: an^
broy
With which is incorporated “CLIMATE”
AND -
Embodying Selections from THE COLONIAL MEDICAL REPORTS.
A BI-MONTHLY JOURNAL DEVOTED TO MEDICAL, SURGICAL AND
SANITARY WORK IN THE TROPICS
EDITED BY
JAMES CANTLIE, M.B., F.R.C.S.; W. J. R. SIMPSON, C.M.G., M.D., F.R.C.P.; GEORGE C. LOW,
M.A., M.D, C.M. C. M. WENYON, M.B., B.S., B.Sc.; anb ALDO CASTELLANI, M.D.F ror.
Sm RONALD ROSS, K.C.B., F.R.S., Mason I.M.S. (Honorary Adviser to the Editorial Staff)
VOLUME XVI
JANUARY 1 TO DECEMBER 15
1913
LONDON
JOHN BALE, SONS & DANIELSSON, Lr».
83-91, GREAT TITCHFIELD STREET, OXFORD STREET, W.
LONDON !
JOHN BALE, SONS AND DANIKLSSON, LTD.
53-91, GREAT TITCHFIELD STREET, OXFORD STREET, v.
INDEX TO
VOL. XVI.
JANUARY 1 to DECEMBER 15, 1913.
INDEX OF
ARCHIBALD, Capt. A. G.—Case of acute agehylostomiasis treated
by au autogenous vaccine of a coliform organism, 260
BALFOUR, ANDREW, C.M.G., M.D., B.Sc., F.R.C.P.E., D.P.H.
—A case of blackwater fever showing the cell inclusions of
Leishman, 35; A year’s auti-malarial work at Khartoum
(illustrated), 225 j
Baspr, Prof. Ivo.—Contribution to the study of bilharziasis,
84; Preliminary note on the identity of certain Leish-
maniases based on biological reactions, 50
BassETT-SwiTH, Fleet-Surgeon P. W., R.N., C.B.—Case of
para-melitensis fever, 50
Bates, JoHN PELHaMw, M.D.—Review of a clinical study of
malarial fever in Panama (illustrated), 145, 177, 209, 240,
241, 297.
B&wTLEY, C. A., M.B., D.P.H.— New conception regarding
malaria, 394
Bevan, Lr. E. W., M.R.C.V.S.— Preliminary notes on a
trypanosome causing disease in mau and animals in the
Sebungwe District of Southern Rhodesia, 113
Birt, Lieut.-Col. C., M.R.C.S,, R.A.M.C. —Phlebotomus fever
and dengue, 169
BLANCHARD, Prof. R. — Pellagra, 56
BnRappos, W. L., M.B., B.S., F. R.C.S. Eng.—Some results of
measures taken against beriberi in British Malaya, 282
BnawcH, Epmunp R., M.B., Ch.B.—Salvarsan in filariasis
(illustrated), 364
Brown, ALEXANDER, M.B., Ch. B.—Native treatment of sleep-
ing sickness —a trial, 167 ; Notes of a case of sleeping sick-
ness found on the hills, twenty-two miles north of Serenje,
in North Rhodesia, 302
CawTLIE, JAMES, M.B., C.M.Aberd, I.R.C.S.— Hepatic
&bscesses which open upwards through the lung (illus-
trated), 345
CASTELLANI, ALDO, M.D.-—Indian oro-pharyngeal Leishman-
iasis, 49; Note on broncho-oidiosis, 102
CASTELLANI, ALDO, M.D. (Florence), and Low, GEORGE C.,
M.A., M. D.—The róle played by fungi in sprue, 33
CHALMERS, ALBERT J., M.D., F.R.C.S, D.P.H., and KING,
Hanorp H., F.E.S.—Distribution of Glossina longipennis
(Corti, 1895) (illustrated), 320
CHALMERS, ALBERT J., M.D., F.R.C.S., D.P.H., and
O'FannELL, Capt. W. R, R.A.M.C.—-Brouchial spiro-
chetosis (illustrated), 329; Pyosis tropica in the Anglo-
Egyptian Sudan (illustrated), 377
CHAMBERS, Capt. R. A., I.M.S.— Enteric fever in Indians, with
special reference to its occurrence in the Indian Army, 250
CHARLES, Surg.-Gen. Sir R. HavELock, G.C. V.O., I.M.S.—
Neurasthenia, and its bearing on the decay of northern
peoples in India, 382
CLELAND, J. BuRrON, M.D., Ch.M. (Syd.).—Injuries and
diseases of man in Australia attributable to animals (ex-
cept insects), 25, 43
Conran, P. C. Report on ankylostomiasis in the North Nyasa
District, 195
Cook, Dr. A. R.—Climatie and other factors influencing the
health of Europeans in Uganda and Mast Africa, 120
Cormack, Dr. JAMES GniEvrE.—Climate and other factors in
relation to the health of Europeans in China, 65
Donovan, Lieut.-Col. C., B.A., M.D., B.C.H., B.A.O., F.L.S.,
F.E.S., I.M.S.—Kala-azar, its distribution an! probable
modes of infection, 253
ErrkMaN, Prof. — Beriberi, 282
AUTHORS.
FLD, F. E., M.D., D.P.H., and MrmxErr, E. P., M.D.,
D.P.H., D.T.M. & H. —Notes on a case of dermal Leish-
maniasis in British Guinea, 349
Fraser, Henry, M.D.—Cultivation of the bacillus of leprosy,
164
GABBI, Prof. UmBerto.—On the identity of infantile and
Donovan's Leishmania (kala-azar), 198 ; Tropical Diseases
in Tropoli, 68
GAMBLE, Mercier, M.D.— Sleeping sickness in the Portuguese
Congo : apparent cures (illustrated), 81
GRAHAM, Major J. D., M.D., D.T.M., LM S.— School
quininization experiments in the United Provinces 368
GRILLO, Dr. UmBerro, and Maz, Dr. Emtt1o, — Ulterior results
on pellagrins subjected in 1911 to Nicolaidi's serothera-
peutic cure, 56
GUTHRIE, J. BIRNEY, M.D.—The effect of drainage on health
in the City of New Orleans: a statistical study (illustrated),
129
HarrFKINE, W. M.—Protective inoculation against cholera,
202, 216, 235
Hearsny, H.—Nyasaland Protectorate:
diary, 384
Heurr, Col. P., 1.M.S.—Ulcerated and swollen gums in
Indian troops, 286
Hetser, Victor, G., M.D.—Quarterly Report of Bureau of
Health for the Philippine Islands, 340, 372
How cert, Prof F. M.—Breeding places of phlebotomus, 255
JAMISON, STANFORD CHAILLA, M.D.—Intestinal parasites in
Costa Rica, 69
Jounston, J. E. L., M.B., B.S., D. T. M. & H., and Macrir,
J. W. Scorr, M.A., M.B., Ch.B.—Case of equine trypano-
somiasis characterized by the occurrence of posterior
nuclear forms (illustrated), 348
Kuna, Harovp H., F. E.S., and CHALMERS, ALBERT J., M.D.,
F.R.C.S., D.P.H.— Distribution of Glossina longipennis
(Corti, 1895) (illustrated), 320
KNAB, Frepertck.—Spider’s web and malaria, 133
Kopkk, Prof. AvnEs -— Treatment of some cases of human
trypanosomiasis by salvarsan and neo-salvarsan, 303.
Letrer, Roperr T., D Se., M B., F.Z.S.—Apparent identity
of Agchylostoma ceylanicum (Looss, 1911) and Agchy-
lostoma braziliense (Faria, 1911) (illustrated), 334.
LErsHMAN, Sir WiLLIAM, F.R.S.—'The etiology of blackwater
fever, 8
Liston, Major W. Gren, C.I.E., M.D., D.P.H., LM.S.—
Plague, 273
Low, GgonGE C., M.A., M.D., C.M.— Filaria loa cases: con-
tinuation reports, 118
Low, GEoRGE C., M.A., M.D., C.M., and CASTELLANI, ALDO,
M.D. (Florence).—The rôle played by fungi in sprue, 33
Low, GEORGE C., M. A., M.D., C.M., and Wenyon, C. M., M.B.,
B.S., B.Sc.—Cell inclusions in the leucocytes of black-
water fever and other tropical diseases (illustrated), 161
MacriE, J. W. Scorr, M.A., M.B. Ch.B., and JOHNSTON,
J. E. L., M.B., B.S , D.T.M. & H.— Case of equine trypano-
somiasis characterized by the occurrence of posterior
nuclear forms (illustrated), 348
Massey, A. YALE, B.A., M.D., C.M.Tor.—Fibro-sarcoma in a
native of Central Africa (illustrated), 301
Maz, Dr. EMILIO, and GRILLO, Dr. UMBERTO.---Ulterior results
on pellagrins subjected in 1911 to Nicolaidi’s serothera-
peutic cure, 56
Sleeping sickness
Minertr, E. P., M.D.—Report of epidemiological survey and
investigation into probable causes of sickness among mules
on plantations Bath, Clairmont, Providence, and Spring-
lands, British Guiana, 362
MixsETT, E. P., M.D., D.P.H., D.T.M. & H., and FIELD,
F. E., M.D., D.P.H.—Notes on a case of dermal Leish-
maniasis in British Guinea, 349
Moss, C. J. A., M.D.— Disease in Madagascar, 17
Nicuouus, Lucius, B.A., M.B., B.C.—Cirrhosis of the liver
of malarial origiu (illustrated), 164
NicoLAipi, Dr. JkAN.— Two cases of pellagra cured with
Nicolaidi's serum, 57
O'CONNELL, Marrnew D., M.D. —Meteorology of malaria, 165,
257, 361
O'FARRELL, Capt. W. R., R.A. M.C.— Preliminary note on a
new flagellate, Crithidia hyalomme, sp. nov., found in the
tick Hyalomma egyptium (Linnieus, 1758), 215
Q'FARRELL, Capt. W. R., R. 4.M.C., and CHALMERS, ALBERT J..
M.D., F.R.C.S., D.P.H.— Bronchial spirochetosis (illus-
trated), 329 ; Pyosis tropica in the Anglo-Egyptian Sudan
(illustrated), 377
RAVENHILL, T. H., M.B., D.C. --Some experiences of mountain
sickness in the Andes (illustrated), 313
Ross, Sir Rosarp, K.C.B., F.R.S., D.Sc., D.P.H.—Sanitary
organization iu the Tropics, 255
Row, R., M.D.Lond., D.Sc.Lond.—Curative value of a
‘‘glycerinated pest vaccine” in plague, 293; Some experi-
mental facts re kala-azar (Indian), 1
Sampon, Louis W., M.D., F.Z.S.—Porocephaliasis in man
(illustrated), 97
SANTAMARIA, J. Martinez, M.D.—Acquisition of acid-fast
properties by a filamentary organism cultivated from an
animal injected with a culture of Hansen's “ bacillus,” 301 ;
Some notes on tropical diseases observed in the Republic of
Colombia, 100
SHIBAYAMA, Dr, S.— Present state of the study cf beriberi in
Japan, 283
SravLEY, Anrruur, M.D., B.S.Lond., D.P.H.- Shanghai
Municipal Council Health Departmeut anuual report, 1912,
353
Srannus, Huanu Srannus, M.D.Lond.— Treatment of suppres-
sion in blackwater fever (illustrated), 131
STEWART, Dr. CHARLES E.—Probable identity of pellagra and
sprue, 287
Srracuan, Henry, C.M.G., F.L.S,, F.G.S.,
African notes, 214
Tirumorti, T. S., M.B., C.M.—Vagrant habits of Ascaris
lumbricoides, with the report of a case of interest, 379
Topp, Joun L., M.D. - l'ick-bite in British Columbia, 58
Van LoGuem, Dr. J. J.—Yellow fever danger for Asia and
Australia, especially after the opening of the Panama
Canal, 292
Wenyon, C. M., M.B., B.S., B S», and Low, GEonG&E L.,
M.A., M.D., C.M.—Cell iuclusions in the leucocytes of
blackwater fever and other tropical diseases (illustrated),
161
Wu Lren Ten (G. L. Tuck), M.A., M.D., B.C.Cantab. — Investi-
gations into the relationship of the tarbagan (Mongolian
marmot) to plague, 275
WYLER, E. J., M.D. Lond. — Some observations on ankylostoma
infection in the Udi district of the Central Province,
Southern Nigeria, 193
Yovsa, Capt. T. C. McCounBrE, I.M.S.-—Account of an investi-
gation of the prevalence of endemic kala-azar in Assam, 338
F. R. A.T. — West
GENERAL INDEX.
A
Abdominal viscera, multiple hydatid infection of, 12
Abscess, liver, and the emetine treatment, 201
, due to Ascaris lumbricoides, 64
-——— ——, experimental amoebic dysentery and, in cats, 141
, syphilis simulating, 74
Abscesses, hepatic, 64, 74, 141, 201, 345
, Which open upwards through the lung (illustrated),
345
ABSTRACTS :—
Account of an investigation of the prevalence of endemic
kala-azar in the plains of Assam. By Capt. T. C.
McCombie Young, I.M.S., 338
Breeding-places of phlebotomus.
255.
Curative value of a ** glycerinated pest vaccine '' in plague.
By R. Row, M.D.Lond., D.Sc. Lond., 293
Diagnosis of pellagra, the, 7
Enteric fever in Indians, with special reference to its
occurrence in the Indian Army. By Capt. R. A.
Chambers, I.M.S., 280
Etiology of blackwater fever, the.
man, F.RS,8
Experimental amoebie dysentery and liver abscess in cats,
141
Investigations as to the relationship of the tarbagan
(Mongolian marmot) to plague. By Wu Lien Teh
(G. L. Tuck), M.A., M.D., B.C.Cantab, 275
Kala-azar, its distribution and the probable modes of
infection, By Lieut..Col. C. Donovan, B.A., M.D.,
B.C.H., B.A.0., F.C.S., F. E.S., I.M.S., 253
Neurasthenia, and its bearing on the decay of the northern
peoplesin India, By Surg.-Gen. Sir R. Havelock Charles,
G.C.V.O., I.M.S., 382
New conception regarding malaria.
M.B., D.P.H., 324
Nyasaland Protectorate: sleeping sickness
H. Hearsey, 384
Pellagra. By Prof. R. Blanchard, 56
Permanganate treatment of snake-bite, 93
By Prof. F. M. Howlett,
By Sir William Leish-
By C. A. Bentley,
diary. By
ABSTRACTS (continued) :—
Phlebotomus fever and dengue,
M.R.C.S., R. A. M.O., 169
Plague. By Major W. Glen Liston, C.LE., M.D., D.P.H.,
I.M.S., 273
Present state of the study of beriberi in Japan.
Shibayama, 283
Probable identity of pellagra and sprue.
E. Stewart, 287
Proceedings of the second All-India Sanitary Congress, 308
Protective inoculation against cholera. By W. M. Hafi-
kine, 202, 216, 235 !
Quarterly report of Bureau of Health for the Philippine
Islands. By Victor G, Heiser, M.D., 340, 372
Sanitary orgauization in the Tropies. By Sir Ronald
Ross, K.C.B., F.R.S., D.Sc., D.P.H., 288 `
School quininization experiments in the United Provinces.
By Major J. D. Graham, M.B., D.T.M., I M.S., 368
Shanghai Municipal Health Department annual report,
1912. By Arthur Stanley, M.D., B.S. Lond. D.P.H., 353
Some results of measures taken against beriberi in British
cag By W. L. Braddon, M.B., B.S., F.R.C.S. Eng.,
282
Studies on pneumonie plague- -the pneumonie strain of
Bacillus pestis, T8, 87, 107, 125
Tick-bite in British Columbia. By John L. Todd, M.D., 58
Two cases of pellagra cured with Nicolaidi's serum. By
Dr. Jean Nicolaidi, 57 j
Ulcerated and swollen gums in Indian troops.
Hehir, I. M.8., 286
Ulterior results on pellagrins subjected in
Nicolaidi’s serotherapoutie eure. By Dr,
Grillo and Dr. Emilio Maz, 56 i
Yellow fever danger for Asia avd Australia, especially after
the opening of the Panama Canal. By Dr. J. J. Van
Loghem, 292 p
Account of an investigation of the prevalence of cademic kala-
aznr in Assam, 338
Acquisition of acid-fass properties by a filamentary organism
cultivated from an animal inje:ted with a culture of
Hansen’s ** bacillus,” 301
By Lieut.-Col. C. Birt,
By Dr. S.
By Dr. Charles
Bv Col, P.
1911 to
Umberto
INDEX oy.
Adulte:ations and “improvements” in articles of diet, 71
ica, West, prevention of disease in, 59
chylostoma ceylanicum and Agchylostoma braziliense, apparent
identity of (illustrated), 334
shylostomiasis, acute, case of (illustrated), 260
\ll-India Sanitary Conference at Madras, the second, 13, 31
-—— — —_ — — — —, proceedings of, 308
Amebic dysentery, 72, 141
—— —, experimental, and liver abscess in cats, 141
—— — , treatment of, 72
An iation, 873
paa sinea the blood-plates in, 106
Andamans, malaria in the, 246
Saxons, can they colonize the Tropics ? 15
Animals, injuries and diseases of man in Australia attributable
- to (except insects), 25, 43
Ankylostoma infection in Southern Nigeria, some observations
on, 193
Aukylostome, new, of man, 201
Ankylostomiasis, report on, in the North Nyasa district, 195
Annals of Tropical Medicine and Parasitology, 185, 208
ANNOTATIONS :—
Bed-bugs and leprosy, 87
Bilbarziasis in Australia, 40
Blackwater fever, 307
Blood-plates in tropical anemia, 106
Blood-vessels in beriberi, the, 54
Bubonic plague in Havana, 6
Budding in entameebe, 186
Case of trichinosis, 296
Cerebral malaria, 389
Cholera vibrios in the biliary passages, 40
Chronic dysentery cured by emetine, 250
—— or resolving plague in rats, 157
Climatic bubo, 222
Clinical test for malaria, 239
Coccidioidal granuloma, 51, 306
Cultivation of malarial plasmodia, 54
Demonstration of the Treponema pallidum, 40
successfully inoculated with Leishmania donovani
in India, 341
Endemicity of yellow fever, 172
Entameebe in monkeys, 386
—— of man, 386
Etiology of beriberi, 76, 157
—o ra, 72
*! Experimental entamcebie dysentery,” 387
— Oriental sore in mice, 341
—— production of pellagra in a monkey, 252
Extrusion of granules by trypanosomes, 271
Health in the Philippine Islands, 175
—— of the Canal Zone, the, 40, 75, 128, 173, 201, 251
Hitherto unknown cause of disease in man, 173
Human botryomycosis, 171
Hydatid disease, 271
Indian Journal of Medical Research, 342
Isolation of typhoid bacilli from fæces, 367
Leishmania in cutaneous lesions of dogs in Tehran, 156
Leprosy, 389
Life-cycle of Clonorchis, 342
Liver abscess and the emetine treatment, 201
Maize and pellagra, 155
Malarial gangrene, 222
—— pigment as a factor in the production of blood-picture
of malaria, 251
Myiasis, 74
New ankylostome of man, 201
— sign in kala-azar, 389
Parasites in the peripheral blood of cases of Mediterranean
kala-azar, 335
Pathological changes in pellagra and the production of the
i in lower animals, 262
Pellagra, 167 :
Plague in Manila, 271, 343
—— in the Philippine Islands, 55
Prevention of enteric fever in military service, 252
Primary splenomegaly, 41
Relapsing fever in Chitral, 365
Relationship of the malarial parasite to the erythrocyte,
136
ANNOTATIONS (continued) :—
Round worms simulating appendicitis, 306 !
Sand-fly fever, 38 -
Sanitary organization of the Isthmian Canal, 4
Schistosomum japonicum, T
Sleeping sickness, 75, 156, 186, 232, 251
—— —— in Nyasaland, 75, 156
—— —— in South Africa, 186
Special methods for the detection of parasitic ova in th
fæces, 137 |
Spirillar fever in the Darjeeling district, 87
Spirochetosis, 173
Sporotrichosis, 156
Sunstroke, 106 "A
Supposed new species of human trypanosome, 270
Syphilis simulating liver abscess, 74
Tick-bite, 188
"Transmission of trypanosomes, 175
Treatment of amcbic dysentery, 72
—— of balantidial infections, 186
of dysentery due to infection with Entameba histoly-
tica, 53
—— of leprosy, 134
—— of pellagra, 139
—— of surra in camels, 188
Tropical bubo, 307
Trypanosoma brucei, 187
Two new genera of helminthes in man, 270
Unusual cases of hydatid disease, 123
Verruga peruviana, 23
Wassermann test in the Tropics, the, 2
Annual dinner of the London School of Tropical Medicine, 350
holiday, necessity for an, for foreigners resident iu the
Tropics, 168
Anti-malarial work at Khartoum, a year's (illustrated), 225
Anti-typhoid inoculation, 381
Apenta water in West Africa, 240
Apparent identity of Agchylostoma ceylanicum and Agchylostoma
braziliense (illustrated), 334 !
Appendicectomy for dysentery, 104
Appendicitis, round worms simulating, 306
Arizona Medical Journal, 192
Articles of diet, adulterations and ** improvements ` in, 71
Ascaris lumbricoides, liver abscess due to, 64
—— , vagrant habits of, 379
Asia Minor as a nut-producing country, 48
Assam, endemic kala-azar in, 338
Asthma, bronchial treatment of, 223
Athletics and candidates for service abroad, 24
Australia, bilharziasis in, 40
,injuries and diseases of man in, attributable to animals
(except insects), 25, 43
Australasian Medical Gazette, 208
A year’s anti-malarial work at Khartoum (illustrated), 225
Bacillus of leprosy, cultivation of, 164
Balantidial infections, treatment of, 186
Bed-bugs and leprosy, 87
Beriberi, 54, 64, 76, 157, 282, 283
———, blood-vessels in, 54
——., etiology of, 64, 76, 157
———, present state of the study of, in Japan, 283
—, some results of measures taken against, in British
Malaya, 282
Bilharziasis, 40, 84, 350
in Australia, 40
——, prognosis of, 350
, study of, contribution to the, 84
Biliary passages, cholera vibrios in the, 40
Bionomies of the rat-flea, 312
Blackwater fever, 8, 35, 131, 161, 307
—— —, case of, showing the cell inclusions of Leishman
(illustrated), 35
——— ——-, cell-inclusions in the leucocytes of, and other
tropical diseases (illustrated), 161
—— — —., the etiology of, 8
—— — —, treatment of suppression in (illustrated), 1:
HENSY 8, WARD.
^ "ICT
STATE UN -
VA me RR
vi. INDEX
Blood, peripheral, of cases of Mediterranean kalar-azar, para-
sites in the, 335
, spirochiete in the, 199
Blood-plates in tropical anemia, 106
Blood-vessels in beriberi, the, 54
Boston Medical and Surgical Journal, 176
Botryomycosis, human, 171
Breeding-places of phlebotomus, 255
British Columbia, tick bite in, 58
— Guiana Medical Annual, 94
—— Medical Association, 190, 233, 247, 262
—— Journal, 312
Bronchial asthma, treatment of, 223
spirochietosis (illustrated), 329
Broncho-oidiosis, no!e on, 102
Bubo, climatic, 222
——-tropical, 307
Bubonic plague in Havana, 6
Budding in entamcebe, 186
Bugs, Leishmania donovani in, 48
—, resistance of, to various reagents, 48
Bulletin de la Société Medico-Chirurgicale de l Indochine, 104,
140
—— of Entomological Rescarch, 54, 192, 323, 376
—— of the Imperial Institute, 60
—— of the Johns Hopkins Hospital, 153
Byno-lecithin, 143
C
Camels, treatment of surra in, 188
Camera, use of metallurgical microscopes with the, 61
Can Anglo-Saxons colonize the Tropics ? 15
Canal Zone, health of the, 40, 75, 198, 173, 201, 251
Candidates for service abroad and athletics, 24
Case of acute agchylostomiasis treated by an autogenous vaccine
of a coliform organism (illustrated), 260
—— of blackwater fever, showing the cell inclusions of Leish-
man (illustrated), 35
of dermal Leishmaniasis in British Guinea, 349
of equine trypanosomiasis characterized by the occurrence
of posterior nuclear forms (illustrated), 348
—— of para-melitensis fever, a, 50
—— of sleeping sickness from North Rhodesia, 302
— — of trichinosis, 296
Cases. unusual, of hydatid disease, 123
Castellani and Chalmers's ** Manual of Tropical Medicine," 184
Cause, hitherto unknown, of disease in inan, 173
Cell-inclusions in the leucocytes of blackwater fever and other
tropical diseases (illustrated), 161
— —— of Leishman, case of blackwater fever showing
(illustrated), 35
Centenary, Livingstone, Livingstone College and, 94
Cerebral malaria, 389
Children in China, 215
China, climate and other factors in relation to the health of
Europeans in, 65
Chinese, opium smoking by the, 38
Cholera, protective inoculation against, 202, 216, 235
vibrios in the biliary passages, 40
Chronic dysentery cured by emetine, 250
—— or resolving plague in rats, 157
Cirrhosis of the liver of malarial origin (illustrated), 164
Climate and other factors in relation to the health of Europeans
in China, 65
—— influencing the health of Europeans in
Uganda and East Africa, 120
Climatic bubo, 222
Clinical study of malarial fever in Panama,
(illustrated), 145, 177, 209, 240, 241, 297
——— test for malaria, 239
Clinician, death of a great, 199
Clonorchis, life-cycle of, 342
Coccidioidal granuloma, 51, 306
Collosol argentum—its use in
conditions, 123
Colombia, Republic of, tropical diseases observed in the, 100
Colonial Nursing Association, 322
Conception, new. regarding malaria, 324
Conditions, post-dysenteric : use of collosol argentum in sprue
and, 123
review of
sprue and post-dysenteric
Conference, second All-India Sanitary, at Madras, 13, 31
—— — — — — , proceedings of, 308
Congo, Portuguese, sleeping sickness in the: apparent cures
(illustrated), 81
Continuation reports: Filari loa cases, 118
Contribution to the study of bilharziasis, 84
CORRESPONDENCE :—
Can Anglo-Saxons colonize the Tropics? 15
Leishmania donovani in bugs, 48
Rapid diagnosis of malaria, 272
Costa Rica, intestinal parasites in, 69
Countries, tropical, difficulties of the milk supply in, 105
Cultivation of bacillus of leprosy, 164
of malarial plasmodia, 54
Curative value of a ‘‘ glvcerinated pest vaccine " in plague, 293
Cutaneous lesions of dogs in Tehran, Leishmania in, 156
Darjeeling district, spirillar fever in the, 87
spirochietosis in the, 199
Death of a great clinician, 199
Demonstration of tbe Tryponema pallidum, 40
Dengue, phlebotomus fever and, 169
Dermal Leishmaniasis, case of, in British Guinea, 349
Destruction of mosquitoes and other insects, 208
Detection of parasitic ova in the fæces, special methods for, 137
Diagnosis of malaria, rapid, 272
—— of pellagra, 7
Diet, articles of, adulterations and ** improvements " in, 71
of Mexicans, 60
Difficulties of the milk supply in tropical countries, 105
Dinuer of the Section of Tropical Medicine of tbe International
Congress of Medicine, 294
Disease, hydatid, 123, 271
, unusual cases of, 123
—— in Madagascar, 17
—— in man, hitherto unknown cause of, 173
——-, prevention of, in West Africa, 59
, special drugs for each, 322
Diseases and injuries of man in Australia attributable to
animals (except insects), 25, 43
———, tropical, in Tripoli, 68
, observed in the Republic of Colombia, 100
Distribution and probable modes of infection of kala-azar, 253
of Glossina longipennis (Corti, 1895) (illustrated), 320
Dogs, Leishmania in cutaneous lesions of, in Tehran, 156
successfully inoculated with Leishmania donovani in
India, 341
LDonovan's and infantile Leishmania (kala-azar), identity of,
Drainage, effect of, on health in the city of New Orleans
(illustrated), 129
Drugs and appliances, 143, 191, 312, 392
, special, for each disease, 322
Dwellings, tropical, 134
Dysentery, 53, 72, 104, 141, 250, 264, 312, 387
, amoebic, treatment of, 72
———, appendicectomy for, 104
—-—, chronic, cured by emetine, 250
— due to infection with Entamaba histolytica, treatment
of, 58
———, experimental amc bie, and liver abscess in cats, 141
— — —— entamobic, 387
-— —, salvarsan in, 312
East Africa, and Uganda, climatic and other factors influencing
the health of Europeans in, 120
Eastern, Far, Olympiad, 85
Effect of drainage on health in the city of New Orleans; a
statistical study (illustrated), 129
Egypt, medicine in ancient, 373
Elephant grass, 262
Emetine, chronic dysentery cured by, 250
— hydrochloride, 312
—— treatment, liver abscess and the, 201
Endemic kala-azar in Assam, 338
Endemicity of yellow fever, 172
INDEX
vii.
Entamæba histolytica, treatment of dysentery due to infection
with, 53
Entamosbe, budding in, 186
—— in monkeys, 386
of man, 386
* Entamæbic dysentery, experimental," 387
Enteric fever in Indians, 280
——., prevention of, in military service, 252
Equine trypanosomiasis, case of (illustrated), 348
Erythrocyte, relationship of the malarial parasite to the, 136
Etiology of beriberi, 64, 76, 157
of blackwater fever, 8
of pellagra, 72
Europeans, health of, in Uganda and East Africa, climatic and
other factors influencing the, 120
— in China, climate and other factors in relation to the
health of, 65
Examination results of the London School of Tropical Medi-
cine, 15
Exhibition, Historical Medical, in London, 47
Experiences with arsen-triferrin, 392
l;xperimental amoebic dysentery and liver abscess in cats, 141
entamabic dysentery, 387
—— Oriental sore in mice, 341
—— production of pellagra in a monkey, 252
Exploration, Polar, and its bearing on medical studies, 52
Extrusion of granules by trypanosomes, 271
Factors, climatic and other, influencing the health of Euro-
peans in Uganda and East Africa, 120
—, in relation to the health of Europeans in China,
65
Feces, isolation of typhoid bacilli from, 367
Far Eastern Olympiad, 85
Fever, blackwater, 8, 35, 131, 161, 307
——, and other tropical diseases, cell inclusions in the
leucocytes of (illustrated), 161
—— ——, ease of, showing the cell-inclusions of Leishman
(illustrated), 35
— —, etiology of, 8
, treatment of suppression in (illustrated), 131
———, enteric, 252, 280
—— ———, in Indians, 280
. prevention of, in military service, 252
———, malarial, in Panama, review of a clinical study of (illus-
trated), 145, 177, 209, 240, 241, 297
——, para-melitensis, a case of, 50
—, phlebotomus, and dengue, 169
—— , relapsing, in Chitral, 365
——, sand-fly, 38
, spirillar, in the Darjeeling district, 87
——, typhus, in China, 191
——, undulant, 192
—— , yellow, 172, 292
——— — danger for Asia and Australia, 292
—— —— , endemicity of, 172
l'ibro-sarcoma in a native of Central Africa (illustrated), 301
Filaria loa cases: continuation reports, 118
Filariasis, 269, 364
———, salvarsan in (illustrated), 364
Flagellate, new, found in the tick Hyalomma ceguptium, 245
Foreigners resident in the Tropies, necessity for an annual
holiday for, 168
Fungi, the róle played by, in sprue, 33
Future of Tropical Ame'ica, 373
Gangrene, malarial, 222
Glossina in Northern Nigeria, 184
Glossina longipennis (Corti, 1895), distribution of (illustrated),
320
—— morsitans, varieties of, 184
“ Glycerinated pest vaccine,” curative value of a, in pligue, 293
Gordon Memorial College, Khartouin, 176
Granules, extrusion of, by trypanosomes, 271
Granuloma, coccidioidal, 51, 306
Great clinician, death of a, 199
“ Guide to Photomicrography,” 61
Gums, ulcerated and swollen, in Indian troops, 286
Hansen's * bacillus,” acquisition of acid-fast properties by a
filamentary organism cultivated from an animal infected
with a culture of, 301
Havana, bubonic plague in, 6
Health, house-fly as a danger to, 107
in the city of New Orleans, effect of drainage on (illus-
trated), 129
in the Philippine Islands, 125
——— of Canal Zone, the, 40, 75, 128, 173, 201, 251
——of Europeans in China, climate and other factors in
relation to, 65
—— —— in Uganda and East Africa, climatic and other
factors influencing the, 120 d
Helminthes in man, two now genera of, 270
Hepatic abscesses which open upwards through the lung
(illustrated), 345
Historical Medical Exhibition in London, 47
Museum, 85, 154
Hitherto unknown cause of disease in man, 173
Holiday, annual, necessity for an, for foreigners resident in the
Tropics, 168
House-fly as a danger to health, 107
Human botryomycosis, 171
trypanosomiasis, treatment of some cases of, by salvarsan
and neo-salvarsan, 303
Hyalomma egyptium, new flagellate found in, 245
Hydatid disease, 12, 123, 271
, unusual cases of, 123
—— infection, multiple, of the abdominal viscera, 12
Hygiene, Society of Tropical Medicine and, 14, 47, 143, 176,
344, 350, 374
Identity, apparent, of -lgchylostoma ceylanicum and Agchylo-
stoma braziliense (illustrated), 334
of certain Leishmaniases based on biological reactions,
preliminary note on, 50
—— of infantile and Donovan's Leishmania (kala-azar), 198
—, probable, of pellagra and sprue, 287
ILLUSTRATIONS :—
Case of filariasis treated with salvarsan, 364
Curve of death-rate from malaria in the city of New
Orleans, 130
Diagram illustrating mountain sickness in the Andes, 313
—— to illustrate paper on hepatic abscesses, 346
Dorsal ray of Agchylostema ceylanicum, vel braziliense, 335
Free parasites in Indian oro-pharyngeal Leishmaniasis, 49
Intracellular parasites in Indian oro-pharyngeal Leish-
maniasis, 49
Map of Khartoum, face p. 226
—— showing distribution of Glossina longipennis (Corti,
1895), 321
Native with fibro-sarcoma on his back, 301
Photographs of patients suffering from sleeping sickness,
Portuguese Congo, 81, 83
Porocephalus clavatus ? and g , 97, 98
——- stilesi, ? and g , 98, 99
—— wardi, 99
Spiroschaudinnia bronchialis (dark-ground illumination),
329
, stained by Leishman's method and carbol-
thionin, 330
Temperature chart illustrating paper on acute agchylosto-
miasis, 261
of case of bronchial spirochætosis, 331
—— —— —— of blackwater fever, 132
charts (three) of typhoid fever, 152
Trypanosoma brucei (pecaudi), 348
Imperial Institute, 60, 240
* Improvements," adulterations and, in articles of diet, 71
Indian Journal of Medical Research, 312
Indian Medical Gazette, 12, 109, 246
Indian aoro-pharyngeal Leishmaniasis, 49
Infantile and Donoyan’s Leishmania (kala-azar), identity of,
198
Infection with Entameba histolytica, treatment of dysentery due
to, 53
Infections, balantidial, treatment of, 186
INDEX
** Infectious Diseases occurring in Schools, Manual of," 15
Injuries and diseases of man in Australia attributable to
animals (except insects), 25, 43
Inoculation, anti-typhoid, 381
———, protective, against cholera, 202, 216, 235
International Congress of Medicine, dinner of the Section of
Tropical Medicine, 294
—— manifestation in honour of Sir Patrick Manson, F.R.S.,
G.C.M.C., 304
Intestinal parasites in Costa Rica, 69
Investigations as to the relationship of the tarbagau to plague,
75
Islands, Philippine, health in the, 175
, plague in the, 55
——, quarterly report of the Bureau of Health for the, 340
Isolation of typhoid bacilli from fieces, 367
Isthmian Canal, sanitary organization of the, 4
J
Journal of the American Medical Association, 159, 160, 232, 312
Journal of the Royal Army Medical Corps, 144, 159, 350, 392
Kala-azar, 1, 253, 335, 338, 389
———, endemic, in Assam, 338
— (Indian), some experimental facts re, 1
———, its distribution and the probable modes of infection, 253
—— (Mediterranean), parasites in the peripheral blood of cases
of, 335
———, new sign in, 389
Khartoum, a year's anti-malarial work at (illustrated), 225
L
Lancet, 199
Launches, motor, for the Tropics, 61
LEADING ARTICLES :—
Adulterations and ** improvements " in articles of diet, 71
Anti-typhoid inoculation, 381
Athletics and candidates for service abroad, 24
Castellani and Chalmers's ** Manual of Tropical Medicine,”
181
Children in China, 215
Collosol argentum its use in sprue and post-dysenteric
conditions, 123
Death of a great clinician, 199
Difficulties of the milk-supply in tropical countries, 105
Far Eastern Olympiad, 85
Historical Medical Museum, 154
International manifestation in
Manson, F.R.S., G.C. M.G., 304
Necessity for an annual holiday for foreigners resident in
the Tropics, 168
Olive oil iu its relation to medicine, 3
Opium smoking by the Chinese, 38
Polar exploration and its bearing on medical studies, 52
Heport on practical sanitation in a district of Ceylon
(illustrated), 365 f
Sir Patrick Manson national presentation, 322
Special drugs for cach disease, 322
Tropical dwellings, 134
When to come home from the Tropics, 336
Leishman, cell inclusions of, case of blackwater fever showing
(illustrated), 35
Leishmania in cutaneous lesions of dogs in Tehran, 156
in ** forest yaws." 240
Leishmania donovani, dogs successfully inoculated with, in
India, 341
—— — in bugs, 48
Leishmaniasis, dermal, in British Guinea, 349
, Indian oro-pharyngeal, 49
Leishmaniases, preliminary note on the identity of certain,
based on biological reactions, 50
Leprosy, 87, 134, 164, 214, 234, 246, 389
——, bed-bugs and, 87
—-, cultivation of the bacillus of, 164
, treatment of, 134
Lesions, cutaneous, of dogs in Tehran, Leishmania in, 156
Leucocytes of blackwater fever and other tropical diseascs, cell-
inclusions in the (illustrated), 161
honour of Sir Patrick
Life-cycle of Clonorchis, 342
Liver abscess, 64, 74, 141, 201
— — ——- and the emetine treatment, 201
——— — due to Ascaris lumbricoides, 64
—— —, experimental amoebic dysentery and, in cats, 141
—— ——, syphilis simulating, 74
———, cirrhosis of the, of malarial origin (illustrated), 161
Liverpool, University of, 128
Livingstone College, 14, 94, 190
London School of Tropical Medicine, 15, 128, 350
Lung, hepatic abscesses which opeu upwards through the
(illustrated), 345
Madagascar, disease in, 17
Madras, the Second All-India Sanitary Conference at, 13, 31
Maize and pellagra, 155
Malaria, 133, 165, 239, 246, 251, 257, 272, 324, 361, 389
——-, blood-picture of, malarial pigment in production of, 251
—— , cerebral, 389
, clinical test for, 239
—— in the Andamans, 246
— —, meteorology of, 165, 257, 361
— —, new conception regarding, 324
— —, rapid diagnosis of, 272
— —, spider's web and, 133
Malarial fever in Panama, review of clinical study of (illus-
trated), 145, 177, 209, 240, 241, 297
——— gangrene, 222
—— parasite, relationship of, to the erythrocyte, 136
—— pigment in the production of blood. picture of malaria, 251
—— plasmodia, cultivation of, 54
Man, entamabe of, 386
——., new ankylosiome of, 201
, porocephaliasis in (illustrated), 97
Manila, plague in, 271, 340
Manson, Sir Patrick, international manifestation in honour cf,
304
——— ———, national presentation, 322
Medical Exhibition, Historical, in London, 47, 85
Medical Journal of South Africa, 392
Medical Museum, Historical, 154
studies, Polar exploration and its bearing on, 52
Medicine, London School of Tropical, 15, 123, 351
—— and Hygiene, Society of Tropical, 14, 47, 143, 176, 344, 350,
374
—— in ancient Egypt, 373
Mediterranean kala-azar, parasites in the peripheral blood of
cases of, 335
Metallurgical mieroscopes with camera, use of, 61
Meteorology of malaria, 165, 257, 361
Methods, special, for the detection of parasitic ova in the feces,
137
Mexicans, diet of, 60
Mice, experimental Oriental sore in, 311
Microscopes, metallurgical, use of, with camera, 61
Milk supply, difficulties of, in tropical countries, 105
Monkey, experimental production of pellagra in a, 252
Monkeys, entameebe in, 386
Mosquitoes and other insects, destruction of, 258
Motor launches for the Tropies, 61
Mountain sickness in the Andes, some experiences of (illus-
trated), 313
Multiple hydatid infection of the abdominal viscera, 12
Museum, Historical Medical, 85, 151
Myiasis, 74
National presentation to Sir Patrick Manson, 322
Native treatment of sleeping sickness, a trial, 167
Necessity for an annual holiday for foreigners resident in the
Tropics, 168
Neurasthenia, and its bearing on the decay of the northern
peoples in India, 332
New ankylostome of man, 201
—— British Journal of Surgery, 224
- conception regarding malaria, 324 ?
- flagellate found in the tick, Hyalomma egpytium, 245
— — Orleans, city of, effect of drainage on the health in the
(illustrated), 129
INDEX ix.
New sign in kala-azar, 389
—- species of tsetse-fly, 208
— ——, supposed, of human trypanosome, 270
Nicolaidi’s serotherapeutic cure, ulterior results on pellagrins
subjected to, 56
serum, two cases of pellagra cured with, 57
North Nyasa district, report on ankylostomiasis in the, 195
Northern Nigeria, glossina in, 184
Note on broncho-oidiosis, 102
Notes of a case of sleeping sickness in North Rhodesia, 302
——— on a case of dermal Leishmaniasis in British Guinea, 349
———, personal, 16, 64, 96, 144, 191, 224, 256, 296, 375
— —, West African, 214
Notes AND NEWws:—
An appreciation, 373
Apeuta water in West Africa, 240
Asia Minor as a nut-producing country, 48
*: British Guinea Medical Annual," 94
British Medical Association, 190
Bulletin of the Imperial Institute, 60
Diet of Mexicans, 60
Gordon Memorial College, Khartoum, 176
*' Guide to photomicrography," 61
Historical Medical Museum, 47, 85
House-fly as a danger to health, 107
Imperial lustitute, 240
Leishmania in ‘‘ forest yaws," 240
Livingstone College, 94, 190
London School of Tropical Medicine, 15, 128
Medicine in ancient Egypt, 373
Metallurgical microscopes with camera, use of, 61
Motor launches for the Tropics, 61
New British Journal of Surgery, 224
Prevention of disease in West Africa, 59
Report of Livingstone College, the, 14
Retirement of Dr. R. M. Forde, 374
Rice in Siam, 60
Second All-India Sanitary Conference at Madras, 13, 31
Society of Tropical Mediciue and Hygiene, 14, 47, 143, 176,
344, 394
Third International Congress of Tropical Agriculture,
London, 1914, 390
Treatment of bronchial asthma, 223
Tropical dinner, 223
** Tropical Medicine,” Castellani and Chalmers’, 159
Typhus fever in China, 191
Union Medical College, Peking, 310
University of Liverpool, 128
West African medical staff dinner, 207
Nut-producing country, Asia Minor as a, 48
Nyasaland Protectorate: sleeping sickness diary, 384
, sleeping sickness in, 75, 156
Olive oil in its relation to medicine, 3
Olympiad, Far Eastern, 85
Opium, 304
——— smoking by the Chinese, 38
Organization, sanitary, in the Tropies, 288
, of the Isthmian Canal, the, 4
Oriental sore, experimental, in mice, 341
Origin, malarial, of cirrhosis of the liver (illustrated), 164
ORIGINAL COMMUNICATIONS ;—
A year's anti-malarial work at Khartoum (illustrated). By
Andrew Balfour C.M.G., M.D., B.Sc., F.R.C.P.E.,
D.P.H., 225
Acquisition of acid-fast properties by a filamentary
organism cultivated by an auimalinjected with a culture
of Hansen’s “bacillus.” By J. Martinez Santamaria,
M.D., 301 r
Apparent identity of Agchylostoma ceylanicum (Looss, 1911)
and Agchylostoma braziliense (Faria, 1910) (illustrated).
By RobertT. Leiper, D.Sc., M.B., F.Z S., 334
Bronchial spiroch:etosis (illustrated). By Albert J.
Chalmers, M.D., F.R.C.S., D.P.H., and Capt. W R.
O'Farrell, R.A.M.C., 329
Case of acute agchylostomiasis treated by an autogenous
vaccine of a coliform organism (illustrated), By Capt.
R. G. Archibald, M.B., R.A.M.C., 260
ORIGINAL COMMUNICATIONS (continued) : —
Case of blackwater fever showing the cell-inclusions of
Leishman (illustrated). By Andrew Balfour, C.M.G.,
M.D., B.Sc., F.R.C.P.E , D.P.H., 35
—— of equine trypanosomiasis characterized by the
occurrence of posterior nuclear forms (illustrated), By
J. W. Scott Macfie, M.A., M.B., Ch.B., and J. E.
L, Johnston, M.B., B.S , D.T.M. & H., 348
—— of para-melitensis fever, a, By Fleet-Surgeon P. W.
Bassett Smith, R.N., C.B., 50
Cell-inclusious in the leucocytes of blackwater fever and
other tropical diseases (illustrated). By George C. Low,
M.A., M.D., C.M., and ©, M. Wenyon, M.B., B.S.,
B.Sc., 161
Cirrhosis of the liver of malarial origin (illustrated). By
Lucius Nicholls, B.A., M.B., B.C., 164
Climate and other factors in relation to the health of
Europeans in China. By Dr. James Grieve Cormack,
65
—— —— —— influencing the health of Furopeans in
Uganda aud East Africa. By Dr. A. R. Cook, 120
Contribution to the study of bilbarziasis. By Prof. Ivo
Bandi, 84
Cultivation of the bacillus of leprosy.
M.D., 164
Disease in Madagascar. By C. J. A. Moss, M.D., 17
Distribution of Glossina longipennis (Corti, 1895) (illus-
trated). By Albert J. Chalmers, M.D., F.R.C.P.,
D.P.H., and Harold H. King, 320
Effect of drainage on health in the city of New Orleans ;
a statistical study (illustrated). By J. Birney Guthrie,
M.D., 129
Fibro-sarcoma in a native of Central Africa (illustrated).
By A. Yale Massey, B.A., M.D., C. M.Tor., 301
Filaria loa cases: continuation reports. By George C.
Low, M.A., M.D., 118
Hepatic abscesses which open upwards through the lung
(illustrated), By James Cantlie, M.B., C.M.Aberd.,
F.R.C.S., 345
Indian oro-pharyngeal Leishmaniasis,
M.D., 49
Intestinal parasites in Costa Rica.
Jamison, M.D., 69
Meteorology of malaria.
165, 257, 361
Native treatment of sleeping sickness,
Alexander Brown, M.B., Ch.B., 167
Note on broncho-oidiosis. By Aldo Castellani, M.D., 102
Notes on a case of dermal Leishmaniasis in British Guinea.
By E. P. Minett, M.D., D.P.H., D.T.M. & H., and
F. E. Field, M.D., D.P.H., 349
—— —— of sleeping sickness found on the Lills, twenty-two
miles north of Serenje, in North Rhodesia. By Alexander
Brown, M.B., Ch.B., 302
On the identity of infantile and Donovan's Leishmania
(kala-azar). By Prof. Umberto Gabbi, 198
Porocephaliasisin man (illustratcd). By Louis W. Sambon,
M.D., F.Z.S., 97
Preliminary note on a new flagellate, Crithidia hyalomma,
sp. nov., found in the tick Hyalomma «eguyptium
(Linnweus, 1758). By Capt. W. R. O'Farrell, R.A.M.C.,
245
By Henry Fraser,
By Aldo Castellani,
By Stanford Chaillé
By Matthew D. O'Connell, M.D.,
a trial. By
on the identity of certain Leishmaniases based
on biological reactions. By Prof. Ivo Bandi, 50
—— notes on a trypanosome causing disease in man and
animals in the Sebungwe district of Southern Rhodesia
(illustrated). By Lr. E. W. Bevan, M.R.C.V.S., 113
Pyosis tropica in the Anglo-Egyptian Sudan (illustrated).
By Albert J. Chalmers, M.D., F.R.C.S., D.P.H., and
Capt. W. R. O'Farrell, R. A. M.O., 377
Report of epidemiological survey and investigation
into probable causes of sickness nmongst mules on
plantations, Bath, Blairmont, Providence, and Spring-
lauds, British Guiana, By E. P. Minett, M.D., 362
— — on ankylostomiasis in the North Nyasa district.
By P. C. Conran, 195
Review of a clinical study of malarial fever in Panama
(illustrated). By John Pelham Bates, M.D., 145, 177.
209, 240, 941 297
x. INDEX
ORIGINAL COMMUNICATIONS (continued) :—
Role played by fungi in sprue. By Aldo Castellani, M.D.
(Florence), and George C. Low, M.A., M.D., 33
Salvarsan in filariasis (illustrated). By Edmund R.
Branch, M.B., Ch.B., 364
Sleeping sickness in. the Portuguese Congo: apparent
cures (illustrated). By Mercier Gamble, M.D., 81
Some experiences of mountain sickness in the Andes (illus-
trated). By T. H. Ravenhill, M.B., B.C., 313
experimental facts re kala-azar (Indian),
Row, M.D.Lond., D.Sc. Lond., 1
notes on tropical diseases observed in the Republic of
Colombia. By Dr. J. Martinez Santamaria, 100
observations on ankylostoma infection in the Udi
district of the Central Province, Southern Nigeria. By
E. J. Wyler, M.D.Lond., 193
Spider's web and malaria. By Frederick Knab, 133
Treatment of some cases of human trypanosomiasis by
salvarsan and neo-salvarsan. By Prof. Ayres Kopke, 303
of suppression in blackwater fever (illustrated). By
Hugh Stannus Stannus, M.D.Iond., 131
Tropical diseases in Tripoli. By Prof. Umberto Gabbi, 68
Vagrant habits of Ascaris liinbricoides, with the report
of a case of interest, By T. S. Tirumurti, M.B., C.M.,
379
West African notes. By Henry Strachan, C.M.G., F.L.S.,
F.Z.S., F.R.A.I., 214
Oro-pharyngeal Leishmaniasis, Indian, 49
Ova, parantin, in the fæces, special methods for the detection
of, 137
By R.
Panama, review of a clinical study of malaria fever in (illus-
trated), 145, 177, 209, 240, 241, 297
Para-melitensis fever, a case of, 50
Parasite, malarial, relationship of, to the erythrocyte, 136
Parasites in the peripheral blood of cases of Mediterranean
kala-azar, 335
——-, intestinal, in Costa Rica, 69
SRM ova in the fæces, special methods for the detection
of, 137
Passages, biliary, cholera vibrios in the, 40
Pathological changes in pellagra, 262
Pellagra, 7, 56, 57, 72, 139, 155, 107, 232, 952, 969, 987
-— and sprue, probable identity of, 287
——, diagnosis of, 7
———, etiology of, 72
— in à monkey, experimental production of, 252
——-, maize and, 155
—— pathological changes in, 262
— —, treatment of, 139, 232
; two cases of, cured with Nicolaidi's serum, 57
Pellagrins subjected to Nicolaidi's serotherapeutic cure, ulterior
results on, 56
Peripheral blood, parasites in the, of cases of Mediterranean
kala-azar, 335
Permanganate treatme:t of snake-bite, 93
Personal notes, 16, 61, 96, 144, 191, 224, 256, 296, 975
Philippine Islands, health in the, 175
—— ———, plague in, 55
——— ———, quarterly report of Bureau of Health for the, 340,
372
Phlebotomus, breeding-places of, 255
—— fever and dengue, 169, 268
“ Photomicrography, guide to,” 61
Pigment, malarial, in the production of blood-picture of
malaria, 251
Plague, 6, 55, 78, 107, 125, 157, 187, 271, 273, 275, 293, 343
; bubonic, in Havana, 6
—, chronic or resolving, in rats, 157
—, curative value of a ** glyceriuuted pest vaccine” in, 293
—— in Manila, 271, 343
—— in the Philippine Islands, 55
——, pneumonic, studies on, 78, 87, 107, 125
—, relationship of the tarbagan to, 275
Plasmodia, malarial, cultivation of, 54
Pneumonic plague, studies on, 78, 87, 107, 125
Polar exploration and its bearing on medical studies, 52
Porocephaliasis in man (illustrated), 97
Portuguese Congo, sleeping sickness in the: apparent cures
(illustrated), 81
Post-dysenterie conditions, sprue and, use of collosol argentum
in, 193
Practical sanitation in a district of Ceylon, report on (illus-
trated), 365
Preliminary note on the identity of certain Leishmaniases based
on biological reactions, 50
notes on a trypanosome causing disease in man and
animals in the Sebungwe district of Southern Rhodesia
(illustrated), 113
Present state of the study of beriberi in Japan, 283
Prevention of disease iu West Africa, 59
of enteric fever in military service, 252
Primary splenomegaly, 41
Probable identity of pellagra and sprue, 287
modes of infection and distribution of kala-azar, 253
Proceedings of the Second All-India Sanitary Congress, 208
Proguosis of bilharziasis, 350
Protective inoculation against cholera, 202, 216, 235
Pvosis tropica in the Anglo-Egyptian Sudan (illustrated), 377
Quarterly report of Bureau of Health for the Philippine
Islands, 340, 372
Rapid diagnosis of malaria, 272
Rat-flea, bionomics of, 312
Rats, chronic or resolving plague in, 157
Reagents, various, resistance of bugs to, 48
RECENT AND CURRENT LITERATURE :—
Annals of Tropical Medicine and Parasitology, 48, 185,
208
Annales d' Hygiene et de Médecine Coloniales, 64
Arizona Medical Journal, 192
Australasian Medical Gazette, 208
Boston Medical and Surgical Journal, 176
British Medical Journal, 312
Bulletin de la Société Médico.Chirurgicale de L’ Indochine,
64, 104, 140
Bulletin of Entomological Research, 184, 192, 323, 376
Bulletin of the Johns Hopkins Hospital, 153
Indian Medical Gazette, 12, 199, 246
Journal of the American Medical Association, 159, 160, 232,
312
Journal of the Royal Army Medical Corps, 144, 159, 850, 392
Lancet, 48, 199
Medical Journal of South Africa, 392 . "A
“ Seventh Report on Plague Investigations in India,"
144
South African Medical Record, 214, 234, 246
Tropical Diseases Bulletin, 12
United States Public Health Reports, 159
Relapsing fever in Chitral, 365
Relationship of the malarial parasite to the erythrocyte, 136
of the tarbagan to plague, 275 Ju: ,
Report of epidemiological survey and investigation into
probable causes of sickness amongst mules on plantations
Bath, Clairmont, Providence, and Springlands, British
Guiana, 362
—— on ankylostomiasis in the North Nyasa district, 195
—.— on practical sanitation in a district of Ceylon (illustrated),
365
REPRINT :— ‘
Injuries and diseases of man in Australia attributable to
animals (except insects). By J. Burton Cleland, M.D.,
Ch.M.Syd., 25, 43 . !
Republic of Colombia, tropical diseases observed in, 100
Resistance of bugs to various reagents, 48
—— of ticks to sheep dips, 48 : r.
Results, some, of measures taken against beriberi in Pritish
Malaya, 282
Retirement of Dr. R. M. Forde, 374 , .
Review of a clinical study of malarial fever in Panama (illus-
trated), 145, 177, 209, 240, 241, 297
Reviews, 15, 61, 62, 63, 80, 05, 96, 128, 143, 158, 159, 374
Rice in Siam, 60
INDEX xi.
Role played by fungi in sprue, 33
Round worms simulating appendicitis, 306
Salvarsan and neo-salvarsan, treatment of some cases of human
trypanosomiasis by, 303
—— in dysentery, 312
—— in filariasis (illustrated), 364
Sand-fly fever, 38
Sanitary Conference at Madras, the Second All-India, 13, 31
organization in the Tropics, 288
—— —— of the Isthmian Canal, the, 4
Sanitation, practical, in a district of Ceylon (illustrated), 365
Schistosomum japonicum, 7
School of Tropical Medicine, London, 15, 128
—— quininization experiments in the United Provinces, 368
Second All-India Sanitary Conference at Madras, 13, 31
Proceedings of, 308
Service abroad, athletes aud candidates for, 24
“ Seventh Report on Plague Investigations in India,” 144
Shanghai Municipal Health Department annual report, 1912,
353
Sheep dips, resistance of ticks to, 48
Siam, rice in, 60
Sleeping sickness, 75, 81, 156, 167, 186, 232, 251, 302, 384
-———— —— -, case of, from North Rhodesia, 302
—— —— diary: Nyasaland Protectorate, 384
—— —— in Nyasaland, 75, 156
—— —— in South Africa, 186
—— —— in the Portuguese Congo: apparent cures (illustrated),
Sl
—— — ———, native treatment of, a trial, 167
Snake-bite, permanganate treatment of, 93
Society of Tropical Medicine and Hygiene, 14, 47, 143, 176, 314,
350, 374
Some experiences of mountain sickness iu the Andes (illus-
trated), 313
—— experimental facts re kala-azar (Indian), by R. Row,
M. D. Lond., D.Sc.Lond., 1
—— notes on tropical diseases observed in the Republic of
Colombia, 100 ,'
——— observations on
Nigeria, 193
— — results of measures taken against beriberi in British
Malaya, 282
South Africa, sleeping sickness in, 186
South African Medical Record, 214, 234, 246
Southern Nigeria, some observations on ankylostoma infection
in, 198
Special drugs for each disease, 322
methods for the detection of parasitic ova in the fæces,
137
Species, new, of tsetse-fly, 208
Spider's web and malaria, 133
Spirillar fever in the Darjeeling district, 87
Spirochete in the blood, 199
Spirochietosis, 173, 199, 329
-—, bronchial (illustrated), 329
—- in the Darjeeling district, 199
Splenomegaly, primary, 41
Sporotrichosis, 156
Sprue, 33, 123, 264, 287
and pellagra, probable identity of, 287
and post-dysenteric conditions, use of collosol argentum
in, 193
—, rôle played by fungi in, 33
Studies, medical, Polar exploration and its bearing on, 52
— on pneumonic plague, 78, 87, 107, 125
Study of bilbarziasis, contribution to the, 84
, clinical, of malarial fever in Panama, review of (illus-
trated), 145, 177, 209, 240, 241, 297
Sudan, Anglo-Egyptian, pyosis tropica in the (illustrated), 877
Suggested treatment for trypanosomiasis, 48
Sunstroke, 106
Supposed new species of human trypanosome, 270
Suppression, treatment of, in blackwater fever (illustrated),
131
Surra, treatment of, in camels, 188
Syphilis simulating liver abscess, 74
ankylostoma infection in Southern
T
Tarbagan, relationship of the, to plague, 275
Test, clinical, for malaria, 239
Third International Congress of Tropical Agriculture, London,
1914, 390
Tick-bite, 58, 188
———— in British Columbia, 58
Ticks, resistance of, to sheep dips, 48
Transmission of trypanosomes, 175
Treatment, emetine, liver abscess and, 201
— for trypanosomiasis, suggested, 48
- —, native, of sleeping sickness, a trial, 167
-—- of ameebic dysentery, 72
— — of balantidial infections, 186
—— of bronchial asthma, 223
— — of dysentery due to infection with Hntameba histolytica,
53
— — of leprosy, 134
— — of pellagra, 139, 232
—— of some cases of human trypanosomiasis by salvarsan and
neo-salvarsan, 303
—— of suppression in black water fever (illustrated), 131
— — of surra in camels, 188
——, permanganate, of snake-bite, 93
Treponema pallidum, demonstration of the, 40
Trichinosis, case of, 296
Tripoli, tropical diseases in, 68
Tropical America, future of, 373
—— anemia, the blood-plates in, 106
—--- bubo, 307 -
— — countries, difficulties of the milk supply in, 105
— — dinner, 223
— — diseases in Tripoli, 68
-—— —— observed in the Republic of Colombia, 100
—— —— Bulletin, 12
— — dwellings, 134
—— Medicine and Hygiene, Society of. 14, 47, 143, 176, 344,
350, 374
— -. —— London School of, 15, 128, 351
— — —— Section of the International Congress of Medicine,
291
Tropies, can Anglo-Saxons colonize the? 15
——, foreigners resident in the. necessity for an annual
holiday for, 168
—— , motor launches for the, 61
, sanitary organization in the, 288
——, Wassermaun test in the, 2
, when to come home from the, 336
Trypanosoma brucei, 187
Trypanosome causing disease in man and animals in the
Sebungwe district of Southern Rhodesia (illustrated),
113
, supposed new species of human, 270
Trypanosomes, extrusion of granules by, 271
———, transmission of, 175
Trypanosomiasis, equine, case of (illustrated), 348
—-, human, treatment of some cases of, by salvarsan and neo-
salvarsan, 303
——-, suggested treatment for, 48
Tsetse-fly, new species of, 208
Tuberculosis in the mines of South Africa, 392
Two cases of pellegra cured with Nicolaidi's serum, 57
new genera of helminthes in men, 270
Typhoid bacilli, isolation of, from feces, 367
Typhus fever in China, 191
Uganda and East Africa, climatic and other factors in-
fluencing the health of Europeans in, 120
Uleerated aud swollen gums in Indian troops, 286
Ulterior results on pellagrins subjected to Nicolaidi's sero-
therapeutic cure, 56
Undulant fever, 192
Union Medical College, Peking, 310
“ United States Public Health Reports," 150
University of Liverpool, 128
Unusual cases of hydatid disease, 125
xii. INDEX
v
Vaccine of a coliform organism, autogenous, case of acute
agchylostomiasis treated by (illustrated), 260
Vagrant habits of Ascaris lumbricoides, with the report of a
case of interest, 379
Varieties of Glossina morsitans, 184
Verruga, 23, 323
-—— peruviana, 23
Vibrios, cholera, in the biliary passages, 40
Vibrona, 312
Viscera, abdominal, multiple hydatid infection of, 12
LIST
A year's anti-malarial work at Kbartoum, face p. 228
Case of blackwater fever, showing the cell-inclusious of
Leishman, face p. 36
Cell-inclusions in the leucocytes of blackwater fever, &c.,
face p. 162
Cirrhosis of the liver of malarial origin, face p. 164
Hyperpigmentation of the skin after an attack of pyosis
tropica, face p. 378
Wassermaun test in the Tropics, the, 2
Web, spider's, and malaria, 133
West Africa, prevention of disease in, 59
African medical staff dinner, 207
— — — notes, 214
When to come home from the Tropics, 336
Work, a year's anti-malarial, at Khartoum (illustrated), 225
Y
‘© Yaws, forest," Leishmania in, 240
Yellow fever danger for Asia and Australia, 292
—— —, endemicity of, 172
OF PLATES.
International tribute to Sir Patrick Manson, G.C.M.G.,
F.R.S., LL.D.. M.D., face p. 304
London School of Tropical Medicine, face pp. 42, 128, 233
Map of Khartoum North, face p. 226
Pyosis tropica in a European, face p. 378
after treatment, face p. 378
Tropical Section of the International Congress of Medicine,
face p. 296
Trypanosome of Sebungwe district, face p. 11
INDEX OF SELECTIONS FROM COLONIAL MEDICAL REPORTS.*
(12) Sierra Leone, 1, 5, 9, 13, 17
13) British Guiana, 17, 21
(14) Bengal (lunatic asylums), 23
(15) Vestern Australia, 25, 29
(16) St. Vincent, 31, 33
(17) Fiji, 37, 41
| (18) Bahamas, 42
(19) Seychelles, 44, 45
(20) Siam, 48, 49, 53, 57, 61
(21) Basutoland, 63
(22) Gambia, 64, 65
(23) Straits Settlements, 69, 73, 77, 81, 85, 89
(24) Northern Nigeria, 92, 93
* Nole to the Dinder.—These are to be bound to follow all the numbers of THE JOURNAL or Tropical, MEDICINE.
Jan. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 1, Vol. XVI.
Original Communication.
SOME EXPERIMENTAL FACTS RE KALA-
AZAR (INDIAN).*
Seconp Memoir.
By R. Row, M.D.Lond., D.Sc, Lond.
Since writing [1] on the subject of localized
lesions induced subcutaneously with kala-azar
cultures in Macacus sinicus I have a few more data,
and these are summarized here.
The monkey which, it may be remembered,
developed after an incubation period of five months
two bean-like subcutaneous nodules at the seat of
infection with a three-weeks-old culture of kala-azar
in N.N.N. medium continued thriving, and was none
the worse for the lesions, and is even now (ten
months after the infection) in a very good condition.
The nodules, however, increased gradually in size,
always remaining firm and movable under the skin,
demonstrable sign of its having had kala-azar in-
fection being a definite but feeble agglutinating
power its blood serum showed to a young and
active culture of flagellates (about two months ago).
The nodule which was excised showed in sections
the structure of a young fibroma or granuloma, sur-
rounded by loose fibrous tissue. There were no
vessels inside the tumour, and the central portion
showed a more dense disposition of granulation
tissue cells than the peripheral parts. In the ex-
tremely thin portions of the sections a few parasites
were clearly seen lying free, as well as packed
in macrophages. The emulsion made out of
the other half of the nodule was injected intra-
peritoneally as follows: (a) About 0.25 c.c. into each
of two tame mice; (b) about the same quantity into
a Macacus sinicus. The fate of these animals, as
also of the parasites they had received, is repre-
sented below in a tabular form.
N.B.—The nodule of Macacus III was not very
rich in kala-azar parasites, i.e., a smear from a
BarcH I.—TaME Mice AND MaCACUS SiNICUS X.
Animal When and how infected Result
Remarks
Mouse (14), white July 17, 1912, 0.25 c.c.| Died September 1, 1912
intraperitoneally
Mouse (13), black s
and white
Mouse (11), black
July 4, 1912, a mere
and white
trace of the juice
from the nodule of
Macacus III ob- |
tained by needle |
puncture and di-
luted with saline
Macacus sinicus X
of the emulsion of
nodule of Maca-
sus III in saline
$5 Killed September 4, 1912
Killed September 30, 1912 ...
July 17, 1912,0.25¢.c.| Liver aspirated December 2, 1912,
i.e., 44 months after infection
Kala-azar parasites—round forms—found post-
mortem iu liver, spleen and bone-marrow ; there-
fore it died of a generalized kala-azar infection.
Kala-azar parasites, oat-shaped, found in liver,
spleen and bone-marrow ; therefore the animal
had a generalized kala azar infection at the
time of killing.
Kala-azar parasites—round forms—found in
spleen, liver and bone-marrow; therefore it
had a generalized infection of kala-azar at the
time of killing.
Animal well apparently. Smear from liver blood
found to contain typical kala-azar parasites
about 8 per slide and 2 macrophages in 6 slides,
each containing 3.
which remained throughout healthy. Of the two
nodules, the one on the right side was excised on
July 17, 1912, i.e., a fortnight after its appearance,
and one half of it was hardened and cut into
sections, while the other half was crushed in about
1 e.c. of NaCl (0.6 per cent.) solution, and the saline
emulsion was taken up for inoculation of other
animals. An account of this will be given imme-
diately. The other nodule (on the left side), which
was left alone for observation, grew further for
about two months of its appearance to the size of a
small raisin, remaining always firm and freely mov-
able under the healthy skin. After this period,
however, the nodule began to show signs of a
gradual diminution, and in six weeks' time got com-
pletely absorbed, so that four months after its first
appearance not a trace of it could be detected. The
animal showed no general symptoms of disease, and,
as stated above, is even now quite healthy, the only
* From the F, D. Petit Laboratory, Byculla, Bombay.
nodule directly on a slide showed about twenty
parasites for each slide, so that the dose given to
monkey X, as also to mouse 11, can be taken as à
minute dose, and by no means massive.
The fate of the parasites in the mice of Batch I
which had a generalized infection :—
The liver and spleen of mouse 14 was removed
eight or ten hours after death, and an emulsion
made in saline and injected intraperitoneally into
mouse 15 on September 1, 1912. "This mouse was
killed on October 17, 1912, and, strange to say,
no Leishmania were found in its liver, spleen, or
bone-marrow smears.
The livers and spleens of mice 13 and 11 of
Batch I were also crushed in saline, and the
emulsion injected intraperitoneally on September 4,
1912, into mice 16, 17, and into Nos. 20 to 23 on
September 30, 1912, the results being given in the
following tables.
From the results of the mice of Batch I and
Batch III, it appears that, although the material
9 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1913.
BarcH II or TAME MICE.
|
Animal When injected j Result
| Remarks
| E
Mouse 16, white | September 4, 1912 ...
Mouse 17 ... ash ï ”
Died September 15, 1912
.| Killed October 27, 1912
.| No definite parasites; round coccal bodies with
a large nucleus found ; altered parasites ?
Liver, spleen and bone-marrow quite free from
parasites,
BarcH III or Tame Mice.
Remarks
.| Decomposed when examined eight hours later;
liver and spleen quite soft and greenish owing to
post-mortem decomposition ; no parasites seen.
Animal When injected Result
Mouse 20... ...| September 30, 1912 | Found dead October 30, 1912
Mouse 21 ... i 5 $5 Living and well, December 14, 1912
Mouse 22 ... ii » 33 » ”
Mouse 23 ... at ys » Killed November 20, 1912
. Liver and spleen smears show dots, but no
definite parasites.
used for infection did contain the parasites, no in-
fection was evident in the mice examined, and the
negative result seems to be attributable to one or
more of the following possible causes :—
(1) The time of the examination of the animals
may have been too early for the infection to be fully
established, although fully seven to nine weeks were
allowed in each case, i.e., more than what was
necessary for a generalized infection of mice of
Batch I, and far more than was found necessary for
kala-azar infection of mice by Laveran [2], viz.,
four weeks.
(2) The possibility of the attenuation of the virus
by passage into mice.
(3) The possible curative effect of the extract of
the liver and spleen which had to be introduced
simultaneously with the parasites in the emulsion
used for infection.
Besides the infections induced so far as indicated
in the above lists, I have to record a local pinhead
nodule induced in a fresh Macacus sinicus (VII) at
the seat of cutaneous infection with the juice of a
similar pinhead nodule of Macacus (VI), an account
of which was given in my last memoir [1]. Here the
incubation period was found to be five months. The
nodule contains fully formed typical parasites with
flagellate forms in culture.
Dogs, rabbits, guinea-pigs, and wild mice have
been found by me to be refractory to small doses
of the virus given intraperitoneally, or massive
doses of the culture given intraperitoneally or sub-
eutaneously during these nine months of observa-
tion.
CONCLUSIONS.
(1) From the above it is clear that of the animals
experimented on, only Macacus sinicus and tame
mice can develop a generalized infection of kala-
azar with a minute dose of the virus.
(2) The way by which one can induce a general-
ized infection is by intraperitoneal injection.
(3) The parasites seem to lose their virulence in
mice by passage.
(4) The dog, the rabbit, the guinea-pig, and the
wild mouse seem to be refractory to kala-azar virus.
(5) The intracutaneous and subcutaneous infec-
tion of kala-azar virus, as well as culture, produces
in the monkey a well-defined localized lesion of the
nature of young fibroma. This lesion gets ultimately
absorbed, leading to no general infection or any
constitutional disturbance in the animal, as far as
can be gathered from the observation of the general
state of the animal and the condition of its hepatic
blood five months after the appearance of the
nodule, and ten months after the day of infection.
(6) The incubation period required for the pro-
duction of a general infection or a local infection in
the monkey has been found by me to be about five
months, while that for tame mice is about seven
weeks.
REFERENCES.
[1] R. Row: JounNALOF TROPICAL MEDICINE AND HYGIENE,
TE QIBSt 1912, and British Medical Journal, November 2,
[2] Laveran: Comptes Rendus des Séances de VU Academie
des Sciences, February 26, 1912.
————»9——————
The Wassermann Test in the Tropics.—Bates dis-
cusses this question in the Archives of Internal
Medicine, vol. x, No. 5, November 15, 1912. He
concludes his work under the following six head-
ings :—
(1) Guinea-pig serum must be tested for native
anti-human hemolysin in certain localities and all
sera in which they are found discarded.
(2) Malarial infection does not affect the Wasser-
mann reaction (Noguchi modification).
(8) Cases of filariasis, yellow fever, blackwater
fever and ameebic dysentery all gave negative re-
actions. "Their number was too small to draw con-
clusions from however.
(4) Two out of three uncomplicated cases of yaws
gave positive reactions.
(5) The Wassermann test is of great value in cases
of arthritis of uncertain etiology.
(6) The Wassermann test should be made an aid
to the pathologist in a considerable number of
autopsies;
Jan. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 3
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THE JOURNAL OF
Tropical Medicine and hygiene
JANUARY 1, 1913.
OIL IN ITS RELATION
MEDICINE.
From several sources lately we have had brougut
to our notice specimens of olive oil with information
that it is pure and therefore suited in every respect
for medicinal purposes. The writer for some years
now has written and spoken about the deleterious
consequences of the varieties of ‘‘ oils '" which are
supplied in our markets, and brought forward the
idea that “‘ sprue " and, perhaps, other gastro-
intestinal troubles were caused by the ''oil'' used
by native cooks in preparing food for Europeans.
Be this as it may, there is no doubt that olive
oil varies in composition, in the amount of adultera-
tion, and according to the extent that ‘‘ purification
processes '" are applied to the crude oil, so does it
vary in taste, in colour, and physiological effects.
As to the possibility of adulteration, we have
only to look to our text-books to see that inferior
brands are obtained (1) by adding the results of
boiling the pulped fruit; (2) by fermentation pro-
cesses; (3) by the addition of cotton-seed oil; (4)
by sesame oil; (5) rape oil; (6) arachis oil; (7) and
other substances, such as hydrocarbon oil. This
OLIVE TO
formidable array shows that olive oil is a more
expensive article to produce than any one of these
mentioned as being used to simulate it and take
its place. As usual, cheapness is the all-conquer-
ing cause of this masquerade of accessory articles
for a natural product; it is the factor, indeed, which
leads to adulteration and substitution in every
branch of commerce and tends to warp man's
honesty and blur his regard for truth. Health
and human life are neglected factors in the race
for wealth; the manufaeturer of this and that
specially prepared article advertises the excellence
and cheapness of his product and the consumer
regards the cheapness with favour and neglects to
consider the ''excellence." The only barrier to
the use of deleterious products is the doctor, and
he is only called in when the damage is done, when
the gustro-intestinal tract presents some one of the
many consequences of unsuitable and irritating
foods. The death certificate obscures the finding,
and the evil proceeds. This seems a roundabout
way of getting at the truth concerning olive oil,
but olive oil is so universal an article of diet, so
useful as a medicine, so widely used in compound-
ing drugs, that its purity is perhaps of as much
account as a pure milk or meat supply.
Cheapness is the root of all the evil. When
asking chemists for a better olive oil than that
generally sold, one is informed it is a question of
price; the ordinary form costs, say, a shilling a pint,
the better quality one shilling and sixpence. A
whole sixpence difference between a poisonous and
a wholesome oil; what a price to pay! But even
at this ‘‘enhanced”’ price, are we sure of the quality
of the oil? By no means, we are still far off the
best oil, and for medicinal purposes it is the best
we want. Olive oil is bought wholesale by the
ton, and the price varies from some £70 for the
cheaper, that is the ordinary oil we use on our
tables, to £120 for the ‘‘ so-called best °’; but for
really the best, the price is some £20 to £25 more.
The best olive oil cannot be supplied at 1s. a pint,
nor at 1s. 6d. a pint, nor yet at double that price.
When health is really considered, when disease has
to be contended with, the price should not, and
will not, stand in the way. Given an honest dealer
who can guarantee a pure olive oil, be the price
10s. a pint, that, and that oil only, will be recom-
mended by the medical profession, and in prescrib-
ing the oil let the producer's name be appended
in the prescription to the oil, so that its substitu-
tion becomes an irregularity, not to say a fraud,
and therefore a punishable act. The writer has
urged this upon several importers of olive oil and
advised them again and again that price has
nothing to do with the matter could they only
guarantee purity.
Olive oil for table or medicinal use has to be
‘“ prepared "'; the oil as originally expressed can-
not be so used, it is disagreeable to taste and
repulsive in both its smell and flavour. The “ re-
finement ’’ implies expense, so that in comparison
with the crude forms of oil increased in bulk by
inferior (cotton-seed and other) oils, one must be
4° THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1913.
prepared to pay. In many ailments olive oil is
of value, especially in constipation, in duodenal
ulceration, in gall-bladder troubles, including gall-
stones and jaundice from various causes and
several other common afflictions.
As an article of diet it is used freely, more
especially in the preparation of salads and salad
dressings. The indigestibility of salads is pro-
verbial, and one blames the vegetables comprising
the salad as the source of the trouble, whereas
the impurity of the salad oil poured over the
vegetables or in the salad dressing is much more
calculated to upset the stomach and produce sub-
sequent gastric catarrh. We are indebted to
several firms for the attempt they have made to
place a pure oil on the market and to none more
so than to Messrs. Cozenza and Co., of London.
Were the consideration of oils extended, the
question of the adulteration of Macassar oil would
not be amiss. As the basis of oil for the hair the
adulteration of this oil must be of importance when
the question of its action upon the hair and the
production of baldness is considered. It is popu-
larly believed that the application of oil to the hair
hastens the falling of the hair, and this can be
readily believed when we know to what an extent
acrid oils are introduced into the composition of
macassar.
J. C.
———,à—
Annotations.
The Sanitary Organization of the Isthmian Canal.
—Colonel Gorgas, in a recent number of the
Journal of the Association of Military Surgeons of
the United States, describes the sanitary organiza-
tion of the Isthmian Canal, especially as it bears
upon anti-malarial work.
The United States on the Isthmus of Panama,
Colonel Gorgas says, owns a strip of land ten miles
wide (of which the canal is the centre). This strip
extends about forty-five miles in length from north
to south. The population to be protected against
malaria consists of about fifty thousand labourers
and their families, and is scattered all over this five
hundred square miles, though they are principally
collected along the line of the canal, and more
particularly into some forty camps and villages near
this line.
The temperature, rainfall and character of terrain
are all excellently suited for the breeding of ano-
pheles all over this territory. The temperature is
the same all the year round, and high enough for
mosquitoes to breed freely in every month in the
year. The rainfall averages over a hundred inches
yearly, and though there are four months in which
there is practically no rainfall, there is enough water
for the anopheles to breed freely during these four
months.
The line of the canal passes through low and
swampy ground for about one-third of its length,
and through hilly ground the other two-thirds, but
streams are so numerous in the high ground that
anopheles breed about as well here as in the low:
ground.
During the five years of the American occupancy
of the Isthmus two hundred and fifty thousand
people have been brought in, and as these have
been located principally in places formerly un-
occupied along the line of the canal, and as the
villages are intended for only temporary occupancy,
the conditions are a good deal like those of an
army going into a new country; and Colonel Gorgas
thinks that the experience at Panama may be use-
ful in the military oceupation of tropical countries.
The anti-malarial measures consisted of:—
(1) Destroying the habitat of the anopheles
during the larval stage within a hundred yards
of dwellings.
(2) Destroying within the same area all protection
for the adult mosquito.
(3) Screening all habitations so that the mosquito
cannot have access.
(4) Where breeding places could not be done
away with by draining, use was made of crude oil,
Phinotas oil and sulphate of copper for the destruc-
tion of larve.
These measures are based upon the knowledge
that the anopheles larve only live, as a rule, in
clear, fresh water, in which there is a plentiful
supply of grass and alge, and that the adult is
weak on the wing, not generally flying far, and
needs an abundant supply of grass and brush for
protection against the breezes.
For the purpose of carrying into effect these
measures, the five hundred square miles of territory
was divided into seventeen districts. These seven-
teen districts were under the charge of a chief
sanitary inspeetor, who had in his office the neces-
sary clerical force and three assistants. One of these
assistants was especially competent in the life,
history and habits of the mosquito; another in
knowledge of ditching, tile draining, &c.; and the
other in knowledge of general executive work. Each
of the seventeen districts had a district inspector
in charge. Each district inspector had a sufficient
force of labourers (forty to fifty) to do the necessary
ditching and draining; a force of carpenters to keep
the screening in repair; and one or two quinine
dispensers, who were kept constantly going round
giving three-grain doses of quinine to those who
wished it. No force was employed to make the
employees take their quinine prophylactically. The
three assistants were kept constantly going over
the work, advising and instructing the district
inspectors.
The district physician sent in daily to the central
office a report, showing the number of malarial
cases occurring in his district and also the number
of employees from which these malarial cases come.
This report, consolidated weekly in the central
office, showed the number of cases of malaria and
per cent. of malaria, A copy was sent to each
Jan. 1, 1918.]
distrie& inspector and he was held responsible for
any excess of malaria in his district. If the admis-
sion rate for malaria during the week rose above
one and one-half per cent. something was con-
sidered wrong, and the assistants to the chief sani-
tary inspector were sent down to look over the
ground and try to discover the cause.
The district inspector, for the purpose of doing
away with the breeding places of larve, put down
tile drains wherever that was suitable. This Colonel
Gorgas considers the most effective and economical
form of drainage. After it is once in, it requires no
more attention. There is no breeding place left for
mosquitoes, as no water whatever is exposed at the
surface. A horse mower or scythe can be used for
cutting the grass over it. Where tile drainage
cannot be used open concreted ditches were adopted.
The first cost of this was nearly as great as that of
tile, and a certain amount of labour was necessary
to keep it clear. It had to be swept out once a
week to prevent obstructions, making little puddles
of water in which the mosquito will breed. If the
ground eould not be drained in either of the above
ways, open ditches were used. This is the least
effective and most expensive form of drainage. In
Panama they rapidly fill up with grass and have to
be cleaned out about once in two weeks.
For the purpose of doing away with places which
might harbour the adult mosquito, the inspector
cleared the ground of brush and grass for a hundred
yards around the place to be protected. Where the
locality was to be occupied for a year or more, it
was more economical to grade the ground and plant
grass. The grass could then be kept down with a
horse mower or scythe. A limited amount of
shrubbery or a few trees about a dwelling are
allowable.
The inspector kept the screens in repair by con-
stantly going over them with his force of carpenters.
The usefulness of screening depended entirely upon
the care as to details with which it was put up.
As put up by the ordinary carpenter, without expert
supervision, it was of comparatively little use. Good
wire should last, on the Isthmus, at least three
years, although there is plenty of screening on the
market that will not last six months.
Prophylactic quinine was furnished in three-grain
doses either in solution, in the form of a tonic, or
in pills. It was placed on the table at all the
messes, and given to any employee who applied for
it. Besides, from one to three dispensers in each
district went round to the various villages offering
quinine to all employees who would take it. In this
way about twenty thousand doses were taken daily
when forty-five thousand people were being em-
ployed. Prophylactic quinine is a most important
measure.
Phinotas oil and sulphate of copper were used in
such places as could not be drained. Oil was used
in temporary pools caused by construction, or at
temporary camps where it would not be economical
to drain, and in all places where for one reason
or another drainage was not done. Phinotas oil was
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 5
used for killing the larve in the alge and grass,
along the edges of lakes or swamps or the banks of
streams. Sulphate of copper was used for killing
the alge in similar places. A very small amount
was found to accomplish this efficiently.
Under the above plan the inalarial rate was
affected as follows :—
Number of
Number of | x Number of
Year Orci Canes: cases per Number of deaths per
dios Morea thousand deaths thousand
*1904 6,747 422 125 9 2.66
1905 16,511 8,496 514 92 5.57
1906 26,705 21,938 821 199 7.45
1907 39,344 16,709 424 138 3.51
1908 43,890 12,372 282 59 1,34
* 1904 commences with the month of July.
Colonel Gorgas thinks that these methods could
be applied in a considerable extent to military
organizations. When troops are on the march in a
malarious country the only practical protection
would be prophylactic quinine. The only exposure
to malarial infection would be in case they were
billeted in some town. With a fresh camp every
night it would not be probable that such anopheles
as bit them would be infected. Where troops re-
mained at one camp for a week or longer it would
be practicable to clear and drain the ground.
The most important practical point in this class
of work is that the sanitary officer should do the
work himself. The men doing the ditching, brush
cutting, &c., should be immediately under his con-
trol und he should be held responsible for the proper
performance of the work. Colonel Gorgas’s experi-
ence has impressed upon him the fact that usually
the officer in charge of this work has no special
knowledge of mosquito life and habits and does not
give due weight to details resulting therefrom. In
general the laity are inclined to look upon the
minutie of such work as trivial, and more or less
ridicule is cast upon them.
As education extends it is possible that such work
may be turned over to the engineer, or the quarter-
master, or the provost of the camp, but at present
Colonel Gorgas would always make it a sine qua non
that the sanitary officer be held responsible for the
proper execution of the mosquito work in all its
details, and, in order to enable him to properly carry
out these details, he should have immediate control
of the working force. Unless this is done the work
is foredoomed to failure. The sanitary officer then
should do the mosquito work himself, and not
merely advise some other officer as to how it should
be done.
This interesting and valuable paper should be
carefully studied by all tropical sanitarians. Similar
results can be obtained in other parts of the world
quite as much as in the Isthmus, provided that the
same care and attention to detail are bestowed
upon the work.
6 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1913.
The destruction of disease-bearing insects.—
Harris and Ellington, in the Australasian Medical
Gazette for October 26, 1912, contribute a paper on
the important subject of the reduction and destruc-
tion of disease-bearing insects. As regards mos-
quitoes, they say that this question can be sum-
marized briefly enough, and has been well stated
by the American Mosquito Extermination Society.
For Queensland it may be put as follows :—
(1) There are some forty or more described
species of mosquitoes in Queensland. Not all suck
the blood of human beings. Of those species which
do, only the female pursues this unpopular practice.
(2) Mosquitoes breed only in water. They may
breed in any kind of quiet water which is free from
their natural enemies, such as small fish, water-
beetles, &c., or which is so shallow or grass-grown
at the edges that their enemies cannot get at the
larve.
(3) Mosquitoes generally require from two to
three weeks to develop from eggs to winged insects
in warm weather, longer in cold weather. The
eggs of some species (e.g., Stegomyia) can survive
for many months, and it is probably in this way
that these species pass through the winter. The
larve of several other biting species can survive the
eold weather, remaining in a sluggish condition in
sheltered water.
(4) The adult female insect may live for several
months, and some species appear to hibernate in
small numbers in cold weather.
(5) Mosquitoes do not breed in grass or under-
growth, but rank growths often conceal breeding
puddles, and these also often form favourite har-
bouring places for the adult insects. The usual
breeding places for domestic species, such as
Stegomyia calopus and Culex fatigans, are in or
very near houses—the tank, for example, or a
defective section of roof-gutter, or a puddle, or an
empty can, or a neglected flower vase or water-jug.
(6) Different species of mosquitoes have as well-
defined habits as different kinds of birds, flies, or
animals. Some are domestics, some wild, some
migratory.
(7) Most domestic mosquitoes breed in fresh
water, fly short distances, and habitually enter or
live in houses.
(8) Most migratory mosquitoes (such as the
Scotch Grey) breed in salt or brackish swampy
areas, and can fly long distances.
(9) The most accurate and precise tests have
proved that certain kinds of mosquitoes are the
only known natural means by which yellow fever
and malaria are transmitted Some other diseases
(for example, filaria, which is frequently met with
in Queensland) are also conveyed by mosquitoes.
(10) The conveyer of yellow fever (Stegomyia
calopus) is common in Eastern Queensland, as is
that of filaria (Culex fatigans). The malaria-
conveying Anopheline mosquitoes occur also in parts
of Queensland.
(11) Mosquitoes are unnecessary and are very
dangerous pests. Their breeding can be largely pre-
vented by such methods as screening tanks with
—
fine wire gauze, by draining or filling in puddles or
pools whieh serve as breeding grounds, or by oiling
these with kerosene or other effective larvicide, or
by stocking them with small fish. Before ascribing
a bad reputation to such places, it should be ascer-
tained whether mosquito larve are actually to be
found in them.
The removal, emptying, or screening of tanks and
water receptacles is essential. They should be oiled
with kerosene (about a tablespoonful to each
ordinary tank, or a dessertspoonful to each square
yard of water surface) once or twice a week, if they
cannot be screened or removed.
Attention should also be given to cisterns, wells,
flower vases, water-jugs, flower pot saucers, drink-
ing places for birds or animals, ant-saucers, cess-
pools, roof-gutters, drains, water-troughs, gutters,
old cans, holes in trees, bamboo clumps with broken
or perforated joints holding water, puddles, drip
places from taps, drain-traps, and similar small
collections of water about houses.
(12) Adult female mosquitoes in a house will
continue their bloodthirsty habits for some time after
their breeding places are destroyed. They shelter
during the day in presses, wardrobes, curtain folds,
and similar dimly-lit places. Their sheltering places
should be located, and clothes, curtains, &c.,
removed to drawers or boxes if found to harbour
them.
Various fumigating preparations can be obtained,
and should be used in the shelter places. A sheet
of paper should be laid at the bottom of the press,
&e., before fumigating, and all mosquitoes found on
it afterwards folded up in it and burned.
The continued breeding of any kind of mosquitoes
in inhabited places is a menace to the health, life,
and comfort of man and beast alike. It is therefore
ignorant and neglectful to allow it to continue.
Bubonic Plague in Havana.—Guiteras in The
Journal of the American Medical Association for
November 16, 1912, reports three cases of bubonic
plague which occurred in Havana. He describes
the present sanitary conditions of the city, and
states that the conditions are favourable for the
control of the disease. Of 8,909 rats examined in
Guiteras’s laboratory none were found plague
infected. Kitasato, the author says, has drawn
attention to this faet that it is not rare to have
summer epidemics of plague without finding plague
rats. Another point in favour of the disease being
stamped out quiekly was that it appeared in sum-
mer, a time when the flea population of rats is at
its lowest in the Tropics. Guiteras has bred
the Læmopsylla cheopis, the common rat flea of
Havana, for several years, and the decrease in their
numbers in summer has been very striking. A
detailed report of the bacteriological work in con-
nection with these cases will be published later by
Dr. Lebredo, who was in charge of that part of the
work, and the reports of other heads of departments
will be published also in Sanidad y Beneficencia,
the official organ of the department.
Jan. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 7
Schistosomum japonicum.” — Miyakawa made a
statistical investigation of the relation of schistoso-
miasis and dermatitis, using a modified Telemann's
method for finding the eggs of the parasite in the faces ;
and tried to determine the way in which the infection
occurs and the mode of its propagation. He also
studied the method of prophylaxis and came to the
following conclusions :—
(1) The dermatitis, which occurs in regions where
schistosomiasis is prevalent, is a dermatitis showing
a few peculiarities. Its cause can be ascribed to a
mechanical as well as to a chemical stimulation.
(2) The modified Telemann's method is as follows ;
a mixture of 50 per cent. HCl and an equal quantity
of ether is used to select the parasite's eggs from
the fæces, and then centrifugalized and the residue
examined for the eggs. By this method the destruc-
tion of the eggs is much less than in Telemann's
method, and there is no danger of explosion.
(3) Nineteen out of 49 persons who had been found
to harbour no schistosomum eggs at the first examina-
tion were discovered to be infected after 50-60 days.
From these 19 persons, dermatitis was found in 9;
and from non-infected persons in 19 cases: thus the
dermatitis occurs more frequently in those who have
no eggs than in those who have eggs in the faces.
(4) The author and his assistant suffered from
dermatitis in this year, but up to the time of writing
no eggs had been found in their faeces.
(5) A servant of the institute bathed, as an experi-
ment, ina brook and in water in a rice field, which
were believed to contain the cause of the dermatitis,
and contrary to expectation he never had a trace of
dermatitis, but developed schistosomiasis.
(6) A similar dermatitis is obs»rved in regions
where there is no schistosomiasis.
(7) The histological changes in this dermatitis are
quite different from those in skin which contains
young worms; and in the former one never finds
traces of the passage of the worms. From these
observations it can be concluded that there is no
causal relationship between dermatitis and Schistoso-
iniasis Japonica.
8) One cannot infect dogs in which an acute gastric
catarrh has been artificially produced, or patients, by
pouring a large quantity of the infected water into the
stomach.
(9) The young forms of Schistosomum japonicum
seem to live more in the bed of the stream than in
running water, but mud does not appear to contain
a perceptible quantity of the worms.
(10) Infection by Schistosomum is not observed in
swampy regions, though the infection seems to be
localized in places where there is plenty of water.
(11) The cause of the infection is present to a
greater extent in brooks and freshly watered rice
fields than in stagnant rice fields.
(12) Chininum muriatum has no prophylactic action
against this disease as was once believed.
(13) Thick woven cotton cloth prevents infection
to some extent.
* No. 7, Vol. xxvi, Journal of Tókyó Medical Association.
Abstracts.
THE DIAGNOSIS OF PELLAGRA.
C. H. LAVINDER, writing in a recent number of
the American Practitioner, points out that pellagra
has been reported now from all parts of the United
States. The disease seems to be constantly extending
its area. Its early diagnosis is important; for treat-
ment in the early stages gives more hope of good
results, and, moreover, in a malady of such protean
character, errors of diagnosis are easily made, and
may involve distressing tragedies, since many cases
have suicidal tendencies.
The diagnosis of the disease in a well-marked case,
fully developed, offers no difficulty, but the early
cases, and cases which do not show typical symptoms,
not infrequently present the greatest difficulty in
arriving at a conclusion. The diagnosis must depend
upon the history, symptoms, and development of the
disease, for as yet we have no precise laboratory
methods which will give confirmation. Many
attempts have been made to devise some precise
method of diagnosis, but so far none has proven
satisfactory. It is of interest to note, however, that
recently Volpino has presented a communication
claiming that, on the basis of extensive experiments,
he has established the presence in pellagrins of an
anaphylactic reaction to extracts of spoiled corn.
This reaction consists of a rise in temperature, accel-
eration of the pulse rate, often vomiting and increase
in intestinal peristalsis with, at times, the passage of
bloody stools, psychic phenomena, and sometimes the
aggravation of pre-existing erythemas. His controls
did not present these phenomena. He suggests the
use of his method in diagnosis. His work will, of
course, require confirmation. Previous similar at-
tempts by others along this line,of work have given
negative results.
Pellagra is an endemic disease characterized patho-
logically by serious organic changes in the central
nervous system, and clinically by a chronic course
with periodic manifestations of acute phenomena
referable to (1) the gastro-intestinal tract; (2) the
nervous system; and by (3) the appearance of an
erythematous exanthem on certain exposed body
surfaces. The disease frequently leads to insanity or
to a fatal cachexia. The striking characteristics of
the malady are its chronicity and protean type, the
seasonal appearance of its striking skin eruption with
acute symptoms, and the “ pellagrous triad,” derma-
titis, diarrhea, dementia. The essential morbid
process involves the central nervous system, and this
conception of the disease is fundamental.
The disease is a slowly progressive one, and may
be divided into prodromal, first, second and third
stages. The prodromal stage is indefinitely marked
both in length of time and symptomatology ; the
first stage has reference to the gastrointestinal and
skin symptoms; the second stage concerns the cere-
brospinal and psychic phenomena; and the third
stage is the terminal one of cachexia. There is no
8 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
sharp line of demarcation between the stages; noth-
ing is implied as to the length of time the disease
may have existed; and the stages represent rather
differences in degree than in kind. Pellagra runs its
course in a series of periodic attacks-—alternating
ameliorations and exacerbations. The exacerbations
occur, as a rule, in the springtime, sometimes in the
fall or even at other seasons, and subside after a time,
only to recur again the next year. Following the
somewhat indefinite prodromal period, there arise
next gastrointestinal and nervous disorders, usually
accompanied in a short while by the striking ery-
thema. The brunt of the successive attacks is borne
by the nervous system, and each annual recurrence
leaves a deeper and more ineradicable impression
upon the nervous and mental condition of the
sufferer.
The skin eruption when present is pathognomonic.
This striking symptom is so much in evidence that it
has given the disease its name: and its peculiar
characteristics are of such weight in diagnosis, that
they must be considered somewhat in detail.
(1) The pellagrous eruption is an erythema in the
dermatologic sense of that word.
(2) The erythema, as a rule, appears suddenly, and
its genesis is not necessarily connected with solar or
atmospheric influences. Often its origin can be traced
to solar influences, applications of various irritating
substances or even pressure, as, for example, on
elbows and knees, which should always be examined.
(3) The edge of the erythema ends in a typically
marked red border, delimiting it sharply from the
healthy skin beyond.
(4) In its evolution it rather develops a broad zone
of scaling which is quite characteristic of the process.
As a rule it does not reach its height for several
days, and requires even a longer time in its retro-
gression, which ultimately occurs by first loss of the
rosy border, then gradual fading of the centre, while
the scaling and crusting zone remains still longer the
seat of the receding process. Exfoliation may take
place with the shedding of the large areas of
epidermis.
Some cases show bullous formation with early loss
of epidermis, and consequent raw, bleeding surfaces
which readily become infected. At times during the
receding process ulcers and painful cracks and fissures
may develop, and even gangrenous processes may be
rarely seen.
(5) One of the most striking characteristics of the
eruption is its symmetry and distribution. It is
nearly always markedly symmetrical and shows certain
places of predilection. These are the backs of the
hands and of the feet, the face, and the neck—those
places most exposed to atmospheric influences. Many
descriptive appellations have been given to the various
localizations of the erythema, such as “ glove,”
" gauntlet,” “ boot,” " neckband," “ cravat,” " mask."
In addition to these favourite spots the eruption
may exist elsewhere and may even be generalized.
(6) The erythema on its first appearance is usually
a fairly bright red, almost like a sunburn, and the part
is alittle puffy. Ina short time this colour often takes
[Jan. 1, 1913.
on a bluish or " plum” tint. Then, in the course of
further changes, the whole passes to a reddish brown,
or sepia, or bronze tint, which is very characteristic.
(7) Itching is usually absent and never marked.
The part burns and has a tense, uncomfortable feeling,
but does not show seratch marks.
(8) The seasonal appearance of the eruption is im-
portant. As & rule, it appears but once annually,
at springtime or in the fall. It may occur at both
seasons in the same individual, but this is unusual.
It may also occur rarely in the winter months.
(9) With early attacks the skin, after the disappear-
ance of the eruption, resumes its normal appearance,
but recurrences lead finally to trophic changes.
(10) Notwithstanding the importance of the skin
symptoms in diagnosis, the associated constitutional
manifestations should be sought for and given due
weight. Cases may occur with only the skin eruption,
and in some localities such cases, especially in
children, are not rare.
Pellagra is reported without any skin lesions, so-
called pellegra sine pellegra. t is a matter of much
doubt whether a pellagra ever occurs without skin
symptoms at some period of its evolution. It is no
rare thing, however, to meet cases presenting the
clinical features of the disease without skin mani-
festations. The diagnosis under such circumstances
is by no means certain.
Pellagra in its chronie course often displays certain
very acute and rapidly very fatal explosions—not
always easy of diagnosis if the patient has not been
seen before the onset of the acute condition. Most
typical of these fulminant attacks is the condition
called by the unfortunate name of typhoid pellagra.
There occur other allied acute conditions. "These may
prove extremely puzzling unless one have pellagra in
mind and make careful inquiry into the history
of the case and scrutinize the skin for evidence
of a past erythema.
The psychic manifestations of pellagra are very
common and very important. Neurasthenic phenom-
ena often usher in the disease, and the diagnosis
remains in doubt until the later appearance of the
erythem. Other psychic states must not be neglected.
Tar ErroLoGY oF BLACKWATER FEVER.*
By Sır WILLIAM LErsHwaN, F.R.S,
(Continued from p. 380, December 16, 1912.)
II.
The author had already given an account of the
cell-inclusions encountered in the blood from cases of
blackwater fever, in two notes in the Journal of the
Royal Army Medical Corps, accompanied by illustra-
tions. In those notes he dealt with the results of
his examination of films of blood from three cases ;
since then he had had the opportunity of examining
films from eight other cases, making a total of eleven.
The cases from which these blood films were taken
occurred in the following places: Uganda (Kampala
* A paper read at the Society of Tropical Medicine and
Hygiene, October, 1912.
Jan. 1, 1913.]
and Entebbe), Sierra Leone, Gold Coast (Quittah),
South Africa (Rand), Lagos, and Southern Nigeria.
In two instances, films taken on successive days
after the onset of the disease were available for study,
but in no case was there a sample of the blood before
the onset of hemoglobinuria. The majority of the
films were accompanied by a note of the clinical
symptoms, treatment, &c., but in some this was not
available. In the majority, the clinical account gave
a clear and characteristic picture of a typical attack.
The only other point needing mention is that in
those instances in which malarial parasites had been
searched for none had been found. In connection with
this last point, it may be added that in all but two of
these cases the author confirmed this absence of
parasites; in one he found a pigmented leucocyte,
and in the other a few rings, after several hours’
search, a time which naturally the busy colonial
surgeon can rarely afford.
The general aspect of these films showed no great
uniformity. In most there was a leucoeytosis,
usually polynuclear in character, and there were
almost always present, sometimes in very large
numbers, a peculiar type of very large mononuclear
cell with coarsely reticular protoplasm, which he
believed to have been of endothelial origin. There
were other curious cells, which may or may not have
some significance.
The small number of cases and the want of
uniformity in the time of taking the films render
futile any attempts to draw conclusions as to the
usual blood picture during the attack. This, how-
ever, is of little moment, since so many valuable
records already exist in connection with this subject.
The author notes the frequency with which he
encountered neutrophil myelocytes, normoblasts and
megaloblasts and Tiirk’s cells as pointing to the
involvement of the marrow, but whether this points
to a primary affection of this tissue, or is only an
indication of the rapidity with which compensatory
mechanism comes into action, he is unable to say.
As to the inclusions, these were encountered
principally in the large mononuclear cells which he
takes to be endothelial in origin, and to have been
disrupted from the walls of the smaller blood-vessels
or lymphatics; in some instances they were also
seen in cells of a smaller type which it was not
easy to differentiate from ordinary hyaline leucocytes
except that the nucleus of such cells was almost
always in close contact with one portion of the
cytoplasmic periphery, a rare occurrence in ordinary
hyalines. They were not found in polynuclears,
eosinophiles, or lymphocytes. The cytoplasm of the
cells which harboured inclusions was faintly baso-
phile, and appeared somewhat coarsely reticular,
much more so, at all events, than the clear hyaline
cytoplasm of the large mononuclear leucocytes.
Granules, as a rule, were not seen, but, in some
instances, very fine granules, taking a reddish tint
with the Romanowsky stain, were noted, seldom
evenly distributed, but more often collected in
irregular clumps or patches.
The inclusions themselves exhibit a considerable
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 9
variation in shape, size and staining reaction, and
their appearance may be gathered from the plate
illustrating the author's first note. They do not
resemble in any respect the azur granules of mono-
nuclear leucocytes. They are small bodies, almost
invariably circular in outline, and ranging from 1 to
5 microns in diameter, the great majority, however,
measuring from 2 to 3 microns. They present them-
selves usually in one of two forms—a structureless,
homogeneous form and a ring form; the former,
which is the commoner, usually assumes a faint
chromatin colour or a greyish tinge with the Roma-
nowsky stain, and, more rarely, a deep chromatin tint.
The ring forms, which are rarer, are almost always
coloured a deep pink, similar to the chromatin of
protozoa. In all cases the inclusions were embedded
in the cytoplasm of the cell and not adhering to its
periphery. At times the inclusions were seen to be
lying in vacuoles, but more often this was not the
case. The exceptionally large inclusions figured in
connection with the author's first case have not
subsequently been encountered.
As regards their frequency in a given case they
are never abundant, several hours’ search over a film
frequently revealing only two or three. In the cases
in which they were most numerous they were found
in about one endothelial (?) cell in twenty. Cells
containing several inclusions were more frequently
seen than those with a solitary one.
Of the twelve cases of blackwater fever of which
blood films had been received, these inclusions were
found in eight. In three cases they were not found,
although in two of these cases the cells of endothelial
type were present in abundance. In the third nega-
tive case no endothelial cells were found, and the
clinical details, which were scanty, suggested a con-
siderable doubt as to the correctness of the diagnosis.
Only in two cases could the inclusions be said to be
fairly common.
Curiously enough, the most numerous inclusions
which were found in the blood were in films from a
case occurring in Uganda which were sent to me,
not as blackwater fever, but under the suspicion
that it had been one of kala-azar. The author
found, however, no parasites of this nature, either
in the blood or in smears made from the spleen
and liver after death. The case was moribund
on admission and died shortly after this, and from
the brief account of the symptoms and of what was
found at the autopsy, there appeared nothing incon-
sistent with the suspicion that this, too, was a case
of blackwater fever. If this were the case—a point
impossible to settle now—it would have been of
interest from the presence of the inclusions calling
attention to its true nature.
In considering the nature of these inclusions the
author is convinced from his study of them upon two
points, that they are not artefacts and they have no
connection with malarial parasites. Again, he had
seen none which suggested to him the possibility of
their being portions of nuclear material; nuclear
extrusions or buds are by no means uncommon in
connection with polynuclear and, less frequently, with
10 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 1, 1913.
mononuclear nuclei, but these are usually in close
connection with the nucleus, and generally united to
it by a thread of chromatin.
The possibility of their being fragments of altered
erythrocytes, previously phagocyted by the cells
which show the inclusions, is one on which the
author was not able to speak with such confidence.
The cells in question undoubtedly exhibit the power
of erythro-phagocytosis, of which he had observed
examples in three of these eleven cases. He had
even, in two or three instances, noted both inclusions
and a red corpuscle in the same cell. In spite of
this he did not think that this is their explanation,
since he had often observed the changes which phago-
eyted red cells undergo-—for instance, in the extensive
phagocytosis of alien red cells, which can be studied
in vitro by the opsonic technique, and he had never
seen the remains of red cell assume either the shape
or the staining reaction of the majority of these
inclusions. It is quite possible that the inclusions
in question are not all of the same nature, indeed
this is rendered almost a probability by the very con-
siderable differences in shape, size, and staining
reaction which they exhibit.
Whether similar inclusions are to be encountered
in the blood of other diseases, as has been suggested
by Low, is a point for the future to determine; the
author could only say at present, with a fairly large
experience, that they are new to him.
Another peculiar cell which he had encountered in
seven out of the eleven cases of blackwater fever, and
which, personally, he had never seen before, were
described in the author’s second Note as “ chrome
cells,” from the extraordinary deep tint of chromatin
colour which they assumed on Romanowsky staining ;
not only was the nucleus exceptionally darkly
coloured, but the whole of the cytoplasm took on a
lighter tint of the same red colour. Their nuclei
were sometimes of polynuclear, sometimes of mononu-
clear, type, and in size they corresponded to the
ordinary polynuclear leucocyte. In most instances
the chromatin tint of the cytoplasm was deepest
round the periphery of the cell, and not infrequently
can be noted an apparent diffusion of the red tint
into the film surrounding the cell, although this was
exhibited by no other type of cell in the particular
film. In some cases the partial rupture of the cell
allowed it to be seen that the cytoplasm had been
filled with deep-staining chromatin granules, often in
ring-form, and much larger than any of the usual
types of granules encountered in leucocytes or
marrow cells. The author was at first inclined to
regard these cells as being in some manner connected
with the inclusions, but since the publication of that
note, he had received a communication from Dr. D.
Thomson, of the Liverpool Tropical School, in which
he had been informed that Dr. Thomson had observed
similar cells in several different conditions, such as
in Hodgkin's disease, in myelogenous leukmmia,
sarcoma of the ileum, blood from leprosy nodules,
and one or two others. Dr. Thomson had sent the
author some of his films, and given permission to
mention his as yet unpublished experience in this paper
for which the author acknowledged his great indebted-
ness. Dr. Thomson had been much struck by their
appearance, as he had never encountered them before
nor seen them figured or described, and he had been
inclined to suspect that the granules were parasitic,
but he is now inclined to regard them as some form
of altered mast cell. However that may be, Sir
William Leishman was at least able to convince him-
self that some of the cells in Dr. Thomson's films
were apparently identical with those that he (Sir
William) had described as “ chrome cells," and it is
thus clear that they have no specific relationship to
blackwater fever. However, such authorities as Sir
Ronald Ross and Professor Adami had never seen
them.
Returning to the inelusions and their possible
nature, it was not unnatural that one should suspect
that, like other inclusions, these might be an indica-
tion of the invasion of the cells by parasites of the
class to. which Prowazek has given the name
Chlamydozoa. This view, with all reserve, he had
suggested in his earlier notes, and it was with this
hypothesis that he oecupied the remainder of his
paper. The author wished, however, to make it quite
clear that he put this hypothesis forward more by
way of a suggestion than from any confident feeling
that it is likely to meet with greater success than has
been the lot of its innumerable predecessors. The
mere finding of certain cell inclusions in a few blood
films may seem a slight foundation on which to raise
a somewhat ambitious structure. At the same time
he held that an occasional excursion of this sort may
at times be permitted to the research worker, whose
daily lotis toil and disappointment. If he should find
among his audience some who, like himself, were not
altogether satisfied with the current explanations of
the etiology of blackwater fever, he could perhaps
claim from them a certain amount of sympathy, if
not of agreement.
The chlamydozoa, of which our knowledge is still
in its infancy, are a class of minute, ultra-microscopic
organisms, capable of passing through the pores of
very finely grained filter candles, and frequently asso-
ciated with the presence of what are rather vaguely
termed cell-binelusions. The best known diseases
supposed to be caused by these organisms are variola
and vaccinia, trachoma, molluscum contagiosum and
bird-epithelioma. In addition to the above, however,
it seems far from unlikely that rabies, scarlet fever,
measles, chicken-pox, and perhaps yellow fever, may
eventually be shown to be due to organisms of this
class. The cell-inclusions associated with molluscum
contagiosum are the oldest known—the so-called
molluscum bodies—but the Guarnieri’s bodies of
small-pox and the Negri bodies of rabies are more
widely known. At first taken for the actual parti-
culate causes of the diseases with which they are
associated, it soon came to be recognized that this
position was not tenable, for one thing their com-
paratively large size was inconsistent with the proven
filter-passing capacity of the viruses of these diseases,
but at the same time they have, in some instances at
least, come to be recognized as in a sense specific to
Jan. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE 11
the disease with which they are associated. As a
matter of fact both the Negri bodies and Guarnieri’s
bodies are now held to be of considerable diagnostic
value.
More recently certain extremely minute granules
have been detected in the affected cells in trachoma,
variola and molluseum contagiosum, and also in con-
tagious epithelioma of birds, in rabies, in varicella
and in both human and experimental scarlatina.
Many of these observations are as yet lacking in
detail and the very needful confirmation, but there
appears little doubt that in some, if not all these
diseases there occur, associated with the presence of
the virus, extraordinarily minute granules, approach-
ing the limits of microscopic visibility, and only
demonstrable by special staining methods or by dark-
ground illumination. In some of the diseases in
question the proof that these minute granules are in
reality the particulate cause of the disease appears
to be very strong. As to the association between
these granules and the cell-inclusions, demonstrated
in the various diseases, the views of Prowazek and
others may be outlined as follows :—
A small granule enters a cell, for example a con-
junctival cell in trachoma, a nerve cell in rabies, or
an epidermal cell in small-pox, and causes a reaction
in that particular cell which is evidenced by the sur-
rounding of the invading granule by a mantle or cloak
(hence the name, which is derived from xAauis, a
cloak) of some secretion which eventually becomes
sufficiently abundant to be stained and recognized as
a Guarnieri's body, a Negri body, a molluscum body,
and so forth. To the buried granule, which may or
may not be visible, is given the name “ initial body.”
The initial body then commences to divide, and there
are formed from it great numbers of extremely minute
granules, which may eventually escape from the in-
clusion and fill the cytoplasm of the cell. These
products of division of the initial body are called the
" elementary bodies," and it is held that it is in this
form that cell to cell infection is brought about, and
that the virus is carried from host to host. To their
minuteness are also attributed the filter-passing pro-
perties which, in a number of these diseases, have
been clearly shown to be a feature of the virus.
In no instance can it yet be said that all is known
about the etiology of the diseases mentioned, but
evidence is accumulating which goes to show that
the chlamydozoa will eventually prove to be the
cause of & number of diseases distinguished both for
their variety and their severity.
The author suggests then, that some, if not all, of
these cell-inelusions which he had described, may be of
the nature of the inclusions surrounding the `“ initial
bodies " of chlamydozoa.
There must now be considered what may be said
in support of this hypothesis, and in how far it may
be held as not inconsistent with the established facis
relating to blackwater fever.
At the outset one finds the prineipal objection to
the idea of a specific virus, namely, that no such
virus has been seen, no longer applies, since the
chlamydozoal hypothesis assumes the existenee of an
ultra-microscopical virus. Incidentally, it may be
remarked that the hypothesis is not necessarily
invalidated should it be proved that the inclusions to
which attention has been drawn are capable of some
other interpretation.
The clinical dissimilarity between blackwater fever
and the diseases associated with chlamydozoa is
freely admitted, but, on the other hand, the lack of
resemblance is scarcely greater than we find among
those diseases themselves.
The majority of the chlamydozoal affections are
extremely infectious and tend to spread in epidemic
form. The author had suggested elsewhere that this
apparent discrepancy may be explicable if it is
assumed that the ultra-microscopical virus of black-
water fever is limited to tissues and cells in the
deeper parts of the body, in contrast to the known
superficial site of the virus—for instance, in the skin
lesions and affected mucous membrane of variola,
molluscum contagiosum and trachoma.
Further comparisons of this sort, however, would
not help much, since definite knowledge of the nature
and mode of action of the chlamydozoa is still
lacking, and, until this is available, it will be obvious
that attempts to compare the known factors in con-
nection with blackwater fever with the uncertain
factors of these little-known micro-organisms would
lack point and precision. He proposed then to limit
this comparison to an examination of the conclusions
reached in the first portion of his paper in the light
of the chlamydozoal hypothesis, dealing with them in
the order in which he placed them there.
(1) The general agreement that blackwater fever is
only encountered in those who have either suffered
from malaria, or who have lived for some time in a
country in which they must constantly have been
exposed to malarial infection. This appears to me
to be the best established fact in connection with the
disease, and unless a reasonable explanation is forth-
coming, co-ordinating this fact with any new hypo-
thesis, the latter must be regarded an untenable.
He would suggest that this association with malaria
is comprehensible if it is assumed that the chlamy-
dozoal virus is one which is transmitted either by the
same insect which transmits the malarial parasite,
or by a different insect whose habits and bionomics
correspond closely to those of mosquitoes and whose
geographical distribution is similar. No novelty was
claimed for this suggestion, which must have occurred
to many, but its possibility was enhanced in the light
of the chlamydozoal hypothesis. It is known already
that mosquitoes transmit at least four diseases,
malaria, yellow fever, filariasis and dengue, so it was
not asking much to assume them capable of trans-
mitting a fifth. If we assumed further that the virus
of blackwater fever is a rare parasite of mosquitoes
in comparison with malaria, or that it is possibly
limited more strictly than the latter to one or two
species of mosquitoes, it is not difficult to account for
many of the puzzling anomalies in connection with
the malarial hypothesis—for instance, the facts that
there is no direct relationship between the number of
the malarial parasites in the blood and the severity
—€——————' € — —] ae
12 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 1, 1913.
of the paroxysm of hemoglobinuric fever, and that
quinine has no effect in aborting or curing the
attack.
He was also inclined to regard as significant the
fact that two out of the four mosquito-transmitted
diseases are shown to be due to filter-passing viruses,
namely, yellow fever and dengue, while the virus of
phlebotomus or three-day fever, transmitted by
Phlebotomus papatassii, is another instance of the
same nature.
(2) The second conclusion, referring to the im-
munity of natives in endemic areas, and the greater
susceptibility of whites and of alien natives introduced
into endemic areas, was not inconsistent with the
new hypothesis on the assumption that immunity fol-
lowed the same lines in the two diseases. If the virus
of blackwater is much more rare than that of malaria,
as suggested above, one had here an easy explanation
of the fact that, as a rule, new comers are not attacked,
and that prolonged residence is a feature in the
incidence of the disease.
(3) The conclusion that immunity to malaria
appears to go hand in hand with blackwater fever
and that the measures which protect against the one
are also effective against the other, supports the idea
that the virus of the latter is also transmitted by a
biting insect, similar in its habits to the mosquito.
(4) The fourth conclusion that there are apparent
discrepancies in the geographical distribution of the
two diseases, but that blackwater fever only occurs
in intensely malarious countries is also explicable on
the above assumption of a specific virus transmitted
by some insect with a life habit resembling the mos-
quito, but either less numerous or more restricted in
its geographical distribution. The rarity or absence
of blackwater fever in certain districts heavily in-
fected with malaria would thus find an explanation
either in the absence of the particular transmitting
species or in the fact that the carrier in that district
was not at the time infected with the virus.
(5) The conclusion that some exciting or secondary
cause is needed would appear to await further under-
standing and explanation, as is also the case with
the sixth conclusion, relating to the mechanism of
the production of hemolysis. These two are evi-
dently closely connected and it is probable that a
common explanation underlies both. It is thought
clear that, even if the chlamydozoal hypothesis be
correct, it would still be found that secondary or
exciting causes played a part in the production of the
sudden and extensive hemolysis. For example, there
were cases on record in which a first attack of black-
water fever had occurred some weeks after the indi-
vidual had left the endemic area and returned to a
temperate country. Such cases would suggest, on this
hypothesis, either that the virus had an exceptionally
long period of latency, which appeared improbable, or
that infection with the virus was not necessarily
accompanied by the symptom of hemoglobinuria.
It appeared from the above consideration of the
agreed facts relating to blackwater fever, in the light
of the chlamydozoal hypothesis, that there were none
which were definitely antagonistic to its possible
correctness while there were some which rendered
our comprehension of those facts distinctly more
easy. He had no wish to build too heavy a super-
structure upon a foundation which he admitted was
very far from stable, and he had put it before the
Fellows as a suggestion and that he might have the
benefit of criticism.
In conclusion, the author ventured to suggest that
there was yet another way in which the connection
between malaria and blackwater fever might con-
ceivably be brought about. There was no reason
why we should deny the possibility of the malarial
parasite itself being subject to disease. The further
we progressed in microscopical research the more
inconceivably minute structures came to our know-
ledge, either by direct observation or by inference,
and to his mind it was a bolder thing to assert that
we had reached the limits of particulate life than to
admit the possibility that there yet remained forms
of life smaller even than the Chlamydozon granule.
—— MÀ
Tropical Diseases Bulletin.
Part No. 8 of Volume I (December 15, 1912), deals with
malaria, sleeping sickness, yaws, protozoology, and beri-
beri. Many of the abstracted papers are of great interest,
and having them presented in such readable form, should
prove a boon to all workers in Tropical medicine, and
especially to those far removed from libraries. The
Bulletin will soon prove itself to be the most useful of
all the varied and numerous journals dealing with this
interesting branch of medicine.
* Indian Medical Gazette," November, 1912.
Multiple Hydatid Infection of the Abdominal Viscera.—
Major Steen, I.M.S., referring to the case of multiple
hydatid infection reported in the Indian Medical Gazette,
August, 1912, says that it brought to bis mind a similar
case met with at Gyantse, Tibet, in May, 1905. The
patient was a Tibetan beggar boy, about 18—19 years of
age. Four years previously he had noticed a swelling in
the upper part of his abdomen, and this swelling had
gradually enlarged. He was a very emaciated creature,
almost moribund, with a huge distended abdomen, 39 in.
in girth. On examination the abdominal cavity appeared
to be packed full of tense cysts of various sizes. The
larger cysts projected considerably, and gave the abdomen
a very irregalar outline. Over one cyst, above and to
the right of the umbilicus, a distinct thrill was obtained.
Two prominent cysts were aspirated, and in the clear fluid
evacuated hooklets and scolises were obtained. The boy
died two days later.
At the autopsy about two pints of yellowish serum were
found free in the general peritoneal cavity. The intestines,
liver, spleen and numerous cysts were inextricably matted
together by adhesions. The liver was enormously
enlarged, and extended almost to the level of the
umbilicus. It contained an enormous number of cysts
varying in size from a child's head to a marble. Three or
four only contained daughter and grand-daughter cysts.
The spleen was also very much enlarged, and proved to
be simply a sac of cysts, large and small, of which only a
few contained daughter cysts. Among the matted coils of
intestine were numerous cysts of allsizes. One large tense
cyst almost filled the pelvis.
"There was a double hydrocele, but the fluid was not
examined. The kidneys and lungs were not involved. The
brain was not examined.
No effort was made to count the cysts, but there must
have been several hundreds present. This is the only case
of hydatids that Major Steen has met with in Tibet,
-- Hlotes- anb. Hetos. -
THE SECOND. ALL-INDIA SANITARY
-CONFERENCE AT. MADRAS.
(Continued from p. 384, December 16, 1912.)
» Parer on Town PLANNING.
Mr. E. G. TURNER, Special Officer, Salsette Build-
ing Sites, Bandra, read a paper on “Town Planning,"
in one of the rooms of the Government Maternity
Hospital, to which place the President and the
members of the Conference drove from the Council
Chamber after the conclusion of the President's
address.
Mr. Turner illustrated his paper by exhibiting dia-
grams with the aid of lantern slides thrown on canvas.
The following is a résumé of Mr. Turner's paper on
“Town Planning” :— l
The lines on which town-planning work is being
considered in Bombay is really a combination of the
English principle of “betterment ” and the German
principle of “ redistribution.”
Redistribution gives power to alter the shape of
plots so as to render them more suitable for building
plots. It is especially necessary in town planning in
a country where buildings are mostly small and
irregular in shape. The power to cut plots from
larger holdings and allow them to owners dispossessed
of their fields by the advent of roads and other public
sites, allows the capital cost of the scheme to be re-
duced by the value of the plot allotted. The owner
of the holding from which the allotted plot is carved
will have his contribution for betterment reduced by
the cash value of such allotted plot.
The power to redistribute will be held in reserve
and used as much or as little as is found expedient.
The wishes of holders should be followed as far as
consistent with the objects of the scheme. Examples
are given in the paper by diagrams of various alterna-
tive redistributions of plots.
Betterment enforces contributions from owners
towards the cost of a scheme in proportion to the
extent to which their land is bettered by the completed
scheme. It is reasonable that holders should con-
tribute some portion of their betterment towards
constructional and other expenses, but no more
should be taken than is necessary for actual ex-
penses. The proportion to be taken should be
limited as in England to one-half, and if any more
is required it must be provided from other sources,
general taxation, &c.
Credit and Debit.—By a method of credit and debit
the amount of capital necessary to be raised is mini-
mized. With each holder an account is opened, on
the credit side of which will be the decrease in the
value of his plot due to rearrangement, and on the
debit side the portion of his betterment which is levied
forexpenses. The balance on the debit side will be
levied from him, on the credit side paid to him..
Instead of paying holders in cash for land they give
up and afterwards levying a contribution from them,
Jan: 1; 1913,]..; THE JOURNAL, OF TROPICAL MEDICINE: AND. HYGIENE. : 13
=
the difference, of, these two items will be levied from
or paid- to them, the. amount of capital to be raised
being materially- diminished.
Betterment.—Method of calculating.
This may be done, as in England, after all the con-
structional works have been finished. Under a system
of redistribution of plots there are advantages in esti-
mating at the same time as the original and final plots
allotted are valued, i.e., before works are started. This
allows of a set off being made in each account, and
provides the local authority with an immediate security
on which to raise loans. With a system of prevalua-
tion power should. be given to the majority of owners
or to the local authority to demand a revised valuation
after a fixed period.
Procedure.—(a) The local authority will publish a
notification of intention to plan a certain area defined
by boundaries and showing existing and.proposed main
roads.
(b) Owners will be fully consulted as to any redis-
tribution that may be necessary and as to accommo-
dation roads.
(c) A block.plan and scheme will then be prepared
showing details and objections invited.
(d) After consideration and alterations, the local
authority will submit scheme and objections received
to the controlling authority.
(e) The controlling authority will appoint an inde-
pendent arbitrator, to be an expert valuer, who will
draw up the final scheme and plan as sanctioned.
(f) He will award compensation payable for extinc-
tion of rights or any property injuriously affected, and
will ealeulate the dues leviable from every holder in
accordance-with his valuations.
(g) The local authority will then notify the final
scheme and date from which it will take effect.
Transfer of Rights.—So far as possible, the rights of
lessees or mortgagees of original plots should be trans-
ferred in the same or à convenient modified form to new
plots, and compensation paid to anyone injuriously
affected. Agricultural lessees should not be trans-
ferred without consent of all parties. The arbi-
trator will decide questions of compensation for
transference of rights, and decide what rights shall
be transferred to the rearranged plots. On the day
the scheme takes effect the old rights will be extin-
guished and the new rights take effect.
AFTERNOON'S PROCEEDINGS.
The afternoon session opened at 2.30 p.m. The
chairman made & few remarks on the subject to be
discussed, and called upon the Honourable Mr. J. P.
Orr, C.S.L, I.C.8., to read his paper on “ Light and
Air in Bombay."
LIGAT AND AIR IN DWELLINGS.
The Honourable Mr. J. P. Orr, in the course of his
paper, referred to the conditions at Bombay, details of
which he gave. He thought it desirable that improve-
ments should come from the people themselves, and
spoke of the hopelessness of continuing methods of
wholesale acquisition and demolition. The Trust, he
said, had only touched 10 per cent. of the congested
14 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1913.
areas, in spite of all their exertions. The remedy lay,
he thought, in the provision of light and air by the
application of 634 degrees to every room in every house.
The importance of this in a place like Bombay, where
85 per cent. of the population lived in one-room tene-
ments, was enormous. The 634 degree standard meant
that there should beexternal airspace outside each room
open to the sky, extending to a distance measured
horizontally from the room wall of at least half the
height of the top of the opposite house above the floor
of the room. The angle so prescribed would strike the
floor at an angle of 63$degrees. Partial remedies applied
to isolated buildings were no advantage. The remedy
must be applied universally to old buildings when
rebuilt materially altered as well as to new buildings.
The first remedy was the direct prohibition of the
use of any room for human habitation inadequately
lighted and ventilated, and, secondly, the wiping out
by degrees of all rooms of that description.
The result of wholesale acquisition and demolition
was to drive out the population to other overcrowded
quarters and to force up rents. When houses were
rebuilt after such demolition the same class did not
come back, but a superior class. Better to pull down
parts of insanitary blocks—thus to render remainder
more sanitary.
The effect of the proposals put forward in the
lecture would be to dishouse 20 per cent. of the
population, but there were ample empty spaces avail-
able for housing them.
The main lessons to be deduced from past experi-
ence and investigation were as follows :—
(1) Partial improvement was of no good. Some of
those houses had been condemned as unfit for human
habitation and rebuilt in accordance with existing
municipal by-laws.
There was necessity for a standard to be fixed
which must rigidly be adhered to. No reduction in
the 634 degree rate should be allowed at any rate in
new houses, though a period of grace, say five years,
might be allowed in old houses.
(2) Building operations must be controlled every-
where so that matters did not become worse.
(3) They must deal with rooms as a unit not with
houses or blocks of houses.
(4) An absolute veto was necessary on the occupa-
tion of rooms which did not comply with the standard
decided upon. Aftera period of say five years all such
rooms should be closed.
(5) There must be removal of obstructive dwellings
and consequent admission of light and air to surround-
ings. In that way the evils of overerowding would
also be reduced.
(6) Window area must bear some proportion, say
1 to 7, to the floor area. Otherwise it would lead to
the evil of long deep rooms lighted by one window at
the end.
In England the provisions for removing obstructive
houses and demolishing houses unfit for human habi-
tation, contained in the Housing of the Working
Classes Act and Town Planning Act of 1909, had been
widely applied at an extraordinarily cheap rate in
Birmingham and other towns. The difficulty in India
was that they were asking owners to go at once from
a very low to a reasonably high standard ; in England
the previous standard was not so low.
In England there had: nevertheless been violent
opposition at first to the Act of 1909, but this was
followed by a ready acquiescenee. "There was a good
deal of public spirit in England where the citizens and
the house owners realized what their duty to the nation
and children was. The work in big cities was being
done by publie-spirited citizens, who qualified thein-
selves for the work in every possible manner.
(To be continued.)
THE SOCIETY OF TROPICAL MEDICINE
AND HYGIENE.
AT a meeting of the Society of Tropical Medicine
and Hygiene, held at 11, Chandos’ Street,
Cavendish Square, W., on Friday, December 20,
iS the following gentlemen were elected Fel.
ows :—
Lieut.-Colonel Cecil Birt, M.R.C.S., R.A.M.C.,
War Office; Sir John Rose Bradford, K.C.M.G.,
M.D., London; Pedro G. Jgaravidez, M.D., Porto
Rico; E. Hill Mayhew, M.B., St. Albans; Reginald
A. Murphy, L.R.C.S.L, Assam; A. F. Wallace,
M.B., Northern Rhodesia; Angus Wylie, M.B.,
Demerara.
Tue Report of Livingstone College for the year
1911-12 opens with a reference to the Centenary of
the birth of David Livingstone, which will be
celebrated on March 19, 1918, and points out that
Livingstone College forms a memorial to the great.
missionary and explorer, whieh has been recog-
nized by those best qualified to express an opinion,
as worthy of the great man whose name the.
College bears. It is proposed in connection with
the Centenary to raise a special fund in connection
with Livingstone College, and an appeal is made
for £10,000: £3,500 to be applied for clearing off
the mortgage, £1,500 for various improvements,
and £5,000 for the nucleus of an endowment. It is
believed that many who desire to do honour to the
name of Livingstone will be glad to co-operate
in support of an institution which is open to mis-
sionaries of all denominations and all nation-
alities. 441 men have already passed through the
College since the foundation of the College nine-
teen years ago.
The past two years have been specially difficult
years attributed to the diminution in the number
of missionaries going forth to the mission field, and
this has led to an accumulated deficiency on the
ordinary funds of the College of £700 at the end
of the financial year.
A statement is given which was made by Sir
Havelock Charles on Commemoration Day, 1912,
at Livingstone College, in which he said that he
questioned whether it was morally right for
Jan. 1, 1918.)
societies. to send out their men unprepared, when
they could obtain knowledge which might preserve
valuable lives.
The Report closes with an appeal for support
for the College, and the statement that “‘in
these enlightened days, with increased knowledge
of Tropical diseases, it is a serious matter to send
out any workers neither forearmed nor forewarned,
and if this view prevailed there would be no diffi-
culty in maintaining the College.”
LONDON SCHOOL OF TROPICAL MEDICINE.
EXAMINATION RESULT (FomTiETH SESSION, OCTOBER
TO DECEMBER, 1912).
Daukes, S. H., M.B., B.C., M.R.C.S., L.R.C.P.,
D.P.H.
Moore, A., M.D.Dub., D.P.H.
Beattie, J. A., M.D.Aber. (Colonial Service).
Condon, Major de V., I.M.8., M.D.Dub.
Footner, G. R., F.R.C.S., M.B.
Ismail, A., M.R.C.S., L.R.C.P.
Mayhew, E. H., M.B., B.C.Camb., M.R.C.S.,
L.R.C.P. (Colonial Service).
Browse, Major G., I.M.S., M.B., B.C.Camb.,
M.R.C.S., L.R.C.P.
Johnston, G. L., M.R.C.S., L.R.C.P.
Pawan, J. L., M.B., Ch.B.Edin. (Colonial Service).
Winter, W. C. P., M.R.C.S., L.R.C.P. (Colonial
Service).
Sinha, A. K., M.B. (Calcutta).
Turton, R. S., M.R.C.S., L.R.C.P., D.P.H.Camb.
(Colonial Service).
Marshall, C. H., M.R.C.S., L.R.C.P. (Colonial
Service).
Dodson, G. B., M.R.C.8., L.R.C.P.
Bana, F. D., M.B., B.S. (Bombay).
Whitehead, F. E., M.R.C.S., L.R.C.P. (Colonial
Service).
Swertz, H. C., M.B.,
(Colonial Service).
Rice, F., M.R.C.S., L.R.C.P. (Colonial Service).
Wallace, A. F., M.B., Ch.B.Aber.
Spurrell, H. G. F., M.B.Oxford.
Lamborn, W. A., M.R.C.S., L.R.C.P.
Dalrymple, J., L.R.C.P. and S.Edin.
Dunn, P. J., M.B., B.Ch., B.A.O.
Condy, E. M., M.B., R.U.L.,
(Colonial Service).
da Gama, A., L.M.S. (Bombay).
Rose, F. G., M.R.C.S., L.R.C.P., M.B., B.C.Camb.
Benson, J. M., M.B., Ch.B.Edin. (Colonial
Service).
Hayes, H. W..McCauley, M.R.C.P.Edin., D.P.H.
Hoare, J. F., M.R.C.S., L.R.C.P. (Colonial
Service).
Mason, C. W., M.D. (Nebraska).
Chakraborty, R. C., V.S.M., S.L.M. (India).
Murphy, R. A., L.R.C.S. and P. (Ireland).
McIntyre, E. T., L.R.C.P. and S.Edin. (Colonial
Service).
Roberts, W. E., M.R.C.S., L.R.C.P. (Colonial
Service).
B.Ch., B.A.O.R.U.I.
D.P.H.Dub.
D.P.H.
THE JOURNAL OF. TROPICAL MEDICINE AND HYGIENE. 15
EUG
A MANUAL OF INFECTIOUS DISEASES OCCURRING IN
ScuooLs. By H. G. Armstrong, M.R.C.S.,
L.S.A., and J. M, Fortescue-Brickdale, M.A.,
M.D.; with chapters on “‘ Infectious Eye
Diseases," by R. W. Doyne, M.A., F.R.C.S.;
and ''Ringworm," by H. Aldersmith, M.B.,
F.R.C.S. Bristol: John Wright and Sons,
Ltd. London: Simpkin, Marshall, Hamilton,
. Kent and Co., Ltd. 1912.
This little manual has been written for and is
being issued by the Association of Preparatory
Schools.. As the authors state in their preface, the
assemblage of large numbers of young persons under
one roof leads to the introduction and ready spread
of the infectious diseases to which they are specially
liable, and such being the case the Association
has felt that a manual setting forth the charac-
teristies of each disease will be of assistance to the
masters and mistresses of schools in dealing with
them. Intended primarily for their use, the effort
of the authors has been to give a clinical picture, as
complete as pessible, of the features of the various
diseases; questions of pathology have only been
lightly touched on and treatment has been dealt
with only in a general way, the special treatment.
of each individual ease being the province of the
medical man in charge. -Though written primarily
for laymen, it is hoped, however, that the manual
may also assist doctors in their school practices.
It has been found diffieult to avoid. altogether
the use of medical and scientific terms, but these
have, as far as possible, been placed in footnotes.
A glossary has been appended of those employed
in the text. More photographs -and illustrations:
might with advantage have been incorporated in:
the text. Their teaching value is very great,
especially when dealing with the laity. The book
supplies a distinct want, and its contents should
prove of use both to the laity and medical men-
generally.
—————
Correspondence.
——
To the Editors of the JOURNAL or TROPICAL MEDICINE AND HYGIENE.
Sins,—In the JOURNAL OF TROPICAL MEDICINE
AND HYGIENE of November 15, Dr. Richard Arthur
asks: “ Can Anglo-Saxons colonize the Tropics?”
Among the first tropical parts to be colonized were
the West Indies; and a careful study of these islands,
and the condition of the inhabitants, supplies almost
a complete answer to this question.
The island most worthy of study in this respect is
Barbados. It is situated lat. 13° 4' North, long.
59° 37' West; it has an equable temperature, and a
rainfall, on an average, of 57 in. The humidity
of the atmosphere is lower than in the neighbouring
16 THB JOURNAL OF, TROPICAL. MEDICINE AND HYGIENE. [Jan. 1, 1913.
islands and this is of some importance. The island
is of coral formation and very: flat, and more than
nine-tenths of it is under cultivation. There has
generally been a keen struggle for existence among
the inhabitants.
Barbados was colonized in 1625, and on the final
defeat of Charles I and the advent of the Common-
wealth a large number of members of noble English
families were deported to or left for Barbados.
Many of the direct descendants of these families are
still flourishing in Barbados; for the most part they
have kept themselves free from intermixture, with the
possible exception of occasional fresh blood from
England.
These families for more than two centuries have
worked in the Tropics, and now in most British Crown
Colonies there can be found white Barbadians holding
high positions and leading keen active lives. It is
true many of them have been sent to England for
their education; but there are in the island many
well-grown, upstanding men and women, of pure
though distant European extraction, who have never
seen temperate countries nor have their ancestors for
generations. They are mentally and physically as
well equipped as Europeans. These people are for
the most part managers and overseers on estates ;
further, they are perfectly capable of considerable
manual labour.
There are also a number of pure white people who
must be considered to belong to the labouring classes,
and were it not that they are harassed by such diseases
as ankylostomiasis, would be almost capable of com-
peting with coloured labourers.
If we turn to the other islands we shall find a
number of white families of ancient tropical pedigree,
who can still hold their heads high in the world, but
the vast majority of these whites are degenerates.
These islands differ from Barbados in two points;
in them malaria and intestinal parasites are rife,
and there is very little struggle for existence in their
luxurious climate; whereas in Barbados malaria is
absent, intestinal parasites are fewer, and the struggle
for existence is very keen, with the result that there
is far less worshipping of Bacchus and Venus, and
although alcoholism and venereal disease are far too
common, they are much Iess rife than in most of the
other islands.
Having considered:the conditions of the inhabitants
of the Tropics from the labourers upwards, I have
come to the opinion that these parts of the world can
support a race of people of white European extraction,
who could successfully compete with the original
stock, provided the first colonization is intelligently
carried out by those who have a thorough scientific
knowledge of the Tropics.
The hours of work must be properly regulated,
proper amusements must be supplied, and sexual
excesses are to be avoided. There must be complete
sanitation; for malaria, intestinal parasites, venereal
diseases and alcohol are practically the sole cause of
failure, death and degeneracy. Without authority
and knowledge there is no place in the Tropics for an
Anglo-Saxon race.
The unique and happy condition ‘of Barbados
shows us that a good race of Anglo-Saxons can live in
the Tropics, and there need be no degeneracy how-
ever far back in time may be their original ancestors.
The study of the Anglo-Saxon in the Tropics is a
large one, but there is probably enough data for its
practical application.
Yours truly,
LUCIUS NICHOLLS.
Fulbourn, near Cambridge,
December 7, 1912.
——À:À S
Personal Motes.
INDIA OFFICE.
From October 26 to November 23.
Captain C. A. F. Hingston, I.M.S,
ExTENSIONS OF LEAVE.
Lieutenant-Colonel J. B. Jameson, LM.S., 6 m. M.C.;
Lieutenant-Colonel T. E. Dyson, I.M.S., 1 m. ; Major H. J. K.
Bamfield, I.M.S., 5 m.; Captain W. H. Riddell, I.M.S., 6 m.
M.C.; Lieutenant-Colonel P. Strickland, I.M.S., 10 days;
Lieutenant-Colonel J. B. Smith, I.M.S., 5 days; Major E. C.
Macleod, I.M.S., 2 days; Captain G. I. Davys, I.M.S., 1 m
1 day.
List or ĪNDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Crump, Captain S. T., I.M.S., 6 m., August 16, 1912.
Dick, Major M., I.M.S., Burma, 18 m. 8d , August 5, 1912.
Hingston, Captain C. A. F., I. M.S., M., 6 m. 16 d., October
23, 1912.
Lethbridge, Major W., I. M.S., Rajpootana.
Nutt, Captain H. R., I.M.S., U.P., 12 m., September 19,
1912.
Weinman, Major C. F., I.M.S., B., 13 m. 14 d., October 3,
1912.
List or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Corkery, Colonel W. A., I.M.S., P.M.O., 8rd Lahore Div.
Fraser, Captain F. C., I.M.S., to November 24, 1912.
Graves, Lieutenant-Colonel, D. H., I.M.S.
Napier, Captain A. H., I.M.S., to April 15, 1913.
Stephen, Major L. P., I.M.S.
Stewart, Captain A. D., I.M.S.
Willcocks, Captain R. D., I.M.S.
Hotices to Correspondents,
1.— Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL oF TROPICAL MEDICINE AND HYGIENE shouid com-
municate with the Publishers.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
Jan. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 2, Vol. XVI.
Original Communication.
DISEASE IN MADAGASCAR.
By C. J. A. MOSS, M.D.
Medical Mission, Tananarivo.
Tue Island of Madagascar is a very large island
situated in the Southern Hemisphere, extending
from lat. 11°57' to lat. 25°88' S. ; all but a small por-
tion in the extreme south is therefore within the
Tropics. Its length is roughly 1,000 miles, its
greatest breadth 350, and its area 250,000 square
miles. Its main physical features are as follows:
A section from east to west at about the latitude
of the capital, Antananarivo, would show, first a
belt of lagoons, then gradually rising ground, ex-
tending to about thirty miles inland, with old sea
beaches at varying levels, then a chain of moun-
tains rapidly rising to about 4,000 ft. high, the
slopes of which are covered with thick forest and
impenetrable jungle. — Following that is a plain
some twenty-five miles broad at a somewhat lower
level, on the western boundary of which is another
mountain range of less altitude than the former,
and again forest clad; this is the watershed of the
country. To the west of this an altitude of about
5,000 ft. is attained, and in this elevated area is
the Central Province of Imerina. A succession of
undulating hills rising from this central plateau
eventually leads to a desert region on the west, the
extreme limit of which is a sudden drop of some
2,000 ft. into a well-watered district with small
isolated areas of forest. Finally, after traversing
another mountainous belt of lower level the dead
level is reached, and one arrives at the Mozambique
Channel.
The features noted in this cross-section can be
traced with fair accuracy through the whole country
from north to south. The forest area, known as
the Great Forest, to distinguish it from the lesser
belt, extends for about 800 miles, und attains a
breadth of about thirty. In the south-west of
Imerina there is a large mountainous mass known
as Ankaratra, which attains a height of nearly
9,000 ft., many of the peaks being volcanic. There
is one higher mountain near the north end of the
island.
The central plateau is characterized by its bare
hills and relative absence of verdure. The valleys
are largely under cultivation, being devoted to the
culture of rice, the staple food of the native popula-
tion. The capital itself, Antananarivo, stands on a
long hill some 400 or 500 ft. above the plateau; and
to the west of it, for a length of about thirteen
miles, there is one continuous rice field on either
side of one of the numerous rivers which course
through the province on their way to the
Mozambique Channel. Connected with this rice
field there is an important health problem, which
will be alluded to later. The capital and the larger
villages in its vicinity demand some modification of
the term bare, for of recent years the Cape lilae,
Norfolk Island pine, and eucalyptus have been
planted in abundance, but such luxuriance is the
exception in Imerina and not the rule.
The climatic conditions naturally vary very much
in this huge island. The most important points to
note are the general humidity of the forest belt and
the low-lying region on the east of the island, the
more uncompromising heat of the low-lying country
on the west and the more temperate character of
the climate in the elevated central province, where
our heat is tempered for so many months of the
year by the refreshing S.E. wind, and where the
division of the year into wet and dry seasons is so
clearly marked. Judging by statistics collected
several years ago in Antananarivo, the average rain-
fall during a term of fifteen years was 53.94 in., of
which very little fell from May to September; the
mean temperature during nine years was 62.04, the
highest reading in the shade being 83? F., and the
lowest 469 F., of which it should be remarked that
the situation was sheltered, as a temperature of 32°,
or nearly approaching it, occurs during the winter
in the central mountains. On the N.W. coast the
rain during one year was: 53.387 in., the highest
reading of the thermometer being 96.59, and the
lowest 629, but it must be noted that the highest
readings in any month never fell below 86.29; the
solar temperature was registered, and was between
151.99 and 177.49.
On the S.E. coast observations were taken which
showed an annual rainfall of 121.96 in., with a
monthly fall of from 3 to 18 in. ; a maximum shade
temperature of 90.99, a minimum of 43.49; and a
solar temperature between 120.99 and 149.39.
Headings at Samatave have shown a rainfall of
95 in.
It is twenty years since Dr. Andrew Davidson,
the founder of the Medical Mission in Madagascar,
discussed the diseases prevalent in Madagascar in
his work on Geographical Pathology. I am unaware
of anything more modern than that having been
written in the English language and covering the
same ground. Unfortunately, I have not at hand
any study of the subject from French sources, and
I have not succeeded in finding such a thing here.
It will be useful before considering the health of
Europeans to study briefly the diseases prevalent
among the natives. Further scientific research is
needed to elucidate many problems connected with
the subject, and that research awaits the pathologist
and the bacteriologist more than the clinician;
French scientists are engaged in investigating these
questions.
Malaria.—As far as observation goes, malaria
would seem to be endemic practically all over the
island. A rapid mental survey of the chief pro-
vinces at once reveals the fact that malaria is pre-
valent in each. The extreme south of the island
may possibly prove an exception, but of this I am
very doubtful. A province known as the Bara,
about 250 miles from the southern extremity, was
eonsidered so highly malarious in the days of the
Malagasy Government that men of inconvenient
(Jan. 15, 1913.
18 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
eminence were sent there as Governors to be out of
the way of possible competition! That district also
was, and still is, very fatal to the Norwegian
missionaries working there. Still farther north is
the province of Betsiles, of which some districts
have an unenviable notoriety on account of malaria,
and throughout which from time to time there are
epidemics of a malarial character of rampant
severity.
Then we arrive at the province of Imerina, of
which the same must be said, and starting again
from there, whether one considers the route to the
coast due east, or north-west, vid the lake province
of Antsihanaka, a hotbed of fever, or north-west, vid
Vonizongo to Majunga, the same holds good.
Neither must exception be made in the west in
favour of the district occupied by the nomadic
Sakalava tribe, for there, too, malaria abounds.
The type as seen in Antananarivo and Imerina is
chiefly quotidian and tertian; it is very prone to
relapse after about a fortnight, and is followed by
much anemia and sometimes an extreme enlarge-
ment of the spleen, the whole abdomen, as far as
the right ileum, being occupied by that organ.
There is a very marked difference now in the in-
cidence of malaria compared with that of the days
of the Malagasy Government. At that time there
were certain notoriously unhealthy villages and
districts, often but not exclusively in the neigh-
bourhood of marshes. People hailing from these
places were brought from time to time to the capital
for treatment, but the inhabitants of the capital
itself were free from malaria, unless they happened
to contract it while away. Now, every year, from
February till June or July, malaria is a terrible
scourge, tens of thousands being laid low in the
capital and surrounding country. One cannot say
whether anopheles was or was not to be found in
those former days, but now there are swarms of
that mosquito.
The explanation, which I believe to be satisfactory
and trustworthy, is two-fold. It was a custom of
the Malagasy to burn the long grass over the hill-
sides and by the rivers and streams so as to produce
a better crop for their cattle. During the rebellion,
which immediately succeeded the French occupa-
tion, beacon fires were used largely by the rebels
as signals, and the French Government took the
not unnatural step of forbidding the burning of
grass. Probably the destruction of grass had rid
the neighbourhood of countless mosquitoes, so that
the decree had the unexpected effect of allowing a
great increase in the number of mosquitoes.
Secondly, in the early days of their occupation
the French Government instituted a system of
general taxation by means of a poll-tax. Those
unable to pay were drafted off to Government
service in lieu of their tax. The greater part of the
male population of the distriet round the capital
were unable to pay. The Government were interest-
ing themselves at that time in the construction of
good roads to connect the capital with important
ports. To this work the men from the villages in
Imerina were sent. Many of the districts in which
the work was carried on were notoriously malarial.
The consequence was, that very shortly there was
a high mortality from malaria among the new-
comers, and many were incapacitated for work, and
so were sent back to their villages. After their
return to their homes there was a pandemic of
malaria all over the province. It is possible that
the lack of men to work round the villages was a
contributory cause to the presence of rank grass
and undergrowth, which would harbour more mos-
quitoes than usual, but the stopping of the burning
seems to me to be the more probable one. The
death-rate from malaria ever since has been exceed-
ingly high.
It is interesting to notice a change going on in
the healthiness or otherwise of certain villages, the
unhealthy ones sometimes losing their malaria, and
the healthy ones becoming infected for no obvious
reason.
As a general rule the most unhealthy areas tend
to gradually lose the virulence of their malaria after
three or four years, and in time become more habit-
able; immunity might effect this, but would not
protect newcomers, and newcomers do seem to
escape infection.
Since the extreme frequency of malaria, a disease
which formerly lurked only in the most unhealthy
regions has made its presence in Imerina and
claimed many victims. I refer to blackwater
fever. My personal experience of this disease is
very limited, but one has no difficulty in dividing
the cases into two types, one where, apart from the
hemoglobinuria, the patient seems almost well, and
where, I believe, he invariably does get well; the
other, where the alteration in the blood is extreme,
the symptoms very severe, and a fatal issue seems
almost inevitable. I believe this disease was first
described to the world at Nosibe, an island off the
N.W. coast, which has been for long under French
occupation; in the old days it was restricted to such
regions, now it may occur anywhere.
To allude briefly to a few of the more common
general diseases before passing to those of the
various systems.
Infective Fevers.—Scarlatina appears not to exist;
I have seen one or two cases which I should have
unhesitatingly diagnosed as that disease in Europe,
but as they never infected others, I am not able to
contradict the received opinion. Measles occurs in
severe but infrequent epidemies; I believe the last
two epidemies have been at nine years' intervals.
The consequence of this is that almost all the
children under that age contract the disease simul-
taneously, a great strain is imposed on the friends
who nurse the sufferers, and lack of care leads to
many eontraeting respiratory troubles, which often
prove fatal. Small-pox has been nearly exter-
minated since vaccination became general; for-
merly it was of great frequency.
Enteric fever is not very frequently met with, and
never now assumes epidemie proportions, but in
the years 1892-03 it was exceedingly rife, more than
Jan. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 19
T ———————————————————— ——
a tenth of our whole in-patients being sufferers
therefrom, i.e., about a hundred per annum. It had
greatly diminished in frequeney before the French
occupation.
Typhus does not exist. Cholera is not known.
Plague has visited some of the principal ports, but
has been promptly and most successfully restricted
in area and wiped out. So far as I know, there is
no ankylostomiasis, bilharziasis, kala-azar, sleeping
sickness, nor yellow fever. Beri-beri has occurred
on the coast, and I believe I have seen it in
Imerina.
Pertussis appears nearly every year. Diphtheria
we meet with occasionally. Influenza arrived
among us in 1890, and has been a scourge ever
since. We are never really free of it in sporadic
form, and occasionally have pandemics, somewhat
allied in form to malaria, but without periodicity.
Among other general diseases we may notice
leprosy, which is far from rare. Patients are
segregated, and the opportunity is taken to use
certain methods of treatment, of which I believe
that by Chaulmoogra oil, and more recently the
Nastin treatment, have had some successes. I
myself have been pleased from time to time with
the results of the former; the latter I have not had
the opportunity of using, but my patients from
leprosy are very few.
The theory that connects the consumption of
dried fish with leprosy does not seem to fulfil the
necessary conditions, as one would expect the
disease to be extremely widespread if such a
universal habit were the cause. On the other hand,
I do not think the bed-bug is of sufficiently common
occurrence as to be the cause; I have very rarely
seen that insect, though fleas and lice are ubiquitous
and multitudinous.
Elephantiasis is rare in Imerina; I have seen it
fairly frequently attacking the vulva, only in very
few cases the legs, and never in my experience the
scrotum. On the east coast it is fairly common.
I understand, however, that observations made at
the French Hospital go to show a very high in-
cidence of filaria in the general population; if I
remember right, about 70 per cent. of all persons
examined showed filaria. I have not had any
chance of verifying this observation.
Syphilis in the form of condylomata in young
infants, and secondary and tertiary manifestations
is of almost universal prevalence. A primary sore,
however, is almost unheard of. I have never seen
a Hunterian chancre all the time I have been in the
island. Soft sores one sees occasionally.
Gonorrhea is exceedingly common.
Cancer is fairly common, chiefly of the breast and
cervix uteri.
To turn for a few moments to Systemic Diseases.
Circulatory System.—Valvular disease is common
among the natives, probably due to strain and hard
conditions of life, and not to acute rheumatism,
which I believe does not exist in the island.
Muscular Degenerations are also fairly commonly
found. Aneurism, in spite of the prevalence of
syphilis, appears to be rare.
Respiratory System.—Pneumonia is exceedingly
common, often in epidemic form, the severity of
the epidemics varying, from very severe to ordinary
types.
Bronchial complaints are fairly common.
Tuberculosis is, unfortunately, very common, and
there is a great need of efficient measures for institu-
tional treatment, as it is nearly impossible to
adequately treat the patients in their homes.
Alimentary System.—Dyspepsia bulks largely in
our out-patient cliniques, probably owing to the
habit of taking two meals only during the day, when
a large quantity of rice is rapidly consumed. Organic
disease of the stomach is rare.
Parasites are extremely common, specially among
children, where a dose of santoin is almost invari-
ably efficacious.
Tenia is fairly frequently met with, and there are
parasites special to the island, e.g., T. Madagas-
cariensis.
Dysentery is not uncommon, specially on the
coast. Of recent years I have seen several cases of
severe syphilitic disease of the rectum with
stricture.
Appendicitis is rare among the natives.
Skin Diseases are extremely frequent, especially
eczema, impetigo, scabies, and secondary syphilitic
manifestations.
Urinary System.—Bright’s Disease is not com-
mon. Calculus is frequent.
Lymphatic System.—Tuberculous glands are
common. Enlarged spleens are very common, and
generally put down to malaria, but possibly further
study, with examination of the blood, would place
some of these cases in other categories.
Nervous System.—Diseases of this system are
rare. Acute poliomyelitis, paralysis agitans, facial
paralysis, are occasionally met with, epilepsy and
hemiplegia perhaps more commonly. Locomotor
ataxia and general paralysis I believe I have seen,
but they are, in spite of the frequency of syphilis,
very rare. Mental disease is rare; more adequate
provision is now made for such cases in a special
hospital. Chorea we occasionally see.
Of diseases of the special senses, perhaps dis-
organization of the eye from injury by the husk of
the rice grain flying up during pounding and hitting
the cornea is specially noticeable; ophthalmia
neonatorum is common; otorrheea is common, occa-
sionally proceeding to serious disorganization of the
ear.
Reproductive System.—Disease of this system in
the female is of extreme frequency, and actually
provides me with at least a quarter of my patients.
Though cases of gonorrheal peritonitis are seldom
seen, or perhaps I should say seldom diagnosed ; the
results in the form of retroverted uterus, fixed by
adhesions with cystic tubes, and often cystic
ovaries, are very common, and apparently out of
all proportion to the initial peritonitis. Disturb-
ances of menstruation are also very common.
New growths, such as fibroid, parovarian cysts
(perhaps more frequently than ovarian), and
20 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1913.
carcinoma are common.
extra-uterine pregnancy.
Diseases of Bones and Joints.— Syphilitie peri-
ostitis of the long bones should be alluded to.
Rheumatic affections are frequent, and possibly may
be eonnected up with forms of purulent discharge,
whether from pyorrhcea or gonorrhvea, which are
also common. Tuberculosis of the joints I find very
rare.
I have now to pass to a consideration of my
European patients. I feel at a disadvantage in
studying such a subject, as I have no records with
me, but I have been able to find full lists of mis-
sionaries, and memory has enabled me to recall with
some fulness the medical history of those families
whom I have treated. There is undoubtedly a lack
of absolute accuracy in my figures, but the error, I
think, cannot be very great. My review is prac-
tically a health record of the missionaries of the
L.M.S. and F.F.M.A. for fifty years. I have from
time to time seen members of the other missions,
the S.P.G., Norwegian and French Missions, as
well as traders and others, but I-have not been the
regular medical attendant for all these, and there-
fore will leave them out of my detailed considera-
tion. I have made a record of 215 adult mis-
sionaries and 459 individuals, including children.
To consider first the health of these 215 adults.
I naturally have no intimate knowledge of the
health of those who had left the island before my
arrival there in 1889, but many of the early mission-
aries were still in service at that time, and to some
extent their medical history remains in my memory.
Though not exclusively so, most of these patients
have been resident in the Central Province of
Imerina. The incidence of disease amongst these
individuals is not of great importance for our
present purpose, apart from what may be attributed
to tropical, or at least, local influences. We will
consider first malaria. Of the 215 adults, I am
quite certain that sixty-five have suffered more or
less from malaria, and of the rest it is quite safe
to say that a fair number have suffered. A difficulty
that confronts one is that people are now so con-
versant with the treatment that they do not send
for a doctor unless the symptoms are unusually
severe or the disease unusually obstinate. Five
deaths have oceurred from this cause, five deaths in
at least sixty-one cases; one of these was due to
sudden collapse, and the patient was, I believe,
found dead in bed, so that the actual circumstances
cannot be detailed. Another was a day's journey
from a doctor, and death may have been due to the
effects of a fall which occurred during fever. Of
those who have prematurely retired from active
service there may have been two incapacitated by
malaria. It is clear that in certain provinces prac-
tically ail the missionaries suffer from malaria
—those are Antsichanaka, Betsileo, the Coast, and
Vonizongo. The attacks of malaria have varied
much in severity and obstinacy, but no cases pre-
senting extraordinary symptoms remain in my
memory. Vomiting, achings in the
We very often meet with
headache,
limbs, restlessness and sleeplessness are the chief
features. What is of more interest perhaps is that
very few Europeans retain spleens appreciably
enlarged, and even sufferers from prolonged and
frequent malaria do not present that organ percep-
tibly enlarged. The most lasting effects appear to
fall upon the nervous system, as obstinate cases of
neuralgia, often of a periodic type, cases of neuras-
thenin, and cases of persistent latent malaria, where
un attack of fever is simulated, but without rise of
temperature or pulse-rate, are sometimes seen.
The treatment adopted has been by quinine, in
different forms and modes. Early on I believe very
large doses were adopted—30 to 60 gr. at a time—
by mouth or by rectum. Some of the early mis-
sionaries became prematurely deaf, but perhaps
only five out of our sixty-five were seriously
affected. Later, the dosage was diminished,
and now I find a practical difficulty in getting
a patient to take more than 15 to 20 gr. a
day, 5 gr. being considered a large dose, and the
stomach frequently objecting strongly to even that,
though I often prescribe an acid with the quinine.
Of late years, however, we have frequently given
quinine by intramuseular injection, of which one
must say that, given with due aseptic precautions,
there seems to be much advantage; as a smaller
dosage is employed, the results are far more sure
and the stomach is not outraged. There is, how-
ever, the disconcerting fact that now and again a
case of tetanus supervenes. I believe this has been
of frequent occurrence on the coast. I have only
seen one case in a native, on whom the injection
was not given by myself, but by my assistant, who,
however, always relieves me of this work, and who
gave several other injections at that very time. A
later case of death from tetanus after malaria and
injection—not in my practice—leads me to think
probably the injection was responsible in that case,
too. I have seen recently that the presence of the
bacillus of tetanus anywhere in the system, quite
apart from the point of injection, is sufficient to
‘cause the appearance of that disease at the seat of
injection.
There is no doubt that this mishap is exceedingly
rare, but that it is a possibility makes one hesitate
to employ injection in what appear the simpler
cases, where quinine is well stood by the mouth,
and to reserve it for the more obstinate and more
irritable cases, and for such serious manifestations
as coma and pernicious malaria.
Blackwater Fever.—I am thankful to say that I
have so far not had any missionary patients with
this disease in Madagascar. One patient, however,
a missionary of thirty-five years’ standing, after
suffering much from malaria during his last year in
the Island, developed hemoglobinuria three months
after arriving in England, that being his first attack.
The attack was not very severe so far as it went
and it readily passed off, and the patient got up
his strength fairly well. There had been, however,
dangerous cardiac debility during the illness, and
after about a couple of months’ convalescenee, when
Jan. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 21
slight attacks of malaria had again supervened,
sudden death took place, probably from interference
with the heart’s action by gaseous distension of the
stomach,
I should like next to say a few words about
typhoid fever. This disease has of recent years
been comparatively infrequent, but during a severe
epidemic in 1892-3 (already referred to) several
Europeans were attacked. I have collected seven-
teen cases of typhoid, including children, from
among our two missions, and I recollect seven other
cases outside.
Of these seventeen cases, three were fatal.
One of these occurred many years ago in very
difficult circumstances, and 1 do not know if there
was any medical attendance; there was the com-
plication of miscarriage, and the illness commenced
during a long journey. The other two cases were
of more recent date. One was a patient of mine,
and got quite over her typhoid in spite of her age,
which was 65, but convalescence was unsatisfactory,
and after lingering about ten weeks she finally suc-
cumbed to hypostatic pneumonia. The other was
a young man living some five hours away from the
capital, who was supposed to be suffering from
malaria, and who was not professionally treated
until he was very seriously ill; he had seriously
overworked, and was unable to stand the strain.
I was not in the island at the time, but from what
I have heard I should gather that there was perfora-
tion. With these exceptions our cases have been
fairly straightforward; I should only regard one of
them as being very severe, and that was the first.
One was followed by phlebitis, and did not regain
her strength until after her furlough. Otherwise
the convalescence has been normal, and by due
regard to the question of change of air and pro-
longed rest, our patients have recovered well.
The other seven cases that I referred to were in
members of other missions or else of the general
community. Of these, three died, one from per-
foration, one complicated by a large fibroid, and
one, that I did not see, from asthenia. One of
the others had an ordinary attack, but remained
semi-delirious for a considerable time.
Of recent years the cases have been sporadie, one
appearing every two or three years. It will be
interesting to see how far protective vaecines are
successful in preventing the disease. I think four
out of the seventeen cases oceurred during the first
year after return to the island.
I will now pass on to diseases of the various
systems.
Cireulatory.—l must here state that of the 215
adults I do not think I ean have had the oppor-
tunity of examining more than eighty-five, and it is
probable that of that number I have not examined
quite all.
Of these there seem to be twelve with cardiac
affections, and they seem divisible into two classes,
valvular and degenerative. Of the valvular cases
we have had four, at least, who have been able
to work fairly well for a considerable number of
years, two certainly for over twenty years. These
patients have had to be taken rather special care
of, but that it has been possible to have them with
us at all is satisfactory. One of the four was
unable to stand the altitude, and after two or three
marvellous recoveries from very severe want of
compensation, she had to leave the island. A
second is not robust, but does not suffer much from
actual cardiae symptoms, and is able to do an
admirable amount of work. The same may be said
of the third. The fourth suffered from time to time
from exacerbations of valvular mischief, but she
lived an exceedingly active life and was, I believe,
60 before she died.
The class of degenerative heart cases includes
chiefly those who have been a long time in the
island, twenty-five years or more; a few have
developed heart disease as a result of severe malarial
fever. Three such cases are prominent in my
mind, but it is possible that several others ought to
be added from our retired lists. Of these three, one
has been wisely kept in England, one returned to
Madagascar on his own initiative, and I thought
right to promptly advise his return to England, a
third recovered his tone fairly well, but proved
unequal to the strain of work and suceumbed out
in Madagascar. There have been other cases pre-
senting arterial degeneration and a so-called weak
heart.
Respiratory System.—I remember four cases of
asthma, who seem to have suffered much more in
the high inland regions than at a lower level; two,
at least, were wonderfully well on the coast. All
remained many years in the island.
Tuberculosis.—I can pick out three cases of early
tuberculosis and four more advanced. The three
early cases recovered either absolutely or nearly so,
one on the field, the other two improved vastly in
the island, and were cured during furlough.
Three cases have died, one a lady who seems to
have developed the disease almost as soon as she
arrived in the island, and who only lived seven
months. Another case, also, I believe, of tuber-
culosis, died during his first year. The other lived
thirteen years in the island and got a very serious
exacerbation, but eventually died in this country.
Alimentary System.—Diseases of this system
present us with a large number of cases, especially
in the form of gastro-intestinal complaints in
children. Probably a bacteriological examination
of such cases would be of great value, and this
could probably be undertaken at our Pasteur
Institute in the capital. A good many infants have
lost their lives from gastro-enteritis, several in
earlier years, of whom I have no knowledge. I
can recollect four in my time, of whom one I did
not see, the illness of another in the country was
more or less of a mystery; a third succumbed to
a second attack of entero-colitis, and a fourth to
malnutrition.
Amongst adults I do not think we have an undue
amount of liver disease; there are several cases of
eongestion of that organ, and one, I believe,
22 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1913.
of cancer. A good many suffer more or less
from hemorrhoids, and three or four have
required operation. Chronic constipation is a great
trouble to a few patients. I met with one case of
sprue, which is not a disease of which I have other-
wise any experience. Dysentery is fairly frequent,
but in most cases is well amenable to treatment.
It does, however, occasionally remain chronic, often
not at all severe but obstinate. A case of this
kind, in which there must have been slight peri-
tonitis resulting in painful adhesions, was much
relieved, if not cured, by vaccine treatment in
England. There have been four cases of appendi-
citis, two not operated on, one operated on too
late, and a fourth, in the country, who was not
seen by me, but who died, evidently from internal
rupture of a large appendicular abscess.
Of diseases of the skin and of the urinary and
hemopoietic systems it is not necessary to say
anything, as they are in no wise of more than
ordinary incidence.
Reproductive System.—Many ladies suffer from
functional derangements and menstruation, menor-
rhagia, dysmenorrhea, and sometimes amenorrheea,
but these do not appear to be of great severity,
though they certainly militate against good health.
Nervous System.—Neurasthenia is by far the
most frequent affection to which our adult mission-
aries are subject. In some it has been sufficiently
severe to demand their being sent away on fur-
lough as early as possible; in others they were
not sent as soon as I ought to have sent them.
The cause of this tendency, which I believe is of
much greater incidence of recent years, seems to
me to be partly overwork and partly anxiety. There
is no doubt at all but that several of our mission-
aries are working at very high pressure; this is a
source of constant anxiety to myself, and involves
a good deal of study of their work in order to try
to regulate their duties and see where strain can
be best relieved. There are always some who are
overworked and who seem to invariably have the
share of two ordinary mortals. I can see no other
way of meeting these cases but by constant watch-
fulness, but one is not always aware of what is
occurring in every household, and one is sometimes
consulted too late to prevent a serious breakdown.
The possibility of sending such patients away to a
sanatorium is a very great boon indeed, but the
question of suitable companionship is a difficulty, as
one wishes, as far as possible, to limit the inter-
ference with mission work to that department in
which the patient is engaged. The lack of daily
exercise and the influence of bright light have pro-
bably something to do with this tendency to neur-
asthenia.
Confinements.—There is not much in the study
of the confinement cases that I have attended that
is of special interest from the point of view of the
part of the world in which they have occurred.
Out of thirty-nine ladies attended, of these cases
I have statistics, there were abnormal circum-
stances in seventeen, a distinctly high percentage;
seven had inertia and forceps delivery; there were
three breech cases, one being stillborn, two foot-
ling, one forehead, one placenta previa, the child
being stillborn, and three adherent placenta. In
twenty-nine confinements of other European ladies
there were seven abnormalities; one had post-
partum hemorrhage on two successive confine-
ments, and one case died from sepsis, which
appeared on subsequent investigation to have been
due to the attentions of a native servant, the sub-
ject of a purulent discharge and erysipelas. In our
total list of European confinements of earlier date
there must be noticed three deaths from septice-
mia, one missionary losing two wives in succession
from that cause, the same bed, I believe, having
been used on each occasion. A death was recorded
also, I believe, from cellulitis in an asthenie sub-
ject. There was one case of puerperal mania, which
recovered.
It may be of use to examine cursorily the causes
of death amongst missionaries; several have been
already alluded to.
Of the older missionaries, who died either in the
island or immediately on arrival in England, there
were twelve. There were four deaths from malaria,
one from tuberculosis, one from mitral disease, one
from cancer, one from typhoid fever, one probably
from liver abscess, one from appendicitis, and two
from causes unknown to me. ‘Two of our senior
missionaries met with a violent death at the hands
of the rebels soon after the French occupation.
Thirteen of the younger missionaries have been cut
off, three dying from septicemia, one from cellulitis,
two from typhoid, one from appendicitis, one from
dysentery, two from tuberculosis, probably two
from malaria, and one from a cause unknown to me.
Of thirty missionaries who have been invalided
home, or who have retired prematurely, seven were
seniors who had anticipated further service; the
causes of their retirement were anemia, neuras-
thenia, asthma, hypertrophied heart, mitral disease,
cardiac irregularity, and malaria. Two of these
have died. The causes of retirement of twelve
younger missionaries have been mitral disease,
cardiac weakness, two each of nerve failure and
delicacy, one each pelvic disease with extra-uterine
pregnancy, mental weakness, tuberculosis, three
probably of malaria. Eleven retired on other
grounds.
An inquiry into the state of health of the children
on the mission field is not feasible, as it is impos-
sible to collect statisties of the children of earlier
missionaries and the exact number of them cannot
now be told, but in my figures of 450 individuals,
I included 243 children of whose existence I am
certain, but I am equally certain that the figures
are a good deal below the mark. Among these
children I know that twenty-nine died in Mada-
gasear from such causes as convulsions, two cases;
broncho-pueumonia, one; three stillbirths ; five from
forms of diarrhoea; one from malaria; and one who
was, I believe, imbecile; fifteen died from causes
of which I do not know.
Jan. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 23
In conclusion, I should like to briefly allude to
some problems of interest in connection with the
health of, our missionaries and, perhaps, the health
problem generally. Perhaps the statements that I
have made may strike others in a different way to
that in which they strike me, but a consideration of
the question of the incidence of disease in the Cen-
tral Provinces leads me to the conclusion that that
field is not remarkable in any way. There has not
been a very high death-rate, either among adults
or children; there has not been a high percentage
of retirements; there is not a very large amount of
sickness. What is, perhaps, more evident, is that
many are never very strong and are frequently
ailing. I believe this to be due often to slight con-
stitutional errors and to physiological sins, which it
is not always easy to discover. Especially is this
the case where the medical man has not the
facilities necessary for research. Minute investiga-
tions, especially, say, with regard to the alimentary
tract, both of what enters and what leaves the
system, are uncommonly difficult, in fact, seem to
me impossible to carry out. And yet, to my mind,
the state of health very frequently depends on some
minute change. I think more may now be done
in Madagascar in the way of chemical and bacteri-
ological examinations if we can make use of the
well-appointed Pasteur Institute for that purpose,
and that may help us to realize just the point
against which treatment must be directed.
But it is also just in regard to this matter that I
consider the careful observations made to the
societies’ medical advisers during furloughs likely to
be of value. By examination, and if necessary by
the consultation of specialists, pathological causes
and tendencies can be detected.
A problem to which allusion must be further
made is that of malaria. I mentioned that Antana-
narivo stands on a hill, with a large rice plain to
the west of it. This plain exercises a most injurious
influence on the health of the community, as is
evidenced by the fact that the inhabitants of the
villages by the sides of the plain are the first, and
perhaps relatively, the greatest sufferers from
malaria. Were it not that the whole population of
the district is dependent on that valley for their
food supply, there would be no complexity about
the problem of malaria. But as it is, the question
arises how the natives are to retain their rice and
lose their mosquitoes. The importance of mosquito
brigades has not, I think, been grasped by the
authorities, but I feel that benefit would accrue
from an attempt on those lines. There is from time
to time an outery against undergrowth, and this is
quite correctly cut down. Lately, I believe, the
Cape lilae has been looked askance at as a harbourer
of mosquitoes, and the increased numbers of this
insect been linked up to the increase of those trees.
But my own observations would lead me to think
that the increase of trees preceded the fever by a
good many years, and I think other steps than the
cutting down of the Cape lilac are necessary. The
Government are assiduous in their distribution of
quinine, and, I hear, are trying to persuade the
natives to use mosquito netting. I fear that the
use of netting is not adapted, either to the customs
or the genius of the people, with their compara-
tively rough houses, ill-fitting roofs, open doors, lack
of attention to small details, and absence of bed-
steads. I fail to see how they can adopt mosquito
netting, and even if they did the Government would
have to institute a new réle of house inspector to
see that the netting is not subject to more than
its usual solution of continuity. Could petroleum
be employed without ruining the growing crop? If
not, would it not be worth the Government’s while
to spend a large sum in importing rice for a year,
so that the rice fields could be fallow, suitable
culicicides be employed, and the people, deprived
of their home-grown rice, be helped from head-
quarters in what would be to them a terrible
hardship ?
I am unaware if this difficulty has been overcome
on a large scale in other parts of the world, but I
feel that, without question, its solution is urgently
demanded for the eradication of malaria and the
release of the whole community from their greatest
menace. I am painfully conscious of the great
defects of this paper, but, such as it is, present it
to the indulgent consideration of the Association of
Medical Officers.
—— 9 ————
Verruga peruviana.—Cole, in the Archives of
Internal Medicine, vol. 10, No. 6, December 15,
1912, describes a comparative study of verruga
peruviana in man and the ape. As regards the
diagnosis of the condition he says that one must
always keep malaria in mind, the two diseases hav-
ing been very frequently confused, but the blood-pic-
ture will serve to differentiate them. In a patient
having the cutaneous tumours as the predominant
symptom it would also be necessary to think of
neurofibromatosis (von Recklinghausen’s disease).
The affection occurring in a tropical country,
frambesia and Bouton d'Orient would likewise
have to be considered in a differential diagnosis. In
the former, suitable examination for the specific
spirochete would be sufficient, while in the latter
there would be the history of painless ulcers on the
exposed parts, in which proper examination would
reveal the Leishman-Donovan bodies.
Finally the author reaches the following conclu-
sions :—
(1) In a case of Verruga peruviana, Eruption de
Carrion, there was success in inoculating the disease
into apes to the third generation, further transmis-
sions being hindered only from want of material.
(2) The lesions from the man and the apes
resembled each other very closely histologically,
were granulomatous in type and had peculiar
lymph-vessel inclusion areas. i
(3) None of the organisms mentioned as specific
for the disease were found either in the lesions
from the patient or from the animals.
24 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15, 1913.
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THE JOURNAL OF
Tropical Medictne and hygiene
JANUARY 15, 1913.
ATHLETICS AND CANDIDATES FOR
SERVICE ABROAD.
Tue medical examiner of young men for service
abroad is often placed in a difficulty by finding that
the heart, the kidneys, the digestion, and at times
the lungs are affected more or less seriously by
unwise indulgence in athletic exercises. Of these
organs the heart is primarily affected, and secon-
dary to the condition of the heart some one of the
other organs are affected. School sports may, or
may not, leave their stamp on the physical condi-
tion; the age at which most young men leave school
to follow a commercial pursuit is about 17, and
except occasionally no marked damage is done be-
fore that age. The lads compete in their sports with
others about the same age as themselves, and the
strenuous endeavour to succeed is less evident at
this stage of their career than when they leave
school and enter into competition with men older
than themselves. Besides, given average healthy
organs, the effect of severe muscular effort on the
condition of the heart and blood-vessels, up to 17,
usually passes off fairly quickly, for these organs
can accommodate themselves more readily to
circumstances, and can recover their equilibrium as
a rule without leaving deleterious consequences.
