestode found parasitic
in the muscles of the frog (Rana nigromaculata)
and the snake (Elaphe cliniacophora). Cyclops
leukartii Sars is one of the first intermediate hosts.
The final hosts are carnivorous animals, such as
dogs and cats.
Bulletin he la Societe de Patholooie Exotique,
November 12, 1919.
Notes on the Protozoal Intestinal Parasites of
Man and Animals, by S. L. Brug. — This paper is
divided into four parts. In the first the author
deals with Entamoeba tenuis, describes the charac-
teristics by which it may be distinguished from E.
histolytica and E. coli, and gives his opinion that
in all probability it is unable to produce amoebic
dysentery. The second part gives details of cysts
in the excreta of rabbits which resemble those of
the E. coli and to which the provisional name of
E. cuniculi is assigned until the identity of the
two shall have been proved. The third chapter is
devoted to results obtained by the author in treat-
ing amoerbic dysentery with emetine and salvarean.
The number of cases handled is small, but salvar-
san gave so much more satisfactory results that he
concludes the success of English writers with
emetine must be due to the fact that the latter
have only treated this form of dysentery to any
considerable extent since the war, so that their
patients were never old c- jes. The fourth part is
a study of the intestinal amoebae of the rat. Very
numerous experiments showed that not only were
exceedingly few rats naturally infected with E.
histolytica but it was vevy difficult to infect them
artificially ; when infected they emitted an infinitely
smaller number of cysts proportionately than
human carriers. In the fifth chapter, on Balan-
tidium coli in the Dutch East Indies, the author
attributes the extreme rarity of infection with this
parasite to the fact that the greater part of the
population being Mahommedan no pork is eaten.
The only case he has seen was that of a Mahomme-
dan who had been employed by a European pork
breeder.
Sleeping Sickness in Worth Katanga (Belgian
Congo) from 1913 to 1918, by J. Schwetz.— Five
years' work in charge of the Government measures
for combating sleeping sickness in a very large
district of the Belgian Congo showed that though
palpalis is undoubtedly the principal transmitter of
the disease and the other species of glossina more
than probably share the responsibilitj' to some ex-
tent, there are other factors in the aetiology which
remain obscure. Like cholera and plague, sleeping
sickness apparently passes through a periodic suc-
cession of epidemic and endemic, acute and chronic
phases. The prophylactic measures adopted so far
have been neither efficient nor thoroughly applied,
and there is urgent need for further study of the
disease, its etiology, epidemiology and prophylaxis.
On the Parasitic Flagellata harboured by some
Insects and the Infections they may Produce in
Mice, by A. Laveran and G. Franchini. — The
flagellata studied were H. ctenopayllse, H. cteno-
Jan. 15, 1920,] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
27
cephali, H. jaculvtn and Crithidia melophagi. In-
traperitoneal injections of H. ctenocephali or C.
melophagi in pure culture were fatal to nine out of
sixteen mice. The symptoms produced by the two
organisms were similar and consisted in the appear-
ance of free or endoglobular haematozoa of the
Leishman type in the blood, rapidly multiplying
in the more serious cases, quickly disappearing
again in the milder ones ; anaemia, often very pro-
nounced, with accelerated respiration ; declining
appetite, loss of weight; and frequently final
diarrhoea. The symptoms shown by mice receiving
intraperitoneal injections of material from the liver
and spleen of specimens infected from cultures
afforded no indication that the virus had increased
in virulence.
Latradectus mactans or " Lucacha " in- Peru. — A
Clinical and Experimental Study of the Action of
its Venom, by Dr. Edmundo Escomel, Ar^quipa
(Peru). — The author has identified L. mactans at
Arequipa, where it was not hitherto known to
exist. Experimental inoculation of the eggs into
animals produced either neuro-myopathic arach-
noidism> or cutaneo-hEemolytdc-gangrenous arach-
noidism according to the dose. Injections into the
peritoneum proved rapidly fatal. Repeated bites
gave a certain amount of immunity but no definite
result in this direction was arrived at by the inocu-
lation of graduated quantities of the eggs, as the
animals died as soon as the toxic dose was reached.
The venom contains a cerebro-neuro-muscular
poison, a thrombokiuase and a haemolysin, and
the eggs a proteolysin in addition. Clinical diag-
nosis is usually easy. Prognosis varies both as to
the effect of the venom itself and that of secondary
infections. Prompt treatment by potassium per-
manganate, internally and externally, is of certain
effect, and explorers would do well to carry supplies
of this substance with them when travelling in
Peru.
Cupric Salvarsan and its Sodium Salt in the
Treatment of Human Trypanosomiasis, by F. Van
den Branden. — Intravenous injections of O'OOS and
0'0025 grm. per kilo body weight of cupric salvar-
san in solution prepared according to Erlich's
formula were of active effect and eliminated try-
panosoma from the blood of infected blacks for
long periods when the patients were in good general
condition and the spinal fluid normal. Rapid
relapse followed small doses of solutions of the
sodium salt administered intravenously to adiilts
rtnd intramuscularly to children, but larger quan-
tities gave better results. For prophylactic pur-
|)0ses cupric salvarsan seemed to be more use-
ful than the sodium salt, as it is quicker and
easier to prepare. Comparison of the average
duration of blood sterility effected by single doses
of the two substances in infected blacks with
normal spiunl fluid and in good general condition
showed: (1) out of fom- cases each receiving 0-004
f^rm. of cupric salvarsan per kilo body weight two
remained sterile for twenty-three and twenty-foui-
months respectively and two were still sterile five
years later; (2) out of four cases each receiving
0-0053 grm. of the sodium salt per kilo body weight
two remained sterile for twelve months, and two
after four and a half years.
Transmission of Piroplasmosia in French Dogs by
Dermacentor reticulatus.. Parasitic Emboli in the
Capillaries of the Encephalon, by E. Brumpt. —
From experimental evidence the author arrived at
the following conclusione : (1) The piroplaemosis
seen in French dogs is transmitted by the adult
oifspring of female Dermacentor reticulatus who
have ingested virulent blood. The infection is
therefore hereditary. (2) The adult progeny of in-
fected female Dermacentor who have been har-
boured during the larval and pupal stages by
refractory animals, such as the guinea-pig, may
transmit the infection. (3) The larvae and pupa;
are apparently unable to transmit the infection
even when the offspring of infected females. (4)
The larvae and pupae, when fed with virulent blood,
do not seem able to transmit the disease to the
next stage. (5) The parasites propagate more par-
ticularly in the capillaries of the brain, and to a
less extent in the kidneys and bone mairow.
.'I Contribution to the Study of Bovine Anaplas-
ntosis, by Professor J. Ligniferes. — Experiments
undertaken with a view to ascertaining the effect
of inoculation of Anaplasma argentium into various
animals showed that though guinea-pigs, rabbits,
pigs and horses were uninfluenced by the organism,
sheep and goats retahi it alive in the blood stream
for years and the passage from sheep to sheep and
from goat to goat may go on indefinitely. The
fact of inoculation proved that the parasite was
jiresent in the red blood corpuscles but, no doubt
because of its extreme smallness, it could not be
detected, and neither the sheep nor tlie goats
showed any symptoms as a result except an occa-
sional rise of temperature of 1° C. about the
thirtieth day. The blood, however, waa active when
injected into animals of the bovine race subject to
anaplasmosis.
The Leucocyte Count and Decrease of Eosinophils
in Relapsing Fever, by H. Jouveau-Dubreuil.^
Blood counts in ninety-one cases showed either
decrease or increase of neutrophilic polynuclears,
nearly always very marked increase of large mono-
nuclears, considerable decrease or complete dis-
appearance of eosinophils throughout the course,
and reappearance of the latter to a larger extent
than normal towards the end of the last feverish
phase. Whenever the spirochsete cannot be re-
covered from the blood in a case of relapsing fever,
diagnosis can be made on the evidence of a blood
count; when the diagnosis is clear, a very small
quantity of eosinophils or their entire absence is
a sign that the disease is still running its course,
and a number higher than the normal that the
final phase has been reached.
Leprosy in the Cameroons, by Dr. Gustave
Martin. — Leprosy is very common throughout the
Cameroons, and assumes all forms. During tours
28
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15. 1920.
of inspection by the French between 1916 and 1918
practically every village produced at least one case.
The ignorance of the people, the inertia of the
chiefs, the opposition of the religious leaders and
the large numbers of beggars and nomads in the
country render isolation and prophylaxis difficult.
Segregation villages are now being established for
lepers, but the question of prophylaxis remains to
be dealt with and the paper concludes with details
of a scheme which includes the education of the
black population in practical hygiene.
Three Cases of Oriental Sore, with Remarks
Concerning the Method of Contamination, by L.
Parrot. — The three cases comprised Dr. P., his
wife and son, living at Mac-Mahon (Constantine),
a locality in which oriental sore is unknown. In
July, 1918, Dr. P. placed eight female phlebotomi
of the species pernicious in a cage in his flat which
already contained six Tarantola mavritanica. The
former were captured at Mac-Mahon, the latter at
El-Kantara, a recognized centre of leishmaniosis.
A fortnight later Dr. P., on recovering from in-
fluenza, found that the phlebotomi had escaped
from the cage. During November, 1918, the doctor
and his wife were attacked by oriental sore, and
on December 25 their son, who had been away at
school since September 30, returned home show-
ing the same condition. A native servant and a
European family living in the neighbourhood
showed no sign of the disease, and no other case
was reported among the population in the locality.
The Granules of Spirocheeta duttoni, by John L.
Todd, M.D.). — The author points out that Dutton
and he were the first to state that the spirochgete
of African relapsing fever probably passed through
some developmental process in Ornifhodoros moti-
bata. Many authors believe that a granular
developmental stage occurs in the spirochaetes.
Others dispute the theory, but Todd, discussing
the reasons advanced by the latter, considers
they offer no proof that a granular stage of develop-
ment does not exist. Much of the work done is
open to the criticism of bringing indirect instead of
direct evidence to the elucidation of the problem.
All that is certainly known cannot controvert an
assertion that spirochaetes multiply only by direct
fission; yet many observations make it probable
that a development by a granular stage does exist,
and it would be fitting if that method of develop-
ment were known by Dutton's name. The paper
concludes with a list of references.
The Weil-Felix Reaction in Exanthematic typhus.
Low Agglutinating Power of Spinal Fluid, by J.
Lapin and G. Senevet. — From t^sts made during
an epidemic at Algiers in April and May, 1919, it
would seem that the Weil-Felix reaction is of great
value in the diagnosis of exanthematic typhus when
positive. As, however, it is often only positive
during the last few days of illness, no account
should be taken of a negative reaction when the
clinical symptoms point to typhus.
The agglutinating power of spinal fluid on proteus
was observed in six cases. In four patients whose
serum agglutinated at 1 in 500 the spinal fluid gave
no agglutination at 1 in .50; in one patient whose
serum agglutinated at 1 in 2,000 the spinal fluid
agglutinated slightlj' at 1 in 50; in the sixth, whose
serum agglutinated at 1 in 3,000, the spinal fluid
agglutinated at 1 in 100. In the two latter cases
the fluid was entireh' free from blood derived from
the puncture.
Plasmodium relictum, the Pathogenic Agent of
Malaria in Birds, gives no Fatal Disease to the
Mosquito which transmits it, by Etienne Sergent.
— Plasmodium has hitherto been regarded as so
pathogenic for the carrier insect that Ruge advised
the selection of birds only mildly infected for the
experimental infection of mosquitoes with blood
containing the parasite. The author has observed
several hundreds of cases of extensive Plasmodium
relictum infection in Culex, and found that the
mortality percentage was never higher among speci-
mens showing at least 100 zygospores of maximum
development than among the controls (those with
only a few zygospores) or among fresh Culex (those
which had not been fed with infected Blood). He
considers that Plasmodium relictum may attain its
full stage of development in Culex without causing
disturbances entailing the death of the insect.
In the Malaria of Birds (due to the Proteosoma)
no -parallel exists between the Infection in the
Blood of the Bird and the Infection of the Mosquito
consequent upon Contamination by the Bird, by
Etienne Sergent. — In the malaria of birds an in-
cubation period of from three to ten days is followed
by an acute stage, during which plasmodium is
present in the blood in very large numbers for about
a week. Mosquitoes fed with the blood at this
period, when the parasites are of all ages and the
gametes very numerous, become intensely infected;
but if they are fed with the blood at a later stage,
when the gametes are very rare, the number of
zygospores obtained from the insect is not reduced
proportionately. The blood of the bird continues to
be very infectious for the insect during the fortnight
which follows the acute stage, although the para-
sites in the blood of the bird have by that time
become extremely rare.
An Autochthonous Malarial Centre in the Seine
ct Oise Department of France, by Dr. Roblin. —
Three cases occurretl, all due to the Plasmodium
fivax and of a mild character. The first patient
was bitten by mosquitoes, of which quantities were
at the time present in that part of the Seine which
runs through the district, and it is presumed that
the insects were infected with malaria by a soldier
returned from the East who had already been
treated with quinine for slight attacks. The two
other cases were infected by mosquitoes either from
the first patient or from the soldier. The circum-
stance goes to show the necessity of carefully
following up all men who return to the civil popu-
lation with a history of malaria if outbreaks are to
be prevented in districts where mosquitoes abound.
Jan. 15 1920.] THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE.
29
The Study of Tuberculous Infection among the
Native Pop^dation of Ouarffla Saharian by the
Tuberculin Skin Reaction Test, by P. Bresson.
— The population consists of coloured iialf-breeds
(of Soudan negro and Arab blood), Arabs and
nomadic whites, all living under conditions exceed-
ingly favourable to the development of tuberculosis.
The infection is imported as the result of teinporary
expatriation and consequent contact with Euro-
peans. Both pulmonary and surgical tuberculosis
are seen, the former running a particularly rapid
course. The disease would seem to be transmitted
rather from one member of a family to another than
by any acquired heredity.
Some hundreds of tests were made, exclusively
on the sedentary part of the population, and 545
results obtained. Of these the number of positive
reactions was 199, or 36-5 per cent. In children
under 1 year the percentage was nil, reaching the
maximum in subjects of 15 and over. It was
higher in the Arabs or Berbers than in the half-
breeds (the latter being a hardy race and thoroughly
acclimatized), and highest of all in the whites.
^bstratls.
HiEMOGIX)BINUEIC BILIOUS FEVEE.'
By Charles Gbeene Comston.
From the writings of the French physicians the
pathogenesis of hjemoglobinuric bilious fever of
tropical countries is now quite clear. As soon as a
European settles in a tropical latitude he is directly
exposed to a defensive struggle of the organism.
All of the physiological resources, the renal, hepatic,
splenio and digestive functions, are put to the hard
labour of adaptation. It is on these physiologically
overworked organisms that malaria imprints its
tenacious and formidable marks. It upsets the
circulatory system, causes morbid change* to take
plac* iu the glandular organs of organic defence
and repair, produces disturbances in the digestive
tract, compromising the physiological secretions.
' The effect on the nervous sysitem is made manifest
i by neurotic disturbances, a special hyperexcita-
I bility, and at times by a temporary change of the
I psychic i)erflonality. This is a summary outline of
I the soil upon which haemoglobinuric bilious fever
■ develops.
Clinical observation shows that it is not one of
these morbid processes which attack the European
as soon as he enters the tropical zone, hut that it
almost always arises in persons who have made
rei)eated visits to or have hf^en some months in the
Trojiics and have contracted malaria. Blackwafcer
fever is essentially a disease occurring in subjects
who have been in the Tropics for years and have
' Abstracted from New York Medical Journal, December fi,
1919.
paid their tribute to malaria or to cUmate. Up to
the present time no specific pathogenic agent ot
the disease in question lias been discovered, so that
if the malarial conception of the process is main-
tained, it would seem logical to attribute the char-
acteristic accidents of the htemoglobinuric syndrome
to paludism.
When the human organism becomes infected with
malaria the circulatory system is completely upset,
since the hsematozoon, which multiplies rapidly,
lives at the expense of the red blood corpuscles.
An immediate ancemia indicates an intense de-
globuhzation, while the blood serum is laden with
the detritus of the struggle, cadavers of the figured
elements and those of the parasite as well, wliich,
perhaps, constitute the orig^in of the toxin of the
Plasmodium. When the cell disintegration reaches
one fifty-seventh of the total mass of the blood, the
serum acquires the property of dissolving its own
red blood corpu'scles ; it has become haemolytic.
Some writers attribute this serological change to
demineralization of the serum. The blood serum
becoming hypotonic, the red blood corpuscle absorbs
water and gives off sodium chloride; following this,
its hsemoglobin becomes free and is dissolved in the
serum, giving it a red tint (slight hse^molysis). If
hypotonia is very pronounced there is a complete
melting of the corpuscle. This is total haemolysis.
What we now know of antigens and antibodies
gives us a more intimate conception of the mechan-
ism of the emission of haemoglobin in the urine.
The action of an antigen of the body, in the cir-
cumstances the paludal toxin, produces an antibody
in the circulating blood which may be h»molytic
for the red blood corpuscles of this body. This
ha>molysin is composed of two elements, the one
thermostabile, the sensibilisatrice ; the other ther-
molabile, the alexin or complement. The sensi-
bilisatrice is alone peiTnanent in the specific serum ;
as to the complement, it is less stable and can
be deviated by the complex : sensibilisatrice plus
antigen.
W^hen there has been considerable parasitic trau-
matism witli a destruction of red blood corpuscles
in the neighbourhood of one fifty-seventh part of
the total mass of blood, the hsemolysis appears, so
to speak, automatically in malarial siubjeots. On
the conti-ary, in cases where the resistance of the
red blood corpuscles does not reach such an exces-
sively low degree, the complement will be deviated
by the complex : malarial toxin plus sensibilisatrice.
Hfemoglobinuria will not ocxiur, but it is on the point
of being produced. Then all that is necessary will
be chilling of the body to at once cause an h»mo-
lyfcic outburst, by the appearance of the necessary
alexin.
Such seems to be the logical explanation of tlic
pathogenesis of haemoglobimu'ic bilious fever of
tropical countries. But like any other morbid pro-
cess its gravity will vary Eupture of the fragile
organic equilibrium may only be temporary if a
sufficient integrity of the organs of repair and
elimination subsists. The spU^cn, whose efforts in
30
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 16, 1920
the struggle can be clinically followed, intervenes
by its haematopoietic functions. The hsematopoiesis
throws new elements into the circulation which will
fill the place of those destroyed by the parasiite.
The liver likewise intervenes by the antitoxic func-
tions it possesses; it can even eliminate the dis-
solved haemoglobin when the amount is not too
great.
When the outcome of the process is favourable
the leucocytic formula follows a parallel evolution.
The number of red blood corpuscles increases at
the same time as their hemoglobin content. A
manifest hyperleucocytosis appears, characterized
by numerous neutrophile polynuclears, and in these
cireumistances a mild, transitory hiemoglobinuria
win represent the principal symptom. But if the
attacks of the parasite have been more violent and
have occui-red in a subject weakened by the action
of the climate, and if they have succeeded in pro-
ducing profound changes of the viscera, the evolu-
tion will be difiFerent. An attack of icterus, with all
it's symptomatological train, occurs. It may appear
suddenly or from the most vulgar causes, such as
a chill, overwork, or even after a small dose of
quinine. It is only too clear that in an intoxicated
organism which no longer eliminates, a drug like
quinine simply adds its toxic effects to those already
present. It is probably to this fact that the genesis
of exotic haemoglobinuria has been attributed to
quinine, hut that is all it implies.
Hemoglobinuria is not of necessity fatal and re-
coveries are frequent, but the first paroxysm must
be looked upou as an important warning. In other
instances the disease effects a very rapid progress.
The patient lies limp upon the bed, marked icterus
is present with dark, scanty urine ; anuria may arise.
Hiccough is persistent and the vomiting incoercible,
the vomituis itself being sometimes haematic, and the
j)atient dies with all the manifestations of uremic
intoxication. Such is the pathogenesis of haemo-
globinuric bilious paroxysm of malarial origin, but
all the cases cannot be explained in the same way.
Has'moglobinsemia can be realized only with some
difficulty since it is only when red blood corpuscle
destruction has attained one fifty-seventh of the
total mass of blood that the serum acquires the
property of haemolysing its oWn- cells.
In these circumstances it was logical to suppose
that other foci which could give rise to the haemo-
lytic phenomenon existed in the organism. In the
spleen of malarial subjects haemolytic, and even
autolytic substances are present, which, in the
physiological state, cannot be placed in evidence by
the technical means employed at present. The
spleen is ca.pal)le of haemolysing a certain number
of red blood corpuscles contained in its parenchyma,
although to a very limited degree, and in the normal
state it remainis within the bounds of physiological
haemolysis. In a more advanced degree it increases
its haemolytic power by the addition of cell fragility
and haemolysinaemia.
The liver acting on blood coagulability and on the
red blood corpuscles causes true haemolytic icterus.
The malarial parasite may provoke hepatic lesions
which cause the bile to enter the cii"oulation and
there it dissolves the haemoglobin by the chelates it
contains.
But of all the organs which should be efipecially
incriminated, the kidney stands foremost. The
frequency of renal lesions found at autopsy in these
cases is notorious and their haemorrhagic nature has
been demonstrated beyond a doubt by a number of
observers. The renal lesions explain why only red
blood corpuscles and no trace of dissolved haemo-
globin are found in some cases of bihous fever.
The malarial parasite produces a true nephritis, and
it is to these cases that the old tenn of haematuric
bilious fever should be retained in our modern
nomenclature. The kidney should no longer be
regarded as a simple emunctory ; it plays a part
in the genesis of haemoglobinuria by itself freeing
the haemoglobin. Thiis can be explained slight
paroxysms of haemoglobinuria without much pyrexia.
To sum up the pathogenesis of the process under
consideration, it may be said that there are several
ways of forming the haemoglobinuric syndrome, viz.,
haemolysis in the circulating blood, renal haemolysis
(frequent), hepatic and splenic haemolysis. In some
serious cases the entire organism is involved in the
haemolysis, and in the clinical evolution of the
morbid process, in its geographical distribution and
in its pathological manifestations, is encountered the
visible, yet mysterious action of malaria, of its
specific agent or its toxins.
The best prophylaxis against the affection is
quinine, as this drug prevents the development of
malaria. Therefore it does away with the soil in
which the process develops. The treatment of the
attacks of haemoglobinuria is not simple. The ex-
hibition of quinine should be reserved for the mild
cases, with high temperature (of the malarial type)
without any serious damage to the general health
and especially when there is sufficient renal per-
meability. Wlien the haemc^lobinuria is intense
and the parasite is found in the blood, when urine
is scanty or even anuria exists, all leading to uraemia,
quinine is both useless and dangerous. The same
applies to all other drugs. The treatment should
be directed to increasing the blood pressure and to
remove all obstruction to renal elimination.
To fulfil this end diuretic drinks must be given
freely. In Africa there are two decoctions which
have a more or less merited reputation, namely.
Cassia occidentalis, which is employed at the dose
of 1 ounce of the plant to a quart of water, and
secondly, a plant of the Combretum genus, called
hinkelibah, in a 10 per cent, decoction. If these
plants are not at hand, very dilute coffee or tea can
he usie<l. The essential is that the diuretic drink
employed shall not contain any active toxic prin-
ciple.
Subcutaneous injections of salt solution may be
given unless there are advanced renal lesions,
especially if there is oedema or anasarca. The renal
congestion can be relieved l)y dry cupping over the
lumbar region. Cold rectal injections, should be
given and the vomiting and epigastric pain can be
relieved by chloroform water.
Jan. 15, 19L0.] i'HE JOUKNAL OF TBOPICAL MEDICINE ANB HYGIENE.
SURGICAL PROBLEMS AND DIFFICULTIES
IN THE TROPICS.'
By D. J. Uaubies.
'J'liii belief that chloroform is the only ansBthetic
tluit can be administered on an open mask in India
was put to the test at Deolali, and it was found that
ether given by the open method acted almost as
well as it does in England; but posisibly a httle
more had to be administered, especially if a pre-
liminary dose of morphia, ^ gr., and atropine,
100th gr., had not been administered half an hour
before the ansesthetic was commenced . The' tem-
perature in the shade at Deolali during the hot
weather goes up to 104-106° F. It is qidte probable
that at temperatures of 110-116° F. the administra-
tion of open ether might present insuperable diffi-
culties, but this should not be made an excuse for
the complete abolition of ether from the operating
theatre during the cold season.
When operating the temperature is important.
The surgeon lias to decide whether the discomfort
caused by the weai-ing of a head-gear and face mask
is more than compensated for by the increased pro-
tection afforded to the patient. By wearing these
articles the amount of perspiration lost by the
operator is certainly increased ; but, on the other
hand, there is less danger of any dropping into the
operation area. The latter advantage outweighs
the disadvantages, and I now invariably use both
a headgear and a face mask when operating. It is
often stated that, even if a few drops of persipira-
tjoii did accidentally fall into the wound, very little
effect would be produced on the way it heals; but
this statement ought not to be accepted as a fact,
and it would certainly not be readily accepted if
the operator happened to have a number of boils or
pimples on his face.
The technique of the actual operation hae to be
modified to meet the abnormal way the tissues
react to trauma. This brings in the question of
oozing into wounds, incisions, &c. Far more bleed-
ing points have to be tied in any ordinary operation
performed in the Tropics than in the same operation
carried out in England. Moreover the tendency
for oozing to take place after the operation, and even
after the removal of the stitches, has to be taken
into account in applying the dressings and bandages.
Collodion dressings should never be employed after
any operation, or even after the removal of the
stitches.
Oozing is more pronounced during the monsoon
season, and like many other unexplained physio-
l();^'i(al phenomena in India, is put down to the
patient's " thin blood."
Tliis subject has an important bearing on opera-
tions on joints; more especially the removal of loose
cartilages or bodies from the knee-joint. If a
tourniquet is used the actual operation presentai no
more difficulties than when carried out in England.
It is imnecessary to add that all vessels external to
tlie synovial membrane should be tied ; and before
' Abstracted from the Tndian Medical Gazette, December,
1919.
a tourniquet ia removed iihe kuue should be firmly
bandaged over a thick layer of wool, extendmg
about b to 4 ill. beyond the limiits of the jomt
capaule. This dressmg is left on until the stitches
are removed on the seventh or eighth day. When
the above instructions have been carried out the
results show no appreciable differences from the
results obtained in HJngland.
Individuals who have contracted malaria make
bad subjects for operative treatiment. In the first
place, the anaemia following an attack of malaria
aggravates the oo2dng into the wound; and this is
a matter of iimportance when operating on organs
where it is impossible either to tie ail bleeding
points or to apply the requisite degree of pressure
after the operation, e.g., operations on the liver or
intestines.
In the second place, it is soon realized by the
surgeon that an operation, even a minor one, will
almost certainly precipitate an attack of malaria.
Sometimes the patient has never had a jprevious
attack, and never knew he had been infected ; or
lie may have gone for several years without an
attack, and thought he had completely got rid of
liis malaria. The most important factors concerned
in precipitating the attack are still matters of per-
sonal opinion. There are obviously three possi-
bilities. The attack may be precipitated by: —
(1) The mental worry.
(2) The actual trauma.
(3) The action of the anaesthetic.
Regai-ding the first, attacks are precipitated in
patients who have been told that they were to be
operated on next day, but for some reason or other
they were not operated on.
The influence of trauma is well known to all
surgeons, as any injury, such as the fracture of a
bone, in a malarial subject is often followed by a
recrudescence of the disease.
It is obviously impossible to estimate the efftjct
of the ansesthetic in stimulating! the activity of tlio
parasite. Cases are known where a malarial attack
has followed an examination under an anaesthetic ;
but here, of course, one cannot eliminate the influ
ence of the accompanying mental disturbance.
It is quite obvious that all these factors interfere
with some mechanisim which keeps the parasite
under control. It is well known that the incidence
of almost any disease, including a " chill," may pre-
cipitate a malarial attack. Many theories could be
advanced to explain this problem, but it would be
more to the point to try to find some explanation
applicable to all cases. It seems reasonable t^>
suggest that the circulatory changes, induced by
all these different disturbing agents, may be the
most potent factor causing the liberation and multi-
plication of the parasites. Collapse, however pro-
duced, rapidly causes the auprarenals to discharge
their chromaffin bodies in the attempt to supply
the pressor substances necessary for the mainten-
ance of a good ciroulation. \ diminution in the
supply of tViese pressor bodies allows changes in the
circulation which possibly favour the activity of the
malaria parasites. The popular expression " that
32
THE JOUENAJL OF TJIOPICAL MEDICINE AND HYGIENE. [Jan, 15. 1920
the patient is run down " means much the same
thmg, and so does the expression " diminished
vitality."
It has been suggested that trauma liberates some
ferment \\hich stimulate® the malaria parasites.
It might also be suggested that the lipoids, which
may help to keep the paras.ites under control, are
dissolved by the anjesthetic; but these two sugges-
tions would not be applicable to attacks following
on mental worry or shock in the absence of an
ansesthetio.
Apart from theoretical considerations, it is a fact
" that a temperature of 102-104° F. coming on a
few days after a carefully conducted laparotomy or
arthrotomy in a mialarial subject is more likely to
be due to the malaria parasite than to sepsis."
Operators should carefulFy ask each patient before
operating if he is a malarial subject, and if so, put
him on quinine for three or four days before the
operation and continue giving it for about ten days.
By doing this he will obviatei all rises of temperature
due to the malaria parasite.
There is another condition due to the malaria
parasite which is of considerable importance to
the operating sturgeon, viz., the condition termed
'■ abdominal malaria." During an attack the
patient has a rise of temperature, and symptoms
and signs suggestive of acute peritonitis, and it is
mistaken for cholera, but the finding of the parasite
in the blood and the absence of the vibrio from the
excreta establish the correct diagnosiis. An abdomen
was opened for what was considered to be acute
peritonitis, secondary to appendicitis; the condition
found was unlike anything seen before. The intes-
tines were slightly injected and appeared to have
been painted over with a thin layer of milk. Here
and there were very small collections of the same
sort of fluid lying between coils of intestines. The
removed appendix was found practically normal.
The appearance of the temperature chart next day,
together with a history of a previous attack of
malaria, Suggested the correct diagnosis and the
parasites were found in the blood.
■On opening an abdomen for what was considered
to be a perforation of some part of the> intestine,
the condition found insiide the abdomen was exactlj"
the same as found in the supposed appendicitis case
mentioned above, and the subsequent discovery of
the parasite in the blood rendered the diagnosiis clear.
An acute dysenteric abscess of the liver presenting
in the epigastric region simulates to some extent a.
perforation of the intestine. This t.vi>f of hepatic
abscess develops very rapidly and within twenty-
four to forty-eight hours of the appearance of sj'm-
ptonis a large swelling is formed in the epigastric
region. A localized collection from a gastric ulcer
which has slowly perforated presents very much the
same symptoms and physical signs, and the exact
diagnosis is often imposs'ible to establish before a
laparotomy has been carried out. An X-ray exami-
nation before operation might demonstrate the col-
lection to be entirely within the limits of the liver
shadow, and so strengthen the evidence in favoiu-
of a liver abscess; but one miust remember that the
same appearance would be presented by a collection
lying under the liver, but covered over by an over-
lapping anterior liver margin. Putting in an ex-
ploring needle is not justifiable in such cases, unless
followed by an immediate, lapai'atomy.
As a laparotomy is the correct treatment for
either condition, there is no advantage in first
exploring with a needle. Another peculiarity of
these epigastric liver abscesses and one which is
rather disconcerting when present, is the fact that
they may show pulsation, which at times appears
to be expansile. One was operated on the size of
a tangerine orange in the anterior margin oi the
liver in a man 42 j'ears of age. It was adherent
to the anterior al)dominal wall and felt like an
aneurism of the abdominal aorta. The temperature
eliart reaching 103° F. and the absence of all mur-
murs decided the diagnosis and this was confirmed
at the operation.
There is one other subject of practical importance,
viz., the subject of mechanical apphances. When
recommending these in preference to an operation
the surgeon must take into consideration the dis-
comfort caused by any apphance in a tropical
counti-y. A truss or belt for a rupture may be
easily tolerated in a cool climate; but in a hot
climate the skin soon shows signs of irritation at
all points of pressure, and mai'ching becomes an
impossibility. Apart from the diminished efficiency
of the man with a truss the above consideration
should influence the surgeon to advise an operation
in every case, imless contra-indicated by some
systemic disease.
DEER FLY FEVER, OR PAHVANT V.\LLEY PLAGUE
In recent years there has occurred among the
rural population of JNIillard County, Utah, a disease
initiated (according to popular belief) by a fly bite
on some exposed surface of the body and mani-
fested by the enlargement of the lymph glands
which drain the bitten area and by a fever of a
septic type lasting from three to siix weeks. The
site of the bite and the afTfected lymph glands be-
come tender and inflamed, and they commonly sup-
purate. There is marked prostration and the patiient
is confined to his bed. The first case known to
have terminated fatally was reported in 1919. The
Surgeon-General of the U.S.P.H. Service detailed
Dr. Edward Francis to investigate this new disease.
Cultures' made on ordinary laboratory mediums from
the lesions of animals dying from the disease were
negative ; but cultures made on coagulated egg yolk
yielded a growth of a .small non-motile coccobacillus.
These cultures reproduced the lesions of the disease
in guinea-pigs. It is believed that this organism is
the Bacterium tularense, first described by McCoy
and Chapin in 1912.
The authorities of the Liverpool School of
Tropical Medicine have conferred the Mary
Kingsley Medal for 1919 on Dr. F. W. Scott
Macfie, in recognition of his distinguished scientific
work in West .\frica.
J,
Feb. 2, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 3, Vol. XXIII.
(firigtiial Communiations.
THE " TENUE " PHASE OF PLASMODIUM
VIVAX (GRASSI AND FELETTI 1890).
By Albert J. Chalmers, M.D., F.R.C.S., D.P.H.,
Director, \Pellcome Tropical Research Laboratories,
AND
Major R. G. Archibald, D.S.O., M.D., R.A.M.C,
Assistant Director, Wellcome Tropical Research Laboratories,
Khartoum.
CoNTENT.s. — Introductory — Historical — Clinical
Notes — The Malarial Parasite — The " Tenuc "
Phase — Summary — Acknowledgments — Refer-
ences — Illustrations.
Introductory. — Quite recently by the kindness
of Captain McKail, Senior Medical Officer, British
peculiar forms were noted by Mannaberg, Bignami
and others.
In due course more especial attention was paid
to these peculiar forms, as seen in the quartan
parasite, by Billet in 1906 and by Ziemann also
in the same year. They both stated that they had
noted the same peculiarities in the subtertian
parasite and gave illustrations.
In 1908 Balfour produced an excellent coloured
plate in the third report of these laboratories which
well illustrates some phases of these forms as seen
in the subtertian parasite.
In 1913 Ed. and Et. Sergent, with Beguet and
Pantier, gave illustrations of the same phase in
the subtertian parasite.
In 1914 Stephens, in the Royal Society and in the
Annals of Tropical Medicine and Parasitology,
drew especial attention to these peculiarities which,
in his opinion, indicated that the parasite pro-
ducing them was specifically different from the
three classical human species, and therefore he
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Troops, Khartoum, we obtainetl a blood slide from
a British soldier suffering from tertian malaria.
This slide was taken during the febrile attack,
i.e., about 10 a.m. on the morning of the IStli
October (vide temperature chart) and before the
patient had received any quinine. It showed in
some of the ei-ythrocytes such peculiar forms that
we think it is useful to record our observations
thereon and to compare them with such similar
conditions as Jiave been described by others. Our
intent is to establish the possibility of the existence
of an occasional phase in the life cycle of all the
human malarial parasites which so far has not
received sufficient attention and when met with is
apt to confuse tlie observer.
Historical.— 'i^oim after Golgi liad traced the life
histoi-y in man of the malarial parasites, various
methods of coloration were brought into play with
flie view f)f demonstrating their structure, and
proposed the new name Plasmodium tenue
Stephens 1913.
Later in the same year Balfour and Wenyon
discussed the specificity of the new parasite, and,
drawing especial attention to the forms already
illustrated by Balfour, and adding two further
cases of subtertian malaria, in the blood of which
a similar phase could be found, came to the con-
clusion that P. tenue was not specifically different
from the subtertian parasite. So far as we know
these peculiarities have not yet been found in the
tertian parasite {P. vivax), and therefore we
attempt to remedy this gap and at the same time
to discuss the nature of these peculiar forms.
Clinical Notes. — These are divisible into three
parts, viz. : The Malarial Attack, the Dermatitis
Scarlatiniformis and the Furunculosis.
f.1) The Malarial Attach.~\ British soldier,
aged 22 years, felt out of sorts about noon on
34
THE JOUENAL OF TROPIGAL MEDICINE AND HYGIENE. [Feb. 2. 1920.
October 9, 1919. He had previously had sand-fly
fever while in Palestine, but never malaria, and
never, to his knowledge, had he taken a dose of
quinine in his life, nor had specimens of his blood
taken for examination.
He did not feel ill enough to report sick and
felt quite well next day, with the exception of
slight headache about noon. On October 11, he
again felt ill and shivered considerably, but did
not report sick, and on the 12th felt perfectly well.
On the 13th he again felt ill and again shivered,
so he went to the hospital, where his temperature
was noted to be 102-4° F. and his spleen to be
enlarged and tender. A blood film was taken at
once, about 10 a.m., while the temperature was
still rising and before any quinine had been
administered.
His differential leucocyte count on this day was
as folltjws : —
Polymorphonuclear leucocytes ... 84
Eosinophile leucocytes 3
Mononuclear leucocytes ... 5
Large lymphocytes 4
Small lymphocytes ... ... 4
Total 100
As the malarial panisites depicted in Plates I
and II were found, the j)atient was treated by
quinine hydrochloride administered orally in solu-
tion.
On October 13, 14 and 15, 45 gr. were given per
diem, supplemented on the 14th and 15th by
9 minims of liquor arsenicalis per diem.
On the 15th, 1.7th and 18th this dosage was
reduced to 30 gr. of quinine daily, supplemented by
the same quantity of arsenic as before.
On the 19th, as he had developed the rash pre-
sently to be mentioned, he received only the early
morning dose of 10 gr. of quinine and 3 minims of
arsenic.
On the 17tli and 19th his temperature rose to
102O Y., but malarial parasites were absent from the
peripheral blood. Although in some way associated
with the dermatitis, which was in full ei-uption,
the elevations of temperature showed tertian
periodicity of a deferred type.
After this the temperature fell by lysis, reaching
normal on the 24th and 25lh, when the malarial
attack may be taken to have ended as no parasites
were again found in his blood, and his spleen
diminished in size gradually and did not again
become tender.
(B) The Dermatitis Scarlatiniformis. — To the
best of his knowledge, prior to October 13, 1919,
the patient had never taken a dose of quinine in
his life.
On that day he began a course of quinine therapy
in order to combat his attack of tertian malaria,
and, as already stated, he took 45 gr. of quinine
hydrochoride orally. The drug was administered
in solution, and was repeated next day, being
supplemented by arsenic.
On October 15 there was some redness of the
skin, but the same doses of quinine and of arsenic
were administered.
On the 16th, after the patient had taken 185 gr.
of quinine hydrochloride, a profuse erythematous
eruption appeared. The quinine and arsenic were
continued, though the dosage of the former was
now reduced to 30 gr. per diem.
On the 17th this rash was more developed and
the patient's temperature rose to 102° F., but
dropped to normal on the 18th, though the eruption
was worse and the lips and eyelids swollen.
On the morning of the 19th the patient only
received the morning dose of 10 gr. of quinine and
3 minims of liquor arsenicalis because a diagnosis
of dennatitis scarlatiniformis due to quinine {vide
Chalmers and Innes in the references) was made,
it is interesting to note that at the commencement
of this day the patient complained of sore throat,
and on inspection the fauces were noted to be red
and congested. The temperature on this day again
rose to 102° F.
With the cessation of the quinine therapy the
temperature gradually fell by lysis, reaching normal
on the 24th and 25th.
The throat symptoms quickly disappeared, while
the erythema grew paler, but an extensive
desquamation (fig. 21) set in, which lasted tili early
in November, though much reduced in amount
after a week.
The dermatitis affected almost every part of his
body from the crown of his head to the dorsa of
his feet, but it appeared later, and was less marked
on the legs than elsewhere. During the eruption
he complained of some slight cutaneous irritation.
While the dermatitis was subsiding quinine was
being passed in the urine, as is evidenced by a trace
being detected on October 26 by Dr. Joseph, the
Government chemist of these laboratories, using
I{ams<len and Lipkin's modification of the Tanret
reaction.
This is interesting, as none had been adminis-
tered since the morning of the 19th, i.e., for no
less than seven days, and therefore this would
indicate a possible locking uj) of the drug in the
system.
In regard to this Derniatiiis scarlatiniformis, it
appears to us to agree with the case reported by
Chalmers and Innes in this journal in 1917, to
which reference may be made for diagnostic and
other considerations.
As to its causation, it appears to be of the nature
of an anaphylactic phenomenon (vide Chalmers and
Martyn and Chalmers and Innes in references).
The condition was treated by salol and calcium
lactate administered orally, and by calamine lotion
externally.
(C) The Furunculosis. — While the Dermatitis
scarlatiniformis was subsiding the patient suffered
from a severe attack of fui-unculosis which caused
the rise of temperature from October 27 to Novem-
ber 3 inclusive, as can be noted by a study of the
temperature chart.
Boils are not uncommon after anv condition
Feb. 2, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
35
which lowers the resistance of the body to the
causal germ Aurococcus mollis Dyar. His differen-
tial leucocyte count at this time was: —
Polymorphonuclear leucocytes ... 63
Eosinophile leucocytes ... ... 15
Mononuclear leucocytes ... 8
Large lymphocytes 8
Small lymphocytes 6
Total
100
The furunculosis is as yet not cured, but this
completes the clinical account of the case, as far
as we are concerned, and we will now turn to the
main subject of this communication, viz., the
malarial parasite.
The Malarial Parasite. — An examination of the
patient's blood prior to the first dose revealed an
infection with two generations of P. vivax (Grassi
and Feletti 1890). The younger generation is
demonstrated in the coloured plate, i.e., Plate I
in figs. 1, 2 and 3, while the older generation is set
forth in figs. 6, 10, 11, 12 and 19. It is unneces-
sary for us to make any remarks on these forms,
some of which are indicated in the photomicro-
graphs of Plate II, figs. 22, 23, 24 and 25.
The " Tenue " Phase.— Fig. 3 of the same
coloured plate depicts a trophozoite, which appears
to us to be smaller than an ordinai-y ring form of
the simple tertian parasite, while figs. 5, 8 and 9
depict peculiar types. All these may or may not
be early stages of the " tenue " phase.
Fig. 7, however, without doubt indicates an early
" tenue " phase. Here two rings are shown joined
together by a narrow loop of cytoplasm, but only
one ring is provided with chromatin.
A further step with two rings, well provided
with chromatin is demonstrated in fig. 13, and
the snapping through of the connecting proto-
plasmic bridge would produce such forms as fig. 4
or fig. 17. It would appear that the big loop in
fig. 13 might be the origin for more rings, as set
forth in fig. 15, where in place of the one large and
one small nng of fig. 13 there are two medium-
sized rings, and one small ring which has evidently
become reduced by giving rise to an achromatic
loop. The separation of four such rings is demon-
strated in fig. 18, while fig. 14 demonstrates a further
development in which four chromatin bearing rings
are visible, one of which is giving rise to an achro-
matic loop while one solid pseudopodial-like form
contains chromatin and reminds one of a possible
earlier stage of fig. 9.
Figure 16 is the furthest development of the
" tenue " phase which we have illustrated, but we
have seen one containing no less than seven such
rings.
The photomicrographs depicted in Plate II, figs.
26, 27 and 28, substantiate the coloured illustra-
tions.
Comparison. — If these figures are compared with
Balfour's Plate VII. in the Third Report of these
laboratories, with Stephens' Plate of Plnsviodiiim
tenue in the Proceedings of the Royal Society, and
more especially with Plate II. of Balfour and
Wenyon's paper in the Journal of Tropical Medi-
cine AND Hygiene, a general likeness to many
forms will be easily recognized, if it is remembered
that the speoies of parasite is different.
Unfortunately we 'are unable to compare our
illustrations with those made for the Quartan
parasite, but judging by written statements they
resemble tlie forms seen in the subtertian parasite
and, if this is so, must in some way resemble our
forms.
Theoretical Considerations. — The usual method of
a sexual reproduction in the telosporidia is by the
formation of merozoites. The human malarial
parasites which belong to this protozoal class form
no exception to this rule, as may be judged by an
examination of Plate I, figs. 11, 12 and 19 and
Plate II, figs. 24 and 25.
Simple and multiple fission are however common
in the flagellata and simple fission is noted in the
piroplasmidas.
We are of the opinion that the correct explana-
tion of such forms as those depicted in Plate I.,
figs. 7, 13, 4 and 17, is that they may be looked
upon as simple fission, while the peculiar conditions
illustrated in Plate I, figs. 15, 16, 14 and 18 and
Plate II, figs. 26, 27 and 28, indicate multiple
fission.
The question now arises whether this unusual
method of asexual reproduction is of any use to the
malarial parasite in its struggle for existence in
the human blood.
Recently Miss Lawson, studying malarial ansemia
due to the subtertian parasites, came to the conclu-
sion that each parasite destroys several red cor-
puscles, by migrating from one corpuscle to another.
She states that the migration takes place in all
oestivo-autumnal (subtertian) infection, and she
supports her contention by a series of photomicro-
graphs, by quoting observers who have noted free
parasites in the blood, and by the fact that in
malarial anaemia the reduction of heemoglobin is
out of proportion to the loss of red corpuscles.
If we could substantiate her findings we should
have an easy explanation for the process of simple
and irniltiple fission which we have described above,
but, unfortunately, our experience does not enable
us to do this.
Neither are we able to support the suggestion
that these forms only appear shortly before the
death of the patient, as the present patient is alive
and convalescent and never was in any danger of
his life at any time of his illness.
Miss Lawson might contend that the parasite in
this present case was trying to benefit by its
advantageous position of living in a patient who
had never previously had quinine and who had
allowed the disease to progress several days without
any attempt to check it.
But if this is the correct explanation we ought
to have been able to see the migration, because she
advises a person who wishes to observe this
36
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 2, 1920.
phenomenon to study heavy infections and certainly
the present case was a fairly lieavy infection with
the tertian, but not with the subtertian parasite.
We are tlierefore compelled to seek some more
theoretical and less provable or disprovable
explanation of the " tenue " phase.
We suggest that the whole process is a throw-
back to a method which may have been useful to
some ancestor of the malarial parasites but which
to-day is entirely without practical importance and
is rarely seen.
Summary. — In the above note we have recorded
the history of an interesting case of malaria caused
by two generations of P. vivax (Grassi and Feletti
18fl0), the parasite of simple tertian malaria.
The blood of this patient showed malarial para-
sites in the peculiar " tenue " phase which we be-
lieve to represent an attempt at asexual reproduc-
tion by fission, both simple and multiple. This
attempt at reproduction we believe to be useless
and we are unable to find any trace of the migration
of the parasites as described by Miss Lawson,
which if confinned would form an explanation of
the fission. We are more inclined however to look
upon it as an occasional vestigial stage indicating
a process which may have been useful to an
ancestral form.
The patient also provided a good exhibition of
Dermatitis scarlatiniforniis due to the action of a
srvlt of quinine.
Acknowledgments. — We desire gratefully to
acknowledge the kindness of Captain McKail,
R.A.M.C, in giving us the opportunity for investi-
gating this case and of Mrs. Archibald in making
the coloured illustrations for us.
REFERENCES.
(A) In regard to the Malarial Parasite.
Balfour (1908). Third Report of the Wellcome Tropical
Research Laboratories (Plate VII and First Review Supplement,
p. 110). Khartoum and London.
Balfour and Wenyon (1914). Journal op Tropical
Medicine and Hygiene, vol. xvii. No. 23, Dec. 1 (with two
coloured plates). London.
Billet (1906). Comptes rendiis de la Sociiti de Biologic,
vol. Iviii, June 19, p. 1147. Paris.
Billet (1913). " Haematozaires du paludisme " (" Traite du
Sang de Gilbert et Weinberg," p. 631). Paris.
Lawson (1919). Journal of Eiperimental Medicine, vol. xxix,
pp. 361-368. Chicago.
Seroents (Et. and Ed.), Bkquet and Pantier (1913).
Bulletin de la Sociiti de Pathologie Exotique, November 12.
Paris.
Seroents (Et. and Ed.) (1905). Annates de L'Institiit
Pasteur, xix, p. 136. Paris.
Stephens (1914). Proceedings of Die Royal Society of
London, series B, vol. Ixxxvii, p. 375 {Plasmodium tenue, with
three plates). London.
ZiEMANN (1906). " Mense's Handbuch der Tropenkrank.
heiten," vol. iii, pp. 291 and 294, Plate IX, figs. 39 and 41,
and Plate X, fig. 10. Leipzig.
(B) In regard to the Dermatitis Scarlatiniformis.
Chalmers and Innes (1919). Journal of Tropical Medi-
cine AND Htgienk, September 1 (" Scarlet Pever-like Eruption
in the Tropic? "). London.
CHiLMEES and Mabtyn (1916). Proceedings of the Royal
Society of Medicine, vol. x (Section Dermatology), pp. 23-50.
(" Anaphylactic Action in Skin Disease.") London.
Kamsden and Lipkin (1918). Annals of Tropical Medinne
and Parasitology, vol. xi, pp. 443-464. Liverpool.
ILLUSTRATIONS.
Plate I.
Coloured illustrations all drawn from one slide before the
patient had taken any quinine.
Fig. 1. — Young Trophozoite. Simple Ring.
Fig. 2. — Young Trophozoite with pseudopodium.
Fig. 3. — Small Simple Ring in smaller and darker corpuscle.
May belong to the " tenue " phase.
Fig. 4.— Double infection— may represent the end of an
attempt at the" tenue" phase as the rings are small and the
corpuscle is dark.
Pig. 5. — Peculiar Ring. Perhaps belonging to the "tenue"
phase.
Fig. 6. — Young Plasmodium.
Fig. 7. — Early "tenue" phase.
FiQ. 8.— Peculiar Ring. Perhaps belonging to the " tenue "
phase.
Fig. 9. — Elongated form probably commencing " tenue "
phase.
Fig. 10.— Plasmodium or adult form.
Fig. 11. — Schizont.
Fig. 12.— Schizont.
Fig. 13.— "Tenue " phase.
Fig. 14.—" Tenue " phase. Late.
Fig. 15.— " Tenue" phase.
Fig. 16. — " Tenue " phase.
Fig. 17.—" Tenue " phase. With larger rings than Fig. 4.
Fig. 18. — " Tenue '' phase. Showing large and small rings.
Fid. 19. — Merozoites and Nucleus de Relirjuat.
Fig. 20.— Normal Erythrocyte to demonstrate magnification
and coloration.
Plate II.
Fig. 21. — Patient with Derm^itilis scarlatiniformis due to
quinine. Note the swollen lips and eyelids and the profuse
desquamation.
Fig. 22. — Plasmodium ziitiax— Double infection with a ring
and a Plasmodium form. Photomicrograph, x 1,600 diameters.
Fig. 23. — Plasmodium vivax — Plasmodium form. Photo
micrograph, x 1,600 diameters.
Fig. 21. — Plas^nodium vivax — Schizogony. Photomicrograph
X 1,600 diameters.
Fig. 25. — Plasmodium vivax — Merozoites separating. Photo
micrograph, x 1,600 diameters.
Fig. 26. — Plasmodium uiDax—" tenue " phase. Photo
micrograph, x 1,600 diameters.
Fig. ^7. —Plasmodium ctuax—" tenue " phase. Photo
micrograph, x 1,600 diameters.
Fig. 28. — Plasmodium vivax — "tenue" phase. Photo
micrograph, x 1,600 diameters.
THREE CASES OF FILARIASIS IN WHICH
INTR.WENOUS INJECTIONS OF TARTAR
EMETIC WERE GIVEN.
By J. W. S. Macfie.
Rogers (1919) has published an account of ten
cases of filariasis (presumably all F. bancrofti) to
whom he administered intravenous injections of
antimony. He found that the treatment produced
" a definite diminution of the number of filarial
embryos in the peripheral blood, which is probably
due to a direct toxic effect on the embryos," and
he considered his results "sufficiently encouraging
to make it advisable to continue the observations."
THE JOURNAL OF TROPICAL MKDICLXE AND HYGIENE.
PLATE IL
February, 2, 1920.
To illustrate paper on " The ' lemie ' Phase of Plasmodium vivax (Grass! and Feletti, IHOO)," by Albert J. Chalmkrs, M.I).,
P.R.C.S., D.P.H., and Major K. G. Akchibald, D.S.O., M.D., B.A.M.C.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[February 2, 1920
r^
ii^
(■■■'■s
13
IS
1 illustrate paper on "The * Untie' Phase of Plasmodium vivax (Grasai and Peletti, 1890)," by Albebt J. Chalmebs, M.D.,
P.R.C.S., D.P.H., and Major R. G. Archibald, D.S.O., M,D., R.A.M.C.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Home montliis before the publication of Rogers
article I had begun an investigation on this subject
at Accra, but had had to abandon it after treating
only three cases with very small amounts of tartar
emetic. The re<sults, although negative, may be of
some interest because they indicate the inadequacy
of such small doses, and because it was possible bo
follow up the cases for some tinne after the cessation
of treatment : in two of the patients moreover the
embryos in the blood were of species' different from
those dealt with by Rogers. A brief account of
the cases is therefore given below, and the data with
regard to them are summarized in the table.
Case I. — The patient, a native policeman, 29 years
of age, had been in hospital for six weeks suffering
from a periodic fever. Blood cultures had proved
negative, and so had Widal tests. His right leg
was swollen and tender. On July 16, 1919, intra-
venous injections of tartar emetic were begun ; a
total of 5h gr. was given, namely, 1^ gr. on the
16th, 17th", and 18th, and 1 gr. on the 20th July.
The temperature at once began to fall, and reached
DATE
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21
22
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24
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IT
27
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10 2'
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M E
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,
Temperature Chart of Case
normal levels within a week (see Chart). On
July 28 the patient was discharged from hospital.
The blood was examined frequently before tiu'
antimony treatment was started and was always
found to contain a few (about ten in 5 c.mni.)
embryos of Acanthocheiloncwa pcrstans. On July
29 the embryos were still present in the same num-
bers as before. The patient was not seen again
until October 2 — that is over twelve weeks after the
!cessation of the antimony treatment. On this occa-
ision he was quite well, but in his blood embryos
of A. perafanx were still present in about the same
numiiers.
The nature of the illness from which this man
suffered is undetermined. The fever and the con-
dition of the right leg were in some respects sug-
gestive of filariasis, but A. pcrsfans is not known
to have any pathogenic action, and no other infec-
tion wiiK demonstrated. Whatever the cause, the
.iienoficial action of intravenous injections of tartar
emetic was striking. No reduction in the number
of filarial embryos, however, was detected either one
week after treatment or three months later.
Case II. — The patient, a native man, about
20 years of age, an inmate of the Accra asylum,
was infected with Filaria hancrofti. He had no
symptoms referable to tnis infection, but in blood
taken at night a fair number of filarial embryos were
found.
Intravenous injections of tartar emetic were given
as follows : July 31, i gr. ; August 5, 1 gr. ; Angust 8,
1^ gr. ; August'15, 19, and 22, 1 gr. The total dose
was therefore 6 gr. The patient vomited after the
dose on August 8.
The blood was examdned at 10 p.m. of the night
following each injection. No dimdnution of the
number of filarial embryos was noted. Subse-
quently the blood was examined at 10 p.m. on
the 8th of September, October, November, and
December. Filarial embryos were always found,
and in about the same numbers. The antimony
treatment did not appear to have had any effect on
the filarial embryos within four months.
Case III. — The patient, a native woman, about
25 years of age, an inmate of the Accra asylum,
was infected with Loa loa and Acanthocheilonema
perstans. She had no symptoms referable to these
parasites, but in blood taken at 2.30 p.m. there were
found in 5 c.mm. from about 150 to 300 embryos of
L. loa and about ten to twenty embryos of A.
perstans.
Owing to the mental condition of the patient
intravenous injections were impossible, but five
intramuscular injections, each of J gr. of tartar
emetic in glycerine, were given instead, on July 23,
25, 31, August 5 and 8. The total dose, li gr., was
therefore very small.
The blood was examined at 2.30 p.m. on each
day ou which an injection was given, and on
August 12, 15, 22, and 27 measured quantities of
blood (5 c.mm.) being taken up and made into tTiick
films. The number of embryos found in these films
varied considerably not only from day to day, but
also in successive films made from the same drop
of l)lood. Speaking generally, however, no altera-
tion was observed in the abundance of the embryos
in the blood. Subsequently the blood was examined
on the 8th of September, October, November, and
December : on each occasion embryos of both specie®
were foamd in approximately the same numbers as
they had been found during treatment and before
the treatment was begun. The antimony treat-
ment did not appear to have had any effect on the
filaria embryos within the observation period of
four months.
Rogers gave to eight of his patients dosee ranging
from"20-5 to 46-0 c.c. of a 2 per cent, solution of
sodium antimonium tartrate, and to the remaining
two 220 and 22-5 c.c. of colloid antimony sulphide
1 in 500. In all but one or two the dose of antimony
was much larger than that administered to any of
my three cases, a fact which may account for the
different results. It may be noted, however, that
I
38
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 2, 1920.
the diminutiou of the number of cnibiyos did not
correspond closely to the size of the dose given ; for
example, his Case 2, who received one of the largest
doses of sodium antimonium tartrate, had more
embryos in the blood at the end of treatment than
at the beginning, and his Cases 7 and 8, who re-
ceived the smallest amounts, showed a notable
diminution within a day or two. In several cases
also a diminution was noted very soon after the
eommeneenient of treatment, at a time when but
little of the drug could have been given.
SU.MM.\KY.
Tartar emetic, in the small doses used, appeared
to have no effect on the number of embryos of
A. perstans, F. bancrofti and L. loa in the blood;
if it had any action on the parent worms the
effect was not appreciable within a post-treatment
observation period of three or four months.
REFERENCE.
Rogers, L. " Preliminari,- Report on the Intravenous
Injection of Antimony in Pila'riasis," Lancet, October 4, 1919,
p. 604.
Three Cases of Filariasis treated with small doses op Tartar Emetic.
Total dose of
species of filaria
embryos found in t
blood
Mf. perstans ... No diminution of the number of embryos was observed.
examination 94 days after cessation of treatment.
Mf. bancrofti ... No diminution of the number of embryos was observed.
examination 108 days after cessation of treatment.
Mf. loa and Mf. j No diminution of the number of embryos was observed.
perstans examination 122 days after cessation of treatment.
ULCUS TROPICUS TREATED WITH TARTAR
EMETIC.
By A. Mei, M.D.
Director, Royal Italian Dispensary, Benglu
(Cyre
r.).
Ulcus tropicum is very prevalent among tlie
natives of Cyrenaica. During my -staj^ \n Benghazi
I have observed and treated a very large number
of cases of this condition, and in most of them the
microscopical examination revealed presence of
Spirochxta schaudinni. The knowledge that tartar
emetic is beneficial in various protozoal disease*,
such as various forms of Leishmaniasis, trypano-
somiasis and spirochaetosis, led me to try it in ulcus
tropicum. I have generally used the drug ex-
ternally, but in two cases I have given it by intra-
venous injection. When tartar emetic is applied
externally the treatment should be carried out as
follows: —
(1) The patient must be kept at perfect rest in
bed.
(2) The vei-j- abundant secretion should be re-
moved gently from the ulcer by using dry sterile
gauze and not lotions.
(3) Tartar emetic, being a caustic, should be
used with care, onlj' a small amount of the powder
being applied to the surface of the ulceration and
underneath the edges. The ulcerated surface is
then covered with some sterilized gauze and is
lightly bandaged. Cotton-wool should not be used,
as in a hot country it favours the increase of puru-
lent secretion and maceration of the tissues. This
procedure is carried out, at first twice a day and
then once a day, according to the amount of secr^'-
tion present. The average duration of the treat-
ment is a month.
As a rule there is a rather severe local reaction,
and the patient complains of a feeling of burning,
which may last from half an hour to two hours
after each application. ^Most of the native patients,
however, bear this painful sensation quite well, and
they think that it gives them lass discomfort than
the pain so often felt in the ulcer, which often be-
comes very severe at night and prevents the patient
from sleeping. Occasionally one comes across cases
of intolerance, especially among native children
and European patients. In such cases tartar emetic
should be discontinued and iodoform used instead.
The tartar emetic treatment appears to have a
powerful action on the spirochcetes. After two or
three days the organisms are present only in small
numbers and in a degenerated condition. The
bacilli of Vincent, on the other hand, are still
present in large numbers and so are various cocci.
After apph'ing the medicament siix or seven times,
spirochffites become extremely rare, while bacilli of
Vincent and cocci are not sensibly decreased in
number. On the twelfth day spirochietes are prac-
tically absent, bacilli of Vincent are in much smaller
numbers, cocci also are lessi numerous. After the
fifteenth day, as a rule, the microiscopical examina-
tion reveals complete al)soMc<- of hotli s])irochsetes
and Vincent's liucilli, and oidy a few cncci can l)e
seen.
Apparently tlu' drug acf« cli.icflv on tlir spn-o-
cliietos whicl) (|uickly (h^gcncrate ' and <lisa|)pear.
Th<> fondition of (he ulcer improves caincidentally
witli tlic (lirriinutidii and disappearance of the spiro-
chietes, whil<' tlic li.u-illi of Vincent are st'll present
;iiid disappear riiiich later, when the ulcer is very
Feb. 2, 1920.] THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE.
greatly improved. I believe, therefore, that Vin-
cent's bacillus has not the importance that many
authorities formerly ascribed to it in the pathogenesis
of ulcus tropicum. Spirochxta schaudinni is the
true etiological agent of ulcus tropicum. Vincent's
bacilli are merely symbiotic elements with little or
no pathological action. Cocci do not play any im-
portant role in the etiology of the condition.
Tartar Emetic by Intravenous Injection. — In two
native boys suffering from ulcus tropicum I gave
tartar emetic by intravenous injections, 0-06 grm.
each time. I gave eight injections in one case and
ten in the other. There was a distinct improvement
in the ulcers, and a smear from the discharge
showed a noticeable diminution of the spirochaete*,
which appearetl to be degenerating. I must, how-
ever, state that the improvement was rather slow,
and it would probably have been necessary to give
a great many injections before obtaining a complete
recovery. In both cases, therefore, 1 discontinued
the intravenous injections and treated the ulcers by
powdering them with tartar emetic, with very good
results.
There is no need to give tai'tar emetic by intra-
venous injection when the drug acts more rapidly
employed externally. I think, however, the intra-
venous injections may prove useful in those patients
to whom the external application of the drug gives
very severe pain.
I hope that medical men working in the tropics
will give a trial to tartar emetic in the treatment
of ulcus tropicum and will be able to confirm my
results.
|l0tt«S.
Secondary Malaria (S. Clavijo, I'rogresos de la
Clineca, July). — This article discusses the excessive
functioning of the spleen, with or without its
enlargement, the localization of symptoms in the
different organs, anaemia and melanaeinia, the
mechanism of relapses, means to foretell the im-
pending chill and fever, the treatment and prophy-
laxis. In Spain and its African possessions statistics
show an average annual mortality from malaria of
301,260. In 9,261 towns in Spain, malaria is
present in 1,818. The expense of reclaiming
malarial regions by proper engineering, &c., would
be more than offset by the increased productivity
of the land, to say nothing of the saving in lives.
In one regiment of 1,748 men, 208'35 per cent,
were given treatment during 1916 wliile only 90-fl7
per cent. re(iuired it in 1913.
Benxtjl Bcnzoatc in Amoebic Dysentery (Augh-
wont and Lantin, Archiv Int. Med., OctobT, 1919).
— A 20 per cent, solution of the drug was used, ten
drops being given in water three times a day. Eight
cases were treated with very satisfactory results.
According tn the authors, as well as to Asuzano, the
drug ap])ears to have a powerful action both on the
trophozoite and the encysted forms of Kntamaba
histolytica.
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THE JOURNAL OF
Cropical ^eUtctnt and i^pgiene
February 2, 1920.
TROPICAL DISEASE PREVENTION
(■OMMITTEE.
Jieing a Committee to Encourage hiternational
Medical Research and the Eradication of Pre-
ventable Disease in Tropical Countries.
.\chievi;mi:nts in riiopicAL Medicink.
(1) Tiiii study of tropical medicine has made great
strides within the last half century, and we now
liave definite knowledge as to the causation of im-
portant diseases such a« malaria, typhus, plague,
dengue, sleeping-sickness, endemic hoematuria,
filariasis, and ankylostomiasis. We know the
specific causative agents of these diseases, their
])arasitic carriers., and many other factors in their
natural history, whicli determine tlicir j>ermanence,
spread, quiescence or disappearance. In various
places indeed, notably the Panama Canal zone, the
South American States, Cuba and Porto Rico, the
40
THE JOUENAL OF TKOPICAL MEDICINE AND HYGIENE. [Feb. 2. 1920.
judicious application of this knowledge ha« led to
the control of nialaria, yellow fever and soime
other diseases. Thus tropical lands once regarded
as deadly have been rendered healthy and suitable
to the white man and fit for animals necessary to
agriculture.
Knowledge not generally applied.
(2) But this knowledge has not been applied
generally, nor in a reasonable and efficient way.
Notwithstanding the triumphs mentioned and the
improvements effected on the West Coast of Africa,
in Egypt, India, &c., it is nevertheless obvious to
the visitor that in most tropical lands disease is still
rampant, general sanitation neglected, and specfic
preventive measures unapplied. As a result dis-
eases prevail, whose causes and methods of spread
have long been known, and which may be considered
rightly as easily preventable. Well-known examples
are ankylostomiasis and filariasis in man and
various tick-borne diseases of cattle.
Many Diseases still Obscdke.
(3) There are many other diseases of which our
knowledge is still inadequat«. Among these black-
water fever (distinct from quinine and malarial
hiemoglobinurias), pellagra, sprue, beri-beri, and
leprosy may be cited as having long baffled investi-
gation. But now approached anew, with an open
mind, and in .a thoroughly scientific way, they
probably will not fail to be brought within the
group of preventable diseases.
Danger of Spread.
(4) All tropical diseases, however restricted their
present distribution, can at any time, under favour-
able conditions, greatly extend their range and be
carried to parts of the world where they were pre-
viously unknown.
Improved transit, increasing transportation of
men, animals, and merchandise are all powerful
agents in spreading hitherto localized diseases. To
combat this greater vigilance becomes necessary and
every effort must be made to throw back invading
diseases to their original localities, there to destroy
them.
Islands once freed can be more easily protected
than mainland, and will cease from acting as foci
of infection to ports and trade routes.
Proposed Work. A Survey of the Lesser
Antilles.
(5) The Tropical Disease Prevention Committee
proposes to commence operations by carrying out a
thorough medical survey of the Lesser Antilles.
This was suggested by Dr. L. W. Sainbon in 1914
in the Journal of Tropical Medicine and Hygiene,
and recently in a paper on " The Sanitation of
Tropical Lands," which he read at the Eoyal
Society of Medicine on June 19, 1919, under the
chairmansihip of its President, Sir Humphry Rol-
lestou, and by arrangement with the West India
Committee. On that occasion Dr. Sambon made
two suggestions, one with regard to the teaching
of tropical medicine, the other concerning research
work on the causes and prevention of disease in
tropical lands. The teaching scheme has been dealt
with by a special Committee appointed by the Royal
Society of Medicine, which has referred it to the
London School of Tropical Medicine and to the
League of Nations. The other has been adopted
by the present Committee.
Reasons for Choice.
(6) In this paper it was pointed out how much
easier it is to carry out investigations within small
areas. The phenomena of glaoiation have been
studied chiefly on the easily accessible Swiss
glaciere. Vesuvius, the Lipari "islands — a series of
small active volcanoes in the very centres of civiliza-
tion— have been the ciief source of our knowledge
on volcanic phenomena. Similarly, small tropical
islands, conveniently placed, are likely to offer the
best conditions for the study of tropical diseases
and for testing the value of measures deemed appro-
priate for their prevention and eradication.
The Committee has selected the Lesser Antilles
for the commencement of its campaign, because
they are a group of small islands which can be
easily surveyed, and because they are dissimilar in
physical features, geological structure, climate,
flora, fauna, human inhabitants, diseases of plants,
animals and man. Thej' are expected, therefore,
to be the most suitable field for investigation of
tropical diseases not yet elucidated. Compared
with vast areas and their complex conditions, small
islands are especially advantageous since they in-
clude in a small compass the essential factors and
diminish the total number of possible factors to be
investigated. Diversity of conditions, existing in
different islands where the same diseases are found,
facilitates tabulation of the various factors present
or absent, and their relation, if any, to the diseases
in question.
Barbados suggested for Initi.\l Preventive
Work.
(7) One of the islands — Barbados — is further sug-
gested for the application of preventive measures
to eliminate ankylostomiasis, filariasis, pellagra and
leprosy. This isJand offers specially favourable con-
ditions, and is, moreover, free from malaria and
yaws.
Probable Duration of Investigation.
(8) It is expected that the survey of the group
will take about three years.
Benefit to all Tropical Countries.
(9) The researches and measures carried out in
the Lesser Antilles would, of course, greatly benefit
these islands, but their purpose has wider scope,
namely, the application of the results obtained to
the elimination of diseases throughout the tropical
world.
Feb. 2, 1920.J THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
Responsibility.
(10) The work will be international, and the Com-
mittee confidently appeals to the people of all
nations owning tropical possessions to contribute to
the sum (estimated at £30,000) necessary to carry
out a scheme, the object of which is to eliminate
the terrible diseases infesting those lands which
they hold as Trustees, and for the well-being of
whose inhabitants they are responsible.
Material Advantage.
(11) There is a large amount of actual inefficiency
in labour due t-o a high sick rate, resulting in grave
economic loss and scaixjity of labour, and it can be
stated confidently that the lethargy and lassitude
which predominate in tropical lands are largely due
to preventable disease.
Nations competing actively with one another in
commerce must see that the foundation of their
prosperity — the health of the workers — is sound.
Innotattons.
Transmission of Typhus by Lice Stools (G.
Mueller and L. Urizio, Reforma Medica, August
23). — Experimental research indicates that the
dejecta of lice are able to transmit typhus even
without the bite of the insect. A laboratory acci-
dent confirmed this even more strikingly : the
syringe filled with the emulsion of lice stools was
being held by Urizio while Mueller was holding
the guinea-pig ready for the injection, when the
animal jerked and spilled the emulsion over the
hands of both. Urizio was immune, having had
typhus two years before, but Mueller, whose hands
were in-itated from other causes, developed
seventeen days thereafter a classic form of typhus.
Dysentery in Palestine (Blackburn, Medical
Journal of Australasia, August 23, 1919). — Cases of
bacillary dysentery were about twice as numerous
as cases of amoebic dysentery. Treatment of the
former consisted in complete rest in bed and the
administration every two hours of sodium sulphate
or magnesium sulphate in drachm dosos. Poly-
valent serum was used with good results, injected
in large doses. Cases of amoebic dysentery were
treated by a course of intramuscular injections of
emetine, followed, when necessary, by the oral
administration of emetine bismuth iodide for twelve
dnv..
F,(l!ipli(ui liilliiirzitiais (N. Hamilton Fa/irlej',
Proceedings Uoyal Society of Medicine, Vol. XIII,
No. 1, November, 1919). — The author suggests that
from a clinical point of view Vr\e manifestations
of hilharziasis can be divided into two stages : a
toxaemic stage occurring four to ten weeks after
infection, and a much later stage of localized
hilharziasis characterized by vesical symptomp in
the case of B. hxmatobia and by intestinal symp-
toms in the case of B. mansoni. In the toxaemic
stage pyrexia and urticaria are of common
occurrence.
The author has applied to the diagnosis of
bilharziastts the Bordet-Gengou reaction, devising
a modified complement deviation test, for
which he used at first an extract made from
bilharzia worms obtained at an autopsy from an
Egyptian ; and later an alcoholic saline extract of
the livers of infected snails.
With regard to treatment the author reports
very favourably on tartar emetic, and confirms the
results obtained with the drug by McDonagh and
Christopherson. It is interesting to note that the
author's complement deviation seems to afford an
index to the therapeutic value of the drug, the
test becoming practically negative after a long
course of treatment.
Canvas destroying Fungi (W. Broughton Alcock,
Journal Royal Army Medical Corps, vol. xxxii,
No. 6, December, 1919). — The author gives the
results of an interesting investigation he has carried
out in Malta and Italy on the causation of canvas-
rot. He finds that the condition is due to fungi
belonging to various genera, the most common
being Macrosporium and Steviphylium.
Cwrrent f iteralurr.
Transactions of the Society of Tropical Medicine
AND Hygiene, November, 1919.
Anti-Mosquito Measures in Palestine during the
Campaigns of 1917-1918 (E. E. Austen).— A very
interesting account of the preventive measures put
in force against malaria during the operations in
Palestine. The suppression of mosquito breeding
was obtained by oiling all wells, pools, &c. The
results were very satisfactory.
In the discussion that followed Surgeon-Com-
mander L. M. Morris gave an account of anti-
mosquito work in the i^gean Islands. Dr. Manson-
Bahr, after congratulating Major Austen on his
paper, said that Major Austen had assisted in
keeping Allenby's forces healthy and active through
a malaria season in one of the most malarious
countries in the world. Prof. Aldo Castellan! while
agreeing as to the paramount importance of anti-
mosquito measures, said that in his experience it
was of great advantage to carry out quinine prophy-
laxis at the same time, particularly in the case of
troops taking part in a war of movement.
Indian Medical Gazette.
Vol. LIV, No. 12, December, 1919.
Surgical Problems and Difficulties in the Tropics
(D. J. Harries). — The author touches on several
points of practical importance, and principally on
42
JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb, 2. 1920
the subject of malaria simulating certain abfloniinnl
acute surgical conditions such as appendicitis,
general peritonitis, and intestinal perforation.
General Vaccinia in Burma (S. Rama Iyer). — The
author describes three cases of the condition. The
vesicular- eruption appeared five days after vaccina-
tion, and two days later the vesicles became pus-
tules. Scabs fonned four days after the appearance
of pus.
Recent Researches of Hookworm Infection in
Indonesia (Samuel T. Darling). — The author has
had good results from the use of cheno podium oil.
In his experience the initial purge may be omitted
and this would lessen the work of the dispenser
and pennit a larger number of people to be visited.
It is very important in order to exert the maximum
toxic effect on the worm, that food be withheld
during the morning of administration, and that the
evening meal before treatment be light and
digestible, leaving Httle residue.
Further observations on Tetanus (A. F. Noronha).
— Antitetanic serum to be of value should be given
at the very outset of the malady and in large doses.
The carbolic acid treatment without serum has
proved most disappointing.
Bulletin de la Societe de Pathologie Exotique,
December 10, 1919.
Arsenobenzol Treatment for Dracontiasis by J.
Montpellier and E. Ardoin. — The success obtained
by Prof. Jeansehne in one case, and his desire to
have further proof of the efficacy of arsenobenzol
(914) in dracontiasis, led the authors to apply the
treatment to four Senegalese in Algeria, all of
whom had been suffering from the condition for
months. Each showed at least one broken Filaria
medinensis, and none had derived any benefit from
the usual antiseptics and ether injections. Com-
plete and rapid cure was obtained after one, two,
or (in a single instance) three injections of 914, the
quantity used being 0'15 gm. for the first dose and
0'3 gm. for the others. In two cases not only were
the active filarial foci healed but hitherto latent
worms were revealed and eliminated.
On the quickest Method of diagnosing Sleeping
Sickness when on travelling practice in the Bush,
by J. Schwetz. — In view of the fact that a single
blood test often fails to reveal the parasite in cases
of undoubted trypanosomiasis, the writer is of the
opinion that palpation of the glands affords more
reliable evidence to the travelling expert and does
not frighten the timid native by requiring the use
of a needle. Under the difficult conditions in
which the work is carried out in the bush he con-
siders it safer to treat all cases showing typical
glands than to exempt those who, on an insufficient
number of tests, fail to show the organism in the
blood.
Human Trypanosomiasis exists in the Eastern
Furcsta of Peru, by E. Escomel. — Escomel has
succeeded in recovering trypanosoma (probably
Schizotnjpanum cruzi) from the blood of a patient
living in the heart of the forest region iirigated by
the Tahuanianu River, which also runs through
the tropical zone forming the boundarj- between
Brazil and Bolivia. Since the discovery of Tria-
toma infestans in Peru he has suspected trypano-
somiasis in several cases showing characteristic
clinical symptoms, but has never hitherto found
the parasite in the blood. He points out that
though the disease may now be considered to exist
in Peru, prophylaxis will be impossible owing to
the dense character and situation of the forests.
The Isolation of and Search for Anaplasma by
Inoculation of suspected Blood into Sheep or Goats,
by J. Lignieres. — As the result of an extensive
series of experiments Lignieres arrives at the
following conclusions: (1) Inoculation of Piroplasma
bigeminuni and Piroplasma argentinum produces no
effect upon sheep and goats, from whose blood it
is not recovered. (2) Inoculation into sheep or
goats of blood containing both Piroplasma and
Anaplasma is only positive for Anaplasma. If from
5 to 10 c.c. of blood taken from sheep or goats
between one and two months after inoculation be
injected into the veins or under the skin of fresh
bovidie, a pure anaplasmosis is determined in the
latter. (3) Inoculation into the sheep or goat of
blood suspected of containing Anaplasma, and the
subsequent injection of their blood int-o animals of
the bovine species, is a simple and very easy means
of seeking and isolating the Anaplasma. (4) This
process will greatly facilitate the preparation of an
epidemiological chart in any region where anaplas-
mosis may exist.
The Use of Monochloride of Iodine for Continuous
Irrigations, by P. Kervrann. — Finding an active
Dakin's solution impossible to obtain in the French
colonies owing to the difficulty of preserving the
lime chloride and to the moist climate, Kervrann
has used the following: 30gnm.Eau de Javel titrate
ing 49° chlorine, 20 c.c. of a 20 per cent, solution
of potassium iodide, and 10 drops of concentrated
HCl, dissolved in 2 litres of water. When used for
continuous irrigations this solution shows rapid
antiseptic and cicatricial action, and does not
irritate the tissues. It costs very little and is
extremely quick and easy to prepare.
The Transmission of Tunisian Canine Piroplas-
mosis by Rhipicephalus sanguineus, by E. Brumpt.
— The disease is transmitted by adult Rhipicephalus
sanguineus, the progeny of females who have fed
on a sick animal, and the infection of the ticks is
therefore hereditary. The larvfE and pups derived
from infected females do not transmit the infection,
but they become pathogenic as soon as they reach
the adult stage. Pupae fed on virulent blood do
not transmit the disease when they become adult.
Feb. 2, 1920.J
THE JOURNAL 01' TROPICAL MEDICINE AND HYGIENE.
The three ticks transmitting canine piroplasmosis,
i.e., Hcemaphysalis leachi, Rhipicephalus san-
guineus, and Dennacentor reticidatus, continue the
hereditary transmission of the germs under the
same conditions. This would seem to show that
the evolutionary cycle of Piroplasma canis is con-
stant, no matter what host may be employed as
carrier. A numljer of pup* of Ixodes ricinus and
Hcemaphysalis concinna, derived from females fed
upon a sick dog, did not transmit the infection.
The Cultivation of Duckweed as a Means of
Combating Malaria, by Dr. F^lix Regnault. — During
the war Regnault noticed that a few muddy pools
in the environs of Ajaccio, Corsica, were covered
with duckweed and contained no mosquito larvee,
whilst others, the majority, in which the water was
clear, showed no duckweed but possessed a large
population of larvae. Remembering the theory of
Centanni and Ora, he put duckweed into the clear
pools but it died. He then threw some cow and
horse manure into them and resowed the duck-
weed; the latter thrived and the larvae disappeared.
Wlhen the manure was exhausted the duckweed
died. Repetitions of the experiment gave the same
result in every case. The author considers the
disappearance of duckweed from ponds in districts
ravaged by the war has much to do with the
appearance of malaria, for men and cattle are gone,
the organic matter in the pools is not renewed,
and the water becomes clearer.
Ocular Myiasis in the Island of Sal (Cape Verd
Archipelago), by Manuel Maximo Prates. — Whilst
on a brief visit to the island the author's attention
was drawn to ocular lesions caused by the larvse of a
fly which he was afterwards able to identify as
(Estrus ovis. Goats would appear to be the natural
host of the parasite, and the infection proves fatal
to these animals when, by way of the sinuses, the
brain is attacked. In man the throat and nasal
passages are often affected, though less frequently
than the eyes, and furuncular-like myiases are
sometimes seen. The natives attribute the infec-
tion to its true cause, and smoke or chew strong
tobacco to ward off the flies. The author intends
to continue his investigations with a view to ascer-
taining whether the fly deposits an egg which
subsequently hatches in the mucosa of its host, or
whether the parasite is already in the larval stage
when emitted.
Sleeping Sickness in the Middle Kwilu {District
of Kwango, Belgian Congo) in 1918, by J. Schwetz
(■Congo Beige). — The report covers the period be-
tween October, 1918, and January, 1919, inclusive,
during which the writer was in charge of govern-
mental measures to check the alarming spread of
sleeping sickness in the Middle Kwilu. He visited
142 villages, all on the left bank of the river, and
examined 19, .378 natives. The district consists of
wooded, undulating country, exceptionally rich in
oil palms. The population is neither robust
nor intelligent, lives in multitudinous but small
and entirely independent villages, and has been
obviously thinned by years of
Palpalis is surprisingly rare between Bulungu and
Kwilu ; to the south of the latter it abounds, even
in the villages. The proportion of sick natives
ranges from 1 per cent, in some villages to 38 per
cent in others, and would appear to bear no relation
to the presence or absence of palpalis in the neigh-
bourhood. The disease has unquestionably followed
the advent- of the white man. No steps have been
taken to deal with it except by a large British
firm and generally by the missionaries. Any at-
tempts at prophylaxis have been sporadic, episodic,
and carried out by laymen. On the advice of tlw
author the Belgian Govermnent is sending out a
medical commission to apply hygienic measures,
but he considers that no prophylaxis can be effec-
tive until more is known concerning the aetiology
of the disease.
An Anti-Malarial Mission in the XVJJfh Region
of France (1917-1918) by Dr. H. Mandoul.— The
French Government, fearing possible outbreaks of
malaria as a result of the importation of African
natives into France during the war and the return
of French soldiers from the East, appointed a com-
mission to study the question and organize anti-
malarial measures. In the Departments near the
Spanisih frontier, where many centres of malaria
existed fifty years ago, A. maculipennis and Culex
infest the entire district. The latter predominates
in spring and autumn, the former in July. Culex is
much more aggressive of the two. The anopheles
hibernate in the adult stage, exist in lioth town and
country, high and low altitudes, and temperatures
varying between 14° and 30-.5O C. Where duck-
weed, watercress or fish are present in pools, no
larvse are seen. He concludes by emphasizing the
necessity for systematic mosquito destruction under
present conditions, which are peculiarly favourable
to the reapparance of malaria in the country.
A Further Case of Black-Grain Mycetoma
(Madura Foot) in Tunisia, by Georges Blanc and
Gabriel Bnm.' — This is the seventli instance of
madura foot in Tunisia. The patient, a farmer
(30), was in excellent general health. The condi-
tion apparently originated in a crushed foot in 1913,
for two years later a small tumour was noticed on
the dorsal surface. This was removed but a fresh
growth appeared two years after. Six months
before admission to hospital ulceration set in.
Pressure caused a cloudy fluid, containing dark,
pepper-com-like grains to exude. On ablation of
the tumour the dorsal muscles and tendons of the
foot were found to be perfectly normal, and the
wound healed rapidly. Microscopical examination
of the grains showed them to consist of masses of
mycelial filaments united by dark brown, amorphous
cementing substance. Fragments of the tumour
inoculated into laboratory animals produced a
growth, containing one grain, on the tarsus of a
pigeon. The author is inclined to <']assify the
fungils in a neighbouring category to the Madurelln
tozeuri of Nicolle and Pinoy, from which it differs
44
THE JOURNAL OF TROPICAI> MEDICINE AND HYGIENE.
[Feb. 2, 1920.
by not liquefying gelatine, by failing to grow in
vitro at a higher temperature than 22° C. and by
the anatomo-pathologieal characteristics of the
grain. He proposes to call it Madurella tabarkcB.
The Existence of Bovine Spirochxtosis in Brazil.
Transmission of the Disease by the Margaropns
australis Tick (Fuller), by E. Brumpt.— The writer
received a quantity of Margaropns australis from
San Paulo in 1915, from which he has since obtained
nine generations of ticks. After losing their power
to infect with Piroplasma higeminum and Piro-
plasma argentinum, and having given no spiroche-
tosis that could be detected in the blood, the eighth
generation infected a susceptible cow. The spiro-
chaetosis induced was, however, so mild that without
the aid of microscope and thermometer the sym-
ptoms would have passed unnoticed. Immunity (or
more correctly tolerance) is soon acquired, for
thousands of infectious embryos produced no effect
on the same cow seventy-five days after the first
infection. The author considers that the name
" Spirochata theileri " should apply in every case,
irrespective of the species to which the animal host
belongs, and that Spirochceta rqui and S. ovina
should be relegated to the category of synonyms.
The Vaccination of Bovidce against Anaplasmosis
(Prof. J. Ligni^ree). — The virulence of Anaplasnia
argentinum is attenuated by inoculation into sheep
or goats, and the blood of the latter animals is then
an excellent vaccine for bovidae against the most
severe forms of anaplasmosns. Sometimes a Bevere
or even fatal anaplasmosis is produced, sometimes
a mild form ; sometimes the result obtained is appa-
rently negative, the animals showing neither para-
sites in the blood nor discomfort, though the tem-
perature may rise to 40° C. and more for some days.
In these apparently negative cases it can be shown
(a) that the blood of such bovidee contains Ana-
plasma argentinum virulent for animals of the
bovine species, and (b) that the bovidse have often
acquired a strong immunity against Atiaplasma of
high virulence. The attenuation of Anaplasma
argentinum, is in proportion to the duration of its
presence in the organism of the sheep or goat. By
choosing those strains which are most virulent at
first, and by passing them successively and at long
intervals through the sheep or the goat, such fixity
in the attenuation of Anaplasma argentinum is
obtained that they may be employed almost without
danger to immunize even high grade and adult
bovidse against natural anaplasmosis.
fitrieto.
Swanzy's Hakdbook op the Diseases of the Eye
AND THEIR TREATMENT. Twelfth edition. Edited
by Louis Werner. London : H. K. Lewis.
Price 228. 6d. net.
This well-known text-book has been brought up
to date and is now a very comprehensive elementary
treatise. It is well arranged, clearly written, and
contains close on three hundred excellent illustra-
tions, including twenty-one admirable coloured
figures representing various pathological and normal
ophthalmoscopic appearances as well as types of
ciliary and conjunctival congestion.
The chapter on glaucoma is thoroughly up to date
and condenses in some thirty pages most of the
modern work on the subject. Among further addi-
tions are descriptions of the corneal lesions found
in acne rosacea, hypotony, a summary of the
methods of diagnosis in chronic uveitis, and a
r6sum6 of Dr. Gordon Holmes's investigations of
the cortical centre of vision. The operation of ex-
cision of the lacrymal sac has been rewritten, but,
whilst three pages are devoted to this procedure,
the indications for the operation of opening and
draining the lacrymal sac from the nose, which is
capable in most cases of replacing the former opera-
tion by a conservative measure, which restores the
normal flow of tears into the nose, is dismissed in
four lines. The article on the localization of foreign
bodies has also been rewritten. In the chapter on
astigmatism, the astigmometer, as a means of
measuring corneal astigmatism, is alone described.
With it it is necessary to make two separate ob-
servations to estimate the corneal astigmatism,
whereas with Sutcliffe's more modern keratometer
the two meridians are measured without rotating
the instrument. Moreover, the statement that :
" The corneal astigmatism ... in most cases
. . . differs only slightly from the total astig-
matism " will not be endorsed by most ophthalmo-
logists.
Apart from a few minor points like these there is
little that is open to criticism.
We can recommend this book both to the student
of medicine and the general practitioner and to
those who are desirous of obtaining a more thorough
knowledge of ophthalmology.
The " Straits Settlements Gold Medal " has been
awarded by the Senate of the University of
Glasgow to Prof. B. T. Leiper, Helminthologist to
the London School of Tropical Medicine, for his
well-known researches on bilharziasis.
liEPROSY is increasing in the Aruwimi district of
the Congo. In German East Africa, now occupied
by Belgium, the epidemic is being held in check.
Ten of the pictures for the Stations of the Cross
in the Leper Church at Pretoria, which are being
painted as a gift by Mr. Frank Brangwyn, have
been completed, and the other four are in course
of completion.
Plague is reported to have broken out in Eastern
Silesia, the disease having apparently been
brought in from Eastern Galicia.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Februaky 16, 1920.
(6) (c)
Toxoplasma ptfTogenes Gskatellam 1913. x 1,000 diameters.
To illustrate paper i
' Toxoplasma pyrogens Castellani 1913," by Albebt J. Ohalmebs, M.D., P.R.C.S., D.P.]
and Sagh (Major) A. Kamab, M.D.
I
Feb. 16, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 4, Vol. XXIII.
Original Commnmcattons.
TOXOPLASMA I'YKOGE^KS CASTELLAN!
1913.
By Albrrt J. Chalmers, M.D., P.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories.
AND
Sagh (Jlajor) A. Kamar, M.D.
Medical Corps, Egyptian Army, Anglo- Egyptian Sudan.
In this brief note we merely desire bo record the
fact that we have observed in a splenic film the
same bodies which Professor Castellani saw,
described, figured and named in Ceylon in 1913.
Early in the present year the Sudan Government
opened a new post called .Jonguls in the Sennar
Province, near Nyeda. This post is very isolated at
I)resent and is in the Burun country. Since going
there some of the soldiers have developed a long
drawn out fever which was not diagnosable. The
symptoms are as follows: —
(1) Irregular fever reaching as high as 105° F.
(2) Enlargement of the spleen and sometimes of
the- liver.
(3) At first the patient does not mind the fever,
and is not inconvenienced by it, no matter how high
the temperature rises.
(4) Later he experiences headache, slight cough
and some diarrhcea, but there are no gastric or
hepatic symptoms.
(5) Quinine has no effect on this type oi fever.
(6) Towards the end severe anaemia sets in, the
gums become sore and bleed, while the breath is
foul.
There have been already three deaths attributable
to this fever, from which the natives say that they
suffer and have had many deaths, but, pending
further investigation, this native statement must
be received with caution.
A post-mortem was made upon one case within
one to two hours of death and a splenic film was
taken.
This film when coloured by Leishman's stain
revealed numerous bodies of which some are de-
picted in the photographs which illustrate this note.
These are all lying free in the film but we have
observed one in an endothelial cell.
When this brief description is compared with that
given by Professor Castellani in this journal of
April 15, 1914 (volume xvLi, No. 8, page 113), it will
be seen that as far as our description goes the two
accounts are comparable, though of course ours is
by no means so complete as that written in Colombo
by Professor Castellani.
If his photomicrographs and coloured drawings
are compared with the few photomicrographs which
we reproduce in this note they will be seen to be
comparable.
At present this is all that we desire to say with
regard to the matter, but, naturally, steps are being
taken to attempt to investigate it more fully,
though the inaccessible nature of the post makes
this difficult, especially as there are no postal or
telegraphic arrangements.
REFERENCES.
Castellani (1913) : Journal Ceylon Branch British Medical
Association, May 31, Ceylon; (1914) JonRNAL op Tropical
Medicine and Hygiene, vol. xvii, No. 8, pp. 113-114 (illus-
trated by temperature chart, photographs, and a coloured plate).
London.
ILLUSTRATIONS.
Three photomicrographs (a b c) illustrating free forms of the
bodies named Toxoplasma pyrogenes GasteUam 1913 and found
in a splenic film from a case of fever with enlargement of the
spleen at Jonguls, Sennar Province, Anglo-Egyptian Sudan.
The measurements of these bodies agree with those made by
Dr. Castellani. x 1,000 diameters.
THE ()CCU,RRENCE OF LATERAL-SPINED
BILHARZIA EGGS {SCHISTOSOMA MAN-
SONI) IN URINE.
By J. W. S. Macfie.
Last August a specimen of the urine of a native
man, aged 26, an inmate of the asylum at Accra,
Gold Coast, was sent to me for examination. It
was bright red with blood, and contained many
eggs of Schistosoma hxmatobium and a few eggs
of S mansoni. The specimen did not appear to
contain fsecal matter, but nevertheless contamina-
tion was suspected. An unquestionably uncon-
taminated specimen was therefore procured on the
following day in which, as before, both berminal-
spined and lateral-spined schistosome eggs were
found. A sample of faeces was also examined, it
contained neither blood nor mucus, and no schisto-
some eggs were found in it.
I proposed to treat the patient with tartar emetic,
but succeeded in giving only a single intravenous
injection, and this was of but half a grain. The
patient refused further treatment, and being insane
was not amenable to persuasion. Either post hoc
or propter hoc the urine cleared of blood in a few
days, and the schistosome eggs became scanty. A
month later the urine was found to be quite clear,
free from blood, and in it there were only a very
few schistosome eggs — all terminal -spined. Two
months later the urine was again examined ; a very
few dead eggs of S. hsematobium were found. At
the same time the faeces were examined ; neither
blood, nor mucus, nor schistosome eggs were
found. Up to the time of writing (December) no
re-currence of the htemBturia has been reported or
observed.
There is a difference of opinion on the question
of the occurrence of lateral-spined schistosome eggs
in the urine. The authors of some well-known text-
books assert that S. mansoni " invariably extrudes
its eggs through the intestine," or that in infections
with this parasite one finds " no ova in the urine,"
THE JOUBNAL OF TROPICiUL, MEDICINE AND HYGIENE. [Feb. 16, 1920.
others state equally clearly that the urinary tract
may be involved, and that lateral-spined eggs may
be passed in the urine.
In the JoDKNAL OP Tropical Medicine and
Hygiene Bandi (1913) described the results of an
investigation on bilharziosis carried out in Egypt
in 1912. I have been unable to consult the original
article, but from the review of it, which appeared
in the Tropical Diseases Bulletin, vol i, p. 695, it
appears that in one case he found in the urine eggs
of both S. hwmatobium and 8. mansoni. This
paper by Bandi is presumably the same as that
mentioned by Manson (" Tropical Diseases, " Sixth
Edition, footnote to p. 756), although his reference
to it reads as if twenty-five cases had been found
in all of which both lateral-spined and terminal-
spined eggs were present in the urine, an experience
which Manson unnaturally considered " very ex-
ceptional." Dr. G. C. Low, who reviewed Bandi 's
paper in the Tropical Diseases Bulletin, described
it ae " a rare event, or one might say an exceedingly
rare event to find lateral-spined eggs in the urine."
It is no doubt an exceptional occurrence, but one
that may be met, the case briefly described above
being an example.
SOME FUETHER OBSERVATIONS ON THE
ETIOLOGY OF "PELLAGRA."
By A. ViswAUNGAM, L.M.S.
In a paper on "pellagra" (Journal of Tropical
Medicine and Hygiene, 1st August, 1918), re-
ferring to the aetiology of the disease in ' this
country I said: " I trust I shall not be far wrong
if I express the opinion that both the ' deficiency
theory ' and the ' parasite theory ' may hold good
m the aetiology of the disease in this country. I
am inclined to think, in individuals whose vitality
is lowered, .... some organism gain-s entry into
the system by way of the alimentary canal, and
sets up a condition of intoxication .... that the
disease in its early stages commences with gastro-
intestinal trouble, followed later by cutaneous and
mental symptoms, &c., &c." Further observations
go to confirm this view.
So far, "pellagra," in my experience, has been
met with only among Chinese field labourers
engaged in mining or vegetable gardening. These
people work and live in the fields, in open sandy
districts far removed from the towns. Their diet
consists of polished rice of the lowest quality, salted
or dried fish, pork fat, tubers, such as sweet pota-
toes, and leaves of some plants which are either
fresh or preserved. No fresh lime juice is ever in-
cluded in the dietary, as the Chinese have a great
dislike to this important and necessary article of
diet. In its place, however, a form of stale vinegar
called "Chinese sauce" (tau-yoo) is used. The
nee is boiled in water collected from one of the
ponds about the " kongsi " (Ceely line). The
tubers, leaves, and the pork fat are cut to pieces
and mixed together and fried in a little " kachang "
oil (ground-nut oil). This, with a httle salt and
vinegar forms the only dish which helps the
Chinese labourer in eating his rice. In the interval
between the two principal meals at 11 a.m. and
at 5 p.m. and whenever he is thirsty, he drinks a
little " congee " (a liquid filtered while boihng the
rice), and a large quantity of Chinese tea. Water
in its pure form is seldom drunk by these people.
Milk, butter, eggs, &c., are lu.xuries beyond the
reach of the labourer and are never used. Milk is
another article which the Chinese greatly dislike.
From the above, it will be seen that animal
protein — such as lean meat, fresh fish, milk, eggs
or butter is seldom used, and the chief source of
the diet principles consists of polished rice, tubers,
pork fat, and " kachang " oil. These articles are
found to contain very little protein and that of low
dietetic value. They are also found to be deficient
in inorganic salts such as calcium, sodium, magne-
sium and chlorine; and also in soluble fats and
organic acids.
The " kachang "oil, the vinegar and the fresh
leaves that are included in the diet are too small
in quantity to be of any use in making up the
deficiency; besides they are, in themselves, of very
low dietetic value. The diet thus composed is
used throughout the year with no variations of any
kind. It is not surprising then that adherence to
such a faulty diet for a considerable period pre-
disposes the -individual to diseases, owing to the
poor quality of the dietetic proximate principles,
chiefly the water soluble and fat soluble vitamines.
One is asked the natural and pertinent question,
" Why should ' pellagra ' be solely met with
among the Chinese?" This question may be
answered as follows : The only other races engaged
as field labourers are Malays and Tamils. The
Malay, however, seldom undertakes strenuous work
and seldom gets exposed to the conditions the
Chinese coolie is subjected t-o in the mines. His
diet is of a better quality and of a varied character.
He eats the " kampong " rice which is merely
husked without being milled or steamed. His diet,
besides, consists of fish, buffalo meat, various forms
of vegetables, fresh fruits, eggs, &c. The Malay
being a native of the country may also perhaps
enjoy an indigenous or natural immunity against
infection.
The comparative f-eedom of the Tamil labourer
is to be explained by his peculiar diet and habits.
His diet chiefly consists of parboiled rice, fish,
occasionally some meat, fresh lime juice or tama-
rind pulp, a liberal quantity of various vegetables
consisting of leaves and pods, and a large quantity
of gingelly oil which is of high dietetic value. This
oil he not only uses to fry his vegetable or roast
his meat with, but he rubs it into his scalp once in
two or three days and smears his arms and legs
with it, thus protecting himself against the bites
of insects and the rays of the blazing tropical sun.
Scurvy, pellagra, and beri-beri are diseases that
are peculiar to the Chinese and what is said with
reference to " pellagra " may also explain the
Feb. 16, 19£0.] THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
comparative immunity enjoyed by other races
against the other two diseases.
From careful observations one is led to conclude
that faulty diet, in itself, cannot cause " pellagra "
and that there is a superadded infection. If diet
should be the sole factor, then the affected indivi-
dual should improve and there should be no re-
currence when he is removed to a hospital and
placed on liberal diet, &c. But this is not so as
shown by cases that were kept in hospital for con-
siderable periods and in which the disease, far from
showing any improvement, advanced and the
cutaneous lesions and gastro-intestinal disturbances
were seen to recur at each succeeding season.
This leads one to the conclusion that, apart from
diet, sunlight, &c., there must be some other
factor, probably a toxin. The habits of the people,
the poor dietary, the extremely insanitary surround-
ings in which they live, the initial gastro-intestinal
troubles, the condition of chronic fibrosis seen in
the organs drained by the portal circulation, and
many other minor factors, favour the view that the
infection must be through the alimentary canal.
Whether the infecting agent is an organism which
enters the gastro-intestinal system and produces a
toxin which gets absorbed into the system and
produces the varied syinptomalogy ; or whether
owing to a deficiency in the vitamines, some
deleterious products are created in the intestines and
give rise to an intoxication of the system, it is
difficult to say at present.
The seasonal i-ecuirences of symptoms in patients
removed from their surroundings and placed in a
hospital with adequate diet for considerable periods
of time would point to the presence of an endotoxin
resulting from the evolution of some organism or
more probably the establishment of a vicious circle
brought about by profound metabolic changes.
Among predisposing causes may be mentioned
dysentery, ankylostomiasis, malaria, and scurvy.
Evidences of one or the other of those were present
in at least 60 per cent, of the cases.
Sfltias.
Injection by a Fusospirillanj Organism (It. R.
Mellon, Journal of Bacteriology, Septtunber, 1919).
— A fusospirillary organism was isolated from a case
in which it caused generalized infection, involving
also the kidney and lung, the point of origin iKMiig
presumably in the appendix. Its branching fila-
mentous forms relate it closely to tlu; str<'i)t()thric<^;s,
while its bacillary and coccal phases n;latei it to the
lower bacteria. The branching filamentsi were not
cultivated from the renal abscess or the lung punc-
ture, although many of them could be demonstrated
from the. material in both locations — in fact they
constitute the bulk of the flora present in the lung
puncture TOaterial. They were (uiltivated from broth
blood cultures., however, partly as the result of
an irregularity in the pr<'paration of the medium
and partly from a radical cliange in the environ-
mental conditions at a certain stage in the culture's
development.
BUSINESS AND GENERAL.
1.— The address of The Joubnal of Tbofioal Mbdicimk asd
Htqiknb is Messrs. Bale, Sons and Dahielbson, Ltd., 83-91,
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stood to be offered to The Joobnal op Tbopioal Medicine and
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every month.
TO CORRESPONDENTS.
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proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
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that all communications should be written clearly.
12. — Special Notice.— Papers can only be illustrated by
special arrangement. In order, therefore, to avoid delay, all
those desiring to have their papers illustrated are advised
to communicate direct with the Publishers at the earliest
possible moment.
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14. — Authors desiring reprints of their communications to The
JODBNAL OF Tbopical Medicine AND Hyqienb should Com-
municate with the Publishers.
15. — Correspondents should look for replies under the heading
" Answers to Correspondents. "
THE JOURNAL OF
Croptcai ® eDictne and l^pgiene
February 16, 1920.
A CIRCULAR BEING ISSUED BY THE
TROPICAL DISEASES PREVENTION
COMMITTEE.
COMMEKCE AND HyGIENE.
Commerce cannot exist without industries, nor
industries without raw materials.
A large proportion of the raw material of inter-
national commerce is produced in the tropics.
In certain tropical areas epidemic dist^ases tram-
mel and at times seriously hamper economic and
commercial projects.
From lack of suitable labour large areas in the
tropics which should be sources of raw material,
remain unutilized.
Under recent peace terms, Great Britain, its
Overseas Dominions, France and Japan have in-
curred increased responijibilities in the development
of tropical areas. It is of international importance
48
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1920.
that these duties be well done. Adequate, willing,
and healthy labour of tropical origin is essential
for this purpose. Indigenous races of certain
tropical countries are not suitable for productive
services, hence importation of labourers from other
tropical areas is requisite. The resulting flow of
immigration and emigration favours interchange of
diseases in ways revealed within recent years by
medical and sanitary research. Vast fields jor
research in this direction remain, however, un-
explored.
The near future holds great promise of increased
facilities for, and rapidity of, intercommunication
between countries, which cannot fail to promote
the interchange of diseases and their dissemination.
Efforts towards reconstruction since the Great
War give proof that tropical labour will, in common
with labour in other parts of the world, demand
increased soaial welfare. The fufilment would re-
quire a correct appreciation of the radical doctrines
of Applied Hygiene and their economical applica-
tion. These doctrines must be based, therefore, not
upon empirical observations, which are of evanes-
cent value, but upon scientifically verified data.
The continuous efficiency of labour must be
guarded in financial and life-saving interests to
meet the conditions above stated by the following
elementary precautions; —
(1) That the areas from which labourers are
recruited be sufficiently under the control of
Applied Hygiene to prevent, within the limits of
recognized science, disease peril to the country re-
ceiving them.
(2) That both at the point of departure and arrival
the labourers be subjected to skilled scrutiny as to
physical fitness and freedom from morbid condi-
tions.
(3) That the sanitary requirementsi of sites,
dwellings, food, labour and disease prevention be
met locally.
These three conditions demand the existence of
organized sanitary staffs and research staffs in the
countries concerned, particularly at their ports ; and
also require a knowledge of the movements of
disease and of data secured by medical and sanitary
research shall not be confined to this or that society
of any nation, but shall be interchangeable with
all nations. On this conviction the efforts of this
Society are based, therefore it is described as " The
Committee to encourage International Medical Re-
search for the Eradication of Disease."
For liberal financial support the Committee
appeals to those who recognize that in the produc-
tion of raw material on a large scale in the tropics
lies, side by side with the amelioration of sanitary
conditions of the races conicerned, the solution of
numerous commercial, economic and political prob-
lems of the day.
The chief of the great benefits which medical
and sanitary research have conferred upon com-
merce and the inhabitants of the tropics have been
won by pioneers, who, without hope of reimburse-
ment of private expenditure, or of remuneration for
toil and danger voluntarily faced, have gained know-
ledge which has rendered possible great engineer-
ing works, and raw material production of economic
importance, which may be valued in many millions
sterling. If by private efforts, practically unaided
by Government or the classes concerned, such
results have been achieved, it is reasonable to
believe that, provided with funds such as the cause
merits, medical research must gain still greater
victories in the cause of science and philanthropy.
The initial steps advised by the Committee, and
the reasons therefor, are set forth in the accom-
panying pamphlet.
The following pages afford indications of the direc-
tion in which . Tropical Applied Hygiene, when
guided by medical and sanitary research, has proved
of commercial and life-saving benefit. It also shows
where incre-ased effort is more obviously needed, but
statements are necessarily confined to briefly demon-
strable instances.
Engineering Works — with and without Hygiene.
During the construction of the Panama Canal
from 1881 to 1889, the French lost by death 22,189
employees, at the rate of 240 per thousand. The
death-rate from yellow fever varied between 7'3
and 20'6 per annum, and from malaria between
12-5 and 20-5. In the hope that West African
negroes might survive the chmate, 1,000 were im-
ported; all died within six months. The same fate
befell 1,000 Chinese.
The Americans commenced the work in 1904;
since 1906 no case of yellow fever has occurred in
the Isthmus. In the latter year the admission rate
for malaria per thousand of employees was 125.
In 1918 the malaria admission rate was 18. The
death-rate from all causes in 1906 was 41-7; in
1918 it was 8'1 per thousand per annum.
The completion of the Canal by the Americans
has been followed by the making of railways and
harbours to facilitate communications, so that it ha«
been caluculated that capital to the extent of
£100,000,000 is involved.
In 1900 the mode of conveyance of yellow fever
was established (Reed Board, U.S.A.) in 1898
(Ross), also that of malaria. Both facts the Ameri-
can sanitary expert — Gorgas — used to the full, and
the result was success, whereas previously it had
been failure. The root of that failure was in-
adequacy of medical and sanitary researcli at that
time. The expenditure on sanitary efforts on the
Canal did not exceed 1 per cent, of the total capital
outlay.
Labour — with and without Efficient Hygiene.
In the Lampong District of Sumatra on certain
estates the mortality amongst labourers has been
reported at 90 per thousand per annum.
In Ceylon, in 1917, the average death-rate per
thousand on estates was 36-4. Hookworm was one
of the three principal causes of death.
In British Guiana admissions to estate hospitals
for malaria gave an average of 210 during 1906-1907 ;
Feb. 16, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
49
by 1915 it had been reduced by Applied Hygiene
to 78.
In North Borneo, in seven hygiendcally managed
estates, the average death-rate per thousand was
10; in two less-carefully managed the death-rate
was 43 and 72 respectively.
In the mines of the Rand disease amongst natives
employed was such asi to cause despair of utiUzing
native labour. Medical research (Lister) has now
rendered that possible.
In the Philippines it has been estimated, on ex-
pert evidence, that the efficiency of labour could be
raised 30 per cent, by the extirpation of hookworm
disease, a medical possibility.
Instancing the seriousness of malaria in the West
Indies, where no organized anti-malarial measures
are taken, the following extracts from the summary
of Dr. W. T. Front's Report on Jamaica, 1909, are
given : —
" The total malarial deaths for the whole island
during ten years amounts to 34,695.
" The average percentage of malarial deaths to
total deaths is 19'7, representing nearly one-fifth
of the total deaths.
" The total admissions to hospitals fi-om all causes
has risen from 16,103 to 21,837 in four years, an
increase of 26 per cent.
" The total admissions from malaria have risen
from 4,827 to 7,510, an increase of 55 per cent.
" Over 33 per cent, of the total admissions were
due to malaria.
" The annual cost to the Colony of treJiting
malarial patients in liospital is over £6,300.
" The annual loss of labour from malaria among
indentured coolies on certain estates amounted to
16-9 out of every 100 working days.
" Among the constabulary, the loss of working
days from malaria in two years amounted to 7,845.
" The average spleen rate among the children
examined was 26'3 per cent., or over a fourth with
enlarged spleens.
" There is a large interference with education on
account of illness, which is preventable."
Communicable Diseases within Labour Recruiting
and Receiving Areas.
India supplies a considerable proportion of labour
to the Colonies and Proti^ctorates, 164,592 adult
Indians, according to the census of 1911. But this
gives little idea of the rate of emigration and im-
migration. From one Presidency of India in 1916
there were 380,339 emigrants and 277,363 immi-
grants.
In 1917, in British India, there were 267,002
deaths from cholera, 62,277 from small-pox, 437,036
from plague, and -1,555,221 from " fevers," a large
proportion of the lust named due to malaria. It
has been estimated that, at present, India contains
at least 150,000 lepers. In its jaals one death in
six is due to tuberculosis.
In India, dealing with families of labourers only,
and assuming that the head of each family earns
only five rupees a month and his wife a smaller
sum, it has been calculated that malarial sickness
and death cause unproductive expenditure to the
extent of more than*£20,000,000 per annum.
Tuberculosas is specially prevalent in the Gilbert
and EUice Islands. It is of increasing importance
on the Gold Coast. I^eprosy is present in certain
of the West India Islands, in Capetown, Mombasa,
Fiji, and elsewhere. There are points on the West
Coast of Africa whence the spread of yellow fever to
parts of Nigeria may occur. The continued presence
of typhoid in Georgetown remains a menace to the
West India Islands. West Indians are affected with
hookworm to the extent of 34 per cent. The em-
ployment of Egyptian I.iabour Corps may in certain
areas be followed by a spread of bilharziasis. Natives
returning from the mines of South Africa are likely
to prove foci for importation of disease to their
tribes. Plague in East Africa offers dangerous
possibilities of spread.
Annotations.
The Routine Treatment of Malaria in Uganda (J.
A. Taylor, Brit. Med. Jour., January 24, 1920).—
During the last ten years the author has adopted
the following routine treatment : Calomel (5 gr.) the
first night; a saline at 6 a.m. in the morning, and
at 7 a.m., 8.30 a.m., 10 a.m. and noon, quinine
hydrochloride is given, in 5 gr. doses. On the
second and following days the same amount of
quinine is given until the temperature becomes
normal. Then the quinine is reduced to 15 grains
daily for a week, after which 10 gr. daily are given
for a fortnight and 5 gr. for two months. If the
[latient complains of severe heiadache phenacetin
is administered in 5 gr. doses, and aspirin if there
are severe pains in the limbs and body. The author
has obtained very gratifying results from this
routine treatment.
Blood Pressure in Yellow Fever (J. Bimey Guthrie,
New Orleans Medical and Surgical Journal, Vol.
LXXII, No. 7, January, 1920).— The author has
used Cook's modification of the Riva-Rocci sphyg-
momanometer, and the pressure recorded is in all
cases systolic. He confirms Azenedo's findings as
regards the progressive fall in the blood pressure
from the first day in most cases, and especially in
mild ones. The author believes that a low average
blood pressure is a rather favourable prognostic
sign, and that therapeutic measures to increase it
should be avoided.
Trench Fever (W. Byam and H. Lloyd, Proceed-
ings Royal Society of Medicine, Vol. XIII, No. 1). -
The work of both authors on Trench Fever is well-
known. In this paper they confirm their previous
50
THE JOUBNAL OF TEOPICAL MEDICINE AND HYGIENE. [Feb. 16.' 1920.
results that trench fever is conveyed by the excreta
or ci-ushed bodies of infected lice; that the virus
may enter through the broken skin or unbroken
conjunctiva ; that rubbing and scratching promote
infection, but that the bites of lice may cause a
sufficient lesion to enable infective material to
enter the body.
Toxins and Antitoxins of B. Dysenterise (Peter K.
Olitsky and I. J. Klieger, Journal of Experimental
Medicine, January 1, 1920). — The authors have
separated an exotoxin and an endotoxin from cul-
tures of B. dysenterise Shiga. These two toxins
are distinct physically and biologically, the exotoxin
being relatively heat-labile and yielding an anti-
exotoxic immune serum, while the endotoxin is
heat-stable and is not neutralized by the anti-
exotoxic serum. Moreover the exotoxin shows a
specific affinity for the central nervous organs of
the rabbit, while the endotoxin exerts a typical
action on the intestinal tract. The authors con-
clude that a potent antidysenteric serum should
contain antibodies against the exotoxin as well as.
the endotoxin.
Preliminary Note on the apparent Transmission
of Leprosy to a Macaque Monkey (Burton Bradley,
Medical Journal of Australia, November 15, 1919).
— The author gives an account of the inoculation
of a monkey {Macacus rhesus) with leprous material
obtained from a leper. The monkey was inoculated
in three places; the wounds healed rapidly. Some
two montbis later rounded swellings appeared ; the
swellings showed no signs of acute inflammatory
reaction, but were slightly pinkish and their sum-
mits slightly abraded (possibly due to scratching);
there was also a lesion on the breast. Smear pre-
parations were made from the three lesions and in
each case leprosy bacilli were found. The monkey
which had been anaesthesized with chloroform for
the examination was left in the laboratory ap-
parently well out of the anaesthetic, but was found
dead three hours later. On a post-mortem examina-
tion being made, the result showed that apart from
great congestion of the viscera accompanied by
haemorrhages, especially in the mesentery, there was
no marked abnormality. Leprosy bacilli were found
in the cut surface of the three lesions, in both
axillary glands, and in the left inguinal gland. No
pus was found in any of the lesions.
I
0?i the Spirobacillus zeylanicus (Castellani)
(Frank E. Taylor, Journal of Pathology and Bac-
teriology, vol. "'22, 1919).— The author has isolated
Spirobacillus zeylanicus (Vibriothrix zeylanica)
from the stools of a case of chronic dysentery. He
confirms Castellani 's opinion that the organism is
probably non-pathogenic ; he considers, however,
the germ to be of practical importance, as its
colonies on coloured media are extremely similar
to those of the true dysentery bacilli.
A Case of Chronic Abscess caused by a Nocardia
(A. Pijper, M.D. (Leyden), Bethal, Transvaal). —
A native was operated on three times by the author
for an abscess in the neck. The micro-organism
isolated in each case was a bacillary organism which
could not be grown at a temperature of 22° F., but
grew very slowly at 37° F. It was found to grow
best on glycerin agar. The author considers the
parasite to be a nocardia.
Sodium Citrate in the Treatment of Pneumonia
(W. H. Weaver, New York Medical Journal,
November 1, 1919, ex, 18). — The author having for
some yeans treated pneumonia with sodium citrate,
gives a further account of his investi<:(ation>^ in the
effects of the drug in this disease. Tin.' drug
is given in large doses with plenty of water at the
rate of 15 to 20 gr. an hour, or 40 gr. every two
hours — sometimes more to a full-sized adult, and
this is continued night and day. The author states
that all the cases of lobar pneumonia of influenzal
origin he treated in this way recovered.
Amccbiasis Cutis (M. F. Engman and A. S.
Heithans, Journ. Cut. Dis., 1919, xxxvii, pp. 7
and 5). — The authors give an account of a case in
which a patient, a boy of 5, developed multiple
ulcers and abscesses. Amoebae were found in
scrapings from the lesions and in the pus.
The amoebae consisted of a spherical mass of pro-
toplasm with a sluggish amoeboid movement, and
seemed to possess the morphological characters of
the Entamoeba histolytica Schaudinn. Inoculations
with the pus from the ulcers were made in rabbits,
guinea-pigs, Sec, without result. The authors con-
sider that the ulcers were due to the pathogenic
action of the amoeba, which produces lesions on the
skin, of two types : progressive ulceration and
Cultural Studies in a Case of Sprue (W. W.
Oliver, Journ. Americaji Med. Assoc., January 3).
— From this case a yeast was recovered which
corresponds to Monilia. The organism was isolated
on glucose-agar plates from the stool, tongue,
sputum and a tool abscess. Intra-peritoneal injec-
tion of a guinea-pig killed the ain'rnal in seven days,
and from" the liver and gall-blachlcr tlio yeast was
isolated, mixed witli Siiiphijlucocciis niircus.
Buried Tube Draimuir of F.lrphauliasis (C.
Waltiier, liullrliii <lr I' .\r,idr iiur ,lr M rdrrnir .
November II, 1 OKI).— 'I'en e.ase.. ,,f ,.|e|il,., I,( lasis of
tile Ic'-s and <me of the am, weiv lieat.d l.v intro-
duein- a tul.e for sii|.pleM,entai\ dr.'.nv.iur u( Iviiipli
from the le.i; into tiie alHlounnal ea\ity. With :i
42 cm. long trocar he tunnels a passage for it
from the crural incision to the abdominal incision.
Feb. 16, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
and fastens the upper end of the tube to the lip
of "the buttonhole in the aponeurosis. The patient
stays in bed four or five weeks, the leg raised on a
cushion and wound with a liglit bandage renewed
daily to induce gentle and regular compression.
When the patient is allowed to get up, the thick
and sagging skin is massaged and electricity
applied, and it may gradually return to its normal
elasticity and aspect. In one case the skin by
the end of a year of massage and electricity had
resumed a completely normal aspect. All still
wear an elastic stocking or compressing bandage.
There has been no recurrence in from one and a
half to three and a half years in those with the
longest intervals, and the fine and durable effects
have encouraged him to persevere in this method
of treating this hitherto almost incurable condition.
All but two of his ten patients were women, and he
remarks that the only feature of the cases which
suggests a bacterial origin is the age at which
elephantiasis began to develop, between ten and
twenty-one in all but four cases, and up to thirty-
two in these.
Hydatid Vesicles Obstruct Bile Duct (F. D^ve,
Bulletin de I'Academie de Medecine, November 11,
1919). — A woman of twenty-eight was operated on
for jaundice that had persisted for over a year,
with fluctuating intensity. The expected gallstones
were not found, but the seventh day a hydatid
vesicle as large as a pigeon's egg was found in the
dressings, and five others presented later, the
biliary fistula then healing in five weeks. There
has been no further trouble during the eight years
since. In 176 cases on record of hydatid cyst in
the liver emptying into the biliary passages, in
fifty-four the obstruction was protracted, from
three weeks to a year in the different cases. The
debris of the daughter cysts are not recognized in
the stools unless the faeces are passed through a
sieve. Drainage of the common bile duct has
sometimes pemiitted the complete cleaning out
of the hydatid cyst in the liver as in the case here
ropoi-ted. The surgeon had better not rely on this,
but opei-ate dii-ectly on the pocket in the liver. The
symptoms with the jatindice do not differ from
th()s<' with gall-stoup obstruction, unless there may
be uiiicaria after an :\tt:iclc of pain, a bulging of the
liver at some jioint, enlargement of the gall-
bhuldor, cosinophilin and deviation of complement.
Occiinrncr of BaciUun hotulinus in Nature (G. S.
Bin-ko, Journal of Bacteriology, Si'iitcmber, 1919).
— Two hinidrcd and thirty-five cultures wore made
from samples collected in five localities in central
California, fifty or more miles distant from each
other. The cultures covered a wide range of
material, including tap water, hay, loaves, veget-
ables and fruits in various conditions, insects,
s])iders, sowbugs, snails and caterpillars, garden
soil, manure from horses, hogs, and chickens, and
also sanjples from the claws, beaks, crops, gizzard
and intestinal contents of birds. Seven cultures
containing B. botulinii^s .were found.
Yellow Fever in New Orleans. — A passenger from
Merida, Mexico, on a steamer which arrived in New
Orleans, December 2, died at noon, December 4,
from yellow fever. The disease was promptly
recognized and all precautions were taken.
Bubonic Plague. — All port facilities of New
Orleans, save five wharfs, are to be ratproofed at
an expenditure of about $2,000,000. The other
facilities of the board will gradually be ratproofed,
the necessary funds being borrowed. The seventh
case of bubonic plague reported this, year in New
Orleans is that of a rat-catcher in the Public Health
Service, who was s.eized with the disease, Novem,-
ber 27. One death from bubonic plague occurred,
November 25. The case was detected, Novem-
ber 22, and was sent to the isolation hospital, where
serum was administered, but it was then too late to
save the life of the child.
Ctimnt Witmiuu.
The Indian Journal of Medical Research.
Vol. VII, No. 1, July, 1919.
Records of the Occurrence of Intestinal Protozoa
in British and Indian Troops in Mesopotamia
(Captain C. L. Boulenger).— The protozoa which
have been investigated by the author are identified
and a comparison is made between the findings in
British and Indian cases. Out of 1,378 European
cases, 201 were found to be infected with Entamoeba
histolytica: 264 with Entamoeba coli; 133 with
Giardia (Lamblia) intestinalis ; 111 with Tricho-
monas intestinalis ; 68 with Chilomastix (Tetra-
mitus) mesnili; 8 with Coccidium (Isospora). Out
of 906 Indian cases, 188 were infected with
Entamoeba histolytica; 276 with Entamoeba coli;
90 with EntanKEba nana; 74 with Giardia (Lamb-
lia) intestinalis; 96 with Trichomonas intestinalis;
30 with Chilomastix (Tetramitus) mesnili; 1 with
Coccidium (Isospora).
Report on Bilharziasis in Mesopotamia (Captain
C. L. Boulenger). — An outbreak of bilharziasis
among the troops in Mesopotamia in 1917-18 led
to an investigation of the incidence of the disease
in the Arab population, when it was found that
29 per cent, of the male j)opulation was infected.
The mollusc Bullinns contortus was found, but did
not seem to be very common.
The Pharmaco-Dynantics of Quinine (J. W.
Carnwall). — The author finds evidence that quinine
administered to healthy rabbits for long periods of
time causes danuige to the cellular element of the
adrenals and of the kidneys, and that the rate of
disintegration of red blood corpuscles in the spleen
is increased.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 16, 1920.
The PatJiogenesis of Deficiency Disease. The
Influence of Dietaries Deficient in Accessory Food
Factors on the Intestine (Robert MoCarrison). — The
author has made a large number of dietetic experi-
ments in pigeons and guinea-pigs and concludes that
dietaries deficient in accessory food factors cause
changes and impairment in the digestive functions.
He also suggests that certain gastro-intestinal dis-
orders in man may owe their origin to deficient
nourishment.
The Pathogenesis of Deficiency Disease. The
Influence of a Scorbutic Diet on the Adrenal Glands
(Robert McCarrison). — According to the author's
experiments a scorbutic diet induces in guinea-pigs
an increase in size of the adrenal glajids ; a marked
diminution in their adrenalin cont-ent; foci of
haBmorrhagic infiltration ; degenerative changes in
the cellular elements of the adrenal cortex and
medulla. The author concludes that a scorbutic
diet impairs the functional capacity of the adrenal
glands, and that this functional impairment occurs
before any symptoms of scurvy appear.
Notes on a Monkey Plasinodiutn and on some
Experiments in Malaria (R. Knowles). — The author
has inoculated blood from malaria patients into
monkeys, but has not succeeded in infecting these
animals. A detailed description of a plasmodium
found in a monkey of the genus Semnopithicus is
given.
The Technique of the Levitation Method (Clayton
Lane). — A very detailed description of the Levita-
tion method for the concentration of liookwonn
eggs.
Presence of Acid-fast Bacilli in the Blood of
Lepers (K. R. K. Iyengar). — The author confirms
the presence of acid-fast baciUi in the circulating
blood of lepers. He is of opinion that the routine
examination of blood films will be found to be
helpful in the diagnosis of the malady.
On the Possible Spread of Schistosomiasis in
India (Stanley Kemp and F. H. Gravely).— The
authors have attempted to infect artificially with
miracidia of human Scliistosomiasis, various mol-
luscs found in India : Melania tuberculata Muller,
Mela-inia variabilis Benson, Lininsea ovalis Gray,
&c. The results have been constantly negative.
Journal of the Royal Naval Medical Service.
Vol. VI, No. 1, January, 1920.
A Retrospective View of Naval Medical Condi-
tions (Surgeon Rear-Admiral Sir Robert Hill). —
This interesting paper deals with the conditions of
medical service at sea from Nelson's day to the
present time. Tables are given showing the casual-
ties at the Battles of Camperdown, The Nile,
Trafalgar, and Jutland.
Typhoid and Antityphoid Record for 1918-1919
(Surgeon Captain P. W. Bassett-Smith).— The
author gives an account of the successful employ-
ment of the triple typhoid vaccine in the Navy
from October 1, 1918, to September 30, 1919. The
number of men inoculated was 17,401 : single
inoculations, 2,273; double inoculations, 15,128.
No change was made in the composition of the
vaccine either in the number of the strains or pro-
portions, and no excessive reactions were recorded.
During the year the total number of oases of enteric
was forty-eight with six in which the diagnosis
made on clinical signs was doubtful, and no
definite records of laboratory diagnosis were given.
Quinine Tabellx and Quinine Salts (Superintend-
ing Pharmacist F. W. Hooper). — Tlie author gives
the results of the examination of various samples
of quinine supphed to the Navy and reported to be
irregular in action. He is of opinion that it would
be advantageous to replace bisulphate tablets by
the anhydrous bi-hydrochloride. The suggestion is
also made that a compound tablet containing other
of the alkaloids of cinchona might be used in con-
juction with pure quinine salts when malarial
patients do not rapidly improve on the latter alone.
Quinine Prophylaxis (Lieut. Commander L. A.
Moncrief). — The author has obtained favourable
results from the use of quinine bi-hydrochloride in
an acid solution, as a prophylactic. He prefers
the bi-hydrochloride to the sulphate.
Heat Stroke (F. E. Fitzmaurice). — Two cases of
heat stroke contracted under exactly similar condi-
tions on board H.M.S. Southampton are described.
One presented all the features of heat exhaustion
and recovered under treatment. The other showed
all the features of thermic fever and the condition
ended fatally.
Journal of the Royal Army Medical Corps.
Vol. XXXIV, No. 1, January, 1920.
Notes on Blackwater Fever in Macedonia (Colonel
A. G. Phear). — The author gives an account of the
incidence of Blackwater fever amongst British
troops in the Salonika Command. In practically
every case a history of malaria was forthcoming.
Quinine did not seem to have any part in the
causation of the symptoms. Treatment consisted
in keeping the patient at perfect rest in bed and
the administration of large quantities of fluid.
Bilharziasis and Malaria during the Palestine
Campaign (Major Charles Searle). — The author
gives an interesting account of the means taken to
protect the troops in Palestine from these two in-
fections. He emphasizes the necessity of all ranks
receiving some training in the prevention of tropical
diseases before proceeding on a campaign, especially
the regimental medical officer, and advocates a
strenuous after-war campaign against malaria and
bilharziasis in Palestine.
Studies on the Weil-Felix Serological Test for the
Laboratory Diagnosis of Typhus Fever (Captain
I
Feb. 16, 1920.J THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
53
Arthur Compton). — Of the fourteen typhus oases
in which the author carried out the Weil-Felix
reaction, thirteen gave a positive result.
The Intravenous Injectioti of Eusol in Subtertian
Malaria (Lieut. -Colonel P. S. Yickerman). — The
author states that he has had good results from the
intravenous injection of eusol (40 to 60 c.c.) in
acute and chronic cases.
Thk Philippine Journal of Science.
Vol. XIV, No. 0, May, 1919.
SoDir Bacicrioiogic Phases of the Cholera-Carrier
Prohletn (John A. Johnston). — The author gives the
results of experiments carried out in 1916 in the
Philippine Islands, with the object of finding a
method to facilitate the discovery of cai-riers. He
comes to the conclusion that the oral administration
of bile seems to be helpful as it causes more vibrios
to appear in the faeces.
Cijstolithiasis among Filipinos in Association with
Dietetic Deficiency (Regino G. Padua). — The
author has made a painstaking investigation into
the chemical composition and into the causation of
calculi in the Filipinos. He concludes that a rela-
tion apparently exists between the general dietetic
inadequacy and deficiency among the Filipinos and
the common occurrence of phosphatic calculi in
them, in contrast with the predominance of uric
acid and urate calculi in Europe and the United
States.
abstriids.
CHARACTER OF THE PREVALENT TYPHUS,
IN POLAND AND ITS ASSOCIATION
WITH RELAPSING FEVER.'
It is well known that different epidemics of
tyj)lius have been reported as being characterized
by special features; thus, the Serbian epidemic of
1914-1.') showed a great tendency to gangrene of
the feet; while those of Ireland have been generally
associated with bronchial and pneumonic complica-
tions. What are the characters of the present
epidemic in Poland? Thanks to the kindness of
the local medical authorities, we have been able
to see and clinically examine numerous cases of
typlius, in evei-y stage of the malady, and a large
number of clinical histories and temperature charts
ha\e been placed at our disposal.
Most cases showed the typical features of the
disease as described in all medical text-books and
us seen by us in previous epidemics.
In Poland the incubation period seems to be —
' Report of loterallied Medical Commission to Polaud
(H. S, Gumming, G. S. Buchanan, A. Castellani, P. Visbecq).
Chapter III. Bulletin of the r^eague of Red Cross Societies,
Tol, i, No. 4.
as in other countries — eix to ten days; the onset,
as is the case .everywhere else, is usually sudden
with severe frontal headache, pains in various parts
of the body, occasionally rigors; rapid rise in
temperature, flushed face and suffused eyes; and
quickened respirations.
Judging from the clinical histories and tempera-
ture charts given to us, the course of the disease
is similar to what one sees in other countries, the
fever generally lasting from fifteen to sixteen days.
The rash generally appears on the fourth or fifth
day. We noted several varieties of the typical
rash, this confirming our experience in the Balkans.
The rash is at first roseolar, and first appears on
the a-bdomen, from there spreading to the chest,
.irms and legs. In many cases it seemed to be far
more abundant than the rash seen in the Serbian
cases. Some of the roseolar s|)ots after a time
become petechial and do not disappear completely
on pressure.
In some cases the roseolar spots were slightly
raised (maculopapular rash). Occasionally an
en-uption of sudamina was present. A case of
typhus exanthematicus sine exanthema was shown
to us at the Infectious Disease Hospital at Cracow.
The Weil-Felix reaction was strongly positive, and
the case apart from the rash had all the symptoms
of the disease.
With regard to complications, it is interesting to
note the comparative rarity of them in Poland,
while in the Serbian epidemic of 1914-1915 they
were extremely common. In Serbia the more
important complications observed were, in order of
frequency, parotitis, gangrene of the feet, polyar-
thritis and polyneuritis.
The diagnosis is generally made on clinical
grounds, but in the towns and districts in which
bacteriological laboratories exist, the Felix-Weil re-
action is much used for confirming the clinical
diagnosis. In the State Epidemiological Institute
of Warsaw, Dr. Anigstein gives much diagnostic
importance to the practically complete absence
of eosinophiles in cases of uncomplicated typhus.
The prognosis of cases of typhus in the present
epidemic in Poland seems to be more favourable
than in epidemics observed elsewhere. The
mortality in Poland has seldom exceeded 10 per
cent, or thereabouts, while in Serbia in 1914-15 it
was as high as 30 per cent.
The treatment carried out in Polish hospitals is
the usual symptomatic one. The lack of nurses,
and the extreme scarcity of the simplest drugs,
food, and medical comforts, is much felt.
.\SS0(IATI0N OF THE TyPHUS EPIDEMIC WITH AN
Epidemic of Relapsing Fever.
During our tour, we have been able to observe
an extremely large number of cases of relapsing
fever. In fact, in certain districts the cases of
relapsing fever were much more numerous than
those of typhus. The co-existence of epidemics of
typhus and recurrent fevers is, of course, no new
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [Feb, 16, 1920
observation. It has been noticed for many years
and we now know that the cause of this frequent
co-existence is that both infections are carried by
the same insect, the louse.
In the Balkans, in 1914-15, we had the same
experience, but there the typhus epidemic ceased
completely in July, while the relapsing fever con-
tinued. In Poland, in many districts, both
epidemics have continued through the summer
months.
Eelapsing fever, though not so grave a malady
as typhus, is a serious disease and in epidemic form
may become a terrible scourge. For relapsing fever,
as is well known, salvarsan and neosalvarsan are
specifics, and one of us found out in the Balkans
that tartar emetic also has a certain action on the
malady, and tliat a lumbined tartar emetic-neosal-
varsan is most efficacious. Unfortunately, there is
a great scarcity of these dnigs in Poland, and it is
essential in our opinion to take steps to have all
Polish hospitals provided with them as soon as
possible.
As regards prophylaxis, all the measures which
will be taken to stamp out typhus will be found
successful in combating relapsing fever.
THE DIAGNOSIS OF CHRONIC CHOLE-
CYSTITIS COMPLICATING CARDIAC
LESIONS. 1
By H. Baucock.
Chronic cholecystitis, with or without formation
of calculi sufficient to cause distinct colic, is apt
to be overlooked. Therefore, the history and
symtomatology should not be disregarded, no
matter how insigtiificant they may seem to be.
It should be kept in mind that pain of a sort
different from intense hepatic colic is a frequent
symptom, and also that its cause may be different.
The pain now referred to is rather more a feeling
of soreness or distress than an agonizing colic, and
may be due to distension of the inflamed viscus
instead of its attempt to expel a calculus, or to the
passage of a stone along the cystic or the comnnon
duct. When due to distension of the gall-bladder
or to congestion of the liver, the distress is hkely
to be more continuous and not so spasmodic as
when caused by calculi. The location of the pain
may be various and referred to the epigastrium or
to the precordial region, or it may radiate upward
over the anterior or posterior aspect of the chest
on the right side.
Nausea and vomiting need not be pronounced
features any more than is jaundice. When these
do occur they are very apt to be attributed by the
sufferer to acute indigestion, especially if succeeded
by cessation or decided diminution of pain. These
are the symptoms so commonly regarded and men-
tioned as " attacks of biliousness."
I Abstracted from the Journ. Avier. Med. Assoc, Dec. 27, 1919.
In cases of cardiac disease, enlargement of the
liver is the result of passive congestion and is so
frequently observed that, when due to chronic
cholecystitis in a cardiopath, one may very natur-
ally attribute its increase in size and tenderness to
stasis in consequence of impeded circulation. It is
this very circumstance that renders the diagnosis
of gall-bladder infection difficult as a complication
of cardiac lesions.
The following points are of great aid in arriving
at the diagnosis : in passive hepatic congestion
from heart disease, the organ preserves its natural
and characteristic outline unless this is prevented
by adhesions or by changes produced by cirrhosis,
the chronic indurative cirrhosis of long-sfcanding
portal stasis. When not cirrhotic, but merely
swollen by congestion, the left lobe is palpable
and tender as well as the right, and one can detect
the notch sepamting the two lobes. This is a
point of great importance in cases of cardiac,
particularly valvular disease. Furthermore, when
secondary passive congestion of the liver exists one
is very likely to find evidences of venous stasis in
other organs and tissues. Consequently, the phy-
sician should search for these before concluding
that the liver changes are the result of passive
congestion merely. These being absent and the
sj'mptoms being referable to the abdomen rather
than to respiratory embarrassment, suspicion
should be attached at once to the liver, not to
the heart.
When cholecystitis is responsible for enlarge-
ment of the liver, it causes a characteristic altera-
tion in the form of the right lobe, first described
by Riedel in 1892, and hence know^n as Riedel's
lobe. As a rule, the more acute the gall-bladder
infection, the more pronounced is this change in
the outline of the liver; and yet this may occasion-
ally be very pronounced in cases of chronic chole-
cystitis. This alteration consists in a convex
enlargement of the right hepatic lobe downward,
so that the edge of the organ curves downward
toward the right for a variable distance and then
upward to or shortly below the margin of the ribs.
In some cases this convex bulging may be small
and obscured by the right rectus muscle, while in
others, Riedel's lobe may reach from the median
line nearly or quite to the extreme limit of the
liver at the right. It may be noted also by careful
palpation that the portion of the viscus lying to
the left of the median line is not at all, or only
indistinctly, palpable.
In pronounced instances there may be an appre-
ciable bulging of the part of the liver overlying the
gall-bladder, so that in well-marked cases it gives
the impression of a rotimd mass like an orange
beneath the liver. If the liver or the gall-bladder
is sensitive to pressure, the right rectus muscle is
apt to stiffen in distinct contrast to the correspond-
ing muscle on the left side. If the right lobe is
small it may be obscured by the rigid muscle, and
yet by careful palpation the liver may usually be
Feb. 16, 1920., THE JOUKNAL OP TROPICAL MEDICINE AND HYGIENE.
55
detected at either side of the rectus, aud with the
characteristic convex shape described.
In many cases, on deep inspiration, the hand
can detect the softer and exquisitely tender gall-
bladder itself extending slightly below the lower
edge of Kiedel's lobe, while in others the hand
must be thrust sharply upward underneath the
edge of the liver in order to come in contact with
the gall-bladder and elicit evidence of pain. This
procedure causes the patient to cry out and shrink
from the hand, and is followed by unmistakable
rigidity of the right rectus muscle.
Palpation of the liver in these cases is a fine art.
Not only should the knees be elevated so as to
relax the abdominal walls, but the flank should be
raised either by the examiner's left hand or by a
firm cushion ; and the physician should avoid too
firm and rough palpation, since by so doing he is
likely to frustrate his own object. The lower edge
and the shape of the lobe is frequently felt by
merely resting the flat hand lightly on the abdomen
and allowing the patient to breathe regularly and
with moderate force. By so doing pain is avoided,
the abdominal walls remain relaxed, and the lower
hepatic border can be perceived to glide back and
forth beneath the hand. If this procedure is per-
formed at each side of the median line alternately,
the state of the two rectus muscles, as well as the
outline of the two hepatic lobes, may be compared.
Another sign of gall-bladder disease of corrobora-
tive value in some cases is the area of cutaneous
hyperaesthesia on the right lower back. When this
is present, simultaneous stroking of the two sides
behind, froin above downward, just internal to the
posterior e<lge of the scapula, will elicit more or
less sensitiveness of the skin at the right, over the
course of the tenth and eleventh intercostal nerves.
This sign has seldom been absent in cases of well-
marked cholecystitis as shown by the evidence
obtained by palpation of the liver.
The degree of systemic disturbance, as shown by
the temperature and leucocytosis, depends on the
intensity of the gall-bladder infection. If the
cholecystitis is chronic, revealing its presence
chiefly by digestive disorder and only moderate
pain, the body temperature may be b\it slightly,
if at all, raised, and may not even attract tlie
j)atient's attention, while during the intervals be-
tween attivcks of acute distress the temperature is
likely to be quite normal. Indeed, it may be said
that the freedom from febrile or other systemic
disturbance furnishes one reason why these chronic
cases are apt to escape detection.
J'he leucocyte count in like manner is subject to
slight deviation from normal. In strictly chronic
cases without marked symptoms the leucocytes are
not likely to show an increase of over eight or nine
or possibly ten thousand with, of course, no pro-
nounced preponderance of the polymorphormclear
elements. One should be careful not to regard
slight increase in temperature and white count in
a given case of valvular disease as indi<^ating an
exacerbation of a chronic endocarditis. Except in
acute instances of cholecystitis, more information
is to be obtained by histoi-y, subjective symptoms,
and painstaking manuaf examination than by study
of temperature and leucocytes or even Rontgeno-
logic examination unless, of course, the Rontgen
ray is so fortunate as to disclose the presence of
stones.
CHANGING THE FLORA OF THE INTESTINAL
TRACT.
Scientific evidence demonstrates the difl&culty
of changing the intestinal flora. Without denying
the possibility that certain forms of bacterial infec-
tion of the digestive tract are harmful, it is not
untimely to point out again that the mere adminis-
tration of Bacillus bulgaricus or similar organisms
will not result in changing the pre-existing intes-
tinal flora. Those organisms which produce indoxj-1
and allied substances in the test tube are the same
organisms that produce them in the human body
with the resulting appearance of indicanuria. It
was impossible in the lower animals to displace
the existing intestinal flora by feeding antagonistic
bacteria. On the contrary, all that was necessary
to produce this desirable effect was a change in
the diet of. the animal. It cannot, of course, be
definitely concluded that a similar course of events
takes place in human beings ; but probably the best
means to reduce one variety and to increase
another variety of bacteria in tlie intestinal tract
is to change the character of the diet. In lower
animals, when the appropriate diet is introduced,
the bacterial substitution takes place automatically.
F. R. Chetham Strode (Lancet, .Ian. 10) advocates
the administration of coarse uncrushed oatmeal.
liirteto.
.X .Manual of Tkopical Diseases. By Aide
Custellani and Albert J. Chalmers. Bailliire,
Tindall and Cox, Henrietta Street, London,
W.C. 1919. Third edition. Pp. 2436. Illus-
trated.
A third edition of this great work has seen the
light and lias been lying on our table for weeks
running into months. We have put off a notice of
the contents from time to time, being well nigh
stunned by the thought of dealing with so great
a mass of concentrated knowledge in a manner
worthy of the subject and of the master minds that
produced it. Built upon a sure foundation in the
first edition the work has borne structural altera-
tions and additions to perfj^ction, and not only so,
but these have enhanced its appearance and its use-
fulness. Much is new in the book, fresh diecoveries
have necessitated a, severe wooding out of former
editions, re-arrangements and eliminations to make
room for new facts; yet the original plan of the
book we are pleased to see has not altered in feature
or in style.
56
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1920.
The authors being faced with an enornaity of
material to Be dealt with, it must have been a great
temptation to cut out whole sections of the pre-
vious editions. One can imagine their scrutinizing
the introductory section with blue pencil in hand
aud threatening whole chapters on, say, " The
History of Tropical Medicine " and " Tropical
Races," &c., with elimination. We are thankful
thisi was not done, and hope that no curtailment
of what some may regard as side issues will ever
be listened to. These and such as these are the
distinguishing features of the manual. Tropical
diseases can only be properly studied when their
whole environment is taken cognizance of; the
various peoples, the climates, the environment, the
geology and the fauna and flora are as necessary
to a knowletlge of tropical medicine as is the micro-
scope and the "test-tube.
To the Section C, dealing .with parasites, much
new and original matter has been added. The
chapter on Trypanosomes has expanded until it
occupies no fewer than 105 pages' of the text. The
great sub-families, the H i-rpclinihihiiia' Cast-ellani
and Chalmers and Trypanosoiunur (jstiUani and
Chalmers have been established. ;uul tlie nomen-
clature has been altered so radically that older
students will become bewildered should they take
up this volume and simply glance throupli it. They
will find old acquaintances, such as the liisluric nanir
Trypanosoma gambiense altered to ('uKtrllaiirlla
gamhicnsis, Trypatiosonia castellanii altered tu
Castellanella casteUani, Trypanosoma cruzi to
Schizotrypanum critze and so forth. New tribes,
new genuses and a multitude of new species in this
enonnous section of the work fill one with amaze-
ment at the labour that has been concentrated on
a subject which is only 18 years old, for it all dates
from the discovery by Ford and Dutton of the
T. gambiense in a case of Gambia fever and by
CasteUani in sleeping sickness. The multiplicity of
species due to variety and change of environment
in this section — Trypanosomidse — is an excellent
example of evolution as recounted in Chapter V,
p. 112, of this volume. No one should skip these
invaluable two pages of matter, for it is a concen-
trated essence of epitomized knowledge, yet ex-
planaton,' to a degree. It is difficult to get away
from the subject of trypanosomes as unfolded in
this book, but we must refer to the Respiratory
Spirochaetes of CasteUani. This great subject fills
but a mere niche in the text and is almost drownetl
in the wealth of material, yet no greater discovery
from a clinical point of view has been made in our
time.
We have to look for familiar friends under head-
ings with which we have not yet become familiar,
although some of them are 20 years old. Gregarina-
coccidia and Plasmodia are to be found under the
heading of chapter and page as Telosiporidia. The
Trematodes, the Cestoidea, and especially the
Nemathelminthes (which, of course, includes the
great subject of Filaria) are given ample space
and are fully dealt with, and the Diptera, the all-
important Diptera, with discoveries dating from
over two hundred years ago until the other day,
are done ample justice to. The fairy tale of the
animul carriers of disease is expanded and re-
fashioned as it is bound to be, and will continue to
be for centuries to come.
The vegetal parasites occupy 200 pages of the
volume and of those no less than 159 are devoted
to the fungi. In no scientific work we are ac-
quainted with, certainly in no medical text-book, is
to be found anything approaching the completeness
with which this subject is handled. The accuracy,
the amount of work accomplished by the authors
in grouping, systematizing and arranging this pro-
lific subject is a masterpiece of editorship. The
systematic study of the fungi dates from the days
of Linnaeus. The fungi attacking plants were
chiefly dealt with, but the study of parasitic fungi
in man began with the discovery of the fungus of
ringworm by Remak in 1837. As years advanced
so did our knowledge of human vegetal parasites,
and it has reached a climax of expansion by the
labours of CasteUani. No one has added to our
knowledge of this all-important subject to the same
extent, nor shown us so exact methods of investiga-
tion as this prolific writer and earnest observer and
investigator. Turn to page 1079, where the genus
of Monilia (Fungi imperfecti) is dealt with, and but
.srlance at page 1082, where of forty species of
Miiiiilia thii-ty-nine are associated with the name of
Castrllani, of which several are met with in the
respiratury tract. Other names there are in this
field of work, Brumpt, Chalmers, Blanchard,
Fuckel, Fries, Vuillemin and many others, but
CasteUani has made the subject his own, and to
him the scientific and clinical world owe a debt.
It is impossible to discuss Part III of the book,
devoted to the Diseases of the Tropics; this must
be dealt with in a future notice, for spa-ce permits
no more at present. We congratulate the authors,
the pnhlisherii, and also the draiightsman upon the
acciu'aey and delicacy of his illustrations.
We are glad the authors and publishers have seen
fit to produce the book in one volume. Were the
first two parts separated from the third, that is,
the part devoted to diseases, there would have
grown up a tendency to separate the scientific from
the more practical part. He who wishes to master
the subject of tropical medicine cannot afford to
neglect the one part for the other; they are part
of a consistent whole ; the science and art of this
subject must not be parted if we are to keep tropical
medicine where it began, namely, a combination of
laboratory findings and practice; each is the hand-
maid of the other, and he who would separate
them will tend to produce a practitioner of a
low degree, to whom the administration of drugs
becomes the be-all and end-all of his existence, a
mechanical man, a reversion to a type we wish to
eliminate.
We have no book equivalent to this manual in
any branch of medicine, and the happy combination
of the gifted authors has given the world an asset
of incalculable value.
J. Cantlie.
Mar. 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 5, Vol. XXIII.
^riflinal Commniurattons.
SADD DERMATITIS.
By Albert J. Chalmers, M.D., P.R.C.8., D.P.H.,
Director, Wellcome Tropical Research Laboratories,
A. P. Joseph, D.Sc, P.I.C,
Qovernmenl Chemist, Wellcome Tropical Research Laboratories,
Khartoum.
Contents. — Introductory — Historical — Clinical
Notes — etiology — Treatment — Summary — Re-
ferences— Illustrations.
Introductory. — In 1917 one of us with Pekkola
described a Sudanese Dermatitis venenata caused
by HaplophyUum tuberculatum (Forskal 1775), and
now we desire to invite attention to skin eruptions
caused by grasses forming part of the Sadd (com-
monly called Sudd) of the Upper Nile and its
tributaries.
This matter is of especial interest at the present
time when attention is being paid to all natural
resources throughout the Empire which may be
converted into useful products.
Historical. — It is common knowledge that the
White Nile above its junction with the Sobat is
blocked by large masses of vegetal matter which
extend into the tributary rivers named Bahr-el-
Gebel, Bahr-el-Zaraf, Bahr-el-Ghazal and Jur.
These accumulations blocking the fairway of
the river are called " Sadd " from the Arabic word
^iu meaning a blockage or dam. This name is
variously written Sadd and Sett, but the above is
correct.
The earliest explorers of the Nile do not mention
Sadd, and Werne as late as 1840-1841 does not
appear to have met with it.
Miss Tinn^'s expedition in 1863, however, was
much obstructed by it, and since that day the
difficulties and dangers associated with the passage
of river craft through the Sadd have become well
known.
This blockage is composed of fixed and swimming
plants which vary in composition in the different
livers. Thus Schweinfurth, writing about 1869,
says that in the White Nile it is mainly composed
of grass, papyrus (Cypcrus papyrus LinnsBus 1753)
and ambatoh (Herminiera elaphroxylon Giiillemin
and Penottet 1832), while Garstin, quoted by
Lyons, adds Pliragmites communis Trinius 1822
and Broun, who considers the ambatch to be
merely accessory, adds Typha australis Schumacher
and Thonning 1827, which is j)robably the same as
T. angustifolia Ijinnseus 1753. The swimming
l)l:uits, .■Kcoiiliiif,' to Gai-stin, are composed of
spirii's litlijii^'irif,' to the genera Azolla I^amarck
17H3, Ohrliii I'ersoon 1805, and Utricularia
Liiuiieus 1735.
Only the grasses are l<nown to cause skin
irritation, and among these there are two of im-
poitaiico in this respect, vi/,., Vossia pruccra Wall
and (irifhtli 1H3(5, more correctly called V. cuspi-
data Griffith and Panicum pyramidale Lamarck;
both these plants bear the Arabic name of Um
Suf, meaning mother of wool.
In regard to the dermatitis caused by Vossiu
procera, Schweinfurth, writing about 1869, says
that the plant derives its name " Um Suf" from
the peculiar hairy character of its leaf sheaths.
He says that these hairs have the disagreeable
quality of covering the entire body of persons who
may have to work in this grass with a thick down
of adhesive bristles. He further states that the
sharpness of these hairs and the scratches which
they inflict increase the irksomeness of daily labour
at the grass barrier. He, however, points out that
cattle, sheep and horses prefer this grass to all
other kinds of herbage.
At present we have no personal experience of
this plant, and therefore are only able to quote
Schweinfurth, but Prain states that some of the
leaf sheaths are scaberulous with small tubercle-
based hairs, which is suggestive.
With regard to the other grass, viz., Panicum
pyramidale, Marn6 in 1881 reported that the Bahr-
el-Ghazal was choked by "Sadd" mainly com-
posed of grasses, and in 1906 Broun, investigating
this barrier and that of the tributary river Bahr-
el-Arab, stated that the grasses were mainly com-
posed of Panicum pyramidale Lamarck and Plirag-
mites communis Trinius, of which the Arabic name
is Bus.
When referring to the former grass, Broun drew
attention to the irritant hairs on the sheaths of the
lower leaves. This is the plant which we have
been able to investigate in its dried condition as
the skin irritation which it is capable of
causmg.
Clinical Notes. — During the present year it
became desirable to investigate the chemical con-
stituents of some of the vegetal substances com-
posing the Sadd, and therefore a quantity of Um
Suf, in a dried condition, was sent to these
laboratories by the Woods and Forests Depart-
ment.
After handling this dried grass the workers in
the chemical section of these laboratories and the
native servants complained of irritation on the
skin of the arms. When these areas were inspected
it was observed that a number of small bright red
papules could be seen in Europeans, while in
natives these papules were dark in colour.
There was no general inflammation of the
affected area, and the rash was strictly confined
to the parts of the body which came in contact
with the hairs, and did not affect the face or otlicr
parts of the body.
If left to themselves the painiles became more
pronounced and lasted several days, but the
cutaneous in-itation subsided after about twenty-
four hours or less.
/Etiology. — This section of the subject under
discussion will be divided into (a) The Plant,
{/>) Persoiuil Idiosyncrasy, (r) Coiifimiatory Test,
((/) The Method of Action.
THE JOUBNAl. OF TROPICAL MEDICINE AND HYGIENE. [Mar. 1, 1920.
(a) The Plant. — The cause of this dermatitis
is the grass Panicum pyramidale, which was
named by J. B. P. Antoine de Monette,
Chevalier de la Marck, who is commonly known
as Lamarck, on p. 735 (not 745) of Volume IV
of the " Encyclopedie Methodique," which was
published in Paris between the years 1783 and
1817.
This plant is noted by Broun as forming one of
the important constituents of the Sadd, especially
that blocking the Bahr-el-Arab.
Fig. 2 illustrates the inflorescence as shown in
the dried specimen left by Broun in the Sudan
Government's Herbarium, while fig. 3 indicates
the pyramidal characters of the inflorescence rather
better than fig. 2. Fig. 4 shows the dried plant
with its rhizome and rootlets. It also shows the
lower leaves covered by their sheaths.
If one of these sheaths is carefully removed, it
will be seen to be covered with hairs as shown in
fig. 5. These hairs, which measure about
0-056 mm. on an average in diameter, are easily
detached and cover the skin with a white fluff,
hence the Arab name Um Suf or Mother of Wool.
That these hairs are the cause of the irritation
will be demonstrated below.
When examined by the microscope the hairs are
noted to be liollow, e.g., figs. 6 and 7 show this
clearly, because air has been allowed to remain
in their cavities.
(h) Personal Idiosyyicranti. — This is not marked
but some people appear to be more readily
affected than others.
(c) Confirtitatory Test. — If some of the hairs
shown in figs. 5, 6 and 7 -are carefully collected
and rubbed into a limited area of the flexor
aspect of the forearm and then (piickly removed
by washing, in ;i few minutes a sense of irrita-
tion is felt in this area, and in about half an
hour definite spots appear.
On examination a number of small red papules
can be observed in the white skin while in the
black they appear bluish-black (fig. 1).
There is no surrounding inflammation but in the
course of a few hours the papules attain the size
shown in fig. 1 and in this condition they remain
for a variable number of days if left untreated.
It is therefore sufficientlj- obvious that the der-
matitis is in some way due to the hairs on the
sheaths of the lower leaves.
(rf) Method of Action. — If figs. 5, 6 and 7 are
examined it «ill be observed that the little hail's
somewhat resemble the ordinary sewing needle
with the important exception that they are
hollow as is demonstrated by the elongated air-
bubble shown in each hair.
It is therefore obvious that the hairs may pro-
duce this mild dermatitis by mechanical means or
that they may introduce into the puncture, so
produced, chemical substances which aggravate the
lesion.
Unfortunately the home of Panicum pyramidale
is far removed from Khartoum and we liaxe had
the dried specimens only to deal with. Neverthe-
less it seemed to us to be worth while examining
the hairs in this condition with a view to seeing
whether the presence of any in-itant chemical sub-
stance could be detected.
For this purpose hairs were removed from the
leaf sheaths by means of a camel-hair brush.
The quantity so obtained was but small, e.g.,
132 grm. of dried leaf sheath only produced
0'28 grm. of hairs, i.e., 0"2 per cent.
Some of the hairs isolated were proved by experi-
ment to give the skin eruption and irritation
described above, while the remainder were sub-
jected to the following experiments ; —
(1) About 0-25 gmi. of the hairs were extracted
with boiling alcohol. This extract waiS filtered
and then evaporat€d to dryness. The residue,
whicJi amounted to about 20 per cent, of the
original mass of hairs, was taken up with a little
alcohol and then applied to the skin.
No reaction was produced, but the residual
hairs gave rise to the typical cutaneous eruption.
(2) A similar extract was prepared by using
equal parts of alcohol and chloroform. The re-
sulting residue was coloured and gave an
aromatic resinous odour.
When applied to the skin this also produced
no reaction while the hairs were as actively
irritant as ever.
(3) Cold water extracts were next prepared
with, and without, previous trituration with
quartz powder which was added with the intent
of facilitating the extraction of any substance
which might be present in the hairs.
These extracts were neutral to litmus paper
and were quite void of activity when applied to
the skin, while the hairs themselves were still
active.
We therefore failed to demonstrate the presence
of any chemical agent in the dried haire, capable of
producing the skin eruption, and are therefore of
the opinion that the rash is due to the mechanical
action of the hairs on the skin.
In a certain degree we have reproduced the
eruption by carefully elevating a few epidermal
scales by means of a sterile steel needle from
several ai-eas of skin closely adjacent to one
another. The papules produced resemble those due
to the hairs but they quickly disappeared ; the
sensations experienced by the person experimented
upon were somewhat different from those produced
by the hairs.
We would, however, again invite attention to the
fact that we are considering dried and not fresh
hairs, which are hollow and may therefore contain
a chemical agent which may act as an adjuvant
to the mechanical in-itation.
Treatment. — Tlie dermatitis should be treated by
washing with water to remove any hairs which
may be adhering to the skin, and after having dried
the skin, applying a lotion (menthol 3 grm., cala-
mine 4 grm., spiritus vini rectificati 200 c.c. made
up to 250 c.c. bv water) to the affected area.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
March 1, 1920.
To illustrate paper, " Sadd Dermatitis," by Albeht J. Chalmers, M.D., F.R.C.S., D.P.H., and A. F. Joseph, D.Sc, F.I.C.
Mar. ], 19i0.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
59
Summary. — We have demonstrated in this brief
note that the hairs on the lower leaf sheaths of
Panicum pyramidale Lamarck, one of the two
plants called by the natives Um Suf, is capable of
producing a mild form of dermatitis.
We have endeavoured to show that the action
of the dried hairs is purely mechanical but we are
not in a position to state whether this is so in the
fresh state or whether there is an adjuvant
chemical substance.
This dermatitis may be irritating to persons who
have to work in the " Sadd," and therefore the
treatment recommended may l)e found useful.
REFERENCES.
Begun (1905). Journal of the TAnncean Society— Bot&ny —
xxxvii. July. London.
Broun (1906). "Catalogue of Sudan Flowering Plants."
pp. 92 and 95. Khartoum.
Castellani and Chalmers (1919). "Manual of Tropical
Medicine and Hygiene," third edition, pp. 2151-2164. London.
Chalmers and Pekkola (1917). Bulletin de la Societe de
Pathologie Exotique, vol. x, p. 512. Paris.
Engler (1895). " Dcutsch Ost-Afrika," v, A, pp. 9 67.
Berlin.
Garstin (1901). Blue Book of Eyypt No. 2 ("Irrigation
Projects on the Upper Nile.") Cairo.
Hope (1902). " Annals of Botany," September (" Sadd of
the Upper Nile "). London.
Lamarck (1783). " En&yclopedie Methodique," vol. iv,
p. 735, Paris.
Lyons (1906). "Physiography of the Nile Basin" (good
bibliography), pp. 134-144. Cairo.
Prain (1917). "Flora of Tropical Africa," ix, part 1,
page 41. London.
Schweinpurth (1868-1871). "The Heart of Africa,"
English Edition, i, pp. 26-27. London.
ILLUSTRATIONS.
Fig. 1.— Experimental Um Suf Dermatitis in the Black
Skin. If the two photographs are removed from the plate by
cutting along the lines AA and placed in an ordinary stereo-
scope the papules will stand out clearly. Stereoscopic photo-
graphs. Reduced.
Pig. 2. The Inttoteicence ol Fanicum pyramidale Lamarck
from one of the specimens in the Sudan Government's Her-
barium. Photograph. Reduced.
Fig. 3. —Panicum pyramidale Lamarck to show the pyramidal
character of the inilorescenco. From a specimen in the Sudan
Government's Herbarium. Photograph. Reduced.
Fig. i. — Panicum pyramidale Lamarck showing the rhizome
and lower leaves with their sheaths.
Fig. 5. — A portion of one of the leaf sheaths shown in fig. 4.
Note the hairs. Photograph. Slightly magnified.
Figs. 6 and 7. — Hairs from one of the leaf sheaths similar
to that depicted in fig. S. Photomicrograph, x 30 diameters.
TURATMENT OF THREE CASES OF MALIG-
NANT TERTIAN MALARIA WITH
SFE(;L\L TREATMENT.
By P. J. Vealk, Captain I. M.S.
Bkfoiik attempting to discuss any treatment in
connection with malaria, I think it is essential to
have in one's mind a clear idea of the class of case
under discussion, and, in this instance, establish
tile fact that quinine, when administered over a
prolonged period, fails to eradicate the disease.
MiK-h confusiou has, 1 think, arisen from the fact
that this same disease may have two very different
aspects, according to the date at which it is seen;
that is to say, a completely fresh infection is a very
different matter where treatment is concerned, to
the same case after it has relapsed iive or six times
and has been taking quinine on and otf for a few
months. Sir Leonard Rogers [1] quotes several
authorities to show that the initial attack of malaria,
presumably occurring in an individual who has pre-
viously lived in a non-malarious district and who
has not had occasion to take quinine, can be com-
pletely cured, and the parasites expelled absolutely
from the blood, by the administration of quinine
for a period of about three weeks.-
Unfortunately at the present time it is almost
impossible to find a case that has become infected
for the first time, and even if such a case were
found in a malarious place like Salonica, the chances
are that he would have taken more or less quinine
before he oame for treatment, a fact which, as I
will show later, has a distinct effect upon subse-
quent treatment.
It is with the chronic case with frequent relapses
that we are more especially interested to-day,
because in these cases quinine, except in heroic
doses, seems to have lost its power, and although
the parasites may be driven temporarily from the
peripheral blood, yet they will return over and over
again, remaining in such small numbers as not to
produce symptoms until some lowering of the
patienfs resistance gaves them a chance to multiply
once more, or even appearing in such numbers as
to cause symptoms during the actual administration
of quinine, a fact which is well brought out in a
series of articles by Lieut. -Colonel Stephens and
others [2].
My own impression of malaria, as seen in
Salonica, is that the majority of cases are relapses,
and that quinine however administered does not
effect a permanent cure, the most that one can hope
for is the temporary disappearance of symptoms;
the examination of the blood of cases discharged
from hospital showed that 50 per cent, of all malaria
cases had the gametes of Plasmodium falciparum
present in fair numbers, and although it is not now
considered that relapses can result from the con-
tinuance of gametes in the blood, yet from a prophy-
lactic point of view their extermination is a matter
of the utmost importance. Ivieut. -Colonel Stephens
and others [3] have shown that administration of
quinine in doses of from 30 to 48 gr. daily for
four weeks will cause a disappearance of crescents
from the peripheral blood in a large percentage of
cases; unfortunately they fail to state whether they
reappeared later or not. The same authoriti(>«,
however, in their introduction to a series of
" Studies in the Treatment of Malaria " admit that:
■' Although quinine accomplishes the first of theee
objects (i.e., the control of the acute attack), the
ideal drug, which while causing the acute attack
to subside also prevents the occurrence of relapses,
is at [)resent uidtnown."
P'alconer and .\uderson \4] quote cases treated
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 1, 1920.
by galyl and quinine with some success, but they
insist that galyl must be combined with quinine ;
in a proportion of their cases disappearance of all
parasites seemed to be permanent.
Sir Leonard Rogers, using intravenous injections
of tartar emetic, thought that this drug was success-
ful in destroying the gametes of malignant tertian
malaria; Lieut. -Colonel Stephens and others [5]
failed to confirm his results and were forced to
conclude that injections of this drug had no effect.
From the authorities I have quoted I think it
may be inferred that quinine by itself has not the
specific action in malaria which was claimed for it,
and that some other mode of treatment is essential
before a definite cure can be obtained in all oases.
Returning now to the statement I made, that the
administration of quinine as a prophylactic may
vitiate the action of quinine as a curative, Tread-
gold [6] in a careful survey of the literature and
his own research has shown that a large proportion
of men taking quinine after an attack of malaria
showed parasites in the blood; and, further, that
a certain proportion in whom no such attack had
occurred also had parasites in the blood, although
they had been taking quinine as a prophylactic
measure ; and he concludes that whether quinine
was given in large or small doses or not at all
seemed to make little difference either to the
number of relapses or to the proportion of cases
in which parasites were found. I^ater in the same
paper he quotes numerous authorities, including
Sir Ronald Ross, Stitt, and Bell, to show that the
general course of this disease may be adversely
influenced by the previous taking of quinine. This
is additional evidence showing that quinine ad-
ministered over a prolonged period loses its curative
action; and from personal experience, and the
experience of other medical officers in Salonica,
there seems little doubt that a high proportion of
cases treated were of this resistant type.
Allowing then that relapsed cases of malaria do
tend to become chronic through an apparent failure
of quinine to produce its efifect, the next considera-
tion is to find some drug which will remove what-
ever cause is acting in opposition to the quinine,
and so enable it to regain its original effect. With
this object in view, I treated three cases of malig-
nant tertian malaria by injecting them intraven-
ously with a solution of disodium hydrogen phos-
phate and sodium chloride in a strength of 3 per
cent, each, the dose varying from 60 to 100 c.c.
My reasons for adopting this line of treatment
were as follows: Matko [7] states that " the pro-
tective power of urine against a hfemolytic action
of quinine depends upon its content of acid phos-
phates," and he relates a case of blackwater fever
successfully treated by injecting 120 c.c. of acid
sodium phosphate 3 per cent, solution intraven-
ously, from which it would appear that the pro-
tection afforded by the phosphate was due to some
action taking place within the body. Now it is
known that quinine when administered is excreted
partly as unaltered drug, partly as quitinine [8],
which has no action on malarial parasites, and
partly as hasmoquinic acid, a powerful haemolytic
agent, to which has been ascribed the production of
blackwater fever. It seemed reasonable to suppose,
therefore, that if this addition of acid phosphate
was successful in inhibiting haemolysis in blackwater
fever, its action might he due to the prevention of
the splitting of quinine into htemoquinic acid in the
body in Matko's case; and that, if the addition of
phosphate prevented this decomposition from taking
place, it might also go one step further, and prevent
also the formation of quitinine, and in fact that it
might stop the breaking down of quinine within the
body and so enable its full effect to be obtained
once more, as is observed in those cases who have
become infected for the first time, and who react
to small doses of quinine as well.
Now, although Ramsden and Lipkin [9] have
shown that in estimations of quinine in blood the
concentrations obtained in chronic malarial subjects
are always much lower than in healthy men taking
the same dose, and suggest that this may be due to
" habituation," and although Lipkin [10] has
shown that various tissues, especially liver, have
a considerable power of destroying quinine post
mortem, yet the spleen and bone marrow in which
parasites undoubtedly shelter from quinine have no
such power, so that local destruction of quinine as
the result of habituation cannot be advanced as the
sole reason for the failure of its action in chronic
cases.
There are, however, two possibilities to explain
this failure : the first is that one of the products
of decomposition of quinine in the body neutralizes
the action of the quinine present ; the other is that
quinine has no action on parasites but that it is
some derivative of this drug produced in the body
which has; as the result of habituation, however,
quinine may become broken down in some way,
other than that which produces this parasiticidal
substance, and so becomes inert. The addition of
phosphate, then, may either prevent the production
of the anti-substance to quinine, or else prevents
the decomposition of the quinine in the direction
which is not fatal to the parasites.
With regard to the actual cases, the patients
were all sepoys in the Indian Army, who had been
in Macedonia for about nine months, and had done
only one malarial season in the country. In all pro-
bability, however, they had acquired some degree
of immunity to the disease during their residence
in India ; all these cases had been given prophylactic
quinine in varying doses before admission. All
these eases showed the gametes of P falciparum
in the blood, and my primary object was to clear
these very resistant bodies from the blood. I used
in all cases the thick drop method for examining the
blood, staining either with Leishman or Giemsa's
stain, and no blood was considered negative until
a drop had been systematically searched from end
to end. Unless definitely stated, no quinine was
administered to these cases during the time of their
observation.
Mar. 1. 1920.] THE JOUKNAL OF TROPICAL MEDICINE ANI> HYGIENE.
61
Case I. — Sepoy M. A.
At (a) Quinine acid hydrochlor. 20 gr. intramuscu-
larly.
(b) Blood showed numerous M.T. gametes.
(c) Blood showed a few schizonts and gametes.
((/) 100 c.c. phosphate solution and quinine
acid hydrochlor. 20 gr. intravenously.
(r) Blood showed schizonts absent, gametes
difficult to find, and poorly staining.
(/) Blood showed one schizont and two gametes
in whole drop.
(l) Blood showed no schizonts, one gamete in
whole drop^.
(wt) Blood showed no schizonts nor gametes in
whole drop.
Case II.— Sepoy A. S. K.
At (o) Blood showed M.T. schizonts in fair
numbers.
(b) Quin. sulph. 10 gr. with iron three times a
day by mouth.
(c) All quinine stopped until September 22.
(d) Blood showed no parasites.
DATE 2
1 22
23 2
1 25
26
27
2B
29
30
... .
2
3 4 S 6
7 8 9
M
E M E
MEM
E M E
M E
M E
¥ C.
M E
M E
M E
M E
ME ME ME ME
MEMEME
^.o!
'Ci
u:
*:-~)i *: :
^: : ?;:
::
i:
1
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Ij
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!r ; iT
,..1
; ]•
li;
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ill ii ': i
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iH^
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iiiiLii :
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t*
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y
/
4
:
(g) Blood showed a few schizonts and gametfs.
(h) Blood showed gametes in fair numbers, no
schizonts.
(i) 60 c.c. phosphate intravenously alone.
(/) Blood showed no schizonts, gametes appear
less.
(k) Blood showed no schizonts, six gametes in
whole drop.
(e) Blood showed M.T. gametes only.
(/) Blood showed schizonts and gametes.
{g) 40 c.c. phosphate intravenously alone.
(h) Blood showed schizonts and gametes re-
duced in numbers.
(i) 70 c.c. phosphate intravenously alone.
(k) Blood showed presence of schizonts and
gametes.
DATE 6 7 8
9 ro II 12
13
14 1
5 16
17
IB 19 20 21 2
2 23 24 25 26 27
28 23 30
12 3 4 5 6 7 8 9
,0 5- • '• '^■'°
: Ivjq; :
: «; *;:~)*: ~j
: 5: : : :
; %; 0;
• ».: : ■ ^. id:: ■ ^i
: iliT :
;;
: jTl;
: >: : ; 1; ; 1; : <:
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; ^~I;
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: ;: : : ;: : !; ; |:
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; ii I-
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; :;:; i
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r ■ ■ ■
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: [: : : I; : li ; •;
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:
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\ \ \ \ \ I I '■■ I
62
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 1. 1920.
(0 Quinine sulph. 10 gr. and iron given three
times a day by mouth until evening of
September 23.
(m) Blood showed no gametes, few schizonts.
(n) Blood showed no gametes, few schizonts.
(o) Blood showed few degenerate gamete«, no
schizonts.
(p) Blood showed no schizonts, no gametes.
(q) Blood showed no schizonts, no gametes,
(r) Blood showed no schizonts, one gamete
in whole drop.
(s) Blood showed no schizonts, no gametes.
Case III. — Sepoy.
At (a) Blood showed M.T. schizonts and gametes.
(b) Blood showed schizonts and gametes.
(c) 60 CO. phosphate and quinine ac. hydro-
chlor. 10 gr. intravenously.
that these persisted for nine days after their return,
whereas the subsequent administration of the same
amount of quinine after phosphate injection caused
the practical disappearance for sixteen days (the
numbers of gametes observed at (o) and (r) being
so much reduced, compared with their earlier pre-
sence, as to be almost negligible), so that, at any
rate in this case, the administration of the phos-
phate seemed to produce a better result than when
quinine alone was administered.
The first case also shows this in a smaller degree,
because the first intramuscular injection of quinine
did not cause the total disappearance of parasites
from the blood; the second dose along with phos-
phates produced a complete, tliough temporary,
removal, whilst an injection of phosphate alone
seven days later was apparently sufficient to cause
DATE
21
22
23
24
25
2b
27
28
^l30
1
2
3 4
5 J6 |7
S 9
F.
10 3-
,0,»
9 9"
9 6°
M E
M C
M E
M E
M £
M e
u L u
ME-
ME
ME
«E
me'meIme
ll
: Q
:^
; 1 :
:
i:
■f
;;
i '■
il
i
iii
1
:■
;i
■h
f\
<■.'
:
:|
<]
vT
1
f
1
f
1 't
■ f
\f\
A
|:
f
7^
1:
/\
/'
\l:
V
V
:
A
.
.
.
.
V
r ■ '^
\
,^
1/
/
f
Y^
.
li
:
':
^
^■.
■
;
[d) Blood showed schizonts present, no
gametes.
(e) Blood showed schizonts present, no
gametes'.
(/) Quin. sulph. 10 gr. with iron given by
mouth three times a day until evening
of October 3.
{g) Blood showed no schizonts or gametes.
(h) Blood showed one gamete, no schizonts.
(z) Blood showed four gametes, no schizonts.
In discussing these cases the first question that
must be decided is: " ^Oght the same result have
been arrived at without any treatment at all? "
To answer this, the patients were kept in hospital
for periods varying from si.x to ten days, during
which time they received varying amounts of
quinine. Examinations of their blood showed tliat
the parasites were not tending to disappear spon-
taneously from their blood.
The second question to be decided is: " Might the
quinine which was administered have produced the
same result by itself? " This question is well
answered in the second case, in which it will lie
observed that the quinine administered orally for
three .days commencing on the 8th only caused the
disappearance of the parasites for three days, and
the disappearance of the parasites for a period at
least equal to that which had seen the reappearance
of the gametes after the firet injection, and was
probably acting in conjunction with some quinine
still present in the tissues.
The third case, although an apparent failure, if
compared with the results obtained by Lieut. -
Colonel Stephens and others already quoted, with
regard to the disappearance of crescents under
quinine treatment, shows a very marked diminution
with much less quinine ; for, whereas in their cases
no very marked improvement was seen in those
cases taking 20 gr. daily by mouth until the third
or fourth week, this case showed a considerable
improvement with a very much smaller dose.
The third question which must be answered is :
" If the parasites have disappeared, is this per-
manent, or only temporary? " Although the time
at my disposal was not sufficient to enable me to
follow these cases to their logical conclusion, yet
the very small amount of quinine which was neces-
sary to produce a diminution in number of gametes
found, together with their gradual disappearance,
suggests, I think, that, by means of the addition
of phosphate to the treatment, the balance had at
least been upset in favour of the patient, and that
Mar. 1, 1920.1 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
63
the gametes were once more placed under circum-
stances which were disadvantageous to their further
continuance in the hlood.
Owing to the difficulty which is experienced in
keeping malaria patients in hospital untreated, in
order to observe the behaviour of gametes in their
blood over a prolonged period, it was not possible
to make control experiments, nor have I been
able to find any mention in the literature of such
observations, though doubtless they have been fully
worked out. But it seemed from the examination
of crescent cases on discharge from hospital that
quinine alone had had very little action upon these
bodies.
Fully conscious as I am that the results obtained
were far from absolute, and the number of cases too
few from which to draw conclusions, still I feel that
the results were sufficiently encourag'ing to justify
their publication in the form of a preliminary notice.
In conclusion I wish to express my indebtedness
to Dr. C. Clarke for his numerous suggestions, and
also to Mr. Bislian Das Sharma, who by his
valuable assistance, at a time when there was a
great deal of routine work to be done, made these
investigations possible.
REFERENCES.
[1] ROQERS, Sir Leonaed. "Fevers in the Tropics."
[2] Stephens, Lieut. -Colonel, and others. Annals of
Tropical Medicine atid Parasitology, vol. xi. No. 4, May,
1918.
[3] Stephens, Lieut. -Colonel, and others. Ibid., vol. xiii.
No. 1, May, 1919.
[4] Falconer and Anderson. Lancet, September, 1917.
[5] Stephens, Lieut. -Colonel, and others. Annals of
Tropical Medicine and Parasitology, vol. xi. No. 1, June, 1917.
[6] Tbeadgold. British Medical Journal, May 11, 1918.
[7 I Matko. Extracted in Indian Medical Gazette, July, 1919.
[8] NiERENSTEiN. Joumal of the Royal Army Medical
Corps, vol. xxxii, p. 215.
[9] Ramsden and Lipkin. Annals of Tropical Medicine
and Parasitology, vol. xi. No. 4, May, 1919.
[10] LiPKiN, J. Ibid., vol. xiii, No. 11, July, 1919.
Splenectoiui) in Malaria (Enrico Cartolavi,
Gazzetta degli Ospedali c delle CUniche, Sep-
tember 21, 1919).— The enlarged spleen in malaria
should be removed when it is causing disturb-
ances by its excessive movabiiity, ptosis, torsion
of the pedicle or adhesions in an abnoi-mal location.
Of six such oases, in all but one the rehef after
operation was iininediate and pennanent, with no
untoward by-effects. The rontgenograins show that
in one case the spleen lay altogether in the right
side, low in the abdomen. In two it lay liorizontal,
in one behind the pubis. In eighteen other cases
with medical measures alone he reduced the sjze of
the spleen more or less. When tlic enlarged 8])leen
is causing di«turl)ances it will generally be found
abnormally movable, which facilitates its removal.
In the one unfavourable case the much enlarged
spleen was in its normal seat, but was adherent to
adjacent organs and there was much hsemorrhage,
the patient succumbing to tlie acute antemia not
long nftcr.
W^atiiti,
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THE JOURNAL OF
Cropical £9ttitctnt and #p9tene
March 1. 1920.
THE SCARCITY OF BRITISH APPLICANTS
FOR SERVICE IN THE ('IIOWN COLONIES
AND PROTECTORATES.
At the present moment the subject of the
organization of the Colonial Medical Service is
again to the fore. It is more than twenty years ago
since Major-General Evatt, K.C.B. (then Lieut. -
Col. Evatt) gave us a coni|)lete scheme drawn up
with the precision which characterizes all that
emanates from the brain and pen of that great
organizer. General Evatt went from India, where
much of his life's experience was gained, to China,
where he came in contact for the first time with
the work of the Colonial Medical Service. He there
became impressed with the chaos which prevailed
in the organization of that service throughout the
Empire, and set to work to alter it. His scheme
w;is iiublished in the British Medical Journal in
64
THE JGUBNAX. OF TBOPICAL MEDICINE AND HYGIENE. [Mar. 1, 1920.
the year 1897, and a reprint of the paper was
issued. No notice was apparently taken of this
publication, for it was in the pre-natal days of
tropical medicine, and whilst yet the Colonial
Medical Service was a thing of shreds and patches.
It had not yet even reached the stage of the regi-
mental doctor system whieh prevailed in the Anny
until the other day, when it was swept away and
replaced by the wonderfully organized service of
to-day — namely, the Army Medical Staff with its
Eoyal Army Medical Corps complete in every detail.
As no one seemed to pay any .attention to General
Evatt's scheme, the writer brought it forward in
1898 at a meeting at the Imperial Institute, with
Sir Joseph Fayrer, Bart., in the chair, and at the
same time the writer dwelt upon the necessity for
a Sohool of Tropical Medicine in England to train
civilian practitioners and the members of the
Colonial Medical Service in the rudiments of
tropical medicine. The two schemes, in the writer's
opinion were really one, for as the Army held their
great school at Netley (now at Millbank, London),
so a special training should be afforded to all doctors
before going out to civil work in the tropics. The
result of that meeting was a petition to Mr. Joseph
Chamberlain, tlie Secretary of State for the Colonies
at that time — a petition which by the energies of
the Minister and Sir Patrick Manson saw its
fulfilment twelve inonths later in the establishment
of the Schools of Tropical Medicine in London and
Liverpool. The scheme enunciated by General
Evatt saw .its partial fulfilment by the establish-
ment of the West African Medical Service, a
service which shows what can be done when the
subject of organization is taken up by master minds.
The extension of this exemplary nucleus in West
Africa to the Imperial needs is only a question of
time and sympathetic handling by capable men.
At present it is at a standstill owing to puny
objections brought forward ; molehills being magni-
fied into mountains, and set up as irremovable
obstruction to the formation of a great service.
A service without a head, a focus to work
towards, a goal to aim at, is no real service in
the accepted meaning of the word. There is no
tradition to uphold, and a service without a history
and no possibility of contributing towards even the
creation of such, has but a soulless existence in
which the members do their daily task, but without
a future as far as the establishment they serve is
concerned. There is no one to encourage them and
say " WeO done " when they deserve it. In the
Navy, Anny, and Indian Medical Service there are
promotions and decorations to reap — these are
encouragements which are stimulating to everyone,
and especially dear to the young man with a career
before him, with a service to work for, a good
name for that service to fight for, to defend and
to honour.
In the Colonial Medical 'Service there is no
standard to salute, there is no Director-General in
command, but a group of individuals striving to
exist sans (sufficient) pay, sans ambition, sans
power to do for their families as they ought to be
done by, sans most of the objects that make life
worth living\
.And all thjs can be changed by the stroke of a
pen. The w^ter says this advisedly, knowing well
the difficultie^; for this is not an opinion fonned
in a moment \of fervour, for the difficulties are
many ; to most\people they appear great ; by some
they are consid^ered to be insurmountable. The
same has been ^id of well-nigh every attempt at
organizing any public body. It has, moreover,
opponents, bitter Opponents, to any change or amal-
gamation of interetets. It is unnecessary to enter
into all the difficulties, and to repeat what has been
so often repeated ad nauseam about the impossi-
bilities of removing these difficulties is but waste
of space and time. What is wanted is construction,
not obstruction ; anyone can do the latter, but to
find men with the constructive ability is the rara
avis. The most recent prom.ise of advance is to
be found in the grouping schemes — namely, West
Africa and East Africa Brigade, Division or Group;
the South African ; the West Indian ; the Indian
Ocean (Ceylon, Mauritius, &c.); the Malayan, the
Far East, the Pacific Ocean Divisions or Groups.
Even within these groups difficulties will be
raised on trifling points, trifling to the organizer,
but magnified locally into mountains by the
" parish -pump " minds warped by trumpei-y
matters, such as exchange, currency, language,
family matters, the question of private practice, of
whole-time and of part-time service, &c. Still,
there are hopes in the grouping system of a solu-
tion of the problem. But even were we successful
in forming these, it is but a step,- towards comple-
tion, for these scattered groups if left to themselves
constitute but a collective fomi of individualism,
a ti-ansfer from an individual to a group of indivi-
duals continuing separatism, and thereby prevent-
ing the formation of a great service — a Colonial
Medical Senice. What is wanted is an Imperial
head and centre in London, as other Imperial
services have. A general staff must be formed
with a Medical Director-General in command. The
consulting board we have at present in connection
with the Colonial Service must be no mere board
for medical consultations, but an administrative
and executive board of lay officials, but one consist-
ing of medical men to whom is handed over the
direction and control of this service. Who does
direct it now? is a pertinent question. Is there a
head? ''Well, there are so many departments,
you see." " Sir has charge of this section."
" Mr. has charge of that," and what is many
persons' business is nobody's, and everyone shuffles
out of responsibility. Such has been the history of
the growth of all departments, but the time comes
when such methods will not do, and in connection
with the Colonial Medical Service such a time has
arrived now. Medical men will not come forward
to join a haphazard service such as we have now.
There is nothing definite to put before a young man
at present that is likely to attract him to take
service in the Crown Colonies or Piotectorates with
an uncertain future. Several " high " ])opitions
Mar. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
65
in the senior ranks are applied for by men of
ability, but to jump into a high position over the
heads of men who have done the junior work and
for many years served the colony well is not a
desirable position for any man who thinks at all of
his fellow-men's feelings and prospects.
It is to be hoped that the authorities will never
consent to continue the bad old system at one
time in vogue in the Amiy Medical Service. It is
to be hoped also that we shall never hear again a
similar threat held over the heads of British doctors
as was the case only a score or so of years ago, when
the Army medical men were moving for a better
organization and the formation of a real Medical
Corps, that the then Adjutant-Oeneral of the Forces,
the foremost soldier of his day in the Empire, said,
" If you push the matter, I will apply to Germany
for doctors and fill the ranks of the Medical Service
of the Army with German doctors." The Army
Medical Service had a bitter fight for their position,
let us hope the Colonial Medical Service will be
better treated; but however it may be settled, be
j it amicably or otherwise, it has to be settled, and
that only in one way. If not being inundated by
: German doctors, there are doctors of other nation-
; alities creeping into the Crown Colonies' service ;
I if that is the most advantageous way let it continue,
! but it cannot be expected that good British medical
I men will jump at appointments in a sei-vice so
i irregularly constituted.
;■ J. c.
iunolations.
The Underlying Causes of the Narcotic Habit
(Alexander Lambert, Modern Medicine, vol. ii,
No. 1, 1920).— The author is of the opinion that
the solution of the drug problem lies in the more
personal consideration of the drug taker, especially
of the causes which led him to become addicted to
the drug. He finds that in youth the cause is the
desire for exhilaration and enhanced enjoyment of
life; after thirty it is to cause forgetfulness of life's
I troubles. Cocaine, heroin and morphia are the
I drugs chiefly used. He states that nearly 80 per
1 cent, of morphia addicts have acquired the habit
I through taking the drug for medicinal reasons.
Obseri'ations on the Cerebrospinal Fluid of Acute
Disease (W. W. Herrick and A. M. Dannenberg,
Journ. Amer. Med. Assoc, 1919, No. 18, p. 1321).
— The authors have examined the cerebro-spinal
j fluid in a number of acute conditions, such as lobar
pneumonia, influenza, tonsillitis, parotitis, &c. In
I about one-third of the oases some variation from
I normal was found as regards pressure ; and a certain
; degree of pleocytosis and heightened globulin con-
'tent was observed. The authors consider that a
\ diagnosis of meningitis should never be made on
i small variations from normal in the cerebro-spinal
: fluid unless definite clinical symptoms be present.
The Incidence of Syphilis as manifested by
routine Wassermann Peactions on 2,925 Hospital
and Dispensary Medical Cases (A. B. Day and W.
McKilt, American Journal of Syphilis, 1919, No. 3,
p. 595). — The authors found that 30 per cent, of
white males and 16 per cent, of white females gave
a positive Wassermann. Of 200 coloured males 48
per cent., and of 273 coloured females 40 per cent.,
were positive. About 15 per cent, of the cases so
examined did not show any clinical evidence of the
disease.
Chronic Diarrhaa due to Syphilis (H. Lisser,
American Journal of Syphilis, 1919, No. 3, p. 592).
— The author describes a chronic case of diarrhcsa
with fatty stools occurring in a woman 26 years
of age. AH the usual causes of enteritis could be
excluded, and the author suspected that the con-
dition might be due to syphOitic lesions of the
intestine and pancreas. The patient was given an
arsphenamine and mercury treatment, and all the
symptoms disappeared.
The Fate of Bacteria introduced into the Upper
Air Passages (Arthur L. Bloomfield, BuRetin of
Johns Hopkins Hospital, vol. xxxi. No. 3471,
January, 1920). — The author, who made a detailed
research into this subject, came to the following
conclusions : (1) Bacillus coli and Staphylococcus
albus swabbed on the tongue or nasal septum
usually disappeared within twenty-four hours. (2)
B. coli and <S'. albus introduced into tonsil crypts
could be recovered after somewhat longer intervals.
(3) In no case was a permanent carrier state set up.
(4) Inert particles disappeared at about the same
rate of speed as the bacteria. (5) The organisms
probably disappear because they are mechanically
removed more rapidly than they multiply. (6) The
disposal of B. coli and S. albus illuBtrates a
mechanisMi radically diflferent from that effective in
removing Sarcina luiea.
A Case of Non-parasitic Hcematochyluria (H. H.
Hampton, Johns Hopkins Hospital Bulletin, vol.
xxxi. No. 3471, January, 1920).— The author, in
recording a case of this ■extremely rare condition
in a young woman who had spent her life in the
mountains in Virginia, was satisfied that the case
was a non-parasitic one. He found that the leak
in the lymphatic system was located in the right
kidney. On the patient being put on a fat-free diet
and on starvation the urine became fat-free, blood-
cells and albumin persisting. Increased water in-
take and urine output increased the " fat loss,"
while it was noted that posture influenced but did
not control the amount of lymph leakage.
Botulism from Eating Canned Ripe Olives (Chas
Armstrong, ,R. V. Story, and Earnest Scott, Public
Health Reports, Vol. 34, No. 51, December 19,
1919). — Eleven persons who took part in a dinnei
party at Canton, Ohio, and three employees at tht
66
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 1, 1920
club wher© the dinner was held (who also, it was
found, had partaken of the infected food), displayed
severe symptoms of poisoning, and six deathe took
place within eighty-seven hours. After an exhaus-
tive investigation of each item of the menu, the
cause wasi found to be in olives of which they par-
took. These ripe olives were placed on the table
in three dishfuls and were eaten raw, some guests
taking four or five in spite of the unusual taste.
There was a striking correspondence between the
amount of olives eaten and the time elapsing before
death, or in the case of recovery, of the severity
of the attack. In the seventh fatal case, in which
death took place 174-5 hours after the dinner, only
0-5 of an olive had been eaten. It was noted that
two of the cases that recovered after eating one and
two olives respectively, had partaken of alcoholic
drinks during the evening; later, on making animal
experiments, the author found that alcohol has the
property of neutralizing the toxin when mixed in
vitro. The remaining olives were siubject^ed to a
chemical examination with negative results. Inocu-
lation experiments were then made on guinea-pigs
and the high toxicity of the olives was demonstrated.
Cultures were then made from the olives and brine
and an organism was isolated which is considered
to be a strain of Bacillus botulinus : this opinion
was confirmed by Sisco of the Harvard Laboratories.
Cnrrent •Citeralurc
Indian Medical Gazette.
Vol. LV, No. 1, January, 1920.
Further Notes on the Treatment of Diabetes
(E. E. Waters). — The author recommends the fast-
ing treatment of diabetes, which has given him good
results. He gives useful suggestions as to how the
restricted diet can be made most bearable to the
patient. Where acidosis or diabetic coma super-
venes the author advises that the bowelsi lie kept
freely open, while liquids (tea, coffee, thin broth,
water) must be freely given up to 1,000 c.c. every
six hours; if necessary the fluid may be given as
normal saline or tap- water per rectum, or even in-
travenously or subcutaneously. The author does
not favour the administration of alkalis.
Quinine Prophylaxis and the Treatment of Malaria
in a Coolie Population (Charles E. P. Forsyth). —
The author is convinced of the uselessness of quinine
prophylaxis among the labour gangs in the tea
gardens, mainly because of the difficulty of ensur-
ing that the quinine given is actually taken. While
admitting the importance of quinine administration
for European or educated natives, he is of opinion
that among natives of a low class the use of quinine
asi a prophylactic is waste of time and money and
should give place to measures against the mosquito.
An Epidemic of Fifty-four Cases of Relapsing
Fever observed in Birjand, East Persia (A. Sargood
Fry). — The author describes an epidemic of relapsing
fever among troopsi in East Persia. He considers
that the infection may be carried by ticks as well
as by lice. Arsenobillon may be used in the treat-
ment of a number of cases with good Vesults.
Cinchonidine in Malaria (D. S. Olleubach). —
Injections of cinchonine bihydrochloride were used
by the author in twenty-four cases of malaria, in-
cluding two children, with entirely successful
results.
Influenza (Bhupal Singh). — The author, in
describing an influenza epidemic at Meerut in 1918,
divides the cases into three groups : (a) mild, (6)
serious, and (c) fulminating cases, which latter
presented serious symptoms from the first and were
scarcely distinguishable from pneumonic plague.
The niiild cases were marked by fever (100° to
1030 F.), and some congestion of the throat. The
fever usually began to subside on the third day.
The serious, cases generally began as mild cases and
on the third day became worse (temperature, 102°
to 105° F.), with breathing more and more hurried,
and often cyanosis. Some of these cases, after
keeping up a high temperature for a week, began
to improve; other cases went from bad to worse.
The fulminating cases were hardly distinguishable
from pneumonic plague, and they all terminated
fatally. Mild and severe cases did well on sali-
cyktes.
Journal of Parasitology.
Vol. VI, No. 2, December, 1919.
Experiments ivith Steam Disinfectors in destroy-
ing Lice in Clothing (R. H. Hutchison). — The
author has made at Camp Mills, L.I.N.Y., a lengthy
investigation into this subject. He finds that steam
penetration at 75° C (1670 F.) will destroy all eggs
and active stages of body lice.
On the Resist ence to Desiccation of the Inter-
mediate Host of Schistosoma japonicum Katsurada
(William W. Cort). — The author has made an in-
teresting examination of snails infected with the
cercariffi of S. japonicum and comes to the follow-
ing conclusions: (1) The resistence to desiccation of
Blandfordia nosophora, the intermediate host of the
Japanese blood fluke, S. japonicum, is limited to
about three months. (3) Desiccation unfavourably
affects the cercariae within the snail, and infected
snails succumb more quickly than uninfected.
(3) Individuals of Blanfordia nosophora will volun-
tarily leave the water and become dry under
unfavourable conditions. (4) Measures for the con-
trol of Japanese schistosomiasis by draining the
breeding places of Blanfordia nosophora, would be
fully effective only if these places were kept dry
at least three months.
Sarcosporidiosis in an East Indian (S. T. Darling).
— Sarcosporidia were found at the post-mortem of
an East Indian coolie who had come from India
and the Federated Malay States, and who had been
admitted to hospital for severe anaemia.
Mar. 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
67
Bulletin de la Societe de Pathologie Exotique.
January 14, 1920.
A Few Facts concerning Vaccinal Prophylaxis
against Anthrax in Morocco (Th. Monod and H.
Velu). — -Experiments on 11,100 sheep, 3,750 pigs,
and 16,500 cattle showed that the vaccines supplied
by the Pasteur Institute are effective against
anthrax in Morocco, but that the immunity only
lasts from eight to ten months, and perhaps less.
To maintain the immunity, therefore, it would be
necessary either to re-vaccinate twice a year, to
give a second injection eonsasting of a double dose
of No. 2 vaccine, or to administer a further injec-
tion of a very slightly attenuated culture. Out of
31,500 healthy animals there were no deaths after
vaccination, but of 100 suspected cases two died,
probably because the dose of serum injected was
insufficient.
A further Case of Rabies in Senegal (Teppaz). —
Thiis case (the third of its kind recorded by the
author) is cited in refutation of the theory prevalent
in Senegal that rabiesi does not exist in that coun-
try. The dog was a fox-terrier who had been
imported from France two years l^efore. It showed
definite symptoms of rabies and died four days
after the condition was first noticed. At autopsy
the nerve centres were found to be markedly con-
gested. An emulsion from the dog's brain proved
fatal to a rabbit, and a second rabbit died after
inoculation with material from the first.
Glioma of the Brain in a Negro (F. Van den
Branden). — The patient, a negro of about 40, had
lived in the Belgian Congo for ten years.. He
complained of intense headache and showed paresis
of the lege to a very slight extent. Pulse slow;
temperature slightly above normal. I^umbar punc-
tiuf produced clear fluid, which showed no
uliiiormal lymphocytosis or albumin. The man
betame very rapidly emaciated, and entering into
a .'^omi-comatose condition died after a fortnight in
hospital. On opening the skull two typical tumours,
showing all the characteristics of glioma micro-
scopically, were found in the posterior lobe of the
right cerebral hemisphere.
Cyanide of Mercury in Blackwafer Fever (P'er-
nando R. Munoz). — The dose employed was half a
centigramme, unaccompanied by other medication.
A second injection was given twenty hours after
the first, and a similar period was allowed to elapse
before the tnird if a third were necessary. In the
fivt- cases treated in this way the results were
vuiiformly satisfactory. The fever abated within a
few hours after the first injection and the albumin
ilisiqjpeared from the urine; the latter rapidly lost
its reddish-brown colour and became successively
stmwberry red, bright orange and picric yellow.
Experiments in the Treatment of Sleeping Sick-
?if.s,<i with Collnbiase d'Antimoine (F. Van den
liranden). — " Collobiase d'antimoine " is a col-
loidal antimony manufactured by Dausse, Paris.
It proved to possess no trypanocidal action in the
(loses tested.
The Importance of the Course rvn by the Jjeuco-
cyte Count and of the Blood Changes in the Clinical
Diagnosis uf Relapsing Fever (Dr. E. W. Suldey).
- — Though the relapsing fever of the West Coast of
Madagascar presents the same clinical picture as
tick fever, the transmitter of both being Ornitho-
doTus moubata, the diagnosis of the former is
difficult on account of possible confusion with
malaria, typhoid, and other febrile conditions. In
studying the daily leucocyte count of a large
number of positive cases in which the spirochsete
was recovered, the neutrophile polynuclears were
observed to increase in number during the attack by
from one-third to double the former quantity, and
to drop suddenly with the temperature ; the lympho-
cytes become considerably fewer during the feverish
phases, but rapidly increase by 35 to 50 per cent,
within three days after a fall in temperature; the
eosinophiles almost disappear when the fever is at
it« height, but increase during the apyretic period;
the large mononuclears and the macrophages appear
to reach a maximum at the beginning of the
apyretic period, and descend to a minimum about
twenty-four hours before a fresh attack.
Method of Search for scanty Malarial Parasites in
the Peripheral Blood (N. H. Swellengrebel).— The
method consists in causing earner anopheles to
suck the blood of the person to be examined. After
four days or more the stomachs of the insects are
opened. If oocysts are present the species of para-
site is identified by the pigmentation. The parasite
of quartan malaria is the only one likely to cause
any difficulty, its pigmentation being intermediate
between that of P. vivar and P. falciparum. Two
eases are given as example.
A Clinical Study of Relapsing Fever in the
Province of Se-chuen {Western China) (Jouveau-
Dubreuil). — No case of relapsing fever was recorded
in China until 1904. Far from being rare, however,
it would appear to ravage every province in which
laboratories and a medical organization exist to
identify it. It is quite common among the poorer
classes ; very few cases occur among the better
classes. In the spring the fever becomes epidemic;
it decreases through the summer, and as the winter
advances it becomes almost extinct. These varia-
tions are coincident with those in the number of
lice infesting the poor among the population. As
mosquitoes, fleas and bugs are ubiquitous and affect
all classes alike, it is improbable that they are
transmitting agents. The mortality is very high.
Prophylaxis consists in exterminating the louse, an
impossibility until some remedy is found for the
extreme poverty at present prevailing among a very
large class of the people.
A Case of Spontaneous Infection of a Dog by
Trypanosoma Marocanum (Sergent, Lh^ritier and
Bellevul. 1915) (P. Delanoe).— A dog, greatly
emaciated and with a double keratitis, showed
numerous trypanosomata in its blood under the
microscope, and was killed. Two guinea-pigs and
a young rabbit died, two, three and a half, and
68
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 1, 1920.
three months respectively, after inoculation with
material taken at autopsy. The trypanosoma seen
in all the animals closely resembled that previously
observed in a spontaneously infected horse. The
interest of this case lies in the fact that it is the
first of its kind obser\'ed in Morocco.
Treatment of Mange in Dromedaries by Tarry
Extract of Colocynthis (L. Musso). — The inhabit-
ants of the Sahara smear their dromedaries with a
"tar" distilled from the seeds of the Colocynthis
plant, one application of which, they claim, gives
nxcellent results, while two are sufficient to effect a
ure in the worst cases. It is prepared in a primi-
tive form of still, 15 litres of seed giving about
4 litres of "tar." The product consists of three
layers, the topmost and pri^ncipal of which is a
black, evil-smelling liquid of the consistency of coal
tar, soluble in chloroform at 1/20, but only partly
soluble in alcohol or ether. It shows an acidity
of 0-840 gr. per cent, (acetic acid). The acidity of
the second layer, which is watery and may also
possess some therapeutic power, is greater (1'020 gr.
per cent.).
On a Case of Intestinal Bilharziosis showing
Schistosomum haematobium, and the Geographical
Distribution of the Disease in the Belgian Congo
and East Africa (E. Lagrange). — A child of 8,
having come from the Belgian Congo to Dodoma
in the district of Ugogo, fonnerly German East
Africa, showed symptoms of acute dysentery with
eggs of S. haematobium in the stools. Free mira-
cidia were seen in nearly all the fresh smears, a
fact which does not occur with S. ryiansoni. In the
Congo basin rectal bilharziosis is known in the
districts of Tanganyka and Upper Katanga, but
only in the form due to S. mansoni. To reach
Dodma (a sandy plain, the inhabitants of which
are provided with wat«r during the dry season by
wagons obtaining supplies from deep wells some
miles away) the chiJd passed through Tanganyka.
Whet/her she was infected in the Belgian Congo,
in passing through Tanganyka, or on arriving at
Dodoma, this is the first time S. haematobium has
been observed within the boundary line formed by
Uganda in the north, Zanzibar in the east, and
Nyassa in the south.
On the Evolution of Anaplasma in the Blood of
BovidsB (J. Lignieres). — In order to study the
development of Anaplasma argentinum blood was
taken from the jugular vein of bovidae suffering
from marked anaplasmosis, defibrinated, placed in
sterilized tubes, and incubated at 37°. Speci-
mens of the fresh blood, stained with Laveran or
Giemsa, showed numerous normal parasites, and
also some very small forms measuring scarcely a
third of the diameter of classic Anaplasma. The"
same blood after twenty-four hours' incubation
showed the formation within the Anaplasma of
rounded granules, highly and uniformly coloured,
usually in fours; these freed themselves later, and
appeared identical with the anaplasmatic forms
seen, in the fresh red blood cells. During the next
few days the phenomenon rapidly became general ;
it was also observed to take place at laboratory
temperature, though the process was then a slower
one.
Anopheles Centres in the Ardennes (G. P^ju). —
In this part of France the Culex family is less
numerous and various than in the Argonne, and is
represented chiefly by species harmless to man.
There are, however, many .Anopheles, distributed
over wide areas, and these, no doubt, were re-
sponsible for the malarial centres which were active
in the district during the war. Some of the latter
would appear to have been already in existence in
the not long distant past, and at one point the
larval forms of an infection in regression seem to
have been preserved. Apart from removing malarial
patients from the mosquito-inhabited areas, the
danger for the future is not great enough to neces-
sitate prophylactic measures.
(Horr^sponbeiuf.
To the Editor of the Journal of Tropical MEniciNE
AND Hygiene.
Sir, — In the Journal for February 16 there
appeared a paper by Dr. Chalmers and Major Kamar
on Toxoplasma pyrogenes from the Sudan. This
paper also gave an account of non-malarial and
non-typhoidal febrile ailments occurring in the
Burun district of the Anglo-Egyptian Sudan. As
I have no personal experience of the organism
termed by Castellani Toxoplasma pyrogenes and
have not seen the splenic film which the authors
mention, I am unable to give any opinion as regards
the protozoon, but I would suggest that the cases
of fever which are described may be examples of
kala-azar. The symptoms detailed are quite com-
patible with those which are characteristic of this
disease and we know that kala-azar must exist in
the Burun country. Dr. A. MacTier Pirrie, who
carried out some anthropological work for the Well-
come Tropical Eesearoh Laboratories in 1906, un-
doubtedly acquired in the Burun country the leish-
mania infection to which, unhappily, he subse-
quently fell a victim. Hence, despite the presence
of Toxoplasma pyrogenes in the splenic film from
one of the cases, I think it would be well not to
exclude the possibility of this febrile complaint being
kala-azar.
I am, yours faithfully,
Andrew Balfodr.
llfMcal jctos.
At the annual meeting of the Society of Tropical
Medicine of France (Societe de Pathologic Exotique),
held on December 10, 1919, Sir William Leishman
and Prof. Aldo Castellani were elected " Membres
honoraires "; Sir Leonard TJogers, Dr. C. Donovan,
Dr. Simon Flexner, Dr. C. Chagas, Dr. A. Broden
and Dr. T. Rodhain " Membres associes "; Dr. R.
Archibald, Dr. F. W. Craig, and Dr. H. B. Ransom
" Membres coiiebpoiiuui-tj."
Mar. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 6, Vol. XXIII.
(Original Commnntrattons.
FOUR INTERESTING CASES OF BILHARZIA
DISEASE TREATED BY TARTAR EMETIC.
By F. G. Cawston, M.D.Cantab.
The following cases of bilharzia disease treated
by tartar emetic are of special interest, because two
of them were cured by comparatively small doses
of the drug. One showed an idiosyncrasy which
interrupted the treatment for a while, whilst the
other was suffering from chronic albuminuria follow-
ing acute Bright's disease when the treatment
commenced.
On November 15, Mr. C, aged 21, reported that
he had noticed slight haemorrhage at the end of
micturition for the last eighteen months. There
was no tenderness or pain, and he attributed his
condition to bathing in the Umbilo river. Five
years ago he had suffered from the same symptoms,
but had apparently recovered. The urine contained
numerous spine-pointed eggs. A quarter of a grain
of tartar emetic was given intravenously, and the
dose gradually increased to 1^ gr. If given regu-
larly every second or third day, 1^ gr. would appear
to be the maximum dose necessary to effect a cure.
He took lOJ gr. in all without the slightest general
effect. On November 27 the urine was much
clearer, and all trace of eggs or cells had dis-
appeared from the urine by December 6, three
weeks from the time the course of injections com-
menced. On December 22 the urine was still free
from cells and eggs, and on January 10 the patient
reported that hiS water was remaining clear. On
January 14 his brother reported that he had noticed
slight haeniaturia and pain in the bladder for the
last week. Six years ago, when 14, he had con-
tracted bilharzia disease from the Umbilo river,
but the symptoms had disappeared during an
attack of pneumonia whilst at Potchefstroom in
1917. As the urine contained the typical spine-
pointetl eggs, | gr. tartar emetic was given intra-
venously. The next day he received f gr., and
on the third day a full grain, without the
slightest constitutional disturbance. He stated that
the pain had already disappeared, and that the
burning sensation whilst passing his water had all
gone. On January 19 his urine was free from eggs,
but he was given 1| gr. tartar emetic and 1| gr.
on January 21. On January 29 the urine was still
free from eggs, and he was given his last injection
of 1 gr. tartar emetic, as he considered further
treatment unnecessary. He had received a total of
only 5f gr. of tartar emetic.
On December 12, Mr. S. reported that he had
contracted billiarzia disease before the war from
jthe Umbilo river, or possibly from the Palmiet lake
or Umhlatazana. I liave found Plujaopsis africana
|in each of these places.
j There was no tenderness, but the patient com-
iplained of occasional backache and pain in the
ibladder, and had been shot through the right lung
land siiffi'red from pericarditis whilst on active
service. The urine contained numerous spine-
pointed eggs.
A 4 gr. of tartar emetic was injected intra-
venously, and produced burning sensation in the
bones of the arm and some general discomfort ; but
the patient was prepared for a second injection next
day.
On this occasion J gr. tartar emetic produced
pins and needles all over the body for about half
an hour and general malaise for the rest of the
day. On December 15 the urine contained numer-
ous eggs, nearly all of which were dead and one
already blackened; on the 17th one living egg was
detected in the centrifugalized deposit.
In view of the severe reaction to tartar emetic,
1 c.c. col'losol antimonium was injected intra-
muscularly. This also produced general discomfort,
lasting twenty-four hours. On this occasion many
living eggs were found in the urine, and two mira-
cldia were seen swimming about in the undiluted
urine, a not uncommon occurrence at this stage of
the treatment. Twenty-five minims of colilosol anti-
monium on December 27 caused somewhat less
general discomfort. On the 29th many dead eggs
were detected in the urine. The following night
tartar emetic 2 gr. in morphine tartrate J gr. was
given as a rectal suppository, but the patient com-
plained that this caused too much discomfort to be
repeated more than once.
Living eggs were present on January 6, and
tartar emetic | gr. was given on January 8. This
dose was gradually increased to IJ gr. on January
23 without any appreciable discomfort Eggs were
present In the urine on January 14 and 19, but the
specimens were clearer. After the intravenous
injection on January 23 the patient went down
town in a tram whilst perspiring freely, and was
confined to bed for a week with sore throat, hoarse
cough, rise in temperature, and general acJies and
pains. On January 30 he had a sudden collapse,
requiring a hypodermic injection of strychnine.
No eggs were detected in a centrifugalized speci-
men of the urine on January 27 and February 4,
and the urine has remained clear since. This
patient received a total of 8^ gr. of tartar emetic
intravenously, 4 gr. by the bowel, and 25 minims
and 1 c.c. collosol antimonium intravenously.
Influenza symptoms are not at aU uncommon in
patients undergoing treatment by tartar emetic,
and may be associated with the death of the
bilharzia parasites and the escape of tlieir debris
In the urine, or may be connected with the accu-
mulation of antimony In the system.
On January 12, Mr. R. reported that he had
suffered from bilharzia disease for five years,
causing frequency of micturition, slight hoematuria,
and right-sided renal colic for two and a half years,
which had been treated by rectal suppositories of
morphia. He had suffered from albuminuria as a
child. Twelve years ago he was in bed for 100
days with acute Bright 's disease and bad oedema
of the legs, abdomen and neck, the urine being solid
with albumin. The oedema recurred ten years ago
and lasted about two months He had had no re-
70
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. tMar. 15. 1920
curreoce of cpdenia, but occafiionally tested his own
urine for albumin, which he found always present.
Two years ago Dr. Strapp of Maritzburg treated
him for albumin and casts. X-ray examination at
that time showed no calculus. He was uncertain
whether he could stand the tartar emetic treat-
ment; but, in view of tlie presence of numerous
spine-pointed eggs in his urine, the risk seemed to
be justifiable with caution, and he was given J gr.
intravenously. On January 16 the dose had been
increased to 1 gr. This caused some difficulty in
breathing for a few minutes only. The urine con-
tained much albumin and numerous eggs. One and
a half grains on January 20 gave rise to temporary
collapse, but no restorative was needed except a sip
of cold water. On tJie 22nd 1 gr. was injected with-
out bad effect. The urine contained dead ova, and
no blood had been noticed since the IQth, the last
occasion on which it was seen. On the 26th there
was much less albumin in the clear urine, which
contained a few cells and eggs. On the 27th black
eggs were seen. On the 30tli there was no trace
of albumin and two glassy eggs were seen. On
February 2 and 4 the urine was still clear and only
dead eggs detected. The patient was feeling much
better for the treatment, and had received a total
of 11| gr. tartar emetic intravenously.
NOTES ON A CASE OF " CASTELLANFS
BRONCHITIS."
By I. UcoNO, M.D.
Captain, Italian Naval Medical Service ; Assistant Physician,
Royal University of Naples.
Bronchospiroch^tosis is very little known in
Itialy, and very little attention has been paid to
it owing to the belief that it is purely a tropical
condition. The researches carried out by Lurie
and Castellani in the Balkans, by Galli Valerio in
Switzerland, by VioLle and others in France, and
by Broughton-Alcock in Northern Italy, have
clearly shown, however, i)hat the malady is a cosmo-
politan one. I began looking for oases of broncho-
spirochaetosis in 1917 at Taranto and other
places ill South Italy, but with negative results.
Recently, however, I have seen a typical case
(acute type), in consultation at Zaira, on the
Dalmation coast.
Miss E. B. No previous disease of importance.
Present illness began eleven days before I saw her,
with general malaise, rheumatoid pains a.ll over the
body and dry cough. The fever remained high and
continued for several days, then it dropped in the
morning and took a serotine type. Rather sus-
picious subcrepitant rales wea-e found on the
physical examination of the chest in the left apex,
and this, together with the serotine fever and
sputum tinged with blood, led the family doctor
to suspect tuberculosis of the lungs. When 1 was
called in the patient was very pale and feeling very
weak ; at the examination of the chest no zones ^f
dullness were found. Moist and dry rales present
all over, but no crepitant ones. Pulse 90, pres-
sure raiher high. Heart normal. As regards the
abdominal organs the spleen was not enlarged,
liver just palpable. Urine contained a trace of
albumin, and there was a slight increase in the
phosphates and indican. Blood: red blood cor-
puscles, 4,000,000 per cm.; leucocytes, 9,000;
hsemoglobin, 70 (Fleish). As regards the leuoo-
cytic formula, there was an incu-ease in the eosino-
philes and lymphocytes. No malaria parasites
and no spirochsetes were found. Examination of
sputum for tubercle bacilli negative. Several glucose-
agar tubes were inoculated, but no fungus was
grown. The microscopical examination of films
from the sputum stained with Giemsa revealed
presence of a large number of spirochsetes of
variable length 5 to 20 microns and vvith three to
six undulations In fresh preparations examined
with the ultra-microsoope numerous verj' motile
spiroehietes were seen. I made a diagnosis of
hroneho-spiroehaBtflsis and prescribed the mixture
recommended by Castellani, the fornnila nf which
is : —
Tartar emetic ... ... gr. ii
Syr. tolu ... ... 5i
Aq. chlorof. ... ... ... ad Jiii
One teaspoonful in water every two hours.
This treatment had a very satisfactoi-y effect, as
witliin three days the serotine fever stopped, and
after less than three weeks all the bronchial
symptoms disappeared, and the patient's general
condition of health became quite good. I believe
that Castellani 's bronchospirochaetosis is of more
frequent occurrence in Soutilieni Europe than is
generally assumed, and I propose to continue my
researches on the subject.
Kefebgkces.
Brodghton-Alcock : " A Case of Bronchospirohaetosis,"
JonRNAL OF Tropical Medicine and Hygiene, December 1,
1919.
ViOLLE : " Hsemorrhagic Bronchitis " (Castellani's Broncho-
pulmonary SpirochiEtosia), Lancet, December 7, 1918.
Mar. 15. 1920.] THE JOURNAL OF TKOPICAL MEDICINE AND HYGIENE.
71
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THE JOURNAL OF
Cropical S&tiiitint ani) l^pgiene
), 1920.
TOBACCO SMOKERS CLASSIFIED.
The number of the male pojnilation over the a!.;e
of 16 that use tobacco in Britain may be put down
at flO per cent. The proportion here stated may be
said to be too low by some and too hi^h by others.
There are no accurate statistics available, and one
has to frame a number from observations made
amongst one's aoquaini/anees .and neighbours. Long
before 16 yeai-s of age many boys smoke, but
amongst these much is done from " bravado "
or " showing off," and in every case it is done
surreptitiously.
The writer, in filling in schedules during exam-
ination as to whether candidat-es are fit or otherwise
for service abroad, finds it difficult to state whether
a man is a " light " smoker or a " heavy " smoker.
What is a light smoker and what a heavy smoker
may be stated in general terms, but we have no
standard set or scale formulated whereby a more or
less accurate conclusion can be come to.
Cigarettes.
Take cigarettes first. Is it possible to say what
constitutes a moderate or an immoderate smoker?
In the first place, it no doubt depends upon the
quality and strength of the tobacco used. The lady
who was stated in the papers last week to have
got amblyopia from smoking cigarettes she made
herself from shag tobacco represents one end of
the scaile and mild Turkish or Virginia the other.
Neglecting for the moment the kind of tobacco
used, we can fall back upon the number consumed
as a gauge of indulgence with a certain degree of
reliability. On this basis cigarette smokers may be
classified as follows: —
When smoking Cigarettes only.
(1) Occasional smokers 0 to 1 daily.
(2) Light smokers ... 3 ,, .')
(3) Verv moderat-e ... T) .,10 ,,
(4) Moderate 10 ,, 18 ,,
(.'-)) Heavy 18 ,, 30 ,,
(6) Excessive 30andover.
'{'he period ;it which heavy cigarette smoking is
indulged in is mostly between 20 and 30 years of
age.
\ young man of, suiy, 21 years of age, who
smokes twenty cigarettes daily, usually regards
himself as " a very moderate suiokei-. " He judges
the amount 'he consumes by comparing himself with
his neighbours. Few would feel justified, however,
in considering this very mcxleiate smoking.
Many make a point of never inhaling, and con-
sider tJiemselves as most abstemious by not
doing so.
Pipe Smoking.
In the trofiical countries few men smoke pipes.
If they do it is seldom they use pipes only; but
use cigarettes or a cigar as well. Some use all
thice — cigarettes, pi])es, and cigars in turn. Taking
an average-sized pii)e, and neglecting the quality
of tlic tolKicco and wihen a pipe only is smoked,
pipt' smokers may be classified as follows: —
(1) Occasional smokers, not even a daily pipe.
(2) Light smokers consunir not uioi.' tli:m ' o/.,
i.e., three pipes a day.
(3) Verv moderate smokeis. f,.ui- pipi's :, dM.v.
(4) Moderate smokers, }. o/.. i.e.. six pipes .l.uly.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 15, 1920.
(5) Heavy smokers, f oz., i.e., nine pipes a day.
(6) Excessive smokers, 1 oz., i.e., twelve pipes
daily.
Cigars.
In size, strength, and quality cigars vary even
more vv-idely than in the case of pipe tobacco.
Cheroots are yet another class of smoke which
range from the light Manila to the heavy Burmah.
As -an example of excessive smoking of cheroots,
the writer has recorded elsewhere the case of a
man whose " allowance " whilst doing out-of-door
(surveying) work in Mauritius was not less than a
box of 100 Manila cheroots daily. Not that he
smoked all of these — he gave some .away. He
always brought home a few in the box, and he
seldom smoked a cheroot more than half-way down.
His own allowance he calculated to be some
seventy-five daily. He began at 5 a.m., and
except during meals never was without a cheroot
in his mouth until bedtime.
Taking a cigar of moderate size and strength we
find: —
1. Occasional smokers ... 0-1 daily.
2. Light smokers ... ... 2 ,,
3. Very moderate ... 3 ,,
4. Moderate 4 ,,
5. Heavy ... ... ... 8 ,,
6. Excessive ... ... 10 and over.
Time of Day.
Early morning smoking is universally condemned,
and rightly, too. It means smoking when the
temperature of the body is low, the strength owing
to the long fast of night at its feeblest, and the
heart muscle readily affected. To those who take
a fair meal before starting upon an early journey,
smoking subsequently to the meal, however early,
need have no really detrimental effect; and even for
those who have a breakfast cupful (not a teacupful
only) of tea with a fair quantity of bread a-nd butter
or biscuits, a pipe or cigarette is easily tolerated.
To the eariy smoker, however, who takes nothing
until breakfast, the effect is fraught with danger for
the moment, and, if the habit is persisted in, many
constitutional evils arise. One naval surgeon of the
writer's acquaintance attributed, rightly or wrongly,
his " progressive muscular atrophy " to the evil
habit of pre-breakfast smoking for many years.
After a meal is the best time to smoke ; the
worst when fatigue is great, or when one is ex-
hausted owing to a long interval between meals.
The whole question of smoking in hot countries
is from time to time dealt with by Government
authorities and doctors. It is not so long ago since
it was oflficially aimouneed by order in West Africa
that smoking was to be reduced to a minimum
by all employees. The lethargy induced, the
detriment to the heart muscle and to the nervous
system generally was so lowering to the whole
system that smoking was recommended — nay,
ordered — ^to be reduced to a minimum. This meant
a cigar, a pipe, or some two or three cigarettes in
the evening only. Some attribute the drinking
habit to the inevitably lowered tone induced by
smoking. Extremists would condemn, even for
the tropics, all alcohol and tobacco, and would
regard the non-smoker and totaJ abstainer as
one lea-ding the hj'gienic life, best calculated to
resist the trying exigencies of a tropical climate.
Extremists in every phase of public life have their
uses, but the very rigidity of their teaching thwarts
the good they might do towards betterment, and
temperance in all things personal as well as
political will continue to hold the field for all time.
Effects of Smoking on the System.
As regards the evil effects of excessive smoking
and its permanent effect upon the heart and the
economy generally, the completion of the story of
the man in Mauritius mentioned above is worthy
of recording. A Government official, this gentle-
man, whilst an elderly man, came from Mauritius
to Hong-Kong and took up work there. After a
few years in Hong-Kong he got an attack of
malaria. (He had malaria in Mauritius severely.)
He was under the care of Dr William Hartigan,
who summoned the writer. The patient had had
a temperature of 110° F., but Dr. Hartigan said
that it must have been a faulty thermometer, as
the patient was better now. That it was not a
faulty observation was evident, for when the writer
saw the patient he was perspiring, and regaining
consciousness, &c., but his temperature was still at
108° F. He gradually recovered, remaining for
many years afterwards in the Government service.
Few men with a hyperpyrexia so extreme ever
recover, and yet here was the excessive smoker
with an " allowance of 100 cheroots a day " who
did so. Whilst in Hong-Kong the patient had
reduced his smoking to about twelve a day, and
continued to adhere to that number through all his
service time. Nicotine is believed to disappear
from the body in three days after smoking is left
ofif. Its legacy may be an enfeebled digestion, but
bearing in mind the story just told its organic
effects may be insignificant.
OuT-OF-DOOR Smoking.
It «ill be observed that the excessive smokers
referred to above — the naval surgeon and the civil
servant — lived an out-of-door life, and it is well
known that out-of-door smoking and indoor smoking
present totally different conditions. One can smoke
with impunit}' three times as much in the open
whilst driving or riding, as when working at a desk,
and no bad effects ensue ; but if the smoker is walk-
ing or cycling the rate becomes slower, the vigour
is lowered, and the amount of ground covered
markedly lessened.
The writer sees no reason to alter the conclusions
come to in the earlier part of this article, but
critics will say he should not have mentioned the
case of the Mauritius smoker. Not so; he would
remind his readers that this excessive smoker had
Mar. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
73
lost the power of resisting disease, that when he got
fever his temperature went to 110° F. Few men
are known to have recovered from so higli a tem-
perature; he was snatched from his grave by the
skill of his ph3'sician, and had he followed tihe rules
enunciated he would have never been in so terrible
a predicament.
Smoking in Officks.
Smoking during office hours is allowed in some
offices all day, in some it is allowed after a certain
liotir of the day, and in others it is forbidden. If
the head of the firm is a great smoker he usually
allows his juniors to smoke; in some offices the
heads of departments only are allowed to smoke ;
and in some no one smokes during office hours. It
will be observed that in offices where smoking is
prohibited the work is got through more smartly
and quickly, and that in offices where smoking is
aJlowed the time taken to cover the work is longer,
for nicotine slows the heart's action, renders the
brain more sluggis.h and listless. Young hearts
are affected more readily than those of more elderly
men; the young men under 27 years of age cannot
do when smoking as inuch as a man of 47 can do,
so that the seniors, although unaffected themselves,
set a bad example to their subordinate staff, and
must not be surprised if these juniors fail in their
smajtness, and if there are continually complaints of
" slackness " amongst them, for their hearts are
more readily affected by tobacco.
The question of '.' compound " smoking — that is
to say, cigarettes and pipes, x>r cigarettes and
cigars, or ringing the changes on all three — is less
detrimental than when only one kind of smoke is
indulged, just as the man who varies his drinks is
less likely to become a drunkard than the man who
sticks to one form of liquor.
ized by the very Jarge blepharoplast, and i« trans-
mitted in Brazil by Conorhinus megistus. The
author agrees with Chagas in regard to the various
clinical types of the malady. He has found the
disease in Venezuela, where, according to the
author's experiments, it is transmitted by
Rhodnius prolixus.
Recent Work on Tropical Diseases (R. T. Hew-
lett, Practitioner, March, 1920). — In this interest-
ing paper the author reviews recent work done on
various tropical diseases. The failure of Bayliss'
gum solution in cholera is recorded, and Kulne's
method of treating the malady described. This
method consists in giving massive doses of kaolin,
and for the first eighteen hours neither food nor
drinlc should be given except water. The author calls
attention to the good results obtained in yaivs by
Guerrero, Domingo and Arguelles, using Castellani's
mixture, the formula of which is tartar emetic,
gr. i; sodium salicyl, gr. x; potass, iod., 51; sodium
bicarbonate, gr. xv; water, ad. 3i. This forms one
dose, which is diluted to 4 oz. with water, and
given three times daily to adults. Bilharziosts :
Christopherson has cured a large number of cases
by intravenous injections of tartar emetic, and his
results have been generally confirmed. Anky-
lostomiasis: According to Wrench's researches,
the best method of treatment is by chenopodium
oil. One capsule containing 1 c.c. of the oil is
given at 1 p.m., 2 p.m., and 3 p.m., and at
4.30 a.m. 6 drachms of castor oil is administered.
Occasionally chenopodium induces vomiting, giddi-
ness, and even symptoms of collapse.
€vixunt fitfratnrf.
Annotations.