After school life is over, when the young man joins
a firm as clerk, lives in lodgings, and has his Satur-
day afternoons only for athletics, the period of
danger begins. Cooped up in an office for many
hours, meals of the type calculated to engender
dyspepsia—the hurried breakfast, lunch whilst
standing at a bar, an office tea, a lodging-house
supper—little or no exercise during the week, and
then an athletic outburst on Saturday afternoons
represents the life of a young city clerk at the
present day, or of a young accountant wishing to
go abroad. The Saturday afternoon exercise is
taken at the end of a week of indoor life with
unwholesome surroundings; the heart is suddenly
called upon to respond to sprinting, long distance
running, football, hockey, rowing, long distance
cycling (Saturday and Sumday), or some one of the
many forms of athletics in vogue. The muscular
tissue of the heart increases in bulk for the time
being, but for the remainder of the week lies
fallow; week after week the process is repeated;
hypertrophy and wasting alternate, and as the years
pass the effects disclose themselves. [t is the young
man as above described that as a rule comes up
for examination as to his fitness to proceed abroad
to a tropieal climate, and the medical examiner has
to make up his mind on the matter. The writer,
after considerable experience in such matters, is of
opinion that only 20 per cent. of the young men
coming up for examination are thoroughly sound
physieally, and if we were to eliminate all those
who have one or two drawbacks, rejection of candi-
dates would be the rule. The commonest ailment
is dyspepsia, as gathered by the dilated state of the
stomach and the stomach '' splash ’’ that can be so
frequently elicited. The candidate always denies all
knowledge of dyspepsia, even when the stomach
occupies the upper part of the abdomen as low as
the umbilicus, and when splashing reaches from
below the left ribs to the right hypochondrium. A
stomach like a bueket of water is a common state
with the city clerk, and he believes that the feelings
to which he is accustomed is the normal condition
of man. Cun the medical man recommend a can-
didate in such a state for service abroad? The
answer is '" Yes " and “ No." The condition of
the stomach is due to irregular and unwholesome
diet, to want of exercise, &c.; a condition brought
ubout by his meagre pay, his lodging environment,
and the impossibility of getting exercise except at
intervals. Once he gets to the Tropics his pay is
inereased perhaps two or three fold; his messing
and lodging are bettered; and exercise, even horse
riding, is daily possible except in very out-of-the-way
places. To send him abroad may probably cure
his ailment, and prevent him becoming a chronie
dyspeptic, with all its complications, to which he
speedily drifts if he remains at home. It is on these
grounds, and on these alone, that a young man with
a dilated stomach ean be allowed to go abroad, and
the medieal examiner has to take the risk of the
change effecting a cure, otherwise the rejection of
candidates otherwise suitable would be 50 per cent.
and over. The condition of the heart also causes
hesitation on the part of the medieal examiner to
pass the candidate. The strenuous and occasional
exercise has told its tale; by the time the young
man reaches 22 years of age (a usual age at which
he comes up for examination) the heart is increased
in bulk, the pulse-rate may reach 110 to 130, and
is at the same time irregular, now fast, now slowed.
The quicker pulse is put down usually to ** nervous-
a mere delusion, for the pulse of a man with
a healthy heart will not increase to well nigh
double the rate under the ‘‘ excitement " of being
examined physically. The rate of the pulse is due
ness,"
Jan. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE 25
to the irregularity of exercise, the heart has lost its
balance owing to the alternating, excessive and
complete absence of exereise. The apex beat is
well to the left, the chest wall throbs violently,
and the epigastrie pulsation is pronounced. Such
a candidate lias usually a dilated stomach, and not
infrequently a trace of albumin in the urine. He
looks older than his years, and is of a reticent and
secretive disposition. Should such a man be
allowed to go abroad? Not as he presents himself.
He should be given three months' reprieve, and be
told to live a healthy life; his exereise should be
regulated, and a dietary should be laid down for
him to follow. If at the end of three months’ care
and treatment the signs and symptoms from which
he suffered have not disappeared, or at any rate
showed marked evidence of improvement, it will
be necessury to defer further examination for twelve
months, or to state that the candidate is unfit for
service in a tropical country. Now and again a
young Oxford or Cambridge student comes up for
examination; from one cause or another he has
given up his University, and has determined to take
to a commercial career. University life has, not
infrequently, left its physical stamp upon him; he
has been passing through the stage of no hat, no
overcoat, no umbrella, no underclothing, no lunch,
and excess of athletics. His heart is dilated; his
pulse quickened, albumin in the urine occurs in 30
per cent. of such men, and the temperature at 12
noon is us a rule one to two degrees above the
normal. Can such a candidate be passed? Were
it left to the writer he would advise the employer
not only to refuse the candidate on physical
grounds, but on intellectual grounds alone; for a
man who has not the mental capacity to know how
to clothe and feed himself and conserve his energies
cannot be of much value to any commercial firm, for
his grasp of things must be at a low ebb indeed. The
young chartered accountants who seek employment
ubroad belong to a class with which the medical
examiner has, as a rule, a good deal of trouble.
They are usually some 22 years of age; they have
just passed their examinations qualifying them as
accountants. They are usually '' run down " to a
degree; on inquiry they will be found to have been
working very hard, they have had no time to take
exercise, and they present a picture of unfitness.
Training for chartered accountants means whole
days spent in an oftice, their time for study is
limited to a degree, and they have to sacrifice
everything that eould promote their health to pass-
ing their examinations. | The consequence is the
medical examiner finds it difficult to ascertain how
much of the usually deplorable condition in which
they present themselves is due to developmental
physical inefficiency, or whether it is a mere tem-
porary phase caused by overwork. No chartered
accountant ought to present himself as a candidate
for service abroad until at least three months after
having passed his examination, for if he does so the
medical examiner will require, as a rule, to send
him away and advise him not to come up again
until after a three months’ holiday.
Reprint,
INJURIES AND DISEASES OF MAN IN
AUSTRALIA ATTRIBUTABLE TO ANI-
MALS (EXCEPT INSECTS).*
By J. Burton CrErLaND, M.D., Ch.M.(Syd.)
Government Bureau of Microbiology, Sydney.
lr has seemed to me of interest and value to
bring together, in one connected whole, all refer-
ences to injuries or disease in man attributable
to animals that have been recorded in the Com-
monwealth of Australia, and to incorporate with
this such unpublished information as I have been
able to obtain myself or through friends. The
accompanying paper is the result of these labours.
It does not include snake bite, platypus poison,
bites of the red-backed spider, and injuries from
Insects. Dr. Tidswell has elsewhere dealt with the
three former, and I have myself collected together
data on the latter which were submitted to the
Australasian Medical Congress last year. I am in-
debted to many kind friends, who are severally
mentioned in their proper places, for much valuable
information and for references. I am well aware
that these records are incomplete, but trust that
those readers who detect omissions, or who have
further information to supply, will be good enough
either to communicate such to me, or to bring
forward themselves such material as they possess.
CLAss MAMMALIA.
Injuries. from Man.—The injuries received in
assaults and murders are not dealt with here,
being merely the same as occur in other parts
of the world. As regards injuries received from
aborigines, very few medical accounts of these
appear to be available, though many deaths have
occurred during the colonization of Australia.
The weapon ehiefly used would seem to be the
spear, its head being formed of chipped stone,
broken telegraph insulators, bottle glass with
jagged edges, fencing wire, &c.
Dr. Gaspare Spellinit has recorded in this
connection, '* Two Cases of Spear Wounds Pene-
trating the Chest." Both cases occurred in
North Queensland. In one, a Chinaman, the
spear was embedded in the body for fully ten
inches. The lung was evidently injured, as a
roaring escape of air accompanied the move-
ments of respiration, but other important parts
had escaped. The spear, with its iron point and
barb made of fencing wire, was extracted and
the patient recovered. The other case had ridden
eighty miles on horseback with a spear in his
body. This was removed but the head was left
behind embedded in the lung. Next day, bleed-
ing set in and the patient died of pulmonary
hemorrhage.
* Reprinted from the Australasian Medical Gazette of
September 14 and 21, 1912, by permission of the proprietors,
+ Aust. Med. Gaz., Aug., 1885, p. 269.
26 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
In Dr. Wilson’s narrative of a voyage round
the world (p. 148), mention is made of a soldier
of the 29th Regiment who was speared near the
camp at Raffles Day in 1827 or 1828. The wound
was dangerous, but the patient recovered.
Injuries from other Mammals.—The native
rats are for the most part few in number, and
of small size. Records of injuries from them
seem unknown. In Flinders’ ** Voyage to Terra-
Australis " is a record of one of the sailors having
attacked a large seal (this would be Arctocephalus
Forsteri), ineautiously at Kangaroo Island on
April 15, 1802. He received a very severe bite in
the leg in consequence, and was laid up until the
ship’s arrival in Sydney on May 9. I know of no
records of injuries from whales.
Amongst the marsupials, doubtless injury is
sometimes received from the claws or teeth. The
large kangaroos, given the opportunity, by hugging
their antagonist and ripping his body with their
hind claws, could produce, and doubtless have
produced, fatal injuries in man. Carnivorous
marsupials, such as the Dasyures (native cats), the
Tasmanian Devil (Sarcophilus ursinus), and Tas-
manian wolf (Thylacinus cynocephalus), might in-
flict severe wounds by their teeth.
Injuries from the spurs of Ornithorhynchus
anatinus, the platypus, are included in Dr. Tids-
well’s ** Researches on Australian Venoms."'
CLASS AVES.
Injuries from Birds.—Birds do not seem, at
first sight, likely to have any medieal interest.
Nevertheless, accidents may be attributable to
them and one disease, psittacosis, due to an
organism allied to the colon-like, food-poisoning
group, is said at times to be conveyed by certain
American parrots to man. This disease has,
however, not been recorded as yet from Australia.
Our common '' magpies,’’ or piping crow-shrikes
(Gymnorhina tibicen and G. leuconota) are, as
many sehool-boys know, very aggressive during
the breeding season. At this time, they will
swoop down within an inch or so of the heads
of unfortunate urchins, rarely of adults, and have,
I believe, been known in this way to strike
through the headgear and inflict a wound. Our
wedge-tailed eagle (Uroetus audas) has been
known to attack and injure a boy near Bathurst,
breaking his leg. The crow (Corvus coronoide)
or raven (Corone australis), which so frequently
attacks the eyes of lambs and dying sheep, has
been stated to have gouged out the eyes of an
unconscious man lying in the open.
Cuass REPTILIA.
Injuries from Crocodiles.—Along the northern
parts of Australia, crocodiles (Crocodilus pora-
gous), popularly called alligators, are a definite
source of danger. There seem no records of
the nature of the injuries received. Banfield, in
his ‘* Confessions of a Beucheomber,’’ refers to
a native who was killed by one of these animals.
(Jan. 15, 1913. .
Injuries from Turtles.—Banfield* says that,
in some localities in the north of Queensland, the
flesh of the hawksbill turtle (Chelone imbricata)
is said to be imbued with a deadly poison.
** Great care is exercised in the killing and butcher-
ing, lest a certain gland, said to be located
in the neck or shoulder, be opened, as flesh cut
with a knife which has touched the critical part
becomes impregnated. One old seafarer acknow-
ledged that he nearly ' pegged out’ as the result
of a hearty meal of the liver of a hawksbill.”’
Banfield also states that the flesh of the luth
or leathery turtle (Dermochelys coriacea), which
diets on fish, crustacea, molluscs, radiates and
other animals, causes symptoms of poisoning.
The species occurs in Torres Straits, though it is
not common near Dunk Island.
Injuries from Snakes.—This portion of the
subject has already been covered by Dr. Frank
Tidswell in his ‘‘ Researches on Australian
Venoms.”
Crass Pisces.
Injuries due to Fish.—Injuries received from
fish may be divided into two classes, viz.: (1)
Those directly due to injuries from bites, spines,
&c.; (2) cases of illness due to eating poisonous
fish.
(1) The various sharks have a bad name along
the whole coast of Australia as attacking man
wherever the opportunity is present. The injuries
received are frequently fatal, even when the in-
dividual is rescued.
The following particulars of a recent case in
Sydney have been kindly furnished me by Dr.
Prevost. The accident occurred * on. January
26, 1912, high up an estuarine creek in deep
water. The victim, in company with others, was
bathing when he was suddenly seized, a large
piece of the tissues of the inner side of the thigh
being bitten out, the wound extending from two
inches above the patella to the groin, including
the penis and scrotum, but not entering the
abdominal cavity. In its upper part it extended
down to the bone. The bite was clean cut as if
made by a knife, leaving no ragged edges, teeth
marks or lacerations. The gaping ends of the
profunda artery and femoral vein were similarly
sharply divided as if incised, and the nerves ap-
peared as if eut. The part scemed almost as if
it had been gouged out. Though at imminent
risk, the patient was rescued. He died from
hemorrhage and shock probably in about half a
minute and before removal from the water. About
forty-eight hours later, the shark itself was
caught and was identified by Mr. D. G. Stead
as a “whaler” (Carchariaf brachyurus). About
two inches from its vent, were found the penis,
scrotum and part of the adjacent tissue of his
victim, almost unchanged, though this amount
of tissue was much less than that originally bitten
out. In its stomach were some corned beef and
fish.
* “ Confession of a Beachcomber,” p. 158.
Jan. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 27
On February 20, 1912, the daily papers in
Sydney recorded another case of an attack by
a shark, in which the vietim fortunately escaped
severe injuries. The accident occurred at Coogee,
Sydney, the patient foolishly having left the
baths and swum out into the surf. A shark pur-
sued him, and in spite of splashing and kicking,
bit a piece out of his right leg, severely lacerated
the left, and tore the right heel, then leaving him,
when he managed to swim ashore.
Amongst the Rays, those commonly called
“ Stingrays " are considered highly dangerous.
They can produce a severe wound by means of
the long-barbed spine attached to the tail. From
the habit of lying partly covered over in the sand
they are naturally very dangerous objects to those
who come upon them unawares.
In a paper entitled ‘‘On Fish Poison " (Aus-
tralian Medical Journal, September, 1877, p. 273),
by Dr. E. M. Wirth, Surgeon to the Burdekin
and Flinders Distriet Hospital, Queensland, is the
following account of a Stingaree or Stingray.
“The fish possesses a long, flexible, whip-like
tail, terminating in a bony spine, very sharp at
the point, and furnished with sharp cutting
teeth. When the ray attacks, it strikes its tail
around some part of the victim and forces the
spine into the flesh, causing a deep and lacerated
wound. The fishermen say that the barbed
spine is covered with some thick gelatinous sub-
stance, containing probably the poison.
A Chinaman, aged 20, was attacked in 1877 while
net-fishing by a Stingray, afterwards killed. He
felt a heavy body forced against his back and
simultaneously a cord tightly drawn in lassoo
fashion round his thigh. As this tightened, he felt
a sharp body enter his thigh. The fish was killed
and he was rescued. ` The patient fainted, but after-
wards regained sensibility, but with paralysis and
complete numbness of the injured limb. A fort-
night later, the patient's strength failing, and a
frightful odour coming from the wound, he was
brought to hospital. On admission he had a pecu-
liar stiff look and unusual glassiness of the eyeball,
extreme weakness bordering on collapse, pallor,
feeble heart, but ravenous appetite. The injured
leg was not swollen, but sensibility was lost. There
was a jagged, irregular sloughing wound, 24 in.
deep, with a copious, very sickening, foetid, thin and
dark grey discharge resembling the smell of rotten
fish. There was no inflammation. With treat-
ment the sloughs gradually came away, though
small subcutaneous abscesses developed on the
limb, large parts of muscles came away exposing
the bone. Finally granulation occurred, though
meanwhile the same fetid pus collected in the knee-
joint. The patient eventually walked out cured on
August 30.''
The various cat fish belonging to the family
Plotosidz are common in Australian waters, whether
estuarine or river. The injuries done by these ani-
mals are very severe and out of proportion to the
mechanical laceration of the parts. They possess
three spines, one dorsal, and two lateral, which
under ordinary circumstances are covered by skin.
When the fins, which are attached behind them,
are erected and put upon the stretch, the skin is
burst through and the sharp pointed spine projects.
At the base of the spine, by means of mieroscopical
sections, I have been able to find a racemose gland,
doubtless providing the poison which enters the
wound made by the spine. I have not been able
to follow out the duct by which the secretion
escapes. In some estuaries injuries from these fish
are very common.
The following deseription, probably referable to
the catfish (Cnidoglanis bostockii, Castlenau), was
obtained from a boatman's wife at Perth, in West
Australia, detailing her own and her husband's
experience. The latter, at the time of interview,
September, 1909, was actually recovering from such
an injury. She says that about twenty minutes
after the injury is received, the finger feels numb
and goes white, and pain shoots up the arm; if the
injury be from a live fish, the symptoms are more
severe. The dead fish, if trodden upon by naked
feet, will produce severe symptoms; even the touch
without a wound will cause symptoms. Pain in
the armpit follows, if the lesion has been on the
hand, and three or four hours afterwards a lump.
The pain sometimes stops for several hours and
then comes on again, and is very severe and of a
shooting nature. It sometimes lasts as long as five
days. Vomiting may occur at the beginning,
though there is no sweating. The patient feels
exhausted, and as if he would like to cut off the
limb. If the end of the finger is ‘* stung,” for two
inches above the part it becomes quite white and
has a burning feeling. It can be put into boiling
water without feeling any pain—it has in fact lost
its feeling of heat or cold. It does not fester and
blisters do not form. Her husband had been stung
the day before about 11 a.m., and the aching had
continued until 10 a.m. that day. He could not
sleep during the night, and he felt as though he
must hold the limb up. The treatment they adopt
is to put the finger into kerosene. The effects of
the female fish are more severe than those of the
male.
Numerous other oral accounts of similar injuries
have all given very much the same history of the
sequence of events. Extensive sloughing and
secondary infections may apparently occur, as I
know of an instance in which a boy’s leg had to be
amputated, following on an injury received from
standing with bare feet on a dead ‘‘ cobbler,” as the
fish is called in Perth. The injuries thus received
from the catfish resemble very closely those
inflicted by the spines of the ‘‘ weaver ’’ fish
(Trachinus draco). Sir James Paget (Surgical
Pathology, 1870, p. 368) reters to its effect on his
brother, who suffered intense pain at the part
affected and up the arm. Next day a black slough
appeared at the puncture.
In searching through the medical literature of
Australia, references to injuries caused by the spines
of these fish ure very rare. The only one I have
found was in the Australian Medical Journal, vol.
28 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15, 1913.
10, 1865, p. 174, where a quotation is given from
the Riverina Herald. It is as follows, the catfish
being evidently the Tundanus tandanus of Mitchell :
“ The bite of the catfish or Murray eel, as it is
sometimes called, appears to be exceedingly danger-
ous. Poor old Flora, the black lubra, whom we
mentioned as having been injured by one of these
creatures while wading through a swamp a month
or two ago, has still a very bad foot and there does
not seem any present likelihood of her recovery.”
Mr. A. MacCulloch, of the Australian Museum,
has been good enough to give me the following
references from Tenison Wood's ‘‘ Fish and Fish-
eries of New South Wales," 1882. Writing (p.
81) on the Estuary Catfish, Cnidoglanis megastomas,
Richardson, he says: ‘‘ There can be no doubt that
these spines are really venomous, and to be punc-
tured by one of them is a really serious matter.
Not only is the pain intense, but the after conse-
quences are generally grave. They give to
fishermen a great deal of trouble with their nets,
and often get their thorns entangled endeavouring
to get through the meshes. William Annan, an
aboriginal, accompanied a party net-fishing to the
head of Darling Harbour one afternoon; the place
was already celebrated for catfish, and after the net
had been hauled, and being prepared again for the
boat, a part of poor William's hand came in contact
with the thorns of one of the catfish. This gave
him great pain, and soon commenced to inflame,
in consequence of which he had his arm amputated
to save his life. He lived long afterwards, and was
useful and cheerful when out with fishing parties.”
The same author quotes (p. 49) Mr. Hill on the
Fortescue, Centropogon Australis, Gunther; not
Pentaroge marmorata, as he names it. ‘‘ We were
out fishing one night with a net towards Chowder,
a bay in this Harbour, and were accompanied by a
black fellow named Wallace. He got hold of one
of these fishes, which was in the net rolled up, and
he had put his whole force and pressure upon that
spot. I never saw anyone in such pain for a short
time. He rolled on the beach, then got up and
ran about like mad. I was necessitated to give him
at intervals all the grog that we had, and which
consisted of nearly a quart of strong spirits. This
was scarce enough to eause the pain to leave, but
it had the effect of deadening it, and in a couple of
hours we were enabled to remove him to his camp,
when a good sleep and the effects of the grog put
him right again. Strong ammonia is the best
thing which can be applied to these parts when
stung with a fish-bone. ”’
The same author, writing on the Bull-rout,
Notesthes orbusta, Gunther (p. 48), says, '* Another
peculiarity is that the spines about the head are
venomous, and inflict most painful stings. ... Now
if any of these spines ehanee to wound you, whieh
they may easily do, for they are as sharp as needles
and very strong, the pain is intense. It runs
through the whole limb like fire. The injured part
becomes red and inflamed. But except the pain,
which all vietims assert is very agonizing, there are
no serious consequences. . . . . Its sting is most
frequently felt by bathers, who tread upon it as
it lies on the bottom amongst the weeds. The
blaeks held it in great dread, and the name of
Dull-rout may possibly be a corruption of some
native word. The venom is probably a mucus
secreted by the skin, and not connected with
any distinct poison gland.”
The stone fish (Synanceja horrida L.), which
occurs off the Queensland coast, can inflict a
dangerous venomous wound. E. J. Banfield, in
his *‘ Confessions of a Beachcomber,’ says that
the blacks treat such a wound by immersion of
the part for a whole day in running water. The
creature is pacific and harmless until handled or
inadvertently trodden on. — '' A full dozen of the
keenest of spines, all in a row, extend from the
depression at the back of the head towards the
tail, each spine hidden in a jagged and uneven
fringe, which, when the fish is in its natural
element, can scarcely be distinguished from sea-
weed. Each spine is surrounded by a sac of colour-
less liquid (presumed to contain the poisonous
element), which squirts out as the spine is un-
sheathed. On the sides, and in lesser numbers
on the belly, are irregular rows of miniature
craters, which on being depressed eject to a distance
of a foot or more, a liquid resembling in colour
milk with a tinge of lavender. From almost any
part of the body this liquid exudes or can be
expelled.”
Saville-Kent*
properties.
S. verrucosa, found at Port Darwin, as a label
attuched to a specimen in the South Australian
Museum states, possesses similar organs containing
a milky poison near the points of the spines.
Saville-Kent! says that some of the Murene
or reef-eels, which may attain a length of six
or eight feet, being of aggressive habits and
armed with formidable teeth, command whole-
some respect from the fishermen. Murena tes-
sclata, Rich., is very pugnacious, and specimens
a foot or so in length will strike viciously at, and
draw blood from, the hand that attempts to
capture them. He also states that an allied and
very ferocious species of reef-eel, attaining to
a length of twenty feet, has been reported to him
as frequenting the vicinity of some of the South
Sea Islands, where it is more dreaded than
sharks, and from the same locality likewise, a
small species of electric eel. He has also heard
rumours of a Barrier Reef electrie species.
Banfield states that the monstrous Groper,
Promicrops italara, will follow a man in the
water with dogged determination foreign to the
nervous suspicious shark. He relates the case
of a young black-boy, diving for béche-de-mer,
who was attacked in this way, the fish taking his
head into his capacious mouth and mauling him
severely about the head and shoulders.
(2) Fish Poisonous to Eat.—Very few references
also refers to its poisonous
* ** The Great Barrier Reef,” p. 286.
t Ibid., p. 903.
Jan. 15, 1913.]
to poisoning by fish, apart, that is, from putrid or
bacteriologically contaminated fish, fresh or tinned,
occur in Australian literature. The following
appears in Aflalo’s “A Sketch of the Natural
History of Australia," 1896, p. 247. “The
poisonous toads (Tetradon) and porcupines (Dio-
don), relatives of the huge but harmless sun-fish
(Orthagoriscus), have often eaused accidents to those
careless or ignorant enough to eat them. Some
lads were poisoned in this way at Coogee not many
years ago, and a family of three died early in the
century from the same cause."'
I am indebted to Mr. A. MacCulloch, of the
Australian. Museum, for the following reference
(Richardson, Zool. Erebus and Terror, Fishes, p.
63, who quotes Mrs. Meredith, Notes of New South
Wales, London, Murray, 1844, p. 155). Writing
on the toad fishes, Spheroides hamiltoni, Richard-
son, from Port Jackson, he says, ‘‘ They are highly
poisonous. . . . . I know one instance at least, of
their fatal effects; a lady, with whose family I am
intimate, having died in consequence of eating
them.
According to the Australian Medical Journal, two
boys died at Randwick in 1871 from eating some
catfish caught in Coogee Bay and cooked on the
beach. "They walked home in great suffering, and
died almost immediately.
Puytum MOLLUSCA.
Bites of Shellfish of the Genus Conus.—Through
the kindness of Mr. Charles Hedley, F.L.S., of the
Australian Museum, Sydney, who has kindly
placed the following references to bites from shells
of the genus Conus at my disposal, I am able to
submit a number of valuable accounts of the severe
effects produced in man by careless or inexperienced
handling of these animals. Save that one of the
implicated species is found along the Great Barrier
Reef, the subject is hardly to be considered as
strictly Australian, but, in view of the interest
attached to the observations, it seemed well to take
this opportunity of bringing the references together.
I am also much indebted to the courtesy of Mr. R.
Etheridge, Curator of the Australian Museum, for
permission to use the very valuable information
supplied by Dr. Corney, the original of which is
filed amongst the Museum Records.
The accounts have been arranged with some
attempt at ehronological order.
Apams, A. (Zool. of the Voy. of H.M.S. “ Sama-
ring," p. 19, 1850).—-The following account of the
bite of Conus aulicus is given :—
“Its bite produces a venomed wound, accom-
panied by acute pain, and making a small, deep
triangular mark, which is succeeded by a watery
vesicle. At the little island of Mayo, one of the
Moluccas near Ternate, Sir Edward Belcher was
bitten by one of these cones, which suddenly ex-
tended its proboscis as he took it out of the water
with his hand, and he compared the pain he
experienced to that produced by the burning of
phosphorus under the skin. . . .. The instrument
which inflieted the wound in this instance was prob-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 99
ably the tongue, which in these molluses is long
and armed with two ranges of sharp-pointed teeth.”
Gray, J. E. (Ann. Mag. Nat. Hist. (2), xii, p.
178, August, 1853).—Gray quotes the above
account, and says that Mr. Adams informed him
that the cone adhered to the hand by its mouth like
a leech, as described by Adamson.
Bennett ('* Gatherings of a Naturalist in Austral-
asina," 1860, p. 382) says, in a footnote: '' The
common Conus textilis of Liunmus is found at
Anaitum, and other islands of the New Hebrides
group; the animal is poisonous. On biting its cap-
tor, it injects a poisonous and acrid fluid into the
wound, occasioning the parts to swell, and often
endangering the life of the injured person.”
Mr. Hedley informs me that this information is
repeated by Coxon (Proc. Roy. Soc. Q'land, x, 1893,
». 3B). :
ene AND Marte (Journ. de Conch., xxii,
1874, p. 353).— The authors give the following
information, roughly translated, about the poison-
ous bites of C. textile and C. tulipa, Linne., New
Caledonia.
The fact already mentioned by many English
naturalists of the venomous properties of the bite of
C. textile was confirmed at New Caledonia. After
an ocular test, a native of Ponebo, having been
stung on the hand, found in his hand and the corre-
sponding arm a considerable swelling accompanied
by very severe pains; this swelling persisted for
some time. In this country the error is committed
of attributing to the operculum of the cone the act
which proceeds from its lingual teeth.
C. tulipa, Linne., Ille Art, Ile des Pins, lle
Lifon. According to M. le Dr. Marie, the bite of
this animal is as venomous as that of C. teztile.
Woopwarp (“ Manual of the Mollusca,” 3rd
Edition, edited by Ralph Tate, 1875, p. 228).—In
speaking of the genus Conus it is stated that these
C. aulicus sometimes bite when handled.
MowTRovziER, R. P. (Journ. de Conch., xxv,
1877, p. 99).—This writer states that at one of the
Loyalty Islands, C. marmoreus, which occurs
abundantly, was known to cause accidents by the
bite of its lingual apparatus. In the New Hebrides
accidents, caused by the bite of C. tertile, were
frequent.
This species, Mr. Hedley informs me, occurs off
the Queensland Coast (Great Barrier Reef).
Garrett, A. (Journ. of Conch., i, 1878, p. 365).
—This article contains the following information :
C. tulipa, Linn. (Viti Islands, Tonga, Samoa,
Kingsmill Island, Caroline Islands, Cook’s Islands,
Society Islands, Panmotu Island, Marquest Island,
Sandwich Islands).
'" When collecting at the Panmotus, I found
three examples of this species, and held them in
my hand while searching for other shells, when one
suddenly threw out its long slender proboscis and
punetured one of my fingers, causing sharp pain
not unlike the sting of a wasp.”
HixpE, Dr. B (Proc. Linn. Soc., N.S.W., ix,
1885, p. 944).—In this article Dr. Cox read a letter
from Dr. Benjamin Hinde, R.N., of H.M.S.
“ Diamond,” containing information in reference to
the poisonous effects of the bite inflicted by Conus
geographus, Linn., on the natives of New Britain.
The summary of this is as follows: His attention
was first directed to the question by a native of
Nadup, of New Britain, who, seeing him with the
specimen of Conus geographus in his hand, re-
marked, ‘‘ Suppose he bite he kill me." On fur-
ther questioning the native stated that the fish
would bite, and that the bite was poisonous, and
it always killed people unless they cut themselves
all round the place bitten so as to let the blood run.
Mr. R. Parkinson, of New Britain, cotton planter,
also supported the statement as to the effects of the
bite of the Conus. Later Dr. Hinde himself saw a
native on the Island of Patupi, Blanche Bay, New
Britain, who had been bitten by one of these shells,
at once cut small incisions with a sharp stone all
over his arm and shoulder, from which the blood
flowed freely, and he explained that if he had not
taken these precautions he would have died. On
examination of the plaee where he had been bitten,
a small mark about the size of a threepenny piece
between his finger and thumb was seen. Upon
close examination of this area, two small incisions
in the centre were seen, from which evidently no
blood had come. He stopped the blood of the
numerous cuts on his arm and shoulders with hot
wood ashes, and the arm seemed to be stiff and use-
less for the time. But Dr. Hinde did not know
whether the effects of the bite or the cure were
responsible for this state. Many other natives
when questioned stated that the bite of this cone
was deadly. Dr. Cox also mentioned that the Rev.
W. Wyatt Gill had recorded the fatal effects of the
bites of C. teztilis, Linn. Mr. Hedley has been
unable to find this reference. Mr. Brasier had
also informed Dr. Cox that he had known severe
effects caused by the bite of Conus tulipa, Linn.
Hepuey, C. (Appendix to Thomson’s ‘* British
New Guinea," 1892).—Information from a Papuan,
p. 283. Copied by Cooke (Cambridge Natural His-
tory, Mollusca).
Mr. Hedley says that “ The natives are quite
aware of the poisonous bite inflicted by several of
the Cones. While collecting on a coral reef, I once
rolled over a boulder and exposed to view a living
Conus textile. Before I could pick it up, one of
my coloured companions hastily snatched it away,
and pointing to its ‘‘ business end," explained with
vivid gesticulations, its hurtful qualities. He
would on no account allow me to handle the shell,
but insisted on putting it himself into my bottle ot
spirits.” :
HarLEN, Dr. A. HrnnBEnT.— The following report
by Dr. A. Herbert Hallen was forwarded to the
Australian Museum, Sydney, by Dr. B. G. Corney,
from Fiji, September 10, 1901. Accompanying it
was a shell, identified as Conus geographus, said to
be similar to the one that inflicted the severe bite
described. The following is the extract from the
Government Medical Officer's Report, Levuka, for
the month of June, 1901:—
“I had under observation the case of an Euro-
pean lady here who was the subject of a severe
30 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 15, 1913.
form of poisoning by a shell-fish, of the species ot
which a shell is now sent for identification.
‘“ The lady was fishing not far from the shore
in the evening, with her family and native servant
in the boat. The shell-fish having been obtained,
the boy cracked it to extract the meat, which was
large in quantity for the size of the shell, and having
eracked the shell, handed it to his mistress with
the meat hanging from its internal attachment.
To free the flesh she inserted her little finger to-
wards the upper end, and, she declares, felt the
animal shoot out a sharp-pointed thing which pene-
trated her finger and caused such a peculiar sensa-
tion that she at once called out that she was bitten
and poisoned.
The poisonous matter is said to be the yellow
pulpy matter at the thicker end of the shell; it
might, of course, be merely reproductive or digestive
tissue, or again there might well be a modification
of some secretory gland to form a protective poison
gland, and in the latter case, nature would surely
provide along with the poison, some mechanical
means to promote injection into an enemy.
‘The point of puncture in this case was minute,
and only to be seen with great care; indeed, that
it was a puncture was much less readily seen than
the local effect of the poison which caused a bluish
discoloration of the surrounding tissues. It was
situated at the point of the patient's little finger
near the side of the nail. Through so small a punc-
ture, and in so short a time as was allowed to its
insertion (she did not unfortunately suck the
wound), but a most minute quantity of the poison
could have entered the circulation, yet the effects
were most grave. Locally a numbness was first
experienced. This extended rapidly up the arm,
which became paralyzed, and the paralysis spread
thence rapidly throughout the body. It was pecu-
liar that not only was general muscular control
nbolished, even so far that the head had to be sup-
ported over the trunk in order that unimpeded
breathing might be allowed to continue; but there
was a loss also in a lesser degree (as I think) ot
sensation, with numbness and ' pins and needles '
beginning in the arm and becoming generalized
through the body, and to more marked degree there
was u disappearance of muscular sensation and a
complete absence of knee jerks. The patient con-
stantly asked where her limbs were. ^ Utterance
was thick and indistinct. The respiratory and car-
diae muscular apparatus did not at any time parti-
cipate to a dangerous degree in the paralysis. The
stomach, however, may have been affected (or was
it the recti abdominis and other abdominal muscles)
for I could not induce vomiting. When at its worst
some three or four hours after the poisoning began,
the condition distinctly affected the throat, and a
good deal of distress was caused by the difficulty in
removing accumulated fluid. The poison seemed to
me to clearly belong to the class of which curari
is the type. Of this I felt assured as soon as I had
examined the patient and observed the freedom ot
the respiratory and circulatory centres from its
actions compared with the absolute abrogation of
Jan. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
31
voluntary muscular paralysis so that, the patient
weighing sixteen stone odd, I felt a good deal of
anxiety as to whether the arms would not dislocate
at the shoulder when the body was lifted in the chair
by the hands under the armpits; indeed it was
exceedingly difficult to move the patient, all the
parts being so abnormally yielding. The treatment
| adopted was merely directed to the sustaining of
life till the poison should have been destroyed. The
heart and lungs were quite equal to their work if
other circumstances could be kept favourable. This
was done by placing the patient in a semi-recum-
bent position in a canvas chair, and by keeping the
head in such a position that breathing and swallow-
ing were facilitated. I should have liked to relieve
the circulation by inducing vomiting, but failed to
do so. Had I had strychnine with me I should
have injeeted it hypodermically, but I did not feel
justified in leaving the patient to get it. Urination
was involuntary. The worst was past in about six
hours. The wound was made about 9.30 p.m.
Paralysis lasted on with steadily diminishing inten-
sity till late next day, but the numbness lasted con-
siderably longer in the injured finger, and for a
month after the patient experienced a shock in the
little finger on hard impaction—as in playing the
piano. This was the last symptom to clear up,
unless the sore eyes which began and lasted later
are to be attributed to this poison as their cause.
Though natives declare that recovery from fish
poisoning is often complicated by sore eyes, yet 1
am not aware that the tradition would apply to this
kind. I have heard since of other cases of this kind
of fish poisoning, and among others of a Kadava
woman who died before she could be got from the
shore.”’
(To be continued.)
———p
Hotes and Mets.
THE SECOND ALL-INDIA SANITARY
CONFERENCE AT MADRAS.
(Concluded.)
Town IMPROVEMENT IN LUCKNOW.
THE Honourable Rai Ganga Prasad Varma Bahadur
(Lucknow), in his note on “ Town Planning and Town
Improvement," gave an account of four town improve-
ment schemes that had been successfully carried out
by the Municipal Board of Lucknow. He advocated
large State expenditure on improvements and the
grant of facilities. He thought that land for new
houses should be sold freehold or given on ninety-nine
years’ lease. He was against levying any rate on un-
earned increments as people would be unwilling to pay
any rate on their property merely for the fact that a
new road was going to be constructed at some distance
from their holdings. He laid special stress on the fact
of having selected offices entrusted with land acquisi-
tion work. He thought that Government should
encourage philanthropic bodies to form new “ bastis,”
and that capitalists should be persuaded to find money
for building sanitary houses. In his experience the
people were ready and willing to spend ten rupees for
every single rupee spent by the local body on town
improvement schemes.
BUILDING BYE-LAWS FOR CITIES.
Major S. A. Harris, Sanitary Commissioner, United
Provinces, in his paper on “ Building By-laws for
Cities," referred to the difficulty in enforcing by-laws,
and gave instances of by-laws having been trans-
gressed without adequate penalties. The control of
the erection and re-erection of buildings was sought
after by members in some municipalities, but many
Municipal members complained of the worry to which
they were subjected by their friends and electors to
try to obtain some concession or escape from the
operations of certain by-laws in their individual cases.
It would be preferable if members were protected
from those importunities by delegating their executive
powers to an official chairman or to a health officer
with whom the individual would have no direct
concern. It was with a view to the relief of the
members from an invidious position that health
officers were enrolled in provincial service and appeals
against their actions could only be directed to the
Commissioner and the Sanitary Board. He sincerely
hoped, therefore, that Municipal members would adopt
a method of delegating their powers for the control
and enforcement of by-laws.
TowN IMPROVEMENTS AND DRAINAGE IN INDIA.
Mr. V. Devasikamani Pillai, Sanitary Engineer,
Hyderabad, next read a paper on " Town Improve-
ments and Drainage in India." He said that pro-
posals for town and village improvements should go
hand in hand with proposals for large cities. In every
town and village in India they found congested areas
and people went on building valuable houses in those
areas, and those towns were far beyond the reasonable
operation of sanitary rules and regulations. Sanitary
inspectors and reports were very necessary there.
There were several methods of improving smaller
towns, some of which were:—
(1) Leaving open areas for ventilation by purchas-
ing old unhealthy houses.
(2) Building up a new town close by the old and
diverting the people to that locality in the way, having
all publie buildings constructed in that locality.
(3) Facilitating transit by extending tram lines to
the extreme limits of the thinly populated area.
(4) The introduction of several publie bathing
houses, latrines and urinals would considerably im-
prove the health of the people as well as their houses.
(5) The construction of publie schools for children
was very essential. It had a great education value,
for the children would be trained to have higher ideas
of sanitation when they saw a fine house in the
school.
(6) Great attention must be given to the health of
children by scattering over the whole town small play-
grounds.
(7) As pure air was very essential, town improve-
ment trusts and village improvement trusts must be
immediately wrganized.
(8) Surface drains must be immediately built.
32 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1913.
SMALL RESIDENCES ON TRUST ESTATES.
The following short note on “Small Residences on
Trust Estates," prepared by Mr. Watson, Engineer
to Bombay City Improvement Trust, was then pre-
sented :—
Formerly houses were built closely packed together
as a security against robbery and physical violence,
but in a more peaceful age such necessity no longer
exists. In spite of this, however, and on increasing
recognition of the fact that overcrowding underlies
the prevalence of numerous diseases, is productive of
plagues and epidemics, and reacts generally in a dele-
terious manner on the mental, moral and physical
welfare of the human race, great difficulty, owing to
apathy on the part of the tenant and the avarice of
the house owner, is still experienced in launching any
scheme of improvement.
The solution lies in co-operation between the two
classes, and the paper proceeds to show how this is
possible to the advantage of both, decent sanitary
accommodation at a reasonable rental to the tenant,
and a fair return of his capital tothe owner. A large
area of land recently acquired by the City Improve-
ment Trust, Bombay, is taken as an example, and
plans showing the " lay out” are discussed, types of
houses with drawings and estimates of cost are
shown, and the whole financial details of the scheme
explained.
RELIEF OF CONGESTION.
Dr. Amritaraj, Health Officer, Civil and Military
Station, Bangalore, next introduced his paper on
“The Relief of Congestion in the Civil and Military
Station, Bangalore, and Results." In doing so he
said that attention was first directed to the need of
sanitary reform by the periodical recrudescence of
plague from 1898 onwards, and though minor im-
provements were made, the real campaign against
congested and insanitary areas commenced in 1906.
In this year a thickly-populated area of the native
bazaar, known as South Blackpully, was chosen for
demolition and reconstruction on improved lines. This
area which covered 51.53 acres contained 1,952
houses with a population of a little over 12,000. In
selecting houses for demolition, main thoroughfares
were avoided and new roads were driven through the
worst slums so as to facilitate the circulation of air,
and open spaces were provided. A large population
was necessarily unhoused, and to provide accommoda-
tion for these people, and also to encourage emigration
from slum areas, a plot of land of 50.35 acres in
extent was acquired and laid out in plots for building
purposes. In this area, now known as " Fraser Town,"
all facilities were given for building, but under im-
proved building regulations which are detailed, and up
to date, no indigenous case of plague has occurred
there. Now a further extension of 47 acres has been
acquired, and this is being laid out, and it is hoped
that the sale of plots will cover not only the cost of
acquisition, but also the laying out of roads and drains,
water and light, and a central park. Various details
of the improvement schemes are given and the better
health conditions which have resulted are shown in a
series of statistical appendices.
Dr. Nair said that he did not want to go into
details, but there was one particular idea underlying
them all : he would like to have an expression of opinion
from that Conference on the following point, Was a
municipality justified in acquiring more land than is
absolutely necessary for an improvement, and selling
the remaining land, after the improvement had been
effected, at the enhanced rate caused by the improve-
ment? This appeared to be permissible in Bombay
and Caleutta, but it was not so in some of the local
Governments of India. In the opinion of the Madras
Government only what was required for the improve-
ments was allowed to be retained, and the rest had to
be resold to the owner at a price at which it had been
bought. If that opinion were generally held, the cost
of improvements would fall heavily upon the local
bodies, whereas if the land could be retained and sold
at the enhanced price the cost could be easily met
by the profits. He would not press the Conference to
pass a resolution at that time, but he would like the
Conference to pass a resolution on that point on
Saturday next.
The Honourable Rai Ganga Prasad Varma said that
local bodies have power to acquire land for frontages
of new houses. A question was put to the Legislative
Council of the United Provinces, and that was the
opinion they had given in reply.
Dr. E. G. Turner pointed out that Bombay had
power to acquire land outside the plot required for
improvements, and to resell it at a higher price.
The Honourable J. P. Orr said he thought it was the
policy of the Bombay Trust to take up more land
than was required for the improvements. He thought
it was fully justified when they considered that if they
only took up so much as was required for roads the
owners on either side had their land bettered but paid
nothing for it. It was because of that that he thought
the municipality should be allowed to take up more
than is required for its roads, and they would thus get
the benefit of a better return for their improvements.
Babu Bepin B. Bramachari, L.M. and §., asked
whether the Corporation could deliberately take more
land than was necessary for public utility with the
view of making a profit for public works.
Major W. W. Clemesha said that he thought that
what Dr. Nair was inquiring was whether the Land
Acquisition Act in any province would allow of aequir-
ing more land than was required for public purposes.
They were not entitled to take more land and resell it
under that Act. It was necessary, if that was desired,
to have a special enactment. It could not be done
under the present Land Acquisition Act. This ended
the discussion.
Rotices to Correspondents,
1,—Manuscripts sent in cannot be returned.
2, —As our contributors are for the most part resident abroad,
proofs will not be submitted vo those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
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JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
5.— Correspondents should look for replies under the heading
** Answers to Correspondents.”
Feb. 1, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 8, Vol. XVI.
Original Communications. oy ag
Lá Rubr 49
THE RÓLE PLAYED BY FUNGI IN SPRUE. mem pid lg
By ALDO CASTELLANI, M.D. (Florence), a}a[nposy | | | | | | o
Director, Government Clinique for Tropical Diseases, Colombo,
AND ujep34ury | I. d oe uec
GkonaGE C. Low, M.A., M.D., se
Lecturer, London School of Tropical Medicine. TENIR | | 3 i | | oja
Tue fungus theory of sprue is an old one. ayısou | Pot s x dre
Kohlbrugge, in 1901, describing the ulcers on the d TEMA. =e
tongue and the intestinal contents, found a fungus per emak | QV €, oe OY m
which he believed to be identical or closely allied to J LE m m
the Oidium albicans, the hyphomycete known at TM | adi Nr cis
the present time under the name of Monilia albi- oupv[at) | ooooolco
cans. He observed the same organism in the stools $
and in the vomit of four other patients suffering wg | sea ie a hag OP
from the same disease. He concluded that the
fungus was the etiological agent of the malady. ds | Qo O a id
This theory has later been upheld by many PRR ouordea | CE TESS ee
authorities, especially amongst Dutch and French m
observers. At the present day the hyphomycetic Wei | Quo +O 5 uS. O
theory still has a number of supporters. Daniels
states that it is possible that sprue is due to some 91q108 | oco Qe o '9
yeasts, but it is not proved, while Le Dantec goes i 1 INQUINS AS ES
so far as to call the disease Blastomycosis intes- a l M, Hire ee a e
tinalis. This authority has described .a sac- 4 sovy | TES i Ton Sls
charomyces as the cause of the disease. 5 =
Lately, having had the opportunity of studying S osoulquiy | oo e 000
several cases of sprue, we have carried out a num- $ - — E ;
ber of researches to determine what róle, if any, $ asouyeyg | O O O Q O 8
fungi play in the etiology of the disease. Out of a E | e
series of eight cases we have observed fungi, either E weed T Ea Or wt
in‘ the saliva or stools, in all but one. The one in Bh. cessad | oooooso
which they were absent was a typical case, but the . à —
stools were not frothy, their reaction was not acid, A auus | 4 o 2.6: S o
and as a general rule there was no diarrhoea. Fy — Oa GIC ER CI
Remarks on the Fungi found.—All the fungi E asov I | er Sy SCF Si
found by us belong to the genus Monilia, namely, z
Monilia enteric, Cast., M. fecalis, Cast., M. insolita, asorByooeS | Z G 2 LE S E
Cast., M. intestinalis, Cast., M. rotunda, Cast.
To these fungi already described by one of us osojov|U S Gaala
(A. C.), we are now in the position to add another, nd es
a w species, of which we here give a brief t5 c
düsertplión. É T ^ MPN | Z x $3339
This fungus was isolated by us from scrapings iode] | Gom ru de E
taken from the tongue which were inoculated into —— = = z = =
maltose agar tubes. We may say in passing that asoony | Se os E ud 2
certain cellular histo-pathological changes noticed by [zt 5 e
one of us recently, were seen in the scrapings. anu muy oS eh Ze 6.2 &
After forty-eight hours the inoculated tubes pre- din = n
sented two types of colonies, some being rather : £
large and of a creamy white colour, while others H
were extremely small, translucent, and dew-like. | E
The latter were colonies of a streptococcus, the ri S
former were those of a fungus. d oe, de (Oy eS LS
. . 0 a 4 a U
Subcultures of these were made in various sugar | de d4 & & €x
agars, in gelatin, in serum, and in a number of | ee S'S gE
sugar broths. 3 2s 3 F 8
The fungus on a slightly acid-solid sugar medium | s 3 3-3 $$
(maltose and glucose) grows very abundantly, giving 15 M ab a n Sa
rise to round colonies which soon coalesce into a SS 3 8 £8
creamy white mass with smooth surface. On this Š 3 Bos 68
A A cw
medium the fungus grows principally in the shape
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of a saccharomyces, but a few mycelial forms may
also be observed, especially in the condensation
water. On alkaline media growth is much less
abundant, and there is a complete absence of
mycelial forms. On gelatin the fungus grows fairly
well, the medium is not liquefied. On serum
growth is rather scanty, and there is no zone of
black pigmentation round the growth, as is the
case with some species of Monilia, such as M.
fecalis, M. insolita, &c. Litmus milk is first
decolorized and then clotted, the clot being finely
granular. As regards sugar reactions the fungus
produces acid and gas in glucose, maltose, and
levulose, while it produces acidity without gas in
saccharose, dextrin, galactose, and glycerin. It has
no action on the following sugars: Lactose, dulcite,
mannite, raffinose, arabinose, adonite, inulin,
sorbite, inosite, amygdaline, and isodulcite.
The cultural characters of the fungus, together
with those of the same genus previously found in
the mouth and intestinal contents of man, are given
in the following table. For comparative purposes
another table is given in which the cultural charac-
ters of all the Monilias so far known are collected.
This table, compiled by one of us (A. C.) has
already appeared in the Journal of Clinical Research.
Presence of the Fungi in the Stools of Sprue
Patients.—As already stated, we have found fungi
of the genus Monilia in seven out of our eight cases.
The fungi are generally present in large numbers
when the stools are very frothy. In such cases the
microscopical examination of a minute portion of
the frothy part of the motion may reveal the
presence of enormous numbers of spore-like bodies
and mycelial elements. There would seem to be an
intimate relationship between the reaction of the
intestinal contents and the presence of the fungi.
We have often observed that by giving very
large repeated doses of bicarbonate of soda the
fungi apparently disappear, or at least decrease, in
amount, and the frothy diarrhea goes, as well as
the feeling of flatulence from which the patients so
often complain. It is probable that sodium bicar-
bonate given in large doses, Ey removing or decreas-
ing the acidity of the intestinal contents, may check
the growth of Monilia fungi which, as one knows,
grow far better on acid than on alkaline media.
Fungi found in Normal Individuals and in People
suffering from various Diseases.—All the fungi
found by us in the stools and in the mouths of sprue
patients have also been observed by us in the
Tropics in the stools and occasionally in the mouths
of normal individuals, as well as in patients suffer-
ing from various diseases such as enteric fever.
It is to be noted, however, in our experience, that
the finding of fungi in temperate or cold climates
is of rare occurrence.
Pathogenicity of the Fungi found.—From some
experiments made by us these fungi, provided they
are given in moderate amount in food to the lower
animals, such as rabbits and monkeys, have
apparently no definite pathogenic action. It is
interesting to note, however, that rabbits inoculated
subeutaneously with cultures of them elaborate
agglutinins in their blood and these are to a certain
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE 35
extent specific, namely, the inoculated rabbit de-
velops a distinct amount of agglutinin only for the
species with which it has been inoculated.
The intraperitoneal inoculation of massive doses
may give rise to an acute purulent inflammation
and death. In a case studied a pseudo-tubercular
peritonitis resulted.
Conclusions.—From our clinical, pathological,
and experimental experiences we can confirm the
opinion which we have always held, namely, that
fungi are not the real cause of sprue. That there
may be secondary hyphomycetic infections, especi-
ally in the last stages of the disease, is certain, and
that these fungi may play a part in the production
of some of the symptoms, such as the frothiness of
the stools, is possible. Analogy supports this view.
In scabies, for example, the main part of the
symptoms is due to a secondary invasion by
staphylococci and not to the primary or real cause,
the acarus, while in tuberculosis of the lungs the
so-called typical serotine fever is not due to the
tubercle bacilli, but to secondary streptococcal
infections.
If we may express our opinion we believe that
sprue will ultimately turn out to be an infectious
disease, probably of protozoal origin.
A CASE OF BLACKWATER FEVER SHOWING
THE CELL INCLUSIONS OF LEISHMAN.
By AnpRew DBALFOUR, oM) M.D., B.8e., F.R.C.P.E.,
Director, Wellcome Tropical Research Laboratories,
Gordon College, Khartoum.
Tue following case is chiefly of interest in that I
found in the peripheral blood the chlamydozoa-like
bodies recently described by Leishman and also be-
cause some attempt was made to carry out research
upon it by the experimental method, so much
neglected in the past and so strongly advocated by
Craig [1].
Further, dark field illumination was employed in
the examination of the peripheral blood, a procedure
not hitherto, I believe, adopted in the disease. 1
Both for access to the case and for the clinical
details I am indebted to the kind courtesy of
Captain A. G. Cummins, R.A.M.C., attached to the
Egyptian Army.
No. 1728, Nafar (Private) Ibrahim Shalabi, an
Egyptian belonging to the Medical Corps, was
admitted to the Military Hospital, Khartoum, on
December 17, suffering from high fever and vomit-
ing, accompanied by the excretion of a *' port wine "'
urine.
This was the patient's second attack of black-
water, as he had suffered from it at Roseires, on the
Blue Nile, in October, 1912.
On recovering, he went on leave to Egypt in
November and was ill for about fourteen days when
on leave. He returned to the Sudan in December,
arriving in Khartoum on December 14. He was
taken ill on the night of December 16, at the time
when the weather was distinctly cold, dosed him-
self with quinine and was admitted to hospital on
the 17th, as stated. In addition to the symptoms
36 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 1, 1913.
SS ee a reo WO Se ACE EE or ee
TM ——— M—M—————————————————————————————————————
mentioned, he was restless, had an enlarged spleen,
a tender abdomen, and was considerably jaundiced.
I saw the case on this day and about 20 c.c. of
blood were taken from a vein in the arm, citrated
and inoculated almost immediately into a young
Cercopithecus :wthiops (sabwus), which weighed
1.12 kilos, whose temperature was 102.69 F., and
whose blood was found to present no apparent
abnormality. At the same time wet films were
secured for the dark field method and dried films
for staining.
It may be said at once that the history of the
case was uneventful. The patient was put im-
mediately on Hearsey’s treatment, enemata of
warm salines were given and hot linseed poultices
were applied to the loins.
On December 18, there was little change, the
pulse being rapid with a tendency to dicrotism, but
fortunately urine was passed in fair quantity. The
treatment was continued and the enemata were well
retained.
About midday on December 18, the urine began
to clear and thereafter the patient rapidly improved,
so that on the 20th the perchloride and soda mix-
ture was stopped and the patient given a tonic.
Thereafter his complete recovery was only a ques-
tion of time.
Turning now to the blood examinations, it may
be noted that three preparations examined by the
dark field method on December 17 showed no
abnormality. In one of the stained films in a cell,
probably of an endothelial nature, I came across
inclusions exactly resembling those described by
Leishman [2], and which he suggested might be
of a. chlamydozoal nature. These are shown in
fig. 1, while fig. 2 represents a ruptured ‘‘ chrome ”
cell found in another of the films. In none of the
films examined, eight in number, were any malarial
parasites found, but, as will be remembered, the
patient had taken a dose of quinine when he first
felt unwell. No other blood parasites were found.
I thought it worth while making a differential
leucocyte count from one of the films taken on the
first day of the illness. The following is the result,
500 cells being counted :—
Eosinophiles M s; 0
Polymorphonuclears ss i.
Large mononuclears 11
Transitionals eu e 04
Large lymphocytes ze X
Small lymphocytes 0 is
Basophiles ... V Od- z
: The increase of large mononuclears and transi-
tionals, the decrease in eosinophiles and the small
number of- lymphocytes form noticeable features
of the count and point to a malarial condition. So
far as one can tell from an ordinary film examina-
tion there was a leucocytosis present.
Blood for examination was again taken on
December 19, but though three stained films were
carefully searched no further inclusions or chrome
cells were found. As before, malarial parasites
were absent, and there was nothing to indicate a
spirochetosis. A normoblast and a megaloblast
were found in one of the films, and it seems worth
4 per cent.
”
Mm» B3 BO DO bw
noting that the number of eosinophiles had
markedly increased. Possibly this may be looked
upon as a favourable omen as regards prognosis in
cases uncomplicated by helminthic infection.
The cells containing the special inclusions were
like those described by Leishman and the reticular
nature of their cytoplasm was well marked. The
inclusions themselves closely resembled those
originally seen by Leishman, though I did not find
the ring forms taking on the deep pink colour of
which he speaks. Possibly my specimens were not
so well stained. He speaks of them exhibiting a
considerable variation in shape and this I also
found to be the case, some even resembling little
clubs or rods. Like Leishman, I found that cells
containing them were not abundant in the blood,
though, curiously enough, I, so to speak, stumbled
on one after a few minutes’ search. Most of them
were to be found along one or other edge of the
film. I met with no example of the erythro-
phagocytosis of which he makes mention, but, as
stated, a chrome cell was found. As fig. 2 shows
very clearly, many of the deep-staining chromatin
granules from the ruptured cell were ring shaped
and some of them were of comparatively large size.
With the unruptured chrome cell one is quite
familiar, especially in films coloured deeply by the
Giemsa stain.
An examination of several blood films made on
December 31, when the patient was convalescent,
showed no cell inclusions, but a well-marked
eosinophilia was present. There is not much to
note about the single animal inoculation performed.
The citrated blood was injected subcutaneously, but
at no time did the monkey exhibit any sign of
illness, nor did its urine become affected.
One point, however, may be mentioned. The
animal’s blood was frequently examined after the
injection, and on every occasion I came across
cells like those shown in fig. 3. It will be
noticed the appearance is not, at first glance,
unlike that of the cells containing Leishman’s
granules. At the same time there are distinct
differences. The granules in the monkey’s blood are
short, stout rods and are never in a ring form.
They stain a little differently to the Leishman
granules, being distinctly basophilic and in un-
ruptured cells are arranged in a more regular man-
ner than are the inclusions seen in the blood of
blackwater fever cases. After finding them in
several films I re-examined my first slides taken
at the time the injection was made and I soon
found that they existed also in these films. I do
not remember having previously seen them in the
blood of monkeys, though it is true they are only
conspicuous in the case of ruptured cells. It
would appear that they are probably normal cell
granules in the monkey, at least they have nothing
to do with the injection of the blood from the
blackwater case. It seems worth while mention-
ing them as they might be mistaken for Leishman’s
inclusions by persons carrying out experimental
work in this way.
As to the nature of the true inclusions, I see
that Schilling-Torgau [8], in a paper just to hand,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, FEBRUARY 1, 1913.
Fig. 1. Fic. 2.
Blackwater Fever: Leishman’s Cell Inclusions. Blackwater Fever: Ruptured Chrome Cell.
Fic. 3. Fic. 4.
Blood of Inoculated Monkey : Ruptured Cell, showing Cell Inelusions in Blood of a Malarial Case.
Short Rods and Granules.
To illustrate a paper on ** A Case of Blackwater Fever, showing the Cell Inclusions of Leishman,” by ANDREW
Barroun, C. M.G., M.D., B.Sc., F. R.C.P.E., D.P.H.
Feb. 1, 1913.]
says that the larger forms are phagocyted normo-
blastic nuclei and that the smaller cannot be dis-
tinguished from the plasmosomes of Wolf and
Ferrata. I did not encounter Leishman’s large
forms, but I agree that the small granules are very
like the plasmosomes which I have figured else-
where (Fourth Report Wellcome Tropical Research
Laboratories, vol. A, Plate vi, fig. 8). At the same
time these plasmosomes occur in lymphoid mono-
nuclears, while in blaekwater the host cells would
seem to have an endothelial origin. This, how-
ever, does not necessarily disprove Schilling-
Torgau's view. When I first read the description
given by Leishman, the possibility of their being
of spirochetal origin occurred to me, but Sir William
Leishman informed me that they did not resemble
the spirochetal inclusions in red cells which I have
deseribed in Sudanese fowls. Now that I havé
seen them I am wholly in agreement with this view.
The chlamydozoal theory is very interesting and
suggestive, but at present, of course, it is nothing
more. I have sometimes wondered if blackwater
fever might not be the expression of a* human
spirochrtosis. We know that Schaudinn thought
yellow fever might be of this nature and due to
an ultra-visible form of a spirochete. Marchoux,
Salimbeni and Simond [4] were also of this
opinion. Stimson [5] has actually described
spirochetes in the kidneys of yellow fever cases,
and blackwater and yellow fever are certainly like
each other in many ways.
Anthony [6] says he found a spirochete con-
stantly present in the peripheral blood of 187 cases
he examined and he boldly claims it to be the cause
of the disease. I confess his brief and emphatic
announcement does not impress one and certainly
in this relapse case I found no evidence of spiro-
chetal infection, even by the dark-field method.
Harford [7] mentions a distinct association be-
tween blackwater and what is stil erroneously
called ‘‘ tick fever," and mentions two cases of
men who suffered from tick fever in Africa and
shortly after returning to England died of black-
water. Here, however, the spirochetal infection
may only have acted as a debilitating agent in
cases saturated with malaria. It may be of in-
terest to mention that I remember a British officer
telling me that a fortnight before contracting black-
water fever in the Bahr-el-Ghazal Province he had
been badly bitten on the scrotum by a tick.
Ornithodoros moubata, however, is not known to
oeeur in the Southern Sudan.
It would not be very difficult to build up some
sort of a case for the spirochetal origin of black-
water, but I do not propose to plunge into specu-
lation of this kind, even though Leishman states
that such relaxation may occasionally be permitted
the weary research worker. It is, perhaps, a pity
one did not carry out investigations on a larger
seale when a ease thus presented itself, but the
faet is I had not the necessary time and had the
single monkey inoculated shown sign of illness it
would then have been possible to perform sub-
inoculations.
I doubt very much, however, if blaekwater is
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 37
anything more than the special action of depress-
ing influences exerting themselves along with the.
malarial toxin and therefore I do not think much
is to be gained from the experimental method in
this disease. Still it must not be forgotten that
what appear to be well-authenticated cases of black-
_ water fever occurring without any previous malaria,
notably, perhaps, that by Rodenwaldt [8] in
German East Africa, have from time to time been
recorded.
In the light of our present knowledge, however,
blackwater fever is more a ‘‘ symptom complex ''
than a well-defined disease, so that errors in
diagnosis are likely enough to occur.
Until the vexed question of etiology is settled it
would appear advisable to employ the Levaditi
silver method or one of its modifications in the
study of the organs from fatal cases. The use of
dark-field illumination or of the Burri method
(Harrison’s [9] recent modification of which
appears likely to ke useful) also seems indicated
in the study of the blood and tissues in blackwater
fever. I would conclude by again thanking Captain
Cummins for his courtesy and help. :
REFERENCES.
[1] Creare, C. F. (1910). “Is Hemoglobinuric Fever a Mani-
festation of Malaria or a Disease Sui Generis?" Collected
Papers American Society of Tropical Medicine.
(2) LetsHman, W. (November, 1912). '' The Etiology ‘of
Blackwater Fever," Trans. Soc. Trop. Med. and Hyg., vi, 1.
[3] Scnirrixo-Tonaav, V. (December 16, 1912). ** Concern-
ing the Origin and Significance of Leishman’s Chrome-Cells
in Blackwater Fever (the Basophile Granule Leucocyte of
Ehrlich)," JOURNAL oF TROPICAL MEDICINE AND HYGIENE.
[4] MagcHoux, E., SALIMBINI, I., and Srmonp, P. N,
(November. 1903). Report of French Mission at Rio, Ann.
de l'Inst. Past. .
[5] Stimson, A. M. (December 1909). ‘ Notes on Stimson's
Spirochzete found in the Kidney of a Yellow Fever Case,"
Trans. Soc. Trop. Med. and Hyg.
[6] AnTHony, C. (November 18, 1911).
amongst Negroes,” Brit. Med. Journ.
[7] Hanronp, C. F. In discussion on Leishman's paper
(loc. cit.) :
[8] Ropenwatpt, E. (November, 1910). ‘‘ Schwarzwasser-
fieber ohne Malariafieberanfall," quoted in Archiv. f. Schiffs
und Trop. Hyg., xv, ii, 1911. TS y
[9] Harrison, L. W. (November 30, 1912). “A Modification
of the Burri Method of Demonstrating the Spirocheta pallida,”
Brit. Med. Journ.
‘“ Infectious Diseases
Norte.
Very shortly after completing this paper I received
for examination the blood of a British officer who
had recently returned to Khartoum from Roseires,
on the Blue Nile, a notoriously malarial station
where blackwater fever is known to occur.
The officer in question was suffering from a fairly
severe attack of fever, and had dosed himself with
quinine. He had no symptoms of blackwater and
no malarial parasites were found in his blood, but
I. discovered the fine example of cell inclusions
shown in fig. 4. There was a marked increase of
large mononuclear leucocytes. The patient re-
covered without any untoward symptoms.
In thinking over matters, I have been wondering
if we may not be on the wrong tack looking for
parasites in blackwater fever. Is it not possible
that some biting insect may introduce into the
blood stream a toxin in the shape of a powerful
hemolysin? That some insects do contain hemo-
lysins we know, and it is conceivable that such
might be injected and, acting on red corpuscles
already predisposed to hemolysis, through the
influence of malaria, or some other detilitating
condition, induce the state of things encountered
in blackwater fever. Considering how small a
quantity of any such toxin would probably be
injected it is perhaps difficult to conceive of its
possessing such potency, but the final effect might
only follow several injections, or repeated injec-
tions; while it is possible the virulence of the
hemolytic toxin might be heightened after intro-
duction into the human body, perhaps only after
a lengthy period.
realms of speculation, but put forward the sugges-
tion as one which would meet many difficulties and
which, for all we know to the contrary, may have
a basis of truth. When we remember how pro-
foundly the toxins of Agchylostoma duodenale, in
all probability, affect the state of the blood it is
perhaps not asking too much to request considera-
tion of the above-mentioned hypothesis, which, so
far as I know, has not been hitherto advanced.
—_—__—_.@—__.
Sand-fly Fever.—From June to September, 1912,
161 cases of sand-fly fever and 112 cases of malaria
were admitted to the Military Hospital, Parchinai.
Capt. E. C. Taylor, I.M.S., and M. H. Khan,
Assistant Surgeon, give an interesting account of
these cases in the Indian Medical Gazette, Decem-
ber, 1912. The authors use the term ''sand-fly
fever '' as opposed to ''three-day fever," for the
period of pyrexia in 161 cases was as follows: One
day, 73; two days, 55; three days, 24; four days
or more, 9.
Three notable features of sand-fly fever are
pointed out by the authors:—
(1) Complaint of very severe body pains.
(2) Presence of catarrhal signs.
(3) Slow pulse.
In differentiating from malaria one may note that
in sand-fly fever the patient complains of severe
pains and not of fever. In malaria their answer to
the question ‘‘ What is the matter with you?’’ is
‘“ I have fever,” not ‘‘ I have pains.”
As to the catarrh, the first cases were isolated
under suspicion of being ''early measles.” The
face is red, eyes suffused, fauces injected. There
is well-marked, angry-looking injection of the soft
palate elearly dividing this from the uninjected
mueous membrane over the hard palate.
In malaria the patient though flushed and with
red eyes during the paroxysm will next morning be
pale, with clear fauces and palate, and though his
temperature be nearly normal his pulse-rate is
generally over 100. In cases of sand-fly fever with
temperature of over 100, the pulse-rate rarely
exceeded 100; and next morning when the tempera-
ture would be over 100, the pulse would be be-
tween 80 and 90, and soon drops to 60 or 70.
The presence or absence of an enlarged spleen
gives little help; because there is nothing to prevent
the subject getting sand-fly infection, even though
his spleen is enlarged as a result of malaria.
`
Y. — =
38 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
I fear I am now in the happy `
[Feb. 1, 1918.
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THE JOURNAL OF
Tropical Medicine and hygiene
FEBRUARY 1, 1913.
OPIUM SMOKING BY THE CHINESE.
AT the present moment the opium question, in
its financial and political aspect, occupies a pro-
minent place in the public eye. Opium from India
in huge quantities, in value some £12,000,000, is
said to be in the hands of merchants engaged in
the China trade, and the question of the loss thereby
threatened is in danger of becoming an international
one. The reason why the opium chests have accu-
mulated in the treaty ports of China is due to one
of two causes: either the Chinese have ceased to
smoke opium and require neither the imported
opium from India nor the home-grown Chinese
product, or the Chinese are continuing to smoke
opium and are being supplied, not with the im-
ported, but with the home-grown drug. The crux
of the question from a political standpoint turns,
therefore, on whether the Chinese are continuing
to smoke the opium produced in China or not.
If it is the case that the Chinese have ceased to
smoke opium everyone will rejoice, and none more
so than the medieal missionaries in China, who have
continued to preach of the evils consequent upon
opium smoking. Even in pre-republican times the ,
people of China were so well in hand, that had the
Feb. 1, 1913.]
authorities wished to do so an edict from the throne
would have stopped opium smoking within a month.
Such an order, however, was not forthcoming; and
if not, why not? Either the authorities did not
consider opium smoking severely detrimental to the
public health of the community, or for financial
or political reasons an edict of the kind was in-
expedient. Now we are given to understand opium
smoking is forbidden by law, therefore opium in
any form, imported or home-grown, is contraband.
This sudden conversion, if conversion it is, to a
high sense of public morality and super-sanitary state
is most interesting; and in view of such a sudden
change one is asked, from a medical point of view,
whether the sudden stoppage of opium smoking to:
one habituated to the use of the drug is detrimental
in any sense. In a general way the answer is: No!
it is not detrimental to suddenly leave off opium
smoking. A prisoner habitually addicted to opium,
when sent to gaol and suddenly deprived of the
drug, is not placed in any danger in a physiological
sense, and nothing but good results as far as the
general health is concerned ensue. The smoker's
mental state is another thing, and without com-
pulsory isolation, as in gaol, it is doubtful if anyone
inured to the use of opium for years has ever had
suffieient courage or self-control to suddenly stop
the practice. It is, therefore, theoretically sound
legislation from a public health point of view that if
the opium smoker is to be cured he should be pre-
vented getting opium altogether, for it is only by
forcible withdrawal that the custom can be checked.
There is another aspect, however, of the use of
opium in China, independent of the mere debauch
point of view. As a medicine in chest complaints,
and in fever from every cause, it is widely used.
In asthma, emphysema, chronic bronchitis, and in
tubercular disease of the lungs, opium is
smoked or eaten as a means of allaying cough.
The writer has never seen an opium smoker in
China who had not some disease of the respiratory
organs; this, however, is nothing to go by as far as
the prevalence of the habit goes, for as a doctor the
writer was not likely to see opium smokers who
were not affected by some form of illness. Still,
there is the fact, and it is a question whether the
habit engendered the disease, or the disease deter-
mined the habit. The latter would appear the more
probable, and moreover, the continuance of the use
of opium seems to have some restraint upon the
advance of pulmonary tubereulosis once it is
established. Certain it is that, with a tubercular
affection of the lung which seemed to be universal,
the opium smoker appeared to live on far beyond a
period that the severity and extent of the infection
would seem to render possible. That opium is a
curative agent in consumption cannot be enter-
tained, but that it delays the rapidity of its advance
would seem highly probable.
In fever of all kinds opium is used in China. In
malaria we know that it was used in England for
ague, which prevailed so extensively and persistently
throughout the South-Eastern counties and in the
fen couutries until the middle of the last century.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 39
The fever powder in use in England, and handed
over to the farmers when they asked for ague
powders when they journeyed to market, consisted of
opium, arsenic, and quinine or powdered cinchona
bark. The powder was given after a mercurial
purge had been administered, so that malaria was
treated by our immediate predecessors not by mere
quinine, but by four of the most potent drugs
known—namely, mercury, opium, arsenic and
quinine. One specific drug for each specific
disease was not in vogue in those days, and recent
investigations have shown that two or more potent
drugs are necessary before the blood parasites can
be reached and destroyed. But there were fever
mixtures long before quinine and cinchona bark
were known, and in these opium was ever present.
The well-known “ fever’’ tincture was used for
some 4,000 years before Dr. Warburg, of Vienna,
added yet another drug—quinine—to the twenty-two
drugs already present. The use of opium, there-
fore, in China will continue for many a day; it will
be used more extensively in China than in any other
country, not only from the mere fact of the
enormous population, but because a far larger per
cent. of the population use opium in cases of illness
than in any other country in the world. The quantity
of opium required in China will therefore continue
to be large, and whether grown at home or imported
is not a matter of consequence from a purely medical
point of view, but financially it means a great deal
to the merchant. If the Chinese have stopped the
cultivation of the poppy, then as it is a medicine
which is used as a household remedy for many ail-
ments amongst the 400,000,000 of people inhabiting
China, a large quantity must be imported to supply
the legitimate demand of the country. On the other
hand, if the importation of opium from India ceases,
it need not imply bad faith on the part of the
Chinese if they continue to cultivate the poppy, for
the just medicinal demands must be satisfied, and
it is shown above that this is large.
At the present time the Chinese newspapers are
asking why are not the missionaries speaking out
upon the subject and helping them in their demand
that the foreign importation be arrested. The
answer is: that the missionaries have already done
their part; it is due to the foreign missionaries that
even the Chinese authorities know how widely
spread the use of the drug in China is; they have
by lectures, at public meetings, in their reports, and
in the newspapers time and again, and for years,
dealt with the subject, and they have succeeded in
rousing public opinion on the matter both in Britain
and in China. It is the missionaries we have to
thank for a serious attempt to enable China to get
rid of a deadly trammel to her welfare and advance.
or
Mn. AUSTEN CHAMBERLAIN has received £200 from
the Suez Canal Company towards the sum of
£100,000 he is raising for the London School of
Tropical Medicine, The fund now amounts to
£45,000,
40 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Annotations,
The Health of the Canal Zone.—Gorgas, reporting
on the Health of the Canal Zone for the month of
October, 1912, states that the total number of
deaths from all causes among employees was thirty-
eight, divided as follows: Disease 28 and violence
10, giving the annual average per thousand of 6.71
und 2.39 respectively.
Among employees for the,month of October of
each year the annual average death-rate per
thousand was as follows: 1904, 20.31; 1905, 32.85;
1906, 46.68; 1907, 25.97; 1908, 12.93; 1909, 9.95;
1910, 10.19; 1911, 11.08; 1912, 9.10.
The annual average death-rate per thousand in
the cities of Panama and Colon and the Canal Zone,
including both employees and civil population, for
the month of October of each year was as follows:
1905, 56.62; 1906, 46.40; 1907, 30.19; 1908, 27.91;
1909, 16.62; 1910, 23.61; 1911, 21.35; 1912, 23.08.
In segregating according to race, the annual
average death-rate per thousand from disease among
employees was: For whites 3.84 and for blacks 7.66,
giving a general average for disease of 6.71. For
the same month during 1910 the annual average
death-rate per thousand from disease among whites
was 4.51 and blacks 5.98, giving a general average
of 5.58; and in 1911 from disease among whites
4.87 and blacks 10.56, giving a general average
of 9.15.
Among employees during the month deaths from
the principal diseases were as follows: Cirrhosis of
liver, 1; lobar pneumonia, 4; malaria fever, xstivo-
autumnal, 1; tuberculosis, 8; leaving 14 deaths
from all other diseases and 10 deaths from external
violence.
No cases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus during
the month,
Cholera Vibrios in the Biliary Passages.—Major
Greig, I.M.S., in the Lancet of November 23, 1912,
describes the occurrence of cholera vibrios in the
biliary passages. He gives details of the clinical
notes and post-mortem examination of the case in
which this important observation was made. The
case presented several interesting and suggestive
features: (1) After the acute phase the patient
lived for twelve days, dying from uremia. (2) The
presence of cholera vibrios in the bile and the
pathological changes in the gall-bladder. (3) The
presence of the organisms in a eonsolidated area in
the lung also. (4) The pathological investigations
indicated that the changes found in the organs were
the result of toxic action, the origin of this poison
being probably the cholera vibrio growing in the
bile. It would appear that as the vibrios die the
intracellular toxin is liberated and passes into the
system. (5) The pathological changes in the cecum
closely resembled the condition found in the large
intestine of rabbits after subcutaneous or intra-
venous injection of Shiga's bacillus. From a con-
sideration of these facts Greig believes that it will
(Feb. 1, 1913.
be necessary to revise the present conception of
the distribution of the cholera vibrio in the tissues
of man, and this revision may help to clear up
certain unexplained problems connected with
cholera.
Bilharziasis in Australia.—Nelson, writing in the
Australian Medical Gazette of November 9, 1912
(No. 408, vol. xxxii, No. 19), describes three cases
of Bilharzial infection. Two of these cases, one a
woman, the other a man, had never been out of
Australia, so this means the disease has been intro-
duced into that country.
The woman lived at a timber mill, where an ex-
soldier from the Transvaal, suffering from bilharzial
disease, acted as a storeman. She undoubtedly then
had contracted the disease from him; but in what
way it is difficult to say, as bathing facilities were
nil, rain water was used for drinking, and the pipe
water for the mill was pumped from a place over
a hill a mile away. Nelson thinks that the infected
man might have contaminated the bread he handled,
with his fingers soiled with urine, as he had to
micturate almost every half hour. The other indi-
genous case was a West Australian male, aged 21,
who had never been out of West Australia. He
lived twelve miles away from the timber mill, but
the contour of the country made it impossible for
any drainage to come from there. He had once
been, for a period of two weeks, at the mill more
than a year before the onset of his first symptoms,
so any connection betwen the two cases is not by
any means clear. His occupation was a platelayer,
and Nelson thinks he may have got his infection
from the flushing of a lavatory car used by a person
suffering from the disease. The recurrence of such
cases is a serious menace to Australia, and the
Central Board of Health has now made such cases
notifiable. In this way it will soon be ascertained
if the infection is widespread or not.
Demonstration of the Treponema pallidum.—In the
Journal of the Royal Army Medical Corps for Decem-
ber, 1912, Major Harrison describes a modification of
the Burri method of demonstrating the Spirochxta
pallida. The method in his own words is as
follows :—-
A disadvantage of Chinese ink for demonstrating
Spirocheta pallida is that unless it is prepared by
centrifugalization or, as Captain Frost has recom-
mended, by the addition of tincture of iodine, the
field is too granular to make the detection of S. pallida
at all easy.
Major Harrison has found that a more homogeneous
field is easily obtained by substituting for Chinese ink a
a suspension of collargol. The suspension is prepared
according to the directions of the makers (Chemische
Fabrik von Heyden), one part of the powder being
made up with nineteen parts of distilled water. The
powder is first put into a black bottle (or an ordinary
bottle wrapped round with black paper) and the
distilled water poured on it. After standing for a
few minutes the bottle is well shaken and again
Feb. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 41
allowed to stand, it is shaken again and is then ready
for use. The suspension is used exactly as if it were
Chinese ink, a loopful of tlre suspected serum and one
of collargol being mixed together at one end of a
microscope slide and then spread like a blood-film.
The film may be examined with an oil-immersion
lens as soon as it is dry; spirochetes appear white
on a reddish-brown field which is almost perfectly
homogeneous. The examination requires a fairly good
light, but good daylight is sufficient.
As a diagnostic measure this method of demon-
strating S. pallida has the same disadvantages as the
Chinese ink, the chief of these being loss of the
characteristic movements of the spirocheta. Under
dark-ground illumination extremely delicate spiro-
chetes may be seen in the secretion obtained from
the surface of sores which were non-syphilitie. Major
Harrison therefore strongly urges that particular care
be taken to clean the sore beforehand so as to prevent
surface organisms from contaminating the exudate
from the deeper layers.
Primary | Splenomegaly.— Mandlebaum, in the
Journal of Experimental Medicine for December 1,
1912 (vol. xvi, No. 6), describes a case of primary
splenomegaly.
As a result of his studies he states that primary
splenomegaly of the Gaucher type is a distinct disease,
related in all probability to the blood diseases. It
begins usually at an early age, frequently affects
several members of a family, and runs a chronic
course.
The clinical manifestations are: pronounced hyper-
trophy of the spleen, subsequent enlargement of the
liver, absence of palpable lymph nodes, absence of
jaundice and ascites, absence of characteristic blood
changes, discoloration or pigmentation of the skin,
and a tendency to epistaxis or other hamorrhages.
The lesions are found in the spleen, lymph nodes,
bone marrow, and liver. These organs show the
presence of iron-containing pigment, and large multi-
nuclear cells with a characteristic cytoplasm. In the
early cases peculiar large phagocytic cells arising
from atypical large lymphocytes are found in the
follicles of the hwmopoietic system. After leaving
the follicles these cells possess phagocytic qualities for
a certain period. Asa result of the phagocytosis the
cells enlarge, the nature of the cytoplasm changes,
and the cells acquire a characteristic vacuolated and
wrinkled appearance. The cells are carried from the
spleen through the portal system to the liver, where
they are destroyed. The irritation produced by this
destructive process gives rise to an increase in the
intralobular connective tissue.
The disease is eminently a ehronic one, without
any of the manifestations of malignancy, and always
terminating as the result of some intercurrent
affection.
The etiology is unknown, although a family pre-
disposition to some toxic agent which causes an irrita-
bility of the follicles in the hamopoietic system prob-
ably exists. The | possibility of some protozoan
infection as an etiological factor must not be over-
looked.
Malaria in the Andamans.—S. R. Christophers in
‘The Scientific Memoirs by Officers of the Medical
and Sanitary Departments of the Government of
India ’’ (New series, No. 56) writes on malaria in
the Andamans. He believes that his observations
enable him to draw some very definite conclusions
as regards the disease in those parts.
The chief carrier of malaria in the Settlement is
the Nyssomyzomyia ludlowi, he states, a species
which breeds in and about salt swamps, and was
not found at a greater distance from salt or brackish
water than half a mile.
The species of parasite proved to be carried by
this anopheles was malignant tertian. It is prob-
able, as happens with other species, that it carries
all forms of the parasite.
Whether any part is taken in the transmission
of malaria by the other common species, Nsm. rossi
and Myzorhynchus barbirostris, is doubtful. In any
ease, the latter species could only be an important
carrier within the forest. The mere clearing of the
land has made it unimportant even in regard to
numbers.
. Owing to the distribution of Nsm. ludlowi, malaria
in the Settlement is confined to a belt around the
margins of the harbour, and is absent, or nearly so,
from villages more than half a mile from the sea
coast or the salt swamps associated with it. This
freedom from malaria is seen even in inland villages
situated on the margins of swamps, amidst rice-
fields, and near jungle.
In the ease of some villages malaria was found in
the portions lying nearest the sea, but not in the
inland portions.
The endemicity even within the malaria belt is
not strikingly high, and only one large village (Port
Mouat) showed a spleen rate of over 50 per cent.
This moderate endemicity is associated with a
moderate prevalence only of anopheles. Suitable
conditions for breeding were unlimited, but fish of
the genus Haplochilus were very common, and were
found in all waters but those of a very temporary
.nature.
The predominating type of parasite among the
children in the villages was simple tertian. Among
convicts admitted to hospital and among the con-
valescent gang, quartan infections formed 50 per
cent. or over. The carrier was the same, and there
is little reason to doubt that the quartan parasite
predominated in the case of the labouring convicts
because circumstances favoured relapses, whilst
actual transmission of the disease was not very active.
It is interesting to note that though infection
with malignant tertian at the time of Christophers’
visit was very little in evidence, yet the only two
‘infected anopheles encountered were infected with
this type of parasite.
There is some reason to believe, he thinks, that
proportionate prevalence of the different forms of
parasites in any community is dependent upon (a)
activity of transmission (numbers of anopheles
carriers); (b) factors increasing or diminishing the
number and continuance of relapses.
Malignant tertian (producing gametes) most
ubundantly increases whenever transmission is
42 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 1, 1913.
active, i.e., the numbers of anopheles are high.
Quartan, producing few gametes but peculiarly
prone to relapse and to remain for long periods in
the blood, relatively increases when transmission
is low, but factors favouring relapse high. Simple
tertian is an intermediate form able to assert itself
most when transmission is moderate and the
antagonism to relapses not too high (native children
as against well-fed Europeans who suffer most from
malignant tertian due to fresh infection).
It remains to be seen, he thinks, whether the
frequency of relapses at different periods after the
original infection does not differ in the case of
different parasites, still further enabling one to
explain the prevalence of different species of
parasite under any given conditions.
Fistulous Diseases of the Buttocks: A Clinical Entity.
—In a paper read before the Society of Tropical
Medicine and Hygiene in December, 1912, Dr. James
L. Maxwell writes that in South Formosa and South
China a disease of some rarity is met with, the
cardinal symptom of which is the spread of deep
fistulous traeks throughout the subcutaneous tissues
of the buttocks in all directions.
The disease is a rare one; only oneor two cases in
& year are seen at the Tainan Hospital, with an in-
patient list^of about 2,700 patients a year, and an
out-patient clinic of twice that number. The disease is
said by the patients to commence with an apparently
ordinary fistula in ano, a complaint very common
there, but it differs from this in being almost painless.
From the original fistula, fistulous traeks spread in
all directions over both buttocks, til the whole
surface is outlined by a maze of tracks, communi-
eating with each other, and marked on the surface
by raised and indurated lines, opening here and there
by small pinholes, which discharge a serous pus.
The actual pain is very slight, but the discomfort in
sitting is sometimes marked. Owing to the lack of
actual pain, the patients are long in seeking treat-
ment, and the cases he had seen had lasted from one
to five or more years. Treatment proves most un-
satisfactory. Slitting up and scraping the sinuses
seemed to be of but little permanent value, and the
radical excision of the whole of the affected tissues
was impossible, owing to the large areas involved.
For the last ten years he had been seeking some
pathological explanation of these cases. He was satis-
fied that they are not pathologically connected with the
ordinary fistula in ano, which yields very satisfactory
results to the ordinary surgical treatment. One’s
first idea of a chronic disease of this nature was to
refer it to the parasites of syphilis or tubercle. The
cases have, as a rule, no specific history, however,
and they do not improve in the least on anti-syphilitic
treatment; nor does microscopic examination of
sections of the tissues confirm the suggestion that
the disease might be syphilitic.
Tuberculous fistule round the rectum is a well-
known disease. Dr. Maxwell's experience was that
in advanced cases these were very painful; that the
fistulous tracks tended to spread deeply in the
ischio rectal fossa, and that there was a complete
absence of the massive induration that is characteris-
tic of the cases under discussion. Further, micro-
scopical examination entirely negatived any suggestion
of tuberculosis.
When in England, a few years ago, he asked Sir
Patrick Manson to suggest the cause of the condition,
and his advice was to be on the look-out for a
mycotic parasite as the causal agent. Dr. Maxwell
had tried to do this since returning to Formosa, but
with negative results. He wished to state quite clearly
that he did not think this was at all sufficient proof
of the absence of such a parasite. Some of these
micro-organisms, such as those of actinomycosis and
madura foot, were easily recognized, and he was
certain that they were absent from the cases. Others,
such as the germ of sporotrichosis can be determined
only by their development on culture media, and both
lack of time and lack of apparatus made it impossible
for him to engage in such an investigation.
Since he began to regularly examine the pus from
the sinuses, he had found, in all of the few cases that
came to hospital, the presence, and that in large
numbers, of amcebe, conforming he believed to the
type of Entameba histolytica ; and he threw out the
suggestion for further investigation, that the disease
was due to the entrance of these amcebe into the
tissues, possibly from an original simple fistula in ano.
The following points were in favour of such a
suggestion :—
(1) Anything like this condition had never been
seen by him in any other portion of the body surface,
and this suggested the probability that the position of
the rectum and anus had some causal relation with
the disease, as for example in conveying the causal
agent to the site indicated.
(2) The known character of the amcebe in the
colon to form chronic sinuses, burrowing beneath the
mucous membrane.
(3) The chronic and relatively painless nature of
the disease.
(4) The absence of any suggestion of syphilis or
tubercle in these cases.
Dr. Maxwell wished definitely to claim for the
disease a separate clinical entity. With some hesita-
tion he suggested that the causal agent was the
Entameba histolytica.
The cases were rare, his time and apparatus very
limited, and he desired that others more qualified to
speak on the problems raised should have their
attention drawn to this disease.
In the discussion that followed Dr. Maxwell's paper,
Dr. Aldo Castellani pointed out that Kartulis had
described an apparently identical disease in Egypt.
Furthermore Dr. Castellani had seen similar cases
in Ceylon, and from the lesions, in every case, he
had been able to isolate a blastomyces which he
considered to be the causal agent of the disease.
Dr. C. M. Wenyon stated that the mere finding of
amaba in discharges did not prove their causal rela-
tion to the disease, for amcebe could easily have
wandered into the sinuses from the gut; especially
so when one remembered that as many as 60 per
cent. of the healthy population harboured such
parasites in their gut.
Feb. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 43
Beprint,
INJURIES AND DISEASES OF MAN IN
AUSTRALIA ATTRIBUTABLE TO ANI-
MALS (EXCEPT INSECTS).*
By J. Burton CLELAND, M.D., Ch.M.(Syd.).
Government Bureau of Microbiology, Sydney.
(Continued from p. 31.)
PHYLUM ARTHROPODA.
Class Arachnida. Order Acarina.
Injuries by Mites.—Mites are of interest from the
irritation and annoyance produced by them when
they burrow into the skin. The acarus of scabies
(Sarcoptes scabei) has been found in most of the
capitals of Australia producing the itch. The first
reference to it that I can find is by Dr. Thomas in
South Australia (A.M.G., December, 1884, p. 65).
A few years ago Dr. Cumpston, of West Australia,
reported the presence of a case in a school child in
Perth, and since then he has found a few more
cases.
In the tropical parts of Queensland, a small red
mite, Leptus sp., causes great misery. S. W.
Jackson, writing in the ornithological journal The
Emu, vol. viii, June, 1909, thus describes the
attacks of these acarids in the Tinaroo scrubs near
Atherton, North Queensland, at the end of October,
1908 :—
‘ October 31. In patient silence we waited, en-
during absolute torture from the bites of the red
serub animalcule (Leptus sp.), irritating parasites
that can give points to all ticks, sand-flies and mos-
quitoes in the world ” (page 249). '' November 1.
One pays, however, for the privilege of these
scrub wanderings. The coin current in this case
was the endurance of that awful ‘ scrub-itch,’ and
I was glad to get back to camp to ease the ceaseless
irritation, which was getting my legs into a really
horrible state ’’ (page 257). Noveinber 2. The
scrub-itch mites, tiny red parasites hardly visible
to the naked eye, punished me severely again to-
day; they mostly attack the legs below the knees,
and quickly reduce them to a raw state of intense
irritation, which was bad enough to make sleep
quite impossible, and I found on enquiry that the
aboriginals suffer to a similar degree ’’ (page 252).
'" Next day, between the severe scalding sting of
the giant nettle-tree and the countless bites of the
serub-itch mites,” Mr. Jackson found it necessary
not to venture into the serubs lest blood-poisoning
should ensue.
Various Gamasid mites from time to time reach
human beings from other hosts. Several Austra-
lian instances have come under my notice.
Gamasids from Rats.—Recently in Adelaide, the
employees of a manufacturing stationer were much
bothered by small mites getting on to their persons
and finding their way to hairy parts, especially the
pudenda. Here they produced intense irritation,
* Reprinted from the Australasian Medical Gazette of
September 14 and 21, 1912, by permission of the proprietors.
necessitating immediate retirement to the lavatory,
where the small mites were detected. These were
forwarded to the Adelaide Museum, where Mr.
Robert Zietz detected their nature and, on making
further enquiries, was led to suspect rats as the
normal hosts. It was then ascertained that these,
Mus decumanus, were present in large numbers,
even nesting amongst old papers. In such situa-
tions mites were in abundance and easily crawled on
to those turning over the litter. From one
such nest containing young rats, a large number of
mites were obtained, which Dr. Stirling, of the
Museum, referred to my colleague, Dr. T. Harvey
Johnston, for identification. He found that in
character they closely approximated to Lælaps
agilis, though differing slightly in the shape of the
body and in the character of the bristles.
Gamasids from Fowls.—Gamasids, probably
Dermanyssus avium, sometimes pass from fowls
and chickens to persons handling them, when the
irritation they cause produces a rash. An instance
of this at Port Pirie, in South Australia, has been
mentioned to me, and doubtless many others have
occurred.
Gamasids from Starlings.—In Sydney, it has
been reported that in some cases, where English
starlings have built in the roof, the dwellers in the
house have suffered much irritation from mites
introduced by the birds. In one case, in a church,
it is said that the roof had to be renovated on
account of the annoyance caused to the congrega-
tion by these creatures. The mites, Dr. T. Harvey
Johnston tells me, may prove the same as the one
on fowls.
HUMAN INFESTATION BY TICKS.
Along the Eastern Coast of Australia in parts
where there are dense scrubs and tropical jungle, it
is not at all uncommon at certain times of the year
to find that ticks (Ixodes holocyclus) attach them-
selves to the human subject. As a rule, beyond
some irritation, they produce no particular ill-
effects, but every now and again a case is reported,
usually in children, in which severe symptoms have
followed and sometimes even death. Not only are
human beings affected, but dogs are especially liable
to suffer from the effects of these creatures, and
pigs are also said to die from their bites. The first
reference that I can find to human infection by
these animals is an article entitled ‘‘ Queensland
Tieks and Tick Blindness," by Dr. Joseph Ban-
croft, of Queensland, in the Australasian Medical
Gazette for November, 1884.
Dr. Bancroft says that these Queensland ticks
frequently kill dogs and cats, though native animals
endure them without much injury. The ticks
generally seize upon the soft folds of the skin about
the neck and ears of dogs. and in man about the
neck, groin, and armpit. In attaching themselves
they produce little pain and are rarely noticed, but
shortly afterwards a small inflamed point results,
suggestive of a small boil. He says that persons
familiar with the tick can tell by the peculiarity of
the pain when the inflamed point is touched that
44 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 1, 1913.
he is suffering from tick-bite. Swelling of the sur-
rounding tissues may nearly bury the tick. He
gives an instance in which he removed a tick from
a man after it had been attached a fortnight. It
was à in. long and had caused considerable pain
and swelling of the neck, together with a sense of
debility.
Dogs with long hair, Dr. Bancroft found, are
especially liable to contract ticks, which attach
themselves most often about the neck and other
parts the dog cannot reach with its teeth. In
puppies when once tick poisoning presents itself
he had never seen recovery. In full-grown dogs,
in two or three days after the attachment the dog
begins to look weary. In eats through not washing
themselves they appear dirty; food is refused and
soon after drink. The animal lies down and crawls
away where he can remain undisturbed. Puppies
travel away and are rarely again found alive.
Weakness in the hind legs is first observed, and in
about five days from the attachment of the tick
the animal becomes unable to walk, and may at
times be found to become timid and delirious. On
attempting to rise on his fore feet he may fall over
insensible, but in a few minutes recovers his con-
sciousness. During one of these attacks it will be
seen that the lips of the dog are pale, his heart can
scarcely be felt to beat, and the condition of faint-
ing is clearly noticeable. During the illness there
is the greatest reluctance to take food or drink.
Forcible feeding brings on the fainting attacks, and
a few days later he dies in one of the attacks,
though dogs live much longer than puppies. If the
tick has been removed early, recovery may occur.
In the only eat Dr. Bancroft has seen affected, the
animal was unable to walk for a week. After for-
cibly feeding with milk, slow recovery was made.
The cause of death appears to be chiefly due to
museular paralysis. The muscles most remote from
the centre of circulation suffered most, for instance,
the hind legs first, the fore legs next, and lastly the
heart. Animals in an infected country become
tick-proof.
Tick BLINDNESS IN Man.
Dr. Bancroft has seen a case of a married
woman, about 40, who came with a tick attached
to the skin near the ear. She complained of weak-
ness, and a fear of falling on stooping or erecting
herself. The tick was removed. She could not
distinguish persons in the distance, and could only
read half-inch type with difficulty. The iris moved
correctly ; there was no pain or inflammation of the
eye; the accommodation was normal and the
amblyopia was the only error noticed. The other
nervous defects disappeared in about a fortnight,
after which her sight gradually improved, and in a
month she could read ordinary newspaper type.
The next note occurs in Professor T. P. Anderson
Stuart's Anniversary Address* to the Royal Society
of New South Wales in May, 1894. Professor
Stuart refers to the frequency of animals being in-
E e M M —
* Journal of the Royal Society of New South Wales, vol.
xxvii, 1894, p. 10.
fested with ticks in the neighbourhood of Sydney.
He summarizes observations of about a hundred
cases in dogs collected from the letters of his cor-
respondents as follows : —
'"" Young animals are especially susceptible. There
is first moping, hot nose and gradually advancing
muscular weakness first noted in the hind limbs
from the staggering gait, then in the fore limbs and
muscles of respiration. Probably owing to the last
mainly is a great diminution of the animal's
activity and an alteration of its bark, which becomes
rather a gruff cough. Obstinate constipation, and
troubles of micturition or retention are noticed.
Epileptiform attacks or prolonged convulsions may
usher in a fatal issue, or there may be no convul-
sive sign and death ensue from heart failure, the
pulse having been flickering, or from failure of
respiration, preceded perhaps by Cheyne-Stokes
breathing. Peripheral nerve paralysis has been
seen during convalescence. The tick when filled
with blood falls off and leaves a hard lump which
does not disappear for two or three weeks. One
attack confers immunity. Some of the ticks are
comparatively harmless, some, such as the ‘‘ bottle
lick," a single one of which killed a dog of 40 Ib.
weight, are very venomous."'
DEATH oF A LITTLE GIRL FROM TICK-BITE.
The following interesting account of the death
of a child following upon tick-bite has been very
kindly communicated to us by Dr. G. B. Douglas
Macdonald, of Eden. The tick was almost cer-
tainly Irodes holocyclus.
'* A little girl, aged 18 months, living near Eden,
on the south coast of New South Wales, became
ill on November 21, 1909. The father and some of
his men had gone for a walk through thickly tim-
bered land, their clothes brushing against the scrub,
which was in parts infested with bottle ticks. On
returning home the child met them and was car-
ried, being handed from one to the other. It is
supposed that a bottle tick must have crawled off
the clothes of one of them on to the child. To-
wards evening she appeared restless and finally so
much so that the mother merely sponged the child's
body rather than worry her with her evening bath.
As she seemed sensitive about having her head
touched her mother did not brush out her long thick
curls. All that night she was very restless and
tossed about, and the next day scemed too listless
to stand, but lay in her mother's arms. On the
23rd the grandmother found a bottle tick behind
the left ear just above the mastoid process; its size
distended with blood was 4 in. by 8 in. After rub-
bing in some kerosene it was pulled off and crushed
on the floor. Dr. Macdonald saw her about
6.45 p.m. on the 28rd; the child was restlessly
moving her head and arms about, but never put
her hand to her ear. She kept whining and moan-
ing; her temperature was 101.69, and the pulse 140;
the respirations were hurried and shallow; she had
a cough and tried to bring up mucus but found
great difficulty in doing so. She did not seem to
have strength enough to cough, but appeared to be
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, FEBRUARY 1, 1913.
LONDON SCHOOL OF TROPICAL MEDICINE.
40th Session. October—December, 1912.
Front Row.—W. Macdonald (Lab. Asst.) C. H. Marshall, A. Moore, F. Rice, R. C. Chakraborty, G. L. Johnston, S. D. Stewart, J. Pugh, F. F. Allan.
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B. S. Gledhill, B. Moiser, M. B. Hay, J. N. Collyns, E. J. Porteous, L. Carbone, S. M. Livesey, A. Ismail, H. M. Hanschell (senior Demonstrator).
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é AS
ALISUI.L(D ELVIS
4 TYtr TR PR
SYA ‘a ANH
Feb. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 45
partially paralysed. The legs did not move during
all the time of examination. At the site of the tick-
bite was a circular redness about 1 in. in diameter,
with a small purple spot 4 in. in diameter in the
centre. After treatment, in four hours she seemed
to get slightly better, her temperature fell to 999,
the pulse to 1209. The respirations had consider-
ably improved. At 11 p.m. Dr. Macdonald left,
but heard afterwards that she continued to improve
until 8 a.m., when she suddenly collapsed and, fail-
ing to cough up the mucus which had collected,
she sank and died about 3.80 a.m.
The treatment adopted was to incise and curette
the poisoned place at once, rubbing in some
potassium permanganate; strychnine and digitaline
were given to increase the heart's strength and to
reduce its frequency, and an enema was adminis-
tered and also a little hyd. subchlor. Vin ipecac.
was given to cause vomiting and bring up the
mucus, but did not have the desired effect, and so
a sterilized feather was used and this resulted in
large quantities of mucus being expelled. The child
also had spt. amm. arom. and brandy as a stimu-
lant. These measures seemed to greatly relieve
her. In the opinion of Dr. Maedonald, death was
caused by paralysis affecting especially the respira-
tory tract. An hour after the patient was dead,
purplish post-mortem discolorations were marked
along the back of the hind part of the legs.
Dr. G. O'Neill has given me the following account
of a patient of his who was heavily infested by these
ticks at Middle Harbour, Sydney. Over 200 were
removed from the trunk, legs, arms and neck.
Symptoms of faintness were noticed within about
an hour after the ticks had fastened on. He was
seen by a medical man within four hours and
showed then extreme collapse and weak cardiac
action with syncope. There was no local irritation.
The patient was very ill for a week with cardiac
symptoms, but no paralysis. The ticks were of
various sizes, the smallest being that of a grain of
wheat, and were removed with difficulty.
SPIDERS.
The small black spider with the red spot, known
as Latrodectus hasscltii, can give rise to a very
dangerous bite in human beings. This species, or
varieties of it, is found in Australia, New Zealand,
India, Africa, &c., and the animal is given the name
of Katipo in New Zealand. It lurks in dark places,
such as under seats of dark closets in country
houses, under boxes, stones, &c. Most instances
of biting appear to have occurred in people who
have visited closets at night-time. In Australian
literature there are some ten references to cases of
bites by these spiders.
SCORPIONS.
The only reference to stings by scorpions that I
possess is one in Colonel Warburton's Journal of
his Explorations (p. 286), under date December 23,
1873, the locality being on the Oakover River in
Western Australia. He states that the camp ''is
infested with scorpions, which is unpleasant, as we
all go about barefooted,’’ and that Sahleh (one of
the Afghans) '' has lost the use of one hand and arm
from the stroke of a scorpion."
CRUSTACEANS.
As in other parts of the world, cases of urticaria,
following the eating of lobsters, are well known in
Australia,
PHYLUM ANNULATA.
Hirudinea.—Leeches are abundant in many parts
of Australia, and at once suck human blood when
opportunity offers. According to Dr. T. B. Wilson
(* Narrative of a Voyage Round the World,” 1835,
p. 259), the natives near King George’s Sound
always exercise great care when drinking water in
which leeches are present, lest these creatures enter
the mouth with the water, which nevertheless they
oceasionally do with fatal consequences. The leech
would, probably, gain attachment to some part of
the pharynx or even the cesophagus or stomach,
where it might cause mechanical trouble at once
or after engorgement, or death might on the other
hand result from uncontrollable hemorrhage after
its removal.
Puytum ECHINODERMATA.
Holothuroidea (Béche-de-mer).—Banfield men-
tions an outbreak of poisoning, from which several
Chinamen died, traced to the species of béche-de-
mer known as ‘‘red prickly fish." The “‘ fish "
had been boiled in a copper receptacle, and it
seemed probable that the boiling exuded juices
which acted on the copper.
Echinoidea (Sea-urchins).—The brittle, sharp-
pointed species of sea-urchins may cause much
trouble by piercing the skin and breaking off,
when the fragments are exceedingly difficult to
extract. Saville-Kent* says that the long, slender-
spined sea-urchin, Diadema setosa, abounds in
places in serial clusters. Their spines are slender,
8 or 10 in. long, and sharper than needles. ‘‘ The
points of the spines of this sea-urchin, though so
easily embedded in the flesh, are very difficult to
extract. Left alone, they in a week or two appa-
rently disappear, and the author was of the opinion
that, being almost pure carbonate of lime, they
probably dissolved in the blood. Professor A. C.
Haddon has, however, informed him that the spine
points, like incepted needles, have, in his own ex-
perience, after a year's interval, worked their way
out at remote distances from where they entered."
Banfield, in his ‘‘ Confessions of a Beach-
comber,'' also refers to this species.
Mr. E. C. Harris has informed me that in
British New Guinea he has seen natives and a
white man injured by standing on the spines of
a sea-urehin the size of an orange, with black
prongs tipped with white. The pain is agonizing
and the patient has to be held down, and nearly
dies from the pain, which lasts some hours. The
spines break off in the wound.
* «* The Great Barrier Reef," p. 42.
46 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
PHYLUM COELENTERATA.
The stinging produced by this class of animals
is well known, and we are all acquainted with
the mechanism by which it is produced. The large
brown jelly-fishes, Rhizostoma, which are common
around the Australian coast, frequently produce
stings on bathers when they come in contact with
them. Experimentally in December, on allowing
the trailers to come in contact with the bare arm,
a kind of slime was left, followed by a faint prick-
ling sensation. Later, in my case, this was fol-
lowed by scattered small erythematous spots, fad-
ing away in about an hour. In other individuals
severe urticaria may result.
The '' Portuguese man-of-war,” Physalia pela-
gica, is a common cause of severe irritation in
children who come in contact with the tentacles
on the coast of Eastern Australia. Dr. George
Bennett, in ‘‘ Wanderings in New South Wales,”
published in 1834, and in '' Gatherings of a Natu-
ralist in Australasia," published in 1860, describes
very accurately and fully the symptoms and
sequence of events. These are well worth repeat-
ing here:
Stings of Psysalia pelagica. ‘‘ Situated beneath
the inflated vesicle of the Physalia a dense mass
of tentacula is observed, some of which are short
and thick, while others are several feet in length.
.... The long tentacula or cables, when minutely
examined, seem to consist of a chain of globules,
filled with fluid, and they have an oval plate or
sucker at the free extremity.’’ On seizing it, per-
sons ‘‘soon drop it on finding the long adhesive
appendages tenaciously attached to their hands,
inflicting most painful stings—more severe than
such a creature could have been supposed capable
of producing. On one occasion I tried the experi-
ment of its stinging powers upon myself, intention-
ally, when, on seizing it by the bladder portion, it
raised the long cables by muscular contraction of
the bands situated at the base of the feelers, and,
entwining the slender appendages about my hand
and fingers, inflicted severe and peculiarly pungent
pain, adhering most tenaciously at the same time,
so as to be extremely difficult of removal. The
stinging continued during the whole time that the
effects were not merely confined to the acute
pungeney inflicted, but produced a great degree of
constitutional irritation; the pain extended upwards
along the arm, increasing not only in extent Lut in
severity, apparently acting along the course of the
absorbents, and could only be compared to a severe
rheumatic attack; the pulse was accelerated, and a
feverish state of the whole system produced; the
muscles of the chest even were affected, the
same distressing pain being felt on taking a full
respiration as obtains in a case of acute rheuma-
tism. The secondary effects were very severe,
continuing for nearly three-quarters of an hour;
the duration of the pain being probably longer
in consequence of the time and delay occasioned
by removing the exciting and virulent tentacula
from the skin, as they adhered to it, by the aid
[Feb. 1, 1913.
of the stinging capsules, with an annoying degree
of tenacity. On the whole being removed, the pain
began gradually to abate; but during the day a
peculiar numbness was felt, accompanied also by
an increased temperature in the limb upon which
the stings had been inflicted. For some hours
afterwards the skin displayed several white eleva-
tions or weals on the part stung, similar to those
usually seen resulting from the poison of the
stinging-nettle. The intensity of the pain depends
in some degree upon the size and consequent power
of the creature; and after it has been removed from
the water for some time, the stinging property,
although still continuing to act, is found to have
perceptibly diminished. To remove the irritation,
at first cold water was applied; but this, instead
of alleviating, increased the evil; an application of
vinegar relieved the unpleasant symptoms and olive-
oil produced a similar beneficial effect. I have
observed that this irritative power is retained for
some weeks after the death of the animal in the
vesicles of the cables; and even linen cloth, which
had been used for wiping off the adhering tentacula,
when touched, still retained the pungency, although
it had lost the power of producing such violent
constitutional irritation.”’
Though not strictly Australian, the following
reference by Mrs. Edgeworth David, in her ‘‘ Funa-
futi ’’ (p. 247), deals with the ‘‘ Portuguese man-o’-
war." ‘‘ The natives were much more afraid of a
Portuguese man-o'-war than of a shark, and if the
harmless looking blue cable of one of these queer
ereatures happened to twine itself round an oar
that a native was holding, that native would leave
hurriedly.”
Of the flexible seaweed-like hydroid zoophytes,
Saville-Kent* says that one species, Aglaophenia
(? macgillivrayi), occurring in some abundance in
the pools off Cape Flattery, is familiar to béche-
de-mer fishers on account of its stinging proper-
ties. When handled, or incautiously trodden on
with bare feet while wading, the sting produced
by its polyparies much resembles that caused by
an ordinary stinging-nettle, or the stinging anemone,
Actinodendron alcyonoideum. The rash raised, as
personally tested, remains conspicuously visible,
and is accompanied by gradually decreasing local
irritation, for about a week.
Of the meduse or jelly-fishes, Saville-Kent states
that many of them, more notably the so-called
“ Portuguese man-o'-war," Physalis pelagica, are
conspicuous for their severe stinging properties.
"There is one species, however, that has been
reported to the author as not unfrequently appear-
ing in Cleveland Bay, off Townsville, whose urticat-
ing properties are so severe that death has been
known to result to bathers from contact with its
training tentacles. The efforts that have been made
to obtain either specimens of this noxious Hydro-
zoon, or sufficient data for its approximate specific
identification, have so far proved unsuccessful. It
would appear, however, from the seant evidence
* «The Great Barrier Reef," p. 203.
Feb. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 47
gathered, to be a representative of the Physo-
phorous meduse, rather than a form allied to
Physalia. It is worthy of note that a large pro-
portion of the free-swimming meduse represent
the sexually specialized derivatives of sedentary
compound hydroids, from whose polyparies they
become detached as minute transparent bells, which
may rapidly grow to relatively gigantic dimensions.
The possibility naturally suggests itself that the
death-dealing medusa of Cleveland Bay is the deri-
vative of the sedentary, urticating Aglaophenia
previously mentioned.’’
In May, 1911, appeared a telegram in the Syd-
ney daily press stating that one (or two) boys
had died at Pioneer Bay, near Mackay, on the
Queensland coast, from the stings of a jelly-fish,
whose long, thread-like tentacles adhered to the
chest, stomach and arms. The animal was prob-
ably the species referred to by Saville-Kent.
In an article on ‘‘ Fish Poison," by Dr. E. M.
Worth (A.M.J., September, 1877, p. 278), surgeon
to the Burdekin and Flinders District Hospital,
Queensland, stings by meduse are mentioned.
While bathing, people not infrequently feel some-
thing like an electric shock, with a stinging sensa-
tion on some part of the body. Sometimes on
coming out of the water, a medusa is found
attached to the skin. The patients soon become
faint and sick and in the case of children remain
for four or five days drowsy and feverish. For
several days numerous red patches may be seen
on the part attacked—these are more or less
painful and end in excoriation of the skin.
Mr. E. C. Harris has informed me that persons,
when paddling in shallow water on the coast of
British New Guinea, are sometimes ‘‘ stung ’’ by
a slimy stuff, apparently from a jelly-fish, which
adheres to the hairs and may cause trouble for
many days. The sting raises a blister in two
minutes.
I have been personally informed by the vietim
that, whilst bathing at Encounter Bay, South
Australia, he was stung on the chest, apparently
by a jelly-fish. An enormous blister followed.
Where the sting and consequent blistering is
more extensive, it can easily be seen that profound
systemic effects may be produced, just as in the
case of extensive burns.
Stinging Anemones.—Saville-Kent, in “ The
Great Barrier Reef," states that a species of
Aetinodendron, probably A. alcyonoideum of Quoy
and Gaimard, with long ramifying tentacles, is
remarkable for stinging or urticating properties.
As personally tested by him, this property was
nearly as powerful as that of an ordinary stinging-
nettle, and the rash produced on the skin through
contact with the animal's stinging-cells or '' cnide "'
endured for several days. He ascribes the same
characters to another Great Barrier sea-anemone,
Megalactis griffithsi, Sav.-Kent.
MxRIAPODS.
Centipedes, often of large size and up to
10 in. in length, are common in the interior
parts of Australia, but records of injuries from
them are few. Those in the interior who have
to camp out much, lying on the bare ground,
frequently find them in or on their blankets. Dr.
Mjoberg, leader of the recent Swedish Scientific
Expedition to North-west Australia, was, accord-
ing to the report in the daily press of an interview
with him, bitten on the finger and shoulder by a
centipede, and had his arm in bandages afterwards
for three weeks.
——
Hotes and Mews.
Tug Society OF 'TRopIcAL MEDICINE AND HYGIENE.
—At a meeting of the Society of Tropical Medicine
and Hygiene, held at 11, Chandos Street, Caven-
dish Square, London, W., on Friday, January 17,
1918, a paper upon ‘‘ Recent Advances in our
Knowledge of Sleeping Sickness," by Arthur
G. Bagshawe, M.B., D.P.H.Cantab., was read.
The following gentlemen were elected Fellows:
Rudolph de Mello, L.R.C.P., Zanzibar; Charles
Hardwicke, M.D., Mexico; William Francis Law,
M.D., Dublin; Charles J. Martin, M.B., F.R.S.,
Chelsea; Lieutenant-Colonel J. J. Pratt, F.R.C.S.,
I.M.S., London; Sir David Semple, M.D., Kasauli;
William R. Watson, M.B., Dublin.
AN Hisroricat MEDICAL EXHIBITION IN LONDON.—
For the first time in twenty-one years the Inter-
national Medieal Congress will meet in London in
the summer of 1918, and, in this connection, an
exhibition of rare and curious objects relating to
medicine, chemistry, and pharmacy and the allied
sciences is being organized by Mr. Henry S. Well-
come. The response to the appeal for loans has
been most successful, with the result that probably
one of the most interesting collections of historical
medical objects ever gathered together will be on
exlubition during the meeting of the Congress.
Among other interesting sections is one including
the medical deities of savage, barbarie, and other
primitive peoples. Through the kindness of friends,
specimens of these have been forwarded from all
parts of the globe, but there are still many gaps to
be filled, and those who possess such objects, and
would be willing to loan them, should communicate
with the Secretary of the Exhibition, whose address
is given below.
Amulets, talismans, and charms connected with
the arts of healing will also form another prominent
feature, and any loans of this description would be
welcomed.
In the section of surgery, an endeavour will be
made to trace the evolution and development of the
chief instruments in use at the present day, and it
is desired to accumulate specimens of instruments
used in every part of the world by both savage and
civilized peoples.
In pharmacy and in botany special exhibits are
projected, which will include models of ancient
pharmacies, laboratories, and curious relics of the
practice of alchemy in early times. Specimens of
48 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 1, 1918.
T———————M— MM
ancient and unusual materia medica from all parts
of the world will also be exhibited.
A complete illustrated syllabus will be forwarded
to anyone interested on applieation to the Secretary,
54a, Wigmore Street, London, W., England.
Asis Minor AS A Nur-PRODUCING COUNTRY.—
Walnuts are exported from Smyrna to the extent
annually of about 12,000 sacks of about 100 lb. each.
Pistachio nuts also come from Syria. As many as
5,000 sacks of 100 lb. each are exported from
Aleppo alone.
Almonds are of two varieties, one native to Syria
and the other from the island of Chios; the latter
is small, soft, and delicately flavoured. Native
almonds are exported to the amount of 3,000 sacks,
and Chios almonds to the extent of 50,000 sacks
annually.
Filberts are a product of the Black Sea littoral ;
as many as 50,000 sacks of 100 Ib. each are sent
abroad.
— 9 —— ——
Correspondence,
To the Editors of the JOURNAL or TROPICAL
MEDICINE AND HYGIENE.
Dear Sirs,—I read in No. 22, 1911, of your
esteemed journal a short notice about my publica-
tion in the Lancet of October, 1911. At one place
it is said, ‘‘ The author seems to have forgotten, or
not to have heard of, Patton's work in India on the
development of Leishmania donovani in bugs.”
I wish to say that I know and have not at all
forgotten the researches of Patton and of others
who have worked at this subject, including the
recent studies concerning the relations between
mosquitoes and tropical Leishmania. The article,
however, not being a complete work, but merely a
simple notice which I published in the Lancet, it
had to be as short as possible, and I had to omit
references, the more so as nobody had made any
okservations on Anopheles claviger.
As to experiments on bugs, though fully acknow-
ledging the importance of Patton’s researches, I
an obliged to state that in 500 preparations of bugs
and fleas, infected with cultures of L. dono-
vani, no traces of parasites in the digestive tubes of
these insects were ever found. (Pathologia, No. 68,
1911, and Malaria e malattie dei paesi caldi, June
1911).
Basile in a notice has confirmed my researches
(R. Academia dei Lineei Conference, June 18,
1911.)
Quite recently Professor Gabbi failed to infect
bugs (canine and human ones) with the spleen-
juice of specimens infected with kala-azar (Malaria
e malattie dei paesi caldi, No. 10, October 1911).
Whether these researches are, or are not, of any
value cannot be decided offhand.
With best regards, believe me,
Yours respectfully,
Dr. Proressor FRANCHINI.
Clinica delle malattie tropicale in Roma,
Policlinico Umberto (Dir., Prof. Gabbi).
Becent and Current Literature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JOURNAL oF TROPICAL MEDICINE AND
HYGIENE will be pleased, when possible, to send, on appli-
cation, the medical journals 4n which the articles appear.
* The Lancet," November 30, 1912.
A Suggested Treatment for Trypanosomiasis.—Johnson
suggests that anarcotine, an alkaloid of opium, might be
tried in the treatment of sleeping sickness. Sir William
Roberts, in 1895, stated that this drug had been used in
India with success in the treatment of malaria. So
impressed with its powers was this author that he said that
there seemed to be valid evidence that in it (anarcotine) we
possessed a second antiperiodic of great power, analogous
to, but not identical with, quinine. So far as one knows it
has not been used again, at least, not extensively, and it
will be interesting to see if it has any action on trypano-
somiasis.
“ Annals of Tropical Medicine Ana Parasitology,” December
, ,
The Resistance of Ticks to Sheep Dips.—Blacklock tested
the resistance of Ornithodorus moubata to various sheep
dips. He found that, (1) the dips tested failed very fre-
quently to prevent Ornithodorus moubata feeding on an
animal. (2) Feeding ticks were not easily caused to loosen
their hold by them, (8) In test tube experiments the resis-
tance of this species of tick to these substances in solution
is marked. (4) Used in the strength recommended and for
the time suggested these dips appear to have very slight
effects on this tick. (5) Possibly other ticks behave in a
different manner under these applications.
* Annals of Tropical Medicine sad Parasitology,” December
The Resistance of Bugs to various Reagents.—Blacklock
tested the resistance of Cimex lectularius to various reagents,
powders, liquids and gases. The conclusions of his researches
are as follows: (1) Cimez lectularius whether in the larval
or adult stage is not readily killed by depriving it of human
blood. (2) It may thus remain alive and active for months
in houses whieh have ceased to be inhabited. (8) Houses
on being re-occupied after being empty for months may still
be found infested with bugs. (4) Bed.bugs may transmit
certain diseases from one human being to another. There-
fore, it is inadvisable that bugs and human beings should
occupy the same house. (5) Human beings must be pro-
tected from the attacks of bed-bugs. (6) Thereisno evidence
that bed.bugs can be cleared out of a house by insecticide
powders. Experiment suggests that powders are of very
limited utility. (7) The same applies toliquid remedies. (8)
Gaseous substances present the best prospect of success.
(9) Of such substances, sulphur dioxide is cheap and effective.
(10) Sulphur dioxide gas under pressure for two minutes,
kills with certainty all stages in the cycle of development of
the bug, including the egg.
Siotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers, :
5.—Correspondents should look for replies under the heading
'* Answers to Correspondents,”
Feb. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 4, Vol. XVI.
Original Communications.
INDIAN ORO-PHARYNGEAL
LEISHMANIASIS.
By Atpo CasrELLANI, M.D.
Director, Government Clinic for Tropical Diseases, Colombo
(Ceylon).
Ir may perhaps be of interest to put on record a
cuse of a peculiar ulcerative condition of the throat
in which Leishmania bodies were found. A few
days before leaving Colombo I was consulted by a
European who had been in India for twenty
years and was then going on a long holiday. He
desired to obtain relief for certain intractable ulcers
of the pharynx. The patient was apparently in
fairly good general health; he was a man aged 38,
tall, strongly built, and with a tendency to
stoutness. There was no history of syphilis, nor of
any skin disease of any kind. He merely com-
plained of an ulcerative condition of his throat,
which, according to him, had been most persistent,
having started nine years previously. The con-
dition gave him a certain amount of discomfort, but
was not very painful. A local examination showed
the presence of several ulcers on the posterior wall
of the pharynx and on the soft palate; they were
roundish and of various sizes, but none very large,
mostly a quarter to a half a centimetre in diameter;
some were covered by whitish débris, none did
show any signs of vegetations nor any framboesi-
form appearance. The lymphatie glands of the neck
were not enlarged.
The patient informed me that the ulcers had been
treated in various ways, including cauterization,
which gave some temporary relief. Energetic
antisyphilitie treatment by mercury inunctions
and potassium iodide had given no result what-
ever. I made deep scrapings from the ulcers
and stained them by Leishman's stain. The
microscopical examination revealed the presence of
Leishmania bodies, not very numerous, but quite
typieal and apparently very similar or identical to
L. donovani and L. tropica. Cultivations were not
carried out. On further questioning the patient the
fact was elicited that for the last few years he had
had attacks of fever to which he attached no
importance, considering them to be of malarial
origin. I examined the blood; no malarial parasites
or pigment were present; there was a slight mono-
nuclear increase. The physical examination of the
patient revealed nothing abnormal; the spleen
seemed to be slightly enlarged on percussion, and
was just palpable on very deep inspiration; the liver
was not enlarged. Further researches in this case
were not possible, as he left for Japan and myself
for Europe. I give a drawing made by Mr. Terzi
from the preparations still in my possession; these
are, at the present time, slightly faded, but the
Leishmania bodies are still very evident, and have
been seen by Sir William Leishman, Dr. Chalmers,
Dr. Low, and others.
The above case recalled vividly to my mind a
. in the throat.
patient I had seen some time before, also from
India. A few words on his case may not be out of
place.
This patient also had been many years in India.
There was no history of syphilis or any skin disease.
He had several rather small uleers on the posterior
wall of the pharynx and whitish scars on the soft
palate and hard palate, due to previous ulcers
which had been cauterized. The ulcers were rather
small, some covered with débris, with no granulo-
matous appearance, and not bleeding. There was
not much pain. The condition, according to the
patient, was of many years’ standing. The first im-
pression I had was that it might be a case of blasto-
mycosis, and I inoculated several maltose agar
tubes with scrapings. As a matter of routine
I directed the patient to undress and I made a
general physical examination; nothing abnormal
was found in the thoracic organs, but I was sur-
prised to find the spleen was very much enlarged.
Free Parasites.
On closely questioning the patient I elicited the
fact that he had been suffering for several years
from attacks of fever, to which he had not attached
much importance, believing it to be malaria. The
blood did not show Laveran’s parasites. The idea
struck me that it might be a case of kala-azar with
ulcerative localizations in the throat. I examined
the scrapings, with negative result; but the patient
had to return to India and further examinations
could not be obtained. In the letter to his medical
attendant I expressed the suggestion that the case
might perhaps be one of kala-azar with localizations
The further history of the patient is
unknown to me.
Résumé and Remarks.—In a case of a peculiar
persistent ulcerative condition of the pharynx and
soft palate, in a patient who had long resided in
50 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 15, 1913.
India, Leishman's bodies were found. It is possible
that the other case I have recorded may have been
of the same nature, but the microscopical examina-
tion having been negative the following remarks
cannot be applied to it.
The question arises: was the condition oriental
sore with ulcerative lesions of the throat? Was
the condition kala azar, or a separate form of
Leishmaniasis, somewhat comparable to the oral
Leishmaniasis or the Espundia of South America, so
well investigated by Splendore, Bueno de Miranda,
Carini, Robledo, Laveran, Nattan Larrier, and
others ?
Cases of oriental sore with localization on the
oral mueosa have been described by Cardamatis in
Greece, and Gabbi and Lacava in Italy. In my
case there were no eutaneous lesions of any kind
and no history of such ; moreover, the condition had
been present, according to the patient, for more
than nine years; in oriental sore the course of the
disease is not as long as that. The case may have
been one of kala azar with ulcerative localizations
on the pharynx, though this manifestation of kala
azar has, as far as I know, never been described;
moreover, in an ordinary case of kala azar the
general condition of the patient after nine years,
if he were still alive, would have been extremely
bad. The appearance of the ulcers did not seem
to be identical to that found in the Espundia of
South America, as they were not frambeesiform.
The possibility, therefore, cannot be excluded that
there may be an Indian or Asiatic type of oro-
pharyngeal Leishmaniasis; but this is of course a
purely a suggestion.
PRELIMINARY NOTE ON THE IDENTITY
OF CERTAIN LEISHMANIASES BASED
ON BIOLOGICAL REACTIONS.
By Professor Ivo Banni, Naples.
DURING ihe month of July, 1912, I undertook some
experimental work in order to satisfy myself whether
the intra-organic destruction of the Leishmania bodies
would bring about the formation of substances having
a specific action on these parasites.
The practical object of my experiments was
to find out a method of diagnosis, based on
biological reactions, to which a specific character is
universally attributed. At the present time the
diagnosis of human Leishmaniasis is based almost
solely on the microscopical examination of the spleen
and liver juice, which may, however, give negative
results.
The first part of my researches consisted in car-
rying out experiments in order to make evident if, and
in what measure, there is an elaboration of specific
substances in the blood of animals which have been
inoculated with Leishmania cultures. I used a strain
of Leishmania infantum,and one from canine kala-azar,
both of which I obtained direct from C. Nicolle during
iny recent tour of investigation in Tunis.
Some rabbits were injected intravenously with cul-
tures of the Leishmania of human origin, and others
with the cultures of the Leishmania of canine origin.
I have observed that the repeated intravenous
injections, while not giving rise to a pathological
condition, induce the formation in the blood of specific
substances which agglomerate the parasites and can
be compared to bacterial agglutinins. The serum of
the inoculated rabbits showed this property in a
dilution up to 1 in 200. The serum of normal rabbits
had no action. Hitherto I have not noted any distinct
lithieal property in the sera of the inoculated animals.
The serum of rabbits inoculated with canine
Leishmania agglutinated this parasite up to a dilution
of lin 160. The serum of rabbits inoculated with
canine Leishmania agglutinated L. infantum also up
to a dilution of 1 in 160. Sera of either the rabbits
inoculated with L. infantum or canine Leishmania,
agglutinated L. tropica only up to a dilution of 1 in
70. There is, therefore, a Leishmanial group
agglutination, but the fact that the blood of rabbits
inoculated with L. infantum influences canine Leish-
mania to practically the same extent as the homologous
parasite, and vice versa, tends to support the opinion
held by most observers that infantile kala azar and
canine kala-azar are due to the same species of
Leishmania.
These experiments corroborate the epidemiological
and micro-biological observations carried out by
Nicolle and other investigators, and the recent experi-
mental work by Basile, all of which show us the way
to follow in the prophylaxis of this infection.
A CASE OF PARA-MELITENSIS FEVER.
By Fleet-Surgeon P. W. BasseTT-SuiTH, R.N., C.B.
Royal Nawal College, Greenwich.
In May and July, 1912, Négre and Raymond [1]
demonstrated the presence of a distinct variety 0
the Micrococcus melitensis, which they calied M.
para-melitensis. This organism was obtained from
Dr. Nicolle [2], Tunis, and was known there as
M. melitensis, Br. Though this form had all the
morphological and cultural characters of the true
M. melitensis it differed in its agglutination re-
actions, and Négre and Raymond by a series of
experiments showed, that though the blood serum
of a case of undulant fever might agglutinate with
this strain in low dilutions, it would not do so with
the high ones which were given by the origina
strain. Further, by a series of absorption experi-
ments, it was found that the para-melitensis
organism did not remove the specific agglutinins
for the M. melitensis and vice versa, neither was
the immune serum of an animal inoculated with
the para-melitensis strain able to agglutinate the
M. melitensis in such high dilutions as its own
homologous organism. They therefore came to the
conclusion that there occurred a para-melitens!s
infection distinct from the ordinary undulant fever
produced by the M. melitensis. :
The following ease which is, I believe, the first
of this kind to be recorded, is important, as it has
many peculiar features, and has been most difficult
to diagnose. ‘The patient, while at Hyères, in the
Riviera, January, 1910, contracted a fever which
was associated with joint pains, neuritis, obstinate
Feb. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 51
constipation, profuse perspirations, loss of weight,
and general malaise; this was believed to be an
irregular attack of influenza, the fever lasted for
five weeks, and when a little better the patient
went to Monte Carlo.
The fever was of an undulant character, there
was much wasting and debility, the fingers and
wrists were painful and swollen, at times the knees
and ankles; many neuritic symptoms were also
present. Infective rheumatoid arthritis was feared.
Tubercle, ulcerative endocarditis, paratyphoid, per-
nicious anemia, &c., were excluded. In April, 1911,
the diagnosis was either post-influenzal infection,
or a toxic trophic neurosis. On returning to Lon-
don a careful examination was made of the blood,
by agglutination tests, &c., by several leading ex-
perts, but beyond showing slight secondary anemia
it gave no clue to the cause of the disease. The
patient was getting steadily worse, and as a dia-
gnosis of pyorrhea had been made, an autogenous
streptocoecic vaccine was used without giving any
benefit. Double sciatica now came on. From
June, 1911, the patient was very seriously ill for
three months with high temperature, rigors, night
sweats, painful joints, double sciatica and insom-
nia, and a muco-membranous colitis set in. During
the latter part of July and August the patient
though very ill was able to lie in the open air, it
being very fine. From August 4 attacks of fever,
generally lasting eight days, came on fairly regu-
larly about every ten days, there being short
periods of apyrexia between these attacks. From
October, 1911, to April, 1912, the patient remained
in this condition, the arthritis of the hands and the
undulant fever being the most marked symptoms.
There was then a period of five weeks’ normal
temperature, then again came the recurring irregu-
lar attacks of fever for six months further, with
slight enlargement of the spleen during the attacks.
The patient often had to stay in bed, and was
always a confirmed invalid. From November,
1911, to January, 1912, he remained in London and
suffered from an irritable short cough, but no
definite cause was found. Examination of the
feces showed an abundant flora, but this was
thought to be of a secondary character. Great
numbers of drugs were tried, chrismol giving the
most relief for the intestinal symptoms.
A diagnosis of undulant fever was made by
several observers from the clinical symptoms, but
as it could not be confirmed, either by culture of
the micro-organisms from blood or urine, by agglu-
tination reaction; or by the complement fixation
method, no positive opinion could be given. Through
the kindness of those in charge of the case I was
able to test the blood many times, and in January,
1912, having received a culture of the M. melitensis,
Br. (M. para-melitensis) from Dr. Nicolle, I was
able again to do so, this time finding a positive
agglutination with this organism up to 1/400, and
a negative reaction with five other strains of M.
melitensis in my possession; the reaction was also
confirmed by using the absorption method with the
two organisms.
A vaccine from this para-melitensis culture was
then made and is being used with apparent benefit,
but it is too early to judge of its efficacy as yet.
Remarks.—The most important features of the
case are, a disease contracted in the South of
France, with an irregular undulant fever of two
years’ duration, associated with arthritic and
neuritic symptoms with a moderate amount of
wasting and anemia. A persistent absence of any
reactions for ordinary undulant fever, but a positive
reaction with the M. para-melitensis.
REFERENCES.
[1] NEcRE and Raymonp: Comp. Rend. Soc. Biol., 1912,
May 24, July 5.
[2] NiconLE and Conor: Arch. Inst. Pasteur, Tunis, 1912,
No. 3, pp. 136-139.
——==<
Coccidioidal granuloma.—Bowles, in the Journal
of the American Medical Association, December 21,
1912, reports a nineteenth case of this rare disease.
Up to the present date, eighteen cases have been
reported and traced to California, the seventeenth
and eighteenth being reported by Brown, of San
Francisco, with a review of the literature. The
first ease in California was discovered by Rixford,
of San Francisco, and later described in conjunction
with Gilchrist, of the Johns Hopkins Hospital
Medieal School. Afterwards Ophüls, of San Fran-
cisco, described the morphology and characteristics
of the fungus, and gave it the name of Oidium
coccidioides. He reported thirteen cases, and dif-
ferentiated the parasite from the closely related
Blastomyces coccidioides of which much has been
written, the latest article being by Hektoen, of
Chicago.
Most infected persons came from the lower half
of the San Joaquin valley, and were men employed
in railway construction or in caring for animals.
The duration of the disease, so far reported, is from
six months to nine years. Most of the patients
gave histories of bone lesions, some having accom-
panying lesions like hypertrophic lupus. Others
gave histories of tumours of the skin followed by
ulceration without tendency to heal. arly in-
volvement of the lymph-nodes is frequently seen
terminating not unlike tuberculosis.
The mode of infection, whether external or
internal, has not been determined, but in the forms
that produce a skin infection as the first symptom,
the skin can in all probability be determined as the
primary focus. In internal cases infection is most
frequently seen in the lungs. The infection travels
by the blood and lymph streams and in autopsies,
the internal organs are more or less attacked with
lesions and distributions as in tuberculosis. In its
predilection for organs the two diseases are rather
similar.
Most of the previous patients were treated with
potassium iodide accompanied with surgery. AN
cases recorded were fatal but one, the first symptom
of that one being a bone lesion of the ankle. The
leg was amputated before other lesions developed
and the patient recovered.
52 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 15, 1913.
Susiness Hotices.
1.—The address of the JOURNAL OF TROPICAL MEDICINE AND
HyGIENE is Messrs. BALE, Sons AND DANIELS8SON, Ltd., 83-91,
Great Titchfield Street, London, W.
2.—All literary communications should be addressed to the
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3.—All business communications and payments, either of
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may commence at any time, and is payable in advance.
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7. —The Journal will be issued avout the first and fifteenth day
of every month.
THE JOURNAL OF
Tropical Medicine andbhpgtene
FEBRUARY 15, 1913.
POLAR EXPLORATION AND ITS BEARING
ON MEDICAL STUDIES.
For a medical journal devoted to tropical diseases
to find points of common interest in the medical
aspects of polar exploration would seem an anti-
thesis which requires explanation. Science and its
ways, however, have universal application, even
when the department of medicine is considered,
and to the protozoologist, the helminthologist, and
the epidemiologist, and even the entomologist, the
Poles, in common with the Equator, come under
the scope of their studies. The absence of a disease
in any quarter of the globe is as interesting a
problem to account for as is the presence of
another; for to explain it the air, the soil, the
fauna and flora, the geological formation, the
extent of communication have to be studied by
experts before coming to any conclusion of scientific
accuracy. All recent polar expeditions have taken
with them experts in several branches of science,
and even in the earlier searches for the Pole the
medical officer was understood to represent and
report for the scientific department. Of recent
years, however, research has become so specialized
that experts for almost every department of investi-
gation are necessary, and it is to the Tropical Schools
of London and Liverpool that we must look for a
supply of these experts, for in them, and in them
alone, do we find established authorities upon such
subjects as helminthology and medical entomology.
In all polar scientific expeditions of the future men
qualified in these subjects must be included, and
we are bound to rely on the Schools of Tropical
Medicine to supply them. The mere '' travellers’ "'
work in Arctic and Antarctic regions has been accom-
plished, the Poles have been reached, and there is
no justification for further risk of life, of expendi-
ture of time and treasure in this direction except
for purely scientific investigations,.for commercial
purposes, such as the presence of coal, iron, gold,
silver, or metals useful in the arts, and for the
investigation of all appertaining to disease in its
varied and several aspects. It is impossible to even
enunciate and far less to specify what these, the
last named, may be, but there are several problems
which afford food for thought, even with our in-
adequate knowledge of those remote regions. For
instance, we are unaware. how far the migration of
birds plays a part in the spread of disease; birds
now in tropical, now in temperate, latitudes may be
and are considered to be the carriers of
parasites infective to man; and, on the other
hand, birds which inhakit the more northerly
or sub-Arctic regions find their way to coun-
tries having temperate climates in their breed-
ing seasons. The constantly recurring migrations
are not without their importance to the epidemio-
logist and to the parasitologist and. helminthologist.
Of late it has been suggested by Dr. Sambon that
birds landing on our coasts are the forerunners of
outbreaks of diphtheria, and Dr. Sambon's well-
considered forecasts in the past have proved to be
the confirmed realities of the present in several
instances. The ailment most frequently referred to
in frigid zones is scurvy, and we have come to re-
gard this disease as peculiar to these regions; an
unfortunate view, for scorbutie conditions are by
no means confined to the coldest latitudes. As the
writer has so often stated, many of the intestinal
troubles so frequently met with in the Tropies come,
at any rate in their later stages, to partake of the
nature of seurvy, and owing to the non-recognition
of the condition cure is delayed or rendered wholly
impossible. Especially is this the case in sprue.
It may even be said that the appearance. of sprue
is coincident with a limitation of diet calculated to
produce a scorbutic taint. The initial departure from
health may be a simple indigestion due to ‘‘ liver ”
or to gastric catarrh, &c.; the diet is modified
for the time, or may be cut down, most frequently
Ey the patient himself or herself, to the most meagre
extent in the hope of getting rid of the trouble.
Fruit and meat are eliminated, and milk and, per-
haps, farinaceous food are alone taken. Should this
treatment be persisted in the patient becomes
anemic, weak, and dreads taking any form of food.
Sameness of low diet we know breeds diarrhaa
in time, and in out-of-the-way places both the milk
and other nutriment may be poor or '' tinned."
A scorbutie condition is inevitable with wasting,
weakness, skin rash of purpuric-looking patches,
receding gums, pyorrhea and mouth irritation, and
a shrinking of organs, such as the liver and spleen.
Without entering into the discussion as to whether
sprue is due to a specific organism or not, we have
enough to indicate a scorbutic sequel at all events,
and until this is recognized and acted upon the
patient may be kept alive, but cannot be cured.
When the diet is changed to fresh meat and fruit
a change immediately takes place, and the reported
cure of sprue by strawberries is readily explained.
That patients are eured by taking strawberries is
‘eb. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 53
undoubted, but so they are by other fruit and ty
fresh meat, especially when underdone or raw, in
the form of fresh meat juice or scraped beef. It
is hinted also, by several ‘‘ old tropical hands,’’ that
a meagre diet is provocative of sprue; some even say
that people who designedly live poorly are subject
to sprue. ‘‘ Live well and you will be well," is
the motto of many experienced tropical residents,
and the advice given by a planter in Ceylon to his
staff to '' avoid alcohol and eat liberally °’ seems to
have been followed by excellent results. The
accusation often brought against British folk in the
Tropics is that they live too well; this is not in
accordance with fact, for the well fed thrive better
than those who, owing to fads as to living, eut down
their nutriment to the level of the ‘‘ nut and raisin ”’
diet, which some hysterieal people profess to sub-
sist on. Scurvy is not limited to men engaged in
polar expeditions; it is present under various mani-
festations and guises in the Tropies and complicates
many of the ailments met with. The signs and
symptoms of scurvy present no definite specific
grouping; now there is diarrhea, now a mere re-
vulsion against food, or cutaneous manifestations
are present, the blue line on gums, &c.; but
all are seldom present, and one person presents
them in one form and another person under similar
conditions of food, &c., in yet another form. It
would be well were practitioners in the Tropics, and
in temperate regions as well, to bear the possibilities
of scorbutic tendencies in mind, and by acting upon
them they will get rid of many of the phenomena
which are inexplicable by any other connection.
Were we to bring the diseases possibly spread by
fish into the discussion, we have here again a
migratory animal passing from cold regions to tem-
perate and presenting the possibility of its being
the transmitter or the generator of disease in man.
Dogs, again, which always take part in all polar
expeditions, are not without their bearing upon man
in the matter of conveying disease. Let it also be
pointed out that overcrowding is unhealthy, be it
in a tent with frozen canvas covered by snow, in a
cabin cut out in a mass of snow, where ventilation
is well-nigh impossible owing to climatie conditions
and in which a number of men live for weeks or
months with unwashed skins and wear unwashed
clothes. These conditions are all calculated to
generate disease, now of a specific, now of a non-
specifie type.
We have much to learn from Arctic expeditions
in their medical aspects, and these lessons are
applicable not only in temperate climates but also
in the Tropies, and we hope that when next a
scientific expedition is fitted out we shall find that
the helminthologist, the protozoologist, and the
entomologist are furnished with a place in the staff,
otherwise the expedition will be shorn-of its useful-
ness and remain a mere '' travellers’ '" procession,
as it has to a large extent—and rightly so—been in
the past.
J. C.
Annotations.
Treatment of Dysentery due to Infection with
Entamaba histolytica.—Deeks, writing on this
subject in the Journal of the American Medical
Association, January 4, 1913, states that the follow-
ing forms of dysentery are more or less frequently
encountered in Ancon Hospital and for the most
part can be readily differentiated : —
‘“ (I) Ameebie dysentery, caused by the E. histo-
lytica of Schaudinn.
‘“ (2) Ameebic dysentery, caused by the E. tetra-
gena of Viereck.
“ (8) Bacillary dysentery, caused by Shiga's or
Flexner's bacillus, and the allied varieties.
'*' (4) Bilharzial dysentery, caused by the Schisto-
somum mansoni.
“ (5) Balantidial dysentery, caused by the Balan-
tidium coli.
“ (6) Malarial dysentery, occurring in the course
of a general malarial infection.
' (T) Dysentery due to tuberculous ulceration of
the intestine.
‘“ (B) Nephritic dysentery, associated with acute
diffuse nephritis or secondary to a chronic neph-
ritis with an acute process superadded.
** (9) Diphtheritic colitis, associated with a diph-
theritic or a gangrenous inflammation of the mucous
membrane of the whole colon, rectum and part of
the adjacent small intestine—a very fatal form.
'* (10) Dysentery in the course of pellagra.
'' (11) Dysentery resulting from the ingestion of
decomposing meats or fish.
“ (12) Dysentery resulting from the ingestion of
infected milk. The last two may be bacillary in
character.
' (13) Dysentery secondary to cardiac or to
hepatic disease.”
As regards the treatment of the amoebic forms he
states that:—
‘ (1) Ameebicidal irrigations are useless.
.' (2) The bismuth-milk-saline method of treat-
ment gives, in almost all cases, a perfect result, if
the lines indicated for its administration are adhered
to.
'* (3) This method of treatment gives a maximum
of cures with a minimum of recurrences and metas-
tatic developments, the most frequent of which is
liver abscess. This offers a serious complication in
the treatment, particularly if of the acute or ful-
minating type.
“ (4) Occasionally, in extreme cases, surgical
interference, after Dr. A. B. Herricks’ method, is
indicated."'
(With ipecacuanha and emetine going so strongly
in the treatment of ameebic dysentery at the present
day Deeks will find few supporters of his bismuth-
milk-saline method.)
Cultivation of Malarial Plasmodia.—Lavinder in
the Journal of the American Medical Association
54 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 15, 1913.
for January 4, 1913, contributes a brief note in con-
firmation of the results of Bass and Johns in culti-
vating malarial parasites.
The technique outlined by these authors was
adhered to closely, and no essential deviation was
made from their description. In two of the cases
the attempt was made to cultivate the second
generation. In doing this use was made of only
one of the methods given by Bass and Johns. This
method was by the test-tube fitted with the little
shelf of paper supported by a piece of glass rod, as
described in their paper.
In the first case, at the time blood was drawn,
smears from the punetured ear showed a rather
heavy infection of Plasmodium falciparum, small
ring forms. This culture was made in the late
afternoon. The next morning many larger, pig-
mented forms were observed. The culture was
returned to the incubator, but on later examination
it was evident that growth had ceased. Lavinder
thinks it very likely that this culture was killed by
undue tilting of the tube in handling. The parasites,
according to Bass and Johns, grow only in the
superficial layer of blood cells, and if the tube is
tilted and this top layer disturbed it results in death
of the parasites.
In the second case, at the time blood was drawn,
smears from the ear showed a light infection of
P. malarig. Indeed, the parasites were quite
scanty, only half a dozen being found in a twenty
minutes’ search of a well-stained slide. The culture
from this case was not successful.
The third case was another heavy infection of
P. falciparum. All forms seen in the smear from
the ear, at the time blood was drawn, were small
rings without pigment. In this case, as in the
second, the attempt was made to grow the first
as well as the second generation. That is, the
blood was drawn, mixed with the dextrose solution,
defibrinated, and centrifugalized to get off the serum
and to eliminate leucocytes in the tubes for the
second generation. The tube with the little paper
shelf was then prepared, and the original tube
was preserved also. Both were incubated at 409 C.
In this case the parasites grew readily in both tubes
and went on to sporulation, but for some reason the
merozoites did not enter fresh blood-cells, and of
course growth ceased. All conditions seemed favour-
able, and this result was a disappointment.
This successful culture was made from a case of
very persistent infection, which had been under
treatment in our wards for some time. At the
time the culture was made the patient was suffering
from a fresh outbreak.
No attempt was made to differentiate varieties,
but the parasites developed into large forms and
rosettes in something over thirty hours. The
sporulation was not uniform and continued to take
place for some time. Motility was observed in the
pigment granules, but amcboid movement in the
parasites was not so prominent. In the tube from
which the leucocytes had not been removed
(original tube), phagocytosis of the rosette forms
was occasionally observed, This, as Bass nnd
Johns state, probably occurs after the parasite has
digested the capsule of the red cell or otherwise
damaged it, since leucocytes will not attack para-
sites in an uninjured red cell.
With Leishman's stain Lavinder succeeded in
staining the parasites readily when the first
rosettes developed, but later for some reason he
was not successful. He states, that as Bass had
said, it is only necessary to see such a stained slide
to feel convinced of the growth of the parasites in
vitro, for such pictures are not observed in the peri-
pheral blood of cases of malaria.
The Blood-vessels in Beriberi.—Ogata in the
Sei-I-Kwai Medical Journal, vol. xxxi, No. 1l,
November 10, 1912, writes on the blood-vessels in
beriberi. He studied the rigor mortis in non-beri-
beri vessels. His conclusions were as follows:—
(a) The results of rigor mortis in non-beriberi
vessels.
(1) The blood-vessels undergo marked changes
after death, and consequently the blood-vessels
seen under the mieroscope do not show the state of
the vessels before death.
(2) Although the vessels contraet in the agony
of death, they relax to a certain extent after a time,
and on the appearance of the rigor mortis they con-
tract again. Finally after a certain period they
become quite soft through autolysis.
(3) There are no exact and characteristic differ-
ences between the vessels which were contracted
EL life and those which were relaxed during
ife.
(4) By the degrees of the vessels' rigor mortis
one cannot judge the degree of the vessels' con-
traetion during life.
(5) The rigor mortis of the vessels in men appears
gradually two to three hours after death and
reaches its maximum seven to fifteen hours after
death. After that it gradually disappears, and
after twenty-four hours the vessels are absolutely
relaxed. The individual characteristics and the
external influences produce great differences in its
occurrence.
(b) The results in the vessels in beriberi.
(1) The appearance and disappearance of the
rigor mortis of the vessels after death are nearly the
same as in the non-beriberi vessels as regards the
time, but the contractions of the vessels are some-
what stronger in the beriberi vessels.
(2) The maximum contraction of the beriberi
vessels described as seen in microscopical specimens
is probably due to the rigor mortis.
(3) As already mentioned the extent of the
vessels' rigor mortis is no standard of the degree of
the vessels’ contraction during life one cannot deduct
from the presence of the maximal contraction of the
vessels the spastic state of the vessels during life.
(4) As regards the states of contractions of the
vessels before the rigor mortis sets in, there are no
marked differences between the beriberi and non-
beriberi cases, but morphologically the author
noticed some differences. In those beriberi cases
which were autopsied soon after death one already
Feb. 15, 1913.]
notices that the spaces in the tunica media are
prominent, and that also there is unevenness in
the thickness of the tunica media. One misses
those changes in the non-beriberi cases.
(5) In the dorsal artery of the foot in one case
a transmigration of the cells of the involuntary
muscle fibres was recognized.
(6) If the unevenness in the thickness of’ the
tunica media and the transmigration of the cells of
involuntary muscle fibres are a rare event in the
non-beriberi cases these changes ought to help one
in judging the state of the vessels before death. If
those changes are the result of the looseness in
the connections between the tissue cells of the
tunica media, they coincide with the relaxed state
of the vessels noticed frequently by clinicians, but
they may be the result of a spastic contraction.
Thus whether those changes are due to the relaxa-
tion or contraction is still unknown.
(7) No rupture of the elastic fibres as mentioned
by Glogner was observed.
(8) There was a slight thickening and fatty
degeneration (so-called endoarteritis) of the tunica
intima in the large arteries.
(9) Swelling and vacuole formations were ob-
served in the endothelial cells in several cases.
(10) Thrombosis was present in the femoral
artery in two cases out of eight.
(11) The dilatation of the trunk of the pulmonary
artery was not marked in the author’s cases.
(12) In three cases out of eight, marked tortuosity
of the pulmonary vessels was noticed.
(13) The follicles of the spleen showed hyaline
degeneration in all cases.
. Plague in the Philippine Islands.—In the Quarterly
Report of the Bureau of Health for the Philippine
Islands—Second quarter, 1912—Heiser states that
after an absence of six yearsin human beings and five
years among rats, plague was again found in the
Philippine Islands, on June 17, 1912. A Filipino
employed as a watchman at No. 235, Calle San
Jacinto, in the Chinese district, who resided at
No. 920, Calle Antonio Rivera, was found dead at
his heme, on the date mentioned above, after an
illness of about three days. On post-mortem exami-
nation, typical plague buboes were found in the right
groin and axilla. Smears made from the spleen
showed Gram negative, bipolar staining organisms,
and inoculations made into guinea pigs resulted in
typical attacks of plague. The organism which was
recovered from the guinea pigs agglutinated plague
serum in high dilutions. The source of the infection
is unknown. The nearest known focus of plague is
at Hongkong, and there is no evidence to show that
this man had been out of the country during the past
few years. Test examination of rats caught in the
different districts of Manila, particularly those from
importers’ warehouses, have been made at weekly
intervals throughout the year since 1907 and have
always proven negative.
Houses in the vicinity of which the man resided,
and where he worked, showed evidences of rat
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 55
infestation, but an examination made of many
hundreds of rats caught there failed to reveal any
plague infection, nor was there any history of
unusual rat mortality having occurred anywhere in
Manila.
The second death occurred on June 26, in the
person of a Filipino woman, aged 44, at 1615,
Calle Azearraga, near the Arranque Market. She
was found alive, in her house, and had been ill for
three days. At the time she was transferred to the
San Lazaro Hospital she had a temperature of 41° C.
and was in a dying condition. The autopsy showed
slightly enlarged glands in the left groin, but the
other usual autopsy findings of plague were con-
spicuous by their absence. Smear preparations
made from the glands of the groin and from sections
of the spleen showed Gram negative, bipolar staining
bacilli. Inoculations made into guinea pigs produced
typical attacks of plague, and the recovered organisms
agglutinated with plague serum. This woman, from
reliable evidence, had also not been out of the Philip-
pine Islands during the past few years. Ata near-by
food store, where the woman is known to have pur-
chased her food supply, four dead rats were found.
These were taken to the Bureau of Science for
diagnosis, but the post-mortem and inoculation experi-
ments have proved negative.
The mortality rate for the city is rather below the
normal, from which fact it may be inferred that no
unrecognized cases are occurring. Three rat-catching
gangs have been put to work with the object of catching
as many rats as possible in the vicinities in which
the patients died, and from other sections which are
considered suspicious. So far, all of the rats found
have proved negative. From the foregoing it is
evident that there is no reliable information regarding
the origin of the disease.
It is possible that the disease has been introduced
by infected fleas, although, in view of recent cases
reported by McCoy in Hawaii, and by observers in
India, food infection cannot be completely disregarded.
If the disease was introduced by infected fleas it
would seem most likely that they reached here on
sick rats which came in cargo, like crates of onions
potatoes, baskets of eggs, garlic, baskets of soy beans
or similar food-stuffs which arrive almost daily, in
large quantities, from China, Japan, and other plague-
infected countries. Rats have actually been observed
in such cargo, and it would not be at all impossible
for an infected rat to have been introduced in this
way. The officers of the Public Health and Marine
Hospital Service located in Hongkong and Manila
have long since recognized the danger of introducing
plague in this way, but up to the present time it has
been impossible to devise a practical method for
entirely eliminating the danger from the introduction
of rats in this manner without placing prohibitive
restrictions upon commerce. The theory of the
introduction of the plague by means of food is slightly
supported by the fact that, at the autopsy of the first
case ulcerated tonsils were found, but as no cultures
were taken it is impossible to submit anything definite
under this head.
56 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Abstracts.
ABSTRACTS OF PAPERS READ BEFORE THE ‘‘ ITALIAN
PELLAGRA CONGRESS,” BERGAMO, SEPTEMBER,
1912, AND THE ' SECOND TRIENNIAL PELLAGRA
MEETING,’ COLUMBIA, U.S.A., OCTOBER 3 To 5,
1912.
PELLAGRA.
By Professor R. BLANCHARD, Paris.
I wave the honour to bring to the knowledge of
the Congress a résumé of the official report sent by
Dr. Vernesco, Director of the Preda Hospital in
Craiova (Roumania), to the General Director of
Public Health in Bucharest, concerning the after-
effects of Nicolaidi’s serum in the treatment of
pellagra.
Dr. Vernesco having been officially appointed by
the Roumanian Government, tried Nicolaidi’s treat-
ment during 1909 and 1911.
Thirty-three patients, all suffering from grave
cutaneous, gastro-enteric and nervous symptoms,
such as: erythema, pyrosis, profuse and fcetid
diarrhea, vertigo, buzzings in the ears, and hallu-
cinations, were subjected to the cure. Some of the
patients were completely unconscious. In all the
general state was bad. Many of them could not
even stand on their feet.
Twenty-three of these patients, after a course of
treatment (eighteen to twenty-three injections), left
the hospital completely cured. The others, after
eight to twelve injections, insisted on leaving the
hospital. Improvement was noticeable in all, how-
ever, and some were able even to return to their
work.
All the symptoms presented by the patients dis-
appeared after a short time, after eight to ten injec-
tions; the weight increased from 2, 4, 6, up to
9 kilos.
The same results were obtained in 1911, with
seven patients. Six of these were completely
cured; the seventh insisted on leaving the hospital,
feeling remarkably improved after a treatment of
fifteen days.
A certain number of patients (ten) with grave
psychical phenomena were sent to the Insane
Hospital at Craiova, and subjected there to the
same cure, by Dr. Mileticiu, the director of this
asylum. Nine left the asylum after twenty-two to
twenty-five injections, and returned to their work;
the tenth, afflicted with '' paranoia," was not im-
proved by the cure.
All the pellagrins subjected by Dr. Vernesco to a
sufficient number of injections (eighteen to twenty),
continue to-day, one to two years after the cure, to
be in good health and able for their work. In those
who had an insufficient number of injections, three
recurrences have been observed.
Amongst the pellagrins with psychical symptoms
cured by Dr. Mileticiu at the Insane Asylum, one
had a relapse one year after the cure. Subjected
again to the same treatment, he left the asylum
after eighteen injections. The other eight pella-
grins cured in the Asylum continue to-day, two
[Feb. 15, 1913.
years after the cure, to be in good health and able
to work.
Dr. Vernesco affirms, in consequence, that Nicol-
aidi’s serotherapy is a treatment of high efficiency
against pellagra, and insists on the satisfactory
results obtained in the gravest cases, if the treat-
ment is continued for a sufficient length of time.
Twenty, twenty-two, or twenty-five injections are
necessary, depending on the gravity of the case.
Relapses are rare, and seem to be due to an insufh-
ciency of the treatment.
ULTERIOR RESULTS ON PELLAGRINS, SUBJECTED IN
1911 ro NICOLAIDI'S SEROTHERAPEUTIC CURE.
By Dr. Umberto GRILLO, Udine, Italy, and Dr. ExiLi0 Maz.
IN September, 1911, we tried some therapeutieal
experiments on pellagrins with Nicolaidi's serum.
The majority of the patients subjected to the cure
were chosen from those afflicted with grave gastro-
enteric and nervous symptoms and the concomitant
general cachexia.
We promised in our last year’s publication in the
Rivista Pellagrologica Italiana, after a certain time,
to report the result of this cure.
For this purpose we examined all the treated
patients, last spring, when the pellagra symptoms
usually reappear, and we did so also in August.
The actual state of these patients is now reported.
an account of the period passed from the cure till
to-day having been kept.
Case 1.—B. Giuseppe, male, aged 47, was
afflicted last year with grave gastro-enterie sym-
ptoms; two to twenty diarrheic, profuse and fetid
stools per day, intense thirst, lips swollen, sensa-
tion of burning in stomach, with general prostration,
diffeult and spasmodic walk, notable emaciation
with marked loss of flesh, inability to work in
the fields, headache and sensorial troubles, fibril-
lary tremors of the tongue, hands and feet, diffused
erythema, during the past five years, on back, hands
and feet, and also on sides of neck.
Now, a year after the cure, the patient presents
only a very slight erythema on the exposed parts of
the hands, with a sensation of slight burning and
fibrillary tremors of the tongue. All the other
symptoms of last year have disappeared, and the
patient can now work regularly. The result is con-
sidered satisfactory.
Case 2.—T. Giulia, female, aged 44; was
afflicted last year with erythema on hands and feet,
sensation of weakness, vertigo, buzzings in the
ears, diarrhoea, headache, startled awakenings.
Apart from these pellagra symptoms, the patient
had also suffered from stomach troubles for five
years.
A year after the cure, the patient though still
emaciated, does not now present any erythema,
there is no diarrhea, nor any other symptoms due
to pellagra. The nutrition is slightly improved.
The result is considered fairly satisfactory.
Case 8.—S. Giuditta, female, aged 63. Was
afflicted last year with definite desquamative ery-
thema over the backs of her hands and feet; there
was also a profuse fuetid diarrhea, not influenced
Feb. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 5
-1
by treatment; headache, lachrymation, blepharitis,
buzzings in the ears, insufficient sleep, continuous
vertigo, organie depression, and a feeling of great
weakness.
A year after the cure the patient had erythema
and slight diarrhea for a short time, and a slight
trace of the erythema still persists. The general
nutrition is good. She does not feel any weakness,
and affirms that she had obtained an important
benefit from the serotherapic cure.
Case 4.—Z. Giulia, female, aged 43, was afflicted
last year, at the moment of the cure, with desqua-
mative erythema on the dorsal aspect of feet, diar-
rhea, heaviness in stomach, craving for a great
quantity of salt in her food, profuse fetid diar-
rhea, diminution of visual acuity, deficient nutri-
tion, physical prostration, with inability to perform
labour continuously. All these symptoms have
returned every year for the last eight years.
A year after the cure the condition was as fol-
lows: Patient had erythema on the hands and fore-
arms for a short time; she has gone on working and
has always felt very well. No diarrhea. Even in
the spring, when the erythema appeared, the gastro-
enteric functidns remained regular. The general
nutrition keeps good.
Case 5.—V. Teresa, female, aged 36, pellagra
for the last ten years; erythema on hands and feet;
every spring diarrhea. During the last two years
has been unable to work in the fields. Sensation of
swelling and pain in stomach, appetite lacking,
intense thirst, disordered taste. Nutrition dimin-
ished, organic exhaustion grave, unable to attend
even to housework, becoming at once exhausted.
A year after the cure, condition of nutrition good ;
no erythema, no diarrhea, no feeling of exhaus-
tion; perfect general health. Resumed work again
since the cure.
Case 6.—M. Clementina, female, aged 30, ery-
thema, burning on hands and lips, intense thirst,
burning in stomach, sensation of heaviness, fre-
quent headaches, vertigo, could attend to house-
work but was soon tired.
The patient improved after the cure, and was
able to return to work. A relapse, however, set in,
which killed her.
Case 7.—M. Agnese, female, aged 31. Cuta-
neous phenomena, grave gastro-enteric symptoms
such as pyrosis, lack of appetite, twenty to thirty
diarrheic stools per day; constant headache, in-
somnia, dreams, terrifying nightmares, continual
vertigo; anemia, emaciation, marked organic wast-
ing, absolute incapacity to work, tiring at least
effort.
A year after cure: General nutrition good. Fora
short time in spring had a slight erythema. Skin
and mucous membranes improved in colour; works
regularly. No subjective troubles. No trace of
erythema, no pyrosis. Sometimes her digestion is
a little laborious.
Case 8.—G. Maria, female, aged 40. For eight
years, desquamative erythema on hands and feet,
pyrosis, diarrhea, two to three liquid fetid stools
per day; erosion of the mucosa of gums; continual
^
headache, perspiration, burning of hands, frequent
hallucinations, sight diminished, insomnia with
troubled dreams, continual vertigo, fitrillary tre-
mors in tongue and hands, weakness, denutrition,
emaciation, sensation of profound physical prostra-
tion, incapacity for work.
All these symptoms disappeared after the cure,
and the patient has gone back to work. This is
considered an excellent result.
Casey 9.—Bal. Giuseppe, male, aged 51. Eight
to ten diarrheic stools per day. In spite of treat-
ment this has never ceased. Erythema on back of
hands every spring. Loss of flesh, anemia, dif-
fused edema in limbs and face. Skin and mucous
membranes very pale, waxy, and dried; face
swollen, unable to work last year in the fields.
On account of his pronounced oedema he was
recently obliged to remain in bed.
A year after the cure: No erythema, though this
made a very short reappearance last spring. No
diarrhea, tongue normal, perfect general state.
He works without feeling tired. (Edema gone, and
no more intestinal troubles.
The results in the nine patients subjected to
Nieolaidi's serotherapy was found to te satisfac:
tory, and the improvement has been maintained in
eight of the cases. One case died in spite of the
treatment, and one had a relapse. Case 9 perhaps
did better than any of the others, and appears to
be really cured.
The authors finally state that the cure is not a
specific one, but it repairs the grave deficiency
which the malady produces in the nutrition of the
pellagrins. The most notable point about it is the
way in which it cuts short the intestinal troubles.
All their patients during and after the cure got the
same kind of food and lived under the same
hygienic conditions.
Two CASES OF PELLAGRA, IN ROUMANIA, WITH
GRAVE NERVOUS SYMPTOMS, CURED IN A SHORT
TIME WITH NICOLAIDI’S SERUM.
By Dr. Jean Nicoraipr, Paris, France.
Case I.—Stef. Georg., male, aged 60, admitted
into hospital on August 10, 1912. Pellagrin for six
years. Every spring desquamative erythema on
the face, head, and feet. Headache with noises in
the head, exhaustion, diarrhea, and burning in the
stomach. Last spring, patient was admitted in the
hospital, where he was subjected to the usual treat-
ment, but without any result.
Present Status.—Last spring he had an extensive
erythema on the head, face, and feet, much graver
than the previous times. Severe headache with a
feeling as if a fire was burning in his head. Con-
tinuous vertigo; sight diminished, hearing bad,
continuous buzzings in ears. Exhaustion, unable
to walk and even to stand on his feet; slight diar-
rhea with burning in the stomach. Erythema and
ulcerations on back of hands, feet and legs.
First injection: With 50 c.e. of Nicolaidi’s
serum, August 12. August 14, 15, 16, second,
third and fourth injection, same dose.
58 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 15, 1913.
August 17.—Patient says that the sensation of
burning and the fire in his head are diminished, also
the fearful noise he always had in his head, but he
still feels as if it were hot. The haziness he had
before his eyes is less thick, but he always has the
impression of a veil before them. He always has
buzzings in the ears.
August 18 and 20.—Fifth and sixth injection of
same dose.
August 21.—Burning in stomach less pronounced.
August 22, 28, 24.—Seventh, eighth and ninth
injections of 50 c.c.
August 25.—Feels much better on the whole; his
expression is calmer. He still complains of the
hot feeling in the head.
August 26, 27, 28.—Tenth, eleventh and twelfth
injection of same dose.
August 30.—Patient feels well.
pletely gone. Head no longer hot. Sight good.
Burning and buzzings disappeared. Can walk,
general state remarkably improved. Feels able to
return to his work, and insists on leaving the hos-
pital.
In this case the disappearance of all grave sym-
ptoms was obtained in a very short time—eighteen
days—and with only twelve injections of the
serum.
Case 2.—Maria Const. Gh., female, aged 58,
admitted into hospital on August 8, 1912.
Patient completely unconscious, impossible to
obtain any information.
Present Stalus.—Extensive erythema on face,
hands, forearms, feet and legs, with numerous
ulcerations. Face cdematous, swollen and staring
eyes. Complete unconsciousness. Mutters in an
incoherent manner; passes her urine and fæces
under her. No diarrhea.
August 12.—First injection of 50 c.c. of Nico-
laidi's serum.
August 14, 15, 16.—Second, third and fourth in-
jection of the same dose.
August 17.—After these four injections the
patient became quieter. Her face was not so
swollen as it was when she arrived at the hospital,
and she began to speak again in an intelligible
manner.
August 18 and 20.—Fifth and sixth injection of
the same dose.
August 21.—Patient again more conscious, but
she still does not know how long she has been ill,
nor how old she is. She remembers that she has
a son called John. Control over bladder and rec-
tum has returned. Says she feels better, but still
has a burning pain in the body. Sleep calmer,
appetite good.
August 22, 23 and 24.—Seventh, eighth and
ninth injection of 50 c.c.
August 26.—The state of the patient has im-
proved in every way, but the memory is not re-
established. She does not remember anything
about the past.
August 26, 27 and 28.—Tenth,
twelfth injection of same dose.
August 80,—Patient declares that she feels well.
Erythema com-
eleventh and
She has lost the burning feeling in the stomach,
speaks well, and her memory has returned. The
uleerations on her hands and feet are almost cured.
September 1, 2, 3.—Thirteenth, fourteenth and
fifteenth injection—same dose.
September 5.—Patient feels well Appetite
good. Answers clearly all questions put to her.
Memory completely returned.
September 5, 6, 7.—Sixteenth, seventeenth and
eighteenth injections—same dose.
September 8.—Progress maintained; face, hands
and feet completely free of erythema and ulcera-
tions. Expression quite calm. Answers questions
well.
September 8, 9 and 10.—Nineteenth, twentieth
and twenty-first injections, same dose.
After this the author gave some further injec-
tions to consolidate the cure. All the symptoms,
which were in this case of a grave nature, dis-
appeared then after twenty-eight injections; a most
satisfactory result.
Tick BITE IN BRITISH COLUMBIA.’
By Jonn L. Topp, M.Dj
Associate Professor of Parasitology, McGill University,
Montreal.
A very fatal disease, with symptoms closely re-
sembling those of typhus fever, occurs in some parts
of Montana. The disease is known locally as spotted
fever, or tick fever. It is called tick fever because
it is transmitted by the bites of a tick. When it
became known that this tick, Dermacentor venustus,
exists in Southern British Columbia, inquiries were
instituted with the object of learning whether the
disease which it transmits in Montana algo exists in
Canada. With this object, letters were sent out in
the middle of April last year to a number of doctors
practising in Southern British Columbia. The
replies received from them were so interesting that
more letters were sent out to medical men in British
Columbia and in the neighbouring states and pro-
vinees. Altogether two hundred and ten letters
were sent out to ask physicians if instances of ill-
effects following tick bites, or of a disease resembling
spotted fever, had occurred in their practices. In
all, forty replies were received. Many of those who
replied had seen cases in which infection of the
wound caused by a tick bite had been followed by
local inflammation that was sometimes very severe.
Six letters mentioned instances in which the bites
of tieks had been followed by paresis, or paralysis,
and, sometimes, by death. "The symptoms reported
in these cases are quite unlike those which occur in
the tick fever of Montana.
Dr. 8. B., Fernie, B.C. About 1898, at Rossland,
two infants died in convulsions; wood ticks were
found on the necks of both,
Dr. G. C. E., Rosedale, B.C. In June, 1910, a
child aged 4 had almost complete paralysis of
the legs. A large wood tick had been taken from
! From the Canadian Medical Association Journal, Decem-
ber, 1912, ,
Feb. 15, 1913.]
the nape of the neck a few hours before the doctor’s
visit. After a purge and a few hours’ rest the child
completely recovered.
Dr. G. B. H., Creston, B.C. A girl aged 4
gradually lost the use of her legs, during two or
three days, until she was unable to stand. A tick
was removed from the nape of the neck, and within
three days the child was well again.
Dr. G. B. H., Victoria, B.C. About 1900, at
Nelson, B.C., a child aged 5 was bitten on the
back of the head by a tick. The patient died
in convulsions. Dr. H. is very certain that the
wood tick causes symptoms, and that there is no
possibility of confusing these symptoms with those
eaused by infantile paralysis.
Dr. C. M. K., Grand Forks, D.C. About 1964 a
child aged 4 had complete paralysis of the legs
and a lesser degree of paralysis of the arms. A
wood tick was removed from the nape of the neck,
and rapid recovery resulted. Dr. K. knows of two
or three such cases.
Dr. O. M., Vernon, B.C. January, 1912. A
healthy child, 34 years old, had been perfectly well
until two hours before examination; when the
patient was seen there was no temperature and the
pulse was normal, but the legs were almost com-
pletely paralyzed. "The child could not stand, and
the reflexes were gone. A tick was found, firmly
attached to the base of the neck; it was removed.
The paralysis eontinued during the day ; next morn-
ing there was a slight improvement, and by the
evening the child had recovered the use of her legs.
Dr. N. also knows of an instance in which an adult
eomplained of weakness of the legs after a tick bite
on the back.
Dr. W. O. R., Nelson, B.C. About 1900 a child
died suddenly with symptoms of acute ascending
paralysis. After death a large tick was found at
the nape of the neck. In 1901 a second child with
the same symptoms died, after an illness of two
days. A tick was found attached to the right
temple. The knowledge of these two cases sug-
gested the presence of a tick when a third child,
previously very healthy, was seen, whose legs had
been becoming weaker for two days. One was found
at the nape of the neck; it was removed, and in two
days the child was quite well again. On April 10,
1912, a little girl aged 3 had become paralyzed.
The legs were completely paralyzed and the reflexes
were gone; paresis of the arms. was marked. Three
ticks were removed from the nape of the neck, and
the child recovered completely.
Dr. D. R. S., Vancouver, D.C. At Rossland a
child aged 3 or 4 had paralysis of the legs with
absence of reflexes. A tick was removed from the
neck and the symptoms disappeared.
Judging from some of the letters received, a belief
that the bites of ticks may cuuse paralysis is quite
common in some parts of British Columbia.
A consideration of these reports makes it seem
very probable to the author that severe symptoms
may follow the bites of ticks in British Columbia.
Children seem to be most affected. In them,
paresis and paralysis of the extremities, especially
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE 59
of the legs, are the most constant symptoms; and
when such symptoms are seen ticks are usually
found about the patient's head.
Dr. Todd makes these notes publie in the hope
that they may induce physicians who have seen
or who may see similar cases to publish their ex-
periences; for it seems possible that an undescribed
disease, caused by ticks, may occur in British
Columbia. The subject demands investigation, and
Dr. Todd would welcome information and material
concerning it. Living ticks, removed from children
in whom their bites had caused paralysis, would be
especially valuable.
Hotes and Hews.
PREVENTION OF DISEASE IN WEST
AFRICA.
METAMORPHOSIS OF FILARIA LOA.
AN important discovery has been made in West
Africa by Dr. R. T. Leiper, Interim Wandsworth
Scholar of the London School of Tropical Medicine.
The Secretary of that institution has received the
following telegram, dated December 27, from Dr.
Leiper at Calabar:—
“The metamorphosis of Filaria loa has been
proved to take place in the salivary glands in a fly
belonging to the genus Chrysops.”
This discovery is of great importance because of
the large number of Europeans who become
infected with this worm in West Africa. The
effects are rarely fatal, but the parental worm
travels under the skin, sometimes under the
conjunctiva, and may in that position set up
conjunctivitis. The commonest result is the so-
called *' Calabar swelling." This is due to the
worm's migrations in the deeper parts of the
limbs, in the muscles and round the tendons. The
swellings are painful and impair movement, so that
the victim may be unable to write or even to use
his hands. The swellings rarely last for more than
a few days, but often recur in the same or another
part of the body. There is some reason to suspect
that at times, when travelling inside the skull, they
cause epileptiform convulsions. The importance
of Dr. Leiper’s discovery is that now science will
be in a position to determine the conditions in
which people become infected, and it is hoped to
prevent such infection.
The members of the genus Chrysops are day-
biting flies, and are very widely distributed not only
in the Tropies, but also in temperate climates, even
in the British Isles. It is expected that Dr. Leiper
will be now able to show which species of Chrysops
are the carriers, as it is known that Filaria loa is
limited to West Africa. The embryos of Filaria
loa are found in the blood only during the day
time, and are therefore called Microfiluria diurna
by some in distinction from Filaria bancrofti, the
cause of elephantiasis, whose embryos are found in
the blood only during the night, and are known as
Microfilaria nocturna. Sir Patrick Manson many
years ago surmised that this nocturnal periodicity
60 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 15, 1913.
pointed to a nocturnal blood-sucking insect as the
intermediate host, and he proved that the inter-
mediate hosts were certain species of mosquitoes.
The diurnal periodicity of the embryos of Filaria loa
suggested that the intermediate host was a day-
biting insect, and Dr. Leiper has proved that the
intermediate host of Filaria loa is a day-biting
insect, a member of the genus Chrysops.
The Wandsworth Scholarship, the income of
which has enabled the School to send Dr. Leiper,
their helminthologist, to investigate the life history
of the Filaria loa and other blood worms in man
and animals, was placed at the disposal of the
School about six months ago. The capital of the
scholarship is a sum of £10,000, which was be-
queathed by the late Lord Wandsworth to Sir
William Bennett for purposes of research, and the
latter placed the whole of the bequest at the dis-
posal of the London School. Mr. Austen Chamber-
lain’s appeal for £100,000 to place the School in a
proper financial position has as one of its objects
the provision of a sum sufficient to keep always in
the field a research investigator. It may be
recalled that Mr. Chamberlain was able to report
at a recent meeting of a committee whieh has been
formed to help him at the London Chamber of
Commerce that more than half the amount for
which he is appealing has now been received.—
The Times.
More than forty varieties of rice are cultivated
in Siam. The “hill” rice is a peculiar variety
planted on the hillsides in Northern Siam, and is
said to be marvellously productive. When ripe the
ears of this rice are black, but when husked and
boiled the grains are of a reddish colour, and have
a peculiar fragrance. The ‘“ glutinous " rice is
another variety, grown in the mountain valleys of
Northern Siam, and forms the main food for the
people of those regions, while white rice only is
grown and used by the people on the plains of
Lower Siam. A common kind of rice cultivated on
land liable to floods during the rains is said to grow
as much as a foot in twelve hours, so that the plant
often attains a height of ten feet in its efforts to
keep its leaves above water. The rice commonly
grown in Siam consists of the so-called light crop,
which is planted as early as February, and reaped
in May or June, and the heavy crop, which is
planted between July and September and harvested
in December and January. Rice that is exported
ean be roughly divided into three classes—Na
Muang, Pasak, and garden rice. Na Muang is the
cheapest quality, and is grown chiefly in the district
of Ayuthia. The grains are short, and have a great
deal of red rice mixed with them, and they are also
very much cracked, and therefore liable to be
broken in milling. Pasak rice, which is of better
quality than Na Muang, comes from the Pasak
River district, and is a variety of golden rice. It is
only due to the soil of this district that it is of
poorer quality than the ordinary garden rice. The
so-called garden rice forms the main bulk of rice
that is exported, and is of the best quality. Na
Muang and Pasak rice are used for mixing with it.
This rice was formerly grown in the ditches of
vegetable gardens, but is now grown on vast tracts
of land, both by broadcast sowing and transplanting
processes, so that the name garden has lost its
original meaning.
Tue Dier or Mextcans.—The principal articles
of food of the Mexicans are tortillas, tamales,
enchilados and frijoles, and of these the tortilla
takes first rank. It is made from corn (maize).
The process is to allow a given measure of corn to
souk for twelve hours in twice its bulk of strong
lime-water, and the swollen grains are then washed
in clean water. The corn is then put through a
mashing process on a metate, which is a single piece
of granite about 18 in. by 24 in., and of suck shape
that when held on the knee there is an easy incline
from top to bottom, with a slight concave towards
the centre over the entire surface. The stone is
placed in a wide, shallow vessel, and with a stone
pestle, called a ‘‘ mano,’’ the soft corn is rubbed up
and down on the surface of the metate until there
is a well and evenly kneaded mass. When sufii-
ciently kneaded it is formed into thin cakes about
4 in. in diameter, which are then baked on an
earthen plate called a ‘‘cornal.’’ The poorer
classes in Mexico use the tortilla not only as a food,
but they make it serve also as spoon and fork. It
is folded into a sort of scoop, and used in eating
beans, thick soup, rice hash, or anything else
usually lifted to the mouth with spoon or fork.