Ulcus Tropicum of the Genitals in Cyrenaica
(A. Mei, Giornale Hal. Malat. Veneree e della I'clle,
1919, p. 29).— The author gives a detailed de-
scription of four cases in which Ulcus tropicum
developed on the genital organs. In all the oases
the lesion began as a rather hard granulomatous
swelling, which later necrosed in the centre, an
ulcer forming of large size. In the secretion
Spiroschaudinnia schaudinni and fusiform bacilli
were present in large numbers.
Trypanosomiasis americana (E. Tejera, Annates
de la Direccion de la Sanidad Nacional, Caracas-
Venezuela, Noa. 1-2, 1919). — A full historical and
clinical account of American trypanosomiasis. The
malady is caused by Trypanosoma cruzi, dis-
covered, as is well known, by Chagas in Brazil in
1907. This tiypanosome is principally character-
Indian Medical Gazette.
Vol. LV, No. 2, February, 1920.
Typhus and Typhus-like Fevers in Birjand, East
Persia (A. Sargood). — The author gives clinical
details of temperature charts of nine cases of
typhus and typhus-like fever which he has observed
in East Persia.
Further Observations on Kala-azar (Saratsasi
Kundu). — The author emphasizes tlie necessity of
the practitioner being thoroughly well acquainted
with all the varying symptoms of the disease, as
the typical clinical features described in many
text-books are not always seen. In the initial
stage almost any type of fever may be seen, its
resistance to quinine being its only noticeable
peculiarity. In the intermediate stages the spleen
and liver do not always show enlargement. The
Leishman - Donovan bodies should always be
searched for when chronic irregular fever, resist-
ance to quinine, emaciation and weakness, and
enlarged spleen and liver point to a diagnosis of
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
[Mar. 15, 1920.
kala-azar. The intravenous injection of tartar
emetic was found the most successful treatment in
all stages of the disease.
Second Series of 25 Cases of Malaria treated by
Hypodermic Injection of Cinchonine Bihydro-
chloride (D. S. Ollenbach).— Of the 25 cases here
described 23 recovered ; the remaining 2 cases were
lost sight of, but probably recovered, as they did
not return for more injections. The number of
injections given varied from one to four, and the
amount given from 3i to 18J gr.
Acute Necrotic Parotitis (R. C. McWatters).—
In recording these two cases of a condition which
he names Necrotic Parotitis, the author mentions
that seven cases having exactly similar features
were published by Mr. Zachary Cope (Brit. Joiirn.
of Surgery, July, 1919), who met with them in
Mesopotamia. In the author's two cases the
parotids became swollen and painful, and on being
opened by Hilton's method necrotic tissue and pus
were found. It was noticeable that both these two
cases and Mr. Cope's seven cases occurred during
extremely hot weather, and mostly in men
weakened by illness; some of the Mesopotamia
cases were fatal. The author concludes that this
acute inflammation of the parotid glands bears some
relation to heat exposure, that it is dangerous to
life, and that it requires very free incision.
Cobra Poisoning (K. K. Alandikar). — The patient
in this case had been bitten by a cobra he had
reared, and from which he had removed the fangs
a month .and a quarter previously. The bite was
situated on the palm of the left hand at the root
of the index finger. The patient was bitten at
11 a.m.; at midnight he complained of pain in the
hand and shivering. Later on his condition became
more serious, and at 5 a.m. he was unable to move
the eyelids and eyeballs or to swallow. He re-
mained in the same state for several hours, but at
11 a.m. the next day he began to show improve-
ment, and by midnight he was vei7 much better.
The snake was found to possess fangs, though
small ones; apparently they had grown again. The
patient was first treated with injections of gold
chloride; the author questions its benefit, and
states that it set up a gangrene of the hand, which,
however, was cured by incisions and by being kept
in a hot pemianganate bath. Later antivenene
was given subcutaneously and intravenously.
JOURN.^I, OF THE ROVAL ArMY MeDICAL CorPS.
Vol. XXXIV, No. 2, February, 1920.
An Anti-malaria Campaign in Palestine (E. P.
Sewell and A. S. M. Macgregor). — An elaborate
account of the preventive measures against malaria
undertaken by the authors in Palestine in 1918.
The campaign was based on the following measures,
which were carried out as far as possible: (1)
Drainage of marshes and canalization of streams ;
(2) oiling or closing of wells and cisterns; (3) avoid-
ance by troops of the neighbourhood of rivers.
marshes, and streams as far as tactical require-
ments would peniiit; (4) mosquito-proof huts; (5)
use of repellant ointment and head-nets for men
exposed on duty at night; (6) avoidance of villages
by at least half a inile or removal of native popu-
lation ; (7) evacuation and thorough quininization
of soldiers infected with malaria.
Larvicidcs (J. F. Mayne and W. R. Jackson). —
The authors believe that one would get better and
more lasting results by mixing the paraffin with
the water in treating pools rather than by simply
spraying it on the surface. They have obtained
very good results with cresol.
Note on the Relative Proportions of Anuibic and
Bacillary Dysentery among the Troops of the
Egyptian Expeditionary Force (H. M. Woodcock).
— The author admits, with most authorities, the
great preponderance of bacillary dysentery in
Egypt and Southern Palestine, but emi>liasizes the
point tJiat due importance should be given also to
the amcebic type.
Pulmonary Manifestations of Malaria (A. W.
Falconer). — The author has observed several cases
of bronchitic and consolidation syndromes due to
malaria. He gives some detailed clinical histories
witJi temperature charts.
Porocephalus in a Hernial Sac (J. W. Tudor
Thomas). — A West African negro soldier was
operated on for right-sided inguinal hernia. On
opening the sac a larva was found coiled up in the
sac wall, and covered over by a thin transparent
lining membrane. The specimen was submitted
to Colonel Newman, who identified it as the larva
of a porocephalus.
^bstrads.
SPREAD OF THE SPIROCHETE OF INFEC-
TIOUS JAUNDICE.'
MoDKHN medicine has taught the im])ortauce of
knowing the parasites of the animals that live in
close contact with man. The louse, the Ilea, the
mos(|uito and the rat are not merely disagreeable
]iests which disturb our comfort oi- damage our
]iroperty; they are the often unsuspected carriers
of hann — the hosts of invisible foes of mankind.
Scarcely five years ■have elapsed since the Japanese
investigator Inada and his colleagues discovered
that Si>irorli:rf(i irtrroluniiorrhagica is the cause <>\
Weil's tlisease, tn wliicJi the name " spirochaetal
jaundice " may now jiroperly be applied. This
discovery was made opportunely, as epidemic _
jaundice became prevalent among some of the C
troops of tiie allied nations early in the war. The f,
rat was found to be a carrier of the parasite ; and '
as the disease reported among soldiers of practically
all nations engaged in combat was found most
' Abstracted from the Journ. Aiiier. Med. As.'.oc, Feb. V, 1920.
ii
Mar. 15, 19£0.] THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
75
frequently at the front, the rat-infested environ-
ment pemiitted an interpretation of the probable
etiologic factors.
SpirochiEtaJ jaundice is not confined to Japan or
to tlie fields of Flanders. As might be expected,
the rat in other parts of the world has given evi-
dence of infestation with the spirochaete of this
disease. Lyons, Marseilles, Barcelona, Tunis,
.\lgier8 and New York feave already given scientific
proofs of the same danger in their midst. London
is the latest city to furnish new evidence of the
widespread occurrence of the parasite in wild rats.
Of a hundred of these rodents, at least 4 per cent,
were infected with the spirochete of jaundice.
The world-wide distribution of reservoirs of this
spirochaetal disease must now be recognized. This
makes it more imperative than ever to Jeam the
mode of transmission to man. Although spirochaetal
jaundice in man has been caused by rat-bite, direct
infection in this manner can be excluded in prac-
tically all instances, in contrast with what happens
in the genesis of rat-bite fever due to Spiroch:eta
morsus-niuris. Although it is not quite certain
whether the spirochaete of jaundice has been
identified in the intestinal contents of the healthy
rat, it has been found in the faeces of infected
guinea-pigs ; and its presence in the faeces in oases
of spirochaetal jaundice in man may be assumed.
The presence of the ispirochaetes in considerable
numbers in the urine of rat-carriers is quite suffi-
cient to ensure a wide distribution in rat-infested
areas. The possible role of insects as accessory or
alternative factors in spreading infection cannot
be excluded. However, as Noguchi has recorded
a case in which 'the urine was actively pathogenic
as late as four weeks after the onset of the disease,
the convalescent stage of which commences usually
at about the fourteenth day, the urine of human
patients must still be looked on as a source of
possible danger.
MIT.K PHODUCED IN SOUTHERN CHINA. >
By C. O. Levine.
Canton Christian College.
Three classes of milk animaJs have been studied :
European cattle, the native water buffalo (known
in the Philippine Islands as carabao), and the
native humped cattle. The work has been done
chiefly in the vicinities of Canton and Hong-Kong,
the only regions in Kwangtung (which is the
southernmost province in China) where dairying
has as yet developed into an industry of any
extent.
European cows, or foreign cows, as the Chinese
call tiiein, are the most popular for dairy purposes.
In the dairies of Canton and Hong-Kong, which
utilize approximately 1,600 cows, about 1,200 are
European. The European cows have been im-
ported from Australia, America, and England, or
' Abstracted from the Philippine Journal nf Science, 1919,
vol. xc, No. 1.
are the offspring of such imported cows. In the
various dairies may be found Shorthorns, Holsteins,
Ayrshires, Guernseys, Jerseys, and crosses among
these breeds and with the native humped cows.
There are a few pure-bred cows. The Shorthorns,
which are the commonest, are chiefly of the white,
hornless variety that have been imported from
Australia.
European cows are never allowed to graze be-
cause of the presence everywhere in tlie grass of
the fever tick. They readily contract fever when
exposed to it, and the disease usually proves fatal.
However, European cattle bom in Southern China
readily become immune to the fever, as they do in
Texas, where fever is common. In spite of the
greater labour and risk experienced in keeping
European cows, they are prefen-ed to the native
cows because of the larger amount of milk given
and their efficiency, as compared with native cattle,
in converting feed into milk.
The Chinese in South China call the native cow
wong ngan, "yellow cow." This bovine is a
variety of the humped species of cattle (Bos
indiciis) common in the Orient. The hump is
much less pronounced than it is in most breeds
of Indian cattle. In the males the hump is usually
6 to 8 in. high above the shouders. It is much
smaller in the females than in the males. The
dewlap is large, but is not developed to the degree
common in Indian cattle. In colour, these native
yellow cattle are similar to the Jerseys. They vary
from yellow-red to brown- black. Many are brindle.
There are no white and very few spotted indivi-
duals. The tongue, nostrils, and teats are black.
The cream-coloured ring above the nostrils in the
Jersey is also a characteristic of these cows. Males
weigh from 800 to 1,000 lb. (about 362 to 454 kilo-
grams). Mature females weigh from 600 to 800 lb.
(about 272 to 362 kilograms). Their milk is con-
siderably richer in fat than is that of any European
breed, though not so rich as is the buffalo milk.
The amount of milk given is usually about the
same as that given by the bufifalo cows or a little
less. They have a full deep quarter and a deep
layer of meat on the loin and back. They are used
chiefly for draft and beef purposes. They are
gentle and much easier to handle than are the
buffaioes. Very few are milked.
Milk Analyses.
In making the fat analyses of milk a Ba.bcock
fat-testing outfit was used. The prot-eins were
determined by the Kjeldahl method described by
Hawk. The total solids were determined by
evaporating a weigihed sample of milk on a steam
bath imtil the weight became constant. The ash
was determined by heating the evaporated totiil
solid over a gas flame imtil the weight became
constant. The amount of sugar was found by sub-
tracting the sum of the fat, ash, and proteids from
the total solids. The percentage of each was foinid
by dividing the weight of the final profluct by the
weigiht of the sample of milk analysed.
76
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 15. 1920.
Table I. — Showing analyses of Canton hviffMin'
milk, European cow's milk in Canton, Eiiro|)ea
cow's milk in America, and native yellow cow'
milk : —
1^ ,|i
Constituent
NUMBEBS OIVK rEBCKNTAQES
European Europenu y^,,^^^.
Canton America ^°^'^
Pat 12-60 3-80
Proteins ... 604 3-23
Sugar 3-70 5-96
Ash 0-86 0-82
Water 76 80 86-20
Total Solids ... 23-20
100
13 90
All the samples of milk analysed were taken by
me directly from the bam as each cow was milked ;
not from bottled milk that is sold to the public and
is frequently diluted with water.
The analyses show that European cow's milk is
practically the same as wihen produced in the
countries from which the cows have come. With
more analyses the slight differences in some of the
constituents will probably prove to be still less.
Sixty duplicate analyses of fat, or one hundred and
twenty in all, from the milk of twelve cows,,
extending over a period of eighteen months, were
made. Ten analyses were made for each of the
remaining constituents.
The analyses of buffalo milk included 400 dupli-
cate analyses for fat in a herd of fifty buffaJo cows
kept in tlie Canton Christian College dairy, includ-
ing both individual and herd tests of five dairies in
Canton. Compound analyses of both morning and
afternoon milk were also made. The average was
found to be 12-60 per cent. fat. The lowest test was
9-80 per cent. The lowest average for a lactation
period of all cows was 9-65 per cent. The highest
average was 15-60 per cent. The percentages of
constituents in the buffalo milk other than fat
represent averages of ten analyses. The proteins
varied from 5'60 to 6' 10, with an average of 6-04
per cent. Sugar was low, varying from 3'51 to
3-75, with an average of 3-70 per cent. The
average for ash was 0-86, varying from 0-71 to 0-99
per cent. The total solids averaged 23'20, varying
from 21 00 to 25-20 per cent.
The milk of the native yellow cow is rich in fat,
averaging about 8 per cent. No analysis has been
made of this milk for constituents other than fat.
In all regions where buffalo milk has been
analysed it has been found to contain a great deal
more fat than does European cow's milk. How-
ever, in no region from which the analysis of milk
has been reported does the buffalo milk contain as
much fat as in southern China.
Buffalo milk is pure white with absolutely no
tint of yellow. Cream and butter made from it
are rather oily and have but a faint tint of yellow.
By mixing European cow's cream with the buffalo
cream and using vegetable butt-er colour the colour
and the texture can be greatly improved.
Like most milk, buffalo milk has little or no
ll;iL(
Wild
niliKi
In
cows
becai
inuL; odour often found .associated
n Inicign substances, such as hair,
.1 .l.a.l skin, that fall into the milk when
iitai-y iiri'L-aiitions are not used in milking,
•h foreign substances get into the milk,
lia that they introduce multiply very
III produce gases with unpleasant odours.
Cdllci^e ilairy both European and buffalo
kept. IJiittalo milk is much preferred,
f its ric-lincss, by both foreigners (Ameri-
can and l']ni()|iean) and Chinese. In modifying
mill; for infants requiring modified milk, the college
piiysicians prefer buffalo milk to European cow's
milk because of the ease with which it lends itself
to modification. The usual formula for modifica-
tion is 100 grm. of buffalo milk, 18 grm. of
sugar, and enough boiled distilled water to make
300 grm. This makes the percentages of fat,
proteins, sugar, and ash about right for infants,
as when thus modified the milk compares well
with human milk. For children of 3 years or
more, the milk is usually simply thinned by adding
an equal amount of water.
Electrical Treatment. By Wilfred Harris, M.B.
3rd Edition. 1919. Pp. 354 + x. London:
Cassell and Co. 9s. net.
A fuller title might be : Electricity — what it is,
when and how to use it. Much more than the
title indicates is contained in the book, as all con-
ditions where electricity is of use are mentioned.
The methods of using are fully described, both for
diagnosis and for curative purposes, marked care
being devoted to avoid pain or accident which
patients so much dread.
Muscular dystrophies and their diagnosis is a
notable feature ; care is taken to avoid confusing
readers by meaningless names and terms.
The theory of electricity is explained, and, except
X-rays, its technique, in a way that assists those
cdiiiiiii-nciiif,' the study of the physics of electricity,
of both anatomy and of physiology of the nervous
system, and to enable them to understand normal
and abnormal function.
The book is of use to beginners in clinical
neurology and to those anxious to revise their
methods of diagnosis and treatment. The author
shows tlie evils resulting from the teaching of
el'ectricity to students by those who refuse to
infonn themselves of the needs of medicine; so
doctors neglect the practical use of this therapeutic
agent, and patients resort to the camp-followers
of medicine.
I
Thr paper " Some Observations on Vibriothrix leylanica,"
by Dr. L. Anigstein, published in this journal on January 1,
1920, was previously communicated by the author to the
Cracow Academy of Science.
I
April 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 7, Vol. XXIII.
^riflinal Commnniations.
OBSERVATIONS ON THE LARV^-DESTROY-
ING ACTION OF SMALL FISH IN THE
MALAY ARCHIPELAGO.
(Prom the Institute of Tropical Hygiene, Amsterdam).
By N. H. SWELLBNQREBEL, Ph.D,
AND
J. M. H. Swellengbebelde-Graaf.
In the Malay Archipelago we find several species
of fish, which as adults or as young forms may be
induced to eat larvse of Anopheles. Three of them
we found to be especially voracious, viz. : Haplo-
chilus panchax and the young of Ophiocephalus
striatus and Dangila cuvieri. The first we found in
salt-water fishponds along Java's north coast and
also in the wet rice fields in the interior, the second
and third in the fresh-water fishponds in the interior
of Sumatra.
Both species occur in great numbers, together
with still greater numbers of larvae. But thie may
be due to the fact of the ponds being, as a rule,
overgrown with vegetation, whicJi is said to protect
the larvEB against the attack of fish.
(1) Experiments with H. panchax.
This small fish is extremely voracious (see Table
I). Two specimens may eat 100 larvae in half an
hour's time. We examined the gut of twenty-sax
specimens caught in fishponds containing abundant
larvaB of M. rossii. After our experiments we were
much surprised to find remnants of larvae in only
two of them. Of the othens, fifteen contained
animal remains (seven, larvse of a water-beetle and
water-bugs, both active destroyers of Anopheline
larvse, which shows that the action of H. panchax
may be directed in several ways). The other nine
only contained vegetable matter.
This discrepancy induced us to observe the be-
haviour of H. panchax under natural conditions.
We found these especially favourable in a broad
salt-water ditch, partly overgrown with algae,
(Enteromorpha).
The larvae (a mixture of M. rossii and Culex
micro -annulat us) were so numerous as to form a
greyish scum on the water. They formed definite
agglomerations, sometimes between the algae, but
often free, with a clump of algae as a centre, or ad-
hering to the stone wall, which formed one of the
banks. This agglomeration around a small piece of
algae was very marked when bringing in a batch of
larvse in a portion of water almost free from algae.
The larvae did not flee among the neighbouring
thick algal growth, but gradually assembled around
the floating piece.
From time to time the larval " colonies " showed
signs of "swarming," leaving their agglomerated
position and spreading in all directions. When a
fish approaches, or any othor large living thing, or
when a shadow falla on the water, they instantly
dive down and then reasaemble in their colony.
(This applies to M. rossii; M. sinensis and barbiros-
tris are not in the habit of diving down or of being
frightened by shadows.)
Among these algse and larvae we observed 106
H. panchax. There appeared not to be the least
difficulty in their moving about under the algae.
M. rossii is in the habit of constantly diving down
and so it is not easy to understand how the algae
can protect them against the attack of the fish.
Still it is impossible to observe what takes place
under the algal cover and so we had to confine our
oliservations to the larvae moving about in places
where observation was not impeded by thick algal
growth.
At first larvse there were scarce and we had to
put in 1,200 larvae in three batches of 400, which
gradually formed new colonies around smaO patches
of weed. During the first minutes H. panchax,
especially the young ones, seemed to be attracted
by the newcomers and twice we observed a larva
to be swallowed, but soon the fishes became accus-
tomed to it and took no more notice of the new
state of affairs. We repeatedly observed a Haplo-
chilus almost to touch with its nose a larva, without
doing it any harm.
Later on free colonies (i.e., not surrounded by
the algal covering) became more numerous, but the
fishes always passed them without molesting them
in any way. This is not because they cannot reach
them : algae are scarce and the water is not too
shallow, for the fish is seen diving under the colony.
At the day's end the free colonies were seen to
retire between the thick algal covering.
Not only did the fishes abstain from attacking
the free colonies, but they even seemed to avoid
them, and when they had to pass under or through
thein they took a start and did so at an accelerated
pace, only resuming their habitual celerity, after
having left the colony behind them. This peculiar
habit we repeatedly observed.
In a neighbouring pond the number of larvae was
much smaller. They were only to be found within
the thick of the algse; H. panchax was swarming
under and around them. In the portion of the
water free from algae, we put a few hundreds of
larvse. Twenty-nine small specimens of Haplochilus
were attracted by them and chased them from place
to place, without, however, catching one of them.
The larger specimens did not take any notice. As
in the other collection of water, the larvae gradually
assembled to form colonies around small patches of
algse. In the Haplochili caught within this swajrm-
ing multitude of larvae, not a single one was found
containing Anopheline larvse in its stomach, the
only animal remains being Daphnia, Cyclops and
Heliozoa.
These observations apply to H. panchax, M. rossii
and M. hidJowi in salt-water. In the fresh-water of
the rice fields wc observed different conditions. In
the localities under observation, rice was planted
in January, harvested in May and June, planted
:if,'airi in July and harvested in Octol)er-November.
In December and January, before the planting of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1920.
Table I.— Experiments Vfith Haploohilus and larvse of M. rossii.
No.
^1
11
If
1
1
1
1
Kind ofgUMiD which
the laiTB were kept
Speci.l condi-
tions (exc.
vegeUtion)
Kind of
vegetation
present
■i
k
It
V
!|
||
Remarks
Total
Per
one
ash
1
2
3
1 X
Ix
1 X
3
2
2
100
100
87
Glass jar of 10 litres
Indoors
None 2J h.
36 m.
Ih. 20 m.
Freshly
captured
100
99
87
100
99
100
33
49
50
Tablk II.— Experiments with Ophiooephalua and larvae of if. ludloioi, M. barbirostris, M. iinen$is.
1
3 X
7
22
Glass jar of 3 litres
Kept indoors
None
3-5 h.
Freshly
captured
19
86
29
2 rt
ax
2
25
,.
2h.
21
84
42
h
2 X
2
25
■ > •!
,,
24 h.
'24
96
48
2 T
2
25
11 •>
,,
48 h.
25
100
50
d
2 X
3
25
..
>.
>.
..
72 h.
25
100
50
3a
Ix
2
75
.,
..
„
Ih. 40 m.
Freshly
captured
67
84
42
h
1 T
2
75
Out of doors
74
98
49
in the shade
1 X
75
20-litre tin
51
68
34
d
2
75
Out of doors
in the sun,
kept cool by
running water
■'
59
78
39
e
1 X
2
75
., ..
Indoors in the
dark
"
43
48
29
ia
3x
2
25
..
Out of doors
in the shade
Najas and
Pistia
2ih.
8
32
16
Exp. 2o, 3 c serve
as control.
b
1 X
3
26
As in exp. 3 d
Najas
5h.
23
93
31
e
Ix
3
25
"
"
Pistia
"
22
87
29
Exp. 3 d serves as
control.
5o
1 X
3
25
.,
Out of doors
in the shade
Najas, Pistia,
fresh
2}h.
72 h.
15
60
30
Exp. 2d serves as
control.
b
Ix
3
25
"
Najas, Pistia,
washed
3h.
22
88
44
TABI.E ni. — Experiments with Dangila and the larvae mentioned in table II.
1 a
b
32
25
GUss jar of 3 Utres
Indoors
None
5h.
2ih.
Freshly
captured
22
22
100
88
33
44
3a
b
35
25
20-litre tin
Out of doors
in the shade
Najas
Pistia
5ih.
Freshly
captured
7
20
28
80
9
27
3 a
b
25
.. ..
" "
Najas, Pistia,
fresh
Najas, Pistia,
washed
3h.
72 h.
6
20
24
80
12
40
April 1, 1920.] THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
79
the first crop, the paddy fields contadned many
small puddles without vegetation harbouring numer-
I ous larvae of M. vaga {indefinita). After the paddy
being planted, the water supply became more
plentiful. With it H. panchax appeared and M.
vaga disappeared, only to be left in small holes in
the dykes separating the fields and in wayside
I puddles. Weeds were carefully eradicated. This
is no longer possible when the paddy becomes
mature ; weeds (grass, algae, Monochoria) begin to
thrive now and with them larvse. But these are
of different speeiee, no longer M. vaga, but M.
barbirostris, aconita, N. fuUginosus. Even if vege-
tation is scarce, the recumbent stalks of the paddy
plants in fields which have not been cut in time
serve as such and this condition seems to be par-
ticularly favourable for the growth of the dangerous
M. aconita. H . panchax is still present, but it does
not check the larval growth, although the vegeta-
tion is never so thick as to prevent it from catching
the larvae. After paddy has been cut, weeds con-
tinue to grow in the fields which are left submerged,
and larvae (barbirostris, fxiliginosus, aconita becom-
ing scarce) remain numerous. The ploughing com-
mences and with it the vegetation and the«e larvse
disappear to be replaced by Af. vaga. The latter
remains numerous, till the fields are again freely
submerged, although during the time of this second
cultivation all sorts of weeds grow plentiful from
the onset and H. panchax remains scarce.
Thus it seems that only between M. vaga and
H. panchax there exists any direct relation. For
the other sipecies such a relation does not become
apparent.
(2) Experiments with Ophiocephalus atriatus.
Only the youngest stages (of 3-4^ cm.) were used,
the older ones being not at all attracted by larvae.
Without vegetation this fish proved a rather good
larva destroyer, although not so powerful as H.
panchax (Table II, 1). Its destructive powers can
be much raised by hunger (Table II, 2). The sur-
roundings, and especially the dimensions of the
vesisel in which fish and larvae are contained, exer-
cise a great influence on the number of larvae de-
voured (Table II, 3). The inhibitory influence of
vegetation (Najas, Pistia) was slight wihen three
fishes were present (Table II, 4 b, c) with two fishes
only, it was appreciable (Table II, 4a) with Najas
(submerged) and Pistia (floating -and submerged)
combined. With floating and submerged algK
(Spirogyra, Cladophora) no inhibitory result was to
be obtained. Even when two fishes only were used
results were slight if they were very -hungry, but
especially so if the vegetation had been freed of the
adhering micro-flora and -fauna by previously wash-
ing it (Table II, 5, a, b).
We also observed Ophiocephalus in nature among
an aquatic vegetation consdsting of Najas, various
algae and rushes on the shores of an extensive lake.
The fishes were very numerous and so were the
larvse (Af. ludlowi, M. sinensis, Af. barbirostris).
The small fishes (hardly more than five times the
length of a full-grown larva of M. barbirostris) were
well able to creep through the small meshes of the
entangled vegetation ^nd did so too, but they never
seriously tried to catch the larvae.
(3) Experiments with Dangila cuvieri.
Similar expeiriments were performed with the
young forms of D. cuvieri. Here again the older
stages are no longer of any use. In the 3-litre
glass jars its voracity was not below that of Ophio-
cephalus (Table III, 1), but vegetation much im-
paired it, especially the influence of Najas appeared
to be inhibitory (Table III, 2). The difference be-
tween washed and unwashed vegetation wm in this
case much more marked than in Ophiocephalus
experiments (Table III, 3).
(4) Conclusions.
Haplochilus panchax and, to a lesser extent,
Ophiocephalus striatus and Dangila cuvieri are good
larva destroyers when kept together with the larvae,
in vessels not containing any vegetation. When
thisi is present it inhibits the action of the fishes
to a greater or lesser extent, dependent on the
number of the fishea and the degree of their appe-
tite. This influence can be reduced by washing
the vegetation before the beginning of the experi-
ment, thereby diminishing the amount of micro-
flora and -fauna adhering to it. FVom these obser-
vations we conclude that the protection afforded by
the plants is not a mechanical one, but is caused
by these plants sheltering numerous other eatables
for the fishes, which in this way are deviated from
the larvae. This conclusion is corroborated by the
results of observations on H. panchax and 0. striatus
in nature, where it appeared that these fishes,
living together with Anophehne larvae among
aquatic vegetation, only rarely tried to catch these
larvae, although there was nothing tangible to pre-
vent them doing so.
We would suggest that the close relation existing
between acjuatic vegetation, larvae and fishes ia to
be explained by the fact that both the latter derive
(directly or indirectly) their food from the former.
Destruction of the vegetation is an antilarval opera-
tion, not because it exposes the larvse to the attacks
of the fishes, but because it deprives them of their
food.
Regarding H. panchax these conclusions only hold
for salt or brackish water; in rice fields the larva-
destroying qualities were quite apparent, provided
that vegetation was absent, at least in regard to
Af. vaga.
As a practical conclusion (which, of course, only
holds for the fishes and larva under observation)
we would state, that in salt-water not much good
is to be expected from the action of fish. In frosh-
wa,ter, and especially in rice fields, their beneficent
activity becomes more marked and it may be
taken advantage of in conjunction with other
measures, viz. : (1) timely cutting of the rice (be-
fore the stalks go down); (2) letting off of the
irrigation water as soon as it is no longer necessary.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1920.
^tttXitS.
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THE JOURNAL OP
Cropf tal £&tf}itint and l^pgtene
April 1, 1920.
SPECIAL INDIAN SCIENCE CONGRESS
NUMBER, 1919.'
The Indian Journal of Medical Research v^hioh
has just come to haod is a welcome addition to
' Pablished by Thacker, Spink and Co., Calcutta.
our library slielf. The facts, opinions and figures,
remarkable in many ways, were duly noted at the
time the Congress was held — namely, January,
1919 — 80 that the information conveyed in this
special number and official publication may be
considered ancient Hterature, seeing how rapidly
tropical investigation work proceeds nowadays.
Yet the number before us can but impress the
world, and the world of medicine more especially,
with the magnificent work our medical brethren in
India liave and are accompHshing not only in the
scientific field of research, but also in the practical
sphere of the application of the discoveries these
researches have brought to light.
We often hear it said the Indian Medical Service
is not what it was. It certainly is not ; it is not
progressing backwards, however, as the above
legend implies; far other is its course. It has left
its old and unwholesome traditions far behind, and
has reached a stage of accomplishment, of organi-
zation and proficiency in the world of science that
sheds a lustre on the service as a whole, a service
of whioli the whole Empire has good reason to be
proud. The best of the old regime culminated and
perished with the deatli of Sir Joseph Fayrer.
He was the Napoleon of pre-research (or what
we wrongly term pre-bacteriological) days. As
Napoleon was the last exponent of war methods
before the introduction of railways and steam
I)Ower into the world, so Fayrer had as capable a
brain and was endowed with a power of observation
and organizing ability as keen and capable as any
of our modem exponents of science, yet he lacked
the means of doing as they have done, for the
microscope was in its infancy as an exponent of
pathology and research as it is known to-day and
was unknown to Fayrer and those of his time.
The writer had the privilege of knowing Sir
Joseph fairly intimately, and of all the memories
of that great man none are more impressed
on his mind than Fayrer's remark when
Manson's researches and opinions on malaria came
before the Royal Society and were gaining ground
in the scientific world. When speaking on the
matter, Fayrer remarked to the writer: " As soon
attempt to keep back the wind by a five-barred
gate as to prevent the great disease of malaria by
the eradication of mosquitoes." He could not
conceive how the " great disease of malaria," the
most widespread, the most terrible, and the most
incapacitating of all diseases, could be brought
about by a humble insect. The thing to him was
incapable of belief. Yet these older men laid the
foundation for the future advance of science in
India; they founded medical schools, they estab-
lished modern hospitals, introduced physiological
teaching on modern lines, and paved the way for
the recejjtion of modern research, although neither
they nor anyone else understood the meaning of
the term, nor could conceive where that was to
lead them.
The gifted President of the Congress, Sir Leonard
Rogers, in his presidential address, ascribes great
April 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
81
credit to the late Sir Paixley Lukis when he was
Director-General of tlie Indian Medical Service,
and we can endorse the testimony. Sir Pardej
Lukis recognized the capable men he had around
him, and by his organizing ability placed facilities
for investigation at their disposal. He early recog-
nized the great asset Indian medicine had in Sir
Leonard Rogers himself, the one man became the
complement of the other, and together they have
accomplished a great triumph. It is none other
than the escape of medicine from official thraldom,
and the freedom given and afforded by the wise
men in authority in India at the present day. The
writer well remembers the struggle in the case of
Dr. N. C. Macnamara, I. M.S., referred to by Sir
Leonard in his address. The writer was in Egypt
in 1883 a member of the Cholera Commission sent
out to that country during the great cholera out-
break. Koch and his assistants came out and
found the cholera comma bacillus. Dr. Macnamara
visited Egypt at that time whilst on his way to
India. He had just been devoting his leav» in
England to th« study of bacteriology, and was well
equipped in methods of research and investigation.
Had he reached India a few days earher, the
cholera bacillus would have been a BritisJi in place
of a German discovery. He returned to India
equipped at every point to deal with the investi-
gation of the cause of cholera, but we learn from
Sir Leonard what happened: —
" Having thus qualified himself for the ta«k by
long experience of the disease and teohnical know-
ledge, in February, 1883, he applied to the India
Office for facilities for pursuing his investigation on
his return to Calcutta, but received an absolute
refusal to entertain his request. The same Govern-
ment, however, within a year gave every possible
facility to a German bacteriologist to investigate
cholera in India, who had in the meantime dis-
covered the comma bacillus in Egypt. I have in
my possession Dr. Macnamara 's own account of
' this sad episode, which reflects so little credit on
Indian administration. I am glad to say he has
lived to see German culture so competely exposed
by the Great War that the recurrence of such a
discreditable event seems scarcely possible in the
future. This episode is, however, typical of the
want of encouragement Indian Medical Service
investigators met with up to two or three decades
ago, which has now happily given place to a very
different spirit."
Something of the same nature happened when
Manson applied to get Ross " research leave " to
carry out Manson 's mosquito-malaria infection
theory; but happily this was managed, to the great
credit of the Indian authorities. How different is
the atmosphere that pervades all civilized Govern-
ments to-day as regards modem medical research
need not be enlarged upon. In India support has
been phenomenal.
Sir Leonard dilates upon this as follows: —
" Bengal and Bihar have generously given me
seven lakhs for the Calcutta Soliool of Tropical
Medicine, half of which has been expended on the
Carmichael Hospital for tropical diseases, and the
remainder will be used for medical research and
the partial upkeep of the hospital under a govern-
ing body of medical experts. In addition, the Tea,
.Jute and Mining Associations are contributing
Rs. 60,000 a year for the support of three addi-
tional workers to investigate on practical lines
those diseases which affect the value of the labour
forces. Bombay has always been noted for the
liberality of her citizens, so I confidently appeal
to this great city to do at least as much for my
friend Colonel Liston's school here, which he has
laboured so long and patiently to foimd in con-
nection with the Parel laboratory.
" But I also desire to make a still wider appeal.
The late Sir Pardey Lukis, one of the ablest and
most far-seeing administrators the Indian Medical
Service has ever produced, founded the Indian
Research Fund Association, to which the Govern-
ment of India give the large sum of five lakhs
yearly. It was hoped that this annual grant would
have been materially increased by liberal contri-
butions from the Princes and noblemen whose
territories will benefit equally with those under
British rule from medical research, and the wealthy
citizens of India, but I understand that this hope
has been sadly disappointed, mainly no doubt
owing to Indian pihilanthropy having been rightly
diverted during the war into other channels. Now
that the world-wide devastation and the destruction
of irreplaceable human life has at length ceased,
I should like to see the flow of money diverted to
the noble object of saving life by means of a great
extension of medical research, and I can conceive
of no more fitting thank-offering for the delivery
of the world from the greatest menace that has ever
threatened modern civilization. What is wanted is
an Indian Rockefeller to come forward with a crore
or two of rupees, backed by large contributions
from many others, to be devoted to the aid of
genuine medical research all over India indepen-
dently of race or position, under the control of a
governing body, the cliainnan and a large majority
of whom should be scientific experts. I feel con-
fident that practical philanthropy of this nature,
by diminishing suffering and disease, and giving
better health to the masses, will be of more real
benefit to India than any so-called boons which
have ever been dreamt of. Legacies for such work
will no doubt be welcomed by the Indian Research
Fund Association at Simla, but those who give
liberally during their lifetime will have the far
greater satisfaction of seeing for themselves the
seed they sow in faith bearing fruit abundantly.
As example is better than precept I may mention
that I am giving as much a* the most libera!
donors to the Calcutta School of Tropica.1 Medicine,
and hope to be able to do still more for medical
research in the near future, so I am not asking
others to do anything I am not willing to do myself
to the limits of my power."
J. Cantlie.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1920.
Annotations.
Cnrwnt f itrratwrf.
Action of Radhnn on Yeast (Journal of Biological
Chemistry, Baltimore, October, 1919). — It is noted
that exposure to the action of radium will partially
inactivate growth-promoting factors in yeast.
Sugiura and Benedict suggest that possibly the
therapeutic effect of radium on neoplasms may be
partly due to this power of destroj'ing growth-
promoting suh
The Etiology and Treatment of Seborrhceic
Eruptions (Barber and Semon, Journal of the Royal
Army Medical Corps, September, 1919). — The
authors have noted that the majority of patients
with seborrhceic manifestationB show a markedly in-
creased alkaline tolerance, and that as soon as the
urine is rendered alkaline the active inflammatory
process ceases and the eruption rapidly clears.
The following mixture is recommended: —
Sodii bicarb. ... ... 5i
Pot. cit. ... ... ... gr. XXX
Calc. lact. ... ... ... gr. v
Mag. carb. ... ... gr. v
Aq. ohlor. ad ... ... 5i
Three times daily before meals.
Externally a calamine liniment or a 2 per cent,
bicarbonate solution will be found useful.
Rocky Mountain Spotted Fever (S. W. Wolbach,
Joum. Med. Research, November). — Three definite
morphologic types of the spotted fever parasite can
be recognized : (1) An extranuclear bacillus-like
form without ohromatoid granules, relatively large
and only present in ticks during the initial multi-
plication of the parasites; (2) a relatively small
rod-shaped form with ohromatoid granules, prob-
ably the same form seen within nuclei in sections
of ticks, and rarely in smooth musole cells in the
blood-vessel of mammals ; and (3) a relatively larger
lanceolate paired form present in ticks and in the
blood and lesions in mammals. This lanceolate
form is characterized by its " clironiatoid " stain-
ing reaction, and according to the evidence at hand
is the form in which the virus is passed between
the tick and mammalian hosts. The other two
forms described are multiplicative stages, and can
only be demonstrated ocoasionally and with diflS-
culty in mammalian hosts. The name Derma-
centroxenus rickettsi is proposed for this parasite.
Yellow Fever is spreading in Mexico, since ca-ses
have been reported at the port of Salina Cruz on
the Pacific Coast far from Yucatan, the focus of
the present epidemic. Dr. Noguchi is employing
his method of prophylactic vaccination by means of
killed cultures of Leptospira. It is expected that
this vaocine will give good results in view of the
fact that yellow fever is one of those diseases that
confer complete and permanent immunity.
Bulletin de la Societe de Pathologie Exotique.
February, 1920.
Preliminary Note on a Fever of Unknown Origin
observed in Cochin China (P. Noel Bernard). — In-
vestigation into the unclassified " climatic fevers "
of the country has led the Pasteur Institute of
Saigon to distinguish from the group one definite
clinical entity in consideration of the fact that the
organism isolated has shown the same general char-
acteristics in every case. The symptoms differ in
intensity only, but, according to the predominating
clinical feature, the condition has been variously
diagnosed as typhoid fever, typho-malaria, pseudo-
dengue, five days' fever, seven days' fever, extreme
eastern and Indian port fever, an attack of malaria,
or simply as gastric trouble a calore. In effect it
appears to combine the symptoms of pseudo-dengue
and of five days' and seven days' fever, though to
regard it as a fusion of the three different clinical
types in question would be premature. The name
" astheno-myalgic fever" is suggested for it as
resumiing its three essential characteristics. The
condition seems to be endemic and to persist to a
certain extent all the year round, assuming an
epidemic form at intervals. In 1919 the periods of
greatest severity occurred in June and August.
Symptomatic Ayithrax in Annam (Henri Schein).
— The disease obaerved appears to be epidemic and
to l>e most in evidence towards the end of July.
Calves are the chief victims. The symptoms are
distress, fever, and infiltration of gas and serum in
different parts of the body. Death occurs in from
twenty-four to forty-eight hours after the onset.
The blood and cedematous fluid contain immo-
bile Spore-bearing Gram-negative bacilli, markedly
smaller than B. chauvsei as known in France. They
grow readily in fresh Martin broth under oil of
vaseline at a temperature of 30°, and give off a
small amount of gas, the broth becoming cloudy
in twenty-four hours. The cultures lose their
virulence in a very few days, and the author was
unable to preserve his strains. On specimens sent
to France, Professor Valine reported that the
organism could be stained by the Gram-Nicolle
method if previously treated with toluene (unobtain-
able in Annam at that time), and that experiments
on guinea-pigs showed that a serum specific against
B. chauvcei was also effective against the bacillus
from Annam.
A Contribution to the Stvdy of the Sero-reaction
and the Fixation of Complement with B. proteus
in Exanthematic Typhus (A. Orticoni). — Two cases
of suspected typhus were tested by the Weil-Felix
method with B. proteus type 19. The serum of
one of them, who had reached the sixth day of
illness, agglutinated the culture at 1 in 200, while
that of the other, who was convalescent, agglu-
tinated the same strain at more than 1 in 500.
The normal serum used as control remained negative
AprU 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
83
on every occasion. Later tesfcs showed positive sero-
reaction in increasing degrees. No deviation of the
complement was obtained by the use of No. 19
B. proteus as antigen in connection with tlie serum
of the same two eases. Agglutination of B. proteus
by the serum of typhus patientsi would only seem
to be para-specific therefore, but it is of great prac-
tical value as an aid to diagnosis and the test may,
moreover, be used retrospectively.
The Dysenteries at Salonica in 1918 (G. Derrieu).
— The author seems to regard Entanueba tetragena
as different from E. histolytica, and considers the
former to be more frequently met with. A vegeta-
tive type of a heematophagous amoeba was also seen,
Amcebo-bacillary dysentery was diagnosed three
times. The most severe and fatal form oi dysentery
observed by the writer was the necrotic type. The
necrosis may affect the whole of the mucous mem-
brane of the large intestine or be localized at certain
points, while the same intestine may show a com-
pletely necrotic segment adjacent to a segment pre-
senting superficial ulcerations limited to the mucosa.
Out of sixteen autopsies, perforation was found in
five cases. The treatment indicated was absolute
rest for the intestine to prevent both perforation
and generalization of the infection when still
localized. The Shiga bacillus was usually recover-
able in these cases, and Trichomonas was fiequently
found in the stoole, becoming more and more
numerous towards the end.
A Contribution to the Study of Flagellata of
Culicidx, Muscidx, Phlebotomi and Blatta orien-
talis (A. Laveran and G. Franchini). — Herpeto-
monas, Crithidia and Trypanosoma were found in
association in the digestive tube of specimens of
Culex pipiens collected near Bologna, and all three
were subsequently recovered from inoculated mice.
The question therefore arises as to whether the
infection was a triple one, or whether, under certain
circumstances, the Herpetom.onas is able to develop
in mosquitoes and assume the form of a Crithidia
or of a Trypanosoma. The same problem occurs
with reference to the Muscidie, for though neither
: Crithidia nor Trypanosoma were found in the vari-
ious species examined, Herpetomonas muscr domes-
ticsr. was identified in specimens of Sarcophaga
hcemorrhoidalis and trypanosomata were recovered
from a mouse inoculated with the Herpetomonas.
Out of 200 Phlebotomus papatasii e.xamined flagel-
|lata were found in the digestive tube on four occa-
Isions. They were fatal for mice, and would appear
to be identical with the H erpetamonas obtained by
iMackie from Phlebotomus minutus and described
by him under the name of H. phlebotomii. A flagel-
|late discovered in the digestive tube of Periplaneta
\orientalis, and pathogenic for mice, is apparently
ia new form. The authors suggest for it the name
of H. periplanetx.
Culicidx collected by the Anti-Malaria Commis-
sion attached to the Armee d'Orient in 1918 (Ch.
Joyeux). — The specimens were obtained from those
Iparts of Macedonia, Albania and Greece which were
occupied by French troops up to September, 1918.
.\s in 1917, four species of anopheles were repre-
sented, viz., A. machilipennis (very common),
A. bifurcatus, P. palestinensis and M. sinensis
(rare). Stegomyia calopus and Theobaldia longi-
arcolata were found on the coast, at Salonica and
Ithea, but not in the interior. T. spathipalpis
was fairly abundant in all seasons. T. anniilafa
and T. fumipcnnis, were seen in larval form from
the begiiming of March, though the latter was
rare. The larvae of Ochlerotatus dorsalis were found
in all qualities of water. Culex pipiens L. was
ubiquitous. The larva of C. hortensis Fie. and of
C. apicalis were very common in fresh water.
Tacniorhynchiis richiardii was sent in in large quan-
tities from the Upper Vardar, especially during the
hot months; its eggs were found in both salt and
fresh water, but those deposited in the former were
white and fell to the bottom. Uranotxnia utigiiicii-
lata was obtained on one occasion only, though
common in 19??.
Health Conditions and Depopulation in the Congo
(E. Jamot). — The report deals with that part of
the French colony of Oubangui Chari which lies
between the Oubangui river and the southern
boundary of the military territory of the Chad,
the population being alx)ut 100,000. The people
belong to the Banda and Mandjia tribes, and are
worn out by many years of forced toil. Robust
and healthy individuals are rarely seen. Sleeping
sickness, yaws, eyphilis, leprosy and various diseases
of the eye abound. In those parts of the country
where sleeping sickness is most common the mor-
tality exceeds the birth-rate to such an extent that
the population is visibly dying out. On the author's
instigation certain villages have been exonerated
from the taxation which is paid in labour and
encouraged to cultivate the land for food production,
and in view of the excellent results obtained by
these measures he urges that Government subsidies
should be obtained to enable their apphcation
throughout the colony.
A Contribution to the Study of the Ixodidx:
Biological Adaptation of the Ambulacra of the First
Pair of Legs (G. Senevet). — On the hypothesis that
a relationship exists between the d;;velopment of
the amlyulacra (or pads) in the ixodidse and the
biology of the parasite, Senevet has endeavoured to
ascertain by measurement whether the hypertrophy
of the amhulacra noticed in the larvae of speciefi
which are obhged to attach themselves firmly and
hurriedly to a passing host is continued through the
pupal and adult stages, and also whether this hyper-
trophy is less or inexintent in those forms which
are laid and hatched on the same host. In nearly
all the speciefi of ixodidae examined the measure-
ments) confirmed the theory. They should, more-
over, be useful in themselves by providing a guide
/or the identification of the various larvae and a
means of judging the mode of life of an ixode not
yet classified from the point of view of the number
of times it requires to change its hoot.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1. 1920.
The Journal of Experimental Medicine.
Vol. XXXI, No. 2, February, 1920.
Mycosis of the Bovine Foetal Membranes due to
Mould of the Genus Mucor (Theobald Smith). —
'he author hae isolated Mucor Thizopodiformis
^ichtheim from the diseased chorion of a ease and
rom the lungs and digestive tract of the foetus.
Experiments on the Nasal Route of Infection in
Poliomyelitis (Simon Flexner and Harold L. Amoss).
—The authors come to the conclusion that the
normal nasal mucosa is an invaluable defence
against infection with the virus of poliomyehtis,
and that the number of healthy and chronic carriers
of the virus is probably determined and kept down
through the prot^ective activities of this membrane.
The authors have found that antiseptics applied to
the nasal mucosa of monke3's upon which the virus
has been deposited show httle protective action and
are of doubtful value. Indeed they are inclined to
believe that such substances may be injurious.
etiology of Yellow Fever: Comparative Immuno-
logical Studies on Leptospira Icteroides and Lepto-
spira Icterohsemorrhatjiw (Hideyo Noguehi). — The
author in a series of interesting researches has
shown that monovalent immune sera prepared by
several successive injections in an animal naturally
refractory to Leptospira icteroides agglutinate homo-
logous and heterologous strains of that organism,
while they agglutinat* only very shghtly L. ictero-
hxmorrhagiiP. The Pfeiffer reaction sharply dif-
ferentiates the two organisms in most cases. More
or less specificity is shown also by the complement
fixation test. As regards active immunity, the two
leptospiras are somewhat closely related. Noguehi
comes to the conclusion that cross-immunity re-
actions in vitro and in vivo strongly indicate that
L. icteroides and L. icterohsemorrhagix are some-
what closely related, though specifically different.
(See Abstracts, in April 15 issue.)
Serum Treatment of Animals Infected with
Leptospira icteroides (Hideyo Noguehi). — The use
of a polyvalent L. icteroides serum of high potency
was found to lie very useful in the treatment of
experimental infections.
Sterilization of Lipovaccines (P. A. Lewis and
F. W. Dodge).— The authors come to the conclu-
sion that pneumococcus lijxjvaccJne gives a definite
protection against pneumoeoccus infected in mice,
and that the immunizing quality of the vaccine is
not greatly diminished by heating it to 130° C. for
three hours.
As regards typhoid vaccines, the authors have
found that the lipovaecine induces in rabbits a
lesser amount of agglutinins than the saline suspen-
sion vaccine. They have found also that heating
at 130° C. for three hours the typhoid lipovaecine,
greatly injures its antigenic properties.
Crescentic Bodies in /Estivo-autumnal Malaria
^Mary R. Lawson). — All malarial parasites are
extracellular and one may trace the destruction of
corpuscle after corpuscle by the migrating para-
sites of sstivo-autumnal infections. As regards the
attachment of the crescent to the red corpuscles,
the parasite is extracellular and wraps itself round
the corpuscle as a worm wraps itself around a berry.
Crescentic bodies go through migratory stages
similar to those of other malarial parasites, and it
is at times possible t« find all the stages in one
film, especially in cases of heavy infection and
when quinine has not been administered.
The Hasmic Basophile (G. S. Graham).— The
basophilic granule of blood and marrow cells does
not show the brown colour reaction characteristic
of the neutrophilic and eosinophilic granules. The
basophile is probablv a degenerated or degenerating
ceU.
^ebical l^etos.
UNIVEjaSITY OF CAMBRIDGE.
Diploma in Radiology and Electbology.
In connection with the courees now running in
London at University College, and at the Royal
Society of Medicine, the Committee for the Diploma
propose to announce to the Senate the following
dates for the next examination, which will be held
at Cambridge : Part I (a and b), Tuesday, Juh' 27,
1920, w-ith practical work and viva voce examina-
tion on July 28; and Part II (a and b), Thursday,
July 29, with practical work on July 30.
Candidates desiring to take the diploma by thesis
next term under Regulation 13, should apply to
the Secretary, Dr. ShillLngton Scales, Medical
Schools, Cambridge, without delay, for the neces-
sary certificate forms.
The Committee propose to hold courses of lectures
and practical work in Physics and in Electrology
during the ensuing long vacation in Cambridge,
beginning June 22 and finishing al>out the middle
of August, and in Radiology in the next Michaelmas
Term, beginning October 12 and finishing in time
for the examination at Christmas. The necessary
chnical work can be carried out at Addenbrooke's
Hospital, Cambridge. The Physics course will be
given by Dr. Crowther, by arrangement with Pro-
fessor Sir Ernest Rutherford : the courses in Radio-
logy and Electrology by approximately the same
lecturers, all leading workers in these subjects, who
have given the courses now nmning in London.
The holding of these courses in Cambridge will,
however, be dependent on a sufficient number of
students entering for them, and for this reason
early application should be made to the Secretary,
Dr. Shillington Scales. It is hoped in future to
hold courses and examinations twice a year, the
coiu-ses in Cambridge alternating with those in
London, so that candidates from overseas may
have an opportunity of taking the diploma.
April 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 8, Vol. XXIII.
i^rifliiwl fiommnnuatioiis.
SOME SOUDANESE DIPHTHEROIDS.
By Albert J. Chalmeks, M.D., F.R.C.S., D.P.H.,
Director, Wellccnne Tropical Research Laboratories,
Norman Macdonald,
Bacteriological Laboratory Assistant, Khartoum.
CoNTKNTS. — Introductory — Historical — Sudan
Strains — Classification — Summary — • Acknoiv-
ledgnients — Addendum — References — Illustrations.
Introductory. — There are always a few cases of
diphtheria, or of diseases simulating it, to be found
in the Anglo-Egyptian Sudan scattered throughout
the year but these become slightly more frequent
during the autumn and winter.
The diagnosis of diphtheria is, however, fraught
with difficulty as, in addition to the true Klebs-
LoeflSer bacillus, other organisms may be found in
cases clinically simulating diphtheria.
On the other hand difficulty may also arise from
organisms resembling the diphtheria bacillus but
found in conditions which do not resemble that
disease clinically.
Further, in our brief periods of sojourn in Egypt
we have met with similar difficulties in diagnosis.
In the Sudan, as in other countries, a species of
Nocardia (fig. 1) occurs in healthy and diseased
tonsils and is apt to confuse the diagnosis,
especially when present only as detached segments
without e.xhibiting long or branched forms.
In regard to the eye we have met with true
diphtheria of the conjunctiva in a British officer,
while conjunctival xerosis has been described
Irecently by Archibald as occuiring in the Sudan.
I Since his description we have met with several
leases during this year in the inflamed conjunctiva
|(fig. 2) and also in the non-inflamed conjunctiva
'which is well illustrated in fig. 1 of the plate
lattached to Archibald's paper of May 1 in this
journal. As this condition is due to a diphtheroid
|(fig. 3) it adds an interesting fonn to those known
to exist in the Sudan.
We may perhaps mention at this jjoint that
avian diphtheria is not rare in the Sudan, where we
lave frequently isolated its organism.
We began to collect material for this i)aper
several years ago but unfortunately we have lost
whole of our early records and can therefore
)nly draw attention to our quite recent work.
Notwithstanding the loss of these records we
hink that the few remarks we are about to offer
nay be of interest to our fellow practitioners in
he Tropics, as they are an attempt to formulate a
cheme for the diagnosis of true and false diphtheria
n these lands.
Historical— In 1883 at the " Congress fiir Innere
iledicin," held at Wiesbaden, Klebs showed that
teculiar bacilli could be seen near the surface
If sections of diphtheritic false membranes obtained
'rom post-mortems and coloured with methylene
blue. He considered that this was a second form
of diphtheria, distinct from that which he held to
be caused by an organism which he called Micro-
sporum diphtheriticum and whicJi was created for
a micrococcus and a fungus found by one of his
pupils, "Brown," in 1877.
The new bacilli were uniform in length, very
slender and frequently presented spores at each
end. These observations were supported by
Edlessen of Kiel. In the same year Kuschbert and
Neisser differentiated the Bacillus xerosis in cases
of xerosis of the conjunctiva. In 1884 Loeffler
having found deeply staining small rods arranged
in groups of false membranes, was able to cultivate
them in the form of yellowish-white colonies on
blood serum containing 25 per cent, of broth. From
these pure cultures were obtained and from them
guinea-pigs were infected by subcutaneous injection.
These animals, dying about the third or fourth
day after inoculation, were found to show charac-
teristic appearances in the form of greyish-white
necrotic local lesions, haemorrhagic subcutaneous
cedema, effusion into the pleural and peritoneal
cavities, lobular consolidation of the lungs, catar-
rhal inflammation of the kidneys and especially
reddening and haemorrhages into the supra-renal
capsules. The bacilli mentioned above were re-
covered from the local lesions but were not found
in the organs, a fact which was held to prove that
the lesions of these organs were due to a toxin. In
rabbits false membranes were experimentally pro-
duced by inoculation of the opened trachea and in
these membranes the typical bacilli were discovered.
In guinea-pigs he also noted post-diphtheritic
paralysis.
Loeffler also found these typical bacilli in one
ajiparently healthy child.
In 1887 he extended his observations and re-
corded the presence of an avinilent organism
morphologically similar to the causal agent. In
1890 he further recognized a diphtheria group of
organisms containing foi-ms allied to the true
bacillus.
This group contained: —
1. The true pathogenic bacillus which he called "Bacillus
bei Diphtherie des Menschen " (1884). This was the
type.
2. His own avirulent strain (1887).
3. The non pathogenic bacillus of von Hofmann-Wellenhof
(1888).
4. The xerosis bacillus of Kutschbert and Neisser (1883).
6. The avirulent diphtheria-like bacillus of Zarniko (1889).
The above may be taken as the first attempt to
classify the so-called diphtheroids, as Loeffler
pointed out that the last four organisms differed
from the first in certain morphological points, in
the good growth on agar at the room temperature
of a temperature climate, and in avirulence to
guinea-pigs. Zaniiko's organism seems to be the
same as Locffler's avirulent strain, but as his
original papers in the sixth volume of the Central-
blatt fiir Bakteriologie are not available in Khar-
toum we cannot say whether this is, or is not,
correct.
86
THE JOURNAL OF TEOPIGAL MEDICINE AND HYGIENE. [April 15, 1920.
Since the days when Loeffler brought forward
this classification, diphtheroid organisms have
multiphed greatly. Little, however, has been done
to consolidate the information concerning them and
hence their recognition is a matter of great difficulty.
In 1894 Parke and Beebe showed that bacilli,
which morphologically resembled the Klebs-Loeff-
ler organism, could be differentiated therefrom by
sugar reactions. They formulated the following
groups: —
I. Those which do not ferment glucose.
II. Those which do ferment glucose ; —
(a) Forms avirulent to guinea-pigs, but otherwise
exactly like the Klebs-Loeffler germ.
(6) Forms virulent to guinea-pigs.
This was a great advance in the process of dif-
ferentiation and was followed in 1896 by Lehmann
and Neumann who fomiulated a new genus for
these germs. This genus they named Corynebac-
terium (from KOfjvpr], a club) and defined it as
follows : —
" Bods, colouring interruptedly (striped) with weak solutions
of stains and hence composed of parts possessing different
staining properties, not stained by methods for the tubercle
bacillus and frequently clubbed, wedge-shaped or pointed.
"Type species. — Corynebacterium diphOierue Klebs 1883
emendavit Lehmann and Neumann, 1896."
In 1898 Kurth investigated the action of diphthe-
roids on sugars and named two species viz., B.
pseudodiphthericus alcalifaciens and B. psettdodiph-
thericus acidumfaciens . Eberson suggests that the
first is the von Hofmann-Wellenhof organism
while the second one is to be considered as
unrecognizable.
From 1894 to 1904 Migula studied the classifica-
tion of the bacteriaceae. He took a step backward
in his " System der Bakterien " in recognizing the
diphtheroids as belonging to the genus Bacterium as
defined by him. He held that B. septatum Gelpke
was a distinct organism, but Eberson is probably
correct in making it a synonym of the xerosis
bacillus.
In 1897 and in 1901 Chester formulated and
expanded a new bacterial family which he called
Mycobacteriacece and which he designed to hold
diphtheroids and allied fomis, all of which he in-
cluded in Lehmann's and Neumann's genus Myco-
hacterium, thus suppressing Corynebacterium,
which was a retrograde step.
It is necessary to be clear as to the definition of
this family, which is as follows:' —
EubacteriaUs. — Non-motile cells, long or short, cylindrical
or filamentous, without a sheath, often clavate, cuneate or
irregular, often with enclosed granules, without endospores and
with a tendency to form branches.
Type genus. — Mycobacterium Lehmann and Neumann 1896.
If this definition be accepted the diphtheroids
producing spores like B. erytheniatis Demme 1887
and those which are motile hke B. endocarditis
yriseus of Weiohselbaum are excluded, and must
find some other resting place.
In 1904 Graham Smith published a valuable
paper on these organisms and increased the number
of those bearing names with clear definitions.
In 1904 and 1907 Hamilton investigated
Ruediger's 1903 virulent pseudodiphtheria bacillus
as well as strains similar to those of Williams in
1898 and Davis in 1899. She divided aural diph-
theroids into two classes as follows: —
I. Forms fermenting saccharose but not maltose and
seldom virulent for guinea-pigs.
II. Forms fermenting maltose but not saccharose and often
virulent for guinea-pigs.
With regard to all these strains Eberson points
out that the diphtheria antitoxin is powerless to
resist their action and considers that they are all
identical with Bacillus auris Graham Smith 1904
and that possibly they are pathogenic agents.
In 1912 Lehmann and Neumann recognized the
following organisms as belonging to their genus
Corynebacterium : —
(1) C. mallei (LoefHer 1886).
(2) C. pseudodiphtheriticum (Hofmann-Wellenhof
1888).
(3) C. diphtheria; (Klebs 1883).
(4) C. xerosis (Kuschbert and Neisser 1883).
(5) C. necrophoTum (Fliigge 1886).
(6) C. fusiforme (auctores).
They also included C. diphtherice avium Kruse
1896 and several other forms. With regard to these
organisms C. mallei is Gram-negative and differs in
many ways from the next three organisms while C.
necrophorum is an anaerobe and most likely
Cohnistreptothrix cuniculi (Schmorl 1891), though
this is not certain.
C. fusiforme would now be classified in the genus
Fusiformis Hoelling 1910.
Also in 1912 Morse studied diphtheroids on the
same lines as those on which the Winslows so
successfully classified the CoccacecB. She did not
refer to Lehmann and Neumann's genus but
divided the Diphtheria Group of bacilli as follows: —
A. The Diphtheria subgroup : —
1. Virulent forms.
Bacillus diphtherice Loeffler 1884.
2. .\virulent forms.
These are distinguished by possessing a heavier
growth and less acid production than the virulent
forms.
B. Tli£ Hofmann Diphtheroid subgroup : —
The species belonging to this subgroup were
differentiated as follows :—
A. Colour of cultures salrtum pink :—
Very heavy growths — B. Iwagii Morse 1912.
B. Colour of cultures— white to yellow : —
1. Non-acid producers in carbohydrates, B.
}wfmanni Morse 1912.
2. Acid producers in carbohydrates : —
(a) Acidity in saccharose. B. exerosis
Kuschbert and Neisser, 1883.
(6) No acidity in saccharose, B. flavidui {
Morse 1912.
In the years 1916 and 1917 Mellon pubhshed
interesting accounts of an organism which was
recovered by puncture from a case of pulmonary
disease characterized, post-mortem, by fibrosis and
infiltration of the alveolar wall and chronic passive
congestion, and, ante-mortem, by clinical signs
resembling phthisis.
Tlie organism isolated was very pleomorphic and
April 15, 1920.] THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
presented a coccus and a bacillary diphtheroid. A
similar organism was described by Walker and
Adkinson in 1917. In 1918 Eberson demonstrated
that the coccus was antigenetically distinct from
the bacillary diphtheroid which is called C. enzymi-
cum (Mellon 1917).
In 1917 Buchanan, and later the Committee of
American Bacteriologists, dealt with the classifica-
tion of these forms in their papers and reports upon
the nomenclature and classification of bacteria.
In regard to the matter in hand we note that
they recognize Nagell's Schizomycetacea and
Schroeter's Eubacteriales (Eubacteria). The latter
however is not a new name, as they indicate, but
has been used by authors for years, e.g., see
Stevens (1913) '" Fungi which Cause Plant
Disease," p. 18.
They also recognize the family Mycobacteria cem
Chester 1897 as one of the families of the Eubac-
teriales and they give it the following genera : —
(1) Actinomyces Harz 1877.
(2) Nocardia Trevisan 1889.
(3) Mycobacterium Lehmann and Neumann 1896.
(4) Corynebacteriiim Lehmann and Neumann
1896.
(5) Fusiformis Hoelling 1910.
(6) Leptotrichia Trevisan 1879.
But to classify Actinomyces, Nocardia, and
Leptotrichia as bacteria is, in our opinion, a retro-
grade step.
We would therefore only recognize: —
(1) Mycobacterium Lehmann and Neumann
1896,
(2) Corynebacteriiim Lehmann and Neumann
1896,
(3) Fusiformis Hoelling 1910.
as named genera of the family, though it is obvious
that there is a need for more genera to be created
to cover tlie known varieties.
In 1918 Eberson inquired into diphtheroids in
general and classified them in Lehmann and Neu-
mann's genus Corynebacterium , the definition of
which he altered as follows: —
"Morphological resemblance to the diphtheria organism.
Gram-positive, non-motile, absence of spores, presence or
; absence of metachromatic granules, no gas production in carbo-
■ hydrate mediums."
In the genus so defined he recognizes the follow-
iiip groups of organisms which (slightly amended
n^ f(i names) is as follows: —
Group I. — Diphtheria. Type : C. dijihlliericc (Klebs
1883).
Species: C. pseudoiiphthericE Eberson iyi8.
Group ll.^Psetidodiphtheriticum. Type : C. pseudo-
diphtheriticum (v. Hofmann-Wellenhof 1883).
Species : C. ceruviinis (Graham Smith 1904)
and C. delicatum Eberson 1918.
Group in. ^Xerosis. Type: C. xerosis (Kuschbert and
and Neisser 1883).
Species : C. epidermidis Eberson 1918. C.
suppuratum Eberson 1918. C. auris
(Graham Smith 1904) and C. ctrebralis
Eberson 1918.
Group IV.— Nodosum. Type : C. nodosum (Lustgarten-
Mannaberg 1887).
Species : C. acidum Eberson 1918, C. ascites
Eberson 1918, C. flocculens Eberson 1918.
■ M
1
Group y.— Pigment -foiming diphtheroids. Type: C
hoagii (Morse 1912).
Species ; 6. aurantiacum Eberson 1913, C.
glanduke Eberson 1918, G. striatum (von
Besser) emendavit Chester 1901, C. segmen-
iosum Eberson 1918.
Group VI.— Gelatine liquefiers. Type : C. pittidum
Eberson 1918.
Group VII. — Anaerobes associated with specific clinical
manifestations. Type : C. typhiexantliematici
(Plotz 1915).
Species: C. acnes (Gilchrist 1901).
Group \ III. —Pyogenic diphtheroids in animals. Type ;
C. psettdotuberculosis (Preisz 1895).
Species : C. pyogenes Glage 1903, C. vaccince
(Galli-Valerio 1904).
Group IX.-- Anaerobic diphtheroids associated with diseased
lymph glands. Type : C. lymphophilus,
(Torrey 1916).
He rejects a number of organisms which used to be included
in the genus, for the following reasons : —
1. B. endocarditis griseus Weichselbaum, which is
motile.
2. B. erythematts Demme 1887, which forms spores.
3. B. epidermidis Bordoni-Uffreduzzi, which has
spores.
4. B. clavatus Flugge 1894, which is motile.
5. De Simoni's diphtheroid 1898, which has spores.
6. B. pseudodiphtJieriticus gmogents. which produces
gas.
B. Are synonyms of the names given in the groups : —
1. B. pseudodiphtheriticus alcalifaciens Kurth 1898,
which is the same as Hofmann's bacillus and
B. hofmanni Morse 1912.
2. B. septatus Gelpke, which is the same as the
xerosis bacillus.
3. B. retmlis bovis Enderlein 1891, which is Glage's
C. pyogenes.
4. B. strialus fiavus v. \ which are C. striatum
Besser I (von Besser) emen-
5. B. striatus albus \. Besser j davit Chester 1901.
6. B. diphtheroides Klein 1900, which is C.
pyogenes.
7. B. variabilis lympfue vacciyialis Levy and Fickler
1901, which is C. striatum.
8. B. diphtlieroides brevis Graham Smith 1904, which
is C. acidum.
9. B. diphtlieroides liquefacies Graham Smith 1904,
which is C. putidum.
C. U n recogni zable : —
B. pseudodiphtheriticus acidum faciens Kurth
1898 ; description incomplete.
C. }iodgkinii Billings and Rosenow 1913, as the
strains differ and are probably not connected with
the disease and represent more than one organism.
Sudan. — In regard to the history of Sudanese
diphtheroids, Balfour in the second report of these
laboratories gives a passing reference to the dis-
covery of the Klebs-Loeffier bacillus in typical
cases of diphthena in the Sudan where the disease
is called Lahada, wliich is rarely a name for
tonsillitis.
In the fourth report in Volume A. p. 239, he
contributes a valuable jjnper on " Diptheria in the
Tropics," in which he states that on several
occasions he has met with a coccal form of the
Klebs-Loeffler bacillus which when sub-cultured on
agar turns into a bacillary fonn though remaining
coccal on blood serum. One of his organisms was
tried on a guinea-pig which was not affected locally
or constitutionally thereby. The question of this
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [April 15, 1920.
mutation or pleomorphism in diphtheroids has been
ably studied by Ebersou on C. enzymicum (Mellon
1917). He excluded a symbiotic coccus from the
bacillary organism and then proceeded to demon-
strate that this latter organism, under certain
circumstances, could be made to assume a diplo-
coccal appearance. These diplococcal bodies were
demonstrated by Castellani's absorption method to
be antigenetically similar to the bacillary forms
and different from the symbiotic coccus.
This granule or diplococcal stage has been seen
by us from time to time (fig. 4) in the diphtheroids
with which we have worked and we can therefore
confirm the observations made by Balfour and by
Ebei-son. Further, we are of the opinion that these
may represent "an infective granule phase" and
may be the infective agent.
With regard to the xeroxis of the conjunctiva,
its existence in the Sudan has been described
recently by Archibald as already noted, but his
strains appears to us to be different from C. xerosis
(Kuschbert and Neisser 1883) in several respects,
and therefore we shall formulate a distinct name
for his organism.
It may perhaps be of interest to note that
Archibald's cases occurred in non-inflamed eyes,
while in one of those seen by us the initial inflam-
mation was so severe that the medical officer in
charge considered that, clinically, it resembled a
case of diphtheria of the conjunctiva. It was, how-
ever, very different from the case of true diphtheria
of the conjunctiva mentioned above, which was
infinitely more serious, but readily yielded to anti-
toxic treatment.
Tbe spore-bearing org.inisin, observed by Balfour as being
present along with tbe Klebs-LoefBer bacillus in a case of
diphtheria in the Sudan, has been studied in detail by
Lieutenant Smith, of the Canadian Medical Corps, working in
these laboratories.
Having reviewed the subject of diphtheroids as
far as the meagre hterature available to us in
Khartoum permits, we will now turn to the con-
sideration of our diphtheroid strains.
Sudan Strains: Strain I: Clinical Notes. — The
first case is from Khartoum North. It occurred in
a small native boy who suffered from fever asso-
ciated with the formation of a whitish membrane
on his tonsils. As the organism (fig. 5) found by
direct examination and in serum cultures resembled
the Klebs-Loeffler bacillus he was given diphtheria
antitoxin (8,000 units), but tliis did him neither
harm nor good, and under local and general treat-
ment his temperature fell gradually from 103° F. to
normal in five days, while the membrane also
gradually disappeared, but the tonsils still remained
large. Apart from his throat and the fever, the boy
was in good condition, and when the temperature
reached normal appeared to be quite well.
Two weeks after the commencement of the ill-
ness (the tonsils being still enlarged and his throat
congested) a swab was examined for bacilli, and
the same diphtheroid organism easily obtained in
pure growth.
Ten days later his tonsils had returned to normal.
but his throat remained congested. This time the
baciUi were only obtained in culture.
Fourteen days later, all local and general sym-
ptoms having disappeared, the same diphtheroids
were obtained by cultivation, but only by this
method.
A few days later they could not be found in
culture or in direct examination.
Organism. — Morphologically it, in general, re-
sembled the Klebs-Loeifler bacillus, as can be
judged by a study of fig. 5. Its length varied from
18 to 4-2 microns, and its breadth was about
04 microns.
The organism is therefore composed of rod-hke
forms, colouring well with the ordinary strains.
Gram-positive, not acid-fast, and with polar
granules. It is non-motile and does not form
spores, but gives rise to club forms in old cultures.
Culturally. — It grew aerobically at 37° C. and
at 22° C, but did not grow anaerobically.
On LoefHer's blood serum it gave a growth closely
resembling that of the Klebs-LoefBer organism. It
did not liquefy blood serum or gelatine. It did not
produce markedly coloured growths on blood serum.
Biochemically. — Its growth in carbohydrate
media produced acidity in some, but not in all,
the chemicals tested, but it never formed gas.
Qualitatively its carbohydrate reactions were as
follows : —
I. Monosaccharides : —
(a) Hexoses: It produced acid but no gas
in Glucose, Lcevulose (Fructose) and
Galactose.
(b) Pentose: It gave rise to acid but no
gas in Rhamnose (Isodulcite).
II. Disaccharides : —
It produces acidity without gas in Maltose,
Lactose and Saccharose.
III. Trisaccharide : —
It forms acid without gas in Raffinose.
IV. Polysaccharides: —
It ferments Dextrin and Inulin, but not
Amylum (starch) with the formation of
acid, but not gas.
V. Glucoside: —
It forms acidity in Salicin.
VI. Alcohols: —
(a) Trihydric: Glycerol, no change.
(h) Tetrahydric : Erythrol, no change.
(r) Pentahydric : Adonitol, no change.
(d) Hexahydric : Dulcitol and Maimitol acid
formation, but no gas.
For its quantitative reactions, see below.
With regard to other biochemical reactions, it
produced acid and clot in Milk and reduced I
Nitrates, but it did not produce Indol nor give the
Voges-Proskaucr reaction.
Animal Inoculations showed that it was avirulent
for guinea-pigs.
Strain II: Clinical Notes. — This strain was ob- [
tallied from a (ireek baby living in Port Sudan ou /
the Red Sea Littoral. It was noticed to have |
some difficulty in respiration, and on examination i
both tonsils were found to be enlarged and covered j
April 15. 1920.] THE JOUliNAL OF TEOPICAL MEDICINE AND HYGIENE.
with a greyish membrane. The fever never rose
above 99-2° F. during the whole illness, but the
child received 0,000 units of diphtheria antitoxin,
ixml in four days, the membrane having disappeared
from the tonsils, the child was considered to be
convalescent.
Organism. — The germ recovered from the swab
sent to the laboratory was morphologically similar
to the Klebs-Loeffler bacillus, as can be judged by
an examination of fig. 6. Its length varied from
1'5 to 2-8 microns, while its breadth was 0-4
microns.
It is therefore a rod -like organism colouring well
with ordinary stains, Gram-positive, but not acid-
fast and with polar granules. It is non-motile and
does not form spores.
Culturally. — It grew aerobically at 37° C. and at
22° C, but it was not tested anaerobically.
On LoefHer's blood serum it produced a growth
resembling that of the Klebs-Loeffler bacillus. It
did not liquefy blood serum or gelatine, and it did
not produce coloured growths on blood serum. It
was not tested on potato.
Biochemically. — Its growth in carbohydrate
media produced acidity in some, but not in all,
the chemical substances tested, but it never formed
gas.
Qualitatively its carbohydrate reactions were as
follows : —
I. Monosaccharides : —
(a) Hexoses : Acid but no gas was pro-
duced in Glucose, Lmvulose (Fruc-
tose) and Galactose.
(b) Pentose: No acid or gas formed in
Rhamnose .
II. Disaccharides : —
Acid without gas appeared in Maltose and
Lactose, but not in Saccharose, which
was unchanged.
///. Trisaccharide : —
There was neither acid nor gas in Raffinose.
IV. Polysaccharides : —
There was slight acidity, but no gas in
Dextrin, Inulin and Starch.
V. Gluc.oside: —
Acid, but no gas appeared in Salicin.
VI. Alcohols:—
(a) Trihydric: Glycerol, slight acidity only.
(h) Tetrahydric : Erythrol, no change.
(c) Pentahydric : Adonitol, no change.
(d) Hexahydric : Dulcitol and Mannitol, no
change.
For the quantitative figures of the acidity formed
ill these rcMgents, see the table given below.
In regard to other biochemical reactions it pro-
duced slight acidity and a deposit in Milk, but no
clof. It reduced Nitrates, but was negative in
rof^'ard to Indol formation and the Voges-Proshauer
rrnrtion.
Animal Inoculations proved that it was avinilent
to guinea-pigs.
Strain Til: Clinical No<e«.— This organism was
obtained from a small native boy living in Khar-
toum. He came to the hospital suffering from
fever and tonsillitis with small patches thereon.
He did not receive antitoxin, and rapidly recovered
under local treatment.
Organism. — Morphologically it, in general, re-
sembled the Klebs-Loeffler bacilhis, as may be
judged from a study of fig. 7. In length it varied
from 1'5 to 3'2 microns, and in breadth it was
about 0-4 micron. It was composed of small rod-
like forms. Gram-positive, but not acid-fast, and it
showed polar granules. It was non-motile and did
not form spores.
Culturally. — It grew aerobically at 37° C. and at
220 C. On LoefBer's blood serum it gave a growth
closely resembling the Klebs-Loeffler bacillus. It
did not hquefy blood serum or gelatine. It did not
produce markedly coloured growths on blood serum.
In broth there was a general turbidity. On gly-
cerine agar no pigment was produced, while on
potato it gave rise to dewdrop-like colonies, which
subsequently became white (fig. 8).
Biochemically. — Its growth produced acidity, but
no gas in certain carbohydrate media, as shown
below :^
I. Monosaccharides: —
(a) Hexoses : Acid without gas appeared in
Glucose, LcBVulose (Fructose) and
Galactose.
(b) Pentose: There was acidity without
gas formation in Rhamnose.
II. Disaccharides: —
It produced acidity, but no gas in Mal-
tose, Lactose and Saccharose.
III. Trisaccharide: —
There wag acid formation, but no gas in
Raffinose.
IV. Polysaccharide: —
It fermented Dextrin, Inulin and Starch
with formation of acid and no gas.
V. Glucoside: —
Acid without gas was produced in Salicin.
VI. Alcohols:—
(a) Trihydric : Glycerol, no change.
(b) Tetrahydric : Erythrol, no change.
(c) Pentahydric : Adonitol, no change.
(d) Hexahydric : Dulcitol and Mannitol
acidity, but no gas.
In regard to other biochemical reactions it pro-
duced acid and clot in Milk, reduced Nitrates, but
did not form either Indol nor give the Voges-
Proskauer reaction.
Animal Inoculations. — It was avinilent for
guinea-pigs.
Classification. — It is obvious that the three
organisms described above have much in common
and that Strains I and III are the same organism,
while they both differ in many respects from
Strain II.
They all belong to Linnseus's Class Fungace:r
because they are Thallophytes without chlorophyll
or chromatophores, and to Naegli's subclass
Schizomycetacea because the usual form of vegetnl
nucleus is absent, and because reproduction is by
fission.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15, 1920.
M0KOSACCHARIDI8
DlSAOCHtBIDXS
Trisac-
PcLVaAC-
Old-
—
Reagenis
1
3
1
1
1
3
1
1
1
^'1
5 1
1
Dextrln
Innlin
Amylun.
1
1
ill
Adonltol
Dulcltol
Mannltol
Remarks
Strain I
II
2-5
0-7
.3 0
3-2 1 1-6
I'll 1-2
1-8 1 1-5
2-3
00
0.3
2-8
1-6
2-8
IG 21
0-6 00
20 2-4
1-4
00
2-7
1-7 3-3 00
0-5 0-3 0-8
1-6 1-5 0-6
1 1
40
0-4
1-6
00 00
0-6 00
00 00
00 10-2 1-3
0-0 00 00
0-0 0-6 10
This resembles Strain III
Differa from I and III
This seems to be the same
as Strain I
The important differences are that I and III ferment Saccharose, RafRnose and Mannitol, which II does not, while it termsnts
Glycerol, which I and III do not.
Further, I and III produced acid and clot in milk, while II only produces acidity.
They must also be placed in Schroeter's order
Eabacteriales because they do not contain sulphur
or bacteriopurpurin.
As they are elongated cells which may be clavate
or irregular in shape and contain granules they
come into Chester's family Mycobacteriacece.
As our strains are not acid-fast and are not
obligatory anaerobes they come under the genus
Corynebacterium Lehmann and Neumann 1896.
It is now necessary to inquire into the modern
definition of this genus, which is as follows: —
Mycobacteriaceae. — Composed of Gram-positive
rod-like forms, not acid-fast, often with club-
shaped swellings at the poles, generally with
variously staining segments or granules, non-
motile, without endospore formation, growing
aerobically, but often capable of anaerobic culti-
vation, never forming gas in carbohydrate media
in which they may or may not produce acidity.
Type Species.
-Corynebacterium diphtherice
(Klebs 1883).
The genus so defined should be termed Coryne-
hacteriuni Lehmann and Neumann 1896 emen-
davit Eberson 1918, Chalmers and Macdonald
1919.
By this definition the following organisms which
came under the older definitions are now ex-
eluded : —
I. All Gram-negative forms of which the type
is Bacillus mallei Loeffler.
All true anaerobes of which B. typhi-
exanthematici Plotz is the type.
All foi-ms producing gas in carbohydrate
media of which the so-called B. pseudo-
diphthericus gazogenes .Tacobson 1908
may be the type.
Having excluded these forms we can divide.
" the genus Corynebacterinm sensij stricto into the
following groups: —
A. Gelatine liquefied: — (1) Piitidum Group.
B. Gelatine not liquefied : —
I. Pigment markedly
formed on blood
serum. (2) Hoagii Group.
II.
III.
II. Pigment not mark-
edly formed on
blood serum : —
(a) Acid produced
in glucose and
often in other
carbohydrates. (3) Klebs-Loeffler
Group,
(h) Acid not pro-
duced in glu-
cose or other
carbohydrates. (4) Hofmann-W ellen-
hof Group.
The first group has as its type species C. putidum
Eberson 1918 found in ascitic fluid, the second
has as its type C. hoagii (Morse 1912) and includes
the diphtheria-like bacilli found in turkeys by
Graham-Smith.
The von HofEman-Wellenhof Group has as its
type C. pseudodiphtheriticum (Hofmann-Wellenhof
1888) and includes the so-called Bacillus diphthe-
roides gallinarum named in 1904 by Graham-
Smith and often found in fowls in the Sudan. It
shoulil be named C. gallinarum. The xerosis
bacillus of dogs and guinea-pigs should also come
into this group and many other forms scattered
throughout bacteriological literature.
At the moment only Group 3, The Klebs-Loeffler
Group, concerns us because the Sudan diphthe-
roids obviously fall into this category.
We propose to divide this group into two sub-
groups as follows: —
Subgroup A: — Members of the Klebs-LoefHer
group morphologically resembhng C. diphiherice
(Klebs 1883).
Subgroup B: — Members of the Klebs-Loeffler
group moi-phologically unlike ('. diphtherice (Klebs
1883).
The various species known to us and belonging
to these two subgroups are as follows: —
(1) ('
Subgroup
diphtheria; (Klebs 1883).
(2) C. xerosis (Kuschbert and Neisser
(3) C. muris (Klein 1903).
(4) C. auris (Graham-Smith 1904).
April 15, 1910.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
91
(5) C. maculatum (Graham-Smitli 1904).
(6) C. emymicum (Mellon 1917).
(7) C. pseudodiphtherm (Eberson 1918).
(8) C. gordoni nomen novum.
(9) C. paragordoni nomen novum.
(10) ('. archihaldi nomen novum.
(11) C. siidanensis nomen novum.
Subgroup B.
(1) ('. nodosum (Lustgarten-M:»nnaberg 1887).
(2) C. epidermidis (Eberson 1918).
(3) C. flocculens (Eberson 1918).
(4) C. suppuratum (Eberson 1918).
(5) (.'. ascites (Eberson 1918).
(6) C. cerebralis (Eberson 1918).
(7) C. acidmn (Eberson 1918).
In the present communication we are only con-
cerned with the first subgroup, whii'li we now
proceed to define.
Subgroup A.
Definition : A Coryneliacteriinn is said to
niorphologicall.v resemble C. diphtherix when it is
in the fomn of slightly curved or nearly straight
rods varying in length but generally thin, usually
with granules or bands when stained but may be
coloured unifoimly, usually with rounded ends and
often arranged in a palisade.
Type: The type is C. diphtheria: (Klebs 1883)
which we will proceed to define together with the
other members of this subgroup.
(1) C. diphtheria; (Klebs 1883) : Corynebar-
teriuni capable of growing below 25° C.
Producing rounded raised translucent
greyish white or very slightly yellowish,
discrete colonies in twelve to twenty-four
hours on Loeffler's blood serum, which is
not liquefied. Forming on potato a thin
dry or hardly perceptible whitish growth.
Producing acidity in glucose, leevulose,
galactose, maltose, dextrin and glycerol
but not in saccharose or mannitol. In
regard to larctose there appear to be strains
which do, and others which do not, pro-
duce acidity in this sugar. In regard to
glucosides, its action therein does not
appear to have been studied fully. Gives
rise to acidity without clot in milk.
Virulent for guinea-pigs with death in
three to four days with characteristic
lesions. Produces toxins.
Originally found in diphtheritic lesions.
(2) C. xerosis (Kuschbert and Neisser 1883):
Synonym li. scptatum Gelpke. Corynr-
bacterium incapable of growing below
25° C. Growing on blood serum more
slowly than C. diphtherice. Producing on
potato an invisible film. Forming acid in
glucose, laevulose, galactose, maltose and
saccharose but forming no acid in lactose,
dextrin or mannitol. Reaction in milk
unknown to us.
Avirulent for guinea-pigs and incapable
of reproducing its associated lesions in
the eyes of animals.
Originally found in eyes attacked with
xerosis of the conjunctiva but can occur
in normal eyes.
(3) C. muris (Klein 1903): Corynebacteriuni
with its capability of growth below 25° C.
unknown. Growing on blood seiiim like
('. diphthericB and producing no visible
growth on potato. Producing acidity in
glucose, but action on other carbohydrate
media unknown.
Virulent for guiaiea-pigs.
Originally found in diseased mice and
rats.
(4) C. auris (Graham- Smith 1904), synonym :
B. Tuedigeri (Mellon 1917), and also
Hamilton's strains. Corynebacteriuni
capable of growing below 25° C. On
blood serum resembling C. diphtherite but
of slower growth. On potato producing a
iirownish-yellow growth. Gives rise to
acidity in glucose and maltose but not in
saccharose. Milk unchanged.
Virulent for guinea-pigs.
Originally found in cases of otitis.
(.")) ('. maculatum (Graham-Smith 1904):
Corynebacteriuni capable of growing be-
low 25° C. On blood sennn producing in
twenty-four hours opaque white colonies
othenvise similar to C. diphtherice. No
visible growth on potato. Glucose is
rendered faintly acid. Milk is unchanged.
Avirulent to guinea-pigs.
Originally found in the throat of a
possible diphtheritic contact.
(6) C. enzymicum (Mellon 1917) emendavit
Eberson 1918. This is the bacillary form
only. Corynehacicrivm capable of growing
below 25° C. On blood-agar producing
very fine transparent colonies in twenty-
four to forty-eight hours which became
translucent or gray. No growth on potato.
Acidity in glucose, maltose, lactose,
saccharose, dextrin, inulin and glycerol.
Milk acid and clot.
Virulent for guinea-pigs.
Originally obtained from a case of
fibrosis of the lung.
(7) C. pseudodiphtherix (Eberson 1918):
Synonym pseudodiphtheiria bacillus of
Loeffler 1887. Corynebacteriuni capable
of growing below 25° C. and resembling
C. diphtherix in all particulars except
avirulence for guinea-pigs and the non-
production of toxins.
Originally isolated from hypertrophied
tonsils.
Remarks: As this definition stands
one must accept the possibility of a lactose
femienting strain and of another incapable
of acting in this manner. Our Strain II
92
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15. 1920.
closely agrees with the definition of an
avirulent lactose fermenting strain. It
grows below 25° C. On LoefHer's blood
serum it produces a growth resembling C.
diphtheria;. It was unfortunately not
tested on potato. It produces acidity in
glucose, laevulose, galactose, maltose, lac-
tose, dextrin, and glycerol, but not in
saccharose and mannitol. It is true that
it forms acid in inuhn, starch and salicin
but we have been unable to find the
result of the action of the Klebs-Loeffier
organism on polysaccharides and glucosides
in the literature available to us in
Khartoum.
It gives rise to acidity without clotting
in milk. It was found in a case of tonsil-
litis associated with the formation of a
membrane.
It may be a variety of corynebacterium
distinct from C. pseudodiphthcricB but it
so closely resembles what is known of this
organism that we prefer to consider it to
be the same variety at present.
(8) C. gordoni nomen novum : Corynehac-
icrium incapable of growing below 25° C.
Growth on blood serum good in eighteen
hours and very coherent. Growth on
potato unknown. Acidity produced in
glucose. Milk remains unchanged.
Avirulent.
Originally found in the throat.
(9) C. paragordoni nomen novum : Coryne-
bacteriiim incapable of growing below
25° C. Producing gray, sharplj- outlined,
coherent colonies on blood serum. Growth
on potato unknown. Acidity produced in
glucose. In milk forms acid and clot.
Avirulent.
Originally found in the throat.
(10) C. archibaldi nomen novum: Corynebac-
terium incapable of growing below 25° C.
Producing on blood serum growths re-
sembling those of C. diphtheria: but very
coherent. Growing on potato in the form
of a fine almost invisible growth. Pro-
ducing aciditj' in galactose, malto.se and
lactose but not in glucose, laevulose,
saccharose, dextrin or mannitol. Forming
acid without a clot in milk.
Avirulent for guinea-pigs but can repro-
duce its lesions in the eyes of rabbits.
Originally found in cases of epithelial
xerosis of the conjunctiva in the Anglo-
Egyptian Sudan.
Remarks : This is the organism found
by Archibald and subsequently by our-
selves as mentioned in the introductory
and historical sections of this note.
(11) C. sudanensis nomen novum: Corynebac-
terium capable of growing below 25° C.
Producing on Loeffler's blood serum
colonies closely resembling those of C.
diphfheri.T. On potato fonning dew-drop
DIAGNOSTIC TABLE.
Genus Corynebacterium Lehmann and Neumann 1896 sensO stricto.
Group 3. The Klebs-Loeffler Group.
Subgroup A. Diphtheriae.
Culture below 25° C.
Growth
1 Viru
Guinea-pigs Diphtheri
Unknown
lent for guinea
i antitoxin non
7. Muris
1
Acid
1
No growth
-protective Blood serum
1
Growth resembles
C. diphtheria
8. Xerosu
1
Virulent
Potato
1
1
Avir
M
ilent
Ik
1
Growth
unlike C.
iiphtlieria
Milk
1
Invisible Brownish
growth yellow
1. Diphtheria 2. Anns
growth
3. Emymicum
Acidity
No change
11. Gordcmi
No change
i. Maculatum
Without clot
9. Archibaldi
1
With clot
10. Paragordoni
Without clot
No acidity in Saccharos
or Mannitol
5. Pseudodiphtherice
e
1
With clot
Acidity in SaccbaroEc
and Mannitol
6. SudancTisis
!
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1920.
-:-v#- v..
F,g. 5.
^'9-
To illustrate paper, " Some Sudanese Diphtheroii-;," by Albert J. Chalmers, M.D., F.R.C.S., D.P.H., and Norman Macdonald.
April 15, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
colonies which become white. Giving rise
to acidity in glucose, laevulose, galactose,
iliamnose, salioin, dulcitol and mannitol,
but not in glycerol, erythrol or adonitol.
A virulent for guinea-pigs.
OriginaUy found in inflamed tonsils in
the Anglo-Egyptian Sudan.
Reina-rks: This variety is created for
the forms described above as Strains I
and ITT, the similaHty of which to one
another has already been pointed out.
Having now completed the definitions of the
organisms known to us, which we have classified
under Subgroup A, we will give a differential
diagnostic table which enables them to be easily
differentiated from one another.
Summary : We have endeavoured in this com-
munication to aid the diagnosis of true diphtheria
in the Tropics by drawing attention to a number
of diphtheroids which, more or less, morphologically
resemble the Klebs-Loeffler organism, i.e., Coryne-
bacterium diphtherice (Klebs 1883).
(2) We have sorted these diphtheroids into those
which belong to Chester's Mycobacteriacex and
those which do not; and again into those which
belong to Lehmann and Neumann's genus Coryne-
bacterium sensu stricto and those which do not.
(3) We have divided the forms included under
this generic name into four groups of which the
third is the Klebs-Loeffler group.
(4) This group we have subdivided into two sub-
groups of which one contains foi-ms morphologically
resembling the Klebs-Ijoeffler bacillus and we have
defined what we mean by the term " morpho-
logically resembling."
(5) Into this group we have brought eleven
organisms of which seven have been previously
named, three have been previously described but
not named, and one which is entirely new. AU
these forms we have defined to the best of our
ability.
(6) We have brought forward a scheme whereby
these eleven forms may be recognized from one
another.
(7) We . have demonstrated the presence of
Corynebacterium pseudodiphtherice Eberson 1918
in the Sudan and also of a new organism to which
we give the name Corynebacteriuvt sudanensis
Chalmers and Macdonald 1919. We have also
pointed out that the xerosis bacillus described by
Archibald and subsequently found by us is different
from Knschbert and Neifiser's organism and have
named it C. archibaldi.
Acknoiolcdgmcnts : We desire, gratefully, to
acknowledge kindness received during the prepara-
tion of this note from Major Archibald, D.S.O.,
E.A.M.C, Dr. Malouf of Khartoum, and Dr.
Soghayer of Khartoum North.
Addendum.
In order to complete the differentiation of the
organisms known to us which belong to the genus
CorynebacteriuTn as defined above we add a
diagnostic table of the forms already mentioned as
belonging to Subgroup B.
REFERENCES.
American Bactebioloqists (1917). Journal of Bacteriology,
vol. ii, p. 505. Baltimore.
Archibald (1919). Journal op Tropical Medicine and
Hygiene, May 1. London.
Abkwbiqht (1910). British Medical Journal, ii, Novem-
ber 12. London.
Balfour (1911). "Fourth Report Wellcome Tropical
Research Laboratories," p. 237. London.
Buchanan (1917). Jouriial of Bacteriology, vol. ii, pp. 155
and 347. Baltimore.
Castellani (1904). Journal of Tropical Medicine and
Hygiene, vol. vii. May 2. London.
Castellani and Chalmers (1919). " Manual of Tropical
Medicine," 3rd edition, p. 963. London.
Chester (1897). "Annual Report Delaware College
Agricultural Experimental Station," vol. ix, p. 02. (Classifica-
tion of Schizomycetes.) Delaware.
Chester (1901). "Determinative Bacteriology," p. 349.
New York.
Eberson (1918). Journal of Infectious Diseases, vol. xxiii,
p. 1. Chicago.
Hofman-Wellenhof (1838). Wiener meditinische Wochen-
schriit. xxxviii, pp. 65 100. Vienna.
Lehmann and Neumann (1896). " Bakteriologie," i, p. 350.
Miinchen.
Lehmann and Neumann (1912). i, p. 546. Muncben.
Genus GorynehacteriHm Lehmann and Neumann 1896 sensA stricto.
Group 3. Diphtheriae.
Subgroup B. Nodosum.
Cultivation below 25 G.
Growth slight
i
Ijactose
1
1
No acidity
Mannitol
1
1 "1
No acidity Acid
Suppuratum 6. Asc
Growth abundant
Lactose
No acidity Acidity
1 3. Fhcculens
Saccharose
1
ty
ites
6
1
Acidit:y
ManLitol
1
1 1
Acidity No acidity
Nodosum 2. Epidermidis i.
No acidity
Cerebrals
7.
lidity
THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15, 1920.
LoEFFLEB (1884). Mitteilungen aus der Kaiserlichen
Qesundheitsamte, vol. ii, p. 451. Berlin.
LoEFFLBB (1887). Cmtralblatl fUr Bakteriologie, vol. ii.
p. 105. Jena.
MiMDBLBiOM and HEiNEMiN (1910). Centralblatt fiir
BahUriologie, Bd. 5, a. 53. Jena.
Mellon (1917). Journal of Bacteriology, vol. ii, p. 81.
Baltimore.
MoBSE (1912). Journal of Infectious Diseases, vol. xi, p. 253.
Chicago.
NoTTALL and Gbaham Smith (1913). "The Bacteriology of
Diphtheria." (A most valuable work Vfith full references).
Cambridge.
ILLUSTRATIONS.
Fig. 1. — Nocardia sp. ? from a culture obtained from the
throat of a native of the Sudan. Stained by Neisser's method.
Note the resemblance to a diphtheroid. Photomicrograph.
X 800 diameters.
Fio. 2. — Stereoscopic photograph of a native of the Sudan
sufiering from conjunctivitis and xerosis. Note the white
patch in the eye, and the watery exudation escaping from the
inner canthus. These photographs can be removed from the
plate by cutting along the line AA, and are arranged for the
ordinary stereoscope. Photographs. Reduced.
Fig. 3.—Corynebacierium archibaldi Chalmers and
Macdonald 1919. Direct amear from the conjunctiva stained
by Gram's method. Photomicrograph, x 1,000 diameters.
Fio. i.—Corynebacterium sudanensis Chalmers and
Macdonald 1919. Strain I. Direct smear showing Balfour's
granules. Photomicrograph, x 1,000 diameters.
Fig. 6.—Corynebacterium sudanensis. Strain I. Diph-
theroids from a culture on Loeffler's blood serum stained
with tolnidin blue. Photomicrograph. x 1,600 diameters.
Fig. f,.—Coryneb<icterium pseudodivhtlierice Eberson 1918.
Strain II. Diphtheroids from a culture on Loeffler's blood
serum. Stained by Neisser's method. Photomicrograph.
X 1,600 diameters.
Fig. 7. — Corynebacterium sudanensis. Strain III. Diph-
theroids from a culture on Loeffler's blood serum stained by
toluidin blue. Photomicrograph, x 1,600 diameters.
Fig. B. — Corynebacterium sudanensis. Strain III. Diph-
theroids. Culture on potato for nine days at 37" C. Photo-
graph, X 4 diameters.
|l0tUIS.
study on the Diffusibility of the Virus of Rabies
(Jlemlinger, P., in the Annales de L'Institut Pas-
teur, vol. xxxiii, No. 1, pp. 28-52, -f 3 tables, -f
plates. Paris, January, 1919). — The author, after
relating his experiments on the diffusibility of the
rabies virus, notes that this possesses a group of
pro{>erties whose presence together isi paradoxical :
at the same time filtrable, diffusible and capable
of reproducing itself, it should apparently be con-
sidered as intermediary between the visible micro-
organisms that are the lower limits of the plant
world and the diastasesi, coUoidal substances which
■are at the upper limits of unorganized bodies. He
suggests the hypothesis that forcing the virus to
pass through the pores of a very fine porcelain filter
BufSoes to produce such a modification in its con-
stitution as to lose the property of reproducing the
disease, without its other properties being altered.
This procedure probably transformsi the ultra micro-
ecopic organism which produces rabies into a
colloid. The rabic toxin would thus be a sort of
allotropio state of the organism. The author states
that this is apparently applicable to otlier so-called
invisrible " or " ultra-microscopic " organisms and
" filtrable virusee."
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THE JOURNAL OP
Cropical Medicine anD l^pgiene
April 15, 1920.
DEATH OF DR. ALBERT JOHN CHALMERS.
It is our sad duty to record the death of Dr.
A. J. Chalmers at Calcutta. A telegram reached
London as we were going to press that he was
dead, no previous warning of illness having been
received. The shock to his many professional
^
April 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
95
friends and intimate acquaintances was intense,
and throughout the world of tropical medicine the
irreparable loss will be keenly felt. Dr. Chalmers
was actually on his way home from the Sudan,
where for many years he worked so assiduously as
the Director of the Wellcome Tropical Research
Laboratories in Khartoum, He had already resigned
his post as Director of these laboratories, where, as
successor to Dr. Andrew Balfour, he bad carried
on and maintained the high standard of work set
him by his famous predecessor. Only a few weeks
ago the writer received a letter from Dr. Chalmers,
in which he sketched his plan of study for tlie
twelve months commencing March, 1920. He
ij regarded this as a year's holiday. But a holiday
to one of Dr Chalmers's temperament meant free-
( dom to follow his bent in that field of research
[I and study which most fascinated him, and one
I along which tropical medicine would be best served
ji and advanced.
I] From Khartoum to Calcutta was not a change
li which a medical practitioner would advise for a
I man already run down in health and strength from
II close and unremitting study in a Khartoum labora-
|: tory. But with Dr. Chalmers neither climate nor
!i work counted; work was his pleasure and the study
1 of disease had become a passion with him. The
!il telegraphic news of his illness and death, which is
/| all we have yet received, briefly state that his ill-
' ness was sudden and the cause of his death was an
•; acute infective hepatitis.
Bom in 1870, he had but reached his fiftieth
. I year, when in the heyday of knowledge, enthu-
fi siasm and reputation he passed away. His parents
/hailed from Aberdeenshire, he was a " child of the
manse "; his father was the late Rev. James Chal-
mers, M.A., Aberdeen, and his mother was a
daughter of the late Captain Martin, of Peterhead.
Their son saw the light of day at Manchester; he
was educated at the Manchester Grammar School,
and subsequently at the University Colleges of
Liverpool and London. He graduated in medicine
I with distinction at the Victoria University, Man-
ichester, in 1893; became an F.R.C.S.Eng. in 1895,
land subsequently was granted the M.D.Liverpool
'in 1905, and took the D. P. H.Cambridge in the
'Isame year. He joined the Colonial Civil Service,
i jand whilst on the West Coast of Africa he served in
i 11900 with the Ashanti Field Force, for which he
jwas mentioned in despatches and granted the medal
Hnd clasp. In Ce.ylon he joined the Volunteer
Medical Corps, in which he held the rank of major,
and came to London in 1911 with the Ceylon Coro-
nation contingent.
In Ceylon he became acquainted with Dr. Aldo
Hstellani, and from this auspicious meeting sprang
III intimate co-operation in work and thought which
; i\o us that storehouse of knowledge, namely, the
' Manual of Tropical Medicine." This meeting of
iien, each endowed with genius of a high order in
'aried and various fields of research, in the practice
if medicine and in literary and scientific ability,
lore the happiest results. The attachment of the
two men was as that of brothers, for the writer has
had it from the lips of both that they never had
even a disagreement, and each declared to the
writer in private that he regarded the other as a
brother. Each recognized the other's worth and
jealousy was, as it ever is amongst really great men,
unknown.
In Ceylon Dr. Chalmers held the official position
of Lecturer on Pathology and Animal Parasitology
in the Medical College of Colombo, and did much
to maintain and improve the status of the Colle.ge
in which he taught.
When Dr. Andrew Balfour left Khartoum, where
for years he had, as Director of the Wellcome
Tropical Research Laboratories, established a world-
wide fame for these laboratories and for himself,
Dr. Chalmers was chosen as his successor. Much
speculation in the scientific world was afoot, when
it was known that he (Dr. Balfour) was about to
retire from Khartoum to become Director-in-Chief
Wellcome Bureau of Scientific Research in London,
as to who would be his successor. The men worthy
of such a distinction could be counted on the fingers
of one hand, but two wise heads such as H. S.
Wellcome, Esq., and Dr. Balfour were not likely to
make a mistake and Dr. Chalmers was selected.
As they honoured him so did he justify their
wisdom, for never was a trust more nobly or more
brillia,ntly fulfilled. The spirit of the great Gordon
it would seem hovers around the College in Khar-
toum which bears his name, and generates in men
the self-sacrifice, the devotion and the ennobling
qualities which have rendered Gordon's name
immortal amongst men. Balfour and Chalmers
have each trod the paths along which Gordon
attained reverence and fame, and we respect and
cherish them accordingly.
In this appreciation let us not forget the man
who founded the institution in which Balfour and
Chalmers have had their opportunities and won
their fame. It was a fortunate day for the Sudan
and for science that Mr H. S. Wellcome made his
way to Khartoum. The founder of the great com-
mercial house with which his name is associated is
endowed with a mind and spirit far in advance of
the daily commercial task which is the portion of
most men. His researches in regard to the phar-
macology and medical art of the Ancients in many
countries le<^l him to the cradle of medicine, namely
Egypt; and he followed his inquiries far beyond
Lower Egypt to Upper Egypt and the Sudan.
There, no doubt as a tribute to the magic
influence of Gordon's spirit, as well as his innate
desire to forward the science of tropical medicine,
and perhaps as an appreciation of the country
of his adoption for the welcome it had extended
to him, he founded and endowed the Well-
come Research Laboratories in Gordon's Col-
lege, Khartoum. The men he chose as directors
were of the highest order and the Sudan and the
scientific world generally have benefited to an in-
calculable degree. The same is to be said of the
more recently formed Wellcome Bureau of Scien-
96
THE JOURNAL OF TKOPICAL MEDICINE AND HYGIENE. [April 15, 1920
tific Research in London; both are a monument to
Mr. H. S. Wellcome and we thank him for the
encouragement he has given to tropical medical
research, and for granting men of the highest scien-
tific attainments opportunities of study which would
have been denied to them otherwise and the world
would have been the loser in consequence. He has
cherished and encouraged such men as Balfour,
Chalmers, Wenyon, Sambon and many others who
have served to place the tropical researches of
Britain on the highest pinnacle of fame. The work
of Dr. Chalmers in the Sudan has been of the most
advanced order; original, important, and convincing
in its thoroughness, he has left a record which is
at once marvellous in its scope and in its quality.
He is cut off at an age which was maturing towards
full fruition and by his death we are deprived of
the full benefits which his powers of observation
and research justified us in hoping for and expect-
ing. He had many projects sketched out for his
future work, each of them of wide interest and
culculat-ed to benefit mankind in the fight against
disease. We can only regret he was not spared to
science, but his example will inspire others as it
has already inspired and attracted other observers
to his laboratories in Khartoum. His many pub-
lished papers in conjunction with associates in his
laboratory shows that he helped and encouraged
them, nor sought to detract from the work done by
them in the laboratory by publishing the papers in
his own name, as many a man of lesser attain-
ments might have been tempt-ed to do.
The Journal of Tropical Medicine and Hygiene
has had the honour and privilege of publishing
many of his papers. He has been a loyal sup-
porter of the journal and greatly added to its
reputation and circulation. The writer hoped
that when he came to settle in London he would
take up the editorship of the journal which he has
benefited to so great an extent; but from this, as
in the larger field of science and research. Dr.
Chalmers has passed away, regretted by friends,
mourned as an irremediable loss to the world of
science, loved by all who knew him for his sterling
qualities. We extend our sympathy to his widow
— his constant companion who dared the climates
of many countries with untoward reputations, and
who by her care and wisdom staved off the effects
of many ailments from a husband whose memory
we will cherish and whose qualities we respect and
Treatment of Influenza Pneiimonia by Serum from
Convalescent Patients (R. Redden, Boston Med.
and Surg. Journ., December 11, 1919). — From an
experience in the treatment of over 250 cases of in-
fluenza pneumonia by the use of pooled serum from
convalescent patients, the author concludes that
both in hospital and private practice the course of
the disease is shortened, the death-rate halved in
serious eases, and reduced three-fourths in hospital
cases seen early.
Annotations.
Malaria Hemiplegia in an Infant (Spolverini,
II PolicUnico, December 21, 1919).— The author
reports a case of Jiemiplegia in an infant. Tlie
microscopical examination of tlie blood revealed
presence of malaria parasites, and quinine cured
the condition.
Acetonuria from Fatigue (Azzi, Eiforma Medica,
November 8, 1919). — The author has noted a large
increase in the elimination of acetone bodies after
taking severe exertion. He carried out the experi-
ments on himself during a period of mountain
climbing. The severe acetonuria persisted as long
as the sensation of fatigue was present ; it dis-
appeared as soon as he felt quite rested.
Emetine Urticaria (Savignac, Paris Medical,
January 10, 1920). — The author describes a case of
urticarial eruption recurring in a dysenteric patient
after each course of emetine injections. The pomphi
at first appeared in the region of the injections, but
later the eruption became general. The urine was
found to contain emetine up to three months after
the last injection.
A Polyvalent Vaccine in the Treatment of
Bacillary Dysentery in East Africa (W. H.
Kauntze, Journal of Hygiene, February, 1920). —
Dysentery was the principal cause of mortality
and invaliding amongst the porters of the MUitary
Labour Bureau in the early days of the East African
Campaign. At first the general opinion was that
the disease was of the amcebic type, but Dr. Pirie,
Government Pathologist at Nairobi, clearly demon-
strated that the great majority of the cases were of
bacterial origin. The author confirmed Dr. Pirie's
observations, and suggested preparing a curative
vaccine which was sterilized by adding 0"4 per cent,
carbolic acid and not by heat, in order to diminish
its toxicity. The earliest vaccine tried was a mix-
ture of B. shiga and B. flexner in equal parts, and
the initial dose was 5 million, but later the vaccine
was made more polyvalent, consisting of Shiga
three strains, Flexner two strains, and Morgan
three strains. The results were on the whole ex-
tremely satisfactory.
[Vaccines in the treatment of dysentery were
used first in 1906 by Greig and Castellani, the
latter observer being the first to sterilize sucli
vaccines by adding 0-5 per cent, carbolic ri<'icl with-
out heating.]
Unusual Forms of Dysentery (George C. T^ow,
British Medical Journal, I'Vl)'niary 21, 1920).—
The author des<;nhes several interesting cases of
dysenteric diarrhd'a of nruisual f)rigin. In one of
the cases a sypliilitic itifcctinn was Mie cause of the
April 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
condition, in another tubercular infection. Several
oases are quoted of schistosomiasis dysentery.
Dysenteric symptoms may also be caused by
Paragonimus wesilermanii, Heterophyes hetero-
phyes and by Ankylostoina duodenalis.
Tetany in a Cane of Sprue (A. L. Barach and
H. A. Murray, Journ. of the Amer. Med. Associa-
tion, vol. Ixxiv, No. 12, March 20, 1920).— The
authors describe an interesting case of sprue with
tetany. The upper extremities were spastic,
ckawn up, and flexed at the elbows, flexed and
rotated outwards at the wrists. The fingers were
flexed at the metacarpophalangeal joints, and the
interplialangeal joints were extended. The lower
extremities were also spastic, with flexion at the
knee and extension at the ankles. A very complete
analysis of the blood showed a decrease in the
calcium concentration of the serum, but calcium
lactate infusions did not relieve the condition. The
case ended fatally.
Ulceratiny Grnniiloma of Pudenda (H. Goodman,
Archives of Dermatology and Hyphilology , Chicago,
Februai-y, 1920). — The author reports four cases of
the condition, in three of whicli Calimatobacterium
granulomatis was demonstrated. In the fourth
case spirochsetes were found. Mercury and sal-
varsan were ineffective. Antimony was not given
for a sufficiently long time to enable one to come
to any definite conclusion as regards its efficacy.
Fat-soluble Vitarnine Content of Green Plant
Tissues (H. Steenbock and E. G. Gross, Journal
of Biological Chemistry, February, 1920). — Accord-
ing to the authors' interesting experiments, it would
appear that of the {)lant structures the leaves an;
usually richest in the fat-soluble vitamine, while
the roots contain it in lesser amount, and the grains
in the least.
Thermostability of Fat-soluble Vitamines in
Plant Materials (H. Steenbock and E. W.
Boutwell, Journal of Biological Chemistry, Feb-
ruary, 1920). — The authors' investigation shows
that autoclaving for three hours at 15 lb. pressure
does not destroy the fat-soluble vitamines found in
yellow maize, caiTots and sweet potatoes. The
fat-soluble vitamine as found in plants is therefore
comparatively thermostable.
Tlie Antagonism between Epinephrin and
Quinine. — Drs. A. Olerc and G. I'ezzi recently com-
numicated to the Academic des Sciences the results
of their researches, which go to pr'Ar tli.if. there is
an antagonism between the action nf .piinine and
that of epinephrin, but that nevertheless there is
no absolute opposition in the different modes of
action of the two substances. There is complete
antagonism in the cells of the bulbar centre of the
pneumogastric nerve, for epinephrin stimulates and
quinine paralyses tSis nerve. There is also
antagonism with respect to cardiac action, epine-
phrin having a stimulating and accelerative effect
and quinine acting as an inhibitor and depressant.
Tihere is even antagonism in regard to arterial
pressure ; epinephrin produces hypertension and
quinine hypotension. But epinephrin causes hyper-
tension by a cardiac and vascular action combined,
whereas quinine produces 'hypotension by over-
coming the vasoconstrictive action common to the
two substances, although in a different degree.
Even allowing for the vasoconstrictive mode of
action which is common to the two substances, the
antagonism between them is nevertheless note-
worthy. While epinephrin acts as a stimulant of
the sympathetic nervous system, quinine must be
accorded a sedative action, which makes possible
new therapeutic applications.
Mouse Oxyuride, Syphacia Onvelata in Man. —
W. A. Riley {Journ. Parasitology, December) found
in the faeces of an American-Bohemian child,
one of a family of five, aid of whom were heavily
infested by the worm. The .food of the child and
of otliers of the family 'had been grossly con-
taminated by mice or irats. This accounts for the
infestation by one of the commonest nematode
parasites of these rodents. Incidentally, it fur-
nishes circumstantial evidence in favour of the
view that Hymenolepis nana of man and Hymeno-
lepis murina of rodents are one and the same.
Sanitary Victory over Yellow Fever. — The epi-
demic which began about the middle of last year,
in the northern part of Peru, has just been officially
declared as having come to an end. An active
sanitary campaign, directed at first by Mr. H.
Hanson and afterwards by Drs. Gastiaburu, Quirds
and Almenara, deserves the credit for its eradica-
tion. Some interesting studies have been made
about Leptospira icteroides, which may throw new
light on the etiology of this disease. Cultures of
Leptospira icteroides have been made at the
hygienic laboratory of Lima. The number of cases
during the epidemic amounted to more than 200,
with a mortality rate of 40 per cent.
Filariasis {Journ. Amcr. Med. Assoc, February
7). — R. G. Lee (Cronica rned.-quir. de la Ilabana
44:15 [January] 1918) reported excellent results in
eighteen cases of filarial hematuria treated with
potassium iodide. Ijconaa'd Rogers {Lancet, 2:604
[OctobeJ- 4] 1919) found repeated injections of safe
doses of sodium antimonyl tartrate, 1 :50 solution,
produced diminution of filai-ial embryos in the
peripheral blood. Jeanselme {Bull. Acad, de med.
81:156 [February 4] 1919) and Deschamps {Bull.
Acad, de med. 81:655 [May 20] 1919) have re-
THE JOUENAL OF TBOPIGAL MEDICINE AND HYGIENE. [April 15, 1920.
ported radical cures after intravenous injections of
arsphenamin. Special treatment will naturally
depend on the manifestations in a given case.
Lymphangitis with fever requires rest, elevation of
the affected part, ice or cooling lotions or warm
fomentations locally, opium or morphine when
necessary to relieve pain, mild aperients, and if
tension is great, pricking or scarifying of the
swollen area. Lymph scrotum sihould be kept
scrupulously clean, powdered, suspended and pro-
tected against irritation or injury. Chyluria
demands absolute rest, elevation of pelvis, restric-
tion of fluid and food — -especially fats — and gentle
purgation. In elephantiasis of extremities, elastic
bandages, massage and eJevation of the part are
indicated. Any or all of these conditions niay
necessitate surgical interference for the relief of
an incapacitating amount of discomfort or frequent
inflammatory attacks with fever. References:
Manson, Sir Patricak : " Tropical Diseases," Ed. 5,
pp. xxiv + 937, New York, William Wood and Co.,
1914. Castellani, Aldo, and Chalmers, A. J. :
" Manual of Tropical Medicine," Ed. 2, New York,
William Wood and Co, 1913. Stitt, E. R. : " The
Diagnosis and Treatment of Tropical Diseases,"
Ed. 2, pp. xiii + 534, Philadelphia, P. Blakiston's
«on and Co., 1917.
Typlnis Fever. — In Esthonia 15,000 cases have
been reported. In eastern Galicia there are more
thaJi 100,000 cases of the disease, with a mortality
of about 10 per cent. At Reval there are 4,600
cases of typlius among Russian soldiers at Narva,
3,500 cases at Wesenberg, and 2,000 cases at
Ziegelkoppel.
TuK Journal of the Royal Army Medical Corps.
Vol. XXXIV, No. 3, March, 1920.
Dysentery and Enteric Disease in Mesopotamia
from the Laboratory Standpoint (J. C. G. Leding-
ham). — For laboratory purposes, dysentery and
dian-hoea cases were divided into two groups accord-
ing to the naked-eye and microscopical appearances
of the motion, viz. : (1) B. and M. grouj) (i.e., blood
and mucus), and (2) non-B. and M. group. Tlie
laboratory returns for the month yielded the per-
centage figure for the presence of E. histolytica in
B. and M. cases and non-B. and M. cases, and
also for the successful isolation of Bacillus dysen-
teric in cases submitted to cultural examination.
The author's view is that in an epidemic season .
practically all the non-amoebic acute dysenteries
may fairly accurately be regarded as bacillary.
The test of the predominance of B. dysenterix
during an epidemic period must be a fall in the
percentage of E. histolytica from that reached in
the month prior to the epidemic. If the amoebic
percentage falls the excess of cases must be due to
bacillary infections. If the amcebic percentage
remains fairly constant or even rises somewhat, the
epidemic may be considered as the resultant of two
forces, one of which, however, will always be more
prominent than the other, in view of the fact that
E. histolytica precentages in B. and M. cases have
only in exceptional circumstances exceeded 50 per
cent.
An Anti-malaria Campaign in Palestine (E. P.
SewelJ and A. S. M. Macgregor). — The authors
made the following observations: —
(1) Adults of A. bifurcatus were found sheltering
in wells in mid-winter, and when disturbed bit
freely. Larvse of this species were found at the
same time in the wells.
(2) An outbreak of subtertian malaria occurred
among troops billeted in close proximity to these
wells in December and January.
(3) In open waters anopheline larvae were not
found until April 10, and breeding was not free
until the end of May.
(4) Swarms of A. niaculipennis appeared in the
vicinity of the Bahret Katuiieh at the beginning of
June, when breeding in the marsh was scanty,
a rapid increase of malaria followed. It
probable that these mosquitoes had hibernated in
the tunnels and caves.
(5) As a result of extensive draining of marshes
and canalization of rivers, larvae and adult mos-
quitoes were reduced to a minimum by August,
when, under natural conditions, it might have been
expected that their numbers would have been rising
to a maximum.
(6) The incidence of malaria among the troops
fell coincidently with the disappearance of ano-
phehnes.
(7) The total loss of men to the Anny Corps from
malai'ia was only about 10 per cent, of the strength
during the twenty-one weeks under consideration,
with the result that the troops were able during the
autumn to Jjngage in a most arduous campaign
v\-hich ended in the amiihilation of the Turkish
Army and the cessation of hostilities.
Capsulated Mucoid Forms of Paratyphoid and
Dysentery Bacilli (William Fetcher). — The author
has isolated capsulated bacilli forming slimy mucoid
colonies from the excreta of two chronic carriers
of B. paratyphostis B and one case of acute infection
with B. aertrycke. These organisms were motile,
Gram-negative, did not produce indol, foiTned acid
and then alkali in milk, and had the same fermen-
tation reactions as B. paratyphosus B, but were
agglutinated only in low dilutions l)y pai'atyphoid
immune sera.
Sphenoidal Empyema and Epidemic Cerebro-
spinal Fever (Dennis Embleton). — In thirty-four
necropsies on persons dying from cerebrospinal fever,
empyema of the sphenoidal sinus was observed
thirty-two times. In forty-seven completely re-
covered cases of cerebrospinal fever no sphenoidal
empyemata were present.
April 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
99
\\NALs OF Tropical Medicine and Parasitology.
Vol. XIII, No. 4, March, 1920.
The Mechanism of tJie Spontaneous Elimination
of Yellow Fever from Endemic Centres (H. R.
Carter). — The author quotes several instances
proving that spontaneous disappearance of yellow
f(\t'.r is not rare. In the absence of adult immi-
gration and of inter-travel, this is expected to take
jilace in a large proportion of towns, and after this,
v\vn when there are influxes of strangers, outbreaks
in such towns do not occur, unless they are in
ciiininunication with some infected focus. These
outbreaks then are re-infections and not recru-
descences of "latent" or "larval" yeJlow fever.
The Metabolism of White Races living in the
Tropics. Influence of External Temperature and
Ii'dfe of Cooling iipon the Respiratory Metabolism
(\V. T. Young). — The author has observed that
during the hot season tliere is greater metabolism
than during the cool season. With tropical heat
the metabolism is at a higih level on account of the
imrease in body temperature produced by even
s;!ii|ht exertion, and which decreases only very
jxradually after the exertion .has ceased. Gold may
also increase the metabolism but by producing
shivering and so increasing the muscular activity.
The Hypopus of Carpoglyphus anonym,us Haller
(Hubert M. Morris). — Detailed zoological descrip-
tion of the hypopus of Carpoglyphus anonymus.
Tlie mite itself was' present in large numbers in a
quantity of dry figs received by the author for
examination from the Port Sanitary Authority of
I>iverpool.
Xerophthalmia in a native of the Gold Coast (J.
W. S. Macfie). — The author comes to the following
(■< inclusions : (1) Epithelial Xerosis of the conjunc-
ti\a is not uncommon in natives of West Africa;
i'l) Attempts to reproduce the disease in animals
by means of a bacillus isolated from a case {B.
xerosis) were unsuccessful.
An Observation on the Effect of Malaria in
J^rakxmia (J. W. S. Macfie).— A gi-eat reduction
in the number of leucocytes was noticed when
malaria parasites appeared in the blood. Tartar
emetic did not induce any improvement in this
case of leukaemia, nor did it prevent the develop-
nicnt of an attack of malaria (/'. falciparum).
Tropical Australia and its Settlements (A. Breinl
and W. J. Young). The hot summer militates
against permanent settlement, especially since the
liousing, lack of water, &c., are causes of great
discomfort. One cannot expect a white population
tfi tiuive in the tropica, unless all possible means
1" adopted to alleviate climatic conditions.
The Experimental Infection in England of Ano-
plirlcs plumbeus Stephens and Anopheles bifurca-
liis L. zvith Plasmodium vivax (B. Blacklock and
Il'iny F. CiU-ter). — The authors have been able to
intict laboratory bred A. plumbeus with Plasmo-
■I I II III vivax. At 28° C. infections of the gut and
salivary glands were obtained ; at room temperature
gut infection only was, obtained. As regards Ano-
pheles bifuTcatus the authors have proved that in
England the native form of this mosquito is capable
of being infected with malaria at 28° C.
Observation on Anopheles plumbeus Stephens
(B. Blacklock and Henry F. Carter). — The authore
have found that A. plumbeus is not uncommon in
the Liverpool area and that it occurs widely dis-
tributed round the city and within the four-mile
limit. They are of opinion that it may be of impor-
tance as a natural earner of malaria especially as
its breeding places frequently occur in isolated trees
often in proximity of a house.
Description of the Male Genital Armatures of
the British Anopheline Mosquitoes (Henry F.
Carter). — Detailed descriptions of the male genital
armatures of Anopheles maculipennis Meig., Ano-
pheles bifurcatus, L., and Anopheles (Ccelodiazesis)
plumbeus Stephens.
On Human Trypanosomiasis in Peru (Warrington
Yorke). — The author suggests the name Trypano-
soma escomeli for the trypanosome found by
Escomel in the inhabitants of the Eastern Peruvian
forests.
ibstrart.
ETIOLOGY OF YELLOW FEVER: SUM-
MARY AND CONCLUSIONS.!
By HiDEYO NooncHi.
It has been previously reported that a filterable
micro-organism belonging to the genus Leptospira
has been recovered from the blood or organs of
human beings suffering from the disease known as
yellow fever in Guayaquil, and that the organism,
which has been termed Leptospira icteroides, in-
duces in certain experimental animals the charac-
teristic symptoms and lesions observed in the
patients from whom it was isolated. It has also
been previously shown that the serum from patients
recovering from an attack of yellow fever in Guaya-
quil had the power to agglutinate and dissolve the
organismi when introduced into the peritoneal cavity
of a normal guinea-pig (Pfeiffer phenomenon). More-
over, the guinea-pigs which had once been inocu-
lated with the blood of yellow fever patients without
succumbing to the infection, notwithstanding the
fact that they had shown a definite febrile reaction
after four to five days, were found to be refractory
to a subsequent inoculation of a culture of Leptospira
icteroides. All these observations pointed to the
possible relation of this organism to the disease
known as yellow fever in Guayaquil. The demon-
stration of the filterability of the organism and the
I Abstracted from the Journal of Experimental Medicine,
vol. xxxi, No. 2, February 1, 1920.
THE JOURNAL OP TROPICAL MEDICINE AND HYGIENE.
[April 15, 1920.
transmission of the infection with the same organism
by Stegomyia calopus have further strengthened the
probable etiological significance of the organism in
yellow fever.
It was by no means a simple problem to determine
the relation existing between Leptospira icteroides
and Leptospira icterohamorrhagix. An experiment
reported in a previous paper seemed to justify the
view that the two leptospirae are closely related,
but not identical, yet it was necessary to exhaust
various other modes of differentiation before the
distinction between them was firmly established.
The present paper continues this phase of the inquiry
in further detail.
There have been taken up here the phenomena of
agglutination, the reaction of Pfeiffer, complement
fixation, the "protective properties of various mono-
valent and polyvalent immune sera and active im-
munity. As the result of experiments in connection
with these immunity phenomena the following data
are presented.
Monovalent immune sera prepared by several
successive injections in an animal naturally refrac-
toi-y to Leptospora icteroides possess the power to
agglutinate in vitro not only the homologous strains,
but also all other strains of icteroides tested. On the
other hand, a slight effect, or none at all, has been
observed when these iminune sera have been mixed
in vitro with various strains of Leptospira ictero-
hamorrhagix. A similar relation exists between the
monovalent anti-icterohiemorrhagiae sera and the
various strains of Leptospira icteroides; that is,
there is a slight agg'lutinating effect in some in-
stances upon the icteroides strains, but it is never
so strong as that occurring in tests against the
icterohaemorrhagiae strains. The Pfeiffer reaction
gave a sharper diafferentiation between the two
gi'oups, for in most instances the phenomenon was
specific for the group. There were occasionally
doubtful reactions, but not enough to waiTant a
confusion of the two groups.
Polyvalent immune sera, one specific for icteroides
and the other for icterohsemorrhagisB, showed a
higher titre of neutralizing power for the cultures of
the homologous groups. It was found, however,
that tdie action of the sera is by no means absolutely
specific, because the injection of a sufficient amount
of the anti-icteroides serurni apparently prevented a
fatal outcome in a guinea-pig inoculated with mul-
tiple minimum lethal doses of a culture of Lepto-
spira icterohxmoTrhagiw, and vice versa. The
specificity of the serum was demonstrated only when
it wais used in smaller quantiticB.
More or less specificity was shown by the com-
plement fixation reaction, but it was not absolute.
Weak fixation occurred when the anti-icteroides
serum was mixed with one or the other of the
icterohaemorrhagia strains and vice versa, and strong
fixation occun-ed only when the anti-serum was
mixed with one of the icteroides strains. The ques-
tion naturally arises whether or not this apparent
specificity is due to the homology of the serum and
not altogether to a difference in genus of the
strains. In other words, it is justifiable to question
whether all these variations in the degree of in-
tensity of the reaction are not due to strain varia-
tions of the same genus. This question is not
finally settled by the present investigation, in which
only four icteroides and nine icterohaemorrhagias
strains have been carefully studied. Nevertheless,
on the basis of the findings with these thirteen
strainsi, it seems probable that Leptospira icteroides
and Leptospira icterohsemorrhagi.x are closely alhed
but are nevertheless distinct in their immunological
reactions. Perhaps the difference l>etween the two
may amount to that between sub-species or races.
It has been pointed out earlier that the pathogenicity
of the two is also distinct, inasmuch as icteroides
produces chiefly icterus and nephritis and ictero-
haemorrhagiae hemorrhage and nephritis, the icterus
being less than the haemorrhage more prominent in
the evolution of the latter infection.
In the study of active immunity — exclusive of
vaccination — difficulty has been experienced in the
evaluation of the results, owing to the existence of
natural resistance to infection among guinea-pigs.
A guinea-pig may recover from the inoculation of
Leptospira icteroides and then resist a subsequent
inoculation with a virulent strain of Leptospira
icterohapmorrhagin-, a condition simulating that
brought about by the identity of the two organisms.
However, the refractoriness of such an animal to
icterohaemorrhagiae may be due to it*? natural im-
munity to it. In the present study, therefore, only
those guinea-pigs were selected which had reacted
typically — though in mild degree — to the icteroides
infection, in order to determine whether they wer^
subsequently immune to the inojulation of ictero-
haemorrhagiae. Indeed, by this mode of experimen-
tation it was found that the guinea-pigs which had
once passed through an attack of the icteroides
infection were absolutely immune to a second in-
fection with the same organism but reacted severely
and sometimes fatally to a later inoculation of ictero-
h8Bmorrhagi«e. Although there were a number of
instances in which a . previous infection with
icteroides did not confer any perceptible immunity
upon the guinea-pigs against ieterohsemoiThagiae,
another group of guinea-pigs showed a considerable
resistance to the icterohaemorrhagiae infection as
compared with those which had never been inocu-
lated with icteroides. There is not much doubt,
therefore, that an icteroides attack brings about, in
some instances at least, a certain degree of resist-
ance to the icteroha?morrhagiap infection. Hence
the situdy of the phenomena of active immunity
strongly "indicates that icteroides is closely related
immunologically to icterohaemorrhagiae.
lleMcal fetos.
The address of the Wellcome Bureau of Scientific
Research will, on and after April 15 next, be
25, 26 and 27, Endsleigh Gardens, Gordon Square,
London, N.W.I.
May 1, 1920.;
JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 9, Vol. XXIII.
tfrtfiinal Commnniattons.
MILROY LECTURES ON THE HIGHER FUNGI
IN RELATION TO HUMAN PATHOLOGY.'
By Aldo Castellani, C.M.G., M.D., M.E.C.P.,
Physician to the Trcypical Hospital (Ministry of Pensions),
Lecturer at the London Sc)iool of Tropical Medicine.
Mr. President, Censors and Fellows of the
College ; I beg, first of all, to express to you my
deep appreciation of the honour I have received in
being asked to deliver the Milroy Lectures for this
year. It is an honour I shall always very greatly
value.
As subject of my three lectures I have taken the
higher fungi in relation to human pathology. The
study of bacteria or lower fungi is so engrossing
and has given results of such magnitude, that there
has been perhaps a tendency hitherto to overlook
the importance, from a medical point of view, of
vegetal organisms higher than bacteria. There is
little doubt, however, in my humble opinion, that
further investigation will tend to increase the
importance of these organisms in the same manner
that the great medical importance of animal para-
sites higher than protozoa ha« already been
recognized.
In the first lecture I propose touching briefly on
the subject of fungi in general, on their morpho-
logical characters and classification and on their
biological properties. In the second and third
lectures I propose studying them in relation to
human disease, discussing briefly^ and giving a
description of some of the less known afiections of
mycological origin in the investigation oi which I
happen to have taken a part.
Historical.
Mycology, the branch of botany which deals with
the higher fungi, may be said to have begun in the
days of Charles II, when Hook constructed a
magnifying lens, and with it examined the yellow
spots so often found on the leaves of the Damascus
rose. He saw that these spots were caused by
certain filamentous fungi, of which he gave a de-
tailed description and left remarkably good draw-
ings. He believed like many other observers aftev
him that fungi arose from spontaneous generation,
especially in decaying matter.
About the end of the same century (1686),
Malpighi in his writings several times referred to
parasitic fungi, especially to fungi of the type
Mucedo. In 17.53, l^innaeus, in his famous book
" De Species Plantarum " collected all that was
known at the time on the subject, and named a
large number of species. After Linnaeus many
botanists caiTied out investigations on fungi : it
suffices to mention the names of Persoon, Link,
Kiitzing. It is interesting to note, however, that
fungi parasitic of man did not, apparently, attract
' Delivered before the Royal College of Physicians of London.
attention until the beginning of the last century.
The first fungus of importance found in man was
the thrush-fungus, by" Langenbeck, in 1839. This
author discovered the fungus examining micro-
scopically the white patches of thrush he found at
the autopsy of a case of typhoid, in the oral
mucosa, the pharynx and the whole of the intes-
tine. He believed at first that the fungus was the
cause not only of the white patches, but of the
typhoid infection from which the patient had died.
Berg in 1842 gave a good description of the
organism, and in 1843 Charles Robin made a com-
plete investigation of it and called it Oldium albi-
cans Charles Robin. Robin wrote also a book on
mycology, which has remained classic: " Histoire
Naturelle des Vegetaux Parasites qui croissent sur
I'Homme et sur les Animaux Vivants," J. B.
Bailliere, Paris, 1853. It took a long time, how-
ever, for the idea that thrush was a mycological
affection to be generally accepted ; even many years
after Charles Robin's classic work numbers of
physicians did not believe in it. In the most
popular text book of pathology of che fifties and
sixties of last century, one reads that the thrush
patches are the result of a morbid secretion of the
oral mucosa, and the author adds " A mycologist,
however, has brought forward the peculiar idea
that such patches are composed of a mass of
vegetable orgaJiisms."
In the same, year in which the thrush-fungus
was found (1839), Schoenlein discovered the fungus
causing favus : this organism a little later was
further investigated by Lebert, who called it
Oldium schoenleini and subsequently by Remack,
who named it Ac.horion schoenleini.
In 1844 Gruby described the fungi found in ring-
worm and made a. distinction between ringworm
due to a large spore fungus and ringworm due to a
small spore fungus, a distinction which was
ridiculed at the time and completely forgotten
later, until many years after, Sabouraud made the
same distinction, and very honourably called atten-
tion to Gruby's forgotten work.
In 1846 Eichstedt discovered the fungus of
Pityriasis Versicolor. Interest in the study of the
higher micro-fungi continued to be great until the
seventies and eighties of last century when the
epoch-making discoveries of Pasteur and Koch
brought bacteriology to the front, and mycology
was relegated to the background. Interest in
mycology slightly revived in the last years of the
century, this being principally due to the work of
Sabouraud — and during tlie last twenty years,
slowly but surely, this braticli of knowledge has
grown in importance.
General Remarks and Classification.
As is well known the Vegetal Kingdom is usually
divided into four large groups or phyla: the Thai-
lophyta, the Bryophyta, the Ptcridophyta and tlic
P]ianernga-m,r or Flowering Plants. The Thal-
lophytii may be defined as being vegetal organisms
with a cellular structure, which is usunlly little
102
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [May 1,1920.
differentiated, and reproducing either asexually by
division and by spore formation — or sexually, after
conjugation, by oospores. These organisms may be
separated into two classes: —
(1) Those with chromatophores and ohlorophyl —
Algse Eoth 1797.
(2) Without ohromatophores and chlorophyl —
Fungaceae Linnaeus 1737.
The Algae are generally subdivided into the
Cyanophycese (Blue-green Algse) the Chlorophycew
(Green Algae) and the Schizomycetacese, bacteria
sensu lato (or lower fungi). It must be noted,
however, that the Schizomycetacese or unicellu-
lar fungi, or lower fungi, or bacteria gensu
lato are without chlorophyl and generally without
chromatophores, and it is therefore doubtful
whether it is correct to classify them with tlie
Algae, as is usually done. They are believed,
however, to be derived from the Cyanophycese
or Blue-Green Algae. They may be defined as
thallophyta without chlorophyl starch or chromato-
phores, and with a vegetative body which is usually
composed of a mass of filaments, or " mycelium. '
The mycelial filaments or threads are also known
as hyphse, and may be of very different shape,
length and breadth ; they may be straight, variously
bent, septate, or non-septate. These organisms
being unprovided with chlorophyl cannot make use
for their nutrition of the carbon-dioxide of the air;
they derive their carbonaceous food material from
complex organic matter, often decaying matter.
Fungi may be saprophytic or parasitic; the same
fungus may at times be a saprophyte, at other
times a true parasite.
Reproduction. — The seeds of the higher plants
may be said to be represented in the fungi by the
roundish or oval bodies known by the generic term
spores, of which there are a number of types, some
sexual, some asexual. The principal ones are the
following: —
(1) Gonidia (endospores, spores sensu stricto). —
These take origin inside a special receptacle called
sporangium, which is frequently terminal and
Pio. 2. — Zygospore formation in Rhizopiis nigricans.
aerial. When the spores are 2, 4, 8, or a multiple
of 8, they are generally called asoospores, and the
cell or spore-case structure containing them is
known as an ascus.
(2) Zygospores. — These spores result from a con-
jugation or modified sexual act between two special
club-shaped hyphal processes (gametes), which are
similar in shape and do not show any apparent
sexual differentiation; the gametes come into con-
tact and unite forming a large cell with a very
resistant double wall, called Zygospore.
(3) Oospores. — These result from a complete
sexual conjugation between sexually differentiated
elements; a female element (oosporangium,
Fio. 1. — Types of ascospores. 1, Saocharomyces ; 2-4,
Willia ; 5, Debaryomyces ; 6, Sohionniomyces ; 7, Sacoharo-
mycopsis ; 8, Monospora ; 9, Nematospore (after Guillii
Fig. 3.— Zygosis and ascus formation in Zygosnccharomyces
octosponts (after Guilliermond).
oogonium), and a male element. The female
element oosporangium or oogonium has a thick
capsule with several pores and containing some
roundish protoplasmatic masses ; female gametes,
macrogametes or oospheres. The male element
(male gamete, antheridium), wliioh originates on a
special delicate hypha, comes into contact with
the oosporangium, sending a protoplasmatic process
through it. In some cases the antheritidium
May 1, 1920.] THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
103
divides into several motile bodies, spermatozoids,
Hntherozoids, which fertilize the female gametes.
(4) Conidia (Exospores). — These are asexual
spores. They are roundish or oval, occasionally
spirally-shaped bodies, which take origin from the
mycelial threads by a process of budding or septa-
tion or abstriction, and may be simple or divided
liy septa. They are at first unicellular, but later
Pig. 4. — Ortspore formation.
Fig. 5. — A blastospore
(after Vuillemin).
a process of division ma}' set in and they become
pluri-cellular. Conidia may be pedunculated or
non-petlunculated, lateral or terminal.
Two principal types of conidium may be distin-
guished : The true conidium and the pseudo-
ronidium or aleuriospore. True conidia are easily
detached from the mycelial hyphse bearing them,
and when they have become free they originate new
spores by a process of budding, or give rise to
mycelial filaments by germination. True conidia
are incapable of forming new spores or new mycelial
threads while they remain attached to the parent
mycelium. The mycelial hypha which carries the
conidia is termed conidiophore or sporophore : a
]ihialide is a flask-shaped segment interposed be-
tween the sporophore and the conidia; a pro-
phialide is a special article on the sporophore sup-
porting several phialides.
The false conidia or pseudo-conidia or aleurio-
spores, which may be lateral, terminal or inter-
calary, are not originally distinct from the thallus
and are not easily detached; they are only set free
by the death of the mycelial hypha to which they
are attached.
(5) Thallospores. — A thallospore is merely a por-
tion of the thallus, or vegetative body, which be-
comes secondarily adapted to the purposes of
reproduction. There are several varieties of thallo-
spores, the principal ones being: —
The Blastosporc, oval or roundish, formed by a
process of budding.
The Arthrospore, formed simply by the segmenta-
tion and disarticulation of a hyphal element or
mycelial thread ; it is at first square, and later
becomes roundish or oval.
The Chlamydosporc. — This is merely an arthro-
spore of large size undergoing encystement.
(6) Hemispores. — The mycelial hypha becomes
differentiated, forming an ampulliform structure
called " protoconidium," which later divides into
several segments or ',' deuteroconidia," which are
the true reproduction spores.
Classification.
Fungi may be separated into two large divisions :
The Myxomycetes, characterized by the vegetative
body being under the form of a multinucleate naked
Plasmodium, and the Eumycetes, characterized by
the vegetative body being generally filamentous.
Fungi parasitic of man are found only in the second
division (Eumycetes), which may be subdivided as
follows : —
Class I. — Fungi Imperfecti. Mycelium septate.
No ascosporea.
Class Il.—Ascomycetes. Mycelium septate when
present. Ascospores.
Class III. — Basidiomycftes. Mycelium septate.
Basidiospores.
Class IV. — Phycomycetes. Mycelium non-
septate in vegetative stage.
(a) Fungi Imperfecti.
The Class Fungi Imperfecti Fuckel 1869 is most
important from a medical point of view; it may
be subdivided into (a) Deuteromycetes Saccardo
1886 (accessory fructification^ present) and (b)
Hyphahs Vuillemin 1910 (accessory fructifications
absfent). Only the latter group contains fungi
parasitic of man. It may be classified as follows : —
/ Order I. — Microsiphonales Vuillemin 1910.
(hyphae-bacilliform).
Order ll. — T)uillosporales Vuillemin 1910. (Re-
production by thallospores).
Order m.—Hemisporales Vuillemin 1910. (Re-
production by hemispores).
Order IV. -Co«idiosj>oraies Vuillemin 1910. (Re-
^ production by conidia).
The Order Microsiphonales contains two families :
The Mycobacteriacese Miche 1909, in which no
definite mycelium is observed, and the Nocardia-
cem Castellani and Chalmers 1918, in which a
definite mycelium is present.
The Mycobacteriacex are generally classified with
the bacteria and not with the higher fungi, and
contain five principal genera : Genus Mycobacterium
Lehmann and Neumann; Leptothrix Kutzing';
Oladothrix Cohn ; Vibriothrix Cast.
The Nocardiace.r. contain two genera : Nocardia
Toni and Trevisan, which grows aerobically, is
easily cultivated and produces afchrospores. Cohni-
streptothrix Pinoy, which is difficult of cultivation,
mostly anaerobic, and does not produce arthro-
sp^res.
The Order Thallosporales Vvillemin 1910 is
divided into two sub-orders: The Blastosporineae,
in which reproduction takes place by means of
blastospores, and the Arthrosporinea;, in which
reproduction takes place by arthrospores.
The sub-order Blastosporineae contain five prin-
cipal families: —
(1) The Cryptococcacex Kutzing. — The hyphae
are hardly different from the conidia, both being
veast-like; conidia not arranged in chains.
HyphaUs
Vuillemin
{ = Hypho.
mycetes
Fries).
104 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 1. 1920
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106
(2) The Ooaporacex Saccardo. Some long
hyphee present, spores typically in chains.
(3) Tlie Enantiothamnacece Chalmers and
Archibald. — Conidia arranged vertieillately around
the septa of the mycelial hyphse.
(4) The Haplographiacex. — Wlien living parasitic
conidia are collected in grape-like masses.
(5) The CladospoTiaceai Saccardo. — Conidia soli-
tary or in chains.
The sub-order ArthTosporinex contains a very
important family, the Trichophytonacex, reproduc-
tion by Arthrospores, long hyphae present in cultures,
often parasitic of hair. This family includes a large
number of genera, including Trichophyton, Micro-
sporon and Achorion. It is to be noted, however,
that many authorities consider these fungi to belong
to the Ascomyeetes (family Gynnoascaceae) and not
to the fungi Imperfecti.
The third Order of the Hyphales, the Hemi-
sporales, reproduction by hemispores, have a
j mycelium composed of abundant hyphse, which are
i thin, but always more than 1 micron in diameter.
The conidiophores are branched, each branch
tenninating in ampullifonn structure, preceded
by an annular constriction produced by a rigid
thickening of the wall.
The protoconidium after a time divides into a
number of sporiform segments (deuteroconidia).
The fourth Order Conidiosporales, which, as
already stated reproduce by means of conidia, con-
tains four principal sub-orders: —
(1) The Aleurosporinese Vuillemin 1914. Repro-
duction takes place by aleurospores.
(2) The Sporotrichinea; Vuillemin 1910.— Repro-
duction by true conidia, but true conidiophores are
absent.
(3) The Sporophoralinea; VuiUemin 1910.— Re-
production takes place by true conidia carried by
true conidiophores.
(4) The PhialidineiE Vuillemin 1910.— Reproduc-
tion by true conidia i)oni(- on phialides.
(b) Class II. Ancoinycctes.
The fungi belonging to this class, as already men-
tioned, are characterized by reproduction taking
place by means of ascospores (gonidiu endospores),
which originate inside special cells called asci. The
Ascomycetes contain tln-ee very important fami-
lies : —
(a) The Saccharomycelacex Uees 1870.— Myce-
lium only slightly developed or absent. Asci
isolated uot differentiated from vegetative cells.
(b) The Bjjrfomi/ce^acc.r.— Mycelium well de
veloped.
(c) The AiipergHlace:i:.—\>n-A generally contained
in a globose hollow structure (perithccium) with a
terminal opening or jjore. Compact peridium.
All these families contain important fungi para-
sitic of man as shown in the diagrams.
(c) Class III. Phycomycetes.
The Phycomycetes which are characterized by the
mycelium being continuous, non-septate, in the
vegetative stage, contain several families, one of
which, the Mucoraceas, has organisms parasitic of
man. The fungi belonging to this family have a
branching mycelium with aerial brancnes (,goni-
diophores), each of which supports on its distal
extremity a globular, pear-shaped or claviform
sporangium, called gonidangium, which is at first
separated from the gonidophore by a septum. This
septum later protrudes into the lower portion of
the sporangium and forms a variously shaped
structure known as Columella. By free cell-
formation, gonidia develops inside the sporangium.
The sporangial protoplasm not used in the forma-
tion of the gonidia is transformed into a peculiar
mucillaginous substance, which later dries up and
is the cause of the sporangium bursting. Each
gonidium which has become free gives rise by
germination to a mycelial filament. There is also
at times a sexual mode of reproduction consisting
in the conjugation of undifferentiated non-motile
gametes, with formation of Zygospores. When
growing in unfavourable media numerous species
reproduce only by conidia and chlamydospores.
The family Mucoi^acese contains a number of
genera, among which the following have species
parasitic of man : —
(1) Miicor Micheli. — Mycelium ramified, rhizoids
absent.
Fig. fi.—Rhi»opus niger
Ciaglinski and Hewelke.
Pig. 7. — Type of spor-
angium found in Genus
Rhitopus.
(2) Rhizoniucor Lucet and Gostantin. — Rhizoids
(slender root-like filaments) present, columella
ovoid.
(3) Hhixopus Ehrenberg. — Rhizoids present, colu-
mella mushroom-like.
(4) LichHieimia Vuillemin. — Peduncle support-
ing sporangium ends in a special formation
encircling the base of the columella.
Diseases due to the fungi of the family Muco-
racete are often called " mucormycoses."
106
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 1. 1920.
Certain Biological and Biochemical Characters
OF Fungi.
The biological and biochemical characters of fungi
are very interesting, and of great practical import-
ance.
Recent investigations have shown numerous
analogies with the lower fungi (bacteria), as regards
production of toxins, and especially as regards
serological reactions developing in inoculated
animals.
About twenty years ago the late Dr. Macfadyen,
Director of the Lister Institute, inoculated rabbits
with cultures of a saccharomyces, and observed a
produc-tioii of specific agglutinins in the blood for
the partifiilitr s|)ei'ies he had inoculated. These
results were confirnied and enlarged, using other
fungi, by G. H. Rogers, Concetti, Quarelli, &c.,
and Widal and Abrami have described a general
diagnostic method, " Sporo-agglutination Method,"
based on the observation that patients suffering
from mycological diseases contain specific agglu-
tinins for the spores of the causative fungi. In my
experience, however, in many cases, in addition to
specific agglutinins, there is present also a large
amount of non-specific ones, and this generally
detracts from the usefulness of the method.
As regards toxins, Auchair and Verliac have
obtained a toxic product soluble in ether from
Nocardia bovis, which they called " Actinimyce-
tine." Ceni, Besta, and other observers have ex-
tracted various toxins from fungi of the genus
Aspergillus, and believe them to be the cause of
pellagra. Charrier, Roger and others have ex-
tracted toxins from fungi of the genus Monilia.
Vaccines have been prepared, using cultures of
Monilias killed by heat or by carbolic acid. Plato
has prepared a trichophyton vaccine by killing
cultures of various trichophytons by heat and tri-
turating them. When injecting this vaccine in
patients affected with ringworm, he has observed
a general reaction similar to that induced by tuber-
culin in tubercular patients. A cuti-reaction in
patients suffering from sporotrichosis has been
described by De Beurmann.
Biochemical Changes induced by Fungi.
Certain fungi may induce profound chemical
changes, and are of great importance in agriculture
and industry. Everyone knows the role played by
organisms of the family SaccharomycetaceEe in
alcoholic fermentation and in the production of wine
and beer. Certain fungi ferment a large number
of sugars and other carbohydrates, others a few or
none. I have happened to find a monilia, which
very rapidly sphts a substance generally considered
to be non-fermentable, viz., inulin.
Mycological Method to detect various Carbo-
hydrates.
As is well known, the property certain fungi have
of fermenting glucose has been used for many years
as a method of routine to detect this sugar in the
urine. In this connection T may perhaps be
allowed to describe briefly a mycological method
for the detection of other sugars and carbohydrates
which I theoretically devised some years ago, but
only recently worked out experimentally, jointly
with Dr. F. E. Taylor in Professor Hewlett's
institute. It may perhaps be of some slight
interest to give here some details of this method
and make it better known.
As already stated, since inany years so-caUed
German yeast (baker's yeast, brewer's yeast) has
been used for the detection of glucose, but this is
the only substance for which so far such method of
detection has been employed in pathological inves-
tigations, and, as a matter of fact, this method of
finding glucose (although considered specific in so
many text-books on Pathology) is inexact, because
in our experience German yeast ferments as a rule,
not only glucose, but also levulose, galactose, mal-
tose, saccharose, and sometimes even lactose. If
a specimen of urine undergoes fermentation after
the addition of German yeast, it does not mean,
therefore, that this urine contains glucose ; it might
contain levulose or galactose or maltose, or even
lactose, &c. To detect and determine with cer-
tainty glucose, it is necessary to use an organism
which will split only this sugar, and no other. We
have such an organism in M. balcanica Cast., which
does not ferment any substance apart from glucose.
As regards detection and identification of other
sugars, sucli as maltose, galactose, &c., we have
no fungi, unfortunately, and apparently they do not
exist in Nature, which will select only one of the
carbon compounds to the exclusion of all others,
fungi which will ferment, for example, only
maltose, or only galactose, or only inulin, or only
lactose, &c. These various substances, however,
may be identified by using our mycological method,
which might be called " Conjugated or parallel
mycological method," because we do not use one
species only of fungi, but two or more, compar-
ing their action on the substance to be deter-
mined. The simplest way of cari-ying out our
method to determine whether a substance is or is
not a certain carbohydrate, is to test on the sub-
stance whenever possible the action of two germs
known^ to be identical in all their fermentative re-
actions except on that particular carbohydrate.
For instance, in order to see wliether a given
chemical substance is maltose, the substance may
be tested with two organisms identical in all their
biochemical reactions, except their action on
maltose, one fennenting it, the other not. I shall
make a few examijles, viz. ; The detennination of
levulose, maltose, galactose, lactose, saccharose,
inulin.
Dctrniiination of Levulose. — Let us assume we
want to determine whether a certain substance is
levulose. A sterile 1 per cent, solution of the sub-
stance is made in sugar-free peptone water and dis-
tributed into two tubes (1 and 2), each containing
a fermentation tube. No. 1 is inoculated with M.
krusei Cast., and No. 2 with M. balcanica Cast.
The tubes are incubated at 35° C. for forty-eight
hours, and the results are then read. If No. 1 tube
{M. krusei Cast.) contains gas, and No. 2 tube
May 1, 1920.] THE JOURNAX, OF TROPICAL MEDICINE AND HYGIENE.
107
(M. balcanica Cast.) contains no gaa, the substance
is levulose. This is easily understood by keeping
in mind the following facts : M. kruaei ferments
tose) ; it cannot therefore be glucose, nor levulose,
nor maltose; it can only be gaJactose.
Deterviination of Lactose. — Same technique as
^tzV
+
Fig. 8. — Identification of laevulose.
Pig. 9. — Identification of maltose.
only glucose and levulose; M. balcanica ferments
) only glucose. The substance we are testing having
j been fermented by M. krusei must therefore be
i either glucose or levulose, but as it is not fermented
' by M. balcanica it cannot be glucose, which is
always attacked by that fungus; it can, therefore,
only be levulose.
Determination of Maltose. — A 1 per cent sterile
solution is made in sugar-free peptone water of the
substance which we wish to ascertain whether it is
maltose. The solution is distributed into two
sterile tubes, which are labelled 1 and 2. No. 1
tube is inoculated witli M. pinoyi Cast., and No. 2
with M. krusei Cast. If after forty-eight hours in-
cubation at 35° No. 1 (M . pinoyi) contains gas, and
No. 2 (M. krusei) does not, the substance is mal-
tose. This i« explained by the fact that M. pinoyi
Cast, ferments only three carbon compounds I
know of: Glucose, levulose, nialtose; M. krusei
ferments only two, glucose and levulose. The sub-
stance being fermented by M. pinoyi might be
either glucose or levulose or maltose; but it is not
fermented by M. krusei; it cannot therefore be
glucose or levulose, and there remains only one
possibility : It must be maltose.
Identification of Galactose.— Same, technique,
but No. 1 tube is inoculated with M. metalondin-
ensis Cast., and No. 2 tube with M. pinoyi Cast.
If after forty-eight hours incubation at 35° C. No. 1
tube (M. metalondinensiH) contains gas and No. 2
tube (M. pinoyi) does not, the substance must be
galactose. The explanation lies in the fact that
M. nietalondincnsis ferments the following four
carbon compounds only : Glucose, levulose, mal-
tose, galactose; while M. pinoyi ferments only
glucose, levulose and maltose. The substance
being fermented by M. metalondinensis , there are
four possibilities : It may be glucose or levulose, or
maltose, or galactose, but is not fermented by M.
pinoyi (which .ittacks glucose, levulose and mal-
for the determination of the carbohydrates already
mentioned, but instead of using micro-organisms
belonging to the higher fungi, we can use bacteria.
The substance to be identified is made into a 1 per
cent, sterile solution of peptone water, and distri-
buted into two tubes, No. 1 and No. 2. Tube No. 1
is inoculated with B. pseudoasiaticus Cast., and
tube No. 2 with B. pseudocoli. If after forty-eight
hours incubation at 37° C. tube No. 1 (B. pseudo-
asiaticus) does not contain gas, while tube No. 2
(B. pseudocoli) contains gas, the substance must be
lactose, because B. pseudoasiaticus and B. pseudo-
coli are absolutely identical in all their fennentative
characters except as regards lactose, which is not
attacked by B. pseudoasiaticus, and is, on the other
hand, fermented with production of gas by B.
pseudocoli.
In practice, if it is known beforehand that the
substance to be determined is Fehling-reducing,
two bacilli found in every laboratory may be used,
viz. : B. paratyphosns B and B. coli. If a Fehling-
reducing substance is not fermented by B. para-
typhosns B and is fermented by B. coli, it is lac-
tose. Why? Because the two germs as regards
fennentation of Fehling-reducing substances differ
only in their action on lactose; B. paratyphosns, as
well known, does not ferment it, while B. coli
ferments it. B. paratyphosus B and B. coli differ
in their fermentative action, and the various sugars
and carbohydrates only as regards raffinose and
salicin, inosite and glycerin. A substance which
is not fermented by B. paratyphosus B, and is fer-
mented by B. coli, may therefore be lactose,
raffinose, salicin or glycerin, but if the substance
is Fehling-reducing it must be lactose.
It is often stated in text-books that if a urine
reduces Fehling and is not fermented by ordinary
baker's yeast (German yeast), the reducing sub-
stance is lactose. There are, however, two im-
portant sources of error : first, quite a number nf
THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [May 1, 1920.
specimens of German yeast ferment lactose;
second, even if the German yeast should not fer-
ment lactose, this is not the only Fehling-rediicing
substance which may not be fermented by baker's
yeast — the Pentoses, for instance.
Determination of Saccharose. — A 1 per cent,
solution of the substance suspected to be saccharose
is made in sugar-free peptone water, and some of
the solution is placed into tubes 1 and 2. Tube
No. 1 is inoculated with M. tropicalis Cast., and
tube No. 2 with M. metalondinensis Cast. If gas
develops in tube 1 (M. tropicalis) and not in tube 2
(M. vietalondensis) the substance is saccharose.
This is easily understood if the following facts are
kept in mind; M. tropicalis ferments only the
following carbon compounds : Glucose, levulose,
maltose, galactose, saccharose; M. metalondinensis
only the following four carbon compounds : Glucose,
levulose, maltose, galactose. If a substance is
fennented by M. tropicalis, there are therefore five
possibilities; it may be glucose or levulose, or mal-
tose, or galactose, or saccharose; but if the same
substance is not fermented by M. metalondinensis,
it cannot be either glucose or levulose or maltose
or galactose, and must therefore be saccharose.
To the above purely mycological method a
chemico-myeological formula, useful in practice,
may be added : —
T^^caUsCst. ;l=Sacoharose.
This is explained by the fact that M. tropicalis
Cast, fei-ments with production of gas, glucose,
levulose, maltose, saccharose, and no other sub-
stance. If Fehling is negative it cannot be any of
the first three substances, as they are all Fehling-
reducing, and it must therefore be saccharose.
Determination of Inulin. — Same techuique as for
saccharose, but tube No. 1 is inoculated with M.
macedoniensis, and tube 2 with M. rhoi. If gas
appears in tube 2 (Af. rhoi) the substance is inulin.
This is easily understood if one bears in mind the
fact that M. macedoniensis and M. rhoi are iden-
tical in all their fermentative reactions except in
inulin, which is fermented by M. macedoniensis,
but not by M. tropicalis. If a substance, therefore,
is fermented with production of gas by M. mace-
doniensis and not by M. rhoi, it must be inulin.
The working of the method can be seen at a
ghince in the accompanying table and key.
Identification of PEHLiHG-BEDnciNG substances.
1
1
^5
6
1
3
t
6 ^ 1
III
1
1
Reducing Substance
-1- -1-
- +
-f 1 -1- -f-
+ i + . +
= - ' t
1 ■
-1-
-1-
-1-
+
+
Glucose.
Laevulose.
Maltose.
Galactose.
Pentoses.
Lactose.
N on -fermentable reducing sub-
stances of the groups creatinin,
hippuric acid, uric acid, &c.
+ — Production of gas ; simple acid fermentation is not
taken into account.
— = No gas.
The reducing substance is made into a 1 per cent, peptone
water solution. Selected strains of the various organisms with
permanent biochemical reactions and producing a large amount
of gas should be used.
Key to the identifi-
cation of certain
Fehling -reducing
substances.
Inoculate tube 1 i
- with Monilia — .
balcanica Cast.
If negative in-
oculate tube
2 with M.-
— krusei Cast.
T, ^. I If negative in-
If negative in- | ^^^^^^^ ^^^^
oculate tube
3 with M.-
pinoyi Cast.
ith M. —
vietalondinensis
- Cast.
If negative inocu.
late' tube 5 with
B. coii Esoh. and
tube — 6 with B.
paratyphosus B
- Schott.
B. coli—
B. paratyph.
"B. -
= Non-fermentable
reducing sub-
stances of the
groups creatin,
uric acid, hip-
puric acid, &c.
~ B. coli +
B. paratyph.
= Lactose.
eoli +
paratiijih. B +
May 1. 1920.J THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE.
109
Presence of more than one Fermentable
Substance.
If more than one sugar or other fermentable
carbon compound is suspected to be present, this
may to a certain extent be , ascertained, and the
various fermentable substaiices determined by our
method. Let us assume that a liquid after gas-
fermentation with M. balcanica Cast, is still fer-
mentable with production of gas by M . hrusei Cast.,
the conclusion is that in addition "to glucose the
liquid contained levulose; of course, care should be
taken to use strains of M. halcanica and M. krusei
having approximately the same fermentation power
on glucose. If now the liquid after exhaustion first
witli M. halcanica Cast, and then with M. krusei
Cast, is fermentable with production of gas by M.
pinoyi Cast., the presumption is that, in addition
to glucose and levulose, maltose was present, and
this is easily understood if we remember that M.
balcanica produces gas in glucose only, M. krusei
Cast, in glucose and levulose; and M. pinoyi Cast,
in glucose, levulose and maltose.
Use of Mycological Method in Urine Analysis.
Dr. F. E. Taylor and myself have carried out a
number of experiments, adding to samples of urine
taining a Durham's fermentation tube. A third or
equal amount of sugar-free peptone water should be
addetl to the urine, otherwise the fungi may grow
very scantily, and there may be no production of
gas. The live tubes are inoculated : one with M .
balcanica, one with M. krusei, one with M. pinoyi,
one with M. metalondinensis , one with B. para-
typhosus, and one with B. coli. The working of
the method can be seen at a glance from the accom-
panying table and key, taken from a joint publica-
tion by myself and Taylor.
AODENDyM.
Unfortunately some months ago an accident, the
catching fire of the 20° C. incubator in which the
collection of monilias was kept, destroyed a number
of important strains, including M. balcanica Cast.,
which is specific for glucose. At the present time
only the following monilias with permanent fer-
mentative reactions for use in urine analysis, M.
krusei Cast, (ferments, glucose and levulose), M.
tropicalis Cast, (ferments, glucose, levulose, mal-
tose, galactose and saccharose), M. macedoniensis
Cast, (fei-ments with production of gas, glucose,
levulose,. galactose, saccharose and inulin).
1
1
i
i
i
i
.■s
s
1
i
1
i
,s
2
'
1
B
1
.3
1
1
a
e
<
~
s
Mmilia balcanica Ci&t
AG
As
0
0
0
0
0
0
0
0
As
o
0
0
M. irusei Cast
AG
AG
0
0
0
0
0
0
0
0
O
0
o
0
if. macedoniensis Cast
AO
AG
AorO
AG
AG
o
0
0
o
0
0
o
AG
o
M. metalondinesis GASt
A(}
AG
AG
AG
O
O 0
o
o
()
o
0
0
0
M. pinoyma.s\.
AG
AG
AG
0
0
0
0
o
o
0
o
0
0
0
M.rftoiCast '
AG
AG
Avs
AG
AG
0
0
0
0
o
^
0
0
0
Bocfflus coH Escherich
AG
AG
AG
AG
O
AG
AG
AG
AG
AG
AG
0
0
AG
B. paratypliosm B SohottmuUer
AG
A(J
AG
AG
O
0 AG
AG
AG
O
AG
0
o
AG
B. pseudoasiaticus G&at
AG
AG
AG
A(}
AG
0 lAG
A(}
AG
AG
AG
0
o
AG
B. pseudocoli Cs^st
AG
AG
AG
AG
AG 1 AG ; AG
AG
AG
AG
AG
o
o
AG
B. typlwstis Eheith
A
A
A
A
0 O 1 A
O
A
As
O
o
o
A
Abbreviatitms used in the above Table:
A = acid; G = gas; S = slight; v3 = Tery slight; 0 = negative result— viz., neither acid nor clot in n
gas in sugar media, non-production ol indol, non-liquefaction of gelatin or serum as the case may be.
iither acid nor
various sugars and other cai-bohydrates, and also
e.xamiijing a certain number of pathological urines.
The conclusion we have come to is that the method
can be used in urine analysis with advantage,
especially in the detection of glucose, levulose,
maltose, galactose, lactose and pentoses. A point
of great importance is that the urine shojjld be
aseptic; if it cannot be collected aseptically it
should be sterilized as soon as possible, after dis-
tribution in the tubes, in Koch's steamer for thirt^
minutes on two consecutive days. It should never
be autoclaved, as this procedure may alter the
characters of the sugars i)resent. A portion of the
iirinc is (listributed in five sterile tubes each con-
However, even with these five s))ecies, in con-
junction with B. paratyphosiis B and B. coli,
stfveral carbohydrates can be detected and identfied
as shown by the following fornmlie : —
Mmiilia krtisei Cast.
M. macedmiiensia Cast. . . .
M. tropicalis Cast.
M. macedoiiiensis Cnsl. ...
M. tropicalis Cast.
M. krusei Cast. •
Jl/. TTiacedonieiwis Cast. ...
M . Inrpicalis Ca&U
H, paratyphiisw B Scliotl.
-I- = Glucose or Iievulose.
'' t ^Maltose.
= Galactose.
110
THE JOURNAL OF TBOPICAL MEDICINE AND HYGIENE. [May 1. 1920.
M. maeedoniensii Oast. ... +|
Af. tropicalis Cast. ... + ■
B. paratyphoaua B Schott. 0 )
M. tropiccUis Cast.
B. paratyphosus B Schott.
B. pseudocoli Cast.
Af. tropicalis Cast.
B. paratyphosus B Schott.
B. coli
-Liotose (most probably, but
it might be raffinose or gly-
cerine ; test with Pehling ;
if positive, Lactose).
= Pentose (if Pehling positive).
For urine analysis it- is advisable to use as a
matter of routine a set of five tubes, one inoculated
with M. krusei, one with M. macedoniengis, one
with M. tropicalis, one with B. paratyphosus B,
and one with B. pseudocoli. The results may be
arranged as follows: —
: Glucose (or levulose).
; Lactose (most probably, but
it might be raffinose or gly-
cerine. Test with Fehling ;
if positive. Lactose).
= Pentose (provided Pehling
be positive).
Monilia krusei Cast. ... +
M. inacedoniensis Cast. ... +
M. tropicalis Ca,st +
B. paratyphosus B Schott. +
B. pseudocoli CtkBt. ... +
M. krusei Cast 0
il. vMcedoniensis C&Bt. ... 0
M. tropicalis Ca,st +
B. paratyphosus B Schott. +
B. pseudocoli Cast. ... +
M. krusei C&st 0
M. Jiwccdoniensis Cast. ... +
M. tropicalis Cast. ... +
B. paratyphosus B Schott. +
B. pseudocoli Cast. ... +
M. krusei Cast 0
M. macedoniensis Ctiiit. ... 0
M. tropicalis Ca,st. ... 0
B. paratyphosus B Schott. 0
13 . pseudocoli Cast. ... +
M. krusei Cast 0
Af. macedoniensis Cast. ... 0
M. tropicalis Cast. .. 0
B. paratyphosus B Schott. -f
B. pseudocoli Cast. ... -f
M. krusei Cast 0
M. inacedonieiisis C&st. ... +
M. tropicalis Cast. ... +
B. paratyphosus B Schott. 6
B. pseudocoli Cast. ... +,
M. krusei Ca.st. ... ... 0'
Af. macedoniensis Cast. ... +
M. tropicalis Cast. ... 0
B. paratyphosus B Schott. 0
B. pseudocoli Cast. ... 0 ,
I venture to think that this method, when more
generally known, will perhaps be found useful in
the detection of those sugai-s and carbohydrates
the identification of which is long and laborious
when made by purely chemical methods.
Having to-day referred to the morphological
charact-ers of fungi and their classification, as well
as, though very incompletely, to their biological and
biochemical properties, I propose, with your per-
mission, to deal in the next lecture with fungi as
specific causes of disease.
A NEW VEHICLE FOR EMETINE
BISMUTHOUS IODIDE.
By T. J. O. Maybb, M.R.C.S., Gambia.
The problem of finding locally a vehicle for
E.B.I. , which would pass through the stomach
unchanged and be digested by the intestinal juices,
was solved by rubbing up the drug with sixteen
parts of mutton fat, moulding the mass into rounded
|)ills of about 7 gr. in weight, and covering each
with a layer of melted mutton fat applied with a
paint brush.
These pills pass through the stomach unchanged.
The fat is solid at body temperature, is not digested
until it is too far from the pyloric orifice to be re-
gurgitated and cause vomiting or even nausea.
That the E.B.I, was altered by the intestinal
juices was shown by the discoloration of the faeces
and the cure of the dysentery.
Pills containing 1^ gr. of the drug and about
7i gr. of mutton fat are about as large as may be
conveniently swallowed. Two were ^iven each
night for twelve consecutive night-s.
We kept the pills so made in the ice chest, but
possibly the addition of thymol to them might serve
as a preservative.
Treatment of Malaria Report of the Sub-rom-
ynittee of Medical Research of the National Malaria
Committee (Public Health Reports. United States
Public Health Service, December, 1919).— The Sub-
committee on Medical Research of the National
Malaria Committee composed of C. C. Bass, ^'.
Krauss, W. H. Deaderick, G. Dock and C. F. Craig,
present the following as a standard method of treat-
ment of malaria for the purpose of curing the
))atient of his infection and recommends its general
use by the medical profession. They believe that
this treatment will, in the great majority of cases,
prevent relapses in the patients and also prevent
transmission of infection to others. Their opinion
is based largely >ipon the results of the treatment
by this metJiod, under average conditions, in their
homes, of a large numfcer of persons infected with
malaria.
" For the acute attack 10 gr. of qaiinine sulphate
by mouth three timesi a day for a period of at lea.st
three or four days, to be followed hy 10 gr. every
night befoa-e retiring for a period of eight weeks.
For infected persons not having acute symptoms at
the time only the *ight weeks' treatment. is re-
quired.
" The proportionate doses for children are : llnder
1 year, i gr. : 1 year, 1 gr. : 2 years. 2 gr. ; 3 and
4 yeaiis, 3 gr. : 5, 6 and 7 years. 4 gr. : 8, fl and 10
years, 6 gr. ; 11, 12, 18 and 11 years. 8 gr. ; ir> years
or older, 10 gr.
" It is not claimed that this is a perfect or even
the best treatment in all cases, but it is the beUef
of the Committee that it is a good and satisfactory
method for practical use to prevent relapse and
transmission to other people."
May 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Ill
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THE JOURNAL OP
Cropf cal £|D eDictne and l^pgtene
May 1, 1920.
THE EXPEN8E OF OVERSEAS TRAVELLING
WITHIN THE EMPIRE AND SOME OF
ITS CONSEQUENCES.
Last week the writer became acquainted with
the case of two travellers from the Straits Settle-
ments to Marseilles, who each paid £140 foi- a
passage in a French steamer. Neither of them had
been home for over seven years, and it was their
first voyage home since going abroad to take up
their duties. From Marseilles they had to pay
their fares, with extra for luggage and certain other
extras which the French Government find it neces-
sary to impose. The figures ran into well-nigh
£200 for each man. The accommodation afforded
was meagre to a degree ; although first-class cabin
charges were imposed, the quarters assigned
them were " cattle truck " in their lack of
convenience. They could, it may be said, have
waited for a British steamer, but no such vessel
could take them for another month. As they had
been granted leave, however, it meant that they
would be spending one month of the leave of six
months granted them in the place where they were
located before starting for home, and as it takes a
month to make the voyage home and another
month to return again, it meant that three months
only of their six months furlough would be at home.
The business firms they belonged to allowed
officially £90 each for the complete journey home,
so that at least the journey refeiTed to exceeded the
allowed amount by £100. Instead of £180 for the
two, the lads had to pay well-nigh £400 and for a
" cattle truck " accommodation. The lads had
not, when the writer saw them, informed the head
offices at home of this expenditure, and they were
not a little concerned aa to how the news would be
received by them. Banks and business firms with
branches abroad are known to he liberal to their
employees abroad, but to spend double the allow-
ance provided for travelling was a serious item to
incur, and they had no authority to do so. They
made themselves responsible for a debt of £100, a
sum which' would cut deeply into the necessary
small amount they could save in their first years
of service abroad.
Shortly before the war there appeared in these
columns an article on the excessive charges imposed
by British shipping authorities on travellers within
the Empire, men connected with overseas busi-
ness firms, and it was pointed out that such firms
thwarted instead of helped overseas development
by these charges. Several lines of shipping are
subsidizwl by the British Government for the caiTy-
ing of mails, Ac, within the Empire, but tihey
charge the employees sums for passages which are
calculated to prevent their taking the amount of
leave necessary to the European living in a tropical
or sub-tropical climate, and the health of these
men suiTers in consequence in several ways, as the
charges are prohibitive.
These charges where a wife and children have to
be reckoned with will become still more serious,
for no amelioration of fares takes place in their
hohaJf. A species of exile in fact obtains which
proves detrimental to mind and body to the hus-
band, wife and children. The men sent for service
abroad in banks, mercantile firms, &c., are ad-
vancing the cause of Empire as surely ns if they
served in any of the great public services. They
112
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 1, 1920.
are chosen after careful medical selection to go
abroad; so that we are sending the cream of our
young men to the tropics which is not and never
can be a white man's country — where he cannot
rear healthy children to full manhood or woman-
hood, where educational facilities are meagre to a
degree, and mental and physical deterioration must
result as time goes on. Intercommunication with
home is thwarted by the price of travel, and the
Empire is the loser in consequence. Nor does the
loss to Empire end here. The man himself by the
nature of his Hfe, oitnn more or less isolated, at an
early period of his life is hampered in his develop-
ment. Home is far off, touch with the vivifying
influence of life in Britain is cut off. His friend-
ships are new friendships, the acquaintances of his
youth, which natui-ally become the real friends of
middle age, are lost to him, and he tends to live
his life unto himself. He becomes introspective
and what is now called " homo-sexual," a term of
wide application, and used to fit psychologically
almost every phase of mental phenomenon of
modem man. To it is ascribed the cause of much
insanity, crime, alcoholism, sexual inunorality
and bachelorhood, and even of intemperance in
the vmy of abstinence in alcohol, &e. The subject
is too long to deal with here, but there is no doubt
that it is prevalent amongst those who go abroad
for a considerable number of years to the detriment
of those men, often of good mental calibre to begin
with, who go abroad for fairly long spells of resi-
dence, especially in a tropical country.
Marriage corrects many of the evils attributed to
homo-sexuality, but marriage is hindered in
many ways until too late in life to thwart the evils
of introspection, as we prefer to call it, rather than
by the new name attached to the condition. By
whatever name it is known, it frequently takes the
form of living to one's self, and regarding one's
neighbours as apart; his failings he attributes to
others, and is imbued with supposed grievances.
He avoids society, and at times seeks relief in drugs
or alcohol, &c., and in time becomes an oddity. In
ordinary parlance he is said to be " hipped."
Unless the man obtains change of scene and sur-
roundings he will likely lose his employment
through drink or by becoming insane or so cantan-
kerous that he cannot be put up with ; he becomes
a bad master and a worse servant.
The psychology of t-o-day is all in this direction,
viz., that there is no such thing as abnormal mental
])henomeno)i without a cause; hence the Bolshevist,
the anarchist, the rabid prohibitionist, and much
of the crime so prevalent amongst us.
The cure for this, as far as the class of men we
are dealing with — namely, the British employee
abroad in our Empire — is change ; that is the pre-
vention of sameness — the chief cause of intro-
spection or ])sycIio-aiiaJj'sis us it is technically
called, due to a long spell in one place without a
real holiday. But change is difficult to get; the
price of travel is well-nigh prohibitive, and untQ
this is met in some way the outlook is bad. The
authorities of the fii-m are naturally not inclined to
spend money unless it is compulsory ; were it a
physical ailment, such as fever, dysentery, &c., all
would be well; but with mental depression, &c.,
the date is put off until it may be too late and the
man has contracted vicious habits. The mental
danger is greater than the physical, but it is less
perceptible, and therefore more serious. The
doctor untrained in mental diseases and pheno-
mena— and few of us are so trained — does his best
with tonics, diet, short changes of climate, &c., but
these are insufficient.
The new psychology will in time come to our
aid, but it is a long way off the practical stage of
treatment at present.
The only practical outcome of this discussion is
how is the question to be dealt with? From the
health point of view it is one which concerns the
medical men w-ho have charge of the health of
British folk overseas. The possibility of cheaper
passages by sea becomes a health and hygienic
necessity, and belongs to the sphere of medical
ti-eatment. The shipping companies will say: " We
are not philanthropic bodies; we have to pay our
way and see to the interests of our shareholders."
What about the French? They see to it that their
overseas countrymen are favoured; that the fares
are at a price which are fair and calculated to
facilitate more frequent visits to the homeland, and
thereby contribute towards the maintenance of
their overseas brethren. If France can do it. Great
Britain can do it if the matter is taken in hand.
For one Frenchman travelling there are twenty
British, and in such proportion is the health of
our people affected. The French will not help folk
of other countries, as see the high price they charge
the two British lads mentioned at the commence-
ment of this article. Why should they? The
policy of Britain seems to be to help foreigners and
exploit their own folk. At times this comes hard
upon us, and especially when it is a question not
of commercial benefits only, but one in which life
and death are involved, in which also the Imperial
welfare is concerned. Who is to tackle it?
Inibersitg fims.
THE UNIVERSITY OF LIVERPOOL.
LrvEHPOOL School of Tropical MEniciNE.
The Senate has awarded the Diploma in IVopical
Medicine of the University of Liverpool to the
following. W. J. W. Anderson, M.D. (Leeds); C.
E. Cobb, L.R.C.P. (Lond.), M.R.C.S. (Eng.);
Enid M. H. Cobb, L.R.C.P. (Lond.), M.R.C.S.
(Eng.); D. D. Fernandes, L.R.C.P. and S. Edin.),
L.R.F.P. and S. (Giasg.); P. T. J. O'Farreil,
L.R.C.P. and S. (Irel.); E. A. Rennor, M.D., Ch.B.
(Edin.); .1. C. Vaughan, .M.D., Ch.B. (Olasg.).
May 1, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
113
^nnctatioji?.
Antihelminthic Treatment of Intestinal Strongi/-
losis of the Horse (M. C. Hall, R. H. Wilson, M.
Wigdor, Journal of the American V eterinary Medical
Association, vol. liv, N.S., vol. vii, No. 1, pp.
47-55). — Experiments carried out in the biologieal
i-esearch laboratories of Messrs. Parke, Davis and
('()., at Detroit, Michigan, sliowed that, contrary
to the accepted theory, it is not very difficult to
eliminate strongykis from the large intestine of the
horse. The most suitable remedj" is chenopodium
nil, which ejects 95 to 100 per cent, of the strongylus
if administered to horses which have fasted for
thirty-six hours. The dose should be 16 to 18 c.c.
given in. one or more times, and accompanied or
foUowed one to two hours later by 900 to 1,000 c.c.
of linseed oil.
Rats as Agents in transmitting Ringworm to the
Horse (D. J. Kok, Tydschrift voor Diergeneeskunde,
vol. 46, No. 2, pp. 37-39, 2 figs. The Hague, Janu-
ary, 1919). — The author saw two horses affected
wdth ringworm {Trichophyton tonsurans) in a riding
school ; the ringworm, was localized to the carpal
region, the head and the inner side of the thigh.
The school had recently been invaded by rats, some
of which the author examined in order to see
whether they were the source of the infection. A
rat was found with whitish scaly patches on the
back and the microscopical examination of the skin
and hair sliowed that trichophyton was pi-esent.
The writer believes that the trichophyton observed
ia the rats was the same species as that found in
the horses, but no culttires were canned out.
Spider Venom (Journ. American Med. Assoc.,
February 14, 1920). — Little is positively known
about the specific nature of the venom of spiders,
alt-hough there has been much speculation. The
venom is an oily, translucent, lemon-yellow liquid
having an acid reaction and a hot, bitter taste. It
gives the xanfchroproteic reaction and is rendered
harmless by heating to 90° C. In many w.ays the
symptoms of spider bites resemble those produced
by snake bites, so that it is probable that the spider
venoms belong to that class of poisons. It is
known that snake venoms are very complex mix-
tures and that they differ greatly in the different
species of reptiles. Among the ingredients that
have been found are fibrin ferment and antiferment,
proteolytic enzymes, cytotoxins for red corpuscles,
and neurotoxins, as weO as leucocytes and endo-
thehal cells. The marked effects on the nervous
system produced by the bite of the black spiders.
Latrodectus mactans, and other species of Latro-
dectus indicate that the venom of these animals
resembles that of the cobra more nearly than the
venoms of Americ-an snakes. All parts of the
spider contain ,a toxalbumin which in some species
is mixed with the secretion of the poison gland.
The secretion of the' poison gland produces only
local symptoms, vinhile the general symptoms are
due to the presence of this toxalbumin. It is
because of the toxalbumin that the bite of the
Latrodectus is so severe as occasionally to cause
death in human beings. It contains a hsemolysin
called .ajrachnolysin which acts on the red cells of
man, rabbit, mouse and goose, but not on the
horse, dog, sheep and guinea-pig. Some authors
question whether the nervous symptoms following
spider bites inay not be due to changes in the blood
rather than to a direct toxic effect on tlie nervous
tissues. References: Wilson: Records of the
Egyptian Government School of Medicine, 1904,
p. 7. CasteOani and Chalmers: "Manual of
Tropical Medicine," 1910, p. 136. Browning:
" Original Investigations of Spider Bites in
Southern California," South California Pract., xvi,
391, 1901. Davidson: South California Pract.,
Cttrwnt f itcratttw.
Indian Medical Gazette.
Vol. LV, No. 3, March, 1920.
Epidemic Encephalitis (L. P. Stephen and K.
M. Bulchiaridani). — The authoi-s give a detailed
description of several cases of the disease. They
have found saJvarsan to be very efficacious in the
treatment of the condition. All the three cases
treated with this drug recovered.
A preliminary note on an investigation as to the
actual weight of the cataractous lens (A. E. J.
Lister). — The author has investigated the subject
with the assistance of Dr. Chandika Prasad Misra
and Dr. Brahama Gupta. There was an enormous
variation in the weight of the extracted lenses, the
lightest being 110 mgr. and the heaviest 340 mgr.
Kala-azar in Europeans in the Nougong district
of Assam (J. Dodds-Price).— The disease nearly
always declares itself at the end of the rains or
during the cold season. The death-rate among
European cases has been over 72 per cent., and
before the introduction of tartar emetic treatment
was practically 100 per cent.
Influenza as observed in the Sambhu Nath
Pundit Hospital, Calcutta (Debendra Nath Sen).—
The author has constantly noted a marked diminu-
tion of chlorides in the urine, and considers this
feature to be of great diagnostic importance.
The Work of a Vaccine Depot, Meiktila (J.
Eiitrican). — This depot was started in 1902 in a
very small way, but from time to time additions
and extensions were made. The best calf vaccina-
tion results are obtained in the cool dry season.
In the dry hot months difficulty has been ex-
114
THE JOURNAL OF TBOPICAL MEDICINE AND HYGIENE. [May 1, 1920.
perienced in keeping up the supply. This has been
overcome by artificially cooling the vaccinated
calves' stable and now the results obtained during
the hot season are practically as good as during
the cold months.
Oil Fuel Refuse Destruction (G. R. Oberai).—
The author describes in detail an oil fuel refuse
destructor which has given very good results. The
personnel required is at least 40 per cent, less than
for ordinary incinerators. The excreta and refuse
are disposed of with great rapidity so that there
is no smell or collection of flies about the area.
Bulletin de la Societe de Pathologie Exotique.
March 10, 1920.
A Contribution to the Helminthology of French
Upper Guinea (A. Henry and Ch. Joyeux). — The
parasites contained in the list belong for the most
part to common species, but are noted with the
object of assisting to define their geographical
distribution.
Host. Wobms.
fAscaris lumbricoides (L.)
Trichocephalus trichiurus
Enterobius vermicularis (L.)
I TcBnia saginata
,, J Bymenolepis nana (v. Sieb.)
'"*° ] Schistoscnnum hamatobium (Bilh.)
I Schistosomum Mansoni (Samboni)
I Necalor americanus St.
CEsophagostomum brumpli (Rnill. and
t Heniy)
( CEsophagoatomum brumpti (Raill. and
! Henry)
Characosiomum asmilium (Raill.)
. ! Subulura distans (Rud.)
Apes ' Di^gfiiaria corynodes{LiDst.)
I Watsonius Watsoni (Conyngham)
Streptopharagus pigmentahis (G. Blanc)
^ Cysticercus tenuicollis (Rud.)
fStrongylua edentatus (Looss)
, Oxyurus equi (Zeder)
Horses, mules ] CyficosuJum sp.
and donkeys , Qastrodiscus otgyptiacus (Sons)
yStrongylus vulgaris (Looss)
iCEsophagostomum radiatum (Rud.)
Hctmonchua contortus (Rud.)
Paramphislomum (probably cotylophorum)
Fischdr.
Fasciola gigantica (Cobb)
(Trichocephalus affinis (Rud.)
I (Esopliagostomum radiatum (Rud. )
„ . , Hcemonchus contortus (Rud.)
Zebus from I ^^^^^^^ digitata (Linst.)
benegal \ Paramphisto^num (probably cotylopliorum)
I Fischdr.
^ Fasciola gigantica (Cobb)
fHceiiumchtis contortus (Rud.)
Fusciola gigantica (Cobb)
Cy::ticercus tennicollis (Rud.)
/ Tricliocephalus affinis (Rud.)
I CEsopliagoslomum columbianum (Ourtice)
Sheep from J Hcemonchus contortus (Rud.)
Senegal j Cysticercus tenuicollis (Rud.)
I Paramphixtomum sp.
\Fasciola gigantica (Cobb)
,„.,, ,, ( Gas/ro^/iuJnx (probably minuiH.'!) Fischdr.
Wild antelope ^ 5^^^^ ^p
Domestic pig ... (Esopha^ostomum dentalum (Rud.)
Native dog ... Ankylostomum caninum {Erco\a.Bi)
Domestic cat ... Belascaris mystax (Zeder)
Felis serval J Bilascaris sp.
Scher \ Par ocephaltis armillatus [Viym.)
'''&'S "" l^'^'^P'^''" armUlatus (Wym.)
Rat \ ^<''"*"^'' campance (Huet)
{Mepaticola hepatica (Bancroft)
/ Teirathyridium (Rud.), species unknown,
Psammophis I to which the authors propose to give
aibilans L. j the provisional name of Tethrathyridium
Kpsammophisi.
A Simple Method of preparing an Eosinate of
Borrel's Blue for Blood Examinations (E. W.
Suldey). — Put 100 c.c. of Borrel's blue into a
beaker with 50 c.c. of a 1 per cent, solution of
eosine in water, stir well, and leave for six to
twelve hours in an ordinary temperature. Pass
through a fine filter, and allow the precipitate to
dry. Carefully scrape the latter together and dis-
solve it in 150 c.c. of alcohol (90° or 95°). Leave
the solution uncovered for forty-eight hours, stir-
ring from time to time, and then pour into a well-
stoppered yellow glass bottle and keep in a dark
place.
Method of Use. — The blood should be dry, not
fixed, and fairly fresh. Place from 3 to 5
drops of stain well over the smear and leave for
one or two minutes (taking care that it does not
evaporate). Pour from 30 to 50 drops of dis-
tilled water over the slide and allow to mix with
the stain. Remove the slide after ten to fifteen
minutes, wash, let it lie in distilled water for one
or two minutes until a clear pink tint appears, and
then dry. If the pink colour is not suflBciently
definite place the slide for a few seconds in a 1 per
cent, solution of tannin. Hanson's borated blue
(in the proportion of 100 c.c. for 100 c.c. of the
1 per cent, solution of eosine), or Stephens and
Christophers' carbonated blue may be used instead
of Borrel's blue, provided they are in good condition.
.1 New Methylene Eosinate (Francois Motais). —
The following simple and effective stain was
evolved in the Hue laboratories: —
HoBscht's medicinal methylene blue 1 grm.
eosine 040 „
Methyl alcohol 403 c.c.
Absolute ,, 80-3 „
Glycerine 3-3 „
.\mmoniated silver nitrate solution (Pontana"s
solution) 3-3 ,,
Dissolve the blue and the eosine in the methyl
alcohol, add the absolute alcohol, the glycerine
(drop by drop), and finally the ammoniated silver
nitrate solution. Boil for three or four minutes on
a water bath, stirring vigorously. Allow to cool
and filter.
Fotitana's Solution .
Dissolve cold, then pour some of the solution
intii a beaker. .\dd the ammonia little by httle
May 1, 19i0.] THE JOUBNAL OF TEOPICAL MEDICINE AND HYGIENE.
115
with a pipette, stimng with a glass rod all the
time. A brownish precipitate will form, which
gradually darkens, and then suddenly begins to
clear. From this point the addition of ammonia
must proceed with great care, and cease while the
solution is still slightly opalescent. If it becomes
quite clear a little more silver nitrate may be
added.
Staining Terliniquc.
Place the slide in u Laveran-Mesnil bath,
sprinkle with fifteen drops of the stain, cover' to
prevent evaporation, and leave for not more than
one minute. Turn the slide upside down, then
pour 15 c.c. neutral distilled water into the bath,
stir well, allow the slide to remain for from five
to fifteen minutes according to the thickness of the
section, wash and dry.
Blood Cultures in Bubonic Plague. Early Septi-
I cxmia in a Case of Bubonic Plague, followed by
' Recovery (H. J. Cazeneuve). — A sailor was ad-
! mitted to hospital with high fever, acute delirium
i and marked inguinal adenitis. Bacteriological
examination revealed no evidence of any of the
. acute infections endemic at Salonica. On the
'. third day 10 c.c. of blood were taken and the plague
i bacillus isolated, though serum from the bubon
j yielded no definitely identifiable organisms. Anti-
' plague serum from the Institut Pasteur was 'ad-
i ministered subcutaneously. On the seventh day
the temperature fell, and the patient became con-
valescent on the tenth day.
,- Questions of Salubrity and Sanitary By-laws in
French Guinea (Marcel Leger). — The paper re-
sumes the measures taken to combat malaria and
j leprosy in French Guinea, and seeks to correct the
I popular impression that the colony is exceedingly
■ unhealthy. It shows that malaria is already dis-
I appearing from the towns, and though more difficult
to handle in the country district is rapidly coming
under control in the villages, where the people are
intelligent and willing to co-operate.
The .etiology of Beriberi (F. Clair).— The writer
has studied beriberi in Brazil, Japan, Java, Indo-
China, India, Mauritius and Madagascar. He is
of the opinion that while unhealthy surroundings,
insufficiently varied and poor quality food, malaria,
worms, digestive troubles, &c., are all predisposing
factors, the actual cause of the disease is to be
sought for in an infective organism as yet un-
identified.
Beriberi and Vitainine Deficiency (E. Marchoux).
— An outbreak of beriberi followed an epidemic of
influenza in a camp of 2,000 Annamites at
.\ngouleme; 432 cases occurred, of which thirteen
'died. The men were particularly well fed, then-
(diet consisting of fresh meat and fish, salads, dried
jand fresh vegetables, cheese and fruit, with decor-
jticated rice in place of bread. The outbreak lasted
Ifmm May to November, and ceased when the rice
ration was discontinued. The writer considers that
in this case the beriberi cannot be attributed to
vitamine deficiency, afld suggests the agency of
some germ thriving on rice debris in the intestine.
Any difficulty in the digestion of starchy matter
would give time for the genn to develop and pro-
duce intoxication, and this explains why only some
men were attacked and not all, as would have
happened had any deficiency in diet been to blame.
How Mange in Domestic Animals should be dealt
with in the French Colonies (H. Velu). — The writer
gives an account of the dipping methods employed
in the British colonies and America. He particu-
larly advocates the use of Cooper's solution, which
he tested on pigs, horses and mules in Morocco,
and found to be most effective.
Encystment of a Cercaria of the Cercaria arniata
Type in a Fresh-water Turbellaria (Ch. Joyeux). —
Attention was first called to the presence of the
cercaria in molkiscs of the genus Planorbis attic us
(Roth) in an irrigation well in Lower Macedonia
during the months of April and May. Subse-
quently it was found in a turbellaria, probably
Dendrocoelum lacteum (Miill), in the same well.
Though belonging generally to the Cercaria armata
group, it could not be identified with any of the
species already classified. A full description is
given in the article. Circumstances connected with
the well would seem to indicate frogs or toads as
the animals in which the cercaria reaches adult
form, though what the last stage in its development
may be is doubtful.
Note on a Case of Kala-dzar in a Child at Gabon
(Elie Toumier). — The child, a boy of 3, had never
left his native village. Both liver and spleen were
enlarged, the latter enormously, and puncture
enabled the identification of large quantities of
typical Leishman bodies. Atoxyl was administered
too late to be effective, and the patient died on the
fifteenth day. This is the first case of Leish-
maniosis observed in Equatorial Africa.
Plasmodium falciparum. Infection and Nov-
arsenobenzol (P. Brau and J. M. Marque).^
Malarial patients at a very \inhealthy military
station (now closed) in Cochin China, from whose
blood P. falciparum (sporocytes and crescents) was
recovered, showed a very much more favourable
reaction to novarsenobenzol than to quinine or
arrhenal.
The Gametes of Plasmodium prsecox and the
Variable Proportion of Male and Female Elements
(P. Abrami and G. Senevet). — As the result of very
careful study of the blood of a non-treated ease, the
authors find that in the intei-val between two
attacks of malaria the total number of crescents
in the blood-stream diminishes, and that the male
elements disappear more quickly than the female.
They attribute the disagreement existing between
writers on the latter point to lack of a definite
116
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [May 1. 1920.
method of estimating probable error, and to the
possibility of their investigations having been made
at diflferent stages of the disease.
The Manufacture and Uses of Essence of NiaouU
(C. Nicolas). — The Niaouli tree (Melaleuca Viridi-
ftora) is found exclusively, but very abundantly, in
New Caledonia. The essence distilled by the
natives from its leaves is mixed with oil in various
proportions in France and sold under the trade
name of Gomenol. In New Caledonia, however, it
is used in a pure state, and during a long period
of service in that country the writer found it of
great utility as an antiseptic. He employed it
with excellent results (generally pure, but on rare
ocoasions diluted with 50 per cent, olive oil) for
clean or infected wounds, for washing out fistulous
tracts, abscess cavities, Ac, for metritis, cystitis,
(fee, for bums, for all forms of external application,
for inhalations, and internally.
On a further case of Amoebic Dysentery in a Dog
(J. Bauche and F. Motais). — A four-year-old
{jointer at Hue, showing the usual clinical and
microscopic signs of amoebic dysentery, was treated
with emetine but died. At autopsy the lesions
found appeared to show that death was due to in-
toxication by the emetine after eradication of the
amoebsB had taken place, and the author considers
that the case establishes a parallel with amoebic
dysentery in man.
Coriccrning a case of Tetanus. Use of Dried
Herum and Large Doses (C. Nicolas). — A New
Hebrides stockman, showing every symptom of
advanced tetanus, was given 60 c.c. of first French
and then American serum (in conjunction witTi
chloral and bromide by mouth) for two days, at the
end of which time the supply ran out. On the
third day a stock of dried veterinary antitoxin of
English origin, at least ten yeai-s old, was dis-
covered, and as the patient seemed in a hopeless
condition this was diluted in boiled and filtered
water and a subcutaneous injection of 60 c.c.
administered. The treatment was repeated until
the seventh day, and the patient made an excellent
recovery. On a later occasion the French manager
of the station was treated for tetanus in a similar
manner (i.e., with dried veterinary antitoxin) and
made an equally satisfactory recovery.
Hcemogregarina in a Macactts Monkey (M.
Langeron). — In view of Krempf's description of
Hxmogregarina hominis in 1917 and Roubaud's dis-
covery of Hcemogregarina inexpectata in 1919, the
author describes an organism which Re recovered
from the blood of a Macaciis cynomolgus in 1912
hut was then unable to identify. He is of the
opinion that the existence of Haemogregorina in
both man and monkey is now proved, and as his
own discovery resembles Hiemogregarina hominis
and Hxniogregarina inexpectata but is identical
with neither, he proposes to give it the name ot
Hsemogregarina blanchardi in memory of Prof.
Blanchard.
U^jiorts aiti Ifjrints lereibrb.
C. H. Treadgold, M.D.Cantab., D.T.M. (Paris):
" On a Filaria, Loa Papionis N. S.P., Parasitic in
Papio Cynocephalvs:" Parasitology, vol. xii, No. 2,
March, 1920.
Prof. Camillo Golgi : "Sulla Struttura dei Glo-
buli Rossi DeU'Uomo e di Altri Animali : " Dal
Bollettino della Societa Medico-Chirvrgica di Pavia
(Anno XXXI— Fasc. 3—1919).
M. Rodriguez Castroman : " Nuevo ciencia Anti-
tnberculosa," De la Semana Medica, No. 20, 1919.
M. Rodriguez Castroman: " El bacilo de Ferraa
y los procesos tuberculogenos : " Trabajo presi
tado al Segundo Congreso Americano del Nino
celebrado en Montevideo del 18 al 25 Mayo de 1919.
M. Nicolle, E. Cesari, C. Jouan : " Toxines at
Antitoxines. " Messan and Co., Paris.
Dott. Costanza Boccadoro : " Di Alcune Speeiali
Formazioni (parassiti 2). Che Si Riscontrano Nel
Vitello Delle Uova Delia Rana Esculenta : " Dal
Bollettino della Societa Medico-Chirurgica di
Pavia (Anno XXXI— Fasc. »— 1919).
Edwai-d Jenner Wood, M.D., Wilmington, N.C. :
" A Mixed infection with Tertian and Quai-tau
Malaria occurring in a Patient with Symriietrical
Gangrene," Journal of the American Medical Asso-
ciation, December 7, 1907, vol. xlix, pp. 1891-
1895.
Edward J. Wood, Wilmington, NortJi Carolina:
" The Occurrence of Yaws in the United States,"
The American Journal of Tropical Diseases and
Preventive Medicine, vol. ii, No. 7, January, 1915,
pp. 431-449.
Edward J. Wood, M.D., Wilmington, N.C:
" The Occun-ence of Sprue in the United States,"'
The American Journal of the Medical Sciences,
November, 1915, No. 5, vol. cl, p. 692. '.
k. K. Yegnanarayana Iyer, M.A., F.C.S.,
N.D.D., Deputy Director of Agriculture in Mysore:
" The Improvement of Indian Dairy Cattle," The
Agricultural Journal of India, vol. xiv, Part v,
October, 1919.
R. Branford, M.R.C.V.S., Superintendent, Gov- ,
eniment Cattle Farm, Hissar: "Note on an out-
break of SuiTa at the Government Cattle Faiin, ,
Hissar, and on Cases treated," The Agricultural \
Journal of India, vol. xiv. Part v, October, 1919.
Prof. John L. Todd, McGill University, Montreal, '
Canada: (1) "The After-History of Ti-ypanoso-
miasis in Africa;" (2) "Concerning Immunity to'
Human Trypanosomiasis," New Orleans Medical
and Surgical Journal, vol. 72, No. 5, November, '
1919.
Prof. John L. Todd, M.D., "The Granules of
Spirochn'ti duttoni," Bulletin dc la Societe de .
Pathologic Exotiquc. tome xii, No. 9, Stance du
12 Novembre. 1919.
May 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 10, Vol. XXIII.
*nj[tnal Commtmirations.
MILKOY LECTURES ON THE HIGHER FUNGI
IN RELATION TO HUMAN PATHOLOGY.'
By Aldo Castellani, C.M.G., M.D., M.Il.C.P.Ldncl.
Physician to the Tropical Hospital {Ministry of Pensions ;
Lecturer at tlie London School of Tropical Medicine).
Lecture II.
The higlier fungi may attack any organ and
system of the human body, the integumentary
system being the most frequently and the nervous
system the most rarely affected. It would take
too much time to discuss seriatim the numerous
mycological affections of the various systems, and
I r will limit myself to only touching on the fol-
; lowing so-called internal mycoses : (1) Thrush.
. (2) Broncho-mycoses. (3) Tonsillo-mycoses. (4)
Certain mycoses of the nervous system and organs
of special sense. (5) Certain mycoses of the uro-
i genital system.
Thrush.
It is generally stated that thrugh is due to the
fungus Oidium albicans, Robin (Syn. : Monilia
albicans, Robin). For many years, however, I
; have endeavoured to demonstrate that the eeti-
I ology of thrush is far from being so simple, and
I that this condition, at least in the tropics, is not
caused by one fungus only,- but by a number of
different fungi, and that in reality the tenn
thrush does not cover one affection, but a group
,of clinically similar conditions due to various
organisms.
The fungi I have so far isolated belong to various
genera and species : —
Oidium albicans, described by C. Robin in 1853,
belongs in reality to this genus, and its correct
name is therefore Monilia albicans (C. Robin,
1853). There is little doubt also that the term
Oidium or Monilia albicayis has been used in the
past to cover a number of different fungi, as proved
by the widely different descriptions of it given by
different authors. For instance, some obsei'vei's
state that the organism liquefies gelatin, others
deny that it possesses such action. Certain autho-
rities describe it as coagulating milk, others as
having no action on this medium.
The more important Monilia fungi I have found
in thrush belong to the following types: —
M. balcanica, Cast., ferments, with production
of gas, glucose only.
M. krusei,' Cast., ferments, with production of
gas, glucose and laevulose.
M. pinoyi. Cast., ferrments, with production of
gas, glucose, laevulose, and maltose.
M. metalondinensis, Cast., ferments, with pro-
duction of gas, glucose, laevulose, maltose, and
galactose.
M. tropicalis, Cast. (fig. 1, 2, and 3), ferments,
with production of gas, glucose, laevulose, maltose,
galactose, and saccharose.
M. guillermondi, Cast, (rare), ferments, with pro-
duction of gas, glucose, laevulose, and saccharose.
M. macedoniensis. Cast, (rare), ferments, with
production of gas, glucose, laevulose, galactose,
saccharose, and inulin.
M. pseudotropicalis (extremely rare), ferments
with production of gas, lactose in addition to other
sugars.
M. pseudolondincnsis , ferments dextrin in addi-
tion to other sugars.
Class: Funqi imperfecti. 1^^ , mi. ,, i -a ■■, n-- o j (Genus Monilia, Persoon— Several species.
» V' Order TAaiiosporaJ^s -Family Oosi,orace<J, Saccardo. | Qenus Oidium, Link-Three species.
Subclass: Hyphales. (Order Hemisporales— Genua Hemispora, Vuillemin— One species.
-,, , i f, u , r, 1 ( Family £/Kio»ti/c«<ace<s Bees —Genus B»(io/»vc«Si Roes —One species,
.lass : .4scomyce<es -Sub-class : ProloA /J f Genus Saccfearo^j/ces, Meyen- One species,
(iscomycetes -Order Saccnaromi/cetales. |Pamily Saccharomycelace^, Rees j ^^^^^ Willia, Hansen-One species.
Fungi of the Genua Monilia, Persoon.
These are the fungi most commonly found in
Ithrush. As regards their botanical characters, it
suffices to say, from a practical point of view, that
these fungi are characterized principally by the
following features. In the lesions the vegetative
|body (thallus) is composed of mycelial threads of
t-ather large size often showing arthrospores and
aumerous free oval or roundish budding yeast-like
forms; in cultures, especially on solid media,
mostly roumlisli or oval budding elements are seen,
[vhile mycelial filaments are very scarce or absent.
jThese fungi, as a rule, ferment with production of
eas, glucose, and often other sugars. The only
jnonilias I know of which do not attack any sugar
kr other carbohydrate are M. .■^eylanica, Cast., and
». zeylanoides. Cast.
'; There is little doubt that the original fungus
' Delivered before the Eoyal College of Physicians of London.
M. zeylanica. Cast. (fig. 4), does not produce
gas in any sugar or other carbohydrate. This
group contains the folowing species: M. zeylanica,
Cast., M. zeylanoides. Cast.
M. albicans, Robin, sensu stricto belongs to the
metalondinensis type, and I have very seldom
isolated it.
I should like to emphasize the point that a large
number of fungi of the genus Monilia Iiave not
permanent sugar reactions, they often lose some of
their original fermentative properties and can be
trained to ferment sugars which they do not fer-
ment when recently isolated, and therefore, for
purposes of classiification and comparison, such
fungi should be investigated, using only recently
isolated strains (see Table I.).
Fungi of the genus Oidium sensu stricto. — This
genus is morphologically closely allied to Monilia,
and mycelial threads are very abundant bof- in
the lesions and in cultures, and budding, yeast like
Monilia alba Castellani 1911
M. albicans Robin 1853
M. balcanica Cast. 1916
M. balcanica Cast, str&in 2
M. bethaliensis Pijper 1918
M. burgessi Ca.&t. 1912
If. chaiffwrsi Cast. 1912
.1/. decolorans Cast, and Low 1913 ...
Af. enterica Cast. 1911
itf./acofe Cast. 1911
M. guillermondi Cast. 1910
M. inUstinalis C&at. 1911
if. fcntsei Cast. 1909
M. J<m<J»TiensM Cast. 1916
M. lustigi Cast. 1912
M. macedoniensis Cast. 1917
M. metalondimnsis Cast. 1916
M. Tnetatropicalis Cast. 1916
Jf. nafcarroi Cast. 1917
M.negriiCast. 1911
M. parabalca7iica Cast. 1916
if . para&ruset Cast. 1912
M. paratropicalis Cast. 1909
ilf. perrji Cast. 1912
M. pinoyi Cast. 1910
M. vsnido-bronchialis Cast. 1916 ...
if. pseudo-guillermmidi Cast. 1916 ...
if. pseiido-Umdinensis Cast. 1916 . . .
if. psettdoUmdinoides Cast. 1916 ...
M. pseudo-metalondinensis Cast. 1916
il. psetido-tropicalis Cast. 1910
if. pseiLdo-tropicaloides Cast. 1919 ...
if. rlioi Cast. 1909
if. rosea Zenoni 1910
if. Iropicalis Cast. 1909
M. seylanica Cast. 1910
M. zeylanica similis 1911
M. zeylanoides Cast. 1917
AG
AG
AG
AG
AG
AGs
AG
AG
AG
AG
AG
AG
AG
AG
A
AG
AG
AG
AG
AG
AG
AG
AG
A
AG
AG
AG
AG
AG
AG
AG
AG
AGs
A
AG
AG
AG
AG
AG
AG
AG
AG
AGs
AG
AG
AG
AG
AG
As
AG
AG
AGs
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
Cor A
Cor Ae
AG
AGs
AG
O
AGs
O
0
AG
A
O
O
0
AG
AG
AG
AGs
AG
AGs
AGs
Cor A
Dor As
A
AG
AGs
O
A
AG
AGs
As
AG
AG
AG
AG
AG
0 or As
A
Avs
AorO
AG
AG
AG
As
O
O
AG
A
AG
AG
0
AG
AG
AG
0
Oor A
Avs
AG
Oor A
Oor A
0
A
0
Avs
0
O
0
As
0
0
0
AGs
0
AG
o
A
0
AG
0
AGs
o
AG
0
A
0
0
A
A
0
AGs
0
AG
0
0
0
AG
0
0
0
AG
0
0
o
O
0
AG
0
AGs
o
0
o
AG
0
AG
0
0
o
O
o
0
AG
AG
AG
AG
O
AG
0
AGs
Oor As
Oor A
Oor As
0 or As
Oor As
A
0
o
o
O or As
0
O
AGs
O
0
0
0
O
0
O
0
AG
O
O
o
0
0
0
o
Avs
o
0
0
0
o
AG
O
0
0 or Avs
Oor A
0 or As
0
0
0
0 or As
O
0
O
A
As
O
0
0
O
0
A
O
O
0
o
0
o
0
Avs
0
o
0
0
AG
AG
0
O
0
O
AC
AC
O
0 or A
O
Alk
ADS
O
AC
0
AC
AC or P
0
AC
AC
AGs
0
ACs
Oor A
Oor A
Abbreviations used in the table— A = acid. G = gas. C = clot (milk) clear (broth and peptone water) ; CTP = clear at first, tift
thin pellicle present. D = decolorized. P = peptonized (milk), pellicle (broth). Alk = alkaline, s = slight, vs = very slight. 0 '^
negative result, viz., neither acid nor clot in milk; neither acid nor gas in sugar media; non-production of indol ; non-liquefactiOB *
gelatine or serum as the case may be. + = positive result ; liquefaction of medium.
May l;j, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
iKsJ
Fig. 2.
Moiiilia tiopicalis : preparation fiom
a ghicose-agar culture.
W'iIIki a--cosi)ores.
Tonsilki-mycosisdiu' U> ll,<ins.i»
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [May 15, 1920.
cells are rare. Fungi of this genus may occasion-
ally induce an acid fermentation, but never pro-
duce gas in any carbohydrate. I have found
fungi of this genus in certain cases of thrush in the
tropics and in the Balkans, but so far not in
England. I have isolated three species (figs. 5, 6,
and 7): Oidium matalense, Cast., 0. asteroides,
Cast., and 0. rotundatuni, Cast. It is interesting
to note that I have found the same species in
cases of mycotic tonsillitis and in the expectoration
of certain cases of bronchitis, while I have observed
O. asteroides also in the stools of certain cases of
enteritis.
Fungi of the genus Hemispora. — The botanical
characters of these fungi I have given in my first
lecture. They are characterized by the presence
of abundant mycelial hyphae, some of which are
conidiophores. Each conidiophore terminates into
an ampulliform or sausage-like structure, which is
called protoconidium. The protoconidium later
divides into a number of spore-like segments, which
are called deuteroconidia.
So far only one species of this genus has been
found in cases of thrush, Hemispora rugosa (fig. 8).
This fungus was first isolated by me from a case
of mycotic bronchitis in 1910, and in a case of
tonsillitis in 1913, and observed in a case of thrush
by Pijper in 1915. T\vo varieties can be distin-
guished; one liquefying gelatin, the other having
no such action on the medium.
Fungi of the genus Willia, Hansen. — These fungi
are characterized by the pecuhar bowler-hat shape
of their ascospores. I isolated a fungus belonging
to this genus in Macedonia from a case of thrush in
a gipsy. In sugar broths it formed a thick pellicle
containing air-bubbles. It produced gas in glucose
and laBVulose only. Cultures on solid media con-
tained asci with '2-4 spores of the peculiar bowler-
hat-like appearance (fig. 9). The fungus seemed
to be somewhat similar to WilUa unomaJa, Hansen,
but the investigation of it is not yet complete.
Fungi of the genus Endomyces, Link. — These
fungi are on supei-ficial examination similar to those
of the genus Monilia, budding elements and my-
celial threads being found in the lesions, and
mostly budding elements in cultures. There is,
however, a very important character which dif-
ferentiates these fungi : in old cultures of endo-
myces asci are present. Only once have I come
across a case of thrush due to a tiue endomyces,
in Macedonia in 1917. I considered it to be E.
vuilleTnini, Landrieu.
Fungi of the genus Saccharomijces, Meyen. — In
the Balkans I found a case of thrush due to a
typical saccharomyces, which I have only recently
studied. Fungi of this genus are characterized by
the vegative body consisting only of budding ele-
ments, and by the presence of asci in cultures.
The saccharomyces isolated by me ferments with
production of gas, glucose, laevulose, galactose,
maltose, and saccharose. It does not clot milk,
which, however, may occasionally become acid.
Gelatin and serum are liquefied.
Clinical Varieties of Thrush caused by above Fungi.
1 have always endeavoured to combine the
laboratory and the clinical investigation of the
cases of thrush observed, in order to see whether
different groups of fungi are causing different types
of the condition. In my experience two prin-
cipal varieties of thrush may be distinguished
clinicaHy : —
(1) White or white-greyish type. — This is by far
the most common, and in this country apparently
the only one found. It is characterized by the
cream-white colour of the patches.
(2) Yellow, or yellow-brownish type. — This is
characterized by the yellowish, occasionally
brownish, colour of the patches.
The first type (or white type) may be caused by
any species of the genus Monilia (except M. zey-
lanica, Cast., and M. zeylanoides. Cast.), by
Oidium matalense, Cast., by Endomyces vuillemini,
Landrieu, and by fungi of the genus Saccharo-
myces, Meyen, and Willia, Hansen. The second
type (or yellow variety) is caused by M. zeylanica.
Cast., M. zeylanoides, Cast., Oidium rotundatum.
Cast., and Hemispora rugosa. Cast.
In conclusion, I should like to say again that
thrush is not caused by one species of fungus only,
the so-called thrush-fungus or Oidium albicans,
Kobin, as generally stated. It is caused by a
number of different fungi, some of which are
botanically very far apart from each other, and
belong to separate species, genera, and families.
Sprue.
Before leaving the subject of thrush I might say
a few words on a very important tropical disease,
which, according to many authorities, is astiologi-
cally connected with thrush — namely, sprue.
This tropical affection, very common in Ceylon, is
characterized, as well known, by pz'ofound ansemia,
progressive '»^oting of the patient, and white,
frothy diarrhoea. Kohlbriigge first in 1901'
ascribed the disease to the thrush fungus: Oidium
or Monilia albicans. He made a very thorough
histological study of one of his cases which ended
fatally, and emphasized the fact that the fungi,
in sections of the tongue, &c., had invaded the deep
strata of the mucosa, the glands, and portions of
the sub-mucosa. These findings were speedily
confimied by other observers, and Le Dante in
1907 suggested for the disease the term of " Blas-
tomycosis intestinalis. " During my long stay in
Ceylon I investigated the intestinal mycological
flora of several cases of sprue, and I found that fungi
v,exe present ahnost constantly. 1 noted the fol-
lowing: M. decolorans. Cast., and Low, M. intes-
tinalis. Cast., M. fxcalis. Cast., M. insoUta, Cast.,
M. tropicalis, Cast., M. enterica. Cast., 0. rotun-
datum, Cast., 0. asteroides. Cast. I believed the
monilias to be the probable cause of the frothy
diairhoea, but I did not agree with Kohlbriigge
that tliey were the primary cause of the malady.
May 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
121
Low came to the same conclusion as I did. Re-
cently Kolilbriigge's work has been supported in
a series of i)ublications by Bahr, Ashford, and
others, while Sir .James Cantlie has brought forward
tlie hypothesis that it is a deficiency disease, and
Sir Leonard Rogers and Nicholl the theory that it
is a streptococcus infection.
I have made tentatively the suggestion that, as
is the case with dysentery, the tenn sprue may
perhaps cover several clinically similar but setio-
logically different conditions : one might be of
mycological origin, another of bacterial oi-igin, &c.
Broncho-mycoses.
Bronchial affections due to the higher fungi are
quite common in the tropics, and are occasionally
met with also in temperate climates. They may
be classified in several groups as follows: —
(1) Causative fungus belonging to the genus
Nocardia, Toni and Trevisan, or the genus Cohni-
streptothrix, Pinoy : Nocardiasis.
(2) Causative fungus belonging to the genus
Monilia, Persoon : Broncho-moniliasis.
(3) Causative fungus belonging to the genus
Oidiutn, Link: Broncho-oidiosis.
(4) Causative fungus belonging to the genus
Hemispora, Vuillemin : Broncho-hemisporosis.
(5) Causative fungus belonging to the genus
Aspergillus, Micheli, and Strrigwnforysfix, Cramer:
Broncho-aspergillosis.
(6) Causative fungus belonging to genus Prni-
riUivni, Link: Broncho-penicilliosis.
(7) Causative fungus belonging to the genera
Miiror, Micheli; Bhizomiicor, I>ucet and Constan-
tin : Broncho-mucormycosis.
(8) Causative fungus is a Sporntricliitini :
Broncho-sporothrichosis.
I have come across cases of all the forms I have
mentioned. The severity of these affections depends
a great deal on the variety of fungus present. If
the condition is of nocardial origin the prognosis is
very bad, if of monilia or oidium origin the outlook
is less unfavourable, though certain cases terminate
fatally. If the affection is caused by a sporo-
trichium, a hemispora, or in general by hmgi which
are rapidly influenced by potassium iodide, the
prognosis is good.
I may perhaps be allowed to say a few more
words about three of the varieties I have mentioned.
(1) Broncho-moniliasis, and in connection with it
" ted- factory and tea-taster's cough."
(2) Broncho-mucormycosis.
(3) Broncho-aspergillosis.
(4) Broncho-penicilliosis.
(5) Broncho-nocardiasis.
Broncho-moniliasis .
This variety of broncho-mycosis was described by
me in 190') in Ceylon. The condition has recently
been found in many tropical and subtropical coun-
Arch. f. Schiff's u. Tropen Hygie
tries, and even in the temperate zone. Pijper has
described cases in South Africa, and Chalmers and
MacDonald and Fahra had a number of cases in
the Soudan and Egypt, while lacono has found
several cases in the south of Italy, and only a few
weeks ago I found a case in this country. The
condition appears to be caused by several different
species of the genus Monilia, which I have de-
scribed on other occasions (see also Castellani and
Chalmers's " Manual of Tropical Medicine," p.
1886).
Clinically, a mild type and a severe type of the
malady may be distinguished, with, of course, a
number of intermediate cases. In the mild type
the general condition of the patient is good, there
is no fever, and he simply complains of cough.
The expectoration is muco-purulent, often scanty,
and does not contain blood. The physical examina-
tion of the chest is negative or reveals only a few-
rales. The condition may last for several weeks
or months, and may get cured spontaneously, or
continuing, may turn into the severe type.
The severe type closely resembles phthisis. The
patient becomes emaciated, there is hectic fever,
and the expectoration is often bloody. The physical
examination of the chest nia.y show patches of dull-
ness, fine crepitations, pleural rubbing. This type
may be fatal.
The treatment consists in giving potassium iodide
to which glycerophosphates and balsamics may be
associated. It is interesting to not*, how-ever, that
ill certain cases potassimn iodide has practically no
beneficial action whatever.
Tea-taster's Cough.
In connection with broncho-moniliasis, I may say
a few words on the so-called " tea-taster's cough "
and "tea-factory cough." In 1906 a young assis-
tant in one of the big Ceylon firms, a tea-taster,
came to consult me for a chronic cough, which he
said had not yielded to ordinary treatment, and had
been sus])ected by several medical men to be of
tuberculous origin. He emphatically stated, how-
ever, that he did not believe it was tuberculosis.
"I am merely suffering," he said, " from tea-
taster's cough," an expression I had never heard
before. The general condition of the patient was
good, and the physical examination of the chest
revealed only a few coai-se rilles. The microscopical
examination of the sputum was negative for T.B. ;
instead I noticed microscopically some mycelial
filaments and some yeast-like bodies. I inoculated
several gluoose-agar tubes and I grew a Monilia
fungus which, at the time, I believed to be an
endomyces.
How did this patient get infected"? Tea-tasters,
in order to judge of the quality of the various teas,
not only taste infusions, but often fill their hands
with the tea-leaves and bury their noses in them,
sniffing them up; in this way a certain amount
of tea-dust enters the nasal cavities. Now if
one examines tea-duat in (Vylon, one finds
that it contains fungi of the genus Monilia
122
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1920.
constantly, of the genera Aspergillus and Peni-
cillium frequently, and of the genus Oidmm occa-
sionally. A peculiar streptococcus is also very
often present. The same organisms are not rarely
found in the nasal cavities of tea-tasters, and when
bronchial symptoms appear in them monilia-like
fungi are present in the expectoration. It is prob-
able therefoi-p tlint tlic so-called tea-taster's cough
is a moniliasis, csiMiially as a guinea-pig, in the
nostrils of wliuli I insufflated tea dust regularly.
■lirnii
-jjueumonia.
died with syiii|i
What I 'li;i\r s.inl al„,ilt ' ' (.■ .-t :i ster's cough"
applie<l to a -rraf rxtent t,, lli,. so-ealled "tea-
factory cougli." For many years planters have
noted in Ceylon that the coolies doing work in the
t«a-fa<;tory, where the leaves -are dried and there is
a large amount of tea-dust floating about, after
some months become weak, lose flesh, and often
have a cough with muco-purulent expectoration.
The planters have found by experience that these
coolies must be taken away from the factory and
sent to work in the field, and then the symptoms
slowly disappear. I have examined some of these
coolies, and their expectoration practically always
contains fungi of the genus Monilia. I hav6 little
doubt, therefore, that the so-caJled tea-factory
cough is a broncho-mycosis and probably a broncho-
moniliasis.
Broncho-m ucormycosis.
While I was in Macedonia a Serbian was sent to
me with the diagnosis of T.B. The patient was
very ansemic, very weak, and was losing flesh
rapidly; slight -fever at night. Sputum muco-
purulent. The examination of the chest revealed
nothing except a few coarse i-ales. Examination of
the sputum for T.B. constantly negative; inst-ead,
a few mycelial segments were noticed on several
occasions. Glucose agar tubes and other media
were inoculated and a fungus was isolated, which
at first showed cultural characters somewhat
monilia-like ; in subcultures, however, the charac-
ters of a niueor appeared ; a yellowish ovoid-shaped
"columella," sporangium globular, about 50
microns in diameter, of yellowish colour; spores
elliptical, smooth.
How did this patient get infected ? It is interest-
ing to note that he was in charge of horses and
often had to remove horse-dung. As is well known,
Mucor niucedo, L., is extremely common in horse-
dung.
Broncho-aspergillosis.
I have seen several cases of this condition in the
tropics — a case in an island in the Adriatic, another
in Macedonia. These two cases have been diagnosed
as T.B.; from one Aspergillus funiigatus, Freseniu.s,
was grown; from the Macedonian case a fungus
very similar or identical with Stcriginatacysiis
nigra, Cramer, was isolated. In France, as well
known, a peculiar bronchial aspergillosis is common
among pigeon breeders (gaveurs de pigeon), who
fill their mouths with grain and blow it into the
mouths of the pigeons. The grain contains s[;ores
of various aspergilli and after a time most gaveurs
become infected.
Bronclio-penicilliosis .
A Serbian soldier was sent to me with the
diagnosis of T.B. He was wasting and had serotine
fever. Expectoration muco-purulent, occasionally
bloody. Examination for T.B. constantly negative.
A few mycelial threads present. A fungus was
grown with the characters of Pcnicillium crusta-
tum, L. Potassium iodide acted satisfactorily.
Broncho-nocardiasis.
In the Balkans I have observed one case of this
condition, in the tropics several. The case seen in
the Balkans was a j'oung Serbian with aU the
symptoms of tuberculosis of tlie lungs; great loss
of flesh, serotine fever^ bloody expectoration; the
physical examination of the chest showed patches
of consolidation, crepitations, and pleural rubbing.
The sputum contained at times some very small,
whitish granules, composed of very thin branch-
ing filaments. Gram-positive, and partially acid-
fast. The fungus was easilj' grown on maltose and
glucose-agar, and in subcultures also on ordinary
agar. The cultures had at times a pink-reddish
colour. Gelatin was liquefied. No treatment was
of any avail.
TONSILLO-MYCOSES.
Mycotic affections of the tonsils are far from
being rare, especially in tropical countries. The
more chronic conditions, especially of the crypts,
associated with nocardia-like and leptothrix-like
fungi, have been known for many years, but I
should like to call attention to certain acute myco-
logical affections which I have described during the
last fifteen years, and which not rareh' have been
mistaken for diphtheria — viz., tonsillar moniliasis,
tonsillar oidiomycosis, and tonsillar hemisporosis
(fig. 10).
Acute Tonsillar Moniliasis. — Case 1. — Singhalese
girl, about 11 years, admitted to the Infectious
Diseases Hospital of Colombo with the diagnosis
of diphtheria. There were white patches on the
tonsils, uvula, and soft palate. The temperature
was rather high (102°); the pulse frequent and
of low pressure. There was swelling of the
lymphatic glands at the angle of the jaw. The
child developed sj'mptoms of broncho-pneumonia
and died three days aft-er admission. (Anti-
diphtheria serum was given twice by the physician
171 cliarge of the hospital.) The microscopical and
bacteriological examination of the patches for the
Klebs-Loffler bacillus, carried out with the usual
technique, using serum-media, &c., remained
negative. No bacteria of any kind were seen in
the specimens directly taken from the patches, but
numerous mycelial and conidial elements of a
fungus were present. On serum and glycerine agar
media no colonies of diphtheria or other bacteria.
The fungus had all the biochemicnl cliar'^cters of
Mnnilid f ropirnlis , Cast.
Case 2. — A young European lady, 22 years of
May 15, 1920] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
123
age, became suddenly ill with sore throat at one
of the Colombo hotels. Her medical attendant
suspected diphtheria, and called me to see her in
consultation. When 1 examined her the tempera-
ture was 101°, pulse 98; she complained of diffi-
culty and pain in swallowing, both tonsils and
uvula were covere-d with white creamy patches.
Preparations made from the patches revealed an
enormous number of yeast-like organisms and a
few cocci, while no bacilli of any kind were present.
This, of course, was sufficient to exclude diphtheria.
On glucose agar tubes a fungus grew in pure culture
with all the characters of a monilia. This monilia
rendered milk slightly acid, and then decolorized
it completely; did not liquefy serum or gelatin.
On serum it induced a narrow zone of black dis-
coloration all round the growth.
Acute Tonsillar Oidiosis. — European, 25 years of
age; since several years in Ceylon. In November,
1914, was taken ill with severe sore throat, diffi-
culty in swallowing, and high fever (104° F.).
When I saw him, twelve hours after onset, both
tonsils were covered with a white exudation, but
not the uvula.
The microscopical and bacteriological investiga-
tion showed absence of the diphtheria bacillus,
while a fungus was grown with, the botanical char-
acters of an oidium. Further investigation revealed
it to be very similar to Oidium matalense.
Acute Tonsillar Hemisporosis. — I am indebted to
Dr. Spaar for the clinical notes of the following
case. European planter, admitted to the Kandy
Hospital on May 2, 1913. The illness had started
two weeks previously. Teinperature on admission
101° F. Complained of severe pain in the throat
and of difficulty in swallowing. Flushed face; felt
extremely weak and exhausted. Voice thick and
nasal. Swallowing painful and difficult. Fluid
regurgitated through nostrils. There was a profuse
flow of saliva. The muscles of the neck were
rigid, submaxillary glands enlarged and painful.