Tortillas are considered a very nourishing article of
diet, many labourers performing a long, hard day’s
work on a diet of tortillas, beans, and black coffee.
Within the last few years machinery has been
devised which grinds the lime-soaked corn.
In view of the spread of pellagra this diet is of
interest. Soaking the grain in lime-water before
grinding seems peculiar to Mexico.
Tne current quarterly issue of the Bulletin of
the Imperial Institute, January, 1918, vol x
(1912), No. 4, contains reports of recent investiga-
tions by the scientific and technical department of
the Institute, of which two are of special interest
to the general reader: (1) An article on the cotton
industry of Nyasaland, showing its great extension
in the Protectorate and describing the evolution of
a type of cotton which has now been acclimatized
and is recognized as a distinct commercial variety
under the name of Nyasaland Upland; and (2) an
article on Bermuda arrowroot, which, in the labor-
atory tests at the Imperial Institute, has been
shown to evince distinctive properties from some
" Bermuda ” arrowroots on the London market
that are reputed to come from Bermuda. A special
article, illustrated by a coloured plate, is contributed
by Mr. Gerald C. Dudgeon, Director-General of the
Department of Agriculture in Egypt, on the
'* Cotton-worm in Egypt," in which the correlation
of the yield in cotton with the degree of severity
of cotton-worm attacks is examined in detail. The
Feb. 15, 1913.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 61
second part of an article on the ‘‘ Coal Resources
of the British Crown Colonies and Protectorates '' is
published; and there are other general notices
respecting economic products and their development,
among which is a comprehensive survey of the
occurrence of bismuth ores, their distribution and
utilization, throughout the world. The Bulletin
concludes with some general notes, and with a sum-
mary of the contents of the more important papers
and reports published during the preceding quarter,
on subjects within its purview, and notices of recent
literature.
MOTOR LAUNCHES FOR THE TRoPi1cs.—The Bergius
Launch and Engine Company, of Glasgow, make a
speciality of launches suitable for tropical work.
In their catalogue detailed descriptions are given
of their Kelvin motor launches with diagrammatic
plans, &c., so that intending purchasers may have
everything before them. Many of the designs are
particularly suitable for missionaries, planters,
fishermen, pilots, and for other general purposes.
The great advantage of motor launches, especially
for tropical work, is obvious. The prices are very
unwisely omitted from the catalogue.
A GUIDE TO PHOTOMICROGRAPHY.—Leitz issues a
new guide to photomicrography. In view of the
ever-extending utility of micrographic methods in
all branches of scientific research the writer of the
guide believes that this book will afford welcome
assistance to many who are not sufficiently con-
versant with all the practical details of the method
and photographic technique in general. Drawing
upon the store of practical experience which he has
collected in the course of years, the writer endea-
vours to explain in simple terms all that need be
known respecting the treatment of the negative, its
exposure, and development, as well as the prepara-
tion of paper prints and lantern slides. He has,
moreover, thought it advisable to append a few
short notes on the preparation of stereoscopic
pictures, also on the use of the cinematograph
attachment and dark-ground condenser for photo-
graphing living bacteria, and at the end of the book
will be found directions for working by the auto-
chrome process.
Tae Use or METALLURGICAL MICROSCOPES WITH
CaMERA.—Metallurgieal microscopes are designed
upon principles which differ fundamentally from
those determining the construction of microscopes
used for biological and mineralogical research. This
difference arises mainly from the fact that the
metallurgist is solely concerned with opaque speci-
mens of metals. In the standard type of micro-
scope objects are studied by transmitted light, that
is, by light passed through a transparent object or
preparation with the aid of a mirror or condenser.
On the other hand, metals and other metallurgical
objects require to be illuminated by light brought
to bear upon them by means of a mirror or prism
in such a manner that it may pass by reflection at
the object through the objective and so reach the
eye or the camera. The appliances required to
achieve this end in an efficient and practical manner
involve a complete departure from the usual design
of the prototype. In a series of directions issued
by Leitz the various arrangements by which the
apparatus is rendered available for work with lenses
of different focal lengths and magnifications is dealt
with separately, as the conditions of working vary
considerably under these different circumstances.
————9————
Achicws.
THE INTERNAL SECRETORY ORGANS:
PHYSIOLOGY AND PATHOLOGY. By Professor
Dr. Artur Biedl, Vienna. With an Introductory
Preface by Leonard Williams, M.D., M.R.C.P.,
Physician to the French Hospital: Assistant
THEIR
Physician to the Metropolitan Hospital. Trans-
lated by Linda Forster. London: John Bale,
Sons and Danielsson, Ltd., Oxford House,
83-91, Great Titchfield Street,
W. 1913. All rights reserved.
As Dr. Williams says in his foreword, the subject
of the Internal Secretions, or Glandular Physiology
as it is sometimes called, is one which is destined
to occupy the attention both of physiologists and
clinicians for a long time to come. The subject, of
course, is of the greatest importance, and all in-
terested in it must be thankful to Professor Biedl
for putting together all the facts, theory, and other
work that has been done upon it into book form. The
value of such a work is enormous, and the labour
that must have been accomplished by the author in
writing it may better be imagined than described.
The book is divided into two parts. Part I,
General, and Part II, Special. In Part I, a brief
account is given of the history of the doctrine of
internal secretion, of its physiological basis, and of
the general principles upon which the teaching is
founded. In Part II the internal secretory organs are
taken separately, and what is known of the nature
and signifieance of their activities is described. In
the present state of one's knowledge anything in the
nature of a systematic classification is impossible.
The only rational basis would be a morphological one,
but this is rendered impossible by the insufficiency of
the data at one’s disposal. There is a general
tendency to ascribe a specific activity to every cell-
form and to every kind of tissue; but though, in a
sense, one is justified in so doing, there is as yet
no certain proof of the internal secretory activity of
the greater number of cells and tissues. From the
structure of a tissue the specific function possibly
may be deduced, but that is a long way from being
able to infer the nature of its chemical correlative
function.
There are also drawbacks to a classification upon
purely physiological grounds. In any such attempt
organs and tissues of the most dissimilar type would,
on account of the similarity of their function, be
Oxford Street,
62 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 15, 1913.
classed together; while organs possessing activities
in more than one direction would be included in
several different groups.
Such being the state of matters the author has
avoided all attempts at classification and simply
gives & list of the internal secretory organs, taking
them, as far as possible, in the order of their im-
portance.
The so-called "vascular" or “ ductless” glands
are first dealt with, then the other internal secre-
tory organs. The first group includes: The organs
of the thyroid apparatus, namely, the thyroid gland
and the parathyroid glands. The thymus gland. The
two suprarenal systems, namely, the interrenal and
the adrenal, together with the carotid and coccygeal
glands. The hypophysis cerebri or pituitary gland,
consisting of the anterior and posterior portions,
together with the pineal gland. The spleen, which
was formerly considered a vascular gland, is now
regarded as essentially hamatopoietic in its activity,
its internal secretion having no great physiological
significance.
The second group includes: The sexual glands and
other tissues concerned in the processes of repro-
duction. The pancreas. The intestinal and gastric
mucosa. The kidneys.
The questions of glycogenesis and the neutralizing
activity of the liver are not entered into. These secre-
tory functions are the oldest known and are fully
described in the current text-books of physiology.
The plan adopted in each instance is: First, to
give the necessary information concerning the mor-
phology and the development of the organ ; second, to
describe in detail its physiological and experimental
aspects; and finally, to estimate its pathological sig-
nifieance by means of material gained from clinical
observation.
The book naturally is a long one— 445 pages—while
the literature covers another 141 pages, making the
total 586 in all. The reference table, although very
extensive, makes no pretension to include the entire
literature of the subjects dealt with, the older litera-
ture, that anterior to about the middle of the last
century, being omitted altogether.
The works are arranged, not according to subject, but
under the authors' names, which are alphabetically
placed, and the list is complete up to the end of the
year 1909, a few publications for 1910 also being
included. The above gives only a very imperfect
account of this monumental work. People inter-
ested, of course, must read the original. The trans-
lation is a very good one, and very few verbal errors
are to be found in the pages.
Tue Britisn JocgNar or Tupercenosts. Edited by
T. N. Kelynack, M.D.
The January number of this journal (vol. vii,
No. 1, January, 1913) contains the following
original articles: ‘* Housing the Tuberculous
Patient," by W. H. Scopes and M. M. Feustmann;
"Carb Spengler's Views and Methods regarding
Tuberculosis,” by W. H. Fearis; ‘ The Future of
Dispensary and Domiciliary Management of Tuber-
culosis,’’ by D. J. Williamson. Two critical re-
views are also published, one on ‘‘ Recent Advances
in the Cultivation of the Tubercle Bacillus,” by J.
Cruickshank, the other on ‘‘ Mixed and Secondary
Infections in Pulmonary Tuberculosis," by J. A.
Radcliffe. In addition to these a part is devoted
to personal opinions, to institutions for the tubercu-
lous, notices of books, preparations and appliances,
and notes. The journal is published quarterly
(single copies, 1s. 6d.; annual subscription, 5s.
post free), Bailliére, Tindall and Cox being the
publishers. Many of the articles are illustrated by
photographs. The difficulty for a journal of this
sort will be the getting of good original communi-
cations. Given these, however, then it should do
well.
A CLINICAL SYSTEM OF TUBERCULOSIS, DESCRIBING
ALL Forms or THE Disease. By Dr. B.
Bandelier, Medical Director to the Sanatorium
Schwarzwaldheim at Schömberg, near Wild-
bad, and Dr. O. Roepke, Medical Director to
the Sanatorium for Railway Workers at Stadt-
wald in Melsungen, near Cassel. Translated
from the Second German Edition by G. Ber-
tram Hunt, M.D., B.S., late Physician to the
Scarborough Hospital. ^ London: John Bale,
Sons and Danielsson, Ltd., 88-91, Great Titch-
field Street, Oxford Street, W. Copyright.
1913.
This is a very valuable work on the subject of
tuberculosis, and it has this great advantage, that
the whole subject is dealt with together in one
volume. Whatever aspect of the disease, there-
fore, one wishes to read about, surgical tubercle,
medical tubercle, tubercle of the special senses, &c.,
will be found within its pages. The present
edition (the second) has not been altered in form,
but the latest discoveries and most recent views on
the subject have been incorporated in the various
chapters. Several of these, on tuberculosis of the
upper air passages, the blood and lymphatie sys-
tems, the digestive organs, the skin, and the ner-
vous systems have been rewritten, while others,
such as the climatie and surgical treatment of pul-
monary tuberculosis, tuberculosis of the kidney,
bladder, tonsil, throat, and larynx have been con-
siderably increased.
New schematic charts for recording the condition
of the lungs and new temperature charts have
been added, and sections on tuberculosis of the
gall-bladder, Hodgkin's disease, the tubercular
psychoses and mental states, make their first
appearance.
Plates on the bacteriological diagnoses, and on
the pathological anatomy of tuberculosis of the
lungs and larynx from Koch’s work “On the
Etiology of Tuberculosis’? have been added by
request. The first edition of the book was very
favourably received both in Germany and other
countries, and there is no doukt that the second
edition will share the same fate. Having this
edition translated into English will make the work
available to the medical profession in England
Feb. 15, 1913.]
generally, and this, of course, should enormously
increase -the circulation and sale of the book. One
can confidently recommend the work to all inter-
ested in the subject of tuberculosis. It is a gold
mine of information, and nothing, even of the
slightest importance, is omitted. A translation has
also been made into Spanish, which still further
indicates its popularity.
ANNUAL Report ON THE RESULTS OF TUBERCULOSIS
RrsEARCH, 1911. By Dr. F. Köhler, Head
Physician of the Holsterhausen Sanatorium,
near Werden on the Ruhr. Reprint from the
'* Clinical Year-book,’’ edited by Dr. Naumann
and Dr. M. Kirchner. Vol. 26. Translated
by Ronald E. S. Krohn, M.D.Lond. London:
John Bale, Sons and Danielsson, Ltd., Oxford
House, 83-91, Great Titchfield Street, Oxford
Street, W. 1913.
The author states that the friendly reception
accorded by numerous readers to the ‘* Annual
Report on the Results of Tuberculosis Research in
1910,’’ published last year, is his justification for
continuing the work then begun, and now submit-
ting a synopsis of the most important works that
have appeared during 1911. The report is larger
this year, because more space has been allotted
for each review, and also owing to the fact that
the literature of the subject increases year by year.
As the translator mentions, it is to be regretted
that the report now submitted is on the work done
in 1911, but the delay has been unavoidable. The
book, with the index, runs to 245 pages, and is
divided up into the following sections: (1) General,
(2) Distribution, (8) Etiology, (4) Pathology, (5)
Diagnosis, (6) Prophylaxis and Treatment, (7)
Index of Authors, (8) General Index. Such a
synopsis must prove invaluable to all workers on
tuberculosis, and an English translation is a very
sound scheme,
THE ETIOLOGY OF ENDEMIC GOITRE.—Being the
Milroy Lectures delivered at the Royal College of
Physicians of London in January, 1913. By
Robert McCarrison, M.D., R.U.I., M. R.C.P.Lond.,
Major, Indian Medical Service. Illustrated.
London: John Bale, Sons and Danielsson, Ltd.,
Oxford House, 83-91, Great Titchfield Street,
Oxford Street, W. 1913.
The Etiology of Endemic Goitre is one that has
puzzled many observers in the past, and will probably
continue to do so in the future. Major MeCarrison's
Milroy Lectures, written up into book form, will now,
however, provide those interested in the subject with
a readily accessible record of the extent of the
present-day knowledge of the causation of the disease.
A most striking discovery is, undoubtedly, that of
Chagas, in Brazil, who shows that many of the goitres
of that country are due to a trypanosome, the Schizo-
irypanum Cruzi. This parasite apparently produces
many lesions in its human host, one of these being
this form of goitre, called now by Chagas Parasitic
thyroiditis.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 63
In the light of these discoveries the etiology of
endemic goitres in other areas requires careful re-
vision. Vianna’s researches show that the trypano-
some in its later stages disappears from the blood and
becomes a tissue parasite, so that un absence of such
parasites from the peripheral blood in a chronic case
of goitre is not sufficient to say that they might not
have been there at some previous time, and have
really been the cause of the condition. The book is
well illustrated with many very excellent photographs,
and it should prove both interesting and instructive
to those who read it. Major MeCarrison has made
the subject of goitre his special study, and the many
observations of his own contained in the pages of the
book show how much valuable work he has done on
the subject.
A System or Surcery. Edited by G. C. Choyce,
B.Sc., M.D., F.R.C.S.; Dean of, and Teacher
of Operative Surgery in the London School of
Clinieal Medicine; Surgeon to the Seamen's
Hospital, Greenwich; Surgeon to Out-patients
ut the Great Northern Central Hospital.
Pathological Editor, J. Martin Beattie, M.A.,
M.D., C.M.; Professor of Bacteriology in the
University of Liverpool, and Bacteriologist to
the City of Liverpool; formerly Professor of
Pathology and Bacteriology, and Dean of the
Faculty of Medicine, in the University of
Sheffield; Hon. Pathologist to the Sheffield
Royal Infirmary and Royal Hospital. In three
' volumes. Volume II. With eighteen colour
plates, eight black and white plates, and 375
illustrations in the text. Cassell and Company,
Ltd., London, New York, Toronto, and Mel-
bourne. 1912.
This, the second volume of Choyce’s System of
Surgery, contains the following articles: The breast,
by W. S. Handley; the spleen, by C. G. Watson;
malformations of the face, lips, and palate, by C.
A. R. Nitch; the tongue, by W. H. Clayton-Greene ;
the salivary glands and floor of the mouth, by I.
Back ; the cesophagus, by H. M. Rigby; the stomach
and duodenum, by J. Sherren; the intestines, by
A. Miles; the appendix and peritoneum, by P. Sar-
gent; hernia, by L. MeGavin; the rectum and anal
canal, by H. S. Clogg; the liver, gall-bladder, bile
passages, and pancreas, by G. G. Turner; the upper
and lower urinary tract, by J. W. Thomson Walker;
the male genital tract, by R. Howard; and the
female genital tract, by V. Bonney. All these sub-
jects, treated as they are by specialists, in many
instances of the individual subject itself, are suit-
ably dealt with.
One of the main features of the work is the
splendid way in which it is illustrated, there being
no fewer than eighteen coloured plates, while eight
black and white plates and 375 illustrations are also
to be found in the text. These greatly enhance the
value of this very excellent system. For those
surgically inclined no better work could be in their
hands. The next volume, the third, will complete
the system.
64 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 15, 1913.
Personal Rotes.
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Arrivals Reported in London.—Captain W. T. Finlayson,
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Colonel S. H. Henderson, I.M.8.; Major E. R. Rost, I.M.S.;
Captain J. J. Robb, I.M.S.; Lieutenant-Colonel E. A. W. Hall,
I.M.S.; Captain L. Reynolds, I.M.S. ; Captain E. S. Phipson.
I.M.S.; Lieutenant-Colonel W. H. B. Robinson, I.M.S. ; Major
L. P. Stephen, I.M.S. ; Captain G. L. C. Little, I.M.S.;
Major F. H. G. Hutchinson, I. M.S. ; Lieutenant-Colonel R. H.
Castor, I.M.S.; Lieutenant-Colonel W. Molesworth, I.M.S.;
Major C. D. Dawes, I.M.S. ; Captain J. J. H. Nelson, I.M.S.;
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Parkinson, I.S. M.D. ; Captain L. Hirsch, I.M.S.
EXTENSIONS OF LEAVE.
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I.M.S., 6m. M.C. ; Major M. Mackelvie, I. M.S., 7 m. ; Captain
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Megaw, I. M.S., 14 days; Lieutenant J. F. H. Morgan, I. M.S., to
March 10, 1913; Lieutenant V. P. Norman, L.M.S., 6 m. M.C. ;
Major C. B. Harrison, I. M.S., 4 m. M.C. ; Major P. P. Kilkelly,
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List oF INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
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Bidie, Major G., I.M.S., 12 m., from June, 1912.
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Browse, Major G., I. M.S., to April 7, 1913.
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Davys, Captain G. I., I. M.S., to January 31, 1913.
Dawes, Major C. D., I.M.S., to December 24, 1913.
Graves, Lieutenant-Colonel D, H., I.M.S.
Hamilton, Major J. A., I.M.S., to December 19, 1913.
Kerans, Captain G. C. L., I.M.S., 1 y., from April 5, 1912.
Little, Captain G. L. C., I.M.S.
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Middleton-West, Captain S. H., I.M.S.
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Nelson, Captain J. J. H. I.M.S.
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Norman, Lieutenant V.P., I. M.S., 2! m., from November 15,
1911.
Phipson, Captain G. S., I.M.S., to November 19, 1913.
Reynolds, Captain L., I.M.S., to May 6, 1913.
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1911.
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India Foreign, 17 m., 23 d., October 9, 1911.
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1912.
Fowler, Captain G., I. M.S., C.P., 16 m., March 1, 1912,
Hall, Lieutenant-Colonel E. A. W., I. M.S., B., 24 m., October
25, 1912.
Henderson, Lieutenant-Colonel S. H., I.M.S., U. P. Prisons,
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98, 1912.
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———9—————
* Annales d'Hygiéne et de Médécine Coloniales," 1912, xv, 3.
The Etiology of Beriberi. Gouzien, from a study of the
records in regard to beriberi in the penitentiary at Hanoi in
French China from 1906 to 1910, concludes that rice un-
doubtedly plays a very important part in the pathogenesis
of the disease, but that the superiority of the unpolished to
the polished rice does not lie in any antitoxie effect of the
husks butin the fact that they protect the grain against
degeneration from heat and moisture. He believes that the
disease is an intoxication, and not an infection. In support
of this theory he cites the fact that a very severe epidemic
of beriberi was followed by an epidemic of scurvy, the latter
disease attacking only those who had been affected by the
former. According to him, the two diseases seem to be in a
sense interehangeable. Moreover, even when polished rice
of the same quality is used, marked decrease is noted in the
epidemie when the diet is varied by a free use of fresh
vegetables, fruits and meat. In addition to the dietetic
factors, overcrowding and dampness seem to play an im-
portant part in the course and severity of the disease.
“Bulletin de la Société Medico-Chirurgicale de L’Indochine,”
Tome iii, December, 1912, No. 10.
Liver Abscess due to Ascaris lumbricoides.—Degorce
reports an interesting case of a child, aged 7, who was
admitted into the Hospital at Hanoi suffering from severe
pains in the abdomen. Peritonitis soon developed with a
high temperature, and the child sank and died. The autopsy
revealed the fact that the liver was invaded by numerous
Ascaris lumbricoides which had caused multiple abscesses,
peritonitis following, and so death. A very clear figure of
the liver shows the invasion of the ascarides and the multiple
abscesses.
Hotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
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3.— To ensure accuracy in printing iv is specially requested
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JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publisners.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
Mar. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Original Communications.
CLIMATE AND OTHER FACTORS IN RELA-
TION TO THE HEALTH OF EUROPEANS
IN CHINA.
By Dr. James GRIEVE CORMACK,
London Missionary Society, Hankow, China.
Tae climate of China is as varied as that found
throughout the length and breadth of Europe. In
the north, especially Chihli and Manchuria, the
winters are semi-arctic in their severity, while in
Southern China the summers are semi-tropical or
tropieal in their intensity; hence in speaking of
climate in China in its bearings upon health, one
must ever keep in mind the part of the country he
is dealing with.
It has been my fortune to spend about eight
years in Western China in the Province of Szechuan,
the richest and most fertile, and in regard to cli-
mate something like that of Italy or Spain. Then
I have had a year and a half's experience of
Eastern China in the city of Shanghai and neigh-
bourhood; four years in Central China in and near
Hankow; and latterly, eighteen months in North
China in the city of Peking, while I have journeyed
for about three months in the north-west of China.
Of Southern China I have no experience but that
of the traveller who passes round the coast of China
on his way to Shanghai.
Briefly stated, the climate of North China is
dry, sandy, very cold in winter, and trying to people
of neurotic temperament. The summers are not
particularly trying. Typhus fever is much more
prevalent throughout Northern China than other
parts. Typhoid fever is rarely met with, and
malaria is not very common.
Central and Western China.—The climate is
moist, humid, with mild open winters, except in
the hilly districts of West China; the snow-fall is
very slight, malaria is very prevalent, and epi-
demies of cholera, dysentery, and relapsing fever
are of frequent occurrence.
Eastern China, generally speaking, is more
bracing from its nearer contact to the sea, but in
many districts, such as the Province of Chehkiang,
where much rice is grown, malaria is very
prevalent.
Southern China, except in high-lying districts,
is usually very trying during the summer, but
spring, autumn, and winter is often delightful.
It is difficult to state with confidence that the
climate of China exerts a great influence on the
health of Europeans, but the changed conditions
and environment in which missionaries and others
away from the great open ports have to spend their
lives is undoubtedly a very important factor. With
care in not exposing themselves to the sun in the
semi-tropical parts of China, Europeans will find
the climate of that great land is not less healthy
than Europe. Of course there are special risks
from epidemic diseases which are all too prevalent
in a land where sanitation is practically unstudied,
(No. 5, Vol. XVI.
yet the real factors affecting the health of Europeans
arise rather from the habits and customs of the
Chinese people, together with the conditions of iso-
lation from one’s own countrymen and_ friends.
Repeated strain upon the nervous system, inci-
dent to life among an alien people, where often
the wildest rumours gain currency and may lead to
riot, rebellion, or other uprising, is also furnished
by the carelessness of the people during epidemics
of small-pox, cholera, &e.
The other Factors.—As the other factors appear
to me the most important in relation to the health
of Europeans, I wish to speak of some of them
under the following headings :—
Food, dwellings, exercise, companionship, isola-
tion, idiosynerasy of temperament; special factors
peculiar to men and women.
The Food Factor.—Throughout almost the
whole of China a plentiful supply of food, both
animal and vegetable, fruit, and fish can be
obtained; though at certain seasons in many of the
interior cities it is frequently difficult to obtain beef
or mutton.
The quality, however, of the food is often coarse
and poor, and many Europeans prefer to use tinned
provisions, and flour and cereals brought from
abroad, because of their better quality.
One of the great dangers to health arises from
the mode of vegetable cultivation in China. The
Chinese market gardener manures his fields most
diligently, using chiefly a fluid mixture of urine and
fæces gathered from all the latrines of the cities.
He has learned by practical experience the richness
in nitrates of human manure, and what we in this
country cast into the sea or at best use for sewage
farms for cultivating grass for cattle and horses,
the Chinaman collects most carefully from the
houses of every street and lane and carries to his
sewage tank, where it is carefully stored and used
during the spring and summer to manure his garden
and fields.
It will be readily understood that vegetables pro-
duced under such conditions are a source of very
great danger. Probably 75 per cent. of the Chinese
suffer from round worms, consequently the millions
of ova which are scattered over the growing vege-
tables as the Chinaman ladles the liquid contents
of his sewage tank on to them, produce a vicious
circle of helminth infection.
Besides the round worm, Schistosomum japoni-
cum, and ankylostomes or hook-worm infection is
frequently met with, and I believe the source of
this infection may be traced to this method of
vegetable cultivation, and to the habit the Chinese
have of washing their vegetables in the stream and
river before taking them to market, thus infecting
the drinking water.
Curiously enough, though there is more pork
eaten in China than among any other nation in the
world, tape-worm infection is not as frequently seen
as one might expect; this I attribute to the fact
that the Chinese eook their pork thoroughly and
probably kill the tape-worm ova where present.
From the foregoing, it will at once be gathered that
66 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Europeans living in China should avoid all uncooked
vegetables and unboiled water; salads, I think,
are especially dangerous.
Milk.—There are few places in China where it
is ever safe to drink unboiled milk, for besides the
risk arising from contamination by air-borne par-
ticles, there is the very serious danger that unboiled
water from doubtful sources has been added to it
by the not overserupulous milkman; at other times
he will add a solution of bean curd, and the specific
gravitv of the milk will be enhanced thereby so
that dependence on the lactometer gives no clue
to the milk not having been tampered with.
In the case where infants are being hand-fed, the
danger of serious mischief being started by the use
of such milk eannot be over-estimated; in fact, I
much prefer to depend on a really good brand of
condensed milk rather than risk the many dangers
arising from the use of milk obtained from Chinese
sources. In this connection, I think it right to
state that I have seen remarkable recoveries in
young infants who were gradually going down from
the use of milk from Chinese sources or from the
use of an inferior brand of tinned milk, when
'" Bear Brand" or Nestlé's Swiss Milk was sub-
stituted and used along with Mellin's Food. My
rule for the past five years has been to confine
myself to unswectened ** Bear Brand " milk, and the
freedom of our family from digestive disturbances
is partly at least due to this.
Water Supply.—Equal risks arise from the water
supply, whether it be from well or river. My rule is
never to drink unboiled water, no matter what filter
it has passed through; in fact, I much prefer the
simple home-made filter, which ean be got for the
matter of 6d. or ls., to any of the many carbon
filters one sees in so many houses of Europeans
abroad. A Berkefeld filter, of course, is very good,
but unless the lady of the house attends to it her-
self and sees to the renewal and cleansing of
the candles, it, too, may become a source of
danger.
Dwellings as a Factor.—In all open ports and
large eities in China, the European usually builds
his house in foreign or semi-foreign style, with
suitable verandahs, but in many of the interior
cities to which missionaries and others have gone,
this is either not possible or impolitie, and they
have frequently to adapt native-built houses. Now
these houses ean be made most comfortable and
healthful; but, as in most parts they are single
storied and have paved or mud floors and may be
built in busy streets, in close proximity to other
native houses, laeking in light and air, and with
no cheering outlook on any landscape, they are
often most depressing, especially when the ladies
are unable to go out on to the street or walls of
the city for exercise. One is not surprised if a lady
finds life somewhat trying shut up in one of these
Chinese houses for several months on end, with
perhaps little room for a walk, except round a small
courtyard within their dwelling.
In spite of what has been written regarding
malarial infeetion, it is the exeeption and not the
[Mar. 1, 1913.
rule to find houses mosquito-netted in China.
Many Europeans are content to sleep under
mosquito curtains rather than go to the trouble of
providing mosquito-netted rooms or houses, though
the difference in the actual cost of the two methods
is really not so great as some think, and the com-
fort and safety of the mosquito-netted house
method needs to be experienced to be fully
appreciated.
Ezxercise.—I have already hinted in the para-
graph on dwellings that exercise in one of the
interior cities of China is often diffieult to obtain,
and ladies and ehildren especially suffer because of
the narrowness of their surroundings and the lack
of change. Too often the city wall may be the
only place where one can get a fair walk and the
pleasure of that is often spoiled because of the
eurious onlooker and children who may wish to
follow the foreigner around. Consequently, we
must often depend upon what can be got within
our own gates if we wish to be free from curious
intrusions. Where there is room for a tennis court
or croquet lawn, this want will not be felt so much.
Apart, however, from opportunity of exercise and
recreation, in the hot weather especially there is
no inclination for it, or during the multitudinous
claims of duty, time is not taken for it.
Want of change of scene and suitable relaxation
may frequently produce a feeling of depression and
weariness, that is the mental attitude inviting
disease and ill-health. The fact that the surround-
ings are so uninviting or circumscribed deters one
from an effort to obtain exercise, though everyone
is theoretically persuaded of its desirability.
Exercise for health reasons seems not to have
occurred to Chinese, and there is no provision for
active recreation and sports, except what has been
introduced by mission schools and colleges, or more
recently by imitation of the West.
Companionship and Isolation as a Factor.—The
isolation that many Europeans, both in mission,
postal and Government service, undergo in inland
China is a most important factor in relation to their
health, and with this isolation must be associated
suitable and unsuitable companionship; in the one
case mitigating the evil, in the other intensifying it.
Added to the loneliness we must also remember
that there is frequently eonsiderable nervous strain
from the wild rumours so frequently circulated and
threatenings of riots. Such occurrences as these,
happening in many eases once or twice a year, leave
their mark upon the strongest, much in the same
way that anxiety in the case of friends nursing
those they love leads sometimes to a nervous break-
down.
If, in addition to the loneliness and isolation,
the number of Europeans at any station should be
very small and people of unsuitable temperament
be constantly together, it also may be, and I be-
lieve is a factor making for ill-health. It is for this
reason that a good holiday in the summer is
essential to the lonely worker, not only because it
allows him or her to get away from his surround-
ings, but also beeause it often gives a great oppor-
Mar. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 67
tunity to meet many friends and acquaintances from
other parts of the field with whom one may have
much social interchange.
Idiosyncrasy of Temperament.—Closely asso-
ciated with companionship and isolation we must
place personal idiosynerasy of temperament. Many
people of bright, happy, social dispositions settle
in so happily with the Chinese that they do not
feel any sense of loneliness, and even the strain of
a riot may not upset them much ; but to others the
long separation from the homeland and its many
social joys is a great privation, and though pos-
sessed of real bravery of spirit and a determination
to fulfil their duty and stick to their work, do so,
however, with expenditure of great nervous energy,
and I fear some of the breakdowns that occur may
be traced not to the climate, however relaxing and
hot that may be, but rather to the effect of
changed environment and diffieult surroundings
upon sensitive and highly-strung dispositions.
The mental attitude is a powerful factor in
bringing about recovery; it is equally powerful in
producing a state which leads to disease, if it does
not actually cause it.
Special Features peculiar to Men.—Isolation and
loneliness is much less felt by men than women,
beeause they ean move about much more freely
among the people, but they often run greater risks
than women because they journey more, and are
less careful about food and water and sleeping in
inns, boats, or other places where they are more
exposed to infectious troubles. The two extremes
are also met with in men who are so careful of
their health that they are always doctoring and
drugging themselves (often with the scantiest
knowledge of medicine), others who are so careless
that they allow serious symptoms of disease to
go on for long periods without seeking medical
aid.
Cases of sore mouth and morning diarrhea may,
for example, go on for months without the person
being aware that he is in a serious condition and
threatened with sprue, or a severe condition
of chronic constipation and a toxemia from
intestinal stasis may continue for long periods with-
out the European realizing what ails him ; probably
he puts the feeling of tiredness down to '' climate,"
or some other such vague term.
It need hardly be mentioned, too, that the heat
of the Chinese summers increases the temptation to
take alcoholic stimulants, and also there is a greater
tendency among foreigners in the East to over-
eat in the matter of meat diet, men being greater
sinners in this respect than women.
Special Features peculiar to Women.—Besides
the factors in the foregoing common to both men
and women, there are a number which have a direct
bearing upon the health of women which are in-
cident to their sexual life, such as menstruation,
pregnancy, puerperium, and other mental condi-
tions associated therewith. Along with these must
be ineluded the question of marriage immediately
before sailing for China, or on arrival there.
To take these in order then: From inquiries J
have made it seems that the menstrual function is
undoubtedly influenced in the majority of cases by
the changed conditions of life in China from those
prevailing at home. In some cases the menstrual
flow seems to be increased in amount and duration ;
in other cases it is accompanied by pain in subjects
who were free from pain at home. Climatic condi-
tions may have a certain effect in bringing this
about, though I am inclined to think it is the sum
total of all the factors making up the changed
environment, rather than the single one included
in the word climate.
Pregnancy.—While in the majority of cases
pregnancy proceeds in its normal course, the
tendency to abortion is perhaps more frequent in
China, and there seem to be few ladies who have
borne several children who have not a story to tell
of at least one abortion.
Hence, there is more need for a word of caution
to ladies abroad to be even more careful during
pregnancy than they would be at home, and especi-
ally to avoid the jolting associated with sedan-chair
riding and cart riding, which are two of the great
means of travel in inland China.
Of the puerperium, one need only remark that in
Western, Central and Southern China, the semi-
tropieal heat of spring and summer lead to a very
abundant growth of all forms of vegetable and
parasitic life, and we can presume that pathogenic
organisms share to a great extent in this exuberant
growth, hence the risk of puerperal infection is
somewhat increased, and where it occurs it tends
to be very virulent.
Mental Conditions.—Women, I am sure, are
more seriously affected than men by the changed
environment incident to residence in China. We
have often noted women who, when in the home-
land were joyful and happy in Christian and social
work, after a short residence in China become
morose, suspicious, jealous, and uncompanionable,
or else subject to morbid fancies and easily taking
offence at supposed slights. A year or eighteen
months of this kind of strain, and all the spring
has gone out of the life and a serious breakdown
can only be prevented by a change to the homeland,
where the freer, fuller conditions of life soon bring
back normal health.
The Marriage Factor.—The seriousness of this
question from the point of view of health of women
who hope to reside in China is one that medical
men should study and form an opinion on, which
should be clearly stated to the various Mission
Boards, who more than others have the responsi-
bility of sending out women to the foreign field.
Broadly speaking, three methods are at present
followed :—
(1) To allow people to get married and set out
for their sphere of service almost immediately.
(2) To allow the lady to go out to her fiancé and
get married immediately on arrival on foreign
soil.
(8) To send out the young lady and have her
spend a definite period of from one to two years
on the field before her marriage.
68 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 1, 1913.
Each of these methods has strong advocates, but
I doubt if the medical point of view has been as
fully considered and presented as it should be.
First Method.—A little consideration will, I am
sure, bring home to us the very great risk attaching
to the first method. Think what it means to a
woman to enter the married state and in addition to
the possible strain ineurred in an early first preg-
nancy, to have the discomfort of a sea voyage of
six weeks' duration. Then the landing in a new
country, with all the difficulties incident to
setting up a home there, ignorant of the language
und customs of the people, and passing through the
trials of accommodating herself to her changed
environment, while at the same time the strain of
a first pregnaney with its hopes and fears is gone
through.
My conviction, after over twenty years of observa-
tion, is that it is an experiment fraught with danger
to the woman's health and happiness, and a tre-
mendous handieap to her learning the language,
and so settling comfortably to her future life's work,
and too often ends in both husband's and wife's
retiral from missionary service.
Second Method.—Little can be urged for this
method in preference to the first, except that the
sen voyage may have brought the young lady out
to her new home in excellent health, having had no
strain upon her physically from the possible changes
that accompany conception and early pregnancy.
The other factors, however, remain unchanged, the
new environment, the strange people, the restricted
conditions of life, must be begun along with the
very important new relation in her sexual life.
Ten chances to one, the pressing cares of house-
keeping prevent her getting time for study of the
language, and the lady remains throughout life in
China very much outside Chinese ways and cus-
toms, and feels keenly throughout all her experi-
ence an alien and an exile in a strange land. True,
she may say that she came to be her husband's
companion and help, and not to do missionary work ;
he will, in the nature of the case, have often to
undertake home duties to assist his wife's deficiency
in the knowledge of the language, and she will
probably feel more than ever that she is not mistress
in her own home, and is often burdensome to her
husband from having to ask him to attend to
domestie matters that should naturally be hers.
It need hardly be added that such conditions make
an extra call upon her mental outlook, and I fear
sometimes cause discontent with her lot which
might have been obviated by six months' residence
in the land, acquiring a knowledge of the people
and language before setting up her own home. Who
shall deny that such conditions frequently lead to
ill-health or an early furlough ?
Third Method.—VFrom the point of view of future
good health and usefulness, I believe strongly that
the third method is the best. Let the lady become
accustomed to Chinese life and conditions, acclima-
tized to the new land and free from the early
difficulties associated therewith, and then get mar-
ried. If such a course is followed then marriage,
as it affects the health of women, presents no other
difficulties than what are met with in the home-
land.
A carefully conducted investigation by medical
men into these factors, will, I feel sure, substantiate
my views on this subject, and might lead to the
formation of rules and regulations for the time of
marriage at least for missionaries in China, and
might materially help in preventing much of the
ill-health and breakdowns that have so often been
seen. Very much more might be said, but if these
few statements set the ball rolling and provoke
questions and discussion, I think some good may
eventuate.
In conclusion, let me apologize for the very slight
way in which I have been able to touch this very
wide subject. It is so very extensive in its range,
I fear it has led me to a mere glancing at some of
its parts, and to none of them do I feel I have done
justice, but some hints may have been dropped that
may guide in future investigations; and if that is
so, I shall feel this short paper has not been written
in vain.
TROPICAL DISEASES IN TRIPOLI.
By Professor UMBERTO GABRI.
Rome.
In the year 1910, I was charged by my Govern-
ment (Home Office, General Direction of the
Public Health) to study the diseases of infection
predominating among our colonists established in
Tripoli. In conjunction with Dr. Visentini I suc-
ceeded in ascertaining the existence of Mediter-
ranean fever (not only in the inhabitants, but also
in the Maltese and indigenous goats). Cases of
three-day fever and oriental sore were also seen.
Major Dr. Fashin Bey had already discovered the
kala-azar parasite (positive puncture of the spleen),
and the recurrent fever spirochete in the blood.
Since 1910 I examined the blood of Turkish soldiers
in the military hospital suffering from malaria, and
observed that all of them suffered from (tropical)
malaria of the tertian type.
In March of this year (1912) I was again requested
to continue the study from a double point of view—
viz., from the hygienic and from that of the tropical
pathologist. The Commission proposed by me was
composed of Dr. Seordo, my first assistant; Captain
Dr. G. Rizzenti and myself. I also proposed a
hygienist, an entomologist and a veterinarian, but
without success.
We confirmed the existence of ‘‘ relapsing fever,”
already studied from the bacteriological point of
view by Captain Dr. Gallia, and my colleagues,
Dr. Scordo and Dr. Rizzenti, have concluded a
series of bacteriological researches on *''typhus
exanthemata,’’ also from the point of view of
serum-dingnosis. "The reader will find the results of
these researches in a paper shortly to be published.
They have also studied an epidemie of infectious
jaundice in the army, which broke out in Tripoli
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE 69
Mar. 1, 1913.]
and in Cyrenaica; the results from the bacterio-
logical point of view were negative. I sup-
pose the infectious agent penetrated into the
organism by inoculation and that it belongs to the
series of ultra-microscopical viruses. I observed two
cases of '' fièvre boutonneuse,'' treated for the first
time in Tunis. I specially concentrated my atten-
tion on the Bedouins in the large camps of concen-
iration, in the periphery of Tripoli, where I studied
malaria, examining the blood and puncturing the
spleen and ascertaining that there are almost con-
stantly cases of tertian fever, though quartan
fever is rare. I determined the index splenicus (54
per cent.) in children. After puncturing the spleen,
in a large number of cases suspected to be kala-azar,
I never succeeded in finding Leishman-Donovan
parasites! While studying infectious diseases I
directed my attention to tuberculosis, and ascer-
tained that this disease is diffused among the
Arabs, especially in the form of pulmonary
tuberculosis !
It was, however, to the diseases of the skin,
in collaboration with Dr. Labella, of the dermato-
logical clinic of Professor Campana (Rome), that I
directed my particular researches, because they are
very frequent among the Arabs. We ascertained
that the parasitical diseases (scabies, tinea, and
tuberculosis) wound the skin by septic invasions,
in the same manner as in Italy. We also found
frambeesia or yaws, psoriasis tropica, ulcus tropicum,
uleus infantum, lichen tropicum, granuloma vener-
eum, tinea alba, and tinea nigra circinata.
Clinical researches were directed towards
ascertaining what tropical diseases of the digestive
apparatus led to the constitution of the presence
of tropical dysentery and of the diarrhea of hot
countries (sprue).
This first contribution to the study of the diseases
of Libya confirms the followiez truths: That the
Arabs on the coast show the same diseases as the
inhabitants of the interior, and that, consequently,
we must determine definitely the nosographism
proper to the country and the race, before one can
indicate the curative and prophylactic means
necessary to defend the natives and the colonists.
We should naturally expect to find in Libya the
tropical diseases mentioned above if we consider :—
(1) That the inhabitants of Libya are almost all
Arabs; the Jews are found only in the towns along
the coast.
(2) That the Arabs of the towns along the coast
maintain a continual contact with the Arabs and
the inhabitants of the interior provinces (Fezzan,
Beriat, Bornu, Sudan, &e.), by means of caravans,
which cause a continual change of people, animals,
and goods. -
(3) That the Bedouins, by reason of their per-
petual mobility, are always conveying infectious
germs to the oases as well as to the towns along the
coast.
(4) That it was natural to find the same diseases
in Libya that we have found in Egypt, in Tunis,
and in Algiers, because the races are similar and
the climate almost the same.
INTESTINAL PARASITES IN COSTA RICA.
A Report based on the Examination of 210 Patients
in the Hospital of the United Fruit Company
at Port Limon.
By Sranrorp CHAILLÉ Jamison, M.D.
Assistant in the Laboratories of Tropical Medicine and
Hygiene, Medical Department, Tulane University.
(Studies from the Laboratories of Tropical Medicine
and Hygiene under the direction of Creighton
Wellman, Medical Department, Tulane Univer-
sity of Louisiana.—No, 27.)
In order to make clear the local conditions
encountered during this study, it will be necessary
to say a few words in regard to the population of
Port Limon, the Atlantic port of Costa Rica, and
the surrounding country. The largest part of the
population is composed of negroes, imported from
Jamaica, who have been in Costa Rica for from a
few months to a lifetime; next to the negroes in
number are the natives, who are rarely pure
Spanish, the majority of them having a taint of
negro blood; lastly, there is a small minority of
Americans and English who have resided in the
country for from a few months to many years.
The negroes and natives have all gone barefooted
from early childhood, and nearly all recall having
had ground-iteh at one period or another. Cistern
water is universal for drinking purposes, and, with
the exception of that used at the hospital and hotel
of the United Fruit Company, is never boiled or
filtered. The soil of the country is loose and moist,
and is ideal for the growth of those intestinal para-
sites which more or less mature in such a medium.
Of the 210 patients examined, only forty-two
were negative. The majority of these negative
stools were subject to not less than three careful
examinations, and the centrifugal method was
repeatedly used. A few of the patients, however,
left the hospital before more than one examination
could be made. It will be seen that of about 20
per cent. of the patients, fourteen had been in Costa
Rica less than one year, nine between one and five
years, four for life, and in twelve cases of Jamaica-
born negroes the length of residence in Costa Rica
could not be obtained, though it was probably less
than five years. Eleven were Americans and
English who had been in the country less than a
year. Six were negroes from the island of St.
Kitts, who had been in Costa Rica less than three
years. Nineteen were negroes from Jamaica who
had been in the country for from a few months to
twenty-five years; the majority, however, for less
than five years, and many for only a few months.
Four were native-born Costa Hieans who had never
been out of the country. The two remaining
patients were foreigners who were examined once,
and no data could be obtained concerning them.
One hundred and sixty-nine cases, or nearly 80
per cent., were positive for some intestinal parasite.
Eighty-one of these positive cases were Jamaica
negroes who had been in the country for from one
month to many years. Twelve were negroes from
St. Kitts, who had been in Costa Rica not more
70 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 1, 1913.
than three years, and not less than eight months.
Two were Englishmen, one an American, and one
a Spaniard; all of whom had been in Costa Rica
over two years, Fifty-six cases were natives of
Costa Rica, or one of the neighbouring Republics.
PROTOZOA.
Family AMŒBIDÆ.
Genus Entamæba, Casagr. et Barb.
Entamæba histolytica, Schaud.—I saw but two
cases of amæbiasis, both of which occurred in
patients with bloody flux. Although I examined
the stools of numerous patients with the clinical
symptoms of dysentery, all were negative for amoeba
with the exception of the two cases; unfortunately,
equipment for bacteriological examinations was
lacking, but I believe that most of the cases of
dysentery occurring in the region under discussion
are of the bacillary type, and that amæbic dysentery
is rare.
Family TETRAMITID;E, Bütsch.
Genus Trichomonas, Donné.
Trichomonas hominis, Dav.—This parasite was
noticed in five cases.
VERMES.
Family ANGUILLULIDA.
Genus Strongyloides, Grassi.
Strongyloides intestinalis, Bavay.—Strongyloides
oceurred seven times. In two cases it was asso-
ciated with other parasites; in four cases it was
the only infection. Three of the cases had an
intractable diarrhea ; the other three showed no
symptoms.
Family TRICHINELLIDÆ.
Genus Trichuris, Bütt.
Trichuris trichiura, L.—The ova of Trichuris
occurred in 141 of the patients examined; it
occurred alone in eighty-one cases—that is, it is
seen twice as often as any other ova; as a single
infection, it is cver four times as frequent as any
other single infection.
The ova of Trichuris were seen as a single infec-
tion in three Spaniards, thirty-five Jamaica negroes,
ten St. Kitt negroes, two Americans, twenty-seven
native Costa Ricans, two Englishmen, one negro
from the island of Barbados, and one Nicaraguan,
Family STRONGYLID;E.
Genus Necator, Stiles.
Necator americanus, Stiles.—The ova of Necator
americanus were found in the stools of sixty-seven
patients. They were found to be the only infection
in twenty cases, and associated with other ova in
forty-seven cases. Fourteen of the twenty cases
were Jamaica negroes, the other six native-born
Costa Ricans; both classes of patients always go
barefooted. From the fact that most of the
Jamaicans have been in Costa Rica for a short time,
some of them only a few months, it is reasonable to
believe that they brought the infection from their
native island. As the Costa Ricans had never been
away from the country, it is also apparent that
hookworm disease is endemic in the Republic.
Hookworm ova occurred in a little over 30 per
cent, of the stools examined—it occurred alone in
10 per cent.
Family ASCARIDÆ.
Genus Ascaris, L.
Ascaris lumbricoides, L.—Ascaris was noted nine
times, but never as a single infection. It occurred
twice in native Costa Ricans, and seven times in
Jamaica negroes.
Genus Oryuris, Rud.
Oxyuris vermicularis, L.—Ozryuris was seen in
two cases; it occurred with other parasites, and the
patients had been violently purged before the
examination was made.
MIXED INFECTIONS.
There were fifty-nine cases of mixed infection.
All the parasites mentioned above were found to
occur in the same patient in one combination or
another. The presence of one parasite in no way
seemed to affect the presence of the other. Necator
and Trichuris were present together thirty-two
times; Ascaris and Trichuris four times; Necator
and Ozryuris twice; Necator, Ascaris, and Trichuris
nine times.
CONCLUSIONS.
It appears that Trichuris is by far the most ex-
tensive infection in this part of the world. When
present the infection is enormous, and I believe
that these large infections certainly give rise to
symptoms by causing anemia of a marked, though
very seldom severe, grade. Hemoglobin estima-
tions were made in the majority of cases, but are
not quoted, as the cases were all hospital cases,
and were in hospital for supposedly other conditions ;
though I am convinced that the lassitude, headache,
and vague intestinal symptoms so frequently com-
plained of were often due to Trichuris infection of
long standing and marked degree.
Necator and Ascaris are not as frequent as in
many parts of the United States. Mixed infection
seems to be more common in Central America than
in our Southern States.
I found ordinary intestinal parasites in cases from
Costa Rica, Columbia, Nicaragua, Jamaica, St.
Kitts, Barbados, Cuba, and Porto Rico.
Of the few English and Americans examined,
Trichuris was not found in those who had been in
the Tropics less than a year, but was present in
those examined who had been in Costa Rica for a
longer period.
In conclusion, the writer would like to thank Dr.
Robert E. Swigart, Medical Superintendent of the
United Fruit Company, for the opportunity of
making this study; Dr. Emilio Escheverria, Super-
intendent of the United Fruit Company's Hospital
at Port Limon, for many courtesies during the stay
in Costa Rica; and Professor Creighton Wellman,
Head of the Tulane School of Tropical Medicine,
at whose suggestion the examinations were carried
out.
Mar. 1, 1913.]
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Tropical Medtcine and Hygiene
Marcu 1, 1913.
ADULTERATIONS AND “IMPROVEMENTS ”
IN ARTICLES OF DIET.
Tue recent discussion at the Royal Society of Arts
in London on ** The Adulteration of Jams ”’ is caleu-
lated to cause a smile amongst those who have not
given the subject a thought. Jam seems at first sight
a trivial matter to be seriously dealt with, but those
who listened to the excellent address by Mr. Ernest
Marriage on the subject were impressed with the
importance attaching to adulterations of this
clement of our diet. Nowhere, perhaps, is the subject
of greater importance than in tropical countries, for
British-inade jams are met with in the most remote
parts of our Empire. So universally have jams
come to be an article of diet, both at home and
abroad, that there is scarcely a household in which
jam is not found on our table at one or more meals.
Young and old, rich and poor alike, are dependent
upon British manufacturers—or is it makers ?—of
Jams for their supply of this article. In military cam-
paigns, in scientific expeditions, be it to the Equator
or the Poles, on sea or on shore, jams are weleomed
and relished, and all expeditions are fitted out with
a stock of these preserves. Why? Is it the mere
sweetness that commends itself, or is it the fruit
juices that dominate the desire? The ordinary
consumer does not think of the reason why, but
takes it because he likes it. Liking an article of
food really means that the system craves for it, and
it is interesting to know which of the two potent
elements in jam are desired. The sugar in the pre-
paration is in large quantity, and we know that in
fatigue sugar has been proved to be physiologically
superior to all other agents as a restorative; and st
is not merely a speedy restorative, but a sustaining
food, by which strength can be maintained for an
appreciable time. There can be no doubt, there-
fore, that the desire for sweet foods is, from the
amount of energy it occasions, a natural craving,
especially after fatigue. The other physiological
elements jams contribute to the dietary are the
juices eontained in the fruits from which they are
made. That these fruit juices ure as potent in the
preserved state as they are in the fresh state is not
believed, and there is everything in favour of the
truth of the belief; but even fruit juices in the
jams and fruit jellies which we use so largely must,
and do, play an important part in the maintenance
of health by warding off scorbutic tendencies and
these are ever imminent in tropieal as well as in
Arctic regions, where dietary is often limited to well-
nigh starvation point in the hope of getting rid of
disease, especially varieties of intestinal flux.
Assuming, then, the usefulness of fruit made into
jams and jellies, and seeing how universally they
are used, it is surely the first care of the publie
health authorities that these articles of diet should
be wholesome and that they should be as carefully
inspected as are the milk and meat supplied to
us.
The adulterations referred to in jam-making by
expert inspectors are declared by them to be not
such crude additions as pips of wood and the
jemployment of turnips, carrots, or vegetables ; these
they leave to the public to detect by a pocket
magnifying-glass. It is to be feared that the public
do not usually examine the jams on their tables even
with a magnifying-glass, which is not in the hands
of the masses; but were it so the recognition of
deleterious elements mentioned is not so easy a
matter as to justify the consumer to take further
steps in the matter, as the expenses of investigation
and the doubtful issue of prosecutions are prohibi-
tive to the poorer classes, upon whom these crude
adulterations are for the most part practised. The
expert investigators regard these adulterations as
‘antique fables," but tropical residents are not
unacquainted with ''fables °” of the kind on their
breakfast tables of to-day, as on the remote tropical
residents these more readily detected adulterations
are very largely palmed off.
The form of adulteration experts consider is a
practice so general and so successful that it
threatens to corrupt the whole jam trade, namely,
the addition of the pulp, or the juice (which is the
filtered pulp), of cheap fruit to dearer jams. The
72 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
mainstay of this adulteration is the apple, whilst
lemons, gooseberries, and even red currants are
used in some cases. Rhubarb, too, though not per-
haps a fruit, plays a part in '' mixed fruit "" jams,
and perhaps provides ‘fruit juices" in other
preserves.
These practices are not, of course, advertised by
the manufacturers as adulterations, but they are
styled '' improvements," “ by the addition of fruit
juices," or “ by the addition of other choice fruit.”’
The consumer cannot, however, see great harm in
adding other fruits to, say, strawberry or rasp-
berry jams. If gooseberries are wholesome fruit,
why not add them to any kind of jam? Or if
rhubarb is added, is it deleterious to the economy ?
Medically considered, however, it does matter
what the improvements in our jams consist of. To
gve young children an ill-assorted composition
containing turnips, vegetable marrow, &e., is
not without danger to the digestion, and to give
older people jam containing the crystals of such
substances as tomatoes, rhubarb, &c., leads in
many cases to kidney irritation attended by pain,
due to the difficulty of passing these crystals
through the kidney tubules.
Doctors are justified in asking that manu-
facturers not only of jams, but of various forms of
preserved and prepared foods, should be compelled
to put on their preparations labels stating exactly
what is contained in their wares; for the doctor has
to write his ‘‘ preparations ’’ in the form of a pre-
scription which all may read and criticize, and it
is surely even more essential that the composition
of the food we eat should be known. It is un-
wholesome food that is largely responsible for
the people becoming the doetor's patients; his
** mixture "' is but to remove the evils the unwhole-
some food has generated, but it is to the public
interest that these evils should be prevented, and
this ean only be done when our food is wholesome,
and when '' adulterations '"' glossed over by the title
“improvements " are rigidly dealt with and pre-
vented.
Home-made jams and jellies are now at a dis-
count in England. Few housewives nowadays take
pride in matters of the kind; the cottager's wife
will not even go to the trouble to pick the black-
berries, which she can gather free of cost in the
hedgerows, but instead gets them made for her
into preserves by the manufacturers, and she says
she can get them ‘‘ just as good from the shops."'
The Chairman (the writer) of the meeting, on
referring to this subject, was held to be an “old
fogy,” as '' out of date," and endowed with other
qualities in which silliness and asinine propensities
were prominent, by one of the ‘* experts "' present.
Such is the opinion of at least one of our “ authori-
ties " in England to-day, and it seems a sorry
prospect for our English home-life on which we were
wont to pride ourselves should such opinions prevail
amongst us.
J. C.
(Mar. 1, 1913.
Aurotations,
The Etiology of Pellagra.—Jennings and King, in
the Journal of the American Medical Association
(January 25, 1913), write on some possible factors
in the causation of pellagra. They believe that if
pellagra is caused by an infection, especially if of
protozoal origin, and is transmitted by an insect,
the present state of our knowledge may allow of
the following deductions being drawn.
Under conditions existing in pellagra regions in
South Carolina, the lice, fleas, mosquitoes and bed-
bugs show characteristics of habit, distribution and
abundance which appear to exclude them from
serious consideration in this connection.
The biting habits and, to a certain extent, the
distribution of flies of the genus Simulium, together
with their lack of habits which bring them into close
association with man, seem to present weighty argu-
ments against the incrimination of these gnats as
the active agent in the transmission of pellagra.
On the other hand, the cosmopolitan biting stakle-
fly, Stomozys calcitrans, from its distributional and
biting habits, its close association with man, its
conformation to the obvious requirements of the
disease-transmitting insect and the agreement of its
special characteristics with the phenomena incident
to the occurrence of pellagra, is to be regarded with
suspicion.
The authors hope that attention may be directed
to this fly, and observations bearing on its possible
relation to the disease be generally made.
They add that, should a causative organism be
shown to exist which is a bacterium rather than a
protozoon, and should this organism invade the
body through either the mouth or the skin, the
house or typhoid fly, Musca domestica, and the
flies whose habits at all resemble it, would lie under
strong suspicion. It is needless to say that the
house-fly is excessively abundant and of universal
distribution in the region studied.
The communication of pellagra in a purely
mechanical manner by biting insects is a possibility,
and, if shown to exist, would radically change ideas
as to the insects which may be involved.
Finally, essential uniformity of causation must be
assumed to exist universally, and the demonstrated
failure of a supposed etiologic factor to account for
the phenomena of pellagra in one locality must
serve to exclude it from consideration as a factor
in another.
The Treatment of Amæbic Dysentery.—In the
Indian Medical Gazette for November, 1912,
Leonard Rogers reports sixty cases of ameebic
dysentery illustrating the treatment by ipecacuanha
and emetine respectively. The following tables
show his results at a glance.
As regards the administration of the emetine,
Rogers states that the occasional failure of hypo-
dermie injections, in the cases of very acute slough-
ing amebie dysentery dying within less than three
Mar. 1, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 73
TABLE I.—Ama@sic DysENTERY CASES TREATED WITH IPECACUANHA.
| 82 | |
mr | Duration be- Type of 28 Red White | Ratio of| Poly- |Daysin|Days on) Graius
Re Rae ox [Aae omi (IR SE, mones corpus i | pes] i fs | sie ae
| mE
1 iN. |M. |19 | 3 weeks | Rem. | 15 4,750,000, 8,750 |1—541| 72.0 1 |... | Died.
2 | H. | M. | 35 | Sdays | Int. 29 6,180,000, 11,000 |1--5€2| 80.4 9 2 80
3 M.|M.|[30| 1 month | Nil 20 8,900,000. 30,250 (1—106| 75.6 2 - : :
4 M.|M.|15 | 2months| ,, 15 2,940,000! 35,750 |1— 82) 76.0 1 v E e
5 H. |M. |32| 7days | Rem. |18 | 6,010,000! 13,000 |1—461| 71.6 8 2 190 | ,,
6,M.|M.|30| 8 ,, Int. 25 | 4,690,000 31,060 1-151) 78.8 7 7 | 260 a
7 |M. |M. |40 |20 ,, | Rem. 20 | 5,290,000 26,000 |1—203| 81.6 4 3 | 90 si
8 H.|M.|80 |15 ,, Nil 25 | 8,650,000 4,250 |1— 859 8 8 410 E
9 H.|M.|21| 8months| ,, 12 | 2300,000' 14,000 |1—164| ... 8 7 | 950 A-
10|M.|M.|45| 3 ,, | Int. 12) 4,450,000, 8,000 |1—556| 72.4 | 12 8 160 | ,,
u |N. |M. | ... | Chronic | Nil 31 | 4,340,000 | 11,750 | 1--347| 82.4 | 10 6 | 180 K
12 H. |M.|32 |18 days | ,, 15 | 5,500,000, 32,500 1-164) 81.6 | 4 8 | 90 | Otherwise better.
19 M.|M.|95|6 , || , 1l 3,220,000 8,500 |1—379| 58.4 | 90 | 20 | 1,000 | ie no better.
14 |©. | M. |99 |10 ,, Int. | 27 8,960,000 25,000 |1—118| 79.6 | 10 | 10 | 850 M very bad.
15 E. | M | 29 | 2months e 11 | 4,700,000, 35,750 |1—124 T 3 1 30 a no better.
16 H. |M. |30| 7 ,, Nil 7 4,870,000, 33,750 |1—144| 87.6 | 1 1 30 | e: no better.
17 | H..|M.] 38| 2 ,, 5 7 4,090,000 12,500 |1—3927| .. 4 3 180 very bad.
18 | M. | M. | 35 |10 days T 25 | 5,580,000 37.950 |1—150| 85.0 | 10 | 9 | 490 | Cured.
19 M. | M. | 40 | 11 "i 11 5,730,000! 13,250 |1—433| 82.4 | 14 | 12 480
20 |M. | M. | 36 !15 7 Int. 7, 5,800,000! 7,500 |1—507| ... | 10 | 6| 360! ,
21 |M.|M.|40 14 ,, Nil 9 4,930,000| 11,750 |1—360| ... | 9 5 300 e
22 |E. |F. |40; 9 ,, 7 4,270,000 12,000 |1—356| .. | 8 5 180 M
99 M. | M. | 55 | 1month | Int. | 29 | 3,440,000 15500 |1—922| .. 26 | 15 460 i:
924 |M. |M.|20 | 1, As 17 | 3,840,000! 9,750 |1—894| 74.4 | 16 13 | 860 5
25 | H. | M. | 21 | Chronic Int. 20 | 2,730,000 7,250 |1—376| 72.8 19 8 | 270 a
26 | M. | M. | 29 | 5months| ,, | 16 | 3,860,000 21,500 |1—181| 74.4 7 7 220 re
7 IN. |M. | 82 |1à : 10,000 |1—398| .. 18 | 10 400 ;
28 H. | M. | 25 |14 years $ 12,500 |1—909| 53.6 | 60 | 44 | 1320| ,,
39H. |M.|15| lyear | .. 13,000 7 7 140 s
30 | H. | M. | 36 | 3months, Nil 14.750 | | 9 7 370 | |.
| |
| n 8 E] |
| Duration 53 Red | White Ratio of | Poly- Days in E E E E E £
No jBace Se | Age M eds M E 2| corpuscles | corpuscles mae perd hospital HE is EE Result
j AS s
| 3 | Š &
5 MC od 1 l] |
1/H.{M. | 45 | 12 days Int. | 26 | 5,960,000 | 22,250 | 1— 268 | 88.4 2 2 | 3 Died gangrene.
2 |H. |F. | 45 | 1 day 35 12 | 5,660,000, 61,750 | 1-- 92 | 84.8 1 S! iis 3»
3 |E. | F. | 30| 7 months, Rem. | 14 A M ns A 6 2,1 2 ,, heat-stroke.
41|H. | M. | 30| 2 55 Int. 10 | 3,190,000 8,000 |1—399 | 52.0 17 4 2 2 » cancrumoris.
5|N. |; F. |40| 5 days 33 12 | 5,340,000; 14,000 | 1—381 | 82.0 9 2 ^x 4 |Cured.
6|M.|F. |38| 1 day Nil 6 | 5,820,000, 14,000 | 1—380 Sr. th 6 8 14 £e $5
7)H.|M.| 15 |15 days Int. 17 | 3,340,000, 10,500 | 1—318 | 70.4 7 3 3 1} 3»
8 |M. |M. | 388 |14 ,, S 11 | 5,560,000 28,000 | 1—198 , 66.0 6 4 21 bos | $3
9|H.|JF.|30]6 ,, iP 24 | 1,930,000! 2,750 | 1— 722 "m 8 4 lf poc; m
10|H.|M./52/90 ,, Nil 11 | 5,240,000! 12,250 | 1—428 | 85.2 8 4 4 vss 2
11|M.|M.| 17 | X057 4.4 lcs 6 | 3 890,000 | 10,250 | 1—380 | 578.4 3 1 1 3 3
1243: PI 39 B a m 7 m E isi - 7 1 1 | Sn T
13 | H. | M., 24 | 1 day | Rem. | 24 | 5,560,000 32,500 | 1—171 , 89.8 8 1 14 1 »
14 | H. M.! 32 |15 days Nil 13 | 5,550,000, 13,750 | 1—404 | 79.6 | 11 3 21 1 35
15 | H. |M. |30| 5 ,, | Int. 6 | 2,490,000 5,500 | 1—483 | 76.0 5 3 1} A is
16 |N. | M. | 30 | 14 months ,, 9 | 6,270,000 30500 | 1—206 | 90.8 11 2 2 1 3
17 |E. |M.| 25| 6 3 Nil 4 | 4,930,000 , 12,000 | 1—411 | ... 6 2 1 là $i
18 H.|F. | 52, 1 month! ,, 13 | 3,600,000. 26,250 | 1—137 , 88.8 7 2 23 2 | 2
19|H. | M. | 32 | 3 months ,, 16 | 5,140,000; 12,250 | 1—348 | 86.8 7 3 13 à 35
20)|H.|M.|[90| 4 $5 P 14 | 5,670,000 21,250 | 1—261 | 68.8 T Vog 2 2 M
21|H. | M. | 32 | 1 year Š 19 | 4,030,000. 13,750 | 1—366 | 90.0 8 | 3 3 res a
22 | M. | M. | 20 | 6 months ,, 6 | 5,210,000 | 13,500 | 1—385 | 56.6 7 1 1 1 js
|H. !M. | 24| 2 55 2 8 | 4,010,000 7,500 | 1--585 | 73.2 5 1 1 11 »
21 |H. | M.| 22 | 4 years Me 7 | 3,460,000 | 11,000 | 1—314 | 67.6 7 2 2 1 22
25 | H. | M. | 86 | 14 months| ,, 6 | 3,040,000 9,800 | 1—320 | 72.4 9 1 1 1i ^
26 | M. | F. |84 | 14, » 11, 3,550,000, 8,950 | 1—430 | 80.4 6 3 23 a 1
Races.—M. — Mahomedan. H. — Hindu. E. — European. N. = Native. J. — Japanese. C. — Chinese.
24 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Mar. 1, 1918.
days of admission, has led him to consider the possi-
bility of giving the salt intravenously. In a recent
very severe case with great thickening of the cecum
and local peritonitis, he gave a dose of half a grain
of the hydrochloride of emetine dissolved in 5 c.c.
of normal saline. This was injected very slowly
into an arm vein, tlie pulse being carefully watched.
No depression followed. In the evening two-thirds
of a grain were given in the same way, and on the
following day a full grain, in addition to subcutane-
ous injections. At the time of writing the local
symptoms have much improved, the passage of
sloughs has ceased, while the amube have dis-
uppeared from the stools within twenty-four hours
of the first injection, and there is a fair hope of
recovery. Whatever the ultimate result may be,
it is at least clear that very full doses of the drug
may safely be injected intravenously, which is
clearly the best plan in desperate cases. There was
no sickness or nausea after the last two large intra-
venous doses, but bilious vomiting both before and
after the first one, so Rogers believes that the
vomiting after ipecacuanha by the mouth is due
to a local action on the stomach.
M yiasis.—Carter and Blacklock, writing from the
Runcorn Research Laboratories, report a case of
external myiasis in a monkey, in the British
Medical Journal, January 11, 1913. The larve
were noted on a Cercopithecus callitrichus. The
monkey was suffering from acute tuberculosis, and
died the day following the observance and removal
of the parasites. One batch of these larve were
taken from the nose and region of the face surround-
ing the mouth, the other from the right side of the
body near the groin. In both cases the larve were
in various stages of development, some of them
having apparently only recently hatched. Alto-
gether twenty-one of these parasites were removed
from the host, and were subsequently placed in
Petri dishes containing raw flesh and sand.
It became evident that at least two species of
diptera were inculpated, sixteen specimens being
of the typical Muscid type and the remainder larvie
of Fannia canicularis. Two examples of the latter
were allowed to complete their development, the
adults emerging on July 27 and August 5. The
majority of the remaining lurve pupated by June
29, but four specimens remained in the larval stage
until July 5, 6, and 7 respectively. The four
specimens referred. to were separated, and sub-
sequently on July 16, 18, and 19 three specimens
of the blow-fly, Calliphora erythrocephala, emerged,
the remaining example having shrivelled up. From
the remaining pupuria seven specimens of Muscina
stabulans were obtained, the period spent in this
stage varying from eleven to nineteen days.
The above records are of some interest, as neither
Fannia canicularis nor. Muscina stabulans can be
classed among the ‘ flesh flies," although both, but
more especially the former, have been known to
occur in the alimentary tract of human beings. The
natural breeding places of the so-called lesser house-
fly (Fannia) are human excrement and decaying
vegetable matter, but records are in existence of its
having been reared from the larvie of a lepidop-
terous insect (Epischnia canella) and of its occur-
rence in the nest of the common bumble-bee
(Bombus). It is possible, therefore, that the larve
in question may have been derived from an external
source, as, for example, the food of the monkey
üt the bottom of the cage; but, however this may
be, they were found by us on the animal itself. In
this connection also it is worth noticing that the
monkey was taken a considerable distance from the
cage before the larve were removed. The larve of
Muscina stabulans also feed on decaying vegetable
substances and dung; they sometimes, however,
attack growing plants, but in these cases have
probably been introduced with the manure. The
fly has also been reared from human excrement and
from the pupe of certain insects, notably those of
the gipsy moth, although there appears to be some
doubt whether the pupæ attacked were healthy or
not.
Syphilis simulating Liver Abscess.—A case of
tertiary syphilis closely resembling a hepatic
abscess is reported in the Journal of the Royal Army
Medical Corps, No. 1, January 1913, vol. xx, p. 88.
The patient was admitted to the medical ward of
the Military Hospital, Mauritius, on August 7, 1912,
which appeared to be the fifth day of his disease.
On admission his temperature was 104° F., and he
complained of headache and of pain in the hepatic
region; the onset had been gradual and there was
no history of preceding diarrhoeal disease. His liver
was enlarged upwards to the extent of two inter-
spaces, the lower margin of the organ being in its
normal position. This enlargement appeared to be
confined to the right lobe, and, as far as could be
ascertained, was uniform. No other abnormalities
could be discovered on clinical examination. Urine
and blood cultures proved negative, as did the ex-
amination of blood films. There was no leucocytosis,
and the urine was normal except for the presence
of considerable amounts of urinary indigogens.
The temperature was irregular, but usually ranged
between 1029 and 103° F. in the evening, and after
the first few days there were marked morning
remissions, the temperature touching normal on
several occasions.
A diagnosis of “inflammation of the liver "'
made, and ipecac. 30 gr. was administered twice
daily. During the patient/s first week in hospital
his liver svinptoms became more marked, and a
slight jeteroid tinge appeared. At this stage
diarrhas occurred, the bowels being moved about
five times a day. No amæbæ were ever seen,
The red cells steadily decreased in number to
3,900,000 (the hospital is 2,000 ft. above sea-level),
and the hemoglobin fell to 50 per cont.; the average
white count was 6,900.
The commencement of profuse night-sweats, the
more heetic type of temperature, and the patient's
was
Mar. 1, 1918.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 75
wasting led to the presence of pus being suspected,
and on September 10 aspiration of the liver was
performed under general anæsthesia. While on the
operating table a distinct bulging of the thoracic
wall over the liver was clearly discernible for the
first time. The right lobe was aspirated at three
different levels, and from each of these points the
needle was inserted into the liver first directly
inwards, then upwards, downwards, forwards, and
backwards, so that very little of the right lobe can
have been unexplored. No pus was discovered,
but, nevertheless, some benefit from the aspiration
was expected. However, this hope was disap-
pointed, for the liver remained unaltered in size,
and his general condition unimproved; indeed, two
days subsequent to the operation he appeared con-
siderably worse.
The possibility of tertiary syphilis was then con-
sidered, but no specific history could be obtained
although the patient acknowledged frequent ex-
posure to infection. However, he was put on anti-
syphilitic treatment, and with most striking results.
There was an almost immediate improvement in his
condition, the temperature steadily fell, and in three
days reached normal. In another three days the
hepatic enlargement had disappeared; the red blood
count and colour index rose rapidly, and the patient
made a quick and uninterrupted recovery. In the
meantime a Wassermann’s test had been carried
out, and the occurrence of a positive reaction
resulted in the hypothetical diagnosis becoming a
certainty.
The Health of the Canal Zone.—Colonel Gorgas,
in his monthly report of the Department of Sanita-
tion of the Isthmian Canal Commission for the
month of December, 1912, states that the total
number of deaths from all causes among employees
was 32, divided as follows: Disease 23, and violence
9, giving the annual average per thousand of 5.13
and 2.01 respectively.
Among employees for the month of December of
each year the annual average death-rate per
thousand was as follows :—
1904, 19.44; 1905, 45.73; 1906, 30.27; 1907,
18.11; 1908, 25.03; 1909, 13.84; 1910, 10.91; 1911,
10.42; 1912, 7.14.
The annual average death-rate per thousand in
the cities of Panama and Colon, and the Canal
Zone, including both employees and civil popula-
tion for the month of December of each year, was as
follows :—
1904, 44.75; 1905, 58.78; 1906, 39.21; 1907,
28.50; 1908, 26.15; 1909, 21.50; 1910, 25.16; 1911,
20.30; 1912, 20.99.
In segregating, according to race, the annual
average death-rate per thousand from disease
among employees was: For whites 3.74, and for
blacks 5.56, giving a general average for disease of
5.13. For the same month during 1910 the
annual average death-rate per thousand from
disease among whites was 5.59, and blacks 8.79,
giving a general average of 7.94; and in 1911 from
` in the chest.
disease among whites 5.71, and blacks 5.68, giving
a general average of 5.08.
Among employees during the month, deaths
from the principal diseases were us follows: Lobar
pneumonia, 6; malarial fever, 1; organic disease of
heart, 1; tuberculosis, 6; leaving 9 deaths from all
other diseases, and 9 deaths from external violence.
No cases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus during
the month.
Sleeping Sickness in Nyasalund.—Hearsey, con-
tinuing his '' Diary on Sleeping Sickness in Nyasa-
land’’ (part xviii), states that since the issue of
the last number of this series, part xvii, seventeen
additional cases of sleeping sickness have been
diagnosed by Dr. Shircore, and these added to the
seventy-six previously recorded now make a total of
ninety-three cases.
Dr. Shircore furnishes the following notes on a
case who came up to the Ngani Camp for observa-
tion and treatment. The patient was first taken ill
on or about May 8, 1912, and died on August 13,
the duration of the illness from its onset to a fatal
termination being a period of approximately ninety-
seven days.
Chituluka, of Mkokawambo village, a male aged
about 32. The patient has been ill since
about May 8, and was first seen and examined on
June 14. He complains of having first suffered
from headache, which was later followed by pain
The patient is thin, and has a tired,
dull expression. There is no puffiness of the face,
and his mental condition is good. No tremors of
hands, and no edema of feet; he can walk well and
without assistance. The glands in the right pos-
terior triangle are just palpable; supraclaviculars
are not enlarged; but the left epitrochlea is about
the size of an almond, the right being somewhat
smaller. Pulse 90, regular in force and frequency,
pressure moderate; respirations 20; temperature
99.6° F. In fresh preparations and with 3 in. objec-
tive, trypanosomes five in 100 fields.
The patient consented to go to the segregation
camp at Ngani, and walked up in three days, a
distance of about thirty miles. The route chosen
was praetieally fly-free, and two men accompanied
him to guard against any stray ones. “He was
admitted into hospital on June 19.
On admission he complained of a slight cough,
but otherwise had no subjective symptoms. On the
29th he passed some loose motions, and on the
following day a slight puttiness of the face was
noticeable.
Some slight difficulty in walking was experienced
on July 5, accompanied with pain in the legs and
knees. On the 6th, glands in the right axilla
enlarged, and on the following day pain in the chest
was complained of. The patient, from the 11th
onwards, began to get progressively weaker, with
deterioration of his mental condition, and somno-
lence. From the 12th to the 19th there was a
gradually developing asthenia. On the 20th the
dye, " B.S.," in 4 gr. doses, once a day, was
76 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 1, 1918.
&dministered. Two hours after the administration of
the first dose the temperature had risen from 96° F.
to 99.89 F.; pulse from 76 to 108; and respirations
from 28 to 32. A blood count made the day before
the dye was given showed: R.B.C. 3,700,000;
W.B.C., 11,800; H.B., 35 per cent. ; C.I., 35,
A differential leucocyte count of 508 cells gave:
Polymorphonuclears, 50.59 per cent.; lymphocytes,
40.835 per cent.; hyaline cells, 9.05 per cent.;
eosinophiles, not observed.
From the 20th the patient objected to blood films
being made, and seemed obsessed with the recol-
lection of the faet that blood had been taken from
his arm and injected into a dog, whieh was sent to
the Commission.
The dye was administered daily up to the 27th,
diarrhea then supervened, both urine and fæces
being stained red, and the patient began to pass his
motions in bed. On the 28th he was very weak, but
still intelligent, stating he thought that the diar-
rhea was due to the dye, and desired that it should
be discontinued. He passed a motion during the
night and vomited the following day. 29th—com-
plained of pain in abdomen; he is now very weak
and much emaciated. Up to the present the even-
ing temperature has always been above 98.49 F.
30th—temperature does not show an evening rise
and is below 96° F. 31st—temperature subnormal,
pulse and respiration failing, dye suspended. In
the evening liq. strych. 3 min., and brandy $oz.
were given; patient's condition grave.
August 1 to 13, no difference in condition, 1s.
somnolent. 4th—disinclined to take nourishment.
5th to 8th—temperature about 959 F. both morning
and evening, pulse and respiration rates diminish-
ing, radial pulse hardly perceptible. 9th and 10th
—pulse 48. 11th—brachial pulse 40; the patient is
semi-comatose and unable to take any nourishment.
12th—condition about the same. 13th—comatose;
brachial pulse 40; respirations 14; died at 9 p.m.
The ease has shown a regular intermittent type of
temperature and low average pulse and respiration
rates. The dye “B.S.” has had no beneficial
effect; on the contrary it has produced diarrhea
which undermined the patient's strength. On the
20ih, 21st and 22nd, with doses of 4 gr. per diem,
diarrhcea occurred; the dose was then reduced for
the next three days and diarrhoea ceased. Resump-
tion of the dye in larger doses again produced
diarrhea and pain in the abdomen up till the 30th,
when this treatment had to be discontinued. From
the 31st onwards, till the fatal termination of the
case, there was no diarrheea, nor did the patient pass
his motions in bed as he had done previously.
The dye ** B.S.” mentioned above (Brieger and
Krause) was received for trial and submitted to Dr.
Shireore, who reports as follows: The dye has
been administered to three patients in doses of from
10 to 15 gr. per diem, for periods varying from nine
to twelve days. In these doses it is most difficult
to dissolve unless a large quantity of water is used.
The dye stains the mucous membranes of the
mouth for days, and probably all such membranes
as come into contact with it. It is excreted in the
urine and feces. The dye has a bitter taste which
at first does not seem to trouble the patients, but
after a few days a growing dislike is acquired. The
first dose caused slight delirium in one of the
patients, who later suffered from diarrhea and
vomiting due to the same cause, In the case just
described the dye had not the slightest beneficial
effect, its trypanocidal action being nil, and the
patient's condition became so bad towards the
end of the trial that it had to be discon-
tinued. Another case at Ngani Camp was
also given the dye. He too took a strong
dislike to it after a few days, and his condition
became rapidly worse, so it was impossible to
persevere further with it. The third case the
dye was given to behaved much in the same
manner; she was a great deal more patient than the
two men mentioned above, though complaining that
none of her symptoms, such as pains in the chest
and legs, were relieved by it. This woman died a
few days after the treatment was suspended. Dr.
Shireore is of opinion that the dye is of no value as
a therapeutic agent, and he considers, moreover,
that it is harmful. A few days after its use
asthenia and emaciation supervene, and the drug
appears to interfere with the digestion and assimi-
lation of food, causing diarrhea, loss of weight and
progressive asthenia. In one of the cases quinine
was later given together with the dye, and on other
occasions atoxyl also, by mouth, with certainly no
appreciable benefit.
Trypanosomes were always present when blood
examinations were made, and Dr. Shircore states
he is unable to mention a single point in favour of
this dye, and cannot therefore recommend its use.
The Etiology of Beriberi.—The Philippine Journal
of Science (vol. vii, sec. B, No. 4, August, 1912) is
given up to papers on the etiology of teriberi, the
first by Strong and Crowell, the second by Vedder.
I.—Strong and Crowell in their conclusions state
that it is evident that among the individuals com-
prising their experiments beriberi was produced
only by means of the diet, and that the disease has,
therefore, a true dietetic causation. It is further
evident from their experiments that beriberi
develops owing to the absence of some substance or
substances in the diet necessary for the normal
physiological processes of the body. Without the
supply of such substances in the food, beriberi
results. Such a substance or such substances are
evidently present in red rice and in rice polishings,
and also in small amount in the alcoholic extract of
rice polishings, and when these articles are added
to what would appear to be an otherwise physio-
logically proper diet, they usually prevent the
development of the symptoms of the disease. In
some instances, however, even when these sub-
stances are constituents of the diet, when the diet
is without variation and composed of very few
articles, and the individual suffers from loss of
appetite and the assimilative functions appear to be
poor and he loses markedly in weight, symptoms of
Mar. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. TT
beriberi may develop in such individuals. How-
ever, such symptoms may be dispersed by causing
a variation in the diet by the addition of other
nutritious substances to it. It is also evident from
their experiments that the disease is certainly not
an infectious one in the sense in which that term is
usually employed. The rigid isolation of the
prisoners undergoing the test would seem to
exclude the possibility of the introduction of an
infectious agent through any other individual or by
the introduction of any article. It is also note-
worthy that the cases of beriberi developed under
the most favourable hygienic conditions with excep-
tion in regard to diet. It is not probable that the
infection could have been introduced with the food,
since this was all freshly cooked, and at a tempera-
ture at which only a spore-bearing organism would
survive. The food was also eaten a very short time
after being cooked. Moreover, if the infection had
been introduced with the food, the incidence of the
disease should have been the same in all of the
groups, which if was not. No fermentation of the
rice employed occurred either before or after it was
cooked, so that it would appear that the action of
such bacteria as have been described by Kohl-
briigge and by Bréaudat could be excluded. It has
been suggested that a diet of white rice predisposes
to the disease, since it furnishes a better medium
for the development of the specific organism which
resides in the intestine of the host, and that the red
rice or extract of polishings forms a preventive for
the development of such a specific organism. There
is no definite evidence of such a hypothesis and,
moreover, the results obtained would argue against
it, since in two instances at least distinct sym-
ptoms of beriberi were present in individuals who
had received these substances in the diet. It
eannot be claimed with reason that the resistance
of the individuals having been lowered by weakness
and loss of weight, the specific organism residing
in the intestine of the individual was able to
inerease and multiply and produce the disease; for
in several instances where the loss of weight of the
individuals was marked and their general condition
poor no symptoms of beriberi developed. The
evidence is definite that beriberi in the Philip-
pine Islands is due to the prolonged consump-
tion of a diet which lacks certain substances
necessary for the normal physiological needs of the
human body. That the disease encountered was
true beriberi was confirmed definitely by the lesions
encountered in the pathological study. As to the
definite chemical nature of the substance or
substances in the food which prevents the
development of beriberi further investigations are
necessary. For the prevention and cure of the
disease in man all that is necessary is that he shall
be supplied with a liberal and nutritious diet suit-
able to the physiological needs of the body. The
recent researches of Schaumann, of Chamberlain,
Vedder, and Williams, of Funk, of Axelholst, and
of Simpson have thrown much light upon the
question of the nature of the protective substance
in the diet. Nevertheless, opinions are not yet in
accord in regard to its exact chemical nature.
Fraser and Stanton have repeatedly called atten-
tion to the fact that the phosphorus content of the
rice serves as an indication of the extent to which
the rice has been polished, and have suggested that
any rice which contains 0.4 per cent. or more of
phosphorus pentoxide might be regarded as safe for
a staple article of diet in preventing polyneuritis
gallinarum in fowls and, hence, beriberi in man.
They state, ‘‘ None of the rices connected with out-
breaks of beriberi yielded more than 0.26 per cent.
of phosphorus pentoxide. The rices substituted for
these, and which were effective in preventing the
continuance of the outbreaks, yielded not less than
0.4 per cent. of that substance." More recently
Heiser advocates for the prevention of beriberi the
passage of a law placing a tax upon rice which con-
tains less than 0.4 per cent. of phosphorus pen-
toxide, such rice being regarded legally as polished
rice, and no tax on riee which contains 0.4 per cent.
or more of phosphorus pentoxide, such rice being
regarded legally as an unpolished rice. Although it
seems quite definite that a rice containing this
amount of phosphorus will prevent the appearance
of polyneuritis in fowls, nevertheless, from our
experiments it is evident that beriberi in man may
be produced by rice containing 0.37 per cent. of
phosphorus pentoxide when it forms the staple
article of a little varied diet. Therefore the ques-
tion arises as to whether the margin of safety is
sufficient between such a rice and that containing
only 0.4 per cent. of this substance. Since it has
been generally admitted that the higher the phos-
phorus content of rice the less is the liability of that
rice to produce beriberi, and since Fraser and
Stanton found as an average result of all their
examinations that unpolished rice contained 0.54
per cent. of phosphorus pentoxide, and Aron found
that unpolished rice in the Philippine Islands con-
tains 0.557 per cent. of phosphorus pentoxide and
freshly husked rice 0.455 per cent., before legisla-
tion is enacted it would seem to be advisable to con-
sider carefully the question of the amount of phos-
phorus pentoxide which a rice should legally be
required to contain in order for it to be regarded as
an unpolished riee and to be exempt from taxation
in the Philippine Islands.
II.—Vedder's conclusions are as follows :—
(1) The administration of large amounts of
aleohol has failed to produce neuritis in fowls.
(2) Fowls develop polyneuritis when fed on a diet
containing a sufficiency of all the alimentary prin-
ciples, providing no one of the ingredients of this
diet contains the neuritis-preventing substance.
(8) The neuritis-preventing substance is not vola-
tile, but is destroyed by heat.
(4) The neuritis-preventing substanee is not an
inorganic salt.
(5) The neuritis-preventing substance is probably
not an alkaloid.
(6) Since it has been shown that this substance
is not a fat, proteid, inorganie salt, or alkaloid, it
seems probable that it is an organic base as claimed
by Funk, but Vedder has not been able to confirm
this yet.
78 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 1, 1913.
Abstract.
PNEUMONIC PLAGUE—THE
‘* BACILLUS
STUDIES ON
PNEUMONIC STRAIN OF
PESTIS.”’
Ricuarp P. Strona and Oscar TEAGUE, who
studied pneumonie plague in Manchuria during the
winter of 1910-1911, state* that during the epidemic
the idea became rather general that the organism of
pneumonic plague differed, in some respects at
least, from Bacillus pestis of bubonic plague.
Apart from cultural variations, some physicians
believed that while the bacillus of bubonic plague
on inoculation into guinea-pigs gave rise to buboes,
the bacillus of this epidemic, on injection into these
animals, caused only pneumonia and septicemia.
Also, it was claimed by some, that the virulence of
the organism of pneumonie plague was much
greater than that of the bacillus of bubonic plague.
These ideas were erroneous, as is apparent from a
consideration in detail of the properties of the
pneumonie strain arrived at from the study of
numerous microscopical preparations and cultures
obtained from the sputum and from necropsies per-
formed during the epidemic.
Morphology.—The causative organism of the
Manehurian epidemie of pneumonic plague appar-
ently differs in no respect from other strains of
B. pestis isolated during many epidemics of bubonic
plague. In stained microscopic preparations made
from the organs at necropsy it appears in its most
characteristic form as a short bacillus, more or less
ovoid in form, swollen in the centre, and rounded
at the ends. It exhibits marked bipolar staining,
the central portion either remaining uncoloured or
staining lightly. Such preparations and those made
from sputum often show, besides these bipolar
forms, great variation in the morphology of the
organisms present. Involution forms, consisting of
longer, thicker, deeply staining rods, or of organ-
isms which have assumed a spherical or orbicular
outline, or, occasionally even appearing very much
as yeast cells, may be encountered. Many of these
forms stain poorly, or sometimes only a portion of
the organism is stained, and in the shorter bacilli
the appearance of ring forms is thus produced. In
agar cultures, and partieularly in 3 per cent. salt
agar, these large involution forms and degenerating
organisms of very different shapes are very
numerous and characteristic; long and slender or
thick bacilli and also boat-shaped, dumb-bell, ring-
shaped, and spherical organisms may all be
observed. The organism generally appears in
preparations from agar cultures as a short or longer
rod, and does not so frequently reveal the marked
bipolar appearance when stained. In hanging-drop
preparations no true motility is exhibited. No
flagella are visible in properly stained preparations,
and no spores have been demonstrated. It stains
easily with all the aniline dyes, and particularly well
* Philippine Journal of Science, Section B, vol, vii, No. 3,
June, 1912.
with dilute carbol-fuchsin solution, and is easily aud
completely decolorized by Gram's stain.
Cultural Characteristics are practically identical
with those of many bubonie strains. Some of the
freshly-isolated pneumonie cultures caused no
turbidity when grown in bouillon, the growth
rapidly falling to the bottom of the media and
leaving the supernatant fluid clear. However, this
is not invariably the case, as other pneumonie cul-
tures cause slight turbidity. These variations in
the different cultures evidently depended more upon
the amount and manner of inoculation of the
organisms and the character of the media than upon
any particular characteristic of the culture itself.
In Manila, the authors have studied three
different bubonie cultures recently isolated—one
from Shanghai, one from Hong Kong, and one from
Mariveles, Philippine Islands—and three cultures
from different pneumonie cases. These were each
inoculated in tubes of bouillon and grown side by
side at room temperature. No difference in growth
as to the cloudiness of the bouillon, amount of sedi-
ment, &c., could be observed in the different tubes.
In one of the pneumonie cultures and in one of the
bubonic ones the growth and flocculi seemed some-
what heavier than in the other tubes. The growth
in all of the eultures became visible, about the
second day, in the form of fine flocculent masses
which later greatly increased in size and became
deposited partly along the sides and at the bottom
of the tubes. The bouillon in all was slightly
clouded. Microscopical specimens from the differ-
ent cultures revealed chains of coccoid bacilli.
Mucus Production.—The production of mucus by
the pneumonic strain when grown upon agar slants
has been marked, but varies greatly, as is also the
case with bubonie strains, according to the tempera-
ture at which the cultures develop.
Another factor, which in their experience had
exerted an important influence upon the mucus
production of a plague strain, is the length of time
it has been cultivated upon artificial media.
Freshly isolated strains, whether from human sub-
jects or from experimental animals, produce more
mucus than strains which have been cultivated on
agar for some time.
The age of the culture is a factor influencing the
amount of mucus present. <A twenty-four hour
culture will contain less mucus than the same cul-
ture several days later.
They had not observed with regard to mucus pro-
duction that their pneumonie plague strains in any
way differed from the bubonie strains.
Virulence.—The organism seems to have retained
a maximum virulence throughout the epidemic; at
least all of the cultures isolated and studied by
inoeulation into animals possessed this very high
degree of virulence. Cultures isolated near the
close of the epidemic showed an equally high viru-
lenee to those isolated near its beginning. How-
ever, the idea that this epidemic of pneumonic
plague was due to the fact that the strain possessed
an abnormally high virulence—much greater than
that possessed by the organism of bubonic plague—
Mar. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 79
and that this accounted for the very high mortality
during the epidemic appears to
The very acute course of the disease, the very
high death-rate during the epidemic as com-
pared with that of bubonie plague, and the
apparently inereased virulence of this pneumonie
strain may be satisfactorily explained by the fact
that the portal of entry of the organism and the
location of the primary points of infection in
pneumonie plague and in bubonie plague are dif-
ferent. The plague organism finds in the pulmonary
tissues a much more favourable and extensive
medium for its multiplication and diffusion than it
does in the lymphatie glands. In bubonic plague,
the lymphatic glands may be said to act as filters
against the general invasion of the organism by the
plague bacillus, while in primary: pneumonie plague
there is no such mechanism for the defence of the
host, the bacilli spreading rapidly throughout the
lung and invading the circulation in every instance
in a comparatively short time and apparently before
the organism has had time to produee any appre-
ciable quantity of immune substances. The bron-
chial lymphatic glands in primary pneumonie
plague offer resistance to the invasion of the plague
bacillus, and in every case of this disease these
glands are very acutely inflamed and frequently
almost of a black colour from the resulting toxie
hemorrhages in the glandular substance. How-
ever, by the time the bronchial glands have become
involved, the bacteria have already spread so ex-
tensively throughout the lung substance that a
bacteremia has usually occurred. Microscopical
preparations made at necropsy from the lungs of
these pneumonic cases invariably contain enormous
numbers of plague bacilli. In no other disease are
the organisms found in such great abundance. In
primary pneumonie plague, the bacilli are found in
very much greater number in the lung than in the
spleen, even though an advanced bacteremia is
present. This fact, also, suggests that the lung
tissue offers a more favourable location for the
growth and multiplication of the bacilli than does
the spleen. The bacteria are also present in far
greater numbers in the lung than they are ever
found in the buboes or spleen in bubonic plague
It is also evident that in pneumonie plague
the infeeted lung (which may be said to correspond
to the primary bubo of bubonic plague) contains, by
reason of the size of the infected area, a far greater
number of plague bacilli than the primary bubo in
bubonie plague. During epidemies of bubonic
plague, there are occasionally small epidemics of
pneumonie plague in which the same high mortality
and acute course of the disease is observed as
oeeurred in the Manchurian epidemie of pneumonic
plague. This is another argument in favour of the
fact that during epidemies of bubonie plague the
causative organism may show the same high viru-
lence. As examples may be cited the epidemic
of bubonie plague in Japan—in Kobe and in Osaka
in 1899 to 1000—in which thirteen cases of primary
pest pneumonia all terminated fatally after a very
rapid course, and the epidemic of bubonic plague
Cases.
be erroneous..
in 1898 in Bombay, in which, toward its close,
eleven cases of pneumonic plague also all quickly
succumbed one after the other.
All this evidenee is in favour of the supposition
that the organism giving rise to the Manchurian
epidemie is of no greater virulence than in the case
of many bubonie strains; furthermore, definite proof
of this fact has been obtained from comparative
inoeulations made in animals with different pneu-
monic and bubonic cultures.
These experiments have shown that the pneu-
monic cultures have not possessed any greater
virulence than that possessed by many virulent
bubonie ones of the organism. Mice, rats, guinea-
pigs, and monkeys inoculated with virulent bubonie
cultures die within the same period of time and
from the same doses as do the corresponding animals
inoculated with the pneumonie cultures. The same
lesions are observed in animals after inoculation
of the pneumonie strain as after the inoculation of
the bubonic strain. Both strains when inoculated
eutaneously, or subeutaneously, into guinea-pigs
nnd monkeys give rise to bubonie plague infeetion.
When the animals are infected by inhalation with
either strain, similar lesions are also produced. In
guinea-pigs, after inhalation, infection results
through the mucous membrane of the throat and
dapper portion of the respiratory tract, resulting in
buboes of the cervical glands and septicemia and
in primary or secondary pneumonia; in monkeys,
after infection by inhalation, primary pneumonie
infection of the lung with secondary septicemia
results.
However, while during epidemies of bubonic
plague reports have been made that there is often
a marked difference in virulence in the different
cultures isolated, during this epidemic of pneumonic
plague the organism seems to have retained a very
high degree of virulence throughout. The cultures
isolated from a number of cases near the close of
the epidemic, upon inoculation into animals, proved
to be fully as virulent and to kill animals as quickly
and in the same doses as did those cultures isolated
near the beginning. That the organism retained
such a stable virulence throughout the epidemic is,
perhaps, not surprising when one considers that
infection occurred directly from man to man, or,
frequently one might say, from lung to lung and
without the passage of the organism through rodents,
as ordinarily oceurs in bubonie plague infection.
Moreover, from the results of previous experiments
relating to infection of animals with pneumonic
plague by inhalation, one would expect that the
organism would have retained its maximum viru-
lence throughout this epidemic.
For these reasons and, also, from the fact that
the acute course and mortality of the disease were
not changed toward the close of the epidemic and
especially from the experimental proof furnished by
the inoculation of animals with cultures isolated
near the beginning and near the close of the
epidemic, we must conclude that the sudden de-
cline and cessation of the epidemic was not due to
any marked change in the virulence of the strain.
80 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 1, 1913.
Such a decline and cessation must have depended
upon other causes. The plague bacillus, whether
isolated from pneumonic or from bubonie epidemics,
usually exhibits marked stability in virulence.
While it is not a very resistant organism in nature
and easily becomes destroyed under certain condi-
tions, it usually does not become markedly
attenuated in passage through the animal body, and
even on artificial culture media, after many months,
its virulence is usually fully retained. Instances of
spontaneous loss of virulence in culture media have
been reported, but this is not usually the case with
fresh, virulent cultures. This quality of stability
of virulence of the plague bacillus, so different, for
example, from that of the cholera vibrio, is of
particular interest from an epidemiological stand-
point,
(To be continued.)
——— »-—————
eviews.
PELLAGRA, AN AMERICAN PmonLEM. By Geo. M.
Niles, M.D. W. B. Saunders and Co., Phila-
delphia and London. 1912. Illustrated. Pp.
253.
Dr. Niles's book on '' Pellagra ” is timely in its
appearance, for there seems no getting away from
the fact that the disease has become a problem
of serious issue in the United States of America.
In bringing out a book on pellagra in a country
where the disease has but recently appeared, an
author has to remember that he is writing for men
in the practice of their profession, who in their
student days were even unfamiliar with the very
name and far less with the clinical manifestations
of the ailment. The author has to teach his medi-
cal colleagues as students are taught, beginning
with the A. B. C. of the subject and leading them
gradually on through the details of the disease.
This the author has accomplished to the letter. He
begins with what is known of pellagra in other
countries, proceeds to discuss its appearance in the
United States, and systematically sets forth the
probable etiology, the clinieal eourse, the pathology
and morbid anatomy, the diagnosis, the prognosis,
the treatment and the prophylaxis of pellagra.
Each part of the subjeet has a chapter to itself, so
that it is easy for a reader especially interested in
any one portion to find what he wants to know.
Dr. Niles has set forth our knowledge of pellagra
up to date, and discusses the etiology of the disease
with an open mind. He gives the pros and cons
for the maize theory, and for Dr. Sambon's claim
that everything points to pellagra being due to a
parasite which is insect borne. He is inelined
to the long-established belief in the connection be-
tween the consumption of maize and pellagra, yet
he gives full prominence in the text to the more
modern or presumed parasitic origin of the
disease.
That pellagra has become a scourge in the United
States of Ainerica is readily gathered from the fact
that thirty-eight States acknowledge its existence
within their confines. Some of these, markedly
South Carolina, Georgia, and Louisiana, had each
over 500 cases of pellagra, and in six others:
Virginia, North Carolina, Alabama, Mississippi,
Texas, and Illinois, over a hundred cases were
known to exist. The seriousness of this infection is
only known to those who have made themselves
familiar with the nature and course of this disease.
The mortality amongst those actually attacked is
sufficiently alarming, but more trying still is the
fact that the disease gradually disables the sufferers
mentally and physically, that they become fit only
for lunatic asylums: and, in fact, in pellagrous
countries they form a large proportion of the inmates
of asylums. "The book is well printed, the illustra-
tions are good, and we congratulate the author and
the publisher upon supplying us with an admirable
text-book on a disease which has recently appeared
in Britain and spread in the United States of
America to an alarming extent.
TREATMENT AFTER OPERATION. By William Turner,
M.S., F.R.C.S., and E. Rock Carling, B.S.,
F.R.C.S., with a chapter on the Eye by L. V.
Cargill, F.R.C.S. London: University of
London Press. Published for the University of
London Press, Ltd., by Hodder and Stoughton
and Henry Frowde.
The authors believe there is a demand amongst
practitioners for an account of the after-treatment
of operation cases. They have therefore written
this book in order to supply the want in a con-
venient and readily accessible form, and hope at the
sume time that it may prove useful to house-
surgeons, senior students, and nurses.
The methods, directions, and data, the authors
state in the preface, are those habitually employed
or relied on by themselves, and no attempt has
been made to include varieties of method or to
indieate differences of opinion.
The book should prove of great value to those
whose duty it is to see to patients after major
operations. Many times a house-surgeon may not
feel quite sure what he ought to do in such and
such a ease after operation, but now with this useful
work by his side all such difficulties should
vanish.
Wilotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
9, —As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly,
4.—Authors desiring reprints of their communications to the
JOURNAL oF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers,
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
Mar. 15,1913] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No.6, Vol. XVI.
Original Communications,
SLEEPING SICKNESS IN THE PORTUGUESE
CONGO: APPARENT CURES,
By Mercier GaMBLE, M.D.
B.M.S. Hospital, San Salvador do Congo.
Durine the nine months, December, 1908, to
August, 1909, I had forty-one unselected patients
under treatment for trypanosomiasis, in whom the
diagnosis was made from the microscopical exami-
nation of fresh gland juice, and the main treatment
consisted in no fewer than 100 gr. of atoxyl, which
was given subcutaneously in the forearms, usually
in doses of 4 gr. daily. They were natives of the
San Salvador* district of the Portuguese Congo;
they submitted to treatment voluntarily and lived
at their own expense. Except when they received
their medicine they were not under observation,
so that the regular taking of pulse-rates and tem-
peratures was impossible. The ages given were
estimated, the extreme weights were 25 lb. and
126 lb. Nineteen patients are alive and well. I
frequently either see them or receive reports that
they continue in good health.
(a) Thirty-five patients had no more atoxyl after
August, 1909, but three had secondary treatment
till December, 1909. Nineteen are dead, though
one died after two years of good health, and
possibly from other causes. Sixteen are alive and
well.
(b) Six patients had no treatment from August,
1909, to October, 1910. The subsequent main
treatment consisted of atoxyl, 74 gr., twice weekly, :
in the gluteal region.
(1) Two are dead; one ceased treatment March,
1911, and died October, 1912; the other was found
to be infected in November, 1911, and recommenced
treatment but died April, 19012. — (2) One is ill
(January, 1913); he had two courses of atoxyl and
two of perchloride of mercury between March and
August, 1909. Being unwell in October, 1910, he
received continuous treatment til April, 1912
(atoxyl 3821 gr., urotropine, perchloride of mercury,
and arsenious acid). During this time he was a
useful and intelligent workman, then, because of
the onset of severe headache, he returned to his
town. (3) Three are alive and well. Two ceased
treatment March, 1911, and the third September,
1911.
A. T., male, aged 21; diagnosed December 8,
1908; felt unwell, and thought it was due to the
enlarged cervical glands.
Treatment.—December 11, 1908, to January 11,
1909, atoxyl, 773 gr. by thirty hypodermic injec-
tions; January 12 to February 25, HgCl,, 5$ gr.,
by mouth; February 21 to March 17, antim. tart.,
86 gr., by mouth; February 26 to April 2, atoxyl,
88 gr., by twenty-three hypodermic injections;
April 5 to May 7, HgCl,, 3$ gr., by mouth; May
26 to June 18, HgCl,, 3 s gr., by mouth.
* “Notes on the District of San Salvador," JOURNAL oF
TropicaL MEDICINE AND HyaIENE, February 15, 1919.
Progress during Treatment (1909).—January 25:
gland juice fresh and stained negative; March:
weight, 110 Ib. ; April: submaxillary gland juice, 80
minutes negative; May: engaged in heavy work,
carrying in the hot, wet season; July: weight
115 Ib.
Result.—November 2, 1910: weight 114 lb.; ho
sleeping, no fever; in ten days, went to the Coast
(90 miles) and back with a three-quarter load, say
56 lb.; November 2, 1911: weight 1184 lb., well;
November 29, 1912: weight 120 lb., well. In
August he had repeated headaches, but they did
not stop him hunting. His second child was born
on August 3l. Carrier to the Coast, October and
December.
Vy
f
LI
`
n
N
" PA "
e
*
F *
Án
D. and A. T.
November 80, 1912,
—— ai -
M. K., female, aged 12; diagnosed January 9,
1909; obvious enlargement of cervical glands; sleep-
ing.
[OMEN (1909).—January 11 to February 24,
atoxyl, 1003 gr., by thirty-eight hypodermic injec-
tions; February 25 to March 28, HgCl,, 413 gr.
by mouth; March 29 to May 8, arsenic 32 gr., by
mouth, and atoxyl, 8 gr., hypodermically; May 4
to June 1, atoxyl, 100 gr., by twenty-four hypo-
dermie injections; June 11 to July 10, HgCl,,
54 gr., by mouth.
Progress during Treatment (1909).—January 27:
Fresh gland juice, negative; February 27: not
sleeping, able for farm work; March 29: weight
66 lb.; May 1: has joined a co-operative girls’ farm
82 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
club, and is quite able to do her share of the work;
June 28: weight 66 lb.
Result.—July 29, 1909: returned home well and
strong; November, 1910: weight 70} lb., well, no
headache, no fever; September, 1911: alive and
well; September, 1912: alive and well, works regu-
larly on farm; weight 84 lb.
N. L., female, aged 183. Symptoms: enlarged
cervical glands; sleeping; no cedema of face; no
hand tremors; very slight tremors tongue. Dia-
gnosis January 27, 1909: fresh blood thick film,
negative; cervieal gland juice contained trypano-
somes.
Treatment (1909).—January 30 to March 6,
atoxyl, £03 gr., by thirty-three hypodermic injec-
tions; March 14 to May 4, HgCl,, 8 gr., by mouth ;
May 17 to June 11, atoxyl, 100 gr., by twenty-three
hypodermic injections; June 28 to August 4,
HgCl,, 8 gr., by mouth.
Progress. during Treatment.—March 15, gland
puncture, negative; March 29, weight 65 lb.; April
13, seems to be dense in school, and sometimes
sleeps; June, cervical glands small, puncture,
negative; weight 61 lb.; August, weight 61 lb.
Result.—Mareh 2, 1912: well, appears to be in
splendid health, weight 882 lb. ; November 29, 1912:
reported alive and well; married in August.
M. N., female, aged 8. Symptoms: cervical
glands enlarged; eyelids cdematous; tongue fine
tremors; some epistaxis; skin healthy; no sleeping.
Diagnosis February 16, 1909; gland juice contains
trypanosomes.
Treatment (1909).—February 17 to April 1,
arsenic, 2 gr., by mouth; atoxyl, 53 gr., by nineteen
hypodermic injections; April 12 to May 18, HgCl,,
34 gr., by mouth; May 24 to June 26, atoxyl, 88 gr.,
by twenty-two hypodermic injections; July 5 to
August 4, HgCl,, 54 gr., by mouth.
Progress during — Treatment.—March, weight
87 Ib. ; April 6, blood film negative; April 13, bright
scholar; April 15, temperature 101.89 F., thiek
blood film contained no trypanosomes; June 28,
weight 38 lb.; June 29, temperature 104.29 F.,
quinine; July 6, repeated fevers, looks thin and ill,
abdomen protuberant, submaxillary gland contained
no trypanosomes; August 12, weight 38 Ib.
Result.—March 2, 1912, well, weight 481 lb.;
January, 1913, reported well.
N. V., male, aged 4. Symptoms: cervical glands
enlarged, some edema of face. Diagnosis February
16, 1909; gland juice contains trypanosomes.
Treatment (1909).—February 17 to April 7,
arsenious acid, 23 gr.; atoxyl, 24 gr., by ten
hypodermic injections; April 12 to May 13, HgCl,,
21 gr., by mouth; May 24 to June 24, atoxyl, 76 gr.,
by nineteen hypodermie injections ; July 5 to August
13, HgCl,, 54 gr., by mouth.
Progress during Treatment.—March 29, weight
25 ]b.; April 26, submaxillary gland puncture, 30
minutes, negative; June 1, sleeping in late after-
noon, but is this due to playing by moonlight?
June 28, weight 25 lb.
(Mar. 15, 1913.
Result.—November 2, 1910, weight 28 lb., no
fever, headache, or sleeping; March 2, 1912, weight
33 lb., well; January, 1913, reported well.
M. U., female, aged 6. Symptoms: enlarged
cervical glands, sleeping occasionally. Diagnosis
February 22, 1909; gland puncture showed try, axo-
somes.
Treatment.—February 22 to April 3, arsenic,
i55 gr, by mouth; atoxyl, 54 gr., by nineteen
hypodermic injections; April 12 to May 18, HgCl,,
34 gr., by mouth; May 24 to June 26, atoxyl, 88 gr.,
by twenty-two injections; Juiy 5 to August 4,
HgCl,, 54 gr., by mouth.
Progress during Treatment.—March, weight
39 lb.; April, ear blood, and gland juice showed
no trypanosomes; bright, intelligent scholar; June,
weight 43 lb.; July, weight 44 lb.
Result.—November 4, 1910, weight 422 lb.; no
sleeping, headache, or fever; skin clear; November
2, 1911, weight 443 lb.; some headache; May 30,
1912, weight 464 lb.; apparently well; September
28, 1912, weight 50 lb.; some nasal discharge;
December 28, 1912, has been under close observa-
tion for three months; well.
N. N., female, aged 11. Symptoms: cervical
glands enlarged; cedema of face; tongue steady; no
sleeping. Diagnosis February 9, 1909; fresh blood
film, negative, fresh gland juice showed trypano-
somes,
Treatment (1909).—February 10 to March 20,
atoxyl, 86 gr., by twenty-five injections hypo-
dermically; arsenic, 74, gr., by mouth; March 21
to May 4, HgCl,, 6 gr., by mouth; May 17 to
June 12, atoxyl, 100 gr., by twenty-four injections;
June 24 to July 23, HgCl,, 54 gr., by mouth.
Progress during Treatment.—March 29, weight
64 lb.; June 28, weight 65 lb.; August 3, weight
68 lb.
Result.—Nepeated reports saying she is well;
September 4, 1912, weight 98 lb.; well, works
regularly; has grown in height.
M. Nd., female, aged 10. Symptoms: cervical
glands enlarged; fever, no sleeping. Diagnosis
March 3, 1909; gland puncture showed trypano-
somes,
Treatment (1909).—March 8 to April 9, atoxyl,
54 gr., by thirteen hypodermies ; April 10 to May 30,
treatment interrupted by the rains; a few doses of
HgCl,, followed by twelve doses of arsenic, Jẹ gr.
May 31 to July 28, atoxyl, 113 gr., by twenty-thre -
hypodermic injections; August 4 to August 14
HgCl,, 14 gr., by mouth.
Progress during Treatment.—March 31 and June
28, weight 56 lb.
Result.—December 4, 1911, weight 652 Ib. ; looks
well, no headache, fever, or sleeping; submaxillary
gland juice, negative; November 12, 1912, alive and
well; weight 70 lb.
D. K., male, sged 10. Symptoms: enlarged cer-
vical glands; no sleeping. Diagnosis March 5,
1909; gland puncture showed trypanosomes.
Treatment (1909).—March 8 to April 9, atoxyl,
Mar. 15, 1913.)
57 gr., by seventeen injections; April 12 to May 7,
HgCl, 21 gr., by mouth; May 12 to June 19,
atoxyl, 109 gr., by twenty-six injections; June 28
to July 24, HgCl,, 5 gr., by mouth.
Progress during T'reatment.—March 29, weight
47 lb.; April 18, general improvement quite obvious
to his relations; June 28, weight 55 lb.; July 23,
gland puneture and fresh blood film, both negative.
Hesult.—October 24, 1910, weight 584 lb.;
December 30, 1911, weight 591 lb.; on his way to
the Coast for loads, he returned well (January 15,
1912); September 2, 1912, weight 60 lb.; well;
January 21, 1913, weight 612 Ib.; well.
D., male, aged 8. Symptoms: cervical glands
enlarged; thin, not sleeping. Diagnosis March 15,
1909; gland puncture showed trypanosomes.
Treatment (1900).—March 18 to April 9, atoxyl,
43 gr., by twelve injections; April 12 to May 18,
HgCl,, 44 gr., by mouth; May 24 to June 26,
atoxyl, 88 gr., by twenty-two injections; July 5 to
July 31, HgCl,, 4ł gr., by mouth.
Progress during Treatment.—March 29, weight
44 1b.; April, a smart lad, mentally and physically ;
June 28, weight 45 lb.
Result.—October 13, 1910, weight 532 lb.; well;
October 12, 1911, well; entered my service as a
personal boy; October 12, 1912, weight 644 1b.; for
the past twelve months has worked and played like
a healthy boy (see photo, page 81).
Z. V., male, aged 16. Symptoms: cervical and
submaxillary glands much enlarged ; sleeping, much
fever, no headache; occasional general weakness;
weight 80 lb. Diagnosis June 3, 1909; gland punc-
ture showed trypanosomes.
Treatment (1909).—June 4 to July 9, atoxyl,
112 gr., by twenty-eight injeetions; July 19 to
August 6, HgCl, 4 gr., by mouth; August 18 to
December 15, he received, through the kindness of
friends, two courses of arsenious acid and two of
perehloride of mercury; the total amounts were:
Liq. arsenicalis, 7dr. 50min.; arsenious acid, 435
gr.; perchloride of mercury, 101$ gr.
Result.—November, 1910, no fever, no sleeping,
strength returned ; weight 1021 lb. ; November, 1911,
well; weight 1124 lb. ; July, 1912, for several months
has been a reliable stone-mason and builder, in
daily work; weight 1094 lb.; October, 1912, weight
116 lb.; admitted by examination into Evangelistic
Training Institute.
S. N., female, born May 14, 1895. Symptoms:
headache and fever; glands in neck; occasionally
much cedema of face; no sleeping; weight 75 lb.
Diagnosis June, 1909; gland puncture showed try-
panosomes.
Treatment (1909).—June 11 to July 20, atoxyl,
121 gr., by thirty injections; July 27 to August 13,
HgCl, 3454 gr. by mouth; August 18 to Decem-
ber 15, through the kindness of friends she received
two courses of arsenious acid and two of perchloride
of mercury; the totals were: Liq. arsenicalis, 7dr.
5min.; arsenious acid, 53%; gr.; perchloride of
mercury, 114 gr.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. : 83
Result:—October 15, 1910, weight 88$ lb.; under
close observation; well; November 30, 1911, weight
1084 lb.; under close observation; well; November
20, 1912, weight 1204 lb.; she has taken a high
plaee in school, and helps in the dispensary.
M. D., female, aged 7. Symptoms: glands in
neck; headache and fever; nasal discharge; supra-
clavieular swelling not tender; not sleeping; illness
of one month’s duration. Diagnosis June, 1909:
gland puncture showed trypanosomes.
Treatment (1909).—June 9 to July 20, atoxyl,
101 gr., by twenty-seven injections; July 29 to
August 11, HgCl,, 2,5; gr., by mouth.
Progress during Treatment.—June 28, 1909,
weight 45 Ib.; July 31, 1909, a bright and jolly
girl.
Result.—October, 1910, well; November 27, 1911,
well; June 25, 1912, well; weight 532 lb.; Septem-
ber, 1912, alive and well.
P. Mb., female, aged 10. Symptoms: glands in
neck; not sleeping, has had some headache; weight
Diagnosis June 12, 1900: gland puncture.
08 lb.
M. U. P. Mb.
G. D. M. NI.
December 11, 1912.
Photographs of Five of the Sleeping Sickness Patients
mentioned in text as apparent cures, Photos by Mercier
Gamble,
Treatment (1909).—June 24 to July 27, atoxyl,
100 gr., by twenty-five M eye August 5 to
August 18, HgCl,, 18 gr., by mouth; August 18
to December 22, through the kindness of friends she
received two courses of both arsenic and of mer-
cury; the totals were: perchloride of mercury,
Tp gr.; arsenious acid, 1,4%, gr.; liq. arsenicalis,
12dr. 6min.
Result.—December 5, 1910, well; weight 662 1b. ;
September, 1912, alive and well, goes to farm daily ;
weight 804 lb.; December 4, 1912, health main-
tained.
84 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
A. V., male, aged 14. Complaint: glands in
neck, headache, fever; no sleeping (?); weight
75 lb. Diagnosis June, 1909; gland puncture.
Treatment (1909).—June 12 to July 20, atoxyl,
109 gr., by twenty-seven injections; July 27 to
August 18, HgCl,, 344 gr., by mouth.
Hesult.—-July, 1911, alive and well; June, 1912,
alive and. well; November 2, 1912, alive and well,
in regular work as a stonemason; weight 115} lb.
P. Mv., male, aged 12. Complaint: fever sleep-
ing about four months, and glands in the neck.
Diagnosis July 11, 1909.
Treatment (1909).—July 12 to August 13, atoxyl,
102 gr., by twenty-five injections.
Result.—July 27, 1912, no fever,
working; January 3, 1913, well.
G. D., female. Complaint and symptoms:
eructations, palpitations, dizziness; some cedema
of face; tongue steady; pregnant six months. Dia-
gnosis April 23, 1909; submaxillary gland punc-
ture, one trypanosome found after twenty-five
minutes.
Treatment (1909).—May 4 to June 1,
100 gr., by twenty-four injections; June 12 to
July 11, HgCl,, 54 gr., by mouth; July 29 to
August 183, atoxyl, 52 gr., by thirteen injections.
Progress during Treatment (1909).—June 1, pal-
pitation and dizziness continue; June 28, weight
110 1b.; July 19, delivered of a premature child
whieh did not survive.
Result.—October 29,
amenorrhea.
Treatment (November, 1910 to September, 1911).
—Attendance irregular; November to March, atoxyl.
1574 gr., by twenty-one injections of 74 gr. into
buttocks; March to May, HgCl,, 35, gr., by mouth ;
June to July, atoxyl, 674 gr., by nine intramuscular
injections; July to September, very irregular attend-
ance.
Result.—July 20, 1912, weight 106 lb. ;
11, 19138, well, but amenorrhea continues.
M. NL, female, aged 16. Complaint: glands in
neck, two years; eyes heavy at midday, twelve
months; amenorrhcea for periods of four months;
headache and shivering fever; no strength ; married
September, 1908. Diagnosis June 29, 1909; cer-
vical gland puncture negative; submaxillary gland
puncture, showed trypanosomes,
Treatment (1909).—July 5 to
no sleeping,
atoxyl,
1910, weight 106 lb.;
; January
August 5, atoxyl,
105 gr., by twenty-five injections.
Result.—November 19, 1910, regular, no head-
ache, no fever, strength returned, weight 114 lb.
Treatment (1910 and 1911).—Attendance irregu-
lar; December 9, 1910, to February 6, 1911, atoxyl,
521 gr., intramuscularly ; January, 1911, urotropine,
255 gr., by mouth; Marsh 3 to 20, 1911, atoxyl,
30 gr., intramuseularly.
Hesult.—July 20, 1911, child born; November
20, 1011, both well; July 20, 1912, mother well,
115 lb., but ehild thin; both loaded with round
worms; November 16, 1912, both well, mother's
weight 109 lb., probably because the child is still
[Mar. 15, 1913.
on the breast, and this is the planting season, which
means heavy work.
S. M., male, aged 15. Diagnosis June 29, 1909;
cervical gland puncture showed trypanosomes.
Treatment (1909).—June 29 to August 5, atoxyl,
107 gr., by twenty-seven injections.
Result.—August, 1910, weight 1103 lb.; exami-
nation of fresh gland juice, negative; September,
1910, through the kindness of Dr. Broden, of the
Leopoldville Clinieal Laboratory, he was examined
by lumbar puneture, and a slight increase of the
lymphocytes was demonstrated.
Treatment (1910 and 1911).—October 31, 1910,
to December 23, 1910, atoxyl, 973 gr., by intra-
muscular injection of 714 gr. doses; February 13,
1911, to March 3, 1911, atoxyl, 45 gr., by intra-
museular injection of 74 gr. doses.
Result.—March, 1912, alive and well; November
16, 1912, reported well, carrying and gardening.
From the above reports it may be scen that these
nineteen natives are living useful lives and that they
have had good health for from three and a half to
four years. They appear to be cured. The method
of treatment has, however, the great disadvantage
that it requires a large amount of time. There-
fore, since my return in October, 1910, I have
given, as a rule, atoxyl, 74 gr., twice weekly intra-
museularly. Of a group of thirty- two, who com-
menced treatment that year, twenty -one are in
good health. I hope to report on them when they
have been longer under observation.
A CONTRIBUTION TO THE STUDY OF
BILHARZIASIS.
By Professor Ivo BaNpr, Naples.
DURING a tour of investigation, which I carried out
in Egypt last year, I had the opportunity of collecting
material for anatomico-pathological and parasitological
researches on bilharziasis.
Among the questions which at the time principally
interested me was that of the assumed existence of a
species of Schistosomum which could be anatomically
differentiated from the Schistosomum hematobium (i.e.,
S. mansoni of Sambon).
I noticed at that time in the walls of a bilharzia
affected bladder that both ova with terminal and
lateral spines were present at the same time.
In investigations which I undertook during the
present year in Southern Tunis I was able to study
twenty-five cases of vesical bilharziasis at Gafsa,
which is a most important centre of bilharizal disease,
The examination of the urinary sediment carried
out on the spot showed, in all these cases, the exis-
tence of schistosomic ova with terminal spines only.
In a single case of intestinal bilharziasis which also
came under observation at Gafsa only ova with ter-
minal spines were again noted. Some months ago
I received from Dr. Levy, of Sfax, a sample of bilhar-
zial urine preserved with formalin, which had been
Mar. 15, 1913.]
obtained from one of Dr. Levy's Arab patients
who was suffering from a slight bilharzial cystitis.
During my sojourn at Sfax I found it impossible
to trace the patient: it was known, however, that
he was living in a locality which was not recog-
nized as being badly infected with bilharziasis. The
examination of the sediment obtained by centri-
fuging this urine, demonstrated the presence in
great scarcity of schistosomum ova of both varieties.
This observation is of some importance as regards
the debated question whether the two varieties
of ova belong to the same species of S. hematobium
or not.
Logically, and on the basis of experiments made,
the separation of the two forms of bilharziasis (intes-
tinal and vesical) as established by various investi-
gators—amongst others Firket, Broden, Gunn, Hol-
comb, Letulle, Piraja da Silva, and Noc—does not
appear to me to be sustainable, as it is based on
the differentiation of the ova, which should invari-
ably be with terminal spines in cases of vesical bil-
harziasis, and with lateral spines in intestinal
bilharziasis.
To the observations of Looss, Ferguson and myself
in Egypt, against Sambon's theory, should be added
the observations of Conor, who, in Tunis—in the rare
eases of intestinal bilharziasis which came under his
observation—saw in some ova of both varieties and in
others only ova with terminal spines. The two
varieties of ova in a bilharzia cystitis in Tunis
were first observed by me.
I believe that most probably Looss's opinion is the
correct one—-—-that both ova with terminal and ova
with lateral spines belong to the same species of
Schistosomum, which may become localized either
in the bladder or the intestine, or both. It is to
be noted that in Tunis, as shown by Catouillard
and Gobert as well as by Conor and myself, the
latter is very rarely met with.
——————M9»————— —
HISTORICAL MEDICAL MUSEUM.
Mr. Henry S. WELLCOME announced some time
ago that arrangements had been concluded to hold
the Historieal Medical Exhibition at 544, Wigmore
Street, London, W., during the summer of 1913.
We look forward with great interest to what is
certain to prove an exhibition of abiding interest.
Mr. Wellcome, himself one of the greatest authori-
ties on the history of all appertaining to the art of
medicine, has had an expert staff at work for
several years, obtaining information from every
available souree and collecting relies, drawings,
instruments used in medicine and surgery in
ancient, medieval, and recent times. Egypt and
Italy will no doubt contribute the major portion
of the more historic objects of interest, for in these
countries, more perhaps than any others, the art
of medicine attained probably the highest develop-
ment in former times.
This is the first time an exhibition of the kind
has been held, at any rate in Britain, and it should
prove both educative and interesting to the medical
profession, as well as to others,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 85
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THE JOURNAL OF
Tropical Medicine and hygiene
Marcu 15, 1913.
THE FAR EASTERN OLYMPIAD.
ATHLETICS IN TROPICAL COUNTRIES.
More than ordinary interest attaches to the
recently concluded meeting of athletes held at
Manila. The gathering was held under the auspices
of the Far Eastern Olympiad, and was of an inter-
national character. Men of several races and
nationalities competed, and perhaps never before
has there been held an athletic gathering of such
magnitude in the Far East, nor one in which so
many varied types of human beings took part. It
is impossible to form a definite idea of the athletic
supremacy of any one race or nationality from a
gathering of this kind, but it is a great advance from
several points of view that natives of many countries
at the present day assemble to test their
relative prowess in friendly antagonism. At the
Manila Olympiad the Chinese carried off several of
the important prizes, and the averages of their
suecess in the competitions are very high. Those
who know the physique of the Chinamen are
86 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
prepared to expect their excellence in several depart-
ments of athletics, and those who have had an
opportunity of witnessing their athletic abilities are
also prepared to expect that in the future keen
competition will arise between European and
Chinese champions. Many Chinese lads in our
schools in England have done well in certain
departments of sport, and in one of the public
schools competitions, in which the great publie
schools in England all took part, many will re-
member how one Chinese lad proved champion in
at least two of the competitions. Curiously enough,
this lad's brother did equally well in the following
year, and several other Chinese students have
proved capable of holding their own in this country
and in the United States of America.
The next meeting of the Far Eastern Olympiad
is to be held in Shanghai; here we may expect a yet
more representative collection of athletes than in
Manila, and it will be interesting to wateh which
of the nationalities best succeed.
These international sports are a new feature even
in Europe, and yet more so amongst Asiaties and
Africans. The area of contest is of widening
interest; for not only international, but inter-racial,
competitions will certainly be the feature of Olym-
piads in the near future. The three typical races
of mankind—the white, the yellow, and the black—
will vie with each other in athletics, and there can
be no doubt as to the keenness of the contests.
Time was, and yet but the other day, when athletic
sports in their highest sense were practised by
British folk only. Slowly, very slowly, hus sport
found its way to the Continent of Europe, and it is
still looked upon there as rather a. frivolous chapter
in the nation's health. Of late years, however, we
have evidence that this idea is passing away, for
we have seen Belgian and German oarsmen of high
calibre at our boat-racing meetings, and keen foot-
ballers from France. Other nations have relied
upon military training as the means of keeping their
youths fit; but in Britain, where military training
is the exception, we have to thank '' sports ” for
preventing our race deteriorating to the lowest ebb.
With, however, the accession of not only other
countries but other races competing with us in the
athletie field, it behoves those interested in sport
to look around and consider what are the prospects
of the several races in the matter of success in
athletic exercises.
To gauge the probable results of inter-racial com-
petitions there are but few facts to go upon, hence
it is difficult not only to attempt to prophesy, but
also to discuss the subject with any prospect of
arriving at even approximate truth. Recent con-
tests have shown us that the negro can box, that
the red man ean run long distanees, that an Indian
Prince can play ericket, that the Chinese lads are
successful competitors on the cross-bar and “horse,”
and there are several instances of the success
of representatives of other races than the white in
sport. The anatomist and physiologist from even
the above bald statements may find data whereon
to predict the sphere in which each racial type will
(Mar. 15, 1913. -
specially succeed. The negro, heavy in build and
slow in movement, with the flat calf and the pro-
minent heel due to the long prominence of his os
calcis, is not calculated to have success on the
racing track or in any sport in which speed is a
necessary feature. The place of the negro in sport
can, therefore, be guessed at, if not conclusively
settled, for Nature has not endowed him with the
lightness required in many games, nor given him
the ‘‘spring’’ required in such comparatively
“still ` sports as putting the shot, &e. Boxing
and weight-lifting may be his, but from the
anatomist’s point of view he cannot go far beyond
these.
The yellow race are of a different build to the
negro; small-boned, light-framed, and capable of
great muscular development, the Chinese and
Japanese are fitted for athletics of a different
kind to those in which the black race may succeed.
Those who have seen the enormous muscular
development of the lower extremities of the Chinese
and Japanese can realize that in athletics they will
be worthy competitors in such sports as sprinting
and exercises in which smartness of movement and
alertness are required, The absence of roads in
China has caused much of the carrying trade of the
country to be done on men’s backs, and the
custom of the better-off members of the community
to travel in chairs borne on men’s shoulders is
common in China. The consequence is that in
their loins and. lower limbs the Chinese are strong
in the parts of the body where strength tells. Man's
natural strength lies in his loins and thighs, not in
the upper extremities to which our modern gym-
nasia teachers devote so much attention to develop.
The teachers elaim that they add inches of inerease
to the circumference of the chest, whereas, more
often than not, it is mere increased development of
the muscles of the upper limb arising from the
trunk that affords the apparent inerease, and not the
vital capacity of the lungs themselves.
If the science of eugenics has any real
accuracy, the generations bred from weight-carrying
ancestry must tell, and at the present time the
Chinese are developed in that sense beyond perhaps
any other peoples. "That this will continue through-
out another generation in China and Japan is ques-
tionable, for modern developments with railways,
machinery, &c., will do away with the necessity for
human beings continuing to do what in other
countries are done by mechanical transport.
Inter-racial contests, Jiowever, are bound to be-
come common in the immediate future at which
black, white, and yellow races will contend; and
there can be no doubt that there will be many
heart-burnings in Europe and Northern Americi
when the palm of victory is awarded to races other
than white, who have hitherto been supreme in all
matters appertaining to sport.
From the anatomist's point of view these contests
are of great interest, and as the area of competition
spreads so will the interest increase. The difference
in physical type between the three distinctive races
of mankind is sufficiently marked to enable the
Mar. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 87
scientific anatomist to understand aright what each
is best capable of performing, and explain why one
man, nationality, or race excels in certain branches
of exercises and fails in others.
The international contests we see around us even
now in so limited a degree have a scientific interest ;
and this will inerease as years advance and the
competitors come from different types of mankind.
We are apt to regard these Olympiads as mere bet-
ting opportunities and dispose of them accordingly ;
but there is a deeper meaning to them which, when
accurately gauged, is of supreme scientific interest.
J. C.
———»9— ———
Aunolations,
Spirillar Fever in the Darjeeling District.—Capt.
A. M. Jukes, I.M.S., describes in a preliminary
note in the Indian Medical Gazette, December,
1912, small localized epidemics of fever, some
with high mortality, which had presented some
difficulty of diagnosis. He had found a spirillum
in the blood of the cases examined by him, and
was inclined to regard this as a new form of spirillar
fever, because of (1) the severity of the illness and
the high mortality (eight deaths out of fourteen
cases in one group, one out of three in another
group); (2) duration of fever eight to ten days;
(3) absence of relapses in those who recover.
Bed-bugs and Leprosy.—Skelton and Parham, in
the Journal of the Royal Army Medical Corps for
March, 1913 (vol. xx, No. 3), narrate some experi-
ments made by themselves to ascertain what part
the bed-bug plays in the transmission of leprosy.
Seventy-five bed-bugs (Cimez lectularius) caught
on beds at Walezo Leper Asylum, Zanzibar, were
teased out, and their intestinal contents examined
microscopically for acid-fast organisms.
The technique employed was as follows :—
Live bugs which had been caught on beds in the
Leper Asylum were placed in sterile tubes and
washed for several hours in many changes of normal
saline. The intestinal contents were teased out,
and films were made of their contents and stained
by the Ziehl-Neelson method, and decolorized for
five to ten minutes in 2 per cent. sulphuric acid.
Acid-fast granules were found in one such pre-
paration. They gave one the impression of the
large azure granules in a large mononuclear leuco-
eyte, but although the film was searched very care-
fully for several hours on two or three days, no
further patches of acid-fast granules could be
detected.
In two films, stained clumps of bacilli that were
neither pink nor blue were seen. They were arranged
somewhat like Bacillus typhosus in the spleen.
It was thought that these organisms might have
been slightly acid-fast bacilli, and that a 2 per cent.
solution of sulphuric acid had only partially
decolorized them.
One of the films, therefore, was restained with
carbol-fuchsin and decolorized in 5 per cent, sul-
phuric acid in methylated spirit for ten minutes, and
counterstained with methylene blue. On examina-
tion a few pink rods could be made out, but the
majority were stained as in the first specimen. The
rest of the film had completely lost the pink stain
in the decolorizing fluid.
In another experiment 100 live bed-bugs caught
at Walezo were washed in sterile normal saline by
repeatedly shaking them up in two tubes for several
hours. The fluid was then poured off and centri-
fugalized. Several films were made of the deposit
and were stained with carbol-fuchsin and decolorized
in 5 per cent. sulphuric acid in methylated spirit
for ten minutes. No acid-fast organisms were
detected after careful search for several hours.
What was left after the fluid had been decanted,
that is to say, the bodies, legs, and arms of the bed-
bugs, were put into a mortar and ground up to a
powder. Several films of this were stained and
examined, No acid-fast organisms were seen.
It may be remembered that Much in his descrip-
tion concludes that the tubercle virus exists in three
forms: (1) An ordinary bacillary form; (2) a non-
acid-fast form showing granulés in its interior; and
(3) free granular forms. It may, of course, be pos-
sible that the granules we saw and the indeterminate
bacilli were forms of the ordinary acid-fast B. lepræ.
The author's conclusions are as follows: (1) With
the above exception it does not appear that the
ordinary common bed-bug harbours any bacilli
which morphologically resemble the B. lepra.
(2) In these circumstances it does not appear
probable that the bed-bug plays any great part in
the transmission of the disease in Zanzibar.
————— ——————
Abstracts,
STUDIES ON PNEUMONIC PLAGUE.
The Pneumonic Strain of “ Bacillus Pestis.”
(Continued from p. 80.)
Agglutination Tests.—Theoretically the agglu-
tination test has two applications in plague: (1)
The diagnosis of the disease by the demonstration
of antibodies in the patient's serum, and (2) the
identifieation of the organism cultivated from a
suspeeted case by means of the serum of an animal
immunized against the plague bacillus.
In pneumonie plague, the agglutination test has
no clinical value, for the patients succumb to the
disease before antibodies are produced or at least
produced in any quantities that are capable of
detection,
With regard to the second application of the
method, as there seemed to be some difference of
opinion as to the value of the agglutination test in
identifying plague bacilli, the authors decided, after
their return to Manila, to carry out a series of ex-
periments in the hope of throwing further ligit upon
this subject.
Two points were strikingly obvious from this series
of experiments: (1) There is great variability in the
limits of agglutination of the different strains, and
(2) the strains freshly isolated from experimental
88
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 15, 1913.
animals agglutinate only at relatively low dilutions
of the serum. It is also to be noted that both
pneumonie strains and bubonie ones are agglutinated
by the same serum.
During the course of these experiments they were
able to identify promptly by the agglutination test
two strains which were isolated from bubonic cases
of plague dying upon ships in the harbour of Manila.
While one of the difficulties in the performance
of the agglutination test with the plague bacillus is
the tendency towards spontaneous flocculation,
under proper conditions, spontaneous flocculation
usually does not occur in freshly isolated strains; in
most strains which have been grown upon artificial
media for long periods of time it can be avoided by
cultivating them at 37° C. The greater difficulty
is to obtain a satisfactory immune serum. Several
rabbits were given repeated intravenous injections
of large doses of killed virulent culture without
obtaining more than a trace of agglutination with
their sera. The authors strongly recommend the
use of a living virulent culture for the preparation
of the immune serum.
If one has a satisfactory immune serum, the cul-
ture grown at 329 C., or even at 379 C., will be
agglutinated promptly, and the control tubes will
remain practically unchanged. Controls with nor-
mal serum should always be prepared in performing
the test.
Infectivity of the Excreta.—In no other disease
is the infecting organism found in such abundance
in the sputum as it is in pneumonic plague. When
the disease is well developed, Bacillus pestis is
present in almost pure culture. In pneumonic
plague as in bubonie plague, when the disease
becomes septicemic, the organisms are sometimes
found in the urine and even sometimes in the feces.
When once the sputum of pneumonie plague cases
becomes thoroughly dried it is no longer infectious,
but when the sputum becomes frozen and pulver-
ized, particles of it may be blown about and remain
infective for long periods of time, or until the
sputum is again thawed.
Examination of the Sputum.—4^ bacteriological
diagnosis from the sputum cannot be made at the
onset of the disease, and not until after the fever
has developed does the sputum appear. Shortly
after the appearanee of the sputum, the plague
organism, even if not visible from the microscopical
examination, may be isolated by culture. When
the sputum becomes bloody, the organism is usually
present in large numbers and in almost pure cul-
ture. Sometimes the organism might be mistaken
morphologically for Diplococcus pneumonia, and
bipolar staining organisms, other than plague
bacli, may sometimes be encountered in the
sputum. While in the microscopical examina-
tion of the sputum Gram’s stain is a very
valuable aid in arriving at a diagnosis of
the organism, nevertheless Gram negative bacilli
have been encountered in the sputum, which
proved later not to be plague bacilli. | However,
usually if the sputum is blood stained, from the
microscopical examination, with the aid of Gram’s
stain, there is no difficulty in arriving at a diagnosis,
since the plague organism is usually present in such
very large numbers. In the later stages of the
disease, involution forms are commonly encoun-
tered in the sputum. The organisms are constantly
found in great abundance up to the time of death.
Examination of the Blood.—In the early stages
of the disease, cultures from the blood are fre-
quently negative. Sometimes, however, the or-
ganism could be cultivated from the blood from
twenty-four to forty-eight hours before death, and it
could always be obtained from the blood a few
hours before death. In many instances the
bacteria are present in very large numbers
in the blood, so that a diagnosis can often
be made from a simple, microscopical exami-
nation. In no other disease is so marked a
bacteremia present. In the early stages of the
disease, cultures from the blood should be made in
bouillon, as much as 1 c.c. of blood being employed.
The agglutination test is of no value in making a
diagnosis, as the course of the disease is too acute
and the patient has succumbed before the agglu-
tinins appear in demonstrable quantities. The re-
action of the deflection of the complement is also
not to be recommended for the same reason; the
examination of the sputum and blood for the
presence of the bacillus gives much greater and
more valuable information. In cases where no
necropsy is permitted, and a post-mortem bacterio-
logical diagnosis is advisable, microscopical exami-
nation of material, obtained by lung puncture with a
syringe, may often be conclusive of pneumonie
plague, B. pestis being present in the microscopical
preparation, in enormous numbers, in pneumonic
plague cases.
From the study of the human lesions and those
produced experimentally in animals, it would appear
that epidemic plague pneumonia results from inha--
lation, the primary point of infection being the
bronchi. Along the bronchioles the infection
extends by continuity directly into the infundibulum
air cells, or by contiguity through the walls of
the bronchioles to the contiguous tissue of the lung,
and gives rise to a consecutive peribronchial inflam-
mation in the tissues immediately surrounding the
bronchioles. From these areas the infection
rapidly spreads to the adjacent pulmonary tissue
and visceral pleura. The bacilli rapidly mul-
tiply and produce at first pneumonie changes
of the lobular type, and shortly afterwards
from the fusion of several rapidly spreading areas
more general lobar involvement of the lung tissue.
The blood becomes quickly infected, and a true
bacteremia results in every case. Secondary
pathological changes occur, particularly in the
spleen, bronchial glands, heart, blood-vessels, kid-
neys, and liver. The fact that the bronchial glands
at the bifurcation of the trachea are always much
more severely affected than any of the other
lymphatie glands argues against the theory that
epidemic pneumonie plague is primarily a septi-
cemic disease, and that the lungs are infected
secondarily from the blood, Moreover, in the
Mar. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 89
earliest stage of the disease, the blood may be free
from plague bacilli. The tonsils may become
secondarily infected in pneumonie plague, just as
other lymphatic glands—for example, the bronchial
ones—become so infected. However, in pneumonic
plague, death occurs before any very marked macro-
scopic changes occur in the tonsils. There is no
doubt also that the tonsils may become primarily
infected in epidemics of pneumonic plague, just as
has occurred in sporadic cases during epidemics of
bubonic plague. This, however, is not the com-
mon channel of primary infection, and in such cases
involvement of the lymphatic glands of the neck
occurs early in the course of the disease. The fact
that the csophagus was found to be normal in
every case examined and that the intestines showed
only slight lesions constitutes another argument
against the idea of the occurrence of primary intes-
tinal plague infection in man, since in many of the
pneumonie cases plague bacilli must have been
repeatedly swallowed in the bronchial secretions and
in the saliva.
Susceptibility of Animals to Pneumonic Plague.
Many cultures isolated by Strong and Teague
during the Manchurian epidemic from the lungs at
necropsy have demonstrated the same pathogenicity
for animals as virulent bubonic strains of the plague
bacillus. The pneumonie cultures have shown
themselves to be particularly pathogenic for mice,
rats, guinea-pigs, and monkeys (Cynomolgus
philippinensis, Geoff.), these animals dying from the
same doses and suecumbing within the same period
after inoculation as has been observed after infec-
tion with bubonic strains. Some evidence was
introduced at the Conferenee held at Mukden that
suggested that when the pneumonic strains were
injected subcutaneously into the guinea-pigs,
usually septicemia was produced very quickly and
typical buboes were not obtained. Moreover, it
was affirmed that the guinea-pigs died within a
shorter time after inoculation than in the cases in
which bubonic strains were employed. However,
in these instances it appears that the results were
dependent upon the size of the dose inoculated, as
much as one-half of an agar culture having been
employed in the infection. The authors showed in
Mukden that the cutaneous or subcutaneous inocu-
lation of very small doses of the pneumonic strain
into guinea-pigs gave rise to the typical lesions
observed in these animals after inoculation with
virulent bubon'e strains, particularly to typical
buboes, to miliary abscesses in the spleen, and to
secondary septicemia with hemorrhages in the
different organs. Statements at the Conference in
this respect have since been borne out by extensive
experiments performed in Manila, and it has been
conclusively shown, in addition, that when guinea-
pigs are inoculated with the pneumonie cultures by
inhalation, they develop primary infection of the
glands of the neck, with secondary septicemia and
oceasionally secondary pneumonia, or, in some
cases, primary pneumonia with secondary septi-
cemia, Very rarely does the spleen show miliary
abscesses in such cases, the animals dying before
such lesions develop.
In monkeys (Cynomolgus philippinensis, Geoft.),
also, the cutaneous or subcutaneous injection of the
pneumonie cultures causes typical bubonic infec-
tion. Monkeys infected by the same cultures by
inhalation develop primary pneumonie plague with
secondary septicemia and without involvement of
the glands of the neck.
Tarbagans.—There has been considerable evi-
dence brought forward during the past in support
of the view that plague has existed in epizoótic
form among a species of marmot, the tarbagan
(Arctomys bobac, Schreb) However, there has
been no direct bacteriological proof of this fact, and
nothing definite was known before in regard to the
susceptibility of this animal to plague infection,
though, according to Preble, Tchaoushow showed
these animals were susceptible to plague infection.
Strong and Teague’s experiments on tarbagans
were carried out in Mukden where, by the kindness
of the Hon. Alfred Sze, Imperial Commissioner to
the Plague Conference, they were supplied with
these animals for experimental purposes. From
experiments they were able to show for the first
time that cutaneous or subcutaneous infection of
the tarbagan with virulent cultures of the pneu-
monic strain gives rise in these animals either to an
acute bubonic or to subacute and chronic forms of
plague infection. In some instances it was shown
by comparative experiments that the tarbagan
seems equally as susceptible to cutaneous or sub-
cutaneous infection as the guinea-pig, these animals
dying in about the same time (two and one-hali to
five days after infection), and from the same doses
of the organism. In these instances there are
hemorrhages about the point of inoculation, typical
buboes, and swelling of the spleen. In other
instanees, after infection with the same organism
and with the same doses, the tarbagans may suffer
from subacute and chronic forms of plague infec-
tion. In three of these animals killed by chloro-
form from ten days to two weeks after infection,
there were found at necropsy abscesses measuring
several millimetres in diameter in the subcutaneous
tissues or in the abdominal muscles, near the point
of inoculation, and swelling of the inguinal glands,
while the liver and spleen showed indurated,
yellowish nodules also measuring several milli-
metres in diameter. Plague bacilli were present in
small numbers in the abscesses and in the nodules
in the spleen and liver. These animals, judging
from their condition at the time they were killed,
would probably have lived at least several weeks
longer. The lesions present were similar to those
which have been described in rats which have
succumbed to chronic plague infection. It was
shown that the tarbagan is also susceptible to
primary pneumonic plague when infection has taken
place by inhalation. Death then occurs three or
four days after infection from primary pneumonia
and secondary septicemia. These experiments
were performed with the species Arctomys bobac
Schreb, It was also shown that another species of
90
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 15, 1913.
marmot (Spermophilus citillus, Linn.), very com-
mon about Mukden and the vicinity, was suscep-
tible to acute plague infeetion, these animals dying
in from three to seven days after cutaneous or
subcutaneous inoculation of small doses of the
pneumonie strain and exhibiting at necropsy
hemorrhages about the point of inoculation, typical
buboes, and acute, splenie tumour.
Donkeys.—Some evidence was introduced at the
International Plague Conference to show that
donkeys became infected with pneumonie plague
during the epidemic. Dr. W. S. Yang reported to
the Conference the death of ten donkeys, the first
of which died with cough and expectoration of
blood. In the case of one of these animals, a
necropsy was performed, and cultures were made
from the heart, spleen, lungs, and liver. All of these
cultures were said to show plague bacilli. It was
also announced that Doctor Otsuki in Fushun had
observed at necropsy two donkeys in which there
was hepatization of the lungs, in one in the right
and in the other in the left caudal lobe. The
pathological changes in the lungs were said to be
similar to those seen in the cases of human infec-
tion. In regard to the question of plague infection
in donkeys, the Conference resolved that the ques-
tion of the occurrence of pneumonie plague in these
animals should be made the subjeet of a special
study with regard to their liability to the infection.
Strong and Teague, accordingly, attempted to infect
donkeys experimentally with pneumonic plague by
spraying suspensions of virulent strains of pneu-
monic plague bacilli into a closed canvas bag,
fastened about the donkey's head in such a manner
that it was necessary for the animal to inhale the
bacteria in breathing.
Although they never failed to infect guinea-pigs
and monkeys with pneumonie plague by the same
cultures which were sprayed into the nostrils of
the donkeys, they were entirely unable to infect
the donkeys, even when these animals were made
to inhale air charged with the most virulent cul-
tures of pneumonie strains of the plague bacillus
for a period of as long as five minutes at a time.
Therefore, they do not consider donkeys susceptible
to pneumonie plague infection, and these experi-
ments render it doubtful that these animals played
any part in the dissemination of pneumonie plague
during the Manchurian epidemie, and suggest that
in the reported cases of pneumonie plague in don-
keys the infecting organism was not Bacillus pestis,
but, perhaps, some other organism of the hæmor-
rhagie septicwmia group.
Dogs.—At the Mukden Conference, one case of
pneumonie plague infection in a dog, observed by
Dr. Takami, was referred to in which there was
pneumonia in the caudal lobe of the left lung. This
dog was found in a house where seven people had
died of plague infection. The Conference also re-
solved that the question of the occurrence of pneu-
monie plague in dogs should be made the subject
of special study with regard to their liability to this
infection. Accordingly, experiments were per-
formed with this object in view. The results were
as follows ;—
On November 4, two fully-grown dogs were
placed in a closed glass cage and a suspension of
two 48-hour agar cultures of a virulent pneumonic
strain of the plague bacillus was sprayed into the
cage for two periods of two and a half minutes
each after a brief interval between them. The first
dog died on November 9, five days after infection.
The necropsy showed there was pneumonia of both
lungs. In the right lung all the lobes were in-
volved. Only a small portion at the apex of the
upper lobe did not show pneumonia. In the left
lung, both lobes, with the exception of the apex
of the upper lobe, were also involved. The
pneumonia was in the stage of engorgement
with the exception of small bronchial areas
scattered throughout the lung, measuring from
about 2 mm. to 1 em. in diameter. These
areas of bronchial pneumonia were greyish in colour
on the surface of the lung, and on section they
were greyish at the periphery and in the centre red
and slightly granular. The areas were not wedge-
shaped, but were circular in outline. Smears from
the lungs showed comparatively few plague bacilli
and a few streptocoeci. The large bronchi were
not reddened. There was much mueus in the
trachea, but the mucous membrane here was also
not reddened. The cervical glands appeared nor-
inal. There was no edema of the cervical tissues.
The spleen was swollen, but contained no miliary
abseesses. The liver showed cloudy swelling, and
also contained no miliary abscesses. Microscopical
preparations from the spleen showed a few plague
bacilli. Cultures from the heart and lung developed
humerous colonies of the plague bacillus.
The other dog died March 21, seventeen days
after infection. He was considerably emaciated.
The necropsy showed that the lymphatic glands
were nowhere swollen. There were no hemor-
rhages or a@dema in the tissues about the neck.
The trachea and larger bronchi contained frothy,
reddish mucus. The left lung was normal through-
out. The upper lobe of the right showed advanced
hepatization throughout and sank when placed in
water. Two greyish wedge-shaped infarcts,
measuring from 1 to 1.5 em. at the base, were
present in this lobe. The whole lobe showed
reddish-grey hepatization with beginning resolu-
tion. The middle and lower lobes were somewhat
congested, but contained no pneumonie areas.
Microscopical preparations from the lung showed a
fair number of Bacillus pestis. No other organism
was present in the lung, as was demonstrated by
cultures. Microscopical preparations from the
spleen showed a few bipolar forms and a number of
involution forms of the plague bacillus.
Therefore, experiments upon dogs show that
these animals are only moderately susceptible to
pneumonie plague, but that, when exposed to
severe infection, they may eontract primary pneu-
monic plague and die of the disease.
Shibayama showed that dogs were not very sus-
ceptible to subeutaneous infection with the pneu-
monie strain, but that they sometimes succumbed
from the subcutaneous inoculation of large doses
or from intraperitoneal inoculation,
4
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE 91
Mar. 15, 1913.]
Pigs.—It was stated that over 300 pigs had dizd
during the epidemic at Harbin, but there was no
evidence presented which showed that the disease
from which they succumbed was bubonic or pneu-
monic plague infection, nor was any evidence sub-
mitted which showed that the disease was not hog
cholera or swine plague.
Method of Transmission and Spread of the Disease.
Richard P. Strong and Oscar Teague,* in their
report of their researches during the Manchurian
epidemic in 1910-1911, write that, immediately after
establishing their laboratory in Mukden, experi-
ments were undertaken with the idea of elucidating
the method of transmission of the infection in
pneumonic plague and the manner of spread of the
disease during the epidemic.
The sputum of pneumonic plague patients in the
advanced stages of the disease always contains
enormous numbers of plague bacilli. The tempera-
ture of the hospital wards at Mukden was suffi-
ciently low, so that the expired «uir became
immediately condensed to a vapour which was
clearly visible to the eye as it issued from the
mouth, and frequently could be seen for a distance
of 30 cm. or more from the face. In many
of the patients advanced pulmonary cedema was
present, and the respirations were sometimes very
forcible and sometimes even stertorous. Therefore,
experiments were carried on to show, first, whether
in cases of pneumonie plague the specific organism
of this disease became disseminated into the air by
the expired air or vapour arising from the breath in
ordinary or dyspneie respiration, and, secondly,
whether this organism was disseminated by
moderate attacks of coughing in pneumonie plague
eases in which the cough did not result in the ex-
pulsion of particles of sputum visible to the naked
eye. These questions were studied extensively by
means of exposing Petri dishes containing agar
before undoubted plague cases, and of then identify-
ing the organisms which developed on the media
by the usual bacteriological methods and particu-
larly by animal inoculations.
In the course of the experiments, on a number
of occasions during coughing, small droplets or
larger particles of sputum, visible to the eye, were
expelled, and touched the surface of the media in
the Petri dishes which were exposed before tho
plague patient. The study of these cultures
voviously is not included in this part of the investi-
gation. The Petri dishes containing agar were
invariably exposed before cases of pneumonie plague
with bloody sputum, in which enormous numbers
of plague bacilli had been shown to be present. All
of the cases before which the plates were exposed
died of plague infection within twenty-four to forty-
eight hours from the time of the exposure. Twelve
series of experiments were performed in which
eighty-two plates containing agar were exposed,
and in seventy-eight the micro-organisms which
* Philippine Journal of Science, Section B, vol, vii, N
June, 1912, f on B, vol, vii, No.
,
developed upon them were studied as far as was
practicable,
The experiments were performed in the following
manner: The plates were sterilized in the hot-air
sterilizer within a metal plate-holder. They were
then removed, the agar cultures melted and poured
in in the usual way, and, as soon as the medium was
sufficiently hard, were replaced within the plate-
holder, and taken to the bedside of the patient in
whose sputum plague bacilli had previously been
found. All of the attendants were asked to retire
from the ward in order that as little dust as pos-
sible might be present in the air. The condition
of the patient before whom the plates were exposed
was noted, and during the exposure of the plate the
character of the respirations was particularly ob-
served and notes made of whether coughing or
talking occurred. The time of the exposure of the
plate and the distance from the patient were also
recorded in each instance. After the exposure the
plate was returned to the holder and placed in the
incubator. Twenty-four hours later the plates con-
taining the eulture-media were examined for the
appearance of colonies and the number of colonies
counted, but the plates were not usually opened
until after forty-eight or seventy-two hours. The
colonies were then again counted and carefully
studied. Any of the colonies which in any way
resembled colonies of the plague bacillus were trans-
planted to slants of agar. The morphology and
staining properties of the organisms on the plate
and agar-slant cultures were then studied. In
every instance in which the morphology was at all
similar to that of the plague bacillus, or the organism
decolorized by Gram's stain, it was inoculated
either into miee or guinea-pigs. In a number of
cases the colonies were so thick on the plate, or
surface growths from contamination with bacteria
from the air were so extensive, that the separate
organisms could not be isolated and studied. In a
few of these instances a suspension of the whole
growth upon the plate culture was made, and a
portion of the suspension either rubbed over the
freshly scarified abdomen of a guinea-pig or inocu-
lated subcutaneously into a mouse. On several
occasions in which it seemed hopeless to determine
whether the plague bacillus was present or not on
the medium in the plate, owing to the extensive
contumination of the culture with bacteria other
than the plague bacillus, the guinea-pig so inocu-
lated died of plague. In some instances the plate
cultures were discarded because of very extensive
contamination, probably from air organisms which
covered the whole surface of the medium with a
very thick layer of growth. The ideal method
would have been to inoculate guinea-pigs by the
cutaneous method with light &carifieation of the
abdomen, with suspensions of the bacteriological
growth on all those plate cultures in which the
separate colonies could not be isolated, and in this
manner, perhaps, in others of these plate cultures
the presence of the plague baeillus might have been
demonstrated. There is no more delicate test
for the presence of the plague bacillus than this
procedure, and its efficacy is very great even when
92 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
the few plague bacilli present are extensively over-
grown by other micro-organisms. Unfortunately
the supply of guinea-pigs was limited to those
the authors brought with them and none could
be obtained in Mukden during the winter. Since
there were numerous other experiments to per-
form which also required the use of guinea-pigs
while in Mukden, a very limited number only could
be allowed for the present study. In the case of
all of the organisms which suggested in any way
the plague bacillus, and the colonies of which had
been transplanted to agar slants from the plates,
inoculations of guinea-pigs were made after the
authors returned to Manila.
During the colder weather in Mukden the plates
containing the agar, exposed before plague patients
during ordinary respiration, were frequently entirely
sterile. The plates were usually exposed vertieally
before the mouth and nose of the patient, the time
of exposure varying generally between two and five
minutes; usually the shorter period was employed.
In the experiments performed in the earlier part
of the investigation the plates were held at a dis-
tance of from 5 to 7 em. to 90 cm. or 1 metre from
the the mouth of the patient. Later in the experi-
ments, when it became evident that in cases with-
out eough during exposure no plague bacilli were
encountered at the greater distances, they were
exposed before cases which did not cough, usually
at a distance of from 5 to 18 cm. in front of the
mouth and nose. Before coughing patients the
distances varied from 5 cm. to 2 metres. A sum-
mary of the details of the experiments is given in
the report.
Of the eighty-two agar plates, eight were ex-
posed in the wards in the neighbourhood of
pneumonie plague patients; four before patients
who talked during time of exposure, and thirty-
five before patients who coughed during such
time. In thirty-nine instances plates were ex-
posed before patients who did not cough dur-
ing the time of exposure, and, notwithstanding
the fact that many of the patients suffered
with marked dyspnea and advanced cedema of
the lungs, in only a single instance was the
plague bacillus encountered in one of these plate
eultures, although in a number of the experiments
the surface of the medium was visibly wet by the
vapour arising from the breath.
In this one case the conditions of the experiment
were as follows : —
Three plates containing agar were all exposed at
& distance of about 7 cm. and for two minutes
before a patient with marked dyspnea, who died
two hours afterwards. A suspension of the bacterial
growth upon one of these plates, which covered
almost the entire surface of the plate, was made,
and a portion rubbed with the side of a scalpel over
the abdomen of a shaved guinea-pig and the skin
then freshly searified. The animal died of plague
infection six and a half days later; there were
inguinal buboes and miliary nodules in the spleen.
The animals inoeulated with the colonies from the
other two plates exposed in exactly the same
manner did not develop plague infection, The
(Mar. 15, 1913.
results obtained from the examination of this one
plate are different from those obtained from the
remaining thirty-eight plates exposed before patients
who did not cough. Two possible explanations of
the result suggest themselves: first, that the plague
bacilli reached the medium on the plate exposed
before the patient in the plague ward in some other
way than by the expired air from the patient; and
secondly, that the plate was infected with plague
bacilli by the droplet method through the forced
expirations of the patient during the time this one
plate was exposed.
The remaining number of plates (35)—in four
other instances the patients talked during the time
of the exposure, but no plague bacilli were demon-
strated on these plates—were exposed before
patients who coughed during the time of exposure,
and in fifteen instance colonies of plague bacilli
developed on the media in the exposed plates. In
some cases more than 100 colonies of this organism
were obtained upon the media after a single cough,
sometimes in almost pure culture.
Guinea-pigs, the abdomens of which had been
shaved and extensively scarified just before the
time of the experiment, were exposed before three
cases of pneumonic plague for a period of two
minutes and at a distance of 5 em. from the mouth,
the abdomen being placed toward the mouth. The
breathing of the patients in all of these experiments
was so laboured that the hair of the guinea-pigs
waved back and forth in the breeze made by the
expired air, but no cough occurred during the time
of the exposure. The animals remained alive, and
did not develop plague infection.
The results of our experiments are in accord with
the well-known bacteriological facts that bacteria
are not detached from moist surfaces by ordinary
currents of air, but that when sudden and forcible
currents of air are forced from a distance through
narrow apertures, as, for example, from the trachea
through the vocal cords, the tongue being against
the gums and teeth, or through the lips, as occurs
in talking or coughing, that small droplets of
mucus, frequently invisible, may be emitted. The
question of whether the expired air of patients
afilieted with pulmonary tuberculosis was infectious
was investigated particularly by — Nügeli and
Buehner, who demonstrated that such air was
sterile. Fliigge and his pupils, however, demon-
strated that by coughing tubercle bacilli were
emitted in droplets from about 40 per cent. of the
tuberculous cases examined. Cornet and Meyer,
after considering all of the experimental evidence,
concluded that droplet infection did not play an
important róle in the dissemination of tuberculosis.
In pneumonie plague the conditions are very
different, owing to the enormous numbers of plague
bacilli which are present in the lungs and bronchi.
In our experiments, performed with cases of marked
pulmonary cedema, the conditions were also
different. The opportunities for infection by means
of the droplet method must be very great in a pneu-
monie plague ward. The distance from the patient
that the air may be infected by droplets containing
plague bacilli would apparently vary up to certain
Mar. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
93
limits, particularly with the strength of the cough,
the amount of mucus in the throat and larynx at
the time, the size of the droplets emitted, the
currents of the air in circulation, and the tempera-
ture in the ward at the time.
Conclusions.
(1) During normal and dyspneic respiration of
primary pneumonie plague cases plague bacilli are
not usually expelled by means of the expired air.
(2) During coughing of such cases, even when
sputum visible to the naked eye is not expelled,
plague bacilli in large numbers may become dis-
seminated into the air surrounding the patient.
The idea that infection of doctors, nurses, attend-
ants, &c., in plague hospitals is caused entirely by
particles of sputum expectorated by the patient and
visible to the naked eye is erroneous. It follows
from these experiments that the wearing of masks
and the proper covering of any surface of the skin
where fresh abrasions are present are important
personal prophylaetie measures against plague in-
fection. It also follows that the eyes should be
protected against this manner of conjunctival
infection by proper glasses.
Articles of clothing worn in the wards should be
sterilized immediately after removal, since plague
bacilli may be present, even though no particles of
sputum may be visible upon them.
From these experiments, also, it is evident how
dangerous an infective agent a pneumonic plague
patient is. In no other disease is the individual
so dangerous, and in no other disease does the
danger from droplet infection approach that which
exists in pneumonic plague. The number of plague
bacilli expelled in droplets from pneumonic plague
cases is probably far greater than the number of
bacilli ever expelled by patients afflicted with tuber-
eulosis, croupous pneumonia, diphtheria, or in-
fluenza.
Manner of Spread of the Discase.—During the’
epidemic the disease was evidently spread directly
from man to man by droplet infection and by the
more or less intimate contact of healthy individuals
with an infected person. Whatever may have been
the primary source of the epidemic, its dissemina-
tion occurred entirely independently of tarbagans,
rats, donkeys, or any other animals.
The disease was introduced into uninfected
villages and towns by the importation of individuals
infected with pneumonie plague or by those in the
incubation period of this disease. No definite bac-
teriological evidence, that healthy carriers of the
disease with plague bacilli in their sputa existed
during the epidemic, has been produced. Oppor-
tunity occurred to examine two healthy individuals
who were supposed to have given rise to the disease
in other persons, but who themselves remained
healthy. The authors were unable to demonstrate
any plague bacilli in their sputum, and it was not
infective for guinea-pigs.
(To be continued.)
Tue PERMANGANATE TREATMENT OF SNAKE-BITE.
Lronarp Rocers (Indian Medical Gazette,
December, 1912) criticizes the preliminary report,
by Surgeon-General Bannerman, I.M.S., of the
latter's experiments on the permanganate treatment
of snake-bite. In the resumé of this work (Indian
Medical Gazette, October, 1912) it was stated that
"even four times the amount which serves to
neutralize cobra venom in a test tube will not with
certainty prevent fatal poisoning in an animal which
has received 10 minimal lethal doses, and that the
same quantitative relations obtained when daboia
venom was used." In reality, writes Rogers, this
afforded the strongest evidence in favour of the per-
manganite treatment. The full amount of venom
obtainable from a fresh vigorous cobra is just about
10 minimal lethal doses for a man; yet by
implication four times its weight of per-
manganate did in some cases prevent death
in animals that had received so large a dose
of venom. The cobra very seldom injects
its full dose into the human subject, and quantities
of permanganate very much larger than four times
the weight of the venom, can be applied—the well-
known necrotic effect on the tissues being nothing
compared with the chance of saving the patient's
life. As to daboia (Russell’s viper) not much more
than 1 minimal lethal dose for a man is injected
from freshly caught snakes when allowed to strike ;
so that in Bannerman's experiments nearly ten times
as much venom as is likely to be received by a
human being was successfully neutralized by the
small amount of permanganate used in the animals
referred to—facts very much in favour of the treat-
ment.
Rogers gives a table summarizing Bannerman’s
results on a number of dogs injected subcutaneously
with cobra and daboia venom respectively, and
shows clearly that the experiments show a uniform
recovery rate of from 50 to 83 per cent. The test
on dogs by subcutaneous inoculation was a very
severe one, for in aetual practice a ligature is
practically invariably tied above the bite in human
subjeets, which at once checks the absorption of
the venom.
In other experiments in which dogs were bitten
by venomous snakes, the doses received by them
would be so far in excess of anything possible in
human subjects, who form the vast majority of
cases in India, that they are of no practical value
whatever. The experimental injections were made
just under the skin, and the report emphasized the
faet that under natural conditions the snake's fangs
penetrate much more deeply, adding considerably
to the difficulty of treatment. Rogers states that
this is only true in those exceptional cases where a
daboia, or possibly an Echis carinata, which have
mueh longer fangs than the minute ones of cobras,
happens to strike a fleshy part. In three-fourths of
a large number of cases collected by him, the bite
was on the hand or foot, nearly invariably on a
finger, the dorsum of a foot, or the ankle, where
there is no great depth of tissue, which makes
94 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 15, 1913.
treatment easy. Moreover, the orifice of escape for
the venom not being at the tip of the fang, but a
little way up on the anterior surface; in such situa-
tions it would be very difficult for the snake to
inject its full quantity of venom. Indeed, he had
a record of a patient, successfully treated by Sir
Lauder Brunton's snake lancet by a layman, after
being bitten by a daboia in three places on the
fleshy part of the upper arm.
Rogers’s experiments with cats in 1908 showed
clearly the value of permanganate treatment. Dogs
were unsuitable for such experiments, for it was
well known, as demonstrated by Fayrer's classical
experiment, that they absorb cobra venom with
extreme rapidity. If Dannerman's experiments
are to be held to prove that the method is of no use
in dogs, then in view of Rogers’s greater success
with cats, the question beeomes whether the treat-
ment is of any value in man, and this must ulti-
mately be decided by actual experience. Rogers
gives a table of twenty-one cases of snake-bite, in
every one of which the snake was identified. The
table includes a number of cases of bites by the
commonest deadly snakes of India, cobras, kraits,
and daboias. Of the twenty-one, twenty were
recoveries—conclusive proof that the permanganate
treatment has saved the lives of a number of per-
sons bitten by undoubtedly poisonous snakes.
Such a lengthy series cannot be explained away
by supposing that in none of them did the patient
receive a lethal dose.
As to intravenous injection of antivenine, it must
be borne in mind that to neutralize the full amount
of venom that may be injected by a cobra about
three-quarters of a pint of serum (probably con-
taining a lethal dose of horse serum), is required.
a Ü Gia ÀÀMÀ
Hotes and Hews.
LIVINGSTONE COLLEGE AND THE LIVING-
STONE CENTENARY.
LirviNGsSTONE CoLLEGE, which was founded in the
year 1893, in order to give instruction to foreign
missionaries in the elements of medicine and sur-
gery, and constitutes a permanent memorial to Dr.
Livingstone in the neighbourhood of London, has
issued an illustrated souvenir in connection with
the Centenary of Dr. Livingstone’s birth, which
took place at Blantyre in Scotland, on March 19,
1813. The souvenir contains two coloured por-
traits, one from an oil painting by Mr. Maleolm
Stewart, and the other from a crayon drawing from
a photograph, both of them in the possession of
Livingstone College. These are considered by
many to be the best portraits available. The sou-
venir also eontains a tasteful reproduction of the
Livingstone Memorial Poem from Punch, of April
25, 1874, which is reproduced by the courtesy of
the proprietors; also an inscription from the tree in
Central Africa carved by Livingstone's native fol-
lowers at the place where his heart was buried.
The actual inscription is now in the possession of the
Royal Geographical Society. There is also a repro-
duction of the inscription on Livingstone's tomb
in Westminster Abbey, and a collection of sayings
from Livingstone's writings, besides a picture of
Livingstone College.
The College is appealing for a sum of £10,000 in
order to meet various needs, one of which is to
clear off a mortgage of £3,500. £1,500 is needed
for making certain improvements, whilst it is
desired to raise £5,000 as the nucleus of an endow-
ment.
Livingstone College has in the past received
support from a very small circle of those who have
been interested in its work. It is felt that the
occasion of the Centenary is one when the public
who recognize the great services rendered by Dr.
Livingstone to the nation and to the civilized world
may be glad to unite in the support of a memorial
which could not fail to be in accordance with the
wishes of Dr. Livingstone.
The fact that fifty-three missionary societies have
at different times taken advantage of the course of
training given at Livingstone College for the benefit
of their missionaries, 446 of whom have been
enrolled as students of the College, indicates that
the work is arranged on no narrow basis, and should
appeal to the wider circle who are joining in the
celebration of the Centenary.
The family of Dr. Livingstone have from the first
expressed their keen interest in the College, and
given it their cordial support.
In many ways Livingstone College has also helped
forward the cause of exploration and travel by the
information which it has circulated concerning the
laws of health and the preservation of disease in
tropical climates. This has been recognized by
the Royal Geographical Society on many occasions,
and on Deeember 17, 1912, the Secretary of that
Society wrote stating that the Council ''are fully
in sympathy with the proposals of the Committee
of the Livingstone Centenary Fund." Sir John
Kirk and Sir Harry Johnson have both written
warmly supporting this proposal.
Partieulars concerning the College may be
obtained from the Prineipal, Livingstone College,
Leyton, E., who will also be pleased to give in-
formation concerning the souvenir which is issued,
price 6d., and also concerning Centenary postcards
which have been prepared from the two coloured
portraits appearing in the souvenir. These may be
obtained price 1d. each, post free lid.
The British Guiana Medical Annual for 1911 con-
tains a number of interesting papers. The follow-
ing is a list of the contents: (1) ‘‘ The Narcotics
and Stimulants of the Guianese Indians," by
Walter E. Roth (Commissioner of the Pomeroon
District); (2) ‘‘Trichosporosis Nodosa,"" by J. W. H.
MacLeod, M.D. (Reprinted from the British Journal
of Dermatology, April, 1912); (3) “ A Case of Tinea
Cruris in British Guiana,” by J. H. Conyers, M.B.,
C.M.Edin.); (4) *' Causes of Cough,” by Mrs. E. M.
Minett, M.B., B.S.; (5) ''The Treatment of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 95
Mar. 15, 1913.)
Leprosy by Nastin and Benzoyl Chloride,” by E. P.
Minett, M.D., D.P.H.; (6) ‘‘ Studies in Enteric
Fever," by K. S. Wise, M.B., B.Sc., D.P.H.; (7)
"The Frequency of Bacillus Violaceous in the
Water and Milk Supplies of British Guiana," by
E. P. Minett, M.D., D.P.H., D.T.M. and H; (8)
“ Review of the Milk Question in British Guiana,”’
by K. S. Wise, M.B., B.S., B.Sc., D.P.H., and
E. P. Minett, M.D., D.P.H., D.T.M. and H.; (9)
** Myiasis," by F. E. Field, M.D., D.P.H. Part
II.—'' Clinical Notes,” by Drs. Robertson, A. C. L.
La Frenais, T. B. MacQuaide, F. E. Field, and
K. S. Wise. Part III.—''Transaetions of the British
Guiana Branch of the British Medical Association
for 1911 and 1912 "' (App.). Part IV.—'' The Public
Health Statistics and Medical Institutions of the
Colony ” (App.).
ae
Acvicts,
THE BACTERIAL DISEASES OF RESPIRATION, AND
VACCINES IN THEIR TREATMENT. By R. W.
Allen, M.D., B.S.Lond., London: H. K. Lewis,
136, Gower Street. 1913.
In his preface the author describes the scope of the
book. Most of the contained matter has already
appeared as a series of articles in the numbers of the
Journal of Vaccine Therapy from February, 1912, to
January, 1913, inclusive. Fresh matter has now been
added to these articles, while important additions have
been made in the section dealing with pulmonary
tuberculosis. One chapter (xi) is entirely new. The
subject is an important one and the author, with his
great experience of it, is certainly the man to write
about it. The book is worthy of close study. Dr.
Vincent’s photographs and micro-photographs which
illustrate the text are excellent.
THE BIOLOGY OF TUMOURS. (The Bradshaw Lecture
delivered at the Royal College of Surgeons,
December 5, 19129) By C. Mansell Moullin,
M.A., M.D., F.R.C.S., Consulting Surgeon to the
London Hospital. London: H. K. Lewis, 136,
Gower Street, W.C. 1913.
A very interesting account of present day knowledge
of the biology of tumours. The author divides tumours
up into two classes: (1) Those which spring from
germ-cells and possess a more or less complete in-
dividuality ; and (2) those which spring from somatic
cells and are due to the escape from control of what
remains to them of their primitive power of growth.
The question of inheritance of tumours and other in-
teresting points are also dealt with.
Turk MosquiTOo, irs RELATION "TO DISEASE AND ITS
ExrERMINATION. By Alvah H. Doty, M.D.,
formerly Health Officer of the Port of New
York. Illustrated. New York and London:
D. Appleton and Company. 1912.
_A useful little manual on the mosquito, its rela-
tion to disease and its extermination. Educative
manuals of this type are urgently required now, in
order to make the laity take an intelligent interest
in the subject.
Teaching in schools should also be adopted, for
by training the children they will grow up fully
realizing the importance of mosquito destruction.
In the part of the manual dealing with remedies for
bites, ‘‘ clean fresh earth," whatever that may
mean, should certainly be deleted as a remedy for
relieving the discomfort of the bites—the dangers
of tetanus are obvious. The manual is well illus-
trated, chiefly by means of Howard's well-known
diagrams.
CLINICAL BACTERIOLOGY AND — HiEMATOLOGY FOR
Practitioners. By W. D'Este Emery, M.D.,
B.Se. H. K. Lewis, Gower Street, London.
Fourth Edition, 1912. Pp. xv. + 274. Price
7s. 6d. net.
Since its appearance in 1902, this book has gone
through three editions. The purpose the author
had in writing it in the first instance was to enable
the practitioner, by giving exact methods of proce-
dure, to acquaint himself with the various manipu-
lations employed in bacteriology and hæmatology,
and to help him in his everyday practice. The teach-
ing is so precise in detail, and so readily under-
standable,that any practitioner, however elementary
his training in methods of laboratory diagnosis may
have been, is enabled to set to work and educate
himself in all the essentials necessary for investi-
gating the ordinary ailments he meets with in his
practice. Part I deals with Bacteriology, Part II
with Hematology, and Part III with Cyto-
diagnosis. With Dr. Emery’s book at hand the
practitioner is in a position to equip a small labora-
tory in his own home at a minimum cost, to
prepare culture media and cultures, to stain speci-
mens, and to recognize the stained organisms
microscopically. In the hematology section of the
work an accurate guide is given to ensure exact
blood counts being made and to the interpretation
attending to blood counts as a whole. The book is
a useful one, well illustrated and clearly printed.
Stuptes 1N SMALL-POx AND VACCINATION. By
William Hanna, M.A., M.D., D.P.H.,
Assistant Medical Officer of Health for the
Port of Liverpool; Visiting Physician to the
Port Isolation Hospital. Bristol: John Wright
and Sons, Ltd. London: Simpkin, Marshall,
Hamilton, Kent and Co., Ltd. 1913.
The author states in his preface that his studies
on the subject of small-pox and its prophylaxis by
vaccination have been the outcome of several years
of observation of cases which have occurred in the
City and Port of Liverpool.
Ample opportunity has been afforded for this
study from the unique position of Liverpool as a
shipping centre and the great tide of alien traffic
which flows through it. The first and second parts
of the work deal with the ever-important problem
of the value of vaccination in preventing and
mitigating attacks of this dreaded malady, and the
inverse relationship of scar-area to severity of attack
is pointed out. The final portion deals with con-
current small-pox and vaccination, a very important
and interesting subject.
The author hopes that his book will appeal to
medical officers of health, vaccination officers, and
those in charge of infectious disease hospitals. In
addition, he believes that general practitioners may
find it useful in furnishing illustrations of cases of
small-pox.
It is certainly handsomely illustrated by a very
excellent series of photographs, which are highly
realistic, and give a very clear conception of the
disease, and as the written matter is equally good
and clear the work undoubtedly has a good future
before it.
A TREATISE ON HYGIENE AND PunLic HEALTH, WITH
SPECIAL REFERENCE TO THE Tropics. By
Birendra Nath Ghosh, L.M.S. (Cal. Univ.),
and Jahar Lal Das, L.M.S. (Cal. Univ.); with
an Introduction by Colonel Kenneth Macleod,
I.M.S. (retired). Hilton and Co., Calcutta.
1912. All rights reserved. Price Hs. 3-8 or
5s. net.
This new addition to our list of text-books on
Hygiene and Publie Health, especially as it relates
to the Tropics, will be welcomed. As Colonel
Macleod says in his Introduction, the work is well
fitted for use as a text-book in colleges and schools,
and both medical men and laymen may derive
instruction and profit from its perusal. Its exposi-
tion is clear and its arrangement orderly, and in all
this the writer of the review agrees. There are
wonderfully few statements in it with which one
ean find fault, though in the part dealing with
infectious diseases a few minor inaccuracies appear.
For example, there is no doubt about the malignant
quotidian malaria parasites forming crescents.
Again (p. 311) it is not the zygote that penetrates
the stomach wall, but the travelling vermicule, and
this latter body does not form a wormlike structure
when it comes to rest there, but a rounded or oval
one—the oócyst. On p. 313 the statement is made
that mosquito-proof houses are prohibitive in their
eost and only applicable for some big houses and
bungalows, and cannot be used universally. This
is, of course, only partially true; many small houses
can easily be fitted up with wire gauze at a com-
paratively small cost, and it is to be hoped that
statements of this kind will not become fixed in
the minds of the laity. On p. 317, re the cultiva-
tion of fish for keeping down mosquitoes, it is
stated that the existence of ''millions ’’ around
the islands of Bermuda and Barbados is the cause
of the absence of malaria and mosquitoes in those
places. These small fish, of course, are present
in the fresh-water collections in the islands, not in
the sea around them. Little points such as these
make or mar a work, and therefore it is necessary
to point them out. The work is not intended to
replace any of the standard works on the subject,
only to supplement them, and it should do this in
& very satisfactory manner. The chapters on
“ Disposal of Refuse,” ‘‘ Sewage ’’ and the
* Dead," are all excellent, as are many of the
others, and the authors must be congratulated on
their suecessful effort.
96 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 15, 1913.
Tue Secretary of State for the Colonies has
appointed Lieutenant-Colonel Sir William B.
Leishman, M.B., C.M.Glas., R.A.M.C., F.R.S.,
Professor of Pathology at the Royal Army Medical
College, London, to be a member of the Advisory
Medieal and Sanitary Committee for Tropical
Africa.
— Qe
Personal Hotes.
Inpia OFFICE.
From January 25 to March 1.
Arrivals reported in London.—Lieutenant-Colonel R. H.
Castor, I.M.S.; Major W. D. A. Keys, I.M.S.; Captain N. D.
Mackworth, I.M.S.; Captain J. G. F. Paterson, I.M.S.;
Captain J. A. S. Phillips, I.M.S.; Captain H. Ross, L M.S.;
Major T. E. Watson, I. M.S. ; Lieutenant-Colonel L. F. Childe,
I.M.S.; Captain A. N. Dickson, I.M.S.; Captain J. Woods,
I.M.S.
Extensions of Leave.— Lieutenant-Colonel C. Duer, I.M.S.,
6 m. ; Major M. MacKelvie, I.M.S., 5 m. ; Captain C. F. Marr,
I.M.8., 8d.
List or IND1AN Civic OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER Civi, RULEs).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Castor, Lieutenant-Colonel R. H., I.M.S., Burma, 6 m,
November 26, 1912,
Childe, Lieutenant-Colonel L. F., I.M.S., Bo., 12 m , January
19, 1918.
Hirsch, Captain L., I.M.S., M., 18 m., January 2, 1913.
Keys. Major W. D. A., I, M.S.
Mackworth, Captain N. W., I.M.S., Behar and Orissa,
15 m., November 18, 1912,
Molesworth, Lieutenant-Colonel W.,
December 15, 1912.
Nutt, Captain H. R., I.M.S., U.P., 12 m., September 19,
1912.
Pridmore, Lieutenant-Colonel W. G., I.M.S., Burma, 24 m.,
December 11, 1912,
Robinson, Lieutenant-Colonel W. H. B., LM.S., 12 m.,
November 7, 1912.
Ross, Captain H., I. M.S., U.P., 24 m., November 20, 1912.
Weinman, Major C. F., I.M.S., B., 13 m. 14 d., October 3,
1912.
I.M.S., M., 12 m,
List or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and ihe Period
for which the Leave was granted.
Dawes, Major C. D., I.M.S., to December 24, 1913.
Dickson, Captain A. N., I.M.S.
Middleton-West, Captain S. H., I.M.S., to December 10,
1913.
Nelson, Captain J. J. H. I.M.S., to December 13, 1913.
Paterson, Captain J. G. F., I.M.S.
Phillips, Captain J. A. S., I.M.8.
Quirke, Captain M. J., I.M.S., to May 28, 1913.
Sharman, Major E. H., I.M.S., to July 31, 1913.
Watson, Major T. E., I.M.S.
Woods, Captain J., I.M.S.
Dr. E. W. Graham, Senior Medical Officer of Northem
Nigeria, has been transferred to the Gold Coast Colony.
Slotues to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing iv is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers,
5.—Correspondents should look for replies under the heading
“ Answers to Correspondents,"
e
April 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 7, Vol. XVI.
Original Communications.
POROCEPHALIASIS IN MAN.
By Lovis W. Samson, M.D., F.Z.S.
Lecturer to the London School of Tropical Medicine.
(Continued from p. 374, vol. zv, 1912.)
Description of Parasite.—Porocephalus clavatus, Wyman
(figs. 9— 12) is greyish-white in preserved specimens and yellow-
tinged during life. Its body is claviform, elongated, more or
less incurved. The cephalic extremity is rounded anteriorly,
somewhat flattened ventrally and strikingly gibbous on the
dorsal aspect. The tapering posterior portion terminates with
Fic. 9.—Porocephalus clavatus 2. x 2
a slight, bulb-like obconical expansion. The largest female
specimen examined by me measures 75 mm. in length, 44 mm.
across the widest part of the anterior extremity, aud 23 mm.
across the narrowest part of the posterior end just before the
terminal swelling, the diameter of which is 3 mm. My
largest male specimen measures 25 mm. in length and 2 mm.
in greatest width. Larger specimens have been observed.
Thus Leuckart mentions a female 80 mm. long and a male
36 mm. long; and Wyman, a female 89 mm. long and a male
38 mm. long. The annulation is distinctly visible throughout
the length of ithe ibody except on the dilated terminal portion.
It consists of from 35 to 40 and occasionally 43 or 44 annuli,
gradually diminishing in size posteriorly, Van Beneden
counted 35 to 87 in his specimens, MacAllister 40 to 45,
Leuckart ‘‘ about 40," and Leidy ‘40 or fewer." Stiles found
35 to 43 annuli in females, 38 to 40 in males. In fully dis-
tended mature females the annulation becomes almost effaced
and the closely packed and tangled coils of the enormously
elongated uterine tube show quite clearly through the thinned,
transparent cuticle, The cephalothorax is short (about 2mm.
long in my largest specimen) rounded anteriorly, slightly
convex, flat or concave on the ventral surface, prominently
~~
U
Fic. 10.— Porocephalus clavatus g. x 3.
Fia. 11. —Porocephalus clavatus 2.’ Ventral aspect of
cephalothorax.
convex on the dorsal surface. The mouth is almost oval.
The hooks are about equal in size, sharply curved and with
robust points, they are longitudinally striated and measure
about 3 mm. in length. The inner hooks are simple, but the
two outer ones are each provided with a permanent, almost
straight accessorv-spine, placed on their back, like the point
over the hook of a boat-hook, or the spear over the axe of a
halberd. ; :
The anal and reproductive orifices in the female open con-
jointly in a subterminal slit placed on the mid-ventra surface,
with its long axis transversely to that of the body. In the
` 98 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1913.
male, the anus is subterminal, the sexual opening is at the
antérior end of the body on. the first or second abdominal
segment;- It is plainly visible in the mid-ventral line, forming
a prominent cone tipped by three papilla: two anterior, one
posterior. i
Fic. 12.—Porocephalus clavatus d . Showing genital opening.
V.—POROCEPHALUS STILESI (Sambon, 1909).
SYNONYMS,
1824.—Pentastoma proboscideum, Bremser (in part
only).
1850.—Pentastomum proboscideum, Diesing (in
part only).
1852.—Linguatula quadriuncinata, Mayer (in part
only).
1893.—Porocephalus crotali, Stiles (in part only).
ZOOLOGICAL DisTRIBUTION.*
Adult Form.
*Lachesis mutus (Linn.) Surucucu or Bush.
master.
Lachesis lanceolatus (Lacep.), Rat-tailed pit-viper
or Fer-de-lance.
Nymphal Form.
Unknown.
GEOGRAPHICAL DISTRIBUTION.
Central and Tropical America.
ANATOMICAL HABITAT.
Lungs.
HISTORICAL Account.
This species was collected by Natterer in 1821,
at Ypanema (S. America), from the lungs and
body cavity of Bothrops jararaca (= Lachesis
lanceolatus), and depicted by Bremser (1824) in his
" Icones Helminthum," pl. X, figs. 22-24, where
it erroneously appears together with Linguatula
subtriquetra under the name of Pentastoma pro-
boscidcum.
Diesing . (1835) enumerates Bothrops jararaca
(=Lachesis lanceolatus) amongst the hosts of Pen-
tastoma proboscideum, and of the figures he gives
to illustrate this species some (pl. III, figs. 87-41)
are of linguatulids taken from the lungs of Lachesis
* Signifies that I have examined specimens of the parasite
from the host in question,
lanceolatus, others (pl. IV, figs. 1-10) from lingua-
tulids found in the body cavity of the Great Teju
(Tupinambis teguexin).
Mayer (1852) mentions finding twelve specimens
of this species in the lungs of a Lachesis rhom-
beata (= L. mutus). He does not describe these
linguatulids, but merely states that they were
‘ quite similar to those found by Humboldt in the
lungs of Crotalus durissus." Mayer suggests chang-
ing the name of Pentastoma proboscideum Rud.
into that of Linguatula quadriuncinata. He does
Fic. 13,— Porocephalus stilesi 9. x 2.
not propose the new name as a particular specific
designation for the linguatulids of the Bush-
master (Lachesis mutus), but only as a more
appropriate name for the parasite discovered by
Humboldt in the Cumana rattlesnake (Crotalus
terrificus), and to which, like Bremser and Diesing,
he ascribes also the linguatulids of the viperine
snakes belonging to the genus Lachesis.
Cobbold (1859), in Transact. Linn. Soc., vol. 22,
p. 164, states that he had the opportunity of
examining a speeimen of Pentastoma proboscideum,
April 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 99
found by Mr. Edwards, of Edinburgh, in the
mesentery of an undetermined species of Bothrops,
but was unable to add ‘‘any new or otherwise
interesting facts."
Description of Parasite.—Though more uniform in diameter
throughout and with a more rounded terminal swelling,
Porocephalus stilesi (figs. 13, 14 and 15) is similar in form
of body and general appearance to Porocephalus crotali (sensu
stricto) and Porocephalus clavatus, Wyman, but differs from
both in the number of annulations, "These, which are over 80
in Porocephalus crotali and only about 40 in Porocephalus
clavatus, number from 45 to 50 in Porocephalus stilesi. I
have had the opportunity of examining several specimens of
both Porocephalus clavatus and Porocephalus stilesi, some
collected by myself at the Lordon Zoological Gardens, others
Fic. 14.— Porocephalus stilesi g. x 3.
preserved in the museums of London and Paris, and I have
found the above mentioned ring numerations to be quite
constant in the respective species.
In some Tongueworms, such as Porocephalus armillatus and
Porocephalus moniliformis, the number of annulations is always
greater in the female; in others, as for instance in Porocephalus
teretiusculus, according to Spencer (1893), it is greater in the
male (9 65—70, d about 88). In both Porocephalus clavatus
and Porocephalus stilesi there seems to be no numerical differ-
ence in the annulation of the two sexes save that of individual
variation which, within restricted limits, is common to all
species. Thus, in nine examined specimens of Porocephalus
clavatus the numbers were as follows: 9 --35, 38, 38, 40, 43;
d —35, 36, 39, 41; and in twelve specimens of Porocephalus
stilesi, Q —45, 45, 46, 47, 48, 50, 50 or 51; d —40, 46, 47, 47,
49. The examined specimens of Porocephalus clavatus were
taken from various specimens of Boa consírictor captured in
different localities. Those of Porocephalus stilesi were taken
some from various specimens of Lachesis mutus from Trinidad
and others from various specimens of Lachesis rhombeata from
different parts of Brazil. :
The largest mature female specimens of Porocephalus stilesi
examined by me measure from 80 to 96 mm. in length by
5 to 6 mm. across the widest anterior portion, and 44 to 5 mm.
across the widest portion of the -terminal swelling. The
narrowest portion of the body measures about 4 mm. The
largest male specimens 80 to 38 mm. in length, by 34 to 4 mm.
across the anterior end, and 14 across the narrowest part of
. the posterior extremity.
The mouth is ovoid and placed with the narrowest end fore-
most. The outer hooks measure $ mm. in length, and are
provided with a straight, pointed accessory spine, The inner
ones are simple and slightly larger. .
The anal and sexual orifices in the female open conjointly in
a subterminal slit about 3 mm. long placed on the mid-ventral
surface with its long axis transversely to that of the body. In
the male the reproductive opening is on the first body ring.
RS
/ es Ts oe?
Fic. 15.— Porocephalus stilesi. Ventral surface of
cephalothorax.
Fic. 16.—Porocephalus wardi after Diesing.
VI.—POROCEPHALUS WARDI (Sambon, 1909).
SYNONYMS.
1885.—Pentastoma proboscideum, Diesing (in part
only).
1850.—Pentastomum proboscideum, Diesing (in
part only).
1898.—Porocephalus crotali, Shipley (in part only).
ZOOLOGICAL DISTRIBUTION.
Tupinambis teguexin (Linn.), Common Teguexin
or Great Teju.
GEOGRAPHICAL DISTRIBUTION.
South America.
ANATOMICAL HABITAT.
Found in abdominal cavity.
100
[April 1, 1913.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
HISTORICAL ACCOUNT.
This linguatulid (fig. 16) was found by Natterer,
in the abdominal cavity of a Podinema teguexin
(Tupinambis teguezin). Two males and one female
were found 3 in. to 6 in. long. They are mentioned
by Diesing and ascribed to the species (Porocephalus
crotali) found by Humboldt in Crotalus terrificus.
They are even delineated on pl. IV, figs. 1-10, as
illustrations of this species together with other
linguatulids from Bothrops jararaca (Lewhesis lance-
olatus).
Diesing (1850), in his “ Systema Helminthum, "
again mentions the Great Teju amongst the hosts
of Porocephalus crotali.
Shipley (1898), following Diesing, also mention:
Tupinambis teguezin amongst the hosts of Poro-
cephalus crotalt.
Diesing’s drawings of the linguatulid of the Great
Teju, coupled with the very scanty information given
in the text, show that the parasite is an immature
form, 7 to 13 mm. long, with about forty-five rings,
and in no way corresponds to either Porocephalus
crotali (sensu stricto) or to any of the other species
(P. clavatus, P. stilesi) already separated from it.
Therefore, in 1909, I suggested that it might be a
distinct species, and proposed for it the name of
Porocephalus wardi.
SOME NOTES ON TROPICAL DISEASES
OBSERVED IN THE REPUBLIC OF
COLOMBIA.
By Dr. J. Martinez SANTAMARIA.
Bogota, Colombia.
Tue following short note is written about certain
diseases which are of interest owing to their clinical
manifestations or to their being unknown in Europe.
Bubas (Yaws, Tropical Frambcesia).—A disease
limited to some of the warm regions of the Republic
and absolutely unknown in the cold districts. It
is a quickly spreading disease and is contracted by
children more easily than by adults. It is spread
either by direct contact or is mechanically trans-
mitted by flies or mosquitoes; and it very often
happens that a whole family in a house is affected.
The disease always appears as a small nodule
near the mucous surfaces or at the edges of wounds,
and it never has a genital origin. The nodule
grows and ulcerates, forming what is called
amongst us ''Buba madre " (Mother of Buba).
Later on the disease generalizes with or without
fever, showing a granulomatous frambcesiform
eruption. This is followed by a calm period, which
in turn is succeeded by crops of '' bubas,’’ ending
in the second or third year by giving the patient
complete immunity.
In the purulent yellowish liquid covering the
ulcerations the spirocheta of Castellani is always
found in abundance.
In the localities where the disease is endemic
fowls are often affected by a severe epidemic condi-
tion very similar to the human ''bubas." This
disease is characterized by the appearance of a
quickly-growing granulomatous nodule on the cocks-
comb, which is followed by several others near the
ear and eyelid. The head swells, the nodule
uleerates, the animal develops u peculiar appear-
ance, and dies in a week's time. The post-mortem
does not show any microscopical change in the
organs. All researches to find the specific germ
have failed; but the inoculation of fowls from the
serum, pus, or liquid has been successful, the
symptonis appearing in between five und eight days.
Toro unsuccessfully inoculated human ‘* bubas '
into fowls.
Bubon de Velez.—4A contagious
known in the Province of Velez,
derives its name.
This disorder commences with a small nodule
near the mouth or nose. It quickly develops and
uleerates, spreading all over the nearest tissues
and destroying them. The clinical appearance is
that of tubercular lupus. No surgical or medical
treatment is able to stop or modify its development,
and the patient dies from septicemia or inter-
current disease.
It is sometimes observed that new nodules appear
in the course of the disease far away from the
original one; and these are of an analogous
symptomatology to that previously described.
Espundiu.—This name is given to a disease
characterized bv the appearance of one or more
nodules in the skin of the head, face, hands, and
feet. The nodule is generally hard, about the size
of a pea, and attached to the skin by a long
pedicle. It suppurates, leaving, as a rule, a small
erosion, difficult to heal.
The only way to effect its eure is the incision
of the nodule. Our country people obtain the same
result by making a strong ligature with a hair.
Carate (Pinta).—This skin disease is endemic in
hot and damp districts and attacks men, women,
and children without distinction. The disorder
begins with the appearance of small chromatic
patehes on the face, thorax, abdomen, arms and
legs, which spread over a large area, staining it
black, white, or blue, and there are frequently to
be seen on one patient two or three discolorations
at the same time.
The characteristic of the patches is that they are
chromatic and exclusively localized to the skin,
while no itehing or pain is produced.
Montoya y Florez has isolated three varieties of
aspergillus corresponding to each of the three types
of earates. Those fungi, cultivated in a proper
medium, grow, producing blue, black, and white
pigment.
Urticaria.—A tree grows in our forests known as
' Pedro Fernandes” and ''Mansanillo," under
the shade of which nobody ean rest, as they are
attneked generally on the exposed parts of the body
by urticaria, which is extremely painful. In the
majority of cases the trouble disappears within
twenty-four hours, but it is not infrequent to see
patients suffering for two or three days.
This tree contains a substance analogous to that
of the ‘‘ urtica urense," which, when it comes in
disease only
from which it
April 1, 1913.]
contact with the skin produces the above-mentioned
phenomena.
Syphilis.—This disease acquires an exceptional
virulence in the hot districts; primary and
secondary lesions are soon over; the tertiary stages
in most cases produce bone lesions and gummata.
Lepra (Leprosy).—This was unknown in Colom-
bia before the Spanish Conquest, when it first
appeared.
It occurs in both cold and warm districts, and
is most frequent amongst persons subjected to
sudden changes of temperature, such as cooks,
ironers, bakers, &c. The clinical forms usually seen
are the tubercular and the maculo amesthetic
types.
Our patients are kept in lazarets, and those who
were treated ten years ago with Carrasquila’s serum
have improved considerably.
Sometimes patients get well with no treatment
at all, and others after having small-pox or
erysipelas.
Fish cannot be considered as the cause of this
disease, as in most of the places where it is endemic
fish is not used as food.
Fiebre amarilla (Yellow Fever).—This occurs
endemically and at long intervals along the Atlantic
Coast, Cucuta, all along the shores of the Magdalena
River, and at the Muzo Emerald Mines. The
last focus is important, as it is situated right in
the middle of the country, and in an uncultivated
and isolated zone, with no possible communication
with the Magdalena River, from which it is
separated by thick and immense forests. The
epidemic there is quite independent of the other
focus. For the last ten years we have not had a
single case in the Magdalena zone, while in Muzo
three epidemies have been recorded.
Fiebre recurrente. (Relapsing Fever, discovered
amongst us by R. Franco).—We have the European
as well as the African form, but the latter is, per-
haps, more frequent. In all the cases studied by
us the spirocheta has been found, and the experi-
mental inoculations performed on white mice by
R. Franco and G. Toro have been positive at the
third day, with no fever reaction, the parasite dis-
appearing from the blood in the course of twenty-
four to forty-eight hours.
In most of the cases it has been observed that
on the eighth or ninth night before the appearance
of the fever the patient has passed a very bad night
owing to the bite of '' Chinches " (Ornithodorus
moubata (?*) Post-febrile sequele may be got in
some cases, iritis often being noticed.
Paludismo (Malarial Fever).—4All its varieties are
known in Colombia. Some of its clinical types
predominate in special zones. In Puerto Wilches,
Chueuri, Patiachoco, &e., pernicious forms are
endemic, while in other places the mild tertian
is found; and, finally, in Mompox, the hwmatozoon
at a certain time of the year acquires an extreme
virulence, the patient sometimes dying during the
rigor.
Ele phantiasis—Up to date Filaria bancrofti has
* Argas persicus probably ia meant.—Ep.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
101
been found only in Cartagena, where elephantiasis
of the scrotum (potra) is also seen.
Trypanosomiasis.—In Tolima, Cauca, and Los
Llanos horses and mules are decimated by a disease
called ‘‘ Renguera," the symptoms of which are
paralysis of the hinder parts. The disease is due to
a trypanosoma.
Esplenomegalia tropical (Tropical Splenomegaly).
—A disease the clinical manifestations of which are
exactly the same as those of kala-azar occurs, but
Leishman-Donovan bodies have not yet been
found.
Fiebre hemoglobinurica (Black-water Fever).—
This complaint is observed amongst those attacked
by chronic malaria, in which cases the hematozoon
found in the blood disappears at the outset of the
disease, reappearing later on. In many cases
quinine is not taken when the disease commences.
Beriberi.—This disease predominates on the
Pacific Coast. The rice theory is not believed in,
as this food is not used in some of the places where
the cases appear.
Disenteria (Dysentery).—In the hot districts
chronic dysentery (amebic) is daily observed, often
followed by hepatie abscesses in many of the cases.
The bacillary form is extremely toxic and the
patients die within a week with septicemic or peri-
toneal symptoms. Shiga’s serum applied in large
doses (90 c.c.) sometimes gives splendid results.
Tun-tun (Ankylostomiasis).—No doubt this is one
of the diseases which occurs most in our country,
with the exception of the mountainous districts,
where the temperature only reaches 169 C. It is
common on the sugar and coffee estates, where
95 per eent. of the inhabitants are infested with
the parasite.
Both Ankylostoma duodenale and. Necator ameri-
canus are found, the latter predominating. Gener-
ally speaking, the ankylostome is found in people
from the centre of the country and the necator in
those from the seaside or Los Llanos.
The beginning of the disease is the water itch
(sabafion), followed by progressive anemia and
gastro-intestinal disturbances. The number of red
corpuscles per cubic millimetre and the amount of
hemoglobin are reduced enormously. The leuco-
cytes are usually not increased per cubic millimetre,
but the eosinophiles and large mononuclears are
always relatively increased. The gastric juice is
much reduced in acidity. An increase of the urea
in the urine is always observed, and sometimes there
are traces of urobilin and albumin.
According to the predominating symptoms, Tun-
tun is divided into the following forms: (Edematous
or beriberic, dysenteric, diarrheeic, dyspeptic, renal,
icteric, and febrile; the last is sub-divided into
regular, irregular, and continued,
The drug which has given best results is thymol,
with a dose of 4 grm., repeated four or five times.
In nearly all mules and horses from the hot districts
of the country an ankylostomum is found which
weakens the animal considerably.
Trichoce phaliasis.—The presence of the Tricho-
cephalus dispar, when in great numbers, produces
anemia and intestinal symptoms analogous to those
102
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1913.
produced by the ankylostomum. The lacteous
juice of Higueron (Ficus glabra) in.a dose of 40 c.c.
gives .most wonderful results in expelling these
worms.
Schistosomum haematobium, Echinococcus granu-
losus, Bothriocephalus latus.—Lesions originated by
these parasites are unknown, but Ascaris lumbri-
coides, Ozyuris vermicularis, Twnia solium, and
T. saginata are very frequent.
Ceguera (Purulent Ophthalmia).—A purulent
and contagious ophthalmia appears in some regions
in the Tolima, and is so virulent that it frequently
produces complete blindness. The appearance of
this disease coincides with the presence of a very
small mosquito, which mechanically transmits the
disease by its contact with the conjunctive.
Cuellar describes a coccus as the agent of ceguera.
Piedra de Colombia.—lt fell to the lot of Nicolas
Osario to discover a hair disease localized in the
east of Boyacá, known as Piedra, characterized by
one or more small hard lumps, like pieces of stone
in the hair, and more frequently in the moustache
and beard.
Chichismo (Josue Gómez's Disease).—In some
places in the cold climate (16° C.) the lower classes
have an aleoholie drink called chicha, prepared in
the following manner. Indian corn (maize), after
being roughly ground, is left to ferment for some
days in a warm place. It is then boiled from six to
eight hours, and, after being strained, is mixed with
molasses and water. This liquid must ferment for
three days before use. As the quantity of alcohol
in it is very small, people drink from two to three
litres a day.
The intoxieation by chicha is very slow and the
first symptoms appear after a year of its daily use.
This is evidenced, by erythema, localized in those
parts of the body which have been exposed to the
sunshine. .Later on the intellectual capacities be-
come stupefied, the knee-jerk is lost, the joints
stiffen by contraction and walking becomes difficult
and characteristic. The skin hypertrophies, loses
all sensibility, and a persistent diarrhcea weakens
the patient, who at lasts shows signs of mental
weakness and dies. The disease is said only to
be contracted by the chicha drinkers, although in
Colombia a great quantity of Indian corn (maize) is
eaten.*
A NOTE ON BRONCHO-OIDIOSIS.
By Arno CasTELLANI, M.D.
Director, Government Clinie for Tropical Diseases, Colombo,
Ceylon.
Since 1905 I have called attention in various
publieations to the great frequeney in the Tropies
of certain types of bronchitis and broncho-alveolitis
due to fungi. In Ceylon the commonest type, as
L have stated in previous papers, is broncho-oidiosis,
called also broncho-endomveosis, bronchomoniliasis,
or bronchoblastomyeosis. It may be, perhaps, of
* This is evidently Pellagra.--Ep.
interest to place on record a further case of this
condition; a patient who suffered from it in Ceylon
and who had another attack recently in England.
, The patient, Mr. S., a planter, aged 40, has
resided in low-lying districts of Ceylon for the last
fifteen years. At present he has been in Europe
since October, 1912. In Ceylon he had always
enjoyed good health except for occasional mild
attacks of malaria, until the beginning of 1911,
when he began complaining of a severe cough, not
yielding to the usual treatment. He came to
Colombo and consulted me in June of the same
year. His general condition was fairly good, but
he had a severe cough.
The physical examination did not reveal anything
abnormal except a few coarse rales on auscultation.
The sputum was muco-purulent, no blood present;
it was examined microscopically several times. In
fresh preparations round and oval yeast-like bodies
were present similar to those I had seen in so many
other cases previously. Several tubes of maltose
agar were inoculated and the fungus Monilia
tropicalis, described by me some years ago, was
grown. The examination of the sputum for tubercle
bacilli, repeated four times, was negative, and its
inoculation into two guinea-pigs gave negative
results.
I prescribed saiodin as usual, and the patient went
back to his estate. He wrote to me some time later
stating that within two weeks all the symptoms
had nearly disappeared, but a slight cough, with
mucous expectoration, remained. In October, 1912,
the patient came to London, and in the beginning
of December he came to consult me, stating that
the old symptoms had reappeared following on a
very slight ordinary ''cold." The physical exami-
nation of the chest revealed nothing at all. The
expectoration was muco-purulent without blood.
Large numbers of yeast-like or spore-like bodies
with double eontour were present in the sputum.
T.B. negative. I put him again on saiodin 15 gr.,
three times daily; all the symptoms disappeared
within ten days, but once or twice a day he would
have a slight attack of cough, with a little mucus
in which the fungus, though scarce, was still
present. He left for the Continent in January,
19183. I have recently heard from him to the effect
that the cough has quite ceased and that he is in
the best of health.
Remarks.—A few general remarks on broncho-
oidiosis and other diseases of the respiratory organs
due to fungi, may not be out of place. In Ceylon
these affeetions—whieh come under the general
term of bronchomycosis—may be classified as fol-
lows :—
(1) Bronchitis and broncho-alveolitis due to fungi
of the genera Monilia, Saccharomyces, and Crypto-
coccus.
(2) Broncho-alveolitis due to fungi of the genus
Nocardia.
(3) Broncho-alveolitis due to fungi of the genera
Mucor, Rhizomucor, and Lichthemia.
(4) Broncho-alveolitis due to fungi of the genera
Aspergillus, Sterigmatocystis, and Penicillium.
April 1, 1918.] THE JOURNAL OF TROPICAL MEDICINE AND. HYGIENE. :
(5) Broncho-alveolitis due to undetermined fungi.
The symptoms are somewhat similar whatever
fungus is the etiological factor; in mild cases there
are signs of slight bronchitis with muco-purulent
expectoration, in which the fungi are found. In
severe cases the patient presents all the symptoms
of phthisis with hectic fever and hemorrhagic ex-
pectoration.
Mild cases may become cured spontaneously,
they are. often benefited by potassium iodide. I
have, in Ceylon, observed and described cases of
Southern India and the Malay States, and it would
appear that the fungus is the real cause of the
disease, as no other etiological agents, such as
tubercle bacillus, &c., are found. Moreover, when
the patient gets better the fungus becomes very
scanty or disappears completely. In some cases I
have observed other species of the fungus, but I
doubt whether all these are really pathogenic.
These species are Monilia paratropicalis, Cast. ;
M. pinoyi, Cast. ; M. guillermondi, Cast. ; M. negrii,
Cast.; M. nivea, Cast.; M. candida, Cast.; M.
FUNGI oF THE GENUS MONILIA FOUND IN CASES OF BRONCHO-OIDIUSIS.
a 9 | | | | a E a |
: 5S JjÄ s "E $4|85/8|8 $|3|5|] 5 ^ E |^ 5 8. |8
Ub li dei e | ets ER | z= — T Pa us UN
Monilia albicans, Robin. ... AC [AG |AGslAGs! AG | Avs |ololoiololoj|ojol|ojorPo|o 4 | | +s
Monilia bronchialis, Cast. O |AG|AG AG [0] AGs | O | O| O | 010 ojo | Cc; c + | | [9]
Monilia guillermondi, Cast. \9-|aG|aG| As, ^ | AG |0 | O | O lo Gs O | o|o|olcrec!o| + | 0 |
Monilia insolita, Cast. Ara AG| AG AG| AG | AG | O | As! O | olo | Ov} 01,010 9. |. 8 + | O |OB
Monilia krusei, Cast. o AG | AG |0 | O O |o O Laaro T O OO LOTO G l4lolo
Monilia negrii, Cast. —AYs | AG| AG| As | AGs | AG o'.olcsoljo!olojclc!ol«|o1!o
Mcnilia nivea, Cast. X AG|AG|4G| AG | AGs| 0 | O , O | O AG 0 |o| 0 | 0|c|C10,4|.0 E
Monilia nitida, Cast. E AG|AG| A | A A | A|A | O |Avs oro O | O| 0} O\cTP} C]|O 4 | olo
Monilia paratropicalis, Cast. = AG |AG AG| AG | AG | O O |Avs; O | 0|0/|0/|0 Ore C}O;+)]0 | Oo
Monilia pseudotropicalis, Cast. ACs | AG isl O | AGs | AG | AG Oo | O. |. O0 TO | O:]- O0 O0 | G O4 O | O
Monilia pinoyi, Cast. O AG aG|AG| 0| ojojojojojojojo 0|c|Ccj[0o|4|0/0
Monilia pulmonalis, Cast. ARD AG | AG AG AGs | AG | O |Avs| O | O | A AGs) (0) O CTE; C|o [ + | O |OB
Monilia rotunda, Cast. .| AC} AAA A Oe 1 1 ^ | We], 0) [^0 20470 Oh Ge 6 [6:1 4 lo
Monilia rugosa, Cast. | at | As As | As| As As 9!159^4, Or) Ov) (OF OO O lolo | C O | 4 (0)
Monilia tropicalis; Cast. 1909 A laclaclac| acs | acs} O | O l O | 0 loļoļojoļojļc | c + | © |OB
Monilia zeylanica, Cast. ACs | A | A |A| A A |As| O| O | A pA o |Avs} O|C|C| tilolo)
|
——— ——— HM — M — — —
(milk), pellicle (broth).
or serum, as the case may be.
Abbreviations used in the table :—
Alk-- alkaline. a acid, then alkaline.
all five groups mentioned, but a more detailed
account may be given, perhaps, of the condition
due to fungi of the genus Monilia (oidium, endo-
myces, saccharomyces), which is by far the com-
monest type found in Ceylon, and from which the
case I have reported suffered. In Ceylon, accord-
ing to my researches, the malady is generally due
to Monilia tropicalis, described by me. I have
found the same fungus in cases coming from
s—slight; vs—very slight.
insolita, Cast. ; M. pseudotropicalis, Cast. ; M. lacti-
color, Cast. ; M. nitida, Cast. ; M. candidans, Robin;
M. lactea, Cast. ; Monilia (?) krusei, Cast. ; Monilia
(?) rugosa, Cast. P
The infection may take place from man to man,
and also most probably by the fungi living sapro- '
phytieally in nature. Monilia-like fungi are ex-
tremely common in Ceylon, in tea-dust, for in-’
stance, and it is very probable that the so-called
Neutral red
A— acid ; G—gas ; C — clot (milk), clear (broth and peptone water) CTP—clear at first, then thin pellicle present. D—decolorized. P—peptonized
B—brown pigmentation of the medium.
O —negative result, viz., neither acid nor clot in milk ; neither acid nor gas in sugar media; non-production of indol; non-liquefaction of gelatine
-- — positive result, liquefaction of medium. :
104
[April 1, 1913.
“ tea-factory cough ’’ is a type of moniliasis, as in
such eases a monilia is found in the sputum, and
monilia-like fungi are constantly found in the fac-
tory tea-dust. Moreover, guinea-pigs, into the
nostrils of which tea-dust is regularly insufflated,
develop after a time a moniliasis of the lungs.
Symptomatology.—A mild and a severe type of
the malady may be distinguished. In the mild
type the general condition of the patient is fairly
good, there is no fever, and he simply complains
of cough. The expectoration is muco-purulent and
very often scanty; no blood. The physical exami-
nation of the chest will reveal a few coarse moist
rales, or absolutely nothing. The condition may
last 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,
muco-purulent and bloody expectoration. Occa-
sionally true hæmophthisis occurs, a teaspoonful or
more of bright blood being spat up at a time. The
physical examination of the chest shows patches
of dulness, fine crepitations and pleural rubbing.
This type is often fatal. Between these two ex-
treme types there are cases of intermediate severity,
with subcontinued und continued fever, with more or
less definite bronchial and broncho-alveolar sym-
ptoms.
Prognosis.—The cases of a mild type may recover
spontaneously or under appropriate treatment.
Those of the malignant type usually end fatally.
Diagnosis.—The diugnosis of moniliasis is based
on finding the fungus in the sputum. It is abso-
lutely necessary that this should be collected in
sterile Petri dishes and examined as soon as pos-
sible, as sputum exposed to the air becomes con-
taminated with all sorts of fungi in the Tropics.
In fresh preparations of the expectoration,
spore-like, roundish, or oval cells, 4 to 6 microns,
with often a double contour, are seen, and occa-
sionally some mycelial elements. The fungus is
Gram positive.
To identify the fungus cultural methods are
necessary. A particle of the sputum is smeared on
maltose or glucose agar plates; after two or three
days, white, rather large, roundish colonies appear,
easily distinguishable, even macroscopically, with
a little practice, from the colonies of cocci, &c.
The fungus colonies are further investigated by
inoeulating maltose agar, ordinary agar, gelatine,
serum, and a series of sugar broths. All the species
of monilia (oidium) found in my cases grow well on
ordinary agar, but much more abundantly on mal-
tose and glucose agar, especially if slightly acid.
On these media the growth—which is generally
white with a smooth surface when young, slightly
crinkled when old—is composed practically of
globular yeast-like cells, while in the water of con-
densation globular cells and particles are found
together. A little mycelium mny, however, be found
also occasionally in the growth on the slope. On
serum all the strains produce at first a white growth,
but some later on induce a peculiar brownish black
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
discoloration of the medium round the growth.
Most species do not liquefy the medium.
On gelatine all the species grow fairly well; a
few, including Monilia candidans, produce liquefac-
tion of this medium. In milk some do not produce
either acid or clot, others induce a temporary or
permanent acidity, others clot the milk or peptonize
it. The reactions of the various sugar broths are
important, and in association with the action of
the fungi on serum, gelatine, and milk yield the
data on which the differentiation of the various
species is made.
Differential Diagnosis. —Primary — bronchomoni-
liasis, as described in this paper, should be dis-
tinguished from the secondary bronchomoniliasis
occasionally met with in cachectic patients suffer-
ing from cancer, diabetes, tuberculosis, &c. In
such cases there is generally thrush of the oral
mucosa, and the thrush monilia spreads to the
pharynx, laryux, and bronehial mucosa, while in
primary bronchomoniliasis the oral mucosa is not,
as a rule, affected.
From pulmonary tuberculosis the condition is
distinguished by the absence of the tubercle bacillus
in the sputum and the negative animal inoculations.
Cases of mixed infection, however, tuberculosis and
mouiliasis, are occasionally met with, the sputum
containing both the tubercle bacillus and the
monilia fungus. Moniliasis differs from broncho-
spirochetosis by the absence of spirochetes, and
from endemic hemoptysis by the absence of the
ova of Paragonimus westermani, Kerbert.
Treatment.—Mild cases and those of medium
gravity respond quickly to potassium iodide (10 to
20 gr.), given well diluted in water or milk, three
times daily. When potassium iodide causes severe
symptoms of iodism, saiodin in the same dosage
(in cachets) may be administered. In the cases of
malignant type I have seen no improvement from
the many different treatments tried. Potassium
iodide, however, should always be tried in these
cases as well as balsamics. The diet should be
nourishing; with hypophosphates and glycero-
phosphates, &c., as tonics.
REFERENCES,
CASTELLANI : British Medical Journal, 1910 and 1912; Lan-
cet, 1911; Philippine Journal of Science, 1910; Ceylon Medical
Reports, 1905 1911.
————— —9————
“ Bulletin dela Société Médico-Chirurgicale de L'Indochine,"
Tome iv, Février, 1913, No. 2.
Appendicostomy for Dysentery.—Le Roy des Barres
reports a successful case of appendicostomy for chronic
dysentery. He specially reports the case because in his
experience operations of this sort, either done by himself,
or seen by him, have not given satisfactory results. He
points out the importance of doing the operation early, and
not waiting till the patient is in extremis. At first per-
manganate ,5]55 was used to wash out the bowel, and the
patient also took in addition a disinfectant powder com-
posed of phosphate of bismuth and charcoal. The number
of stools rapidly diminished, and when the fistula closed
spontaneously they were solid and naturally formed, the
general health of the patient also being very good.
April 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
105
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THE JOURNAL OF
Tropical Medictne and Hygiene
APRIL 1, 1913.
THE DIFFICULTIES OF THE MILK SUPPLY
IN TROPICAL COUNTRIES.
WHEREVER Europeans, especially English-speaking
foik, dwell in tropical countries the question of the
milk supply is an ever-present anxiety. Without a
sur ply of fresh cows’ milk the doctor is handicapped
in the treatment of disease, and parents are harassed
to know how to supply the deficiency for their
children’s wants. The several animals from which
the milk possible for human consumption may be
derived are the imported and native cow, the
* buffalo, the mare, the ass, and the goat. Of these
cows' milk is always preferred, and the milk of cows
imported from Europe, Australia, or America,
whenever it can be had, is chosen to the exclusion
of that from the native cow. Chemical analysis
shows why cows’ milk is selected, and there are
several reasons why the milk of the imported cows
has the preference. The establishment of a local
dairy of European, American, or Australian cows is,
anl will continue to be, a question largely of ex-
pense. To bring cows, say, from the western
shores of the United States of America to the
eastern coast of Asia, from Singapore to Japan, is
fraught with anxieties to the importer, for there are
the dangers of the long voyage across the Pacific
to be thought of, the difficulty of acclimatization to
be considered, and the chances of the imported cows
contracting disease from native cattle. There is
also the possibility of the imported stock proving
useless, either on account of the age of the cattle
sent by unscrupulous vendors, or owing to changes
in the climate, food, and surroundings affecting the
tlow of milk.
The distance which these animals have to travel
increases the price to the importer to well-nigh
double their original cost, so that with the prospect
of accidents during transportation and subsequent
disease there are sufficient reasons to cause im-
porters to hesitate before embarking upon a ven-
ture which is fraught with difficulties and all too
often financial loss. It comes about, therefore, that
the establishment of a dairy of imported (that is,
European or American) cows resolves itself more or
less into a philanthropic undertaking, at any rate
in the first instance, ahd is usually undertaken by
some of the more thoughtful and public spirited
members of the community combining to form a
company. The local Government ought to do so in
the interests of the publie health, but we have not
reached that higher stage of practical science in
publie health matters in many parts of our Empire
as yet. The advantages of an '' imported cow”
dairy are several; the milk is usually of a better
quality, the dairy is generally in charge of, or at
any rate under the supervision of, a European, so
thnt greater cleanliness is likely to be, and is, taken
in all matters appertaining to the cows themselves,
the milking, the storing, and the distribution of the
milk and the making of butter. These factors,
quality and cleanliness, are of primary importance
when dealing with dairy produce. The quality of
a cow's milk largely depends on the food supplied
her. The fine English meadow land is unique; it
is green practically all the year round; it is the
product of scores, sometimes hundreds, of years of
land undisturbed by the plough, and it affords a
quality of grass and hay, and consequently of milk
(and of beef or mutton) unequalled in their whole-
someness and nourishing qualities. To transfer a
cow from pastures of this kind to a tropical country
where the ''grass cutter” finds the green food,
where the dry food consists of straw or hay rapidly
ripened and dried to a cinder almost under a hot
sua, and wanting that ‘‘ sappiness "' so essential for
milch cows, with turnips and mangolds out of the
question as articles of food, it comes to merely
getting sufficient food to just keep the animal
alive somehow with the available material to hand.
The milk suffers thereby in quality, and yet it is
calculated to be superior to that of the native cows
in the neighbourhood ; for they are given no imported
supplementary food, but are turned out to find a
living on bare and burnt patches where unwhole-
some weeds may spring up, but where, except for
it may be some few weeks during the wet weather,
106
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1913..
nothing approaching grass is seen. Milk analysis
has reached as near perfection as the chemist can
attain, and yet the essential '' goodness °’ of milk
it is beyond the chemist to state. Milk is like no
other element of our food; it is the only product,
exeept raw eggs, of a living animal used by man;
all other articles of food are not only taken from
animals. that have been killed, but the meat de-
rived therefrom is cooked before it is eaten. Milk,
being an animal secretion, varies directly with the
food, the water, the health, and the breed of cattle,
so that there is no finite analysis of milk possible,
and it is this ‘‘ living ’’ factor of milk, combined
with the idiosynerasy of, say, individual children
that causes milk from the same cow or dairy to dis-
agree with one or more members of a family, while
it suits others of the same household. The quantity
of cream present in a specimen of milk, although
the popular test, is wholly misleading. The milk
of the buffalo cow shows some 17 per cent. of
cream, whereas ''good'' cows’ milk yields but
about 10 per cent.; yet is buffalo cream difficult to
digest, whilst the skimmed milk is of a low nutritive
value compared with the skimmed (not separated)
milk of dairy cows.
Many tropical residents, especially in the more
northern parts of India, where more green food is
obtainable than elsewhere in that country, keep
their own cows, which are usually of the native
breed of cattle, and pride themselves on their supply
of milk. When they contract intestinal troubles
and have to come home in consequence, and when
treatment by milk is suggested, the answer not
infrequently is: ‘‘ Oh! I tried milk in India (or else-
where), and it did no good." When asked if the
milk was good, the answer may be: '' Oh, yes; we
kept our own cows.’’ From the above discussion it
will be gathered that milk in the Tropies or sub-
Tropics, even when '* our own cow’s,”’ is not of the
quality of English milk, and that because milk did
not do good abroad, it is no criterion that milk from
cows fed on English pastures will not have a
beneficial effect.
The argument in favour of foreign versus native
cow's milk may be pushed even further; for
residents in Burma, for instance, where Australian
cows are imported to some extent, find that children
given the milk of native cows may not thrive,
whereas when they are put on to milk from im-
ported Australian cows their health improves im-
mediately. The explanation of this observation is
that the quality of milk varies with the breed; for
the cows, native and imported, in several dairies
kept by residents in Burma are herded together
and fed alike.
Is it possible to maintain and aeclimatize a breed
of cattle in the Tropies imported, say, from Europe,
so that they will go on reproducing their kind
satisfaetorily? The answer is yes and no! Young
bulls must be imported every year or two if the
breed is to be maintained; it is not possible to
prevent the herd degenerating without this even in
the Argentine, the most favoured place, outside
the British Isles, for the rearing of cattle. The
farmers there have to import fresh blood from
Britain at frequent intervals.
This difficulty of rearing British cattle in the same
perfection as at home, for either milk or calf-
producing, cannot seemingly be overcome; for as
the climate of Lancashire favours the quality of
eotton manufactured, &o the quality of the food and
elimate of the British Isles enhances the quality of
the cattle reared within its shores to an extent
which is recognized throughout the world.
J. C.
—— —(fp————
Aunotations.
The Blood-plates in Tropical Anawmia.—In the
Proceedings of the Canal Zone Medical Association
for the half-year, April to September, 1911, is a
paper by Darling on ‘‘ The Blood Platelets in
Tropical and Other Forms of An:emia." He follows
Wright in believing that the blood-plates are
detached portions of the cytoplasm of certain large
marrow cells, called by Howell megalokaryocytes.
His observations have led him to the belief that
the platelets are diminished in number in certain
diseases, such as malaria, hwmoglobinurie fever,
uncinariasis, verruga peruviana, relapsing fever,
kala-azar and typhoid fever at certain phases of
the disease; they are also diminished in number in
Addisonian anemia, lymphatic leukemia, and pur-
pura hemorrhagica.
On the other hand, the platelets are increased in
number in myelogenous leukemia and in myeloid
neoplasms, such as Hodgkin's disease. This
suggests that the giant cells described by Reed and
others in Hodgkin’s disease are megalokaryocytes
and that Hodgkin’s disease is a myelomatosis of
certain lymphoid elements; as a diagnostic corol-
lary, the clinical separation of true Hodgkin's
disease from lympho-sarcoma follows when the
latter does not contain megalokaryocytes.
The size and staining characters of the platelets
are sometimes altered, this being analogous to such
changes in the erythrocytes as microcytosis,
poikilocytosis, macrocytosis and polychromasia.
It is believed that if the changes in numbers and
morphology to which the platelets are subject in
various diseases will be observed more carefully,
they will furnish material help in the diagnosis of
diseases affecting the blood-forming organs.
Sunstroke.—At the sixty-fourth meeting of the
Canal Zone Medical Association (Isthmian Canal
Commission), July 12, 1911,* Crabtree reported
two eases of sunstroke occurring on the Isthmus
of Panama. He states that the classification found
* Proceedings of the Canal Zone Medical
Isthmian Canal Commission, for the half-year, April to
September, 1911. Vol. iv., part 1, I.C.C. Press, Quarter-
master's Department, Mount Hope, Canal Zone.
Association,
April 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE
in most American text-books of the diseases pro-
dueed by the sun's rays and high atmospheric
temperature is as follows :—
(1) Sunstroke.—The description of which may
be thus epitomized: Headache and giddiness
coming on while exposed to the sun’s rays, in very
hot weather, soon followed by coma, hot dry skin,
flushed face, rapid, bounding pulse, high fever—
from 106° to 1129 F.—deep, laboured and stertorous
breathing; and, in some cases, involuntary evacua-
tions and epileptiform convulsions. The severer
the case the more likely are the latter to occur.
Alcoholism is a predisposing factor, very frequently,
in fact.
(2) Heat Exhaustion.—This may result whether
exposed to the sun’s rays or not, if the temperature
is high with humidity. More frequently it occurs
indoors. Skin cool and livid, rather than red as in
sunstroke; bodily temperature often subnormal,
pulse rapid and weak, and breathing rapid but not
laboured. (In other words, symptoms of collapse.)
Restlessness, anxiety, and sometimes delirium are
noted, but the sensorium is practically normal in
most cases.
These two conditions are almost diametrically
opposite in symptoms, and treatment required.
Both the cases described by the author gave
histories typical of sunstroke. One case recovered,
but though regaining his strength was never quite
clear mentally, and had to be invalided home after
several months’ observation in hospital. The
other case died, and the autopsy bore out the
clinical diagnosis.
— eo
Hotes and Mews.
Tue HovsE-FLY as A Dancer to Hrauru.—The
British Museum (Natural History) Economic Series,
No. 1, bring out a pamphlet on '' The house-fly as
a danger to health, its life history, and how to deal
with it." The pamphlet has been prepared by Mr.
E. E. Austen, of the Entomological Department of
the British Museum, the well-known authority on
flies. Such information is urgently required by the
laity because of the numbers of these insects during
the summer months in parts of London. In many
instances they are a veritable pest, and now that it
is known that they are also active disseminators of
disease, it is high time that steps were taken to
limit their numbers by abolishing or destroying their
breeding grounds.
To those ignorant of the life history of the
common house-fly the pamphlet will give all the
necessary information, and the illustrations found
throughout its pages will make all the points quite
clear. It would be well if it were widely distributed
throughout schools and other teaching centres, so
that the youth of the present day might grow up
possessing information upon which they could act
later in life. It is by getting at the young that the
best results in elementary sanitation will be attained.
107
Abstract.
SrUDIES ON PNEUMONIC PLAGUE.
Influence of Atmospheric Temperature upon the
Spread of Pneumonic Plague.
(Continued from p. 93.)
In Maifehuria, during the winter of 1910 to 1911,
pneumonie plague spread with such rapidity that
within three months 50,000 people died of the
disease. Except toward the close of the epidemic,
sanitary conditions were bad, the weather was bit-
terly cold, and quarantine measures were in-
adequately enforced. In India, where sanitary
eonditions are, perhaps, equally as bad, although
there have been numerous isolated cases of pneu-
monie plague during the past fifteen years (from
2 to 5 per cent. of all plague cases), this type of the
disease has not assumed epidemic proportions.
Why was there a rapid spread of the pneumonie
type of the disease in the one instance and a failure
to spread in the other? The most obvious differ-
ence in the two instances is one of temperature, in
the one case as low as 309 C. below zero as com-
pared to 309 C. above zero in the other. Can the
failure of pneumonic plague to spread in India be
due to the high temperature that prevails in this
country? If one considers only the direct action
of the high temperature upon the plague bacilli,
this question must be answered in the negative;
for the optimum temperature for the cultivation
of the plague bacilli upon artifieial media is 309 C.,
which is approximately the temperature to which
they would be subjected in India. Teague and
Barber,* however, believe that indirectly the tem-
perature of the atmosphere is a factor of vast
importance in the spread or failure to spread of
pneumonic plague.
It is quite generally accepted that infection in
pneumonic plague is due to the inhalation of plague
bacilli and, as plague bacilli are readily killed by
drying, it is fair to assume that infection is due to
the inhalation of moist bacilli—the so-called ‘‘ drop-
let infection." In plague pneumonia, the mucous
membranes of the bronchi, trachea, larynx, and
mouth are covered with enormous numbers of
plague bacilli. It follows that such a patient in
coughing throws out droplets of sputum which must
contain plague baeilli. Strong and Teague demon-
strated that this does, in fact, occur. Petri dishes,
containing solidified agar culture medium, were
held before the mouths of coughing plague patients,
and, even when no visible particles of sputum
appeared, colonies of plague bacilli developed on
the plates. Granted that infection is due to the
inhalation of droplets of sputum containing plague
bacilli, it follows that the longer these droplets
remain suspended in the air, the greater the danger
of infection.
* Philippine Journal of Science, Section B, vol. vii, No. 3,
June, 1912,
108
_ These droplets may disappear from the air in the
immediate neighbourhood of the patient in three
ways, namely (1) by evaporation, (2) by settling,
and (3) by being borne away by currents of air.
The rate of evaporation depends chiefly upon the
water deficit of the atmosphere. Under ordinary
conditions this is far greater in warm weather than
in cold, and hence, ordinarily, evaporation of drop-
lets of moisture in the air will take place far more
rapidly in warm weather than in cold. At 409 C.,
with a maximum of moisture in the air, the water
vapour has a pressure of only 6.0 millimetres of
mercury; hence, even if the atinosphere were
absolutely dry at this temperature, the water deficit
would be small and evaporation would take place
very slowly.
At 309 C., with a maximum of moisture in the
air, the pressure of the water vapour amounts to
31.5 mm. With 70 per cent. of moisture in the
air, there would still be a greater water deficit
(9.4 mm. of mercury) than in a perfectly dry
atmosphere at 49 C. In a cold climate, with snow
on the ground and a rise of several degrees in
temperature during the middle of the day, the
water deficit of the air would be approximately
zero during the greater part of the twenty-four
hours. These were the conditions in Manchuria
during the recent epidemic of pneumonie plague;
hence there must have existed a very low water
deficit in the air and little tendency for the droplets
of sputum to disappear by evaporation. In India,
on the contrary, with a temperature ranging around
809 C., there is usually a large water defieit in the
air and hence the droplets of sputum would tend
to disappear quiekly by evaporation, thus leading
to the death of the contained plague bacilli by
drying.
According to curves given in the Report of the
International Plague Conference, the temperature
at Harbin during the course of the epidemic ranged
between —99 C. and —329 C. and the humidity
between 61 and 92. At —109 C., the vapour ten-
sion of water is 2.00 mm. of mercury and at —209
C., it is 0.02 mm. Hence, with an average
humidity of about 80, the water deficit of the air
at Harbin during the epidemic would be repre-
sented by from 0.4 to 0.2 mm. of mercury. Under
these circumstances, evaporation could take place
only with extreme slowness.
In India, with a temperature of 4-309 C. and a
humidity of 70, the water deficit of the air would
be represented by 9.46 mm. of mereury. In other
words, evaporation would take place from twenty-
five to fifty times more rapidly in India than in
Harbin.
During the plague epidemies of both India and
Manchuria, the fact that the poor people were much
overcrowded in their living quarters undoubtedly
hastened the spread of the disease. In Manchuria,
on aecount of the bitterly cold weather, the doors
and windows of the overerowded houses were kept
tightly closed. Under these circumstances, another
factor is introduced of perhaps no small importance
in its bearing upon the rate of disappearance by
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1913.
evaporation of droplets of sputum in the air;
namely, the moisture in the expired air. In the
cold, the moisture from the breath of the inmates
of an overerowded room would quickly saturate the
air and reduce evaporation to a minimum, whereas
the air of a similar warm room could take up large
quantities of moisture without becoming saturated.
The surface tension of water at 4° C. is 74.9,
and at 309 C. it is 71.08. The surface tension
being greater at the lower temperature, with the
same amount of water deficit, evaporation would
take plaee more slowly there than at the higher
temperature. This is, therefore, an additional fac-
tor which would tend to cause droplets of pneu-
monie sputum to persist longer in the air in a cold
climate than in a warm one. However, it is a
factor of far less influence than the water deficit of
the air and hence deserves no further discussion.
It seems highly probable that plague bacilli in
suspended droplets of sputum would survive much
longer at a low temperature than at a high one,
even were the water deficit of the air the same
in both cases; or, in other words, that with the
same rate of drying, the bacilli would remain alive
longer at low temperatures than at higher ones.
This would, then, be also an important factor in
eausing pneumonie plague to spread more rapidly
in cold climates than in warm ones.
It is noteworthy that the only large epidemic of
pneumonie plague in India, of which we have a
record, occurred during cold weather in Kashmir
in the winter of 1903 to 1904. The epidemic is
described by A. Mitra, who stated that it lasted
from November, 1903, to August, 1904, '' but the
virulence was only from December to March.”
In the distriets there were altogether 1,443 cases
with twenty reeoveries; the recoveries being
bubonic cases, which were seen at the end of the
epidemic. We judge from these statements that
the epidemic of pneumonic plague lasted from
December till March. Mitra says:—
“ The conditions of life in these villages during
the months of January and February were extremely
unfavourable. Everything round was frozen.”
The Indian Weather Review shows that Srinagar,
which was the centre of the Kashmir epidemic, had,
during the month of December, 1903, a mean daily
temperature of 36.19 F. and a mean humidity of
81.090; during January, 1904, a mean daily tem-
perature of 29.19 F. and a mean humidity of
88.00; during February, 1904, a mean daily tem-
perature of 36.00 F. and a mean humidity of
85.09,
Therefore the conditions were such that droplets
of sputum suspended in the air would have had a
tendeney to evaporate to dryness only with extreme
slowness.
Gill appears to have been the only investigator
who has devoted especial attention to the epidemi-
ology of pneumonie plague in India.
That plague bacili may be unable ''to long
maintain their unusual or perhaps exalted degree
of virulence " by passage from lung to lung, as is
suggested by Gill, appears to us to be highly im-
April 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
109
probable, since the experimental data at hand in-
dicate that passage from lung to lung in susceptible
animals is the method of choice and, perhaps, the
only method of exalting the virulence of plague
bacilli and maintaining the high virulence thus
attained.
The epidemiological observations of Gill possess,
however, great interest with regard to the influence
of atmospheric temperature upon the spread of
pneumonic plague. He found that pneumonic
plague occurred during cold weather and ceased
when the warm weather began, in spite of the fact
that the number of bubonic cases was still on the
increase. Unfortunately, he did not publish his
notes in sufficient detail to allow of determination
of the atmospheric temperature and humidity
which existed during his several epidemics, but as
far as his observations go, they indicate that the
atmospheric temperature was probably a factor of
importance in the spread of pneumonic plague and
the suppression of the epidemic.
The only other epidemic of pneumonie plague of
recent years, of whieh we find a reliable record, is
the small one which occurred in Osaka, Japan, also
in the cold season of the year. The first patient
was taken sick on December 19, 1899. This case
was quiekly followed by twelve others, the last
dying on January 13, 1900.
The above discussion has been confined entirely
to pneumonie plague, but obviously the same ideas
apply also to other pneumonias. In other pneu-
monias, however, it is not unlikely that the dosage
and virulence of the inhaled bacilli and the suscep-
tibility of the host at the time of exposure are
factors of far greater importance than in plague
pneumonia; hence, the influence of atmospherie
temperature on their spread would be more or less
obscured by these other factors.
Teague and Barber endeavoured to obtain experi-
mental data confirmatory of the ideas advanced in
the foregoing discussion. It was, of course, im-
practicable to perform actual experiments with
plague bacilli sprayed into the air on account of
the danger of contracting pneumonic plague. They,
therefore, sprayed harmless bacteria and determined
how they behave in the air under different condi-
tions, believing that the results obtained would
justify them in drawing conelusions as to how plague
bacilli would aet under similar conditions. They
seleeted for most of the experiments B. prodigiosus
and a yellow sarcina obtained from the air. Those
organisms possess the following advantages for these
experiments: (1) "They are harmless; (2) their
colonies on agar are readily recognized on account of
the eharaeteristie pigment production; and (3) they
differ considerably in their resistance to death by
drying, the B. prodigiosus being killed more readily
than the sarcina. In a few experiments the cholera
vibrio was used; this organism is much more
readily killed by drying than is B. prodigiosus.
The authors found by experiment that the plague
bacillus occupies an intermediate position between
cholera and B. prodigiosus with regard to its resist.
ance to death from drying. Sarcina is much more
resistant than the other organisms.
Having determined the relative resistance to
death by drying of sarcina, B. prodigiosus, and
cholera vibrio when spread in a thin layer upon
glass slides, they next planned an experiment to
find the result with these same organisms when
contained in fine droplets of saline solution sus-
pended in the air.
lt was found that when sprayed into the air
under similar conditions, living cholera vibrios dis-
appear from the air in about six minutes and living
B. prodigiosus in about twenty minutes, whereas
sarcina remains alive for more than three hours.
There is a striking similarity shown by these
organisms in their relative resistance to drying on
glass slides and their persistenee in the air when
contained within fine droplets of saline solution.
It would seem, therefore, that had plague bacilli
been sprayed under similar conditions, the living
ones would have disappeared from the air between
six and twenty minutes after spraying.
This similarity in the behaviour of the organisms
on the slides and in droplets strongly suggests that
also in the latter instance the disappearance of the
living bacilli from the air is due to death from
drying. If this were true, then if one were able
to retard the evaporation of the water of the fine
droplets, the living bacteria should remain in the
air for a longer time. The most obvious method
of retarding the evaporation of the fine droplets is
to spray them into an atmosphere saturated with
moisture. Such an experiment was therefore car-
ried out.
In the dry hood the living cholera vibrios had all
disappeared from the air six minutes after the
spraying was discontinued, whereas in the wet hood
living cholera vibrios were present after twenty-
seven minutes. The wet and dry bulb thermo-
meters showed that the air of the wet hood was
nearly saturated with moisture, and hence evapora-
tion of suspended droplets of water must have been
reduced almost to the minimum. Therefore, one
is justified in concluding that the extremely rapid
disappearanee of the living cholera vibrios in the
dry hood is due to the rapid evaporation of the
suspended droplets of saline solution which leads
to the death of the contained cholera vibrios from
drying.
The last part of the experiment shows conclu-
sively that the rapid disappearance of living cholera
vibrios is not due to settling or removal through
air eurrents, for droplets containing cholera vibrios
and those containing sarcina were subjected to
identical conditions and yet living sarcinæ were
present in the air long after the cholera vibrios had
disappeared. The sarcina, being a larger organism
and having a greater tendency to remain in clumps,
would settle out more rapidly than the cholera
vibrio. It remained alive in the air longer than
the cholera vibrios because of its greater resistance
to drying. A similar experiment was performed
with B. prodigiosus.
As with the cholera vibrios so also in the ease of
B. prodigiosus there is a striking difference in the
length of time that the bacilli remain alive in a
dry and in a moist atmosphere. In the cold room
110
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1913.
the bacilli remain alive in the air even longer than
in the wet hood. Unfortunately, the humidity of
the cold room during this experiment was not
determined.
It was, therefore, necessary to perform the fol-
lowing experiment. The same suspension of B.
prodigiosus was sprayed for one-half a minute into
a moist hood and into a cold storage room, and
Petri dishes containing solidified agar were exposed
in both places for periods of two minutes each at
intervals of four hours. In the cold room the dry
bulb thermometer registered 12° C. and the wet-
bulb one about 10.59 C. throughout the experiment.
In the hood the dry-bulb thermometer varied be-
tween 31.1 and 31.5 and the wet-bulb one regis-
tered about 0.29 below the dry one. It is clear
that the water deficit of the atmosphere was greater
in the cold room than in the hood.
In spite of the fact that the water deficit of the
air of the cold room was greater than that of the
hood, the bacilli remained alive longer in the cold
room. The only interpretation of this result is that
B. prodigiosus resists death from drying longer at
low temperatures than at high ones, even when
the rate of drying is the same in both instances.
It seems highly probable that this is also true of
the plague bacillus; if so, the bearing of the
phenomenon is an additional faetor in the longer
persistence of living plague bacilli in droplets of
sputum, and hence upon the more rapid spread of
pneumonie plague in cold climates is obvious.
Summary.—1t is shown that when spread on
glass slides and exposed to the air, plague bacilli
occupy an intermediate position between the cholera
vibrio and B. prodigiosus with regard to resistance
to death from drying. Sarcina resists much longer
than B. prodigiosus. | When suspended in saline
solution and sprayed into the air, the living cholera
vibrio disappears with surprising rapidity, B. pro-
digiosus persists for a longer time, and sareina much
longer than B. prodigiosus. "The relative length of
time that these organisms remain alive when
sprayed into the air agrees strikingly with their
survival on glass slides. This suggests that their
disappearance from the air is also due to death from
drying.
This was shown to be in fact the case by spraying
the same cholera suspension into a comparatively
dry atmosphere, and then, under similar conditions,
into an atmosphere nearly saturated with moisture;
living cholera vibrios remained in the air much
longer in the latter instance. A similar experiment
was performed with B. prodigiosus with the same
result.
By spraying sareina and immediately thereafter
cholera vibrios, so that the droplets containing these
organisms were subjected to identieal conditions,
living sareina was found to persist in the air long
after the living cholera vibrios had disappeared.
Sinee the sarcina is a larger organism than the
cholera vibrio, it follows that the disappearance of
the latter was not due to settling.
They believe they are justified in concluding from
these experiments that were the plague organisms
sprayed under similar conditions they would persist
longer than cholera vibrios, but a shorter time than
B. prodigiosus. Hence, it seems probable that
the plague bacilli contained in fine droplets of
pneumonic plague sputum would suffer death from
drying in a few minutes unless they were suspended
in an atmosphere with an extremely small water
deficit. Infection in pneumonic plague follows the
inhalation of droplets of pneumonic sputum, and
obviously the longer these droplets remain sus-
pended in the air, the greater is the danger of
infection. As has just been stated, these fine
droplets disappear very quickly except when they
are suspended in an atmosphere with a very small
water deficit. Such an atmosphere is under or-
dinary circumstances of common occurrence in
very cold climates, whereas it is extremely rare in
warm ones. Hence, since the droplets of sputum
persist longer, the plague bacilli remain alive
longer in the air, and there is a greater tendency
for the disease to spread in cold climates than in
warm ones.
In harmony with the above ideas, they find that
the only great epidemic of pneumonic plague of
modern times occurred in Manchuria during the
winter of 1910 to 1911, when the atmospheric tem-
perature was many degrees below zero Centigrade.
The disease spread with amazing rapidity. Further-
more, although during the past fifteen years there
have been millions of plague cases in India, and
2 to 5 per cent. of these have been cases of plague
pneumonia, yet this form of the disease has not
assumed epidemie proportions. The largest epi-
demie of pneumonie plague in India (1,400 deaths)
occurred in Kashmir in Northern India at an eleva-
tion of 1,524 metres above the sea level during very
cold weather.
SrroxG and TEAGUvE,* continuing the report on
their researches, state that they studied experimen-
tally the question of the portal of entry of the organ-
ism and the method of the development of the
lesions in pneumonic plague. Animals were placed in
closed glass cages, and agar cultures of virulent
pneumonie strains of the plague bacillus suspended
in saline solution were sprayed for a period of from
about two to three minutes into the surrounding
air which they breathed. Thirty-four normal
guinea-pigs and fifty-five normal monkeys were so
infected with plague bacilli, and all suecumbed to
plague infection. The animals were necropsied
in each instance, and the lesions present observed
and studied. It would be very tedious, say the
authors, to record the individual necropsy reports,
since the lesions found were so often similar.
Therefore, only a general description of the lesions
is given, and the different types of lesions empha-
sized.
In the guinea-pigs so infected, the following
changes were encountered at necropsy. In general
* Philippine Journal of Science, Section B, vol. vii, No. 9,
June, 2912.
April 1, 1913.]
there was marked evidence of plague infection about
the cervical and laryngeal tissues. The subcu-
taneous tissues showed extensive cedema, and there
was swelling of the cervical lymphatic glands and ct
those about the trachea. Usually the glands were
not only swollen but more or less hæmorrhagic and
presented the appearance of small early buboes.
Throughout the body marked evidences of septi-
cemia were usually present. There were fre-
quently extensive hemorrhages in the intestinal
wall. The spleen sometimes showed the typical
changes encountered in bubonie plague infection
with miliary abscesses. Distinct evidences of pneu-
monia were present in only about 23 per cent. of
the guinea-pigs. Plague bacilli were frequently not
very abundant in the lungs, unless pneumonie
areas were encountered, but were always present in
the heart’s blood. The lungs were sometimes red-
dened, congested, and cedematous, and sometimes
contained hemorrhagic infarcts. Small areas of
primary bronchial pneumonia were encountered in
some of the cases, and in one a whole lobe of the
lung showed pneumonie engorgement. In two
instances either red or early grey hepatization was
present. | Numerous miliary abscesses were occa-
sionally encountered in the lungs. The areas of
bronchial pneumonia were firm, contained no air,
and were usually irregular in outline and red,
reddish-yellow, or yellow in colour. On cut sec-
tion they were sometimes wedge shaped. In those
instances in which hemorrhagic infarcts, miliary
abscesses, and in addition reddish-yellow or yellow
areas of lobular pneumonia were present, one must
conclude that the infection of the lung is secondary,
and that in these instances one is not dealing with
primary pneumonic plague, in which infection
enters through the bronchi, but with secondary
infection of hemotogenous origin. Such a conclu-
sion is supported by the microscopical study of these
lesions. Sections of the lung in the vicinity of one
of the hepatized areas showed the bacteria in very
large numbers both about and within the small
blood-vessels, and in places infarctions had oc-
curred; numerous hemorrhages from the vessels
had also taken place; in the neighbourhood of the
pneumonic areas the bacteria were also plentiful in
the lung alveoli and in the perivascular spaces.
Therefore, these changes suggest that the primary
point of infection did not always occur in the
bronchi or alveoli of the lung. From a study of all
the lesions in guinea-pigs, it would appear that these
animals, under the conditions of the experiments in
which the spraying was carried on, did not fre-
quently develop primary plague pnuemonia, but
that infection occurred through the mucous mem-
branes of the mouth and throat, resulting in. a
general septicemia generally preceded by the for-
mation of early buboes of the cervical glands, and
sometimes followed by the development of secon-
dary areas of plague pneumonia. It would appear
that in guinea-pigs, either on account of too shallow
respiration or the small size of the larynx and
trachea, the bacteria are not so likely to penetrate
to the smaller bronchi by means of the inspired air.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
111
Instead, they are apparently deposited largely upon
the mucous membranes of the mouth and throat.
The experiments performed on monkeys seem to
throw much more light upon the mode of pneu-
monic plague infection in man. The lesions in
fifty-five monkeys infected by spraying were studied
at necropsy. There was a marked similarity in
general in the pathological changes encountered.
In practically all of the animals there was absence
of any sign of plague infection about the cervical
tissues. The submaxillary and cervical lymphatic
glands and those about the trachea were not
swollen, nor was there any cedema of the cervical
tissues, as was practically always seen in the experi-
ments with guinea-pigs. In none of the cases
examined did the tonsils show evidence of primary
disease, though in a number of instances they were
sectioned and stained. .In some instances they
were moderately congested. Plague bacilli were
scanty in them, and when present were not more
numerous than in the heart’s blood, and never so
numerous as they were in the lungs or spleen.
There was frequently cedematous fluid in the
trachea, and in a few cases the trachea was slightly
reddened. The larynx and vocal cords were not as a
rule injected. There was not such marked evidence of
septicemia as seen in the experiments with guinea-
pigs, but plague bacilli could always be recovered
from the heart's blood by culture. No hemor-
rhages were noted in the intestines and omentum.
The spleen and liver showed no miliary abscesses.
There were no cervical, axillary, nor inguinal
buboes. The lungs showed primary pneumonic
changes in every case. There was always much
cedema. In those animals which succumbed a
shorter time after infection, the lobular type of
pneumonia was much more frequently encountered.
In those which survived a longer period, whole
lobes of the lung usually showed pneumonia. The
process evidently begins as a lobular bronchial
pneumonia. By the fusion of a number of the
areas of lobular pneumonia, the whole lung may be-
come involved. The large pneumonic areas were
either in the stage of engorgement or of red or early
grey hepatization. In a number of cases a pleuritic
exudate was observed over the hepatized areas. In
no case were miliary abscesses observed in the
lungs. In the cases with the early lesions, the
plague bacilli were always most numerous in the
lungs, and in section were found in greatest pro-
fusion about the bronchioles, in the peribronchial
lymph spaces and alveoli, and beneath the pleura.
In some instances the cells lining the alveoli ap-
peared normal even when they contained large
numbers of bacilli. Although the blood-vessels
between the lobules and septa were dilated, and
hemorrhages sometimes occurred, practically no
bacteria were found within them. ;
From these observations, it is obvious that the
infection in monkeys occurred by inhalation, and
resulted in primary plague pneumonia.
It also is evident that in some instances in- which
monkeys are exposed to infection by inhalation, the
primary point of infection may be not only the
112 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1913.
lungs, but also the mucous membranes of the
mouth and throat. That plague infection may
oecur through the mucous membranes of the mouth
and throat alone in monkeys was demonstrated by
placing a small quantity of plague bacilli upon the
posterior portion of the throat by means of a glass
rod.
These animals all died of plague septicemia with
or without bubonic infection of the cervical glands;
that is, in the cases in which the infection was severe
and the susceptibility of the animals more marked,
they succumbed to septicemia before cervical
buboes developed. In none of these instances was
pneumonia present. Primary plague pneumonia
only results when infection by inhalation has in
addition taken place.
It has been claimed by several observers, and
more recently by Koulecha, that pneumonic plague
in man is primarily a septicemic disease, the lungs
becoming secondarily involved by way of the blood
circulation. According to this observer, the infec-
tion is supposed to spread from the perivascular
spaces to the neighbouring lung alveoli. He fur-
ther believes that the bacilli enter the blood by the
lymph vessels through the lesions in the tonsils, and
are deposited in the interstitial tissues around the
lung alveoli, the tonsils being regarded as the pri-
mary point of infection. In some instances he
assumes it to be possible for the plague bacilli to
pass from the mucous membranes of the trachea
and bronchi to the neighbouring lymphatic glands,
and from them to enter the blood, and in this way
later to reach the lung. Albrecht and Ghon have
shown that by the intravenous injection of plague
bacilli in animals, pneumonic plague did not result.
Strong and Teague are of opinion that the view
that pneumonie plague is primarily a septiceemic
disease and that the lungs become secondarily
involved by way of the blood circulation, and that
the tonsil is first infected is not acceptable.
From their study of pneumonie plague both in
man and animals, they feel justified in concluding
that infeetion in epidemie pneumonie plague results
from inhalation, the primary point of infeetion
being not in the tonsils, but some portion of the
bronchi, the organism either passing along the
bronchioles directly to the alveoli or through the
walls of the bronehioles to the contiguous tissue of
the lungs, giving rise, first, to peribronchial and
perivascular inflammation in the surrounding
tissues, und then to more diffuse inflammatory pro-
cesses throughout the lung. Having reached the
lung tissue, the bacilli rapidly multiply and produce
at first pneumonie changes of the lobular type, and
shortly afterward more general lobar involvement
of the lung tissue.
The blood becomes quickly infected and a true
bacteremia results in every ease. The fact that
the bronchial glands at the bifureation of the trachea
are always much more severely affected than any
of the other lymphatic glands also argues against
the theory that epidemic pneumonic plague is
primarily a septicwmic disease and that the lungs
are infeeted secondarily from the blood. More-
over, in the earliest stage of the disease, the blood
may be free from plague bacilli, as the authors have
shown by eultures.
It is true that in some instances the bacteremia
occurs early in the course of the disease and before
hepatization of the lung may have taken place.
However, microscopical examination will reveal
enormous numbers of plague bacilli in the engorged
lung tissue, from whieh it appears that the origin of
the bacteremia is clear.
The tonsils may become secondarily infected m
pneumonie plague just as other lymphatie glands—
for example, the bronchial ones—become so
infected. | However, in pneumonie plague death
usually occurs before any marked macroscopic
changes occur in the tonsils. There is no doubt
also that the tonsils may become primarily infected
in epidemics of pneumonie plague just as has
occurred in sporadic cases in epidemics of bubonie
plague; such cases have been previously reported.
This, however, is not the common channel of
primary infection, and in such cases involvement
of the glands of the neck occurs early in the course
of the disease. Such cases are really instances of
bubonie plague in which the lungs may, or may not,
become secondarily infected.
In some instances plague infection may occur
directly through the mucous membranes of the
mouth and throat. Primary septicemia may then
result. In those instances in which the infection
is virulent and severe, and the susceptibility of the
host marked, death may sometimes occur before
bubonic involvement is apparent. In other in-
stances, bubonie involvement of the glands of the
neck and septicemia are present. No true pneu-
monia oeeurs unless infection by inhalation has in
addition taken place. The German and the Aus-
trian Plague Commissions concluded that primary
plague septicemia probably does not exist. How-
ever, these Commissions made their observations
only during epidemics of bubonic plague. From
studies made upon human beings, during the Man-
churian epidemic, as well as from the animal ex-
periments quoted above, the authors conclude that
primary plague septicemia does sometimes take
place and that death may oceur, though rarely,
before visible lesions have taken place cither in the
lungs or lymphatic glands.
(To be contin ued.)
Hotices to Correspondents,
1.—Manuscripts sent in cannot be returned,
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JOURNAL oF TROPICAL MEDICINE AND HYGIENE should com-
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5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
—|
April 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Original Communications.
PRELIMINARY NOTES ON A TRYPANOSOME
CAUSING DISEASE IN MAN AND ANI-
MALS IN THE SEBUNGWE DISTRICT OF
SOUTHERN RHODESIA.
By Lr. E. W. Bevan, M.R.C.V.S.,
Government Veterinary Bacteriologist, Southern Rhodesia.
INTRODUCTION.
THE various strains of trypanosomes used in these
observations were obtained by Drs. Fleming,
Stohr, and Huggins in November, 1912, from
natives and animals found to be suffering from
(No. 7, Vol. XVI.
trypanosomiasis in the vicinity of the Busi River,
Sebungwe District, Southern Rhodesia.
Blood taken from these natural cases was inocu-
lated into clean rabbits kept in fly-proof cages,
which were returned without delay to the Veteri-
nary Laboratory, Salisbury.
Six animals were thus. inoculated, namely, two
rabbits with each of the following strains :—
(1) Human strain, from a native from Siandola’s
Kraal, carrier to Dr. Stohr. Two rabbits (Nos. 1
and 2) inoculated October 21, 1912.
(2) Dog strain, from Native Commissioner’s dog,
which had been with its master through the fly
area some-six weeks previously and had visited the
SEBUNGWE TRYPANOSOMIASIS.
First passage into rabbits. Inoculated, October 21, 1912.
Received Salisbury, October 29, 1912.
; HUMAN STRAIN Doa STRAIN GOAT STRAIN
Date * i E:
Rabbit 1 | Rabbit 2 Rabbit 3 Rabbit 4 Rabbit 5 Rabbit 6
October 29, 1912 2—100* | 100—100 100—100 Negative 5—100 Negative
„ 30 ,, is | — 400—100 300—100 e 2—100 e:
» 91 , " Numerous Negative rt Negative Negative
November 1, 1912 300—100 500 —100 5 Negative » »
$5 S. us e Dead TA f às
19 3 ” Dead wee m wee wee wee
$3 £ 4 ai 20—100 Negative 55—100 38—100
» Ta, 4—100 8—100 900—100 Negative
m 9 ,, Dead 15; T a.
» 12 ,, e. 1—100 400—100 Negative
w 14 ,, iav Negative Negative $3
LAJ 15 ” 10—100 mn .
n Y, "m Dead mL.
» 18 ,, 10—100 A 4—100
D E 3—10 | 2s
T 22 ,, 1--100 20—100
December 2 ,, Negative 20—100
» 5, es 1—100
» 12 ,, 1—100 Negative
» 18 ,, 3—100 s$
m 20 ,, Ea Re-inoculated
es - 26 » one Dead
January 24, 1913 Alive sey
* Average of trypanosomes found in 100 fields.
TABLE SHOWING PERIODS OF INCUBATION AND DURATION OF
DisEASE IN RABBITS INOCULATED FROM NATURAL CASES.
pne e JI
Period of incubation Duration of disease
Human strain—
Rabbit 1... Infected on arrival, | 18 days.
therefore less than
8 days
‘Rabbit 2... Ditto 12 days.
Dog strain—
Rabbit 8 ... ey Ditto 19 days.
Rabbit 4 ... ‘| 17 days | Chronic (alive
January 24, 1913).
Goat strain—
Rabbit 5... .. | Less than 8 days ... | 27 days.
Rabbit 6... | 14 days ..|Chronie (re - inocu-
lated December 20,
1912, and died,
December 26, 1912).
TABLE SHOWING PERIODS OF INCUBATION AND DURATION OF
DISEASE IN ANIMALS SUB-INOCULATED FROM ABOVE RaBBITS.
Doos SHEEP
Origin of virus BE * 3 is 38 h 2
Esa Rid |riá HE
A8 ET |*"8 A”
a! JT E -
Human strain— |
Through rabbit 2 ...| 4 34 | 4 |49
Dog strain-- |
Through rabbit 3 ... 5 22 8 | Alive January 24,
E |
| 1913
Goat strain— |
Through rabbit 5 ...| 8 26 8 |Alive January 24,
1913.
Dennen EEE
114 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1913.
Busi Valley. Two rabbits (Nos. 3 and 4) inoculated
October 21, 1912.
(3) Gout strain, from a sick goat at Siandola's
Kraal, on the Busi River. Two rabbits (Nos. 5
and 6) inoculated October 21, 1912.
The table of observations (p. 113) made of these
six rabbits is given in some detail, since being the
first passage, in similar animals, of trypanosomes
obtained direct from their natural hosts, the results
are of more importance for purposes of comparison
than those obtained after a series of subinocula-
tions.
Morpno.oey.
Living, Unstained.—The movements of trypano-
somes taken from Rabbit No. 1 (human strain),
tabbit No. 3 (dog strain), Rabbit No. 5 (goat strain),
were similar. The parasites were seen to wriggle
violently ''sur place,’’ but showed no active trans-
lation. When they left the field they could easily
be followed up and kept under observation. In
these respects they corresponded with similar pre-
parations of the Ellacombe strain of the so-called
T. rhodesiense, which were obtained from a rabbit
for purposes of comparison.
Dr. Fleming, who examined living preparations
taken from the original hosts in the field, expresses
the opinion that the trypanosomes in subinoculated
animals are less active.
Fired and stained with an Azur-Eosin modifica-
tion of Giemsa stain, the trypanosomes encountered
in Rabbits Nos. 1 and 2 (human strain), No. 3 (dog
strain), and No. 5 (goat strain), and in animals sub-
inoculated from them, have appeared identical.
‘* Tadpole ” forms of ‘‘ pecorum ”’ type, short and
stumpy, intermediate and long free-flagellated
forms of ‘‘ nagana’’ type have been encountered,
but it has not been possible to draw any sharp
divisions between one type and the next, the one
merging into the other.
The posterior extremity of the trypanosomes has
differed with the various types; in the long free-
flagellated varieties it has been drawn out to the
extent of some 5 mierons beyond the kinetonucleus,
thus presenting the ‘‘ snout ’’ and ‘* pike-headed ”’
forms commonly described. In shorter forms it
has been less prolonged and has appeared conical
or rounded, the kinetonucleus being relatively
nearer the end, and sometimes actually at the end.
In blood from dogs about to die the *''hippo-
headed " forms described by Bruce, and shown in
the drawings of the trypanosomes of Nyasaland,
have been encountered, being most numerous at
the edges of the film.
A number of individuals in each of the strains
have showed numerous large metachromatie gran-
ules, not only in the anterior but also in the posterior
half of the body.*
* T, brucei is often described and depicted as having a
number of such granules in front of the nucleus, a feature which
is said to differentiate it from T. evansi., In Lady Bruce's
drawings of the T. brucei of Uganda posterior granules are
shown in the short and stumpy types, but not in the long types.
In the drawings of 7. dimorphon (T. brucei ?), Khartoum,
granules are seen in the posterior half of the long forms.
** Reports of the Sleeping Sickness Commission of the Royal
Society," No. xi, section 27, plates 4 and 5.
These granules were scen as frequently in the pos-
terior as the anterior half, und were present in all
forms of the parasite. Some types contained three
or four granules close to and as large as the kineto-
nucleus, which could only be distinguished by its
association with the flagellum. In some specimens
the nucleus appeared diffuse with granules embedded
in its substance; in others granules appeared to be
situated in the undulating membrane close up to
the flagellum.
In some individuals the granules in the anterior
portion of the body have showed the peculiar
arrangement described by Kinghorn and Yorke! in
connection with the human trypanosome of North-
East Rhodesia, viz., “a row along either side of
the trypanosome with a clear strip of protoplasm
intervening,” but in the majority of parasites they
were not so arranged.
The nucleus was round or shortly oval, and
generally situated about the centre. In each
strain, and especially when stumpy types of parasite
prevailed, forms were met with having the nucleus
situated in the posterior third. The number of
parasites met with in preparations of the peripheral
blood of rabbits and dogs varied from an average
of 1 to 500 in 100 fields. Just before death as many
as twenty in a field could sometimes be counted.
In sheep, parasites were rarely found, and the
course of the disease had to be considered from the
temperature and clinical symptoms. In these
respects the Sebungwe trypanosome corresponds
very closely with that met with in animals inocu-
lated with the original W.A. strain of T. rhodesi-
ense (Veterinary Journal, 1911, p. 41).
The following measurements were made of
trypanosomes obtained from the original first
passage rabbits :—
Strain Rabbit No | Minimum Average | Maximum
nas | Ua PE |
Mierons Microns -4 Microns
Human avs 1 11 23.15 33
Dog ju sw] RB 44 126 91.12 31.5
Goat M 5 | 10.8 20 31.5
Average 11.46 21.42 82
The discrepancies in the above may have been
due to the fact that the preparations from which
the measurements were made were not taken at
identieal stages of the infection in each host, the
proportion of types varying considerably from day
to day. However, the measurements of the
Sebungwe strains do not differ more from one
another than do those given by various authorities
for T. rhodesiense and trypanosomes of the same
class, as may be seen from the table on p. 117.
From the above it will be seen that the Sebungwe
trypanosome in the rabbit—first passage from its
natural hosts—shows shorter minimum and maximum
+ Annals of Tropical Medicine and Parasitology, March 29,
1912, vol. vi, No. la, p. 9.
April 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 115
OCTI9I2. NOV. DEC.
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The beginning of the Temperature Chart of x Dog inoculated with T. gambiense (Laveran and Mésnil).
[April 15, 1913.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
116
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April 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
A COMPARISON OF MEASUREMENTS OF VARIOUS
TRYPANOSOMES.
2 5 8 v E
3 E E TE AE
& n 8 E %
> ô a 3
Sebungwe Trypanosomiasis.
Microns|Microns Microns
Human strain Bevan Rabbit |11.0 | 23.15 | 33.0
S E E 19.6 | 21.12 | 31.5
Goat S is P 10.8 |20.0 |81.5
HOMER ae ee MEIN
Average... | 11.46 | 21.42 | 32.0
T. rhodesiense.
\Microns)Microns)Microns
Stephens and | Rabbit 14.0 | 19.4 | 27.0
Fantham
M Various |12.0 | 23.6 | 39.0
hosts |
Kinghorn and | Human | 13.25 | 21.25 | 89.0
Yorke |
s Game | 11.75 | 21.38 | 35.5
a Fly | 13.0 | 21.67 | 36.25
T. gambiense.
Microns|Microns{ Microns
| Bruce Rabbit ps 22.1 | 33.0
T. brucei.
| Ae Rag UAE
| Bruce Rabbit | 13.0 | 23.2 |38.0
forms than allied species of trypanosomes, but
that the average corresponds very closely with
Kinghorn and Yorke’s estimate of T. rhodesiense as
met with by them in man, game, and flies.
CLINICAL SYMPTOMS.
Rabbits have become very emaciated, but have
not shown the cdema of the head which charac-
terized the infection produced by the strain of
trypanosome obtained from W.A. one of the first
to become infected with the human trypano-
somiasis of the Luangwa Valley.
Dogs.—There has been no marked difference in
the symptoms set up by the various strains of
trypanosomes. Dogs have shown intense angemia
and weakness, and have rapidly wasted away.
During the last few days they have appeared dull
and sleepy, and have remained lying upon their
sides in a helpless condition. When called by their
names they have wagged their tails, but made no
attempt to rise. Opacity of the cornea has
developed in each case. No marked cedema of the
face has been noted. The temperature charts here-
with of the three dogs may be compared with that
given in the English edition of Laveran and Mesnil’s
work on ‘‘ Trypanosomes and Trypanosomiases,''
p. 386.
Sheep.—The progress of the disease in sheep has
been slow, and characterized by marked and pro-
longed elevations of temperature. Shortly after
inoculation some degree of cdema of the face
has developed, and it was at first thought that.
117
this symptom closely identified the disease with
that caused by the so-called T. rhodesiense, but this
cedema did not increase to the same extent as did
that of .sheep inoculated in 1909-10 with the
Luangwa trypanosome, but rather showed a ten-
dency to reduce. The same results were obtained
with each strain.
Rats.—Since the above observations were made
we have received from the Onderstepoorte Labora-
tory a number of white rats with which experi-
ments can be more rapidly and economically per-
formed.
It is too early to venture upon a diagnosis of the
parasite with which we have to deal. The pre-
sence of the small ‘‘ tadpole " types in close
association with and inseparable from '' nagana ”
types is very confusing and might suggest that we
are dealing with a mixed infection were it not for
the fact that the same phenomenon has been met
with in subinoculated animals, whether the virus
has been derived from man, dog, or goat. It
seems improbable that two species of trypanosome
should exist coincidently in three distinct species
of host.
The fact that posterior nuclei have been fre-
quently found does not justify us in regarding this
parasite as T. rhodesiense, inasmuch as such forms
have been met with by Blacklock in a strain of
T. brucei from Uganda, by Wenyon in an animal
trypanosome of the Bahr-el-Ghazal, and by Yorke
and Blacklock in a strain of T. equiperdum.
It wil be noticed that no reference is made in
this report to the results obtained in Rabbits Nos.
4 and 6 and their subinoculated animals. These
have necessitated a separate series of experiments
which are not yet completed, but which are of
sufficient interest to merit a separate report which
will be presented in due course.
Blood smears taken by the members of Dr.
Fleming's party, and independently by Mr. Jack,
Government Entomologist, from wild animals shot
in and around the Sebungwe “fly ' area, were
stained and examined at this laboratory. No para-
sites could be found in preparations from three
eland, two zebra, five m'pala, a tsessebe, a roan
antelope, three duyker, a waterhog boar, two reed-
buck, a sable bull, and five waterbuck, but in three
other waterbuck trypanosomes were encountered.
In one the parasites were very scanty, but in the
other fairly numerous, on an average one in a
hundred fields.
No distinction could be drawn between these
trypanosomes and those met with in infected
natives and domestic animals in the Busi Valley.
They were long forms of the '' nagana ” type, and
many showed the posterior granulation previously
referred to.
Smears were also taken from a dog noticed to
be sick at Sinamzangwa's Kraal, and these proved
very rich in trypanosomes of all types, from
the ''tadpole '" forms measuring no more than
9.5 microns to the long free-flagellated forms
35 microns long. Some idea of the varieties met
with is given by the drawing, showing eleven para-
sites which presented themselves in three fields.
118
FILARIA LOA CASES: CONTINUATION
REPORTS.
By GeorGE C. Low, M.A., M.D.
Lecturer, London School of Tropical Medicine.
IN a paper published in the JOURNAL or TROPICAL
MEDICINE AND HYGIENE, January 2, 1911, on Filaria
loa, the clinical histories of five cases of infection
with that parasite were given. At that time í
stated that prolonged investigations of individual
cases were required to clear up much of the
obscurity which the different symptoms of the
disease bore to each other. In 1912 (JOURNAL OF
TiRoPicAL MEDICINE AND HYGIENE, February 1, 1912)
I examined the blood of Case III again, and found
u persisting eosinophilia and a persisting absence of
embryos in the peripheral blood. ^ Lately I have
had the opportunity of seeing this case again, and
also two of the other ones, viz., Cases IV and V.
The results of the examinations of these cases are
of great interest, but before going into them in
detail, one must mention a very interesting paper
by Meinhof* on the same subject.
This author had the exceptional opportunity of
following up a ease of F. loa over many years in
much the same way as I am doing with my cases
now. Meinhof's ease was a lady who went out to
the Cameroons in 1903. In 1905, after several
attacks of severe fever, multiple swellings, having
all the characteristics of Calabar swellings, appeared.
lor the next years these swellings kept coming and
going, but it was not until May, 1911, that an
adult filaria appeared. At this date, six years after
the first swellings were noticed, a male F. loa
measuring 2 em. in length was’ extracted from the
left eye. In October, 1911, the author examined
the patient’s blood, but did not find filarial embryos
in it. The eosinophiles were then 8 per cent. On
December 15, 1911, a filaria appeared under the left
eye, but was not extracted. On January 4, 1912,
loa embryos were found, for the first time, in the
blood, and a differential count of the leucocytes on
that same day gave the eosinophiles at 22 per cent.
On February 2, 1912, a male adult measuring
24 em. in length was removed from beneath the
conjunctiva of the left eye, and on various occasions
embryos were again found in the peripheral blood.
Another worm was extracted in July, 1912.
If the date of the infection of Meinhof's case is
taken at 1905, when the first Calabar swellings
appeared, then the first adult filaria appeared six
years afterwards and embryos eight months after
that, i.e., almost seven years from the beginning of
the infection. Such a result helps to explain the
persisting absence of embryos in some of the cases
now to be described.
Case III.—After seeing this case on January 2,
1912, the patient returned to Africa, but to a non-
endemic area. From that date until he was seen
again in London, April 7, 1913, his filarial mani-
festations were few in number, no further Calabar
* “Zur Klinik und Morphologie der Filaria und Mikro.
filaria loa (diurna)," Beihefte zum Archiv für Schiffs- und
Tropen-hygiene, 1913, Band xvii, Beiheft 2,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15, 1913.
swellings appearing, but once or twice he felt a
filaria near his left eye, and on another occasion
had the sensation of one wriggling about under the
skin in front of his left ear. His blood examination
(April 7, 1913), the eighth, gave the following
results :—
Reds 4,500,000 | Size and shape of corpus-
Whites 7,400 cles normal. No malarial
Hemoglobin 90% J or other parasites.
DIFFERENTIAL,
Number of | | Number of
leucocytes Percentage | leucocytes per
counted cubic millimetre
a es Ss ees E.
Polymorphonuclears ... 285 57 4218
Large mononuclears ... 21 4,2 310.8
Lymphocytes ... 534 125 25 1850
Eosinophiles ... cul 66 13.2 | 976.8
Transitionals ... ed 2 04 | 29.6
Mast cells ése - 1 : 0.2 14.8
Total 500 100.00 | 7400.0
Five slides of blood each containing 20 c.mm.,
i.e., 100 c.mm. in all, were examined for filaria, but
the results were again absolutely negative. The
eosinophilia, however, as the table shows, persists
as it did in 1912, and this fact, together with the
appearance of the filaria in the vicinity of the eye,
points to the infection still going on.
As I have already stated in previous communica-
tions, the failure to find embryos at any given time,
even though large quantities of blood are taken,
does not necessarily mean that they may not have
been present in the intervals between the examina-
tions. k
This on the whole, however, is unlikely, because
when embryos once appear they are remarkably
constant in their presence, and may be found at
any time during the day over periods of years (vide
Case V later) In a ease of Sir Patrick Manson's
at the London School of Tropical Medicine which
I used to study the same thing eccurred, and I
have also seen it in others as well.
I think, therefore, that the absence of embryos
in the eight different examinations made on Case III
over a prolonged period of time mean that for some
reason or other they have never been there.
Case IV.—After my examinations of this case
during 1910 and the early part of 1911 the patient
returned to Northern Nigeria in February, 1911,
the endemie area in which he acquired the disease.
In the course of his following tour he five times got
a fleeting swelling on the back of the right wrist.
These swellings came up suddenly, they did not feel
hot, there was no pain, and they only lasted a day
or so (Calabar swellings). In April, 1912, he got
boils whieh kept coming and going until his arrival
in England, June, 1912; they then disappeared, and
he has not had them since. During his tour he had
one attack of fever, and on some other occasions
felt somewhat off colour, but had no temperature.
Since his return home no further indications of
filariasis have manifested themselves.
April 15,1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE
119
The physical examination showed all the patient’s
systems to be practically normal; the spleen was
very slightly enlarged, the blood examination was
made on September 3, 1912, with the following
results :—
Reds 4,880,000 Size and shape. of red
Whites ... 8,200 corpuscles perfect. No
Hemoglobin 95 % ) malarial or other parasites.
DIFFERENTIAL.
erea C — — — —— — ÍÀ——'
Number of Number of
leucocytes Percentage leucocytes per
counted cubic millimetre
Polymorphonuclears ... 262 52.4 4296.8
Large mononuclears ... 18 3.6 295.2
Lymphocytes ... TE 131 26.2 2148.4
Eosinophiles ... ui 85 17 1394
Transitionals ... scil 8 0.6 49.2
Mast cells ds us 1 0.2 16.4
Total 500 100.0 8200.0
Four slides of blood each containing 20 c.mm.,
that is, 80 c.mm. in all, were examined for filarie,
with negative results both as regards F. loa and
F. perstans embryos. An embryo of the latter, it
may be remembered, was seen once in 1910, but
that infection has now apparently completely died
out.
It is now practically two years since I first
examined the patient, and it is well over two years
since he first saw his filaria in his eye, i.e., four
years in all.
Further, fugitive swellings have appeared in the
lust years on his arms, and this probably means
that there are more adults moving about in his
subeutaneous tissues. Re-infection cannot also be
excluded in this case, as he returned, as mentioned
above, to an endemic area.
Embryos have not yet appeared in the blood, but,
as the blood-count shows, the eosinophilia still per-
sists, and is higher than it was at my first examina-
tions.
Case V.—The synopsis of this case in my paper
in the JOURNAL oF TropicaL MEDICINE AND HYGIENE
of January 2, 1911, was as follows: ‘‘ This is a some-
what remarkable case; the patient had been over
three and a half years away from the endemic area
(all that time living in this country), and had never
presented any signs of filarial infection. I simply
examined his blood on the off-chance of something,
as he had been in Nigeria, and was rewarded by
finding the embryos. His subsequent history
should be interesting.”
After writing that paper I again saw the patient
on February 21, 1911, and 20 c.mm. of blood taken
in the morning showed thirty-six filarie present.
After this date I lost sight of him until the other
day (April 8, 1913), when he came to see me again.
During the last two years he has been abroad, but
never in a F. loa endemic area.
During the whole of this time he has never shown
the slightest signs of Calabar swellings or of any
filaria moving about either under the skin or about
the eyes; he has lately, however, complained of a
little breathlessness and a suspicion of some pre-
cordial pain with slight palpitation. Whether this
has anything to do with the F. loa infection or
not it is difficult to say, but in this connection it is
interesting to note that Meinhof’s patient also
developed cardiac symptoms, e.g., irregularity of
the heart, with some increase in the diameter
towards the left.
I made a careful physical examination of the
heart, but could detect no increase in its size, nor
were there any murmurs indicative of organic
disease. As the patient was and had been a heavy
smoker I suspect tobacco may have had something
to do with it.
A complete blood examination gave the follow-
ing :—
Reds 5,160,000 Size and shape of corpus-
Whites 7,400 cles perfectly normal. No
Hemoglobin 100 % ) malarial or other parasites.
DIFFERENTIAL,
SS...
Number of Number of
leucocytes Percentage leucocytes per
counted ‘cubic millimetro
|
Polymorphonuclears ... 264 52.8 3907.2
Large mononuclears ... 26 5.2 384.8
Lymphocytes ... x? 117 23.4 1731.6
Eosinophiles ... SA 86 17.2 1272.8
Transitionals ... e 4 0.8 59.2
Mast cells z E 3 0.6 44.4
Total 500 100.0 | 7400.0
Examination for Filariz, 12 noon.—Five slides
containing 20 c.mm. of blood each were examined.
The following numbers of filarie were counted in
each: 46, 37, 42, 35, 86, or a total of 196 in 100
e.mm. of blood, e.g., an average of 39.2 per slide.
These embryos had all the anatomical and other
characteristies of those of F. loa, being quite typical
in every respect. Of course, the time at which the
blood was taken (12 noon) would show the embryos
at their greatest number, but, even granting that,
such a number per 20 c.mm. of blood* must meun
quite a good infection of adults.
Why these should have never come near the
surface of the body it is difficult to say; possibly
they are living in the deeper tissues of the chest
or abdomen; but even so, one would have thought
that in the long period of time the patient has had
his infection, some of them would have come up
under the skin. One thing the history of this
individual case emphasizes very clearly is the long
time that such an infection may persist. Two
years have now elapsed since I examined the patient
in 1911, and to that time have to be added the
three and a half years which elapsed between his
* I now always usc the measurement 20 c.mm. of blood
as my standard, and would suggest that other filariologists
might adopt the same. By doing so more harmonious results
would be obtained in the comparisons of numbers of filariw
present in the blood at any given time. The blood is blown
out on to a slide, spread into a film, dried, dehemoglobinized
by placing in water, fixed and then stained in the usual manner.
120
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1918.
leaving Nigeria and my first examination of him.
This makes five and a half years away from the
endemic area. That the fecundity of the breeding
adults has not diminished in the last two years is
also shown by the number of embryos per 20 c.mm.,
this coming out at practically the same as in 1911.
Other points of interest brought out by the com-
plete blood-counts of these cases are that the infec-
tion does not produce anemia. The red corpuscles
are just about normal in numbers, and their size
and shape are good. The leucocytes again are not
influenced, 7,000 per c.mm. or thereabouts being
the usual thing. In differential leucocyte counts
eosinophilia is the feature in the blood, and this is
a distinetly high one, much more so, for example,
than in cases of F. bancrofti. Y
Not only are these cells differentially inereased,
but they are absolutely so as well. Normally taking
the leucocytes as 7,000 per c.mm., the eosino-
philes should total from 140 to 280 per c.mm., but
as will be seen from the details of the examinations
given above, in F. loa infections, they are absolutely
inereased to as high as from 976 to 1,304 per c.mm.
What this means is by no means clear. It may
be produced by some toxin excreted by the worms,
but if this is so it certainly does not appear to
influenee the general health detrimentally, or at
least as far as one can determine clinically.
With Leiper's discovery of a- chrysops as the
intermediate host of F. loa our knowledge of the
life history of this parasite is gradually becoming
complete. We can, for example, easily distinguish
the embryos from those of F. bancrofti, and prac-
tically all that is required now is to solve the riddle
of why, in so many cases of the infections, embryos
are so long in appearing in the peripheral blood.
Do some cases occur in which they never appear at
all? Clinieally also, several points require solution.
One must, before concluding, refer to the most
instruetive and interesting paper by Fülleborn* on
the morphology and differential diagnosis of micro-
filarie, which has recently appeared. In it the
distinction between loa and bancrofti embryos is
summed up most clearly, and many excellent plates
give all the details of the minute anatomy of these
and the other human embryos. His system of
measurements should be adopted by all workers on
the subject of filariasis.
CLIMATIC AND OTHER FACTORS INFLU-
ENCING THE HEALTH OF EUROPEANS
IN UGANDA AND EAST AFRICA.+
By Dr. A. R. Cook.
C.M.S., Uganda.
Dn. Cook prefaced his remarks by giving his
personal experiences when landing and his experi-
ence with members of his party.
Climatic Conditions in Uganda.—The word climate
* © Beiträge zur Morphologie und Differential diagnose der
Mikrofilarien,’’ Beihefte zum Archiv für Schiffs- und. Tropen-
hygiene, 1913, Band xvii, Beiheft 1.
t Paper read before the Association of Medical Officers of
Missionary Societies.
connotes a complex of conditions, not only that of
temperature, but also the pressure of the atmo-
sphere, the prevailing winds, the actinic effects of
the sun's rays, and intimately bound up with the
climate are the bites of insects, and lastly, there
is dust. : : ; :
Temperature.—The diurnal tange in Uganda is
‘extremely small, and the person who arrives in the
country fresh from home, seeing little rise of tem-
perature in the day, thinks the climate is a very fine
one; but it is really a very bad one.
Look outside now and see what deplorable con-
ditions you live in in England! In comparison that
of Uganda is delightful in the extreme. But
although the climate of England is deplorable, yet,
in that very deplorable condition which God has
given to the Anglo-Saxon, so varied, we see one of
the factors in producing a character of that kind
which calls out all the moral forces of a man,
and in this we have the secret of a high national
character.
We find in Uganda the range of temperature is
very small. The adaptability of a European for a
climate depends very much on the range of climate.
In many places during the year there is a very wide
range of temperature, but in Uganda the lowest
temperature recorded by myself was 599 F. and the
highest 869 F.; I think you will realize -the
significance of such a thing. The ordinary low
- temperature of the day is 65° F., and it rarely rises
above 859 F. The temperature varies between 659
and 859 F. year in and year out. This must affect
the physical condition. What we feel in Uganda is
chill. There is no cold. With the very narrow
range of temperature the climate is distinctly
enervating to any European. You feel after a time
that you must more and more bring your moral
forces into play. You get up feeling tired each day.
We all know the immense advantages of the cold
bath. If you are exposed to great and sudden heat
the well-trained body has the cutaneous arterioles
in a very responsive condition; that is very largely
lost in Uganda.
Having this temperature in Uganda, when we
come home we find the vessels have to be retrained
to stand the cold. When one inquires of people
home from the Tropies, one realizes that those who
have had a small range of temperature feel the
cold of England very much, and feel it for several
years. Very few Europeans are able to keep up
the cold bath which they used to enjoy in England.
Sometimes we find people who keep it up for a year,
but sooner or later the inevitable result follows and
they get no reaction after the bath. At first,
though the water is not cold, you feel chilly and
depressed afterwards, and it is even more dangerous
should you be carrying, as many do, the germs of
malaria, as a cold bath is apt to rouse these into
activity.
When I was travelling in the Sudan from Uganda,
about a six-weeks’ journey, marching to Mongalla,
I came to a very well-known unhealthy station.
When I got to this place, after a long march of
twenty miles, I was kindly put up by the Govern-
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'"ÉIGDCOD TINAY CUHNSHIDAH ANV UNIOIGHN CIVOIJONIL TO TIYN NOL THL
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, APRIL 15, 1913.
PLATE 2.
A and B. Sheep infected with Sebungwe Trypanosomiasis.
Sheep infected with the original ** W.A.” strain of T. rhodesiense.
To illustrate paper by Lr. E. W. Bevan, M.R.C.V.S,, * Preliminary Notes on a Trypanosome causing Disease in Man
and Animals in the Sebungwe District of Southern Rhodesia.’
April 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ment Official on the spot, and, not wishing to keep
him waiting, I departed from my invariable rule and
took a cold bath, not waiting for the water to be
boiled as usual. I had hardly emerged out of the
bath when I had a headache and my temperature
suddenly rose till the next day it was 105° F.
Almost as speedily it went down again, and after
forty-eight hours was normal. I felt fatigued and
exhausted. I had been taking 5 gr. of quinine a day,
and I think there is very little doubt that what
happened was that the unusual conditions had
stimulated into activity latent germs. I would point
dut, as will be seen by these symptoms, that one
cannot. take a cold bath with impunity if not
accustomed to it. It takes some time to retrain
this eutaneous responsiveness.
During the last time when I was on furlough, in
1897, I did not venture to bathe the whole time,
but this time I resolved to do so, in spite of dis-
agreeable sensations. We were staying at Woola-
combe Bay, where we had probably as favourable
circumstances as anywhere this summer. I took
my temperature before going into the sea, and I
found the temperature depended upon the length
of time I spent in the water. After staying only
twenty minutes in the sea my temperature dropped
69. The impression left on my mind was that one
did not get the glow one used to get. One had to
undertake active exercise on getting out of the sea.
If I had sat down on a rock I should have been
decidedly depressed in health, but by running about
I regained a normal condition.
In observing the health of people coming from
Uganda to the English winter one finds a tendency
to bronchitis. Many children who are born out
there are especially liable to bronchitis when they
come home. One family left Uganda some years
ago with several.children, and one boy has had
bronchitis every Christmas regularly since then.
Now we will turn to a more cheerful aspect, that
of the good to be derived from a sojourn in England.
Although the sea bathe is unpleasant there is no
doubt it tones up the system. It is quite interesting
to see the effect of the English climate on the colour
of children. Our two children when we came home
exhibited tropical pallor, and although they were
pale during the summer, as the autumn came
on a proportionate colour came, and now they have
as rosy cheeks as any children, which is no doubt
due to the tonic effect of the cold.
Nervous System.—There is a certain amount of
neuralgia associated with malaria. A man is not ill,
but he gets run down. Irritability is a sign of a
heightened nervous system which is too often put
down to idiosynerasy. All the reflexes are height-
ened. When I wish to find what is the general
condition of health I try the knee-jerks, and it is
very striking to see the brisk reaction of people who
have been for some time in Uganda. We notice
especially the effect of small stimuli, as, for in-
stance, the effect of a sudden noise.
We see the effect of loneliness on missionaries,
especially in the case of individuals inclined to look
on the dark side of things. It is shown more even
121
in men than women. Loneliness may affect very
injuriously the health of the man who has been left
a long time alone. In fact, there may be in cases
unstable equilibrium.
With regard to insanity, we see the effect of the
climate where there has been a direct family history
of insanity. This point is of immense importance
to medical officers, and neglect to consider it may
lead to disastrous effects.
Next there is the question of insomnia. My own
plan is to divide sleeplessness into insomnia and
mere sleeplessness.
Speaking to medical confréres, few of us have
undisturbed nights, and for many years I have
slept badly myself, and I am frequently wakened
in the night and find a difficulty in getting to sleep
again, yet I would not for a moment allow that
there was any insomnia in my case.
With reference to many of those people who think
they suffer from insomnia, one finds when one
carefully goes into the case that they are not
suffering from insomnia, and one can set their mind
at rest by explaining to them the difference between
insomnia and mere sleeplessness.
Many have a certain heightened, keyed-up con-
dition which is really produced by the great mental
effort of preparing for the mission field. It is
particularly necessary that medical officers should
look into the method of cram which is carried on
in colleges where the knowledge is given in so-called
tabloid form, and concentrated head-learning is
stuffed into them. This is by no means the best
preparation, and it gives effect to a restless state
of mind.
The nervous system is the first that shows signs
of stress and strain. The second most important is
the
Vascular System.—High blood-pressure is very
uncommon in the Tropics. Narrowing our inquiry
to missionaries, it is very seldom the case. I have
not often taken a blood-pressure under 95 and
seldom above 120.
Again, there may be organic heart disease. It
is very seldom that a person escapes with this con-
dition after the very careful medical examination
to which they are submitted before they go out.
At the same time some cases of organic heart
disease with compensation may do very well.
Tachycardia is very important to our mind. It
connotes a difficulty, that of slackened control of
the veins. I mean a much looser term by this—
undue frequency of the pulse. We find it in people
who have been a considerable time in the Tropics.
The pulse is unduly sensitive to posture—lying
down 60, standing up 80.
I have taken trouble by X-rays to map out the
area of the heart to see where it is dilated, out of
position, and so on. The dimensions of the heart
by X-rays are more or less normal. Undoubtedly
the condition improves on getting home to a colder
climate. I think there is no harm at all if pre-
cautions are taken, and I do not think it is in itself
any contra-indication to sending a person to the
mission field.
122
Irritability of the Bladder.—Certain missionaries
suffer from irritability of the bladder. In a certain
proportion of cases the irritability is undoubtedly
due to chemicals, sometimes due to tea, or to the
undue concentration of the urine.
Digestive System.—There is remarkably little
indigestion among the missionaries in Uganda.
Perhaps this is due to the large proportion of
vegetable diet.
I have never seen a single case of appendicitis
out there during the sixteen years that I have been
in Uganda. One of our doctors had an appendix con-
dition which needed the removal of that organ while
at home, but he had no attacks while in Uganda.
Cutaneous System.—The cutaneous system is
very little affected.
INFECTED INsECTS AND WORMS.
Here there is a tremendously rich field for re-
search. Among the lethal insects which surround
us there are mosquitoes, ticks, tsetse, sandfly, &c.
The Problem of Malaria is still the problem of
great importance. We are all of us quite unanimous
in the Tropies as to the very close connection
between malaria and blackwater fever. One can
almost go far enough to say to a man, '' You are in
a ripe condition for blackwater fever.”
Standing on Namirembe Hill, where the hospital
is situated, and looking out on the valley, 900 yards
away is the hill of Kampala, then a mile away is
another little hill. Possibly 90 per cent. of black-
water fever cases come from these two hills, yet
they are only 900 yards away in one case. This is
due to the fact that there are anopheles there and
they are often infected.
Quinine.—I deprecate the use of large doses of
quinine. One Government doctor gave 80 or 90 gr.
I believe the maximum dose which should be given
in the day is 30 gr., or even 20. This should be
kept up for a few days, then give 10, and then 5 gr.
I think we ought to use different sorts of quinine.
It is no use to treat every form by one sort. For
several years we used the sulphate. Now we use
very largely the hydrochloride, and I think on the
whole it has done better, but one cannot say even
with this that you never get blackwater fever.
Oecasionally the taking of even 5 gr. of quinine
produces insomnia, or muscular tremors or in-
digestion, and the addition of some bromide may
prevent this.
A senior Missionary was carried into Mengo one
day suffering from a double benign tertian attack,
and refused to take quinine, as he said it made him
feel so nervous. I gave him a hypodermic injection
of morphia with quinine, and he did not know that
he was taking it. When he recovered I told him,
and his delusion was shattered.
One eannot speak too highly of the great use of
cuquinine in children. I have found it useful in
several very serious attacks. It can be given to the
children in jam or butter, and they take it without
knowing. It can be given in slightly larger doses to
adults.
A well-known engineer, who came to me suffering
from malaria, said he could never touch quinine, and
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1913.
his doctor in India forbade him. We gave him
large doses of euquinine, and he took it without
knowing it, with the result that his temperature
dropped to normal.
In pregnancy the salt I like is the tannate or
hydrochloride with bromide.
Does Blackwater Fever Need Invaliding ?—When
Dr. Koch came to Mengo we consulted together
over a case of blackwater fever, and he told me that
he had given up invaliding anyone with blackwater
fever. He believed his system of taking quinine
every eight or nine days was completely successful,
and in only one case had it failed. Then the man,
after taking quinine, washed it down with a dozen
lager!
There is no system of prophylaxis by quinine
against malaria that you can guarantee not to be
followed by blackwater fever. The system of 5 gr.
of quinine daily is in my own opinion the best
method, taken just as one takes a lump of sugar in
a cup of coffee in the morning. There is no harm
at all if one goes on for months or for years.
When I went to the Sudan and led a party of
young fellows, pioneers of the Sudan Gordon
Memorial Mission, we pitched our tent at Bor, and
one could hardly imagine a worse place. South of
us the Belgian Government had had to abandon a
station, and north of us the Austrian R.C. Mission
had had to withdraw. I told the men that they
must take 5 gr. of quinine each day, and they did
so, and for twelve months we got practically no
attacks. I had just a few attacks of fever with a
temperature of 100° F. after I had been especially
fatigued. I am sure that all kept their health
through that dose of quinine. When I had to go
one man departed from the rule; the reason he gave
for omitting the dose was that he was so healthy.
As a result he speedily got fever.
Selection of Candidates.—YVor some years people
were a little relaxing in the selection of candidates,
and the Medical Officers here have had the greatest
difficulty in persuading them that Uganda is not a
health resort.
A Government officer asked his friend whether he
was finding much company on the road to Uganda.
‘ Yes,” he replied. ''I see plenty of fools going
up and invalids coming down !''
Extreme Value of Previous Medical Training.—
What a training like Livingstone College does for
men is simply invaluable. You will find this the
testimony wherever medical men have come across
those who have been through the training. It helps
to dispel the evil effects of funk.
The training also helps to dispel the evil effects
of ignorance, both as to diagnosis and treatment.
Discussiox.
In answer to some questions, Dr. Cook said :—
We have had men who have taken 10 gr. quinine
on two days in the week. I do not think 10 gr.
twice a week at all suffieient in sub-tertian.
If a moderate attack of blackwater fever, I believe
in changing the station first and not invaliding.
People may be allowed to return to the country after
two attacks.
April 15, 1918.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Some Missionaries go about freely when on duty
with a beetroot complexion; others are completely
protected from the sun.
With regard to the irritability of the bladder being
due to quinine, in one case not a grain of quinine
had been taken for many weeks together. In
another case a Missionary had two attacks of black-
water fever, and then was living in another place
where there was no blaekwater fever, and yet had
irritability of the bladder.
Advisable not to let any Missionary go out with
taehycardia. Take the pulse repeatedly.
In connection with accepting candidates with the
history of family insanity, other conditions would
have to be very favourable, i.e., the nervous stability
of the candidate.
Of the six Missionaries I mentioned who had near
relatives suffering from insanity three of them
suffered from irritability—not moral.
Cutaneous System.—Boils are not unduly com-
mon. Very few kinds have needed medical aid.
As regards dysentery, this is quite common in
Uganda. I think it is due to at least two causes:
(1) Flies; (2) nearly all the dysentery is of vascular
type.
With reference to the hypodermie method of
administering quinine, we have given quinine in this
way in hundreds of cases, chiefly in cerebral malaria
and in children.
If a fever resist quinine insistently, undoubtedly it
is not malaria.
If one gets a chill one is almost certain to have it.
Quinine is used per rectum in cases of infants.
——— 9 9— — ——
Unusual Cases of Hydatid Disease.—Hall, in the
Australasian Medical Gazette, February 22, 1918,
reports two unusual cases of hydatid disease. The
first case had suffered from hydatid disease of the
liver, and after being operated upon for this
developed a hydatid cyst in the scar of the opera-
tion wound. Such a condition is extremely rare,
Dr. Clelland, who has been compiling a biblio-
graphy of hydatid disease in Australian medical
literature, having failed to find a similar case
recorded, while the author himself can find no
allusion to such a case in any of the text-books at
his disposal. The other case was one of double
hydatid cyst of the lung. One of these cysts was
opened and drained, the patient having a rather
alarming hemorrhage through the tube, as well as
considerable hemoptysis, after the operation.
Later it was discovered that what was supposed to
be a pleural effusion was really another cyst, and
this was drained at a second operation. The
adhesion which had formed around the site of the
first operation wound prevented much collapse of
the lung and consequent hemorrhage, with the
result that the patient stood the operation much
better than the first one. The author comes to the
conclusion that when double or multiple hydatid
cysts are present in the lungs they should be
opened separately, or at least one first and the
others at a subsequent operation.
2
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THE JOURNAL OF
Tropical Medtctne and Ppgiene
APRIL 15, 1913. -
COLLOSOL ARGENTUM.—ITS USE IN SPRUE
AND POST-DYSENTERIC CONDITIONS.
COLLOIDAL preparations of metals have been
known for some time, but the ‘‘ collosols ’’—or
chemically prepared colloids—are a very recent
addition to our list of therapeutic agents.
So far two collosol preparations are available for
use, namely, argentum and hydrargyrum, but
within the past few weeks copper has been added
to the number. The argentum preparation pos-
sesses an interest of itself, for it has been shown
by Mr. Crookes's investigations that as a bactericide
silver possesses superlative qualities. Upon a
silver coin, for instance, bacteria cannot live,
whereas upon copper coins they thrive, and also
on gold coins they are to be found.
It is no doubt this property of silver which
accounts for the universal desire for silver cups,
spoons, forks, &c., for domestic use, bearing out
the prineiple that it is practical use and not mere
ornamentation which accounts for many of what
we have come to look upon as mere decorations. The
most marked instance of this is the presence of
curtains over our windows; originally of fine muslin,
with fine mesh caleulated to exclude (malaria)
mosquitoes and other insects, the curtains remain
with us, although the danger from malaria in
England no longer exists. Experience showed the
curtains were useful in preventing malaria,
although the part played by mosquitoes in its
spread was not understood, and they are present
to-day in our houses as decorations merely, and
with a mesh which is no longer fine, but enriched
with ‘‘ patterns’’ which cannot exclude insects.
Similarly, the desire for silver for practical use,
124
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1913.
although the scientific reasons for the desire were
not interpreted until lately, has also led to its use
for ornamentation. Mr. Crookes mentioned to the
writer the action of silver as a preservative by its
power of destroying organisms in the case of cut
flowers. Mr. Crookes placed cut flowers in vases
or bowls of different materials, glass, earthenware,
tin, copper, brass, aluminium, &c., and in silver,
and found that cut flowers kept many days
longer in silver vases than in any of the others he
experimented with, and found that the water in
which the flowers stood remained freer from
organisms when of silver than in the case of any
other of the receptacles employed.
The ''eollosol ' preparations consist of metals
in suspension as solid particles of extremely minute
dimensions, and they microscopically show marked
" Brownian ° movements. It is believed that the
action of collosol depends upon the physical con-
dition of the metals rather than upon their specific
action as metals. "Moreover, the peculiarity of the
metals reduced to the collosol state does not end
here, for it is said that their action is parallel with
that of organic ferments, so much so that they have
been termed metallic ferments.
In the Lancet of February 3, 1912, Mr. C. E. A.
MacLeod, F.R.C.S., gives an account of many ail-
ments in which he has proved the benefits of
collosol preparations, and it was Mr. MacLeod’s
experiences, and after consultation with Mr.
Crookes, that the writer determined to try collosol
argentum in cases of intestinal lesions.
Experimentally, it has been shown that collosol
preparations inhibit fermentative processes, and it
occurred to the writer that this property was one
caleulated to benefit cases of sprue in which in-
testinal fermentation is perhaps the most prominent
feature of the disease. Moreover, it has also been
shown that amongst other bacteria upon which
collosol preparations act, it is recorded that the
Bacillus coli communis is killed within ten seconds.
This fact also still further induced the writer, to
administer the drug; and yet more confidently, see-
ing that the intestinal flora are legion, that no
microbe is known that is not killed in laboratory
experiments in six minutes.
The first case in which the writer administered
the drug was one in which sore tongue, enormous
fermented stools, and the usual symptoms of sprue
were present. The dose was one drachm of collosol
argentum (Crookes) thriee daily for two days; the
effect was immediate, the fermentation in the stools
ceased immediately, the stools became somewhat
watery and of a green colour, masses of gelatinous-
looking material, stained of a bright green, were
passed, and the patient felt ‘‘ bad "' in an indefinite
way, and ascribed her feelings to the medicine. For
this reason the administration was stopped after two
days—six doses in all. The stools did not again
become bulky or frothy; in fact, the ** sprue stools "'
had disappeared, and in seven days after leaving
off the drug the patient passed a stool normal in
bulk, in shape and colour.
Experience has shown that the dose (60 minims)
was much larger than necessary, and although with
“ eollosols ’’ there is an absolute freedom from toxic
effects to the human organism, the writer found
that even with 5 minims the stools showed the
greenish colour referred to above, and that fer-
mentation disappeared.
The writer has also used collosol argentum in
post-dysenterie states, and in (so-called) colitis in
patients returning from the Tropics with marked
benefit.
The writer now administers the drug as follows:
The patient is given a couple of teaspoonfuls (2
dracims) of castor oil on waking, and three hours
afterwards collosal argentum in doses ranging from
5 to 60 minims in a tablespoonful (4 oz.) of distilled
water; food may be given two hours after the drug
has been taken. It is unwise.to give the drug soon
after food as digestive fermentation is checked by
the collosols.
On the second morning the drug may be given
early morning on waking, and continued on succeed-
ing mornings until the fermentation in the stools
ceases, or until they become green-tinged. Usually
two or three doses suffice, and even one dose of
10 minims served to check the fermentation char-
acteristic of sprue stools.
The writer now combines the collosol argentum
with the rigidly ‘‘ meat’’ diet which he has
advocated and used for the past fifteen years.
An interesting paper by Dr. H. C. Drury on
‘The Ceeliac Affection” appeared in Dublin
Journal of Medical Science of April, 1918. This
affection, although it so far has been described
in England as occurring in young children only,
bears a close resemblance to sprue—the bulky stools,
their pale colour, their porridgy consistence, and
their frequently frothy condition, combined with
marked wasting of the body, all present a picture to
the practitioner in the Tropies which suggests sprue.
All kinds of diet and drugs failed until Dr. Drury put
his patients on a ‘* meat "" diet—raw meat, meat
extracts, &c. Drs. Gee and Finny had also pre-
viously tried ‘‘ meat ’’ diet in ‘‘ the cceliac affection ”
with success. These experiences are a corroboration
of the value of meat treatment in intestinal lesions,
and the writer, after full fifteen years’ experience,
has never had occasion to use milk, except on an
occasional '* fast day,” during which for twenty-four
or forty-eight hours a ‘‘ change ’’ seemed indicated.
But even with meat fermentation at times super-
venes, and when the patient is convalescent and when
a fuller diet is observed acid fermentation of the stool
at times returns. This may be checked by collosol
argentum in small doses properly administered.
That the use of this drug is rational it cannot be
gainsaid, for fermentation betokens bacterial
activity of a pathological type, and the destruction
of these organisms by the silver preparation is a
safe and effective method of dealing with this, the
determining factor in sprue.
J. C.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, APRIL 15, 1913.
LONDON SCHOOL OF TROPICAL MEDICINE.
41st Session. January—April, 1913.
Front Row.—R. O. Sibley (Demonstrator), H. B. G. Newham (Director), Miss J. McDonald, Miss C. L. Houlton, Mrs, A. McLaren, P. Michelli, Esq.,C.M.G.
(Secretary), Dr. F. M. Sandwith, F.R.C.P. (Lecturer), Miss E. M. Layman, Miss L. S. McLean, Miss S. Summers (Assistant Entomologist),
Miss S. O'Flynn, C. M. Wenyon (Protozoologist).
Middle Row.—W. E. Lewis, M. C. F. Easmon, G. P. G. Beckett, J. A. Hamilton (Maj. I.M.S.) W. T. P. Meade-King, D. Birt, W. H. R. Robinson
(Lt.-Col. I. M.S.), F. C. Doble, H. M. Hanschell (Senior Demonstrator), S. L. Symonds, F. W. O'Connor, C. A. Gill (Capt. I. M.S.), W. McDonald
(Entomological Lab. Asst. ).
Back Row.—F.P. Connor (Capt. I.M.S.), W. Beattie (House Surgeon), R. M. Easton (Senior House Surgeon), C. Ll. H. aripp, J. F. H. Morgan, J. R. Boyd,
G. C. McGregor, G. B. Warren (Senior Lab. Asst.) A. P. Watkins, F. H. Preston, C. J. Stauffacher, E.
(Major 1. M.5.), R. McKay (Lab. Asst.).
Absent.—Col, A. Alcock (Entomologist), Dr. R. T. Leiper (Helminthologist), A. Lundie, W. I. Martyn-Clark, H. R. M. Ferguson, L. Wynne Davies, W. A.
Nicholson, E. H. Tipper, S. H. R. Lucy, C. A. Cummins, A. Aitken, N. C. Hollins, B. J. Courtney, M. W. Fraser, B. W. Cherrett, E. J. Wyler,
G. B. Norman, S. W. J. Scholefield, H. G. McKinny, F. N. Ashley, R. W. Orpen, Miss X. G. Appleton, E. S. Krishnaswami, J. B. Davey,
W. C. P. Winter, Miss F. M. Harper, H. Melhuish (Capt. L M. S.).
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON,
Under the Auspices of His Majestys Government,
CONNAUGHT ROAD, ALBERT DOCKS, EB.
In connection with the Albert Dock Hospital of the SEAMEN’S HOSPITAL SOCIETY.
HE SEAMEN’S HOSPITAL SOCIETY was established in the year 1821 and incorporated in 1833, and from time to time
has been enlarged and extended. It now consists of the Dreadnought Hospical, Greenwich, to which is attached the
London School of Clinical Medicine; the Royal Victoria and Albert Docks Hospital; the East and West India Docks
Dispensary; and the Gravesend Dispensary.
Over 30,000 Patients treated annually. Of this number many are Cases of Tropical Disease.
The School buildings are situated within the grounds of the Royal Victoria and Albert Docks Hospital.
MEDICAL STAFF OF THE HOSPITAL AND LECTURERS IN THE TROPICAL SCHOOL.
Aserappa, J. H. Hugo, D.S.O.
JAS. CANTLIE, Esq., M.B., F. R.C.S., D.P.H. Professor R. TANNER HEWLETT, M.D., F. R.C.P. | L. W. SAMBON, Esq., M.D.
L. VERNON CARGILL, Esq., F. R.C.5. G. C. LOW, Esq., M.B., C.M. FLEMING MANT SANDWITH, Esq., M.D., F. R.C.P.
E. TREACHER COLLINS, Esa., F.R.C.S. J. M. H. MACLEOD, Esq., M.D., M.R.C.P. Professor W. J. SIMPSON, C.M.G., M.D., F.R.C.P.
C. W. DANIELS, Esq., M.B., M. R.C.P., M.R.C.S. | Sir PATRICK MANSON, G.C.M.G., F.R.S., LL.D. | K. WILLIAMS, Esq., M.D., M.R.C.P., D.P.H.(Camb.
KENNETH W. GOADBY, Esq., D.P.H.(Camb.), M.D., F. R.C.P.
M.R.C.S., L. R.C. P., L.D.S. R.C.S.
Dean—Sir F. LOVELL, C.M.G., LL.D. Arthropodist—Colonel A. ALCOCK, I.M.S., C.I.E., F.R.S.
Helminthologist—R. T. LEIPER, Esq., D.Sc., M.B., Ch.B., F.Z.S. Protozoologist—C. M. WENYON, Esq.. M.B., B.S., B.Sc.
Director—H. B. NEWHAM, M.R.C.5., L. R.C.P., D.P.H., D.T.M. & H. (Camb.). Secretary—P. J. MICHELLI, Esq., C.M.G.
LECTURES AND DEMONSTRATIONS DAILY BY MEM2ERS OF THE STAFF.
There are three Sessions yearly of three months each, viz., from October 1st to December 31st, from January 15th to
April 14th, and from May Ist to July 31st inclusive. Women Graduates are received as Students.
Certificates are granted after Examination at the end of each Session, and the course is accepted by Cambridge University
as Qualifying for Admission to their Examination for the Diploma in Tropical Medicine and Hygiene, and by London University
as Study for the M.D. in Branch VI. (Tropical Medicine).
Fee for course £16 16s.; shorter periods by arrangement.
Students can be provided with Board and Residence, or partial Board, at the School. .
Medical men requiring posts in the Tropics may apply to the Secretary at the School, where a Register is kept.
A syllabus, with ihe general course of study, can be had on application to the undersigned, from whom further
information may be obtained.
Students of the London School of Tropical Medicine, who join the London School of Clinical Medicine, will be allowed
an abatement on their fees and vice versa.
Chief Office—SEAMEN's HOSPITAL, GREENWICH, S.E.
April 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Abstract.
STUDIES oN PNEUMONIC PLAGUE.
Protective Masks and Pneumonic Plague.
(Continued from p. 112.)
M. A. BARBER and Oscar TEAGUE* carried out
experiments to determine the efficacy of various
masks for protection against pneumonic plague.
They write: During the epidemic of pneumonie
plague which raged in Manchuria during the winter
of 1910 to 1911, it was believed and, toward the
close of the epidemie, was experimentally demon-
strated, by Strong and Teague, that sputum in the
form of invisible droplets containing viable plague
bacilli was frequently suspended in the air near the
coughing pneumonic-plague patients. There was
every reason to believe that even the smallest
number of these bacilli inhaled into the lung would
lead to infection, and that this was, in fact, the com-
mon mode of infection in pneumonie plague. The
obvious method to protect against such infection
was to interpose a barrier to the passage of these
droplets into the mouth and nostrils. ^ With this
object in view, masks were worn quite generally by
physicians and attendants when in the presence of
plague patients or suspected cases. That protec-
tion was afforded by the masks apparently went
unquestioned and, without the sense of security
that their use gave, the mental strain in connection
with the work would have been almost unbearable.
The total number of deaths that occurred among
physicians, nurses, attendants, and inspectors dur-
ing the recent epidemic of pneumonie plague in
Manchuria will never be known. The following
death roll at Fuchiatien, the Chinese city near
Harbin, shows that the total must have been
extremely high.
List of Deaths of Anti-plague Staff at Fuchiatien.
—Doetors, 1 out of 20; students, 1 out of 29;
native practitioners, 4 out of 9; police inspectors,
2 out of 31; police, 30 out of 688; sanitary police,
11 out of 206; mounted police, 5 out of 80; firemen,
9 out of 20; coolies, 102 out of 550; cooks, 4 out
of 60; ambulance parties, 69 out of 150; soldiers,
63 out of 1,100; total, 297 out of 2,948.
In South Manchuria the plague sanitary corps
suffered a loss of 122 persons, among whom were
one Japanese, one English, and forty Chinese
physicians. This represents 2.66 per cent. of the
total plague mortality in the districts concerned.
The presumption is that all the members of the
sanitary corps wore masks. The masks were, how-
ever, not worn constantly nor were they always
properly adjusted; coolies were often seen with the
masks hanging around. their necks instead of being
over their mouths. Hence the high death-rate of
the sanitary staff cannot be regarded as proof of the
inefficiency of masks.
* Philippine Journal of Science, Section B., vol. vii, No. 3,
June, 1912.
125
In Mukden the mask which was almost univer-
sally employed consisted of a pad of absorbent
cotton about 16 by 12 cm. and about 1.5 em. thick;
this was wrapped in gauze, the ends of which were
tied at the back of the head. A many-tailed
bandage composed of three layers of gauze with
holes for the eyes was tied around the entire head,
and served to press the mask firmly against the
face and keep it snugly in place for hours at a time.
When first put on, this mask was decidedly uncom-
fortable, but after a few minutes one became some-
what aceustomed to it, and could wear it for two
or three hours at a time. There was, however,
always an intense feeling of relief on removing it.
This type of mask is designated in the discussion
to follow as the ‘‘ Mukden mask.”’
The following experiments were undertaken with
the idea of determining whether this Mukden mask
is, in faet, an efficient barrier against the passage
of plague bacilli into the lungs and, also, whether
or not other types of masks are more efficient.
At the International Plague Conference held in
Mukden in April, 1911, Broquet, the French dele-
gate, demonstrated a mask '' copied from those used
by doctors in the epidemic of the fourteenth cen-
tury as shown in old books." It consisted of a
hood of light canvas or khaki cloth, covering the
entire head and drawn in at the neck. In front
was a window of mica. No experiments had been
performed to test the efficacy of this mask. We
shall refer to this type of mask hereafter as the
“ Broquet mask." It was not used during the
recent epidemic of pneumonic plague in Manchuria
with the exception of a few times by Broquet him-
self.
Preliminary tests indicated that a hood of heavy
Canton flannel with a nap was more effective in
holding back B. prodigiosus than hoods of lighter
cloth such as the one demonstrated by Broquet.
Instead of mica for the window, Barber and Teague
used sheet celloidon such as one sees in the storm
curtains of automobiles. The hood was made nar-
row at the neck so that it would spread out over
the shoulders and could be drawn in and tied snugly
around the neck. Comparative experiments were
made with this mask and the Mukden mask; the
subjects wearing the two masks were forced to
breathe air containing B. prodigiosus simulta-
neously for the same length of time.
B. prodigiosus was selected for the experiments
as being entirely harmless and easily recognizable
on account of its pigment production. An ordinary
throat atomizer was used for making the spray, but
with the idea of getting smaller droplets the rubber
bulb was removed and a stronger air blast was
obtained by using an automobile pump.
Special precautions were taken to avoid accidental
contamination with B. prodigiosus on removing the
mask. The subject was clothed in an operating
gown and, in the case of the Mukden mask, his
head was covered with a cloth and the eyes pro-
tected by automobile goggles. The spraying was
generally done in a small, single-roomed stable,
which was boarded up on all sides to keep out the
126 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15, 1913. .
light and to avoid, to a certain extent, currents of
air. The gowns, goggles, and head-cloths were re-
moved after the subjects had left the stable and
before they entered the laboratory building. One
of the authors attended to the spraying and ex-
posure of the subjects, the other endeavoured to
keep himself and his laboratory room free from
B. prodigiosus and made the necessary plate cul-
tures in order to determine the result of the test.
At first the saliva, taken before and after the spray-
ing, was smeared over agar plates, but later it was
found that small pieces of moistened cotton, placed
in the nostrils and before the mouth (underneath
the Mukden mask), rendered the test much more
delicate.
Agar plates were exposed during the course of
the experiment in order to obtain an indication of
the living B. prodigiosus that were in the air
around the mask at the time.
Experiments showed that neither the Mukden
mask nor the heavy Canton flannel Broquet mask
is able to hold back completely B. prodigiosus
when they are sprayed in large numbers continu-
ously for a period of three minutes about the heads
of the subjects. As this Broquet mask is the most
efficient of all the masks with which we have ex-
perimented, it follows that none of our masks can
withstand this test. "The fact that the moist cotton
from the centre of the Mukden mask contained
many B. prodigiosus shows that some of the
B. prodigiosus passed directly through the mask;
or, in other words, that the ineffieieney of this
mask is not due solely to the fact that the bacilli
pass around the edges of the cotton pad or through
the free spaces at the sides of the nose which were,
perhaps, only imperfectly plugged with cotton. In
this experiment the masks were subjected to a much
more severe test than would occur in practice;
nevertheless, it presents conclusive evidence, we
believe, that these masks do not offer absolute pro-
teetion against infeetion with pneumonic plague.
In another series of experiments, three minutes
after spraying had been stopped, Canton flannel
Broquet mask subject and Mukden mask subject
were taken into room and allowed to remain for
ten minutes. Living B. prodigiosus were very
numerous at the beginning of the test, but de-
ereased very rapidly during the ten minutes that
the subjeets were exposed. "This must be regarded
also as a very severe test, though by no means so
severe as the preceding one. The Broquet mask
withstood the tests, while the Mukden mask failed
to hold back all the B. prodigiosus. "This ex-
periment, therefore, demonstrates clearly the
superiority of the Broquet mask over the Mukden
mask.
In a third series, the two subjects entered the
room six minutes after stoppage of spraying, and
remained in for ten minutes. "This test was an
extremely light one. A Petri dish exposed during
the first three minutes that the masked subjects
were in the room developed only 280 B. prodigiosus
colonies, and another, during the last three minutes,
onlv twenty-nine eolonies, In spite of the small
number of living DB. prodigiosus that were in
the air, the Mukden mask failed to hold back all
of them. We are inclined to believe that this test
is even a less severe one than that to which the
masks were subjected during the recent plague
epidemic in Manchuria, as the coughing patients
in the crowded wards must have been throwing
out hundreds of fine droplets almost continuously
and, on account of the low temperature, the plague
bacilli in these droplets must have remained sus-
pended in the air in a viable condition for a con-
siderable period of time. Since we have found
repeatedly in tests which were not severe that the
Mukden mask allowed bacilli to pass, we are forced
to the conclusion that the sense of security felt by
those who wore this mask in the Manchurian
epidemic was not justified.
Experiments were carried out in a cold-storage
room measuring about 2.5 by 3 metres at a tem-
perature of 120 C, A 24-hour agar culture of B. pro-
digiosus was suspended in about 40 c.c. of 0.5 per
cent. sodium chloride solution and filtered twice
through cotton. A portion of this suspension was
sprayed by means of a throat atomizer connected
by rubber tubing with a two-cylinder force pump,
such as is used in filling automobile tyres. The
spraying was continued for a period of two minutes,
the spray being directed toward all portions of the
room. The pump was then removed and the door
of the cold room quickly elosed. A period of two
hours was allowed to elapse, and then the three
masked boys were hurried into the room and the
door was closed behind them. They remained ten
minutes in the room. During this time each held
in his hand an open Petri dish containing solidified
agar and closed it immediately after leaving the
cold room. :
Boy No. 1 wore a Mukden mask, boy No. 2 our
Canton flannel Broquet mask. The usual measures
against accidental contamination with B. pro-
digiosus were adopted. Boy No. 3 wore a mask of
wet gauze. Strips of gauze were boiled and while
still warm were squeezed out and applied loosely
over the lower portion of the face from the eyes
to below the chin. The gauze was not in layers,
but was placed irregularly as in surgical dressings
which are intended to absorb pus. A many-tailed
bandage with holes for the eyes, such as is used
with the Mukden mask, pressed the moist gauze
firmly against the face and held it snugly in place.
This mask was about five or six centimetres thick
over the mouth and beeame thinner toward the
edges. Goggles were worn by this boy also and the
top of his head was covered with a cloth reaching
down to the mask.
In spite of the long interval (two hours) which
elapsed between the spraying and the exposure of
the subjects, this test must be regarded as a very
severe one, for the plates show that numerous liv-
ing B. prodigiosus still remained suspended in
the air at the time of the exposure. Furthermore,
the number of living bacilli in the air in the eold
room remained practically constant during the ten
minutes of the test, while in the second series of
April 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
experiments carried out in a warm stable there was
a rapid decrease. This experiment shows again the
superiority of the Broquet mask over the Mukden
mask. It also proves that B. prodigiosus may
pass directly through the cotton pad of the Mukden
mask, for a piece of moist cotton placed near the
centre of the pad contained B. prodigiosus after
the test. The mask of wet gauze also failed to
hold back all the bacilli, and is hence inferior to our
Broquet mask. The experiment does not afford
any evidence as to the relative efficiency of the
Mukden mask and the mask of moist gauze.
Experiment No. 5.—March 1, 1912. The mouth
of one of the authors was rinsed with sterile salt
solution and then about 10 c.c. of saliva were col-
lected in a sterile test tube. One slant of a fresh
prodigiosus culture was suspended in this saliva.
The resulting suspension was thoroughly shaken and
then taken a little at a time into the mouth and
made into a spray by being blown between the lips.
The spraying was done in a cold storage room at
99 C. The room was then kept closed for one hour,
when the three masked subjects were quickly taken
in and the door closed behind them. They re-
mained inside ten minutes, each subject holding
during that time an open Petri dish of solidified
agar.
The masks were removed and cultures made as
in the preceding experiment.
This experiment was designed to approximate
more nearly to the conditions that occurred in
Manchuria. It seemed possible that the viscid
sputum of pneumonie plague might form larger
droplets than the salt solution of our experiments
and on that account be unable to pass through the
masks. Preliminary tests were made by taking
B. prodigiosus into the mouth and then holding
Petri dishes containing solidified agar immediately
before the mouth while talking or coughing. It
was found that under these conditions B. prodi-
giosus were emitted in too small numbers and too
inconstantly for the method to be satisfactory in
testing our masks. Swabbing the vocal cords with
the bacilli might have given satisfactory results,
but this was not tried. Instead of this, it was
decided to blow saliva containing B. prodigiosus
between the lips, thus converting it into a spray.
The droplets of saliva produced in this way appa-
rently passed through the masks as readily as the
salt solution droplets from the atomizer. This
experiment furnishes strong evidence that droplets
of sputum from pneumonie plague patients may be
able to pass through the Mukden mask.
General Discussion.—The protocols which have
been cited could be supplemented by numerous
others giving similar results.
While these experiments furnish evidence that
fine droplets of sputum of patients suffering from
pneumonie plague may pass through the mask that
was so widely used in Manchuria, yet they do not
at all indieate that this mask was entirely without
value. Obviously, the mask would hold back gross
visible partieles of sputum which are sometimes
thrown out in coughing. Moreover, in our experi-
127
ments, when B. prodigiosus were recovered
from the nostrils, it is probable that in the same
test without the mask far greater numbers would
have entered; in other words, it seems probable
that great numbers of bacteria that otherwise
would have entered the nose and mouth, remain
on the surface of the mask and in its substance.
Hence we believe that masks should be worn by
those attending pneumonie plague patients, but
that they should not be regarded as affording
absolute protection against infection; bearing this
in mind: even when masked, one should remain in
the near vicinity of the patient only so long as is
necessary for the work in question.
CONCLUSIONS.
(1) The ‘‘ Mukden mask ’’ in general use during
the epidemie of pneumonie plague in Manchuria,
during the winter of 1910 to 1911, does not prevent
the passage into the mouth and nostrils of B. pro-
digiosus when contained in small droplets sprayed
around the mask. This mask consists of a pad of
absorbent cotton held over the mouth and nose
by a many-tailed gauze bandage.
(2) A hood of heavy Canton flannel cloth, cover-
ing the entire head and tied in snugly at the neck,
withstands much severer tests than does the
Mukden mask. It does not, however, offer an
absolute barrier to the passage of B. prodigiosus
into the mouth and nostrils of the subject. This
mask, with a window in front, is not more incon-
venient nor more uncomfortable than the Mukden
mask.
(3) It is shown that the inefficiency of the Muk-
den mask is not due solely to the fact that the
mask fails to conform to the configuration of the
face, but that the bacteria may pass directly
through the mask; for a piece of moist cotton
placed in the centre of the mask was found after
the test to contain B. prodigiosus.
(4) It is believed that, although masks hold back
many baeteria that would otherwise pass into the
mouth and nostrils, nevertheless their use during
the recent epidemic of pneumonic plague in Man-
churia lent a false sense of security whieh may
have led to the taking of unnecessary risks. We
believe that these experiments fully justify the
conclusion that masks such as were used in that
epidemic do not offer an absolute protection against
pneumonie plague.
[We desire to make due acknowledgment
for the lengthy abstracts here given, and
to congratulate the authors on-the interest and
importance of their work. The studies on pneu-
monie plague contained in this number of the
Philippine Journal of Science form a contribution
of great value to our knowledge of this important
disease and contain much that is quite new. The
new data here given to medical science make but a
small part of the whole report, which will remain
as a classic for all future students of plague.—
H. M. H.]
128
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1913.
Aunotations.
The Health of the Canal Zone.—Phillips, Acting-
Chief Sanitary Officer of the Canal Zone, in sub-
mitting his report of the Department of Sanitation
for the month of January, 1913, states that the
total number of deaths from all causes among
employees was 51, divided as follows: Disease 32,
and violence 19, giving the annual average per
thousand of 7.37 and 4.37 respectively.
Among employees for the month of January of
each year the annual average death-rate per
thousand was as follows :—
1905, 15.40; 1906, 40.93; 1907, 25.62; 1908,
12.72; 1909, 10.98; 1910, 10.57; 1911, 10.14; 1912,
8.10; 1913, 11.74.
The annual average death-rate per thousand in the
cities of Panama and Colon, and the Canal Zone,
including both employees and civil population for the
month of January of each year, was as follows :—
1905, 46.55; 1906, 47.70; 1907, 35.12; 1908,
26.66; 1909, 22.86; 1910, 21.26; 1911, 21.05; 1912,
17.67; 19183, 23.24.
In segregating according to race, the annual aver-
age death-rate per thousand from disease among em-
ployees was: For whites 3.82, and for blacks 8.49,
giving a general average for disease of 7.87. For
the same month during 1911, the annual average
death-rate per thousand from disease among whites
was 1.89, and blacks 6.23, giving a general average
of 5.07; and in 1912 from disease among whites
7.57, and blacks 3.98, giving a general average of
4.86.
Among employees during the month, deaths from
the principal diseases were as follows: Hemo-
globinuric fever, 2; lobar pneumonia, 5; malaria
fever, E. A., 2; organic disease of the heart, 2;
tuberculosis, 8; typhoid fever, 1; leaving 12 deaths
from all other diseases, and 19 deaths from external
violence.
No eases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus dur-
ing the month.
———dÁQ———
Hotes and Melos.
LONDON SCHOOL OF TROPICAL MEDICINE.
EXAMINATION RESULTS (FoRTY-FIRST SESSION,
JANUARY-APRIL, 1913).
G. P. G. Beckett, M.D., B.Ch., B.A.O., L.M.Dub.
(Colonial Service).
D. Birt, M.B., B.S.Durham (Colonial Service).
J. R. Boyd, M.B., Ch.B.Edin. (Colonial Service).
Capt. F. P. Connor, F.R.C.S.Eng., with distinction.
F. C. Doble, M.R.C.S., L.R.C.P. (Colonial Service).
M. C. F. Easmon, M.B., B.S.Lond., M.R.C.S.,
L.R.C.P.
Capt. C. A. Gill, LM.S., M.R.C.S., L.R.C.P.,
D.P.H., with distinction.
Major J. A. Hamilton, I.M.8., M.B., F.R.C.S.E.
Miss F. M. Harper, M.B., B.Ch.Edin., D.P.H.
Camb,
Miss C. L. Houlton, M.B., B.S.Lond.
Miss E. M. Layman, M.B., B.S. Lond. (Colonial
Service).
W. E. Lewis, M.B., Ch.B.Edin. (Colonial Service).
Miss J. McDonald, M.B. (Toronto), M.R.C.S. Eng.
Miss L. 8. MeLean, M.B., Ch.B. (Colonial Service).
W. T. P. Meade-King, M.R.C.S., L.R.C.P. (Colonial
Service).
J. F. H. Morgan, M.R.C.S., L.R.C.P. (Colonial
Service).
F. W. O'Connor, M.R.C.S., L.R.C.P.
Miss 8. O'Flynn, M.B., Ch.B.Edin.
A. P. Watkins, M.R.C.S., L.R.C.P.
Office).
(Foreign
THE UNIVERSITY OF LIVERPOOL.
EXAMINATION Lists, APRIL, 1913.
Faculty of Medicine.
Diploma in Tropical Medicine.—J. G. Becker,
C. Forsyth, M. C. R. Grahame, K. K. Grieve, A. R.
Hargreaves, P. Hiranand, O. E. Jackson, M. Mac-
Kelvie, J. MeP. MacKinnon, R. J. A. Macmillan,
C. E. F. Mouat-Biggs, E. Olubomi-Beckley, D. S.
Puttanna, J. H. Reford, F. D. Walker, U. B. Yin,
W. A. Young.
es
Review.
Lessons ON ELEMENTARY HYGIENE AND SANITATION
WITH SPECIAL REFERENCE TO THE Tropics. By
W. J. Prout, C.M.G., M.B., C.M.Edin.,
Medical Adviser to the Colonial Office, &c.
Third Edition. Sixth Thousand. London: J.
and A. Churchill, 7, Great Marlborough Street
1913.
This useful little manual on elementary hygiene
and sanitation has now reached a third edition.
That it should have done so indicates how valuable
and popular it has been. The present edition runs
to 184 pages, and has been brought thoroughly up
to date. It is divided up into fourteen lessons,
with a note on personal hygiene and a conclusion
containing a summary of what has been learned in
the different lessons. Its aim is to form an ele-
mentary text-book for the use of schools in the
Tropics, and for this purpose it has rightly
succeeded.
Hotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
9. —As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
May 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 9, Vol. XVI.
Original Communications.
THE EFFECT OF DRAINAGE ON HEALTH IN.
THE CITY OF NEW ORLEANS; A STATIS-
TICAL STUDY.*
By J. Brrney Gururiz, M.D.,
Professor of Clinical Medicine, Tulane University of Louisiana.
(Studies from the Laboratories of Tropical Medicine and
Hygiene, under the direction of Creighton Wellman, Tulane
University of Louisiana, No. 32.)
THE city of New Orleans has been through a
greater variety of experiences in regard to health
matters than any other city on this Continent.
Settled in 1718 on a narrow strip of alluvial land
along the bank of the Mississippi, lying in the midst
of a cypress swamp, and subject to yearly overflow
until 1728, when the first levees were constructed,
the city was the centre of a large commerce with
Kurope and with the Tropics. With no maritime
sanitary regulations, it was little wonder that
epidemic diseases of temperate and tropical coun-
tries obtained a foothold here from time to time.
During several years of the last century both
Asiatic cholera and yellow fever occurred simul-
taneously and produced a mortality frightful to
contemplate. The year 1832 furnished the most
striking instance, in which year the death-rate
mounted to 147 per thousand, exceeding one out of
every seven of the city’s population. The period
of the city’s greatest growth, 1830 to 1860, was
marked by its two severest epidemics. This is not
surprising when one takes into account the large
number of persons non-immune to yellow fever who
had come in from other states. Yellow fever was
considered endemic.
Sanitary maritime regulations involving inspec-
tion of vessels at tropical ports of sailing, together
with close scrutiny of crew and passengers at the
mouth of the river, and mosquito destruction on
ships, have made the introduction of yellow fever
extremely unlikely; but it will always be a source
of anxiety and labour until all the tropical Americas
are free from it. However, the measure whereon
the safety from epidemics rests, the ridding premises
of small collections of water, is one of the phases
of drainage—a problem of mosquito destruction
solved alike in Havana, New Orleans, and Panama.
The introduction into New Orleans of a case of
yellow fever would cause no panie and no epidemic;
for the greater part of the breeding places of
Stegomyia have either been destroyed or rendered
harmless through screening. If we leave out of
consideration artificial inoculation of actual blood,
there is no means of transmitting the disease known
to science, except by the bite of this insect after
having bitten a person sick with yellow fever.
In consequence of these variations in health
conditions, and in consequence, perhaps, of a lack
of frankness in times past, New Orleans has
suffered, and indeed still suffers, from a misappre-
hension regarding its health conditions on the part
of the people of the United States. Fortunately
* A paper read before the Second National Drainage Congress.
the root of the evil has been eliminated by the
expenditure here of twenty millions of dollars on
drainage, sewerage, and water supply during the
past twelve years. The necessity of perfect honesty
in the matter of notification of the existence of
infectious disease is generally conceded. The busi-
ness community and those in authority are now
thoroughly alive to the importance of a policy of
absolute frankness in all health matters. To-day
New Orleans is in a position to court investigation
of its health conditions; and to-day no one need look
forward with apprehension to a visit of any length
to New Orleans at any season of the year. It is to
be hoped that these facts will become generally
known, and that the knowledge will serve to remove
the existing handicap.
In addition to the mosquito-borne disease, yellow
fever, there has existed from the earliest times in
New Orleans another scourge of low-lying lands
likewise dependent for its propagation on a particular
mosquito carrier—malaria. Formerly the entire
population suffered from some form of malarial
infection, and the mortality from this cause was
enormous. Men now living and practising medicine
tell of the most pernicious forms of the disease
originating within the city’s built-up district. Every
settlement in a swampy area as it increases in
population shows a diminishing death-rate from
malaria. This results from drainage put in to make
possible the paving of roadways, which cannot be
maintained without drainage. The same is true of
agricultural districts, but to a less extent. Here
the chief factor in stimulating drainage operations
is the cultivation of lands. This cultivation is
possible only after making provision for carrying off
water. When the lands are put under the plough
evaporation is very much increased, and the amount
of standing water still further reduced.
Such drainage as had been done in New Orleans
incidental to the maintaining of roadways open to
traffic had, even up to 1900, materially improved
health conditions; but the greater part of the task
was still undone. The problem has been peculiarly
dificult. The area of the city is 196 square miles,
and of this only 41 square miles are improved. The
yearly rainfall is about fifty inches. Downpours of
more than six inches in a single afternoon are a
matter of record. The surface of the ground is flat,
and the difference in level but slight, the highest
point being fifteen feet above the mean gulf level,
and the lowest one foot below. It becomes neces-
sary, therefore, in order to get rid of the rainfall
in anything like a reasonable time, to establish an
artificial system with a gradual and uninterrupted
fall to the main outflow canals. From these the
water must be pumped up to the sea level again and
discharged. "The varying height of the Mississippi
(from mean gulf levelto twenty feet above mean gulf
level) makes it impossible to use the river to carry
off the rainfall without enormous operating expense
for pumping. Hence, Lake Pontchartrain, which
is practically always at sea level, has been utilized
for the drainage outlets, and the average lift in out-
lets is fifteen feet, decreasing to ten feet during
Storms. :
130
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
On the other hand, it would be most unwise from
a sanitary standpoint to use the lake to receive the
sewage of the city, and the river becomes the only
possible outlet for the contaminated waste water.
A second system, therefore, has been installed for
this, lying at a greater average depth than the
drains proper, with the main sewer emptying into
the Mississippi. The main sewer lies at about
twenty-four feet below sea level, and the average
resultant lift, including friction in the outflow pipe,
is thirty-five feet. This is increased during periods
of high water to fifty-five feet. Actually one-third
of the total rainfall of the city finds its outlet
through the sewer system proper.
The system of drainage was set in operation in
1900, and the sewer system in 1906. It should not
be thought that before this there was no provision
for taking care of the storm water, as this was not
the ease; but the fall in the then existing system
was inadequate, and the pumps were insufficient to
get rid of a heavy volume of water in a reasonable
time. Large areas lacked proper connection with
the drainage canals, and floods were exceedingly
frequent. Water stood in sheets in certain districts
for days, and even weeks at a time, disappearing
either by slowly oozing through a rather impervious
soil, by evaporation (likewise a slow process), or by
flowing over the surface to the nearest available
outlet. To-day local floods occur in certain districts
in which there has been delay in construction of the
secondary drains, or after extraordinary downpours.
Visible standing water is becoming a rare sight.
The general death-rate in New Orleans during
1890 to 1899 was 28; that of the following decade,
1900 to 1909, 21.5, the computation being on the
basis of United States census returns, adding each
year 10 per cent. of the ten-year increase of
population. These figures were computed by Mr.
George Earl, Superintendent of the Sewerage and
Water Board (to whom I am indebted for the above
data regarding the present drainage system), and
include both white and coloured population, and
deaths of non-residents occurring in Charity Hos-
pital. In considering these figures, we must bear
in mind that New Orleans has about one hundred
thousand negroes, and that this element in the popu-
lation maintains a death-rate about 40 to 50 per cent.
higher than the whites. If it were not for this
‘white man's burden " of ignorance and super-
stition and shiftlessness, the showing would be
better; for the white population, including deaths in
Charity Hospital, gives a deuth-rate of 18.8 per
cent., less than the average of American cities in
general. The charted curve of mortality rates in
New Orleans took a rather sudden drop in 1900, the
year the drainage system proper was put in opera-
tion, and it has been steadily declining ever since.
Students of sanitary conditions lay it down as a
principle that the improvement of drainage con-
ditions brings about a diminution in malaria and in
respiratory diseases. In order to study the effects
on mortality rates under these conditions, the writer
undertook a study of the mortality statisties of
pneumonia, of tuberculosis, and of malaria in New
Orleans for a period of thirty-two years, 1880 to 1911
‘inclusive, computing the death-rate on the basis of
United States census reports, adding each year one-
tenth of the ten-year increase. The death-rate was
computed for the period before the installation of
the drainage system proper, 1880 to 1899, and
compared with the period, 1900 to 1911, since the
drainage installation. This latter period was
further subdivided at the year 1906, when the
sewerage system was set in operation and the five-
year period, 1900 to 1905, was compared with the
seven-year period, 1906 to 1911. There was no
appreciable diminution to be noted in the figures
representing mortality from pneumonia and tuber-
culosis, and the tabulations are not included in this
paper; but those representing the malaria mortality
are most striking.
The decade, 1880 to 1889, gives a mean mortality
from all forms of malaria of 149.8, with the
"U"issns222329220222225229:022235882-*7
Curve of Death rate from Malaria in City of New Orleans—
33 years, 1880 to 1912— Based on Estimated Population
from U.S. Census, adding each year 10 per cent. of ten
years' Increase.
maximum for thirty-two years of 180 per one
hundred thousand occurring in 1886.
The decade, 1890 to 1899, shows a mean malaria
mortality of 125.5 per one hundred thousand.
The twelve-year period, 1900 to 1911, shows 23.8
per one hundred thousand.
The first five years of the drainage period, 1900
to 1905, after the installation of the drainage
system proper and before the installation of the
sewerage system, give a mortality of 37.8 per one
hundred thousand.
In the seven years, 1906 to 1911, during which
time both systems have been in operation, the
mean mortality per one hundred thousand is 13,
and the smallest death-rate from malaria in thirty-
two years occurs both in 1910 and 1911, namely,
9 per one hundred thousand, a diminution from the
maximum of 180 in 1886 of exactly 2,000 per cent.
The recently published statisties for 1912 show that
the malaria death-rate for last year is even less
than for the two preceding years—viz., 8.3 per
one hundred thousand.
The morbidity from malaria could be studied only
in the reports of the Charity Hospital, and by com-
munication with physicians whose experience ex-
tended into both periods. The records of total
admissions to the Charity Hospital with diagnosis
of malaria in any form were compared for two five-
year periods, 1895 to 1899 (previous to the instal-
lation of the present drainage system) and 1906 to
1910 (subsequent to the operation of both drainage
and sewerage systems). For the first period, 1895
to 1899, there were 6,369 patients with diagnosis
of malaria admitted out of a total of 39,434 ad-
missions, making 16.9 per cent. For the second
period, 1906 to 1910, there were 1,893 patients
diagnosed as malarial out of a total number of
admissions of 47,731, or 3.9 per cent. Here’ we
find a diminution of 15 per cent. in morbidity in
the second period (after the operation of combined
drainage and sewerage system) as compared with
the first period (previous to the installation of the
present drainage system).
The writer is aware that the above mortality and
morbidity figures are subject to errors of diagnosis.
It is probable that errors have occurred, but such
errors would not be sufficiently great to make the
statistics valueless, especially as they coincide with
the conclusions of numerous individuals who have
had the matter under uninterrupted observation.
The writer has always lived in New Orleans, and
during the last fourteen years has continually
followed the practice of examining the blood of
such patients as came under his charge with
symptoms pointing at all to the existence of
malarial infection, so that such errors as are above
mentioned are, to a certain extent, minimized in
his own experience. It is his opinion that malarial
infection in New Orleans has almost ceased to exist.
The only cases he has seen during the last two
years, which had not received infection elsewhere,
were among dairymen living on the outskirts of the
city or among labourers along the docks during a
low stage of the river. These were all simple
tertian infections. This experience is corroborated
by his colleagues, Professors Elliott, Bass, Lemann
and Weis, of the Department of Medicine of Tulane
University of Louisiana, who in personal com-
munications agree with him in the view that the
eases which they see now in which death occurs
from malaria are cases infected elsewhere. Doctor
Joseph Holt, a clinician of long experience, also
confirms the above opinion. Fatal types of malaria
have ceased to exist in New Orleans; very little of
any type is to be seen at present, and none at all
in the districts drained, sewered, and paved. The
reason is that enopheline mosquitoes have been
banished from all but the outskirts.
It is a victory won by drainage over disease. It
may be diffieult to classify exactly the part played
by the work done in the rural districts of Louisiana
and of other Southern States which send their sick
to New Orleans to be treated, and the part played
by the operations in the city of New Orleans itself;
but from a sanitary standpoint the conclusion is
obvious that the results have been achieved by
getting rid of the breeding places of that species of
May 1,1913] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
131
anopheline mosquitoes which alone can transmit
the infection from one person to another.
What has been done in New Orleans can be done
in the rural districts of Louisiana, Mississippi, and
Alabama. The laws of Louisiana are now so framed
that a drainage district for the issuance of bonds can
be readily formed and drainage operations perfected.
The present faulty drainage systems in compara-
tively extensive areas lying along the Mississippi
River and its tributaries, and the malarial con-
ditions resulting therefrom, are due in a measure
to the blocking of the various small streams which
would normally flow into these rivers. The block-
ing of these streams has been done at the point of
their entrance into the larger river. This has been
incidental to the construction of levees along the
main streams, as it is impossible to construct a
system of levees along both banks of all these minor
streams. The burden of the maintenance of the
levee system along the larger streams has been
very great in itself, and drainage has been sacrificed
to economy.
In closing let me make a plea for drainage primarily
instituted for sanitary purposes, then health and
immigration will come to the districts so drained,
and capital will come to develop the richest lands
on our continent.
THE TREATMENT OF SUPPRESSION IN
BLACKWATER FEVER.
By Huu Stannvus Srannus, M.D.(Lond.),
Zomba, Nyassaland.
Sowg eight years ago, when I was face to face
with my first case of blackwater fever in which the
urine measurement was small, I puzzled over the
probable cause of suppression, and came to the
conclusion that blocking of the kidney tubules was
the only reasonable explanation.
Having a short time previously seen a case of
acute nephritis with suppression operated on under
the mistaken diagnosis of calculus suppression, with
nothing but good results, I wondered whether relief
of tension in the kidney in the suppression of black-
water fever by nephrotomy would be beneficial.
Sinee then double nephrotomy has been per-
formed actually for the suppression of acute
nephritis, and operative intervention has been, I
believe, advocated in blackwater suppression by one
author to whose paper I cannot at the moment find
reference. The pathological conditions underlying
the suppression of blackwater fever have now been
demonstrated by Barratt and Yorke and others, and
the prophylactic treatment of suppression by flush-
ing the kidneys, which one had carried out before
empirically, has now been put upon a. rational
basis.
It still appeared to me that where suppression
had occurred, the tubules being blocked and dis-
tended by débris, with strangulation of the kidney
within its capsule, treatment by incision, as has
been done in acute nephritis, would be the correct
132
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
procedure, but until the present time no case had
come under my care actually with suppression,
means for prevention of its onset having always
succeeded. I have never seen any case reported in
whieh surgical means had been adopted for the
treatment of blackwater suppression, and for
reasons which are mentioned later I have thought
it worth while to publish the single case detailed
below. It will be recognized that my remarks are
only intended to deal with cases of acute suppres-
sion in the early stages of the disease, and not with
that occurring later on.
M., male, aged 25, a planter, was admitted
to hospital at 11.30 a.m. on November 3, 1912,
with a history of ‘‘ blackwater ’’ commencing
twenty-two hours before. He had travelled some
25 miles in a hammock, and had not passed water
for two or three hours before admission.
Interrogation elicited the following history:
Patient returned from England to a cotton estate or:
the Shiré Hiver nine months ago, and during this
period had been in the habit of taking 10 gr. of
quinine sulphate, in tabloid form, each Wednesday
and Thursday. About a month before the present
illness, however, he had an attack of ‘‘ fever," but
did not take any extra quinine. Patient had never
had blaekwater fever before and was of very tem-
perate habits, being a teetotaler and non-smoker.
The onset of the “ blackwater ’’ was on a Satur-
day; on the previous Wednesday and Thursday he
had taken his usual quinine, on the Friday he was
very well, but on Saturday at noon he felt ill and
feverish, and took 10 gr. of phenacetin, followed an
hour later by 10 gr. of quinine sulphate in tabloid
form. Half an hour later ‘* blackwater '' appeared,
accompanied by rigor, vomiting and diarrhea.
The patient was a man of good physique, with
no signs of organic disease, icterus fairly marked.
The spleen not palpable, the heart not dilated but
sounds rather of a tic-tac type. Pulse, 108 per
minute. Temperature, 100.69 F. Respirations, 15
per minute. A catheter passed did not draw off a
single drop of urine. During the next twenty-four
hours vomiting and diarrhcea were very troublesome,
but were much relieved by a mustard leaf to the
epigastrium, and starch and opium enemata. Eight
ounces water containing 30 gr. sodium bicarbonate
were given every hour by the mouth, saline under
the skin, cupping over the loins and digitalis, but no
urine appeared in the bladder. I, therefore, with
the patient's permission, decided to operate before
his condition was any worse. A wire to my nearest
medical assistance found the medical officer away,
but later in the day, on his return to his station, it
was promptly responded to by Dr. Eldred, to whom
my best thanks are due. Having travelled 100
miles, he administered chloroform at 9 p.m. on the
4th inst., and having exposed the left kidney by the
usual loin route and freed it from the surrounding
eapsule, I incised the capsule from pole to pole, and
the bulging purple grey organ was then incised
through the middle two-thirds of its free edge;
bleeding was not very free at first. Gauze plugs
were led down to the bed of the kidney, and to the
unsutured wound, dressings were applied.
On return to bed the patient's condition was satis-
factory, though later in the night restlessness
necessitated the use of a hypodermie injection of
i gr. of morphine given with digitalein.
On the following day (November 5) it was found
that there had been free oozing from the wound,
and some 12 oz. of dark-brown fluid containing
brown colouring matter were withdrawn from the
bladder.
General condition of patient good, comfortable,
and without any distressing symptoms ; perspiration
free.
During the remaining three and a half days small
amounts of urine were passed naturally or drawn off
by catheter (see chart), but the general condition
progressed unfavourably.
NOV. 1912
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There was some cedema of the face, and flatulence
with abdominal distension and hiecough were also
troublesome; diarrhea recommenced and tempera-
ture rose again, while the heart showed increasing
signs of failure. Symptomatic treatment and intra-
venous saline injections were then given.
On the 9th inst. there were a number of uremic
seizures, followed by coma and death.
On admission, and subsequently, no malarial or
other parasites were found in the peripheral blood.
The principal facts of the case are hemoglo-
binuria for twenty hours, followed by complete
suppression for forty-eight hours; nephrotomy
(unilateral) performed, followed by the passage of
small amounts of urine beginning within twenty-
four hours of operation, and going on until death,
with symptoms of uremia on the morning of the
fifth day after operation.
Though I have seen no case of suppression before
in my own practice there have been a number of
May 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
183
such cases in this country, and, as far as I can
ascertain, complete suppression has always been
followed by a fatal termination, and the restoration
of the functions of the kidneys has never been seen.
In the above-mentioned case it would appear that
some slight degree of restoration of function did
take place, and that such was due to the relief of
pressure within the kidney by nephrotomy.
Is it possible that operation at an earlier period
in the suppression would have been successful in
saving life? I think very possibly. The difficulty
which naturally presents itself is to know at what
hour surgical interference should be considered.
How long may suppression last to be followed by
restoration of kidney function in these cases?
If a fatal termination were found in every case
of suppression untreated by operation, then the use
of a catheter might determine an early surgical
interference.
Is there a definite, or more or less definite, period
for whieh suppression may last and be followed in
a large proportion of cases by restoration of renal
function ?
If such exists, then it would constitute valuable
information in deciding when to seek surgical aid.
These are questions which I cannot answer, as I
am not in the possession of sufficient data and have
no access to them, but it is with the hope of eliciting
them from others that I venture to publish this
single incomplete and unsuccessful case.
SPIDER'S WEB AND MALARIA.
By FREDERICK KNAB,
U.S. Bureau of Entomology, Washington, D.C.
UNDER the above caption Colonel M. D. O'Connell,
in the Journal of the Royal Army Medical Corps,
vol. xix, 1912, pp. 491-4983, pleads for the web-
making spiders as effective destroyers of malaria-
transmitting mosquitoes. It has been generally
taken for granted that mosquitoes are entangled in
spider-webs, just as are other diptera, and the
colonel’s observation supports this view. It is far
from the writer's purpose to discredit the spiders,
and undoubtedly mosquitoes are sometimes their
prey. Many references to the supposed efficiency
of spiders as mosquito destroyers occur in economic
mosquito literature; yet these do not give the im-
pression of being first hand. Records based upon
actual observation seem to be exceedingly few. In
fact, there are more actual observations directly at
variance with the generally accepted idea than in
agreement with it. As the writer has already shown
in a previous paper, mosquitoes (as well as certain
other species of diptera belonging to the group
Nemocera) have been observed to choose spider-
webs as a resting-place and to habitually repose
there.* In every case the mosquitoes so observed
have been Anopheles. During the past season the
* “ Diptera at Home on Spiders’ Webs." Journ. N.Y. Ent.
Soc., vol. xx, 1912, pp. 143-146.
writer was able to confirm these observations and
determine an additional point. As the records in
question are probably not generally known, or not
accessible to the readers of this Journal, it may be
permissible to repeat them for the sake of clear-
ness.
The earliest observations seem to be those of
Doctors Sambon and Low, and are recorded in their
account of the famous malaria experiment in the
Roman Campagna in 1900.1 '' The fully-developed
Anopheles claviger [A. maculipennis] was found in
great numbers in the houses, stables, and hen-
houses, frequently resting on cobwebs.’ Theobald,
in the third volume of his '' Monograph of the
Culicide,’’ 1908, p. 4, makes the following state-
ment: '' Generally speaking, it is not usual to find
gnats or midges thus caught; indeed, they may be
seen to settle on them and to fly away again.”
In North America, Mr. W. L. MeAtee, in June,
1911, while at Big Lake, Arkansas, observed
Anopheles resting in numbers on a spider's web.
*" On a rainy day a large number of Anopheles
quadrimaculatus were found sitting on a spider-
web in a hollow tree. Thinking they must be at
least slightly entangled, I counted on capturing
them easily. Upon putting my cyanide bottle near
one the whole swarm rose lightly on the wing, not
sticking to the web at all. By further tests I found
they were perfectly at home on the web.’’}
The writer's observations were made during the
past season in the vicinity of the city of Washington.
Having found that a variety of nemocerous diptera
frequent spider-webs and habitually rest on them,
he made further investigations. A suitable locality
was found along the banks of the Potomac—well-
wooded, damp, and with numerous rocks, where
spider-webs abounded on the overhanging rock-
surfaces and between the crevices. The majority
of the diptera frequenting the webs were Cecido-
myida, and these were sometimes present literally
in hundreds; second in abundance were certain
Tipulide, and finally there were Anopheles of both
sexes. Most remarkable was the fact that all the
Anopheles observed on the webs belonged to one
species, Anopheles quadrimaculatus, although a
second species, A. punctipennis, was present in that
locality in larger numbers. This latter species was
found resting on the under surfaces of overhanging
rocks and other shelters, but it carefully avoided the
webs. The former, on the contrary, was always on
the webs.
Now A. quadrimaculatus, the species which
frequents the webs, is the North American repre-
sentative of the European A. maculipennis; indeed,
by many it is considered identical. In the northern
United States A. quadrimaculatus is the principal
malaria transmitter, and over a large area prac-
tically the only one. The more abundant A.
punctipennis has been proved incapable of serving
as the host of the malarial parasites. The form
p The Malaria Experiments in the Campagna.” Brit. Med.
Journ., vol. ii for 1900, pp. 1679-1682.
I Proc. Ent. Soc. Wash., vol. xiii, 1911, p. 193.
134
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
found on the webs in Italy by Sambon and Low
was A. maculipennis, the prineipal malaria-trans-
mitter in that region. Thus it appears that in some
cases at least the spider-webs have no effect in
checking malaria.
It is, of course, possible that in other parts of the
world other species of Anopheles are caught in
spider-webs ; but, if so, this has not yet been shown.
In fact, it has not been possible to find a single
record of Anopheles caught in a web. These state-
ments must not induce us to condemn spiders as a
whole as altogether useless. Perhaps mosquitoes
other than Anopheles become ensnared, although
the writer does not recall seeing mosquitoes in
spider-webs, even where both mosquitoes and
spiders were abundant. Nor do there seem to be
concise records of mosquitoes so caught. The hunt-
ing spiders that frequent dwellings and outbuildings
no doubt destroy many of the mosquitoes that
hibernate, or sstivate, as the case may be, in these
situations ; but we have very few actual observations
on this point. It has seemed to the writer worth
while to show that generalizations unsupported by
sufficient and accurate data, with which economic
mosquito literature now abounds, are likely to prove
valueless and indeed misleading.
e
The Treatment of Leprosy.—In the British
Guiana Medical Annual for 1911 Minett writes on
the treatment of leprosy by nastin and benzoyl
chloride. The work recorded in his paper is a
continuation of an investigation commenced in
December, 1908, by Professor Deycke at the Leper
Asylum, Mahaica, British Guiana.
The conclusions Minett has derived from his study
are as follows :—
(1) That nastin has apparently very little
beneficial effect on cases of leprosy; (2) a solution
of benzoyl chloride in oil shows a slightly higher
percentage of improvement than nastin; (3) anæs-
thetic cases of leprosy run a definite course, after
which the disease: seems to die out, leaving the
patient no longer infective; (4) these cases recover
sensation after a time in areas previously answsthe-
tic; and after self-amputation only scars remain.
This is a natural process and takes place without
any treatment whatever. It is not apparently in-
fluenced by either nastin or benzoyl chloride; (5)
nodular cases do not tend to improve naturally as
above, except in very rare instances; nor do they
appear to be affected appreciably by either nastin or
benzoyl chloride; (6) the so-called destruction of
bacilli is a natural process varying considerably and
does not appear to be influenced by nastin or benzoyl
chloride; (7) the variation of the amount of destruc-
tion of bacilli observed is of limited value as an indica-
tion of the effects of treatment; (8) benzoyl chloride
in petroleum oil is extremely valuable às a nasal
spray or a paint for ulcerating surfaces, it quickly
renders the discharge free from the presence of
bacilli; (9) its regular use for this
: purpose is
strongly recommended in leper asylums.
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THE JOURNAL OF
Tropical Medictne and Ppgiene
May 1, 1913.
TROPICAL DWELLINGS.