The patient was unable to open the mouth wide.
Tongue thickly coated and dry ; soft palate swollen.
Greyish membranes were present on the left tonsil,
left anterior pillar, and soft palate. Diphtheria
antitoxin (2,000 units) injected the same day into
the flank and a spray of hydr. perox. prescribed.
During the. next foiir days the general condition
improved, but the white-greyish membrane in the
cleft between the left tonsil and the left anterior
pillar was still vei-j' evident. Nine days after ad-
mission there was still a small whitish patch
visible, but the patient felt quite well and was dis-
charged the following day.
Dr. Spaar sent swabs tiiken with all possible pre-
caution to me for examination. In smears made
from the swabs no bacilli were seen, a few cocci
were present, and rujmerous large mycelial seg-
ments of a fungus. Serum tubes and glycerine-
agar tubes were inoculated as usual, and gave
the presence of mycelial threads, also sever;il
sugar-agars. The serum and glycerine-agar tubes
did not show any growth of the diphtheria bacil-
lus; instead there was growth of a fungus with
a peculiar crinkled ^urfacie which 1 had found
pi-eviously in 1909 in a case of bronchitis. I was
uncertain about its classification, and placed it
temporarily in the genus Monilia, and called it
Monilia rugosa. However, 1 sent cultures of the
fungus to Professor Pinoy, of the Pasteur Institute,
who, after a long botanical investigation, came to
the conclusion that the organism belonged to the
genus Hemispora. The correct name of the fungus
became therefore Hemispora rugosa (Cast.). During
the war I have seen several cases of acute tonsillo-
mycosis in the Balcanic-Adriatic zone, and recently
a case in Paris, and a case in this country.
My<?otic Affections of the Nervous System and
OF Organs of Special Sense.
In 1904, from the pus of a cerebellar abscess, I
grew an extremely delicate fungus, a nocardia
which was Gram-positive and partially acid-fast.
No club-Uke formations were present in micro-
scopical preparations. This nocardia grew com-
paratively well on sugar media, very slowly and
scantily on ordinary agar. On all media the
colonies had a black pigmentation. Abscesses of
the brain and cerebellum due to true actinomyces
have been described by several authors. In cases
of general infections due to saccharomyces, monilia,
and endomyces-like fungi, abscesses containing
such fungi may be found in the brain and spinal
cord, as in other organs of the body.
Organs of Special Sense.— Mycological affections
of the eye may be classified as follows : Due to
species of genus Nocardia and genus Cohnstrepto-
thrix, ocular nocardiasis. Due to various species
of—
Genus S(iccharomyces\
Cryptococcus [ -rOcular blastomycosis.
Endomyces )
Due to fungi of genus Motiiiia, ocular moniliasis.
Due to fungi of genus Oidium, ocular oidiomycosis.
Due to fungi of genus Aspergillus and Penicillium, ocular
aspergillosis and penicilliosis.
Due to fungi of genus Sporotrichum, ocular sporotrichosis.
Due to fungi of genus Olenospora, ocular glenosporosis.
The commonest mycological affection in Ceylon
is moniliasis. I have seen several cases in
Singhalese children of a conjunctivitis apparently
due to a monilia; the conjunctiva was highly in-
flamed, there were photophobia and purulent dis-
charge. The microscopical examination showed in
addition to pus cells, numerous yeast-like bodies.
No gonococci or any other bacteria were present.
Agar and various sugar-agar tubes were inoculated
with the pus, and a monilia fungus was grown. It
is to be noted that not rarely, at least in the tropics,
spores of various fungi are found in the slight
secretion which so often collects at the angles of
the eyes even in normal people, but these spores
do not, apparently, usually give rise to any
symptoms.
Rhinomycoses. — Yeast-like and other fungi are
often observed in the nasal mucus; they may play
only a saprophytfc role or they may give rise to an
inflammation of the mucosa. In Colombo a little
124
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [May 15. 1920.
nativp boy was brought to me by liis parents, who
stated that he had been suffering for the last three
months from repeated attacks of severe sneezing,
and that they had observed that on blowing the
nose minute black dots were coming out in the
mucus. Microscopical and cultural investigations
showed this case to be one of aspergillosis due to
A. niger. In the literature cases of aspergillosis of
the nose due to A. glaucus (De Bary) and A. fumi-
gatus (Fresenius) have also been described.
Otomycoses. — Various fungi may be present in
the ext-emal auditory canal without causing any
symptom. In some eases, however, the fungus
multiplies abundantly, and may be the cause of a
local inflammation or may apparently facilitate the
formation of a wax plug. In several cases I have
found a monilia which I have called M. rhoi. In
two cases of otomycosis I have found a fungus
belonging to the family Mncoracese, Lichteimia
ramosa (Lindt, 1886). It was present in great
quantity, and the patient complained of tinnit>is
aurium and deafness. It is interesting to note that
this fungus is found often in the nasal mucus of
horses, and both my cases were Tamil muttris
(horse-keepers). Various authors (Siebenmann,
Boke, Huckel, &c.) have recorded cases due to
Lichteimia corymbifera (Cohn), RhizomucoT sep-
tatvs (von Bezold) ; Maggiora and Gradenigo found
Saccharomyces eUipsoides (Rhees) in a case of
chronic otitis media. The same authors found a
new species of saccharomyces (>S. rosevs) in the
Eustachian tube.
Aspergillomycosis of the ear is comparatively
frequent; I have seen several cases in Ceylon,
apparently due to A. jumigatus (Fresenius); Cramer
observed A. niger (von Tiegham) ; Wreden, A.
flaws (De Bary); Siebenmann, A. repens (De
Bary); and A. niduJans (Eidam). Fungi of the
order Basidiomycetes, family Ustilaginece, have
also been obser^'ed ; Ustilago carbo and TiUetia
levis. Of the order Hyphomycetes, sensu stricto,
Tricothecium roseum (Persoon, 1801) has been
observed in a few cases.
I may here mention that the best treatment I
have found for the various forms of otomycosis is
syringing with hydrogen peroxide 2 parts and
alcohol 1 part.
Certain Mycoses of the Genito-drinary System.
Vrethntis of Hyphomycetic Origin. — In the
tropics and in the Balkans I have come across
several such cases, which in my experience may be
classified as follows: —
(1) Discharge whitish or yellowisJi — the causative
fungi generally belong to the genera Saccharomyces,
Monilia, Cryptococcus, Oidium.
(2) Discharge dark brownish or greenish-black,
or black. These cases are generally due to fungi
of the genus Cladosporivm (Foxia), Aspergilhts,
Penicillium.
(3) Discharge reddish or pinkish : Generally due
to the red-pigment-producing fungi of the genera
Cryptococcus, Saccharomyces, and Monilia. At
times two organisms are found : a higher fungus
such as a monilia, and in symbiosis with it a red-
pigment-producing coccus or baciUus.
I may quote the following cases illustrating the
various clinical types I have mentioned: —
Mycotic Urethritis with Yellow Discharge.- — A
young Serbian officer in Macedonia consulted me
for ■a. fairly abundant purulent urethral discharge.
The patient was greatly distressed ; he was engaged
and believed he was suffering from gonorrhoea,
though he denied having exposed himself to infec-
tion. I examined the secretion; no gonococci
present; instead a very large number of yeast-like
cells and a few mycelial filaments could be seen.
The cultural investigation showed presence of a
monilia very similar to M. krusei. I prescribed a
mixture containing pot. iod., soda bicarb., glyeer.,
syr. of tolu, and irrigations with a solution of per-
chloride of mercury 1 in 20,000. The discharge
disappeared completely' within ten days.
Black Mycotic Urethritis. — An old Tamil coolie
came to the Colombo Clinic in January, 1906, com-
plaining of black urethral discharge dating from
several months back. He stated that he had not
had sexual contact for several years. The secre-
tion was blackish and contained numerous small
granules, which on microscopical examination were
seen to consist of mycelial threads and spore-like
bodies. Various sugaj- media were inoculated and
a fungus was grown, producing a black pigmenta-
tion, and very similar also in other characters to
Cladosporium mansoni (Cast.). In two other clinic-
ally similar cases, one in a native and the other in
a European, I found aspergillus-like fungi.
Red Discharge. — A little Singhalese boy, 6 years
old, was brought to my clinic in Colombo by his
parents because they believed he was passing blood
from the urethra. The discharge, examined micro-
scopically, consisted of some leucocytes and numer-
ous budding cells. Several sugar-agar tubes were
inoculated and a red-pigment-producing crypto-
coccus was grown. The child was given an alkaline
mixture, and instillations of diluted glycerine of
borax were carried out. This, however, did not
improve the condition. Urethral injections of a
solution of perchloride of mercury, 1 in 20,000, were
then made and a speedy cure resulted.
Very similaj mycological conditions of the female
genito-urinary organs may be observed, and cases
of vaginitis and vulvo-vaginitis due to fungi of the
genus Monilia, Cryptococcus, Aspergillus, Peni-
cillium, and Cladosporium have been recorded; and
as the same fungi are found in urethral and vaginal
discharge, it cannot be excluded that in certain
cases these mycological infections may be con-
tracted by sexual intercourse. When the monilia-
like and saccharomyces-hke fungi are the causative
agents two clinical varieties may be distinguished.
In some cases thrush-like patches are present on
the mucosa (vaginal thrush); in others no such
patches are present, but the discharge is purulent,
very thick, and, in my experience, these latter
TUB JOURNAL OF TROPICAL MEDICINE AND HYGIENE,
MAY 15, 1920.
LONDON SCHOOL OF TROPICAL MEDICINE.
62nd Session. February— April, 1920.
JUtck Horn (Left to Right).— N. Nedergaard, M. Bernara Foster, J. Gray (Sis. Selllrmenls Med. Srr.), E. 0. Mack (foi/fcm Mttl. Ser.), G. Warrcr. (iMhoratory
Assistant), I. G. Cummings (Mei. Ser., Nigeria), C. Basile (,1'ro/. I'ttrasUology, Hume), G. A. Freudo (M.J)., C.C. Uosfi., MaiUi), A. Y. Cantin,
W. P. Hogg, M.c. Wupt. I.M.S.), J. A. Cruickshank, M.c. (Hiij. l.M.S.), J. 8. Armstrong.
Second Kov.-E. .1. Wood, W. Russell Square. M. .lac-k.sninl''. A/nr,n, Mnl. .s.,.l, IC. Koi ri-.sl,T F.iU)ii,
M. K. Abdul Klialik (Cairo,) A. K r, .-•,.>,,■,, . i/ir ,,-.. i;.,; ,,, \ i .,,.,. V'
{^fajor R.A.ir.M.S.), J.R.C.i<U]': , :■ ■ , . \ w M li • '
First Bow.-^li. Clicua, C. M. Vevers {Den,., . ■ i: i r
Wt(min(Ao!oj7!(), Miss R. M. 8V.-1I M I i , h [■ j , . i ,.
c.M.c. (Lecturer), Dr. L. W. SaTiil:Mii (/,.; i, 'r ll \;,,, i, h, !■ ,, i ;...,<, i .1 1 1. I
On C,round.~l.i. A, S. Madgwick, J. R. Crtilius {li. A.M.r.).
Alitn\t.—i,\. Wong, D. Schokman (aylon Meil.
II), Miss Turner (Ttesearch .
. v.. Low {UHurer), Prof. A. Cast«llani,
Demonstrator in Tropical Pathology).
IT.), b. A. KlJaab,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. MAY 15, 1920.
To illustrate a paper on " Histological Observations on the Possible Pathogenicity of Trichomonas intestinnlis and Chilomastii
mesnili, with a Note on EndoUmax nana, by C. M. Wenyon.
May 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
125
cases have not rarely been mistaken for gonorrhoea.
In 1914 the surgeon in charge of the Colombo
Lying-in Home had a case in which a pelvic opera-
tion was urgent; a thick purulent vaginal discharge
was, however, noted, and he felt inclined to post-
pone the operation. A specimen of the discharge
I was sent to me with the request to examine it for
gonorrhoea. No gonococci, however, were found,
i instead an enormous amount of mycelium and
I conidial elements. Further investigation revealed
the fungus to be Monilia pinoyi, Cast. Cases of
hypomycetic vaginitis are found, though not so
frequently, in temperate climates, and Taylor and
myself have placed on record several such cases.
It must be added, however, that finding fungi in
\;a'inal mucus is nothing new; one may read in
til' Lancet of as long ago as 1840 (p. 448) a paper
liy Wilkinson with the following title: " Some
liiinarks upon the Development of Epiphytes with
the Description of a New Vegetal Formation found
in connection with the Human Uterus."
HISTOLOGICAL OBSERVATIONS ON THE
POSSIBLE PATHOGENICITY OF TRICHO^
M0NA8 INTESTINALIS AND CHILO-
MASTIX MESNILI, WITH A NOTE ON
ENDOUMAX NANA.
By C. M. Wenyon,
Director of Research in the Tropics, Wellcome Bureau of
Scientific Research.
The question of the pathogenicity of the intes-
itinal flagellates of man is a problem which still
awaits solution. It is a well-known fact that these
'.organisms are encountered most frequently in
jdiarrhoeic stools, and their presence there, some-
Itimes in enormous numbers, has naturally led some
Ito regard them as pathogenic agents. As they
loocur in diarrhoea and are rarely found in the
Iformed healthy stool it naturally comes about that
as the diarrhoea gives place to the normal evacua-
tions the flagellates disappear, and what is more
(natural than to conclude that with this disappear-
iance recovery has taken place ? A dose of salts,
however, will show that these deductions are not
iwell founded, for the liquid stool resulting may
contain as many organisms as during the attack of
diarrhcea. It may be necessary to repeat the salts
pn two successive days to produce the flagellates,
jas I saw in a case recently. It must be admitted,
therefore, that the pathogenicity of the intestinal
flagellates still awaits absolute proof, even though
the work of Esconel and others seems to have con-
nced those observers that this is the case.
The presence of an organism of a more or less
striking character in large numbers is in itself no
jroof that such an organism is pathogenic. Quite
■ecently Delamere (Bulletin et Memoires de la
■iociete Medicale des Hupitaux de Parin, June 12,
1919) has noted spirochaetes in enormous numbers
u certain eases of dian-hoea, and he attributes the
disorder to their presence. Anyone who has
examined stools to any extent must have met with
this condition, and 1 myself have frequently seen
stools simply swarming with spirochaetes. Simi-
larly, the presence of spirochaetes in large numbers
in the sputum is again no proof of a spirochaetal
bronchitis. The mouth constantly harbours several
species of spirochaste, and it would not be surpris-
ing if under certain conditions these organisms
spread to the bronchi or intestines. They are
accused because they are easily recognized, and it
would be just as logical to blame any of the less
striking bacteria which are present at the same
time.
Within the last few weeks I have seen Tricho-
monas in a case of tonsillitis. There was a bead
of yellow pus protruding from one of the follicles.
This was removed by means of a platinum loop
and examined in saline. Fair numbers of Tricho-
monas were present, and following the methods of
some observers, I would have been justified in
describing a new disease. Trichomonas tonsillitis.
The truth of the matter is that such hasty con-
clusions are unscientific. The question of the
pathogenicity or harmlessness of an organism
requires very careful investigation and experiment,
and until this is carried out no one can know
whether any of the above-named organisms are
pathogenic or not.
In order to obtain some light on the behaviour
of the flagellates in the human intestine it is
necessary to examine them there. They are usually
seen only in the stool. To this end, during the
epidemic of influenza in Salonika in September,
1918, a certain amount of material was collected.
The cases had all died of pneumonia complicating
the influenza. At the autopsies the contents of
the large intestine were searched for a flagellate
infection, and if one was found the gut was pre-
served in Zenker's fluid for future investigation.
Before fixing the intestine the gut contents were
examined at various levels.
Five cases of Trichomonas infection and three of
Chilomastix (Tetramitus) were observed. With the
exception of one Trichomonas infection the flagel-
lates were limited to the large intestine. In the
one case the Trichomonas extended into the small
intestine and were found over the lower two or
three feet, but not higher up. In no case were
flagellates seen in the appendix. In three of the
Trichomonas cases, including the one where the
infection extended to the small intestine, the
flagellates were present over the whole large intes-
tine and cfficum. In two cases the infection was
limited to the lowest part of the large intestine,
even though in one of these the flagellates were
present in very large numbers.
Of the three Chilomastix cases two had a general
infection of the large intestine, and in one it was
limited to the lower part.
There were no noticeable lesions of the intestine
which one could attribute to the flagellates. In
one case there were small submucous heemorrhages
126
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15. 1920.
in the caecum, but these were readily accounted for
by the toxsemia of the pneumonia from which the
cases died.
Escomel (An. de la Fac. de Medicina, September
and October, 1918, Arequipa, Peru) has described
various forms of Trichomonas dysentery. He gives
photographs of the altered conditions of the intes-
tine and even of the hver. From what one can
make out from the photographs, it appears that the
lesions depicted could very well be accounted for
on the assumption that they are chronic bacillary
dj'sentei-y cases. At any rate, the pictures resemble
fairly closely the conditions one is familiar with in
the old chronic dysenteries of a bacillary nature.
It is not surprising that often a Trichomonas infec-
tion should run concurrently with a bacillary one,
and in fact one has often seen such double infec-
tions. However, in the five cases described in this
paper there were no lesions of the intestine com-
parable with those described by Escomel.
On histological examination the general distri-
bution of the flagellates as detailed above was
confirmed. There was a complete absence from
the appendix, and only in the one Trichomonas
case were they seen in the small intestine. In the
large intestine the flagellates were distributed over
the surface of the mucosa, but their exact relation
to this was not as clear as it might have been
owing to the usual post-mortem loss of the super-
ficial epithelium.
The flagellates were also found in the lumen of
the glands of Lieberkiihn and in some of the
Trichomonas cases in large numbers. In the case
of Chilomastix never were there more than half a
dozen flagellates seen in a single gland. In all but
one case the flagellates were not found in any other
situation. In one Trichomonas infection it was
noted that the lumens of the glands were particu-
larly full of flagellates, and on studying these more
carefully definite ruptures of the gland epitheUum
could be made out, and the Trichomonas were
evidently passing through these. It was further
noted that the flagellates were scattered about in
the inter-glandular loose connective tissue, so that
there was a definite invasion of the tissues of the
gut. Unfortunately only the upper part of the
large intestine and caecum of this case was kept,
but wherever a part was sectioned the same condi-
tion was discovered. There never appeared to be an
extensmp of the invasion beyond the mucous layer.
Furthemiore, there did not seem to be any reaction
on the part of the tissue as regards cell proliferation
or invasion. The Trichomonas were there distri-
buted regularly all through the tissue, and either
they had been there only a short time, or they
produced so little irritation that no tissue reaction
had taken place.
The figures in the plate show the condition of
affairs (juite clearly. The ruptures in the epithe-
lium through which the Trichomonas are passing
<)(n;iir always at the lower end of the glands.
,\ similar condition was noted by Hadley, who
has described an invasion of the wall of the intes-
tine by Trichomonas in turkeys (Journ. Med. Re-
search, March, 1919). The disease known as
blackhead is attributed to this infection. The
Trichomonas invade the glands of Lieberkiihn and
Hadley believes they commence their passage
through the gland epithelium by penetrating the
empty goblet cells. Such a channel seems highly
probable, and it is possible that in man, too, the
primary opening through which the Trichomonas
pass is a broken-down goblet cell. Hadley noticed
also that it was only at the fundus of the gland
that this breaking through took place. Dr. Steven-
son has shown me sections of the caecum of guinea-
pigs where the Trichomonas have penetrated
beneath the epithelium, but in this case it is the
inter-glandular epithelium on the surface of the
intestine through which the flagellates have
migrated.
The question at once suggests itself: Is it
possible that this invasion has occurred post-
mortem? It was noted in only one case, but this
was the best one as regards preservation of the
tissue. There was httle post-mortem change, while
in the other cases, where post-mortem degeneration
was more marked, the Trichomonas could not be
found in the tissues If they had been there they
would have been recognized, as they were easily'
seen elsewhere.
That Trichomonas will pass from the intestine
during life has recently been clearly demonstrated
by Chatton (C.R. Hoc. Biol., No. 3, 1920), who
was able to obtain a culture of it from the blood
a gecko which had an intestinal infection of th
flagellate.
In the case under discussion the invasion w
so extensive that it is difficult to attribute it all
post-mortem change. I am inclined to regard it aa"]
an ante-mortem invasion. There is so little tissue
reaction that either it has occun-ed only a short
time before death or the Trichomonas cause no
appreciable irritation.
in one Trichomonas case there was a concurrent
infection with EndoUmax nana (Entamoeba nana).
This amoeba occurred only in the lower part of the
large intestine and, as in the case of the flagellates,
it invaded the glands of Lieberkiihn. One of the
figures shows an amopba at the fundus of the gland.
There was no evidence that it could wander beyond
the limits of the lining epithelium.
The present paper therefore shows that Tricho-
monas may invade the tissues of the intestine but
whether this is evidence of its pathogenicity or not :
future work alone will show. So little is known at
present that any expression of opinion would be
merely valueless guess work.
Description of Plate.
The illustrations are photographs of coloured dr.iwiiigs which
are now in the Museum of the Wellcome Bureau of Scientific
Research.
Pig. 1.— Portion of two glands of Lieberkiihn in the cecum,
showing Trichomonas intestinalis in the lumen of the glands
and also passing through the ruptures in the epithelial lining.
Two Trichomcmas are to be seen in the connective tissue.
May 15. 19^0.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
127
Fig. 2. — The inter-glandular connective tissue invaded by
TiicJMDKmas. The black line indicate the flagellates.
Fig. 3.—Chilomastix mesnili in the lumen of a gland in the
lower large intestine.
?'ig. i.—Eyidolimax nana in the lumen of a gland in the
lower large intestine.
(Magnification of drawings about 700 diameters.)
Eotts aui) lletDS.
LONDON SCHOOL 0¥ TKOPICAL MEDICINE.
The following students gained the School Certifi-
cate at the termination of sixty-second session
(February- April, 1920): H. E. Whittingham, A. K.
Cosgrave, A. Khalil, E. J. Wood, E. Forrester-
Paton, J. Fanstone, E. G. Mack, W. P. Hogg,
J. S. Armstrong, J. K. C. Stephens, M. Wong,
G. A. S. Madgwick, G. A. FVendo, C. Basile, M.
Jackson, E. U. MaoWilliam, N. Nedergaard, H. P..
Dive, J. R. Crolius, A. Y. Cantin, D. Schokman,
C. H. Brangwin, J. Gray.
The first five obtained the certificate with
distinction.
The " Duncan " Medal was awarded to Dr. H. E.
Whittingham.
Tardy Post-arsenical Jaundice (Sicard, Bulletins
de la Societe Medicale des Hopitaux, October 24,
,1919). — The drug is responsible for the jaundice
that develops during treatment. Five instances
occurred among 100 cases of chronic syphilitic
idisease of the nervous system treated by their
, method of small frequent (every day or every
second day or third day) intravenous injection of
0-15 gm. of (French) neoarsenical to a total of
.thirty to fifty injections. The drug was suspended
when the jaundice developed in all but one case,
^nd this case was the only one that proved fatal.
jIn two of the five cases the drug was being given
for some pathologic condition other than syphilis,
there being nothing to suggest either inherited or
Required syphilis. Among the other arguments
3resented is that the azotemia slowly and pro-
gressively increases under the neo-arsphenamin
bnd for some time after its suspension. A further
argument is offered by recent cases in which fatal
liaeniorrhages followed a course of neo-arsphenamin,
focompanied in one case with jaundice. These
lymptoms developed si-x weeks after the course
[total dose 8'.50 gm. in six weeks at five day
ntervals). Necropsy revealed acute yellow atrophy
ff the liver. Syphilis is not responsible for the
^undice and frequent small doses are without any
igns of anaphylaxis. It is the most reliable and
•armless means for administering a given amount
f the drug in a given period, far safer than by
/eekly injections.
|l0tU£5.
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THE JOURNAL OF
Croptcal fl^etltttneantl^^pgtene
May 15, 1920.
WHEN TROPICAL RESIDENTS CANNOT
TAKE QUININE.
Tin: question of quinine idiosyncrasy is perhaps
more worthy of consideration than we are inclined
to think or believe. So far as it has been investi-
gated, we merely know that quinine does cause a
128
THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1920.
hasmoglobinuria in a certain percentage of indivi-
duals resident in tropical countries, but whether
due to previous malaria infection or not is not so
clear. We do know that quinine does cause haemo-
globinuria in Britain in a minute and infinitesimal
number of people who have never left the country,
and therefore amongst those who have presumably
never had malaria nor any other periodic fever.
Most of these have been given quinine in small
" tonic " doses, say | grain in amount, yet the
haemoglobinuria syndrome has occurred.
It would appear, however, that the condition
occurs to a much greater extent amongst white
residents in the tropics than amongst residents in
Britain. This may be due to one of three causes,
viz., climate, previons infection by malaria, or the
larger doses given. As regards climate, which it is
the fashion to disregard, it must be remembered
that the kidney in the tropics is subjected to much
more severe strain than in Britain. The skin does
so much work in warm climates that the concen-
tration of urine results to a marked degree ; and
even the morning and evening flushings obtained
by drinking copiousl}' of fluids at these times do not
counteract the concentration. This combined with
the excretion of quinine no doubt affects the kidney
tubules, and may thereby induce disturbances end-
ing in either a haemoglobinuria or an actual hema-
turia. In the tropics haemoglobinuria is presumed
always to have been preceded by malarial ailments
and the taking of quinine by quantities multiphed
at times ten-fold over and above home dosages.
When we are informed that " the patient cannot
take quinine," we are not always told what is
meant by the phrase. If it is that the patient is
upset geneTally by quinine taken at the time of a
febrile attack, the patient is apt to blame the drug
rather than the disease. This is, of course, a state-
ment to be disregarded scientifically, because many
people blame the doctor's drugs for their feelings,
and attribute them to anything but the evils the
germs of the disease are giving rise to. If, how-
ever, the impossibility to take quinine is due to
a haemoglobinuria it is a different matter and must
be dealt with seriously.
The inability to take quinine is generally dis-
covered when the tropics are reached. The medical
examiner at home is asked to report upon a candi-
date as to his fitness to go to the tropics; it is
evident that if the question of the candidate being
able or unable to stand quinine has to be settled,
then all candidates must have quinine given them
for a certain definite time and in big doses. This is
not the case merely of old tropical residents in
whom quinine has been known to produce haemo-
globinuria as to whether they should go back to
the tropics, and in whom quinine taking at home
has been followed by a recuirence of haemo-
globinuria. The answer to such cases is in the
negative of course. When, however, a young man
or young woman of, say, one or two-and-twenty
comes up for examination as to fitness to live in
a warm climate, are we to insist that large doses
of quinine be given for, say, a week before deciding?
This might be resented by candidates or others
wishing to go out, and it really seems a rather
" thorough " line of investigation to say the least
of it. It may be said that this is not necessary;
better wait and see whether the patient can stand
quinine when he gets malaria. This is too late, for
the patient, if he or she cannot take quinine, has to
be sent home, it may be within a month or two
after arrival. The patient's life may be in jeopardy
owing to the fact of intolerance ; and the loss to
the bank or firm that sent him out may amount
to several hundred pounds.
On the other hand, it may be argued that all
people approaching a malaria-infected locality
should have been given quinine previously as a
prophylactic measure ; and if the quinine did not
agree — that is, caused blackwater — he should be
sent back. But here again he has gone a long and
expensive journey before this was known, and as
the evidence of blackwater resulting from quinine
taking necessitates his going home again, the loss
to the firm is just the same as regards the outlay
and the passage money — an item of £200 or
£300 it may be, or more.
Following this line of argument to its bedrock
conclusions, it would seem that the test by quinine
before leaving Britain is the only measure of
settling the question satisfactorily. Admitted that
this is agreeable to all concerned, it would further
mean that thS candidate would have to be sub-
mitted to a few days' test by giving, say, 5 to
10 grains of quinine daily and waiching the effects ;
for those anxious to go abroad are quite capable
of hiding the fact that quinine does not agree. If-
this fact were declared a man would lose a good
appointment; a wife could not join her husband,
nor a young girl go out to be married. k\\ suffi-
cient reasons for attempting deception. These
candidates would have to be kept in surveillance in
a home for, say, a week to ensure rclialle evidence
of fitness or unfitness, .<» condition of things
which is scarcely likely to be submitted to with
equanimity.
After all is the inability to take quinine so general?
In a long experience of tropical patients of thirtj'-
five years, the writer has only found one person
with whom quinine seriously disagreed. It was
the case of a marriwl woman related in this journal
by the writer a few months ago. She was man-ied
to a man whose area of work was on the West
Coast of Africa. She had never been out with him;
but he, having obtained suitable accommodation, '
was anxious to take her with him. His wife said
she could not take quinine as it caused a furious
eczema of the skin, attended by fever and an
illness which lasted a whole week. So seriously
did it affect her that the writer, after administer-
ing a small dose of quinine, had to forbid lier going.
This, however, was not blackwater, and the writer
has never seen blackwater result from the ingestion
of quinine unless the patient had malaria pre-
vioiisly; and of these only once in China did lio
May 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
129
find quinine cause haemoglobinuria in a white man
— ^a traveller who had been in Indo-Ghina.
To those susceptible to quinine poisoning it does
not require a large dose to bring about symptoms.
In the woman reported above who got fever, eczema
and severe illness, the effects were produced by one
dose of i grain of sulphate of quinine. But how
many hundreds of thousands of people in Britain
have quinine in small doses given them in the
course of the year and no untoward symptoms
result? The whole question seems straining at
a gnat; and the fact seems to be that with no
previous malaria there will be no blackwater, but
there may be untoward symptoms of a disagreeable
kind, but in no sense dangerous.
The other great question involving responsibility
on the part of the examining physician as to fitness
to go abroad is the effect of quinine on the ear and
hearing. Of course many candidates come forward
with the history of ear troubles in childhood, with
not infrequently (a) a histoi-y of discharge from
the ear at intervals; (b) a continuous small amount
of discharge ; (c) evidence of a mastoid operation
having been done; (d) a ruptured tympanum; (e)
deafness from shell shock, and a number of aural
lesions of more or less significance. The rule the
writer follows is to send these candidates for going
abroad to an ear specialist before deciding, and in
every case thus dealt with the specialist declares
that it is quite safe to send them abroad. The
results of t>heir going abroad for better or for worse
the writer has had no means of ascertaining, but it
is a matter that requires elucidating by tropical
practitioners in the countries where these men
reside.
If we were to decide in which class of candi-
dates it is most necessary that the quinine test for
toleration should be enforced before going abroad,
it is in ear troubles old or recent.
The whole question turns upon whether we are
dealing with it from a prophylactic or a treatrpent
point of view. As a prophylactic we know of no
substitute for quinine, but when we speak of treat-
ment the matter is not so hmited. There are many
modifications of the form in which the alkaloid of
cinchona may be given. Of the several varieties of
quinine salts in our pharmacopoeias and the various
preparations from the cinchona bark, such as de-
coction of cinchona, tincture of cinchona, and a
multitude of allied preparations, one preparation
— the tinctura antiperiodica — Warburg's tincture —
was in use for some 4,000 years before Warburg
added quinine to it some 40 years ago. Without
the quinine there is nothing to prove that any one
of its many ingredients, some twenty-one in number,
were fatal to the malaria parasite, although several,
being " bitter tonics," as they are officially classi-
fied, may have that power to some extent.
Thus j)icrorrhiza rhizome as a liquid extract and
tincture is known to have distinct antiperiodic
power, although not so active as quinine. (J. M.
Bnice's " Materia Medica.")
As coadjutors to quinine in the treatment of ague
we have arsenic, opium, ipecacuanha and mercury.
each ingredient of which serves a useful purpose,
but as destroyers of the malaria parasite none are
by themselves efficacio"us.
The conclusion is, therefore, that if we wish to
ascertain positively if a candidate for the tropics is
or is not likely to stand quinine, the only reliable
way to test the matter is by administering quinine
in doses of not less than 5 grains a day for three
days before leaving British shores. Be this as it
may, one thing seems imperative, namely, that the
quinine test should be applied to all persons with
aural defects of any kind before sending them to a
malarial district. . J. Cantlie.
Annotations.
Slow Evolution of Peritonitis foUonnng Perforation
of Typhoid Ulcer (P. Gautier and P. Brutsch, Rev.
Med. de la Suisse rom., December, 1919). — The
authors report a case of peritonitis following perfora-
tion of a typhoid ulcer in a male patient aged 26,
in which an interval of a month occurred between
the perforation and death. At the post-mortem an
adhesdve peritonitis was found loca;lized in the right
iliac fossa. The intestine presented multiple per-
forations, including one in the colon. The mild
character of the onset was a striking feature in the
case, the patient being able to continue hie work
for a fortnight, when signs of perforation suddenly
developed. The peritonitis due to the perforation
■became rapidly localized, but from time to time an
exacerbation of tlie symptoms/ occurred probably
owing to a fresh perforation. Various hafcmorrhagic
manifestations were observed, namely, intestinal,
renal, and cutaneous haemorrhages. The patient
showed a considerable loss of flesh during the month
which elapsed between the perforation and his death.
Optic Neuritis following Typhus Fever (V.
.\rnold, Wien. klin. Woch., September 4, 1919). —
The author, eight years ago, found optic neuritis in
eight out of fourteen oases of typhus, and since
then he has examined 244 further cases, and has
noticed the condition in 144, viz., 59 per cent.
The tenth to twelfth day was the usual date of the
appearance of morbid cJianges in the optic disc,
this coinciding, more or less, with the last days of
high fever. At this period the rash has often
almost or completely disappeared, and therefore the
appearance of the optic disc is, in the author's
opinion, of great assistance in the diagnosis of
typhus.
The changes seen in the optic disc are charac-
terized by reddening and blurring, the sharply
defined outlines of the healthy disc being partially
obscured. The veins ai-e distended and tortuous,
but there is little or no change in the appearance
of the arteries. The outline of the margin of the
disc is also blurred owing to oedema. In most cases
a fall in the temperature to normal is followed by
complete disappearance of the optic neuritis: but
at times this survives all the other complications
of typhus.
130
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, lSi20.
Castellani's Bronchospirochxtosis and its Treat-
ment (Najib Farah, Presse Medicale, December 17,
1919).— The author reports from Egypt ten cases
of this disease, and states that in Alexandria it is
very common among both the natives and Euro-
peans. The Spirochxta bronchialis occurs in large
numbers in the sputum, and is readily stained by
the Ziehl method, with carbol gentian violet, with
crystal violet, or the Fontana-Tribondeau silver
nitrate method. It is negative to Gram's. The
ten patients ranged in age from twenty to forty-five
years. Eight patients had had a chronic cough,
while two were acute cases. General health
seemed unaffected, and all patients complained of
a sense of oppression in the chest. Cough was
most pronounced in the evening, at night, and on
awakening. Expectoration varied from slight to
copious and mucopurulent; in seven instances the
sputum was bloody or blood-streaked. Acute cases
began with chills, fever, headache, and bronchitis,
and resulted in a prolonged state of prostration.
Haemoptysis was rather frequently observed.
Tubercle bacilli were uniformly absent. In the
treatment, successful results were obtained by in-
tramuscular injections of iodine in the form of
lipiodol, a preparation similar to iodipin and con-
taining 54 per cent, of pure iodine in oil of poppy.
Five to ten daily injections of two mils were given,
followed by ten to twenty injections at intervals of
two or three days, according to individual tolerance.
Injections were" made in the buttock. No manifes-
tation of iodism was noted, save dryness of the
throat and nose in a few instances. In cases with
hsemoptysis, calcium chloride by mouth was simul-
taneously given. In some cases syrup of hypo-
phosphites was also prescribed. Practically all the
patients were relieved by this treatment, as shown
by physical examination of the chest and the dis-
appearance of cough. No recuiTence took place.
Generally improvement followetl. the initial iodine
injection. Sputum examinations after the fifth in-
jection showed marked reduction in the number of
spirochsetes. After the second series of injections
they had practically disappeared, and little expec-
toration remained. The iodine treatment was
applied also in two cases of bronchial moniliasis,
with encouraging results.
The Combined Quinine and Methylene-blue Treat-
ment of Malaria (R. Eeitler, Wien. klin. Woch.,
January 10, 1920). — The author emphasizes the
value of methylene-blue as advocated by Ehrlich
and Guttmann in the treatment of malaria. Reitler
was induced to use it in a number of cases owing
to its action in a case of quartan fever which was
refractory to quinine. He found that though it was
of little or no "value by itself in the treatment of
malaria, when given with, or s-hortly after, quinine
it prevented any further attacks in cases supposed
to be refractory to quinine. It also enabled the
qiainine to be considerably reduced below the
ordinary therapeutical dose, a point of gre'at im-
portance in the treatment of patients wto ha,d an
intolerance for the drug.
Oxyuris Appendicitis (A. Lawen and A. Rein-
hardt, Miinch. med. Woch., December 12, 1919). —
The authors examined 620 appendices, surgically
removed, and found oxyurides present in 60, or
9-76 per cent. The clinical picture was that of
acute or chronic appendicitis. Severe attacks were
rare. The writers accept the general opinion, which
is that the worms penetrate the mucous membrane
and so open up the way for a bacterial infection.
They consider it probable also that the parasites
cause by their toxins a superficial transient inflam-
mation of the mucous membrane with symptoms
of appendicitis. A certain diagnosis cannot be
made, but relatively slight objective findings with
fairly acute or chronic symptoms may indicate
oxyuris appendicitis. The diagnosis is rendered the
more probable if oxyurides have already been found
in the stools several years previously.
Rat-bite Fever: Report of a Case (Aaron Arkin,
Archives of Internal Medicine, January, 1920,
vol. XXV, No. 1). — The author, after giving a full,
historical and general clinical account of the disease,
describes a case he has observed in an American
boy. The patient was bitten on the right index
finger by a large grey rat. When the boy reached
home the finger was pvainted with tincture of iodine.
The wound healed nicely, but on the fourteenth
day he began to complain of pain and of a burning
sensation in the finger. The supratrochlear glands
and the glands in the right axilla became enlarged.
Three days later symptoms of drowsiness, general
weakness, headache, diarrhoea and vomiting ap-
peared, and the temperature rose to 102° F. The
temperature became normal after a few days, but
a little later two other attacks of fever developed.
The .blood examination showed: Erythrocytes,
4,100,000; leucocytes, 16,000; polymorphonuclears,
80 per cent. ; mononuclears, 16 per cent. ; eosino-
philes, 4 per cent. ; hemoglobin (Sahli), 75 per cent.
No spirochsetes were found. Two guinea-pigs were
inoculated with blood derived from the patient, but
remained healthy. Although spirochsetes were not
found, the case was clinically a typical one of rat-
bite fever. All the symptoms disappeared under
arsphenamin treatment.
I
Current f iteratnrf.
The Indian Journal of Medical Research.
March, 1919.
On the results of a Mosquito Survey of Indore
City (M. O. Tirunardyana Iyengar). — ^The species
of mosquitoes found in Indore City were (1) Ano-
pheles rossi (Giles), (2) A. culicifacics (Giles), (3)
A. stephensi (Liston), and (4) A. barbirostris (Van
May 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
131
der Wielp) besides several species of culicines,
some of which breed in fresh and some in foul
water. Methods for their control are suggested.
Hydrocyanic Acid Gas as an Insecticide (W.
Glen Listen and S. N. Gove). — The authors found
that 30 parts of HCN per 100,000 parts of air
within a room kills bugs and lice in all stages of
development, including the eggs, with an exposure
of two hours. 110 parts of HCN per 100,000
parts can be obtained in a 100 cubic feet of space
by mixing J oz. potassium cyanide with i oz. of
sulphuric acid, each made into watery solutions of
33-3 per cent. A detailed paper is promised.
Beriberi (P. Heliir). — The author has had an
extensive experience of beriberi during the last ten
or twelve years in Assam, Burma, the Philippines,
Japan and also had charge of a series of outbreaks
among British troops in Mesopotamia in 1915-1916.
Wherever encountered the disease was always
clinically identical, falling into the accepted classical
types. He considers that the theory that beriberi
is a deficiency disease due to the absence of a
special vitamine in the diet appears to explain the
conditions of the Mesopotamian outbreak more
rationally than any other theory. He therefore
accepts this theoi7 in the absence of any more
convincing view.
Report on the Anti-beriberi Vitamine Content
and Anti-scorbutic Property . of Sun-dried Vege-
tables (J. A. Shorten and Charubrata Roy). — From
experiments on fowls and guinea-pigs Shorten and
Roy found that sun-dried carrots, spinach, cabbage
and onions all retain in full their anti-beriberi vita-
mines and that sun-dried cabbage, carrots and
onions retain tlieir anti-scorbutic properties to some
extent, whilst sun-dried spinach seemed to have no
protecting power whatever against the onset of
scorbutic symptoms.
Scurvy (P. Heliir). — During the seige of Kut
scurvy caused about 1,050 admissions — all but one
in Indian troops and followers. The disease arose
principally from an absence of fresh vegetable food.
It was found that as soon as wild herbs and shrubs,
including grass, sprang up at the end of February
in sufficient quantity to be collected, cooked and
eaten, tlie disease incidence declined although the
men were on semi-starvation rations. It would
appear that the anti-scorbutic principle is con-
tained in all harmless green stuffs and herbs.
Meteorological Conditions in Mesopotamia affect-
ing the occurrence of Heatstroke (J. Taylor). —
It was found in Mesopotamia that when high
temperatures of 110° F. are reached, a wet-bulb
reading of 8.5° F. is a warning to look out for heat-
stroke, and that a further rise of these figures is
sure to produce cases, the individuals most likely
to suffer being those who already have febrile
runditions.
Diagnosis on a large scale in Hookworm Infec-
tions (Clayton Lane). — By adopting the levitation
method of examining stools in laboratories placed
where it is most convenient for communications
four thousand-stool units under two commissioned
officers would have a capacity of a million positive
stool examinations annually. Each thousand-stool
unit would comprise one commissioned officer, one
assistant surgeon, three sub-assistant surgeons,
fifty-six compounders, thirty-four sweepers, one
clerk and five chapraissis.
Is Human Bilharziosis likely to spread in India
(M. B. Soparkar)? — AlthougJi bilharziosis is com-
mon in animals in India there is no evidence to
show that men become infected in that country
except very rarely. Many soldiers infected with
the two common types of this worm in Egypt have
returned to India during recent years. Whether
they will spread the disease to others depends on
the existence of suitable intermediary hosts. No
species of Bullinus has been found in India, though
the nearly allied genus Physa has been found on the
Coromandel coast. A number of species of Planor-
bis are widely distributed throughout the country
and these may possILly sene as the intermediate
host of Schistosoma mansoni.
Enteric Carriers (J. H. Cruickshank and H. M.
Jiapenais). — Of 1,886 convalescent British soldiers
admitted to the Enteric Depot at Parel, forty-nine
earriei's (2'6 per cent.) were detected by stool
examinations. Of these thirty-nine were carriers
of B. paratypliosus A, nine of B. typhosus, and six
of B. paratyphosus B. The treatment of chronic
cai-riers was found very unsatisfactory. The authors
consider that the dangers which carriers constitute
are often exaggerated, patients being often subjected
to unnecessary segregation. Given good general
sanitary conditions, the most important of which is
a water-caniage system of sewage disposal, and pro-
vided that the carrier has nothing to do with the
cooking or distribution of food, there is little danger
in his mixing with the general population.
The Amoebic Dysentery Carrier (W. MacAdam).
— .\ttention should be concentrated on the thorough
early treatment of, primary acute attacks by the
combined hypodermic and oral administration of
emetine, and of cystic carriers when the signs and
symptoms of ulceration of the colon are so slight as
to be relatively negligible.
The Rat Problem in India (J. L. G. Kimhardt).—
.\dvocates improvements in the methods of rat
destruction.
Rat and Plague Conditions in Hutted Camps (J.
Taylor).— The distribution of rats and the incidence
of plague were found to be directly associated with
the standard of camp management. The camps in
which the largest number of cases occurred were
THE JOUKNAL OF TKOPICAL MEDICINE AND HYGIENE. [May 16, 1920
those which did not receive the necessary degree of
attention.
Existence of Distoma Disease in India (N. F.
Surveyor). — Records a case of fluke disease (prob-
ably of the paragonimus species) in a Chinaman in
India.
Prophylaxis of Dracontiasis (D. A. Turkhud). —
Since such methods of prevention of dracontiasis
as filtration, steam sterilization and chemical disin-
fection are uncertain or otherwise inapplicable the
only certain method of obtaining permanent free-
dom from the disease is to cover every well which
supphes drinking water and to hft water from it by
means of a suitable pump.
Note on a small outbreak of Lobar Pneumonia in
Baghdad due to a Bacillus of the Gaertner Para-
typhoid Group (W. MacAdam). — Blood culture
from cases of lobar pneumonia with two deaths in
cases not clinically suggestive of an " enterica "
infection yielded organisms with the characters of
B. paratyphosus B. To differentiate this organism
from B. suipestifer the author is awaiting the
arrival of a suipestifer serum from England to carry
out Castellani's absorption test.
Sodium Morrhuate in the Treatment of Tubercu-
losis (Sir Leonard Rogers and others). — Sodium
morrhuate, which is the sodium salt of the volatile
fatty acids found in cod liver oil, is recommended
by Sir Leonard Rogers in the treatment of tuber-
culosis on account of its lytic action on acid-fast
bacteria. Encouraging clinical results are reported
by several observers.
Marine Hygiene and Sanitation. A Manual for
Ships' Surgeons and Port Health Officers.
By Gilbert E. Brooke, M.A., L.R.C.P., D.P.H.
With 4 Plates and 27 figures in the text.
Pp. X 4- 409. London : Bailliere, Tindall and
Cox. 15s. net.
Although Public Health problems have the same
object in view both afloat and ashore marine hygiene
has become a highly specialized subject possessed
of a literature quite inadequate to its importance.
Hence we welcome Dr. Brooke's " Marine Hygiene
and Sanitation," which he modestly claims has no
pretence to rank as a text book, but simply aims at
providing a handy manual of " Sailing Directions "'
in as practical and colloquial a setting as possible.
Be that as it may, it is a book which no ship's
surgeon or port health officer can afford to do with-
out. He will find in its pages not only much useful
information, but also much good advice often
humorously given. The importance of tropical
medicine in marine work is readily gathered from
a glance through these pages, especially as regards
that great tropical triad : plague, cholera and yellow
fever.
An Atlas of the Primary and Cutaneous
Lesions of Acquired Syphilis in the Male
By C. F. White, M.B., and W. H. Brown,
M.D. 1920. London: Bale's Medical Books
and Journals. Price 27s. 6d. net.
This unique work is the outcome of the photo-
graphic record of 19,000 cases of syphilis seen
in an Army Venereal Disease Hospital. In addi-
tion to four beautifully executed plates, there are
seventy-nine photographs, mostly stereoscopic, for
use with a hand stereoscope, which can be supplied.
The commentary whicJi is concise and to the point
is explanatory of, and supplementary to, the
photographs, so that this Atlas makes no pretence
at being a treatise on syphilis. In addition to the
primary sores, both genital and extra-genital, and
the secondary and tertiary cutaneous lesions, a sec-
tion dealing with non-syphilitic or soft sores is
added together with one on some common skin,
diseases not infrequently mistaken for syphilis.
The Atlas should accordingly be of very consider-
able service to practitioners in any part of the world
as an aid to that early and accurate diagnosis of
syphilis which is of paramount importance and
upon whioh adequate early and systematic treat-
ment depends.
Personal Hygiene. By M. R. Samey, M.D.
Pp. vii -1- 96. Calcutta, and London : Butter-
worth and Co. 3 rupees net.
Manuals of personal hygiene are only too rare,
especially those dealing with India in conformity
with the social, economic and religious customs of
that populous empire. Hence we welcome this
little work of Dr. Samey, whose efforts have nothing
to fear from " the rude gaze of the carping critic "
which he appears so much to dre^d. Signing him-
self " Sentinel of Hygiene and Servant of India,"
he lays " the lame labours of this limping LiUiput "
as a devout offering at the feet of his patron Deity,
Hygiea, who can warmly reply to him '" Well done
thou good and faithful servant " and unto other of
her devotees " Go thou and do hkewise." We look
forward to the forthcoming companion volume on
" Public Health and Hygiene " promised by Dr.
Samey.
A Primer of Tropical Hygjene. By Col. R. J.
Blackham, C.B. Sixth edition, revised and
enlarged. Pp. 154. 1919. Bombay: Clar-
ridge and Co. 1 rupee.
In addition to reaching a sixth English edition
Col. Blackham's brochure has been translated into
various Indian vernaculars and is accordingly well
known in India. It is equally adapted to other
tropical regions and also deserves to be equally well
known in those regions outside the Indian Empire.
Containing accurate and concise information on
tropical hygiene in non-technical language we
warmly endorse Sir James Cantlie's recommenda-
tion that it should form part of the outfit of every
person taking up an oflBcial or commercial appoint-
ment in a' warm climate.
June 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 11. Vol. XXIII.
Original Commnntations.
MILROY LECTURES ON THE HIGHER FUNGI
IN RELATION TO HUMAN PATHOLOGY ..i
Trichomycosis Axillaris, Flava, ^igra, et Rubra.
This condition has. been known under the term
Leptothrix for many years, but the various types of
it were not differentiated and the aetiology was not
By Aldo Castellani, C.M.G., M.D., M.R.C.P.
Physician to the Tropical Hospital (Ministry of Pensions),
Lecturer at the London Sciiool of Tropical Medicine.
Lecture III.
Mb. President, Censors and Fellows of the Col-
lege,— In to-day's lecture I propose to treat very
briefly the subject of fungi in relation to certain
skin diseases.
The role played by fungi an these diseases is of
extreme importance ; it suffices to bear in mind
the various trichophytoses, the blastomycoses, the
sporotrichoses, the mycetomas. It is interesting to
note, however, that though, of course, during recent
years the all-important role played by the higher
fungi in dermatology has been ajnply recognized,
not many decades ago most authorities denied them
any importance, some considering Buch organisms
to be merely saprophytes, and others going so far
as to state that the so-called fungi found in the
epidermis and the hairs did not exist, these struc-
tures merely representing a granular degeneration
nf the epidermial cells.
These affectiona may be separated to a certain
ixtent into two groups: —
(1) The trichomycoses.
(2) The dermatomycoses sensu stricto.
Of the first group I shall eay a few words on the
following : —
(1) Aspergillomycosis of the beard.
(2) Trichomycosis axillaris, flava, rubra, et nigra.
As regards the second group I propose touching
briefly on the following:^
(1) Tinea flava,
(2) Tinea nigra.
(3) Cryptococcosis epidermica.
(4) Accladiosis.
(5) Blastomycosis.
f6) Dhobie itch (tinea cruris).
(7) Tinea imbricata.
Aspergillomycosis nf the Beard.
Aspergillomycosis of the beard and moustache
appears under the form of minute dark-greyish
nodules, one or several on each individual hair.
The first case I saw in Equatorial Africa in 1902
in an Indian merchant; later Chalmerii and myself
observed several such cases in Ct^ylon. The fungi
found are generally of the aspergillar type, but occa-
sionally organisms of the genus Penir'illinm may bp
seen. The sianplest treatment consists, of course,
in shaving, but if the patient does not wish to
shave, turpentine will be found useful.
' Delivered before the Royal College of Physicians of London,
I found in a case of aspergillomycosis
of the beard.
completely cleared until recently. In the large
literature on the subject, the affection is ascribed
to the most diverse germs : Eisner describes a diplo-
coccus; Payne, Patterson Pick various bacilli,
among wliich is B. prodigiosus.
'i'he condition is characterized by the presence
on the hairs of the axillary region (occasionally of
the pu'bes also) of small nodular formations. These
nodules may be, in my experience, yellow, or black,
or red. I have therefore differentiated three varie-
ties erf the affection: Trichomycosis axillaris flava,
T. axillaris nigra, T. axillaris rubra.
Pio. 2.— Trichomycosis axillaris flavia.
PlO. 3. — Trichomycosis axillaris nigra.
.\t times one axilla may show the variety nigra,
and the other the variety rubra or flava ; occasionally
the same axilla and even the same individual hair
may present two varieties at the same time. In
Ceylon and Southern India the three kinds, yellow,
black and red, are common ; in North Africa mostly
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1, 1920.
the yellow kind is seen, and at times the red; the
black variety seems to be absent in Europe.
What is the aetiology of trichomycosis axillaris?
In the researches I carried out in Ceylon in 1911
on the subject, I came to the following conclu-
sions : —
The yellow variety, tinea flava, is caused by a
fungus of the genus Nocardia (Streptothrix), which
1 called Nocardia tenuis.
The black variety is caused by the same nocardia
plus a black pigment-producing coccus, which hves
in symbiosis with the nocardia. This coccus I suc-
ceeded in growing ; the colonies after a time become
jet black. I called it Micrococcus nigrescens.
The red variety is caused by the same nocardia
(N. tenuis) plus a red pigment-producing coccus,
which I cultivated on various media; the coccus
gives rise to red colonies and has been further in-
vestigated by Chalmers and C'Connell, who have
paid me the compliment of giving it my name.
Trichomycosis axillaris is an affection of little or
no importance, but I have known European ladies
in the tropics greatly distressed by it, as when
wearing a low-necked dress the disfiguring red or
black patches in tlie axillary regions are quite
visible. It is a curious fact also that natives when
affected with trichomycosis seem to regard it with
disgust, and readily seek treatment, and Chalmers
and O'Connell have recently brought forward the
suggestion that the general custom of shaving the
axillary hair among certain native tribes may have
originated in their profound dishke to this com-
plaint.
The treatment which I found most successful in
Ceylon, apart, of course, from shaving, was dabbing
the hair two or three times daily with a 1 per cent,
alcoholic solution of formalin, with the application
of sulphur ointment at night.
Tinea Flava.
Ninety per cent, of the natives of the low country
in Ceylon are more or less affected with this
mycosis. It generally starts at a very early age, it
slowly spreads and seldom, if ever, disappears
completely. Variously shaped, bright yellow epots
are seen most commonly on the neck and chest,
but any part of the body may be affected. In
Singhalese poetical literature, reference is often
made to the tiny canary-coloured beauty-spots pre-
sent on the face of Ceylon young women. These
spots so much admired by native poets, who have
coined a special poetical expression for them,
"gomera, " are in reality merely minute patches
of tinea flava, and are produced by the fungus
described under the name of Malassezia tropica.
Sometimes all the patches of tinea flava coalesce
together, giving rise to the diffuse form of the
disease. Occasionally one is giurprised to see a
Singhalese or Tamil native with the face, chest,
and trunk of m'uch lighter colour than other natives;
on <'loser exafliiination it will often be found that
this apparent lighter colour of the skin is merely
(l\ic to a diffuse form of a very light variety of
tinea flava. Tinea flava was considered to be,
until recent years, identical with pityriasis versi-
color of temperate chmates. I separated from it
for the following reasons : —
(1) Tinea flava affects the face more frequently
than any other region of the body.
(2) It is extremely chronic, developing in early
childhood and lasting for life.
(3) It is most difficult to cure.
(4) The fungus, which I called Malassezia tropica,
seems to have almost a permanent disturbing action
on the pigmentation processes of the skin, as even
when the fungus has been destroyed the patches
remain discoloured for a very long time, months
and years, though they may in the end become
again normally pigmented.
The treatment, as I have already stated, is most
-difficult; turpentine is useful, and on covered parts
of the body a cJirysophanic ointment may be used.
Tinea Nigra.
This tropical dermatomycosis, fairly common in
natives, is characterized by the presence of jet-black
patches- <lue to a fungus of the genus Chladosporium,
which I called 0. Mansoni, in honour of Sir Patrick
Manson. This fungus grows on glucose and mal-
tose media, giving rise to black colonies. It may
attack Europeans, as shown by the following case.
A European medical man went to Burma for a
pleasure trip. On coming back to Ceylon he
noticed a roundish, very slightly elevated, black spot
on the palm of his left hand. Thisi spot slowly
increased in size for two months, becoming the size
of a sixpenny-piece. A single app'ieation of formalin
made it disappear, but three months later it re-
appeared. A second application of formalin cured
the condition permanently. From the patch, before
treatment cultures were made and a chladosporium
isolated identical to that found in native cases.
Cryptococcosis Epidermica.
Some years ago I noticed on the skin of one of
my bungalow servants several brownish dirty-look-
ing patches, which looked very much like dirt. He
told me, however, that they did not disappear on
using soap. I made a scraping and saw that these
pati^hre consisted of a large number of budding celb
which 1 bflipved to he saccharomyces. I found the
same patches, not only in other natives, but also
in Europeans, especially on the chest and arms, and
called the condition saccharomycosis epidermica,
which term I changed later into the more correct
designation cryptococcosis epidermica. I did not
succeed in growing the fungus. Recently Chalmers
arid others have confirmed my findings in the Sudan
and North Africa, but the organism has not yet
been cultivated. As to treatment, ordinary soap
will not remove the patches; sand soap occasionally
does. In obstinate cases the patches may be
touched with an alcohohe solution of salicylic acid
and then a salicylic-sulphur ointment may be
applied.
KiidodernwphytoH tropicaJc Cast.
Experimental tinea iinbricata obtained by inoculating a culture of Kndodermophyton indiciim.
To illustrate paper, " Millroy Lectures on the HiRhor Fungi in Relation to Human Tathology," by Aldo Castkm
Acelndiiim cisfellanii Pinay
enltnre on glucose agar.
hidinm casiellanii PicoT,
! on potato (old).
To illostrale paper, " Milroy Lcetcircs cu the Higher Fungi in Relation to Human Paliiology," liy Aldo CiSiKLLAKr,
C.M.G., M.D., M.rt.C.P.r.ond.
June 1, 1920.] THE JOLUiNAL OF TROPICAL MEDICINE AND HYGIENE.
135
Accladiosis.
Thi.s dermatomycosiis, described by me some years
ago, is caused by a fungus of the genus Accladium.
I grew tlie fujiguis from the lesions and sent cultures
to Professor Pinoy, of the Paris Pasteur Institute,
who kindly described it botanirally, and honoured
me by calling it after my name. I quote his
description : —
' ' The growth on artificial media (sucii as can-ot,
])otato, glucose-agar) consists of many small roundish
masses, which later on may coalesce, and are
ctivered by spiciilated formations, giving them a
Fia. 4.— Glucose-agar culture of Accladium cnstellanii,
Pinoy.
prickly appearance, and consisting of erect, straight
filaments, parallel to each other, or at times in-
terlacing. These filaments are approximately '2
microns in diameter, and carry laterally pseudo-
FiG. 5. — A case of accladiosis, showing clianu^tiiristic rouiidisli
or oval ulcers, with sharply defined edges and a granulating
fundus.
conidia of variable shape, oylindriform, ])yri.form, or
spherical, attenuated in size at their jwints of in-
sertion. Most of these piseudoconidia are 4 microns
in length, and have a breadth of 3 microns. This
type of fructification recalls the type Accladium,
described by Bodin in certain species of the genus
Trichophyton (Malmsten, 1848). These pseudo-
conidia become detached and then develop by
sprouting, and mycelial filaments are formed.
Certain filaments produce spherical chlamydospores
arranged in small strings, as found in certain fungi
of the genus Fnsarium. These small cJiains of
chlamydospores are very frequently terminal, the
dimensions being variable — 8 to 10 microns."
The affection is observed in Ceylon and the
Federated Malay States, and during the war I
found a case in Macedonia. Chnically this derma-
tosis is very characteristic; in a .well-marked case
ulcerative lesions are present all over the body ; the
ulcers are roundish or oval, sharply defined, and
with a red granulating fungus. There is often a
fairly abundant purulent secretion, which dries up
in thick bright yeUow crusts covering the ulcers.
Occasionally gummatous nodules and fuinmcle-hke
lesions are seen. The course of the disease is very
long, and generally there is very little or no tendency
to spontaneous cure. Potassium iodide when given
in full doses is generally successful.
Blastomycosis.
The term blastomycosis is generally applied to
affections due to fiuigi of the genera Saccharomyces,
Cryptococcus, Monilia, Oidium, and Coccidwides.
The clinical appearance may greatly vary ; the cases
I have seen may be classified into three principal
groups : —
(1) The cutaneous type.
(2) The muco-cutaneous type.
(3) The gluteal blastomycosis.
Tl\e cutaneous type, characterized by verrucose
patches with minute abscesses, is quite common in
5 1 Ceylon and other tropical countries, and occasionally
case? aFe seen also in temperate climates.
Muco-cutaneous type. — In this type the disease
attack..;' not only the skin, but also the mucosee,
)H-incipally the oral mucosa and the pharynx, giving
rise to numerous small verrucoid papillomatous or
frambipsiform patches, which later may ulcerate.
This type is common in South America, where it
has been investigated by Splendore and others, bub
a very similar ty])e is found also in Ceylon and other
tropical and subtropical countries.
Three weeks ago I saw a demobilized officer with
lesions on the left angle of the mouth, portions of
the oral mucosa and of the tongue, which closely
r(!seJnhled a syphilide. The lesions had made their
appearance in Egypt. The patient denied ever
baving contracted syphihs ; moreover, in Egypt Ids
blood "wa.s examined for Wassermann three bimeis,
always with negative resiult. Notwithstanding the
negative Wassicrmann the patient had several
salvarsan injections and a long coTirso of mercurial
treatment without any benefit. In scrapingi? from
the lesions I found a few yeast-like bodies, and
culturally I have grown a fimgiis which resembles
more a monilia than a saccharomyces or a crypto-
cocc.us. Under an iodide of potassiiim treatment
the lesions are already very much better.
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [June 1, 1920.
Gluteal Blastomycosis. — This variety has been
described by Kartulis in Egypt, and I have seen
cases in Ceylon. The gluteal regions present a
diffuse induration and are cribrated with numerous
openings from which a thin purulent liquid exudes.
Fungi of the genus Saccharomyces or Monilia are
generally isolated from the pus.
As regards the prognosis, this is on the whole
favourable in the cutaneous type provided an appro-
priate treatment is carried out — much less favour-
able in the muco-outaneous and in the gluteal
varieties. It must also be remembered that occa-
sionally the organisms enter the general circulation
and give rise to a pyaemia-like fever. Oooasionally,
in fact, one comes acros? cases of blastomycetic
septicaemia without any skin lesion, and these cases
as a rule terminate fatally.
Dhobie Itch.
I know of very few Europeans who, after one or
two years residence in the tropics, have not com-
tracted that most distressihg and intensely itching
condition of the inguino-scrotal region, which is
known all over the East as dhobie itch, from the
popular belief that it is acquired from ainderclothing
and linen contaminated while being washed by the
dhobie (native laundi-yman).
What is dhobie itch? It is in reality the old
eczema marginatum described by Hebra. The his-
tory of the disease is briefly the following : About
the middle of last century Hebra in Vienna de-
scribed eczema marginatum of the inguinal regdone.
Later trichophyton-Uke fungi were found by various
observers, and the condition was considered to be
an inguinal localization of tinea corporis, and the
fungus was believed to be the same as Trichophyton
tonsurans.
In Ceylon in 1905 I suggested that the condition
should be definitely separated from tinea corporis,
having found a fungus very different from those
observed in the usual types of tinea corporis ; this
fungus was characterized by not attacking the hair
or hair follicles, and by its colonies on maltose or
glucose agar being of a peculiar yeUovrish colour,
lemon-yellowish or orange-yellovmh. I called it
Trichophyton cruris.
In 1907 the same fungus was found by Sabouraud
in France and called Epidermophyton inguinalis.
I sent the cultures of the Ceylon strain both to
Sabouraud and Pinoy, and they concluded that the
French strains, and the Ceylon strains were identical.
.•\ccording to the laws of nomenclature the correct
name is Epidermophyton cruris and not Epidermo-
phyton inguinalis, as when a fungus is moved from
a genus into another it does not lose its specific
designation. As is. well known, the generic designa-
tion of an organism may be changed, but the specific
designation cannot be altered.
In 1909 I found that certain cases of dhobie itch
were due to a different epidermophyton (E. rubrxim),
and later I observed that a few cases were due to
a true trichophyton (T. nodoform.ans). There are,
therefore, three species of fungi which may give
rise to dhobie itch: E. cruris, E. rubrum, T. nodo-
formans.
(1) E. cruris, as already stated, is characterized
by its lemon-yellowish or orange-yellowdsh colonies.
(2) E. rubrum, which I described in 1909, is
characterized by the deep red pigpnentation on
glucose agar.
(3) Trichophyton nodoformans is characterized by
the fact that the surface growth is white and
powdery, while the submerged portion is of a
brick-red colour, which, however, disappears after
repeated transplantationis.
It is interesting to note that i .'ch species gives
rise to a slightly different type of dhobie itch.
E. cruris causes the common festooned variety
identical with eczema marginatum of Hebra.
E. rubrum causes an eczematoid-like variety; the
edge is less raised and is made up of numerous
small close-set papules covered at times by minute
bloody crusts. It has great tendency to spread
from the scroto-inguinal region to any part of the
body and may, in fact, begin on practically any
region.
T. nodoformans induces an eruption with a very
thick nodular margin, and the fungus may attack
the hair follicles.
One word as to prognosis and treatment. An
apparent cure is quite easily achieved, but a true
cure is much more difficult. In patients who had
dhobie itch in the tropics and have settled in
Europe the infection may last for very many years,
remaining dormant in winter, but breaking out
regularly every summer ; the best treatment con-
sists, in my experience, in a salicylic-sulphur oint-
ment, and in very obstinate cases chrysophanic acid
may be used.
Tinea Imbricata.
Thisi dermatomycosis, which is extremely common
and of great practical importance in certain tropical
countries, was first described by Dampier in his
-^^
Fig. 6.— Tinea imbricata.
book, " A Voyage Round the World," in 1789. In
Alibert's " Atlas of Skin Diseases," published in
1832, there is a very good illustration depicting the
disease. In 1874 Tilbury Fox gave a description
of the complaint under the term Tokelau Ringworm.
He detected in scales a filamentous fungus and
considered it to be identical with the fungus of
June 1, 1920.J THE JOURNAL Of TROPICAL MEDICINE AND HYGIENE.
European ringwonn. From that bime disous&ion
began and continued for many years on the subject
wliether the disease was a separate entity or merely
European ringworm modified by the different
chmatiic conditions. The great majority of the
European autiiorities, who, however, had no per-
sonal experience of the malady, were opposed to
considering the disease a «^eparate one, while the
medical men practising in the tropics generally
believed it tw be a different affection from ring-
worm. Very valuable researches were carried out
by McGregor in 1870 tmd Coniger in 1871, but
Manson's researches in China during the period
1879-1882 are by far the most important. He de-
scribed the eruption in a masterly manner, and first
introduced the very appropriate naiii^ of Tinea Tiii-
bricata. Moreover, he gave a very good micro-
scopical description of the fungus, although, as
might be expected, using the technique of that time,
he did not succeed in cultivating it. He considered
it to be a non-cultivable trichophyton for which
Blanchard suggested the name T. conccntricutu .
In recent years the malady has been generally con-
sidered to be a form of Aspergillosis, especially after
the well-known researches of Tribondcaii, Wehmer
and many other observers. Tribondeau described
fructifications somewhat similar to those of an
aspergillus and created for the fungus the genus
Lepidophtjton. Wehmer described it as a true
aspergillus (Aspergillus tokelau). I investigated
the malady in Ceylon, and I think I may venture
to say that I succeeded in proving that these asper-
gillus-like fungi have nothing to do with the disease,
and that when thej- are present in the scales, as
they often are, are merely saprophytes or contami-
lations. By using a special technique I succeeded
n growing the fungi which I consider to be the
rue causative agents of the affection. I created
or Hum the genus Kiulodermophyton, of which
htrc are at least four species: (1) Indicum, (2)
"n.pirnle. (3) Concentriciun. (4) Mansoni. The
ungi belonging to the genus Endoderniophyton
ly their growing between the superficial and
leep layers of the epidermis, form an interlacing
elt of mycelium which detaches the horny and
;ranular layers from the rett^ Malpighi. They do
lot invade the hair follicles and do not cause sup-
luration. Their cultures are similar to those of the
enus Achorion (see Castellani and (Jhalmers'
Manual of Tropical Medicine," p. 1016). The dif-
cnlty in growing artificially such fungi is explained
y the fact that they do not grow on solid media
ir( ( t from the scales. These after being treated
illi iilidhol tiDin five to ten minutes must be placed
1 j^hicose broth tubes, one scale in each tube. Most
f the tubes become contaminated with bacteria, but
1 those which remain clear, after a time, five to ten
ays, a few delicate short mycelial filaments will be
!en originating from the scales. The growth slowly
icreases until after a few weeks it takes the appeur-
ice of a small white fluffy mass with a dark spot
he s(^ale) in the centre. The fungi can then be
iirisplanted on solid sugar media, on which they
then will grow quite well, and from which they can
be sub-cultivated indefinitely. The species may be
differentiated as follows : —
(1) Glucose agar cultures — amber coloured. Duvet
— absent or present only in very shght amount.
— Tropicale.
(2) Glucose agar cultiu-es — deep orange or pinkish
or red, white. Duvet often present. — Indicum.
(3) Glucose agar cultures after some weeks become
black. — Concentricum.
(4) Black pigmentation very rapid. — Mansoni.
By inoculating cultures of the first two species
1 have succeeded in experimentally reproducing the
disease in natives who had volunteered (see plate).
A few words on the predisposing causes. As re-
gards age, in my experience young adults are mostly
affected, but children and very old people may con-
tract it. Men are much more frequently infected
than women. It is doubtful whether there is any
racial disposition. In Fiji it is said, however, that
the innnigrant Tongas rarely contract the malady,
while the indigenous Fijians are extremely prone to
it. Some auth'orities believe that this relative im-
munity is due to the habit the Tongas have of
anointing their skin.
As regards climatological influences, Mansou has
made the interesting observation that tinea imbri-
cata is rife especially in those tropical countries
and districts in which the climatic conditions are
favourable for the growth of the coconut tree. I
can confirm Manson's observation. In Ceylon tinea
imbricata is not very common, but the cases one
sees generally come from the coconut districts.
There is no doubt that a hot moist equable climate
is the most suitable for the fungi of tinea imbricata,
as it is the most suitable for the growth of the coco-
nut tree.
Clinical Symptoms. — The development of the
eruption is most interesting. At the very beginning
one or several small roimdish or oval dark brown,
very small spots appear, generally on the arms,
chest or back. After a short time each brownish
spot splits in the centre, and in this way a ring of
flaky large scales attached at the periphery is formed ;
this scaly ring expands peripherally, and while it
does so another brownish spot appears in the centre,
in the same site as the first brown spot; this new
brown patch also breaks in the centre, and in this
way a second scaly ring is formed, which expands
towards the periphery inside the first ring ; again
in the centre a dark patch appears, which splints,
and a third ring is formed inside the second ; and
so on until a number of scaly rings develop. Sir
Patrick Manson has aptly compared this develop-
ment of concentric rings to the concentric ripples
prodiiccnl by a pebble thrown into a poo! of water,
and when the eruption starts from many points,
as is often the case, owing to auto-inoculation, it is
as if a shower of pebbles had fallen in the pond,
and many systems of spreading rings are produced
which intersect each other in various ways.
The scales are flaky, tissue paper like, large, up
to half an inch in length, dry and of a dirty greyish
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1. 1920.
or brownish colour. The fungus never invades the
hair follicles, nor, according to some authorities, the
nails. I must say, however, that in my experience
the nails are often affected, becoming discoloured
and brittle, and this has been also Hanson's experi-
ence.
The eruption has not much effect on the general
health of the patient, but the pruritus it induces
is really terrible, and the native patients refuse to
do any work and remain in their compounds, where
they can be seen squatting or lying down and
scratching their bodies the whole day long. I have
noticed that the itching is greatly increased by
giving certain diets : for instance, the dry fish diet
often given in Ceylon hospitals makes the pruritus
absolutely unbearable.
Diagnosis. — The clinical picture of the disease is
most characteristic, even when the eruption is of
the diffuse type; the farge dry tissue paper like
scales overlapping each other like tiles on a roof
are quite typical, but the diagnosis is certainly very
difficult to the newly arrived European medical
man, who may never have heard of the disease.
On superficial examination the malady does not
strike one as being of epiphytic origin, and the
cases I generally had in the Colombo Clinic were
often diagnosed by visitors — and naturally so — as
cases of ichthyosis or of pityriasis rubra, and it is in
fact interesting to note that one of the many
synonyms of this malady is " tropical ichthyosis."
Of course, the microscopical examination of the
scales will reveal presence of an enormous number
of mycelial filaments, and this will clear the dia-
gnosis at once.
Progyiosis. — The disease, as I have already stated,
has not at first a serious influence on the health of
the patient, but the affection is chronic, and after
rt time the patient not rarely becomes anaemic,
emaciated and a nervous wreck, owing to the con-
tinuous sensation of pnu-itus and loss of sleep. At
any rate the patient is not fit for any work, and
this is of great practical importance as it tends to
decrease the labour force on low country estates.
I may be allowed to say one word with regard
to treatment. The disease never shows any
tendency to spontaneous cure, and its treatment is
most difficult as every tropical practitioner knows.
It is easy enough to obtain a temporary improve-
ment and even a disappearance of the eruption;
but as a rule a few days after discontinuing the
treatment the eruption starts afresh.
In the Colombo Clinic I experimentally tried the
most different drugs and ointments and came to the
conclusion that the best routine treatment is by
resorcin dissolved in tr. benzoin co. (res. 5!, tr.
benz. ad jij) or by ehrysarolnn ointment.
It is interesting to note that resorcin in oint-
ment or in alcoholic solution has practically no
action and that tr. benzoin co. alone has also prac-
tically nf) action, but when the resorcin is dis-
solved in the tincture very good results are obtained.
OBSERVATIONS ON A CASE OF ONYALAI IN
THE EAST AFRICAN PROTECTORATE.
By T. B. Welch, M.B.London.
Medical Officer in charge, Kenya Province, E.A.P.
Since Dr. Yale Massey in 1904 and in 1907
published articles in the Journal of Tropical'
Medicine and Hygiene on " Onyalai, a disease of
Central Africa " a number of cases have been
recorded having features in common, if not iden-
tical, with those that he described. Such cases have
been met with in Portuguese West Afi-ica, in the
Congo Basin, and in the Tanganyika tenit-ory.
So far as I am able to ascert-iiin tlie disease has
not 'hitherto been reported as 'having oc<?urred in
the East Africa Protectorate. Some particulars
therefore of a case recently under my care and
bearing a close resemblance to the disease as
described by Dr. Yale Massey, may be of interest.
The patient, a native aged about 25, came to the
Native Hospital, Fort Hall, complaining of bleeding
from the mouth.
He gave the following history : Five daySj
before coming to hospital he first noticed that hii
mouth was sore and was bleeding. The haemor-
rhage had become neither worse nor better since
shortly after the outset. In all other respects he
felt quite well, and had reported sick to his J
employers, who ordered hijii to hospital, solely on *
account of the iuoonvenience of the condition. On *
being questioned he stated that on the day preced-
ing, and on the day of his airival, he had noticed
that his urine was of a very dtrk colour but that
micturition v\as painless and that there was no ;
pain in the abdomen or loins. ^
The man, who is of good phj'sique, reached the '
hospital in quite satisfactory general condition
although he must have lost a considerable volume
of blood and had walked a distance of over thirty-
five miles in about a day and a lialf. When seen
he was emitting saliva in large quantities and
mixed with blood at very short intervals ; the total-
amount was large; since it was found that he
emitted nearly half a pint in twelve houi-s, and
this process according to his statement had now
lasted five days and was to last yet another ten
before any diminution was noticed.
The following lesions were found, \\7... hull*
or ulcers or both in the mouth, nose and skin.
There was no evidence of any lesions of the digestive
apparatus, with two doubtful exceptions to be
refeiTed to later, nor of the respiratory apparatus
other than these : The thoracic and abdominal
viscera appeared normal except the spleen which
was slightly tender, readily palpable, firm, and
extended one and a half inches below the costal
margin on expiration.
The organs of special sense appeared to be
normal except that a slight yellowness of the
sclera, such as is often seen among natives
apparently in good health, was noted.
Slight pallor of the face and of the Iniccal and
j):ill)ebral surfaces were observed ; this vanished
ii
June 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
139
during convalescence and appears to have been
secondary tn the lo^s of blood.
The conditiMM ul i.lir mouth was as follows: The
teeth were >.' 1: liu' -idhs rather pale but other-
wise quite iiaiural, Ihcre was no pyomhcEa. The
tongue was Habby and tremulous, its dorsum was
covered with black fur; aJso the following lesions
were jiresent : a small very superficial ulcer about
one-(]uarter of an inch in diameter was situated
one inch from the tip of tlie tongue, blood was
oozing freely from the surface ; between the ulcer
and the tip there was a bulla not more than one-
eighth of an incli in diameter and of a blue-purple
colour. On the right margin of the tongue and
crossing the level of the attachment of the frenum
lingua there was a nan-ow ulcer about one inch in
height and a little deeper than that on the dorsum
of the tongue, and from the surface of this also
blood was oozing.
On the roof of the mouth, lying mainly to the
left of the middle line and crossing the junctioji of
the soft and hard palates there was a mass of clot
of about three-eighths of an inch in diajneter.
From the edges of this clot thefe was a flow of
blood and of a brown fluid, presumably altered
blood. The clot was readily detachable and
markedly friable; when it had been separated, a
superficial ulcer whicli bled freely and which
resembled that on the dorsum of the tongue was
seen. The clot re-formed in about a day.
Tlie inner surface of the right cheek showed a
mass of clot resembling in size and in other respects
that upon the palate. None of these lesions showed
any surrounding zone of hyperaemia.
In the anterior nares there was a bulla, resem-
bling that on the tongue, situated on the right side
of tihe septum.
The skin showed during the course of the disease
about eighteen bulte; they were all circular in shape
and of under one-quarter of an inch in diameter.
If the covering skin was removed, or if they broke
down, they bled freely. Some, when opened,
showed trabeculation much more markedly than
did the lesions in the mouth. A few of the bvillce
were umbilicated. Most of these bullae were on the
chest and abdomen ; a few occurred on the thighs
and arms, in which situations the patient also had
scabies : but the majority were well away from the
scabies-infected areas. There were no buJlse on
the face, hands, feet, or posterior aspect of the
trunk. There was no pitting on recovery.
The urine was at first mixed \inifonnly with
rrmoh blood and this condition lasted from tlie fiftli
to the ninth day of the disease ; thereafter the
blood diminished in amount until nn the thirteenth
day it could not be recognized macroscopically,
and after tlie fifteenth day I failed to find any
evidence of liieinaturia by microscope. Casts were
repeatedly sought for, without success, though the
uniform mi.xture of blood and urine suggests renal
haemorrhage. The daily output of urine gradually
fell and did not rise when saline diuretics were
given, but did so very markedly when the patient
was allowed to drink large quantities of fresh lime
squash.
The fs&ces were of -a black-brown colour, and
this was probably due to swallowed blood. On only
two occasions did I find cause to suspect any lesion
of the intestinal tract, and these were : the first on
the ninth day of his illness, the second when con-
valescence was far advanced, and the patient was
at this time under treatment to secure the expul-
sion of a tapeworm (Tcenia saginata) ; on each
occasion 'he passed one stool containing very little
fffical matter, but much blood-tinged mucus. Un-
fortunately I saw botli these stools too late for
microscopic examination to be of any value.
During his stay in hospital he required treatment
for tapeworm and for round worms; only two of the
latter were found.
Fresh lesions of the mouth and skin appeared
up to about the eighteenth day of the disease, con-
currently with repair of older lesions. Throughout
the patient said that he felt very well and his
general condition was good. His temperature was
usually subnormal, its maximum, and that on
admission, 99° F.
Little was done wifcli regard to pathological in-
vestigation. Examination of blood films showed no
parasites; the following was the result of the only
differential leucocyte count done, viz. : —
Polymorphonuclear 67 per cent.
Large mononuclear ... 4 ,,
Small ,, 23
Eosinophile cells ... ... 6
Basophile ,, ... ... —
No ftbnoniial white or red cells were found. No
total leiKtocyte count was done.
I am entirely doubtful whetlier treatment in any
way influenced the course of the disease. Calcium
chloride was given in moderate doses for two days,
and thereafter an ordinary tonic mixture (fern et
quin. cit., &e.). The motions were kept soft by
means of liq. paraffin, and he was kept on a milk
diet, both with a view to reducing ths efforts of
the intestinal tract to a minimum, and so to
minimizing the strain upon any ulcerated surfaces
that might be formed if the same process occurred,
which it probably did not, throughout the alimen-
tary apparatus. The use of diuretics and anthel-
mintics in this case has been indicated.
The patient left hospital in excellent health
thirty-four days after the outset of his illness.
This disease appears to be unknown to the natives
of Kenya Province and to those of the East Africa
Protectorate in general so far as I am able to
ascertain. The patient, a particularly intelligent
member of the Wa Mem tribe who inhabit the cool
foothills to the north-east of Mount Kenya, was
very indefinite, stating that he had never heaid of
any such condition among his people ; no othei'
result has followed on my inquiries of Kikuyus,
Swahilis, or Kavirondos, i.e., of representatives of
tribes hailing from parts of the country differing
greatly from one another, not oidy in position, but
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1, 1920.
in climate and in conditions of life. It seems to me
suggestive that in this respect my experience differs
from that of observers of apparently the same or
of allied conditions who have been able to ascertain
the name by which the natives knew them, and in
some instances to state that the diseases were
greatly feared.
The patient had been exposed to the possibility
of infection outside of this Protectorate, if, as Dr.
Wellman has held, this disease is an acute specific
infection. He had served for three years of the
war in our IntelUgence Ser\'ice both in German and
Portuguese territory, and had been in the country
of Wa N\'amwezi, among whom an allied condition
Kavindo has been described by Mense, while
Feldman, also in East Africa, has found a similar
disease known as Edjuo. If, however, the disease
is an infection foreign to this Protectorate, then it
must be one which may long remain in abeyance,
for the patient had returned to this country some
nine months before he fell ill.
During the three months preceding the outset of
his illness the man had worked in the hot and un-
healthy country traversed by the upper waters of
the Tana River. This is a sparsely inhabited
country, and I have had no opportunity to find out
whether symptoms such as the patient presented
are known among the scanty population.
It is to be regretted that this particular case
throws no new light upon the etiology of this obscure
disease.
I have to thank the Principal Medical Officer of
this Protectorate for his courteous permission to
put forward these observations on an unusual and
interesting condition.
^etiiis.
Nutritional (Edema and " War Dropsy " (Maria
B. Maver, M.D., Chicago. The Journal, of the
American Medical Association, vol. Ixxiv, No. 14,
April 3, 1920, p. 941).— The author comes to the
conclusiqji that the condition seems not to be a
typical " deficiency disease " in the sense of being
the result of a deficiency in one or more specific
unknown constituents (vitamines) in the diet. In
a broader sense it is, however, a deficiencj' disease,
and is the result of a protracted existence on a diet
deficient in total calories, especially in protein.
Undoubtedly a high fluid intake,- and possibly a
high salt intake, are important accessory features.
Hard work and exposure to cold are factors simply
in that they increase the caloric deficiency of the
food supply. The experimental work agrees with
the clinical evidence in establishing that a com-
bination of low calories, low protein and excessive
fluid intake will lead to a marked dropsy corre-
sponding to war dropsy in all respects. The import-
ance of specific vitamines seems to be excluded.
Undoubtedly dropsy occurring in many conditions
associated with other defective food supply or
absorption (as in some types of infantile dropsy)
or in conditions of protracted anaemia or cachexia
is essentially the same as w-ar dropsy. Hence the
author recommends the general term " nutritional
cedema " for this class of oases.
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THE JOURNAL OF
Croptcai ^l^edtctne and l^pgtene
June 1. 1920.
TYPHUS.
A circular has reached us to the following
effect : —
Sir, — Your readers are well aware of the serious
increase in typhus in Eastern Europe, but few
realize that this terrible scourge in the near future
June 1. 1920.] THE JOUENAL OF TBOPICAL MEDICINE AND HYGIENE.
may be knocking at our own doors. Adequate
assistance must be sent to Poland to deal with the
endless streams of refugees pouring through her
country.
We most earnestly appeal for funds to send to
Poland a completely equipped unit, armed with all
the latest scientific discoveries and fruits of modern
research, to combat this appalling disease. [Signa-
tures are asked for in this appeal.]
It is hardly necessary to add that the need is an
urgent one ; there are now in Poland itself 250,000
cases of typhus and this number is increasing
daily. Thousands of lives can be s.aved by sending
a unit of this description.
This appeal is issued by the Polish Red Cross.
Donations should be sent to the Princess Sapieha,
45, Grosvenor Square, London, W.l.
We need scarcely say that the appeal has our
hearty sympathy and we agreed to sign the appeal
for insertion in the Lancet, the British Medical
Journal and the Medical Press and Circular, at
the behest of the Polish Red Cross Committee,
London. Co-operating with the Polish Committee
we find that the Serbian and the Russian Red Cross
societies are working in harmony and were repre-
sented at the meeting in the London County Hall
of the National Committee for the Relief of Distress
in Eastern Europe.
Typhus fever is considered for the most part as
a disease not of the tropics but of temperate
climates. This is true, but it may be stated at
once that whenever or wherever in the tropics the
climate approaches that of the temperate or even
the colder regions of the world typhus prevails, and
Castellani, and Chalmers did wisely to include a full
description of typhus in their recently published
third edition of their famous manual. Anywhere
in the sub-tropics where a cold season is experienced
typhus is met with; for given a high altitude and
I a cold season in any " tropical " region the disease
'is wellnigh invariably met with.
' The explanation is simple. In these " tropical
regions where cold is experienced at any time of
the year shut windows and closed doors obtain, and
overcrowding results so as to economize fuel used
for the purpose of ensuring warmth. The fewer
the fires the greater the economy in a house, with
the result that the family sleep in one apartment
- more or less, and overcrowding — the breeder of
typhus — prevails. It may appear in families living
In isolated abodes far removed from neighbouring
]! dwellings, be it in the mountainous districts of
Afghanistan where the outside air is fresh and
clear, or in the isolated " cabins " on the West
^ Coast of Ireland exposed to the fresh sea brwezcs
"rom the Atlantic. In such abodes in Ireland we
inow that as many as a dozen persons sleep in one
?mall apartment and severe outbreaks of typhus
nave occurred in the country even during quite
ecent years.
How do these people, seeing but little of their
•' jieighbours, carry the disease from one worker to
another':' Does the contagion remain in the humau
body? Does man remain a carrier as in the case
of typhoid, in which we know that some few
persons, who have had typhoid, may remain carriers
of the typhoid bacillus for the rest of their days and
so remain a standing danger to their neighbours,
or are the recurrences of the disease explained
otherwise ? The louse — Pediculus corporis de Geer
1778 — is now known to be the infecting agent. The
overcrowding due to pgverty or cold seasons ex-
poses the family to louse bites, and if the louse is
infected the chances of infecting mankind are
evident. Does the louse remain infected from one
season to another? Is the typhus infecting agent
transmitted from louse to louse without the neces-
sity of it passing through an alternative host? Is
it a case of the young getting infected after birth,
or is it transmitted to the young in utero? Both
theories have their supporters. The only way to
prove these surmises as to transmission is to find
a dwelling in which typhus has prevailed during
the cold (or overcrowded) season, and place another
large non-immune family in the same room
when next cold season comes round but under
completely sanitary conditions and await events.
If they do not develop typhus in this sanitary
room in which no lice can live then may we assume
(but of course not wholly prove) that it is the
absence of lice that explains the negative finding.
This is one form of investigation ; there are many
other plans, all of which have been considered and
gone into fully by several observers, amongst whom
Dr. Wm. Hunter, C.B., and Dr. A. Castellani,
C.M.G., have, whilst in Serbia, gone fully into and
given us a basis for our knowledge of how an epi-
demic of typhus is to be handled scientifically.
It seems that it is not the fact that poverty
prevails, with poor clothing and insufficient food,
that brings about typhus, but the presence of
vermin, and the louse in particular, for other car-
riers besides the louse are accused of spreading the
disease. The bed-bug ranks high in this category,
and yet others — blood-sucking insects, &c., have
been accused. The tick and even the flea have been
pilloried also, but the Pediculus corporis is con-
sidered the aggressor and transmitter. All recent
beliefs centre around this pest; it may be, however,
too acutely. In 1912 Anderson and Goldberger
showed that Pediculus humanus Linnaeus 1775 and
Pediculus corporis de Geer 1778 could both become
infected and that these by their bites and when the
insects were crushed were capable of transmitting
typhus to man. Patton found on the Northwest
frontier of India Clinocoris lectularius Linnseus, and
Husband and MacWalters drew attention to the
fact that the distribution of this bug coincides with
the distribution of typhus without attempting to
determine the part it plays. The class of insects
looked upon as " bed vermin " are no doubt the
infective agents in typhus and in other ailments;
this explains the intuitive dread that women more
especially have of vermin about their beds. The
dread has been for all time so groat with all people,
142
Tl-I ri JUUJKJNAJj UJ* TJSUriUAlj fll JjiUiUJJN Ji; AJNU illtrlJSJNlS. IJune 1. 15^5
ancient, mediaeval and modem, that it seems proof
that these bed vermin were tacitly regarded as
carriers of disease and hated accordingly. This
time-honoured belief has been worked out scientifi-
cally at the present day and a confirmation of
ancient and rather mythical belief established.
It seems then war has to be waged against bed
vermin and especially against the louse. Over-
crowding by itself will not cause typhus where .no
vermin are present, so that the work of any expedi-
tion sent from this country to Poland or elsewhere
will have to be equipped with fl) measures to
cleanse the home of vermin, and (2), most im-
portant, the means of protecting the persons en-
gaged in this cleansing against being themselves
infected; a process difficult in the extreme.
No better scheme for this combined effort of
sanitary work is to be found than that published
in Castellani and Chalmers' third edition, page
1338, under the heading of Prophylaxis, and we
quote from that as follows : —
Prophylaxis.
This is summarized in one word, " lousing," in
which we include the destruction of lice on the per-
son and on the clothes.
The procedure is sufficiently simple : the person
goes into a room, takes off the clothes, which are
steamed or boiled, passes into another room, and
is sprayed with kerosene oil or petrol, passes into
a third roorh, and receives clean or sterilized
clothes.
The sterilization of the clothes may be conducted
by boiling, but better still by making them into
lightly packed bundles and placing them into a
truck or room into which steam is blown. This is
easiest done in a truck, the steam being brought
from the engine.
A campaign against lice may be conducted on
the following lines : —
(A) Meihods applied to Man.
(I) Give illustrated lectures, so that people may
understand about the louse, its habits, its associa-
tion with disease, and its prevention.
(II) Advocate the use of soap and water and of
the frequent bath, as well as of clean linen
frequently changed.
(B) Mrfho(h applinl to the Louse.
(1) PnllcUrldcs: —
(a) Dry Heat. — Lice and nits can be killed by
exposing them for fifteen minutes at 60°
to 650 C.
(h) Moist Heat. — liice and nits are killed in-
stantaneously by moist heat at or over
80O C.
This is the method most used for clothing
which may be boiled or exposed to steam,
but must not be in tightly rolled bundles.
(C) Chemicals.
For Use on the Person. — Kerosene oil or petrol
spray or vaseline, or cresol soap.
For use on Stored Clothimj. — Naphthalene.
(II) Lice Repellents: —
Better-class patients. — Dusting powder of
menthol 3-5 grains, zinc oxide 1 ounce.
Poorer-class patients. — Naphthalene as a
dusting powder
(III) Special Points: —
Head Lice. — Shave the head or cut the hair
very short, or wash the hair thoroughly
with 1 in 40 carbolic acid lotion, which is
left to act for an hour, the head being
wrapped up in a towel in the form of a
turban. Then wash the head with soap
and water and apply a dressing to any
raw areas ; carbolic vaseline (2 per cent.)
or white precipitate ointment may also
be. used to destroy head lice.
Body Lice. — The following drugs arranged
in order of efficiency (according to Castel-
lani and Jackson) may be used : (1) Petrol
and kerosene oil. (2) Plain vaseline. (3)
Guaiacol. (4) Anise preparations. (5)
Iodoform. (6) Lysol, cyllin. &c. (7) Car-
bolic acid, 5 per cent, (8) Naphthalene.
(9) Camphor.
(IV) General Insecticides : —
The experiments of Castellani and Jackson
in Serbia have demonstrated that pyre-
thrum is a very feeble pediculicide, while
sulphur, boric acid, perchloride of mer-
cury, when used in powder, have no
action whatever.
Substances which maj' be efficient pediculi-
cides may, however, have little or no
action upon other insect parasites of man,
such as bugs and fleas. For example,
iodoform will kill lice in ten to fifteen
minutes, but has no action on bugs and
little on fleas. Pyrethrum acts more
powerfully upon bugs than upon lice. In
order to formulate a general insecticide
several chemical substances must be com-
bined. As an example of a general in-
secticide for use against lice, bed bugs, and
fleas, the following is given: —
Equal proportions of naphthalene, previously
soaked in guaiacol or creosote, pyrethrum.
zinc oxide.
The wearing of undergarments made lice-
proof by soaking in various disinfectants
(crude carbolic acid and soft soap emul-
sion), as recommended especial l.v by
Bacot, is useful. TiCgroux's " sachets "
or small bags containing naphthalene
treated with citronella oil may be used.
J. Cantlik.
innotations.
Poisoning by Castor Oil Seeds (Epitome of Cur-
rent Medical Literature, British Medical Journal,
No. 3093, April 10, 1920, p. 58).— M. Gioseffi {11
Policlinico, Sez. Prat., January 12, 1920) recalls
two cases in twia brothers, aged 10 years, in whom
symptoms developed two hours after eating castor
oil seeds. The first symptoms were tremors of the
liands and a burning sensation in the throat fol-
lowed by a bitter taste in the mouth and severe
colicky pains in the umbilical region, vomiting,
diarrhoea, headache, and giddiness. Considerable
improvement followed iirigation of the intestine and
injection of caffeine, and by the third or fourth day
the vomiting and diarrhoea ceased, but the weakness
lasted another week. In neither case was there
nny sign of impaired function of the kidneys or liver.
Sores analogous to Veld Sores and Barcoo Rot
appearing among Soldiers ivorking in Blue Clay
and in Chalk (D. T>. Ix)gan, Olas. Med. Journ.,
1919, xcii, p. 261, and 1920, xviii, p. 13).— The
skin becomes, dry and craaks easily, besides be-
coming easily damaged by slight knocks. Hands
that are washed after prolonged contact with chalk
become dry and harsh and remain so for some time.
The washing appai-ently can-ies away the oil, pre-
viously split up with the fonnation of calcium soaj).
A staphylococcal infection becomes superimposed.
A routine treatment of an application of bipp and
staphylococcal vaccine is set out, together with
precautionary measures that will be of interest to
physicians and administrators in mining areas.
A Stndy of Netv Elements in the Treatment of
Syphilis (Mario Copelli, Giorn. Ital. d. Mai. Ven.
<: delta Pelle, 1919, fasc iii, p. IM. British
Journal of Dermatology and Syphilis, No. 377,
vol. xxxii. No. 3, March, 1920, p. 86).— Organic
compounds of arsenic, vanadium, phosphorus and
antimony were tried separately and all combined.
The pharmacological action on rabbits and human
beings was ascertained, and also the therapeutic
effects tested in experimental syphilis in rabbits
and in cases of syphihs in man. In the present
paper only the experimental results on rabbits are
reported. P>xperiments were first done to ascer-
tain the mininnim lethal dose to rabbits of each
drug separately and of the four drugs combined.
Babbits were also treated with regular small doses
daily for a month. No effect followed except a
slight rise of temperature after every injection, and
on being killed the animals showed no changes in
the organs. The anti-parasiticide properties of the
preparations were teste<l in vitro, and these drugs,
even in «)ncentrations of 1 in 50, had no effect on
spirochsetes or the other commoner organisms, and
did not inhibit their growth in cultures. The
therapeutic effect was tested on rabbits infected
on the scrotum with primary syphilis, and it was
found that in such an experimental syphilis all the
four preparations had a therapeutic action, and in
doses considerably under the lethal one had a com-
pletely curative action. The preparation of vana-
diimn was found to* be the most active; then
followed the preparation of antimony, which was
slightly less active. The phosphorus and arsenic
preparations were found to be the least effective of
all. These preparations were all given intra-
venously, and the author concludes from his ex-
periments that they have an elective parasitropic
■action on the spirochaetes in the lesions. As the
preparations had no parasiticide action in vitro, he
concludes that some chemical change takes place
when the drug is absorbed into the tissues. The
same results were obtained in rabbits with experi-
mental syphilis when the above drugs were given
intramuscularly, but the action of the drugs was
not quite so rapid. In the third series of experi-
ments a combination of all the four preparations
was given intravenously, and it was found that in
doses of 20 eg. (per kilo of animal) the syphilitic
lesion rapidly disappeared. The author is of opinion
that this combination of drugs is more efficient than
either of theiTi singly.
Trench Nephritis. — Bianchi (// Morgagni, Decem-
ber 15, 1919), discussing Trencli nephritis at the
Medical Congress at Trieste, said all the armies
suffered, and the longer the war lasted the mor6
they suffered, which suggests that there was some-
thing in the prolonged strain and unusual conditions
of war which predisposed soldiers to nephritis.
Strictly speaking, trench nephritis is not a new
disease, not a special form of nephritis peculiar to
war, nor possessing well defined clinical and anato-
mical characters — it is a nephritis occurring in
soldiers at war. The usual type was an acute
diffuse glomerulo-nephiitis, resembling a post-scar-
latinal nephritis. No constant cause could be
found and still less any specific germ. Some
mild infective condition, perhaps most commonly
a streptococcal infection, seemed to be a necessary
condition for the development of the disease.
Spirochetes were frequently found as concomitant
saprophytes. Clinically it was characterized by
sudden onset, fever of short duration, early oedema,
mostly confined to the face and limbs, dyspnoea
and iisematuria. Albuminuria was constant, but
varied in amount. High pulse tension was slight,
and an early symptom. The renal function was
relatively only slightly affected. The immediate
prognosis was almost always favourable and the
mortality very low. On the other hand, the ulti-
mate prognosis should be reserved, not only for fear
of relapses, or persistent albuminuria, but chiefly
lest the acute nephritis should become chronic,
which happened in about 19 per cent, of the cases.
How far cure is established can only be ascertained
with certainty by testing the functional capacity of
the kidney by the so-called concentration test.
144
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1, 1920.
coupled with the elimination of water. Mere ex-
amination of the urine is not sufficient, as this leads
to both negative and positive errors. The author
also draws attention to the cases of nephritis which
characterized the recent pandemic of influenza, of
which there were twc5 main types : (1) An acute
glomerular nephritis, with scanty albuminuria,
hsematuria, cylinduria and renal desquamation ;
this type was almost always fatal. (2) Degenera-
tive renaJ lesions, with much albumin, no haema-
turia, no cyliudruria, hyaline casts, of prolonged
7^ Effects following Novarsenobillon. — In the
London Hospital Gazette of December, 1919, Dr.
S. Batchelor describes at length, with chart, the
ease of a Jewess, aged 26 years, in whom urticaria
of moderate degi-ee followed a third intravenous
injection of novarsenobillon, the fourth injection a
week later being followed by general anasarca, a
temperature of 105° i\, profuse general watery
exudation from the skin and a lat-er general desqua-
mation, with a convalescence delayed by pustular
infection. There was no albuminuria.
Dr. L. G. Leonard, of Manchester, in the British
Medical Journal of December 13, 1919, p. 773,
describes the cas« of a private suffering from a
macular secondary rash in which the third injection
was followed by shivering, backache, and diarrhcea,
temperature 105° F., and bile-stained vomiting.
There was a profuse watery exudate from the skin.
After general desquamation there was a short
attack of jaundice.
In the October number of the Journal of the
Royal Naval Service F. J. F. Barrington describes
his experiences on a hospital ship in the administra-
tion of 2,000 doses of novarsenobillon. Fever of
100° F. or more followed 107 of the 2,000 injections,
these cases being distributed among all st^ages of
the disease. Where the primary sore was unhealed
there was fever in 42 to 48 per cent, after the initial
injection.
Fourteen cases are picked out, however, as a
well-defined group in which fever and rash occurred
in the middle of a course of injections. Except for
the absence of albuminuria the symptoms suggested
serum sickness, due to some body produc-ed by the
action of novarsenobillon on the syphilitic virus.
The Action of Various Flower Cryptogams other
than Bacteria in the Soil (I. — Wakeman, S. A.,
The Importance of Motild Action in the Soil, in
Soil Science, vol. vi, No 2, pp. 137-1.55.— Biblio-
graphy of 62 publications. II.— Wakeman, S. A.,
and Curtis, R. E., The Occurrence of Actinomycetes
in the Soil, ihid., vol. vi. No. 4, pp. 309-319— Biblio-
graphy of 25 publications. Baltimore, 1918). —
I. — Moulds and Other Lower Cryptogams. Since
the first microbiological investigations into soil up
to the last four or five years, the bacteria have been
almost exclusively studied to the detriment of the
other groups of micro-organisms of which the pre-
sence was reported now and again but nothing
more. It cannot be denied, however, that the soil
contains large numbers of active moulds, actino-
mycetes, protozoa, rotifera, and, under certain con-
ditions, algae.
The work of Russell and his collaborators on the
influence of protozoa on the fertility of the soil has
given rise to a series of other studies on the activity
of these micro-organisms. Several workers have
also studied soil algs and several papers have re-
cently been published on the presence and probable
action of actinomycetes in the soil.
The author examines the metabolic processes of
moulds and other lower cryptogams in the soil with
a view to determining their influence on fertility.
He reviews sixty-two pubhcations on the subject,
compares the biological activity of various lower
cryptogams with that of bacteria, and discusses the
most important changes of the organic and mineral
matter of the soil which are attributable to the
action of non-bacterial ci-yptogams.
Taking his own observations and those of other
workei-s as a basis the author shows that there have
been isolated from both cultivated and uncultivated
soils a large number of lower, non-bacterial crypto-
gams, many of which it has been possible to identify.
It has been possible to divide this cryptogamic
flora accoixling to the conditions under which they
live. Mucorineas and Penicillium predominate in
the soil of the cold (northern districts), whereas
the soil of the warm (southern) districts contains
more especially Aspergillus. Trichodermic algsE
are found in large numbers in acid soils. Many
soils contain fungi of the genera Fusarium, Clado-
sporium, Chtetonium, Altemaria, &c.
As regards the action of these various crypto-
gams in the soil, it appears that the developrnent
of their mycelium causes modifications in the
organic and mineral constituents, but no fixation
of nitrogen or nitrification. The decomposition of
organic matter by these micro-organisms, however,
causes the fonnation of ammonia, the amount of
which depends on the sources of nitrogen and car-
bohydrates available : these, in decomposing, set
free carbon dioxide.
Nitrogenous manures apphed to the soil are
utilized by these cryptogams to fonn protein sub-
stances at the expense of the plants cultivated
which are deprived of part, of the substances destined
for them. This loss may, however, be largely com-
pensated for by the fact that the soluble nitrogenous
matter absorbed by the cryptogams is not absorbed
by the sub-soil and when later the ci-j-ptogams are
subjected to autolysis much of the nifa-ogen assimi-
lated by them is returned to the soil in a soluble
form and may thus be of benefit to the crops.
These cryptogams may also have a beneficial
effect on the soil in virtue of their vigorous produc-
tion of enzymes and acid substances which may
modify the constituents of the soil in a manner
favourable to the development of cultivated plants.
June 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
in particular they may help to dissolve the phos-
phates and other minerals.
Unfortunately cryptogams capable of living para-
sitically on certain plants (potato, &c.) may occur
in virgin soils in which these plants have never
been grown, thus forming a latent danger of
contamination.
II. — Actinomycetes. These include parasitic and
saprophytic forms and are found in the air, wat«r,
sewage, milk, and certain wounds, but especially
in the soil, where they form a large and important
group of micro-organisms (in particular in soils rich
in undecomposed organic matter), the activity of
which varies with the' different species.
After reviewing historically the question of soil-
actinomycetes, the author describes their presence
and relation to the bacteria in twenty-five soils of
North America and the Hawaii Islands. He shows
that heavy soils or those rich in undecomposed
organic jnatter generally contain more actino-
mycetes than light soils, or those poor in such
matter.
In the twenty-five soils examined the actino-
mycetes represented on an average 17 per cent, of
the total cryptogamic flora (bacteria and actino-
mycetes), whereas in an acid soil the proportion of
actinomycetes did not exceed 3-5 per cent. Many
forms of actinomycetes were isolated from the soils
studied, including Actinomyces chromogenns, A.
Upmanii, A. aureus and ,4. rutgersensis. These
were so numerous that they may be considered as
species characteristic of the soil.
cases of pseudo-hermaphroditism collected by
Neugebauer there were 722 of the masculine variety
and only 188 of the feminine variety.
The Treatment of Leprosy (Sir Leonard Rogers).
— Tlie author, as sCated in previous publications,
has proved that the strong power of chaulmoogra
oils on acid-fast bacilli is not specific to that group,
but is also possessed by cod-liver oil and appears
to reside in the unsaturated fatty acids as a class.
The sodium salt made from soya bean oil proved to
be far less irritating to the subcutaneous tissues
and to the veins than the hydnocarpates.
A Report on the Gynocardatc and Morrhuatc
Treatment of Leprosy based on forty cases treated
in ths Kashmir State Leper Hospital (Ernest F.
Neve). — Half the author's cases derived distinct
benefit from the gynocardate and morrhuate treat-
ment and the others remained stationary. These
remedies should be given with great care in laryn-
geal and ocular leprosy.
Sodium Morrhuate in Tuberculosis (P. Ganguli).
— The use of sodium morrhuate in tuberculosis has
given satisfactory results. In some cases in which
sodium morrhuate failed to reduce the temperature,
sodium hydnocarpate succeeded.
SbstrErts.
Cnmeiit yiitevntntt.
Indian Medical Gazette, Vol. UV, No. 4,
April, 1920.
The result of trials of Sodium Hydnocarpate
and Sodium Morrhuate in thirteen Indian Leper
Asylums (D E. Muir). — The author comes to the
conclusion that sodium hydnocarpate and sodium
morrhuate represent a distinct advance in the
treatment of leprosy. In certain cases all the
lesions completely disappeared. He advises a com-
bined use of the two drugs. As it is essential that
the treatment should be begun when the malady
is in its first stages, he considers that every effort
should be made through schools and the Press to
educate the public, and inducements should bf
created to undertake treatment.
Notes on a case of " Hypospadias I'erinealis
(Pseudo-hermaphroditus Masculinus Externus)
(S. Chelliah). — The author's patient was admitted
to the Colombo General Hospital as a female
patient. The penis was imperfectly developed,
looking not imlike a hypertrophied clitoris, with no
meatus urinarius. The scrotum was cleft, looking
like labia majora. TTie right half contained a
testis. The other testis was found in the left
inguinal canal . The author states that in 910
THE QUESTION OF NATURAL ENEMIES.'
Bjr Captain Malcolm E. Macgregor.
Royal Army Medical Corps, Officer in cluirge. War Opce
Entomological Laboratory, Sandwich.
It is far too geiierally believed tliat fish and
insects predacequs on mosquito larvae are of
immense value. * Unquestionably they are of some
value, but only under the most unnatural con-
ditions.
If the so-called natural enemies had anything like
the power witli which they are often credited they
would deserve a better name. Tlie balance of
Nature is much too stable a thing to be so easily
upset. One must remember that in Nature the
natural enemies generally exist side by side with
mosquitoes, and yet the latter thrive unchecked ;
and that to introduce fish and other natural enemies
is often like bringing coals to Newcastle. The
maxim is, " Under unnatural conditions natural
enemies may be utilized sometimes with advan-
tage."
Make the natural conditions as unnatural as
possible, and one then temporarily upsets the
balance of Nature, allowing' the enemies a freer
action, with a beneficial result sometimee as far as
man is concerned.
' Abstracted from the Journal of the Royal Army Medical
Corpi, vol. zzzhr. No. 8, Haroh, 1920.
146
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1, 1920.
We have around us at Sandwich innumerable
anopheline breeding places in the system of dykes
that cover so many miles of this part of the country.
Here almost all the natural enemies of mosquito
Iai-V8B that have ever been cited as such may be
foimd living side by side with the larvae. Small
fish and notonecta (the water-boatman) live in the
waters of the dykes in myriads, and yet there is
no scarcity of anopheline larvae in the same water
and at all stages of their development.
I have particularly been struck with the often
repeated suggestion from people who have heard
of the " natural enemy theory " that " millions "
might be introduced here advantageously and the
mosquitoe^s thereby controlled. Yet it is easy
enough to demonstrate that the fish in the dykes
are themselves voi-acious larva eaters in the labora-
tory, but in spite of this thej' are still of little use
under natural conditions. If in the natural con-
dition of a locality larvivorQUS fish already exist,
it is generalh' an utter waste of time introducing
others.
The whole question of " natural enemies " is
mixed up with tlie less obvious factor, by the factor
of prime importance, i.e., simply the rendering of
existing conditions unnatural. Here in Sandwich
it is upon this achievement only -that success or
failure turns. Our course is the clearing of the
vegetation from the water surface and sides of the
dykes, and cutting the sides that sheer edges are
formed. Probably in so doing the natural enemies
are enabled to attack the larvae more easily, but
this is only a cog in the system of lai-v£e destruction,
and not the whole of the machinery. Natural
enemies count for very little indeed in Nature as
far as practical politics are conogrned, unless con-
ditions are quite unnatural.
Let us consider, therefore, under what conditions
natural enemies can with advantage be emplo.yed,
and as, for all the enemies cited as such, fish are
the only enemies that have been proved of any real
importance, my remarks are confined to fish.
The cardinal point of advantage is, of course,
introducing larvivorous fish into localities where
none previously existed, but one must take into
account the environment demanded by the fish
themselves. It is of no use introducing fish into
stagnant pools, for instance, if the pond is too foul
for the fish to live in. It is equally useless intro-
ducing fish into streams with swampy land on eacli
side of the main cun-ent, unle-ss the swampy
ground is drained by a system of " herring-bone "
or other waterways, up which the fisli may a'^(>fn(l,
and in order that they may do so the w itciw :iys
must be kejjt clear of weeds and vegetatiou of all
sorts.
In Africa during the recent campaign larvivoroua
fish were introduced from Zanzibar and placed in
a lake with swampy surrotmding groimd, but it was
soon foimd that until the water was well drained
by a system of shallow waterways, and these water-
ways kept clear of vegetation constantly, so that
the ^sh could ascend and descend, there was no
marked reduction of the anopheline larvae. In
other words, " no result until conditions had been
made quite unnatural."
The most striking application of the use of fish
as natural enemies with beneficial results is the
introduction of lan'ivorous fish into water tanks
where anophelines are breeding, and where the
water cannot be treated with oil or other larvicides,
as, for instance, drinking water reservoirs. But
this success is due in the main to the fact that the
anophelines are living in conditions not provided by
Nature and wholly artificial.
One finds this is true for the whole subject of
control on insects by natural enemies, and is not
merely confined to the control of mosquitoes. It was
once thought in America that by the introduction
of a certain foreign species of CoccinelUdse (" lady-
birds ") which is predaceous on a woolly aphis
which caused great economic loss to fruit farmers
in California, a splendid means of extermination of
the aphis had been hit upon. By the introduction
of the " lady-birds " an unnatural condition had
been set up, and all went well for a time, to the
great delight of everyone concerned. All might
have continued well if it had not rested with Nature
to have the first and last say in the matter. Her
univei-sal demand that a balance be struck in the
operation of her affairs prevailed, and in a short
time the introduction of the " lady-birds " for the
purpose they were to have achieved failed misei'-
ably, and the insects w'ere ultimately, I believe,
more of a curse than a blessing.
Natural enemies alone will never be a solution
,to the control of any animal, and it is time that
we recognized that the credit given to them is a
credit largely due to the advantage that is some-
times gained by man in his ingenious ability to
upset the balance of Nature temporarily.
I have no faith in natural enemies as a means of
control. Far greater certainty in anti-mosquito
measures is always attained by the employment of
jjurely mechanical and chemical agents with the
aim of rendering conditions unsuitable to the larval
development.
THE SWAR.JMING OF ANOPHELINE
MOSQUITOES. 1
By Chablus S. Banks.
Professor of Entomology, University of tlie Philipinncs.
The t;warming of Culicidae hasi been reported from
all ])art,s of the world where these insects are found.
Almost every record of such swarming has to do with
memliers of the sub-family Culicinae, as far as it is
possible to ascertain. W. W. Smith says that in
New Zealand " a train passed through a wall of
mosquitoes three-quarters of a mile in length, twenty
feet high and eighteen inches thick," and that this
' Abstracted from the Philippine Joiminl of Sriencf,
No. 3, September, 1919,
I
June 1, 1920.] THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
147
swann was composed of Cidcx (Uranotirnia) argyro-
pus Walk. J. W. Douglas reports a eimLlar occur-
rence in London, where for ten daysi hordes of mem-
bers of the genus Culex swarmed over the neigh-
bourhood and appeared like smoke when it issues
from chimney's. They rose in the air for 10 metres
and coutinuaJly danced up and down in the twilight
stillness. Holiday records a like j)henomenon in
which CuUcada nemorosa Meig (synonym Culex
(Iffritiis) wasi the species. F. V. Theobald gives an
account of Ciilcr pipicns L. on the Downs, near
Wye, England, " dancing in little clouds where they
were sheltered from the wind." Romolo Gessi
Pascha speaks of myriads of -mosquitoes, which
obscured the air at Meshra-el-Rek.
Accounts similar to these have come from every
Arctic explorer ; and persons who have retin-ned from
•Juneau, Nome, and Skagway, as well as other partM
of Alaska, and from northern Siberia, including
Kamchatka Peninsula, even north of the Arctic
Circle, mention the immense swanns of mosquitoes
that are to be encountered. It would seem from
the reports that many of the swarms there were
made up largely of females, which accords with my
observations in northern New York in years gone bj'.
The consensus seems to be that the swarms seen in
the warmer parts of the earth are largely composed
of males.
No mention seems to have been made in accounts
deaUng with mosquito swarming of .\nophelines
performing this interesting act. Two years ago this
month (in March, 1917), having had occasion to
descend Faculty Hill at the college campus;, at
dusk, I encountered two or three distinct swarms
of Myzomyia rossii Giles dancing in the air, at a
height of about 2'5 metres above the roadway,
liapidly sweeping my hand through the swarm I
caught a few specimens for the purpose of identi-
fication, asi I did not observe at the time that they
were Anophelines, not Culieines. A note of the
occurrence was made, but no further observations
were had and the matter was forgotten until ^larch 4
of this year (1019), when, upon returning home from
my laboratory at 6.25 in the evening I encountered
four distinct swarms within 60 metres of my house,
which stands on a rise of ground at the foot of
Faculty Hill. These swarms were hovering at about
l-.T metres above the roadway ; their nuisic was (]uite
audible, and they were flying against a wind having
a velocity of 12 to 15 kilometres an hour, maintain-
ing themselves without the slightest difficulty at
any point desired (.is, for instance, directly over-
head) and following me as I passed through the
swarm .
When my hand swept among thorn, in order to
capture a few, the whole mass darted off to right
or left, or up or down the road, with the greatest
ease and with a decidedly concerted motion, return-
ing when the disturbance ceased. T^ tening to the
Jiouse, I secured a net and ret'mied to find that
they were even closer to the ground than before,
the base of the swarm being less than a metre from
the roadway ; but, as the entire swarm was' dancing
up and down, the individuals frequently rose to a
height of 3 to 4 metres in the air.
Further observations, made on the evening of
March 6 at the same hour, revealed other interest-
ing and important 'features of this swarming of
Anophelines. Having stationed myself at 6.15 in
the evening at the upper end of the road, nearly
opposite the Forestry Station, I noticed some half-
dozen males of M. tossH flying swiftly up and down
the road, about 1'5 metres above it. Within five
minutes several hundreds had assembled, and within
five minutes more there were many thousands,
grouped roughly into three distinct clusters about
8 to 10 metres apart, each cluster connected with
the other by numerous stragglers. Selecting a
favourable spot, which would place the swarms be-
tween me and the sky, which was then of a pinkish
i)lue, I waited to see what would occur.
At 6.30 the first female was seen to be caught
by a male, and the pair flew slowly and obliquely
upward and away from the swarm and was soon
lost to sight. At intervals of about fifteen seconds
other females were observed and this continued until
6.40; so that approximately fifty females were seen
to enter the swarm and to be seized by males, each
time the pair flying slowly but directly out of the
swarm. Two pair.s: were seen to separate after about
thirty seconds in copulation. At 6.45 the swarms
had diminished more than half, and at 6.50 only a
few stragglers could be seen against the rapidly
darkening sky.
During the whole time of swarming two dragon-
flies were darting in and out of the swarms, and
each quite obviously caught a mosquito every time.
The two remarkable features of these occurrences
are that the insects are Anophelines, and that they
were swarming during a very stiff breeze on each
occasion. Many observers, entomologists as well as
non-entomologists, have maintained that high winds
were inimical to the welfare of the mosquito, and
that tlie insects will not venture forth when strong
winds are blowing. It has been repeatedly stated
that when mosquitoes are found at a distance from
water, they have been wafted thither by gentle
breezes.
I feel very safe in asserting that, from the observa-
tions made upon these Anojiheline mosquitoes in
their action of flying against a stiff wind, we must
certainly conclude that they have much greater
power of flight than would be inferred from their
apparently frail structure. If it l>e true that this
species is so resistant to the wind — or rather, so
capable of maintaining itself in safety in a high wind
— what may not be - -ected of the more robust
rulicines, such as Culex jaliijans Wied. Maiixouin
vniformis Theob., Strgortivia scntellaris Walk., and
one or two other specie? the occurrence of whic+i
in a given locality can ojiy be explained by the fact
that they must have '' come upon the wind."
Many difficulties lie in the way of ascertaining
precisely the minimum -^r even optimum, distances
which mosquitoes will liy ; but it is certain that at
least in the Philipj)ines we must revise )ur ideas
148
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1,
with respect to their bein^ such frail creatures, not
daring to venture forth except in a summer zephyr ;
and it is hoped that further observations along this
Hne will enable us to say with greater certainty
how far a mosquito can or will fly.
PAPULO-UKTICARIAL RASHES CAUSED BY
THE HAIRLETS OF CATERPILLARS OF
THE MOTH {EUPROCTIS EDWARDSI
NEWM.).'
By J. BcBTON Clelai.!^, jn.U.
Principal Microbiologist, Microbiological Laboratory,
Department of Public Health, Sydney.
At the end of March, 1916, reports were received
of the occurrence of irritating rashes amongst a
number of people residing in Lindfield, on the
North Shore line near Sydney. The rashes occurred
amongst members of several famihes and followed
the handling of dead wood, as, for example, get-
ting wood ready for the copper or even in the case
of a boy from sitting on a log at the Killara Golf
Links. Touching old fencing also was said to give
rise to them.
A special visit was made and inquiries con-
ducted. At one house one of the inmates was a
girl, aged about 20, who was said to be liable
to the rash. At my request she went to the back
of the wood-house and handled some fire wood.
Two or three minutes later she developed extensive
irritation on the arms and neck. I myself then
handled the same wood, but felt no immediate
effects; eight hours later, however, there was some
irritation and next day there were forty-two small
wheals on the right ann and about four on the left.
At the time, the cause of these rashes was not
ascertained. Several possibilities suggested them-
selves, one being that the wood in question might
be one of those that set up a dermatitis. A recent
experience in mj' own family seems to indicate,
however, the cause of the rashes that occurred in
the Lindfield district. On November 16, near
Mosnian, three of my children, aged 10, 9, and 7,
found about half-a-dozen pupating caterpillars in
flimsy cocoons under the bark near the base of an
apple tree (Angophora lanceolata). The dry cast
skins of tlie hairy caterpillars were mixed with the
slight webbing forming the cocoons. The children
gathered the cocoons into boxes. Within two
minutes the two elder children complained of irri-
tation on the neck. Shortly afterwards minute
urticarial papules could be seen. The children
went home hun-iedly and calamine lotion was there
applied, which eased the irritation considerably.
Next day their necks were covered with hundreds
of small papules, still very irritating. One of the
children, in addition, had papules on the side of
' Abstracted from the Medical Journal of Australia, vol.
7th year, No. 8, February 21, 1920, p. 169.
the face, accompanied to a certain extent with
oedema and swelling of the adjacent eyelid. In the
course of several days the papules gradually dis-
appeared, so that little reaction was visible at the
end of a week. A younger child and the two
parents who had not handled the caterpillars
later in the evening also developed on the hmbs
and body a number of small papules, often ex-
tremely irritating, which continued to appear in
crops for several days. These were attributed to
fine spicules being carried in the mr, lodging on
the clothing or exposed parts and being from time
to time rubbed in.
Inquiry has elicited that a number of other in-
stances of similar irritating rashes have recently
occurred amongst children, more particularly in the
North Shore district. Usually flie cases have
occurred in boys climbing trees for cicadas and we
have heard of such a child apparently conveying
the cause of the rash to its parents. Presumably
these rashes were also due to the same caterpillars.
It seems reasonable to assume that the Lindfield
cases probably had the same origin.
On examination of the webbing of the flimsy
cocoons they showed entangled in the threads very
numerous minute spicules. These ara sharp-
pointed, acuminate, with a central cavity and
measure 85 /x to 172 fi long. The cavity, which
appears as if filled with air in mounted specimens,
varies from 31 /i to 58 /i in length. The base of
the hairlet is 4 /a to 5 /x broad and is surrounded
by four backward projecting clasping barbules, by
which the hairlet is additionaUy supported. Ex-
tending forwards, up to and sometimes opposite
to the cavity, but not in front of it, are a few
smaller backward-projecting barbules arranged in
four decussate rows.
When portion of the webbing containing the
hairlets is placed on moistened blue litmus paper
between two glass slides and these are rubbed over
each other, the litmus paper is clearly, but slightly,
turned red, no such change affecting blue litmus
paper, on which are placed some fibres of cotton-
wool, after moistening with the same water and
handling with the same instruments in the same
way. This reaction suggests that an acid, perhaps
fonnic acid, is present in small amounts.
Dr. A. Jefferis Turner has kindly identified the
moth for us as Euproctis edtcardsi Newm.. Fam.
Tjiparids ( Lyman tridiadae).
In various parts of the world, Australia included,
caterpillars of the family Liparidae are known to
produce these imtating rashes. I am not aware,
however, that this particular species has hitherto
been incriminated. The site of the cocoons, under
the bark of the trees which may be later cut for
firewood or other purposes, gives opportunity for
injury to human beings under circumstances that
may render obscure the cause of the irritation.
Our own experience suggests that the hairlets, after
aerial dispersion, may remain in clothing for some
days and from this position gradually enter the
skin.
June 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 12, Vol. XXIII.
^riflinal Commnnications.
THE DIAGNOSIS AND TREATMENT OF
TROPICAL HEPATIC ABSCESS.
By Sir Dtce Dockworth, Bart., M.D., LL.D., P.B.G.P.
Consulting Physician to St. Bartholomew's, the Italian
Hospital, and tlie Seamen's Hospital, Greenwich, tic.
We have liere to consider a malady which rarely
arises in this country. Our experience of it, there-
fore, comes from imported cases. We naturally
associate this disease with dysentery, and com-
monly recognize it as arising from an infection by
way of the portal vein. Three forms of hepatic
abscess are now described: —
(a) Suppurative pylephlebitis;
(b) Pyaemic abscess (which is generally multiple,
the worst form of the disease) ; and
(c) Tropical, or amoebic abscess (usually single).
(a) Suppurative pylephlebitis may be met with
in any part of the world. It arises commonly from
diseases of the colon or appendix ; but it may ha.ve
as its origin suppuration of the mesenteric glands,
abscess of the gall-bladder, or disease of any pelvic
origin. The result is spreading purulent suppura-
tion along the portal veins to the liver. It is com-
monly a fatal condition, and jaundice may be asso-
ciated with it.
(b) Pyaemic abscesses are closely related to this
latter form. They may arise from any purulent
focus, middle-ea;r disease, and acute periostitis, or
they may originate in the oounse of the portal vein,
from baoillary dysentery, appendicitis, or from the
bile-ducts in connection with gallstones,. In tlus
grave condition there is high fever, jaundice, with
enlarged and painful liver. Pyaemic abscesses are
small and commonly multiple.
In all fonns of dysentery we have to make sure
whether we have to deal with the bacillary or with
the amoebic variety. These are very different in
their course, and they need very different treat-
ment.
(c) Tropical abscess of the liver. — The leading
characteristics of amoebic hepatic abscesses are: —
They are solitary or few in number, may be very
large, form rapidly, or occupy months before urgent
obvious symptoms arise.
Course often latent and insidious.
A history of dysentery is generally elicited, but
not alwayB.
Infrequent in women, unknown in children.
Rare before 20, commoner after 25 years of age.
May occur in temperate and careful living
persons.
Have a tendency to burst.
Ja.undice slight.
Spleen not'enlargcd.
Some constitutions, e.g., strumous subjects,
more apt than others to suffer.
Commoner in the East than in the West Indies.
May occur on the Mediterranean littoral.
Tropical liver abscess is practically a sequel of
amcebic dysentery, and commonly a single lesion,
having its usual site in the right lobe. Successful
treatment of the original disease should prevent its
occurrence, and modem methods of treatment may
now be regarded as promptly cutting short flmopbic
dysentery.
Entamoeba histolytica, which is the cause of
amcebic dysentery, may set up an abscess of the
liver — commonly a solitary one. The onset is
insidious. The classical symptoms are a hectic
temperature and night-sweats. Leucocytosis occurs.
We note dinuinished movement of the right half
of the diaphragm, pain under the right scapula,
dragging sensation on the right side, with a fullness
and tenderness in the right hypochondrium, and
rigidity of the right rectus nauscle. But many of
these symptoms may be absent. The liver has no
sensory nerves, so a large abscess may form deep
in its substance without causing any pain. If the
swelling is on the upper surface of the liver, ii is
under the ribs, and not to be felt. How is the
diagnosis to be made in such instances ? We find
that cases of amoebic dysentery are chronic.
Bacillary dysentery is acute and generally febrile,
with a rapid course. Toxaemia is a marked feature.
Pyrexia is rare in amoebic dysentery, and only when
an abscess is forming.
We judge of the likelihood of an abscess in a
patient who has had amoebic dysentery, and shows
no plain physical signs of it by noting his general
condition. If he is toxaemic, losing flesh, with
drawn face, sallow complexion, expression listless,
and a furred tongue, we may safely assume the
presence of abscess.
These symptoms at once justify exploration of
the liver by punctures with long trocars and can-
nulae. No harm is likely to occur if pus is not
found. If the abscess is reached, and is small, the
.further treatment consists in irrigating the cavity
with a solution of bichloride of quinine, 1-5 gr.
per oz.
The pus in these cases is peculiar and character-
istic. It much resembles anchovy sauce, orange
in colour. Recovery is the rule under this surgical
treatment. Prevention being better than cure, we
tnay now readily avert the occurrence of amoebic
abscess by employing an effectual very old remedy,
derived from the radix antidysenterica, ipecacu-
anha, long known (for nearly four centuries) as a
specific for dysentery. This is emetine, the active
principle of the root, and it is very deadly to
amipbae. Sir Leonard Rogers, I.M.S., has the credit
of discovering its extreme and rapid amtpbaciih-
action. It is, in fact, a specific remedy. The best
salt is the hydrochloride, and this is to bo given in
gr. i doses dissolved in 2 c.c. of steriMzed water
twice a day. This dose is o<)uaI to .'^i of the pow-
dered ipeca<!uanha root, and is given hypodennic-
aliy. This dosage is often found to destroy nil the
amoebae in the body in two or three days, riivcii
150
THE JOURNAL OF TBOPICAL MEDICINE AND HYGIENE. [Jnne 15, 1920.
in tablet form by the mouth, gr. i tablets may be
given on an empty stomach without exciting severe
vomiting. The hypodermic method is preferable.
If no benefit is found in three days, we may be sui-e
that we are not dealing with amoebic dysentery at
all, for it is of no use in bacillary dysentery. This
drug has a powerful effect on the intestinal mucous
membranes. Many years ago I made many e.x-
periments with emetine, and published them in St.
Bartholomew's Hospital Reports. I reported in my
second contribution to a study of emetine, p. 112,
vol. vii, the experience of my friend and former
fellow-student, Mr. William S. Eccles, Senior Sur-
geon to the Great Indian Peninsula Railway Com-
pany in Bombay, who was then (1869) employing
emetine very freely, and with marked success, in
the treatment of acute dysentery. He prescribed
doses of I gr. with ^ gr. of morphia and 2 gr. of
sugar in powders every four or six hours. These
seldom induced nausea. This practice was there-
fore long antecedent to that of Professor Rogers of
Calcutta, and never received, so far as I am aware,
any other publication than the above. Sir I^eonard
Rogers has the credit of having proved that emetine
is a specific amoebacide, and a rapid agent for clear-
ing the body of these pestilent invaders.
Powdered ipecacuanha in large doses was for-
merly very useful, but was always ajit to excite
severe vomiting.
In this country we do not often meet with the
early stage of hepatic abscess. My connection with
several of the Indian Railway Companies has
enabled me to follow the course of several such
cases.
The results of operation on these has been satis-
factory in all but two instances. No harm has ever
come from exploration. The only unpleasant sequel
I noted was in the case of an officer in the Horse
Artillery, who found that the weight of his sword
was provocative of pain when riding, probably due
to some adhesions around the old discharging
orifice.
The diagnosis is assisted by careful coinparison
of the two sides of the chest and hypochondria.
The respiratory movement on the right side is
generally impaired, and there may be an area of
basic and lateral dullness over the right pulmonary
base, with absent or enfeebled breath-sounds.
These signs alone in a patient from the tropics,
who had no history of any pulmonary ailment,
would justif}' exploration with the trocar with a
view to find pus. Rometiines subjects of hepatic
ahscess arrive in this country in a|ii>,irtiit t'liod
health, and subsequently suffer from ]);iiii-, plcui isv,
with some cough, and wasting. Their in.iy lit- no
obvious indications of any hepatic ailment for some
weeks, when a palpable tumour may be detected,
or a characteristic area of diffused dullness, with
tenderness and slight oedema of the right hypo-
chondriuin, becomes noticeable. The spleen is not
enlarged. There may be slight jaundice sometimes
(hepatic pain is due to distension of its capside).
On .inquiry, a history of dysentery may commonly
be obtained. There need be small doubt as to the
nature of the ailment in such a case. Pain is com-
monly felt when the patient lies on the left side
from the falling of the liver to that side.
There is now no doubt that early and free open-
ing is the best and only sure method of treatment
for tropical hepatic abscess.
The practice prevents several dangerous risks,
such as rupture into the lung, pericardium, or peri-
toneal cavity. Sometimes there is a favoura,ble
outlet by way of the howel, but we cannot afford
to wait for such exits. The results are generally
favourable, and the general health rapidly improves
as the abscess cavity heals. Preparations of cin-
chona, at first with sodium bicarbonate, and sub-
sequently with nitro-hydrochloric acid, are valuable
during convalescence. Later chloride of ammonium
with nitro-hydrochloric acid is desirable. A shel-
tered seaside climate should be sought, and warm
sea-water baths employe<l. With renewed general
health, there need be no hesitation in permitting
these patients to return to their duties in the
tropics.
SOME COSMOPOLITAN SUDAN
SKIN AFFECTIONS.
I. — Hkrpes Iris.
By Albert J. Chalmebs, M.D., P.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories,
AND
NOBMAN MaCDONALD.
Bacteriological Laboratory Assistant, Khartoum.
Contents. — Introductory — Historical — Sudan
Cases — Morbid Anatomy — ^Etiology — Pathology — -
Diagnosis — Prognosis — Treatment — References —
lUiistrations.
Introductory. — Papers have already been pub-
lished by one of us on several cosmopolitan skin
diseases occui-fing in the Sudan, e.g., Acnitis,
Ichthyosis, Pityriasis Rubra Pilaris, Lichen Scrofu-
losorum, Atrophodermia Biotriptica, &c., and now
we bring a few illustrations to show the characters,
in the black skin, of some well-known cosmo-
politan skin affections.
We begin our short seriesi of notes with remarks
upon eases of Herpes Iris kindly sent to us by
iriedii-nl officers of the Egyptian Army. This
eiujition is not common in the tropics and during
two decades of medical life therein we know of only
three cases.
HLsturical. — Although the disease shown in figs.
1-4 is commonly knovra as "Herpes Iris," it be-
longs to the " Erythemata," being merely a
\ariety of Erythema mvltiforme.
The term Erythema was used by Hippocrates for
anv i-ntani'ons redness, but Sauvawes. and later
June 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Plenck, restricted its meaning, wliile Willmi gave
it a definition which is as follows: —
" A nearly continuous redness of some portion of
the skin attended with constitutional disorder but not
contagious."
As the second part of his well-known work
" Cutaneous Diseases " was issuing from the press,
Willan came across a curious form of Erythema
which he called " Iris," and announced the fact
on the cover of this second part.
In 1813 Bateman reclassified it, placing it under
" Vesiculae " and calling it Herpm Irix, by which it
is known at the present time, although we recognize
that Bateman took a retrograde step in naming it
Herpes.
On page 235 of his " Practical Synopsis of
Cutaneous Diseases " he gave an excellent account
of the disorder, which can be readily understood by
comparing it with figis. 1 and 3 of the present note.
He writes as follows : —
" Its first appearance is like an efflorescence, but when
it is fully formed not merely the central umbo but the
surrounding rings become distinctly vesicular. The
patches are at first small and gradually attain their full
sire, which is nearly that of a sixpence, in the course of
a week Or nine days, at the end of which time the central
part is prominent and distended and the vesicular circles
are also turgid with lymph and, after remaining nearly
stationary a couple of days, they gradually decline and
entirely disappear in about a week more."
In Plate LII of his " Delineations of Cutaneous
Diseases " appears the classical and much copied
representation of the disease which is comparable
with figs. 1 and 3 of our illustrations.
Rayer, the celebrated French dermatologist, in
1835 described an Erythema Iris and expressed the
opinion that Erythema Iris and Herpes Iris were
modifications of the same affection.
Hebra, writing in the sixties of last century,
drew a distinction between the fugitive cnjflieniata
and those of longer duration, which undergo suc-
cessive metamorphoses and are attended by various
symptoms. These latter he called " Erythema
exudativum muHijormr," which is, in many ways,
a suitable term as their clinical features are multi-
form', while they are certainly associated, patho-
logically, with exudation. He objected to the
term Erythema being applied to these diseases and
in that he was right as they are. inflammatory in
character. Nevertheless he thought it to be more
advisable to retain the old names rather than to
coin new terms. He.rpes Iris is, therefore, a variety
of his Erythema exudativum multiforme which is
generally shortened to Erythetna multiforme .
For long it was believed that these eruptions
were only associated with the mildest of con.>ititu-
tional symptoms, but the researches of Osier in
1900 made it clear that there existed, though
rarely, a type of case which exhibits severe
visceral symptoms, e.g., gastro-intestinal crises,
nephritis, haemorrhages from mucous membranes,
endocarditis and pericarditis, or more raiely,
pulmonary disease, as had indeed been noted by
Hebra to be associated with hsemorrhage into the
skin lesions, and at times, death. There are, there-
fore, two types of the disease : Erythema m.uUi-
forme levc and Erythema m,ultiform,e grave.
Luckily, the severe form is rare in the tropics and
we have never heard of such a case therein.
This brief history brings our clinical knowledge
of Herpes Iris up to modem times and we may
now consider our own cases.
Khartoum Cases. — We have met with two cases
in the Sudan, the first is portrayed in fig. 1 when
the eruption was mainly confined to the face, while
the second is shown in figs. 2-4.
The first case showed many spots on the fore-
head, face, and neck, while in the second case the
eruption developed on one hand, one forearm, and
on the lips. These latter were ulcerated when we
first saw the patient.
In both cases the eruption came out suddenly
and without obvious cause, and both occurred
during very hot weather. In both there was slight
rise of temperature and malaise.
The clinical features of the disease can readily
be gathered by a study of figs. 1 and 3, which
depict roimded spots distinctly raised above the
level of the surrounding skin and having their
centres occupied by largish vesicles which are
separated by a zone of congestion from a peripheral
ring of vesicles.
There was little or no local pain' in our cases,
and but slight constitutional disturbance, and the
eruption quickly disappeared when appropriately
treated as will be described below.
Morbid Anatotny. — Histological preparations
could only be made from one case, and owing to
a series of climatic and other misfortunes, were
distinctly poor; nevertheless they were sufficient to
indicate the essential features of the disease.
The first signs are the dilatation of the vessels
of the papilLsB followed by a considerable amount of
(pdema (fig. 8). This is followed by dilatation of
the intercellular spaces of the epidermis (fig. '7),
which may go on, in certain places, to vesicle
fonnation, the commencement .of which is shown a
little to the right of the centre of fig. 7.
About this time cellular accumulations may be
noted around the vessels in the cutis, even in its
deepest parts (fig. 5), while the oedema of the
papilke' disappears. This cellular exudate is also
to be noted in the papillae (fig. 9) and to extend
into the epidermis (fig. fi) in which the cells of the
rete may be seen to be degenerating in plaoos,
while the stratum granuloeum has disappeared.
The elements forming this exudate are largely
polymorphonuclear, but mononuclear cells are also
to be noted.
/Etiology. — No causal organisms can be found in
the cutaneoirs lesions and the general tendency
to-day is to look upon all forms of crybherna multi-
forme as being due to anaphylaxis caused by the
absorption of some chemical product from the
152
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1920.
int<>stin© {vide Chalmers and Martyn), or other
passages, or from a diseased organ. As to the
adjuvant in this action, this is not clear; though
the relative infrequency of the disease in the
Tropics might indicate cold, yet this cannot be so
because our cases occurred in the very hot weather
of the Sudan.
No cases have been fully studied on these lines
as yet but the success of treatment by .intestinal
antiseptic therapy in certain cases offers some
support to this theory, which explains the slight
febrile and constitutional symptoms accompanying
the skin eruption [vide Chalmers and Martyn).
Pathology. — It would appear as though the pri-
mary seat of the disease was in the papillae, or
in other words, that anaphylaxis took place there,
and that all the other pathological phenomena were
processes of excreting the poisonous products or
neutralizing their effects.
Diagnosis. — The essential features of Herpes
Iris are: — (a) the central vesicle or bulla; (b) the
surrounding ring of vesicles; (c) the affection of the
lips and mouth; (d) the formation of several rings
of vesicles outside the first; (e) the slight consti-
tutional disturbance; (/) the tendency to recur if
not properly treated.
It can be differentiated from its nearest ally in
the erythema multiforme group, viz., erythema
iris, by the fact that in the former there is a vesicle
surrounded by an erythematous blush. The central
vesicle dries up and forms a scab and a ring of
secondary vesicles forms outside this scab while
the erythematous area embraces the whole.
Prognosis. — This is good in the usual simple form
of Hei-pes Iris as depicted above, because the
tendency is for the disease to ameliorate of its own
accord, but recurrences are liable to occur without
appropriate treatment.
Treatment. — The first aim of the treatment is to
find the site from which some chemical absorption
is taking place. In our second case the intestinal
tract appeared to be the only possible place, and,
therefore, tlie patient was placed in bed on a
restricted diet and given purgatives and salicjn,
with immediate and excellent results.
Khartoum,
Noi-ember 24, 1919.
REFERENCES.
Herpes Iris.
Bateman (1813). " Synopsis of Cutaneous Diseases," 235-
236. London.
Bateman (1814). "Delineations of Cutaneous Diseases,"
new edition (1840), Plate LIT. London.
Castellani and Chalmers (1919). " Manual of Tropical
Medicine," 3rd edition, p. 2266. London.
Chalmers and M.\rttn (1916). Proceedings of tJie Royal
Societji of Medicine, vol. x, Section Dermatology (Anaphylaxis).
London.
Hebba (1866). "Diseases of the Skin, Sydenham Society's
Translation," i, 146-147 and 285-289. London.
OsLEB (1900). British Journal of Dermatology, 227-245.
London.
Pardee (1898). Bultetinof the Johns Uophins Hospital, ix.
165. Abstract in the British Journal of Dermatology, 1899, xi,
171. London.
Rayee (1835). " Maladies de la Peau," i, 372377. Paris..
WiLLAN (1808). " Cutaneous Diseases," second part ; (refer-
ence to " Iris " not found if the two parts are bound together).
London.
ILLUSTRATIONS.
Pig. 1.— An Egyptian soldier showing the eruption of Herpes
Iris on the forehead and face. It was also present on the back
of the neck but not elsewhere. Photograph. Reduced.
Fig. 2. — Forearm of another Egyptian soldier with a single
spot of Herpes Iris. Photograph. Reduced.
Fig. 3.— Eruption on the finger of the same case as fig. 2.
Photograph. Reduced.
Fig. 4. — Eruption on the lips of the same case as fig. 2.
Photograph. Reduced.
Fig. 5. — Vessel situate deeply in the cutis showing the
cellular exudation. Photomicrograph. x 450 diameters.
Fig. 6.— Cellular exudate in the rete Malpighii, the cells of
which are degenerate. Photomicrograph. x 800 diameters.
Fig. 7- — Dilatation of the intercellular spaces of the rete
Malpighii and the commencement of a vesicle therein. Photo-
micrograph. X 800 diameters.
Pig. 8. — Dilatation of the vessels and oedema into the
papilla;, Photomicrograph, x 200 diameters.
Fig. 9. — Dense cellular infiltration into a papilla around its
vessels. Note also that the cellular exudation is penetrating
between the cells of the epidermis. Photomicrograph, x 450
diameters.
Atypical Dysentery Bacilli. — Dumas (C. R Soc.
Biol., December 27, 1919) points out that there is
no serum reaction that allows one to differentiate
true dysentery bacilli from the atypical strains
found during the course of an iUness. Several
observers have relied on the results of subcutaneous
injections of bouillon cultures in doses of 10 to 15
c.cm., and if a local abscess, from which the rabbit
dies, is produced they have judged the particular
organism to be pathogenic. Dumas thinks that
the only way to establish the dysenterigenic role of
an organism is to produce experimentally the same
lesions as are found in the human subject. He
makes the cultures in Martin's peptone broth,
arranging the alkalinity so that the acidity of tlie
medium after ten days' incubation is neutralized
by a certain quantity of soda, and filters tlirough
a Chamberland F candle at moderate i)ressure.
The filtrate injected subcutaneously into rabbits
failed to produce any pathological condition. He
therefore concludes that these atypical dysentery
bacilli are avirulent and non-toxic. There is no
doubt that such bacilli can be found in dysenteric
muco-colitis in association with true dy.sentery
bacilli, but the author says that they ajipear late,
about the fourth day of the illness, aiul are to be
regarded merely as saprophytes of the large intes-
tine. In the course of bacillary dy.sentery a new
intestinal flora appears at tlie ulcerated parts about
the fifth day. It is a floia of secondary infection
comparable to that found in open infected wounds,
but it plays no fiart in the etiology of the disease.
In his opinion the reason why these atypical bacilli
have so often been held to be tlie cau.se of dysen-
teries is liecaiise the search for the authentic patho-
genic genus (Shig.-i or l'"Ic\iier) has been instituted
too lat<i in tlie ilisr.-isc, ;inil tlicy have tliercfore not
h(H>n detected in tlie pL-it.^s.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
June 15, 1920.
To illustrate paper, " Some Cosmopolitan Sudan Skin AffectionB: I.— Herpes Iris," by Albert J. Chalmers,
M.D., F.B.C.S., D.P.H., andNOBMAK Macdonald.
June 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HiGlENE.
153
llotwis.
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THE JOURNAL OP
Cropical ^Pedtctneandi^pgtene
June 15, 1920.
" .\ MALAMAL BLOOD."
WiTiiniT iiitcri?!',' into iibstnisc or (Ichatiililc
points in conru:ction with (changes in the blood of
malaria patients, let us go no further to start with
than the .article at page IfiO in this issue of the
Journal. The article in question is entitled " Some
Experiences in the Commoner Tropical Diseases in
(late) German New Guinea," abstracted from the
Medical Journal of Australia, vol. 1 — seventh year
—No. 5, January 31 1920, page 97. The writer
is Laurence H. Hughes, M.B., Ch.M.Syd., and
he gives his beliefs, opinions and observations in
a manner indicative of scientific conviction found
upon close clinical observation and sound scientific
work. The experience was gained in New Guinea,
in a district occupied by the Germans until quite
lately; a district where malaria reigned in plenty
and wholly unchecked. He comments that, apart
from typical attacks of malaria met with, the
disease presented itself in atypical forms to an
extent that excited his interest, and led to careful
study of febrile ailments in general that came
within his ken. For this reason. Dr. Hughes
states, every patient who came under observation,
even though he complained of some apparently
trivial symptom associated with the slightest rise
in temperature, was considered to have malaria
until the blood examination should prove the
absence of this infection. Did the blood of these
cases prove negative subsequent examinations
were made during the ensuing twenty-four hours.
It is presumed then that Dr. Hughes regarded the
ailments to be of non-malarial origin, although this
is not stated, but later in his article the absence
of parasites alone does not seem to uphold this
opinion with, in our opinion and experience, full
justification. We may state at once that the
absence of parasites, even after repeated blood
examination during twenty-four hours, is not, in
our opinion, a conclusive proof that malaria infec-
tion is absent in any given case. Dr. Hughes
endorses this by admitting that cases are _ not
infrequently met with, particularly in malignant
infection, in which repeated examinations fail to
show the presence of the parasite. This is a
common experience, of course, where quinine has
been taken prior to the blood examinations, but
such instances do not wholly account for the many,
many times the blood of patients subject to malaria
shows no parasites on microscopic examination. The
(juestion naturally arises, therefore : Is the presence
or absence of malaria parasites the only means of
determining malaria infection? Dr. Hughes deals
witji this problem by remarking that a notable
increase in the percentage of large mononuclear
leucocytes in the blood is an almost constant
feature in malarial cases. This is, of course,
present in sevenil ailments independent of malaria,
and must only be accepted as diagnostic as part and
parcel of a group of changes in malarial blood. To
this is, however, to be aidded the presence of pig-
ment granules in the leucocytes as another sign
frequently met with in malarial blood, which serves
to further help to the belief that it is a malarial
infection we arc dealing with. That we also meet
with polychromasia of the n^d corpuscles in malarial
cases is another commonly met with condition, but
by no means characteristic of this infection, for it
154
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15. 1920.
is found in other ailments. It is, however, yet
another addition to the group of conditions that
obtain in malaria. Do these several entities com-
bined suffice to justify the term " a malarial
blood"? When parasites are absent, does pig-
mentation, the increased leucocyte count, the poly-
chromasia, &c., allow us to conclude that the
patient has had recent malaria or is still the subject
of the disease?. One fact stands out deiinitely,
viz., that the absence of parasites alone is an un-
reliable test of the absence of malaria either recent
or remote. The writer has been testing the subject
recently. He has had the blood examined for
malaria parasites, for several years, of persons
returning to Britain after a stay of not less than
three and up to thirty-five years' residence in a
tropical climate in which malaria is known to exist.
In all some 900 cases have been so examined, and
during the past eight months every man and woman
and (almost every) child have been examined by
experts, including Dr. George Low, Dr. Manson
Bahr, Dr. Castellani, in the laboratory of the
School of Tropical Medicine, and by the experts
in several of our accredited private public labora-
tories. The writer did not intend announcing
these results until 1,000 such tests were made, but
in connection with the subject raised by Dr. Hughes
and other writers it may be stated that the pro-
portion of malarial parasites actually found in these
bloods works out at about 2 per cent. only. The
cases were not selected; the examinations were
made upon those who confessed to having had
malaria and those, by far the larger number, who
denied ever having had malaria. It is an extra-
ordinary fact that some 5 per cent, only of the
900 questioned and examined confessed to having
had malaria. They denied it perfervidly, scorned
the idea in fact they ever had it, stated that they
never had been absent from work for a day since
they went to the tropics from malaria, and seemed
to regard it as a slur upon the locality they lived
in and upon themselves to merely suggest the
idea. They led one to the conclusion that where
to go to avoid malaria was to the tropics, and
yet they gave harrowing accounts of what happens
in other places from the disease ; but on examining
persons from these " maligned climates " the same
tale is told: " We do not have malaria," it occurs
to a great extent in the very regions where the
formerly exainined resident came from, and so on.
It is the pot calling the kettle black principle, for
both regions are known to be malarial, but the
dweller therein will have nothing said against his
"tropical home," and Scott's lines come up:
" Breathes there a man . . . this is my own,
my native land," Ac, and I will not hear a word
against it. The blood of the 900 cases mentioned"
was examined for parasites alone ; and although
Dr. Low on a few occasions mentioned it looks like
"a malarial blood," it is evident that the test
for inspection by the presence or absence of para-
sites is unsatisfactory and quite useless as a guide
to treatinent ; a blood count is necessary, and the
search for pigment and polychromasia must be
made. In addition to the time and the expense
involved in such an investigation, there is no
guarantee that it is reliable; in fact, everything
points the other way, and one has to come to the
disappointing conclusion that we have no definite
guide, nothing to point assuredly to present, recent,
or more remote malaria infection, nor to latent
malaria from the blood with no parasites.
One is glad to see that Dr. Hughes does not
agree to the uselessness of quinine as a prophylactic
with the light-heartedness that is found to be fairly
widespread to-day. He is, in fact, strongly in
favour of it. He advocates in the treatment of an
acute attack of fever the administration of quinine
at frequent intervals. He contends that a certain
concentration of quinine is necessary, and this can
best be obtained, owing to the fact that quinine
commences to be excreted immediately after it is
administered, by continued dosage. He recom-
mends that a solution of 0-6 grm. of sulphate of
quinine be given every four hours for a period of
ten days, then twice daily for six weeks, and sub-
sequently the daily dose at (juinine parades.
An important point Dr. Hughes also mentions;
it is that several of the commoner ailments met
with in practice in regions where malaria prevails,
such as convulsions, apoplexy, dysenteric sym-
ptoms, pneumonia, and a host of others, even boils,
skin affections, &c., occurring in a patient who has
been the subject of malaria, declared or otherwise,
should be regarded with suspicion, and the possi-
bility of the malarial parasite as a causative agent
kept in view.
These rather elementary matters are drawn
attention to in the hope that the question of " a
malarial blood " be gone more thoroughly into.
The attempt to disignose the presence of malaria
by searching for the parasites alone is practically
useless in this direction. Is the " malarial blood "
likely to prove a more hopeful test, and are
the microscopic findings in the matter calculated
to prove of more practical use in the recognition
and the treatment of malaria?
J. Cantlie.
Spontaneous Pneumonia in Monkeys (Francis G.
Blake and EusseU L. Cecil, Journal of Experi-
mental Medicine, May 1, 1920). — The authors came
to the following conclusions : (1) Monkeys in cap-
tivity are subject to spontaneous lobar pneumonia.
(2) Spontaneous lobar pneumonia in monkeys is
caused by the pneumococcus. (3) Lobar pneu-
monia in monkeys may occur as an epidemic
disease. (4) Spontaneous lobar pneumonia in
monkeys is identical in its clinical features, com-
plications and pathology with lobar pneumonia ex-
perimentally produced by intratracheal injection of
pneumococcus and with lobar pneumonia in man.
il
June- 15. 1920. J THE JOUKNAL OF TROPIGAL MEDICINE AND HYGIENE.
155
Annotations.
.1 CnniiihiitUm to flic Amcnical Treatment of
Lcprosii (Alfonso de Nicola, Giorn. Hal. d. Mai.
Vrn. c Delia Pelle, 1919, fasc. v, p. 378. The
British Journal of Dermatology and Syphilis, vol.
xxxii, No. 377, InJo. 3, March, 1920, p. 84).— The
author has treated, two oases of leprosy with
novarsenobenzol with very good results. The
author strongly recommends its trial in leprosy,
and especially in the early stages of the disease.
In his opinion it is the only drug which will arrest
the evolution of the disease.
Practical Contribution to the Therapeutics of
Epizootic Lymphangitis in the Horse (G. Ruggerini,
La Clinica veterinaria, Naa. 1-3, pp. 1-10 and 69-83,
Milan, .January 15, 31, and February 15, 1919). —
Amongst the diseases which have been very common
among Army horses during the war the second place,
after mange, belongs to epizootic lymphangitis.
The author briefly describes the various methods
of treatment used up to the present, then deals
with those applied by him to 315 horses, 180 mfules
and 17 donkeys at the Army Veterinary Hospital at
Verona.
Among all the methods of treatment that which
so far seems most preferable consistsi in combining
surgical treatment of the lesions with careful anti-
septic measures. There is no need to destroy one
by one all the nodules present in the regions peri-
pheral to the swollen glands ; the extirpation of the
glandular tumours diminishes the swelling of the
hard nodules and prevents the formation of new
ones. At the same time the treatment improves'
the progress of the wounds already present or de-
rived from abscesses that are opened after extir-
pating the tumefied glands; even the diffused con-
gestions begin to be absorbed after the operation,
while the other lesions improve and heal.
The extirpation of lymphatic glands affected with
slow cryptococcal uifection is fairly easy and not
dangerous. Iodine and arsenic are useful.
Pathology and Pathogenesis of Pneinnococciis
Lobar Pneumonia in Monkeys (Francis G. Blake,
M.J)., and Russell I.. Cecil, M.D. The Journal of
Experimental Medicine, vol. xxxi. No. 4, April 1,
1920, p. 445). — The investigation carried out by
the authors tends to show that the pathology of
pneumonia experimentally produced in monkeys by
the intratracheal injection of pneumococcus is
identical with the pathology of lobar pneumonia in
man. The authors have found that the pneumo-
coccus primarily invades the pulmonary tissue at
some point or points in the portion of the lobe
proximal to the hilum, that it spreads rapidly
throughout the lobe by way of the perivascular,
peribronchial, and septal interstitial tissue and
lymphatics, quickly reaching the pleura, and that
it invades the alveolar stnicture primarily by way
of the alveolar walls, subsequently passing into the
alveolar spaces simultaneously with the outpouring
of exudate into the alveoli. It has been shown
that the initial mode of invasion may be by direct
penetration at one or more points into the walls
of the bronchi near tbe hilum. The possibility that
primary invasion may occur in terminal bronchi-
oles, alveolar ducts, or alveoli of the parenchyma
near the hilum has not been certainly excluded,
though the evidence is against this supposition. In
harmony with the mode of distribution of pneumo-
cocci it has been found that the initial lesions of
lobar pneumonia are of the interstitial framework
of the lung, with respect both to the grosser frame-
work and to the alveolar framework. Hepatization
begins centrally and spreads towards the periphery
and is a constantly progressive process. With the
development of hepatization the conspicuous inter-
stitial lesions of the earliest stages gradually
diminish, and are often largely masked when com-
plete lobar consolidation has developed. Resolution
is frequently accompanied by a varying degree of
organization of the grosser framjswork of the lung.
.\ variable amount of organization of the alveolar
exudate also may occur.
Botulism, Preliminary Report of a study of the
Antitoxin of Bacillus Botulinus (Ernest C. Dickson,
M.l)., and Beatrice M. Howitt, San Francisco,
The Jourrutl of the American Medical Association,
Vol. 74, No. 11, March 13, 1920).— The authors havf
come to the following conclusions: (1) A true anti-
toxin may be prepared from the toxin of Bacillus
botulinus. (2) There are at least two types of B.
botulinus, which are distinct so far as their toxin-
antitoxin relationships arc concerned. (3) Experi-
ments show tliat in the laboratory the antitoxin
may |)rotect against the action of the toxin for at
least twenty-four hours after the administration of
one test dose of toxin, but that the effectiveness is,
U) a certain extent at least, dependent on the
amount of toxin injected. (4) For therapeutic
administration a polyvalent antitoxin should be
employed, and it should be given in large amoimts
and intravenously.
Production of Pneumococcus Lobar Pneumonia
in Monkeys (Francis G. Blake, M.D., and Russell
1>. Cecil, M.D. The Journal of Experimental
Medicine, vol. xxxi. No. 4, April 1, 1920, p. 442).—
The authors come to the following conclusions: —
(1) Lobar j)neunionia has been consistently pro-
<luced in normal monkeys by the intratracheal
injection of minute amounts of pneumococcus
culture.
(2) The disease produced has been shown to be
clinically identical with lobar pneumonia in man.
(3) Lobar pneumonia has been produced in the
monkey in one instance by experimental contact
infection.
(4) Normal monkeys inoculated in the nose and
throat with large amounts of pneumococcus culture
have failed to develop lobar pneumonia, though
156
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1920.
cah-yiiig the organism in their mouths for at least
a month. They have hkewise failed to show any
evidence of upper respiratory tract infection.
(5) Monkeys inoculated subcutaneously or intra-
venously with pneumococcus cutture have in no
instance developed pneumonia, but have either
died of pneumococcus septicaemia or recovered
without localization of the infection in the lungs,
(6) The pneumococcus is the specific cause of
lobar pneumonia.
(7) The i)neumococcus is unable to initiate art
infection of the normal mucous membranes of the
\ipper respiratory tract or to produce pneumonia
following intravenous injection, but must gain
access to the lower respiratory tract by way of the
trachea in order to cause pneumonia.
(8) Lobar pneumonia is, therefore, bronchiogenic
in origin.
(9) Invasion of tihe blood-stream by the pneumo-
coccus in lobar pneumonia is secondary to infection
of the lungs.
(10) The character of the leucocyte r&action
during the course of lobar pneumonia bears a fairly
definite relation to the course of the disease.
Studies on the effect of Light on Vitiligo (Carl
With, Brit. Journ. of Dermatology, May, "l920).—
According to the author's experiments, the carbon
arc light produces upon the vitiligo patches a
macular pigmentation more or less decided ; it
spreads from the periphery to the centre, and may
last at least fourteen months. In three cases this
pigmentary process continued after the light-bath
had ceased.
The vitiligo patches react with a stronger ery-
thema than the pigmented skin, but little by little
the patients are able to stand a quantity of light,
to which they formerly reacted with an erythema,
not only upon the pigmented, but also upon the
vitiliginous regions of the skin. Consequently the
organism is capable of protecting itself against the
light in another way than by pigmentation. The
final proof that the role of the pigmentation is to
form a protection against light has not yet been
forthcoming. So many observations, however, go
to show that it must be considered the most
probable conclusion.
Results of Prophylactic Vaccination against
Pneumococcus Pneumonia in Monkeys (Russell L.
Cecil and Francis G. Blake, Journal of Experi-
mental Medicine, Maj' 1, 1920). — According to the
authors' experiments pneumococcus vaccination
does not protect monkeys against spontaneous or
experimental pneumonia. The course of the
disease is, however, modified, the blood infection
is milder and the proportion of recoveries is con-
siderably higher. Pnevnnococcus saline vaccine
seems to be more efficacious than pneumococcus
lipo- vaccine.
ibstrart.
MI.XEI) B. PARATYPHOHllH A AND B IN-
OCULATIONS WITH SERUM-TRE.\TED
BACILLI".
By Capt. (Local Major) W. Bbougbton-Alcock.
Royal Army Medical Cotps {Special Reserve), Officer in charge.
Infectious Diseases Hospital Laboratory, Imtarfa, Malta.
Towards the end of October and early in
November, 1915, it was noted that paratyphoid
A and B fevers were being contracted by the
personnel of the hospitals in Malta, where cases
from (i;illi|i()li were being received. It was then
thiit I rerdiiiniended and made a request through
Colonel GuUand, A.M.S., to Surgeon-General Sir
H. R. Whitehead, the D.M.S. Malta, that sanction
might be given to prepare preventive paratyphoid
inoculations and administer them on a voluntary
plan.
In July, 1915, a mixed paratyphoid vaccine had
been prepared and issued from fche Vaccine Depart-
ment, Royal Medical Army College, and Lieut. -
Colonel Cummins had previously earned out some
mixed B. ti/plinmia and B. paratyphosus A vaccine
inoculations :it the lioy.il Army Medical College.
TJie earliest eniplnviiieiit of mixed enterica vaccine
dates from Castellani's work in 1905, but for some
unaccountable reason, and its falsity has been
proved by experience, there existed in the minds
of many a strong prejudice against paratyphoid
inoculation because of the very severe reaction
anticipated from the injection of B. paratyphosus B.
From comparative inoculation of fifty subjects
following the injection of five different strains of
B. paratyphosus B, obtained from blood cultures,
I found that though two (one having been isolated
as the causati\e micro-organism of an epidemic
from food poisoiiiii;^. and s'liowitig by the absorption
test a certain rtlationship to the B. acrtryck group)
were extremely toxic to man as they were also to
the mouse, yet the others were not so toxic. In
the original researches the experience gained from
the injections of the three latter strains led to the
selection of one which gives but a mild reaction
while promoting a rich response in antibodies for
the several strains of the group tested (Lancet,
September 24, 1914). In the same paper are given
the initial experiences with the strain of B. para-
typhosus A that was used also in the inoculation
in Malta.
In the preparation of this mixed vaccine the strains
employed were cultured separately on peptone agar
in Roux bottles for twenty-four hours at 37° C,
then washed off in 10 c.c. normal sterile saline,
centrifuged and the deposit of the bacilli emulsified
in 3 c.c. per Roux bottle of normal sterile saline.
These enmlsions were heated for one hour at 53° C.
for B. paratyphosus A, and 56° C. for B. para-
typhosus B. A platinum loopful thereof was then
' Abstracted from the JouiimI of the Royal Army Medical
Corps, vol. xxxiv, No. 3, March, 1920.
June 15, 19£0.;
JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
167
tajicn and thi" miiiiluT jjrcsciit i>er cubic centimetre
(letennini'fl tjy tlii' T'lniiii.i-Zciss counting ohamber.
Twice the i|i]aiititv nf iiiartur nonnal horse serum
was added to eacdi tul)c containing the emulsified
bacilli. After one hour at 37° C. and a night in
the ice-chest the tubes were again centiifuged and
the deposit emulsified in normal sterile saline
containing 0'5 per cent, carbolic acid, so that each
1 c.c. contained 1,000 million bacilli. A loss of
10 per cent, of the bacilli during the further pre-
paration was allowed for. The emulsions of each
strain were then mixed in equal proportions and,
proving pure and sterile, were issued in 20 c.o.
rubber-capped bottles.
Three doses ^ c.c, i c.c, and 1 c.c were
recommended and given wJien possible, the interval
between them being seven or eight days. Over
80 per cent, were so inoculated. The greatly
diminished local reaction that follows the injection
of these and other micro-organisms when treated
with inactive normal horse serum has been dis-
cussed in a previous communication. It was
again noteworthy. The number inoculated — 2,531
— included ofhcers, nurses, non-commissioned of-
ficers, and men mainly of the hospital's personnel.
The inoculations began in November, 1915, when
Colonel Purves Stewart, C.B., A. M.S., joined me
in being the first to receive the vaccine and our
example was helpful in the plan of encouraging
men to be inoculated. Within one month 2,000
persons had been inoculated or \*ere willingly
undergoing the inoculations.
These were carried out in various hospitals by
rtiedioal officers specially detailed to do so and to
make observations and. forward them to me in the
reports, which were summarized and sent to head-
quarters. Prior to undertaking this work these
officers met, and details in connection with the
preparation, doses, &.C., of vaccine were e.xplained.
The ready collaboration and the int-erest of Officers
Commanding hospitals and of these medical officers
were of invaluable assistance and led to the high
percentage of personnel inoculated, which in more
than one hospital exceeded 90 per cent.
Reactions were mild or nil in all but twelve, and
such results are of great importance when viewed
from the administrator's and the subject's stand-
point. Save for these twelve leave from duty for
twenty-four hours was not necessary or requested.
Four men showed what might be termed inocula-
tion fever; this was characterized by a raised
temperature beginning on the night of inoculation
and lasting five or seven days, falling by lysis to
normal. One man developed a scarlatiniform rash
within thirty-six hours after the first, but had no
reaction after the second injection.
As the inoculations were carried out during an
epidemic of paratyphoid fevers and so few cases
were reported amongst the personnel din-ing their
inoculations, such inoculations do not ai)pear, in
the doses given, to give nse to a negative phase in
the subject. Three men during the course of their
inoculations were bacteriologically proven to be
suffering from paratyphoid fever, due to B. ■para-
tijphotsus A (two), or B. paratyphosus B (one). The
three recovered, and save in one case of B. para-
typhosus A who had but J c.c. of vaccine two
days before the declaration of fever they had very
mild attacks of the clisease. In another hospital
there were two other cases which were diagnosed
on clinical grounds only, no confirmatory bacterio-
logical evidence being obtained, as suffering from
paratyphoid fever of exceptional mildness. These
results, though the cases are 'few, point to no
deleterious, and perhaps to a beneficial effect from
inoculation early in infection. My results from
the treatment of paratyphoid fever with serum-
treated vacine further these premises.
An attempt was made to draw up statistical
results from the incidence of paratyphoid fever
amongst the inoculated and non-inoculated, but
suoh has been unfortunately impossible with
accuracy for several reasons, mainly the changes
in personnel and the report of certaan cases as
" enterica " without classification. However, suf-
ficient evidence could be gained from a survey of
all cases during the three months prior and six
months following the inoculations to show the total
incidence of paratyphoid fever became to a definite
degree quickly reduced. Infection in an inoculated
person was of very rare occurrence.
Inoculations were given to 136 of the ship's
complement during an epidemic of paratyphoid A
fever on board H.M.H.S. " Panama " when at
Malta. Tihere followed an immediate cessation of
the disease, and no fresh cases had arisen up to a
month later when the last report was sent rby the
medical oflficer in charge. It must be added that
special sanitary measures were adopted at the same
time as the inoculations were begun.
Agglutination Findings. — From the agglutina-
tion test done by my time-governed slide method
on a numher of unselected inoculated people it was
found that specific agglutinins for both B. para-
typhosus A and B were detected in the blood on
the sixth to eighth day. The specific agglutinins
for B. paratyphosus A tended to disappear at about
the sixth month, very rarely earlier, while those
for B. paratyphosus B tended to disappear about
the tenth or twelfth month after inoculations.
There was a slight temporary rise in the specific
agglutinin for B typhosus when previously present
in response to earlier antityphoid inoculations.
NOTES ON MOUTH SEPSIS.'
By Lestee R. Cahn, D.D.S., New York.
Member of Die Oral Surgery Clinic, of the New York Throat,
Nose and Lung Hospital.
By oral sepsis we mean any infective or suppura-
tive process going on within the buccal or oral
' New York Medical Journal, Yol. cxi. No. IG. Whole No.
2159, April 17, 1920.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 16, 1920.
cavity. These pathological conditions can be
divided into two classes— namely, conditions affect-
ing the gums and peridental membrane, such as
the various forms of stomatitis and pyorrhoea
alveolaris; and infective processes occurring around
the apices of the teeth or apical infection.
Pyorrhea Alveol.4ris.
Of the diseases of the gums and peridental mem-
brane, pyorrhoea alveolaris is by far the most
insidious and dangerous. Playing such an impor-
tant role in oral sepsis, a brief consideration of its
etiology, pathology and treatment is permissible.
Etiology. — The cause of this disease is not under-
stood, yet we know that trauma in the form of
ill-fitting crowns, ill-fitting fillings, tartar, clasps,
and other mechanical devices play an important
part in the etiology of this condition. Malocclusion
of the teeth, infective organisms and systemic
involvements are other etiological factors.
Pathology. — The disease can be grouped into two
classes : (1) Suppurative, and (2) non-suppurative.
The suppurative type has its inception at the gum
margin. It first forms a condition known as gingi-
vitis. As a rule trauma is a common cause of this
phase of this disease. The peridental membrane
is next involved, and as the inflammation con-
tinues, the membrane breaks down and pus
appears. As the pus forms a liquefaction necrosis
of the alveolus takes place, so that finally the
tooth's investing tissues become destroyed, it be-
comes loose and is exfoliated. With the destruc-
tion of the peridental membrane and the alveolus
a pocket is formed between the gum and the tooth,
which is called a pyorrhoea pus pocket. The
absorption of bacteria and their products from these
pockets is great, and constitutes one of the greatest
oral foci of infection.
Clinically we find the mucous membrane con-
geste<l and the gums more or less tumifie<l around
the necks of the teeth. Pus can be squeezed from
the pockets and the gums bleed freely. The patient
will complain that they cannot brush their teeth
because of the excessive bleeding. This type of
pyorrhoea is the more dangerous of the two types
because of the copious discharge of pus and the
absorption from the pockets.
Treatment. — The treatment consists of radio-
graphing all the teeth and determining which may
be saved. Where more than half of the alveolus
is destroyed the tooth had better be extracted.
Those teeth that can be saved are relieved of all
trauma. The tartar is tlioroughly scaled away, all
ill-fitting and irritating crowns and fillings are
removed. Next the pyorrhoea pockets are curetted,
all senimal calculus, necrotic peridental membrane,
and alveolus are removed. Where the pocket is so
deep as not to permit thorough curettage the over-
lying gum tissue is completely excised. This is by
far the most positive way of clearing up the pus
pockets. This is also done where the systemic
condition is such that quick elimination of all foci
is imperative. The operation is very simple.
Under infiltration anaesthesia or nerve blocking with
a 2 per cent, novocain suprarenin solution, the
loose retracted gum overlying the pockets is excised,
the line of incision following, as nearly as possible,
the normal festoons of the gums. This incision is
preferable to a straight one as the result has a
better cosmetic effect. The area exposed is
thoroughly curetted so as to remove all necrotic
tissue. The wound is painted with Churchill's
iodine and covered with a strip of iodoform gauze.
The patient is given instructions in proper oral
hygiene.
The choice between this operation -and the scaling
and curetting of the pockets is determined by the
operator. There are many cases where this opera-
tion is uncalled for, where simple scaling and
curettage of the pockets will accomplish the pur-
pose. Then again there are cases where a com-
bination of both these methods can be used. In
cutting away the gum tissue the ultimate cosmetic
result must be considered. Many times the labial
muscles of the patient draw the lips up to such an
extent that excising the gum may result in a rather
hideous appearance. The one great factor is the
eradication of the pockets, no matter how, as long
as it is efficiently done.
Other Infections.
Of the other diseases of the gums there are the
various forms of stomatitis. These do not have
much bearing upon focal infection as they are not
of long duration as a rule, and are eradicated before
the system is altered by any absorption from these
lesions. Before passing from this group of diseases
of the gums a word or two must be said about an
infection of the gums caused by the organisms of
Vincent. This condition attacks the gum margin.
At some point of lowered resistance in the mouth
these organisms, the Bacillus fusiformis and the
Spirillum vincenti, gain entrance into the tissues,
incubate and multiply. A favourable site for these
bacteria to lodge and become activated is under
the flap of inflamed gum covering an erupting
wisdom tooth, or in the pocket caused by an im-
pacted third molar. Tlie infection spreads along
the free margin of the gum and around thei necks i
of the teeth until a good portion of the mouth is
involved. This infective process may extend back-
wards to the soft palate, fauces, tonsils and larynx,
causing a severe angina with serious complications
and creating a condition that closely resembles
diphtheria. The gum margin becomes necrotic
and the dead epithelial cells are thrown off, becom- i
ing enmeshed in a fibrinous exudate, and give the |
appearance of a grayish membrane. The patient
feels quite ill and shows a temperature around
100° I'\ In some cases there is much difficulty in
swallowing. The mouth is painful and the gknda
in anatomical relationship are usuailly involved.
The membranous appearance may simulate a
purulent discharge, and this has led not a few
dentists to call this, disease pyorrhoea alveolaris.
June 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Calling this condition pyorrhoea is a rather danger-
ous procedure, because the men that make this
diagnosis are likely to treat it as such with serious
results. The ordinary pyoirhoea treatment, which
consists mainly in scaling, is absolutely contra-
indicated, because by using instrumentation of any
kind during the acute attack we are hkely to cause
deeper infection of the tissues. A true Vincent's
gingivitis attacks only the soft tissue. If neglected,
secondary infection by the pyogenic organisms sets
in and the alveolar process is desta-oyed. So we
must be sure to make a proper differential diagnosis.
The pseudo-membrane, glandular involvement,
pain, and, most important, the bacteriological
examination, and tlie finding of Vincent's organisms
help us to differentiate it from an ordinary case of
pyorrhoea alveolaris.
The treatment consists in antisepticizing the
mouth. During the acute stages instrumentation is
not indicated. The membrane is wiped away with
sterile gauze and the ulcerat-ed areas are painted
with Churchiirs iodine. The patient is instructed
in oral hygiene. After the acute stage has passed
tihe mouth is thoroughly cleaned and all infected
gum flaps are removed.
Apical Infections.
Now we come to those pathological conditions
occurring about the apices of the teeth. These
infections constitute another form (jf oral sepsis.
Together with pyotrhoea alveolaris they represent
the two most serious forms of mouth sepsis. These
apical infections are of both the acute and the
chronic varieties. They are caused by infection
through the root canal. In the acute variety the
peridental membrane is overcome by the infecting
organism with the accompanying pus formation.
We also have all the symptoms of acute inflam-
mation— namely, pain, redness, swelling and the
accompanying manifestations. This type of the
apical infection is the less insidious of the two,
because there is fair warning that some abnormal
process is going on and the patient attends to the
condition, but the chronic form of apical infection
is by far the more dangerous, and the one that we
are most interested in.
These conditions are also caused by infection
through the root canal. This type of inflammation
is of the productive variety. Due to toxic irritation
the peridental membrane proliferates, and this pro-
liferation is called the dental granuloma, or under
the old terminology, a chronic dento-alveolar
abscess. These so-calle/i granulomata are infec-
tious, and cultures of Streptococcus viridans,
Streptococcus hxmolyticus and other varieties can
be grown from them. Histologically they possess
a great many capillaries through which the bacteria
and their products gain access to tlie blood and
lymph streams. As these granulomata grow the
centre breaks down and the lining membrane be-
comes of an epithelial character, and they become
radicular cysts. These cysts at times assume large
proportions.
The treatment of the apical infections is usually
the extraction of the offending tooth and the
thorough curettage of the sockets. The curettage
of the socket is most important, as these granu-
lomata are sometimes tenacious and do not come
away with the tooth, but grow and continue to do
as much damage as though the tooth had not been
removed at all. I have seen many cases where
these granulomata persisted after an extraction and
developed into cysts, causing both local and
systemic trouble. Jn anterior teeth the root canals
may be thoroughly cleaned, sterihzed and £Ued,
and then the apex amputated, and the infected
area curetted. No matter what the treatment is
it must be thorough and radical. If the patient
shows any systemic involvement we cannot tem-
porize.
The results of oral sepsis may be local — that is,
where neighbouring parts become involved through
direct contact with infected material from pus
pockets. Under this class of local contamination
we have cases of pharyngitis, tonsillitis, and some-
times parotitis. This type of contamination is
usually due to pyorrhcea. Gastritis and gastric
ulcer are often due to direct extension of an infec-
tive process in the mouth. During the process of
mastication the cheeks, lips and tongue, coming in
contact with the gums, massage the pockets and
squeeze the pus out of them. This discharge be-
coming mixed with the bolus of food is swallowed.
Some observers may state that the antiseptic
properties of the gastric juice deprive the swallowed
material of any potency. We know that the gastric
juices' antiseptic properties are due to the hydro-
chloric acid, and that hydrochloric acid is only
produced during eating. What then sterilizer, the
swallowed discharge when one is not engaged in
eating? In a large number of cases of malignancy
of the stomach, F. St. J. Steadman, of London,
reports that in every case of cancer of the stomach
he has found chronic suppurations of the gums or
pyorrhea alveolaris.
Systemically, oral sepsis causes many obscure
conditions. Due to the absorption of bacteria and
their products from foci in the mouth we find con-
ditions of arthritis, myositis, infective endocarditis
and toxic neuralgias. These are only some of the
disturbances caused by oral sepsis. The toxic
neuralgias are very interesting. The writer has
seen some very persistent cases of headaches almost
miraculously disappear after the extraction of an
infected tooth, or after the eradication of an old
pyorrhoea. In some cases the results of eradicating
oral sepsis have been little short of wonderful.
In conclusion it might be said that while a great
number of teeth have been needlessly sacrificed yet
the great good that has been done by the eradication
of oral sepisis should not dampen one's ardour for
eradication of focal infections in the mouth. Sup-
posing the systemic affection is caused by a focus
not situated in the mouth, and an oral focus was
removed, what harm has been done? We have
given the patient the benefit of the doubt, and a
THE JOURNAL OF TROPICAL MBt>IClKE AND HYGIENE. [June 15, 1920.
focus of 'nfection should be removed, whether it is
causing immediate trouble or not. It may at
some future time. If we have the welfare of the
patient in mind, we should advise the removal of
any affected area, no matter where it is, be it in
the mouth, throat or prostate. The removal of
vital and healthy teeth for the supposedly clearing
up of an oral focal infection is gross ignorance and
criminal malpractice and should be treated as such,
but the removal of dead infected teeth or the clear-
ing up of a pyorrhcea alveolaris can only be compli
mented and strongly advised.
SOME EXPERIENCES IN THE COMMONER
TROPICAL DISEASES IN (LATE) GERMAN
NEW GUINEA. 1
By Laoresce H. Hoqhes, M.B., Ch. M. (Syd.), Sydney.
(1) Malaria.
I AM given to believe that, prior to the occupation
by Australian troops and for some months after-
wards, Rabaul and Madang, to take two of the
main commercial centres of the possessions as an
example, were both hotbeds of malaria. The
advent of Colonel Strangman as Principal Medicaf
Officer in November, 1914, and his crusade upon
the mosquito wrought some marked changes for the
better in regard to the prevalence of this disease.
An outline of some of the methods adopted will be
briefly touched upon later. In regard to the
symptoms of the disease, those which occur during
a typical attack are well known and need not be
reiterated. One is struck, however, with the
atypical manner in which the disease may present
itself. For this reason every patient who came
under observation, even though he complained of
some apparently trivial symptom associated with
the slightest rise in temperature, was considered
to have malaria until the blood examination should
prove the absence of this infection. In this way
alone could possibly regrettable mistakes be
avoided. Blood slides were taken as soon as
possible after the patient was first seen. Should
these prove negative, subsequent examinations
were made during the ensuing twenty-four hours.
Leishman's stain was used as a routine in all cases
and gave very satisfactory blood pictures.
Diagnosis. — A word may be said here m regard
to the diagnosis of malaria from the microscopical
examination of the blood slide. The presence of
the parasite in one of its numerous forms is, of
course, the main positive evidence. But it is by
no means the sole indication. Cases are not infre-
quently met with, particularly in malignant infec-
tions, and in those instances in which the patients
have dosed themselves freely with quinine prior
to examination, in which repeated examinations
'The Medical Journal of Australia, Vol I.
January31, 1920, page 97.
fail to show the presence of the parasite. A notice-
able increase in the percentage of large mono-
nuclear leucocytes in the film is, I think, of marked
diagnostic importance in malarial infections. I
made it a practice to carry out, when time per-
mitted, a differential count in all blood smears
examined, and found this increased percentage to
be an almost constant feature in malarial ca«es.
This feucocytic variation is not affected by quinine
and, although sometimes found in other diseases,
is a valuable indication of recent malaria. The
presence of pigment granules in the leucocytes is
another sign not infrequently observed in malarial
blood. Polycromasia of the red cells is common,
but the same condition is, of course, frequently
seen in other pathological blood conditions. The
tertian and subtertian parasites were those most
commonly seen. Personally, I saw only one case
of quartan infection. Mixed infections commonly
occurred. In this connection it may be observed
that, as the subtertian or malignant parasite is
see^n solely in its ring fonn in the peripheral blood
during the early stages of infection, it is helpful
from the point of view of subsequent treatment to
discriminate between it and the ring form of the
tertian or benign parasite. This is not always an
easy matter, but I would mention the compara-
tively larger size and fainter staining properties of
the infected red cell in the benign form, and
especially the frequently found flattening of the
chromatin in the subtertian ring as compared with
the rounder dot-like form of the chromatin in the
benign ring. The presence of the subtertian
crescent form, of course, clinches the diagnosis of
malignant infections, but it is rarely detected in
the peripheral blood before the seventh day of the
attack. Multiple infection of the red cell, i.e., the
presence of two' or more parasites in the one cell,
is perhaps more common in the subtertian type,
but is by no means diagnostic, as the same con-
dition is frequently found in the benign form.
Treatment. — Treatment must be considered,
firstly, from the point of view of prophylaxis, and
in this matter much can be done to decrease the
incidence of the disease. The main part of prophy-
laxis consists, of course, in the destruction of the
breeding places of the mosquito and of the larval
form of the insect. In New Guinea this work was
carried out extensively and thoroughly by means
of gangs of native work-boys under the supervision ,
of medical orderlies. It consisted largely in the
collection and destruction of all open receptacles
that might hold fresh water. In a tropical country
this is no mean task. In the first place the long <
Kunai grass, a pest in more ways_than one in the '
possessions, has to be kept constantly cut in order
to facilitate the search for empty cocoanut shells,
bom-boms, or the boat-shaped, ensheathing leaves
of the cocoanut palm, tins, sea shells, bamboos and
other receptacles capable of holding water. In the
bungalows sagging water spouts were a constant
source of trouble and had to be regularly examined
and rectified. Trees, especially paw-paws, fre- ,
June 15. 1920.J THE JOUBNAl, OF TEOPICAL MEDICINE AND HYGIENE.
161
quently had t/o be destroyed ; in the case of shade
trees, with which of course a conservative plan
was adopted, gutterings in the trunks were made,
or tlie liollows in the trunks filled up with cement.
Tanks containing drinking water, and also collec-
tions of water which could not be drained, were
treated twice weekly by applying kerosene to the
sui-face of the water. Swamps, when practicable,
were drainexi into the salt water. As regards other
means of prophylaxis, mention may be made of the
building of European dwellings at a safe distance
from native villages, the use of mosquito nets and
the prophylactic use of quinine. Quinine parades
were held daily, and 0'3 to 0"6 gramme doses,
according to the prevalence of infection, issued to
each man. Much has been written for and against
the prophylactic use of quinine; personally, I am
strongly in favour of it. The treatment of an
attack of malaria, once it is established, consists
mainly in the exhibition of quinine. In regard to
this matter it must be remembered that we aim
at destroying the parasite in the blood ; conse-
quently a certain concentration is essential.
Furthermore, when quinine is administered by the
mouth its absorption into the system takes some
time, and almost simultaneously with absorption
excretion of the drug begins. On these grounds
the administration of large doses at frequent inter-
vals seems to be theoretically advisable. From a
practical point of view it certainly jiroved the most
satisfactory method in New Guinea and was
adopted as a routine procedure. A solution of
0-6 grm. of sulphate of quinine was given every
four hours for a period of ten days, then twice
daily for six weeks, and subsequently the daily dose
at quinine parades. The solution is the surest
form in which to administer quinine by the mouth.
Tabloid and pill preparations are not to be relied
upon, and capsules or cachets are unsatisfactory.
Intramuscular injections were also made use of in
cases when quinine for some reason could not be
given by the mouth and as an adjunct to oral
administration in malignant cases. In addition to
quinine treatment a course of soamin injections,
9' 18 grm. every second day for ten doses, was given
after the second week. This treatment, however,
was abandoned during the early part of last year,
and intravenous injections of arsenobenzol were
given with more satisfactory results. Two injec-
tions were given, one 0'4 to 0-6 grm. during the
second or third week, and the second, 0'6 grm., a
week lat«r. It was, of course, impossible to
ascertain its effect as to the ultimate destruction
of the parasite, owing to the possibility of re-
infection, but its general and tonic effects were
most marked in many cases. X-ray exposures of
the spleen were carried out largely in Rabaul, but
I am unable to speak from experience in this
matter. Before leaving the subject of malaria,
■mention should be made of some of the commoner
diseases which it not infrequently simulates in its
malignant form. Cerebral symptoms, e.g., coma,
convulsions or apoplexy, dysenteric symptoms and
pneumonic symptoms, occurring in a patient who
has been infected with malaria, should be regarded
with suspicion, and the possibility of the malarial
parasite as the causative agent kept in view.
(2) Blackwater Fever.
This disease is closely associated with malaria
in some of its manifestations. It does not seem
possible, however, that it is caused by infection
with the malarial parasite. It is true that in some
cases of blackwater we find malarial parasites in
the blood. But many other illnesses will provoke
an attack of malaria in a person in whom the
parasite is latent. Then, again, there are the cases
of blackwater fever in which conclusive evidence
of malarial infection is wanting Of ten cases
which came directly under my observatiofi malarial
parasites were found in two. Furthermore, it
must be noted that the presence of haemoglobinuria,
detected by the spectroscopic test, is a cardinal
point in the diagnosis of blackwater fever, whereas
it is never present in malaria. Another theory that
has been advanced is that this disease is caused by
quinine. This may be tenable in regard to the
provocation of an attack of blackwater by the
administration of quinine to a patient in whom the
disease is already latent, in which case the con-
nection between the disease and the quinine is one
of coincidence. In regard to this theory mention
may be made of the bearing which irregular dosing
with quinine possibly has on the incidence of
blackwater fever. I saw no cases of the disease
amongst the troops in New Guinea ; my experience
in it was limited to cases amongst the German
residents and the Japanese, Malay and native
races. As has been mentioned previously, the
troops were supplied with a daily ration of quinine,
whereas in the case of the other people alluded to
quinine was, as a rule, taken more or less irregu-
larly, until an attack of malaria was responded to
by large doses of quinine, and followed not infre-
(juently by the manifestations of blackwater fever.
Treatmekt. — Treatment is mainly symptomatic,
accompaniM by the frequent administration of
large amounts of fluid by the mouth or per rectum.
In the latter instance 250 to 500 c.c. of saline
solution should be administered as an enema every
hour. If these are not retained, subcutaneous
injections of saline solution should be resorted to.
The desideratum is to keep the renal tubules well
flushed. The administration of quinine to these
patients needs careful handling and caution must
be exercised. If the blood examination be negative
for malarial parasites it should be withheld. If
parasites be present it should be administered in
tentative doses, due attention being paid to the
extent of the h«moglobinuria present and to the
intervals at which it recurs. In this respect it may
be suggested that when the htemoglobinuria is pro-
nounced, it is reasonnbh' to suppose that the
haemolysis is carrying on the work of quinine in
regard to the destruction of the parasite and the
exhibition of the drug is not indicated.
JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1920.
(3) Dysentery.
The two main types of this disease that were met
with were the amcebic and bacillary forms, though
occasionallj cases that were apparently purely
malarial in origin were seen. I saw no cases of
a bacillary infection alone amongst the white popu-
lation, whereas this type predominated amongst
the coloured races. Occasionally mixed infections
occurred amongst the troops; but in my experience
the amoebic type was much more common. The
diagnosis of the latter, apart from the difference in
tlie nature of onset and general symptoms, is, of
course, confirmed by the finding of the Amceba
histolytica in the infected stool. It is to be dis-
tinguished from the non-pathogenic Amoeba coli.
The main points of difference are the smaller size
of the histolytica, the clearer differentiation between
its ectoplasm and endoplasm and its eccentric, in-
distinct nucleus as compared with the central,
clearly-defined nucleus of the non-pathogenic form.
Finally, the cystic form of A. coli contains eight
amoebae, whereas the cyst of A. histolytica contains
but four and the refractive chromidial bodies as
well. Prophylactic measures were, of course,
adopted in regard to drinking water, the eating of
uncooked fruit and vegetables, and the immediate
disinfection and disposal of excreta. A condenser
was installed in Rabaul, and from this the troops
were supplied with drinking water. On the out-
stations the boiling and filtering of the water were
substituted. As regards treatment I made it a
practice in all cases to begin with an initial dose
of 15 to 30 c.c. of castor oil, with 0-6 mils of
tincture of opium ; during the attack the bowels
were regulated by means of castor oil and salines.
In bacillary cases the sulphate treatment was
adopted from the outset. In,amce-bic infections a
course of emetine injections, 0-02 grm. hypo-
dermically three times a day for ten days, was
given. Owing to the scarcity of supplies of
emetine bismuth iodide I only had the opportunity
of using it in three cases, and can consequently
not speak from experience in regard to it; but
recent observations, e.g., those of Dobell recorded
in the British Medical Journal of November 4,
1916, give apparently conclusive evidence as to its
superiority in these cases. I saw but one case of
hepatic abscess complicating amoebic dysentery. I
may mention that cases were occasionally seen
which presented symptoms of severe diarrhoea
somewhat simulating dysentery, but without the
presence of marked tenesmus or of blood in the
stools. The latter contained numerous yeast cells
and tyrosin crystals ; the condition improved under
the administration of chrome santonin in 0'06 grm.
doses three times a day for three or four days.
The condition is probably a mild type of sprue,
though no other symptoms of typical sprue were
manifest.
(4) Ankylostomiasis or Hookworm Disease.
The disease is prevalent in certain parts of these
possessions, and it is very probable that if a ' British Medical Journal, No. 3093, April 10, 1920, page 497.
thorough investigation were carried out, such as
was done in Papua, a large percentage of the
native population would be found to be infected.
Numerous natives from plantations in the vicinity
of Rabaul were examined, and the ova of anky-
lostomum found in the stools in a large percentage
of them. In regard to symptoms, the combination
of epigastric pain and symptoms indicative of
derangement of the digestive organs, together with
a well-marked anaemia, is always strongly sugges-
tive of the disease. Two signs which were com-
monly noted in the natives were a peculiar dry
lustreless, exfoliating condition of the skin and a
prominent abdomen, the latter being due to ascites.
The outstanding feature of the blood examination
is the anaemia, accompanied by a well-marked
eosinophilia, though the latter is sometimes not
present. Neither anisocytosis nor poikilocytosis
was observed. The diagnosis is confirmed by the
microscopical demonstration of the ova of anky-
lostomum in the infected stool. These are oval
and thin-shelled, and show a wide, clear zone
separating the shell from the central granular
portion, which is characteristically divided into
four segments. The ova of ankylostomum may be
confused with those of Oxyuris vermicularis or
common thread worm, but it is to be noted that
the latter are smaller and asymmetrical, one side
being more curved than the other, that they have
a doubly-outlined shell, and that they contain an
embryo which is almost or already completely
developed. Treatment was carried out by the
administration of calomel and salines, followed on
the ensuing day by 1 grm. of thymol, and another
gramme half an hour later. A purgative was again
administered five or six hours afterwards and the
stools examined for tlie mature worm. Oil is a
solvent of thymol and should not be given during
the course of the treatment, which is carried out
at weekly intervals until a negative result is
obtained.
THE OPERATIVE TREATMENT OF
ULCERATIVE COLITIS. >
By P. LocKHART-MoMMERY, F.R.C.S., Eng.,
Senior Surgeon to St. Mark's Bosjhtal for Diseases of the
Rectum, ttc.
Some of the worst cases of ulcerative coHtis are
those in which the chronic condition is secondary
to an acute epidemic form such as amcebic or bacil-
lary' dysentery. There is a certain similarity be-
tween these cases and the ordinary form of chronic
phthisis. In both we find an acute specific infec-
tion causing lesions which become secondarily in-
fected with other septic organisms, and it is this
latter secondary infection which causes much of
the trouble.
These cases of chronic ulcerative colitis are par-
June 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ticularly important at tlie present time, because
very large mimbers of men liave been infected with
Hciite dysentei-j- while fighting at different parts of
the front [luring the last five years, and are now
suffering from the chronic and often much more
serious condition.
Not only have a large number of these cases re-
turned to this country during the last eight-een
months, but quite a considerable number of cases
have occurred among men who have never left
England, and among women. These latter cases
do not start with acute amcebic dysentery, but are
chronic from the beginning. I have little doubt,
however, that they have in many eases become in-
fected from the class of cases first mentioned.
This is rather borne out by the fact that several
cases of ulcerative colitis which came under my
observation last year came from one seaport town
where many troop.s from abroad were landed.
A typical case would be that of a man who con-
tracted acute dysentery in Africa or Arabia during
the war and had been more or less successfully
treat-ed at the time, but the diarrhoea has recurred
subsequently until it has become almost con-
tinuous, and he has gradually begun to go down-
hill with constant liquid blood-stained stools, pro-
gressive loss of weight, failure of appetite, &c.
An examination with the sigmoidoscope (the value
of which in these cases as a means of diagnosis
does not even yet appear to be fuUy appreciated)
shows deep and extensive ulceration of the mucous
membrane of the rectum and colon. In a bad ca.se
islands of mucous membrane can be seen standing
up from the ulcerated surface, presenting an ap-
pearance closely resembling a polypoid condition.
Examination of the stools shows numerous bac-
teria, mostly of the coli or streptococci groups, but
no sigfl of protozoa.
The clinical history of cases of ulcerative. colitis
varies considerably. In those cases in which the
disease is not secondary to acute dysentery the con-
dition often starts insidiously. The patient appears
to recover satisfactorily from the initial attac,k, but
recurrences become more and more frequent and
Jess amenable to treatment, until the condition
becomes so serious that no treatment seems to have
any effect. It is generally at this stage that the
surgeon is called in.
There may sometimes be confusion between
chronic ulcerative colitis and other forms of chronic
recurring diarrhoea, but this can at once be cleared
up by an examination with the sigmoidoscope. In
true ulcerative colitis tTie temperature is almost
always raised 1° to 2° F. at night. Blood is more
or less constantly present in the stools, and wasting
is a marked feature of the case.
The best treatment for an ulcerative colitis is
appendicostomy, and I have seen very many really
desperate cases recover as a result of this operation,
which I and those associated with me were certain
uuist otherwise liave died. Unfortunately the
surgeon is too often only called in when the patient
is already seriously ill and the ulceration has be-
come very extensive. The operation should be per-
fonned at a much earlier stage of the disease, and
recovery would be then much more rapid and more
certain.
In true ulcerative colitis non-operative treatment
appears to be of very little use. Even when re-
covery does occur it is a slow and tedious process.
One of the reasons for this is that the ulcerated
surface is very large and cannot be directly dealt
with. Douches and enemas cannot be tolerated in
sufficient quantities to ensure that they reach the
whole of the diseased area.
Appendicostomy acts in two ways. The first and
most important action is te allow of the large
ulcerated area being kept clean and free from pus
and accumulated discharge. The frequent wash-
ing of the colon by removing the products of in-
flammation allows the ulcers a chance to heal, and
to a large extent prevents the absorption of septic
by-products into the blood.
The second important action is to compensate for
th£ great loss of body fluid, which is always pre-
sent owing to the constant diarrhoea. Many of
these patients are wasted till they are little more
than skin and bone, and it is often quite remarkable
to see the improvement that follows frequent irri-
gation of the colon through an appendicostomy
opening.
As already stated, the proper time to perform
appendicostomy is as soon as the condition has
been diagnosed; but in practice it has been my
experience that the surgeon is usually not called
in until medical treatment has been tried for months
and failed. Then when appendicostomy is sug-
gested it is argued that the patient is in such a poor
condition that he will not stand the operation.
This is, however, not the case, as the operation can
quite well be performed under local aneesthesia
without running any risk at all.
In a bad case the patient should after the
operation be treated by continuous saline irrigation
for six or eight hours at a time. This is easjly
arranged by using a metal bed-pan with a tap and
a rubber tube attachment. Very careful nursing
is, however, necessary to prevent the formation of
bedsores.
As soon as the diarrhoea has been checked and
improvement has set in, a 3- or 4-pint wash through
twice or three times a day will be sufficient. On
no account should any antiseptic be added to the
fluid used for irrigation, as poisoning symptoms are
almost sure to result. Solutions of silver nitrate
and protargol can be used, but in the case of the
former only for a short time. I have seen a very
bad case of staining of the skin with silver which
resulted from frequent washing through with silver
nitrate. Salt water seems to give the best result
in most cases.
There still are people who think that an appen-
dicostomy opening is an objectionable thing and
that it results in the escape of gas and fieces. This
164
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (June 15, 1920.
is, of course, not the case with a properly made
opening. In ulcerative colitis the opening should
be kept patent for at least six months after all
symptoms have subsided, but after this it may be
allowed to close, which as a rule it will readily do.
Conclusions.
(1) Chronic ulcerative colitis is a very serious
and often fatal disease.
(2) The best treatment is by frequently washing
through with saline solution after an appendicos-
tomy opening has been established.
(3) The operation should be performed as soon
as a diagnosis has been made and not left as a
last resort, although it may sometimes succeed
even then.
(4) The diagnosis should always be confirmed by
sigmoidoscopy.
meningococci, Micrococcus catarrhalis, Micrococcus
flavus, Micrococcus pharyngis siccus, gonococcus
and others.
Conclusions.
(1) The Gram-negative, non-motile, haemoglobino-
philic bacilli can be classified biologically by re-
actions which admit of subdivisions of the group.
(2) In working with a suspected B. influenzx,
tlie following routine should be followed : (a) De-
termination of haemoglobinophilic qualities. (b)
Colony formation, (c) Hiemolytic test, (d) Gram
stain. (e) Morphology. (/) Motility. (g) Indol
formation, (h) Reduction of nitrites to nitrates,
(i) Amylase formation. (/) Reaction in blood-
broth-milk.
(3) B. pertussis can be differentiated from the
group of B. influenza; by cultural characteristics.
THE BIOLOGICAL CLASSIFICATION OF
INFLUENZA BACILLI. i
By T. M. RivBBS.
Many people have never felt absolutely certain
that the difference between Bacillus pertussis and
B. influenzas were sharp enough to be beyond doubt,
in spite of the serological proof. B. pertussis, after
a period of artificial cultivation, can be grown on
plain media, forms no indol, no nitrites, and makes
milk very alkahne. Some of the influenza bacilli
also form no indol and no nitrites, but none of them
has ever made milk nearly as aUcaline as B.
pertussis.
Time alone will tell whether these cultural char-
acteristics will be constant. While there are dif-
ferences in the biological activities of the various
strains of B. influenza; at the same time there are
definite groups, the individual members of which
are similar culturally. Only one group will be dis-
cussed at this time. It consists of ten strains, five
from the spinal fluid of patients with influenza
meningitis, two epidemic strains from New York,
and three from normal throats. The growth and
morphology of these are similar, all from indol, all
reduce nitrites to nitrates, and make blood-broth
milk slightly acid within forty-eight hours.
Whether the strains of large bacilli that are
amylase formers, or the haemolytic ones, should be
included in this big influenza group is a question
that will have to be decided. The nine amylase
formers and three haemolytic strains have character-
istics in common with the big group, as shown by
certain ones forming nitrites and by one of the
haemolytic strains forming both indol and nitrites.
Possibly this is a big group or organisms, like the
streptococci, which have been divided into haemoly-
tic and non-haemolytic strains, and further sub-
divided by cultural characteristics and serological
tests. Possibly the group can be compared with
the Gram-negative diplococci, meningococci, para-
' Bulletin of the Jnhvx Hopkins Hospital, Vol xxxi— No. 348.
Baltimore, February, 1920, page 53.
llcMcal ieiDS.
Veterinary Surgeon James Brand, F.R.C.V.S.,
in a letter to the Times, from Nigeria, states that
in trypanosomiasis of horses he has obtained re-
markably good results by • giving ten intravenous
injections of an equal parts mixture of a 1 in
100 watery solution of methylene blue, made
from a saturated alcoholic solution of the dye,
and a 1 in 500 watery solution of corrosive
sublimate. The dose is 10 c.c, which is given daily
direct into the blood-stream. It is suggested that
this treatment will be found useful for all animals
suffering from trypanosomiasis, and for sleeping
sickness.
Dr. Sandes, in an address delivered at the
annual meeting of the New South Wales Branch
of the B.M.A., made the suggestion that there
should be a " Federal Minister of the Red Cross,"
whose department should be charged with the work
of co-ordinating preventive medicine measures.
The Medical Research Council have made
arrangements with the authorities of the Lister
Institute (Chelsea Gardens, London, S.W.) to
maintain a collection of type cultures of the prin-
cipal pathogenic bacteria and hyphomycetes. Cul-
tures will be supplied to scientific workers at a
sfnall charge to defray the cost of media and
postage.
The President of the French .Republic has con-
ferred the honour of Knight Officer of the Legion
of Honour on Dr. .'Mdo Castellani, in recog-
nition of his discovery of the combined typhoid -i-
paratyphoid A -i- paratyphoid B vaccine and the
enteric -I- cholera vaccine, adopted during the war
by the Allied Armies,
July 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 13. Vol. XXIII.
^rifliiial Commnnirations.
THE TREATMENT OF BILHARZIASIS WITH
ANTIMONY.
By J. E. R. McDoNAGH, P.R.G.S.
Hunterian Professor B.C.S., Surgeon London Lock Hospital.
My original reason for using antimony in bilharzi-
asis was because I found this metal to succeed in
three cases of sleeping sickness I was treating in
1910 and 1911, when it was not practicable to
prescribe further injections of arseno-benzene, and
iDecause I had found arseno-benzene to be useless in
two cases of bilharziasis. I treated my first case of
bilharziasis with intravenous injections of tartar
emetic in 1911, and first drew attention to the use of
the drug in this disease in my " Biology and Treat-
ment of Venereal Diseases," which was published in
1915. At about the same time I found tartar emetic
to be the most useful drug in ulcus molle serpiginosum,
one of the most chronic conditions known, and later
that antimony had its uses in certain chronic cases
of gonorrhoea. So far as protozoal and bacterial
infections are concerned antimony appears to be the
best metal to employ in those cases where the
organism is intracellularly situated.
In such infections antimony acts indirectly on the
parasites by stimulating the oxidizing action of the
protective substance — the protein particles in the
serum — but whether this is the way it acts in
bilharziasis, or kills the worm directly, is a point not
yet settled. I have used three preparations of
antimony : (l) tartar emetic, (2) antiluetin, (3) colloidal
antimony, and although all three have much the same
action, tartar emetic is the drug for choice as being
the most convenient to use. Antiluetin is difficult to
obtain, and colloidal antimony, which is antimony
sulphide, has to be freshly prepared, as it is not a
particularly stable colloid. Owing to the severe pain
all these preparations cause when injected intra-
muscularly, it becomes practicable only when many
patients are being treated, and as many injections are
required for each to rely upon intravenous injections
of tartar emetic. I have ampoules made up contain-
ing I'O c.c. of distilled water and 1 to li grains of
tartar emetic. It is best to dilute the contents of one
ampoule with water and inject about 100 c.c, as
concentrated solutions are apt to cause venous
thrombosis and temporary mild shock, which is
exhibited by violent fits of cougliing, feeling of con-
striction around the neck, with occasional swelling of
the lips and tongue.
Ten injections prescribed at about five-day intervals
is the average number required. The bleeding begins
to stop after the first injection or two, and the ova to
gradually disappear as tlie injections are continued.
In all I have had 22 cases under treatment ; 7 came
from Egypt and the rest from South Africa, and 5
were sent to nie as intractable cases of gonorrhoea.
In all intravenous injections of antimony caused an
improvement, 2 of the cases have since relapsed, 11 of
the cases I have lost sight of, but I hear periodically
from the other 9 and so far they liave not relapsed,
the oldest case having received treatment eight years
ago.
REFERENCES.
McDoNAGH (1915). "Biology and Treatment of Venereal
Diseases," London, Harrison and Sons.
McDoNAQH (1916). Lancet, September 15, 371.
BILHARZIA DISEASE: THE STERILIZA-
TION OF THE OVA DURING THE COURSE
OF CURE BY ANTIMONY (TARTRATE).
By J. B. Cheistophkbson, C.B.E., M.A., M.D., F.R.C.P.,
P.R.C.S.
Consultant Tropical Diseases Clinic, Ministry of Pensions.
In the Journal of Tropical Medicine and
Hygiene articles have been published from time to
time confirming the statement that antimony in-
troduced into the veins of a patient with bilharzia
disease kills the bilharzia worms in the portal
circulation and cures the person. There seems to
be little doubt about this, in fact it appears to be
a remarkably sure remedy.
Your correspondent. Dr. F. G. Causton* confirms
the statement which the writer has made^ that
antimony tartrate may and should be given in
cases of bilharzia disease eomplicated by conditions
which are not of themselves bilharzia though arising
from it — albuminuria, fistulas, stone and renal com-
plications. It should be used in complicated cases
with more caution however, as befits the treatment
of cases of greater gravity. That it may be used
in complicated cases is an important statement,
because the cases which come up for treatment in
a country such as Egypt where bilharzia is endemic
are many of them complicated and, serious as the
disease is, as met with in England, it is many
times more so in these countries, where people
are exposed to infection and reinfection almost
daily, and where something like 10 per cent, oi
the total mortality is due to bilharzia disease and
its complications.
There are several points open to discussion with
regard to the administration of this remedy. Two
of them are: —
What is the required dose?
How is the dose determined?
Your correspondents do not state how they de-
termine when a patient is cured, and therefore
when the injections may be stopped. My own
view is that it has not much to do with the presence
or absence (per se) of the ova, but it has to do with
the condition of the ova coming away.
The disappearance of the ova from the urine at
an early period of the injections is certainly remark-
able, and requires explanation— it suggests direct
action on the ova; they may seem to disappear
altogether, after a few grains of antimony (tar-
' JoDBNAL OP Tropical Medicine and Hygiene, September
15, 1919, and March 15, 1920.
» JocRNAL OF Tropical Mbpicink and Hvoiene, July 15,
1919, p. 138,
THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE. [July l, 1920.
trate) have been injected, or they may remain
plentiful, until close on 30 gr. have been injected.
The disappearance of the ova during the course
of injections is caused by the injections — still the
fact itself has nothing to do with determining the
dose necessary for the paiient, or with the deter-
mining the time when injections may be suspended
in ajiy particular case.
I lay stress on this point, because if it can be
shown that antimony not only kills the adult bil-
harzia worms but that it also sterilizes the ova,
which tlie wonris have deposited in the bladder and
rectum. I think there is reasonable hope of elimi-
nating endemic bilharzia disease by means of anti-
mony (tartrate) for as time goes on and the propor-
tion of cured cases increases in an affected country,
the intermediate hosts will have difficulty in the
supply of raw material for the extra-corporeal cycle.
The fact that antimony is prc^phylactic in its action
therefore is a very important one.
For bilharzia disease can by this means be eradi-
cated from countries in Africa where it has now a
finn hold on the population, Egypt and adjacent
places — East Africa, Nyassaland, South Africa.
And in countries such as Australia where " its
disabling effects are sufficiently serious to cause
uneasiness lest it becomes prevalent, ' ' the impor-
tance of this prophylactic action cannot be over-
stated.
It is definitely established that the molluscs
capable of acting as intermediate hosts are plentiful
in South Australia, and other parts of the Common-
wealth.'
It therefore behoves Australia not to allow those
molluscs to be infected with bilharzia. This may
be accomplished by compulsory treatment of in-
fected soldiers by antimony (tartrate), and by con-
tinuing the treatment of cases until the ova are
granular.
Now although the ova apparently disappear from
the urine during the course of injections, they do
not do so altogether.
If the urine be examined daily and systemati-
cally— I should like here to acknowledge the help
I had from two skilful workers in this department
of my work, Mr. J. R. Newlove of the Khartoum
Civil Hospitals and Mr. H. R. Johnson of the
Tropical Disease Clinic lat the Ministry of Pensions,
Cheltenham Terrace, London — it will be found that
at a certain period (varying) annually I think after
a total of 10 gr. of antimony tartrate have been
injected, that some of the ova coming away are
altered. They are becoming granular, shrivelled,
blackish in colour, their double contour is disappear-
ing and they do not hatch — they -are sterile.- When
the ova examined for several days in successive
specimens of urine are all sterile, then I think the
injections may be suspended, for the worms are
'The Medical Journal, Australia, September '27, 1919, p. 259.
' Crystals— oxalates urates, mucin particles and the debris
found in urine become blackish during the antimony
injections. -J, B. C.
dead (they die early in the course) and the patients
have ceased to be carriers of the disease, for the
ova are sterile and although they still periodically
appear in the urine and will do so for months and
perhaps years, they cannot infect the intermediate
hosts.
This point (w^hen all the ova are sterilized) is not,
always, an easy one to detennine, because they be-
come very scanty in number during the course and
are only found periodfcally. They are found in
shreds of tissue ulcerating from the inner surface
of urinary passages.
I am not sure that it is practicable to use this
method at all in cases of bilharziasis of the rectum
or even in some cases of mild infections of the
urogenitary tract.
It becomes therefore necessary to look for other
means of ascertaining the required dose. (1)
Colonel Hamilton Fairley's complement- fixation
reaction may prove useful, in places where the
antigen is obtainable easily "(e.g., Egypt and S.
Africa) though it has not yet proved to be of
practical application ; the real difficulty in applying
this method will lie I think in procuring snails for
the manufacture of the antigen. (2) Eosinophilia
at first increases during the injections and after-
wards decreases and should in an uncomplicated
case disappear, » but the presence of other intestinal
parasites interferes with this test. From this
clumsy and not too exact method not much help
is to be expected in determining the time to stop
injections. Therefore it is my opinion that the
microscope is the most practical means we have for
determining the quantity of antimony (tartrate)
necessary to inject and its effect. The urine should
be frequently examined by the ordinary clinical
tests, especially for albumin, to ascertain the effect
of the antimony on the renal epithelium.
Based on the result of treatment of a good many
cases where careful observations were made up
to a maximum of two years from the time of injec-
tion, my opinion is that the dose of antimony tar-
trate required for an adult is between 20-30 gr.,
and that it is generally nearer 20 than 30 gr.
In the case of an otherwise healthy adult — un-
complicated by fistute, stone or renal complications
— if I do not find ova in the urine to guide me I
fix the dose at 25 gr. In complicated cases the
dose, needless to say, should be smaller.
Antimony tartrate is no doubt a dangerous drug
when given by the mouth and considerable caution
should be exercised in administering it intra-
venously, until further facts are known regarding
its toxicity when introduced in this way. We know
however, that considerably more than a total of
30 gr. may be injected and indeed are necessary in
cases of kala-azar.
The writer has given 89 gr. antimony tartrate in
115 days to a Sudan boy of 18 suffering from
kala azar — he was cured and afterwards accepted
' Journal of Tropical Medicinb
1919, p. U3.
Hygiene, July 15,
July 1. 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
167
for service by the Sudan Government and' was two
yeai-s after injection classed fit and well.' I do not
quote this case as a precedent for giving large
quantities in bilharzia — kala azar and bilharzia are
two very different diseases and require different
doses. I am quite prepared to admit that regarded
in comparison with the lethal doses of the drug by
the mouth, 2 the dose 20-30 gr. appears to be
" perilously high," but 1 think that, in order to
obtain the full advantage (prophylactic) of the
course of A.T. you must inject till the deposited
ova are all " granular." If this does not take place
before 30 gr. then I think it best to suspend opera-
tions and later on give a second course if necessary
(as a matter of fact, all my cases of bilharzia have
been cured before 30 gr. have been reached).
I am aware too that the pathological changes
said to be found after acute antimony poisoning in-
clude fatty c^egeneration of the glandular organs and
C.N.S. I therefore have always maintained that
the remedy should not be placed in the hands
of Bob Sawyers, and I believe that the operation,
though small, requires sliill and care and judgment
and that the patient should constantly be watched
for symptoms of over dose. It is needless to say
that although the injections may be given in out-
patient practice they should be given with cai-e.
Acquaintance with the case by thoroughly examin-
ing before commencing injections will place the
operator in a sound position and, especially, exami-
nation of urine is necessary to determine whether
the albumin present is due to blood or to renal
inadequacy.
Further we know that a good proportion^ of the
antimony given is eliminated by the kidney; we
may assume therefore that toxic effects on the
internal organs will be early shown in the urine ;
the urine should be examined daily for albumin.
I am of opinion that a small amount of albumen
(not accounted for by the presence of blood in the
urine) does not signify much. It will disappear
when the injections are suspended but not before.
If, however, the albumin increases — one would
want to know — does this indicate changes in the
renal epithelium ? If one cannot give a satisfactory
answer to this question one must suspend the
injections.
Moreover any symptoms, such as jaundice, inter-
vening would cause one to suspend injections.
In this communication the writer has emphasized
three points : —
(1) The prophylactic action of antimony (on the
ova). Because, if this point can be sustained, then
the intravenous injection of antimony promises to
be a direct means of eradicating bilharzia disease
from countries where it is endemic.
(2) That the dose is not a constant one fixed at
24/1/20.
' The Pharmacopoeia dose of antimony tartrate ib gr. J.
JouKNAi. OF Tropical Mkuicine and Hygiene, July 15,
20-30 gr. or less; watch the ova and inject until
they are all granular, when this has been accom-
plished the proper dose is reached — this is of special
importance in countries like Australia where the
intermediate hosts exist but are not yet infected.
(3) That the injeclions call for a considerable
amount of judgment and care and require a sense
of responsibility in the administration. As little
antimony should be used as is necessary to accomp-
lish the effect on the ova.
Experimental Studies in Diabetes (¥. M. Allen
Journal of Experimental Medicine, vol. xxxi,
No. 5, May 1, 1920). — Practically every detail of
clinical diabetes can be produced in partially
depancreatized animals. They are susceptible to
acidosis and coma, and present anatomical changes in
the islands of Langerhans. They show at first a
tendency to regain assimilation comparable to that
seen in the early stages of human diabetes, and some-
times recover so as to be able to endure any degi'ee or
duration of carbohydrate feeding, and can be made
diabetic only by removal of additional pancreatic
tissue. Similar recovery in some human cases,
especially after acute pancreatitis, is a probability.
This recuperative tendency can be negatived by over-
feeding, even without glycosuria. With duration of
the diabetes the power of recuperation diminishes or
disappears as in human cases. In the absence of
progressive pancreatitis or other extraneous causes,
these animals show no inherent downward tendency
in their assimilation, which fits them for further
accurate feeding experiments. Every detail of the
downward progress of human patients on various
diets is reproduced in such animals. They lose
assimilation and die most raj^idly on diets rich in
carbohydrate, and less rapidly on excess of other
foods. The differences between sugar and starch or
between starch and protein are not absolute, being
only those of degree and time. The downward
progress is purely the result of over strain of the
internal pancreatic function by excess of food. The
benefit of the classical treatment by exclusion of
carbohydrate and limitation of protein is confirmed.
In the majority of cases the results are not
permanent. Diabetes of great severity is controllable
only by radical undernutrition. In still more severe
cases glycosuria can be abolished only by such under-
nutrition as to entail death from inanition. In the
most severe cases glycosuria cannot be stopped as the
food derived from the body stores in fasting cannot be
of.
Some Interesting Instances of Tuberculosis in
Animals (J. B. Cleland, Medical Journal of Australia,
vol. 1, No. 2, March 13, 1920).— Tubercular
meningitis was foimd in a Malayan bear, and in a
bulldog granulomata were found in the lungs, liver,
spleen and lymph glands, which, though devoid of
giant cells, contained tubercle bacilli.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 1, 1920.
flotuis.
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THE JOURNAL OP
Croptcal £)3edtctneanD!^pgtene
July 1, 1920.
HOUSING AT HOME AND ABROAD.
In Britain just now the housing of the people
ia causing keen anxiety. The scarcity of house
accommodation, be it hotels or private houses, is
acute. The cause is multiple ; but to no single
factor can be ascribed the cause of the difficulty,
there are major and minor idiosyncrasies due
to the upset for the past few years of the ordinary
course of life. The number of houses are really
not less than before the war, for no one was allowed
to pull down a house, nor were they likely to do
so, for any dwelling, however dilapidated, was
welco'med, if only for the mere shelter it could
afford from the elements, and the proprietor
obtained a rent much above anything expected
when the house was new. The population has not
actually increased, for well-nigh a million of men
were killed during the war, which would more than
cover the normal increase of population.
Since the war the marriage rate has mounted
up rapidly, and the newly married couples require
more houses. The Government has taken over
hotels, clubs, private houses, and the fresh build-
ings put up have been temporary merely ; barracks
for soldiers, offices for temporary employees, and
sheds for machinery and so forth. The women
refuse to do house work in private families,
or if they do take it up they do so on the " living
out " plan; so that the dwellers in private houses
are fewer owing to the servants' rooms being vacant.
And they have to obtain lodgings outside, causing
congestion and the demand for more houses
to accommodate them. All of these and several
other causes might be mentioned as each and all
contributing to the scarcity of acconmiodation, but
there are yet others which are perhaps even more
poignant.
Before the war for some years contractors were
unwilling to risk building houses on speculation,
as the laws concerning house property, like every
other property, were uncertain. Socialism, of the
bastard type, was raising its evil head; anarchy,
although only talk for the most part, was render-
ing all property precarious, and for some five or
six years before 1914 few houses were erected,
so that for twelve years at least houses were not
being built to meet the ordinary conditions of the
country's needs.
The labour troubles, as tlxoy are called, due to
the trade unions' iniquities apd absurdities, help
to complete the picture of a people gone tem-
porarily mad. Temporarily it is, of course, because
the world cannot go on whilst present conditions
exist, for men are not going back to slavery, and they
will brealc a way to freedom in future as they have
done in the past ; and trax^le unions with their soul-
destroying practices and principles will be scotched,
destroyed and buried, never to rear their heads again
and enthral mankind in their toils. The strangling
of thought amongst the so-called labouring classes
is but a passing piece of terrorism; they are not
to be fooled for ever, and the day is not far distant
when they will emerge from their thraldom and
seek liberty from tht'ir venomous teachers ami
their slave masters.
In the tropics it is not a question of labour .'it
present, but a disregai-d of the principles of hygiene
and sanitation amongst employers in tropical coun-
July 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
tries. Tlie British in the tropics are housed for
the most part in a manner which does not do credit
to the architects, nor to those who are responsible
for the character of the houses they request the
architects to build. The bungalow system con-
tinues with all its evils. The bungalows appor-
tioned for the Europeans on estates to dwell in are
insanitary to a degree. They are makeshift build-
ings, at best built upon a clearing on unprepared
ground and run up rapidly. Wood is the chief
material in their construction ; the ground beneath
the flooring is not covered by cement, concrete, or
any damp-proof material. If brick is employed for
the lower part damp-proofing between the bricks is
conspicuous by its absence. The damp rises in the
bricks, as is readily seen by the bricks peeling,
becoming covered with fungi, and as they harbour
water — a pint to each brick — the dampness in the
inside wall causes ailments of many kinds which
are wholly preventable. The wood above the bricks
rots and decays, and vermin, white ants, &c., infest
the buildings from top to foundations. The general
health of the dwellers is thus lowered and their
powers of resisting disease lessened.
Further, it is necessary to remark also that
practically no house is rendered mosquito-proof. A
little expenditure would render it so. Mosquito
netting is cheap enough surely. The mosquito cur-
tains around the beds is not enough ; people do not
go to bed when the sun goes down at 6 p.m. ; the
evening is spent on the verandahs or in the sitting
room, and it is then that malaria, yellow fever,
filariasis, &c., are acquired. Were the houses,
including the doors and verandahs, rendered mos-
q.uito-proof, malaria would be lessened and the
entrance of mosquitoes defied. That this is the
case is not mere idea or theory as was conclusively
proved in the Roman Campagna, when in their
mosquito-proof house Dr. Low, Dr. Samson, and
their staff escaped malaria, whilst those dwelling
in unprotected houses suffered from malaria in its
most virulent form.
In no part of the tropics are better houses to be
seen than in the colony of Hong-kong. Many of
the houses are raised from off the ground 4 ft. or
5 ft., and the earth beneath is covered by concrete.
Were these houses rendered mosquito-proof, which
few are, by netting of windows, verandahs, and
doors, malaria could be defied, and quinine taking,
which serves to diminish the quality of blood,
would be rendered unnecessary. A well-nigh per-
fectly hygienic house would result were these pre-
cautions taken. All agree that this doctrine is
sound, and yet it is .not practised. Tlie young man
going out to the tropics is ushered into a dwelling
where these precautions arc not taken, and he early
succumbs to disease from which there is no reason
for his ever acquiring.
In regard to epidemic hospitals in the tropics the
steps usually taken are excellent. .7>ist o\itside the
precincts of the town a tpiriporary hospital is
rapidly erected of bamboo and dried palm leaves,
and the flooring raised some 3 ft. or 4 ft. off the
ground. The place selected for the hospital should
be uncultivated ground, and one especially where
plant life is, if not impossible, at least sparse. By
being away from habitations rats and mice are not
likely to come, at any rate for some weeks — a most
important point wh(to the epidemic is nlague.
After, say, six or eight weeks a fresh hospital should
be erected near by, and the evacuated hospital
burnt, so that infection may not be carried by using
the old materials in the construction. In colder
climates the same rule should be adopted, but it
involves an expense which may render this im-
possible. Blocks of buildings at sufficient distances
would allow of transference from another which
has been long in use, and the nearest approach to
the system in practice in the tropics would be
followed.
Man has not devised the perfect dwelling at homo
or- abroad ; he has not yet settled upon a standard
clothing, and his diet is still being experimented
with, each one being a law unto himself. Mankind
is yet in its infancy from a hygienic and sanitary
point of view, and it will be many a long day before
stable rules and regulations are adopted in regard
to sanitary matters generally.
Annotations.
Anthrax : Comparison of Surgical and Non-surgical
Methods of Treatment. A Review of fifty-one cases
treated at the Massachusetts General Hospital from
1888 to 1918 (Albert J. SchoU, Jr., M.D., Los
Angeles Journal of the American Medical Associa-
tion, voi. Ixxiv. No. 21, May 22, 1920, p. 1441).—
In all the patients the diagnosis was made bacterio-
iogically by the demonstration of the anthrax bacilli
in the wound. The general symptoms gave no con-
stant indication of the severity of the infection : the
mortality in the cases reviewed was 137 per cent.
Four of nine patients (44 per cent.) treated surgically
died ; only three (7 per cent.) treated non-surgically
died. The patients treated non-surgically were con-
fined to bed. There lesions were loft absolutely alone
and exposed to the air ; no special general measures
were carried out. In Several of the surgical cases a
rapid increase in the oedema, a steady decline in the
patient's general condition, and death several hours
later definitely pointed to the operation as the causa-
tive factor.
On Entavweha Serpcntis (A. M. da Cunha and*
O. da Fonseca, Memorias do Institute Oswaldo Cniz,
Rio de Janeiro, 1918, vol. x, fasiculus ii, p. 95).—
Entamoeba serpenlis was found by the authors in the
intestine of a Brazilian snake which was examined
for parasitic protozoa. It is very similar to Hart-
mann's E. testudtnis, but no dimorphism is seen in
this species. One of the most striking features of
this species consists in changes in the nucleus, which
are probably to. be regarded as cyclic variations of the
caryosome.
170
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE. [July i, 1920.H
Experimental Study of Pandemic Influenza (A. M.
da Cunha, 0. Magalhaes, and O. da Fonseca, Memorias
do Instituto Oswaldo Cruz, Rio dc Janeiro, 1918, vol. x,
Fasiculus ii, p. 103). — As the result of experimental
investigations the authors consider that influenza is
due to a filtrable virus which is present in the sputum
and blood during certain stages of the disease. Before
or after filtration the virus can provoke reactions on
inoculation into different species of animals producing
intense and prolonged hyperthermia often after a
period of incubation. The heated and phenolized
virulent filtrates appear to possess curative properties ;
autohiemotherapy is often efficacious, and depends on
the presence of th'e virus in the blood. A monkey
■was immuned by one injection of virus from the
sputum, so that it did not respond to a second in-
jection after a suitable delay. The precipitive re-
action with the filtrate of the sputum and the seruna
of the convalescent is often positive whilst the com-
plement fixation reaction with the filtrate is negative.
Gramiloma Inguinale in the United States
(D. Symmers and A. D. Frost, Journal of the
American Medical Association). — Although endemic
in many tropical countries, granuloma inguinale has
not hitherto been recognized as indigenous to the
United States. Two cases are here recorded in
negroes, aged 29 and 26 respectively, who had never
been outside the United States. That the second
case can be classified as tropical granuloma inguinale
is uncertain, since syphilis and the secondary inva-
sion and phagocytosis of Donovan bodies cannot be
denied. It would appear to be established that
lesions similar to or identical with those of granuloma
inguinale as seen in the tropics associated with
morphologically indistinguishable intracellular para-
sitic inclusions are occasionally found in American
lesions — hence the disease in indigenous to the
United ~
€uxunt f itfraturr.
The Indian Journal of Medical Research.
October, 1919.