AwoNGST the many buildings to be seen at the
Building Exhibition in London the architect or
resident in tropical regions can find little to help
him. The changes not only in the planning of
houses, but even in the material of which they are
constructed, show that man has not yet reached
finality in what is the oldest form of construction
in which he has engaged. Dwelling houses in
temperate climates are made of stone, brick, con-
crete, ferro-concrete, lath and plaster, &e., &c.,
and roofed with slate, tiles, straw thatching, peat
and turf thatching, or some one of the many devices
and material now in vogue, such as asbestos com-
pound, &e. Naturally the materials for building a
house depend largely upon the geological formation
of the ground in any particular area; thus granite,
freestone, whinstone, limestone or brick are
chosen according to the character of the rock
formation in the neighbourhood or the components
of the soil In the Tropics also, as in more
northerly climes, the building material varies with
the geologieal formation and the available supply
of wood; now it may be granite as in northern
climes, wood in many American countries, or mud
May 1, 1913.]
as in Egypt, India, and many equatorial regions.
That any one of these materials possesses super-
lative benefits over all others is doubtful, although
it may be claimed that stone is theoretically and per-
haps practically the one which most commends itself.
What is wanted in a tropical dwelling particularly ?
In equatorial regions, say 12 degrees north and
south of the equator, there is no cold weather to
be guarded against; nor need there be any provision
made against typhoons, cyclones, &e., for in the
purely equatorial area calm prevails well-nigh
perpetually. In this belt heat, rain, and a saturated
atmosphere are the rule in Asia, but in some arid
South American countries heat alone is the factor
to be regarded. A thick-walled stone house in the
equatorial area is by far the best for all purposes;
it is cooler than either brick or wood, and does not
absorb or hold the moisture during the rains. The
inner wall may be wet from condensation, but that 1s
not the damp that is so much dreaded in houses
of less satisfactory material, and the very condensa-
tion helps to still further cool the air of the rooms
when it evaporates. Next to stone, and leaving
concrete out of the question, perhaps a mud wall
carefully prepared of available materials is the best;
being cheap, it may be made thick—two or
three feet even—giving thereby coolness by
reducing the penetration by the sun’s rays to a
minimum ; mud, of course, has many disadvantages,
for unless carefully looked after it is readily acces-
sible to rats, and it is apt to crack and flake away.
Bricks, more especially the inferior or blue bricks
so commonly used, are not the best material for
tropical dwellings, even if bricks are readily avail-
able. The quantity of water a brick can absorb is
a feature calculated to engender deleterious conse-
quences in a hot, moist climate and during the wet
seasons. That the Israelites had trouble in their
houses from this source was plain, for they not
only described (Leviticus xxxiii) the greenish or
reddish ‘‘ strakes’’ on the walls due to a fungoid
growth on a damp surface, but they considered that
these were unwholesome signs and capable of pro-
ducing skin diseases and even the plague of leprosy.
The dampness of the walls means also dampness of
bed and bedding, and accounts for the muscular
rheumatism which is so frequent an ailment
amongst Europeans in tropical countries. Rheu-
matism of the kind is more prevalent amongst
Europeans in the Tropics than amongst persons
native to the soil from the fact that cotton sheets
are in general use, whereas the natives prefer
blankets when they can get them, and dispense with
sheeting.
Wood in the construction of houses in tropical
countries has many drawbacks. Suitable as wood,
in planks or in logs, may be in more northerly
climates, it is not a material caleulated to be
hygienic in tropical climates. Built on unprepared
ground as they usually are, it is impossible to
protect the wood from the penetration of the ex-
cessive damp, from white ants, from ground insects of
many kinds, and from the '' dry rot ’’ which attacks
woodwork in all houses. To such an extent do
THE JOURNAL OF TROPICAL. MEDICINE AND. HYGIBNE.
135
these detrimental conditions prevail, that in Ceylon,
for instance, intestinal lesions, and amongst them
sprue, are ascribed by many old residents to the
presence of decayed wood in their dwellings.
Rubber and tea owners do not seem to realize the
complaints of many of the overseers on their estates
as to the evils ascribed to dry rot, &e., in the
residences they provide for their occupation. That
Dr. Bahr’s suggestions that sprue is ‘‘ catching,”
and that it may be communicated from one person
to another dwelling under the same roof, is a step
in the same direction, and it may be a common
infection, rather than an inter-personal communi-
cation, due to ‘‘ house’’ infection, that explains
both husband and wife contracting sprue and several
indefinite intestinal ailments allied thereto.
In addition to the actual materials of which the
house is made, the drainage of the dwellings must
be considered as well as the disposal of sewage.
Houses built on ground not previously prepared--
and most houses, at any rate, away from large towns
in the Tropics are so—are calculated to be un-
healthy, whatever their construction may be.
Throughout India, for example, the bungalow
system holds good for the most part: a one-storeyed
house, as a rule, built of unsubstantial material,
devised originally as a temporary building, but
seldom superseded by anything more permanent.
The bungalow is built on the ground and, until re-
cently, without any ventilation beneath the floor.
This cannot be otherwise than an unwholesome
dwelling, and as time goes on becomes dangerous.
Yet it is in such houses that many Europeans live
in these regions; women and children suffer
especially, for they spend most of the day as well
as the night indoors, whereas the man is out and
about at his work. Constant complaints keep pour-
ing in from outlying districts to the heads of firms
that the houses provided for their employees are
defective. "The reply all too often is: '' The house
was good enough in my time, why should it not
suit you?" The argument is untenable, the house
was but newly built when the head of the firm,
himself an employee at the time, dwelt there; damp
and dry rot had not as yet affected it, but in time
the house built of materials other than '' pucka "'
deteriorates and the outery of the more recent
occupant is justified. The fact is that in many
parts of Ceylon, Southern India, Assam, Java, and
Sumatra, the exploitation of tea and rubber has
led to rapid construction of dwellings, accompanied
by the detriments which invariably belong to hasty
building. Malaria is not the only enemy.
In our fight against actual disease, by scientific
inquiries and experiments, we are apt to forget
that sanitation in its broader aspect must be equally
considered and dealt with. The hygiene of the
house is the first principle in sanitation; our efforts
to curtail disease without this principle being
accepted and dealt with is but tinkering with the
matter; and to continue occupying bungalows as
they are usually met with in tropical countries is
but encouraging disease and laying the foundation
for future trouble. That people in bygone times
136
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1918.
had a similar difficulty with their dwellings in
tropical countries is proved from the fact that they
from time to time moved their residences; that even
a whole city would be deserted and a fresh one
built near by; and not only have we proof that one
such move was made, but with many cities in India,
such as Delhi and elsewhere, several such removals
were accomplished. Europeans would do well to
follow the example thus set, and unless the dwell-
ing they erect is made of durable materials,
raised off the ground to a considerable extent, say
three or four or more feet, drained satisfactorily,
rendered impervious to damp by concrete or stone
foundations, and the ground even on which it stands
treated so that damp does not rise directly into the
house, then it is well to condemn a house that has
been standing for ten or twelve years and erect
another. This is but false economy, however, and
it would be well for all concerned to see that houses
are built on sounder principles than as a rule
ut present obtains in many rural distriets through-
out the Tropics.
——————^»——————
Aunotations.
The Relationship of the Malarial Parasite to the
Erythrocyte.—Miss Mary Rowley-Lawson, in the
Journal of Experimental Medicine, vol. xvii, No. 3
(March 1, 1913), discusses this question under the
title, “ The extracellular relation of the malarial
parasite to the red corpuscle, and its method of
securing attachment to the external surface of the
red corpuscle.” She believes that the malarial
parasite is extracellular during its entire develop-
mental cycle; that is, with the exception of the
brief periods when it is free in the blood serum,
it is attached to the outside surface of the red
corpuscle.
The parasite secures its attachment to the out-
side of the red corpuscle by means of filamentous
pseudopodia thrown out by the parasite for that
purpose. The attaching processes are described as
(1) primary, and (2) secondary (accessory) attach-
ing pseudopodia.
(1) Primary Attaching Pseudopodia.—These are
delicate thread-like processes, arising from the cyto-
plasm of the parasite, near its nucleus. The para-
site appears to secure its primary hold on the red
corpuscle by means of these pseudopodia; but as
the corpuscular mound to which the parasite is
attached becomes dehemoglobinized, or decolor-
ized, or as the parasite increases in size, accessory,
or secondary attaching pseudopodia are formed.
(2) Secondary Attaching |. Pseudopodia, —These
may be thrown out from various portions of the
cytoplasm of the parasite, apparently for the pur-
pose of securing a firmer hold on the red corpuscle.
The pseudopodia can be seen overlying the red
corpuscle in the form of a loop, while the body of
the parasite, with its nucleus, may lie either on the
surface of the red corpuscle, or along its periphery
in close apposition to the corpuscle. Occasionally,
especiully in the very young parasite, the loop may
be formed from the entire protoplasm of the
parasite.
The parasite squeezes up that portion of hemo-
globin substance which lies within the boundary of
this loop into a mound, circular at the base, with
a more or less rounded apex. The parasite when
thus attached maintains its position on the outside
of the red corpuscle by means of the pseudopodia
encircling this mound at its base. With very few
exceptions the adult parasite is attached to the
surface rather than to the periphery of the red
corpuscle. Miss Lawson believes that the explana-
tion of this is that the surface of the red corpuscle
affords a larger area for occupation as well as for
absorption. In this situation, moreover, the
chances for the forcible removal of the parasite from
the red corpuscle are fewer.
When the parasite is attached to the under sur-
face of the red corpuscle the blue staining proto-
plasm of the parasite viewed through the red
corpuscle is paler and the outlines of the parasite
are less distinet than when the parasite is seen on
the upper surface of the red corpuscle. When two
parasites are attached to the one corpuscle, one on
either surface, these differences can be well seen,
and also the same differences can be noted when
a single parasite is seen on both surfaces of the red
corpuscle.
When a parasite, especially an adult, is attached
to the under surface of a red corpuscle, the nucleus
may be indistinct or obscured from view by the
overlying, blue-stained protoplasm of the parasite,
and may give the impression of a parasite without
a nucleus.
Occasionally an adult parasite is attached to a
corpuscular mound in a position so close to the
periphery of the red corpuscle that the nucleus of
the parasite projects beyond the periphery. It is not
at all uncommon to see the nucleus of the young
parasite of the. æstivo-autumnal infections project-
ing beyond the periphery of the red corpuscle to
which the parasite is attached, and occasionally the
nucleus of a tertian ring may be seen beyond the
periphery of the red corpuscle.
The terms achromatic area, or milky zone, have
been applied to the decolorized, transparent, and
pigment-free corpuscular area encircled by the
filamentous pseudopodium of the parasite.
The decolorization of the corpuscular mound is
gradual, proceeding as the parasite digests the
hæmoglobin. All stages between the deeply
coloured mound of unaltered hæmoglobin and the
completely decolorized one have been observed,
and can be followed with the microscope in fresh
blood as well as in stained specimens.
Complete decolorization, or dehæmoglobinization,
of corpuscular mounds surrounded by parasites may
be seen in red corpuscles showing Schuffner’s granu-
lation, and in red corpuscles with blue stippling,
suggesting that these granulations form a part of
the corpuscular substance digested by the parasite.
The decolorization of the corpuscular mound by
the young ring-form parasite, especially of the
gstivo-autumnal infections, may be complete before
May 1, 1918.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
137
the appearance of any demonstrable pigment in the
protoplasm of the parasite.
It has been believed that the achromatic area
was an essential part of the malarial parasite, and
it has been variously described as a vesicular
nucleus, a digestive vacuole, and a thinning of the
protoplasm of the parasite which allowed the red
corpuscle to show through. When certain of these
decolorized areas were seen at the periphery of
the red corpuscle they were pictured and described
by Mannaberg and Marchiafava and Bignami, who
interpreted them as extracellular parasites resting
in niches at the periphery of the red corpuscle.
That the colourless, or dehsmoglobinized, cor-
puscular area surrounded by the parasite is more
or less transparent seems proved by the following
facts: (a) When the achromatic area of one cor-
puscle partially overlies the periphery of another
red corpuscle, this periphery can be distinctly seen
through the achromatic area. (b) When the
achromatic area of one red corpuscle partially over-
lies that of another red corpuscle, the nucleus and
the protoplasm of the parasite surrounding the
underneath decolorized area is clearly seen. (c)
When the smear is made on the cover-slip, pre-
cipitation of stain may be seen more or less clearly
through the decolorized corpuscular mound. (d)
When the parasite-infected corpuscles are piled up,
one completely over another, it is impossible to find
any completely decolorized corpuscular mounds,
although many decolorized areas surrounded by
parasites may be seen where the smear is thinly
spread.
The fact that the area which is surrounded by
the parasite is sometimes seen to be achromatic and
transparent, when other portions of the infected
corpuscle show good colour, proves that this area
is not parasitic. For if this area belonged to a
parasite which was attached to a deeply coloured
red corpuscle, the area would have to be opaque in
order to be achromatic, otherwise the colour of the
corpuscle would show through it more or less clearly.
Infection of a corpuscular mound by more than
one parasite may be seen in all the malarial infec-
tions. The best examples are observed in the æstivo-
autumnal infections. As might be expected,
instances of multiple infection are most frequently
met with in cases where the parasites are numerous.
The majority of young parasites occupying the
one corpuscular mound are in similar stages of
development. This similarity in size is easily ex-
plained, as the parasites are probably of one brood,
and it may be the result of one segmenting parasite.
Parasites of varying sizes occupying the one cor-
puscular mound may be explained by supposing
that a young parasite attaches itself to a corpuscular
mound already occupied by a parasite of an older
brood.
The parasites seem to follow no rule as to their
position in relation to each other in the occupancy
of the one corpuscular mound. The bodies or nuclei
do not coalesce, as with careful examination with an
apochromatic lens of high power the parasites can
be differentiated, one from the other, even in some
of the cases where the parasites are actually super-
imposed.
In cases of multiple infection of a corpuscular
mound, the parasites seem to proceed with the
destruction of the mound in the same way that the
single parasites do. Occasionally one of the young
parasites may show a grain of pigment in its
protoplasm.
Multiple infection of a corpuscular mound should
not be confused with the appearance produced by
a single parasite whose protoplasm is intact, but
whose nucleus is broken up by the technique used
in spreading the smears. Such parasites with
nuclei forcibly separated into parts, which may be
of varying sizes, are usually found along the edges
of smears made on slides, and the interpretation is
made easy by the fact that parasites with nuclei
similarly distorted may be found in groups. A
young parasite never has more than one nucleus.
The close approximation of two parasites occupy-
ing the same corpuscular mound has undoubtedly
led to many conceptions or theories as to the con-
jugation of malarial parasites; but the fact that the
corpuscular mounds occupied by more than one
parasite may be seen at the periphery of the infected
red corpuscle makes this appear doubtful.
Miss Lawson has not been able to find any
evidence of conjugation of malarial parasites in any
stage of development, and she believes that Craig's
'' conjugating parasites ’’ are the result of a wrong
interpretation of the infection of a corpuscular
mound by two young parasites. The idea that the
parasites were intracellular perhaps led to the mis-
conception. 3
The majority of free parasites seen in malarial
infections have a compact structure. Free, para-
sites are rarely seen with pseudopodia extended for
attachment, but occasionally free parasites are seen
with their pseudopodia in the form of loops, with
or without the nuclei at the extremity of the loops.
These free parasites with the loop-form pseudo-
podia are in migration, and have been set free while
their pseudopodia are still in the form assumed by
the parasites for attachment to corpuscular mounds.
[This interesting paper is splendidly illustrated
and should be read in the original in conjunction
with the plates delineating the infected corpuscles. f
Special Methods for the Detection of Parasitic
Ova in the Feces.—Darling, in a paper published in
the Proceedings of the Canal Zone Medical Associa-
tion for the half-year, April to September, 1911 (vol.
iv, part 1), gives details of an investigation on the
intestinal worms of three hundred insane patients
detected by special methods. He thinks that
nearly all the routine examinations of fæces for ova,
larve or worms, and nearly all the published
aecounts of the prevalence of intestinal worms in
man and animals, are defective on account of the
imperfect means used for detecting ova or parasites.
The method of examining undiluted or diluted feces
in cover-slip preparations is uncertain, and when
many preparations are to be examined, it is too
138
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
laborious to yield results of high relative accuracy.
When results giving the absolute incidence of infec-
tion are desired, special methods must be used.
During a recent investigation of Strongyloides
infections, he had a favourable opportunity for
noting the incidence of intestinal worms in 300
insane patients at Ancon Hospital, Canal Zone. The
results reported in his paper were obtained by a
combination of three methods :—
(1) Plate-culture method.
(2) Differential-density method.
(3) Direct smear method.
Each of these methods is designed to give special
information more exactly, and when many stools
are to be examined more quickly with less labour
and eye fatigue than the direct smear method does
when used alone.
The specimens of the stools were collected in
heavy glass test tubes, five by five-eighths of an
inch. First a portion of the stool was placed in the
centre of a Petri dish, several drops of sterile tap-
water added, the dish covered and incubated at
room temperature, 769 to 849 F., for eighteen to
twenty-four hours. Upon examination with the dis-
secting microscope the presence of S. stercoralis,
either filariform embryos, or the sexually differen-
tiated adult free-living generation would be detected
if present. Sometimes adult Oryuris vermicularis
and hookworm larve could be seen in the Petri dish
culture as well.
Next, a portion of the feces, diluted with sterile
tap water, if necessury, was placed on a slide and
covered with a cover-slip. This was examined for
protozoa, ova of different helminths and larve of
Strongyloides. The method was used chiefly for
the detection of amabe and flagellates and in a
number of instances for comparison with the other
methods.
Finally, the tubes containing the feces were
nearly filled with sterile tap water thoroughly
mixed with a glass rod and centrifuged at 1,800 to
2,000 revolutions for a few seconds, the supernatant
fluid removed and the tubes refilled with a solution
of calcium chloride of a specific gravity of 1.250,
thoroughly mixed and centrifuged as before. The
surface film was now pipetted off and exumined
microscopically on a slide for ova. The upper
layers in the tubes and the supernatant fluid near
the surface were also examined grossly for adult or
immature worms (threadworms and hookworms).
This method segregates all the ova, worms and
some of the Strongyloides larve, chiefly the dead
ones. By a combination of the methods men-
tioned Darling believes it is possible to increase the
number of positive findings very considerably.
From 100 stools in which the fresh film method
was compared with the plate culture and differen-
tial density method (Bass'), the following results
were obtained :—
Number of times detected
in fresh film prepar-
ations (two cover-slip
preparations were used) 3
do. Plate culture method
(by) 22
Strongyloides stercoralis (1) :
larvæ of adult
free-living generation
Number of times detected
in fresh film prepara-
tions
do. By differential
method
Number of times detected
in fresh film prepar-
ations 1
do. By differential density
method
Number of times detected
in fresh film prepar-
ations
do. By differential
method
Hookworm ova
density
49
Whipworm ova
Roundworm ova
density
In contrast with other tropical regions, such as
the Philippines, Egypt, Hong-Kong, &c., the
Canal Zone does not support a very varied human
intestinal fauna, the reason being that the sanitary
disposal of dejecta, modern and eflicient methods
of disposal of sewage, the wearing of shoes by
labourers and the enforcement of salutary sanitary
regulations have reduced materially the number
and grade of infections encountered.
The following intestinal parasites were detected
however :—
Nematodes: Ankylostoma duodenale, | Ozyuris
vermicularis, Necator americanus, Strongyloides
stercoralis, Ascaris lumbricoides, Trichuris trichiura.
Cestodes: Tenia saginata, T. solium, Hymeno-
lepis nana, Tenia echinococcus.
Trematodes: Schistosomum haematobium.
Protozoa: Balantidium coli, Entameba_ histo-
lytica, E. coli, Trichomonas vaginalis, and other
flagellates.
Among the natives of this region and the West
Indies no instance of infection by a cestode has
been authenticated at autopsy. Cestode infections
are confined to the Europeans and Americans.
From a comparative point of view this is strange,
because the native dogs, cats, rats, birds, &c.,
harbour many varieties of this class of worms. Few
opportunities for examinations of native Panamans,
living in the Provinces, have occurred, however,
but in no instances have cestode ova been detected.
The methods of examination used give a much
higher proportion of infected individuals than those
usually used in routine examinations and in the
reported accounts of other investigations, excepting
those of Calvert in India, and Ashford, King and
Gutierrez.
From autopsy material Darling has determined
the presence of Ankylostoma duodenale and Necator
americanus, Trichuris trichiura and Ascaris lum-
bricoides as the nematodes corresponding to the
ova detected.
From cultures he has further identified Strongy-
loides stercoralis and Oxyuris vermicularis has been
identified from the stools.
The persistence of hookworm infections, most of
which were mild, illustrates how difficult it is to
thoroughly rid the intestinal tract of this worm by
the customary methods.
The relative infrequency of typhoid fever among
the blacks in the Canal Zone compared with many
towns and cities in the United States, as well as
the great rarity of appendicitis among the blacks
May 1, 1913.]
here and the relative frequency of whipworm in-
fections in the same class of individuals, indicate
that in this region among the blacks, the whipworm
does not play any part in the causation of the
diseases’ mentioned. On the other hand, Darling
believes that there is little doubt that amebic
colitis may begin by the infection of and entrance
of amcebe through the points of attachments of the
whipworm in the large bowel, particularly the
cecum. Ameebic infections of the intestinal tract
are always confined to the large bowel and appendix,
and frequently the only lesions noted at autopsy
are a few ulcers in the cecum in the exact location
of the point of attachment of the whipworm to the
mucosa. These points of attachment are some-
times the seat of inflammation, and the association
of amebic colitis and of whipworms in the same
bowel has been noted a number of times.
The small number of infections by Ascaris lum-
bricoides is probably due to the following reasons:
Ascaris infections usually yield readily to treatment
and they are more commonly met with during
adolescence. The patients in the insane division
are mostly in the third and fourth decades of life
and they have all been under anthelmintic treat-
ment.
Strongyloides stercoralis in cultures was found to
develop in both modes: the direct filariform and
also the indirect mode. The latter is much more
commonly encountered among natives of the
Tropics than the former.
The proportion of infections by this nematode is
higher among the insane than among other in-
dividuals to judge from the literature on this sub-
ject, but it must be said that the cultural method
has not been carried out in other examinations re-
ported in the literature.
The infection is probably a very persistent one,
for it has been found in several insane patients
between 60 and 70 years of age.
With regard to the question of the relation of
Strongyloides in diarrhea, Darling was informed by
Drs. Lawler and Drennan, who have charge of the
patients, that in not one of the fifty-seven cases of
Strongyloides infections detected was there a case
of diarrhea, thus confirming the view of Grassi
and others that this nematode does not cause
diarrhea.
The infections by Oxyuris vermicularis are
peculiarly interesting on account of their relative
infrequency among natives, and also that by the
differential density method it is necessary to look
for adult worms in the supernatant fluid of the
centrifuge tube, as well as for ova, for the latter
may be absent and the former present.
The Treatment of Pellagra.—Martin, in the New
York Medical Journal for March 15, 1918, writes on
“The Specific Treatment of Pellagra." The re-
lative values of sodium arsanilate and salvarsan are
compared. Eighty-three cases were studied. Of
these, four came first under observation in 1909,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
139
nine in 1910, thirty-five in 1911, and thirty-five in
1912.
A very careful analysis of their records caused
the author to exclude forty-five on account of the
data being insufficient for certainty. These forty-
five cases were treated for a short time with sodium
arsanilate in some instances, and some others had
single doses of salvarsan, and almost all of them
ended in recovery, but the cause and effect are not
absolutely certain, and they are, therefore, not
offered as evidence. Some of the forty-five are also
still under treatment. Of the thirty-eight others,
eleven come from the sodium arsanilate series and
twenty-seven from those treated with salvarsan.
The eleven cases sufficiently treated with sodium
arsanilate gave nine recoveries and two deaths.
Of the nine patients who recovered there were two
who had received single doses of salvarsan, but the
arsanilate treatment preponderated. Each patient
received many doses of the arsanilate, and treat-
ment was kept up in most instances over two
summers. One of the recovered cases dates from
1909, four from 1910, and four from 1911.
Of the two fatal cases, one terminated fatally
from chronic nephritis, the other from cerebral
complications probably made worse by the slight
reaction sometimes following sodium arsanilate in
very severe cases.
Of the twenty-seven cases taken from the
salvarsan series twenty show apparent cure, three
are doubtful, but greatly improved, and four ended
fatally after treatment was begun.
Of the twenty presumed cures, seven were treated
in 1911 and remain cured. Four of these came
back and received midwinter doses of salvarsan
which may or may not have been necessary. There
were thirteen patients seemingly cured by salvarsan
in 1912, of whom nine were discharged previous to
August l and are still well. These twenty cases
and the three doubtful ones received the following
number of doses: Four received five doses each,
twelve received six doses each, two received seven
doses eaeh, three received eight doses each, one
received ten doses, and one received twelve doses.
These doses were usually given at intervals of
from seven to ten days, and the first dose was
usually 0.2 grm., the second dose 0.4 grm., and the
subsequent doses whatever the patient's weight
called for, basing the full dose on 0.1 grm. for every
twenty pounds after allowing for clothing.
Comparing final results from sodium arsanilate
and salvarsan, there seems to be but small choice
between them. Each seems entirely to cure the
cases completely treated. The arsanilate must be
given hypodermically from three to five days apart
for from eighteen months to two years, allowing
a three weeks’ interval between each course of
100 gr. This is laborious, but it is at least possible,
while intravenous medication is not. lor this
reason alone the arsanilate treatment will probably
be the most used in rural distriets where distilled
water cannot be procured fresh from the still, and
where the intravenous needle is not required often
enough for the practitioner to acquire sufficient
140 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
skill to administer repeated doses in the same spot
without injuring the vein, often the only available
vein and needed for future doses. On the other
hand, the early results from the uarsanilate are
extremely slow compared with the almost miraculous
disappearance of symptoms in the majority of cases
after using salvarsan, and many cases are so slow
to begin to improve on sodium arsanilate that
the patients and the physieian both become dis-
couraged.
The average patient will take six doses of sal-
varsan in five weeks and be cured thereby, and that
is evidently preferable and should be the course
pursued whenever the patient can be so treated or
can reach such treatment. Some patients can
afford to remain away from home only about two
weeks, long enough to get three doses. When that
is the case it is well to give them that much intra-
venous treatment and then have the arsanilate kept
up after they get home. With two such specifies
which will practically cure all cases not rapidly
approaching the grave, the author thinks it is time
for physicians in America to cease thinking of
pellagra as an incurable disease.
Typhoid Vaccination.—Young gives a very ex-
cellent summary of recent literature on this subject
in the Boston Medical and Surgical Journal for
March 13, 1913.
He states that typhoid vaccine may be used in
three ways: (1) As a prophylactic; (2) as a thera-
peutic agent in active typhoid; (8) as a therapeutic
agent in chronic typhoid carriers.
The method of immunization used in the American
Army is as follows: the site of puncture is sponged
with alcohol and a small area is sterilized with
tincture of iodine. The injection is then made with
a sterile syringe, the puncture wound being sealed
with collodion. The first dose contains 500 million
bacilli, the second and third one billion each. An
interval of ten days is allowed between doses, the
entire procedure thus taking twenty days. The
injection is given subcutaneously, and no vaccine
over four months old is used. The duration of the
immunity conferred is stated by Firth to be
two and a half years. Leishman believes reinocula-
tion should be done after two years.
The treatment of typhoid fever by vaccines is
still in the experimental stage. Different authors
recommend doses from one million to one billion,
with varying intervals between doses. The sum of
opinion is favourable. It is claimed that the fever
period is shortened, and that complications, relapses
and mortality are markedly reduced; while the use
of the vaccine is attended with no bad results and
in no way increases the patient's discomfort.
Callison has recently collected 475 cases of typhoid
fever treated with vaccines from the literature.
Omitting 52 cases in which the dose was one or
two millions, unquestionably a dose too small to
have any effect, the mortality in the remaining
423 cases was 5.4 per cent., with relapses in 6.5 per
cent. Callison recommends that vaccine treatment
should be instituted as early as it is possible to
make a diagnosis. His initial dose is 500 million
bacilli; the inoculation is repeated at four-day
intervals as long as required, increasing the dose
100 million each time. In his last series of fourteen
cases no patient received more than six, with an
average of three to four inoculations. Although
475 cases is too small a number from which to draw
conclusions, especially in so protean a disease as
typhoid fever, the results obtained are encouraging.
Medical literature contains numerous reports oi
chronie typhoid carriers, but there has not been
much discussion of the treatment of these patients.
Brem and Watson, reviewing the literature in
November, 1911, found, including one case of their
own, only twelve recoveries of typhoid carriers.
Three chronic intestinal carriers recovered after
operations on the gall-bladder, one during the
administration of Bacillus bulgaricus in large doses,
one after repeated exposure of the gall-bladder to
X-rays, and one urinary carrier after the administra-
tion of hexamethylenamin in combination with
borie acid. One intestinal, three urinary and two
carriers discharging bacilli from bone lesions were
cured with autogenous vaccines. Cummins,
Faweus and Kennedy treated seven typhoid carriers
by various methods and were sure of the recovery
of only one patient, an intestinal carrier treated with
lactic acid bacilli. Vaccine treatment failed in the
three cases in which it was tried, one intestinal and
two urinary carriers. Since the publication of Brem
and Watson’s paper, six cases, one urinary and five
intestinal carriers, treated with vaccines have
been reported. Two intestinal carriers, one with
an acute cholecystitis that recovered without opera-
tion, and a bacilluria of twelve years’ duration were
cured. Two intestinal carriers have remained free
from typhoid bacilli for three and one-half and six
months. The sixth case, a chronic suppurative
cholecystitis, was drained and the discharge gave
a pure culture of B. typhosus. The sinus gave no
evidence of healing until a vaccine was given. In
the treatment of typhoid carriers Meader recom-
mends an initial dose of 100 million bacilli repeated
at intervals of two weeks, increasing the dose 200
million each time.
The author’s summary is as follows: (1) Typhoid
vaccine as a prophylactic provides almost certain
protection from typhoid fever. (2) Typhoid vaccine
as a therapeutic agent in active typhoid is still in
the experimental stage. A sufficient number of
cases have not been studied to enable one to draw
definite conclusions. The results so far obtained,
however, are favourable. (3) Typhoid vaccine as à
therapeutic agent in chronic typhoid carriers, while
it does not offer certain cure, is the method of treat-
ment that has given the best results.
Ore
“Bulletin de la Société Medico-Chirurgicale de L’Indochine,”
Tome iv, Février, 1913, No. 2.
Liver Abscess.—Degorce reports an interesting case of
& liver abscess in which gas and a biliary caleulus were
found. The patient was operated upon, and made a good
recovery. The abscess was situated in the liver substance,
and had no communication with the intestine. An ex-
amination of the calculus found in the abscess showed that
it consisted of a hard and soft part, the former consisting
of phosphate of lime, the latter of fatty débris, fibrin, and
dried blood.
May 1, 1918.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
141
Abstract.
EXPERIMENTAL AM«&BIC DYSENTERY AND LIVER
ABSCESS IN Cars.
WENYON, in his interesting paper on this subject
in the Journal of the London School of Tropical
Medicine, December, 1912, giving details of his
experiments, writes that Hlava and Kartulis first
showed that amebic dysentery could be produced
in cats by infecting them per rectum with mucus
or feces from cases of amcebic dysentery in man.
Quincki, Roos, Kruse, Pasquale, Strong and Mus-
grave repeated these experiments, while Kartulis fur-
ther showed that dogs could be infected similarly.
Musgrave and Clegg produced dysentery in mon-
keys in the same manner. Kruse and Pasquale
succeeded in producing dysentery in cats by the
injection of pus from an ameebie liver abscess which
was shown to be bacteria free. Hartmann has
pointed out that the entire absence of bacteria in
a liver abscess is very difficult to demonstrate. One
cannot state more than that the cultural methods
adopted failed to reveal their presence. It is pos-
sible that some other method of culture would have
succeeded. Jurgens stated that the amæbæ
actually forced their way through the healthy
epithelium of the cat's gut; and Schaudinn attri-
buted their power of doing this to their tough
ectoplasmic pseudopodia. It was Schaudinn who
first clearly distinguished a non-pathogenic and
pathogenic amcbe of man under the names of
Entameba coli and E. histolytica respectively. By
feeding cats on material containing cysts of E.
histolytica amæbic dysentery was produced.
Is E. tetragena the same as E. histolytica? In
cases of dysentery, Viereck discovered an amaba
that differed in life-history from Schaudinn’s E. his-
tolytica, and named it E. tetragena because the
mature cyst contained four nuclei. These tetragena
cysts were then recognized by Hartmann and have
now been found in almost every part of the world
where amebic dysentery occurs; and Viereck’s
amcebe is now looked upon as the common
pathogenic ameba of man. It is thus difficult to
account for Schaudinn’s E. histolytica.
Hartmann has re-examined many of Schaudinn’s
preparations and finds that his E. histolytica, in
most cases at least, corresponds with E. tetragena
of Viereck. It seems highly probable that Schau-
dinn failed to recognize the cysts with four nuclei
and that the small spores described by him were
structures unconnected with the ameba. Adopting
this view, it comes about that E. tetragena, Viereck,
is none other than E. histolytica, Schaudinn; and
that Viereck regarded it as a distinct species be-
cause he had discovered the true life-history, which
of course differed from the erroneous one given
by Schaudinn. Provided the latter was right in
naming the pathogenic amceba E. histolytica,* the
* E. Brumpt (''Précis de Parasitologie,” Masson et Cie.,
Paris, 1910) gives Amæba dysenterie ; Councilman et Lafleur,
1893, synonymie: Entameba histolytica, Schaudinn, 1903.—
H. M. H.
name tetragena is no longer required; the common
pathogenic amaba of man is still histolytica, but
the life-history is that discovered by Viereck—not
that described by Schaudinn.
Attempts to confirm Schaudinn’s Observations
on E. histolytica.—Wenyon, in 1907, in Khartoum,
studied cases of amæbic dysentery, but failed to
discover any indication of the development described
by Sehaudinn for E. histolytica (Third Report,
Welleome Research Laboratories). Since then he
had tried repeatedly to obtain some confirmation
of this development and especially of the produc-
tion of the small infective tough-capsuled spores,
but always without success. Viereck’s discovery
cleared the ground and we now know that the
human pathogenic amceba produces not the tough
spores of Schaudinn, but the transparent cysts
described by Viereck. On account of the doubtful
technique he employed, Craig's confirmation of
Schaudinn’s results are hardly convincing.
Out of a large number of observations on cases
of ameebic dysentery in man, Wenyon has found
the typical cysts of the pathogenic amceba on six
occasions only. It is unfortunate, for diagnostic
purposes, he writes, that the cystic forms occur in
only a small percentage of cases of amcebic dysen-
tery, for they are comparatively easy to recognize;
they can be readily distinguished from the cysts of
E. coli, and it is their presence which assures one
more than anything else that the amæba in question
is the pathogenic form. It is admitted that the
pathogenic and non-pathogenic amoeba of man are
subject to much variation, so that differences at
one time marked are hardly to be recognized at
other times. The cause of encystment is unknown.
As a rule, during the height of a dysenteric attack
encysted forms are not seen; they appear to be
formed when the patient is recovering naturally
from the disease. The encysted forms of the
pathogenic amcebe are seen, therefore, most often
during periods when the dysentery is in abeyance.
When cysts occur they usually do so in large
numbers; at such times one finds more encysted
amcebe than free forms. From such cases Wenyon
has been able, by suitable methods of preparation,
to confirm in every essential respect the observa-
tions of Viereck and Hartmann on the encystment
process of the pathogenic amaba, but not any of
the life-history as Schaudinn described it.
The Production of Amabic Dysentery in Cats.—
The material used in the experiments was obtained
from a European from Bombay, whose stools con-
tained numbers of free and encysted amebe. The
patient was admitted to the Seamen’s Hospital,
Royal Albert Dock, not for dysentery, but for
severe anemia. On close inspection the stools
were found to contain some small flakes of blood-
stained mucus and the microscope revealed amebe,
the encysted forms having the typical character of
E. tetragena, Viereck. About 5 c.c. of this material
was injected per esophagus and per rectum into
two cats. Both animals developed amcebic dysen-
tery. Such experiments have been conducted
with this ameba by Viereck, Werner, Hartmann,
142
and recently by Darling in Panama. These
observers have shown that ingestion of the amcebe
alone by the cats does not produce dysentery,
whereas ingestion of the encysted forms will do so.
Injection of the amæbæ themselves per rectum will
produce dysentery. In Wenyon’s experiment, both
cats were passing typical dysenteric stools contain-
ing much blood and mucus and many amebe,
nineteen days after the injection. It is probable
they had been already infected for some days, so
that the ineubation was less than nineteen days.
From these cats others were infected, and Wen-
yon was able to carry on the infection through four
passages; and but for an accident could have car-
ried it much further, as there was no sign of
decreasing virulence in the strain of amcebre em-
ployed. Hartmann states that from his own
experiments with this amæba, and those of Viereck
and Werner, the infection of eats is not satisfactory,
and that after two, or at most three, passages the
infection ceases. Wenyon, from his experiments,
holds that with care it would be possible to carry on
the infection indefinitely in cats. In the sub-
inoculations the ulcerated large intestine of the cat
(which had died naturally from the disease, or had
been killed when about to die) was opened and
washed in physiological saline solution, the wash-
ings being then injected into the large intestine of
the next cat. Only once did this fail to produce
ameebie dysentery, and in that instance the cat
was the largest one used; therefore, to ensure suc-
cess one must employ young kittens soon after
they have become independent of the mother.
The Production of Amabic Abscess of the Liver
in Cats.—It was often seen that the mesenteric
glands draining the ulcerated areas of the gut
(nearly always the lower part of the large intestine
was ulcerated) are swollen, and on section these
contained a large number of amcebe which appeared
to be feeding on the gland tissue, for their bodies
were often packed with gland cells, resulting at
times in the complete destruction of the glandular
tissue. One of the cats which contracted dysentery
as a result of the injection of amcebe from a cat
of the third passage, not only developed typical
dysenterie uleeration of the gut, but also abscess
of the liver in which were numerous amebe. There
were four superficial abscesses, the largest with a
diameter of 1 em. Had not the cat died of
dysentery before the abscesses increased in size, it
would have been possible to conduct experiments
with the amiebe from them. The liver of this cat
had not been injured in any way; the abscesses had
developed spontaneously as a result of the amoebic
infection. The whole picture of amcebic dysentery,
with its complication—amecebic liver abscess—in
man was thus produced experimentally in the cat.
The fact that it was in the fourth passage that the
abscesses developed indicates that the amcebe had
lost none of their virulence in these passages; and
pointed in a striking manner to the true patho-
genieity of Viereck's E. tetragena.
The Invasion of the Tissues by the Amabe.—
It is difficult to decide exactly how the amæbæ
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
reach the liver from the intestines. It would pro-
bably be by way of the portal blood-vessels; this
is perhaps borne out by the fact that one cat
developed pyemia in which the whole blood system
contained pus. The amob:s commonly invade the
mesenteric glands, so that a lymphatic course is
possible. The invasion process is easily studied in
sections of the ulcerated large intestine. The
amcebe make their way to the bottom of the
tubular gland. There they multiply and by pres-
sure of their numbers or by the exertions of their
pseudopodia, and probably through some toxic
substance excreted by them, the living cells are
weakened and separated and the amcebe pass into
the connective tissue beneath. The epithelial cells
begin to degenerate and the earliest stage of ulcera-
tion is reached. Bacteria are thus admitted, the
destruction becomes more rapid, and the amobse
push on to the deeper layers and give rise to the
characteristic undermined ulcers of amcebic dysen-
tery. Wenyon has shown, in the case of the
natural infection of mice with E. muris, that these
amcebe often enter the tubular glands of the large
intestine of the mouse, and may reach their deepest
extensions. In the case of this harmless ameba,
the invasion of the glands is not followed by any
disintegration of the glandular epithelium, whereas
the similar invasion of the glands of the cat by the
human pathogenic ameba is immediately followed
by ulceration. Wenyon believes that with the
pathogenic form there must be some toxic substance
which so weakens the epithelium of the glands that
the amæbæ are able to force their way through,
perhaps before it has actually disintegrated. It is
difficult to believe that the pathogenic amcebe can
force its way through uninjured and healthy epithe-
lium. If so, then E. muris should penetrate the
glandular epithelium of the mouse’s gut. To state
that, for this purpose, the pathogenic amcba has
a tougher pseudopodium is a pure assumption; for
E. muris may have pseudopodia quite as substantial,
as far as one can judge, as those of the pathogenic
forms.
Other Amebe from the Human Intestine.—One
cat was given per csophagus and per rectum a
large quantity of feces containing numerous free
and eneysted E. coli; another cat received per
rectum an injection of feces from another case in
which only free forms of E. coli occurred. Neither
became infected, nor did they suffer in any way
from the injections. They were later infected with
material from dysenterie cats and both developed
amcebie dysentery. An attempt was made to infect
another cat with a small amceba which occurred in
enormous numbers in the feces of a native of India.
The ameeba varied in size from 3 to 10 microns, and
had a nucleus of the typical limax type. It was
constantly present in the stool for the three weeks
the case was kept under observation. Numerous
as were the ammbe, they seemed to have no ill-
effect on their host, who was admitted to hospital
for quite other reasons. The cat, though it re-
ceived per rectum many millions of this amceba,
did not become infected.
May 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
143
The Amebe as they occur in Cats.—The normal
healthy amcebe correspond exactly with those from
the human intestine ; and just as in cases of amoebic
dysentery in man, many of the amcbe are
degenerate and show abnormalities in nuclear
structure, so in the cat one encounters many altered
forms; as Hartmann has shown, in the cat the
number of altered abnormal amcebe is greater than
in man.
The oceurrence of these abnormal forms,
especially those in which the nucleus has undergone
a change and broken up into scattered chromidia,
may easily lead to errors of observation. Hartmann
admits that he himself was misled by such altered
forms and that he saw in them a confirmation of
Schaudinn’s development of E. histolytica.
On no oceasion did Wenyon find the cysts of
Viereek in the feces of the cats, probably because
in the cats the dysenteric process did not pass
beyond the acute stage. If the cats had begun to
recover naturally, it is possible the encysted forms
of the amcebe would occur in the feces.
This experimental work is justly claimed to have
established that the amceba (E. histolytica, Schau-
dinn; E. tetragena, Viereck) is the true and exciting
cause of amcebic dysentery and liver abscess in
man ; and further that there occurs in man, besides
the pathogenic ameba, a non-pathogenic form,
E. coli.
— €
Hotes and Mets.
Tue Society oF TROPICAL MEDICINE AND HYGIENE.
—At a meeting of the Society of Tropical Medicine
and Hygiene held at 11, Chandos Street, Cavendish
Square, London, W., on Friday, April 18, 1913, at
8.30 p.m., the following gentlemen were elected
Fellows: Alakh B. Arora, L.R.C.P. and S.Edin.,
India ; Fleet-Surgeon F. H. A. Clayton, M.D., R.N.,
Haslar; R. A. O'Brien, M.D.Melb., Battersea
Park, S.W.; Francis W. O'Connor, M.R.C.S.,
London School of Tropical Medicine; David Thom-
son, M.B., Liverpool; J. G. Thomson, M.B.,
Liverpool; G. C. Vickery, M.B., Devonport.
— 9 ——————
Bugs and Appliances.
Byno Lecithin.—Allen and Hanburys, Ltd.,
are bringing out a new addition to their well-known
series of Bynin preparations. This is called Byno
Lecithin (malted lecithin), and is a valuable tonic,
nerve food, and digestive.
Lecithin is a phosphorized body of the formula
C,,H,,PO,. It enters largely into the composition
of the nervous system. It is stored in the liver;
and while ordinary fats vary directly with the
supply, lecithin is a constant constitüent of the
liver cells, even in prolonged starvation. This has
suggested that lecithin is the first step in the syn-
thesis of inorganie phosphorus to form the complex
nucleins of the cells, and that the fats of the liver
may act by combining with this phosphorus to fix
the latter and prevent its excretion.
Lecithin was first isolated and described in 1850
by Gobley, who obtained it primarily from the eggs
of the carp. He concluded that a similar substance
occurred in large amounts in the brain, and this
view was subsequently confirmed by Hoppe-Seyler
and Diaconow. When decomposed, lecithin yields
glycero-phosphorie acid, stearic acid, and neurine.
The ash contains metaphosphoric acid. Recent
research suggests that the term ''lecithin '"" must
apply to several allied organie substances containing
phosphorus radicles united to varying fatty bases.
It is usual, therefore, to speak of such as the
‘lecithin compounds.’
This brief survey of the chemistry and physio-
logical distribution of lecithin is sufficient to indicate
its importance in the animal economy. Foods con-
taining lecithin are now recognized to be of the
utmost value in the dietary of those suffering from
nervous debility, whether of primary origin, or
secondary to acute or chronic disorder. Products
containing lecithin derived from egg or milk proteid
have been in considerable demand, and have been
administered with success.
In Byno Lecithin, lecithin is combined with
Bynin, a pure malt extract, containing the complete
activity of the diastasic ferment.
The combination also contains in solution a
definite standardized amount of the compounds of
einchona in combination with their natural acids,
and in addition in each ounce an amount of nux
vomica equal to 1/40th of a grain of strychnine,
which powerfully reinforces the tonic action of the
cinchona.
These alkaloids exert a direct stimulating action
on the nervous system and organs of the body. The
dose of the new preparation is half an ounce, three
times a day, half an hour before meals.
— eo
A:ebieto,
Tark MiNERAL WATERS or Vicuy. For the use of
Practitioners. By Charles Cotar, M.D.Paris,
Consulting Physician at Vichy. London:
H. K. Lewis, 136, Gower Street, W.C. 1913.
The literature dealing with the general study of
mineral waters, and the thermal stations in par-
ticular, is very scattered, so the above work should
be welcome.
The author, Dr. Cotar, a consulting physician at
Vichy, gives in it a complete account of the subject
of hydrotherapy.
After giving the theories concerning the origin of
the waters and their chemical, hygienie, and
gaseous properties, he reviews their physiological
action, so that it becomes easy to deduce their
medical indications and contra-indications ; the latter
144
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
are corroborated by the observations and numerous
contributions of his colleagues on the spot, and the
author’s own personal experiences are also, of
course, added. These are of very great value.
A chapter is devoted to diseases of children, and
in the concluding chapter a comparison is made
between Carlsbad and Vichy.
A complete index makes it easy to find any
information which may be needed.
—— 9 ——— —
Personal Hotes.
COLONIAL MEDICAL SERVICES.
West African Medical Staff.
April, 1913.
No deaths.
No transfers.
Retirements.—A. W. Atkinson, M.B., Ch.B. Edin., Medical
Officer, Gold Coast, retires with a gratuity; St. George Gray,
M.D., B.Ch.Dublin, Senior Medical Officer, Southern Nigeria,
retires on pension.
New Appointments.—The following gentlemen have been
selected for appointment to the Staff:—N. A. D. Sharp,
M.R.C.S.Eng., L.R.C.P.Lond., Gold Coast; J. C. C. Hogan,
M.D., B.Ch., B.A.O., L.M.Dublin, Northern Nigeria; J. A.
Beattie, M.D., Ch.B.Aberdeen, D.T.M. and H.Cantab.,
Northern Nigeria.
Other Colonies and Protectorates.—W. W. Martin, M.B.,
Ch.B.Vict., J. W. Adams, M.R.C.S.Eng., M.R.C.P.Lond.,
M.B., B.C.Cantab., and J. London, M.B., Ch.B.Liverpool,
have been selected for appointment as Medical Officers in the
Straits Settlements; J. M.G. Ewing, L.R.C.P., L.R.C.S.Edin.,
L.F.P.S.Glas., has been selected for appointment as a District
Medical Officer, St. Vincent; W. N. A. Paley, M.R.C.S.Eng.,
L.R.C.P.Lond., has been selected for appointment as a
Medical Officer, Fiji; W. S. Coffey, L. R.C.P., L.R.C.S.Ireland,
has been selected for appointment as a Medical Officer in the
Federated Malay States.
INDIA OFFICE.
From March 1 to April 5.
Arrivals Reported in London.—Captain C. H. Barber, I.M.S. ;
Major Bhola Nauth, I.M.S.; Captain J. B. Christian, I.M.S.;
Colonel G. W. P. Dennys, I.M:S.; Captain S. Haughton,
I.M.S. ; Captain D. L. Graham, I.M.S.
Extensions of Leave, — Captain R. E. Gamlen, I.M.S., 6 m. :
Captain C. A. Gill, I.M.S., 14 d.; Captain G. C. L. Kerans,
I.M.S., 6 m.; Captain L. Reynolds, I.M.8., 6 m., M.C.
List or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Barber, Captain C. H., I.M.S.
Graham, Captain D. L., I.M.S.
Haughton, Captain S., I. M.S.
Nauth, Major B., I.M.S.
Taylor, Captain J., I.M.S., to May 7, 1913.
Watson, Major T. E., I.M.S.
Woods, Captain J., I.M.S.
List or INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULEs),
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted,
Christian, Captain J. B., I.M.S.
Dennys, Colonel G. W. P., I.M.S., C.P.
Ross, Captain H., I.M.S., U.P., 24 m., November 20, 1912,
———— 49———————
Becent and Current Literature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JouRNAL oF TROPICAL MEDICINE AND
HyaiENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
“Journal of the Royal Army Medical Corps,” No. 4,
April, 1913, vol. xx.
Dengue.—Colonel Smith, D.S.O., believes that the dengue
fever seen amongst the troops in Calcutta is identical with
seven-day and three-day fever. He states that year after
year the troops in Calcutta are attacked by a short fever
which is productive of much inefficiency but no mortality.
It has been returned as pyrexia of undetermined origin.
This year, 1912, the author had the good fortune to have to
deal with the disease personally and experienced an attack
in his own person. Last year (1911) very careful notes of
the disorder were taken under the direction of his pre-
decessor, Lieutenant-Colonel T. McCulloch, R.A.M.C. From
reading these notes and seeing the temperature charts, he
(Colonel Smith) has no doubt that the fever of 1911 was
the same as the fever oi 1912. He is also confirmed in this
view by officers who have seen the fever in both years.
The conclusion arrived at is that the fever of 1912 is the
same fever as that of many previous years, and is un-
doubtedly dengue. But the same fever has previously been
called seven-day fever and three-day fever, so therefore
seven-day fever and three-day fever are in reality dengue.
Seventh Report on Plague Investigations in India,
January, 1913.
THE above report, which is published as a Second Plague
Supplement of the Journal of Hygiene, contains the follow-
ing papers:—
(xlviii) “Plague in Madras City? (with 1 chart); (xlix)
“Statistics of the occurrence of plague in man and rats in
Bombay, 1907-11”; (l) “The distribution of white-bellied
Mus rattus in Bombay Island” (with 1 map); (li) “ The
immunity of the wild rat in India" (with 1 map); (lii)
“ Chronic or resolving plague? (with 1 chart and plate xv);
(liii) “The experimental production of resolving plague in
rats"; (liv) " Experimental plague epidemics | among
rats”; (lv) “Observations on flea-breeding in Poona”
(with 7 charts); (lvi) “The serum treatment of human
plague"; (lvii) * Attempt to separate the antigen from the
nucleo-protein of the plague bacillus by filtration through
gelatine,” by Dr. S. Rowland; (lviii) * Besredka's method
of vaccination" by Dr. S. Rowland; (lix) * The relation
of pseudotubercle to plague as evidenced by vaccination
experiments,” by Dr. S. Rowland; (lx) Observations on
the mechanism of plague immunity," by Dr. S. Rowland;
(Ixi) ** The onset and duration of the immunity consequent
on the inoculation of plague nucleoprotein," by Dr. S.
Rowland (with 2 charts); (lxii) The opsonie index in
plague vaccination,” by Dr. R. St. John Brooks (with 5
charts); (lxiii) * The preparation of antitoxic plague
sera," by Dr. A. T. MacConkey.
Ln
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1.—Manuscripts sent in cannot be returned,
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
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JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
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5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
May 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 10, Vol. XVI.
Original Communication.
A REVIEW OF A CLINICAL STUDY
MALARIA FEVER IN PANAMA.*
By JouN Pernas Barres, M.D.
Ancon, Canal Zone, Panama.
OF
THE COURSE AND DURATION or MALARIA FEVER
UNDER THE ADMINISTRATION OF QUININE.
Tue conclusions that are to follow in this series
of articles have been deduced from a large general
medical service in the two main hospitals of the
Isthmian Canal Commission in Panama. The
method by which these conclusions have been
reached was to make a routine examination of the
blood for malarial parasites of each patient when
admitted to the hospital, regardless of what disease
the patient might be suffering from, and to follow
their clinical course until the patient was discharged
from the hospital. The urine and feces were also
examined as a routine measure. Red and white
blood-eell counts, differential counts, and hæmo-
globin estimates were made if the nature of the case
indicated. In addition to the clinical laboratory
facilities for routine use in diagnostie purposes, the
main laboratory of Ancon Hospital, bacteriological
and pathological, was always at the service of the
general staff, and I made the fullest use of this
latter opportunity at all times.
In such a general work it was not possible for one
to do all the detail work, but in my service I visited
and examined each patient daily, or oftener when
the nature of the case required. In order to avoid
deducing conclusions from a too restricted class of
patients, I made frequent comparisons between my
results and those of others, in the different wards
of the hospital, noting the different effects, if any,
of race or colour.
After one has in this manner noted the clinical
course of malaria fever in a large number of cases
and over a considerable length of time, one will be
particularly struck by the uniformity of its course,
and the promptness of its subsidence under treat-
nent by quinine; while this striking fact of its sub-
sidence is being observed in cases amenable to treat-
ment, it is also equally as noticeable that in those
cases where the infection is too great to be affected
by treatment in a given time, such cases are just as
prompt in the opposite direction—towards death.
These phenomena one would naturally expect to
be contradicted in some cases at least; in those, for
instance, where the amount of quinine which could
be administered would be about equal to the amount
of the infection present, and under such circum-
stanees one would infer that there would be a
balancing between the two opposing forces, until
sufficient immunity principles are evolved to finally
terminate the course of the disease, and therefore
the paroxysms would then continue over a consider-
able length of time.
Such a condition, however, never occurs, even
* Read before the eighty-fourth meeting of the Canal Zone
Medical Association, March 15, 1913.
under average treatment; there are then no long
or lingering malaria fevers, nor are there any that
approximate a period that could be in any sense
termed continuant. In malarial countries it is also
observed that there are no diseases which may not
be, in their earlier stages at least, complicated by a
superadded malarial infection; and, on the other
hand, there are no malarial infections that may not
have some underlying disease, either frank or
eryptogenetie, to complicate its course. It becomes
then extremely difficult at times to be certain just
how far one is studying the clinical phenomena and
course of malaria fever, or adding to them the
phenomena of some other disease.
To do so with any degree of satisfaction it is
necessary to have an abundance of material for com-
parative estimates, and laboratory facilities at hand
or of easy aecess, for the final determination of
obscure problems. I have been fortunate in having
both, and shall in what follows give somewhat in
detail the results of this study, and the practical
conclusions according to my interpretation of the
faets observed.
In order to follow up this review in proper
sequenee, I think it best to sketch in its general out-
line the accepted knowledge and teaching of malaria
as found in the text-books in the latter part of 1905,
the time I first began to note the points in the
clinical phenomena of malaria which I thought were
not quite in keeping with the ideas conveyed to me
by such teachings.
In 1905, Marchiafava, Celli, Bignami, Bastian-
elli, Golgi, Osler, Manson, Ross, Thayer, Manna-
berg, and many others not without due influence,
were the most powerful factors in shaping our ideas
of malaria in America. They, with many other
painstaking workers, had followed the life cycle of
the malarial parasites both in the human organism
and in the mosquito; they had differentiated the
different morphology between the varieties of para-
sites, classified them in zoology, and given their
biological characteristics ; drawn and tabulated them
in such a way that any worker after a little experi-
ence could follow them. They had put upon a sure
basis the mosquito theory of the transmission of
malaria between man and man, and defined the
varieties of mosquitoes; and they in the meantime
had followed the clinical course and symptoms of
malaria, and described its characteristics accurately
up to a certain point, where there arose some con-
siderable divergeney of opinions.
This point of divergence arose over certain sym-
ptoms of the malaria fevers, and the effect of
quinine on the duration of the fever in particular
infections, notably the wstivo-autumnal, and upon
the resistance of the wstivo-autumnal parasites to
quinine. These, then, being the points over which
most of the confusion arose, I shall here examine
some of the different views as then held, without
any particular comment, and take them up later on,
together with the management of the case, and the
dosages of quinine advised by each; and seek to
explain some of the reasons for these various ideas,
as those reasons appear to me. The course of the
146
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1913.
fever and its duration and its susceptibility to treat-
ment, among the most accepted authorities, were, to
quote briefly, as follows :—
Thayer [1], after stating that the malaria fevers
were usually very amenable to quinine, and speak-
ing further of the wstivo-autumnal fevers, says :—
Certain of these cases may pursue a course quitc similar to
typhoid fever through some days, or even weeks. To these
cases Baccelli has given the name *' subcontinua,”
Osler [2], in describing the estivo-autumnal
iever, states tbat the
Fever may be continuous with remissions more or less
marked. In some the fever subsides at the end of the
week, and the practitioner is in doubt whether he has had to
do with a mild typhoid or a simple febricula. In other
instances the fever persists from ten days to two weeks; there
are marked remissions, perhaps chills, with a furred tongue and
low delirium. It is under this form of malaria fever
that so much confusion still exists. The fever yields,
as a rule, promptly to quinine, though here and there cases
are met with—rarely, indeed, in my experience—which are
refractory.
Scheube’s [3] view of the estivo-autumnal fever
is decidedly more discouraging, as he says of it:—
The period of the duration of remittent fever fluctuates
between three days and three weeks, sometimes it even lasts
longer. Quinine usually has but little effect on re-
mittent fevers, and good results are not obtained immediately
even on a change of climate.
I think it fair here to let Scheube speak his views
on the dosage of quinine, in which he says :—
As regards the dose, the administration of small occasional
doses has now been quite relinquished in favcur of a single
larger dose at longer intervals. In mild forms 1 grm. is the
usual dose for adults ; in serious forms 1 to 2 grm. are adminis-
tered. Experience has taught us that it is useless, and may
prove dangerous, to exceed this quantity.
Manson [4], in describing the estivo-autumnal
fevers, speaks as follows :—
A modification of the bilious remittents—what Kelch and
Keiner call typhoid remittent—is very much more grave as
affecting life than the simple bilious remittent.
In the typhoid remittent, typhoid symptoms, such as low
delirium, prostration, dry tongue, swelling of the spleen and
liver, subsultus tendinum, marked melanemia, are superadded
to the usual symptoms. The quinine test is generally
conclusive iu intermittents and in the various larval forms of
malaria, but the more severe remittents are often singularly
resistant to the drug. Moreover, time may not be available in
which to test such cases with quinine.
Manson's statement that the more severe remit-
tents are singularly resistant to the drug, followed
by the qualification that time may not be available
in which to test these cases with quinine, can with
propriety be interpreted in two ways. First, that
the fever cannot be controlled by quinine, and from
the clinical description of them one could expect
them to continue over a considerable length of time.
Or, from the qualifying remarks one may infer that
these symptoms had arisen from neglect of treat-
ment, and death was so near that quinine would
now be useless. I prefer to take the latter interpre-
tation, as he states further on :—
The quinine may not always prevent the next succeeding fit,
but it nearly always diminishes its severity. In ninety-nine
cases out of a hundred the second following attack does not
develop.
Marchiafava and Bignami [5], who had made
such a long and careful study of malaria, have not
allowed themselves to be confused about these
fevers. They go directly to the point without
hesitation, and tell us what to expect about their
duration :—
Their duration depends nearly always upon the treatment;
if the specific remedy be promptly administered, the fever
usually remits with promptitude, or it may intermit, to
resume again for a short time, and terminate definitely. Thus
their duration is usually four, five, or six days, or a week at
most,
They did, however, encounter some cases that
did not pursue this uniformity of course and dura-
tion, and refer to them as follows :—
We have already spoken of the duration of the fever, stating
that when it is properly treated it does not last more than five
or six days. But sometimes cases occur in which, in spite of
the administration of quinine and the decrease or disappearance
of the parasites, the fever continues for two, three, or even four
days longer, with a progressively milder course.
Mannaberg [6], in discussing the subcontinued
type of fever, states :—
The fever-curve of a subcontinued fever, for one or two weeks,
will sometimes show the original type, whether tertian or
quartan, though in the majority of eases this is not decisive.
In addition to spontaneous temperature fluctations, which are
difficult to recognize, there are others due to quinine (adminis-
tered necessarily from the beginning).
It would be useless, I think, to continue this
review any further, as all will be found more or less
similar. With the exception of Marchiafava and
Bignami, and Osler to some extent, and perhaps
Manson, it will be seen that malaria was held to be
a somewhat variable entity, and variable in its
manifestations. Most usually it would yield
promptly to quinine, but again it would be extremely
resistant, and continue for weeks in spite of the
administration of the drug, to end in recovery, and
sometimes in a long and tedious convalescence. In
the midst of such manifestations, if the descriptions
are followed further, pernicious symptoms might
arise, and these in turn manifest characteristics
equally as variable as the course and duration.
Naturally I held these sume views with regard to
malaria, and in a country, then, like Panama, where
the name of malaria was held as a seourge—the
dread pernicious of the French, and the even more
terrible ‘‘ Chagres fevers ’’ were to be met with—
one naturally expected to contend with malaria in
all of its infinite forms.
As to the matter of the severity of these fevers,
my apprehensions were fully realized; the admission
of eases already in coma was not unusual; the
sudden onset of pernicious symptoms a few hours
after admission was also not uncommon, and grave
ases without pernicious symptoms were always
present. But as to the duration and course of these
fevers, I was not a little surprised to note that not
even the gravest of those which recovered showed
a duration or course comparable to the description
of the grave malarial fevers quoted above. (These
statements apply to the beginning of our work in
Panama in 1904, 1905, and 1906.)
May 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
147
The most of the malaria fevers terminated in
from two to three days, the tertian subsiding some-
times with an elevation of temperature on the third
day, and the estivo-autumnals with a lessening rise
of fever each day, or with a prolonged paroxysm ;
this final paroxysm beginning on the second or third
day, and lasting from twenty-four to sometimes
even forty-two hours, and thus terminating its
course.
With the exception of the deaths from the per-
nicious fevers, and the consequent interesting
autopsy, and a normal number of blackwater fever
cases, it was rare that anything occurred to break
this clinical monotony.
There were also observed quite a number of fevers
in which routine blood examination proved negative
for malarial parasites. The clinical symptoms in
most of these negative cases were so characteristic
and their duration so short that they could not be
other than malaria. But among these nega-
tive fevers it was noted that now and then some of
them continued for from ten to fourteen days or
even longer under the usual doses of quinine. In
not all of these latter continued fevers, however, was
the blood examination negative, for in very rare
instances, indeed, parasites were found in these also.
I was diagnosing all these fevers, including the
continued fevers, malaria. Those without parasites
“clinical” malaria, and those with parasites
malaria under the different classifications according
to the variety of parasites disclosed under the
microscope.
This much already noticed, I was becoming a
little interested in what appeared to me to be an
exceptional course or duration of tropical malaria,
and also somewhat curious about these mild fevers
that were mostly negative for parasites—although I
grant that in mild early malarial infections parasites
are difficult to find, and perhaps I had missed them.
I began to be curious also why it was that all the
positive malaria eases responded so promptly to
quinine, and why the greatest majority of the nega-
tive fevers did the same, and yet a few of these
negative fevers did not do so, but as I have said,
continued from ten days to two weeks.
Just at this time (December, 1905) there occurred
a case with blood negative for malarial organisms,
and with a sub-eontinuous fever and an enlarged
spleen and liver, a fever that I was unable to
classify under any head. This man died, and at
autopsy Dr. $8. T. Daring [7] found bodies
resembling the Leishman-Donovan bodies of kala
azar, which he has since named Histoplasma cap-
sulatum. This special fever I thought, then, was a
clue to the indefinite fevers of one to two weeks’
duration which I have just referred to, and that they
would prove to be the earlier stages of something
similar to kala azar. Acting on this impression, I
began watching for more of these mild fevers, and
a little later was able to select one. This patient
had a slight fever with no specially marked sym-
ptoms, he was allowed the run of the wards, and
almost a full diet. The only watch kept of him was
a careful record of the temperature, and a daily
examination of the spleen for enlurgement. About
the twentieth day after his admission the tempera-
ture rose in the afternoon to 1089 F., the following
morning it remained elevated, and by the afternoon
it had risen to 1049 F., at which point it remained
fairly eonstant for six days, when the patient died.
The autopsy in this case disclosed the lesions of
typhoid fever at the beginning of the second week.
These two widely different diseases following so
closely on the heels of each other, confused me
somewhat, and I was at a loss for a while to know
what course to pursue. But inasmuch as there
were occurring a number of well marked typhoid
fevers in my wards at this time, I at last concluded
these indefinite fevers I was meeting with were most
likely typhoid, and on this assumption began work
along that line. I at that time had but little know-
ledge of mild typhoid fever. Osler [8] had described
these indefinite fevers as typhoid fever, and quoted
some of Dock’s work along the same lines. Victor
C. Vaughan [9] had brought out his admirable paper
on the spread of typhoid fever during the Spanish-
American War, and concluded that a large number
of cases diagnosed malaria must have been typhoid
fever in a mild form. Our laboratory* was only
equipped at that time for Widal tests. However, I
commenced the work in the following manner. In all
cases of fever admitted with blood negative for
malarial parasites, and which showed no other
obvious cause for the fever, a routine series of Widal
tests were made every other day throughout the
patient's stay in the hospital, unless a positive test
was returned earlier. During the year 1906 and to
September, 1907, [10], two hundred cases of
typhoid fever were collected in this way in my own
service, in which 33 per cent. of them were of short
duration.
In the latter part of 1907 our laboratory was
equipped for blood culture work, and I continued
this study of the mild fevers with blood cultures,
though our typhoid epidemie was now under control
and well toward its end. As in the Widal work,
every fever in which the cause was not clear, a
culture was asked for on the first or the second day
after the patient’s admission; and in some, where
the blood smears were positive for malarial para-
sites, cultures were also made. Working in this
routine manner, a large number of cultures were
made which, of course, were useless, but it enabled
me to pick up some of the milder cases of typhoid
which would have been impossible if time had been
taken to attempt a differentiation.
This work was ended in August, 1908. During
this time sixty-eight cases of typhoid fever were
collected. In thirty-seven of these sixty-eight
cases the blood cultures were positive for either
Bacillus typhosus or its kindred strains. Of the
thirty-seven positive typhoids nine were of the short
* Iam indebted to Dr. Samuel T. Darling, Chief of Labora-
tory, for his assistance and encouragement in this entire work.
He and his assistants in the laboratory, chief among whom was
Dr. Thomas R. Brown, made this work possible by their en-
thusiastic support and prompt answering to every call for blood
cultures and Widal tests.
148
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(May 15, 1913.
duration variety, the fever terminating in a total of
eight to fourteen days. In this small series of cases
7 per cent. had a superadded malarial infection, but
curiously enough not any of the short duration cases
showed any evidence of malarial infection, as I had
seen in my earlier work with Widal tests. Since
this time, however, Dr. W. M. James has kindly
furnished me with a chart of an American patient
whose blood culture was positive and the smears
from his peripheral blood disclosed tertian malarial
parasites, (See Chart IIT.)
During the time of this work over eight thousand
ases of malaria had passed directly under my obser-
vation, and nothing had transpired in all these cases
to disturb the first impressions made on me in
reference to the course of malaria at the beginning
of the work; in fact, this mass of cases served only
to confirm those first impressions. I have analysed
several thousand malarial charts in my own wards
and in other wards of Ancon and Colon hospitals.
(The charts of 1904 and most of 1905 have been
excluded because we were all rather new at malarial
blood work, and as new beginners will be, were over
zealous in our findings.) I separated them into
nationalities and different races with regard to
colour, and it has all been the same thing as to the
duration of the fever under proper treatment.
In the analysis of this large number of charts it
was found that the fever subsided in one day, two
days, three days, or a number at four days; occa-
sionally it was the fifth day, and very rarely an
afternoon's rise to 999 or 100° F. on the sixth day.
This uniform course led me in 1907 to state as
an axiom, any fever that did not yield to quinine in
five days was not malaria. This did not mean
that a malaria fever was likely to continue for five
days nor anything like five days, but it might in
some instances do so. Then if a fever should con-
tinue for more than five days, with quinine properly
administered, there was something else other than
malaria the cause of its continuance.
Dut before going any further into this phase of
the subjeet, I think it best to digress a little until
we have examined the opinions of some of the later
writers on the course and duration of malaria.
The writers for the current medical magazines
have given considerable attention to malaria in the
past seven years, in its numerous points of interest,
but little or no notice of its course or duration under
treatment. It is necessary then to again return to
the later text-books for this least interesting but
most practical side of the subject. The first of
these I shall refer to is Rogers [11], who, in speak-
ing of the duration of malaria fever under proper
treatment, states that the duration of malaria fever
is about four days, and further adds :—
It may therefore be laid down as an axiom that any fever
which lasts longer than the time limits stated, under proper
doses of quinine, is not malarial, or at least not purely
malarial in its nature.
Deaderick [12] :—
A fever that resists quinine is not malaria fever. The maxi-
mum period of resistance to quinine is ordinarily stated as four
days.
After which he deseribes a post-malaria fever,
articularly in wstivo-autumnals if the infection has
asted for some time, in which he states the fever
persists for weeks uninfluenced by quinine. The
blood examination is negative for parasites. He
then offers several explanations as to its cause, but
states that none of these are satisfactory.
Craig [13] in his description of the estivo-
autumnal fevers, states :—
If properly treated, the symptoms are easily controlled within
a week, although in very rare instances the plasmodium may
be very resistant to quinine and persist for eight to ten days.
As to the administration of quinine, he advises
that 40 gr. of quinine a day never be exceeded,
and believes that 2 grm. administered in divided
doses in each twenty-four hours is amply sufficient
to eure any ordinary case of estivo-autumnal
infection.
Castellani and Chalmers [14] of the later writers
are rather hopeless in their outlook for the eure in
the wstivo-autumnal fevers, and say :—
It is generally stated that a fever which within four days is
not influenced by quinine in full doses is not malaria. This is
true as regards malaria fevers due to the quartan and tertian
parasites, but not always as regards those caused by the subter-
tian parasites. We have met with cases in which the fever has
remained unaffected. while the parasites can be found in the
peripheral blood, notwithstanding several weeks’ quinine therapy
by various methods.*
It is difficult to know just what comments to offer
on these statements of Castellani and Chalmers
with regard to finding parasites in the blood of the
periphery, “‘ notwithstanding several weeks’ quinine
therapy by various methods." I should like to
reconcile this statement, so contradictory to the
experience of all other workers in malarial blood
work, by the doses of quinine being too small. But
thev recommend 5 to 10 gr. of quinine three
times a day for ordinary malarias, which I think is
quite sufficient to destroy the parasites to a number
so low that it would be extremely diffieult to find
them in the peripheral blood. For severe cases
they recommend 10 to 15 gr. by the hypo-
dermie method, though not specifically stated, I
presume at least three times a day. — This also
would be suflieient to destroy the parasites in severe
cases, ' below the detectable limit " in the blood
of the periphery. Thirty grains a day did so in
Hoss's and Thomson's [15] case of relapse. Per-
haps it is just as well to call the attention of
Castellani and Chalmers to these few faets, and
leave them to expluin.
Brem [16], in speaking of the duration of the
fever in malaria and the quinine test for the
diagnosis, states that :—
Even in Colon Hospital, where routine examinations of the
blood are made, and where routine blood cultures are taken in
all undiagnosed fevers continuing for more than three days,
we have sometimes been left in doubt, As a rule, then, in first
attacks four days is suflicient for the test, and six days is a maxi-
mum time to be allowed it.
From my experience with blood culture tests in
the mild typhoid fevers, three days is too much
* Italics mine,
May 15,1913] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
149
delay if one expects to dispel one's doubts by cul-
tures from the blood. I have found it necessary to
have the cultures made within twenty-four to thirty-
siz hours after admission if one is to have satisfac-
tory results.
Patients with this class of fevers have already
delayed coming to the hospital from two to ten
days. It is well understood that blood cultures
must be taken early to get the best results, in even
severe typhoid. In this class of fevers positive
cultures are rather uncertain at best; and it there-
fore becomes necessary in some of the cases to base
the diagnosis on symptoms or complications that are
characteristic of other typhoid fevers, as we some-
times have to do in some of the mild malarial infec-
tions without being able to determine parasites in
the blood of the periphery.
In our inquiry into the opinions of the various
writers on the subject of the duration of malaria
fevers, especially the wstivo-autumnal fevers, we see
a mass of ideas more varied than in any other
disease. It is to be noted, however, that most of
the writers since 1905 are placing the duration of
malaria fever within decidedly more circumscribed
limits.
A number of reasons have been offered why
malaria should be so varied in its duration
under treatment. As I understand them, these
reasons are us follows: (1) Varieties of parasites that
are inherently resistant to quinine; for instance, the
subtertian wstivo-autumnal parasites, as stated by
Castellani and Chalmers; (2) at times the condition
of the patient is such that quinine cannot for the
time being act efficiently in the circulating fluid; (3)
" fastness " of the parasite or ''effective resis-
tance " to quinine; and, finally (4) it was formerly
assumed that there was some peculiarity about the
virulence of tropical malaria, and this accounted for
some of the discrepancies in the views about its
duration. I do not think either of these reasons are
satisfactory. I have not seen either the one or the
other hold good iu the malaria fevers of Panama.
One can either get enough quinine into the circula-
tion to destroy the parasites, to a number suffi-
ciently low to relieve the paroxysms, or one cannot.
In the latter event death is always tlfe result; in the
former, which fortunately is usually the case, the
relief is always decided and rarely requires more
than three, four, or five days.
In the beginning of this review of the literature
on malaria, I expected to be able to reconcile some
of these discordant ideas, by perhaps the too timid
administration of quinine. I find, however, I
cannot very well do this, for with the exception of
Scheube, who makes 15 gr. a day an average
dose, and 30 gr. a day a maximum dose, there
is a remarkable uniformity of opinion that 30 gr.
is a small enough dose for average cases, and
all are agreed that in severe cases the dosage should
be inereased. This seems to me to be in most
instances sufficient dosage.
I am then forced to seek some other reason. I
have already spoken of the faet that in malarious
countries there are no diseases whieh muy not be,
in their earlier stages at least, complicated by
superadded malarial infection; and on the other
hand there are no malarial infections that may not
have some other underlying disease, either frank or
cryptogenetic, to complicate its course.
It would be unreasonable to assume that such
careful observers as are quoted here could have been
led into any errors by the frank complications.
Then if we must account for these discrepancies—
"and we must, for all cannot be correct—it must be
done under the cryptogenetic diseases, or what were
obscure diseases at the time that most of these
writers were making their studies.
The obscure diseases, that is, obscure with refer-
ence to their relation to malaria, and which have
had the greatest influence for evil in shaping our
views erroneously, I think are three: First, kala
azar; second, typhoid fever; third, uncinarial
amemia and its consequent irregular fever.
Uncinurial Aneemia.—The secondary anemia of
uncinarial infection is attended by a rather variable
and irregular fever. Most of the subjects of un-
einariasis have been also infected with malaria, and
often come under observation to be treated only
for the malaria. Unless routine stool examinations
are made, one is most likely to overlook the princi-
pal cause of the fever—the uncinariasis—and attri-
bute all the symptoms, the anemia and the
irregular fever, to a malarial infection. This has
no doubt been frequent in the past, and in this
manner given rise to the descriptions of a so-called
post-malaria fever. Hirsch [17] points out that
uncinarial anemia was always looked upon as
malarial cachexia until about 1885. These two in-
fections are present in the same individuals in a
very large percentage of natives in the Tropics,
and they cannot be separated unless the stools
are examined as well as the blood. I shall dis-
cuss the uncinarial anemias in a more appropriate
place under the head of the grave malarial anemias.
Kala Azar.—According to Rogers [18], kala azar
was first noted in 1882 by Dr. Clark, and described
by him as a very severe form of malarial cachexia.
Throughout the years that followed up to 1902 kala
azar was looked upon by the medical men in India
as a severe form of malarial infection, attended with
chronicity, enlarged spleen and liver, and with
usually a fatal termination, and only slightly, if at
all, affected by quinine. In 1903, Leishman and
Donovan [19] announced their discovery of the
parasite of kala azar, without at that time being
able to classify it. Leishman first thought the
parasite was u degenerate form of a trypanosome.
Since this discovery numerous investigators,
principally Rogers, have been studying the disease,
and through their combined labours kala azar was
shortly placed as a disease sui generis, as Was sug-
gested by Manson at a little earlier period.
— The symptoms of kala azar ure those in toto
of a chronic untreated malarial infection, namely,
an acute onset of fever, more or less irregular,
sometimes marked remissions to be followed by
sharp exacerbations. During this attack the spleen
becomes enlarged and the liver also. According to
|
150
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1913.
Bentley [20] and Hogers [21] this attack may last
from two to six weeks, to be followed by a period
of apyrexia. Repeated accesses of fever occur from
time to time and splenic enlargement becomes per-
manent. With each recurring febrile attack the
anemia becomes more marked, until, with the
enlarged spleen and pronounced anemia, the patient
is a complete clinical picture of chronic, untreated
malaria. Moreover, according to Manson [22]
malarial infection may be a frequent complication
of kala azar.
The mere statement of these brief facts is
sufficient to explain the relation of kala azar to
malaria in the descriptions of the malaria fevers
of the Tropics: the long continued malaria fevers
unchecked by quinine, and not immediately bene-
fited by a change of climate. Although kala azar
is now fairly easily diagnosed, the evil effect of
these old descriptions is still present, at least to
some extent, in our interpretation of the malaria
fevers.
Typhoid Fever.—When stating the original pro-
position that underlying diseases, especially the
cryptogenetic ones, must account for the dis-
erepancies in the views about the course and dura-
tion of the malaria fevers, typhoid fever was placed
in this latter class. However, it must not be in-
ferred that I mean that typhoid fever as a distinct
entity is in any sense cryptogenetie, but obscure
only in some of its many phases in its relation to
malaria fever.
Typhoid fever has always borne a rather intimate
relation to malaria, especially in the matter
of the differential diagnosis of the one from the
other. This fact, I think, makes it necessary to
inquire into typhoid fever and its relation to
malaria fever at some length.
Manson [23] and Rogers [24] call our attention
to one fact which I think has considerable influence
even to this day on the ideas of the course and
duration of malaria. They state that it was long
held, and up till very recent times, by the English
and French surgeons in India and Africa, that
typhoid fever did not occur in either of these coun-
tries. Rogers states, however, that the English
surgeons recognized typhoid fever in Europeans
residing in India and Africa (since 1854—Scriven),
but they did not believe it occurred in natives.
Therefore all or nearly all of the continued fevers
of India and Africa were looked upon as malarial
in nature, and they were classified as malarial under
such terms as ''continued," ‘‘ remittent,’’ and
“ bilious remittent " fevers. At a somewhat later
date many good observers thought that typhoid in-
fection and malarial infections never occurred
simultaneously in the same individual. This latter
contention was being discussed, particularly during
the years of the period of the greatest advance in
malarial knowledge, that is, from 1882 to 1900.
Hence, when the two infections did co-exist the
symptoms of the one or of the other of these two
diseases must necessarily have crept into the
clinical descriptions. And particularly into the
descriptions of malaria, for the symptoms of that
disease can be more easily obscured by typhoid
fever than the symptoms of typhoid fever can be
obscured by malarial symptoms.
Laveran himself and Boudin [25], with many
others, held that there was an antagonism between
the two infections, and from this antagonism one
infection would preclude the other. Marchiafava and
Bignami [25], while not denying the co-existence
of the two infections, state that in their experience
they and many others had never seen the occur-
rence. At about this time Thayer and Barker [26]
found that the two infections were present simul-
taneously in the same individual. Since this im-
portant contribution to our knowledge of these
infections there is no longer any question of the
co-existence of the two, and moreover it is a well-
established fact that typhoid fever occurs in all
portions of the world.
Keleh and Keiner [27], while working in Algeria,
described a malaria fever which they called bilious
remittent fever, in which all the clinical features
of a well-marked typhoid fever are present, such
as low delirium, subsultus tendinum, &c.
Marchiafava and Bignami [28] also describe a
malaria fever as typhoid subcontinuous, in which
every sign of typhoid fever is present, even to the
rose spots, ' in a word, a complete clinical picture
of typhoid fever.”
In malarious countries, with people living in
highly infected localities, it is not infrequent to
encounter untreated cases of malaria, in first attacks
or acute recurrent attacks which have continued
for several days. In this class of cases the appear-
ance of the patient when first seen presents many
of the symptoms that strongly suggest typhoid fever
in the stage at the latter part of the first week,
or at the beginning of the second week, and the
practitioner will be in doubt for a short time.
At this point though all similarity ceases between
the two diseases. If the fever is due to malarial
infeetion alone, even indifferent treatment will
ameliorate the symptoms to such a degree that it
will in a brief period no longer resemble typhoid
fever, and if the treatment is active and vigorous
the fever is eut short promptly. While, on the
other hand, if the fever is due to both malarial and
typhoid infection co-existing or to typhoid infection
alone it pursues a course unchecked, in spite of any
amount of quinine, and takes on all the charac-
teristics of typhoid fever within the limits of the
gravity of the infection. It appears to me that one
of the most important points in the study of malaria
has been largely overlooked, and that point is, that
malaria has no analogue in any other infectious
discase.
1f, then, one undertakes to deduce any given facts
about malaria by analogy from any of the other
infectious diseases one is likely to be led up to
erroneous conclusions. We know that with the
exception of pneumonia the duration of the in-
fectious diseases is largely dependable on the gravity
of the infection. But this is not the case in malaria
when under treatment. We possess a specific
remedy for malaria which does not allow it to
May 15, 1913. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
151
pursue a normal course, as other infectious diseases
necessarily do in the absence of a more than rela-
tive specific remedy.
In the cases I have encountered in which the
symptoms present were typhoidal in character, such
as low delirium, subsultus tendinum, rose spots,
&e., these symptoms persisted, and the ultimate
findings by Widal's test or blood-culture methods
proved the greatest number of such cases to be
typhoid or allied fevers. In the few instances where
one or the other of these tests failed to conclude
a positive diagnosis, one could, by analogy, without
any great diffieulty conclude that the remaining
cases were also typhoid fever.
Now it must be remembered, and it is the main
point at issue, I think, that all typhoid fevers do
not display positive Widal reaction while under
observation, nor will they all yield a positive blood
culture, with one single culture at least, and that
the negative cultures will pari passu increase with
the mildness of the disease. Just us in malaria the
milder cases fail to disclose malarial parasites in
the blood of the periphery, in frequent instances
under routine blood examinations. With these facts
made clear, we can readily account for the so-called
malarial fevers which may continue from three days
to three weeks, or for those that may continue for
weeks even after parasites have disappeared from
the blood of the periphery. Such fevers as these
I conclude must be something other than malaria.
And those that have been classed as malarial with
a complete clinical picture of-typhoid fever, I must
be permitted to assume were typhoids which in the
beginning disclosed malarial parasites in the blood
of the periphery, and later failed to yield a positive
culture or return a positive Widal.
It appears to me that such a conclusion is the
logieal one, especialy as the long duration or
moderately long duration malarias occur so infre-
quently as to cause two of our writers to offer more
or less qualifying statements when describing them
or noting the effects of quinine.
One of these is led to state that '' here and there
cases are met with—rarely, indeed, in my experi-
ence—which are refractory '"" [29]. The other, that
‘“ quinine may not always prevent the next succeed-
ing fit, but it nearly always diminishes its severity.
In 99 eases out of 100 the second following attack
does not develop.”
An analysis of one hundred or two hundred
charts of malaria fever, with positive blood findings,
wil amply justify these qualifying statements just
alluded to. Then, when an occasional fever does
occur which will not obey the law of the ninety and
nine, the inference ought naturally to be that the
ineorrigible one is not wholly malarial in nature.
We come now to the discussion of the short
duration, or atypical typhoid fever. This is the
most difficult part of the problem, the differentiation
of the short duration fevers from true malaria.
The differentiation would be, in most instances, of
little or no moment so far as the patient's welfare
is concerned, but it becomes of utmost importance
from the standpoint of preventive medicine. It is
not, however, wholly a negligible matter to the
patient, for accidents can arise in these mild fevers,
and relapses that are severe can also occur, either
of which might be prevented if the nature of the
disease is known and the proper precautions taken.
I have already stated that at the beginning of
my service here I had had but little knowledge of
the mild typhoid fevers. I recall with some interest
now that just a few years before this time th:
medical men of the Southern portion of the United
States were discussing a '' third fever," one which
they thought was intermediate between typhoid
fever and malaria; and how accurate some
of the descriptions of this third fever were, of the
symptoms and the duration of what we now know
to be mild typhoid fever. These discussions were
carried on under different names for the ‘‘ third
fever," such as ' "X fever," ''toxinterieus," and
finally one man put it ‘‘ fever, just fever.”
In the United States, as I have said, Osler [29],
Dock, Vaughan [30], and one or two others have
recognized and described the atypical typhoid
fevers. Curschman and Osler [31] had given con-
siderable space to them in 1902, but these writers
did not seem to make the impression on the pro-
fession at large that the importance of the subject
warranted. In 1907, McCrae [82] again called
attention to these mild typhoid fevers, and dis-
cussed them at length, with apparently no better
result than Curschman and Osler. For medical
men at large at that time expected, as a rule—and
some do expect yet for that matter—of typhoid
fever, a week of slow rise of the fever, the one to
two weeks' fastigium, the rose spots, the meteorism,
the distended belly, the delirium, &c., and finally
the slow decline of the febrile curve.
The evidence for the short duration fevers as
described by McCrae and Osler was based on Widal
reactions, whieh could in a measure be doubted
when one for reasons of his own wished to do so,
on the grounds that the patient had had typhoid
fever some time in the past and that the Widal
reaction was the result of a past infection.
But with the perfection of the cultivation of the
bacilli from the blood-stream no such argument
could be made. Koch [33] and his co-workers in
1904, employing the blood-culture method, worked
out a number of these mild fevers, and established
their typhoid nature. Drigalski [33] at the same
time by stool and blood cultures also was able to
ascertain unquestionably that these mild fevers were
due to typhoid infection. Rogers [84], in India,
worked out these same fevers by blood cultures,
and found them caused by B. typhosus and kindred
strains. In 1909 [85] I published the results of
my blood-culture work on these fevers which was
begun in 1907, and confirmed my own ideas about
these short duration fevers, as well as the work of
the foregoing writers. After my work was broken
off in 1908, Deeks [86] took it up, and reported his
findings in 1909, confirming all of my previous work.
Warren Coleman [87], who must have been
working at these fevers about the same time that
I was with blood-culture methods, published his
152
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1913.
results in 1909, establishing the fact that the short
duration fevers existed in the United States also.
Sinee that time the work has apparently lapsed,
but sufficient work by culture methods has already
been done and reported from widely separated
sources to establish beyond peradventure that
typhoid fever, like any other infection, varies be-
tween cases so mild as to be perhaps unrecognizable
by any methods to those so severe as to cause death
in a few days.
1908
JUNE
CnanT I.—Typhoid fever with a temperature curve markedly
similar to malaria fever. Cultures from blood positive B.
typhosus. No malarial parasites found in the blood of the
periphery.
JULY 1908
[ DATE [15 [16 |
DAYorDIS.| 5 | 6 |7 |
IM EJM E]
Cnuanr II.— Typhoid fever with a temperature curve fairly
characteristic of the short duration typhoid fevers. Cultures
from the blood-positive B. typhosus. No malarial parasites
found in the blood.
The question of the nature of these intermediate
fevers settled, it now remains to try to explain their
relation to the cause of the belief of the slightly
prolonged duration of malarial fever. It will be
notieed by referring to Charts I, II, and III, or any
description of the mild typhoid fevers, that the tem-
perature curve is often irregular, and corresponds
very closely to the description of the remittent or
subcontinuous type of malaria fever, Some typhoids
of moderate severity terminate abruptly as malarial
fevers often do, and at least some of these typhoids
have malarial parasites in the blood along with the
typhoid infection.
With these similarities between the two diseases
in view it becomes at once obvious how such fevers
us these can be mistaken for malaria. In fact,
when one is not familiar with the mild typhoid
fevers, the only conclusion left is that they are
malarial, especially as an occasional one of them
may exhibit malarial infection present also.
After a separation of these mild typhoid fevers
by blood cultures from malaria, I think it
will explaiu why some oi the later writers found
a few of the latter continuing during quinine
treatment for a period of eight to ten days; and
how Marchiafava and Bignami [38], otherwise so
correct, in their conclusions about malaria, must
have been deceived by these same mild typhoid
fevers when they refer to some cases occurring
JUNE 1909
DATE [15 [16 | 17 | i8 | I9 | 20 | 21 | 22 |
DAYorDIS.| 10 | i! | i2 | 13 | 14 | 15 | I6 | I7 |
CHMBEE BB aW BL en
CnanT III.—-By courtesy of Dr. W. M. James. Typhoid
fever. Cultures from the blcod.positive B. typhosus, and in
which the tertian malarial parasites were found in the peri-
pheral blood also.
‘in which, in spite of the administration of quinine
and the decrease or disappearance of the parasites,
the fever continues for two, three, or even four
days longer, with a progressively milder course.
I have here shown that all the fevers oceurring
in Northern Africa and in India, up to within quite
recent times, were looked upon as malaria and
described as malaria fever. And I have further
shown that during the period of the greatest pro-
gress in malaria knowledge, the co-existence of
malarial infection and typhoid infection was dis-
puted, and in this manner, when the two infections
did co-exist, it was the typhoid symptoms that were
described and not the malarial, as malarial sym-
ptoms were masked by those of the typhoid, or
promptly jugulated by quinine.
In the present review I have related the early
causes Which led me up to certain conclusions with
regard to the duration and course of malaria fever;
I have also related some of the methods by which
153
May 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. :
I have been able to exclude the milder typhoid
fevers from confusion with malaria, and these
methods in turn have led me to various kinds of
detailed work which have enabled me to exclude
numerous other diseases from being confused as
malaria, until I have found true malaria to be a
very simple entity, and neither complex in its
manifestations nor difficult to cure if it is taken
before the human organism is overwhelmed by the
infection.
It is found also that malaria fever has no
analogue in other infectious diseases (that is, the
greater the infection the more prolonged the course),
but that it either responds to the specific remedy
with promptitude or rapidly terminates in a fatal
issue.
By this detailed inquiry into the three diseases,
uncinarial anemia, kala azar, and typhoid fever, I
have shown that these diseases have very great
similarity in their clinical symptoms to malaria,
and thus have offered the greatest difficulty in
differentiating them from that disease; that two of
these were for a long period regarded as wholly
malarial, and that one of them, typhoid fever, in
many instances was also looked upon as malarial.
In this detailed study I have undertaken to show
how these three diseases have been responsible for
the idea that malaria could be in most instances
readily amenable to treatment, and yet in other
instances be only slowly influenced by quinine.
To do this it has been necessary to assume that
the resistant cases were not malaria, but were one or
the other of the three diseases alluded to above, or
some other disease confused in the same manner.
I think that in the exposition of the facts as herein
set forth I am amply justified in this assumption.
I may then conclude that malaria is a simple entity,
and in the majority of cases readily amenable to
treatment. That when it is efficiently treated the
paroxysms can be controlled in from three to four
days. In a few instances primary infections, as
was pointed out by Marchiafava and Bignami [39],
may be a little stubborn, and it is also the case with
children, but these cases will slowly subside on the
fifth and sixth days after treatment is begun.
The occasional case that cannot be affected by
the specific remedy will rapidly terminate in a fatal
issue.
{I wish to thank Colonel W. C. Gorgas, Chief Sanitary Officer,
for permission to publish this paper.]
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[2] OSLER, Str Wm. ‘ Principles and Practice of Medicine,"
pp. 20-21, fifth edition, 1903.
[3] ScHEvBE. ‘Diseases of Warm Countries," p. 125, 1902.
[4] Manson, SIR P. ‘‘ Manual of Tropical Diseases," revised,
pp. 78-148, 1903.
[5] Marcuiarava and Brosawr, ‘‘ Malarial Fever," pp. 323-
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(7j DanLrNG, SAMUEL T. ‘Histoplasmosis: A Fatal In-
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[8] CURSCHMAN and Oster. ‘* Typhoid and Typhus Fevers,”
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[11] Rocers, L. ‘ Fevers of the Tropics,” p. 218, 1908.
[12] Deaperick, Wm. H. ‘ Practical Study of Malaria,”
pp. 194-195, 1909.
[13] Craic, CapraIn CuanLEsS F., U.S.A.
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[16] Brem, WaLTER V. “Studies of Malaria in Panama.”
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[19] Cited by Manson, ‘‘ Manual of Tropical Diseases,”
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[20] Idem.
[21] Rocers, L. ‘‘ Fevers{in the Tropics,” pp. 31-47, 1908.
[22] Manson, Sig P. ‘‘Manual of Tropical Diseases,"
p. 114, 1909.
[23] Idem.
[24] Rocers, L. ‘‘ Fevers in the Tropics,” 1908.
[25] Cited by Marcurarava and Bicnami. ‘ Malarial
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[26| Idem.
[27] Cited by Manson.
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(28] Marcuiarava and BrcNaMr, ‘‘ Malarial Fever," p. 406 ;
Twentieth Century Practice of Medicine, vol. xix, 1901.
[29] Oster, Stk Wma. ''Principles and Practice of
Medicine,” fifth edition, 1908.
[30] VavGHaN, VicTOR C. Loc. cit. "
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[32] McCnmaE, THoMas. ''Osler's System of Modern Medi-
cine," vol. ii, pp. 173-174, 1907.
[33] Cited by Warren ConEMAN, “Short Duration Typhoid
Fever,’ The American Journal of Medical Sciences, vol.
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[34] Rocers, L. ‘‘Fevers in the Tropics,” pp. 109-147,
1908.
[85] “Atypical Typhoid Fever: Results with Blood Cul-
tures," The Journal A.M.A., vol. lii, No. 14, pp. 1093-1096,
April 3, 1909. : :
[36] Deeks, W. E. -“ Typhoid and Allied Fevers in
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pp. 41-51, April, 1909—March, 1910.
[87] COLEMAN, Warren. ‘Short Duration Typhoid Fever,”
The American Journal of the Medical Sciences, vol. cxxxvii,
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[38] Marcurarava and BIGNAMI.
[39] Idem.
“The Malarial
“Manual of Tropica
* Manual of Tropical Diseases,"
Loc. cit.
— e0
“Bulletin of the Johns Hopkins Hospital,” xol. 24, No. 266
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Dengue.—Stitt, writing on this subject, lays stress on the
early leucopenia occurring in the disease, and also mentions
a slowing of the pulse. This latter symptom would not
seem to be a universal one, however, as other observers have
not noticed it in other parts of the world. The author
believes the infection is mosquito borne, and mentions the
work of different observers in support of this.
154
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1913.
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the Publishers.
T.—The Journal will be issued avout the first and fifteenth day
of every month.
THE JOURNAL OF
Tropical Medictne andhypgtene
May 15, 1913.
AN HISTORICAL MEDICAL MUSEUM.
For a considerable time we have been looking
forward with interest to the Historical Medical
Museum which Mr. Henry S. Welleome has been
organizing and preparing. Assuredly the Museum
will form one of the most interesting features of
the International Medical Congress of 1913.
Nothing so elaborate of the kind has ever been put
together and the wealth of treasures of historic
interest presented will prove a revelation. Com-
mencing with the most ancient times represented
by statutes of healing gods from Egypt, China,
Greece, Rome, Mexico, and the less-civilized coun-
tries, we are made acquainted with such phar-
maceutical appliances as pharmacy vases, mortars,
scales, weights, drugs, orthopedic appliances,
surgical tables, accouchement chairs, and many
alchemical upparatus used in early times. The
result of a study of these and other modes, methods
and appliances used by the ancients will bring home
to us that modern medicine owes much to the past,
and that the science and art of medicine is but a
product of the experience of many thousands of
debt of gratitude for the great educational treat
that he has organized.
The thought that will arise in everyone’s mind
on visiting the Museum will be: Are the precious
items of this unique collection to be dispersed as
years. There is scarcely a surgical instrument
known to us that had not its prototype in ancient
times, certainly in principle, and for the most part
in actual detail. The more we look into this phase
of the Wellcome Collection the more are we com-
pelled to avow with Solomon that there is nothing
new under the sun. The evolution of our modern
surgical instruments, as set forth in the Museum,
where they are arranged in historical sequence, will
afford not only surprise, but must prove, in addi-
tion, highly instructive to every medical man who
even cursorily examines the collection.
Tropieal medicine is well represented in its
historical aspects. Such subjects as plague, malaria,
yellow fever, sleeping sickness, ankylostomiasis,
filariasis, bilharziasis, Oriental sore, kala azar,
pellagra, &c., are illustrated by maps, portraits,
prints, medals, books, and pamphlets. Of special
interest are the exhibits relating to the history of
dracunculus, filaria, and to the etiology and pro-
phylaxis of plague in ancient times. 1n the Museum
there will be found also reconstructed barber-
surgeons’ and apothecaries’ shops, alchemists’
laboratories, and even a taberna medica or surgery
of the Roman period in Pompeii. Relics of famous
inventors and discoverers in the realm of medicine
and the allied sciences form another attractive
feature of the exhibition. Amongst these we have
personal relics of Dr. Edward Jenner, including the
original lancets and searifiers he employed; his case
and account books, and several of his personal and
domestic surroundings. The discovery of anesthesia
by Henry Hill Hickman and Sir James Y. Simpson
is presented to us by several interesting relics and
appliances. The advent of the knowledge of gal-
vanism and the original apparatus used by the
famous Galvani in making his first experiments
undoubtedly prove not the least fascinating section
of this wonderful Museum.
Wonderful it all truly is, not only as regards the
objects themselves, but we stand astonished at the
amount of labour, forethought, historical acumen
and zeal bestowed upon the organization and de-
velopment of so vast a collection.
The drawings by Terzi, Cooper, Schwarz, and
Monro-Orr are at once artistic and instructive, and
especially is this the case in the department of
tropical medicine and tropical parasitology. It is
neither the time nor place to give a categorical
description of the various items in the several sec-
tions of the Museum; that we hope to accomplish
later. ‘Suffice it to say, that the Historical Medical
Museum will become itself historical, for it is a
veritable revelation. To Mr. Henry S. Wellcome
scientific medicine, and especially tropical medicine,
is already deeply indebted, but the medical pro-
fession of every country will owe him a permanent
soon as the Congress is over? The fervent hope
will be that in some way this calamity may be
prevented. The question arises: How is this to be
accomplished? Mr. Wellcome has possibly already
considered the future place and purpose of the
Museum; if so we are content, for we know that
whatever is done will be done judiciously and
loyally. The monetary value of the collection and
the expenses of bringing it to its present state of
perfection must have been enormous, and the
intrinsic value of many of the treasures it contains
cannot be represented in pounds, shillings, and
pence. Whatever may happen, it is to be hoped
that the acknowledged usefulness of the Museum
to science will be so great that an attempt should
May 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
be made to secure its permanency as a national
asset.
In the department of tropical medicine we are
greatly beholden to Mr. Wellcome. First and fore-
most amongst the many benefits he has bestowed
are the Wellcome Laboratories, in Khartoum, where
Dr. Andrew Balfour has worked for many years and
has advanced our knowledge in many directions.
Without Mr. Wellcome’s timely assistance the sub-
ject of pellagra would have been neglected; and the
London School of Tropical Medicine is deeply
beholden to the same generous donor. Yet another
immense help has been afforded by the prominent
position given to tropical medicine in the great
Historical Medical Museum he has estublished.
J. C.
—,9————
Annotations.
Maize and Pellagra.—Keed, in a recent paper
published in the New York Medical Journal, xci,
164, 1910, called attention to the presence of the
fungus Diplodia zee upon maize and to the possi-
bility that this fungus may play a róle in the
etiology of pellagra. Data were presented showing
that following the growth of the fungus a toxic sub-
stance was generated in the maize which was
believed to be similar to or identical with the
* pellagrozein °’ of Lombroso. The investigation
of protein constituents of mouldy maize is still under
way, but in the meantime some data have been
secured upon the relation of phosphorus com-
pounds of maize.
The idea that spoiled or mouldy maize may con-
tain larger amounts of inorganic constituents would
seem to be a logical assumption, since it is well
known that the active respiration of the moulds and
bacteria oxidizes large amounts of the carbon com-
pounds. Black and Alsberg find, however, that a
badly spoiled maize is not always characterised by
a high ash content, although in Italy a high ash
content is regarded as significant.
The object of Reed’s present contribution (New
York Medical Journal, March 22, 1918) is to bring
together some data on the presence and possible
significance of inorganic phosphates in maize inocu-
lated with pure cultures of mould fungi, along with
some samples of moulded commercial corn. `
From the data collected he concludes that it
would appear that Diplodia zee and other fungi
grown upon corn meal liberate material amounts of
inorganic forms.
Corn meal infected with diplodia loses in weight,
the loss increasing with the age of the culture.
Aside from the question of the possible toxicity
of any of the inorganic phosphates thus liberated
or their possible réle in the etiology of pellagra, the
data show what is interpreted as a marked deterio-
ration in the food value of the maize, due to the
degradation of organic phosphorus and other com-
pounds. As the fungi continue to grow they may
take up a portion of the inorganic phosphates,
possibly to form bodies having toxie properties.
155
The Health of the Canal Zone for 1912.—Gorgas,
in his Report of the Department of Sanitation of
the Isthmian Canal Commission for the year 1912,
states that the death-rate among employees of the
Isthmian Canal Commission and Panama Railroad
Co. for 1912, compared with similar figures for
previous years since 1904, is as follows :—
Number of
employees Deaths Rate
1904 6,213 335 82 13.26
1905 16,512 375 427 25.86
1906 26,547 1,105 41.73
1907 39,238 1,131 28.74
1908 43,891 an 571 13.01
1909 47,167 Va 502 10.64
1910 50,802 Pis 558 10.98
1911 48,876 sis 539 11.02
1912 50,893 tes 467 9.18
The death-rate among the white employees from
the United States from disease was 3.25 per
thousand, while the total death-rate for the year
for this class of employees was 5.52, as against
5.14 per thousand in 1911. If American women
and children are included it will raise the death-rate
of Americans from disease to 4.22. Including in
the above figures the officers and men of the
United States Army and Marine Corps stationed
on the Canal Zone and their families, the death-rate
from disease is lowered to 3.86 per thousand. The
death-rate from disease in the Army for the year
1911 was 2.66 per thousand.
Taking special diseases, the
employees have been as follows :—
deaths among
19050 1906 1907 190S 1909 1910 1911 1912
Typhoid fever 19... 42... 98...19 ... 13... 13... 10... 4
Dysentery .. 14... 69... 48...16... 8...21...183... T
Pneumonia... 95...413... 328 ... 93 ... 70 ... 78 ... 94 ... 57
Malaria .. 86... 233... 154 ... 73 ... 52... 50 ... 47 ... 20
The improved conditions as regards deaths from
malaria among employees continue, and the same
is true of the admission rate to hospitals, as is
shown by the following :—
Per thousand: 1904, 125; 1905, 514; 1906, 821;
1907, 424; 1908, 282; 1909, 215; 1910, 187; 1911,
184; 1912, 110.
Deaths among employees from the other principal
diseases were as follows: Abscess of liver, 4;
nephritis, acute and chronie, 36; from all forms
of tubereulosis, 70; leaving 126 deaths among
employees from all other diseuses, und 143 deaths
from external violence.
Considering the death-rate of the total popula-
tion, including the cities of Panama and Colon and
the Canal Zone, the rates for the different years
are as follows :—
Per thousand: 1905, 49.94; 1906, 48.37; 1907,
33.63; 1908, 24.83; 1909, 18.19; 1910, 21.18; 1911,
21.46; 1912, 20.49.
One case of yellow fever, on a ship from
Guayaquil, Ecuador, was isolated in Santo Tomas
Hospital, and died there on July 14.
With this exception, no cases of yellow fever,
plague, or small-pox occurred on the Isthmus during
the year.
156
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1913.
The Health of the Canal Zone for the month of
February, 1913.—Gorgas reports that the total
number of deaths from all eauses among employees
wus 42, divided as follows: Disease 27 and violence
15, giving the annual average per thousand of 5.86
and 3.25, respectively.
Among employees for the month of February
of each year the annual average death-rate per
thousand was as follows :—
1905, 14.05; 1906, 29.00; 1907, 30.74; 1908,
12.80; 1909, 9.42; 1910, 8.75; 1911, 9.88; 1912,
10.57 ; 1913, 9.11.
The annual average death-rate per thousand in
the cities of Panama and Colon and the Canal
Zone, ineluding both employees and civil popula-
tion, for the month of February of each year was
as follows :—
1905, 42.07; 1906, 43.96; 1907, 36.07; 1908,
21.40; 1909, 18.59; 1910, 17.50; 1911, 18.60; 1912,
16.33; 1918, 21.10.
In segregating according to race, the annual
average death-rate per thousand from disease among
employees was: For whites 6.52 and for blacks
5.65, giving a general average for disease of 5.86.
For the same month during 1911 the annual
average death-rate per thousand from disease among
whites was 5.67 and blacks 6.47, giving a general
average of 6.27; and in 1912 from disease among
whites 4.61 and blacks 7.34, giving a general
average of 6.66.
Among employees during the month, deaths from
the principal diseases were as follows: Abscess of
liver, entameebie, 1; hie moglobinurie fever, 1; pneu-
monia, 4; malaria, 1; tubereulosis, 5; leaving 15
deaths from all other diseases and 15 deaths from
external violence.
On December 15, 1912, all the sick camps were
closed, with the exception of those located at
Culebra, Toro Point, and Porto Bello.
No eases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus during
the month.
Sporotrichosis.—Taylor, writing in the Journal of
the American Medical Association (vol. Ix, No. 15),
April 12, 1918, contributes a paper on '' Sporo-
trichum Sehenekii." He reports the results of his
work on the morphology and cultural characteristics
of the organism, and describes also the lesions pro-
duced by it. He found, for example, that :—
(1) The spores of the organism were attached to
the mycelia by short pedicles.
(2) That so-called chlamydospores were of fre-
quent occurrence.
(3) That spores, similar in form to those grown
on blood-serum, could usually be demonstrated in
paraffin sections of the tissue lesions, and shown in
most cases in direct preparations from the abscesses.
(4) That in one case it appeared that mycelial
growth took place in the necrotic tissue at the centre
of a large abscess caused by the organism.
(5) That methyl thionin proved best for staining
the organism grown on artifieial mediums, and à
modification of Gram's stain was most satisfactory
for its demonstration in the tissues.
(6) That the organism failed to liquefy gelatin
after six weeks’ growth at room temperature.
(7) That milk was coagulated after two weeks’
growth at room temperature.
(8) That some hint of the possibility of producing
an immunity in animals by previous injection of
small doses of pure culture may perhaps be based
on these observations, but that for the present the
work carried out is insufficient to make any definite
statement about this.
On the Discovery by Dr. A. R. Neligan of Leish-
mania in Cutaneous Lesions of Dogs in Tehran, Per-
sia.—Dr. A. R. Neligan, who has been working with
Oriental Sore in Tehran, Persia, informs me [ Dr.
C. M. Wenyon] by letter that he)has discovered
leishmania in great abundance in uleers on dogs’
faces. In no ease has he found the parasites in the
liver or spleen, so that it seems highly probable that
Dr. Neligan is dealing with Oriental Sore in dogs, for
the disease in man is very common in Tehran. It has
long been held popularly that dogs suffer from this
disease, but this is the first instance cf the definite
discovery of Leishmania tropica (for the parasite is
probably such) in the skin lesions of these animals,
and is of the utmost interest in that it places Oriental
Sore on the same footing as infantile kala azar, which
is known to affect dogs as well as children fairly
commonly in the Mediterranean distriets. It may
be of interest to note that in the Transcaucasus,
Dschunkowsky and Luhs (1909) discovered leish-
mania in a dog which was covered with uleers. In
this ease, however, the authors make no mention
of the occurrence of leishmania in the skin lesions,
for they found the parasites only in the internal
organs and in mononuelear eells of the blood.
Sleeping Sickness in Nyasaland.—Hearsey con-
tinues his diary on this subject (Part XIX). He
states that during the past quarter fifteen additional
cases of sleeping sickness have been reported; of
this number twelve cases were found by Dr. Shircore
and two by Dr. Conran, in the sleeping sickness
area; the remaining ease was notified by Dr. Morgan
from the Marimba district. These added to the
cases previously reported now make a total of 108.
The author also made an inspection of the
sleeping sickness area. He found that tsetse flies
were frequently to be seen in and around many of
the villages; and it was accordingly recommended,
in order to prevent the spread of infection in village
communities, that clearings should be made around
all the villages in the proclaimed area. This has
been done, and Dr. Shircore has reported that these
clearings have been attended with marked success
in banishing the flies.
These investigations came to a termination on
November 30. During the eight months over which
May 15,1913. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 157
they extended only one case of trypanosome infec-
tion was discovered, the patient being a native of
the adjoining Marimba district. It should, how-
ever, be remembered that some ten cases of
trypanosomiasis have up to the present been dis-
covered in, or found to have emanated from, the
distriets lying to the north and south of the
proclaimed area; and it is therefore reasonable to
assume that the factors necessary for acquiring
infection are not limited to the Dowa sub-district.
Mueh diffieulty has been experienced by medical
offeers owing to the natives refusing to present
themselves for examination and hiding their sick.
This diffieulty has, however, been largely overcome
in the proclaimed area of the Dowa sub-district by
the employment of special police.
Chronic or Resolving Plague in Hats.—In the
Seventh Report on Plague Investigations in India
there is a very interesting account of chronic or
resolving plague in rats.
The Commissioners have already dealt with this
subject in previous numbers of these reports (vol. vi,
p. 580; vol. vii, pp. 457, 719; vol. x, p. 835). In
order, however, to obtain a more complete know-
ledge of the condition, it was decided to make a
careful examination daily of some two hundred
rats (100 Mus decumanus and 100 M. rattus) caught
alive in Bombay city. It is proposed to carry on
this examination for a whole year. At the same time
the Commissioners continued to gain experience of
the condition in other places in India, for example
at Poona, and they were thus able to compare the
frequency and character of the lesions found in rats
in these plagüe-infected centres with similar lesions
found in rats in the plague-free city of Madras.
The conclusions which were ultimately reached
are as follows :—
(1) Lesions, for which the terms resolving and
resolved plague lesions are proposed, are found in
rats which have been subjected to plague infection
and in certain individuals are stages in the natural
process of recovery from the acute form of the
disease.
(2) These lesions are very different from the
lesions found in the acute stages of the disease.
They are generally localized and confined for the
most part to the spleen.
(3) It is not always possible to prove that these
lesions are due to the plague bacillus by isolating
that bacillus from them, for in many cases the
bacilli have been killed, have disappeared, or been
replaced by some other organism.
(4) That the lesions are frequently produced by
the plague bacillus has been shown by (a) demon-
strating the presence of plague bacilli in some of
these lesions which exactly resemble others, either
in the same rat or in other rats, in which no plague
bacilli can be found; (b) by showing that the lesions
increase in numbers during and after epizooties of
the disease.
(5) Nevertheless the fact must be borne in mind
that very similar lesions can be produced by other
causes, as has been shown by an experience of the
examination of rats in Madras city, where plague
is not present.
The Etiology of Beriberi—Vedder and Clark, in
continuation of their studies on beriberi, contribute
a paper to the Philippine Journal of Science (the
Philippine Journal of Tropical Medicine), vol. vii,
October, 1912, No. 5, entitled ‘‘ A Study of Poly-
neuritis Gallinarum; a Fifth Contribution to the
Etiology of Beriberi." The paper is divided up as
follows :—
(1) Observations on symptomatology ; (2) observa-
tions on pathology; (3) observations on the earliest
degenerative changes in the nerves; (4) the influence
of various articles of food on the production of poly-
neuritis gallinarum; (5) summary; and (6) conclu-
sions and discussion.
As regards degeneration in the peripheral nerves,
in polyneuritis gallinarum, such changes as shown
by the Marchi method were observed in all the
cases examined. Unlike the sciatic nerve, however,
the extent and degree of degeneration in the vagus
did not always correspond to the severity of the
symptoms before death, nor was the most extensive
degeneration to be seen in the vagus nerve of those
cases which showed prostration. Fowls in good
general condition sometimes showed extensive
degeneration in the vagus. Likewise, the authors
were not able to establish an interrelation between
the severity of the degeneration in the vagus and
the amount of pathologie change in the heart.
The authors summary of their work is as
follows :—
(1) There appear to be three types of polyneuritis
gallinarum : —
(a) A form in which the symptoms of neuritis and
those of general prostration are combined. This is
the usual form. When these birds are given an
extract of rice polishings they improve at once in
general condition, but the symptoms of neuritis only
disappear after several months of treatment.
(0) A form in which there is pronounced neuritis,
but the fowl remains in good general health. These
fowls will also recover from the neuritis after
several months' treatment with the extract of rice
polishings.
(c) A form described above as fulminating cases,
in whieh the symptoms of neuritis are absent, but
in which greater general prostration occurs. These
fowls recover speedily when given extract of rice
polishings.
(2) In polyneuritis gallinarum developing after a
prolonged diet of polished rice the heart may show
no microscopic change. In other cases the heart
may show slight cdema, a slight increase in pig-
ment, or an appearance of beginning mucoid or
parenchymatous degeneration. j
(3) While in marked cases of neuritis every
fibre of the vagus may and usually does show
degenerative changes, as indicated by the Marchi
158
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1913.
method, no fibre has been observed in which the
change was far advanced. The authors have not
been able to correlate the extent of degeneration in
the vagus with the change in the heart nor with the
severity of the symptoms before death.
(4) No marked changes suggestive of degenera-
tion have been observed in the cervical sympathetic
ganglia nor in the post- or pre-ganglionic fibres.
(5) In every one of the fifty-six fowls which had
been fed thirty-five days or more on polished rice,
changes indicative of degeneration (Marchi method)
were seen in the fibres of the sciatic nerve, regard-
less of whether symptoms of neuritis had or had not
manifested themselves before death.
(6) Advanced degeneration in the peripheral nerve
fibres manifesta itself by a change in both myelin
sheath and in the axis eylinder. The myelin sheath
breaks up into globules and droplets, which stain
black in the Marchi solution—indicative of fatty
degeneration. The axis cylinder breaks up into
segments or disintegrates in all those fibres showing
advaneed degeneration in the medullary sheath.
(7) The degree of degeneration in the sciatie nerve
corresponds closely with the extent of the paralysis
of the legs. Advanced degeneration was observed
in only 10 to 15 per cent. of the fibres of the sciatic
nerve of fowls showing pronounced symptoms of
leg paralysis. In the remaining fibres the change
was not advanced.
(8) The authors could detect no difference in
the degeneration in the sciatic and its peripheral
branches either as regards extent or time of onset.
(9) Degeneration was observed in both dorsal and
ventral nerve-roots, being most pronounced in the
latter.
(10) Degenerative changes in both axis cylinder
and medullary sheath were seen in fibres of all
columns of the thoracic spinal cord.
(11) Changes were observed (Nissl method) in
certain large eells of both ventral and dorsal horns
of the grey substance of the lumbosacral cord. In
the cells of both horns, the tigroid bodies were not
visible, and the stainable material was collected at
one side of the cell around the base of one of the
processes. Cells were occasionally seen whose
nuclei stained very poorly.
(12) Mitochondria were observed in the nerve-
cells of the lumbosacral cord, even though there
was a pronounced alteration of the tigroid bodies.
The mitochondria here were of similar appearance
and almost or quite as numerous as in corresponding
cells of the normal cord.
(13) In the medullary sheath of fibres of the
sciatic nerve of normal fowls numerous small,
bacilli-like rods, arranged radially around the axis
cylinder, were made apparent by the various mito-
chondria methods. These structures are probably
mitochondria.
(14) Fowls show alteration in the medullary
sheath of the sciatic fibres after only seven days on
a polished rice diet. In the sciatic fibres of fowls fed
for seven days on polished rice alone, the rods are
scarcely to be observed. Instead, the stainable
material shows remarkable alterations and occurs
in the form of irregular, branched, and anastomosing
masses.
(15) In fowls fed for a longer period these masses
show, in a certain percentage of the fibres, progres-
sive changes which manifest themselves in the form
of more definite skeins and segmentations and
larger masses and globules of stainable material.
In fibres showing marked degeneration by the
Marchi method these occur as larger or smaller
vesicular, oval globules and correspond to the black
globules shown by the Marchi preparations.
(16) When fowls are fed on polished rice and in
addition given some protective substance, such as
is contained in extract of rice polishings or in
various foods, but in insufficient quantity to confer
complete protection, the disease appears in its
characteristic form and with all the evidences of
nerve degeneration, but after a prolonged incubation
period—forty-five to ninety days, or even after one
year of such feeding (Eijkman).
(17) When fowls are fed on polished rice and in
addition receive daily 10 grm. of white wheat bread
or 5 c.c. of canned milk, they receive little or no
protection from polyneuritis gallinarum.
(18) When fowls are fed on polished rice and in
addition receive daily 10 grm. of meat cooked or
uneooked, 10 grm. of potatoes cooked or uncooked,
or 5 c.c. of fresh cow's milk, they receive partial
proteetion as indieated by the prolongation of the
incubation period.
(19) When fowls are fed on polished rice and in
addition receive daily 10 grm. of dried peas or
10 grm. of peanuts, they receive complete protec-
tion for at least sixty days.
—— —»9——————
Reviews.
SURGERY OF THE Lune. By C. Garré and H.
Quincke. Second Edition, with 114 coloured
and other illustrations, and two coloured plates.
Translated from the German by David M.
Bancroft, M.D. London: John Bale, Sons,
and Danielsson, Ltd., Oxford House, 83-91,
Great Titchfield Street, Oxford Street, W.
The second edition of this useful work is now to
hand. Since the publication of the first edition
surgery of the lung has made considerable progress.
As the authors say, not only by constant and care-
ful elaboration of the old methods of procedure
have the operations then in vogue been more
frequently and, on the whole, more successfully
carried out, but new methods have been invented
and new indications laid down. The most impor-
tant advance is the method of maintaining difference
of pressure, which has enlarged the sphere of
surgical operation to an extent hitherto unimagined.
Amongst other new operations worthy of note
are those of artificial pneumothorax and thoraco-
plasty and the surgical mobilization of the thorax
by the bisection of the costal cartilage. Owing to
the increase of material the first edition has had
to be considerably altered, and in many parts
May 15,1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
re-written. <The result, the second edition, is
thoroughly up to date, and should prove very
valuable.
Toe REpvcrroN or Domestic Furs. By Edward
Halford Ross, M.R.C.S., L.R.C.P., of the
John Howard McFadden Researches, the
Lister Institute of Preventive Medicine,
London. With illustrations. London: John
Murray, Albemarle Street, W.
A very useful and instructive work on a problem
of the very greatest importance to public health,
especially as regards the prevention of the spread
of disease. The author in his introduction states
that in some countries anti-fly campaigns are in
progress, but that in Great Britain little has, so far,
been done generally to attack the problems. A few
individual efforts have been made, but these have
been few and far between.
It is to be hoped that the production of the
author’s work will rectify these omissions and help
to start a campaign which all far-seeing men,
whether medical, scientific, or of the laity, should
support by all means in their power.
——9————
Hotes and Mews.
Messrs, BAILLIERE, TINDALL AND Cox announze
that the new edition of Castellani and Chalmers’
‘Tropical Medicine’’ will be published almost imme-
diately. This text-book, written from the authors’
wide experience in the Tropics, contains all the
most recent researches. The new edition has been
brought fully up to date (March, 1913). All the
more important parts were kept in the authors’
hands until the last moment, so that no fresh dis-
covery should be omitted. The book has been
revised throughout, and many of the chapters,
notably the ones on protozoa, fungi, skin affections,
pellagra, enteric fever and trypanosomiasis, have
received special attention. Some 250 new illustra-
tions have been introduced, and the text has been
increased by the addition of some 500 pages; the
price, however, remains the same.
——— 9—————
BPecent and Current iterature. .
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JouRNAL OF TROPICAL MEDICINE AND
HyGIENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
* United States Public Health Reports,” vol. xxviii,
No. 6, February 7, 1913.
Ankylostomiasis in Southern China.—Brown reports
that in addition to ankylostomiasis, Ascaris lumbricoides,
Trichocephalus dispar, Clonorchis sinensis, Strongyloides
intestinalis, Fasciolopsis buski, and Oxyuris vermicularis
infections occur. Brown treats his cases of ankylostomiasis
either by the eucalyptus chloroform mixture or by tbymol.
159
“Journal of the Royal Army Medical Corps,” vol. xx,
No. 4, April, 1913.
Malaria.—Lieutenant-Colonel Beach and Captain Leeson
report an interesting outbreak of malaria in a company of
the 2nd Devon Regiment. The company was sent from
Alexandria to Cyprus on May 80, 1912. On arrival it was
posted to Nicosia, where it remained one month, sub-
sequently proceeding to Troodos (Hill Station) for three
months. At the end of this time it was not considered
necessary to keep the company in Cyprus any longer, and
it was ordered back to Egypt. As the place of bivouac on
the march down from Troodos to Limasol was reported to
be malarious, prophylactic doses of quinine were given to
all the men before leaving Troodos, 10 gr. on September 27
and 29. The march was about 35 miles, and they bivouacked
for the night of October 1 at a place called Zeegoe. This
place was apparently infested with mosquitoes, as most of
the men complained that they were severely bitten that
night. The next day they reached Limasol and embarked
for Alexandria. During their stay in Cyprus the health of
the men was excellent : one man only, Private A., contracted
malaria while the company was at Troodos. For eleven
days after arrival in Alexandria the health of the company
was good, but from October 13 cases of fever began to occur
and a number of men were sent to hospital with symptoms
suggestive of malaria.
The admissions were as follows :-—
October 13, 1912 1
So HA v5 ia n: A, 7
zy 15 ,, vei Ai ads 1
Y 16- 4; ess ind ess 1
s 175 35 6
” 29 ” 1
When all the circumstances of the case are taken into
consideration, viz., the limitation of the cases to this com-
pany, their freedom from malaria in Troodos, their having
been bitten at Zeegoe, and their immediate return to Egypt,
there is no doubt that the disease was contracted on the
evening and night of October 1, and this is interesting as
showing very definitely the period of incubation.
“The Journal of the American Medical Association,”
vol. Ix, No. 15, April 12, 1913.
Sporotrichosis.— Walker, writing on this subject in the
above number of the Journal of the American Medical
Association, gives the following useful bibliography of the
subject :—
(1) Widal and Abrami. Ann. de lInst. Pasteur, 1910,
No. 24, 1.
(2) Gougerot,
1908-9, i, 263.
(3) De Beurmann and Gougerot. “Les Sporotrichoses,”
Paris, 1912.
(4) Page, Frothingham and Paige. Journ. Med. Research,
1910, No. 18.
(5) Greco. Argentina Med., 1907.
(6) Walker and Ritchie. Brit. Med. Journ., 1911, No.
2635, p. 1.
(T) Lutz and Splendore. Ann. dig. sper., 1907, xvii., 581.
(8) Kren and Schramek, Wien. klin. Woch., 1909,
p. 1519.
(9) Schenck, B. R. Bull. Johns Hopkins Hosp., 1898,
ix, 286.
(10) De Beurmann and Gougerot.
Syph., 1911, ex, 25.
(11) Hektoen and Perkins.
Pal
(12) Garin, Charles. Provence med., 1911, No. 18, p. 194.
(13) Ripal and Dalous. Ann. de derm. et de syph.,
1910, li, 372.
H. “Folia Clinica et Microscopica,”
Arch. f. Derm. u.
Journ. Exper. Med., 1900
160
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(May 15, 1913.
(14) Arndt, G. Derm. Zeitschr., 1910, xvii, 24, 171.
(15) Armstrong, John M. St. Paul Med. Journ., xiv,
No. 4.
(16) Taylor, K. Journ. Amer. Med. Assoc., August 10,
1912, p. 441.
(17) Bonnet, L. M. Rev. de méd., 1911, p. 99.
(18) Pinoy and Magrou. Compt. rend. Soc. de Biol., 1911,
Ixxi, 387.
In addition to these, which are cited in his paper in the
order given, he also gives the following :—
LABORATORY Work.
Adamson, H. G.. Brit. Journ. Derm., 1908, No. 20,
. 296.
F De Beurmann and Gougerot. nn. de derm. et de syph.,
1906, pp. 887, 914, 993; Bull. Soc. méd. des Hép., 1907,
pp. 268, 302, 308, 380, 585, 1055, 1060; 1908, Nos. 24 and
25; Compt. rend Soc. de Biol, 1909; “Les Nouvelles
Mycoses,” Paris, 1911.
Dor. Presse méd., April 14, 1906, p. 234.
Pearsom, L. Penn. Livestock Bull., 1907, No. 8.
Pinoy, E. Compt. rend. Acad, Sc., 1911, clii, 286.
Rothe, L. Deutsch. med. Woch., 1910, No. 1.
Reudiger, G. F. Journ. Minnesota State Med. Assoc.,
November, 1911.
Stelwagon. “ Diseases of the Skin," Ed. 6, p. 1119.
Tokishiga, H. Centralbl. f. Bakteriol., 1 Abt., 1896,
xix, 165.
Troisler and Berthelot. Compt. rend. Soc. de Biol., 1911,
Ixxi, 264.
CLINICAL Work.
Archard et Ramond. Bull. Soc. méd. des Hôp., 1909,
». 738.
r Arndt, G. Berl. klin. Woch., 1909, No. 44.
Balzer et Vandet-Neveux. Bull. Soc. franç. de derm.
et de syph., July, 1910, No. 7.
Balzer et Marie. Ibid., March 1910.
Beam, Albert. Journ. Amer. Med. Assoc., June 10, 1911,
p. 1719.
Block, Bruno. Bethefte zur med. Klin., 1909, v, Nos. 8
and 9.
Bonnet. Lyon méd. 1911, No. 8, p. 115; Bull. Soc.
franç. de derm, et. de syph., December, 1910.
Burlew, J. M. South California Pract., 1909, xxiv, 1.
Capart. Centralbl. f. Path. u. Bact., 1911, No. 2, p. 85.
Costa, S. Compt. rend. Soc. de Biol., 1911, lxx, No. 24,
pp. 35-97.
Danlos et Flaudin.
No. 7, July, 1909.
De Beurmaun and Gougerot. Rev. de méd. et dhyg.
trop., T. 7., 1910, No. 8, p. 185; Bull. Soc. mid, des Hôp.,
1909, S. 739 ; 1909, No. 17.
De Beurmann , Gougerot et Laroche. Bull. Soc. méd. des
Hóp., 1909, No. 15.
Gross, G., et Heully, L.
Harker, H. J.
p. 1312.
Hodara, Menahem et Fuad Bey.
Syph., ex, 1911, H. 3, p. 987.
Hügel, G. Arch. f. Derm u. Syph., 1910, cii, 95.
Jeanselme, J., et Chevalier, P. Bull. Soc. fran;.
derm. et de syph., p. 190.
Jocas, R. La Clin. Ophth., 1911, p. 62.
Josset-.Moure, Bull. Soc. méd. des Hôp., 1908, No. 37;
1909, No. 11.
Legry, Sourdel et Velter.
Hôp., Paris, 1911, No. 25.
Letulle, M., et Débré,
Ofenheim, V.
Pantrier et Lutembacher.
et de syph., No. 7, July, 1909.
Steward, W. B. Journ. Amer, Med. Assoc., August 5,
1911, p. 482.
Bull. Soc. franc. de derm. et de syph.,
Rev, mid. de l'Est, 1911, p. 65.
Journ. Amer. Med. Assoc., May 6, 1911,
Arch. f. Derm. u.
de
Bull. et mém. Soc. méd, des
Bull. Scc. méd., 1908, p. 379.
Luncet, London, 1911, i, 10.
Bull. Soc. franç. de derm.
Sutton, J. M.
p. 1309.
Sutton, L. R. Boston Med. and Surg. Journ., 1911,
No. 6, p. 179.
Thibierge, G., et Weissenbach, R, J.
de derm. et de syph., 1910, xxi, 186.
Thibierge et Gastinet. Bull. Soc. méd, des Hôp., 1909,
No. 11.
Trimble, W. K. Journ. Kansas Med. Soc., 1909, ix,
p. 805.
Widal, F., et Weill, A. Bull. Soc. méd. des Hóp., 1908,
No. 22.
As the author points out, any one watching research work
in the last two years must have been struck by the growing
interest in sporotrichosis. The organism was only recovered
by Schenck in 1898 in human lesions, but since that time
a very large amount of work, as the above bibliography
shows, has been done on the subject.
Journ. Amer, Med. Assoc., May 6, 1911,
Bull, Soc. frang.
“The Journal of the American Medical Association,”
vol. Ix, No. 16, April 19, 1913.
Budding in Entameba tetragena.— Darling, after having
studied kittens experimentally infected with Æ. tetragena,
believes that he has established a correlation between the
findings of Schaudinn and Craig on the one hand, and those
of Viereck, Werner and Hartmann on the other. He agrees
with the latter observer that E. tefragena is the common
pathogenic entameba of man, and that the so-called
E. histolytica is in all likelihood a spurious species, the
alleged spore-eyst development having been described from
degeneration forms in senile races of H. tetragena.
“The Journal of the American Medical Association,"
vol. Ix, No. 16, April 19, 1913.
Fimetine in the Treatment of Amabic Dysentery.—
Lyons, writing on the treatment of amcbic dysentery by
emetine, summarizes the advantages of this method as
follows : (1) Simplicity and ease of administration of the
drug; (2) no vomiting or depression; (3) accurate dosage
(no loss through bowels); (4) rapid absorption and effect ;
(5) reliability of product (hvdro-ehlorid). In answer to the
question— Does it cure? he gives the subsequent histories
of five patients who recovered. Four have been heard from
or seen and all have remained well. Patient 1 is still cured
after three months and three weeks; Patient 3 after two
months; Patient 4 after three months; Patient 6 after two
months and three weeks, Patient 5 has unfortunately been
lost sight of. While these intervals of good health are not
long, the outlook is, however, very encouraging. While no
definite conclusions can be drawn from the observations of
so small a number of cases, the author believes that the
results are highly suggestive that in the subcutaneous injec-
tions of soluble emetine salts an ideal method has been
found of treating amebic disease. The application of
Vedders experimental work to clinical cases has certainly
been a most happy one, and as far as it has gone a most
successful one.
Slotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written ciearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE snould com-
municate with the Publisners,
5.—Correspondents should look for replies under the heading
** Answers to Correspondents,”
June 2, 1913.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 11, Vol. XVI.
OO
SS ooo
Original Communications.
CELL INCLUSIONS IN THE LEUCOCYTES OF
BLACKWATER FEVER AND OTHER
TROPICAL DISEASES.
By GgonaE C. Low, M.A., M.D., C.M.
AND
C. M. Wexyon, M.B., B.S., B.Sc.
London School of Tropical Medicine.
IN a paper published in THE JOURNAL or TROPICAL
MEDICINE AND HYGIENE, vol. xv, No. 11, June 1,
1912 [2], one of us (G. C. L.) stated that cell inclu-
sions similar to those described by Sir W. Leishman
in the blood of blackwater fever cases [1] had been
seen in the blood of fever cases from Borneo and
also in the blood of pellagra cases from Italy. Since
that time we have followed up the subject by
examining the blood of many different tropical
conditions, viz., malaria (recent and chronic), black-
water fever, trypanosomiasis, sprue, filariasis,
anemias of various kinds, &c., and have specially
noted the presence or absence of chromatin inclu-
sions in the cells in such cases. In addition we
have made a special study of what are usually called
** Large Mononuclear ’’ cells, and have come to the
conclusicn that these must be differentiated up into
different varieties or types. Two at least of these
occur. Following the nomenclature proposed by
Leishman one may term them (a) the endothelial
type, and (b) the hyaline type.
Fig. I,
(a) Endothelial type. (b) Hyaline type.
In addition to these cells, about which there can
be little or no confusion, another type of cell occurs
in a certain number of bloods. This is the large
lymphocyte—a cell which contains a larger nucleus
and a larger amount of protoplasm than the ordinary
small lymphocyte. The protoplasm of this large
lymphocyte often takes on a blue colour. The
differentiation between this cell and the hyaline
type ‘‘b’’ of the large mononuclears is a much
more difficult proceeding, many of the forms run-
ning more or less into each other. In bloods where
such cells occur it is not fair to classify them either
with the ordinary lymphocytes or with the large
mononuclears, and the best thing to do is to make
a special class for them, terming them large lym-
phocytes, or dividing the lymphocytes up into large
and small.
Apart from having very small red-coloured inclu-
sions, which according to Schilling-Torgau [6] cannot
be distinguished from the well-known plasmosomes
of Wolf and Ferrata, these lymphocytes do not show
the large chromatin inclusions, so need not be con-
sidered further. According to the same observer
the cells described by Leishman as chrome cells
are the basophile granular leucocytes of Ehrlich so
often called in this country '' mast cells.”
In examining malarial bloods, especially chronic
cases, one is at once struck with the great variation
in number and variety of the large mononuclear
cells met with. As recovery takes place and the
parasites die out there is of course a tendency for
these cells to return to their normal numbers, but
even in cases where infection is still undoubtedly
e
(d) Small cr ordinary lymphocyte.
Fro. II.
(c) Large lymphocyte.
present such variations oceur. In some bloods the
endothelial type of large mononuclear prevails,
while in others it is not seen at all. Again, the
hyaline type may be the predominant cell present,
either alone, or associated with the endothelial in
varying numbers. The amount of malaria suffered
from does not seem to determine the amount of
inerease, and probably it is due to some factor or
factors of which at present we are ignorant. As
examples of this, one may quote the case of a lady
who had suffered, by no means severely, from fever
on the Gold Coast. Her differential leucocyte count
gave 26 per cent. of large mononuclear cells, almost
every one of these being of the endothelial type.
On the other hand, a young man from Northern
Nigeria who had also suffered from slight attacks
of malaria, got blackwater fever and died of this,
his blood, taken the day before his death, showing
no endothelial cells at all after a prolonged search
and only 3 per cent. of cells that could in any way
be called large mononuclear—these being of the
hyaline type. (This case, as well as that of another
patient, who said he had never suffered from malaria
at all, but whose blood showed both types of large
mononuclear cells in large numbers, will be referred
to later.)
In addition to malaria and blackwater fever, how-
ever, cells of the endothelial type occur in other
tropieal diseases, such as kala azar and trypanoso-
miasis, so their presence cannot be taken as
diagnostic of any one of these diseases. As regards
chromatin inclusions seen in this type of cell, it
seems probable that they may have different origins.
The largest inclusions seen in fig. 18 of Leishman's
coloured plate appear to be derived from ingested
normoblastie nuclei, a view suggested by one of us
(C. M. W.) and with whieh Sehilling-Torgau [6]
agrees. The medium-sized, or, as we have termed
them, large inclusions—by this meaning the com-
pact or ring-shaped chromatin masses, not the dust-
like granules or specks—would seem in many cases
at least to originate in the nuclei of the cells them-
selves (vide figs. 2 and 4 of coloured plate), but in
other instances might result from the ingestion of
162
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 2, 1913.
parasites containing chromatin (trypanosomes,
leishmania, malaria, &c.), or even be the products
of disintegration of ingested nuclei, such as the
nuclei of lymphocytes or normoblasts (nucleated red
cells). (Vide fig. 12.)
The cells depicted in the coloured plate have
been taken from various sources. The first case
(figs. 1 to 6) is of special interest. The patient
was sent home from China (Hankow) supposed to
be suffering from pernicious anwmia.* Clinically
symptoms of sprue, as evidenced by the passage
of large, bulky, poorly coloured stools, were present,
but the blood count was not typical of that com-
plaint in many respects, other pathological factors
evidently playing a part in the production of the
amemia. According to the patient he had never
suffered from malaria, and of course had never had
blackwater fever.
His complete blood count was as follows :—
Reds 2,400,000
Whites Pes 2,000
Hemoglobin ... Öl per cent. (Von Fleischl's).
DIFFERENTIAL LkUCOCY1E COUNT.
Number Per-
counted centage
Polymorphonuclear ses X eo. 542,8
, {Endothelial tv pe 37 7.4
Large mononuclear | Hyalinetype ... 50 10.0
Lymphocytes NA be a: 181 26.2
Eosinophile i3 js RE s 61 12,2
Transitional E ia ^ vet 3 0.6
Mast cells ... m b. "T X 3 .. 0.6
Myelocytes... T oe ae e M. Nonus O!
500 100.0
Poikilocytosis not very marked; extraordinary
irregularity in size of reds, enormous numbers of
megalocytes; two normoblasts, and a fair number
of megaloblasts seen. No polychromatophilia or
basophilic degeneration of reds. No malarial or
other parasites, no pigmented leucocytes. Many
chromatin inclusions in the large mononuclear cells.
A perusal of the above blood count is distinetly
against the diagnosis of pernicious anemia. There
is, however, a very marked leucopenia, and dif-
ferentially a large relative increase of the large
mononuclears and eosinophiles. Both the endothe-
lial and hyaline type of large mononuclears are
present, and why this should be is not quite clear,
as the patient is quite emphatic in stating that he
has never suffered from malaria. He might, of
course, have had the disease in a latent form, but
against this is the complete absence of malarial
parasites in his blood in the prolonged examinations
made. In one cell there was what appeared to be
black pigment, but as this was not found again in
other cells its significance must be regarded as
doubtful. Kala azar would also seem to be ex-
cluded, because of the normal size of the liver and
spleen.
The eosinophilia in turn requires explanation.
* Dr. C. W. Daniels has very kindly permitted us to use the
details of this case, and has also allowed us to reproduce the
cells from the Rhodesian case of human trypanosomiasis,
Having come from Hankow the question of schisto-
somiasis of course crops up, but no ova of this,
or any other parasites, have so far been discovered
in the stools, nor have any other signs of helminthic
infection been detected.
The blood count certainly is a peculiar one.
Turning now to the cells from this case shown in
the plate, figs. 1 to 4 are typical cells of the
endothelial type; three of these possess many fine
chromatin granulations which are apparently in-
distinguishable from those in Leishman's case of
blackwater fever. Figs. 2, 3, and 4 have large in-
clusions and in two of these it is clearly evident that
they are taking origin from the cell nucleus. These
two cells, it may be stated, are not isolated in-
stances of this mode of origin as they are fairly
frequent in the single film from which the ones
referred to were taken. Figs. 2 and 3 show the ring
form very clearly. Fig. 5 is a typical hyaline, large
mononuclear cell, and illustrates those chromatin
inclusions which have been described as plasms-
somes. There remains fig. 6, which is a cell inter-
mediate in some ways between the endothelial and
hvaline types; it contains a typical chromatin ring.
The second case (figs. 7 to 10) are cells of the
peripheral blood of a case of Rhodesian trypano-
somiasis (Case G) taken when the trypanosomes
were very numerous. ig. 7 might be a myelocyte ;
it contains moderate-sized chromatin bodies. Fig. 8
is a distorted cell with many fine granulations in
its substance. Figs. 9 and 10 are typical cells of
the endothelial type. The first of these shows a
large ring-shaped chromatin inclusion, which may
possibly be the remains of the nucleus of an ingested
trypanosome. In the protoplasm of the second will
be seen very fine dust-like granules.
The endothelial cells (figs. 11 to 16) are from a
totally different source. They were seen in large
numbers in a peritoneal exudate which had resulted
from the inoculation by one of us (C. M. W.) of
Leishmania tropica into the peritoneal cavity of a
mouse. They are remarkable on account of their
extraordinary phagocytie activity, for they are
evidently ingesting every type of smaller cell (lym-
phocytes and polymorphonuclears, &e.) in the
exudate. After ingestion the nuclei of these cells
undergo digestion with the result that all kinds of
cell inclusions are produced. In the case of the
lymphocyte nuclei (figs. 13 and 15) the process
of digestion results in ring-shaped structures, with
chromatin centres which are indistinguishable as
far as one can judge from Leishman’s [1] fig. 13
in his first paper.
Fig. 11 js an endothelial cell and contains a poly-
morphonuclear leucocyte, a lymphocyte, and a
chromatin inclusion of uncertain origin. Fig. 12
shows many moderate-sized inclusions which prob-
ably have resulted from the disintegration of some
ingested nucleus. Fig. 13 illustrates an inter-
mediate stage of the nuclear degeneration of a
lymphocyte, all stages of which are well shown also
in fis. 15. Fig. 14 is a smaller cell showing two
inclusions, one of which has a definite ring struc-
ture resembling very closely the inclusions seen in
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, JUNE 2, 1913.
18
19-2 p 21-6 p
I5;6u
13-2 y.
18 p
l6
C. M. W. del.
Figs. 1—6. From the case of anemia from China.
Fics. 7—10. From case of Rhodesian Trypanosomiasis.
Fics. 11—16. From peritoneal exudate of mouse.
For detailed description of Figures see tert.
”
To illustrate a paper on ‘‘Cell Inclusions in the Leucocytes of Blackwater Fever and other Tropical Diseases,
by Grorcr C. Low, M.A., M.D., C.M., and C. M. Wenyon, M.B., B.S., B.Sc.
ee p
HENRY B, WARD
STATE Uv IVERSITY,
_ June 2, 1913.]
figs. 2 and 3. At fig. 16 are two free lymphocytes
and one endothelial cell containing two recently
ingested lymphocyte nuclei and a peculiar body
probably of the same nature as that in fig. 13.
As regards the origin of the various endothelial
cells pictured in the plate- those found in the peri-
pheral blood most probably are derived from the
vascular endothelium, while those of the peritoneal
exudate of the mouse must be derived from the
exfoliated peritoneal endothelium. The kind of
degeneration exhibited by the ingested lymphocytes
in the peritoneal cells of the mouse supports very
strongly the view that the similar bodies seen in
the endothelial cells of the peripheral blood have
had a similar origin.
As has already been stated endothelial cells are
not necessarily found in all cases of blackwater
fever. The blood of the young adult referred to
gave the following differential count. ^ Unfortu-
nately a total leucocyte count per cubie-millimetre
could not be made, but from the appearance of
the films a fairly marked leucoeytosis had been
present :—
DIFFERENTIAL LEUCOCYTE COUNT.
Number Per-
counted. centage,
Polymorphonuclear |... nef 3894 . 78.8
Large mononuclear ... ET 8 ..- at 0.6
Lymphocytes T 53 so... 17.8
Eosinophile m i D «i eS 0.6
Trausitional s aa B ets ‘ita 1.6
Mast cells
Chrome cells j 3. os 0.6
Myelocytes For 2: Te. qim ze —
500 100.0
The blood when taken was extraordinarily thin and
watery and spread on the films very badly. There
was a marked tendency to rouleaux formation and
a sticking together of the reds. ^ Marked poikilo-
cytosis was present, there were many megalocytes,
and one normoblast and one megaloblast were seen.
The evidence then was that of a severe anemia. No
endothelial cells were present, nor could any chro-
matin inclusions be detected. Differentially the
blood showed an increase of the polymorphonuclear
leucocytes. There were no signs of any malarial
parasites.
The case was a severe and fatal one. The patient
had only been abroad for fourteen months, having
served that time in Northern Nigeria. During that
time he suffered from several small attacks of
malaria and took quinine irregularly, but had had
no blackwater fever. He was also somewhat
addicted to alcohol. After his return to England he
had further relapses of malaria, after one of which
blackwater fever developed. As just mentioned,
symptoms of great severity quickly developed, a semi-
comatose condition appearing on the third day of
the illness, suppression of urine on the fourth day,
complete unconsciousness on the fifth, and death
on the sixth. The patient never seemed to be able
to combat the toxemia from the beginning. The
absence of endothelial cells and cell inclusions is
interesting, and may be important in view of the
severity of the case.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
163
It seems an undoubted fact that these endothelial
cells, in whatever situation, are derived from the
lining endothelium, and what causes their exfolia-
tion remains a mystery, for it does not seem to have
any definite relationship to the severity of the con-
dition producing it. The same may be said of the
cell inclusions which appear in large numbers in
some conditions, while not at all, or very scantily,
in others. As far as one can judge then from the
varying origin and occurrence of these inclusions it
does not seem legitimate at present to associate them
with any partieular disease, and in our opinion there
now seems to be no possibility of them being para-
sitie in nature.
Certain peculiar looking bodies recently des-
eribed by Coles [8] in a blackwater fever blood
resemble artefacts more closely than anything else.
They are certainly not parasites, and we have never
seen such appearances in the many blackwater
bloods we have examined. The suggestion put for-
ward in the same paper that the blood of the inner
viscera, bone marrow, and lymph glands should be
examined for protozoa has, of course, been done
repeatedly by competent observers, but so far with
negative results.
Apart from the cell inclusions in the leuco-
cytes, the etiology and significance of which
have been described above, no other appearances
resembling protozoal parasites, as far as we
know, have been seen or described in the blood of
blackwater fever by the many investigators who
have studied the disease. Anthony has, of course,
described spirochetes, but as no one else has con-
firmed this statement, his observations must be
looked upon with doubt. Though looking for these
specially we have never succeeded in seeing any-
thing in the slightest degree resembling such
organisms.
LITERATURE,
[1] W. Letsuman: ‘‘Cell Inclusions in the Blood of a Case
of Blackwater Fever," Journal of the Royal Army Medical
Corps, vol. xviii, No, 5, May, 1912,
[2] G. C. Low: “Cell Inclusions in the Blood of Black-
water Fever and other Tropical Diseases," JOURNAL OF
TROPICAL MEDICINE AND HYGIENE, vol. xv, No. 11, June 1,
1912.
[3] W. LErsuMaN: ''Cell Inclusions in the Blood in Black-
water Fever: Second Note," Journal of the Royal Army
Medical Corps, vol. xix, No. 2, August, 1912.
[4] W. LErsHMAN: “The Etiology of Blackwater Fever,”
Transactions of the Society of Tropical Medicine and Hygiene,
vol. vi, No. 1, with discussion by Wenyon and others,
November, 1912.
[5] ALDO CASTELLANI: ‘‘ Note on Certain Cell Inclusions,”
JOURNAL OF TROPICAL MEDICINE AND HYGIENE, vol. xv, No. 23,
December 2, 1912,
[6] SCHILLING-TORGAU : ** Concerning the Origin and Signifi-
cance of Leishman's Chrome Cells in Blackwater Fever (the
Basophile Granular Leucocyte of Ehrlich)," JOURNAL or TROPI-
CAL MEDICINE AND HYGIENE, vol. xv, No. 24, December 16,
1912.
[7] ANpnEw BALFOUR: “A Case of Blackwater Fever show-
ing the Cell Inclusions of Leishman,” JOURNAL or TROPICAL
MEDICINE AND HYGIENE, vol. xvi, No. 3, February 1, 1913.
[8] A. C. CorEs: *'Protozoalike Structures in the Blood
in a Case of Blackwater Fever," Lancet, May 3, 1913.
. HENR
Y B, WARD,
161
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 2, 1913.
THE CULTIVATION OF THE BACILLUS OF
LEPROSY.
By Henry Fraser, M.D. Aberd.
Director, Institute for Medical Research, Federated Malay
Slates.
In your journal of October 15, 1912, p. 307,
directions are given by Professor Creighton Wellman
and Dr. Hand for the preparation of Wellman's
placental agar. The method is that already de-
scribed by Professor Wellman in the Centralblatt
fiir Bakteriologie (p. 143) of August 24, 1912, and
similar to that described by Professors Duval and
Wellman in your journal of July 15, 1912, p. 221.
l'or the cultivation of the Bacillus lepre Dr. Bayon
has also employed a placental agar. The method
for the preparation of his medium is not described
in his published papers, but in response to a letter
the necessary information was kindly furnished by
him. His procedure differs in some respects from
that employed by Professors Duval, Wellman and
Dr. Hand.
During the past nine months we have carried out
experiments with a view to the cultivation of the
bacillus of leprosy. A placental agar was prepared
in accordance with the directions given by Professor
Wellman in the Centralblatt referred to. In this
country the placental extract when mixed with
equal parts of 2 per cent. agar does not set properly ;
a 4 per cent. agar was therefore employed.
On October 11, 1912, thirty tubes of this placenta!
agar were inoculated with nodules of leprous tissuc.
removed under aseptic precautions and swarming
with leprosy bacilli.
The inoculated tubes were incubated at 879 C.
After forty-eight hours two of the tubes were seen
to be contaminated. Incubation of the remaining
tubes was continued and from time to time a small
quantity of sterile distilled water was added to each
tube in order to keep the medium moist.
These tubes have now been under observation for
seventy days. In none of them is there any
evidence of growth or multiplication of the bacilli.
Tubercle bacilli inoculated on this medium grow
slowly; the growth is not to be compared with that
obtained on a blood-agar prepared by mixing
glycerine-agar with an equal quantity of citrated
human blood.
On September 26 thirty-five tubes of placental
agar, prepared in accordance with Dr. Bayon's
directions, were similarly inoculated with nodules
of leprous tissue, incubated at 379 C., and kept
moist in the manner already described.
These tubes have now been under observation for
eighty-five days. In none of them is there any
evidence of growth or multiplication of the bacilli.
Professor Wellman and Dr. Hand state that the
placental agar can be prepared by the merest tyro
in bacteriology; to this statement I must take
exception. It can only be prepared by one trained
in bacteriologieal methods and with a properly-
equipped laboratory at his disposal. It is wrong to
encourage amateur bacteriologists in this way and
to delude them into the belief that the culture of the
me
leprosy bacillus is a simple matter. Such action can
only further intensify the present confusion.
They further state that '' the acid-fast organisms,
either of human or rat origin, grow on this medium
so readily that microscopic growth can be discerned
in from five to seven days,” and in the Centralblatt
already referred to Professor Wellman states that
'* the acid-fast organisms from bits of leprous tissue
either of human or rat origin grow so readily that
macroscopic growth can be discerned in from five to
seven days." Microscopic growth can, I assume,
only be detected in films prepared from the
inoculated nodules of tissue. In such films we have
invariably found numbers of acid-fast bacilli, but in
no instance have we been able to convince ourselves
that the organisms are more abundant than they
were in the tissue at the time of inoculation. We
have never discerned a macroscopic growth of acid-
fast bacilli after from five to seven days nor at any
later period.
The conditions under which our work is carried
out are most favourable. The leper asylum is
situated within half a mile of the Institute, it con-
tains more than 250 patients. Selected cases come
willingly to the Institute, so that it is easily
possible, under aseptie conditions, to transfer the
leprous tissue directly from the patients to the
media. In this way materials have already been
obtained from twenty-two patients. The tissues
were invariably obtained from non-ulcerated cases.
From ulcerated cases of the disease it is possible
to grow all sorts of organisms, and equally so from
tissues removed post-mortem, more especially in
the Tropies.
Inconsistency and pleomorphism are the out-
standing features of the recent publications on the
subject of leprosy.
CIRRHOSIS OF THE LIVER OF MALARIAL
ORIGIN.
By Lucivs NicnoLLs, B.A., M.B., B.C.
Pathologist, &c., to the Government of St. Lucia, British
West Indies.
Cirruosis of the liver is a common condition of
many tropical countries, and numerous authorities
have asserted that some cases are caused by re-
peated attacks of malaria, but this has been dis-
puted, and at the present time there appears to
exist much doubt that malaria is ever a cause of
the condition. The pathology of the disease has
been but seantily described, and this possibly
accounts for the existing uncertainty.
Hepatic cirrhoses can be divided into two main
classes—the multilobular portal type, and the mono-
lobular biliary cirrhosis. In the former, fibrosis
takes plaee around areas composed of numerous
lobules, whereas in the latter the fibrous tissue is
increased primarily around the bile capillaries and
single lobules of liver tissue; the former is the
common disease of heavy spirit drinkers, and need
not be further considered. Cirrhosis, which is
initiated by malaria, falls into the second group.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, JUNE 2, 1913.
Fia. 1.
To illustrate paper by Dr. Lucius NicHoLrs on “ Cirrhosis of the Liver of Malarial Origin.”
June 2, 1913.]
Hanot and the French school were the first to
separate biliary cirrhosis, but some confusion has
since arisen from the fact that in the later stages the
tissues are apt to undergo multilobular fibrosis as
well, and thus obscure the original picture. Numer-
ous very long names have been suggested to distin-
guish the various clinical types of biliary cirrhosis,
and these depend upon the relative sizes of the liver
and spleen, or the period in the disease in which
enlargement of one or other of these organs first
becomes demonstrable.
Biliary cirrhosis must originate as an ascending
or a descending inflammation of the bile-ducts or
capillaries, and for this the causes in various cases
will be different.
If ascending catarrh was a common cause, an
initial dyspepsia and a concomitant swelling of the
pancreas would be expected. Therefore the majority
of cases are probably due to some poison excreted
by the liver and irritating the bile-ducts in its
passage along them or to a damming up of bile by
pressure from below.
There is a cirrhosis somewhat of the nature of
that which I am considering which is due to con-
genital obliteration of the bile-ducts.
In malarial cirrhosis, the liver is moderately en-
larged, its surface is smooth, the capsule is greatly
thickened, and the peritoneal attachments are
thick, hard, and fibrotic. There are numerous
adhesions binding the liver to the diaphragm and
surrounding organs. The changes which have taken
place around the gall-bladder and transverse fissurs
are of the greatest importance. The lymphatie
glands in this neighbourhood are much enlarged
and bound down by thick, fibrous adhesions to the
transverse fissure. The entering bile-duct and
vessels are difficult of dissection, for they are firmly
adherent to each other and matted together by
fibrous bands. The walls of the gall-bladder are
much thickened and the viscus is bound down to
the adjacent capsule. The substance of the liver
is hard and firm, with a dark mottled colour on
section; islets of glandular cells stand out above
the surrounding adventitious fibrosis.
Fig. 1, a photograph of this condition, shows these
points; note the enlargement of the lymphatic
glands, and the mass of fibrous bands in the trans-
verse fissure. Also the shrunken, bound-down
appearance of the gall-bladder. The thickening of
the peritoneum at its reflections is well shown.
In Hanot’s hypertrophic cirrhosis these changes
in the transverse fissure and gall-bladder are rarely,
if ever, present.
Microscopical sections of malarial cirrhosis show
that the fibrosis has taken place around single
lobules, and there is an enormous increase in the
fibrous tissue around the bile capillaries. Fig. 2
shows this monolobular cirrhosis. Vig. 3 is a
photograph of a bile capillary, and shows the mas-
sive increase of fibrous tissue around it.
The fibrous tissue of the liver eapsule and the
subjacent tissues may be even more than 4 in.
thick.
In post-mortems on chronic malarial subjects
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
considerable perisplenitis and fibrous adhesions to
the diaphragm and surrounding peritoneum are
present, frequently also there is perihepatitis and
various adhesions in connection with the liver.
Enlargement and swelling of the liver takes place
at each attack of malaria, this is especially well
marked in the case of children.
The production of this cirrhosis depends upon the
presence of adhesions in the transverse fissure of
the liver, thickening of the walls of the gall-bladder,
and swelling of the neighbouring lymphatie glands.
The sequence of ehanges appears to be: (1) The
formation of adhesions, and enlargement of lym-
phatie glands, which press upon the bile-duct; (2)
the swelling of the liver at each attack of malaria;
(3) as the adhesions and perihepatitis increase, the
organ is held as in a vice, and the glandular swell-
ing must take place against considerable internal
pressure; (4) thus there is an increased internal
pressure, acting against pressure on the bile-ducts
and in the gall-bladder. Therefore fibrous tissue
must be formed around the bile capillaries as a
compensatory act; (5) malarial ‘‘ toxins ’’ are
formed in the liver, and being excreted under un-
usual pressure along the bile capillaries, add a
further irritating factor.
The deleterious products, which should normally
be excreted with the bile, are absorbed into the
system and cause the enlargement and profound
changes which take place in the spleen.
I therefore form the opinion that malarial
cirrhosis is primarily of a mechanical nature, and
the adhesions and capsular thickening so frequently
observed in post-mortems on malarial subjects have
been unusually accentuated around the transverse
fissure and gall-bladder, and the post-mortem
changes in this area are almost pathognomonic of
malarial cirrhosis, and serve to distinguish it from
allied monolobular biliary cirrhosis.
THE METEOROLOGY OF MALARIA.
By MarrHEW D, O'CosxsELL, M.D.
IN continuation of previous remarks on this sub-
ject, I give below two observations of the dry and
wet bulb temperatures of the atmosphere at Putta-
lam and at Kurunegala, in Ceylon, for which I am
indebted to Mr. Bamford, the acting superintendent
of the observatory at Colombo. $
PUTTALAM.
Temperature of Wind
air, F.
— =
NU ; oS ENES
1911 Dry Wet Direction Velocity
per hour
October 3, 3.80 o'c. p.m. 759? 73.9" SW 11 miles.
Octc ber 4, about 5.30 0'c. a.m. 72.6 71.3 S 5 ,
lrom these observations it is seen that the dry
bulb temperature of the air fell 3.39 F., or at the
rate of 0.23579 per hour during the night, and the
wet bulb temperature fell 2.69, or at the rate of
0.18579 per hour,
166
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 2, 1913.
At Kurunegala on the same night the atmospheric
conditions were as follows : —
Temperature of Wind
air,
ee es ———
1911 Dry Wet Direction Velocity
October 3, 3.30 o'c. p.m. 79.9? 74.85? Not given
October 4, about 5.30 o'c. a.m. 74.8 71.0 " T
From these observations it is seen that the dry
bulb temperature fell 5.19, or at the rate of 0.30429
per hour, and the wet bulb temperature fell 3.89,
or at the rate of 0.27149 per hour during the night of
October 3 to 4 at Kurunegala. From these figures
I construct the two tables given below, showing
approximately the hourly atmospheric conditions at
Puttalam and Kurunegala, and give for comparison
the atmospherie conditions having the nearest dry
bulb temperatures which were found, by actual
observation in the Lancashire cotton sheds, to raise
body temperature. To these tables I have added
the drying power of the air in each atmosphere to
make clear the rate of loss of heat from the body by
evaporation.
In the tables below it is seen that exposure to
certain atmospheric conditions in the Lancashire
cotton sheds for less than four hours raised the body
temperature of many of those so exposed above
97,79 C. (100,09. F.). It ean also be seen that the
Atmospherie conditions at Pattalam, Ceylon, during
impediment presented to loss of heat from the body
by the atmospherie conditions for many hours of
the night, both at Puttalam and Kurunegala, was
even greater than in the atmosphere of the cotton
sheds. Must not, then, exposure to the night
atmospheric conditions at Puttalam and Kurunegala
for fourteen hours raise the body temperature of
many even higher than 37.79 C. (1009 F.)?
The inhabitants of Puttalam and Kurunegala then
were immersed in an atmosphere which raises body
temperature and accelerates the pulse and respira-
tion for fourteen hours on the night of October 3
to 4, 1911. For them there was no escape from
it until sunrise, when the atmospheric temperature
begins to rise and the air again becomes gradually
drier.
It seems to me that nightly, i.e., intermittent,
exposure to such atmospherie conditions for any
length of time must inevitably produce an inter-
mittent fever in many of those exposed. Perhaps
it was recognition of the fact that ague, whatever
its cause, does become prevalent under such
atmospherie conditions, which of old led to their
being deseribed as bad air (mal'aria) The appli-
cation to a disease of the name given to the con-
ditions believed to eause it is both common and
scientific,
Atmospheric conditions which Degree to which body tempera-
the night of October 3-4, 1911. raised body temperature in ture was raised by exposure in
cotton sheds of Lancashire ectton sheds
ee ee, eee —— ~ — A —— — — — — — a a Me — —À — — — —
Temperature of Drying Wind Temperature of Drying Body tempera- Pulse Respira-
air, F power of air air, power of air ture, F, tion
per 10 c, ft. per 10 c. ft.
p— — Ü
Puttalam, 1911 Dry Wet Grains Direction Velocity Dry Wet — Grains
vcr hour
October 3, 3.30 o'c. p.m. 175.9? 73.9? 10.0 SW 1i miles 76.0° 72.0 20.0 99.4” 88 20
R 4.2 5 75.6 73.7 9.5 75.5 70.5 25.0 99.4 132 22
5.30 5" 75.4 173.5 9.5 75.5 70.5 25.0 99.4 132 22
5 6.30 4$ 75.1 73.3 9.5 75.0 69.5 26.0 160.2 110 18
^n 7.30 X 74.9 73.1 9.0 75.0 69.5 26.0 1C0.2 110 18
A 8.30 74.7 72.9 9.0 75.0 69.5 26.0 100.2 110 18
ys 939 74.4 72.7 8.5 74.0 70.0 19.0 100.0 98 22
Ys 10.30 74.2 72.6 8.0 74.0 70.0 19.0 1000 98 22
25 11.30 ji 74.0 72.4 8.0 74.0 700 19.0 100.0 98 22
October 4, 12.30 o'c. a.m. 73.7 72.2 7.5 73.5 68.0 24.5 160.0 90 22
s 1.30 , 73.5 72.0 7.5 73.5 68 0 24.5 100.0 90 22
rf 2.30 "m 73.3 71.8 7.5 13.5 68.0 24.5 100.0 90 22
7 3.30 s 73.0 71.6 7.0 73.5 68,0 245 100 0 9 22
P 4 30 r 72,8 71.4 5.0 72.5 68.0 24.5 100.0 90 22
tr about 5.20 oc. a.m. 72.6 71.3 6.5 S 5 miles 72.0 65.0 29.0 99.0 Not given
Atmospheric conditions at Kurnnegala, Ceylon, during
the night of October 3-4, 1911,
Atmospheric conditions which Degree to which body tempera-
raised body temperature in ture was raised by exposure in
cotton sheds cotton sheds
—
ae = — "R
Temperature of Drying Wind Temperature of Drying Body tempera. Pulse Respira-
air, F, power of air air, F. power of air ture, F. ation
per 10 e, ft. per 10 c. ft,
mE Ner edt m i
Kurunėgala, 1911 Diy Wet Grains Direction Velocity Dry Wet Grains
October 3, 3.30 o'c. p. m. 79 9? 4.8? 27.4 80 0° 73.0° 36.0 99,2° 90 16
= 4.30 i 79.5 74.5 26.5 79.5 74.5 26.5 100.2 90 24
ii 5.50 ” 70.1 74.9 25.6 79.0 73.5 28.0 100.3 110 24
ss 6.30 re 78.8 73.9 25.4 79.0 73.5 28.0 100.3 110 24
35 7.30 ” 78.4 73.7 24.2 78.5 73.5 25.5 99 6 116 22
8.30 ” 780 73.4 23.4 78.0 73.5 25.5 100.0 100 30
n 9.30 : 77.7 73.1 23.1 780 13:5 25.5 100.1 100 18
ee 10.30 " 71.3 72.9 29.0 77.0 73.0 20.0 109.1 100 18
mm 11.30 - 76,9 T2. 21.5 TCO 73.0 20.0 100.1 100 18
October 4, 12.30 o'c, a.m, 76.6 723 21.5 770 730 20.0 100.1 100 18
+ 1.30 xi 76.2 72.0 21.0 76.0 72.0 20.0 99 4 "8 20
br 2.30 3; 75.8 71.8 20.0 75.5 70.5 24.5 99 4 132 22
$i 3.30 $i 75.5 71.5 20.0 75.5 70.5 24.5 99.4 132 23
35 4 30 $7 5.1 71.2 19.5 750 69.5 26.0 100.2 110 18
ñ 9.30 ji TAS 71.0 19.9 75.0 69.5 26.0 100.2 110 18
June 2, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
167
NATIVE TREATMENT OF SLEEPING
SICKNESS—A TRIAL.
By ALEXANDER Brown, M.B., Ch.B.
Serenje.
Iv Serenje and district there is a persistent
rumour that people have had human trypan-
osomiasis and been cured by native remedies.
After consulting with one or two friends, and having
a patient suffering from this disease, I thought I
might test this rumour. Now that it is done I have
come to the conclusion that the native remedies for
sleeping sickness are as efficacious as that for per-
sistent vomiting, which the great divine, John
Wesley, prescribed as an infallible eure, ‘* Place a
puppy on the belly!" The unele of the sick boy,
who eume in, said he had had it and was cured.
The chief of a near village said he had had it and
was cured. Fully realizing the responsibility I was
tuking upon me, I asked the latter, who said he
knew the medicine, to bring it and let me see him
administer it. The medicine consisted of the bark
scraped off a tree called Musolkwe. It was a
eoarse, reddish, tasteless, and insoluble powder,
and this was how it was given. "There was a basin
of water for the patient in which to rinse his hands,
a small tin ean, and a native cooking-pot. The
empty pot was put on the fire and made thoroughly
hot. About two tablespoonfuls of meal, made from
Indian eorn, and about 8 oz. of cold water were
placed in the tin can. The patient was told to
rinse his hands with the cold water. When the
pot was thorouglly hot about 2 oz. of the mealy
water was put in and then the coarse reddish
powder. It boiled up at once. The patient was
told to stand up. Then he had to jump over the
pot; then he had to jump back again. He then
squatted down at the pot and had to dip his
fingers and lick the medicine off his fingers. He
naturally complained about it being too hot. He
repeated the dipping and licking process, perhaps
ten times, and might have swallowed from half to
one teaspoonful. The next process was the anoint-
ing of his body, arms, legs, face, head, &c. He
had to do it himself, and a most perfunctory anoint-
ing it was. He could not have put on more than
half an ounce of the liquid. '* What next? " '' He
must go to the stream and wash.” ‘‘ Could he not
wash here?” “No, he must go to the stream.”
'" Can we not carry him?” * No, he must walk.”
We went to the stream and he washed. We had to
cross a cutting for irrigation in which the water was
running. ''Could he not wash here?” '' No, it
must be in the river." His washing in the river
was much more thorough than his anointing with
the medicine had been, and we returned to the
house. The ceremony was over. I looked at the
medicine and tasted it before throwing it away. It
was dirty, red, and tasteless, with nearly the whole
of the powder lying at the bottom of the vessel as a
sediment.
“ How often do you do this?" ‘‘ Every four or
five days if the sleep does not go away from his
eyes." “‘ IT want to sce you prepare the medicine:
bring it to-morrow.’
As I am not of the number who can get behind
the native mind, I was surprised when the next
day but one the medicine man turned up with
half a dozen of the common shrubs which he said
was the medicine they gave after the one which had
been given. He was told to proceed. He broke
up the leaves, branches, and roots of the shrubs
and put them into a pot. Along with the shrubs
he put about 10 oz. of water. On the top of this
pot he put another pot, made some clay, and
sealed the connection between them with the clay.
The double pot was put on the fire: the upper one
empty and acting merely as a tight-fitting lid; the
lower one, from which the steam could not escape,
containing the water and medicine.
When the whole of the water had turned to
steam the patient was enveloped completely in a
thick blanket. The double pot was put under the
blanket. The upper one was then removed and the
patient steamed in this way. He was urged to
open his eyes and breathe freely. ‘‘ Woe! woe!”
cried he. And no wonder, for it must have been
painful. I tried the steam and found the odour of
it exaetly like that of hot roasted potatoes.
My faith in the British Pharmacopæia is not
boundless, but in native medicine it is altogether
microscopic. They may have been hoodwinking
me; one never knows. In any ease, I think the
tender mercies of the wicked are cruel.
———— —4Ó—— m
Pellagra.—Grimm, writing on this subject in the
Journal of the American Medical Association, vol.
Ix, No. 10, May 10, 1913, summarizes some facts as
regards the epidemiology of the disease. He states
that as regards :—
Race.—More cases developed among the whites
than among the negroes.
Sex.—More cases occurred among the females of
both races than among the males.
Age.—More cases occurred at ages between 20
and 40 years than at other ages.
Marital Condition.—Among the married and
widowed pellagrins the females predominate; the
single pellagrins are equally divided between the
sexes.
Dates of Onset.—More cases had their onset
during the months of May and June than in other
months, and more in 1911 than in any previous year.
Environment.—More cases developed under con-
ditions of poverty than of comfort, and more under
conditions of comfort than of affluence.
Relationship of Cases.—More cases developed
in the vicinity of other cases than otherwise.
IIcredity.—None of the facts seem to indicate
that pellagra is hereditary.
Food.—The food used by the people in whom
pellagra is prevalent deserves consideration as a
possible etiological factor.
The most promising field for the investigation of
the etiology of pellagra is the food being used by the
people in whom pellagra is developing.
168
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 2, 1918.
Business Rotices.
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T. —The Journal will be issued about the first and fifteenth day
of every month.
THE JOURNAL OF
Tropical Medicine andbhpgiene
JUNE 2, 1913.
THE NECESSITY FOR AN ANNUAL HOLIDAY
FOR FOREIGNERS RESIDENT IN THE
TROPICS.
Uxrin the European goes to the Tropics to take
up work there he has been accustomed to an annual
holiday, it may be for a week or two only, yet it
is a holiday, a period looked forward to with antici-
pation, and when the reality comes it is enjoyed, if
for nothing else than that the routine of the daily
life is broken. A sense of freedom enters into the
pleasure of a holiday, as if man wished to bring
it home to himself that he is not a slave to the
round of custom, nor to the will of his employer.
On reaching the seat of work in the Tropics, how-
ever, the young man finds that an annual holiday
is not the rule, that his first spell of leave may be
five or six years hence, but that then he will have
six, or nine, or even twelve months’ leave. To a
lad of, say, 21, the unrelieved monotony of, say,
a five years’ spell of work is apt to tell on him.
Everything in his environment lends itself to same-
ness. The weather follows an invariable monotony
day after day, be it the wet season, or during the
period when the sun blazes from a cloudless sky
week after week, month after month, until one
comes to object to its rays shining on even one’s
boots. The regularity of the weekly mail from
Europe, the presence of the same companions at
mess, at work, at games, and at every turn, begets
a weariness in the daily round which gradually
enthrals the mind and makes one become more or
less of a machine. The life has its pleasures, no
doubt, especially to men who have experienced the
rough and tumble and uncertainty of city life in a
large European city, but to the inexperienced youth
it becomes intolerable at times and threatens to
cause that indefinite condition known as a
“nervous breakdown." The commonest cause of
a so-called nervous breakdown is, no doubt, all too
frequently excess of alcohol, but a certain propor-
tion is due to anxiety on the part of the head or re-
presentative of a firm, bank, mine, plantation, &c.,
when troubles arise which threaten ruin to himself
or his firm, producing insomnia and all its attendant
evils. The young man, however, whose responsi-
bility is small, is apt to get into a condition alliad
to nostalgia. It is not really the home sickness, the
intense longing, of the mountaineer for his home,
but it is a condition, a '' habit ’’ of mind, brought
about by the monotony of environment which
gradually develops and leads to a want of buoyancy
and joyousness and to a mechanical routine of daily
work devoid of interest. Apart, altogether, from
the likelihood of drifting into alcoholic ways under
such conditions, there is the danger of developing
& frame of mind such as the exile feels, a hope-
lessness and helplessness which amounts at times
to despair. It is true, few allow themselves to
reach this stage or they are prevented doing so
by the doctor or by friends; but no one with experi-
ence of the Tropies is ignorant of such cases, and
there are many who, falling short of the more
serious stages, yet advance far enough to make life
miserable, although they may present a fair face to
the publie. To a man in the condition depicted
there is but one eure, namely, to go home. A local
change to some adjacent district or country is in-
sufficient and practically useless. Unless he has
been home once, that is, to his native place, there
may be an alleviation but no cure for the depressed
frame of mind. The glamour of the home and its
perfections are upon him, and until he goes home
these will not be got rid of. It is one thing setting
out from home with the promise of youth upon
one, it is another returning more or less a failure
and finding that the sympathy of those at home
wears off after a few weeks, and the young man
is often only too glad to return to his work with a
fresh outlook on life.
Without, however, reaching a stage of mental
aberration such as that described above, there is
no doubt that every man working in a tropical
country requires a change if he is to be kept sound
in body and mind. The tether of routine at times
tells upon men, especially in the Tropies, to such
an extent that the mere suggestion of a change is
repudiated, and it may be with difficulty that such
an one can be got to go away at all. The very fact
of such a frame of mind is the best evidence for the
necessity of insisting upon a change being taken;
and the more the man tries to prove the useless-
ness of the move, the more the medical officer is
strengthened in his opinion of the correctness of
his judgment in advising it. To fall into a routine
of work tends to produce a machine-like mind and
not a thoughtful or alert intellect. Men reduced to
mere machines may have their places in the work
of any commercial or Government establishment,
but young men selected for their abilities to go to
the Tropics should not be allowed to run to waste
in this fashion. It is to prevent their becoming
so that a change is necessary and compulsory. The
man will be able to do more work and better work
after being absent from routine for a short spell;
and apart from the service in which he is, there is
the man himself to be thought of, for neither he
June 2, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
169
ee eee a L——
nor his family are calculated to be but mere drones
in the world’s work if allowed to side-track away
from the active work on the main line of the world’s
doings. Some firms known to the writer make pro-
vision for their employees taking a few weeks’
holiday yearly, which in no way interferes with the
long leave which becomes due to them in course of
time. The benefits of this arrangement are apparent
in the whole atmosphere of such firms; their men
are more alert, and there is a feeling of buoyancy
abroad conspicuous by its absence in houses where
the yearly holiday is unknown. The white man in
the Tropics need only take example by the native
servants; they holiday-make to an extent which
their masters and mistresses find annoying, and
their employers profess not to understand their
doing so. We often hear men, both at home
and abroad, who in the position of masters tell their
staff that they never take a holiday, and the juniors
should take example by them if they want to get
on. These men become selfish, develop into mere
machines, and are of little account in the world’s
work and anything but a comfort to their families
or a good example to their employees. But a youth
in the twenties cannot be dealt with as a man in
the fifties without detriment to his mind and body.
A common answer when a man in the Tropics is
advised to go for a few weeks’ holiday is that there
is nowhere to go to. Ina few, a very few, regions
of the earth this may be true, but in 99 per cent.
of instances it is not so; a short sea voyage is often
possible, travel to the hills, to a neighbouring
country—anywhere, in fact, away from the routine
of office and of daily life.
There is no doubt that in many instances too
much is expected of a young man engaged in a busi-
ness house in the Tropies. After a service of, say
two years, the head of his department goes home
on holiday or sick leave, and the responsibility falls
on the young shoulders. All may go well, but if a
crisis arrives in business the inevitable breakdown
follows due to exhaustion from want of sleep, loss
of appetite, mental anxiety, with the result that
the young man is sent home suffering from nervous
breakdown to such an extent that he is terrified to
face the ordeal again, and resigns from an employ-
ment which gave him the one great chance of his
life. The wise master, employer, or head of the
department should be able to detect when his clerk
or assistant has had ‘‘ enough of it." The doctor
can tell the physical state, and may find nothing
crganically wrong, but the employer should keep his
eyes open to the state of the young men, and be
able to detect listlessness, so-called laziness, which
is not really laziness but physical or mental in-
ability to do the work assigned to them. The merci-
ful master will make careful inquiries about his
protégé’s habits, &c., and if satisfactory will see tc
it that he has a holiday at onee—not next year; the
hard task-master will upbraid the youth for his
laziness, eut down his salary, or dismiss him from
his employment; when had he instead insisted on
the youth taking a holiday, both the master and
man would have benefited, J. C.
Abstract,
PHLEBOTOMUS FEVER AND DENGUE.*
By Lieutenant-Colonel C. Birt, M.R.C.S., R.A.M.C.
THE author began by saying that, after an in-
cubation period of from four to seven days,
phlebotomus or sand-fly fever is ushered in with
violent headache, chiefly confined to the forehead
and back of the eyes; pains in the calves of the
legs; discomfort in the epigastrium; and stiffness
of most of the muscles of the body: the face is
deeply flushed and the features are swollen; the
conjunctive are injected; vomiting occurs in a
quarter of the attacks, and diarrhea almost as
frequently, but constipation is noted in the majority
of instances; the temperature rises rapidly to
101° F. to 108° F., and falls gradually to the normal
level on the third or fourth day; the pulse remains
slow throughout the illness; leucopenia, with a
relative decrease in the polymorphonuclears, is an
almost constant sign; there is considerable debility
during convalescence; in an epidemic, more than 90
per cent. of the cases are first attacks, hence a high
degree of immunity is afforded after recovery. A
historical account of the disease is then given.
In the year 1908 Doerr announced the results of
his experiments on the infectivity of the blood of
the Dalmatian summer fever, and on the mode of
the transmission of the virus by the phlebotomus.
Since then the closely related ailments in Malta
have been investigated in a similar manner.
Tedeschi and Napolitani have made a similar inquiry
into the nature of the Italian ‘‘ summer influenza,”
and Kilroy has put to the test of experiment the
causation of the fever as it occurs in Crete.
On combining the successful experimental results,
it is found that :—
(1) The subeutaneous injection of blood or serum
withdrawn during the first twenty-four hours of the
patient's illness causes the disease.
(2) Inoeulation with the filtrate obtained by pass-
ing the diluted blood through a porcelain candle
which retains the Micrococcus melitensis also
excites the disease.
(3) Feeding experiments with infected sand-flies
have been successful on twenty-one occasions.
This evidence is sufficient to show that the fever
is specific, and that it is caused by a filter-passing
virus, which circulates in the blood during the first
day of the illness, and that it is conveyed by the
phlebotomus.
A phlebotomus when examined with the aid of a
pocket lens is immediately recognized by its form
and its very thick hairy coating, which obscures all
the fine details of its structure. On removal of this
dense clothing, slender microscopical differences
may be observed in the venation of the wings, the
length of the segments of the palps, the number and
arrangement of the bristles or spines on the claspers,
* A paper read before the Society of Tropical Medicine and
Hygiene, May 16, 1913. i
170
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 2, 1913.
&e., on which entomologists base a classification,
but up to the present there has been little agree-
ment amongst them; a species has been given more
than one name, not only by different entomologists,
but sometimes by the same.
Grassi has studied the life-history of the phle-
botomus in Italy, and Marett in Malta. It breeds
in caves, crannies of walls, and among heaps of
stones. The eggs hatch in six to nine days after
being laid; the larval stage lasts about eight weeks,
and as pupe they exist fixed in crevices in fragments
of stone for a fortnight. These flies survive in cap-
tivity about ten days only, hence great difficulties
are encountered in tracing their history. The
phlebotomus is widely scattered throughout the
tropical and sub-tropical world, and sand-fly fever
is almost as broadly expanded.
Dengue breaks out in epidemics which are far
more explosive in character than are those of sand-
fly fever. The infection courses swiftly through a
community, until almost all susceptible people have
been attacked. In a few weeks its energy is ex-
pended. The rashes which occur in about 70 per
cent. of the cases, and the greater severity of the
pains, differentiate it from sand-fly fever.
Both infections may occur in the same locality.
At Aden, in 1898, the summer outbreak of phle-
botomus fever was followed by one of dengue in the
autumn. No immunity was afforded by the former
infection against the latter; whole families were
seized; papular or urticarial rashes broke out in most
cases. Colonel Birt was himself attacked at this
time, and in his case joint pains were severe—much
more so than in phlebotomus fever—and the initial
rash was accompanied with itching of the palms and
soles. Dengue has often visited Aden, and is well
known to the native inhabitants, who call it ** father
of the knees.”’
In Gibraltar and Malta dengue has appeared
among the troops in the autumn at the end of the
sand-tly fever epidemic. The occurrence of rashes
and breakbone pains, it is stated, were prominent
symptoms, hence there was no confusion in deter-
mining the infections.
In Greece, Aravandinos say that dengue arises
every few years in epidemic form along the coast,
and that it can be distinguished readily from sand-
fly fever, to which visitors to Greece are liable.
Many excellent accounts of dengue have been
published, notably by Sandwith in Egypt, and by
Bassett-Smith in Bombay. There is considerable
variety in the character of the symptoms observed
in the various epidemics. Bassett-Smith noted the
absence of severe bone and joint pains, and of
enlarged lymph glands. In an outbreak reported
by Beveridge, in Natal, many of the cases of which
were seen by Colonel Birt, swelling of the lymphatic
glands was noted in 99 per cent. of the 325 cases,
along with the classical signs and symptoms of the
infeetion.
Aberrant eases of dengue, and they occur in every
epidemie, closely resemble sand-fly fever. After a
similar incubation period there is the same intense
frontal headache, flushed face, injected and tender
eyes, pains in the body and limbs, slow pulse, and
leucopenia. Stitt found that the average white
blood count in 100 cases of dengue was 3,200 per
cubic millimetre. Moreover, the late eosinophilia
observed by Balfour in Khartoum, by Harnett in
Caleutta, and by others, also occurs in sand-fly
fever, so that the infections cannot be separated by
mieroscopical examination of the blood.
Graham, of Beyrout, was the first to investigate
dengue experimentally. After feeding Culex fati-
g«ns on dengue patients, he caused them to bite
susceptible people residing in places where the
disease was absent. He thus transmitted the in-
fection to six persons. He also induced the disease
by inoculating a man with an emulsion of the
sulivary glands of an infected eulex.
In 1900 Ashburn and Craig ascertained that the
blood of dengue patients was infective, and that
the virus passed through a filter which was imper-
vious to the Micrococcus melitensis.
Summarizing suecessful experiments, one finds:—
Inoculation with the blood of dengue sufferers
caused dengue eight times.
Inoculation with filtered infective blood induced
the disease twice.
Inoculation with the salivary glands of an infected
culex gave rise to dengue once.
Infection has been conveyed by infected culices
eight times.
Infection has been conveyed by infected stegomyia
once.
There are considerable differences in the infec-
tivity of the virus in sand-tly fever and dengue.
Blood extracted after the first twenty-four hours in
the course of sand-fly fever no longer can excite the
disease. It has failed to do so in every attempt
(five experiments made). The blood of dengue
patients with which the successful inoculations were
performed was drawn off on the second to the fifth
days of the disease.
Whereas phlebotomi are not capable of transmit-
ting sand-fly fever until six days after feeding on a
sand-fly fever patient who is in the first day of his
illness, dengue has been conveyed by mosquitoes
immediately after their meal of dengue blood ; never-
theless, the virus survives in them, for they have
conveyed the disease eight to twenty-seven days
after feeding on a dengue sufferer.
Graham protected families from dengue by means
of mosquito curtains. E. H. Ross extinguishel
epidemies of dengue which had been of yearly occur-
rence in Port Said by exterminating mosquitoes.
Evidence is accumulating that the Stegomyia is
an agent in the propagation of dengue. Legendre
concludes from a study of an extensive epidemic of
dengue at Hanoi in 1910 that this mosquito was
the responsible veetor, since the outbreak was coin-
cident with a great increase in their numbers, while
other species were few.
There is a close resemblance between dengue,
sand-tly, and yellow fever infections; they are all
caused by some virus which circulates in the blood,
and is capable of passing through a filter which
retains bacteria; the onset of the fever is similar in
June 2, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
171
many instances, and during the first forty-eight
hours of the illness it may be impossible to distin-
guish between the infections; even later a diagnosis
on clinieal grounds may be unattainable, for atypical
cases of dengue and yellow fever may bear every
likeness to phlebotomus fever. Hence, too, great
stress should not be laid on the symptoms of in-
dividual patients during the course of an epidemic;
it is the general type of case which will give the
name to the outbreak.
Colonel Birt concluded his very interesting paper
with the following statement :—
" Dengue, phlebotomus, and yellow fevers are
caused by distinet but closely related kinds of virus.
'* A fever lasting several days in which the exam-
ination of the blood for parasites, by culture, an]
by serum tests, is negative; characterized by slow
pulse, leucopenia, and relative polynuclear decrease ;
occurring in a locality where mosquitoes are numer-
ous, should be attributed to a virus carried by these
flies, although some of the symptoms significant of
dengue or yellow fever may be wanting.”
——— —4»——————
Aunotations.
Human Botryomycosis.—Opie, in the Archives of
Internal Medicine (vol. ii, No. 4, April 15, 1913),
describes a case of human botryomycosis of the
liver. Botryomycosis in man, he states, was first
deseribed by Poncet and Dor. On the hand of a
woman near the digito-palmar fold of the little
finger an indolent red spot ulcerated and gave place
to a pecluneulated tumour the size of a small nut.
In sections of the tumour they found the masses
of coccus-like bodies to which Bollinger gave the
name Botryomyces, and by personal observation
convinced themselves of the identity of the bodies
they observed with those found in the fungus-like
growths from the spermatic cord of geldings. Poncet
and Dor have perhaps diminished for subsequent
observers the value of these bodies as criteria for
the identification of botryomycosis by the inter-
pretation which they have offered. They have
maintained the untenable view, wholly unsupported
by the baeteriologists who have studied botryo-
mycosis, that the peculiar bodies are not micro-
organisms, but products of the degeneration of
tissue cells. They regard the coccus-like bodies as
pyknotie nuclei. From the lesion Poncet and Dor
isolated a staphylococcus, which, inoculated into the
udder of an ass, produced a small pedunculated
growth. No examination of the nodule was made.
Poncet and Dor have described as botryomycosis
three small pedunculated growths, two being on the
hand and one on the most prominent point of the
stump formed by amputation of the arm at the
shoulder.
Faber and Ten Siethoff have described a group
of little nodules on the border of the eyelid occurring
at the site of stye in a boy who had tended a horse
suffering with a fungoid growth from the cut
spermatic cord. In the viscid pus squeezed from
the lesion were mulberry-like masses with the
structure of those which occur in the horse. Pedun-
culated tumours containing similar bodies have been
observed in France by Sabrazes and Laubie (in one
case on the auricle, in a second on the palm of the
hand), and by Delore and Gauthier (in one case
above the eyebrow, in a second on the finger).
Similar observations have been made in Switzer-
land; Reverdin and Gulliard have described a
pedunculated tumour the size of a pea on the palm
of the hand, and Galli-Valerio has seen a nodule
of similar size and shape on the anterior surface of
the fore-arm.
The disease is apparently much more common in
northern Africa than in Europe, and French phy-
sicians living in Algeria have described in consider-
able number instances of a similar but much more
severe disease. Brault has described two cases in
which small peduneulated tumours containing the
characteristically grouped micro-organism have
occurred on the fingers of women in Algeria.
Legrain has described a considerable number of
cases of botryomycosis. Attached to the dorsal
surface of the right hand of a Berber woman he
found a tumour the size of her fist; it consisted
of five masses each pedunculated and the whole
attached by a narrow base. A tumour in another
Berber woman made its appearance on the stump
of a finger accidentally amputated, and attained the
size of a large mandarin. It was removed, but
reappeared, forming a mass larger than before;
the growth did not invade the underlying muscles
or tendons. In a subsequent publication, Legrain
described other growths on exposed surfaces,
the largest of which was the size of a child's
head. Somewhat similar observations have been
made by Archibald on material sent to him
from various parts of the Sudan; seven growths
removed from the scalp, breast, arm, hand, foot
or cheek of natives contained agglomerations of
coccus-like micro-organisms identical with those
peculiar to botryomycosis. The same bodies had
been previously observed by a member of the
laboratory staff in a growth removed from a camel.
In one instance the lesion occurred in a native
woman, aged 45, who had suffered with a swell-
ing of the breast since childhood; it implieated
the entire breast, resembled a fungoid cancer and
exuded greyish-white pus from numerous sinuses.
In another case a tumour of the scalp implicated
the underlying bone and from sinuses on the surface
thin, pus-containing yellow granules escaped.
Butler and Welsh, in New South Wales, found
à swelling outside of the left orbit eausing softening
of the temporal bone in a child aged 4. The
scant viscid pus contained numerous yellow granules
which consisted of masses of cocci. In a Japanese
Kayser and Gryns found the right foot swollen and
riddled with sinuses from whieh matter escaped
containing botryomyeotie granules.
Cases of pseudo-botryomyeosis have also been
deseribed. The author's summary of the subject,
including the ease seen by himself, is as follows ;—
172
'' Bacteriological examinations indicate that the
disease of horses, cattle and swine known as
botryomycosis is caused by a micro-organism
resembling Staphylococcus pyogenes aureus, but
characterized by the formation of compact colonies
held together by a homogeneous material which
forms a kind of capsule. About these colonies or
granules which are formed only in the tissues there
is suppuration and tissue formation producing a
lesion which has all the characters of the infectious
granulomata.
“ Human botryomyocosis has been observed most
frequently in tropical or subtropical countries, such
as Algeria, the Sudan, Australia and Java. It has
been observed in France and Switzerland, but here-
tofore has not been observed in the United States.
‘“ The disease in man affects exposed surfaces such
as the hands or face, and has repeatedly followed
injuries of infected parts. Pedunculated masses of
considerable size may be formed. They consist of
newly formed fibrous tissue in which are foci of
suppuration and sinuses opening on the surface.
The peculiar botryomycotic granules are always
present.
'* Small pedunculated growths having the structure
of exuberant granulation tissue have frequently been
described as botryomycosis, although the micro-
organism peculiar to the disease has not been dis-
covered in the lesion. There is no demonstrable
relation between these growths, which have been
designated granuloma pyogenicum, telangiectatie
granuloma or pseudo-botryomycosis, and botryo-
mycosis as it occurs in man and lower animals.
"The case which has been described represents,
as far as the author has been able to determine, the
first instance of the disease described in the United
States, and is, it seems, the first instance in which
it has affected an internal organ. The disease
has attacked a child aged 11. A massive lesion
replaces almost the entire liver and consists of
fibrous tissue and foci of suppuration within which
occur botryomycotie granules in large number. It
is not improbable that some peculiar mode of infec-
tion explains the unusual situation of the lesion.
The child received milk from several cows, one of
whieh died with a wasting disease, but no more
definite history can be obtained. Botrvomveosis
has been observed in domestic animals in Missouri,
where the human instance of the disease occurred.”
The Endemicity of Yellow Fever.—Dr. Juan
Guiteras has decided upon the reproduction of an
old paper*, published by himself in 1888 (Annual
Report of the Supervising Surgeon-General of the
Marine Hospital Service), because it contains matter
that is serviceable for the present study of the
epidemiology of yellow fever, and also hee
opinions of the author are frequently
reference to this, his first paper o
paper which is rather inace
readers,
cause the
quoted without
T on the subject, a
essible to-day to most
* “ Sanidad y Beneficencia,” Deana hee; 1919.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 2, 1913.
As will be seen in the reading of the paper the
author was by no means the first to state that
the children of endemie areas were susceptible to
yellow fever; but he believes he was the first to
insist upon tlie importance of this class of cases, as
well as of others of benign character, in maintain-
ing the endemicity of the disease.
At the present time, the investigations as to the
endemicity in the West Coast of Afriea, and in
Yucatan, revive the interest in these studies, and
the apparition of fresh outbreaks, not clearly
traceable to foreign importation, is giving rise, here
and there, to a tendency to seek for other explana-
tions of the epidemie phenomena than those that
logically derive from the work of Dr. Finlay, of the
American Army Commission, of the present author,
the United States Marine Hospital Service, the
French Commission to Brazil, and others who con-
tributed to the building up of the new doctrine of
the mosquito transmission of yellow fever.
Some authors are suggesting, for instance, the
necessity of admitting the existence of another
intermediary host, beside the mosquito and man,
which might act as a storehouse of the endemie
infeetion in the intervals between the outbreaks.
Others suggest the possibility of the existence of
chronic parasite carriers to explain the continuance
and perpetuity of the infection. In this connec-
tion Guiteras finds that recent investigators are
inelined to ignore the data we possess as to the
acquired immunity against yellow fever, and to
maintain that frequent infections in the same
individual are by no means rare.
Seidelin, of the Liverpool School of Tropical
Medicine, believes he has discovered the parasite of
yellow fever, but finds some degree of incompati-
bility between the manifestations of his parasite
and the generally accepted facts in the epidemio-
logy of the disease. Others such as sanitary
officers who, either for want of the adequate means,
or for the lack of the proper attention to details, or
because of the existence of insurmountable local
obstacles to the success of their anti-yellow fever
campaigns, or because of the lack of confidence in the
means now universally recommended, also have
tried to throw doubt upon the generally accepted
views of the etiology. They have failed to obtain
the success that has signalized the work in Cuba,
in Panama, in Rio and in Veracruz, the four foci
where the infection was most intense, and where
it should have been more difficult to eradicate it.
The ideas suggested by these observers Guiteras
thinks are purely hypothetical, they lack demon-
stration, and in his opinion are not at all required
for the explanation of the epidemiological pheno-
mena.
He himself was always of opinion that the funda-
mental errors in the appreciation or interpretation
of these phenomena proceeded from a lack of
experience with the two phases of yellow fever
epidemiology : the phase that one may call endemic,
and the phase presented in the epidemic manifes-
tations. It appears to him that the recent investi-
gators of the disease are restricting themselves to
June 2, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
178
the viewpoint of tropical physicians of the past
century, and that they are not sufficiently con-
sidering the experience acquired in the great
migrations of the disease from its primitive foci.
It is well to remember the prejudices that blinded
workers in Cuba with respect to these epidemic
manifestations outside of the Tropics. Guiteras
remembers well that in 1887, at the time when the
Key West epidemic he describes in his paper was
developing, he visited Havana for a few days.
Upon stating his experience us to the large number
of children affected, both of Cuban and American
parentage, he was told by two of the most
prominent practitioners of Havana that the disease
could not be yellow fever, since this affection was
extremely rare in childhood.
Upholding the same opinions that he maintained
in his 1888 paper, he wrote the article on yellow
fever in Keating’s Encyclopedia of Children’s
Diseases, 1889, and in 1894 he published in the
Crónica Médico Quirürgica de la Habana a study of
the infantile mortality in the city of Matanzas,
showing that it was subject to the same reactions,
with respect to yellow fever, as the infantile popu-
lation of Key West.
Guiteras is perfectly correct in his contention,
that workers of the present day are very apt to
ignore the past literature of the subjects they are
working upon. There has been much of this of
late, with, in many instances, somewhat disastrous
results. Such offenders will now have the chance
of reading Guiteras’s paper in the original.
The Health of the Canal Zone.—Gorgas, in sub-
mitting his report for the month of March, 1918,
states that the total number of deaths from all
causes among employees was 82, divided as follows.
Disease 19, and violence 13, giving the annual
average per thousand of 4.05 and 2.77 respectively.
Among employees for the month of March of each
year the annual average death:rate per thousand
was as follows :—
DATE Toran DISEASE
1905 12.27 os z —
1906 37.44 35.05
1907 40.23 36.28
` 1908 12.47 9.42
1909 8.76 6.84
1910 8.91 CAES T 5.39
1911 10.76 Pert ee 6.76
1912 8.45 en 6.57
1913 6.82 ^ 4.05
The annual average death-rate per thousand in
the cities of Panama and Colon and the Canal Zone,
ineluding both employees and civil population, for
the month of March of each year was as follows:
1905, 36.51; 1906, 46.72; 1907, 32.32; 1908, 20.67;
1909, 17.07; 1910, 18.33; 1911, 22.22; 1912, 14.67;
1913, 19.32.
In segregating according to race, the annual
average death-rate per thousand from disease among
employees was: For whites 2.79, and for blacks 4.48,
giving a general average for disease of 4.05. For
the same month during 1911, the annual average
death-rate per thousand from disease among whites
was 3.88, and blacks 7.76, giving a general average
of 6.76; and in 1912 from disease among whites
2.75, and blacks 7.90, giving a general average of
6.57.
Among employees during the month, deaths from
the principal diseases were as’ follows: Duodenal
ulcer, 2; lobar pneumonia, 3; tuberculosis, 7; ulcer
of stomach, 1; leaving 6 deaths from all other
diseases, and 13 deaths from external violence.
No cases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus during
the month.
On a Hitherto Unknown Cause of Disease in Man.
—In a paper in the Centralbl. f. Bakt., of March 15,
1913, Dr. O. L. E. de Raadt describes a [parasite
which he found in smears of the spleen of a soldier
who died of a febrile malady which resembled in
some ways malaria and typhoid fever. The liver
was palpable, but the spleen extended to three
fingers' breadth below the costal margin. No
parasites were found in the peripheral blood, but in
Giemsa-stained smears made from the spleen
numerous blue ring- or bean-shaped structures were
seen both in the red and white cells and also free.
The largest of these had a diameter of 3 microns,
and each had a comparatively large vacuole. The
curious feature of this parasite, for the structures
are supposed to be of this nature, is that prolonged
staining with Giemsa for twenty-four hours does not
bring out any nucleus, so that there can be no
question of the structures being malarial rings.
Reproduction appears to take place by simple
division and by budding, which latter feature,
together with its Gram positive staining reactions,
suggests that the organism is related to the yeasts.
The author has encountered the same organism in
the spleen smears from two cases from Java, but
only in small numbers, so that he was led to
believe the organism to be harmless. However,
the present case which is from Borneo contained
such large numbers that he is convinced of its
pathogenic nature, and suggests for the organism
the name Ovoplasma anucleatum.
Spirochetosis.—In his first lecture in the Herter
Foundation (Bulletin of Johns Hopkins Hospital,
February, 1913), Professor George H. F. Nuttall re-
views in a most interesting manner the present state
of our knowledge of the diseases included under the
name spirochetosis. Special attention is paid to the
transmission by blood-sucking arthropoda. Spiro-
chetes in birds were first discovered by Sacharoff in
geese in the Transcaucasus in 1891, while Marchoux
and Salimbene (1903) observed a similar disease in
fowls in Brazil, a disease which is now known to
occur in South-Eastern Europe, Asia, Africa, South
America, and Australia, and in all places where it
exists it is transmitted by the tick Argas persicus
174
as Marchoux and Salimbene first demonstrated.
Professor Nuttall believes that Sacharoff’s original
spirochete of geese, and called by him Sp. anserina,
is identical with the Sp. gallinarum. The mortality
in fowls varies from 40 to 100 per cent., and death
takes place in anywhere from three to fifteen days.
As regards the development of the spirochete in
Argas persicus, it is pointed out that the ticks are
best rendered infective by maintaining them at a
temperature of 309 to 359 C. after feeding on
infected blood. If kept at a low temperature, 159
to 189 C., the spiroeh:ete disappears very quickly
from the alimentary tract, and the tick may bite
repeatedly without producing infection. They may,
however, be rendered infective after three montlis
by placing them again at 309 to 359 C., when spiro-
chetes reappear in the eclomic fluid. After being
taken up by the tick à certain number of the spiro-
chetes degenerate, whilst others pass into the
eclomie cavity, where again some perish. The
survivors then penetrate the various organs, especi-
ally the cells of the Malpighian tubules and sexual
organs, in which they break up into a large number
of small particles, coccoid bodies, which multiply
by fusion, and give rise to large agglomerations.
The coccoid bodies may also be found in the lumen
of the gut and Malpighian tubules, and in the
excreta. In the act of feeding the tick occasionally
voids excrement, which is diluted with fluid from
the coxal glands, and thus helped into the wound
inflicted by the bite of the tick. Infection may
take place without any escape of fluid from the
coxal glands.
infection is transmitted hereditarily from one tick
to another. Another species of Argas (A. reflexus)
is also able to transmit the fowl spirochete.
In reference to human relapsing fever in Africa
mention is made of the fact that Dutton and Todd
were the first in 1905 to show that transmission
was effected by the tick Ornithodorus moubata,
which also passed on the infection through the egg
to the succeeding generation. A tick may remain
infective for eighteen months or more after its
initial infective meal of blood, as proved by Möller,
who has also shown that infection may be trans-
mitted hereditarily to the third generation of tick
when the ticks are fed throughout the ex-
periment on clean animals. Manteufel (1910)
has shown that ticks may acquire an immunity
to spirochetal infection, so that only a small
percentage of any batch will become infective.
In the tick Ornithodorus moubata, according to
Leishman, the spirochetes invade the tissues
and break up into granules. The gut with
its contents, the Malpighian tubes, the sexual
organs, and the excrement are infective when
injected into susceptible animals, while the coxal
secretion is always and the salivary glands nearly
always negative. After ingestion the spirochetes
disappear in nine to ten days, but reappear if the
tick is placed at 359 C., when they are to be found
in the cælomic fluid. Ornithodorus savignyi has
been shown by Brumpt to convey the human spiro-
chete of Abyssinia, while O. turicata is suspected in
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
By means of the coccoid bodies |
(June 2, 1913.
Columbia, O. talaje in Mexico and Central America,
and O. tholozani in India (Quetta). Further,
Sergent and Foley have shown that the Argas per-
sicus may transmit the human spirochete.
The author points out that the various names
given to spirochetes of human origin in different
parts of the world cannot be regarded as valid, for
virulence and immunity reactions are not adequate
tests of specificity. O. moubata has served for the
transmission not only of S. duttoni and two other
so-called species, S. recurrentis and S. novyi, which
affect man in the Old and New World respectively,
but it has also been found to transmit the fowl
spirochete. | S. duttoni has, moreover, been
successfully transmitted to rats by the rat-louse
Hamatopinus spinulosus. The author sums up
this part of the lecture by stating that ‘‘ There is
every reason to suppose that a spirochwte capable `
of adapting itself either to a tropical African tick or
to a rat-louse occurring all over the world, will be
able to accommodate itself to a variety of human
hosts."
As regards the transmission of relapsing fever by
bed-bugs, the author records an experiment of his
own whereby thirty-five bugs were transferred
directly from an infected to an uninfected mouse
which thus became infected. It is therefore con-
cluded that bugs can occasionally transmit relapsing
fever. As regards lice the most convincing results
are those of Nicolle, Blaizot, and Conseil (1912).
These observers found that the spirochetes dis-
appear from the gut of the lice five or six hours
after the feed, and none are to be discovered micro-
scopieally in twenty-four hours. After eight to
twelve days active spirochetes reappear, at first
short forms, but afterwards forms like those seen
in the blood. Monkeys inoculated with the con-
tents of lice crushed on the fifteenth day after the
infective feed become infected. In man infection
takes place by the infected lice being crushed on
the excoriated skin, and smeared in by the fingers,
or even by the transference of such infective
material to the conjunctiva on the fingers. These
authors proved, moreover, that the spirochetes are
transmitted hereditarily to the offspring of the lice,
for they found that eggs laid twelve to twenty days
after the infection of the parent lice contained
spirochetes. The crushed eggs were infective to
monkeys. These fucts refer to both Pediculus vesti-
menti and P. capitis, which appear to be the ordinary
vectors in most parts of the world. Some interest-
ing original observations of Mr. Cecil Warburton
on the biology of the lice infesting man are
described by the author.
Reference is made to the transmission of the
African cattle spirochwete (Sp. theileri) by the tick
Boophilus decoloratus, which again is able to trans-
mit the infection to its offspring. The spirochetes
oceasionally found in horses and sheep are probably
Sp. theileri.
According to Nicolle and Comte bats in North
Africa suffer from typical relapsing fever due to
S. vespertilionis, which may be conveyed by
several of the ectoparasites of the bats.
June 2, 1913.]
IHE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
175
Reference is made to the important discovery by
Noguchi (August, 1912) of a means of cultivation of
the blood spirochetes in sterile hydrocele, or ascitic
flud containing a piece of freshly excised rabbit's
kidney.
In summing up, the author remarks that spiro-
chetes are not specialized parasites. Infection
may take place through the skin through a mucous
membrane to which the spirochetes gain access by
being deposited therein in the arthropod's dejecta,
or by an infected individual scratching or rubbing
himself with hands which have become contami-
nated with the contents of the vermin which they
have crushed.
Transmission of Trypanosomes.—Mitzmain con-
tributes a most interesting paper to The Philippine
Journal of Science (B. The Philippine Journal of
Tropical Medicine), vol. vii, December, 1912, No. 5,
on ** The Role of Siomerys calcitrans in the Trans-
mission of Trypanosoma evansi.’’ This, of course,
is a most important subject, and the author's careful
observations ought to be closely studied. Many
interesting experiments were done, and a series of
photographs show how the flies were applied to the
different animals. These methods should prove
useful in dealing with other biting flies.
The conclusions which the author reaches at the
end of his paper are as follows :—
(1) Only negative results were obtained in the
attempts at direct mechanical transmission of surra
with flies which were induced to bite healthy animals
at intervals ranging from five minutes to three days
after being permitted to complete the feeding upon
infected animals. Thousands of Stomozys calci-
irans were employed in twenty-nine experiments
involving the use of three horses, six monkeys, and
twenty-two guinea-pigs.
(2) Twenty-seven experiments were performed in
attempts to transmit surra by the interrupted
method of feeding. All attempts proved negative
where a single application of a varying number of
flies was used, as many as thirty-eight on a horse,
and a maximum of forty on a small guinea-pig.
The intervals between feeding on infected and
healthy animals averaged twenty-five to forty
seconds in the two instances cited.
(3) In three trials interrupted feeding was
employed in successive daily applications. In
attempting to determine the minimum number of
bites necessary to infect an animal, as high as forty
were followed by negative results. The only positive
result obtained was produced from a succession of
206 interrupted bites in which the flies were trans-
ferred immediately from the infected to the clean
animal. The flies were applied thirty-two hours
during a period of six days.
(4) The results of these experiments indicate that
Trypanosoma evansi does not develop in the body
of Stomozys calcitrans. Ninety-four days was the
longest period in which laboratory-bred flies were
tested for a cyclical development, and sixty-seven
days the maximum for wild flies.
(5) Organisms of surra were not found in
Stomozys calcitrans beyond eighteen hours after
feeding on an infected animal, and the limit for
infection by inoculation was ascertained in these
experiments to be six hours.
(6) Pathogenie trypanosomes were found in the
proboscis of the fly thirty seconds after feeding on
infected blood. Within one minute and thirty
seconds the organisms were not present in the
mouth parts in a form capable of infecting by inocu-
lation into guinea-pigs.
(7) The wounds made by the labium of Stomoxys
were not found to be a suitable channel for infection.
Consequently it is not likely that surra in domestic
animals is produced through this avenue by external
contamination, namely, fæces, mouth parts, and
pulvilli of infected flies.
(8) The intimate relation in the feeding habits of
Stomoxys and of house-flies has been pointed out.
Stomorys has been demonstrated to provide through
its bites the infection of Musca domestica and other
dung flies. These flies have been demonstrated to
act as carriers, harbouring the surra organisms for
several hours.
(9) No evidence was obtained to indicate that
T. evansi is hereditarily transmitted to the off-
spring of S. calcitrans. The larva of this fly fed on
surra blood does not continue to harbour th»
trypanosome and the fly is '* clean ’’ upon reaching
maturity.
(10) It is demonstrated that the individual glass:
tube method is the most suitable for applying flies
in feeding on experimental animals and for keeping
flies for long periods under laboratory conditions.
These experiments indicate that the Stomozys
calcitrans is not the transmitter of surra. If it is
not, then what fly does transmit it? The answer
to this will probably be found in one or other species
of the Tabanide.
Health in the Philippine Islands.—Heiser, in his
quarterly report of the Bureau of Health for the
Philippine Islands (Fourth Quarter, 1912), states,
as regards typhoid fever, that while not so specta-
cular, nor the cause of great public alarm, yet the
constant increase in the number of cases of typhoid
fever over a wide area of the Philippines is a
greater menace than the outbreaks of cholera with
which the islands had to deal some years ago.
Active steps are being taken to educate the public
with regard to the seriousness of this disease and
the manner in which it may be avoided, and the
steps which should be taken to prevent its spread.
Blood examinations made of persons reported ill
with fever show that the disease prevails exten-
sively in Pampanga, Bulacan, Tarlac, Pangasinan,
Union, and the lowland sections of the Mountain
Province. He asks physicians to send to his office
blood samples in the case of any continued fever
that lasts over a week, in order that proper labora-
tory tests may be made to establish a diagnosis.
Plague.
The measures against plague described in the
previous quarterly report were continued, but it
176
was deemed advisable to augment largely the force
of men employed to carry out general cleansing,
rat proofing and rat catching. The sanitary
engineering division has issued many orders to
abate nuisances with regard to rat runs. Particular
attention is given to making new constructions rat
proof. Hollow walls, ceilings, floors, &c., are
forbidden.
During the latter part of December opportunities
presented themselves in Manila for placing guinea-
pigs in houses in which plague had occurred, and
in two instances these test animals contracted the
disease.
No further cases of plague have occurred in Iloilo
since September 17, 1912. In all, there were nine
cases, with nine deaths. The fact that all of these
cases were confined to two houses, and that a
rat-catching campaign extending over a period of
three months failed to reveal any infection among
rodents, somewhat supports the theory that perhaps
this outbreak of plague may have been introduced
into Iloilo by means of bed-bugs.
Bacillary Dysentery.
During the early weeks of October there was a
marked diminution in the number of cases of this
disease, and only a few scattered cases are now
being reported. The apparent seasonal prevalence
of this disease during the past few years has been
most marked, which fact would seem to hold forth
the hope that further advances in the study of its
etiology may result in better methods for preventing
its spread.
Segregation of Lepers.
During the quarter 284 lepers were collected from
the Provinces of Zambales, La Union, Mountain,
Ilocos Norte and Ilocos Sur, Cagayan, Isabela,
Tayabas, Ambos Camarines and Albay, Sorsogon,
Samar, Leyte, Surigao, Agusan, Misamis, Moro,
Cebu, Bohol, Romblon, Mindoro, Occidental Negros
and Oriental Negros, Iloilo, Capiz, Antique, and
Palawan. It is interesting to observe that a more
careful survey made of the more remote sections of
the Island of Palawan shows that the belief here-
tofore entertained, that no lepers were present
there, is erroneous. Three persons were actually
transferred to Culion, and there is reliable evidence
to show that a number of others are still at large.
With a few isolated exceptions, it is believed that
all cases of leprosy recognizable as such are now
in confinement, but as the incubation period of the
disease is a prolonged one, it is very likely that
many additional cases will come to light in the near
future.
———— S —————
Hotes and Aews.
THE SOCIETY OF TROPICAL MEDICINE AND
HYGIENE.
Ar a meeting of the Society of Tropical Medicine
and Hygiene, held at 11, Chandos Street, Cavendish
Square, London, W., on Friday, May 16, 1913, the
following gentlemen were elected Fellows :—
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 2, 1918.
J. G. Becker, M.B., Transvaal.
Arthur D. Clanchy, L.R.C.P. and S.I., Dublin.
Charles Forsyth, M.D., F.R.C.8., Hong Kong.
E. Humphry, M.H.C.S., Townsville, Australia.
Oswald E. Jackson, M.B., South Rhodesia.
Lucius Nicholls, M.B., East Africa.
W. B. Nisbet, M.B., Townsville, Australia.
E. Olubomi-Beckley, L.R.C.P. and 5. Edin.,
Sierra Leone.
Henry Priestley, M.B., Townsville, Australia.
Fred. D. Walker, M.B., Bolivian Survey Com-
mission.
W. A. Young, M.B., Forfar.
GORDON MEMORIAL COLLEGE, KHARTOUM.
Marcu, 1913.
Dr. ANpREW BALFOUR begs to inform his friends
and correspondents that, having been appointed
Director-in-Chief of the new Wellcome Bureau of
Scientific Research with headquarters in London,
he is leaving the Sudan early in May. Dr. A. J.
Chalmers, D.P.H., late of Ceylon, will succeed
him as Director of the Wellcome Tropical Research
Laboratories at Khartoum. From May, 1913, until
further notice Dr. Balfour's address will be: Wood-
cote, Churt, Surrey, England.
e
Recent and Current Literature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JOURNAL OF TROPICAL MEDICINE AND
HyariENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
“Boston Medical and Surgical Journal,” May 8, 1913.
Infantile Beriberi. —Gregg states that infantile beriberi in
the Philippines is a nutritional disease which occurs among
native breast-fed infants. 1t causes about 25 per cent. of
the total native mortality in the city of Manila. He
believes that it is due to the absence of some as yet un-
known nutritional substance in the breast milk of the
nursing mother, and states that it has been successfully
treated by the giving of an extract of rice polishings, whic
is believed to supply the nutritional substance absent in the
mother’s milk.
In the Philippines, where babies are almost always of
necessity breast-fed, the reduction of the infantile mortality
is dependent, even more than in other countries, upon the
care and proper nourishment of the nursing mother.
Rotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly,
4.—Authors desiring reprints of their communications to the
JouRNAL OF TROPICAL MEDICINE AND HYGIENE shouid com-
municate with the Publisners.
5.— Oorrespondents should look for repi.es under the heading
** Answers to Correspondents.”
June 16, 1913;] THE. JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 12, Vol. XVI.
Original Communications.
A REVIEW OF A CLINICAL STUDY OF
MALARIAL FEVER IN PANAMA.
By Jonn PevHam Bares, M.D,
Ancon, Canal Zone, Panama, `
II.
SYMPTOMS AND THE DIFFERENTIAL DIAGNOSIS
OF MALARIAL FEVER.
IT seems at first thought superfluous to dor
take at this late date a discussion of the symptoms
or the differential diagnosis of malaria
ordinary clinical study. But as I undertook to show
in a previous paper that certain other diseases and
their symptoms must have been included in the
general descriptions of malarial fever, it follows as a
logical sequence that I must hold some views in
consonance with the general spirit of that paper
with regard to the symptoms of an uncomplicated
malaria, and also its diagnosis. Therefore, this
review could not be complete without some expres-
sion of those views. Moreover, the character of the
first paper precluded a discussion of the differential
diagnosis of malaria from other diseases, even those
diseases alluded to in that paper.
The nomenclature of the different varieties of
malaria is not very satisfactory. The names tertian
and quartan answer the purpose well enough when
these two fevers pursue their normal course, but
they do not always do so. In the presence of
multiple generations of parasites both of these fevers
change their characteristic febrile curve; in the
former it. becomes a quotidian fever, in the latter it
becomes either a subtertian fever or a quotidian fever,
depending of course on the number of sporulating
generations of the parasite that may be present.
/Estivo-autumnal malaria seems to be the term most
generally adopted for the irregular, continued
malarial fevers. But this term is not very appli-
cable in the Tropics, for we have no summers
changing to autumn, and these fevers occur with a
fair degree of constancy throughout the whole year,
although there is some seasonal incidence corre-
sponding to the wet and dry seasons. Quotidian and
subtertian are terms also suggested for these irregular
fevers, but they, like the tertian-and quartan, -vary
their characteristic febrile curve in the presence of
multiple generations of parasites, and lose all sem-
blanee to a true quotidian or subtertian course,
They may give rise to a chart which has an outline
irregularly dentate, or in some instances sub-con-
tinuous, or at times almost a continuous fever.
On account of the inability to coin a satisfactory
term, I shall in these papers adopt the term malarial
fever to apply to all the malarias which do not
pursue a distinetly tertian or quartan course, no
matter which variety. of parasites may cause the
fever. The nature of this paper does not require
a discussion of the tertian or quartan fevers, as. they
offer no difficulty for diagnosis so long as they main-
tain a normal course, and when, on account of
multiple generations of parasites, they assume a type
in an
. possibility of still another ;
. of fever that is quotidian or irregular, they will
also be included under the term malarial fever.
Therefore, the tertian and quartan as distinet entities
will be dropped from the discussion of the differential
diagnosis.
There is yet some gon fasion as to whether there
is one or more varieties of parasites causing the
irregular malarial fevers. Thayer and Hewetson [1]
believed that there was only one variety of these
parasites, and ‘that the different forms seen in the
blood of the periphery were merely different phases
of development in the life of the same organism ; the
complete life cycle taking place in the internal organs,
so that these various phases occurred only occasion-
ally in the blood of the periphery, now at one stage,
now at another, and thus giving rise to the idea
of two varieties. The Italian [2] observers described
two varieties of parasites, the mstivo-autumnal
tertian parasite (subtertian) and the :estivo-autumnal
non-pigmented parasite (quotidian). Mannaberg [3]
. described three varieties of parasites causing the
irregular fevers, the malignant tertian (subtertian),
‘non-pigmented quotidian, and pigmented quotidian.
two, which he terms P.
quotidianum, and admits the
while Manson [5] agrees
Mannaberg, and suggests the possibility of
three; namely, non-pigmented quotidian, pigmented
quotidian, and subtertian, also pigmented. All of
these varieties give rise to gametes of crescentic form.
I think my observation justifies me in assuming
that there are only two varieties of parasites giving
rise to the irregular fevers and having gametes of
crescentic form, and that neither of these varieties
are without pigment, and that Manson and Manna-
berg’s pigmented parasites are only an advanced
stage of development of the so-called non-pigmented
quotidian, which oceur occasionally in the blood
of the periphery. During my studies of the various
malarial parasites in Panama I have found that the
parasites most frequently present in the irregular
varieties of malarial fever corresponded to the des-
criptions of the so-called non-pigmented æstivo-
autumnal parasites, and also parasites from autopsy
examinations in most cases bore out this likeness.
Nevertheless I have found myself quite frequently
confused in routine blood examination work in some
of the stages of the development of these parasites
by certain bodies containing pigment, in association
with young and advanced ring forms, and at times
with crescents and ovoid forms also. These pig-
mented bodies, when mature, occupy all or neatly
all the red blood cell’s substance, without increas-
ing its size or decreasing it to any appreciable
extent. In conjunction with these pigmented bodies,
crescents were observed too often to be easily
explained on the are of an accidental mixed
infection.
In fresh blood smears these dnai forms are
found occupying half to three-fourths and up to all of
the red blood cell substance. The pigment is scattered
throughout the body of the parasite, and is rather
sluggish in motion. Its colour is brownish. The
Craig [4] describes
falciparum and P.
with
178
body itself is a pale hyaline mass, flat and smooth,
in contrast to the highly refractile, globular mass of
the subtertian organism, at the same stage of maturity,
which sometimes appears to be an oscillating droplet
in the red blood cell. In the stained smears the pig-
ment in this body is seen in small granules, and is
brownish in colour, and scattered throughout the
entire body. The chromatin is usually faint, and is
arranged throughout the body in irregular lines.
These bodies are apparently schizonts and a normal
life phase in the development of the so-called non-
pigmented æstival parasites ; as I have said, they do not
swell or shrink their erythrocytic host to any appreci-
able extent, but some shrinkage takes place in the
body before sporulation occurs. At the same time of
this shrinkage, aggregation of pigment takes place to
about the centre of the organism. The body appears
to be morphologically indistinguishable from the quar-
tan parasites when the quartan is at the stage of
development in which it occupies nearly all, or all,
of the structure of the erythrocytes. Therefore, after
James [6] had made painstaking studies of the quar-
tan parasites in Panama, I reluctantly accepted these
bodies as probable quartans, and if they appeared with
crescents present in the same smears, they were then
accepted as a mixed infection. But when I had an
opportunity to view the life phase of the quotidian
parasites in Bass’s [7] cultures in vitro, in Panama,
I again met with these same bodies just before sporu-
lation occurred. There was also an intermediate phase
in vitro between the large ring phase and this body
just described, in which pigment is already beginning
to occur. These intermediate phases later become
the pigmented bodies alluded to, and as schizogony
begins to take place, the brownish pigment accumu-
lates centrally or slightly eccentrically in the organism.
In Bass’s cultures in vitro the pigmented bodies
evidently became sporulates, as in the smears contain-
ing the sporulating phases these bodies had almost, or
quite, disappeared from the scene.
The developmental morphology of these parasites
terminating in the bodies spoken of and schizogony
with later crescent forms may be described briefly.
When the young ring forms have proceeded up to
where they begin to occupy one-fourth or more of the
erythrocyte as broad rings of cytoplasm, with a rela-
tively large nuclear chromatin body, other forms will
be occasionally observed which spread as a band of
blue-stained cytoplasm across the entire diameter of
the red blood cell; in this band-like body the chromatin
nucleus is at or near the centre of the cytoplasmic
band, and the chromatin is sometimes elongated or
streaked throughout the organism. A later phase will
show an oblong mass of cytoplasm occupying about
one-third or more of the erythrocyte, with small
amounts of pigment and a relatively large chromatin
nucleus. The growth apparently continues, with a
diffusion of the chromatin nucleus into wavv ‘irregular
lines, sometimes blotches, throughout the ‘cytoplasm
and pigment, until the body has attained the diameter
of its erythrocytic host. After this stage shrinkage
occurs, while at the same time accumulation of pig-
ment takes place in the centre of the organism, and
later the body breaks up into spores. i
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 16, 1913.
It will be noted that the description of the different
phases of development of these parasites is similar to
Craig's [8] description of his so-called conjugating
forms. And the final stage of this parasite before
sporulation occurs gives rise to a pigmented body
morphologically- similar to Craig's “resting stage
body,” or resisting forms that are ultimately to give
rise to a later brood of parasites, and relapse. J have
never been able to follow in the blood of the periphery
all these various phases in one single series of smears.
They have been seen now in one smear, now in
another, and in each the phases were various, some
belonging to a younger age or an older age, as the
case might be at the time of the examination. In one
case all the forms of the life phases were present in
the blood of the periphery, except schizogony and
crescent forms. They began with small ring forms,
and continued up to the large ring forms, with trans-
verse band forms, oblong pigmented forms, and pig-
mented forms occupying half or more of an erythrocyte,
and the final pigmented bodies free in the blood plasma.
There were no sporulates or crescents seen. Forty-
eight hours later, after sixty-five grains of quinine had
been given, another smear disclosed only a few young
ring forms and innumerable crescents. On account of
the younger ring forms of parasites which are most
frequently seen in Panama, corresponding morphologi-
cally to the so-called non-pigmented parasites, and the
frequent co-existence of pigmented bodies and crescent
forms with these ring forms, together with the life
phases seen in Bass’s cultures, I have been led to
conclude that these were all life phases of the same
parasite. And that this was not, as formerly believed,
a non-pigmented forming parasite.
This conclusion is certainly in harmony with the
clinical appearance of all cases of malaria in which
there have been a few repeated attacks of fever, and
also with autopsy findings.
I have never been able to see any patients in which’
there have been two or three attacks of fever without
evidence of melanemia. In the autopsy smears from
the spleen and bone marrow pigment is always found,
and usually a number of poorly stained shrunken
hyaline bodies containing pigment in rodlets or
granules. Marchiafava and Bignami [9] discussing
the so-called non-pigmented estival parasites of
Marchiafava and Celli under the head of melangmia,
state that although they have seen parasites in the
blood of the periphery and in the cerebral capillaries
pursue their life cycle up to sporulating forms without
the formation of pigment, they have not been able with
great richness of material to see cases at autopsy
without melanzmia, and that in the spleen there were
both pigmented forms and pigment included in the
leucocytes. On this account they expressed some
doubt about there being a parasite which pursues its
whole life cycle without the formation of pigment.
The conclusions that can be drawn from the examina-
tion of post-mortem blood are not satisfactory in the
differentiation of the varieties of parasites, for there
is considerable change of the parasites in dead blood
in all their forms except in the gametes and sporu-
lates, as is indicated by the marked difference in the
staining affinity of the parasites in the dead blood,
June 16, 19138.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 179
and the staining affinity of the same forms as seen in
the living blood. In post-mortem blood the ring forms,
instead of showing as faint rings of cytoplasm and
a marked achromatie space, stain heavily blue, with
little or no achromatic space, and often the chromatin
nucleus is overshadowed by a brownish discoloration,
which is probably pigment. The larger bodies are
hyaline, and take the stain poorly, while their pigment
is seen in little rodlets or granules. Moreover, the
parasites seen in post-mortem blood, especially the
nearly full grown forms, appear much smaller than
similar ones in the blood before death. My conclusion
then is, that there are only two varieties of parasites
giving rise to the irregular fevers, and having gametes
of crescentic form, and that both are pigmented in
some of their stages of development. I shall for
convenience, then, term these varieties, Plasmo-
dium falciparum subtertianum and P. falciparum
quotidianum.
The subtertian or malignant tertian parasite shows
pigment early in its development. The pigment is
coarse and granular, rather dark in colour, and the
pigment nearly always remains more or less aggregated,
and occupies usually an eccentric position in the
cytoplasm. The parasite does not attain the full
size of its erythrocytic host, and in many instances
shrinks and distorts the red blood-cell to a quite con-
siderable degree, “brassy bodies." The so-called
non-pigmented parasite shows pigment late in its
development. The pigment is in small granules,
brownish in colour, and is usually disseminated
throughout the cytoplasm until just before sporula-
tion occurs, when it becomes aggregated about the
centre of the organism. Tbe parasite attains nearly
or quite the full size of its erythrocytic host.
The characteristic fevers that these two varieties
give rise to, and the many irregular or intermediate
types of fevers these parasites may give rise to in the
presence of multiple generations, are sufficiently
described in all the text-books, and need not detain
us here for a recapitulation. I shall then pass on,
and take up briefly some of the salient features of the
clinical symptoms of these forms of malarial fever.
At the present time, with the prompt administration
of quinine the attack of malaria is eut short so quickly
that very little opportunity is offered to observe any
of the special features of the symptoms. Therefore,
the symptoms that can be noted are such as manifest
themselves at the time the patient first presents him-
self for treatment, and such as may be elicited in the
history taking. In cases of ordinary severity the
patient usually states that he has been ill from one to
two or three days. Headache is the most prominent
symptom alluded to, then lumbar pain, weakness,
especially in the knees, general muscular pains, and
rather marked restlessness. Vomiting is nearly
always present; if not spontaneous, it occurs as soon
as medication is begun, the appetite is lost, and thirst
is marked. Unless the patient is the subject of
previous attacks of malaria, the spleen is not
perceptibly enlarged, though pain in the splenic region
is often noted. Jaundice is not often present in
primary cases, but an icteric tint of the sclera is
noted in secondary and third attacks. In the re-
current attacks and untreated attacks anemia begins
to appear as a prominent feature. In the grave cases
the patient in most instances states that his illness
has been of four, five, or six days’ duration. The
symptoms described for the milder cases are present
in the grave cases, with increased intensity. Vomit-
ing becomes a prominent and troublesome symptom.
The spleen is now palpable, or its enlarged area can
be noted by percussion dulness. Jaundice is present
in some degree, but at times is obscured by the
injected conjunctiva. Pain in the gall-bladder region
is at times complained of. Another prominent sym-
ptom noted in the case history is vertigo. The patient
will state, if English, that he is troubled with “a
giddiness in the head," if French, “ étourdissement ; ”
and both are insistent that one takes notice of this
symptom. Patients in this class of fevers will also
state that while trying to perform their regular duties
they were "struck down by the fever" —" je tombe
par le coup de fièvre.’ They sometimes lose con-
sciousness, to regain it again in a short time. They
are then brought to the hospital, and in those able to
walk the gait is staggering or reeling, ataxic, and in
every particular the gait resembles an ordinary
alcoholic " drunk." When these patients are put to
bed and quiet is obtained, they often drop off into a
restless sleep, with muttering delirium, which may
now and then arouse them from sleep with the sense
that they have said something foolish or absurd.
And at times, when aroused for medicine, they appear
slightly lost or dazed. Jactitation is frequent in
women, and convulsive seizures not uncommon in
children. In other severer forms the patient, while
up and about, and even trying to work, will suddenly
fall in an unconscious state. He may not regain
consciousness, or he may at the end of the paroxysm
clear up mentally to a certain extent, and when
treatment is not efficacious, to relapse again with the
next sueceeding paroxysm into a state of deep coma,
or active delirium. In other severe infections the
patient may have had one, or two or three, initial
attacks, with intervening periods of fair comfort, to
be seized at last by an attack in which the first
warning of perniciousness is that when the patient is
noticed by his friends, he is already in coma. In the
most grave pernicious fevers a history is not easily
obtained. Such as can be obtained will usually dis-
close the fact that the patient has been the subject
of one or more previous attacks of fever; that in his
present illness he has been sick a week or more, but
most of the time up and trying to work if he happens
to be a labourer. Patients with such a history
may walk into the wards in the intervals between
paroxysms, and aid in putting themselves to bed. As
the time for the next succeeding paroxysm comes on
active pernicious symptoms become manifest. As
the fever mounts upward, most frequently it will be
noted that the patient is becoming quieter, it is
difficult to arouse him, he soon sinks into a deep
coma, and death may end the scene in the next six
to twelve hours. In other instances, at the begin-
ning of the next succeeding paroxysm, active delirium
180
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 16, 1913.
supervenes. Sometimes the patient is so maniacal
that forceful restraint is necessary. If in these
cases recovery does not take place, the patient later
sinks into a deep coma, and thus ends the scene.
When -such an untoward event occurs, death may
take place on the upward rise of the temperature, or
at its fastigium, or on the downward slope, or, finally,
as the temperature reaches normal. In some fatal
cases death may be delayed to the third, or fourth, or
even the fifth day. These cases will be described
later.
It has never been my experience to see pernicious
symptoms arise in malarial fever during active treat-
ment, without some evidence of perniciousness having
already manifested itself. Sometimes these pre-
monitory signs are easily overlooked. It must be
noted that in the grave malarias the patient may
still appear perfectly conscious, and if questioned in
such a way as to require direct answers, the answers
are quite satisfactory. But if questions are put so
that the answers will require a compound sentence,
or an effort of memory, it will be found that the
patient will wander off into vague and confused ideas,
and leave the answer incomplete. Or, again, he
answers in a morose way, or is entirely indifferent
about it. When put to bed, he is usually quiet, but
sometimes makes half-hearted attempts to sit up in
bed, or attempts to get out of bed, and will have no
reason to offer for doing so.
I have already stated that the fever curve is variable,
and loses all semblance to its normal characteristics,
but, curiously enough, in the grave and in the per-
nicious fevers the fever curve shows the greatest
tendency to remain true to type. The temperature
does not always rise to a height proportionate to the
gravity of the infection. Thus, a pernicious case may
have a temperature not above 100° F. The maximum
temperature is usually 102° or 103° F., but at times
it rises very much higher. The tongue shows nothing
characteristic. In the severer cases the tongue is
heavily coated with a colour from greyish white to
yellow, or even dark brown, and sometimes dry. It
may be of normal width, or in other instances narrow,
and pointed at the tip, and red at the edges as in
typhoid fever.
In these grave and pernicious cases of malaria, an
examination of the blood of the periphery will in most
instances disclose parasites in such great quantities
as to easily account for the gravity of the symptoms.
The variety of parasites will also be a notable feature.
They will be found to be one or the other of the two
varieties of the P. falciparum. The parasites of
either varicty are all sometimes found to be at about
the same stage of maturity. Or, again, they may
be found representing every life phase of the organisms.
Thus, we may in some cases see only young ring
forms present in the smears, again half-grown ring
forms, with an occasional sporulating form, to,as I have
said, all the life phases, with leucocytes, both large
mononuclears and polynuclears containing pigment,
and engulfed parasites partially disintegrated. If
death takes place in a few hours after the examina-
tion of the peripheral blood, the same forms will
be seen blocking the capillaries of the cerebral and
cerebellar substance. The same will be observed in
the splenic and bone marrow smears, with pigment
scattered in abundance throughout the fields of the
microscope.” There occur, however, occasional cases
in which the examination of the peripheral blood
discloses no such picture as just described. In these
latter cases the number of parasites seen in the
blood of the periphery will be no greater than the
number seen in cases of ordinary severity. One will -
be surprised, then, on close examination of the
patient to see him show signs of incoherence and
bed restlessness, described under pernicious manifesta-
tions, and later break out into a delirium to end
in coma and death. The autopsy smears in these
cases will show the same blocking of capillaries,
and great abundance of parasites in the internal
organs, as noted above.
There remains to be described a form of pernicious
fever in which the examination of the peripheral
blood may not necessarily disclose a very great
number of parasites, and during treatment the para-
sites rapidly decrease in the circulation; and yet the
gravity of the symptoms continue to increase till
death takes place on the fourth or fifth day after
admission. At autopsy smears from the brain
substance will show the capillaries patulous, and only
a red blood cell here and there containing parasites.
Smears from the spleen and bone marrow, and other
organisms, are likewise scanty in parasites. The
general autopsy findings are indefinite, and such as
are found, macroscopically or microscopically, are
insufficient as a rule to account for the: cause of
death, Marchiafava and Bignami [10] describe this
form of pernicious malaria and remark that others
have also seen them. They admit themselves
unable to give a satisfactory rexson for the cause of
death. These authors note several hypotheses that
have been offered as an explanation for these cases,
among which the most important is a special toxicity
of parasites. They do not accept this hypothesis,
and neither do I. It is not clear to me how a special
toxicity, or the usual toxins for that matter, can
continue to increase in the circulation while at the
same time the agent causing the toxin is decreasing.
James [11] has noted this class of cases also, and
offers a hypothesis of retention of toxins. As a
tentative hypothesis I think we can assume a reten-
tion of toxins by the faulty elimination of organs
concerned in this process, particularly the kidneys.
But the evidence I have at hand makes this hypo-
thesis of doubtful value. I have notes on four of
these cases, two of which died on the eighth and
tenth days respectively after admission. Parasites
disappeared from the circulation rapidly under treat-
ment, and the temperature of one reached normal on
* For a long time iu my work I had never seen a case of
this latter description, and on that account was led to the
postulate that parasites did not accumulate in the internal
circulation, but remained everywhere in the circulation in
proportion to the amount of the blood supply of a given organ.
I have since had that conclusion rudely shaken, and take this
opportunity to withdraw it.
June 16, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
181
the second day, and that of the other on the third
day. The temperature then began to rise again,
and continued upward till death. Blood cultures
during life and at autopsy were sterile, the autopsy
findings disclosed some pigment, but no parasites.
The cause of death in these two cases was shown at
autopsy to be acute nephritis. The remaining two
died on the fifth day after admission. The autopsy
smears from the cerebral and cerebellar substance
showed the capillaries patulous, and here and there
a red cell containing parasites. Smears from the
other internal organs were also equally scanty in
parasites. Malarial pigment was present in the
splenic pulp and bone marrow. In one of these
cases the kidneys showed macroscopically evidence
of cloudy swelling. Sections of the kidneys from the
same case did not show sufficient histological changes
to account for death. In the other case the
kidneys were large and swollen, cloudy swelling
was apparent, but no sections were made.
A test of the renal functions by the Rowntree-
Geraghty [23] method with phenolsulphonephthalein
would no doubt shed much light on this class of
cases.
Albuminuria in Malaria.—Albuminuria in malaria
is quite a common feature, though it varies to some
extent in ‘different localities. In 200 cases analysed
I found albuminuria present in 42 per cent. of all
cases of malaria. In the pernicious cases albumin
and casts of various kinds are quite a common
feature, sufficiently so that in my first case of
pernicious malaria the diagnosis was uremic coma in
spite of the presence of large numbers of parasites in
the peripheral blood. Brem [12] has also noted that
the urine of pernicious cases shows the presence of
hemoglobin. These he designates “ pernicious
malaria with haemoglobinuria.’’ Working with
Brem’s method of testing for hemoglobin in the
urine, the reaction occurred with such a degree of
constancy in pernicious fevers that it led me to
conclude this phenomenon may be expected in all
grave pernicious fevers.
Authors are in the habit of classifying malarias
according to some particular symptom which
manifests itself most prominently during an attack.
This is more especially true with reference to the
pernicious fevers. Thus we have comatose, delirious,
syncopal, apoplectic, ataxic, algid, dysenteric, and
choleraie, &c., ke. The four first forms noted here
are already sufficiently described under the head of
symptoms of the grave and pernicious fevers, in
which I have noted the ataxic gait, and the patient
may fall down, while he is attempting to perform his
regular duties, in a temporary unconscious state,
or at other times in a more or less continuous un-
conscious state, either of which may terminate in
coma or delirium. Ithink it may be said that these
symptoms are so common in this class of fevers that
they do not require any special classification, but may
be considered under one general head of symptoms
of the grave and pernicious fevers. A few of the
remainder can be taken up seriatum.
The algid and choleraic have been extremely rare
here. I have seen one case of the algid form in which
recovery took place without any after rise of fever,
and James reports he has had one case of the choleraic
form. The clinical symptoms described for both the
algid and the choleraic forms are so strikingly like
some cases of heat-exhaustion that I have had the
opportunity to observe, that it has occurred to me
that there must be a co-existence of heat-exhaustion
and a severe malarial infection to give rise to such a
train of symptoms. In heat-exhaustion the most
prominent symptoms are a small running pulse and
cold, clammy skin, intense cramping in the bowels,
with vomiting. The stools are frequent and watery,
and flaked with mucus, to later become tinged with
blood.
As I have stated, the algid and choleraic forms of
malaria are extremely rare here, and heat-exhaustion
is also rare. Moreover, in James's choleraic case the
sectioning of the mucous membrane of the intestinal
tract disclosed no evidence of an inflammatory nature,
nor any evidence of a determination of parasites to
the intestinal mucosa (Darling). It is true that
Marchiafava and Bignami [13] report otherwise, but
at the same time they explain that the so-called
ardent fevers are the effect of sunstroke and co-
existent malarial infection. I think it is just as
reasonable to assume that heat-exhaustion and co-
existent malarial infection would be necessary to
present the symptoms of either type of the opposite
picture—the algid and choleraic forms.
Dysenteric Forms.—A number of observers have
held that there is a variety of dysentery caused
directly from malarial infection, or “ malarial
dysentery,” Manson [14] and Craig [15] maintain-
ing this postulate, while Mannaberg [16] maintains
that the dysentery is an accidental infection co-
existent with a malarial infection,
Mannaberg’s view, in the light of my experience,
appears to me to be the correct one. I think it would
strike one as logical, that where malaria is endemic
and dysentery also endemic there might be some-
thing accidental between them when both diseases
occur at once in the same individual; and that dysen-
tery may be a contributing cause for an outbreak of
latent malarial infection, or, on the other hand, an
attack of malaria act as a contributing cause of
dysentery by lowering the resistance. But for malaria
to have any grounds as a cause of dysentery, dysentery
should be present with a fair degree of constancy in
malarial attacks, just as other symptoms of malaria
occur, for instance, anemia, or at least show some
rise in seasonable incidence simultaneously with the
rise of the malarial morbidity. This it does not do.
Dysentery in Panama shows a slight seasonal inci-
dence twice a year. First in May, " el Mayo " of the
Spanish, and again a slight increase in December and
January, though in the main dysentery is fairly con-
stant throughout the whole year, while the rise in
malarial morbidity begins in June, and continues
throughout July, August, September, October, and
November, to slowly decline by the mid-dry season
in March. The argument that dysentery is of malarial
origin because malarial parasites are sometimes found
182
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 16, 1913.
in the discharged blood from the intestinal mucosa,
I do not think is of any value, because parasites would
be found just as readily from any other hemorrhagic
source during a malarial infection. The so-called
cure of these dysenteries by quinine, while the patient
is at rest, seems to me to be only a tribute to quinine
that it does not deserve, for the dysentery might have
subsided just as readily on the rest and quiet without
the quinine. I have tried ten consecutive cases of
ordinary clinical dysentery without any medication,
with rest and quiet, and had very satisfactory results.
Special Varieties of Malaria.—Special varieties of
malaria and special complications of malaria, such,
for instance, as malarial neuritis, reported from par-
ticular localities, towns, or villages; and malaria
sufficiently characteristic to bear the name of par-
ticular places—one may be permitted to assume that
these peculiar cases have not been investigated any
further than the examination of the peripheral blood.
And, putting it mildly, it is highly suggestive that
some endemic or epidemic entity is confused with
malaria, and is being overlooked. To divide malarial
attacks into various forms according to the pre-
dominant symptoms is not of much service at the
present, when we depend so largely on the micro-
scope for the diagnosis. These divisions served a
good purpose in the pre-parasitic days, as they
warned the practitioner not to be too sparing in the
use of cinchona bark, and later quinine, in the
presence of symptoms that might simulate apoplexy
or uremic coma.
Differential Diagnosis. —l have already said that
malaria, when properly treated, responds so promptly
to quinine that one has but little opportunity to
study its symptoms. Those that one can observe in
the acuter cases will be found to be so similar to &
number of other diseases, that to undertake to set
them off in contrast will not be of much value in
differential diagnosis. Some of the most character-
istic manifestations of malaria are periodicity in the
on-coming of its paroxysms, with more or less rigor
or chilliness, attended by a rise of temperature, then
a decline in temperature, with sweating. Thus, in
the quotidian fevers these phenomena occur within
approximately a period of forty-eight hours, or rather
the paroxysms hold through or delay during a
period of twenty-four or even forty-two hours, and
then remission or slight intermission takes place.
These characteristics, however, are not constant, and
the fever, as already noted, often becomes an ex-
tremely irregular one. All of these same phenomena
may be present to some degree in numerous other
diseases. For instance, tuberculosis; suppurating
diseases, such as liver abscess; general septic con-
ditions, and in the later stages of long-duration
typhoid fevers. The more chronic cases—I mean
here the indifferently treated or untreated cases—will
show symptoms fairly characteristic and of some
diagnostic value. The most marked of these sym-
ptoms are a peculiar colour of the skin, melanemia,
jaundice of the sclerotics, and enlargement of the
spleen. All of these features may be present before
active paroxysms manifest themselves, and hold
throughout an attack until treatment puts a partial
end to them. There is one characteristic in the
acuter malarias that may be of considerable value in
differential diagnosis, and that is the bodily distress
and pain which so quickly subside with the inter-
mission or remission of temperature, and this takes
place whether the intermission or remission is spon-
taneous, or brought about by the administration of
quinine. The nature of this paper hardly requires a
restatement of all the methods that may be made use
of in the differential diagnosis, or the particular
diseases one must differentiate from malaria. I am
only trying to bring out what appears to be the most
salient features. After the few symptoms that may
be depended on for diagnosis comes the quinine test.
And: I regard this as the final test. I showed in a
previous paper that all are agreed that the majority
of malarial cases are readily controlled by quinine.
I think I showed that I had eliminated one or two of
the most troublesome diseases to differentiate from
malaria, namely, uncinarial anemia and typhoid fever,
and how these may be eliminated; and that other
workers in India had eliminated another, kala azar.
With these problems out of the way, one can by
various methods eliminate others, until we may return
to the first principles laid down by Marchiafava and
Bignami [17], that when the specific remedy is
properly administered, malaria terminates its course
in five or six days, or a week at most. By pushing
quinine a little more vigorously than they did, we
have been able in Panama to cause malaria to
terminate its course a little more quickly than they
were able to do in Italy. That is, under increasing
dosage to meet the requirements of an increased
infection we are able to cause malaria to terminate
its course in two, three, four, five, or six days at
most, with the temperature of the fifth or sixth day
so slight as to be insignificant with regard to the
differential diagnosis.
I have also said in a previous paper that malarial
infection may complicate any other disease. To
name the diseases in which malaria may complicate,
it would be necessary to name practically every
malady that can occur in a malarious country.
Malaria, while it does complicate other maladies in
numerous instances, varies in this respect quite con-
siderably, and probably varies in different localities.
It may vary in this respect between 1 and 20 per
cent. Hence, with this point in view, one cannot
consider one's duty finished by merely examining the
blood and finding malarial parasites. Other diseases
must still be considered. And any symptom which
points to any other disease must be carefully weighed,
and workedout. Someof these will strain our diagnostic
skill to the utmost, and even exhaust our laboratory
facilities. While this is true as to the undetermined
diseases one may be contending with, I do not think
it holds good as to the elimination of malaria. As
I have said, the elimination of malaria may be readily
accomplished by quinine.
Therefore, I may again state the axiom. A fever
that continues for more than five days unchecked
by quinine is not malarial fever. I make it a rule,
June 16, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
183
however, to consider malaria out of the case if the fever
is uninterrupted by quinine to the morning of the
third day. I also make it a rule to consider malaria
out of the case if the fever is once completely con-
trolled by quinine, and a second later rise of tempera-
ture occurs without any decrease of dosage or change
in the patient’s regimen. I have notes of one case
which I think will illustrate my whole method of
dealing with malaria, and the methods by which I
have been led up to the conclusions that are re-
sponsible for this series of papers. One morning on
rounds I had just stated the two above rules to my
associates, when I was confronted by a chart of a
patient in whose blood malarial parasites had been
found, in which the fever had obeyed the first rule,
but not the second. Three quarters of an hour of
diligent search was taken to ascertain the cause of
the second rise of fever. I had about abandoned the
case in despair, and hoped to turn to the laboratory
for the solution, when another examination over the
heart area revealed a faint friction scratch at the left
margin of the sternum in the fourth interspace. The
scratch was now heard, now lost, with each rise and
fall in the chest's movement in respiration. Peri-
earditis then was clearly the cause of the second rise
of the fever. :
In this case two conclusions were open to me.
The first one was, that I had to do with a malarial
infectiom resistant to quinine, and simply left off any
further examination, and permitted the case to pursue
its course. And I might have followed this reasoning
until the pericardial symptoms became so obvious
that they could not be overlooked—which they did
do in four or five days. Or, when the pericardial
symptoms could be no longer overlooked, consider
the case then malarial pericarditis. As I had never
seen pericarditis in malaria in 10,000 to 11,000 cases,
either clinically or at autopsy, I did neither the one
nor the other. But as pericarditis occurs frequently
in tubercular conditions, I turned then to tuberculosis
for the solution, and was rewarded by a positive
tubereulin reaction, both Calmette's ocular test and
Von Pirquet's skin test. These two tests are not
held in such high esteem now as they were then, but
they are of far greater value than the presence of
malarial parasites in the peripheral blood three days
previous to the pericardial scratch, and especially
when a pericarditis had never occurred before in
10,000 cases.
It remains to consider the malarial cases in which
it is necessary to depend solely on a few clinical
symptoms, and the quinine test for diagnosis, that is,
in acute infections with not a sufficient number of
parasites yet in the blood of the periphery to be
detected microscopically by ordinary routine blood
work. The question as to whether parasites can
always be detected in the peripheral blood if the
number be sufficient to cause paroxysms and fever,
has been discussed at length. Mannaberg [18] held
that there are acute cases in which fever and
paroxysms are present, and yet the parasites in the
peripheral blood are not in sufficient numbers to be
detected by ordinary blood-smear work. Thayer [19]
admitted this, but considered such cases rare.
Marchiafava and Bignami [20] state that by re-
peated and careful examinations the parasites can
always be detected in the blood of the periphery if
the numbers present are sufficient to cause paroxysms
and fever. Ross [21], in order to simplify and
quicken the examination process, devised a method
which he calls the ‘thick film” method, with which
he is able to detect parasites in the blood of the
periphery in almost every case with fever and
paroxysms. James[22], working with Ross's method,
was able to find parasites in 94 per cent. of clinical
cases of malaria. Ross’s method, however, requires
considerable skil in determining just what are
parasites and what are artefacts, and on this account
most men will rest content with ordinary blood films.
Therefore under the methods of examination as
ordinarily carried out there will occur quite a number
of acute malarias which will fall under Mannaberg's
distinction ; and hence the final diagnosis will depend
on a few clinical symptoms and the quinine test.
This being true, the question arises, What are we
to expect of the clinical course and duration of these
"negative" malarias? If the infection is too small
to admit of parasites free in the general circulation
to a number sufficient to be detected by ordinary
smears, one would be inclined to infer that such an
infection would give rise to mild symptoms which
would respond readily to treatment. My experience
is in accord with this inference. It is true that
primary infections are sometimes a little stubborn,
but not sufficiently so for one to admit that one of
these mild fevers should continue uncontrolled by
treatment for four, or five, or six days. I may say
I have never seen a case of uncomplicated malaria
in which the symptoms were at all severe, where
I have been unable to find from at least a few
ring forms up to, of course, almost the whole life
cycle of parasites in the blood of the periphery.
The infection being less, one should expect these
“negative” malarias to respond to quinine even
more promptly than the positive ones do, and the
time allowed them to terminate their course should
rarely be more than one to three days. In depending
on the quinine test for diagnosis in the “ negative "
malarias, one should remember that all ephemeral
fevers whieh may subside under quinine treatment
are not necessarily malaria, and that many ephemeral
fevers might just as well have pursued a similar
course without quinine as with quinine.
(I wish to thank Colonel W: C. Gorgas, Chief
Sanitary Officer, Isthmian Canal Commission, for
permission to publish this paper, and also Dr. C. C.
Bass, for his kindness in reviewing my description
of the quotidian parasites. |
BIBLIOGRAPHY.
[1] THAYER, Wm. S.
1897.
[2] Marcutarava and Braxaur. “ Malarial Fevers,” Twentieth
Century Practice of Medicine, vol. xix, 1902.
[3] MannaBerG, J. ‘* Malarial Fever," “ Encyclopedia of
Medicine,” 1905.
[4] Cratc, Cuas. F.
“ Lectures on the Malarial Fevers,
** The Malarial Fevers,” 1909.
184
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 16, 1913.
[5] Manson, Sir P.
edition, 1909.
[6] James, W. M. "'Quartan Malaria and its Parasite,"
Proceedings of the Canal Zone Medical Association, April to
September, 1910.
[7] Bass, C. C. Proceedings of the Canal Zone Medical
Association, Seventy-sixth Meeting, July 10, 1912.
[8] Craic, Cnas, F. ‘Studies in the Morphology of Malarial
Plasmodia after the Administration of Quinine and in Iutra-
corpuscular Conjugation," Journal Infectious Diseases, vol. vii,
No. 2, March 1, 1910.
[9] MarcuraFava and Bianamt. “ Malarial Fevers,” Twentieth
Century Practice of Medicine, vol. xix, 1902.
[10] Idem.
[11] James, W. M. *'*A Preliminary Report on a Method for
Preventing the Development of Pernicious Malaria," Proceed-
ings of the Canal Zone Medical Association, 1911.
“ Manual of Tropical Diseases," Fourth
(12) BREM, Warrer V. Archives of Internal Medicine,
February 15, 1912.
[13] MarcuraravaA and BrGNawr, “Malarial Fever,”
Twentieth Century Practice of Medicine, vol. xix, 1902.
[14] Manson, Sir P. “Manual of Tropical Diseases,”
Fourth edition, 1909.
[15] Craig, Cuas. F.
[16] MANNABERG, J.
of Medicine,” 1905.
[17] Loc. cit.
[18] MANNABERG, J.
Medicine,” 1905.
[19] THayEer, Wm. S.
1897.
[20] MarcHIaFava and Brianami. ‘* Malarial
Twentieth Century Practice of Medicine, vol. xix, 1902.
[21] Ross, Sir Ronaup, ‘The Thick Film Process for the
Detection of Organisms in the Blood," ‘‘Thompson Yates
Reports," V, Part 1.
[22] James, W. M. “The Practical Value of the Ross Thick
Film Method in the Diagnosis of Malaria," Southern Medical
Journal, vol. iii, No. 11, December, 1910.
[23] ROWNTREE and GEkRAGHTY. Archives of Internal Medi-
cine, 1912, vol. ix, p. 284.
t The Malarial Fevers,” 1909.
“ Malarial Fevers,” ‘* Encyclopædia
“ Malarial Fevers,” ** Encyclopædia of
** Lectures on the Malarial Fevers,”
Fever,”
——
* Bulletin of Entomological Research,” vol. iv, Part 1,
pp. 1-93, May, 1913.
Varteties of Glossina morsitans.—Shircore believes there
are two varieties of G. morsitans in Nyasaland. He
suggests the names G. morsitans var. pallida and G.
morsitans var. paradora, The pallida is distinctly paler
throughout than the ordinary morsitans ; paradoza super-
ficially resembles it (the ordinary morsitans) in appearance
and size, but the hind tarsi are entirely dark, as in the
palpalis group. The superior claspers of the male genitalia
resemble those of G. submorsitans, but are more deeply
pigmented throughout, and especially along the lateral
and posterior borders. Shircore believes that if paradora
were casually observed, it would probably be taken for an
ordinary G. morsitans, but if the abdomen had become dis-
coloured it might be mistaken for G. palpalis.
* Bulletin of Entomological Research," vol. iv, Part 1,
pp 1-93, May, 1913.
Glossina in Northern Nigeria.—Mactie furnishes an
interesting study of the distribution of Glossina in the
Ilorin Province of Northern Nigeria. Talking of the question
of the big game as reservoirs of trypanosomiasis he says it
should undoubtedly be determined what forms of trypano-
some they harbour in Northern Nigeria; but before under-
taking extensive measures to drive back the game from the
inhabited areas some experiment on a large scale should be
carried out on the lines suggested by Dr Yorke. It is
perhaps unnecessary to insist that, in view of the discoveries
of Kinghorn and Yorke in Rhodesia, the destruction of big
game in the vicinity of native towns and European stations
should be encouraged instead of being artificially restricted.
Business Notices.
1.— The address of the JOURNAL or TROPICAL MEDICINE AND
HyGiENE is Messrs. BALE, Sons AND DANIELSSON, Ltd., 83-91,
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of every month.
THE JOURNAL OF
Tropical Medicine and hygiene
JuxE 16, 1913.
CASTELLANI AND CHALMERS'S “ MANUAL
OF TROPICAL MEDICINE.”
Tue second edition of this manual is more than
the mere fresh issue of a book consequent upon the
exhaustion of a previous volume. No one who has
even easually looked through the recently issued
copy ean but be struck by the vast accumulation
of material compressed within the 1,747 pages of
which the volume is composed. The appearance
of the work gives food for reflection in many
directions, and perhaps in none more so than in the
fact that within a couple of decades a new depart-
ment of medical literature has been created and
developed to an extent and degree to which this
book bears ample testimony. Until Manson wrote
his great pioneer book on Tropical Medicine we had
no literature founded on a scientific basis to guide
or instruct us in this branch of study. Previous
volumes, not wanting in bulk, told us of Diseases
of the Tropics, but they were mere descriptions of
the signs and symptoms of ill-defined ailments
combined with recommendations of drugs and
schemes of treatment empirical in their choice and
application. Not that these volumes were not
pregnant with valuable information; we make a
mistake if, in our haste to redeem past ignorance,
we neglect to know and to appreciate. what has
been done previously. Castellani and Chalmers
have not made that mistake; in their all too
short history of Tropical Medicine they tell us
of ancient practices in the fight against disease;
these are not presented to us in a manner calculated
to provoke derision or ridicule; but instead the
Jewish, Indian, or Egyptian rites and customs are
analysed so that the seeds of truth are sifted from
amongst the chaff of ritual, and due respect paid to
the kernel. Another feature of the manual is the
encyclopedic character of the information it affords.
It is but yesterday that we looked upon the elucida-
tion of the malarial problem as if it were the '' be
- June 16, 1913]. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
all and end all” of knowledge necessary for a
generation to come; but we find that this was but
the spark needed to set alight the torch and illu-
minate a world of science. It served to set free the
pent-up, unsatisfied longings of men who, peeping
from behind the curtain of ignorance, had guessed
at truth, and has given vent to a torrent of know-
ledge such as no department of science has equalled
in so short a space of time. From the days when
Ross was dealing with the '' tiger °’ mosquito to the
present time would seem to indicate an epoch in
knowledge, yet it is but some fifteen years since, as
medical men, we were ignorant of even the rudiments
of entomology, and knew not the names of even the
commoner families of insects around us. Nor can
we lay this ignorance at the doors of medical men
only, for the naturalists amongst us had but skirted
the confines of the subject whieh lay enshrouded
in dense folds of ignorance. Entomology has grown,
from being a frivolous or at best an academic study,
at the behest of the doctors to be a practical science,
and the stir occasioned by the doctors’ demands in
the realm of entomology and biology generally is
not the least of the triumphs the advance in Tropical
Medicine has occasioned. The practical necessities
of medical research anticipated and demanded
activity amongst biologists, and it is satisfactory to
know that the latter have risen to the occasion, and
led by the scientific staff of the British Museum,
Blanchard, of Paris, and others, they have supplied
the information demanded.
Whilst congratulating all who have thus added
to our information and brought light to bear upon
obscure problems, we must also think of the effect
of this accumulated knowledge upon the student
of medicine. Until Manson’s book appeared, the
medical man about to take up practice in a tropical
country had no real guide on which to rely as a help
in the new field of practice he was about to enter.
He picked up his knowledge as best he could, often
with bitter regrets on his part in consequence of his
ignorance to check disease or save life.
For this ignorance he has no longer excuse; far
other is the case, for he is now confronted with a
plethorie storehouse of new matter to study, which
may well appal the half-hearted student. A glimpse
at Castellani and Chalmers’s book shows a range
of subjects new to ordinary medical study, for in no
published book in any department of medicine, from
ancient times until the present moment, has there
been collated in any one volume a range of subjects
so apparently diverse, yet so closely knit in neces-
sary union, To mercly enumerate the headings
bears out the truth of this statement. A knowledge
of climatology, ethnology, bacteriology, helminth-
ology, parasitology, entomology, in addition to special
pathology and clinical work, are necessary require-
ments of the medical man intending to take up the
practice of medicine in the Tropics. In our tropical
schools, in the all too short three or four months’
course of instruction, practically all these subjects
have to be learned; for in our Universities and
Colleges the knowledge acquired of the various
subjects mentioned is but of little practical value;
and the necessity for thorough practical instruction
185
in at least the rudiments of Tropical Medicine is
abundantly apparent when one considers the nature
of the character of the work required of medical
men whose life’s work lies in a tropical country.
The diagnosis of the diseases met with neces-
sitates an intimate and exact knowledge of the
ordinary laboratory methods; for, except in the
large cities, there is no laboratory expert to send
specimens to for diagnosis or investigation. To even
eursorily look through Castellani and Chalmers’s
encyclop:edia of information, one unaequainted with
these facts would gather the impression that we
expeet our young men to be all-round experts before
proceeding abroad. In a sense this is true, but
only in a limited sense; what is demanded is that
they should be thoroughly grounded in their work,
so that they may be capable of treating their
patients on a rational basis, and not along the
empirieal lines in vogue until recent years. After
all, it must be remembered that the treatment of
disease is the sole object of all the elaborate train-
ing insisted upon. It is not to make experts in
entomology, helminthology, or parasitology that is
the object of teaching, but to produce intelligent
practitioners in the first instance.
In every line of Castellani and Chalmers's great
work this fact is never lost sight of; the application
of scientific methods to clinical work and observa-
tion is the watehword of their teaching, and excel-
lently and consistently they have executed their
task.
A detailed review of a work of the kind is out of
the question, nor is it called for. We are not deal-
ing with personal opinions, but with a compendium
to date of the world's knowledge of Tropical Medicine
and the sciences with which it is directly allied.
Diverse opinions and observations are given duc
prominence, and yet the subject matter bears, as it
should, the stamp of the authors' trend of thought,
and conveys their well-considered judgments and
opinions on many debatable points. Time will no
doubt serve to alter many of the recorded state-
ments set forth; this is in accordance with the
advance of science in every direction, and cannot
be ascribed to the faults of authors, but to the
hiatuses in our present-day knowledge.
The volume before us has no superior in any
braneh of medical literature; thorough, practical,
and scientific, it stands as a monument to the
authors, and credit to the medical literature of 1913.
J. C.
———9————
* Annals of Tropical Medicine and Parasitology,"
June 10, 1913, - ol. vii, No. 2.
Age and Sex in Trypanosomiasis.—Todd has studied this
subject in Africans suffering from trypanosomiasis. He
arrives at the following conclusions: (1) The proportion of
elderly individuals among them is lower than it is among
Europeans. (2) Dy far the majority of cases of trypanoso-
miasis are persons of middle age ; almost none of them are
elderly persons. (3) The percentage of individuals with a
considerable degree of glandular enlargement— which is
coincident with trypanosomiasis—is very much greater in
adults, and in children, than in elderly persons. (4) It is
possible that the low incidence of trypanosomiasis among
elderly persons may be due, in part at least, to an immunity
acquired by them.
186
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 16, 1913.
Re | CA SS SS eee Á-
eee
Annotations.
The Treatment of Balantidial Infections.—The
“ Quantitative determination of the balantidicidal
activity of certain drugs and chemicals as a basis
for the treatment of infections with Balantidium
coli ” is the title of a paper by E. L. Walker in the
Philippine Journal of Science, B Tropical Medicine
(vol. viii, February, 1913, No. 1). The work was
done at the Biological Laboratory, Bureau of
Science, Manila, P.I. Dysenterie conditions due
to the Balantidium coli have frequently been re-
ported from the Philippine Islands and other parts
of the world now, so it is important to determine
what are the best drugs to treat these conditions
with. Walker’s work will help in this respect.
His conclusions are as follows :—
(1) The compounds of arsenic and antimony, the
aniline dyes, quinine, ipecacuanha and its alkaloid
emetine, substances which are employed more or
less suecessfully in the treatment of other pro-
tozoan diseases, possess little or no balantidicidal
value.
(2) The salts of the heavy metals, especially
mercury and silver, have been found to be eminently
balantidicidal.
(3) It is possible that some of the inorganie salts
of mereury or silver, administered by the mouth, or
by subeutaneous or intravenous injection, might be
efficient in the treatment of balantidiasis. The
salts of mercury are successfully employed in the
treatment of certain spiroch:ete infections, and when
given internally are eliminated in part by the
mucosa of the large intestine; consequently, the
mercury would be brought in direet contact with
the infected tissues in balantidiasis.
(4) The application of these inorganie salts of
mercury and silver to the local treatment of balan-
tidiasis is rendered impracticable by the facts that
they are precipitated by albumin, and consequently
possess little power of penetrating the tissues, and
that they are relatively toxie for man.
(5) The organic compounds of silver are not pre-
cipitated by albumin or, if precipitated, form soluble
compounds that should be capable of penetrating
the tissues, and they are relatively non-toxic for
man.
(6) Quantitative tests have demonstrated that
certain of these organie compounds of silver possess
& balantidieidal activity as great, in proportion to
the amount of silver contained, as silver nitrate.
(7) The practical value of these organic com-
pounds of silver in the treatment of balantidiasis
can be determined only through clinical experience.
Budding in Entamabce.—Darling, in the Archives
of Internal Medicine (vol. ii, No. 5, May 15, 1913),
contributes a paper on “ Budding and other forms
in trophozoites of Entamaba letragena." These,
he states, simulate the "spore cyst” forms
attributed to E. histolytica. He believes that
Schaudinn's interpretations were wrong in so far as
they referred to a mode of development. Darlings
observations on his stained specimens lead him
to the conclusions that as regards the trophozoites
of E. tetragena chromidia is not given off by the
nucleus, but is formed in the cytoplasm. Chromatin,
however, in these pathological forms does diffuse
out in fluid form from the nucleus into the
cytoplasm. The nucleus does degenerate and is
extruded. In some trophozoites chromidia was
present in rather small particles and collected in
reticular masses in the ectoplasm, as Schaudinu
deseribed. Eetoplasma buds filled with a ehromi-
dial mass were seen apparently pinched off of the
parent body. The free globules, while detected
with more difficulty in wet-fixed preparations, were
seen very well in dry-fixed Romanowsky prepara-
tions. Nothing like a sheath was seen, for the buds
stained either navy blue or light blue like the
cytoplasm of the parent entamceba. When an
extruded nucleus was encountered it always stained
like one.
In fresh preparations of E. tetragena from a
fatal case of dysentery Darling has seen bizarre
pseudopodia and buds with refractile bodies in the
extremities, though extrusion of buds or nuclei was
not observed. If one had merely observed in fresh
preparations alone from a case of dysentery in man.
the changes corresponding to those seen in stained
preparations, the impression received would no
doubt have been very much like that described by
Schaudinn and Craig as the spore cyst formation
of E. histolytica; but from an examination of the
far more richly infected material from the kitten
‘“ which occurs after a lengthy period of lively
increase,” the true nature of the budding forms is
understood and the opinion is formed that these
changes are analogous to such essentially patho-
logical manifestations of cellular degeneration as
karyolysis, karyorrhexis, pyknosis and dislocation
and extrusion of nuclei; moreover, the buddiug
process is analogous to changes seen in mononuclear
metazoal cells; for example, in defunct plasma cells
or lymphocytes in the blood-stream, lymph-nodes
and other locations.
The descriptions of the life cycle of E. histolytica
by Schaudinn and Craig, therefore, are in all likeli-
hood those of a spurious species, having resulted
from observations of pathological changes in senile
races of E. tetragena.
Sleeping Sickness in South Africa.—The final
report of the Luangwa Sleeping Sickness Commis-
sion of the British South Africa Company, 1911-
1912, appears in the Annals of Tropical Medicine
and Parasitology of June 10, 1913 (Series T. M.,
vol. vii, No. 2). It is written by Kinghorn, Yorke
and Lloyd, the latter being the entomologist to the
Commission. The work is divided under six
sections, namely: (1) The human trypanosome;
(2) trypanosomes of game and domestic stock;
(3) trypanosomes found in wild Glossina morsitans;
(4) description of trypanosomes; (5) development
of Trypanosoma rhodesiense in Glossina morsitans;
June 16,1913] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
and (6) report of entomologist. There is also an
introduction and two appendices. A very large
amount of work is covered in the report, and
many very important observations and researches
generally are incorporated in its pages. As regards
the presence of trypanosomes in game and domestic
stock, the author's summary is that trypanosomes
are of frequent occurrence in game and domestic
stock in North Eastern Rhodesia. As a conserva-
tive estimate the percentage of big game infected
with trypanosomes pathogenic to man and domestic
stock may at Nawalia (Luangwa Valley) be placed
at 50, and at Ngoa (Congo-Zumbesi watershed)
at 35.
At Nawalia six species of trypanosomes were
isolated from game and domestic stock, viz.,
T. rhodesiense, T. vivax, T. nanum, T. pecorum,
T. montgomeryi, and T. multiforme; whilst at
Ngoa five species were found, viz., T. rhodesiense,
T. vivaz, T. nanum, T. pecorum, and T. tragelaphi.
The results of examination of over 400 monkeys,
wild rats and mice were invariably negative.
Three species of trypanosomes were isolated
from wild G. morsitans, namely, T. rhodesiense,
T. pecorum, and a third, hitherto undescribed
parasite, for which the authors propose the name
T. ignotum.
These could easily be obtained by feeding wild,
freshly-caught G. morsitans on healthy monkeys.
Dealing with the development of T. rhodesiense
in G. morsitans, the authors say that :—
(1) The salivary glands of all G. morsitans
capable of transmitting T. rhodesiense are infected,
and conversely without invasion of the salivary
glands there is no infectivity of the fly.
(2) Invasion of the salivary glands is secondary
to that of the intestine.
(3) The first portion of the developmental cycle
of the trypanosome takes place in the gut. In
order for its completion and for invasion of the
salivary glands to occur, a relatively high mean
temperature, 759 to 859 F., is necessary.
(4) Invasion of the salivary glands was only found
in flies infected with the human trypanosome, T.
rhodesiense.
(5) The predominant type of the trypanosome in
the intestine of infected G. morsitans—a large
broad form—is quite different from that which
predominates in the salivary glands, where the
parasite resembles somewhat the short form seen
in the blood of the vertebrate host.
(6) Both the intestinal forms and also those from
the salivary glands of infective G. morsitans are
virulent when inoculated into healthy animals.
In the entomologist's part of the report a record
of blood-sucking insects and ticks collected in the
Luangwa Valley from August, 1911, to Mareh,
1912, and at Ngoa from March to May, 1912, is
given, while the appendices deal with: (1) An
experiment to ascertain whether tabanids transmit
trypanosomes in nature (Wallaee and Lloyd): and
(2) an attempt to transmit T. rhodesiense by means
of Ornithodoros moubata (Wallace).
Trypanosoma brucei.—Stephens and Blacklock
(Annals of Tropical Medicine and Parasitology,
June 10, 1913; and Proceedings of the Royal
Society, B. vol. Ixxxvi) write on the non-identity
ot T. urucci (Plimmer and Bradford, 1899) with the
trypanosome of the same name from the Uganda
ox. In dealing with the subject they believe there
are three possibilities :—
(1) That the strain they possess, which they have
been designating T. brucei, Zululand, is not this
strain at all, but some other trypanosome inoculated
erroneously during the course of inoculations ex-
tending over years. They think this view is unten-
able, for it would not explain the monomorphic
character of the old slides examined, nor would
it explain Laveran's monomorphie trypanosome.
(2) While Bruce may have been working with 4
dimorphie trypanosome in Zululand, and still has
slides showing these characters, it is quite possible
that the strain sent by him to England was some-
thing quite different. This is all the more likely,
as Bruce successfully infected dogs from a variety
of wild game, viz., wildebeeste, kudu, bush buck
and buffalo, and, as Bruce himself states, '' when
T. brucei was discovered in Zululand in 1894, it
was naturally thought to be the one and only
trypanosome in Africa," und no suspicion arose at
that time of a multiplieity of trypanosomes in
native game.
This is the simplest explanation, and the fact
that Plimmer and Bradford do not describe or
figure stumpy forms, and the authors' examination
of Dr. Plinmer's slides had the same result, makes
it probable that this is the true one.
(3) That the strain originally sent to England
was dimorphic, but that it has now become mono-
morphic. This may have come about in two
ways :—
(a) The strain originally was a mixture of a long
trypanosome and a stumpy trypanosome, and the
stumpy has now died out. If this explanation were
valid, it would probably imply that T. gambiense
and other dimorphie trypanosomes were also mix-
tures. "This the authors regard as a not impossible
view, but one they cannot at present prove or
disprove.
(b) The strain was originally dimorphic (but
not a mixture) and that it has now become
monomorphic. If this were so, it would modify
materially our notions of specificity of trypano-
somes, at least in laboratories. Of such a change
there is at present not much evidence. The
authors have noted, however, above that the
Uganda strain kept in mice for a year was almost
(but not entirely) monomorphie, but that in guinea-
pigs it at once showed its normal characters.
It is impossible at present to decide between these
explanations,
They come back, therefore, to the fact of which
they have no doubt, viz., that the trypanosome
that Plimmer and Bradford worked with, and
which they named T. brucei in 1899, is certainly
now a monomorphic trypanosome, and is not the
same as the trypanosome from the ox described
188
under the same name by Bruce and others in
Uganda.
According to them, these facts brought forward
prove the non-identity of the Zululand and Uganda
strains.
In order to avoid confusion, they think it
advisable that the Uganda trypanosome should be
re-named, and propose for it the name T. ugande.
Treatment of Surra in Camels,—Leese reports
successful experiments on the treatment of surra in
the camel with recommendations for systematic
treatment (Memoirs of the Department of Agricul-
ture in India, April, 1913, Veterinary Series, vol. i,
No. 3). Various lines of treatment are described,
soamin, tartar emetic, asenious acid, sodium
arsenate being the drugs employed. In some cases
complete cure seemed to result.
When a treatment fails to cure, relapses usually
occur between two and seven weeks, but one or two
cases did not relapse until 88 or 89 days after the
last dose. The camels therefore require some
inspection during the three months following
treatment, and should be kept within reach until
then. The camelman should watch for and report
any sign of fever, which should then lead to exam-
ination of the blood for trypanosomes. It is a good
thing if the temperature can be taken daily so as to
detect relapses.
Cases which relapse may be treated again with an
excellent chance of cure, provided the camel is in n
fit state to stand a second treatment. If the second
treatment fails, a third can be applied; the author
has had a cure on the third trial.
When a camel has relapsed and it is desired to
treat it a second time, the record of the first treat-
ment is a very good guide as to the seale of dosage
that will be most suitable for the second treatment.
Emaciated camels cured by treatment take several
months to get into working condition. After treat-
ment, no camel should be worked for a minimum
period of one month, and generally longer, according
to the case.
Leese has only treated one cow-camel, but recom-
mends at present the same way of estimating dosage
as for males. Experience may show whether this is
correet or not.
He has also no data as to dosage for camels
under 4 years of age. The difference between the
dosage which cures and that which kills is not big
enough to justify fixing the doses by guesswork.
It must be left to experience. The chances of
spontaneous recovery are pretty good in bachas of
1 or 2 years of age in breeding-herds, as they are
not required to work, and it would not always be
a good plan in a breeding-herd to apply treatment
to a dachi or bacha which had passed the acute
stage of the disease, if segregation is possible.
During the treatment of surra the camels may be
kept together in one herd provided they are not
placed in it until trypanosomes have gone from the
blood. In practice (as apart from experiment)
microscopic examination of blood is only necessary
for a few days, viz., to find out when to give the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 16, 1913.
first dose, and to note when the trypanosomes have
dispersed (generally within twenty-four or forty-eight
hours after the first dose).
Trypanosomes do not re-appear during treatment
when the instructions given are carried out; it is
unnecesary to burn the careases of any camels
which die from poisoning during treatment.
Camels eured of surra by drugs are not immune
to second infections. One, for example, which,
subsequent to treatment, had gone 408 days under
daily blood-examination without relapse, and whose
blood had also been found innocuous to a guinea-
pig, was inoculated with 15 c.c. of blood, containing
numerous trypanosomes, obtained direct from the
jugular vein of a camel suffering from surra. A
control inoculation was also made into a guinea-pig.
After an incubation period of four days, trypano-
somes appeared in the blood of the camel and
rapidly inereased until on the third day they were
swarming. The control guinea-pig also got the
disease.
Tick-bite.—Eaton, in the Australasian Medicul
Gazette of April 26, 1913, describes a case of tick-
bite which was followed by a widespread transitory
muscular paralysis. The patient was a little girl
aged 44, and Eaton, after a description of the tick
by the child’s father, concluded that it must either
have been Ixodes ricinus or Ixodes holocyclus. The
tick, attached to the back of the right shoulder, was
only found when the child was being put to bed un-
well. Its body was eut off, leaving the head and
mouth parts embedded in the skin. The same
evening the patient vomited, and during the rest
of the night was very restless and did not sleep
much. The bowels moved twice, the motions being
of a brown colour and semi-solid consistency. Ou
the second day the child vomited three or four
times, and it was then found that she could not
stand and appeared very ill. She was sent to Dr.
Eaton, who examined her in the afternoon; ue
found a state bordering on delirium, a temperature
of 101.49 F., a pulse of 132, knee-jerks absent,
and the muscles of the legs and thighs quite flaccid
and motionless. Over the lower part of the right
scapula there was a bright pink patch about the
size of a penny, neither raised nor indurated, and
in the centre of this was a purplish-black spot a
quarter of an ineh in diameter. In the middle of
the spot was an aperture somewhat less than a pin's
head in size, and through this a greenish-grey
body, which grated with a stony hardness against
the point of a knife, was visible. A minute droplet
of pus was expressed from the aperture. The
objeet felt with the knife, evidently the head and
chitinous mouth-parts of the tick, could not be re-
moved without breaking it into fragments. It was
ultimately scraped out, and the cavity, about the
size of an average match-head, was cleaned with
a small curette, and cauterized with pure earbolie.
Strychnine was given hypodermically.
On the third day the bowels moved nine times,
the motions being liquid and bile-stained. The
temperature had become normal, and though there
June 16, 1913.]
were still signs of irritability the mental state had
cleared. There was still, however, no sign of return
of voluntary movement to the legs, but the muscles
were not so limp, and the strength of the arms was
better. By the next day, the fourth since the onset
of symptoms, the knee-jerks were both obtainable,
but deficiently. The child could stand, and even
walk a few steps with support. The pupils were
still inactive to light, but reacted well to pilo-
earpine. Diarrhea continued, but was less severe.
On the fifth day the patient could walk without
support, but the gait was knock-kneed, so that each
leg was brought more directly under the weight of
the body. In walking no attempt was made to rise
on to the ball of the foot. The pupils now reacted
to light, but were still somewhat dilated. The
pulse rate was 96, and the temperature was normal.
The bowels had moved twice since the preceding
day. The discoloration around the bite-mark had
become reduced to about the size of a shilling, an1
had faded to a duller red shade. The cavity had not
yet filled up, but was healing well. This was the
last time Dr. Eaton saw the patient, but he was
informed that her progress to complete recovery
within the next few days was uninterrupted.
Bites of ticks causing severe intoxication in the
human subject, Eaton states, have been recorded
in Australia several times, and one at least with ^
fatal issue. Lambs and dogs are not infrequently
killed by them, and it would seem that in most
cases the symptoms are chiefly muscular paralysis,
affecting first the hind limbs, later the fore limbs,
and leading to death by respiratory paralysis.
Cleland, in the Australasian Medical Gazette of
September 21, 1912, quotes Bancroft, who had
observed many such cases in the lower animals.
He mentions that symptoms commenced, as a rule,
two or three days after the tick had attached itself ;
that unwillingness to take food and drink is usual;
that the muscles most remote from the heart are
those paralysed first and most severely, and that
the heart suffers last of all. He also says that
animals in infected country become immune to
tick-bite.
Of the cases in the human subject, quoted by
Cleland, the same uniformity of symptoms is not
to be observed. In one, amblyopia was the most
striking symptom, the pupillary movements were
normal, and only slight museular weakness was
present. In another (an infant of 13 months),
which proved fatal within two days, paralysis ob-
tained in the legs and respiratory muscles. These
symptoms appeared on the second day from attach-
ment of the tick. In a third case, in which a man
had 200 tieks removed from his body, faintness
commenced within an hour of their attachment.
There was no paralysis, but severe cardiac syni-
ptoms lasted for a week. These three cases bear
little resemblance to each other, and it seems as
if the symptoms must have been caused by different
poisons.
The present case, that of the infant quoted, and
those of the lower animals under Bancroft’s obser-
vation, all closely resemble each other. In all,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
189 —
there was & period varying from one to several days
after the attachment of the tick before muscular
symptoms ensued. In the case described above
the presence of fully-formed pus at the first exam-
ination indicated that the tick had been there at
least 48 hours. i
The most striking feature was, Eaton says, the
severity of the intoxication, and the way in which
the motor functions were selected by the toxine,
the mental faculties only being moderately affected,
and the sensory ones probably not at all. The
absence of reflexes, taken in conjunction with the
seeming integrity of the afferent paths, and also
the complete loss of tone of the muscles, fix the
site of motor interference either'in the muscles
themselves or in the lower motor neurone; that is,
in the cerebrospinal nerves with the cells of the
anterior horn and of the cranial nerve nuclei
respectively. Suspension of the function of the
cells centrally would account for most of the
phenomena, but not for the grouping of the muscles
affected nor for the behaviour of the pupil. The
intensity of paralysis and the lateness of regaining
function followed an order of remoteness, in the
blood-stream, from the heart, while of groups closely
associated in the central nervous system some were
deeply affected, and others only lightly; as, for
example, the glutei, on the one hand, and the
muscles below the knee on the other, with their
centres close together in the lower lumbar part of
the cord, or the sphincter pupille and the extrinsic
ocular muscles, with their centre in the third and
closely adjacent fourth and sixth nuclei.
In general, the resemblance of the symptoms to
those of conine poisoning is very close; an intense
paralysis of the motor nerve end-plates, a particular
picking out of the respiratory muscles due probably
to an action on the centre in the medulla, a late
and relatively slight interference with mentality,
gastro-intestinal irritation, and so on; in fact Eaton
thinks the only point of difference from a typical
hemlock case was that the onset of symptoms was
more prolonged.
As to the source of the poison, there are, Eaton
thinks, three possibilities: its pre-formation by the
tick, its development in the blood of the patient, `f
the poison were an infective one, or its elaboration
chemically or biologically, at the situation of the
bite, with subsequent absorption. There are many
reasons, he thinks, for believing that it is not
already formed in the glands of the tick. Bites of
this kind must be exceedingly common, yet such
symptoms are relatively rare. Again, in the cases
quoted, the symptoms are very variable, although
the ticks have probably all been of the same species,
at any rate, all of the genus Ixodes. Were the bite
itself venomous, one would expect a certain degree
of constancy in the type of symptoms and a more
frequent incidence of them, and it is improbable
that the latent period would be nearly so long—
sometimes several days. Increase of severity of
symptoms after removing or killing the parasite
would be improbable also; yet this usually occurs.
——9————
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 16, 1913.
Hotes and "Retos.
BRITISH MEDICAL ASSOCIATION,
(Highty-first Annual Meeting, Brighton, July 22,
23, 24, and 25, 1913.)
SEcTION OF TROPICAL MEDICINE.
President:
Lieut.-Col. Sir. Wm. Leishman, M.B., F.R.S.,
R.A.M.C., Rotherwood, Linden Gardens,
Leatherhead.
Vice-Presidents :
Edward Irwin Scott, M.D., 28, St. Aubyn’s, Hove;
Professor William John Ritchie Simpson,
C.M.G., M.D., V.R.C.P., 31, York Terrace,
Regent’s Park, N.W.; Major William Sandi-
lands Harrison, RH. A.M.C., Royal Army Medical
College, Grosvenor Road, S.W.
May, 1913.
Tue Section of Tropical Medicine will meet on
Wednesday, Thursday, and Friday, July 23, 24,
and 25, 1913, from 10 a.m. to 1 p.m., under the
Presidency of Lieut.-Col. Sir Wm. Leishman,
M.B., F.R.S., R.A.M.C., when it is hoped that you
will be present and take part in the work of the
meeting.
The following subjeets have
discussion : —
Wednesday, July 23.—'' The Causes of Invalid-
ing in the Tropies." Dr. Basil Price will read a
paper and open the discussion on this subject:
Professor Simpson and others will take part.
Thursday, July 24.—'' Dysentery." Captain
Douglas will open the discussion.
Friday, July 25.—'' Filariasis.” Dr. G. C. Low
will read a paper and open the proceedings.
It will greatly conduce to the success of the
meeting if members will kindly notify as soon as
possible whether they propose to take part in the
discussions, or wish to make any communication to
the Section.
Any such communication must not occupy in
reading more than fifteen minutes (about 1,500
words), and, for profitable discussion, it should
take the following form: (i) A definite statement
of what it is intended to suggest, or prove; (ii) a
statement of the facts or arguments on which such
thesis rests; (iii) a very brief summary of the
leading points.
Papers if not read form no part of the proceed-
ings of the Section. If, however, you are unable
to be present your paper will be read for you by
one of the Secretaries.
Error CunwEN, M.A., M.B., B.C.,
1, St. Aubyn’s, Hove;
Francis WiLLiam O’Coxnxor, M.R.C.S.,
London School of Tropical Medicine,
Royal Albert Dock, E.,
Hon. Secs.
been selected for
LIVINGSTONE COLLEGE.
Tue Commemoration Day proceedings at Living-
stone College, on Saturday, June 7, gave the oppor-
tunity for the celebration by the College of the
Centenary of David Livingstone, after whom the
College is named. The Principal, Dr. Harford,
pointed out in his opening statement that Living-
stone College had been associated with many of the
united meetings and services in connection with the
Centenary, and that on the occasion of the National
Memorial Service in St. Paul’s Cathedral, at the
suggestion of the Dean, after consultation with the
Missionary Committee which organized the service,
it was decided that the collection after expenses
were paid should be given to the Livingstone
College: a gratifying tribute to the fact that the
College is a memorial to the great Pioneer Missionary
of a truly representative character.
Dr. Harford further stated that very few of the
speakers at recent mectings had recognized the
relation between Livingstone’s medical training and
the great contributions which he made to the know-
ledge of the African Continent. It was felt to be
most appropriate that this should be emphasized at
Livingstone College, where Missionaries receive
elementary medical training in order to fit them to
go forth as missionary pioneers. A large number of
old students had gone forth to Central Africa to
follow in the footsteps of Livingstone, whilst some
were to be found in almost every part of the world,
but in every case they could carry with them
the spirit of Livingstone shown by keen powers of
observation, large-hearted sympathy, and a readi-
ness to co-operate with other Christian missionaries.
An illustrated souvenir of the Livingstone Cen-
tenary, containing coloured reproductions of the
portraits in the possession of the College, had been
issued, and copies had been graciously accepted by
their Majesties the King and Queen, H.R.H. the
Prince of Wales, and her Majesty Queen Alexandra.
These souvenirs, as well as postcards, were on sale
for the Livingstone Centenary Fund. It was desired
to raise a fund of £10,000; £3,500 to clear off a
mortgage on the property, £1,000 to effect further
improvements, and £5,000 to form the nucleus of
an endowment.
A valuable piece of land had been presented to
the College by Mr. Robert Barclay, and £490 had
been received towards the Centenary Fund. The
Rev. W. D. Armstrong, an old student of the
College, from the Congo, where he had proved the
practical benefit of the training, was endeavouring
to create interest in the fund. Contributions might
be sent to him at Livingstone College, Leyton, E.,
or to the Principal.
After Dr. Harford’s statement, Bishop Mont-
gomery, who presided, warmly commended the
College, and referred to the great benefit which had
been received by the missionaries of the S.P.G. from
its training.
Sir Alfred Pearce Gould pointed out the careful
distinction which should be made between medical
missionaries, who must have a full qualification
June 16, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
191
LL ———————————————————
and students who received elementary medical
training; yet the latter was of vital importance,
particularly in order that the missionary should
safeguard his own health. He would like every
missionary to have nine months at the College
before going abroad, and he would advise mission-
aries on furlough to undergo the training.
The Rev. J. -du Plessis, Secretary of the Missions
of the Dutch Reformed Church in South Africa, now
a student at the College, paid an eloquent testimony
to the advantages of the College as a centre for
Christian union.
The Rey. W. D. Armstrong, as an old student,
stated that by the training received he believed that
he had been enabled to save his own life and that
of his wife in dangerous illness, as well as fellow
missionaries, traders, and other Europeans.
Monsieur Lenoir, Secretary of the Mission
Romande of Switzerland, who had taken a special
journey to England for the purpose, expressed the
congratulations of his society.
A representative gathering of friends and others
interested in missions was present, tea being served
after the meeting in the grounds of the C ollege.
Tyeuvs Fever IN. CrirsA.—We regret to record
the deaths from typhus fever of several well-known
men in China: Dr. Hart, of Wuhu; Dr. G. F.
Jenkins, of Taoyuan; Dr. Robertson, of Hunan;
Professor Luther Knight, of the Chinese Univ ersity
of Chengtu.
Fuanpin and JorTrRaiN (Report of the Société
Médicale des Hôpitaux, La Presse Médicale de
Paris, April 16, 1913, p. 309), having noted the
beneficial effect of emetine on subduing hemorrhage
in ameebic dysentery, tried this drug on a case of
tubercular hemoptysis. The patient was a man
with profuse hemoptysis, which had resisted all
the usual remedies. After an injection of 0°04 C.
of emetine hydrochloride the bleeding stopped
abruptly. This may, of course, only have been a
coincidence, but further observations with this drug
might be inade.
————9P———————
Brugs and Appliances.
A NEW wine food, ' Winox," for which special
features of quality and purity are claimed, has
recently been put upon the market. The analysis
of a well-known authority shows that the product
is exceptionally high in specific gravity and has
a large percentage of nitrogem and phosphoric acid.
This is not due to the addition of drugs, but is
arrived at by using natural grape juice in a con-
centrated form, by which means the organic phos-
phates in the wine are materially increased. The
wine is, moreover, guaranteed to be compounded
exclusively with British beef, and as the extract
employed is prepared by The British Drug Houses,
Ltd., its excellence and purity are assured. The
proprietors have supplied to the medical profession
throughout the United Kingdom the analysis re-
ferred to, which is as follows :—
Specific gravity 1062:20 per cent.
Alcohol (by vol.) 19:12 ,,
Solids 5.8 20:42 ,,
Nitrogen ; rus OLD =
Mineral constituents A 074 a
Phosphoric acid
Equal to 0168 ,,
Phosphate of lime Q367 ,,
Residents in tropical countries should find it
particularly efficacious in cases of lassitude, inertia
and debility, as well as in convalescence from
tropical diseases.
———9—————
Personal Hotes.
Inp1a OFFICE.
From April 5 to May 17.
Arrivals Reported in London. — Lieutenant-Colonel T. W.
Stewart, I.M.S.; Lieutenant.Colonel M. Aker, I.M.S.; Lieu-
tenant Colonel C. Crawford, I.M.S.; Major E. L. Perry,
I.M.S.; Lieutenant Colonel E. Wilkinson, I.M.S.; Major
F. E. Baines, I.M.S. ; Major C. R. Pearce, I.M.S.; Major
C. M. Goodbody, I.M.S. ; Major A. B. Fry, I.M.S. ; Major
A. G. McKendrick, I.M.S. ; Major F. O. N. Mell, I.M.S. ;
Major J. H. McDonald, I.M.S. ; Lieutenant-Colonel J. T.
Calvert, I.M.S. ; Major H. M. Mackenzie, I.M.S.; Captain
P. L. O'Neill, I. M.S.; Captain T. C. Rutherford, I. M.S. ; Cap-
tain J. L. Lunham, I.M.S. ; Lieutenant-Colonel G. W. Jenney,
I.M.S.; Major H. M. Cruddas, I.M.S.; Major E. A. C.
Matthews, I.M.S. ; Captain J. B. D. Hunter, I. M.S. ; Captain
A. E. Grisewood, I.M.S.; Lieutenant.Colonel J. J. Bourke,
I.M.S.; Major W. R. Battye, I.M.S. ; Captain H. E. Stanger-
Leathes, I. M. S. ; Colonel G. F. A. Harris, I. M.S.; Lieutenant-
Colonel C. R. M. Green, I.M.S. ; Lieutenant-Colonel J. Penny,
I.M.8. ; Major V. E. H. Lindesay, LMS.
Extensions of Leave.—Lieutenant-Colonel G. Bidie, M.D.,
I.M.S., 6 m., M.C. ; Captain W. Gillitt, I.M.S., 2 m.; Lieu-
tenant.Colonel R. H. Castor, I.M.S., 6 m., M.C.; Lieutenant-
Colonel K. Prasad. I.M.S., 11 days; Major C. B. Harrison,
I.M.S., 7 days, M.C.; Major de V. Condon, I. M.S.. 10 days ;
Captain W. H. Riddell, 1.M.S., 6 m., M.C.; Captain F. T.
Thompson, I. M.S., to December 11, 1913; Captain M. J. Quirke,
I.M.S., to June 16, 1913 ; Captain R. E. Lloyd, I.M.S.. 9 days ;
Major E. L. Ward, I.M.S., 6 m., M.C. ; Captain J. L. C.
Little, I.M.S., 6 m., M.C. ; Captain S. A. Ruzzak, I.M.S.,
5 m.; Major W. G. Hamilton, I.M.S., 5 days.
Permitted to Return.—Major C. B. Harrison, I.M.S. ; Major
L. P. Stephen, I.M.S.
List or INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CiviL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Battye, Major W. R., I. M.S., India Foreign, Rajpootana.
Bourke, Lieutenant-Colonel J. J., I.M.S., Assay Master,
India, 24 m., February 3, 1913.
Calvert, Lieutenant-Colonel J.
9 m., March 8, 1918.
Crawford, Lieutenant-Colonel J. M., T. M.S., U.P., 8 m. 15d.,
March 7, 1913.
Dennys, Colonel G. W. P., I.M.S., C.P., 8 m., February 28,
1913.
Gage, Major A. T., I.M.S., B., Med. Dept., Botanical Survey.
Grisewood, Captain A. E., E: M.S.
Hunter, Captain J. B. D., I.M.S., 18 m., January 14, 1913.
Lunham, Captain J. L., I.M.S., Bo., 9 m., March 20, 1913.
McDonald, Major J. H., I. 264 Bo., 6 m., March 19, 1913.
McKendrick, ae A. G., I. M.S., 24 m., February 24, 1913.
Mell, Major F. ., 1.M.S., C.P. Gaols, 19 m., March 18,
1913.
Perry, Major E. L., I. M.S., Pun
Rutherford, Captain T. C., IM
March 5, 1913.
T., I.M.S., B., Med. Dept.,
njaub.
5. C.P. Med., 33 m. 18 d.,
192
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 16, 1913.
Wilkinson, Lieutenant-Colonel E., I.M.S., Punjaub Sanitary
Comm.
Woolley, Major J. M., I.M.S., Port Blair.
List oF INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Aker, Lieutenant-Colonel M., I.M.S.
Baines, Major F. E., I.M.S.
Bidie, Major G., I. M.S., to December 20, 1913.
Cruddas, Major H. M., I.M.S., to March 31, 1914.
Graham, Captain D. L., I.M.S., to August 24, 1914.
Jenney, Lieutenant.Colonel G. W., I.M.S.
Mackenzie, Major H. M., I.M.S.
Matthews, Major E. A. C., I.M.S.
Moore, Lieutenant-Colonel C. M., I. M.S., to April 3, 1914.
Nauth, Major B., I. M.S., t» October 14, 1913.
O'Neill, Captain P. L., I.M.S.
Pearce, Major C. R., I M.S., to March 15, 1914.
Quirke, Captain M. J., I. M.S., to June 16, 1913.
Riddell, Captain W. H., I.M.S., to December 18, 1913.
Stanger-Leathes, Captain H. E., I.M.S., to December 13,
1913.
Stewart, Lieutenant Colonel T. W., I.M.S.
Thompson, Captain F. T., I.M.S., to December 11, 1913,
Woods, Captain J., I. M.S., to January 29, 1914.
COLONIAL MEDICAL SERVICES.
West African Medical Staf.
4th June, 1913.
No deaths.
No transfers.
Retirements.—E. E. Maples, M.D., B.S.Lond., F.R.C.S.
Eng., L.R.C.P.Lond., Medical Officer, Southern Nigeria,
retires on pension; C. W. S. Boggs, L.S.A.Lond., Medical
Officer, Gold Coast ; IT. Fleming, M.B., Ch.B., B.A.O. Dublin,
Medical Officer, Sierra Leone.
Resignation. — G. M. Gray, M. D.Glas., F.R.C.S.Eng., Medical
Officer, Southern Nigeria.
New Appointments. —The following gentlemen have been se-
lected for appointment to the Staff: T. A. Dowse, M.R.C.S.
Eng, L.R.C.P.Lond., D.P.H.Cantab, Gold Coast; J. M.
Benson, M.B., Ch.B.Edin., Northern Nigeria; E. H. Mayhew,
M.D., B.C.Cantab, M.R.C. S. Eng., L. R.C. P. Lond. , Sierra Leone;
E. M. Condy, M.B., B.Ch., B.A.O. Dublin, D.P.H.Belfast, Gold
Coast; F. M. P. Rice, M. R.C.S. Eng., L.R.C. P. Lond , Southern
Nigeria; F. E. Whitehead, M.R.C.S.Eng., L.R.C.P.Lond.,
Sierra Leone; G. G. P. Beckett, M.D., B.Ch., B.A.O., L.M.
Dublin, Gold Coast; W. A. Young, M.B., Ch. B.St An irews,
Sierra Leone.
Other Colonies and Protectorates, —E. G. E. Arnold, M.D.Dur-
ham, M.R.C.P.Lond., has been appointed District Medical
Officer, Medical Officer of Health, and member of the local
authority, Lautoka, Fiji; T. R. Boyd, M.B., Ch.B. Édin., has been
selected for appointment as a Medical Officer in Fiji; W. M.
Chambers, L.R C. P. and S. Edin., L. F. P. S.Glas,,has been selected
for appointment as a Medical Officer, in the Federated Malay
States; V. T. W. Eagles, L. R.C.P. and S. Edin., L. R. F.P. and
S.Glas., has been selected for appointment as a Medical Officer in
the Federated Malay States; G. D. Freer, M.B Lond., M.R.C.S.
Eng., L.R.C.P.Lond., D.P.H. (R.C.P.S.Eng.), has been granted
leave from his duties in the Federated Malay States; V. Blacher
Kyle, M.D., B.Ch., B.A.O.Dublin, L.M.Rotunda, has been
selected for appointment as a Medical Officer in the Straits
Settlements; Miss E. M. Layman, M.B., B.S.Lond., has been
selected for an appointment as a Lady Medical Officer in the
Federated Malay States; Miss L. S. McLean, M.B., Ch.B.
St. Andrews, has been selected for appointment as a Lady
Medical Officer in the Federated Malay States; A. J. McClosky,
M.D.Edin., Medical Officer, Grade 1, Federated Malay States,
is acting as Senior Medical Officer, Selangor, Negri Sembilan,
and Pahang, in consequence of the departure on leave of Dr.
G. D. Freer; C. R. Maitland Pattison, L. R.C.P. and S.Irel., L.M.
Irel., has been selected for appointment as an Assistant Medical
Officer at the Leper Asylum, Makogai Island, Fiji; G. S.
Richardson, L.M S.S.A. Lond., has been selected for appoint-
ment as a supernumerary Medical Officer in Jamaica; L. H.
Taylor, M. B., B.S.Lond., M. R.C.S.Eng., L.R.C.P Lond., has
been selected for appointment as a Medical Officer in the
Federated Malay States.
Accent and Current Piterature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JouRNAL OF TROPICAL MEDICINE AND
HyGiENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
** Arizona Medical Journal," Phoenix, April, No. 4.
Undulant Fever.—Yount and Looney report five cases of
undulant fever occurring in Arizona during the past eighteen
months. Their first patient was a goatherd. In June,
1911, he developed fever and malaise, with pain and aching
in the bones. During July the fever and aching were worse,
so that he had to give up his work as a herd. He felt
chilly at times and had profuse perspirations at nights. On
August 4 he took to bed, but did not remain in it all day.
Chills continued at night with profuse perspirations, this
lasting for two months. He did not consult a physician, as
the nearest one was fifty miles away. Later on * rheuma-
iism" developed in the right hip, right leg, and both
shoulders, and constipation continued obstinate. In Febru-
ary, 1912, the right testicle began to swell, and this was
accompanied by slight chills and constant chilly sensa-
tions. The organ swelled to about four times its normal
size and became very tender to pressure. Temperature,
102° F. Blood and serum were drawn off from the testicle,
and gave a positive agglutination with the Micrococcus
meliiensis. "Phe second and third patients used goat's
milk or cereals. The fourth patient used goat's milk
and worked with goats. The fifth patient drank goats
milk and assisted in herding the goats. All the patients
were in some way connected with the goat-raising in-
dustry. [There seems to be no doubt whatever, from
the symptoms described above, that the disease is undulant
fever, and its association with the goats is most striking.|
* Bulletin of Entomological Research,” vol. iv, Part 1,
pp. 1-93, May, 1913.
The above number of the Bulletin contains the following
original articles: * Notes on Insect Pests in Antigua," by
H. A. Ballou; ** On Some Nondescript Anoplura and Mallo-
phaga" (illustrated), by Bruce F. Cummings; ‘‘ Further
Notes on African Culicide " (illustrated), by F. W. Edwards;
“On the Bionomies of the Sandflies (Phlebotomus) of Tokar,
Anglo-Egyptian Sudan,” by Harold H. King; “ Note on an
Entomological Store-box suitable for use in the Tropies,” by
Harold H. King; “Some Observations on the Larva of
Auchmeromyia luteola, F.," by Dr. Robert E. McConnell ;
“The Distribution of Glossina in the Ilorin Province of
Northern Nigeria," by Dr. J. W. Scott Macfie; “On a New
African Species of Coccidte” (illustrated), by Dr. J. W. Scott
Macfie ; “Notes on Scale insects (Coccidæ)” (illustrated),
bv Professor R. Newstead; “On Two Varieties of Glossina
morsitans from Nyasaland,” by Dr. J. O. Shircore ; ‘Ona
New Species of Mymaridie from Trinidad” (illustrated), by
Charles O. Waterhouse.
Aotices to Correspondents,
1.—Manuscripts sent in cannot be returned,
2. —As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4,—Authors desiring reprints of their communications to the
JOURNAL oF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publisners.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
July 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 13, Vol. XVI.
Original Communications.
SOME OBSERVATIONS ON ANKYLOSTOMA
INFECTION IN THE UDI DISTRICT OF
THE CENTRAL PROVINCE, SOUTHERN
NIGERIA.
By E. J. Wyier, M.D.Lond.
West African Medical Staff.
THESE investigations were made with a view to
ascertaining the extent of ankylostoma infection in
the Udi District, and with the idea of trying to
arrive at some estimate of its effect upon the public
health. A few points in connection with treatment
I have thought of sufficient interest to include. The
results set out are based entirely on examination of
the prisoners in Udi jail during a period of eight
consecutive months. The convicts examined came
from over sixty-five different villages, scattered
widely over the district, which is approximately
1,537 square miles in extent. There can be no
doubt, therefore, that they are representative of the
population as a whole (about 460,000), but allow-
ance has to be made in the interpretation of my
statistics for the fact that they are for the most
part persons of young adult or middle age.
Extent of the Infection.—Out of 200 cases
examined 199 were found to be infected, and it
may thus be said that the infection is practically
universal among the natives of the district.
I found both Ankylostoma duodenale and Necator
americanus,
This widespread helminthiasis is due to absence of
all sanitary precautions.
The natives—outside the European station—use
no latrines of any kind. They build their villages
in '' bush," and any more or less retired spot is
used for defecation. The conditions of moisture
and temperature amidst the ‘‘bush’’ are well
suited to the development of the ova, the dissemi-
nation of which is further aided by fowls, which are
everywhere allowed to run at large, and scatter
feces about with their feet after scratching in
them.
Moreover, ‘‘ It has been shown by direct experi-
ment that ankylostoma eggs can be fed to chickens,
and larvæ readily hatched from the eggs when they
are subsequently passed by the fowls. In this way
infection might be disseminated very widely. Pos-
sibly also by flies ’’[3].
Ova were quickly found (within a minute or two
and often seen in the first field) in 187 out of the
200 cases. In only one ease had a second or third
slide from the first sample of dejecta examined to
be prepared. In nine cases no ova were found in
the first sample of dejecta examined, but were found
in the second sample. In one ease no ova were
found in the first two samples, but were found in
the third sample. The dejecta were in all cases
examined without subjection to special treatment
for separation of ova. From consideration of these
facts I conclude that the average infection is a heavy
one.
The dejecta of the uninfected case were examined
five times at intervals of two weeks, only Tricho-
céphalus trichiura ova being found. This case ‘s
of interest in that the subject was a man of some
edueation, formerly an interpreter, who had worn
boots for seventeen years. All the other prisoners
were '' bush '" men and women belonging, with few
exceptions, to the Ibo tribe.
ASSOCIATION OF ANKYLOSTOMA WITH OTHER
HkELMINTHS.
In a series of 200 infected cases :—
In 44 per cent. ankylostoma was the only infec-
tion.
In 124 per cent. it occurred with Ascaris lum-
bricoides.
In 29 per cent. it occurred with Trichocephalus
trichiura.
In 124 per cent. it occurred with ascaris and
trichocephalus.
In 2 per cent. it occurred with teniasis and
trichocephalus.
ANEMIA.
With the exception of a varying degree of eosino-
philia, and occasionally some micro- and poikilo-
cytosis, blood films showed no abnormality due to
helminthiasis. This was even so in the cases (see
below) with cedema of the feet and cardiac dilatation
due to anemia,
Of 100 consecutive hemoglobin estimations :—
6 had 60 per cent. hemoglobin.
8
” 65 ” ”
29 19 70 ” ”
23 , 80- ,, T
14 ” 90 Él LEd ”
21 ,, 100 35 »
In this connection it may be pointed out that the
degree of anemia found by different workers in
ankylostome infected localities varies considerably.
Thus in one series of cases in Porto Rico '' about
half the agricultural population (i.e., about 800,000
persons) appear to have had 50 per cent. or less of
hemoglobin. This is in marked contrast to the
degree of anremia found among Belgian coal miners.
Of 200 cases recorded by Hermann and Dascotte,
only two had less than 60 per cent.''[3].
By reason of the kind of instrument I was using
(Hall’s rotary hemoglobinometer) I can only claim
approximate accuracy for my figures, but it will be
seen that the degree of anemia agrees on the whole
with that found by Hermann and Dascotte.
‘t In 1899 Ashford found (in Porto Rico) that the
prevalent anemia was due to ankylostoma and not
to malaria and bad food, as had been commonly
supposed ’’[3].
From observation of the effect of treatment, I
think that this remark is probably equally true of
the anemia prevalent here.
CIRCULATORY CHANGES,
Out of 200 cases :—
Cardiac dilatation with hemic bruits was present
in six cases (—8 per cent.) All improved after
thymol treatment.
194
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1913.
- -Œdema. of the feet, not. ascribable to any other
cause than ankylostoma infection and cured by
tréatment with thymol, occurred in four cases
(=2 per cent.).
Of 100 pulse-rate estimations (taken with due
regard to the avoidance of variations dependent
upon emotion) :—
Fifty-four were normal (72).
Thirty-six had bradycardia (three of these had a
rate of between 42 and 48 per minute; seven had a
rate of between 50 and 54; and twenty-six a rate of
between 57 and 62).
Ten had tachycardia (seven of these had a rate of
between 82 and 87 per minute, and three had a rate
of 96).
While, of course, small variations from the normal
are of no clinical significance, the high proportion
of cases with brady- and tachycardia seems to me to
be worthy of record. In no case was the pulse
irregular in rhythm.
TEMPERATURE.
Under the conditions of prison practice in a
'' bush ” station I found it was not feasible to take
continual temperature readings. I found, however,
‘that the pulse-rates appeared on the whole to bear
no definite and consistent relation to the tempera-
ture,
DIGESTIVE DISTURBANCE.
The number of cases of digestive trouble (epi-
gastric pain, diarrhea, &c.) were relatively numer-
ous. I have, however, not thought it worth while
to give statistics under this head, since change of
diet and conditions of life incidental to incarceration,
and concomitant helminthic infections make it im-
possible to ascribe such symptoms directly to anky-
lostoma. But there is, of course, no doubt that
this infection predisposes to such troubles,
SKIN LESIONS.
None of my cases showed any evidence of infec-
‘tion through the skin of the feet (ground itch), nor
have I met with any such evidence in the district.
In my hospital practice, however, a very large
number of natives haye presented themselves com-
plaining of an itching eruption on the nates and
thighs, often occurring in repeated attacks, and
occupying the part of the buttock and thigh which,
‘in squatting and reclining, would be in contact with
the ground. The eruption is papular and discrete ;
never vesicular; occasionally with a superimposed
‘pus infection.
I venture to suggest, though with some hesitation,
that ‘this may be a site of entry of ankylostoma
infection.
TREATMENT,
There appears to be no doubt that thymol is the
most efficient anthelmintic for this disease [8]. I
have found it perfectly safe, and from perusal of
some of the literature on the subject one feels bound
'to conelude [4] that many of the evil effects ascribed
to the drug are really due to improper administra-
tion. Some writers advocate a light or fluid diet on
the day preceding treatment. But it seems to me of
the greatest importance that no food whatever should
be given on the day preceding the administration of
the drug, or on the day itself until at least six hours
after the last dose of thymol, and I think it very
probable that neglect of this precaution has some-
times enabled sufficient fat or oil to gain admission
to the intestinal tract to cause a toxic dose to be dis-
solved and absorbed. (I have made it an invariable
rule to exclude meat—on account of the accompany-
ing fat—and also, of course, palm oil from the first
meal after treatment.) Though the number of cases
treated by me by the 90 gr. method (see below) is
too small to enable absolute conclusions to be
drawn, the fact that no toxie symptoms of any kind
were displayed in any of my cases suggests that
with proper precautions the drug may be adminis-
tered in this dose with safety.
It was given in the following way when the 90 gr.
dose was employed :— `
(1) On the previous day no food of any kind, and
at 4 p.m. 6 drachms of sulphate of magnesium.
(2) On the following morning :—
At 6 a.m. 30 gr. of thymol
At 7 a.m. 30 ,, T
At B a.m. 30 ,, n
At 4 p.m.* 6 dr. mag. sulph.
(3) From 6 a.m. until noon the patients were kept
recumbent,
When the 60 and the 40 gr. dose was employed
it was given in two equal doses, one at 6 a.m. and
the other at 7 a.m., with the precautions above
described.
The thymol was always given in a finely triturated
state and washed down with a little water. The
two smaller doses were tried in order to ascertain
whether an efficient anthelmintic action could be
obtained with them, but they were soon abandoned
in favour of the 90 gr. dose.
The dejecta, not specially treated for the separa-
tion of ova, were examined one week after thymol
administration, with the following result :—
Of seventeen prisoners who received the 40 gr.
treatment ova were found in eight (—47 per cent.).
Of forty-seven prisoners who received the 60 gr.
treatment ova were found in fourteen (= 29:7 per
cent.).
Of fifty-seven prisoners who received the 90 gr.
treatment ova were found in six (— 10:5 per cent.).
The examination of the dejecta as I have carried
it out is only, of course, a very rough test of the
relative efficiency of the 90 gr. treatment, but I give
the figures for what they are worth.
It would seem desirable in a routine practice to
give at any rate two 90 gr. treatments, since only
a certain proportion of the worms (about 90 per
cent.) are expelled at the first onslaught.
* This hour was chosen on account of its convenience in
prison practice.
July 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
195
CONCLUSIONS.
Hook-worm infection is practically universal
among the natives of the Udi District:
The average individual infection is a heavy one.
Both Ankylostoma duodenale and Necator ameri-
canus are found,
Pure infections occur in about 44 per cent. of the
cases.
About 79 per cent. of the population is anemic,
though the anemia is rarely profound.
Approximately half the adult population has a
normal pulse-rate.
Ground itch does not occur (on the feet).
The 90 gr. thymol treatment is probably quite
safe when given with proper proportions.
REMARKS.
An observer of the Ibo people of this district
cannot fail to be struck by their general poor
standard of physique, their incapacity as carriers
and workers, and their obvious disinclination for
bodily exertion.
As testimony to their indolence and poor physique,
I cite the following remarks of Mr. G. H. Fleming,
Chief Surveyor, Onitsha-Udi Railway Survey,
whose wide experience of West African negroes
lends additional emphasis to his views. In a letter
to me, from which he kindly allows me to quote,
he says :—
“ I have had the following different tribes working
for me during the past twelve years: Timinies and
Mendies (Sierra Leone); Kroo, Waussa, and Fantis
(Gold Coast); Yoruba, Haussa, and Ibo (Southern
Nigeria).
'" Out of the whole lot I find that the Ibo is the
most indolent.
"The Mendies are the best workers as labourers;
a man will do double the amount of work in one day
that an Ibo will do. The Ibo is also a poor carrier.”
It would be of no small interest to know precisely
to what extent the tribes mentioned by Mr. Fleming
are infected by the hook-worm, for it seems not
improbable that the saturation of the inhabitants
of this distriet with ankylostoma infection, bringing
in its train grave systematic changes, probably pro-
duced by. actual toxic absorption [5] (Weinberg)
and other minor changes, such as digestive troubles,
which, though transient, are none the less pro-
duetive of considerable disability, is largely re-
sponsible for some of the tribal characteristics of
the Ibos in these parts, and that these features are
not aseribable either to malaria or bad food per sc.
Moulded as are the characters of tribes, as of
nations and individuals, to a great extent by their
physical conditions, I think that we may have here
à picture of the effect of chronic poisoning by an
intestinal parasite on a large community. In the
words of Boycott (Milroy Lectures, 1911) :—
“ Taking the world as a whole, with the possible
exception of the malarial organisms, ankylostoma is,
suppose, responsible for more unhappiness and in-:.
efficiency than any other parasite, and, for the most `
part indirectly, for no inconsiderable number of
deaths. Praetieally all tropieal countries are per-
meated with the worm, and in places where the
conditions for its propagation are not: unfavourable
it may reduce four-fifths of the population. to a
continual state of chronic ill-health which is only
terminated by their premature decease, commonly
from some secondary infection.”
A knowledge of the exact geographical dis-
tribution beyond the Udi borders of the heavy
infection which obtains here would certainly afford
no little assistance in arriving at a just estimation
of its economic effect upon the people.
The great prevalence of the infection, with all its
attendant disabilities, is of massive importance, not
only from the standpoint of the medical officer or
of the student of eugenics, but also from its
influence, probably profound, on commercial
prosperity [2].
And in view of the mining operations which will
shortly be in progress in the Udi District, ankylos-
toma here assumes a very definite economic import-
ance in connection both with European and native
labour, to which the extensive measures that have
had to be taken against the infection. in the. coal
districts of Belgium, of Northern France, of West-
phalia, and in the metalliferous mines of Cornwall,
amply testify. j
REFERENCES.
[1] BuRTON Nicor. ‘‘ Observations on the Effect of various
Drugs in Expelling Hook-worms," JOURNAL OF "lROPICAL
MEDICINE AND HYGIENE, January, 1912.
[2] Si& Patrick Manson. “Tropical Diseases," 4th ed.,
. 120.
j sd A. E. Bovcorr.
Lectures, 1911.
[4] E. E. LINDEMAN. *'Treatment of Hook-worm Disease,”
Journal of American Medical Association, 1910.
[5] Stccarpr. Archives de Parasitologie, vol. xii, 1910.
“Ankylostoma, Infection," Milroy
A REPORT ON ANKYLOSTOMIASIS IN, THE
NORTH NYASA DISTRICT.
By P. C. CONRAN.,
Lately Medical Officer, Karonga, Nyasaland.
In June, 1912, on my assumption of duty as
Medical Officer at Karonga, I was requested by the
Principal Medical Officer to investigate the extent
of ankylostomiasis infection in the distriet. In the
course of my observations I found that a large
number of cases were complicated by the presence
of other helminths in the intestines, notably Schis-
tosomum himatobium, so that these also are
ineluded in my report. i
It is noteworthy that my observations extended
over the dry period of the year only, that is to say,
the period during which the minimum number of
infections occur.
The fact of my arrival becoming known, a large
number of natives came to the dispensary for treat-
ment, not only from Karonga itself, but also from
distant villages. ;
A large number of these complained of pain in
the epigastrium, ‘‘as if something were biting them
inside," accompanied by constipation or diarrhea,
often with blood in the stools, examination of which
196
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1913.
revealed the presence of ova of ankylostomum,
schistosomum, or both.
The numbér of cases which came for treatment
showed that there must be a very great many
natives who, while harbouring parasites, refrained
from coming owing to lack of severe symptoms or
for other reasons.
I now proceeded to make preparations from the
stools of 522 natives who were taken, haphazard and
irrespective of age or sex, from Karonga and the
adjoining villages.
These preparations were examined after as short
* an interval as possible, and the presence or absence
of ova noted. My results are seen in Tables I to
IV.
TABLE I.
Ova Number of persons Percentage of total
infected number examined
Ankylostomum m 211 40:42
Schistosomum Ves 169 32:38
Ascaris "T RE 47 9:0
Trichocephalus is 8 1:54
Negative "e ies 87 16:66
A MM MÀ MÀ M MÀ A—
TABLE II.
p o——————————————————————————ÀÀ1
Ova Men. Women, Boys. Girls | Infants
Per cent. | Per cent. | Per cent. | Per cent. | Per cent,
Ankylostomum 44:0 4907 | 30:0 92:35 45:83
Schistosomum...| 31:0 16:0 48:57 44:12 29:17
Ascaris ... à 50 11:33 1:43 8:82 22:92
Trichocephalus 1-0 1:33 1:43 2-94 2:08
TABLE IIT.
— Á——ÓP—M——Órá— €
| Chisindiri , Kambombo PERET
M b
Ova Per cent. Per cent. Per cent, Por oant
Ankylostomum | 41:6 254 434 | 509
Schistosomum .. | 31:6 | 381 38:5 38:18
Ascaris ... i 3:3 6:3 13:2 10:9
Trichocsphalus | | — | =- | 2:4 =
TABLE IV.
|
Ova Number of | Percentage of total
persons infected | number examined,
|
Ankylostomum alone 149 28:54
Ankylostomrnum and
Schistosomum ... 62 | 11°85
Schistosomum E 98 18°77
Table I shows the number of individuals infected
with ankylostomum, schistosomum, ascaris, and
trichocephalus respectively, each number expressed
both in actual figures and as a percentage of the
whole number examined.
The schistosomum ova were in nearly every case
of the lateral-spined variety. In a few instances,
however, terminal-spined ova were seen, possibly
owing to admixture of urine with the stool.
Table II shows the comparative incidence of the
infection in the case of men, women, boys, girls,
and infants.
The result of the extent of the disease among
children is seen in the exceedingly high infant mor-
tality in the district, diseases from which a healthy
child would easily recover proving fatal owing to
lack of resisting power.
Table III shows the variation observed in regard
to loeality in some of the larger villages of the
neighbourhood.
It is noteworthy that Mwangolera and Mwan-
bungo, the distriets with the highest percentage of
ankylostomum infections, lie inland at some dis-
tance from the shore of the Lake, while Chisindiri
and Kambombo are near the mouth of the River
Rukuru.
In the two former districts the whole population
derives its water supply from the Upper Rukuru
and its tributaries or from shallow pools; in the two
latter, from the Lake or the wide mouth of the
river. As regards race, the bulk of the population
round Karonga is Wankonde; Chisindiri, however,
is a Wahenga village.
Table IV indieates the relative number of pure
and of mixed infections in the case of ankylostomum
and schistosomum.
Judging from my observations, melena is never
observed with the naked eye in the case of a pure
ankylostomum infection. When schistosomum is
present, however, the case may closely simulate one
of dysentery, almost pure blood being passed with
mucus, and accompanied by marked griping and
tenesmus.
Having by this time ascertained to some extent
the condition of the Karonga distriet, which prob-
ably typifies the whole strip of flat country lying
along the shore of the Lake between it and the
inland hills, I proceeded to Fort Hill, which is
situated at an elevation of 4,400 ft. and at a dis-
tance of about 40 miles from the Lake. Here I
examined the stools of 100 natives from the small
TaBLE V.
————————
r Number of pers: infected
Ova out of 100 examined
Ankylostomum ... es: 39 13
Schistosomum ... ei ais 11
Ascaris — ... ae 55 "T 7
Trichocephalus ... ^ $55 2
Negative ... 3i aye én 67
Taste VI,
—— — eel
|
Ova Men Women Boys Girls
Per cent. Per cent. Per cent. Per cent.
Ankylostomum 15 79 16 29 12:0 5:26
Schistosomum . A 10:53 811 | 8-0 21:03
Ascaris ... $ 5°26 541 8-0 10°53
Trichocephalus — -- 40 5:96
Lc ———— — ———————————————————————————
July 1, 1918.]
THE JOURNAL OF TROPICAL. MEDICINE AND HYGIENE.
197
and scattered mountain villages. My results are
shown in Tables V and VI. These natives were
mostly of the Mambwe tribe, and their water-supply
is derived from mud-holes, shallow pools, and
streams which are rapidly flowing during the rains,
but almost stagnant during the dry season, at the
latter end of which they are represented by a series
of pools.
In Deeember I was transferred elsewhere, but I
venture to think that the foregoing statements are
sufficient to indicate with some degree of accuracy
the state of North Nyasa in general as regards
infection with the helminths considered.
Bass states that, in examining stools for anky-
lostomum ova, some 20 cases per cent. examined
are missed. This being so, the true number of
natives infected at the Lake level is probably 60
per cent. of the total, and in the hills about 38 per
cent.
A few observations on the subject of the chief
symptoms and signs observed in my cases of anky-
lostomiasis, and of the chief difficulties to be over-
come in the institution of efficient prophylaxis, may
not be out of place.
Most of the symptoms usually described were
observed, but certain of them were particularly
emphasized. Of these the most constant were pain
and tenderness in the epigastric region, symptoms
of which all the cases who caine for treatment com-
plained. Next, in order of frequency, came
dyspnea, palpitation, weakness, dizziness, head-
ache.
Joint pains, simulating rheumatism, were com-
mon. Many patients complained of blood passed
with the motions, but this was invariably accounted
for by the presence of schistosomum infection.
From information indirectly obtained it seems
certain that earth-eating is common, especially
among children. Every patient, however, stoutly
denies the fact when questioned concerning his own
case.
The chief signs were a dull, listless, vacant
expression ; a coated, flabby, enlarged tongue ; rapid,
low-tension pulse; hemic murmurs, and flabby
muscles.
No reliable information concerning ground itch
could be obtained, owing to the fact that my
observations were made during the dry season. Few
cases had any recollection of a definite attack.
Treatment, whether with thymol, Beta-naphthol,
or eucalyptus and castor oil was most successful,
especially when the vermifuge was followed by a
short course of iron.
In every case the patient at once began to put
on weight, his intellect became clearer, the trouble-
some symptoms disappeared, and his capacity for
work increased daily,
Prophylaxis offers difficulties which cannot be
appreciated unless one is already acquainted in some
measure with the special local condition in North
Nyasa, so that the following short description of
these may be of use.
The natives of the district belong to various
tribes, of which the chief are the Wankonde and the
Wahenga, who inhabit the strip of low-lying land
along the shore of Lake Nyasa, and a large portion
of the mountainous hinterland as well.
Several other tribes are scattered among the hills
to the north and west, such as the Mambwe and
Awemba, and, with a few Swahili and Arabs, com-
plete the entire population.
As regards their mode of living, for the present
purpose all the aforesaid tribes can be classed
together. All live in so-called villages which, for
the most part, consist of widely scattered groups of
huts, each group being connected with the rest of
the village by narrow bush paths. Each village
thus covers a large area and has no definite boun-
daries, and, although there is a headman, his
authority, such as it is, only extends over the imme-
diate neighbourhood of his own hut,
The Wankonde and, to a less extent, the other
tribes are enthusiastic cattle breeders, and all grow
maize, millet, and other grain, almost everyone
working in the fields during the months immediately
preceding and during the rains.
Their diet is mainly vegetarian, but fowls, eggs,
and fish are used as a relish, fish being caught for
the most part during the rains.
It is of interest to note that Looss states that a
pure vegetable diet produces a less favourable
medium for ankylostomum ova than a mixed diet.
Now both fish and fowls are more abundant near
the Lake, where ankylostomiasis is rife, than in the
hills, where it is comparatively rare.
Their water-supply is derived to a very small
extent from the Lake; more often from rivers and
their tributaries, especially during the rains; most
often, at any rate, during the dry season from
muddy water-holes.
Defecation and micturition are performed, when-
ever the desire arises, at the nearest spot sheltered,
or partly sheltered, from the public gaze. If the
person concerned is on a path he steps into the bush
or one side of it; if in a village he makes his way to
the nearest clump of bushes, a shady spot that has
probably been used for years for the same purpose,
and which, every rainy season, must be saturated
with very slightly diluted feces mixed with the
sandy soil. During the night he is afraid to venture
so far from his hut, and merely goes a few yards
from his door to a spot where his children may be
playing about next day.
In the bush near a village, therefore, we have,
during the rains, all the chief factors favourable to
the existence of ankylostomum infection in a district,
namely, a high temperature, the optimum being
from 77° to 95° F., moisture, shade, and dilution
of the feces with sand. So that, during at least
five months in the year, natural conditions and the
habits of the people combine to produce an ideal
state of things for the production of ankylosto-
miasis on a vast scale.
In the dry cool months from May to September,
however, and even in the heat of October and
November, the conditions are much less favourable
to the spread of the disease. The south-west wind
dries up the soil; the temperature falls below the
optimum; the long grass withers and the leaves fall
from the trees, allowing the direct sunlight to reach
198
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1913.
the soil. There are now- no rains to scatter the
feces, mix them with sand, and help to apply the
infective material to the skin.
In addition, the soil over a great part of the
district is very efficiently disinfected, for the natives,
in order to prepare it for cultivation, kindle the long
grass, and great bush fires sweep over the country,
sterilizing the surface of the ground. These fires
are allowed to burn close to the huts, and by the
end of November a comparatively small area of the
bush is left untouched.
Thus one would expect that there would be an
annual rise in the number of fresh and of acute
cases of ankylostomiasis during the rains, followed
by an annual fall during the dry season, and my
observations fully confirmed this view.
Any patient, when questioned, will date his
troubles from the rainy season, and, although no
reliable statistics are obtainable, the constant sound
of wailing throughout the district testifies to the
great rise in the mortality at this time of the year.
The above brief description of the local conditions
will, I hope, make it clear that before any prophy-
lactic measures can be successfully applied a drastic
reform of the village system is necessary.
Preventive measures, to be effective, must attain
three objects : —
(1) To destroy the mature worms in the bodies of
the population.
(2) To prevent the growth and existence of larve
in the places where they develop.
(3) To prevent infection by larve that have
developed.
(1) The first object can .be effected by a
systematic examination of the natives, and treat-
ment of those in whose motions ova are found.
Under present conditions this would be a most
difficult task, but with concentration of the villages,
the installation of responsible headmen, and a
census of the population, it would be rendered
comparatively simple.
(2) The second object resolves itself into the
prevention of soil infection. If an efficient publie
latrine were installed in each village and the
inhabitants induced to use it, the disease would
steadily decrease and eventually disappear.
Here, again, the scattered arrangement of the
huts and the lack of any local authority nullify
any efforts in this direction. Under improved con-
ditions each headman would be responsible for the
sanitary state of his village, and by periodical visits
from the Medical Officer or Resident would be
induced to do his duty.
The latrine should be of as simple a deseription
as possible, such as a deep trench or pit, sheltered
by an open thatched shed, and so situated that it
cannot be flooded during the rains.
(3) Prevention of infection by larve is to be
effected only by educating the natives with regard
to the subject. This, under improved conditions,
could be done firstly through the village headman ;
secondly, through the native teachers at the mission
schools. A few of the headmen to whom I have
spoken on the subject quite realize the gravity of the
situation, and would willingly assist the Medical
Officer. The native teachers for the most part have
been educated at Livingstonia, where great interest
is taken in the subject, and the Minister at Karonga
would gladly arrange for the instruction of the
members of his school.
ON THE IDENTITY OF INFANTILE AND
DONOVAN'S LEISHMANIA (KALA-AZAR).
By Professor UMBERTO GaBBI.
Rome.
MARSHALL's [1] recent experiments with regard to
the susceptibility of Sudanese dogs to the infection
of Leishmania from the splenic juice of individuals
suffering from kala-azar are of no small value, when
one considers that in the Sudan, beside the cases
which oceur in infancy and adolescence, some adult
cases are also found [2].
Wenyon [3] and Mayer [4] both have maintained
that Sudanese Leishmania is almost identical with
Mediterranean kala-azar, but definite proof was
lacking of the susceptibility of dogs to infection by
the human virus. This has now been obtained, how-
ever, by the above-mentioned experiments, from
which it follows that dogs, especially very young
ones, are easily infected. Sudanese Leishmania
(kala-azar) is thus shown to be identical with that
of the Mediterranean Basin, since it is capable of
infecting dogs as well as monkeys (51, and thus the
difference in age disappears entirely.
From previous experiments, also by Marshall, it
has been shown that the parasite lives not only in
the N.N.N. medium (Nicolle’s modification of Novy
and MacNeal’s medium), but also in citrated blood,
which, according to some, is not the case with the
Italo-Tunisian Leishmania. In this connection it is
right to mention what Nicolle [6] has written with
reference to this point :—
“ Rogers has obtained cultures from the blood
of rats, to which sodium citrate had been added,
but these cultures could not be transplanted, and
in the opinion of other authors who have performed
the same experiments, they cannot be obtained
with any certainty of result. I have failed in two
attempts that I have made with this medium, but
my failure signifies nothing."
In Italy, both Jemma and Lorgo obtained positive
results, and recently Spagniolio also. It is there-
fore a matter of astonishment that any should
insist on this difference in character, because they
have not succeeded, out of a limited number of
experiments (six), in obtaining the culture (Pianese,
Petrone), whilst Nicolle, who can really speak with
authority on the subject, has written what we have
quoted above. Nicolle [7], however, insisted neither
on this, nor eyen on the characteristic of the non-
infectibility of Indian dogs, nor on that of age, for
he writes: '' For this reason, without waiting for
proof to be given me of the susceptibility of the
dog to the Indian virus, I admit, and declare that
I believe kala-azar to be one disease and indivisible
in whatever country it js seen in, and whatever the
age of the subject.”
July 1, 1913.]
After the recent investigations which have caused
the disappearance even of the smallest differences,
it seems strange that he should have taken back his
old opinion, without any proof to the contrary, and,
without being attacked, have given himself up to a
lively controversy.
The reader must judge for himself, and will
appreciate his conduct. As for me, I can only
conclude that Marshall's experiments deal a final
blow to the theory of difference, founded on a flaw
by those who, in full daylight, close their eyes and
say that the sun does not shine, because they refuse
to look at it. Their contradictions enable us to
judge of the logieal value of their arguments on
the question which is before us.
LITERATURE,
[1] MansHaLr. Journal of the Royal Army Medical Corps,
September, 1912.
[2] BocsrrELp. Transactions of the Society of Tropical
Medicine and Hygiene, April, 1912.
(3) Wenyon. Kala-azar, Bulletin No. 3, p. 162.
[4] M. Mayer. ‘‘ Uber Leishmanien." (‘‘ Handbuch der
pathog. mikroorg." Kelle und Wassermann. E. Fischer, 1912.)
[5] MansHanr. Journal of the Royal Army Medical Corps,
September, 1911, p. 255.
(6] NicorrLE. Archives de l'Institut. Pasteur de Tunis, 1911.
No. 2, p. 125.
[7] Arch. de V Institut Pasteur de Tunis, 1909. No. 2, May.
(In this number, on p. 124, he writes as follows: ‘It is
known on the other hand that there have been authenticated
cases of adult kala-azar in Egypt and in Crete." While he has
written recently: ''It is well to know that in Mediterranean
countries the existence of adult kala-azar still remains to be
proved!!!" Arch. de l'Inst. No. 3, 1912, p. 196.)
a
* Lancet," June 21,1913.
A Spirochete in the Blood.—Helen Chambers describes
a new spirochete found in human blood. She states that
the organism is extremely common, so much so that it occurs
in almost every specimen of blood examined, whether from
the sick or healthy. She describes the technique which is
required to demonstrate it. So far successful cultivations
have not been obtained. She concludes that the organism is
identical with some of the numerous forms of spirochæte
which occur on ulcerated lesions and that the pathogenic
effects of the organism, if any, have still to be determined.
{In the Lancet of June 28, 1913, Balfour, Hunt and
McLeod all write to say that this supposed new organism
is only a fallacy, and is not a real parasite. ]
“Indian Medical Gazette,” June, 1913.
Spirochetosis in the Darjeeling District.—Jukes states
that during the months of September and October, 1912,
he had the opportunity of commencing the investigation
of some cases of fever caused by a spirochete, which he
believes to be hitherto undescribed. The materials were
very scanty, but sufficient, he thinks, to enable him to draw
some conclusions from them.
In every case the illness was severe. The temperature
was irregular and showed no resemblance to that of relapsing
fever. No relapses occurred in the case of those who re-
covered.
The spirochetes disappeared before death or recovery,
and their disappearance was accompanied by a leucocytosis,
and there appeared to be no crisis.
Jukes is disposed to regard this as a fever caused by
spirochetes, and hitherto undescribed; there are many
points about it, however, which require further study, and
it would be unwise, he thinks, to speak too certainly about it
for the present.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
199
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THE JOURNAL OF
Tropical Medictne andHpgiene
JuLY 1, 1913.
THE DEATH OF A GREAT CLINICIAN.
Sin Jonatuan HvrcuiNsoN's death removes from
amongst us one who was the greatest clinician of
his time. He has been styled the foremost general
practitioner of his day, a tribute to his ability which
implies a mastery of many subjects, and indicates
his all-pervading knowledge. Surgery claimed his
energies in the first instance, and his services to
the science and art of this branch of medicine
were conspicuous even at a period when such men
as Syme and Ferguson flourished, when Paget
laid the foundations of surgical pathology, and
when by the genius of Lister modern surgical
methods were initiated and established. But
surgery pure and simple was not sufficient in its
scope to satisfy one endowed with Hutchinson’s
abilities and fertility of mind. As an ophthal-
mologist he attained pre-eminence; and as a
dermatologist his investigations and observations
have become classical. Nor was the range of his
200
studies limited by immediate professional work.
In several branches of science Hutchinson found
recreation; and the members of the London Poly-
clinic must recall with pleasure, when at a demon-
stration clinical material gave out, how they were
fascinated and instructed by some of the great
master’s addenda on subjects of a biological or
purely botanical nature. Even as a farmer
Hutchinson’s pure-bred shorthorns attained con-
siderable fame. Many-sided to a degree, he
touched no subject he did not illuminate and
advance. His professional work depended for its
foundation, development and conclusions on patient
observations and careful records. The observations
he rejoiced in were ‘purely clinical, that is, signs
and symptoms as opposed to laboratory work as
we know it to-day. The microscope, when
Hutchinson began to study disease, played but an
unimportant part in medicine, and applied bacteri-
ology was unknown. It may perhaps be said of
Hutchinson that he was the last of the great
clinicians of the old school. Jenner knew nothing
of modern laboratory methods, yet by clinical study
alone he settled the diagnosis of typhoid for all
time. Hutchinson placed the subject of the
heredity of syphilis on a scientific basis by years
of patient clinical study. On several occasions the
writer has been favoured with his remarks on
modern methods in relation to clinical observations.
None of these were perhaps more pertinent than
when the subject of the relations of yaws to
syphilis was brought forward. Hutchinson long
maintained that yaws and syphilis were related,
and held that in fact yaws was the original source
of modern syphilis. Shortly after the spirochete
was found in syphilis Castellani found a spirochete
in yaws. The writer hastened to inform Hutchin-
son of the fact, and congratulated him that the two
diseases he long thought associated were now proved
to be allied etiologically if not identical, thereby
confirming his previous statements. His good-
natured smile was tinged with something akin to
amusement and deprecation as he remarked:
“There was no need of microscopic investigation
to prove that point; more attention to the study of
disease, and less time spent on culturing microbes
in test tubes would be better for the individual and
for our increase of knowledge. Mind you, I do not
wish to detraet from laboratory work or say a word
against it, but I would like to see disease studied
more at the bedside and at our clinies than it is
to-day. Mere test-tube knowledge will never make
a capable practitioner of medicine; that can only be
done at the bedside and by careful observation and
study." Hutchinson was always very concerned
at the absence of what he called the “study of
disease '’ at the present day, and in no department
was he more outspoken than when talking about
ophthalmology. He held that ‘‘ ophthalmic men
all over the world were devoting themselves to the
adjustment of spectacles, but that no one as far as
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1913.
he could make out was working at the diseases of
the eye." All these no doubt seem old-fashioned
notions and out-of-date ideas to modern clinicians
who look upon the ward laboratory as an
essential addition to our methods of diagnosis
and the rational treatment of disease. We are
not all Jenners and Hutchinsons, and the faculty
of observation and the study of the meaning of
signs and symptoms are given but to few, so we
are thankful for the presence of laboratory workers
amongst us to help us in our dilemmas and to clear
up faulty diagnosis. Yet it must come about that
the very fact that we rely more and more upon
these welcome adjuvants, so the less are we called
upon to develop the faculty of observation, which
perhaps reached its climax with the two great
clinicians referred to.
Sir Jonathan Hutchinson's name will ever be asso-
ciated with the study of leprosy, and more especially
with his well-known belief that to uncooked and
ill-preserved fish was to be traced the cause of
leprosy. He had few, if any, actual believers in
this theory of his, and the chief work of leprologists
during the past quarter of a century has been to
refute this doctrine. The absence of bacteriological
confirmation of his idea carried little or no weight
with him; he had anticipated several such relation-
ships in other directions which laboratory workers
had proved to be correct, and he regarded their
announcements with a little touch of amusement
when he was told of these corroborations. Similarly,
their want of confirmation was as amusedly smiled
upon when it was represented to him. His belief
in his observations in the relationship of fish eating
to leprosy, in spite of world-wide opposition, was
brought home to everyone by the journey of Hutchin-
son, when well-nigh an octogenarian, to India and
South Africa, where with the keenness of the most
ardent youthful enthusiast he scoured these
countries, note-book in hand, in the quest of
evidence to support his contention. We may or
may not agree with his belief in this matter, but
we cannot but admire the enthusiasm, the clinical
acumen, the wide knowledge, and, above all, the
power of observation possessed by this remarkable
man. He has lived to the ripe age of 85, and not
a moment of his life has been wasted. In even his
exercises he was studying and observing; a country
walk was but an opportunity for studying geology,
to which he was devoted; the natural history
of the fields, the hedgerows, the ponds, the rivers,
the forests, and the birds and other game that fell
to his gun. The museums he founded and
developed at Haslemere, in Surrey, where he lived,
and at Selby, in Yorkshire, where he was born,
wil remain as permanent monuments to his
memory; and it is to be hoped that the Polyclinic
in London, to which he devoted his time, his
talents, and his money will be developed into a
national institution in commemoration of the genius
of a great man.
July 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
201
Annotations.
Liver Abscess and the Emetine Treatment. — Marvel-
lous results of the treatment of amcebic dysentery and
amebiasis generally with emetine continue to be
reported. Sewell (Journal of the Royal Army Medical
Corps, No. 6, June, 1918, vol. xx) now reports a case
of amaebic abscess of the liver which had burst into
the lung, cured by emetine hydrochloride. After
rupture of the abscess into the lung the cavity in the
liver was opened and drained, but though improve-
ment was at first noticed pus began to be discharged
again through the lung in inereasing amounts. A
second operation on the liver was performed and
pus again found, but though, just as before, a slight
improvement appeared, the patient soon relapsed into
his old condition. Sewell then tried injecting emetine
hydrochloride, starting with a third of a grain and
increasing the amounts until 24 grains in all had been
taken. After this treatment the patient's general
health improved rapidly. He regained his appetite,
slept well, and felt a new man. His cough improved
at once, and the sputum gradually diminished in
quantity, until eleven days after the commencement
of the treatment the cough and expectoration ceased
altogether.
The discharge from the tube, which was very free
before emetine was given, also decreased rapidly, and
the tube was finally removed.
After this the only difficulty was in supplying him
with as much food as he wanted, and he left for
England on board the transport " Rohilla," in the
best of health, and weighing 9 st. 13 lb., having gained
2 st. 1 Ib. in six weeks.
The Health of the Canal Zone.—John L. Phillips,
Acting Chief Sanitary Officer of the Isthmian Canal
Commission, in his report for April, 1913, states
that the total number of deaths from all causes
among employees was 51, divided as follows:
Disease 24, and violence 27, giving the annual
average per 1,000 of 4:84 and 5:45, respectively.
Among employees for the month of April each
year the annual average deuth-rate per 1,000 was as
follows : —
Total Disease
1905 10:95 —
1906 30:00 29:12
1907 38:67 35:22
1908 TU 4:56
1909 8:57 7:01
1910 13:04 8:62
1911 9:38 6:42
1912 11:38 8°77
1913 10°29 4:84
The annual average death-rate per 1,000 in the
cities of Panama and Colon and the Canal Zone,
including both employees and civil population for
the month of April each year, was as follows: 1905,
39-29; 1906, 39:06; 1907, 40°97; 1908, 20:04; 1909,
Os 1910, 19°73; 1911, 17°74; 1912, 17:21; 1913,
21:18.
In segregating according to race, the anrmal
average death-rate per 1,000 from disease among
employees was: For whites 2:82, and for blacks
5:39, giving a general average for disease of 4°84.
For the same month during 1911 the annual average
death-rate per 1,000 from disease among whites
was 2:85, and blacks 7:67, giving a general average
of 6:42; and in 1912 from disease among whites
3°74, and blacks 10°48, giving a general average of
8°77.
Among employees during the month, deaths from
the principal diseases were as follows: Lobar
pneumonia, 5; organic disease of the heart, 3;
tuberculosis, 7; leaving 9 deaths from all other
diseases, and 27 from external violence.
No cases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus during
the month.
A New Ankylostome of Man.—In the Indian Medical
Gazette, vol. xlviii, No. 6, Calcutta, June, 1913, Major
Clayton Lane describes the occurrence of Ankylostoma
ceylanicum in man. Looss first described this species
in 1911, finding itin material from a civet cat, sent
to him by Willey, of Colombo. He applied the name
A. ceylanicum to it, and stated that so far as was
known it only infected wild animals. Major Lane,
while examining stools at a jail at Berhampore, found
ankylostomes in three cases which did not conform
to the ordinary type of human parasite. They were
shorter and thinner, and when subjected to micro-
scopic examination were seen to be examples of
A. ceylanicum. The teeth in the mouth capsule of
this latter species differ from those of Ankylostoma
duodenale and Necator americanus.
Major Lane says it is not possible to determine to
what extent the parasite infests man in Bengal.
Having hitherto taken for granted that there were
only two human ankylostomes in India which could
be easily distinguished by the naked eye (the two
are,. of course, 4. duodenale and Necator americanus),
and having disposed of the worms he had collected up
to a recent date, he is at present unable to offer any
facts as to the frequency with which 4. ceylanicum
occurs as a human parasite. Looking back on the
ankylostomes he has collected, he is under the impres-
sion that he has previously found it occasionally in
small numbers.
It is scarcely necessary to point out, Major Lane
goes on to say, that the discovery of this worm as a
human parasite introduces an entirely new factor into
the question of the prevention of human ankylosto-
miasis. Necator americanus has not been found up to
the present time except in man and the gorilla;
Ankylostoma duodenale has never been found except
in man. Their practical prophylaxis is concerned with
man alone. <Ankylostoma ceylanicum is a constant
parasite of healthy domestic animals in the part of
India from which Major Lane writes. Should the
time ever come when an anti-ankylostome cam-
paign becomes necessary or practical in India, and
should it turn out that 4. ceylanicum is at all a
serious factor in human ankylostomiasis, then the
problem of prevention will entail, not merely the
freeing of man from his parasites, a difficult enough
matter seeing that, in the immense majority of
cases of infection, this is, in India, so slight that
202
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1913.
if produces no symptoms, but also the similar treat-
ment of healthy dogs and cats, and probably jackals,
and other canines and felines. In other words the
task would be impossible. It does not, however,
appear at all probable that A. ceylamicum is at
present a numerously occurring human parasite ;
and, judging by the well-known history of the genus,
it is not easy to see how any increased domesticity of
the dog and cat (a change in habit which appears
likely to take place, as Indians gradually adopt
European customs) will produce through their means
a greater measure of human infection than that which
is at present in existence.
———————————
Abstract.
PROTECTIVE INOCULATION
CHOLERA.*
By W. M. HAFFKINE.
Iw his preface Haffkine writes that the present
note has been written in connection with certain
offieial correspondence regarding vaccination against
cholera and the preparation and study, in India, of
a devitalized form of anti-cholera vaccine. The
purpose of the paper has rendered it desirable to
make certain references to the support which the
author’s personal views have received so far from
the results of other workers.
The work is divided up into three parts, as
follows : —
Part I deals with the preparation of an anti-
cholera vaccine;
Part II with
cholera; and
Part III with the anti-cholera vaecine after its
devitalization.
AGAINST
immunization of man against
Part I.—PREPARATION OF AN ANTI-CHOLERA VACCINE,
The Virus of Cholera.
The preparation of a vaccine comprises a number
of separate problems, the first of which is that of
identifying and selecting an appropriate strain of the
specific virus. In the case of cholera this problem
is rendered complicated by the fact that the various
specimens of virus found in patients and in inani-
mate nature present considerable differences, and
that, further, the properties of individual specimens
undergo comparatively rapid alteration in the course
of their cultivation in the luboratory.
The Cholera Virus as found in Naturc.
The following details may illustrate the matter
as regards the condition of the virus in nature.
The form of the germ Varies from a curved rod, or
“ comma,’ to a small oval speck, or to a long and
straight, or slightly undulated bacillus. The germ
is endowed with spontaneous movement; but the
mode of that movement and the apparatus which
produces it are not always the same, while some
specimens show no mobility at all. Again, the
* Calcutta : Thacker, Spink and Co. London: W. Thacker
and Co., 2, Creed Lane, 1913.
cholera microbe, like a number of other germs,
secretes a ferment with which, when planted out
on solidified gelatine, it digests and liquefies the
jelly. The dissolution is seen to take place to some
distance around the mass of microbes and to form
a clearly delineated fluid area. As is well known,
the figure of this area is typical for various species
of germs and for the cholera bacillus in particular,
and is made use of as a diagnostic feature, for
distinguishing species of microbes; but in the case
of the cholera germ there may occasionally be no
liquefaction at all, or, on the contrary, the whole
mass of gelatine contained in the culture tube may
become rapidly and completely dissolved. The
secretion of other ferments by these germs is
similarly uncertain. As a rule, the bacilli grow in
milk without causing in it visible alteration; yet
some strains bring about a rapid coagulation of that
medium. On vegetable substances certain repre-
sentatives grow luxuriantly, and others do not grow
at all. A few specimens found in patients were
phosphorescent in the dark, but the vast majority
do not manifest this property. The serum of
immunized animals and man, when put in a culti-
vation vessel in contact with a watery emulsion of
cholera germs, agglutinates these into lumps and
causes them to fall to the bottom of the fluid. Many
of these germs are sensitive to the minutest
additions of such serum; but others remain prac-
tically unaffected. A fairly characteristic feature of
& eultivation of microbes is its ability or otherwise
to dissolve the red corpuscles of the blood. In the
case of cholera some apparently true strains have
been observed to produce this effect; but the vast
majority do not do so.
Practically all other properties of the cholera germ
show similar variations; but the most essential are
obviously those which concern its relations with
animals and man. Cholera bacilli have generally
no virulence for the lower animals, or are harmful
to them only when inoculuted in certain peculiar
ways. Even then the morbid symptoms caused by
the inoculation have no resemblance to human
cholera. Strains have, however, been met with
which caused death even to the resistant species of
animals, in whatever way inoculated, while the
character of the disease produced in them was
singularly analogous to the disease in man. The
virulence of the germs ulso differs greatly, for a
lethal dose may vary as much as from 1 to 500.
Again, in man, the main seat of the development
of these bacilli is the mucous membrane of the
small intestine; they do not invade the circulating
blood, the subcutaneous tissue or the muscles, and
when experimentally introduced into those tissues
in animals, cholera germs, as a rule, rapidly die
out; yet specimens have been found which, in these
circumstances, speedily penetrated into the whole
system of the inoculated animal.
Variability of some degree is proper to all germs,
as it is to higher animals and plants; but the cholera
microbe is one of those in which, owing to their
organization and mode of life, that variability is
particularly marked; so much so that not infre-
July 1, 1913.]
quently, after an examination with all available
tests, it is impossible to say whether the germ dealt
with is, or is not, a representative of the cholera
species.
The above résumé, Haffkine thinks, will be
sufficient to show that, in dealing with the problem
of preparing a vaccine for cholera, it is essential
first very carefully to consider the various points in
favour of and against the particular variety of the
germ which should be selected as authentic and
appropriate.
The Cholera Virus in the Laboratory.
The fact next confronting the operator is that,
in the course of, sometimes, a short interval, the
specimen selected undergoes ‘‘ spontaneous "' altera-
tions of considerable importance, some of a tem-
porary, others of a seemingly permanent character;
so that a plan based on the properties of the virus
as seen originally does not hold good for very long.
A cholera germ, for instance, which, when first
obtained, has been dissolving blood corpuscles,
coagulating milk, digesting gelatine and albuminous
matter and deoxidizing colouring substances, such
as litmus safranine and methylene blue, may, after
a time of laboratory cultivation, show none of such
effects. In the most important properties—those
concerning the pathogenic effects of the virus—a
decrease in strength, in a short time, in the pro-
portion of, say, 75 to 1, and ultimately the total
disappearance of virulence is of no unusual occur-
rence. This means that, if at first a given dose of
that virus has been prescribed for producing a
certain desired effect, later on any quantity smaller
than seventy-five times the original one may fail
to give the expected result. Instability of virulence
has come to be regarded as a characteristic feature
of the cholera microbe, and where this peculiarity
is not sufficiently pronounced, the fact has been
treated as an objection to admitting the cholera
nature of the germ. The marked mutability thus
observed in one and the same specimen renders,
of course, less paradoxical the differences which
distinguish various specimens of these bacilli.
VIRULENCE AND IMMUNIZING POWER.
Their Inter-relation.
Turning now to the main subject of Part I of this
Note, namely, the preparation of a vaccine against
cholera, Haffkine says, it is of importance to
examine into the question as to whether variation of
observable characteristics, such as mentioned above,
carries with it variation in the immunizing faculties
of a virus.
In the experiments which the author carried out
on this subject in 1890-1892, he observed repeatedly
that a cholera germ of a low degree of virulence
conferred on animals less immunity than a germ
of high virulence. The special features of the pre-
paration of the cholera vaccine, the effects of which
were subsequently studied in India, were based on
this fact. The inter-relation just stated may be
taken as a basis for a general working rule; but this
need not exclude the possibility of so-called '' ex-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
208
ceptions,” for it is conceivable that, in isolated
instances; some, yet undefined, peculiarities of a
germ may intervene and disturb the habitual
position of the case.
Observations by other Workers.
The fact of the relationship in question between
the virulence and immunizing faculty of a cholera
germ has now been confirmed by many experi-
mentalists. Some three years after the publication
of the above-mentioned process of cholera vaccina-
tion, on the conclusion of his first inoculation
studies in India, Haffkine had the privilege of dis-
eussing the matter with the late Koch, Pfeiffer, and
Kolle, of the Institute for Infectious Diseases in
Berlin. Soon after that conference Pfeiffer and
Kolle tested the subject in connection with the
typhoid bacillus, and, in the subsequent year (1896),
with the bacillus of cholera. In 1897, having visited
Bombay with the German Imperial Plague Com-
mission and studied the plague there, Pfeiffer, in
collaboration with Friedberger, investigated the
same point in application to the plague bacillus. It
must be remarked that the latter germ, as found in
patients or preserved in a laboratory, differs from
the germ of cholera by a much greater stability of
properties. On various occasions bacilli of plague,
kept under observation for several years, even when
subjected to multifarious processes, of which some
were of a nature to weaken, and others to increase
their virulence, showed no appreciable modification
of strength. This circumstance simplifies greatly
the work of preparing a prophylactic from the plague
germ. Nevertheless, specimens of that germ of
different virulence are met with in nature and can
also be produced artificially, and so the question as
to the relationship between virulence and immuniz-
ing power can be tested on this virus also. In all
instances—cholera, typhoid, and plague—the above
investigators found that the result of immunization
stood in direct connection with the virulence of the
germ used; that as the virulence rose or fell, the
protection afforded to the inoculated was greater or
ess.
In 1903 the point under consideration came again
under discussion. The problem of combating
cholera had, at the time, acquired importance in
the new American possessions in the Philippines,
and the matter was submitted to a fresh study in
the Institute in Berlin, this time under the direction
of the well-known German pathologist, Wasser-
mann. The experiments were conducted by Strong,
the Director of the Government Biological Labora-
tory of Manila, who published, in the subsequent
year, detailed accounts of that inquiry. Strong
applied in this study such procedures of measure-
ment and calculation as the subject admitted. In
his words, Pfeiffer and Friedberger’s experiments
on the relationship of virulence and immunizing
power ‘‘ seemed of such great importance that it
was decided to repeat them, and, in addition, to
perform them in as accurate a comparative way,
with relation to the virulence of the stem, as prac-
ticable. This seemed desirable because in Pfeiffer's
204 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1913.
and Friedberger's work, as far as can be ascertained
from their article, no attempt was made previously
to determine the exact relationship of virulence of
the different stems to one another."
Haffkine believes the investigation was under-
taken in a spirit of scepticism as regarded the
relationship in question; but Strong’s findings were
ultimately summarized as appears below. He ex-
perimented with two different specimens of cholera
germs, '' virulent’’ and ''avirulent," the strength
of which stood in the proportion of 15 to 1. The
variation in virulence was, therefore, very far from
reaching the limits previously mentioned; yet it
sufliced to give clear indications of its effects on the
immunizing power. Strong states :—
'' It became evident that the rabbits inoculated
with the virulent culture always furnished better
serum than those inoculated with the avirulent
one; but that the value, in both agglutinative and
bactericidal properties, of the serum from the
animals treated with the former was in no case (?)
more than two and one-half times that of the serum
furnished by the animals treated with the latter
stem.