The Pathogenesis of Deficiency Disease. No. V
— Histo-Pathology (R. McCarrison). — In pigeons an
exclusive diet of milled and autoclaved rice gives
rise to atrophic and congestive changes in all the
organs, being particularly severe in the organs least
essential to life — namely, the thymus, testicles and
spleen. They gravely affect the organs of digestion
and assimilation. The kidneys are less affected,
and the least affected of all the organs are the
thyroid and the glandular part of the pituitary
body.
The Pathogenesis of Deficiency disease. No. VI
— The Infiuence of a Scorbutic Diet on the Bladd-r
(R. McCarrison). — Degenerative changes in the
bladder epithelium were found in scurvy, thus
;ifiording an explanation of the frequent occurrence
of hseinaturia in this disease.
The Pathogenesis of Deficiency Disease. No. VII
— The Effects of Autoclaved Rice Dietaries on the
Gastro-Intestinal Tract of Monkeys (R. McCarri-
son).— Autoclaved rice dietaries in monkeys cause
congestive, necrotic and inflammatory changes in
the mucous membrane of the entire gastro-intestinal
tract and degenerative changes in its neuro-museular
apparatus. Intense toxic absorption from the dis-
eased bowel takes place, and impairment of its
protective power against infecting agents ensues.
The Pathogenesis of Deficiency Disease. No. VIII
— The General Effects of Deficient Dietaries on
MonkSys (R. McCarrison). — Dietaries deficient in
protein, though rich in starch or fat, are potent
sources of disease, particularly of the gastro-
intestinal tract. An excess of fat, together with
deficiency of " B.-vitamine " and protein and
superabundance of starch, is particularly harmful,
whilst deficiency of vitamines-and protein, together
with an excess of starch, favour the invasion of the
blood and tissues by bacteria.
The Pathogenesis of Deficiency Disease. No. IX
— On the Occurrence of recently developed Cancer
of the Stomach in a Monkey fed on Food Deficient
in Vitamines (R. McCarrison). — Since cancer
developed in the stomach of a monkey fed on food
deficient in vitamines, the possible influence of
vitamine deficiency in favouring the onset of cancer
of the stomach should be further investigated.
Report on an Epizootic Disease among Calves at
the Amara Dairy Farm (T. H. Gloster and G.
Shanks). — Enteritis caused a high mortality among
calves at .\mara. An aertrycke-like bacillus was
isolated, but it was not decided whether the disease
was due to this organisin or to a filter passer with
the aertrycke-like bacillus as a secondary infection.
Studies in the Value of the Wassermann Test.
No. I — Frequency of a Positive Wassermann Re-
action in the Unselected Adult Male Indian Popu-
lation. No. II — Significance and Value of a
Positive Wassermann Reaction in Leprosy (K. R. K.
Iyengar). — The Wassermann reaction was found to
be positive in 22 per cent, in an unselected and
apparently healthy adult male Indian population,
showing no differences among the various castes
and religions, whilst in 100 cases of leprosy 41 per
cent, of positive Wassermann reactions was
obtained.
The Prevalence of Ankylostomiasis in the Madras
Presidency (K. S. Mhaskar). — Among Tamil coolies
in Southern Madras the hookworm infection, though
universal, varies in intensity in the various districts
and in the various communities, the highest being
in the Tanjore District with an average of 91 N.
ainericanus and 10 .4. duodcnale per person.
Identification of Three Strains of Trypanosomes
from cases of Sleeping Sickness contracted in Portu-
guese East .Africa with Trypanosoma rliodrsicnse
(T. .\. Hughes). — Three strains of trypanosomes
from cases of trypanosomiasis contracted in the
hinterland of Port Amelia, in Portuguese East
July 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
171
Africa, were classified as Trypanosoma rhodesiense
on account of their general pathogenicity, morpho-
logy and atoxyl resistance, and the fact that they
came from an area free from G. palpalis, but in-
fested with G. morsitans.
The Correlation between the Chemical Composi-
tion of Anthelmintics and their Therapeutic Values
in connection with the Hookworm Inquiry in the
Madras Presidency (J. F. Caius and K. S. Mhasker).
— Thymol may be looked upon as one of the higher
homologues of benzene, phenol, or metacresol.
As a matter of fact its physiological properties
are but variations of the properties exhibited by
those three substances. It is a powerful antiseptic,
acting as a caustic irritant of the mucous membrane
and causing excitant effects in the alimentary canal.
Its toxic effects are similar to those of phenols, but
of a somewhat milder grade. In poisoning from its
use, locally there is a burning sensation in the
stomach and slightly caustic effects on the mucous
membrane of the intestines, producing intestinal
irritation and evacuation of faeces, nausea and
vomiting. Tremor and convulsions are induced,
though rarely, and are less intense than those
induced by phenol.
Thymol is a drug of uniform quality, and one that
keeps well almost indefinitely.
Thymol is a powerful vermicide, acting both on
ankylostoma and necator. Any dose from 30 to
60 gr. administered in one portion will prove
effective.
Studies in Ankylostomiasis, No. IV (G. T.
Wrench). — Comparing the various methods of exam-
ining the stools for ankylostoma ova, the following
was- found to be the most efficacious : —
Particles of faeces are scooped up from five
different parts of the stool with bazaar-made scoops.
This faeces is placed in a test-tube and shaken up
with equal parts of methylated ether and hydro-
chloric acid (33 per cent.), the emulsion strained
through fine muslin and centrifuged. The fat and
debris are carried or " levitated " to the top, the
ova with heavier debris are deposited below in a
fine emulsion. This emulsion is sucked up by a
pipette, and as much as possible placed on the
upper surface of a coverslip resting on a slide, three
coverslips being made by cutting an ordinary slide
into three equal parts. Five minutes or more are
allowed for settlement. The excess fluid is thon
pipetted off and the coverslip examined. If the
emulsion is too thick for vision, it may be diluted
and mixed with more of the ether and hydrochloric
acid mixture, and, after a further five minutes for
settlement, the excess again pipetted off.
The Tinturomctcr, an Instrument for Measuring
Tint and Turbidity (W. V. Harvey). — An instru-
ment consisting of a cylindrical measure glass and
a steel foot rule has been devised for measuring the
tint and turbidity of fluids. It has been used to
measure (1) the degree of growth of organisms in
fluid media of different composition, (2) the con-
centration of erythrocytes in the blood, and (3) the
haemoglobin content of the blood.
Measurement of Bacterial Content in Fluid Sus-
pension (W. F. Harvey). — Measuring the bacterial
content and rate of growth of organisms in fluid
and culture media by means of the tinturometer,
it was found that growth was influenced by the
presence of (a) fermentable sugar, (6) peptone,
(c) meat extract.
The Determination of Incubation Periods from
Maritime Statistics with Particular Reference to
the Incubation Period of Influenza (A. G. McKen-
drick and J. Morison). — The mean incubation period
of influenza was found to be 32'7 hours, whilst the
initial period of non-infectivity must be of short
duration.
Evidence regarding the Immunity conferred by
an Attack of Influenza with a Study of Three Local
Epidemics ; with Mathematical Note by Major A. G.
McKendrick, I. M.S., R. H. Malone). — An analysis
of the figures obtained in all three epidemics
adduces strong evidence that immunity is conferred
by one attack of influenza.
Pasteur ellosis in Rabbits following the Intra-
venous Injection of Influenza Bacilli (R. H.
Malone). — Paste urella organisms were obtained
from rabbits which had died after intravenous
inoculation of influenza bacilli for the preparation
of high titre agglutinating sera. Similar organisms
were obtained from the nasal secretion of rabbits
showing no signs of illness which had been in con-
tact with the animals which had died of the
Pasteurella infections.
Pstracls.
THE EXPERIMENTAL DETERMINATION OF
THE VERTEBRATE HOSTS OF SOME
SOUTH AFRICAN CERCARI^ FROM THE
MOLLUSCS, PHYSOPSIS AFRICANA AND
LIMN/EA NATALENSIS.'
By Annie Poeteb, D.Sc. Lond., P.L.S , F.R.S.(S.A.).
Parasitologist, South African Institute for Medical Research.
Schistosomes.
Schistosoma hsematobium and S. mansoni have
both been studied. The former fluke is the more
common. S. hxmatobium is present in larval form
in I'hysopsis africana, and I have found it also in
a very small number of specimens of Limnwa
natalensis (4 out of 620). The former snail is to
be regarded as the common intermediate host of
S. hxmatobium, as was first determined by Dr.
J. G. Becker, by the inoculation method. The
cercarisB of S. mansoni have been found by me in
three specimens of P. africana only.
1 Abstracted from the Medical Journal of South Afn
vol. XV, No. 6, Johannesburg, January, 1820.
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE. [July 1, 1920.
The life-history ot-S. haematobium briefly is as
follows: The eggs of the worm pass from the
human body with the urine and may reach water,
preferably stagnant or very slow moving. A
ciliated larva, the miracidium, hatches from the
egg and swims about actively. Should the mira-
cidium not meet a pond snail, usually P. africana
(in South Africa) within six to eight hours after
hatching, it dies. By experiment I have been able
to determine a certain amount of attractioa of
P. africana for the miracidia of S. hsematobium,
but I have not observed any attraction between the
miracidia and the mollusc before the organisms
have been in the same dish of water for at least
forty-five minutes. Attraction between the mira-
cidia of S. hsematobium and L. natalensis has only
been observed to a very slight extent. If the mira-
cidium reaches a physopsis it penetrates the
pulmonary cavity of the snail, settles down there,
and develops into a hollow structure termed a sporo-
cyst; active multiplication occurs, and it gives rise
to a number • of active, forked-tailed larvae, the
ceroarise, which spread throughout the liver and
generative organs of the snail, which they eventu-
ally destroy. The body of the cercaria of S.
haematobium is about 240 fi long by 100 /x broad,
its tail is about 200 fi by 45 /it broad, while the
forks of the tail are 80 /i to 100 u. long. The head
shows a small oral sucker, and a small acetabulum
or ventral sucker, the latter being often less obvious
than the former, as three pairs of mucin glands
partly obscure it. There are three pairs of hollow
piercing spines at the openings of the ducts of the
mucin glands at the outer margin of the anterior
or oral sucker. A group of several large germ
cells lies behind the posterior .sucker. Numerous
cercarise are present in a heavily infected snail —
I have obtained over 1,500 active cercariae from
one P. africana. These cercarias leave the snail
ultimately, and are capable of piercing the skin
of a. vertebrate such as man, whence they find
their way to the liver of the host, where they grow
into adult worms. After copulation, the fernale
deposits har eggs in the walls of the bladder,
whence they ultimately pass out with the urine.
Modes of Infection. — These have been shown
experimentally by me as' follows: —
(1) A white rat, A, was exposed for one hour to
water containing schistosome cercariae from P.
africana. A control rat was exposed for the same
time to ordinary tap water. The rat merely paddled
about in the water for the given time. In the case
of the experimental rat, it commenced to nibble at
its paws three minutes after it was placed in the
water, and the skin of its paws and feet became
reddened. The control showed no sign of dis-
comfort. Later, the fur of the experimental rat
was staring, particularly as the maliidy progressed,
the fur fell out, the eyes became cloudy, there was
great emaciation and incontinency, and finally
death occurred. Over forty S. haematobiu7n, both
male and female, were recovered from the liver of
this rat. Sixty-four days elapsed from the time of
its exposure to the schistosome cercarise to the time
of its death.
(2) A white rat, B, was fed with bread soaked in
a little water containing a few schistosome cercariae.
The experiment was so arranged, that no part of
the rat other than the mouth came in contact
with the infective material. The animal ate the
bread greedily, but as soon as it was allowed to do
so it commenced to scratch its mouth and palate.
A control rat similarly treated, but fed on bread
only, gave no such indication of distress. The
symptoms during the course of infection were like
those of rat A, and the animal died ninety-five days
after the infective feed. S. hxmatobitini was re-
covered from its liver as in the case of the first rat.
(3) A white rat, C, was exposed to infection by
paddling in water containing schistosome cercariae
from L. natalensis, but in very small numbers, on
two occasions of an hour's duration each. It died
seventy-nine days after the first exposure, and
seventy-six days after the second. The illness ran
a similar course to tliose of the former rats, and
adult S. hxmatohium were recovered at the autopsy
from the liver and mesenteric veins.
Two guinea-pigs similarly exposed or fed gave
similar results, but the foregoing examples are given
as typical of the series.
Thus P. africana and Limnaea have been proved
experimentally to be the hosts of S. haematobium,
and the former snail to be one host of S. mansoni,
though it may not be tie common host.
DiSTOMES.
Distome cercariae have been observed in both
P. africana and L. natalensis, both of which
molluscs can harbour the parasites of bilharziasis.
The determination of the adult form and of the
final hosts of these cercariae is therefore necessary.
The present results have been obtained by feeding
certain vertebrates with cercariae parasitic in L.
natalensis, and believed to be identical with those
named Cercaria pigmentosa by Dr. Cawston in
1919. These cercariae encyst on vegetation. They
are thus described and defined by Cawston (1919)
when writing on "Encysted Cercariae": "The
other encysting cercaria possesses a terminal, oral
and a median ventral sucker. No eye spots could
be detected. The head of the cercaria is heavily
pigmented, as are also the redise in which these
cercariae are produced. These rediae are three-
eights of an inch in length and whiten the liver
substance of infected snails. The cercaria itself is
fully a millimetre in total length. The rediae possess
a well-defined oral sucker and gut distended with
particles of food. Towards the posterior end of the
rediae on the left side is a poorly-developed loco-
motor appendage." Cawston named the cercaria
" C. pigmentosa in view of their pigmented head*."
A brief outline of the Trematode, as I have
obsei-ved it, can be presented here, but fuller
details will appear later.
The livers of the L. natalensis infested witli this
11
July 1, 19!20.] THE JOUBNAL OF TBOPICAL MEDICINE AND HYGIENE.
173
parasite appear streaked with wnite threads, which
sometimes show orange to black markings. These
threads are the rediae, the intestines of which con-
tain orange to black contents. The rediae vary in
size according to the season and to the particular
time of reproductive activity of the fluke in the
snail. The largest specimens that I have observed
were about 12 mm. long, this size being quite excep-
tional in my experience. Some few were from
6 mm. to 7 mm., but the majority were 1'5 mm.
to 2 mm. in len^h. The rediae produce cercariae,
and daughter redias appear to be formed only
towards the end o(f the multiplicative activity of
the parent redia.
The cercariffi are active organisms and vary in
appearance according to their degree of activity.
Thus, the body of a cerearia measures about 500 fi
when extended fully, while when contracted it
appears rounder and may measure only 250 /a. The
length of the tail varies from 159^ to 200 fi. The
anterior sucker is fairly prominent and the posterior
one easily seen. The intestine is typically distome.
In life, the body is crowded with masses of cysto-
genous granules (" pigment " of Cawston) which
largely obscure the finer details of the organization.
These granules are soluble in alcohol, chlorqform
and formalin, so are not well seen in preserved
materiail.
When an infected ^nail is isolated in water, the
cercariae readily leave it and can be seen with the
naked eye swimming actively in the surrounding
water. After a time they leave the water and creep
up the stems of any water plant in their vicinity,
or failing water plants or grass, they creep on to
the shell of the snail itself. Each cerearia com-
mences to extrude the cystogenous granules from
its body and soon casts its tail. The body then
contracts into a spherical mass surrounded by a
black cloud of granules. These graduaUy condense
and form a thick cyst wall which hardens on ex-
posure and contracts somewhat. The encysted cer-
earia shows its two suckers, forked gut and the
remains of the cystogenous granules. I have
obtained 1,070 perfect cysts from one L. natalensis,
and several hundred from one snail are common.
The encysted cercariae on herbage by the waterside
are in favourable situations for ingestion by any
herbivorous animal, such as ox, sheep or buffalo.
By direct experiments of feeding herbivorous
animals (sheep, rabbits and guinea-pigs) and omni-
vorous animals (rats, mice) on green barley and
cabbage contamhiated with cysts of C. pigmentosa,
I have succeeded in obtaining adult flukes, which
correspond with the adult trematode known as
Fasciola gigantica, Cobbold, reported from oxen,
buffaloes, sheep, goats, giraffes, and in one instance
from man. Brief notes on certain typical experi-
ments are given.
A rabbit was fed with green food contaminated
with cysts from L. natalensis. After some time it
showed signs of emaciation. It died sixty-four days
after the infective feed, and over twenty adult
riukes were obtained from its liver at post mortem.
The liver was enlarged; it was greyish with white
patches, which proved to be flukes, some of which
emerged from the disintegrating capsule and moved
about actively. Beoent haemorrhages into the con-
nective tissue round the terminal part of the rectum
and the superficial fascia of the lower part of the
abdomen and the posterior aspect of the thighs, and
a large haemorrhagic sac between the superficial and
deep muscles of the thigh were present. These
heemorrhages contained one or more flukes.
Similar results were obtained with a guinea-pig,
which died 74 days after the inifective feed. The
morphology of the flukes obtained was the same as
those of the rabbit.
A young sheep, bred from and belon^ng to a
stock known to be free from " liver fluke," was fed
with green barley contaminated with cysts from
L. natalensis, two such feeds being given. On the
first oocasion only a few cysts were available, but
on the. second oocasion, twenty-four days after the
first, about 250 cysts were administered. The
animal died 143 days after the first and 119 days
after the second infective feed, and 223 adult flukes
were recovered from it at autopsy.
Examination of the fseces of the sheep was made
daily, but trematode eggs were not detected. Sixty-
four days after the second infective feed the animal
was noticed to be less active and to lie down a
great deal, but the weather was hot and it was
thought that this might account for its laziness.
However, this attitude continued at intervals until
its death. The animal refused most of its food for
seven days before it died. Diarrhoea occurred
during the last three days.
At post mortem the body was well nourished and
was fat. The hver showed marked perihepatitis,
was greenish in colour, with numerous small
blackish areas that proved to be haemorrhages.
There was slight oedema. The bile ducts were
greatly thickened and fibrotic. The kidneys were
normal, except that they were small and pale, and
one fluke was recovered from the pelvis of the right
kidney. The intestines were heavily bile-stained
and flukes were present in the canal, which also
showed numerous small haemorrhages and contained
free blood. All the blood-vessels of the mesentery
were engorged. A small hagmorrhage beneath the
skin near the anus contained one fluke. The other
organs of the Ixidy were normal.
The organ most affected was the liver, from which
189 flukes were removed. The bOe ducts were
blocked in parts and two and three flukes entangled
together were found in these places.
The adult flukes varied in size, large ones being
45 mm. long, and about 7 mm. broad, while small
specimens were about 20 mm. long. Sexually
immature forms were also present, varying in length
from 5 mm. to 19 mm. and in breadth from 2 mm.
to 4 mm.. The sides of the body were nearly
parallel, but there was a short cephalic cone. The
anterior sucker was distinct, about 1 mm. in dia-
meter, the posterior sucker was prominent and in
large specimens reached 1'8 mm. in diameter. The
174
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [ju]y l. 1920.
pharynx was well marked, the oesophagus short, and
the lateral, branching, intestinal caeca were directed
sUghtly backwards.
The reproductive system is typical of Fasciola.
There are two testes, placed one behind the other
and much branched. Each has a vas deferens and
the vasa deferentia unite anteriorly. The ovary is
relatively small and is branched. The uterus and
oviduct are convoluted. Yolk glands are present
and are greatly branched. The viteUine ducts are
readily seen, especially the transverse junction,
which is dilated centrally into a vitelline re^ceptacle.
A large shell gland is present.
The eggs are large, measairing about 175 fi long
and 85 fj. broad.
The fluke is identified with F. gigantica, Cobbold,
known as a parasite of oxen, buffaloes, sheep, goats,
giraffes, hares and rabbits in Africa. Its life-cycle
and intermediate host are now determined for the
first time.
F. gigantica is likely to be found to be much
more common in sheep and cattle in South Africa
than might at first be supposed. Its natural occur-
rence in the Transvaal is already known to the
Veterinary Research Division.
ECHINOSTOMES.
Both P. ajricana and L. natalensis harbour the
young forms of Echinoetome flukes. I have found
the larval forms of three hitherto unrecorded forms
of echinostomes in the above mentioned molluscs,
P. ajricana being more frequently parasitized. As
a rule the mollusc harboured one kind of fluke only,
but in a very few cases alt three larval flukes were
present. The parthenita (redias) agree in being
orange coloured, and the hvers of infected snails
appear orange masses. The life-cycle of one of
these Echinostome flukes is here briefly outlined.
The redisB vary greatly in size, many being about
1"5 mm. long, though occasionally specimens 3 mm.
long have been found. They are actively motile
and possess one or two pairs of locomotor appen-
dages. The rediae contain bright orange chromato-
phores and their body fluid is pale orange in colour.
They have a large simple intestine, frequently with
almost black contents, and usually distended.
Within the redia there are usually several morulae
and cercarias. Daughter rediae may also be present.
These are simall and are about 0-5 mm. long when
they emerge from the parents.
The oercarias are relatively large, varying in length
according to the degree of extension or contraction.
Many have a body about 450 fj. long, with a simple
tail about 350/i long and body width of about 150 /i.
The anterior end of the body is somewhat flattened,
the oral sucker is rather large, and the " head "
has the characteristic epined armature of Echinos-
tomes. It consists of two alternating rows of simple
spines with a group of four spines at each lateral
extremity of the head. The acetabulum is promi-
nent. The pharynx is small and rounded, the
oesophagus long and narrow, passing backwards to
the anterior genital^ mass and then forking into the
two cBBca constituting the intestine. The ceeca end
almost at the base of the body on either side of
the bladder. Two germinal rudimente are present,
one well-marked mass, almost in the median line,
embracing the caudal edge of the acetabulum, com-
posed of many small cells, and one smaller mass at
the anterior end of the acetabulum, partly occupy-
ing the space between the forks of the intestine.
The excretory system consists of a more or less
polygonal, laterally compressed bladder, from which
two sinuous collecting tubules arise anterolaterally
and pass forwards, diverging somewhat outwards
about one-third of the distance between the anterior
and posterior suckens. The body is crowded with
masses of cystogenous granules which render obser-
vation of minute internal details very difficult. The
cercariae are easily visible to the naked eye, and are
very active when they swarm out of the snail.
The next phase of the organism is passed in the
" clawed toad or frog," Xenopus Ixvis, as I have
determined experimentally. Thus: —
A frog, X. laivis, was put in water containing
the Echinostome cercarix from P. ajricana and
L. natalensis. The oercariae quickly swam round
and attached themselves to the frog by their
suckers, choosing first the area around the eyes and
then the glandular areas that represent the remains
of the lateral line system in Xenopus. The cercariae
pierce the skin, cast their tails, extrude their cysto-
genous granules and form round cysts beneath the
skin of the frog. Within each cyst the cercariae
becomes curved, gradually contracts and changes
its shape, curving itself. The newly-formed cysts
are from 120 /a to 175/4 in diameter. In some cases,
not only the skin and the subcutaneous tissue, but
also the surface of the muscles showed numerous
small nodules at post mortem due to the cysts of
the Echinostome. The presence of the parasite has
harmful effects on the host, and the illness usually
has a fatal termination in Xenopus.
In the case of the Xenopus referred to previously,
it was placed in water containing the E. cercarise,
its control being placed in ordinary tap water. It
soon showed signs of irritation, rubbing its eyes
frequently, and by the use of a hand lens the
cercariee could be seen attached to the skin. After
a short time the blood-vessels of the eyes became
greatly inflamed and the circum-ocular ring of
skin became markedly oedematous and showed
granulations, the nodules projecting outwards and
also into the subcutaneous tissue. Alx>ut fifty days
after the experiment began, the whole body of the
frog l)ecame very oedematous, the eyes becoming
entirely concealed by the overhanging cedematous
skin of the head. Scratching occurred, and on the
sixtieth day a small piece of skin was scratched
out, the fluid beneath the skin poured forth, the
skin collapsed and the Xenopus became relatively
normal in appearance except for some wrinkling.
Sonne encysted Echinostomes and some freshly
emerged from the cysts were present in the fluid
exuded. On the sixty-fifth day the Xenopus died.
For some days prior to the draining away of the
July 1, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
cedemabous fluid, email freely moving Echinostomes,
about 540/1 long and 180 yii broad, were found crawl-
ing on the skin ai the frog, having burst from their
cysts. The process of emergence from the cyst has
been often observed. The small flukes obtained
from the surface of the skin and those still encysted
show similar structures, and the same head arma-
ture is present asi in the cercariae from which they
were developed.
A second Xenopus was exposed to iniecbed water
in the same way as the first one. The infection
ran the same course, but the frog, which was
younger, died eighteen days after the exposure.
Other Xenopus exposed to infection are still alive,
but look unwholesome and show cysts beneath the
skin. It may he mentioned that the frogs seem to
suffer little or no inconvenience if the cysts are
removed from their skin from time to time, so that
the transition from the cercariae to the adult form
can be fairly readily traced.
Fully sexually mature Echinostomes have not
been observed as yet, though flukes with the geni-
talia in a much greater stage of development than
those of the cercariae have been observed. I siuggest
the provisional name of E. xenopi for this organism,
as it appears to have been unrecorded hitherto, the
life-'cycle and morphology being as outlined.
MoNOSTOMES.
Another amphibian fluke, but a Monostome, has
been obtained by exposing X. Ixvis to water infected
with cercariae from P. africana. The larval stages
of the fluke are rare panusites of the mollusc, and
I have need of much more material before final
results can be given. The redia is simple, about
1'5 mm. long, possessing no marked locomotor
appendages, but a muscular contractile body. The
pharynx is oval and the intestine a simple sac.
The cercariae appear to mature one at a time. Each
eercaria possesses an oral sucker, but no acetabulum.
There is no excretory bladder at the posterior end
of the body and two excretory tubules pass for-
wards uniting near the sucker. The oral sucker is
small, the oesophagus is very narrow, while the
csecal forks of the intestine are close together at
first but diverge somewhat further on. The whole
body is full of unicellular cystogenous glands which
obscure details of the body structure.
When the cercariae leave the snail they swim
freely in the water, lashing their rather powerful
simple tails. When X. Lrvis is placed in water con-
taining the cercariae, they pierce the skin, selecting
first the ring of skin round the eyes and then the
glandulose areas along the lateral lines, just as the
Echinostome larvae do. Encystment rapidly occurs,
the tail is cast off, the cystogenous granules are shed
and harden to form a compact cyst wall. The cyst
is larger than that of the Echinostome, often
reaching 0-.5 mm. in diameter.
The effects of the host resemble those produced
by the Echinostome previously mentioned, the
oedematous circum-ocular ring being very noticeable.
Rupture of the cyst also occurs, and the actively
moving Monostome, asi yet sexually immature,
reaches the surface of the skin in some cases. The
further development of the Monostome has not yet
been fuUj' established, but work on both it and the
Echinostome is in progress's.
Summary.
S. hsematobium and S. mansoni, the respective
excitants of urinary and intestinal bilharziasis, have
been found in larval form in the South African
molluscs, P. africana and L. natalensis. The infec-
tion of the molluscs with S. mansoni is uncommon.
The presence of S. hxmatobium is much more fre-
quent in P. africana than in L; natalensis. Adult
Schistosomes have been obtained in laboratory
animals by submitting them to such natural modes
of infection as bathing or exposing them to water
containing the cercariae, and by causing them to
drink water so contaminated.
L. natalensis harbours the larval forms of
F. gigantica, the large, narrow liver fluke producing
liver rot in oxen, sheep, buffaWs and goats. Full-
grown, sexually mature, adult flukes have been
obtained by feeding sheep, rabbits and other labora-
tory animals with food contaminated with the
encysted cercariae (apparently C. pigmentosa),
obtained from the pond snails.
Both P. africana and L. natalensis harbour the
larval stages of an Echinostome fluke, which
undergo encystment and subsequent development
in the "clawed frog," X. isevis. The life-history
of the Echinostome is established, and it is pro-
visionally named E. xenopi.
A Monostome fluke has also been produced in
-Y. Ixvis by exposing it to water containing cercariae
from P. africana.
Thus, it has been experimentally determined that
in the two South .\frican snails transmitting human
bilharziasis, in addition to the Schistosomes, an
important cattle Distome, an Amphibian Echinos-
tome !md an .•\mphibian Monosloni(> arc (jrcscnt.
STATISTICAL REMARKS ON THE TREAT-
MENT OF BILHARZIASIS BY TARTAR
EMETIC.'
By Hemri Garin, M.D. ,
Lourenco Marqius.
Of the 4 per cent, tartar emetic solution, we gave
the first day 1 c.c. (0"6. gr.), and afterwards 3 and 4
c.c, up to 5 cc. (3"1 fir.) to strong patients. For
small children we fixed the doses accordinfi to age.
The treatment gave no trouble or complications, if
we except the fit of coughinR and sometimes voniitinfi
which began directly after the injection and lasted
from a few minutes to half an hour. On three
patients we tried quotidian injections, but this caused
continuous nausea and vomiting after every meal,
and the effect on the disease did not seem to bo more
' The Medical Journal of South Africa, vol. xv, No. 8,
Jobaoneiburg, March, 1920, p. 179.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 1. 1920.
rapid, so we stopped this way of administration. A
consequence of little importance was the appearance
of a papular and very itchy rash, starting at the site
of the injections, and probably due to minute doses
of the fluid remaining on the outside of the needle
which had been used to draw up the medicine, and
sufficient to irritate the skin, without bringing on
inflammation or gangrene, such as bigger quantities
may do when injected outside the vein. This trouble
stopped when we used two different needles for
aspiration and injection.
The urine of every patient was examined before
beginning the treatment, and again after every two
or three injections. Ten c.c. were centrifuged for five
minutes, the sediment spread on a slide and the whole
of it examined field by field before stating that no
eggs, or only degenerate ones, were present.
After a few injections the majority of eggs appeared
dead or degenerated, the shell deformed and thinner,
the embryo transformed into a granular body, getting
smaller and disappearing altogether, leaving only
empty shells.
One hundred and twenty-two patients suffering
from vesical and two from rectal bilbarziasis were
treated. All of them had living eggs at the first ex-
amination. Twenty-one never came back after the
first injection. Twelve came only twice, but their
urine, as also the urine of nine patients who received
three, four or five injections were not examined again
for diverse reasons.
The subjective effect of treatment is even more
marked ; after a few injections the patients declare
that they feel much better and do not suffer any
more pains and burning sensation during micturition,
although blood and degenerate eggs are still being
passed. The contrast between the subjective ameli-
oration and the small amount of change in the
quantity of blood and the number of eggs passed
(although all degenerate or dead) is sometimes very
striking. Two patients continued to pass a notable
quantity of blood for weeks after careful examination
of several samples of urine did not show any eggs,
but they felt absolutely well. Without cystoscopic
examination it is difficult to know what anatomical
change in the bladder was responsible for that fact.
In two other cases exceptionally, the patients con-
tinued to complain of pain and burning feeling at the
end of the micturition, for months after the urine was
quite clear, and showed no blood nor eggs. Of the
two rectal cases, one was cured after five injections,
no blood and no eggs bemg found, and the other still
showed living eggs after two injections, when he
stopped the treatment.
If we look at the results from another point of
view, and count the days after the beginning of treat-
ment until no more living eggs could be detected, we
find that until the eleventh day the cures are very
few, only four out of twenty-nine patients, who all
received only four injections or less, one only getting
five : one was cured on the third day (after three
quotidian injections), one on the fourth day (after
two injections), one on the eighth (after two injec-
tions), and one on the eleventh (after four injections).
After the eleventh day, living eggs were the excep-
tion, even in patients who had received only a few
injections. Among fifty-one patients, only three
showed them : one on the fourteenth day (after five
injections), one on the sixteenth day (after three in-
jections), and one on the thirty-fourth day (after two
injections only). Of the for|,y-one cured, 50 per
cent, had received five injections or less (twelve had
got five, eight had had four, two had had three, and
two respectively two and one only). This last case
was examined one month after his first and only
injection, and in several samples of urine we were
unable to detect a single egg. But we are Lot pre-
pared to give the. credit of this disappearance t^o the
treatment, and think rather that it was due to some
coincidence or external cause.
After comparing these various figures, it seems
possible to fix a routine treatment for busy dis-
pensaries, giving six injections in twelve days, with a
total dose of 0'9 grm. (or about 14 gr.) of tartar
emetic, and examining the urine after these injections
only, to detect the few patients requiring further
treatment.
^c&iciDS.
Essentials of Tropical Medicine. By Walter
E. Masters, M.D.Brux. London : Bale, Sons
and Danielsson, Ltd. 1920. Price 42s. net.
This work is intended to be a vade-mecum for the
student and busy tropical practitioner. It does not
claim to contain anything new, or to substitute any
other work. It is a well arranged digest of our
knowledge of tropical medicine in all its branches,
including skin diseases, eye diseases, venoms, tropical
sanitation and hygiene and laboratory hints, in a
form handy for ready reference. There is a useful
appendix on fallacies in blood examination, on the
general treatment of fevers, on embalming, and hints
in tropical surgery, &c. There is also a full and
complete index.
Diathermy in Medical and Surgical Practice
By Claude Saberton, M.D. London ; Cassel
and Co. 1920. Pp. vi + 138. Price 7s. 6d.
net.
The aim of this little book is to serve as a guide to
students and practitioners who wisli to master the
'technique of diathermy, and to appraise its place in
the treatment of disease, and has been extremely well
carried out. We thoroughly endorse the author's
statement that this therapeutic method should not be
given by unqualified operators, and that no kind of
electrical treatment, indeed, should be administered
by the untrained. If dangers are to be avoided and
beneficial results obtained, the employment of these
agents should certainly be limited to those who have
a working knowledge of their effects in diseased
conditions. We warmly commend this little book to
all those interested in the subject.
.luly 15,1920.j THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 14, Vol. XXIII.
®riflinal Comummrationg.
SOME NOTES ON FIFTEEN YEARS' EX-
PERIENCE OF MALARIA IN THE UPPER
CONGO.
By Arthur Pearson, M.B., B.S.Lond., M R.C.S., L.R.C.P.
Katanga, Belgian Congo.
At the commencement I would emphasize the
fact that, while I feel justified in being dogmatic
in regard to malaria as it is met with in the Katanga
District of the Belgian Congo, I do not believe that
my findings and my methods would necessarily
apply with the same force to malaria in other parts
of the world. Indeed, I believe that much con-
fusion has resulted in the past from attempts made
by individuals to apply their own limited experience
of malaria in laying down the law upon the whole
subject. In illustration of this point I may note
that whilst the malignant tertian parasite of the
Katanga is morphologically indistinguishable from
that of the Lower Congo, of Gernian East Africa
;iud of Sierra Leone, wide symptomatic differences
liave shown in my cases of infection from those
places.
Thus, a Katanga infection is a relatively benign
affair, in which grave pernicious symptoms, such
as malarial coma, were rarely to be noted. The
chief danger in the local infections lay in the pre-
disposition to blackwater fever under those circum-
stances which experience has shown to be favour-
aide to the onset of this dangerous development.
Cerebral coma here has generally been noted among
the very few cases coming under observation after
infection in the Lower Congo or at Sierra Leone.
Cases from German East Africa have also been
few in number, and have shown greater resistance
to treatment than is met with in most cases of
local infection. This resistance has, however, been
shown in the same way, i.e., by persistent relapse
each month rather than by resistance to treatment
during the attack.
Again, it is a very frequent experience to find
that individuals who have lived for years in one
malarial district without adopting any effective
measures of prophylaxis and yet without suffering
nuich from fever, may find themselves as sus-
ceptible to malaria in a new district as any new-
comer from England. This point is generally
exemplified in the Katanga by arrivals from
Southern Hhodesia, whose experience in malai-ial
districts in that country prompts them to neglect
the precautions recommended here. Disaster nearly
always follows within a month or so.
Prophylaxis.
Moaquito (Icntrurtiun is, of course, the best pro-
phylaxis. Very often indeed, however, it is not
practicable. Tliere is no need for me to take up
space in discussing it, beyond noting that however
apparently hopeless it may seem to attempt it, a
genuine effort will always meet with a certain
degree of success. Too often in the tropics no
attempt is made because local conditions render
complete success impossible without excessive
expenditure.
Protection from Mosquitoes. — Protection of houses
by netting and of individuals by mosquito nets.
This enormously important subject needs no dis-
cussion in these notes. Again, however, it is for
the most part neglected by most individuals, or the
rules with regard to it are supplied with a sloven-
liness which renders them useless.
Quinine Prophylaxis. — When I left England for
the Congo in 1903 I held fresh in my memory one
sentence from a lecture by the late Dr. Crosse,
who had had nine years' experience with the Niger
Company: —
" If you get your men to take 5 gr. of quinine
each day they will never get blackwater."
Until two years ago I have been actively engaged
in practice. About 75 per cent, of the Europeans
under my care suffered from malaria in varying
degree each year, and about 25 per cent, of all
eases attended have been due to this cause. Dr.
Crosse's dictum still holds good. I have not yet
met with a single case of blackwater fever in a
man who claims to have taken his 5 gr. of quinine
each day. Those who have taken their 5 gr. with
unfailing regularity are probably few in number.
Those who have meant to do so, and have forgotten
occasionally, are probably many, and are among
those who claim to observe the rule.
Taking these two classes together, one finds a
considerable number (I include myself, my wife,
and a number of personal friends of whose habits
in this respect I am sure) who never suffer from
f(>ver. Nearly the whole of the remainder enjoy
good health and suffer from fever not more than
once or twice in the year, the 'form then being very
light, of short duration and of uncertain diagnosis,
parasiles being but rm-ely demonstrable.
The dangers of which one reads hero and there
consequent upon this daily dosage of 5 gr. of
quinine do not exist. I have not seen dyspepsia,
loss of memory, or deafness follow in a single
instance; once only have I seen urticaria. In one
or two cases I have seen pre-existing deafness
become slowly more pronounced in the patient's
opinion, although the difference was not evident to
me. Qtiinine amblyopia I have never seen with
these doses. There are those who think quinine at
night induces insomnia; such can take their dose
at breakfast. Others complain of small disagree-
ments at first, such as shaking hands and nervous-
ness, but these soon get habituated to it if they
commence with half a dose night and morning.
The case of urticaria was one in which the skin
trouble followed the taking of even 1 gr. I advised
this patient to leave the country. He did not do
so until after an attack of blackwater in the
following year.
Among those who have not adopted the daily
dose, malaria and anaemia have given rise to many
ills, and the considerable dosage of quinine noces-
178
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 15, 1920.
sitated has been very irksome to those already
jiartially deaf.
\Mien I had been three years in the Congo I
began to receive inquiries from neighbouring dis-
tricts as to why the pioneers of the Tanganyika
Concessions, then under my charge, did not get
blackwater fever. Over three years of pioneering
in such a country without a death must be some-
thing of a record. I wrote on the subject at that
time to the British Medical .Journal, but still have
my letter — which I held back — believing that my
experience had been too small. What I wrote still
holds, however, and I believe there is not a medical
i7ian within 500 miles who does not agree that daily
prophylactic quinine makes all the difference here
between good health and bad. Certain of those
who follow the rule will still get occasional malaria.
It is of course necessary for them to adopt curative
doses for a time on such occasions before returning
to their daily dose.
Treatment.
In 1903 I commenced quinine administration
on the lines recommended by Sir Patrick Manson,
i.e., I gave 30 gr. daily by the mouth, in 5-gr.
doses, spaced through the day. I gave intra-
muscular injections in those cases only where
vomiting was a symptom which interfered with
quinine by the mouth. After a year or so I com-
menced to experiment with smaller doses. 1 found
I got equally good results with 25 gr. a day. I
reduced to 20 gr. a day and found it good. I
reduced to 15 gr. a day, and found that, whereas
many cases seemed to do well with this dosage,
there was an appreciable number in which the
response was more slowly arrived at. At the same
time I found that the convenience and certainty
associated with the intra-muscular method made it
of great value, and I made progressively greater
use of it as years passed. I found that a daily
injection of 15 gr. for three days was sufficient in
practically every case, a fourth daily injection being
required so seldom as to be almost countable in my
memory of cases to-day. Within five years I had
fallen into a routine treatment as follows: —
(1) By the mouth : Four doses of 5 gr. of bisul-
phate of quinine, spaced at four-hourly intervals
during the day; 20 gr. per day. This to be con-
tinued until three consecutive days have passed
without fever. The dose then to be dropped to
15 gr. a day in three doses of 5 gr. ea^h. Then
10 gr. a day in two 5-grain doses for a week.
(2) By injection : Three daily injections of 15 gr.
of quinine (bihydrochloride) deeply into the
muscles. One injection each day. Thereafter, in
the rare event of a continuance of pyrexia, a fourth
injection on the fourth day. Thereafter, quinine
by the moutli, 15 gr. daily for three days, and then
10 gr. daily for a week. In both cases the 5-gr.
daily dose is then enforced.
On certain points in connection with these
methods of treatment here I can be definite : —
(n)'The best quinine must be used. I have
always used Burroughs and Wellcome's. If this
be employed, it is as useful and certain to give
quinine tabloids by the mouth as in solution
Anyone can see this for himself who will drop one
of Burroughs and Wellcome's bisulphide of quinine
tabloids into water and watch it break up and dis-
appear within two minutes.
(b) The smallest efficient dose should be used.
When one sees four times the efficient dose given,
as I have at times seen it in this country, one
realizes how the popular prejudice against quinine
is brought into being. Unnecessary headaches,
deafness and gastric irritation must certainW often
result from the administration of quinine in un-
necessary quantity.
(c) Intra-muscular injections can be given \^ith
safety. I have never seen an ill-effect from my
own administration by this method. I have only
once seen ill-effects when injections have been
given by a local colleague ; in this case sloughing
resulted from a subcutaneous injection.
I give it in concentrated form and inject very
slowly. The 15 gr. is dissolved in 30 minims of
freshly boiled water. The solution is then reboiled.
Injection is made while this solution is still warm
with a syringe which, with its needle, has been
boiled on the spot in water. Tincture of iodine is
used for the skin. The needle is plunged in at
right angles to the skin to a depth of 3 centimetres.
I cannot believe from my own experience, which
covers an enormous number of such injections,
that any harm can result from quinine injections
made in this way if proper precautions are taken.
Injection may be made in several places. I have
used the insertion of the deltoid ; the inter-scapular
site and the upper and outer quadrant of the gluteal
region. The last is best, and I have used it almost
exclusively for the last ten years. Finally, for
patients who are bedridden for a time, as when a
typhoid patient shows malaria, I have injected into
the muscles of the flank, slanting-wise. This has
been quite a good situation. Nearly always the
injection is followed by some pain and slight
induration. This passes off in three days, and does
not compare with the pain and induration following
injections of grey oil. The pain from the quinine
injection commences at once, and is passing off at
the period when pain from grey oil injection is
commencing.
Exceptionally, but not very rarely, quinine
injections give no pain whatever.
(d) It will be seen that, so far as my experience
in Katanga goes, 20 gr. of quinine by the mouth
give the same results as 15 gr. by intra-muscular
injections. Treatment by either of the two methods
along the lines which I have indicated have never
failed here to bring to normal within four days a
temperature which has been raised on account of
malaria. A pyrexia here which is not brought to
normal in this way within this period is not due
to malaria. The chief advantage of injection is
that one knows the patient gets it. I have imagined
also that absorption from quinine injected into the
July 15. 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
179
lAuscle is slower and more regular than in the case
of quinine by the mouth. For this reason I have
preferred to use the injection method when the
general condition of the patient and his blood
threatens blackwater fever, or when quinine is
given during blackwater.
Under these circumstances I have believed that
I have found it useful to give sodium bicarbonate
in large doses by the mouth for twenty-four hours
before giving quinine, and have commenced when
I have given quinine during blackwater with in-
jections of 5 gr. only — twice daily. I have never
seen increased haemoglobinuria result from this.
(e) Blackwater fever may undoubtedly follow
upon quinine administration if this is upon the
wrong lines. I have seen this many times. Given
an individual who objects to quinine and takes it
only occasionally during days of fever and never
as a prophylactic. Such an individual gets much
preyed upon by malarial parasites which generally
demonstrate the fact to the patient by repeated
attacks of fever, but may, in idividuals with strong
natural resistance, bring about a considerable degree
of anaemia without inducing actual pyrexia. Time
passes, and the condition of such a person grows
progressively worse until he is in a stage of pre-
disposition, which only requires an exciting agent
to precipitate a haemolysis. Then, one day, with
an attack of fever, he takes 15 or 25 gr. of quinine
in a single dose ; six to eight hours afterwards
blackwater shows. I have seen this many times.
Let me repeat that I have never seen it in a
man who took his 5 gr. of quinine daily. Thus,
quinine is the best prophylactic against blackwater
fever, and yet may produce it, an apparently
paradoxical state of affairs which leads to much
confusion in the lay mind.
I have only twice seen it follow a less dose than
15 gr. On one occasion it was a dose of 10 gr. in
a man who usually took 10 gr. three times a week.
The other occasion was after a dose of 5 gr. with
a man who had frecjuently preached his objections
to any quinine, and had probably had none for six
months previously. Both occasions referred to men
who had just sustained extraordinary fatigue.
(/) The maximum dose at any time by the mouth
should be 5 gr.
(g) Quinine resistant parasites I have not met in
the Katanga in the sense that an actual febrile
attack persists in spite of the administration of
quinine. Parasites do, however, manifest resist-
ance in a few patients by showing early relapse in
apite of this treatment. Two cases, prominent in
my mind, illustrate this point, and the two methods
of treatment which are successful in dealing with
such in the Katanga.
The first case was that of a Belgian who had
been in the country four or five months only. He
had had several attacks of fever at intervals of from
two to three weeks when I saw him. Quinine
injections brought the temperature to normal within
three or four days each time. Daily quinine by
the mouth, probably in insufficient quantity, had
been given after the injections, which were irregular
as to the number given. Fever always returned
within three weeks. I adopted my routine, but
fever returned. I increased the daily quinine to
10 gr. a day instead of 5, after repeating the
routine. In spite of this fever returned, and para-
sites were found in the blood, whilst 10 gr. daily
were being taken. 1 may note that this is almost
the only case in which I have found parasites in
peripheral blood under such conditions. I then
commenced injections of soamin, 5 gr. being
injected weekly for six weeks, placing the patient
under my usual quinine routine at the same time.
During the next three years this man had no further
attack, taking his 5 gr. daily. This was a local
infection.
The second case was that of an Englishman who
returned from German East Africa with fever. His
fever persisted in returning every three or four
weeks for several months. He was given soamin,
galyl, intravenous tartar emetic and much quinine,
but the fever persisted in returning each month
until he was given 10 gr. of quinine daily for sixty
consecutive days After that he had no more fever.
(h) The small fevers which persist for a day or
so only, and cause little discomfort to a patient,
are more dangerous in their predisposition to black-
water fever than the more severe attacks. Probably
this is because such fevers are more often neglectecl,
and medical advice not considered necessary. The
very fact of their frequent repetition in this country
denotes inefficient treatment.
(i) Intravenous injection of quinine I have used
freely with natives. The method is one with which
I have been cautious in dealing with Europeans,
because I have had some fear of precipitating an
attack of blackwater fever. I have only used it,
therefore, for European patients when symptoms
have demanded urgency of treatment, as where
malai-ial coma is present. Such cases arc rare in
Katanga.
(;■) Usually one cannot expect to see results from
a quinine injection on the following day. The
quinine may be killing parasites, but does not affect
the toxins which bring about the fever. Therefore
the temperature will not be affected in a subtertian
injection until about forty-eight hours after the first
sporulation following the injection. The rise of
temperature expected at this stage will be modified
or absent. I see that attention has been drawn
to this point by Sir Ronald Ross. I have very
frequently seen lack of understanding on this point
lead to confusion and errors of diagnosis here, and
not only in the minds of laymen. Earlier results
from quinine in cerebal and intestinal cases may
be due to its inmiediate action on extra-corpuscular
forms constituting capillary emboli.
I conclude these notes with a query : If an
individual takes daily quinine in a malarial country
and gets no fever, is this due to: —
(1) Killing of the sporozoites at the time they
are introduced by the mosquito, so that infection
of corpuscles does not take place, or
180
THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE. [July 15, 1920.
(2) The holding in check by the quinine of such
parasites as are introduced, so that these parasites
are unable to multiply to a sufficient extent to
produce fever?
The latter is, I believe, the theory in favour.
The former seems to me to be possible, and to be
supported by my certain knowledge of at least two
individuals who leave off quinine at the moment
of leaving a malarial country, and in whom no
malaria has shown whilst they were on long leave,
even under the depressing influences of an English
winter. No doubt individual natural powers of
resistance differ widely and complicate the question.
To save space in these notes upon quinine in
malaria, I have not attempted to touch upon
supplementary treatment or the treatment of com-
plications. Such questions, for example, as the
objections to giving aspirin in addition when
tinnitus aurium is troublesome, or to the necessity
of using calomel as a routine. To enter upon this
subject would necessitate notes of much greater
volume.
EUsabethville,
Congo Beige,
March 4, 1920.
COLLOIDAL DEUGS IN THE TREATMENT
OF BILHARZIA DISEASE IN YOUNG
PEOPLE.
By F. G. Cawston, M.D.Cantab.
In view of the severe local reaction that is some-
times experienced, when tartar emetic in solution is
injected into the small veins of young people, I have
recently tried the effect of treating bilharzia patients
with some of the colloidal preparations of antimony.
In some cases the colloidal preparations have been
used alternately with intravenous injections of tartar
emetic, whilst others have been treated with ' oscol
stibium" alone. I have seen some promising results
from the use of coUosol antimonium, when given
intramuscularly ; whilst I have been able to test the
efficacy of oscol stibium when given orally, intra
muscularly and intravenously.
A case was reported in the Lancet on November 15,
where 3 c.c. of collosol antimonium, intramuscularly
combined witli 12j gr. of tartar emetic given intra-
venously cured a case of long standing. In October,
1919, I found blackened ova in a child's urine after
only 10 c.c. of collosol antimonium given intra
muscularly. .\s these blackened ova were numerous
and the urine clearer than when the injections com
menced, it is reasonable to suppose that the blacken
ing was due to the antimony, and this opinion is
supported by the effect of oscol stibium on several
other cases.
Further study of the value of collosol antimonium
on persons suffering from bilharzia disease was im-
possible, as it was only possible to obtain in South
Africa ampoules of the drug which showed the
characteristic fungus formation, which renders solu-
tions of antimony tartrate dangerous unless recently
made up. However, in January, 1920, I found
collosol manganese of value when combined with
intravenous injections of tartar emetic in a case of an
unhealthy urinary tract, associated with bilharzia
infection.
On February 24, R. came to me for treatment for
bilharzia disease, contracted four and a half years
ago along the north coast of Natal. The haematuria
was constant, and the urine contained numerous
spine-pointed ova. Three c.c. oscol stibium was
given on the first day, 2 c.c. on the 25th, 3 c.c. on the
26th, and 4 c.c. on February 27. Each dose was
injected through a small needle into the deltoid
muscles. Two black ova were found in the urine on
February 26. On February 27 the miracidia, were
seen moving in the shells in the undiluted urine. On
February 27 and 28 "1 xv of oscol stibium were given
orally without ill-effect. This same dose was given
three times during the day on February 29. The
following day the urine was cloudy but clearer, and
the centrifugalized deposit contained a few black ova
besides living ones. On March 1, 2 c.c. of the drug
were given intramuscularly, and I'l xlv orally without
iU effect. On March 2, the patient received 4 c.c.
intramuscularly and 90 c.c. by the mouth. Many
black ova were found in the urine, and some living
ones. This same dose orally and intramuscularly
was repeated next day, when the urine was clear but
tinged with blood. Microscopically there were much
fewer ova and some miracidia swimming free in the
undiluted urine. The temperature rose to 102 on the
evening of March 3, and there was some diarrhcEa for
two days, with a rise of temperature to 105 on the
evening of March 4, apparently due to the large doses
of the drug given orally and intramuscularly on March
2 and .3.
On March 7 the urine was clear and contained
much fewer ova, most of which were black. The
temperature was normal. The following day 2 c.c.
were injected without ill effect, and on the 10th 4 c.c.
without ill effect. This dose was repeated on March
12 and 14, making a total of 34 c.c. intramuscularly
and 15 c.c by mouth.
From March 8 the urine remained clear and con-
tained only a few ova, and a deformed miracidium
was seen swimming about in the undiluted urine on
March 10. The ova never entirely disappeared from
the urine, but treatment was discontinued on March 16,
when the patient returned home. In making the
examination for ova on each occasion, the last ounce
or ounce and a half of urine passed by the patient was
collected and centrifugalized.
On June 3, eighty-one days after the treatment was
discontinued, this patient stated that he was enjoying
the best of health. There was now no sign of blood
in the urine, but microscopically a fair number of ova
were seen in the centrifugalized specimen of urine.
In every instance the ova showed evidences of
degeneration, the miracidia were distorted, and no
sign of life could be detected within the shells, even
though the urine was well diluted.
The very promising effects of treatment in this case
suggests that oscol stibium intramuscularly and orally
July 15. 1920.]
TBE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
181
should effect a cure, not only of the symptoms but of
the infectivity of such cases, if the injections are per-
sisted in for a few weeks.
Intramuscular injections of oscol stibium were
given to an Indian coolie whose urine contained much
blood and typical spine-pointed ova on March 8. He
did not ask for treatment, and took little interest in
his condition. Treatment was discontinued on
March 16. A total of 19 c.c. were given intra-
muscularly without any general symptoms. None
was given by the mouth. The blood almost com-
pletely disappeared from the urine, which became
cloudy with phosphates towards the end of the week ;
this made it somewhat difficult to seek for the ova.
On March 12, when the urine was fairly clear, the
centrifugalized deposit showed a few pus cells, no ova,
but two apparently normal miracidia and two dis-
torted miracidia swimming about in the undiluted
urine.
Miss P. F., aged ten, came for treatment on
March 13, with a five years' history of haematuria
and constant eneuresis. The urine contained much
blood and many spine-pointed ova. '11 x oscol stibium
were injected intramuscularly on March 16, ill xx on
the 17th, 111 XXX on the 18th. On the 17th, she
reported that " the urine was much clearer already."
On the 18th the clear urine contained shreds of
mucous membrane, blood cells and ova ; "1 xx were
injected on March 19, and on the 20th the clear urine
contained only a few ova with very active miracidia
within the shells. Occasional injections of tartar
emetic into the veins were given, and occasional
intramuscular injections of oscol stibium. On April
18 she had received a total of 37 c.c. oscol stibium
intramuscularly, 3 c.c. intravenously, and Ij gr.
tartar emetic intravenously. A rigor followed an
intravenous injection of tartar emetic i gr, but no ill
effects could be traced from the injections of oscol
stibium which appeared to clear the urine right from
the start, but did not free the urine of living ova. At
the end of May, she reported that the urine had
remained fairly free from blood, though she noticed
blood occasionally, and stated that she never wetted
the bed now. On May 22 there were numerous ova
present in the urine, many were alive whilst others
were black. She was given two injections of tartar
emetic intravenously, and the case is being kept under
observation.
On March 1.5, A. R., aged ten, reported that he
had suffered from bilharzia disease on and off for
three years. The blood-stained urine contained
numerous spine-pointed ova. By April 13 he had
received a total of 35 c.c. oscol stibium intramuscu-
larly and 15 c.c. intravenously, with a total of | gr.
of tartar emetic intravenously. The urine still con-
tained spine-pointed ova, and on May 3, after a short
holiday, the ova were numerous. The blood became
less and the urine cleared during the treatment. On
several occasions during the treatment the ova became
very few, and on two occasions free-swimming
miracidia were seen in the undiluted specimen.
Though the general health of the boy improved as a
result of the injections, the preparation of antimony
that was used seemed incapable of eradicating the
living ova from the urine.
Small Veins.
On March 19, S. W. reported that he had con-
tracted bilharzia disease from the Palmiet river,
where Physopsis africana is common. He had
recently suffered from much indigestion and fre-
quently vomited. He was 14, and the veins were
too small for regular intravenous injections. The
urine contained numerous spine-pointed ova. On
April 22 the urine still contained ova, though some
were degenerated. He had received a total of
I4 gr. tartar emetic and 3B'5 c.c. oscol stibium,
30 c.c. intramuscularly and 8'5 intravenously.
His brother, aged 15, who had contracted bilharzia
disease from the same source, commenced treatment
on March 19. On April 22 the urine still contained
a few living ova and blood. He had received a total
of 4 gr. of tartar emetic, 33 c.c. oscol stibium intra-
muscularly, and 2'5 c.c. oscol stibium intravenously.
On May 8 he was given ill xv oscol stibium in water
three times daily ; on May 12 he commenced taking
111 XXX daily. On May 22 he was taking 5i four-
hourly, and on May 26 he began to take 5ii t.d.s.
However, as the urine remained cloudy and s^ill con-
tained numerous living ova, and was no clearer than
when the injections were discontinued, it was not
considered beneficial for him to continue taking this
preparation of antimony by the mouth, and treatment
was postponed entirely for a while.
On April 1, H. Mel. reported that he had noticed
blood in the urine occasionally since bathing in
Pondoland two and a half years ago. He was ansemic,
weighed 84 lb., and had an attack of right-sided renal
colic six months ago. The veins of the arms were
too small to risk intravenous injections of tartar
emetic, as the boy was only 14 ; so intramuscular
injections of oscol stibium were used, commencing
with 1 c.c. and working up to 4 c.c, when intravenous
injections were started. On April 26 he received
4 c.c. intravenously without ill effect. On April 28,
when he was sent away for ten days' holiday, lie had
received a total of 44 c.c. oscol stibium, 36'5 of which
had been given into a vein. Right from the start the
urine bfegan to clear, and the discomfort in passing
water disappeared, but there was still some blood
occasionally, and living ova were continually present
in tlie centrifugalized deposit from the urine.
On his return, on May 12, the urine contained
some black ova, some dead ova, and some living ova,
and 1 c.c. oscol stibium was given intramuscularly.
The following day a miserable-looking miracidium
was seen swimming in the undiluted urine, and 2 c.c.
oscol stibium were injected into the vein. As the vein
of the right arm was now well developed and the
intravenous injections seemed certain, a solution of
tartar emetic was substituted for the other prepara-
tion of antimony. Two grains were dissolved in 8 c.c.
of distilled water and the solution injected before it
had become quite cold. A total of IO2 gr. was given
in a fornight without any ill effect, except a rise of
temperature to 101 degrees after the third injection.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. . [July 15, 1920.
The ova rapidly disappeared from the urine, and dis-
appeared completely on May 24, except for one dead
one on May 25. Treatment was discontinued on
May 28, and his weight was now 100 lb. He weiglied
100 lb. on May 15, and the increase of 16 lb. and
general improvement can possibly be attributed to the
clearing of the urine during the time he was being
treated by oscol stibium. In this case it would seem
that oscol stibium helped to improve the condition of
the urine, but that a few injections of tartar emetic
were necessary to complete the cure.
Conclusions.
That oscol stibium can be given by the mouth up
to a teaspoonful three times daily without ill effects;
but that intramuscular injections are much more
effective, and that intravenous injections from 1 to
4 c.c. may be given with benefit in cases of bilharzia
That oscol stibium and coUosol antimonium
definitely help to clear the urine and blacken the
eggs, and can therefore be recommended in children
to pick up the general health and prepare them for
intravenous injections of tartar emetic.
That intravenous injections of tartar emetic are
usually needed to complete the cure and, if follow-
ing a course of treatment by oscol stibium or coUosol
antimonium, that smaller total doses are required.
QUININE PROPHYLAXIS.
By W. M. McDoHALD, M.B.C.S., L.B.C.P.Lond.
Medical Officer District No. 2, Antigua, West Indies.
The question of quinine prophylaxis in malaria is
of great importance, particularly in military adminis-
tration where numbers of troops may be suddenly
called upon to occupy an area in which mosquito
control has not been attempted. Under these circum-
stances numerous heavy infections will occur while
anti-mosquito measures are being organized.
Much has been written of late years in favour of
scrapping this method which had long been regarded
as a valuable defensive measure against malarial
invasion. Quinine prophylaxis is too valuable a
weapon to be scrapped, and it is with a view to
saving it from the scrap heap that I venture to write
these notes. The chief arguments advanced by the
detractors of the method are : —
That in the Macedonian campaign, quinine com-
pletely failed to prevent the occurrence of relapses.
The weak points in this argument are : —
(1) That no differentiation is made between quinine
prophylaxis to prevent infection of new arrivals and
to prevent occurrence of relapses.
(2) That no differentiation is made between the
different varieties of malaria to be affected by quinine
prophylaxis.
(3) That no weight is given to the records of the
results of quinine prophylaxis as used in Italy for
the last twenty years.
There is a great difference in the quinine-resisting
power of the different varieties of parasites.
P. vivax in its early stages is readily cured by
appropriate quinine treatment. P. falciparum on the
other hand is extremely resistant to quinine, and the
degree of quinine resistance is increased as the para-
site increases in age. The youngest forms, although
we cannot say with certainty that they will always
yield to quinine treatment, are yet much more
amenable to treatment than the older forms. By
the time the crescent form is reached we have a
stage at which the parasite is practically immune
to quinine.
I have not had enough experience of the third
variety, P. malarice, to write with certainity, hut the
indications are that it is more resistant to quinine
than is P. vivax.- It is obvious therefore that the
stage of the parasite is an important factor in assess-
ing the value of quinine prophylaxis
The gametes even of P. vivax will offer some
resistance to quinine, and the gamete stages of all
three varieties offer much greater resistance to quinine
than the earlier stages, also it is possible that the
merozoites which are developed by parthenogenesis
are more resistant to quinine than the sporozoites
which are injected by the infected mosquito.
Therefore quinine prophylaxis is likely to lose
much of its value when used in order to prevent
The variety of the parasite is also an important
factor. I have no doubt that if a regiment were
moved into a malarial region where we knew that the
only type of malaria was benign tertian, that we
could with certainity prevent the occurrence of a
single case of fever by the use of quinine prophylaxis
alone. It is of course impossible for us to know on
entering a malarious region w^hat type of infection
we are called upon to treat. The chances are that
two or perhaps all three varieties are present.
I am convinced however that quinine prophylaxis
efficiently and promptly applied to troops entering
for the first time a malarious region would very
greatly reduce the incidence of malaria and should
eliminate the possibility of any sick rate from benign
tertian infection. To be of value, however, quinine
should he administered on parade so as to avoid the
probability of the dose being lost or hidden if left to
the individual to take or not as he pleases.
Secondly, as it is of importance that the parasites
should be caught in the early stages, quinine should
be administered daily, 7i grs. per day in preference
to large doses at intervals of several days.
In the history of malaria the Italian records entirely
uphold the value of quinine prophylaxis. In 1902 the
Government began the gratuitous distribution of
quinine. For the 10 yeai's preceding 1902 the num-
ber of deaths from malaria was 14,048 per year. For
the 9 years following 1902 the average was 5,435.
As to incidence, cases treated from the Agro Romano
in 1900 numbered 11,653 before quinine prophylaxis.
Average for five years 1908-1913 during quinine
prophylaxis 2,974.
When it is remembered that these figures represent
the result of quinine prophylaxis, which was entirely
dependent on the wish and the memory of the indi-
!l
July 15, 1920.] THE JOUKNA.L OF TROPICAL MEDICINE AND HYGIENE.
183
vidual with regard to dosage, they afford a very strong
argument in favour of quinine prophylaxis.
In the penal agricultural colony of Castrades where
the quinine was given under orders the results were
more remarkable. Cases in 1904, 1905 and 1906,
where no quinine was given for the prophylaxis,
amounted to 76 per cent, of the force. In 1911, after
four years use, there were 5 per cent. only. Such
records as these cannot be lightly set aside.
This question is of the utmost importance in
tropical medicine, and while it is admitted that
quinine prophylaxis may be negligible in value as
compared with methods aimed at the extermination
of the mosquito, yet it is of great value in that it is a
method which can be employed quiclily and effectively
in places where no prophylactic methods have been
previously employed, while methods aimed at control
of the mosquito require months of work before any
effect is produced.
A NOTE ON THE USE OF THE TOURNIQUET
IN OPERATIONS FOR ELEPHANTIASIS
SCROTI.
By Robert Howabd, M.D., B.Ch.Oxon.
Medical Officer, Pemba, Zanzibar ; late M.O. Universities'
Mission to Central Africa.
In many of the published descriptions of the
operation for elephantiasis scroti, it is stated that
haemorrhage may be considerable in spite of the use
of a tourniquet. Some authors, e.g., Stitt, go so far
as to recommend operating without a tourniquet, on
the plea that the bleeding from the deeper vessels
cannot be controlled.
In a recent paper in this journal ' it was stated,
" In amputating these tumours the operator is apt
to lose his self-confidence in the early days owing
to the difficulty in controlHng tlie bleeding."
There is also great diversity of advice as to the
method in which the elastic cord tourniquet is to be
applied, some authors recommending a figure of eight
round the waist of the patient and the neck of the
tumour, others that it should be applied round the
neck of the tumour only.
The figure of eight method, though the one originally
recommended by Manson, has many disadvantages.
Its application and removal is difficult, and as a large
part of the tourniquet passes altogether outside the
prepared field of operation it is difficult to maintain
asepsis during the operation. Further, the pull of
the elastic- is oblique, and it does not directly com-
press the neck of the tumour. It is, I imagine, for
this reason that it may fail to completely control the
hasmorrhage.
On the other hand, if the cord is simply wound
tightly twice round the neck of the tumour, its
application is much easier, and it does not pass any-
where outside the field of operation ; while when the
time comes for its removal one only has to remove
the forceps or grip which is lying on the towel just
in front of the pubes.
To prevent slipping when the tumour is removed
towel clips should be inserted into the skin, one on
either side, just below T,he tourniquet ; failing towel
clips tissue forceps will answer as well. Such a
tourniquet cannot slip, and in my experience it never
fails to completely control arterial haemorrhage. I
attribute this to the fact that the pressure on the
elastic is applied directly all round the neck of the
tumour.
I recently removed a large tumour weighing 86 lb.,
which had a very thick pedicle, but all arterial bleed-
ing was completely controlled. Of course, in the
early stages of the operation there, is always some
venous bleeding from the tumour itself, but this is of
no consequence, and if the surgeon has complete
confidence in the efficacy of his tourniquet it may
be ignored.
In short, I maintain that it is possible to begin
an amputation of the scrotum with every bit as much
confidence that no arterial haemorrhage will occur
until the tourniquet is loosened as would be felt by
a surgeon in amputating a leg after applying a circular
tourniquet to the thigh.
' Journal op Tropical Medicine and Hyqibne, vol. xxii,
p. 221.
The Rancidity of Edible Coconut Oil (Granville
.\ Perkins, Philippine Journal of Science, Novem-
ber, 1919). — Thirty samples were investigated. The
action of light was found to be a powerful, but not
necessary, factor in the production of rancidity.
Enzymes from the fresh coconut meat has some
effect on the keeping qualities of the oil, but
sterilization was of doubtful benefit. An oil of low
initial acidity remained sweet during two years'
exposure to air and light.
Acidosis: its Mechanism, Recognition and
Clinical Manifestations (G. M. Piersol, New York
Medical Journal, vol. cxl, No. 19, May 8, 1920).—
Under the term acidosis is included " any modi-
fication of the normal equilibrium between the
acids and bases within the organism, whereby the
power to neutralize the acid is diminished." There
arc four chief factors responsible for maintaining
the acid-base equilibrium : (1) The elimination of
carbon dioxide by the lungs; (2) the so-called buffer
action of the blood to acids and alkalies; (3) the
ability of the kidney to eliminate an acid urine
from an alkaline blood ; and (4) the production of
alkalies in the form of ammonia. A disturbance of
one or other of these factors may occur in many
different conditions as in diabetes, starvation,
pregnancy, nephritis, anaesthesia, bums and many
infective conditions in childhood. It is thus evident
that acidosis is not a disease per se, but is a
secondary condition or symptom which appears
under a variety of circumstances, and depends
upon several different mechanisms for its pro-
duction.
184
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 15. 1920.
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THE JOURNAL OF
Cropfcal ^ttiitint anDl^pgiene
July 1.5, 1920.
THE DEATH OP GORGAS.
The death of Major-General William Crawford
Gorgas, K.C.M.G., D.S.M., LL.D., D.Sc, is an
event of world-wide significance. His name has
been associated with events in tropical medicine
which have taught the meaning and worth of
applied science to an outstanding degree, and
ensured him a lasting fame in the annals of
medicine.
His has been the directing mind in these events,
and the primary place has been assigned him in
the great drama which culminated in the practical
e.xtinction of one of the greatest scourges of man-
kind by conquering disease in the Canal zone, and
thus rendering possible the making and completion
of the Panama Canal.
We may regard Gorgas 's work from two points
of view — namely, the scientific or classical and the
practical, although the two, in his case, are bound
together, the latter being the outcome of the
former. Starting with a firm belief in the mosquito-
malaria theory of Manson, Gorgas came to the
conclusion that yellow fever so resembled malaria
in its manner of spread and mode of infection as
to lead him to believe in a serious attempt being
made to eraflicate the scourge at its headquarters
in and around the Gulf of Mexico. So positive was
he of the possibility of this being done that his
enthusiasm carried conviction to the Government
of the United States of America, and to their
great credit they not only justified, but actually
supported and furthered in every way Gorgas's
conception. As is well known, Gorgas and his col-
leagues, under the auspices of the U.S.A. Govern-
ment, undertook the Cuban campaign against
yellow fever which ended so successfully. The
results of the campaign were the practical ex-
tinction of the yellow fever scourge and the
ensurance of health and freedom from disease of
a large section of humanity. The steps taken are
known to all mankind. The enemy was attacked
at its base ; the breeding places of the yellow fever
carrying mosquito were destroyed, as were the
breeding places of the malaria mosquito in England
in the early parts of the last century. In both
cases the method was the same : in England by
free drainage of the fen (in other words, the
malaria stricken) country, and in Cuba by atten-
tion to the more " domestic " environments where
the yellow fever mosquito bred. In both cases
success was complete. Whereas in the eighteenth
and the early part of the nineteenth centuries, when
malaria was as prevalent in regions where swamps
prevailed in England as in several of the severely
malaria-stricken countries of to-day, the steps
taken freed England of malaria; so by the energetic
campaign in Cuba, not only from Cuba itself, but
also from the islands and shores in and around the
Gulf of Mexico, yellow fever was swept away in
some two years from the start of the campaign.
In the former case the drainage of the swamps was
undertaken from an agricultural standpoint, with
the surprising result of the extinction of malaria.
In Cuba the campaign was undertaken as the result
of well-considered and closely studied scientific
knowledge. The disappearance of malaria in
England was what may be termed an accidental
result not present to the minds of the swamp
July 15. 1920.] THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
ilrainei's of the country ; in Cuba, on the other
hand, it was the result of applied science. It was
no accidental sequel in the ease of Cuba. Gorgas
anticipated the result, and convinced his country-
men that the work was bound to succeed. The
conversion of the U.S.A. Government and the
inhabitants of the States to his belief was perhaps
the most dit!ieult task Gorgas had to do. Lot tried
to impose his beliefs on his countrymen and failed;
Gorgas attempted the same role and succeeded,
with the magnificent sequel we know. By Gorgas"s
success the eradication of disease by the application
of scientific knowledge has brought it about that
science and its application in matters of disease
must be listened to and treated as a sanitai-y
and political step of paramount importance; and
that no Government can afford to thwart its
advance or doubt its teaching and possibilities.
The doctor has been held in chains too long; he is
beginning to raise his heafl and to make his voice
heard. In the public services he was merely
tolerated ; as a regimental surgeon be held an
honorary but not an honourable position. In the
Naval service the same held good. To-day the
position is better — ^nay, good, and it is daily im-
proving. Gorgas has done a great thing for his
profession. When an attempt was made, in accord-
ance with precedent, to restrict his power as the
real head of the Panama Commission of inquiry and
action, he made it plain that as an authority on
the subject in hand he was to be unfettered in his
methods and plans of work, he fought a great fight
for medicine and the medical profession. The days
have gone when the voice of the half-crown doctor
was neglected ; when the lady of title asked her
friend if she shook hands with her doctor [the
" doctor " on this occasion was a baronet who held
the highest position in medical circles], said: "I
never do, no more than I would with my baker."
The honour i)aid to Major-Gencral Gorgas on
Friday, July 9, 1920, at St. Paul's Cath(>dral was
in keeping with the work accomplished by the
great man. Tlie British Empire paid tribute to
this American citizen in a manner that did the
Empire credit. No higher compliment could have
been paid ; yet it was no mere compliment, but a
debt the Empire paid — a just debt, and one which
honoured the nation that was privileged to settle it.
Official Britain was there, the scientific bodies
sent their n-presentatives, private individuals of
world-wide reputation begged to be allowed to be
present to ))ay their tiibute. The public thronged
the streets so that they might raise their hats to
this great doctor from America. Not all the
I^eagues of Nations and Peoples have done so
much to bind the United States of America and
the Motherland closer together than did the service
under the dome of St. Paul's on that Friday in
July. At the heart of the Empire the hearts of
the peo]ile went out to this ma.n. Crowned lieads
and statesmen receive at times this tribute, but for
a " doctor " to be thus honoured shows that at
last he is coming into his own. Gladstone said
some time ago " the future was in the hands of
the doctor," and it would seem that the words of
that great parliamentary wizard are coming true.
And what about Royalty? When Gorgas lay
sick in the Military ^Hospital at Millbank, His
Majesty King George V visited Gorgas and
decorated him with a knighthood of the Most
Distinguished Order of St. Michael and St. George.
By this act the King represented the feelings of
the nation as is his wont, and we his subjects
thank His Majesty for thus expressing the feelings
of the peoples of the British Empire.
J. Cantlie.
Annotations.
The Reaction of the Saliva (Arthur L. Bloomficid
and John G. Huck, Bulletin of the Johns Hopkins
Hospital, vol. xxxi, No. 350, April, 1920).— Study
of freshly expectorated saliva from normal people
shows that the reaction tested by the colorimetric
comparison method may vary within considerable
limits— 6-0 to 7-3— although 80 per cent, of the
specimens fell within the range of 6-6 to 7-1. The
reaction varied in different individuals, and in the
same individual at various times apparently with-
out any definite or constant relation to the time
of day or to the ingestion of food or fluid. It was
temporarily altered by mouth-washes such as
Dobell's solution, but only for a short time (thirty
minutes). Internal arlministration of acid and
alkali did not seem to influence the reaction of the
saliva in any definite manner. Observations on a
group of patients suffering from a variety of diseases
showed no constant relation between the reaction
of the saliva and any particular disease, although
the variations covered a slightly wider range than
was found in the case of normal group.
The Dnigless Therapy of Diabetes (H. S. Stark,
New York Medical Journal, vol. cxl. No. 19, May 8.
1920). — Individualizing is one of the mainstays in
the treatment of diabetes. Prophylaxis should be
as conspicuous as therapeutics. Heredity, over-
feeding, goutiness, obesity, mental strain and
sedentary existence ai'e factors which make for
diabetes and should be suitably combated. Drugs,
including opium and hormone therapy, are dis-
appointing, and diet is the mainstay of treatment.
In considering the drugless treatment of diabetic
coma the diet should be relaxed when ketonuria
increases. An exclusive diet of proteins and fats
must be proscribed, while carbohydrates in the
form of potatoes, wheat bread and milk and
alcoholic beverages in limited quantities should be
allowed. If coma is pending the patient should
be put to bed, kept on a milk diet, and oxygen
inhalations freely given.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 15, 1920.
^stncts.
GUINEA- WORM IN THE INGUINAL CANAL."
By Capt. S. K. Ray, I.M.S. (T.C.)
On the evening of November 11, 1919, I was
called to see an urgent case in the hospital, a
patient admitted for the treatment of strangulated
hernia. His name was Mandi Pechiar, of 147
Labour Corps, aged 20 years. From his ap-
pearance it struck me that he had no abdominal
trouble. The patient noticed a swelling in the left
inguinal region on the evening of November 10,
1919, while he was in his bed. Since then he
passed motions and urine and had no sickness. On
examination, I found a diffuse oval-shaped swelling
in the left inguinal region. The skin of the penis
and scrotum was thickened and pitted on pressure.
There was no tenderness, tlie patient had 99 de-
grees temperature and pulse 108 per minute. No
impulse could be elicited on coughing. The local
appearance of the swelling simulates an irreducible
inguinal hernia. There were no signs or symptoms
present requiring immediate operative interference.
Cold compress was given in the night with no im-
provement on the next day. Warm compress was
then tried, and on the 13th the swelling had sub-
sided a good deal. A distinct hard lump couW be
felt and tlie lump could be moved fi-om side to side
with the cord in the canal. I operated on the case
on November 20, 1919, with no idea as to what I
would meet. The incision was as for an operation
of hernia. I noticed a hard lump about the size of
a big walnut adherent anteriorly to the cord.
There were marked signs of inflammation in the
surrounding tissue. The lump was shelled out
from the cord and, on incising it, I found it to be a
sac containing whitish pus and a guinea-worm 14i
inches long. The wound was sutured with a drain.
The patient recovered without any trouble or
temperature.
Curutnt IfUcntou.
Bull. Soc. Pathologie Exotique.
April 14, 1920.
Two Cases of Oriental Sore, contracted in Spain
and France respectively. (First case of contagion
in France) (P. Ravaut).— The first case was badly
bitten by mosquitoes and flies while travelling in
Tarragona in the neighbourhood of nomads from
Northern Africa. The bites healed, but six months
later two sores broke out, from which Leishman
' Abstracted from the Iiidian Medical Gazette, vol. Iv, No. 3
March, 1920.
bodies were ultimately recovered. In the second
case the sores were contracted as a sequel to mos-
quito bites received in the Pyrenees Orientales,
where Kabyles and Annamites were stationed. In
both instances the lesions consisted of small in-
flamed nodules, showing no ulceration or suppura-
tion, but with a tiny orifice in the centre containing
a drop of serous fluid. The author considers that
as the sores may neither develop to any great
extent nor present a very characteristic aspect in
European climates, more cases will probably be
identified in France if doubtful lesions be carefully
studied microscopically.
American Leishmaniasis in Venezuela (E. Tejera).
— Sixty-two cases were seen in the State of Zulia
during 1917. All were of the cutaneous form
except one, which is somewhat surprising in view
of the fact that in the neighbouring coimtry,
Brazil, the mucosal is the most common type. Of
the two remedies used, novarsenobenzol and tartar
emetic, the latter produced much the better results,
and never gave rise to ill-effects of any kind, how-
ever large the number of doses administered. In
the only instance in which it failed, the patient was
subsequently cured by an Indian who treated the
ulcer with herbs.
On Trypanosoma Dimorphon Infection in Horses
and Mules (G. Curasson). — Of ten animals treated
with galyl four died and six recovered. Two of
the former arrived at the veterinary hospital in a
moribund condition, and all were in a very bad
state when treatment was begun. Though no
definite conclusion can be drawn from these
results they were much more satisfactory than
those obtained from tartar emetic. The galyl was
given in two injections at intervals of a week,
3 grm. on the first occasion and 1 grm. on the
second ; it was put up in ampoules containing
0-37 gr. sodium phosphate, 025 gr. of caffeine and
0-25 gr. of sodium benzoate per gramme of galyl,
the whole dissolved in sufficient water to fill the
ampoule. The (edema of the hind quarters and
burssB, which Button and Todd say they never
saw, was present in about half the horses (never
in the mules) in the hospital, and appeared just
before the animal became too weak to stand.
lodosalyl in Trypanosomiasis and Yaws (Clapier).
The writer has tested the value of iodine in sleep-
ing sickness and yaws in the treatment of some of
his own native patients, and confirms the generally
accepted view that, while iodosalyl is useful in the
former condition when associated with specifics, it
has no rapid sterilizing power in either.
Remarks on the Hematological and Clinical
Aspects of Bancroft's Filariasis in French Guinea
(Marcel Leger). — Children up to the ;ige of 15.
examined at night, showed parasites in the blood
in 1625 per cent., the number of individuals tested
being fifty-five. The youngest positive ease was
July 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
4 years old. During a period of three yeai's Micro-
filaria nocturna was obtained twenty-five times
from specimens of urine (adults) showing blood,
blood and chyle, or chyle alone. Two fatal cases
are described as evidence of the existence of a
malignant form of filariasis in French Guinea
corresponding to the lymphatites perniciosas of
the Brazilians, and described by Carlos Claudio da
Silva in 1880.
A Further Contribution to the History of the
Guinea Worm (E. Roubaud). — Experiments with
Cyclops viridis in Paris afforded exactly the same
results as obtained recently by Chatton in Tunisia,
viz., that though it is possible for the embryo of
the guinea worm to live in the general cavity of
this host for a period far exceeding that of its
normal existence in the larval form (as long as
three months instead of some days only), it does
not develop or undergo any transformation, the
only change before the final dissolution being a
slight increase in diameter. It would therefore
appestr that all species of Cyclops do not lend
themselves in an equal degree as intermediary for
the development of the worm and thus to the
transmission of dracontiasis. From the biological
point of view, the fact that such abortive infesta-
tion of certain species of Cyclops is possible pro-
vides ground for closer comparison of the evolution
of the filaria in <|uestion with that of some of the
blood-inhabiting filarial parasites.
Note on the Parasitic Ixodes infesting Domestic
Animals collected at Mitylene between February
ayid June, 1916 (G. Senevet). — While stationed at
Mitylene with the French Army of occupation in
the beginning of 1916 the author classified the Ixodes
he recovered from various animals as follows : —
Host Ixodes
' Bhipicephalus sanguineus,
I Ltttreille
Bos taurus L. I R. bursa, Conestimi and
Numberexamiued 5-| Fanrago
R. simus, L. Koch
Hyalomma cegyptium,
' Linne.
Rhipicephalus sanguineus,)
Latr. V
R. simus, K. )
Rhipicephalus sanguiiieus,
Latr.
Hyalomma syriacum, L.
Koch
Rhipicephalus bursa, L. (
Kumber examined 1 f and F. '(
Teitudo Sp. (?) Hyalommasyriacum, Koch
13
EquuB asinus L. J
Number examined 5 I
Capra bircusL.
" Charlatans and Psrudo-jiarasites " and " Eye
Worms " (G. S. Swaminath). — In connection with
two notes under the above titles published some
time ago by Professor H. Blanchard, the writer
relates that while in Calcutta in 1917 he saw a
Chinese woman "curing" toothache by persuad-
ing the patient that the trouble was caused by
maggots, and then, after pronouncing incantations
and receiving a fee, producing the offending larvsE
by sleight of hand.
Contribution to the Study of Osteoporosis or
" Big Head " in Horses as it occurs in New
Caledonia (Ch. Nicolas). — After seeing two horses
cured, at least temporarily, by applications of Mere
ointment, the author is inclined to the opinion that
the condition is not due to absence of lime in the
food and drinking water, as believed by some
authorities, but rather to some infectious organism.
Malarial Infection and Novarsenobenzol (Q.
Senevet). — Referring to an article in the March
number of the Bulletin de la Societe de Pathologie
Erotique by P. Brau and J. M. Marque, the
authors suggest that the favourable results obtained
might have been influenced by variations in the
season or climate. They also point out that the
said results do not concord with those published
by other writers, who are practically unauimous
in declaring that as far as Plasmodium falciparuvi
infection is concerned no form of arsenical treat-
ment is effective in itself, though it may be of
value when employed in conjunction with quinine.
.-1 New Treatment for Oriental Sore (Cretan) by
Local Injections of Emetine Hydrochloride (Georges
Th. Photinos). — The emetine "is injected under the
sore, holding the needle almost parallel to the
surface. The Leishmania tropica frequently dis-
appear after one dose varying from O'Ol grm. to
005 according to the size of the lesion. Cure is
radical and complete, and is usually effected in
from twenty to thirty days. Details of thirteen
successful cases are given.
The Trypanosomiases of Animals in Venezuela
(E. Tejera). — Equida- : The two conditions known
locally as peste boba, hermosura or tristeza, and
desrengandera are described from their clinical
aspects. The former proves fatal in 80 per cent,
of cases, the latter in nearly 100 per cent. Both
are due to Trypanosoma venezuelense, the vector
of which is unknown. Experiments with this
organism on guinea-pigs, rats, mice, one horse,
two monkeys, a cat and a calf, showed it to be
fatal for all but the last-named, from whose blood
the trypanosomata disappeared eleven days after
inoculation, though guinea-pigs were infected from
it five months later.
Bovidse : A trypanoaoma recovered from the
blood of a cow suspected to be suffering from piro-
plasmosis appeared to be identical with that
described by Leger anl Vienne under the name of
Trypanosoma guyanense.
Craw-craw or Filarial Itch, and its Origin in
Subcutaneous Onchocerca volvulus Cysts (J. Mont-
pellier and A. Lacroix). — Many of the native
troops from French West Africa showed u papulo-
vesiculo-pustulous eruption, accompanied by mode-
rate irritation, which corresponded very closely
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 15. 1920.
with the craw-craw originally described by O'Neil
in 1875. The skin in the affected areas was finely
wrinkled and the natural creases were accentuated,
but there was no pachyderma. The first stage of
the eruption consisted in flat pustules; on these
vesicles fonned, which pustulized, dried and left
behind depressed scars varying greatly in size. No
fever or general symptoms were observed beyond
an inguinal adenopathy and an increase in eosino-
philes of from 5 to 40 per cent. Embryo filaria
were present in the papillary and subpapillarv-
layers of the derma in every case examined, but
never in the epidermis, the vascular system or the
blood, either by day or night. They were found in
greatest abundance in the healthy skin, and only
rarely in the suppurating pustules. Cysts dis-
covered in a few individuals yielded one male and
several sections of a female filaria presenting the
appearance of Onchocerca volvulus.
Hypertrophic Osteitis and Yaws (Dr. Clapier). —
The possibility of a relationship between goundou
and yaws suggested by Castellani and Chalmers
has been investigated by the writer in French
Equatorial Africa. Six hundred patients suffering
from yaws showed an accompanying osteitis in so
many cases that until experimental evidence be
forthconiing, he considers connection between the
two conditions clinically proved. Both long and
and shoM bones were affected as well as the nose,
goundou being indeed the form least frequently
seen. The osteitis was seen in children as well as
adults, not at the onset of the yaws, but some
months after the lattw had become generalized, or
even after cure had apparently taken place. Four-
teen cases are described as exanaples.
The Roumanian Epidemic of Exanthematic
Tijphus during the late War (J. Cantacuzene). —
After the Roumanian defeat at the end of 1916,
when the exhausted army was crowded together
with the civilian population, without food, clothes
or sanitary organization, typhus, until then un-
known in the country, set in with such violence,
that in February, 1917, the railway platforms and
hospital approaches were piled with corpses. The
culminating point was reached in March, after
which the eases became fewer until July, when
they practically ceased. In the autumn of 1918
a slight recrudescence occurred, but was imme-
diately extinguished in all districts except those
occupied by German troops, who, while effectively
safeguarding themselves, deprived the inhabitants
of all means of combating the infection. The
average mortality during the epidemic was between
15 and 17 per cent., and increased with the age of
the victims; among the doctors it was 41 per cent.
An outbreak of an exceptionally virulent form of
relapsing fever occurred simultaneously and often
in association with the typhus attained its maxi-
mum at the same time, but declined earlier. On
the other hand, scarlet fever, usually very frequent
and violent in Roumania, disappeared during the
typhus epidemic, and is only now beginning to
show itself again. The extensive gangrene seen in
Serbia in 1915 was entirely absent. In many cases
the nervous centres were attacked, and symptoms
resembling hydrophobia and tetanus respectively
were observed. Diarrhoea was not rare, and intes-
tinal haemorrhages were seen from time to time.
Characteristic lesions noted post-mortem were
encephalo-menigitis (invariably) and a petechial
eruption of the gastric mucosa (generally). In
some rapidly fatal cases cholera was associated
with the typhus; it never, however, attacked those
who had been vaccinated against it. All the
evidence collected during the epidemic pointed to
the louse as carrier of the infection, and as soon
as this parasite was eradicated the typhus dis-
appeared.
^e&iftos.
Malaria at Home and Abroad. By S. P. James,
M.D., D.P.H. London: John Bale, Sons
and Danielsson, Ltd. 1920. Pp. xi -t- 234.
Price 25s. net.
During and since the war interest in tropical
diseases has become more widely diffused. Many
practitioners who in ordinary circumstances would
have never left these shores were sent abroad on
active service, many of them to tropical areas,
where they were thrown into intimate contact with
cases of malaria. This fact, together with the
return to this country of large numbers of soldiers
infected with malaria, has awakened a much wider
interest in this subject of malaria.
Cases of malaria, too, of indigenous origin have
been found to occur in a number of widely
separated places in this country, a considerable
local spread of the disease having occurred in the
county of Kent. It has also been found that there
still remain a few areas in England where endemic
(true indigenous) malaria still persists.
The appearance of Colonel James's excellent
monograph dealing with " IMalaria at Home and
Abroad '" is most opportune. It gives a lucid and
detailed description of the symptomatology, patho-
logy, diagnosis and treatment of malaria, together
with the practical work necessarv^ to inquire into
malaria, malarial surveys, the prevention and
eradication of malaria and the control of mos-
(juitoes.
The volume is dedicated to Sir Patrick Manson.
who, on being asked to write a " Foreword,"
replied: " I have kept your book long, but it is a
big affair which does not admit of skipping. I
have read it from alpha to omega, and can con-
scientiously say that it is a fine perfonnance. which
is bound to do an immense amount of good. The
book requires no foreword from me or anyone else:
it speaks for itself." A word to the wise is
sufficient !
J
Aug. 2, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 15, Vol. XXIII.
^rlfllnal Commnimation.
EXPERIENCES OF MEDICAL AND PRISON
WORK IN A NEW COUNTRY (KEDAH,
MALAY PENINSULA).
By A. L. Hoops, M.D., D.P.H., B.A., T.C.D., Cert. Trop.
Med., London.
Stale Surgeon and Superintendent of Prisons, Kedah.
Kedah is one of the non-federated Malay States on
the west coast of the Malay peninsula ; it came under
British protection in the year 1909, along with the
small adjacent state of Perlis, and the considerable
states of Kelantan and Tringana on the east coast.
Until 1909 these four countries were under the
suzerainty of Siam, wliich latterly had encouraged
them to improve their administration by the intro-
duction of European advisers.
It was thus tliat in March, 1906, I was seconded
from the medical service of the Straits Settlements to
organize medical and prison departments in Kedah.
The field was new.
Even in Alor Star, the capital of Kedah, a town of
10,000 people, situated some eight degrees north of
the equator, there was no qualified medical man, and
no hospital ; the gaol was an overcrowded den, where
from one quarter to one half of those confined died
each year, chiefly from bowel diseases. There was no
vaccination ; smallpox was endemic, and most adults
bore traces of it. There was no proper registration
of births and deaths. It was necessary to collect
and train native staffs, to build institutions, to draft
rules and enactments suitable for a primitive country,
and to have them enforced. In all these matters
constant encouragement and assistance were received,
not only from the European advisers to government,
but also from the Malays on the State Council (who
at present number four, the British adviser being the
only European member).
During my first year, 1906, H.H. Abdul Aziz bin
Tajudin, a most enlightened prince, was President of
the Stats Council. On his death he was succeeded
by his brother, H.H. Tunku Mahmud, and later by
H.H. Tunku Ibrahim bin Abdul Hamid (eldest son of
the Sultan of Kedah), who has been Regent since
1913.
These three nobles gave me generous sympathy and
useful advice. Without their aid, and that of other
leading Malays, such success as has been achieved in
medical and prison development would have been
impossible.
I am also deeply indebted to Mr. W. George
Maxwell, C.M.G., British Adviser, Kedah, from 1909
to 1914. Son of Sir William Maxwell, a distinguished
administrator and Malay scholar, Mr. George Maxwell
is himself unsurpassed in knowledge of the Malay
people, their habits, customs and modes of thought.
He is in sympathy with medical work. To his initia-
tive is due the early completion of the North Kedah
waterworks scheme.
In this article I sliall confine myself to my experi-
ences of cholera in Kedah.
Some Account of four Cholera Epidemics
IN THE Malay State of Kedah.
Kedah is 130 miles long, and not 50 miles across
at its broadest part; area about 3,800 square miles,
population in 191 1 quarter of a million.
Kedah, with Perlis, is the most northern state on
the west coast of the Malay peninsula. To the north
and east it is bounded by the Siamese provinces of
Sinzora and Patani ; its west is mainly seacoast,
extending nearly to Penang island, while to its south-
west and south lie Province Wellesley and the
Federated Malay State of Perak.
Kedah is separated into two distinct parts. North
and South Kedah, by Kedah Peak, a mountain 4,000
feet high, running down to the sea, and inland to this
by swamps. From time immemorial North Kedah
has been scourged by cholera every two or three
years ; the physical barrier between North and South
Kedah has prevented most of the epidemics from
spreading to South Kedah.
In undeveloped Malaya travelling was almost
entirely by rivers or by sea. No river gives access
from North to South Kedah ; the few tracks leading
round Kedah Peak, or through the swamps inland,
were so difficult that travellers usually made the
journey from North to South Kedah by sea, via Penang.
During cholera epidemics, quarantine, imposed by
the Penang health authorities, almost closed the sea
route, and thus protected South Kedah, as well as
Penang, Province Wellesley and Perak. Dry weather
is the rule from January to March, while there are
rains in the other months, with a distinct wet season
from August to October. Kedah was visited by
epidemic cholera four times during the eight years
1907 to 1914. Each outbreak commenced in the
capital town of Alor Star which is situated on the
(North) Kedah river about 50 miles by sea from
Penang.
With the development of communications each
epidemic spread more widely and claimed more victims
than its predecessor. During the period the water
supply of the whole country was from rivers or shalWw
earth wells. It was especially bad in Alor Star, where
the river becomes l)rackish in dry weather, and the
earth wells contain an evil-smelling soupy liquid.
Native jambans (latrines) are commonly placed over
rivers or streams. Where the water supply is from
a well, the jamban is near the well, and often on
higher ground. After defaecation, ablution is per-
formed at the river or well. Conditions favouring
epidemic cholera are therefore not wanting. It was
evident that a good and non-poUutable water supply
was the only radical remedy. Such a sujjply was
provided late in 1914, an impounding reservoir being
formed in the hills, eighteen miles north of Alor Star.
Thence water was distributed by pipes to the cajntal,
and many other centres of population in North Kedah.
During the five and a half years since that date there
has been no epidemic cholera in any part of Kedah.
Tlic building of a hospital in Alor Star was started
in 1906, and soon afterwards a (luarantino camp, for
tile isolation of cholera and smallpox patients, was
established. Sj)ecia) difficulties in dealing with the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 2, 1920.
first two epidemics arose from shortage of staff.
The dressers and attendants, though they worked
devotedly, were mostly Indians. As years went
on many Malays were trained in elementary sanita-
tion, and some became efficient dressers. The gaol
afforded a splendid training ground ; several ex-
prisoners are at present honoured members of the
medical department. The early hostility of the Malays
was converted to friendship and trust in 1911 and
1914, when many of their Mahommedan fellow
countrymen worked amongst them. Though death
registration was made compulsory, concealment of the
cause of death, with consequent lack of precautions,
greatly increased the cases and mortality, especially
in remote districts.
I.
The first epidemic was in August — September,
1907, after a long spell of dry weather in what is
usually a wet season. 330 cases were recorded, with
247 deaths. It is probable that at least double this
number of cases and deaths occurred. The disease
did not spread much outside Alor Star and the
villages between it and the sea. There was no
extension to South Kedah.
II.
The second epidemic was in March and April,
1908. It was more widespread. 686 cases were
recorded, with 541 deaths. The number of deaths
that year exceeded the normal by over 1,000 ; it may
be taken that there were at least 1,000 deaths from
cholera. The disease spread to Kota Kuala Muda in
South Kedah and for some distance up the Muda River.
125 of the reported cases were in Kuala Muda dis-
trict. Three other districts in South Kedah, however,
were not affected.
III.
The third epidemic was in 1911, a very dry year.
It lasted nearly six months, from February to July.
1,211 cases were recorded, with 966 deaths. The
cases were more fully reported than in previous
epidemics ; but it is probable that not less than 1,500
deaths were due to cholera (as the excess of deaths over
a normal year were more than this). Alor Star and the
environs suffered heavily ; most parts of North Kedah
were affected. There were 170 deaths in Sungei
Limau, on the seacoast, and Lankawi island suffered
for the first time. Strange to say there was no ex-
tension to South Kedah, although the epidemic was
so prolonged.
IV.
The fourth epidemic was in the year 1914. It
really started in the last week of November, 1913,
when there were eleven cases in .•Mor Star and Kuala
Kedah. Unlike previous outbreaks it began after an
excellent wet season and befo.e the rains had ceased,
but only became serious when drought set in. It
lasted a full five months, urtil after the middle of
April, 1914. During this tune, 2,196 cases and ] ,502
deaths were registered. Very few places in North
Kedah escaped. The disease spread to Kuala Muda
in South Kedah, and thence upstream to Baling, but
Kulim and Bondar Bahm districts in South Kedah
remained free. There was no case in May, but there
was a recrudescence in June, when there were 70
cases and 43 deaths reported in and about .\lor Star,
and a few were returned from Bahng.
The number of deatlis registered in Kedah during
the year was 7,551, against 4,873 in the previous
year (a normal one), an excess of 2,678. There was
no other disease epidemic in the country ; nearly the
whole increase must therefore be attributed to cholera,
which caused, I estimate, not less than 2,500 deaths
amongst about 3,600 cases (the death-rate averaged
nearly 70 per cent.). The bulk of the concealment
was in Kuala Muda and Baling districts, where
though the deaths exceeded those of the previous year
by 1,051, only 325 were returned as due to cholera.
V.
Total
um Choluru
500
1,000
1,500
2,500
5,500
It is a conservative estimate that there were 5,500
deaths from cholera in Kedah in these eight years
out of a total of 37,000 odd deaths from all causes :
that is to say cholera caused nearly 15 per cent, of
the total death-rate over the whole period. In the
year 1914, one-third of all the deaths in the country
were due to cholera.
In addition to the four epidemics, there were
sporadic cases in Alor Star in January, 1910 (two)
and in January, 1913 (two). In the latter month the
supply of tank water from a galvanized roof catch-
ment area over the market to the people of .\lor Star,
probably averted another epidemic.
VI.
Some text-books accept as a truism the state-
ment that cholera is always imported ; wliile this
may be so in countries with good water supplies and
sanitation, I am convinced it lias not been so in
Kedah. Not one of these outbreaks has been traced
to an imported case. On the other hand, they have
commonly been associated with drouglit and badness
of the river water, and have usually commenced in
the same part of Alor Star Town near Titi Batu.
There are undoubtedly conditions in Alor Star favour-
ing the life of tlie cholera bacillus ; not only does the
clay subsoil form an ideal culture medium for the
l)acillus, when the disease is active (in a more oi)en
soil there would be purification by natural filtration),
but after the disease dies down the organism may
perhaps continue to exist, although haniless, in the
soil or water, until a combination of conditions partly
unknown to us, but of which drought and bad water
are two, causes it to regain its virulence, and start a
new epidemic. The growth and spread of the cholera
vibrios are favoured by the nature of the river and
shallow well water around Alor Star : the district
suffers accordingly. On the other hand, from Gurum,
Aug. 2,
3.]
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
191
near Kedah Peak, to Sungei Patani, where the sub-
soil is more open (much of it is latorite) and the
water better, cholera has never taken a hold, although
infected persons have frequently visited these places ;
but as soon as it passes them and reaches Kota Kuala
Muda wjiere the soil and water resemble those of
Alor Star, widespread infection again occurs.
VII.
Dr. Stanton, of the Institute of Medical Eesearch,
Kuala Lumpur, visited Alor Star towards the close
of the late epidemic, early in April, 1914. On his
return to Kuala Lumpur, he did some interesting
experiments with water drawn from the Wan Mat
canal, which is practically Alor Star river water.
Emulsions of cholera bacilli from a case were added
to samples of this water ; it was found that even
when the water was previously sterilized, the vibrios
grew and multiplied rapidly in it. On the contrary,
emulsions of cholera bacilli added to Kuala Lumpur
tap water (unsterilized) rapidly died out. Dr. Stanton
therefore, concludes that the Alor Star river water
itself contains ingredients which are favourable to
the spread of cholera.
Against the possibility of the Kedah epidemics
aiising from fresh imported cases, Dr. Stanton favours
the hypothesis that there is within certain areas in
Kedah a natural reservoir of virus, the renewed
activity of which is derived from some special com-
bination of circumstances. Such a reservoir may be
in man himself, or in water or in some other medium.
Recent work done by Greig in India has proved
that the cholera bacillus can exist for considerable
periods in the gall bladders of apparently healthy
persons who have recovered from the disease ; and
when passed in the stools of such carriers can infect
other healthy persons. It is known that typhoid
fever is mainly spread by healthy carriers of typhoid
bacilli, and tliat some typhoid carriers remain infective
throughout the whole of their lives. Should the
cholera vibrio be capable of a similarly prolonged
existence, one need go no further to find the exciting
cause of our constant outbreaks.
" The factory of the virus is man himself." With
a good water supply however, and efficient scavenging,
the other conditions essential for an outbreak such as
tiie last one, no longer exist in Alor Star.
VIII. Spread of Cholera.
In sections VI and VII it has been suggested that
the cholera outbreaks in Kedah are not due to im-
ported cases, but to the persistence of the cholera
I vibrio in the country between the epidemics, either
(l) in an altered and unrecognizable form (temporarily
non-pathogenic) in the earth or water, or (2) in the
gall bladder of human carriers. It is certain that to
infect man the cholera vibrio must be swallow(!d ; by
what channels then does cholera spread? Largely
by the same agencies as typhoid fever : Food, fingers
and flies (Osier's Trinity).
Food and Flies. — Infected water is the commonest
vehicle; it becomes infected in many ways ; directly
from the excreta (faaces, vomit and urine) of persons
who have cholera ; by the washing of dead bodies,
infected clothing and other articles in wells, or rivers
used for drinking, by the dipping of infected buckets
in wells or infected cups, &c., in large drinking vessels ;
conversely cups, plates, &c., may be infected by wash-
ing them in infected water. The washing of the
mouth in infected water can produce the disease. I
have frequently noticed ducks and hens walking under
cholera infected houses on ground which is permeated
with cholera dejecta. Thence they contaminate the
wells, padi, mats, &c., around the house. Gimlette
condemns the eating of fish from infected rivers.
Shell fish scraped from the bottom of ships, have been
found to contain cholera vibrios. Shell fish, stale
fish, over ripe fruit and uncooked vegetables frequently
cause cholera. Sometimes these articles are actually
inoculated with cholera bacilli by handling or by flies
which settle first on cholera dejecta and then on
them. Even if uninfected, such foods predispose to
cholera by causing dyspepsia and diarrhoea. In three
difi'erent places in North Kedah the first cases of
cholera followed the drinking of toddy, viz., in Alor
Star, where the 1914 epidemic started in a toddy
shop ; at Sungei Wang, a place with an ideal water
supply, where nevertheless eleven cases of cholera
occurred amongst 90 Tamil coolies after a toddy
debauch, and at Jitra, where the habitu6s of the
toddy shop were the first victims. An analysis of
the toddy for vibrios would have been interesting, but
could not be carried out. Flies may have infected it,
as they frequently infect milk.
Toddy drunk to excess upsets the digestive system
and causes severe vomiting and purging, and therefore
always acts as a predisposing cause. All Kedah
toddy shops were closed after these outbreaks.
Sherbet, ice-cream, sweetmeats, and the food sold off
stalls in the streets and at native coffee shops are
specially liable to contamination by flies, and are also
often made with infected water, as are native mineral
waters. In gaols and other institutions it has been
remarked that although every other precaution has
been taken the disease continues to spread until all
vessels which receive dejecta have disinfectant placed
in them before use. When this is done flies cannot
settle on the dejecta ; new cases then cease to occur.
Ants abound in Malay houses, and doubtless take a
minor part in the spread of cholera. So do mosquitoes
and other insects.
Firmers. — All personal contact may be classed under
this head. In this country it is a common cause of
spread. Males are often infected at funerals, where
they assist to bathe and bury the dead, and then
partake of food. In the house women are more ex-
posed to infection than men, as they do more of
the nursing and washing of clothing. In a Malay
iiouse one usually finds the patient on a mat. His
head is on the knees of one friend, two more sit
on either side shampooing his limbs, while a fourth
waits on him. The sufferer passes his motion under
him, and often vomits on the floor. The whole of
his attendants become infected in a few hours. Por-
tions of the dejecta drip through the loose bamboo
floor to the ground below, whence they sometimes
reach the well. .Ml the rags and old clothes in the
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 2, 1920.
house are used to mop up the wet around the patient.
They are not destroyed afterwards.
The spread of cholera upstream, as pointed out by
Fox, S.M.O. Perak in 1910, is frequently due to trans-
mission in bundles of clothing which have been soiled
by cholera dejecta. Gimlette especially remarks on
the spread of cholera by the Tamil loin cloth. In
Malay countries a large proi^ortion of the population
hves on the waterways which were in the old days
the only means of communication. In Kedah cholera
invariably spreads upstream — a proof of the large part
that personal contact takes in its spread. Of the
many persons who are undoubtedly infected with
cholera only a comparatively small proportion develop
symptoms.
The cholera vibrio apparently cannot infect a
healthy stomach, but is destroyed in it or passes
through the system without doing damage.
MacNamara quotes an example where nineteen
persons drank water which had been contaminated
with a rice water stool. Only five developed the
disease. This explains why only one case is the rule
in a rural household, although every member has
probably swallowed the cholera vibrio.
IX. Preventive Measures.
A consideration of the channels by which cholera
is spread suggests the steps that should be taken to
limit an epidemic.
(1) First among these is the provision of pure, or,
at any rate, of sterile drinking water. Drinking
water from any suspected source must be boiled
before use, and while boiling placed in a closed vessel.
On no account should water after boiling be filtered
through a drip-stone or any other kind of filter. If
deposits in it render filtration desirable it should he
filtered before boiling.
In Alor Star a galvanized iron catchment area was
put up over the market after the 1911 epidemic. The
tanks connected with this held 480,000 gallons of
rain water. Though the river had still to be used for
bathing, the drinking of river water was forbidden ;
no bathing water was allowed to be carried to houses.
Sikh guards were put on the river to enforce the
restrictions. The townspeople were permitted to take
water for drinking from the tanks to their houses free
of charge. The water was carried in empty kerosene
oil tins ; to increase the domestic stocks the Govern-
ment bought and lent nearly 5,000 kerosene oil tins
(each holds 4 gallons). When this water began to
run short in January, 70 tons of drinking water were
brought from Penang daily in a water boat. Part of
this water was pumped off into tanks which the
Government erected in the village at the mouth of
the Kedah River (Kuala Kedah). Thence surround-
ing villages were also supplied. The remainder was
brought to Alor Star, pumped off into tanks at the
jetty, drawn into kerosene oil tins, and issued.
This supply was not available for tlie coolies work-
ing on railway construction in 1914, of whom there
were about 3,000 in the country. For them, 5-ton
tanks were erected at various points. In these tanks
river or well water was boiled. It was drawn off' into
empty petrol tins, which were then closed by screw
tops. These tins were distributed to the coolie lines
along the railway construction (40 miles).
In March, the railway authorities also erected a
Jewell filter near Kobah ; it was found to effectively
clarify and sterilize water from a most filthy pond
(most of the wells had gone dry). AU drip-stone
filters were taken from the railway coolies.
The Government erected tanks for the boiling and
distribution of water at the worst affected villages in
the country, such as Langgar, when the only water
supply was from a stagnant and heavily infected
stream. The people were everywhere ordered to boil
their drinking water. Sanitary tindals went round
the rural districts disinfecting every well with
potassium permanganate crystals. Where the water
is muddy and contains much organic material, I fear
that the potassium permanganate quickly becomes
inert. Late in the last epidemic I was able to pro-
cure a limited amount of thalassol, a hypochlorite
of magnesium disinfectant and deodorant. It may
be added to drinking water in the proportion of 1 1000
without causing an unpleasant tasre. It is colourless,
and is especially useful as a rapid disinfectant of
wells. If there is much organic matter, I believe it
to be better than potassium permanganate.
(2) Disinfection chemical. — For general use a good
coaltar disinfectant is the best. Izal or Sanitas Okol
mix well with both fresh and salt water : a solution
of one ounce to one gallon is sufficient in strength.
For throwing on damp places quicklime, and where
obtainable, chlorinated lime, is unsurpassable. For
disinfecting valuable clothing a solution of carbolic
acid is preferable to coaltar. Dead bodies may be
bathed in water to which perchloride of mercury has
been added. It is unnecessary to go outside this list
of disinfectants.
In Alor Star town the Sanitary Board made abun-
dant use of disinfectant in night soil, in drains,
watering roads, &c. They also kept control over
bakeries and the manufacture of mineral waters, and
native drinks and sweetmeats. It is fortunate that
in Kedah prisoners are available for extramural labour.
Prison gangs cleared every street house in the town
seriatim under the senior warden's supervision. Each
house was cleared of its impedimenta, and washed
out by means of a fire hose from top to bottom with
a dilute solution of coaltar disinfectant. The walls
were sprayed. Over 600 houses in Alor Star were
thus treated. Every house in the village at Kuala
Kedah was also done. The same routine, but with a
stronger solution, was carried out in each house
where cholera occurred. Quicklime was freely used
in drains around latrines. Stretcher parties of
prisoners were on duty in the town, day and night,
to carry cholera patients to the quarantine camp.
The work of the sanitary tindals in the rural districts
may conveniently be recorded in this section. There
were ten of these parties, three men in each. The
tindal was sometimes a hospital attendant, more often
an intelligent ex-prisoner who could read and write,
and had shown aptitude in a previous epidemic. The
other two members of the party were always prisoners.
They took with them a good supply of disinfectants,
Aug. 2, 1920.] THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE.
193
a sprayer, buckets, an astringent diarrhoea mixture
and 2 gr. tabloids of potassium permanganate. They
had orders to disinfect every well on their route, and
to advise every household to boil their drinking water
and take the other precautions detailed in our cholera
circular. Boats and bullock carts, which are fre-
quently infected, were disinfected when necessary.
Their instructions on reaching an infected house
were : —
(a) Put the patient in a separate room in the house
or in a corner or outhouse. Remove everything,
except the sick man's bedding and clothing.
(b) Wash all pots, cups, mats, bedding and utensils,
and the whole house in disinfectant, and put every-
thing out in the sun.
(c) Put hme under the house, and especially under
tiie part where the patient lies, and under the kitchen,
and wherever the ground is damp.
(d) Disinfect the well with permanganate crystals,
(c) Fill a vessel with disinfectant and keep it at
the sick man's door; order his attendants to wash
away his vomit and motions with it, and to wash
their own hands and feet in it when entering and
leaving his room, and especially before eating and
drinking.
(f) AU drinking water is to be bottled and kept in
a covered vessel.
(g) Motions or vomit which have been passed into
a pot are to be mixed with disinfectant and buried
away from the water, or burnt if fuel is available.
(h) The attendants on the sick are not to admit
other friends or relatives to visit the sick person, and
they themselves are not to mix with outsiders.
(i) Treatment is to l^e offered but not forced on the
sick person. (Some of the tindals took permanganate
tabloids themselves to prove their harmlessness to
the household ; in this way their use was encouraged,
and I believe that the lower death-rate in the 1914
epidemic may be partly attributed to this.) The
bathing of the sick in cold water, a common practice,
must be prohibited.
(j) Directions about diet as in section 21 of the
circular are to be given to the attendants on the sick.
(k) The dead are to be buried privately, and (juickly.
Disinfectant is to be mixed with the water used for
the ceremonial bathing of corpses. For this purpose
strong uncoloured perchloride of mercury solution
was supplied.
Note.. — When there is cholera about, some cases
will always escape detection. It is therefore important
to carry out thorough disinfection in the case of
every death (to whatever cause attributed) in an
affected area. This has been done in Kedah where
the strength of the staff permitted.
(/) All who assist at a burial are to be bathed in
disinfectant.
(w) The clothes, mats, &c., of the dead are to be
burnt.
(n) After a death the house and every person and
thing in it are to be disinfected. The inmates are
not to mix with outsiders for seven days.
Regular rei)orts of new cases and deaths wore sent
in to headquarters by sanitary parlies. Tiieir work
was periodically inspected by Medical Officers.
Depots of disinfectants were formed at centres
such as police stations and penghulus' houses.
At the height of the 1914 epidemic, including large
town parties under senior warder, rural parties, toties
(night soil scavengers), water parties, quarantine camp
convict nurses and cooks, &c., an average of 100
prisoners was employed on cholera duty. 89 prison-
ers received remissions of sentence for good work.
The prospect of a remission made the majority very
keen.
Cases amongst prisoners. — There were 23 cases of
cholera amongst prisoners, and nine deaths (average
daily number in prison 280) ; of these prisoners, six
(three on intramural and three on extramural labour)
were not employed on cholera duty ; one had dysen-
tery on admission to prison, and afterwards developed
cholera ; one had cholera on admission to prison ;
two were in cholera burial parties ; eight were work-
ing in disinfecting parties (one hospital, three town,
four rural ; of the rural, three were infected at the
same place, Langgar) ; three were carrying water
from the river for washing purposes ; two were in
attendance on choiera sick ; total twenty-three.
Nearly half were 'infected during the first month ;
infection was doubtless due in most cases to neglect
of precautions. All prisoners on cholera duty were
bathed in a coaltar disinfectant, and had their clothes
changed at the prison gate on their return, and were
kept in separate wards. Their nails were cut short.
(3) Disinfection by fire and heat. — The sterilization
of water by boiling has been mentioned. Infected
clothing is best sterilized by boiling, and boiling water
may be used to wash household utensils. The cloth-
ing, mats, blankets, curtains and other soft effects of
all people who either die or recover from cholera
should be burnt, unless they are boiled. The rays of
the sun are a most powerful disinfectant. The whole
contents of houses should be spread out and placed
in the hot sun for five days running. If thus
thoroughly exposed in a dry place they wiU become
sterile. In the case of Malay houses the part of the
bamboo floor on which the patient has been lying
may be pulled out and burnt, Fox and Gimlotte
recommend that the whole of the underneath of the
floor be scorched by the flame of a torch. If the
house is a cheap one and surroundings insanitary, it
is better to burn the whole house and effects, should
two or more cases of cholera occur. Compensation
must be paid. Dead bodies are best dispensed of by
cremation. In the case of non- Mohammedans I
adopt it wherever possible.
(4) Isolation and quarantine. — When cholera occurs
amongst a labour force the sick coolie must always
be moved out to a quarantine hospital or shed, his
belongings destroyed, and room disinfected. Further
cases may necessitate the burning of his (juarters. I
am however much opposed to taking largo numbers
of coolie contacts used to healthy work, and a free
life, away to a quarantine camp. Where there is
European supervision as on rubber estates, railway
construction and other Oovernment works, it is bettor,
after carrying out a thorough disinfection of all con-
tacts and their belongings, to place them in one line
apart from the rest of the labour force, feed them
194
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 2, 1920.
well, and allow them to do their usual daily task.
After seven days without a case all restrictions may
be removed. This plan I adopted amongst the rail-
way construction coolies, during the whole 1914
epidemic — 58 cases (30 deaths) occurred amongst
them in six months — strength of labour force 3,000.
Twenty-two of these cases (mostly due to the care-
lessness of one dresser) were in one month, Mai'ch.
I believe that, had all contacts been carried off to a
quarantine camp, there would have been more cases
and the whole work of construction would have been
stopped in places.
Mental depression, fear and fatigue, are great pre-
disposing causes of cholera. These influences must
be combated by altering the contacts' mode of life as
little as possible, and by feeding them well. This
system was followed by estate managers also, with
the result that in 1914 only three estates out of 70,
employing 9,000 coolies in the affected districts
became infected. Only 18 cases occurred on these
three estates ; similar measures were taken with
police, &c. Had protective inoculation against cholera
been practised in Kedah, the small number of cases
amongst railway and estate coolies would have been
attributed to it. It was not possible to introduce it
and retain the confidence of the people.
The isolation of sick private persons must be aimed
at, but cannot always be carried out in a country
like Kedah ; undue harshness leads to concealment
and makes matters worse. Where there is a hospital
available the patient must if possible be removed to
it, and his household kept under observation for
seven days. If he is treated at home, a guard should
be placed on the house, and the inmates quarantined
with himself and the number of his attendants
restricted. When necessary, food must be supplied
to the household.
Infected shops must invariably be closed. In rural
areas however, when the disease spreads, it is impos-
sible to quarantine the house of every infected ryot.
Occasionally the sufferer can be moved to an empty
house or shed; usually he must be treated in a sep-
arate room in his own house, or in a corner of it,
when there is only one room. More can be done by
sanitary parties of his fellow countrymen than by
any other agency. They can explain the cause of
cholera and the orders and precautions recommended,
and instruct the household in carrying them out.
Any beneficial native customs must be encouraged ;
for instance the "Tali Pupoh " which prevails in
some parts of Kedah and in Kelantan and in other
Malay States.
The bomo (village medicine man) places a string
from which bent twigs and leaves depend across a
path leading to an infected house or kampong.
Visitors are not allowed to enter past this string, nor
the household to come out. Sometimes a tali pupoh
is also put up to protect an uninfected area from
infection. As a rule, persons are afraid of the hantu
(spirit) which is guarding the tali pupoh, and do not
transgress it.
Although land and river quarantine guards have
been abandoned in Europe, they have tlieir place in
a new country. By these means, when there is not
too much traffic, it is possible to partly cut off an
infected area. The non-spread of cholera to South
Kedah in the third epidemic was, I think, due to a
quarantine of this nature, for the overland journey
was then possible.
In the 1914 epidemic the great amount of traffic
up and down the railway construction caused the
land quarantine to fail, and South Kedah therefore
became infected.
Along the seacoast boats from an infected district
must either be denied entrance, or must do five days
quarantine before landing cargo or passengers at a
healthy place.
(5) Instruction bij Posters and Pamphlets. — Notices
in the colloquial should be posted in all places where
people meet, e g., penghulus' houses, police stations,
mosques, coffee shops, and on trees, &c.
The attached poster " advice " about cholera, in
the drawing up of which I received much assistance
from the adviser, Mr. Maxwell, was used in Kedah
during the 1914 epidemic. I wrote it originally in
Malay, so as to make it as comprehensible as possible,
then put it into English, and had Chinese and Tamil
translations made by competent translators. The
English copy was circulated amongst all Europeans,
as was Dr. Gimlette's excellent memorandum on
cholera.
The President of the State Council, with the Shaik
ul Islam and Chief Kathi, also drew up and issued a
Malay notice pointing out that the measures advised
by the Medical Department were in accordance with
Mohammedan law. This notice was fortified by texts
from the Koran and quotations from Mohammedan
divines. Through the help of its authors the dis-
infection of mosque water with potassium per-
manganate was widely adopted.
(6) General. — Assemblages of people must be pre-
vented, if possible. The celebration of festivals is to
be discouraged, especially where feasting is involved.
Native theatres must be shut. In towns people who
feel ill frequently go to lie off in lodging houses,
opium divans, or brothels, which must be constantly
inspected. Simple living is to be inculcated. The
avoidance of alcoholic drinks, unripe fruits and raw
vegetables, and indigestible and tinned foods, should
be recommended. The subordinate cholera staff
should be co-religionists of the people amongst whom
they work. The medical officers should know the
language, customs, and ideas of the people, and must
always respect their religious prejudices. Medical
officers can set a good example by drinking per-
manganated water in the presence of the people, to
prove that it is harmless, by taking an active part
themselves in disinfection, and by showing sympathy
with the sick. The removal of the dead to a distant
burial ground must not be allowed. Death registers
must he frequently inspected ; an undue increase in
the death-rate in any makim points to cholera in-
fection. Government officers, especially police and
penghulus, who commit breaches of the regulations
or connive at concealment of disease, kc, should be
severely dealt with. The same rule applies to dwellers
in towns generally. In a rural area where conceal-
ment of disease is widespread the fining or imprison-
Aug. 2. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
195
ment of one or two householders may have a good
effect, but indiscriminate severity defeats its purpose.
Amongst the ignorant more is to he gained by
admonishment and advise.
X. The Quarantine Camp, Alor Star.
Treatment adopted in it. The quarantine camp,
Alor Star, contains one large permanent cement-floored
ward with latrines and hath, incinerator, mortuary,
&c. When an epidemic occurs, materials are bought
and temporary buildings erected by prison labour on
cement floors for the housing of contacts, and of
dressers, attendants and guards. The nursing,
scavenging, and cooking are done by selected
prisoners, under the superintendence of dressers.
Treatinent.
In the first epidemic I tried elimination. Castor
oil was used with some cases, calomel with others.
The huge mortality, 6869 per cent, amongst 135
cases, lod me to abandon this treatment.
In the second epidemic, hypodermics of morphia
were used ; permanganate drinks were given ; the
mortality was 6275 per cent. (102 cases).
In the third epidemic, similar lines were followed.
Normal saline solution was injected intravenously in
a number of cases. It was found that normal saline
solutions relieved the painful symptoms, but did not
save life. This fact was noted in 1833 by Assistant
Surgeon Murray of Meerut, who was probably the
first to try this remedy (the mortality was 64 per
cent, in 236 cases).
In the fourth and last epidemic, transfusion was
not employed in the first 41 cases ; of these 16
recovered. Mortality, 6049 per cent. Transfusion
with hypertonic saline solution was used whenever
indicated amongst the next 192 cases ; of these 104
recovered, and 88 died. Mortality, 46 per cent.
During the recrudescence in June it was used amongst
a further 45 cases, of whom 23 died ; mortality 51
per cent. The mortality amongst the whole 278
cases in the quarantine camp was 48'92 per cent.
Hypertonic transfusion therefore gives much better
results than any other line of treatment. This was
especially noticeable amongst the 23 prisoners who
got cholera. Most of them were previously healthy,
and well fed men. Two were brought in moribund
from distant rural sanitary gangs ; the others, how-
ever, all had early treatment. Nine died, a percentage
mortality of 39.
Formerly the ijercentago mortality amongst prison-
ers always exceeded fifty. The hypertonic saline
solution used was that recommended by Col. Leonard
Rogers, I. M.S., in his " Cholera and its treatment,
1912." The indications he gives for its use were
followed, except that it was seldom possible to take
the specific gravity of blood or to use a sphyguiograph
to estimate the blood i)ressure. The amount of work
left no time to make these precise tests ; besides the
quarantine camp was for the greater part of the day
in charge of a dresser, who was unable to carry them
out. The estimation of the pulse was therefore made
by the finger ; weak ])ulse, restlessness, cramj>s and
cyanosis were taken as indications for transfusion.
Both intravenous injections in the arm (Rogers'
method) and intraperitoneal administration (Bishop's
method) were carried out. The intraperitoneal
technique is simpler, 3,nd less risky; for most dressers
it is the only one possible, though two dressers learnt
to perform intravenous injections quickly and well.
In 33 cases the intravenous method alone was used,
in 54 the intraperitoneal. In 56 cases (all injected
more than once) both methods were used. The
amount given at one injection varied from three to
four pints.
The appended table gives certain particulars about
the 143 cases injected from January to April, 1914.
A. — Total amount of Saline in each case.
Route and mortality.
Route injected
Mixed
7
g
73
3
fi
100
9.
?.
67
2
2
100
2
2
1(X)
1
1
100
1
1
100
19
Two persons died after two pints had been injected.
The value of the intraperitoneal route is shown by
the fact that it was adopted in 28 out of 31 cases
who received three pints, and that the mortality in
this section was only 35 per cent., although the three
intravenous cases died. Among those who received
four pints (13 intravenous and 7 intraperitoneal cases)
with the death-rate of 30 per cent., the odds slightly
favour the latter route.
It will be gathered from the table that it is useless
to give more than three injections (more than twelve
pints). In the most desperate cases the patient cer-
tainly responds more quickly to intravenous injection;
in two very bad cases injected intraperitoneally it
was found post-mortem that little fluid had been
absorbed. This however was the exception and not
the rule. The intestines were never injured in the
intraperitoneal method, thougli at one post-mortem
a small puncture was noticed in the great omentum.
In one case post-mortem a small localized abscess
was found, in another peritonitis was commencing :
in both there had probably been an error in steriliza-
tion. In one intravenous case, cellulitis of the arm
ensued. This may have been due to the low vitality
of the tissues, and not to any want in antisepsis at
the time of injection.
At no other jwst-mortems was anything abnormal
noted that could have been due to lack of surgical
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 2. 1920.
cleanliness. Where the urine was deficient in the
latter stages, small intraperitoneal injections of nor-
mal saline solution were sometimes tried, but did not
meet with success. They are included among the
injections shown in the table. Dry cupping over the
kidneys, and high salines were also tried. It is
unsafe to carry a patient any distance after a hyper-
tonic injection. Four cases were transfused in the
town and then cai-ried three miles to the quarantine
camp. Three of them died.
Particulars of 192 cases amongst whom hypertonic
injection was used whenever indicated.
Number of injections
, .. Total
0 12 3 4 .^ li
Number of cases ... 49 54 48 28 9 2 2 192
How many died ... 5 22 27 21 9 1 2 87
Percentage of recovery 88 59 44 25 0 50 0 54%
Complications or terminal
causes of drath—
Uraemia — 3 11 15 7 1 1 38
Collapse 2 14 14 2 1 — _ 33
Diarrhoea — 3 1 2 — — — 6
Cellulitis — 1 _ — _ _ _ 1
Septicasmia — — — — — — 1 1
Ruptured liver abscess... — — 1 — — — — 1
Double pneumonia ... — — — 1— — — 1
Septic broncho-
pneumonia ... 1 — — — — — — 1
Parenchymatous
nephritis ... — 1 — — — — — 1
Malaria, comatose ... 1 — — 1 1 — — 3
Asthenia 1 — — — — — — 1
Perforation, bowel,
dysentery ... 1 — — — — — — 1
Total deaths ... 88
Three of the six fatal cases not transfused in this
series were complicated by pre-existing diseases, viz.,
dysentery 1, broncho-pneumonia 1, malaria 1. Alto-
gether 3 malarial cases (all subtertian) from the water-
works construction, developed cholera ; all died.
Six men, 5'4 per cent, of total deaths, died of a late
terminal diarrhoea, and one of broncho-pneumonia,
which was probably due to infection of the lung by
the cholera vibrio. One man was found to have a
ruptured liver abscess. 38 deaths (43 per cent.) were
due to uraemia, and 33 (37'5) to collapse. This is
exactly the reverse of what one finds in a series of
cases where saline transfusion is not used. For in-
stance, out of 25 deaths amongst the first 41 cases
not transfused, 20 deaths (30 per cent, of the total)
were due to collapse, and only 4 (16 per cent.) to
uraemia.
This means that a considerable proportion of those
who are tided over the collapse stage by transfusions
succumb to uraemia later on. In my opinion some of
these deaths are due to the hypodermic use of vaso-
constricting drugs, such as digitahn, adrenalin and
pituitrin, which have lately been strongly recom-
mended in cholera. Tlieir use was abandoned to-
wards the close of the epidemic. In some cases of
suppression 2 gr. doses of sodium nitrate were tried.
I sijspect that the hypertonic saline injection at
times aggravates the tendency to urseinia. In two of
the first series of cases which were not transfused
there was almost complete suppression of urine for
five days. No vasoconstricting hypodermics were
used. Rectal injections of 4 oz. normal saline solu-
tion were given every four hours. Both recovered.
I saw no recovery amongst any very severe cases of
uraemia that had been transfused (even though normal
saline per rectum was tried). Three of the men who
died of uraemia were found post mortem to be suffer-
ing from advanced interstitial nephritis. Where
stimulation was necessary, aether was injected hypo-
dermically. Strychnine was to a lesser extent in-
jected. Potassium permanganate tabloids (2 gr.)
were given to all patients, as many as 30 were ad-
ministered on the .first day, and ten on subsequent
days up to one week. After active symptoms sub-
sided, if troublesome diarrhoea continued, bismuth
salicyl was found useful. No morphia or opium was
used, and no alcohol.
In some cases which were mild when admitted, one
or two doses of an astringent diarrhoea mixture were
given. Most of them did not become severe. The
diet followed was that recommended in section 21 of
the attached circular.
Three of the admissions early in the epidemic
passed porridgy stools, and never had rice-water
motions : yet they exhibited great coUapse, and all
died.
The liability of new comers to contract cholera was
shown by the admission of four persons, from Penang,
who had been four days or less in Alor Star. Three
of them died.
Cholera superimposed on antecedent bowel disease
is usually hopeless. The prognosis is bad for opium
smokers also. Amongst sequelae paresis chiefly affect-
ing the lower limbs was noticed in two cases. In
one, who developed melancholia in addition, it per-
sisted for nine months.
The stool of every case admitted to the quarantine
camp was examined for cholera vibrios. The stools
of contacts were also periodically examined ; many in
whom no symptoms developed were found to contain
vibrios. The stools of all convalescent patients were
examined weekly, and they were not discharged until
vibrios were absent. This entails a much longer
detention in camp. One who had a mild attack still
continued to pass vibrios 67 days after admission.
Post-mortems were held in the majoi'ity of cases.
Dr. Smart took special interest in this work. Bile
from a number of gall-bladders was sent by him to
Singapore, and examined by Dr. G. A. Finlayson, to
whom hearty thanks are due. He found cholera
vibrios in about one quarter of the specimens sent.
During the cholera recrudescence in June, two
Chinese coolies from the town were admitted to the
camp, who had passed through typical attacks less
than four months previously. Cultures from their
stools were sent to Dr. Finlayson, Singapore, who
pronounced one case to be true cholera (he died), but
was doubtful about the other. This proves that the
protection conferred by an attack of cholera is very
short. Dr. Stanton suggests that a prophylactic
cholera vaccine be tried should a cholera epidemic
again occur here. Several Europeans developed
Aug. 2, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
cholera in 1914. They were probably infected by
the substitution of river water for rain water in the
club by a boy. Four had severe attacks ; of these,
two died.
XI. — Preceiitage mortality from cholera amongst the
cases reported in four Kedah cholera epidemics.
PercenLise
Percent a t;e
A.D.
Oases
leported
ilfiatb-rate
death. rat« on
rases treatr.l ,n
reported
t
oe camp
1907
330
74-8
68-80
1908
686
79-9
62-75
1911
1,211
79-7
64-00
1914
2,266 ...
68 8
48-92
Details of
reported cases
1332 A.H., 1914 A.D.
epidemic.
Casea
Deaths
Percent3{!e
Mortality
North Kedah-
Treated in quarantine camp,
December-
-April
233 ...
113
... 48-4
Treated in quarantine camp,
June ...
45 ...
23
... 511
Treated at home or untreated.
December-
-April
1,515 ...
1,064
... 70.2
Treated at home or untreated,
June ...
25 ...
20
... 80-0
Euala Muda
205 ...
151
... 73-6
Baling ...
243 ...
174
... 71-6
XII.
The total extra cost of the 1914 cholera epidemic
to Kedah (paid for from a special vote) amounted to
141,043.38.
The chief items were : —
Purchase of water from Penang, including pump-
ing and distribution 512,
Disinfectants and medicines 8
Pay of extra medical officers 2
,, ,, dressers and sanitary tindals 3
Travelliug of M.O's., dressers, and sanitary parties 2
Cholera gratuitiei^ to subordidates 1
Material for temporary building at Quarantine
Camp, Alor Star ..
Diets, Quarantine Camp, Alor Star 3
Firewood (including cremations) and oil, Quaran-
tine Camp, Alor Star 2,
Clothing, mats, utensils, blankets for Quarantine
Camp 1
Compensation, Alor Star
Printing of notices, advertisements, and payment
for translations
Payments in Kuala Muda district 1
,, Baling district
Yen „
711.48
841.52
952.46
791.40
,346.01
Total
.$41,043.:
The last three items were bills for compensation, firewood,
special guards, temporary bills, Ac, mostly on signatures of
the European police officers, South Kedah.
The average daily number (excluding fractions) dieted in the
Alor Star Quarantine Camp for seven months was 93.
Approximate cost of diet per head daily, 17 cents.
One Straits dollar = 2s. 4d.
XIII. Results Obtained and OrUlook for the Future.
The results obtained within the Sanitary Board
area, Alor Star, in the last epidemic are encouraging.
With a makeshift supply of drinking water, and witli
no bathing water except the deeply infected river, the
cases averaged only one per day (amongst 10,000
people). Since its close waterworks and pipe lines
have been finished, and Alor Star is provided with a
permanent pure water supply. The Sanitary Board
is efficient, the disinfection and removal of nightsoil
is thorough, and the river bordering the town is no
longer used as a latrine.
Should cases of cholera occur in the future, it is
therefore possible that they may be stamped out
before the country becomes infected. It must be
admitted, however, that the immediate results in
rural areas are disappointing, and disproportionate to
the work done and money spent. Little active oppo-
sition is now met, and the disinfection of wells and
houses is not objected to. Even women occasionally
ask for the obat merah (pot. permang.) and put it in
their wells themselves, although a few years back all
disinfectants were regarded as poisons. But this
does not get to the root of the trouble. Most natives
still fail to realize the infeotivity of cholera excreta,
and regard our statements as romances. Generations
of riverine dwellers have defaecated in the river.
Why, they argue, should they cease to do so ? The
immediate disinfection of aU stools, or instant burial
where disinfection is not possible, though strongly
insisted on, is rarely carried out, unless a sanitary
party is present.
The isolation of patients in rural districts is another
difficult problem. Asiatics have always been used to
visit their sick friends, and consider our restrictions
inhuman. Until the ryots realize the danger of their
habits and are willing themselves to co-operate with
the Government, the stamping out of rural cholera,
once a few cases have developed, will always be a very
uphill task. Much of the pioneer work that has been
done will, it is hoped, bear fruit among the rising
generation.
XIV. Spread of the Disease. Localities Affected.
(1) Alor Star. — The first case occurred in a toddy
shop in Jalan Penjara Lama : the man had not been
out of Alor Star for months ; he and the contacts were
removed, the toddy in stock destroyed, and the shop
disinfected and closed.
Three other cases during the first week were proved
to have drunk toddy at this shop. In five months,
December to April, there were only 182 cases in Alor
Star (estimated population 10,000), or an average of
little more than one daily. During the cholera
recrudescence in June, 70 cases were reported in
North Kedah, half of them in Alor Star.
(2) Kuala Kedah and the coast southward. — Within
two days after the first Alor Star case, a fisherman at
Kuala Kedah, who had recently visited Alor Star, but
not the toddy shop, developed cholera and died.
Other cases then followed in the Malay theatre at
the Kuala. Thence Kuala Salak on the coast ten
miles south of Kuala Kedah, became infected in
December, free in January, but again infected in
February. Sungei Limau, sixteen miles south, after
one case, remained free until March, when many
deaths occurred there, and at Dulang and Yen.
The island of I'ulau Bidan was also infected in March ;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 2, 1920.
the disease was then brought to Penang Island by
runaway fishermen.
(3) Places around Gunong Griang {and the coast
northward from Kuala Kedah.) — AU the mukims
around Gunong Griang became badly infected in
January ; most of the kampongs are situated on small
stagnant streams, in which the water is vile in the
dry season.
(4) From A lor Star north to the Siamese frontier
306 cases were returned. Included in this return
were 21 prisoners, and 16 hospital patients, 10 of the
latter only were in hospital a few hours, having
entered just before active cholera symptoms developed.
During the recrudescence of cholera in June two more
prisoners were attacked ; one died.
(5) Langgar road and mukims round Langgar. — As
usual there was a heavy incidence in Langgar village
and the surrounding kampongs, situated as they are
on stagnant streams from which they take their water
supply ; there were 90 deaths in the mukim of
Langgar alone.
(6) Along the Sangei Korok Canal. — The disease,
as usual, made no headway along the Sungei Korok
after reaching Kota Sarong Semut. A few cases
occurred at Padang Lumut and Gurun, but Semiling
and Sungei Patani were skipped entirely. The soil
here is laterite.
(7) Along the raihvay between Alor Star and Gurun
44 railway coolies were attacked, of whom 21 re-
covered. The Malay kampong at Tokai was infected
from the railway in March, and 29 cases resulted in
it. During the recrudescence in June, six more Alor
Star railway coolies got tlie disease.
(8) Kuala Muda District, Soutli Kedah, remained
free until February, but in that inontli and March
205 cases were reported there.
(9) III Baling, upstream from Kuala Mnda, 243
cases were returned between February and April. A
few also occurred late in June. The majoi-ity of
Baling cases were never reported. Tiirougli lack of
staff and difficult communications, very httle could
be done in this district. Two police oflicers, Mr.
Speers and Mr. Gilroy, visited it, and the latter
remained there for nearly three weeks witli a tem-
porary dresser.
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a point of interest and importance. The writer, from oxperi.
ences gained on the Cholera Commission sent to Kifvpt in IH-i'i,
of which he was a member, drew attention to the fact tliat
cholera appeared in that year at the Damietta mouth of the
Nile where it falls into the Mediterranean. The disease spread
from thence to the spot where the Nile divides into the
Damietta and Bosetta branches. The infection spread from,
thence up the main river ; town after town and district after
district were attacked, until the track of the infection was lost
somewhere about the Dongola district. The towns in the
Rosetta branch and in the Delta were irregularly attacked,
showing overland infection in all probability. The writer
ascribed the upstream infection to fisln, but he has not had the
opportunity of investigating this supposition. Perhaps Dr.
Hoops would take up this question if he has the opportunity.
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THE JOURNAL OF
Cropital ^ttsitim and f^pgiene
August 2, 1920.
THE ROYAL SOCIETY OF TROPICAL
MEDICINE AND HYGIENE.
The term " Royal " prefixed to the Society of
Tropical Medicine is one which becomes the
sovereign who bestowed it, and the subject which
Aug. 2, 1920.;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
199
tlio Society deals with. On no society of so short
an existence has the term been so speedily
bestowed ; for it seems but yesterday that Sir James
Cantlie called some half-dozen of the best known
tropical men to his house in Hurley Street, and
laid his scheme before them. He had the scheme
formulated, a set of rules for the society drawn
up, the names for a Council and Executive Com-
mittee set out, and even the names of the officers
already on paper. The President he named was
Sir Patrick Manson, the Secretary Dr. Carnegie
Brown, and the IVeasurer Dr. William Hartigan.
Manson and Hartigan were his old colleagues in
Hong-Kong, and Brown the first doctor ho met in
the Tropics when he called at Penang on nis way
to the Far East. The scheme, the rules, and the
officers were practically accepted as they stood,
when some months afterwards a meeting was
called of all those interested in tropical medicine,
which met at the Colonial Office by the kind per-
mission of the authorities. The Society has
flourished ; it was welcomed all over the world by
Britons and scientific men of every nationality.
By quiet and earnest work the Society has grown
in numbers and in importance. Its Presidents
have been men of importance and renown, beai-ing
names which will be handed down as the fathers
and founders of tropical medicine. Manson, Ross,
Leishman, Charles, Sandwith, I5ruce and Simpson
have held the position of Presidents. They need
no initials to differentiate them, neither pre-
fixes nor suffixes to distinguish them, for their
names are engraven deeply on the tablets of all
men's memories. In the early days we smiled —
nay, laughed in derision when the founder. of the
Society in his enthusiasm sketched the future of
the Society in glowing tenns, ending up with the
prophecy that it would become all-powerful in the
world of tropical medicine, and that it was only
a (juestion of time before it would be known as the
Hoyal Society of Tropical Medicine and Hygiene.
Tlic success of the Society, owing to the paucity
nt men at home who could attend the meetings,
«as doubted in several quarters. The devotion,
lidwc'ver, of these few to the subject which the
iSncioty had marie its own gradually began to tell,
ami in no long space of time the list of members
^^ri \v to ample proportions. The officers in the
Navy and in the Army (Inditm and Home) were
a wtleome accession to the Society, for in both
these Services the lethargy of previous days was
s( I aside, and there arose a group of men, in the
iiiiMlical ili|jartiiii'nt of both these great public
s(r\ie,s, eiiiiuwi d with the instinct of research
aiul tiiu eapability of carrying out investigations in
a manner at once scientific and fruitful. The
Tropical Society, moreover, brought the officers
ijf the Navy and Army into intimate association
with their civilian brethren. Far too long cut
adrift from each other by the exigencies of service,
the military and civil medical men had no common
;;r<.und in which to meet; they knew little of each
other, and there was no interest to draw them
together. In the sphere of tropical medicine,
however, a basis was provided; the Society has
served as a means of furthering acquaintanceship
between men hitherto kept unfortunately asunder
for want of a common meeting ground. The
civilians must remember that through the great
school at Netley the medical department of the
Army kept alive the study of tropical diseases. In
civil life nothing was being done; the medical men
going out to the Tropics for i)ractice in civil life
had no instruction in tropical disease. There was
no school corresponding to Netley for them. They
learned their lessons in the hard school of bitter
experience ; bitter for themselves and for their
patients. Had Netley been open to them how
different would have been the story." The teaching
then could not, of course, be considered as ex-
cellent as to-day, but it was proportionately as good
as our practitioners in civil life at home were given
at that time. We owe a great deaJ to the men at
Netley — Fayrer, McLean, Longmore, McLeod, and
to many others — for the systematized teaching in
tropical ailments they afforded. The generation
coming after them has continued in the forefront
of medical science. We have but to mention Ross,
Bruce, Leishman, Rogers, James, Giles, Lewis (of
filaria renown), and a host of others as evidence
of what old students of Netley and the Royal Army
Medical College, London, have accomplished. The
military and the civil branches of medicine have
come to respect each other, and through the
Society of Ttopical Medicine and Hygiene they
have become better acquainted and united. Their
efforts have advanced the study of disease in the
Tropics by leaps and bounds. In hygiene the
civilians yield the palm to the military, for Parke
stands forth as the greatest of all names in modern
hygiene unapproached and unapproachable. We
have to go back to Moses to find even a parallel
to this great military hygienist. In the present
President of the Society of Tropical Medicine and
Hygiene, Professor J. W. R. Simpson, we have a
worthy civilian successor to Parke. It was a wise
move of the Founder of the Society to tack the
word Hygiene to the name of the Society, and we
must not forget that it was under the segis of our
present President that the word Royal was added
to the designation of the Society. At present the
Society has no permanent home of its own ; that
must and will come about in the course of time;
and that the Royal Society of Tro|)ical Medicine
and Hygiene will continue to flourish in usefulness
and importance in the future is certain. With its
maintenance and development the future of our
Empire is linked up. It is playing a great jiart
in the bearing of the " white man's burden," and
thereby fulfilling an imperial need of vital im-
portance.
200
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE. [Aug. 2, 1920.
%bstmt.
THE LESIONS IN WOOD ALCOHOL
POISONING.'
By Charles Nobbis, M.D., New York.
Methyl alcohol attacks the most highly differen-
tiated nerve elements, inducing a deep and pro-
longed coma and blindness, and it has a marked
selective affinity for the most highly differentiated
nerve elements in man, which are therefore more
rapidly and severely damaged than those of the
monkey. Whereas drunkenness in man from grain
alcohol is easily recovered from, it is almost
uniformly fatal when due to methyl alcohol.
The toxic action of this alcohol is best demon-
strated by Birch-Hirschfeld, who states that methyl
alcohol is capable of injuring the eye more severely
than ethyl alcohol, and that blindness ensues after
the acute intoxication and even after very small
doses, a result which does not occur with grain
alcohol. The cumulative effects of wood alcohol
poisoning are striking. Extensive fatty degenera-
tion of the liver was always present in animals
which had received daily small doses, the animals
remaining comatose for days and refusing to eat.
The reason for the differences in effects on the
animal organism between the two alcohols is ex-
plained by the difficulty which the organism experi-
ences in oxidizing methyl alcohol; whereas ethyl
alcohol is rapidly split into hannless end products
(carbonic oxide and water), methyl alcohol is slowly
and partially oxidized in the body and is split into
substances which are in themselves more toxic than
the methyl alcohol — namely, formaldehyde and
formic acid. The formic acid is excreted and found
in the urine. According to Pohl, the acid is
excreted slowly ; the maximdm amount in the urine
did not appear until the fourth day after an initial
dose and even when small quantities are adminis-
tered to animals, formic acid is still found, showing
how difficult it is for the body to oxidize completely
methyl alcohol. The protective mechanism of the
body to wood alcohol is overwhelmed, and we have
the curious anomaly of the conversion of one poison
into another many times more toxic. It is beheved
that formaldehyde may be the intermediate product
in the conversion of methyl into formic acid, and
that if it is, it becomes rapidly converted into its
acid. It has been estimated that fonnaldehyde is
thirty times as toxic as methyl alcohol, and Mayer
has found that formic acid is approximately six
times as toxic — namely, one hundred and twenty-
five hundredths grammes to the kilogram was fatal
to rabbits in an hour and ten minutes.
Bongers states that methyl alcohol, unlike ethyl
alcohol, is found in the urine in large amounts.
The slow excretion of the alcohol and of its oxida-
'The New York Medical Journal, vol. cxi., No. 14, Whole
No. 2157. April 3, 1920. Page 583.
tion products accounts for the long continued effects
observed in acute poisoning and for its selective
action on the retinal elements and the optic nerves.
Bongers furthermore observed that, as in the case
of many other poisons, such as morphine and bi-
chloride of mercury, methyl alcohol is excreted into
the stomach, where it acts as an irritant to the
intestinal tract.
The gross pathology of methyl alcohol Boisoning
is indefinite. General visceral congestion is the
only constant finding in acute methyl alcohol
poisoning. Many authorities have emphasized the
presence of petechial hsemorrhages in the various
viscera, especially in the lungs. Strassman has
noted the contractures of loops of the small intes-
tines in a number of patients who were examined
in the municipal lodging house catastrophe in
Berlin during the Christmas celebrations in 1912,
and has called attention to the fact that it may
account for the acute abdominal distress which is
present so frequently in cases of acute poisoning.
None of our cases have shown this condition. The
haemorrhages so largely emphasized, except those
of the gastro-intestinal tract, in my opinion, are
probably asphyxial and terminal in origin, and
therefore are largely determined by the manner of
death. One would expect to find them most pro-
nounced and marked in the patients dying of a
slow asphyxia. In tlie Fulton Street cases all the
victims (middle-aged men) had marked ohronic
visceral lesions, such as adhesive pericarditis, wet
brain, chronic visceral nephritis "and arteriosclerosis,
and they all belonged to that period of life in which
such lesions are consistently present.
In cases coming to autopsy without a clinical
history, and where the surrounding circumstances
throw no light on the cause of death, the diagnosis
of wood alcohol poisoning may not be made until
chemical analysis shows the presence of this
alcohol. Frequently it is difficult for us to deter-
mine the exact extent or relation to the cause of
death which the methyl alcohol has played. I refer
to a class of cases in which very large amounts of
ethyl alcohol are found with mere traces of methyl.
I feel that I must emphasize this point for the
reason that it is by means of such cases that the
inference may be justified that much of the grain
alcohol sold since prohibition has contained methyl
alcohol.
In regard to the microscopic changes which we
have found in our cases, I am at the present time,
unfortunately, not able to give definite information.
There are two reasons for this : First, on account
of the lack of help and press of work we have not
been able to examine our material thoroughly;
secondly, much of the material is poorly preserved
for microscopic purposes. I may say, however,
that the sections of the optic and other nerves that
we have thus far examined are unsatisfactory. The
changes are so slight, when compared with a normal
nerve, that at the present time nothing further may
be stated. I reahze that this phase of the subject
is of the utmc^t interest and importance.
il
Aug. 16. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 16, Vol. XXIII.
^rifliiuU. CoramimUation.
A CASE OF UNDULANT FEVER WITH
UNUSUAL NERVE SEQUELS.
Bv Surgeon Rear-Admiral P. W. Bassett- Smith, C.B.
C.M.G., F.R.C.S., F.R.C.P., R.N.
One of the most noticeable Naval medical
features of the past war, when such large numbers
of men were employed in the Mediterranean, has
been the extraordinarily few cases of undulant or so-
called Malta fever tidmitted for treatment. Whereas
twenty years ago tlie hospital at Malta would have
been crowded with these cases, during the years
1914-1918 there was a total of only fifty-seven; of
these six were French, eighteen Maltese, and
thirty-three British ratings.
This happy result is due to the precise know-
ledge gained by a scientific Commission as to the
etiological and epidemiological characters of the
disease and the enforcement of the preventive
measures recommended; the chief feature of these
latter consisted in the use only of preserved or
thoroughly sterilized fresh milk both ashore and
afloat.
Of the few cases which were sent to England
and came under my care at the Seamen's Hos-
pital, Greenwich, the following was of particular
interest : —
Histurtj. — The onset of the disease was in the
Adriatic in May, 1919. He rarely went ashore,
and stated that he did not drink any milk. After
two months he was invalided convalescent to
England, and in the fourth month (September) was
admitted to Greenwich, a typical case of chronic
undulant fever. There was a history of long,
irregular, undulatory pyrexia, early arthritic
attacks, with constipation, sweats and increasing
debility. He now felt and looked almost well.
There were no subjective symptoms, but objective
signs Were abundant; slight irregular temperature,
99'4; pulse TOO and easily increased; heart excit-
able; impulse diffused; tongue large, flabby and
indented by /all the teeth, high degree of blood
agglutination' with M. niclitensis to a titre 1/2000.
There was a secondary anismia with low poly-
morphonuclears (30 per cent.) and high lymphocyte
count (56'7 per cent.), the clinical features in-
dicating a persistent niclitensis toxiemia and prob-
able relapses.
He was treated with arsenic, iron, yeast and
good nourishing diet, and a course of sensitized
melitensis vaccine (1 c.c. every fifth day = 300
million) was conmienced early. At the beginning
of October there was a fresh pj'rcxial attack asso-
ciated with a vesicular eruption on the right side,
extt'nding downwards to the knee over an area
su])i)lie(l by the fourth imd fifth lumbar nerves,
pain was moderate, reflexes were increased, and
jis the eruption dried some desquiunation and loss
of sensation ensued. This continued for about
three weeks, and was followed by an apyretic
interval. Subsequently several abortive waves
occurred with slight neux-itis and a sharp attack in
December (eighth month), associated this time with
acute right orchitis. A freshly prepared non-
sensitized vaccine was now given and the patient
steadily progressed; teji months after admission he
was discharged, apparently convalescent. Through-
out the agglutination titre was high (1,000 or
more), no doubt partly due to the vaccine treat,
ment, and the relative count still remained very
abnormal with 40 to 56 per cent, of lymphocytes. It
is the first case I have seen, and I cannot find any
previous record of one of herpes zoster as a com-
plication of undulant fever, in this instance im-
plicating the posterior root ganglia of the fourth
and fifth lumlsai- nerves. Though the evidence of
the specific toxin was so abundant, the organism
could not be isolated from tl;ie blood or urine.
With regard to treatment, the administration ol
yeast, though well tolerated, did not appear to
influence the blood count, neither did the sensitized
vaccine prevent relapses, but under a course of
freshly prepared ordinary melitensis vaccine im-
provement was marked.
A further interesting case has recently been
under my care, in the Seamen's Hospital. The
patient was admitted for undulant fever contracted
in the Mediterranean during 1915. He was quite
convalescent, but his serum was found to agglu-
tinate with M. melitensis to a titre of 1/200 and to
M. parameiitensis to 1/2,500. An absorption test
showed the case to be a true parameiitensis infec-
tion; it is the first recorded in the Naval service.
SPRUE IN AMERICA.
By Edwabd J. Wood, B.Sc, M.D., D.T.M. (Eng.)
Tropical sprue was described by Hillary in Bar-
badoes as early as 1776. There has always been a
question whether this disease in the western hemi-
sphere was the same as sprue of the East. It will be
recalled that Sir Patrick Manson regarded it as true
sprue, while, on the other liand, Carnegie Brown says
only in tropical and sub-tropical eastern Asia can the
disease be found. It may be on account of this
declaration of the latter observer that the disease is
being so generally overlooked in America.
After seeing numerous cases of what I regarded
as sprue, I was desirous of determining for myself
whether or not there was any real difference between
the two conditions. In London at the Tropical
School it has been my privilege to see the disease
from the East diagnosed by men whose experience in
the eastern tropics made their opinions all that the
critical could demand. A careful observation of the
cases in London shows conclusively that there is no
ditt'erence in the condition of the West and of the
East. In both regions the characteristic signs of the
disease are the same. The diarrhoea was found
to differ none at all, manifesting itself in large,
light-coloured motions, which were acid in re-
action and passed chiefly in the early hours of the
202
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. IG, 1920.
day. The tongue of the cases I have seen in London
was the same as the tongue of my American cases.
From reading the hterature of eastern cases, I had
expected to see in tlie tongue the point of distinction
if there was any. It was surprising to see in these
eastern cases in London no more severe mouth symp-
toms. This fact seems to justify the suspicion that
frequently the hterature over-emphasizes the tongue
symptoms which, in a hirge proportion of the cases
under my observation, are quite secondary to intestinal
and blood symptoms. It is altogether probable that
a larger number of observations would have demon-
strated many with a more severe glossitis than I liave
recorded. The general opinion prevails with us in
America who have studied sprue that in the eastern
disease the tongue symptoms are moie exaggerated.
It would not be amiss, tlierefore, to point out to the
observer seeing his first cases that there may i)e all
degrees of tongue involvement.
The anaemia in sprue is more characteristic than is
usually regarded. Tiie general opinion seems to be
that it is of the secondary order and there is no
evidence presented to the contrary, but it is a notable
fact that the colour index, especially in the advanced
stages, is above one: that is, on the pernicious anaemia
side. This fact is likely to be in the future, as I have
suspected in the past, a source of error in diagnosis,
for there are a number of points in sprue strongly
suggesting pernicious anasmia, I have seen grave
cases with high colour index, comparatively trivial
tongue symptoms, and the usual diarrhcea, together
with great chronicity and a marked tendency to re-
mission. It will be recalled that Hunter mentions
mouth symptoms in pernicious anaemia. One of my
patients with sprue had been deprived of all her
teeth in the hope of relieving the condition which was
not recognized as sprue. In sprue I have found a
dearth of nucleated red cells, though the colour index
was high, hut this does not seem to be the universal
experience.
The remissions of sprue much sinmlate those of
pernicious anaemia. Thi.s has probably resulted in
a faulty conception of the curative value of many
therapeutic procedures, for in both diseases the symp-
toms at certain times tend to abate without treatment
or in spite of it.
American cases of sprue have been chiefly confused
with pellagra. Tliis source of error is especially un-
fortunate as it is not justifiable, though many who
have the riglit to speak with authority still regard a
differentiation as difficult in some cases. Tlie (juestion
ci»^ be readily settled by a study of the utilization of
fat. In sprue, as was shown by ■). H. Pratt, there is
a marked loss of fat in the stool and also an increase
ill nitrogen loss. Pratt used a modified Schmidt-
Strassburger three day test diet. The fieces was
collected and the amount of the extracted fat coni-
l)ared with tlie original fat of the food. This same
line of investigation was done for me by Captain
(ieo. F. Catlett (U.S..\.) in my pellagra cases, and it
was shown that in this condition there was not
present this great fat loss nor was the tntrogen loss
so marked. In sprue, Pratt and Spooner found pan-
creatic insufficiency which was indicated by the
Einhorn-Schmidt thymus test and the Sahli glutoid
capsule salol test. It will be recalled that Manson-
Bahr in his Ceylon cases fountl that the fat absorption
ranged from 70 to 90 per cent. In the American
cases this was often exceeded.
In addition to these differences tliere are many
other points of distinction between pellagra and sprue.
In pellagra there is a marked macroscopic difference
in the stools, as the colour, consistency, reaction and
time of passage differ widely. In sprue the anaemia
is a marked feature while in pellagra it is quite
inconspicuous. The nervous features usually occur
early enough in the course of pellagra to make a
point of great practical importance. The seasonal
incidence of the outbreak of pellagra which is so
definite is another helpful point in differentiating.
The final test should be the absolutely characteristic
skin lesion of pellagra. It is seldom if ever justifiable
to diagnose pellagra without this symptom or a
satisfactory history of its past occurrence.
The tongue differs markedly in sprue and pellagra.
But there are typical cases especially of a mild type
in whicli the differences are not notable. As a general
rule I have found that in pellagra the colour of the
tongue is » deeper hue than in sprue. In pellagra
the tongue is more pointed and less flabby tiian in
spi'ue. In pellagra, salivation is often a most dis-
tressing feature, while in sprue if it occurs at all it is
of comparatively trivial nature. In sprue I have
never seen salivation, though some writers have
recorded it. It would he helpful if information were
forthcoming on this point. My own observation
would make it a point of helpful differentiation.
Crombie's molar ulcers have been described in sprue,
but also occur in pellagra. It is not infrequent to see
a line of ulceration extending almost completely
around the free edges of the tongue. In cases of
pellagra witii salivation the odour of the mouth is
exceedingly offensive. The pain in tlie mouth and
oesophagus in pellagra is much greater than in sprue,
though in the latter it is often distressing. The
ulceration of the papillai of the tongue in sprue must
be considered in a differentiation as it is infrequent
in pellagra according to my experience.
One of the sources of error in the recognition of
sprue is chronic pancreatitis. .\s above indicated,
there occur in sprue evidences of pancreatic inactivity.
It will be remembered tliat in 1907 Mayo Eobson
reported the finding of chronic inflammatory changes
in the pancreas in cases diagnosed as sprue, and
stated further that in other instances sprue was com-
plicated by pancreatitis. In numerous post-mortem
examinations in sprue there has been observed an
atrophic condition of the pancreas. One of the much
needed contributions to the knowledge of sprue should
he on the relationship of the pauci'eas. Whether
))ancreatic changes are result or cause of sprue needs
to be doterniined. It is interesting Ici jiM-ord lioic a
personal conintiiiiicatiun fmni Dr. I'latI mi a c;isc df
sprue in whicii he did imli liml liancrc^alic insiiniriciu^y
hut a fat loss of 59 pi'v cciil. licforc doli'iniiiiiiiL;
finally tlie part played by the pancreas in this prohloiii,
Aug. 16. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
we must not lose sight of the possibility of the duo-
denum being a factor of importance.
The distribution of sprue in America is a matter of
considerable interest and importance. Until more
interest is aroused and the diagnosis is more generally
made, no statistical data can be had. In North
Carolina where my observations were made, it was
found through a discussion in the State Medical
Society that the disease wiis by no means a rarity
nor a recent addition. There is evidence of it in the
States of Virginia and Georgia also. One of my
cases came from near Boston. This patient had not
been in the tropics or sub-tropics in twenty-live years
and the case was absolutely characteristic. This
patient had reached a lower physical point than any
case I have seen in London, but a recent letter from
America states tiiat he is i)erfectly well after several
years of diet l)attle. In this case the strawberry
played an important therapeutic part. I am told
that in California the strawberry has proven a
valuable therapeutic test in the diagnosis.
It cannot be too strongly emphasized that sprue,
like so many otiier conditions, may occur beyond even
the sub-troi)ics, and should l)e more generally had in
mind, especially in cases with anaemia and diarrhoea
to which may be added sore tongue, even though
trifling in cliaracter.
It is reasonable to presume that sprue will be
generally recognized in America, and the number of
diagnoses will increase with an increase in interest
in tropical medicine.
REFP^UENCES.
Castellani and Cualmeus. " JIanual of Tropical Jledicine,"
3rd edition, p. 1780.
Mayo-Robsok. Brit. Med. Jniirn., July 27, 1907.
JIaN30N-Bahr, p. Trans. Soc. Trap. Ued. and lltig., 1914.
PHATTand SpooNisR. Jonrn. Am. Med. Associi., li'x, No. 3.
Editorial. London Joubnal Tbopical Medicine and
Hyoiene, Sept. 1.5, 191-8.
Pratt, J. H. .liii. Joitrn. Med. Sci., JMaich, 1912.
Wood, K. J. Am. Jonrn. Med. ScL, Nov., 1915, and Trans.
Assocn. Am. Phys., 1915; Journ. Am. Med. Assocn., 1919;
U.S. Navnl Med. Bulletin, 1919 ; "Pellagra," D. Appleto;i and
C ... 1912.
LONDON SCHOOL OF TKOl'K'AL MEDICINE.
E.\AMiNATiON Eksi'lt. (>3ui) Skssu)n. M.w-Julv,
1020.
Passed with l)i.^tinrlini,.-^-\M\r. T. .1. 1)., M.B ,
B.Ch., gained " Dimcan ' M,<lal ; .Jamison, R.,
M.B., Ji.Cb., IJ.U.I., 1' .MO., Swa/.ihmd; O'Dris-
coll, Miss E. .1., M.H., ( |,H., IMM.; Hoynolds,
F. E., M.B.. Ch.B.
Passed.— M:w\<rirAr. M. ,), M.B,, B.S. ; Mac-
Kay, .1. .M.. M.U., (h.P,.. West .African Medical
Service; Haw. s, |;. B., M.K.C.S., L.R.C.P.;
Ci.avina. .1., ^f.l). (Malta) : Fonvst. .T., M.B..
Ch.B., Ma.j<,r I. .M.S.: Criticn. V. E.. M.D. (Malta):
Eldaab. S. .\ . M.B,(\S. ; Hnlnu-s, .J. V., ]M.B..
B.Ch., B.A.O., ]).P.H.: Wilson, G. C. R.
M.R.C.S., L.R.C.P., Tanganvika Territoi7; Parrv,
■L H., M.R.C.S., L.R.C.P.. Tanganyika Territory.
fioticti.
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THE JOURNAL OP
Croptcal £@eDittneanD!^pgiene
Ai:(a:ST 10, 1920.
REFLECTIONS ON SOIME .\1T>]MENTS IN
THEIR TEMPEH.\TE .\ND TROPIC.XL
ENVIliONMENT.
RlIKl-M.VTISM.
TiiK vory mention of rheumatism as a subject
for discussion is one calculated to at once lessen
interest and to check enthusiasm on the part of
204
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 16. 1920.
the investigator and the practitioner of medicine.
The definition of the disease is as impossible as its
treatinent, and it therefore opens wide the portals
for the entrance of the theorist and the quack.
The multitude of names assigned to the several
forms of the malady is evidence of the hopelessness
of inexactitude which surrounds the subject and the
empiricism which attends its treatment. Tropical
medicine has not helped us in this direction as it
has in so many others, and we know but little of
the disease in the tropics. Few writers on tropical
medicine deal with it ; even in the encyclopaedic
volume by Castellani and Chalmers rheumatism in
any one of its hydra-like forms is only mentioned
in a general way; and although the disease has
been found in animals in the fonn of rheumatoid
changes in the bones entering into the joints of
animals, showing its prevalence in periods long
antecedent to the appearance of man upon the
earth, our advance in knowledge is clinical merely,
and yet the amount of knowledge in this sphere
is infinitesimal and unsatisfactory. The root of
the term rheuinatism is " associated " with the
word rheum, derived from the Greek word pev/j,a
= flux, stated to mean any watery or catarrhal
discharge, but as rheumatism in any form is seldom
associated with a disehargt' in the common accept-
ance of the term, confusion and not elucidation is
added thereby. The Latin and Greek synonyms
are the mere dialectic equivalents of the modern
name, and in no way help us to determine any
reason for the adoption of the name. Yet the
disease perhaps of all diseases the most widespread
in the world has not advanced with modem science
in accordance with other branches of medicine.
It is extraordinary that this ailment which is on
every lip has been allowed to be side-tracked by
investigators who seem contented to allow it to
occupy an unexploited region in the great field of
disease. Are rheumatism and rhevmiatoid ailments,
be they of joints, bones, muscles, viscera or con-
nective tissues, generally to be allowed to defy
man in future as they have done during the ages,
or are we to take up the cudgels to tackle- this,
one of man's greatest detriments to health? Can
tropical men help us ? It is not an inviting field for
research; the disease is commonplace, and neither
the pathologist nor the bacteriologist have helped
us in any but to an infinitesimal extent. Several
varieties come before. Amongst these we may
mention rheumatic fever. Is it prevalent within
the tropical zone? This is readily answered, and
a definite "No, it is not," is forthcoming. That
fact has only been established of late years. The
writer brought the subject before the Royal Society
of Tropical '^Medicine and Hygiene a short time ago.
whilst dealing with the subject of the absence of
certain well-known diseases of temperate climates
not met with in the tropics. The writer, whilst
analysing several annual medical reports of tropical
countries, found rheumatic fever included in the
list of recorded ailments dealt with. The medical
officers of the tropical countries thus mentioned
happened to be present, and stated that this was
a false statement, and explained that in drawing
up these reports several native medical officers,
unacquainted with the British meaning of rheu-
matic fever, hatl called cases of fever associated
with muscular (rheumatic) pains (and undoubtedly
put these down as) rheumatic fever. We may
therefore state definitely that acut-e rheumatism, or
rheumatic fever as it is known in Britain, is not
met with in the tropics. A further note may be
appended to this, viz., that persons who have had
rheumatic fever in Britain, and who subsequently,
to the attack have taken up residence in the
tropics, very rarely have a recurrent attack. The
absence of this recurrence is worthy of careful
notice ; is it the hot climate alone that kills
out the disease, be the origin what it may, or is
it some cause independent of heat and due to
environment in some other form? The tendency
in this country is for a recurrence to take place — in
the tropics it is not so; and here a wide field of
research is open to investigators to determine what
part heat plays, if anj\ in this marked phenomenon.
Speculation in the matter will be rife, and if heat
is proved to be the cause of the disappearance of
the disease, then a help towards treatment is at
once brought about and advanced. The basis,
however, for real advance is not yet made. The
etiology of rheumatism in any form is not known ;
and until that is discovered we are practically at
a standstill. Our chief cause for valvular disease
of the heart is, we may say, undoubtedly rheumatic
fever. The suggestion then presents itself. Given
the absence of rheumatic fever in the tropical zone,
what are the chief causes of valvular disease in
young (native) people in the tropics? Do they
suffer widely from " heart disease " of the kind?
If so, to what is this ascribed ? We confess our
knowledge on this subject is limited, and we should
welcome information on the point; it is a subject
everyone in practice in the tropics can assist in
elucidating, and it is to be hoped it will be done.
Eheumatoid arthritis, a disease so common in
England and in most parts of Britain that few
escape it in old age, has again to be considered as
regards its prevalence. Do the Chinese, Indians,
&c.. suffer from the disease as do we at home? Do
we see the bent-backed, stiff-jointed, swollen-
knuckled, hirpling old people in tropical countries
we meet with in our villages? " Ould Jarge " is
the type of old-age villagers in England. It is put
down to beer drinking — probably a totally wrong
idea. We get it in the well-to-do, who seldom or
never touch beer; the lady maj- not be able to get
her rings off her swollen finger joints without a deal
of pain and troubli'.
In her and in her class it is usually put down to
gout, also an error in all likelihood ; and but another
camouflage to hide ignorance in regard to the elusive
borderland between gout and rheumatism, and so
forth. The evidences of ignorance are plentiful,
the evidence of real knowledge in this subject prac-
tically nil. When is this well-nigh universal ail-
Aug. 16, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
meat, to be dualt with'.' It requires scientific
liandling, and tlu! geographical distribution of the
disease is the first line of attack to follow, not only
the distribution as to climatic zones, but even to
districts in the homeland and the effects of soil,
environment, food and drink. Is it favoured or
otherwise by beer, wine, or spirit di'inking ; is it
more prevalent in clay or gravelly soil? Even
these are not settled. It is a popular stigma attach-
ing to clay soil, but it is not proved, a mere popular
legend as fai- as proof is concerned, and may turn
out to be a wholly fallacious one.
Will tropical practitioners help in this matter
not necessarily by way of bacteriology, but by
observation in what form rheumatism comes into
their practices. We have crushed out our " ordi-
nary " observers by bacteriology. They think that
unless it is a new germ or a new insect that they
have to report it is not interesting and of little
importance to anyone but themselves. It will take
some time to eradicate this slavery to the
"ologies." The practitioner is the outpost in all
our observations in disease, and nothing is more
important, none more elucidative than the record of
the diseases met with in daily practice, in other
words, the geographical distribution of disease.
llcbifal sBoUs.
Dr. Guido Cuem()N15SE, in a paper on the preven-
tion anrl treatment of malaria by means of mercurial
preparations, states that, some years ago, he noticed
that sj'philitic patients who had undergone treat-
ment with mercury were apparently immune to
malaria and he came, therefore, to the conclusion
that mercury might have a preventive and curative
action in malaria.
At first he gave mercury by intramuscular injec-
tions of a 1 in 1,000 corrosive sublimate solution.
Later on he adopted the following pills: —
Mercuric biniodide
Extr, gent, q.i
grm. 001
He claims very good results from the adminis-
tration of these pills both in the prophyla.xis and
curative treatment of the malady.
As a matter of fact, preparations of mercury
were tried in malaria many years ago without any
very definite results.
We would also refer our readers to what Sir J.
Cantlie styles a modification of the old English
pill (or powder) used in chronic mal.u-ia and freely
used by him to-day.
Quininfe bihydrocbloridi
Acidi arseniosi
Pil. saponis co.
Hydrarg, subchloridi ...
14 gr
14 .,
■t'l ..
in which small doses of mercury arc introduce4.
€\ixunt fiterattirf.
Bulletin de la Societe de Patholoqie Exotique.
May, 12, 1920.
Tuberculosis of the Sknll Wall in a Soudanese
Negro (F. Noc and A. Esquier). — The case is pub-
lished as a contribution to the study of infectious
lesions of the skull in the natives of West Africa,
though the patient was lost sight of before any
definite method of treatment could be decided
upon. Two painful abscesses were present in the
parietal region, one on each side of the head, of
the size of an egg and a nut respectively. Puncture
produced a clear liquid containing neither bacteria
nor parasites, but a guinea-pig which died after
inoculation with it showed typical tubercular lesions
and Koch's bacillus at autopsy. The possibility of
an association of syphilis with the tuberculosis
could not be ruled out.
The Herpetomonas and Spirochxta of the Blatta
orientalis (A. Laveran and G. Franchini). — In cock-
roaches taken from Paris bakeries the authors found
a very few flagellata of the type previously described
by them under the name of Herpetomonas peri-
planetce; in the digestive tube spirochceta, gre-
garina and microsporidia were more common; and
bacteria wei-e always present in large quantities.
The spirochete would appear to be a new species,
to which the authors give the name of Spirochceta
periplanetce ; four mice out of five were infected
experimentally with the organism, and two of them
died within forty-eight hours after inoculation.
An Attempt at Medical Prophylaxis against
Sleeping Sickness in Oiibangui-Chari (E. Jamot). —
With a very limited staff and the barest of equip-
ment, the author succeeded in visiting nearly the
whole of a district comprising 100,000 square kilo-
metres in twenty-two months and examining 89,743
natives, 5,347 of whom showed trypanosomata. In
certain regions, where the disease had acquired
epidemic proportions, the mortality was reduced by
65 per cent., and the virus in circulation by from .
54 per cent, to 90 per cent., thus proving that it
is not only jjossible but comparatively easy to
combat the infection if properly organized measures
be taken. In the author's experience it is quite
possible to train natives in the work (both of
examination and treatment) sufficiently to enable
the assistance of Europeans to be dispensed with
for all but supervisory purposes. He considers the
most suitable method of prophylaxis to be that of
a/lministering injections of atoxyl every two or
three months to all infected persons.
Ldhoratori) Methods in the Diaquosis of Sprue
(1. Gonzalez-Martinez). — The author recommends
the simultaneous use of the culture and complement
deviation reaction tests in the diagnosis of all eai-ly,
incomplete and latent forms of sprue. In ordinary
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 16, 1920.
gelatine Parasaccharoniyces ashfonli cultures are
quite characteristic, and never licjuofy the media;
tho.y neither coagulate litmus milk nor turn it red,
and invariably ])roduce fermentation in maltose
broth. In the complement deviation reaction test
the author, using warm serinn and an emulsion of
a si.\-day-old culture of Farasacchurontyccs atili-
fordi in glucose gelose (Sabouraud), obtained a
positive reaction in Dl'So per cent, clinically posi-
tive cases. All reactions showing an anti-haemolytic
power of less than 25 pcv cent, were considered as
negative.
On the ivorlihuj o/ a TnjjmnosoiniaHiti rrophij-
lactic Sfcfor in the French Comfo (1019) (A. Plot).
— The sector (Ibenga-Motaba) is the first to be
organized in accordance with the reconunendations
of the Sleeping Sickness Conuuission. The inhabit-
ants have been examined and grou])ed, and all
positive and suspect cases registered. At least one
dose of atoxyl has been given io every infected
person, and the results have been satisfactory
enough to inspire the confidence of the native
population, which, having been reduced from 18,000
to 1,000 in the last eleven years, is now fully alive
to the danger of the infection.
Experinientti in the Aiifti-hu'vidthcmiiic Treat-
ment of BJaektrater Frvcr (Henri Fabre).— In
Upper Tonkin 3 i)er cent, of the native troops were
attacked by blackwater fever during the last two
years, the mortality being about one-third of the
cases and the average length of stay in hospital,
when recovery took place, six weeks. Treatment
with horse serum having reduced this period con-
siderably in one instance, injections of the patients'
own blood were tried, with the result that the two
cases in which the experiment was made were able
to leave hospital in eleven and fourti'cn days
respectively.
Malaria at Camblanca (Moruero) (L. d'Aufre-
ville). — The writer urges the necessity of conduct-
ing a more effectively organized campaign than is
at pn-sent being made against this scourge.
Vaccination against Cattle Plague (H. Schein). —
Referring to Dr. Croveri's article in the Bulletin for
October, 1019, in which he reports unfavourable
results from the use of Schein 's method of vaccina-
tion against cattle plague, the author objects that
the experiments were insufficient to justify the con-
clusion arrived at, especially as there were no
controls. " Contrary to the opinion of M. Croveri,"
he states, " 1/1,000 c.c. of virulent blood, injected
simultaneously with the serum, appears sufficient,
at least in the case of Indo-Chinese cattle, to pro-
voke a reaction strong enough to confer an active
and stable immunity; moreover, in the case of
buffaloes, which are ultra-sensitive animals, the
process is attended by so low a mortality as to in
no w?y prohibit its use.
%Html
OBSERVATIONS ON CASES OF SEASONAL
HAY FEVER DIAGNOSED AND TREATED
WITH POLLEN EXTRACTS.'
By Captaia W. C. Williams,
Sanitary Corps, United States Army.
During the month of August, 1919, it was decided to
make an effort todiagnose and treatautumnal hay fever,
with a view to determining the specificity and efficacy
of the cutaneous tests for sensitiveness to plant poUens
and the amount of relief that could be expected in the
treatment of this condition with the extract of the
particular pollen responsible for the symptoms.
It was well understood at this time that the
opinion of workers iu this field was practically
unanimous that the greatest relief was to be expected
from a prophylactic rather than from a curative stand-
point, and that the process of desensitization was
more effective when started before the commencement
of the hay-fever season than during an attack. It is
to be regretted that we were unable to study the pre-
liminary desensitization of any patients, and that the
only cases that we saw were those who applied to the
attending surgeon for relief after the development of
well-marked hay fever symptoms.
Bearing in mind the above facts, the results
obtained at the Army Medical School are not to be
taken as a final criterion of the value of pollen extracts
in the prophylactic desensitization of persons subject
to seasonal hay fever, and are presented only as a
matter of general interest.
In all cases diagnosed, the simple cutaneous test
was used, with pollen extracts obtained from a reliable
commercial house. A slight abrasion is made on the
flexor surface of the forearm for each pollen to be
used and one for a control. These were to be made
with an ordinary needle, or with a Von Pirquet borer,
the abrasion being not over one-eighth inch in length
and preferably not drawing blood. A drop of pollen
extract is placed on each abrasion, while the control
receives a drop of dilute alcohol in saline. A careful
diagram should be made beforehand showing the dis-
tribution of the extract to the abrasions. If rapid
drying takes place the spot may be moistened with
another drop of the extract. In positive cases a
distinct reaction takes place usually within ten
minutes, and is seldom delayed later than twenty
minutes. An urticarial wheal and more or less
hyperemia rapidly develops at the site of the abrasion
to which has been added the particular pollen to
which the patient is sensitive. The control, naturally,
shows no wheal and only a slight redness due to the
irritation of the scarification. The treatments were
carried out with gradual dilutions of the specific
pollen extract, as determined by the cutaneous tests.
A total of twenty-nine patients was seen from the
time that we were in a position to diagnose, and
' Abstracted from the Military Surgeon, vol. xlvi, No. 2,
February, 1920, p. 199.
Aug. 16, 1920.] THE JOtJRNAL OF TROPICAL MEDICINE AND HYGIENE.
make an effort to treat, autumnal hay fever (August 15)
until the last patient had cleared up with the advent
of cool weather (October 10). Of these twenty-nine
people, eight came in for diagnosis only and were
not treated, while twenty-one were diagnosed and
received a varying number of treatments.
The cases were diagnosed as sensitive to either
ragweed or goldenrod pollen as follows : —
Ragweed ... 22 or 81'4 per cent, of cases diagnosed
Goldenrod ... 5 or 185
No reaction .. 2
Total
29
Of the cases failing to give any reaction one cleared
up rapidly under treatment for bronchitis, while the
other was not heard from again. Both cases were
probably " colds " instead of true hay fever.
Ragweed Cases.
The twenty-two cases of ragweed sensitiveness
were divided as follows : —
For diagnosis only .. ... ... ... 6
One or two treatments onlv ... ... ... 4
Treated cases ' 12
The cases "for diagnosis only" need no remark,
as they merely came in to find out which pollen
tliey were sensitive to. Of the four cases receiving
insufficient treatment but one is of interest, the
other three being discharged or leaving the city.
The one case in this group that is of interest,
" Captain X," received a diagnostic skin test on
August 25, followed by tlie smallest injection ordin-
arily given (O'l c.c. of a 1 to 10,000 dilution). On
August 27 the attending surgeon informed us that the
patient claimed to have had an extremely severe re-
action, with accentuation of eye and nose symptoms
and great distress in breathing.
Of tiie remaining twelve treated cases, all received
regular treatments of graduated doses. Not a single
one of the twelve patients showed any marked or,
in fact, noticeable improvement or alleviation of
symptoms until the advent of cooler weatiier and the
end of the pollen season. One case, in spite of
strenuous efforts to control it, progressed so rapidly
and so severely that the patient was forced to leave
the city for a prolonged sea voyage in order to obtain
relief. Two of the cases stated that they felt a little
easier after the injections, but this was not constant
or permanent.
The results with tiie -ragweed pollen extract as a
therapeutic measure could not be considered en-
couraging. However, tliese patients were all requested
to report next spring or early summer for a course of
desensitizing treatments, to i)o completed before the
commencement of tlie autumnal bay-fever season.
GoriDENiioi) Casks.
An analysis of the five goldenrod patients shows
tliat one case came in " for diagnosis only " ; one had
a very severe reaction following the first injection
(O'l c.c. of a 1-10,000 dilution), including increased
asthma and some of the typical signs of bay fever
which she had never had liefore ; while three cases
received from three to six injections. The case with
the severe reaction received, six days later, a
diminished dose of 01 c.c. of a 1-20,000 dilution, but
unfortunately did not return or inform us of the
reaction following the second injection. It was later
understood that she had left the city shortly after
the second injection.
Of the three remaining cases, one received three
injections with a remarkable improvement of both
local and generalized symptoms, commencing after
the first treatment and witli all symptoms entirely
subsiding after the third injection. Tlie other two
cases each received six treatments with a gradual but
complete subsidence of all symptoms. It is of course
possible that this may have been due to the change
in the weather and the elimination' of the pollen, as
the final treatment was given one case on September
26, and the other case on September 30.
The use of the extracts of goldenrod pollen gave
manifestly better results than the ragweed pollen
extracts. Although the series of cases was smaller
and the treatments started slightly later in the season,
introducing the uncertain element of the weather
influence, it was felt tiiat the patients received a
distinct benefit from the treatments.
Summary.
1. Of twenty-seven cases of bay fever diagnosed,
81'4 per cent, were due to a sensitiveness to the pollen
of tlie ragweed, while 18'5 per cent, were due to a
similar sensitiveness to goldenrod pollen.
2. The diagnostic cutaneous reaction offers a simple
and clear-cut method of determining sensitiveness to
|)ollen proteins.
3. Treatment with the extract of ragweed pollen
did not appear to have any favourable influence upon
the course of the disease or the severity of the
symptoms in twelve cases treated.
■i. Treatment with the goldenrod pollen extracts in
three cases was apparently beneficial in two cases
and markedly so in one particular case.
Any method of diagnosis or treatment that will
offer a suggestion of relief to the vast army of sufferers
from this really serious condition should bo given a
thorough and conscientious trial. It is hoped that
wo will be able to try the effects of early desensitiza-
tion upon many of the same patients before the com-
mencement of the autumnal hay-fever season this
year.
P^Xl'EHIMHXTAL FELLAOHA IN WHITE
.MALR CONVICTS.'
By JoSKi'H (ioi.i.p.P.iKiKR, M.D. and ('.. A. Wiikk.i.er, W.D.
Washington, D.C.
Si'MMAUV.
(1) Am rxpriiuK'nt was cui-ricd out at the Hankin
farm of the .Mississipi)i ))fnitt'ntiary to test the
jjossibilit.v of |)roducin{^ ])cllagrii in previously
liealthy nu'n hv ftvding a monotonous, principally
cereal, di.'t.
' Abstracted from the Archives of Internal Medichie, vol. xxv,
No. 5, p. 451, May 15, 1920.
208
THE JOURNAL OP TROPICAL MEDICINE AND HYGIENE. [Aug. 16. 1920.
(2) The subjects of the experiment were eleven
white adult ni.ilr cdnvicts who volunteered for the
purpose. Thr\ were segregated and kept under
special guard N<mc frave a history of having had
pellixgra or ol' tlic occun'ence of this disease in any
meiiiluT lit til,' laniil\ iir a near relative.
(3) All pcisiiiis i.th.r than the volunteers resident
on the farm were under observation as controls.
This included 108 convicts, of whom thirty-five
were under observation for a period comparable to
the period of observation of the subjects of the
experiment. In addition there were twelve free
persons who were present throughout the study;
included in these were four adult females and two
children.
(4) The general sanitary environment was the
same for subjects and controls. With respect to
personal cleanliness, cleanliness of quarters, and
freedom from insects and vermin, the volunteers
were decidedly better off than the convict controls.
(5) No direct communication with the outside
was permitted the volunteers. There was no
special restriction imposed on the controls, convicts
or free. Direct exposure of some of the controls
to a hypothetical infection was possible and may
have occurred when beyond the limits of the farm;
this possibility is believed to have been excluded in
the case of the subjects of the experiment.
(6) The volunteers continued to do a share of
the work of the farm, but, when compared with
the convict controls, they had shorter hours of
work and had regular rest periods when in the field.
The work of the convict controls is rated as requir-
ing moderate to hard, that of the volunteers as
moderate to light muscular exertion.
(7) The study falls into two periods. One ex-
tended from February 4 to April 19, during which
the volunteers were kept under observation without
any change in the regular prison fare ; the second
period extended from April 19 to and including
October 31, during which the volunteers subsisted
on the experimental diet.
(8) The average intake by the convict controls,
as shown by four periods of a week, each varied
between approximately from 3,500 and 4,500
calories, between 90 and 110 grm. of protein, 95 and
185 grm. of fat, and between approximately from
540 and 580 gi-m. of carbohydrate. Approximately
from 20 to 85 per cent, of the protein was from
animal food.
(9) The ingredients of the experimental diet were
highly milled wheat flour, maize meal and grits,
cornstai-ch, white rice, cane sugar, cane syrup,
sweet potatoes, pork fat, cabbage, collards, turnips,
turnip greens, coffee, " Royal " baking powder, salt
and pepper. During the first three months some
buttermilk was used in making wheat biscuits. All
ingredients were believed to be of excellent quality
and, with one or two exceptions, were part of the
general camp supply. In its essential make-up the
experimental diet was probably not entirely typical
of the average pellagra-producing diet.
(10) The average intake by the volunteers, as
shown by eight periods of a week each during the
experimental period, varied between 2,500 and
3,500 calories, between 41 and 54 grm. of protein,
between 91 and 134 grm. of fat, and between 387
and 513 grm. of carbohydrate.
(11) Although both classes of controls (convict
and free) were exposed to the chance of direct
contact with pellagra, and although, as compared
with the volunteers, the convict controls were at
a disadvantage hygienically, and were required to
work harder, and furthermore, although various
minor ailments and a number of rather sharp
attacks of malaria were observed among them, none
of the convict (or other) controls developed any
evidence of pellagra. On the other hand, although
segregated and under special guard and the possi-
bility of direct contact with pellagra excluded, and
although under much more favourable hygienic
conditions, not less than six of the eleven volun-
teers who remained in the test to the end developed
evidence which experienced observers joined with
us in recognizing as those of pellagra.
(12) Significant subjective symptoms made their
first appearance among the volunteers during the
second month after beginning the test diet. These
included weakness, abdominal discomfort or pain,
and headache. All subjects lost weight, the loss
becoming particularly marked during the last four
weeks of the experiment. At least six of the
eleven men developed a well-marked eruption.
The earliest date of the beginning of this was
September 12, or at about the end of the fifth
month of the diet. The initial site in all the cases
was the scrotum ; later classical lesions also
developed in one on the hands, and in another on
the neck. The knee-jerk became exaggerated in
five of the men, the earliest being October 17, at
the close of the sixth month of the experiment.
(13) Having due regard for the controlled con-
ditions of the experiment, the conclusion seems
warranted that pellagra developed in at least six
of our eleven volunteers as the result of the diet
on which they subsisted.
(14) The scrotal lesion is a much more common
early skin manifestation of pellagra than has here-
tofore been realized, but is nevertheless a some-
what unusual one.
(15) It is suggested that the site of at least the
initial dermatitis accompanying an attack is bound
up with a specific quality of the diet. The view
is advanced that there exist essential differences in
the intimate make-up of the diet corresponding to
observed differences in some, at least, of the clinical
types of the disease.
(16) In relation to the production of pellagra,
the dietary factors to be considered as possibly
essential are (1) an amino-acid deficiency. (2) faulty
mineral siqiply or constitution, and perhaps (3) an
as yet unknown (vitaniine?) factor. As to which
or what combination, or combinations, of these
constitutes the specific pellagi-a-producing dietary
defect or defects remains to be determined.
Aug. IG, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
PREVALENCE OF PELLAGRA AMONG
TURKISH PRISONERS OF WAR.'
By W. H. Wilson, P. S. Lelban, H. E. Roaf.
The objects of this experiment were as
follows : —
(a) By comparison of the fascal and urinary
nitrogen, to determine the relative percentages of
protein lost by non-absorption in two groups of
(/) healthy and (ii) pellagrous prisoners of war
receiving identical diets.
(b) By comparing the nitrogen intake with the
urinary and fsecal niti-ogen excreted by the healthy
I group, to estimate the availability (per cent.
j absorption) of the protein of the prisoners of war
I rations as issued to non-labour prisoners.
; Two groups of five men each were placed in a
J separate enclosure, under the charge of a sergeant
; and two orderlies — day and night. The men were
• for two days, before the collection of samples began,
: living under the conditions of tdie experiment.
Their weights were taken daily, and careful super-
vision was maintained over practice in tlie collection
and measurement of excreta by the orderlies.
The faeces and urine, pooled for each group, were
collected separately, and a daily analysis was made
of the urine and faeces for each group. The average
; amounts per man were calculated from these daily
analyses.
' The food was that ordinarily consumed in the
I camp, but was issued by weight from bulk in the
Quartennaster's stores, and was cooked in a
separate kitchen for the two groups together. The
conditions of the experiment did not admit of com-
plete supervision of the issues from stores nor of
the actual cooking, nor was it possible under the
circumstances to obtain daily samples of rations
coiresponding to those issued to the subjects of the
experiment; but samples were taken from the
(^uai-termaster's stores on the day before the ex-
luriment began. The amovint of foo<l left over was
( iircfully recorded.
The sequence of events consequent on lack of
f^astric acid is : Deficient pancreatic digestion ;
passage of undigested protein into the large intes-
tine ; bacterial putrefaction in that protein, leading
Id its destruction. The loss of protein, and especi-
ally of fat, even in the non-pellagrous, is obviously
of extreme importance. Whether the digestive
failure is due to pellagra, or the reverse, remains
undotonnined, but in either ease the stage of mal-
ril)sorj)tion is regarded as being antecedent to
ilcvelopment of clinical pellagra.
It is to be noted that indican was present in the
pellagrin's urine. This substance is derived from
tiie important amino-acid tryptophane of the protein
molecule. On being broken up by intestinal putre-
faction tryptophane is converted into indol, which
is absorbed and excreted in the urine as the potas-
sium salt of indoxyl-sulphonic acid. The indican
• Abstracted from the Journal of llie Royal Army Medical
Corps, vol. xxxiv, No. 3, March, 1920.
is evidence of the destruction not only of trypto-
phane, but of the whole protein molecule, and thus
of complete loss of the organism of an amount of
protein corresponding to tlie amount of indican
present in the urine. , With a diet of a composition
of the rations consumed by these men, the amount
of indican present in the urine may, when a large
quantity of this substance is present, represent a
daily loss to the organism of as much as 20 grm.
of protein. This amount ought probably to be
deducted from the metabolized nitrogen as indi-
cated by the nitrogen of the urine ; whetiier this
latter suggestion is justified or not, the presence of
indican implies that the figure of 35-1 per cent, loss
of protein in the alimentary tract represents only a
part of the actual loss.
Perhaps the most important result of the experi-
ment is to show that the percentage loss of ration
protein in the intestines of healthy prisoners of war
amounted to approximately one-third of the protein
intake, instead of about 23 per cent, as estimated
from previous knowledge. This means that whereas
the Turkish prisoner of war (non-labour) diet, con-
taining 91 grm. of gross protein, is assumed to give
68 grm. of protein available for nutrition, it actually
yields no more tlian 60 grm. The biological value
of the daily protein intake is thus reduced from
about 38 to 33 gi-m.
From this experiment it is evident that, as com-
pared with non-pellagrous, the pellagrous prisoners
suffered from deficiency of food by : —
(o) Lack of appetite.
(b) Mal-absorption of protein and fat.
(c) Destruction of protein by bacterial putre-
faction as shown by indioanuria.
TYPHOID AND PARATYPHOID INCIDENCE
AND DEATHS IN THE AMERICAN EX-
PEDITIONARY FORCE. 1
By Dr. Haven Embrson.
Including the cases of both typhoid and para-
typhoid the case mortality was 11-25. For the
French Anny during the same period the com-
bined death-rate from typhoid and paratyphoid
fevers was 9-76. In addition to typhoid and para-
typhoid fever there was a considerable number of
benign enteritides among the troops of the A.E.F.
Conditions were such that a thorough study of these
cases in respect to the organisms concerned and a
diagnosis on the basis of the laboratory findings as
well as the clinical symptoms was impracticable.
At one convalescent camp, during December, 1918,
and January, 1919, a considerable number ot
patients came who had been treated for influenza
eight weeks earlier. The attitude of the medical
officers throughout the A.E.F. was such that they
did not like to report typhoid or paratyphoid fever.
' Abstracted from the Medical Record, New York, vol. xcyii,
No. 11, p. 462, March 13, 1920.
210
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 16, 1920.
The intestinal type of influenza served to obscure
the diagnosis of subacute enteritides, dysenteries,
&c. The medical officei-s seemed to have an idea
that, owing to protective inoculation, they would
not find typhoid or paratyphoid fever. They were
seemingly deaf and blind to the evidences of these
diseases. Dr. Emerson related the history of three
yei-y definite epidemics of typhoid fever occurring
in the A.E.F., one occurring in the Argonne region
and including the personnel of a hospital there, a
second in a traction company in Marseilles. In
both instances the apphcation of well-known sani-
tary procedures served to check tlie epidemic. In
certain regions of France typhoid fever was endemic
and it was probably only because of prophylactic
inoculation that severe epidemics were prevented,
as it might be recalled that there was an epidemic
of typhoid fever in the French Army early in the
War before it was possible to inoculate the soldiers
against typhoid and paratyphoid. The third epi-
demic of typhoid fever which the speaker described
was that occurring in the Camp Cody replacement
company of 250 men of whom 99 came down with
the disease. These men had all been vaccinated
in different camps in the United States and by
different medical officers. It seemed that this out-
break could be explained only by what might be
called a massive hand to mouth infection. It
seemed that the source of the infection was a water
barrel attached to a kitchen car at Camp Cody.
The Marseilles epidemic was due to failure to
recognize large spleens, abundant roseola, and, at
autopsy, Peyer's patches and even intestinal per-
forations. Failure to recognize early cases and
exposure to massive doses of infection appeared to
be the reason the jirotective power of prophylactic
vaccination was overcome. There was no reason
to believe that vaccination did not afford the
greatest protection against typhoid and para-
typhoid fevers. It was of the greatest value in
our forces who were exposed to infection at count-
less points. In closing. Dr. Emerson urged the
need of recoi-ding the weekly change in population
in connection with the rates of incidence and mor-
tality of disease.
Dr. Harlow Brooks stated that he had seen
forty-seven cases of typhoid fever in France and
some of them were held for three weeks before a
diagnosis could be made. One of the best articles
in the Bulletin published for the medical officers
in France was on the subject of the anomalous
symptoms presented by these patients. In one
case ten blood cultures and ten stool cultures were
made before it was possible to an-ive at a diagnosis.
The symptoms were different from those of a typi-
cal case of typhoid fever; especially in respect to
the typhoid spots and the size of the spleen. He
therefore felt there was some excuse for the failure
to recognize the condition.
Dr. Emerson suggested the possibility that the
symptoms of typhoid fever had been modified in
th^e atypical cases by vaccination. He knew of
several instances in which cases of typhoid fever
were not diagnosed because of the unwillingness to
accept typhoid fever as a probability in view of the
indefinite symptoms present. However, there were
a great many records in hospital reports in which
the history qn review seemed to be typical of
typhoid fever. The pathologists were the first to
discover the epidemics and this served as an illus-
tration of the possibility of using the results of
pathological examination as a warning of the
presence of epidemic disease.
PYREXIA NOT YET DIAGNOSED, OF DENTAL
ORIGIN. 1
By Captain Herbert Wallis, K.A.M.C.
It should be emphasized that in these days of
dental decay (and in certain classes of dental
neglect) an oral examination in cases of what would
otherwise be labelled pyrexia not yet diagnosed will
reveal a definite cause and diagnosis, leading to
immediate treatment and more rapid cure of
patients.
Whatever may be the original cause, it is a
chnical fact that septic conditions of the teeth and
gums are of serious import in tropical climates, as
there seems to be a tendency to more rapid develop-
ment of the virulency of pathogenic organisms in
the mouth giving rise to vague pathological con-
ditions leading to definite disease.
Their blood films and cultures give negative
results for malaria, relapsing fever, and for the
enteric group.
In the absence of any apparent cause of fever
the dental surgeon is called in for advice and
treatment.
I examine the mouth for septic teeth and roots
causing inflammation and pus discharge, and for
evidences of pyoirhcea alveolaris, or for general
neglect of the teeth.
(a) In cases where there are septic teeth and
roots causing inflammatin, these are extracted,
and wann mouth-wash such as a 1 in 120 lysol or
any similar solution, is used every two hours; in
addition, the mouth is syringed out two or three
times in the manner described later. Under this
treatment the temperature goes down, and the
patient is ready for discharge in a few days.
{b) A frequent cause of pyrexia not yet diagnosed
(particularly amongst Indian troops) is pyorrhoea.
The routine treatment for this is : —
(1) Thorough scaling.
(2) Syringing the gums under pressure three
times daily.
(3) Local application of mist. dent, arsen.
Of these treatments special attention is given to
syringing under pressure. For this purpose I use
a rubber Higgenson's syringe, adapting a metal or
vulcanite nozzle, the size of the bore being a little
• Abstracted from the Journal of the Royal Army Medical
Corps, vol. xxxiv. No. 4, April, 1920, p. 360.
Aug. 16, 1920.:
THE JOUENAL OP TBOPICAL MEDICINE AND HYGIENE.
larger than the lead in a lead pencil; this gives a
fine powerful jet or stream of fluid which is capable
of forcibly penetrating between the teeth and within
the gum margins. An orderly works the syringe
bulb with both hands, using as much force as
possible.
The operator is protected from the sjiray thrown
back by a sheet of glass or eelhiloid held in front of
patient's mouth.
A warm solution of 1 in 120 lysol or similar solu-
tion is used.
This syringing treatment is given two or three
times daily, depending on the intensity of the
condition.
Pyorrhtea alveolaris is very prevalent amongst
the Indian troops, and, in addition, is, in many
cases, the cause of anaemia, debility and other fonns
of sickness amongst them. A special ward is
allotted for these cases for convenience of treatment,
and to prevent the spread of infection.
Large concretions of tartar are often found,
causing ulcers on cheeks and tongue. Thorough
and extensive scaling is performed.
(2) A mouth application of mist. dent, arsen. is
given. Mist. dent, arsen. is composed of: —
^ Vin. ipecac.
oii
Liq. arsen.
,^i
Glycerin
;-)ii
Aquam
3vn
This mixture is issued in two-trachm bottles (to
obviate self-poisoning).
Three drops should be used twice daily; apply
one drop at a time on the toothbrush. The gums
should be gently brushed with this mixture on tlie
brush.
SURGERY IN CHRONIC DIARRHO-^A. '
By Samuel Goodwin Gant, M.D., LL.D., New York.
There are many types of diarrhcsa, such as gastro-
genic, enterogenic, neurogenic and others, that are
not surgical conditions, since they are relieved or
cured by rest, diet and medication. Mild forms of
enterocolitis also respond to this treatment reinforced
by medicated colonic irrigation. Chronic diarrhcea is
a surgical condition when the rectum and colon are
extensively involved through catarrhal or mixed in-
fection processes, accompanied by a violently inflamed
or extensively ulcerated mucosa causing frequent
fluid evacuations containing a considerable amount of
mucus, pus, and blood. Formerly, when a patient
complained of severe diarrhcea, abdominal pain, and
mucus or bloody evacuations a diagnosis of dysentery
was made, but the term shovdd be discarded since
this symptom complex accompanies several types of
ulcerative colitis.
Considering the subject from an etiological view-
point we have to deal with catarrhal, tuberculous,
luetic, amoebic, bacillary, balantidic and helminthic
'Abstracted from the New York Medical Journal, vol. cxi,
No. 17, whole No. 2160, April 24, 1920, p. 709.
colitis. There is another form of diarrhoea requiring
surgical treatment, viz., obstructive, and this is seldom
correctly interpreted. This variety of loose move-
may be induced by benign or malignant
stricture, Ijypertrophied rectal valves, or
any lesion that constricts or occludes the colon or
rectum, and patients afflicted in this manner are
usually treated for constipation in the beginning and
ordinary diairha'a later, without the physician having
suspected an obstruction.
The surgical treatment in such cases consists in
excising the lesion, or if inoperable and dangerous
obstruction prevails, in making an artificial anus.
Several operations have been employed in the surgical
treatment of chronic diarrhoea due to catarrhal or
specific ulcerative colitis, appendicostomy, caecostomy,
Gant's ileocaecostomy and colostomy, procedures not
resorted to until medical treatment and irrigation by
way of the anus have proved ineffectual.
Appendicostomy is simple, effective and requires
but ten minutes to perform when the caecum is ex-
posed through the right rectus and the appendix is
brought out and anchored in a stab wound incision.
When diarrhcea is increased and the stools contain
an abundance of pus, blood, and mucus, the appendix
is opened, a Gant appendiceal irrigator or catheter is
inserted, and the colon immediately flushed ; but ir
less severe cases the appendix is amputated a week
later and irrigation inaugurated, which diminishes
danger of infection and skin abscesses.
Caecostomy. — This operation is resorted to following
previous appendectomy, and when appendicostomy
is attempted and found impracticable because the
ap|)endix is congenitally absent, too short, narrowed,
strictured or othei'wise diseased. The technique of stab
wound caecostomy is not difficult ; leakage is prevented
by infolding pursestring sutures, and tiie caecum is
suspended to the parietes to lessen danger from peri-
tonitis. Mortality of this operation is slightly higher
(two per cent.) than appendicostomy, and there may
be superficial infection owing to opening of the bowel
during operation.
Gant's Ileocsecostomii . — Appendicostomy and caeco-
stomy and through-and-fchrough irrigation are effective
in colitis, while ileocaecostomy is indispensable in
cases of ulcerative, cataiThal and specitic ileocolitis.
In this procedure which is not dangerous, following
the opening of the caecum, a Gant rubber entorocolonic
irrigator is introduced and fastened by circular infold-
ing sutures after its distal end has been projected
through the ileocaecal valve into tiie ileum. This
instrument enables tlie attendant to separately or
simultaneously irrigate the colon and small bowel
after the plan demonstrated. Patients sufl'ering from
chronic diarrhoea, anaemia and autointoxication rapidly
improve in appearance and weight when the bowel
is thoroughly cleansed daily by irrigation, using
warm water, normal saline or an ichthyol two per
cent., balsam Peru two per cent, solution or an oil
and bismuth emulsion, provided the position of the
patient is changed from time to time during the
irrigation in order to ensure the solution reaching
the ulcers wherever they may be. My patients aro
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 16, 1920.
placed upon practically a normal, full diet when
irrigations are inaugurated, and on account ot this
and feeling that a cure is being accomplished the
mental attitude of these patients is quickly improved.
The catheter or irrigator is not removed and the
opening is not closed earher than from three to six
months, otherwise recurrence sometimes takes place.
Appendiceal and cffical openings are closed by electric
cauterization or preferably fulguration of the mucosa
and adjacent skin, which may require one or several
applications.
Colostomy. — This procedure has been employed
formerly, but has been superseded by appendicostomy
and caecostomy in the treatment of chronic diarrhoea,
because of the severity of the procedure, and patient
objecting to bowel movements through the side and
serious operation required to close the artificial anus.
BOTULISM; PROTECTIVE MEASURES AND
CAUTIONS. •
The U.S.A. Public Health Service, in common
with other federal. State and municipal authorities
charged with the enforcement of laws and regula-
tions for the protection of the public health, has
been deeply concerned because of the fi-equent re-
ported fatalities in different sections of the country
attributed to the consumption of food products in-
fected with the organism known as Bacillus botu-
linus. These fatalities have quite recently been
traced to the consumption of ripe olives, although
some cases have also been traced to home-canned
string beans, home-canned asparagus, and home-
canned corn. In making inquiries as to the activities
of various Government agencies in connection with
outbreaks of botulinus poisoning, the Public Health
Service has learned that the Bureau of Chemistry of
the Department of Agriculture, which is charged
with the enforcement of the Federal Food and Drugs
Act, has been particularly active in the investiga-
tion of these cases. Investigations have been
directed by that bureau, not only toward an appli-
cation of the safeguards provided by the terms of
the law for the removal of dangerous material from
the market, but also to a scientific investigation of
the causes and characteristics of botulinus decom-
position.
No one Imows just how the Bacillus botulinus
gets into any particular food. It has been found
in articles put up in the home by the careful house-
wife and in goods packed by commercial establish-
ments. It may be present in a few packages only
of any lot. There is no method, the Bureau of
Chemistry states, by which the packers or home-
canners can assure themselves by casual examina-_
tion before canning that a product does not contain'
the B. botulitius. If the food were in all cases
properly sterilized and perfectly sealed, the de-
' Abstracted from the U.S. Bureau of Cliemistry, Department
of Agriculture, Public Health Reports, vol. xxxv, No. 7, Feb-
ruary 13. 1920. D. 327.
velopment of the poison would be impossible,
but no method of preserving food has yet been
found which eliminates the occasional spoiled pack-
age. Failure to sterilize may not become apparent
for weeks or even months after the canning of the
article. If signs of spoilage have appeared when
the container is opened, it is a clear warning that
the product is no longer edible.
There is no greater probability of botulinus
])oisoning in olives than in many other food pro-
ducts, either commercial or domestic. Until this
year it has been more commonly found in string
beans, asparagus, and the like. It was originally
found in sausage. It has been found in cheese; it
i5 present sometimes in stock food, such as mouldy
hay and other kinds of spoiled forage, but it has
never been found in the Bureau of Chemistry's
investigations in any kind of food which was not
spoiled.
A "FROGHOPPER" AS A BLOOD-SUCKING
INSECT. '
By C. Donovan, Lieut. -Colonel, I. M.S.
To add to the list of several blood-sucking insects
already known, I now send in the name of a member
belonging to the order Homoptera or Hemiptera-
Homoptera. So far as I am aware, this order has
not supplied any instance of a species with such
propensities. In Madras, especially after the North-
east monsoon — that is, in the months of November
and December — large numbers of small whitish-green
" froghoppers " come to light at night, and some of
these bite, or rather sting, by means of their sharp
proboscides. Several people used to complain to me
of being stung by these insects, but, not being cog-
nizant at the time of such habits among the Homo-
ptera, I discountenanced these tales of the presumed
aggressors. It was only when I was myself a victim
of the insects' action that I was disillusioned.
These insects sting both at night and on cloudy
days. I procured four of these " froghoppers," two
caught actually in the act of sucking blood and two
others hopping about at the same time and place.
These I took to Dr. Gahan, of the South Kensington
Museum, and they were identified by Dr. Distant.
The two blood-suckers were Phrynomorphus indiciis,
Distant, and the other two included one of the same
species and another Jassid, named Nephotettix bipunc-
tatits, Fabr., which I cannot accuse of any malpractice.
Dr. Gahan tells me that Dr. Guy Marshall informs
him that he has from time to time received Jassidae
sent to him from .Africa as blood-sucking insects, and
he does not know of any records of the kind published.
In adding this member to the list of blood-sucking
insects, I wish to demonstrate that we have reached
no finality in our knowledge of sanguinivorous flies.
'Abstracted from the British Medical Journal, No. 3,(
February 14, 1920, p. 220.
THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
Reptkmher 1, 1920.
nma hhb ■bq
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B m e
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Fig. 1.— Malar:
Coup d'ceil of the i
Fig. 2.— Portion of leprosy section.
To illustrate paper, " The Graphic Method of Demonstrating Tropical Medicine and Hygiene," by Andbew Balfour,
C.B., C.M.G., M.D., F.R.C.P.E., D.P.H., and S. H. Daukes, O.B.E., M.B., D.P.H., D.T.M. and H.
Sept. 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. J 7, Vol. XXIII.
^rifliiml Commtmiations.
THE GKAPHIC METHOD (JF DEMON-
STRATING TROl'ICAL MEDICINE AND
HYGIENE.
By
Andrew Balfoub, C.B., C.M.G., M.D., F.E.C.P.E., D.P.H.,
Director ill-Chief, Wellcome Bureau of Scientific Research,
AND
S. H. Daukes, O.B.E., M.B., D.P.H., D.T.M. and H.,
Curator, Wellcome Museum of Tropical Medicine and Hygiene.
The power of conjuring up a mental picture from
a written description varies in different individuals ;
some possess an extraordinary facility in this direction,
but to the vast majority some visual representation is
necessary to bridge the gap. This is a fact which is
acknowledged by almost every textbook dealing with
practical medicine or surgery, and it is especially
true of the larger works devoted to tropical medicine,
which usually teem with plates and text figures.
Such illustrations are of value even where every
facility is provided in the ward, out-patient depart-
ment or post-mortem room, for seeing the actual
condition under consideration. In certain circum-
stances a carefully arranged scheme of pictorial
representation is invaluable, more especially where
the student is preparing himself to deal with condi-
tions and circumstances which are foreign to his
immediate environment.
Two examples are especially apposite : the army
medical officer being trained at home to carry out
sanitary work abroad, and tlie medical practitioner
who is about to take up some appointment in a
tropical or subtropical climate. To expect such men
to learn their lesson from bitter experience is unsatis-
factory and wasteful ; as far as possible they must be
brought into touch with tiieir future environment and
the diseases they will meet.
What is true of medical men is even more tiuo of
the laity, and it is most essential for a nation which
boasts a world-wide empire to safeguard its man-
power by furnishing information regarding the dangers
inseparable from the administration of its possessions.
Tropical conditions cannot be reproduced, and
clinical material is often not available : it is therefore
desirable, indeed essential, to illustrate as graphically
as possible every subject upon which knowledge is
required. A museum in the ordinary sense of the
word is not sufficient ; the most complete series of
pathological siseciinens can give only a very imperfect
idea of the morbid processes to which these specimens
pay a grim tribute. Photographs and coloured illus-
trations carefully chosen and arranged are needed to
complete the picture, and they can carry conviction
oven to those whose powers of mental imagery are
markedly deficient. Moreover, scope is afforded for
aesthetic treatment. There is n. reason wliy a
museum should, as is so often the case, bo dull and
ugly. Sul)iects, even if in themselves repellent, may
be so handled as to produce a pleasing effect without
there being any accompanying loss of scientific
interest or accuracy.
Tropical medicine lends itself admirably to such a
system of pictorial representation, and an effort
which is being made -in this direction possesses
special interest at the present time.
In 1913, thanks to Mr. Wellcome's interest in the
matter, a museum of tropical diseases and hygiene
was started in connection with the Wellcome Bureau
of Scientific Research. It was hoped to provide
means of visual training, and to bring before those
going to tropical climates the various details of
environment, hygiene and disease which they would
encounter. Furthermore, it was felt that a museum
of this kind would appeal to medical officers and
others returning from the tropics. ' Such men are
often too tired and jilayed out to settle seriously to a
course of hard study. Their time may be limited,
and they may not care, during a period of leave and
recuperation, to devote many hours to hard reading.
On the other hand, there is every possibility, and
events have shown this to be the case, that they will
be glad to turn their attention to exhibits which can
be studied profitably without much mental effort and
which will be useful to tiiem not only by refreshing
their memories, but by supplying them with mental
pictures which on tlieir return abroad are likely to aid
them in their work.
The two illustrations accompanying this paper,
figs. 1 and 2, which were taken early in the history of
the museum, gives some idea of the lines upon which
it was hoped to develop the scheme.
Little progress could be made during the war, as
practically the whole medical staff of tiie Bureau was
on active service ; but after demobilization the work
was resumed, and has been considerably developed
along the original lines, which it is believed constitute
a new departure in museum work.
A short description of tiie section on malaria, as
now arranged, will illustrate the method, which is
generally applicable.
Fach section is introduced by_,a summary of up-to-
date knowledge. After a short historical survey, an
introductory screen supplies a coup d'csil (fig. 1) in
colour of the etiological factors : every painting is
carefully selected so as to emphasi/.e some lesson with
regard to the disease. Tiie three different parasites
are shown, together with a selection of mosquito
vectors from different parts of the world. The motiiod
of transmission follows, and lends itself especially
well to grapliic representation. The lower portion of
the screen is occupied by a series of coloured draw-
ings demonstrating the factors which predispose to
infection — various breeding jilaces in stagnant pools,
defeciive gutters, unscreened water-barrels, irrigated
fields, paddy fields, derelict boats, (tc. The lesson of
the mosquito net is taught iiy a picture showing a net
improperly arranged and torn. This screen is of
value to the layman as well as to the medical man,
and tliroughout the museum a similar coup cfaeil has
been designed for each important disease.
Following on this introduction the etiology is dealt
with more completely, and illustrations are given to
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 1, 1920.
emphasize the more important differences between
the various forms of parasites : aberrant forms are
included, also the method of cultivation, with a short
descriptive summary. Microphotographs demonstrate
Thomson's grounds for disputing Schaudinn's theory
of parthenogenesis. Illustrations of the haemamoebae
of birds and apes follow, and immediately precede a
detailed, illustrated description of how to make a thin
and thick blood film.
A schematic representation of the life history of the
parasite is followed by paintings, coloured prints and
photographs showing in detail the development of the
Plasmodium in the mosquito. The next series of
illustrations deals with the breeding of mosquitoes in
captivity, and with the dissection of the insect.
Points in epidemiology are elucidated by appro-
priate maps and plans. The distribution of the disease
is explained by maps showing the world distribution,
and others dealing with points of special interest.
The clinical section includes temperature charts
and illustrations of patients suffering from the disease.
In the pathological section, specimens of various
affected organs are displayed, and paintings, photo-
graphs and microscopic drawings illustrate all the
important points in the morbid anatomy.
Treatment is dealt with in the same graphic
manner : charts show the effect of various drugs upon
malarial pyrexia. Methods of treatment are fully
described and discussed. The cultivation of cinchona
is represented by a series of photographs carrying one
from the seedling through the small plantations to
the forests, where the bark is stripped. Samples of
the crude product of tha factory are exhibited, and
finally the various forms in which quinine is adminis-
tered. Each preparation is labelled to show its dose,
method of administration and equivalent strength.
The importance of preventive measures is brought
home by a large series of photographs exemplifying
first of all mosquito breeding grounds grouped under
the headings : (1) Woodland ; (2) ponds and
(3) marshes; (4) those due to defective
— bad roads, borrow pits, &c. ; (5) domestic breed-
ing places, such as water-barrels and faulty guttering.
The section is partitioned into ten divisions :
(l) Examination of carriers ; (2) mosquito surveys ;
(3) propaganda work in various countries ; (4) filling
in ; (5) draining ; (6) municipal works ; (7) use of oil ;
(8) natural enemies, including specimens of larvi-
vorous fish ; (9) personal protection, mosquito net, &c. ;
(10) prophylactic quinine.
A very useful type of mosquito trap, as employed
in Zanzibar, is also included in this section in the
form of a model.
The entomological relations of malaria are fully
considered in a series of illustrations with descriptive
text and specimens, and these can be viewed through
a special glass designed so as to show their minute
characteristics, thus rendering it unnecessary to
remove fragile specimens from the glass cases.
The general arrangement also of the. museum is
planned upon somewhat new lines. Recent years
have borne abundant testimony to the value of pre-
vention in tropical medicine, and an effort is being
made to group the diseases in such a way that by
their arrangement they will emphasize the chief
factors concerned in their etiology. Such a scheme
has a great practical value, for the preventive
measures for each group are very similar.
One may classify diseases etiologically in the
following way : —
A. Parasitic.
(i) Due to " contact," either direct or through the
agency of clothes, bedding, &c. Also due to direct
inoculation through the skin or mucous membrane.
Examples : Many skin diseases, venereal diseases,
small-pox, tetanus, yaws.
(ii) Due to " mouth to mouth " infection, through
the agency of so-called " droplet " infection, ex-
pectoration, coughing, sneezing, &c.
Examples . Influenza, pneumonia, pneumonic
plague.
(iii) Due to " droplet " infection, as above, or to
infected scales from the skin, or to infected discharges
from the nose, throat or ear.
Examples : Measles, small-pox, chicken-pox,
diphtheria.
(iv) Due to excremental infection, through the
agency of water, food, flies, fingers and dust.
Examples : Enteric fever, dysentery, diarrhoea,
cholera, worm infections of many kinds, including
schistosomiasis.
(v) Due to inoculation through the bites of insects,
or the entry through skin abrasions of the infected
excreta or infected crushed tissues of insects rubbed
or scratched into these lesions.
Examples : Malaria, yellow fever, tick fever, sleep-
ing sickness, filariasis, relapsing fever, typhus fever,
bubonic plague.
(vi* Due to invasion of the body by insects in their
adult or larval stages.
Examples : Chigger, myiasis of various kinds.
B. Non-parasitic.
(i) Due to climatic conditions.
Examples : ^ B.ea,t stroke, diarrhoea in some in-
stances, constipation in many cases, rheumatism,
prickly heat.
(ii) Due to errors in diet.
Examples : Diarrhoea, beriberi, scurvy, sprue (?).
(iii) Due to poisons.
Examples : Scorpion sting, snake-bite, vegetable
poisons.
(iv) Miscellaneous, including developmental defects,
mechanical injury and new growths (non-parasitic).
Such a system of grouping, though it presents
certain difficulties, emphasizes many important points
and lends a fresh dignity and force to the work of
prevention. There is far too great a tendency to
divorce clinical from preventive medicine, with the
result that the latter is frequently relegated to a
secondary position. All are willing to acknowledge
that prevention is better than cure, but few are
disposed to accord this belief practical recognition.
In addition to these arrangements there is a part of
the museum wholly devoted to the liygiene of the
Sept. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
tropics. Every branch of sanitation is represented,
special attention being given to tropical foodstuffs
and the pests, be they animal or vegetable, which
attack and destroy them, for it must be remembered
that famine is only too frequently a precursor of
epidemics.
Moreover, an attempt is being made to collect
pictorial representations of all the' institutes, in the
tropics and elsewhere, which are concerned with the
study of tropical medicine and hygiene. In this way
persons proceeding abroad can readily get some idea
of the facilities which exist for research in any
particular country. It is surprising how little is
known about this subject, and how such a display
gives a rude shock to the complacency which adopts
as its motto, " We are the people and wisdom shall
die with us."
At present the museum is in a state of transition,
but ere long it is hoped to have it adequately housed
in suitable premises adjacent to the Bureau.
Help in the way of photogiaphs, specimens, &c.,
from those who have it in their power to aid this
work wiU be gratefully accepted and duly acknow-
ledged. There is undoubtedly a great need for a
museum of this kind, which can be made thoroughly
representative only by the good offices of those for
whose use it is intended and to whom it makes its
appeal.
THE SURGICAL TREATMENT OP ULCUS
TROPICUM.
By RoBEBT HowAED, M.D., B.Ch., Oxou.
Medical Officer, Pemba, Zanzibar, late Medical Officer of the
Universities' Mission to Central Africa.
Tropical phagedaena, or the tropical sloughing
ulcer, is familiar to most doctors in the tropics,
especially to those whose work lies in hot, damp
agricultural districts. The causative germ is gener-
ally stated to be the Spirochata schaudinni. It is
found in great numbers in the discharge, and also in
the softened tissues at the edge of the ulcers, gener-
ally in symbiosis with Bacillus fusiformis.
In most text books of tropical diseases, a detailed
description of the distribution, clinical symptoms and
i pathology of this disease is given, but little space is
devoted to its treatment. Local antiseptic applica-
tions or various caustics are recommended, and the
statement is made that with this treatment the
I sloughing process can generally bo got under control
1 in a week to a fortnight, but a warning is added that
I not infrequently a relapse of phagedaina may occur
in an ulcer that is apparently going on well.
Those who are familiar with the horrible smell and
I profuse discharge from these ulcers will surely want
to apply some more radical treatment before admitting
the patients to the general ward of their hospital.
About eighteen years ago I was told by Dr. Norris,
of the Scotch Established Church Mission, Blantyre,
Nyaaaland, that he had found scraping with a Volk-
mann's spoon under an anaesthetic far the most
satisfactory treatment. This is the treatment to
which I now wish to call attention. I have applied
it wherever possible to all except very slight cases,
or where the patient declined to submit to an opera-
tion. In these latter instances the unsatisfactory
result obtained from the local antiseptic treatment
generally recommended has brought out in a con-
vincing contrast the advantage of the surgical method.
The operation is of the simplest possible character.
It consists in scraping away all the sloughs and
softened tissue with a( Volkmann's spoon. It will be
found that the infected tissue readily breaks down
under the spoon, while the sound tissue underneath
is resistant. When a firm base of sound tissue has
been obtained, the undermined edge of skin is cut
away with scissors curved on the flat, so as to leave
no pockets. Any ragged pieces of fibrous tissue that
remain in the base of the ulcer are then cut away
with scissors.
Tiie surface is washed over with an antiseptic, and
then dressed with cyanide gauze and some antiseptic
wool, and firmly bandaged. The operation only takes
about five minutes, and it could easily be done under
nitrous oxide anteathesia if available, though in the
parts of Africa in wl^ich I have worked I have always
had to use chloroform.
The first dressing is done forty-eight hours after the
operation, and the wound will be found clean and free
from any smell. If th'e ulcer has been treated early
before it had reached the deep fascia it will show a per-
fectly clean granulating^urface in a week. If the deep
fascia has been penetrated, and especially if tendon
sheaths have been reached, there are often fibrous tags
which take some time to separate, but there seems to
be no tendency to any recurrence of the phagedaenic
process. I imagine that this easy cure of the condition
is due to the observed fact that the spirochaites do
not penetrate deeply into the tissues, and that they
are only in the softened tissue which is removed by
the spoon ; while any that may remain on the surface
of the cleaned ulcer are easily destroyed by antiseptics.
At one time in the more severe cases I tried applying
10 per cent, chloride of zinc to the cleaned surface,
but I have come to the conclusion that it is quite un-
necessary, and the sloughing which it causes delays
the granulation process. I continue tlie cyanide gauze
dressing until the granulations are well formed, and all
fibrous tags have disappeared, and then dress with
ointment.
If the surface is comparatively small it may be
allowed to granulate up ; if it is large it is possible to do
Thiersch's grafting from fourteen to twenty-one days
after the ulcer was first scraped. The now granulations
are found quite healthy and can be lightly scraped away,
giving a firm Hat surface on which the grafts readily
grow. If grafting is adopted theoriginal size of the ulcer
makes little difference to the ease with which it can
be cured. On the other hand the depth to which the
sloughing has penetrated does make a difference in
prognosis.
As mentioned above, an infected tendon may delay
the establishment of really healthy granulations, and
216
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [Sept. 1. 1920.
this is still more the case where the periosteum of the
tibia is involved, resulting in local caries of the hone.
The softened hone can he scraped away, and the ulcer
got clean, but it is of course slow to granulate so as to
be ready for grafting.
Such cases require patience, hut eventually they can
be perfectly cured, whereas on the old method of
treatment it was this involvement of a patch of bone
or tendon that proved a refuge for the spirochietes and
served as the starting point for a recurrence of the
phagedaenic process after apparent improvement.
The relief to the patient that results from this simple
operation is most marked. Once the ulcer is scraped
clean there is practically no more pain, the oedema
rapidly subsides, while the smell, of which the patient
and his friends are often acutely conscious, entirely
disappears. In my experience once natives are made
familiar with the idea of this operation, and see its
benefits, they readily consent to it. The operation
itself requires no instruments beyond sharp spoons and
scissors, and is of such short duration that it can,
if necessary, easily be done in the out-patient depart-
ment, and the patient permitted to go home and come
for regular dressings. Several babies have been treated
on this method whose mothers would never have con-
sented to leave them in hospital. Lastly, no elaborate
method of after treatment, e.g., irrigation, is required.
Coiicbisicm.
In the treatment of tropical ulcer thorough scraping
and cutting away of overhanging skin under an
anaesthetic is at once the simplest, quickest, and most
effective method of treatment, and should he adopted
as a routine practice.
HcMcal ietos.
Impoetant recommendations for extending the
scope and usefulness of the work of the Institute of
Tropical Medicine at Townsville, North Queensland,
were decided upon at a recent meeting of the com-
mittee, when it was decided to recommend to the
Federal Cabinet proposals for strengthening the staff
of the Institute and extending and intensifying its
work. These include the opening of experimental
stations at Port Moresby, Papua, and Rabaul, and an
addition to the staff of oflicers to carry out investiga-
tions on the spot into any outbreaks of tropical
disease without interfering in any way with the
regular routine of the laboratory work and tests.
While these proposals involve some educational ex-
perience, it is held that the committee will be amply
justified by the more thorougli manner in which it
will be possible to cope witli tropical diseases in
Australia, and by tlie extension of the sphere of
operations to Papua and former German territory.
It is hoped that eventually all the medical officers
appointed to posts in the Pacific territories will take
a course at Townsville.
^Bimi.
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THE JOURNAL OP
Cropical S&tt>itint anDl^pgtene
September 1, 1920.
BODILY POWERS AS TESTED BY THE
OLYMPIC GAMES.
Representatives of most countries of the world
have been assembled in Belgium lately, engaged in
contests of almost every known sport, game and
athletic exercise. Each nation has carried hence,
also, its national characteristics in regard to its
Sept. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
methods of physical training and its mental attitude
bearing upon sport as it is understood at its home in
Britain. Such gatherings are supposed to promote
good fellowship between peoples, and foster the good
feeling that all hope to promote between nations.
How far this has been carried out during the present
" Olympiad " is not evident as far as can be gathered
from the reports that have reached us.
The peoples allowed to be the foremost athletes in
the recent contests are Great Britain, the United
States of America, the Swedes and the Finns. Of
these the Swedes alone regard athletic exercise as a
national asset in the physical training of their people,
and place such training on a higher platform than
any others. With the Swedes, physical training is a
national question, and by encouraging and enforcing
it they hope to better not only the physique, but also
the mental fitness of their nation. It is an interest-
ing experiment. We are familiar with the legend of
the Healthy Body as regards producing a healthy
mind. By a healthy mind in this connection is
meant a moral mind, and morality from the sexual
point of view ; but that it leads to a capable brain, or
one endowed with gifts of intellectual; commercial or
judicial greatness, is another matter. The whole
process of athleticism to-day is an artificial process,
something added on to the daily life, something out-
side the bodily development which accrues from work
necessary to produce a livelihood. The original call-
ing of man was tilling the soil and following the
chase, and making the instruments for these caUings
to be carried on. These afforded all the physical
exercises sufficient for man's welfare. Military train-
ing became necessary as mankind multiplied, and the
grouping into tribes, states, nations and empires
resulted, whereby these several communities could
defend themselves from aggressive neighbours, or
when they in turn became aggressive themselves.