"By the intravenous injection of the living
organisms in quantities of one-half Oese, the ratio
representing the bactericidal value of the sera of
the animals inoculated with the virulent and the
avirulent organisms was never greater than 43:1;
that is, the virulent organisms never furnished a
serum more than four and one-half times as potent
as the avirulent one. Therefore, it cannot be said
that the immunity obtained was directly propor-
tional to the virulence of the organisms, since the
latter was 15 to 1 before inoculation. However,
with the digested extracts of the organism of
different strains and the killed organisms of the
different degrees of virulence this may, within
certain limits, be said to be the case.
** As the results were somewhat at variance with
the ideas of Haffkine and quite different from what
Pfeiffer and Friedberger found upon the intravenous
injection into rabbits of dead cholera spirilla of
different degrees of virulence, it was decided to
repeat them. Accordingly, a second series of
animals was inoculated just as the first, and on the
day of inoculation, as in the previous series, the
virulence of the injected organisms was verified as
15 to 1. The result was practically the same, for
at the end of eight days the examination of the
sera showed that the virulent stem had in only one
case given a serum of more than about two and
one-fourth times the bactericidal value of that
produced by the avirulent one. In this one case
the avirulent serum was between one-fourth and
one-fifth as strong.”
While thus confirming, as Pfeiffer, Kolle, and
Friedberger had done before, the fact that by a stem
of higher virulence higher immunization effects were
produced, Strong opposed the view that there was
a simple numerical proportion between the two
values. The divergence, even thus restricted, is,
however, lessened further, inasmuch as in Strong's
plan of experiment there appear to be certain
features which tend to mask the true proportions,
namely, to reduce part of the numerical values
recorded by him; and as, further, on devitalizing
the virus, or using its extractions, he observed, as
stated in the above quotation, results actually
approximating to the proportions he expected.
In conformity with these findings, in 1907, the
same experimentalist emphasized the importance of
using, for the preparation of cholera vaccine, stems
of germs of the highest virulence, namely, in con-
nection with the inoculations which he carried out
for the suppression of the cholera outbreak in
Manila in 1905. Similarly, Pfeiffer, in a com-
munication to the International Congress of Hygiene
and Demography in Berlin, in September, 1907,
took the opportunity of reiterating his conclusion as
to the importance of using fully virulent stems for
the preparation of typhoid vaccine. On yet another
occasion, when testing the matter in application to
plague and examining the immunity of animals
treated with live cultures of different strengths,
Strong ascertained, as Pfeiffer had done in 1897 in
regard to devitalized cultures, that the virulence of
the stem was of decisive importance in this instance
also, the immunity conferred on the inoculated
animals rising concurrently with the rise of the
virulence. Accordingly, in some of the laboratories
situated in non-infected centres and having no
facilities for regularly renewing their stock of plague
bacilli, special measures are taken for maintaining
the virulence of the germ used in manufacturing the
plague prophylactic.
The necessity of using fully virulent strains of
germs for the preparation of the cholera vaccine
has been acknowledged also by Japanese bacteri-
ologists, and similarly, in 1910, Aaser, in Chris-
tiania, laid stress on the same point in preparing
vaccine for the cholera inoculations which he carried
out in that town.
Microbial Virulence and some of its Elements.
In the present exposition the words virulence and
pathogenic power are used as meaning the capacity
of a stem or species of germ to live in an animal
and produce in it morbid effects. To this end ^
germ requires a variety of properties, some of which
enable it to resist the adverse effects of the animal's
tissues and humours, others to derive food from the
same elements, and others again, to produce in the
animal morbid symptoms. A stem of pathogenic
germs which has lost, or has been artificially
deprived of, one or more of these faculties, loses its
virulence for the animal, though the rest of its
characteristics may remain intact.
The actual nature of the properties here referred
to varies with the species of germ and with the
nature of the animal for which the germ is virulent,
but a few peculiarities common to considerable
groups of pathogenie mierobes have been observed
and some of them minutely studied. Such are, for
instance :—
(1) The faculty of resisting various specific sub-
stances in the animal bođy—“ agglutinins,”
''baetericidins," ^ ''alexins,"' bacteriolysins ''—
July 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
205
which tend to destroy the germ; or of absorbing
and thus neutralizing these substances; or of pro-
ducing others—'' aggressins "—which seem to
ward off and injure the protective elements of the
body.
(2) The faculty of calling forth in the system of
the animal the formation of the defensive sub-
stances mentioned in the foregoing paragraph, or of
others of similar purpose, such as “‘ stimulins,’’
“ bacteriotropins,’’ &c.
(3) The faculty of comparatively rapid growth
and multiplieation.
(4) The faculty of produeing and setting free
poisonous substances or ''toxins," which cause
morbid symptoms in the animal, and so on.
The author believes that at present it would not
be a safe procedure to consider a germ pathogenic
or virulent if it possesses one or some of the above
properties, singled out above the others; or to
declare an animal immune, if it resists a germ
“virulent ’’ in that restricted sense. A true
vaccine is perhaps best defined as one which pre-
pares the individual to face the virus in its most
common manifestations in outbreaks.
GENERAL AND SPECIAL FEATURES OF THE PROBLEM
UNDER CONSIDERATION.
Peculiarities dependent on the Nature of the Germ.
The above observations go to show that the
immunizing power of a germ varies with its viru-
lence; and in order to produce a vaccine of given
definite efficacy, a strain of virus is required of as
definite a degree of pathogenic strength. The germ
of cholera being of the varying and unstable nature
mentioned above, the problem of anti-cholera
inoculation, as à measure of practical application,
becomes dependent on the possibility of steadying
that virus on an adequate level of potency, namely,
on a level sufficient for conferring on man immunity
from epidemic cholera.
These requirements were overlooked in an experi-
ment of cholera vaccination which was tried in
Spain in 1885 by the Barcelona physician, Ferrán.
In this attempt use was made, for inoculating man,
of different specimens of cholera germs obtained
from patients and employed alive in the condition
in which they were obtained, or which they assumed
spontaneously afterwards. The plan corresponded
to that, still prevalent in some parts of the East,
of inoculating man with virus from a patient
attacked with a mild form of small-pox, and is
known as variolization, in contradistinction from
vaccination. The procedure takes no account of the
peculiarities of the virus found in the patient, that
is to say, of the question as to whether the virus
is actually mild and yet possesses the requisite
degree of potency to be immunizing, or whether the
mildness of attack is due to the patient's individual
resistance which masks the true character of the
germ. These circumstances must have had some
part in influencing the outcome of the Barcelona
experiment ; for, according to the inquiries made at
the time by numerous government commissions
deputed to observe the operations, the trials gave
uncertain, in some instances clearly negative, and
on the two special occasions when a Spanish
Government commission, associated with Dr.
Ferrán, watched the events, directly disadvan-
tageous results. The procedure was therefore not
adopted in other countries, and was discontinued in
Spain.
Peculiarities of the present Problem as concerns
Animals.
The problem set forth in the preceding lines, of
ereating and preserving in a virus stable and
uniform qualities, necessitates as an essential con-
dition that the germ be maintained in appropriate
uniform cireumstances of nutrition and multipli-
cation. When the particular properties which it
is desired to fix in a mierobe are those which con-
cern its relation to the animal body, the plan for
achieving the object is to make the germ live in
that definite relation to the animal selected. Thus,
in the classical instance of Jenner's vaccine, the
desired uniform qualities of cow-pox lymph are
maintained by continued cultivation in the skin of
the calf. In this instance the plan offers no com-
plieations, as the virus has its natural abode in the
skin of cattle.
In the case of cholera the method which suggests
itself for maintaining the germ on a steady level of
virulence is, similarly, that of cultivating it in the
tissues of an animal; but man is the only animal
known to suffer from the disease; lower animals do
not contract it spontaneously, and when the virus
is injected into them artificially, it is, as a rule,
rapidly destroyed, as previously mentioned.
THE VIRUS OF CHOLERA IN ANIMALS AND ANIMAL
Humours.
Experimental Cultivation in the Intestine.
The first attempt at solving this phase of the
problem was made in 1888 by Gamaleia, a pupil of
Pasteur’s, who tried the plan of introducing the
cholera germ into the intestinal canal of the guinea-
pig and transferring it subsequently from the
intestine of the first animal into that of another,
and so on, in a continuous series of cultivations—
the obvious reason for the plan being that, in its
development in man, the cholera germ affects the
intestinal tract. The digestive organs are, however,
an inconvenient medium for the artificial cultivation
of a germ; for, among other reasons, these organs
are already inhabited by vast masses of microbes,
which, according to their species, interfere in one
way or another with the development of the new-
comer. In the case of guinea-pigs and other lower
animals the circumstances are unfavourable to the
growth of the bacillus of cholera; so, after a certain
number of transfers from animal to animal, the
series generally breaks down, and the germ dis-
appears from the intestinal contents, as was seen
repeatedly in trials made in Paris. A modification
of the procedure was then attempted in which the
cholera bacillus, after its cultivation in the intestine
206
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1913.
of one animal, and preliminarily to being transferred
into that of another, was freed from extraneous
germs, so that it might get a fresh start in each
new host. This plan involved operations tending
partially to counteract the desired effect; for the
technique of separating the cholera germ from
others necessitates its maintenance, for some
generations, in artificial media, that is, outside the
tissues of the animal to which it is desired to
acclimatize it. From this or other causes, Pfeiffer
and Nocht, who performed many experiments on
the intestinal infeetion of animals with the germ of
cholera, found it impossible to raise the strength of
that virus to such a degree, for instance, as would
make it virulent to birds.
Cultivation in Animals outside the Intestine.
To meet the above difticulties, Gamaleia proposed
to cultivate the cholera virus in the thoracie cavity
of animals, namely, of pigeons, the thorax being
free from extraneous germs. This plan proved
successful in the case of a microbe much akin
to that of cholera and designated by Gamaleia,
who discovered it, Vibrio metchnikivo; but when
the same procedure was applied to the strains of
cholera germs then available, it was found that
such animals as birds remained immune against
infection,
The plan which was tried next was that of
Hiippe, of Prague, who suggested the growing
of the cholera bacillus in the peritoneal cavity
of animals, between the intestines and the outer
walls of the abdomen, a region ordinarily free
from germs. This plan had failed some time pre-
viously in the hands of Vincenzi; but the idea was
nevertheless taken up by Pfeiffer, who found that
a fatal form of cholera peritonitis could, indeed, be
induced in an animal in that way, but that the
germ itself perished in the process. In cases in
which the virus was still recoverable on the death
of the first animal and was transferred into the
peritoneal cavity of another, it perished in the
latter, or in the third animal, and so continuous
cultivation was again found to be impossible. The
accuracy of these observations was verified at the
time, and on various occasions subsequently by
many observers, including Roux and Haffkine.
Cultivation in Animal Humours.
Under these circumstances the author tried to
modify the nature of the germ of cholera pre-
liminarily to introducing it into the animal body,
namely, to immunize it first ugainst the animal,
By a series of cultivations in test-tubes, he
gradually accustomed the bacillus to live in
meat-broth mixed with increasing quantities of
fresh blood serum, which ordinarily is inimical to
it; until, after a time, the germ became capable of
growing luxuriantly in blood serum pure. When it
reached this condition it was injected into the circu-
lating blood of an animal.
In cholera the germ, on being introduced into the
animal body, instead of rapidly perishing, as is
ordinarily the case, struggled on successfully and
caused the animal an attack of illness which often
ended fatally. The duration of that illness, how-
ever, varied greatly, viz., from a few days to several
months, and occasionally the animal ultimately
resisted. This irregularity of results rendered it
impossible to utilize the plan for practical purposes.
Tne METHOD ULTIMATELY ADOPTED,
Cultivation in Animal Series.
The problem was eventually solved by reverting
to the Vineenzi-Hiippe intraperitoneal injection
and working out, from that starting-point, a plan
which permitted the cultivation in animals of the
germ of cholera, in a state of purity, indefinitely,
generation upon generation; the raising of it to a
well-determined degree of virulence, sufficient for
the protection of man; and its maintenance at that
level for an unlimited period of time, with the same
certainty of result as obtains in the preparation of
small-pox vaecine lymph and of Pasteur's antirabic
virus.
Cholera bacilli do not live in the body of man
uninterruptedly. This fact is expressed when one
says that '' cholera is not a contagious disease ” in
the sense of measles or small-pox, i.e., it is not
transmitted direct from man to man. The germ
obviously needs to spend part of its existence out-
side the human body; and, indeed, it grows readily
in various natural and artificial media, most com-
monly in drinking water. A peculiarity of its
eulture in sueh media is its great avidity for the
air, in apparent contradiction of the fact that, when
it infects a human being and grows in the intestinal
tract, it lives in a medium devoid of oxygen. The
alternation of aerobic and anaerobie conditions
appears thus to be a marked peculiarity of this
germ; and this peculiarity may account for the
fact, observed in the course of the author's experi-
ments of 1890-1892, viz., that the chief obstacle to
the cultivation of the cholera virus in an uninter-
rupted series of animals is the continuous depriva-
tion of air.
Another and unexpected condition was found to
be the necessity of varying the size of the animals
selected for grafting the virus upon.
The formula given by the author in 1892 for
obtaining a cholera virus of stable properties, con-
tains the following three clauses :—
(1) The series of cultivations must be begun by
giving the first animal a superlethal dose of virus,
so as to obtain a rapid effect and to find, upon the
death of that animal, in the fluid exudating into
the peritoneal cavity, a remnant of resistant germs
surviving the destruction of others.
(2) On the death of the first and of each sueceed-
ing animal, the serous fluid found in the peritoneum
(or else a culture of cholera germs made from that
fluid) must be aerated for a few hours, before being
injected into the peritoneum of another animal ; and,
lastly,
(3) For this latter injection, an animal of greater
July 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
207
body weight than the previous one must be taken,
if the amount of serous fluid found in the peri-
toneum is small, and vice versa.
The Properties of the cultivated Cholera Virus.
The peculiarities imparted to the virus by the
above process of animal cultivation are as follows : —
As the germ is being passed from animal to
animal its virulence gradually rises, so that smaller
and smaller doses of it become sufficient to cause
an animal a fatal illness. With the particular strain
of virus with which Haffkine then experimented,
the dose lethal to an adult guinea-pig gradually sank
to one-twentieth, one-thirtieth, and eventually to
one-fiftieth of what it had been originally.
The animals successively inoculated succumb
after a shorter and shorter duration of illness. In a
Parisian breed of guinea-pigs, the time for animals
of 350 grm. weight was reduced from twenty hours
fo eight, the latter period then remaining constant.
The virus becomes fatal to rabbits and pigeons in
doses which have been harmless to them before, and
inoculation into the depth of the muscles becomes
fatal to guinea-pigs.
Inoculation under the skin, in the animals just
mentioned, causes mortification of the cutaneous
tissues and the subsequent sloughing off of the
region concerned.
THE CHOLERA VACCINES,
Vaccine '* II."
This was a virus in live condition, brought by the
above described procedure of successive cultivations
in guinea-pigs to a uniform and stable degree of
virulence, such as is obtained in small-pox vaccine
lymph by cultivation in the calf. Haffkine desig-
nated this cholera vaccine; and, for reasons men-
tioned below, referred to it as cholera vaccine “ II.”
The subcutaneous inoculation of an appropriate dose
of this vaccine protected the guinea-pig, the pigeon,
the rabbit, and the dog against all such forms of
infection with cholera virus as, without previous
immunization, were fatal to them. The results
were thus found to apply to several species of
animals—mammals and birds—which appeared
susceptible to the same process of immunization.
Cholera Vaccine “ I."
The hypodermic injection into the guinea-pig of
the cholera vaccine proper mortifies, as already
mentioned, the skin at the seat of the injection and
leaves an open wound, which becomes, however,
regularly covered with granulations and. heals up
without suppurating.
To prevent the formation of this wound an
attenuated derivation of the same vaccine was pre-
pared, and was designated cholera vaccine Qd grs
This, when inoculated in a guinea-pig, not only
caused no mortification, but immunized the skin
against the deleterious effect of the cholera vaccine
proper. The inoculation of this preliminary vaccine
alone conferred on the animal also a certain degree
of immunity against a lethal infection. These two
vaccines were applied to the preventive treatment
of man and used in studies in India in 1898-95 and
part of 1896.
Inoculation Reaction of Anti-cholera Vaccine.
In 1895 Haffkine ascertained, however—first on
himself and afterwards on others—that vaccine
“I,” when inoculated in the doses prescribed, with-
out preliminary immunization with vaccine ** I," had
no mortifying effect on the human skin. This result
is possibly due to the subeutaneous tissues of man
being more inimical to the germs of that vaccine
than are the corresponding tissues of the guinea-pig,
so that the activity of those germs is arrested before
any harmful effects are produced. In accordance
with this observation, in all operations on man
performed in the summer of 1896 and subsequently,
up to 1904 inclusive, and in the operations in Bengal
in 1908, vaccine ** II ’’ alone was employed. Under
these conditions inoculation with that vaccine
causes a rise of temperature and a local reaction,
developing, on the average, in ten hours, and then
gradually subsiding. The length of time required
for getting over most of these effects has been
ascertained from long observation, and an idea of
the subject may be gathered from the correspond-
ence which took place, in 1904, between the
emigration authorities of Bengal, who had had
several years of experience in the matter. They
stated that (1) emigrants arrived at Asansol from
the Central Provinces daily at 9 a.m.; (2) were
inoculated between 3 p.m. and 5 p.m. of the same
day, after they had had their midday meal and
some rest; and (3) left Asansol by the 4 p.m. train
on the next day.
This arrangement had been in operation uninter-
ruptedly for eight years and had worked satis-
factorily.
(To be continued.)
————»9————
Hotes and Mews.
Tug summer dinner of the West African Medical
Staff took place at the Grand Hotel, London, on
Monday, June 16.
Dr. Prout, C.M.G., late Principal Medical Officer,
Sierra Leone, presided. Dr. Fagan, late P.M.O.
Northern Nigeria; Dr. Tweedie, Deputy P.M.O.;
Dr. Best, Prov. M.O.; Dr. Cameron-Blair and Dr.
Charteris, P.M.O. of the Gambia; together with a
number of past and present medical officers of the
staff were present.
Among the guests were Sir H, Just, K.C.M.G.,
Under-Secretary of State for the Colonies; Sir
Ronald Ross, K.C.B.; and Messrs. Baines and
Machtig, of the Colonial Office.
Dr. Provrt, in proposing ‘‘ Success and Prosperity
to the West African Medical Staff," stated that this
was now the thirteenth dinner. He briefly reviewed
208
THE JOURNAL OF TROPICAT, MEDICINE AND HYGIENE.
[July 1, 1913.
the cireumstances which led up to the dinner being
held, and thought they were justified in claiming
that it had been successful, and the means of
bringing together men who would otherwise have
had few opportunities of meeting, and promoted a
feeling of esprit de corps, which was to be desired.
He thought the junior members of the Staff did not
appear to fully appreciate the advantages of such
a gathering, and he hoped the senior members
would bring all their influence to bear to get them
io attend in large numbers. He believed the West
African Medical Staff had opportunities of distinc-
tion and work in connection with the building up
of our great Empire, which is second to none, and
it was a body to which they had every reason to
be proud to belong.
He alluded in feeling terms to the deplorable loss
the Staff had sustained in the death of Dr. Langley,
Principal Medical Officer, Southern Nigeria, a
tactful, sympathetic, and popular officer, whose
place it would be difficult to fill.
Dr. Faaan then proposed ‘‘ The Health of the
Visitors," and welcomed them on behalf of the
Staff. Sir H. Just was especially welcomed, as
representing the Colonial Office, and as showing
its sympathy with the aims and work of the
West African Medical Staff. He suggested to the
members of the Staff that they should not hesitate
to let Sir H. Just know their grievances, and he
was sure they would be remedied at once.
Sir H. Just, in responding, said he felt he was
there rather under false pretences, as he had not
been connected with the West African Department
for some years, but at one time, as Private Secre-
tary, he had a great deal to do with the selection
of medical officers. At that time the Staff was a
very small one; now it was a very large and respon-
sible one, and he congratulated them on their work,
and the good results which were now being shown
in the diminishing invaliding and death-rates. He
would ask them to believe that they had the entire
sympathy of the Colonial Office in their work, and
that they could rely upon a fair and sympathetic
hearing to any representations they might make,
with a view to improving the efficiency of the
service.
Sir RoNALD Ross, in replying, said he thought the
West African Medical Service was destined to rank
with the other great services in connection with the
British Empire.
At a later period Dr. CaMERON-BLarR proposed
“The Health of the Chairman,” and said he re-
gretted that Dr. Prout found he was unable, from
pressure of other work, to continue as their Presi-
dent. It was to him the inception and carrying
out of the dinner was entirely due, and they owed
him a great debt of gratitude for what he had done.
He hoped, however, that although he no longer
was able to undertake the active management of
the dinner, he would always be present and give
them his assistance.
Dr. Provrt thanked Dr. Blair for his kind expres-
sion of good feeling, and said he was always willing
to serve his old Staff in any way he possibly could.
“ Australasian Medical Gazette," May 3, 1913, vol. xxxiii,
No. 18.
The Destruction of Mosquitoes and other Insecis.—
Purdey gives & résumé of the recent literature on the
subject. Though the campaign against biting insects is
moving slowly, nevertheless it is advancing. The destruc-
tion of domestic flies is as important as that of any of the
other species, and in this connection a letter received by
Purdey from the secretary of the largest butchering firm in
Auckland, in answer to a communication re the effect of
introducing screening from flies, is of interest. The letter
speaks for itself.
* Sir, —In reply to your favour of the 15th instant re the
screening of our shop, Dominion Road, we find that it has
turned out a great success; the public have appreciated
the change, and, in consequence, the cash trade has con-
siderably increased. We found the meat kept better, also
a great saving in handling, not nearly so much trimming
being required, as the ‘blows’ from flies were fewer. We
also found a great saving in ice, as under the old system of
keeping meat in the ice chest during the summer months,
fonde the constant opening to take out joints as required
very expensive. As regards ventilation, we do not find
that the screens interfere to auy great extent, but at the
same time, as the electric system extends here, we shall
instal fans; at present it would be too expensive. We are
so satisfied that the idea is a good one, that we are screen-
ing all our suburban shops, and already have ten shops
finished in the same style as the one you remember in the
Dominion Road. We are, &c."'
* Annals of Tropical Medicine and Parasitology,"
June 10, 1913, Series T.M., vol. vii, No. 2.
A New Species of Tsetse-fly.—Newstead describes a new
species of tsetse-fly for which he proposes the name Glossina
severini. This was discovered amongst Monsieur Severin’s
collection of tsetse-flies from the Congo. The following
are the characteristics of the male of the new species.
Hind tarsi either uniformly dark brown or with the first
and second segments slightly paler than the rest; pleure
and hind coxæ dusky grey, harpes very small, narrow and
irregularly serrated distally.
Length (two specimens), 10:8 to 105 mm.
wing, 10:5 mm.
Palpi relatively long and stout. Third segment of the
antenne clothed with short hair. Thorax very robust,
markings well defined and of the usual type or similar to
those in Glossina palpalis ; pleure dusky grey. Legs with
the hind coxe grey or greyish buff; tips of front and middle
tarsi black; hind tarsi all dark (almost uniformly so in one
example), or with the first and second segment slightly
paler than the rest. Abdomen almost unicolourous. Genital
armature with the superior claspers free, the hairs with
which these appendages are clothed very long. Editum
with very long marginal hairs, the longest reaching almost
to the tip of the vesica; median process narrow, being much
less than the width of the inferior claspers and projecting
slightly beyond the latter ; harpes rudimentary, being quite
short and narrow, with the distal margin irregularly serrated.
Length of
Hotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4,—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
July 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 14, Vol. XVI.
Original Communications.
A REVIEW OF A CLINICAL STUDY OF
MALARIAL FEVER IN PANAMA.
By JoHN PELHAM Bares, M.D.
Ancon, Canal Zone, Panama.
III. i
MALARIAL AÁNZEMIA.
ONE of the distinctive features of the malarial
syndrome, after two or three acute attacks of fever,
is the anemia.’ It rarely fails to manifest itself under
such circumstances, and if the attacks continue
irregularly for a month to three months, this feature
becomes especially marked. The anemia is in most
instances characteristic. It is attended by a rather
peculiar leaden hue of the skin, along with pallor,
and jaundice of the conjunctiva and mucous mem-
branes. This feature of malaria has attracted the
attention of all observers since the earliest times,
and it is looked upon clinically, and not with-
out reason, as one of the diagnostic points of
the disease. Before the discovery of the malarial
parasite, the cause of the ansemia was shrouded in
mystery. The manner in which the anemia is
brought about is generally accepted to be in the main
by the normal habitat of the malarial parasites in the
red blood corpuscles, and the growth of the parasites
at the expense of the hemoglobin and the final
destruction of the red cells.
All recognize, however, another factor in the cause
of malarial anemia, at present unknown, that acts
as a hemolysin. This factor may account for the
apparent inequality in the degree of anemia’ in the
primary attacks of malaria, and the number of para-
sites that can be detected in the blood of the peri-
phery. It must account for the grave destruction of
red blood corpuscles and liberation of hemoglobin in
hemoglobinuric fever, as there can be no relation
between the loss of these blood elements and the
number of parasites which may precipitate an attack
of this latter syndrome of malaria.
A recent writer, Rowley-Lawson [1], has noted
the supposed inequality of parasites, and the amount
of angemia following in acute attacks of malaria, as
found by Dionisi and others, and undertakes to
explain the hiatus by offering the hypothesis of intra-
vascular migration of parasites. She assumes that
the parasites found free in the blood plasma can and
do re-enter or attach themselves to uninfected red
blood cells. It is certainly not a very uncommon
sight in stained malarial blood work to see young ring
forms free in the blood plasma, or young ring forms
attached along the margin of the red corpuscles, or,
again, to see parasites at various stages of develop-
ment free in.the plasma, but that they re-enter other
ted blood cells to continue their destructive process,
I think is wholly without any basis of fact. In the
first place, the necessity for such a hypothesis is not
well taken. As Rowley-Lawson has stated, Dionisi
noted that the anemia seen in primary invasions of
malaria is nearly always greater in degree than the
number of parasites that can be estimated in the
smears of the blood of the periphery would lead
one to expect. This, I think, is true, but of late
I have come to regard this inequality as more
apparent than real. The number of parasites seen
in the smears of the blood of the periphery is not
always a fair indication of the richness of the infec-
tion. As stated in a previous paper, I once held the
view that the parasites seen in the peripheral smears
represented the number of parasites throughout the
circulating medium, to finally have it rudely shaken
by the death of a patient in whom, by depending
alone on the blood picture of the smears from the
peripheral blood, I never once suspected the gravity
of the case until pernicious symptoms were already
present, eight hours after admission.
Marchiafava and Bignami [2], studying the pheno-
menon of the migration of the parasites from the
red corpuscles, considered that the phenomenon was
brought about by the action of quinine on the
endoglobular parasites. Be that as it may, they
make use of the phenomenon in quite the opposite
direction to Rowley-Lawson; that is, to explain
why the anemia is often less in degree than the
number of parasites seen in the blood films would
indicate. They assume further that the red cor-
puscles from which the parasites have been driven by
quinine remain intact and continue to perform their
function. The extruded parasites—though they do
not state this specifically—when free in the plasma,
cease developing, and are destroyed. This latter
inference is in keeping with Bass’s findings in cultures
in vitro that the younger parasites cannot live free in
the blood plasma for even a short time, and even the
merozoites are phagocyted unless schizogony occurs
with uninfected red cells in apposition to the
sporulating forms.
Kelch [3] in 1875-76 began a systematic study of
malarial anemia by estimates in the reduction of the
red blood corpuscles during the attacks of fever. He
determined the reduction of the red corpuscles to
be in some cases as much as 2,000,000 to 4,000,000
in a period of twenty-four hours. But as he depended
on the clinical symptoms alone for the diagnosis, he
must have included other diseases in his studies,
notably uncinarial disease. His findings, while true
in the main, have not been fully confirmed by later
researches—those carried‘out since the discovery of the
malarial parasite.
The most systematic study of this phase of malaria
appears to have been made in Italy, principally by
Dionisi [4], who, by various studies of the blood
changes, that is, the reduction of the red cells, variation
in hemoglobin, the specific gravity, &c., in malarial
attacks, found the loss of the red cells to be as much
as 2,000,000 per cubic millimetre in the course of an
attack lasting from three to four days, or again, a loss of
1,000,000 red cells per cubic millimetre in a period of
twenty-four hours. The loss in the hemoglobin value,
it was found in these studies, corresponded fairly con-
stantly with the reduction of the red blood cells.
Rogers [5] later confirmed Dionisi’s observations with
'. 210
. regard to the equality in the reduction of the red
blood cells, and the loss of hæmoglobin value, and
offered this characteristic as a point in the differentia-
tion between. malarial anemia and other secondary
ansmias. Dionisi [6] also noted that in repeated
attacks of fever the reduction of the red blood cells
began to become less and less with each succeeding
attack until the losses ceased altogether, and finally
there began an increase in the red blood corpuscles in
spite of recurrent attacks of fever. This increase took
place whether the number of parasites seen in the
peripheral blood smears were few or many. Brem
and Zeiler (7] studying the hemoglobin value of
labourers with malaria in Panama confirmed Dionisi's
findings with regard to the inerease of the red blood-
cells in spite of repeated attacks of fever. They, by
estimating the hemoglobin value of patients through
from one to several treated attacks of fever, found that
after the fifth or sixth attack there was usually a rise
.in the hemoglobin value over patients in whom there
had been a less number of attacks.
In 1910 I began a study of secondary anemia in
Panama [8]. In the course of this study the work
extended itself somewhat beyond my expectations.
Although it was first intended to be confined to
secondary ansmias of long duration, I later took up
acutesecondary ansmias, following the repeated attacks
of primary malarial infection. As opportunity has
offered the study has been continued to the present
time. The cases presented for study divided them-
selves into three groups. First, acute malaria with
irregular attacks extending over a period of from two
to three months—outside patients. In these a case
of hemoglobinuric fever was included, as the anæmia
of hemoglobinuria, though more grave, is of the same
acute character as that of the acute malarial type.
Second, hospital patients with a history of from five
to thirteen attacks of fever, in which the attacks had
extended over a period of from three to six years.
And, third, natives who had spent their lives amid
continuous malarial infection with various attacks of
fever over this period. This latter group I shall refer
to under the head of chronie malaria.
The first one in these groups was a healthy boy
twelve years old, who had never had a previous
malarial attack. His infection, a simple tertian, had
continued over a period of two months, with irregular
attacks of fever, and under indifferent treatment.
At the end of this period his hæmoglobin value
registered 60 per cent. (Dare's). The attacks were
here cut short by treatment, and within a period of
thirty days his hæmoglobin value registered 102 per
cent. (Dare's). The second case in this group was
a double tertian infection in an American adult with
one previous attack of fever " two or three years ago."
This infection had continued irregularly for three
months, with an occasional dose of quinine. At the
period of his entrance to the hospital his hemoglobin
value registered 55 per cent. (Sahli's), and his red cell
count was 2,704,000 red cells per c.mm. of blood,
with colour index of 1'07. In the hmmoglobinurie
case the hemoglobin value registered at the begin-
ning of the attack 75 per cent. (Dare's). Twenty-
THE JOURNAL OF TROPICAL. MEDICINE AND HYGIENE.
[July 15, 1913.
four hours later the hemoglobin was again estimated,
at which time it registered 55 per cent. In the
second twenty-four hours another estimate of the
hemoglobin was made, and at this time it registered
45 per cent. while in the third twenty-four hours
there was a loss of hemoglobin of about 5 points, or
it now registered 40 per cent. The loss of hemo-
globin here ceased, and as recovery began to take
place there was some variation in the hemoglobin
value of no moment. At the time of his discharge
the hemoglobin value had risen to only 45 per cent.
No red cell counts were made in this case. But, as
we have already seen, the reduction of red blood cells
and the hemoglobin loss is about equal in malaria,
it is reasonable to assume that the loss in the red
blood corpuscles in this period of seventy-two hours
was approximately 1,750,000 per c.mm. of blood.
I shall here take up the cases of repeated attacks,
all of which had been under good treatment during
each attack. Four of these were studied with the
hemoglobin estimates alone, and one with both hemo-
globin estimates and red corpuscle counts, and seven
with red corpuscle counts alone. Of the first four with
hemoglobin estimates alone, their hemoglobin value
was as follows :—
TABLE I.
Case 1, with 5 attacks of fever, Hb* value (Sahli's), 75 per cent.
n 2 » 6 , ,* LEJ ” 84 : ”
” 3 » 7 ” ” EAJ » 85 LAJ
uA 4, 18 T n ” ” 81 n
” 5 ” 18 ” ,» ” » 92 ,
* Hb = Hemoglobin.
In case 5 a red cell count was made, in which the
blood contained 5,240,000 red cells per c.mm., with
a colour index of '87 plus. The remaining seyen
cases with red cell counts alone had had from seven
to ten attacks of fever. For the sake of brevity, and
to avoid repetition, I shall here give the minimum
and maximum counts in these. The minimum count
in these cases was found to be 4,240,000 red cells,
and the maximum count was 5,310,000 per c.mm. of
blood. A number of these counts were repeated at
twenty-four hour periods for from three to four days
in order to avoid a possible error from counts while
the blood volume might be somewhat concentrated
from restricted diet, purging, and sweating. There
was no change in these repeated counts, however,
that could not be accounted for by such errors as
will naturally arise in making the different counts.
It is of importance to note that all the hemoglobin
estimates and counts first made were made from ane
to two days after the patient’s admission to the
hospital, while yet in the midst of the febrile attack.
However, most of the recounts were made after the
fever had subsided under treatment, yet little or: no
change in the number of the red cells could be ascer-
tained by these counts. It is still further necessary
to note that all the cases here reported were under
rather unusually good conditions for the Tropics.
Their hours of labour were regular and not over long,
usually ten hours a day. They had opportunity for
good food, and were encouraged to make use of the
opportunity. When they were attacked by fever,
medical attendance was prompt, and if they showed
any tendency to a severe illness they were sent to the
hospital for further treatment, where they usually
remained from seven to twelve days.
This survey confirms in a uniform way the findings
of Dionisi [9] with regard to the reduction of the
red corpuscles and loss in hemoglobin value in acute
primary attacks of malaria, and the general tendency
to an upward rise in both of these elements of the
blood in the course of numerous repeated attacks.
Apparently this improvement occurs whether the
repeated attucks are due to relapses or renewed
infection.
Thus, in the acute cases a rapid and profound
loss of the red blood-cells and the hemoglobin takes
place, to be as rapidly restored when the attacks are
checked by quinine; while in the repeated attacks
the tendency is always upward in spite of the con-
tinued attacks of fever, until in some cases, as we
have seen, the red cells and hemoglobin are restored
almost, or quite, to normal. I have tried in this
series .of cases to deal with cases in which there
could, be, no other factor to cause the anemia than
malaviat infection. I think I have succeeded in
this effort.
Hence, I may conclude that where malarial infec-
tion alone is the cause of anemia one may expect
first a sharp and marked loss in the hemoglobin and
in the red blood corpuscles. When this has reached
a certain point the losses cease; and if then the
attack is checked by treatment or spontaneous re-
covery, in the intervals there will be a rapid rise
in both the red corpuscles and in the hemoglobin.
In the next succeeding attack the fall of each is
usually lessened, and so on, until finally the losses
cease altogether. Here, then, there begins a reproduc-
tion of the red cells and hemoglobin in excess of the
losses, in which the red cells usually share in this
gain to a greater extent than the hemoglobin. The
human organism has now reached a stage of toler-
ance to the malarial poison which ends finally in
an immunity either relative or absolute. This course
of malaria is the one pursued among the “old
timers” in malarious countries, whom we speak of
as “salted.”
All writers on the subject of malaria describe an
anemia which may occur in chronic malaria that
does not tend to improve within the intervals of
apyrexia, but, on the other hand, after the attacks
of fever are cut short the anemia remains stationary,
or it may continue to progressively increase. I shall
consider this form of anemia in the section. on
chronic malaria. '
Chronic Malaria.—In malarious countries the in-
habitants dwelling therein are all exposed to malarial
infeetion more or less continuously throughout their
lives. Under these circumstances nearly or quite
all of the people will be the subject of malarial
attacks at some period of their existence. In many,
these attacks occur in childhood and even infancy.
Of these, such as survive the initial attacks of fever
by the possession of a hardy constitution or by
July 15, 1918.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
211
treatment are often the subjects of repeated attacks
of true relapses, or of repeated reinfection. Most
often in those treated the treatment is irregular and
insufficient, and the subject becomes discouraged at
a never-ending dosing with quinine. He finally
reaches a stage where, if the paroxysms are severe,
sufficient quinine only is taken to cut short the dis-
comfort, and then it is dropped until necessity drives
him to it again. Fortunately, in those who survive
several acute attacks a certain degree of immunity
is established, relative in some and apparently abso-
lute in others. In the first stages of this process the
patient merely gains a tolerance to the malarial
poison in which he may harbour rather large numbers
of malarial parasites without giving rise to active
paroxysms. Thus, in Panama [10], in the native
inhabitants that have been studied, this stage of
tolerance or latency was found in from 20 to 40 per
cent. of those examined. This included children of
school age and a goodly portion of men and women.
Just how long this tolerance can be maintained with-
out paroxysm, or how long after tolerance is estab-
lished until actual immunity takes place, is unknown.
I presume it varies in different individuals. Sub-
jects in acquiring tolerance and later immunity, go
through several attacks of malaria with a certain
kind of dosing with quinine, in whom each succeed-
ing attack becomes milder, and the period of
apyrexia becomes lengthened. In the tertian malaria
I have seen this process extend over a period of
eighteen months, to finally cease and never recur,
although the subject remained in the same locality
and exposed to infection. In some of the quotidian
fevers I have known the attack to end in an
explosion of hemoglobinuric fever without another
recurrence.
The natives of Panama who have been exposed
all their lives to malarial infection, and who have
markedly enlarged spleens, I have for convenience
classed as chronic malaria. In this class of patients,
I have gathered from the history, taking in adult
natives, that the period between active attacks of
fever have usually been of quite long duration.
During a great deal of the time in the intervals
between the active attacks of fever, these people
must have harboured parasites without symptoms,
yet in some of the intervals of long duration it is
necessary to assume that they were entirely free
from parasites. Thus, young men of from 20 to
35 years of age will state that they have had fever
" several times " during childhood and from four to
five or six attacks of fever during adult life. The
anemia in such cases as these will be the marked
feature, together with enlarged spleens. The hæmo-
globin value is found to range from 50 to 70 per
cent. and the red blood corpuscle count from
2,000,000 to 3,000,000 or thereabout. Their spleens
are in size, from easily palpable to masses filling all
the left hypochondrium, and at times extending over
in the right as well. These very large spleens are
hard, irregular masses, or, again, they hang down
as long, tongue-shaped organs. Many of these
people reach a degree of anemia far below that
212
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1913.
which is stated here, while others may remain well
above these estimates. Thus, in some I have noted
the hemoglobin value to be as low as 13 and 21 per
cent., in which the red corpuscle counts are from
850,000 to 1,703,000 per cubic millimetre respectively.
Individuals with a hemoglobin value from 70 per cent.
downward must be counted as chronic invalids,
though some of those here noted seem to bear up
under this condition surprisingly well.
The general description of these cases and the
long train of concomitant symptoms are all suffi-
ciently described in the text-books on malaria and
I can add nothing to them here. I am only con-
cerned with the etiological factors having to do with
these cases of grave secondary anemia. In a detailed
study of eleven of these chronic malarias—or malaria
cachexias, as some would have been termed—I ascer-
tained that there was more than one factor entering
into their causation. By inquiring carefully into the
patient’s history of previous attacks of illness it was
found that practically every previous illness was
simply termed “ fever.” It was evident, however, that
whatever other illnesses they might have had, the
most of them were unquestionably malaria. By
continuing the inquiry further into their mode of
living, it was found that all lived upon a diet low
in protein value, and often insufficient in quantity.
Thus, they would state that they ate mostly
rice, native fruits, dried codfish, and tubers of
native growth, such as yams and yucca. Some
stated that they often made a meal by chewing sugar-
cane. One of the worst stated that “many times "
he had gone as many as three days without food.
This must have been, however, after he had reached
a stage of invalidism in which he was practically
unable to go about. Finally, in all the cases studied,
examinations of the stools disclosed the presence of
uncinarial infection to a greater or less degree. It
was further ascertained by treating these people with
thymol, and recovering and making an actual count
of the worms, that the anemia corresponded more
closely to the amount of uncinarial infection than it
did to the number of the previous attacks of ‘ fever."
There were variations, of course, in this respect, but
it held good as a rule. As is to be expected in the
presence of malarial infection and uncinarial infection
in the same individual, the anemia was usually
found to be the most grave. In the worst case in
this series, with several attacks of fever in his life-
time, and at present sick thirteen months, who on
admission had a few crescents present in the blood,
and whose hemoglobin value was 13 per cent., I
recovered 896 adult uncinarial worms. While on
the other hand, in a patient with several attacks of
fever in childhood and four attacks in adult life, and
whose hemoglobin value was 50 per cent., I recovered
68 adult worms. This study was carried out in
sufficient detail, I think, to enable me to say that
I have never seen cases of extreme anzemia in Panama
in what may be termed chronic malaria without the
presence of uncinarial infection also. I may be
permitted to add that this detailed study has the
supplementary evidence of a long observation in
patients whose stools and blood were examined as
a routine practice.
But while the above facts were being disclosed,
other cases presented themselves with histories of a
number of attacks of malaria and, often with positive
blood findings, in whose stools the examination
showed an average uncinarial infection present also,
but their hemoglobin estimates reached no such
degree of anemia as noted above. This fact required
some other factor than uncinarial infection in the
etiology to explain this discrepancy. This factor I
think I have ascertained to be poor food ; food poor
in protein value, with a great deal of coarse fibrous
stuff which requires large quantities to be ingested to
meet the bodily needs. To illustrate: In the report
of the Porto Rico Anemia Commission [11],
Ashford found among the hill people a very grave
anemia due to uncinarial infection. This anemia
reached such an extreme degree that the average
hemoglobin value was 40 per cent., with red blood
corpuscle counts averaging about 2,500,000 per cubic
millimetre of blood. According to Ashford, malaria
here was a very small factor in the causation of this
anemia. The poverty of these people in addition was
extreme. They were unable to procure any kinds of
food except such as grew around them—such food for
instance as I have already described for the natives
of Panama; but sometimes in periods of financial
distress their food was limited largely to bananas and
black coffee. On the other hand, here on Taboga
Island, in a people who are very similar in race to
the hill people of Porto Rico, but in a very much
better financial state than that described by Ashford
for the Porto Ricans, I found in 104 estimates that
the hemoglobin value averaged 66 per cent. Malaria
in Taboga played a considerable part in the causation
of the anamia. There were four cases in this series
who harboured malarial parasites at the time of the
examination. Fourteen others stated that they had
"fever" at one time or another in their lives; but
parasites could not be demonstrated in the examina-
tion of their peripheral blood. Splenic enlargement
was present in all the cases with a malarial history,
but the largest spleen was only 20 em. in its greatest
diameter. Uncinarial infection was demonstrated in
88 per cent. of sixty-two stool specimens examined.
Some of these infections were very severe. The
lowest hemoglobin value found in this series of
estimates in the non-malarial cases was 25 per cent.,
while in the malarial cases it was as low as 10 or 12
per cent. The food of these people can be stated as
fair in protein value, that is, while it consisted princi-
pally of the usual tropical foods, they had beef, fowl,
and a plentiful supply of fish.
Here then I have been able to compare similar
peoples living under similar conditions with regard
to the exposure to uneinarial infection—the one ex-
tremely poor, the other fairly well-to-do for the
Tropies—in which comparison it is shown that the
average hemoglobin value of the yery poor is 40 per
cent., while in the fairly well-to-do it is 66 per cent.,
or 26 per cent. more in favour of the fairly well-to-do,
and this in spite of the fact that 18 people in the
July 15, 1913.]
fairly well-to-do—or 17 per cent.—showed evidence of
previous attacks of malaria. I think then I may con-
clude that food alone, that is poor food, must be
reckoned as one of the principal factors in the causa-
tion of the grave secondary anemias of the Tropics,
and it also explains the discrepancies already alluded
to in cases with both uncinarial infection and chronic
malaria in the same individual, in which some show
an extreme degree of anemia, while others average up
and around 70 per cent., or sometimes even above.
These findings are in harmony with the observations
of Marchiafava and Bignami [13] where they state
that this condition of anemia does not occur in patients
whose diet is good, and who are not subjected to exces-
sive fatigue, or who live under good hygienie surround-
ings. They are also in harmony with Mannaberg's [14]
observations when speaking of malaria cachexia, where
he stated “it is almost always the very poor and the
miserable, who live under bad hygienic conditions, that
become its victims.”
As I have already stated, all writers describe a
malarial ansemia which may persist even after the
attacks of fever have ceased under treatment. Marchi-
afava and Bignami [15] call attention to an anemia
that not only persists after the malarial attacks are
cured, but tends to progressively increase, “ post
malartal anemia.” While they suggest another factor
"at present unknown” as a cause of the progressive
anemia, they offer, however, as a possible explanation
the exhaustion of the hematopoietic organs, notably
the bone marrow, from long and continued attacks
of malaria. This explanation is plausible enough,
but I shall show later that exhaustion of the hemato-
poietic organs is not the cause. For in all my severe
anemias, as soon as the patients were rid of their
uncinaria there was a decided and satisfactory gain
in the patient’s general condition, and a rise in the
hemoglobin and red cells. The red cells usually share
in this gain, as was seen in the secondary anemias of
malaria, in greater proportion than the hæmoglobin.
Thus, in the worst case of my series, whose hæmoglobin
value registered 13 per cent., and whose red corpuscle
count was 850,000 per cubic millimetre, after the
recovery of 896 uncinarial worms the hemoglobin
value at the end of six months registered 55 per cent.,
while the red cell count was 4,336,000 per cubic
millimetre, with a colour index of ‘63. In another
case whose hemoglobin value registered 54 per cent.,
and whose red cell count was 2,704,000 per cubic
millimetre, with a colour index of '99, after the recovery
of 68 uncinarial worms his hemoglobin value increased
to 90 per cent., and his red cell count to 4,760,000
per cubic millimetre, with a colour index of '93,
within a period of fifty-five days. All the other
cases responded with equal promptitude after treat-
ment for their uncinarial infection. -Hence it must
be accepted, that if a patient in the conditions cited
for the first case in my series can recover, and
reproduce red cells to 4,336,000 per cubic millimetre,
there is no exhaustion of the hematopoietic organs.
And it is then necessary to conclude that Marchiafava
and Bignami were studying cases in which the
unknown factor to which they allude was most
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
213
probably uncinarial infection, as it is now well known
that Italy is infested with this pest as well as other
warm countries.
As herein set forth, I have shown that after acute
initial attacks of malarial fever the loss of hemo-
gobin and the reduction of the red blood cells is
rapid. The loss of hemoglobin in two or three
months of irregular fever may take place to an
amount of 40 to 50 per cent. of the normal, and the
red cells share this loss to the extent of from 2,000,000
to 2,500,000 per cubic millimetre. After the attack
is cut short by treatment the recovery of these
elements of the blood is also rapid. In uncomplicated
malaria in repeated attacks extending over a period
of from three to six years, which may with propriety
be termed chronic, the loss of hæmoglobin and the
reduction of the red cells, as I have shown, not only
cease, but tend to increase almost or quite to normal;
and this in spite of repeated recurrences of fever. In
the grave secondary angmias there are other factors
which enter into their causation besides malaria.
These are, first, uncinarial infection; and second, a
state of semi-starvation, not always on account of
the quantity of food, but on account of its poor
value.
Therefore, with uncinarial infection and poor food
made to bear their due share in the cause of the
grave secondary anemias in malarial subjects in
tropical and other malarious countries, and with kala-
azar as now excluded, I may conclude that there is
no such thing as a grave malarial anemia persisting
over a long period of time, to finally terminate in a
distinct entity, malarial cachexia. The term malarial
cachecia is misleading, and serves only to misdirect
one’s efforts toward alleviating this truly pitiable state,
and it ought to be abandoned in medical nomenclature.
[I wish to thank Colonel Gorgas, Chief Sanitary
Officer, Isthmian Canal Commission, for his permission
to publish this paper.]
BIBLIOGRAPHY.
[1] Rowtey-Lawson. ‘The Cause of Malarial Anemia and
the Intravascular Migration of the Malarial Parasites,” Archives
of Internal Medicine, vol. ix, No. 4, April 15, 1912, p. 420.
[2] Marcutarava and Bignami. ‘‘ Malarial Fever," Tuwen-
tiet Century Practice of Medicine, vol. xix, 1902, p. 192.
[3] Idem.
[4] Cited by Marcurarava and BIGNAMI.
[5] Cited by ScHEUBE.
second edition, p. 429.
[6] Cited by MancHiaFAvA and Bicnami. Loc. cit.
(7] BREM and ZEILER. ''A Study of the Hemoglobin of
Coloured Labourers in Panama," Archives of Internal Medicine,
June, 1910, p. 569. i
[8] “A Study of Secondary Anemia in Panama," The
Journal A.M.A., vol. lviii, January 27, 1912, pp. 268-272.
(9) Cited by MancHIArFAVA and Bicnami. Loc, cit.
[10] DARLING, SAMUEL T. ‘ Studies in Relation to Malaria,"
Public Doc. Isthmian Canal Commission, Laboratory of the
Board of Health Dept. Sanit., 1910.
[11] Loc. cit.
[12] Asuronp and IcARAVIDEZ. ‘‘ Report of the Porto Rico
Anemia Commission Senate," December, No. 808, pp. 12, 13, 17.
[13] Marcuiarava and Bienami. Loc. cit.
[14], MasNaBERG, J. ‘‘Malarial Fever,” ''Encyclopedia
of Practical Medicine,’’ 1905, p. 350.
[15] Marcutarava and BIGNAMI.
Loc. cit.
* Diseases of Warm Countries,"
Loc. cit,
e
214
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
{July 15, 1913.
WEST AFRICAN NOTES.
By Henry Srracuan, C.M.G., F.L.S., F.Z.S., F.R. A.I., &c.
Late Principal Medical Officer of Southern Nigeria.
(1) Norg on A PORTABLE IxsEcT-PROOF Room.
IN view of the number of diseases dependent on
insect carriers in the Tropics—particularly in West
Africa—a portable, eflicient, and inexpensive insect-
proof room, not only for sleeping, but for dining and
working in, in the late hours of the day and during
the night, is almost a necessity for those who have
to travel and work in sueh regions.
For some years I made shift with such a room
constructed of mosquito netting, but the frequent
injuries which occurred to such a flimsy structure
rendered it very soon practically useless. I, how-
ever, designed a portable insect-proof room which
I used on a recent visit to West Africa with perfect
satisfaction.
It is necessary that such a building should be
(a) thoroughly efficient for the purpose for which
it is intended; (b) capable of being rapidly put
together and taken apart; and (c) of such moderate
cost as to allow its advantages to be available to
the great majority of those whose work renders
such a protection necessary for the preservation of
health and life in tropical regions.
The main feature of my portable insect-proof
room is that it is constructed of '' sectional units,”
which are panels of mosquito-proof gauze, 7 ft. long
by 34 ft. wide. The woodwork is painted with
'"' solignum,"' a material which is repugnant to the
attacks of white ants. At one end is a door with a
strong spring to close it. My own room was 17} ft.
long, and, of course, 7 ft. broad, and 7 ft. high.
This was divided by a transverse eurtain; one room
containing bed, table, and chair, while the other
comfortably contained a small, writing-table, and
chairs. There was also ample room for small, and
for valuable, articles of baggage. Over the bed-
room was stretehed my tent, and over the front,
or sitting-room, the fly of the tent. All of this was
erected in a shed or hut of native workmanship,
with palm-leaf thatehed roof and walls, the roof
being some 6 ft. above the top of the room, and the
walls 5 ft. from the sides, thus allowing trunks,
stores, &c., to be under cover at the sides, while
the end made a good bathroom. The gauze being
of No. 16 hole (which I some years ago pointed
out prevents the passage of even the smallest
mosquito—an observation which, by the way, has
been independently recently confirmed by Dr. H.
Seidelin), admits the maximum of light and air, and
is far more comfortable to the occupant than the
smaller-meshed gauzes which have been popular for
anti-mosquito work. The absence of the hot
“stuffy "" mosquito-net was a very great comfort
at night.
Not only did I benefit by the fact that mos-
quitoes, tsetse-flies (Glossina palpalis chiefly),
which abounded, and the common, filthy house-
fly, which swarmed in myriads, were kept out,
but also by the fact that ‘ winged ants ’ (termites,
&e.), moths, and other insects were prevented after
lamp-light from interrupting meals and writing.
The room was constructed for me by Messrs.
Conner and Sons, builders, 263, Lewisham High
Road, S.E., to my complete satisfaction.
I am so convinced as to the great comfort and
the protection from illness which are afforded by
such a portable insect-proof room to all Europeans
who have to work in tropical regions, either as
explorers, surveyors, and engineers (engaged in
railway or waterworks, or in mines), as well as to
political officers travelling on tours of inspection,
that I bring the above facts to their notice.
(2) NOTES on THE BITES or THE TSETSE-FLY
(Glossina palpalis).
The following observations by one who has been
bitten frequently by Glossina palpalis may be of
some little interest.
The attack of the fly varied strangely. It was
sometimes accompanied by a loud buzz and violent
impact, with a sharp and painful stab. At others
it was so silent and painless that I (on two or three
occasions) only by chance saw the fly gorging itself
on one hand (when I was able to capture it with
the fingers of the other hand), and it not infre-
quently happened that only the discovery that blood
was staining the site of the puncture revealed the
fact that one had been bitten. In all cases, how-
ever, very soon the puncture was surrounded by a
weal, sometimes as large as a threepenny-bit, which
was painful and itching for several minutes.
I have been bitten by G. palpalis as far as, or a
little beyond, a quarter of a mile from a river.
The flies bite most vieiously during the heat of
the day. T
There was no sleeping sickness known to exist in
the area where I was bitten in Southern Nigeria,
but it was said that cases had occurred some thirty
or forty miles north of that place.
It is obvious that there is grave danger of the
disease gradually extending southward along the
river valleys. It is noteworthy that the only cases
which came to notice in the Western (Yoruba)
Province of Southern Nigeria had been infected in
other countries (such as Fernando Po, Congo, &c.),
and that although Glossina palpalis abounds in
the Western Province, and trypanosomiasis of
horses and cattle is common, there appeared to be
no instance of infection from the few immigrant
cases (of sleeping sickness) which were detected by
the Medical Department in the Western Province
during the fourteen years that I was there as
Principal Medical Officer.
—$<$—$—@~—_—_——_
* South African Medical Record," May 24, 1913.
Leprosy.—The above number is devoted chiefly to the
subject of leprosy. There is a leading article on the
subject ; then a very interesting paper on the “ History of
Leprosy in South Africa up to the establishment of the first
Leper Asylum at Hemel en Aarde,” by Dr. Morrow ; then
another paper on “ The Administrative Side of the Leprosy
Question," by Dr. Murray; and, finally, the “ Report of
the Government Research Pathologist on Leprosy for 1913,’
by Dr. Bayon. (All these papers are worthy of study.)
July 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. ~“
215.
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of every month,
THE JOURNAL OF
Tropical Medicine and Hygiene
Jury 15, 1913.
CHILDREN IN CHINA.
Tuar the Chinese understand how to successfully
bring up their children would appear to be evident
seeing the enormous multitude of the population
which inhabit the central provinces of China—a
population numbering somewhere about 400,000,000,
frellwigh a quarter of the human race; although,
however, the people swarm in number the infantile
death-rate is not small. .The fact that there are
practically no unmarried men or women in China
helps to explain the large number of children born,
and because polygamy is practised almost. all
women become mothers even should the female
population outnumber the male. Loss of men in
war, in dangerous occupations in times of peace,
such as in factories, mines, at sea, or on railways,
&c., is soon made up in countries where polygamy
prevails, but it takes a generation or two in non-
polygamous countries to make good the severe
losses of men in war, &c.
In China, mothers wellnigh invariably suckle
their children, and the period of lactation. is often
continued for fifteen to twenty months or more.
Lactation continued for so long a period would also
tend to limit the population were it not for
polygamy. In dealing therefore with the numbers of
population in polygamous countries these facts must
be taken into account.
Infants in China being breast-fed the question of
rearing children by other methods would searcely
appear to require consideration. Yet this is not so,
for Chinese children from the earliest period of
their existence have their natural food supple-
mented by rice in some form.
Cow's milk is not used as a substitute for
mother's milk; for cow's milk is not an article of
diet in China. "There are few cattle of any kind in
China and cow's milk is considered very rationally
as fit only for calves, and not for human beings.
Buffalo milk is more often 'fnet with :
it is seldom +
used, however, as milk, but is made into curd or'a®!
kind of cream cheese.
Instédd of milk, rice.in the."
form of rice water or rice congéé (soft boiled rice int
which both the rice water, and the softened rice:
grains are present) is given to children as: a supple-
One may see a Chinese `
ment to their natural food.
mother feeding her week-old baby. with soft boiled :
rice, or rice which she herself has chewed, and
thereby moistened and softened. The effect upon `
the infant's stomach is very’ patent to- behold, for
the distension at times becomes extensive; one
would expect the infant’s digestion to be upset
thereby, and it not infrequently ensues, for
‘infantile diarrhea " is one of the commonest
causes of infant mortality. Rice water is an excel-
lent substitute for milk, but chewed or soft boiled
rice is calculated to, and actually does, upset the
child. Rice water, that is, the water rice is boiled
in (and given after the particles of the rice are
removed by straining), is an excellent substitute for
milk, and especially in cases in which neither the
mother's milk nor cow's milk is tolerated. Rice
water does not curdle in the stomach, and is there-
fore free from the evil consequences of milk clotting
in a stomach which is irritated from any cause.
European children in the Tropies when the gastro-
intestinal tract is irritated or inflamed, and infantile
diarrhea is present, do well on rice water as a tem-
porary substitute for cow's milk.
A common cause of intestinal ailments in
children in China, especially South China—that is,
the districts south of the Yang-tse river—is the
presenee of round worms. Children, whether
Chinese or European, as young as seven months old,
may have round worms in plenty, and consequent
intestinal flux, with at times mucus and blood
alternating with obstinate constipation, is a
common cause of death in quite young children.
Trismus nascentium or neonatorum—the lock-jaw
of newly-born infants, which so long remained a
mystery as to its cause, has proved a scourge in
many parts. The infection is by way of the
umbilical cord; the soiled string and cloth with
which the navel is tied and dressed, or the nurse's
hands and clothing, convey the infection, and the
disease showing itself on the fourth to sixth day
causes a fatal issue by the tenth or twelfth day.
Nor do European children escape; the writer was
witness of a European child nursed by a European
monthly nurse dying, on the tenth day, of trismus;
the nurse came from a local convent where trismus
was endemic, and conveyed the infection to the
European infant.
One great conservative factor in infant life in
China is the fact that the mother carries her child
on her back; the child is thereby prevented becom-
ing chilled, and an equable temperature by contact
with the mother’s body is constantly maintained.
In Britain the mother or nurse used to carry the
child on the arm with a shawl wrapped round her
body and the child; an equable temperature being
thus kept up. The child was thereby prevented
being overheated as happens to-day when a hot water
216
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1913.
bottle is put into perambulators in cold weather, to
be followed by a state of cold and chill when the hot
water cools. The perambulator has proved a source
of illness in many ways in this country, and its
most recent pattern, a chair on wheels without
protection from wet or cold, is the most detrimental
carriage conceivable. The Chinese, in common
with all Oriental peoples, have as yet avoided the
perambulator, but the modern ways of the West
are penetrating the East in every direction; let us
hope that this racial destroyer may be shunned and
avoided by rejuvenated China.
The ‘* comforter °’ has not as yet found its way
into China, hence we seldom meet with adenoids
and the various oral, dental, aural, and thoracic
deformities which came in with the use of the
comforter, and will remain with us until the com-
forter is prohibited by law.
The mortality due to the widely reported destruc-
tion of female children when these are ‘‘ not
wanted ” is a wholly negligible quantity. No race
of people cherish children more than the Chinese.
Their desire for, and fondness of, children is pro-
verbial, and cruelty to children is unknown. That
children are often ‘* found drowned ”’ in harbours and
rivers is a fact, but when it is remembered that the
boat population of China numbers some ten millions
accidents to children can be readily understood.
The boat population actually live on the boats; they
have no shore habitation, but the family has its
being from generation to generation on the boats.
Finding a drowned child now and again therefore
cannot be wondered at, and foreigners are apt all
too often to ascribe what is an accident to design.
Searlatina in Southern China is unknown, but
not infrequently met with in the North. Measles
in the South is quite rare, but is prevalent in the
North of China. Diphtheria occurs for the most
part in sporadic form, seldom in epidemics.
Rheumatic fever in the South of China is prac-
tically unknown amongst either Chinese or
Europeans. °
Small-pox is a great scourge in China, and
every Chinese expects to have the disease at some
time. The mortality from small-pox is very great,
in spite of attempts at inoculation and of vaccina-
tion. Except at some of the coast ports where
European methods obtain vaccination is extremely
limited.
Enteric is probably universal, and it is possible
that every Chinese child has an attack rendering it
immune in adult years. That the Chinese have
recognized this is evident from the fact that they do
not drink water unless boiled in the form of
tea, and as the Chinese make tea it may be and
is taken freely at any time, and even given to
children without apparent harm. Tuberculosis in
all its forms prevails in China to perhaps a greater
extent than in any other country; the introduction
of opium smoking was probably due to the presence
of pulmonary tuberculosis with its attendant cough,
which opium smoking helps to allay.
J. C.
Abstract.
PROTECTIVE INOCULATION AGAINST
CHOLERA.*
By W. M. HAFFKINE.
(Continued from p. 207.)
PART II.—IwMUNIZATION OF MAN AGAINST
CHOLERA.
The Nature of the Problem.
Tue foregoing explanations refer to the prepara-
tion of a stable cholera virus of given strength and
to the study of its immunizing effect on the lower
animals, which, under ordinary conditions, enjoy
natural immunity from the disease. Special re-
search of a different nature is obviously required
in order to find out whether the same or another
virus may be efficient in immunizing man against
the disease which affects him specifically, and,
indeed, whether immunization of man against
cholera is realizable at all.
When Haffkine undertook the study of the matter
scientific and medical authorities were divided on
the latter. question; or, perhaps, the balance of
opinion was in favour of a negative reply. The
effect, which the results of the inoculations in Spain,
in 1885, had on the views of the Russian authori-
ties have been mentioned in Part I. In India
observers were impressed with the fact that cholera
had been known to recur in persons who had pre-
viously suffered from the disease, and who seem-
ingly had not benefited by what should be a highly
efficient course of immunization. Others considered
that the comma bacilli which served for the pre-
paration of the vaccine were not the primary cause
of cholera, but only a harmful concomitant of it,
and that consequently the vaccine could not affect
man's susceptibility to a cholera attack, though it
might affect the rate of recovery from such attack.
Among authorities in Europe, Pfeiffer and
Wassermann, Sobernheim, Metchnikoff, Zabolotny,
and others held immunization against intestinal
cholera impossible, or at least very unlikely, both
on grounds of theoretical consideration and on the
result of laboratory experiments on animals and
man. Metchnikoff aptly summarized the views
then prevailing in the following passage :—
“ As we have seen, intestinal cholera of rabbits
is an intoxication by the poisons prepared in the
digestive canal. Now, it has been shown in several
investigations that vaccination does not protect
against poisoning of the organism. One can, there-
fore, easily conceive a priori that an animal, very
well vaccinated against the cholera vibrio introduced
into the tissues, may not resist intoxication by a
poison manufactured in the intestinal contents.
The experiments described in the preceding chapter
have given a result which accords with the view
of authors who conclude that vaccination by live
or sterilized cultures against intestinal cholera pro-
* Calcutta: Thacker, Spink and Co. London: W. Thacker
and Co., 2, Creed Lane, 1913.
July 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
217
duced by Koch's method* is ineffectual. In the
memoir in which they treat this subject, Pfeiffer
and Wassermann come to the same eonclusion as
regards the prevention of this experimental disease
by means of a very active serum, obtained from a
person who recovered from cholera. While very
weak doses of that fluid sufficed for preventing
choleraic peritonitis in guinea-pigs, considerable
quantities (up to 5 c.c.) were powerless to vaccinate
these animals against infection by Koch's method.”
Metehnikoff had also been led to the above view
in another way, namely, by the result of an experi-
ment on two men whom Haffkine had inoculated
against cholera in Paris in 1892, from six to seven
months previously, and whom, on his departure
for India, he had occasion to submit to an artificial
infection, by the mouth, with measured doses of
cholera virus. The result of the experiment
appeared to be as follows :—
“ Haffkine’s subcutaneous vaccinations, done six
and a half months before the experiment, did not
prevent, therefore, either the diarrheic effect of
the cholera vibrios, or the causation of a condition
of general malaise. . . If the two persons
inoculated with Haffkine's vaccines had less
diarrhcea, they experienced a pronounced general
malaise, which was absent in a non-inoeulated
individual. Of the two persons who underwent
Haffkine's vaccinations, the one who had been
vaccinated twiee wàs more affected by the vibrios
than the other, who was vaccinated only once.
" As in the old experiments of Ferrán's, it is in
no way possible to consider as proved that hypo-
dermie inoculations of vibrios prevent the action
of those microbes when they are introduced in the
digestive canal.”
The Plan of Rescarch in the Indian Epidemic Arcas.
It was thus of essential importance to investigate
first the above question of principle, that is to say,
to find out whether cholera immunization of man
was possible at all; and for this reason, throughout
the author's studies in India of 1893-96, he em-
ployed the most promising form of vaccine which he
could evolve, irrespective of the amount of labour
and technical difficulties whieh this implied; and
such a preparation was considered vaccine “I”
in a live condition. Haffkine had already worked
out then and used on animals and man, as is stated
in various publications of the time, the devitalized
form of that vaccine, namely, the form which,
lately, has not unfrequently been referred to as
Kolle’s vaccine; but he held the live variety to be
by far the more reliable, and this from two points
of view: on account of its immunizing power and
of the duration of immunity likely to result from it.
The latter point was an essential one, as it was not
known how long an interval of time would elapse
between the date of inoculation and the occurrence
of an epidemic in which. the immunity of the
inoculated was to be put to the test, a consideration
the significance of which appeared clearly in the
events which afterwards took place in India. The
superiority of immunization by live vaccine became
apparent early in laboratory experiments, and
the fact of this superiority has been confirmed,
during the last ten years, by experimentalists
working on various diseases, namely, in plague, by
Kolle, Otto and Strong; in typhoid, by Vincent,
Metchnikoff and Besredka; and so on.
In the course of the years 1892 to 1895, Haffkine
studied the effects of the above-described two
live vaccines and inoculated, first, himself and
a number of his personal friends, so that the
reaction produced by the injection could be
carefully observed, and its harmlessness estab-
lished. Then he extended the operation to 42,197
persons inhabiting ninety-eight different localities
in India, viz., in Bengal, Behar, the then North-
Western Provinces and Oudh, the Punjab, the
Brahmaputra Valley, and Lower Assam. In 1895-
96 he inoculated a further 30,000 people in Bengal,
Behar, Assam, the Central Provinces and the
Bombay Presidency. It was necessary to spread
the inoculations in this manner, as it was not known
exactly where cholera outbreaks might occur, while
in some of the localities most threatened with
outbreaks, namely, in Bengal—where were sub-
sequently carried out the most instructive of Haff-
kine’s operations—he was unable, for a considerable
time, to obtain assent to his work. Efforts were
directed to inoculating people under such conditions
as would afterwards render possible an accurate
study of results. In this manner part of the
officers, non-commissioned officers and .men in
sixty-four British and native regiments were
inoculated; a proportion of the coolie population in
forty-five tea estates in Assam, Cachar, Sylhet and
the Chittagong district; part of the inmates of
boarding schools and orphanages and of nine civil
jails; the population of a supervised village of Sansis
(one of the criminal tribes) near Sialkot, Punjab;
inhabitants of Himalayan villages situated along the
Hardwar pilgrim route, between Naini Tal and
Mussoorie, and liable to become infected with
cholera; residents of the suburban quarters (bus-
tees) of Caleutta, and so on. Elaborate arrange-
ments were made among these communities for
recording cholera oecurrences for a certain period
to come; and by 1896 a mass of material was
collected.
Some of the Difficulties of the Research.
It will be easily understood that it was not in
all parts of India that the author was able to obtain
the precise conditions necessary for his work. In
a statement which he made at the First Indian
Medical Congress in Calcutta, at the end of 1894,
twenty-one months after the commencement of his
operations in the country, concerning one point
which caused him special anxiety, he said :—
“ I could not carry with me a laboratory. It was
most fortunate for my work that a short time
before my arrival in India, the Government of the
North-Western Provinces and Oudh decided to
found a bacteriological establishment in that part
of the country, and entrusted it to the able direction
218 THE JOURNAL OF TROPICAL/MEDICINE ANIY HYGIENE. [July 15, 1913.
of. Mr. Hankin. He and his laboratory were of (2) An alphabetical register containing the
the greatest help to me during the whole time of
my work in the upper part of India. But great as
was this assistance, it was far from being sufficient.
I have mentioned already the great variations which
the cholera virus undergoes when ¢ultivated in the
laboratory. For keeping it in the required state,
it is necessary to pass it constantly through animals,
in the same way as vaccine lymph must always be
taken fresh from a calf or a child, if one wants to
have it at its full power. It is sufficient to say that,
when I came from Calcutta to Agra for the first
time, I was able to procure and bring with me only
six of the required animals. The most essential
part of my method, which forms its distinguishing
feature, could only be carried out, during the whole
time of my nomadic operations in the country, in a
most unsatisfactory manner.”’ 5
Nevertheless, the results obtained, though vary-
ing in direct relation to the variety of vaccine
employed, the duration of the particular epidemies
and the lapse of time between the date of inocu-
lation and the date of exposure to cholera’ infection,
all pointed to the fact that éffective protection was
conferred by the operation, as will be detailed
presently.
Safeguards adopted for securing Accuracy of
à Results.
The arrangements for a systematic study of the
subject culminated in a special organization made
in Caleutta, where elaborate machinery for the
purpose, under the then Health Officer, W. J. R.
Simpson, was kept in operation for thirty-three
months. The facts brought to light in that city
coincided accurately with those observed in all
other parts of India, and may be said to form the
basis of knowledge on the immunization of man
against natural cholera. In view of this circum:
stance it is, perhaps, desirable to mention the
particulars of the arrangements by means of which
the results were gathered, and the safeguards
adopted for securing accuracy. The statement may
be the more opportune as the question of anti-
cholera inoculation has been coming up lately for
animated discussion, and the precise details of the
Indian studies, which were consigned mostly to
special reports and publications, are perhaps not
sufficiently known. :
The information as regards the arrangements in
Calcutta is given in the report submitted by the
Health Officer, on July 1, 1896, to the Chairman
of the Munieipal Corporation concerning the first
twenty-four months of the observations in that city.
The details of the service which was employed in
the work, and which formed part of the Municipal
Health Office, are described in the report thus :—
“The following records of the inoculations are
kept in the Health Office :
' (1) A daily register filled up at the time of
inoeulation, containing name, father's name, sex,
age, caste, occupation, residence and place of
inoculation; also any relative who may have been
inoculated.
names of the inoculated with the above details, so
that ready reference can be made.as to whether
a person attacked with cholera has been inoculated.
'" (8) A ward register showing the residences of
the inoculated people, so that when any particular
locality is affected with cholera, the inoculated in
that locality may be easily found.
‘Cases of cholera are notified to the Municipal
Office by the following agencies: the registrars of
births and deaths of each of the wards; the sub-
registrars at the burning ghats and burial grounds;
the authorities of the local hospitals, jails and the
fort; the police; the medical practitioners who are
asked, in conformity with the Municipal law, to
notify all cases of cholera on special postcards with
which they are provided; and by officers of the
Health Department. All notified cases are imme-
diately subjected to an inquiry by the Medical
Inspector in éharge of the district, who has person-
ally to-visit the house and take the necessary pre-
cautionary measures to prevent the spread of the
diseiise. In his inquiry as to the circumstances of
the attack, he has to fill up a printed form embody-
ing the necessary information; and one of the
questions, since the introduction of the inoculation,
is whether there are any inoculated people in the
house, and whether the attacked person was inocu-
lated or not. This information is at once com-
municated to the Health Office; and when the case
occurs in a house where inoculated people live, the `
Medical Officer in Charge of the Inoculations im-
mediatély visits the house, accompanied by the
Medical Inspector of the district, and makes a
thorough investigation as to the particulars of inocu-
lated and uninoculated inmates and the incidence of
cholera on these respectively. The accuracy of the
statement as to who is inoculated is checked by the
inoculation registers, which have. already been re-
ferred to. A list of these cases is given to the
Health Officer who periodically visits the cases
and verifies the results.
'" On two occasions the results have been sub-
jected to a further serutiny. In July, 1895, when
the number of houses in which observations had
been made was thirty-six, Haffkine re-visited with
me” (W.J. R. Simpson) ‘‘ten of the most important,
which he had not previously seen, and satisfied
himself that the returns were absolutely accurate.
He would have seen all, but he was not well at the
time. And quite recently, during my absence in
England, Surgeon-Captain Robson Scott, I.M.S.,
Deputy Sanitary Commissioner of the Presidency
Circle, made a special investigation on the subject,
which lasted several weeks. Dr. Mookerjee and Dr.
Chowdry, of the Municipal Medical Service, were
specially deputed to assist him in his inquiry, and
the local Medical Inspectors were asked to give him
every assistance. The inquiry consisted in visiting
affected localities and those in which inoculation had
been carried out, and in collecting information
from the members of the households and neigh-
bours, which, on being brought to the Health
Office, was checked by the inoculation registers
July15,1913] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
and by the cholera death registers. The result of
this investigation confirmed the accuracy of the
previous observations, and Surgeon-Captain Robson
Scott has furnished me with the following note :—
‘** In compliance with your réquest of yesterday,
I now send you a short account of my visits to
the bustees in Caleutta during last May.
'"' [n the beginning of last May, M. Haffkine
asked me to visit those wards in the town in which
anti-eholeraie inoculation has been performed on
the inhabitants, with the view of testing the
accuracy of already recorded observations, and to
try and find out if any observations had been
missed.
'"* During the eleven afternoons or mornings
that were devoted to the work, fourteen wards were
visited, and inquiries were made in 164 different
bustees and houses. I was either accompanied by
a Medical Inspeetor or by the Town Inoculator (Dr.
Chowdry), and was taken by him to the various
quarters where inoculation had been carried out.
'** * First of all I found out from the inhabitants
those dwellings in which cholera had broken out;
and afterwards the individual residents in those
partieular dwellings were questioned, and their
statements taken down by me.
““*T have been able to convince myself that
the method of recording the observations in Cal-
cutta is most satisfactory, and that the recorded
observations are correctly stated.
** * [ intend to continue these visits to the bustees
in Caleutta from time to time, and I shall be glad
to furnish you with any new information I may
gain.’ "'
Results of the Studies on Man exposed to Cholera
Infection.
From the end of March, 1894, to the end of
December, 1896, 7,908 people were inoculated in
Caleutta, mostly in the cholera-stricken suburbs.
The disease visited subsequently eighty-five of the
houses in which inoculated persons lived, and one
of the ships in the harbour, the Majestic, part of
the crew of which had been inoculated. The total
number of inhabitants in these houses and on the
ship was 1,395. The details are embodied in a
series of tables which comprise the addresses, the
number of inoculated members in each house and
on the ship, and the date of their inoculation; the
number of non-inoculated members; the name, sex,
age and caste of the individual or individuals
attacked with cholera, and a statement as to
whether the attacked had been previously inocu-
lated or not, and, if inoculated, whether with
^ : ? m ,
preparatory vaccine only, i.e., vaccine '* I,” or with
vaccines 'I'"' and '' II"; the date of attack and
the interval which had elapsed between the date
of inoeulation in that partieular house, or on the
ship, and the date of the cholera occurrence; and a
statement as to recovery, or, in the event of death,
the date of this. Only one instance of failure in
a patient inoculated with the two vaccines was
observed, the attack in that case occurring 688 days
after the date of inoculation.
219
A list of a series .of cases is then given in
tabular form. i
The details of the inoculations performed during
the month and all occurrences of cholera in houses
where inoculated individuals lived were published
as the events were taking place in a special inocu-
lation bulletin. The information included .all the
details summarized in the tables mentioned. In
this manner the medical and sanitary authorities
and the medical practitioners of Calcutta, of whom
many were keen critics of the method, were kept
informed of the progress of the work and placed
in a position to verify the facts. Further, through-
out the period of investigation detailed reports,
showing the occurrences of cholera in households
containing inoculated members, were submitted
periodically to the Municipal Council of Calcutta,
at whose expense the inoculation service was main-
tained. The Council includes, as is well known,
a high grade Government officer, a member of the
Civil Service, as Chairman; officials of the Govern-
ment of Bengal; lawyers; officers of the Indian
Medical Service and medical practitioners; news-
paper proprietors and editors; house and land-
owners; members of European and Indian mercan-
tile and trading firms, &c.—who represent and
reside in each of the localities referred to in the
tables. The Municipal Commissioners were thus
enabled to control the statements embodied in the
reports. The facts and the whole inoculation sys-
tem were challenged whenever a Commissioner had
doubts about them; questions were put officially to
the Chairman of the Municipal Corporation; the
matter was debated publicly in the Corporation
meetings, of which reports appeared in the daily
press and in the medical papers; and a detailed re-
investigation was on each such occasion made. In
the course of these re-investigations a few errors
were discovered and corrected.
Had it appeared at any time that the study was
being impaired by inadequate investigation, by
exaggerating the results or by minimizing cases of
failure, or by any other manifestation of careless-
ness or of bad faith, the progress of the work would
have been at once arrested, as it depended wholly
on the confidence which the public and the authori-
ties had in the operators.
Another table in the report at once reveals the
fact that the incidence of cholera among the inocu-
lated varied according to three periods. During
the first four days after the date of inoculation:
cases were observed both among the inoculated and
the non-inoculated; after the first four days there
was a period of nearly fourteen months (412 days)
in which three attacks occurred among the inocu-
lated, while among the non-inoculated, ih the same
houses, cases were taking place at short intervals
throughout the whole of that period; and from the
417th day, during the remaining thirteen months of
observation, cases reappeared among the inocu-
luted. As time went on the field of observation
gradually contraeted owing to the usual migration
of the occupants of suburban tenements.
Analysing his tables according to the above three
periods, Haffkine states that :—
220
(1) In twelve houses and on the ship Majestic
where cases of cholera occurred during the first four
days after inoculation—a period in which the pro-
tective effect of the vaccine gradually asserted itself
—there lived a total of 123 non-inoculated in-
dividuals, who had six cholera deaths (4:88 per
cent.) and four attacks ending in recovery, and
142 inoculated, who had five deaths (3:52 per cent.)
and one attack with recovery.
(2) In the fifty-four houses where cholera occurred
during the second period, extending over fourteen
months, i.e., from the fifth to the 416th day after
inoculation, there lived 539 non-inoculated, who
had sixty-one deaths (11:32 per cent.) and five
attacks ending in recovery ; and 279 inoculated who
had two deaths (0°72 per cent.) and one attack
with recovery.
(3) Lastly, in the sixteen houses where cholera
occurred during the third period, i.e., between the
4l7th and 800th day after inoculation, there were
126 non-inoculated, who had fifteen deaths (11:90
per cent.) and two attacks with recovery, and forty-
one inoculated who had six deaths (14°63 per cent.).
During the immunization period, which occupied
four days, the number of deaths among the inocu-
lated was, therefore, 1:39 times smaller than among
the non-inoculated. During the period of im-
munity, lasting 412 days, the number of deaths
among the inoculated was 15°79 times smaller than
among the non-inoeulated; which is to say that of
every 100 deaths from cholera, which were to take
place in that period of 412 days, ninety-four could
be averted by the use of the vaccine. Lastly,
during the third period, from the 417th to the 800th
day after inoculation, when the effects of the im-
munization had vanished, the number of deaths
among the non-inoculated was 1:28 times smaller
than among the inoculated.
Of the six inoculated belonging to the last group,
who were attacked more than 416 days after inocu-
lation, five had received only one injection, with
the first, or preparatory, vaccine; and the sixth,
inoculated on May 29 and June 3, 1894, and
attacked with cholera on April 16, 1896, 688 days
after the first inoculation, had had the two vaccines
in very weak doses, as was practised before the
date of the observations made in July and August,
1894, in the East Lancashire Regiment, at Luck-
now. It was the latter observations that indicated
for the first time at what rate the effect of the
doses with which the inoculations had been com-
menced in India tended to disappear as time went
on. Since the summer of 1894 the doses and the
strength of the vaccine were increased, with the
objeet of extending, if possible, the duration of im-
munity, as will be stated lower down.
The results observed throughout the rest of the
country agreed in every instance with and con-
firmed the Caleutta observations.
In the 1st Battalion East Lancashire Regiment
inoculation was carried out in May, 1893, soon after
Haffkine had begun work in India, and cholera, in
a severe form, broke out in July and continued in
August, 1894, that is, during the fourteenth and
fifteenth month after the date of inoculation.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 15, 1913.
Among 640 non-inoculated officers, non-com-
missioned officers and men there occurred 120 cases
(18°75 per cent.) with seventy-nine deaths (12°34
per cent.); and among the 183 inoculated, eighteen
cases (13:58 per cent.) with thirteen deaths (9°77
per cent.) The inoculation had been done with
vaccines ** I " and “ II" given in very small doses.
Among the British troops at Cawnpore, in July
and August, 1894, thirteen months after inocula-
tion, there occurred, among 797 non-inoculated,
nineteen cases with thirteen deaths, and among
seventy-five inoculated, no cases. Inoculation in
this regiment had been done by Mr. E. H. Hankin,
of Agra.
In the 2nd Battalion Manchester Regiment, at
Dinapore and Camp Beta, in July-August, 1894, a
few cases occurred two to six days after inoculation,
viz.:—
Among 729 non-inoculated, six cases with three
deaths, and among 193 inoculated, no cases.
On the tea estates in Lower Assam, viz., Kala-
cherra, Chargola, Pollarbund and Lungla, there
occurred in the summer of 1895, during the first
few weeks after inoculation, among 4,747 non-
inoculated coolies, twelve cases (0°25 per cent.)
with nine deaths (0°19 per cent.), and among 1,374
inoculated, all with vaccine ''I"' only, one case
(0°07), fatal.
On one estate only, at Adam Tila, 657 non-
inoculated remained free from cholera, while among
the 318 inoculated, all with the preliminary vaccine
only, there occurred two cases (0°63 per cent.) with
one fatal issue (0°31 per cent.).
In the Gya Jail inoculation—first with vaccine
“1,” and five days later with vaccine ‘‘ II," both
in small doses—was applied in July, 1894, while
an epidemic of cholera was in progress. In the
fifteen days during which the epidemic continued,
and including the cases which occurred during the
first days, i.e., while the protective effect of the vac-
cines was still asserting itself, there were, among
a daily average strength of 202 non-inoculated
prisoners, twenty cases (9°91 per cent.) with ten
deaths (4°95 per cent.); and among a daily average
of 208 inoculated, eight cases (3:85 per cent.) with
five deaths (2:40 per cent.) Of the five fatal
attacks, four occurred within four days after the
first inoculation, before the second inoculation was
done, and the fifth in a prisoner who had both the
preparatory vaccine and the vaccine proper.
In the Durbhanga Jail, in April, 1896, inoculation
was applied, similarly, during the progress of an
epidemie, but this time one injection only, with
vaccine ‘‘ IL," in strong doses, was given from the
first. The prisoners had been told to seat them-
selves on the ground in rows, and every second man
or woman, as they happened to have placed them-
selves, was inoculated. After the time of inocu-
lation the epidemie lasted only five days, but was
of exceptional fatality. There occurred among an
average daily strength of ninety-nine non-inoculated
prisoners, eleven cases (11:11 per cent.), all fatal;
and among an average strength of 110 inoculated,
five cases (4°55 per cent.), with three deaths (2°73
per cent.).
July 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
221
Few operations made by the author within the
walls of a laboratory exceeded in precision the one
just described. Its results confirmed some essen-
tial conclusions which were deduced from previous
observations; and henceforth Haffkine accepted
those conclusions confidently as a guidance for his
future work.
In the studies described above there is one
desideratum which a baeteriologist might have
wished to see fulfilled to a greater extent than it
actually was, and which the author would have
endeavoured so to fulfil, had there been at the time
the necessary requirements at his disposal. That
refers to the bacteriological examination of the pro-
ducts of the cholera patients, so as to have that
method of diagnosis of the disease added to the
clinieal diagnosis made by the physieians who
observed and investigated the cases. A baeterio-
logical examination was carried out on many
patients under his charge by Dr. Powell, of Cachár,
and in certain cases by the officials of the Caleutta
Health Office; but in most other instances such an
examination was not practicable and was not desired
by the regimental or jail authorities, by the medical
officers in charge, by the tea estate managers and
their medical officers, or by the sanitary authorities
of the country. The reason of this is that the per-
centage of doubtful cases in an epidemic of cholera
is relatively unimportant, as is known to those who
have ever been in the midst of an outbreak of
this disease and are familiar with its manifestations.
As a safeguard, however, against possible mistakes,
the rule was adopted, on the occurrence of any un-
certainty, always to record doubtful results against
the cause of inoculation. Thus, if a doubtful ill-
ness occurred in an inoculated, it was arranged to
record this as a case of failure, i.e., a case of
cholera in an inoculated; while if it occurred in a
non-inoculated, the doubtful attack was not to be
taken into account.
The effect of the anti-cholera inoculation was
thus established by carefully studying the history
of and comparing inoculated and non-inoculated
members of the same households, the same regi-
ments, the same batches of coolies, or inmates of
the same prisons. In this way sources of error
arising out of privileged social position, sanitary
locality, good housing, pure food and water, or any
other adventitious cause of immunity in the inocu-
lated were obviated. Students of medicine and
sanitation will, the author believes, find it not easy
to reply, if they are asked to name, in the history
of those sciences, a method, whether preventive
or curative, the effect of which has been estab-
lished with a greater degree of precision than in
the case of the method under consideration.
General Results of the above Studies.
The facts of general significance revealed in the
course of the studies detailed above were the fol-
lowing :—
(1) “ Active " immunization, realized by means
of a purely bacterial vaccine, as contrasted with
immunization by means of lymph or tissue of
another, previously inoculated, animal, was effective
in application to man.
(2) Such immunization eould be carried out with
safety during the progress of acute and fatal out-
breaks, as was, e.g., the outbreak in the Durb-
hanga Jail; and the febrile and other reaction
caused by the injection of the vaccine, in the
doses used, did not increase the susceptibility to
infection among the inoculated and did not aggra-
vate the disease when an inoculated happened to
become infected during the progress of that re-
action or during the days immediately following;
and
(3) The development of a rapidly incubating
disease, such as cholera, could be mitigated or
entirely averted by applying the same form of
immunization to individuals previously infected, in
whom the disease was already in the incubation
stage. This latter fact, theoretically of a much
more paradoxical nature than the others, received
in the next two years (1897 and 1898) extensive
confirmation in the results of the anti-plague
inoculation, which was planned upon the results
of the inoculation against cholera; and the principle
thus established was adopted for guidance in thera-
peutic practice and applied in treating diseases
actually developed, first tentatively, by some of
Haffkine’s co-workers in India, and subsequently
by Sir Almroth E. Wright, who learned it during
his visit to India as member of the Plague Com-
mission of 1898-1901. It must be mentioned, how-
ever, that, at the time, the Commission did not
see their way clear to acquiesce in the validity of
the discovery and in their official report pronounced
themselves against the applicability of inoculation
in the incubation stage of plague. Inoculation as
a remedy against a condition of infection developed
beyond the incubation stage has since been exten-
sively tried, and its effects and degree of actual
utility in such circumstances are studied in many
diseases.
Another feature of the anti-cholera inoculation,
which was taken into account in devising the plan
of the inoculation against plague, was that, while
the incidence of cases of cholera and—parallel with
this—the incidence of deaths from that disease were
powerfully influenced by the inoculation, no effect
of any constaney was observed upon the recovery
rate of the inoculated attacked, a result which,
unfortunately, went against the expectations sug-
gested by a priori consideration of the matter. In
devising the plan of inoculation against plague,
endeavours were made to affect favourably also the
recovery rate; and, apparently in answer to the
measures adopted, the result proved successful.
Subsequent work by various experimenters and
by Haffkine himself regarding the immunization
of man against cholera, typhoid and plague was a
continuation and outcome of the studies of 1890-6.
As concerns immunization against typhoid, Pfeiffer
and Kolle, shortly after 1895, undertook the first
anti-typhoid vaccine operations in Germany. In
their original publieation on the subject the authors
quote the Indian researches as opening the way
422
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1913.
for.further application of the method, and state
that ''as the experiments made to realize artificial
immunization of man against cholera gave such an
unexpectedly favourable result, the problem which
presented itself next was to inquire how man would
react to inoculation of typhoid bacilli." The
. examination of the blood of the persons subjected
to such inoculation showed a certain similarity with
the blood of individuals who had recovered from an
attaek of typhoid fever, and the authors surmised
that typhoid inoculation was also likely to be
effective. ‘‘ We are," they state, ''the more
entitled to this conclusion, as the analogous experi-
ments-of Haffkine on preventive inoculation against
cholera have already stood the test of many
thousands of practical applications.” The interest
of this statement is enhanced by the fact,
aeknowledged in the above passage, that, at the
commencement of the Indian investigations, in the
memoir of 1898, Pfeiffer and Wassermann had
expressed themselves as not expecting that immuni-
zation against intestinal eholera was realizable. In
England, Wright and Semple started anti-typhoid
inoculation upon a plan given by the author to the
former worker. In their paper the writers say:
'" Haffkine suggested rather more than twelve
months ago to one of us that the method of vaccina-
tion which has proved so effectual in combating
cholera epidemics in India might, mutatis mutandis,
be applied also to the prophylaxis of typhoid fever."
Inoeulation against plague was similarly a direct
outcome of the cholera inoculation in India, and,
as already mentioned, was based on the teachings
which resulted from that work. A further applica-
tion has now been given to the same methods in
the preventive inoculation against dysentery.
(To be continued.)
———— eo
Annotations.
Malarial Gangrene.—Hammond (Indian Medical
Gazette, June, 1918) reports two cases of what he
believes were examples of malarial gangrene.
The first occurred in a young Hindoo male, aged 19,
who was admitted into hospital at Maymyo in a
state of collapse.
On examination of the blood an enormous number
of malignant tertian rings were found, one corpuscle in
.every three containing these forms, and each infected
corpuscle often containing two or three rings. The
spleen was enlarged and hard and extended three
inches below the costal margin. The liver was normal
and the heart and lungs were sound. There was a
previous history of malaria; no syphilis. On the
fifth day after admission it was noticed that the skin
over both calves was becoming dusky in patches, which
spread rapidly over the whole surface of the leg, and
it’ was obvious that gangrene was threatening. In
addition to his daily injection of quinine bihydro-
chloride 10 gr. an intravenous injection of 5 gr. to the
pint of saline was given, the legs were kept warm, and
every effort possible was made to maintain asepsis.
In spite of all precautions three days later moist gan-
grene became fully established in both lower extremities
and the usual train of septic symptoms supervened. An
irregular lineof demarcation commenced to form in both
limbs and onJune 20— fifteen days after admission—the
right leg had to be amputated at the knee. On the left
side the foot sloughed. The patient finally recovered.
The other case was in a male, aged 25, admitted for
fever, vomiting, pain, and inability to lift his hands.
On admission both wrists were dropped, and he was
quite unable to elevate the hands, which were cold and
insensitive. Both feet were very cold and inactive,
and cedema extended as high as the knee on both sides.
Gangrene of all four extremities, which rapidly became
moist and septic, developed so that the temperature,
which had been consistently subnormal, rose on the
seventh day after admission to one typically septic in
character. (Edema of the bases of the lungs became
pronounced, and the patient sank and died. No post-
mortem was allowed, so the actual cause of the
gangrene was not determined ; whether the tissues
died from venous thrombosis (due to lack of vitality
and consequent venous stasis) or through sheer in-
anition from enfeebled arterial supply, or possibly
arterial thrombosis, it was difficult to conjecture. In
the first case, the arteries of the amputated leg
showed no thrombi, but as Hammond was unable to
select the site of removal, the knee-joint being chosen
for the sake of rapidity, it was possible that the artery
was blocked at a higher level.
The author draws attention to the fact that an
interesting point in both cases was, that on admission
the collapse and continued subnormal temperature
were the outstanding features, whilst the history of
malaria was so indefinite that if a blood specimen
had not been taken the eause of the condition might
have easily been overlooked. The intravenous injec-
tion of quinine which usually effects so marked an
improvement on malarial coma proved very ineffectual
in both cases. It is probable that the French method
of sterilizing the limbs with hot air would have been
useful, but no apparatus was available for the pur-
pose, and, in its absence, it was impossible to keep
the patients from developing septic infection in the
dead tissues.
Climatic Bubo.-—Gray, in a paper read at the
Triennial Conference, January, 1913, and republished
in the China Medical Journal, vol. xxvii, May, 1913,
No. 3, discusses the subject of climatic bubo. He
says that of the three sets of groin glands, the
superfieial oblique inguinal, the superficial vertieal,
and the deep inguinal, the first is the group with
which one is concerned in dealing with this affection.
The glands of this group are disposed irregularly
along Poupart's ligament and receive the lymphatic
vessels from the integument of the scrotum, penis,
parietes of the abdomen, perineal and gluteal regions
and the mucous membrane of the wrethra. The
vertical interior group receives the superfieial lym-
phatie vessels from the leg, and the deep inguinal
glands which are of small size communicate with
the latter group through the saphenous opening.
With regard to the first group and the glandular
enlargements it undergoes from diseases implieating
the parts from which its lymphaties originate, one
July 15, 1918.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
has to think of the following causes, viz., malignant
or venereal affections of the prepuce and penis, or
of the labia majora in the female, cancer of the
scrotum, abscess in the perineum, or any other
disease affecting the integument and superficial struc-
tures in these parts or the sub-umbilical part of the
abdominal wall or gluteal region. The lower groups
become implicated in diseases affecting the lower limb.
Etiology. —-The diseases mentioned in the first
group gave no indication of actually being or of
having been present in any of the cases seen by
Gray, nor did any show evidence of malaria, for not
only did he not find Plasmodium malariz in the
blood but quinine injections had no effect.
As regards climate, a case was seen in October
and one in November. In these two cases the
production of the bubo could not have been favoured
by high atmospheric pressure or by any of the
deletarious effects of life in a hot climate that often
result in a certain predisposition in the individual
which would give him a lessened organic resistance
to microbie injection. Septic absorption resulting
from scratch or insect bite can also be ruled out of
court, for the integumentary area which is drained
by the oblique glands is that part of the body which
is kept covered. In addition, how many cases of
dhobie itch are seen with a thoroughly septic skin in
which the inguinal glands show no sign of enlargement?
Pathology.—All the cases were infections of glands
of the inguinal group, and not the femoral group, a
point to be remembered in discussing infective sites.
Specimens taken out bodily consist of a mass of
enlarged and matted lymphatic glands, many of
which show more or less advanced areas of necrosis.
Clinically the patient becomes cognizant of a groin
swelling which does not trouble him much. This he
attributes to some strain, and hopes it will subside in
a day or two, during which period he is able to walk
about. In from three to eight days he seeks medical
advice, and a strict inquiry fails to elicit any cause
for the hard, almost painless glandular swelling. The
progress of the disease is slow, and rest in bed with
anti-inflammatory local treatment does not, as a rule,
effect any amelioration. Blood examination reveals a
steadily increasing leucocytosis. Palpation gives a
sense of bogginess without any definite sign of
fluctuation as is found in purulent venereal buboes.
The temperature is remittent, rising every evening
during the first week to 100° F., and subsequently
to 101° and 102° F. The patient becomes restless
and sleepless, and gives a general indication of septic
infection. No other symptoms present themselves ;
the disease is purely local.
Medicinal treatment is of little or no use. Iodides,
quinine, arseno-ferratose, &c., have all been given
with no noticeable effect. In one case Gray gave
606 intravenously, and in another a course of mixed
staphylococcie vaccine, but was unable to see any
benefit. As far as his experience goes, the sooner
an operation is performed and the glands extirpated,
the more chance will the patient have of recovering
quickly. Every gland that can be palpated must be
removed. If done early enough, this is easy, as the
223
glandular tissue is only slightly inflamed and the
subcutaneous tissue is not adherent. The usual
incision is an oblique one, but in fat abdomens with
redundant integument a vertical incision is preferable,
as there is not the same tendency for the edges of
the wound to curl inwards. After extirpation, and
after the cavity has been made as dry as possible, deep
sutures reaching to the floor of the cavity and ap-
proximating both walls are inserted. A gauze wick
may be left in for two or three days. Gray sums up
his paper as follows :—
“Sufficient cases have been found in which there is
no evidence of venereal disease, past or present or
even subsequently,’ to warrant the belief that in
climatic bubo we have a specific separate disease.
The term “climatic "seems inappropriate, but there
is still not enough evidence to show that idiopathic or
non-venereal inguinal bubo is in any way better.
This disease is different from pestis minor in many
important respects. Its course is slow and non-
fatal. It occurs in men in the prime of life; is
neither contagious nor infectious, and is characterized
by small foci of suppuration throughout the gland
substance. Early extirpation of the glands is the
best treatment.
———9————
Hotes and "lets.
TROPICAL DINNER.
A JoINT dinner of the Section of Tropical Medi-
cine and Hygiene of the International Medical
Congress and of the Society of Tropical Medicine
and: Hygiene will be held at the Trocadero
Restaurant, Piccadilly, on Friday, August 8, at 7
for 7.80, Surgeon-General Sir David Bruce in the
chair. Tickets, price 7s. 6d., exclusive of wine,
may be obtained at the Tropical Diseases Bureau,
Imperial Institute, S.W., and after August 6 at
the Albert Hall also. Application for tickets must
be accompanied by cheque or money order payable
to Dr. A. G. Bagshawe. Members of Congress or
Fellows of the Tropical Society are requested to
apply early for themselves or guests.
THE TREATMENT OF
ASTHMA.
Proressor Erich Meyer states in the Deutsch.
med. Wochenschrift, 1912, No. 38, that adrenalin
treatment appears to be superior to the older
atropin treatment for bronchial asthma. It is,
however, but little known that in many cases
diuretin is able to diminish bronchial asthma as well
as the cardiac variety, as was first shown by. Van
den Velden. It is often sufficient to give 15 to
30 gr. before the. time of the anticipated attack
(evening). The preparation may be given for
weeks without any injurious effects.
In the discussion which followed the paper,
Professor Cahn stated that he had been giving
diuretin in cardiac asthma since 1889, and that
he had scarcely had a failure. The dose was
15 gr. two to three times in the late hours of the
BRONCHIAL
224
THE JOURNAL OF TROPICAL MEDICINE: AND HYGIENE.
[July 15, 1913.
IRR M——M——————M————M———M—————M—M———À
evening, . He, „was. led to its use. by the observa-
tions in a.water-logged cardiac patient that, diuretin, .
did: not inerease: the diuresis in that case, but
superseded all narcotics and hypnotics in the pre-
vention and relief of the nightly attacks of dyspncea.
Diuretin may be continued for a considerable time;
one patient took 865 grm. (— 304 oz.) in the course
of fifteen months without any harm and without
contracting ‘a’ drug habit.. Cahn also has used
diuretin for--mény years ‘in cases of bronchial
asthma. The result is doubtful in purely nervous
asthma. It is more certain in the bronchitic forras,
but is especially valuable when the latter variety is
complicated by cardiac debility. The reason that
diuretin has not been able to establish itself firmly
as a remedy for dyspnoea is partly because of its
inappropriate name, which only indicates one aspect
of its action, partly because it has been given in too
small doses. z
A NEW BRITISH JOURNAL OF SURGERY.
Tur -Chairman and Secretary of the Editorial
Committee of the new Journal, Mr. Moynihan and
Mr. Groves respectively, state in their circular that
during recent years there has been great develop-
ment in all branches of scientific medical research
and of literature connected with these subjects. But
in this country, although teaching centres, operating
surgeons, and scientific laboratories have rapidly
multiplied, there has hitherto been no periodical
devoted entirely to surgery.
On the ‘Continent ‘and in America, on the other
hand, there are many purely surgical journals, which
contain most of that original work which always
marks the advance of every great and practical
science.
The extensive circulation of such journals as the
Archiv fur klinische Chirurgie, the Beiträge zur
klinische Chirurgie, the Deutsche Zeitschrift fiir
Chirurgie, the Revue de Chirurgie, and the Annals
of Surgery.is striking evidence ,of the enthusiasm
for progress in their respective countries, and this
is the more remarkable inasmuch as some of these
papers have existed for more than fifty years, and
‘command a wide circulation at a high price.
It is true we possess at home several periodicals
in which’ surgical articles appear, but these only
correspond with the similar general medical journals
abroad, and cannot give either space or illustrations
sufficient for dealing adequately with articles of a
special character, which often embody much
original research.
We believe that ‘those who love their profession
must often- regret this absence of purely surgical
literature in England, as being unworthy of the
position the British nation should take in regard to
that'pregressive science in which Lister, Simpson,
Tait and many others have done pioneer work that
has received world-wide recognition.
It seems to us that British Surgery at the present
time-has two urgent wants : —
o (1) A Periodical devoted solely to Surgery; and
(2) An Association of those engaged in the prac-
lice or teaching of Surgery, or:in Surgical Research,
for thie promotion of scientific advance by. regular
meetings and.discussions.. (Such. a body. would, by
its corporate existence, encourage progress from
within, as well as make it easier for its members
to keep in touch with surgical.progress as repre-
sented by similar associations in other countries.)
The establishment of am Association may possibly
be facilitated by the publigation of the Journal, and
both maybe best promoted by starting the periodical
for which we now plead.
Two informal meetings have been held for the
preliminary discussion of this undertaking, an
Editorial Committee-has been formed, and it has
been decided that a BRITISH JOURNAL OF SURGERY
shall be forthwith issued.
It is the Committee's intention that this shall
begin as a Quarterly Journal, with the general size
and quality of the Quarterly Journal of Medicine.
It is abundantly clear from the names of the
collaborators which appear with this prospectus
that there will be no lack of interest in the project,
and numbers of valuable papers have already been
received- and promised. For the permanent success
of the Journal, however, it is clear that a generous
circulation is also needed.
The Editors and Publishers therefore make an
earnest appeal to all those who really desire the
advancement of British Surgery to become Annual
Subscribers.
Each number will contain between 140 and 200
pages, will be fully illustrated, and will be made up
of (1) Original Papers; (2) Critical Reviews—each
article to be signed by the writer; and (3) Notices of
Surgical Books, Instruments, and Appliances. The
general dress and appearance will be of.the highest
character, and the ilkustrations—which will be a
prominent feature—will be in the best modern style,
whether black. and white, coloured, or stereoscopic.
The price of the Journal is fixed at 7s. 6d. per
quarter, or 25s. per year,-to subscribers.
Orders. and, Subseriptions may be sent to John
Bale, Sons and Danielsson, Ltd., the publishers of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
— eo
Personal Hotes.
COLONIAL MEDICAL SERVICES.
West African Medical Staff.
July 11, 1913. :
Death.—W. H. Langley, F.R.C.S8.L, L.R.C.P.L, F.Z.S.,
Principal Medical Officer, Southern Nigeria.
No transfers.
No resignations. s
Retirement. —R. M. Forde, L.R.C.P., L.R.C.S:, Principal
Medical Officer, Sierra Leone, retires on pension,
' New Anpointments, — The following gentlemen have been
selected for appointment to the Staff: K: K, Grieve, M.B.,
B.Ch.Edin., D.T.M.Liv., Southern Nigeria; D. T. Birt,
_M.B., B.S.Durh., Southern Nigeria. :
Other Colonies and Prot.clorates; 3 2
Miss S. O'Flyn, M.B., Ch.B.Edin., has been selected for
appointment as a Lady Medical Officer in the Federated Malay
States. ]
W. T. B. Meade King, M.R.C.S.Eng., L.R.C.P.Lond.,
F. ©. Doble, M.R.C.S.Eng., L.R.C,P.Lond., and R. J. A.
MacMillan, M.B., Ch.B.Edin., have been selected for appoint-
ment'às Medical Officers in Uganda, ` DART TES
Aug. 1, 1913.]
Original Communication.
A YEAR'S ANTI-MALARIAL WORK AT
KHARTOUM.
By AwpREW Barrovn, C.M.G., M.D., B.Sc.,
F.R.C.P.E., D.P.H.
Director, Wellcome Tropical Research Laboratories, Gordon
College, Khartoum, late Medical Officer of Health,
Khartoum.
OF late years but few papers have appeared dealing
with the epidemiological aspect of malaria in Africa.
Hence it may be of interest to give an account of the
anti-malarial work in Khartoum for last year (1912),
considering it in the main, but by no means wholly,
from the epidemiological point of view. It was, as it
happens, a specially interesting year, for, so far as can
be told, the climatic conditions favoured a prevalence
of malaria, and Khartoum, which has enjoyed a very
considerable immunity in past years from the disease,
did not altogether escape, having been visited by a
small epidemic following the occurrence of a short
but heavy rainfall. Moreover the town is undoubtedly
suffering from the fact that, until recently, very little
attention was paid to the irrrigated areas along the
Nileto the north, and far outside municipal boundaries.
These areas were allowed, for reasons into which I
need not enter, to go from bad to worse, and as a
result they began to constitute themselves a serious
nuisance to Khartoum as nurseries for anophelines.
This will lead me to speak of the influence of
mosquito immigration, a subject of great importance,
whieh has of late received little attention, and, indeed,
since the pronouncement of Sir Ronald Ross [1] (1905)
upon it, has scarcely been seriously considered save
perhaps in India.
I [2] have already, in numerous papers, considered
so fully the local conditions at Khartoum as regards
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 15, Vol. XVI.
malaria and mosquitoes that there is no need to enter
into a detailed description of the locality of ano-
pheline breeding places and other matters bearing on
malarial infection. The accompanying map sufti-
ciently illustrates most of the points to which I
desire to direct attention.
It is, however, necessary to say something with
reference to the population, as the figures previously
given (Third and Fourth Reports, Wellcome Tropical
Research Laboratories) do not now apply. A census
was taken in the course of the year, and the following
are the official figures for the civil population of
Khartoum and Khartoum North over which the
Sanitary Service exercises control.
KHARTOUM City AND ADJOINING VILLAGES.
Europeans age ji aut T 1,114
Egyptians and other non-Europeans 8,645
Natives ... TT ae TE is ... 15,968
Total AT .. 25,722
KHARTOUM NORTH.
Europeans .. fen T: A 482
Egyptians and other non-Europeans 1,467
Natives... Pan TR ias ET ... 15,176
Total ses ... 17,125
Central Prison (average) P Ls 363
17,488
Grand total for civil population... ... 43,210
In addition there are the British and Egyptian
army garrisons, amounting in all, according to the
most recent returns (1912), to 5,507 men, 780 of
these being British troops—infantry, camel company,
garrison gunners—Royal Army Medical and Army
Service and Ordnance Corps.
I now submit a table giving meteorological statistics
for 1912.
TABLE I.—MrrEOROLOGICAL STATISTICS FOR 1912.
—A——————— M ———— ——— — — —
|
MONTHLY AVERAGE |
|
Rainfall in
Temperature, degrees Cent. millimetres
Humidity* at Direction of
8 a.m., degrees wind
Maximum Minimum | Mean
peasy 28:9 | 137 21:3 30 N. —
ebruary 31:0 14:8 99-9 28 N.N.E. eA
March 34:5 | 18:6 26:6 22 N. | €
April ... 39-0 20:8 29:9 16 N.N.E. | T
May ... 42:6 26:0 84:3 17 N. | =
June ... 49-9 26:4 34:3 | 36 S.S.W. | 2
July ... 39:8 | 26:1 33:0 50 S$.8.W. | 04
August 37:4 24:6 31:0 63 S.S.W. 98:1
September 39:4 25:6 32:5 48 S.S.W. 17:7
October 38:6 24:9 314 33 N. =
November ... 35:4 20°4 97:9 33 N. =
December... 29-9 15:9 22-9 33 N.N.E. | =
* This is a little higher than the mean.
Mean annual temperature, 29:0 degrees Cent,
Total rainfall, 116-2 millimetres.
-^ Highest temperature, 467 degrees Cent., May 29.
Lowest temperature, 9:0 degrees Cent,, February 20.
226
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 1, 1913.
For these particulars I am indebted to Mr. Addison,
of the Gordon College Workshops, who has charge of
the meteorological instruments, and is responsible
for the daily observations. There is nothing of special
note save the comparatively heavy rainfall during
August. Table II shows how this rainfall became
operative as a factor favouring mosquito prevalence
and propagation.
TABLE II.— DETAILS OF RAINFALL AT KHARTOUM FOR
It will be seen that it was the rainfall of August 6
and 7 which was the chief cause of the flooding.
The surface soil is of such a nature that, when
thoroughly soaked, it takes on a clay-like consistency,
loses its porosity, and, where there are depressions,
presents ideal conditions for the formation of pools
and puddles. Heavy rain showers, following each
other at brief intervals, converted some of these pools
into miniature lakes, great stretches of land being
under water.
AUGUST, 1912. There being no means of drainage, these water
collections persisted for lengthy periods and, despite
Rainfall in 24 hours, Sida every effort in the way of petrolage, baling and even
ending at 8 a.m. pumping, not only attracted anophelines, but also
——— ———— — — served as breeding places for them. This leads us to
Angust! 9 26 Rainfall from 2.50 to 3.30 August 1. a consideration of the mosquito statistics for the year.
ii 1-1 | Light rain fell intermittently from These are presented in the form of two tables, one for
6 p.m. August 2, to 4 a.m. August 3. Khartoum, the other for Khartoum North and, so far
» 6 -19:3 Reinen ronm awm to ARON 20 a as anophelines only are concerned, are shown in a
au LT dh di graphic manner on the accompanying map, which
uod 45°6| Heavy rain 1 a.m. to 6 a.m. August 7, will be explained in due course.
gradually diminished in force after In Table III, which is of a statistical nature, all the
10 13:9 Mien ad poesi eiim from three genera of mosquitoes which are commonly found
Us 19-30 a.m. to 6 a.m. August 10. in Khartoum are considered, i.e., Culex, Stegomyia
» 18 7:9 | Gentle rain from 7.45 p.m. to 11.30 p.m. and Pyretophorus. The last-named anopheline genus
August 12. is represented by a single species, Pyretophorus
costalis, which, judging from my experience of the
Total — 98:1 mm. Northern Sudan, must be one of the worst of the
TABLE III.—MosqouiTO STATISTICS FOR THE YEAR ENDING DECEMBER 31, 1912. KHARTOUM.
|
Number of wells, pits, Number of zeers and Number of steamers | Number of pools P
&e., infested other small receptacles | and boats infested infested crmenent penaga of
Month a | EN. 'collections a iin UT. Last year—1911
| in the collections
C. 8 A. C E A. | ©. | 8. A. C. 8 A. city.
January et et BI] ee ER eet] ee | su 1-97 | 2-67
February ...| 23 -- — — 5 — -— —|-— 1 — 8 894 2°35 | 9-92
March 25 | — — | — 2 — — = | = 3 — 2 885 2:82 | 3:28
April go. icm d m UI PESE SE: 1.4] <=. = 4 | 20 | 869 2-41 | 2°84
May 16 — 2 — — 12 | — 23 | 865 1:96 2:33
June 14 -- 1 | — — - 3 — -— 2 — 3 , 860 1:62 | 2°60
July 39 "mq e osi wd es om c xu ssl xk 456 | 248
August . 70 — 6 30 -— — 5 — 2 45 — | 58 853 8'67 3:60
September 98 | — 6 | 4 | «mol = We vm 7 , — | 16 | 858 2:81 2:21
October 13 — 1 — 6 -— 4 = 1 3 29 | 849 1°41 211
November..| 15 | — 2 | — 3 | — Be ABE WE ae 8 95 | 848 1:65 1-07
December ... 15 — 1 — 4 — — 4 | — | 34 — 142 846 1:65 174
Total 299 i 20 46 | 96 = 16 6 3 | 121 — | $28 2:82 average 2°46 average
i | | | |
Of the above, the following were outside the Municipal Boundaries.
19 Buri | 2 Buri 1 Buri | | 1 ‘* Evelyn Z — 12 Buri 1 Mogren |
| 8 Tuti 1 Tuti | | | | 1 White 1 Whiite Nile
; 1 Daims (villages to south of town) Nile 30 Tu ti
rr ard | 1 Sha mbat | 75 Buri
B ER E 2 Dai ms 10 Dajims (villages to south lof town)
ed aa | | | 1Tuti 122 Blue Nile | Banks (above | Koko)
30 Blue
| | Nile Banks |
| | i (above/Koko) |
—— | |
—— a ——— ——— |——— — — IL. ——— s -| —— | —————— —— ——— —
Total ...| 23 = | 3 1 2 t Tn os = 4v | — | 289
: |
RE
C. = Culex. B. - - Stegomyia. A. — Anophelines.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, AUGUST 1, 1913.
d|
pc Sere C eee
Fic. 3.—Infested ** khor" at Gereif. Mosquito brigade in action, Fic. 5. —Mosquito trap open.
To illustrate article, * A Year's Anti-malarial Work at Khartoum,” by ANDREW Barroun, C.M.G., M.D., B.Sc., F.R.C.P.E., D.P.H.
Aug. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
227
malaria-carrying mosquitoes. It will be seen that,
with the exception of the anopheline pool infesta-
tions, the highest figures both for Culex fatigans and
P. costalis were recorded during the rainy month of
August. As a matter of fact, however, the figures
for the various months cannot very well be compared,
for the simple reason that latterly it has been found
necessary to extend the scope of the anti-mosquito
work, in other words to range further afield and bring
new areas outside the town into the protected district.
This is why 142 anopheline pool infestations were
recorded in December, for it was at this time the
heavy infestations in the Blue Nile sandbanks south
of Koko village, and more especially in the so-called
" Gereif Swamp” (fig. 1) were discovered. Of these
more anon. It is to be remembered that these figures
on the west by a line passing through the Mogren
Point, on the east by one passing just to the east of the
water-works and to the west of the farm at Khartoum
North, and on the north by a line passing between
the villages of Khogali and Sababa. The search is
so constant and unremitting that it is but rarely
breeding places are missed and the larvæ are enabled
to enter the pupal stage. Still more rarely, and then
usually as the result of an oversight, or of careless-
ness on the part of a native inspector, do breed-outs
occur, as evidenced by the presence of empty pupal
shells. These statements are illustrated in Table V.
TABLE V.—KHARTOUM. ANOPHELINE INFESTATIONS WHERE
Pup® on PUPAL SHELLS WERE FOUND, JANUARY 1 TO
DECEMBER 31, 1912,
in the main refer to the finding of larve. Date, Situation Pupe Pupal
Table IV represents the findings at Khartoum April 11. «peluoca." near River Bath 2 pc
North. Here again, August and December furnish abt British batracks
the highest figures for anopheline infestation, and for May 12. Buri (river bend) 1 —
the same reasons. In addition, however, April and EUM 98 ila i aa Buri : =
May show more than the average number of pools Movember l7. Buri (one of 5 pools) `.. 1 1
infested. The April infestations were chiefly found * 98 , Lee ae Ope 2 =
in river pools, while those in May demonstrated the ” 25 ay 1 1
pernicious eftect of the area of cultivated land oppo- Dasha z Tun x =
site the Buri sandbank, an area which should never „ 10. Sand bank above Koko 20 M
have been permitted so near the town, even though » 14. Swamp near Gereif (first in- — 70 70
there is a bare stretch between it and the nearest
dwellings, though this is not shown on the map (vide
infra). It is about the end of April that the heavier
pumping begins and there is more water to be got
rid of.
Of the total 473 anopheline infestations recorded
for the year, no less than 305 occurred outside the
municipal boundaries, which, though now being ex-
tended on the north and east, were in 1912 bounded
TABLE IV.—Mosguiro STATISTICS FOR YEAR ENDING DECEMBER 31, 1912.
spection)
In all these infested waters larve were also found.
I do not say that there may not have been in-
stances of larve developing into pup: and of pupe
becoming empty shells in addition to those stated,
for work of this kind cannot be absolutely perfect,
and breeding places will sometimes evade the detec-
tion of the most skilled and careful inspector. Still
KHARTOUM NORTH.
— — t —— ——— —A——— — ————— ]
Number of wells, pits, Numberofzeersand | Number of steamers Number of pools Permanent
&c., infested other small receptacles | and boats infested infest water Bp donee, lt
| i infes J .
Month LA. = dm yer Ur nent water | Last year—191]
c s A Q | 8 A c. s A C s A fos LAE
January ..| 18 | — | — fw. <S fo 9.24 3e]. m 3 | 221 5:88 10°14
February ...| 10 — — 2 1 — | 1 1 — — — 222 4:50 10:55
March e| 14 — — — — — | 1 _— 1 — 9 224 6°25 10°55
April Salle 22 — — = — — | — — | — 2 — 14 9294 | 9:82 5:45
May .| 16 | — = 1 4 — 95 |. zm oss 16 — 28 225 711 9:09
June 333 8 — — — — — 1 2 — T — 5 226 2:65 6:36
July zo. 6 — j — = -— — — | — — 3 1 — 226 2'21 9:54
August ... T boc | 2 4 2 — ». oq | 1 18 — 28 226 3:98 9:54
September 12 | — — 3 1 — 3 1 | 4 1 — 2 226 5:30 14:09
October... 5 — — — 1 -— | 2 9 — 9 — 3 226 2:21 10:00
November ... 11 — | = 1 — 2 1 — | L 2 — 8 226 4:77 7°72
December... 3 — , '—- 1 2 = = = = 2 1 24 226 1:32 4:54
———JL———L- -—-—--—L-—-—L--—-4—-—-—-—--—————
Total 197 | | elau cà a *$]|ox]o | 3» do | 466 average — 8:96 average
| | | |
Of the above, the following were outside the Municipal Boundaries.
Municipal [2Koko) | 42 | 1 | 63 |
Boundaries 1 She mbat | | | |
| | | |
A. — Anophelines,
228
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 1, 1913.
one knows from experience and the results of this
systematic warfare that the figures are not far wrong,
and it is worth while considering for a moment the
condition in which Khartoum would have been during
some of these months had not the mosquito-breeding
operations been, so to speak, in many cases nipped
in the bud. f
The inspecting staff is small, especially during the
leave season, which, naturally, is during the summer
and consequently (if there is any rainfall worth
speaking about) in the rainy months, and the area,
even within municipal boundaries, large. Some parts
of it are not readily accessible, and at certain times
of the year, owing to the rise and fall of the river,
the conditions alter from day to day. The work of the
Khartoum Sanitary Service should, strictly speaking,
not extend beyond these boundaries, and yet every
year it has been necessary to go further and further
afield. It was thought that, by controlling an area
reaching from the so-called Mogren Point to the
place where the Blue Nile turns sharply to the south
opposite the village of Koko, Khartoum city would be
efficiently protected ; but this has proved erroneous, as
shown by the discovery of the heavily infested banks
to the south of Koko and more especially of the
curious khor or swamp near Gereif, the pools of which
were not visible from the river, and which was indeed
only discovered by accident, and then found to be a
veritable hotbed of mosquito life.
In future it will be absolutely necessary at low
Nile to include a point at least two miles from
Khartoum as the crow flies within the inspection
area.
Similarly, at Khartoum North, the defensive
operations have had to be pushed further and
further north, till now, as shown by the map, they
have reached the Government Farm and the river
sandbanks which form near it.
This map is instructive in several ways and
merits a few explanatory notes. The river sand-
banks, the pools in which form the most important
breeding places for anophelines, are shown as areas
marked off from the river by dotted lines. The
larger are distinguished by letters as follows :—
F.B. = Ferry Bank; T.N. = Tuti North; C.B. °
Channel Bank ; T.S. — Tuti South; T.W. = Tuti
West; B.B. -- Buri Bank ; K.B. = Koko Bank.
In addition there are strips between the Ferry
and Channel Banks and in front of the British
Barracks and of Koko village.
It must be remembered that the Blue Nile usually
begins to rise early in May and to fall early in
October.
A riverine area to the south-west of Khartoum and
hatched with oblique lines indicates the site of the
so-called Gereif Swamp, to which reference has
already been made.
The hatched strips along the river banks, with the
exception of that which forms part of the Govern-
ment farm, represent land irrigated by the natives,
either by means of the sakia wheel or the shadoof
(weighted pole and bucket), and are of practically no
importance from a sanitary standpoint, save in’ so
far as they may serve to attract mosquitoes. The
larger areas, on the north-east of the map, hatched
in horizontal lines, indicate land cultivated by means
of pump irrigation and the use of irrigation channels
or “ gadwells ” as they are called. These, and more
especially that at Khartoum North, opposite the
Buri sandbank, are of very great importance from
the point of view of the hygienist. I have alreađy
mentioned the pernicious infimence of the larger
farm. Quite apart from its affording breeding-places
for mosquitos unless very carefully controlled and
very well managed, I wish to insist upon its acting
as an attraction centre for these insects. This is a
rôle played by cultivated land of this class which
I am inclined to think is too often forgotten. By
constant and unremitting care mosquitoes may be
prevented from breéding out in such an area, they
may even be prevented from finding any suitable
breeding-places, though this is difficult; but they
cannot be deterred from visiting such an area
in search of food unless one ranges far afield and
destroys their broods in places from which, if left
unmolested, they would speedily invade the culti-
vated land. When such invasion takes place, if no
breeding pools present themselves, the anophelines
will seek other quarters in the neighbourhood and,
if infected, may give rise to cases of malaria. It is
in such a case that trap pools are found of special
value. The evil influence of the farm in question has
been mitigated to some extent by the establishment
and maintenance of a dry zone immediately to the
west of it. This zone is broken only by the chain
of dwellings along the river bank. Otherwise it is
perfectly bare and is usually swept by a north or
south wind, which possibly explains why so few
cases of malaria occur in its vicinity. (As previously
stated the map is not correct in its delineation of
this neighbourhood. It shows building plots on
which, however, no houses have been erected.) As
a rule during the winter months the mosquitoes are
carried by the north wind from the farm to the
Buri pools, where they endeavour to breed out.
I believe they usually reach the farm. by working
along the eastern bank of the Blue Nile from
Karkoj village via Koko. It has been discovered
that at Karkoj village there are disused brick works.
Here the borrow pits have been sunk in the bank
below the level of high Nile and consequently at
certain seasons seepage occurs and produces ideal
breeding-places for mosquitoes.
The anopheline infested waters for the whole year
are marked upon the map in the form of black dots,
black circles, circles with crosses, and numbers. On
the farm and throughout Khartoum and Khartoum
North the black dots have been used, each represent-
inga separate infestation. In the case of the town
areas this serves to bring out the relationship of the
infested water collections to the red dots, which indi-
cate cases of locally acquired malaria (see Appendix).
The total sandbank infestations are indicated by
means of numbers, as are those which were found at
the Khartoum Dockyard and some of which occurred
on board steamers and boats (see Tables III and IV).
Aug. 1, 1913.]
In the case of sandbanks, and also elsewhere, the
infestations where pups were found are represented
by black circles, while a black circle with a cross
surmounting it indicates a breed-out, as evidenced by
the presence of empty pupal shells. These pupal and
pupal shell infestations are included in the number
stated. Thus in the large Buri sandbank extending
from the ice factory to the bend in the Blue Nile there
were one hundred and eleven infestations throughout
the year, in five of which pups were found, while in
two out of the five pupal shells were discovered. On
the bank of Koko thirty-eight infestations are noted,
of which twenty showed pups.
In the Appendix further details of the infestations
will be found, and more especially a consideration of
the dates when they were discovered. This will be
found to furnish interesting information regarding the
relationship, so far as time is concerned, of some of
the infestations and some of the cases of locally
acquired malaria.
Attention is drawn to the comparatively large
number of infestations found on the privately owned
farm at Khartoum North. This would have been
much greater had there not been constant supervision
and a useful system of trap pools in operation. It is
worthy of note that at the Government farm, where
&reater care has been exercised, especially during the
last eight months of 1912, not a single anopheline
infested water was found. It is only fair to state,
however, that this farm has not received the constant
attention from the sanitary inspectors that has been
bestowed upon its nearer and more dangerous rival.
Hence infestations may have been missed from time
totime. Elsewhere I [3] have entered fully into the
faulty conditions obtaining in irrigated areas in the
Sudan, and hence there is no need to consider these
here, but something may be said regarding the river
pools. These vary greatly from year to year as
regards size, position and number. Last year was
exceptionally bad for them. Those at Gereif were
quite peculiar, there being here a kind of khor' formed
atlow Nile by a bend in theriver. (Figs. 2 and 3.) A
stony area which speedily becomes grass grown is un-
covered and, the surface being irregular, numerous
pools, screened by grass and often with grass growing
in them, form in the bed of the khor. A more ideal
nursery for anophelines it would be difficult to con-
ceive. It has been found that when the pools in the
banks have clay-like, rather than sandy bottoms, they
are preferred as breeding grounds, possibly because
the water in such pools is usually clearer, possibly
because the larve find more food in them.
Speaking of larvie I may say that, so far as those
of P. costalis are concerned, I have made a few obser-
vations on the diagnosis of their sex by the method
described by Helen A. Adie [4] for certain anophe-
lines. I have been able to confirm her findings. It
is quite easy to recognize the future male by the
brownish oval tumidity representing the testis and
sac on either side of the sixth abdominal segment.
' Khor is a word in common use throughout Africa and signi-
fies a dry or partially dry watercourse.
THE JOURNAL OF TROPICAL MEDICINE.AND HYGIENE.
229
Larve showing these eventually turn into male
imagines.
In a previous paper I [5] discussed the róle of
Steamers and native boats as introducers of mosquitoes
both in the larval and the imago stage. They were
again operative throughout the year, but once the
quarantine station with its zeers and trap pits became
an established fact, a marked improvement resulted, as
indeed had been foretold. The site of the station is
shown on the map as a red square. It is a little to
the east of Mogren village, near the Mogren Point.
The situation is very suitable, as the reclaimed land
to the south, no longer flooded at high Nile, is still
destitute of human habitations, and mosquitoes driven
ashore either hang about and lay their eggs in the
zeers and pits, are destroyed at the station, or, while
the north wind is blowing, get carried over to Tuti
Island, where they can do little damage, and where
their broods are found and killed. Moreover, it so
happens that from the station there is an extensive
view up the White Nile, so that steamers can be seen
approaching a considerable time before they are due
at Khartoum.
Last summer trains were for the first time found
to be operative on a considerable scale as mosquito
vectors. Trains from the north pass close to the
anopheline-ridden farms of which mention has been
made. Those from the south pass alongside the
Tayiba cultivation near Wad Medani, which for a
time also harboured anophelines. It is no wonder
then that they served to introduce these pests.
Observe the incidence both of anophelines and of
malaria cases round the Central Station. Mosquitoes
of the sub-family Megarhinine were found there.
They have not hitherto been discovered in the Sudan
and must have been introduced by the railway. It
will probably be necessary to establish a quarantine
trapping station here also, at least during rainy
seasons.
In this connection I was interested to find that
Gill [6 ] describes an invasion of murree in the northern
Punjab due probably, or at least possibly, to the con-
veyance of anopbelines in the adult state by means
of carts and vehicles. As regards the district he in-
vestigated he concludes this “ the rate of diffusion of
anophelines may be greater than might be anticipated
from their powers of flight alone." I should not
wonder if this were found to be very generally true.
It is most certainly the case in and about Khartoum.
I had hoped to enter a little more fully into the im-
portant question of immigration, but I found my data
are insufficient to enable me to discuss it in anything
like an exhaustive manner, while the difficult mathe-
matical problems involved tend to deter one from
making the attempt. While I am still in agreement
with Ross's [7] dietum that "as a general rule for
practieal purposes, if the area of operations be of any
considerable size, immigration will not very materially
affect the result," it must be recognized that at
Khartoum the problem is complicated by the part
played by.steamers, boats and possibly trains. More-
over, the river pools may be likened to the connecting
links of a chain or chains of breeding places. In
230
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Aug. 1, 1913.
practice it is impossible to get to the distal ends of
these chains, for they stretch far afield to the north
and to the south-east. One can only deal with them
up to a certain distance from the town, and hence
there are always foci of possible infection at no great
distance beyond the outermost of the treated pools.
I do not think there is much emigration to be con-
sidered. For various reasons the mosquito current
sets towards Khartoum both from the north and the
south. It is possible that during the rains what
Ross calls "flock migrations” occurred, but being
absent from Khartoum at that time I can record no
personal observations on this point. There is no
doubt that Melville [8] is correct when he says:
“However energetic and systematic an officer may
be, he need never hope to eliminate all the malaria-
bearing mosquitoes, nor even all the harmless indi-
vidual members of that family, in his station. A
station can be malaria-free without being mosquito-
free, and life can be easily supported even where the
gnat occasionally winds his sleepy horn, as long as
the music is not too insistent.” At the same time,
so far as Khartoum is concerned, the cordon will
every now and then be pierced, and one or two cases
of primary, locally acquired malaria will remind the
health officer that his persistent foes are still on the
alert and have at all times to be reckoned with.
Malaria Cases.—FEighty-seven cases of locally ac-
quired primary malaria were notified throughout the
year. The following table showing the monthly dis-
tribution of these cases indicates that the great
majority followed the rainfall of August :—
1912 Number of cases
January
February ...
March
April
May...
June
July...
August
September ...
October
November ,., oy ER d te T TES
December ... E rss ae M a. IB
|
A
TTE
e
Of these cases 62 occurred in Khartoum and 25 in
Khartoum North, the latter being distributed as
follows :—3 in March, 2 in May, 1 in July, 3 in
August, 10 in September, 2 in October, 1 in November
and 3 in December. Thirty-six of the total 87 cases
occurred amongst the civil population, 20 amongst
men of the Egyptian Army and the remaining 31
amongst British troops.
There were no deaths amongst these cases, the only
fatal case of malaria recorded during the year having
acquired infection outside Khartoum.
I am far from saying that there were not more
primary, locally-acquired cases than the 87 recorded.
I think it very probable that cases occurred amongst
the native population which were never returned.
Indeed, at the time when the anopheline infestation of
the pools at Buri was at its worst, inquiry showed
that there were some cases of fever in the neighbour-
ing villages, and I made representations to the Sudan
Medieal Department which resulted in a distribution
of quinine being made there. It would have been
interesting to conduct a “ spleen ” survey amongst the
children in this locality, but for several reasons this
was not possible at the time. Still, I think the figures
stated give a very fair idea of the state of the town as
regards locally acquired cases. There was, of course,
a large number of imported cases, and these, and more
especially carrier cases, doubtless play an important
róle as reservoirs of the virus. In this connection a
recent very interesting paper by Firth [9] may be
studied with advantage. In Khartoum an effort has
been made to ensure a full three months' treatment
with quinine for all infected sailors and employees in
the steamer department. There were two types of
malaria present—quartan and malignant. Curiously
enough benign tertian was not represented and the
majority of the cases were due to P. falciparum.
The few cases occurring scattered throughout the
year do not call for much notice, and perhaps suffi-
cient has been said to explain the outbreak in
September. The cases in December were rather inte-
resting. They all occurred amongst the British troops,
and the most careful search with the free use of traps
failed to reveal any anopheline infection of the barracks.
Further, the anopheline-infested area at Buri had
been put out of bounds, while there was nothing to
show that infection had been derived when the men
were in camp near the Shabluka Cataract on the main
Nile. After going carefully into the matter with
Major Forrest, R. A.M.C., the Senior Medical Officer
British Troops, we were driven to the conclusion that
these were recrudescences of slight or masked cases.
It appeared certain that these men were infected in
August and September, but had either suffered so
slightly that they had not reported or had dosed them-
selves with quinine bought in the town, thus keeping
their fever in abeyance for a time. As soon as the
cold weather set in, however, these cases relapsed and
came into hospital. The distribution of cases in the
different barrack rooms and quarters was kindly
worked out by Major Forrest, but it was found to
be very general and there was nothing to indieate any
local determining cause.
The earlier cases amongst British troops, i.e., those
in September, were easily explained by the presence
of a huge rain pool immediately to the south of the
barracks. Such sheets of water, of course, attracted
mosquitoes from afar, while the prevailing S.S.W.
wind favoured their being wafted into the town from
the central railway station, and also possibly from
Karkoj and other places far outside the municipal
area. British regiments invariably have amongst
them men who have suffered from malaria elsewhere
and who often relapse with the advent of the cold
weather. One would now direct attention to the
close association between the anopheline infections
and the malaria cases. This is shown all over the
area under consideration, the anopheline infections
being marked on the map in black, the malaria cases
by red dots. It is, I think, very instructive to see
how the black dots and the red dots are grouped. A
graphic display of this kind saves pages of description
and speaks for itself. On the whole, considering the
Aug. 1, 1913.]
determined anopheline onslaught, I think Khartoum
escaped fairly well, but the least relaxation in
vigilance, the least slackening in the work, would
undoubtedly have been followed by calamitous con-
sequences. At one period the defence was partially
overwhelmed, with results which are self-evident.
There is nothing to prevent another season of heavy
rain, and hence it is very essential that levelling up
and drainage operations be taken seriously in hand.
For years one has preached this doctrine, but the
question is a difficult one from an engineering stand-
point, and there is a woeful scarcity of funds. Some-
thing has been done in the past, but more is required
if the public health is to be safeguarded.
A word as to the use of larvicides. Petroleum has
its limitations, for in pools exposed to a high wind it
gets blown aside, leaving an untreated water surface
on which mosquitoes readily lay their eggs. Hence
we have come to rely more or less on such a prepara-
tion as sanitas-okol, which answers admirably.
Recently we have been experimenting with a new
preparation—-izo-izal, into the larvicidal properties of
which Mr. King, our entomologist, has been making
an inquiry. This is not yet complete, but, so far, he
has found that it kills or at least renders moribund
al larvee of P. costalis in half-an-hour when in a
strength of 1 in 30,000. In 1 in 40,000 it is effective
in one and a half hours. Pups require a stronger
emulsion. Owing to its higher price it does not seem
to possess any advantage over sanitas-okol, which, as
stated, is a very satisfactory larvicide.
Creosote has also been tried, but does not seem to
have any special virtue to commend it, though perhaps
a more extensive trial is required. I employed it
after reading what Drs. Maynard and Murison [10]
had to say regarding its use. According to the latter
it is not so affected by the sun's rays as petroleum,
and the film which it forms lasts much longer. He
does not use it emulsified with soap in the manner
advocated by Maynard.
The steamer quarantine station has been mentioned.
It has proved most useful. For dealing with adult
mosquitoes in the cabins and holds we employ the
method of eresyl fumigation described by Bouet and
Roubaud [11] and in addition use the special spray
together with the ‘‘ Mücken " fluid which Giemsa |12]
recommends. This consists of a special tincture of
pyrethrum, soft soap and glycerine, the fluid being
diluted for use with twenty times its amount of
water.
As stated, it may yet be well to have a similar
quarantine or trap station at the Central Railway
Station. Trap pools on the farm at Khartoum North
have proved exceedingly useful. They not only
indicate the presence of anophelines, but limit their
breeding operations if they are few in number.
Figs. 4 and 5 show the type of trap used in houses.
It is on the lines of those advocated for sandflies, and
consists of a wooden box lined by a dark material or
painted black inside. There is a hinged door closing
it below, and in this flap door there is a hole which
can be closed by a metal slide and through which
fumigation ean be conducted. An inspection door
guarded by mosquito netting completes the simple
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
231
apparatus, which has, now and then, proved useful
and would, I think, be certainly valuable, given any
great prevalence of anophelines. As Dr. Beam has
pointed out to me, the type would be improved by
altering the position of the flap door, and putting in
a glass front guarded by a wooden flap. This would
greatly facilitate inspection.
Lastly, I would again lay stress on the danger of
irrigated areas generally, and on the part they play
as attraction centres." When the Gezira to the
south of Khartoum is irrigated on a large scale, the
Sudan Government will be face to face with a very
serious problem. It is not, however, one which
cannot be solved. With due care, the wise expendi-
ture of the necessary funds, and the stringent
enforcement of existing rules and regulations, it
should be possible to carry out such work without
any very great danger to the health and welfare of
the community.
The lesson which has been learned in Khartoum is
that in this anti-malarial warfare the motto must be
defiance, not defence. It is necessary to go out to
the attack, not to wait to be attacked. The further
the skirmishing line can be extended, the safer will
be the area which has to be protected.
The more mobile your force, the better will you be
served, and every facility should be afforded the
Sanitary Service for making river surveys, and for
enabling the inspectors to get quickly from place to
place. It is a straightforward fight, but it has to be
waged carefully, persistently, and thoroughly, if it is
to be successful, and one must not be surprised if,
now and again, the defences are pierced. This will,
however, happen but rarely if the staff are keen on
the work and the sinews of war are adequately
supplied.
In conclusion, I wish to make mention of the zeal
and energy with which the Sanitary Inspectors have
carried out the work of mosquito reduction.
I am specially indebted to Messrs. Murray and
Davidson for the careful way in which they have
collected and compiled the statistics for the year.
To Mr. Buchanan, my senior laboratory assistant, I
am indebted for the photographs illustrating the
paper.
REFERENCES.
[1] Ross, R. (1905). ‘The Logical Basis of the Sanitary
Policy of Mosquito Reduction,” Brit. Med. Journ. vol. i, pp.
1025-1029. Also ''The Prevention of Malaria," 1910. Murray,
London.
[2] BALFOUR, A. Various articles in the first four Reports
of the Wellcome Tropical Research Laboratories.
[3] BALFOUR, A. (1911). ''Sanitary Notes.” Fourth Report,
Wellcome Tropical Research Laboratories, vol. A.
(4] Apre, H. A. (1912). ** Distribution of Sex in the Larval
and Pupal Stages of Anophelines," Paludism, No. 5, p. 41.
And (1912) *' Notes on the Sex of Mosquito Larve," Ann,
Trop. Med. and Paras., Series, T. M., vol. vi, No. 4, pp. 463-
464.
[5] BALFOUR, A. (1912).
Lancet, vol. i, pp. 1048-1051.
[6] Gitt, C. A. (1912). ** Note on the Seasonal Prevalence
of Anophelines with Special Reference to the Potentialities of
a Single Breeding Place," Paludism, No. 5, pp. 65-70.
[7] Ross. Loc. cit.
[8] MELVILLE, C. H. (1912). “Military Hygiene and Sani-
tation," pp. 376-377. Arnold, London.
[9] Frrru, R. H. (1913). “The Nature and Detection of
** Mosquitoes and River Vessels,”
232
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 1, 1913.
Apyrexial Malaria," Journal of the Royal Army Medical Corps,
vol. xx, pp. 129-134.
[10] Maynarp, G. D., and Murison, P. (1912). [In discus-
sion on paper by R. Caldwell, entitled, ‘‘ Malaria and its Pre-
vention, with Special Reference to South Africa ”], Transv.
Med. Journ., vol. vii, pp. 231-239.
[11] Bover, G., and RouBaup, E. (1912). *' Expériences
de désinfection stégomycide par le Crésol," Bull. Soc. Path.
Erot., vol. viii, pp. 627-633.
[12] Giemsa, G. (1912). ** Über die Vernichtung der Stech-
mücken mit Hilfe des Sprayverfahrens," Arch. f. Schiffs-u.
Trop. Hyg., vol. xvi, pp. 565-507.
APPENDIX.
The monthly incidence of the anopheline infesta-
tions has been given in Tables III and IV. The
exact date of each infestation is available for refer-
ence, and is charted, but it is scarcely necessary to
give these figures here. It is, however, a matter of
interest to compare the dates of some of these
infestations with those of the primary locally acquired
cases of malaria occurring in the vicinity of the
places where Pyretophorus costalis was found to be
breeding.
The relationship is not clearly shown at Khartoum
North, but I have selected certain definite areas in
Khartoum which exhibit it very well. The dates of
notification of the malaria cases are arranged, for
each area, in tabular form and chronological order,
and parallel and similar tables show the dates of the
anopheline infestations. Reference to the map will
readily make the reader acquainted with the areas
which have been chosen, and which are those that
demonstrate the relationship in the most marked
manner. I am indebted to Professor Nuttall for
advice as to the method of tabulating these facts.
BRITISH BARRACKS AREA.
Dates of notification of cases of
primary, locally acquired malaria
Dates of discovery of anopheline
infestation
April 19, 1912 April 10, 1912
» 21. ,, se A 1L- 3
v 29, ,, as , 18, ,,
September 25, ,, (3) ... d: 30, ,, Sandbank
5» 1, , (5 .. July 20, 4,
f 17, , (4) .. October 3, 5,
En Sh. 3n .. November ll, ,, :
October 8, ,, (3) .. October 12, p | Near ice
November 17, ,, A 32 14 4] ?
December 3, ,,
British
T 12, ,, August 19, ,, Í
» 90, , (2) .. Beptember 11, ;, Jensina,
n 24, ,,
> 25, 5,
” 28, » (3)
» 29, ,,
There were in addition numerous infestations on
Buri Bank throughout the year.
AREA BETWEEN CHAIN FERRY AND Post Boar LANDING
BACK AS FAR AS KHEDIVE AVENUE.
Dates of notification of cases of
primary, locally acquired malaria
Dates of discovery of anopheline
infestation
July 28, 1912 April 14, 1912
September 4, ,, June s
at Ikac 0) .. August M. 45
x 21. a 5 18. 7
” 19, 43
September 1, ,, (2)
” 11, ,,
” 15, ”
October Bi
November 30, ,,
RAILWAY STATION AREA.
Dates of notification of cases of Dates of discovery of anophelive
primary, locally acquired malaria infestation
September 4, 1912 (4) September 26, 1912
5 8 ( Tewfik
” , ” uL ” 94. » J Pasha
d ' | Barracks
ABBAS PASHA BARRACKS AREA.
Date of discovery of anopheline
infestation
August 25, 1912
Dates of notification of cases of
primary, locally acquired malaria
September 8, 1912
” 17, Lu
,»* 25, ”
October 7, ,, (transport lines).
SUDANESE NATIVE VILLAGE.
Date of notification of cases of
primary, locally acquired malaria
August 29, 1912
Date of discovery of anopheline
infestation
August 26, 1912 (9)
(jp.
Sleeping Sickness.__The reports of the Sleeping
Sickness Commission of the Royal Society, No. xiii,
contain many interesting papers on the subject of
trypanosomiasis. Duke shows that antelope are
still infectious in the islands off the shore of Uganda,
in the Victoria Nyanza, and they seem, since the
population was removed, to have increased in num-
bers. Miss Robertson contributes an interesting
paper on the life-cycle of the Trypanosoma gambtense;
both in man and in the tsetse-fly. The former she
terms the endogenous cycle. Her summary of the
subject is that T. gambiense is a polymorphic species
with a continuous range of variation.
The shorter forms of 14-20 p in length, constitute
the normal adult blood type.
The intermediate individuals measuring 20-24 p in
length are growth forms and lead to the long forms of
23-33 #, which are those about to divide; the poly-
morphism of the trypanosome is thus due to growth
and division phenomena and does not correspond to
a sex differentiation.
The shorter forms are. those destined to carry on
the cycle in the transmitting host. :
There are definite periods when the blood is not
infective to tsetse-flies, although trypanosomes are
present. Such periods are: (1) Just before an out-
burst of multiplication ; (2) during the destruction of
trypanosomes preceding a depressed period ; (3) the
summit of an exalted period involving very numerous
trypanosomes—at such a time the parasites very fre-
quently show signs of exhaustion; (4) certain periods
of rapid multiplication, when both the absolute and
relative numbers of the shorter forms are low.
————
“The Journal of the American Medical Association,"
vol. lxi, No. 1, July 5, 1913.
Treatment of Pellagra.—Law states that the last five
typical cases of pellagra in his practice have been treated
with Bulgarian lactic acid bacilli in tablet form, each about
74 gr. Two tablets were given half an hour before each
meal and at bedtime.
The improvement in the appearance and subjective symp-
toms of these patients warrants him, he believes, in making
this preliminary report.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
233
Aug. 1, 1913.]
THE JOURNAL OF
Tropical Medictne and hpgiene
AUGUST 1, 1913.
BRITISH MEDICAL ASSOCIATION.
SECTION oF TROPICAL MEDICINE.
President: Lieutenant-Colonel Sir William Leish-
man, M.B., F.R.S., R.A.M.C., London.
Vice-Presidents: E. Irwin Scott, M.D., Hove;
Professor W. J. R. Simpson, C.M.G., M.D.,
F.R.C.P., London; Major W. S. Harrison,
R.A.M.C., Royal Army Medical College, Grosvenor
Road, S.W.
Hon. Secretaries: E. Curwen, M.A., M.B., B.C.,
1, St. Aubyn's, Hove; F. W. O'Connor, M.R.C.8.,
London School of Tropical Medicine, Royal Albert
Dock, E.
Wednesday, July 23
Discussion ON THE CAUSES OF INVALIDING IN THE
TROPICS.
Opened by Dr. Basin Price, Colonel R. J. S.
Smpson, C.M. d.e A.M.S. (ret.), and Dr. W. F.
Law.
Dr. G. Basil Price, in opening the discussion on
the ‘‘ Causes of Invaliding in the Tropics,” re-
marked that many factors influenced health and
disease, such as average temperature and thermic
influence; humidity of atmosphere; elevation of
different districts; the persistence of endemic
disease, prevalence of mosquitoes and malaria
during certain seasons; the insanitary conditions
associated with Eastern and primitive life; the pre-
valence of infective disease, such as tuberculosis,
malaria, amongst native populations.
Special factors also influenced the health of
Europeans in the Tropics, such as the location of
the individual according as to whether in a large
city or in a remote district; the habits of the indivi-
dual as regards food, alcohol, exercise, &c., and
individual idiosyncrasy, namely, temperament and
the possession or absence of ''common sense."
Dr. Price diseussed the section of Europeans in
the Tropies belonging to missionary bodies.
The total of 1,479 lives were distributed as
fcllows :—
Total Men Women
India ad es R^ .. 533 lives 245 288
Ceylon... Ae ps fe TA 65 ,, 32 33
China se zu m was .. 894 ,. 162 232
Japan ine a E ise Le 405. y, 29 76
Africa : X :
North, Algeria "T" 36s 20 ,, 12 8
Egypt, Palestine, Arabia... ee 757 19 52
West and Nigeria... 65 ,, 34 31
Central, and East Africa and i Uganda 152 ,, 79 73
South ... yu 81 ,, 25 6
Madagascar TA id ae a 14 ,, 5 9
Persia -.. v see - ME ies 2974 10 19
Total 2v dd
i]
9 , 652 827
Analysing the causes of invaliding in these various
countries, the following facts emerge.
India.
Church Missionary Society lives.—379 (men 188,
women 191), of whom 93 were invalided—24°5 per
cent.
Other societies.—Invalided 154 (men 57, women
97).
CAUSES OF INVALIDING IN THESE 247 CASES.
Percentages
Nervous conditions of a neurasthenic type 51 = 20:6 254
Mental disorder of acute type sai i 44 18]
Enteric fever ... hx .. 41 = 16:6
Malaria E 33 = 13:3
Dysentery ss 16 = 64
General debility is A E .. 12-2 48
Pulmonary tuberculosis’... des e 82 8:2
Cardiac disease js 8- 32
Anemia 82 32
Small-pox 4= 16
Gall stones 8- r2
Eye conditions j T n s. (o 14
Blackwater fever teh 22 T es 4-9. 58
203" out of 247.
* The remainder being isolated cases, having no particular
bearing on tropical life.
The prominence of '' nerve strain " and neuras-
thenie conditions is worth noting, and whilst this
was the terminating phase before invaliding, it must
be reniembered that illness, chiefly malaria or bowel
disorder of a comparatively light character, had
occurred in probably many of these previously, and
were factors in inducing both this condition, as also
general debility , anemia, and functional cardiac
conditions.
China.
It is interesting to note that a decidedly large
proportion of ''nerve " cases occurred in North
China; perhaps some cause for this may be found
in the drier atmosphere, and also long periods of
monotonous sunshine, which tends to promote at
first increased mental and physical activity, but
afterwards leads on to nervous irritability, a condi-
tion often hastened or exaggerated in many cases by
the long-continued political unrest in that country,
with the freqüent reign of mob law, and scenes of
violence.
Insanity, characterized by mania, religious delu-
sions, or melancholia has unhappily oecurred in all
parts of China, but is most marked in Central China,
according to these figures.
Japan.
In Japan, whilst the general conditions for health
seem good, '' neurasthenia ” is even more prominent
as a cause for invaliding than in China.
The Chureh Missionary Society gives records of
105 lives. Of these 17 or 16:1 per cent. were in-
valided (6 men and 11 women).
Of this number 14 were due to neurasthenic con-
ditions, that is, 81:25 per cent.
It has been suggested that the inhalation of
monoxide fumes from charcoal stoves in the
234 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 1, 1913.
Japanese houses may partly contribute to the nerve
and head symptoms met with in missionaries, but
also the constant occurrence of earthquakes is a
contributory factor in nerve conditions.
Africa.
The figures are, unfortunately, small, but enteric
is present as a definite cause in North and South,
absent in Central and West Africa.
Malaria is the cause of 75 per cent. in West
Africa, blackwater fever and malaria 40:4 per cent.
in Central Africa, where also oceur isolated cases of
tick fever and sleeping sickness. Neurasthenia
again is prominent as a eause in North, Central,
and South Africa, forming 20°8 per cent. of the
whole.
Dr. Price worked out the average years abroad of
missionaries for each sex, periods of invalidings at
home, the percentage of invalided for each country,
and the incidence of disease. These figures may
be best shown by the following tables :—
Isolation, overwork, under-staffing of stations, the
heavy incidence of minor illness which does not
immediately necessitate invaliding, the possible ex-
perience of scenes of violence and alarm, especially
during recent years in China, will try the most
placid or callous temperament, and largely accounts
for the heavy incidence of this class of disease, i.e.,
20 to 80 per cent. of invaliding.
(3) The prominence of a large class of infectious
diseases calls for note, since an average of 42 per
cent. of invaliding is due to them.
Against this latter elass many safeguards ean be
taken; small-pox should never occur if re-
vaccinations were enforced. Enteric fever should
be greatly diminished with wider and more frequent
recourse to inoculation and extended knowledge as
to methods of intection amongst the laity.
Malaria and blackwater fever can be more nearly
controlled if more persistent efforts were made to
efficiently teach all who go abroad the facts so
universally acknowledged as to malarial prevention.
CHURCH MISSIONARY Socrety RECORDS.
E. Africa, W. Africa, Arabia, China
Uganda Nigeria Egypt, Persia India Ceylon Japan Total
Palestine Ss. Cent.
Number of recorded lives ... 125 7l 3. 39 879 56 123 98 105 1,051
Men ... sis - aes 60 31 19. 4...419 188 25 40 31 29 433
Women ET P 65 34 52 10 191 31 83 67 76 618
Average
Percentage Invalided iss 20 18:5... OT ess. 114 24:5 5:3 ... 81 204 . 16:1 17-4
Percentage of incidence of 88 861... WH... 656... 13:6 75:0... 65:9 69:39 . 61:9 1377
disease (not necessarily
invalided)
Percentage free of disease... 12 .. 189.. 229:5.. 344.. 26:4... 250... 34:1... 30:61... 38:1... 263
From this table it will be seen that Egypt, Arabia,
East, Central and West Africa are, on the whole,
the countries which offer greatest risks to health.
CHIEF CAUSES OF INVALIDING.
Invaliding—Chief causes India China Japan Africa
(Nerve conditions of a
Class I - neurasthenic type ... 20° 25 81:25 20:8
Insanity 3 ro 4'8 8:8 — 1:5
Enteric fever ... .. 16:6 9:8 — 8:2
Malaria ... mi 133 11:8 — 19:4
Dysentery 7 T 6:4 5:9 = 37
Class II Pulmonary tuberculosis 3:2 10:8 — 3
Small-pox ds 6 14 — 15
Blackwater fever dés — — — 97
Percentage due to Class II. diseases 41:1 397 -— 45:5
Conclusions.
(1) That a missionary's life and sphere of work
is not a matter or place of healthy recreation.
(2) That capacity for '' nerve strain " is a real
factor to be considered in passing candidates to go
übroad, and therefore it would be wise to exclude
those who have any decided taint of mental in-
stability in their family history, also those of highly
nervous temperaments, except for special location
and work. The impulsive, enthusiastic, but easily
depressed person will not stand the strain of the
conditions inseparable from a tropical life and work,
unless there is also a leaven of common sense,
humour, and good self-control.
teferring to the section I represent, many societies
do not even yet see the necessity for any systematic
instruetion on health and hygiene for their mission-
aries, whilst they insist on a too long course (as it
seems to the writer) in theologieal studies, if health
and life have to be sacrificed for it, owing to the
missionaries’ ignorance of tropical dangers, and the
safeguards which should be practised.
(4) The frequent appearance of pulmonary
tubercle—due generally to infection abroad—points
to the necessity for eliminating by medieal examina-
tion all those who may from their family or personal
history have shown predisposition to the disease.
(5) Most of the lives considered in the above
statisties are select lives; the examinations by many
of the societies being as strict as for a large insurance
poliey ; but the need for such medical eritieism and
elimination of the unfit still needs emphasizing to
certain other societies and associations.
Dr. Price gave as an addendum a compendium
of the enteric and tubercular cases in several
countries.
—————p—— ——————
* South African Medical Record," vol. xi, No. 11,
June 14, 1913.
Leprosy.—Bayon in the above number of the South
African Medical Record critically reviews the recent ex-
perimental research work that has been done upon Leprosy.
The paper goes into the subject in great detail and is well
illustrated. Those specially interested in the subject should
consult the paper in the original.
Aug. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
235
Abstract.
INOCULATION AGAINST
CHOLERA.*
By W. M. HAFFKINE.
(Continued from p. 222.)
Part III.—VacciuE ‘‘ II" AFTER DEVITALIZATION.
CONDITION OF THE CHOLERA VACCINE AFTER
DEVITALIZATION.
PROTECTIVE
Conservation of Essential Properties in Devitalized
Vaccine: Its Reactionary and Immunizing
Effects.
Some of the most notable properties imparted to
vaccine '' II" by peritoneal cultivation, namely,
the enhancement, up to a certain constant level,
of its toxic and immunizing effects, are still
observable in that vaccine when it is devitalized
by delicate chemical or physical processes. Appa-
rently devitalization in these circumstances leaves
uninjured part of the specifie substances stored up
during life in the bodies of the germs. The pre-
paration of such devitalized vaccine and the results
of its injection into animals and man have been
described by several authors to whom Haffkine had
occasion to demonstrate its effects.
Devitalization by carbolie acid reduces, or alto-
gether suppresses, the mortifying effect which vac-
cine ** II" has on the guinea-pig’s skin; and the
effect on man is also correspondingly mitigated.
In all cases, however, the degree of fever and of
local reaction is in direct connection with the dose
administered. The desire of lengthening the dura-
tion of protection and the uncertainty, which at
present cannot be removed, as regards the precise
amount of vaccine which will ensure an immunity
of a given durability, have often led operators into
using exaggerated doses in inoculating man. This
cireumstance is responsible for the impression that
the reaction after the inoculation is severe and
stands in the way of a wide application of the
method.
As has been stated already, inoculation with
devitalized vaccine confers on animals a lesser
degree of immunity than inoculation with the same
vaccine in a live condition. It remains possible,
however, that the former preparation may still have
preserved sufficient potency for immunizing man
against natural cholera. The solution of this ques-
tion in the affirmative would bring about great
practical facilities in the application of the method;
for devitalized vaccine ean be handled as a chemical
drug and may be preserved and supplied to distant
operators, who thus require no preliminary training
in the technique of its preparation, such as is
necessary in the use of live vaccine.
It is, therefore, desirable that devitalized vaccine
“ II "—already used on a certain scale in 1892 and
* Calcutta: Thacker, Spink and Cc. London: W. Thacker
and Co., 2, Creed Lane, 1913.
1893 and on various occasions subsequently, and
the further investigation of which has been delayed
until the question of anti-cholera vaceination was
decided in principle by means of the more reliable
preparation—should be subjected to a careful study
in cholera epidemies.
Expectations of other Observers.
The view just expressed has the endorsement of
various authorities, some of whom have recom-
mended the use of the vaccine in question, while
others have already been trying it in practice.
Kolle recommends the following method of
human inoculation: a well-grown culture containing
about 20 mg. of growth is suspended in
10 c.c. of physiological salt solution and sterilized
for a few minutes at 509 C.; 0°5 per cent. phenol
is added to the preparation without apparently
interfering with the effectiveness of the virus.
The plan of inoculating man with the devitalized
form of cholera vaccine has, further, the endorse-
ment of a number of bacteriologists who, as stated,
have aetually tried it, in some cases, on à con-
siderable scale. The first operations on such a
scale, with vaccine prepared in the Bombay labora-
tory, were carried out and studied, under Haff-
kine's directions, in August and September, 1900,
by the late Major Lamb, I.M.S., and Major
Buchanan, I.M.S., Superintendent of the Nagpur
Central Jail.. The vaccine was used on 451
prisoners of that jail, eighteen of whom received
two injections. No cholera cases occurred in the
jail subsequent to the date of inoculation, whether
in inoeulated or non-inoeulated prisoners.
The beneficial effects obtained, since 1897, from
the anti-plague prophylactic, the wide application
of which has been facilitated by the devitalized con-
dition of the virus, have stimulated attempts to
apply the same plan for the protection of man
from typhoid and cholera and, latterly, from certain
forms of dysentery.
Among those who have used the devitalized anti-
cholera vaccine subsequent to the inoculations in
Nagpur may be cited the bacteriologists of the
Japanese Imperial Serum Institute, while in the
following years many other inoculations with the
same vaccine have been performed in various parts
of the world.
In 1904, a Russian physieian, Zlatogoroff, inocu-
lated in Tauris, Persia, 1,269 invididuals. In 1905,
Serkowski first performed a few dozen inoculations
at Kharkoff and Lodz; then, in 1907, Zabolotny
reported at the International Congress of Hygiene
and Demography, in Berlin, a considerable exten-
sion of the work which had taken place in the
Volga region and elsewhere in Russia. In that and
in the subsequent year, 4,877 people were inocu-
lated in the Southern provinces of that country,
while in St. Petersburg the number reached 31,637.
In the Ekaterinoslav province, Lookiantchenko
inoculated, in 1907, 11,178 people, and Maslako-
wetz, in the summer of the same year, 4,287 in
the town of Astrakhan and its suburbs. Between
1906 and 1909, inoculation with devitalized cholera
236
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[&ug. 1, 1913.
2
vaccine was carried out also in several districts and
provinces of Russian Poland, such as Parczew,
Kielce, Tuszyn, Ozorkow, Piotrkow. The vaccine
was manufactured in St. Petersburg, in the Im-
perial Institute of Experimental Medicine.
In the Dutch East Indies, in Batavia, Nyland
has inoculated, since 1910, 31,000 people, including
8,000 Europeans.
The Question of the Degree of Immunity obtainable
from Devitalized Cholera Vaccine.
The documents which Haffkine has been able to
examine on this essential matter show that the
authors were in a position to obtain only approxi-
mate information as to the immunity derivable
from the vaccine.
Metchnikoff makes a somewhat similar state-
ment. Referring to the inoculations which were
performed in Persia, in 1904, in various provinces
of Russia, in 1907, and in St. Petersburg, in
1908-09, he points out that the inoculated were gen-
erally persons not exposed to the same chances of
infection as was the average population; that those
who availed themselves of the preventive treatment
belonged to such classes as observed also precau-
tions of general hygiene; that individuals living in
localities already infected, or in any way specially
liable to contract the disease, were refused inocu-
lation, so as not to discredit the procedure in the
eyes of the public; and that the incidence of
cholera among the inoculated was not accurately
known. The official instructions issued at the time
by the authorities enjoined, indeed, on the operators
certain rules which were reasonable from a general
point of view, but which tended to interfere with
the subsequent estimation of the results.
The precise circumstances of the operations just
referred to are unfortunately unknown to Haffkine ;
but he presumes that in many cases the operators,
though using the vaccine in a devitalized form,
considered that they were applying a method the
general protective effects of which had already been
established; and their efforts may have been
absorbed mainly in meeting the demands of in-
dividuals who applied for inoculation or agreed to
avail themselves of the protection which it possibly
offered. Under such circumstances, the conditions
required for a scientific study are rarely realized.
When, at the end of an epidemic, the operators
collect information concerning the results and
endeavour to extract from it the teaching it offers,
they almost invariably find the data incomplete.
Not infrequently that incompleteness is clearly
perceived by the operator and acknowledged by
him. Thus, in the case of the most extensive of
the above-mentioned inoculations, those carried out
in Japan in 1902, Murata, in his account of the
work, quotes the studies made in India on cholera
immunization with live vaecine and states that he
introduced inoculation in the Hiogo district, with
the devitalized preparation, at the desire of the
inhabitants, who were severely tried in the out-
break of that year.
In regard to the 77,907 persons
who availed themselves of the treatment and to
the incidence of cholera among them, he states
that he has reason to view the results optimistically,
but adds :— :
"I am unable to say whether the protective
inoculation was applied uniformly under all cireum-
stances, or whether the inoculated and the non-
inoculated were equally exposed to infection. It
is impossible for me to enter into such circum-
stances with a degree of exactitude, às the inocu-
lations were carried out by many hands. However
this may be, one cannot deny that the mortality
among the inoculated was much smaller than
among the non-inoculated."'
From the details supplied previously in the
present note, it will have been seen that the sources
of error alluded to by Professor Metchnikoff were
obviated in the Indian studies of 1898-1896; but,
as mentioned, those studies were made with live,
. and not with devitalized vaccine.
Experiments with Vaccine Extractions.
The precise effects of inoculation with the devi-
talized form of the vaccine require, therefore, to
be submitted to further investigation. In doing
so, the most reliable: preparation ought, in Haff-
kine's opinion, to be tried first, the actual study
being conducted on lines analogous to those which
were worked out in India in 1893-6. He deals first
with the question of the form of the vaccine.
A considerable number of bacteriologists have
adopted a favourable view as to the ultimate effects
of devitalized vaccine and have recommended for
use extractions of such vaccine. The extraction is
obtained, in some instances, by merely leaving the
vaccine to soak in water, at the temperature of
the room or incubator, then filtering off the solids
and using the watery solution; in other cases the
process is aided by triturating the bacillary bodies
in water or serum, or by freezing them and thus
rendering them more brittle; or by subjecting them
to the effect of an alkali, or aleohol, or ether, or
common salt, or sulphate of sodium, &e. Such
extraetions have been prepared with the germs of
cholera, typhoid, bubonic plague, dysentery,
chicken cholera, pig-septicemia, hemorrhagic
septicemia of cattle, Bacillus coli, &c.
The question as to whether vaccine should be
used in extraction or in its entirety was dealt with,
in reference to plague, by the Indian Plague Com-
mission of 1898-1901, when examining Lustig and
Galeotti’s proposal of applying ‘‘ nucleoprotein ''
(alkali extraction) of plague bacilli for anti-plague
inoculation. The Commission did not commend
the plan, and, so far as Haffkine is aware, in the
twelve years which have elapsed since then, nucleo-
protein has not come into use. He thinks this
result is not without bearing on the question. As
he has already intimated, it is not possible at
present to determine accurately the particular con-
stituents of the bacterial body which create in an
animal immunity against natural disease, though
it is already apparent that in different diseases the
effective agents must differ in constitution. For
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, AUGUST 1, 1913.
LONDON SCHOOL OF TROPICAL MEDICINE.
42nd Session. May—July, 1913.
Back Row.—R. H. Miller, J. W. B. Hanington, P. Nunan, V. R. Phadke, E. O'Connor, S. Hoyte, E. C. Perkins, A. G. Peter, J. L, Keeler, H. H. Stewart,
G. Warren (Lab. Asst.), J. M. Cure, A. Robertson, O. Arnott, J. Dunlop, F. W. O'Connor (Demonstrator), E. Marshall (House Surgeon).
Second Row.—E. J. Quirk, G. Dunderdale, G. Da. Silva, J. W. Lindsay, R. Trudinger, P. V. Early, R. P. Ratnakar, T. Singh, G. K. Monani, B. W. F. Wood,
E. V. Smith, H. S. Dube, H. North, J. Y. Ferguson, H. H. G. Knapp (Capt. I.M.S.), D. B. Birtwell, Robert (Lab. Asst.).
Third Row Sitting.—R. T. Leiper (Helminthologist), J. E. H. Gatt (Capt. R. A.M.C.), J. A. Valentine, C. N. Davies, C. S. G. Mylrea, P. J. Zepeda, H. B.
Newham (Director), Miss G. Mackinnon, Dr. F. M. Sand with (Lecturer), Col. A. Alcock (Entomologist), J. B. D. Hunter (Capt. I.M.S.), W. E.
Glover, C. E. F. Mouat-Biggs, B. B. Paymaster (Capt. I. M.S.), L. R. Thompson, Miss E. N. Koss, Mrs. Parsons,
On the Ground.—W. McDonald (Lab. Asst.), C. J. H. Pearson, R. Pergande (Lab. Asst.), C. R. Patton, W. L. Webb, W. E. Adam, W. E. 8. Digby, H. Fretz.
Absent. —C. M. Wenyon (Protozoologist), H. M. Hünschell (Demonstrator), R. O. Sibley (Demonstrator), R. Semple, B. Percival, F. S. Harper, M. Cameron
Blair, J. P. B. Snell, J. E. Moffatt, A. R. Wellington, R. Y. Stones, B. S. Chalam,
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON),
Under the Auspices of His Majesty's Government,
CONNAUGHT ROAD, ALBERT DOCKS, E.
In connection with the Albert Dock Hospital of the SEAMEN’S HOSPITAL SOCIETY.
THE SEAMEN’S HOSPITAL SOCIETY was established in the year 1821 and incorporated in 1833, and from time to time
has been enlarged and extended. It now consists of the Dreadnought Hospital, Greenwich, to which is attached the
London School of Clinical Medicine; the Royal Victoria and Albert Docks Hospital; the East and West India Docks
Dispensary; and the Gravesend Dispensary.
Over 30,000 Patients treated annually. Of this number many are Cases of Tropical Disease.
The School buildings are situated within the grounds of the Royal Victoria and Albert Docks Hospital.
MEDICAL STAFF OF THE HOSPITAL AND LECTURERS IN THE TROPICAL SCHOOL.
JAS. CANTLIE, Esq., M.B., F. R.C.S., D.P.H. Professor R. TANNER HEWLETT, M.D., F.R.C.P. | L. W. SAMBON, Esq, M.D.
L. VERNON CARGILL, Esq., F.R.C.S. G. C. LOW, Esq., M.B., C.M. FLEMING MANT SANDWITH, Esq., M.D., F.R.
E. TREACHER COLLINS, Esq., F.R.C.S. J. M. H. MACLEOD, Esq., M.D., M.R.C.P. Professor W. J. SIMPSON, C.M.G., M.D., F.R.C.
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LECTURES AND DEMONSTRATIONS DAILY BY MEMBERS OF THE STAFF.
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Chief Office—SEAMEN’s HOSPITAL, GREENWICH, S.E.
Aug. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
237
the present, therefore, one is on surer ground by
transforming into vaccine the whole of the sub-
stances of the germ which the individual has to
deal with in the event of infection. Then, the use
of the entire germ, compared with extractions made
from it, offers facilities of considerable importance
in the matter of manufacture. For the purpose of
making the extraction, the scale of preparation
would need to be increased to many times its
present volume, for only a small amount of specific
matter is obtainable in solution from a given volume
of vaccine. The larger the scale of preparation, the
more complicated are the measures necessary for
assuring satisfactory results. Further, the tech-
nique of effecting the actual extraction, of handling,
with all the requisite care, the additional substances
necessary for this, of applying the various proce-
dures which are suggested for facilitating the solu-
tion, and of filtering off the residual solids, on a
scale required for practical purposes, is a far
heavier addition to the work than is the extended
scale of cultivation.
In this connection Haffkine refers to the plan
which Besredka, of the Paris Pasteur Institute, has
suggested with the object partly of mitigating the
reactionary symptoms caused by the cholera, plague
and typhoid vaccines, partly of meeting the danger
whieh is believed to result from inoculating persons
previously infected or about to become infected with
the disease. The plan consists in emulsitying the
vaccine, in its entirety, in water, passing it through
fine silk, immersing for twelve to twenty-four hours,
at a temperature of 689 F., in serum of prelimin-
arily immunized animals, washing it three or four
times in saline water, and centrifuging after each
washing, till the removal of all traces of serum has
been assured. This procedure obviously involves a
degree of elaboration to which, if carried out on a
small scale, there can be little objection, but which
becomes of importance when the volume of material
is large, and when, at every stage, great precautions
are necessary for obviating the possibility of mishap.
It may be observed that the reactionary symptoms
caused by inoculation are only very marked when
exaggerated doses of vaccine are used; while the
danger from inoculating persons incubating or about
to ineubate infection has been definitely proved not
to exist. The additional exposures involved in
Besredka's plan of manufaeture would, therefore,
to Haffkine's mind, not be sufficiently compensated
for by the expected advantages.
The Methods of Study in Preventive Medicine.
As regards the mode of investigation of research
in the case of the devitalized cholera vaccine this
must, in Haffkine’s opinion, be as strict and scien-
tific as that employed to establish the efficacy of
the live vaccine; for the immunizing properties of
the two preparations differ sufficiently to render it
cee to rely upon inferences from the one to the
other.
There is only one way of finding out, as a lasting
scientific truth, whether a method such as vaccina-
tion against small-pox, cholera, plague or typhoid
fever, protects man against those diseases or other-
wise; and the way is that of studying the subject
in the midst of and in application to the communi-
ties which it is intended to protect. This, indeed,
has been the plan he has applied in India.
The conditions of such a study are obviously very
different from those obtaining in a bacteriological
laboratory or in an animal outhouse; and the
responsibilities of the work are, needless to say,
widely different. The methods of obviating experi-
mental illusions and arriving at the right facts and
deductions are special and cannot be worked out
without prolonged investigation; and the difficulties
of execution, every part of which, whether pre-
liminary and tentative, or final, has to be performed
in the glare of publicity and under the incessant
observation and opposition of critics and oppo-
nents, are on a scale not to be measured only by
the scale of the studies themselves. The opera-
tions alone, besides a vast amount of laboratory
work, imply travelling over long distances, combat-
ing prejudice, apprehension and obstruction;
searching for suitable conditions of inquiry and fer
volunteers, in their hundreds and thousands, ready
to undergo loss of time and temporary illness, for
advantages yet unknown; waiting indefinite inter-
vals of time for a concurrence of events necessary
for the study of results; carrying out house to
house investigations and tracing individuals who
have become concerned in the experiment; investi-
gating causes of absence and of disease or death,
by conferences with local authorities, relatives and
medical attendants, and a variety of other laborious
inquiries and proceedings unknown in work on
animals. The subsequent part of the investigation,
the study of the facts, is an elaborate and technical
research. It comprises a scrutiny of the data
collected and the determination of all possible
sources of error and of the methods of their elimina-
tion; an analysis of the results, and the collection
of such supplementary data as have been found to
be necessary; and the formation of conclusions and
their verification. When the investigator has
established the main facts for which he has been
searching, and has assured himself of their reality
by experiment many times repeated, long years
must further elapse before other observers, of an
impartial mind, are in a position to verify his find-
ings and to assist in ensuring their acceptance by
the world at large.
It is on account of these circumstances that,
inevitably, endeavours have been made to solve
questions relating to man by experiments on small
animals—guinea-pigs, rabbits, mice, &c.—which
could be handled in the laboratory. A vast amount
of valuable information has thus been obtained;
but, unfortunately, differences of organization and
of the conditions of life, both in health and disease,
make it often impossible to conclude from the effect
upon lower animals the effect on man. Thus, for
instance, the fact that active immunization offers a
means of saving individuals who have contracted a
rapidly incubating disease would have remained
undiscovered without the studies of cholera and
238
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 1, 1918.
plague in man; for experiments on laboratory ani-
mals gave diametrically opposite results and indi-
cated that, during the first succeeding days,
immunization not only did not protect from, but
directly predisposed to and aggravated such a
disease, and that when infection had been con-
tracted previously an attempt at immunization
would render a fatal issue inevitable. The whole
subject of inoculation against cholera offers, of
course, an instance of a problem which could not be
solved by experiments on animals. An attempt is,
therefore, frequently made to arrive at conclusions
concerning the immunization of man, by examining
samples of blood and serum from individuals
operated upon, or else by subjecting inoculated
persons to artificial infection, in a manner permis-
sible in human beings.
The last-mentioned plan of investigation was,
perhaps, as well and as fully exemplified as it could
be in the experiment described by Metchnikoff on
the two men inoculated by the author in 1892. The
difficulties in arriving at a reliable conclusion by
that method are due to the wide divergence
between the mode of infection as it takes place in
Nature, on the one hand, and as it js done in the
laboratory, on the other; to the restricted number
of individuals on whom the experiment can be
attempted and the idiosynerasies of the patients
which, in these circumstances, affect the results;
and to the impossibility of trying on man a decisive
mode of infection. Thus, concerning the last-
mentioned point, in the case of the two persons
referred to by Metchnikoff, a conclusion had to be
formed both from the apparent mitigation of their
choleraie symptoms and from the degree of general
malaise experieneed by them, while the interpreta-
tion of the latter symptom was complicated by the
fact that it possibly included some manifestation of
defence against infection. Metehnikoff, therefore,
rightly indicated, in the wording of the conclusions
which were cited above, that he did not view that
experiment, or the experiments made on rabbits,
and the a priori considerations connected with
vaccination against poisoning, as containing the
data for the final solution on the question.
The information obtainable from the other mode
of inquiry, that of examining blood samples,
instruetive in very many ways as it is, is equally
far from being of a decisive character. In view cf
the importance of the matter involved and of the
weight which, on various occasions, has been
attributed to sueh information, it is perhaps desir-
able to examine with some detail the experience
gained in it.
Human blood serum, when injected into a guinea-
pig simultaneously with, or a day or so prior to an
injeetion of a lethal dose of cholera virus, is found
in certain cases to Ede the effect of obviating the
fatal action of such virus. In ]&
observed this property in the serum rusa
had recovered from an attack of cholera; and in the
same year, Klemperer found it in the serum of men
artificially inoculated with cholera germs. Pfeiffer
and Kolle’s observations of 1896, made on the blood
of persons inoculated with cholera vaccine, both in
its live and devitalized conditions, were on analo-
gous, though not identical, lines. The question is
how far the appearance in the blood of the above-
mentioned property indicates that the individual
possesses the necessary immunity to protect him
against cholera. The following facts bear on the
matter :—
(a) Of twelve Europeans examined by Metchni-
koff and who were free from any previous history
of cholera, five were found to have in their serum
substances which protected guinea-pigs against a
fatal injection of cholera germs, and seven had no
such substances.
(b) Of twenty-two Europeans suffering at the
time from cholera and similarly examined, protec-
tive substances were found in the serum of ten
and not found in the twelve others.
(c) In the bodies of ten persons who succumbed
to cholera, protective substances were found in five
cases; and
(d) Of twenty-four persons who recovered from a
cholera attack, protective substances were found in
fourteen.
Metchnikoff summarizes these observations on
the preventive power of human blood thus :—
“ It results from our researches on the property
of the blood of sixty-eight persons, that that power
with referenee to the typieal vibrio, of Indian
origin, is extremely variable. It exists in almost
half the men who have not had cholera, and in 58
per cent. of persons who have had an attack.