This implied, in the earlier days especially, physical
fitness to a degree more advanced even than to-day,
when man met man in personal conflict, and the
better developed man overcame his enemy. This
was notably the case in Greek and Roman times
before firearms were introduced, but since then the
introduction of modern weapons extended the arts
and sciences necessary to produce them. Commerce
demanded an enormous section of the people with
whom physical exercise played no great part in the
scheme of daily work, and it is amongst these artificial
means of exercise had to be introduced, and as some-
thing added on to their life's work, and it is mostly
amongst these that our modern athletes are to be
found. The clerks in our cities are being trained to
a degree that exceeds what is required either to till the
soil or to produce machinery. The farm labourer
and the blacksmith's upper limbs are shabby com-
pared with those of the gymnasium-trained clerk.
The huge muscles of the city clerk are trained to a
degree far beyond the needs of men engaged in the
heaviest toil ; his work is to drive a quill at his desk,
yet he has a biceps like a leg of mutton in size and
chest muscles- alongside of which the labourer's
muscles are insignificant in development.
Women are in the same category- In earlier days
her duties were in the house or in the fields, each
sufficient to maintain her physique. But as society
became more complex, servants did her work in the
house and men took her place in the fields. En-
forced leisure drove her to artificial exercise, hence
the tennis and golf players, and the many forms of
exercise she now takes part in.
The artificial form of exercise came to bo known as
games, sports and such like names ; and amongst the
men more especially some became known as pro-
fessional players, in other words men who did nothing
but played games for a livelihood. The Olympic
Games are regarded as contests by amateurs only,
that is those who add sport to their daily work and
do not take payment for the part they play. It is
here that troubles have arisen in such contests, for an
amateur athlete in British estimation has no real
equivalent in another. To the amateur the contest
is a mere pastime, for the professional the results are
bread and butter, that is a means and the only means
it may be of livelihood. Success and failure to each
of these groups differ widely, so much so that to a
man or woman making a livelihood by his or her
muscular efforts failure may mean ruin. That so-
called " shady " means of winning creep in is not sur-
prising, for to win is to live, to fail is starvation, to
the professional. In Britain, with her accumulated
wealth and a multitude of leisured folks, amateur
" sport " was possible ; in other countries, without,
or practically without, a leisured class, such a product
of society was impossible. Britain set the example,
and " sport " became a national feature of the people.
Honour in sport became an emblem of our national
character, and to " play the game " a legend of our
faith. The phrase " it is not cricket " is our modern
expression to indicate dishonesty in business as well
as in sport.
That this phase of sport has done much good in
Britain is undoubted, but there are often whisperings
that other nationalities fall short of this standard,
and " they are out to win," and the means to that
end, are not always as they should be.
To such a climax has this grown in the most
modern of these International contests that the
British seem inclined to withdraw from taking part
in them. If sport is not to train our youths to ' play
the game," the question arises is it worth while to
make the fetish of it we do ?
Is sport necessary to produce a powerful and
physically fit people '? The Turk, who can take a
load, say a grand piano, on his back and carry it to
its destination, is not artificially trained by sports or
games. He bears a load which it takes usually three
or four men of other nations to carry. The Japanese,
who pulls a rickshaw with a passenger or two behind
him at a trotting pace for forty or more miles, owes
his power to working at his calling. The China
woman, who can carry across her shoulder a bamboo
laden with anything from seventy to eighty bricks for
several miles, accomplishes her task by muscular
power acquired by a training having nothing to do
with sport, or contest in games, but by the neces-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 1, 1920.
sities of her daily life. If our athletes and those
devoting themselves to sport were to become athletes
by doing work whilst training, the results of their
energy and muscular expenditure, instead of " beating
the air," would develop people fitted to carry out the
work of the world and at the same time play the
game to some better purpose than by being high
amongst the averages." The tendency of the present
day athletes is to develop arm muscles in a gymnasium
which they will never be called upon to use, whereas
the lower extremities are neglected. Any game, sport
or exercise which develops the upper to the neglect of
the lower extremities (which is usually the case) is
not training the body aright. Eeal good is brought
about by also developing the lower extremities.
This can best be done by walking, not running (which
from the hygienic standpoint should be confined to
boys). Were the citizens of our large towns to walk
to and fro to their offices they would be doing athletic
work which would add to their physical strength, and
would not necessitate them wasting their time, as in
the eyes of tropical folks we do, in gymnasia, tennis,
golf, &c., &c.
Walking would improve the physique of our town
dwellers, lessen the number of vehicles in our streets,
fill the pockets of the workers in our cities, teach
people to take pride in themselves by making them
self-reliant, and to take heed in an exercise which
saves their pockets and brings health to their system
and power to their limbs. Let us have exercises
which bear immediate fruit, and which gives us
something more than the empty and frivolous glory
of driving a ball over a net or into a hole in the
ground. If we work to become a nation of athletes,
let it be by doing something useful. Whilst we
practice exercises in our gymnasia with doubtful good
to our frames, the fisherman brings home something for
food, the man who " follows the chase " fills our
larders with grouse, partridge, pheasant, a rabbit, or
a hare, and at the same time brings well-being to his
own frame ; but ball games have nothing to show for
all the energy they expend, nor does climbing ladders
hand over hand. By learning to swim or to shoot
straight (which can only be perfected by keeping
oneself fit by walking), by carpentry, by gardening, by
field work on our farms and many other exercises, we
have natural forms of .vork whereby our frames can
be kept fit, and without further training let us by all
means have contests, but of a character in keeping
with useful ends without artificial training, and the
man or woman who does lier natural daily task best
has the honour and credit of his or her superiority.
J. C.
Injections of Adrenalin in the Diagnosis of Latent
Malaria (Azzi, Policlinico, November 30, 1919). —
The author has found injections of adrenalin by far
the most certain and satisfactory method for driving
malarial parasites into the blood of the general
circulation. According to his experiments 1 milli-
gramme of adrenalin, injected subcutaneously, is
uniformly followed by the appearance of plasmodia
in the blood-stream, commencing about twenty
minutes aft«>- the injection. The injection is
always harmless.
ittttotations.
On the Relation of Temperature to Malaria in
Eiigkind (Angus Macdonald, Journal of the B.A.M.C.,
August, 1920). — The author calls attention to the
fact that anopheline mosquitoes are widespread in
England, and that malaria has occurred in England
in the past, though its continuous endemicity is
doubtful. The normal temperature of England is
insufficient to maintain malaria endemic under
modern living conditions. According to the author's
researches, temperature decides infection and deter-
mines incidence ; but as it is impossible to prognosti-
cate the temperature of any year, it is necessary to
take preventing measures in England in face of a
large importation of malaria patients and malaria
carriers.
The Alkali Reserve in Pellagra (Sullivan and
Stanton, Archives of Internal Medicine, July 15,
1920). — The authors have tested fifty-six pellagra
patients for alkali reserve by the alveolar air
method and by the determination of the carbon
dioxide bound by the blood plasma. None showed
a marked depletion, about one-third showed a
slightly, subnormal level, while the greater number
were within normal limits. The authors came to
the conclusion that there is very little uncom-
pensated acidosis in pellagra.
Anti-typhus Work in Belgrade (L. F. Cope,
Journal of the Royal Medical Service, No. 3, July,
1920, vol. vi). — The cases, as a general rule, were
not of a severe type, and the mortality was not
high. The spread of the epidemic was largely
limited by the fact that a large proportion of the
population had already had the disease, and still
more by the fact that methods of communication
were very difficult. All the railways had been
destroyed by the enemy in their retreat, and the
majority of wheeled vehicles, horses and draught
cattle removed, so that walking was the only means
of getting about, and this in the bitter winter
weather was only resorted to in cases of absolute
necessity.
Before the author took up the work there had
been sixty-five cases of typhus in Belgrade, mostly
among repatriated Czechs. During the first five
weeks upwards of 5,000 men were deloused.
During this period there were only thirty-seven
fresh cases, though it was the coldest weather ex-
perienced during that winter, and the whole of
Northern Serbia was full of typhus centres. There
were several instances in which a regiment or
establishment furnished one or two cjises, and aftor
immediate delousing no furtht'r t^a.scs appcitfod.
Of the thirty-seven fresh (raises that iipiiciircd aftc-r
the author and his co-workers began work, twenty
declared themselves in thi^ first wei^k. The author
is of opinion that typhus will probably remain
endemic in sporadic outbreaks throughout Northern
Serbia for many years to come; but that, with
energetic handling of such small outbreaks, any
further pandemic, such as that of 1915, should not
recur, nt any rate in our generation.
Sept. 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Cwmnt iiteratttw.
Annals of Tropical Medicine and Pathology,
Vol. xiv, No. 1, June 30, 1920.
Notes 071 Blackwater Fever in Macedonia (J. F.
Gaskell). — From an analysis of seven cases of black-
water fever encountered in the Serbian Army during
the winter of 1917-18 the author concludes that the
pathology of this condition consists in the sudden
occurrence of an extensive haemolysis in the blood-
stream brought about in certain cases of chronic
malaria by the administration of quinine ; exposure
to cold being usually a contributory factor. The
haemolysis is comparable to that of paroxysmal
haemoglobinuria, being chemical in nature and rapidly
completed. The excretion of haemoglobin occurs if
not too highly concentrated, otherwise coagulation
takes place in the loops of Henle, and suppression of
urine occurs, which is usually fatal. Continuation
of quinine administration increases both the toxicity
and the probability of suppression, though it does not
prolong the period of haemolysis. Treatment should
be directed to the prevention of collapse and to the
dilution of haemoglobin and toxins by the adminis-
tration of fluids in quantity by every available method.
Quinine should be stopped immediately the black-
water fever is discovered ; its further administration
is dangerous and unnecessary, for the blackwater fever
itself destroys the malarial parasites in the blood.
In any particular patient a critical dose of quinine is
necessary to produce an attack of blackwater fever ;
malarial attacks in such a patient can be successfully
treated by doses below this limit.
The Nomenclature of the Parts of the Male Hypopy-
gium of Dipteria nematocera, with special reference to
Mosquitoes (F. W. Edwards). — The great diversity
and confusion which exists in the classification and
nomenclature of the structure of the tip of the male
abdomen amongst msects generally, and particularly
amongst the mosquitoes, is pointed out. The hypopy-
; gium of mosquitoes is composed of four distinct parts.
(1) A more or less complete chitinous ring, repre-
senting the tergite and stemite of the ninth abdominal
(2) A pair of appendages of the ninth segment,
I more or less ventral in position (except secondarily in
I mosquitoes).
! (3) Chitinized pieces surrounding the anus.
j (4) Chitinizations of the genital tube as opposed to
I the main body wall which forms the other three
parts.
I Each of these elements is discussed in great detail.
I A table is given showing the chief terms which have
' been used by different writers on the culindu3 and
those proposed by the author, together with those
used by Newstead for phlesoforms and by de Meijore
for the tipulidiE for purposes of comparison.
Studies on the Various Types of Malarial Infection
and the Effect of Quinine Treatment thereon among the
Native Population of the Malay Archipelago (N. H.
Swellengrebel and J. M. H. Swellengrebel de Graaf). —
In epidemic districts in the Malay Archipelago
quinine treatment greatly reduces the number of
crescent carriers among the adults, the chances of
the anophelines becoming infected being thereby
reduced. This alters the nature of the parasite in-
fection among the inhabitants, causing it to approach
the endemic type. In the endemic areas it is the
children only who are the gamete reservoirs, and it is
an extremely difficult matter to cure them.
Heat and Stegomyia Fasciata : Short Exposures to
Raised Temperatures (J. W. S. Macfie). — The author's
experiments showed that the ability of Stegomyia
fasciata to withstand sudden exposure for five minutes
to a raised temperature is greatest in the egg stage,
slightly less in the pupal stage, and least in the larval
and adult stages.
Oral Administration of Quinine or Quinine and
Arsenic for Short Periods to Young Native Children
infected with Malignant Tertian Malaria (J. W. S.
Macfie and M. W. Fraser). — Seventeen native chil-
dren at Accra, in the Gold Coast, West Africa, were
given quinine hydrochloride gr. 10 and quinine sul-
phate 10 to 20 gr. without ill-effects, showing how
well children stand relatively large doses of quinine.
In seven of the cases parasites persisted in the blood,
notwithstanding treatment, showing the necessity ot
blood examinations in the rational treatment of
malaria, since it is the presence of parasites, and not
the occurrence of fever, that is the actual and poten-
tial danger in malaria. They also found that native
children may have malaria parasites in the blood
abundantly for many consecutive weeks without being
troubled by febrile attacks.
Oral Administration of Quinine Sulphate, 20 gr.,
to Adult Natives Infected with Malignant Tertian
Malaria (J. W. S. Macfie). — Quinine sulphate, 20 gr.,
was administered orally in solution to eleven adult
native men infected with malignant tertian malaria
in the Gold Coast. In all the cases the pophazoites
disappeared from the cutaneous blood in one to two
days, and there was no febrile or parasitic relapse in
sixty to sixty-four days.
Oral Administration of Quinine Sulphate, 10 gr.,
daily for two conseciUive days only to Native School-
boys Infected with Malignant Tertian Malaria
(J. W. S. Macfie). — Quinine sulphate 10 gr. for
two consecutive days only were given to sixty-two
native schoolboys at Accra, whose ages ranged
from 5 to 18 years. All the boys appeared to be
healthy, but were found to be infected with malignant
tertian malaria by blood examination. This dose of
quinine was sufficient in every case to cause dis-
appearance of the parasites from the cutaneous blood
in one to two days. After this treatment parasites
reappeared in the blood in the majority of the cases,
the percentage of parasitic relapses being highest in
the age-group comprising boys of 12 to 14 years.
220
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 1. 1920.
Oral Administration of Quinine Sulphate to Natives
Infected with Quartan and Simple Tertian Malaria
(J. W. S. Macfie).— In quartan and simple tertian
malaria, as has been shown to be the case in
malignant tertian malaria, the percentage of relapses
in natives other than very young children treated in
the tropics is decidedly less than in Europeans
treated in England.
Crossocephalus Zebra N. Sp. (W. Yorke and T.
Southwell). — A profusely illustrated description of a
nematode worm found in considerable numbers in
the intestines of six zebras {Equus hurchelli) shot in
Northern Rhodesia. Morphologically similar it pre-
sents some differences in detail from the worm
described by Von Linstow (1899) and subsequently
named Crossocephalus by Railliet (1909). The authors
therefore consider their worm as a new species of the
genus Crossocephalus. Bayliss (1919) gave the name
Crossocephalus kmgicaiuiatus to a closely allied species
found in a rhinoceros from the Malay Peninsula.
On the Besults Obtained from Surveys for Breeding-
places of Tree-hole Mosquitoes in Liverpool and
Neighbourhood (B. Blacklock). — In a series of six
surveys, five in the Liverpool district and one in
Delamere Forest, Cheshire, 2,500 trees were ex-
amined up to a height of twenty-five feet for breeding-
places of Anopheles plumbeus and Ochlorotattis geni-
culatus. Eighty three holes and fifty-one- forks and
clefts containing water were found. Sixteen breeding-
places of A. plumbeus and nineteen of O. ge^iiculat'us
were found ; larvae of A . plumbeus and 0. geniculatus
were associated thirteen times. Breeding-places of
A. plumbeus occurred in 064 per cent, of trees ex-
amined, and in 19'2 per cent, of holes containing
water. The majority of the breeding-places were
over six feet from the ground. Elms, horse-chestnuts
and sycamores provided the great majority of the
breeding-places ; oaks, Spanish chestnuts and firs
provided no breeding-places, and very few holes con-
taining water.
SUCCESSFUL TREATMENT OF GIARDIASIS
IN MAN WITH NEO-ARSPHENAMIN.'
E. I. Care, M.D., Lansing, Mich., and W. L. Chandler, Ph.D.
The pathogenicity of Giardia (Lamblia) intestinalis
is now fairly definitely established ; in fact, this
flagellate has recently been described as the causative
organism of " trench diarrhoea," a condition which
most of the overseas troops experienced and from
which a number of the returned soldiers are still
sufifering.
Several different medicaments have recently been
employed in the treatment of this disease ; and, while
some of these have been found to give temporary
relief, no permanent cure has hitherto been effected.
' Abstracted from the Journal of the American Medical
Association, vol. Ixxiv, No. 21, May 22, 1930, p. 1444.
The role which salts of heavy metals, notably
mercurial and arsenical preparations, play in the
treatment of syphilis and some other flagellate diseases
is common knowledge ; and at least two groups of
workers have observed that the cysts of Giardia muris
disappeared from the faeces of infected rats following
intravenous injections of heavy doses of arsphenamin.
Probably the most noteworthy of these observations
are those made by Kofoid and his associates. How-
ever, so far as we are aware, no attempt has been
made to utilize these substances in the treatment of
human diseases caused by intestinal protozoa.
Since neo-arsphenamin is being used with good
success against the syphilis flagellate, it occurred to
us that intestinal flagellates, and possibly also other
intestinal protozoa, might prove to be susceptible to
the action of this product ; and, moreover, since the
oxidation products of neo-arsphenamin ai'e readily
excreted by the way of the intestinal tract, intestinal
protozoa ought to be more easily reached than the
syphilis organism, which is often intracellular. It
was, therefore, not surprising when in the course of
our investigations we observed that not only the cysts
of Giardia intestinalis and Chilomastix mesnili, but
also those of Endamaba coli, E. histolytica and
E. nana, rapidly disappeared from the stools of man
following intravenous injections of neo-arsphenamin,
and that the cysts of Eimeria stiedm disappeared
from the faeces of rabbits following intramuscular
injections of heavy doses of neo-arsphenamin.
Whether or not the results obtained through this
treatment are permanent is yet to be determined.
A number of cases are under observation, and these
will be reported on as soon as a sufficient period of
time has elapsed to enable one to draw definite con-
clusions. In the case here reported, however, a
permanent cure appears to have been established.
Neo-absphenamin Treatment (three
injections).
December 24, the patient reported a recurrence of
the abdominal discomfort. An examination of his
stool made on this day revealed numerous cysts of
Giardia intestinalis. These cysts varied greatly in
size and shape ; some typically shaped cysts were
only one-third the usual size, others were larger than
normal, while still others were flat on one end.
December 24 and 29 and January 2, intravenous
injections of 0'6 grm. each were made ; and, following
the second injection, calomel and castor oil were
administered by mouth. Stool examinations were
made daily for twelve successive days during and
following the period of treatment ; and for six
successive days once a month thereafter.
Results.
The cysts of Giardia intestinalis were greatly
reduced in number in the first sample collected
after the first injection and were entirely absent from
the stools on the second day after the first injection,
and have not since recurred. The patient's condition
has greatly improved ; his stools have become normal
and his abdominal discomforts have abated.
Sept. 1, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
LIPURIA ASSOCIATED WITH CHRONIC
NEPHRITIS.'
By Louis Badman, M.D., Iowa City.
Almost all of the recorded instances of fat in the
urine appear under the caption " chyluria." The
several features of this condition which are now more
or less well recognized are the occurrence of fat, fibrin-
ogen or fibrin, red and white blood cells in the urine,
the direct quantitative relationship between the fat
ingested and that excreted in the urine, and lastly,
the increase in fat elimination during rest in the
recumbent posture. Both the parasitic (filarial) and
the nonparasitic forms have been explained by a
fistulous communication of the lymphatics with some
part of the urinary system. In 1908, Magnus-Levy
stated that lipuria could arise only in this manner.
Five years later, Sakaguchi found that the average
fat elimination through the urine in health and in a
variety of diseases was about 8'5 mg. per day, and
that this amount could be increased fourfold by fat
ingestion. Only in one case of chronic parenchy-
matous nephritis did the fat rise to 73 mg. This
the author thought was probably due to an altered
permeability of the renal tubules. In the course of
their work on the behaviour of stained fat in the
animal organism, Mendel and Daniels noted that rats
fed on lard stained with Sudan III excreted both fat
and dye in the m-ine. Dr. Amy L. Daniels has
kindly permitted us to insert two typical protocols of
unpublished experiments.
More recently the work of Sanes and Khan also
indicated that an abnormal permeability of the renal
capillaries or epithelium might be a factor in the
production of lipuria. The data at our disposal
appear to support this view. At least, the available
evidence makes it probable that there are at least two
types of lipuria, the one associated with fistulous
communication, tlie otlier entirely due to an abnormal
permeability of the renal cells.
Report of Case.
History. — A white farmer (clinical number 4,928),
aged 37, who had never lived in a tropical region,
married, and the father of four children, admitted to
the University Hospital, August 2, 1918, admitted a
gonorrhoeal infection about one year previously, but
denied syphilis, though his wife had had two mis-
carriages. His family history was not significant.
He had undergone two operations : an appendectomy,
in 1913, and another operation for peritoneal adhesions
one year later. He had also suffered from small-pox
and scarlatina. His present illness began in March,
1918, with headache, swelling of the ankles and
dyspnoea. July 1, 1918, he first noted that his urine
was cloudy and oily. Physical examination detected
an oedema of the legs, a hypertrophied lieart, and
blood-i)ressure of 150 systolic and 100 diastolic.
Blood examination revealed a moderate secondary
anajmia and a strongly positive Wassermann reaction,
' Abstracted from the Journal of the American Medical Asso-
ciation, vol. Ixxiv, No. '20, May 15, 1920, p. 1,376.
which was negative on three subsequent occasions
after arsenical treatment. The patient was discharged
much improved Sept. 13, 1918, but was readmitted
November 2G of the same year, with headache, gen-
eralized oedema and fullness of the abdomen. The
heart was large, the liver palpable and tender, the
blood-pressure : systolic, 190, and diastolic, 120. In
spite of treatment the headache increased in severity,
and the eyegrounds, which were normal on the first
admission, now showed albuminuric retinitis and
retinal haemorrhages. The signs and symptoms of
pneumonia developed, and death, which occurred
Dec 16, 1918, was preceded by vomiting, convulsions
and coma.
Urine examinations. — The urine was always cloudy.
Its specific gravity ranged from 1*013 to 1'018. It
was neutral of alkaline, and contained much albumin
and many casts, and occasionally a few red and white
blood cells. Fat globules were never present. The
renal dietary test (August 6) showed a maximum
specific gravity of 17 points. The night urine
measured 220 c.c. and had a specific gravity of 1'018.
A sample of the turbid urine was evaporated to dry-
ness and extracted with alcohol-ether mixture. The
extract was precipitated with acetone. The precipitate
gave positive results for phosphorus and glycerol,
thus indicating the presence of lecithin. The filtrate
responded to the test for cholesterol.
The influence of fat ingestion on the fat content
of the urine was studied by Bloor's method.
A second dietary test was performed, December 12.
The maximum specific gravity was 1020, the variation
of specific gravity was 12, the night urine measured
950 c.c, and its specific gravity was I'OOB. No
retention of nitrogen or chlorine was found during a
period of five days.
Necropsy findings. — (By Dr. Frank Paul.) — Each
pleural cavity contained about 300 c.c. of yellowish,
watery fluid, which coagulated spontaneously. The
lower lobes of both lungs showed bronchopneumonia.
The heart showed hypertrophy and dilatation, es-
pecially of the right side. The aorta was normal
throughout. There was no enlargement of the
thoracic duct or other lymphatics. The abdomen and
its contents were normal except for the kidneys.
These measured 13 x 8 x 3 cm., and weighed 215 grm.
On section they cut with little or no resistance. The
cortex measured 1 cm., was soft, and presented a
yellowish, fatlikc appearance. The capsules stripped
easily. The pelvis contained an unusually large
amount of fat. Frozen sections stained with sudan
gave negative results. Further microscopic examina-
tion of the kidneys disclosed the fact tliat the tubules
in the cortical region were swollen, and that the cells
were large, cloudy and granular, but not fatty. In
some, the lining cells were entirely absent. The
glomeruli were enlarged, and many showed an increase
in connective tissue but no fatty or amyloid degenera-
tion. A large number were adherent to the cai)sular
wall. The capsules were thickened and very vascular.
The capsular epithelium showed proliferation in certain
instances. Areas of round-cell infiltration were
present. The medulla was very vascular. The
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 1, 1920.
tubules were not as large as in the cortex. Their
lining cells were clear. There was a slight increase
in connective tissue. Sections of the kidney stained
by Levaditi's method for spirochaetes were negative.
Excepting for a marked degree of endarteritis, micro-
scopic examination of other organs, including the
brain, was negative.
Comment and Conclusions.
The clinical, chemical and pathologic data suggest
a progressive nephritis, possibly of syphilitic origin,
associated with lipuria and terminating in uraemia.
The lipuria was influenced by the amount of fat in
the diet. The absence of coagulated protein, the
scarcity or absence of cells in the urine, and the
apparent absence of a fistulous communication, indicate
that the Hpuria was due to an altered permeabihty of
the renal epithelium. The presence of lecitliin and
cholesterol are worthy of note (though both substances
have been found by a number of authors on previous
occasions). In this case there was no increase of
cholesterol in the blood. The occurrence of typical
m-aemic symptoms without cerebral oedema or reten-
tion of urea has also been pointed out before. The
incidence of syphilis in this case recalls the work of
Stengel and Austin, who noted the frequent occurrence
of doubly refractile bodies in the urine in nephritis
associated with syphilis.
ARSPHENAMIN REACTIONS.'
By John F. Martin, M.D.
In large hospital clinics where syphilis is treated
with various arsphenamin preparations, reactions
occur more or less frequently, depending on the care
taken in preparing solutions, the purity of contents,
the elapsed time between the making of the solution
and its administration to the patient, the amount of
arsphenamin given, operative technic and skiO, and
factors within the patient. While a given brand of
arsphenamin might, through some circumstance, very
rarely prove toxic, the precautions taken to make
such possibilities remote (chemical, animal and chnical
controls), usually mean that arsphenamin has to be
discharged for want of evidence. Arsphenamin might
have been guilty of causing some of the reactions on
which this paper is based, but this could not be
proved.
When directions are carefully followed in preparing
the arsphenamin solution, and in administering it to
the patient, if a reaction follows, then the cause of'
the reaction is attributable either to the brand of
arsphenamin used or to the patient. Printed directions
accompany each ampoule of arsphenamin, whetlT£r
it be diarsenol, arsenobenzol, salvarsan or arsaminol,
and are specific and easy to understand; and it is
laxness in following these directions that accounts for
the greater number of reactions to treatment. When
'•Abstracted from the Journal of the American Medical Asso-
ciation, vol. Ixxiv, No. 18, May 1, 1920, p. 1,218.
a trained and careful person prepares the solutions of
arsphenamin, reactions will seldom occur in hospiwi
chnics or in private practice.
Necessary Precautions.
One should note any departure from the normal
lemon-yellow colour of the brand of arsphenamin
being used, and then immerse the ampoule in 95 per
cent, alcohol for fifteen minutes to detect obscure
cracks. Cracked ampoules or ampoules that contain
discoloured arsphenamin are to be rejected, the sub-
stance having become oxidized. It is a good plan to
mark down the serial numbers of the ampoules used
in order to check up with the manufacturer in case
the arsphenamin is suspected of being the cause of a
reaction. One is further directed to prepare individual
solutions, and when this is not practical, not to pre-
pare more solution than can be disposed of within
half-an-hour. Using the syringe-container method,
and allowing six minutes for each 0'5 grm. of ars-
phenamin in solution, limits the number of ampoules
that may be used at a time to five. The sooner the
solution is disposed of, the less danger of oxidation.
Using the directed technic for one brand of ars-
phenamin while preparing the solution of another
will, in some cases, cause reactions. Salvarsan
(Metz) calls for freshly distilled water of not more
than room temperature ; diarsenol requires warm,
freshly distilled water ; and arsenobenzol is to be
dissolved in boiling hot, freshly distilled water.
Salvarsan becomes oxidized when dissolved in hot
water. The directions call for freshly distilled water
or physiologic sodium chloride solution, prepared from
chemically pure sodium chloride — not from table salt.
It is directed that normal sodium hydroxide (4 per
cent.) or 15 per cent, solution be used to neutralize
and alkalize arsphenamin in solution. Faulty pre-
paration with impure or altered sodium hydroxide, or
contaminated distilled water, may cause reactions.
Neutralizing arsphenamin, which is dihydrochloride
salt, requires a definite amount of sodium hydroxide to
render it slightly alkaline and suitable for use. A
large percentage of reactions resulting when technic
is not strictly followed are due to hypo-alkalization,
while hyper-alkaline solutions, due to faulty measur-
ing of sodium hydroxide solution, causes reactions at
times. A graduated pipette or burette is recommended
to be used, the certainity being a normal-sized drop
and accurate measure. Arsphenamin is precipitated
as a basic salt by sodium hydroxide ; it requires a
definite amount to redissolve the precipitate, changing
the basic salt to a monosodium salt, the solution
being just alkaline to litmus paper. On further ad-
dition of a definite amount of sodium hydroxide, a
disodium salt is formed which is completely soluble
in water. The basic precipitate and monosodium
salt will cause reactions, the disodium salt in solution,
properly diluted and filtered, being suitable for use.
All manufacturers agree that solutions should be
of room temperature. Injecting too cold solutions
into the circulation will induce cliill reactions. Too
rapid giving of the solution, particularly in high con-
centration, will cause reactions in some instances.
TEE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
One i3 advised not to give more than O'l grm. of drug
(30 c.c. of solution) in two minutes ; tlie gravity
method is the one advised ; the rate of flow is con-
trolled by the size of the needle (No. 18 or 20 B. k S.
gauge) and the height of the column of fluid. The
syringe-container method is favoured by many opera-
tors, and while not as " fool proof " as the gravity
method, an expert can handle difficult work with
greater precision.
Giving too large a dose of arsphenamin at the
beginning of a course of treatment accounts for some
reactions. Lack of preliminary preparation for treat-
ment— a laxative the night before, and a light breakfast
four or five hours before operation — is sometimes a
cause. Every patient should be given a careful
physical examination to determine organic or func-
tional impairments, as findings may limit or contra-
indicate arsphenamin treatment. When two or more
reactions occur from a multiple ampoule solution, in
the majority of instances the fault will be found in
the technic of preparing the solution, and the usual
cause will probably be hypo-alkalinity.
Factors attributable to the Patient.
Both arsphenamin and the technic in preparing its
solution having been excluded, factors attributable to
the patient are to be considered. Tissue susceptibility
to arsphenamin medication include allergic idiosyn-
crasy, an inherited dominant susceptibility to
arsphenamin medication ; anaphylaxis, protoplasmic
sensitization from repeated doses ; blood synthesis
reactions, in which arsphenamin becomes altered or
precipitated from causes not understood, or ascribed
to excess of carbon dioxide in the blood, or faultily
prepared arsphenamin solutions ; and the nitrioid
reaction, ascribed to the action of arsphenamin in
destroying spirochaetes and liberating large quantities
of bacterial protein to which the tissues have to be
sensitized. The Herxheimer reaction is attributed to
the stimulating activity of non-sterilizing doses of
arsphenamin.
Reaction symptoms occur singly or in syndromes,
•while the injection is being given, soon after the
patient leaves the table, or a few hours or days later.
The most common type of table reaction is the
vasomotor syndrome, usually manifesting dermal
capillary flushing, dyspnoea, coughing, nausea and
subcutaneous oedema, two or more symptoms being
present. The vasomotor type of reaction has been
ascribed by Pardo and otliers to the vasodilating
action of arsphenamin. Insufficient alkalization of
arsphenamin solutions account for a largo number of
this type of reaction. Hirano claims that arsphenamin
anaphylactoid symptoms are due in many cases to a
deficient epinephrin content in the blood resulting
from sudden consumption after intravenous injection
of arsphenamin, and from an inhibition of epinephrin
secretion by the suprarenals. When repeated reactions
of this type occur, preceded by a number of arsphena-
min treatments without reaction, epinephrin deficiency
as a possible factor causing the reaction is to be
considered. Preinjection of epinephrin tends to pre-
vent this reaction, as well as relieve the symptoms
when it occurs.
Another type of reaction occurring infrequently,
but liable to occur while the patient is on the table,
is the " spine-pain," characterized by the patient's
complaining of stabbing pains in the lumbosacral
region. The pain is usually intense ; it is in most
cases accompanied by vasomotor symptoms, and
might be the result of vasomotor influence on various
viscera, and registering on respective nerve centres
in the spinal cord.
According to Kolmer and Yagle, arsphenamin
causes haemolysis, particularly when injected in con-
centrated solution, but it is not so likely to do so
when in weaker solution or when isotonic salt solu-
tion is used instead of distilled water. Ha;molytic
action of arsphenamin solutions is said to be increased
by hyper-alkalization. Dilute solutions of neo-
arsphenamin (0'9 grm. in 90 c.c. or more water) are
claimed to cause haemolysis, while concentrated solu-
tions (09 grm. in 30 c.c. or less of water) are not
haemolytic.
Functional and Organic Impairments.
Reactions other than those due to anaphylaxis and
blood synthesis arise from functional and organic
impairments causing certain viscera to be more sus-
ceptible to arsphenamin medication. Neurologic
reactions present the hysterical type, usually not
attributable to arsphenamin but to psychophysical
upsets, before or after treatment. Syncope, headache,
vertigo, neuritis, pseudo-epilepsy, and Herxheimer
manifestations affecting special nerve centres occa-
sionally arise, owing to either sensitization, vasomotor
action, or activating syphilitic lesions. Reflex enuresis
has been observed in two cases, immediately follow-
ing arsphenamin treatment.
Dermal reactions sometimes occur, and appear to
be due to large doses of arsphenamin, dominant
susceptibility, anaphylaxis, faulty elimination, blood
synthesis, and the administering of toxic arsphenamin
solutions. The eruptions appearing may be scarla-
tinal, maculopapular, or may simulate dermatoses,
as pityriasis rosea.
"Arsphenamin jaundice" is a coined term applied
to jaundice manifested by patients who have received
arsphenamin medication. There are two forms, cor-
responding to the catarrhal or hepatogenous, and the
toxic or hmmatogenous, the former being due to
obstructive elimination arising from such causes as
cholangeitis or hepatitis, which may or may not bo
due to arsi)henamin treatment. The haematogonous
form is probably duo to toxic products of arsphenamin
blood synthesis, toxic arsphenamin solutions, sensi-
tized hepatic tissue, or overworked hepatic function,
resulting in low-grade or toxic degeneration. Chronic
hepatitis may be a contributory cause.
Jaundice following arsphenamin treatment usually
occurs after a number of doses of arsphenamin have
been given, and it has been observed that patients
tliat show an exhausted or diminished tolerance,
manifested by various reactions, are prone to iiave
jaundice at a later period if arsphenamin treatment
is carried on without a rest from treatment of one or
more weeks. The usual case of arsphenamin jaundice
224
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 1, 1920.
clears up in from two to four weeks ; the severe,
toxic type of jaundice, while rare, is likely to he fatal.
Reactions to arsphenamin treatment are a warning
signal that there is a cause to be found, and that a
review of the patient's history, physical condition,
the brand of arsphenamin used, and the technic of
preparing the solution and administering it to the
patient should be undertaken. It sometimes happens
that treatment has been too prolonged in persistently
positive cases, and the tolerance to arsphenamin, and
also to mercury, has become exhausted. In such
cases a rest from treatment of one or two months
does much to rejuvenate the patient.
Classification of untoward Incidents and
Reactions.
Sequelie arising from arsphenamin medication may
be thus classified : the incidents, slight untoward
symptoms occurring in patients with normal tolerance
to arsphenamin, such as vertigo, palpitation, disturb-
ances of taste and smell, or slight nausea ; the
reactions usually occurring in syndromes, and causing
discomfort and sometimes incapacity, which may be
ascribed to allergic or acquired susceptibility to
arsphenamin, functional or organic complications, or
toxic arsphenamin solutions ; the grave reactions
(sometimes fatalities), such as dermatitis exfoliativa,
toxic jaundice, haemorrhagic excephalitis, and gan-
grene ; the accidents, such as thrombosis, phlebitis,
and infiltrations about a vein. .
With careful observance of all precautions in the
administering of a properly prepared arsphenamin
solution to a risk-free patient, if treatment is not too
energetic, reactions may be reduced to a minimum,
both in private practice and hospital clinics. Each
patient, during a course of treatment, should be care-
fully observed as to individual susceptibility and
tolerance for arsphenamin. Standard treatment may
serve as a guide for the average case, but one must
individualize to prevent reactions and best treat the
patient.
The subject of the rarity of finding malaria parasites
in malaria infected persons elicited the following
interesting letter from Dr. W. G. Heath, of Mont-
serrat, British West Indies, on the benefits of
continuous vaginal irrigation in post-partem febrile
cases. He also confirms the remarks on the rarity of
finding malaria parasites in malaria infected persons
as enunciated by Sir James Cantlie in the editorial
in question.
To the Editors of the JOURNAL OF TROPICAL Medicine
and Hygiene.
Montserrat, B. W. I.,
July 23, 1920.
Dear Sirs, — Reading an article in the JOURNAL
OF Tropical Medicine and Hygiene entitled " A
Malarious Blood," recalls a case which I attended about
two years ago, which has always been a puzzle to me,
and which also presents one or two points of interest.
This was a labour case (multipara). She had before
marriage lived in a malarious district and had suffered
severely from malaria, but had not had an attack for
some years. She also suffered from boils, and bad
to cut her hair short to treat those on the scalp. The
labour presented nothing peculiar. I was only present
at the end of it. The child was large, weighing about
12 lb. No douching was ordered, as it was thought
unnecessary ; but a day or two after the temperature
gradually began to rise. Douching was then ordered,
and quinine prescribed. The temperature stiU kept
up, and then I made a vaginal examination, and
found a split in the cervix. A vaginal douche was
given, after which the temperature went up to 104 F.
A colleague was called in consultation. He made an
examination of the cervix, and within a few minutes
the patient turned very white, and had a severe
attack of ague, and the temperature shot up suddenly
to 107" F. Fortunately ice was at hand, and we soon
had her packed in it, and this brought the tempera-
ture down to about 104" F. It then occurred to me
that it would be a rational thing to irrigate the torn
cervix by continuous saline irrigation. We filled a
douche can with physiological saline solution and
hung it over the bed. The nozzle at the end of the
tube had a stop- cock which was arranged to let the
solution flow at a " quick drip." The nozzle was
then tied into the vagina, as one ties in a catheter,
and the vagina lightly packed with gauze. The
patient lay on a rubber sheet ; quinine was also con-
tinued. The temperature gradually came down,
though there was another — a shghter ague attack the
next day, and in a few days the temperature fell to
normal, and did not rise again above normal. The
continuous irrigation was kept up for about 48 hours.
Afterwards ordinary douches with the saline was
given .
Was the toxaemia due to malaria, or to septic
infection, or perhaps due to the furunculosis, or to
both ? The continuous irrigation with physiological
solution was a novelty, as I have never seen it men-
tioned before for this purpose, but if it succeeds in
deep-seated wounds, why not in wounds of the
cervix ?
As you know. Government medical ofiicers, especi-
ally in these small places, as Montserrat, are supposed
to do everything. We do our own operations, from
opening abscesses to abdominal sections. We are
gynaecologists, and midwives, and anaesthetists. We
diagnose, and prescribe, and pull teeth, and do our
.own microscopic work in the intervals of dispensing
worm powders and dressing ulcers. We are consulted
on a sick cat or cow. We are members of all sorts of
boards, committees and councils, and even have to
check the Treasury cash or departmental stores.
Thus there is little time for preparing and examining
blood slides, but in those I have done have seldom
found parasites.
Please excuse this rapidly written note, but it may
be of some interest.
Yours faithfully,
W. G. Heath.
Sept. 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 18, Vol. XXIII.
(SrigimU CommMications.
ii slight rise. The physical signs are those of bron-
chitis. The attack lasts from a fortnight to several
BRONCHO-SPIROCH.ETOSIS (CARTELLANI'S
BRONCHITIS).
By C. L. Brownk, L. R.C.I'., L.R.C.S.
AssisUml Medical Superintendent, Clare Hall Sanatorium.
This condition was first observed by Castellani in
1905-06 in Ceylon, and his findings were subsequently
confirmed by other workers : Branch, in Kingston,
St. Vincent, in 1907 ; Jackson, in the Philippines in
1908; Waters, in India in 1909; Phalea and Kilbourne
in the Philippines in 1911, and in the same year by
Chamberlain in tlie Philippines and Macfie in West
Africa.
Cases liave since been recorded as having occurred
in various parts of Europe. In 1915 and again in
1917 Galli Valerio recorded some cases in Switzerland.
Lurie described a case in Serbia in 1915. In 1917
VioUe was first to observe this affection in France and
recorded some cases. Since then other cases have
been recorded by Bine, Dide, and Ribereau, by Netter,
by Dahmier, by Barbary, and by others. Rubiere and
Gautier, in 1918, described some cases in France
among French and Indo-Cliinese soldiers. Jacono has
observed the malady in Dalmatia, and .\lcock described
this condition as occurring in a British soldier in Italy,
and Villa, Corvetto and Carini have noted a few cases
in South America.
Castellani did some further work in this connection
in the Balcanic-Adriatic Zone.
Investigations were carried out by Chalmers and
O'Farrell in the Soudan in 1913, and they successfully
reproduced the disease in a monkey, but attempts to
infect guinea-pigs and rabbits were unsuccessful. In
1914, Taylor also investigated this condition in the
Soudan. Fanthani studied the morphology of the
SpirochcBta bronchialk and published his observations
in 1915.
Geograpliically the distril)ution of this disease
appeai-s to be general.
The aetiology of this complaint is unquestionably
due to the activity of the .S'. bronchialis (Castellani).
In morphology, the organism varies in length from
5— 30/i, in breadth from 0.2— 0.4m. It is actively
motile with tapering ends. In addition to the free
and motile stage Fantham describes a coccoid stage
and an intracellular stage.' lie considers the coccoid
or granular stage as being a resting stage.
Fantham, Chalmers, O'Farrell and Taylor recognize
iS'. bronchialis as being quite distinct from the oral
forms. There are three types of this disease described
by Castellani : the acute, sul)acute and chronic.
Acittr type. Onset sudden, with a feeling of chill —
the temperature is raised, witli cough and some
generalized pains. Expectoration is small in quantity.
Physical signs of bi'onchitis are jjresent. Recovery
usually takes place in a few days.
Subacute type. Onset more or less sudden, with
frequent cough associated with a pink coloured mucus
expectoration. There may be actual liiRmorrliage.
The temperature may remain normal or there may be
Chronic ti/pc. This type usually follows the sub-
acute form. Cough is fhronic and sputum usually not
abundant. Slight haemorrhages may occur from time
to time, and sometimes on two, three or more days in
succession. The quantity of blood is usually small,
from about two to four drachms. Larger (juantities
may also occur. The temperature is generally
normal. Some cases may present a small evening
rise, or the chart may show instead a morning rise.
The physical signs are usually those of bronchitis.
The patient is usually fairly well nourished. There
may be some slight secondary anaemia where there
has been frequent loss of blood. It is this chronic
form which is more likely to be mistaken for pulmonary
tuberculosis.
The two following cases treated in the Clare Sana-
torium will probably help to illustrate the chronic form
of this malady.
Case 1. E. B., male, aged 47 years. Admitted on
May 5th, 1919. Born in England and lived there all
his life. Health was good till nine years previous to
admission, when he had a severe attack of bronchitis.
This left him with a cough, which continued slight till
October, 1918, when a second attack of bronchitis
ensued. After recovery cough still continued and
became very persistent. About the middle of February,
1919, he had an attack of haemoptysis, in quantity
about an ounce. Between the middle of February and
the end of April he had five similar attacks, and on
each occasion the amount was about an ounce. No
family history of tubercle bacilli traceable. The
general condition of patient on admission was good
and his temperature was normal.
Lungs. Signs of bronchitis present.
MotUh. Some carious teeth present on spongy
gums, bleeding easily on pressure.
Pharynx. Injected but no definite soreness present.
Patient did not feel his throat sore.
Sputum. Frequent and careful examinations were
made and no tubercle bacilli were found, but spiro-
chajtes were present in enormous numbers. Sputum
was almost purulent in character with an offensive
odour. As secretion from crypts between teeth and
gums showed heavy infection, great care was taken in
liaving the mouth thoroughly washed with antiseptic
lotion, just before obtaining sputum. This appeared
to make no difference in the enormous numbers of
spirochaetes jMesent. Morphologically the spirochaete
was actively motile and varied in length from 7--29^,
with tapering ends. The spirals varied from 2 — 9 and
were quite irregular. An occasional one witli regular
spirals was found. On staining, carhol gentian violet
gave tlie best result. Fontana's method was also
good. The Romanowski stains did not give such good
(lefinition. Gram's stain was negative.
Tmitmenl : — Adrenal (disodium methyl arsenate)
was given by mouth in i gr. doses twice daily after
food, for some weeks. There was a diminution in the
tmmber of spirochaetes at the end of this period, and
an improvement in the general health of the patient.
Cough was less persistent. Kharsivan in doses of 01
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15. 1920.
gramme was next given intramuscularly, till 1'2
grammes had been administered.
Under this treatment the number of spirochaetes
diminished rapidly and cough became considerably
less. Patient slept better and his general condition
was satisfactory. On discharge spirochaetes were still
present, but not many. A mouth wash was used
throughout the course of treatment and the teeth were
attended to by a dentist.
The patient had no recurrence of hsemoptysis
while under treatment. I interviewed this patient six
months after his discharge. He has kept well since
he left the sanatorium. His cough has practically
ceased, except for a little on waking in the morning.
I examined his sputum, and after an hour's careful
search of a series of films taken from different parts of
the sputum, I was unable to find a single spirochaete.
Case 2. D. L., aged 28 years. Female. Admitted
on July 21st, 1919. Her trouble commenced with
haemoptysis in March, 1915. She has had frequent
haemorrhages since then, sometimes for several days
consecutively. She has been in several institutions
for the complaint. She was bom in England, and has
lived there except for three years spent in Canada,
1911—1914. In November, 1912, she was operated
on for gastric ulcer, and a month later a second
operation was performed for the same cause. In the
winter of 1913 she underwent an operation for
appendicitis. On her return to England she developed
intestinal obstruction, and was operated on at St.
Mary's Hospital, Paddington. Later, in the winter of
1914 — 15 she had pneumonia and pleurisy, which left
her with a cough. Her first attack of haemoptysis
came on very shortly after this. On the first day of
her admission she had a small hjemoptysis of about
an ounce at most. During her stay here she has had
frequent haemoptysis, varying in quantity from two
drachms to four ounces, and occasionally more. On
five or six days in succession she has produced coloured
sputum. Routine examination of sputum showed
enormous numbers of spirochaetes. Examination of
mouth showed some carious teeth, with spongy gums,
which bled easily on pressure. Secretion from crypts
between the teeth showed very large numbers of
spirochaetes. The same precaution was taken to pre-
vent contamination from the mouth. Frequent and
careful examination of the sputum resulted in no
tubercle bacilli being found. Physical signs in the
lungs were those of bronchitis. Abdomen showed
operation scars. The stomach and colon were dilated.
Constipation was marked, with passage of large
quantities of mucus with each motion. The character
of the sputum was a peculiar pink mixture, as described
by Castellani and VioUe, and with minute air bubbles
intimately mixed. The amount of blood was always
considerably less than it appeared to be, there being
quite a large quantity of sanguineous fluid, with the
thicker portions floating on the surface.
The microscopic characters of the spirochaete were
identical with Case 1.
Treatment. — At first this w^s directed to the ali-
mentary tract, and then adrenal was given by the
mouth in h gr. doses twice daily after food. At the
end of three weeks severe gastro-intestinal irritation
was set up and adrenal was at once discontinued.
She soon recovered from this and general treatment
was then given for the rest of her stay.
Kharsivan was not given as the patient did not take
the suggestion kindly.
In spite of unsatisfactory treatment the general
condition of patient improved, and spirochoetes
diminished considerably in numbers at the time of
discharge.
LITERATURE.
Castellani (1906). Lancet, May 19(1900-13). Ceylon Med-
ical Reports (1909). Brit. Med. Journ., September 18 (1917)
Presse Medicate, No. 37, and Joobnal of Tbopical 1L«:d:cine
AHD Hygiene, August and September.
Branch (1907). Brit. Med. Journ.
Jackson (1908). Philippine Journal of Science.
RoTHWELL (1910). Journ. Amer. Med. Assn.
Chalmers and O'Paerell. (1913). Journal op Tropical
Medicine and Hygiene.
Harper (1914). JonENAL op Tropical Medicine and
Hygiene, July.
Taylor (1914). Annals Trap. Med. and Paras.
Pantham (1915). Annals Trap. Med. and Paras.
Galli-Valerio (1915). Centr. f. Bakt. (1917). Correspon-
demblatt f. Schweizer-Aerzte.
Magpie (1915). Journal op Tropical Medicine and
Hygiene, May.
Hallenbeeger (1916). Arch. f. Schiffs-u. Tropen- Hygiene.
Ragazzi (1916). " Un caso di Spirochetosi bronchiale "
(Castellani). Pathologica, January 1.
Villa (191G). " Espiroquetosis Pulmonar." Repert de
Med. y. Cirugia, vol. vii., No. 6.
Alcock (1918). Journal op Tropical Medicine and
Hygiene.
Barbary (1918). Bull. Ac. de Med.
Beau, Dide, and Ribebeau (1918). SociM M(d. des Hop-
piteaux.
CoRVETTO (1918). " Espiroquetosis broncho-pulmonar de
Castellani." An. Facult. Sled, de Lima, vol. v. No. 5.
Derrien (1918). Reunion Medico-Chirurgicale de la 15me
Rt'gion.
Netteb (1918). Bull. Acad, de Mid., September 17.
Sabhazes (1918). Qaz. hebd. des Sciences tn^dicales de
Bordeaux, June 30.
Thomson (1918). Brit. Med. Journ.
Vebliac and Turlais (1918). Quoted by Netter.
ViOLLE (191,8). Bull. Path. Exot.. No. 1, tome xi. (1918),
Bull. Acad, de Medecine (1918). Presse MMicale, " La Bron-
chite sanglante " " Spiroehetoise Bronchopulmonaire de Cas-
tellani," No. 39, p. 359 (1918). " Hsemorrhagic Bronchitis,"
" Castellani's Broncho-pulmonary Spirochaetosis," Lancet,
Castellaxi and Chalmers (1919). "Manual of Tropical Med-
icine," 3rd edition, p. 1882.
Delamare (1919). Soc. de Biologic.
Dahmier (1919). " A propos de la broncho-spirochetose de
Castellani." Presse Medicate, No. 14, p. 124.
Browne (1920). Lancet.
Jacono (1920). Journal op Tropical Medicine and
Hygiene.
Cabini (1920). Bull, de la Soc. de Path. Exot., September.
LOCALITY DIFFERENCES IN THE FEEDING
HABITS OF MOSQUITOES.
By Malcolm E. MacGregob,
Wellcome Field Laioratori/ {Wellcome Bureau of Scientific
Research).
Lately it has seemed to me not at all remarkable
that there are so many contradictory statements
recorded concerning the blood-sucking habits of
certain species of mosquitoes. One obser^'er will
record the fact that he has never been bitten by a
particular species of mosquito : that he has never
Sept. 15, 1920.] THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE.
met with a specimen with blood in the abdomen ; and
that in consequence he doubts altogether whether the
particular species ever requires a blood meal. I must
confess tliat until recently I was inclined to share
this belief as regards Theobaldia annulata rather than
believe that this species could ever be called a vora-
cious blood-sucker. Innumerable times I have en-
countered this mosquito in stables, in out-houses of
all sorts, and elsewhere ; but as far as I can remember
I have not until just recently ever been attacked by
the species, or seen blood in the abdomen.
At the War OfBce Entomological Laboratory at
Sandwich, Kent, certain stables where we obtained
our anopheline supplies often contained large
numbers of T. annulata, but never once was an
engorged specimen seen. Specimens were captured
at all times of the year, but none could ever be
induced to "bite" in the laboratory, though they
were encouraged to do so by day and by night.
This is my experience in Kent : contrast it with
the two following experiences in Surrey.
At Wisley, Surrey, where my present laboratory is
situated, among the huge mosquito population of the
locality, T. annulata is widely represented. It breeds
in stagnant ditch water, and very largely in rain-tub
barrels around houses. The adults enter dweUings
in numbers, but although we resided for three months
near Wisley, and specimens of T. annulata were often
in our bedrooms throughout the night, we were never
once bitten, nor did I ever find an engorged mosquito
of this species.
Within the last week I have moved from Wisley
to Woking — from completely country surroundings,
to the surroundings of a country town. From the
first night of my arrival at Woking I have been
repeatedly attacked each night by T. annulata, and I
have captured engorged females in the mornings
three days out of the five that I have searched for
them. The mosquitoes exhibited an unusual amount
of daring. One evening, after a specimen had buzzed
around my pillow until my patience was exhausted,
I switched on the electric light suddenly and chased
the creature about the room for fully five minutes,
but as the walls of the room were high, I decided
that the mosquito had the best of it, and went back
to bed. In my attempts at capture I had ascertained
quite definitely that there was only one in the room,
yet the Hght was no sooner extinguished than it
resumed the attack.
During the last few years I have been much im-
pressed, both in England and abroad, by what seems
to be locality ditferences in particular species of
mosquitoes.
To confine such experiences to England, let me
cite two other rather striking examjilcs.
There are not many records in England of Culex
pipiens ' biting" human beings, although this species
is common in houses all over the country. Personally
I have tried my best on numerous occasions l)y day
and night to get C. iitpicns to bite in the laboratory.
On one occasion in London, in lOir), a cage containing
C. pipiens was tied to the forearm of a volunteer and
was kept in that position tliroughout three consecutive
nights, yet none of the insects could be got to feed.
Nevertheless about the same time under different
conditions, and in a different locality, this same
species was attacking workmen so viciously in the
Highgate Station of the Underground Electric Eail-
way, 66 ft. underground, that the Company appealed
for help in subduing the pest.'
The third example which I will quote concerns
Anopheles maculipennis. In June to September,
1917, I was stationed at Bordon Camp, in Hampshire.
A. maculipennis was present in large numbers, and I
had sometimes counted as many as thirty females
resting on the walls and ceilings in our bedrooms at
a house in Whitehall district, Bordon. Never once,
however, were we attacked.
While residing near Wisley recently, although
A. maculipennis was at no time nearly so numerous
as at Bordon, they attacked me so viciously at night
that for a fortnight early in July I had to sleep under
a mosquito-net in order to be comfortable.
What underlies these local differences in the habits
of mosquitoes it would be difficult to say. In the
case I have mentioned with regard to C. pipiens, one
would be inclined to explain it as a matter of atmo-
spheric temperature, for the temperature of the
"dead ends" of the Tube Railways was distinctly
tropical. On the other band, in the case of A. maculi-
pennis, it is certainly not a matter of increased tem-
perature that induced the insects to " bite " at
Wisley though they did not "bite" at Bordon. I
have no temperature charts to consult for comparison
of the records of 1917 with the records of this year,
but I think it can be safely assumed with the almost
continuous wet and cool weather we have had during
July, that the average temperature this year for July
has not been higher than it was in 1917.
I think a more likely explanation is to be found in
the suggestion that possibly it is due to local differ-
ences in the normal food supply of the insects. In
the Tube there was only one available supply, i.e.,
human beings. Again, at Wisley, it may have been
that there was a sliortage in the cattle-blood-* supply
— live stock is certainly scarce in the locality. While
in regard to T. annulata, whatever its main blood
supply may be normally, the supply may be absent
for this particular region of Woking.
It is clear, at any rate, that a particular species of
mosquito may exhibit differences in its blood-sucking
habits in different districts irrespective of the influ-
ence of atmospheric temperature, and it is necessary
to guard against the likely error of assuming that
because the habits are known fully in one locality
that these habits are necessarily the same in some
other locality.
THE TREATMENT OF ULCUS TROPICUM.
By Nathaniel Gbichlow, M.B., Ch.B. (Glasgow.)
Governntenl Medical Officer, liritish Solomon Islands.
The definition of Ulcus Tropicum, given by Castellani
and Chalmers, correctly describes the main features
of the ulcer. It is a chronic sloughing ulcer, very
' JoDiiNAL ov Tbopical Medicine and Hyoienk, 1'J15.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15. 1920.
often, in my experience, phagedaenic in character, and
spreading down to tlie muscles and bones. It shows
little or no tendency to spontaneously heal. The
most hequent sites are on the outer aspect of the leg
in the lower third and the ankle.
.■Ml of the cases I have dealt with were found in
natives, and were present foi- months and even years.
They presented a very dirty appearance, and were
covered with a thick dirty-grey and foul-smelling
secretion. On removing this secretion, the fundus
was dark-red in colour and funnel-shaped. The
causative organism, in my opinion, is a spirochaete.
Treatment. — Ulcus tropicum is very resistent to
ordinary treatment and slow to heal, -often taking
months to do so. I have never tried methylene blue
ointment, as recommended by Mason, or protargol
ointment, as recommended by Castellani and Chalmers.
The treatment I have found most effective is as
follows : —
At the outset, an intravenous injection of galyl is
given. Every day the native 'soaks the ulcer in a
bucket containing a hot antiseptic solution for 15 to
30 minutes. Kerol is used, as it is very cheap and
answers well. After the hot antiseptic bath, the
ulcer is dusted with iodoform powder and a dry
dressing applied. When the ulcer presents a clean
appearance, the antiseptic bath is dispensed with,
and the ulcer is cleansed with an antiseptic lotion
such as 1-1,000 corrosive sublimate solution, and
then dusted with the iodoform powder. At this stage,
" bipp " ointment is sometimes used instead of the
iodoform powder.
Under the above treatment, ulcers which have
resisted treatment for months heal in from 14 to 28
days. I have had no occasion to repeat the injection
of galyl, as one injection in all my cases was
sufficient. Galyl, in my hands, has proved so wonder-
fully effective, that I have no hesitation in recom-
mending it as a routine treatment in all eases of
tropical ulcers.
The Defects of Deficient Dietaries m Monkeys.
(McCarrison, Brit. Med. Journal, February 21, 1920.)
Some of the author's conclusions are as follows :-
'•' Dietaries which ai-e deficient in vitamines and in
protein, and at the same time excessively rich in starch
or fat, or in both, are potent sources of disease, and
especially of gastro-intestinal disease.
An excess of fat, in association with deficiency of
B. vitamines ' and protein and superabundance of
starch, is peculiarly harmful to the organism.
" Certain dietetic deficiencies greatly favour the
invasion of the blood and tissues by bacteria."
(.Edema as a Symptovi in Food-deficiency Diseases.
(Bigland, Lawet, January 31, 1920.)
The author mentions three possibilities as to the
mechanism of cedema production in such cases : —
(1) Toxic products of albuminoid metabolism may
damage the endothelial linings of the vessels ; (2)
deficiency in calcium salts ; (3) increased production
of adrenalin causing increased intracapillary pressure.
|l0tias.
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THE JOURNAL OP
Cr opical S^thitim anD l^pgiene
September 15, 1920.
FRUITS AND THEIR SALTS.
A VAGUENESS amounting to ignorance exists amongst
us as to the part played in the economyby the salts which
exist in dietary articles in connnon use, more especially
in the fruits and vegetables we consume. Some of tliese
agree with certain individuals whilst others find them
Sept. 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
229
actually dangerous. We are familiar with the effect
of rhubarb, for instance. Oxalates are known to take
a prominent part amongst its ingredient salts, and
with many people this fact renders table rhubarb pro-
hibitive eating. Tlie writer can speak from personal
experience ; on three separate occasions he has passed
oxalate calculi from the left kidney, and on one occa-
sion from the right. There could be no doubt about
the incident, for each attack was attended by acute
agonizing pain over the kidney on one side, and with
a sharp occurrence of haemorrhage. Being abroad for
a time where edible rhubarb was not to be had, no
more attacks occurred, but on returning home and
when again eating rhubarb the left kidney was the
seat of violent pain which died away in the course of
two or three days. Aware that the trouble was due
to rhubarb and its oxalates no more was eaten for
twelve months, in fact until the young rhubarb came
into vogue again in the following spring. Anxious to
test whether he had recovered from the rhubarl) idio-
syncrasy he took it again, but the pain returned in the
left kidney.
For seven years in succession the experiment was
repeated and for all the seven years the same concord-
ance of events happened. Since avoiding further
experiment no recurrence has taken place. Wliat are
the physiological and pathological traits in tliis
sequence ? Do some people possess congenitally smaller
kidney tubules than others and thereby suffer in con-
sequence by the passage of oxalates, or are the oxalates
of rhubarb and other plants changed by the absence of
something amiss with the digestion of tliese salts,
or is the digestion such that oxalates of a larger
calibre are produced ? We are, at least most of us, ha/,y
as to the actual cause of the presence of oxalates in
such quantity, and are content to believe that it is due
to " indigestion," that whirlpool of evil into which so
many unsolved problems ai'e cast. If due to indigestion,
what faulty pi'ocess in that complex entity is amiss ?
' In our chemical text-ijooks we read that oxalates are
1 met with in addition in such plants as wood-sorrel,
the common dock and certain lichens. No mention
[ is made of tomatoes in the category, perhaps because
the tomato of our tables is more recent, and the fact that
' it is also impregnated with oxalates has not come to be
so generally known. The tomato, once known as the
" love-apple," was, when under that designation, small,
shrivelled, crinkled and unattractive, but by the
genius of Mr. Adam Duncan — just deceased — smooth-
skinned globular fruit, now so popular, was evolved.
In earlier days it was a mere table decoration, now
under its present and perfected form it has become a
.popular article of diet. With those to whom ihubarb
lis anathema tomatoes also produce similar untoward
leffects. Now and again there crops up the legend
jthat tomatoes cause cancer. It is very foolish of
course, but if cancer is in many cases due to irritation,
Ithe crystals of oxalates are irritating to a degree to the
whole length of tiie urinary tract. Oxalic acid itself
|is an artificial product and does not exist in nature.
Tt can be produced experimentally in the purest form
ny boiling nitric-acid and loaf sugar together for a
time. Sufl'erers from the oxalate diathesis are mar-
kedly fond of sweets and arc invariably dyspeptics.
In practice we give acids as a rule and nitro-hydro-
chloric acid by preference. Does this acid taken imme-
diately after a meal, in which sugar — whether in tea,
coffee, &c., or in stewed fruit, milk puddings, or as
"sweets" — is freely taken, act upon the oxalate of
lime in rhuljarb, tomatoes, and in dozens of other
fruits and vegetai)les in quantity, and set free the oxalic
acid and cause a form of poisoning, slight it may be,
hut sufficient perhaps to account for some of the'symp-
toms which afflict dyspeptic people ? This may seem
far fetched and a chemical impossibility. The writer
is not deterred thereby from mentioning these points
for any such contention. Physiological chemistry is
not so precise as to frighten us from such tenets, viz.,
that what is true in the chemist's laboratory may not
be the case in the living organism. As we discuss
opsonins in tiie pathological field of research, that is
that cells are stimulated to activity by certain sub-
stances, be they chemical or vital, so may salts in the
presence of others afford results which are not met
with when these salts are dealt with singly in the
laboratory. Speculation in this direction lands us in
an illimitable field of complex investigation which by
its enormity seems too appalling to enter upon.
Nor is the subject limited to substances pronoun-
cedly impregnated with oxalates. Others there are,
such as gooseberries. Wlien a large quantity of these
are consumed there occurs in many people a peculiar
form of "poisoning" characterized by swelling and
fullness of various parts, best seen in the face, hands
and feet. The face becomes puffy, the lips swollen,
the features lose their ciiaracteristic lines and folds, the
fingers become swollen and stiff, and it is impossible
to clench the fist pioperly; the feet become uncomfor-
table, demanding removal of the boots for relief, and
the person so upset has to lie down for some hours
owing to a feeling of being " overcome." In a day or
two tlie " feeling '' and the symptoms disappear.
Strawberries, to a person with an oxalate diathesis,
cause discomfoit in the lumbar region if many are
eaten, and in those of a uric acid temperament they
are regarded as " forbidden fruit." Yet in certain
ailments such as sprue — a disease characterized l)y
intense anaemia, diarrhcea, wasting of the muscles
and shrinking in size of all abdominal organs — straw-
berries can be consumed in enormous quantities with
the greatest benefit. The writer has seen a helpless
case of sprue, that is one in which death seemed at
hand and in which all forms of known treatment bad
failed, consume as many as twelve pints (or pounds)
of fresh strawberries a day, and in a week become
practically a sound man, and at the age of (55 (an
almost unheard of age to recover in sprue) get quite
well and retmn to the tropics (Manilla) and resume
work. To persons afflicted with oxalates or uric acid
strawberries are anathema, whilst on the other band,
to persons suffering from anaemia — spruc-aiiaimia, a
condition akin to pernicious ananmia and well-nigh
indistinguishable microscopically — they are curative to
well-nigh a miraculous degree. So far but some half-
dozen of substances have lieen mentioned ; were the
growtii of the groups of tartrates, citrates, glucosides
and many more such l)rought into the discussion the
subject would assume illimitable dimensions. Tar-
THE JOURNAL OP TROPICAL MEDICINE AND HYGIENE. [Sept. 15. 1920.
trates exist in the juice of many fruits, but it is from
the grape that our supplies are usually obtained. This
involves the subject of brandy, and all natural wines
of which the variety is legion. Grapes eaten in fair
quantity cause in some people kidney discomfort,
frequency of micturition and a feeling of sickness and
repulsion to grape eating.
Whilst grape-juice is fermenting in the process of
winf -making, the acid tartrate of potassium, not very
soluble in aqueous liquids, is still less so in spirituous
and hence crystallizes out as the sugar of the grape
juice is gradually converted into alcohol. There is
nothing so confusing, so perplexing to the young prac-
titioner of medicine as the question of wines. He has
had no instructions in this subject in his medical
student career. He may be suddenly asked what he
thinks of, say, sparkling moselle as a beverage by some
elderly man or woman, the subject with a gouty ten-
dency. He may never have heard of such a wine,
and as to its probable effect upon his patient it is a
closed book. He shutHes out of the dilemma as best
he may, seeks for information upon the wine in
question, but can think of no book where he can gain
it, and should he ask a brother practitioner will
receive in reply mere generalities of no practical value.
Is there a book published which imparts even
a superficial knowledge of the kind he requires ?
Opinions there are in plenty, but of accurate scientific
knowledge there is none obtainable. It may be
" Pussyfoot " legislation may free him of the neces-
sity for acquiring such information on such subjects,
and some doctors, so perplexed are they when asked
for a definite opinion on such and such a wine in pref-
erence to another, that they may even hope the
ridiculous mania of a dry country may come to pass.
The doctors to whom people fly for advice on the
subject of food or drink have no real education in
either ; a condition of things which turns out prac-
titioners ill-equipped in the real basis of the treatment
of disease.
May we hope that such a course of instruction will
ever be given, or are we to listen only to the evils
caused by alcohol in any form, and how it fills our
asylums with a lunatic progeny ? Will no one tell us
how wines, &c., behave in the economy ; their scientific
bearing upon health and disease ; the actual part they
play, if they do play a part, in gout ; their adulteration
with many obnoxious substances, and the difference
between bad and good wines — the knowledge we
possess is not scientific in any sense, it is mere gossip —
the therapeutic value of wines of different kinds and the
suitability of such and such a wine in varying diatheses?
Most people favour " dry champagne." ' Sec and Extra
Sec "wines are regarded as safe in gouty folk. Yet gout
is an acid plethora in the blood : and acid or dry, or sec
champagne, that is wine to which hydrochloric acid is
added by the French on purpose to please the Enghsh
taste — such wine is adding but fuel to the fire, acid
in the wine to an econ.-my already loaded with acid :
a condition of things which carries its own punishment.
The French do not drink "sec" champagne, but
wine that is neither sweet nor acid, but neutral. This
wine does not cause headache next morning, nor does
it produce gout.
gnnctattons.
On the results ohtaiiied hy the Weil-Felix Reaction
for Typhus Fever at the Garrison of Baku during the
period March — July, 1919, inclusive (F. E. Eeynolds.
Journal of the Royal Army Medical Corps, vol. xxxv,
No. 1, July, 1920). — From a long series of investiga-
tions the author concludes that : —
(1) Agglutination obtained by serum in dilution
1/100 indicates typhus fever.
(2) After about the eighth day from onset of the
disease, if no agglutination is given by the serum in
dilution 1/100, acute typhus fever is excluded.
(3) A positive reaction is given by the serum for a
varying number of weeks after an attack of typhus
fever. There is no relationship in different cases
between the time after the attack and the agglutination
titre of the serum.
Toxic Jaundice in Patients under Antisyphilitic
Treatment (C. V. Bailey and A. Mackay. Archives o;
Internal Medicine, vol. xxv, No. 6, June 15, 1920, p
628). — From a chemical study of the blood and urine
it was found that in patients whose hvers are damaged
by arsenobenzol derivatives hypercholesteroluria is
an early and marked sign which persists after other
clinical signs have disappeared, and its routine
estimation may be of value in detecting the onset of
liver injury in patients under antisyphilitic treatment.
In debilitated patients, particularly if the liver is dis-
ordered, the oxidative activity of the urine is dimin-
ished. In such cases the oxidative activity is greatest
during absolute rest, hence exercise should be
restricted greatly during the course of antisyphilitic
treatment, and for the following few weeks. _
A diet rich in carbohydrate and very low in fat and
protein should precede, accompany, and succeed the
administration of arsenobenzol derivatives in the treat-
ment of syphilis. Increase of protein in the diet and
exercise should be controlled by the estimation of urea
in the blood.
The appearance of toxic symptoms in delayed
poisoning by arsenic, phosphorus, chloroform, &c., is
possibly due to the premature increase of protein in
the diet and of exercise.
Current f itaratuw.
The Indian Medical Gazette, June, 1920.
Standard Diets (J. A. Shorten).— In this interesting
lecture, delivered at the Calcutta Health and Child
Welfare Exhibition, the .author gives the following ,
diet rules: — , . ^, ^ I
(1) Avoid a one-sided diet, remombcring that you
require prot.Mns, fats, carbohydrates, and accessory
food factors.
(2) As good digestion is said to follow appetite, have ^
your food cooked to satisfy your tastes and desires. ^
(3) In the case of children, lomcmiier the import-
Sept. 15. 1920.] THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
231
ance of fat-soluble " A," and give fresh milk, butter
and eggs.
(4) Remember the value of wholemeal flour and
unpolished rice when flour and rice form the main
articles of your dietary.
(5) Remember the anti-scorbutic value of fresh
vegetables and fruits. Fresh vegetables, such as
salads, can be made safe by simply scalding in boiling
water or using some simple disinfectant such as
Condy's fluid.
(6) Do not boil your vegetables for too long a time,
and, above all, do not add soda to soften them.
Ti/phus and Typhus-like Fevers in East Persia
(A. S. Fry). — Clinical notes on nine cases of fever,
with symptoms identical or very similar to typhus.
An Outbreak of Relapsing Fever in Turkey (Clive
Newcomb).— The outbreak first made its appearance
in April, 1918, and continued till June. Neosalvarsan
was used with very good results.
Notes on Influenza (J. H. McDonald). — The author
gives importance in the aetiology of the disease to a
bacillus belonging to the Friedliinder group, which
was isolated in pure culture from pleuritic effusions
following an attack of influenza.
The Indian Journal of Medical Research,
Vol. VII, No. 3, January, 1920.
Estimation of Erythrocytes and Hiemoglobin Con-
tent of Blood. — W. F. Harvey describes a method of
estimating the volumetric content of erythrocytes in
the blood by means of capillary pipettes and one for
obtaining the concentration of erythrocytes in the
blood by measuring the tint and turbidity in a tint-
urometer. The same instrument may also be used
\ for the estimation of hemoglobin after taking the
blood with N-10 hydrochloric acid.
On the Use of Birds as Laboratory Animals. —
W. F. Harvey finds that birds can satisfactorily take
the place of the rabbit in the production of liigh-titre
agglutinating sera, but are not suitable for the pro-
duction of anti-sheep hsemolytic sera.
A Bacteriological Investigation of Influenza. —
R. H. Malone found heated pigeon's blood agar the
I best medium for the isolation and identification of
i Pfeiffer's bacillus. From the sputum of influenza
i patients he obtained : —
Pneumococcus ... ... in 96 percent.
J Streptococcus —
(a) Viridans ... ... ... in 63|
(6) Non-haemolytic non-pigmented inl6[86 ,,
I (c) Haemolytic in 7'
I Pfeiffer's (heated pigeon's blood agar) in 78
Diphtheroids (heated pigeon's blood
agar) ... ... ... ... in 32
Catarrhalis group ... ... in 28 ,,
Staphylococcus aureus ... ... in 13 ,,
I The pneumococcus was the only organism isolated
' from the blood. In the cerebrospinal fluid the Diplo-
j coccus intracelhdaris was isolated from seven cases
1 tentatively diagnosed as influenza with meningeal
; symptoms ; otherwise the pneumococcus was the only
organism isolated. From the accessory respiratory
sinuses P. bacillus or the pneumococcus was isolated
in every case save one. The blood serum of influenza
patients infected with P. bacillus agglutinated the
homologous strain in 82 per cent, and heterologous
strains in 42 per cent. Mouse inoculation proved a
satisfactory method for recovering P. bacillus from
tlie sputum.
Tlie Production of Indole by Pfeiffer's Bacillus
(R. H. Malone).^— P. bacillus was the only hssmo-
phylic organism found in the respiratory tract of
influenza patients and of healthy persons which pro-
duces indole when grown in suitable culture media.
The indole reaction can tlierefore be used as a means
of identifying P. bacillus in pure cultures and recog-
nizing its presence in mixed cultures, and should
also serve as a rapid and easy means of detecting
" carriers " in a healthy population.
Lethargic Encephalitis in Karachi during an Epi-
demic of Influenza (R.H. Malone and G. C. Mitraj.
— In ten cases of lethargic encephalitis which occurred
in Karachi during the present influenza prevalence
there was no history of an attack of influenza, and in
one case only was there influenza in the family during
the present epidemic. No light was thrown on the
aetiology of the disease, and there was no evidence
that it is contagious. Examination of the blood
revealed a moderate leucocytosis with an increase in
the polymorphonuclear cells. As the patient recovered
a decrease in the polymorphonuclear neutrophiles
and a relative increase in the eosinophiles and small
monocysts was found. The cerebrospinal fluid was
clear and contained an excess of globulin, and there
was no increase in its cell content.
The Preparation of a Culture Medium suitable for
the Growth of Organisms used as Vaccines. — D. Norris
recommends the use of a caseinogec broth for this
purpose.
Preliminary Notes on a Method of Utilizing the
Natural Amboceptor in Hsemolytic Sera in the Wasser-
mann Beaction. — R. B. Lloyd and G. C. Mitra estimate
the amount of natural amboceptor present in the
serum, and then put up the volume of serum with
antigen and complement and no antigen and comple-
ment respectively, controlling these witii no serum
plus antigen and complement. With non-syphilitic
sera baemolysis occurs in all three tubes, and inhibi-
tion in the first tube means a positive result.
(1) Bionomics of Houseflies. I. Outdoor Feeding
Habits of Houseflies, with Si)ecial Reference to Musca
promisca [F.'R. Awati). (2) II. Attraction of House-
flies to Different Colours (P. R. Awati). (3) III. A
Preliminary Note on Attraction of Houseflies to
Certain Fermenting and Putrefying Substances (P. R.
Awati and C. S. Swaminath).
Houseflies were found to respond to different colours
l)0th by day and night. Yellow had the greatest
attraction, red and violet the least ; blue, green and
orange being intermediate. Some strongsinelhng sub-
stances connected with putrefaction, sucii as anunonia,
sulphuretted hydrogen, compounds of phosphorus, &c..
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15. 1920.
attracted liouscflies liiit did not cause tlieni to deposit
their eggs.
On the Occunrncc of CoUoptcra m thf Unman
Intestine (R. A. Senior). — Tlie fcTCcs of a Sinlialese l)oy,
aged 4 >ears, who suffered from slight pyrexia, cough,
pain in the abdomen, and soft stools, contained living
imngines of OrtJiophacjusbi fascial us after tlie adminis-
tration of an anthelmintic. Though seldom or never
serious, the condition is sufficiently common to have
a vernacular name in Sinhalese, viz., Kurumini
standama (lit., beetle-disease). The method of invasion
is obscure.
(l) Tlie Correlation between the Chemical Compo-
sition of Anthelmintics and their Therapeutic Values
in connection with the Hookworm Inquiry in the
rresidencij of Madras. II. Oleum Chenojiodii. C2)
III. Oleum Absinthii. (3) IV. Oleum Tanaceti.
(F. J. Caius and K. S. Trihaskar). — American cotton-
seed oil {olewii chenopodii) has long been in vogue in
that country as a household remed\- for worms,
particularly for ascarids. The authors have found it
to be a mixture of several constituents which are
present in varying proportions. It deteriorates with
age and may easily be adulterated. It is highly toxic.
It is a powerful vermicide, acting both on ankylostomes
and on necators. The toxic and vermicidal properties
reside in the same active principle — ascaridol — and
are interdependent. The optimum dose is different
for every sample, and there is no accurate and simple
method of determining it. There will thus always
exist an element of doubt as to the safety and efficacy
of the treatment. Oil of wormwood (oleum absinthii)
and oil of tan^sy (oleum tanaceti) were found to possess
very slight anthelmintic properties.
Note regarding Malaria in Kashmir (C. A. Gill). —
Except altitude no factors can he found to account for
the freedon of Kashmir from malaria. The absence of
malaria in localities having an altitude of 6,000 feet or
over, especially in view of the presence of malaria
carrying mosquitoes, suggests that the critical altitude
is between 5,000 — 6,000 feet, which is the average
height of the Kashmir valley. The significance of
altitude in relation to malaria is thus worthy of more
extensive investigation.
The relationsliip of Malaria and Rainfall (C. A.
Gill). — In all malarious countries there is a general
association between rainfall and malaria, yet no
constant relationship was found to exist between
excessive rainfall and the incidence of autumnal
malaria at Amritsar.
The Pathogenesis of Deficiency Disease : X. The
Effect of some Food Deficiencies and Excesses on the
Thyroid Gland. — R. McCarrison found that dietaries
deficient in vitamines lead to a reduction in size and
weight of the thyroid gland, rendering it susceptible
to the noxious action of intestinal bacteria and their
products, with resultant atrophic and necrotic changes.
Dietaries containing adequate provision of vitamines
and rich in proteins and fats induce hyperplasia of
the thyroid, which is retarded by the ingestion of
onions. It is therefore suggested tliat suecus nlii
jnight prove of benefit in retaining the thyroid hyper-
plasia of Graves's disease.
(changes in the parathyroids are also induced by
a diet deficient in vitamines and ricli in starch and
fat. Tliey appear to be due to the action of intes-
tinal anaerobes, the noxious action of which is
favoured by the defective diet.
Secretion and Epithelial Regeneration in the Mid-
intestine of Tabanus.—V. W. Cragg describes in detail
and illustrates the cellular changes which are asso-
ciated with the processes of digestion and absorption
of food in the mid-intestine of Tabanus, and suggests
that similar processes occur in the mosquito in view
of the close relation of the two families and their
general similarity in structure and liabits.
ibstrnrts.
HITHERTO UXDESCRIBED SIGN IN DIAG-
NOSIS OF LETHARGIC ENCEPHALITIS.
By Thomas F. Reilly, M.D. New York.
W'niLi-: there is no great difficulty in arriving at
a diagnosis in the cases of encephalitis presenting
a liistory of double vision, ptosis and other cranial
ner\e ])henomena, a not inconsiderable number
of patients are encountered in hospital practice
wlio aie brought in unconscious or delirious, and
from whom no such history- is obtainable. In such
instances the patient presents a picture closely
simulating that of one in the third week of typhoid
fever. Tliere are no focal symptoms pointing to
a local central lesion. The leukopenia, so fre-
quently present, is also stronglv suggestive of
tyi)lioi(l fever.
In cliildren the picture is almost identical with
tuberculous meningitis. I have noticed in the
majority of cases of encephalitis a sign that is very
startling when recognized. It consists of a
rhythnn'e con\iilsive twitching of the muscles of
the al)domen in the neighbourhood of the eighth
and ninth ril)s. It often simulates the muscular
inovenient of hiccough, except that it is one-sided.
It has been present in the mild as well as in the
severe cases, although in two j)atients it was not
elicited when I observed them.
The term " lethargic " is unfoitunate, as many
of the jiatients having encephalitis are never
lethargic: on tlie contrary, they are frequently
delirious and often have t-lioreifoi-m movements of
tiie limbs.
In some cases there are almost no cerebral
sym[)toins, not even tlie ordinary placidity; in
others ;i curious fear and ap))rehension may be
(■\ident, and a<,'ai)i the patient presents only the
painfid -sensations of an ordinar\ neuritis confined
' Abstracted from the Journ. Amcr. Med. Assoc, vol. Ixxi'
No. 11, March 13, 1920, p. 735.
Sept. 15. 1920.;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
233
to certain peripheral nerve tracts, the central origin
of which is evident hy reason of its rapid trans-
ference to other regions of the border.
Often in these doubtful cases the convulsive
twitching mentioned above is the only symptom
tli.it may serve to suggest that the patient is
suffering from encephalitis.
It may be too early to regard this symptom as
of absolute diagnostic value; but it has been pre-
sent so frequently in the cases that I have observed
that I am certain that it is at least a strongly
suggestive sign.
TREATMENT OF THE TOXIC REACTIONS
WHICH FOLLOW THE INTRAVENOUS
IN.IECTION OF " 914."'
By Surgeon Lieuteaaut-Commander R. J. G. Pabnell, R.N.
The Cause of Toxic Symptoms.
P. FiLDES and I have expressed our views in a
recent publication as to the origin of these reactions.
We do not support the view commonly expressed
that the toxic reactions are due to an accumulation
of arsenic from a too rapid succe-ssion of doses.
According to this theoiy, the subsequent doses
should be more and more toxic, instead of less
toxic. As a matter of fact, we found that a re-
action after the third dose was less likely to occasion
one after the fourth, and after further doses there
was a marked diminution in the number of toxic
reactions. Our observations rather suggested that
the susceptible structure of the body, the " intoxi-
cation " of which causes sj'mptoms, cannot be
I "intoxicated " again until an interval of recupera-
tion has occurred. The tissue is, in fact, no longer
susceptible; it may be said to be desensitized. On
the other hand, it appeared to us probable that
these toxic symptoms are due to an optimum
concentration of " 914," or some derivative of
" 914 " in the tissues. If this is too high or too
low (within limits), no intoxication occurs. The
concentration may be governed by variations in the
rapidity of excretion.
The Prophylaxis of Toxic Reactions.
Too much emphasis cannot be laid on the im-
portance of a thorough physical examination of the
patient before treatment.
Abnonnalities of the urine, visceral lesions,
aortitis and arterio-sclerosis call for special caution
in dosage. Intensive courses which can be given
with impunity to the majority of young " fit " men
are not suitable for men over 40.
The question of " water- fever " does not arise in
this paper, yet I think it advisable to insist on the
adoption of great precautions in the preparation of
the water, since impurities of water may increase
the toxicity of the drug.
Attention to all these points should eliminate the
' Abstracted from the Journal of the Royal Naval Medical
Service, vol. vi, No. 2, April, 1920, p. 130.
preventable causes of disaster. A syringeful of
adrenalin (1/1,000) should always be prepared
before injections are commenced. Oxygen should
be obtainable at short notice. Lumbar-puncture
needles and the necessary implements for phlebotomy
may be required.
PRELIMINARY REPORT OF EXPERIMENTAL
INVESTIGATION OF SCURVY IN THE
ROYAL NAVY.i
By Surgeon Captain P. W. Bassrtt Smith, C.B., C.M.G.,
F.B.C.P.,F.R.C.S ,R.N.
Following up the very valuable work done at
the Lister Institute, and recognizing the futility of
the issue of ordinary lime juice as previously suj)-
plied to the Navy, I have been experimenting for
the last four months to provide an anti-scorbutic
which is efficient, portable and palatable.
Many observers have shown that lemon juice and
orange juice have large accessory factor contents
for scurvy, particularly when used fresh, but this
is not very stable, being rapidly destroyed by heat,
diminished by alkalies and by time.
Givens and McClugage have shown that dried
orange juice can be prepared, and is efiective for
a considerable period.
In the investigations carried out at the R.N.
Medical School, Greenwich, various methods of
preparing the juice were tried : Evaporation at
60O C., de-acidification, impregnation on filter-
paper, and so on. The final method evolved, and
which is in continuous use, is as follows: —
The juice is roughly filtered through muslin, and
then through filter-paper under reduced pressure.
The filtered juice is evaporated in vacuo over
sulphuric acid at ordinary temperature (15° C).
The residue of non-erystallizable syrup is worked up
into as stiff a paste as possible with a mixture of
anhydrous lactose, 97 per cent.; gum tragacanth,
3 per cent. The paste is cut into sections, each
containing the juice of half a lemon. These are
rolled, faced with the mixture, and pressed to
assume the lozenge form. These tablets have been
kept at ordinary temperature and at 37° C. for
months, and are being used for the experiments.
The tablets dissolve fairly readily if added to
water containing a small quantity of bicarbonate
of sodium.
Guinea-pigs used in the experiments are given
one-fifth of a tablet, i.e., one-tenth of the juice of
a lemon daily, or 4 c.c. ; but one-tenth of a tablet
(equal to 2 c.c. of fresh juice) has protective action.
First Series. — A basal diet of oats and bran,
plus 60 c.c. of milk which' had been previously
sterilized in the steamer for one and a quarter
hours, and an abundance of water was given.
Control animals died about the fortieth day, and
scurvy signs were evident. Further controls, with
' Abstracted from the Jnurnal of the 1
Service, vol. vi, No. 2, April, 1920, p. 117.
234
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15, 1920.
an addition of (a) fresh dc-acidified lemon juice,
and (b) raw fresh cabbage, grew normally. Those
on the tablet at first ceased to grow, then their
weight increased, and after three months they
remained perfectly healthy.
Second Series. — A basal diet of ship's biscuits,
30 gmi., sterilized milk, 60 c.c, and lime water,
20 c.c, was given.
Diet contains 144"80 calories, assuming com^plete
digestion. A change of diet to bran and oats was
given once a week. The control animals on this
diet died about the fortieth day from scurvy, and
t/hose witli an addition of raw cabbage grew
nomially.
The animals on one-fifth of a tablet grew, and
after three months are normal ; those on the same
amount of tablet which had been stored for month?;
at room temperature are doing equally well.
The animals are at first hand-fed with the tablet,
but generally later will eat it readily. The tablets
kei)t at 370 C. darken markedly in colour, probably
due to caramelization of the lactose, and it is more
difficult to get the animals to eat them. There is
no reduction of the acid content after storage. It
has been shown that 5 c.c. of fresh lemon juice is
sufficient to prevent scurvy in infants.
The adrenal glands of all the animals which have
died with scurvy signs have shown enlarged and
haemorrhagic changes, with atrophy of intestinal
tract, but no marked csBcal distension.
It would seem that this methotl of preparation,
in which heat is not used, provides an efficient,
portable, and palatable compound, rich in anti-
scorbutic vitamine, and one which appears to retain
its potency at ordinary temperatures.
A EEPORT ON THE GYNOCARDATE AND
MORRHUATE TREATMENT OF LEPROSY
BASED ON FORTY CASES TREATED IN
THE KASHMIR STATE LEPER HOSPITAL.'
By Eenbst F. Neve, M.D., F.R.G.S.E.
We owe the introduction of chaulmoogra oil for
the treatment of leprosy to Le Page of Calcutta. It
was favourably reported on by Bevan Rake, who
mentions a case in which 4 to Ij drachms were
administered internally daily for six years with great
benefit. He also recorded eighteen cases in whicli,
under this treatment, he noted improvement of sensa-
tion and diminution of tubercles. For, in 1890,
reported a case in which, between 1884 and 1890, a
leper treated with this oil had completely recovered.
Rennie and Carter also observed marked improvement
after internal administration of chaulmoogra oil. 7n
India, systematic treatment was carried on in Madras
with oil pressed from the seeds of Gynocardia odorata
(UydnocarpHs odoratus), 2 gr. of which were given
twice daily in an ounce of milk, and it was clainaed
' Abstracted from the In/liun Medicnl (lateltc vol Iv No 4
April, 1920, p. 1'28.
that anaesthesia cleared up and the skin became
smoother.
In 1913 four cases were reported in the United
States of America as having been apparently cured
by chaulmoogra oil treatment. In two of these the
remedy had been used hypodermically. Victor Heiser,
Director of Health for Philippine Islands, then tried
a filtered mixture of chaulmoogra oil, camphorated oil
and resoroin, 4 gim. of the latter and 60 c.c. of each
of the former. This was given hypodermically in
Ice. doses, gradually increasing at weekly intervals.
He treated twelve cases, some of tliem for two years,
and in some cases doses of from 5 to 10 c.c. were
ultimately reached. He claimed improvement in
evei^y case, and in 55 per cent, practical cure.
Encouraged by Reiser's apparent success. Sir
Leonard Rogers, who had previously obtained good
results by oral administration of large doses of
gynocardic acid, now determiued to try the intra-
venous use of soluble sodium gynocardate. After
obtaining the assistance of Dr. Sudhamoy Ghosh in
the investigation of the hydnocarpus fatty acids and
their melting points. Sir Leonard Rogers decided to
limit his trials to the Taraxtogenos kurzii, and he had
a solution made of the sodium salts of mixed hot and
cold pressed oil of a strength of 3 per cent., 1 gr.
of the salts being present in 2 c.c. of the sterilized
carbolized solution-
In October, 1917, Sir Leonard Rogers published
details of twenty-six cases injected with sodium
gynocardate and chaulmoograte. While all his cases
showed some improvement, those subjected to treat-
ment for upwards of a year gave the best results.
Indeed, eight out of twelve ave classed as lesions ,
disappeared.
In June, 1918, Muir, of Kulna, published a report
on thirty lepers treated with this solution, and in
April, 1919, he brought the record up to date, and
added notes of twenty-three other cases. He records
rapid improvement in many of his cases, especially in
early cases and children.
Sodium morrhuate, prepared from cod-liver oil, we
also owe to Sir f^eonard Rogers; it has one great:
advantage over the gynocardate, for it can be used
subcutaneously. Twice a week a dose of 5 c.c. is
given, and gradually increased by a i c.c. until 4 c.c.
is reached. The large do.-^es may be given only once
a week. Sir Leonard Rogers has recorded several
cases which showed marked improvement under this
treatment.
In 1919 we selected forty cases of nodular or
anifisthetic leprosy. Those who were debilitated
were excluded. Twenty were treated with intra-
venous injections of gynocardate and twenty with
subcutaneous or intramuscular injections of morrhuate
of sodium.
Commencing with 1 c.c. twice weekly, the metiiod
has been gradually to increase till the large doses
are reached and then to administer it once a week.
Our cases were very chronic, and most of them, it
may be added, very severe. The milder cases do not
care to come to a hospital where there are so many
liad cases.
Sept. 15, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Each case was photographed at the beginning of
tiie special treatment. In estimating improvement a
careful comparison is made with the print.
About half the cases treated showed distinct signs
of improvement. Seeing that this is so, it is curious
that so many of the others failed to respond in the
same way. Of course, to some extent in these cases
of some years' standing the conditions of cure have
ceased to exist. Deformities, the loss of fingers and
toes, contractures, muscular atrophy, deposits of
fibrous tissue causing pressure, atrophy of neurones
and cicatrices cannot be expected to clear up. For
this reason it would appear that nodular cases have
benefited more than those of old standing anaesthetic
leprosy.
The general results of the two methods of treat-
ment may be tabulated as follows : —
Gynocakdate Treatment.
Much improved ... 2 Improved ... 7
Percentage ... 10 Percentage ... 35
Not improved ... 11
Percentage ... 55
Moerhuate Treatment.
Much improved ... 2 Improved ... 6
Percentage ... 10 Percentage ... 30
Not improved ... 12
Percentage ... 60
Most of the cases are very chronic, and they have
been under treatment for less than a year, so the
results may be considered as encoui-aging. Many of
the patients are most unwilling to undergo continued
treatment with injections. The gynocardate pills are
likely to be specially useful in those cases in which
for any reason the treatment is interrupted and also
as a supplement to the intravenous injection.
Conclusions.
1. On an average treatment of six months, about
half the cases appear to derive benefit from the
gynocardate and morrhuate treatment.
2. Those not definitely improved appear to remain
stationary. Only about 10 per cent, show fresh
manifestations of disease while under treatment,
some of which have been due to the freeing of toxins
by over-action of the drug.
3. Laryngeal and ocular leprosy require great
I caution in the exhibition of these remedies.
FATAL MOUSE TYPHUS IN A HUMAN
BEING.'
j The Loeffler mouse-typhus bacillus is morpho-
logically, culturally, and biologically akin to the
tmratyphoxus B, from which it differs chiefly in its
pathogenicity toward the mouse. Experiments many
years ago appeared to show that mankind is immune
I to this organism. Later, however, it was realized
t that it could attack men, and mass infections have
resulted from the consumption of contaminated flour,
the fiesh of sick horses, kc, the symptoms being
'.abstracted from the Medical Record, vol. xovii, No. 14,
whole No. 2, 5(8, New York, April 3, 1920, p. 670.
those of gastroenteritis. At least seven fatalities
have been recorded.
Staub, an assistant at the clinic of Professor
Stahelin, at Basle, has reported a case in the
Schweizerische medizinis-che Wochenschrift for Feb-
ruary 5, 1920, i, 6. The patient, a man of 62, ate
some potato which was covered with mouse poison
in the shape of cultures of mouse-typhus baciUus
intended to destroy these animals. He later com-
plained of vertigo and prostration and vomited
repeatedly. The physician found him asleep, and
when roused with difficulty he staggered, behaving
exactly as if drunk. The pupils were extremely
narrow. He was given some coffee. Next day the
pulse, previously good, became rapid and weak, and
digitalis was ordered. Constipation had set in from
the first and castor oil was followed by persistent
diarrhoea. There was no fever. The patient arrived
at the hospital on the third day of the disease and
was somnolent, highly emaciated, prostrated, and
cyanotic, the blood pressure being 90. The emacia-
tion, cyanosis, thirst, rice-water discharges, and other
symptoms were decidedly choleriform. The highest
temperature was 37'3° C. (99'1° F.) in the axilla.
There was no response to treatment and the fatal
exit took place on the fourth day after swallowing
the poison.. Section showed marked congestion of
the gastroenteric tract. Pure cultures from the blood
would ordinarily have passed for the paratyphosus B,
but when tested on mice along with the culture used
on the potato proved to be the Bacillus typhi murium
of Loeffler.
Characteristic of the disease is the extremely brief
incubation period of about ten hours, the severe
watery diarrhoea setting in on the third day, and the
acute dehydration and absence of fever. In other
words it mimics closely the choleriform type of
paratyphosus B infection, otherwise the form of
cholera morbus due to that germ, the autopsy finding
also agreeing with that aflfection. Commercial mouse
poison should therefore be placed officially amongst
the substances dangerous to man.
A CLINICAL METHOD OF DETERMIN-
ING THE TYPE OF THE INFEC'nN(i
MENINGOCCX:CUS IN CASES OF CERE
BROSPINAL MENINGITIS.'
By Major A. S. Gokdon Bell, R.A.M.C,
0/ tite Central Cerebrospinal Fever Laboratory.
Ik the standard method of agglutination at 55° C.
be employed seventy-two hours generally elapse be-
tween the lumbar puncture and the type being
determined.
With the rapid methotl herein described, twenty
to twenty-four houi-s only are needed to type;
homologous curative seruin can then be given.
The advantage is obvious.
Technique.
Use a i)ii)ette made from glass tubing, drawn to
' Abstracted from the Journal of the Royal Army Medical
Corps, vol. xxxiv. No. i, April, 1920, p. 379.
236
THE JOURNAL OP TROPICAL MEDICINE AND HYGIENE. [Sept. 15, 1920
a very fine point and fitted with a teat. On a glass
plate drop one drop of each of the four type sera;
along each side of these drop an equal volume of
the emulsion of the coccus under e.xainination ; this
should be 40,000 millions to 50,000 millions per
cubic centimetre. Mix and examine the four pools
with a watchmaker's glass. Type is indicated by
the pool in which agglutination first appears.
(a) After five minutes if a negative result obtain,
arrange the serum on the plate thus: —
Type I Type II Type III Type IV
2 drops 2 drops 2 drops 2 drops
3 „ 3 „ 3 „ 3 „
4 „ 4 ,, 4 „ 4 „
To each of these pools of serum add a drop of
emulsion, mix and examine as before.
(b) If the result is not specific, i.e., agglutination
appears in two pools within two minutes of each
other, vary the emulsion thus: —
I drops
3 drops
. drops
1 drops
To each of these add one drop of Type I serum
in the first vertical row, one drop of Type II in
the second row and so on. Mix and examine as
before. Agglutination will no longer appear with
the heterologous serum. If there is agglutination
with both I and III and a si^ecifio reading cannot
be obtained, the type niay be called provisionally I,
as the Type I serum, so far as I know, is specific.
(c) If there is not sufficient growth to allow of a
40,000 million emulsion, take a few drops of saline,
pick off colonies and make an emulsion. Now in-
stead of a pipette use a platinum loop to make the
several mixtures.
General Rules.
(1) If the coccus has been grown on blood, get
rid of as much as possible of this before making
the emulsion.
(2) Always kill the coccus at 65° G. before
testing.
(3) In the end agglutination will generally appear
with all four type sera and even with the normal
serum. This agglutination may be disregarded.
Again, if by varying the emulsion specificity cannot
be obtained, and at least one minute does not
elapse between the agglutination by two sera of
different types, the result should be disregarded and
the patient treated with pooled serum till the type
can be detennined by the usual slow method.
(4) Always confirm results by the slow method
at 55° G.
Results of Laboratouy Tests.
With fifteen laboratory specimens of Type I : —
Correct answers Negative Incorrect
13 11
With twenty-five laboratory specimens of Type II : —
Correct answers Negative Incorrect
24 1 —
With twelve laboratory specimens of Type III :
Correct answers Negative Incorrect
12 — —
With seven laboratory specimens of Type IV: —
Correct answers Negative Incorrect
As Type IV is so relatively rare this is of small
account.
With fourteen recent cases of cerebrospinal fever
a correct answer, as subsequently confirmed by the
slow method, has been given in twelve; one was
negative and one wrong.
All these results were obtained in under twenty-
four hours after lumbar puncture.
This method is at present no use in typing cocci
obtained from post-nasal swabs, as agglutination
has been known to take place with Gram-negative
nasopharyngeal cocci which do not absorb and
therefore are not true meningococci.
Too umch weight nmst not be laid on the results
obtained with laboratory specimens, as experience
has show!i that meningococci under prolonged cul-
ture on egg and trypagar media rnay tend to become
more specialized than when recently isolated.
The general correctness of the results obtained ^
with actual cases indicates that this method should
be tried in view of the simplicity of the technique.
Any metlical man with sufficient skill to add blood
asepticaJly to a slope and possessed of a 37° G. in-
cubator can grow the meningococcus ; the putting
up of dilutions of varying strength and the need of
a 55° G. incubator are dispensed with.
The opinions expressed in the Medical Research
Committee's recent pamphlet " The Specific Treat-
ment of Cerebrospinal Fever, with an Analysis of
the Reports on the first Ninety Gases treated with
Monotypical Sera " emphasize the necessity of early
typing and the use of monovalent sera. " Although
the aggregate of cases is not large, a considerable
proportion of them were severe — some very severe
— and the positive evidence which they afford of the
therapeutic value of monotypical semm is, there-
fore, of considerable weight " (M. H. Gordon).
Final deduction from the same pamphlet: " The
great importance of promptly determining the type
of meningococcus and of using the appropriate
serum at the earliest moment " (T. G. M. Hine).
A titre of 1 : 2,000 is desirable to start with.
It is necessary to get rid of the group agglutinins
which are always present with sera of this strength.
These group agglutinins are eliminated by saturat-
ing them with cocci of the heterologous types.
Technique.
One hundred thousand million cocci of each
heterologous type, killed by heating to 65° C., are
added per cubic centimetre of the serum under
treatment. Details as follows: —
•Grow a large number of plates, wash oflf in a few
cubic centimetres of saline solution. Kill at 65° G.,
j)henolate, centrifuge for two hom-s, decant the
supernatant fluid, add the serum to the solid cocci
remaining. Stir up, put in a bottle, shake well,
incubate for two hours at 37° G., rejieating the
shaking three times during this j)eriod. Re-spin
till the serum is clear, decant and test against a
large mnnher of ^nmlsions of homologous and
heterologous cocci for catholicity with regard to the
former and specificity with regard to the latter. If
specificity is not present, repeat the process of
saturation.
Oct. 1.1920.] THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE. [No. 19, Vol.XXIII.
^riflinal (ILommniucations.
AN ATTEMPT TO EXPLAIN THE GKEATEK
PATHOGENICITY OF PLASMODIUM
FALCIPARUM AS GOMPAEED WITH
OTHEK SPECIES.'
By C. C. Bass, M.D.
New Orleans.
Of the three common species of malaria Plas-
modia, P. vivax, P. malarise and P. falciparum, the
latter is far the most pathogenic. This greater
pathogenicity is observed and reported wherever
malaria prevails throughout the world. The number
of deaths caused by infection with P. vivax and
P. vialarice is insignificant as compared with tlie
number produced by P. falciparum. In fact, prac-
tically all deaths caused by nndaria are caused by
P. falciparum and almost none by the other species.
Not only are nearly all deaths caused by it, but
it causes almost all of the pernicious clinical types
of malaria
One of the explanations offered for this greater
pathogenicity is that the organism produces a more
harmful or more powerful toxin. This explanation
is theoretical entirely. Another explanation offered
is the larger number of parasites that are present
in the blood of many of the moi'e pernicious and
destructive cases. It is undoubtedly true that the
number of pai-asites is very much larger ih the
blood of the severer cases due to P. falciparum than
in those due to other species, but I am not familiar
with any definite explanation for this fact. The
object of thf present paper is to bring up for dis-
cussion an c.vphmation which has not previously
been advanced, so far as I know, and which, though
theoretical, is based upon definite facts. It offers
to explain the greater pathogenicity, without the
necessity of the supposed greater toxicity. In fact,
if one should judge by the number of parasites pre-
sent in the blood, one would be inclined to think
tliiit r f.ilripfinim is less toxic than the other para-
siles, if iiuli 111 lliere is any toxin produced by either.
rile ^^( lu r;il impression is that malaria parasites
grow and rejji(jduce in the circulating blood. As a
matter of fact, however, the asc!xual parasit<>s found
in the circulating blood are most, if not all of them,
more or less accidentally or incidentally swept into
the bloodstream from the capillaries in thosi'.
(jrgaiiisms anil tissues where much larger numbers
are lodged and growing. Growth and reproduc-
tion of malaria piirasit-es takes place chiefly if not
entirely in the smallest blood-vessels of certain
organs and tissues of the body. To a certain extent,
it takes place in capillaries of all organs and tissues,
but the parasites are usually more numerous in the
bone maiTow, s)>1een, brain and liver in the oi-der
named.
P. vivax .^nd /'. miihiriir have more or less
' From the Department of Experimental Medicine, Tulano
College of Medicine, New Orleans, La.
amteboid activity and are, therefore, more likely to
move about and to pass through or be dislodged
from the capillaiies than P. falciparum, which has
extremely little amoeboid movement. This may be
observed by watching large asexual pai-asites of
the different species under the microscope. The
amueboid parasites give one the impression that in
the event of lodging in front of uaiTow places in
the capillaries, they would change their shape and
at least tend to pass through such places very much
like the blood cells do. As a parasite gets lai-ger
and larger, most of them finally lodge and remain
until segmentation takes place.
After segmentation, the much smaller parasites
can, of course, be swept out of a capillary in which
the larger parasite has been retained. This lodging
of the pai-asites of these two species is no doubt
the explanation for the fact that the number of
small parasites present, which is large soon after
the paroxysm, becomes smaller aiid smaller as the
pai-asites get older and larger. It is true that occa-
sionally a few of the amoeboid parasites, including
rosettes, appear from time to time, and sometimes
some of the rosettes actually burst while in the
circulating blood. It is not at all probable, how-
ever, that any of the merozoites produced in the
circulating blood succeed in attaching themselves
to other erythrocytes and survive.
In falciparum infection, only ring foiins of the
schizonts are found in the general circulation. As
soon as these parasites reach the proper age and
size they disappear from the circulation and do not
reappear until merozoites are produced, some or
many of which may appear.
The size and age at which young P. falciparum
disappear from the circulation is different in different
individuals. It is quite conceivable that the ex-
it! anation of this may be the probability that there
is slight variation in the size of the capillaries of
different individuals. We see a greater number of
large parasites in the blood of very young children
than wc do in that of older persons. In fact, almost
all of the large falciparum schizonts that we ever
see in ordinai-y blood preparations are from babies
under 1 year of age, in whom it is supposed the
capillaries are larger and more patulent than they
are in older persons.
Most or all of these parasites disappear from the
circulating blood by the time they are 10 or 12
hours old. It appears that by the time this age is
reached the parasite has attained a size which does
not pennit it to pass through the pUiccs in whicli
they lodge. Only comparatively small faleiparum
parasites, therefore, can pass through the places in
which parasites lodge and through which much
larger vivax and malarise parasites can pass.
If we take cultures of P. falciparum in which the
parasites are much older and larger tlian those
found ill the circulating blood of infected persons,
s:iy 3() or 40 hours old, and study them under the
microscoi)c, I believe that we can recognize and
demonstrate a very striking (|uality which very pro-
bably affects their triuisportation by the circulating
238
THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 1. 1920.
blood. If we place a droplet of culture containing
such parasites on a microscope slide, cover it with
a cover glass and observe the parasites under the
microscope while making pressure on the cover glass
with a very delicate instrument, we observe a very
remarkable and impressive condition. It is noticed
that when pressure is made on the cover glass the
erythrocytes present which do not contain any para-
sites flow back and forth with the current as the
pressure is increased or decreased. On the other
hand, erythrocytes containing the large parasites
remain fixed between the cover glass and slide and
do not move with the current. At once one gets the
impression that the substance of the parasites is
much more resistant to pressure than that of the
blood cells. Not only is the consistency much
firmer, but the parasite is so laa-ge and thick that
it holds the cover glass ofi of the thinner blood cells.
In fact, if one makes and stains preparations of
large falciparum schizonts, many of the parasites
appear to be much thicker than the erythrocytes!
which contain them. The impression is very simi-
lar to that produced by the nuclei of nucleated
erythrocytes, in which case sometimes the nucleus
is not in sharp focus when the sharpest focus is on
the erythrocyte.
The other species of parasites, on the other hand,
do not show this apparent firmer consistency. It
is very reasonable, therefore, to assume that the
greater pathogenicity of P. falciparum results largely
from the condition just explained which favours the
production of very much larger numbers of para-
sites, as is known t-o occur in the pernicious cases.
It is not probable that the few merozoites produced
in the circulating blood by either species succeed
in getting into other cells. They are probably all
destroyed in the circulation. It is only those para-
sites that are produced in the capillaries and succeed
in attaching themselves to other cells before they
are swept out that survive and reproduce. They pro-
bably are the chief source of the clinical symptoms
in malaria.
In the few instances in which autopsies have been
made in cases where P. vivax or P. malariie were
either the cause of death or at least were found
present, the number of parasites found in the tissues
is extremely small compared with the number of
parasites found in autopsies where death was caused
by P. falciparum. In such instances, frequently the
tissues are so packed with malaria parasites as to
add some colour, produced by the pigment present,
in the parasites, as well as that retained in the
tissues after the parasites have been destroyed.
One of the most striking pictures of the manner
in which disease is produced by specific parasites is
that seen in sections or smears from the brain and
other organs of patients dying of estivo-autumnal
malaria. In the capillaries of the brain most of
them may be so obstructed with parasites that no
blood could possibly pass through them. Ansemia
of the brain results from so many capillaries being
obstructed, producing coma, as anaemia of the brain
produced in any other way does. It may be of in-
terest to note in this connection that coma is one
of the most prominent symptoms in a very lan-t
per cent, of all cases of malaria resulting in death.
±*ernicious symptoms referable to other organs are
quite likely produced in a similar manner.
If the lodgment of parasites in the capillaries is
largely responsible for the pernicious symptoms, the
question may arise as to why the gametes do not
also lodge in the capillaries in the same way.
Perhaps there is a tendency for them to lodge, and
in fact it is quite possible that only certain indi-
viduals possess such blood-vessels as are necessary
to be most favourable for the exit of gametes. The
gametes are amoeboid parasites, and in the instance
of P. falciparum their shape is such as to favour
their passage through narrow spaces. In fact, there
is some doubt as to whether the crescent has any
amoeboid ability whatever. Shape and size may be
the favourable influences upon which its abiUty to
pass through the capillaries depends.
In conclusion, the theoretical explanation offered
for the greater pathogenicity of P. falciparum^ is
that the shape of the parasite and unyielding con-
sistency of the substance of which it is composed
results in parasites lodging in capillaries to greater
extent and there multiplying in larger numbers,
more of which survive, than occurs in the other
species. The amoeboid activity is greater and the
cytoplasm is less resistant to pressure in the other
species, which is unfavourable to their lodging in
capillaries, causing more of the segmentation to
take place in the circulation where the merozoites
produced are promptly destroyed. This theoretical
explanation is based largely upon the observation
that artificially cultivated falcipai-um parasites are
more resistant to pressure, that they have little or
no amoeboid motion in contrast with the other
species and upon the finding at autopsy of much
larger numbers of capillaries obstructed by falci-
parum parasites.
LEPEOSY AT EODEIGUES.
By E. Mangenib,
GoveniTnent Medical Officer, Rodrigues.
Fbom information gathered from the oldest inhabi-
tants and from personal investigation there is not the
slightest doubt that leprosy was introduced in this
island by a man known as " Diango," who came from
Mauritius about 40 or 50 years ago.
This " Diango," who evidently married a native of
Eodrigues, was employed as a fisherman by a certain
family residing at Oyster Bay, a small coast settlement.
Four or five years afterwards he developed leprosy ;
owing to his condition he left Oyster Bay, and went
to reside up the mountain about four miles from Oyster
Bay.
A year or so after his departure, one of the sons of
his employer, who used to fish with him in the same
boat, became affected with the disease and from this
one and only source of contagion the disease gradually
made its apperance in other families all residents of
.i
Oct. 1. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
239
Oyster Bay. Actually, as far as I am aware there are
twenty-three cases of leprosy, sixteen of which are the
" direct or through marriage " descendants of the first
family affected with the disease and who at one time
or other were residents of Oyster Bay. The other
seven cases are scattered over the island and these
sufferers are the descendants of ' Diango."
During the last seven years ahout five deaths due
to leprosy have been registered and about nine new
cases of leprosy have come to light, namely five in
Oyster Bay, two in Port Mathurin and two at La
Ferme.
As the disease tends to ran in certain families with
a leprous taint, there is some evidence that families
coming from a leprous stock are more predisposed
to the disease ; especially when residing in the same
locality, living in close contact with the sufferer, i.e.,
sleeping, wearing the same clothes, together with the
poor diet and bad hygienic surroundings ; coupled with
these, marriages taking place between near relatives
and between leprous and non-leprous families resi-
ding in the same neighbourhood — facts which are
of daily occurrence in this island — must necessarily
play a great part towards the spreading of the disease.
Leprosy being a germ disease and contagion being
a primary factor towards the spread of leprosy ; while
here lepers are allowed to wander where they like,
even I am told washing their clothes in the rivers,
I would suggest that a scheme for proper and strict
isolation should be put in force by Government.
Botim.
A Case of Multiple Echinococcus Cyst (H. M. Jones,
The Military Surgemi, August, 1920). — An American
soldier of Italian birth, aged 24, had a fall on Septem-
ber 10, 1918, striking his abdomen, after which pain
in the hepatic region developed. Shortly afterwards a
diagnosis of "hypertrophy of the liver" was made.
Multiple abscesses of the liver developed and were
operated upon. They had developed from multiple
echinococcus cysts which had become infected and had
ruptured into the hepatic duct, causing obstruction by
cyst membranes. The patient died from sepsis, and
autopsy revealed also echinococcus cyst of the spleen,
and a right empyema from rupture of the hepatic
abscess through the diaphragm. Many leucocyte
counts showed no eosinophilia.
Latent Infection in Experimental Spirochatosis
(J. L. Todd. Proc. of Soc. for Exper. Biol, and Med.,
1920, vol. xvii, pp. 83-84). — Studied the immunity of
white rats to Spirochrta recurrentis. By inoculation
of 15 to 2 c.c. of blood aspirated from the heart of the
rat under chloroform, spirochsetes were proved to be
present in an apparently immune rat thirty-two days
after the parasites were last seen by the daily examin-
ation of blood films. Previous and subsequent inocu-
lations showed this rat to be immune to the strain
employed in the experiment. Several similar experi-
ments, however, failed to reveal latent infection in
immune rats.
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THB JOURNAL OF
Cropital £|^eDtetne and i^pgiene
OCTOBKR 1, 1920.
THE EXTRA-PHARMACOPOEIA OF MARTIN-
DALE AND WESTCOTT.
The first Volume of the Seventeenth Edition of
the Extra-Pharmacopoeia by W. Harrison Martindale,
Ph.D., Ph.Ch., F.C.S.. and W- Wynn Westcott,
M.B.Lond., D.P.H., has just been published. The
book is welcome to the whole profession and has been
240
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1920.
waited for impatiently for some time. The Extra-
Pharmacopceia is a necessity to every practitioner at
home and abroad. The tropical practitioner will find
it indispensable and that his branch of medicine is
comprehensively dealt with. How does the medical
man acquire a linowledge of drugs, prescriptions,
writing and combinations ? Not from the British or
any other pharmacopoeia, nor from our several books
on materia medica, for they are but the alphabet of
this great department of medicine. It would seem to
be mostly acquired by watching others — our clinical
teachers in the hospital at whicli we -are trained. But
they mostly prescribe according to the pharmacopoeia
of the hospital to which they are attached, and they
dictate such stock formulae by initial letters only, such
as M.R.C.P., or F.A.C., meaning Mistura Rhei cum
Potassffi and Ferri et Ammonia Citratis, and many a
House Physician or House Surgeon goes into practice
with these widely used compounds to hand, but unable
to write out the prescriptions in full, and but ill
equipped to write few others. The consequence is he
falls back upon tablets, tabloids, and such like
"simples." Where is he to turn for help? He
will find more guidance in Martindale's Extra-Phar-
macopoeia than in any other in our armamen-
tarium. He will find there no mere dogmatic infor-
mation, but an education in the choice of drugs and a
scientific account of their origin, history, and physio-
logical uses, given in a useful and practical setting.
It was the former Mr. Martindale we have to thank
for the conception and initiation of this gi-eat work.
His was a mind with special endowment, earnest and
enthusiastic in the task he had undertaken, a task
requiring an exact knowledge, a scientific mind of the
first order, an intimate acquaintance with pharmacy,
materia medica and the therapeutic and clinical value
of drugs. Such men are rare ; whilst Martindale lived
he had few, if any equals, and no superior. The present
Extra-Pharmacopoeia is an inheritance of national im-
portance and the spirit in which it first saw the light is
being ably carried on by the present authors. It is
impossible to even scan the many additions brought
forward in the present volume, the 17th edition. In
every department of medicine there have been advances
since the last edition appeared. The war has not
checked these, in fact several points of importance
have been added to our knowledge owing to the
existence of a state of war, and in no section of the
vast subject has more activity been shown than in that
of tropical medicine. To mention some of the newer
substances brought prominently before us as antiseptics
owing to their use in war we liave (a) such a substance
as Eusol, a name given to a solution made by inter-
action between chlorinated lime and hypochlorous
acid and boric acid : (h) Dakin's hypochlorite
solutions, and (c) Milton's disinfectant, another hypo-
chlorite. These are claimed to be deodorizers, or
preservative, or insecticide, or all combined, and that
they are harmless to the human system. These are
examples of modern preparations for wound dressings,
&c., but there are many others, such as the chloramine
preparations, of equal significance.
During the past few years antimony has come into
its own again. Some fifty years ago this drug was in
frequent use and a doctor who failed to introduce
antimony into a prescription for bronchitis, jineu-
monia and almost any lung trouble was looked at
askance and came vs-ithin the range of being guilty of
malpraxis. Then for some reason the " fashion "
died out, for drugs vary in their therapeutic history as
fashions in dress and other things do. Recently as a
parasiticide in several tropical ailments antimony has
engaged supreme attention. In trypanosomiasis,
espundia, granuloma inguinale, kala-azar, oriental
sore, and also in yaws andrelapsing fever, tartar-emetic
has been tried and is found efficacious in some of these
ailments and promises good results in all. It has even
been tried in malaria but the effects did not justify
its continuance. The account given of the uses of
antimony in the Extra-Pharmacopaia is set forth in
lucid and ample style, and not content with the mere
exposition of the matter to hand, Dr. Martindale has
himself added to our antimony armamentarium by in-
troducing an "injectioantimonii oxidi," and an "injec-
tio antimonii oxidi fortior" for several of these protozoal
infections. An " injectio antimonii cinnamica" is
also to hand for injections into the mass of carcino-
matous tumours. Antimonii oxidi for hypodermic
injections is now being extensively used, and gives
promise of a useful future. We have long known
of James's powder, which contains as much as
331 per cent, of antimonious oxide, and the Italians
we know use a Pil. antimonii oxidi et quininse in
malaria, but in almost all febrile states antimony in
all its phases is dealt with ; now it is lauded for its
virtues, now warned against for 'Ae physiological
disturbances it tends to engender. Its uses still
radiate round antemic and rheumatic affections with
a fairly prominent place in the treatment of malaria,
a place which is gradually becoming greater day by
day. The "quinine alone" treatment of malaria is
passing ; the one drug, one disease (what the writer
has styled the " dock and nettle " system of medicine
giving) in vogue for the past 20 years and more is
passing, and combinations of drugs — that is wise
and scientific therapy — is again asserting itself. The
treatment of malaria by quinine alone in enormous
doses dies however but slowly ; yet we now find arsenic,
opium and mercury being added, as they were until
about the seventies of last century when the practice of
medicine was upset by the introduction of the tabloid
and tablet vehicle of treatment. Our old English
powder for tiie ague contained all of these four drugs,
and only coincidently perhaps did malaria practically
disappear from our land. The writer has used tliis
form of treating all recurring malaria fevers for some
twenty years with the greatest benefit ; in fact the
writer's pill of quinine, arsenic, opium and calomel was
given in the Extra-Pharmacopoeia of 1915, but it lias
been " crowded out " of the present edition. X deser-
vedly prominent place is given in the present volume
to organic arsenic compounds. In two series the
aliphatic (or cacodylate) and the aromatic are
discussed in many pages of text, not a bit too ample
for the growing work being done in the world of
therapy. Tlie great scheme of colloidal metals, theii'
Oct. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
constitution and their therapeutic value is handled in
a masterly fashion hy the authors of the Extra-Phar-
macopcEia ; the intricacy of the production of these
substances and the part they play as drugs in the
treatment of disease is still being tested by practiti-
oners. The unfamiliar essence of their existence is
bewildering by its newness, and resembles nothing
that has gone before. To handle such a mode, of
treatment scientifically requires a close study of their
vito-chemical behaviour, for they seem on the
border-land of tilings organic and inorganic. A great
future lies before these wonderful productions, but time
will prove their value, and they promise to outstrip
all known elements in their therapeutic powers. A
careful study of colloids as they are set forth by the
authors will well repay interested readers, for no
better exposition of their practical application and
usefulness has ever been given us.
We have not left space to deal with even the great
subject of Quinine, and many others which form the
A. B. C. of our drugs in daily use, and we cannot find
a niche in tiiis preliminary notice of the encyclopaedia
of "things practical and scientific" in the world of
drugs and their uses. "Vaccines and their anti-toxins,
organo-therapy, and the Therapeutic Index of Diseases
and Symptoms, &c., &o., &c., occupy a large part of
this maymim opus and must be reviewed separately
and individually.
We thank the writers for their pains and the
arduous work they have undertaken on our behalf, and
we congratulate them on the success of their labours.
We believe a book of this nature is unique in medical
literature, and we feel proud to think that we have
men amongst us with the patriotism and the ability to
raise the prestige of British research, therapeutics and
pharmacology upon so high a pinnacle.
Annotations,
Spirochceta recurrentis : A Filter Passer. J. L.
Todd {Jour, of Parasitology, March, 1920, vol. vi, pp.
152-1.54) has shown that Spirochseta recurrentis can
be forced in its type form through a " W " Berkefeld
filter, and that all infective forms of this organism are
not thrown down by centrifugalization at varying
speeds and for varying times.
Penetrationof the Intestine by Endamceba Histolytica
(Kenneth M. Lynch, M.D., Journal of the Amer-
ican Medical Association, vol. Ixxv, No. 1, July
3, 1920). — The author gives observations made by him
in post-mortem work regarding the manner in which
the amoeba gains entrance to the tissues of the wall of
the intestine, a point which is not yet decided. The
author did not meet with any evidence that the amoeba
passes tlirough the surface of the mucosa, but noted
that there was an invasion into the glands ; groups of
three or four or more amoebsB being found in the bottom
of crypts in which the epithelium had been wholly or
partly destroyed. From this nest the amoebae migrate
through the basement of the gland and through the
intervening tissues and muscularis into the submucosa.
The entrance once established there occurs a migration
in all directions except towards the lumen of the
intestine. A thrombosis of submucosa or muscularis
occurs, and a necrosis of the tissue above, and the
development of the ulcer leading to the surface.
llemarks on some cases of Paratyphoid B (I. Jacono,
Studium, Rivista di Scienza Medica, June 20, 1920). —
In this interesting paper the author describes ten cases
of paratyphoid B. In several the temperature was of
an intermittent type during the whole course of the
malady, and in these the haemocultures carried out
using Castellani's dilution method were negative with
blood collected during the afebrile liours, while they
were constantly positive when the blood was collected
during the acme of the daily febrile attack. In all
cases of whatever type, it was found that towards the
end of the malady when the agglutination was very
high, the percentage of positive blood-culture decreased
rapidly.
A Case of Hereditary Diabetes (F. M. Allen, M.D.,
and J. W. Mitchell, M.D., Archives of Internal
Medicine, vol. xxv. No. 6, June 15, 19 0). — Allen and
Mitchell record the case of a soldier suffering from
diabetes who came of a family in which seven out of
fourteen children of one father (one by one woman,
thirteen by another) were diabetic. In addition to
treatment, clinical and pathological investigations were
undertaken to throw light on the hereditary feature of
the condition. The patient when received was in the
later stages of diabetes and tuberculosis, with dangerous
acidosis, emaciation and weakness. In consequence
of a week of fasting and a month of extreme under-
nutrition, he became able to tolerate diets between
1,500 and 2,000 calories without glycosuria or acidosis,
showed improvement in strength and lung symptoms,
and lived six months. Tiiis result in a case of this
severity adds to the evidence that the combination of
diabetes and tuberculosis is best treated by a diet
which controls diabetes.
Clinical examination of the patient and his family
for general or focal infections were negative. The
Wasserniann reaction was negative. Glucose tolerance
tests afforded an early diagnosis of one of the above-
mentioned seven cases of diabetes but were negative
in the mother and remaining cliitdron. The gross and
microscopic pathological findings excluded syphilis,
being characteristic of tuberculosis. The pancreas
showed occasional hydropic degeneration, the result of
functional over-strain, and slight fibrosis and hyaline
formation in islands, indicative of infections or toxic
damage as tiie cause of the diabetes.
In general the diabetic heredity came through the
father and occurred in tlifl children which most
resembled him. From the glucose tolerance tests the
diabetic tendency was inherited as a unit character,
the tolerance of the remaining children being normal.
Tiiis case conforms to the general rule that signs of
infectious or toxic damage are found similarly in
heredity and other cases of diabetes. The reason for
the peculiar liability to diabetogenic injuries in certain
families is undetermined.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 1. 1920.
Ocular Symptoms in Encephalitis Lethargica (E. B.
Spaeth, The Military Surgeon, Aug., 1920.)— The
ocular symptoms presented in five cases of encephal-
itis lethargica of varying severity which all recovered
included varying combinations of dilated and unequal
pupils, sluggish reaction to light and accommodation,
disturbed muscle balance with diplopia, whilst one
case showed mild bilateral optic neuritis, and one case
showed bilateral lagopthalmos with diminished corneal
sensitiveness and commencing corneal ulceration. The
principal forms and treatment included hydro-therapy,
electro- therapy, prism and other muscle exercises,
atropine and heat.
Prevention of Simple Goitre in Man (D. Marine and
O. P. Kimball, Archives of Internal Medicine, vol. xxv,
No. 6, .Tune 15, 1920). — Prom thirty months obser-
vations on the prevention of simple goitre in man
Marine and Kimball found that the disease is as
readily prevented as in fish and domestic animals.
Of 2,190 pupils in a girls' school taking 2 grm. sodium
iodide twice yearly, five have shown enlargement of
the thyroid, while of 2,305 pupils not taking the
prophylactic 495 have shown enlargement. Of 1,182
pupils with thyroid enlargement at the first examin-
ation and who took the prophylactic, 773 thyroids
have decreased in size, while of 1,048 pupils with
thyroid enlargement at the first examination who did
not take the prophylactic 145 thyroids have decreased
in size. These figures strikingly demonstrate both the
preventive and the therapeutic effects of sodium iodide.
Some experiments bearing upon the Intravenous
Vaccine Treatment of Typhoid Fever. (Oscar Teague,
M.D., Proceedings of the Medical Association of the
Isthmian Canal Zone). — The results obtained in 1914 by
Ichikawa in Japan and independently by Prof. Rudolph
Kraus in the Argentine Republic, in the treatment of
typhoid fever by the intravenous administration of
vaccine, effecting a cure by crisis, has created a strong
revival of interest in this method of treating typhoid.
During the war it was tried in the German Army Hos-
pitals with satisfactory results, the course of the disease
in successful cases being shortened by from one to
three weeks. The treatment causes a violent reaction
consisting in a severe chill beginning in about half-an-
hour after the injection is given (dose 100,000,000 to
750,000,000 bacilli) and a rise of temperature to 105°
or 106° or more. In from 24 to 48 hours the tempera-
ture drops to normal and the general condition of the
patient shows a most remarkable improvement. In
the unsuccessful cases the reaction occurred but the
temperature again rose and the disease proceeded as
though the vaccine had not been administered.
The present paper is an investigation into the cause
or process of the cure by crisis. As the whole reac-
tion is accomplished within 48 hours the process
cannot be an immunization against typhoid, for immu-
nization antibodies only begin to appear on the third
or fourth day. The reaction is not specific. Kraus
has shown that not only injections of typhoid vaccine,
but injections of Bacillus coli vaccine and cholera vac-
cine cause the reaction to occur in typhoid patients.
Teague and his assistants made leucocyte counts and
smears of the blood of two typhoid cases for dififeren-
tialcountsevery hour for 34 hours following the injection.
The white cell counts dropped to 1,500 at the third hour
in one instance and to 2,500 in one-and-half hours in
the other. The counts then rapidly rose to a Httle
over 20,000 in both cases. The counts then dropped,
reaching their original level in 48 and 36 hours respec-
tively. Teague then made various animal experiments
of which he gives the results. He investigates the
various hypotheses which have been advanced to
account for the cure by crisis ; he concludes that none
of these offer an adequate explanation of the phenom-
enon. Beheving that typhoid fever is a local disease
and not a septicaemia, Teague's solution is that the
bacteria multiply, not in the blood, which has been
shown to contain bacteriolytic substances, but in cer^
tain tissues, the tissue fluid or lymph of which is not
bacteriolytic. The intravenous injection of vaccine
may be the cause of a more active passage of bacteri-
olytic substances from the blood capillaries into the
lymph, thus causing a destruction of the typhoid
bacilli and healing of the local lesions. This explana-
tion would also account, Teague thinks, for other
instances of so-called non-specific vaccine therapy ;
the bacteria antibodies in each instance being probably
transferred from the blood where they are present in
excess, to the fluids- of the diseased tissues where they
are urgently needed.
THE ASCARIS LUMBRICOIDES AS THE
CAUSE OF URGENT SYMPTOMS IN
DISEASE AMONGST CHILDREN.'
By Charles Pentlahd, M.D., M.Ch., B.A., J.P.
In my practice amongst children during the past
six months, I have been very much struck by the
number of oases of severe acute forms of sickness
directly attributable to worms, and practically
almost in every case to the Ascaris Iwnhricoides.
The embryo, as we are aware, forms in each ovum
after its discharge in the stools, and then re-enters
the body, by means, it is supposed, of drinking
wat«r, vegetables, or impure starchy material; but
the endeavour to trace the exact cause of the
appearance of worms in so many children is found
somewhat difficult. In most of the cases which
came under my notice, the source of the water was
from " spring wells," samples of which I have had
analysed. These were reported pure and free from
traces of ova of the ascaris.
ContraJ-y to what one would expect, all <)he
children before being attacked were of an unusually
'Abstracted from the Practitioner, No. G22, vol. civ., No. 4,
April, 1920.
Oct. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
^43
healthy and vigorous type; one is accustomed to
associate worms chiefly with strumous and delicate
children. An acute attack of worms presents,
from a diagnostic point of view, symptoms which
are by no means characteristic. I have found that
severe pain refen-ed to the umbilical region has
been the most constant symptom, associated with
a high temperature ranging from 105° to 103° F.
Closely simulating an attack of peritonitis or appen-
dicitis in its early stage, the tenderness apparent
in some of the cases has been very pronounced and
most acute ; other local symptoms have been un-
easiness, attacks of severe colic, vomiting and
faintness, capricious appetite, and irregularity of
the bowels, constipation and diarrhoea alternating.
When one is confronted on a first visit with the
following type of case, it is extremely difficult to
form a diagnosis: —
Child, aged 5 years. — Tongue heavily coated, of
a putty-like appearance, great malaise, complain-
ing of severe pain and tenderness in region of
umbilicus, cough, and temperature 104° F., with
constipation, but no history of having passed worms
according to the knowledge of the child's mother.
I have had three such typical cases during the
past month. A, B, and C. : —
In each case I prescribed a diaphoretic mixture,
and santonin and hydrarg. c. cret., with the result
that, on the first evacuation of the bowels in
Case A, five round worms, measuring from 4 to
6 inches, were expelled ; in Case B, twelve worms
were expelled, measuring from 2 to 4 inches; in
Case C, one large worm measuring about 5 inches
was vomited, and five small ones were expelled per
rectum. In Case A, the temperature, which was
104° F., came down to normal on the second day.
In Case B, the temperature, which was 105° F.,
was normal on the fourth day, and in Case C, the
temperature, which was never above 102° F., came
to normal on fifth day. No further symptoms were
manifested, and the children appeared in normal
health, quite lively, and anxious for food, though
subsequently these cases showed a fair amount of
ansemia which has practically disappeared with
the administration of the usual tonics.
Another case equally remarkable and equally
difficult of explanation occurred in my practice
some months ago : —
Child, aged 9 years. — Temperature 102° F.,
tongue roughly coated, great thirst and a distinct
degree of jaundice present, much tenderness over
right hypogastrium, with vomiting and delirium.
This case, however, had a history of having fre-
quently passed worms a month previous to my see-
ing her. After the usual examination and excluding
urgent diseases, I prescribed santonin powders com-
bined with hydrarg. subchlor. ; in two days after-
wards a large round worm was evacuated. I con-
tinued the calomel in 1-gr. doses for six days; the
jaundice rapidly cleared up ; three small worms were
passed. About the twelfth day the patient returned
to health quite normally, all symptoms of jaundice
having disappeared.
Here, I am of opinion that the worm must have
been lodged in the common bile duct, causing
temporary jaundice. These cases may be of in-
terest in so far as the symptoms appeared to be so
unusual of worms, and resembling more the forms
of acute disease. In many forms of sickness, no
matter how rare, amongst children it is advisable
not to overlook worms as a probable cause of the
urgent and distressing symptoms which one so
often meets with.
BETANAPHTHOL POISONING IN THE
TREATMENT OF HOOKWORM DISEASE.'
By Wilson G. Smillie, M.D.
In recent years it has been discovered that betanaph-
thol is useful in the treatment of hookworm disease-.
The dose of 02 to 0'5 grm., usually recommended for
internal medication, has been regarded as only slightly
toxic to the patient. Thymol and oil of chenopodium,
the other two drugs commonly employed in the
treatment of hookworm disease, have always been
considered more effective than betanaphthol, but the
dosage generally recommended produces toxic symp-
toms that are both more frequent and more severe
than those caused by betanaphthol. Theoretically
betanaphthol should be a valuable addition to the
anthelmintic armamentarium, if it can be proved
efficacious and non-toxic.
The report of Gonzaga and Lima is most encourag-
ing. It states, in brief, that betanaphthol, in the
heavy dosage which they used was practically non-
toxic, and was almost as efficacious as thymol, much
more so than oil of chenopodium. From among 400
heavily infected cases treated by this method 73'5 per
cent, of cures were effected, and no severe toxic
symptoms were encountered.
Field Experiments with Large Doses of
Betanaphthol.
In view of these increasing developments from
betanaphthol treatments, and in order to test the
efficacy and toxicity of large doses of this drug in the
treatment of hookworm disease, a series of four experi-
ments involving, in all, seventy-nine cases, was under-
taken.
Experiment 1, carried on among a representative
group of twenty-nine labourers (nineteen adults and
ten children) on a coffee fazenda near Ribcirao Proto-
Sao Paulo, Brazil, included nearly equal numbers of
males and females. The children were between 6 and
14 years of age. The average ha!moglobin of the group
was 632 per cent. There were no cases of malaria on
this fazenda, no palpable spleens among the group,
none of the patients had had intermittent fever in at
least ten years, and there was no record of malaria
having been in the valley for many years. (Jonzaga
and Lima's field treatment dosage was adopted. For
persons from 20 to 50 years old one dose of 6 grm. of
Mallinckrodt's sublimated betanaphthol was given on
' Abstracted from the Journal of tlie American Medical Asso-
ciation, Vol. 74, No. 22, May 29, 1020.
244
THE JOUllNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1920.
three successive mornings (with a graduated dose for
children), in hard gelatin capsules with a little water.
The final dose was followed after two hours by a saline
purge. Symptoms produced by treatment were mild
and transient; practically no vomiting occurred. A
fresh spscimen of urine was obtained every morning
from each patient ; no highly coloured, bloody or
smoky urine was found. The conclusion from experi-
ment 1 was that betanaphthol in 18-grm. doses is only
slightly toxic.
Experiment 2 was carried out to obtain a larger
series of cases. Nineteen adults and eleven children —
Brazilian mulattoes and negroes — on another fazenda
were selected. There had been a few cases of malaria
on this fazenda in two years, and the group included
two cases of severe anaemia. The average haemoglobin
was 69 per cent. The drug, dose, and method of ad-
ministration were all the same as in Experiment 1'.
Except for one case (Case 1), which will be discussed
in detail later, no symptoms appeared as a result of
treatment. Most of the patients worked in the harvest
fields throughout their three days of medication.
In Experiment 3 there were ten men suffering from
trachoma or other chronic eye disease, all of them field
labourers from coffee fazendas in the interior of the
state of Sao Paulo. The races chiefly represented
were Italian and Brazilian. Sixty-seven per cent, was
the average lisemoglobin of the group, some members
of which had suffered previously from malaria. The
same method of treatment and the same dosage of
betanaphthol were adopted as in the preceding experi-
ments, but the drug was a Parke, Davis and Co.
preparation, already mixed with charcoal, and put up
in 0'5-grm. doses in gelatin capsules. Symptoms
following treatment were extremely slight and tran-
sient. One characteristic was common to all ten cases
— increase in the transitional cells. One man (Case 2,
io be discussed later) suffered marked destruction of
.ed blood cells, as revealed by blood and urine examin-
ations.
Experiment 4 had as its chief object a careful study
of the urine pigment which. Experiment 3 had shown,
sometimes turned brown or black on standing. A new
group of ten men received exactly the same treatment
as that given in Experiment 3. Mallinckrodt's subli-
mated betanaphthol was used, as in experiments 1 and
2. The symptoms following treatment, as in Experi-
ment 3, were negligible, except in the case of one man
(Case 4), whose history will be discussed later.
Conclusions.
The four experiments prove that betanaphthol in
6-grm. doses, given on three successive days, may pro-
duce a severe toxic effect similar to that caused by
benzol (benzene, CsHu), in that it specifically attacks
the red blood cells. In the four cases of betanaphthol
poisoning reported, while the symptomatology varied
greatly, the essential pathology common to all cases
was simply a destruction of red blood cells with
perhaps in the severe cases a destruction of the blood-
forming cells in the bone marrow. It is hard to explain
how the betanaphthol destroys the red blood cells, and
^vhy seventy-five of the cases which I treated showed
no symptoms, while four became victims of the drug's
toxic action. Comparison of the cases and of their
history previous to the betanaphthol treatment would
certainly seem to indicate, first, that the intoxication
shown by the poisoned cases was not due to their
greater intestinal absorption of the drug ; second, that
the size of the dose was not proportionate to the degree
of intoxication, and third, that the degree of previous
ansmia in the patient had apparently nothing to do
with the toxic effect of the drug. The experiments
also showed that the drug had little or no effect on
normal kidneys. In certain cases, to be sure, there
was much albumin in the urine, with many casts ; but
this condition was due to the elimination of the waste
products from the blood.
Finally, the following definite conclusions concerning
the toxic action of betanaphthol were arrived at as a
result of the experiments that have been described.
1. Large doses of betanaphthol (18 grm. for adults)
used in the treatment of seventy-nine cases of hook-
worm disease produced very severe toxic symptoms in
two cases, and also produced marked changes in the
blood cells of two other cases.
2. The toxic action of betanaphthol in these four
cases was a destruction of the red blood cells. The
drug selected the red blood cells and destroyed them
in great numbers, with resultant severe anaemia, icterus,
enlargement of the spleen and liver, enlargement of the
gall bladder and haemoglobinuria. The white blood
cells were apparently not destroyed by the drug. The
liver, spleen, kidneys and other organs of the body
were not affected primarily, but were markedly affected
secondarily, because of the anaemia, and because of the
injurious effects produced by the elimination of large
numbers of destroyed red blood cells.
3. The type of cases that are most susceptible to
the toxic action of betanaphthol poisoning has not
been determined. In all three of the severe cases of
poisoning there was a history of recent malaria. It is
probable that those cases in which the red blood cells
are rendered more fragile by recent malaria are more
susceptible to betanaphthol poisoning.
4. Betanaphthol, in 18-grm. doses, is so toxic that it
cannot be recommended for general use in the treat-
ment of hookworm
LETHARGIC ENCEPHALITIS. HISTORY,
PATHOLOGIC AND CLINICAL FEATURES,
AND EPIDEMIOLOGY IN BRIEF.i
By Simon Plbxner, M.D.
New York.
Historical.
With this introduction I shall now consider
certain historical points regarding lethargic en-
i^ephalitis. It appears that the first cases of that
disease recognized in the United States occurred in
' Abstracted from the Jo
No. 13, March 27, 1920, p. S
Imer, Med. Assoc, vol. Ixklv,
Oct. 1, 1920.]
THE JOURNAL OF TBOPICAL MEDICINE AND HYGIENE.
245
the winter of 1018-1919. In contradistinction to
epidemic poliomyelitis, there is no reason to sup-
pose that this epidemic affection of the central
nervous system ever before existed in America.
This point is an important one. At present the
disease seems to be widely distributed, as cases
have bccti rc]i(iitiil from many States.
It is ]i(issililr t(i tr:u!e the cases of lethargic or
epidemic cnci'ijlialitis now arising in this country
to an outbreak which occurred in Vienna and
neighbouring parts of Austria in the winter of 1916.
Because of war conditions, knowledge of this un-
usual disease did not at once reach Western Europe
and the United States ; but nevertheless cases of
the disease occurred in England and France in the
early months of 1918, and in America about one
year later.
Both in Austria and in England, in which
countries the first cases were observed respectively
in Eastern iuvl Western Europe, the disease was
first mistakenly attributed to food intoxications.
In Austria the early cases were ascribed to sausage
poisoning, in England to botulism arising from
various foods.
This error is not perhaps as remarkable as might
at first sight appear. In the first place, both
countries were labouring under unprecedented con-
ditions of food shortage, Austria because of the
blockade, England because of the submarine.
Moreover, because of this shortage preserved foods
were employed on a scale never before equalled,
and, of course, waste and refuse were reduced to a
minimum. Furthermore, an early symptom of this
encephalitis is third nerve paralysis — giving rise to
diplopia, ptosis, Ac. — which happens also to be an
early symptom in certain forms of food poisoning,
and notably in botulism.
Ultimately, in both countries the notion of food
origin became untenable, and the disease was
recognized as arising independently of diet and
other usual conditions of life, and came to be
viewed as probably of microbic origin and of com-
municable nature.
Pathologic.
Th(' first fatal cases, which occurred in Vienna,
supplied on historic study a physical basis for the
symptoms ebservcd during life ; and the first
English and French cases similarly examined
microscopically showed lesions identical with those
described for the Austrian cases. In due time the
anatomic study of cases arising in the United States
and still other countries showed close agreement
with the others, and now a histologic basis of the
pathology of the disease, of remarkable concord-
ance, has been provided. On this basis we may
aow regard lethargic encephalitis as representing
i definite pathologic as well as clinical complex,
ind to consider it as a distinct disease.
The histologic changes or lesions of lethargic
encephalitis may be both extensive and profound.
Those so far described as confined to the central
lervous system affect particularly the brain and
especially the gray matter at the base of that organ.
While, indeed, any part of the gray matter may
be involved, the lesions are found in the cortex
and in the cerebellum, the structures particularly
affected are those about the third ventricle, the
aqueduct of Sylvius, the lateral ventricle and optic
thalamus, and the pons and medulla. The spinal
cord is variably involved. In general, it may be
stated that the severity of the cerebral lesions
diminishes from before backward ; the upper or
cervical cord often shows changes; but it is still
to be determined how often and to what extent the
cord as a whole is affected.
The lesions themselves consist of cellular aggre-
gations about the blood-vessels, cellular infiltrations
in the nerve tissue themselves, small, often micro-
scopic haemorrhages, and an outpouring of plasma
or lymph into the tissue interstices (oedema). The
cellular accumulations and invasions are chiefly
mononuclear in nature (lymphocytes, plasma
cells, polyblasts) ; polymorphonuclear cells are also
encountered, but are relatively inconspicuous. The
lesions themselves occur in nodular and in diffuse
forms ; and those of the tissues are at times clearly
associated with the vascular affections, and at
other times are so extensive as not to be brought
into relation with particular vascular involvements.
The paralysis of the ocular, facial and other
muscles which sometimes occur arise, with rare
exceptions, from the cellular and other invasions
of the nuclei of the corresponding nerves.
Clinical.
The clinical phenomena or symptoms of lethargic
encephalitis are referable to the lesions of the
central nervous organs or the pathologic process,
as sketched. It is perhaps too early in the study
of the disease to set up hard-and-fast clinical
varieties or types. However, attempts at classi-
fication have already been made. One of the
most comprehensive is that of MacNalty, which is
reproduced here, as it is suggestive and may prove
useful in pratitice. MacNalty distinguishes six
groups of cases : (1) Cases with general symptoms
and without localizing signs; (2) cases with third
nei-ve paralysis and general disturbance in the
function of the central nervous system ; (3) cases
with facial paralysis and general disturbance in the
function of the central nervous system ; (4) cases
with spinal manifestations and general disturbance
in the function of the central nervous system ; (5)
cases with polyneuritic mimifestations and general
disturbance in the functions of the central nervous
system ; and (fi) cases with mild or transient mani-
festations (so-called " abortive " cases). To these
should be added cases of paralysis of other motor
cranial nerves than the third and fifth, such as
those of deglutition and respiration.
Probably there is an incubation and prodromal
jx'riod which precedes the onset of the striking
subjective and objective symptoms of the disease ;
but thus far these have not been defined. Hence
246
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
[Oct. 1. 1920.
the so-called onset of the disease is usually
described as sudden or acute. The latter is, indeed,
so striking that the patient is able often to tell the
precise hour of a particular day on which he fell
ill. Actually the striking symptoms often develop
more slowly than in poliomyelitis.
The initial symptoms are described as chills,
lassitude and general malaise, headache and
general pains, nausea and anorexia, associatc<l
often with the common symptoms of upper
respiratory catarrhal affections. Fever is an irre-
gular manifestation. It may be present at onset
or may appear only later. The temperature range
tends not to be high — from 101° to 102° F. — but
it sometimes swings to 103° or 104° F. A-s the
symptoms develop there arise lethargy or drowsi-
ness, vertigo, tinnitus, muscular weakness, blurred
or misty vision, diplopia, photophobia, tremors and
twitchings, ataxia, delirium, irritability, restless-
ness, mental depression and other alterations,
difficulty in articulation and in swallowing, stiff-
ness of neck and spasticity of other muscles,
sweating, hiccough, Ac. Amongst the earliest
symptoms to arrest the attention of the patient
and the physician are diplopia and ptosis with vary-
ing degrees of lethargy. But still other paralysis
(e.g., facial) may appear, and lethargy may arise
independently of all localizing nervous signs.
The outstanding features of the disease is the
lethargy, which is progressive in character and
present in the great majority of cases (80 per
cent. ?) It may appear suddenly, but usually is
gradual in onset. The patient becomes apathetic
and dull, appears dazed or stupid, the hours of
sleep become prolonged, and he is hard to wake in
the morning. Moreover, he may fall asleep at odd
hours — while engaged at work or at meal times.
The lethargy may deepen into stupor or even into
coma. Its duration is variable — a week, a month,
or even longer — up to four months. Even after
long periods recovery may still follow. During the
lethargy there may be lack of facial expression
(mask-like features), from which the patient can
be aroused by loud speaking, prodding, &c., to
partaJce of food or answer questions. But cases in
which marked restlessness and even mania have
been present followed by lethargy have been noted.
Symptoms referable to irritations of the meninges
appear. Usually they are slight, and while some-
times arousing suspicion of acute meningitis, that
condition is excluded by lumbar puncture and
examination of the cerebrospinal fluid. The fluid
tends to be under somewhat increased pressure,
but clear. The number of cells is lightly increased
(very rarely 100 per c.mm.), and the globulin content
little and sometimes not at all excessive. The
cells, which range usually around 10 to 20 per c.mm.,
consist partly of mononuclear and partly of poly-
morphonuclear leucocytes. In addition, the im-
portant point of the rare presence of Kernig's sign
should be mentioned.
The occurrence of paralysis of the face muscles
has been mentioned. Paralysis of the extremities
is rare; vn-ist drop has been noted in at least one
instance. But a far more common symptom is
rigidity or spasticity, chiefly of the extremities,
which in a few cases has been observed to extend
to the spinal and even the facial muscles, making
a picture suggestive of paralysis agitans. This
spasticity of the extremities is ascribable to involve-
ment in the encephalitic process of the lenticular
nucleus and the corpus striatum.
The duration of the stupor is very variable; it
may last a few days, for weeks, or even for months,
and recovery still take place. The return to clear
mentality is usually grjidual ; muscular power also
tends to return slowly, and general convalescence
tends to be prolonged. In paralytic examples of the
disease, rapid, complete, or partial clearing of the
palsies has been noted.
The number of cases of undoubted lethargic
encephalitis thus far reported is too small to
indicate the age periods of greatest incidence. For
the present it may be stated that the disease occurs
at all ages — namely, from a few months to ad-
vanced years (over 70 years). Likewise, it appears
as if the two sexes were about equally attacked.
The fatalities reported range from 20 to 35 or
40 per cent. Probably the higher mortalities refer
to groups of the severer cases of the disease. Since
knowledge of the disease is still very restricted and
diagnosis still in its beginnings, probably many
ca-ses of lighter affection are overlooked or given (
other names and interpretations, thus making it [
impossible at present to arrive at an accurate
estimation of the prognosis and mortality. At
best, however, the disease is to be regarded as I
serious, whether from the point of view of long |
duration from onset to restoration of health, or»ofi
fatality. The chief immediate causes of death}
reported have been intercurrent pneumonia and ,
paralysis of the respiratory centre in the medulla.
Present indications are that the degree of com-
municability of lethargic encephalitis or suscepti-
bility to the disease is low, possibly equalling that
of epidemic poliomyelitis as observed in ordinary
times. The seasonal incidence seems to be mid-
winter, in that respect resembling epidemic menin-
gitis and differing widely from epidemic polio-
myelitis, which prevails usually in midsummer and(
early autumn. .|
Explanations of the lethargic state have beer,
offered. A toxic origin is, of course, possible. Ii
seems more likely, however, in view of the natun
and distribution of the lesions, that its source ii
rather a mechanical one. It is known that thi
sensory stimuli from the special and other sense
pass by way of the thalamus to the cerebral cortex
Since, therefore, the thalamus is so commonly th
seat of the cellular infiltrative lesions described, i
would appear that the stimuli arc interrupted ii
that organ on the way to the cortex, whence a kini
of sleep supervenes. The obstruction to the stimu
is not absolute, since the patient can be arouse
by increasing their intensity (as by loud speakinc
prodding, Ac).
Oct. 1. 1920.J THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE.
247
Epidemiologic.
It is now sufficiently otvious why the popular
name of " sleeping sickness " has been applied to
thia malady. The disease is, of course, wholly
distinct from African sleeping sickness, wiich is a
trypanosomal infection carried from person to
person by means of an insect vector — the tsetse-fly.
When an appai-ently new disease arises, it is
always important to inquire whether the particular
set of symptoms that are taken to characterize it
has been observed and recorded before.
In the present instance there are two signiiieant
records which may easily refer to a similar and
possibly identical disease. The first one dates from
1712, and refers to an outbreak of so-called sleep-
ing sickness centring about Tubingen in Germany.
The second record datee from 1890, and deals with
a rather puzzling malady called " nona, " which is
described rather in the lay than the medical litera-
ture of the time, and seems to have prevailed in
the territory bounded by Austria, Italy and Switzer-
land. In respect to neither instance, however, do
the records contain the minuter data which would
admit of a certain identification of the disease
described with the encephalitic malady we are
considering.
One circumstance is, however, significantly sug-
gestive. The location of the 1890 affection " nona,"
which was characterized by somnolence, stupor and
coma, coincides roughly at least with that of the
first cases reported in the present epidemic. The
question may, therefore, well be raised whether
the endemic home of this epidemic variety of
encephalitis may not be that comer of South-
eastern Europe overlapping the three countries
mentioned. If this should prove to be probable,
the next questions to arise would relate to the
circumstances under which the disease slumbered
on in ordinary times, and to the conditions that
favoured a greater activity and a wider spread about
the year 1916.
To deal with the first one will require particular
and intensive studies carried out with the especial
object in view to disclose hidden cases in the region
originally affected. An answer can in the mean-
time be hazarded to the second question. The
depressing effects of war, acting by way of hunger,
cold, migrations of population, and general insani-
tation, might initiate the conditions through which
a low endemic might well be converted into a
higher epidemic incidence of the disease.
In effect, a similar set of depressing and favour-
ing conditions may be supplied by a highly
debilitating and destructive epidemic, such as the
periodic waves of pandemic influenza which recur
from time to time. In this manner may possibly
bo explained the coincidence of the Tiibingen
epidemic of 1712, also called sleeping sickness, and
of the "nona" of 1890 with epidemic influenza,
just as the wider distribution of the encephalitic
malady and the influenza epidemics of 1918 and
of 1920 may be similarly associated. In other
words, what the depressing circumstances of the
war did for Austria-Hungary in 1916, the pandemic
of influenza may have done for the rest of the
world in 1918 and subsequently — namely, prepare
the soil, as it were, for the growth in number of
cases and for increase in intensity and capacity for
spread of an infectious nervous disease ordinarily
narrowly localized and moderately benign.
This relationship of lethargic encephalitis to the
epidemic of influenza has, indeed, led to a dis-
cussion as to whether the former is not merely a
sequel early or late— attending a certain, if only
small number, of cases of epidemic influenza.
Regarded merelj' chronologically, the question
thus presents itself. In 1916, when the first cases
of encephalitis appeared, or at least were recognized
in Austria, the epidemic of influenza which pre-
vailed later, in 1918, had not yet been noted. In
the instances of England, France, the United
States and some other countries, the epidemic
influenza and cases of lethargic encephalitis were
more or less coincidental. Since influenza varies
so much in degree of severity, it is of little moment
to debate whether or not victims of the encephalitis
had previously suffered from influenza.
On the other hand, there is no recognized
numerical relationship between the extent of
influenza and the number of cases arising, or at
least identified, of the encephalitis. It is, of
course, true that encephalitis has long been recog-
nized as one of the sequels of epidemic influenza.
Indeed, in the etiology of encephalitis, influenza
occupies a prominent place ; but in no other
pandemic of influenza has this remarkable associa-
tion of encephalitis occurred with certainty. Little
weight can be given the supposed coincidence of
influenza and the "sleeping sickness" of 1712;
and it is highly improbable that the semi-mysterious
affection, "nona," which dates from 1890, should
have taken its origin from the influenza epidemic
in South-eastern Europe at that period, and the
association not have been observed elsewhere* in
Europe or even in America at the same time as a
concomitant of the influenza epidemic, which raged
with great intensity in those countries. Moreover,
the occasional cases of encephalitis definitely ob-
served to follow attacks of influenza have presented
a more haemorrhagic character, and sometimes have
been attended by Pfeiffer bacilli in the nervous
tissues and meninges, which is not the case in the
lethargic disease we are now considering.
Finally, should the reported experimental trans-
mission of the encephalitis to animals be confirmed,
a further distinction from the influenza variety will
have been established. Therefore, the outbreak of
lethargic encephalitis either ante-dated (Austria)
the pandemic of influenza of 1918, or (in other
words) the two diseases more or less overlapped,
that is, although probably quite by accident, they
prevailed concurrently. It is desirable, for the time
being at lea'-.t, to regard them as independent
diseases
■n .,',to:y of lethargic encephalitis indicates its
248
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 1, 1920.
infectious and also its communicable nature, but
thus far single rather than multiple cases have been
observed in family and other intimate groups of
persons. However, two cases in a family have very
rarely been noted; and in one instance an institu-
tional outbreak has been reported in which among
twenty-one inmates of a girls' home twelve cases
arose, with five deaths. Whether more accurate
means of diagnosis, through which the non-
localizing or " abortive " and the frankly paralytic
lethargic cases would be more certainly associated
and thus lead to a general revision of present views
regarding multiple cases, can only be surmised.
Obviously, in the interest of knowle4ge as well as
of the prevention of the disease, close attention to
this point is desirable.
It is now a matter of great importance to deter-
mine the precise nature or etiology of lethargic
encephalitis. Many unsuccessful attempts have
been made to communicate the disease to monkeys
and other animals through the inoculation of
nervous tissues showing the particular lesions, in
the manner so readily and successfully employed
in monkeys for poliomyelitis. This circumstance
would alone serve to distinguish this epidemic
encephalitis from epidemic poliomyelitis. But in
two or three instances what are stat«d to be
successful transmissions of the disease to animals
have been reported.
von Wiesner of Vienna inoculated a monkey
subdurally with nervous tissue from a fatal case
of von Economo's. This animal quickly became
severely sick and died in about forty-eight hours.
At necropsy a meningo-encephalitis was found, and
from the lesions a diplo-streptococcus was culti-
vated. While von Wiesner regarded this expeii-
ment as successful, further investigation has
indicated that the infection with the bacteria was
an accidental and secondary process, and the diplo-
streptococcus is not etiologically related to lethargic
encephalitis.
Loewe, Hirschfeld and Strauss inoculated rabbits
and monkeys with filtered extracts of the naso-
pharynx of ca-ses of the encephalitis, and also with
filtered nasopharyngeal washings, and have induced
a meningo-encephalitis in those animals. Ap-
parently they did not succeed in infecting those
animals by inoculating the affected nerve tissues
themselves. They also believe that they have
cultivated a minute organism, resembling the
globoid bodies of poliomyelitis, which they think
may be the inciting microbic agent of the disease.
Discrepancies exist between the positive results of
these authors and the many failures of others with
similar inoculations which only greater experience
can clear up
Finally, Mcintosh, of the London Hospital,
announced that a monkey inoculated with the
material from the fatal cases in the home for girls,
.ilroady referred to, presented lethargic symptoms
and troiuors and died. The brain on examination
is said to have shown lesions similar to those found
in human cases of lethargic encephalitis.
Currat ^itmiuxt.
Indian Medical Gazette, July, 1920.
Notes on certain Cases of Fever (E. B. Seymour
Sewell). — Clinical notes on cases of fever of unknown
etiology of a few days with headache, pains in the
joints, constipation. The author believes that the
unknown infective agent of this fever is carried by
body-lice.
Human Bites (L. H. Hennessy). — From what
appears at first to be a trivial wound a protracted
may arise, with necrosis of bone. Spirocha
and fusiform bacilli are often found and treatment by
novarsenobenzol either locally or by injection is
indicated in early cases.
Treatment of Purpura Haemorrhagica (Pratap Singh
Khosla). — The author confirms the usefulness of cal-
cium salts combined with iron. His usual prescrip-
tion is calcii chlorid. gr. x-xv, tinct. ferri perchl. iilx,
tinct. hyoscyami iilxxx, aquam ad 5i~~sig. t.d.s.
Treatment of Plague by the Solution of Iodine and
Camphor (S. Mallanah). — In the author's experience
the combination of iodine and camphor reduces the
percentage of mortality more than any other treatment
he has tried.
A plea to ligate the Hydrocele Sac with living tissue.
(M. L. Bundu). — The author considers that this
procedure is very useful in preventing hEemorrhage,
sepsis and recurrence.
Flavine in Ophthalmic Practice (P. Ganguli). — !
The author has found flavine very valuable in oph-
thalmic practice especially in the treatment of^
mucopurulent conjunctivitis and ulcerative keratitis
caused by Koch- Week's bacillus and pyogenic cocci.
Ikbiral iftos.
Mb. Balfour, on behalf of the Council of the
League of Nations, has addressed to the various
Governments an appeal for £250,000 to combat ty-
phus in Poland.
The Bureau of the Public Health Service, Wash
ington, announces that at the present moment several
foci of bubonic plague are known to exist at New
Orleans, Pensacola and Galveston.
We regret to announce the death of Lieut. -Genera
Babtie, V.C, K.C.M.G., of the Army Medical Staffi:
Son of the late Mr. John Babtie, of Dumbarton, h(
was educated in Glasgow University and his services
in many corners of the Empire are well known. Hi;
death removes a distinguished man from amongst us
Oct. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 20. Vo). XXIII.
(Original Communications.
CHAULMOOGRA OIL IN LEPEOSY.
By T. A. Henry, D.Sc,
Director, Wellcome Cliemical Research Laboratories.
The announcement in the Times of July 10 that
Dr. J. T. McDonald and Professor Dean, working in
Hawaii, had obtained promising results in the treat-
ment of leprosy with ethyl esters prepared from
chaulmoogra oil, brings to a point the results of a
number of isolated researches conducted during the
last twenty years. It is moreover of special interest
from a chemo-therapeutical point of view, since these
new results may afford an explanation of the fact that
in spite of our fairly complete knowledge of the
chemistry of chaulmoogra oil it has so far not been
possible to associate with certainty the undoubted
remedial value of the oil with any of its components.
Chaulmoogra oil has long been known as a some-
what uncertain remedy for leprosy and various skin
diseases, but it was not until 1900 that its exact
botanical origin {Taraktogenos knrzil) was ascertained,
thanks to the work of Sir David Prain. Up to that
time it was believed to be derived from the seeds of
Gynocardia odoruta, whence arise such names as
" sodium gynocardate " and " gynocardic acid," still
unfortunately applied to products made from the
genuine oil. It was reasonable to hope that once the
true source liad been recognized, making it possible
to produce an oil of uniformly good quality and free
from admixture with other oils, that more "certainty
would attend its use, and though there is no definite
evidence that this has been achieved, it seems possible
that the greater interest shown in its use in leprosy
in recent years may be due in part to improvement
in the (luality of the oil obtainable.
Our knowledge of the chemistry of chaulmoogra oil
is chiefly due to the work of a former director of these
laboratories — Dr. F. B. Power, and his collaborators,
who in a series of papers published in 1904 — 05 dealt
exhaustively with the constituents, not only of cliaul-
moogra seeds, but also with those of Gynocardia
odorata (false chaulmoogra) and of the closely related
seeds of two species of Hydnocarpus, the oils from
which are used, though to a much less extent, for the
same purposes as chaulmoogra oil. Three of the
seeds examined, viz., chaulmoogra, Hydnocarpus
anthelmintica and gynocardia, contained cyanogenetic
compounds, i.e., they yielded prussic acid when ground
up in a moist state, due, no doubt, as was proved in
the case of gynocardia, to the interaction of an
enzyme and aglucoside present in each of the three
kinds of seed, just as emulsin and amygdalin react
and liberate prussic aci<l, wlien l)ittor almonds are
crushed in water. Apart from these constituents
none of the seeds yielded any product of interest other
than the fatty oil present in considerable quantity in
each of them. The four oils extracted from the seeds
were sharply differentiated into two groups. Gyno-
cardia oil was proved to consist of a mixture of well-
known fatty acids including palmitic, oleic, linolic.
linolinic and iso-linolinic ; it thus resembled the oils
belonging to the class known as " drying oils," of
which linseed oil is the best known example. The
chaulmoogra and hydnocarpus oils, on the contrary,
although they contained, some ordinary fat acids, had
as their chief components members of a new series of
acids (of which two, chaulmoogric and hydnocarpic,
were isolated in a pure state and characterized) which
differed from ordinary fat acids in being optically
active and in possessing as a part of their molecular
structure a ring or closed chain of carbon atoms.
It was natural to suppose that any remedial value
possessed by chaulmoogra and hydnocarpus oils
must be due to these peculiar acids ; but although a
considerable amount of work was done at that period
on this point, it seemed to be clear that better results
could be obtained from the use of the raw oils than
from any single derivative. Since then considerable
improvements, especially in the teclmique of adminis-
tration, have been effected by the labours of Sir
Leonard Eogers and those associated with him in
India, and by other workers. Chaulmoogric and
hydnocarpic acids, the two definitely known members
of this series, yield sodium salts which are sparingly
soluble in water, and are therefore unsuitable for
injection. The other acids of the series appear to be
lower homologues of these two and to yield more
soluble salts, but they have not so far been isolated
in a pure state, and they undoubtedly occur mixed
with some ordinary, unsaturated fat acids. It is
this mixture which in the form of sodium salt consti-
tutes the bulk of sodium " gynocardate " which lias
been used in the treatment of leprosy. The replace-
ment of these sodium salts of the acids peculiar to
this group of oils by their ethyl esters, first prepared
by Power and his co-workers in 1904-05, which
appears to be a special feature of the new work in
Hawaii, is distinctly advantageous since it renders
possible the trial of pure preparations of even the
higher acids, ethyl chaulmoograte and hydnocarpate
being both limpid yellow oils, which, mechanically at
least, are eminently suitable for injection. Dr. Balfour
informs me that a mixture of ethyl esters prepared
from chaulmoogra oil was being used with some success
for the treatment of leprosy in Venezuela in 1915.
Messrs. McDonald and Dean's work is probably a
continuation of that done by Messrs. Hollmann and
Dean, of which some details were published last
year, from which it appears they used the ethyl esters
of four fractions of chaulmoogra oil acids. Their
method of fractionation is less elaborate than that
adopted by Power and his co-workers, but on the
basis of the latter's results it is possible to work out
with some degree of probability the approximate
composition of Hollmann and Dean's fractions, and
to suggest their probable lelationsbip to the various
sodium salts used by Rogers and other workers.
Hollmann and Dean state that although all four
fractions produced reactions on leprous lesions when
injected subcutaneously, fractions C and D appeared
to act most rapidly, though the numbrr of cases
treated was tiien too small to permit of a final ex-
pression of opinion on the point.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 15, 1920.
Bth 1 esters of Corresponding sodium salt
Chaulmoogrio acid Sodium chaulmoograte.
Hydnocarpic and
chaiilmoogric acids
Lower homologues of /Corresponds approximately
chaulmoogric series I to sodium gynocardate.
which Rogers ' first used,
but which he gradually
improved by replacing
more and more of the
lower melting point acids
by hydnocarpic and
chaulmoogric acids, thus
approaching fraction
ith some chaulmoo-
gric and hydnocarpic
acids and some un-
saturated ordinary fat/
acids
D As C, but the un-
saturated ordinary
fat acids replaced by
palmitic acid
On the whole, the evidence seems to indicate that
it is the acids of the chaulmoogric series to which
chaulmoogra and hydnocarpic oils owe their value,
and that possibly the lower homologues are the more
active members of the series. Whether this action
on the bacillus of leprosy and other acid fast bacilli is,
as the work of Walker and Sweeney in Cahfornia
suggest, specific to acids of this type or is merely a
special case of a more general action on such bacilli
exerted by low melting unsaturated acids or their
esters, as appears to be indicated by recent work by
Rogers and others, only further research can deter-
mine.
It is now over twenty years since the work out-
hned in this note was begun. With adequate facihties
for research in those regions of the Empire in which
leprosy is prevalent, the point now reached could
have been attained long ago. Though opportunities
for research in tropical diseases have been increased
in recent years through the foundation of Institutes
for Medical Research, and in other ways, in the British
tropics, so that much iiseful work has been, and is
being done, the facilities are still far from adequate.
With the example in front of us of what can be
accomplished in this cotintry by comparatively small
financial means when the work is directed into the
channels of greatest importance and most urgent
need by such a body, as the Medical Research Council,
it is to be hoped that the authorities concerned will
in the near future constitute an analogous body to
take in hand the problems of tropical medicine. The
necessity of dealing with these problems should weigh
heavily with this country, since the promotion of the
physical weU being of the native populations in the
tropical areas we have undertaken to govern, should
be a first and most important part of our duties.
NOTES ON SOME CASES OF CASTELLANI'S
BRONCHO-MONILIASIS.
By I. Jacono, M.D.,
Physician, Naval Hospital, Naples.
Fob the last two years I have examined for presence
of fungi — using Castellani's methods — a number of
cases of bronchitis in which tubercle bacilli were always
absent. The sputum was collected in sterile recep-
tacles with every precaution, the patient rinsing his
' See especially Indian Journal of Medical Beseareh, 1917,
vol. V, No. 2, pp. 277-300.
mouth and gargling with a permanganate solution
(1 in 5,000) before expectorating. In each case par-
ticles of the muco-pus were washed in sterile broth
and then several glucose agar tubes were inoculated.
Some tubes were incubated at 37°, others at 28 C,
others were kept at room temperature. After 48
hours the tubes were examined and any white monilia-
like colony were further investigated microscopically
and bacteriologically. Every strain of monilia found
was passed through the principal sugars and its action
on gelatine and serum was noted.
Cane 1. — Young sailor with no family history of
tuberculosis. Complained of cough with muco-puru-
lent expectoration for the last two months. His
general condition is good, no serotine fever. The
physical examination of the chest reveals no zones of
dullness ; there are moist rales, especially on auscul-
tation of the left apex. Cuti-reaction negative. The
examination of the sputum repeated many times shows
absence of tubercle bacilli, instead several round
Sputum in a case of Broricho-moniliasis.
bodies with a double contour and Gram positive are
seen. The sputum is sown in glucose agar and a
monilia-like fungus is isolated (B. 12), the biochemica
characters of which are collected in the table. This
fungus is probably Monilia balcanica Castellani.
Case 2. — Sailor from a torpedo-boat. Has hac;
symptoms of bronchitis for the last six months. Ver>|
Uttle expectoration. The patient is very pale and hail
lost flesh. Cuti-reaction negative, tubercle bacill:
and Spirochseta bronchialis absent. A moniha-likil
fungus is isolated (B. 20), the characteristics of whici
can be seen in the table. It is probably MonilitY
krusei Castellani.
Case 3. — Sailor. Symptoms of acute bronchiti
with fever and rather scanty muco-pm'ulent expecto
ration. Tubercle bacilli negative. A fungus i
isolated (B. 21) with the characters of Monilia parn
krusei Castellani. ;
Case 4. — Sailor. Has been ill for the last six months
serotine fever, has already lost weight. The physicf
examination shows clearly symptoms of broncho-alvet.'
Oct. 15. 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
litis of the right apex, but the sputum shows constant
absence of tubercle bacilli, cuti-reaction negative, and
the inoculation of the sputum in a guinea-pig gives
also a negative result. A fungus is isolated (B. 33)
with the biochemical characters of Mo7iilia tropicalis
Castellan i.
Case 5. — Sailor. Acute bronchitic symptoms with
mucous expectoration, slightly blood. Moist r^les all
over. Cutireaction negative, tubercle bacilli and
Spirochieta bronchialis absent. A fungus is grown (B.
38) with the characters of 3f. guillermondi Castellani.
Glucose-agar
of Uonilia krusei Castellani.
Case 6. — Electrical worker. Has been ill for three
months. Symptoms of diffuse bronchitis, which are
greatly ameliorated by the administration of iodine
preparations. Cuti-reaction negative, tubercle bacilli
absent. In fresh preparations of the sputum no fungal
bodies are seen, but cultures show growth of ahypho-
mycete (B. 40) witli characters of M. parabalcanica.
The fungi I liave isolated belong to the genus
monilia, as defined by Castellani, Pinoy, and Chalmers,
and are therefore probably cases of bronchomonili-
asis, the form of bronchomycosis first fully described
by Castellani, whose work has been confirmed by
Chalmers and others. Castellani for practical pur-
poses distinguishes several types of monilias : (1)
Monilia balcanica Cast, group. Glucose is the only
sugar fermented with production of gaa : (2) Monilia
krusei group. Fermentation with gas production, of
j
S S S S S 2
;a 3 2 3 3 2
^ ^ ^ ^ ^ ^
1
x«p ^■^zl
Xup qis
xbp mi.
o o o o o o
o o o o o o
o o- o o o o
1 1 xiipmsi o o o o o o
< 1 -C»PH18 o o o o o o
5 I x^pw o o o o o o
1
X«p M151 j ^ o o ^ o o
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xspqif -< o o <: o o
5
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xup mi
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i
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s
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1
Xvp qiEl
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< o < % % <
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■< o < ^ % <
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xsp mx
X«p qit.
-<: o -< ^ o «<!
«: o < ^ o -:
<! O <i § O -!
i
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< ^ s ^ ^ -=
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S 2 .2 .2 .2 .2
llllll
?a
252
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1920.
glucose and levulose. (3) Monilia pinoyi Cast. type.
Fermentation with gas production of glucose levulose
and maltose. (4) Monilia metalondinensis group.
Gas fermentation of glucose, levulose, maltose, and
galactose. (5) Monilia tropicali Cast, group. Gas
fermentation of glucose, levulose, maltose, galactose
and saccharose. (6) Monilia giuUermondi Cast-
group. Gas-fermentation of glucose, levulose and
saccharose. (7) Monilia macedoniensis group. Gas
fermentation of glucose, levulose, galactose, saccharose
and inulin. (8) Monilia pseudo-tropicalis group (very
rare). Gas fermentation of lactose in addition to
other sugars. (9) Monilia zeylanica Cast. Absence
of gas production in any sugar.
As shown by the table the monilia fungi I have
isolated belong to tlie Monilia balcanica Castellani
group, Monilia krusei Cast, group, Monilia tropicalis
Cast, group, Monilia (juillermondi Cast, group.
I hope the cases I have recorded, confirming the
previous work of Castellani, Pfnoy and Chalmers, may
perhaps cause more attention to be paid to the subject
of bronchomoniliasis and bronchomycoses in general,
a subject of great practical importance from the point
of view of diagnosis and prognosis, as such cases are
generally mistaken for pulmonary tuberculosis.
REFERENCES.
Castellani (1904-1905), Cenlon Medical Reports.
Castellani and Chalmers, "Manual of Tropical Medicine,"
p. 1886.
Chalmers and MacDonald (1920), JonnNAt op Tropical
Medicine and Hygiene, January 1st.
Farah (1919), Lancet, p. 1919.
TJie Cultivation of a Trypanosomc from the Blood
of Panamanian Cattle (Oscar Teague, M.D., and
Herbert C. Clark, M.D.), Proceedinqs of the Medical
Association of the Isthmian Canal Zone, July, 1917
to DecemiDer, 1917, vol. x. Part 2, July 20, 1917.—
The autliors have found trypanosomes in tlie blood of
cattle from several different districts of Panama and
liave demonstrated the fact by making cultures. Broth
or blood agar was generally used. The temperature
at which the cultures are grown and the osmotic
pressure of the medium are important factors to obtain
successful results. The trypanosomes disintegrate at
body temperature and multiply at temperatures
between 22 and 28° C. The medium should contain
enough salt to make it isotonic with the blood to be
cultured. Two c.c. of defibrinated blood are added to
10 c.c. of broth ; five or six tubes being prepared from
each animal. The cells settle to the bottom of tlie
tube and remain in fairly good condition for a week or
ten days. After twenty-four hours incubation a't
2G C. no trypanosomes are found ; a few may appear
after forty-eight liours and on the third or fourth day
they may be present in large numbers. The authors
are now conducting experiments with the cultures and
with tlie blood of cattle harbouring trypanosomes, and
hope to make a further communication later on.
"S-nittts.
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THE JOURNAL OF
Cropicai Hldeotctne and l^pgteni
October 15, 1920.
SO.ME ASPECTS OF POISONING IN THl:
'I'KOPK'S AND SOME OK THE ]\I01lli:
CO.MMON VEGKTAHLE POISONS ME'}
WITH IN THE TROPICS. j
I'disoxiNG as practised by natives in seven)
trdpical countries has become a fine art practise?
by ■' specialists " or professed poisoners, and know
Oct. 15, 1920.] THE JOURNAL OF THOPICAL MEDICINE AND HYGIENE.
hjrally as a.ijortionists, bone-setters iUid siniilai'
(|uarks ill cither uountries. Their services are not
iiil'ie(|ucnlly railed in quite openly by the authorities
el' the tribe or sect to get rid of lives under vai'ious
eircuuistances : —
(a) For tlie destruction of enemies their services
are called for in a sense similar to that in which
the (irnna.iis introduci'd gas on the battlefield iuid
(b) for the removal of rivals in love.
((■) for hastcTung the end of persons suffering
from incurable or foully smelHug ailments, such as
gangrene, widespread ulcerations, especially of the
lace and e.xi)()sed parts, cancers of the breast and
other organs that have ulcerated.
((/) Family feuds handed down from father to
sun through several generations are settled in this
way, especially when the hate bearers cJinnot meet
owing t(; distance, or when the more cowardly of
the i-oiubatants shuns personal conflict.
((•) To get rid of defornred children.
(/) To get rid of " surplus " children. One fre-
(|Uently hears of natives, and especially the Chinese,
drowning children that are not wanted, more especi-
ally female children. The truth of this is freciuently
doubted, for the Chinese are passionately fond of
children, and on this account tJie tale is doubted.
IJut the Chinese are praetical above everything in
matters of race problems, and the following account
of a case of the kind may be interesting.
.\ patient of the wr:ti'r's had twins, a boy and
girl. Three bojs had already been born to the
jiareiits, and this therefore was the fourth boy,
and the girl twin the only girl in the family. The
Chinese nurse (ainah) had enough on her hands,
foi' the children were all (|uitf' young, not mori' than
eighteen months intervening between any two of
the succession. The accession of two to the family
llie ainali re^'arded with disfavour, and she evidently
made U|i her mind to get rid of one of the twins,
because she said: " Missussee no wantee more
hoy." The fact, of course, being that she (the
amah) found the twins an inconvenience to nurse,
and decided to get rid of one — the boy. In course
of time — a few months — the boy's health became
indifferent, aj>petite grew less keen, strength flagged,
the features became more i)uffy, the boy's natural
joyousness left him and he became more solemn,
and his skin of an ashen grey colour. Yiirious
remedies were trii'd in the way of diet and drugs
but nothing did any good, the amah meantime pro-
testing that the cliild was " all i)ro|)er. " (lradu;dly
it became evident that something out of the way
was amiss, and my medical colli'.igue. Dr. \Vm.
Hartigan, suggested that it might be fjoisoning, as
he had seen a similar cjuse before. He suggest<^'d
"datura" poisoning as the possible cause, and on
observation the signs and symptoms fulfilled the
" textbook " description of poisoning by this drug.
The process was very insidious and slow, the amah
being clever enough to make it appear tha,t the
child, being a twin, was backward and in a
"decline." So ill and listless did the hf)y become
that the writer luul the cliild removed to his own
house and placed it under a skilled English child's
nurse. Gradually the child recovered, lost all
symptoms of backwai-dness, and in a month's time
was (juite well and robust. At the end of two
months the mother removed the child from the
writer's house t« her own. Very shortly the pre-
vious symptoms recurred, and the amah, afraid of
the child being removed again, increased her
poisonous doses and the child died rather unex-
])ectedly. Datura is a well-known and connnonly
used drug in China for poisoning ])urposes. This
amah was a very clever womati, intelligent to a
degree, and conducted her " cast' " in an expert
manner. According to her " light " she j)robably
saw nothing amiss in her conduct, but believed
no doubt she was doing a good turn to her mistress.
It may be interesting to know that this amah
the writer has described elsewhere as being the first
woman in China who recovecwl after the removal
of an ovarian tumour of large size ; the ovarian
cyst and contents weighed after removal 81 lb.,
and the woman herself subsequent to the operation
weighed 1 lb. less, namely, 80 lb.
((/) .Another reason for the Chinese making use
of i)oison is in connection with insurance.
Some twenty-five years ago the Chinese too-k to
insuring their lives, and the .\ineric;uis and some
of the American agencies, as well a,s insurance
companies of other countries, took uj) this line of
business. British insurance companies declined to
have anything to do with any widespread dealings
in these matters, and only with a few of the C'hinese
of standing and liritish subjects of well-known posi-
tions in the commercial world did they now and
again have life insurance dealings.
The relations of the doctor to such wholesale
insurances were seldom in the way of pri'liminary
examinations, as most of the insurajice companies
anxious for business took tlii' Chinese ])remiums of
insurmice without any j)revi()Us medical examina-
tion, so that Chinamen and their families took out
insurance policies, and if any member was delicati^
the more readily did they do so. The trouble came
later, of course; when any one of the insured
died the question of paying the insurance due wa«
always a vexed problem. The claim if not paid
within thirteen months, according to agreement,
lapsed, and delay in settlement was therefore a
paying concern to the company, and unless claims
were settled within a spi'cified time the client's
relations lost the money. The way out of it was
to get the jierson that was ill identified by a Euro-
])eiui doctor previous to death and to give a certi-
ficate that the i)atient was ill and that lie could
not live more than, say, four or six or eight weeks.
It is to settle this latter point that the doctor is
called upon, and the friends will press the doctor
to say exactly whether he will live four or six or
eight weeks. If the doctor mentions any of these
dates the insured patient will most certainly die
on one of th{<se days — tlu' one the doctor ])erhapa
rather casua'ly mentions. The doctor is requested
to write the date down, state what is wrong and
how long the j)atieut will live ; this is shown to the
254
THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 15. 1920.
insurance agent the moment the patient dies, and
the claim enforced with the European doctor's
certificate as a witness that this is the person who
died. The insurance agents have, of course, another
loophole of escape, viz., that one Chinaman is so
like another that they cannot tell whether the dead
man is the insured man.
The interesting point from the medical point of
view is that the sick man — the insured man — dies
to date, no doubt by poison. The doctor unac-
quainted with such proceedings amongst natives
may and often does hasten the sick (insured) man
to his end. If he in a casual way says, " Well, I
should not think the patient can live more than
a fortnight," the poor man will be done away with
in a fortnight to the minute, so that the doctor
unconsciously may be the man's executioner.
There is no space to discuss even the more
common vegetable poisons used in the tropics. A
few of the more common are : —
Aconite, although a native of the northern tem-
perate zone, has been imported into India and
China and used as a medicine, but especially as a
poison.
Calabar bean (Physostigma venenosurn) and its
active principle physostigmin (eserine) is met with
only in Africa, and used there as an " ordeal "
poison.
Cassava (bitter cassava) — Manihot idilissima — a
native of Brazil, is cultivated there for food.
Java bean (Phascolus lunatus) is the wild form
of the haricot bean, and it is now distinguished
from the cultivated variety by its brownish or
purple beans, whereas the haricot bean itself is
white.
Mushrooms in the tropics are found to be poison-
ous in the same way as they are in temperate
climates.
The treatment for the several poisons mentioned
above is a hypodermic injection of atropine gr. ,V,
repeated if necessary.
(To be continued.)
Early Use of Convalescent Serum in Influenza (F. D.
Francis, M. W. Hall, and A. R. Ganies, The Military
Surgeon, .■\ug., 1920). — During tlie epidemic of influ-
enza at Fort Saen, Houston, Texas, in January and Feb-
ruary, 1920, the serum from early cases of influenza
before secondary infections had developed was injected
intramuscularly in doses of 50 to 100 c.c. on from one
to three occasions in 26 cases of influenza of special
initial severity. Compared with 219 cases treated
without serum the mortality was reduced from 6 to 0
percent, the average days of fever from 5'8 to 3'6, and
the percentage developing pneumonia from 30 to 4.
When such results can be obtained with serum as
relatively poor in immune bodies as that of convales-
cents, it is to be expected that ultimately with the
discovery of the primary cause of the disease a potent
autoserum may be developed. Meanwhile this method
seems so promising that it should be employed when
it is' possible to obtain a supply of the serum.
gbstrarts.
THE VITAMINES.i
By Walter IJ. Eddy.
Assistant Professor Physiological Chemistry.
Historical.
The name " vitamine " was given to these
substances by Casimir Funk. Since 1911, when
he suggested this name for the substance (isolated
from rice polishings and yeast), which was curative
of polyneuritis in birds or beriberi in man, the
study of this substance has been nmch extended,
and the importance of the types now classified
under this name as related to diet, growth and
scurvy has increased in proportion to the progress
made in investigation. To-day three types are
under investigation under the names of " fat-
soluble A," " water-soluble B," and " water-
soluble C."
While the name " vitamine " was first applied
by Funk in 1911, the suggestion of its presence
and significance antedates his work. Previous
to 1909 a number of attempts had been made to
nourish animals on diets composed of purified pro-
teins, fats, carbohydrates and salts. Such attempts
were usually attended with failure. These earlier
studies are well summai-ized by McCaJlum in thi'
Amcricayi Journal of Phj/siology. He calls attention
to the fact that some of the first experimental work
suggesting the reciuirement of accessory substances
in the diet is found in the work done by Stepp.
In atteni[itlug to ostimate the importance of lipoids
in the diet, this author showed that by the ex-
traction of bread and milk with ether-alcohol some-
thing was taken away that rendered the mixture
inadequate to support life in mice, and that when
the extracted material was restored to the diet the
food became efficient once more. Stepp thought,
of course, that the substance extracted was a
lipoid, but was unable to obtain the same result
by substituting for the extracted substance any
known lipoid. Here then was a suggestion that
ether-alcohol extracts from diets something that is
not fat and which is essential to the diet.
The actual discovery of the substances no\v
classed as " vitainines, " "food accessoi-y sub-
stances," "fat-soluble A," "water-soluble B,"
&c., came about through the work in two distinctly
different fields, which later converged as the sub-
stance sought in each field was seen to be identical.
In 1897 Eycknian had shown that polyneuritis
could be induced in fowls by restricting them
to a diet of polished rice, and that a diet of
iindeeorticated rice would cure fowls in this con-
dition. In the Philii)])incs the siilijoct had been
p. 313.
' Abstracts of Bacteriology," vol. iii. No. G, December, 1919, '
Oct. 15, 1920.] THE JOURNAL OP TROPICAL MEDICINE AND HYGIENE.
255
under extended investigation by a number of
American workers. In 1907 Fraser and Stanton
showed that thi^ alcohol extracts of rice polishings
would relievi' experimental polyneuritis. In 1911
]''unk took up the study of the problem, and
showed that ])iessed yeast, hydroiysed with 20 per
cent, sulpliui-ic acid for twenty-four hours, re-
tained its property of curing polyneuritis when
aiiministcred to birds. Funk had previously been
interested in this problem, and his contributions
from 1909-1911 were preliminary to his state-
ment that in yeast and in rice polishings there
was present a chemical entity of a basic nature
which he named " vitamiiie. " The fact that this
substance was precipitable by phosphotungstic
acid, and therefore an organic base, was an-
nounced simultaneously by Funk and by Suzuki
working independently of one another. From
1911 to 1915 this announcement was followed
by further attempts by Funk and others to deter-
mine the nature of the new substance. The sig-
nificant papers in this series will be discussed in
detail in the later topics of this article. Suffice it
here to note that the presence of the substance
« a-; established, its anti-neuritic property confimied
and its chemical nature suggested, but not estab-
lished. In fact, it soon became clear that the
term ■' vitamiiic " was in some respects ill-chosen.
Hopkins, in England, suggested the term " acces-
sory food substances," and later R^cCallum sug-
gested the specific terms " fat-soluble A " and
" water-soluble 13 " to identify the unknown dietary
factors. The controversy over the nomenclature
has some historical interest, and McCallum's j)oint
of view and Funk's defence of his name arc set
forth in various articles. As a matter of fact,
however, usage has settled the controversy by
retaining the name " vitamine " to designate the
class of substances and the terms " fat-soluble A "
and " water-soluble B " to specify the class referred
to. The pursuit of the pathological phenomena of
i)criberi, therefore, led up to the naming of vita-
mines. Let us now consider the parallel line of
endeavour that in 1911 merged with it in search of
vita mines and their properties.
In 1911 Osborne and Mendel reported a scries
of experiments involving the study of the effect
of feeding purified proteins and mixtures thereof
with other purified nutrients. In these experi-
ments (hey called attention to the peculiar growth
effects induced by the use of a ))reparation called
by them " proti'in-free milk." A little earlier
Hopkins h;id called attention to the fact tlnit the
addition of milk to purified food mixtun^s produced
results out of all pioportion to the caloric value of
the milk. In 1912 McCallum and Davis showed
that butter fat iuid egg yolk contained somtithing
that stimulated growth and was absent in lard and
olive oil. A publication by Hopkins in this year
also bore upon the same matter. The discovery of
these facts simultaneously with the announcement
of the discovery of vitamine in rice polishings and
yeast suggested the possible identity of the two
substances. Hence, since 1911, the different schools
of workers have converged upon the problem.
Osborne and Mendel pursued their studies of
purified mixtures with the view of extending their
conclusions to explain the reaction of the accessory
substance in butter fat ;md protein-free milk.
McCallum and his co-workers began the series of
.studies upon the dietai-y efficiency of cereal grains
and other food-stuffs that in 1915 led to the pro-
posal of the A and B terms as describing the factors
necessai-y to growth and limiting the anti-neuritic
j)roperties of the " B " vitamine.
The revival of interest in the subject of scurvy
during the past two years and the present state of
the investigations has waiTanted Drummond in
suggesting that the anti-scorbutic vitamine be
classified as "water-soluble C."
Mktiiods of Trepakation.
The eai'lier methods of preparation aimed at estab-
lishing the properties and chemical identity of the
vitamine. These methods may be gleaned from
the earlier pa])ers of Funk and his co-workers, but
the student is especially referred to references 18
and 19 in which Funk has summarized these ex-
periments. Quoting from one of these articles.
Funk states the original method to be as follows: —
Rice polishings were extracted with cold absolute
alcohol which was partially saturated with gaseous
HGl. The extracts were evaporated in vacuo at
a low temperature, and the fatty residue melted
and extracted with water. These aqueous extracts
were precipitated with 50 per cent, phospho-
tungstic acid solution after addition of sulphuric
acid to the extent of 5 per cent., and the pre-
cipitate decomposed in the usual way with baryta.
The solution, entirely freed of baryta and sulphuric
acid, was filtered, and the filtrate neutralized with
HCl and evaporated iii, vacuo. The residue was
extracted with alcohol, and the solution freed by
filtration from the inorganic chlorides. The alcohol
solution was then pn^cfipitated with alcoholic mer-
curic chloride solution. The active substance was
found to a small extent in this precipitate, but the
bulk was in the filtrate. From each of these
fractions vitamine could be completely thrown
down by use of silver nitrate and baryta. From
this fraction, after decomposition with hydrogen
sulphide, there was isolated a very small quantity
of a crystalline substance with a melting point of
233° C;. This was not recrystalli/.ed and ])ossessed
very marked curative jwwer.
This substance was afterwards shown to be
impure nicotinic acid.
Funk extended his study of the phos|)hotungstic
precipitate, and improvements were devised for the
fractioning of this precipitate. It was found that
if the phosphotungstic ])reeipitate were rubbed up
with acetone a large pai-t of it went into solution
and that the vitamine remained in the smaller
insoluble fraction. H was also found that bsiryta
aj)i)eared to havir a dcslructive inlluence on the
256
THE JOURNAL OF TKOPICAL MEDICIKE AND HYGIENE.
[Oct. 15, 1920.
vitamine, and neutral lead acetate was substituted
to break down the precipitate. Another feature
that developed was the fact that autolysed yeast
yielded larger quantities than could be obtained by
extraction of the material without autolysis. These
and other features were incorporated into the
methods, and are fully treated in the articles
referred to.
The desirability of obtaining the vitamine in
active form for experimental use, and at the same
time of avoiding the slow, tedious process of pre-
paration noted above, has developed other methods
of extraction.
The procedure devised by Seidell is as follows : —
(1) Autolyse the yeast at 40° C. for forty-eight
hours.
(2) Filter off the extract and add 200 grm. of
fuller's earth to each litre of the extract. (Seidell
used the particular fonn of fuller's earth known as
Lloyd's reagent.) Shake for fifteen minutes.
(3) Filter off the earth on a hardened paper in a
Buehner funnel, dry to constant weight in a
vacuum desiccator over sulphuric acid, and use as
Kaolin and similar substances have not proved
substitutes for fuller's earth in this process. Bone
black absorbs some of the vitamine, but not with
the efificiency of the earth.
A third method of obtaining vitamine ior experi-
mental purposes has been devised and reported by
McCallum. The method consist in the following
steps : —
(1) Extraction of the matei-ial with alcohol-free
ether on the Soxhlet apparatus uutil all fatty
matters are removed. Ether will not extract
B vitamine.
(2) Hot alcohol extraction of the residue from
the ether extraction by Soxhlet or Caldwell method.
This removes the vitamine, and apparently in
neutral or acid reaction the vitamine will stand
boiling for hours without deterioration.
(3) Deposit of alcohol extracted vitamine on
dextrin by evaporation and use of this activated
dextrin as material for experimentation. Or dis-
solve the vitamine from the dextrin with benzene
and thus further purify it. (Benzene will not
extract vitamine from the raw material, but will
extract it after it has been deposited from alcohol
extract on dextrin.)
The methods described above apply to the ex-
traction of the anti-neuritic vitamine of water-
soluble B. The fat-soluble vitamine presenis
certain peculiarities that must be considered in its
extraction.
While soluble in fats and extractable through
the agency of ether from butter and milk and such
animal tissues as contain it, M«Callum has pointed
out that isolated plant fats as obtained either by
ether extraction or by hot pressing do not contain
the fat-soluble A.
Suitably planned feeding experiments have
shown that it is the fat-free residue of the seed
that still retains the content of the substance that
was originally present in the seed. We have
demonstrated this only in the case of the maize
kernel and the flax seed, but the experiments of
Richardson and Green indicate that cotton-seed
flour still contains a fair amount of this dietary
factor. We have shown that cotton-seed oil is
without the peculiar growth-promoting property
which it would show if it contained this substance.
We have obtained potent preparations as follows :
Spinach leaves and young clover respectively, dried
in a current of air at about 60° C, were extracted
with U.S. P. ether. The resultant green extract,
yielding an oily residue equal to about 3 per cent,
of the dried plant, was evaporated upon starch.
These preparations, fed in dailj' quantities equiva-
lent to 1 to 2 grm. of dried plants, promoted
recover}' and renewal of growth in rats declining in
weight on diets deficient in fat-soluble vitamine.
Inasmuch as only 30 mg. per day of the ether
extract of spinach sufficed for this purpose, it
appears that this substance ranks among the most
potent of the oils heretofore tested.
In practice the presence of fat-soluble A is deter-
mined by feeding a diet suitable in all other
particulars, and then using the suspected substance
to supply the " A." Another method is to add to
such a diet a .sufficient amount of butter fat to
secure normal growth and thus determine the
sufficiency of the suspected substance in terms of
the butter fat standard. McCallum uses the
following diets in testing substances for the water-
soluble B, and similar ones minus the butter fat
and with the " B " vitamine for testing the " A. '
The extraction of the anti-scorbutic vitamine
" C " has merely progressed sufficiently to demon-
strate that it is neither " A " nor " B " and to
justify its name.
SouRcic OK Vitamine.
In the absence of any satisfactory quantitative
measurement for vitamine, it is impossible to
indicate absolutely the amounts of any type in a
given source. The system adopted above aims to
show the relative abundance. (-F-(-4-) indicates
abundance; ( -I- -I- ) sufficient to reijuire no supple-
ment in feeding experiments where the source
indicat«l is the sole supply; (-I-) present, but not
in sufficient (|uantity to be relied upon as the sole
source ; ( - ) means absent or so little as to be
negligible; ( '.') undetermined.
lii:.AtTU).\ OK Tin-; Vitaminks to Hkat. .\i ids,
Alkaliks and Solvknts.
The <iuestion of the effect of heat, aeid and alkali
upon extracts of vitamine or u\>nn tluse vitaniiucs
in nitu is still unsettled, and it is iiiijiossiblr to speak
dogmatically. .
The following statements of a few investigators j
on this subject ju'e presented to liiiug out the
variations in the point of view and the necessity
of defining the effects of heat, cle., in terms of
particulai- vitamines and sources lather than in
generalized conclusions.
Oct. 15, 1920.]
THE JOURNAL OF TBOPICAL MEDICINE AND HYGIENE.
257
Chamberlain, Vedder, Williams and others, and
]''iink early showed that hydrolysed preparations
were more rather than less active and suggesting
the resistanpo to acid. McCallum and Davis
showed that milk whi'v, wheat embryo and crude
lactose could .iiiiiarciitly be heated for one hour
under 1,5 lb. prcsiuirc without destruction of the
water-soluble B. Osborne and Mendel confinned
these views in the study of the protein-free milk.
Osborne and Mendel also pointed out the failure
of live steam to destroy the fat-soluble A in butter
fat, and at the same time called attention to the
fact that butter fat allowed to stand at room tem-
perature for several months gradually lost its
potency. Steenbock and his workers have recently
maintained that heat may destroy the " A "
vitamine in butter fat. They explain the failun;
of other investigators to note the destructive action
as due to the high initial content of the substance
used by these investigators and the use of biologietal
tests whereby partial destruction was not observ-
able. Chick and Hume call attention to the same
feature. They hold that temperatures above
l{)()o C. d(^cidedly afiect the stability of the " B "
vitamine. They report that forty minutes' exposure
to a temperature of 113° C. reduced the potency
of the solution used to one-half that of the unboiled
control, and that two hours' heating at 118° to
124° C. reduced the efficiency of the solution to
less than one-fourth of the unboiled control. They
urge the necessity of quantitative methods in such
studies.
On the alkali side of the question, Williams and
Seidell have extracted vitamine " B " from Lloyd
reagent adsorption product with strong alkali and
found the extract potent to a high degree. On the
other hand, McCallum has shown that wheat
embrj'o " B " heated with alkali is very quickly
destroyed .
Daniels and MeClurg call attention to the, fact
that the effects of heat and reagents upon vitamines
in extract and the like must not be confused with
the behaviour of these substances in situ. An
extensive scries of experiments conducted by them
on th(> cooking of vegetables with and without the
addition of alkali shows that under these conditions
neither heat nor dilute alkalies proved destructive
to the vitamine.
In general, then, the views stated in the first
ptu-agraphs of this topic hold. Only specific tests
should be accepted as guaranteeing safety under
any given condition. There is great need for the
development of (|uantitative research in this par-
ticular field.
Tlie relation of vitamine " B " to solvents has
been reported by McCallum with the following
observations : Vitamine B may be extracted with
alcohol or water, but is not extractable with ether,
benzene or acetone. On the other hand, after
extraction with alcohol and deposit upon dextrin,
the dextrin deposited vitamine may be dissolved
in benzene, but not in acetone. In the same report
McCallum observes the great stability of the " B "
to nitrous acid and HCl.
The peculiar relation of the " A " vitamine
toward ether extraction is explained by McCallum
as follows : He suggests that the reason for the
failure of ether extraction of plant tissue to remove
the " A " vitamine with the fat is due to the
chemical union of the " A " in the plant tissue in
a forni that is not soluble in ether, and that during
digestion and absorption of plant tissues this
vitamine is set free from this binding, and being
readily soluble in fat passes into the animal fat,
and is afterwards removable with this animal fat
by ether extraction. Whether this is the true ex-
planation or not the facts are as stated. Cotton
seeds contain the " A," cotton-seed oil does not.
In a recent paper Sugiura and Benedict have
shown that X-ray emanations are destructive to
the vitamines of yeast.
T^lR CriEMTCAL STRITtlTURK OF A VlTAMINE.
Funk attributed the vitamine properties to nico-
tinic acid, adenine and other substances allied to
purins and pyrimidines, since these substances
were the invariable end-products of his methods of
extraction. Funk's work was not pioneer in this
direction, but while the chemical nature of the
vitamines remains unknown to-day, his researches
contributed methods of study that must be con-
sidered carefully by the student of this phase of
the subject. Closely allied to Funk's idea has
been the theory advanced by Williams and Seidell,
in which they try to show that vitamines are
tautomeric substances existing in active and in-
active form. They suggest that vitamine is a
pseudo-betain, and Williams has shown that alpha-
hydroxyl-pyridine possesses anti-neuritic power that
is lost on standing. These theories above noted
refer to the anti-neuritic or " B " vitamine.
Steenbock has recently advanced a theory in
which he suggests that the " A " vitamine may be
a yellow pigment or a substance closely allied to
the yellow pigments. The idea has sprung from
the association of the " A " vitamine with yellow
pigment, e.g., it is present in butter and egg yolk
fat, but absent in lard ; yellow com contains con-
siderably more of it than white corn. Such facts
tend to lend support to the idea. In the references
presented on these theoretical phases there has
been included a set of references to the work of
Palmer on the yellow pigments as contributory to
the last-named theory and its development.
'J'liK Explanation of the Method.s in wnicn
Vitamines Function.
The inevitable sequence to the discovery of the
vitamines was the tendency to attribute to them
flirect relationship with all matters of dietary
deficiency. Thus growth, polyneuritis, pellagra,
sprue, marasmus, scurvy, Ac, presented problems
which it was hoped the study of vitamines might
^olve. Workers in each field have endeavoured to
secure evidence of the relation of vitamine to the
particular disease. The. results vary with the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Qcfc. 15. 1920.
disease studied. Pellagra and sprue, for example,
have not yet been demonstrated to be linked
definitely with vitaniine activity. Growth, poly-
neuritis, xeropthalmia in rats have been shown to
be directly related to the activity of the, " A " and
" B " factors. Marasmus has shown some evidence
of connection with the two vitamines, and scurvy
has been linked with the " C " vitamine. In the
study of these diseases and of growth, certain views
have been advanced to explain how the vitamine
functions in each case, and while none of these
views may be considered as demonstrated beyond
doubt, it seems worth while to collate them here
for the guidance of the student. In this connection
it must be borne in mind that empirical result.^
with a curative agent may often develop great
progress in practice of medicine without adding
much to our actual knowledge of how the agent
works.
Polyneuritis and Beriberi.
Funk has not^d that when the curative fraction
was administered orally or subcutaneously to pigeons
suffering from induced polyneuritis the birds re-
covered speedily, but that it was impossible to
keep them on a diet of polished rice permanently
even if the injections of the curative substance were
made every few days. Williams points out that
pigeons restricted to polished rice do not all run
the same course. Some never develop polyneuritis
but die of starvation. Others recover temporarily
from an acute attack without treatment. Eyckman
cured pigeons but not chickens with injections of
20 to 40 mg. of a mixture of one part NaC, and
three parts KCg. From these studies and his own,
McCallum has formulated certain views as to the
anti-neuritic vitamine and its method of action.
We quote from the article : The following explana-
tion, while purely speculative, may possibly account
for the recorded observations and assist in clarifying
the confusing data relating to this subject.
Histological methods have shown that in poly-
neuritic animals there is a degeneration of the
motor cells of the cord. This change is pro-
gressive; some cells present the normal appearaner
while others in the same field are degenerated. It
would appeal- plausible that when the motor cell
changes have reached a certain point loss of func-
tion supervenes and paralysis results. There still
remain in the cord of a paralysed animal motor
cells which appear normal when stained, and which
may be capable of restoring the motor functions of
the muscles when influenced by substances which
stimulate them to heightened sensitiveness. In
other words, the temporary relief of polyneuritis
may be the result of the pharmacnld^^iral action of
certain substances rather than :i nsiioiisr with
renewed function of cells which have been sub-
jected to a selective fast, and later have been
supplied with the missing food complex. If this
line of reasoning could be shown to be valid, it
would follow that experiments with pure chemical
substances of known constitution, with a view of
finding by good fortune the one playing an impor-
tant physiological role, might be entirely mis-
leading unless it were shown that the " cure " was
permanent. For such complete proof it is neces-
sary to demonstrate the resumption of growth and
maintenance of health as long as the substance is
supplied in the food mixture. Animals which have
been brought into a critical condition where death
is certain within twenty-four hours, and which havt'
been permanently cured on the addition to the food
mixture of a very small amount of a preparation
obtained in efforts to isolate the unidentified food
factor, furnish absolut-e proof that the physiologic-
ally active dietary factor is being dealt with.
Sustained normal function is indispensable to
adequate proof that the dietary essential in ques-
tion is being administered. If this condition should
be insisted upon by investigators before concluding
that a test is positive, it is probable that we should
not have such a list of totally unrelated chemical
substances reported as protective against poly-
neuritis.
McCallum believes that the lack of " A " in a
diet is responsible for the eye disease known as
xerophthalmia. Hi^ believes that the lack of
" B " results in polyneuritis. But he does not
support the view that there are specific vitamines
pi'esent which protect against scurvy, rickets,
pellagra, sprue, Ac.
Whatever the point of view, the vitamine " B "
is now definitely associated with the treatment and
cure of i)olyneuvitis.
Growth.
Fxtt-nsiv.' studies on the nutritive efficiency of
varidiis diets and on the specific behavioiu- of the
ilictaiv factors " A " and " B " have shown that
both are essential to the normal growth of such
experimental animals as rats, swine, fowls, &c.,
and by analogy or, in a few cases by direct experi-
mer.t, to human animals. He has reci'iitly ques-
tioned the necessity for the "A " tj-pe in the
development of human infants. The details of
these experiments may be obtained from the
literature of the vitamines, and for convenience
the references are divided into two groups, those
relating directly to vitamines and those con-
tributory.
Pellagr.\.
As the vitamine relation to this disease has been
merely suggested and not definitely demonstrated,
a list of references to the analysis of pella.gi-a diets
will siiftice lo bring out the factors at issue.
Scurvy.
In 1017 and 1918 McCallum tried to show that
scurvy was not a deficiency disease. His announci'-
ment in this respect stimulated re-investigation of
the entire subject. The references cited are not
exhaustive, but give sufficient data to show the
student why McCallum 's view is now considered
untenable, and why Drummond is justified in
suggesting the name water-soluble " f " to desig-
nate the anti-scorbutic fixctrir. The evidence ag:ainst
Oct. 15. 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
259
the " A " and " B " factors as related to scurvy
is well covered in the article by Cohen and Mendel.
This phase of the subject would be incomplete
without a reference to Butcher's work, in which
he has attempted to show a relation of the vita-
niines to oxidative activity. Dut<!her observed that
the tissues of the polyneuritic birds showed a
marked reduction in catalase, and that this cata-
lase activity was restorable by curing birds with
vitamine " B." He has tried to deduce from this
some relation between vitamines and the oxidative
processes. The main difficulty lies in the com-
plexity of the factors that function between cause
and effect. The suggestion, however, deserves
attention.
INTESTINAL PEOTOZOAL INFECTIONS
AMONG OFFICEES AND MEN OF THE
ROYAL NAVY AND MAEINES, DEALT
WITH AT THE EOYAL NAVAL HOSPITAL,
HASLAE, DURING 1916 to 1918.'
By H. A. Baylis, M.A.
(1) What is a Carrier of Amcebic Dysentery ?
The importance of carriers of amoebic dysentery,
among the Forces and elsewhere, is a question which
has become of great moment during the war, and
which had not previously received very much
attention. We have to consider it from two points
of view ; (i) the possible danger of carriers to
themselves ; (ii) their possible danger to their healthy
comrades. Before discussing it, however, it may,
perhaps, be useful to attempt some definition of what
is meant by a " carrier" of amcebic dysentery, and to
consider briefly what are the necessary conditions
of infection.
A carrier of amoebic dysentery is a person who
harbours Entamoeba histolytica in his intestines, but
is in such a relation with the parasite that it is
not at the moment producing symptoms of active
In a carrier, a colony or colonies of amoeba; are
hving under the conditions most favourable for their
continued life and reproduction, while their host is
probably living in complete ignorance of their
existence. In other words, a carrier and his parasites
exhibit the relationship most desirable from the point
of view of the parasites and least objectionable from
that of the host. It is probable that a certain amount
of ulceration of the intestine is always going on even
in such a carrier case, but we know that such
ulceration may occur on quite an extensive scale
without giving rise to any disturbing symptoms.
The carrier is unconsciously repairing any damage
to his tissues caused by the amcebEB just as fast as is
necessary to maintain the conditions of equilibrium.
At the same time, a certain number of the amcebte
are constantly encysting and being passed out in the
faeces for the infection of new hosts. This condition
of balance may be regarded as a normal state
' From the Journal of the Royal Naval Medical Service,
No. 3, July, 1920, vol. vi.
comparable with the conditions of parasitism by
relatively harmless animal organisms such as the
great majority of intestinal protozoa and worms.
It is not in the interest of the parasite to produce
disease and death to ]ts host, for this ultimately leads
to its own extinction. When serious symptoms arise,
as in acute amcebic dysentery, we must regard this as
a sign of the abnormal upsetting of the delicate
balance between parasite and host, and as due to
some cause which has prevented the host from being
able to repair rapidly enough the damage done by the
parasite.
We now know that in the case of E. histolytica
the infective organism is the encysted stage of the
amoeba, and that the passage of the cysts is a constant
feature of the carrier condition. The person suffering
from acute amoebiasis, on the other hand, passes, as a
rule, numbers of the active amoeba?, which are swept
out of the intestine before they have had time to form
their protecting cyst wall. He seldom passes cysts
while in the acute stage of the disease. We have
experimental proof that infection does not take place
through the ingestion of the active amcebae by the
mouth — these are killed during their passage through
the stomach. It is the encysted form, the cyst wall
of which has to be acted upon by the pancreatic juice
in order to liberate its contents, and which is not
killed in the stomach, that gives rise to new infections
in the same or another host.
It is the carrier, therefore, and not the acute case,
who is dangerous to the community in which he
lives. The acute case may fall back again into the
condition of a carrier, and there is reason to believe
that in many cases acute attacks alternate the
periods of " carrying." On the other hand, many
cases who are found to be carriers have no history of
acute onset or periodical attacks.
(2) Conditions of Infection.
Thanks to researches largely carried out during
the war, we now have some definite ideas as to the
manner in which infection with amoebic dysentery
is spread. We know, as stated in the last section,
that the cyst of E. histolytica is the infective agent.
We also know that the cyst cannot withstand drying
even for a few minutes, and therefore that it must be
kept in a moist state in order to retain its vitality
until it can find its way in a new host. Evidence
points to the conclusion that there are two chief
means of conveyance — water and flies. Wcnyon and
O'Connor have shown that cysts of E. histolytica will
survive for over a month in water, provided that the
faeces in which they wore contained are much diluted.
They have also been able to confirm experimentally
the suspicion that flies acted as vehicles for the cysts.
This takes place, not to any great extent, through the
habit of regurgitation on the part of the flies, and
probably not at all through infective material adhering
to their feet, since in the latter case desiccation would
be rapid, and moreover the flies usually clean them-
selves thoroughly after a food. The chief mode of
spread by flies is by means of their droppings. The
cysts have been found to pass uninjured through
the intestines of the flies, and to be deposited in their
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 15, 1920.
faeces from five minutes to twenty hours after they
have fed on human faeces containing them. This has
not only been proved under laboratory conditions,
but wild flies caught in Alexandria were found to pass
cysts which they had evidently ingested with human
faeces in the streets of the native community.
It seems, therefore, that infection may occur either
from contaminated water supplies or by eating food
on which flies have deposited infected droppings.
(3) Danger of Carriers to themselves.
We are now in a better position to attempt answers
to the original question in its two aspects.
With regard to the first, it must be frankly admitted
that very little can be said at present. All that we
know is that carriers may, after a period during
which no symptoms of the presence of the amoeba
have been observable, develop acute dysentery or
hepatic abscess. Wenyon and O'Connor (1917) state
that " it is possible that the great majority of carriers
eventually show dysenteric symptoms, but as yet we
have a very few data to go upon." The data, in fact,
are so few that there is no means of estimating what
percentage of carriers are likely to become acute cases,
and this applies, of course, as much to the Navy as to
any other community.
The possibility of re-infection of the carrier himself
by means of his own cysts has, of course, to be
considered, as well as the possibihty of his lapsing
into the acute cond.l'on without re-infection.
(4) Danger of Carriers to their Comrades.
With regard to this aspect of the question, the facts
derived from the study of persons who have not been
abroad must have some weight. If there are, as we
have seen, reasons for suspecting [Section vi (3)],
something hke six carriers of amoebic dysentery
among every hundred of our adult male population at
home, and if the disease, in its acute form, is almost
unknown in this country, the danger of carriers would
seem to have been much exaggerated. This, however,
is putting the case for the harmlessness of carriers in
the most favourable light. In reality certain questions
are involved with regard to which our ignorance must
be confessed. It is possible that cases of obscure
intestinal disease occurring in this country might
often prove to be due to amoebae, if the protozoological
examination of the patient's faeces were a general
practice. We are therefore not in a position to state
that amoebic dysentery is really so rare as has been
Another point to be considered is to what extent
the present prevalence of carriers at home may be due
to their infection from men who have served abroad
during the war. This is a question which can
probably never now be answered, since before the war
no inquiry had been undertaken, and consequently no
data are available.
After all, the question of the importance of carriers
is in the main a matter of sanitary arrangements. In
a civilian community, where good sanitation is the
rule, and similarly under the conditions prevailing in
modern ships and in shore establishments, the chances
of fnfection must be very slight. Men of the Eoyal
Naval Division and Marines, who served ashore in the
East or in France during the recent war, had, of
course, similar chances of infection to those of the
Army. We have seen, however, that there is evidence
that infection among the naval forces was considerably
less frequent than in the Army, and there is reason
to believe that the percentage of incidence has been
kept low owing to the fact that many of the men ex-
amined had not seen shore service abroad, or had only
served ashore for very short periods. It is probably,
therefore, only in so far as the naval forces are sub-
jected to the conditions of campaigning ashore that
the naval carrier of amoebic dysentery becomes a
serious problem for consideration.
Prevention of carriers, on the whole, offers greater
promise of success than cure under these conditions.
The discovery and cure of all carriers presents great
difficulties even at home, and it is doubtful whether it
is either practicable or desirable in war time. As
Wenyon and O'Connor (1917) say, " It may be im-
possible to isolate and cure every carrier case in a
large body of men, but much can be done by the
careful use of fly-proof latrines and covered re-
ceptacles. With an efficient system of fly and faeces
destruction and arrangements for the prevention of
flies coming into contact with excreta, there is every
reason to believe that amoebic dysentery, as well as
many other intestinal disorders, would be very
materially reduced, if not entirely eradicated." Valu-
able suggestions, based on practical experience, as to
methods for dealing with the fly nuisance in the field,
are made by Austen (1920).
(5) Treatment of Cases and Carriers of
Amcebic Dysentery.
It may be objected that it is not the part of the pro-
tozoologist to concern himself with the question of
treatment. It is nevertheless obviously highly im-
portant for the proper co-operation of the laboratory
staff and the medical officer in charge of cases that
each should know something of, and be to a large
extent guided by, the work of the other. Experience
at Haslar frequently showed that consultation between
the two parties led to more satisfactory results than
were attained when the only line of communication
was the written laboratory report.
It is by no means easy to cure, even superficially,
all cases of infection with E. histolytica ; still less is
it easy to ensure against the occurrence of relapses.
Moreover, the value of protozoological reports from
the laboratory on the same case at difl'erent periods is
not a constant quantity — a fact which medical officers
who are not protozoologists cannot be expected to
realize. At the same time, the laboratory findings are
the only means available for deciding whetlier treat-
ment is effecting a real cure or not. A " clinical "
cure may not be very difficult of attainment in some
cases, and might be effected without any help from the
laboratory.
But the estabhshment of an absolute cure, con-
sisting in the complete eradication, not only of
symptoms, but of the causative organism, depends
upon a proper understanding between protozoologist
and medical officer.
Nov. 1,1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 20, Vol. XXIII.
Original Commuufitjtron's,
ON THE PRESERVATION OP THE ANTT
SCORBUTIC PROPERTIES Ot^ CABBAGE
BY DRYING.
By Professor Axel Holst and Theodob Frolich, M.D.
From the Ili/gienic Institute of tJie University of Christiania,
Norway.
We have published previously [1] , a series of results
concerning the experimental scurvy of guinea-pigs,
showing that the causation and prevention of this
disease coincides, in all the main features, with the
practical experiences concerning human scurvy.
Dr. V. Fiirst [2] has also published records of his
research work along with one of our last papers on
this subject. He has shown, at the Hygienic Insti-
tute of the University of Christiania, that ordinary
dry peas and grain, which do not prevent the experi-
mental disease, acquire pronounced antiscorbutic
properties when moistened and allowed to germinate.
This process converts them into " fresh vegetables."
The experiments of Dr. Fiirst have been repeated
by other scientists. A most interesting series of
researches have been carried out in the Lister Insti-
tute of Preventive Medicine in London, where Chick,
Hume, Skelton and Delf [3] have obtained correspond-
ing results. Also British soldiers during the war have
practised the germinating method with success [4] .
It is-a useful remedy against scurvy, when fresh vege-
tables are not obtainable. It may, however, in
emergencies, be useful to be able to substitute
ordinary fresh vegetables treated in a different way.
We have tried, therefore, to retain the antiscorbutic
properties by a process of drying.
We have been experimenting, for these purposes,
with ordinary cabbage. We have shown, in our
previous papers, that if cut in thin slices and dried
(for about a week) on the shelves of an incubator at
37° C, this vegetable loses its antiscorbutic properties
when kept in an open vessel. This result coincides
with that of other scientists [-5] , as well as with experi-
ences of human scurvy. But, unlike the loaves of
dandelion, the cabbage does not lose these properties
immediately on being dried. The i)roi)erties are lost
little by little during some months, and perceptibly
faster when the cabbage is kept at the laboratory
temperature, that is about 18 to 20° C, than when
kept at 37° C. in an incubator [6].
Endeavouring to explain the cause of this differ-
ence we found that the relative moisture of the air of
our laboratory rooms was about twice as much as that
of the incubator. We therefore came to the conclu-
sion that the loss of the antiscorbutic properties of
dried cabbage might be due, at least to some extent,
to the moisture of the surrounding air. Working
on this hypothesis, we made the following experi-
ments : We cut a large quantity of fresh cabbage
in thin slices, dried them for about a week at 37° C.,
and divided them in two portions. Each of these
portions was placed in an open exsiccator, and each
exsiccator in a separate incubator at precisely 37 C.
We then filled the bottom of one of the exsiccators
(but not of the other) with water, taking care to pre-
vent any of the cabbage being immersed. Accordingly,
•in one of the incubators, but not in the other, the
dried cabbage was continually exposed to an air
saturated with moisture. After four weeks we began
to feed some guinea-pigs, with the moist and others
with the dry cabbage in addition to oats. The result
was, that the moist cabbage had lost most of its
antiscorbutic properties, whilst the dry cabbage had
retained them [7].
Having repeated this experiment with the same
result, we imagined that the successive discrepancy in
antiscorbutic effect of dry cabbage, mentioned above,
may be due to some sort of hydrolysis of the anti-
scorbutic " vitamines," and that this loss may be
prevented if the cabbage (1) is dried so effectively as to
be deprived of all of its natural contents of water,
and (2) is kept in a closed vessel in order to protect it
against the moisture of the air.
In order to ascertain the correctness of this view we
placed cabbage, dried for a week as mentioned, above
concentrated sulphuric acid in a closed exsiccator at
37° C. After about twelve to fifteen months guinea-
pigs were fed on it, each animal receiving daily 3 grm.
dried cabbage in addition to oats and water ad lib.
The result was, that the antiscorbutic effect was pro-
nounced after about fifteen months, when the cabbage
was given without previous soaking in water and
boiling. On the other hand, when given after about
twelve months, the loss of preventive properties was
very distinct, when the cabbage was soaked, before
feeding, in water for twelve hours and thereupon
boiled for a half hour in i per cent, saline water [8] .
As dried vegetables before being eaten have to be
soaked in water and boiled, this experiment was not
satisfactory from a practical point of view. Assuming
that phosphorus pentoxide is a stronger drying remedy,
we made the following experiment. Having dried a
considerable quantity of cabbage for a week as men-
tioned above, and having mixed it thoroughly, we
divided it into four portions, wjiich were treated in
the following ways :
(1) One portion was placed into closed exsiccators
at 37 ' C. On the top of the cabbage of each exsic-
cator was placed a saucer with phosphorus pentoxide,
the latter being renewed as soon as it was liquified ;
this ceased to be the case after a couple of weeks.
Thereupon the cabbage was put into bottles, the air
exhausted from the bottles and hermetically sealed by
means of a blower. Before the evacuation wo put
into each of most of the bottles, but not into all of
them, a glass tube with phosphorus pentoxide.
Having kept both sorts of bottles for eighteen
months at 37" C, we began to feed guinea-pigs, each
animal receiving daily 3 grm. dried (equal to about
30 grn). fresh) cabbage, in addition to oats and water
ad lib. Before feeding the vegetable was soaked for
twelve hours in ordinary water and thereafter boiled
for a half hour in i per cent, saline water. The
result was that it showed very pronounced anti-
scorbutic properties (Tables 6 and 8). The same
applies, after twenty-six months, to the cabbage in
bottles with phosphorus pentoxide (Table 7 : for this
experiment, however, nothing was left of the contents
of the bottles without pentoxide).
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Nov. 1, 1920.
Tables showing Results op Experiments.
Table 1 (6 animalsl.— Oats and water
Table 2 (5 animals). — Oats, water,
and 30 grm. fresh cabbage per day
an animal, boiled for one hour in
J per cent, saline water
Table 3 (3 animals).— Oats, water,
and 30 grm. fresh carrots per day
an anim;il, boiled for half an hour
in J per cent, saline water
Table 4 (3 animals).— Oats, water
and 30 grm. fresh cauliflower per
day an animal, boiled for half an
hour in J per cent, saline water
Table 5 (4 animals).— Oats, water
and cabbage, <iried for a week at
37"C. in an incubator, soaked in
water for 12 hours, and boiled for
halt an hour in ^ per cent, saline
water. Each animal received daily
3 grm. dried = about 30 fresh
cabbages
Table 6 (3 animals). — Oats, water
and cabbage, dried as in Table 5,
and afterwards in exsiccators with
phosphorus pentoxide at SVC.
The cabbage was then kept at .37^
for 18 months in evacuated bottles
with phosphorus pentoxide, and
fed as in Table 5
Table 7 (4 animals). — As in Table 6.
but the cabbage had been kept for
26 months
le 8 (3 animals).— As in Table 7,
ut the cabbage had been kept for
3 months in evacuated bottles
ithout phosphorus pentoxide
Tablb 9 (3 animals). — Oats, water
and cabbage, dried for a week in an
incubator, and then kept for 18
months at 37" in not-evacuated,
closed vessels with calcium chloride
Table 10 (3 animals).— As in Table 9,
but the cabbage bad been kept for
18 months in an ice-cupboard at a
temperature between + 4-10 at
12''C
Table 11 (4 animals).— As in Table 10,
but the cabbage had been kept for
26 months at -f 4°C. in the cave of a,
Deatli after the
beginning of the '
24 to 30 days
71 and 91 days
(4 animals, all
killed)
30, 4;
dayo
96 days
killed)
27 (pleuro-peri-
card, fibrin.),
71 (.synechia
pericard.) and
112 days
(killed)
85, 112 and 160
days; the
latter animal
was killed
90, 101 and 107
days
58, 70 and 72
days
42, 64, :
79 days
weight at the end of
Ihe experiment
- 37, 38, 39
and 57 per
cent.
- .8 per cent.,
- 2-5 per
cent. (71
days), 0 and
-f 7 per cent.
- 20, 4C and
46 per cent.
- 7 per cent.,
0, + 1-5 per
cent,, and +
11 per cent.
- 33 per cent.
(71 days), +
15 per cent (27
days), and +
50 per cent.
(112 days)
- 24 (112 days),
- 14 (85 days),
and + 26 per
cent. (160
days)
- 12, 5 (101
days), - 16
and - 20 per
cent. (107
days)
- 18, — 32 and
— 3i per cent.
- 9, 21 (58
days) and 43
per cent. (72
days)
- 10, 14, 23 and
24 per cent.
h;rmorrhagi'l
(ribs anrt knee
No alterations
except in one
animal (71
days) where
pronounced
No alterations
No alterations
No alterations
No alterations
13, 4 of 11, 12 of 17, 16 of 17, and 11
of 19 examined ribs ; these were not
examined in the 6th animal, which,
however, had 2 scorbutic tibiae and 1
scorbutic femur. (Of the 5 other
animals 4 had corresponding alter-
ations of both tibije, and 3 of both
femora)
10 of 20 (71 days), 1 of 21, 3 of 21, and 2
of 22 examined ribs ; the second animal,
but not the others, had also one scor-
butic tibia. The 5th animal had no
alterations (19 ribs, 2 tibise, and 2
femora examined)
2 animals, no alterations (12 resp., 15
ribs, 2 tibiae and 2 femora examined).
In the 3rd animal (97 days) 3 of 15
ribs, 1 tibia and 1 femur were scorbutic
10 of 16, 3 of 16, and 10 of 15 examined
ribs ; in the 1st and 3rd au'imal also, 1
tibia
2 animals : no alterations (17 resp., 2.3
ribs, 2 tibiae and 2 femora examined).
In the 3rd animal 4 of 17 ribs (but none
of 2 tibiae and femora), in the 4th 3 of
23 ribs and one femur (but no -tibia)
were scorbutic
No alterations (12 resp., 13 and 15
2 tibiae and 2 femora examined)
No alterations (11 resp., 13 and 16 ribs,
2 tibiae and 2 femora examined)
No alterations (17, resp. 22 and 22 ribs,
2 tibiae and 2 femora examined)
3 of 21, 4 of 22, and 5 of 13 ribs were
scorbutic. In all animals also both
tibiae (but not the examined femora]
(2 animals) were affected
No alterations No alterations (13, resp. 19 and 20 i
except in one 2 tibiae and 2 femora examined)
animal (58
days), where j
rhagic rib
Pronounced al-
terations ex-
cept in the
animal living
for 42 days
2 of 20, 4 of 21, 6 of 15, and 15 Of 21 rib
as well as most of the examined tibia
and femora were scorbutic
Nov. 1, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(2) A second portion, having been dried for a week
in the incubator, but not treated with phosphorus
pentoxide, was put into cyhndrical corked glass vessels,
which were not evacuated, but at the bottom of
which was placed a thick layer of calcium chloride.
Having kept this portion for eighteen months at 37° C.
in the same incubator as the cabbage mentioned under
(1), we began to feed animals in exactly the same way
as in the earlier experiment. This portion scarcely
exercised any anti-scorbutic influence (Table 9).
(3) A third portion was treated like the others, but
the vessels were placed in an ice cupboard, where the
temperature, according to the season, varied between
4° and 10'^ or 12° C. This cabbage, after eighteen
months, exercised marked antiscorbutic influence, but
not so great as the portion treated with phosphorus
pentoxide and kept at 37° C. (Table 10).
(4) The fourth portion was kept in corked cylindrical
glass vessels, without any dr>Tng remedies, at about
+ 4" C. in the cellar of a brewery. When soaked in
water, &c., as in the other experiments, it exercised,
after twenty-six months, a moderate antiscorbutic
influence, being less than that of the third portion,
but markedly better than that of the second
(Table 11).
As we have had nobody to assist us, we regret not
to have been able to apply the methods for measuring
the antiscorbutic value worked out at the Lister
Institute of London. Considering, however, the
details of the accompanying tables, it is evident that
cabbage, dried by means of phosphorus pentoxide, can
be kept at tropical temperatures, and yet, after eighteen
to twenty-six months and a soaking for twelve hours
in ordinary water and a boiling for half an hour in
i per cent, saline water, be possessed of very pro-
nounced antiscorbutic properties. As shown in the
tables, these properties are even much greater than
those of fresh carrots and fresh cauliflower boiled for
the same time. (Tables 3 and 4.)
We have not made any experiments with oats,
water and fresh cabbage boiled for half an hour in
i per cent, saline water ; as for these nutriments, we
must limit ourselves to give, in Table 2, the results of
a previous experiment with boiling for one hour in
such water. On the other hand, we have previously
daily fed guinea-pigs on white bread, water and
30 grm. fresli cabbage per animal, boiled for half an
hour in i per cent, saline water [9], the results being
not markedly better than those obtained by drying by
means of phosphorus pentoxide.
It may be added that the " sharp " drying by the
pentoxide deprives the cabbage of some of its genuine
taste. But it keeps nmch of it, and the many
colleagues who have used it in their households have
unanimously agreed with us, that it is a good and
palatable nutriment, especially as " sour cabbage "
(boiled with a little butter, vinegar and carvey seed)
and as Irish stew. In these disheS; which are very
common in Norway, the carvey seeds and pepper
(Irish stew) hide the fact that the cabbage has lost
some of its taste.
These results have therefore given us tiie hope to
be able to preserve not only cabbage, but perhaps
also other vegetables, in such quantities as will be
necessary for provisions on board ships. This ought
to be a considerable benefit to Norwegian sailors It
is true that they now very seldom suffer from manifest
scurvy. But on the one hand they not seldom, on
board sailing ships, pass two to three months without
getting fresh provisions.- And, on the other hand, the
bones of guinea-pigs already show the specific alterations
after a feeding on oats and water for ten days [10] .
that is a good time before the microscopic symptoms
of the disease. Under these circumstances it is very
probable that the lack of fresh provisions is, at least,
able to produce weakness, which might be prevented
by vegetables preserved without loss of much of their
antiscorbutic properties. Supposing that they also
keep much of their original taste and therefore are
eaten with a similar appetite as when they are fresh,
these vegetables might also be useful with respect to
the prevention of ship beri-beri. The reason is that
the polyneuritis gallinarum has been proved to be
prevented by dried cabbage and other vegetables [11] .
However, the phosphorus pentoxide method is too
expensive and takes too much time for manufacturing
purposes. We have, therefore, tried to obtain a
corresponding result by depriving cabbage of its
moisture by drying it for one to two days by means
of an electric fan and thereupon for the same time by
means of an air-pump. This process has, however,
till now given unsatisfactory results. As regards the
second to the fourth of the experiments mentioned
above, their results wiU appsar from the following :■ —
Summary.
(1) Thin slices of cabbage which are dried for one
week in an incubator at 37 C, and thereupon at the
same temperature by means of phosphorus pentoxide,
show very pronounced antiscorbutic properties when
kept at 37°C. for eighteen to twenty-six months in
vacuum bottles.
(2) The same cabbage loses almost all of these
properties when not treated with phosphorus pentoxide
but kept for eighteen months at 37°C. in closed vessels
with calcium chloride.
(3) If treated as under (2) the cabbage keeps its
properties much better at + 4° to -f 10° to 12° C.
(4) The results are better than mentioned under
(2), but not so good as under (3), when the cabbage
is kept at + 4" in closed vessels without any drying
remedies.
REFEHKNCES.
[1] Epidemiol. Soc. of Lomlon, 1907 ; Joum. of hygiene, 1907 ;
JouBN. OP Tbop. Mbd. and Hyq., 1911; Zeitschr. f. Hygiene,
Ixxii and Ixxv ; IiUemat. Congr. of Hygiene, Waahingtoo, 1912.
[2] Zeitschr. f. Hyg., Ixxii.
[3| Chick and Hume, 2rans. Soc. Trop. Med. and Hyg., x,
1917 ; Chick, Hume and Skelton, Biochem. Jouni., xii ; Chick
and'Delf, Biochem. Joum., xiii.
[4] Chick and Delf, Biochem. Journ., xiii.
1 5] Delf and Skelton, Biochem. Journ., xii.
[Gj Holsitand Krolich, Zeitschr. f. Hyg., Ixxii.
[7] Ibid., Ixxii.
[8] Jbid., Ixxv.
[9] Ibid , Ixxii.
[10] I6i<i., Ixxii.
[11] Axel Hoist, CcntraWlatt f. Bakteriologie, 1918; Shortc
and Charubiiila, Itoy. Special Indian Science Congress, 1919,
Indian Journal of Medical liescarch.
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1920.
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THE JOUENAL OF
Croptcal ^tDtctne and l^pgiene
November 1, 1920.
AN X-RAY MOTOR-AMBULANCE WAGON
FOR USE AT HOME AND IN TROPICAL
COUNTRIES.
The X-ray wagons were found of considerable
value in various seats of war. It is now a (]uestion
whether they cannot also be used in peace upon
a more extended sc;de and with even increased
benefit to patient and doctor. In Britain there is
a prospect of their value being widely tested, and
the development is being watched with interest.
The writer has been privileged to initiate the test
in London and its neighbourhood. The idea of
utilizing the X-ray motor-ambulance originated in
a conversation between Major Robert Mitchell,
('.B.E., of the Polytechnic, Regent Street, London;
])r. Robert Knox, the well-known X-ray authority,
of 38, Harley Street, London ; and the writer
of this note. The furtherance of the idea was
I'endeied possible by the acquisition of an X-ray
HKjtor -ambulance which was built by the British
Red Cross Society for use in Italy, and now, being
no longer required for war purposes, was available
for civil work wherever required. Through the
intluenee of Major Mitchell an introduction was
obt;une<l to the authorities of the Eccentric Club,
Ryder Street, Piccadilly, London, and the writer
was placed in touch with Mr. Montague Bates and
Mr. Gerald Cripps of that Society. The work of
the Eccentric Club during the war is well known ;
the hostel system in London for the sick and
wounded soldiers was founded by the Society and
is now a matter of history which will live as a model
of practical philanthropy, economically but wisely
and liberally conducted, and as a humanitarian work
of supreme value.
To the members of a Club imbued with such
ftrliii^'s and instincts an appeal for help for such
a scliciiii. as tliat put before them by Major Mitchell
and his colleagues found ready listeners and willing
helpers. Their help was put into practical shape
by a contribution in money sufficient to purchase
the wagon; luid the British Red Cross Society, at
the instigation of Sir Arthur Stanley, K.C.M.G.,
the Chairman of the Executive Committee of the
Sciciety, prt'sented th^ X-ray equipment. The
Eccentric Club presented the wagon to the College
(jf Ambulance, ,")6, Queen Anne Street, London, W.,
on tli( ciaidition that it should be used whenevei
re(|uiri'(l in Loudon or provinces.
\i; mean ;;itt estimated in monetary value alone
for these wai!ons have to be specially made for th(
work ro(|uirc(l of them, and the equipment is costly
seeini; that delicate wad fragile apparatus has t(
be so made and protected as to be capable of beinf
transuiitti'd f. i- long distances and over rough roadfi
it uia\ be, sii as to reach their destination. Wha|i
is their destination".' In other words, to what U8i.
are wagdus (if this kind to be put in times -o
pra 'o .' Fbc story of their purpose may perhap
be best told as follows: —
^^■|uu the writer was introduced by Mr. Crippj
to Mr !\lontai,'iie Bates at the Eccentric Club, h"
proceeded to give a short account of the purpose!-
to which he pro])osed to put these wagons. The
are none other than that, instead of bringing th
injured or sick man to the X-ray apparatus, th
ai)paratus would be brought to him. In place cj
the injured man being taken from his bed, placet
on a stretcher, and conveyed by cab, motor-caj|
ambulance wagon or train, to where the X-ra|
])icture can be taken, say, in liospital or the privaf
rooms of the X-ray expert, and after the pictm
Nov. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Si65
is taken he has to travel back home again, the
X-ray expert jiikI his wagon shall proceed to the
house and even the room of the patient and the
picture tiiken tlicre without the discomfort and pain
involved in tlu> uioveuient, however carefully done.
The wagon stands outside the liouse, the X-ray
apparatus is carried into the house or bedroom, a
cable (or lead) from the wagon to the house is taJieu
by the door or through the bedroom window to
the apparatus within. It resendjles and reminds
one of the vacuum cleaner brought to one's door
with " the lea<ls " passing by way of a window to
the dust-removing machine within.
Mr. Montague Bates listened attentively to the
story, and when it was told, he said : " I broke my
leg in Cornwall. I was taken to London and occu-
pied a room near the top of a house in Portland
Place. I was taken from there upon a stretcher,
carried down the narrow stairs from the top of
the house and conveyed in a car to the house of the
X-ray expert, lifted upon the table, and after the
picture was taken had to travel back to my quarters
in Portland Place. I shall never forget the agony
I suffered by that journej', and in my hope that
no one else shall ever be exposed to such torture,
I promise you all the support I can give to this
humanitarian movement, and although I cannot
pledge you that tlie connnittee and members of
the Eccentric will do so, I am of opinion from what
I know of them that they will do likewise."
The result of this conversation is known to-day,
for the Club has presented an X-ray wagon for
public use, and it has already been used for that
purpose by the College of Ambulance authorities.
Major Mitchell took the matter in hiuid, and by
his personal exertions the procedure of transference
was brought about.
After settling the X-ray motor-ambulance in its
quarters a trial expedition was made to test its
mobility and to get the bearers used to handling
the contents. The occasion was an ambulance
demonstration the writer was giving at Mr. Howard
Carter's residence, Anleley, Stevenage, Herts, 35
miles from London. A doctor from Hitchin, Herts,
some 40 miles from London, saw the aimouncement
in circulars issuc-d in that part of Hirtfordshire
about tlu> ambulance demonstration and brought a
patient with an injured leg to be examined.
Although the a])i)arMtus was only taken for demon-
stration and ])raetiec, yet we were ;ihle there and
then to " sere<>n " tlic'le^r sucecsslnliv.
Dr. (Jiibertson's letter given l)el„w best testifies
to the appreciation with which the i.lea of an
X-ray apparatus on wlieels ca.pable of biing tal<en
to any part of the countiy is regarded. Herewith
T)v. Gilbertson's letter eoneerning the matter: —
" Bancroft,
" Hiehin, Herts.
" Orlnhrr 12, 1920,
D|;AU Sill .J-AMKS rANTi.ii:.
I saw from an aimounceiiient circulated in
this part of Hertf(jrdshire that at the Ambulance
Demonstration by the College of Ambulance,
Loudon, you were giving at Ardeley Bury on
October 9, 1920, you were bringing an X-ray mobile
ambulance with you. I had a case in the heart
of the country which required 'screening ' or a
photograph taken, and so availed myself of the
opportunity and brought my patient over, who hail
injured his leg.
" I was proud to learn that I was the first to
make use of tliis X-ray apparatus. The leg was
successfully 'screened,' the injury showing quite
l)lainly. I understand the scheme provides for an
X-vay motor-ambulance to visit cases within 50
miles radius of I^ondon to be paid for when pos-
sible, and given free in cases which cannot afford
to pay. As a country practitioner I feel a great
responsibility will have been removed if such a
splendid scheme can materialize, as in cases of bad
fractures and other ailments, especially among the
poorer classes, it is absolutely impossible to get the
best results without an X-ray photograph.
I feel sure the idea will find whole-hearted sup-
port in the rural districts, both from the medical
profession and the public. May I congratulate the
Eccentric Club on their foresight and generosity in
providing such an up-to-date mobile X-ray wagon?
" Yours sincerely,
(Signed) " H. Marshall Gilbertson,
" M.R.C.S., L.R. C.P.London."
In an accompanying note Dr. Gilbertson states
that the town of- Hitchin, with a population of
14,000 people, has not an X-ray apparatus within
its boundaries, and patients have to be sent 40 miles
to London to have an X-ray picture done. If this
is the case in some towns within 50 miles radius
of London, how much more is a portable X-ray
apparatus likely to be required in the country vil-
lages or fannhouses where an accident has occurred
and movement would be dangerous or painful '.'
The X-ray motor would be sent to the village or
farm with an expert in X-ray work — a medical
expert if possible — free of charge or at a modified
charge when folks are poor, but those who are
well-off pay for the privilege.
Any X-ray specialist) — a medical man, of course —
can obtain the use of the wagon and himself go
to his better-off patients in the country and receive
his fees as he would in towns, or will be able to
charge at the rate of consultfuat medical fees when
the iiatieiit is at a distance; in this way no practice
is lost to the specialist and the motor X-ray expert
will thus not be lobbed of his just duties.
In hos])itals where an X-ray apparatus is to hand
it will net be necessary to obtain the wagon, but
in |)rivate liouses in London and in the country
where it is dangerous to move the patient, as in
fractures of the spine, Ac, the College of .Ambu-
lance wagon is available at all times.
If in England this proceeding is necessary, how
much more in parts of our Empire where the dis-
tances are great, where means of conveyance are
limited and few and far between, the practical use
of a wagon of this sort is at once apparent. Where
roads are rough it will not hinder the wagon
266
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1920.
getting along, nor will the apparatus be thereby
injured. It is so carefully made that it can stand
bumps and jolts with impunity, and the wagon at
the College of Ambulance was intended for th(^
rough hill ro;uls in northern Italy, so it will stand
almost any rugged road. Where no road exists, as
in the interior of China and West Africa, the wagon
with its contents could be conveyed by boat, or
the apparatus could be removed from the wagon and
conveyed by boat and hence by bearers to places
beyond the river banks.
Several doctors from towns outside London have
seen the writer about the scheme here unfolded, and
they iiru already endeavouring to get X-ray motor-
anilmlaiiccs to serve districts in Scotland and Eng-
land tnr a radius of 50 miles or more around centres
where wagons of the kind may he housed. In this
way a network of areas could hv spread covering
all parts of the country which could be served with
the X-ray motor-ambulance to the benefit of the
medical profession and the lessening of pain and
suffering to the people.
James Cantlie.
Annotations.
Some Notes on Animal Diseases in Panama, with
Special Reference to Blood and Muscle Parasites
(Herbert C. Clark, M.D., Proceedings of the Medical
Association of the Isthmian Canal Zone, vol. x, Part 2,
July 1917 to December 1917.)— The first protozoal
disease to be noted in Panama was murrina, a fatal
trypanosomal disease of mules and horses, discovered
by Darling in 1909. Anthrax was next noted in cattle
and hogs. A further outbreak of disease among im-
ported animals was investigated and was thought to be
identical with bovine piroplasmosis or Texas cattle
fever, but the parasite was not isolated.
The importation of large numbers of beef cattle (and
other animals) by the Bureau of Animal Industry was
followed by the real epidemic of anthrax disease on
the Canal zone. The disease was soon controlled but
continues to require close attention. Following this
outbreak a great deal of illness was noticed among the
imported cattle on Miraflores pasture, chiefly among
calves of 6 to 10 months. An investigation was
undertaken. The sick animals gave every evidence of
suffering from piroplasmosis but the parasite could not
be identified in the blood films. Two of the sick calves
were then killed and examined while the cadavers were
in a perfectly fresh condition — this had not previously
been the case. A severe anaemia and some type of an
acute infection were noted ; and on the brain capillaries
being examined Babesia bujemina was found to be
present in large numbers. On the native cattle being
examined it was found that practically all of these were
carriers of the parasite, it being found with ease in the
brain films, and in a few cases in the spleen and marrow.
The dependence on blood films in tlie former investi-
gations had caused the diagnosis to be missed as these
were too scantily infected to reveal the presence of the
parasite.
Relapsing Fever — Its Occurrence in Panama (Roland
O'Connor. M.D., Proceedinijs of the Medical Associ-
ation of the Isthmian Canal Zone, July, 1917 to
to December, 1917, vol. ix, Part 2). — The relapsing
fever seen in Panama is of a mild type with one to
three relapses and no fatality. The infection is
frequently mistaken at first for malaria. A blood
examination will reveal the spirochaete, which is the
true cause of the infection, Spirochete recurrentis
Obermeier 1873. Relapsing fever combined with
malaria is frequently found, however; and it also
very frequently exists with typhus, as was seen in
the epidemic in Serbia in 1915. This gives additional
support to the generally accepted theory that relapsing
fever is a louse-carried disease, although it is possible
that there is more than one carrier. As regards
treatment, salvarsan and its substitutes are apparently
specific for this affection.
Gastric Polyposis {Papillomatosis) (Ernest du Bray,
Archives of Internal Medicine,, vol. xxvi, August
15, 1920). — The author reports a case of gastric
polyposis of the papillomatous type in which the
clinical and Roentgen-ray diagnosis had been carcinoma
of the stomach. Exploratory laparotomy revealed a
broad based benign tumour situated in the greatei
curvature of the stomach. This tumour was exciset
and, following this, the patient bad an uneventful
convalesence, and six months later had had nc
recurrence of his former symptoms.
Tick Fever in East Persia. R. D. Wright anc
C. H. H. Harold {Journ. Royal Army Medical Corps
September, 1920) investigated an outbreak of tie!
fever occurring in a company of Indian Pioneer
stationed at Sharijabad, north of Turbat, in Eas'
Persia. The patients had been bitten whilst living i:
a serai, the healing scars of the bites being found o'
the ankles, wrists or neck. Several ticks of th
species Argas persicus and Ornithodorus lahorensi
were found in the bedding, and one of th
ornithodorus ticks was seen to be gorged wit
•blood. The total number of cases admitted int
hospital was twenty-two, and spirochetes wer
eventually found in four cases. All the cases showe
generally the same symptoms, namely, intermittei
fever, with severe headache, frequently frontal, pair
in the loins and down the backs of the limbs, (
generalized pains all over the body. The majorit
had palpable spleens, and a lew had a superadde
bronchitic condition. The cases, however, show«
great variability in their symptomatology, and wei'
relatively resistc.nt to salvarsan. In consequence s-
efficient and prompt treatment no case suffering fro.
this disease died or was invalided from East Persi,
but it would appear that casualties did occur amoil;
foreign civilians prior to the authors introduction I
arsenical compounds. \
Although tick fever in East Persia does not cauj
loss of life, it causes those suffering from it to remsi
in hospital for periods varying from twenty-three i
Nov. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
seventy- seven days, and thus entails a considerable
loss to the State, both in efficiency and money.
by a properly balanced diet which includes lean meat,
eggs, milk, butter, a,nd vegetables.
Emergency Measure and Foresight in Malaria
Cojitrol (L. D. Fricks, The Military Surgeon, Aug.,
1920.) — In addition to the ordinary measures for the
prevention of malaria in mosquito-infected regions
such as mosquito nets, drainage, oiling, screening,
quinine prophylaxis, &c., Fricks recommends the
method of hand-catching and destroying engorged
anopheles which has proved to be effective and is
worthy of careful consideration when confronted with
an unusual emergency in malaria control round a
recently established camp.
Delousing the American Army in France (H. L. Gil-
christ, The Military Surgeon, August, 1920).—
Although the work connected with the bathing and
delousing of the troops of the American Expeditionary
Force was done under the direction of the Quarter-
master Corps it was actually carried out by the pfersonnel
of the Medical Department, under whom it should be
placed.
In combating lousiness the first step is to teach the
individual what lice are and to impress upon him the
harm they can do. He sliould also be taught simple
means by which they can be eliminated. The serious-
ness of lousiness should be realized by all officers in
command of troops, and unremittant attention given
by them in the examination of all members of their
command, for without their personal supervision the
work will not be accomplished. Along these lines the
following should be closely followed : (a) the detention
of men who are infested with lice ; (b) the immediate
disinfestation of all clothing and bedding belonging to
the infested man; (c) the cleanliness of the man himself,
bathing; {d) the cleanliness of his billet.
By allowing the men a share of the responsibility
many ingenious contrivances were made by tlie
soldiers, without which the delousing and bathing
could not have been so successfully accomplished.
T!i2}es and Treatment of Pellagra (Stewart R
Roberts, S.M., M.D., Journal of the American Med-
ical Association, vol. Ixxv, No. 1, July 3, 1920). —
I The author comments on the widesi)read distribution
I of pellegra in the United States, where it occurs in
I practically every State, and has caused probably
' 500,000 cases and 50,000 deaths in the last 20 years.
j The cases are now on the decrease. He emphasizes
I the fact that i)ellagra is difficult of diagnosis wiiere
the cases do not present the typical eruption and urges
medical practitionei's to be continually on the look-out
for it.
As regards etiology. Dr. Roberts considers vvo have
got altogether beyond the theory of an unknown
infectious agent, and the other theory that the cause
is to he found in one food : corn ; and aihrms tliat
Dr. Goldberger's researches and experiments, which
,. j are here recapitulated together with twenty-five other
-j ( cases given in detail, have proved that the disease can
I lie caused l)y an improperly balanced diet and cured
The Influence of Vitamines in the Course of
Pellagra. (Voegtlin, Neill and Hunter, Hyg. Lab.
Bull., Washington, January, 1920.) The author has
treated a number of cases of pellagra with extracts
made from fresh ox liver, from yeast and from rice
poljshingg. The dosage was based on the effects these
preparations had in relieving the symptoms of
polyneuritis in fowls. The cases treated with liver
extract showed a rapid improvement, while no
improvement whatever was obtained in those treated
with yeast and rice polishings.
A Trypanosome associated with a Fatal Disease in
the Carabao (Philippine Joxirnal of Science, January,
1920). — F. G. Hough wont and S. Youngberg record a
fatal case of trypanosomiasis in a male carabao which
was inoculated simultaneously with virulent rinder-
pest blood and anti-rinderpest serum. They believe
the organism to be a new species. It is one of the
large trypanosomes, and bears most resemblance
amongst the described trypanosomes to the " trans-
valiense " type of Trypanosoma theileri, which has
not hitherto been recorded as occurring in the
Philippine Islands.
Remote Manifestations of Focal Dental Infections
with Case Reports {Philippine Journal of Science,
January. 1920). — R. Fernandez points out that
Sinclair Tonsey, in his preface to his monograph on
" Roentgenographic Diagnosis of Dental Infection in
Systemic Disease," mentions the observation on the
wife of an eminent jurist who died as the result of an
infection localized in the socket of a tooth, this focal
infection being diagnosed rather late by means of
X-ray. Fernandez quotes with approval the following
passage from Tonsey : " The widest publicity should
be given to the fact that greatly varying or sometimes
serious or fatal systemic diseases and those affecting
remote organs are often due to infection connected
with the teeth or with the pneumatic sinuses of the
face. The infected foci are discoverable by the
X-rays. Some of these cases are cured by treatment
of the oral lesion, and some require also autogenous
vaccination with a bacterial culture from the pus in
the oral lesion."
Fernandez's paper is, in fact, a commentary on
this passage with illustrative cases.
A Case of Human Synophthalmia [Philippine
Journal of Sciericc, January, 1920). — S. de los
Angeles and A. Villegas record and figure a male
synopthalmia bilentica which was born of normal
parents, who had had five previous children all
normal. They consider it has no duplicate in
literature differing from other recorded cases of
Cyclops with respect to the following characters :
The apparent absence of the external nares (there
being no proboscis to substitute them) ; the. peculiar
shape, size and position of the mouth ; the location
of tlie ears, and the shape of the face.
268
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1920.
A Note on the Treatment of Surra in Camels by
Intravenous Injections of Tartdr Emetic (H. E.
Cross, Agricultural Research Institute, Pusa Bulletin,
No. 95, 1920). — The author tried the treatment on six
camels in 1917. The camels were kept under obser-
vation from August 27th, 1917, to July 22nd, 1919.
The treatment caused the trypanosomes to disappear
from the blood. A 1 per cent, solution of the drug was
used, the doses given varying from 60 c.c. to 600 c.c.
Number of injections varied from three to ten.
The author considers that tartar emetic gives
promising results in the treatment of surra, but is of
the opinion that it should be tried on a large scale
before being definitely considered a cure.
Cttrrcnt f itwraturf.
The Indian Medical Gazette, Vol. LV, No. 8,
August, 1920.
A Case of Melancholic Stupor (Psychocoma) (O. St.
John Moses). — The patient, a Hindu male of 42,
after an attack of melancholia in 1917, passed (in
August, 1917) into a state of utter stupor, in which
he remained for two and three-quarter years. During
the whole of this time he lay on the flat of his back
with his limbs flexed and quite rigid. All the muscles
were of such an extraordinary stiffness that if he
were lifted up by the occiput the entire head, neck,
and body could be raised as if he were a block of
wood. The eyes were wide open and fixed in a
vacant stare, and he appeared quite unconscious of
his surroundings. He was carefully watched during
the whole period, and was fed by means of a nasal
tube. His recovery was as sudden as his illness ; he
awoke on the morning of April 9, 1920, as if from a
long sleep, and from that time he steadily progressed
towards complete recovery.
A Note on Vaccine Therapy in Typhoid and Para-
typhoid Fever (C. J. Fox). — The author strongly
advocates the use of typhoid vaccine as a curatiye
treatment, having tried it in twelve cases with good
results as regards eleven of these. He urges that
the treatment should be tried on a large scale in a
military or civil hospital, and considers that the
question of carriers can be efi'ectively dealt with by
this means.
Note on a Case of Hydrophobia (S. Amritaraj). —
The author gives an account of a fatal case of hydro-
phobia in a 10-year old boy which was only brought
to his notice after violent symptoms had set in. He
suggests that more Pasteur Institutes are needed, as
natives will not make the long journey to obtain
treatment. He also urges that there should be more
stringent supervision regarding dogs.
Sodium Morrhuate and Sodium Hydnocarpate in
Leprosy (P. Ganguli). — The use of sodium morrhuate
and sodium hydnocarpate in five cases of leprosy of
different types, by the author, has given most en-
couraging results. Both drugs were used and "both
appear to have a remarkable action on the maculo-
anaesthetic type of leprosy. In two cases sodium
hydnocarpate had to be substituted for sodium
morrhuate, as the latter drug caused severe reactions.
Mixed treatment with both drugs gave good results.
It was noted that when sodium morrhuate failed to
quickly reduce the nodules, sodium hydnocarpate
succeeded. Sodium morrhuate appeared to be the
more powerful drug in combating nervous lesions.
As regards the dose, i c.c. of the 3 per cent, solution
was given, gradually increasing by i to I c.c. weekly
till the maximum of 5 c.c. was given in each dose.
This dose was repeated weekly till a cure was effected.
All the cases improved in every respect, and three
were discharged as cured by a medical board.
Bacteriological Investigation of Normal and Diseased
Eyes (Charu Chandra Sinha). — The author gives the
results of the bacteriological examination of 100
native patients. In each case a smear was taken on
a slide and a culture made on an agar slope. Some-
times a culture gives a negative result, while a film
made from the same source shows some organisms.
The microscopical examination of a stained film is
generally sufficient for the clinical diagnosis of cases.
Loftier methylene blue will be found a suitable stain
for most cases. Staphylococcus albus was the chief
organism found in cataract cases. Pneumococci and
streptococci were also found in two cases. Con-
junctivitis and ophthalmia cases showed gonococci,
influenza bacilli, pneumococci, staphylococci and thick
diplobacilli. Trachoma staphylococci and streptococci.
Bleijharitis staphylococci only. Lachrymal obstruction
and abscess, staphylococci and pneumococci. Corneal
ulcers showed chiefly staphylococci in mild cases,
while those of a severe type are complicated with f
other organisms such as pneumococci and streptococci. I
Staphylococci were also found in normal healthy eyes. I
Observations on the Treatment of Hoohvorm Disease I
(Babu Hira Lai.) — While investigating and treating a I
large number of cases of hookworm disease at Bhowra ■
Colliery under the supervision of the Jharia Mines
Board of Health with thymol (given in two doses,
each containing 30 gr. of thymol with an equal
quantity of sugar of milk, the interval between the
doses being two hours), the author noted that eight
of his cases that had previously suffered from night
blindness were completely cured of this defect two or
three days after the first administration of thymol.
The author thinks there may possibly be some asso-
ciation between hookworm disease and night blind-
ness, and that the latter complaint, which in some
parts of India is extremely prevalent, may be found
to be curable by thymol.
Organo-therapeutic Treatment of Malaria (H. J.
Naronha). — Twelve bottles of a preparation called
bazogen, purporting to consist of the extract of spleen
pancreas, thyroid and adrenal, were supplied to the
author, who tried them on some cases of malignani
malaria and malarial cachexia. The author con
I
Nov. 1. 1920.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
siders that while the drug causes the temperature to
drop, it has no special action on the parasite.
Hazaribagh : A Pojmlar Health Resort (Ashutosh
Roy). — A very complete account of this station is
given with a view to hringing it to the knowledge of
medical men in India as a health resort for patients
needing a change of air.
ibstracts.
THE TREATMENT OF CHRONIC INDIGESTION
IN CHILDHOOD.'
By John Lovett Morse, A.M., M.D.
Chronic indigestion in childhood may be divided
into indigestion with intolerance for fat, indigestion
with intolerance for sugar, indigestion with intolerance
for starch, indigestion with intolerance for protein,
and indigestion with fermentation. The borderline
between simple indigestion with intolerance for one
or more of the individual food elements and indi-
gestion with fermentation is necessarily somewhat
indistinct, because there is always fermentation
going on normally in the intestinal contents. The
line between normal fermentation, fermentation
with simple indigestion, and indigestion with ex-
cessive fermentation must evidently be very
indefinite.
Symptoms.
All types of chronic indigestion in childhood have
certain general symptoms in common, such as loss of
weight and other manifestations of disturbed nutri-
tion. Among these are dryness of the skin and hair,
cold extremities, pallor, irritability, peevishness and
disturbed sleep. Other symptoms, which vary ac-
cording to the type of indigestion, are diarrhoea and
constipation and the alternation of diarrhoea and
constipation. The abdomen may be distended,
normal in size or sunken ; there may or may not be
vomiting ; fever of varying degrees may or may not
be present. None of tliese symptoms are however
definite enough of themselves to justify a positive
diagnosis as to the type of indigestion.
Diagnosis.
While something may be told from tlie con(htion
of the bowels, the odour of the breath, tlie condition
of the tongue, the presence or sense of gas, nausea
and vomiting, and the history in general, the diag-
nosis must be made mainly, however, on the results of
the examination of the stools, as the different types of
indigestion have characteristic stools. Tlie macro-
scopic examination of the stools is often sufficient to
justify a positive diagnosis as to the tyi)e of indi-
gestion present. It should never be depended on
alone, however, but sliould be verified by a micro-
scopic examination, because the microscopic examina-
tion will sometimes show that the conclusions drawn
' Abstracted from the Jouinal oj the Americnn Medical
Aiiociation, July 10, 1920.
from the macroscopic examination were not justifiecl.
The microscopic examination of the stools should,
therefore, always be njade. This is not a difficult
matter and requires but a few minutes.
A small portion of the stool is spread on a slide and
stained with either Lugol's or Gram's solution. Starch
granules stain blue or violet. Another portion is
spread on a slide and stained with a saturated alco-
holic solution of Sudan III. The neutral fat drops
and fatty acid crys,tals stain red. Soap crystals do
not stain with sudan III. A drop of glacial acetic
acid is then allowed to run under the cover glass.
The specimen is then heated until it simmers. This
changes the soap into fatty acids, which then stain.
If it is desired to determine whether the fat is in the
form of neutral fat or fatty acids, another specimen is
stained with carbolfuchsin. This does not stain
neutral fat, but stains fatty acids a brilliant red and
soaps a dull red.
The bacteriologic examination of the stools is not
usually necessary, but in certain cases is absolutely
essential, as a positive diagnosis is impossible
without it.
Thk Stools in Indigestion.
The stools vary decidedly in the different types of
indigestion.
Fat Indigestion. — The stools are usually large, semi-
solid, grey, acid in reaction, and often contain a con-
siderable amount of mucus. They are sometimes
dry, hard and grey or white. More often they are
loose, frothy, grey and extremely acid. The odour is
that of butyric acid, and they contain considerable
amounts of mucus. Sometimes the fat is in the form
of small, soft curds, or the stools appear oily, as in
babies. Microscopically, the fat is present in various
forms, rarely as neutral fat, more often as fatty acids
or soap.
Sugar Indigestion.— The stools ai-e loose, yellow,
sometimes green, frothy and acid in reaction. The
odour is that of acetic or lactic acid. The stools are
very irritating to the skin, and often contain mucus.
Microscopically, little abnormal is seen, except that
sometimes, as the result of the diarrhoea, they show
unabsorbed fat and undigested particles of food which
have been hurried through the intestine.
Slarcli Indigestion.— The stools are loose, yellow-
brown, sometimes green, often frothy, and acid in
reaction. The odour is acid', usually being that of
acetic or lactic acid, but sometimes, if there has been
a change in the starch to fat, that of butyric acid. If
very acid, the stools are irritating to the buttocks,
but usually are not. They occasionally contain
mucus, and almost invariably considerable amounts
of starch, either unchanged or partially converted
into dextrine.
Protein Indigestion.— The stools are loose, brownish
and alkaline in reaction. The odour is foul or musty.
They usually do not contain mucus.
Indigestion with Fermentation. — The characteristics
of the stools are the same as in other types of in-
digestion, with the addition of those due to the
fermentation. They are likely to be frothy and to
270
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1,
contain more mucus. The acidity or alkalinity of the
reaction is increased, according to the type of
fermentation present and the odour is more acid or
putrefactive.
Bacteriology.
In general the bacteriologic examination of tlie
stools is not of great importance in diagnosis. Usually,
no additional information is obtained from it. The
intestinal flora is, of course, either fermentative or
putrefactive, that is, one which forms acids or alkalies
from the intestinal contents. The type of the intes-
tinal flora can always be determined from the reaction
of the stool. In the acid stool of carbohydrate
indigestion, however, the preseuce or absence of
organisms of the gas bacillus group is of considerable
importance in indicating the form of treatment. The
determination of the presence or absence of the gas
bacillus by the fermentation test is not difficult, and
can be carried out by any one in his office without
special training. In protein indigestion there is an
excess of putrefactive organisms. Porter and his co-
workers have recently developed a method for the
recognition of this type. It is very possible that
organisms of the butyric acid group or Bacillus
acidophilus may be of importance. There are, however,
no easy methods for recognizing these organisms, and
no specific treatment, if they are present.
Treatment.
There is no place for the so-called digestants in the
treatment of chronic indigestion in childhood. There
is probably never an insufficiency of either hydrochloric
acid or pepsin and, as pancreatin is destroyed in the
stomach, it cannot possibly be of any use. The
general methods of treatment have already been men-
tioned. Further treatment, therefore consists
primarily in regulation of the diet to fit the digestive
capacity of the individual child. The element or
elements of which it cannot take care must be cut
down to the point where it can take care of them.
This point can be determined only by the examina-
tion of the stools. The deficiency in calories, brought
about by the cutting down of the amount of one or
more of the food elements, must be made up by in-
creasing the amount of the others. The amount of
the element that is causing the trouble must be
increased as fast as the increasing tolerance will allow.
It is not enough in severe cases of chronic indigestion,
due to intolerance of one or more of the food elements,
to give general directions as to the diet.
The diet must be laid out explicitly, and the number
of grammes of the offending food element allowable
daily must be definitely stated. The number of calories
which the child needs must also be indicated.
A list showing the caloric value and the content in
grains of the various food elements in the foods
allowed must be given to the parents and its use
explained. In my experience, almost all parents are
intelligent enough to use these tables. I have had no
difficulty in getting their interest and co-operation.
In the cases in which there are marked clinical
evidences of fermentation, bacteria undoubtedly play
an important part in the pi'oduction of the symptoms.
They unquestionably also play a part in the cases in
which the evidences of fermentation are less marked,
because bacterial fermentation is always going on in
the contents of the gastro-intestinal tract under
both normal and diseased conditions. What propor-
tion of the symptoms in a given case is due to bacterial
fermentation and what proportion to disturbance of
the chemical processes of digestion is, however, almost
impossible to determine. It is impossible, moreover,
to know whether the trouble was originally due to
bacteria or to disturbance of the chemical processes of
digestion. In general, however, it is probable that
the difficulty was not originally due to bacteria, as it
is impossible to implant permanently any organisms
in the intestines by giving them in the food.
Fortunately, it is not important to know which is
primary because the two factors are finally active in
every case.
Whether primary or not, however, abnormal
bacterial activity must be stopped. It is impossible
permanently to change the intestinal bacterial flora
by giving bacteria by the mouth, although the flora
may be temporarily somewhat modified if the bacteria
are given continuously. The intestinal flora can be
changed by changing the composition of the food, that
is, the flora may be changed from the acidophilic to the
putrefactive by changing the composition of the food,
and vice versa. Cutting down the proportion of the
carbohydrates and increasing that of the protein in the
food changes the flora from fermentative to putre-
factive, and cutting down the proportion of protein
and raising that of carbohydrates changes it from
putrefactive to fermentative. This can be proved by
bacteriologic examination of the stools, but is shown
equally well by the change in the reaction of the
stools, the stools bei?ig acid when the bacterial flora is
mainly fennentative, and alkaline when it is mainly
putrefactive.
Organisms growing on fat have relatively little to
do with fermentation in the intestinal tract, but the
products of their activity increase the acidity of the
stools. Treatment by regulatioo of the diet on the
indications furnished by the examination of the stools
thus not only aids the weakened digestive powers but
also changes the bacterial flora.
When the organisms of the gas bacillus group are
the cause of the fermentation in the intestinal con-
tents something may also be done to limit their
activity by the administration of organisms that pro-
duce lactic acid. The best type for this purpose is
probably B. btdgaricus. It is more effective
when given in the form of buttermilk than in tablets
or cultures, because it is numbers that count, and
there are infinitely more organisms in buttermilk than
in any tablets or little tubes of cultures. Furthermore,
the buttermilk contains considerable amounts of lactic
acid, which is of itself inimical to the growth of the
gas bacillus and putrefactive organisms. The lactic
acid forming organisms are also sometimes of benefit
in the treatment of putrefactive conditions. It must
be remembered, however, that the lactic acid or-
ganisms cannot change the bacterial flora permanently.
Nov. 1, 1920.] TBE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
This can be done only by so changing the diet as to
change the character of the culture medium in the
intestine. It is doubtful whether the growth of other
pathogenic organisms can be influenced by the ad-
ministration of any other organisms in the food.
There is no place for drugs, except for the temporary
relief of symptoms, in the treatment of chronic
indigestion in childhood. Cure can be brought about
only by regulation of the life and diet. In severe
cases the most minute attention to every detail is
absolutely essential. In these cases recovery is a
matter of many months and often of years, while
relapses are frequent. Recovery is, however, almost
always possible, provided the treatment is careful
enough and is kept up for a sufficiently long time.
RELAPSING FEVER IN EAST PERSIA.'
By Major C. T. H. H. Habold.
Dkscription of the Disease.
Incubation period one to twelve days. The attack
commences with the same symptoms as Indian re-
lapsing fever, viz., rigor accompanied frequently by
vomiting, intense headache and pains in the limbs.
The headache is frontal and often causes photophobia,
and this is very characteristic of the disease. In the
case of the Indian variety of relapsing fever the
temperature of the patient during the first attack
usually remains at a fairly steady high level for five
to six days, with possibly one slight fall about the
third day. After this initial rise of temperature
there is almost invariably an apyrexial period of
eight to nine days before the first relapse occurs.
In this Persian type of relapsing fever the first
attack of fever may last anything from one to five
days, usually three days, and the temperature of the
patient is rarely as steady as in the Indian variety,
the chart showing a very swinging type of fever with
' remissions which may touch the normal line. Pro-
j fuse sweating accompanies the fall of temperature.
j The first apyrexial period may be anything from one
to five days, and is usually two days. The subsequent
relapses rarely exceed forty-eight hours in duration,
and may last twelve hours only. They take place at
fairly frequent but irregular intervals, the periods of
apyrexia getting longer as the disease progresses. The
largest number of relapses noted by us were seven,
and these occurred within a period of forty-two days.
In all probability many more would have been re-
corded if the disease in all cases had not been cut
short by the administration of neosalvarsan. During
the course of the disease the patient becomes pro-
gressively weaker, anaemic, debilitated and wasted.
Splenic and hepatic enlargement is usual. Between
the relapses the patient feels well and is cheerful.
Bronchitis and epistaxis were observed in two of the
cases and jaundice in one case only.
The swinging irregular type of fever with short and
irregular apyrexial periods and numerous relapses is
diagnostic of the Persian variety, and in this it is
comparable to African relapsing fever, which is also
tick borne.
Description of Spirochete.
In the majority of cases the number of spirochaetes
seen in any one blood film is much smaller than the
Indian variety, and this is indicated by the number
of examinations that had to be carried out before the
discovery of the first spirochaete. Out of a total of
nineteen cases, and after prolonged searches by
several observers, spirochaetes were only detected in
eight cases. In fourteen of the cases, however,
examinations of the blood did not take place until
the first relapse, and observations were cut short
after the third to fifth relapse by the administration
of neosalvarsan, which the bad state of the health of
the patient necessitated. The diagnosis of the cases
in which spirochaetes were not found was made on
clinical grounds, and the reaction of the patients to
neosalvarsan confirmed the diagnosis. The use of
the thick drop method, using dilute Loeffler methy-
lene blue as the stain which we now adopted, would
have undoubtedly given better results. In one case
only were spirochaete found in fairly considerable
numbers, and in this respect the disease resembles
African tick fever, in which it is stated the spirochaetes
found are few.
The spirochaete may be said to be longer, a little
coarser than the Indian variety, and its spirals are
more regular and deeper, the Indian spil-ocbaate
being less regular and possessing open flexures.
Its length without showing divisional characters
averages eighteen to twenty-one microns and short
forms are rarely seen. On one slide a spirochaete
thirty-five microns in length was seen by me without
any attempt at division being visible in the protoplasm.
Figure of eight and loop forms are met with.
It might be noted that although in length this
spirochaete is comparable with the African variety it
may be differentiated from it by tiie fact that it
possesses fairly regular and deep spirals, whereas the
African type is stated to have open flexures. It does
not show, however, the extremely regular spirals
which .S'. vovyi is said to possess.
The characters of this spirochaete have received the
confirmation of Captain Fry, I. M.S., Captain Walker,
R.A.M.C, and Captain Venugopal, I. M.S.
Geographical Distribution of Disease.
Accurate information is extremely diflSculfc to obtain
in Persia. It is apparently thought that the Mianeh
disease is more or less confined to Mianeh and
district, but it is undoubtedly more widely spread.
There is evidence to prove that it is known on the
Tehran Meshed Road and on the Eastern side we
have the tales of ' strangers' disease," tick bite fever,
and Amrani fever. Amrani being an extremely
filthy village in which Argas persiciis is extremely
common.
All definite cases of this disease admitted to our
hospitals have come from the lines of commimication
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1920.
above Kain and alvyays from down-coming convoys.
In up-going convoys Indian relapsing fever has only
been found. All this points to this disease being
endemic in the upper sections of the lines of commu-
nication above Kain and we have definite evidence
from the Consular authorities at Meshed of infection
of Kafir Kalah and Khaimi and the infection of
Moore's convoy implicates Jainuk. It is possible
that practically all old sarais built of burnt brick are
more or less infected.
All cases of relapsing fever admitted to hospital
below Kain with one possible exception have been of
the Indian variety and undoubtedly without exception
louse borne.
In Meshed and also in Transcaspia during the
winter of 1918 — 1919 cases of Indian relapsing fever
occurred among the Indian troops. These troops
were frequently lousy and the spread of this disease
was probably by means of Indian carriers and lice.
It was not until the warmer weather when ticks
became more active and convoy duties due to the
Afghan War brought our troops more frequently in
contact with sarais that this endemic disease of
Mianeh or relapsing fever of Persia showed itself.
NOTE ON A SPECIFIC COMPLEMENT-FIXA-
TION TEST FOR BILHARZIASIS.'
By W. A. Mdbray, M.B., Ch.B.
Technique Employed.
The technique followed was based on a modification
of the original Wassermann test as outlined by
Taylor (vide Lancet, January 5, 1918) and the results
have been so satisfactory that, although the number
actually performed has been small, it was thought
well to publish a preliminary note on these, in order
to stimulate similar investigations elsewhere in South
Africa.
Antigen. — A very satisfactory antigen has been
obtained from the livers of snails {Physopsis africana)
infected with the cercarise of Schistosoma haema-
tobium. These have been supplied by Dr. Cawston
who finds that 30 per cent, of snails in the pools
around Mayville and Sydenham (Durban) are thus
infected. The livers are ground up in alcohol (1 grm.
liver substance to 10 c.c. alcohol) ; the mixture is
kept at room temperature for five days with frequent
shaking, is then filtered, and the alcohol extract used
as antigen. For the test the antigen is mixed with
1 per cent, cholesterin (3 — 2), and is then titrated.
The three antigens used so far have each given an
anticomplementary titre of 1 — 3, and an antigen titre
of 1 — 80. A dilution of 1 — 8 is used in the actual
test.
An attempt was made with whole snails (infected)
used in the same way as the livers described above,
but with poor results. As soon as available, an
infected guinea-pig's liver will be tried as antigen
J South .Afiican Medical Record, May S, 1920.
material, and if this is found satisfactory it will solve
the present difficulty experienced in obtaining material
for antigen.
The amboceptor, complement, and sheep cells are
used exactly as in the Wassermann test.
Patient's Serum. — These are supplied by Dr.
Cawston before commencing treatment with tartar
emetic. At first each serum was inactivated at once
and tested within twenty-four hours of having been
drawn, as Fairley found that the results after twenty-
four hours were not so reliable. I have, however,
found no diminution in complement-fixing power for
several weeks if the sera are kept on ice. Control
sera were taken from various individuals who had
never had bilharzia disease, and these have proved
uniformly negative. Further the sera of syphilitic
patients who do not suffer from bilharzia were also
negative. The reaction is, therefore, a specific one.
There has as yet been no opportunity of re-examining
the blood of these bilharzial patients after they have
uwlergone a curative course of treatment, lasting three
to four weeks. It is proposed, however, to do this,
commencing a month after cessation of treatment, and
repeating the test at regular intervals whenever
possible, in order to determine how soon a negative
reaction may be obtained.
Comsponbciicc
To the Editor of the JOURNAL OE TROPICAL MEDI-
CINE AND Hygiene.
September 24, 1920.
Dear Sir, — We have read with very much interest
the article contained in your valuable JOURNAL OF
Tropical Medicine and Hygiene for July 15 by
Dr. F. G. Cawston, upon the employment of oscol
stibium in the treatment of bilharzia with so much
success. We have received a letter from him which
is practically confirmatory of what he has written in
the article, and further lie suggests that there is a
wider employment for this cscol stibium in the treat-
ment of what is known in South Africa as nagana
disease among cattle. The chief veterinary officer at
Nairobi has had very good results, upon his suggestion,
and he also states in his letter that there are oppor-
tunities that might be taken of treating cases of
bilharzia in human beings, extremely poor persons,
who are unable to pay the fees. We would like to
say that if you indicate the same through your
valuable Journal, we are quite willing to send a
reasonable supply of this oscol, free of charge, to any
medical practitioner who is treating such cases, so
that he may be able to use it without consideration
of expense, and we trust with gi-eat advantage to the
patients, as they are poor and are unable to pay for
treatment. We feel certain that you will fall in with
these ideas.
Thanking you in anticipation of your consideration.
Yours faithfully,
Oppenheimer, Son and Co., Ltd.
Nov. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 22, Vol. XXIII.
(Srifltiial ftommimirattons.
NOTES ON AN OUTBREAK OF ASIATIC
CHOLERA IN SYRIAM MUNICIPALITY,
BURMA, IN JUNE-JULY, 1920.
By J. C. TULL, M.D., M.R.C.P.Lond.
Civil Surgeon, Syriatn.
DuKixu the latter half of June and the first da.ys
of July, 1920, there was a sudden outbreak of
Asiatic cholera in the Bogyok' Works of Messrs. the
Burma Oil Company, Limited. These works con-
sist of a [ictroK'um refinery, in which about 1,100
natives are em])loyed, of whom some 500 are housed
in the lines of the refinei-y. The housing accom-
modation consisted of two long huts, with gaJ-
viinized iron sides and roofs, and a cement floor and
verandah. The huts were subdivided into a vary-
ing number of compartments, to suit the wishes of
various castes and races accoinmodated. The in-
habitants consisted of Chinamen and Indians, the
latter being of the Hindu, Choringhee and Uriya
castes. Beitween the two huts were situated cook-
houses, latrines (pails emptied twice daily), and a
Jarge water tank, served from an artesian well about
800 yai'ds away, the well being about 800 ft. deep.
Unfortunately the cook-house and latrines were
only about 10 ft. apart. This is important, for to
this unfortunate occun-ence I believe the outbreak
to be due.
The native has never been persuaded to keep- his
cook-house clean. He insists on spilling cooked-
rice, remnants of cun'y, water in which rice has
been boiled, Ac, anywhere but into the receptacles
providi'd for the refuse. He will not keep covers
on receptacles, and if you give him a cemented area,
with running water, specially for his ablutions, he
is sure to use this as the most desirable spot in
which to throw his refuse.
Suddenly on June 19 in these lines, where there
were between three and four hundred coolies, with
several cook-houses and latrines in close proximity,
and where, unfortunately, a ])erfect plague of flies
h(ul di\('l(ipe(l in the early part of June, when the
r;iiny scasf)n began, a case of Asiatic cholera was
found. Nothing seemed lacking to make the out-
break serious. Flies abounded; coolies would not
be sanitary; cook-houses and latrines were far too
close to each other; and the native regarded the
disease as being sent from the gods, and no efforts
should be miule. to check it.
The one bright spot was that the disease was in
the lines of a company who are always anxious to
do the best for its employees. The -Xssistant
General Manager, A. C. I>ochhead, Esq. ; the local
Manager. .\. Sharp, Esq.; and the Chief Engineer
at Bogyok, R. Cloudsley, Esq., came to my assist-
ance nobly, and gave mo all necessary moral and
financial support.
Methods .\nopTKD in haxdlixc; tiik Octuhkak.
(1) The Isolation Department of the Municipal
Hospital, Sj-riam, was given over for the treatment
of the victims. Orders were issued that all men
failing ill with diarrhcea were to be immediately
removed, with their clothes, to this hospital, where
Sub-Assistant Surgeon, H. J. Andy, and a staff of
menials were placed on duty.
(2) All coolies were confined within their lines,
which were policed. Their supplies of food were
bought for them in the local bazaar in bulk, brought
to the lines, and issued as required.
(3) The source of the infection was sought for.
The first victim had been resident in the lines for
more than a month, had had no illness, and had
not, as fai- as could be ascertained, been in any area
known to be infected.
(4) The water supply was beyond suspicion. It
came from an artesian well, and had it been guilty,
many more victims must simultaneously have been
attacked. Similarly, the general food supply was
ruled out as the source of infection.
(5) The presence of a plague of flies made it very
likely that they were the medium of infection. I
was, however, unable to detect the comma bacillus
in any flies. I believe there was a " cholera
carrier," with the house-fly as the medium of con-
veying the disease. Supposing the flies to be the
danger, our efforts were directed to getting rid of
them. Of course, the natives would give us no
help. With a sanitary staff we sprayed all cook-
houses, latrines, and sleeping (]uarters and surround-
ings every few hours with formalin ; washed the
same area with oyllin twice daily; spread fly-papers
everywhere ; and (what was most effectual eventu-
ally) we arlopted the American " fly-swatter," with
which we kille<l flies by the thousand. But never
a fly would a coolie kill !
The first case developed on June 19. Next day
there was another case. On June 21 there were
three new cases; June 22, six new cases; June 23,
one new case; June 24, no new cases; June 25, six
new cases.
It was therefore obvious that, in spite of our
efforts, the outbrealc was not being controlled. We
therefore decided to build temporary lines, well
removed from the infectt-d lines, and move all non-
infected persons from the old lines to these new
temporai-y ones. The construction of these now
lines was of bamboo matting, and the latrines of
the deep-trench variety. Burnt pa^ldy husk atiis
used to cover the trenches as they were used.
While these temporary lines were being built, on
June 26 there were two new cases; June 27, three
now cases ; June 28, nine new cases ; June 29, three
now cases; June 30, four new cases.
On July 1 we began to move the non-infected
persons to their new quarters. Each coolie was
made to take a bath; his entire kit (not very
elaborate usually) was fumigated, and 'the whole
lot were led literally, in squads of fifteen to twenty,
to their new home, every- effort being made to avoid
transporting flies.
On July 1 there were no new cases; July 2, one
new case ; July 3, one new case ; and July 4, one
new case. On this day we finally had all non-
274
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Nov. 15, 1920.
infected persons in their new quarters, free from
flies, and from this date we had no new cases.
An interesting feature was the fact that of a
dozen Chinamen whose quarters were sandwiched
between two of the worst parts of the infected area
not one developed cholera. The explanation was
that the Chinamen kept their quarters scrupulously
clean and killed the flies.
The victims were treated according to the method
developed by Sir Leonard Rogers. Forty- one cases
arrived in the hospital alive, and of these twenty-
one subsequently died. One case lived only one
hour after admission. All were of a severe type,
with severe muscular cramps and early collapse.
The saddest incident of all was that the matron
of the hospital, in her untiring devotion to the care
of victims, developed the disease. She recovered,
however, with no complications.
Such is the story of an outbreak, which promised
at the beginning to be very serious. The lesson to
be learned from it, I believe, is the one so often
taught and so seldom heeded : destroy the
fly by every means in your power.
SOME INFECTIONS DUE TO FRESHWATER
SNAILS AND THEIR ERADICATION, i
By F. G. Cawston, M.D.Cantab.
The survival-time of the cercariae which are con-
tinually escaping from certain species of freshwater
snails is a very short one. Cercarise do not usually
live longer than the day on which they commence
their free aquatic existence.
Members of that group to which the bilharzias
belong can prolong their existence only by entering
the blood-stream of some warm-blooded animal.
Once thej' have gained an entry they never leave
the blood-stream, and often live as long as their
host.
Several distinct parasites which closely resemble
the cercaria of Schistosomum hxmatobium infest
freshwater snails in South Africa. Physopsis
africana, a common snail of stagnant pools, is
heavily infested with thgm. I have found them in
552 out of 1,896 specimens of this snail which I
have collected from Sydenham and Mayville. Many
Eire the typical cercaria which produces bilharzia
disease, and by feeding a number of guinea-pigs .on
green food containing them, I have obtained the
adult parasitic worm, S. hsematobium. Others are
almost twice the size of the bilhai'zia, measuring as
much as 7 mm. in total length. These have
developed into the typical bilharzia worm of cattle,
S. bovis.
In July I obtained a physopsis from the Um-
hlangana river that was only 12 mm. in length,
and yet was infested with mature bilharzia cercarise.
By artificial means I have produced similar infection
in specimens of this common freshwater snail that
' Paper read at the South African Medical Congress, Durban,
October 8, 1920.
were even smaller than this. I have also collected
infested specimens from the Umbilo as high up as
Sarnia, from the Pinetown stream which flows into
the Umbilo, from tributaries of the Umhlatazana
at Be.llair, the Umsindusi at Maritzburg, the
Umhlangana at Avoca, the Umhlanga at Ottawa,
and various other parts of the Transvaal. Physopsis
from these localities harboui-s the bilharzia parasite
at all seasons of the year.
P. africana from the Umbilo, the Umgeni, and
the Umhlangana is infested with a somewhat nar-
rower and longer ccrcaria which may be an avian
trematode. Its oral sucker is provided with boring
processes somewhat stouter than those of the bil-
harzia. Some of these cercariae are as much as
0875 mm: in total leJigth ; the prongs of their divided
tail being as long as the tail itself. They may be
identical with the cercaria which infests physopsis
at Maritzburg which I have described as Cercaria
secobii.
Dr. Annie Porter has reported bilharzia infection
in Limnxa natalensis, which mav be looked upon
as our commonest freshwater snail. This infesta-
tion is rare; but L. nataleiisis which I have collected
from the Umgeni river harbours a. redia-produced
cercaria, somewhat resembling the bilharzia, but
possessing longer prongs to its divided tail.
Recently I have found cercariae resembUng the
bilhai-zia in Isidora tropica from Mayville, but I
have not yet secured their adult forms. Infested
snails will reiuain alive for several months and
produc.' fr.r s\\ iniiiiing cercariffi all the while. Dt.
Annii' I'liii r lia^^^ found over 1,000 distinct parasites
in one uifrstcd physopsis.
There is another cercaria, not unlike the bilharzia,
but possessing pi-ongs having the resemblance of
drawn-swords, which infests /. schackoi jickeli at
Potchefstroom. Unlike the bilharzia, it is redia-
profluced, and may be a parasite of the water-rat,
otter, or other water animal. It has been described
by Dr. E. C. ]-'aust as C. gladii.
Dr. E. C. Faust has reported the larvae of Schis-
tosotiia Diansoiii in some of the material I sent him.
This p;u-asite may have been introduced into the
Durban suburbs by soldiers returning from Egypt;
but, until the larvLe of S. bovis is defined with
certainty or tlic ail nit stages of >S'. 7nansoni obtained
in Natal, the stalian.ait must be taken with caution.
L. natalrtisis at. Lake Chrissie in the Transvaal
and in the Ihnliau suburbs is infested with other
cercariw which may be a danger to man and cer-
tainly attack ajiinials. One of these, C. pigmentosa,
develops into Fasciola gigantica, which has been
found in the liver of man, and commonly occurs in
that of oxen. Other specimens are infested with
cercariae closely allied to C. pigmentosa, which may
prove to be Distomum hepaticum, the more com-
mon liver-fluke which has been found associated
with liver-abscess in man.
The presence of these varieties of cercariae shows
the importance of securing their adult forms by ex-
perimental means. A cercaria somewhat resem-
bling S. japonicvm is reported from Calcutta, where
Nov. 15, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
275
the adult parasite has not been found. Dr. W. A.
Murray has recently shown that the blood of a
patient of mine who harbours this pai-asite from
China gives a positive reaction to the antigen test
prepared from our infested /-*. africana.
Eraduwtion of the Uercari.*; from Tools.
To a certain extent all fish may help to keep
water clear of cercaiiEe, but I have recently shown
that the small fish called " millions " are pai-ticu-
larly valuable in this respect. I have watched them
feeding greedily on bilhai'zia parasites, and, by
keeping them under observation for several weeks,
have shown that they are incapable of can-ying the
infection themselves or of passing the infection on
to others, once the parasites have been digested
along with other food. I have also watched them
ridding a collection of water from the free-swimming
cercaria; of liver-fluke. These valuable allies in
eradicating bilharzia infection from pools should
certainly be used more extensively in the infected
areas of Natal and the Ti-ansvaal. They may be
obtained direct from the fish factory at Stellen-
bosch.
As the life of a cei'caiia outside the body is so
short, any collection of water that is free from snails
soon becomes free from infection ; but, although no
snails may be found in a river, the river-water may
be heavily infested with cercariae which have been
washed down-stream from snails remaining in its
tributaries.
A very efficient means of destroying cercariae in
water is by adiliug common salt to it, and this is
probably the best way of freeing green food, par-
ticularly watercress, from cercariis. Lime is also
useful in destroying cercariae, but probably no better
than strong solutions of salt. Sir Ronald Ross's
LAKViciDE will quickly destroy all bilharzia cercariae
and allied organisms from collections of water; it
would also destroy a large proportion of the snails.
The average mixture is about 300 gallons of crude
carbolic acid, '200 lb. of resin, and 30 lb. of caustic
soda. One part of the mixture placed in 5,000
parts of water containing mosquito larvse will kill
them all in less than five minutes.
Eradication of Freshwater Snails from
Collections of Water.
In supplying birds with freshwater snails as food,
Nature has })rovided tha.t they should not exter-
minate the species, however greedily they feed on
individual snails. In visiting a ])ool in setu-ch of
food, wild birds can-y in the mud attached to their
claws numbers of minute snails and snails' eggs;
thus, when devouring all the mature snails they
can find along the li.uiks of a river, they uncon-
sciously iiitr(]<lncc iiiiiiihcrs of smaller snails to take
the place of those ili<y have eaten. In this way
wild birds of all kinds are of little use in destroying
freshwater snails, and I usually find the home of
wild duck a useful ])!ace to search for new species
of fn^shwater snails.
On the other hand, domesticated duck clear pools
of freshwater snails without introducing new speci-
mens. The pools on the Natal estates at Mount
Edgecombe are remarkably free from freshwater
snails on account of the presence of domesticated
duck. A pool at the Natal Poultry Exchange is
also free from them, whilst the neighbouring pool
at the cable-station which hai'bours wild fowl con-
tains numerous snails infested with cercariae.
Sydenham Pools.
The value of domesticated duck in ridding collec-
tions of wat.er from freshwater snails and thus
eradicating the infection they produce is well
brought out by my recent experience at Sydenham.
These pools swarm with P. africana and L. natalen-
sis, a very large proportion of the mature specimens
being heavily infested with the bilharzia parasites
or with cei-cariae resembling those of the liver-fluke.
During the last few weeks I found cercariae and
redias resembling fasciola infestation in six out of
ten limnaeae from these pools, and bilharzia para-
sites from these pools, and bilharzia parasites in
seven out of eight physopses. One physopsis har-
boured leptocercariae besides the bilharzia.
One of these pools is so infested with these fresh-
water snails that I have often collected over 200 in
it at one visit. On August 28 I could find only
one ancylus there and some snail's eggs on a water-
lily leaf. Just a month before the Indian who owns
the pool had taken my advice and introduced three
white duck ; these were swimming there when I
arrived in search of snails. To show that the
absence of snails was not due to climate changes,
I visited a smaller pool within three minutes' walk
which was fenced in and contained no duck. Here
I found numerous L. natalenais and P. africana, one
of the latter being 20 mm. in length.
The Depai-tment of Public Health might well re-
consider the desirability of introducing domesticated
duck into suitable places known to hai-bour fresh-
water snails in any quantity. The duck might be
given free to the foremen at railway stations
situated close to dams. This course is pai-ticularly
indicated wherever dams have been erected along
the course of rivers. Such dams often prove ex-
cellent hunting-grounds for snails and other evi-
dences of stream-pollution. Legislation might even
be introduced to protect these natural enemies of
the freshwater snail, as the swan is protected on
the Ijondon Thames.
Besides the fish and the birds which help to keep
a river clean, occasional floods assist in washing
away the pollution of rivers; but, in many low-lying
districts, and amongst the sugar-cane especially,
these floods often tend to iru^rcasc the number of
stagnant pools containing infested snails.
Tlie majority of freshwater snails die when the
pools become dry; but Mclania tubvrculata, which
is very abundant in the experimental watercress
beds at Prospect Hall, and is closely related to the
intermediai-y host for S. japonicuni, is provided
with an operculum or lid which enables it to resist
drying for close on three months. 1 have found a
monostome and a styletted cercaria in this species
of snail in Natal.
276
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Nov. lo. 1920.
Lime has been shown to definitely help in keeping
down the niunber of snails on a fluke-infested farm,
and a farmer in Victoria has had some good results
in this respect from using a bag of lime to every
1,000 cubic yards of water.
Of primai-y importance is the constant removal
of rushes and floating sugar-cane from the rivers.
Water weeds and water-lilies should be removed as
far as possible and special attention paid to all
dams.
Sources of the Rivers.
So long as infested snails ai-e found close to the
source of a river, efforts to cleanse the river lower
down-stream will be unavailing. In view of the
fact that some of the largest missionai-y institutions
are situated close to the source of the Umhloti,
Unihlatazana, Umgeni and the Umlaas, all pupils
known to harbour the biiharzia parasite should
undergo the curative treatment or be removed to
the coast in the interests of both the European and
the native population lower down-stream. The
Educational Department might well give this aspect
of disease prevention their very serious considcra--
tion ; whilst the Provincial Administration might see
their way to follow the commendable procedure of
the South African railways, which pays half th*;
cost of treatment of the members of the Railway
Sick Fund suffering from biiharzia infection and
undergoing treatment by a specialist.
Treatment of Bilharzia Carriers.
In view of the number of native and Indian
patients harbouring the biiharzia parasite and con-
tinually spreading the infection, some means will
have to be devised to afiford free treatment in out-
lying districts. This would have a very decided
effect in eradicating the disease and lessening the
number of infested snails. Following; tli, iinuMMluro
of the suggested travelling hospitals in I'^^rvpt. a
temporarj- hospital might be improvisiil at St;uii;!er,
Tongaat, or Sea View, where the treatment of large
numbers of patients could be imdertaken for a
complete month. The Indian Immigration Boairl
would be sure to render ^erj' assistance, and the
affected sugar farmers would probably be willing
to share in the cost. With several recent schemes
for providing free medical attention to venereal
])atients in South Africa, some such means of ren-
dering the poorer-class patients free from biiharzia
infection might well be considered with the view of
the necessary action being taken.
notices.
Kfjfrl (if Therapeutic Doses of Mercury on ihc
Kidneys and the Duration of its Excretion (L. G.
Beinhauer, American Journal of the Medical
Sciences, June, 1920). — According to the author's
researches the excretion of calomel given in ordi-
nary therapeutic doses begins within six to twelve
hours, and is continued until the sixth day. In so
far as can be determined by the urine analysis
the drug is excreted without bad effects upon the
kidnevs.
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THE JOURNAL OP
Croptcai SS^ttiitim anD l^pgtene
November 15, 1920.
THE LONDON SCHOOL OF TKOPICAL
MEDICINE.
Openinc; thk New Premises of the School.
It is one-aiid-twenty years -October, 1899, to be
precise — since the London School of Tio])ical Medicine
opened its doors to students wishing to obtain instruc-
tion in tropical diseases to fit them for the practice
Mov. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
277
of their profession in warm climates. The opening
ceremony was an address by Dr. Patrick Manson (now
Sir Patrick Manson, G.C.M.G., M.D., LL.D.. F.R.S.'
Founded at the instigation of Mr. .Joseph Chamberlain,
then Secretary of State for the Colonies, and with the
support and under the direction of Sir Patrick Manson,
at that time medical adviser to the Colonial Office, the
Sciiool has flourished to an amazing degree and proved
itsimportance and usefulness in a mannerso convincing
that it has received unstinted support in every corner
of the Empire. The idea of the formation of a school
of the kind was taken up heartily by the authorities of
the Seamen's Hospital, Greenwich ; and the Committee
of the Hospital granted a space for building the School
beside the Branch Hospital at the Royal Albert Docks,
Poplar, London, Iv To the chairman of the Seamen's
Hospital Committee, Mr. Perceval Nairne (now Sir
Perceval Nairne), to the Secretary to the Hospital, Mr.
P. Michelli (now Mr. P. Michelli, C.M.G.) and the
members of the Committee of the Hospital, the Empire
owes a deep debt of gratitude for their sympathy,
financial direction and support, and their unfailing
interest and devotion to the maintenance and advance-
ment of the school at all times and on all occasions.
The growth of the school is now a matter of history,
and its usefulness is demonstrated by the multitude of
medical men practising their profession in every region
of the Empire.
For many reasons it was found advisable to remove
the School from the Albert Docks, and it was finally
settled to establish it at Endsleigh Gardens, Euston,
London. A Hospital for Tropical Diseases is also part
and parcel of the School ; a most valuable addition, for
not only will the instruction be theoretical and practical
but clinical as well. The buildings are ample, the
laboratories, lecture rooms, museum and the special
department being convenient and capable of accommo-
dating the many departments which are now necessary
for the teaching of tropical medicine and for research.
The Bureau of Tropical Literature is now established
in the School premises under the able direction of Dr.
Bagshawe. On November 11, 1920, H.R.H. the Duke
of York formally opened the new premises of the School
in Endsleigh Gardens, Euston Road, London.
His Royal Highness was received by Viscount Milner
(Secretary of State for the Colonies), the Marquess of
Miltord Haven (President of the Seamen's Hospital
I Society), Sir Patrick Manson (founder of the School),
' representing the teachers and honorary medical staff,
! and Surgeon-General Sir Havelock Charles (Dean of
'; the School). Among others present were Mr. Austen
; Chamberlain (Chancellorof the Exchequer), Sir William
i and Lady Leishman, Lady Maude, Lady Manson, Sir
\ Edward Hope, Captain Sir Acton Blake, Sir William
Bennett, Major-General the Hon. Sir Reginald Talbot,
Sir Perceval Nairne (Chairman of the Committee of
Management), Sir Artliur Clarke (Deputy Chairman),
.\dmiral of the Fleet Sir Henry Jackson, Sir Herbert
Read, Sir .fohn Rose Bradford, Professor Alcock, Mr.
I ' Aa a matter of history ft is of interest to note that Sir
Patrick Manson's address was delivered by Mr. James Cantlie.
Miciielli, Miss Knight, Dr. Andrew Balfour, Mrs.
Chalmers, Professor Hewlett and Mrs. Hewlett,
Colonel J. J. Pratt, Colonel R. H. Elliot, Professor
Leiper, Dr. and Mrs. Sambon, Professor Simpson,
Dr. Low, Dr. and Mrs. Manson-Bahr, Dr. Bagshawe,
Dr. Wenyon, Dr. Castellani, Dr. J. G. Thomson, Miss
Wheeler, Sir James Cantlie, &c.
Lord Milner, having presented the members of the
committee of management, the medical staff, and the
teachers of the School to the Duke, described the bene-
ficent work of the Hospital and School in connection
with the Seamen's Hospital Society at Poplar, and in
conjunction with a similar institution at Liverpool.
As extensions became necessary the requisite financial
support had always been forthcoming, and when they
moved to the present premises, and it became desirable
to bring with them also the Seamen's Hospital, the
British Red Cross Society and the Order of St. John
gave them the munificent donation of £100,000. Since
then it had been found necessary to raise for working
expenses an additional sum of £.50,000, of which he
was glad to say they had been able to obtain £20,000,
thanks to the energetic work of the Committee of
Management. With the support and patronage of the
Duke of York he had no doubt that they would be able
to get the whole of the sum required.
H.R.H. the Duke of York, having unveiled a
tablet recording the gift of the £100,000 by the
Red Cross Society and the Order of St. John, said :
" I have great pleasure in declaring this building open
for the purposes of a School of Tropical Medicine and
a Hospital for the cure and treatment of persons
suffering from tropical diseases. In doing so, I cannot
too strongly commend the work that is being done in
the interests of those who have helped to build up the
great tropical dependencies of the Empire. We stand
under a great debt of gratitude to all those who have
aided in bringing to sucli a successful issue an under-
taking so beneficial not only to those scientific men
who have devoted their lives to the cause but to those
who have contributed and assisted in raising the
necessary funds. To the successive Secretaries of
State for the Colonies we owe much ; and now we
have the able assistance of Lord Milner, the present
Secretary of State. We also record our gratitude to
the British Red Cross Society and the Order of St. John
of Jerusalem.
" To the students who are beginning the forthcoming
session- many of whom, I understand, are officers who
have been appointed to the Medical Department of the
Colonies and India — I wish every success in theii'
vital and interesting studies. There is no need for me
to emphasize to them the importance of their Imperial
task. It is the first duty of a civilized community to
provide the conditions of a healthy life, to sweep away
the plague spots, and to take measures against infection,
and possibly most important of all, to instruct the
public as to the habits of life which make for health.
" The School of Tropical Medicine holds a watching
brief for the health of the outposts of our wide Empire,
and it is here that schemes may be initiated such as
have made what was once known as the ' White Man's
Grave ' a land where to-day work and effort may be
THE JOURN'AL OF TROPICAL MEDICINE AND HYGIENE. [Nov. 15, 1920.
advanced without the toll of death and suffering which
formerly attended life in those regions. I venture to
hope that still further funds may be forthcoming to
carry on this great work, and especially to advance
research."
His Royal Highness afterwards occupied an hour
in inspecting the Hospital and unveiled a tablet in the
Stanley Maude Ward recording that it was endowed
by the Mesopotamia Comforts Fund in memory of the
late Lieutenant-General Sir Stanley Maude and the
oflBcers, non-commissioned officers, and men who
gave their lives for their country in Mesopotamia
during the war.
The Duke of York said : " I deem it an honourable
and grateful duty and privilege to unveil this tablet to
the memory of that distinguished soldier, General Sir
Stanley Maude, who on the eve of the successful com-
pletion of his great military operations in Mesopotamia
was stricken with and died from a virulent tropical
disease to the grief and loss of his country. In doing
so I have to thank the Committee of the Mesopotamia
Fund for the endowment which they have created to
provide hospital accommodation and highly skilled
treatment for sufferers from tropical diseases.".
fcMffo.
Handbook for Tubebculosis Workers. By
Noel Bardswell, M.V.O., M.D., F.R.C.P., Prin-
cipal Assistant Medical Officer, Public Health
Department, London County Council. London :
John Bale, Sons and Danielsson, Ltd., Oxford
House, Gt. Titchfield St., Oxford St., W. 1920.
Pp. 66. Price Is. 6d. net.
This handbook has made a timely appearance, for
the universal demand just now is for information upon
the subject of Tuberculosis. The British Red Cross
Society at the moment are encouraging tbeir voluntary
aid workers to take up the practical work of visiting
and looking after cases of consumption, especially in
their own homes, after returning from sanatoria, and
in our schools.
Dr. Bardswell's book meets the occasion and will
serve to help those devoting themselves to the care of
consumptives. This manual covers the subject apper-
taining to tuberculosis in a very complete fashion :
conditions which predispose to tuberculous disease are
given succinctly and sufficiently ; the latency and the
manifestations of tuberculosis, and the many forms in
which it shows itself in different organs are clearly set
forth ; the principles of treatment explained in a simple
yet complete fashion.
The great subject of prevention is handled in a
masterly manner, and in a fashion that all who run
may read. The so-called " Care Committees," spring-
ing up in different parts of the country, composed for
the most part of voluntary workers who are in touch
with the social life of the people, are performing
useful work by acting in co-operation with official
administration in anti-tuberculosis work.
voluntary workers focus their attention upon the
families within their sphere of work and become the
outposts of observation in the great fight against
tuberculosis. When the bread-winner of the family
gets laid aside the members of the Care Committee
can relieve anxiety by applying to proper quarters
where financial help may be obtained, so as to appease
his anxiety in regard to his family's maintenance, and
by getting the infected person removed to a sana-
torium early in the disease prevent the infection of
others living in the same house. All the essential
difficulties that require seeing to are ably dealt with
by Dr. Bardswell in a manner at once authoritative,
humane and convincing.
A section of the manual dealing with the care of
the tuberculous child is worthy of close perusal ; it is
practicable, bears the mark of an intimate knowledge
of the subject, and all the troubles that develop when
a member of a family is attacked by consumption.
We congratulate Dr. Bardswell on his work, and
thank him for giving the nation a guide so simple, so
complete, and so adapted to present-day wants.
Annotations.
Blackwater Fever (Leonard S. Dudgeon, Journal
of Hygiene, vol. six, No. 2, October, 1920).— The
author gives the following summary of his investi-i
gation : — I
(1) True jaundice, due to the presence of bile!
pigment in the plasma, occurred in a high percent'
age of the cases which ended fatally. Haemoglo
binasmia, varying from deep red coloration of th(
plasma to a faint tingeing, occurred in the acut<
stages of the disease. There was no evidence o
auto-agglutination or auto-haemolysis. The fragility
of the red cells was unaltered. No relationshi]
between syphilis and blackwater fever was obtained
Spiroehaetes were not demonstrated in the blood ii
any instance. In the hundred cases in this series -
a malarial history was obtained in every instance:
and without exception the infection was contract©;
in the Balkans during 1915-1918. The only blooj
parasites found were Plasmodium vivax and fl
falciparum. I
(2) The most important tissue changes were s*
follows : Fatty degeneration of the myocardiun
Reduction of the fat lipoid content of the adren;
gland. Enlargement of the Malpighian corpusch
of t4ie spleen due to various changes in the endi
theliaJ centres. Recent or chronic perisplenitis wt
present in every instance. The other changes i
the spleen were numerous and variable and due '
blood destruction and malaria. Haemorrhages
the liver tissue and foci of central necrosis, in whi<
reactionary changes had occurred, were met with .
many instances. Inspissation of the bile in tji
gall-bladder and bile passages was of commci
occurrence.
Nov. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
The changes in the kidneys during the acute
stages of black water fever were very pronounced,
but complete recoveiy rapidly ensued during the
period of convalescence without subsequent nephritis
as far as the information available indicated. Spiro-
chaetes were not found in any of the tissues in this
disease. Scattered hsemorrhages occurred in the
most rapidly fatal cases.
(3) From alcoholic and acetone extracts of the
dried residue of the urine, obtained during the
period of hiemoglobinuria, hfemolytic substances
were demonstrated. From alcoholic and acetone
extracts of the dried organs very active haemolytic
substances were obtained, more especially from the
acetone extracts. The alcoholic extracts of the
urine were more potent than the acetone in the
three cases which recovered. Similar results were
not obtained by extracting the dried viscera from
other cases other than blackwater fever, including
malaria.
(4) There was no evidence that quinine adminis-
tered by any method during the attack of black-
water fever increased the severity or influenced the
progress of the disease apart from its effects on
malaria. Quinine administered to animals rendered
anaemic did not excite haemoglobinaemia. Quinine
was obtained from the urine by extraction, during
the period of hoemoglobinuria, in amounts which
corresponded to those obtained in the malarial
cases. Rabbits injected with quinine previous to
and during the period when both ureters were liga-
tured failed to develop haemoglobinaemia or haemo-
globinuria.
(5) The urine in cases of blackwater fever rapidly
returns to the normal from the period of haemo-
globinuria. Clumps of red cells which possess
certain characteristics were found in the urine in
some cases. Cliunps of red cells were of common
occurrence in the tubules of the kidneys. The in-
jection of sterilized urine from cases of blackwater
fever obtaine<:l during the period of hiemoglobinuria
failed to produce any ill-effects in animals.
(6) Blackwater fever was most fre^juently met
with during the months of March and April, at the
time when the temperature was at the commence-
ment of its upward summer rise. No evidence was
obtaine<:l that blackwater fever is in any way related
to anaphylaxis, ft was not possible to employ any
method to demonstrate whether blackwater fever is
due to a filter passer.
The Intestinal Animal Parasites found in One
Hundred Sick Filipino Children {Philippine Journal
of Science, January, 1920). — F. G. Houghwont and F.
S. Horrilleno have made an elaborate study of one
hundred sick Filipino children with regard to intestinal
parasitism. Of the total number 92 per cent, were
found to be infested with one or more parasites Under
one year the incidence was 66'6 per cent., the youngest
being seven months old. All the children between
two and thirteen were found to be parasitized. No
pathogenic protozoon was encountered. The apparent
immunity of the Fihpino child to forms such as
Entamceba histolytica and Balantidium may have a
physiological basis in the child. The incidence of
Spirochseta eurygyrata. -wa-s 61 percent. Although no
significant phenomena were recorded further investi-
gation of this parasite is called for.
No definite train of symptoms other than those
specifically pathogenic could be attributed to intestinal
parasites. Several patients not parasitized presented
symptoms that might easily be attributed to parasites.
Concomitant infestation with Trichuris and Ascaris
was accompanied by a train of symptoms referable
to the digestive tract that presented an almost
characteristic picture. The clinical diagnosis of this
case was usually ascariasis.
No data were secured that would aid in determining
a possible influence of parasitism on the mental
development or of effects on the nervous system. Nor
could any satisfactory evidence concerning the
influence of parasitism on the incidence or course of
ileocohtis be obtained.
Infestations with Trichuris and Ascaris were re-
garded as offering a serious problem in pediatrics. The
combination of the two helminths is specially serious,
inasmuch as the entire alimentary tract is involved.
Children occasionally purge themselves of Ascaris
infections, particularly if they are complicated by
Trichuris infection. This occurs through vomiting or
defaecation of the worms, or both.
Helminth infections were restricted to the nematoda,
no infections with either cestoda or tremada being
encountered. It was suggested that the lung stages of
Ascaris may be responsible for much of the respiratory
disease among Filipino children. Infection with
hookworm was found in twelve per cent, of the series,
no differentiation between Necator and Ancylostoma
being made. Only one severe case was recorded, and
it was suggested that the traditional mildness of hook-
worm disease among the Filipinos should not produce
a false sense of security.
Sanitary conditions are a heavy factor in the
infection of children. Parasitism starts coincidentally
with bottle or artificial feeding, but even breast-fed
children do not entirely escape.
Domestic animals do not appear to be important
factors in the spread of parasitism among Filipino
children.
Houghwont and Hoerrilleno believe that intestinal
parasitism, both directly and indirectly, contributes
heavily toward the high death rate in young Filipino
children. Sanitary conditions are largely responsible,
and the problem is one of education of the masses in
simple domestic hygiene, and calls for the development
of the principles of parasitism and preventive medicine
on a particularly high piano in the Philippine Islands,
where parasitic infestations are probably more
common than in any other country from which there
are records.
EndoUmax nana and Dlentamceba fragilis are re-
ported for the first time from the Philippine Islands,
and Entrichomastix is provisionally reported.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 10, 1920.
ibstraits.
YAWS ; WITH A REPORT OF A CASE WHICH
DEVELOPED IN A TEMPERATE CLIMATE.'
By Lieutenant Commander C. S. Stephenson, M.C,
U.S. Navy.
An .\mfeiican sailor, white, aged 26, married, was
admitted to the sick list December 15, 1919, in Brest,
France, complaining of headache and fever of 101 F.
At this time he liad a sore on the chin, another on the
body near the left nipple, one at the nasofrontal
junction, and three or four on the scalp. He says that
he ran a daily fever for about a week and always had
some headache and bone pains. He got better except
the sores, and on .Tanuary 4, 1920, was transferred to
the United States with the diagnosis of impetigo
contagiosa.
On admission, January 14, 1920, he presented the
following crusted, circumscribed and pustular, foul-
smelling lesions : one on the forehead, one on the top
of the head of one month's duration, two that looked
very like ringworm of the scalp located on the occiput.
These he had had for about three weeks. One at the
peno-scrotal junction of about two weeks' duration.
The most interesting were those at the frontonasal
junction and one on the chin. They were both granulo-
matous and not unlike a fig, both for colour and con-
sistency. The one on the forehead was about the size
of a small strawberry and bled easily when examined.
The lesions of the head were ulcerative and distinctly
ring-shaped, with raised borders, and had a tendency
to bleed when touched. .\11 the lesions of the scalp
exuded a yellowish foul-smelling discharge which had
a marked tendency to crusting.
At the time of admission the accuracy of the
diagnosis was doubted as it was believed to be a case
of syphilis — the lesions frambcesiaform syphilides,
excepting the two on the occiput which were believed
to be ringworm. Scrapings were made from these and
found negative for mycelial threads. Two days later
the Wassermann report came back 4 plus in all
antigens, but doubt arose over the character of the
lesions and the patient was taken to Vanderbilt Clinic
for consultation. Various diagnoses were made by
the attendants with the majority voting for syphilis.
A Brazilian dermatologist was visiting that day and
gave the unhesitating diagnosis of yaws. Immediately
serum from the lesions was examined and treponema
demonstrated. Sections were taken from the biopsy,
reports of which follow : Intravenous administration
of arsephenamine 6 grm. and salicylate of mercury
intranmscularly '065 grm. once a week. The improve-
ment was little short of marvellous after the first dose
of arsephenamine, and after the third practically all
the crusts had fallen off. It is interesting to note that
he had a chill on the day following the third dose of
arsephenamine. His blood was examined, and many
parasites of benign tertian malaria were found. The
arsenic was discontinued and intravenous quinine
substituted for malaria. He had one moderately
severe reaction following the quinine and made an
> The Military S^irgemi. (Navy Number), vol. xlvii, No. 3.
uneventful recovery. One month after admission the
Wassermann was still plus 4 in all antigens. No open
lesions. He was given 30 days' leave and on his return
to the hospital his blood was still plus 4. Another
dose of arsephenamine was given and the blood was
found to be 3 plus. Two more doses were given and
he was sent to duty after 90 days well. Wassermann
negative — all antigens.
Pathological Reports.
(1) Sections stained with hffimotoxylin and eosin
show tissue to be composed largely of irregularly
hypertrophied epithehal tissue with a relatively small
amount of corium, the surface being covered with
exfoliated epithelial cells, hsemorrhage and debris.
Through the tissue proper there is marked infiltration
by polymorphonuclear leucocytes with here and there
small abscess-forming undoubtedly secondary infection.
(2) Sections stained by Levaditi method of staining
show treponema fairly numerous in the epidermis and
not in the corium. It was unfortunate that tissue
received did not include a larger section of corium on
account of the fact that an important point of differ-
entiation between the pathological picture of a skin
lesion due to yaws and a skin lesion due to syphilis is
the finding of the Treponema perteiiue in the epidermis
in yaws and the Treponema pallida in the corium in
syphilis.
(3) Diagnosis, yaws.
Low Power. — The slide can be divided into two
areas, one of which is deeply infiltrated, the other
slightly so. Over the first area there is a fairly
marked acanthosis with enormous thickening of the
granular layer. These features are lacking in the
second area.
The infiltration in the main involved area extends
from just below the epidermis down for three-fifths of
the section. In the second area it is disseminated and
lies about the vessels and skin adenexia in numerous
foci in the upper three-fifths of the section.
Hi(ih Pojccr. — In both areas the infiltration consists
almost entirely of large succulent polyhedral plasma
cells. The vessels are slightly increased in number
and somewhat dilated, but there is no inflammatory
change in the walls such as found in syphilis. Neither
is there any change in the connective tissue such as
might be indicative of syphilis.
Summary.
Acanthosis plasmoma speaks either for syphiUs
or yaws. Probably the latter because of the epidermal
changes and the absence of vascular disturbance.
Diagnosis.
From bromide eruption which it may well resemble.
The history of taking bromides and eliminating the
drug will clear this point.
Syphilis.
Priniary lesions differ from secondary ones.
Pleomorphism of lesion.
.\ffects mucous membranes.
Visceral involvement.
Central nervous system involvement.
Primary sore usually genital.
Nov. Ic
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Yaius.
Priiiiaiy and secondary lesions identical.
No variations of lesions.
Only affects the skin or region at junction.
Viscera spared.
Absence of cord and brain involvement.
Primary sore always extra-genital.
Yaws is distinguished from (1) Actinomycosis and
rhinoscleroma hy the absence of their specific
organisms. (2) From the lepromataides by the absence
of Hansen's bacillus. (.3) From mycosis fungoides by
the absence of " fragmentation " of the infiltrating
cells, and of degenerative changes with the formation
of products of degeneration in the collagen and
elastin ; by the presence of the epidermal changes
peculiar to yaws. (4) From tuberculosis, apart from
the tubercle bacillus, by the absence of the character-
istic architecture with its giant cells, daughter plasma
cells, more marked disintegration of the fibrous stroma
and complete disappearance of blood cells.
From syphilis hy the following details, which, con-
sidered collectively, strongly suggest that yaws and
syphilis are different histological entities : (a) Cellular
infiltration ; plasma cells not so definitely arranged in
rows or clustered around the blood vessel as in
syphilis; no large multinuclear cells (chloriplaques),
or true giant cells, or intracellular hyaline degeneration
noted in yaws ; (h) fibrous stroma : rarefaction of
collagen more marked than in syphilis, but no organi-
zation or celloid degeneration found, such as occurs
in syphilitic gummata ; (c) blood vessels ; no distinct
proliferative changes in the vessel walls or endothelium,
as frequently occur in syphilis; (d) epidermis: marked
proliferation and down growth of the epithelium, witii
great thickening of the horny layer (due to hyperkera-
tosis or parakeratosis) are characteristic of yaws,
while tiiey are unusual in syphilis.
Comment.
It is interesting to note that almost two years had
elapsed since the patient had been in a country known
to have endemic yaws, and the disease developed in the
winter when the possibility of fly contamination was
exceedingly small. He had not been away from Brest,
France, for more than nine months.
The most likely source of infection was from a
barber shop where he had been shaved regularly. This
place was patronized by French colonial.troops recently
returned from Africa, and it is believed that this is
where he Ijecame infected. Another probability is
from an Algerian trooper who helped him make repairs
on telephone lines, but he did not notice anything
wrong with this soldier. The first thing he noticed
was the sore on his cliin, but he does not recall being
nicked by a razor. It is probable that this is where the
infection gained enirancc and that it was the " mother "
yaw. The lesions on the occiput so closely resembled
ringworm of the scalp that almost every one seeing
them made tiiat diagnosis.
Tiie improvement of the skin condition after the
first dose of arsephenamine was little short of
marvellous. The lesions began to dry, many of the
scabs dropped off, and l)y the end of tiie week the dis-
charge had almost lost its odour, and by the middle of
the following week had- entirely ceased.
A SIMPLE METHOD OF CULTIVATING THE
MIORO-OIiGANISM OF ACTINOMYCOSIS. '
By M. H. Gordon, M.D.
Cases of actinomycosis are apt to be overlooked
unless film preparations are invariably made from
all purulent material submitted for bacteriological
examination. The writer has had experience of
two tragic cases in which, apparently from this
omission, the true nature of the disease was only
diagnosed shortly before death. One of these oases
was a young woman who had suffered for some
months from metastatic abscesses; a number of
consultants had been called in, but as blood cultures
were negative and cultures from the pus had only
yielded staphylococcus, the condition was thought
to be due to that micro-organism. The writer saw
the patient for the first time a few hours before
lier death. A film of pus discharging from a sinus
in the wall of the aMomen when stained by Gram
revealed the typical actinomycotic mycelium. The
ot>her case was an empyema of some standing which
had been attributed to the pneumococcus. Here
again the detection of actinomycas, which was
present in abundance, was effected too late for
treatment either by iodide or vaccine to be of avail.
The second point to which I wish to draw atten-
tion is that the actinomyces fungus can be readily
cultivated in ordinary nutrient broth to which a
few drops of fresh human blood have been added.
It is advisable to sow the material in two blood
broths, one of which is covered by a layer of oil
1 cm. deep. After incubation for a few days at
37° C, the actinomyces fungus c^n be seen growing
at the foot of the tube in small white masses — like
little puff-balls. As a rule, growth occurs first in
the broth covered with oil, but when other bacteria
are present the actinomyces may come up first in
the aerobic tube. Before, using this method the
writer could never get a satisfactory primary growth
of actinomyces, but since employing it he has
succeeded in doing so with ease in all of seven
cases. The practical advantage of getting a growth
is that a vaccine can then be prepared. In two
cases in which a vaccine of the homologous
organism was employed improvement resulted. In
the majority of the cases, however, vaccine treat-
ment was not attempted, as secondary infections
were present and the disease was too far advanced.
Vaccination with a stock actinomyces vaccine is, in
the writer's experience, useless; it seems essential
trj employ the actual strain infecting the patient.
In the case of patients whose lesions clear up under
vaccine treatment, it is wise to preserve a pheno-
lated suspension of the vaccine in a sealed glass
tube, so that it may be available in case of recur-
rence. In one case recuiTence took place after an
interval of nearly two years.
' Abstracted from the British Medical Journal, March •il, 1920.
THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 15, 1920.
A METHOD OF CHOLERA DIAGNOSIS.'
By Captain Abthub Davies, E.A.M.C.
The details of the technique are as follows ;—
(1) Put a platinum loopful of faeces into a test tube
containing 5 cubic centimetres of ordinary 1 per cent,
peptone water (slightly alkaline to litmus). Incubate
for eighteen hours.
(2) From each of the resulting cultures, pipette one
drop of the peptone water growtli on to one of the
divisions of a Garrow agglutinometer slab. (Twenty-
four specimens can be conveniently examined on one
slab.)
To each of these drops is added a drop of Lister
cholera agglutinating serum (1/80 dilution).
The slab is then rotated for three minutes (at the
rate of one revolution per second) sb as to bring the
drops of culture and agglutinating serum into intimate
contact.
At the end of this period the slab is removed and
examined in a suitable light, when it will be found
that cultures containing vibrios give well-marked
agglutinated clumps obvious to the naked eye.
The positive cultures are kept for further investi-
gation, the negative being discarded.
(3) All the positive cultures are assembled, also
bottles containing agglutinating serum in dilutions of
1/320 and 1/640.
Pipette on to the Garrow agglutinating slab one
drop of the 1/320 dilution of cholera agglutinating
serum ; one drop of the 1/640 dilution of cholera
agglutinating serum ; one drop of normal saline.
To each of these drops add an equal drop of the
culture under examination. Rotate the slab for three
minutes, remove and examine. Cultures containing
vibrios give well-marked agglutination clumps, obvious
on naked-eye examination, i.e., the peptone culture
contains cholera vibrios agglutinated by the specific
agglutinating serum in a dilution of 1/1280.
(4) These positive cultures can be further investi-
gated by plating them out on any suitable medium
(e.g., MacConkey, alkaline agar, &c.) Suitable colonies
are selected for sub-culture and subsequently for
biochemical reactions.
This arrangement enabled the medical officers in
charge of wards to examine their cases and to arrange
for the dispatch of stools in the morning, and for the
segregation and treatment of cases returned as positive
in the afternoon and evening.
Accuracy of the Technique.
In order to establish the accuracy of the technique,
the first hundred peptone water cultures reported as
positive were plated out on MacConkey medium. In
each case the cholera vibrio was recovered from plates,
and in each case the vibrio isolated gave the correct
morphology and biochemical reactions of Koch's
cholera vibrio. Each vibrio exhausted the full titre of
the Lister cholera agglutinating serum used. No
anomalous vibrios were found. The only slight
variations were in the degree of acidity and rapidity
' Abstracted from the Jotimal of tlie Boyal Army Medical
Corps, vol. XXXV, No. 4, October, 1920.
with which the acid was produced in lactose and
mannite. These first hundred plate cultures invariably
corroborating the results obtained under Stage 4 during
the remainder of the epidemic.
Rate of Reporting.
Each worker can report on 150-200 specimens per
day, for as many days as an epidemic lasts. The
technique involves no mental strain. The rate of
reporting depends chiefly on the number of peptone
water tubes available.
Antagonism of Intestinal Organisms to th
Cholera Vibrios.
A sharp scrutiny was kept on the peptone water
cultures for evidence of the Bacillus pyocyatieus or
other micro-organisms that might kill the cholera
vibrio during incubation.
The B. pyocyaneus was conspicuous by its absence,
as far as could be ascertained from the observations
made of both plates and peptone cultures. During the
early days of the epidemic, an emulsion of .5 cubic
centimetres of fluid fseces was sown with a loopful of
a peptone culture of cholera, and kept on the laboratory
bench. Sub-cultures in peptone water at weekly
intervals for two months invariably gave positive
results on incubation, showing that the cholera vibrio
had held its own with the other intestinal organisms
for this period. These observations enabled us to
accept stools for examination from difi'erent camps.
Microscopic Examination of Positive Peptone
Cultures.
A considerable number of these peptone cultures
which gave positive readings by my technique and
from which the vibrio had been recovered from plates,
were examined by the hanging-drop method and stained
films. Even at the end of the epidemic, when con-
siderable experience had been gained, tlie vibrios
present were recognized with difficulty. If reports
had been sent out on such examinations, the error
would have been great and it would not have been
possible to control the epidemic under consideration.
Possible Errors.
In the Bandi "Method of Rapid Cholera Diagnosis,"
the suspected faeces is inoculated into peptone water
containing agglutinating serum, but this method is
modified on account of the too great expenditure of
agglutinating serum involved for the carrier examin-
ations on a large number of cases. A preliminary and
ordinary peptone water culture is made from the faeces
and looked through after twelve hours. Those cases
without vibrios are not proceeded with. Those with
vibrios are inoculated into peptone water, containing
cholera serum of two or three times its titre strength,
and agglutination looked for after two hours.
This modification, in my opinion, economizes agglu-
tinating serum at the expense of accuracy. It is
especially desirable in the case of carrier cases, where
vibrios may be comparatively few, to be independent of
the necessity for microscopic examination for the pre-
liminary selection of cultures.
J
Nov. 15, 1920.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
283
Comfnt Ifiteratttrf.
Bulletin de la Societe de Pathologie Exotiqde.
September, 1920.
Pathogenic Action of a Fungus Parasite on Bam-
boos in Central Africa. — J. Bequaert was suddenly
seized with violent colic, accompanied with persis-
: tent diarrhoea and pains in the joints of the limbs
I after having slept with a cryptogam under his bed.
The fungus was an acidium form of an Uredinea,
I and was found growing on a bamboo of the species
I Arunditiaria alpina K. Schumann, growing on the
; slopes of the Ruwenzori Mountains in Central
Africa. No analogous fungus of bamboos could be
: found mentioned in the Sylloge fungarum of Suc-
I cardo and previous travellers to the Mountains of
the Moon seem to have been unacquainted with it,
though its pathogenic action was familiar to the
natives. The symptoms rapidly disappeared on
removal of the cause.
lonoid of Arsenic in the Treatment of Paludism.
— V. Dupont recommends a new arsenical prepara-
tion, a colloidal arsenic prepared by Fouard's
method to which the name of ionoid of arsenic is
given. It is given in doses of 3 c.c. as intra-
muscular or intravenous injections which cause no
pain or reaction, the drug possessing little toxicity.
A Case of Bronchial Spirochsetosis in Brazil. —
A. Carini records the first case of Castellani's
broncho-spirochaetosis in Brazil. A Portuguese
married woman, aged 83, who had lived six years
in Brazil, had an attack of influenza, the con-
valescence from which was prolonged. During the
attack of influenza the sputum was bloodstained,
and the bloodstained sputum reappeared during
convalescence. Tubercle bacilli could not be^ound
in the sputum, btit spirochaetes conforming in every
particular with those described by Castellani were
present in large numbers. Treatment by injections
of neosalvarsan and of sodium iodide and tartar
emetic and Fowler's solution by the mouth, as well
as injections of the patient's sputum sterilized by
ether, after the method recommended by Kraus in
the treatment of whooping-cough, produced only
slight improvement. The cough still persists with
sanguineous sjjutum containing numerous spiro-
chtetes.
A Leucocytozoon of the Little Owl of Brazil. —
A Carini found a leucoeytozoon, as well as a hal-
beridum, in the blood of the Brazilian little owl,
Scofs brnsiliensis. It presents characters very
similar to those of Leucoeytozoon zemanii, and it
is difficult (o decide whether it is a new species or
not. If so, the name Leucoeytozoon lutzi is
proposed.
The Probable Syphilitic Origin of J uxta -articular
NodositicH. — Poupelain has observed five cases in
a dozen years in the French hospital at Tcheng Ton
which ail developed in syphiltics and disappeared
under iuiti-syphilitic treatment.
Juxta-articular Nodosities in the Annamites :
Treatment by Novarsenobenzol. — L. R. Montel
constantly noted the cp-'existenc© of juxta-articular
nodosities and syphilis, and that treatment by intra-
venous injections of novarsenobenzol lead to their
complete disappearance.
Contribution to the Study of Trypanosoma vene-
zuelense Mesnil 1910 (M. Leger and E. Tejera). —
Trypansoma venezuelense resembles T. evansi mor-
phologically, but serological and biological experi-
ments confirm the opinion of Mesnil that they are
two distinct species of trypanosome.
Strongyloides iniestinalis Bavay 1877 in the
Intestine of Man in Senegal. — F. Noc, V. Henry,
and A. Esginer report the first two cases of the
presence of this worm in the human intestine in
Senegal.
Intestinal Parasitism in Annam (F. Motais). —
Intestinal parasitism is very common in Annam ;
the association of parasites — as many as six
different species having been found in one stool —
brings the percentage of infestation to 140 per cent.
Experimental Infections of Dogs and Guinea-pigs
with Cultures of Herpetemonas of Insects. — A.
Laveran and G. Franchini having previously shown
that severe and even fatal infections niay be pro-
duced in white mice by the inoculation of cultures
of flagellata from various insects, carried out experi-
ments of the same order in the dog and the guinea-
pig. In old dogs local sores resembling those pro-
duced by Leishmania tropica were produced with-
out general infection, whilst in young dogs general
infection with the presence of the pai-asites in the
blood resulted without local lesions. Elongated
forms of the parasite were observed having the
appearance of herpetemonas without flagella. In the
guinea-pig no symptoms were produced, infection
only being revealed by histological examination of
the blood.
The Prevalence of Leptospira Ictero-hsemorrhagix
in the Wild Rats of Sao Paulo, Brazil— W. G.
Smillie inoculated guinea-pigs with the kidneys of
forty-one normal-appe<iring rats captured in the
city of Sao Paulo, with the result that four of the
guinea-pigs developed typical symptoms of epidemic
jaundice, and Leptospira ictero-hsemorrhagix were
found in their organs. Three of the strains were
cultivated by the method A of Noguchi. A large
proportion of the guinea-pigs inoculated with rat
kidneys developed a high immunity to a virulent
strain of Leptospira ictero-hsemorrhagix. A large
percentage — 7li or more — of Stio Paulo rats thus
harbour Leptospira ictero-hxmorrhagix of a low
virulence which produced immunity in guinea-pigs'
without producing objective symptoms.
Ankylostomiasis and Beriberi in French Guiana.
— W. Dufoug^re shows how anj^ylostomiasis has in-
creased in French Guiana during the war owing to
the relaxation of prophylactic nieasuros. Cases of
(Edema also occurred in French Guiana which were
found to be due to beriberi.
284
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Nov. 15, 1920.
The Treatment of Leprosy b'y Intravenous Injec-
tions and by Ingestion of Emulsions of ChauU
moogra Oil. — L. Stevenel finds that chaulmoogra is
a specific for leprosy when intensively administered
as a well-rnade emulsion, either by intravenous in-
jections, by ingestion, or by rectal administration.
At the same time an appropriate alimentary regime
causing decalcification of the organism is a great
factor in bringing about a cure and should not be
omitted.
Observations on the Pasteurelloses in Morocco. —
H. Velu records epizootics of pasteurelloses amongst
pigs and cattle in Morocco. The epizootics occur in
the spring, and infection results from drinking con-
taminated water supplies. Good results, both cura-
tive and prophylactic, were obtained, from the use
of a polyvalent serum.
Two Cases of Cerebrospinal Meningitis in Goats.
— H. Velu and F. Bosavy record two cases of
cerebrospinal meningitis in goats with characteristic
symptoms and autopsy findings, but in which no
micro-organisms could be obtained from the blood
or cerebrospinal fluid.
Paludism and Islovarsenohenzol. — G. Paisseau
recommends the systematic treatment of paludism
by the combined use of intramuscular injections of
quinine and intravenous injections of novarseno-
benzol, each course comprising eight injections of
1-20 grm. of quinine and one of 015 gnn. and eight
of 0'30 grm. of novarsenobenzol in eleven weeks.
Although sterilization does not result, relapses are
prevented during the whole period with considerable
improvement in the general condition as shown by
increase in weight, disappearance of anfemia, and a
return of strength.
Experimental Researches in the Hole of the
Gecko (Tarentola Mauritanica) tti the Etiology of
Oriental Sore (C. Nicolle, G. Blanc, and M. Lan-
geron). — From the blood of two out of twelve
geckoes at Tanierza, where oriental sore is endemic,
a leptomonas distinguishable from leishmania and
the leptomonas of the gecko at Tatouin was culti-
vated on the NNN lurdium. It grew extremely
slowly, and was not virulent for man, monkeys,
mice, or geckoes. Parasites are thus only seldom
found in the blood of the gecko, but more frequently
in the digestive tube. The gecko does not appear
to play an important role as the natural reservoir
of the virus of oriental soro.
The Reservoir of the Virus of Oriental Sore. —
C. Nicolle considers that the hypothesis of the gecko
or the camel being reservoirs of the virus of oriental
sore should be abandoned, no proof of the hypo-
thesis having been brought forward.
Stallions Clinically Cured of Dourinc as Healthy
Carriers of Pathogenic Germs. — E. Sergent, A.
Donatien, and A. L. Heritier found that in stallions
thoroughly cured clinically of dourine, whose blood
was non-iiofective in doses of several litres, ttypano-
somes may suddenly reappear in the blood after an
interval of more than three years. Hence a stallion
which has suffered from dourine may remain infec-
tive even when presenting the appearance of a
perfect clinical cure.
The Experimental Diagnosis of Dourine. — E.
Sergent, A. Donatien, and A. L. Heritier recom-
mend intraperitoneal injection of dogs with the
blood of horses suspected of dourine. Only the
positive results are of value, since ^^ to ^V of the
total bulk of the infected horse's blood may be so
injected without result.
Experimental Infection of the Dromedary with
Trypanosoma berbcrin of Drbab. — Edm. and Et.
Sergent and A. Donatien find that experimental
infection of dromedaries with Trypanosoma ber-
bcrin comprises two stages — an acute of throe to
four months and a chronic of months' or years'
duration passing into a latent infection with relative
immunity against reinfection. Wasting and weak-
ness diminish the resistance of the dromedaries to
every pathological influence, death being often due
to a complication. In the female abortion occurs.
On the Heredity of Infection and Immunity in
the Trypanosomiasis of Dromedaries. — Edm. and
Et. Sergent and A.. Donatien found that two baby
camels, bom of cured but still infected mothers,
were not infected with trypanosomes or possessed
no immunity against debab.
A new Flag-cUum of Rhoduius prolixus, Trypano-
soma (or Crithidia) rangcli. n. sp. (E. Tejera). — In
searching the int-estinaJ contents of Rhodnius vro-
lixus in Yenezuola for Trypanosoma cruzi, a new
crithidial form, named Trypanosoma rangcli, was
found by Tejera to the exclusion of Trypanosoma
cruzi.
Filarial Itch as a Manifestation of Volvulosis. —
J. Monpellier Degouillon, and A. Lacroix consider
that the microfilaria of Onchocerca volvulus and
those found in the skins of dai'k races in filarial itch
are morphologically identical and cannot be differ-
entiated from them.
On the Relationship of Onchocerca volvulus and
Filarial Itch. — E. Brumpt doubts the role of Oncho-
cerca volvulus in the production of filarial itch,
and he denies the identity of the microfilaria found
by O'Neill in filarial itch with the embryo of
Filaria perstans.
The Importanrr of the Cervical PapilLr of Anky-
lostomes. — M. Langeron points out that amongst
certain spiroptera the cervical papillae present suffi-
cently specialized modifications as to be character-
istic of the species.
On Anaphylaxis from Quinine — Anti-anuphylaxis
and Desensitization (Pasteur Vallery-Radot). — Re-
marking on a case of anaphylaxis from quinine
taken by the mouth reported by Montel, Vallery-
Radot states that desensitization may be brought
about by giving per os a small dose of quinine an
hour and a half before the harmful dose of quinine.
Dec. 1,1920] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 23, Vol. XXIII.
(Sriginal tfommunimtions.
PKELlMINAliY NOTE ON THE TREATMENT
OF NODULAR LEPROSY BY INTRAVEN-
OUS IN.JECTIONS OF CHA ULIMOOGRA
OIL.
By P. Harper, M.R.C.S., L.R.C.P.
Makogai.
The mixture used is tlie following : —
R Iodine ... ... ... ... 1 gr.
Ether 500 m
01. ohaulmoogra 500 ni
The chaulmoogra oil is not warmed to clarify. It is
well shaken, so as to mix up its solid and liquid con-
stituents, and then the quantity is measured off. The
ethei' is relied on for clarification of the solution and,
as a fact, the resulting solution is a fine clear maroon
colour. The iodine is relied on for sterilization of the
solution. For the first two or three days only 10
minims of the mixture (containing .5 minims of ol.
chaulmoogra) is injected. Thereafter 20 minims are
given. The following veins have been used for injection :
ext. jugular, median basilic, median cephalic, small
veins of forearm and of back of hand, cephalic,
basilic, internal saphenous and veins of dorsum of foot.
Tlie bigger the vein the better, because in a big vein
the fluid is diluted more quickly by the blood. The
injection may bo given quickly for the first .5 minims
of the mixture, but must tliereafter be given very
slowly, taking about three minutes for the 20 minims.
Intravenous injections of 20 minims of the mixture are
given daily for six days a week, none being given on
the seventh day. I propose to continue this as long as
indications point as at present.
An ordinary 20-nainim hypodermic syringe with the
finest possible needle is used.
Immediate Resitlts.
(1) Taste of ether on injection of first 5 minims.
(2) Acceleration of respiration and pulse.
(3) Cough in cases with marked nasal or laryngeal
disease.
Later Results.
(1) Four hours after injection there is a rise of
temi)erature gradually reaching 100° to 101° and
lasting about 8 hours, falling gradually to normal.
(2) Leucocytosis.
Remote Results.
It is too early to give a definite opinion. Literature
of the intravenous exhibition of chaulmoogra oil is
scanty. The only references I can find are in the
Tropical Diseases Bidletin. M. Varham, Stevenal and
Noc appear to have' used minute doses, e.g., in Vol.
XI of the Tropical Diseases Bulletin Varham's dosage
is described as being 00002 grin, per kilo of patients'
body weiglit. This is about 1/40 (one-fortieth) of my
dosage, and Varham's dosage appears to have been
given on alternate days, whereas I give the drug daily
for six days a week.
Varham first tried an emulsion of these minute
doses in gum arable, but later he seems to have
saiionified with NaOH.
So far I have given hundreds of these intravenous
(loses of chaulmoogra oil and ether (seventeen patients
now under treatment &nd many more wanting to start
it), and we have had no suspicion of fat embolus or
other serious trouble. All patients have gained weigiit
with one exception and his weight has remained
stationary. I report my method (l) in order to put it
on record and (2) to secure its trial in other Colonies.
NOTES ON THE PREVENTIVE USE OF
QUININE.
By Dr. Haeald Seidelin,
Principal Medical Officer, S. A. des Huileries du Congo Beige,
Kinshasa, Belgian Congn.
The effect of quinine, whether therapeutic or
prophylactic, has probably never been subject to
more discussion than during the last few years. So
far, unfortunately, the discussions have by no means
cleared away the difficulties. Valuable material has
been collected, i)ut the conclusions drawn differ as
much as ever, and often appear equally well founded.
It is impossible that all observations should lie
expressed in actual figures, and sometimes a general
impression may count more than rows of such. But
when figures are given, they ought to be both correct
and accurate. Otherwise, they become misleading
instead of instructive. Thus, when the author of a
recent paper to which I shall return later (Pearson,
1920) states that 20 gr. of quinine orally correspond
to 15 by intramuscular injection, he conveys — and
means to convey — the impression that the same
quantity of quinine would have greater effect by the
latter method than by the former. But as he gives
bihydrocloride (74'8 per cent, alkaloid, according to
Ziemann, 1918) intramuscularly, and bisulphnte (.59'1
per cent.) orally, a simple calculation shows that the
proportion between the quantities given instead of as
4 to 3 is as 197 to 187, the difference would appear
so small as to be negligible.
As we wish to obtain the effect of quinine, not of
an acid, it ajjpears sound to administer the alkaloid,
as some authorities do. With this 1 have no experi-
ence, but, with a few exceptions (euquinine when the
taste is objected to), I have always used the hydro-
chloride, witli 817 per cent, of alkaloid. The general
use of such an effective preparation which apparently
has no inconvenience, would among other advantages
probably possess that of doing away with most of the
indications for the use of quinine injections wliich
would then be reserved for cases in which persistent
vomiting makes oral administration impossible.
In prophylactic use, no method has proved effective
under all conditions. Sometimes the daily adminis-
tration of 20 or 25 eg., or of 5 gr. (32 eg.), has been
a success, sometimes it has failed, and as much may
be said about the administration of larger doses,
generally one grm. (15 gr.), at longer intervals. A
definite conclusion could probably only be arrived at
by experimental study of the effect of quinine on the
various parasites, controlled by exact observations in
practice. Decisive results have so far been obtained
in neither way. Many statistics have been publishi-d,
THE JOURNAL OP TROPICAL MEDICINE AND HYGIENE. [Dec. 1, 1920.
but I know of few figures which are both exact and
comparable. Such figures could only be obtained
through the long-continued administration for a long
period, according to two different systems, in the
same place, and at the same time, to two series of
individuals chosen at random among a body of men
who had never before been infected with malaria.
The experiments would liave to be repeated in the
same way in places of different degrees of endemicity.
The problem ought admittedly to be solved on the
strength of accurate observations and actual figures,
and on such alone. But in their absence it may be
permissible to go, on the one hand by personal ex-
perience, and on the other by logical reasoning.
The various methods fall in two groups, those of
smaller daily doses, and those according to which
larger doses are given at intervals. The underlying
principles are so different that in all probability both
cannot have even approximately the same value. It
would help towards a general understanding if these
principles were kept clearly in mind, and I submit
that if one method has a decidedly sounder logical
basis than another, the former ought in the first
instance to be given a trial, and in the absence of
opportunity for exact experiments should be adopted
until another method be proved superior.
It appears to me that the logical basis of the
" week-end prophylaxis " is more logical than that of
any other system, and as it is often known only in a
vague and general sort of way, I propose to state it
here as I believe it to be accepted by most of its
advocates.
(1) Our object is to prevent malaria parasites from
establishing themselves in the blood, i.e., to kill them.
For this purpose we know from the therapeutic use of
quinine salts that small doses are useless, hut we
have good reason to believe that about 1 grm. of
quinine hydrochloride per diem, for an individual of
about 65 kilos body-weight, is effective, at any rate
in infections of moderate severity. We have no
reason to believe that the amount of quinine required
to kill should vary to any gi-eat extent with the
number of parasites. Presumably the concentration
of alkaloid obtaining in the blood is decisive. There-
fore the prophylactic doses should be the same as the
therapeutic, i.e., about 0015 grm. per kilo body-
weight or, when individualization is impracticable,
] grm. per diem per individual.
(2) In order to prevent disease, the prophylactic
dose should be given before the parasites have increased
sufficiently in number to produce fever, i.e., before the
end of the natural incubation period, of which the
minimum in " malignant tertian " infections is six
days, according to Eoss (1911).
(3) A certain amount of evidence tends to show that
malaria parasites may acquire an increased resistance
to the deadly effect of quinine. This we hope to avoid
by killing them off, instead of keeping them under,
living in the tissues, subject to the continued action of
quinine, but unable to produce fever, until perhaps
they have become "quinine-resistant."
To these fundamental principles I would like to add
a few remarks.
The administration of 1 grm. every sixth day might
perhaps be sufficient. But as we know from treatment
that the cumulative effect is of importance, and have
often seen parasites persisting in the blood after the
first day's dosis of 1 grm., only to disappear after the
second dosis, it is strongly advisable to add another
day's administration and fix two consecutive days of
each week for its administration. This has the great
additional advantage that it makes it easy to remember,
especially if one of the two days is Sunday, thus eithei'
Saturday and Sunday, or Sunday and Monday.
Another additional advantage is that the dosis may be
varied without having recourse to tablets of various
sizes. Thus, individuals of between 60 and 70 kilos
bodyweight take four tablets of 25 eg. each, on Satur-
days and Sundays, individuals of 50 to 60 kilos four
tablets on Saturdays and three on Sundays, of 40 to 50
kilos three on each of the two days, of 70 to 86 kilos
five on Saturdays and four on Sundays, of 85 to 100
kilos five on each of the two days, and so on.
Should the prophylaxis fail a febrile attack would
probably develop and be treated. On the other hand,
by the daily administration of small doses we may
expect chronic infections without fever, but with
anaemia and cachexia, or with low fever, likely to
present considerable difficulties for diagnosis and
treatment.
If the prophylaxis has achieved its result, the
administration of quinine may cease at once when
exposure to infection comes to an end. On the other
hand, the survival of parasites in an enfeebled condition
in the blood, the result to be expected from the use of
daily prophylaxis, would make it necessary to continue
the use of quinine for a long time after return to non-
infected places. We see, in fact, that the advocates
of the small daily doses advise the continued quinine-
taking at home, often during the whole of the leave.
It would be useless to give statistics, because I have
no means of controlling whether the persons under my
care actually take quinine with regularity. An no fair
comparison between two or several groups would be
possible, because the people who have sufficient
intelligence, and sufficient confidence in their medical
adviser, to adopt whole-heartedly the system recom-
mended, are also likely to be particularly meticulous in
adopting other preventive measures, such as those of
mechanical prophylaxis. Thus, they would be less
exposed to infection.
Therefore, I can only state that the results have
been exactly as expected. For the last twelve years or
so, whenever in malaria-infected countries, I have
adopted and advised the adoption of this system, and
I have never yet seen a case of malaria in an individual
whom I had reason to regard as its regular follower.
I have seen short fevers in individuals who had adopted
it late in their tropical career having already been
infected before. This is what one would expect. A
few cases occurred in men who said tliey had adopted
the system, but in which I could prove that they
had not taken nearly the total amount of quinine
corresponding to the period in question.
On the other hand, I have seen quite a number of
cases in men who said that the\ were regular daily
quinine-takers, but also this ma\- he open to doubt. It
appears, however, significant that if has also been
Dec. 1, 1920.,
THE JOUKNAL OF TEOPICAL MEDICINE AND HYGIENE.
among their number that I have occasionally found
numerous parasites in the blood on routine examination
of men without any febrile symptoms. This occurrence
I have never observed in people who had adopted the
" week-end system."
As so many observers from different parts of the
world have arrived at other conclusions it would be
absurd to believe that this system would be effective
under all conditions. But I consider it highly probable
that it will prove so everywhere where endemicity is
mod*ate and the fevers of no unusual intensity. In
the treatment of malaria fevers in the parts of the
Congo which I have visited, I have never found any
reason to exceed the dosis of 1 grm. per diem, in 4
tablets taken in the morning with hourly intervals,
for a man of average weight. In case of persistent
vomitting, a similar quantity has been given in injec-
tion, but oral administration adopted as soon as vom-
iting has ceased.
Although my experience in the Congo has been
obtained in regions very different from those discussed
by Pearson (1920), my impression is the same that
malaria here is a comparatively benign disease, cer-
tainly more benign than many cases I have seen in
Yucatan, Mexico, and some in Jamaica and in West
Africa. Even in Yucatan, however, where very severe
cases occurred in native and Asiatic labourers who
had taken no prophylactic quinine, it was hardly ever
found necessary to give higher doses than the above-
mentioned.
It may perhaps be asked whether the very large
doses of quinine now so much in use, have ever been
required except in individuals who had already been
taking large quantities as a preventive measure, and
who had probably acquired their infection in countries
where prophylaxis had been extensively used.
If a malarial infection is at all amenable to treat-
ment, it may be expected that the dosis of quinine
fatal to the strain of parasites obtaining can be deter-
mined, and the natural incubation period. The com-
bination of these two factors should make it possible
to determine in each case a prophylactic system likely
to be effective and unlikely to produce quinine-resis-
tant strains.
I would like to add a small remark of great practical
importance. In all this work it is necessary to have
a reliable and rapid method of microscopical diagnosis.
No busy practitioner can find time for examining half-
a-dozen tliin lilood films in a day. If he attempts to
do so, he will run a great risk of missing positive
results. It is disheartening to see that the thick film
method after Koss, or Ross-Ruge, has not yet become
universally adoijted. It appears so far to be the only
way in which a considerable amount of fairly reliable
work can be carried out within a reasonable time.
REFERENCES.
Castkllani and Chalmers (1919). "Manual of Tropical
Medicine," 3rd edition.
Peabson. a. (1920). " Some Notes on Fifteen Years' Expe-
rience of Malaria in the Upper Congo." Journal ok Troi'icai,
Medicine and Hyoiene, July 15, pp. 177-180.
Ross, K. (1911). "The Prevention of Malaria," 'ind edition.
ZiEMANN, H. (1918). " Die Malaria, in Mense's Hdbch. d.
Tropenkrankh,'"2nd edition, V.
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TUK JOURNAL OF
Croptcai ® etiictnt anD l^pgtene
Decemhek 1, 1920.
SPRUE.
In the Indian Journal of Medical Research,
.\pril, 1920, there is au article by Trevor B.
Hcaton, M.A., D.M.Oxon., M.R.C.P.Lond., on
" Etiology of Sprue." It was written as a thesis
for the degree of ]).M., Oxford University, 1919.
Many of our readers are no doubt ncijuainted with
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
iDec.l, 1920.
the article, but to those who have not read it, it
will ifjiay them to do so. The number of sug-
f^'cstrd causes are legion — micro-organisms, cHmate,
lulinintlis, fungi, and a host of others. Their very
nuiiiln r li( trays the difficulty of elucidating this
will-()'-iii,'-wis]i of ailments, and we are still
engaged in the search after truth. Whether sprue
is even a speeitir disc-is, ■ has not vrt lunn settled.
and the field is still .i|hii to investigators and
clinicians, more i specially as i-egards treatment.
These uncertainties admit of empiricism to a
degree that is uneciualled perhaps in the wide field
of medicine.
Empiricism extending to quackery prevails, for
l)atients leave their doctors to tiy this and that
" wise man or woman " skilled in " herbs " and
secret remedies of sorts. Nor even are members
of the medical profession free from fads and fancies
in treatment which liave little of scientific basis.
One of the best known was that of the late Peter
Sys, a billiard marker in tlie Shanghai Club. He
was born in Sumatra, it is said, and he brought
with him to China a compound known as " Sys'
powder," which in one form or another is used to-
day in many countries. It is to be noted that in
Java and Sumatra sprue as a (liseasc was first
reported and named, and it spread tmni tin in . to
the Malay Peninsula, Ceylon, China and India.
Its spread, so far at least as nomenclature indicates,
was from the Equator northwards ; it apjjeared in
the South of China, and spread northwards from
thence, and in India a similar course is recorded.
Whether it was the disease that s|irc[id thus or
the na.mc merely is another question, most probably
the latter, for we find " diairhcea alba " and
"chronic tropical dian-hoea " recognized ailments
in India long before the name sprue was introduced
into that countn-. The many theories of origin,
such as hepatic exhaustion, a helminthiasis, a
penetrating fungus, a pyogenic micro-organism, a
protozoon of unknown nature, and a host of others
are so far unfortunately " not proven." The writer,
as so frequently stated in these columns, has long
favoured the chemico-physiological origin of the
disease, and he sees no reason to depart from it.
It is not a pojjular line of thought at the present
da.y, as it is not demonstrable in the direct, definite
and i-eadily apparent way that a bacterium or
protozoon entity is. It requires investigation along
a line that, as medical men, we have little training
in, and conse(juently is troublesome. It is a branch
of clinical work that will advance as the years pass.
.Ml are agreed that the disease is one of long
residence in the tropics. All also agree that the
European digestive organs in a ti-opical climate are
first stimulated to action by the heat, and subse-
quently decline in their activity, reaching: ;i stage
below the nonnal a.nd again acquire tluir b.daiico
and proper tone. If this continues all is well,
but the digestion is ever meagre in the tropics
and wants watching and some consideration in even
the most robust.
.As lif(> advances t( late middle age in the tropics
the digestive organs gradually lose their responsive-
ness, and a staid and set type of dieting prevails
becoming stereotyped in its quantity, quality and
variety (of which there is little). The digestive
organs are not encouraged in their range of work,
and certain of their functions and possibilities are
allowed to fall into abej-ance. The body is sup-
])lied with but a pai-t of the nourishment it
requires, and the digestive fluids being but
poorly endowed cannot but degenerate in their
])owers and produce secretions which, going phy-
siologically awl'y, lead to chemico-pathological pro-
ductions. A general atony obtains, and the normal
physiological secretions of the alimentary canal
give jdaee to fluids giving an acid in place of an
alkaline reiK-tion or vice versa. Firments are
thereby generated with residts which are so
marke<lly found in the alimentary tract from end
to end. Diarrhcra supervenes, the bodily strength
declines, and a mental ])erversion as regards food
and treatment shows itself. The patient leaves off
this and that food in the hopes of stopping the
diarrhci-a luitil a |>roi'ess of starvation, anaemia and
diminished bodily and mental power and aptitude
is engi iidcn d \vhi<li defies the doctor to combat.
-Micro-oi-^'.iin' ms of various sorts invade the ali-
nii iitat\ 1 .inal, and being found in stools (and
tissues it may be) leafl us astray in our efforts to
ascertain the cause and luiture of wdia.t is primarily
a digestive ailment due to a chemico-physiological
disturbance. The secretion of the mouth gives an
acid, and at other times an intensely alkaline
reaction; the gastric juice is well-nigh neutral;
the contents of the small intestine lose their
alkalinities and lend themselves to an acid fermen-
tative process v hich causes the bulky stools, the
frothincss of the jiultaceous mass, a.nd the loss of
the natural cobiur of the intestinal excretion. The
nourishment of the body is lessened, hence the
weakness, the excessive amount of sleep demanded,
the atony of the liver, Xc, and when the powers
of resistance fail the termind fever supei-venes.
True sprue always ends in a rise in temperature,
owing to uiicfo-oi-anisms and toxic jjroducts, from
six to ciglit wo ]>s b,.fore death.
The ti-iatnicnt of sprue resolves itself into two
schools, the milk- and the meat treatments. The
latter is gi'adually gaining ground, slov\ly because of
tlu' trouble it entails. Re it noted nothing but evil
will result from any atteni])t at a mixture of these
pbuis of trcitnicnt! Milk nt'ver did go with meat.
The Jewish laws as laid down in the Tahnud forbid
milk until two hours after fish, three hours after
i-hicken. and four hours after meat. In no .strict
Jewish household at the present day even are milk
])uddings given after meat or flesh of any kind.
The reason for this is apparent to those who think
of the matter at all; but " physiological treatmenf "
is not fashionable to-da.,>'. Milk for sprue gives no
trouble in the way of treatment, and so the fetish
continues. It is part of the " dock and nettle
system of ti'ea.tment we follow : quinine for malaria,
mercury for sy))hilis, and so on is the type of treat-
Dec. 1, 1920.] THE JOUENAL 01 TROPICAL MEDICINE AND HYGIENE.
289
iiifiit in vogue to-day amongst practitioners, whereas
none of our gieat teachers aiid predecessors ever
gave (juinine alone for malaiia, nor mercury
alone for syjjhiiis. We have fallen into the one
tablet or tabloid for each disease, a state of things
which neither experience nor physiology justifies.
Milk is given to " lessen the diarrhcKa, " it is
said, but milk on reaching the stomach and intes-
tine has its casein precipitat<;d, which is excrett-d
in a mass which looks like a solid stool, but it is
neither fcEcal in its smell, its appearance, nor its
consistence. It is like a piece of cream cheese, and as
the writer said, when asked to inspect a " beautiful '"
spiue stool as the result of milk : " it does not smell
of faeces ; it looks like a ' beautiful ' piece of cream
cheese, and if I did not know its origin, I would
have no hesitation in eating it." Milk will not
increase the size of the liver, for it does not call
upon the liver or the bile to help to digest it ; but
meat will, and in a few weeks insteatl of many
months or yeais. The fetish of milk and checking
the dian-hcEa is not the treatment of sprue, nor is
the death of any of the secondary organisms which
attend the pathological state. The primaiy disease
is an atonied liver and allied organs; meat will
stimulate them to activity, and by the stimulation
of the secretion of bile and by that alone will the
acid feniientation in the small intestine be checked
and normal alkalinity restored and sprue cured.
J. Cantlie.
Annotations.
Journal des Practiciens, September 20, 1920). — The
child is given hypodermic injections of the same milk
to which it is intolerasit. One injection of 5 to 10 c.c.
is usually sufficient. The mother's milk may be used
raw or boiled, but cow's milk must be boiled or heated
to 110° C. in a bain-marie for twenty minutes. The
injection causes a mild general reaction and a slight
rise of temperature. In most cases very satisfactory
results are obtained, and the restlessness, vomiting,
and diarrhosa disappear.
Operation for Pruritus Ani and Vulvas (C. W. Allen,
Neiv Orleans Medical and Surgical Journal, vol. Ixxiii,
No. 4, October, 1920). — By this operation the author
has in view the separation of the skin from the under-
lying tissues, thus dividing all the nerves which reach
the affected parts, rendering these anaesthetic ; a rapid
cicatrization is prevented by packing, which is main-
tained until a firm bed of granulation has formed,
which usually takes about a week, when the packing
is discontinued. An anaesthetic area is formed which
seems to be regarded by patients as a welcome change.
It gradually diminishes in size after a few months
with the return of normal sensation, and as yet no
complaints of the return of pruritus have been reported.
In the case of anal pruritus a series of incisions are
made beginning at the anal margin and continued
outward to about one-half inch beyond the affected
area, which is rarely known to exceed two inches. The
incisions are made at about an inch apart at their
peripheral extremities until the entire perineal region
has been covered.
Trcatmenl of Threadworms ivith Carbonate of Bis-
muth (M. Loeper, Progrcs Medical, 1920, p. 330.)—
The usual rectal medication succeeds only imperfectly.
The oxyuris develops in the large intestine but is
generated at the end of the small, where enemata do
not penetrate. Unfortunately, especially in the child,
santonin and thymol are not without drawbacks and
calomel has only a temporary effect. The author
believes to have discovered a remedy which is effi-
cacious an-d is non-toxic, even in children. He once
prescribed bismuth carbonate for two patients suflering
from gastric ulcer, and was surprised to find some
months later that not only had their gastric symptoms
disappeared, but that they were cured of oxyuriasis
fromwhich they had suffered for months. Since that
time he has adopted the treatment both in children
and adults.
For an adult the minimum dose is 10 grm. daily
in two doses. A child of 7 is given 4 grm. daily,
and a yovmger one 2 or 3 grm. according to age.
This diug has none of the toxic effects noted with the
other remedies. The sub-nitrate of bismuth might
possibly have the same effect, but occasionally is
toxic.
Hypodermic Injections of Milk in the Treatment of
Intolerance of Milk in Nurselings (Prof. Weill, Lyons
The Therapeutic Use of Oxygen (R. D. Rudolf,
American Journal of the Medical Sciences, July,
1920). — Oxygen is of value whenever a state of
anoxemia exists, as in cases of mountain sickness,
sickness from high flying, in poisoning by carbon
monoxide, nitrites, and arseniuretted hydrogen, and in
the effects of enemy gas. It should be employed in all
cases of cyanosis, and in such acute respiratory con-
ditions as pneumonia when anoxaemia threatens. The
usual method of giving oxygen by holding a funnel
connected with the oxygen cylinder near the face of
the patient is practically useless ; it should be given
through a rubber tube inserted in one nosiril, and this
may bo made more effectual if the opposite nostril is
rhythmically comjiressed during inspiration, the mouth
being kept closed.
Value of Complement Fixation Test in Tuberculosis,
(R. Upham and A. J. Blaivas, Joxirnal of Laboratory
and Clinical Medicine, St. Louis, vol. v. No. 12, Sep-
tember, 1920). — The authors tested for tuberculosis
patients who came for gastrointestinal disturbances,
and in whom tuberculosis was not suspected. The
antigens used were those of Petrofif, Miller and
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [Dec. 1. 1920.
Fleisher-Ives. There were eight positive results in the
original technic with Petroff's antigen, four with
Miller's, and three with Fleisher-Ives'. There was
not a single case in which Miller's or Fleisher-Ives'
antigens were positive that Petroff's was negative ; on
the contrary there were cases where Petroff's antigen
was positive and Miller's and Fleisher-Ives' was
negative. These conclusions are not regarded as final,
as future experiments may prove otherwise. The
authors agree with Singer and Ives that a serologic
test for tuberculosis is desired that will be as useful as
the Wassermann test in syphiHs is, but they do not
think that so far such a test has been found.
The JEtiologij of Denyue Fever (C. F. Craig,
A.M., M.D., Journal of the American Medical
Association, vol. Ixxv, No. 18, October, 1920).— The
author is of the opinion that dengue fever is caused
by a parasite which is closely related to the one
which causes yellow fever. As it has been proved
that yellow fever is caused by a spirochaete, Leptospira
icteroides, the search for a similar organism in the
blood of dengue patients, the cultural and animal ex-
perimentation methods used being those followed by
Noguchi in his demonstration of L. icteroides, is
believed to offer the most promising chance of demon;
strating the causative parasite of dengue. In 1906,
unsuccessful experiments were made by tbe author
and Ashburn, using every method available in an
endeavour to find such an organism in the blood of
dengue patients. The anaerobic culture methods
devised by Noguchi, so successful in cultivating
spirocheetes together with improved methods relating
to animal experimentation, are powerful aids to the
investigation of disease, and it is thought that if
properly applied in the study of etiology of dengue
fever it is only a question of time before the causative
parasite is found.
The Flagellate Character and Reclassification of the
Parasite producing " Blacky Head " in Turkei/s
(E. E. Tyzzer, Journal of Parasitology, vol. vi, No. 3,
March, 1920). — The author summarizes his investiga-
tion as follows : —
" •Classification. Smith originally placed the para-
site of the black-head, on account of its amoeba-like
characteristics, tentatively in the genus Amceba, and
much latei (Smith, 1915) retained the same generic
name under a different spelling, Ameba. The view-
expressed by Hadley that this organism is identical
with a previously described coccidium, Eimeria avium,
is untenable, and was later abandoned by this author.
Dofiein's suggestion that the organism as a parasitic
amoeba should be included in the genus Entamceba
now fails to apply with the discovery of flagellate
characteristics. Both Jowett's (1911) and Hadley 's
(1916-17) incorporation of the parasite into the genus
Trichomonas appears to be based upon a confusion of
at least two intermingled species for a single species
and is unacceptable without more conclusive evidence.
" The pi-oof that this organism is not an amoeba
makes necessary its reclassification. Its trichomonad
affinities are indicated by the type of nuclear division
which it presents, by the number of flagella indicated
in the five lines radiating from the blepharoplast and
by the character of its pulsating movements which
appear under certain circumstances so that it may
thus be included in the family Tetramitida;, Saville
Kent, 1880, as modified by Chalmers and Pekkola,
1918. The assumption of amceba-like characters
with respect to both movement and ingestion of solid
particles together with its ability to invade vertebrate
tissues appear to justify tlie creation of a new genus
for the species. In case it should prove to be an
aberrant form of a type species already described, the
generic name here offered may then be suppressed.
The name Histomonas is proposed for this genus,
which may be defined as follows : —
" Histomonas gen. nov. Pleomorphic parasite
TetramitidaR with amoeba-like phases of development
within tissues of host. The kinetic structures, asso-
ciated with blepharoplast, intraprotoplasmic during
amoeba-like phase. Nuclear division trichomonad in
type with well-developed paradesmose.
" .\part from the pulsating forms in hanging drop
preparations of material from lesions, flagellated
stages are unknown. No contractile vacuole, no
cytostome observed.
" Type species : Histomonas meleagridis (Smith,
1895) Tyzzer, 1919, Amaba meleagridis Smith, 1895,
Entamaba meleagridis Doflein 1911, Ameba melea-
gridis Smith, 1915, Eimeria avium Hadley, 1909,
Trichomonas eberthi Jowett, 1911, Trichomonas
Hadley, 1916."
gbstrarts.
THE TEE.\TMENT OF LEPROSY, WITH
ESPECIAL EEFERENCE TO SOME NEW
CHAULMOOGRA OIL DERIVATIVES.'
By J. T. McDonald, A.M., M.D.
United States Public Health Service.
AND
A. L. Dean, A.B., Ph.D.
President and Professor of Chemistry, Vniccrsity of Hawaii,
Honolulu.
The Use of Chaulmoogka Oil.
The remedy to which we pin our faith as superior
to all others is chuulmoogra oil. For many years
it was used in Hawaii in its crude state, with results
very similar to those obtained elsewhere. To the
majority of patients it is nauseating and offensive
to the stomach even when taken in slowly increasing
doses by capsules, and its use has to be discontinued
for a time, to be begun later at a diminished dose.
Given intramuscularly it is painful and slow of
absorption.
' Abstracted from the Publi<
August, 1920.
Health Picports, vol. 35, No. .34,
Dec. 1, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Many attempts at its modification have met witli
more or less success according to reports from various
sources, and one report which has attracted especial
attention is that of Dr. Victor G. Heiser, surgeon,
United States Public Health Service, director of
healtli for the Philippine Islands, published in 1914.
Although the report covers but twelve cases, it is men-
tioned in this connection because it seems to have been
the starting point of an awakened interest and especial
effort in the Orient, where the treatment was tried
with favourable results in various missionary hospitals
in India and China. The Heiser formula is as
follows : —
Chaulmoogra oil ... ... 60 c.c.
Camphorated oil ... ... 60 ,,
Resorcin ... 4 grm.
Mix and dissolve with the aid of heat on a water bath and then
filter.
It is used intramuscularly and " tlie injections are
usually made at weekly intervals in ascending doses.
The initial dose is 1 c.c, and tliis is increased to the
point of tolerance."
A review of the earlier literature covering the use of
chaulmoogra oil may be found in United States Puhlic
Health Service Bulletin No. 75, January, 1916, by
Surg. G. W. McCoy and Acting Asst. Surg. Harry T.
Hollmann. Their summary of this review is as
follows :^
" Our personal experience leads us to the conclusion
that most writers have readied — that the oil is helpful
to many cases of le])rosy, perhaps the majority.
" The hypodermic method of administration, while
not free from disagreeable complications, seems to have
given good results, and, in view of the nature of the
disease, ought to be given a further trial.
" We are sure that the use of chaulmoogra oil as at
present practised is not the solution of the problein of
the therapeutics of leprosy."
The use of injections of mixtures containing crude
chaulmoogra oil along the lines reported by Heiser had
given sufficiently encouraging results to stimulate
further investigation, and was continued at the Kalihi
Hospital in the period following the work reported in
Bulletin 75.
A mixture of the following composition was
employed :
Formula No. 1.
Chaulmoogra oil ... 500 c.c.
Olive oil 500 „
Camphor ... 5 grm.
Guaiacol ... ... 10 ,,
This method of treatment was employed on many
patients with generally favourable results. In most
cases the oil was given by mouth as well as by intra-
muscular route. The amount of oil which could be
tolerated in this way varied considerably with
individuals. The practice was to increase the dosage
until the limit of tolerance was approximately reached.
Lugol's solution, which was fre(iuently administered,
was likewise varied in doses, beginning with small
amounts and gradually working tlio dosage up till the
patient was receiving substantial quantities of iodine
in this form.
This combination of intramuscular and oral admin-
istration was beneficial in the majority of cases, and in
a number of them resulted in the patient's becoming
apparently bacteriologically negative and being paroled
from the hospital. A report covering twelve of these
paroled cases is given by Hollmann. In the great
majority of cases which became bacteriologically
negative, there has been no reappearance of the disease.
Chaulmoogra Oil Derivatives.
Chaulmoogra oil is one of the few members of the
group of fatty oils which are believed to have distinct
physiological effects outside of their nutritive value.
The fatty oils are of great physiological importance,
hut, hitherto, chiefly in relation to nutrition and the
general metabolism of the body. In a series of papers
from the Wellcome Research Laboratory, by Power
and his collaborators, the constitution of chaulmoogi-a
oil and some of the closely related oils was elucidated.
They discovered a new series of fatty acids represented
by two members— chaulmoogric acid, C1SH32O2, and
hydnocarpic acid CieH-isOa. These acids differ from
any other known fatty acids in that they rotate the
plane of polarized light to a notable degree—
chaulmoogric acid (a)d-- + 62'l° and hydnocarpic
(a)d=" + 68.' The studieson their constitution indicated
that each of these acids contains a five-carbon-ring
nucleus. Both of these acids were isolated from
chaulmoogra oil derived from the seeds of Tdrahtogenos
kurzii, and also from the oil of closely related species
belonging to the genus Hydnocarpus. Power and his
co-workers did not concern themselves with the
tlierapeutic use of chaulmoogra oil.
It would appear possible that the distinctive action
of chaulmoogra oil, as heretofore reported, may be due
to the glycerides of the uni(|ue fatty acids of chaul-
moogra oil or to the presence of some other oil-soluble
constituent not a glyceride. The first step in the
attempt to identify the active agents would be the
separatmg of chaulmoogra oil into fractions on groups
of lepers. The separating of the glyceride mixtures
which make up the various vegetable fatty oils is very
difficult ; the fatty acids obtained by tlie decomposition
of the glycerides are somewhat more readily separated.
Sir Leonard Rogers, in his experiments using tiie
intravenous injections of the sodium salts of the acids
derived from the chaulmoogra oil, made use of fractions,
separtod by Ghosh. The data presented by Ghosh
showed clearly that he was dealing with mixtures of
fatty acids, and probably very complicated mixtures.
Tlie separation of the constituent fatty acids from the
mixed product derived from the saponification of
chaulmoogra oils by means of fractional crystallization
is a tedious and complicated task, and Ghosh did not
meet with mucii success.
It is quite clear from the results heretofore published
that although there is a therapeutic agent (or agents)
in cliaulmoogra oil of marked value in leprosy, none of
the attempts to isolate or identify this agent lias led to
conclusive results.
A recent publication of Sir Leonard Rogers describes
theaise of " gynocardate of soda " and " morrhuate of
soda." His term "morrhuate of soda" refers to the
292
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1920.
sodium soaps of the fatty acids of cod-liver oil, and he
reports excellent results (totn the intravenous and
hypodermic injections of this material. The fatty
acids of cod-liver oil are of a pecuhar and unusual
type, although not of the chaulmoogric series. If the
results of Rogers are confirmed, it will appear that the
fatty acids of cod-liver oil are useful in leprosy.
Although it may be, as suggested by Rogers, that
other " unsaturated fatty acids may also be expected
to yield effective preparations against the acid-fast
bacilli of both leprosy and tuberculosis," it seems to us
unlikely that this is a property common to all unsatu-
rated fatty acids. For example, oleic acid, which is
unsaturated to the same extent as chaulmoogric acid,
is a common body constituent, and it would therefore
be rather improbable that weekly injections of, say
5 c.c. of a 3 per cent, solution of sodium oleate,
amounting to 015 gi-m. dry material, would have any
such eft'ect in leprosy as has been reported following
the use of even smaller quantities of the sodium soaps
of the fatty acids of chaulmoogra oil. Obviously a
wide and important field for chemical and physiological
investigation has been opened by this work of Sir
Leonard Rogers and our own work here.
As an initial step, the fatty acids of chaulmoogra oil
were separated into four fractions in the chemical
laboratory of the College of Hawaii. One of these
fractions was chaulmoogric acid, and the other three
were mixtures of acids liaving somewhat different
properties. These fatty acid fractions are solids, and
therefore unavailable directly for hypodermic or intra-
muscular injections. One of the first problems was to
find a suitable form of material for injection which
would allow rapid absorption into the circulation. It
was found that the ethyl esters of the fatty acids were
thin fluid oils lending themselves readily to intra-
muscular injections and were readily absorbed.
The four fractions originally tried out, and designated,
respectively, " A," " B," " C," and " D," were of the
following character :
Fraction " A " : The ethyl ester of chaulmoogric
acid.
Fraction " B " : The ethyl esters of the other fatty
acids readily separating on cooling the alcholic solution
of the mixed fatty acids of chaulmoogi-a oil, doubtless
containing considerable of " A."
Fraction " C " : The ethyl esters of the fatty acids
remaining in the mother liquid from the separation of
the acids in "A" and "B" and yielding lead salts
readily soluble in ether.
Fraction " D " : Ethyl esters of the fatty acids
accompanying " C " in the alcoholic separation, but
yielding lead salts not readily soluble in ether.
The early results of the use of these fractions " A,"
B," C," and " D," together with some details of
the methods of their preparation, are given by
Hollmann and Dean.
The results published and a continuation of the same
lines of work lead to the general conclusion that
the therapeutic agent in chaulmoogra oil is able to
survive the chemical treatments involved in the making
of these preparations, and is itself distributed through
all four of the fractions. The differences in results.
using the different fractions, are not sufficient to
warrant any final conclusions regarding their relative
efficiency ; patients receiving each of the fractions
have shown marked imijrovement, have become
bacterially negative, and have been paroled. It is
impossible, however, to draw definite conclusions from
this work becausS of the fact that all patients who
received the injections also regularly received chaul-
moogra oil by mouth in substantial quantities. We
cannot say, therefore, whether the beneficial action in
any particular case is due to the material injected or to
the combined action of the material injected and that
taken by mouth. The general observation that
chaulmoogra oil taken by mouth has a beneficial but
not decisive action lends colour to the belief that the
most important factor in the improvement of the
various cases is the injection material. As a series of
experiments intended to develop the best method for
leprosy treatment the plan followed was satisfactory,
but it is not satisfactory as a method of demonstrating
the relative efficiency of different fractions of tlie oil.
Distilled Esters.
As already indicated, the processes whicli resulted
in the fractions "A," "B," "C,"and"D,' areof sueli
a character as to make it improbable that any otlier
material except fatty acids would survive them and
be distributed in all four of tliese fractions. Still
further evidence on this point was gained by a different
system of fractionation. In this case tlie mixed fatty
acids derived from the saponification of chaulmoogra
oil were converted into ethyl esters by heating with
absolute alcohol in the presence of dry hydrochloric
acid gas, giving a mixture of ethyl esters of all the
acids present in the crude oil. This acid mixture was
distilled in vacuo at a pressure of 30 to 34 mm. The
distillate was cut into three fractions of different
boiling ranges, designated " E," '' F," and "G." These
distilled esters are colourless Hquids. At the time the
first work of this character was done no apparatus was
available to provide higher vacua and allow satisfactory
distillations. The fractions " E," " F," and "G,"
were used for intramuscular injections in a number of
patients, beginning in January, 1919, and in some
cases extending until the 1st of July of that year. It
was found that all tlie cases receiving each one of the
fractions " E," " F," and " G," showed improvement —
some of them quite rapid — indicating that the methods
employed in their production had not resulted in the
destruction of the therapeutic agent or agents.
The same uncertainty surrounds the interpretation
of these results in the cases receiving fractions "A,"
"B," " C," and " D," since all were getting chaulmoogra
oil in capsules three times daily in addition to the
weekly injections. We can say, however, that what-
ever virtue resides in the use of chaulmoogra oil
derivatives injected intramuscularly in com.bination
with the oral administration, that virtue is probably
not lost or segregated to an appreciable extent by any
of the chemical or physical conditions to which these
various preparations have been exposed.
The use of vacuum distillations as a means of
separating the esters of the fatty acids and the fatty
Dec. 1, 1920.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
293
acids themselves is receiving extensive application in
the clieinical investigations now in progress.
The Administration of the Ethvl Esters.
The intramuscular injections are given once a week,
Wednesday being known as " Injection Day." An
adequate supply of injection material, together with
syringes, needles, &c., is previously subjected to about
15 lbs. of steam pressure for from a half to one
hour in tlie autoclave. Other methods of sterilization
would doubtless answer equally as well ; for instance,
an ordinary kitchen double boiler ought to servQ every
purpose, especially when only a few patients are to be
treated. The patients, instead of dreading what must
l)e rather a painful performance, make a gala day of it
and fill the hour with laughter, noise and chatter
on the lawn outside while awaiting their turns.
The site chosen by us for the injection is the upper
and outer quadrant of the gluteal region, alternating
sides weekly. One of the patients, who is called the
" painter," applies tincture of iodine to a spot the size
of a silver dollar. The syringe is an ordinary 20 c.c.
all-glass model, and the needle selected is a No. 20,
although with the thin and limpid ethyl esters a
smaller size would undoubtedly serve. Sterile needles,
one for each patient, are in readiness ; the material is
poured from the Hask into a sterile beaker, a patient
assistant stands on one side with a previously prepared
basin of cotton pledgets, and on the other side is the
clerk, usually the laboratory assistant, record book in
hand, to enter opposite the name in a properly ruled,
dated column the number of cubic centimetres given
each patient on that day. A syringe full of the material
is drawn up from the beaker, then, with a small spring
forceps, a needle is picked up from the large Petri dish
containing them and placed on the stem of the syringe.
The patients ar« taught to step lively, and one by one
they quickly enter from the preparation room, the
needle is passed its whole length to reach the muscu-
lature, and the proposed dose is gently administered.
The instant the needle is withdrawn the assistant claps
a pledget of cotton over the puncture and the patient's
own I'.and is applied to retain it with a gentle pressure
for a few minutes in the preparation room. By the
time the operator has removed and discarded the used
needle and replaced it by a clean one the next patient
is in position. We can thus easily administer from 75
to 100 injections in an hour or two and do it well.
Employing 1 c.c. as the initial dose, it is our custom at
every second or third injection to increase the dose by
1 c.c. until we have reached a maximum of from 3 to
5 c.c, according to the age or weight of the patient.
A phenomenon noted by many other observers in
using chaulmoogra oil injections occurs with ua also ;
in a few instances, immediately following the injection,
the patient is seized with a violent fit of coughing. It
quickly begins to subside, however, and in less than
five minutes has entirely disappeared, leaving no
serious results.
As to effects, or so-called " reactions " following our
injections, there is a considerable diversity of reports.
Some claim that duiing the following twenty-fourhours
they experience creeping sensations of chilliness at times.
that they are rather out of sorts and feverish, with an
inditi'erent appetite, &c. ; others say they do not notice
any such symptoms ; while all admit a soreness for a
day or two, deep under the point of the injection. In
a few instances we have taken the morning and evening
temperature of all the patients on injection day and
the day following, with the result that not 3 per cent,
of the number showed any rise whatever, either on the
evening of injection day or morning or evening of the
day following. The rise of temperature in those who
did show any appreciable rise did not exceed one
degree ; from which it may be inferred that the
constitutional symptoms following our injections are
practically nil.
While some have reported from other sources rather
frequent abscess formation" as derogatory to intramus-
cular injection of chaulmoogra oil, we are happy to
report more favourable results, as in 4,892 deep
injections administered from October 1, 1918, to the
present writing (January, 1920), we have had but one
case of resulting abscess.
Combined Iodine in Treatment.
For a number of years iodine has been employed in
the treatments, chiefly in the form of Lugol's solution.
Since the fatty acids of chaulmoogra oil are for the
most part unsaturated acids, and therefore capable of
adding iodine to form iodine compounds, it seemed
possible to utilize this property to introduce iodine
into the body either through the skin, by injection, or
by way of the mouth. Iodine combined in this way
has none of the irritating action of free iodine. We
have been employing treatments since February, 1919,
in which combined iodine has been used.
In the period between February 5 and March 12,
1919, nine newly received patients were placed in
a group to receive injections of a preparation consisting
of the mixed ethyl esters of chaulmoogra oil carrying
4 per cent, of combined iodine. Subsequently, the
percentage of iodine has been varied between 2 and 8
per cent.
In addition to the weekly injections, these patients
received capsules three times per day, containing the
mixed fatty acids of chaulmoogra oil carrying 5 per
cent, of combined iodine. The fatty acids were used
instead of the oil itself because hydrolysis of the
glycerides to fatty acids is the normal digestive process
which precedes fat absorption. We were therefore
using a predigested oil. We can see no advantage in
the use of the sodium salts, as practised by Rogers,
since thesjp' scraps would be reconverted into the fatty
acids by the " hydrochloric acid of the stomach.
Between May 14 and June 4, 1919, two additional
patients were placed on this treatment. About the
last of June it became necessary to ship a considerable
number of patients to Molokai on account of the
crowded condition at Kalilii. This unfortunately
caused the loss of four of our eleven patients in this
experiment. The remaining seven have all been
paroled. Since the cases sent to Molokai were the less
promising ones, they would not have been fit for parole
in November, and might, iierhaps, never have become
l)acteriologically negative.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1920.
" Standard Treatment."
Because of the excellent process which patients were
making on the treatment just described it was decided
to adopt this as the standard routine practice, placing
on this treatment all patients who were received,
unless they were to be in some group for special
investigation. As already indicated, we have done
some shifting about with the proportions of iodine
employed, and the standard treatment now consists in
weekly injections of a preparation which consists of the
mixed ethyl esters of the acids of chaulmoogra oil with
2 per cent, of iodine in chemical combination. The
amount used starts at 1 c.c. and is gradually increased
to a maximum of 4 or 5 c.c. for adults.
Three times each day, an hour and a half after
meals, the patient receives capsules containing the
fatty acids of chaulmoogra oil with 21 per cent, of
iodine chemically combined. The dosage for the first
fifteen days is z grm. per 100 lbs. of body weight three
times daily ; for the second half of the first month ^
grm. per 100 lbs. ; and after that 1 grm. per 100 lbs. of
body weight. This means, for example, that a 150 lb.
man would get li grm. per dose, or 4i grm. per day.
In addition to this treatment, the patients also
receive such other medical care as may be indicated
in each case
Treatment by Injections Only.
It has already been pointed out that the injection of
various preparations has been accompanied by the
ofal administration of crude chaulmoogra oil or its
derivatives. The experiences of others, as set forth in
the hterature of leprosy, as well as our own obser-
vations, point to the conclusion that the oil which
passes through the digestive tract plays a minor part
in the improvement noted. Much larger quantities
are taken by the mouth than by injection ; yet, when
the injections are not employed the recovery is slow,
uncertain, and incomplete.
In administering treatment on a large scale, great
economy of material would be effected by using
injections only, and the whole treatment simphfied. In
order to test the efficacy of the injection of our standard
treatment without the feature of oral administration of
the iodized fatty acids, a group of ten patients who had
recently been admitted to the hospital, and had never
received more than very small amounts of chaulmoogra
oil, were placed on treatment by injection only. A
small dosage of strychnine was given, partly for its
tonic effect and partly for the psychological value of
of having " something to take," like the others. It is
too soon to draw final conclusions, but the results to
date are very encouraging. Perhaps these patients are
not improving quite so rapidly as those on the regular
treatment, but they are certainly improving.
Accessory Treatments.
Although experience indicates that the chief factor
in the good results we have attained is the intra-
muscular use of chaulmoogra derivatives, aided by
those taken orally, it is nevertheless advantageous to
make use of any adjuvant measures which have proved
of value. It has been shown that aqueous solutions do
not penetrate the sound skin, whereas oily ones do to
greater or less depths.
Iodine liniment. — We have tried the superficial
apphcation of a " green oil " consisting of the ethyl
esters of chaulmoogra oil, carrying combined iodine
amounting to from 10 to 25 per cent, by weight. This
oil penetrates well, especially when aided by brisk
massage. Definite and convincing data covering its
value are not available, but it is in considerable demand
by the patients, who are given 50 c.c. vials and allowed
to apply the oil three times daily.
Ointments. — For old and sluggish ulcers as well as
for chronic eczematous looking spots and areas which
need stimulating, we employ the ointment of ammoni-
ated merctry of the United States Pharmacopoeia,
which we modify by mixing it with ointment of zinc
oxide in equal parts when we desire to render it milder,
or, on the other hand, if we have a lesion whicli requires
something stronger, we rub into our ointment of
ammoniated mercury a dash of finely powered salicylic
acid, much or little, as the appearance of the lesion
seems to indicate. Patients coming in with open sores
or ulcers are expected to have them all healed in a few
weeks' time, and they seldom disappoint us.
Trichloracetic acid. — While we never use the actual
cautery as employed by Unna, we have had excellent
results from painting nodules with pure trichloracetic
acid, which immediately produces a considerable
escharotic action ; the skin turns white and there is
more or less smarting and burning for a few moments.
By the time the effects of the acid treatment have
passed off, usually one or two weeks, the nodule is
a little softer and a little smaller and the patient is
anxious for another application. There is one serious
drawback to the use of the acid,, noticed also in the
case of carbon dioxide snow used here some years ago,
and that is its interference with the pigmentation
of the part to which it is applied. In some cases the
skin is hyperpigmented and in others hypopigmented.
The former is illustrated in the case of a young woman
still with us who over a year ago had decided
thickenings over each malar region. Several appli-
cations entirely cleared up the infiltrations on the
cheeks, but, unfortunately, left two unsightly areas,
each the size of a silver dollar, almost entirely black.
After several weeks, liowever, they began to fade, and
now, after many months, they are barely visible. On
the other hand, a young man, paroled over a year ago,
the lobes of whose ears were similarly treated, has
a distinct loss of pigment and it shows no sign of
returning.
Nodular injections. — We have been cautiously trying
tiie injection of material which we have employed
intramuscularly directly into the leprous nodules. Of
course, it is understood that ithis and the preceding
methods are applicable only when the nodules are few ; \
for instance, we have a few patients whose stay with i
us has been prolonged by the lingering nodular
enlargement of the lobe of one or both ears, their
other lesions liaving disappeared. With aseptic pre-
caution, we slowly instil a very few drops in various
parts of the nodule, employing for the purpose an
Dec. 1, 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
295
ordinary all-glass hypodermic syringe with the same
technique as in our intramuscular injections ; that is,
slipping on a clean sterile needle for each injection.
It is evidently rather painful and is followed usually by
a considerable swelling which soon subsides, however,
leaving the nodule appreciably softer and smaller.
We think better progress is being made by the
injections than by the external application of the
trichloracetic acid. Both are good, and each has its
use. For a very superficial, hard, nodular area the
acid is preferable.
Heliotherapy. — Another accessory treatment used,
rathercrudely, however, at this hospital, is heliotherapy,
or the employment of sun baths. We have had some
remarkable cures of ulcerations, including the plantar
pedis variety, in presenting them to the direct rays of
the sun, but whether it is a case of post hoc or propter
hoc, it is not easy to say. A patient enters the hospital
and is found to have an ulcer as lai-ge as a silver dollar
on tlie sole of the foot, extending nearly or quite to the
bones'. He has been a labouring man, on his feet
nearly tlie whole of every day. We discover it only
by inspection, for he does not betray its presence by
the slightest limp in his walk, for the foot is absolutely
anaesthetic. He is slightly anasmic and is put upon
our ferruginous tonic ; he is put upon our standard
treatment of injections and capsules ; he is handed a
pair of crutciies and absolutely forbidden to put a
pound of weight on the foot affected or touch it to the
ground in moving about. He gets his ulcer washed
out every day with a permanganate solution. He gets
three good meals a day, a good clean bed to sleep m by
night, and all the rest and relaxation he desires by day.
That ulcer begins at once to heal, sun bath or no sun
bath. The sun-bath measure, however, is very popular
with our patients. They have more faith in it, perhaps,
than has their medical attendant ; but no matter,
sunshine is abundant and inexpensive, and as yet
untouched by the high cost of living. The one great
thing is that the ulcers fill and close. The above is
not a fanciful picture, but one of constant occurrence
with us ; and we are ready to admit that heliotherapy
is a therapeutic aid of no inconsiderable value. In
cases of rebellious plantar ulcers, liowever, especially
with necrotic tissues, nothing ajjproachos in efliicacy
the operation of Goodhue of Molokai in thorough
ablation of the affected parts and allowing the wound
to heal by granulation.
Neural Leprosy.
Cases of leprosy of the nerve type are likely to be
ignored at institutions as far as treatment is concerned,
and attention is likely to be concentrated on nodular
cases.
In view of our success during the past year with
several instances of the neural type of leprosy, the
conviction has forced itself ui^on us that it is highly
important that all these ciisis should ho l)rought in and
subjected to the regular roni me In .m uicnt for a course
of several months at leiisL, osijcciiilly in tlie case of
children or even of adults of more recent attack. We
believe our remedies arrest the disease and prevent
further destruction of hands and fingers, even when, as
in long-standing cases, normal function cannot be
restored.
But during the past year we have done better than
simply arrest the destructive process ; we have had the
satisfaction of seeing marked improvement in a con-
siderable number of these purely neural cases, and
apparently a complete recovery in others. One young
man who came in with a decidedly ataxic gait, unable
to raise his body or his toes and with one hand so weak
and deformed that he had been compelled to abandon
the use of the typewriter a year before entering, so far
improved before his parole that his disability in walking
had not only disappeared but he became one of the
leading tennis players and one of the swiftest runners
in the compound. He has now returned to full and
efficient clerical duty in an oltice. A woman with all
fingers absorbed to less than half their original length,
after a year's treatment, became able to write, to sew
and knit, and to execute many movements and functions
of wliich she had for years been deprived. We have
had several cases of young men and boys who, on
entering, were absolutely unable to button or unbutton
their clothing and were compelled to accept assistance
of their fellow patients, but who, after a few months'
treatment, became entirely independent and self-reliant
in that respect. We have some young women and
girls who entered with little and ring fingers partially
crooked, who are now able voluntarily to straighten
them after many months of inability to do so.
Conclusions.
The following conclusions may be drawn from our
recent experience in the treatment of leprosy :
(1) The intramuscular injection of the ethyl esters
of the fatty acids of chaulmoogra oil usually leads to a
rapid improvement in the clinical symptoms of leprosy.
In many cases the lesions disappear, except for scars
and permanent injuries, and the leprosy bacillus can
no longer he demonstrated.
(2) When combined with iodine, the fatty acids of
chaulmoogra oil and their esters give good results ; but
there is no adr^iuMlr ix|)erimental proof that this
addition of iolii mis any increase in the effective-
ness of tilO lii;ilri i:(l ii .cd.
(3) All of the availalile evidence obtained from the
use of fractions of tiie fatty acids of chaulmoogra
oil indicates that tlie therapeutic action is duo to one
or more of the fatty acids of the oil or to some as yet
unidentified substance associated therewith. The
various methods of fractionation heretofore employed
have failed to demonstrate the active agent.
(4) Although conclusive evidence is not at hand, it
is probable tliat tiie oral administration of chaulmoogra
oil derivatives is of minor importance compared with
the injections.
(5) In treating leprosy, it is important to make use
of all auxiliary agencies to build up and maintain
bodily vigor.
(6) Hypodermic injections of the ethyl esters into
leprous nodules are followed by marked swelling,
with ultimate recession of the lesions. This is a
296
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 1, 1920.
valuable auxiliary treatment for especially resistant
lesions.
SUMMAEY.
It has been sufficiently established that chaulmoogi-a
oil contains one or more agents which exert a marked
therapeutic action in many cases of leprosy. We can
not say as yet that the disease is cured, since we have
no test adequate to estabhsh such a verdict. Whether
or not the apparent cures are real and permanent, it is
evident that we have a yaluable agent at our disposal
in the control of the disease.
PROTEIN SHOCK REACTION IN LEPROSY.'
By Emanuel M. Josephson, M.D.
New Tcn-k.
I HAVE had occasion to observe a protein shock re-
action in a leper, and deem the observation of sufficient
interest to report it. An unknown amount of a
vaccine was accidentally administered with an intra-
venous dose of sodium gynocardate to a patient
suffering from a quiescent but well advanced leprosy.
A typical protein shock reaction followed shortly
after the injection. For several days following the
recovery from the shock the patient stated that he
felt an improvement, notably in several anaesthetic
areas. Within the week, however, there supervened
a marked exacerbation of the disease. A crop of
macules rapidly appeared, more markedly over the
parts previously more extensively involved, the face
and the arms ; a chronic ulnar neuritis lighted up
and once again became hyperacute, and the patient
ran a low fever as compared with his previously sub-
normal temperature. When I last saw the patient
two months later, the exacerbation had not yet
subsided.
This case indicates that the protein shock reaction
has some possibilities in the diagnosis of latent
leprosy. The reaction, however, bears the very un-
pleasant feature of creating an exacerbation of the
disease. But where there a*'e no other metliods of
diagnosis, and when the importance of diagnosis out-
weighs the risk to the individual, the reaction might
be put to the test. Experimentally its use is certainly
pardonable in checking up cases of suspected cures
where release of the patient from the leprosarium is
advocated, and in preventing spread of the disease by
immigration from the endemic zones.
It is a known fact that the course of leprosy is
hastened by intercurrent infections even of a very
mild nature. A scant experience with the disease
has led me to believe that the same results may follow
on reactions to vaccine subcutaneously administered
and on anaphylactic reactions. Hesitation to put
tliis theory to a test does not permit me to state the
latter with any degree of positiveness.
lejjcrts anb llfjrtnts Icreikb.
" Paludisme et Dysenteric amibienne autoch-
tones." Neveu-Lemaire et Zemboulis. Extrait des
BiiUctius ct Mcmoires dc la Societe medicale des
Hopifaux dc Paris. (Stance du 9 Mai 1919.)
"Notices Biographiques, XXIII. — Adelphi Negri,
1876-1912 " Joycux. Extrait des Archives de
Parasitologic, tome xvi, p. 161, 1913.
Chaii'e de Parasitologie et d'Histoire naturelle
medicale." Lecon inangurale de Brumpt. Extrait
du Facultc de Medicine de Paris, 8 .Janvier 1920.
" Notices Biographiques, XXII. — Pierre Simon
Pallas, 1741-1811." Joyeux. Extrait des Archives
dc Parasitologic, tome xvi, p. 134, 1913.
" Les Piroplasmes des Bovides et leurs Hotes
vecteurs." Brumpt. Extrait du Bvlletin de la
Societe de Pathologic exotiqiic, tome xiii. No. 6,
1920.
" Quelques Coutumes gyneeologiques ct obst^tri-
oales de la Guinee francaise." Joyeux. Extrait des
Archives mensucllcs d'Ohstctriqvc et de Gyne-
cologic, No. 9, 1912.
"Notes sur I'Etat sanitairc dans un Camp de
Prisonniers en Allemagne. " .Joyeux et Dalle.
Extrait du Bulletin de la Societe de Pathologie
erotiquc, tome viii. No. 7, 1915.
" Le Necator americanus en Haute-Guinee, notes
d 'epidemiologic." Joyeux. Extrait du Bulletin de
la Societe dc Pathologie exotiqvc, tome v. No. 10,
1912.
" Hymenolcpis nana (v. Siebold, 1852) et
Hynicnolepsis nana var. fraterna Stiles, 1906."
Joyeux. Extrait du Bvlletin de la Societe de Patho-
logie exotique, tome xii, No. 5, 1919.
" Quelques Ooififures indigenes en Africjue occi-
dentale frangaise." ■\Ime. Blanchard-Zaborowska
et Joyeux. Extrait du Bevue anthropnlogiqve.
trentieme annee, Nos. 5-6, Mai-Juin 1920.
" Note sur \me Grahamella : Grahamella vinsculi,
n. sp., trouv^p dans le Sa^ig de Miis viusciihis."
Benoit-Bazillo. Extrait du Bulletin dc la Societe
dc Potliolnqie exotiqiic, tome xiii, No. 6, 1920.
The Australian Medical Congress which recently
met in Brisbane, Queensland, accepted a recom-
mendation from the Dermatology Section, suggesting
the appointment of a committee to report on the
occurrence of skin cancer in Australia ; and a resolu-
tion from the public health section, urging tlie
establishment of a mosquito eradication campaign was
also adopted.
The Canton Hospital, founded in 18.35, is celelirating
its eighty-fifth anniversary this year. It is tlie oldest
and one of the largest missionary hospitals in tlie
Orient. In the past decade 120,000 dispensary and
20,000 in-patients were treated, and 14,000 operations
lierformed upon in-patients.
Dec. 15, 1920.] THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [No.24. Vol. XXIII.
(Original Commwnirations.
USE OF TOWN REFUSE FOR MOSQUITO
WORK.
By E. P. MiNETT, M.D., D.P.H., D.T.M. and H
Capt. R.A.M.C. (T.F.).
Governtnent M.O.S., British Guiana.
The city of Georgetown, British Guiana, situated at
the mouth of the Demerara River, lies four feet below
high tide level. The soil is a rich heavy clay, therefore
very little in the way of sub-soil drainage is possil)!e
In the old days of the Dutch occupation the only
method of making up roads, sea dams, &c., was by
digging canals. As the* whole country is dead flat, to
make a mound in one place it was necessary to dig a
hole in another. The expense of bringing stone down
from the interior was, and still is, so great that earth
burnt in heaps by the roadside is largely used for road
surfaces. This, of course, results in more holes being
dug, and these become mosquito breeding-places.
During the last ten years the open stagnant trenches,
caused by taking earth for road-making in the city
itself, have been gradually and systematically filled in
with refuse from the city. As the city is a beautifully
unless the upper layers of the soil are lightened by
admixture with other substances to render them more
porous. Surface water, the result of the heavy rain-
fall (approximately 100 inches per annum), can only l)e
got rid of by expensive pumping machinery, or by
using the fall of the tide and opening the sluice gates
at low water.
laid out garden city, this refuse is largely of a vegetable
nature with a proportion of domestic city refuse of the
usual tyi)e and a small amount of trade refuse, sawdust,
tins, clinker, &c.
Dead animals and such condemned meat as is dealt
with by the Meat Inspector are destroyed in the town
incinerator, but the bulk of the refuse, as described
298
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 15, 1920.
above, is used for filling in low places in and around
the town, which would otherwise become mosquito
breeding-giounds, especially in the wet seasons.
Large areas of abandoned land around the city have
been raised by this method and after a time used for
building purposes. The open trenches down the centre
of many of the streets have been filled in with rubbish,
given a top dressing of clay soil, allowed to settle and
remade until there is no longer a depression. The
filled-in trench is then given a top dressing of burnt
earth, sand, shell, or stone, and forms a beautiful shaded
avenue, as shown in the illustrations. — Fig. 1 being a
trench before treatment and Fig. 2 the same after
filling in.
The result is shown as a wide shaded avenue for
pedestrians in the centre and two wide roads for
vehicular traffic on either side.
It has been found by experiment that it is not
necessary to treat rubbish with paraffin or other
manent concrete surface drain. The cost of doing this
work for a trench i\ ft. deep 19i ft. wide works out
about 22 cents per cubic yard for labour and supervision.
The usual practice is to detail a Sanitary Inspector to
remain on the job permanently during working hours,
in order to make quite sure all rubbish is properly
covered in at the end of the day's work, otherwise an
unsightly collection of miscellaneous rubbish remains
exposed.
Fig. 3 shows a filled in area completed and pro-
vided with a small concrete drain for surface water.
The above method is, of course, very slow, but it is
efficient and permanent. It is the only method possible
in a flat country, below sea level, and where no other
material is available except at prohibitive cost. The
soil for covering in the rubbish is obtained by digging
out other trenches required for drainage purposes
which have silted up so that the flow of water is
impeded.
Fig. 3. — Completed concrete
after settling down has finished and permaner;t level reached.
methods to prevent fly-breeding, provided that each
day's deposit of rubbish is covered with earth imme-
diately the rubbish carts have ceased bringing rubbish
for the day.
The cost of keeping trenches free from vegetation
in order that the small fish, locally called " millions,"
can get at the larvae is very great, and requires to be
done frequently in a tropical country where vegetation
is of rapid growth. Therefore, unless the trench is
required for main drainage purposes filling in is con-
sidered the best remedy.
In fining in these trenches it is necessary that the
filled portion of the trench should be higher than the
surrounding land level ; this >s to allow for settling.
We find that, using the type of refuse we do
in British Guiana, after a few months filled in areas
settle down to about two-thirds of their original
height. Areas so dealt with are usually allowed to
settle for at least six months. They are then remade
and again allowed to settle before putting in a per-
Oiling of trenches, ponds and marshy areas has been
tried on a small scale in British Guiana but is not a
success, especially iu large areas of water, as the strong
breeze prevailing during most of the year quickly clears
the surface of oil and a film is not lasting, except in
places shaded with trees, &c. On the coast lands
shade trees are very rare ; the few trees growing being
mostly of the palm variety, coconut, or cabbage.
H^MOGREGARINES IN BL.\CK RATS.
By G. E. F. Stammers,
Wellcotne Bureau of Scientific Research.
In the Kitasato Archives of Experimental Medicine,
vol. iii, No. 2, for October, 1919, Shigeru Kusama,
Katsuya Kasai and Rokuzo Kobayashi in their paper
" The Leucocytogregarine of the Wild Rat with
special reference to its life history " record the finding
of haemogregarines iu wild black rats of Tokyo.
!l
Dec. 15, 1920.;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
A free gametocyte. (In films from this rat all the parasites
were extracellular). ( x 1,000 diam.)
It does not appear from a reference to the literature
that haemogregarines have been described as occurring
in wild black rats in Europe and it may therefore be
of interest to mention that the parasites shown in the
accompanying microphotographs were found in wild
black rats from timber ships calling at the Port of
London from Sweden.
So far haBmogregarines have not been found in
native English black rats, only those from the above-
mentioned ships being infected. Of the black rats
from various sources so far examined 12"5 per cent
have been found to harbour the parasite.
An example of double infection, (x 1,000 diam.)
" Cream Ckikes " arid the Paratyphus B. (La
Presse Medicate, October, 1920). — The authors,
Lesne, Violle and Langle, of this interesting paper
comment on the 700 cases of alimentary intoxi-
cation, collected by Lecoq, in which cream cakes
figure as the cause. At first the symptoms were
ascribed to the use of copper vessels, vanillin,
synthetic vanillin and ptomaines; later it was
decided that a micro-organism was the cause, and
finally it was proved that the sole ofifender was the
paratyphus B. The next question taken into con-
sideration was the cream which caused so much
morbidity. Studies of samples brought out the
fact that the germs present were those belonging
to the Salmonelloses, which are very similar to the
paratyphus B., the difference being in the absence
of reaction towards maltose. Cultures from the
cream gave positive agglutination with paratyphoid
scrum, but the action was not specific owing to the
fact that the test was also positive with the Eberth
bacillus. The incubation of the fever of cream cake
poisoning was very short, and the number of bac-
teria ingested at a time was enormous. The fever
was only typical of paratyphus B. when the incuba-
tion was exceptionally long. Apparently the
authors haid not recourse to Castellani's absorption
test with the object of finding out whether the
paratyphoid-like bacillus isolated was the true B.
paratyphus B. or B. aertrykc, which can be differ-
entiated from it only by using such a test. Bam-
bridge and others have clearly demonstrated that
most cases of food poisoning ascribed to B. para-
lijphus B. arc in reality due to B. aertryke.
Treatment of Typhus Fever (G. C. Shattuck,
A.M., M.D., International Journal of Public
Health, vol. i, No. 3, November, 1920).— The
author emphasizes how greatly early hospitalization
improves the prognosis, and of what importance for
treatment is skilled nursing. The chief aims of the
physician should be (a) to prevent or to reduce
toxsemia; (b) to distinguish between circulatoi^
disorders due to cardiac weakness and those attri-
butable to vascular dilatation and to treat each
appropriately; (c) to give careful individual atten-
tion to diet and bowels in all severe cases. Purga-
tion, lumbar puncture, or the free administration
of alcohol are occasionally useful in certain types
of cases.
300
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1920.
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THE JOURNAL OP
Cropical £Idedtctnt anDl^pgienc
December 15, 1920.
THE ROYAL SOCIETY OF TROPICAL
MEDICINE AND HYGIENE.
Tin-; Council ha-s just issued the thirteenth annual
report of the Society. It will be seen that the
work done iuid the enthusiasm which has prevailed
ever since the Society was first founded increase
from year to year. Several new paths of work
have come under the scope of the Society, and its
usefulness as a centre for tropical literature and for
meetings of men interested in tropical medicine in
the Empire and in other countries is much appre-
ciated.
Many phases of tropical work have sprung up
aidund us since tropical medicine first took a
ilifinite position in 1899. A list of these makes a
Ininiidable group. Beginning with the foundation
of the two great Schools of Tropical Medicine in
1,1 nil Ion and Liverpool, we find in the same year —
IH'.i!) — the first issue of The Journal of Tropical
.Mkdicixe AND Hygiene appeared through the enter-
]iiiso of Messrs. Bale, Sons and Danielsson. The
re ports of the Liverpool Tropical School added a
second publication. Then came the establishment
of the Society (now Royal) of Tropical Medicine,
which during the first year of its existence published
its Transactions in The Journal of Tropical Medi-
cine AND Hygiene, but after twelve months the
Society issued its own Transactions, adding thereby
a third publication to the two already in being. The
military medical staff — the R.A.M.C. — gave us a
fourth journal dealing with general tropical medi-
cine and surgery and hygiene, intended chiefly for
the officers of the R.A.M.C, and mainly supported
by them.
Cambridge in 1901 issued the Journal of Hygiene,
and later, in 1908, the Journal of Parasitology, both
largely devoted to tropical diseases. The Wellcome
publications from the Khartoum laboratories have,
also filled a prominent place in tropical medical
literature. In 1908 was foundeil the Tropical
Diseases Bureau, now housed at the London School
of Tropical Medicine; and the School itself pub-
lished a short-lived tropical journal. Within the
Empire also we have ma.ny journals issued locally
dealing with clinical, pathological and sanitary
matters in the Crown Colonies, in India, .\ustralia.
South Africa, and elsewhere.
The latest addition to the ranks of the study of
tropical diseases is the Tropical Section of the Royal
Society of Medicine, the Transactions of which will,
no doubt, be published in the reports of the doings
of that Society.
All are doing good work, and each fulfils a useful
part in the dissemination of knowledge. .\t the
same time efforts are thereby divided, and ingteatl
of a united effort, each stands in more or less rivalry
— a rivalry which stimulates each body, but adds to
the bewilderment of the medical men more especi-
nWy abroml, and involves an expense which many
practitioners in the tropics can ill afford. It also
hinders busj' practitioners gaining the infoiTna-
tion thoy may require in any one subject they are
interested in. A great man will arise no doubt who
will succeed in gathering these independent units
into one; but until the original founders of these
several items are removed from amongst them,
there is but little chance of this bi'ing done, for each
desires to see his creation maintained, and resents
its being swept away by any otiiei' rival body which
lias sprung into being.
Dec. 15. 1920.J THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
301
Tho Royal Society of Tropical Medicine and
Hvgii'iic', howL'vpr, continues to hold its own, as the
most recent report shows. Herewith is appended
the report for 1919 of the Society: —
llOYAL SOCIKTY OF TrOPICAL MkDICINE AND HyGIENE.
Thirteenth Annual Report of the Council.
Chief Events of the Year.
In January, 1920, the new edition of the Laws,
which had been under revision by the Council, was
passed, ancFhas since come into operation. It will
be useful to Fellows to have a short account of the
chief changes: —
(1) Among the objects of the Society is now
included " the study of the diseases and hygiene
of the lower animals in warm climates "; this
was always tacitly admitted, but, in view of the
increased membership of veterinary surgeons, it
was thought advisable to incorporate it in the
Laws.
(2) There are now to be three Vice-Presi-
dents in place of one. The effect will be to
create two more vacanies on the Council at the
biennial elections.
(3) Local Secretaiies are to be members of
Council when in London. It has long been a
source of dissatisfaction that Fellows abroarl
had so little influence in the management of
the Society ; they can now, through their Local
Secretaries, bring their weight to bear.
(4) Missionai-ies are no longer accepted at
half-rates; the sum of 10s. 6d. does not suffice
to pay for the Transactions which are supplied
to each Fellow, and it was felt that this
anomaly should cease. The new Law docs not
apply to present P'ellows.
A complaint having been received from a Fellow
resident abroad that the D.T.M. & H. was not a
registrable diploma, and hence that its possession
did not aid in securing an appointment from lay
bodies, which consult the Medical Register, the
Council afldressed a letter on the subject to the
Registrar of the General Medical Council. A reply
was received to the effect that the General Medical
Council had no power to enter this (|ualification on
the Medical Register without further legislation, to
which at [ir(K( iit there were obstacles. There the
matter for Die time lidng rests.
An intenstiii-,' divelopmont is taking place in
Malaya. Dr. A. T. Stanton, who is a Local Secre-
tary in that area — in which capacity he attended a
Council meeting on May 14 — has proposed to form
a local branch of the Society, for the purpose of
" promoting scientific and social intercourse among,
workers in tropical medicine." The experiment
was approved, and its outcome will be watched with
interest.
At the .\nnual Meeting in 1919, Professor
W. J. R. Simpson, (J.M.G., was (elected President
in the place of Sir David Bruce, K.C.B., F.R.S.
Sir James Cantlie, K.B.E., became Vice-President,
and Dr. Andrew Balfour, C.B., C.M.G., Treasurer.
In May of this year the Society lost the services,
as Secretary, of Dr*. G. C. Low, Joint Secretary
since September, 1912. The Society owes a debt
of gratitude to Dr. Low for his work, and especially
for having piloted the Society through the difficult
period of 1914-19. Dr. C. M. Wenyon, C.M.G
has succeeded him.
During the Session meetings were held in
October, November, January, February, March,
May and June. A return was made to the pre-war
hour of 8.30. The meetings were well attended,
and some interesting discussions were held.
The following papers were read at the meetings
during the year: " Some Considerations regarding
Preventable Diseases and their Prevention," by
Professor W. J. R. Simpson; "Anti-Mosquito
Measures in Palestine during the Campaigns of
1917-18," by Major E. E. Austen, D.S.O.;
" Bacillary Dysentery," by Dr. Philip Manson-
Bahr, D.S.O.; " The Etiology of Rheumatic Fever
from a Tropical Point of View : a Flea the Probable
Cai-rier, " by Dr. J. Tertius Clarke; " Treatment of
Malaria, and chiefly of Chronic Malaria and Black-
water Fever," by Dr. F. Roux ; " Small-pox and
its Prevention," by Colonel W. G. King, I. M.S.;
" The Causes of Death from Malaria in Palestine:
a Study in Cellular Pathology," by Lieut. -Col. N.
Hamilton Fairley and Capt. H. R. Dew, R.A.M.C. ;
" The Etiology of Pellagra from the Standpoint of
a Deficiency Disease," by Dr. Edward J. Wood;
and " Recent Work on Roundworm Infection," by
Lieut.-Col. F. H. Stewart, I. M.S.
Dr. Andrew Balfour contributed a Method of
Demonstrating Spirochsetes for Museum Purposes.
In March, tho Society enjoyed the hospitality of
tho Royal Army Medical College, at the laboratories
of which a very successful meeting was held. A
large number of microscopic preparations were set
out and demonstrated.
Fellows.
Since the last report 175 Fellows have been
elected. This constitutes a record for one year,
rnaking a total of 1,157 since the formation of the
Society. The number now on the books is 674.
The Council has to regret the death of one of the
Society's Honorary Fellows, Sir William Macgregor,
and, amongst tho ordinary Fellows, of Dr. Albert
Chalmers, Dr. Jiunes, C. M. Bailey, Dr. Alexander
R. Ferguson, Dr. Arthur Neve, Colonel F. Wyville-
Thomson, I. M.S., and, among ex-Fellows, of Sir
William Osier. He had resigned his membership
of tho Society, but had, since the outbreak of the
war, read a paper on " The War and Typhoid,"
and taken part in a discussion on the treatment of
inaliiria.
Library and Headquarters of the Society.
Tho room forming the heachiuarters of the Society
at 11, Chandos Street, is open daily from 10 a.m.
to 5 p.m. for th(> use of Fellows, and the books and
current periodicals in the library can be consulted.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 15, 1920.
Publications.
Six issues of the Transactions were made during
the Session. As Fellows know, there should be
eight, but the cost of production is such that the
Council has not seen its waj' to return to the pre-
war niunber. The Council is aware that the present
type is unsuited to the tropical worker with his
meagre means of illumination after sunset, and
intends going back to the larger type as soon as
paper is in freer supply, or finances on a firmer
basis. It is intended next Session to hold six meet-
ings for papers and two laboratory meetings.
A fresh issue of the Year Book is in course of
preparation. The year in which each Fellow was
elected will be given, with information as to which
Fellows have served on the Council, or as Office
Bearers, and for what period. Mistakes in the list
will be avoided if Fellows will inform the Secretaries
promptly of changes of address or of any inaccu-
racies in the last list.
Fellows coming home on leave should at once
notify the Secretaries, 11, Chandos Street, W.l,
or should call and record their addresses. If they
wish, the Editorial Secretary will be pleased to
print such information in the succeeding issue of
the Transactions, under headings: " Reached Eng-
land," "Left for ," "Change of Address,"
Ac. The Society's journal could usefuUy carry out
this function, but the Editor would be dependent
on the information supplied to him.
Fellows who do not keep the Secretaries thus
posted cannot expect to receive their Transactions
regularly.
The Secretaries will be glad to hear of any papers,
long or short, which Fellows wish to communicate
to the Society. They would welcome an increase in
the offers of short communications. Full-dress
debates do not always perform as well as they pro-
mise, and the type of paper received by the Societe
de Pathologie Exotique of our French colleagues
has many advantages over the monograph. The
Transactions should be recognized by the Fellows as
a medium for publication of any interesting obser-
vations they may have made.
Messrs. J. C. Phelp and Son, 64, Beulah Road,
Walthamstow, E.17, are the agents for the sale of
the Transactio7is to the public, and copies of the
current issues are supplied bj' them to non-Fellows
at the price of 3s. 6d. each.
A title-page and table of contents for each volume
is issued with the June issue of the Transactions,
and loose cases for binding will be supplied on appli-
cation to the agents, at the price of 2s. 6d. each,
post free (inland), or if the copies are sent to them
for binding, 4s. complete.
Local Secretaries.
The oflBce of Local Secretary has now an increased
importance. Fellows who think that they are in-
suflBciently represented in their districts should
writ* to the Secretaries, suggesting the names of
.suitable Fellows as Local Secretaries. Such nomi-
nations would naturally carry more weight if they
were supported bj- several Fellows. The ultimate
decision in the case of any appointment must rest
with the Council.
^nnotationg.
The Clinical Significance and Therapeutic In-
dications of Abnormal Blood-pressure (A. S.
Blumgarten, M.D., F.A.C.P., Medical Record,
November, 1920). — The author has carried out a
long investigation on the significance of abnormal
blood-pressure. When the blood-pressure varies
from the average, it is the hypertension that is
mostly of clinical importance. He attempted to
emphasize its importance in conditions where the
blood-pressure itself is the dominating objective
feature. Under these conditions its importance lies
in its vital prognostic value in association with the
definite evidence of injury to the vascular system
or the kidneys. Without this associated evidence
it is merely the pressure gauge of a life of tension,
except in those instances in which it records the
effort on the part of the endocrine system to adjust
itself to temporary discord. When it occurs in
young people and is not associated with vascular
or renal phenomena, it is probable that the mani-
festation of hyperpiesis or hypertension is largely
produced by intensive living, which in the majority
of cases is followed by vascular and visceral
changes, the most measurable of which are in the
kidney.
Hypotension may be regarded as an endocrine
stigma, and is merely an individual marking of
an endocrine disturbance. It is amenable to treat-
ment only in the absence of vasculai- or renal
changes, and the best results are obtained by
relaxation in everything — work, diet, pleasures, &c.
Medicinal substances are not of great value.
Coffee and the Vitamines (P. D. Mattei, Policlinico,
Rome, vol. xxvii. No. 37, September, 1920).— The
author confirms that pigeons develop typical deficiency
polyneuritis and paralysis if fed on polished rice ; but
if given 8 c.c. of a 5 per cent, infusion of coffee, the
nervous symptoms disappear, and the pigeons become
apparently normal again for a time, although they do
not gain in weight. This satisfactory condition is
maintained for several weeks, the coffee making up for
the deficiency in the rice. The infusion of unroasted
coffee has not the same effect as the roasted, and the
author suggests that the beneficial effect of coffee is
due to the generation of certain substances by heat in
the roasting, these substances having a similar effect to
true vitamines.
Body Tempen-atiire determined by Temperature of
Urine (T. Kasparek, Journal of Laboratory and Clint-
i
Dec. 15, 1920.;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
cal Mediciiie, Sfc. Louis, vol. v. No. 12, September,
1920). — The author as the result of an investigation
comes to the conclusion that the temperature of freshly'
passed urine is of great practical value in determining
the temperature of the body. This applies mainly to
cases in which measurement by rectum is impossible
or obnoxious ; it is also of value as a diagnostic
method in diseases of the urinary tract.
CttrnM fiUratari.
^bstrarts.
A METHOD OF CONCENTRATION OF PARA-
SITIC EGGS IN F^CES.i
By William H. Gates.
After straining through a sieve a large quantity of
material, or using a smaller quantity without this,
faeces are centrifuged first with water to wash off
surplus lighter material, and later with sodium
chloride, or better, calcium chloride solution, specific
gravity 1,250, to remove the bulk of the material and
float the eggs practically free from sediment. The top
1 or 2 c.c. are then removed with a pipette, di-awing
chiefly from the rim of the menisicus, and centrifuged
again with water, which throws the eggs to the
bottom. The water is then poured off, leaving all of
the sediment at the bottom. This sediment is
agitated vigorously by holding the tube in the closed
hand and pounding on the table. This stirs up all or
nearly all of the eggs which may have stuck to the
bottom, though a few eggs cannot be removed except
with a brush. The sediment is quickly poured into a
small dish. The centrifuge tube is rinsed out by
squirting water forcibly into it, and this is also poured
immediately into the dish. The eggs settle rather
rapidly and are loosened from the bottom by forcing a
little water around the edge to produce a slight whorl.
Then before the eggs have a chance to settle, agitate
the dish in the same circular direction so that the
water tends to form a vortex, gradually diminishing
the motion until it is hardly more than a jar. Practi-
cally all of the eggs will be found to have settled
within a very small field.
For gross examination with the low powers, the
eggs may be left in the dish and examined directly.
To examine more carefully under a higii degree of
concentration, draw up with a pipette a small quantity
of water from the centre of the mass of eggs ; hold
this vertical and steady for a half a minute or so.
Most of the eggs will settle, so that a single drop
forced out on the slide will contain nearly all, if not
all, of the eggs drawn up into the pipette. For still
further concentration, allow the eggs on the slide to
settle, and then with a blotter or lens paper very
carefully remove a portion of the water from the top of
the drop and add another drop. If repeated with care,
a large mass of eggs may be collected in the space of a
cover slip. This is especially satisfactory if the eggs
have been in alcohol for the alcohol will evaporate,
leaving the eggs in the centre.
' Abstracted from the Journal of Parasitology, vol. vii, No. I,
Scptembur, 1920.
The Indian Jodrnal of Medical Research,
Vol. VIL No. 1, July, 1919.
Records of the Occurrence of Intestinal Protozoa
in British and Indian Troops in Mesopotamia.
-^C. L. Boulenger found marked differences as
regards the frequency of Entamwba histolytica in
British and Indian troops in Mesopotamia both in
cases of dysentery and in non-intestinal cases, the
difference being most notable in the acute dysentery
cases, where the percentage for Indians is twice
that for British. The percentage of Giardia
(Lamblia) intestinalis is remarkably constant in
the two classes of patients. Trichomonas was more
commonly found among the Indians, whilst Chilo-
mastix (Tetramitus) was found more abundantly
amongst the British.
Report on Bilharziasis in Mesopotamia (C. L.
Boulenger). — Only one outbreak of bilharziasis
occurred among the troops in Mesopotamia up to
August, 1918, seventy-one of the personnel of a
General Hospital having become infected with
Schistosoma hivmatohium at Basra in 1917. In-
vestigation of the Arab population of Mesopotamia
showed that the disease was common throughout
the country both in the Tigris and the Euphrates
districts, the average infection of the male Arabs
examined being approximately 20 per cent. The
mollusc Bullinus contortus, known a-s the second
host of the parasite in Egypt, was found in Meso-
potamia, but does not seem to be of common occur-
rence in that country.
Coma as a Cause of Death in Diabetes (McCay,
Banerjee, Ghoshal, Dutta uinl Hay). — As the result
of an elaborate series of blood examinations in
diabetics, with and without albuminuria, in cases
of renal disease, with and without ursamia and in
noniial individuals, coupled with the absence of any
real signs of acidosis in Indian diabetics, the authors
conclude that acidosis and diabetic coma practically
do not occur in India, and that the coma that com-
monly ends the scene in India is uroemic and not
diabetic. They found no essential difference be-
tween the chemical condition of the blood in those
with unemia and in those dying in coma who have
been suffering from diabetes, except for the presence
of hyperglycemia in the latter, and this can hardly
be regardexi as a cause of coma. The outstanding
feature of the dying diabetics is the great increase
in the non-protein nitrogen of the blood. Acetone,
urea, phosphates, &c., may be increased to a great<T
or less extent, but the signs of acidosis are far too
slight to enable one to ascribe, the coma to the
nifjigre retention of acetone bodies in the blood.
Hcncii the functional derangement of the kidney
that accompanies diabetes is the idl-important
factor in producing the necessary conditions of the
blood that lead to coma and death.
The type of coma most commonly met with is
that characterized by restlessness, followed by
304
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1920.
drowsiness and gradually deepening coma. The
respirations may be quickened slightly ; there is
practically never any typical "air hunger."
Cheyne- Stokes respiration may be present.
They consider that the influence of renal elimina-
tion has not been taken sufficiently into account
in the various forms of coma that may terminate
diabetes, and that it will be essential in future to
pay more attention to the retention and accimiula-
tion of nitrogenous waste products within the body
than to the possible depletion of the body of so-
called " buffer-salts," which is supposed to lead to
acidosis and coma. They suggest thai the favour-
able influence exerted by the starvation of patients
on the verge, or in the early stages, of diabetic
coma, so long as the kidneys continue to act, can
best be explained on the hypothesis that the coma
is uraemic in nature. The injection of alkaline
solutions, normal saline, Ac, so long as they cause
a free flow of urine, wUl assist in eliminating the
poisonous nitrogenous bodies, and thus their bene-
ficial effects in treatment are made evident. So
far as they neutralize any acid bodies present in
the body they will also assist. If, however, the
excretory functions of the kidneys have become
seriously disturbed, the injection of these solutions
is useless and no treatment is of any avail.
The Treatment of Diabetes in India (McCay,
Banerjee, GhosaJ, Dutta and Ray). — The onward
march of glycosuria, from the pre-glycosuric stage,
transient and intermittent stages, to a permanent
condition, can be reversed by prolonging the inter-
vals between meals. Even severe cases of the
Indian type of diabet^>s can be made sugar-free and
the hyperglyeaemia reduced to a normal glycaemia
by a restricted dieting for a few days. The glyco-
suria of India is a true diabetes from the beginning,
since "it is a specific deficiency of the power of
assimilating food " (Allen). The specific function
of the internal secretion of the pancreas is below
normal in those who develop glycosuria. The pre-
vailing form of diabetes in India is of a very mild
type, milder than the Diabetes levis of Europe.
Patients rarely die from diabetic coma, and the
type shows little tendency to pass into the grave
forms of the disease.
Reduction of the carbohydrates below the level
of the patient's tolerance is practically never fol-
lowed by signs of severe acidosis. A trace of acetone
may occur in the urine, di-acetic acid is never found,
and the ammonia content of the urine remains un-
changed, hence the fear of acidosis and coma is
imaginary.
Patients were kept on a low carbohydrate diet for
several days, or even weeks. Hyperglyeaemia and
glycosuria disappeared. The different proximate
principles could then be effected without the return
of hyperglyeaemia and glycosuria. Starvation was
unnecessary to prevent acidosis — a practical asset in
treatment, as the Indian patient much prefers a diet
of milk, green vegetables, and a little butter to
nothing at aJl.
The Pathology of Experimental Rabies. I.
Kidneys, Adrenals, Liver, Pancreas, Spleen (J. W.
Cornwall). — The growth of the rabies organism in
the central nervous system causes irritative stimuli
to pass along the splanchnic nerves to the adrenals
and liver, which give rise to the discharge into the
blood-stream of an excess of sugar. There may or
may not be an accompanying excessive secretion of
adrenalin.
The toxic agents in the blood derived from the
growth of the rabies organism in the central nervous
system seriously damages the cells of the secreting
tubules of the kidneys and the medullary cells of
the adrenals, whilst the pancreas, liver, and spleen
escape damage.
The Pharmacodynamics of Quinine. II. Some
Effects of Quinine on the Kidneys, Adrenals, and
Spleen of Healthy Rabbits (J. W. Cornwall).—
Quinine administered intravenously and intra-
muscularly to healthy rabbits for eight to nine
months causes damage to the cellular elements of
the kidneys and adrenals, and the rate of disinte-
gration of red blood corpuscles in the spleen is
increased.
The Pathogenesis of Deficiency Diseases. III.
The Influence of Dietaries deficient in Accessory
Food Factors on the Intestine (R. McCarrison). —
Dietaries deficient in accessory food factors give
rise in pigeons and in guinea-pigs to congestive and
atrophic changes in all coats of the bowel, to
lesions in the neuro-muscular mechanism, to im-
pairment of its digestive and assimilative functions,
and to failure of its protective resources against
infection. The functional perfection of the gastro-
intestinal tract is dependent in considerable measure
on the adequate provision of accessory food factors
derived from fresh fruit and vegetables. Certain
gastro-intestinal disorders in man may owe their
origin to the long-continued sub-minimal supply of
accessory food factors.
IV. The Influence of a Scorbutic Diet on the
Adrenal Glands. — A scorbutic diet causes pro-
nounced depreciation in functional activity of the
adrenal glands in guinea-pigs. The impairment
of adrenal function occurs before evidences of
scurvy manifest themselves.
Notes on a Monkey Plag7nodiii7n and on Some
Experi7nents in Malaria (R. Knowles). — During the
course of some animal experiments undertaken to
test Schaudinn's hypothesis that relapse in malaria
is due to a reversion of a female gametocyte to the
malaria ring by a process of parthenogenesis,
Knowles encountered a new plasmodium, which he
provisionally terms Plasmodium semnopitheci. In
the Lanuman monkey P. scmnopithcci shows resem-
blances both to the B.T. and M.T. parasites of man.
In its early forms it is an almost non-pigmented
ring, closely resembling that of M.T., though some
of the rings are larger and more flimsy and more
resemble B.T. rings. The gametocytes recall those
of the B.T. parasite. Innumerable free forms also
Dec. 15, 1920.] THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
exist, some undergoing schizogony whilst extra-
cellular. They seem to possess a definite cycle of
development. The malaria experiments yielded
negative results.
The Association of the Bacillus of Hofmann with
Diphtheria in India (R. Knowles). — Knowles inves-
tigated two limited epidemics of diphtheria in
schools in Shillong and Gauhati originating from
carrier sources. The incidence of the bacillus of
Hofmann was entirely different from that in tem-
perate climates. It was found in 30 per cent, of
eases of diphtheria, in 11 per cent, of diphtheria
carriers, in 0"4 per cent, of healthy throats among
European children during an epidemic, and in 5 per
cent, of the throats of Indians in the absence of any
epidemic.
The bacillus of Hofmann was encountered before
along with, and after Klebs-Loffler bacilli in the
same throat. Whilst the two organisms differ on
morphology, cultural reactions and pathogenicity, it
would appear that there is a symbiotic relationship
between them. The rarity of the bacillus of Hof-
mann in India may be associated with the relative
rarity of epidemic diphtheria, the reverse holding
good in temperate climates.
Observations on the Cultural Methods of Gono-
coccus (G. C. Maitra). — Maitra found that the
coccus is best cultivated under reduced oxygen ten-
sion. Primary cultures grow equally well on
Loffler's blood serum or urine agar with egg-yolk,
provided a fair amount of purulent exudate is used,
while subcultures grow better on Loffler's blood
serum. Bacterial yield can be augmented by the
a/^Idition of fresh, preferably human serum, whilst
human serum heated to destroy its bactericidal pro-
perties gives no advantage over fresh serum in
promoting the growth of the gonococcus.
A Note on the Presence of Acid-fast Bacilli in the
Blood of Lepers (K. R. K. Iyengar). — Acid-fast
bacilli agreeing morphologically with the leprosy
bacillus are demonstrable in a considerable propor-
tion of blood films made from lepers. Although
they are presumably present in the blood, it is
possible that they rnay have been derived in the
process of venepuncture. The skin at the site of
puncture showed no sign of leprosy. The possi-
bility of their presence in the reagents has been
excluded by not finding them in the blood films
from healthy controls.
The examination of the blood may bo used with
advantage as a routine method of diagnosis in cases
of suspected leprosy, and may afford evidence of
infection when other methods of examination have
failed.
On the Possible Spread of Schistosomiasis in
India (S. Kemp and F. H. Gravely). — None of the
species of mollusc which have been cited as inter-
mediate hosts for the human forms of schistoso-
miasis have been found in India, and that any of
them will henceforth be discovered is improbable.
The genus Planorbis (svnsu Into), has numerous
representatives in India; but Bullinus, Phy-
sopsis and Hypsobia are not known to occur. There
is, however, no reason to discredit the view that a
potential intermediate host may exist, and that the
return of infected troops from Egypt will possibly
result in an outbreak of schistosomiasis in India.
All attempts to infest molluscs artificially with
miracidia of human schistosomiasis were negative.
^fports m\> Reprints ^eceikb.
" Importance des Papilles cervicales des Anky-
lostomes." Langeron. Extrait du Bulletin de la
Societe de Pathologie exotique, tome xiii, No. 7,
1920.
" Contribution a la Faune helminthologique de la
Haute-Guinee franqaise." Henry et Joyeux. Ex-
trait du Bulletin de la Societe de Pathologie
exotique, tome xiii, No. 3, 1920.
" Enkystement d'une Cercaire du type Cercaria
arinata chez un Turbellari^ d'eau douce." Joyeux.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xii. No. 3, 1920.
" Notes sur I'Eurroctus montanus, Urodele apneu-
mone caract^ristique de la Faune corse." Dehaut.
Extrait des Comptes rcndus des Seances de la
Societe de Biologic. (Sf^ance du 23 Octobre 1909,
tome Ixvii.)
" Espeees europ6ennes du genre Phlebotomus
(Rondani)." Larrousse. Extrait du Bulletin de la
Societe entomologique de France, 1920, No. 4.
" Note sur les Culicides de Macedoine." Joyeux.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xi. No. 6, 1918.
" Biologic de Cimex Boueti." Joyeux. Extrait
des Archives de Parasitologic, tome xvi, p. 140, 1913.
" Au sujet des Rapports entre I'Onchocerca vol-
vulus et la Gale filarienne." Brumpt. Extrait du
Bulletin de la Societe de Pathologie exotique, tome
xiii, No. 7, 1920.
" Contribution h I'Etude des organes reproducteurs
et de la Reproduction chez les Strongles d^pourvus
de Capsule bucc.ale {MetastrongilidcB)." Nevue-
Lemaire. Extrait des Memoires de la Societe
Zoologique de France, tome xxvii, 1917, p. 5.
" Estudio sobre la leche que se expende en Guaya-
quil." Andrade. Extrait, Boletin del Laboratorio
Municipal, tomo i, No. 4, Julio de 1920.
" Recherches ^pid^miologiques sur la Leish-
maniose forestifere am^ricaine dans I'Etat de Sao
Paulo." Brumpt et Pedroso.
" Sur unc Spiroch^tose des Poules du S6n(5gal
produite par Spirochxta Neveuxi n. sp." Brumpt.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome ii. No. 6, 1909.
" Transmission du Spirochxta duttoni par
r Ornithodorus savignyi, et du Spirochxta galUnarum
par V Ornithodorus moubata, non transmission des
Spirochetes de la Fifevre r^currente am(5ricaine et
alg6rienne par ce meme Parasite." Brumpt. Extrait
JDUBl^AL or TROPICAL MEDICINE AND HYGIENE. [Dec. 15, 1920.
du Bulletin de la Societe de Pathologie exotique,
tome i, No. 9, 1908
" Transmission de la Piroplasmose canine tuni-
sienne par le Rhipicephalus sanguineau." Brumpt.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xii, No. 10, 1919.
" Existence de la Spirochetose des Bovides au
Bresil. Transmission de cette Affection par la
Tique : Margaropus australis (Fuller)." Brumpt.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xii, No. 10, 1919.
" Transmission de la Piroplasmose canine fran-
Qaise par le Dermacentor reticulatus. Embolics para-
sites dans les Capillaires de I'Encephale. Brumpt.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xii, No. 9, 1919.
' ' Note sur le Parasite des Hematics de la Taupe :
Grahamella talpx, n.g., n. sp." Brumpt. Extrait
du Bulletin de la Societe de Pathologie exotique,
tome, iv, No. 8, 1911.
" Les Cerfs de la Foret de Chantilly sont decimes
par les Helminthes. " Brumpt.
" Fixation du Plomb par les Cestodes d'Animaux
saturnins." Brumpt. Extrait des Comptes rendus
des Seances de la Societe de Biologie, tome Ixvi,
p. 953, May, 1908.
" Le Necator americanus en Haute-Guin^e, notes
d'epidemiologie." Joyeiix. Extrait du Bulletin de
la Societe de Pathologie exotique, tome -v, No. 10,
1912.
" Une nouvelle Filaire pathogene parasite de
rhomme (OnchocercU cxcutiens n. sp.)." Brumpt.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xii. No. 7, 1919.
" Note sur le Bacillus Duhoscqi, nov. sp. de
rintestin d'un Rat africain, Golunda campanx
Huet, 1888." Joyeux. Extrait du Bulletin de la
Societe de Pathologie exotique, tome v. No. 9, 1912.
" Vaccination antivariolique aux Pays chauds
avec de la Lymphe dessechee. Joyeux. Extrait
des Comptes rendus des Seances de la Societe de
Biologie, tome Ixvii, p. 624, 1909.
" Le X^nodiagnostic. Application au Diagnostic
de quelques Infections parasitaires et en particulier
h la Trypanosomose de Chagas." Brumpt. Extrait
du Bulletin de la Societe de Pathologie exotique,
tome vii. No. 10, 1914.
" Cycle evolutif des Opalines." Brumpt. Extrait
du Bulletin de la Societe de Pathologie exotique,
tome viii. No. 5, 1915.
" Etudes sur les Infusoires parasites." Brumpt.
Extrait des Archives de Parasitologic, tome xvi,
p. 187, 1913.
" A propos de I'Hxmocystozoon brasiliense de
Franchini." Brumpt. Extrait du Bulletin de la
Societe de Pathologie exotique, tome vi, No. 6, 1918.
" Sur quelques Particularitds morphologiques et
physiologiques des Trypanosomes (Perte du Flagelle
et Formation de Pigments divers)." Brumpt. Ex-
trait du Bulletin de la Societe Pathologie exotique,
tome iii. No. 6, 1910.
" Sur un Infusoire nouveau Parasite du Chim-
panze Troglodytella (1), abrassarti (2), n.g., n. sp."
Brumpt et Joyeux. Extrait du Bulletin de la
Societe de Pathologie exotique, tome v, No. 7, 1912.
"Globules geants ou 'corps en demi-lune ' du
Paludisme; autres Alterations globulaires au cours
de cette Maladie infectieuse. " Brumpt. Extrait
du Bulletin de la Societe de Pathologie exotique,
tome i. No. 4, 1908.
"Existence de la ' Fievre des Tiques ' en Abys-
sinie. " Brumpt. Extrait du Bulletin de la Societe
de Pathologic exotique, tome i. No 7, 1908.
" Au sujet d'un Parasite (Richettsia Prowazeki)
des Poux de THomme considere, a tort, comme
1 'Agent causal du Typhus exanthematique."
Brumpt. Extrait du Bulletin de la Societe de Patho-
logie exotique, tome xi. No. 3, 1918.
" De I'Origine des Hemoflagelles du Sang des
Vertebres." Brumpt. Extrait des Comptes rendus
des Seances de la Societe de Biologie, tome Ixiv,
p. 1046, 1908.
" Importance du Cannibalisme et de la Copro-
phagie chez les Reduvid^s hematophages (Rhodnius
triatoma) pour la Conservation des Trypanosomes
pathogenes en dehors de I'Hote vertebre." Brumpt.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome vii, No. 10, 1914.
"La ;Myiase oculaire de I'ile de Sal (Archipel du
Cap Vert)." Prates. Extrait du Bulletin de la
Societe de Pathologie exotique, tome xii, No. 10,
1919.
" Sur une nouvelle Espece de Mouche Ts^-Tse,
la Glossina decorsei, n. sp., provenant de I'Afrique
centrale." Brumpt. Extrait des Comptes rendus
des Seances de la Societe de Biologie, tome Ivi,
p. 628, 1904.
"Contribution a I'Etude des Ixodes." Senevet.
Extrait du Bulletin de la Societe de Pathologie
exotique, tome xii, No. 2, 1919.
" Le Typhus exanthematique a Porto, 1917-1919."
Jorge.
"La Grippe." Jorge. 1919.
" Sur le cycle evolutif de quelques Cestodes."
Joyeux. Extrait du Bulletin de la Societe de Patho-
logie exotique, tome ix. No. 8, 1916.
" Hygiene militante." Jorge. 1920.
" Sur quelques Especes nouvelles de Trypano-
somes parasites des Poissons d'eau douce; leur Mode
d'Evolution." Brumpt. Extrait des Cotnptes renews
des Seances de la Societe de Biologie, tome Ix,
p. 160, 1906.
" Contribution a I'Etude de I'Evolution des
Hemogregarines et des Trypanosomes." Brumpt.
Extrait des Comptes rendus des Seances de la Societe
de Biologic, tome Ivii, p. 165, 1904.
" Existence d'une Spirochetose des Poules a
Spirochxta gallinaruin, R. Bl., dans le Sud-Oranais,
Transmission de cette maladie par Argas persicus."
Brumpt et Foley. Extrait des Comptes rendus des
Seances de la Societe de Biologic, tome Ixv, p. 132,
1908.
" De I'Heredite des Infections a Trypanosomes
et a Trypanoplasmes chez les Hotes intermediaires. "
Brumpt. Extrait des Comptes rendus des Seances
de la Societe dc Biologie, tome Ixiii, p. 176, 1907.
Jan. 1, 1920.]
COLONIAL MEDICAL REPOBTS— CEYLON.
Colonial Medical Reports. —No. 104.— Ceylon.
CEYLON MEDICAL REPORT FOR THE YEAR 1917.
By G. J. RUTHERFORD,
Principal Civil Medical Officer and Inspeclcrr-Geiieral of Hospitals.
Population.
The population of Ceylon on December 31, 1917,
inclusive of immigrant coolies (but exclusive of
military and shipping), was 4,632,384. Of these,
7,220 were Europeans, exclusive of those who left
on war service.
Public Health.
Vital Statistics. — 183,976 births were registered
in the proportion of 39 per 1,000 of the population
per annum, showing an increase of 9,049. The
deaths registered in 1917 totalled 113,389, as com-
pared with 120,162, a decrease in the death-rate
of 6,773, in the proportion of 24 per miille. The
total number of persons treated in the hospitals in
1917 was 98,134, of whom 8,734 died. At dis-
pensaries 1,210,380 persons were treated, who paid
1,832,733 visits.
The following table shows the causation of death*
registered under the several classes of disease: —
General diseases—
(a) Epidemic diseases ... ... ... 5,485
(6) Septic diseases ... .... ... 158
(c) Tuberculosis diseases ... ... ... 4,112
(d) Venereal diseases ... ... ... 185
(e) Cancer or malignant diseases „ ... 421
(0 Other general diseases ... ... 10,475
Diseases of the nervous system and oi^ans of
special sense .. ... ... ... 14,972
Diseases of the circulatory system ... ... 981
Diseases of the respiratory system ... ... 9,267
Diseases of the digestive system ... ... 18,828
Non- venereal diseases of g
and annexa
The puerperal state ...
Diseases of the skin and cellular tissues
Diseases of bones and organs of locomotion
Malformations
Diseases of early infancy
Old age
Affections produced by external causes
Ill-defined diseases . .
inary system
16
10
7,528
2i347
20,112
The more notable causes of death were the follow-
ing diseases : —
Infantile convulsions
Diarrhoea ...
Pneumonia
Rickets
Phthisis ...
Anifmia
Dysentery ...
Intestinal parasites ...
Anchylostomiasis and its sequflic
Dropsy
Puerperal septicaemia
Malaria
Enteric fever
Tetanus
Rabies
Deaths attributed to pyrexia of unknown
origin
12,916
10,174
5,005
2,639
2,58G
1,839
15,022
Deaths due to Preventable Diseases, i.e., to
diseases due to faulty sanitary conditions, over-
crowding, soil infection, defective or infective water
supplies, &c., amounted to 32,106. This figure
does not include infantile diarrhoea or infantile con-
vulsions, though it is probable that a large number
of deaths from infantile convulsions are due to
malarial infection, and a large number of cases of
infantOe diarrhoea to improper dieting, defective
sanitary sairroundings, and neglect.
Infantile Mortality. — The infantile mortality in
the thirty-three principal towns during the year was
at the rate of 233 per 1,000. 12,916 deaths from
infantile convulsions were, registered during the
year, and from infantile diarrhoea 1,148. During
1917 twenty-two midwives were trained at the
De Soysa Lying-in Homie, Colombo. Midwives have
been appointed to sixteen Government hospitals
in large centres to try and decrease the infant
mortality.
Vital Statistics on Estates. — The mean birth-rate
on estates was 34-4 per 1,000 and the death-rate
36'4. The prinoipal causes of death were : debility,
diarrhoea, anchylostomiasis, pneumonia, dysentery,
infantile convulsions, dropsy, phthisis, anaemia.
Malaria. — The incidence of the disease in any
province cannot be estimated, as in the more remote
districts and in districts where the population is
scattered patients may not resort to medical insti-
tutions for treatment. To meet this an issue of
quinine is made to Government agents and others
for free distribution, both as a prophylactic and for
remedial purposes before and during the periodical
outbreaks. The amount of quinine distributed for
these' purposes during the year was 98 lb. in powder
and 40 bottles of 100 pulverettes in each.
The total number treated for malaria in 1917 wa«
6,960 at hospitals and 341,768 at dispensaries,
making a total of 348,728. There was very little
epidemic malaria during the year, which accounts
for a very large decrease compared with the previous
year.
Plague. — There were 77 oases treated at the
Infectious Diseases Hospital, Kanatta, Colombo, 58
of which proved fatal ; 63 cases were of the bubonic
type and 14 septio»mic, all of the latter proving
fatal, while 19 of the bubonic- type recovered. Five
cases — all fatal — occurred at Beruwala, a township
on the west coast, about thirty-five miles south of
Colombo, largely inhabited by Moors. All these
cases were presumably directly infected in Colombo.
Two cases occurred in the Central Province : one
in Kandy and one in Nawalapitiya. Here, again,
the infection was fiorn Colombo. Plague did not
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 1, 1&20.
occur in any of the other provinces of the island
during the year under review^
Cholera. — No case of cholera was admitted to the
Infectious Diseases Hospital, Colombo, in 1917,
thus comparing favourably with the previous year,
when forty-two cases were treated. No cholera
occurred in the provinces.
Small-pox. — 105 cases of this disease, with a
mortality of 13, occurred in the island during the
year; of the 105 cases under review, 5 were treated
at the Infectious Diseases Hospital, 4 of which were
landed from vessels in the harbour. One case only
was indigenous, the source of infection not being
evident. Ninety-eight cases with eleven deaths
occurred in the Northern Province, which, since the
reopening of small coastal ports and roadsteads to
native craft from South India, is more exposed to
infection than other parts of the island, especially in
view of the difficulty or impossibility of maintaining
the strict quarantine vigilance adopted in the larger
ports of the island. Six separate outbreaks were
due to infection directly imported from South India.
It would appear that the existing precautions are
inadequate to prevent the importation of this disease
to the norfcliern parts of the island, though it is
not easy to see what measures can be adopted that
would not press with undoie severity upon the traffic
and commerce between Ceylon and the Indian coast.
Vaccination. — The total number of primary vac-
cinations performed during the year was 125,455.
Of these, 116,294 were successful, 1,956 unsuc-
cessful, and the results not ascertainable in 7,205
cases. It is satisfactory to report that 98-48 per
cent, of all primary vaccinations were successful.
The Government Vaccine Establishment has
worked most satisfactorily during the year. Seed
lymph, as in previous years, was obtained from the
Lister Institute of Preventive Medicine, London,
and the King Institute, Madras, while a certain
amount was also prepared at the local institute.
The lymph used is glycerinated calf lymph, and is
issued for use either in glass capillary tubes or in
metal collapsible tubes to stations where the daily
consumption is large.
Enteric Fever. — The case incidence of this disease
during 1917 was 518 with a mortality of 93. These
figures, however, apply only to cases registered in
the Government hospitals, and do not give any fair
index of the actual prevalence of the disease in
towns and rural districts generally. Another factor
which obscures the statistics of this disease is the
error of diagnosis not uncommon among practi-
tioners of native medicine, who treat a considerable
number of cases of " fever " without much dis-
crimination as to type or causative agents.
Dysentery. — The number of cases of this disease
treated in Government hospitals in 1917 was 2,883 .
with 620 deaths, and the number treated in dis-
pensaries was 14,276. It is hoped the introduction
of latrine accommodation on estates during the year
will result in a reduction in the epidemics of this
disease hitherto of common occurrence. This
disease and many of the acute and chronic diar-
rbneas- rcisiiU from defective sanitation in and around
dwellings, pollution of water supply and insect con-
veyance being important factors in its spread.
Leprosy. — There are two leper asylums in the
island: one at Hendala, to the north of Colombo;
and the other at Kalmunai, in the Eastern Province.
At the Hendala Asylum there was a total of 531
inmates for the year. Of these, 24 were discharged
and 78 died; with regard to those discharged, 18
absconded, 7 of whom were subsequently arrested
and again interned, 3 were granted home isolation,
and 3 were found to be free from manifestation of
the disease. As far as the admissions to the leper
asylums indicate, the disease appears to be more
prevalent in the maritime districts than in the
interior of the island. Home isolation (sanctioned
where housing conditions are approved) was allowed
in 16 cases.
Anchylostomiasis. — -The total number of cases of
this disease treated in the Ceylon Government hos-
pitals during the year was 8,617, with a mortality
rate of 17 per cent. Besides these cases, a large
number was treated by Government medical officers
on estates, and a considerable number was treated
by estate dispensers. The disease appears- to be
most prevalent in the Central Province, and, though
most common among the estate coolies, has spread
to a considerable extent to villages.
The activities of the Anti-Anchylostomiasis
Directors of the Rockefeller International Health
Foundation continued during the year in the Matale
District. Over 10,000 coolies were treated on the
intensive plan; however, the fact that about thrse
times that number of persons living in the neigh-
bourhood of estates have not been subjected to
treatment must inevitably result in a certain degree
of re-infection. Considerable progress has been
made in sanitation, both on estates and in villages,
and the ultimate outlook is good. Campaigns
against the disease were also completed in the
Dikoya and Bogawantalawa di.stricts during the
year, and very satisfactory progress can be claimed,
notwithstanding certain discouraging incidents and
temporary setbacks, due to ignorance and prejudice
on the part of the coolies, and sometimes to
malicious, organized, active, or passive opposition
on the part of designing persons. Patience, tact
and persuasion has to some extent succeeded in
overcoming local opposition. The outlook will pro-
gressively improve, it is hoped, with time, when,
as the resmlt of lessened soil pollution and regular
and systematic treatment, aided by the active co-
operation of planters and labourers, the difficulties
now met with have become a thing of the past.
Parantji (Framba'sia, or Yaws). — The total number
of cases of this disease treated in Government
medical institutions during 1917 was 46,032; 853
were treated with specific remedial preparation as
substitute for salvarsan, the following being those
made use of: Kharsivan, arsenious iodide, arseno-
benzoi, or iriodifications and combinations of these.
The administration of these remedies or combina-
tions and modifications of the same were
torily reported upn!i.
Cancer and Sarcoma. — The hospital and
Jan. 1. i920.J
COLONIAL MEDICAL BBPORTS— CEYLON.
peasai'y statistics of thes€ diseases in Ceylon afford
unsatisfactory data as to the prevalence of the
disease, as the dread of operative procedure deters
many sufferers from seeking medical assistance, and
those that do seek such assisitance have frequently
allowed the disease to progress to such an advanced
stage as renders their cases inoperable. Labial and
buccal epitheUoma is a common form of the disease,
and is probably much induced by inveterate betel
chewing.
Tuberculosis of the Lung {Phthisis). — The hospital
records of this disease show a total of 1,862 eases
treated, with 569 deaths. Overcrowding, defective
sanitation, ignorance, and neglect in the matter of
ventilation are the chief predisposing causes of this
scourge. Only cases in the more advanced- stage
seek hospital or dispensary aid, and in such eases,
where the reparative powers of the patient have
beien much undermined, little or nothing can be
done beyond the relief of urgent symptoms.
Port Health Precatdioiis. — Eight vessels were
placed in .strict quarantine. Five cases of small-
pox, 4 cases of chicken-po.\, 9 cases of measles, and
1 case of plague were landed and sent to the Infec-
tious Diseases Hospital. A vessel, ss. Atlantique
i (French), infected with cerebrospinal fever (spotted
: fever), arrived in October, and 11 suspects sent to
; the Infectious Diseases Hospital, while 776 Anna-
: mites in charge of 9 French officers were segregated
, at ,Ragama for observation and pending disinfection
of the vessel. 113,884 persons were disinfected,
and 245 persons vaccinated.
Meteorological Conditions.
The rainfall for the year was heaviest on the
north-east and the south-west slopes of the hills,
being specially heavy in the district east of Matale
I and in the Nitre Cave district, and in the south-
t west monsoon to the north of Ratnapura and the
lAmbegamuwa district. An excess over normal was
i experienced practically throughout the east, and a
j deficit to the south-west and the north. The
weather conditions for the year were, on the whole,
somewhat unl)alanced, and resulted in S{>ell9 of
i unseasonable weather, but no great extremes were
experienced. The mean shade temperature for the
island was in most months below normal, and in no
month was it above normal at more than two-thirds
of the stations. Unusually heavy rain set in towards
|the end of Septeml>e.r and caused extensive flooding
the south-west of the island.
E Sanitakv Branch of the Medical Department.
I The following is a summary of the work done :
175,366 premises were inspected during the year,
Df which 23,702 were found insanitary, and 2,416
jictnal mosquito-breeding places were discovered and
jlealt with. There were 839 proisecutions, with 795
ronvictions. Pr<^>socutions are sanctioned only after
inspection by the sanitary officers, Government
igents, or assistant Of)\cinment agents.
Infectious Diseases. — The following infoctiouB
lieeases were reported and prophylaxis carried out :
dysentery, measles, chicken-pox, enteric fever, con-
tinued fever, while 225 cases of plague occurred
in the island, of which 23 were outside Colombo
municipal limits. There is no evidence to point to
any endemic plague centre or rat epizootic existing
outside of Colombo.
In the Western Province 4,531 rats were caught
during the year, 1,149 were examined bacterio-
logically, and one was found positive for plague.
This rat was caught at Beruwala on May 24; five
cases of plague occurred there in May, the first one
being reported on May 15. There are two possible
sources of the rat infection in this instance : one
from Colombo, the other from Negapatam, through
the open port of Beruwala, w'ith which it has direct
communication by sea, but through which channel
the infection gained entrance isi not evident.
Sanitary Conveniences. — ^Pubhc latrines of an
approved type were constructed at Government ex-
pense in the Sanitary Board towns of Kochchikade,
Henaratgoda, and Mirigama. In the Colombo Dis-
trict 4,791, and in the Kalutara District over 9,000
new private lati-ines were constructed in the rural
areas.
In the Matale District 2,424 latrines were in-
stalled in the villages in connection with the anti-
hookworm campaign. The sanitation of schools is
receiving attention, and in the 'Matale District all
those schools in the territories being treated for
hookworm disease have been provided with sanitary
conveniences at Government expense.
HookwoTtn Disease.— Microscopical surveys were
carried out at Eayigama and Gorakapola villages;
90 per cent, were posiitive for hookworm. At
Medapola mines in Ingiriya 500 labourers were
examined, and 95 per cent, were found infected.
At Cotta Church Missionary Society School 400
children were examined ; all were infected. At
Maggona Reformatory, where boys fiom all parts
of the island are admitted, 471 were examined ; all
were infected. These were treated and re-examined,
when all but eleven were found cured. Infection
did not occur at the home, as it is well sanitated.
In Rayigama village arrangements were made for
the treatment of the infected, but the staff had to
be withdrawn after three days' work, owing to the
aggressive attitude of the people brought about by
the circulation of false rumours.
Specimens were collected in two isolated Cingalese
villages in the North-Central Province and micro-
scopically examined, when 70 per cent, were found
to be infected with hookworm.
Tlic General Hospital, Colombo. — This is the
largest medical institution in the Colony and is
divided into two sections : the paying section and
the non-paying section.
As regards! particular diseases, the following show
their comparative prevalence and mortality figures
as registered by hospital admissions: —
Acute Pneumonia.— ^r^B cases, with 136 deaths.
Ancliylostomiasis . — 408 cases, with 55 deaths.
Dysentery. — 222 cases, with 29 deaths.
Enteric Fever. — 174 cases, with 42 deaths.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 1,1920.
Pulmonary Phthisis. — 319 cases, with 178 •
Malaria. — 764 cases, with 15 deaths.
Enteritis and Diarrhoea .—A09 cases, with 112
Appendicitis. — 144 cases, with 4
Accommodation. — For several years past certain
wards for certain classesi of cases in the pauper
section have been overcrowded during the greater
part of the year. As there are no poor-house-si in
this country a large number of aged and infirm
cases have to be kept for lengthy periods in our con-
valescent wards, and this prevents the transfer of
cases to these wards from the acute wards. Pro-
vision will have to be made to house theses aged and
infirm cases elsewhere, or we shall have to increase
our accomimodation. Occasionally cases have to be
refused admission or delayed when seeding admiis-
sion to the paying wards, bub when circumstancea
permit of the opening of the new ward now ap-
proaching completion, the accommodation for paying
patients should suffice for several years to come.
A large amount of useful work was done by the
inmates of the Colombo Lunatic Asylum, the males
being employed in carpentry, manufacture of string
rugs and matsi from coir, repairs to furniture, basket-
making, rattanning of cots and chairs, &-C. ; and the
females, besides engaging in the coir industries,
employed their time in sewing and tailoring work
for the General Hospital, the Eye Hospital, the
Lady Havelock Hospital, and also contributed their
handiwork to the Queen Mary's Needlework Guild.
Great credit is due to the matron for her super-
vision of the needlework. The foundations for the
new asylum at Angoda on the Colombo-Avissawella
road were commenced during the year.
The Infectious Diseases Hospital. — 864 cases were
treated in this hospital, with 67 deaths. The
following table is instructive: —
treated
Death>
Small-pox
5
2
Cholera
—
—
Plague
... 77
58
Diphtheria
7
2
Chicken-pox
... 506
—
Measles
... 157
1
Mumps
.. 22
—
5
Acute diarrhoea
5
—
... 58
—
The De Soysa Lying-in Home. — The institution
continues to be useful for purposes of instruction
to pupils in midwifery. I am of opinion that the
infant mortality of the island, particularly on the
estates, could be appreciably reduced if modern
methods and precautions could be more generally,
adopted.
The King Edward VII Tuberculosis Institute, the
Ragama Tuberculosis Hospital, and the Kandana
Sanatorium for Consumptives. — These institutions
now provide for the medical treatment and cure of
tuberculous patients. The Colombo institution,
under the care of an officer who has specialized in
the disease, is being increasingly patronized. 1,331
new cases; of phthisis of the lung were admitted;
290 were sent for indoor treatment at Ragama ;
459 cases of more or less advanced tuberculosis of
the lung were treated at the Ragama hospital with
a mortality of 100.
The Kandana Anti-Tuberculosis Sanatorium. —
This institution and buildings cover forty acres of
land. The site is an excellent one, on high ground,
with a dry porous soil, on the Colombo-Jaela road,
and near the railway station. The building con-
sists of four wards with half walls, designed to
accommodate fifty patients. There are suitable
quarters for resident medical officers, nurses and
staff, with ample grounds for recreation, gardening
and open-air pursuits. I am confident that the
public-spirited donor, Mr. A. E. de Silva, has con-
ferred a great and lasting benefit on the people of
the country, and greatly deplore his untimely
demise, which has denied him the satisfaction of
seeing the completion of the good work.
The Bacteriological Institute, Colombo. — The con-
structing and equipping of a Pasteur Institute for jj
the treatment of persons bitten by rabid dogs is >
being taken in hand. I:
Medical Aid to Immigrant Coolies.
The health precautions and medical care of
immigrants commences on the Indian coast at Tata-
parai and Mandapam, and continues in the medical
inspection at Talaimannar and at the Colombo
Wharf Depot, and consists in internment of infec- )'
tioug cases, contacts, or suspects at Tataparai, j,
Talaimannar, or Ragama, and medical care of all I,
cases of iUness. The different immigration depots j
are manned by officers of the ^iledical Department, j
The new Immigration Camp and Quarantine Depot .'
at Mandapam was opened on May 1, 1917, replacing
the temporary camp that had previously existed.
The medical and sanitary provisions are excellent.
Water supply, sewage disposal, hospital disinfection
and housing has received careful attention, and
ample provision has been made for all requirements
and contingencies, and for the safety and comfort
of travelling immigrants. ' J]
Government District Hospitals in Planting Areas.
— There are fifty such hospitals, staffed by efficient
and fully qualified medical ofiicerB, nurses, and
attendants, and equipped with modern require-
ments. Each such hospital has an out-patient dis-
pensary attached. The medical officers, besides
attending to their hospitals and dispensaries, pay
domiciliary visits to coolies in their lines when
summoned by the superintendents of estates.
Estate (Rebate) Hospitals.— Fiity-eight estates k
have established hospitals for the better treatment, '-■"
dieting, and medical care of the sick. Such hos-
pitals entitle the estate to a rebate on export tax,
in proportion to the efficiency of the medical and
sanitary provision made. A sum of Rs. 50,880 was
refunded to estates during the year as rebate under
the above system. It is satisfactory to report that t..
progressive improvement is evident in many of these 'if
hospitals, some indeed having achieved a high'«ii
degree of efficiency.
y
Jan. 15, 1920.;
COLONIAL MEDICAL REPORTS.— CALCUTTA.
Colonial Medical Reports.— No. 104.— Ceylon (contd.).
A system of medical iiistructiou, in the form of
lectures, demonstrations, and practical clinical work
at Government hospitals in the planting districts
was introduced during the year. These lectures,
&c., were given by the district medical officers, and
at the termination of the -course a written and oral
examination was held by the provincial sxirgeons.
The number of candidates presented for instruction
was 360. Of these 281 presented themselves for
examination; 155 satisfied the examiners, and 126
failed to do so. Those who did not present them-
selves for instruction and examination will be called
upon to do so at a subsequent course of instruction,
which those who failed will also be required to
attend.
Latrines. — A rule was promulgated making it in-
cumbent on every estate to provide latrine accom-
modation for all employees within one year from the
date. The type of such latrine was subject to
approval, one compartment being provided for every
fifteen employees, two children being computed as
one adult. Type plans of latrines on the jwt and
the pail system- were furnished by the senior sanitary
officer. It is satisfactory to report that 1,156 estates
have complied with the requirements.
Sayiitary Inspection of Estates. — The systematic
and methodical sanitary inspection of estates in the
Western, Central and Southern Provinces was com-
menced during the year, two specially selected
senior officers of the Medical Department being
delegated for these duties. A report on the vital
statistics, site and construction of lines, drainage,
water supply, scavenging, latrine accommodation,
sanitary state of surroundings, and medical provi-
adons, if any, isi made by these officers through the
senior sanitary officer. The latter officer takes such
action a« may be indicated if the sanitary conditions
are defective. The reports of the inspecting medical
officers would serve to indicate that, while the coolie
has no actual objection to the use of the latrines
provided, there remains on many estates a tendency
to revert to insanitary customs of the past. Nothing
short of regular and systematic inspection of the
surroundingsi of coolie lines by the superintendents
or by persons appointed by hun and the admonish-
ment or punishment of offenders will check this
tendency. It is gratifying to note that among
superintendents of estates there is a growing sense
of responsibility as regards the health of their labour
force. Greater knowledge of' the preventability of
a large am.ount of sickness and death among coolies
is, I trust, resulting in greater care. It is regret-
table that on many estates, especially in the older
districts, the present-day manager has to contend
with an inheritance of ill-constructed lines on un-
suitable sites, with defective drainage and faulty
water supply, in addition to the soil pollution that
has existed for many years past. The financial
stringency resulting from war conditions and the
paucity of assistants further hamper the efforts of
managers in the direction of sanitary improvements.
One of the inspecting officers reports that on
second or subsequent visits paid to estates on which
he originally found sanitary conditions much
neglected there was evidence of a marked and sus-
tained effort to remedy evils previously indicated;
this shows that planters are showing an encourag-
ing interest in sanitai7 reform. I am hopeful that
with the co-operation of estate managers and estate
agencies this will eventually result in a substantial
i-eduction in sickness and deaths due to preventable
disease on estates.
Colonial Medical Reports. — No. 105. — Calcutta.
LEPOET OF THE HEALTH OFFICER OF CALCUTTA FOR
THE YEAR 1917.
By H. M. CRAKE, M.D., D.P.H.,
Fellow of tli£ Royal Instiiution of rublic Health.
Metkorology and Vital Statistics.
CHmatic Conditions.
The mete^jrologieal records for 1017 show tliat tiie
'eather conditions throughout the year were fairly
ormal in character. This is in inarked contrast
1916 which with its prolonged high temperaturti
1 the hot season and its heavy rainfall, which con-
nued till late in the year, was distinctly abnormal,
he maximum temperature curve shows a rapid rise
om between 75-80° F. in January to over 95° F.
April. A more gradual fall then occurred during
[ay and June, the temperature falling to 90° F.
1 hiring July and September the temperature re-
mained fairly constant between 85-95° F. A rapid
drop then occun-ed in Noveimber, bringing the tem-
perature down to below 80° F. in December. The
highest maximum temperature recorded, 96'9° F.,
occurre^l in Api-il, and the lowest, 76-40 F., in
December. The minimal temperature follows the
curve of the maximal at a lower level, being about
10° F. lower during th© rains, i.e., from June to
October, and about 20° F. lower during the re-
mainder of the year. It ie rathe!P striking to find
tliat the nights are 20° F. cooler than the day
during the hot weather as well as in the coolest
THE JOUBNAL OF TEOPICAL MEDICINE AND HYGIENE. [Jan. l5. 1920.
Eetxjrn of Diseases and Deaths in 1917 by the Health Officer of
Calcutta.
GENERAL DISEASES. f
Alcoholism 2
Ansemia 59
Anthrax —
Beriberi 2
Bilharziosis . . . . . . . . . . . . . . —
Blaokwater Fever —
Chicken-pox . . . . . . . . . . . . . . —
Cholera 866
Choleraic Diarrhoea —
Congenital Malformation —
Debility —
Delirium Tremens . . . . . . . . . . . . —
Dengue —
Diabetes Mellitus 79
Diabetes Insipidus . . . . . . . . . . . . —
Diphtheria . . . . . . . . . . . . . . 32
Dysentery 1,707
Enteric Fever 209
Erysipelas . . . . . . . . . . . . . . 19
Febricula . . . . . . . . . . . . . . —
Filariasis . . . . . . . . . . . . . . —
Gonorrhoea . . . . . . . . . . . . . . 2
Gout —
Hydrophobia 3
Iiifluenza . . . . . . . . . . . . . —
Kala-Azar 86
Leprosy 88
(o) Nodular —
(6) Anaesthetic —
(c) Mixed —
Malarial Fever— 984
(a) Intermittent . . . . . . . . . . . . —
Quotidian —
Tertian . . . . . . . . . . . . —
Quartan . . . . . . . . . . . . . . —
Irregular . . . . . . . . . . . . —
Type undiagnosed 1,484
(6) Remittent —
(c) Pernicious .. .. .. .. .. .. —
(d) Malarial Cachexia —
Malta Fever —
Measles 138
Mumps . . . . . . . . . . . . . . . . —
New Growths — . . . . . . . . . . . . —
Non-malignant . . . . . . . . . . . . —
Malignant . . . . . . . . . . . . . . 60
Old Age 1,537
Other Diseases 1,319
Pellagra —
Plague 81
Pyaemia . . . . . . . . . . . . . . . . —
Rachitis . . . . . . . . . . . . . . . . —
Rheumatic Fever 7
Rheumatism 56
Rheumatoid Arthritis . . . . . . . . . . . . —
Scarlet Fever . . . . . . . . . . . . . . —
Scurvy —
Septicaemia . . . . . . . . . . . . . 70
Sleeping Sickness —
Sloughing Phagedaena —
Small-pox 28
Syphilis . . . . . . . . . . . . . . . . 45
(a) Primary —
(6) Secondary —
(c) Tertiary —
(d) Congenital . . . . . . . . . . . . —
Tetanus . . . . . . . . . . . . . . . . 873
Trypanosoma Fever
Tubercle— —
(a) Phthisis Pulmonalis 1,432
(6) Tuberculosis of Glands
(c) Lupus . . . . . . . . . . . . . . —
Genbbal Diseases— cotiiinueti.
{d) Tabes Mesenterica
(e) Tuberculous Disease of Bones .
Other Tubercular Diseases
Varicella
Whooping-cough
Yaws
Yellow Fever
LOCAL DISEASES.
Diseases of the —
Cellular Tissue 98
Circulatory System —
(a) Valvular Disease of Heart 449
(6) Other Diseases 141
Digestive System — . . . . . . . . . . . . —
(a) Diarrhoea 744
(6) Hill Diarrhoea —
(c) Hepatitis —
Congestion of Liver . . . . . . . . . . —
(d) Abscess of Liver . . . . . . . . . . 45
(e) Tropical Liver —
If) Jaundice, Catarrhal . . . . . . . . . . —
(g) Cirrhosis of Liver . . . . . . . . . . 124
(h) Acute Yellow Atrophy —
(i) Sprue . . . . —
(j) Other Diseases 1,038
Ear — .. .. —
Eye —
Generative System— —
Male Organs . . . . . . . . . ■ . . 15
Female Organs . . . . . . . . • . . . 60
Lymphatic System 3
Mental Diseases . . . . . . . . . . . . —
Nervous System . . . . . . . . ■ • . . 466
Nose —
Organs of Locomotion . . . . . . . . . • 2
Respiratory System 4,764
Skin— 134
(a) Scabies —
(6) Ringworm . . . . . . ■ . • • • • —
(c) Tinea Imbricata . . . . . . • • • • —
(rf) Favus —
(e) Eczema . . . . . . . . . - • • ■ • —
(/) Other Diseases ■• —
Urinary System . . . ■ • • • • • ■ • • 323
Injuries, General, Local — .. •• •■ •• •■• —
(o) Siriasis (Heatstroke) .. •. .• •• •• —
(6) Sunstroke (Heat Prostration) —
(c) Other Injuries . . . . • . . . ■ • • • 97
Parasites— .. .. .. •. ■• •• •■ 1
Ascaris lumbricoides . . . . . • • • . . —
Oxyuris vermicularis —
Dophmius duodenalis, or Ankylostoma duo-
denale . . . . . . . . • . • • • • —
Filaria mediaensis (Guinea-worm) .. .. .. —
Tape-worm —
Poisons— .. .. .. .. .. ■• •• —
Snake-bites
Corrosive Acids
Metallic Poisons . . . . . . . . • • . ■ —
Vegetable Alkaloids —
Nature Unknown —
Other Poisons H
Surgical Operations — . . . . . . . • ■ . • • —
Amputations, Major . . . . . . . . • - • • —
,, Minor . . . . . . . • . • • • -~
Other Operations —
Eye —
(o) Cataract
(6) Iridectomy .. .. .. .. •• •• —
(c) Other Eye Operations —
J
COLONIAL MEDICAL BEPORTS.— CALCUTTA.
month of the year. The mean daily range varied
from 9-10 F. in July and August to 22-5o F. in
January. The moisture-laden atmosphere of the
rains tends to int«a-fere with the radiation of heat
from the earth ju-st as it interferes with radiation
from one's body. The reisulb is a capital repre-
sentation of a Turkish bath.
The total rainfall for the year was 70-68 inches.
This .is slightly above the average but considerably
lesis than in 1916, when 82-78 inches of rain were
recorded. The most remarkable feature of the
rains of 1917 was that although we had six solid
months of rain, from May to October inclusive, the
rainfall was so uniformly disturbed and so moderate
that the early onset and late cessation did not result
in any abnormal downpour. There were only two
months, January and December, in which no rain
fell. From February to April about 4-5 inches fell.
In May 8-22 inches were recorded, followed by
116 inches in June and 12-1 inches in July. The
wetbeisb month was August with 14-27 inches. A
temporary lull in Septembei-, when only 8-09 inches
were recorded, was followed by a wet October with
11-31 inches. The largest rainfall recorded in
twenty-four hours was 4-14 inches. This occurred
in August. The contrast with 1916 is very marked.
In that year a prolonged drought was followed by
a very wet June. Then a " break " occurred in
; July followed by heavy raine lasting from August
1 to October.
Tne barometer was higher than usual in May,
otherwise the readings followed the usual curve,
being highest in the cold weather and lowest during
the rains. The prevailing direction of the wind was
north-west in January, February, November and
December; south-west from March to July; south
east from August to October. From June to August
it was almost due south.
Vital Statistics.
Death-rates.
The total number of deaths registered during the
year was 21,360, equivalent to a death-rate of
238 per mille calculated on the census population
of 1911. This is the loivest death-rate ever recorded
ill Calcutta. Calculated on the mean jx>pulation for
the year, which is estimated at 927,610, the death-
rate in 1917 was. only 23 per mille. As there is no
" natural increase " of population in Calcutta the
number of deaths exceeding the number of births
by about 2,500 or more every year, the increase in
the population which undoubtedly occurs, as the
ICensus reburriB show, is entirely due to immigra-
hion. The extent and volume of tliis constant
stream of immigrants is shown by the following
figures. During the ten years inter-cenaiual period
1901 to 1911, there were 295,733 deatlis and
150,099 births registered in Calcutta, i.e., the excess
)f deaths over births was 145,634. And yet the
xjpulation, according to the census of 1911, had
ncreased by 48,271. That is to eay, 193,905 immi-
^ants, or an average of 19,390 per annum, had
migrated from the country and settled in the city.
These figures give some idea of the difficulties
encountered in admmistering sanitary regulations
relating to registration of births, vaccination, the
control of epidemics, &c. As I have previously
pointed out, " crude " death-rates, such as those
given above, i.e., without corrections on account
of variations in the constitution of the population,
particularly as regards age and sex, are useless for
purpofses of comparison with other cities. They
are, of course, of the. greatest value for ascertaining
the state of the public health in Calcutta compared
with previous years. Although the " factor of cor-
rection " calculated by the Eegistrar-General in
England is not available here, nor have death-rates
for each age and sex group in a " standard million "
Ijeen worked out, an attempt may be made to work
out a partially corrected death-rate in the follow-
ing manner. The actual death-rates in Calcutta
amongst each age group are calculated for both
sexes. From, the census the normal proportion of
each age and sex gi-oup in Bengal is ascertained and
the population of Calcutta is redistributed amongst
the various age and sex groups according to the
normal distribution in Bengal. The number of
deaths in each group is then calculated from the
actual death-rates recorded in Calcutta. The result
is a death-rate which approximately represents the
death-rate of Calcutta if the age and sex distribu-
tion of the population was exactly the same as in
Bengal.
Principal Variation in Mortality from Different
Causes. — The principal infectious diseases — plague,
cholera and small-pox — caused only 975 deaths.
One has to go back twenty years, to the time when
plague was unknown in Calcutta, to find a figure
comparable to this. Th«< most remarkable diminu-
tion has occurred in the mortality from cholera,
which only caused 866 deaths. This is the lowest
figure ever recorded in Calcutta with the exception
of 1898, when only 665 deaths were recorded.
This remarkable figure was followed by two severe
epidemics which caused 3,449 deaths in 1896 and
2,349 deaths in 1897.
The number of deaths fi-om j)lague was only 81.
This is the second year in succession that there has
l)een no epidemic of plague. During the preceding
four years the mortality from plague fell rapidly.
Eac;h succeeding year the mortality was less than
iuilf that of the previous year. The mortality from
small-pox was almost negligible, only 28 deaths
being recorded.
The remarkable diminution in the mortality from
tuberculosis is most satisfactory, particularly as
there has be«n a steady and uninterrupted fall in
the number of deaths during the last four yeare.
Deatii-uates amongst Males and Females.
In spite of the improvement in the general death-
rate of the city, the death-rate amongst females is
still more than 40 per cent, higher than amongst
males. The actual death-ratee m 1917 were : males,
198 per mille; females, 321 per mille. This in-
8
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15. 1920.
version of the usual ratio between male and female
death-rates is a remarkable feature of the vital
statistics of the city. Until it is realized that the
strict observance of the purdah eystem in a large
city, except in the case of the very wealthy who
can afford spacious homes standing in their own
grounds, necessarily involves the premature death
of a large number of women, this standing reproacli
to the city will never be removed. Although the
ratio between the two death-rates ie practically
unchanged the death-rate amongst femaJes. has
shared in the improvement of the general death-
rate.
Death-rates among Different Classes. — The prin-
cipal communitdes forming the population of Cal-
cutta has been silightly modified. The Christian
community has been sub-divided into non-Asiiatic
(including Anglo-Indian) and Indian ; the former
heading " Christian," which included Asiatics and
non- Asiatics, was obviously uselesis for statistical
pm-poseis. On the other hand, "Buddhists" and
" other classes," both comprising a very small sec-
tion of the population, have been amalgamated.
Seasonal Variations in the Death-Rate. — In the
Tropics the shai^ly defined seasons, with their
marked variation in temperature and rainfall, exert
a very powerful influence on the public health. In
large cities, such as Calcutta, with a large excess
of adult males, a considerable number of whom ai-e
primarily agriculturists, who come down to Calcutta
and after working for several months return to their
country to till the. ground and reap the crops,
allowance must be made for the ebb and flow of
the labouring classes in dealing with fluctuation in
the death-rate. Making every allowance for this
well-known feature of city life in India, it certainly
cannot account for the extremely marked and
regular variation in the death-rate at different
seasons of the yeai-. That these are absolutely in-
dependent of the movements of the labouring classes
is clearly shown by the fact that precisely similar
fluctuations occur amongst the female population
of the city which, of course, is comparatively stable.
Mortality at Different Ages. — The infantile mor-
tality rate was 239 per mille. In three years the
infantile mortality rate has been lowered by _one-
sixth. If this continues, another half a dozen yeans
will see the rate reduced to half that recorded in
1915. As I have previously pointed out, the in-
fantile mortality rate, unlike all other mortality
rates, is calculated on a purely hypothetical popula-
tion, which is assumed to be equal to the number
of births registered during the year. Obviously any
defect in registration diminishes the population on
which the rate is calculated and automatically in-
creases the infantile mortality rate, and vice- versa.
Death-rates amongst Males at Different Age-
Periods. — The death-rate amongst males of all ages
was 19-8 per mille, as compared with 20-5 in 1916.
Both these rates are a marked improvement on the
quinquennial average of 23-3 per mille.
With the exception of the ag© period 50-60 years,
which had an increased mortality rate, the mor-
tality rates at other age periods show an all-round
improvement. It is satisfactory to note the rela-
tively marked improvement in the death-rate
amongst children over 1 and under 5 years of age.
As in previous years, the age-group 10-15 yeare had
the lowest death-rate, 6-6 per mille, and the age-
group 60 years and over the highest, viz., 95'2 per
mille.
The most remarkable feature is the manner in
wliieh is demonstrated the profound influence the
abnormal constitution of the population has on the
vital statistics of the city. Not only do males form
over tv.'o-thirds of the population, but more than
half of them belong to the age-groups 20-30 years
and 30-40 yeare, i.e., are in the prime of life. The
death-ratesi for these two age periods were 8'1 per
mille and 11'4 per mille respectively. As I have
shown elsewhere, were it not for this excess of
young adult males the general mortahty rate would
undoubtedly be considerably higher.
Death-rate amongst Females at Different Age
Periods. — The abnormal inversion of the ratio be-
tween the mortality rates amongst males and
females, which is one of the saddest features of the
vital statistics of the oity, still continues. The
death-rates amongst females of all ages was 32'1
per mille, as compared with 19'8 per mille amongst
males. The difference, 12-3 per rnUle, is equivalent
to 60 per cent, of the male death-rate. In other
words, for every three deaths amongst males, five
deaths occur amongst females.
With the exception of a slight increase amongst
children under 10 years and women of 50-60 years
of age, there has been an all round improvement in
the mortality rates amongsit females. Under 10
years of age the death-rate is almost the same for
girls as for boys.
Similarly between 40 and 60 years the rates are
very similar. At 10-15 yeare of age the death-rate
amongst females is 25 per cent, higher than amongst
males, whilst at age-j)eriods 15-20 years, 20-30 years '
and 30-40 years it is actually more than double.
That is to say, the whole of the excese mortality:
amongst females occurs amongst young women in
the prime of life. ]
The following comparative statement shows the.'
death-rates per mille amongst males and females
of the principal diseases in which the rate amongst
females was markedly higher than amongst males : —
riise.ise
Mortality rate
Mortality rate
amongst maUs
amongst females
Fever*
1-6
2-0
Dysentery
15
2-6
Tuberculosis
13
2-5
Malaria
0-87
1-5
Senility
0-92
3-3
Diarrhcea and eutentist
0'60
1-3
Bronchitis and Broncho-pneu-
monia
3-2
53
Paralysis
Suicide
0-26
0-41
004
0 07
Burning
0 04
0-24
Drowning
0 04
007
I
Feb. 2, 1920.J
COLONIAL MEDICAL REPORTS.— CALCUTTA.
Colonial Medical Repopts.— No. 105. ~ Calcutta {contd.).
The principal cause of these high rates of mor-
tahty is undoubtedly the observance of the purdah
system in a great city where there are great masses
of insanitary dwellings crowded together in the
slum areas. The heavy mortality from respiratory
diseases and tuberculosis amongst women is clear
proof of the deadly effect of depriving them of fresh
air and light, by confining them in the zenana,
which, as I have repeatedly pointed out, is always
the most insanitary part of the house. The
women's apartments are always the inner apart-
ments, and beJng constructed with the sole object
of securing privacy, adequate lighting and ventila-
tion are secondary considerations. Constant ex-
posure to insanitary environments must lower the
power of resistance to infection, and this probably
accounts for the heavy mortality from Buch diseases
as malaria, dysentery, &c. Social and economic
conditions, such as poverty, overcrowding, child-
marriage, particularly the latter, which subjects
young and undeveloped girls to the strain of re-
peated pregnancies and prolonged lactation, all play
an important part in raising the death-rate ajnongst
women.
Infantile Mortality.
Principal Causes of Deaths amongst Infants. —
The total number of deaths amongst infants was
4,499. Of these, 1,674, or 37 per cent., occurred
during the first week. The principal causes of
mortality were premature birth and congenital
debility, which caused three out of four deaths (1 ,282
deaths out of 1,674), and tetanus neonatorum,
wliich caused 312 deaths. The latter is an entirely
pii'ventable disease due to dirty midwifery, and, as
1 have repeatedly urged, it is high time that the
Indian illnii \\:is |,revented by law from causing the
ileatb of ^u iniitiy babies. As this disease has an
iiicnliatidu iicriod of from three to ten days, it causes
r\.ri greater mortality amongst babies from 7 days
to 1 month old.
Ilic heavy mortality from respiratory diseases is
lar■^'|.ly dm- tn cyposure. In Calcutta the childrpji
of tbi' poonr rlasscs are very inadequately clothed.
Diiirrbical ilisiascs are responsible for a compara-
tively small number of deaths, due to the fact that
the great majority of babies are breast-fed.
Tlie very high mortality from premature birth
:\ut\ congenital debility points unmistakably to
something radically wrong with the conditions under
uliicli expectant women have to live. The principal
factors concerned are (a) poverty with its necessary
(•orollari<'«. underfeeding and anaemia; (()) constant
(■x|iosurc to insanitary surroundings, particularly
want of fresh air, intensified by th<! purdah system ;
(r) child marriages, immature girls being subjected
to the strain of repeated pregnancies and prolonged
periods of lactation.
Birfh-rate.
The number of births r6£;istered in Calcutta
during the year was 18,807. The birth-rate for 1917
cal(nilat<>d on the total population was 209 per
mille. Owing to the exceptional constitution of the
population this obviously conveys a wrong impres-
sion. The birth-rate calculated on the total female
population was 65 per mille. Even this birth-rate,
however, is of little use as an index of the fertihty
of the women of Calcutta, as it includes a large
number of women who are not of child-bearing ages,
and others, such as widows and prostitutes, who
should obviously be excluded. Excluding these
classes, the number of married women of child-
bearing age isi approximately 100,000, and the birth-
rate amongst this group of women was 188 per
mille.
Principal Causes of Deaths.
General Prevalence of Infectious Diseases.
Plague has almost vanished from the vital
statistics. Only 81 deaths were recorded during
the year.
Cholera, the mortality from which was only 866,
as compared with 1,335 in 1916 and a quinquennial
average of 1,787, shows a most remarkable diminu-
tion. There has been nothing approaching this
figure in the vital statistics of the city for twenty
years past.
There were only twenty-eight deaths from small-
pox. Thisi, I hope, indicates that a series of non-
epidemic years will intervene before it again
assumes epidemic form. " Fever," including
malaria and enteric, caused 2,925 deaths, a slight
increase compared with 1916 when 2,887 deaths
were recorded. The increase is due to deaths from
"other fevers," both malaria and enteric showing
a decrease.
Dysentery and diarrhrea (including enteritis and
puerperal diseases) accounted for 2,577 deaths, or
2-9 per mille, as compared with 2,487, or 2-8 per
mille, in 1916.
Tuberculosis shows a further decline, from 1,738
deaths in 1916 to 1,539. During the last five years
the mortality from tuberculosis has fallen from
2,196 in 1913 to 1,539 in 1917, a decrease of nearly
30 per cent.
Measles, unfortunately, appears to have departed
from the three-year cycle which has prevailed since
1910. There were 138 deaths in 1917 as compared
with 191 in 1916 (an epidemic year following two
non-epidemic years).
The total number of inoculations for plague done
during the year was sixteen, and so far ais is known
no deaths! occurred among persons who had been
inoculated. The campaign against rate was con-
tinued during the first eight months of the year.
About 65,000 rodents were destroyed and a little
over Rs. 1,000 was paid by way of reward. The
campaign was considered futile and with the approval
of the Corporation was abandoned with effect from
September 1, 1917.
The number of deaths from cholera was 866, or
0-96 per mille, the lowest figure recorded in Cal-
cutta since 1898. During the last four years the
mortality from cholera has fallen from 1,983 in 1914
bo 866 in 1917, a reduction of over 50 per cent.
THE JOUKNALr OF TROPICAL MEDICINE AND HYGIENE. [Feb. 2, 1920.
Age, Sex and Class Incidence.
As ill previous years, Hindus S'uffered far more
severely than Mohammedans, Out of a total of 866
deaths there were 767, or 1-2 per mille, amongst
Hindus and only 93, or 0'3 per mille, amongst
Mohammedansi. Only six deaths occurred amongst
non-Asiatics and Indian Christians. These figures
corroborate in a very striking manner the statement
that the bulk of the cholera in Calcutta is water-
borne as the Hindu community regards the water
of Tolly's Nullah and the river as sacred and bath-
ing is a religious ceremony fi-equently performed.
The incidence aimongst females was slightly less
than amongst males. This is unusual as the two
sexes are usually attacked in almost exactly the
same proportions.
Young children and adults over 50 suffered nearly
twice as severely as adults in the prime of life.
There were only twenty-eight deaths recorded as
due to small-pox. At the time of writing a local
outbreak of considerable intensity has broken out
in Jorasanko and Barrabazar. The outbreak com-
menced in March — an unprecedented occurrence in
Calcutta, and the majority of the early cases were
unprotected recent arrivals in Calcutta. An in-
spection of Barrabazar showed that there had been
a great influx of people from plague-stricken areas
up-country, particularly Rajputana. I have every
hope that there will be no general epidemic this
year.
Measles.
The number of deaths from measles was 138,
or 0-15 per mille. From 1910 to 1916 measles fol-
lowed a definite cycle, an epidemic year being fol-
lowed by tw^o non-epidemic years. This year it
appears to have reverted to its former type with
irregular fluctuations from year to year. The disease
was most prevalent in March, April and May, over
50 per cent, of the deaths occurring in these months.
Hindus appear to be much more susceptiljle than
Mohammedans, and females are attacked slightly
more frequently than males.
The number of deaths recorded as due to enteric
was 209, or 0-23 per mille, this represents a marked
im])rovement.
Ages, Sex and Caste Incidence. — Males and
females appear to be about equally susceptible.
Children and young adults are much more sus-
ceptible than older persons.
The incidence amongst the different communitiei?
varies enormously. The 209 deaths recorded as due
to enteric were distributed as follows: Hindus. 172,
or 0-28 per mille; Mohammedans, 12, or 0-04 per
mille; non-Asiaties (including Ansrlo-Indians), 16,
or 0-57 per mille; and Indian Christians, 8, nr
0-67 per m^le.
Non-Asjiatics and Indian Christians appear to be
more susceptible than either Hindus or Mohamme-
dans. The most striking feature, however, is the
comparative immunity of Mohammedans, the attack
ratio amongst this com.munity being only one-
seventh of that amongst Hindus. A good deal of
tliis immunity is probably more apparent than real,
a number of untreated and theretore undiagnosed
cases occurring amongst the ignorant poorer classes.
Local Outbreak.
A local outbreak occurred in the Loreto Convent,
Entally.
The epidemic proper lasted from July 30 to
August 31. Not a single case occurred amongst
the seventy-four infants and younger children in
the nursery.
Nearly half the total number of cases were in-
fected during the week ending August 12, 1917.
There were only two deaths.
The chief defect was found to be the extremely
inadequate supply of filtered water in the orphan-
age and also in the boarding school, particularly in
the former.
The blood of the men in charge of the main
kitchen and of eight cooks employed there, and of
two cooks in the Bengali school kitchen, was ex-
amined for " carriers." AU gave negative Widal
reactions with the exception of two cooks from the
main kitchen. These men were sent to the labora-
tory and fuller tests made. The Mother Superior
was warned and advised to exclude both men from
the Convent.
It seems clear that " carriers " play a very im-
portant part in the spread of enteric in Calcutta.
Perhaps the most important factor, however, is
the number of cases — many unrecognized and un-
treated— which are allowed to remain in their houses
without skilled nursing. This means endless oppor-
tunities for the spread of the disease through dis-
charges, soiled linen, utensils, &«., not being
disinfected.
The total number oi deaths recorded as due to
malaria was 984, or 1-1 per mille. From this it is
clear that the apparent reduction in malaria is
almost entirely due to the practice adopted of
registering deaths which were formerly ascribed to
malaria, as due to "other fevers."
Age, Sex and Caste Incidence. — Mohammedans I
suffered much mo'-e severely than Hindus, the mor- fi
tality rates per mille being 1-8 and 0-83 respectively.
Th's is largely due to the fact that the suburban
wards with high fever rates contain a relatively
large Mohammedan population.
The mortaUty rate amongst the females was
1"5 per mille as compared with 0'87 amongst
males.
The age incidence shows that children and young
adults are more suscpptililf than the later age-
group.
Dysentery and Diarrhaa. — The total number of
deaths from these causes was 2,577, or 2'9 per mille.
The incrensod mortality is mainly due to diarrhoea
And enteritis, the deaths from dysentery showing a
relativelv small increase.
.Aqe, Srx and Class Incidence. — Hindus, with a
mortality rate of 3-2 per mille, s^lffered more
severely tlian Mohammedans amongst whom the '
Feb. 2, 1920.]
COLONIAL MKDIOAL REPORTS.- CALCUTTA.
1
death-rate was 2'2 per mille. Amongst " other
classes " it was slightly less, 1"9 per mille.
Females suffered twice as severely as malee, the
death-rates per mille being 4'3 and 2-1 per mille
respectively.
A further marked decline in the mortality from
tuberculosis occurred this year, the total number
of deaths recorded being 1,539, or 1-7 per rnille.
A moet remarkable reduction in the death-rate from
tuberculosis has occurred during the last five years.
It is actually nearly 30 per cent, loiver than it was
five years ago. Of the 1,539 deaths recorded as due
to tuberculosis 1,433 were due to pulmonary tuber-
oulos:is and 106 to tuberculosis of other organs.
One common factor appears to be insanitary
housing conddtions. Whether it is a dark ill-
ventilated room in a hut, in the suburbs, or a
gloomy stufify den in the slums, the results are
identical. Given thousandsi of cases of tuberculosis,
spitting promiscuously and crowded together under
insanitary conditions, tuberculosis is bound to play
havoc, particularly when so many of its victims are
predisposed to infection by under-feeding, and the
struggle for existence under depressing conditions.
Age, Sex and Caste Incidence. — Hindus and
Mohammedans appear to be about equally
susceptible, the mortality rates being 1-7 and
1-6 per mille. The death-rate amongst " other
classes " was slightly higher being 1'9 per
mille. Females siuffered nearly twice as severely
as m^ales. As I have repeatedly pointed out,
I am convinced that the observance of the
purdah system in a large city is very largely
responsible. The consequence is that women
rarely escape from their insanitary " inner apart-
ments " which are usually the most ill-lighted and
ventilated in the house as privacy must be secured
at all costs. The following statement showing the
incidence at different age periods reveals: the saddest
feature of tuberculosis in Calcutta, the heavy toll
taken by tuberculosis amongst young females.
The number of deaths from respiratory diseases
(excluding pulmonary tubercle) was 4,769, or 5-3
per mille. Althougli the returns have been station-
ary for the last two years, a marked dirainutdon in
the mortality from these diseases has occurred since
1913, when 5,310 deaths were recorded.
Seasonal Prevalence. — This is extremely marked
by an almost uninterrupted rise and fall with its
minimum in .July and its maximum in January. As
the returns for December are almost identical wnith.^
those for .January, the curve is almost symmetrical,
the steady fall from .January-July being followed
l)y a steady rise from July-December.
Age Incidence. — As already pointed out in dealing
with infantile mortality, acute bronchitis is one of
the principal causes of deaths amongst infants.
Out of 1,917 deaths from acut«i bronchitis 1,354
occurred amongst infants. With the exception of
twenty-seven deaths amongst older children, the
whole of the remaining deaths occurred amongst
children 1 to 5 years of age.
Out of 1,298 deaths from chronic bronchitis 826,
or 63 per cent., occurred amongst old people 60
yeans of age and over.
Pneumonia. — This" appears to be a disease of adult
life. Out of 1,128 deaths recorded as due to pneu-
monia, 66 per cent, occurred between the ages of
20 and 50 years. The mortality rate rapidly rises
with advancing years.
Broncho-pneumonia is particularly prevalent
amongst children, nearly 50 per cent, of the total
deaths occurring amongst infants and children
under 5 years of age.
Work of the Sanitary Department.
The following statement shows the principal im-
provements, effected and in progress : —
Provision of new house drains
Improvements to existing drains
Provision of connected privies
Cleansing and enclosing open lands
Improvement • .f insanitary buildings
FiUing-up wells
Filling-up tanks ...
Improvement of cowsheds, cattle-sheds and stables
Improvement of food shops ...
Removal of jungle . .
Miscellaneous
Total
1,361
608
487
67
123
214
8,706
Improvement of Insanitary Buildings.
In drawing up requisitions for improvements, the
object aimed at is the provision, so far as may be
practicable, of some open space or spaces at the
back or on the sides, and the foUowing methods
have been adopted to improve the buildings in
question: —
(1) Provision of B(^ck Space. — By the demolition
of the ill-ventilated Sj,ack block, and by providing
windows in the back wall facing the open land of
the adjoining premises' belonging to another owner
by making the party pay compensation.
(2) Provision of Side Spaces. — By the demolition
of some ill-ventilated rooms entirely or partially.
(3) By the enlargement of the central courtyard
—as in 33, 40, 41, 42, 43, 44/1, 50, 53, 54, 54/1,
.56 and 57, 63/2/1, 63/3, 63/5 and 33/2, Mallanga
Lane; 2, 8 (four huts), Abhay Haldar T^ane ; 3, 5,
11, 10, 18, Madan Boral Lane; 4/1, Lai Behari
Thakur Lane; 16, Sreenath Das Tjane.
(4) By the dem.olition of the middle room of an
ill-ventilated range.
(5) By the re-arrangement of the courtyard and
the rooms in a block of buildings.
(6) By opening sky-lights or ventilators over one-
sforied ill-ventilated rooms.
In some of the worst cjises the owners have on
receipt of notice erected altogether new sanitary
masonry buildings. In other cases the owners have
been granted conc/cssions and allowed to erect a
second storey over one-storied rooms on the road-
side, the building regulations being relaxed.
The revised by-laws relating to oattle-shede, Ac,
liave not yet been sanctioned by Government, but
their requirements have been kept in view and
closely followed in enforcing improvementB.
12
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 2. 1920.
Improvement of Aerated Water Factories. — By
the direction of the Markets Special Cominittee all
these places have been regularly inspected and
action has been taken to rectify defects, the princi-
pal improvements enforced being the paving of
floor, the provision of proper drainage, lime wash-
ing and general cleanliness and an adeqnato supply
of filtered water with arrangements' for two or three
changes of water for cleansing bottles.
Improvement of Grog Shops. — All the grog shops
in the city were inspected by the Health Depart-
ment during the year. Sixty-one were reported
upon.
Improvement of Bakeries. — All the bakeries in
the city were inspected and reported upon during
the year, the total number dealt with being 214.
About half were found situated in huts with kutcha
walls, and twenty-five bakeries were in objection-
able surroundings, i.e., near stables, dustbins, ser-
vice privdes, &c. The lighting and ventilation were
either altogether bad or deficient. There is no
denying the fact that a large proportion of the
bakeries are in a verj' insanitary condition.
Improvement of Markets. — Towards the end of
the year, directions were issued to the district
health officers to make a detailed inspection of all
the private markets and to submit a comprehensive
report in regard to their present sanitary condition
and thei improvements required.
During the year an application was received for
sanction to establish a market. A site was
selected and was generally approved by the
Markets Special Committee who however postponed
formal approval until the building plans were sub-
mitted.
Food Inspection. — It had long been recognized
tlmt the provision® of the Calcutta Mamicipal Act
of 1899 relating to foodstuffs were very defective.
During the year under report, however, complaints
in regard to the sale of adulterated ghee became so
acute that imme/diate legislation was found neces-
sary. There was a widespread belief that much of
the ghee sold in Calcutta was naixed vpith animal
fat. The Marwaris, whose rehgious sxisceptibilities
were hurt, took up the matter, and besides putting
social pressure upon dealers of their own com-
munity who had been selling adulterated ghee,
pressed Government to take drastic action. This
.\et came into force on September 13, 1917. The
principal provisions of the new law are the defini-
tion of adulterated ghee, prohibition of the sale, &c.,
of impure ghee, and of any article similar to ghee
under a name resembling the name given to any
brand of ghee, it being left to the court to presume,
unless and tmtil the contrary is proved, that any
ghee found in the possession of a person who is
in the habit of manufacturing or storing ghee has
been manufactured or stored for sale. The prohi-
bition of the keeping of adulterants in places where
ghee is manufactured or stored, power to seize un-
wholesome ghee found in godowns or in coojrse of
transit, and higher penalties for offences. A special
committee of the Corporation considered the
measures to be adopted to enforce the provisions
of the new law, and on their recommendation two
extra analysts and a special food inspector to deal
exclusively with wholesale and liig retail vendors
were appointed.
Up to the end of the year under review 308
samples of ghee were analysed, of which eighty-three
samples were ol)tained from wholesale dealers and
225 from retail vendors. Eighteen of the wholesale
dealers' samplesi and forty of the samples from re-
tailers were found adulterated; fifty-five prosecu-
tions were instituted during the year for selling
adulterated ghee, of which seventeen were against
wholesale dealers, and tliirty-eight against retail
traders. Convictions were obtained in twelve cases,
the fines inflicted amounting to Es. 1,214, The
number of prosecutions instituted for refusal to sell
samples of ghee for analysis was eleven, of these
seven were decided during the year, the accused
being fined Rs, 830, A big consignment of ghee
consisting of 369 maunds was seized at a shop and
godown, and was ordered by the Municipal Magis-
trate to be deetro,yed. The ghee was sold to the
North-west Soap Company and was immediately
alkalized in the presence of a food inspector.
.Judging from the results of analysis both during
the year under report and since, there appears to
be a marked improvement in the quality of ghee
sold, particularly, in wholesale and big retail shops.
The question of the improvement of the milk
supply of the city remained in abeyance pending
the receipt of Major Matson's report. Meanwhile
the possibilities of a site at Gadkhali in the Jessore
District for a dairy farm are being investigated,
and a suggestion had been made for the formation
of a dairy company for the supply of pure milk on
a commercial basis.
The total number of vaccinations done during
the year was 30,422.
There were 20,667 primary vaccinations, being
an increase of about 15 per cent.
The total number of re-vaccinations done during
the year was 9,755, The results were successful
in 2,469 cases and unsuccessful in 4,173 oases: in
3,113 cases the results were unknown.
The number of vaccinations done at the Vaccina-
tion Stations rose from 9,732 to 11,059, the increase
being almosit wholly due to the large number of
vaccinations done in the station at the Sambhunath
Pandit Hospital (1,836 against 647), The stations
with the highest figiu-es are those situated at the
Ezra Hospital (1,421), Campbell Hospital (797) and
District Offices I and IV (714 and 711 respectively).
The system of allowing vaccinators to retain the
fees for home vaccinations, which was introduced
as an experimental measure in July, 1916, was con-
tinued throughout the year under report. The
results were considered disappointing, but since the
close of the year it has been decided to give the
svstem a fiirther trial.
Feb. 16, 1920..
COLONIAL MEDICAL REPOBTS.— CALCUTTA.
Colonial Medical Reports.— No. 105.- Calcutta {contd.).
JMosQurro Bkigadks.
Ill my last annual report I referred to the recom-
mendations of Dr. Bentley, and the decision of the
Corporation to retain the i?ervices of the brigades
throughout the year instead of having them for a
few months only as before.
Besides tlie above work, nearly 300 oesspabsi were
treated several times, and in 109 cases of obstruc-
tions to surface drains were removed.
From the more complete records kept in the dis-
trict (evei-y tank being examined regularly all the
year rouii(l), it will be seen that there is a marked
seasonal variation in the prevalence of anopheles.
Broadly spcal<ing, anopheles are most jjrevalent in
the cold se;',soii and least prevalent in the rains.
The largest number of breeding grounds were found
in December and the smallest in August. A great
deal of useful work is carried out by the mosquito
brigades, but it must be clearly understood that
the present staff is really a nucleus on which I
hope a complete organization will gradually he
built up.
IauIij Hrallh Visit„r.H and Miclwircs.
The work of the maternity and baby welfare
section for tlie year is of si)ecial interest as this
is the fii-ist complete year the present system has
been in operation.
Combining the returns for the two units it will
be seen that eight midwives, under the supervision
of two lady health visitors, delivered 1,065 women,
with only tiu'ee maternal deaths. One woman died
of tuberculosis, another of chronic dysentery, and
one from post-partum. hajmorrhage (placenta-
prffivia). That is to say, in spite of the ajjpalling
conditions under which manj- of the women were
delivered, often after ignorant ilhais had done their
worst, there was only one maternal death due to
childbirth in over 1,000 deliveries. The entire
alxsience of serious eases of septiccemia is another
gratifying feature and the staff are to be congratu-
lated on the very satisfactory results obtained vinder
extremely unfavourable conditions. A large and
well-equipped maternity hospital with a much
bigger staff might well be proud of results like these.
Out of 522 deliveries in Circle I there were six-
teen twins, the number of babies born being 538.
In Circle 11, out of 543 deliveries there wer©
two triplets, fourteen twins, the uutnber of babies
born being .561.
The total number of JKibies born «as 1,000 an.l of
tliese forty wen' stillborn. Exchiding these there
were 1,0.59 living babies horn of which sixty-eight
died before the tentli day, a mortality rate of 64 per
mille. Til is compares very favourahly with tlie
general infantiU' mortality rate during the first week,
viz., 89. Mo.st of the deaths occurred amongst pre-
maturely born liabies, particularly the twins and
triplets. In Circle 11, out of two sets of triplets
only one baby survived, and out of fourteen sets,
of twins only seven babies survived. Only five out
of forty deaths amongst infants under 10 days old
were full-time babies. The most striking fact, how-
ever, is the entire absence of tetanus neonatorum, a
convincing proof that this disease isi entirely due to
dirty midwifery.
As an example of the unnecessary suffering and
loss of life caused by the ignorant, dirty, super-
stitious dhai, I quote the following from Miss Lewis'
report : —
" In many cases the midwives were called in
where the people had tried several unqualified mid-
wives without success. In one particular case the
woman had been five days in labour before we were
sent for. As all my midwives were engaged, I went
myself and found the woman in a most t>errible
condition with a temperature of 105° F. and a
correspondingly high pulse rate. On examination
bits of foetus came away and it was impossible to
make out the presentation, owing to the decom-
posed state of the child. The stench was some-
thing awful. When I asked the female relatives
why they had not sent earlier when they knew that
trained midwives were available day and night free
of charge, they said that the dhai had prevented
them and assured them that everything was all
right. The male relatives, when questioned, said
that they never interfered and when they asked
how the woman was progressing, they wero in-
formed that she was doing well. I removed the
woman to hospital, where she died undelivered a
few hoiu's after admission."
Surely it is time that ghastly tragedies of this
kind were made impossible by making it a penal
offence for any unqualified {)erson to attend a
confinement.
liuby Wclfarr Work.
This branch of work is comparatively new, and
is an attempt to adapt the baby (dinic to suit local
conditions. .\s all attempts to induce mothers to
bring their babies to the lady health visitor for
advice and treatTnent have failed the health visitors
visit every baby delivered by the Corp<jration mid-
wives till it is 3 months old. Where the baby is
being artificially fed, what is urgentlj' wanted is an
organization for the supply of clean pure milk at
reduced rates. Until a municipal dairy m started
there is little hope of getting an adequate supply
of good milk, but 1 hope to start small milk depots
at the health visitors' quarters on a very moderate
scale and if these are a success a small municipal
dairy nnist he started, solely for the«e depots.
The results of the present system of Ivaby welfare
work, imperfect as it is, are very encouraging.
W(
DONK IN TIIK COKI'OHATION TyABORATOUY.
The total number of samples analysed in the
laboratoi-y wa« 5,496. These samples may be
groupcul under the following heads: —
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 16, 1920.
I. Chemical examination of water 206
II. Bacteriological examination of water 2,791
III. Chemical and microscopical examinations of blood,
sputum, urine, &c., received in the laboratory ... 226
IV. (a) Examination of blood, faeces, urine, &c. ... 69
(b) Examination of rats 37
(c) Examination of vaccine lymph 94
V. Analysis of food-stuffs 2,075
VI. Analysis of substances other than food and water... 61
Total 5,562
Chemical Examination of Water.
Fifty-three samples of filtered water from the
collecting welfe at Pulta, and twelve samples of
water from the river at Pulta, were fully analysed
during the year. The amount of dissolved solids
was also determined in fiftj'-three samples of river
water at Pulta collected once a we>ek and in the
same water after settling. The results of these
analyses taken together show that the river water
after passing through the filters lost on an average
9 parts of dissolved solids, 0-7 part of total hard-
ness, 0006 part of albuminoid ammonia, 0005 part
of nitrates, and 0014 part of oxygen consumed per
100,000 parts. In the process of filtration the fil-
tered water was altogether freed from free and
saline ammonia, but the chlorides remained almost
unaffected.
The water was found to be free from nitrates and
saline ammonia throughout the year. Judged
chemically the filtered water of Calcutta is of great
purity.
Bacteriological Examination of Samples of Water.
In the filtered water the total bacterial count
varied from 8 to 78, the average being 27 colonies
per c.c. Lactose fermenters were always absent
in 10 c.c. The bacterial efficiency of the filter beds
was very high throughout the year. The reduction
in the bacterial content of the original wat(!r aver-
aged 99-95 per cent.
One hundred and six samples of filtered water
were examined for the presence of Comma bacillus
with negative results. Thirteen samples of river
water collected from the bathing ghate in connection
with the prevalence of cholera in the city and two
samples of tank water from a bustee where cases
of cholera occurred were also examined but no
" Comma's " forms were observed.
Chemical and Microscopical Examinations of
Blood, &c.
Twenty-five specimens of blood were examined
for Widal's reaction with B. typhosus and para-
typhosus and in nine positive results were obtained ;
eighteen specimens of sputum, were examined, of
which four showed tubercle bacilli. Two speci-
mens of secretion from the throat taken with swabs
gave negative results for diphtheria bacilli ; 160 speci-
mens of urine were analysed chemically and micro-
scopically and five specimens bacteriologically for
the presence of B. coli.
Special Bacteriological Investigations in Connection
with Infectious Diseases.
From a report received that three members of
a chummery had attacks of enteric, one after the
other, within a year, and there being suspicion of
the presence of a carrier among the menial staff,
all the men employed in the chummery were
examined and nineteen specimens of blood were
taken. All the specimens were fouud to give nega-
tive Widal except that of the cook, which gave posi-
tive reaction with B. typhosus in 1 in 20 dilution.
The blood of the suspect was examined again and
this time positive reaction was obtained even in
1 in 100 dilution. Specimens of urine and stools
were collected and examined. The urine was found
to be sterile but suspiciousi colonies were found in
Conradi and Drigalski plates and were sub-
cultured in different sugar media for identification.
One organism closely resembled organisms of the
typhoid-Gartner group, but no agglutination reaction
was obtained with the blood of the suspect. His
urine and stools were examined on two further occa-
sions but no organisms of the typhoid group were
isolated.
After three months another servant of the same
chumnaery who reported himself to be convalescent
from an attack of enteric was sent for examination.
Widal's reaction of the blood was found to be
negative for typhoid and paratyphoid in 1 in 10
dilution. The specimen of urine was found to be
sterile and the examination of the stool showed that
organisms of the B. coli group preponderated. A
few suspicious colonies were found, which on fur-
ther examination in sugar media were found to
organisms of the coli group.
Analysis of Foodstuffs.
The total number of foodstuffs analysed during
the year was 2,075.
The following table shows the number of samples
of foodstuffs analysed and the results : —
Kind of
Number of
Number found
Number
food
Samples
adulterateil
found good
Milk
436
203
233
Ghee
716
'.'. 165
351
Butter
87
7
80
Sweetmeat ...
... 275
120
155
Mustard oil ...
352
116
236
Barley powder
30
9
21
Cornflour
11
5
6
Sago
8
6
2
Flour
80
—
80*
Cassara food . . .
3
—
3
Dal
3
—
3
Arrowroot
7
1
6
Rice
21
21
Chhona
2
—
2
Honey
3
—
3
Sugar
3
—
3*
Cream
2
—
2
Aerated water
4
—
4
Tea dust
12
—
12
Coffee
2
--
2
Cocoa
1
—
1
y
Feb. 16, 1920.].
COLONIAL MEDICAL REPORTS.— COLOMBO.
Colonial Medical Reports. — No. 106. — Colombo.
ADMINISTRATION REPORT FOR 1917 OF THE PUBLIC
HEALTH DEPARTMENT: COLOMBO MUNICIPALITY.
By Wm. MARSHALL PHILIP, M.D., D.P.H.,
Medical Officer of Health.
Population. — The population of Colombo esti-
mated to the middle of 1917 was 258,050, which,
reckoned on the area available for building (6,901
acres), represents an average density of 37-4 persons
per acre. This seems far from overcrowded, but
the vast majority of the people in Colombo are
housed in "ground story" buildings, the "up-
stairs " bungalow, which favours concentration of
population, being as yet very much the exception
here. This is fortunate in view of the narrowness
of the majority of the streets, the smallness of
the backyards, and the general absence of back
lanes.
The question of housing in Colombo is a serious
problem, the accommodation being far short of the
requirements. This makes the work of dealing with
houses unfit for habitation very difficult, and it has
recently been suggested (53, of January 31, 1918)
that as the landowners are hanging back in the
■matter of building houses suitable for the poorer
classes, the Council should give a lead by building
a sufficient number of model tenements to accom-
modate all the workmen whom they employ in their
service.
Births. — 5,860 births were registered in Colombo
during the year, representing a birth-rate of 22-7
per 1,000. In these days when national birth-rates
are being so anxiously scrutinized in connection
with man-power, it .may be of interest to state that
although the birth-rate of Colombo, as recorded, is
invariably lower than the death-rate, this does not
really mean that the indigenous population is dying
out, or in other words, that there is a " natural
decrease " here. The census prove<l, on the con-
trary, that there is a very good " natural increase "
here, and that the indigenous population is rapidly
increasing. The explanation of this paradox lies in
the fact that many of the birthsi of children born
of Colombo parents are not registered in the toiun.
As has previously been explained at length, this is
due, not to defective registration in Colombo, but
to the custom which prevails, especially amongst
the Cingalese, whereby prospective mothers go to
the homes of their parents, which in many cases
are in the country, for the birth of their children —
especially their first-bom. Such children are pre-
sumably registered in the district where they are
born, but that does not help the Colombo birth-rate.
Such of these children as survive long enough are
brought into Colombo by their mothers when they
return to their hu8.band's homes, where without in-
creasing the birth-rate they help to swell the infant
population, and incidentally to create a fallaciously
high infant death-rate, since the infant death-rate
ie always reckoned on the number of births registered
in the town during the year.
The true birth-rate of Colombo is therefore un-
doubtedly higher, while the true infant death-rate
is equally certainly lower than the records indicate.
It has unfortunately not been found practicable so
far to obtain the data necessary for ascertaining the
true infant rates here.
Deaths. — 6,280 deaths at all ages were recorded
in Colombo during 1917, representing a crude death-
rate of 24-3 per 1,000, which is the lowest yet
recorded. To these must be added 48 deaths of
Colombo residents, which occurred in the extra-
urban hospital for advanced eases of phthisis at
Ragama. On the other hand, 649 deaths of non-
residents of the town which occurred in the Colombo
hospitals must be deducted, leaving a corrected total
of 5,679 deaths of Colombo residents during the
year, which represents a death-rate of 22-0 per 1,000.
A further correction for age and sex constitution
gives a death-rate of 25'9 per 1,000, which i® the
nearest approach to the correct death-rate of
Colombo that can at present be obtained.
Race Death-rates. — The rates of exotic races like
Europeans and Tamils are liable to considerable
vitiation as the result of migration of these people
to and from their homelands. Thus during the last
three years large numbers of young European males
have left Ceylon in order to take part in the war;
while on the other hand, numl>ers of old people
and children, who would in normal times have gone
home, have remained in the island. Scarcity of
employment has doubtless led to a good many
Tamils returning to their own country.
Infant Mortality. — The infant death-rate during
the year was 251 per 1,000. Great as this wastage
of infant life is, it is nevertheless a great improve-
ment upon what used formerly to occur here. It
has fallen from a rate of 410 in 1903 to 251 in 1917,
i.e., from being 34 per cent, above, U) 24 per cent.
below the mean for the fifteen years 1903-1917.
The diseases which were chiefly responsible for
the deaths of infants during the year were atrophy
and debility, premature births, convulsions, diar-
rhcea and pneumonia. The chief causes of infant
mortality in Colombo are (a) those which affect the
mother, and through her the child before birth, e.g.,
bad housing and insanitary conditions generally in
and around the home, such as prevail to a great
extent in the slums; (b) those conditions which
affect the child after birth, including those referred
to in (a) and in addition improper feeding, con-
16
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 16. 1920.
tamination of food by flies and otherwise, and the
debilitating effect of epidemic diseases, especially
measles.
Thus one finds that the highest average infant
ward mortalities occur in the wards with the highest
average densities, which in turn denote the exiet-
ence of slums, and it is not to be expected that the
infant death-rate of Colombo will fall to what may
be considered a satisfactory level until these slums
have been abolished. Another very important
sanitary measiire in connection with the infant
mortality here is the abolition of the insanitai-y,
fly-breeding and disease-spreading dry-earth latrines,
and the .substitution of water-carriage, in which
respect the progress made hitherto has been pain-
fully slow, although sewers are now nearly every-
where available in the more densely populated parts
of the town.
Pulmonary Diseases. — Under this heading are in-
cluded phthisis, pneumonia and bronchitis. The
death-rate from these causes is of special interest
not only because phthisis and pneumonia are the
two greatest causes of mortality in Colombo, but
also for the reason that whereas it rose steadily
during a period of at least thirteen years, from
5-41 per 1,000 in 1897 (prior to which the statistics
are unreliable) to the extraordinarily high rate of
9-32 in 1909, it has since fallen rapidly during the
last eight years to 5-73 in 1917 per 1,000, i.e., nearly
half what it had been.
There are thus two distinct periods to be con-
sidered, one a period of degeneration extending from
1897 to 1909, and the other a period of improvement
extending from 1909 to 1917.
1897-1909. Period of Degeneraiion.— The gradual
increase of mortality from pulmonary diseases
during the period 1897-1909 was undoubtedly due
to a gradual degeneration in the housing eonditionfi
in extensive areas of the town, concurrently with or
more correctly as a sequence to the increase of the
population at a time when there was no proper
legal control in respect of such important sanitary
matters as the lighting and ventilation of dwellings,
the erection of new buildings, the provision of
drainage, &c.
Thus, the increase of the population necessarily
created a steadily growing need for more house
accommodation which, in the absence of a sufficient
number of houses to meet the demand, led to
overcrowding and a rise in rents. This in turn
encouraged landlords to increase the rent-earning
capacity of their properties, which, in the absence
of effective legal control, and in defiance of the
efforts of the Coimcil's officers to direct it on sani-
tary lines, they proceeded to do by (a) subdividinj>
their houses so that eaeli house midit acc,)iiini(»late
more than one family. This \\,i^ ^ iTciteil l,\- n.iiliii:,'
up communication doorsi or hv .arrlmi,' partitions,
both of which tended greatly to obstnict the lighting
and ventilation of the buildinijs; (h) by making
obstructive additions to their liouses, which further
interfered with lighting and ventilation; (c) by
erecting new buildings upon such open spaces as
remained upon their properties, which still further
interfered wifli the lighting and ventilation not
only of their own, but also in many oases of their
neighbour's houses as well, and in addition ren-
dered access for scavenging more and more difficult
and the problem of drainage more and more com-
plicated.
Thus whole properties, and as time went on whole
blocks and eventually whole areas of the town be-
came covered with a medley of irregularly disposed,
badly designed, defectively constructed, ill-lighted
and insufficiently ventilated dwellings, stretching in
many cases far back from the public street. In this
manner what are now known as the " insanitary
areas " or " slums " of Colombo, were gradually
created, and it is just in such areas that the mor-
tality from pulmonary diseases, but especially from
phthisis, is always highest. As an illustration of
this point two adjoining areas were selected for com-
parison in 1911 in connection with the prevalence
of phthisis. The population of each of these areas
having been obtained from the census, the number
of cases of phthisis which had occurred in each
during the year was as far as possible ascertained,
whereupon it was found that whereas the non-con-
gested area had had 1'33 cases per 1,000 of its
population, the congested area had had 4' 70 cases
or more than three times as. many in proportion to
its population.
1909-1917. Period of Improvement. — In view
of the explanation which has just been given of
the gradual rise in the death-rate from pulmonary
diseases, as a sequence to the progressive increase
of the population, the question naturally arises ae
to why, since the population has continued steadily
to increase, did the death-rate not also continue to
rise? Why on the contrary has it been steadily
falling since the last quarter of 1909?
The answer to these questionsi is to be found in
a study of the sanitary records of Colombo, from
which it may be concluded that the improvement
has talcen place as follows: —
Althougli the insanitary conditions in the town
had been carefully investigated and although more-
over the crude data required for the calculation of
the death-rates were available in the Registrar-
General's Reports on vital statistics, no attempt
appears to have been made prior to 1906 to work
out and tabulate in comparative form the death-
rates fromi individual diseases in Colombo.
The result of this was that although various large
scbi.'iii's for tlie general sanitary improvement of
the town \\,-v,> recommended, and some of them
wir.' a:lopt.Ml and talcen in hand, there was a want
of rs|riMiti.' knowlfilg,' in regard to the relative im-
portaiicr ol, and a consequent luck of concentrated
rffoit il)fi;'tiMl towards the prevention of individual
(lisrasrs siM-li as plitliisis, .altliougli the cost of Siuch
tipirial inrasnros wa- in some cases insignificant
coinpaird with \]\v benefits to be derived therefrom.
As an illnstiation of this point it will be found that
wlieieas e|ii(lemic diseases, siuch as cholera, small-
pox and enteric fever, are frequently referred to in
the older reports, phthisis is seldom or never even
mentioned, although, as will presently be shown,
it was then as it is now the chief cause of deaths
in Colombo.
J
Mar. 1. 1920.;
COLONIAL MEDICAL BBPOKTS.— COLOMBO.
17
Colonial Medioal Reports.— No. I06.-Coloinbo (cotUd.).
In lieport No. 383, dated June 11, 1906, attention
was for the first time directed to the fact that
the diseases of the pulmonary group but especially
phthisis, were the greatest causes of deaths in
Colombo.
Following upon this disclosure special measures
for the prevention of phthisis were undertaken by
the Public Health Department at the earhest oppor-
tunity. Thus in view of the well-known fact that
deficiency of light and air in dwellings is a power-
fully predisposing factor in the causation of phthisis,
an effort was made to improve matters, in these
respects in the small tenement class of dwellings
in the insanitary areas. This work has been con-
tinued up to date, and has had a very considerable
effect in improving the lighting and ventilation of
small dwellings, and may therefore fairly be re-
garded as having been in a measure responsible for
the reduction in pulmonary mortality which was
first observed during the last quarter of 1909.
In view of the fact that phthisis is what is known
as a " house disease ' ' — the infection once implanted
in a house tending to linger there and attack sub-
sequent occupants, the direct preventive measure
of disinfecting every house where a death from
phthisis occurred was undertaken as soon as the
necessary staff was available, in July, 1909, and
continued up to the present time. This work must
have had a powerful effect in preventing the spread,
and in reducing the mortality from phthisis from
July, 1909, onwards.
The Government appointed a Commission in
January, 1910, to inquire into and report upon
tuberculous diseases generally in Ceylon, and upon
the most effective measures for checking their die-
semination. Their seven recommendations in-
cluded the introduction of compulsory notification,
the establishment of a hospital for advanced cases,
the segregation of the sick from the healthy, the
establishment of sanatoria, the education of the
people in matters relating to the prevention of
phthisis, the prevention of spitting in public places,
and the abolition of coir mats as spittoons, the pre-
vention of dust, &c.
In addition the Commission made the important
recommendation that an Anti-tuberculosis Dispeni
eary should be estabHshed in Colombo, on the lines
of the original one which was founded by Sir R. W.
Philip in Edinburgh.
As a result of all this investigation and represen-
tation the following measures were subsequently
adopted, and have without doubt had their share
at various stages in reducing the mortality from
pulmonary diseases.
Phthisis was made a compulsory notifiable disease
in August, 1910.
Spitting in public conveyances and public places
was made a punishable offence by by-law in Novem-
ber, 1910.
The evacuaton and closure pending improvement
of houses unfit for habitation was rendered possible
by the advent of plague which automatically brought
the Plague Regulations in respect of such buildings
into force in January, 1914.
The Anti-tuberculosis Institute was opened in
October, 1916.
The hospital at Ragama for advanced cases of
phthisis was opened in February, 1917.
To sum up therefore the improvement in the mor-
tahty from pulmonary diseases which has been going
on during the period 1909 to 1917 has been due
chiefly to the following: —
From 1907. — Improvement in the lighting and
ventilation of insanitary tenements.
Improvement in the general cleansing and
scavenging of the town — especially (since 1909) in
the matter of dust prevention. The effect of both
of these measures would necessarily be cumulative
and take some time to produce any effect upon the
death-rate.
From July, 1909. — Disinfection of phthisis
" death-houses." The effect of this measure would
be immediate.
From August, 1910. — Compulsory notification of
phthisis, followed by visitation, instruction of occu-
pants and adoption of precautions in connection with
persons suffering from the disease.
From October, 1926.— Establishment of the Anti-
tuberculosis Institute.
From February, 1917. — Establishment of the
hospital at Ragama for advanced cases of phthisis.
The esitablishment of the Anti-tuberculosis Insti-
tute being of recent date has scarcely had time yet
to produce much effect upon the death-rate, but it
opens a vast field of useful work and is expected to
have a powerful effect in reducing the prevalence
of and the mortality from phthisis in Colombo. A
complete understanding with a view to co-operation
between the Institute and the Public Health Depart-
ment has been arrived at.
No other single disease caused so many deaths in
Colombo during the year as phthisis, which has held
the premier place as a cause of deaths for a number
of years and therefore merits the title of " The
captain of the men of death " which was conferred
upon it over 200 years ago in England by John
Banyan.
Diarrhoeal Diseases. — Under this heading are in-
cluded diarrhoea and enteritis with 511 deaths, and
dysentery with 134 deaths. The more specific term
" enteritis " is gradually supplanting the term
" diarrhffia " in the death returns.
The diseases in this group are all what are some-
times described aptly as " filth diseases," and their
mortality therefore affords a valuable indication of
the state of the town as regards general cleanliness
and scavenging.
The remarkable association between the " diar-
rhoea " mortality and the state of the town as
regards general cleanliness is shown by the follow-
ing brief histories of the scavenging and cleansing
on°the one hand, and the " diarrhoea " mortality on
the other hand.
History of Scavenging and Cleansing. — Prior to
THE JOUBNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 1, 1920.
1903 no systematic inspection with a view to the
cleansing and scavenging of private premises was
carried on. During 1903 and 1904 a system of
routine house-to-house inspection was gradually
evolved and introduced with the result that there
was an undoubtedly great improvement in the state
of the town as regards cleanliness of compounds,
&c. This work of private scavenging was however
much hampered by the very unsatisfactory manner
in which the pubhc scavenging was conducted. At
that time the public scavenging was carried on by a
system of contract which as the result of two years
of strenuous endeavour to make it a success was
ultimately demonstrated to the satisfaction of the
Council to be a wholly impracticable system of
carrying out such work. The Council therefore de-
cided to abandon the contract system in favour of
departmental work. It necessarily took some time
to organize this work, but by 1907 it had been placed
upon a fairly satisfactory footing and has since then
been steadily improved until now it must be patent
to everyone that the scavenging of Colombo is an
exceptionally well-conducted public servi<;e.
History of Mortality from Diarrhoeal Diseases. —
The death-rate from diarrhoeal diseases which had
been gradually rising since 1899, suddenly dropped
in 1904 coincidently with the improvement in
scavenging of private premises referred to above.
It began to fall again in 1907 as the result mainly
of the improvement in public scavenging at the
hands of the Works Engineer, and it has continued
to fall ever since, until in 1917 the record low death-
rate of 2"50 was attained.
All Fevers. — Under this heading are included
enteric fever, continued fever, remittent fever, and
intermittent fever.
The death-rate from this group of diseases
gradually fell from 3-75 in 1897 to 2-01 in 1905.
It then rose to 3-28 during the abnormally unhealthy
year of 1906, and as a result, a great deal of enteric
infection was implanted in the town in the shape
of "carriers" and otherwise. Since 1906 it has
with two exceptions steadily fallen, the exceptions
being the years 1911 and 1916, during each of which
there was a slight set-back in respect of enteric
fever. Every race has shared in the improvement,
and none so strikingly as the Europeans, whose rate
is however liable to fallacious variations owing to
the smallness of the community and their habit of
migrating to England. Thus since the war began,
although there are no complete statistics available,
it iiB well known that a large number of the young
and susceptible males have left Ceylon, and this no
doubt accounts to some extent for the very marked
drop in the mortality from enteric fever which has
occurred during the last three years.
With a view to the prevention of enteric fever
in Colombo, it is essential that not only should the
work of connecting latrines to the sewere be pressed
on as fast as possible, but also that every other
measure which will tend to reduce the prevalence
of flies should be adopted. Thus the open srtoring
of manvue for garden purposes, and the top-dressing
of grass fields with manure and scavenging rubbish
in proximity to residential quarters must be rigor-
ously put down, otherwise there is no hope of con-
trolling the fly nuisance with its associated dangers
of enteric, dysentery, diarrhoea of infants, &c.
Plague. — The chief points of interest in regard to
plague during 1917 were as follows: —
There was an unusually large number of cases
during the first three and a half months of the year,
and the outlook at one time threatened to be
serious. Thus whereas the average number of
cases during the first fifteen weeks of the three
previous years was only 5'6 cases per week, the
average during the corresponding period in 1917
was 10-3 per week, or nearly double.
It was ol>served that as hitherto, the cases were
occurring almost exclusively amongst the occupants
of insanitary ranges of tenements, and as the
ordinary measures of isolation, segregation, fumiga-
tion of rat runs, &c., failed to check the spread of
the disease, it was decided to resort to the more
drastic measures of evacuation and closure of the
worst of these insanitary tenements. Thus, whereas
only thirty-tliree insanitary dwellings had been
closed during the first quarter, 129, mostly in the
infected localities, were closed during the second
quarter.
The effect of this measure was that the number
of cases of plague suddenly dropped during the
sixteenth week, from being far above the average
for the corresponding period of the previous three
yeans, to below the average and remained much
below during the rest of the year.
This experience confirms the conclusion which
had previousily been arrived at that evacuation and
closure of insanitary dwellings is by far the quickest
and most effective of the measures for the prevention
and suppression of plague in insanitary areas.
The effect of evacuation appears to go further
than merely the removal of the occupants from im-
mediate danger. It appears very often to have the
effect also of stamping out the disease amongst the
rats in the locality. The healthy vigorous hungry
rats no doubt move into the adjoining occupied
areas in search of food, while the plague rats, on
the other hand, especially those in the acute and
most infectious stages, have no desire for food, are
languid, weak, and in the later and most infectious
stages are even paretic, and in consequence pro-
bably remain for the most part in and die in their
tunnels or are killed there later by the fumigation.
The rat fleas which live and breed in the rat nests
being thus deprived of both human and rat hosts
perish in a very short time and thus the place be-
comes plague free. No doubt a certain number of
rats in the early stages of the disease, or suffering
from chronic plague, or " carriers," stiU retain
sufficient vitality and interest in food to range away
from the evacuated dwellings into the adjoining
areais, but the system of establishing a circle of
Clayton fumigators around the infected house and
working tbwards it as a centre tends to prevent
niigi-ations of this sort.
I
Mar. 1,
COLONIAL MEDICAL BBPORTS.— COLOMBO.
Rat I'layuc— Out of a total of 23,382 rats ex-
amined for plague, seventy or 0'30 per cent, were
found to be infected. The highest rates of infection
occurred in February and March, and the lowest
in May to September. Six domestic cats, all of
which were found looking ill in premi'see known
to be plague infected, were examined with the
result that three were found to be plague infected.
The seventy-three cases of animal plague recorded
during the year came from thirty-nine streets, in
twenty-four of which cases of human plague also
occurred. Rat plague occurred in fifteen streets
where no human cases occurred.
One thousand two hundred and fifty-six rats were
killed by the Clayton fumigators during the year,
and sixteen mummified rats, which had probably
died of plague, were found either within or close
to the infected houses. Although infected rats were
found in twenty-four streets in which human cases
occurred, they were found in only nine of the actual
houses in which human cases occurred.
Preventive Measurex. — The preventive measures
adopted were as usual, removal of the patient to
hospital, rsegrogation of contacts, pesterining floors,
unroofing of ' infected houses to let the sun in,
fumigation of rat holes, and, where dangerous out-
breaks were threatening, evacuation and closure of
insanitary tenements pending the carrying out of
the necessary improvements by the owners of the
properties.
Thus during 1917, 1,699 dwellings were pesterined,
35,262 rat holes in 8,285 buildings were fumigated
by means of the Clayton machines and filled up with
cement, &c., and 196 dwellings where plague had
actually occurred were unroofed.
The work of rat capture and poisoning is carried
out by the Department of the Veterinary Surgeon
to whom I am indebted for the information that
160,261 rats were trapped and 228 were found dead,
making a total of 160,489 for the year.
Sanitary Inspection.
Non-stTuctural Improvements. — The defects
come chiefly under the heading of " Filthy
premises " and include such gross defects as dirty
dwellings, colleetions nf garb:ige and household
1 rubbish generally, in the coiriprinnds, dirty latrines,
catehpits, drains, Ac, unclean bakeries, eating
li'iiises, boutiques, dairies, aerated water factories,
liinndries, &c., nuisances associated with the keep-
iiiL' of animals, nuisances asociated with offensive
tr iilcs and such like.
\- a result of personal instruction and warning,
:iii'l where this failed, then as the result of written
II iiiie or prosecution 4,066 of the defects were
II' tified during the year.
Insanitary Dioellings. — Structural Improve-
nirnfs. — The defects fall into two classes (a) de-
fi'f^ in the premises exclusive of the buildings,
L , broken drains, lack of drains, lack of paving
n compounds, Ac; (/)) defects in buildings,
■f-'., obstructive buildings, obstructive partitions,
ibstructive eaves, insufficient door or window
pare, lack of smoke vents, enclosed verandahs,
&c. As the result chiefly of written notices
495 buildings, and 514, buildings other than dwell-
ings, were structurally improved during the year.
184 dwellings (i.e., separately assessed tenements)
which were so defective and insanitary as to be
unfit for human habitation were closed, while 111
which were hopelessly obstructive or otherwise
defective, were demolished during the year. It is
a well known fact that badly designed and irregu-
larly disposed buildings, such as the closure notices
invariably deal with, not only obstruct lighting and
ventilation, but are at the same time far more
prodigal of space than are properly designed and
methodically arranged buildings. Thus the con-
demnation of a medley of insanitary tenements
frequently results in the erection in their place of
ranges of healthy new dwellings the total accom-
modation of which is much in excess of what has
been abolished. Many of the existing dwellirigs
are so grossly insanitary than nothing can justify
their being allowed to remain and occupied by
human beings, since they constitute a perpetual
danger to the health and Ufe not only of those who
reside in them but also to the health and safety
of the public at large, as the experience here in
connection with such diseases as plague and
phthisis has demonstrated again and again.
Dairies and Milk Supply.— The ordinary cow-
men and milk vendors have no sanitary conscience,
and constant super\'ision is therefore necessary in
the conduct of dairy operations, otherwise all sorts
of abominations are liable to be perpetrated. As
the supervision which can be exercised by the
Sanitary Ofiicers is necessarily very occasional, it
is fortunate that a few of the better classes have
within the last year or two taken up the business
of owning and personally conducting dairies. It
is also fortunate that this work has attracted the
interest of the Colombo Ladies League, which had
done much to encourage emulation by offering a
number of prizes and certificates each year for the
best kept dairies.
The sanitary condition of dairies is vastly better
now than it used to be but it still leaves much to
be desired.
Bakeries.— The condition of the bakeries during
the year was on the whole satisfsjctory, but much
difficulty is experienced in securing compliance
with the rule that the workmen shall wear clean
aprons and caps, and shall keep their hands and
nails clean. To engage in the mixing and knead-
ing of dough with dirty hands and nails is an
unpardonable offence.
Eating Houses. —They are for the most part very
simple and indeed primitive in their arrangements,
as one cannot set the standard too high in regard
to the quality of the accommodation, furnishing,
Ac, without entailing an undue limitation in the
number of these essential establishments. The
manner in which they are conducted and their
general sanitary condition, has however been greatly
improved, and there are now a number of really
well-furnished and very well-conducted eating
houses or restaurants in the City.
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE. [Mar. 1, 1920
Laundries. — Laundry houses like eating houses,
are constantly springing up and disappearing all
over the town. This is due to the fact that laundry
work, as conducted here, requires practically no
stock-in-trade, and can be started practically any-
where, at s, moment's notice, all that the laundry-
man requires being water, soap, a washing stone,
a heating iron, a table, and an utter disregard for
the rapid destruction of one's most cherished
linen. The sanitary requirements, although also
quite simple, are less easy to attain, viz., clean
water, separate acconamodation for clean linen,
soiled linen, and domestic purposes, paved floors
and cement faced walls in the linen rooms so that
bugs and other vermin may not find these places
too convenient and secure a refuge from which to
sally forth and torment and possibly convey disease
to the dhoby's customers.
The question of improving laundry work in
Colombo is full of difficulties. It is recognized
that to allow washing of clothes in such places as
the Lake, in the stagnant water of swamps and
such like, is grossly insanitary, but, for pubhc
health and other reasons the time has come when
the old order must be abolished and new methods
must be adopted.
Offensive Trades. — None of the ofiensive trades
such as plumbago curing, copra storing, manure
storing, (fee, may be established in Colombo with-
out a licence from the Chairman. The interests of
the public health demand that the residents of the
town shall be protected against nuisance, while, in
the interests of legitimate trade and as a matter of
equity, where hcences have already been granted,
the tradesmen should be granted reasonable facili-
ties for the establishment of, and should be secured
against undue disturbance in the carrying on of
these trades.
As the present discretionary method of granting
licences is most unsatisfactory, and if continued,
wiU, it is feared, result in much trouble, and
possibly great expenditure in the future, it is urged
that the matter be considered at the earliest oppor-
tunity and that a definite policy be adopted for the
guidance of the executive officers of the Council
on the one hand and of the tradesmen concerned
on the other hand.
Markets. — There are two types of markets in
Colombo, viz., public markets, built and owned by
the Municipal Council, the stalls in which are let
or leased; and private markets, represented for the
most part by roadside shops or boutiques.
While the public markets leave much to be
desired, and require for the most part complete
rearrangement and reconstruction on up-to-date
lines, the private markets, but especially the road-
side boutiques in which meat and fish are sold, are
infinitely worse. They are in fact without excep-
tion, primitive, grossly insanitary and a constantly
recurring source of public nuisance. A definite
policy in regard to the market service of the town
being urgently required for the establishment of
a series of public markets to serve the needs of the
population.
Slaughter-house. — No slaughter of animals for
food, is allowed except in the Municipal Slaughter-
house at Welikade, ynless a special licence is
obtained for private slaughter.
A considerable number of applications for private
slaughter in connection with religious ceremonies
are received annually and they are generally
allowed.
The cruel method of slaughter by cutting the
animal's throat without previous stunning, is
adhered to by the Mohammedan butchers on reli-
gious grounds and has for that reason been allowed
to continue. An attempt was made some yeans ago
and was at the request of the Society for Preven-
tion of Cruelty to Animals renewed during 1917,
to induce the Cingalese butchers to stun the
animals before bleeding, by using the Humane
Cattle Killer (a species of gun), but without success,
the butchers refusing to use it on the mercenary
grounds that it damaged the brains of the animals
and made them unmarketable. If stunning is to
be introduced here it must be made compulsory
by law, but there are almost insuperable difficulties
in the way of introducing this, even in the case of
animals the flesh of which is destined for the use
of non-Mohammedans.
The public slaughter-house is merely a j>aved
shed, open all round, in which animals are
slaughtered within sight of each other. This has
been objected to on humanitarian grounds, and
the adoption of a system of ' ' separate slaughter
has been advocated by some people. There are,
however, arguments both for and against each
system, and in the writer's opinion the balance is,
on sanitary grounds, distinctly in favour of the Hall
system.
The slaughter-house is accessible to crows which
infest the place and foul the meat. Crow-proofing
by means of wire-netting should be carried out as
has previously been recommended.
Food Inspection is carried on with difficulty in
Colombo owing to the lack of a special staff for
that purpose. It is comparatively easy to detect
unsound food in the public markets where whole
ranges of stalls can be inspected in a few minutes,
but it is very different when one has to deal with
scores of small boutiques scattered aU over the
100 miles of streets in the town.
A considerable amount of difficulty is experienced
in inspecting damaged rice imported through the
Customs, as this task has to be carried out by the
Pettah Ward Inspector in addition to his multi-
farious other sanitary duties.
House Drainage. Public Latrines and Bathing
Places. — The slowness, for unavoidable reasons, of
the progress which has been and is being made in
the matter of connecting house latrines to the
sewei-s, and the abolition of the insanitary, fly-
breeding, disease-spreading dry-earth privies may
be judged from the fact disclosed in the City
Sanitation Engineer's reports, that up to the end
of 1917 only 3,496 water closets had been installed
in the town, thus enabling only 2,912 dry-earth
privies to be removed.
I
Mar. 15, 1920.]
COLONIAL MEDICAL REPORTS.— HONGKONG.
Colonial Uedical Reports.— No. 106.- Colombo (contd.).
A more satisfactory feature is tlie establishment
up to the end of the year, of a total of twenty-eight
public latrines throughout the town, with seating
or rather squatting acx-ommodation for 430 persons.
In conjunction with a number of these latrines,
bathing accommodation is provided with places for
a total for the town of 198 persons. The principle
has now been adopted of building a greater number
of small public latrines in different parts of the
town, as it was considered that this would meet
the public needs and convenience better than
having a smaller number of large latrines.
Mosquito and Fly Prevention. — As everyone
knows, the average householder will do practically
nothing in sanitary matters unless he is required
to do so by law. The very fact that there is no
specific law on any particular subject induces
those who have not had the necessary scientific
teaching to enlighten them, to believe that any
attempt on the part of ofUcials to enforce preven-
tive measures is merely an unwarrantable and
vexatious interference with their liberties, which
they are liable to resent accordingly.
Notwithstanding the lack of specific powers for
dealing with insect pest nuisances, a good deal of
useful work was done during the year, including
practical demonstration to householders of mosquito
breeding in their premises.
It is unfortunate for the safety and comfort of
the inhabitants of Colombo that the very practical
recommendations which were submitted four years
ago by Major James, I.M.S., after a year's work
in connection with mosquitoes in Colombo, have
not yet been given effect to, even in the simple
matter of making it a punishable offence for house-
holders or owners of property to permit the breeding
of mosquitoes on their premises.
Colonial Medical Reports,— No. 107.— Hongkong.
HONGKONG MEDICAL AND SANITARY REPORTS
FOR THE YEAR 1917.
The Sanitary Department.
Diseases. — There were 595 cases of emall-pox as
compared with 220 in 1916. The vaccination cam-
paign was ably carried out by Dr. Woodman, who
received the greatest assistance from Mr. Ted and
other Chinese gentry. By the end of February the
epidemic had practically ceased. The total up to
March 5 being 549 cases. The other diseases
notified during the year were : enteric fever, 188 ;
diphtheria, 69; puerperal fever, 20; paratyphoid
fever, 7 ; and scarlet fever, 3.
Population. — The last census was taken in 1911.
The estimate of the population for 1917 is based on
till' usual rate of increase of the numbers given in
tlu' last census with the addition of 10,000 allowed
for the influx of Chinese due to the revolution.
Tills estimate is probably much too low, but only
l)y taking another census could reliable information
111' obtained.
' l« ing to the war the estimate of the white popu-
lation for 1916 has been adopted unchanged for
tlir year 1917.
Iliiii.tc ('leansing. — House building has gone on
uihl tlic staff has been depleted thus rendering
it 111 1 1, 1 limbic to maintain a quarterly cleansing.
T'ai'il.y tliita; house cleansings per annum have been
I-nssible.
Limewashing. — The annual limewashing of
f'liiiipse tenement houses is still carried on and
iiitails a great amount of trouble both to this
1>< l>artment and to the general public. Little or
no improvement has resulted from By-law 4, which
makes compulsory limewashing possible, and it
would seem as ii the only possible solution of the
difficulty lay in making this measure a part of the
ordinary routine public scavenging services.
Scavenging and Refuse Disposal. — In May the
barges conveying town refuse were unable to re-
move all the material by making one trip on each
alternate day and had to make the journey daily.
A new steam barge, S.D. 2, was therefore built
and taken over by the Department.
There was a brisk demand for manure from the
Cattle Depots in Kennedy Town, but owing to the
existence of cattle disease (anthrax) in the latter
half of the year it was deemed inadvisable to
permit the use of this manure in gardens. It was
accordingly dumped at sea.
Adam Gibson, M.R.C.V.S.
Joint Report of the Principal Civil Medical
Officer and the Medical Officer of Health.
Area. — The Sanitary Board's control extends
over the island of Hongkong, which has an area
of about 32 square miles, and to that portion of
the mainland between the shore and the range of
Kowloon HiUs extending from the village of Tseung
Kwan O in Junk Bay on the east, to the village of
Kau Pa Kang on the west, with a seaboard of
about 13 miles and an area of about 16 square
This area include
Old Kowloon," which has
22
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 15, 1920.
Return of Diseases and Deaths in 1917 in the Civil, Victoria, Gaol and Tung Wa Hospitai,s.
Hongkong.
GENERAL DISEASES.
Alcoholism
Anaemia
Anthrax
Beriberi
Bilharziosis
Blaokwater Fever
Chicken pox
Cholera
Choleraic Diarrhoea
Congenital Malformation
Debility
Delirium Tremens . . . . . . . . —
Dengue 6
Diabetes Mellitus —
Diabetes Insipidus . . . . . . . . —
Diphtheria 28
Dysentery 219
Enteric Fever . . . . . . . . . . 51
Erysipelas . . . . . . . - . 3
Febricula 37
Pilariasis . . . . . . . . • . —
145 49 161
GonorrhcEa
Gout
Hydrophobia
Influenza
Kala-Azar
Leprosy
(a) Nodular
(6) Anaesthetic . .
(c) Mixed
Malarial Fever—
(a) Intermittent
Quotidian . .
Tertian
Quartan
Irregular . .
Type undiagnosed
(6) Remittent ..
(c) Pernicious . .
(d) Malarial Cachexia .
Malta Fever
Measles
New Growths —
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra
Plague
Pyaemia
Rachitis '
Rheumatic Fever
Rheumatism
Rheumatoid Arthritis
Scarlet Fever
Scurvy
Septicaemia
Sleeping Sickness . . . . . . . . —
Sloughing Phagedaena
Small-pox 11
Syphilis . . . . - . . . . . . . —
(a) Primary 137
(6) Secondary 42
(c) Tertiary 68
(d) Congenital 3
Tetanus 30
Trypanosoma Fever . . . . . . . . —
Tubercle— 183
(a) Phthisis Pulmonalis 378
(b) Tuberculosis of Glands —
(c) Lupus —
29 9 30
1 ^ 1
267 97 272
92
29
GfiNEBAL DiSEkSES— continued.
(d) Tabes Mesenterica
(e) Tuberculous Disease of Bont
Other Tubercular Diseases
Varicella
Whooping-cough
Yaws
Yellow Fever
LOCAL DISEASES.
Diseases of the —
Cellular Tissue
Circulatory System
(a) Valvular Disease of Heart
(6) Other Diseases . .
Digestive System —
(a) Diarrhoea
(6) Hill Diarrhoea
(c) Hepatitis
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver
( f) Jaundice, Catarrhal
(g) Cirrhosis of Liver
{h) Acute Yellow Atrophy
(') Sprne
(j) Other Diseases . .
Ear
Eye
Generative System — . .
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervous System
Nose
Organs of Locomotion
Respiratory System . .
Skin—
(a) Scabies . .
(6) Ringworm
(c) Tinea Imbricata
(d) Favus
(e) Eczema . .
(/) Other Diseases
Urinary System
Injuries, General, Local —
(a) Siriasis (Heatstroke)
(b) Sunstroke (Heat Prostration)
(c) Other Injuries
Parasites —
Ascaris lumbricoides
Oxyuris vermicularis . .
Dochmius duodenalis, or Ankylostoma duo-
denale
Filaria medinensis (Guinea-worm) . .
Tape-worm
Poisons — . .
Snake bites
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids . .
Nature Unknown
Other Poisons
Surgical Operations — . .
Amputations, Major
,, Minor . .
Other Operations
Eye
(a) Cataract
(6) Iridectomy
(c) Other Eye Operations
136 39 151
Mar. 15. 1920.:
COLONIAL MEDICAL REPORTS.— HONGKONG.
been British since 1861, and hasi an area of about
2f square miles, and a portion of the New Terri-
tories, leased to this Government in 1898.
The remainder of the New Territories — about 2G6
square miles — is outside the Board's jurisdiction.
The City of Victoria, situated on the northern
side of the Island, has a frontage on the sea at
nearly five miles and is separated from the Kowloon
portion of the Colony by the harbour.
The domestic buildings in Victoria number 10,335
(excluding barracks and police stations), of which
992 are non-Chinese ; there are also 183 European
dwellings in the Hill District. The number of
houses completed during the year was as follows :
Victoria 163, Kowloon 120, outlying districts and
Peak 52, making a total of 335, as compared with
314 in 1916.
rats 86 much as possible out of houses 111 ground
surfaces have been cemented in Victoria and
27 in Kowloon, whilst 496 buildings have had
rat-runs filled with cement in Victoria and 487 in
Kowloon.
Obstructions have been removed fi'om backyards
in twenty-six houses.
Notices prohibiting the breeding of mosquitoes
were served to the number of 38 in Victoria and
15 in Kowloon.
Other sanitary improvements have been carried
out by the Public Parks Department during the
year, including additional nuUah training, and
scavenging lanes have been provided.
Meteorological Returns. — The following table
gives the meteorological data recorded by the Royal
Observatory during the year: —
January
February
March...
April ...
May ...
June ...
July ...
August
September
October
November
December
Ins.
30-24
30- 13
30 09
29-89
29-87
2978
29-69
29-76
29-86
29-95
30-12
30 15
65-9
73-5
79-4
8G-6
85 4
87-2
86-6
Deg.
55-8
59-4
74-8
818
81-1
82-0
82-0
77 0
68-2
59-2
Deg.
51-7
55-3
70-9
78-4
77-7
78-3
78-1
73-8
64-7
55-2
0-29 ,
0-37 ,
0-43
0-63
0-72
0 90
0-90
, 0.85
, 0-68
043
, 0-32
Cloudi-
64 ..
78 ..
87 ..
134-5
116-9
76 9
168 6
Ins.
0-345
0-405
2-670
5-230
9-685
11-540
30075
11-950
Points
ENE
EbyN
Eby S
SbyW
SEby S
SSW
Vel.
Miles
per hour
. 11-0
. 12-9
. 14-2
. 13-5
9-9
7-4
10-4
14 0
12-5
Mean or Total
byl
111 addition to the above, misceUaneous buildings,
siiili as offices, godowrus, &c., were erected to the
number of 63.
Administration. — The City of Victoria is divided
into twelve, and Old Kowloon into three Health
Districts, with an inspector in charge of each. The
t inspector in charge of No. 3 Health District has
I also charge of the sanitary work on the Peak.
There are also five inspectors engaged in the
supervision of scavenging and coiTservancy work
including the upkeep of dust-carts, boats, &c., used
in this coimection.
In the outlying districts the sanitary work is
supervised by the police officer of the district. The
inspectors in Hongkong work under the supervision
I of the Medical Officer of Health, and in Kowloon
) under that of the Assistant Medical Officer of
'Health.
Grneral Sanitary Conditions. — The activity in
i)uililing operations which has been such a notice-
ahlf feature since 1912 hasi not abated and the
ilcinand for housing accommodation for the Chinese
is still in excess of the supply.
The Colony has several times since 1911 been
subjected to the influx of many thousands of
Cliiiifse seekigg refuge from disturbances in their
)wn country and of these not a few appear to
emain after the majority have returned to China.
In connection with anti-plague measures to keep
The rainfall for the year was slightly more than
in 1916 and is rather above the average of the last
decade.
Population. — The distribution of population esti-
mated to the middle of 1917 was as follows: —
Non-Chinese Civil Population
Chinese Civil Population : -
City of Victoria (including Peak)
Villages of Hongkong
Kowloon (including New Kowloon)
New Territories (land)
Population afloat
Total Chinese Population
Total Civil Population ...
280,700
15,300
77,200
89,900
58,500
13,500
521,600
635,100
The population figures have been estimated by
the usual method based on the natural increase, as
shown by the census returns of 1906 and 1911, to
which the immber 10,000 has l>een added to allow
of the influx of Chinese due to disturbances in the
Kwongtung Province.
There is no means of estimating the number of
Chinese in the Colony at any given time except by
a census, and until a new census is taken the
present ptimated population figures must be con-
sidered t)o be quite unreliable and are in all proba-
bility much too low.
The civil population consists chiefly of male
adults, but owing to the disturbances in China
24
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 15, 1920.
during the last few years, which resulted in the
immigration of refugees and their famiUee, the pro-
portion of femalesi to malesi appears to be increasing.
The boat population numbered 58,500, and the
registered boats belonging to the port and villages
of Hongkong are as follow: —
Passenger boats, classes A and B 1,114
Lighters, cargo and water boats 1,759
Other boats 13,068
Fish drying hulks 60
Total 16,001
There is a large passenger traffic between Hong-
kong and the mainland of China; the number
travelling by the river siteamers being as follows :
Arrivals, 870,837; Departures, 844,480; whilst the
figures for the Kowloon-Canton Railway are :
Arrivals, 352,008; Departures, 309,394.
Births. — The births registered during the year
were as follows: —
Male Female Total
Chinese 1,458 661 2,119
Non-Chinese 142 139 281
This gives a general birth-rate of 5-3 per 1,000,
as compared with 6-1 in 1916 and 6-1 in 1915.
The birth-rate among the non-iChinesie community
was 20-08 per 1,000. The nationality of the non
Chinese parents was as follows : British 128, Fili
pinos 8, Portuguese 66, Indian 47, American 5
Malay 7, Parsee and Eurasian 3 each, French
Arab, West Indian and Jewish 2 each, Dutch
Turkish, Swise, Italian, Australian, Japanese and
Russian 1 each.
The number of births of Chinese nationality
registered does not give an accurate record of the
number of tirths which has occurred. Owing to
the custom of the Chinese of not registering any
birth unless the child hasi survived for a month,
and often, in the case of female children, not at
all, it is probable that the majority, if not all,
of the infants who are sickly at hirth or die before
reaching the age of one month have not been re-
gistered. It is customary, therefore, to assume
that all children of one month or less admitted to
the various convents, together with those found
dead in the streets, harbour, hillsides, &c., have
been bom in the Colony but have not been regis-
tered. The addition of this number to that of the
registered births, gives a more correct estimate of
the birth-rate. The number of such children in
1917 was 886.
The :birth-rate so corrected is therefore 7-3, and
for the Chinese community the rate becomes 6'9
instead of 49 per 1,000, but even this addition
is not sufficient as the total of infant deaths is still
greater than the total of births so calculated, from
which it is evident that many are brought into the
Colony from the mainland of China.
The preponderance of male over female registered
l)irths is very marked among the Chinese, there
being 219 males to every 100 females.
In the non-Chinese community the proportion of
male to female births was 102 to 100.
Deaths.— The total number of deaths registered
during the year was 10,438. The general death-
rate was 23-4 per 1,000.
The number of deaths amongst the Chinese was
10,244, which gives a death-rate of 23-7 per 1,000.
The deaths registered in the non-Chinese civil
com'mnnity numbered 189, giving a death-rate of
■ 14-00 per 1,000. The nationalities of the deceased
were as follows : British 53, Portuguese 38, Anna-
mite 3, Indian 24, Japanese 29, Malay 7, French 5,
American and Filipinos 8 each, Russian, Italian and
Eurasian 2 each, Dutch, Peruvian, Jewish, Swiss,
Canadian, Brazilian, Australian and Parsee 1 each.
The death-rate for Europeans and those of Euro-
pean origin is 7-7 per 1,000; 5-9 per 1,000 for
Indians; and 16-9 per 1,000 for races classed as
mixed or coloured.
The exclusion of the Army and Navy from these
statistics increases both the birth- and death-rates
for Europeans and Indians.
Age Distribxition of Deaths. — The total number
of deaths of infants under 1 year of age was 3,596,
being 34-4 per cent, of the total number of deaths.
The number of deaths of children between 1 and 5
years, of age was 1,640.
There were 32 infant deathsi among the non-
Chinese, being 11 '1 per cent, of the total number
of deaths.
Among the Chinese population the deaths of
infants numbered 3,564, while only 2,119 Chinese
births were registered, or taldng the corrected
number of births among the Cliinese to be 3,005,
as explained above, it is tsftill found that there were
more deaths than births. It is obvious, therefore,
that many infants must be brought in from China,
or the births in Hongkong concealed.
Diseases.
Respiratory Diseases. — The t-otal number of
deaths of thisi nature was 2,248, of which 34 were
among the non-Chinese community. Of these
1,130 occurred in infants under 1 year of age. '
Pneumonia was the cause of 360 deaths, 16 of
which were non-Chinese and 55 of which oceurred
in infants under 1 year. Broncho-pneumonia was .
the cause of 1,172 deaths, 8 of which were non-
Cliinese and 805 of which occurred in infants under • ,
1 year. The death-rate among the Chinese from ^
diseases of this system was 5'1 per 1,000.
Tubcrctdosis. — The number of deaths from tuber- ^'
cular disease was 1,493 and 23 of these occurred j.'
in non-Chinese. There were 877 deaths from 1
pulmonary tuberculosis, 859 Chinese and 18 non-
Chioiese, and 57 deaths from tubercular meningitis. J
The percentage of deaths due to tuberculosis was ' ™
14-3.
Nervous Diseases. — The number of deaths from ,
these during the year was 427, as compared with ,
405 last year. The deaths of Chinese infants from ^
tetanus and convulsions were 159, aiid from mening- ' ^
itis undefined 75. . |' j
Malaria. — The number of deaths from malaria
in 1917 was 416, of which all but 5 occurred in
Chinese. In a large proportion of the cases the
disease was contracted outside the area of the
Sanitary Board.
i
April 1, ]920.]
COLONIAL MEDICAL RBPOBTS.— HONGKONG.
Colonial Medical Reports.— No. 107.— Hongkong (contd.).
Beriberi. — There were 054 deaths from thi»
disease during the year. With the exception of
two deaths in Indians and one in Japanese ail
occurred in Chinese.
Ankylostomiasis. — During the year specimens of
the fajces of 500 prisoners at the gaol were examined
by Dr. JNIcKenny and 94 of these were found to be
infected.
Infectious Diseases. — The number of these noti-
fied during the year was 919, of which 38 were
l>lague and 595 small-pox.
Playue. — The inoidence of this disease was very
light, there being only 38 cases; 36 of the patients
were of Chinese nationality, 2 non-Chinese.. Thirty-
five deaths occurred. Two cases were imported.
During the year a total of 106,522 rats were
caught, aTi average of 291 per diem. Thirty-one
were found to be infected with plague.
Owing to the increase of plague-infected rats
found during May, June and July, rat poison was
laid down in many Chinese houses throughout the
city with satisfactory results.
Enteric Fever. — The number of cases of this
disease notified during the year was 188. Five
cases were imported. The cases of European or
American nationality were 21, Portuguese 2,
Japanese 4, Indian 6, and Parsee 1. The re-
mainder of the cases were Chinese.
It has not been possible to trace the source of
the infection in these cases, nor the direct infection
of one case from another. The incidence of the
disease has not been of the nature of a water or
milk-borne epidemic, but may have been acquired
by the eating of raw vegetables grown by the
Chinese method or by the eating of shell-fish. As
it is the custom in Hongkong to use uncovered
latrine buckets in Chinese latrines the contamina-
tion of food by flies probably plays a considerable
part in conveying this disease.
Paratyphoid Fever. — Seven European cases were
notified.
Scarlet Fever. — Two European cases and one
Portuguese were notified.
Small-pox. — During the year 595 cases occurred.
In the latter six months of the year only fopr cases
were notified.
Diphtheria. — Sixty-nine cases occurred during the
year two of which were imported ; 62 of the cases
affected were Chinese.
Puerperal Fever. — Twenty cases were notified,
one of which was of Japanese nationality, one Portu-
guese, and the remainder occurred in Chinese.
Public Bath Houses.
The following table shows the nunil)er of persona
who have used the four public bath houses in the
city during the year: —
District. 1917.
Wanchai (men only) 156,968
Pound Lane (men and women) 251,39.3
Second Street (men only) 56,920
Sheung Fung Lane (women and children) 30,019
495,330
Ambulance Service.
Ambulances can be- procured at any time of the
day and night from the disinfecting stations.
Ambulancesi are also obtainable in Victoria fix)m
the Eastern and Western District Sanitary Offices.
Coolies for ambulance work are available.
J. T. C. Johnson, r.,R.C.S.Ed.
Abstract of Heport by Du. H. Macfarlane,
Acting Colonial Veterinary Surgeon.
Disease in Depots.
Rinderpest. — Twenty-three cases occurred in the
Kennedy Town Depot cliiefly in the esurlier part of
the year.
Anthrax. — Seven cases of anthrax were found
during the year. AU of the cases occurred in
October and November. Five came from Wuchow.
Importation of cattle from Wuchow was prohibited
for the remainder of the year.
Tuberculosis. — As in former years no case
occurred in cattle, but three cases were found in
dairy cows sent in for slaughter.
Black Quarter. — Two cases of black quarter
occurred.
Kennedy Town Crematorium.
The carcases destroyed in the crematorium for
the year were: —
Cattle 222
Sheep and Goals 42
Swine 218
Horses 75
Dogs and miscellaneous animals ... ... 216
Condemned meat from Slaughter House ... 13,692 lb.
Rabies. — Dogs were unmuzzled throughout the
year. Six dogs were detained at Kennedy Town
under observation but none were found to be
infected.
Importation of dogs from Shanghai and Chinese
I)orts north of Shanghai was prohibited until
further notice.
Importation of dogs from Canton was prohibited
for six months from July 20.
Civil Hospital.
.\iistract ok Uei'ort by Dr. C. W. McKenny,
Superintendent.
The total number of admissions W'as 3,292. This
includes 99 patients brought over from 1916.
One hundred and seventeen patients were in
hospital at the end of the year. The daily average
of patiente was 108'3.
Out-patients.— &,82Q came for treatment; 7,421
new prescriptions and 5,644 old prescriptions were
dispensed; 3,178 vaccinations were performed.
Nationality of Patients. — Europeans 378, Indians
685, Asdatics 2,229.
Sex of Patients.— MA\e 2,666, Female 626.
Deaths. — 167 deaths occurred, which gives a
death-rate of 5-07 per cent. Of these deaths 71
(i.e., 42 per cent.) occurred within twenty-four
hours of admission.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1S20.
Varioits death-rates : —
Per cent.
Men
... 110 deaths
4-1
Women
... 57 „
91
Europeans
... 12 „
= 31
Indians
... 15 „
21
Asiatics
... 140 „
6-2
Injuries accounted for 51 deaths an
d diseases of
the respiratory system
for 23.
Review of the medical work performed: —
Prevalent Diseases.
Death-rate
percentage.
Malaria
361
1
Typhoid fever
46
6
Beriberi
81
6
Dysentery
37
0
Tubercle
95
8
Diphtheria
17
29
Rheumatism
46
0
Respiratory System
183
12
Digestive System ...
314
5
Among rare diseases may be enumerated : Black-
water fever, 1; hydrophobia, 1; Raynaud's disease,
1; disease of ductless glands, 4; sprue, 4.
Operations. — 444 operations were performed.
Maternity Hospital. — There were 383 patients
admitted. There were 156 male and 134 female
infants bom. Four cases of twins occurred and
23 infants were stillborn.
Deaths. — Four mothers died : three from nephritis
(])resent on admission) and one from shock following
an operation. Ten premature children died.
Infectious Diseases Hospital, Kennedy Town.
Report by Dr. C. W. McKenny, Medical Officer.
The hospital was open during the year as follows :
From January 1 to April 12 ; from December 24 to
December 31.
Thirteen patients were can-ied over from 1916.
Twenty-three new patients were admitted during
the year. Of the total (36), 31 patients were
suffering from emall-pox, 2 from chicken-pox, 2
were in attendance, and 1 was under observation
but proved not to be small-pox.
The patients were ' classified as follows : Euro-
pean, 22; Japanese, 5; Eurasian, 5; Indian, 8;
Chinese, 1.
Four deaths occurred, whicli gives a deatli-rate
of 12'9 per cent, among the 31 cases of smaU-pox
treated. Three of these patients were suffering
from the confluent and one from the haemorrhagic
type of the disease.
The following table shows the relationship be-
tween vaccination and tlie virulence of small-pox.
Unvaccinated
Vaccinated in childhood
Multiple vaccinations ...
Couflnont. Discrete.
7 4
Victoria Gaol.
Report by Dr. C. W. McKenny, Medical Officer.
Health of the prisoners has been satisfactory.
Six deaths from disease took place. The causes
were as follow^.-*: Tuberculosis, 3; cancer, 1; beri-
beri, 1; typhoid fever, 1.
Seven prisoners were liberated for medical
reasons. They suffered from: phthisis, 5; insanity,
1 ; syphilis, 1.
Four cases of typhoid fever were admitted with
one death.
Two cases of dysentery were admitted with no
death.
Twenty-six cases of beriberi were admitted with
one death.
None of these patients contracted the disease in
gaol, and they showed for the most part improve-
ment during their term of imprisonment.
Eighteen cases of pulmonary phthisis were
recorded with two deaths.
Twenty-eight cases of malaria occurred with no
deaths.
As in 1916, during July and .\ugust an epidemic
of dengue occurred. The condition was similar in
mildness and lack of complications to that of last
year and numerically less important.
Fifty-eight pereons required medicinal treatment
as a result of indulgence in opium.
Conditions of Prisoners on Admission to Gaol.
The following facts show the physical condition
of prisoner on their admission. They are of in-
terest as compared with the figures of actual disease
and as an indication of the bodily state of the
criminal class.
It was found that 1,105 were physically unfit,
i.e., 33-6 per cent, of the total admissions to gaol.
Of these 1,105 it was found that: —
(a) 367 were under weight, i.e., their weight was
much below the standard weight for each individual
height. These men were graded into two classes.
The first class (297) was able to perform light work
and the second (70) was unfit for labour which
required any serious effort.
(b) 208 were incapacitated owing to age, i.e.,
they were above 50 years of age. All of these were
unfit for any form of laborious toil.
(c) 493 were suffering from disease or the results
of disease. It was necessary to ad?nit 59 of these
to hospital at the time of or witliin a few days of
their entry into gaol.
((/) 37 were on reduced labour by reason of
juvenility.
There were 147 females admitted.
The total admissions were 3,286.
The total admissions to hospital for illness were
174. The dengue epidemic cases are not counted
in this total.
The total number of prisoners who received treat-
ment in the out-patient department was 998.
Vaccinations. — 2,244 prisoners were vaccinated
and of this number 945 were successful, 718 unsuc-
ccsisful, and 581 were not examined owing to early
discharge at tlie exj)iration of their sentence.
During tlie year 500 prisoners were examined
with a view to ascertaining whether they were in-
fected with certain common intestinal parasites on
admission to gaol.
April 1, 1920.]
COLONIAL MEDICAL REPORTS- HONGKONG.
27
It was found that over 60 per cent, were har-
houriiii.; the round-worn (Ancaris lumbricoidcs),
almost oO per cent. tJie whip-worm (Tncliocephahis
(Uspar), and 22 per cent, the hooli-worm {Anhy-
lu>iiomiim diioilenale).
KOWLOON AND THE NeW TERRITORIES.
Report bv Dr. J. T. Smalley, Medical Officer.
Kowloon-Canton Railway.
The health of the European and Asiatic staff has
been good througliout the year. There has been
very little malaria amongst the staff at the stations
in til© New Territories.
There were five serious accidents on the railway
resulting in the death of four persons and severe in-
juries to thirteen others. The medicine chests in the
trains and at the stations have been kept re-
plenished. They have proved to be of great service
during the year.
IvowLOON and New Territories.
During the first quarter there was a severe
outbreaki of small-pox, being the extension of the
outbreak that started in December, 1916, the last
few cases occurring in April. A vigorous vaccina-
tion campaign was instituted, about 90,000 vaccina-
tions being performed in Kowloon by a willing band
of helpers and myself; in addition a large number
of vaccinations vi'ere performed by the Chinese
Public Dispensaries and the Kwong Wa Hospital.
The campaign was extended to the New Terri-
tories where after a few demonstration® by me the
whole work was carried on by the Distract Officer,
A.S.P., and the Police Force, with the help of the
Government vaccinators.
Great credit is due to them all for the splendid
work they did. In Kowloon vaccination centres
were installed in Hung Hom and Yaumati Police
Stations and at my house. At the latter 5,522
people were vaccinated before January 1, and 3,240
after that date.
The bulk of the work was done l)y standing in
the streetsi and vaccinating the passers-by and by
house-to-house visitation. I think great credit is
due to the Ijand of helpers — included in them are
the European staff and interpreter at Hung Hom
and Yaumati Police Stations, sanitary inspectors,
(te. — who worked very hard with me in addition
to performing their normal duties.
With the exception of this outbreak the year has
been a healthy one. Only five caiics of plague were
recorded at the Public Mortuary.
.\t the Public Mortuary 1,503 post-mortems were
performed, as compared with 980 in 1906. The
increase is partly due to 154 cases of small-pox
and partly to the rapid expansion of the district.
During the year 18,751 rats were examined.
Eleven were found to be plague-infected.
The British schools and missionary establish-
ments have been visited regularly and all scholars
and inmates examined and reported on. These
reports are forwarded — when necessary — to the
parents for compliance with my remarks, which
mainly concern the condition of the teeth, throat
and eyes'. This procedure has resulted in a marked
improvement in the condition of the children's
teeth and, as a natural sequence, their general
health. New inmates of the missionary establish-
ments were vaccinated in December.
Kowloon Dispensary.
It is again satisfactory to note that the Chinese
aversion to We-ytern medicine is becoming very
steadily less marked. Whereas last year about
one-third of the patients attending were Chinese,
their numbers this year constitute well over a half
of our total.
Tung Wa Hospital.
Report by Dr. C. W. McKenny, VisitirKj Medical
Officer.
University Students (Medical CJmic).— During
the year, as heretofore, students have attended for
lectures, case-taking and anoesthetic work, in this
hospital.
The following figures express the comparative
results of Eastern and Western treatment. It
should be understood that all cases admitted are
diagnosed by a staff trained in European methods
and the diagnosis is then confirmed or rejected by
the visiting medical officer. It is then quite open
to the patient to choose whichever of the two forms
of treatment he may desire. The methods of
Eastern medicine are not interfered with provided
they do not endanger public health and sanitation.
To the credit of the Eastern practitioner it must
be stated that he frequently refuses to treat con-
ditions in which he believes Western methods to
be more successful.
The total number of in-patients were divided
thus: —
Cases treated by native methods : -
Original choice 3,062
Transferred from Western treatment ... 213
Less transferred to Western treatment ... 8
Total 2,4
Cases treated by Western methods :—
Original choice ... 2,2
Transferred from native treatment ... 8
3,1
Less transferred to native treatment ... 2
As the U}ia,\ number of cases treated was 5,352,
it will be seen that of this number 55' 1 per cent,
were under European and 44-9 per cent, under
Eastern treatment. Last year the figures were
respectively 50*7 per cent, and 49-3 per cent. This
is the largest percentage of European treatment
that has yet l>een attained and m a definite im-
provement on the figures for 1915 (52-3 per cent.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1920.
European treatment) which had constituted a
record.
Death-rates.
Deaths under native treat-
ment 1,064 -^ 442 per cent.
Deaths under Western
treatment 391=13-2
These rates can hardly be looked upon as accu-
rately representing the mortality in the hospital as
they include 598 moribund cases which were dis-
tributed as follows: —
Native treatment 496
Western treatment 102
If these be deducted we may consider the follow-
ing as accurate : —
Native treatment 1,907 cases with 568 deaths = 297 per cent,
mortality.
Western treatment 2,847 cases with I
mortality.
( deaths = lO-l per cent.
Remarks on Special Diseases
Beriberi. — In all 826 cases were treated, with
291 deaths.
It is to be noted that more careful examination
of the patients in the wards of the medical clinic
frequently revealed the fact that in addition to the
disease for which the patient had been admitted
he was also suffering from beriberi.
Such additions would probably bring the total
up to 1,000.
It may, therefore, Ix; said that some 20 per cent,
of all patients in hospital were suffering from beri-
beri.
The number of cases of this disease is increasing
and must be considered as easily the most im-
portant cause of physical disability among the
poorer class of natives.
It has a lower mortality than phthisis but pro-
bably causes more general harm than that malady.
Malaria. — There were 803 cases treated, with 102
deaths, i.e., 33-6 per cent.
The following were the various types as dif-
ferentiated by microscopic examination: —
MaUgnant
.. 257 cases with 94 deaths
Benign tertian
10 „ ,, 0 ,,
Quartan
2 „ „ 0 „
Malarial cachexia
.. 34 „ ,, 8 „
The usual routine as to treatment was observed.
Plague. — Nineteen cases with nineteen deaths
were recorded.
Diseases of Central Nervons System. — 293 such
cases were admitted, but it is of interest to note
the extremely rare occurrence of locomotor ataxia
and general paralysis of the insane. It is generally
admitted that these diseases are the result of
syphilis, but here we have the curious fact that
syphilis is a common disease among our patients
and does attack the central nervous system, but
not as either of the alxjve diseases, except in a
fractional percentage of cases.
Colonial Medical Reports.— No. 108.— Agra and Oudh.
EEPOKT OF THE UNITED PROVINCES FOR THE
YEAR 1917.
By C. MACTAGGART, C.I.E., M.A., M.B„ Colonel, I.M.S.,
Itispector- General of Civil Hospitals and Officiatiiig Sanitary Commissioner, United Provinces.
General Population — Vital Statistics.
General.
According to the census of 1911 the total popu-
lation of these Provinces (excluding certain reveii je
estates formerly belonging to the Meenit District
hut transferred to the Delhi Province) anionnts to
46,820,-556. On this figure (as in 1916) are
calculated all the birth- and death-rates shown in
this report.
(Note. — The terns "towns" and "urban
areas " refer only to towns with a population of
10,000 and upwards and fche term " rural tracts "
to districts excluding such towns.)
The birth-rate of the Provinces in 1917 was 46-08
per mille of the population, against 43'09 in 1916,
and 44^91 the quinquennial average. The provin-
cial deatli-rate was 37"91, as compared with 29'50
in 1916 and 31'55 the mean for the previous five
years. It will be seen that the birth-rate is higher
than that of the preceding year by 2-99 and than
the quinquennial average by 1'17. It is satisfac-
tory to note that this rate (46'08) has been exceeded
onlv four times during the last tiliirtv-seven veai-s,
viz", in 1899 (48-09), 1913 (47-67), "1904 (46-67),
and 1903 (46-13). The death-rate in 1917 exceeded
that of the preceding year by 8-41. The excess
has been chiefly due to mortality from fever and
plague, the death-rates of which are higher by
5-75 and 1-71, respectively, than those of tho
preceding year.
k
April 15, 1920.]
COLONIAL MEDICAL REPORTS.— AGRA AND OUDH.
Colonial Medical Reports.— No. 108.— Agra and Oudh (contd.).
The birth- and death-rates and the infantile
mortality of these Provinces are, in the subjoined
table, compared with those of other provinces.
The position of the United Provinces was third as
regards high birth-rates, ninth .as regards low death-
rates, and seventh as regards low infantile
mortality.
Province
I!irth-iate
Dtath-rat»!
mortality
United Provinces ...
... 4608
.. 37-91 ..
21573
Bombay
... 35-72
.. 40-76 ..
216-67
Madras
... 32-37
.. 26-23 ..
193-99
Bengal
... 35-91
.. 2619 ..
184-60
Bihar and Orissa ...
.. 40-45
.. 35-21 ..
180-43
Assam
... 31-35
.. 2709 ..
189-28
Central Provinces ...
... 48-13
.. 3606 ..
226-15
Punjab
... 45-34
.. 37-91 ..
247-95
Burma
... 36-25
. 25-30 ..
21314
North-West Frontier
Province
... 32-11
.. 29-95 .
194-27
Delhi
... 52-75
.. 32-68 ,.
224-16
Births.
During the year under report 2,157,642 births
were registered, against 2,017,756 in the preceding
year (an increase of 139,886), the birth-rates being
46-08 and 43-09, respectively. Tlie quinquennial
average is 44-91. The birth-rate curve was below
the monthly provincial average (3-84) during the
months of February, April, May, June, and July
and higher in the remaining mont-hs of the year —
the actual rates in the former months being 3'46,
3-79, 3-38, 2-85, and 3-48 respectively, and in the
latter months, viz., January (4-06), March 3'97),
August (4-14), September (4-40), October (4-32),
November (4-06), and December (4*15).
The proportion of male to female births during
the year 1917 was 108-36:100. The ratio of male
to female bii-tlis has been practically constant for
the last seven years.
The excess of births over deaths amounted to 8-17
per mille of population, against 13-59 in 1916. The
excess was shared by all the districts of these
Provinces with the exception of Shahjahanpur,,
Pilibhit, Naini Tal, Budaun, Kheri, Bareilly, and
Ghazipur. In Shaihjahanpur the excess of deaths
over birtlis was due mostly to fever and " all other
causes " and partly to cholera. In Pilibhit and
Kheri it is accounted for by high mortality from
fever. In Naini Tal, where the birtli-rate is also
very low, it was due to fever and partly to cholera,
dysentery and diarrhoea and respiratory diseases.
The excess of deaths over births in Budaun was
due to fever atid, to a certain extent, to small-pox;
in Bareilly to fever and partly to cholera. Plague
and oholesra were responsible for the excess in
Ghazipur.
Deaths.
The total number of deaths recorded during the
year under report was 1,774,896 and the death-
rate per mille of the population was 37-91, against
1,381,299 and 29-50, respectively, for the preceding
year and the quinquennial average of 31-55.
Twenty-three districts out of forty-eight recorded
death-rates above, and twenty-five death-rates
below, the provincial average.
In 1917 the number of deaths among males was
933,723 and among females 841,173, against 720,097
and 661,202, respectively, in 1916, the correspond-
ing deatili-rates being 38-17 and 37-62, against 29-43
and 29-57. The total mortality was higher among
males than femailes, but, taking the death-rates at
different age periods, more females died than males
between the ages of 5 and 30.
In 1917 the infantile mortaJity, though higher
than that of tlie preceding two years, was con-
siderably lower than that of other previous years
except 1912. The total number of deaths during
the year under report w.as 465,467, against 423,130
in 1916, showing an increase of 42,337 over the
figure of tlie preceding year. Fever accounted for
the largest number of deaths (228,139), followed
by tetanus (113,574), against 205,583 and 116,833,
respectively, in 1916. llhe number of deaths from
tetanus is still suspicioualy high, aJthough its per-
centage to the total infantile mortality has declined
to 24-4 in 1917 from 27-6 in 1916 and 31 2 in 1915.
The following measures were adopted for the
reduction of infantile mortality: —
Pamphlets containing instructions to mothers
and midwives, in Urdu and Hindi, have been
distributed in many districts.
In twelve districts 104 dais were admitted to
training in midwifery and the care of young
children. Of this number 20 passed the examina-
tion, 62 were discharged, and 22 remained at the
close of the year.
The three co-operative dairies at Benares, Luck-
now, and Allahabad were maintained during the
year 1917. The business of the Lucknow co-opera-
tive dairy continues to shrink owing to the heavy
indebtedness of its members and the consequent
impossibility of advancing money for the purchase
of new cattle.
Important as the question of the supply of pro-
perly trained dais is in order to reduce infantile
mortahty, I believe that a far more important
question is the provision of a cheaper supply of
reasonably pure milk. Indian mothers almost in-
variably nurse their children, but in thousands of
cases, when the mothers' milk-supply is for various
reasons insufficient, children die of malnutrition
because the parents are unable to buy milk for
them at the prevailing rates, and I do not hesitate
to say that if the cost of milk could be reduced in
our municipalities, to a figure which would bring
the milk within the reacih of the poorer classes,
more would be effected towards reducing infantile
mortality than the presence of any number of
trained dais would accomplish. The whole question
of the supply of milk in our cities was recently
considered by the Sanitary Board, and the recom-
mendations of the Board were forwarded to Govern-
ment; but the question is a most difficult one to
solve.
The number of " stillbirths " which took place in
1917 was 31,9.54, against 26, .541 in 1916.
Medical officers amd their subordinates and inde-
30
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15, 1920.
pendent medical practitioners submitted, as usual,
tlie returns of deablis whicsh occurred in t?he course
of their practice, and of which t>he causes were
definitely ascertained.
Of the 4,412 deaths verified during the year, G7
were attributed to intermittent and remittent fevers,
21 to enteric fever, 2 to simple fevers, 315 to other
fevere, 502 to pneumonia and other respiratory-
diseases (excluding 303 from phthisis), 496 to
dysentery and diairhoea, 360 to injuries, 100 to
hepatic congestion aiid abscess, 81 to anaemia and
debility, 14 to splenic diseases, and 35 to apoplexy
and heat-stroke- Small-pox caused 20, measles 32,
cholera 203, and plague 429 deaths. The number
of deaths reported from " aJl other causes " was
1,432.
Chief Diseases.
Cholera.
The total number of deaths from cholera regis-
tered in all the districts amounted to 21,440 in
1917, against 33,300 in 1916, tlie death-rates from
this disease being 0-46 and 0-71 respectively, as
compared with 1-00 — the average for the preceding
five years. A peculiar feature of the disease last
year was its persistence in epidemic form into the
late cold weather in certain districts.
Fourteen districts out of forty-eight recorded a
death-i'ate higher, and thirty-one lower, than the
provincial average, 0-46. It is interesting to nolo
disinfection of wells by permanganate of potash or
bleaching powder was cai-ried out; it proved more
or less satisfactory.
The mortality from cholera in the urban areas
was 0'84 and that in the rural tracts 0-48, against
0-75 and 0-71 respectively in the preceding year.
Small-pox.
During tilie year under report 2,011 deatJis
occurred from small-pox, giving a death-rate of 0-04
l)er mille of po])ulation as compared with 1,515 and
0-03 respectively in 1910. The highest mortality
occurred in May and the lowest in October.
Plague.
In 1917 the deatJi-rate fioiii jila-ue was 2-76 per
mille of population, against 1-05 in tlie preceding
year. The quinquennial average was 1-85.
The total number of deaths recorded in 1917 was
129,084, against 49,368 recorded in 1916. It is
rather disquieting that, after a steady decline in
the plague mortality din-ing the preceding five
years, the disease should have reappeared with
such greatly increased incidence during the year
under rc-i)ort, lint the climatic conditions of the
year were fa\ ..iirablc i,,r tlic spivad of j)lague. The
hot weather ciiKlitMiiis srt iii late and weiT less
marked and less |,rol,,nj;i.d than usual, and the
rains oi)ened early, the result l)ehig that the winter
e|)idemic was prolonged, the disease did not die out
nltogether as usual in tlie liot months and many
foci of disease remained. As a supjilenient to the
medical, establishment of the districts, eighty-seven
travelling dispensaries were employed during the
year as in the preceding three years. As anti-
plague measures inoculation and evacuation were
resorted to as usual.
Fevers.
During the year under report 1,266,519 deaths
from fever were registered, against 997,496 in 1916,
representing a death-rate of 27-05 and 21-30,
respectively. The quinquennial average was 21'74.
The largest number of deaths from fever this
year occuiTed in May, as has been the case for
several years past except in 1915 and 1916.
From tlie weather conditions of tlie year 1917,
it appears that rainfall was in excess of the nomial
in certain months of the year, and this probably
caused more malaria than usuaJ, but deaths from
malaria undoubtedly constitute only a small pro-
portion of the deaths returned as due to " fever."
School Quininization. — Owing to the great rise in
the price of quinine and the necessity for conserving
the stock of the drug in India, the quininization of
school oliildren was ordered by Government to be
altogether dropped in 1917, and until the price of
quinine fell to a reasonable figure. A proposal
made by Lieutenant-Colonel Harriss, to issue
"residual alkaloid" as a substitute for quinine
was not accepted by Government.
During the year under report 2,056 one-rupee
packets, 1,023 three-rupee packets, and 560 five-
rupee packets of quinine were sold, against 6,267
one-rupee packets in the preceding year.
Quinine amounting to 300 lb. was also issued
from the Aligarh Jail for the use of the travelling
dispensaries.
The disease is cert^ainly very prevalent in the
llohiUflhand and Agra Divisions, and probably is
more or less epidemic all over the western and
northern districts.
kn outbreak of scarlet fever with 133 cases and
88 deaths occurred in the Pitlioragarh Sub-Division,
Almora District. By proper and timely segrega-
tion of the sick and early treatment through the
agency of the travelling dispensai-y the outbreak
was controlled.
Dysentery and Diarrhaa.
The total number of deaths registered from these
diseases during 1917 amounted to 22,308, against
17,731, and 10,477 in the two preceding years, the
respective rates being 0-48, 0-38, and 0-41. The
qjiincjuennial average was 0-37.
Tlie highest mortality from these causes was
returned in May (2,522) and the lowest in February
(908).
Eespiratory Diseases.
Diseases of the respiratory organs accounted for
28,926 deaths in 1917, as compared with 25,963
in 1916, the death-rates being 0-62 and 0-55 respec-
tively. The quinquennial average is 0-49. As
stated in previous .\nnual Sanitary Reports, deaths
from respiratorv diseases are not suffieientlv reco;,'-
April 15, 1920.] COLONIAL MEDICAL REPORTS.— AGEA AND OUDH.
iiized by the local reporting agencies. Averaging
from falie return of medical practitioners there
should be, exclusive of phthisis, 201,949 deatlis and
a death-rate of 4-31 instead of 28,926 reported with
a death-rate of 0-62.
The highest mortality from these causes was
recorded in April and the lowest in July.
Injuries.
During the year under report 26,753 deaths were
recorded from injuries, giving a death-rate of 0-57
per mille of population, against 27,149 and 0-58
respectively in 1916.
In 1917 the number of deaths reported to have
been due to suicide was 2,404 — 610 among males
nid 1,794 among females — against 2,219 in 1916.
The total number of deaths caused by wounds
and accidents in 1917 was 17,283, and 6,807 deaths
were caused by snaJces and wild beasts, while the
loss of life from rabies during 1917 was 259.
Sanitation Department.
Observations.
The provincial birth-rate, which had been falling
for the last three years, rose again to 46-08 per
thousand of the population, which, though 1-59
lower than the rate for 1913 (the record since 1899),
is 1-17 higher than the quinquennial average, and
has been exceeded only four times in the last thirty-
seven years. Only two provinces, Delhi and the
Central Provinces, showed a higher rate. The
birth-r-ate in municipalities was 47'93, the highest
recorded in the last thirty-seven years. In notified
areas the rate was 46-60.
The provincial death-rate was 37-91 per thousand.
This was 8-41 higher tlian the rate for the previous
year and 6-36 higher than the average for five
years, tliough only ()-42 higher than the average
for the preceding ten years (1907 to 1916). Oidy
one provmce, Bombay, showed a higher rate, while
that for the Punjab was the same. The death-rate
in municipalities was 47-10, an increase of 10-56
over the previous year, and in notified areas 41 71,
an increase of ten. This excess is chiefiy due to
the mortality from fever and plague.
The infantile mortality, though higher than that
of the preceding two years, was considerably lower
than that of other previous years excejjt 1912. Tlie
high proportion of death* from tetamis still throws
doubt on the accuracy of the diagnosis of the causes
of infantile mortality, though the steps taken for
the verification of reports in Benares, Allahabad
and Gawnpore appear to have resulted in a reduc-
tion of the proportion in these municipalities.
Whatever allowance be made for inaccuracies, there
can unfortunately i)c no doubt that the number of
deaths froiri tetanus, a disease usually due to un-
cleanly midwifery, is extremely high. Good xyorU
is being done in the ti-ainiiig of midwives in Dufferin
hospitals with the aid of the Victoria Memorial
Fund soholarships, but the systematic attempt to
train bazar dais, which has been carried on for a
number of years, has proved a failure. It has been
found impossible to get these women to observe the
most rudiinentai-y rules of cleanliness, and they are
too nuicli attached to their old hereditary methods
ever to abandon them. A scheme for the grant of
diplomas to ti-ained midwives is now under the con-
sideration of the State Board of Medical Examina-
tions. There is muoli weight in what the Sanitary
Commissioner says in regard to infantile mortality
that, important as the question of supply of properly
trained midwives is, a far more important question
is the provision of a cheaper supply of reasonably
pure milk.
There was a satisfactory increase in the number
of birth and death entries tested by the local
authorities and by the vaccination staff. Of the
districts showing the largest number of entries
tested by local authorities, Gorakhpur is easily first,
followed by Allahabad, Hamirpur, Hardoi and
Basti. That there is still room for improvement
is shown by the great divergence in the number of
entries tested in different districts, the extremes
being 214 in Bulandshalir and 103,431 in Gorakh-
pur. As regards the work of the vaccination staff,
Ganhwal and Bulandshahr headed the list for the
third year in succession.
The greatest increases in mortality from par-
ticular diseases, as compared with the previous
year, were shown under fever and plague. The only
disease the death-rate from which fell was cholera,
under which 21,440 deaths were registered, giving
a death-rate of 0-46 per thousand. The death-rate
from this disease has been lower only eight times
in the last forty-seven years. Bleaching powder
was substituted for permanganate of potash for the
disinfection of wells under the cholera scheme, but
the supply of bleaching powder was only possible
to twelve out of the twenty districts protected by
the scheme. It is remarkable that the ratio of
the death-rates in the protected and unprotected
districts, which in the six years before the intro-
duction of the scheme was as three to one, and in
the three years 1914 to 1916 was nearly equal,
returned in 1917 to a proportion of three to one.
It is very probable, as the Sanitary Commissioner
suggests, that this rise in the ratio is due to the
insufficient supply of permanganate and bleaching
powder. There can be no doubt that the syetematic
cleaning of wells has been doing good and saving
life.
There was a great increase in the number of
deaths from plague, of which 129,084 were
recorded as against 49,368 in 1916. The death-
rate of 2-76 was 0-91 higher than that of the quin-
quennium, and only 0-02 lower than that of the
preceding ten years. It is disquieting, as the
Sanitary Commissioner remarks, that after a steady
decline in the plague mortality in the preceding
five yeai'iH, the disease should have reappeared with
such greatly increased incidence; i)ut the climatic
conditions of the year, with its late and short hot
weather and its early rains, were specially favour-
able for the spread of plague.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [AprU 15. 1920.
The greatest increase was in the number of
deaths registered as due to fever, whieh was
1,266,519 as against 997,496 in the previous year.
Tlie death-rate, 27-05, is higher by 5-31 than the
quinquennial average, and by 0-62 than the average
for the preceding ten years. Very little progress
could be made with malarial investigation owing to
the scarcity of qualified officers, and when Colonel
Harriss reverted to militarj' duty in July, 1917,
the work had to be closed till the end of the war.
The quininization of schools had to be discontinued
owing to the prohibitive price of the drug. The
abnonnally early and heavy rains probably caused
more maJaria than usual, but deaths from malaria
undoubtedly constitute onlv a small proportion of
the deaths returned as due to fever. The districts
in which tliere was the highest mortality are chiefly
tlaose in which relapsing fever is present in epidemic
form, and the Sanitary Commissioner is convinced
that one of the main factors, if not the main factor,
in the high mortality in these districts was relapsing
fever. Travelling dispensaries which could be
spared from plague work were lent to these dis-
tricts, which are mainly those of the Agra and
Rohilkhand divisions, and a pamphlet giving in
simple language the symptoms, treatment and
means of preventing this disease was prepared by
Dr. Pandya and widely circulated.
The expenditure on works of a sanitary nature
under the provision of the Sanitary Engineer
amounted to Rs. 16,18,320, exclusive of the cost
of preparation of schemes. Among the more
importarnt sanitary works completed may be noted
the anti-malarial works at Meerut, Saharanpur
and Nagina. The water works machinery at Luck-
now and Allahabad continued to give trouble. It
is hoped that the improvements effected will pre-
vent further breakdowns, but it is clear that in both
cases the trouble was largely due to neglect of
ordinary petty repair and maintenance.
The post of Sanitary Commissioner was held by
Lieut. -Colonel Harriss up t-o July 25, 1917, when,
on his reversion to mihtary duty. Colonel Mac-
taggart took charge of the duties in addition to his
own duties as Inspector-General of Civil Hospitals.
The thanks of Government are due to both these
officers and to Mr. West, who has held the office
of Sanitary Engineer throughout the year.
Colonial Medical Reports, — No. 109. — New Soath Wales.
REPORT FOR THE YEAR 1916.
By ROBERT T. PATON,
Director-General of Public Health.
Year by j'ear the need for the amendment and
consolidation of the Public Health Act of New South
Wales becomes more and more evident. In com-
mon with all the other States of Australia, the
Public Health Act of this State is framed more or
less closely upon the model of the Enghsh Public
Health Act of 1875, with modifications in several
directions to meet the special needs of this country.
Many provisions for the control and safeguarding of
the pubhc health are, however, to be found in other
legislative enactments than the Public Health Act,
as for instance the Local Government Act, Dairies
Supervision Act, Noxious Trades Act, Cattle Slaugh-
tering Act, &c. The dissemination of legal provi-
sions for the safeguarding of the public health in
so many different Acts constitutes a weakness in
administration. Comparing the public health of the
different States of Australia it will be found that
that of New South Wales is the most conservative
and cumbrous to administer. This latter fact is due
to the want of concentration just referred to. .\s
an instance may be quoted the extensive public
health regulating powers contsyned in the Local
Government Act. This Act is'^ot witlu'n tlie direct
administration of this de])art.ment, ai.d desirable
supervision over the very valuable i)ublic iiealth pro-
visions of that Act can only be exercised by a round-
about and difficult process; more direct administra-
tive authority by this department is essential.
Directions in whiola such control is urgently
needed are the super\^ision of the appointment by
local authorities of their sanitary inspectors. The
Local Government Act, it is true, gives the Board
of Health the power to require local authorities to
appoint a sanitary inspector if they have not already
such an officer, but this provision can be easily
evaded by a mere nominal appointment on the part
of local authorities. The Department of Public
Health has no power to enforce the appointment
of a competent officer for this important work.
Another direction in which important powers are
lacking to the health authorities of this State is that
of making regulations, particularly regulaticns for
the control of infectious persons. Many of the
other States of Australia are far ahead of New South
Wales in this particular. In Victoria and Queens-
land the Public Health Department can make regu-
lations for the effective control of " carriers " of
infectious disease. One of the recent developments
of sanitary science has been the discovery that
certain persons, though not themselves suffering
from any symptoms of an infectious disease, may
nevertheless carry the germs of such a disease on or
in their persons, and may infect other persons with
v\hom they come in contact with the disease in a
viiiilent foi-m. Such individuals unless they are
kept under some sort of control may become very
dangerous to the public.
i
May 1, 1920.] COLONIAL MEDICAL REPORTS.— NEW SOUTH WALES.
33
Colonial Medical Reports.— No. 109.-New South Wales
{conti7iucd).
TliL-ix- aic othei- directions in v\ liifli auieiulnieuts
(,f tile Pul)liv Hcaltii Aets aio nr-fntly needed, and
ahov all IS essential the (■(insdli.lation of all legisla-
tion dealiiif,' with the puhlie. health into one compre-
hensive x\ct. Ally amendment introduced should
aim at conserving and extending the elasticity of
control of the puhlic healtli hj' granting powers to
the Board of Health to make regulations, rather
than hy the introihietion of haid and fast legislative
provisions.
CU
H(
A special inspection was made of the sanitary
condition nf hotels, tlie chief defects disclosed were
those )-elating to deficient lighting an<l ventilation of
rooms; and, in the more outlying suburbs, unsuit-
able <lrainage systems. On service of notice these
defects were in most instances promjitly )emedied
by the licensee without the Department having
recourse to fui-ther action.
Cukmical Laeokatoky.
The work undertaken by this branch during tie
year comjirised the testing of some 11,000 samples,
consisting of milk and otlier fo(Kls taken under the
Pure Eood Act; food supplied to troopships;
materials tested for the Stores Supply Department
and other services, and medico-legal examinations
conducted for the Police and Justice Departments.
There was an increase on last year's figures of all
samples except milk. A notable example of this
increase is S'liown in the number of samples of food
taken from troopships, which amounted to 630, or
more than double the immber submitted in 1915.
The value of the systematic inspection supplied to
the tr-ansjioi-ts is evidenced by the decided improve-
ment in its quality, as the number of samples fail-
ing to comply with the requirements of the Pure
l''ood Act fell from 20 per cent, in 1915 to just
under 11 per cent, this year.
Several samples of drinJcs and cordials prepared
and sold in country towns were found to be dirty
and unfit for human consumption, owing largely to
the lack of projier filtering apparatus. Owing to the
Department's continued activities for the suppres-
sion of 7iostrums and " quack medicines," several
l)i-osecutions were undertaken against vendors of
nuich-advertised " fat producei-s " and " flesh " re-
ducei-s "; the jiroprietors of an appendicitis mixture
consisting of cream of tartar, carbonate of soda, and
tartaric acid; and a worthless cancer " cure " adver-
tised and sold at 15s. per bottle. All of these so-
called " cures " were the subject of careful analysis
to ascertain their curative value, if any.
|)Aiiin;s Si'i'KuvisioN Aci'.
ri,r Mill,- Siipijlu is a subject which receives
special attention from this office. Oversight of this
very important food is secured under the Dairies
Supervision Act, 1901, and by certain clauses of the
Pure Food Act, 1908. Supervision of the milk
supply begins at the daii^y farm, where proper provi-
sion must be made for collecting and storing, and it
is under control from that time until it reaches the
consumer. Administration of the Dairies Supervi-
sion Act is vested in the local authority of each
district — in the municipalities this is the Council;
in places where there is no municipality, the senior
police officer of the police district. These duties
consist of keeping a register of all dairymen and
milk-vendors, and inspecting each premises together
with appliances and utensils at least four times a
year. The Board of Health has its own dairy
inspectors, consisting of a field staff of fourteen in
the counti-y, and one in the meti'opolitan area, who
supervise as far as possible the work of the various
local authorities. On account of the small staff
employed it is not possible to compass this work in
so complete a manner as the Department would
wish. Any diseased animals discovered ire
destroyed under supervision.
Milk in transit to market is also kept under super-
vision, the Department insisting upon the absolute
cleanliness of all milk receptacles of every descrip-
tion used by dairymen and milk vendors.
Upwards of 10,000 samples of milk are taken an-
nually for analysis by the officere autliorized under
t^e Pure Food Act, from milk vendors in the metro-
politan and country districts. In 1916 the number
of adulterated milks was 516 out of a total of 8,493
samples examined. A number of samples referred
to were taken in restaurants and refreshment rooms
from the milk jugs sei-v(Hl with tea and other
beverages, and in a large ,umber of instances this
milk was found adulterated, in some cases the
amount of added water being as high as 24 per cent.
Proceedings taken resulted^ in fines ranging from £5
to €12 being imposed.
Milk Standard. — In dealing with milk there is
another aspect which is of almost as great impor-
tance to the public as its purity, namely its value as
a food. For a number of yeai-s the Health Depart-
ment has insisted that the fat content of milJ< S'liall
not be less than 3"2 per cent. Attempts have been
made from time to time by certain sections of those
interested in the milk trade to have this standard
lowered, and pressure has been brought to bear with
that object in view. The Department, however, has
consistently maintained that 3'2 per cent, is not too
high a standaixl. Its attitude in this respect is now
being ap{)reciated by many of those who fomierly
were most persistent in their efforts to secure accep-
tance of a lower fat content, as milk companies are
paying higher prices for a richer article. Had the
Department yieldetl to pressure and allowed the
standard to be lowered, the only effect would have
been to offe^r a premium to dairy farmei-s who kept
herds producing a greater quantity of niiUi of a less
mitritive character.
The Dairy lMdu8ti7 Act, 1915, administered Tiy
the Department of Agriculture dealing with the
manufacture, sale, storage, transit, and export of
34
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
IMay 1, 1920.
dairy produce was in operation during the year 1916,
and t-he administration by two separate Depart-
ments has to some extent given rise to complaints
in regard to overlapping of inspection by two dif-
ferent sets of ofKcers. The advisability of arriving
at some means by which this dual control can be
obviated is too apparent to need comment, and an
efiFort should be made so that those engaged in the
dairy iiidusti-y shall not be subjected to unnecessa,ry
expenditure as to which department's instructions
shall be coinplie<l with in cases of doubt.
Meat inspection in country districts. — The inspec-
tion of meat in the Metropolitan and Hunter River
districts is now controlled by specially appointed
Boards. Outside these areas the Department con-
tinues its supervision over all meat slaughtered for
food.
Pure Food .\ct.
A bulky volume would be needed to adequately
describe the improvements secured by the Depart-
ment in connection with food supplies in this State
since the Pure Food Act caxne into operation in
July, 1909. Inspectors at first directed attention to
the gross adulteration of the more common foods
which then existed. The revised code of regulations
fixing legal standaivils for every article in general use
came into force on 1st January, 1916, and is proving
satisfactory. In the code referred to the Pure Food
Committee endeavoured, as far as possible, to follow
on the lines laid down by the interstate conference
held in Melbourne in 1913.
Phemises used tor Preparing Food.
Since the passing of the .let a systematic inspec-
tion has been made of all premises used in connec-
tion witli the preparation of food, and the clean and
wJiolesome conditions now aJmost everywhere exist-
ing are a v^elconie evidence of progress when com-
parison is made with the laxly kept premises and
insanitary conditions so frequently found six or
seven years ago.
Bakeries. — All premises used for the preparation
of bread and pasti^ are ^carefully inspected with
beneficial results.
Manufacturing Confectioners. — The premises used
for the manufacture of sweets, &c., have received
detailed inspection. Iri a few instances the whole
interior of the building, including walls, benches,
floors, and utensils were in a dirty condition, and in
several cases it was found necessary to take proceed-
ings for insanitaiy conditions. Attention was also
given to the fruit products used at these premises,
and on several occasions traders were found using
damaged and deteriorated fruits for trade purposes,
evidencing the need for the strictest supervision
being maintained.
Jam Manufactories were another class of premises
which were systematically examined. Here also in
a few instances very unsatisfactory conditions were
found to exist, some of the largest traders being
guilty of wilful neglect, not only in connection with
the general condition of the premises, but also in
regard to deteriorated food prtxlucts stored thereon.
Prosecutions taken i-esulted in the imposition of
fines ranging from £5 to £30.
Fisli and Small doods Sliops. — The sanitary con-
ditions of these premises were examined and struc-
tural a.lterations made where necessary. In all
cases where wilful neglect was apparent or dirty or
insanitary conditions found, traders were prose-
cuted, and fined in sums ranging from £5 to £10.
Fruit Barrowmen. — Attention has been given to
the exposure of fruit on barrows and elsewhere in
the public streets, and in some instances ban-owmen
have been prosecuted for selling fniit unfit for
human consumption. In the more flagrant cases
tlie whole of their stock was seized and destroyed.
It was occasionally found that dirty rags were use<l
for the purpose of polishing fruit, and in one in-
stance a trader was fined £2 and 6s. costs for using
a soiled handkerchief for the purpose. Action is
also being taken to stop the practice of " topping-
uj) " fruit, and then selling an inferior article.
This branch initiated and energetically proceeded
with the work of endeavouring to secure the removal
from the market of all falsely described remedies
and " cure-alls," several prosecutions being under-
takeTi during the year.
PntLic Health and Sanitary .Administration.
All mattei-s connected with sanitation are imme-
diat-ely under the jurisdiction of the Deputy Director-
General of Public Health who is fumisihed with a
staff consisting of a Chief Sanitary Inspector and
trained inspectors.
From the report of the Chief Sanitai^ Inspector
it is evident that the amended Public Health Act
has proved of great benefit in dealing with houses
unfit for human habitation. The provisions of the
amended Act have been availed of by many of the
suburban and country municipal councils, and very
little friction has resulted from their enforcement.
Nuisances. — A frequent cause of complaint is of
nuisances arising from stables or from the keeping
of poultiT. It is hoped before long that legislation
will be introduced which will provide effective
means for suppressing or effectively supervising
these and similar nuisances.
Bats. — Many complaints were made also by resi-
dents in the metropolitan district of nuisance caused
by rats, and the attention of councils was invited to
the provisions of Local Government Ordinance
No. 39, which requires that the floors of produce
stores, &c., shall be impervious to rats, and fixes
penalties for allowing refuse or waste matter likely
to encourage rats to visit or frequent premises, or
to fonn or afford shelter or harborage for them ; and
councils were requestetl to take early measures to
cope with the trouble.
Pollution of Ocean Beaclies. — The firm action
taken by the Department has resulted in a great
diminution in the fonner pollution of beaches by
garbage discharged from punts and sea-going vessels.
Punts conveying garbage from the city are required
to go at least five miles out to sea before dumping
May 1, 1920.;
COLONIAL MEDICAL REPORTS.— NEW SOUTH WALES.
35
tlieir cargoes, and all garbage so dumped must be of
a sinkable nature. Restrictions of this kind do not
ex'st in regard to ocean-going vessels, and the Com-
nionwealth authorities, whose jurisdiction extends
three miles from the coast line, were requested to
take measures to put an end to the practice followed
by such vessels of discharging their refuse as soon
as they cleared the Sydney Heads, thereby con-
tributing largely to the pollution of the local
beaches.
Garbage Tips and Destructors. — As a result of
notices served and action taken by the Department,
considerable activity has been exhibited by various
suburban mtinicipalities in an attempt to deal with
garbage in a more satisfactory manner, and destruc-
tors have now been provided by Ma-rrickville,
Woolahra, and Paddington Councils. Several other
councils have the question under consideration. In
view of the financial position which exists at i>he
present time, it would be advisable in many cases
for two or three councils to combine and con-
jointly erect a modern destructor. This course was
adopted many years ago by Petersham, Leichhardt
and Annandale Councils, and has worked very satis-
factorily. It has the great advantage of providing
an efficient and economical service at a compara-
tively small cost to each of the councils concerned.
In general it can very truly be said that there has
been a vei^y great improvement in suburban garbage
tips as compared with the conditions found existing
when a systematic inspection was made in June,
1915, hut strict supervision is still required in
certain locahties if gross nuisance is to be avoided.
Laundries. — During the year an examination was
made by the Chief Sanitary Inspector of large and
small laundry premises in the metropolitan district,
and of the methods employed in sorting and disin-
fecting soiled clothing. Certain recommendations
made in connection therewith are receiving atten-
tion.
PiuvATii Hospitals Act, 1008.
The year 1916 has shown several additions to the
private hos))itals already in existeuije. During the
year several large jwemises situated in the metro-
pohtan area have been entirely remodelled and fitted
with every convenience, the results being vei-j' satis-
factory. The increase in the number of cases of
scarlet fever, measles, diplitheria, and infantile
paralysis, again emphasized the need for establish-
uiciit of ])rivate hospitals for well-to-do patients
siiffcring from infectious illnesses. For lack of such
accoHiMiodation j)ersous residing at hotels or board-
iiii,'-li()uses have frequently to be pi'ovided for at the
Coast Hospital at great inconvenience to the Depart-
iiK^ut, already overtaxed in finding beds for needy
Inkkctious Diseases.
Typhoid Fever. — The behaviour of typhoid fever
during the year was in marked contrast to that of
diphtheria. There has been less typhoid fever in
this State during 1916 than at any time during the
lust twenty years — year by year for some time this
disease has been on the decline. This is highly
satisfactory, as typhoid fever is one of the most
serious of the common infectious diseases, and has
in the past cost the State large numbers of valuable
lives. This reduction is the outcome of the Depart-
ment's insistence on local authorities enforcing
effective sanitary measures in their districts, such as
efficient sanitary and garbage service, cl&anliness
of dwellings and yards, properly protected water
supplies, kc, and particularly by the increased
vigilance in connection with the supervision of
dairies and the milk supply generaMy. In many
counti-y towns where formerly there was a severe
outbreak every summer, only three or four cases
are now reported in the course of the year.
In this connection may be mentioned the report
on typhoid fever issued in May, 1916, by the com-
mittee appointed to inquire concerning " Causes of
Death and Invalidity in the Commonwealth," which
concludes -that the great and steady diminution in
the typhoid mortality rate in the last thirty years
is due to measures of sanitation, the principal factor
probably being controlled disposal of human excreta.
The committee, in pointing out that there still re-
mains considerable typhoid mortality in the Com-
mon wealth, particularly directs attention to the high
rates in country districts as compared with the
capital cities, and expresses the opinion that " the
continuing loss of valuable lives every year from
this disease is probably largely due to defective or
incomplete application of recognized principles of
saJiitation ; or to direct or indirect infection by
infective humans (cases or carriers) probably largely
by means of personal neglect of cleanliness, and by
food infection."
Typhoid Fever at Broken Hill. — This year again
there were a number of cases in this city whioh has
be^n notorious as a hot-bed of the disease for a
number of years. The department, both two years
ago and again this year, offered the citizens of
Broken Hill free inoculation against typhoid fever,
but the offer was not taken advantage of. In
another country town, Forbes, which has been badly
affected with typhoid fever for several years, anti-
typhoid inoculation has had a satisfactory result, the
number of cases reported this year and in 1915 from
Forbes having shown a considerable decrease.
In the metropohs an extensive outbreak of typhoid
fever which occurred at Alexandria appeared to be
chiefly due to total lack of sanitary precautions on
the part of certain householders. Another outbreak
occurred at Botany, and an investigation made by
the Acting Medical Officer of Health points to the
infection of the fifty-two cuses which comprised the
outbreak being due to a typhoid " carrier " case at
a dairy in that district.
Diphtheria. — The incidence of diphtheria, which
has been increasing steadily in New South Wales
for eight years, was again higher than ever, and the
number of cases notified, namely 6,588, was greater
than that of any previous year. Towards the close
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1920.
of the year there was some indication that the
epidemic had begun to decline.
The disease was prevalent throug'hout the metro-
polis. It should be noted, however, that diphtheria
is not one of those diseases which depends for its
spread upon the prevalence of insanitary condi-
tions. Like scarlet fever, it is a disease the infec-
tion of which is disseminated by personal contact.
The infective germ of diphtheria may be carried in
the throat of an individual who is not himself suf-
fering in any way, but who is nevertheless liable to
spread the infection.
Infantile Paralysis. — Quite a disturbing little out-
break of infantile paralysis occurred during the
summer months^ — 294 cases were notified, of which
181 were in the metropoHs. This disease is a sea-
sonal one, and affects people during the summer
months, in opposition to cerebrospinal meningitis,
which is chiefly a winter disease. Although the
prevalence of the disease reached alarming propor-
tions during one part of the summer, the outbreak
never approached the intensity to which it attained
in New Zealand, where, with a. Jittle above half
the population of New South Wales, the authorities
had to deal with over 1,000 cases.
During the epidemic a rumour caused many
persons to think that infantile paralysis was a
associated with the seaside. In order to
jh the fallacy of such a belief, special investi-
gations were undertaken by the medical officer of
health. These fully demonstrated how erroneous
the supposition was.
Cerebrospinal Meningitis. — The outbreak which
began in 1915 continued during the current year,
but with less severity than in the preceding year.
To a great extent it was confined to those districts
in the immediate vicinity of military camps ; and in
several instances in which outbreaks occurred in
districts remote from such canips, infection was
traced to soldiers who had visited the district a few-
days before. This is another of those diseases in
which " carriers " are more numerous than pereons
actually suffering from the disease, and are probably
in many instances the source from which infection
is derived. During 1OT5 and 1916 outbreaks of
cerebrospinal meningitis were common all over the
civihzed world, and New South Wales was not
exceptional. The other Australian States also
suffered considerably.
Small-pox
I'or the fourth year consecutively smaJl-pox con-
tinued in New South Wales, but the epidemic
showed evident signs of disappearance. No cases
occurred in the metropolitan district after the
middle of the year, and from September 19 there
was a complete cessation of cases, the indications
being that the epidemic was at an end. Howevei-,
early in December a case was notified from Coon-
amble, -Mid there is reason to believe that the
disease had been lurking in the district known as
the " Pilliga Scrub." The characteristics of the
malady continued to conform to the mild type
experienced from its first appearance in 1913. No
deaths were recorded.
During the year several prosecutions were found
necessary owing to neglect on the part ot patients
or their friends to notify that they were suffering
from small-pox, or owing to careless exposure in
public places of persons who were suffering from
the disease. In four instances heavy penalties were
inflicted by the magistrates.
One hundred and seven cases of small-pox were
recorded for the year. The decline of the epidemic
in this State was signahzed on January 14 by the
discontinuance of the medical inspection of Sydney
passengers in the neighbouring State of Victoria ;
and all quarantine restrictions against Sydney were
lifted iij Samoa and Fiji on November 2.
Throughout the disease has continued to be the
very mild type of small-pox introduced from Canada
in 1913. It has proved itself to be no more deadly
than chicken-pox, and its behaviour during a period
of nearly four years makes it tolerably clear that no
increase of virulence need be anticipated.
Lady Edeline Hospital for Babies.
During 1916 very good work in saving babies was
done; 241 babies were treated, of whom 181 were
discharged cured. The highest number in hospital
— 43 — was in January, when there was an epidemic
of gasti-o-enteritis of a very severe type.
In the summer of 1916, up to the end of Decem-
ber, there was very little gastro-enteritis as com-
pared with the same period of 1915. This may be
the result of the establishment cif baby clinics in
eleven of the more congested of the metropolitan
districts. Nui"ses from these clinics constantly visit
mothers, and impress upon them tlie iiujiortance of
careful feeding and scrupulous fleaiiliness in lear-
ing their babies.
By means of these district clinics the matron ot
the Lady Edeline Hospital is able to keep in touch
with babies after their discharge from hospital.
Many of the babies admitted to the hospital arc
sent in through the baby clinics, particularly cases
of gastro-enteritis, bronchitis, pneimionia and inal-
mitrition.
Convalescent Hospitals.
Over 1,000 patients have been admitted to these
homes since they were established in 1914. The
majority of the patients are received from the acute
medical and surgical wards of the metropolitan
hospifals. Occasiona.lly subacute and chronic cases
are admitted for short periods. In all cases the
I)atients are greatly benefited by tbeir residence at
these hospitals, which is usually about four weeks,
extensions being made for exceptional cases.
Persons suffering from infectious or inciuable dis-
eases are not eligible foi' admission, as the homes
are intended for j)atients c()M\ alesuent from serious
illness, or for those pei-sons whose health has been
seriously impaired or weakened, and who are likely
to be benefited by rest and change.
I
V
May 15, 1920.J COLONIAL MEDICAL REPORTS.— NEW SOUTH WALES.
Colonial Medical Reports.-No. 109.-New South Wales
(cvntinued).
Pulmonary Tuberculosis.
Tuberculosis was proclaimed in 1915 a notifiable
disease in the Metropolitan and the Hunter River
Combined Districts, from August of that year, and
regulations were issued for its control there. These
districts embrace the two largest centres of popu-
lation in the State, and include the greater number
of consumptives. The object in confining noti-
fication to these areas was to ascertain in the first
instance how the Act and Regulations operated, as
the wish was to avoid inflicting hardships upon
those members of the community who had been so
unfortunate as to conti-act the disease. As a result
of the e.xperience gained, operation of the Act was
extended to the Blue Mountain Shire and Katoomba
Municipality from October 2, 1916, as these districts
are the resort of a large number of consumptive
persons. So far no complaints have been received
of any harshness caused in the administration of
the Act, and considerable progress has been made
in safeguarding the public from the likelihood of
acquiring infection. When conditions become more
settiled it is proposed to extend the provisions of
the Act to the whole State.
It is proposed to establish a central bureau under
this department, which would either see or would
have medical evidence before it in regard to all
notified cases of consumption. It could then
arrange for treatment of the more advanced cases
in one institution, whilst other less advanced cases
holding out more hope of complete cure could be
accommodated in sanatoria elsewhere. Patients
I well on thb. road to recovery could be occupied out-
side of institutions in selected districts where the
conditions appeared to be such as would expedite
their restoration to normal health.
This classification of cases is a matter of very great
importance, for, as emphasized by Dr. H. W.
Palmer in his report on Waterfall Sanatorium, the
gradual collection there of a large number of
advanced cases prevents the institution from cairy-
ing out its true functions, namely, the providing of
early care and attention for patients who under such
conditions have a prospect of more or less complete
recovery. He again points out that hopeful cases
cannot be satisfactorily or economically treated
alongside dying patients, and that as the latter
become innre numerous favourable sanatorium con-
ditions become more and more impossible.
In fighting consumption the principal weapons
are : First, education of the public to the dangers
of the disease, and the necessity for personal
hygiene. Secondly, compulsory notification and
registration of all cases of tuberculosis to permit
of surveillance in order that the danger of spread
of infection liy tlicm may be reduced to a minimum.
Thirdly, proxisiun in suitable localities of sanatoria
for the treatnioiti of early cases or recovering oases
of the disease. Fourthly, provision for the chronic
incurable cases in special hospital near the city,
where they can be frequently visited by their
I'elatives and friends.
Microbiological Laboratory.
A very large nimiber of examinations were made
in connection with typhoid fever and malaria. In
addition a large number of tissues were examined
for cancer and other disease processes, whilst foods
and disinfectants of various kinds have been sub-
mitted from time to time for bacteriological exam-
ination. A large number of vaccines were also
prepared for human diseases for curative purposes,
the results in some cases being very striking.
Dengue Fever. — Probably the most important
work carried out by the laboratory during the year
was an investigation into the means of spread of
dengue fever on the north coast of New South
Wales. , By means of mosquitoes caught in the
infected area and transmitted to Sydney, the
disease was conveyed to four individuals in Sydney,
thus establishing the fact that dengue is spread by
the yellow fever mosquito Stegomyia fasciata.
Though dengue does not occur in Sydney, its occur-
rence in epidemic fonn in our northern coastal
towns leads to great disorganization of business and
much commercial loss. Now that it is known
definitely that the yellow fever mosquito, Stegomyia
fasciata, is a transmitting agent, systematic
measures may be adopted to destroy the breeding
places of this pest and to prevent its entrance into
houses. In this way, with intelligent co-operation
between municipal authorities and the public, the
occuiTence of future epidemics of the disease should
be capable of prevention.
Anti-typhoid Vaccine. — During the year anti-
typhoid vaccine were prepared and supplied chiefly
to the military authorities. The value of this pro-
tective measure is hardly realized by the general
public, and it is regretted that so few country towns
have accepted the department's offer to supply
sufficient anti-typhoid vaccine to protect all the
inhabitants of the district. In those districts whicli
did accept the offer there has been a great diminu-
tion in the yearly number of typhoid cases.
Venereal Diseases.
This important subject has had the department's
most serious attention, and a Select Committee has
been appointed by Parliament to inquire into the
best method of combating them.
To persons not acquainted with the difficulties
of such a coin-se notifioation seems to possess the
most effective first measure to be adopted, but the
English Royal Commission on Venereal Diseases,
which presented its report, in 1916, took a great
deal of evidence bearing upon notification, and
after the most careful and even anxious considera-
tion members of the Commission unanimously
decided not to recommend any system of noti-
fication, even of a confidential nature. In many
quarters this decision caused great disappointment.
Tiio chief roHsons to he iirgrd for and against noti-
fication arc fluif it has been apphcl to one infcc-
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE. [May 15, 1920.
tious disease after another, with great benefit to
the pubhc health in such diseases as typhus and
typhoid fever, small-pox, scarlet fever, and diph-
theria. In tuberculosis also it is proving of great
value. Notification tends to check the dissemina-
tion of these diseases, because it affords the oppor-
tunity of isolation of cases of acute infectious
fevers soich as scarlet fever; which can be arranged
for, either in a fever hospital or at the patient's
own home, and, if necessary, certain measures of
isolation enforced respecting those who have been
in contact with such cases ; also on recovery of
the patient measures of disinfection are duly
carried out.
Such measures are not applicable to venereal
diseases, as these diseases are not infectious in the
sense in which epidemic fevers are. Venereal
diseases are contagious, the infection is not diffu-
sive, is neither air-borne nor water-borne, and
while it is necessary that the patient in the infec-
tive stages should avoid certain kinds of physical
contact, and that articles contaminated by him,
such as drinking vessels, should not be used by
others, there is no need for isolation, which is
frequently as impracticable as it is unnecessary.
Nor is disinfection apphcable to venereal diseases,
for it is the patient who needs to be disinfected,
not his surroundings, and the only way of disinfect-
ing him is to cure him. This can only be accom-
plished by rendering accessible to him the best
means of treatment, whatever his circumstances,
and by bringing him to realize the grave and irre-
mediable consequences of neglecting to use them.
To attain these ends the patient must feel assured
that the nature of his complaint will be kept secret.
The most effective method of dealing with these
diseases will be by obtaining the co-operation of
public hospitals throughout the State in regard to
treatment of such patients, and measures ia this
direction are in contemplation.
I am convinced that the difficulty is not in
inducing persons suffering from these diseases to
submit themselves for treatment, but in securing
the co-operation of hospitals, and provision of
funds for the establishment of clinics for their
treatment in convenient and suitable localities.
Mosquitoes and Spread of Diseases.
The introduction into New South Wales of
several cases of malaria by means of returned
soldiers, the opening of the Panama Canal, where
yellow fever is endemic, and the occurrence on the
northern rivers of an outbreak of dengue, focused
the attention of the department upon mosquito-
borne diseases, and it has in conjunction with the-
local Government department formulated a code of .
ordinances under the Local Government Act, which
enables a municipality to enforce an anti-mosquitn
campaign within its district.
Curing Wounds by Open-air Treatment.
The department by circulars directed the atten-
tion of the various country hospitals to the success
obtained from the open-air treatment of wounds.
Sir Almroth Wright, Consulting Physician to the
British Expeditionary Forces in France, has
demonstrated during the war that Septic wounds
improve rapidly with open-air treatment, and the
climate here is even more suitable than the climate
of England for the caiTying out of such treatment.
The "First Eastern General Hospital," at Cam-
bridge, was specially designed for the carrying out
of such treatment, and the building is a very in-
expensive one, as each ward has only three walls,
the fourth side being open to the weather, and even
the back wall has a large aperture protected by
louvres to enable a very free circulation of air.
Adulterations. — These included some curious
examples, a few of which may be considered of
sufficient interest to mention here. A ground
coffee submitted was found on examination to con-
sist largely of roasted beans or peas; a sample of
pepper contained as high as 60 per cent, of ground
shell or stones from some fruit or other seed ; and
a "blackberry" jam • contained no blackberries
whatever, but consisted of apple pulp artificially
coloured.
Many of the cordials- and soft drinks prepared
and sold in country towns were found to be so
dirty as to be unfit for consumption. This was
probably largely due to the lack of efiBcient filtering
apparatus.
A great many drugs, patent inedicines, pills, &c.,
were examined' during the year. Several much-
advertised " flesh-formers " and " fat-producers "
were proved to be worthless for the purposes for
which they were sold. A couple of astonishing
examples of the effrontery of the people who adver-
tise and sell " cure-alls " were found in an " appen-
dicitis cure," which was prepared from & mixture
of cream of tartar, carbonate of soda, and tartaric
acid; and a cancer cure, sold at a high price, which
consisted simply of a weak solution of chloride of
gold.
An article of especial interest submitted by the
mihtary authorities was an alcoholic liquid equal in
strength to rum, which had been prepared by a
member' of the German Concentration Camp by
means of an illicit still made in the camp itself.
An interesting investigation was carried out with
the object of ascertaining the radio-activity of the
Moree Artesian Bore water. This water flows from
the bore with a temperature of, approximately,
112° F., and is used in the baths for the treatment
of various complaints more or less of a rheumatic
character and for stiffness of the muscles and
joints. It is reputed to be very efficient for this
purpose, and it has been suggested that its efficacy
is partly due to thfe presence of radio-active matter.
The result of the examination showed that the
amount of radio-active substance per litre of water
was equivalent to that derived from one ten-
millionth of a milligram of radium.
The most interesting of the criminal investigation
cases were those submitted in connection with the
I.W.W. charges, for which about twenty different
exhibits were examined. The articles used for
incendiary purposes consisted of cotton waste im-
May 15, 1920.;
COLONIAL MEDICAL REPORTS.— NEW SOUTH WALES.
pregnated with nitre, the ignition being caused by
the application of a mixture of carbon-bisulphide
and turpentine containing phosphorus in solution.
The majority of the deaths by poisoning investi-
gated were found to be due to the use of strychnine.
One case recorded was due to oxalic acid, and
another remarkable ease was that in which a
woman died from drinking ordinary bottled beer
which contained pot^assic cyanide. No evidence
was adduced to show how the cyanide found its
way into the beer.
Thomas Cooksey,
Government Analyst.
Pure Food Act, 1908.
Milk Supply. — The supervision of the handling
and distribution of milk has received particular
attention. About 8,262 samples of milk have been
procured from milk vendors, all of which have been
tested by the Government analyst. Special in-
spections have also been made of premises used
for the storage and distribution of milk. In this
connection may be mentioned the action taken
during the past twelve months against the keepers
of restaurant and refreshment rooms for serving
milk to customers, either for drinking or for con-
sumption with other beverages, adulterated with
large percentages of water.
Milk Receptacles. — Attention is constantly given
to the state of cleanliness of milk receptacles used
by dairymen and milk vendors. One practice that
the department is determined must cease is the use
of rusty and worn-out lids, under which rags are
frequently placed to prevent leakages. Wherever
this insanitary condition has been found, the re-
ceptacles have been seized by the Pure Food
Officers and destroyed, proceedings also being taken
against the users. Occasionally it has been found
that traders had stopped the holes in their cans
with rags, soap, or similar material.
Bread. — The subject of bread delivery and the
premises of manufacturing pastrycooks has received
special attention, a thorough inspection being made
j of all such premises. In maJiy oases, it was found
necessary to prosecute traders in a large way of
business.
The question of bread delivery also received
attention, and has resulted in very great improve-
ment. Prosecutions were taken on several occa-
sions against careless carters for failing to protect
bread from dust whilst delivering to customers.
The former general practice where carters carried
bread on the footboard of their carts within a few
feet of the horse, and unprotected from dust, has
now almost wholly ceased. The regulation dealing
with this subject provides that all food consumed
iti the S'ame state as it is sold shall be at all times
protected from flies and dust until delivered to the
purchaser.
Damaged and Deteriorated ■ Food. — Special ex-
aminations are made of food-stuffs exposed for sale
in aiiction rooms, elsewhere by auction, and also
of salvage goods. This close supervision is essen-
tial from the fact that it is frequently foods
damaged by fire or water which are disposed of in
this manner. During the year the officers of this
branch have examined many tons of assorted
groceries in auction rooms and elsewhere, with the
result that the following, among others,- have been
seized and destroyed : Mixed groceries, preserved
fruits and dates, butter, salted fish, flour, salt,
rice, sugar, tomato pulp. Other articles of food
seized and destroyed included meat, vegetables,
13,198 tins and 58 cases of fish, 702 tins and 83
cases of preserved fruits, and 36,067 bottles of
patent medicines.
This work is of special importance, for it is safe
to say that prior to the passing of the Pure Food
law such goods found their way to the cheaper
restaurants or to sauce, jam, or pickle factories.
The examination of salvage goods from one fire
alone necessitated a considerable amount of work
aiKl resulted in over 50 tons of damaged food-
stuffs being sent to the garbage tip. Iricluded in
the condemnations were 31 tons of dried fruits,
13 tons of tea, 1:^ tons of breakfast foods, and 50
cases, 2,500 boxes, and 698 tins of other assorted
groceries.
Ice Cream and Ices. — During the year there
have been several inspections of premises where
ice cream is prepared, resulting in the prosecution
of some eighteen traders for selling adulterated ice
cream. The examination showed that the " ice
cream " was either deficient in milk-fat, or was
the article commonly known as "ices," fraudu-
lently sold as "ice cream," there being a distinct
difference between the two articles.
Premises Used for Preparing Food. — During the
year inspections have been made of factories and
other premises used in connection with the pre-
paration and storage of food. Many traders have
been prosecuted for not keeping their premises in
a cleanly and sanitary condition, and have been
fined.
Fruit Barrowmen. — Prosecutions were taken
against barrowmen who were found selling fruit
unfit for human consumption. In some cases the
whole of their stock was seized and destroyed.
During these inspections it was noticed that dirty
rags were used for the purpose of polishing the
fruit; and in one instance a trader was found using
a soiled handkerchief.
The fraudulent practice of " topping up " fruit
must be stopped. In many cases it was found that
traders were exhibiting a good quality of fruit, and
selling fruit which was decomposed and unfit for
consunlption.
Manufacturing Confectioners. — A detailed in-
spection has been made of premises used for the
manufacture of sweets and confectionery ; at a few
premises the whole interior of the building, includ-
ing walls, benches, floors, and utensils were foimd
in a dirty condition. Attention has also been given
to the fruit products used in such manufacture,
and many traders were found using damaged and
deteriorated fruits for trade purposes.
Jam Manufactories. — In a few instances very
40
THE JOUBNAL OF TBOPICAL MEDICINE AND HYGIENE. [May 15, 1920.
unsatisfactory conditions were found to exist, some
of our largest traders being found guilty of wilful
neglect, not only in connection with the general
condition of the premises, but also in regard to
deteriorated food products stored thereon.
Fish and Smallgoods Shops. — The sanitary con-
dition of these premises received considerable
attention, and many notices were served requiring
structural alterations; where dirty and insanitary
conditions were found the traders were prosecuted.
Falsely described Remedies and " Cure-alls." —
Four traders in a large way of business, making a
speciahty of so-called "flesh foods," were pro-
ceeded against for selhng "flesh-forming tablets."
Medical evidence was produced, and the pro-
prietors were fined.
Another " herbalist," advertising a so-called
blood purifier, claimed to have cured hundreds of
patients suffering from various diseases. This man
was fined for selling a falsely described article, and
also for manufacturing drugs under filthy con-
ditions.
Food Inspection on Transports. — Stores and food
supphes on evei^ transport which has left New
South Wales during the year have been examined,
and, where necessary, seized and removed when
unfit for consumption. The result of this inspec-
tion has been very beneficial, for in no instance
has it been necessary to take legal proceedings.
Arthur Kench,
Chief Inspector, Pure Food Branch.
Cattle Slaughtering and Diseased Animals and
Meat Act, 1902.
During the early part of the year pleuro-
pneumonia was very prevalent among dairy herds,
but owing to the action of the Dairymen's Associa-
tion in arranging for their secretary to inoculate all
cows on dairy premises, it has now practically been
stamped out. All the cows at the institutions under
the supervision of the Board of Health have been
inoculated.
Contagious mammitis is now making headway
among dairy stock, and arrangements are being
made to cope with this outbreak of the disease.
Veterinary oflicers of the Meat Industry Board re-
port large numbers of affected cows passing through
Flemington sale-yards. Should the disease become
prevalent a very serious st.ate of affairs will arise
as the city's supply of fresh milk will be appreciably
affected.
Report of the Chief Sanitary Inspector.
Several smaU outbreak* of infectious diseases
occurred during the year. A young man who was
suffering from scarlet fever at a private hospital in
the metropolitan area left the hospital while s.till
infectious and visited a friend, who was enjoying a
holiday with his family at a seaside resort. A young
daughter of the family contracted the disease. On
receipt of complaint the matter was investigated.
and the young man prosecuted by the inspecting
officer for exposing himself in a public place while
suffering from an infectious disease, and fined.
As instances showing the effectiveness of enforcing
sanitary measures such as efficient sanitary and gar-
bage services, improved w:iter supply, propel- con-
struction of closets, cleanliness of dwellings and
yards, protection of food from dust and flies, storage
and removal of manure and other waste matter, &c.,
it might be mentioned that several country towns
where typhoid fever was usually prevalent in sum-
mer months are now comparatively free from that
disease.
With a view of inducing the residents to reahze
the importance of systematic destruction of flies,
several local authorities are giving much publicity
in their districts to the part played by house-flies in
spreading disease, and the measures to be taken for
control and eradication of the pest.
At Narrabri the local sanitary inspector refused
to be vaccinated, and as his work included disin-
fection of infected premises he contracted small-pox.
Before going to the hospital, however, and while in
an infectious state with the rash well-developed, he
continued to carry out hisi usual duties in addition
to acting as ticket collector at a concert held at the
Town Hall. When the matter was reported to the
Board, the Chief Sanitary Inspector was instructed
to prosecute, and the local coxmcil's inspector was
fined for exposing himself vihile suffering from an
infectious disease, .\nother local resident who con-
tracted small-pox and escaped from the hospital one
night to visit his friends, was prosecuted on the
same day and fined on a similar charge.
The number of rats caught on the wharves from
fumigated ships and similar sources totalled 7,943.
.\11 rats caught were examined at the Microbiological
Ijaboratory, and none found infected with plague.
Private Hospitals Act, 1908.
No private hospital is now allowed to be carried
on until there has teen a proper inspection of the
premises and investigations made as to the suit-
ability of the proposed licensee and resident mana-
ger. All private hospitals throughout the State are
suhject to inspection at all times by an officer
authorized by the Board of Health.
When this Act first came into operation it was
recognized by the Board that a certain amount of
consideration had to be given to persons who had
conducted such an establishment for perhaps many
years prior to the passing ai the Act ; but since
July 1, 1910, the Department insists that as far as
possible premises shall be struct?urally suitable, and
that the resident managei"s shall comply with the
requirements as to personal qualifications.
During this year, owing to the scarcity of trained
nurses, arrangements slightly less strict have been
made in order thflt hospitals -ilready established shall
be conducted under the circumstances as efficiently
as possible. These arrangements are only tem-
porary, and as soon as possible reversion will he
made to pre-war conditions.
li
June 1, 1920.J COLONIAL MEDICAL REPOJaTS.— NEW SOUTH WALES.
Colonial Medical Reports.— No. 109.— New South Wales
{continued).
The police were frequently called upon to inspect
hoepitals and submit information concerning then)
in accordance with a detailed report supplied by this
Departmeiit, pending a visit from a medical officer
of the staff. In the metropolitan area many of the
hospitals have been inspected, and also those in
! some country towns when opportunity offered.
Hospitals in which a septic puerperal case has
i occurred are prohibited from receiving any addi-
i tional lying-in case, pending the enforcement of
certain regulations; as a consequence, no second
I case was infected in any hospital.
I All births and deaths which occur in private hos-
i pitals must be reported within twenty-four houre.
i Further, in compliance with the definition of birth,
1 all miscaiTiages or stillbirths are reported.
Very few infectious cases are received by private
] hospitals owing to the necessity for the provision of
a building approved by the Board. There is doubt-
j less room for hospitals suitably equipped for these
I cases in many large country towns, but the demand
j is especially insistent in the metropolitan area.
Metropolitan Combined Districts of Sydney.
The population of the metropolis proper (Sydney
and suburbs) was estimated by the Government
' statistician to be 764,600 on December 31, 1916, of
j which the City of Sydney contained 106,000, and
I the suburbs (including the shire of Kuring-gai)
\ 658,600.
! The mean population for the year was estimated
to be 763,800. In this report the estimated popu-
I lation figures have only been departed from in the
j municipalities of Hunter's Hill and Letehhardt,
i since each contains large mental hospitals. As in
; fonner reports, deaths among iinnates of these
, hospitals have lieen distributed to the districts in
I which they had previously resided, and consequently
I it was necessary to exclude such inmates from the
j estimate of the population. The hospitals in ques-
' tion were (Jladesville (1,2.57 inmates) and Callaii
i Park (992 iinnates).
I The number of Ijirths registered in the metro-
I poLis during the year was 20,856, equivalent to a
i rate of 27-31 per 1,000 of the population. The
I number of births was fifteen below that of the year
1915, which was) the highest ever recorded in the
metropolis. The rate is 4 per cent, below the
average of the preceding five years, and is the lowest
since 1910.
The numljcr of illegitimate children born during
the year was 1,334, or 6-40 per cent, of the total
I births, and equivalent to 1-75 per 1,000 of the popu-
! lation. Of these children, 57-6 per cent, were bai-n
j in public institutions.
I The recorded deaths of residents in the metro-
I polis, after correction for institutions, totalled 7,800,
' equivalent to a rate of 10-24 per 1,000 of the popu-
' lation. This rate is 2 per cent, below the average
of the previous five years.
Meteorology.
The mean temperature of the air in Sydney dur-
ing 1916 was 63-4 degrees Fahrenheit, which is 04
degrees higher than the mean of fifty-seven years'
observation. The mean temperature was above the
average, except in the months of March, April,
October, November, and December. January, Feb-
ruary, and December were the warmest months of
the year, whilst July was the coldest.
The rainfall for the year was 3-161 inches below
the average of fifty-seven years. The months of
Aprii, September, October, and December showed
a rainfall above the average, October exhibiting by
far the heaviest rainfall of the year.
Scarlet fever was most prevalent in the months
of May and August, and least so during the months
of June and December.
Diphtheria was slightly more prevalent in 1916
than during the previous year, the attack rate being
3-39 per 1,000 of the population. The monthly
numbers of cases notified were highest in March,
April, and May and lowest in October, November,
and December.
Typhoid Fever. — The largest number of cases re-
ported for any municipality during the year was
eighty-three from Alexandria.
This outbreak was, in my opinion, due to grossly
insanitary conditions in certain streets of the muni-
cipality, caused chiefly by the utter lack of sanitary
sense on the part of inhabitants. Energetic action
was taken by the local sanitary inspector with most
beneficial results.
Fifty-two cases were notified from the munici-
pality of Botany, and, in my opinion, many of these
were due to infection from the dairy conducted by
^Xrs. D , owing to the presence of another car-
rier on the premises. (This dairy was the cause of
an outbreak in the previous year.) It is interesting
to note that as the result of the vacation of this
dairy by certain members of the family the cases
decreased in numbers. However, the family con-
cerned moved to the municipahty of Ryde on ceasing
to reside at Botany, with the result that a smaU
outbreak occurred in Ryde. On investigation, this
second carrier was detected and removed from the
district with dramatic results in the decline of the
immber of cases. This carrier is being kept under
observation, and strict precautionary measures have
been taken with respect to such person.
Tuberculosis.
The number of deaths from all forms of tubercu-
losis in the metropolis proper during 1916 was 558,
of which 489 were due to tuberculosis of the lungs,
29 to tubercular meningitis, and 40 to other tuber-
cular diseases. The total does not include 65
deaths from phthisis which occurred in the Bene-
volent Asiylums, all former metropolitan residents.
When these figures are included the total deaths
from phthisis for the year were 623.
THE JOURNAL OF TllOPICAL MEDICINE AND HYGIENE. [June 1, 1920.
Infantile Paralysis.
This disease occurred in epidemic form in New
South Wales during the early part of the year, result-
ing in the. notification of 186 cases within the metro-
politan area for the year 1916, which is by far the
largest number reported since the disease was
declared a notifiable one.
The epidemic actually began in December, 1915,
and persisted through 1916 during the months of
January, Februai-y (maximum), March, and April.
A rapid dechne occurred in the months of May and
June, subsequent to which months the epidemic
practically ceased.
The press gave prominence to the epidemic, and
numerous theories as to the causation oi the disease
were put forward, one of which sought to imphcate
more particularly the marine suburbs and the prac-
tice of sea-bathing. As the result of a special in-
vestigation made in connection with each case re-
ported in the metropolitan area, the above theory
could not be substantiated.
Featuresi of interest in connection with the
ep-demic were the facts that the rainfall during the
months of January, February and iMarch wee below
the average, and that the mean temperature in the
shade was above the average during the months of
January and February. It will thus be seen that
the epidemic was at its height duiang a warm, dry
and dusty season.
Outbreak of Mild Small-pox in New South Wales.
During 1916 New South Wales continued to be
affected by the mild type of small-pox which was
introduced from Canada in 1913. The outbreak
steadily declined throughout the year.
A question which here presents itself as worthy
of very serious consideration is the following.: Are
the health authorities of New South Wales justified
in further maintaining their attitude oif special
watchfulness against this particular form of small-
pox ; is it necessary or desu'able to continue the
campaign, which it must be remembered is a fau'ly
expensive one, against a disease which is after all
no more deadly than chicken-pox? For that is the
plain truth about this particular type of small-pox,
which invaded New South Wales in 1913, and is still
existent in some parts of the State. Among the
2,275 cases which have come to the knowledge of
the authorities up to the close of the year 1916,
there have been but four deaths recorded, and in
each of these four instances there was some other
condition existing concurrently with and independent
of the disease small-pox, which was in itself suffi-
cient to account for death.
At the time of the first introduction of the disease,
and for many months afterwards, there can be no
question that the proper attitude of the health
authorities was that actually adopted by them. The
disease responded to every clinical and scientific test
for small-pox which could be applied to it. It was,
in fact, small-pox, and although after a few months
the fact emerged that the type of the disease was
extraordinarily mild, the authorities were by no
means convinced that it would continue so.
But the behaviour of the disease during a period
of nearly four years has made it tolerably clear
that no increase of virulence is to be reasonably
anticipated. The epidemic of small-pox id New
South Wales to-day is as regards virulence and
clinical features unaltered from the type of the
disease that was introduced early in the year 1913.
The principal arguments which justify a con-
tinuation of the efforts of the health auhorities to
stamp out this disease may very briefly be stated.
In many instances the effects of attacks of this
mUd form of small-pox have been very disfiguring.
Except in the mildest cases the complexion and
features of women who have undergone attacks have
been permanently disfigured in a greater or lesis de-
gree. The disease also tends to produce abortion
when it attacks pregnant women. Add to these
facts that the eruption is a very loathsome one, and
that a great deal of pain and discomfort precede
and accompany an atta-ck, and a fairly good case
emerges for the enforcement of strong repressive
measures. Finally the attitude of the adjoining
States of the Commonwealth has no little bearing
upon the question. They have all apparently
escaped infection so far (probably because they are
better vaccinated than New South Wales), and they
are naturally apprehensive of invasion from this
State, and would strongly resent any slackening of
the precautions which are being taken to check and
limit the spread of infection here.
The supply of anti-typhoid vaccine for military
purposes was continued as previously, and the pro-
tective value of this vaccine appears to have been
very satisfactory.
Actinomycosis. — One of three specimens consisted
of an actinomycotic abscess in the submaxillary
region of a cow. The second case consisted of
lesions in the face of a human being strongly sug-
gestive of actinomycosis; the result was nes^it'^'^'-
The face was greatly disfigured by extensive tun-
nelling sinuses discharging watery pus. There was
much induration and a reddish discoloration over
the bridge of the nose, the sides of the face, neck,
&c. The bridge of the nose was depressed, which
the patient said was the result of a blow in boxing.
There was a strong ozaena smell. Cultures revealed
the presence of ordinary pyogenic organisms and a
vaccine made from these very greatly ameliorated
the condition of the patient. It seems clear, there-
fore, that there could have been no actinomycotic
basis in the c^se. The third case was pus from the
rectum of a youth which also proved negative.
Anthrax. — Specimens from six suspected cases
of anthrax in man were submitted. The materials
from four cases proved negative. In the case of a
typical mahgnant pustule from the right forearm,
which developed in a man employed at a hide and
wool store in Sydney, anthrax bacilli were detected.
In another specimen diagnosed as a malignant pus-
tule, received from Tarn worth in February, micro-
scopic sections showed a number of anthrax bacilli.
June 1, 1920.]
COLONIAL MEDICAL REPOKTS.— NEW SOUTH WALES.
Favus. — Thiu oonsisited of a mouse forwarded
from Coonabarabrau. There were exteneive favus
cups on the left side of the head.
Malaria. — ^A number of blood films were sub-
mitted from persons who had returned from malarial
districts, and had symptoms suggestive of the possi-
bility of the continuance of a previous malarial
infection. In a certain number of cases, the indi-
viduals concerned were desirous of enlisting, but
haviiig been previously in a malarial district, ex-
amination of the blood was required before accept-
ance. Though examinations in these cases might
prove negative, and yet the patient still have a
latent infection, these examdniations were conducted
in the hope that some at least of such infections
might be detected. Thirty-two of the total cases
proved negative, and five showed the presence of
malarial parasites. Of these five cases, one had
contracted the disease at Rabaul, New Gruinea,
.eighteen months previoujsly and had been away
from the Tropics for ten months. A second case
contracted his disease in the Soloinon Islands ; a
third, in which crescents were numerous, was in-
fected in the Northern Territory ; a fourth case was
a woman who received the infection in Malaya —
she had been away from a malarial district for four
months — whilst there her husband had contracted
malaria, but she herself had not manifested any
signs of the disease until after she had left the
distriot.
Tetanus. — Of three cases in which tetanus was
suspected, the organism was found and grown from
one, the specinaen having been taken from a wound
in the foot. Tetanus bacilli were not detected in
the other two cases.
Tinea. — Tinea versicolor was foimd in the scales
from the chest of a patient. In the other case
snippings from the nails did not reveal the presence
of fungal hyphse.
Reseaeches on Plague.
In coimection with routine measures taken for
the detection of the presence of plague and the
prevention of its spread, 7,943 rats and mice were
examined during 1916. Plague was not found in
any of the specimens. The last plague-infected rat
was found at Sydney in April, 1910.
Species of Fleas.
The fleas collected were determined as belonging
to four species: Xenopsylla {Jjicmopsylla) rhfiopin,
Ctenopsylla musculi, Ceratophyllus fasciatus, and
Ctenoce phallus felis (or canis).
Examination of Rats.
The report of a second outbreak of plague at
Sydney, 1902, contains the following statement re-
ferring to all rats examined during the first and
second outbreaks of plague in 1900 and 1902
respectively :
" All the rate received belonged to one of two
species — Mus decumanus and M. rattus. No re-
cord was kept of the actual number of each. In
the whole collection there were about as many of
one as of the other f but M. rattus predominated
among those taken along the shores, and M. decu-
manus among those taken inland. The infected
specimens were all M. decumanus."
Typhoid Fever.
Widal {Agglutination) Reactions.
This reaction was performed on 718 specimens
of blood from 700 different cases during the year.
Of this number 211 were complete positives, while
36 showed strong, but not quite complete, agglu-
tination. Talking these two results together the
percentage of positive results to the total number
of specimens examined was 34'3 per cent.
In a number of cases, when the diagnosis was
obscure, the reaction was repeated, generally after
a week's interval. As a routine procedure, when
the re.sult was incomplete, a fresh specimen was
asked for — in many cases these were not forwarded.
In addition, three specimens were received, one
of which did not contain sufficient blood to enable
an examination to be performed, and the other two
arrived in one box with no marks for identification.
Apparently so far we have no evidence that para-
typhoid fever is endemdo in Australia, or that some
cases diagnosed as typhoid fever are really instances
of this disease. Occasionally sporadic cases do
undoubtedly occur. Thisi matter is worth much
fuller investigation, as unquestionably the data in
our possession are too small to allow of anything
beyond a somewhat vague generalization.
In tlie case of agglutination reactions with B.
paratyphosus A we first used dilutions of 1 in 60,
l)ut later in the year, owing to the agglutinating
titre of this organism being often' low, we instituted
a dilution of 1 in 10 for routine purposes.
Cultures.
Cultures were made from^ urine, faeces, blood,
water, milk, pus, &c., and B. typhosus searched for.
Urine. — iSeventeen routine specimens were ex-
amined, with one positive and twelve negative
results. From one specimen an organism was
isolated w'hich gave the positive sugar reactions,
but did not agglutinate the srt>ock, vaccines. From
three specimens no growth was obtained. Thirteen
military cases were all negatives.
Faces. — Twenty-one routine specimens were ex-
amined. B. typhosus was detected in one case, on
November 30, the blood from which gave a negative
Widal reaction on November 27, and a positive one
on December 14. Three of the abpve specimens
were iiJso examined for B. paratyphosus A and B,
giving negative results in each case. In thirty-two
military cases no B. typhosu.f or B. paratyphosus B
were detected. In one an organism giving the
biochemical reactions of B. paratyphosus A was
isolated — this gave imiperfex-t agglutination at 1 in
60 with the only B. paratyphosus A serum avail-
able, which was of unsatisfactory titre, even against
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1920.
stock culitureB, and it gave a negative reaction at
1 in 60 with B. paratyphosus B serum.
Drainages from Gall-bladders. — Two specimens
from the same case were examined at an interval
of fourteen days. The first specimen yielded an
organism in its suger reactions like B. typhosus,
but of doubtful agglutinability. The second speci-
men faOed to yield B. typhosus. The patient gave
no history or s.ymptoms of typhoid fever.
Note on a Typhoid Carrier with Large Numbers
OF B. TYPHOSUS (?) IN THE StOOLS FOR SeVERAL
Years.
Although this case has not been the subject of
complete bacteriological and other investigations,
the short notes collected from numerous routine
examinations conducted in the laboratory are inter-
esting from several points of view.
The first case came under our notice in January,
1915. He wasi a patient in one of the mental
hospitals. At this institution there had been a
small outbreak of typhoid fever and the present
case, a male, aged 53, was suspected and found to
be a carrier. There was a history of typhoid fever
seven years before.
He was transtferred to the Coast Hospital and
during the subsequent three years his stools have
been submitted for examination fifty-six times.
Except on one occasion when no B. typhosus was
found, posisjbly due to some other organisms over-
growing the plates, B. typhosus has always been
present in large numbers.
We have not always fully tested the organism,
relying on the extremely characteristic fine " blue "
colonies on agar plates, but periodically these
colonies have been more or less fuUy tested and
when so tested always gave the reactions) of
B. typhosus.*
The culture when first isolated by us from this
case produced aoid only on glucose mannite, sorbite,
and litmus peptone water, and produced no change
on dulcite, lactose, cane sugar, and arabinose, and
produced also shght acid on milk and gave a nega^
tive indol test. These reactions were read after
four days' incubation. The cultures subsequently
obtained whenever tested gave similar reactions
although not always tested so completely.
The urine of this case tested on one occasion
contained no B. typhosus.
With tlie kind co-operation of Dr. Wallace, the
Acting Medical Superintendent of the Coast Hos-
pital, it was decided to make an endeavour, by
therapeutic means, to diminish or eliminate the
number of typhoid orgainiams excreted in the faeces
of this patient. With this object in view various
drugs were administered, and milk, soured with
lactic bacilli (butter starters) administered in the
diet. The drugs tried were hexamiti, mercury, and
betanaphthol with bismuth salicylate. In no in-
stauce did the various courses of treatment appear
to have any effect on the number of typhoid colonies
' The agglutination reaction was atypical.
Hexamin. — Though this drug is only sup
to liberate formaldehyde in an acid medium, and
therefore would not be expected to be active in
the pre.sence of alkaline bile, it was, nevertheless,
tried on the off-chance of meeting with conditions
under which it might be operative. From January
■29, 1915, to May 15, 1915 — a period of about three
and a half months — 5 gr. were administered three
timies a day. The drug was discontinued until
September 10, 1917, when a course of 15 gr. four-
hourly was again instituted.
Mercury. — As mercury is a cholagogue purgative
it was thought that if it was administered over a
period of time in doses approximating as nearly as
possible to the amount that would lead to saliva-
tion, but without actually reaching this hmit, it
might be excreted in the bile in sufficient concentra-
tion to exert a deleterious effect upon the typhoid
bacilh present. It was presumed that in this case
in all probability the gall-bladder formed a reservoir
for tile typhoid organisms, and thus kept up the
number of typhoid bacilli found in the faeces. With
this object in view, one-sixth of a grain of calomel
v\ as given three times a day from January 29, 1915,
to May 15, 1915. The same dose was given again
from May 31, 1915, to June 9, 1915, and from
August 11, 1915, to September 13, 1915; i gr. three
times a day was administered from November 4,
1916, to January 6, 1917. From June 9, 1915, to
June 26, 1915, a mixture containing hq. hydrarg.
perchlor. 1 grm., and quin. sulph., acid sulph. dil.
and aqua chloroformi ad 4 oz. was given, the dose
being ^ oz. three times a day.
Betanaphthol and Bismuth Salicylate. From
Augu&t 12, 1915, to November 4, 1916, a powder
consisting of 10 gr. of each of these drugs was
administered three times a day.
Sour Milk (Lactic acid bacilli). — The alleged pro-
perties of milk soured by lactic acid bacilli in
controlling bacterial processes in the intestine sug-
gested its apphcation to the present case. A 6-oz.
medicine bottle full was given daily for about six
weeks from March 3, 1915, and it was administered
again for a few weeks from June 26, 1915.
Agglutination reactions have been performed wiiii
the cultures and with the blood of this case on
several occasions, but as we intend to investigate
this matter fuUy it will not be discussed in detail
here. It will be sufficient to say that so far they
are most contradictory.
The principal interest in the present eommunica-
fioii is found : —
(1) In the peiTsistent and constant presence in
the stools of a bacillus closely resembling, if not
identical with, B. typhosus.
(2) In the fact that the typhoid bacilli usually
outnumber, and often greatly outnumber, the colon
bacilli.
(3) The apparent long duration of the carrier
condition.
The patient physically enjoys the best of health
and is a voracious feeder.
J
June 15, 1920.] COLONIAL MEDICAL REPORTS.— fTEW SOUTH WALES.
45
Colonial Medical Reports.— No. 109.-New South Wales
{continued).
Diphtheria.
Routine Examinations of Swabbinyg.
During the year, 1,925 swabbings were examined
in ordinary routine for the presence of diphtheria
hacilh. In addition, 849 swabs were received from
Ijoys on the training ship Tingira.
Tlie 1,925 swabs were received from general prac-
titioners in the neighbourhood of Sydney and in the
country, from the simaller hospitals, more especially
country ones, and occasionally for diagnostic pur-
poses from small institutions, soldiers in camp, &c.
' The same procedure in their exaimination was
carried out as. in previous years, the cultures being
examined at the end of twenty-four hours, and, if
negative then, again at the end of forty-eight hours.
The staining method adopted was that of Neisser,
chrysoidin modification.
As in previous years, the positive results, have
been again divided into positives after twenty-four
hoursi' incubation, and positives after forty-eight
hours' incubation. Though, in most cases a culture
of forty-eight houre' incubation has been examined
twice, in some instances, ae, for example, in swabs
arriving at the week-end, the cultures have only
been examined once, viz., at the end of forty-eight
hours' incubation. Therefore the positive resiults
under the forty-eight hour division are again divided
into those positive after one examination, and those
only positive after a second examination. As 477
swabs were positive after only twenty-four hours'
incubation, and 118 were negative after twenty-four
hours' incubation, but positive after forty-eight
hours:' inoubation, the value attached to the re-
examination of negative swabbings after further
incubation is again illustrated, as it has been in
previous reports.
During the year the disease was again, as in the
previous year, rather endemic than epidemic, and,
contrary to our experience previous to that period,
there was an increased number of positive cases in
the warmer months rather than in the colder
months of the year.
In a list of cases examined on more tluui one
occasion, five of these castjs were under observation
for from two to three months, one being examined
on fifteen occasions over a period of 163 days, being
positive thirteen times and negative twice.
SwabhnKja fnim ihc T raininij-ship " Tinifna."
We iiave given details in previous reports of
swabbings submitted from boys of this training-ship.
These have i)een taken either with the view of pre-
venting the introduction, by new boys acting as
" carriers," of diphtheria baciUi to tlie siliip, or for
the purpose of diagnosis in eases of suspicious sore
throats. The routine has i)een aflopted of taking,
in each case, one swabbing from the throat and one
from each nostril. During 1916, 41 throat swabs
were found to be positive, 21 suspicious, and 462
negative. Of nasal swabbings, of which, as a rule,
two were taken from eaoh individual, 38 were posi-
tive, 73 suspicious and 622 negative. It is probable
that most of the suspicious organisms were diph-
theroid bacilli. In view, however, of the import-
ance of preventing the introduction of diphtheria,
any case in which organisms were found which,
though by means typical, nevertheless might pos-
sibly be unusual forms of diphtheria baciUi, we-e
regarded as suspicious and precautions! taken.
In one case nine examinations were made from
one individual, extending over a period of three
months. Six of these examinations, including the
ninth, revealed the presence of diphtheria bacilh,
whilst three were negative. Full tests were made
of the organism isolated from the last specimen
submitted, with the result that morphologically
typical diphtheria bacilli were found which gave the
typical " sugar " reactions, but proved non-toxic to
a guinea-pig.
Tuberculosis.
Examination of Sputa for Tubercle Bacilli.
During the year, 1,394 specimens of sputa were
received from general practitioners, &c., to be
examined for tubercle hacilh. Of this number, six
bottles were found to be in a leaking condition,
thus constituting a dangerous menace of infection
to the stafF, and the contents were destroyed with-
out examination. In addition, 884 sputa were
received for the same purpose from the Rookwood
State Hospital and Asylum.
As in previous yeans the percentage of positive
results during the late winter and early spring
months of the year are lower than at any other
period of the year. Comparing a six-monthly period
extending from May to October, inclusive, with a
similar period from November to April, inclusive,
the average percentage is 20-98 in the first instance
and 25-5 in the second.
Routine Complement Fixation Reaction for
Syphilis.
In considering the 886 cases examined during
1916, we have not attempted to make a full analysis
of the figures, and this for several reasons, but
principally be<;ause the historical notes forwarded
to us on the cases tested do not form a reliable
sourcx; of information necessary for a scientific
analyses of our re^sulte. In many cases we had no
reply to our request for historical details, and in
otliers the reply was so meagre as to be useless for
fclie i)urpose.
No definite winchisions can therefore lie drawn
from these figures as to the value of the method
adopted in the diagnosis of syphilis.
It is interesting to note that whereas amongst
the whole series of tests approximately 25 per cent,
show a full ix>sitive reaction, yet there are con-
sid<!rab!e variations in the i)ero^ntage of positives
found in the various classes of patients dealt with.
It is doubtful, however, what these differences
46
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1920.
really indicate, as quite a number of circumstances
may affect the type of cases submitted. Thus,
unless every inmate of an institution be tested it
is manifestly impossible to draw definite conclusions
as to the relative prevalence of syphilis. The type
of institution and the type of patient vs'ill vary the
results greatly.
As. regards cases tested on more than one occa-
sion, 94 were tested twice or more, and of these
75 were tested twice, 10 were tested three times,
6 were tested four times, 3 were tested five times.
Dengue Fever 'in Austraiia.
Its History and Clinical Course, its Experimental Trans-
mission BY Stegomyia fasciata, and the Results of
Inoculation and other Experiments.
(By J. Burton Cleland and Burton Bradley, assisted in the
Inoculation Experiments by W. McDonald, M.B., Ch.M.,
Rookwood State Hospital and Asylum, Sydney.)
Scheme of Presentation of the Results.
Owing to the large amount of data which we
have accumulated in carrying out our investigations
into the nature of dengue fever as met with in
Australia, and the necessity for presenting these
data in full so that they, and our conclusions, may
be subjected to detailed criticism, it has been neces-
sary to adopt a rather unusual scheme of presenta^
tion in submitting our results and conclusions.
Introduction.
Epidemic dengue first reached Australia early in
1885. In the saane year, according to Castellani
and Chalmers in their " Manual of Tropical Medi-
cine," it reached the Fiji Islands, " to which it
was conveyed by a European suffering from the
complaint." As later on in the same year a record
occurs of cases of dengue fever on a steamer which
arrived in Sydney from Fiji and Noumea, it is pos-
sible that the disease reached Austraha from Fiji.
Since this date, from time to time very extensive
epidemics of dengue have occurred in Queensland,
sometimes extending to the northern coastal towns
of New South Wales.
A careful comparison of previous clinical descrip-
tions of the epide-mic disease known as dengue in
Austraha, with the description of the disease com-
piled from various sources as given in Castellani
and Chalmers's "Manual of Tropical Medicine,"
does not reveal anything tangible to suggest that
more than one disease has, up to the present, been
comprised under the term "dengue fever." The
only important clinical difference appears to be that
in the Australian disease, though the pulse varies
more or less with the temperature, it is neverthe-
less relatively slow, and sometimes absolutely so.
Further, the dengue fever met with in Australia is
undoubtedly not indigenous, and as a disease of this
nature, which is confined to human beings, cannot
arise de novo, the dengue fever of Australia must
have had its origin outside Australia, and must be
a disease which has affected from time immemorial
the inhabitants of some other part of the world.
Such a striking disease cannot have escaped observa-
tion and accurate record. It is quite obvious that
it is included under the term "dengue," as this
is used, for instance, by Castellani and Chalmers.
Origin of these Experiments.
In March, 1916, an extensive epidemic of dengue,
then prevalent in Queensland, reached some of the
north coast towns of New South Wales. The in-
cidence on the population was exceedingly heavy,
and business was greatly disorganized in conse-
quence. As the experiments into its means of
spread m Australia hitherto carried out had been
few and inconclusive, it was considered advisable
to visit the area affected and collect material there
for further study of the disease. It was recognized
that if infective material could be conveyed to
Sydney, a town in which indigenous cases of the
disease have never been known to arise, results
might be obtained which would be free from faUacies
attendant on experiments conducted in the epidemic
area. At the beginning of April one of us therefore,
with an assistant, paid a visit to Murwillumbah.
He found that though the chief incidence of the
disease had passed, there were still numerous cases,
and that two species of ^mosquitoes were very
abundant in the town, namely, Culrx fatigans and
Stegomyia fasciata. He collected a number of both
species of these mosquitoes, more especially from
houses in which cases of dengue had occurred and
preferably in the actual rooms of patients then iU
with the disease. In addition he withdraw speci-
mens of blood, some of them being allowed to clot
and some being received in citrated normal saline
solution, from patients suffering from the disease.
The materials thus obtained were brought back to
Sydney.
The failure to transmit the disease by the first
batch of mosquitoes brought down from the epidemic
area led \io another of us with an assistant visiting
in May tJie adjacent town of Mullumbimby, then
suffering hea\^ly from the epidemic. A furtiier con-
siderable number of Culex fatigans and Stegomyia
fasciata were brought back to Sydney, and the
typical disease was conveyed by the bites of the
batch of .S'. fasciata to four volunteers in Sydney,
thus establishing conclusively the role that this
mosquito can play in the spread of the disease.
I. The History of Dengue Fever in Australia, with
a short Summary of the Clinical Descriptions
of Previous Epidemics.^
II. Clinical Description of the 1916 Epidemic of
Dengue Fever on the Nortli Const of Ncir South
Wales.
The facts utilized in compihng this description
v\ere mostly obtained by observations and notes on
■This has been fully dealt with by one of us (J. B.C.) in
the Third Report of the Government Bureau of Microbiology
dealing with the work performed during the year 1912. and
published during 1914 by the Government printer, Sydney.
Those Interested are referred to that report.
June 15. 1920.] COLONIAL MEDICAL SBPORTS.— NEW SOUTH WALES.
47
I
canes seen liy u-i on visits to the infected district,
and l)y sunn oL^. i \ at luiis ou imported, mositly mili-
tary, cases 111 SmIiii \. Thus our description is one
largely of the s.) inp turn ato logy of the illness compiled
from histories given us by patients, who, at the
time, were suffering or had recently sufifered from
the disea^;e. In particular we have little e.xact in-
formation as to the type of temperature or the pulse
charts in the naturally occurring cases, and our
descriptions of these are for the most part based on
observations! on our experimental mosquito-lx)rne
cases, or on what we have been told was the case
by observers in the infected district. We have
availed ourselves also of the excellent description
by Goldsmid and Crosse,^ to which we refer the
reader.
Definition. — ^Dengue fever is an infective, non-
contagious disease caused by an unknowai organism
which may be transmitted by the bite of Stegomyia
fasciata. It is characterized by one or more febrile
paroxysms more or less severe, head and body pains,
and usually by polymorphous skin eruptions.
Incubation Period. — This is approximately one
week (five to nine days). During this time the
patient may feel perfectly well or may experience
towards the end of the period some vague pains,
malaise, headache or sleeplessness.
Onset. — This, in the large majority of cases, is
described as sudden. Frequently the patient will
give the exact hour at which he was taken iU, and
may narrate how before a certain time he was quite
well, and that after an extremely short period, per-
haps half an hour from the first symptom, he was
prostrate with the disease. Out of thirty cases re-
plying to ques'tionis as to the nature of the onset,
twenty-five replied that it was sudden, three that
it was gradual. In two cases tlie replies were
dooibtful.
The onset is usually accompanied by fever, bead-
ache, malaise and slight shivering, and to a greater
or leas extent by 7>ains and aches, which arc very
oharacterltitic in the typical cases. In certain cases
the relationsliip between the fever and other eym-
ptomB i« less definite and the fever may precede
or post-date the other symptoms.
Course. — After the onset the disease runs a course
lasting from a few days to a fortnight or more (four
to seven: days — Goldsmid and Crosse). There may
be two periods of intensity of fever and symptoms,
separated by a period, varying in length but usually
onJy of a day or so, of comparative abeyance of fever
and symptoms, during which the patient may regard
himself a.s well. This double phase is, however, in
our experience, by no m't^ans a constant phenome-
non, and its absence cannot he regarded as militat-
ing against the diagnosis of dengue. Moreover,
especially in mild cases, although a four-hour tem-
jjerature chart may show a distinct double-phase
variation, the «ymptome and temperature do not
always vary -pari passu. In some cases there
■-■ Goldsmid and Crosse, " Some Notes on Dengue." Med.
Joum. of Australia, May 6, 1916, p. 377.
appears to be a tendency to relapse at a later i)eriod,
but we have no very precise information on that
point. In a typical ca,&e, aiter a sudden onset
accompanied by a rapid rise of temperature, shiver-
ing and headache, and oocas.ionally sUght vomiting,
the patient takes to bed with pains in the back and
limbs and severe headache. He passes a very rest-
less night and may be dehrious. He finds it almost
impossible to rest in any position. For the follow-
ing day or so the headache ajid body pains are
worse. The temperature soon falls, and this may
be accomjpanied. by sweating, and the patient gets
up, not feeling very well, and with a dirty tongue
and a residue of pains. . One, two or three days
later the temperature goes up again and the sym-
ptomsi return. The second attack lasts for one or
two days, and then convalescence ensues. In the
stage of onset there is usually an erythematous
blushing of the skin and later on, from the second
to the seventh day, a more distinct rasih frequently
appears.
It will be best now to review seriatim the out-
standing symptoms- and signs of the disease as met
with in the North Coast.
The Temperature and Pulse. — We do not wish to
discuss these fully at the present time, as our in-
vestigations have not enabled us to take first-hand
records of many natural cases. From the informa-
tion we can gather, however, the double-phase
temperature is; not constant, but inasmuch as few
of the cases are in hospital where accurate records
can be obtained, we cannot dogmatize on this point.
Goldsmid and Crosse say: "The temperature
rfxse sharply and reached 101-103 deg. F. During
the course of the illness it remained high and did
not undergo marked fluctuation. Not infrequently
it reached 105 deg. F. just before the termination
of the fever. The fall was as rapid as the rise."
The pulse rate in natural cases has not come
under our j)ersonal observation to any extent, but
Goldsiniid and Crosse confirm the results we ob-
tained in our injection experiments. They say : " It
(the pulse) was invariably slow in proportion to the
temperature. A pulse rate of 75 to 00 was fre-
quently associated with a temperature of 102 deg.
or 103 deg. A more rapid pulse rate than 90 was
rarely noted save just before the final fall of tem-
perature."
The pulse rate and its relation to the temperature
in experimental cases is discussed fully in a separate
section.
The Fades. — The face soon assumes a very
characteri«.tic appearance, and in our experience this
is one of the most useful signs of the disease. It
looks re<l, swollen, Inrt and puffy. The eyes are
usually somewhat injected, but there is neither ex-
cessive lacrymation nor any running at the nose.
Coryzal signs are notably absent, although it must
not he forgotten that an ordinary " cold in the
head " may coincide with an attack of dengue. Out
of twenty-six cases questioned a« to the occurrence
of "running at tlie uose " only one described it as
being present.
48
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1920.
The faciesi of dengue has been described as re-
sembling that of a person recovering from an
alcoholic bout. It is also somewhat suggestive of
the face in the early stage of measles but without
the coryzal condition. The typical faciee is most
marked shortly after the onset, or, when this occurs,
in the recrudescent period.
Headache. — Headache is a practically constant
phenomenon. Thus, out of twenty-six cases ques-
tioned all gave a hietory of headache. In some
cases it was located as frontal ; in others as vertical
or occipital; and quite frequently as " all over the
head." Frontal headache is hard to distinguish
from the characteristic eye pains, and the sufferer
frequently refers to pains " at the back of the eyes. "
The intensity of the headache varies very miich.
In certain cases it appeared to be the principal cause
of complaint, sometimes being described as " agoniz-
ing," whilst in others it was referred to as slight.
Eye Pains. — The painful eyes are, in our opinion,
quite one of the most characteristic single signs of
dengue, and are almost always present in some
degree. Sometimes the eyes are said to be aching
severely and painful on movement, and we have
seen cases where the whole head was turned rather
than move the extremely sensitive eyes. In othens,
it is only by careful questioning that the presence
of some pain or tenderness in the eyeballs or eye-
muscles is elicited.
Out of twenty-eight cases questioned, twenty-five
described pains in the eyes and three denied their
existence. Out of thirteen cases questioned on the
point, eleven said the eyes were painful to move,
and two replied negatively.
Apparently the earlier symptom is pain in the
eyes or in the " back of the eyes," easily confused
with frontal headache. Later there is definite pain
and tenderness apparently in the eyeballs, which is
associated with pain on ocular movement and pro-
bably often with some photophobia.
Oocasionally the eyes are described as "sore,"
which word may be used to refer to the irritation of
shght conjunctival congestion, but conjunctival sym-
ptoms are never prominent and the adjective
" sore " is probably frequently used to refer to the
deeper-seated pains in the eyeballs.
General or Body Pams.— These vary very much
in degree and are by some described as intense and
agonizing, and they may require the administration
of morphine ; in other cases they are described as
" tired feelings," "gone in the knees," and " in-
fluenzal pains." In our experience the "break-
bone " type of case is the exception, and the pains
are, as a rule, not a very prominent feature. Some-
times their occurrence is denied in a particular case
or only elicited after careful questioning. Restless-
ness and inability to stop in one position is charac-
teristic of some cases, and is ptobably closely linked
to the body-pain symptoms. Out of thirty-two per-
sons questioned, all described various degrees of
hod If pains souiewlierc in the spinal axis, and out
of twenty-six questioned, all described jjains in the
limbs. ■ The back of the neck is a common seat of
fairly severe pain (sixteen out of eighteen ques-
tioned). Lumbu-sacral pain is also common —
" across the back " — fourteen out of fourteen ques-
tioned. Real pams in the joints appear to be un-
common apart from the general limb ache. Move-
ment does not seem to definitely increase the pains,
but when severe, the patient generally takes to bed
because of the pain and associated symptoms. -The
body pains of dengue are, in our opinion, not asso-
ciated with any readily demonstrable lesion. No
swelling, redness or tenderness, were noted in any
case. This is in striking distinction to the descrip-
tion by Osier, who refers to red, swollen and painful
joints.
Abdominal Pains. — These were described by ten
out of a series of sixteen cases questioned, and are
sometimes associated with diarrhoea. At other
times they are apparently a "spreading round"
from the lumbar and dorsal region of the back pain.
Pain in the epigastric region, associated with vomit-
ing, is spoken of by Goldsmid and Crosse as occur-
ring in several cases.
The body pains gradually Subside, but there U
usually a recrudescence of the pains when the
second phase occurs. After the febrile stage is
over there is generally some tiredness or aching for
several weeks in the spine or limbs, which, how-
ever, gradually passes off.
Other nervous symptoms occurring in the disease
are giddiness, dehrium, mental irritability, depres-
sion and sleeplessness.
Giddiness is a common feature at various lames
in the course of the disease (nineteen out of twenty-
two questioned).
Delirium is not frequent, but we have seen cases
where there was maniacal delirium for three nights
after the onset, and many cases show some mental
wandering when the temperature is high. Deliriuna
was mentioned as a symptom in six out of twenty-
one cases questioned on the point.
Mental Irritability is a sitriking feaure of the dis-
ease, especially in the later stages.
Depression. — The depression following the attack
is one of the most mai^ked features, and the patient
may be actually incapable of concentration or serious
mental effort for a week or so after the attack.
Sleeplessness is found at some time in nearly all
cases.
Gastro-intestitial symptoms are not marked.
There is, however, a dirty tonyne, which is rather
characterisitic, being furred at the back with a
strawberry tip very like that seen in scarlet fever.
The fauces are reddened — Goldsmid and Crosse note
a fine stippling of the soft palate as an early charac-
teristic sign — and there may be some sore throat.
This is usually not marked. Anorexia is a feature
• in most cases (thirty out of thirty questioned).
Nausea is fairly common (eighteen out of twenty-
nine (luestioned), and vomiting, though not as a rule
nia'rlied, is met with especially at the onset (thir-
tteii nut of twenty-nine questioned) and occasionally
may lie severe. Some cases suffer no disturbance
of the bowels, but diarrhoea is present in a few cases
(two out of twenty-nine). Constipation is not
goiicrni (four out of eleven).
Mi
July 1. 1920.:
COLONIAL MEDICAL REPORTS.— NEW SOUTH WALES.
49
Colonial Medical Reports.-No. 109.-New South Wales
(continued).
Shivering occurs commonly (twenty out of twenty-
four cases questioned). It may occur with the onset
and during the febrile stage, but rigors are the ex-
ception.
The Skin Emotions. — According to Goldsmid and
Crosse the preliminary and terminal rashes werp
well marked in cases seen by them. They note,
however, that the preliminary rash could easily be
overlooked. They describe this as a " fine puncti-
form rash usually found over points of friction.
. It appeared and disappeared very suddenly.
A fine stippling of the soft palate was often
the only rash present when the patients were first
seen." They describe the terminal rash as " poly-
morphous," and as being present in nearly every
case. " It was either papular or a dark red, blotchy
rash, or an urticaria."
Our own experience probably covers a somewhat
different type of case to that seen by Goldsmid and
Crosse, as a great number of dengue sufferers seen
by us had not consulted any medical man at all,
and these were generally the mild cases which may
show an absence of certain symptoms or signs.
Thus, while we agree in the main with them, we
would modify their description in certain particulars.
We do not think, a rash is often entirely absent, but
it is often so transitory or slightly marked that
unless the patient is under medical examination,
and even then at times, it is easily overlooked. This
applies not only to the preliminary but to the later
rash. Our experimental cases bear this out. It will
be seen that in several cases we were unable to
make up our minds at all as to whether a rash was
or was not present.
The distinction also between the prodromal and
later rash is, in our opinion, not very valuable.
Although in some cases it is possible to note definite
skin eruptions at two periods separated by a period
in which the rash is absent or not marked, there
are such great variations in the degree and type of
the skin conditions of dengue that the distinction
into two rashes is not of great value.
Early in the disease it- is unusual to find a definite
eruption though we have seen cases with well-
marked measly rashes within forty-eight hours of
the onset. A hypersensitiveness of the skin which
tends to the production of blotchy erythema on points
of pressure is an early sign, and tdche cerehrale is
well marked in most oases. The red congested con-
dition of the face has teen referrcxl to before. In
the early stages it is quite frequent for two observers
to differ as to the presence of a rash. The more
definite skin eruption is generally found later.
Though it may be found well marked from the
second day, it may not be notic^ till the fifth or
seventh day. It prestmts somewhat variable charac-
teristics and lasts from a day or bo to (rarely) several
weeks, and is usually followed by slight desquama-
tion and sometimes by intense itching.
We have not siufficient data to describe a<-curately
the distribution of the rash, but we have found it
affecting almost any part of the trunk and limbs.
It seems as a rule to be less marked on the face,
which merely shows congestion. On the back,
especially in the lumfcar region, it is frequently very
distinct, and extends round on to the abdomen,
where it is often less marked. The legs and arms
are frequently affected, as a rule the arms showing
more definite lesions. The hands are liable to be
affected, and bright pink spots, followed by intense
itching and desquamation, are sometimes found on
the palms.
The characteristic of the rash has been described
by someone as its " want of characteristic." We
think a good definition for the rash in many cases
is " mid- way between those of measles and scarlet
fever, but less definite. " It is, as a rule, some form
of a blotchy erythema, though especially in later
stages the eruption does not completely fade on
pressure. The size and shape and intensity of the
blotchings, to a great extent, account for the differ-
ences in ap|>earance. In most of the cases seen by
us patches of red skin alternate with pale (normal)
patches in a most irregular mottling. The red
patches show no definite point of maximum intensity
but at times the hair folii-cles are red and prominent,
giving a strawberry appearance to the red blotches.
The red areas do not show definite lines of demarca-
tion from the adjacent normal skin. The blotchings
vary in size, but are usually not more than a J to ^
an inch square. On the legs of one patient, how-
ever, there were large irregular patches much larger
than this and of a very bright pink. At the same
time this ease had a dull measly motthng on the
trunk.
In some cases we have seen a very characteristic
reddening and swelling of the elbows of a peculiar
tint suggestive of a stain of eosin that has been
partly washed out. This may be surrounded by a
papular condition in the vicinity. Papular rashes
have been rarely noted by us, but sometimes are
seen on the feet or lower legs.
We have seen no urticarial cases, but these are
described by Goldsmid and Crosse and others, and
some cases have told us they had this condition.
They present another variation of the skin lesion.
Two other skin conditions should be noted here.
In the North Coast district we have seen several
cases of a papulo-pustular condition around the
ankles and extending up the leg for perhaps
12 inches. This was described to us by several
patients as a sequel of dengue, but we are not sure
whether this was not due to infected mosquito bites
or to infection conveyed by scratching the irritable
desquamating skin.. Jaundice is said to occur in
some cases and we have seen it in a few ourselves,
but it has never been more than slight. It is of
interest, however, in connection with the suggested
relationship of dengue with yellow fever.
Diagnosis. — From " influenza " the diagnosis rests
chiefly upon the absence of coryzal symptoms,
usually present with the so-called " influenza " seen
in this country. As we have previously mentionc<],
the absence of coryza is a noticeable feature in
dengue. Twenty-six persons were specifically ques-
tioned on this point, and all but one denied having
50
THE JOURNAL OF TEOPICAL MEDICINE AND HYGIENE.
[July 1. 1920.
any "cold in the head," " running at the noee,"
&a. Cough, again, wiiich may be a feature of cer-
tain influenzal attacks, is usually absent. It was
described in only seven out of twenty-four cases
questioned. When present i-t is seldom more than
a slight irritative cough, probably associated with
the naso-pharyngeal congestion which is often pre-
sent. The rash, and double-phase temperature, and
eye-pains on movement, are important points when
present.
From scarlet fever and measles dengue may be
difficult to dififerentiate in isolated cases, and typical
cases with a rash occurring early in an epidemic
are often diagnosed as measles or scarlet fever.
The coryza, nature and distribution of the rash, and
Kophk's spots should generally, however, make a
diagnosis of measles possible. The pulse in measles
is rapid ; in dengue often relatively slow. In scarlet
fever the early vomiting, throat angina, type of rash,
quick pulse, and leucocytosis are important points.
The diagnosis from yelloiv fever is not of much
importance in this country at present, but should
be kept in mind in view of the possibility of the
introduction of yellow fever into the Stegomyia-
infested part of Australia. Jaundice, though some-
times seen in dengue, is not frequent. Albuminuria
is absent in dengue. The slow pulse of yellow fever,
which is used as a differential sign hy Guiteras,
cannot be employed with the dengue of Australia.
The mild nature of the disease is a practical point
when dengue i* epidemic, though we cannot exclude
the possibihty of mild cases of yellow fever appear-
ing. In fact some observers have suggested that
the dengue of Australia is really a modified yellow
fever. The history of the disease and the known
variability of dengue in various parts of the world,
even in different parts of Australia, and the fixed
mild character of the disease here, are arguments
against this. It seems probable, however, that
dengue fever is a closely related disease to yellow
fever.
Acute rheumatic fever should be considered, but
the localization of pains in the joints and the absence
of rash are usually sufficient. Inasmuch as other
observers have described painful hot swellings of
the joints in some epidemics of dengue, it is pos-
sible that further investigation may disclose such
cases in Australia. With one doubtful exception,
we have never seen any joint affections. This case
was a child in the early febrile stage of some infec-
tion, who had pains and some swelling in several
joints, but we were not able to follow the case
further and do not know the final outcome. One
of us diagnosed the case as " acute rheumatism."
AustTolian Mosquitoes as Conveyors of Disease.
As both Culex fatigans and Stcgomyia fasciata arc
common household pests in most parts of Australia,
which have suffered from this recent epidemic of
dengue, it seemed quite probable that, if a mosquito
were a vector of this disease, it might be one or
other or both of these two species. Culex fafigana
is common in summer time in the southern districts
of Australia where dengue does not occur, whilst
the distribution of the disease is practically that of
Stegomyia fasciata. Coupling these facts with the
observations and experiments of Dr. Bancroft,
greater susipicion naturally falls upon Stegomyia
fasciata than upon Culex fatigans. In our experi-
ments both of these species were used. Stegomyia
fasciata was found to bite freely in captivity in the
day time, but Culex fatigans, though it did bite at
night time, was more shy and difficult to handle.
In considering the transmission of the disease, a
study of the habits of the mosquitoes in an infected
area is important. Observations of the mosquitoes
in general will show why it is that some species
can readily transmit disease, whilst in the case of
others disease transmisisdon is unlikely. Culex
fatigans and Stegomyia fasciata are e^sentiaUy
domestic mosquitoes, thereby possessing increased
facilities for transmitting diseases to human beings
over " wild " mosquitoes. It is highly probable
that both are introductions to Australia, having been
non-existent here before the arrival of the white
population. Both can apparently be easily con-
veyed from place to place by means of human
agencies.
In this place it may be well to review shortly
a few of the Australian mosquitoes which may
play a part in conveying disease, or are present in
exceptional numbers.
Culex fatigans Wied. — ^This is the common
domestic mosquito, and is probably almost uni-
versally distributed throughout .\ustraha. One of
us (J. B.C.) has met with it abundantly in Sydney
and in many country towns in New South Wales,
and also in .\delaide. In the warmer parts of
.\ustraha it may probably be found biting through-
out the year, but in the southern parts it disappears
throughout the cold months,, though during warmer
evenings an occasional individual may be met with.
It is essentially a night-biter and a feeder in the
dark. We have never met with it biting during
the daytime, but it occasionally bites in the even-
ing in a poorly-lighted room. Under these circum-
stances it is more especially the legs or some other
jxjrtion which is not exjwsed to the light that are
bitten. The hum of the mosquito at night-time is
very disturbing, the anticipation being more annoy-
ing than the bite itself, which in the cases of a
number of individuals can hardly be noticed. Many
of those bitten by the mosquito do not react by
the raising of a wheal. At any time in bed the
approach of the mosquito can usually be felt by the
currents of air produced by the wings. This draws
attention to the parts where the mosquito settles,
and, as it begins to feed, in many cases a slight
but indefinite pricking sensation indicates the exact
site. However quickly the hand is raised without
disturbing the bedclothes, it is only rarely the move-
ment is sufficiently. quick to enable the mosquito
to be destroyed. Its breeding place is in various
domestic water supplies — probably the cisterns of
water-closets may prove to be one of the most
important of these. In places such as Sydney
where, during sununer in some seasons, there may
be long periods without any rainfall, and in other
July 1, 1920.] COLONIAL MBDIOAL BfiPORTS— NEW SOUTH WALES.
51
seasons abundant rains for many daye, the nunaber
of mosquitoes may be grea-tly increased under the
latter conditions, indicating that breeding places
form as a result of collections of rainwater. It has
not yet been ascertained exac^,ly where these out-
side breeding places are located in a city like
Sydney, where, in the better residential localities,
tins, broken bottles, and similar receptacles are not
left lying about; but it is probable that places, such
as depressuons in gutter spoutings, are some of the
most important sites.
The distribution of this mosquito extends far
beyond the areas in which dengue fever has oc-
curred. For instance, though the mosquito is
abundant in the neighbourhood of Sydney, no in-
digenous cases of dengue are known to have arisen
in this city. Considering that imported cases of
dengue have been not uncommom, the inference
might b^ drawn that if Culex fatigans were capable
of transmitting this disease, endemic cases should
in consequence have arisen in Sydney.
Stegomyia fasciata Fabr. — Stegomyia fasciata
occurs im Queensland and extends into the northern
coast towTis of New South Wales. We have found
it at Tweed Heads, Murwillumbah, Mullumbimby,
Byron Bay, Casino, and Grafton. Dr. Ferguson
has also identified specimens from Maclean and
Tabulam.
Though the species has been recorded from New-
castle and from Victoria, there seems considerable
doubt as to the identification, and in all probability
specimens so designated were really Scutomyia
notoscripta.
The insect is a day-biter, and during the recent
dengue epidemic it was abundant in houses in the
affected district, usually being more active in rooms
that were dimly lighted. It was found breeding in
water tanks, and in similar domestic supplies, one
such source worthy of notice being open water in
connection with acetylene gas installations. It is
interesting to note that larvae were drawn off from
the bottom of a tank which was 4 to 5 feet high,
and which, as heavy rain had been falling for some
days, was presumably full of water. In two or
three jugs of water drawn off froan the bottom, some
larvse were obtained which afterwards hatched out.
It is possible that these larvae had sunk to the
bottom for the purpose of moulting, as it is hard
to believe that the insect in its active phase could
descend to a depth of 4 to 5 feet in the water
and rise again sufficiently quickly to maintain its
activities with their necessary accompannment of
oxygen.
We were able to confirm the statement recently
made that the eggs of Stegomyia fasciata can resist
drying for some while and then develop under
suitable conditions. In our second batch of these
mosquitoas a number of eggs were laid in a small
dish of water. On June 29 this dish had become
I perfectly dry and was left exposed on a laboratory
bench until August 30, that is, during the end of
winter and the beginning of spring. It was then
I immersed in water, and in a few days some of the
tjeggs hatched. Owing to the weather being cold
these developed very slowly, but early in November
a recently hatched adult was found floating on the
surface of the water. " At this period dt was also
noticed that a number of further eggs had hatched,
the weather having become warmer. It would
therefore appear that not only can the eggs resist
two months' absolute drying and then develop im-
mediately on immersion in water, but that they
may also remain for some period without develop-
ing in this water until the weather becomes warmer.
A review of the above distribution of Stegomyia
fasciata will show that the recent epidemic of dengue
was nearly co-extensive with it. Thus, the epidemic
appeared in all of the towns mentioned with the
exception of Maclean and Tabulam, about which
we have no information. It is interesting further
to note that the epidemic extended southwards
along the railway line, and this is doubtless ex-
plained by travellers becoming infect-ed an one town
and developing the disease in another, and there
infecting the local mosquitoes and starting a fresh
centre of the infection. Probably railway commu-
nication also facilitates the dispersal of Stegom.yia
fasciata. Though we did not find Stegomyia
fasciata in railway carriages at Murwillumbah during
the epideinic, we found them in the station-master's
office at Byron Bay. At Murwillumbah the mos-
(juitoes found in the railway carrLagee were chiefly
Culex fatigans and occasionally Culicelsa ennuli-
Tostris.
Scutomyia notoscripta Skuse. — This is a widely-
distributed jnosquito throughout Australia, though
we have never met with it in abundance. It re-
sembles very closely Stegomyia fasciata in its
thoracic markings, but can be at once distinguished
by a pure white band on the proboscis. It may
occasionally be found biting inside houses. It is
not known to be responsible for conveying any
disease to human beings.
Culicelsa vigilax Skuse. — This is the common
bush mosquito so numerous at certain periods of
the year in the neighbourhood of Sydney and other
similarly situated districts. In places it is exceed-
ingly numerous, as, for instance, in some of the
creeks running into the Hawkeebury River, where
human beings may be attacked by hundreds of
these insects at a time. The bite is fairly painful,
and often raises small wheals. It is very interesting
to compare the behaviour of this mosquito when
attacking man with that of such domestic mos-
quitoes as C'xlcx fatigans or Stegomyia fasciata.
As already indicated, these two latter are exceed-
ingly wary in their habits, so that it is a matter
of skill to kill them when they are attempting to
bit^. With Culicelsa vigilax, however, the insects
settle on the hand or face, and the finger can be
slowly lowered down upon them, and can crush
them without disturbing them. Culicelsa vigilax
is an Australian species accustomed to live in our
bush, and probably to feed chiefly upon birds and
marsupials. Ijiving on these hosts, which are
unable to protect themselves against attacks of the
mosquitoes by slapping them with hands, there has
been no need for the mosquito to be very dexterous
THE JOUENAL OF TEOPlCAL MEDICINE AND HYGIENE.
[July 1, 1920.
in leaving the host on which it has settled. Kest-
IcBS movemente on the part of the animal attacked
would be tie usual means of dislodging tlie pest.
Consequently, natural selection would allow a type
to develop whicli was comparatively slow in remov-
ing itself from danger. Since the domestic mos-
quitoes Culex fatigans and Stegovryia fasciata feed
probably to a great extent on human beings, and
to a less extent on birds, such as sparrows and
swallows living in the neighbourhood of houses,
and on domestic mamimals, the perpetuation of the
species has necessitated the development of ex-
ceedingly alert habits so as to escape from their
most potent means of destruction — the hands of
man.
Culicelsa annulhostris Skuse. — Though a widely-
distributed mosquito in Aoistralia, and present in
the area affected by the recent epidemic of dengue,
there seems no reason at present to consider that
it is responsible for the conveyance of any disease
in man.
Nyssorhynchus annulipes Walker. — This mos-
quito, tJie chief malarial transmitter in Australia,
appears to be widely distributed throughout the
continent, tmt in the southern parts, as a rule,
only in small numbers. Here and there areas exist
where it is present in sufficient numbers to be a
3ource of danger should imported malarial cases
reside there. In the coastal parts of Queensland,
however, and in the Northern Territory, its inci-
dence is sufficiently great to maintain in places
endemic foci of malaria.
As regards the diseases spread, or possibly spread,
by mosquitoes in Australia, malaria has already
been mentioned. Our experiments on the convey-
ance of dengue have clearly proved that Stegomyia
fasciata is responsible — is perhaps alone responsible
— for the spread of this disease in Austraha. The
same mosquito, as is well known, is the transmitting
agent of yellow fever. Culex fatigans, the common
domestic mosquito, is a transmitting agent of
Filaria bancrofti, and is apparently responsible for
the distribution of this disease in Queensland. So
far there ai-e no other diseases of human beings in
Australia which are known to be transmitted by
mosquitoes.
Summary of Experiments.
The following is a short summary of the experi-
ments made and the results obtaifled with the
mosquitoes, taking the nine persons volunteering
seriatim : —
Case 1. — J. G., male, laboratory assistant (18
yeans), the subject of an unsuccessful Stegomyia
biting experiment of the first series, was bitten on
May 11, 1916, at 2.15 p.m., by some twenty-eight
Stegomyia mosquitoes. He remained well until
the afternoon of May 19, 1916, eight days later,
when he noticed he had headache. That evening
at 7 o'clock (eight days and five hours), he was
again bitten by Stegomyia, and, while sitting with
his hand in the cage, first became definitely ill.
He passed through a typical attack of dengue fever,
J
showing a double temperature curve, rash, and
symptoms described in detail below. Blood from
this case reproduced the disease on injection.
Result positive.
Case 2. — McD., male, laboratory assistant, not
previously the subject of experiment, was bitten on
May 12, 1916, by ten Stegomyia, and on May 18,
1916, by three or four Stegomyia. He remained
well until June 3, 1916, seventeen days from the
second biting and twenty-two days from the first
biting, when he had an influenzal attack with coryza
for a few days, with no rash and nothing suggestive
of dengue. Result negative.
Case 3. — G., male, laboratory assistant, not pre-
viously the subject of experiment, bitten by about
nine Stegomyia on May 13, 1916, and by about
three Stegomyia on May 17, 1916. No symptoms
have followed these bitings to date — July 14, 1916.
Result negative.
Case 4. — 'Wm., male, laboratory assistant, not
previously the subject of experiment, was bitten by
about thirty-six Stegomyia on May 14, 1916 (mid-
day), and by about thirty-six Stegomyia on May 15,
1916 (12.30 p.m. and 4.30 p.m.). On May 20, 1916
(six days and nine hours from first biting), whilst
going to bed at night, he became ill and had a
typical attack of dengue, with double temperature,
rash and other symptoms det-ailed in Appendix III.
His blood on injection repixjduced the disease.
Result positive.
Case 5. — M., female, a nurse, was bitten by
eighteen Stegom.yia on May 16, 1916 (noon), and
became ill on May 25, 1916, 10 p.m. (nine days
and ten hours later), and passed through a rather
severe type of dengue, with marked rash and double
temperature. No blood was taken from this case
for injection experiments. Result positive.
Case 6. — B. B., medical practitioner, was in
dengue fever districts — ■Mullumbimby, Casino and
Grafton — leaving Grafton for Sydney by boat on
May 13, 1916. To keep the mixed Grafton mos-
quitoes aUve, he allowed them to bite him on
May 12, 1916, and May 14, 1916, but remained
perfectly well till, on May 23, 1916 (2 p.m.), ten »
days after leaving the dengue district he was bitten ' ?
by fifteen Stegomyia. He remained quite well till =«
May 29, 1916, and the temperature normal till \ "
May 31, 1916, on rising, 9 a.m., seven days and *i
nineteen hours, when he became definitely ill and *
passed through a severe attack of dengue, with ';>'■
definite prodromal and secondary raslies, double •^•i
temperature, and marked pains, &c., as described 'H
in Appendix III. Blood from this case reproduced ■ li
the d'sease on injection. Result positive, but open ' '«
to criticism as having been in a dengue district ' fk
eighteen days before the attack developed. , r»li
Case 7.— W. T., bitten by one Stegomyia on May ^i
12, 1916. No illness followed. Result negative. iei
Case 8. — M., a patient at a hospital, wais bitten ; ii
on May 11, 1916, by about twelve Culrx fatigans, h
and on May 12, 191(5, and May 13, 1916, by an I«
unknown number of Culex fatigans, and on May 14, "'V
1916, by at least twenty Culex fatigans. Result >\>i
negative.
i
July 15, 1920.:
COLONIAL MEDICAL REPORTS.— NEW SOUTH WALES.
Colonial Medical Reports.— No. 109.— New South Wales
{contintied).
Caxc 9. — J. O. S., laboratory assistant, a subject
of Cidcx experiment in the first series, was bitten
on May 1.5, 1916, by two Culex fatigans, and on
-May 18, 1910, by — Culex jatigans. No symptoms
followed. Result negative.
General Conclusiuns.
Stcynmyia fasciata mosquitoes caught in a dengue
infected district in the surroundingis of cases of the
iliaease, and some of them known to have fed ou
a dengue patient on the first and second days of
his illness, transported to a non-dengue district,
reproduoed the disease in four out of seven persons
on whom biting experiments were conducted.
Blood taken from three of these four cases re-
produced the disease when injected into further
pereons. The blood of one case was not tested.
The incubation period of the four cases was found
to be possibly lietween five and nine and a half
days, probably between six and a half and nine and
a half days, counting from the biting to the definite
onset.
No known case of contagion occurred from any
of the above four cases.
No evidence was obtained from two cases, one of
which was heavily and repeatedly bitten wdfJi Culex
jatigans, that Culex jatigans is capable of acting as
a transmitter of dengue fever.
A Contribution to the Expekimental Pathology
OF Acute Poliomyelitis (Infantile Paralysis).
A. W. Campbell, M.D., Ch.M. ; J. Bubton Cl
M.D., Ch.M. ; and Burton Bbadley, M.D., D.P.H.
Introduction.
The leading features of this communication are,
firstly, the positive diagnosis by laboratory methods
of a previously doubtful case of Acute Poliomyelitis
(Infantile Pwalysis); secondly, an example of the
successful transmission of the human disease to a
monkey by intraperitoneal injection of unfiltered
spinal emulsion; thirdly, an example of a failure
similarly to transmit the disease when the emulsion
was filtered; fourthly, an experimental failure to
transmit the disease by means of the Stomoxys
calcitrans ; and lastly, illustrations of the histo-
pathology of the human disease in an early stage,
and of the expei'imental disease as it appeared in
a monkey.
It cannot be chi.imed that the communication
brings to light any unknown facts concerning acute
l)olioriiyelitis, but we feel that its publication is
justified in the first place, because opportunities
seldom arise foi- the pathological examination of
the nervous system in acute stages of this disease :
and secondly, the experimental researches of
riexner and his collaborators at the Ilockefelier
Institute, of Levaditi at the Pasteur Institute, ;uul
of s{!vei!il others on the Continent, are so recent
■M to be ot :u,-iite interest, Mtid so important ami
so technically dehcate as to call for repetition by
others.
Report of a Case of Human Poliomyelitis.
Ou April 6, 1916, by direction of the Coroner of
Sydney, Dr. A. A. Palmer conducted a post-mortem
examination of a boy, Il.G.,R., aged 6 years, who
had died after two days' illness with obscure sym-
ptoms. He had had a high temperature, headache,
and furred tongue.
The body was thin, and the teeth irregular and
notched. There was. a good deal of frothy mucus
in. the air passages; the lungs were (Edematous, and
their lower lobes deeply congested. There were
some yellow-patches on the mitral and aortic valves.
The liver was congested and firm ; the spleen en-
larged and firm ; the right kidney was absent, and
the loft kidney enlarged and congested. (Albumin
was present in the urine.) The mncous membrane
of the duodenum was intensely congested and the
mesenteric glands were enlarged ; the thymus also
was enlarged. The brain was congested.
The fact that at the time this examination was
made a moderately extensive epidemic of infantile
paralyiSiis was on its wane, together witli the obscure
symptoms of the case and the rapid death, directed
special attention to the possibility of the case being
one of acute poliomyelitis. The cord was conse-
quently removed and on naked-eye examination the
unusnal pink appearance strengthened suspicion.
The «i>inal cord and v.arious organs were then
submitted to the ^Microbiological Laboratory for de-
tailed examination with the following results: —
The heart showed patches of atheroma in the
inter-ventricular septum and in the aorta. Micro-
scopical examination of a section of the wall near
the apex showed no special changes. The liver
showed nothing notable macroscopically or micro-
scopically. A portion of lung submitted was red
and oedematouis; nothing special was noted micro-
scopically. The spleen was enlarged to about 3^ in.
by 2J in., wa.s red and congested, iuid showed
marked prominence of the ^Malpighian bodies; no
special changes were notice<l microscopically. The
right Inulney was absent; the left was large. The
only change" seen microscopically was congestion of
the capillaiie.^. The mesenteric glands were en-
larged and firm, and showed no special microscopical
changes. The thymus was about 2 in. long by about
1} in. broad, biit showed no special microscopic
changes. In the spinal cord the meninges were very
pink, whilst the gi-ey matter was deeply coloured,
and very clearly marked. Portions of the spinal
cord were cut from four different levels for micro-
scopical examination, the details of which will bo
given later, whilst the rest was ground up with
50 c.c. of 1 in 3 glycerine and normal saline solution.
MdNKKV
SlMNAL COKO F
Li,\Ti:i) WITH AN Emul.sion of Hi'.man
C.\SF, OF Acute Poliomyelitis.
.\ l.argo monkey, ^tnrlU•llK ciinowohji:
54
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July i5, 1920.
oculated iutiaperitoueally ou May 24, 1913, with
about 5 c.e. of tlie above-mentioned emulsion.
May 30. — To this date the animal continued active
and healthy, and took its food well.
May 31. — At 9 a.m. the monkey was noticed to
be very quiet. He was undisturbed. At 11.30 a.m.
he was found to l)e markedly paretic in both hind
lim'bs. On moving he flopped from one to the other
side of tilt; loins. He was able to draw liimself up
to the hars of tlie cage by the hands aind legs. In
the afteruoon he was found lying on one side.
June 1. — He was lying on his side. He could not
raise himself higher than his arm*; he was quite
paretic in the liind limhs, but the tip of the tail
occasionally moved. The rectal temperature was
37-75 deg. C.
June '2. — His condition was worse. The hind
limhs were now ([uite paralytic. There was ehght
movement in the tip of the tail. The arms had
become flaccid, but he was able to move them
slightly and j)artly raise himself. He could move
the head normally and'yawn. The rectal tempera-
ture at 4.30 p.:ai. was 34 deg. C.
June 3. — Still lying down. He could just move
slightly the arms, wliich were now very paretic.
The eyebrows and face were alert and movable.
The temperature was 85 deg. C.
June 4. — The hind limbs fell heavily when lifted.
The tail showed slight movements of the tip when
moved by someone, but these were apparently pur-
poseless. He could not move the forearms himself,
but when these were lifted up they did not fall so
heavily as the hind hmlfc. Movements of the head
were apparently normal, and food was eaten when
placed in the imouth. He gave no indication of pain
when a number of Stomoxys calcitrans confined in
ii tube were allowed to bite his side, but continued
eating his food while being thus bitten. From being
a nionlcey dangerous to handle he now gave a
chuckle (yf pleasure when patted. He seemed to-day
a trifle l>etter. The temperature was 34'8 deg. C.
June 5. — He was much the same. The tempera-
ture was 34 deg. C
June 6. — Perhaps a slight improvement in the
fore-limbs. The temperature was 34 deg. C.
June 7. — The hind limbs were completely flaccid,
falling heavily on lifting. The fore-hmbs we^e
paretic, but showed some toniciiy when they were
let go, falling less heavily than the hind hmbs.
They also showed occasional slight movements.
Movements of the face and neck were normal, and
he ate well when food was placed in hisi mouth.
When food was placed iiL his hand he tried to move
his head towards it, but could not move the hand
towards the mouth. Dr. George Kcnnie kindly
examined him on tliis occasion. Knee-jerks were
absent, but an ankle jerk was present. There was
a slight periosteal reflex in the fore-limbs. There
was no elbow jerk. He was apparently entirely
insensitive to pain (pin pricJis) up to a transverse
line behind the fore-limbs. In front of this, and in
the fore-hmbs, shght pain was evidenced by the
physical expression. This evidence of pain became
naore definite as the head wa& approached. He had
been passing a little blood in the urine during the
last few days.
June 8. — The arnas could perhaps be moved a
little more freely. The temperature was 34 deg. C.
At 3 p.m. be was killed.
I'ost-mortem Examination. — The spleen, liver,
heart, and lungs were found normal ; the kidneys
were slightly congested; the salivarj' glands were
apparently normal. Tliere were no enlarged Peyer's
patches in the intestines ; the bladder was normal.
The brain appeared slightly congested. There was
perahps a slight excess of clear oerebro-spinal fluid
in the spinal cord. The upper part of the spinal
cord appeared normal, but from the mid-dorsal area
downwards seemed softer than usual. In the lumbar
culargecment this softening was. definite and the grey
matter appeared deeply congested. Sections of the
liver showed microscopically nothing special. The
kidneys showed congestion of the capillaries, whilst
the mesenteric glands allowed the presence of some
blood pigment in the walls of the medulla. The de-
tails of the microscopic oxamination of the spinal
cord are given later.
Monkey inoculated with the same Emulsion as
monkev no. 1, but after filtration through
A Pasteur-Chamberland Filter.
This small Macacus was inoculated at the same
time as the large animal on May 24, 1916, with the
same material after it had passed through a Pasteur-
Chamberland filter F. It never manifested any
evidence of illness or paresJs.
The Monkey on whom Stomoxys Calcitrans were
fed after feeding on the monkey inoculated
WITH THE Virus of Acute Poliomyelitis.
The monkey used in this experiment had a
' ' withered ' ' left arm which was flexed at the elbow
and the wrist. He was kept in a separate room
in a quite different part of the building to the in-
oculated monkey.
On June 1, 1916, about 300 Stomoxys calcitrans
caught in the neighbourhood of the abattoirs, near
Sydney, were allowed to bite the inoculated mon-
key. Til is was the day after the first development
of its illness. At noon on June 2 the Stomoxys cal-
citrans which fed on the inoculated Monkey No. 1
on June 1 were allowed to bite the Stomoxys Mon-
key No. 3. About a dozen had died, but the rest
fed freely, probably most of them biting. In the
afternoon about fifty more Stomoxys which had been
starved for two days were fed on Monkey No. 1, and
then within fifteen minutes on Monkey No. 3.
June 3.— The Stomoxys, of which 110 were
counted, were fed firet on Monkey No. 1 and then
on Monkey No. 3. They fed freely on both.
June 4. — The Stomoxys still alive, about ninety
in number, were fed for five minutes on Monkey
No. 1, and then for ten minutes on Monkey No. 3.
The latter monkey was evidently bitten severely, as
it screamed several times.
1
Jtdy 15, 1920.] COLONIAL MEDIO AL REP0BT8.— NEW SOUTH WALES.
55
June 5. — About 70 flies were fed on each of ths
moiiikeye.
June 6. — The flies were agaio fed on both tiie
monkeys.
June 7. — The fliee again fed on both monkeys.
June 8. — The flies still alive, about seventy in
number, were fed on both monkeys. The inoculated
monkey was killed on this date.
June 9 and 10. — About sixty flies fed on. the
monkey.
June 12. — Fifty-six flies fed. His temperature,
which from June 5 to 10 had been consistently 36°,
was now 37-50
June 13. — Thirty-five flies fed. Temperature, 38o.
June 14. — Thirty-two flies fed. Temperature, 37°.
June 15. — Twenty-eight flies fed. Temperature
380.
June 16. — Eighteen flies fed. Tem,perature, 38°.
June 17. — Four flies fed. Temperature just over
380.
June 19. — Two flies fed. Temperature, 37°.
June 20. — All the flies were dead.
Throughout this period and thereafter the animal
showed no evidence of illness or paresis whatsoever.
The question may be raised as to whether the
withered arm of this monkey might have been due
to a naturally contracted attack of acute polio-
myelitis. The fact, however, that the arm was
rigidly flexed and not flaccid would seem to exclude
this.
Remarks.
A case is here shown in which the cause of death
wais doubtful until microscopic examination of the
, spinal cord, and an experiment on an animal, defi-
j nitely proved it to be acute poliomyelitis.
Experimentally the human disease was reproduced
in a Macaque monkey by intraperitoneal injections
of unfiltered glycerinated spinal cord emulsion, but
there was failure to transmit the disease when the
emulsion w.as filtered and similarly used.
Concerning the successful experiment it was but
a repetition of what has been found by many others;
while the failure to transmit the disease with filtered
emulsion, puzzling to us at first, ii; now readily to
be explained. We have since leai'ned, first from
the experiments, of Flexner and his school, that
although infection has been produced by injection
of the virus, filtered or unfiltered, into the peri-
toneum (aJeo into the anterior chamber of the eye,
the subcutaneous tissues, the spinal canal, veins
and the sheath of nerves) the most certain method
of producing infection is by injecting the virus into
the brain. The reason for this; is that within the
nervoue tissues the disease findsi the most favour-
able conditions for operation. Secondly, although
we knew from the experiments of Landsteiner and
Levaditi, and others, that the virus would pass
through porcelain filters and withstand glyceriniza-
tion, ,we were not aware that after giuch treatment,
especially filtration, the virus lost strength, and
thereby the incubation period of the disease was
prolonged, or only a mild form of the disease was
produced. From the foregoing it is easy to under-
stand our failure with the filtered emulsion.
Concerning our attempt to infect by using
Stomoxys calcitrans (the stable fly) as a carrier we
would indicate that the experiment was cautiously
conducted and thorough, inasmuch as steps to pre-
vent contagion were taken by keeping the infected
animal' .and the test animal widely apart in cages
in different parts of the building, and by employing
numerous flies and giving them abundant opportu-
nities of feeding on both animals. The negative
result is in accordance with recent experiments car-
ried out at the Rockefeller Institute, and in accord-
ance, moreover, with the belief that the infection in
])oliomyelitis is local and neura.1 and by way of the
lymphatiesi, not general by way of the blood-stream.
On this point we may mention that ex.periment has
shown it to be diffieult to infeot a monkey with the
blood of a patient suffering from acute poliomyelitis,
a large quantity of blood being required. How much
more difficult must it be for the Stomoxys to carry
over a sufficiency of the viruis. We would sub-
scribe, therefore, to the belief that epidemic poho-
myehtis is not spread by means of the stable fly.
Lastly, concerning the histological findings in
both this human and this experimental case, al-
though they depart in no important respect from
what has been described by others as characteristic
of the disease in an acute stage, they have con-
firmatory value in showing that diistended blood-
vessels, perivascular haemorrhages and perivascular
lymphocytic infiltrative exudations are the dominant
histological features, and that in the nervous system
the process follows the blood-vessels and the result-
ant destruction of tissues is the outcome of vessel
obliteration and perivascular heemorrhage, exudation
and oedema.
THE JOUENAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1920.
Colonial Medical Reports.— No. 110. — Trinidad and Tobago.
ADMINISTRATION REPORT OF THE ACTING SURGEON-
GENERAL FOR TRINIDAD AND TOBAGO FOR
THE YEAR 1917.
Colonial Hospital, Port-of-Spain.
Administration.
Owing to the exigencies of the strenuous times
through which we are passing the medical staff was
kept at a minimum strength during practically the
whole year, and indeed on several occasions for
short periods it was below even the minimum
strength. In addition to this disability the fre-
quent temporary changes among our staff for one
cause or another and the imposition on the assistant
medical officers of duties unconnected with the
hospital greatly hampered the management of the
institution.
Although the strain has been severe and constant
throughout the year and has unfortunately told on
the health of almost every member of the staff, as
the sick list for the year shows, I am pleased to be
able to report the ready and willing response made
by members of the staff to the call for increased
duty. It cannot, however, be said that under the
conditions referred to above the standard of effi-
ciency has been maintained on the same high level
as in previous years, although the best has been
done in the circumstances.
The practice of throwing the full brunt of extra
work on the hospital staff whenever the resources
of the Department are strained is conducive to in-
efficiency and is detrimental to the best interests
of the institution. The staffing of the Colonial
Hospital with a fixed and adequate staff so that
the institution may at no time suffer is a matter
which I hope will receive careful consideration when
normal conditions are restored.
Training of Nurses, Midwives, dtc. — Our nurse-
midwives continue to do excellent work in the town
and its suburbs in connection with our extern
maternity.
During the year 154 women who were unable to
procure the services of a medical practitioner or
certified midwife were delivered at their homes ;
four others were transferred for their confinement
to our maternity ward owing t« complications —
eclampsia, transverse, face and footling presenta-
tions demanding special skill for safe delivery.
Among the mothers a fatality occurred ten hours
after confinement from pulmonary embolism. This
ciise was seen by the district medical officer.
There were eleven stillbirths and six prematurely-
born infants; among the latter four succumbed to
debility. 4,947 visits were paid to mothers after
delivery and 240 to infants after the mother ha<l re-
covered from the puerperium po as to ensure their
proper care and feeding. There were also 245 visits
to expectant mothers to whom necessary advice was
given to guide them safely to full term. Whatever
inay be the results of other measures adopted to
conserve infant life in Port-of-Spain it is gratifying
to note the marked success which attends the efforts
of our nurse-midwives in the campaign to combat
infantile mortality. Their work is purely preven-
tive, and of all the measures adopted it is the most
economical and practical. Apart from the saving
of the lives of infants at birth, the evil is fought
on educational lines by instructing the mothers in
the best way of feeding and caring for their infants
and by practical demonstrations not only in regard
to feeding but also in respect of the general cleanU-
ness and the clothing of the infant. In view of the
encouraging results obtained at such small expendi-
ture I would strongly urge the extension of their
scope of work not only to embrace a larger area
than is now within their range, but to prolong their
attendance on the infant during the early months
of life when infant mortality is at the highest.
Water Supply. — The water supply has been ample
and of good quality.
Sanitary Arrangements. — These conform to
modern ideas of sanitation, but constant supervision
and vigilance ai-e necessary to maintain them in a
satisfactory condition.
Diet. — There has been no change in the diet scale
of 1894. Owing to the advance in the price of
every article of diet an inevitable increase of ex-
penditure under this head has resulted.
The daily cost per bed per diem calculated on the
gross expenditure for the year was 2s. 5d. Tlie
cost of maintenance per bed per diem (salaries not
included) was Is. 8d.
Accommodation. — The number of beds in the
tuberculosis ward has been increased from twenty
to forty, so that the institution now provides accom-
moclation for 340 patients. Some of the chronic
wards have been overcrowded to an insanitary extent
during the year on account of the largo number of
incurable and senile cases who are sent here owing
in part to inadeqviato provision for their turcoin-
modation at the House of Refuge and the .\riapitii
Asylum. This has formed the subject of a special
report in which 1 have submitted various sugg(!s-
tions to prevent the degeneration of this institution
into an almshouse.
u
Aug. 2,
COLONIAL MEDICAL BEPOBTS.— TRINIDAD AND TOBAGO.
Colonial Medical Reports.-No. 110.- Trinidad and Tobago
{continued).
The chief diseases treated were as follows: —
Malaria
Enteric fever
Pulmonary tuberculosis
Ankylostomiasis
Chronic nephritis
Acute nephritis
Mitral regurgitation ...
Aortic regurgitation ...
Chronic bronchitis-
Acute dysentery
Chronic dysentery
Cirrhosis of liver
Acute lobar pneumonia
Acute entero-colitis ...
Chronic entero-colitis
Colitis
Venereal diseases
Ulcers
Other diseases
5,275
Mortality.— 'Among 5,27.5 patients treated during
the year there were 655 deaths, or a mortality per-
centage of 12'41. The gross mortality rate of this
institution must necessarily be high as compared
with that of other hospitals in view of the large
number of deaths occurring among the phthisis cases
who are admitted to the tuberculosis ward in
the last stage of the disease: (See above table.)
Deaths among the incurable and senile cases, for
whom this institution was never intended, also go
to swell unduly our mortality rate.
Surgical Operations. — ^There were 1,654 opera-
tions performed during the year under notice. In
addition to this 1,244 minor operations were per-
formed in the casualty.
R. Seheult,
Resident Surgeon.
Colonial Hospital, San Fernando.
The Water Supply was of good quality, but its
quantity was deficient towards the end of the pro-
longed dry season when the institution had to rely
entirely on the water supplied from the Union
Springs. Some temporary inconvenience was then
experienced.
The Drainage within the hospital grounds is good.
It is very desirable, however, that the pools of water
collected along, the seashore to the west of the in-
stitution, and kept by the retaining wall in connec-
tion with the railway line, should be dealt with at
the earliest date possible. Mosquito larvce (malarial
type) have been found in these pools, and with the
hospital — which is not mos(juito-proof — situated
between the town of San Fernando and the pools,
it is reasonable to infer that they contribute towards
tlio spread of malaria. During 1917 an increase in
till iiuirilicr of malarial fever cases from the town
')! S:iii I I raando has been noticed.
Sdtiihnii ConditioHH. — The Hy-proofing of the
latrines, an urgent necessity, was completed.
The Dietary has continued to be very satisfactory
when the difficulty of obtaining certain articles is
taken into consideration — a consequence of the
cancellation of contracts and increased cost.
Accommodation is provided for 123 patients. The
greatest number in hospital in any one day was
137 and the lowest number was 87, the average
being 108.
It has been found that the difficulty in restricting
the admissions to hospital so as not to exceed the
authorized number is increasing. The following are
the chief causes which are contributing towards this
condition : —
(1) An increase in the number of maternity cases.
During 1916, sixty-eight cases of pregnancy were
admitted. This year, 124 cases of pregnancy, in
addition to thirteen cases of abortion and twenty-
two cases in the puerperal stage — a total of 159
cases. Many of these patients came to hospital
from a great distance and could not be refused
admission ; while those who resided in San Fernando
invariably waited until they were advanced in labour
before seeking admission, a course that precluded
any possibility of their being rejected.
The supply of midwives to the town of San
Fernando is inadequate to meet the demands of the
public, especially the poorer classes.
(2) The admission of large numbers of advanced
ankylostomiasis, dysentery, malarial fever and
enteric fever cases.
The Mortality. — The total number of patients
admitted was 3,074.
The total number of deaths was 356, forty-six of
which occurred within forty-erght hours, and fifty-
four within seventy-two hours of admission.
The mortality percentage on cases treated was
11-21.
The chief diseases treated were : —
Admissions DeAtlis
315 .
4
218 .
4
313 .
. 57
'207 .
. 39
146 .
0
144 .
, 40
125 .
5
115 .
0
95 .
. 44
Ankylostomiasis
Venereal ...
Malaria
Dysentery
Respiratory diseases (excludingphthisis)
Ulcer
Chronic nephritis
Wounds
Abscess and cellulitis
Cirrhosis of liver
Knteric fever
Phthisis pulmonalis
Ankylostomiasis. — This disease was again respon-
sible for the largest number Of admissions and con-
tributed towards the production of cirrhosis of the
liver and kidneys, which latter together produced
the greatest number of deaths-.
Venereal Diseases — 315 admissions, fonr deaths
— were in excess of the admissions of the previous
year.
Dysentery. ^-213 aflmissions, fifty-seven deaths.
This disease individually contributed the largest
share towards the death-rate, and the admissions
were also in excess of those of the previous year.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 2, 1920.
Return of Diseases and Deaths in 1917 in the Colonial Hospital, San Fernando Hospital
AND the District and Yaws Hospitals.
Trinidad and Tobago.
GENERAL DISEASES.
I M
Alcoholism
Anthrax
Beriberi
Bilharziosis
Blaokwater Fever
Chicken-pox
Cholera
Choleraic Diarrhoea
Congenital Malformation
Debility
Delirium Tremens
Dengue
Diabetes Mellitns
Diabetes Insipidus
Diphtheria
Dysentery . .
Enteric Fever
Erysipelas
Pebricula
Filariasis . .
Gonorrhoea
Gkjut
Hydrophobia
Influenza . .
Kala-Azar
Leprosy
(a) Nodular
(6) Anaesthetic . .
(c) Mixed
Malarial Fever —
(a) Intermittent
Quotidian . .
Tertian
Quartan
Irregular . .
Type undiagnosed
(6) Remittent ..
(c) Pernicious . .
(d) Malarial Cachexia . .
Malta Fever
Measles
61
_
fi,->
124
21
],S2
70
5
70
New Growths —
N on -malignant
Malignant
Old Age
Other Diseases
Pellagra
Plague
Pyaemia
Rachitis
Rheumatic Fever
Rheumatism
Rheumatoid Arthritis
Scarlet Fever
Scurvy
Septicaemia
Sleeping Sickness
Sloughing Phagedena . .
Small-pox . .
Syphilis
(a) Primary
(b) Secondary ..
(c) Tertiary
{d) Congenital . .
Tetanus
Trypanosoma Fever
Tuberole—
(a) Phthisis Polmonalis
(6) .Tuberculosis of Glands
c) Lupus
84
85
08
U
117
24
8
2S
23
13
23
Jill
GsnEBAL DiaKA.SES— continued.
(<J) Tabes Mesenterica
(«) Tuberculous Disease of Bones
Other Tubercular Diseases
Varicella
Whooping-cough . .
Yaws
Yellow Fever
1506 14 1679
LOCAL DISEASES.
Diseases of the—
Cellular Tissue 422 8 445
Circulatory System . . . . . . . . — _
(a) Valvular Disease of Heart . . . . 83 14 36
(6) Other Diseases 248 86 266
Digestive System— — —
(a) Diarrhoea 190 60 198
(6) HiU Diarrhoea — — _
(c) Hepatitis 4 — 6
Congestion of Liver . . . . . . 6 1 6
(d) Abscess of Liver . . . . . . 20 6 21
(e) Tropical Liver — — —
( f) Jaundice, Catarrhal 5 2 5
(g) Cirrhosis of Liver 186 51 197
(ft) Acute Yellow Atrophy . . . . 1 1 x
(») Sprue _. _ _
ij) Other Diseases 735 132 780
Ear 40 — 41
Eye 227 — 241
Generative System — . . . . . . . . — —
Male Organs 821 21 832
Female Organs 574 33 586
Lymphatic System 18 1 18
Mental Diseases 92 — 94
Nervous System 253 66 273
Nose .. 36 9 40
Orgiins of Locomotion 216 4 M8
Respiratory System 932 275 981
Skin— — — _
(a) Scabies — — —
(6) Ringworm — — —
(c) Tinea Imbricata — — —
(d) Favus — — —
(e) Eczema 31 — 32
(/) Other Diseases 978 21 1072
Urinary System 645 204 680
Injuries, General, Local — — — —
(a) Siriasis (Heatstroke) . . . . . . — — —
(6) Sunstroke (Heat Prostration) . . . . 3 — 3
(c) Other Injuries 819 37 846
Parasites — .. .. .. .. .. 4 — 4
Ascaris lumbricoides 24 3 24
Oxyuris vermicularis . . . . . . . . — — —
Dochmius duodenalis, or Ankylostoma duo-
denale
FUaria medinensis (Guinea-worm) .
Tape-worm
72 782
_ Z «i
12
73
Snake-bites
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids . .
Nature Unknown
Other Poisons . .
Surgical Operations — . .
Amputations, Major . .
,, Minor . .
Other Operations
Eye
(o) Cataract — — _ ^
(6) Iridectomy . . . . . . . . — —
(c) Other Eye Operations
1664 29 1664
_ _ *e
u
Aug. 2. 1920.] COLONIAL MEDICAL BEPORTS.— TRINIDAD AND TOBAGO.
Jjike enteric fever, water ami flies are chiefly
rcsjionsible for its increase.
Cinhusiii of the Liver and Kidneys. — 219 admis-
sions, eighty-five deaths. As previously mentioned,
malaria and ankylostomiasis cannot be overlooked
as primary factors towards producing these incur-
able conditions.
Tetanus. — Nine cases, four deaths. The admis-
sions were double those for 1916.
Scorpion Poisoning. — Twenty-five cases, no
deaths. An unusually large number of admissions ;
there were ten admissions in 1916. The treatment
with potassium permanganate is probably respon-
sible for the absence of deaths.
Burns. — Thirty-two admissions as compared with
twelve in 1916. There were eight deaths. During
the latter half of the year the method adopted at
this institution has been the application of the
modified Ambrine preparation (i.e., paraffin wax,
&c.) in vogue in France. The results here have
heen more satisfactory than those previously
obtained by other methods.
Eclampsia. — (o) A reference to the one death from
this cause, which occurred in the series of twelve
cases treated, is interesting in consequence of the
long period which supervened subsequent to the
cessation of convulsions before death occurred. A
young woman, aged 19, was admitted with premoni-
tory symptoms of eclampsia (cephalalgia, giddiness,
albuminuria, &c.). Five days later she delivered
normally, twenty-four hours later she developed con-
vulsions which ceased after twenty-four hours. She
then remained four days in an unconscious state
before succumbing.
(h) An unusual condition, diflftcult of explanation,
ought also to be recorded. A primipara, aged 20
years, was admitted in the first stage of labour
suffering from eclampsia. The routine treatment
was adopted, the convulsions ceased and conscious-
ness returned twelve hours after admission. Five
hours later she had a normal delivery, with no
surgical interference whatever, of a full-term in-
fant. Twelve hours later only a faint trace of
albuminuria persisted. After twenty-four hours the
patii-nt sudilctily collapsed and died with symptoms
suggestive of serious intra-abdominal mischief.
Post mortem. — The original placental site situated
at the fundus of the uterus was in a gangrenous
condition and had yielded, leaving a large aperture.
The specimen was submitted to the pathologist,
who could render no aid in arriving at its causation.
Cancer. — A very pronounces) feature of the cases
adtnitted during 1917 was the comparatively early
.igc at which they became victims of the disease.
The ages in years were : 26, 32, 34, 44, 45, 46,
18, 49, .50, 64 ; average 43'9 years. It is therefore
very much to be desired that the general public
would realize tliat cancer is no longer a disease
of old age, and that early surgical treatment alone
offers them any possibility of obtaining relief or cure.
Operations. — These numb(>red 1,006 during the
year. Brief mention may be made of the following
cases : —
Injuries.
(A) Bullet Wound Perforating Intestine. — Lapar-
otomy, suturing of bowel. A young East Indian,
aged 23 years, was admitted to hospital at 8.40 a.m.
with the history that he had been shot about 9 p.m.
the previous night. On admission his general con-
dition and pulse were bad, but with continuous
saline infusion per rectum he improved. Under
ether anaesthesia, his abdomen was opened and
revealed the fact that the bullet had entered behind
in the lumbar region to the right of the spinal
column, penetrated into the abdominal cavity to the
right of the ascending colon, perforated the small
intestine (ileum) in two places and lodged in the
anterior abdominal wall (right rectus muscle). The
bullet was extracted, the wounds in the intestine
closed by sutures, the abdomen washed out and
drained. The wound of entrance, posteriorly, was
slow in closing; otherwise his recovery was un-
eventful.
(B) Penetrating Wound of Abdomen. — Protrusion
of bowel, reduction and repair. A boy, aged 11
years, was brought twenty miles to hospital with
a wound of the abdominal wall above the bladder
through which two feet of small intestine were pro-
truding, caused by falling on the broken branch of
a tree. Under chloroform the gut was cleansed,
returned to the abdomen, and wound closed. A
mild peritonitis, which subsided after the removal
of a few sutures for drainage, developed. He left
hospital six weeks later.
(C) Incised Wound of Chest Wall. — Protrusion of
lung, reduction, &c. .\n elderly East Indian woman
was admitted in a semi-collapsed and very dyspncsic
condition with an incised wound on the left side
of her chest cutting through the seventh and eighth
ribs into the pleural cavity, a portion of lung bulging
through the wound. The lung and pleural cavity,
which latter contained a quantity of blood and clots,
were irrigated with Dakin's solution, the lung re-
stored and a firm pad applied. Forty-eight hours
later Carrel's method of irrigation was commenced.
The patient also had other severe incised wounds,
one of which had divided her right clavicle and
another cut through the shoulder-blade into the
shoulder-joint. These latter were treated with the
" Bipp " preparation. .\11 her wounds healed very
rapidly.
(D) Rupture of Spleen. — Laparotomy, tampon-
age. A moderately nourished East Indian was
admitted from Couva with a history that a cart
wheel had passed over his abdomen. On admission
he showed signs of intra-abdominal hemorrhage,
and a weakening pulse. Laparotomy was per-
formed under chlorofonu and. ether smaesthesia and
the abdominal cavity was found to contain a large
()uantity of blood which was washed out. The
spleen— the source! of the htemorrhage — had two
rents situate<l on the jjosterior border. These wen-
plugged with a large sterilized cloth, the end of
which was brought through an incision at the left
subcostal margin in a similar manner to the
60
THE JOUBNAL, OF TBOPICAL MEDICINE AND HYGIENE.
[Aug. 2, 1920.
method adopted with the successful case described
in my last year's annual report. Five days later,
adhesions having formed, the cloth was removed
and a drainage tube substituted. The wound
subsequently suppurated, but eventually healed
coinpletely.
Intestinal.
(.4) Intestinal Obntruction — Volvulus. — Lapar-
otomy. A well-nourished woman, aged 25 years,
was admitted with a history of intestinal obstruction
of five days' duration. Laparotomy revealed a
general peritonitis with volvulus of the small intes-
tine causing extensive thrombosis of the mesentery.
A small portion of the omentum which was gan-
grenous had to be excised, after which her abdomen
was washed out and drained. Her recovery was
uninterrupted.
(B) Intestijial Obstruction — Bands. — Laparotomy.
An ill-nourished woman was admitted with the
history of chronic intestinal obstruction becoming
acute. Five years previously she had been operated
upon for a ruptured ectopic pregnancy which had
been followed by general peritonitis necessitating
drainage. Laparotomy demonstrated the presence
of numerous bands of adhesions between the coils
of intestines, while one portion of the small intes-
tine which was constricted in two places was becom-
ing gangrenous. This portion was resected, the
gut reunited with a ^lurphy's button and many of
the adhesions divided. Apparently paresis super-
vened as no action of the bowel resulted ; the gut
with button was therefore examined, a leakage
found to have occurred, the button removed and
an artificial anus instituted. Immediate relief was
obtained, but though the patient improved, she
and died eleven days later apparently from
(C) Acute Intestinal Obstruction — Hernia reduc-
tion "en bloc." — Laparotomy. A man, aged 39
years, was admitted with a strangulated inguinal
hernia, which was reduced by taxis. The symptoms
of intestinal obstruction persisted however, and
laparotomy had to be resorted to. The abdomen
contained much bloody effusion and a portion of
small intestine which had been reduced en bloc.
An incision had to be made into the distended
bowel to allow of the escape of some faeces and
gas before reduction could be effected. After clos-
ing the wound in the gut with sutures, the abdomen
was washed out and closed. He was discharged
well one month later.
(D) Strangulated Inguinal Hernia in a Female
with Reduplicated Sac. A. stout woman, subject of
mitral stenosis, was admitted with a strangulated
inguinal hernia. With cocaine anssthesia the sac
was exposed and found to have a double sac. A
piece of omentum which was gangrenous had to be
excised. Her convalescence was rapid.
(£) Artificial .inus. — ^Closure and restoration to
normal. This patient had been operated upon the
previous year for general purulent peritonitis
secondary to a ruptured pyosalpinx. Her condition
later was so critical in consequence of the develop-
ment of " ileus " that a temporary artificial anus
was made and she gradually improved.
Under stovaine anaesthesia (five months later) the
adhesions around the. artificial anus were separated
from the abdominal parietes and the opening in the
bowel closed by two layers of sutures. The bowel
was reintroduced into the abdomen and the ab-
dominal wound repaired and closed. Her recovery
was excellent, and she gained rapidly in weight.
(F) Idiopathic Dilatation of Colon. — Laparotomy.
This very rare condition presented much difficulty
in arriving at a diagnosis. A young girl, aged 13
years, was recommended to hospital for removal
of a firm tumour in her lower abdomen. She had
also a severe ankylostomiasis infection which neces-
sitated prolonged treatment, after which her general
condition rapidly improved. The tumour, which
was mobile, could be pushed upwards to the Uver
and downwards into the pelvis. On opening her
abdomen she was found to have a congenital dilata-
tion of the descending colon, the apex of the dilata-
tion being occupied by a large mass of impacted
faeces. This was inassaged downwards and the
abdomen closed. No re-accumulation had occurred
previous to her discharge from hospital.
(G) Ruptured Duodenal Ulcer — General Periton-
itis.— Laparotomy. Thi= man was admitted at
1.30 a.m. with the history of no action of the bowels
for four days. His abdomen was very distended,
pulse 104 and irregular, while vomiting and hic-
coughs were persistent symptoms. At 4 a.m. his
abdomen was opened and a generalized peritonitis
caused by the perforation of an ulcer in the duo-
denum near the stomach was discovered. After
Hushing out the abdomen with saline solution, the
perforation was tightly plugged with gauze and the
upper end of the wound lightly packed with gauze
around a drainage tube. Three days later the plug
came away and a second one was inserted. Six
weeks later the wound had completely healed.
(H) Enteric Fever with Acute Gangrenous Appen-
dix {perforation) and Peritonitis. — Appendicectomy
and drainage. A moderately nourished East Indian
was admitted from Couva with general purulent
peritonitis. Laparotomy revealed a gangrenous
appendix which had ruptured. The appendix was
removed and abdomen drained but without averting
a fatal issue. Post mortem. There was present in
addition enteric ulcers of the small intestine.
GyN.a;coLOGicAL.
(.1) Extni-uterine or Ectopic Pregnancies. — Six
cases : —
(1) .\n East Indian was admitted with a history
suggestive of an extra-uterine pregnancy. Lapar-
otomy was performed and the right Fallopian tube
was found to contain a sac with blood-clots and an
eight-week-old foetus. From a small rupture in
the tube blood was oozing into the abdomen. The
affected tube was ligatured and removed. Her
recovery followed.
Aug. 16. 1920.] COLONIAL MEDICAL SEPOBTS— TEINIDAD AND. TOBAGO.
Colonial Hedieal Reports. -No. 110. -Trinidad and Tobago
{contmiicdf.
(2) An East Indian was admitted with the mis-
leading history that after two months amenorrhcea
she had an abortion ten days previous to admission.
Per vaginani a tumour connected with the left
broad ligament could be palpated. Laparotomy
revealed the fact that the fluid accumulation was
shut off entirely above from the abd(,minal cavity,
the peritoneal covering of the pelvis being lifted up-
wards. The abdomen was closed, and per vaginani
the cystic cavity opened into through the posterior
fornix and was emptied of it^s putrefying foetal
elements, evacuated, and irrigated through a small
Bozemann's intra-uterine canula. She was dis-
charged well six weeks later.
(3) This was a very similar case to the last and
was treated in the same manner with a like result.
(4) An intensely anteinic woman was admitted
with the history of three months amenorrhcea suc-
ceeded by a profuse and prolonged menorrhagia.
Her temperature was l()3-80 F., pulse 132, and
abdomen distended. Laparotomy showed her peri-
toneal cavity to be full of blood and clots, the result
of a left tubal pregnancy which had ruptured.
After salpingectomy of the affected tube, her abdo-
men was filled with saline and she slowly improved.
Eight days later she developed a thrombosis of her
left femoral vein, and the next day suddenly ex-
hibited symptoms of an embolism of the lung which
caused her death. Post nioviem : A well-marked
embolism was found cutting off almost the entire
blood supply to the right lung.
(5) This patient was admitted from Erin with
apparently general peritonitis, a thick purulent
vaginal discharge and a history of regular menstrua-
tion with abdominal pains of four weeks' duration.
The evidence therefore pointed to a ruptured pyo-
salpinx with peritonitis. Her temperature was
103-80 F., pulse threa<ly and very fast. Laparot<jmy
demonstrated a rupture in the left broad ligament
leading into a haematoma between its layers. The
left tube contained a sac which evidently some time
previously had ruptured downwards between the
layers of the broad ligament, the latter of which had
given way at a more recent date into the general
peritoneal cavity, the blood-clots and effusion in
which were semi-purulent. Salpingectomy and
drainage came too late however to save her life.
(tj) The last case was that of an East Indian who
was admitted with a history of an abortion but
showed symptoms of intraperitoneal haemoiThage.
Laparotomy confirmed the source of the haemorrhage
to be a ruptured left tubal pregnancy. Salping-
ectomy was carried out. For twenty-four hours her
condition remained critical, after which she rapidly
proceeded to recovery.
The presence of advanced ankylostomiasis in a
very large proportion of East Indian women,
together with the misleading history of an abortion,
renders it a matter of extreme difficulty to decide
in some cases whether the patient is suffering from
a leaking ectopic pregnancy or merely a severe
ankylostomiasis injection with intense anaemia,
slight ascites, and a recent abortion.
As failure to diagnose a ruptured ectopic preg-
nancy means certain death for the patient, it is
now my invariable practice in such doubtful cases
to infiltrate the middle line of the abdomen below
the umbilicus for a distance of 2 in. with a
local anaesthetic. A small painless incision is then
made dividing the tissues down to and exposing a
small area of the peritoneal sac, a minute incision
into which at once demonstrates whether its con-
tents is serous or hsemorrhagic. In the former case
a trocar can be inserted and its contents evacuated ;
in the latter a general anaesthetic is at once ad-
ministered and the major operation proceeded with.
(B) Hysterectomy — Uterine Fibroids. — The only
case which ended fatally is of interest in demon-
strating the difhculty which is sometimes encoun-
tered when arriving at a decision with regards to
operative interference. An ill-nourished woman
was admitted in an intensely anaemic condition
suffering from severe menorrhagia due to uterine
fibroids and which completely incapacitated lier
from pursuing any vocation. In spite of prolonged
treatment for many months in hospital, it was
found impossible to coinpletely overcome the
anaemia in consequence of the very profuse menor-
rhagia which still continued on an average for two
weeks during each month. It was therefore even-
tually decided to operate shortly before an attack
was expected when her condition was at its best.
Subtotal hysterectomy was performed. Towards
the end of the operation she showed signs of col-
lapse but rallied. After coming out of the ana;s-
thesia, she exhibited symptoms suggesting delayed
chloroform intoxication (coffee ground vomitus,
&c.), a consequence apparently of the anaemic con-
dition of her blood, and succumbed eight hours later.
(C) Bicornuate Uterus. — Laparotomy — Salpingec-
tomy.— ^A young girl, aged 17 years, was admitted
with the history of a uterine tumour increasing in
size. She was kept under observation in hosprtal
and as her menstruation was quite regular, laparo-
tomy was performed. A large cyst involving the
tiirminal jiortion of the right Fallopian tube (whose
contents had all the characteristics of retained
nicnstriial fluid) was excised. Her uterus was bifid,
the cleft which hemisected the organ extended
down almost to the lower uterine segment. Her
abdomen was then closed, and she has- been kept
under observation, but no recurrence of a blockage
has been observed.
(D) Congenital Absence of Cervix — Atresia Uteri.
— Hysterectomy (partial). — ^The case was unique in
many respects. A young woman, aged 26 years,
was admitted to hospital with a uterus enlarged to
about the size of a five inonths' pregnancy. Her
history was that at the age of puberty it was
noticed that her condition was not normal as she
never menstruated via the vagina but always and
regularly via the rectum. As she suffered no in-
convenience otherwise and her health never suffered
she never sought medical advice. Six months
THE JOUKNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 16, 1S20.
before admission to hospital all menstruation
ceased, even via the rectum, a tumour developed
which became progressively larger and more tender,
while her health suffered considerably and she began
to get thin. Examination per va<jiiiam revealed an
hour-glass-shaped vagina with a perfectly smooth
dome and entire absence of any cervix; while bi-
manually ithe tumour above was found to be a
distended uterus.
Under chloroform her abdomen was opened and
the uterus was found to have been converted into
a huge thin-walled cyst very much thinner at the
upper (fundal) extremity ; on the antero-superior
aspect it was adherent to the bladder surroimded
by omentum and commencing to leak. The entire
dilated and attenuated portion was excised down to
the openings of the Fallopian tubes until healthy
uterine tissue was reached. The two halves of the
uterus were then sutm'ed together with two layers
of sutures until the uterus was restored to about
its normal size. A drainage tube was then in-
serted down to the bottom of the pouch of Douglas
as it was impossible to avoid a certain amount of
contamination of the peritoneal cavity with the con-
tents of the uterus which consisted of retained
menstrual fluid. After closing the abdominal
wound, an artificial opening was made through the
roof of the vagina into the lower segment of the
uterus.
The abdominal woimd eventually healed com-
pletely and the patient presents herself periodically
to have the artificial opening dilated ; and through
which she now menstruates regularly. She has
gained considerably in weight and her health has
been quite restorea to normal.
(E) Suppunitivr Salpingitis uith (Icnfidl I'uiiilciif
Peritonitis. — 'Three cases were admitted with the
classical signs of general purulent peritonitis.
Two cases were treated by laparotomy and drain-
age of the abdominal cavitv suprajiubically, of which
one ended fatally. The third case was treated by
drainage of the abdomen through the vagina (pos-
tero colpotomy) with a successful result.
(F) Ruptured Dermoid Ci/st with General Pundcnt
Peritonitis. — Ovariotomy. This case, which ended
fatally, was admitted from Erin in an almost mori-
bund state. Laparotomy with excision of the cyst
and drainage only succeeded in postponing her
death thirty-six hours. Post mortem, her kidneys
were found to be cystic.
(G) Ruptured Ovarian Abscess with General
Purulent Peritonitis. — The condition of this patient
on admission was found to be very siinilar to the
previous case. Laparotomy revealed the cause to
be an abscess of the ovary which had burst. Re-
moval of the diseased organ with drainage ended in
recovery.
During the year very gratifying results have been
obtained in the treatment of septic wounds,
especially compound fractures, by either a modified
Carrel's method of irrigation with Dakin's solution
or by the application of Rutherford Morrison's
" Bipp " paste. The former is utilized in very
purulent cases and the latter when the sepsis is
slight.
E. A. TuRPiN,
Resident Surgeon
Lunatic Asylum.
Admissions, Discharges, Deaths. — The admissions
were forty fewer than in the previous year, the
decrease being nearly equally divided between the
sexes. Cases about 65 years of age were also below
the average number, while admissions under 21
years of age were more numerous than usual.
Incjuiry into the history of the admissions disclosed
that (a) only seventeen were known to be relapsed
cases; (b) the duration of mental disorder before
admission had probably not exceeded three weeks
in over 50 per cent, of the cases; (c) insane heredity
or obvious congenital defect existed in 45 per cent.,
the real proportion being probably much higher;
((/) alcoholism and mental stress (not apparently
due to war conditions) were the chief exciting causes
of the mental disorder.
The proportion of relapsed cases among the ad-
nussions continues to diminish — probably a result of
the tendency of recent years to bring mental dis-
order earlier under asylum treatment, leading in
many cases to more stable if not earlier recovery.
It is, however, the number of " first attack " cases
which affords the real index to the incidence of
insanity in a community, and although there were
thirty-one less than in the previous year, the aver-
age of the past three quinquennial periods shows no
tendency to decrease, the extent to which inherited
predisposition enters into causjition being rather
)nore marked each period.
The percentage of recoveries on admissions was
the highest since 1909. This increase which was
more marked among the females may be attributed
to the more favourable character of the admissions
during the past two or three years. In more than
half of the recoveries the duration of residence in
the institution exceeded eighteen months. It is
impolitic to regard mere subsidence of mental dis-
order as recovery or fitness for discharge. The
benefits of prolonged treatment in the institution
associated with regular hours and freedom from
responsibility are reflected in a reduced relapse rate.
The deaths numbered eighty-six and included
twenty-eight from pulmonary tuberculosis and
eleven from dysentery (colitis). The percentage
(12- 18) of deaths on the average number resident
WHS the lowest for the past five years.
In spite of the occurrence of mild chicken-pox
among the patients and staff and of four cases of
typhoid fever the general health of the institution
was fair.
The high average of work attained in recent years
was well maintained with regard to indoor as well
as outdoor employment. The cultivation of ground
provisions was largely extended and the yield was
double that of the previous year.
Geo. a. Vincent,
Medical Superintendent.
Aug. 16, 1920.J
COLONIAL MEDICAL REPORTS— CAIEO.
63
CocoRiTE Leper Asylum.
On December 31 the population of the asylum
was 502, consisting of 304 men, 32 boys, .140 women,
and 26 girls. The general accommodation of the
institution therefore will be seen to be inadequate
to :neet the increase in the number of patients, and
consequently temporary arrangements had to be
made by using verandas and other available space.
The buildings are in good condition and the
grounds kept in good order.
The water supply is efficient and the water of
good quality and ample.
No changes have been made in the dietary. The
meal hours of the prison have been altered to fit in
with those of the asylum.
General Remarks. — One birth from a leper inother
outside and one inside are noted. Both children
were born healthy. There were the usual number
of cases before the magistrate. The prison is now
under control of the Prison Department. The new
latrine by the infirmary should have been placed
farther away. C'oDcerning absconding, under the
existing conditions this cannot be bettered. Even
if absolute segregation were enforced escapes of in-
mates could easily be effected. The grounds are
still not efficiently illuminated at nights, and the
sickly lights allowed the wards can do no more than
make darkness visible. Therefore it is desirable
that an installation of the electric light should be
made.
Charles W. Howatson,
Medical Superintendent.
St. Augustine Yaws Hospital.
Water Supply and Drainage. — The water supply
and drainage are both unsatisfactory. A large sum
is paid annually for water, whereas the large roof
of the hospital could supply all that is needed if a
cistern were built.
Concrete drains are needed in front of the build-
ing.
The diet scale is satisfactory, but beef and pro-
visions were at times unobtainable.
There were two prosecutions for misbehaviour in
hospital. Six patients absconded.
Isolation rooms for the segregation of infectious
diseases are required to be built apart from the
hospital.
There were 1,203 admissions durmg 1917, and
the number admitted since the opening of the hos-
pital is 11,596.
Deaths 13, from the following causes : Tubercu-
losis, 1 ; dysentery, 5 ; abscess and anaemia, 1 ;
meningitis, 1 ; worms, 1 ; dysentery and Bright's, 1 ;
influenza, 1; senility, 1; cardiac failure, 1. Two
of these cases were not injected. Two deaths, one
from abscess and the other from meningitis, I think
were results of the injection.
There was an epidemic of varicella which started
in January and ended in August. The total number
of cases was 156. If there were proper means of
isolation it is probable that the epidemic would have
been checked earlier. Five lepers were admitted
and subsequently transferred to the Leper Asylum.
The hospital has been overcrowded often during
the year. This overcrowding is not conducive to
the welfare of the institution and the inmates, from
a disciplinary point, nor from a sanitary.
T .^LnRI(• Perez,
D.M.O. St. Joseph.
Colonial Medical Reports. — No. 111. — Cairo,
REPORT OF THE MEDICAL OFFICER OF HEALTH
CAIRO CITY, FOR THE YEARS 1915 AND 1916.
By J. FERGUSON LEES,
Medical Officer of Health, Cairo City.
\'lT,\
Statistic
For IfllC) the pf)pulation \\:is estimated at
7 40,000. consisting of 665,000 Egyptians and
75,000 foreigners.
During 1915, 29,033 births occurred in Cairo.
The annual birth-rate was therefore 40-8 per thou-
sand of the population, as companvl with 43' 1 per
thousand in 1914.
Of these 451 were foreigners.
In 191C> the number of births was 31,170, making
an annual iiirtli-rati' of (21 jicr thousand of popu-
lation, as compared with 108 per thousand in
1915.
Of these 456 were births of foreigners.
The total number of deaths occurring in Cairo
during the year 1915 was 32,5,54. This gives an
annual deatli-ratc- of 443 per thousand of th(!
po|)ulation, as compared with a rate of 360 per
thousand for 1914.
In 1916, the total number of deaths in Cairo was
28,320. This gives a death-rate per thousand of
the population of 38"3, as compjired with a rate of
44-3 in 1915.
64
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 16. 1920.
Of children under the age of 1 year, 9,592 died
in Cairo in 1915. This gives an infantile mortality
rate for the whole city of 320 ppr thousand births,
as compared with 283 per thousand in 1914.
In 1916, 9,208 children under the age of 1 yeai-
died in Cairo. The infantile mortality rate per
thousand births was therefore 295 in 1916, as com-
pared with 320 in the previous yeaa-.
The principal causes to which the infantile deaths
in 1915 and 1916 were attributed were, as usual,
diai-rhoea, enteritis and marasmus.
Infectious Diseask.
During the year 1915, 11,422 cases of infectious
disease were recorded in Cairo, as against 5,413 in
1914; 4,161 in 1913; and 2,895 in 1912. This
enormous increase in 1915 over the pi-evious year's
figures is such as to call for special consideration.
In 1914 the increase was largely due to increased
discovery of cases, but also partly due to the occur-
rence of an epidemic of small-pox.
In 1915, of the total of 11,422 cases of infectious
diseases recoi-ded, approximatelj- three-fifths were
reported as cases of typhoid fever.
The year 1915, from an infectious disease point
of view, may therefore be considered as character-
ized by an undue prevalence of typhoid fever, and
of a disease presenting such a close resemblance to
typhoid fever that almost aJl the cases were origin-
ally notified as the fonner disease.
The total cases and the morbidity rates of the
eight principal notifiable diseases recoitled in 1915
show a very considerable inci'ease over those of the
previous years. As regards those figures, how'ever,
the effect of tlie increased measures of control
applied since 1912 has so interfered with the
recorded annual totals as to render a free accept-
ance of them as a basis for the comparison of
zymotic incidence in the various yeai-s vmjustifiablo,
and to call for some analysis of the results before
arriving at any conclusion.
Typhoid Fever. — During 1915 the number of
cases of typhoid fever attributed to Cairo was ex-
tremely high, there being a total of 2,378 cases,
giving a morbidity rate of 3-242 per thousand of
population, as compai-ed with 1-941 per thousand
in 1914, 1-017 per thousand in 1913, and 0-642 in
1912. The number of deaths was 1,012, giving :i
death-rate per thousand living of 1379, as com-
pared with rates of 0-428 in 1914, 0-313 in 1913,
and 0-248 in 1912.
This increased tleath-iatc was not, however,
altogether unexpected.
As has already been indicated, in the beginning
of 1915, with the advent, first, of an undue pre-
valence of typhoid fever and later of the epidemic
of the unidentified fever already refei-red to. tlie
situation as regards the public health of the city
became such as to call for the apiilicatiim of exci'])-
tional measures.
Both diseases were occurring princi])ally in the
more poverty-stricken cjiiarters, where the condi-
tions of home life were such as to render any home
control impossible, and a considerable proportion
of the cases had therefore to be removed to hospital.
The increased death-rate from this disease, there-
fore, may largely be attributed, in the manner pre-
viously spoken of, to this action, which from the
nature of the disease, substituted, in the case of
a considerable proportion of its deaths, the cer-
tainties of hospital diagnosis for the possibilities of
missed post-mortem identification of the cause had
the case only been seen after death.
The Unidentified Fever of 1915. — The most pro-
minent feature in 1915, from a zymotic point of
view, was the extensive outbreak of an imidentified
fever, which began in March and ended in August
or September.
Certainly none of the twenty-three hospital cases,
which were reconled in the last three months as
possible cases of the disease in question, could be
taken as typical examples of those which had pre-
viously been diagnosed as such, and it is almost
certain that, without the previous occurrence of the
unidentified fever, these would have been adjudged
merely somewhat atypical cases of typhus. I am
afraid, therefore, that as regards these later cases
the wish was to some extent father to the thought,
and that the desire to find examples for a con-
tinuation of the investigations produced a tendency
to record cases certainly open to doubt as actual
cases of the disease. As, however, the number of
typhoid notifications in the last three months was
unimportant, it was considered, for reasons of con-
tinuity, advisable to continue to show the estimates
as based on the hospital figures.
As already indicated, circumstances did not
admit of sufhcieiit investigations to det<?nnine the
nature of the disease, but certain facts have been
recorded in an apjjeudix to this i'eport.
Typhus Fever. — The number of cases of typhus
fever recorded in 1915 was 1,112 cases, giving a
morbidity rate of 1-516 per thousand of population,
as compared with rates of 0483 per thousand, 0-301
per thousand, and 0329 per thousand in 1914, 1913,
and 1912 respectively.
It is difficult definitely to state to what extent
the increased rate in 1915 is to be taken as indi-
cating iUi actual increase in incidence, inasmuch
as the figures for this year ai-e undoubt^dlj- inflated
by the inclusion of a large number of cases which
Were incidentally brought to light in the course of
the special investigations regal-ding concealed cases
of tyjihoitl and the unidentified fever.
The death figures for this year ai-e, however, un-
doubtedly erroneously high as a result of a known
source of error affecting one district, but discovered
too late to permit of any satisfactory basis of re-
adjustment.
Eehip-siuy Fecer. — The nmnber of cases of re-
lajising fever recorded in Cairo in 1915 was 456.
giving a morbidity rate of 0-621 per thousand of
])oi)ulation, as comjiared with rates of 0018, 0-029,
and 0-052 per thousand in 1914, 1913, and 1912
respectively.
ll
Sept. 1, 1920.]
COLONIAL MEDICAL BEPORTS.— GAIEO.
65
Colonial Medical Reports.— No. 111.— Cairo (continued).
Tlicro wero eighteen deaths, t,'i^'"o ■'' <ioath-ratti
of 0024 i>('i- thousand living, as coinpared with
0 (iiil in IIU 1, 0-006 in 1913, and 0004 in 1912.
'I'lidii^'li tiirsc figures would aj^pear to indicate an
iiuTi-asi' ill the incidence of this disease in 1915,
there was nothing to suggest that an explanation
of the increased figures need be looked for further
than in a larger proportion of discovered cases found
in the course of inijuiries into concealed cases of
unidentified fever.
Diphtheria. — During 1915 there were recorded
1,286 cases of diphtheria, giving a morbidity rate
of 1-753 per thousand of poj)ulatiori, as compared
with rates of 1-945, 1-827, and 1-573 for 1914,
1913, and 1912 respectively. Of the 1,286 cases,
462 died, making the death-rate for the disease
0629 per thousand living, as compared with 0943
in 1914, 0-785 in 1913, and 0748 in 1912. The
ratio of deaths to cases recorded was 35-9 as com-
pared with 48-5 per cent, in 1914, 42-9 per cent,
in 1913, and 47-6 per cent, in 1912, a diminution
in the ratio for 1915, which suggests an improved
position as regards the discovery of cases.
The disease showed its usual seasonal prevalence,
being most marked in the autumn, reaching its
maxinmm at the end of October, and being lowest
in April, May and June.
Measles. — During 1915 the incidence of measles
was low, only 363 cases being registered, giving a
rate of 0-494 cases recorded per thousand of popu-
lation, as compared with 0-646 per thousand in
1914, 1-518 per thousand in 1913, and 1-085 per
thousand in 1912.
The highest weekly record of cases was in April.
The ratio of deaths to cases recorded for the whole
city was 303 per cent, as conipsu-ed with 264 in
1914.
Hmall-pox. — The numbi'r of cases of small-po.x
recorded in 1915 was onlj' fifty-nine, giving a mor-
bidity rate for the disease of 0-080 per thousand of
population, as compared with rates of 1-354, 0385,
and 0-096 in 1914, 1913, and 1912 respectively.
The number of deaths was twelve, giving a death-
rate for the disease of 0-016 per thousand living,
as comijured with death-rat«s of ()-249, 0-069, and
0-022 in thi^ three previous years.
In my report for the previous year I entered at
some length on the reasons upon which was based
a decision in 1914 to include chicken-pox in the
small-pox records. In a year such as that, which
was characterized by an extensive epidemic of
small-pox, the proportion of cases wrongly reported
as chicken-pox was found to be so extremely lai-ge.
that the inclusion of the small number rightly so
diagnosed amongst the sinall-pox figures had little
material effect on these.
In 1915, how('V(-r, no undue prevalence of the
graver disease occurred, and thc^re was nothing to
indicate that any of the 143 cases notified as
chieken-pox in 1915 were other than as labelled.
Cercbrosjiinid Finer. — The incidence of this
disease in 1915 was lower than in any year since
I have been in charge of Cairo, the total number
of cases recorded, being only fifty-three, with
twenty-six deaths, giving a ratio of deaths to cases
recorded of 49-05.
The majority of the cases occurred in Mai-ch,
April and the beginning of May.
Scarlet Fever. — Only thirty-seven cases of scarlet
fever wei'e recorded in 1915, giving a morbidity rate
of 0-050 per thousand of population, as compared
with 0-135 per thousand in 1914, 0233 per thou-
sand in 1913, imd 0-151 per thousand in 1912.
Of the thirty-seven cases, seven died, giving a
death-rate for this disease, in 1915, of 0-009, as
compared with 0-012 in' 1914, 0037 in 1913, and
0-032 in 1912.
The ratio of deaths to cases recorded was 18-9
per cent.
Puerperal Fever. — During 1915 there were eighty-
five deaths recorded from puerperal fever. Of
these, eighty-one were deaths of Egyptian women
and four of European.
These eighty-five deaths give a death-rate of
0-115 per thousand of population, as compared with
0-066 per thousand in 1914, and 0-103 per thousand
in 1913.
Calculated on the number of births the maternal
death-rate from this cause per thousand births was
2-839, as compared with 1-532 in 1914 and 2-34 in
1913.
Considering the parturition conditions in this
country amongst the lower classes, these rates are
remarkably low and comi)ai-e very favourably with
countries where the conditions are much more
advantageous.
In addition to the eighty-five deaths actually
certified as from puerperal fe^'er, thirty-two deaths
of parturient women were noted as occurring
within a period of fifteen days after confinement.
The causes of death assigned in these cases were :
Haemorrhage, eight; tuberculosis, two; dysentery,
one; ruptured uterus, one; difficult labour, three;
heart disease, one ; adherent placenta, one ; typhus,
one; typhoid, three; uraemia, one; nephritis, one;
abortion, three; peritonitis, one; and eclampsia,
five. Possibly some of those cases ought rightly
to have been certified as |)uerperal fever, but even
if we include them all with the eighty-five deaths
actually reported as from that cause, the total of
117 deaths only gives a rate for deaths in con-
nection with parturition of 0-159 per thousand of
population, or a maternal death-rate per thousand
births of 3,903, a result which must be rather sur-
prising to anyone aware of the circumstances
surrounding parturition amongst the lower classes
in the country.
Typhoid Fever. — In 1916 there were 1,462 cases
of typhoid fever recorded in Cairo, as against 2,378
in 1915. The 1916 morbidity rate from this disease
was therefore 1-975 per thousand of population, as
compared with 3242 in th(^ i)revious year.
'llieri' were 632 deaths re(!orded from this cause,
the death-rate in 1916 being therefore 0854 per
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 1. 1920.
thousand living, as against a rate of 1-379 in 1915.
If reference be made to the description of the
disease for 1915 it will be seen that, in that year,
Old Cairo, of all the other districts, showed the
lowest morbidity rate and one of the lowest death-
rates. This position was almost certainly entirely
fictitious, and was undoubtedly due chiefly to a
eonceahnent of large numbers of cases.
An increased discovery of cases in the present
year furnishes, in large part, the explanation of
the altered position in which this district finds
itself in 1016, not only with regard to typhoid fever,
but to typhus luid relapsing fever as well.
The weight to be attached to the ratios of deaths
to cases recorded as indices of relative case detec-
tion has been so modified by the comparatively
greater increase in the discovery of cases likely to
prove fatal, that its value is somewhat problem-
atical in diseases such as typhoid, typhus, and
relapsing fevers, where the post-mortem external
appearances present no obvious characteristics.
Typhus Fever. -—During 1916, 1,858 cases of
typhus fever were recorded in the city, giving a
morbidity rate of 2-510 per thousand of population,
as compared with a total of 1,112 cases and a
morbidity rate of 1-516 in 1915.
Of the cases recorded, 1,075 died, giving a death-
rate of 1-452, as compared with a total of 718
deaths, and a death-rate of 0-978 in 1915. The
ratio of deaths to cases recorded in 1916 was 57 8
per cent., which was somewhat lower than the
646 per cent, of 1915. Both ratios, however, have
been subject to the influences already described,
and it is to be remembered, in connection there-
with, that typhus fever is one of the diseases most
likely to be affected thereby.
Relapsing Fever. — During 1916, 1,035 cases of
relapsing fever were recorded in Cairo city, giving
a morbidity rate of 1-398 per thousand population
in 1916, as compared with a rate of 0-621 in the
])revious year. Of the cases occurring in 1916 there
were fifty-nine deaths, giving a death-rate for this
disease of 0-079 per thousand of population, as
compared with a death-rate of 0-024 in 1915.
The ratio of deaths to cases recorded was 57 per
cent., as compared with 3-9 per cent, of the pre-
vious year, but the amallness of the figures and the
fact that the influences, already described as tend-
ing to an increase of this ratio, may have acted with
varying effect in the two years renders any deduc-
tions based on their comparison open to objection.
Diphtheria. — There were 836 cases of diphtheria
registered in Cairo city during 1916, with a, mor-
bidity rate of 1-129 cases per thousand inhabitants,
as compared with a rate of 1-753 in 1915.
There were 335 deaths recorded from this disease,
giving a death-rate of 0-452 per thousand living, as
compared with a rate of 0629 in 1915.
The ratio of deaths to cases recorded was 40-07
per cent, of deaths recorded in 1916, as compared
with 359 per cent, in 1915.
Measles.— During 1916, 1,222 cases of iiuasUs
wi-n- recorded in Cairo, giving a niiirl)i(lit\ latr of
l-651*i)er thousand of population, a.s (.iuuiuul.I v\ith
0-494 in 1915.
There were 607 deaths, giving a death-rate for
this disease of 0-820 per thousand living, as com-
pared with a death-rate of 0-149 in 1915.
The ratio of deaths to recorded cases was 49-6 per
cent., as against 30-3 per cent, in 1915.
Small-pox. — In 1916 there were 277 cases of
small-po.x recorded in the city, giving a morbidity rate
of 0-374 per thousand of population, as compared
with a rate of 0080 per thousand in 1915. The
number of deaths from this cause was 103, with a
death-rate of 0139 per thousand living, as against
a rate of 0-016 in 1915.
During 1916, 162 cases were notified as chicken-
pox. There was nothing to suggest that these were
otherwise than rejwrted, but in discussing the
incidence of small-pox in 1915, reference was made
to the possible utility of charting the relative sea-
sonal prevalence of chicken-pox in comparison with
that of small-pox, in years when a comp'arative
paucity of cases permitted of some confirmation of
the individual diagnoses, with the view of obtain-
ing information as to possible differences of seasonal
incidence such as might provide assistance during
excessive prevalence of one or other of the diseases
in checking the fallacious diagnoses of chicken-pox
frequently made in order to avoid hospital isolation.
Cerebrospinal Fever. — In 1916 there were thirty-
three cases of cerebrospinal fever recorded in the
city with a morbidity rate of 0-044 per thousand
of population, as against 0-072 in 1915. The deaths
recorded were twenty-three, showing a death-rate
from this cause for the whole city of 0-031, as
compared with 0035 in 1915. The ratio of deaths
to cases recorded in 1916 was 69-6 per cent., as
against 49-05 in 1915.
Scarlet Fever. — During 1916 there were recorded
in Cairo city forty-eight cases of scarlet fever. The
morbidity rate was therefore 0-064 per thousand of
population, as against 0050 in 1915. Two of the
cases died, giving a death-rate of 0-002 per thousand
living, as compared with a death-rate of 0-009 in
1915.
Puerperal Fever. — In 1916 the number of deaths
certified as from puerperal fever was seventy-five,
of which seventy-three were deaths of Egyptian
women and two of European. The death-rate for
this disease, therefore, per thousand of the general
])()I)iilati(in was 0-113, as comparexl with 0-115 in
1!II5. Estimated on the birth figures for the year,
the maternal death-rate from puerperal fever was
2 '406 per thousand births, as compared with 2-839
in 1915. The rates for this disease in Cairo are
.therefore low.
With the object of checking the correctness of
the figures, special note has been taken for the last
three years of deaths of all women dying within
fifteen days of their confinement, but even if all
such cases were included as puerperal fever, the
position would still be far from unsatisfactory,
especially in view of the circumstances generally
surrounding the parturient woman in this country.
Tlius, in addition to the seventy-five deaths
ilcclarcd as from puerperal fever, twenty-nine other
inatiinal deaths oceun-ed within fifteen days of
confinement. The causes of death assigned in
Sept. 1, 1920.]
COLONIAL MEDICAL REPORTS— CAIRO.
67
those cases were : Uraemia, five ; peritonitis, two ;
eclampsia, four; nephritis, one; dysentery, one;
difficult labour, one, hfemorrhage, nine; typhus,
thrc^e ; heart disease, one ; and tuberculosis, two.
'I'hc provision of ambulance transport, as regards
materials and personnel, remained the same as in
1913.
With the additional demand, however, made on
this service as a result of the increased number of
infectious cases now dealt with, considerable diffi-
culty has at times been experienced in meeting
all demands, and in 1915 the numiber of convey-
ances h;ul to be augmented by two motor ambu-
lan(^es lent by the Military Authorities. Without
these it would have been impossible to cope with
the very considerable calls for infectious transport
which cccuired in tlie summer of 1915, as a result
of the extensive prevalence of infectious disease at
that time.
The primiu-y duty of the service is naturally the
provision of transport for the infectious sick, but
it is expected to provide, in addition, for the car-
riage of dog-bitten persons undergoing treatment at
the Antirabic Institute, between that place and
Qasr el 'Aini Hospital, and to supply conveyance
for non-infectious sick when these are called for.
The requirements of the city as regards the last
are, however, ably met by the very efficient service
provided for this by the Agsociution Internationale
d'Assistancc Publique, and, with the exception of
the f)crir)d in 1915 when the unusual demands for
infectidiis transport necessitated the assistance of
till' .Militar\ .Authorities, it has been possible for
us s(j far to nn'ct all calls for the removal of the
infectious sick by limiting the service to this as
far as possible.
I'n^xcrtitinns.^At the end of August,, 1914, the
j)roinulf;ati()n of the law decreeing the establish-
mtiit of maxiinnin tariffs for foodstuffs and articles
of iJiiiiii 111 I-. ssit y, by making it an offence to refuse
to s( II at (li, l.ariff price fixed, enabled us to deal
iiKiir \ ti mat ically with dishonest milk dealers
ulio liail Intlii'itd been able to evade, to a groat
.■\tiait till' consciiiiirices of their dishonesty, as a
ii siat of tile (litficiilties previousli^ attending the
iWtaiiiinL' of till- samples required for examination.
I'lioi- to the aiiplication of this law, the formali-
ti's of piircliasr necessary for a successful prose-
riition srrvL'd as a warning to the vendor of the
|nirpose for which the purchase was intended, and
resulted usually in a refusal to sell whenever the
milk had been adulterated.
Under Article 4 of the new law, however, refusal
fo sell at the tariff price itself is an offence, and
vendors of milk have therefon- now to su[)p!y the
sample re<)uired on the legal price being tendered,
or rendi'r themselves liable to prosecution.
Taking advantage of this, on .\ugust 29, 1914,
arrangements for a systematic examination of milk
samples were put in operation.
Generally speaking, therefore, it may be said
that (he decrease in the number of prosecutions
niav, in tlu' main. In' taken as an indication of the
marked improvement in the position which has
resulted from an increased stringency of control,
to which reason may' also, to a great extent, be
attributed the general diminution in other classes
of prosecutions such as those dealt with under the
vaccination and infectious disease laws, though
these, however, are more exposed to accidental
influences rendering any assessment of the extent
to which this might have occurred too open to
criticism for discussion to serve any useful purpose.
There has, since 1912, been a marked and pro-
gressive decrease in the number of cases filed in
each year, and coincident with this a similarly
progressive increase in the percenttige of convictions
obtained.
Sanitary Control of Public Women.
As a result of special circumstances arising out
of the war, certain alterations have been made in
the arrangements for the registration and examina-
tion of prostitutes, which it will be desirable to
refer to briefly before proceeding to a presentation
of the position, as regards the subject, for the years
1915 and 1916.
Anterior to the war, under the powers conferred
by the civil laws, all brothels were required to be
licensed and their occupants, irrespective of nation-
ality, registered and submitted to a weekly exam-
ination, either at the central Bureau or at one of
its two branches.
Thus far in the arrangements no distinction was
drawn between native and foreign prostitutes, save
possibly such as might result from the general
difficulties attending the free application of any
regulations to foreigners. Beyond this point, how-
ever, differences occurred and the law ceased to be
of uniform application.
In the case of native prostitutes, the control sug-
gested by registration and periodical examination
was carried to its logical conclusion by the segre-
gation and treatment of their sick in the special
Lock hospital. As regards such women, therefore,
the arriingemonts in force permitted of some prac-
tical effort being given to the general idea upon
which a State control of vice is base<l.
On the other hand, the sanitary control of foreign
prostitutes wiis merely nominal. It is true that a
certain proportion of them, living in licensed
brothels, were registered and submitted to a weekly
examination, but the effect of this, in the prophy-
laxis of venereal disease, was almost entirely
heutra:lized by the absence of powers of compul-
sory isolation imd treatment in cases of disease.
Attempts were? made to curtail the activities of
such diseased women by the withdrawal of their
cards of registration, with the object of preventing
them from fre(|uenting recognized brothels. Apart,
however, from the difficulties in actual practice of
enforcing this prohibition, its object, from a health
j)oint of view, was almost entirely defeated by the
existence of numerous low-class hoti'ls and waisotia
lie IHIKHC, affording such faciliti.>s for assignation as
68
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1920.
gave ample opportunity to diseased foreign pros-
titutes for cUi unintenupted continuation of their
usual motle of life.
In order to remove this anomalous situation, and
to pennit of the extension of control to the inmates
of such houses of ill-fume as had previously escaped
this under the shelter of a foreign nationality,
towards the end of 1914 a meeting of the various
Consuls in Cairo was convened by His Britannic
Majesty's Consul, at the re(juest of the Com-
mandant of Police acting on instructions from
the Military Authorities. This was held on Decem-
ber 23, 1914, when the recjuest for the additional
powers necessary was acceded to, and it wiis agreed
that the same control as had previously been applic-
able to native prostitutes should be extended to
foreigners, subject to this condition, however,
that some consideration should be given to the
differences of habit and mode of life as between the
European and Egyptian women, by providing the
former with special hospital aeconnnodation in
which treatment would be given by European
doctors, and the living arrangements made such as
would be more in conformity with European habits
than would be the case in a native hospital.
In giving effect to this decision, arrangements
were made for the establishment of a new bureau
des mtrurs, hospital, and medical examination
room in El Ezbekiya iiuartcr for the puqiose of
dealing solely with foreign ])rostitutes, the old
bureau des niarurs and examination rooms already
mentioned being then reserved for work in con-
nection with the examination and control of public
women of Egyptian nationality.
The new hospital and examination room were
started in February, 1915, with a provision of
thirty-five beds for in-patients. This accommo-
dation, however, proving insufficient, forty-nine
more beds were added, subseijuently bringing the
in-patient capacity of the hospital up to eighty-four
beds.
At first the hospital was administered under a
somewhat complex arrangement with a military
medical officer in charge of the medical work, ex-
penses met from the Suspense Account of the
Egyptian Government, and the Police Adminis-
tration in general charge, whilst a vague and ill-
defined responsibility rested on this office, through
which the hospital accounts were passed.
This co-operative system, however, with its ill-
defined spheres of activity, did not prove an admin-
istrative success, and the control of the hospital,
a-s it stood, with the work of the examination
rooms, was finally taken over by us at the end of
1916. Previous, however, to this assumption of
definite control, this ofRce, as the channel of
financial communication, had of necessity been
more or less in touch with all arrangements for the
control of foreign jirostitutes, and the review of
the me/lical part of this control has therefore been
included in the present report, though during the
greater part of the time the work was not nominally
under our charge.
With the extension of the scope of supervision of
foreign prostitutes which resulted from the greater
powers of control thus obtained, and with the
administrative distinction between native and
foreign women demanded by the extension, a
necessary readjustment of the arrangements obtain-
ing in previous years has rendered the figures for
1915 and 1916 scarcely comparable with those of
antecedent records, unless certain allowances be
made for the modifications introduced.
Coincident with the application of a more strin-
gent control to all recognized public women, the
desirability was suggested of imposing some sort of
supervision over that large class of women, chiefly
employed in connection with places of entertain-
ment and for the most part residing in special
"pensions," who submit themselves to occasional
or partial prostitution. This desire was met at
first by requiring the weekly submission, by each
woman, of a certificate of good health from a
j)rivate ])ractitioner recognized by this office.
Though absolute efficiency of control could scarcely
be claimed for such a method, it had the certain
advantage of affording information upon which
individual action might have been based if this
were called for.
In August, 1916, however, it was decided to
discontinue this arrangement and to substitute for
it a more definite control by registration and weekly
examination.
As was to be expected from a measure of such
doubtful expediency as the fresh arrangement
seemed likely to prove by its indiscriminate appli-
cation to women submitting themselves to the
practice of a merely casual prostitution, innate
objections to its employment soon manifested them-
selves and wisely led to an early discontinuation
of an inadvisable procedure. During the brief
period, however, when the arrangement was in
force, these «vomen were submitted to a regular
examination in no way differing from that imposed
upon regulai- prostitutes, except that some allow-
ance was made for the greater delicacy of feeling
likely to be met with in the case of the occasional
prostitute than is usually found in the more
hardened habitual practitioner, by the provision of
a separate centre for the examination of the
fonner.
In deference to an undertaking given to the
women by the authority concerned in making
the arrangements, no definite medical records of the
results of the examinations are available for this
report.
(a) EXANflNATION OK NaTIVK PhOSTITUTES.
During the course of the yeai', 1,513 women wcrf
found suffering from syphilis or gonorrhoea. Of
this number, 1,117 were cases of gonorrhfea and
396 of syphilis. All were sent for treatment to the
liOck branch of Qasr el 'Aini Hospital at Hod el
MarsCid.
During 1916, the names of 2,049 women were
borne on the registers, including the 1,143 remain-
ing from the previous year.
Ji
Sept. 15, 1920.]
CX)LONIAL MEDICAL REPORTS.— CAIRO.
Colonial Medical Reports.— No. Hi.- Ca.iro (continued).
Of those, 670 were struck off during the course
<if the year, leaving 1,379 names on the books of
the old bureaux des mocurs at the end of 1916 to
be can-iod on to the following year.
During the year, 1,203 cases of syphilis and
gonorrhoea were discovered, 795 of these being
cases of gonorrhoea and 408 of syphilis.
The comparative figures show that the general
increase in the number of native prostitutes regis-
tered in 1916, as compared with the previous year,
was derived from an increase in the prostitute
population of the two quarters in closest proximity
U) military camps, or most frequented by soldiers,
whilst an actual diminution took place in the other
two quarters.
(b) Examination of Europkan Prostitutes.
There were 706 women inscribed on the registers
of the European bureau dcs iiuvurs in 1915.
Diseased conditions were found, upon examina-
tion, in 525 cases in 1915 and in 896 in 1916.
It may be mentioned, however, that, obviously
as a result of continued neglect and lack of ordinary
cleanliness, the local conditions found on the
examination of a vei-y large proportion of the pre-
viously unregistered European prostitutes then
brought on the register were truly deplorable, and
compared very unfavourably with those found in
the case of native ;uid previously registered
European prostitutes.
Associated with, and, to some extent, the indirect
result of these unsatisfactory conditions, which in
themselves constituted a deviation from health,
were many neglected cases of actual disease, which,
existing to a relatively much greater degree amongst
the previously unregistei-ed European prostitutes
than was the case generally, contributed to an
expectation of greater frequency of disease in the
former case, subsequently justified by the numerical
results.
The ultimately improved position in these cases,
as regai'ds the conditions found, furnished an
interesting example of one of the few undoubted
advantages which may be generally conceded to
the control of prostitution in the prophylaxis of
venereal disease. Apart altogether from the im-
jjrovement which resulted from medical interference
in those cases which actually called for this, .a
distinct general amelioration of the unsatisfactory
conditions originally existing resulted from the
weekly cleansing and prepsu-ation to which almost
all the women had obviously submitted themselves
before appearing for their examinations.
ix liOCK Hospital
During 1915, 525 European prostitutes were
treated in the European Txick Hospital, of whom
H 13 were suffering from sy])hilis, 357 from gonorrhopa,
I 58 from chancroiil, and 11 from labial abscesses,
whilst 86 \ui(lcr suspicion wore admitted for
nil-, rvalion.
Of the thirteen cases of syphilis, eight were in the
primary stage and five in the secondary.
Of the 357 cases ef gonorrhtea, only four were
noted as acute, the remaining 353 being returned
as cases of chronic gonorrhoea. Many of these
latter, however, might have been more properly
described as cases of vaginal discharge, largely
resulting from neglect and want of ordinary cleanli-
ness, but showing, on examination, the presence
of gonococci. Such cases were found to cleai- up
rapidly under appropriate treatment.
The average stay of each patient in hospital was
148 days for all cases.
Eor the syphilitic eases, the average period of
detention was 49-3 days, that for the primary cases
having been 32-3, and for the secondary 76-6 days.
The average period of detention of the patients
suffering from gonorrhoea was 17-0 days, that for
those suffering from the acut« form having been
30-5, and that for those returned as chronic
gonorrhfBa 16-9 days.
For the cases of chancroid, the average stay in
hospital was 12-2 days, whilst the period for
patients atlmitted with small abscesses of the labia
was 11-0 days.
Patients under observation, subsequently found
free from venereal disease, underwent a period of
detention of three days on an average.
The number of patients admitted to the
European Lock Hospital in 1916 was 896. Of
these, 35 were suffering from syphilis, 729 were
cases of gonorrhcea, 43 had chancroid, 53 were
cases of labial abscess, whilst 36 suspicious cases
were detained under observation, but subsequently
discharged as free from disease.
Of the thirty-five cases admitted as syphilis, nine
were in the primary stage ;md twenty-six in the
secondary.
Of the 729 ca.scs of gonorrii.ca, 15 were returned
as acute, 34 as subacute, and 680 as chronic.
The average stay of each patient in hospital in
1916 was 19'3 days for all cases.
For the cases of syj)hilis the average period of
detention was 42'2 days, that for the primary cases
being 49-2, and for the secondary 39'8.
llie I)atients returned as gonorrhoea were de-
tained on an average 20-1 days, the various periods
of detention having been 30-4 days for the acute
cases, 21-5 for the subacute, and 19'8 for the cases
returned as chronic.
The average stay of the chancroid cases was
12' 1 days, and of the cases of labial abscess 9"8
days.
The average period of detention under observa-
tion for patients subsequently found free from
disease was three days.
Unhkalthy, Inconvkniknt and Dangerous
establisumionts.
Formerly, the chief difficulty experienced in deal-
ing with the establishments licensed under the Law
of August 28, 1904, resulted from the lack of a
subsequent efficient control.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15. 1920.
The powers conferred by law of laying down con-
ditions, and the initial verification of their appli-
cation before any issue of a licence, enabled us
primarily to start these establishments with some
approach to a satisfactory condition, but the
absence of any provision for a regular systematic
inspection to ensure subsequent compliance with
the conditions imposed resulted in a graydual falling
away from initial standards in the great majority
of cases.
Spasmodic inspections at irregular intervals had,
it is true, some slight effect, but the infrequency of
the visits, combined with the smallness of the
penalty for failure to observe the conditions,
rendered efficient control impossible.
In 1914, however, the provision of a small staff,
specially for the purpose of supplying means for a
subsequent control, permitted of a start being made
in this direction.
It was considered advisable, however, in taking
advantage of this, to confine the activities of the
new service to the control of those establishments
which were of prime importance from a public
health point of \-iew, rather than to attempt to deal
with the whole (juestion, and thus impair the
efficiency of control by a diminution in the fre-
quency or regularity of the visit-s.
Acting on this principle, it was decided, in 1914,
to limit the inspections at first to such establish-
ments as dealt in foodstuffs and drinks, and this
arrangement was continued in 1915 and 1916.
The figures for the three years, therefore, during
which the inspections have been in force, show a
gradual tendency towards improvement, the per-
centage of visits at which unsatisfactory conditions
were found having diminished from 17-2 per cent,
in 1914 to 14-2 per cent, in 1915, and 6-8 per cent,
in 1916.
This improvement is in reality even more marked
than is shown by the figures*, as, in the first year
of the new arrangement, it was not considered
politic that full advantage should be taken of this
in any way such as would operate needlessly with
sudden or undue harshness on the establishments
concerned, and many faults not of a pressing nature
were, for the time being, overlooked.
From this it will be seen that the general im-
])rovements in the conditions found applied broadly
to all the individual establishments, and, generally
speaking, shows a marked advance in each year
over that of its predecessor.
In all cases where conditions were found unsatis-
factory, the proprietor of the establishment was
warned, and a time limit fixed within which the
necessary improvements had to be carried out,
failure to comply being followed by legal pro-
ceedings.
With the a.ssistance of the Military Authorities,
pressure was brought to bear on the. proprietors of
certain of the older soda-water factories in which
the conditions of exploitation left much to be
desired. A notice of the conditions generally
applicable to mineral water factories was served on
the proprietors of all such establishments, and a
time limit fixed for each within which whatever
alterations were necessary should be carried out, if
such were called for.
A warning was sent at the same time to the effect
that failure to comply would result in a prohibition
of all supply of the mineral water concerned to
troops, and would entail the putting out of bounds
of any establishments selling or keeping such
mineral waters.
This resulted in a considerable improvement, and
an attempt has been made to preserve the higher
standard thus attained by a bi-monthly inspection
of each establishment.
Anti-mosquito Service.
The arrangements for dealing with mosquitoes in
1915 and 1916 remained the same as before; that
is to say, measure.s for the destruction of mosquito
larvae were applied in certain selected areas in
wbrch a sufficient bulk of the inhabitants had
agreed to grant access to their houses and gardens
for the purpose of dealing with any breeding
grounds existing therein, and to pay the small
voluntary tax imposed for the purpose of defray-
ing the expenses.
The optional character, however, of the accept-
ance of the application of measures renders these
of limited utility, as the occurrence of a compara-
tively few untreated houses and grounds in any
treated area may be suflficient to provide a supply
of mosquitoes such as will infect the whole area.
As regards this, there seems to be a very general
misconception on the i)art of the public as to the
possibilities of remedying a pest of mosquitoes.
Frequent applications are received for the treat-
hient of individual houses, or even single flats, in
untreated localities.
It might be expedited to be more generally recog-
nized that, as far as any obvious effect was likely
to result from such a limited application of
measures, it would serve no practical purpose to
initiate these, but it would seem, on the contrar}',
to be the general expectation that a total disappear-
ance of all mosquitoes in any place, and under any
circumstances, is the natural corollary of the pay-
ment of the small tax and the signature of the
permit of entry.
To the logical acceptors of this creed the obvious
inference to be marlc from any persistence of mos-
quitoes is that such a condition could only be due
to some neglect on the part of the person respon-
sible for carrying out the measures of larval
destruction, with the result that every new exten-
sion of the work serves to provide an additional
source of complaint.
It would be of considerable advantage, therefore,
if it were more clearly understood that no public
health authority can possibly eliminate mosquitoes
from any locality under such conditions, and that
the most that can be expected is that the appli-
cation of measuri's is likelv to be followed by an
I
Sept. 15, 1920.]
COLONIAL MEDICAL RBPOBTS.— CAIRO.
evident diminution in numbers of mosquitoes, pro-
vided that the ai-ea is sufficiently separated and
does not contain an undue proportion of untreated
houses.
No great improvement, however, is likely to occur
until the onus of ])revention of mosquito-breeding
is k'f,'ally placed upon the occupier, and the right
of mtry for inspection granted to the Public Health
Authority.
The e.\ceptionally high Nile of 1916, by enor-
mously increasing the breeding areas, led to a
serious phigue of mosquitoes in that year. This
occurred principally in the more suburban areas,
in most of which there appeared enormous numbers
of anopheles in addition to the stegomyia and culex
usually found. This naturally proved a source of
soine anxiety in view of the presence of large bodies
of troops, of which some were likely to have been
recent arrivals from malaria-infected countries.
By an-angement with the Military Authorities,
malarial sick were kept out of the anopheles-
infected areas, whilst special observation was kept
on the conditions of health of the residents of these
areas with the object of obtaining early information
of any malainal infection.
A few cases actually did occur, but the number
of these was very small, and with the fall of the
Nile and the disappearance of the anopheles the
danger ceased to exist for the time being.
It is to be remembered, however, that such a
situation may return again, and though the condi-
tions which arose were unusual and resulted from
a Nile flood of exceptional height, the possibility
of a, repeated annual sequence of high floods, lead-
ing to a return of similar conditions in a scries of
years, might result in a grave malarial infection of
the localities concerned.
APPENDIX.
NoTi;s (IN Tin-; Umdkntikd;!) Fkvkk ok 1915.
As has alrea<ly been described, the year Ifllo was
marked by the occurrence in a grave epidemic form
of a fever pi'csenting such clinical contradictions as
to rendei' inadvisable the iuloption of any nomen-
clature which might tend to indicate a possibly
erroneous a,])j)i-eciation of its characters. Under
the circumstancses, therefore, it was (lecidt>d to
adopt throughout this report the unsuggcstive tenn
f,'iven above for the purpose of distinguishing the
liiscase, and to put on record a short description
of the charactei'istic points observed during the
I Iiiclciiiic. This has been largely based on the
iiutcs iriadc (in those IJAl cases treat-e<l in the
(idxciniiiciiL I'lver Hospital, and is supported by
I he fa4:ts observed in the Kafr el 'Elwa and El
■Ma'sara cordons.
'I'he disease in its moat typical form presented
itself as a fever of variable duration, chai-acterized
li.v clinical manifestations strongly suggestive of
t.\phoid fev(M-, but giving negative results to
laliuratorv tests for the latter disease.
huuhation Period. — This could not be determined
with any accuracy, as no definite conclusions could
be justifiably based 'on the indifferent histories
supplied by the patients and their friends. Experi-
mentally, in monkeys, it was found to vary from
four to eighteen days, but, as will be subsequently
indicated, these results are open to certain
criticisms, attaching to all the experiments on
monkeys carried out in connection with this
epidemic.
Tmnsmission. — The disease was of a highly-
infectious character, with a high attack rate
amongst those in close association with tho sick,
and spread rapidly in th^i localities in which it
broke out.
The actual method of conveyance of the infection
was not, however, determined.
Mode of Onset. — In the majority of the cases the
onset of the disease was gradual, with a history
of malaise for several days before the patient took
to bed or even, in some cases, ceased his work. A
certain number of cases, however, gave a history
of sudden onset of illness attributed frequently by
the patient to the effects of ilie sun. Of the cases
treated in hospital, 78 per cent, give a history of
a gradual onset, whilst 22 per cent, stated that the
disease had commenced suddenly.
General Symptoms. — The most prominent early
symptoms were headache and fever. In no case
was any clear history given of an invasion marked
by rigors or vomiting. The mental condition was
quite clear, and even with temperatures of 40° C
the patients were inclined to sit up in bed and
talked brightly. General body pains, aching in
limbs, or abdominal pains were occasionally com-
plained of. Backache was more rarely noted. The
eyes were bright and clear, or showed various
degrees of injection, though never very intense, or
were watery. The pupils were unaltered. T&ere
was no coryza or complaints of sore throat, though
the latter occasionally showed marked dryness of
its mucous membrane. The tongue was in the
majority of cases quite early covered with a thick
white fur. The pulse was full and bounding.
^'arious skin rashes were observed in a certain
proportion of the cases.
As the disease j)rogressed the patient became
content to remain lying, though the mental con-
dition usually remained clear, except in some very
bad cases, when delirium and restlessness were
noted. In the great majority of cases severe h'ead-
a<-he was the symptom most complained of. Most
cduuiionly no rash appeared, but occasionally
pctechi* of the limbs and trunk were to be seen,
whilst in a few cases roseolous body rash was
noted.
'i'he duration of the disease was variable, being
only si'vcn days in some cases, whilst in others it
lasU'd several weeks. Most of the cases varied
from nineteen to twenty-four days. In the majority
of the cases the fever terminated by lysis, but the
condition of the patient did not always improve
with the cessation of the fever, an asthenic condi-
tion with drj- tongue and feeble pulse frequently
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [Sept. 15, 1920.
persisting for many days after the defervescence.
Kelapses were not infrequent, though but few
relapsed twice.
Fatal results occurred in 22-.38 per cent, of the
cases. In those, hyperpyrexia, with gradually
increasing coma and heart failure, usually occurred.
Tongue. — This, in about two-thirds of the cases
observed, was moist and covered with a thick white
fur. In the remaining cases the tongue was found
dry and red, or covered with a brown fur. In such
cases, the dirty condition frequently was inclined
to persist even after the fall of the temperature.
Digestive Sijstem. — As a general rule the appe-
tite was bad, gastric pain was occasionally com-
plained of, whilst nausea and vomiting occurred in
some of the cases. Pain in the lower part of the!,
abdomen, with intestinal gurgling, was almost
always present. Diai-rhoea occurred in only about
a tenth of the cases, but never to any troublesome
extent. In the remainder the functions of the
bowels were usually regular, though showing occa-
sionally a tendency towards constipation. The
spleen was enlarged in about 40 per cent, of the
cases, varying from a condition of being just
palpable under the ribs to that of extending to
about two finger-breadths beyond the costal margin.
The liver showed signs of enlargement in about
5 per cent, of the cases. Abdominal pain at times
seemed chiefly centred in the splenic region. The
abdomen was usually full and tympanitic, with
acute tenderness in those cases which complained
of abdominal pain.
Circulatory System. — The pulse was invariably
fast, and occasionally showed a tendency to be
dicrotic, or irregular and intermittent. Associated
with the rapid heart action, accentuation of the
second sound was occasionally met with, whilst
haemic murmurs were to be noted in some cases.
Blood taken for examination showed a marked
tendency to rapid coagulation.
Respiratory System. — No special manifestations
of the disease occurred in connection with the
respiratory system, but signs of pulmonary con-
gestion, or of mild bronchitis, were not infrequently
to be detected, whilst definite patches of pneu-
monia were occasionally met with as compli-
cations.
Nervous System.— The most marked nervous
symptom was the persistent and severe headache
usually complained of. In the majority of the
cases this was very pronounced.
The mental condition was generally good, though
stupor and prostration were at times to be met
with. In some cases delirium occurred, mostly of
the muttering variety, with diminution of the
acuteness of vision ; there was one case of actual
amaurosis. Stammering speech, subsultus tendi-
num, and tremors were occasionally seen. In fatal
cases, coma for a day or two usually preceded the
death. Varying degrees of deafness were noted in
a large number of the cases. The deafness and
tremors at times persisted for several days or even
weeks after recovery. No cases of otorrhoea were
encountered. No hiccough, muscular rigidity, or
alteration of the knee jerks were noted. Incon-
tinence of urine and fseces at times occurred.
Aching of the limbs was not infrequently com-
plained of as tke fever abated.
Urinary System. — No symptoms of any special
interest affecting the urinary system were noted.
A few cases of slight fever albuminuria were seen,
whilst cystitis and retention of urine were met with
in a few cases.
Cutaneous Appearances. — In 72'0 per cent, of
the cases no indication whatever of any rash
occurred.
In 279 per cent, in which signs of skin change
were observed, it presented itself in the form of a
cutaneous mottling or of a roseolous or petechial
rash. In the earlier stages of the epidemic the
petechial rashes sometimes developed into large
subcuticular haemorrhages. No eruption, however,
typical of the disease, could be said to occur.
Temperature. — In the relatively few cases which
came under observation at the commencement of
the illness the temperature chart invariably showed
a gradual rise.
That this was the usual mode of onset is borne
out by the histories of the majority of the cases
admitted in the later stages of the disease, whilst
in none of the cases seen sufficiently early to permit
of conclusions being derived from the progress of
the case were any indications of other than a
gradual invasion. As against this, however, are
definite histories of sudden onset in almost a fifth
of the cases. These, however, rest solely on the
statements of the patients or their friends, and are
to be discounted to some extent by the possibility
in some of these cases that the less obtrusive initial
symptoms of the disease have been masked by the
racial tendency towards a symptomatic insensi-
bility. Such histories may possibly in some cases,
therefore, indicate more a sudden obtrusion of the
fact of illness than an actual sudden onset.
In the majority of cases the temperature dropped
gradually to normal, the disease tenninating by
lysis in 77'2 per cent, of the cases which recovered.
In 22"8 per cent, the fever ended by crisis.
In the cases terminating by lysis the period of
defervescence varied from two to nine days, or even
longer, and was frequently accompanied by profuse
sweating.
The mode of onset bore no relation to the manner
in which defervescence took place.
Relapses. — Relapses, at intervals after the defer-
vescence, varying from three to ten days, were not
infrequent. Thus, of the 1,546 eases treated in
hospital, 146, or 9-4 per cent, relapsed. This per-
centage, however, does not exactly express the
probabilities of relapse in this disease. Of the 1,546
oases, 346 died, of which only six occurred during
relapse. From the total 1,546, therefore, there
should be deducted 340 cases from which death had
removed the potentialities of relapse. Calculated,
therefore, on the remainder of 1,206 cases exposed
to the chances of relapse, the 146 which actually
occurred gives a percentage of 12'1 as a truer
expression of probability.
Oct. 1. 1920.:
COLONIAL MEDICAL SEPORTS.— CAIEO.
73
Colonial Medical Reports.— No. 111.— Cairo {continued).
The relapses varied considerably, being in some
cases exactly similar to the original attacks in their
duration and severity, whilst in other cases the
second attack was markedly milder and of shorter
duration. Second relapses were rare. They only
occurred in seven of the hospital cases. Of these
seven, two of the cases relapsed a third time.
Mortality. — There were 346 deaths in hospital
from the 1,546 cases admitted. The percentage of
deaths was, therefore, 22'38. The European deaths
were thirteen out of a total of twenty-eight cases
admitted, giving a hospital case mortality for
Europeans of 46'42 per cent. The number of
Egyptian admissions was 1,518, of which 333 died,
giving a percentage of 21-98 as the Egyptian case
mortality.
Judged by this, the occurrence of the disease
would seem to give rise to the least risk to life
between the ages of 11 and 20 for both sexes, the
mortality being .lowest in the group 11 to 15 years
in the case of the male, and in that of 16 to 20
years in the case of the female. Above this, each
group shows a gradually increasing case mortality,
which is high for both sexes in patients over 40
years of age. The case mortality amongst young
children is below the average rate. It is highest as
regards those in the youngest group of zero to 5
years, and gradually diminishes to the ages of least
case mortality.
In these hospital cases the female case mortality
is somewhat lower than the male.
Duration. —Independently of relapses, the disease
was of variable duration, though as a rule it lasted
about three weeks. Occasionally, milder cases, with
a duration of as little as seven days, were met with,
whilst cases which dragged on considerably beyond
the usual three weeks were not uncommon, many
cases of protracted fever with slow lysis lasting for
five or six weeks.
Complications. — The complications most generally
met with were pulmonary and bronchial abnormalities,
which in mild forms constituted not infrequent con-
comitants of the disease. The most common of these
was bronchitis, but broncho-pneumonia .was not in-
frequent. Parotitis, phlebitis, gangrene of both lower
extremities, laryngitis, epididymitis, nephritis, in-
sanity, and abortion were all met with.
Diagnosis. — The distinction of the disease from
typhoid fever was mostly based on laboratory tests
consisting in the negative Widal reaction and the
absence of typhoid bacilli from the blood, urine, and
stools in the disease under consideration, thougli
clinically the marked prominence of the headache
in this disease raised suspicions of its nature.
The mental condition, the absence of the char-
acteristic smell, the full abdomen associated with
acute tenderness and pain, the general absence of any
characteristic rash, the tendency usually to a pro-
longed lysis, and the frequency of relapses served to
differentiate this disease from typhus fever.
Experimental Investigations. — For the reasons
already given in the report, the experimental investi-
gations into the nature of the disease were somewhat
handicapped by the circumstances obtaining at the
time of the occurrence of the epidemic, and by the
difficulties attending post-mortem examination in this
country. In the few cases, however, in which limited
autopsies were possible, no appearances were found
throwing any light on the nature of the disease,
though in this connection it must be remembered that
no very extensive examinations could be carried out,
as circumstances only permitted of a somewhat un-
satisfactory inspection of the abdominal organs in
these cases through a small incision made in the
abdominal wall. This, however, was sufficient to
show the absence, at least in the cases examined, of
any pathological condition of the intestine beyond an
occasional slight congestion.
Numerous attempts were made during the course of
the epidemic to isolate a causal organism, and efforts
were directed towards obtaining cultures of such, on
various media, under both aerobic and anaerobic con-
ditions, but without success.
No organism was isolated from either the blood,
urine, or faeces, or from splenic smears from a few
fatal cases in which a partial post-mortem was per-
missible, which justifiably could be considered the
causal agent. The negative Widal results were
naturally based on a series of trials in each case,
made at different periods, both during the course
of the illness and after the defervescence, and not on
single attempts.
Owing to circumstances resulting from the war,
monkeys were not obtainable for experimental pur-
poses in the initial stages and during the height of the
epidemic. Later, a few animals were received and
inoculated with blood from patients suffering from the
disease. AU developed an illness clinically indis-
tinguishable from that which would have been pro-
duced in monkeys by the inoculation of typhus blood.
On this alone, however, it would be unjustifiable to
presume identity with typhus, as the clinical features
upon which was based the distinction in the human
cases were not such as would clearly indicate them-
selves in a monkey.
One of the inoculated monkeys was kept and was
subsequently inoculated with blood from the heart of
a monkey suffering from typhus, and thirty days later
with blood taken straight from a human case of
typhus, without result. The same monkey was
again tried this year with a large quantity of
virulent blood taken from a fresh case of typhus, but
no disease developed.
The few inoculation experiments, therefore, which
it was possible to make would seem to suggest a sus-
picion of the identity of the disease with typhus. As
opposed to this, however, it is to be remembered that
monkeys only became available when typical cases
of the human disease were not available. During the
height of the epidemic the disease differentiated in
this report showed itself in a form which enabled
a distinction to be drawn between it and those
cases which were obviously typhus. With the ter-
mination of the epidemic, however, as has been
THE JOURNAL Of THOMCAL MEDICINE AND HYGIENE.
[Oct. 1, 1920.
already mentioned in the report, dropping cases of
disease still continued to be diagnosed as cases of
the unidentified fever, though such as were so
diagnosed did not present any features which would
have been hkely to raise any suspicion that they were
other than somewhat atypical cases of typhus, had not
the previous epidemic tended to supply grounds for
diagnostic suspicion. Moreover, the desire to obtain
material for investigation was so inclined to prejudice
the diagnosis that, though it is but right that the
results of these inoculation experiments should be put
on record, they can scarcely be accepted as throwing
any conclusive light on the nature of the epidemic.
Unfortunately, no cases could be obtained, after
monkeys became available, presenting the diagnostic
distinction from typhus which would have been pro-
vided by a relapse, and, under the circumstances, it
must be taken that there is not sufficient evidence to
show that the material for investigation was not
obtained from probably atypical cases of typhus
instead of from the disease which it was desired to
investigate.
In two cases attempts were made to transmit the
disease through the agency of lice, and 245 lice from
four patients considered to be suffering from this
disease were fed on one monkey, and 350 from two
other patients on another. These experiments were
unsuccessful, but, in any case, they would have been
open to the same criticisms as were attached to the
inoculation experiments.
Whilst leaving the question open, therefore, I am
inclined to the belief that the disease was truly the
result of some new infection, probably introduced into
this country through the agency of those troops of
varifed races, and of the most diverse origin, which
were then being poured into this country, and to
attribute the high infectivity shown by the disease to
the absence of any racial insusceptibility such as
would have existed had the disease been previously
prevalent in this country.
Colonial Medical Reports. — No. 112.— Jamaica.
ANNUAL REPORT OF THE SUPERINTENDING MEDICAL
OFFICER FOR THE YEAR ENDED MARCH 31, 1918.
One has once more to call attention to the large
number of deaths which have not been medically
certified, and attention has to be drawn to the possi-
bihty if not probabihty that had cheap medical
attendance been available many of those who died
might have had their lives saved. The number of
persons who die in Jamaica without a medical
certificate as to the cause of death is very great.
Possibly the mileage charges may have something to
do with this, also the large amount of unlicensed
practice now reported as being carried on by
dispensers and others.
The very large number of deaths of children
under 1 year and 5 years is a bad feature.
During the past year the Child Saving League, for
which £150 has been allowed on the estimates, has
been doing a good work in Kingston.
One portion of the work consists of certain centres
where small children are fed, and in connection with
these is a creche where children are left by their
mothers during the daytime in charge of a nurse. The
£150 voted by the Legislative Council goes to paying
two nurses.
The daily average of babies in the cr6che since its.
start was eleven, and the highest number on any day
has been twenty.
The nurses also visit at the homes of the children.
The attendances of children for feeding during the
year at the centres have been 2,514, and the visits
made by the nurses at their homes were 1,224.
Yaws.
From the reports sent in by the various district
medical officers it is very evident that the above
disease is extremely prevalent throughout the island,
and it would appear that some of the district and
acting medical officers have forgotten the existence of
Law 23 of 1910, which was passed during Sir Sydney
Olivier's tenure of office.
Section 5 gives a district medical officer the power
of requiring : —
(1) Any person suffering from yaws to attend at a
time and place.
(2) Any parent, guardian, or person in charge of a
child suffering from yaws to attend with such child
at a time and place.
Section 6 gives the district medical officer the power
of requiring such person {a) to present himself for
inspection and treatment ; (b) to bring such child for
inspection and treatment at such times and places as
may appear necessary.
We thus have all the power necessary in order to
enforce compulsory attendance and treatment, but
what is still required is the " finance " to cover the
cost of what everyone admits is necessary, namely,
" the compulsory and continuous treatment of
yaws."
As soon as money is available and the Medical
Department is allowed a free hand in the treatment
of yaws, there should be no great difficulty in gradu-
I
Oct. 1, 1920.]
COLONIAL MEDICAL EEPORTS.— JAMAICA.
75
Eeturn op Diskasrs and Deaths in 1917-1918 in the Public Hospital, Kingston.
Jamaica.
GENERAL DISEASES.
|i I III
Alcoholism .. .. .. .. .. — —
Anajmia 17 — 17
Anthrax — _ _
Beriberi .. .. .. .. .. .. — — —
Bilharziosis .. .. ..' . .. — — —
Blackwater Fever . . . . . . . . — — —
Chicken-pox .. .. .. .. .. — — —
Cholera .. .. .. .. .. .. — — —
Choleraic Diarrhoea . . . . . . . . — — —
Congenital Malformation . . . . . . — — —
Debility 6 1 6
Delirium Tremens . . . . . . . . — — —
Dengue — — —
Diabetes Mellitus . . . . . . . . — —
Diabetes Insipidus .. .. .. .. — — —
Diphtheria .. .. .. .. .. — —
Dysentery 22 4 22
Enteric Fever 267 47 267
Erysipelas .. .. .. .. .. 1 — 1
Febricula . . '. . . . . . . . . . — —
Pilariasis — _ ^
Gonorrhea . . . . . . . . . . 253 2 253
Gout __ _
Hydrophobia .. .. .. .. .. — — —
Influenza 46 — 46
Kala-Azar .. .. .. .. .. — — _-
Leprosy 1 — 1
(a) Nodular __ _
(6) Anaesthetic .. .. .. .. .. — — —
(c) Mixed .. .. .. .. .. — — —
Malarial Fever — . . . . . . . . — — —
(a) Intermittent . . . . . . •. . — — —
Quotidian .. .. .. .. .. — — —
Tertian 250 18 250
Quartan .. .. .. .. .. 1 — 1
Irregular .. .. .. .. .. — — —
Type undiagnosed . . . . . . — — —
(6) Remittent — _ —
(c) Pernicious .. .. .. .. .. — _ —
(rf) Malarial Cachexia . . . . . . . . — — —
Malta Fever — -- —
Measles 53 — 53
Mumps . . . . . . . . . . . . — — —
New Growths—
Non-malignant . . . . . . . . 32 2 32
Malignant 33 5 33
Old Age — — —
Other Diseases 402 81 402
Pellagra 11 2 11
Plague .. .. .. .. .. .. — — —
Pyifimia .. .. .. .. .. .. — — —
Rachitis .. .. .. .. .. .. — — —
Rheumatic Fever . . . . . . . . — — —
Rheumatism 52 1 52
Rheumatoid Arthritis . . . . . . . . — — —
Scarlet Fever — — _
Scurvy .. .. .. .. .. .. — — —
Septicsemia 10 9 10
Sleeping Sickness — — _
Sloughing Phagedaina -- — —
Small-pox .. .. .. .. .. .. — — —
Syphilis - - -
(a) Primary 76 — 76
(6) Secondary 31 — 31
(c) Tertiary 49 5 49
(d) Congenital 12 5 12
Tetanus 8 3 8
Trypanosoma Fever . . . . . . . . — — —
Tubercle- .. .. .. .. .. — — —
(rt) Phthisis Pulmonalis .. .. .. — — —
(6) Tuberculosis of Glands . . . . . . — — —
(c) Lupus _ _ _
General Diseksks -continued.
(d) Tabes Mesenterica . . . . . . —
(e) Tuberculous Disease of Bones . . . . —
Other Tubercular Diseases . . . . —
Varicella . . . . . . . . . . . . —
Whooping-cough .. .. .. .. .. 1
Yaws —
Yellow Fever —
LOCAL DISEASES.
Diseases of the —
Cellular Tissue 105
Circulatory System 88
(a) Valvular Disease of Heart . . . . —
(6) Other Diseases . . . . . . . . —
Digestive System— 457
(a) Diarrhoea . . . . . . . . —
(6) Hill Diarrhoea —
(c) Hepatitis —
Congestion of Liver . . . . . . —
(d) Abscess of Liver . . . . . . —
(e) Tropical Liver . . . . . . . . —
( O Jaundice, Catarrhal 2
(g) Cirrhosis of Liver . . . . . . —
{h) Acute Yellow Atrophy . . . . —
(i) Sprue
(j) Other Diseases . . . . . . . . —
Ear 4
Eye 88
Generative System — . . . . . . . . —
Male Organs . . . . . . . . 82
Female Organs 148
Lymphatic System . . . . . . . . 93
Mental Diseases 6
Nervous System . . . . . . . . 191
Nose 4
Organs of Locomotion .. .. .. 128
Respiratory System . . . . . . . . 106
Skin- 182
(a) Scabies . .
(b) Ringworm . . . . . . . . —
(c) Tinea Imbricata —
(d) Favus —
(e) Eczema . . . . . . . . . . —
(/) Other Diseases —
Urinary System 142
Injuries, General, Local — . . . . . . 146
(a) Siriasis (Heatstroke) —
(6) Sunstroke (Heat Prostration) . . . . —
(c) Other Injuries . . . . . . . . —
Parasites — . . . . . - - - • . 60
Ascaris lumbricoides . . . . . . . . -
Oxyuris vermicularis . . . . . . —
DochmiuB duodcnalis, or Aukylostoma duo-
denale .. .. —
Filaria medinensis (Guinea-worm) .. .. —
Tape-worm —
Poisons — . . . . . . . . . . . . 12
Snake-bites . . . —
Corrosive .\cid8 . . . . . . . . —
Metallic Poisons —
Vegetable Alkaloids —
Nature Unknown —
Other Poisons . . . - . . . . . . —
Surgical Operations— . . . . . . —
Amputations, Major 25
Minor 606
Other Operations 563
Eye 34
(a) Cataract —
(6) Iridectomy —
(c) Other Eye Operations . . . . —
76
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1920.
ally abolishing it and making it a thing of the past,
just as is small-pox.
Until finance will allow of that the disease must
continue to spread, as every case uncured in a district
is a " focus " of infection, leading perhaps to many
new infections, or to use a Biblical expression, " A
little leaven leavenetb the whole."
Venereal Diseases.
It gives me much pleasure to record the fact that,
after urging the necessity for some long time past for
the passing a law dealing with and providing for the
control of these very serious diseases, it became my
pleasant duty to introduce to the Legislative Council
a venereal diseases law, which was based on the
recent English law and the Grenada law.
The points that one wishes to impress upon the
public and upon those who are sufifering from venereal
disease are : that
(1) One should try and prevent infection con-
tinuing from the earliest moment of infection if
possible ; while
(2) Neglect of early and efficient treatment make
subsequent treatment more difficult, protracted, and
consequently more expensive.
(3) Economically it is sound to spend money on
efficient and early treatment, and so save later on
expenditure on the treatment of chronic cases that
have been neglected in the early stages of the disease,
and which so often lead to social wreckage and do so
much towards filling our hospitals, poor-houses, and
lunatic asylums.
The necessity for treatment from the earliest
moment of infection is obvious. It may here be
mentioned that the Federal Government of Australia
has decided to spend something like £25,000 a year
for furthering facilities for diagnosis — it being esti-
mated that full 16 per cent, of those in receipt of
pensions have become invaUds through the efifects of
inherited or acquired syphiUs.
Hitherto the trouble in the treatment of venereal
disease has been that patients will insist on consider-
ing themselves " cured " as soon as any inconvenience
that may be felt or the external manifestations of
whichever form of the disease that they may be
infected with have disappeared, and after that the
disease is neglected, only, in many cases, to appear
later on in other and worse forms, the patients being
in a position to spread the disease without being
aware of the fact.
The new law provides for compulsory and con-
tinuous treatment, and for a penalty for non-compliance
with the orders of the medical officer under whose
care they are.
From the reports of the medical officers one
gathers —
(1) That unless conpulsion is enforced no possibility
of keeping venereal disease within bounds can be hoped
for.
That the peasantry and labouring classes regard
these diseases as " very simple ailments," which are
of small importance, and in the case of the male
population as being more or less a manifestation of
manhood.
That cases of these diseases are commonly never
seen by medical practitioners until far advanced, or
until complications have occurred at a period when
treatment is not likely to be so satisfactory or cure so
rapid as would have been the case had the patient
been taken in hand at an early stage.
One point in the treatment of venereal disease must
be borne in mind, and it is this : that unless one is
able to finance the " continuous " treatment of venereal
disease the law must remain a dead letter ; by
financing the treatment I mean continuous and not
spasmodic treatment.
Yaws still remain rampant on account of the
absence of sufficient funds to carry on a ' con-
tinuous " campaign against it, and the same will
happen in the case of venereal disease unless the
wherewithal is provided.
General Sanitation.
It is evident that very little in the way of new
sanitary works has been accomplished by the various
local boards, presumably due to the lack of money and
the high cost of materials. This of course is to be
regretted, but it is very evident that " one cannot make
bricks without straw."
With regard to the introduction of an efficient latrine
system in the various towns and villages of the island,
one has to record the fact that very little has been
done in this matter, and that the latrine systems of
the towns and viUages are generally unsatisfactory,
and it is to be hoped that as soon as the International
Health Board starts work in connection with hook-
worm, the various local boards will enforce the pro-
vision of efficient and antihookworm latrines through-
out the parishes.
In spite of enforcing the installation of latrines on
premises people, it is said, will retain their old customs
and use the bush.
That may be the case for a time, but after a number
of prosecutions have taken place people will learn to
do what is right, and if in the schools children are
instructed in cleanly habits, it will be found that the
rising generation will soon learn to use latrines,
and will not be satisfied unless they have them,
and the hookworm pest wiU become a thing of the
past.
Port Maria has installed a bucket system, and it
will be noted that whereas typhoid fever was at one
time prevalent in that village, it has now practically
disappeared.
The question of the unsatisfactory condition of the
latrine system of the island raises the question of
the necessity for having a superintending sanitary
inspector.
As at present there is no one to see that the various
sanitary boards are carrying out the law, it is abso-
lutely necessary, if improvement is to lie made, that
a superintending inspector should be appointed who
will take the law into his own hands, and see that
both the law and the by-laws are enforced.
Regarding water supplies, it may be said that the
freedom from yellow fever of the towns and villages
on the coast is due principally to the number of water
supplies now existing in those towns and villages, and
to the comparative absence of the cistern and water
barrel that used to be so much in evidence.
Oct. 15, 1920.]
COLONIAL MEDICAL EEPOBTS.— JAMAICA.
Colonial Medical Reports.— No. 118.— Jamaica (conid).
The subject of a water supply for Stony Hill has
been discussed and estimated for ad nauseam, and up
to the present no result has been arrived at in the
matter, although the industrial school, containing some
hundreds of boys and girls, has during one summer at
least had to send to the Wagwater river in order to
get its water.
Cleanliness is next to godliness, and so long as the
boys in this institution have to carry water on their
heads from place to place no thorough instruction in
cleanliness can be carried out.
The water in the reformatory wells has been con-
demned by the pathologist on many occasions, and
in the interest of health a proper water supply
should be installed, as typhoid has also been prevalent
at times.
Water being a necessity, everything possible should
be done to provide supplies that are above sus-
picion, and that at the same time are plentiful and
which furnish water adequate to the calls made on
them.
Hookworm.
During the month of February, 1918, Dr. H. H.
Howard, Director of the Rockefeller International
Health Board, in the West Indies, arrived in Jamaica,
and arrangements were suggested in accordance with
which that foundation should commence work in
Jamaica, operations being started by the making of a
survey.
The selection of a district in which a commence-
ment will be made is naturally left to the International
Health Board although it would seem advisable that
the work should commence in a district where one
can be sure of the willing and effective co-operation of
the estate owners.
Jamaica's part is the introduction of proper
sanitary improvements in the shape of a satisfactory
latrine system," and to pay for the medicines and
stationery. The Rockefeller International Health
Board will carry out the treatment and will provide
its own staff.
Dr. Howard laid great stress on the fact that he
wishes the sanitary work and the distinctly medical
work to be carried out by different officers and to be
entirely separate — as it might imperil the success of
all attempts at treatment were the public to associate
the carrying out of the health law and its sequence
of possible notices and prosecutions with the treatment
of the disease. In other words treatment of and in-
vestigation of disease should be run separately from
the enforcement of sanitary legislation.
Dr. Howard has urged that the International Health
Board should deal with the government of the island
only and not with the several local hoards of health.
This apparently is the custom in every place where
the International Health Board carried on operations.
Dr. Howard told me the following fact, which is of
interest : —
He stated that while going through a reformatory,
somewhere in the West Indies, the manager or
superintendent of the institution informed him that
praedial larceny used to be very common among the
boys admitted thereto, and that he used to have
thirty or thirty-five at one time undergoing punish-
ment for this form of theft, but that since regular and
systematic treatment had been given the boys for
hookworm infection the number of boys at one time
under punishment for praedial larceny had decreased
to five or six at a time.
The question would therefore arise : " How much,
if anything, has hookworm infection in children to do
with prffidial larceny?'" We know that some of
those who are suffering from hookworm infection or
disease owing to perverted sense become dirt eaters —
may they not also become prsedial thieves. Possibly
the systematic treatment of hookworm infection may
also reduce the amount of praedial larceny among
children, just in the same way that a dirt eater when
cured of hookworm drops his unnatural habit and
regains his natural instincts. This island is fortunate
in having obtained the services of the International
Health Board, as I understand that when once a
colony or country has refused or has not accepted
the board's assistance when offered, as Jamaica has
done, the said board goes elsewhere to help public
health.
Port Antonio, Mne 17, 1918.
Copy of letter sent to the Superintending Medical
Officer, Kingston.
" Sir, — Hookworm and its treatment is now very
prominent in the minds of the profession and public,
so I beg leave to give my experience to correct a fallacy
which has always existed as to thymol.
" It is stated in most works and papers written on
thymol treatment that thymol given with oil or
followed by oil will exhibit marked toxic effects.
This is not so, as tlje records of this hospital
can show.
"Dr. Moseley finding thymol easily soluble in
castor oil and very convenient for administration has
for years given 20 gr. doses in this way, every third
morning, and I have for the past year followed on
these lines, with good results, and absolutely no ill
effects. Very recently a child of 7 years who was
badly infected took 28 gr., divided in three doses, in
twelve hours with no ill effects except the usual
depression which follows heavy doses, and with
marked benefit to this condition.
" I am, Ac.
" (Sgd.) Fred G. Grossett, Actg. D.M.G."
(The above would seem to show that thymol may
be given as medicine in oil without any serious after
effects.— Ed.).
Malaria.
In so far as the hospital -service is concerned
malaria shows a smaller return than during the
previous year.
The returns from hospitals depend very much upon
the incidence of malaria among East Indians and are
as a rule especially high in those hospitals to which
East Indians chiefly resort.
What the actual prevalence of malaria may be
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 15. 1920.
among the general public who do not live near a
hospital it would be difficult to say, malaria not being
a notifiable disease.
One of the best results achieved in the matter of
the prevention of mosquito life is the gradual filling
up of Warner's pond at Port IMaria.
It would be well were it possible now to devote
more money to the filling in of swamps and thus
abolish a preventable disease that efifects to a very
great extent the working power of the labouring
There are several swamps down the Hochfort Road
in the parish of Kingston, which should be filled up,
as that portion between Rochfort Road and the
seashore, if freed of swamps and mosquitoes should
Ijccome a most pleasant residential quarter,
Ciieiip labour could always be supplied l)y i)rison
labour, and the work would be done quickly, there
being no insuperable obstacles in the way.
Quinine is still being sold at the post offices at tlie
original price of one farthing a 5-gr. dose or a penny
for four doses ; the Department is naturally a great
loser financially, tlie difference in the price of quinine
before the war and at present being 21s. 6d. the pound.
It was thouglit better, however, not to raise the
price of these packets of quinine as the public are
now accustomed to the prices charged and any inter-
ference with recognized charges made might interfere
with the sale of the drug.
Isolation Blocks.
As mentioned on previous occasions some of the
hospitals are very hard pressed for space in which
they could isolate infective cases requiring isolation,
in fact such space can hardly be said to exist in certain
hospitals.
AcKEE Poisoning.
During the past year a large number of cases of
ackee poisoning have occurred in various parishes,
whereas there are also parishes in which the trouble
does not seem to occur.
Tlie ackee appears to have been mentioned in times
gone by in songs by the peasantry. One song has a
verse as follows : —
Carry me ackee go a Linstead market
Not a quatty worth sell.
Carry me ackee go a Linstead market
Not a quatiy worth sell.
Lawd ! not a light, not a bite.
Not a quatty worth sell.
Lawd ! not a light, not a bite
What a Saturday night!
Another song however (many of the verses of wliich
I am told are unsuitable for publication) mentions the
ackee in the words below — showing distinctly that
even the poisonous nature of the ackee has been
recognized and has been commemorated in song or
folk lore of this island.
Then you tek ackee bwile soup '.'
Tek natta (i e. annatto) colour it ?
Gal, you want fe come kill me, kill me.
Gal, you want fe come kill me.
In view of this song which would appear to bear
out Dr. Scott's theory that the ackee under certain
conditions is poisonous, a theory that he has proved
by pathological work, it would seem proper now to
cease using the term " vomiting sickness," a name
given to the ailment some years back due to ignorance
as to its cause.
When vomiting occurs in the course of a disease it
simply does so as a symptom and nothing more —
one might even call billiousness with vomiting by the
name vomiting sickness. The term does not exist in
tlie nonienclature of diseases.
Now that the ackee has been shown to be, under
certain conditions, poisonous, one must take care that
til is poison is not systematically used by evil disposed
persons in order to rid themselves of other persons
that they wish to get rid of.
Curiously enough the ackee (Blighia sapida) also
exists in West Africa in the Lagos country under the
name of " isin " and in the Journal of Tropical
Medicine dated April 15, 1918, No. 8, vol. xxi, there
is a report by Dr. A. Connal, Director of the Medical
Research Institute, Lagos, and Mr. W. Ralston,
Government Chemist, Nigeria, on some experiments
that were made by them on animals, using the various
portions of the " isin " (ackee) with a view to finding
out whether that fruit was poisonous or not and
which portion was poisonous.
The results are interesting for they corroborate
Dr. Scott's investigations, inasmuch as the animals
that died after being fed with extract of unripe
ackees showed the same post-mortem appearances
as Dr. Scott has found to be the case in Jamaica,
fatty degeneration of the liver cells being very
noticeable.
Further than that it is evident that the inhabitants
of that region are quite aware of the poisonous nature
of the ackee because these investigators quote a local
Yoruha saying which is as follows " He who knows
to eat the ' isin ' knows to remove the poison."
It seems curious that in spite of much discussion
from time to time in the local newspapers on the
part of " amateur experts " on the subject of the
non-poisonous properties of ackees that the folklore
of two Colonies should have already settled the
matter in one case (Jamaica) in a song and in another
case (Nigeria) in a " saying."
The above-mentioned investigators also state that
there is no trade in the fruit and that very occasionally
a basket of " isin " is seen exposed for sale in the
various markets, but that for all practical purposes
it may be accepted that the fruit is eaten only by
those who collect it tliemselves from an easily
accessible tree and that further it appears to be the
general custom to eat the " arrilli," discarding husk,
seeds and " placenta."
It will now be necessary to have the school children
in the elementary schools taught to distinguish by
name the various parts of the fruit and which fruit to
select for consumption and how to cook it, and what
to consume and what not to consume when once the
ackee has been cooked.
COLONIAL MEDICAL REPORTS— JAMAICA.
79
Annual Report on the work carried out in the
Government Bacteriological Laboratory,
April, 1917— March, 1918.
Pathological Laboratory, Public Hospital,
Kingston, Jamaica.
Two important matters have been made the subjects
of special research, namely, the acute outbreak of
central neuritis in Spanish town and its neighbourhood,
and secondly, fresh investigations into the outbreak of
" vomiting sickness " so-called.
Enteric fever has been more rife this year than last,
and the increase is not due to any spasmodic outbreak
but to a continued increase in cases throughout the
year. If the old dictum that the incidence of typhoid
is to be regarded on the sanitary index of a district
holds good, the moral is clear, and the macter should
be very seriously taken in hand before the return of
the contingent with the necessary introduction of
several more carriers to act as foci for the spread
of the
Fxcal Examinations for the Presence of Helminthiasis.
The examinations were made primarily for the
detection of ankylostomiasis, but incidentally other
worms or their ova were looked for at the same time.
Owing to many medical men being away the treatment
has probably not been so carefully or so thoroughly
carried out, for there has ])een no fresh immigration of
coolies during the year, nevertheless the percentage
of infection has risen considerably.
During the twelve months under review 4,073
specimens have been examined for this purpose.
Of these 3,497 contained ova of some worm or other
— Ankylostoma, .\scaris or Trichuris. This gives a
percentage infection of 85'85 as compared with 80'79
during the preceding year.
Taking account of the country districts only, that
is excluding Kingston itself, and those who are
apparently healthy and who merely have to be
examined to obtain a certificate to enable them to
emigrate to the United States, out of 3,362 specimens
examined from the various parts of the island only
150 have been free from all helminth infections,
giving a positive percentage of 9554. No benefit
would arise from going into the details of the Ascaris
and Trichuris infections.
Other faecal examinations were carried out for
deciding as to the presence of the amccba^ of dysentery,
and some also for the isolation of the B. typhosus and
paratyphosus in suspected carriers ; 665 such have
been examined.
Many of these examinations have been in connection
with some research work which was started in
October. This, however, had to be abandoned
temporarily when the outbreak of vomiting sickness
arose and I received orders to investigate this last
matter over again. I hope to be able to continue this
during the present year.
On the subject of dysentery, without going into the
figures in detail, it will suffice to say that cases giving
positive results are becoming more numerous ; in part,
at least, this is due to more patients being examined
and the gradual elimination of the idea that amoebic
dysentery did not exist in Jamaica. Many of the
contingent who have gone to the front will certainly
return infected with the amoebae. Some have already
returned and possibly have contributed in part to the
increase. Under the present sanitary, or insanitary,
condition which many of the class of men from which
the contingents have been recruited, pass their lives,
this fact will constitute an even more serious menace
to the community than does enteric fever at the
present time.
Other examinations have been carried out for the
isolation of enteric bacilli from the stools of suspected
carriers and of those who. leave the hospital after
passing through an outbreak of the disease, as already
mentioned.
A few specimens have also been sent up for
examination for occult blood in cases of suspected
duodenal ulcer or malignant disease.
Wassermann Beactions. — During the year April,
1916— March, 1917, there were 202 sera submitted
to this test. During the first six months of the
succeeding year now under review 146 were tested
and facilities for free examination having been given
subsequently to this the number sent up for the
second half year has been considerably increased,
viz., to 248, giving a total for the year of 394, almost
twice that of the previous twelve months.
As regards this test I have found it necessary here
to go through the whole process of standardizing the
hajmolysin and the antigen each time, as well as the
complement. At home it is a common practice to
make an original test of the first two and then check
them occasionally. Here, however, the variations
are so marked that the preliminary standardizations
have to be performed on every occasion. This is
laborious, necessitating five hours' work each time
before the test proper can be started, but the increased
trouble means far greater accuracy and is consequently
well worth while.
Among specimens of sputa sent up for examination
for the presence of B. tuberculosis it is interesting to
note that there were three cases of bronchomycosis
and one of streptothorix infection. One of the former
apparently cleared up completely, that is to say, all
physical signs of active mischief disappeared, the
health improved and the patient was able to be
discharged from hospital and return to work, and
there was no sputum for some time prior to leaving
hospital. Of the other two, one died in two to three
months after coming under observation, with extension
involving the pleura.
Special Matters arising from BotUine Examinations.
(A) Relative to Enteric Fever. — (1) A localized
enteric fever outbreak on board' a vessel.
A certain vessel put into Kingston Harbour with
several of the crew ill, and I was ordered by the
Central Board of Health to visit the ship and see the
patients with a view to elucidating the nature of the
complaint. I found six of the crew ill, four of them
seriously. The other two had only reported sick
within the previous forty-eight to seventy-two hours.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1920.
The vessel had come from an insanitary port and in
view of the febrile nature of the complaint and that
four had palpable spleens and some abdominal tender-
ness I took specimens of the blood from these patients
to test by the Widal reaction for typhoid or para-
typhoid fever (none of them had been vaccinated for
either of these conditions) and smears for malaria.
The results of the examinations were : —
(i) Chief Officer H. had been ill about ten days ;
he showed some suspicious rose spots and had had
headache for the first week or so but not severe. His
blood gave a well marked agglutination reaction with
B. typJiosus and in low dilution with B. para-
typhosus A also (this proved to be merely a group
reaction). No malarial parasites seen in the smear
and no increase in the large mononuclear cells, none
of those seen contained any pigment ; there was a
relative lymphocytosis.
(ii) Chief Officer S. This patient's serum gave the
same reactions as the last, and it was rather curious
they were both taken ill on the same day, June 19th.
The smears from this patient showed the presence of
the Plasmodium falcijiarum.
(iii) (a steward) : This man had reported sick " off
and on for a week or so " feeling ill one day and a
little better the next and going on with his duties, but
somewhat lethargically apparently. His blood gave
a strong agglutination with B. typhosus, none with
either of the paratyphosus organisms and his blood
also contained malarial parasites.
(iv) N.A.B. This man was very weak and looked
more seriously ill than any of the others, but was
walking about in a partially dazed condition. He had
been ill, it appeared, some twelve days. During the
morning of the 29th he had fallen down " through
weakness." His blood also gave a good agglutination
with B. typhosus and a few plasmodia were seen in
the smear of hie blood.
(v) E.S. : another of the crew. This man had only
been ill for two, possibly three, days. He was up and
about and complained only of headache and sleepless-
ness. Smears of his blood were taken for examination
for malarial parasites and in case he had been ill
really longer than he stated a Wright's pipette of
blood was also taken on the off chance that an
agglutination reaction might be obtained. His tem-
perature when I saw him was just upon 100" F. No
parasites were seen in the smears, but the Widal test
gave a positive reaction with B. paratijphosus A, no
agglutination with B. typhosus at this stage at least.
(vi) The blood from another man was taken as
smears for malaria. As he had been well until the
same day (29th) no specimen was taken for a Widal
reaction. No malarial parasites were found in his
blood.
They were all six landed and taken to the hospital,
and except the last who rapidly got well, they all
passed through a typical attack of enteric fever.
In view of this outbreak and hearing that the first
two were taken ill the same day, I took samples of
the water supply for analysis and it proved to be
remarkably pure. I also obtained specimens of the
urine and faeces of several, asking specially for those
of the cook and stewards, and in fact any who took
part in the preparation or handling the food.
Briefly stated, I was fortunate in finding that the
assistant cook was a carrier and was excreting typhoid
bacilli.
(2) A girl, aged 9, suffered from an attack of enteric
fever ; Widal gave well marked agglutination on
December 27, 1916. She passed through an attack
of average severity. Early in March, 1917, when the
child had been convalescent for three to four weeks,
her mother began to suffer with acute attacks of
trigeminal neuralgia of the right side with photo-
phobia at the onset. Prior to this the mother had
always been quite healthy, in fact she did not re-
member ever having been ill in her life. The neuralgia
lasted with great intensity for three days, practically
without intermission and unaffected by the adminis-
tration of gelsemium, croton, chloral, morphia, &c.
During the ensuing four or five days there was a
certain degree of alleviation, but a duU headache
remained. While the attack was on and also after-
wards there was marked cutaneous hyperassthesia. In
the second attack the occipital area of the same side
became affected. There followed another interval of
comparative comfort for five or six days and another
attack came on. The temperature was variable ; it
was occasionally 99° F. and once rose to 102" F., but
was mostly subnormal. On April 9, in view of the
illness of the child, whom she nursed, and in view of
her rise of temperature and the intractability of the
neuralgia, her blood was examined, and the serum
gave a marked agglutination of B. typhosus. She was
constipated, had no abdominal pain, possibly a slight
enlargement of the spleen, but no other sign of typhoid
fever, in fact no symptoms except the neuralgia. She
vomited occasionally when the pain was at its worst.
On suspicion of there being antrum or dental
affection, the practitioner called in the aid of a dentist,
but treatment of the teeth did not give any rehef,
Since the second attack she had complained of a
" brow ache " on the left side. On or about April 15
she began to see double any objects more than 10 in.
distant, and on examination there was seen to be a
very slight internal strabismus of the right eye. In
view of the occasional vomiting, marked frontal head-
ache, and the signs of intranuclear affection of the
right sixth cranial nerve, a tentative diagnosis of
cerebral tumour was made ; the discs were difficult
to examine as the patient was very intolerant of
opthalmoscopic examination, and no optic neuritis
was made out. Another possibility suggested was
typhoid or post-typhoid neuritis, affecting the fifth
and sixth cranial nerves.
Specimens of the urine and faeces were asked for,
for bacterial examination, and the B. typhosus was
isolated from the latter. In the course of time, fully
another month, all the symptoms cleared up, the pho-
tophobia, the neuralgia and the strabismus, so the
condition was in all probability a typhoid neuritis.
The question as to whether the child had infected
the mother, or whether the mother was a chronic
carrier and had infected her child could not be
determined.
r
[Nov. 1, 1920. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Colonial Medical Reports.— No. il2.— Jamaica (contd).
(3) Lastly, it may be noted that in a former report
of three years ago, an" account was given of outbreaks
of enteric fever occurring yearly at the reformatory,
some fifteen to twenty cases arising each year. No
carrier could be discovered among tlie inmates or
workers there. It was decided therefore to inoculate
all the inmates as a prophylactic measure. This has
been most successful ; the Medical Officer in charge
tells me that for two years there has been no case
among the inoculated ; only one case occurred this
year, and that was a new arrival who had not received
the vaccine.
(B) Vaccine Treatment. — A case representing very
fortunate results of vaccine treatment also deserves a
brief record.
A girl, aged 18, suffered with dental trouble for
a considerable period and for two years had had a
chronic discharging sinus in the left upper alveolus.
Scraping had been tried repeatedly, but the condition
remained unrelieved, the sinus being too tortuous to
clear properly. As a last resource the patieut was
sent up with a view to having an autot;enous vaccine
made. This was done, and after the second injection
there was considerable improvement, and in three
weeks the discharge was very slight. The patient
did not come for further treatment for a month,
thinking all was well, but the discharge was then
becoming more free, so she had a further course of
injections. The condition soon cleared up altogether,
and there has been no sign of any recurrence.
(C) Post-mortem. — Lastly under this group mention
must be made of three post-mortem cases which pre-
sented features of special interest.
(l) A case of fatal laceration of the lung without
any external marks of violence pointing to any pul-
monary mischief. That the lungs may sustain serious
injury from a blow, a fall, compression and so forth,
although no external marks of violence are visible is
a well known fact ; nevertheless definite instances
of such are still sufficiently rare to warrant the
following being placed on record.
So far as I can ascertain from the literature
at my disposal the concrete cases are few and
none of them quite correspond with the one related
below.
The subject was a man L. R,, aged 25, strongly
built and of good physique. He was walking in the
street and talking to a friend about 8.5 to 8.10 p.m.
on June 28, 1917, when they heard the sound of a
motor car close beliind them, and l)eariiig down upon
them. They jumped one on each side; the friend who
was on the right succeeded in getting out of the way,
but the other was struck on the right side by the car
and fell. It is uncertain whether the lamp or mudguard
came into actual contact, but the witnesses of the
accident were unanimous in stating that no part of
the car passed over the patient's body. He was
picked up insensible and driven in the car to the
hospital which is less than quarter of a mile from the
scene of the accident. He arrived at 8.20 p.m. and
was found to be dead.
Superficial examination then showed wounds of the
left side of the head, but no bleeding from the ears or
mouth.
At the post-mortem carried out at 10 a.m. the next
day, the following conilitions were found : With the
exception of the head injuries described below, there
were no marks externally of any violence or injury.
No long bones (including the ribs) were fractured, and
there were no signs of any contusions or even abrasions
anywhere on the body, back or front.
Head. — (i) A wound extending to the bone, 8 cm.
in length, curving outward from the left malar emi-
nence to just above the left eyebrow : the malar bone
was fissured- (ii) From the middle of this was a
lacerated wound involving the outer half of the upper
eyelid ; the eye itself was not injured, (iii) Extending
from the root to the nose, a wound 3 cm. in length
passing upwards and outwards to the right ; this was
separated by a narrow bridge of skin from (iv) a
triangular wound of the inner canthus of the left eye
as if cut by the point of a stone, (v) A small lacerated
stellate wound of the left parietal eminence down to
the pericranium. From this site a fissured fracture
passed through the occiput to the base, and there was
a small subdural blood-clot beneath the parietal
eminence. The left orbital plate of the frontal bone
was also fissured.
The brain showed no h£emorrhage whatever, and
there was no laceration of its substance.
On opening the thorax the right pleural cavity was
found to contain about 1\ Htres of blood. This was
removed and careful examination again made for any
fractured ribs ; all, however, were intact and there
was no sign of any contusion of chest wall internally
or externally.
The lung was then raised to the surface and a tear was
found in the lower lobe vertical in direction, some 6 cm.
long but not deep. The middle lobe was intact, but the
upper lobe just above the line of separation from the
middle lobe showed a piece of the lung tissue 7 by 5
by 4 cm. almost completely severed ; it was hanging
by a mere thread of lung tissue and attached visceral
pleura. The lungs were everywhere perfectly healthy,
as were also all the other viscera, thoracic and abdo-
minal. There were no pleural adhesions. The head
injuries were not very severe, and the rapid death was
due to the laceration of the lung and hasmorrhage.
The head injuries are easily explained by the effects
of the blow on the right side throwing him to the
ground, and the left side of the head coming into
contact with stones in the road.
1 cannot explain the mechanics of the lung condi-
tion. The man was certainly not run over, all the
witnesses swore to that fact, and the deceased was a
strongly built adult and the ribs were not very
yielding and elastic like those of the child mentioned
in the case previously cited, yet there was no fracture
or even contusion visible; nor was there any obvious
manner in which counter- pressure could be applied ;
lastly, the lung condition was not a mere superficial
tear, nor a separation at the root, but an almost
complete severance of a piece of lung tissue of
considerable size at the periphery of the organ.
Nov. 1, 1920.]
COLONIAL MEDICAL BBPORTS.— JAMAICA.
82
(2) A case of extensive wounds of the throat, larynx
and trachea self-inflicted.
The suicide carried out his object in front of a crowd
of people, but as it has been stated that one severe
injury of the trachea precludes the person from
inflicting a second on liimself (in fact this has been
used as an argument in favour of homicide as against
suicide), I think this case worthy of record, for if it
had been perpetrated in the night or when no one was
about to witness the act, it is more than likely that
some unfortunate person might have been indicted for
murder.
C. E. M., male, aged 25, admitted to hospital at 5.55
p.m. on May 31, with an extensive cut throat wound.
He died ten minutes later. At the post-mortem the
only signs of violence were those in the neck and
were as follows : (i) A long wound (probably made
up of three or more) gaping and witli jagged edges
extending from the middle of one sternomastoid
muscle to the other, (ii) Small wound through thyro-
hyoid membrane, horizontal, (iii) Vertical cut 2 cm.
long through upper part of right side of the thyroid
cartilage, (iv) Incised wound 7 cm. long passing to
the right from the lower part jof the left thyroid
across the middle line extending right through,
(v) Incised wound severing thyroid from cricoid and
detaching lower part of right thyroid from the body
of the cartilage. Deep vessels of neck not severed.
Left lung contained blood in the bronchi extending
down from the severed windpipe ; and trachea
contained blood and frothy-bloodstained mucus.
Eight lung somewhat less affected, though in similar
condition. Eight pleura adherent at apex, and the
lung beneath was infiltrated with tubercular disease
over an area the size of a lives' ball. Finger tips and
nails of right band showed dried blood. Nothing else
noticeable.
Comment is needless except to say that had not
the deed been perpetrated in front of several witnesses
one could hardly have credited that such extensive
injuries could have been self-inflicted.
(3) A case reveahng very clearly the connection
between the so-called vomiting sickness and ackee
poisoning: A.S., male, aged 3. Between the hours
of 3 and 4 p.m. (August 9) he was seen to be eating
ackee ; shortly after this vomiting started and con-
tinued repeatedly tiU he was brought to the hospital
at 8 p.m. When seen at 8.5 p.m. he was still vomiting,
the vomitus consisting of mucus and yellowish un-
digested food. The pulse was low and the extremities
were cold. Temperature 98° F. The stomach was
washed out and stimulants freely administered. He
improved greatly to all appearances, but at 1.30 a m.
(lOth) vomiting and retching returned, coma rapidly
supervened, the Cheyne-Stokes type of perspiration
was noticed and the child died at ^.30 am. No
convulsions were reported.
At the autopsy on August 10 the body was found
to be that of an exceptionally well-nourished child.
Stomach. — The mucous membrane of the stomach
was congested especially towards the cardiac region.
The organ itself was practically empty, there being
merely a little mucus and a few minute yellow masses.
Duodenum and upper part of the intestines had similar
contents (ackee fragments).
Peyer's patches were prominent and mesenteric
glands slightly enlarged and pinkish in colour.
Liver. — Was of a purple red colour over a con-
siderable ijart of the surface ; in other parts and on
section of these congested areas the tissue was seen
to be very yellow and fatty, almost the colour of
cornmeal.
Pieces of the following tissues were taken in alcohol
and also in Fleming : liver, kidney, spleen, pancreas,
heart muscle. All the tissues showed the changes
which have been described in detail in the monogi'aph
on the vomiting sickness. This is a valuable case in
that the symiitoms were typical of the " vomiting
sickness," as were also the post-mortem findings, both
naked eye and microscopical, and the child had
actually been seen eating th€ fruit shortly before the
onset of the illness.
Special Investigation.
(1) An acute outbreak of " central neuritis " at
Spanish town.
A brief mention was made at the end of my last
annual report of a peculiar epidemic which was
occurring in the Spanish Town district. The condition
was given the title tentatively of the Spanish Town
epidemic because the disease was first notified from
tliis place by Dr. C. Eedwood White, and the majority
of cases occurred there. It must be distinctly under-
stood, however, that subsequent inquiries have shown
that the condition is also met with elsewhere and
moreover there is a considerable weight of evidence
to support the thesis tliat the " Spanish Town
epidemic " represents the acute stage or an acute
onset of the disease, which, when it has become chronic,
has for a long time been designated in Jamaica as
peripheral neuritis.
General History. — Nearly all the patients are adults.
Of a large number of cases seen there were but three
children, and they were far from typical in the
symptoms they exhibited. The youngest patient
coming under my observation was a girl of 14 years
of age. All of those attacked during the epidemic
were of the peasant class, that is, natives who worked
as labourers on the sugar estates or who in i-are
instances had small holdings of their own. Males
and females were equally affected. The epidemic
started during the cutting and carrying of tlie cane
crop, and the reporting of fresh cases ceased almost
abruptly as soon as the crop was finished.
The following is a brief general description of the
main features of the condition ; differences shown by
individual cases will be noticed in the detailed account
of such.
In practically every instance the first symptom
complained of was a sensation of " itching in the
eyes. " This would come on with comparative
suddenness while the patient was at his usual work.
In some cases both eyes would be attacked about the
same time, in others one eye would be affected alone
at first, and after an interval of varied length from a
few (three to four) hours to as many days similar
il"
[Nov. 1. 1920. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
sensations would be felt in the other eye. At this
eai-ly stage the conjunctiva would he congested and
there would he photophohia, hut not of much intensity.
Within the next three days or so the conjunctiva, both
ocular and palpebral, would be in a swollen, red,
ccdematous condition, the edges of the lids would show
aljrasions, and small superficial ulcers would form witii
discharge of pus.
Within four days to a week of the onset of the eye
symptoms, a burning sensation in the mouth is com-
plained of. Tiiis is referred to the mucous membrane
of the lips and cheeks, but not the tongue. Tlie
lining membrane becomes red and inflamed and
aphthic make their appearance, especially along the
e3ges of the mucous membi-ane of the lips. At the
angles of the mouth a small ulcer or fissure is often
present. Salivation is not a common feature. I
noticed it only once in the twenty-one cases detailed,
and did not observe it in any of more than 100 other
patients seen at the hospital.
The soreness of the mouth gives rise to pain on
eating for the first twenty-four hours or so ; after that,
in spite of the congestion and ulceration, food is taken
without any difSculty or complaint. This soreness
is by the patients themselves often attributed to
eating sugarcane.
The affection of the eyes was usually treated by
yellow oxide of mercury ointment and the conjimctivitis
cleared up fairly readily. For the stomatitis a mouth-
wash containing chlorate of potash and boric acid soon
gave relief.
The above was the sequence of events at the onset
in almost every case. One patient stated that the
mouth was affected before the eyes, hut this was the
only exception.
No further symptoms develop during the succeeding
week or so, in other words till about fourteen days
after the first onset with itching sensations in tlieeyes.
After this interval, however, further symptoms declare
themselves and the cases naturally relegate themselves
to one or two categories.
(1) Those with diarrhaa and intestinal syniptovis. —
These patients have loose actions increasing in
frequency to as many as twenty-five in the day. Of
those so affected, some die in a few days apparently
from exhaustion, others slowly recover. No treatment
seems to benefit the diarrhoea, whicii appears rather to
cease gradually and spontaneously in those who
recover. In the latter no further symptoms occur
and recovery seems to he complete. The stools are
watery and brown in colour.
(2) Those with ncvvous symptoms. — These patients
. are invariably constipated. As far as I myself
observed, and from the histories of a large number of
cases reijortcd to nie by the medical officer in charge
of the hospital, in all of those exhibiting nervous
symptoms constipation was the rule, and as a corollary
to this, in none of the cases belonging to the pre-
ceding class (intestinal cases) did any nervous
symptoms develop.
The following gives a general resume of tiie progress
of nervous cases.
The patient states that he feels a sensation of
riuiulniCNS and tiii{;liiig starling in the loes and soles
of the feet, occasionally accompanied by a feeling of
lieat and burning.. The numb sensation slowly
extends over the dorsum and up the legs to the knees
— in some patients to the hips. Both limbs are
affected together and the spread is equal in both ; in
other words the logs appear to be affected segnientally,
symmetrically, and simultaneously.
Some patients state that they feel " pain in the
knees," but this is only comjjlained of when move-
ment of the joint is carried out. Palpation is quite
painless, and there is no heat, redness, or swelling,
in fact no objective sign of any joint trouble. With
the spread of the numbness walking begins to be
impeded, and in the course of three or four days, when
the condition has extended to the knees, walking is
impossible. The patient can no longer stand unless
supported, there is marked inco-ordination, and the
patient has practically no control over the lower
limbs. When supported and assisted in getting out
of bed, the legs are thrown about with wild, exag-
gerated movements. In some cases, in the inter-
mediate stages, between the " delicate," unsafe gait
of early numbness and the later total inability to
walk, the gait is suggestive of that of tabes. Also
at this stage there is no real loss of power, the
knee-jerks and other deep reflexes are quite abolished,
Babinski's sign gives no response normally in a
native owing to the horny thickness of the soles caused
by their walking barefoot. Sense of position is not
always, or even often, defective, although spontaneous
disposition of the limbs is no longer possible.
In spite of the general complaint of numbness
over so large an area, no alteration of sensation
could, as a rule, be detected objectively. With the
eyes bandaged, the responses to finger-touch, to cotton
wool, pin;head, and pin-point were correctly estimated
and localized
The differentiation between heat and cold even with
a fairly wide difference of temperature was frequently
defective. Although no change of sensation, at least
no recognizable blunting of the sense of touch, was
observable objectively, I noticed more than once in
those who were still able to walk that one or botii
slippers might come off' the feet and yet the patient
would continue his progress down the ward without
them, or with one oft' and one on, and not notice tlie
loss until ho happened to look down and discover
that he had left one slipper behind, when he would
return for it.
The difficulty of walking was not made worse by
closing the eyes, nor again did tlie patients watch
their feet to help their jirogress.
Some cases remain in this condition, but in
others a similar sensation of numbness is com-
plained of after a further interval of one to four
days or more, and, in a few, the backs of the hands,
the forearms and occasionally the upper arms are
affected also.
In the worst cases tiiere was some difiiculty of
speech, due, as the patients described it, to numbness
of the tongue. No numbness of the face was men-
tioned by any of the patients. No alteration of sen-
sation could bo detected in upper limbs or toogue by
objective tests.
84
COLONIAL MEDICAL REPORTS.— JAMAICA.
Nov. 1. 1920.;
In those cases which terminated fatally after a
considerable period (four to six weeks or more), there
was marked general emaciation ; no localized wasting
of muscles could be detected at any time. The
reaction of degeneration was not found in any
instance, though in some there appeared to be a slight
alteration in the nature of a less brisk response than
normal, but nothing very tangible could be made out.
Some of the patients with nerve symptoms com-
plained during the early stages of " pain in the
stomach," and described it " as if someone was
pulling a rope tight round the chest." It waS clearly
the nature of a girdle pain, and only occurred in the
second group of patients — those with nervous symp-
toms, not in any of those with diarrhoBa and in-
testinal symptoms. This pain was not aggi-avated by
food, in fact the iiatients ate well without any
discomfort.
The last stage of the fatal nervous cases was
always the same. About forty-eight to seventy-two
hours before death, when the patients were lying
helpless in bed, diarrhoea would set in, and the ex-
haustion from the combined inanition, emaciation
and diarrhcEa ^oon brought about the fatal issue.
Even towards the last, though the patient lay
helpless, and to all appearances totally paralysed,
nevertheless there was not in reality a condition of
paralysis, all movements could be performed, though
feebly on account of the emaciation and general state
of exhaustion.
A large number of examinations, both clinical and
pathological, were carried out in connection with these
cases. Over 100 patients must have been seen and
examined clinically, but twenty-one were fully investi-
gated. Specimens from these took six months to
complete from the examination point of view,. Blood
examinations were made, both total and differential
counts, serum reactions Ijy the Wassermann test,
the excreta were tested and cultivated, eye, mouth
and throat cultures carried out, and from those who
died parts of the vaiious tissues were subjected to
examination in detail.
The so-called Vomiting Sickness of Jamaica.
When the third hurricane in three successive years
struck this island in September last and destroyed
a large proportion of the natural foodstuff's, one pre-
dicted that the outbreak of the so-called " vonuting
sickness" would probably be both severe and wide-
spread in the succeeding cooler months. This prophecy
has been only too amply fulfilled. With a view of
minimizing the disastrous effects of this disease
placards were printed and distributed all over the
island warning the people of the dangers and notifying
them of the precautions which they should take to
mitigate the ravages of this epidemic. Since, however,
many, in fact the majority, of the inhabitants were
still sceptical of the fact that vomiting sickness and
ackee poisoning were synonymous terms. His Excel-
lency the Governor issued instructions that I should
visit the various districts in wiiich cases occurred,
and carry out fresh investigations into the condition.
It is giatifying to be able to state that the fresh
investigations have absolutely confirmed the results
of my former work.
The outbreak this year has been exceptionally
severe, as the following record of cases proves, but
whereas in former years the mortality has been
exceedingly high (between 80 per cent, and 90 per
cent.) in this last outbreak, although the number of
persons attacked has been far higher, the mortality
rate has been very greatly reduced. This can only be
attributed to the propaganda issued in the shape of
the pamphlets and notices spoken of above.
When carrying out my investigations this year it
was quite a common occurrence to find that though
several members of a family might be attacked, only
one, perhaps none, might die, the prompt treatment
and precautions recommended having led to the
recovery of the other members, and thus to the
saving of many lives. At a rough estimate obtained
by making inquiries when one was investigating a
case, it would be safe to say that the mortality rate,
in spite of the great incidence, is more in the
neighbourliood of 30 per cent, than 90 per cent., in
other words, some 250 to 300 lives at least have been
saved. Though tliis is a matter for congratulation, it
is not enough. My investigations this year, as already
stated, and as the records given in tiie sequel prove,
have shown that, putting out of the category of
tliseases which have been hitherto returned as " vomit-
ing sickness " those which are well known, such as
cerebral malaria, meningitis, gastritis, and so forth, by
far the largest proportion of the residue are cases of
ackee poisoning.
The ackee, the fruit of the lllighia sapida, is an
excellent food, and quite harmless when used with
caution and when properly prepared, but when im-
properly gathered, when carelessly prepared, when
eaten in an immature state, it is a deadly poison,
probably one of the most deadly known.
To get this fact to penetrate is uphill work. The
natives and Europeans also have been accustomed
to eat this fruit for many years. The latter are ex-
ceeding cautious in the gathering and preparation
of it, and will rarely eat it unless plucked from trees
in their own gardens and under their personal super-
vision, and consequently cases of poisoning amongst
them are rare. The native, however, is not so careful ;
consequenth- he and his are the greater sufferers.
As soon as the people generally can be made to
understand the conditions under which the food can
Ije eaten with impunity, and to follow out the pre-
cautions necessitated by these conditions, ackee
poisoning cases will become less and less, and may .
even be abolished altogether, and the dread vomiting
sickness be a thing of the past, and hundreds of lives
saved which are now needlessly, one might almost
say wantonly, thrown away. The difficulty is this.
The fruit has been eaten for many years, and these
mysterious sudden deaths have occurred year after
year, but the two things have never been connected
until one's investigation and experimental work of
1915 onwards had tlie fortunate results of elucidating
the matter.
J
Nov. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Colonial Medical Reports.— No. 112.— Jamaica {contd).
These deaths were and even are now attri-
buted to worms, to cold (in the tropics), to
starvation (ah.hough the majority are well nourished),
to duppies and evil spirits and to obeah. This last
is not an imaginary danger, for the poison almost
certainly belongs to the toxalbumin or phyto-
albumose (phytotoxin) group in common with cirin,
crotin, abrin and robin for which no distinctive test
is known, and may be used for purposes of homicide
with little risk of detection.
These points, however, are side-issues ; what one
would impress upon the people is that if the
precautions recommended were conscientiously carried
out, vomiting sickness and ackee poisoning would
disappear from the record of causes of death, and
hundreds of lives would be saved. Even this year
with a large incidence of cases the reduction of the
mortality by some 50 per cent, is gratifying in showing
that one's efforts have not been altogether fruitless
and gives ground for the hope that further propagandist
efforts may lead to total eradication of the disease in
epidemic form.
I would like to acknowledge the help which has
been afforded me in this last investigation by the
various medical officers who took the trouble to make
personal inquiries as to the histories of the cases,
particularly Drs. Campbell, Purchas and Watson in
Trela%vny ; Dr. Dryden in Clarendon ; Dr. Wilson
in St. Ann's ; Dr. Gideon in Portland and Dr. Crooks
in St. Andrew.
Direct questioning of parents in nearly every case
is met at first with a fiat denial of the use of the food
at the meal preceding the illness. The reasons for
this are three : —
(1) The child may have picked the immature fruit
and eaten it without the parents' knowledge.
(2) The use of the term " ackee poisoning." When
the police make the preliminary inquiries before
an autopsy is ordered, the native is afraid that
he will get into trouble either for not looking after
the children carefully, or on the graver charge of
"poisoning" the children.
(3) They fear that, if it is acknowledged, the trees
may be cut down and they will thus be deprived of a
useful and palatable food.
The denial is valueless. In many instances at the
post-mortem examination ackees are found in the
stomach. In this connection the following extract
from a letter sent to me by a district medical officer
is of interest. ..." I may mention that in the past
there have been several instances at post-mortem
in which ackee has been found by me in the
alimentary tract, but out of several only in one" case
did the relatives admit that the child ate the
If the vomiting has removed these, confirmation of
the suspicion is often found by examination of the
kitchen, where ackees ripe and unripe, and husks
of those which have been recently used, are seen.
Many examples of this are afforded by the brief
histories given in the fuller report. Fortunately
although there is no known chemical test for proving
the presence of the poisons of this class in the tissues,
the microscopical changes are so very marked and
characteristic that -they are unmistakable. These
changes need not be given in detail here, they have
Ijeen described in my former reports and monograph
on this subject.
However, the response to my request was almost
universally acceded to ; in the majority of cases the
post-mortems were ordered and specimens sent.
I regret to say that in one district in the island where
cases are rare, burial was ordered and post-mortem
examination refused, but this is almost the only place
where full investigation was negatived.
Two or three points only need be especially insisted
upon. The most important of these is the fact that
of all the cases which have been reported to me as
vomiting sickness in this epidemic, there was one case
of fish poisoning, terminating in recovery, one of
ptomaine from tish in which, however, ackee was a
part cause of death ; two of gastritis, both recovering ;
one fatal case of scarlatinal nephritis ; seven of
malignant malaria, only one of which recovered, and
one in which death was due to ackee during the
course of a malignant attack, and one from gastro-
intestinal troubles associated with dentition. There-
fore of the 172 cases all but fourteen were cases of
ackee poisoning, and in two out of these fourteen
ackees took part, although not being solely responsible
for the symptoms ; in other words in the recent
epidemic, out of 172 cases which were brought
personally to my knowledge as " vomiting sickness "
no less than 158, or 91'86 per cent, were instances of
ackee poisoning.
This in a nutshell is the final corroboration of my
discoveries of 1915, the proof of what I put forward
then merely as a theory that vomiting sickness, the true
vomiting sickness which was recorded as accounting
for so many deaths each year, was nothing more nor
less tha;n ackee poisoning, the fruit of the Bllghia
sapida used in an unfit, immature condition for food.
Experimental work carried out with extracts made
from these constituted the proof and has been already
recorded and need not be narrated again in the
present report.
It is high time then that this reprehensible term of
vomiting sickness be expunged from the nomenclature
of diseases in this island, for the labelling of a disease
by the name of one symptom, which symptom even
may be absent, hinders advancement and leads to
carelessness in diagnosis. This state of things would
be analogous to diagnosing " death from headache "
when the patient may have suffered from the head-
ache of typhoid fever, or that of cerebral tumour,
or that of ura;mia, and so forth, and disregarding the
origin of the headache. Seeing that the macroscopical
and still more the microscopical anatomy of the
condition of ackee poisoning is so marked and
distinctive there is no longer any excuse for not
separating these cases from the large nondescript
group of " vomiting sickness."
The poorer people may be excused for using the
term just as they use the term " fever " for practically
all conditions from malaria to stomach-ache, but
there is little or no excuse for any medical man to
COLONIAL MEDICAL REPORTS.— JAMAICA.
[Nov. 15, 1920.
employ the term, since it is indicative of either
(a) insufficient examination in not detecting abnor-
malities post-mortem, or (b) a false conception of
what is meant by " diagnosis," in chinking that by
naming a symptom they diagnose the disease, or
(c) want of interest in not inquiring properly into
the history, or, where there is any doubt, in failing
to send tissues to the laboratory where they can be
examined and reported upon at no charge or trouble
to therqgelves ; and in my future reports should cases
of ackee poisoning call for special mention they will
be spoken of as such and not again as so-called
" vomiting sickness."
Seeing that the facts are now definitely established,
that the knowledge of them is gradually permeating
through the people even to the most sceptical, such
an epidemic as this last should never occur again.
I think, therefore, that this is a fitting place to give
a brief summing up of the whole matter of the dread
vomiting sickness, so-called, which had been the
cause of hundreds, nay, thousands, of deaths in
.Jamaica during even the thirty-two years of which
records have been kept. In some years there may
have been only 100 or so, in others as many as
400 cases with a mortality of 80 per cent, to 90 per
cent., so that by the moderate estimate of an average
of 150 per annum, there will have been the loss of
nearly 5,000 lives since the disease came into
prominence in the records of 1886. How many
occurred prior to that date is a matter of guess work
only.
The duration from the first appearance of symptoms
until death occurs may be very short ; in one case,
J. DeV., it was only half an hour, in another, E. W.,
it was an hour, and the average duration of all the
cases in which this was ascertainable with accuracy
works out at fifteen and a halt hours.
Lastly : I beg to report that unless the people are
wilfully careless, or wilfully ignorant, such an epidemic
as this last should never occur again, and to form a
fitting summary of the whole question I submit the
following remarks which, taken in conjuction with
my previous reports on the so-called vomiting sickness
of Jamaica will enable any inquirer in the future to
make himself cognizant of all the salient facts of the
hitherto mysterious condition, clinical, pathological
and experimental.
The separation of the toxic principle, the devising
of chemical tests for identification of that principle
are matters for the chemist and the physiological
botanist, and are out of my domain.
For the purposes of this summary to avoid vain
repetition the question will be dealt with under the
headings of: —
(1) Prior to 1915.
(2) The investigations of 1915.
(3) Furtherpoints brought out by the 1918 epidemic.
(1) Prior to 1915.
Briefly this period may be summed up as follows :
The disease had existed for many years, particularly
prevalent in the cooler months, November to March
or .'\pril, and in each year it had been responsible for
a considerable number of deaths, and in some years
had exacted a terrible toll among children.
The earliest records which I have been able to
trace date from thirty-two years ago, when the non-
committal but descriptive name of " the vomiting
sickness' was given to a condition which was
beginning to command respect owing to its mysterious
nature, its sudden onset, and its high mortality rate
180 to 90 per cent.).
Tracing the history of the disease from that time
(1886) to the present has been an interesting study,
but it must be passed over to enable us to come to
more important matters. Briefly, the period 1886
to 1915 may be summed up by saying that, during
the season in which the disease was usually prevalent,
any child that died after vomiting was diagnosed (by
some practitioners) as having suffered from vomiting
sickness while other medical men, rightly scorning so
indefinite a term, erred in signing up true vomiting
sickness cases as having died from gastritis, yellow
fever and so on ; while yet a third group, fortunately
a small one — on attending patients with some obscure
condition terminating fatally would sign the certificate
by the delightfully safe but paradoxical diagnosis,
" vomiting sickness without vomiting."
In 1906 letters were sent to the other West Indian
Islands asking whether any such or similar disease
was met with there and the replies all went to prove
that the condition is practically limited to Jamaica.
So serious were the ravages of the disease that,
in 1910, an expedition was sent out from England to
investigate it, but without result, and again in 1912,
a second expedition was made, which in turn went
hack baffled.
(2) Investigations of 1915.
In February, 1915, a severe outbreak occurred on
the north side of the island, and eighteen deaths took
place in a small district in two days, and I was sent
down to investigate the mattei? on the spot.
I had the good fortune to see a considerable
number of cases, some almost from start to finish,
and to perform autopsies on all who died during my
stay in the district. I visited the huts where cases had
occurred, and interviewed survivors and the relatives
of those who had died. Briefly the symptoms of the
condition are these : —
The patient—almost invariably a child — in appar-
ently perfectly health, suddenly complains of feeling
ill, and occasionally of pain in the stomach. This is
usually mere discomfort and not, I believe, actual pain,
but as the native tersely puts it, " him belly trouble
liim, doctor." He then vomits ; perhaps only once,
perhaps three or four times at short intervals.
Recovery then seems to take place, and, if the attack
occurs at night, the child drops ofi' to sleep, apparently
well again. Some three or four hours later, (occa-
sionally after a longer interval) the child wakes up,
again complains of feeling sick, and begins once more
to vomit, usually frothy mucus, and later watery
fluid only, or it may be bile-stained. There is little if
any accompanying effort, unless the stomach be
empty, when troublesome retching may ensue. Within
a very short time, often a matter of a few minutes
only, convulsions make their appearance, coma rapidly
supervenes, and terminates in death.
Recovery from the first attack of vomiting being to
Nov. 15, 1920.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
all appearances complete, a doctor is not usually sum-
moned until the relapse occurs. The majority of
patients, therefore, first come under observation during
the convulsive or comatose stage. The temperature
is usually normal or subnormal ; the pulse is of good
volume, and rate is 90 to 100 per minute : respiration
26 to 30, and regular until towards the end, wlien the
Cheyne-Stokes rhythm may be noticed. The pupils
are equally, moderately dilated, and, if the coma is
not too deep, react to light. There is no delirium, and
shortly before passing into the comatose stage, the
child may remark that it feels very bad, but does not
call attention to any particular symptoms or complain
of any localized pain. There is no rigidity in the true
vomiting sickness cases (except, of course, during a
convulsion) but a general limpness of muscles ; move-
ment, such as turning the patient over for examination
purposes or to obtain fluid by lumbar puncture,
frequently leads to a repetition of the vomiting.
Such is the picture of the majority (80 to 90 per
cent.) of such cases, for the mortality rate is very
high. In the rare instances which recover the vomit-
ing is practically the only symptom. I have never
met with a recovery when once convulsions or coma
has set in. Recovery when it occurs is very rapid.
Within twenty-four hours or so, a child who had
appeared to be seriously ill may be up and about,
showing nothing but a little pallor and debility, as
after any severe bout of vomiting, while others in the
family, who did not seem any worse at the time, have
passed into a state of coma and died in a few hours.
A few of the symptoms merit a little more detailed
description : —
(1) Vomiting. — This may be, and usually is, the
first objective symptom. The nature of the material
vomited is usually at first food or if a considerable
interval has elapsed since the last meal (and this is
uncommon), frothy mucus, then watery matter, later
bile-stained. At times the vomiting may be replaced
by troublesome retching. Next, as regards the times
at which vomiting occurs. In a typical case, vomiting
takes place at the onset, and may be the very first
symptom. It is usually accompanied by considerable
effort and is repeated two or three times, at short
intervals. This I have termed the " initial vomiting,"
and gives one distinctly tlie idea of an effort on
the part of the stomach to rid itself of some noxious
naaterial.
After an interval of calm, during which there arc
practically no symptoms, there is a return of the
vomiting, and now it is of a different character. It is,
to a great extent, effortless, and may be unaccompanied
by nausea. This I have designated tlie " secondary
vomiting," and it is in my opinion, cerebral in origin,
owing to its character of being effortless and induced
by movement, and to its being followed almost at
once by other nervous symptoms, twitchings, con-
vulsions and coma.
Initial or secondary vomiting nuiy be absent. Thus,
as stated already, tlie former only is seen in cases
wiiich recover — in other words, the patients never
reach the stage when the secondary cerebral symptoms
appear. On the other hand, this " initial vomiting "
may be suppressed in the very rapid and acute cases.
There is an attack of vomiting which is so rapidly
followed as to be almost accompanied by the con-
vulsions and coma, the entire symptoms being cerebral,
owing to rapid absorption of the toxin from an empty
stomach. Death in these cases may occur in an hour,
or even less. More rarely, the secondary attack of
vomiting is suppressed ; the patient may pass through
the initial attack and appear to improve ; then after
a considerable but varying interval, he is seized with
convulsions, passes into the comatose stage and dies.
Lastly, vomiting may be absent, and the cerebral
symptoms may be the first indications of anything
wrong. For example, I have among my notes the
following case : A child, 4 years of age, was quite well
when she ate her dinner at 1 p.m. Two hours later
she felt out of sorts and went to lie down. An hour
or so afterwards her mother went to waken her, but
could only partially do so ; twitchings of limbs
and slight convulsions came on, and the child lost
consciousness altogether and remained comatose till
death.
Such cases have been diagnosed somewhat paradox-
ically as " vomiting sickness without vomiting," and
I am sure that they do occur, though with exceeding
rarity. Such a diagnosis, however, could not be
made unless, firstly, true vomiting sickness cases
were occurring at the time; secondly, all other causes
could be excluded ; or thirdly, the post-mortem signs,
especially the microscopical were those of vomiting
sickness.
(2) Convulsions. — These may vary from merely
slight twitching movements of the limbs to definite
massive convulsions. They may be tonic muscular
contractions lasting for a few seconds only, or more
clonic, and epileptoid in character. Looking over my
notes in cases which recovered, slight twitching
movements occurred in one patient only, a child of 4
years of age. We have all of us seen slight twitching
movements in a child asleep, in ordinary health, or
possibly with a little dyspeptic disorder. With
reference to the vomiting sickness one may safely
say that in no cases which recover are convulsions
seen.
(3) Coma. — In most of the cases which I have
seen this has been deep; as a rule, there was absolute
unconsciousness with absent conjunctival reflex. In
some, at an earlier stage of the coma, there was
general flexion, and some irritability was exhibited
when attempts were made to rouse the patient; but
this " cerebral irritation stage " was transitory and
soon passed into one of deep coma.
A few remarks may be added on the question of
age, sex, and duration of illness. These all refer to
the 1915 investigations with which this section deals
and are corroborated in the essential features in the
1918 epidemic.
Aye. — The condition is, to a great extent, one of
childhood; sucklings are not attacked. I have records
of only three cases under the age of 12 months, and
these were not breast-fed. Nearly half the cases
(44'84 per cent, of my series) occur in the fir.^t ([uin-
(juennium, another 30 per cent, in the second and 85
per cent, of cases are under the ages of 15 years.
The mortality rate is high in all these periods ; thus,
COLONIAL MEDICAL REPORTS.— JAMAICA.
[Nov. 15, 1920.
of those under 5 years, 85 06 per cent, died ; of those
between 5 and 10 years, 86'21 per cent, died ; and
84:'24: per cent, of those attacked under 15 years
succumbed.
Sex. — The affection shows no predilection for sex.
Thus, in the first decade 45 percent, of those attacked
were males and 55 per cent, females ; and the death-
rate was closely similar, 46 per cent, and 54 per cent. ;
while in the third quinquennial period, of fifty-eighc
cases of which I have full notes, thirty were males
and twenty-eight females : of these fifty terminated
fatally, and this number was contributed to equally
(twenty-five each) by males and females.
Duratio7i of Illness. — In 140 instances I have been
able to obtain reliable accounts of the duration of
illness. The shortest recorded was in a female child,
1 year, death taking place in thirty-five minutes. The
average duration of the total number works out at
12'72 hours. Sex has no influence on duration for
although of those whose duration is given eighty- two
were females and fifty-eight males, the length of
illness from the time of onset to death — including,
when present, the period of calm — works out at ]2'5
hours in the case of males and 12'89 in females, a
difference of only twenty-three minutes.
It will not be time wasted if I briefly recapitulate
the symptoms by shortly describing four cases
exhibiting the different types : —
(1) A mild case ; a girl, aged 9, was given some
" soup " from boiled ackees and bananas at noon.
A 2 p.m. she complained of pain in the belly and
vomited. The vomiting continued on and off for
three hours. She was seen by a medical man, who
gave her a mixture containing ether and ammonia.
The vomiting ceased, and the child had quite recovered
by the fonowing evening.
(2) A male, aged 3, in normal health when he was
given an evening meal of the soup made from bananas,
yams and ackees. Two hours later, without any
complaint of pain, he vomited. He rapidly recovered
from this, and appeared quite well on being put to
bed an hour or so later, and slept well till just before
dawn. He then without any warning suddenly
vomited again, was shortly afterwards seized with
convulsions, and coma supervened, which lasted till
death at 11 a.m. The total duration was sixteen
hours ; there was a symptomless intermission of eight
to ten hours, and death occurred in five hours after
the onset of the secondary vomiting. Here we have
an example of a case apparently quite mild at first, but
nevertheless terminating fatally.
(3) A girl, aged 6, after a similar meal, went to bed
in her usual good health. Early in the morning,
without any warning or previous complaint, she
suddenly vomited, and did so three times in the course
of an hour. During the day she stayed in the house
and did not feel quite well, but took food. She seemed
better in the evening, and slept well during the night.
Early the following morning, without warning, again
she started vomiting frothy watery material, without
any effort. A few minutes later she was attacked by
convulsions and passed into a state of coma, dying at
2 p.m. This case resembles the last, but differs in the
longer duration of illness, and in the fact that the
interval was one of improvement, not total abatement
of symptoms.
(4) A girl, aged 12, left home in good health for
school, three miles away. At midday she had a meal
containing ackees, and returned to school, where
nothing amiss was noticed, until three hours later she
started to vomit ; this occurred four times. Feeling
better she started _ for home, but during the walk
she felt ill again and vomited at intervals, taking
three hours to make the three-mile journey. Shortly
after arriving she became drowsy, this drowsiness
deepened to coma, and she died about midnight
without recovering consciousness. Here we have an
example of a case in which convulsions were absent.
The changes set up are very widespread, and may
be summarized as follows : —
Hyperoemia of most of the organs, including the
meninges, with csdema or the supporting tissues ;
there is a tendency to haemorrhages evidenced by
small extravasations, e.g. in kidneys, adrenals, lymph
glands, spleen, lung ; the epithelium, particularly of
the kidney tubules, the pancreas and liver, shows
necrobiotic changes ; and, lastly, and most important,
is a marked fatty change in many organs, notably the
liver, kidneys, sometimes in the cells of the pancreas
and heart muscle, and the large Betz cells and others
ill the brain.
Of course, in a disease such as this, which becomes
epidemic every year, bacteria have been suspected
and carefully looked for, without result. In fact,
during the course of my investigations of 1915 I stated
" in my opinion the disease has no bacteriology. The
organisms which have been found in some of the
patients (a small percentage only) I can see no reason
for regarding as in any way causative." The absence
of prodromata, of any true incubation period, the
serious and extensive lesions, the negative results
of attempts frequently repeated at finding or isolating
any organisms, all made me incline to the opinion
that the condition was not a bacterial infection, but a
pure intoxication, and the sequel bore out the surmise.
To sum up the thirty-two cases which came under
my notice in this outbreak in the small district on the
north side of the island : in seventeen the attack
followed closely on the ingestion of ackees or a watery
extract (soup or pot-water) made from them. In
eight others there was a strong probability that
ackees comprised one of the constituents of the meal
prior to the onset of the illness. In these instances
the parents had had a meal containing ackees and the
children " may have had some." In the remaining
seven cases no definite history of the food could be
obtained ; but I visited the huts in which the cases
had occurred and noticed in every instance, without
exception, that trees bearing ripe fruit were growing
in the yards, and it is most unlikely, to say the least,
that such a food, ready at their very doors, a food of
which they all are fond, and which was then ripe,
would be avoided, especially at a time when other
articles of food are scarce or at least relatively expen-
sive. In none of the thirty-two then could the eating
of the fruit be definitely excluded.
Dec. 1, 1920.]
COLONIAL MEDICAL BEPOBTS.— JAMAICA.
Colonial Medical Reports.— No. lit.— Jamaica (contd).
The next point was to make inquiries concerning
the ackee, the fruit of Blighia sapida, which is used
to a considerable extent as an article of diet in
Jamaica. Amongst the better classes the ackees are
gathered carefully, one by one, and not only those
which are properly opened and appear ripe and sound
in every way are taken for food. Unopened ackees
are not used by such people, nor any which have not
opened naturally on the tree or have been gathered
from an uninjured branch ; those forced open after
falling from the tree unopened are dangerous. Among
the poorer people, however, less care is taken, and a
boy is sent up the tree to shake down the fruit ; ripe
and opened and unripe unopened fall together ; the
former is collected and the latter left. In time, some
of these may open and be gathered with fresh ripe
ackees brought down at the nest shaking. This point
is referred to again and in greater detail in the next
section.
By the time the investigations into the Montego
Bay outbreak and the examination of the various
tissues taken post-mortem were nearing completion, I
considered that sufficient evidence had been presented
to warrant the bringing in of a true bill against the
ackee, sufficient, that is, to put it on its trial, so
experimental work was started with this end in view.
In order to simulate as closely as possible the con-
ditions under which, by this hypothesis, cases of
vomiting sickness occur, some ackees were obtained,
which to all appearances were good except that they
were unopened or had been forced open after being
gathered immature. The part used for food was then
boiled with water just as was done by the natives in
making their soup or " pot-water." The product,
practically a watery extract of ackee, was then filtered.
The result is a liquid of the colour of weak tea with
a layer of oily, fatty matter like melted butter floating
on the surface.
The extract after administration by mouth to
kittens or pups set up the foUovving train of symp-
toms : Within an hour of administration of a small
quantity vomiting set in, and the animal was inclined
to be heavy and dull for about half to one hour.
Eecovery then took place and the animal became
normal and lively again. The following day a slightly
larger dose was given with similar results, recovery
being apparently complete in two hours or a little
more. After an interval of three hours a third dose
was given twice the size of the first. Vomiting came
on forty-five minutes later, and the animal became
dull and drowsy, its bead nodding as with sleep in
some cases, in others it merely lay about and was dis-
inclined to move and vomited at intervals. This
drowsiness gradually deepened to coma during tbo
succeeding hour, and death took place some four
hours after the last administration. The total amount
given was the extract from one ackee. The post-
mortem appearances were, both naked eye and micro-
scopically, absolutely typical of those found in human
vomiting sickness patients. I repeated the experi-
ment on several animals, merely varying the dosage,
and except for a slight difference of interval between
the feeding and the onset of the vomiting, according
as the dose was smaU or a little larger, the symptoms
and post-mortem appearances were the same.
Briefly stated, the characteristic symptoms of the
so-called vomiting sickness appear an hour (more or
less) after the administration of filtered watery
extract of ackee. In human cases, where other food
was taken as well and the action probably slower in
consequence, the interval was usually two hours.
x\fter a small dose there was vomiting, and after a
larger still, vomiting, drowsiness, coma and death.
The matter had by this time progressed beyond the
realm of mere hypothesis, and a most welcome con-
firmation came three months later, when the
following cases occurred : —
On the evening of August 19, 1915, a family of
eight, all at the time in good health, partook of a
meal of ackees taken from a branch of a tree which
had been damaged by the hurricane of the previous
week. About two hours later, five of them com-
plained of feehng sick ; later three of these were
attacked by vomiting, and one who had drunk some
of the soup, shortly afterwards became convulsed,
rapidly lost consciousness and died within twenty-
four hours of the meal. The remainder completely
recovered.
Six days afterwards, at 6 p.m., another similar meal
was prepared. The soup together with some of the
boiled ackees were eaten by a woman 24 years of
age. At 8 p.m. she vomited and soon afterwards
stated that she felt better ; at 10 p.m., however, the
vomiting returned, convulsions followed, coma set in
and death took place shortly after midnight. Another
member of the family wrs also taken ill, but recovered
after vomiting. The autopsy I carried out myself
and took specimens of practically every organ and
tissue. Full details of both maci-oscopical and micro-
scopical appearances have been given in the paper
already spoken of.
Here then was a definite history of a patient
previously in good health partaking of a meal of
ackees from a bruised limb. She with other members
of the family suffered from vomiting and recovered.
A week later another meal was prepared with fruit
from tha same tree. The patient drank the soup and
also ate some of the solid. Two hours later the
symptoms appeared and ran their course to a fatal
termination in six hours or so, and at the post- mortem
the typical changes were revealed. In this case the
term " vomiting sickness " was not used from first to
last, but the case showed typically the onset, course,
and pathological changes of that disease.
Certain peculiarities and characteristics of the
affection which at the onset was most puzzling, then
found a ready explanation in the light of our present
knowledge of the similarity (identity) between
vomiting sickness on the one hand, and the effects
and results of experimental administration of ackee
extract on the other, linked together by the clinical
case of definite ackee poisoning just related.
These were : —
(1) Tfie Peculiar Seasonal Prevalence. — The epi-
THE JOUENAL OF TEOPICAL MEDICINE AND HYGIENE. [Dec. 1, 1920.
demic character of the disease corresponds exactly
with the main ackee season, when other fruits and
natural foods are relatively scarce. If the ackee
season lasts longer than the usual November-
December to March-April, then also cases of vomiting
sickness continue to be reported for similarly longer
periods. Ackees are also obtainable in smaller
quantities at other times, but other foods are then
plentiful and this fruit is less eaten. Occasionally
cases of vomiting sickness, however, appear at other
times as the one just related. It used to bethought
that it was a disease of which occasional, sporadic
cases occurred during the warmer months, becoming
epidemic in the cooler, comparable, for example, with
cerebrospinal fever due to the meningococcus.
(2) Limitation to Jaynaica. — The results of the
circular letter sent to the authorities of the other
West Indian Islands have already been mentioned.
I myself have made inquiries of inhabitants of other
islands and am told that the Blighia sapida does not
grow to any extent in any of them. It is true that
one or two trees are found, but they are looked upon
as curiosities and are not used for food. They grow
in British Guiana but are not used for food, nor in
Cuba where the natives call it "vegetable brains"
and never eat it : in Barbados they will not grow to
maturity, being killed off by " scale " at the bush-
stage.
(3) Sudden onset of symptoms in the midst of
apparent good health, without any incubation period
or prodromata, and in the well nourished and not
necessarily the emaciated or debilitated. We see
now that the symptoms, being those of an acute in-
toxication, would depend not so much on the general
well-being of the subject as on the dose of the poison
and the condition of the stomach, whether empty or
fuU, and its consequent readiness for absorption.
(4) The Rapid and Complete Recovery of Non-fatal
Cases. — This is obvious, and explained by the fact
that an acute vegetable poison is taken ; if the dose is
small it is got rid of by the vomiting, and the patient
recovers.
(5) Affection of several persons practically simul-
taneously in one house, or close neighbours in a
settlement. Several members are affected in one
house because the food is cooked togetlier and shared
in common. Close neighbours in a settlement are
affected be'cause the trees are in and about the settle-
ment and all share in the produce.
(6) Hie vastly greater Prevalence in Children. —
This is explained by the fact that they are given the
pot-water," the most toxic part — an extracted
poison, in short — and that the lethal dose of a poison
is far smaller for a child than for an adult ; and also
the adults know the risks of eating unopened ackees
while children naturally do not.
(7) Attacking the West Indian Native in much
greater numbers tkan the East Indian or the White
Man. — In Jamaica the coolies live largely on rice and
split peas, often in the form of curry ; they also like
green fruit — mangoes, guavas, jack-fruit. They rarely
indeed eat ackees. A few after they have served
their time and settled in Jamaica, may eat them, but
not at all commonly. The white buys 1
the market, where he can see and select them ; while,
safer still, many will only eat ackees which have been
carefully gathered under their own superintendence
and from their own trees.
A few words may be added to explain the rationale
of the precautions recommended.
The statement has been made that Europeans and
the better class natives exercise considerable caution
in picking the ackees, only those fruits which are
fully open and mature are used, and even then as an
additional precaution the fruit is boiled separately
from the other ingredients and the water thrown away.
As has been proved by experiments, the details of
which I have already reported, the poison is extracted
by boiling with water, and, therefore, if an immature
(or poisonous) fruit is inadvertently used the poison is
thus removed.
With the peasants the procedure is different. A
boy is sent to shake the tree, and the fruit in all
stages falls to the ground. Mature and opened and
immature fruits are there together. The "fit" ones,
that is the mature and opened fruits, are taken, the
remainder being left on the ground. The children
wandering about the yard, many of them hungry, pick
up some of the immature fruits, force the husks open,
and eat the fruit, and are poisoned.
Keturning for a minute to the fruit left after re-
moval of the opened and mature ones. Some will
open soon by action of the sun's rays — such, not
having opened naturally on the tree, are poisonous,
analogous, one may say, to those forced open. Those
which are "full " or mature will open naturally in a
couple of days or so in the shade, and such, so far as
my experimental work goes, are harmless. If they
are not " full " they will not open within that time,
and though apparently " full " are not " fit," and must
not be used for food.
It is necessary to understand the use of the terms
employed, as the significance is not the same as it
would be at home. The word " ripe " is applied as a
general term to indicate that the tree looks well, that
the fruit is coming towards maturity, that the pods are
red. A " ripe " tree does not mean that the fruit on
it is ready for eating. The stages to that point are (1)
ripe, (2) mature or full, (3) fit or opened; to these a
fourth may be added : the fruit must consist of well-
developed arilli. Each fruit contains three of these
ariUi, and although opened one or more may be de-
formed, with small and poorly developed seeds, such
are sometimes at all events poisonous. If a branch
has been partly broken or bruised by high winds, the
fruit on it does not open naturally, and is poisonous.
Fruits in the " full " stage are shipped abroad to Colon,
and open naturally on or before arrival there, and are
consequently harmless.
We can see from this description what should be
the proper procedure to prevent ackee poisoning. When
the tree is shaken and the fruit in various stages falls,
the " fit " and opened pods should be picked up, and
those alone used for the next meal, and only those
with undeformed arilli ; the mature and full ones
should next be taken and placed to open away from
i
Dec. 1, 1920.]
COLONIAL MEDICAL REPORTS.— SHANGHAI.
the direct sun's rays before they can be used with
absolute safety, and any of these which do not so
open in two or three days should be discarded ; the
immature, unopened pods should all be picked up
and taken away, as they will never be fit for eating ;
in order that they may not be found by children
and inadvertently eaten they ought to be burned.
Boiling with water appears to remove the poison
completely, or nearly so. The reason for boiling
separately from other food is that if one with de-
formed fruit or if an immature fruit should happen
to be used, from careless supervision, the water or
"soup" then contains the poison, and should be
thrown away. If other articles of diet, such as
yam, rice, &c., are boiled with it, some of this water
(with extracted poison) is absorbed by these articles,
and may cause poisoning.
Amongst the poorer natives the soup is not thrown
away, but is given to the younger children, who thus
constitute a large percentage of cases, and the poison
being taken avidly on an empty stomach is rapidly
absorbed and rapidly kills. The poison is precipitated,
or at all events appears to be rendered inert, by
alcohol. Hence, if this is given at the very onset
of the vomiting, before much has been absorbed, the
poison is ejected at the succeeding attack of vomit-
ing, and recovery rapidly ensues. Absorption, how-
ever, is very rapid, and if the administration of
alcohol (rum, whisky, brandy, or as sp. eetheris and
sp. ammon. aromat. of which the ' vomiting sickness"
medicine is composed) be delayed till the secondary
symptoms appear, all chance of recovery is lost.
Sometimes there is no interval between the vomiting
and the secondary symptoms, " cerebral " vomiting,
convulsions, and coma : in other words, absorption is
so rapid that no primary local symptoms occur. The
initial " gastric " vomiting is absent, and the first
indications are the (usually) secondary " cerebral "
symptoms. Such is not uncommonly the case
where the " soup " is taken at the last meal of the day
shortly before bed time. A few hours later the child
wakes up and vomits, and before the mother can give
any help or any medicine can be obtained, convul-
sions and coma have supervened, with the invariably
fatal result.
Examples of each of these are amply supplied by
the record of cases in this year's epidemic. One can
only hope that the experience of this epidemic, dearly
bought as it has been, will drive home for good and
all the lesson that ackee poisoning is a preventable
disease, and that if the precautions which have been
drawn up as the outcome of these investigations are
conscientiously carried out, the people will be able to
use the food with safety, while epidemics of vomiting
sickness and ackee poisoning will become things of
the past. Then instead of the few hundreds of lives
which have been saved this year by those who fol-
lowed the advice given and the precautions laid down,
there would be thousands spared to grow to maturity
— children whose lives are now needlessly, thought-
lessly, wantonly thrown away.
H. Harold Scott, Government Bacteriologist.
Colonial Medical Reports.— No. 113.— Shanghai.
ANNUAL REPORT OF THE MEDICAL OFFICER OF
HEALTH, SHANGHAI, FOR THE YEAR 1918.
By ARTHUR STANLEY, M.D., B.S.Lond., D.P.H.
Health Officer.
II
Though the public health was threatened in three
different ways by extreme danger, the past year
proved a healthy one. With the exception of a few
cases of smallpox early in the year, due to the care-
lessness of new comers in regard to vaccination, and
a limited number of fatalities from influenza pneu-
monia, the incidence of preventable disease was
remarkably small.
Yet the year was an anxious one because of the
urgent need of guarding against imminent dangers
when the foreign health and nursing staff was depleted
by the fourth year of the war and working for the
most part without the necessary period of rest away
from China which long leave affords.
The salient feature of the record of the public
lii'alth during 1918 is that of a series of shocks. The
year opened with pneumonic plague again dramatically
in the picture as a menace from the north. What is
now known as the Shansi Epidemic, which killed
some 15,000 people, made a tragic sweep from the
Suiyuan District in Mongolia, just to the north of
Shansi Province, through Pekin and down the Tientsin-
Pukow Eailway to Fengyang and Nanking, where it
opened up dire possibilities among the populous and
overcrowded centres in the lower part of the Yangtsze
Valley. Immediately plague was reported in Fengyang,
special preventive measures were formulated, and
when Nanking was infected such steps as were possible
were taken to limit passenger traffic by rail and river
from the infected areas, and in the Settlement itself
for the discovery of cases and means of preventing
further infection. However, in none of the places
south of Shansi did the outbreak show signs of much
momentum, and, after a smiill flare up in Nanking, it
subsided with the coming of spring.
Another bolt from the blue was the remarkable
93
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 1. 1920.
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epidemic of cerebrospinal fever in Hongkong in the
early months of the year during a period of unusual
cold. This exceptional cold led to the closing up of
fresh air openings into living and especially into
sleeping rooms, vehere people huddled for warmth, so
that such an infection once introduced had the best
chance of spreading. This should be an object lesson
to us in Shanghai, where overcrowding is excessive
and practically unrestricted. A careful watch was
kept for cases in Shanghai, and when no less than
live cases were reported within two days a similar
epidemic seemed likely. However, nothing more
alarming than a few sporadic cases arose, although
in Hankow and in some Japanese ports a considerable
number of cases were reported.
The third unusual shock occurred towards the end
of May when the great pandemic of influenza suddenly
impinged on Shanghai without warning, except that
some vague reference to " Spanish Disease " had
already appeared in the press. The tremendous
sweep of influenza is so distinctive that no other
disease but dengue resembles it, and the latter is
limited to warm countries. A definite diagnosis was
made within a couple of days, which proved to be
the right one. Though Shanghai was visited by two
epidemic waves, that is in June and October, com-
pared with many other places it escaped lightly,
which is remarkable considering the excessive over-
crowding. China is, however, generally considered
the real home of influenza, so that close acquaintance
has conferred some degree of immunity on its people.
A former epidemic originating in China was known in
Russia as " Chinese Influenza," passing into Europe
it was known as " Russian Influenza," from Europe
it spread to America and was known as " European
Influenza," finally it reached Japan, where it was
called " American Influenza "; having circled the
globe and reached its original home, China, where
many millions constitute the fountain head of
epidemic disease. As communications are increased,
it becomes ever more necessary for the safety of the
whole world to develop modern public health
administration throughout China.
The influenza pandemic with its millions of dead
compels attention to the preventive possibihties of
a suitable respirator or face mask, to the use of
which the Manchurian epidemic of pneumonic plague
first called serious attention. In the presence of
pneumonic plague the Mukden plague mask rendered
the wearer immune from danger. The mechanism
of spread through droplets sprayed out from nose
and throat in coughing, sneezing or even speaking is
the same in influenza ; but also in many other of the
great gioup of respiratory infections. The use of a
suitable respirator, or mask, or veil, under con-
ditions where infection is probable, would tend to
wipe out the whole group of respiratory infections,
of which the "common cold" is the most ob-
vious, but which also covers lung tuberculosis,
scarlet fever, diphtheria, measles, whooping-cough,
cerebrospinal fever, and many of the dangerous
pneumonias, including those caused by influenza and
plague.
Dec. 15, 1920.]
COLONIAL MEDICAL REPORTS.— SHANGHAI.
Colonial Medical Reports.— No. 113.— Shanghai (contd).
In the pursuit of wealth and pleasure the most
difficult, tiresome anu laborious precautions are
taken to procure the desired result ; but to secure
the absence of often fatal illness the smallest pre-
cautionary restraint is usually cast aside. The
damage due to wild animals and crime is fully
recognized, but the hidden dangers, infinitely
greater, from the microbes of disease brought to
light by scientific research during the last fifty years,
have not yet been incorporated into the essential
code of everyday life. How great are the potentialities
of future preventive work. How great the need for
education in the things that matter, of which self-
preservation is the most fundamental. It is only by
a general knowledge of natural processes that a due
assessment of the dangers which surround life can be
made and guarded against by the public. Without
such general knowledge no amount of preaching or
compulsion can secure the right mode of conduct of
life.
In the present generation, such diseases as small-
pox, leprosy, plague and typhus fever, previously
quite common, are almost as extinct as the dodo in
those nations which have most profited by scientific
education. And it seems certain that within a few
generations all disease which is now known to be
preventable will indeed be prevented.
A little while ago epidemics were looked upon as
visitations of Providence sent for punishment for
sin and so accepted as beyond the power of man
to combat. But epidemics are a punishment for
sin — the sin of ignorance. The removal of such
ignorance by the study of nature, rather than by
metaphysical speculations into the unknowable, is
rapidly making for new conditions of life ; so that
in the near future, say within two or tiiree gener-
ations, it will be the rule rather than the exception
to live the allotted span.
As every case of preventable disease prevented
means increased efficiency and happiness, the
broad outlook as regards public health is sublimely
optimistic.
ViTAi, Statistics.
Population.
The Foreign Po\iulation of the scttleiiient north
of the Yangkingjjang, including the outside roads
and Pootung, at the last census taken on October
10, 1015, was 18,.'519, and consisted of 8,197 men,
0,044 vvonu-n and 4,278 children. The foreign ship-
))iiig jiopulation, which numbered 2,290, was not
inciu<lc(l. The foreign population for the middle of
1918 was calculated as 21,000. The census of the
fonugii pcj]Hdation taken at each <|nin<juennjal period
since 1870 shows the following expansion: 1,666,
1,673, 2,197, 3,673, 3,821, 4,684, 6,774, 11,497,
13,530, 18,519.
The, Chinese Population on October 16, 1915, was
620,401, and consisted of 284. IHH men, 165,623
women and 170,581 children. The Chinese popu-
lation for the middle of 1918 was calculated as
659,000. The census of the Chinese population
taken at each quinquennial period since 1h70 shows
roughlv the following expansion : 75,000, 96,000,
108,000, 120,000, 108,000, 241,000, 345,000, 4,y2,UuO,
488,000, 620,401.
DcathH.
Deaths among the Resident Foreign Population.
— During the year 1018 the total corrected number
of deaths registered among foreigners, including
non-Chinese Asiatics, was 434; of this number 348
occurred among the resident population.
Six months spent continuously in Shanghai is
taken to constitute residence as in former reports.
As the non-resident population is a variable and
indeterminate factor, the deaths in this category are
eliminated in the calculation of the death-rate.
The death-rate per thousand per annum, therefore,
calculated from 348 deaths occurring among the
resident foreign pop.ulation of 21,000, is 16-5 as
against 20" 7 in 1917. The deaths of 129 children
(persons under 15) have been registered, as against
169 last year ; of the deaths among adults, 137 were
men and 82 were women ; of children, 67 were boys
and 62 girls. The mean age at death among the
adult resident population was 41'2.
The sharp incidence of small-pox at the end of
1917 rapidly subsided early in 1918 and then con-
tinued completely absent.
Cholera remained conspicuous by its absence.
Typhoid fever diminished and paratyphoid in-
creased, but the respective incidence was due rather
to improved diagnostic methods than to epidemio-
logical change. There was a considerable diminution
in the total mortality of the combined infections.
Scarlet fever showed a marked diminution.
Diphtheria continued of mild type.
There was an entire absence; of plague both in
rats and miin.
Pneumonic plague imminently threatened but
Shanghai remained immune when Nanking was in-
fected by an extension of the Shanse epidemic.
Tuberculosis flourishes apace and awaits the
coming campaign.
Th(!r(! were no deaths from hydrophobia.
Beriberi increases with the .Japanese community.
Influenza was epidemic in .j\me and October,
killing nine persons as a part of the universal
j)and('mic killing millions.
Cerebrospinal fever which was so fatally prevalent
in Hongkong during the early months of the year
caused a few sporadic cases in Shanghai.
Deaths among the Chinese Population. — 8,441
deaths among the Chinese have been reported, com-
pared with 10,217. 8.\m. 8.329, 8, .524, 6,799, 9,663,
8,062, 8,453, 8,173, 8,198 and 9,612 in sequence of
preceding years.
The death-rate per thousand per anniim is 12-8.
Of the deaths. 4.519 were male and 3,922 female.
The deaths of 2,733 children (persons under 1.5) have
94
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 15, 1920.
been registered; of these, 1,395 were boys and 1,338
girls.
Infectious Disease.
Notification. — In the absence of legal obligation
to notify, an arrangement has been made with the
(jualified medical practitioners of Shanghai requir-
ing notification of infectious disease for the facilita-
tion of preventive measures, in consideration of the
use of the resources of the Public Health Laboratory
for the purposes of pathological diagnosis and the
payment of a fee of one tael for each case. The
notifiable diseases are : small-pox, cholera, dysen-
tery, typhoid fever, paratyphoid fever, typhus fever,
diphtheria, scarlet fever, tuberculosis, plague,
anthrax, glanders, leprosy and hydrophobia.
The system of notification, so far as it goes, has
worked well, and the best thanks of the community
are due to our colleagues in general practice for their
co-operation. Chinese cases are beginning to be
usefully notified by Chinese practitioners educated
according to the foreign standard.
During the year 77 Bills of Health for ships and
cargoes were issued, as against 126, 149, 90, 86 and
95 in sequence of years from 1913.
Weekly returns of infectious disease have been
exchanged so as to keep in touqh with the sanitary
condition of places in the Far East in communica-
tion with Shanghai.
Isolation. — Isolation for cases of infectious disease
among foreigners and Chinese is provided in the
Isolation Hospital, Range Road.
Disinfection. — The Disinfection Station adjoins
the Isolation Hospital. Prior to disinfection each
disinfeetor puts on a sterile overall. The general
method of disinfecting in a house after a case of
infectious disease is first to remove to the Station
everything that can be disinfected by steam ; then
to spray and ^ash walls, floors, fittings and furni-
ture with disinfecting solution (cyllin). Fragile and
delicate articles, such as bonnets, books and photo-
graphs, are disinfected by formalin. In many cases,
such as after typhoid fever or diphtheria, disinfec-
tion of walls, &c., is not considered always neces-
sary, the washing with disinfectant being then
limited to articles that have been actually in con-
tact with infected material. After disinfection,
painting or colour-washing of walls and ceiling is
advised to be done by the occupier before the room
is again occupied.
Small-pox. — The recrudescence of small-pox in
1917, attributable to an accumulation of non-
innnune material from outside Shanghai, yielded
early in 1918 to the speeding up of vaccination.
The number of free vaccinations done at the Branch
Hcaltli Offices during January, 4,219, of which 682
were foreigners, made a new montlily record. A
considerable nunnber of vaccinations were done of
the Chinese staff of business firms by special request
at the offices of finns, as an emergency measure.
This was, however, discontinued, as it was felt that
such free vaccination should be done only at the
Branch Health Offices to which the public should
mainly look for their practical sanitation.
Where taipans or householders wish to make cer-
tain that their employees have been vaccinated at
the Branch Health Offices, if a chit stating the
number to be vaccinated is sent with them it will
be signed as done by the Health Inspector in
Charge ; substitution can be defeated by stamping
the palm of the hand of each employee with their
office rubber stamp ; or an examination of the upper
part of the left arm five days after will reveal a
definite proof of vaccination.
It may be noted that the old practice of inoculat-
ing small-pox is still done to a small extent in
Shanghai. One or more " practitioners from
Ningpo " come to " place the seed " of genuine
small-pox within the nose of babies. This sets up
small-pox, usually of mild type; but each case is
as much a focus of infection as a case caught in the
ordinary way. With the facilities now provided for
vaccination the practice of " inoculation " can only
be regarded as pernicious, being calculated to create
more small-pox than it prevents.
China is no place for the unvaccinated. Since the
beginning of the war there has been an unusual
influx of foreigners who had not taken the very
necessary precaution of vaccination before they
embarked from their homelands for China. These
furnished very easy meat for the infection of small-
pox, which is ever present in China. Several severe
cases among such foreigners were infected on the
very day they landed in China. It seems necessary
to give a warning to those who are responsible for
bringing employees out to China, that vaccination
should always be done before embarkation.
In China there is so much small-pox infection that
vaccination should be repeated every three years;
and care should be taken to have the vaccine fresh,
as it soon spoils, especially in warm weather. As
a rule the best time to be vaccinated is early in
November.
Cholera. — ^Shanghai since 1912 has continued very
fortunate in the absence of cholera and the limita-
tion of the incidence of choleraic diarrhoea to very
small proportions, although Japan and the Philip-
pines have been rather severely infected. Mean-
while such precautions as were possible in regard
to the food supply were continued vmabated. The
regrettable "hawkers' riot " jirevented the prosecu-
tion of a very necessary development having for its
object the limitation of the sale on the streets of
foods especially liable to be infected with cholera,
dysentery, typhoid fever, &c.
Typhoid Fever. — The incidence of typhoid fever
remains an important sanitary factor. Every case of
typhoid fever, cholera and dysentery means a short
circuit between the bowel discharges of one person
and the mouth of another. In nearly all cases where
the origin was investigated obvious breaches of the
ordinary rules of health, as laid down in the Public
Health Notice, were observed.
The infection of typhoid fever may be conveyed
by vegetables and oysters which have been con-
taminated with infected ordure, by water, by milk
cimtaniinateii with infected water, through the air
Dec. 15, 1920.]
COLONIAL MEDICAL REPORTS.— SHANGHAI.
95
by means of infected dust, and directly from persons
suffering from the disease or who act as " typhoid
carriers " subsequent to recovery. Typhoid fever is
a preventable disease, its prevention being largely
a matter of individual care in the observance of the
rules set forth in the Public Health Notice which
has been issued to all applicants at the Healtli
Office. It is important to remember that the urine
as well as the faeces are infective in cases of typhoid
fever.
The cause of typhoid fever is practically always
taken into the body with infected food, and the
foods most commonly infected are vegetables, by
reason of the manner in which they are grown.
Especial stress should be laid on the fact that
vegetables are frequently the source of infection with
typhoid fever, cholera, dysentery and other forms of
diarrhoea, and i)articular care should be given to
their thorough cooking and separation before cooking
from the rest of the food. The larder or room for
storing uncooked food should be separated from the
l)antry or serving room where table utensils, ice-
chest, bread, milk, germ-proof filter and cooked food
are kept. There should be a washing-up sink in the
serving room so that table utensils need not be taken
into the kitchen to be washed. A place in the yard
outside the kitchen for the washing and preparation
of vegetables prior to cooking is an additional pre-
caution that may be recommended.
The evidence in favour of typhoid vaccination
increases and it involves no risk. Young people
especially are advised to have it done on first coming
to Shanghai when the danger of infection is greatest.
Useful immunity probably lasts three years. Not
only is it now certain that the liability to disease
is lessened but if contracted the mortality also. It
is advisable to repeat every year if especially ex-
posed to infection. The time would appear to have
come for offering free vaccination against typhoid
fever in the same way as against small-pox.
Paratyphoid Fever. — ^There were 62 cases of para-
typhoid fever notified and 4 fatal cases. Cases of
paratyphoid B predominate over those of .\ in the
proportion of 3 to 1. It has been the practice when
issuing typhoid vaccines from the Laboratory to
combine the organisms of paratyphoid fevers A and
B. The reaction is scarcely greater for the com-
bined vaccines while the protection is secured
against all three infections, to the great content of
those who are wise enough to appreciate the value
of preventive medicine. The loss of service to
business firms occasioned by these fevers clearly
demonstrates the advisability of having their staffs
protected by the mixed typhoid and paratyphoid
vaccination, material for which is prepared in, and
always obtainable from the Municipal Laboratory.
Ama.bic D]jsentery. — -The incidence of amoebic
dysentery was considerably less than in the two
])receding vears. In practically every case investi-
gated after notification obvious breaches of the
Public Health Notice were found which might have
led to the conveyance of infection.
Servants with chronic dysentery are numerous
and are carriers of infection by finger infection of
food. A house-boy,, for example, with chronic
dysentery cutting bread and butter is practically
certain to pass on the infection to the consumer.
Such chronic cases may pursue their usual avoca-
tions so that it is advisable to have any house-boy,
cook or coolie, who apj)ears to be getting thin, pale
or weak, seen by a doctor and his fseces examined
for dysentery amoeba in the Municipal Laboratory
so as to ensure the safety of the household.
Amoebic dysentery has always been endemic in
Shanghai and, in the past, a frequent cause of
chronic invalidism. The disease is carried by cysts,
the amoebae assuming a more resistant capsulated
form which are passed in large numbers in the faeces
of persons suffering or convalescent from untreated
or improperly treated dysentery. Such persons,
especially if house servants, are a great danger by
infecting food, dishes, glasses, napkins, &c., with
their fingers. Again, a fly within a few minutes of
feeding on infected faeces begins to deposit droplets
of liquid excrement and, in these, unaltered and
living dysentery cysts occur. Thousands of such
cysts may pass through a single fly and be deposited
on food, &c., and the persons who consume the food
become infected with dysentery.
Hoolnoorin Disease. — The disease is prevalent
around Shanghai in the rice districts, but among
foreigners it is rare and is uncommon among Chinese
residents, due mainly to the ehamiel of infection
being usually through the skin — that is to say, it
is only common among those who wade or bathe
in infe(;ted water. It is caused by the Anchylostoma
ihioilniah:. In its passage through the skin the larva
produces an inflammatory reaction known as ground-
itch. Within the body it j)roduces anaemia by its
blood-sucking habits. Infection is voided by the
bowel.
Diphtheria. — Diphtheria was of mild type.
Twenty-eight foreign cases were admitted into the
Isolation Hos])ital with three deaths in very young
children. Diphtheria antitoxin is supplied free for
indigent patients in Shanghai on the recommenda-
tion of the ))hysician. In any case of suspected
diphtheria, antitoxin should be given at once, with-
out waiting for the result of the bacterial diagnosis.
Formerly bad drains and sewer-gas were given as
one of the causes of diphtheria; this is a fetish
which dies hard, and tends to obscure the real cause,
namely, direct transfer of infection from a previous
ease or carrier, and to mislead the public in whose
hands prevention really lies. The control of diph-
theria is almost entirely the control of the infective
person. The use of antitoxin has reduced the case
fatality to one quarter of what it was but has not
materially reduced the number of cases and has
probably increased the nmnber of carriers. In those
cases where the diphtheria bacillus persists in the
throat or nose after convalescence it seems likely
that a spray of the recently prepared dicliloramine-T
would greatly helj) in rendering them non-infective.
iScarlet Fever. — Early diagnosis and isolation is
Mecessar\ for preventing spread. Transmission is in
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 15. 1920.
accordance with the general rule regarding the re-
spiratory group of diseases, namely, by droplets
sprayed from nose and throat. A discharging ear
following scarlet fever is usually a sign of danger
that the throat may still be infectious. The peeling
skin has nothing to do with the transference of the
disease but is an outward and visible sign of pre-
vious scarlet fever. Disinfection of rooms, clothing,
&c., is far less important than preventing infection
from the nose and throat of the patient. Such
infection can be prevented by a face mask of gauze
and wool. Contacts should be quarantined and
inspected daily
Cerebrospinal Fever. — ^An unprecedented epidemic
of cerebrospinal fever occurred in Hongkong from
January to May, considerably over a thousand cases
being reported, although only four were Europeans.
Some 760 deaths occurred. It is believed that
sporadic cases had occurred from time to time in
previous years. In Manila 70 cases were reported
in 1915. The prominence given to the epidemic in
the press gave rise to a feeling of apprehension in
Shanghai. It was, however, pointed out that though
cerebrospinal fever was widely distributed through-
out the world, and occasionally flamed up in
epidemic form, such epidemics are not as a rule
widely diffused and that, therefore, it did not follow
that Shanghai was necessarily so endangered by
the prevalence in Hongkong. A careful watch was
kept for cMes, facilities afforded for bacteriological
diagnosis and for examination of carriers, for isola-
tion of cases and for the provision of curative serum.
Our prognostication proved correct, a few cases
occurred sporadically, singularly enough five "cases
were discovered within two days ; in all thirteen
cases during the year, one of which was traced to
Hongkong and one to Hankow, where the disease
was also reported prevalent. Cases have been re-
ported in previous years as occurring sporadically
in the Yangtsze Valley, but it has rarely been found
in the mortality figures of Shanghai. There were
sixty cases reported in Swatow in March this year
but none apparently in Canton, which is in such
close proximity to Hongkong. It was also reported
prevalent in Amoy and Hankow in April.
Cerebrospinal fever is a winter disease, corre-
sponding very closely with the prevalence of " colds
and sore throats," with a maximum in ^larch. It
is spread by droplets sprayed out of the nose and
throat, apparently mainly by unknown carriers, who
do not themselves become sick but who harbour
in the back of the nose the microbic cause, the
meningococcus. In this sense it is a generalized
infection in the locality where prevalent, eases
being as a rule single and independent. This makes
prevention very difficult. Even where epidemic
there are many carriers and comparatively few cases.
The meningococcus is exceedingly susceptible to
drying and scarcely has existence outside the human
carrier, so that preventive measures may be so
limited.
In his report to the Hongkong Government, Dr.
Peter K.-Olitsky of the Rockefeller Institute records
that the infection in Hongkong was caused in 95
per cent, of cases bytype 1 of Gordon's classifies^
tion of meningococci. By agglutination tests all
strains can be referred to four main types. The
same type was found in Manila cases. It is pro-
bable that this type would be also found in Shanghai
cases, so that it would be advisable to use a curative
serum in which this type was prevalent. Most
commercial sera are described as polyvalent. The
commercial sera tested, however, gave poor results.
Large quantities of serum may be used, e.g., 200 c.c.
intravenously and 40 c.c. intraspinally. The earUer
serum i ■ given the better the results. Exceptionally
dry and cold meteorological conditions prevailed
during the epidemic in Hongkong, leading to un-
usual overcrowding and lack of ventilation. There
is a probability that preventive vaccination may
become useful. As regards contacts a search should
be made for the " dangerous " carrier, that is, one
harbouring numerous meningococci of the type
found in actual cases locally. During the prevalence
of an epidemic it is advisable to prohibit the depar-
ture by rail or ship of any actual contact with a
case, especially those contacts shown by bacterio-
logical examination to be dangerous carriers.
The following memorandum for medical practi-
tioners was prepared, acknowledgments being made
to the United States Public Health Service Reports.
CEREBROSPINAL FEVER.
Mkmorahddm fob Medical Pbactitionebs.
The following observations are offered bo as to help in the
prevention of the disease.
Infective agent : The meningococcus.
Source of infection : Discharge from the nose and mouth of
infected persons, convalescents, mild cases, and healthy persons
who may be carriers. Carriers and mild cases are believed to
be the principal agents in the spread of the disease.
Incubation period : Two to ten days, commonly seven days.
Methods of control :
{A) The infected person.
(1) Recognition of the disease — Clinical signs, confirmed
by laboratory examination of spinal fluid obtained
bv lumbar puncture and of nasopharyngeal swabs.
(2) Isolation of infected persons, and carriers, until the
naso-phar\'nx is free from the meningococcus, or
at the earliest uatil one week after fever has sub-
sided. Does not necessarily require isolation in
Isolation Hospital.
(3) Immunization by vaccines still in experimental
stage.
(4) Disinfection of discbarges from the nose and mouth
and articles soiled therewith.
(6) Carriers have been found to clear up well with j
gargles and nasal douches of normal saline solution.
(6) Terminal disinfection. i'
(B) General measures. |
(1) Search for carriers among families and associates ■
of recognized cases by laboratory examination of
swabs from posterior nares of contacts.
(2) Instruction as to necessity of avoiding contact and |
droplet infection. i
(3) Prevention of overcrowding and inadequate venti- J
lation. Avoidance of crowds, especially indoors, j
crowded cars, cinematographs and other crowded
places. Limitation of visiting. Keeping chil- '
dren, especially below school age, at home so far
as possible; children and young adults being ;
most susceptible.
o
I
^ «iWL»mG SECT. f|g 1 1 jgfj
RC
960
J68
V.23
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