Almost half the eholera patients and hal the indi-
viduals who died of that affection present equally
the preventive property of the blood. One may
consider as proved that natural recovery in cholera
takes place without the appearance of the preven-
tive property of the blood. On the other hand, that
property may develop without preventing the man
attacked with cholera from dying of the disease,
even in the first period of its evolution."
Observations of a similar purport have been
made in Kolle's laboratory, where it has been seen
that the serum of an inoculated individual, when
d on an animal infected with cholera germs.
may have the effect of destroying those germs, and
vet be inefficient in preventing à fatal issue of the
disease. These results, conjointly with the results
mentioned higher up and with others to be quoted
unfortunately render uncertain some of
ds on which Kolle had formed favourable
ith regard to the author's devita-
use
presently,
the groun
expectations with
lized cholera vaccine.
Another illustration of the same nature is the
fact that a guinea-pig immunized against the
cholera germ contains In its blood substances by
means of which it is possible to protect other ee
pigs against the same germ; after a time these to
stances disappear from the blood of the immunizé
guinea-pig. but the latter remains aN "e
In plague. Strong. following Kolle and tto, * 8
that live virus has greater immunizing pow ers t pe
any form of devitalized vaccine; yet when he
examined the serum of twenty-six persons Mocu-
Aug. 1, 1913.]
lated with such virus, he found that it possessed
neither the power of agglutinating the plague germ,
nor that of protecting an animal against plague
infection.
The above instances could be easily multiplied,
but those given should suffiee to show that, at
present, it is no more possible to infer from blood
examination the existence of immunity in an inocu-
lated man or animal, than to infer from the natural
or conferred immunity of a lower animal the exis-
tence of similar immunity in man. Authors who
have worked on the lines under consideration are
not unaware of the inevitable uncertainty of the
conclusions obtainable in that way. Thus, refer-
ring to vaccination against cholera and the effects
of the watery extraction of the author's devitalized
vaccine '' II," Strong states :—
“ We have seen that by the subcutaneous injec-
tion of the cholera prophylactic ’’ (extraction of
vaccine “ II) **an excellent cholera immune serum
can be obtained in human beings. However, the
question naturally arises, whether these individuals
are protected against intestinal infection with the
cholera spirillum. In other words, are they really
immune to the disease, Asiatic cholera? Experi-
ments upon animals cannot satisfactorily answer
this query. Since animals are not naturally
susceptible to intestinal infection, and since it is
only through artificial means that such may be pro-
duced in them, evidently the answer to our question
ean be given only by a practical observation of the
human beings inoculated with the prophylactic
during a severe and general epidemic of the disease.
. . It would appear from the numerous statisties
of Haffkine in India, and the more recent work of
Murata in Japan, that simply by the injection of a
small amount of the killed organism a certain degree
of immunity against the natural mode of infection
is acquired. Therefore, judging from what has
already been said, it is probable that by the use of
our prophylactic, human beings may acquire a good
active immunity against the disease.”
General Summary.
A description has been given of the experiments
by means of which the possibility of immunizing
man against cholera has been demonstrated in the
studies in India with live vaccine ‘‘II.’’ The
nature and the mode of preparation of that vaccine
have also been described.
A number of observers have concluded from this
result, and by inference from observations on ani-
mals and on human blood serum, that the same
vaccine in a devitalized condition, as used tenta-
tively in the author's experiments of 1892-93, and
again, on a somewhat larger scale, in 1900, was also
likely to be useful. The further study of that
preparation in India has been delayed by the advent
of the plague; but the above expectations are justi-
fiable. An investigation on the subjeet, made in
the midst of actual outbreaks of cholera, under
conditions of accurate scientific research, following
the lines whieh haxe been deseribed, is desirable,
in view of the advantages which a devitalized
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
239
prophylactic offers in practical application, and of
the great difficulties in the way of using live vac-
cine on an extensive scale, under the conditions
prevailing in many parts of the country.
Just as it was important to obtain first a positive
result on the question of cholera immunization in
general, and to use, in investigating that matter,
the most reliable vaccine preparation, so it is
important to avoid in the beginning the possibility
of failure in the study of the vaccine in a devita-
lized form. For this reason it is preferable at
present to use the devitalized vaccine in its en-
tirety, as against extractions or other derivations of
it. The facilities of manufacture in the cost of the
entire preparation are also of considerable impor-
tance.
In devitalizing vaccine '' II,” it is essential to
employ. only the most delicate physical and
chemical processes.
Two forms of that vaccine in devitalized condition
commend themselves to the author for first investi-
gation :—
(1) One, prepared by prolonged cultivation in a
fluid medium and devitalized by heat and carbolie
acid ;
(2) The second, prepared by cultivation on a solid
medium and devitalized, as soon as developed, by
a solution of the same antiseptic compound.
The study of the protection derived from the
employment, separately, of these two forms of
vaeeine, in various doses, should afford information
as to the direetion in which the plan will require to
be modified for further study.
(Concluded.)
—
Annotations.
A Clinical Test for Malaria.—Atkinson, in the
Lancet of June 28, 1913, draws attention to
Schlesinger’s reaction for demonstrating the pre-
sence of urobilin in the urine. This can be obtained
in patients suffering from malarial fever even when
the malarial parasites are absent from the peripheral
blood.
As is well known, the high colour of urine in
malaria depends upon the increased amount of
urobilin present. Plehn, in 1909, recommended
this very delicate and simple reaction to demon-
strate the presence of urobilin in the urine. To
obtain it the following are required: (1) Schlesinger's
solution, which consists of zine acetate, 1 part;
alcohol, 10 parts. (2) Tincture of iodine. (8) A
sample of urine to be tested.
In a test tube one-third filled with the unfiltered
urine an equal quantity of Schlesinger’s solution,
which has previously been well shaken, is added. A
few drops of a weak solution of tincture of iodine are
now poured in, as this accelerates the reaction. The
mixture is then filtered, and if urobilin be present
the filtered mixture shows a more or less distinct
240
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Aug. 1, 1913.
fluorescence. This reaction is met with in the urine
of patients suffering from all types of malarial fever.
To show how delicate it is, in cases of malignant
malaria it can be obtained after diluting the urine
with 200 parts of water. Quite healthy urine does
not give the reaction, as it contains, if any, only
the slightest amount of urobilin. Urobilin is
present, of course, in many other diseases, such as
cirrhosis of the liver, liver abscess, many infectious
diseases, &e.
Atkinson used the test frequently in the Govern-
ment Civil and Victoria Hospitals, Hong-Kong, and
found it useful, particularly in diagnosing doubtful
cases where parasites were not present in the blood.
The absence of the reaction speaks strongly against
acute malarial fever, a fact of great value when a
quick diagnosis is to be made.
Sp
DR. MINETT, of Georgetown, British Guiana, has
recently demonstrated the presence of Leishmania in
that Colony, having found such parasites in specimens
of smears from "forest yaws." In some of these
sent home to the London School of Tropical Medicine,
Leishmania are present in large numbers. Although
forest yaws and similar parasites have already been
reported from Dutch and French Guiana we believe
that this is the first authenticated record of the
demonstration of Leishmania in British Guiana. Dr.
Minett proposes to give a full account of the case in
due course.
APENTA WATER IN WEST AFRICA.
REPRESENTATIVES of the Medical Faculty, prac-
tising in West Africa, express favourable views of
the usefulness of Apenta Water in that country,
especially as a preventive and cure of chronic
constipation.
Professor Külz, Imperial Government Physician,
Cameroons, observes that he has always given
the preference to it in the West African Tropics
on account of its many advantages. He points
out that it is specially in hot climates that
the European is predisposed to suffer from constipa-
tion, partly because of the loss of fluid from the
skin, partly by change of diet and partly as a sequel
to the most prevalent of tropical maladies, viz.,
malaria! The Professor testifies that Apenta has
proved itself a mild but reliable aperient, free from
unpleasant after-effects and one which patients take
readily. The water has also been found to bear the
heat of the Tropies well.
IMPERIAL INSTITUTE.
SYNOPSIS OF CONTENTS OF THE “ BULLETIN OF
THE IMPERIAL INSTITUTE," Vor. XI (1913), No. 2.
THE second quarterly issue of the Bulletin of the
Imperial Institute contains, among the reports of
recent investigations by the Scientific and Technical
Staff, an article on cotton- growing in the Sudan, with
reference chiefly to the proposed scheme for cotton
cultivation under Anglo-Egyptian auspiees, involving
a guarantee by H.M.'s Treasury of the interest on a
loan to be raised by the Sudan Government amounting
to three millions sterling; and the space usually
occupied in the Bulletin by special articles is devoted
exclusively to a comprehensive report (illustrated) on
“ Tea: its Cultivation, Manufacture, and Commerce,”
by Dr. S. E. Chandler and Mr. John McEwan, a
notable feature in which is the pre-eminence, in the
figures quoted, of the people of the British Empire as
tea-drinkers--the consumption per capita being no
less than ten times that of foreign countries, excluding
the United States. A notice on the cultivation and
preparation of Turkish tobacco refers to the progress
made, in that respect, in South Africa. Among the
General Notes is an interesting reference to the rock-
strueture of Egypt, contained in a recent Report of the
Egyptian Geological Survey, to the effect that, con-
trary to the prevalent view, " erosion following local
folding "—and not fault-effects, or trough-faulting—
is, perhaps, sufficient to account for all the observed
conditions. The latest official statistics are given of
the total mineral production of Ontario and Western
Australia; and numerous notes deal with recent pro-
gress in agrieulture and the development of natural
resources, chiefly within the Empire.
——— ——»—————— -
ERRATUM.
Dr. BATES writes, pointing out that a line of his
original manuscript in his " Review of a Clinical Study
of Malarial Fever in Panama," Part II, which appeared
in the June 16, 1913, number of the Journal, has been
omitted. Under the heading of Differential Diagnosis,
p. 182, line 12, it is stated: " Thus, in the quotidian
fevers these phenomena occur within approximately
a period of forty-eight hours, or, rather the paroxysms,
&c." This should read: “Thus, in the quotidian
fevers these phenomena occur within approximately a
period of twenty-four hours, while in the subtertian
these phenomena occur within a period approximating
forty-eight hours, and its febrile curve holds through
or delays during a period of twenty-four or even
forty-two hours, and then remission or slight inter-
mission takes place."
The omission of the line of course renders the text
inaecurate and misleading.
Hotices to Correspondents,
1.—Manuscripts sent in cannot be returned,
2.— As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municaie with the Publishers,
5.—Correspondents should look for replies under the heading
** Answers to Correspondents,"
Aug. 15, 1913.) THE JOURNAL OF TROPICAL. MEDICINE AND HYGIENE.
Original Communications.
A REVIEW OF A CLINICAL STUDY OF
MALARIAL FEVER IN PANAMA.
By Jonn PELHaAM Barres, M.D.
Ancon, Canal Zone.
IV.
RELAPSE IN MALARIA.
IT appears from my observation that relapses
follow the primary invasions in malaria so frequently
that they, like anemia, may with propriety be con-
sidered a syndrome of malarial disease. It is not
certain, however, that all the recurrences I have noted
are true relapses. For in a tropical country like
Panama, with the infectious agent present through-
out the entire year, it is not an easy matter to separate
relapses from reinfections. A large proportion of our
population is. well protected by screening and mosquito
destruction, but the nature of the canal work is such
that exposure to reinfection cannot with certainty be
eliminated. That is to say, most of our population
work out of doors, and they go to work before day-
light, and often return to their homes after sunset,
and hence expose themselves at the time of the day
when mosquitoes bite the most greedily; and a
number of the labouring class live in quarters of their
own providing without screening, and unprotected
except for the work of the mosquito brigade. Thus,
with these conditions prevailing, one necessarily
meets with considerable difficulty in the study of
relapses.
I have been able, though, from time to time, to
have under observation a small number of malarial
cases in which reinfection could be eliminated, and
which I could watch from the primary invasion
through the various relapses that followed. Among
these there were a few which I could control as to
treatment and regimen, and in this number checking
relapses has not appeared very difficult, for in most
of these the recurrences have ceased with one or two
or three attacks, or four at most. It is important
to note that in three persons with apparent relapses,
as soon as their quarters, which had been screened
a short time previously, were thoroughly fumigated
the relapses immediately ceased.
It is especially among children, who are always
active and impatient of control, and adults whose
duties force them out again too quickly after the sub-
sidence of the fever, that the relapses are most
troublesome and persistent. In this class of patients,
the active ones, it is found that the relapses occur at
short intervals, such intervals, for instance, as two
or three weeks, and on up to one month or three
months, or even four months. It is found that those
having intervals of from three to four months are
usually subjects who have taken quinine in moderate
doses, 10 to 15 gr. a day, during the intervals, to
finally discontinue it, when after a period of eight or
ten days after this the fever recurs. One can
well assume in this class of relapses a small
number of the plasmodia have managed to survive
[No. 16, Vol. XVI.
the effect of the drug, and hence, when quinine is
discontinued, multiplication begins anew, and thus
a recurrence of the original symptoms takes place.
The intervals of time between these attacks then bear
some relation to the thoroughness of treatment in
the primary invasion or in the succeeding attacks.
Thus, if the treatment is perfectly thorough, there is
of course no relapse, but failing in this, treatment
may be of any degree of inefficiency, from those cases
in which the active symptoms are barely ameliorated,
and recurrence takes place so promptly after the
quinine is discontinued that the recurrence is no more
than an exacerbation of symptoms, and so on through
various widening intervals, according to the vigorous-
ness of the treatment.
There is a more general class of relapses than this,
of people who may reside in malarious countries, and
who may be the subject of several attacks of malaria,
and who finally reach a stage in which they can con-
tinue to live in malarious countries in a state of
apparent well-being, but as soon as they change to
a cooler latitude or a cooler climate by virtue of a
higher altitude, they are immediately struck down
by an attack of fever. Such was the case in the early
days in our work in Panama, when most of the
Americans exposed were the subjects of malaria.
They, after having suffered two or three attacks of
malaria in Panama, began to remain in a state of
well-being as long as they continued to reside here,
but as soon as they made a change back to their
homes in the States a portion of them would be
immediately attacked by fever. These relapses were
separated by periods of five, or six, or eight months
and sometimes even longer. Quinine was frequently
taken during these intervals, usually prophylactic
doses of about 9 gr. a day.
There are yet other relapses from this latter class,
those which are reported from time to time that are
separated by periods of several years. These I shall
refer to later. The relapses then of people residing
in malarious countries and exposed to infection are
quite different from the short interval cases I have
first named, and to account for this latter class of
relapses is not so easy as in the first. One naturally
wonders in what form have the plasmodia existed
during all this time. Have they continued to develop
regularly in the usual schizogonous cycle in small
numbers, under the check of immunity principles
produced in the blood and the phagocytic properties
of the leucocytes? Or have they developed a resist-
ance—a property that parasites are said to possess
of "altering rapidly, not their form and external
appearance, but their chemical reaction and probably
strueture, when too closely pressed or menaced," in
brief, a “ state of effective resistance or fastness ” ? [1]
Or do they preserve their existence by the formation
of spores that lie dormant, awaiting a favourable
opportunity to reproduce the original strain? Finally,
do they manage to preserve themselves through the
gametes, whieh we know are unaffected by quinine
and on this aecount manage to survive, and later
through some process of aberrant development repro-
duce the original schizogonous cycle? All of these
249
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 15, 1913.
questions have answers in analogous properties of
other lower orders of life, and hence all have been
advocated in various theories or hypotheses to explain
the eause of relapse in malaria.
I do not think it is necessary to attempt to discuss
all of these questions, but prefer to take up those
which have been developed into working hypotheses
and which have the greatest number of followers,
and one I shall discuss on the account of its
uniqueness.
Among the answers to these questions that have
been developed into working hypotheses there are
three. First, residual parasites— parasites that have
managed to survive the effect of quinine, and continue
to develop in the usual asexual cycle. Second,
parthenogenesis, as advanced by Schaudinn and his
followers. Third, intracorpuscular conjugation, as
advanced by Craig, in which he believes a body is
formed to harbour the dormant spores. The unique
one has been recently suggested by Thayer [2] as
a possible explanation of the cause. This suggestion
was introduced on aecount of an article by Rowley-
Lawson,[3] in which she describes a series of
phenomena in the male and female crescent bodies,
which were interpreted to be evidence of sexual
development in the human host. Rowley-Lawson's
studies were made in a series of blood smears con-
taining crescents and asexual forms of the plasmodia,
and they were carried out in great detail by photo-
micrographs, &c. She explains that the reason this
phenomenon has not been observed heretofore is
because it takes place very rapidly, in the internal
organs—the spleen and bone marrow. The pheno-
mena she describes are, that in the male crescent
bodies there was displayed within them small
chromatin filaments, flagellate-like in appearance,
and in the female crescent the chromatin particles
were arranged into a sporulating-like formation, and
thus she assumed that these latter bodies had been
fertilized by the filaments or flagella of the male
crescents, and segmentation was taking place.
This paper is remarkable in that she describes these
forms as evidence of a sexual cycle in man in the face
of the fact that the Italian school and Manson have
already described these same metamorphoses, and
explained their cause. Marchiafava and Bignami [4]
have described these phases in detail in contending
against the sporulation of female crescents in man,
and have shown that the metamorphoses pictured
by Rowley-Lawson occur in erescents only when they
are exposed to some disintegrating process, usually in
moist-chamber smears, which was used for expediting
flagellation. And they show that when disintegra-
tion in the crescent’s protoplasm has taken place by
virtue of the moisture, the arrangement of their nuclear
chromatin can be seen within them. In the macro-
gamete the chromatin is arranged rosette-like around
the pigment wreath, and this arrangement gave to
some observers the idea of sporulation of these
bodies ; in the microgametocyte the nuclear chromatin
is arranged in flagellate-like filaments. The arrange-
ment of the nuclear chromatin in the male gamete
eaused Manson to suggest that the flagella existed
preformed in the adult or "ripe" crescents.
Now, if one will note carefully Rowley-Lawson's
[5] plates it will be readily seen that all her crescents
are in states of disintegration. Their cytoplasm is
fissured and broken into granular clumps, in contrast
to the smooth and regular plump forms of crescents
seen in smears freshly prepared and freshly stained,
showing that she must have been working with old and
much-used smears. Even if the phases she described
had not already been noted and described, and their
cause explained, she has not given a sufficient explana-
tion why the many and painstaking observers bave
not accidentally seen these phases from smears from
the puncture of spleens, and in autopsy smears from
patients dead only a few hours. Indeed, a crescent
has been seen in an autopsy smear from the spleen
(Darling), with small filaments of chromatin flagellate-
like within it, but this also occurred in a smear that
had dried slowly in a humid atmosphere. The work
of Rowley-Lawson is well done and interesting, but
her conclusion is not at all convincing, and the
phenomena as illustrated must be accepted only as
phenomena displayed when degenerative changes have
occurred in the protoplasm of the crescent bodies.
Intracorpuscular Conjugation of the Plasmodia.—
Mannaberg [6] first called attention to intracorpus-
cular conjugation of the malarial organism, a pheno-
menon through which he believed the formation of
the crescent bodies occur. Ewing [7] later described
what he interpreted to be intracorpuscular conjuga-
tion, but he appears to consider it of no especial sig-
nificance in the life phases of the malarial organism,
and thinks the phenomenon occurs very rarely.
Craig [8] has lately taken up the hypothesis of intra-
corpuscular conjugation again, and makes use of it
to explain the cause of relapses in malaria with more
than ordinary long intervals. The phenomenon as
usually described may take place when two young
ring forms occupy the same red corpuscle. Conjuga-
tion begins by the amceboid movements of the young
ring bodies. The cytoplasm of each organism is
pushed out in prolongation until it meets with its
opposite fellow, when blending of the cytoplasmic
substance of each organism begins. Fusion of the
cytoplasm when complete gives rise to a larger ring
body with the original chromatin nucleus of each yet
intact, the chromatin particles usually occupying
various positions in the cytoplasmic ring substance
of the new organism. In the further development
of the resultant body the chromatin particles unite,
forming an irregular chromatin mass occupying a
position somewhat within the ring body. According
to Craig [9] the resultant organism or zygote formed
by conjugation continues its development until it
completely occupies the substance of its corpuscular
host, and ultimately destroys the red cell, thus
becoming a body free in the blood plasma. The free
body contains pigment, but the pigment is in smaller
amounts than in other forms not produced by con-
jugation, and “in some instances the chromatin
masses are numerous, and are collected at one side
of the organism, giving rise to an appearance suggest-
ing sporulation.” This free, lightly-pigmented body
* [talies are mine.
Aug. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
he believes becomes encysted, and contains spores.
The whole body is resistant to quinine and other
injurious influences, and retires to the spleen and
bone marrow to await a favourable circumstance,
when the spores are liberated. The liberated spores
now enter the red corpuscles, and thus begins anew
the original schizogonous cycle, and in this manner
he assumes relapses are precipitated.
If I understand fully Craig’s description of this
free, pigmented, or "resting-stage " body, I believe
it is the same pigmented body that has so long given
me trouble to interpret, and which I now know to be
nothing more than an unripe schizont of the quotidian
parasites. I believe I have already described this
free, pigmented body in describing the developmental
morphology of the quotidian parasites, and correctly
interpreted its function in the life phases of this
variety of malarial parasites, in which it was seen
that this body was a schizont or presegmenting body.
This explains why the chromatin in Craig’s “ resting
body ” is sometimes arranged in such a manner as to
suggest sporulation. I am prepared to admit an
intracorpuscular fusion of two amceboid protoplasmic
particles, but I am not convinced that Craig's lightly-
pigmented, resting-stage body is the resultant or
zygote from such a fusion.
Parthenogenesis.—The second hypothesis of par-
thenogenesis arose from the behaviour of the gametes
in the presence of quinine. The gametes appear to
be wholly unaffected by the drug, and at times may
be found in the peripheral blood for some time after
the asexual forms have apparently disappeared.
These facts then have been seized upon by numerous
observers to explain the reappearance of fever after
long intervals of well-being in malarial subjects.
The idea of the cause of relapses by quinine-resistant
gametes was further strengthened when Schaudinn
while studying the blood of a patient in a tertian
relapse saw a female gamete undergo a series of
changes which he interpreted as parthenogenesis.
And from this observation he immediately concluded
that parthenogenesis was the cause of relapse.
Grassi [10] had in 1901 already seen certain changes
occur in a tertian macrogamete, which he interpreted
as parthenogenesis. Schaudinn’s study has been
followed by Maurer [11], Neeb [12], Harrison [13],
Karrewij [14], and others. Each of these observers
has seen and followed similar changes in tertian
macrogametes as described by Schaudinn, but the
changes noted by these latter workers occurred not
alone in relapses, but in the regular course of tertian
malaria. Karrewij, I believe, was the only one of
these latter workers who was willing to commit him-
self that the phenomenon as seen was true partheno-
genesis.
I may admit for the sake of argument that partheno-
genesis may occur in the malarial gametes, but it has
not been proved that this form of development occurs
solely in relapse, and its relation to relapse is at best
but conjectural. The studies that have been made
of this aberrant process of development have been
made in the presence of asexual parasites, developing
in the regular schizogonous cycle, and it appears to
243
me that in order to make the evidence for partheno-
genesis complete, as the cause of relapse, the pheno-
menon should occur only when gametes are present,
and the asexual forms are absent from the blood.
This demand upon the advocates of parthenogenesis
is not too great, for it is no difficult matter to find
cases where there are only gametes present in the
blood.
After this review of the various hypotheses intro-
duced to explain the relapse in malaria I may now
return to the first and older theory of residual para-
sites in malaria, which, like the poor, we have always
with us, and if it has no other merit, it at least has
that of simplicity, and admits of rational treatment.
All are familiar with latency in malaria—in which
persons in malarious countries harbour parasites in
the blood, and under ordinary circumstances these
parasites do not give rise to any symptoms. For the
term latency, I prefer the term, the stage of tolerance,
and I believe that the stage of tolerance is one of the
first steps in the process towards acquired immunity
to malaria. All relapses occur during the stage of
tolerance, and the intervals between the relapses, that
is, whether long or short, depend first upon the
thoroughness of the treatment of the primary invasion
or in the succeeding attacks, and second, upon the
degree of immunity already established. I hold then
that the relapses in malaria are not produced by aber-
rant process of development of either the asexual para-
sites or the gametes, but they are brought about by
residual parasites too few to be detected in the blood,
which continue to reproduce themselves in the usual
asexual cycles. They are held in abeyance for a time
by the immunity principles of the blood and the phago-
cytic properties of the leucocytes. When circumstances
are favourable to the parasites from some breaking
of the advantage held by the host, the parasites
multiply to numbers sufficient to reproduce the sym-
ptoms of the original attack.
Darling [15] in 1909 undertook a work among the
labourers and other inhabitants in the Canal zone to
ascertain the number of malaria “ carriers " or latent
cases that were among this class of people. March
was selected as the best month of the year for this
work, for it is at this time that malaria is at its lowest
ebb in Panama, and hence reinfections are less likely
to beencountered. He found in 276 persons examined,
all of whom were up and about their regular duties,
that 13 per cent. harboured malarial parasites in
various stages of development. A critical analysis
of Darling’s findings will be found highly significant
in connection with the cause of relapse in malaria.
Indeed, the analysis appears to be not only significant
in this connection, but actually to answer the question.
Thus, in Darling's cases there were found thirty-four
people harbouring parasites ; of these twenty-six dis-
closed the parasite to be in the young ring forms or
in partially grown forms; while in only eight were the
parasites shown in the gamete forms exclusively. In
these tolerant cases then the parasites were develop-
ing steadily in the regular asexual cycles, and yet
not giving rise to active symptoms, and one among
the number in whom the malarial organisms were
244
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 15, 1913.
developing in the usual asexual forms, had just been
discharged from the hospital nine days previously.
Here, then, it is shown that over three-fourths of all the
tolerant cases were harbouring parasites, which were
developing in just the same way as they are seen to
do in the course of regular attacks of fever. If, then,
people can harbour the usual asexual forms of para-
sites while up and about their duties for even short
periods of time, it is not unreasonable to assume that
they may do so indefinitely or until sufficient quinine
is taken or immunity principles are produced to check
further development of the parasites.
The chances favouring residual parasites in the
blood even in treated cases are too numerous to be
passed over. In the first place, I have noted in dis-
cussing chronic malaria “that patients grow tired of
a never-ending dosing with quinine, and finally reach
a stage where they take sufficient quantities only to
relieve the urgent symptoms, and then discontinue
the drug till necessity drives them to it again. In
these instances all the parasites are certainly not
destroyed. I have recently watched a patient who
has been having recurrent attacks of fever for about
a year. In his three last attacks I have examined
his blood, and found the same variety of parasites
present in each succeeding attack. The last attack
was separated by an interval of four and a half
months. During this interval he was prevailed upon
to continue quinine in doses of 10 gr. a day, which
he did up to within a period of ten days before the
last attack observed. At this time he grew tired of
the quinine, and discontinued its use, when, after an
interval of ten days, the fever recurred, with the same
forms of parasites again present. Even in what we
presume are well-treated cases the asexual parasites
are not all destroyed, as I have just shown in
Darling's series of cases, in which one man still had
young ring form parasites in the blood, although dis-
charged from the hospital nine days previously.
Ross and Thomson's [16] ease of relapse is another
instance of a well-treated case with residual asexual
parasites in the blood. Thus, after taking 30 gr.
of quinine continuously for fifty-seven days, in which
time the parasites were below the detectible limit
by even Ross's “thick-film” method, this patient
developed a relapse after quinine had been discon-
tinued for “ a few days."
I have notes of two other cases, one of which on
15 gr. of quinine solution daily continued to have
fever for seven days, with an afternoon's rise of
temperature reaching to 103° F., and which was not
checked until quinine was increased to 30 gr. a day.
The other one, whose blood on admission to the ward
was negative for either sexual or asexual forms,
received 30 gr. of quinine solution daily for six days.
After this time the quinine in solution was reduced to
10 gr. daily for a period of twenty-two days. On the
twenty-eighth day after admission there was an
afternoons rise of temperature. On the following
morning the blood was again examined, disclosing
young ring forms and numerous crescents.
It is here shown, then, that every circumstance
favours residual parasites. First, in people who
refuse to take sufficient quinine to be effective;
second, cases in which the physician may not very
well estimate the quantity of quinine necessary to
destroy all the parasites; and finally there are other
cases in which in all probability the patient cannot
safely be given quantities of quinine sufficient to be
effective in the destruction of all the parasites. In
addition to the circumstances which may favour the
probability of the residual parasites, I have shown by
the analysis of Darling’s [17] tolerant cases that
people may harbour parasites for periods of time
unknown, for the simple reason that no one has
carried out a detailed study in these cases to ascer-
tain what becomes of the parasites or how long they
may exist. In other instances, such a study is not
possible, for all the forms, asexual and sexual, are
below the detectible limit, by our methods of exami-
nation. There is, therefore, nothing in reason to
prevent one from inferring that people may harbour
parasites which develop regularly in the asexual cycles
indefinitely, or until they are checked by efficient
treatment, or by immunity. Indeed there is every-
thing in reason to lead one to infer that such is the
case.
Immunity, combined with treatment, become
factors whieh finally limit relapses. The time it
may take for an individual to develop immunity to
malaria is not known, though it is reasonable to
assume from experience that this is not more than
two or three years in most instances. I have shown
in discussing chronic malaria that immunity developed
in one case in eighteen months. On the other hand,
I reported another case in which there had been
thirteen attacks of fever during a period of six years,
and the patient was not yet wholly immune, as, at
the time he came under my observation, in the
thirteenth attack, he had a temperature of 103 F.,
and an abundance of parasites in the blood. But it
is important in this case to remember that the patient
had been, all the time during the six years, exposed
to renewed infection. He had, however, developed
a certain degree of immunity in that he was able to
bear thirteen attacks of fever, and yet show a red cell
count of 4,240,000 per cubic millimetre with a hæmo-
globin value of 92 per cent. Thus, the time for
acquiring immunity may be over long periods, and
once acquired, it may be later lost altogether. As an
instance, I may relate my experience in person with
malaria. I have been the subject of seven widely
separated attacks of malaria in my lifetime. The
first of these occurred at four years old, and continued
for a period of four months, to finally cease. My
father, a country practitioner, was suffering from
irregular attacks of fever at the same time, and his
attack continued well over into the following year.
I remained and grew up in the locality where I had
received the primary infection, through a healthy
boyhood and adolescence, all the time exposed to
infection, and wholly ignorant of its source. At 17
years of age I was again the subject of another attack
of malaria. This attack continued for five days. I
have since had five other attacks, two of which have
occurred in Panama. Thus it appears that I
Aug. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
developed an immunity which continued for about
thirteen years, after which it disappeared, and
left me in a state highly susceptible to every new
source of infection. Omitting the repeated attacks
in childhood, I have never suffered from relapses
in any of these subsequent attacks of malaria
fever.
It now remains to note the relapses that are
reported to occur after intervals of from three to five
to seven and thirteen years. I do not believe that
such cases are relapses, yet I have no well-proved
facts by which I can contradict them, all I can offer
is, that the course of malarial relapses is against
their oceurrence. Thus the issue becomes a matter
of beliefs, the discussion of which makes for no
advance in medicine. I shall therefore dismiss them,
and await a report of a long interval relapse in
malaria, in which all the evidence is so complete
that there can be no grounds for denying them, and
confine myself in closing to what appear to be well-
proven facts.
Ross and Thomson [18] have recently reported a
series of cases in which 17 per cent. showed a slight
rise of temperature after the paroxysms of fever had
ceased under quinine, and while the quinine was
continued without decreasing the doses. They term
these slight rises of temperature pseudo-relapses. In
a certain number of the cases they were able to
explain the cause of the second rise of fever by
intercurrent disease, but in others there was no
explanation, yet from blood examinations malaria
could not be demonstrated as the cause. I have
had some experience with this class of relapses. In
these I believe I have been able to demonstrate the
cause. I have found that where intercurrent disease
was not the cause it was due to allowing the patients
to be up too early and to eat too freely immediately
after the subsidence of the fever, hence detracting
from the efficiency of the quinine treatment. I have
therefore considered these slight second rises to be
true mild relapses with the parasites below the
detectible limit. Ross and Thomson [19] have since
reported an instance of true relapse on vigorous and
continuous quinine treatment, which proves that my
inference with regard to these later slight elevations
of temperature are true mild relapses.
I have now discussed some of the various hypo-
theses that have been advanced to explain the
cause of relapse in malaria—parthenogenesis, intra-
corpuscular conjugation, sexual development in the
human host. Í have shown that their connection
with relapse is only conjectural, and that they depend
more on inference in this connection than they do
on proof. I have shown that the chances for a few
of the regular asexual forms of the parasites surviving
the effects of quinine and continuing to multiply are
numerous, and I have also shown by calling attention
again to the well-known facts of latency in malaria,
that the malarial parasites survive and continue to
develop in the asexual cycles over indefinite periods
of time. These facts then being true, there is every
reasonable ground to assume that residual parasites,
although they may be so few in numbers as to be
below the detectible limit by our methods of examina-
245
tion, also can continue to survive, and multiply
slowly until a favourable opportunity offers, when
they increase rapidly, and thus bring about the next
succeeding relapse. I therefore hold that aberrant
processes of development of either the gametes or the
asexual parasites are not necessary to explain the
cause of relapse in malaria. And with Ross [20]
and others, rest content with the simple hypothesis
of residual parasites “ until a better one is established.”
BIBLIOGRAPHY,
[1] Fuexner, $S1iwow. “Biological Basis for Specific
Therapy,” Boston Med. and Surg. Journ., November 9, 1911,
p. 710.
[2] THavEn, Wm. S. ‘On Malarial Fever with Special
Reference to Prophylaxis,” reprint from the Harvey Lectures,
Series 1911-1912, J. B. Lippincott and Co., Philadelphia.
[3] Rowrey Lawson, Mary. ‘‘ The Estivo-Autumnal Para-
site: its Sexual Cycle in the Circulating Blood of Man, &c.,
&c.," The Journ. of Experimental Med., vol. xiii, No. 2,
February 1, 1911, p. 263.
[4] Marcuiaraya and Bianami. '' Malaria," Twentieth
Century Practice of Medicine, vol. xix, 1902, pp. 44-59.
[5] RowrEv-LawsoN, Mary. Op, cit.
[6] MannaBerG, J. ‘‘ Nothnagel’s Encyclopedia of Prac-
tical Medicine,” p. 52.
[7] Ew1nc. ‘ Clinical Pathology of the Blood," New York,
1903, p. 454.
[8] Craic, CHas. F. ‘‘ Studies in the Malarial Plasmodia
after the Administration of Quinine, and in Intracorpuscular
Conjugation,” Journal of Infectious Diseases, vol. vii, No. 2,
March 1, 1910, pp. 285-318.
(9) Craic, Cnas. F. Op. cit.
[10] Gnaassr Cited by Ross, Sir R. '' Prevention of
Malaria," E. P. Dutton and Co., New York, 1910.
[11] Maurer, G. Centralbl. für Backt., &c., November 5,
1902,
[19] Nees, H. M. ‘The Parthenogenesis of the Female
Crescent," JOURNAL OF TROPICAL MEDICINE AND HYGIENE,
vol. xiii, No. 7, April 1, 1910, pp. 98-102.
[13] Harrison, W. S. Journal of the Royal Army Medical
Corps, December, 1910.
[14] Karrewis. Cited by Branami, A. ‘‘Concerning the
Pathogenesis of Relapses in Malarial Fever.” Translation by
Dr. W. M. James, Southern Med. Journ., vol. vi, No. 2, Feb-
ruary, 1913, p. 80.
[15] Darina, S. T. ‘Studies in Relation to Malaria,"
Govt. Print, Washington, D.C., 1910. $
[16] Ross and THowsowN. ‘‘ A Case of Malarial Fever Show-
ing a True Parasitic Relapse during Vigorous and Continuous
Quinine Treatment,” Annals of Tropical Medicine and Para-
sitology, vol. v, No. 4, February, 1912.
[17] Darina, S. T. Op. cit.
[18] Ross and THomson. ‘‘ Pseudo Relapses in Cases of
Malarial Fever during Continuous Quinine Treatment,” Annals
of Tropical Medicine and Parasitology, vol. v, No. 3, December,
1911.
[19] Ross and THomson. Op. cil.
[20] Ross, Sır R. ‘‘ Prevention of Malaria," E. P. Dutton
and Co., New York, 1910, p. 115.
PRELIMINARY NOTE ON A NEW FLAGEL-
LATE, CRITHIDIA HYALOMM.E, SP.
NOV. FOUND IN THE TICK HYALOMMA
JEGYPTIUM (LINN/EUS, 1758).
By Captain W. R. O'FARRELL, R.A.M.C,
Protozoologist to the Wellcome Tropical Research Laboratories,
Khartoum.
(Forwarded by Dr. Albert Chalmers, Khartoum.)
THE protozoal parasite which forms the subject of
this foreword is found in the common cattle tick of
the Anglo-Egyptian Sudan—Hyalomma ægyptium
(Linneus, 1758).
246
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 15, 1913.
In this brief note I confine myself to a short
description of the flagellate stage, leaving a more
detailed account of the organism and its life history
for a future communication.
Flagellate Stage.—This stage is best studied in the
cœlomic fluid of the tick, where, indeed, many of the
pre- and post-flagellate stages may also be observed.
The adult parasites present the usual crithidial
type of body, but are unusually long and slender. The
length of the body and flagellum varies from 260 to
48'0 u, the length of the flagellum alone being usually
1275 M. The average breadth is 2'5 M. The breadth
of the nucleus varies from 2'0 to 2'5 p.
The flagellar extremity tapers gradually to a narrow
point, while the flagellar end is continued for some
distance along the flagellum.
The undulating membrane is well marked, running
from the neighbourhood of the blepharoplast to the
flagellar extremity of the body.
Crithidia hyalomme (O'Farrell, 1913).
EXPLANATION OF FIGURES.
All figures outlined with Abbé-Zeiss camera lucida, after wet
fixation with osmic vapour and absolute alcohol, and stained
with Giemsa’s solution ; 2 mm. apochromatic objective (Zeiss)
and compensating ocular 12 used.
Figs. 1 to 5.—Flagellate Crithidia, showing relative position
of blepharoplast and nucleus,
Figs. 6 to 8.— Various stages in division.
The nucleus is roundish or oval, and generally lies
about the middle of the body, the whole breadth of
which it nearly occupies.
In quiescent stages the intranuclear material is
compact, but when active division or cyst formation
is about to occur it becomes granular. In the
quiescent stages it contains a well-defined central
karyosome.
The blepharoplast is usually situated on the
flagellar side of the nucleus. In appearance it may
be rounded or rod-shaped, and when it assumes the
latter form it is placed tranversely to the long axis of
the body. At times it may be closely applied to the
exterior of the nucleus, from which it can readily be
differentiated by its assuming a deeper tint with the
usual stains. It often presents a diplosome appear-
ance; and when division is about to take place it
apparently splits into two bodies, one of which moves
to the aflagellar aspect of the nucleus which, in this
way, comes to lie between the two portions of the
original blepharoplast. The flagellum, taking its
origin in the vicinity of the blepharoplast, to which it
is not connected, runs along the free border of the
undulating membrane until the extremity of the body
is reached. Here it escapes from the periplast and
projects freely for a considerable distance. No basal
granule has so far been noted.
The movements of the adult flagellate are moder-
ately slow. In forward progression the flagellar end
is anterior, but it may move at times with the
aflagellar extremity situate anteriorly. This latter
movement usually occurs only in short-distance
movements, or when the organism is about to turn
round.
The method of the forward movement may be
described as follows: The body and flagellum describe
an are of a circle, then they suddenly fly back,
straightening the organism, which is driven forwards
by the fibrillary movements of the undulating mem-
brane and the oscillations of the flagellum, which
often shows very rapid whip-like lashing movements,
especially if the organisms are present in large
numbers or are attached to debujs.
Classification.—From the above description and
the attached drawings it will be obvious that the
parasite belongs to the genus Crithidia, Léger emended
Patton, 1908, and I therefore propose for it the name
of Crithidia hyalomme.
———»——————
* South African Medical Record," vol. xi, No. 12,
June 28, 1913.
Leprosy.—The above number of the South African
Medical Record is devoted to leprosy. The following
papers will be found in it: * The Surgery of Leprosy," by
T. Lindsay Sandes; M.A., M.D.; “ The Care of the Leper,”
by R. Morrow, M.D., Ch.B., M.A.; “Symptomatology and
Diagnosis of Leprosy,” by S. P. Impey, M.D.; “The Eye
Complications of Leprosy,” by D. J. Wood, M.B., C.M.;
“Surgical Treatment of some Eye Affections in Leprosy,”
by A. Heymans, M.D.; “ Notes on the Specific Treatment
of Leprosy by means of a Cultural Extract,” by T. Sydney
Davies, M.R.C.S., L.R.C.P.
“Indian Medical Gazette,” vol. xlviii, No. 7, July,
3.
Malaria.—Lalor believes he has found some unusual
forms of malignant malaria parasites in an endemic black-
water fever centre in Burma. The forms were found in
children's blood. A coloured plate is given showing the
supposed peculiarities.
* Indian Medical Gazette," vol. xlviii, No. 7, July, 1913.
Malaria in the Andamans.—Woolley notes that among
the various forms of malarial fever met with in the
Andamans there is a form associated with marked jaundice.
In favourable cases this tends to improve in five or six
days, and the temperature may come down to normal.
The stools which have been white, and the urine which has
been very dark during the jaundice, return to the normal
conditions, but the brunt of the disease seems to fall on the
circulatory system, and though the dangerously rapid and
weak pulse may improve in volume at this time, it often
remains unusually rapid, 115 —120, for some days.
The prognosis is bad, 40 per cent. of the cases dying,
mostly from cardiae syncope. x
‘Aug. 15, .1913.]
_THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
247
Susiness Hotes.
1.—The address of the JouBNAL oF TROPICAL MEDICINE AND
HyGreNE is Messrs. BALE, Sons AND DANIELSSON, Ltd., 83-91,
Great Titchfield Street, London, W.
2.—All literary communications should be addressed to the
Editors.
8.—A1l business communications and payments, either of
subscriptions or advertisements, should be sent to the Publishers
of the JOUBNAL or TROPICAL MEDICINE AND HYGIENE. Cheques
to be crossed The Union Bank of London, Ltd.
4.— The Subscription, which is Eighteen Shillings per annum,
aar commence at any time, and is payable in advance.
5.—Change of address should be promptly notified.
6.—Non-receipt of copies of the Journal should be notified to
the Publishers.
T.— The Journal will be issued about the first and fifteenth day
of every month.
THE JOURNAL OF
Tropical Medicine and Hygiene
AUGUST 15, 1913.
BRITISH MEDICAL ASSOCIATION.
* (Continued from p. 234.)
Enteric Fever.
From records of 133 cases of enteric fever occur-
ring in 69 men and 64 women in the following
countries: India, 77; China, 26; North Africa,
Egypt and Syria, 11; Persia, 6; under 5 in South
Africa, Ceylon, Japan, South America, Bahamas,
Tuberculosis.
Pulmonary tuberculosis comes third in order of
frequency in China, and seventh in India as a cause
of invaliding, whilst occasional cases occur from
other countries. This would not be remarkable had
there not been by process of medical examination
an elimination of susceptible persons, though it
must be owned some societies are less strict in their
medical regulations than others as regards this
disease.
Countries. —China (North excluded, except in two
cases) .. Ae is a ii s. 2l
India... 6
S. America and S. Africa, "Madagascar, ‘Turkish
Arabia, West and East Indies - 3 each
Family predisposition (tuberculosis in one or more
members) was stated in iis A: see S!
No record of predisposition was stated in... as oo 2
Healthy family histories stated in... e d
Reported ‘‘ healed tubercle ” before going abroad in a d
This shows that in 33 per cent. of those invalided
for tuberculosis there was a decided family predis-
position or direct earlier personal infection. This
percentage might have been higher had details been
afforded in the other 22 cases.
Colonel R. J. S. Simpson, C.M.G., said that the
materials used in order to ascertain the causes of
invaliding in the Tropics were the Army Medical
Reports from 1886-1895, 1896-1905, and 1906-1910.
The numbers invalided per 1,000 of strength over
each of these periods have been compared. These
three periods correspond fairly well to three stages
in the development of our knowledge of the causes
of disease, and therefore with our ability to deal
Spain; the following are the statistics :— with them by hygienie measures.
Years of service abroad... 1... 2... 3.. 4.. 5 ..6..7..8.. 9 . 10-15 ... 15 20 ... 20.30
Cases, 133 ... T wo 2955714, MI odd Td eB eed seth uu x uiu AB Lu MU aos i2
In first 3 years Tm 64
In first 5 years T 87
In a series of 54 cases of deaths from enteric also collected from these sources:—
DEATHS.
Years of service ... nl ste 21..9..8..4..5..6 ..7 ..8.. 9 ... 10 ... 10-15 ... 15-20 ... 20-30
— amaa
Cases, 54. (Men 33, women 21.) ss db te Dek coe uud ix... 4 Soe ^ Gh, US. Lus M
In first 3 years oan 28.
In first 5 years TD 34.
1 Incidence of, Deaths from There is difficulty in finding some standard by
Period of service. enteric. enteric. ‘ 3 "
“ah Per cent. Per rent. which to measure the results at any given station,
Within first 3 years ana ue and the only method is to compare groups of
LEE : i 70-0 10:3 diseases at the whole of our foreign stations, but
” 39 9
It is noted that cases do occur even after 20 to 30
years of service.
The conclusion is obvious :—
(1) All persons going abroad should have know-
ledge as to the usual modes of infection by this
disease.
(2) The general practice .of inoculation with anti-
typhoid vaecine should be carried out every three
years if possible for a but not all countries,
especially China, India, N. Africa and Palestine.
here we are hampered by the great variations in the
populations exposed: in some of the smaller stations
an accidental small increase in the number of cases
results in an unduly large increase in the ratio, even
over a period of five years. Again, in India, since
1907, men have been sent to the hills instead of
being invalided home, which has reduced the tem-
porary and permanent invaliding since that year.
Invaliding due to Tropical Disease.—The tem-
porary invaliding average of the ratios per 1,000 for
all foreign stations for all diseases between 1906-10
248
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 15, 1913.
was 24, of which 8 were due to tropical disease—
usually malarial fever.
The permanent invaliding average of the ratios at
the same stations for the same period was, for all
ile aa 9°2 per 1,000, and for tropical diseases
In India, between 1907-1911, both inclusive, the
following were the actual numbers of cases invalided
permanently for tropical disease: Enteric fever, 21;
beriberi, 4; dysentery, 1; kala-azar, 3; malaria, 18;
or a total of 47 cases in five years on an average
strength of about 72,000 men.
It is surprising to find how few cases are in-
valided for dysentery, hepatitis, enteritis, or diar-
rheea.
Debility holds a comparatively high place in the
tables. This term, like anemia, really includes
many of the cases due to acute or recurrent disease,
and should be recorded under that heading. But,
even including all cases of debility and anemia with
the tropical diseases (which is, of course, not cor-
rect) the total still remains insignificant among the
causes of permanent invaliding.
Invaliding due to Non-Tropical Disease.—The
more important diseases causing temporary or per-
manent invaliding are, in order of magnitude,
these :—
TEMPORARY.
Tropical diseases.
Nervous and mental diseases.
Unnamed diseases.
Tubercular disease.
Diseases of special senses,
Heart and circulation.
PERMANENT.
Nervous and mental diseases.
Tubercular disease.
Diseases of special senses.
Heart and circulation.
Unnamed diseases.
The predominance of nervous and mental diseases
is distinct. Of those sent home, 85:5 per cent. are
finally discharged. The commonest forms of
disease are epilepsy, melancholia, and delusional
insanity. In India, between 1907 and 1911, of the
total permanent invaliding for mental diseases,
epilepsy accounted for 28 per cent., melancholia
21 per cent., delusional insanity 17°5 per cent.,
altogether 61:5 per cent.
Neurasthenia is not recorded frequently among
the men, perhaps less frequently than it might be.
Tubercular disease is for practical purposes
tubercle of the lung.
South China and Ceylon showed a definitely
higher rate for tuberculosis than any other foreign
station during the period 1906-1910.
Diseases of the special senses are almost entirely
those of the eye (errors of refraction) and ear
(middle ear). In India, during the period 1907-
1911, of the total permanent invaliding under this
head, 19:3 per cent. was due to refractive error,
58:5 per cent. to diseases of the middle ear, or a
total of 72:8 per cent.
An appreciable part of the invaliding for non-
tropieal diseases would appear, therefore, to be due
on the one hand to congenital structural defects,
whieh are not influeneed to any great extent by a
tropieal environment, and, on the other, to ante-
cedent infection or to that aggregate of partially
known qualities which we call predisposition.
Relation between Temporary and Final Invalid-
ing.—There is a comparatively close agreement
between the order in which the different stations
appear when placed in series according to the magni-
tude of the ratios for temporary and permanent
invaliding respectively. So that the temporary in-
validing from a station is a fair indieation of what
permanent loss may be expected.
Relation between Invaliding for Tropical and
Non-Tropical Disease.—It is interesting to inquire
how far statistics support the general impression
that a tropical environment influences the incidence
and severity of non-tropical diseases, as far as this
is shown by invaliding.
Arranging the foreign stations in two series in
order of magnitude of the invaliding ratios for
tropical and non-tropical diseases, we find a very
strong resemblance between the two series. Hence
we are justified in saying that the invaliding rate
for non-tropical disease on the whole rises and falls
with that for tropical disease; or, putting it another
way, at most stations the relative magnitude of
the invaliding ratio depends on all classes of disease,
not only on that for tropical disease.
The important question here is whether this rise
in non-tropical disease, with an increase in tropical
disease, is determined by co-existing and antecedent
tropical infection, or whether it is the result of other
factors. One knows, as a matter of fact, that as
cases are invalided for the more important disorders,
many cases invalided from infective stations for non-
tropical disease also suffer from some tropical in-
fection, and in a good many cases this has increased
the severity of the non-tropical disorder.
Using the ratio per 1,000 of invalids sent home
during the decade 1886-1895 as a standard, we
have the following comparison :—
Invalids sent home, Finally discharged.
1886-95 ... as 100 as TY 53
1896-1905 TN 134 5 és 58
1906-1910 .. 70 io at 31
1911 ... .. 80 de T 26
The rise in the period 1896-1905 is due to the
South Afriean War, while part of the decrease
in the last quinquennium is due to the policy
of sending men to the hills instead of home,
also during the last period there was a very great
reduction in venereal disease. But the increase
and decrease in each group of diseases is fairly
regular over the different periods. Hence the con-
clusion that those conditions which influence the
prevalence of tropical disease also influence the
prevalence of non-tropical disease is supported by
the statistics available.
Comparing these different periods, and comparing
the different foreign stations for the same period
with the United Kingdom, one sees that the same
diseases are numerically important in temperate as
well as tropical stations and that the only difference
is in degree not in kind.
Conclusions.—(a) Tropical diseases of themselves
produce only a relatively large temporary invalid-
ing. (b) The temporary invaliding from a station
Aug. 15; 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
249
for causes other than tropical disease, taken gener-
ally, rises and falls over the whole of our foreign
stations with the invaliding for tropical disease.
(c) The important causes of invaliding, temporary
and final, are in order of importance: Nervous and
mental diseases; tubercular disease; diseases of the
special senses, including the eye; diseases of the
heart, functional and organic. (d) These are the
same causes which are effective in Great Britain
and almost in the same order.
Dr. Law’s observations were based on work done
in British Guiana, which was confined to no par-
INVALIDS SENT HOME PER 1,000.
even if all tropical diseases were wiped out, climate
would still remain a powerful enemy to the settle-
ment of tropical countries by the Caucasian.
Apart from climate, by far the most fertile
source of invaliding in British Guiana is malaria,
which accounts for nearly three-fourths of the
temporary invaliding and is an important element
in bringing about permanent disability. The disease
is, indeed, so common that it is treated with too
little respect. People often get what we familarly
term ‘‘a touch of fever ’’ without lying up at all,
or do so for at most a day or two. This accounts
1906—1910.
ae Exile] 3 ax 2
= £ 2 4 2 i s z8 28 328
= E Se] = E 28 £8 B
Bil Bia | & à$| 8, | &/ 28 | 83
id S ud a | &
Tropical ... um 0:73 | 6:20| 1:48| 0°16| 3:68 |30:36| 0:65,|40:78| 2:63, 884| 051| 399| 8:03
Rheumatic fever 0:41| 0:38, 0°30) 0:32| 0:46 | 2:83| 0°58; 0°76| 0:44, 034| 0°51) 015| 0:29
Tubercle ... 2:42| 2:00) 1:59| 2:41] 1°84] — 0:97| 095| 5:26 | 2:94| 051| L:84| 1:26
Venereal ... Ys. 0:57, 041, 0:553, 065| — 9:89 | 0:45, 1318, 1°32) 1:58| 077| 4:14| 0:86
Debility ... sv . | 026| 0:67, 087| 016| 1:84 | 4:67| 0°44] 2°64, 2°63) 1:13) 051| 8:53| 1:52
Nervous and mental 2°53 | 2:25 | 2:69| 2:41| 2:76 | 8:56| 1:61] 1°89| 3:07, 2:15, 1:28) 1°84] 1:85
Specialsenses ... 216} 1:28| L:35| L:45| 0-46] — 074| 1:52, 2°20) 0:34| 1:79 | 7:50| 1:70
V.D.H. and D.A.H. 1:24| 1:30! 273| 113, 3°68] 078| 1°31! 1:51) 0°44! 3:97| 077| 062| 1:87
Inflammation of liver ... -- 010| 038| — — 0°78 | 0:26| 1°70; 088| 068| 026| — 0:75
Digestive ... à | 0:46| 013| 0:83, 0°65 1:38 | 2:38 | 0:63, 2:27, 0'44| 1:13] 0:26, 061| 0°63
Urinary ... 0:57| 032| 0:53, 0°32! 0'46 | — 0:37 | 0°94) 044| 057| 026| 0:46| 0:30
Locomotion | 031| 048| 083| 065| 092| — 0:336, 057) — 0°68} 0:51, 061; 0°62
Unnamed 2°01; 1:33, 92:07 | 1:61 | 2'32 | 3°39] 1:02, 3:86| 2°61) 4:99] 279| 2'17 164
| |
60:52 | 22:36 | 29:34 | 10°73 | 27°46 | 16:32
Malarial fevers predominate in Jamaica, West Africa, Mauritius, South China, Straits Settlements and India; dysentery in
Ceylon ; Mediterranean fever in Malta.
ticular class, but included Government officials,
employees on sugar plantations, business men and
their families. If it is admitted, as most do, that
the white races are unfit for permanent residence
in tropical countries, it follows logically that Euro-
‘peans who go to these countries must return to
temperate climates at more or less regular intervals
if they are to maintain their health and energy for
‘work. There are some apparent exceptions to this
rule, but they are few.
The primary cause of invaliding is climatic; it
is the unpreventable factor that comes into the
great majority of cases.
He states that his views on this point are not
in agreement with those of some distinguished
workers, notably Colonel Gorgas, who is quoted
by Dr. David Thomson, in a paper recently read
before the Society of Tropical Medicine and Hygiene,
as saying that ''the work on the Isthmus will
demonstrate to the world that the white man can
live and work in any part of the world, and that
the settling of the Tropics by the Caucasian will
date from the completion of the Panama Canal.
He maintains that, though Colonel Gorgas’s bril-
liant work on the Isthmus of Panama has shown how
much can be done by energy and organization, there
is, on the contrary, every reason to believe that,
for many recurrences, and it is well to emphasize
the fact that invaliding, both temporary and perma-
nent, would be less if after every attack, no matter
how slight, rest for a day or two and continued use
of quinine were looked on as essential.
Dysentery and enteric fever are, perhaps, the
only other acute diseases deserving of notice as
causing any special invaliding. In our towns and
on sugar plantations the former is certainly not
common, though a few cases do occur. It is more
in evidence amongst the few Europeans who work
in the interior at gold diggings or on timber grants.
Enteric fever, which was formerly a very rare
disease, has within the last ten or twelve years
become comparatively common in Georgetown and
on some sugar estates, and the amount of invalid-
ing from this cause is becoming considerable, if not
alarming.
Blackwater fever we see little of; yellow fever
has been absent from the Colony since 1888; plague,
cholera, and beriberi are unknown; and the try-
panosome has not yet visited us. Filariasis and
intestinal parasites, though extremely common
amongst our working classes, are practically absent
from our European population.
Nervous disease is next, perhaps, to malaria the
most frequent cause of prolonged or permanent
250
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Aug. 15, 1913.
invaliding. It is not so much that the lesions are
grosser, involving the locomotor system, as that the
so-called functional derangements, varying from
mere nervous irritability or slight mental depression
to actual melancholia with suicidal tendency. These
are mostly to be found in persons occupying
responsible positions, such as heads of departments,
professional men, managers of estates and business
men. Heavy work of a responsible nature is not
easily borne in the trying conditions of tropical life
and frequently leads to the condition commonly
spoken of as “‘ nervous breakdown." In British
Guiana we see a great deal of this; possibly our
low-lying country, with its constant moist heat, is
favourable for its development. Be the cause what
it may, we know that when the placid man becomes
nervous and irritable, or when mental depression
takes the place of the usual cheeriness, the sooner
that individual goes for a good long leave to a
temperate climate the better.
Valvular disease of the heart is not more common
than in England, possibly less so owing to the total
absence of acute rheumatism, but still heart affec-
tions figure largely amongst the causes of invalid-
ing, being, perhaps, next in importance to nervous
diseases. The term ‘tropical heart " has been
used by some writers, but I do not think there is
any condition of the heart peculiar to the Tropics.
A weakening of the heart muscle, accompanied by
a greater or less degree of dilatation, very fre-
quently follows attacks of acute disease, just as it
will in this country, but the point seems to be
that it takes less to produce this condition in a
tropical than in a temperate climate.
Anemia as a cause of invaliding must also be
mentioned. A great deal of it, due to intestinal
parasites, is met with in British Guiana amongst
the labouring population, but amongst Europeans
this is extremely rare, and in this class the condi-
tion must be ascribed chiefly to climatic influences
and malarial fever.
Strain of work is not unfrequently overlooked by
writers who seem to think that life in the Tropics
is mostly one of comparative ease and luxury. Few
Europeans are capable of as much work in a hot
climate as at home, and yet they are not un-
commonly called on to do more. Little wonder
that breakdown occurs.
Speaking generally, it may be said that the
abuse of aleohol is not greater in British Guiana
than in England, but its effects are more rapid and
serious. It is not a question of actual drunkenness,
which is rare, but the habitual free use of alcohol
which stops far short of intoxication. The climate
is to blame for much of the over-indulgence of this
sort.
To epitomize the conclusions drawn from his
experience, Dr. Law considers that permanent in-
validing is most frequently demanded in eases of
nervous heart affections, and obstinate
anemias, whereas temporary invaliding, if of suffi-
cient duration, will, as a rule, set right an otherwise
healthy person suffering from malaria, enteric fever,
dysentery, or other acute disease. He lays par-
disease,
ticular stress on the qualification in the last sentence,
as he has so often seen men, particularly overseers
and junior officials, who, perhaps, could ill afford
long leave, go home for two or three months after
severe malarial fever, only to be laid up again by
serious recurrences immediately after their return
to the Tropies.
Dr. Law concluded by remarking that more atten-
tion to early symptoms, particularly with regard
to slight malarial attacks, is required. In malarial
countries the regular daily use of quinine as a
prophylactic is a necessity. Longer rest after acute
malarial attacks have passed off. Longer leave to
temperate climates when such is needed. Fairly
frequent return to temperate climates even in the
absence of acute illness. Great caution with regard
to the use of aleohol. Careful selection of candi-
dates for work in the Tropics.
———
Annotations.
Chronic Dysentery cured by Emetine.—Verteuil
reports a case (Lancet, June 28, 1913) of amebic
dysentery of three and a half years’ duration rapidly
cured by injections of emetine hydrochloride.
The patient, a Frenchman, aged 44, left France
for Panama in 1909, where he was to represent an
important French firm. Previous to this he had
always enjoyed excellent health, and was a strong,
powerfully built man. Two months after his arrival
in Panama he suffered from a sharp attack of
dysentery with passage of mucus and bloody stools.
From January 1 to April, 1910, he was constantly
ill, suffering from fever and diarrhea. Besides
various other drugs he was dosed with quinine. As
he was rapidly going downhill he was advised to
leave immediately for France. Immediately on his
arrival in Paris (April 21) he was operated on for a
huge liver abscess. Three months after this opera-
tion he felt fairly well. This period of comparative
health was, however, of short duration, for as soon
as he attempted to return to a normal diet he had
a recurrence of his dysenteric symptoms, and had
to confine himself to a strict milk diet. During the
following two and a half years he had six severe
subacute attacks. These attacks would last for
several weeks. Two of them were followed by liver
abscess, for which he underwent two further opera-
tions.
In April, 1913, the patient arrived in Vancouver,
where shortly after his arrival he had a subacute
attack, and consulted Verteuil for this. He had an
urgent and constant desire to go to stool, and he
was passing from twenty to thirty stools daily, the
majority of which consisted of only a little mucus
and blood, accompanied by a good deal of griping
and tenesmus. There were pain and tenderness
over the region of the colon. He had a slight even-
ing rise of temperature, and also suffered from
Aug. 15, 1913.]
external hemorrhoids, which had apparently been
caused by the constant straining at stool. The
patient appeared a complete nervous and physical
wreck; he was thin and emaciated, with a muddy,
icteric-looking complexion, prominent cheek bones,
and with sunken eyeballs. He received an in-
jection consisting of 4 gr. of emetine hydro-
chloride dissolved in saline solution and enclosed in
a glass ampoule (Burroughs and Wellcome) on
May 10. On the following day at noon he received
a second injection. During the night of the 11th
he had no call to stool; previously he had to get up
seven or eight times during the night. On the 12th,
36 hours after&he first injection, he received a third
injection, and from that date there was a complete
disappearance of all dysenterie symptoms. That
day he had but one stool, which was quite normal
in appearance. He subsequently received seven
more injections as a matter of precaution. During
the time he was receiving the emetine injections
no other drug or treatment was used. The injection
of the drug did not cause the slightest unpleasant
sign or symptom.
Verteuil thinks it is too early to speak of a per-
manent cure in this case, but the results obtained
have appeared to him to be so extraordinarily rapid
that he has described the case in some detail. There
are few specific drugs in medicine, and the addition
of a new one is cértainly an epoch-marking dis-
covery. Emetine seems to be as potent a specific
in ameebic dysentery as quinine is in malaria or
salvarsan in syphilis and yaws.
Malarial Pigment as a Factor in the Production of
Blood-picture of Malaria.—Brown, writing on this
subject in the Journal of Experimental Medicine,
vol. xviii, No. 1, July, 1913, concludes that malarial
pigment, termed by him hematin, plays a part in the
production of the blood-pieture of malaria. He con-
cludes that :—
(1) Doses of less than six milligrammes of hematin
and, under certain conditions, larger doses may cause
a slight rise of blood-pressure.
(2) That large doses of hematin cause a profound
and prolonged fall of blood-pressure. The principal
factor in this fall of blood-pressure is the marked
dilatation of the splanchnic vessels. The splanchnic
dilatation either does not occur at all or but very
slightly if tbe splanchnic nerves are cut. The
splanchnic dilatation is partly compensated for by a
marked constriction of cutaneous vessels, and it seems
probable that the cutaneous constriction is active and
not simply passive to the splanchnic engorgement.
(3) That hematin acts upon the cardio-inhibitory
centre causing a marked slowing of the rate of the
heart-beat, and in large doses produces a typical vagal
pulse or even marked irregularities in the amplitude
and rhythm of the pulse. Under hematin the heart
at first shows great loss of tone, but later the tone in-
creases beyond the normal. The cardiac output for
a time is greatly diminished.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
251
(4) That in the large doses employed by him
hematin depresses the respiratory centre, and that
death under hematin is due to paralysis of this centre.
Sleeping Sickness.—-Hearsey, in his "Sleeping Sick-
ness Diary for the Nyasaland Protectorate,” Part xx,
dated April 30, 1913, states that twenty cases of sleep-
ing sickness have been reported during the past four
months, namely, seven in January, six in February,
five in March, and two in April. Of this number
nineteen were found in the sleeping sickness area,
and one near Kota-Kota, in the Marimba district.
These twenty cases added to those previously reported
make a total of 128. .
Clearing of bush and scrub and the lopping of
branches of trees which might afford shelter for tsetse-
flies are being carried out around all the villages in
the sleeping sickness area, and Dr. Conran, the
Medical Officer now in charge of this area, reports that
the work is attended with marked success in banishing
the flies from the villages.
A re-investigation of the districts to the north and
south of the proclaimed area will shortly be under-
taken, as it is necessary to ascertain definitely whether
these localities harbour cases of sleeping sickness.
A detail account of the new cases is given in the
report.
The Health of the Canal Zone.—Phillips, Acting
Chief Sanitary Officer of the Isthmian Canal Com-
mission, in his report of the department of sani-
tation for the month of May, 1913, states that
the total number of deaths from all causes among
employees was 38, divided as follows: Disease 27,
and violence 11, giving the annual average per
thousand of 5°42 and 2°21 respectively.
Among employees for the month of May of each
year the annual average death-rate per thousand was
as follows :—
Year Total Disease
1904 5°35 x RE —
1905 16:65 4v yx --
1906 24°79 23°88
1907 30:15 24:00
1908 10:44 803
1909 9°45 5°36
1910 7°72 4°77
1911 10°89 8:17
1912 8:01 4-61
1913 1:63 5:42
'The annual death-rate per thousand in the cities of
Panama and Colon, and the Canal Zone, including
both employees and civil population for the month
of May of each year, was as follows: 1905, 41°95;
1906, 43:32; 1907, 3157 ; 1908, 20'87 ; 1909, 15°77;
1910, 18°69 ; 1911, 22°32; 1912, 19'01; 1913, 19°66.
In segregating according to race, the annual average
death-rate per thousand from disease among em-
ployees was: For whites 3°65, and for blacks, 5°94,
252
THE JOURNAL OF TROPICAL MEDICINE AXD HYGIENE.
[Aug. 15, 1913.
giving a general average for disease of 542. For the
same month during 1911 the annual average death-
rate per thousand from disease among whites was
5°81, and blacks 8°97, giving a general average of
1°17; and in 1912 from disease among whites 1°95,
and blacks 5°50, giving a general average of 4°61.
Among employees during the month deaths from
the principal diseases were as follows: Dysentery, 1;
heemoglobinuric fever, 1; lobar pneumonia, 5 ; organic
disease of heart, 3; tuberculosis of lungs, 1; typhoid
fever, 2; leaving 14 deaths from all other diseases
and 11 deaths from external violence.
During the month of April the Culebra Hospital
and sick camp were discontinued, the dispensary alone
being continued.
No cases of yellow fever, small-pox, or plague
originated on or were brought to the Isthmus during
the month.
Experimental Production of Pellagra in a Monkey.
—Harris (Journal of the American Medlcal Asso-
ciation, June 21, 1913) believes he has experiment-
ally produced pellagra in a monkey. He states that
the inability to produce pellagra satisfactorily in
animals by means of various foodstuffs (spoiled
maize and other cereals), which are considered by
many observers to be in some manner responsible
for the production of the disease, led him to investi-
gate the hypothesis that pellagra is caused by a living
micro-organism and not by a chemical intoxicant.
It seemed logical, therefore, that the causal agent
would be contained in one or more of the various
tissues affected, and by utilizing these the disease
could be reproduced in a susceptible animal. It
was considered inadvisable to attempt injections of
the whole tissue emulsions because of the heavy
bacterial flora of the intestinal tract, the contamina-
tions of the skin, and the probable secondary infec-
tion of the patient dead of pellagra. These
considerations, together with the view that the
disease in man might be due to a filterable virus,
occasioned the employment of filtrates from the
various organs. For this purpose the skin,
alimentary tract, and more especially the brain and
cord—since many of the characteristic symptoms of
pellagra indicate disorders of this system— were
filtered and utilized for animal injection.
In the spring of 1910 experiments with a Berke-
feld filtrate of the infected human tissues were
carried out on the monkey. These materials were
selected from the fresh necropsy of a case of un-
doubted pellagra which presented clinically a typical
pieture of the disease, namely, extensive skin
lesions, stomatitis, diarrhea and the various nervous
manifestations. The skin lesions involved the
hands, face, legs and scrotum, and were sharply
defined, being of a distinet black colour, dry,
elevated and scaly. A complete necropsy was held
within two hours after death, and the only lesions
found macro- and microscopically were those
present in fatal pellagra; no concomitant disease
was present. The tissues of the different parts of
the central nervous system, especially the cord,
portions of the skin lesions and of the alimentary
tract, including the nasopharyngeal mucous mem-
brane, were removed. These were mixed with equal
amounts of normal saline solution, ground together
in a mortar and allowed to stand in the ice-chest
over night. After coarse filtration the juice was
passed through a Berkefeld filter, letter N.
The filtrate from the tissue mixture was then
injected in large quantities into monkeys and pro-
duced in them symptoms closely resembling pel-
lagra. Photographs of the infected animals showing
lesions on their hands and face are given, and these
bear a resemblance certainly to the analogous skin
lesions seen in man.
Harris believes it is pellagra, and sums up his
work thus :—
** These experiments would indicate that pellagra
may be transmitted to the monkey (Macacus rhesus)
by means of a Berkefeld filtrate derived from the
tissue of the human subject; at least, the animals
develop all the essential clinical signs and symptoms
together with the pathologic picture discerned in the
disease in man. Furthermore, they suggest that the
etiology of pellagra is a filterable virus or a micro-
organism capable of passing through the pores of
certain Berkefeld filters. The details of this work
and the further experiments which have been under-
taken with a view of determining the nature of this
filtrate and other phases of the problem will appear
in a subsequent publication.”
The Prevention of Enteric Fever iW Military
Service.—Cummins, in the Journal of the Royal
Army Medical Corps, No. 1, July, 1913, vol. xxi,
writing on this subject, deals specially with the
typhoid carrier.
He believes that the discovery and disposal of
chronić carriers should be carried out in peace in
order that the Army may take the field with as few
‘carriers ’’ as possible within its ranks.
The procedure that should be followed through-
out the Army has been already initiated in India.
It seems illogieal that the splendid work of the
Enterie Convalescent Depót at Naini Tal should
not have already led to the formation of similar
institutions outside India. The author recom-
mends that in all foreign stations where the garrison
exceeds a certain strength—say 2,000 troops—there
should be a depot for enteric convalescents under
the charge of a '' specialist ’’ officer, trained in the
bacteriological study of enteric fever. This officer
should be regarded as the pathologist of the com-
mand also, where the work of the depót is not so
heavy as to justify a whole-time worker. To deal
with convalescents from foreign stations with
garrisons below this strength there should be a
“ Home Depót ” at some such place as Netley, to
which all enterie convalescents should be sent.
This station would also dispose of ‘‘ carriers ’’ sent
home from the other depóts, and receive con-
valescents from military hospitals in England.
The duties of this central Home Depót would
Aug. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
253
be arduous, and would require the whole time
of one officer, under whom the clinical patho-
logist at Netley might serve as an assistant
when available. He would further recommend
that all ' temporary " and ''ehronie " carriers
regarded as cured and returned to the ranks should
be ''followed ” during at least a year after return
to duty, samples not only of feces, but of blood
being sent either to the depót at Netley or the Royal
Army Medical College for examination. | Where
'"' immune bodies ’’ were found to persist for many
months in the blood, the soldier should be invalided.
A negative result in a sample of fæces sent by post
means very little where twenty-four hours or more
have elapsed since it was passed; on this account
a blood sample would be advisable. No enteric
convaleseent should return to the ranks without
having passed a period at a convalescent depót and
being certified as no longer excreting germs.
As regards the detection of early, atypical, and
abortive cases in peace, this should be, and is,
fairly successfully carried out. It is another matter
on active service. Cummins believes that there is
too great a tendency to regard bacteriological work
as '' out of place "" on actual active service. There
is no sanitary measure more important to a com-
mander than the early diagnosis of enteric fever
cases. If this is successfully carried out, and the
methods of observation and isolation of ‘‘ contacts ''
laid down in ‘‘ R.A.M.C. Training ’’ are honestly
and thoroughly observed, he sees no reason why
enteric fever should prevail in the future to any-
thing like the extent that it has done in the past on
active service.
The early diagnosis of typhoid fever is a matter
of blood culture. This requires skill, care, and
deliberation, but not an elaborate outfit of bacterio-
logical appliances. His idea is that a mobile
*' ]aboratory,'' consisting of a closed motor vehicle,
containing the apparatus for preparing media, incu-
bating ‘‘ cultures,’’ and for the necessary micro-
scopie and other work of isolating bacteria, should
be attached to each division and accompany
this formation as part of the Divisional Headquar-
ters. A specially trained officer with two trained
orderlies and a driver should constitute the staff.
Regimental medical officers and officers command-
ing field ambulanees should be directed to co-
operate with this officer by sending to him all
suspicious cases for blood culture and such other
work as may be necessary. At present this work
is allocated to the laboratory at the advanced base
or railhead. In place of this, Cummins suggests a
mobile laboratory marching and working with the
divisions.
During active operations, convalescent enteric
cases should invariably be invalided to home terri-
tory, and should not rejoin the Colours until
certified ‘‘safe’’ by the Central Home Depót.
The numbers so invalided would be comparatively
few if the measures already mentioned had been
thoroughly carried out.
— ———
Abstracts.
KALA-AZAR, ITS DISTRIBUTION AND THE
PROBABLE MODES OF INFECTION.*
By Lieutenant-Colonel C. Donovan, B.A., M.D., B.C.H.,
B.A.O. (R.U.I.), F.L.S., F.E.S., I.M.S.
Surgeon, 4th District, Madras.
Tne author gives a brief accomnt of the
geographical distribution of the disease to show the
nature of the localities in which it is endemic. Its
occurrence in such places, he believes, may help to
throw a sidelight on some of the factors needed
towards the discovery of the infective agent. He
then describes fhe different insects that have been
suspected as carriers of the virus, and the possi-
bility of infection by means of or through the
mucous membrane of the intestinal tract.
Geographical Distribution.—Outside India, there
are records of the prevalence of the disease in
China, in the Yangtse Valley, and in the Soudan,
in localities on the Blue Nile bordering the western
boundary of the Abyssinian plateau.
The author excludes the disease as found along
the littoral of the Mediterranean, relegating it to
another form of Leishmaniasis, affecting mainly, if
not exclusively, children and apparently closely con-
nected with the canine form of the disease.
As regards the occurrence of kala-azar in India, it
is found endemic in the damp, low-lying districts
near the deltas of the Ganges and Brahmaputra ;
for instance, at Purneah, Dinajpur, Rangpur, the
Burdwan district, Jessore, in and about Calcutta,
Garo Hills and up the valley of the Brahmaputra
river in Assam.
Donovan is doubtful if Orissa is affected, but
would suspect the low-lying areas of the deltas of
the Brahmani and Mahanadi rivers, especially near
Cuttack, to be suitable localities. Cases occurring
in other parts of the north of India are apparently
not indigenous. Dr. Row’s case of kala-azar from
Baroda is an exceptional instance, but perhaps
others may be discovered there when more search-
ing inquiries are made.
As far as the Madras Presidency is concerned,
the disease is endemic in Madras City, especially
in the northern congested part, i.e., Georgetown
and Royapuram; to the west there are smaller foci
in Choolai, Vepery and Pursewalkum, and to the
east a very small focus in Triplicane. Recently a
single case has been discovered in the family of a
servant employed by a European residing at
Nungumbakam, the residential part of Madras for
Europeans. In the mofussil, three cases have been
traced to Madura and a couple to Negapatam and
Cuddalore.
Thus all the places where this disease is endemic
are low-lying, damp and near rivers, places very
* Proceedings of the Third Meeting of the General Malaria
Committee, held at Madras, November 18, 19, and 20, 1912,
Simla: Government Central Branch Press, 1913.
254
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 15, 1913.
suitable for malaria, and here malaria and kala-azar
co-exist.
Probable Modes of Infeetion.—These may be
divided into two: (1) By means of insects, &e.,
absorption of the infection by the eutaneous lym-
phaties, and (2) by oral ingestion, infection through
the mucous membrane of the intestinal tract.
(1) By Insects—(a) Bed-bugs.—Patton has
brought very strong evidence to bear on the trans-
mission of the disease by bed-bugs; yet there are
several points still wanting to satisfy one in accept-
ing the fact in its entirety. The disease is very
local and bed-bugs everywhere. Patton has
attempted to explain this anomaly by the fact that
a few bugs may take a single meal only of blood,
the majority satisfying their appetites more often
and not being condemned, for some unaccountable
reason, to an unnecessary fast; and that it is in
these exceptional cases of single feeds that the
Leishmania flourish and flagellate. There may be
something in this deduction, but further proofs are
required. Patton has done a considerable amount
of work in connection with bugs, and can speak with
authority, yet an independent confirmation of his
findings is required. Donovan himself met with
no success, but he has not had an opportunity of
trying experiments with the single feeding of bugs.
Cases of kala-azar with numerous Leishmania in
the peripheral blood, according to him, are of rare
occurrence. Subsequent to Patton’s announcement
of success with single feeds, he has, Donovan under-
stands, fed bugs on a kala-azar patient with nearly
a thousand Leishmania in a blood film. Large
numbers of these insects were fed on this most
exceptionally suitable case, but the results are said
to have been negative. Of course, conditions
favourable on the first occasion might have been
inimical on this the second attempt, for the flagella-
tion of the parasites; for instance, there may not
have been a suffieiently large number of Leish-
mania in the endothelial cells.
(b) Conorrhinus.—Donovan has suspected another
member of the bug family to be a transmitter of
the disease, e.g., Conorrhinus rubrofasciatus. So
far he has not succeeded in obtaining any develop-
ment of Leishmania in the gut of these Hemiptera,
but what makes him still adhere to experiments
with them is the fact that they suck human blood
under natural conditions, and that another species
of the same genus in Brazil is the transmitter of
a human trypanosomiasis. The popular belief that
this bug feeds on bed-bugs is of curious interest,
and a similar belief is held in Europe with regard
to its congener, Reduvius personatus.
(c) Mosquitoes.—Patton has carried out a few
observations on these insects, but with negative
results. It must not be forgotten that some
Culicids harbour flagellates and these may very
readily be confused, by an inexperienced observer,
for Leishmania. A fact to be noted is that where
kala-azar is endemic, there too malaria prevails;
to give a few instances: in Assam, in Lower Bengal
and in Georgetown.
(d) Housc-fly.—The
ubiquitous house-fly of
India, very similar to that of Europe, but singled
out for specific distinction as Musca nebulo, has
been incriminated as acting as a transmitter, not
by biting, as it possesses no such apparatus, but by
transferring by its mouth or excreta the materies
morbi on to foodstuffs or on to a breach of surface.
This fly has a Herpetomonas of its own and a very
distinctive one, in several ways differing from Leish-
mania. Donovan would place this Herpetomonas
of the fly in a different genus, and considers it
has no bearing whatsoever with the Leishmania
of man.
(e) Lice and Ticks.—The head and body-lice have
undergone a trial at Patton’s hands and proved
ineffectual as transmitters. Similarly a large tick,
Ornithodorus savignii, has been put through a like
ordeal of sucking the blood of kala-azar patients
with no positive results.
(f) Fleas and Dogs.—In Europe, especially with
regard to infantile kala-azar, the dog has been
found to harbour Leishmania, and a fairly pre-
sumptive case has been made out as to the part
this animal plays as an intermediary host, the dog-
flea being the actual transmitter. Donovan be-
lieves, however, that the evidence adduced so far
is not in all respects convincing. The occurrence
of a natural flagellate of the flea has evidently
not been taken into sufficient account.
As far as the kala-azar of India is concerned,
dogs examined in Madras have not afforded any
evidence of harbouring Leishmania.
(2) By Oral Infection.—Donovan having discussed
the different kinds of insects that have been sus-
pected of bringing about infection and spread of
the discase, either by biting and so injecting or by
depositing the infective material on the skin, next
passes to the mouth as another channel by which
infection may be possible, Leishmania being in-
gested by food contaminated by exereta or other
substances containing the encysted forms of this
flagellate.
In a fairly large proportion of cases of kala-azar,
the disease begins with symptoms of intestinal in-
volvement, simulating very closely cases of typhoid
fever; the typical pyrexial course, the looseness of
bowels and the gradual descent of the fever by
lysis on about the twentieth or thirtieth day,
presents a picture very like enteric.
After a period of apyrexia for a month or more,
the temperature rises again, disillusionment of the
diagnosis follows and kala-azar is made manifest.
Then, again, in the course of all cases of the
disease, there are periods of diarrhea and dysentery.
In fatal cases evidence of ulceration of the large
intestines is marked and Leishmania are found in
scrapings from these ulcers; involvement of the
intestinal tract lends a certain amount of probability
for suspecting a primal attack of the parasites on
the mucosa of the alimentary system. It is true
no Leishmania have been found in the fæces of
kala-azar patients. Ankylostomes and Trichomo-
nads are frequent in such evacuations; could these
organisms harbour and carry the Leishmania and
thereby bring about infection of the intestinal
Aug. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
255
mucosa? Ankylostomes have been examined by
Christophers, but he could find no trace of Leish-
mania in them. Trichomonads are very commonly
found in infusions of earth; for instance, the earth
containing intestines of white ants are packed with
these flagellates, and again sawdust used in Madras
for storing ice, on occasions, affords a good supply
of these protozoa. Could Leishmania be a com-
mensal in the cytoplasm of Trichomonas ?
' Further research on the subject Donovan believes
is required. '
THE BREEDING PLACES OF PHLE-
BOTOMUS.*
By Professor F. M. HOWLETT.
Imperial Pathological Entomologist.
HowrETT states that the investigation of the
natural breeding-places of sand-flies is by no means
easy, owing to the minute size of the larve and the
faet that their colour harmonizes with that of damp
earth. Repeated attempts were made at Pusa to
discover whether the breeding-places were restricted
to one particular type of locality on which it might
be possible to concentrate the application of
remedial measures. Experience indicates that no
such definite assertions can be made in a district
where the climatie conditions are such as obtain
at Pusa, although it is probable that breeding-
places may be found to be far more narrowly
restricted in such areas as the Punjab, where tem-
peratures are higher and humidity low. A certain
degree of moisture in the soil is essential to the
welfare of the larve, they are never found in really
dry earth, and are killed by a comparatively short
exposure to the dry air of the hot weather. In very
dry areas one should thus expect to find them only
in those places where there is a reasonable amount
of moisture, and the difficulty of finding them would
thus be considerably lessened.
Although the number of larve found has been
small, it is sufficient to show that in Pusa the
necessary conditions are:—
(1) A moderate degree of moisture, roughly
equivalent to that of good garden mould in Eng-
land.
(2) Protection from light.
(8) The presence of nitrogenous refuse; particu-
larly the debris of dead insects, decayed fungi, and
perhaps insect and other excreta. An excess of
nitrogenous matter, however, appears to be dis-
tasteful and unsuitable. No larve have been
hitherto found in latrines, although search has been
made on several occasions.
(4) The presence of brick, stones, tiles, or cement
has been associated with all but one of the breeding-
places seen hitherto; this is probably due to the
fact that these substances are comparatively cool
and often have condensed moisture on the surface,
* Proceedings of the Third Meeting of the General Malaria
Committee, held at Madras, November 18, 19, and 20, 1912.
Simla: Government Central Branch Press, 1913.
while they also act as a protection from the light.
Grassi has found larve in cellars and damp places
where there were bricks, and Marett, in Malta,
only found them in caves and in the crevices of
stone walls, while it has been suggested that they
feed exclusively on the excreta of wood-lice. Ail
these observations fit in with the conditions out-
lined above. The brick-work of wells is indicated
as a promising locality in dry districts, though no
results therefrom have yet been got at Pusa.
Two other points are worth noting. One is the
very frequent association of sand-flies with the
common wall-lizards; the flies bite the lizards
readily, particularly the young and tenderer in-
dividuals, and are often to be seen sitting on or
near a lizard; the latter seem to suffer no annoy-
ance from the bite. It is very possible that the
cracks and crannies in the walls in which lizards
reside during the day are sometimes used by
Phlebotomus as breeding-pluces, and the excreta of
the lizard, consisting as it does of the remains of
digested insects, might provide suitable food for the
larve, though these have not yet been found in
lizards’ haunts. The other point is the possible
utilization as breeding-places of the nests of. ter-
mites. The author has twice observed adult
Phlebotomus in some numbers in the surface-
galleries of these nests, but has had no oppor- .
tunity as yet of pursuing the matter further, as
nest-building termites do not occur in the Pusa
district. Mr. Fletcher writes that he has observed
the same thing while working at termites in Madras,
and since the nests would provide just the right
conditions as regards moisture, darkness, the pre-
sence of nitrogenous refuse, and even the brick-like
walls of the galleries, this line of investigation seems
a promising one.
The following are the localities from which larve
or pupe have been obtained at Pusa :—
(1) The nearly dried mud of cement, channel
leading from a well-reservoir. One larva. August.
(2) A small heap of kitchen refuse near the base
of a wall. One larva. August.
(3) The damp earth between the bricks forming
a small platform for a plant of the sacred Tulsi,
in the courtyard of a house. The bricks were more
or less covered with an algal growth, and among
them were found ants, with larve and nymphs,
wood-lice larve of Mycetophilide, mites and a few
nematode worms, together with the remains of
numbers of dead inseets of various sorts, on which
the larvie were feeding. Four larve and seven
empty pupa cases. October.
(4) Among the bricks and tiles in a small heap
of earth and rubbish. The conditions were similar
to those in the locality just mentioned, the larve
feeding on -fragments of dead insects. The heap
was about a foot high, on a piece of waste land
some thirty yards from a block of houses. Five
lurve, three pupe, and twenty-three empty pupa
cases. The pups were nearly all on the edges of
tiles and bricks; they can be recognized by the
fact that they stand upright, anchored to the sup-
port by the larval skin which remains encasing the-
256
tail-end. The larve (2-3 mm. long) can be recog-
nized by the two or four very long stout bristles
at the tail.
(5) The damp algal muddy leafy stuff taken from
the earthy sides of an open reservoir where water
from several gutters accumulated; the gutters,
which were of cement, led from houses and the
water contained nitrogenous matter. Six adults
emerged. May.
——————
Personal Hotes.
INDIA OFFICE.
From May 17 to August 4.
Arrivals Reported in London.—Colonel P. Hehir, I.M.S.;
Lieutenant-Colonel J. Jackson, I.M.S. ; Lieutenant-Colonel
F. C. Pereira, I.M.S. ; Major T. Hunter, I.M.S.; Captain W.
P. G. Williams, I.M.S.; Captain A. J. Symes, I.M.S. ; Captain
R. D. Saigol, I. M.S. ; Lieutenant-Colonel F. R. Ozzard, I. M.S. ;
Lieutenant-Colonel W. H. Ogilvie, I. M.S. ; Lieutenant-Colonel
R. H. Elliot, I.M.S. ; Lieutenant-Colonel H. S. Wood, I. M.S. ;
Major A. A. Gibbs, I.M.S.; Major W. H. Cox, I.M.S.; Major
G. Hutcheson, I.M.S.; Captain W. C. Ross, I.M.S.; Captain
A. E. J. Lister, I. M.S. ; Captain R. Kelsall, I.M.S. ; Colonel
R. W. S. Lyons, I.M.S,; Lieutenant-Colonel C. N. C. Wim-
berley, I.M 8. ; Lieutenant.Colonel G. F. W. Ewens, I.M.S. ;
Major J. J. Urwin, I.M.S.; Captain G. G. Jolly, I.M.S.; Cap-
tain D. P. Goil, LM.S.; Colonel C. F. Willis, C.B., V.H.,
'LM.S.; Major A. Leventon, I.M.S. ; Major F. N. Windsor,
I.M.S.; Lieutenant-Colonel J. Crimmin, V.C., I.M.S.; Major
W. H. Cox, D.S.0., L.M.S.; Major A. W. Tuke, I.M.S.; Cap-
tain W. S. McGillivray, I.M.S.; Captain W. R. J. Scroggie,
I.M.S.; Captain S. G. S. Haughton, I.M.8. ; Captain H. M.
Inman, I. M.S. ; Captain J. H. Horne, 1.M.8.; Captain R. S.
Kennedy, I.M.S.; Colonel J. Smyth, I.M.S.; Captain A. C.
Ingram, I.M.S. ; Captain M. F. Reany, I.M.S.
Extensions of Leave.—Captain W. A. Mearns, I.M.S., 2 m. ;
Major H. R. Nutt, I.M.S., 1 m. 13d. ; Major G. Y. C. Hunter,
I.M.S., 8 m., M.C.; Captain F. P. Connor, I.M.S., 10 d.;
Major S. R. Christophers, I. M.S., 3 m. ; Major R. F. Standage,
LM.S., 2 m. ; Captain N. N. G. C. McVean, LM.S., 6 m.,
M.C. ; Major J. H. Hugo, I.M.S., 14 d.; Lieutenant V. P.
Norman, I. M.S., to November 11, 1913, M.C. ; Captain C. A.
Gill, I.M.S., 4 d.
List or IwprAN CivinL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CrvinL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Battye, Major W. R., I.M.S., India Foreign, Rajpootana,
7 m., March 31, 1913.
Bird, Lieutenant-Colonel R., C.I.E., M.V.O., I.M.S., B.,
6 m., May 9, 1913.
in Major W. H., D.S.O., I.M.S., Burma, 12 m., April 12,
13.
Elliot, Lieutenant-Colonel R, H., I.M.S., M., 7 m., April 19,
1913.
Ewens, Lieutenant-Colonel G. F, W., I.M.S., Punj., 6 m.,
May 4, 1913.
Goil, Captain D. P., I.M.S., B., 32 m., April 5, 1913.
see Major C. M., I.M.S., Rajpootana, 6 m., March 20,
Green, Lieutenant-Colonel C. R. M., I.M.&., B. Med., 7 m.,
April 17, 1913.
Harris, Colonel G. F. A., C.S.I., I.M.S., B. Med., 7 m. 15 d.,
April 11, 1913.
ae Captain E. C., LM.S., N.P., 23 m. 96 d., April 27,
d Major T., I.M.8., U.P. Med., 9 m. 15 d., April 20,
Hutcheson, Major G., I.M.S., U.P. Med. Dept., 11 m., April
16, 1913,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Aug. 15, 1913.
Ingram, Captain A. C., IL.M.8., M. Med. College.
Jackson, Lieutenant-Colonel J., I. M.S., Bo. Prisons, 14 m.,
April 18, 1913.
Kelsall, Captain R., I.M.S., Burma, 18 m., April 15, 1913.
Leventon, Major A., I.M.S., Assam, 18 m., May 8, 1913.
Lethbridge, Major W., I.M.S., Rajpootana, 23 m. 2 d,
October 13, 1913.
Lindesay, Major V. E. H., I.M.S., Behar and Orissa.
MeConaghy, Captain C. B., I.M.8., India Foreign, Persian
Gulf.
Penny, Lieutenant-Colonel J., I.M.S., Burma.
Perry, Major E. L., I. M.S., Punj., 7 m. 1 d., March 5, 1913.
Pereira, Lieutenant-Colonel F. C., I. M.S., M., 14 d., April
15, 1913.
Reaney, Captain M. F., I.M.S., C.P.
Ross, Captain H., I.M.8., U.P., 24 m., November 20, 1912,
Ross, Captain W. C., I.M.S., B. Med. Dept., 19 m. 21 d.,
April 16, 1913.
Saigol, Captain R. D., I.M.8., Burma, 24 m., February 10,
1913.
Stewart, Lieutenant-Colonel T. W., I.M.S., Burma, 24 m.,
December 14, 1912.
Tuke, Major A. W., I.M.S., Bo., 9 m., May 22, 1913.
Wilkinson, Lieutenant-Colonel E., I.M.S., Punj. Sanitary
Comm., 21 m., February 13, 1913.
Windsor, Major F. N., I.M.S., B., 19 m. 29 d., May 9, 1913.
Wood, Lieutenant-Colonel H. S., I. M.S., B., 33 m., February
18, 1913.
Urwin, Major J. J., I. M.S., Behar and Orissa, 18 m., May 14,
1913.
List oF INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Baines, Major F. E., I.M.S., to November 15, 1913.
Cox, Major W. H., I.M.S.
Crimmin, Lieutenant-Colonel J., V.C., I.M.S.
Eliot, Lieutenant-Colonel R. H., I. M.S.
Gibbs, Major A. A., I.M.S., to December 13, 1913.
Grayfoot, Colonel B. B., I. M.S., to October 30, 1913.
Haughton, Captain S., I.M.S., to March 5, 1914.
Hehir, Colonel P., I. M.S., to October 16, 1918.
Horne, Captain J. H., I.M.S.
Inman, Captain H. M., I. M.S., to February 17, 1914.
Jolly, Captain G. G., I. M.S., to May 8, 1914.
Kennedy, Captain R. S., I.M.S.
Lister, Major A. E. J., I.M.S., to October 1, 1913.
Lukis, Surgeon-General Sir C. P., K.C.S.I., Director-General
I.M.S., to November 12, 1913.
Lyons, Colonel R. W. S., I.M.S., to November 7, 1913.
McGillivray, Captain W. S., I.M.S.
Mearns, Captain W. A., I.M.S., to August 20, 1913.
Ogilvie, Lieutenant-Colonel W. H., I.M.S.
Ozzard, Lieutenant Colonel F. R., I.M.S., to May 9, 1914.
Symes, Captain A. J., I.M.S., to December 2, 1913.
Williams, Captain W. P. G., I.M.S., to December 31, 1913.
Willis, Colonel C. F., C.B., I.M.S., to September 30, 1918.
Wimberley, Lieutenant-Colonel C. N. C., I.M.S., to January
15, 1914.
Rotices to Correspondents,
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proofs will not be submitted to those dwelling outside the United
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8.—To ensure accuracy in printing it is specially requested
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JOURNAL oF TROPICAL MEDICINE AND HYGIENE should com-
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Sept. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 17, Vol. XVI.
Original Communications.
THE METEOROLOGY OF MALARIA.
By Matruew D. O'CoxNELL, M.D.
Colonel R.A. M.C. (Retired).
BELow I give hourly meteorological readings
recorded by the thermograph (Kew) and anemo-
graph (Beckley's) for a continuous period of forty-
Hourly atmospheric conditions at
Calcutta (Alipore)
Temperature of Drying Velocity
air F. power of air of wind
per 10 c. ft. per hour
— —
Calcutta, 1912 Dry Wet Grains Miles
March 9, 6 o'c. a.m. 73:3 715° .- 90 0
» 7 » 73:3 71:5 9:0 0
3s 8 " 75:0 72:2 16:0 0
$5 9 T 781 70:9 30:9 3
A 10 vi 80:3 72:0 41:5 3
»y 11 h 82-9 73:0 50:5 4
pig 12 o'c. noon 84:2 72:0 62-0 4
2i 1 o'c. p.m. 85:9 71:0 14:4 4
-" 2 5 86 9 71:5 78:4 t
a 3 25 86:9 71:0 79:5 4
$5 4 is 88:9 68:5 98:0 7
3» 5 c 87:1 69-0 86:5 5
$a 6 ab 83:2 70:4 62:0 3
as 7 e 79:1 7071 49:2 1
a5 8 we 76:8 70:2 31:4 1
3s 9 i 75:6 70:6 24:6 1
s 10 T 74:4 677 30:2 1
Ah 11 se 73:1 67:0 26:5 0:5
a 12 o'c. midnight 71:6 67:0 20:4 2:5
March 10, 1 o'c. a.m. 70:0 67-6 10:6 2
s 2 ü 69-7 680 78 2
5 3 9 70:8 68:5 11:0 3
$5 4 "T 71:3 68:0 15:2 5
55 5 a 68:7 66:2 11:5 1
35 6 + 67-7 63:8 16:6 2
ay 7 ” 67:4 64:3 13:4 0
b 8 Js 71:5 66:4 22:4 2
jy 9 »" 76:6 62:5 55:9 2
$5 10 85 79:6 63:9 65:2 4
*$ 11 X 82:6 65:2 74:8 4
35 12 o'c. noon 88:9 65:5 80:0 4
$$ 1o'c. p.m 85:4 640 92:0* 2:5
=e 2 $ 86:0 65:4 99:4 2:5
s 3 A 87:9 657 99:4 4
A 4 " 88:8 65:5 102-2 6
? 5 ef 85:4 68:5 79:5 3
$5 6 s 82:0 69:4 59:8 4
3s T » 771 68:8 38:2 2
is 8 » 75:3 68:0 33:2 2
2 9 "T 73:2 66:0 31:9 1
3s 10 as 71:5 65:5 25:5 1
3$ 11 Err: 71:6 66:0 24:4 4
7 12 o'c. midnight 68:7 66:5 10:0 2
March 11, 1 o'c. a.m. 69:1 66:5 12:2 2
ys 2 yx 69:2 66:6 114 4
m 3 " 69*0 66:6 10:6 4
35 4 pA 69-0 67-0 9:0 3
35 5 "a 69:2 67:5 78 3
6 68:9 67:4 6:9 2
eight hours at Calcutta in the season September,
when malaria is prevalent, and, for contrast, similar
readings in the season March, when malaria is not
prevalent. For these readings I am indebted to
Gilbert T. Walker, Esq., C.S.l, F.R.S., the
Director-General of the Meteorological Observa-
tories of the Government of India. In order to
show the effect of such atmospheric conditions on
the body temperature of the inhabitants of Caleutta,
I have placed in line with each hourly reading, as
a standard for comparison, the meteorological con-
ditions which were found by actual observation to
raise body temperature above normal in the humid
cotton-weaving sheds of Lancashire. In each in-
stance I have added the drying power of the air
to indicate the impediment to loss of heat from the
body by evaporation.
To estimate the effect of a warm, or hot, damp
Atmospheric conditions which
raised y temperature in the
Degree to which body tem-
perature was raised by ex-
cotton sheds posure in the cotton sheds
Temperature Drying Movement Body tem- Pulse Respira-
of air F. power ofair of air perature in tions
per 10c. ft. per hour mouth
—
Dry Wet Grains Miles
73:5? 68 24:5 100-0? 90 22
73:5 68:0 24:5 100-0 90 22
75:0 69:5 26:6 100:2 110 18
78:0 73:5 23:0 100-0 100 30
80:0 73:0 36:0 99:2 90 16
83:0 74:0 47:0 99:8 104 21
84:0 77:0 39 0 100°3 84 25
86:0 77:5 49:0 99:2 80 20
87:0 79:0 48:0 100°4 108 24
87:0 79:0 48:0 100:4 108 24
890 76:0 73:0 99:6 98 18
870 79:0 48-0 100:4 108 24
83:0 75:0 43:0 99:3 92 16
79:0 73:5 28:0 100:3 110 24
71:0 73:0 28:0 1001 100 18
75:5 70:5 24:5 - 994 132 22
74:0 70:0 19:0 100-0 98 . 20
73:5 68:0 24:5 E: 100:0 90 22
72:0 65:0 29:0 2 99:6 Not given.
69-0 65:0 17:0 A 100:0 100 26
69:0 650 170 3 100-0 100 26
69-0 65:0 17:0 z 100°0 100 26
72:0 65:0 29-0 ie 99°6 Not given,
69-0 65:0 17:0 '* 99:6 ` Not given.
690 65-0 17:0 * 99:6 Not given.
69-0 65-0 17:0 jo 99:6 Not given.
72:0 65:0 29-0 a 996 Not given.
76:0 72:0 29°0 g 99:4 88 20
79:5 74:5 26:5 9 100°2 90 24
82:0 75:0 38:0 9 99:2 92 16
840 — 770 890 & 100:8 84 — 95
85:5 78:0 44:0 pA 100:1 82 22
86:0 71:5 49:0 99:2 80 20
88:0 T5 61:0 100°2 104 20
88:0 T1:5 61:0 100:2 104 20
85:5 78:0 44:0 100:1 82 22
82:0 75:0 38 0 99:2 92 16
71:0 73:0 20:0 100:1 100 18
75:5 70:5 24:5 99:4 132 22
73:5 68:0 24:5 100:0 90 22
72:0 65:0 29:0 99-6 Not given.
72:0 65:0 29-0 99:6 Not given.
69-0 65:0 17:0 100:0 100 26
69:0 65:0 17:0 100:0 100 26
69:0 65:0 17:0 100:0 100 26
69:0 65:0 170 100°0 100 . 26-
69-0 65:0 17:0 100-0 100 26
69-0 65:0 17:0 .100*0 100 26
69:0 65-0 17:0 100°0 100 26
atmosphere on body temperature, physiologists
regard its wet bulb temperature as the most im-
portant point. In the evidence given before the
Departmental Committee on Humidity and Venti-
lation in the Laneashire Cotton-sheds, Professor
M. S. Pembrey and Dr. Colley, Inspector of Fac-
tories, say: ‘‘All must have their powers of
accommodation taxed when the temperature of the
258
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1913.
wet bulb rises much above 70° F. (21:19 C.);"
and again ‘‘ prolonged exposure to the hot, moist
atmosphere would appear to be more injurious than
exposure to even higher (wet bulb) temperatures
for a shorter time." Sir T. M. Legge, H.M.
Chief Inspector of Factories, says: '' The general
opinion I have formed from the detailed study of
Hourly atmospheric conditions at
Calcutta (Alipore)
of the observations from which he forms the opinion
in which the body temperature was raised above
normal by exposure to a much lower wet bulb
temperature, and at least one observation in which
the body temperature in the mouth rose to 100° F.
(37-8? C.) under an atmospheric wet bulb tempera-
ture of 65? F. (18:3? C.) in less than one hour.
Degree to which body tem-
AM conditions which
perature was raised by ex-
raised body temperature in the
cotton sheds posure in the cotton sheds
fm — aa — ————
Temperature of Drying Velocity of Temperature of Drying Movement Body temperi Pulse Respira-
air, F. power ofair wind per air, F, power ofair ofair per ture in the tion
3t per ten c. ft. hour per ten c. ft. hour mouth, F.
Calcutta, 1912 Dry Wet Grains Miles Dry Wet Grains Miles
September 21, 6 o'c. a.m. 79:99 78:5? 7:9 1 79:5? 745 26:5 100°2° 90 24
5 , Fy 814 800 84 0 A 81:0 74:0 37:0 99-9 190 90
5 B^. 3 88:5 80:4 186 2 83:0 75:0 48:0 99:3 92 16
S: D. T 86:0 80:5 840 6 86:0 _ 77:5 49:0 99:2 80 20
5 10^ ., 87:4 81:5 850 5 87.2 76:0 63:0 100:4 100 20
s 11 s 88:4 811 458 Á5 88:0 80-0 49:0 100-0 108 16
5 12 o'c. noon 90:4 81:8 545 6 90-0 75:0 82:0 99:8 94 A
$ 1 o'c. p.m. 88:9 78:0 644 7 88:0 775 61:0 100-2 104 20
n 2 T: 87:0 175 550 7 B 870 79:0 48.0 100-4 108 (24
5 & 5) 88:5 81:6 49:9 5 88-0 80-0 49:0 100-0 108 16
i 4 res 85°7 79:5 384 8 85:5 78:0 44:0 100-1 82 299
x b. 5 84:5 18:5 360 5 84:5 71:5 41:0 100:3 130 25
Bo. 4 88:4 78:5 988 5 88:0 75:0 48:0 99:8 92 16
" \ - os 81:6 767 2711 8 81:5 75:6 32:5 100-2 112 31
a 8* v 81:6 17-5 236 2 81:5 75:5 82:5 100:2 112 31
£ 9^" 3 81:2 77:5 21:3 2 81:0 75:0 32-0 100-0 112 31
2 10' 4 80:9 71:6 185 1 80:5 73:0 38:5 : 99:6 92 90
” Ho, 79:7 77°6 11:6 1 795 — 7456 265 3 100:2 90 24
5 19 o'c. midnight 80:2 78:0 130 1 80-0 75:0 27-0 "s 99-2 92 98
September 22, 1 o'c. a.m. 80:1 78:0 19:5 15 80:0 75:0 21:0 e 99-2 92 28
js 2 3 79:8 77-9 100 1 C 795 74:5 26:5 g 100:9 90 24
3 B5 455 19:2 71:6 86 1 79:0 — 7855 98:0 & 100:8 10 294
5 4 c 79:2 TI 80 05 79:0 73:5 28:0 H 100:3 110 24
» 5. $ 79:0 77:5 80 0 78:5 73:5 25:0 £ 99:6 116 22
n 6. on» 79:6 71:9 92 0 79-0 78:5 28:0 o 100:8 110 24
” 7 + 811 79:5 9:6 15 81:0 75:0 82:0 a 100-0 119 31
5$ B: £5 82-7 19:6 186 05 82-0 76:0 33:0 E 99-2 88 14
T 9. uw 85:0 19.5 835 2.5 85:0 71:0 45:0 9 1004 190 24
5 10 , 86:6 79:6 49:3 25 865 79:5 42:0 $ 99:2 99 16
» li o5 88:0 781 585 40 88:0 80-0 49:0 g 100:0 108 16
$ 12 o'c. noon 88:8 19:0 596 40 88:0 80:0 49:0 2 100-0 108 16
a lo’c. p.m. 88:9 80-0 558 40 88:0 80:0 49-0 100:0 108 16
» 2 yy 90°1 79:0 658 40 }D 900 75:0 82-0 99:8 94 A
» 8. , 89:5 78:8 513 60 89-0 790 60-0 100-0 108 24
53 £. E 89:8 78:8 664 50 89:0 79:0 60-0 100-0 108 2%
» 5 a» 871 79-7 451 20 87:0 79:0 48:0 100:4 108 24
” 6 o, 846 78:8 352 30 84:5 77-5 40-0 100:8 130 25
E T ves 82-7 17-5 297 50 82-0 76:0 33:0 99-2 88 14
» 8 , 81:6 T5 236 20 81:5 15:5 32:5 100-2 112 31
» 9 —, 80:9 78:2 153 00 80-0 75:0 21:0 99-9 92 28
» 10 ,, 80:4 78:1 134 0*5 80-0 75:0 27:0 99-2 92 98
» ll ,. 80:2 78:0 13:0 00 80:0 75:0 27:0 99:2 99 28
” 12 œc. midnight 80-1 78:1 11:9 0-0 80-0 15:0 27-0 99:2 92 98
September 23, 1 o'c. a.m. 79:6 776 110 00 $E 79:5 74:5 26:5 100:2 90 A
n 2 ,, 79:4 175 104 00 79-0 73:5 28:0 100:3 110 24
» 8 y 79:1 17°3 104 10 79:0 78:5 98:0 100:8 110 24
» 4 y 79:4 77:5 104 10 79:0 13:5 28-0 100:3 110 24
” b yy 79:8 775 98 O05 79:0 73:5 98-0 100:8 110 24
» 6 y 79:2 71:5 9:2 15 19:0 13:5 28-0 100:8 110 24.
Conditions which caus» fever, A, C, E,
33 » do not cause fever, B, D,
the observations. (in the sheds) is that a rise of
mouth temperature makes itself distinctly felt when
the wet bulb (temperature of the air) exceeds
75° F. (23°7 C.)."
I think that in fixing the degree of atmospheric
wet bulb temperature at which body temperature
begins to rise above normal, at 75? F. (28:7? C.),
Sir T. Legge fixes it too high, for there are many
But accepting 75° F. (23°7° C.) as the degree of
atmospheric wet bulb temperature at which body
temperature begins to rise above normal, it is seen
that the September atmosphere at Calcutta, details
of which have previously been given, is such as
must cause pyrexia, as its wet bulb temperature
was above 75° F. (23°7° C.) for the whole period
of forty-eight hours, and even reached a maximum
Sept. 1, 1918.]
of 81°6° F. (2777? C.), but the March atmosphere
at Caleutta is not such as would raise body tem-
perature above normal, for its wet bulb tempera-
ture never rose above 73° F. (22:7? C.) during the
whole period of forty-eight hours, and even fell as
low as 62:5? F. (18? C.).
But in thus concluding that the September
atmosphere at Caleutta must raise the body tem-
perature of many immersed therein we are leaving
out of consideration the rate of movement of the
air which regulates the rate of loss of heat from
the body by conduction and convection, and which
must therefore modify the effect of the high wet
bulb temperature in raising body temperature.
In the details of the September atmosphere at
Caleutta it is seen that the velocity of the wind,
from 8 o'clock a.m. throughout the day until
9 o'clock p.m., varied from 2 to 8 miles per hour;
whilst from 9 o'clock p.m. throughout the night
until 8 o'clock a.m., the velocity of the wind never
exceeded 1:5 miles per hour and fell to 0°5 and
even 0'0 (dead calm) at several hours.
Thus the smaller movement, and at times even
absence of all movement, of the air throughout the
night must, by reducing loss of heat from the body
by conduction and convection, increase the effect
of the high wet bulb temperature in raising body
tem perature above normal; whilst the greater move-
ment of the air throughout the day must, by in-
creasing loss of heat from the body by conduction
and convection, minimize the effect of the high wet
bulb temperature in raising body temperature.
I thus arrive at the conclusion that any fever
caused by the September atmosphere at Calcutta
comes on and inereases gradually throughout the
night until about sunrise, and then, as a rule,
deelines gradually throughout the day, as the
dampness of the air diminishes and the velocity
of the wind inereases.
The recurrence of atmospherie conditions which
so raise body temperature on consecutive nights,
as they did recur on the nights of the 21st to 22nd
and 22nd to 23rd September at Caleutta, must
make any fever so caused of a quotidian inter-
mittent character, whilst if they recur only every
second or every third night the fever must be
respectively intermittent tertian or quartan.
Up to the present I have only considered the
effect of the atmospheric conditions at Caleutta in
September from the point of view of the impedi-
ment which they present to loss of heat from the
body, and from this alone conclude they must raise
body temperature above normal. But it is not
only by impeding loss of heat from the body that
the atmospheric conditions of the September nights
at Calcutta raise body temperature. For the high
atmospherie temperature, 799 F. (26:19 C.) to
83° F. (28:39 C.), impedes excretion of water
through the kidneys, and the low atmospheric dry-
ing power, 8 to 27 gr. per ten cubic feet, impedes
evaporation of water from the skin and lungs. They
therefore produce an accumulation or increase of
water in the blood, for physiologists tell us that the
sweat glands are not stimulated to increased action,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
259
i.e., sweating in resting conditions, until the tem-
perature of the air reaches 91:49 F. (330 C.). The
inerease of water in the blood so produced is, of
course, aggravated by the increased amount of water
taken into the body as drink under such atmospheric
conditions. But increase of water in the blood
increases destructive metabolism or heat production
in the body. The injection of 6 c.c. pure distilled
water into the blood produces a transient rise of
body temperature to 1009 F. (37:89 C.).
Such inerease of water in the blood, and con-
sequent inerease of heat production in the body,
caused by the September night atmosphere at Cal-
cutta subsides slowly during the following day as
the drying power of the air, and consequently
evaporation of water from the skin and lungs, in-
creases. On September 21 at Calcutta the drying
power of the air so increased from 84 gr. per ten
cubic feet at 9 o'clock a.m. to 64:4 gr. at 1 o'clock
p.m. And on September 22 at Calcutta the dry-
ing power of the air so increased from 33:5 gr.
per ten cubic feet at 9 o'clock a.m. to 06:4 gr. at
4 o'clock p.m.
If during the day the temperature of the air
reaches 91:49 F. (389 C.) the accumulation of water
produeed in the blood by the night atmosphere,
would be rapidly reduced by sweating, and with it
would also be reduced the increased metabolism or
heat production caused by it; or if sweating is
induced by drugs or by covering the body with
blankets, the same effect would be rapidly pro-
duced.
Hence it appears that the night atmospheric con-
ditions at Calcutta in September raise the body
temperature of many above normal, cause pyrexia,
by increasing heat production in the body as well
as by impeding heat loss from the body.
Now, if it be asked, of what tissue in the body
an increase of water in the blood produces increased
destructive metabolism the first tissue mentioned
must undoubtedly be the red corpuscles of the
blood. For increase of water in the blood increases
hemolysis, that is, increases the destruction of red
corpuscles, the liberation of their hemoglobin into
the liquor sanguinis, the production of pigment in
the blood, and gives rise to the appearance in the
blood of those bodies which, from their resemblance
to Laveran's bodies, have been called pseudo-
parasites.
Such inereased hemolysis demands an increased
funetional activity of the spleen, for the chief func-
tion of this organ is the disposal of the products or
fragments of such hemolysis. But with increased
functional activity of the organ there must be en-
largement, at first like the increased hemolysis,
of an intermittent character, but subsequently from
repeated recurrence becoming permanent.
Is there then at Calcutta in September, and at
other places having a similar or nearly similar
climate, an intermittent fever, an ague, which is
obviously caused by the meteorological environ-
ment under which it arises? So it was believed,
and, although, perhaps, in a rather vague and in-
definite way, taught in the medical schools of the
- 260
THE. JOURNAL.OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1913.
world for centuries. But in the medical schools of
to-day such a view of malaria, if mentioned at all,
is only referred to as a curious ancient superstition !
In this paper I have adopted, as many physio-
logists do, the wet bulb temperature of the air as
an indication of the effect on body temperature of
atmospheric conditions, but I prefer taking
separately, as I have done in previous papers on
this subject, the dry bulb temperature, the drying
power, and the rate of movement of the air for such
purpose, for by these are regulated the rate at which
heat is being lost from the body by radiation, by
evaporation, and by conduction and convection.
The advantage of regarding malaria from this
meteorological point of view is that by so doing we
avoid the necessity of presuming the existence of a
toxin, which has never been isolated, in order to
explain the intermittent pyrexia, hemolysis, and
enlargement of the spleen which are so characteris-
tic of the disease.
A CASE OF ACUTE AGCHYLOSTOMIASIS
TREATED BY AN AUTOGENOUS VAC-
CINE OF A COLIFORM ORGANISM.
By Captain R. G. AncHIBALD, M.B., R.A.M.C.
Pathologist and Assistant Bacteriologist, Wellcome Tropical
Research Laboratories, Khartoum.
THE patient was an Arab admitted to the Khar-
toum Prison Hospital suffering from fever and
marked anemia.
Previous History.—Up till six months ago he
had always enjoyed good health, but since then
he had been subjeet to febrile attacks. For about
a month previous to admission he had apparently
suffered from continuous fever and increasing weak-
ness and had acquired the habit of geophagy.
Condition on Admission.—The patient was ex-
tremely thin, weak and ansmie, and complained
of headache, anorexia, vertigo and constipation.
The tongue was furred, and his general appearance
resembled that of a serious toxemia. The pyrexia
was of a remittent type, showing an evening rise
of 29 or 3° and a morning fall.
There was no evidence of tuberculosis. The
spleen was very much enlarged, firm in consist-
ence, and extended to.a point about an inch above
the umbilicus. The liver also showed some
enlargement below the costal margin.
Several peripheral blood films were examined,
but with negative results as regards the presence
of malarial or other parasites. There was a very
definite eosinophilia present. "The red cells showed
a marked poikilocytosis, and both microcytes and
megalocytes were noted. Myelocytes and erythro-
blasts were not found. The eosinophilia suggested
the possibility of an intestinal parasitic condition.
A purge was therefore administered to the patient,
and a sample of the fæces obtained for examination.
The fæces were very offensive and alcoholic, and
-gontained large numbers of adult agchylostome
worms and their ova. Eucalyptus oil combined with
chloroform was administered in large doses, but
with little or no benefit, for the patient became pro-
gressively weak, and to all appearances a fatal issue
seemed imminent. Having previously obtained
encouraging results by the use of an autogenous
coliform vaccine in a case of acute intestinal
schistosomiasis, the writer suggested that this line
of treatment might be employed.
Another specimen of the feces was obtained and
suitably plated out. Almost a pure culture of a
coliform organism was obtained, and its cultural
characters worked out (see p. 262). A vaccine
of the organism was prepared. The patient re-
ceived an injection of 500 million organisms,
followed five days later by an injection of 1,000
million, and this amount was subsequently repeated
at the end of a week. The result obtained was
striking. There was an immediate improvement
following the first injection of the vaccine. The
tongue became clean, and all the toxsmie signs
disappeared. After the third injection the patient's
temperature remained consistently lower, but, as
will be seen from the charts, each injection of the
vaccine was followed by a temporary rise in the
patient's temperature. The spleen and liver
diminished in size and the patient commenced to
put on weight rapidly, and was shortly afterwards
discharged from hospital.
Remarks.—Certain points in the above recorded
case appear to be worthy of comment. The patient
represented one of those serious toxic types of
cases that apparently would have ended fatally but
for the timely employment of vaccine therapy. In
admitting this the writer does so without reserve,
for although cognizant of the fact that certain cases
of intestinal parasitic infection frequently show an
amelioration of their symptoms, it would be diffi-
cult in this instance to attribute the striking and
immediate improvement in the patient’s condition
to anything but the use of the vaccine. To all
appearances the serious state of the patient was in
a chief measure due to the absorption not so much
of the toxins of the causal helminth, but to the
toxic products of intestinal organisms, and it was
based on this hypothesis that vaccine therapy was
suggested and employed. The effect of the vac-
cine treatment on the enlarged liver and spleen
certainly appeared to support this hypothesis, for
no enlargement of either of these organs could be
detected by the time the patient left the hospital.
During the last few months the writer has had
opportunities of studying clinical cases of intestinal
schistosomiasis, and from observations made has
come to the conclusion that the clinical picture of
some of the acute toxie types of these cases is
dependent on an absorption of toxins of certain
intestinal bacteria. These toxins, apparently owing
to the reduced state of health of the patient, give
rise to grave symptoms. In two such cases vaccine
therapy was employed, and with most encouraging
results. Our present knowledge of the part
played by the Agchylostoma duodenale in producing
certain symptoms seen in agchylostomiasis is far
from satisfactory, and, in the writer's opinion, the
Sept. 1, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.:
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MOTIONS] | | 1 | !
causal helminth is possibly credited with more than
its due share. One knows that in a certain class of
these cases the signs and symptomatology are out
of all proportion to the number of worms found in
the host, a fact suggestive of the presence of an
additional toxic agent in the intestinal tract. What
is the nature and source of this toxie substance
remains yet to be proved. Little is known of the
chemistry of the toxins of intestinal bacteria ;
indeed, the subject has not received the attention
it deserved, considering the important part played
by the alimentary tract in health and disease, and
in the writer's opinion some far-reaching results
might be obtained in the treatment of some cases
of agchylostomiasis and intestinal schistosomiasis
were evidence forthcoming regarding the significance
of certain intestinal organisms found in patients
affected with these diseases. Castellani [1], in his
researches, noted the presence of different types of
fever in agchylostomiasis, a clinieal fact difficult
of explanation if the worm is to be considered the
sole agent for the pyrexia. Further, in some cases
the pyrexia continues long after the patient has got
rid of the agchylostome under adequate treatment.
Padoa [2] and others found that the processes of
intestinal putrefaction were very marked in this
disease, in which case it is more than likely that
the resultant toxins must necessarily affect the
health of the patient.
There appears, therefore, a certain amount of
ground for the supposition that other factors, pro-
bably intestinal bacteria, are partly responsible for
the clinical picture sometimes observed in agchylos-
tomiasis and intestinal schistosomiasis, and it is
for such cases that the writer puts in a plea for
the trial of vaccine therapy as a means of tiding
the patient over a toxemia. If this treatment be
followed by, or combined with, the specific anthel-
mintic remedies some good might be done for a
class of case that usually terminates fatally. The
toxic properties of many of these anthelmintic drugs
are well known, and if exhibited to such a case as
described in this paper may have anything but a
beneficial effect; if, however, the patient’s general
condition can be improved and the ‘‘ toxiemie tide °’
lessened by previous vaccine treatment his chances
of reacting to anthelmintic measures are increased.
The writer recently examined the case forming
the subject of this paper and found him in appar-
ently good health and carrying out manual labour.
A specimen of his feces was obtained and agchylo-
stome ova were still found to be present.
The organism isolated from the patient's feces
and from which a vaecine was prepared possessed
the following characters: It was a sluggish, motile,
Gram-negative, non-spore-forming indole-producing
bacillus which gave the following, cultural re-
actions : —
(Sept. 1, 1913.
Business Motices.
1.—The address of the JOURNAL OF TROPICAL MEDICINE AND
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262 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Glucose + Mannite +
Levulose + Dulcite +
Maltose + Adonite -
Galactose + Dextrine —
Raffinose - Inulin ... x eR - Great Titchfield Street, London, W.
Lactose + Litmus milk acid, no clot
Saccharose — Voges-Proskamer reaction Editors.
negative
+ = Acid and gas. — = Nochange.
Conclusions.—Briefly summarized the chief points
referred to in this paper were as follows :—
(1) In certain cases of severe and intractable
agchylostomiasis, the symptoms present may ap-
parently be dependent on an absorption of certain
intestinal organisms and their toxins.
(2) In such cases beneficial results may be
obtained by the employment of autogenous vaccines
of the suspected intestinal organism, combined with
or followed by specific anthelmintic measures.
Thanks are due to Dr. Mashowef, of the Sudan
Medical Department, for the clinical notes and
facilities given in the examination and treatment
of the case.
REFERENCES.
1l. CASTELLANI, A. (December, 1912). ‘Discussion on
Ankylostomiasis in British Guiana and Methods of Treatment.”
Transactions of the Society of Tropical Medicine and Hygiene.
2. Papoa (1909). ‘‘ Rivista critica di clinica Medica.”
Se
Pathological Changes in Pellagra and the Produc-
tion of the Disease in Lower Animals. — Lucius
Nicholls, in the Journal of Hygiene for July, 1913,
describes the pathological changes found in man in
pellagra. He bases his description on eight post-
mortems and microscopical sections of specimens taken
from these subjects.
The pathological changes which take place in
pellagra, he says, are to a great extent due to de-
generation of the capillaries and smaller vessels; this -
gives rise to stenosis and blood stasis which cause
leakage or actual hemorrhages from the weakened
vessels. This explains the atrophy of the tissues by
impaired nutrition, and the eruption on the exposed
skin surfaces where solar radiations and possibly other
factors accentuate the damage which has taken place
in the vascular supply with consequent exfoliation of
the stratum corneum, bleb formation from exuding
serum, and pigmentation from altered hemoglobin.
The tissue cells, especially those of the liver, spleen,
and alimentary tract, are also attacked.
The author believes he has produced a condition
similar to pellagra in rats by feeding them upon
decomposed corn meal. He describes the symptoms
in the rats and also the post-mortem appearances.
It is doubtful, of course, if the condition can be
looked upon as the same as human pellagra.
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THE JOURNAL OF
Tropical Medicine and Hypgtene
SEPTEMBER 1, 1913.
BRITISH MEDICAL ASSOCIATION.
DISCUSSION ON THE CAUSES OF INVALIDING IN THE
TROPICS.
(Continued from p. 250.)
Dr. C. F. Harrorp (Livingstone College) pointed
out that there was a special difference between the
military and missionary statisties, the latter includ-
ing women as well as men. Both classes, however,
may be regarded as selected lives.
(1) Bowel Disorders.—These he regarded as
directly or indirectly the most important cause of
invaliding, and, apart from severe nerve troubles,
the most serious.
Enteric Fever undoubtedly has been the most
serious cause, but with the employment of anti-
typhoid inoculation it is lessened.
Sprue is again a common and serious cause of
invaliding.
Colitis has proved to be very persistent, and often
difficult to deal with.
Intestinal parasites are probably more commonly
associated with intestinal disorders than is generally
recognized.
Bowel disorders seem to be most prevalent in
China and India.
Sept. 1, 1913.]
(2) Nervous disorders, he thought, were in many
cases the result of fevers and bowel disorders, but
he was of opinion that there were special climatic
causes.
(3) Fevers.—These seemed to be the most com-
mon cause of invaliding in Central Africa, and he
would place first in importance blackwater fever,
and second, especially in Uganda, tick fever.
Malta fever also had to be reckoned with.
(4) Women’s Diseases.—He had noted a special
prevalence of fibroid tumours in China and Japan.
Troubles connected with the climacteric also have
to be remembered especially neurasthenie in
character.
(5) Arthritic troubles of a serious character he
had noted, especially in cases from the Punjab, but
he did not desire to lay stress on this.
(6) Tubercular cases, he thought, were chiefly due
to infection.
Dr. Harford stated, in reply to Sir William
Leishman's question as to the return to the Tropics
of those who have suffered from blackwater fever,
that he thought each case should be treated on its
merits.
He did not believe in any arbitrary rules. Pro-
fessor Koch advised that if a man had black-
water fever he should as soon as possible after
start taking small doses of quinine until he got
back to the regular prophylactic dose, and that if
he continued this he might continue to reside in
the country where he had contracted the disease.
This he believed to be good advice. If the indivi-
dual had an exceptionally severe attack with
cerebral symptoms or any tendency to suppression
of urine, then he should not return. If, however,
the attacks were not exceptionally dangerous, and
the patient could and would take quinine prophy-
lactically, then he might return.
Dr. Duncan WnirE (China) said that for the
purpose of guarding the lives of Europeans in South
China—where tuberculosis is so rife amongst the
natives—it is desirable that the household servants
should be carefully examined. One’s bed should
not be made and one's food should not be prepared
by servants who are expectorating tubercle bacilli.
Major W. S. Harrison, R.A.M.C., said: During
recent years there has been a very great reduction
in the total numbers sent home from the Army in
India on account of tropical disease. Part of this
reduction is due to a general improvement in the
health of the Army, part of it to more effective
treatment, and a part to the more extended use of
hill stations. With regard to enteric fever, we
formerly sent home from 3°6 per cent. to 6 per cent.
of those admitted, and 0'4 per cent. were finally
discharged. We now send home 1'7 per cent. of
the patients, and 1:3 per cent. are finally discharged.
For dysentery we used to send home 4 to 5 per cent.
of those admitted; now we send 1:5 per cent., and
at the same time we have reduced the numbers of
those finally discharged from about 4 per cent. of
admissions to less than a tenth per cent. Malarial
cases used to be sent home at a rate of approxi-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
‘in the Tropics apart from any disease.
263
mately 1 per cent. of cases; now we send home 0'1
per cent. These improvements have been accom-
panied by a reduction in the case mortality of
typhoid fever from 22 per cent. to 18 per cent., and
of malaria from 0'2 per cent. to 0'09 per cent.,
while the case mortality of dysentery has remained
stationary at about 3 per cent.
Neurasthenie conditions and the sequele of heat
stroke always call for a return home. I have been
particularly struck with the high proportion of
neurasthenics among officers, either primary in
origin or following such things as chronic bowel
disease.
Sir WILLIAM LkisHMAN, the President, said that
it was important to consider the advice to give to
those invalided from the Tropics in respect of their
return thereto. In his opinion tropical physicians
had fewer graver decisions to make than in many
of these cases, where a man's whole career might
depend on whether he was advised that he should
never return to the country from which he had
been invalided. In some cases he thought such
advice was hardly justifiable on our present know-
ledge, and he was familiar, as many others must
be, with instances in which the advice, by stress of
circumstances, had been disregarded, and the indivi-
dual had nevertheless returned to his station and
enjoyed good health for many years. On the points
raised by Dr. Price in connection with the pro-
phylactic use of anti-typhoid vaccine, he might
answer in the light of his experience with this
vaccine in the Army. The advantages of employ-
ing a local strain of B. typhosus for the prepara-
tion of a vaccine appeared to him purely theoretical,
and he had no evidence in support of this proving
a useful modification. Reinoculation, in his opinion,
should be carried out after a lapse of two and not
of three years.
Dr. MarnconLM Watson (Malay States) con-
sidered that women suffer more than men from life
Neuras-
thenia is the chief trouble, and a yearly change for
a month to a hill station frequently prevented the
condition. Neurasthenia in men is frequently asso-
ciated with loss of weight; the stout, well-fed man
is seldom neurasthenic. The return of invalids to
the Tropics should depend largely upon the disease
and upon the region to be lived in. A man who
has had blackwater fever should avoid if possible
a highly malarial district. Dr. Watson believed in
the preventive value of small doses of quinine.
Dr. Cameron Buarr (Nigeria) thought that the
fact that officers suffer more than private soldiers
from neurasthenia is due to the more solitary life
the officer leads, especially in out-of-the-way dis-
tricts, where there may be but one or two officers
in charge of a company. Cardiae dilatation he
considered to be due to the hard work entailed,
sitting up during half the night it may be, writing
out reports after the strenuous work of the day.
An attack of malarial fever demands a three months’
course of quinine. After recovery from blackwater
fever, provided the heart is sound and the urine
264
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1913.
free of any trace of disease, a man may safely return
to the Tropics.
SPRUE.
Mr. James CaNTLIE (London) brought forward
several points concerning sprue which he said
he was surprised to find did not seem to be gener-
ally recognized.
(1) Temperature in sprue: A continued fever
coming on in chronic sprue cases generally marked
the last stage of the disease. As a rule, the patient
lives from five to eight weeks after persistent high
temperature of 1009 to 1029 F. In one case
recently, however, the febrile state had lasted four
months before the fatal issue. He had never seen
a case of sprue recover in which this condition
obtained. It would appear as if a toxin had
developed which the tissues were incapable of
keeping in check.
(2) Neuralgia of the anus is a late development
in sprue, but a very troublesome condition, and met
with only in cases which are near—a few weeks
from—the end. Often in sprue there is an itch-
ing of the anus, with some dryness and discomfort,
but this is quite different from the acute suffering
which Mr. Cantlie styled neuralgia. At times this
is accompanied by excoriation, crack or ulcer at
the anus, but more often there is no lesion to be
seen or felt.
(3) A general tetany is recorded by Mr. Cantlie in
six cases of sprue observed by him within the past
eighteen months. It is a condition which he has
not noted previously, and at first he was inclined
to think the tetanic spasms were due to the medi-
cinal treatment in use. This, however, was proved
not to be the case. The tetany is characterized by
acutely painful spasm of the muscles, not only of
the extremities, but in the neck, face, chest and
abdomen. The fingers are pressed firmly against
the thumb or doubled up in the palm, and it is
impossible for either patient or doctor to separate
them. The temperature may rise to 1089 F. or
more, or it may be only a fraction above the normal.
The attack, when severe, may last one to two or
three days, gradually subsiding. Mr. Cantlie stated
that the condition comes only in very anemic
persons and those who had suffered from sprue for
years.
Treatment.
As regards treatment, Mr. Cantlie says he has
lately used Collosol argentum (Crookes); a solution
containing the metal silver in a colloid state. This
Is a preparation by Professor Crookes of silver in
which the actual particles are of extreme minute-
ness and exhibit, under ultra-mieroscopie conditions
only, marked ‘‘ Brownian " movement. Bacterio-
logical tests show that the B. coli communis is killed
in ten seconds, and no microbe is known that is not
killed in laboratory experiments in six minutes.
Castellani's recent findings in sprue suggest the use
of a bactericide and an antiseptic, and Mr. Cantlie
has used the preparation with some degree of
success. Being non-toxic, the dose can be increase:
from 1 to 2 or more drachms twice or thrice daily.
In several cases of sprue Mr. Cantlie finds that in
from 76 to 118 hours stools lose their frothiness and
their bulk, and a fairly solid motion can be anti-
cipated showing the presence of bile. This he has
found even in the last stages of sprue when the
temperature was over 101° F., and anticipated
death actually occurred.
As regards diet, Mr. Cantlie adheres to the meat
treatment of sprue, and when recurrences occur
and persist he advocates for three days nothing but
milk, three days nothing except meat, and three
days a strict farinaceous diet; but no mixture of
these on any account. Strawberries continue to
hold their position as a curative agent. When the
short strawberry season is over, ripe gooseberries
(not in pies) in quantity, or raspberries or melons
do almost if not quite as well. As a medicine,
powdered cuttlefish bone and native carbonate of
soda is a remedy which has stood the test of some
thirty years, and retains its position.
Major W. S. Harrison said he had seen one case
of sprue with marked tetany. With regard to the
sore mouth, he had noticed that when a patient gets
an intercurrent attack of acute diarrhea the mouth
symptoms improve when the stools get more into
the chracteristic sprue condition, and especially
when they become solid the mouth symptoms recur.
Thursday, July 24, 1913.
Discussion oN DysENTERY.
Carrain S. R. Doucras, 1.M.S., introduced the
subject by a paper entitled *' The Life History of
the Amæba causing Dysentery." He reviewed the
work of Schaudinn in establishing the Entamaba
histolytica, and of Viereck’s finding of the E.
tetragena. Schaudinn’s researches concerning the
life-cycle of E. histolytica are now doubted as re-
gards the exogenous cycle, and Viereck’s is con-
sidered the true life history. Darling’s experiments
with kittens by feeding them on mucus from dysen-
teric stools containing cysts of E. tetragena con-
stantly produced signs and symptoms of dysentery
in these animals; if no cysts were present no
infection resulted.
Virulent entamebe have never been grown on
artificial media. Ameebic dysentery is usually con-
sidered a tropical ailment, but several cases of the
kind have been recorded from France, Germany,
and Britain.
Complications less commonly met with are:
Abscess of the brain in which the amcebe have been
found; phagedenic ulceration of the skin in which
amæbæ are present.
Treatment.—Emetine, introduced by Vedder and
used extensively by Rogers, has proved successful
when administered subcutaneously; the symptoms
of dysentery rapidly disappear, hepatitis resolves,
and when an abscess of the liver supervenes injec-
tion of emetine, combined with simple aspiration,
has proved successful.
It would seem that the use of emetine in
dysentery is not new to therapeutics, for in 1817
Sept. 1, 1913.]
Magendie and Pellitier recommended its use, and
L. Bardsley, in 1829, obtained good results in
dysentery and chronie diarrhea. That this very
effectual remedy passed from the ken of medicine
was most probably due to the fact that the differ-
ences between ameebic and bacillary dysentery were
not diagnosed; but with Vedder's scientific experi-
ments proving that emetine kills the amebe, and
Rogers’s practical application of the knowledge thus
gained we are in a position to regard amoebie
dysentery and its complieations with much less
dread than heretofore.
F. GRAHAM WiLLMoRE and A. HAROLD SAVAGE
(Egypt) contributed a paper entitled ‘‘ The Dia-
gnosis and Treatment of Epidemic Bacillary Dysen-
tery." After alluding to the prevalence of dysen-
tery amongst Mecca pilgrims, to the frequency of
epidemies in even temperate zones, to the preva-
lence of dysentery in war, and to the persistent and
fatal nature of epidemies of dysentery, the authors
proceeded to give the results of treatment of 227
eases of bacillary dysentery. Accepting the present
division of dysentery into amoebie, bacillary, and
mixed forms, the authors discussed the diagnosis
of bacillary dysentery by the isolation of the specific
germ or germs from the stools and by the agglutina-
tion reactions of the patient’s serum against them
and against stock cultures.
It seems sufficient to prove by one or other of
these tests singly the nature of the malady, i.e., to
say that a bacillary dysentery is present. A positive
diagnosis is most readily arrived at by one of the
serological tests, especially the agglutination re-
action of patient’s serum, and it has been the
authors’ practice recently to test the serum of every
patient against four types of bacilli in dilutions of
1:20, 1:40. With the lower type the agglutination
is usually multiple, and an attempt to overcome
this proved unsuccessful. If, then, a bacillus is
isolated from the stools, or if a positive agglutina-
tion reaction is obtained for one or more bacilli, the
authors consider bacillary infection is present.
The number of dysenteric patients who succumbed
to nephritis caused some anxiety as to whether the
massive doses of serum were the cause of this
fatality; but this was refuted on further investiga-
tion and was proved to be due to the rapid elimina-
tion of the serum administered.
The clinical routine was as follows :—
Immediately on entering the hospital the patient
was given a dose of castor and almond oils, and a
few cubie centimetres of blood were taken aseptically
from the median basilic vein. The stools were
examined microscopically and plated out. If
amcebe were found to be present, emetine was at
once given. (This last remark applies only to 1912-
13.) According to the data furnished by the blood
reactions and the stool plates, appropriate serum
was administered. In 1911 multivalent and dif-
ferent monovalent serums were used; in 1912-138
multivalent serum only was employed, with the
exception of a few doses of monovalent Shiga serum
in eases where B. shiga was isolated from the stools.
In urgent cases, stimulants were given and treat-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
265
ment with multivalent serum and emetine was
initiated immediately after the blood was taken
without waiting for the results of the laboratory
examination. With regard to the quantity of serum
to be injected, later experience tends to confirm the
opinion that the best results are obtained from the
administration of very large doses—from 80 to
120 c.c.—injected either deeply into the subcu-
taneous tissues of the flank and abdomen or intra-
venously ; this procedure is entirely without danger.
Moreover, anaphylaxis is less likely to occur after
a massive initial, followed by decreasing repeat
doses, than it is after a small initial dose. Secondly,
the cases treated arrived at the hospital saturated
with dysentery toxins, which had to be neutralized
before the beneficial effect of rest and appropriate
diet could be brought into play. In 1913 a com-
paratively small quantity of the multivalent serum
was used, supplied by the Lister Institute, which
is recommended to be given in doses of 20 c.c.
Without entering into any discussion as to the rela-
tive potency of the Lister serum and the authors',
trials of this serum in the dose recommended by
the Lister Institute, and the dose which he habi-
tually employed himself, the results led to absolutely
parallel conclusions and furnished no less striking
a plea in favour of the massive dose. These doses
are repeated twice daily or at longer intervals, as
the patient's condition demands, during not longer
than ten days after the first dose. It was often
noted that the patient exhibited marked improve-
ment for a few hours following the injection, only
to relapse when the effect had presumably worn off.
Such cases should be injected repeatedly until the
improvement becomes permanent.
In such a case, it may be noticed, that whereas
at first injections may be necessary every few
hours, later injections may be only required at
intervals of some days. Another advantage, which
in our opinion accrues to this method, is that
among patients who have thus been thoroughly
saturated with the serum relapses when conva-
lescence has once definitely set in are practically
unknown; at least, we cannot call to mind any
such failure. "This point is of considerable import-
ance as regards carriers. Dr. Warnock, the Direc-
tor of the Government Hospital for the Insane at
Abbassia, in a private letter to one of us (F. G. W.),
states that in asylum epidemies in England prac-
tically all ‘‘ cured ” cases later relapse and become
carriers. This seems to be his experience also at
Abbassia, where cases of dysentery are continually
occurring and are treated with, at the most, one. or
two injections of 30 c.c. of multivalent serum. In
mild and especially early acute cases, 40 to 60 c.c.
were sufficient, unfortunately such cases at Tor are
very rare. The first and most appreciable result
of an injection is an improvement in the patient's
general constitutional condition, which becomes
apparent in a few hours. One or two cases im-
proved so rapidly that, from being apparently mori-
bund on admission, they were able within a few
hours to enjoy with impunity a meal, the bounds
to which were set by the dietates of prudence rather
266
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept: 1, 1913.
than by the appetite of the patient. The improve-
ment in the character of the stools takes place
much later, and in the chronic and gangrenous cases
may not be apparent for many days. The physician
should not be discouraged in this event, and
especially should not discontinue the treatment
with the idea that it is doing no good. It should
be remembered, as numerous autopsies’ in pre-
serum days at Tor only too clearly showed, that in
these cases the entire mucosa of the large gut and
often some 8 ft. of the lower end of the ileum may
be the seat of a coagulation necrosis, which has
destroyed the superficial layers and replaced them
with a bright green or blackish green diphtheritic
false membrane. This dead tissue must be got
rid of; as in diphtheria the injection of serum is
followed by an improvement in the patient's con-
dition and expulsion of the membrane by coughing,
so in bacillary dysentery the passage of sloughs is
not incompatible with a critical amelioration of the
disease.
Death, when it occurs, is due to poisoning by the
absorption of toxins secreted by the bacillus, and
never to the local effects of the latter. In contrast
to the destruction of tissue seen in amæbic dysen-
tery, in the bacillary variety ulceration is always
comparatively superficial, and never gives rise to
perforation and peritonitis, or to liver abscess.
For the above reasons the strict limitation of diet
necessary in amoebic dysentery is inadvisable, while
particular attention should be paid to the heart,
lungs, and kidneys.
Prophylaxis consists in free administrations of
serum and stimulants, discouraging a dorsal de-
cubitus and the most scrupulous attention to secur-
ing an aseptic condition of the mouth. Once
broncho-pneumonia is well established, no treatment
seems to have the least effect in averting a fatal
issue—it is mere waste to inject serum.
It occasionally happens, after the patients have
recovered under serum treatment from all imme-
diate danger, that convalescence is retarded by an
intermittent diarrheea—with or without mucus and
muco-pus—which serum appears to be unable com-
pletely and permanently to control.
If such a ease come to autopsy, be it for dysen-
tery or intercurrent disease, the large intestine is
often found entirely denuded of its mucosa and
of a bright red colour, showing where the false
membrane above mentioned has sloughed away,
leaving what is practically a large granulating
wound, on which are small patches showing all
stuges of the morbid process. The condition is very
similar to that seen in large superficial burns of the
skin. It is obvious that this surface not only is
functionless, but is in any case extremely irritable
and an excellent door for the entrance of secondary
infecting bacteria. No one in his senses would
expect a granulating wound of the skin of such
superficies to heal up in a few days, even though
it be kept comparatively aseptic. How then can
a similar wound in the intestine, continually bathed
in septic material, be expected to heal more
rapidly ?
Treatment in these cases must aim, obviously, at
supporting the patient’s strength, securing as
aseptic a condition as possible of the intestinal
contents and giving the inflamed bowel as much
rest as possible. As regards treatment by medical
means, it may be laid down as an axiom that the
fewer drugs that are given the better. It is con-
ceivable that this class of case would offer a fair
field for vaccine therapy; and in fact we tried it
in 1910 with apparent success; our experience was
limited, however, to one or two very obstinate cases,
convalescing from gangrenous bacillary dysentery
(B. tor isolated), one of whom ultimately recovered
completely—we did not give it a more extended
trial as our multivalent serum was on probation
and we did not wish to obscure the main issue by
introducing elements of polytherapy. Reliance, at
present, must be placed, therefore, essentially on
an appropriate dietary, which should be appetizing
and combine a maximum of concentrated, easily
digested nourishment with a minimum of residue;
milk fulfils none of these desiderata—it is bulky,
most patients loathe it after a certain time, it
leaves a hard massive residue of undigested casein.
Citrated milk is, in our experience, little better,
whilst most of our patients flatly refused to take it.
Yaghürt,* on the other hand, was always taken with
the greatest avidity, being in one form or another
the staple diet of many Oriental peoples; while
examination of the stools showed it not to be com-
pletely digested, it had an undoubted effect in
arresting the putrefaction of the intestinal contents,
and never gave rise to the meteorism and colies
which were so often seen in the days of the plain
milk diet. The Yaghürt may be supplemented in
severe cases with albumen water, expressed raw
meat juice and lean raw meat pulp, given in warm
—not hot—soup or beef tea. Later thick purées
of potatoes, peas or lentils, well-strained gruel and
porridge, lightly cooked chicken and fish— prefer-
ably made into a cream with potato purée—light
omelettes, soft white cheese, &c., may be added
to the dietary; sugar should be given freely and is
conveniently administered in the form of malted
milk (Horlick). Feeds should be given often and
only a small quantity allowed at a time; nothing
very hot or very cold should be allowed. Stimulants
should be given freely when their use is absolutely
indicated, but alcohol in any form is to be avoided
as much as possible. As far as local treatment is
concerned, lavage with any solution stronger than
physiological saline or linseed tea is, in our opinion,
* (Yaghürt must be prepared with the greatest care; it has
been our practice to buy in Suez at the commencement of the
pilgrimage season several samples of Leban Zibad and to
inoculate them into sterilized milk—that which gave the softest
and most homogeneous curd was then plated out on Maconkey
or lactose cochineal agar and pure cultures obtained of a large
lactic acid-producing bacillus and a long streptococcus (? S.
lebensis). These were then inoculated into sterilized milk
(* Natura" brand), (the Australian condensed milk is un-
suitable), and each batch of Yaghürt, prepared in covered
sterilized jars in an incubator a5 37°C., was inoculated with
a flamed spoon from the preceding one. The curdled milk
prepared from the various so-called lactic acid tablets on the
market should, in our opinion, never be used.]
Sept. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
267
to be condemned. We particularly dislike the
much-vaunted injections of silver nitrate. In any
case, we use lavage, as a rule, only in cases of
post-dysenteric constipation.
REFERENCES.
[1] Hrrscu: ‘‘ Historical and Geographical Pathology.”
[2] RurrER and WinLMwonE: British Medical Journal,
November 12, 1910.
[3] CrENDIROPOULO: Archives de Med. Experimentale, Tome
xxxiv, No. 6, November, 1912.
[4j NEaRE et Raynaup: Compt. rend. de la Soc. de Biologie,
Séance du 18 Mai, 1912.
[5] Rurrer and WILLMORE:
September 25, 1909.
[6] S. Gryauewicz: Ann. de l Inst. Pasteur, xxvi.
[7] VarnraRD and DoprER: Ann. de l Inst. Pasteur, xxi.
British Medical Journal,
Dr. C. M. Wenyon, Protozoologist, London
School of Tropical Medicine, read a paper on
‘ Some Remarks on the Morphology of the Intes-
tinal Amoebe in Man.” He said (1) that the clear
separation of the various amæbæ or entamcebe from
one another is most difficult, and until some satis-
factory method of cultivating them has been dis-
covered the diffieulty will remain. For just as it
is possible by altering the quality of the water in
which fresh-water amæbæ live to produce changes
in the individual amcebe, so the eutamæbæ in the
intestine will vary with the changes in the quality
of the contents of the bowel, and it is the non-
recognition of this fact that has led to the multi-
plieation of so-called species of this protozoon.
(2) An unwarranted assumption exists that
entamcebe should be uniform in appearance at
every stage of its existence; this is disputed by
Darling, who has shown that the pathogenic
entamcbe of man passes through a life-cycle in
which entire multiplication alternates with a stage
of encystment and the entamcebe assume quite a
different appearance as these stages develop. (8)
Many of the entamoebs escaping with the stools
are in a condition of degeneration or actually dead,
and the appearance of these has caused several
observers to fall into error in the belief that they
were dealing with separate species or varieties.
Two fairly well-defined types of entamobs are
known. One is the pathogenic entamceba known
variously as E. histolytica, E. tetragena, &c. In a
definite type of this variety there is a clear ecto-
plasmic layer, enclosing the more liquid endoplasm,
in which the comparatively small nucleus and food
vacuoles lie. Red blood corpuscles are frequently
seen to be enclosed. In stained specimens the ecto-
and endoplasm and the nuclear structure can be
seen; there is a definite nuclear membrane upon
the inner surface of which chromatin granules are
arranged. At the centre of the nucleus a central
granule ean usually be distinguished representing,
according to Hartmann, a karyosome with centriole;
the presence of the centriole at times is more or less
of an assumption and is largely dependent upon the
view that the centriole represents the centrosome,
which must be present for the purposes of nuclear
division. Although the above-described entamoebse
is that usually met with in amebic dysentery, many
of the entamcebe present in a specimen will be
found to have nuclei of different types, but in
which one or other of the features of the typical
nucleus is shown. Wide variations, however, do
not justify their being considered different species,
even although the cytoplasm is equally variable.
In non-pathogenic E. coli there is little tendency
to. separation into ectoplasm or endoplasm, as in
the typical amcebe of dysentery, but in some cases
the E. coli met with in healthy intestines may
simulate very closely the pathogenic form, and the
question is whether we have a mixed infection.
After discussing the encysted forms and their
variations, and that these forms are more readily
recognized than the entamæbæ themselves, Dr.
Wenyon ended where he began by saying the
various problems these variations in amoebe present
cannot be settled by the mere examinations of
stained preparations nor by inoculation experiments
with possible mixed infections; and they probably
will not be settled until some method has been
devised by which pure cultures of these intestinal
entamcebe can be maintained for study and used
for infecting animals.
Major W. S. Harrison, R.A.M.C., said: By far
the most frequent form of dysentery in the Army
in peace time is amæbic dysentery. A number of
patients with amæbic dysentery never have had an
acute attack with the appearance of bloody mucus
in the stools, but in all one gets some history of
irregularity of the bowels with griping at times.
The irregularity may consist in occasional attacks
of diarrhea with intervals of constipation, or the
patient may never pass a solid stool; profuse watery
stools are, however, unusual as a regular feature.
One can usually find a tender spot somewhere along
the colon, the most frequent places being the
cecum, the sigmoid, and the region of the two
flexures, and in a thin subject it is often possible to
determine that there is some thickening of the colon
over these areas. If the history and symptoms
point to amebic dysentery it is not necessary or
desirable to wait until amæœbæ are found in the
stool before making a diagnosis. My present
routine is to examine the freshly passed stool for
amcebe, and also to make cultures from it. If the
culture does not show the presence of one of the
dysentery bacilli, and the history and symptoms
are sufficient, I assume that amebic infection is
possibly present, and I commence giving emetine
in doses of 1 gr. to 3 gr. daily. In addition I irrigate
the bowel with saline followed by saline containing
quinine.
In liver abscess emetine is of the greatest value;
many cases which one could confidently say had
gone on to pus formation subside under the influence
of the drug. I usually keep up the use of emetine
for ten days, then go on with ipecacuanha for two
weeks, giving it in 20 gr. doses daily; the pre-
liminary treatment with emetine seems to produce
8 tolerance for ipecacuanha, and one rarely then
gets vomiting even when the drug is given as an
uncoated bolus.
Lieut.-Colonel MorEswonTH, I.M.S., said that in
268
Madras Hospital emetine had been given in doses
from $4 gr. to 4 gr. up to nine injections during a
week. Emetine given before an operation for liver
abscess reduces the temperature, lessens the
cachexia, and thereby improves the patieni's
chances of recovering from the operation.
Lieut.-Colonel A. Leany, I.M.S. (retired) drew
attention to the good effects of a saturated solution
of sulphate of magnesia in both acute and certain
chronic dysenteries. Colonel Leahy insisted upon
the direct connection between dysentery and liver
abscess.
Sir WiLLiAM LkisHMAN, F.R.S., said that the
results which Drs. Willmore and Savage had shown
of the results of a multivalent serum in the treat-
ment of bacillary dysentery were very striking, and
had done something to raise serum-therapy from
the disfavour it had of late fallen into.
Major HovenroN, Major Jackson, and Dr. MAL-
COLM WATSON also took part in the discussion.
Professor WASIELEWSKI then gave a lantern
demonstration of his investigations on dysentery.
PHLEBOTOMUS FEVER AND DENGUE.
By Lieutenant-Colonel C. Brrr, R.A.M.C.
In the year 1908 Doerr proved by experiment
that the summer febrieula which year by year
attacked the Austrian troops stationed in Bosnia
and Herzegovina was of specific origin.
Similar febrile ailments had been reported in the
records of our Army and Navy in the Mediterranean
stations for nearly 100 years. They were attri-
buted to solar influences, climate, intemperance,
disorders of the digestion, and so forth.
On combining the successful experimental results
of Austrian, English, and Italian investigators, it is
found that (1) the subcutaneous injection of blood
or serum withdrawn during the first twenty-four
hours of sandfly fever excited the disease nineteen
times; (2) inoculation with the filtrate obtained by
passing such diluted blood through a germ-proof
filter induced the infection fourteen times; (3) and
that feeding experiments with infected sandflies
were successful on twenty-one occasions.
Phlebotomus major (Annandale), called P. per-
niciosus by Newstead, is the common sandfly of
Malta. P. minutus is widely distributed in sandfly
fever localities; specimens of this variety have been
sent recently by Capt. Loughnan, R.A.M.C., from
Aden, where for many years the infection has been
prevalent among our troops; hence it is probable
that both these flies transmit the disease in addition
to P. papatasit.
The existence of the phlebotomus and of the
infection has been reported recently in Portugal,
South of France, Italy, Corsica, Sicily, Greece,
Palestine, Egypt, Soudan, Aden, Persian Gulf,
Ceylon, Mexico, German East Africa, and India.
In the Army Medical Report of the year 1911 it is
stated that there were 1,393 admissions on account
of sandfly fever among the European troops
stationed in India. Phlebotomi have been captured
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1913.
in many part of Europe, Africa, Asia, and in North,
Central, and South America.
Sandfly fever occurs every summer year by year,
but dengue breaks out in sudden epidemics at inter-
vals of many years. In Malta there are annual
summer epidemics of sandfly fever among our
troops, but the last occasion on which they were
attacked with dengue was in the year 1881. The
rapid dissemination of the dengue infection through-
out a community, and the presence of rashes in
about 70 per cent. of the cases, distinguish a dengue
from a sandfly fever epidemic. No eruptions have
been observed in the Maltese, Italian, and Chitral
phlebotomus fever.
The causation of dengue has been investigated by
Graham, Carpenter and Sutton, and by Ashbum
and Craig. Inoculation of healthy persons with the
blood of dengue patients gave rise to dengue eight
times. Inoculation with filtered infective blood
induced the disease twice. Inoculation with the
salivary glands of an infected culex originated the
ailment once. Infection has been conveyed by
infected culices eight times, and by an infected
stegomyla once. Graham protected families from
dengue by mosquito netting. E. H. Ross extin-
guished epidemies of dengue in Port Said by exter-
minating the mosquitoes. Stitt prevented the
spread of infection from 200 dengue patients by
enclosing them in mosquito-proof wire cages.
Blood withdrawn after the first day of sandfly
fever is no longer infective, but the blood of dengue
patients in the second to the fifth day of the fever
excited the disease. ^ Phlebotomi are unable to
transmit sandfly fever until six days after feeding
on a sandfly fever sufferer in the first day of his
illness, but dengue has been conveyed by mos-
quitoes immediately after sucking infective blood;
nevertheless the virus survives in them for twenty-
seven days. An attack of sandfly fever does not
confer immunity against dengue, and vice versa.
The stegomyia was regarded by Legendre as the
transmitter of dengue in a widespread outbreak at
Hanoi in 1910. Davidson noted that this mosquito
was present everywhere in Brisbane during the
dengue epidemic of 1911.
There is a close resemblance between the sandfly
dengue and yellow fever infections; they are all
caused by a virus which circulates in the blood, and
is able to pass through a bacteria-proof filter; the
onset of the fever is similar in many instances, and
during the first two days of the illness it may be
impossible to distinguish between the ailments ; even
later a diagnosis on clinieal grounds may be unat-
tainable, for atypieal eases of dengue and yellow
fever, and they are numerous, may bear every like-
ness to phlebotomus fever.
Dr. G. C. Low said that the differential diagnosis
of yellow fever from other diseases was not an easy
one. Weil’s disease, acute yellow atrophy, infee-
tious and other jaundices, had all to be considered.
Further, yellow fever might occur in a malarial
individual. The origin of sporadic cases of the
disease had never been satisfactorily explained.
Dr. Fuemina Jones said, from a wide experience
Sept. 1, 1913.]
of yellow fever cases, if he had to depend upon one
symptom only in the differential diagnosis between
yellow fever and other tropical fevers he would rest
upon the ‘‘ rising temperature and the falling
pulse." `
Discussion ON FILARIASIS.
Friday, July 25, 1918.
Dr. GroncE C. Low (London) reviewed the
literature of Filariasis from July, 1912, to July,
1913. Several French writers, he said, had made
contributions dealing with the geographical distri-
bution of Filaria bancrofti, F. loa and F. perstans
amongst natives of the French possessions on the
West Coast of Africa.
Fülleborn had also published the results of his
investigations in the islands of the Bismarck Archi-
pelago, in the Pacific, and in German New Guinea.
He found that a high percentage of the natives of
some of the islands were infected with F. bancrofti,
and that the embryonie forms in these areas pos-
sessed a well-marked periodicity. This is in marked
contrast to the behaviour of the embryos in Samoa,
Fiji, &e.
Fülleborn has also dealt with the morphology and
differential diagnosis of the various human micro-
filarie; it is now believed that the embryos of
F. diurna are the larval form of F. loa.
Low has shown that the milky fluid occurring in
some cases of chyluria originates from the lym-
phaties of the kidney and bladder and not from the
thoracie duct, so that the condition might be termed
lymphuria instead of chyluria, and suggests that the
term filarial lymphuria be used to express this
condition.
Wise and Minett have shown that tissues damaged
by filaria become infected by organisms, with the
result that abscesses form, either locally or diffused.
Several new methods of removing elephantoid
enlargements have been brought forward. It would
appear from the number of surgical cases of this
nature reported in regions remote from the Tropies
that these growths were due to other conditions
than filaria.
Leiper has shown that the intermediate host of
the F. loa is Chrysops dimidiata and C. silacea, and
that metamorphosis of the embryos takes place in
their salivary glands.
The geographical distribution of Filaria bancrofti
requires further investigation and its epidemiology
systematically handling. The subject of hyper-
filariation also requires elucidation; the constancy
of the number of embryos in the peripheral blood
for long periods is another subject full of interest;
and the pathology and pathological anatomy of the
diseased conditions produced by F. bancrofti are but
ill understood. Bahr’s work in Fiji shows that the
death of adult filarie is fairly common, and that
the calcification of the remains, which often occurs,
may be a source of further trouble.
One of the most peculiar features in many cases
of F. loa infection is the prolonged absence of
embryonic or larval forms from the peripheral blood,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
269
and that even although there is strong evidence of
a fair infection of adult forms. Low, in a series
of cases which he is following up now, some little
time ago published a continuation report upon
them. A reference to this paper shows that some
still have no embryos in their peripheral blood four
years and even longer after their original infection.
One, however, does not give up hope of their
ultimate appearance, as Meinhof has recently de-
scribed a case where calabar swellings appeared in
1905, then the first adult filaria was seen six years
after that, and embryos appeared in the peripheral
blood eight months after that, i.e., almost seven
years after the original infection.
This case, with Case 5 of Low's series—a patient
who has been away from the endemic area for
54 years and yet has numerous loa embryos in his
blood—indieates how long and protracted the infec-
tion may be.
Another point illustrated by the same case is that
a patient may be infected and act as a carrier and
yet be unaware of this, none of the usual clinical
signs of the disease having shown themselves.
This is rare, but it leads one to ask what are the
evidences of infection with F. loa. Low has already
entered into this in a paper on Filaria loa, pub-
lished in the JOURNAL oF TropicaL MEDICINE AND
HaGiENE in 1911, but for convenience what he
wrote then may be repeated here: ''In coming to
a diagnosis that a case is one of F. loa infection,
four points should be attended to:—
“ (1) The actual presence of the worm. Has this
been seen, or has one been extracted? If so, of
course, the diagnosis is complete.
“ (2) The presence of diurnal (F. loa) embryos in
the peripheral blood.
' (8) The actual presence or history of calabar
swellings.
“ (4) Eosinophilia with no explainable cause.”’
Dr. Duncan Wnuvrk (Swatow, China) confirmed
the views of Dr. Low as to the absence of hyper-
filariation. Patients in whom the number of micro-
filarie in 20 c.mm. of blood had been counted at a
certain hour of the night, showed no increase in
that number five or six years later, although there
seems no reason to doubt these persons had been
often bitten during the intervening years by mos-
quitoes which he had himself infected.
Dr. Low had given no definite information as to
the duration of life of micro-filarie in the blood-
stream, and Dr. Duncan Whyte thought it worth
while reporting that (in three filariasis patients from
whom an elephantiasis scroti had been removed) the
miero-filari& could be found in the peripheral blood
for from a week to ten days afterwards. Dr. Whyte
referred to the '' patchy ’’ distribution of filariasis
and elephantiasis in South China.
Dr. R. Fiemina Jones (New Guinea) said he had
often noted the patchy distribution of elephantiasis.
In British New Guinea he found an average of
7 per cent. of blood infection with micro-filarize
(F. bancrofti), and yet he got nearly all his cases
of elephantiasis from one small district. The sug-
gestion of symbiosis at once occurs.
270
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1913.
Dr. P. H. Bann gave a lantern demonstration of
changes in the tissues produced by filaria from
material he collected in Fiji. In the course of his
demonstration he referred to the fact that adult
filarie were found most commonly in Fiji in the
lymphatie glands. In these glands were noticed
giant cell formation and fibrosis, and the filariæ pro-
bably set up irritation partly by their presence as
a foreign body and by their toxins and excreta.
When an adult filaria dies its remains may calcify,
and these possibly act as an irritant, and further
increase the amount of fibrosis. Caleified remains
of filaria have been found in almost every lymphatic
gland of the body, the testis, the epididymus,
tunica vaginalis, in the lymphatics of the kidney
and the peri renal fat. Their effects on lymphatic
vessels are marked blockage, which may occur in
three ways: first, mere mechanical obstruction ;
second, by surrounding fibrosis; and third, by pro-
liferation of the endothelial lining of the vessel wall.
Dr. Bahr also showed specimens of the develop-
ment of embryos in the mosquito. The mosquito
Stegomyia pseudo-scutellaris is the intermediate
host for Fiji, and no periodicity is found in these
parts.
In Culex fatigans the embryos develop badly,
although a few may live to enter the proboscis.
The Stegomyia pseudo-scutellaris is a day-biting
mosquito, and Dr. Bahr suggests that the cause
of the periodicity of the embryos in the blood of
man is a distinet adaptation of the habits of the
favourite intermediary host.
Professor WasrELEWSKI (Heidelberg) suggested
that a chemieal effect might be produced by the
filarie and have something to do with the lesions
present in filariasis.
Dr. Cameron Barn (Nigeria) referred to the perio-
dieal attacks of filarial fever and to lymphangitis.
Dr. Bahr believed this was due to a definite breed-
ing season for the parent filaria and the birth of
young embryos set up the lesion.
Dr. Marcom Watson (Malay States) referred to
the '' patchy "' distribution of filariasis. Dr. Bahr
suggested that the chemical composition of the
water in which mosquitoes breed may have some-
thing to do with it analogous to the case of
anopheles carrying or failing to carry malaria in-
fection, as pointed out by Christrophers.
Dr. Low then replied and answered the different
questions raised. He doubted if Dr. Bahr’s sug-
gestion, that the periodicity of the embryos in the
blood of man in Fiji was an adaptation to the habit
of the intermediary host, could stand, because in
the case of the dog Diro filaria immitis embryos
were present by night as well as by day, though the
intermediate host was a night feeder.
The Presipent (Sir William Leishman), in bring-
ing the proceedings to an end, said that he thought
the section had every reason to congratulate itself on
the highly interesting nature of the papers and
diseussions which had occupied them during the last
three days, and he felt sure that most of the
members would feel, as he did himself, that they
had derived from them great and lasting profit.
Before bidding them good-bye he had two very
pleasant acknowledgments to make. First, he
wished to express his warmest thanks to the secre-
taries of the section, Dr. Curwen and Dr. O'Connor,
on whom had fallen the brunt of the organization,
and he assured the members that they owed them
a deep debt of gratitude for their untiring and able
efforts to ensure a successful meeting. Secondly,
he felt sure he was only expressing the feelings of
everyone present when he acknowledged in their
name the warm welcome and the generous hospi-
tality of the Brighton Division, which would make
this meeting so pleasant a memory to them all.
————99—————
Annotations,
Two New Genera of Helminthes in Man.—
Leiper, at the annual meeting of the Society of
Tropical Medicine and Hygiene, in a paper on
“ Remarks on Certain Helminthes in Man,”
described two new genera of helminthes in man
from Asia.
Heterophyes yokogawa, named by Katsurada in
1912, was shown to be a new genus Yokogawa (type
species, Y. yokogawa), characterized by the extra-
ordinary absence of a ventral sucker. The genital
sucker was highly developed, but did not possess
the circlet of hooks or ‘‘ antlers '" characteristic of
the genus Heterophyes. In other respects the para-
site bore a close resemblance to Heterophyes
heterophyes. The other known genera exhibiting
this peculiar feature are Cryptocotyle, Tocotrema,
Scaphanocephalus. In the last-named the testes
lie one in front of the other. The genus Yokogawa
is distinguishable from Cryptocotyle and Tocotrema
in the peculiar restriction of the yolk glands. In
this respect Yokogawa comes near to the Hetero-
phyine. Yokogawa yokogawa is only 1 mm. to
1:4 mm. in length, and thus displaces Heterophyes
heterophyes as the smallest fluke in man.
The Amphistomum hominis from Eastern India
has been found to be a much more common parasite
of man than was formerly supposed. A study of serial
sections has convinced Leiper of the necessity of
removing this species from the genus Gastrodiscus
to a new one now named Gastrodiscoides, on
account (1) of the presence of a large, prominent
genital papilla in place of the genital atrium of
Gastrodiscus; (2) testes tandem; (3) genital orifice
on the neck, not on the ventral surface; (4) ventral
aspect of the disc is smooth and quite free from
sucker-bearing papille. The recent discovery that
the pig is the normal host of this species lends
added interest to the find of a new species of Gastro-
discus in the bush pig in Uganda and the Congo.
This form closely resembles G. sonsinoi in the horse,
but is smaller, and the genital atrium opens nearer
the edge of the ventral disc.
A Supposed New Species of Human Trypanosome.—
Scott Macfie, in the Annals of Tropical Medicine and
Parasitology, August 11, 1913, Series T.M., vol. vii,
No. 3A., publishes al paper on the morphology of a
Sept. 1, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
271
trypanosome from a case of sleeping sickness from Eket,
Southern Nigeria. He believes that the parasite
presents differences from the ordinary T. gambiense
and proposes the name T. nigeriense for it. The
reasons for this are given in his summary and con-
clusions, which are as follows :—
“The trypanosome, of which a preliminary account
is given in this paper, seems to differ in several
respects from a typical strain of T. gambiense. In
man it produces a form of sleeping sickness that is
relatively mild, occurs most commonly in young
people, and in which the trypanosomes are, apparently,
either absent from the peripheral blood altogether, or
present in such small numbers that hitherto they
have not been detected. To the smaller laboratory
animals the strain seems to be but slightly pathogenic.
The morphology of the trypanosome as it appears
in the blood of a guinea-pig shows some peculiar
features. The trypanosome is smaller than T. gam-
biense, the cell protoplasm when well stained is
homogeneous, and there appear constantly in the blood
films a few very minute parasites measuring as little
as 84 in length. Some of the short and stumpy
parasites have the nucleus situated far forwards at
the anterior (flagellar) end of the body. The occur-
rence of a few peculiar trypanosomes which appear to
have a flagellum free in its whole length is also
remarkable.
Considering the morphological features of the
parasite, and the peculiar symptoms of the disease
produced by it, I am convinced that this trypanosome
from Nigeria cannot be regarded as belonging to the
same species as T. gambiense. I therefore propose for
it the name T. nigeriense."
Unfortunately, it has been found impossible to
reproduce the plates illustrating the paper at the same
time, but it is proposed that they should appear in
the next number. Until they appear criticism pos-
sibly should be suspended, but it certainly looks, as
far as the paper goes, that sufficient evidence is not
forthcoming for manufacturing a new species of human
trypanosome.
The Extrusion of Granules by Trypanosomes.—Fry,
Ranken and Plummer continue their studies on the
extrusion of granules by trypanosomes and on their
further development. (Journal of the Royal Army
Medical Corps, vol. xxi, August, 1913, No. 2.) The
granule when it escapes from the trypanosome and
becomes free in the blood is seen to be a small spheri-
cal or pear-shaped body. In dark-ground preparations
it is seen to be highly refractile, and by its activity it
causes considerable disturbance in the surrounding
fluid; with vital staining this young granule takes on
the stain rapidly and uniformly, and seems to be un-
differentiated. It frequently remains near its former
host for some little time before showing independent
movement. At first only a dancing movement may be
seen; this, however, is a preliminary phase, and soon
the granule begins to move slowly across the field,
turning over on itself. There is no doubt as to the
motility: they have often been observed to move out
of a microscope field in preparations where there was
no question of currents, &e.. In the author's opinion
a pseudopodial protrusion appears early, which at first
is short and rather thick.
In animal infections and in cases of sleeping sick-
ness in man, granules are found in the blood, glands,
and internal organs. They are, of course, much more
numerous in animals in which the adult parasites
appear in great numbers. In experimental animals
granules have been found in the proximal glands
twenty-four hours after inoculation. This fact seems
to be of great importance.
The criterion in the recognition of granules must be
their motility, but their greater affinity for such stains
as toluidin blue is of undoubted assistance in distin-
guishing them from the countless small bodies seen in
wet preparations, e.g., blood-platelets and leucocyte
granules.
As regards the further development of these granules
the further changes are difficult to follow as all stages
cannot be seen in any individual preparation. The
authors apparently believe, however, that the granule
can develop and become a trypanosome again. Their
plate (No. 9) shows this in diagrammatic form.
Plague in Manila during 1912.—Heiser, in the Phil-
ippine Journal of Science, vol. viii, Sec. B., No. 2,
April, 1913, describes the recent outbreak of plague in
Manila. He states that after an absence of six years
in human beings, and five years among rats, plague
was again found in the Philippine Islands on June 19,
1912. On account of the almost daily communication
which Manila has with badly plague-infected foreign
ports which are within a few days’ steaming distance
for the average vessel, and since, therefore, passengers,
crews, rodents, and vermin may arrive well within the
incubation period of the disease, it seems remarkable
that the Philippines should have remained free from
plague for so many years. During this period plague
has been detected from time to time, among human
beings upon incoming vessels, but such infections were
invariably intercepted at quarantine. All vessels
plying between the Philippines and Oriental ports
have been fumigated with sulphur, at not greater than
six-month intervals, to destroy rodents and vermin.
As regards the introduction of the present outbreak
Heiser believes that the infection might have been
introduced through the means of infected bedbugs.
In a case of human plague which was taken from
508 Calle Magdalena, bedbugs were caught from the
petate (straw mat) upon which the man died, and
smears made from the intestinal contents showed
plague-like bacilli; the pathological findings, however,
were not confirmatory. It is not impossible that bed-
bugs may have been concerned in the introduction of
the disease. On account of the fact, however, that
all second- and third-class passengers’ clothing and
effects are steamed at Mariveles, it does not seem
likely that bedbugs could have been introduced with
them.
Hydatid Disease.—Ramsay contributes an inter-
esting paper on unusual eases of hydatid disease, to
the Australasian Medical Gazette for June 21, 1913.
His experience extends over a period of seventeen
years, and in that time he has met with many curious
272 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1918.
examples of the disease. The following viscera have
been noted to be affected—the lungs, liver, the meso-
appendix, the peritoneum, and the Fallopian tubes,
while cysts were also found near the bladder, in the
posterior axilla, in the abdominal parietal muscles, in
the neck, in the mediastinum, in the thyroid gland, in
the femur, and in the antrum of Highmore. Com-
moner sites also invaded were the brain, spleen, kidney
and breast. These examples, in the author’s words,
show the ubiquity of the Tania echinococcus when it
takes up its residence in the human body.
——9———
Correspondence.
THE RAPID DIAGNOSIS OF MALARIA.
To the Editor of the JOURNAL OF TROPICAL MEDICINE AND
HYGIENE.
Dear SiR,—I have read in the JOURNAL or TROPI-
caL MepiciInE AND HyaorENE, May 1, 1912, Dr.
Cropper’s method for the rapid diagnosis of malaria,
and have tried it successfully in my blood exam-
inations in Santa Izabel Hospital, Bahia, Brazil.
The method is as follows: ‘‘ Thick films are made
on a slide, without even a cover-slip, so thick that
the blood when allowed to run to one side is seen
of a bright red colour. This is rapidly dried and
examined directly under a drop of cedar oil and a
js in. immersion." The examination can begin
“before the whole film is dry, and very often the
information got is sufficient before the thicker edge
ds properly set. The thicker part of the film is best
examined first, and from the character of the pig-
ment the species of malarial parasites can, after
a very little practice, be diagnosed in most cases
with great ease, almost as easily as in a wet film.
The diffuse and fine dots of tertian, the compact
and coarser dots of quartan, and the peculiar
arrangement of the pigment in the crescents in
malignant malaria are very characteristie, not to
mention pigmented leucocytes.''
Before I had the above information I sometimes
worked with Sir Ronald Ross's method, but cannot
recommend it on account of the difficulty of recog-
nizing the parasites, more or less deformed by the
watery application used in order to dissolve the
hemoglobin. On this point Dr. Cropper’s method,
though more rapid than the one referred to, does not
solve the diffieulty, as one cannot see the malarial
parasites very distinetly, but only their pigments.
This method may be very useful for parasitologists,
but is not sufficient for the beginners in blood
examinations.
In order to facilitate detection of the malarial
parasites, I thought I would modify Dr. Cropper's
method by staining the thick blood-films without
a previous dissolution of the hemoglobin, as recom-
mended by Sir Ronald Ross.
I took a thick blood-film, made with five large
drops of blood, and when dry I stained half of the
blood with a methylene-blue acid solution (Gasis's
solution) without fixing and with about two minutes’
careful washing. When dry, I examined it under
a drop of cedar oil and a 4," hom. Leitz's oil
immersion objective. I was rewarded, as I could
see very clearly, not only the melanin pigment
as detected by Dr. Cropper's method, but also the
whole malarial parasite with its unchanged mor-
phology, just as on the dried and stained thin
films of the common method of examining malarial
blood.
Upon careful consideration I discovered the
success was due to the fact that the staining was
performed at the same time as the acid solution
influenced the erythrocytes, dissolving their hæmo-
globin; so that, in two minutes, one could see the
parasites stained in blue, as the nuclei of the leuco-
cytes. -I think this modification very useful in
tropical work, and, as I stain only a half of the
blood-film, it is not difficult to make a comparison
of the two halves of the same slide, in order to
recognize the advantages of my staining method.
After this discovery the method was practised
daily in my medical clinics at the Bahia Medical .
School, where it met with the approval of my
assistants and pupils alike, as the best method of
detecting rapidly the malarial protozoon.
In a patient under my observation suffering from
malarial motor aphasia, who was dumb during
twenty days, the detection of the parasites was
easily made and their disappearance observed daily
by the aid of my method of staining the thick blood
films. The patient recovered, as I explained in the
medical journal, Brazil Medico, of Rio de Janeiro,
and in my lecture, ‘‘ Um caso de aphemia tran-
sitoria palustre °’ (A case of malarial aphemia).
I should be glad of the advice of scientists and
practitioners upon this small contribution for the
examination of malarial blood, and should be
pleased to receive any criticisms of my remarks.
The technique I adopted was as follows:—
(a) To make the films very thick with five large
drops of blood.
(b) After the blood is dry, to stain it (two
minutes) with Gasis's solution :—
Methylene-blue
Hydrochloric acid sse
Alcohol M "T des 10
Distilled water aes H
(c) To wash with care, to dry, and to examine
the films under a drop of cedar-wood oil and a 45"
oil immersion objective.
Pror. Dr. Joao A. G. Frogs,
Professor das Faculdades de
Medicina e de Direito.
Bahia, Brazil.
Rotices to Correspondents,
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JOURNAL OF TROPICAL MEDICINE AND HYGIENE shouid com-
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5.—Correspondents should look for replies under the heading
** Answers to Correspondents,”
INTERNATIONAL CONGRESS OF MEDICINE.—NOTICE No. I.
ABSTRACTS OF IMPORTANT PAPERS.
Sept. 15, 1913. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 18, Vol. XVI
PLAGUE.
Report by Major W. GLEN LisToN,C.I.E., M.D., D.P.H., LM.S.
Bombay Bacteriological Laboratory.
Tug EPIDEMIOLOGICAL FEATURES OF BUBONIC AND
PNEUMONIC PLAGUE CONTRASTED.
Maor Liston said that the historians of plague
did not differentiate clearly between the pneumonic
and bubonic types of plague; nor is this surprising,
for, in epidemics in which the two types are asso-
ciated together, plague is obscured by the occur-
rence of cases of secondary pneumonia in typical
bubonic cases.
The discovery of the plague bacillus by Kitasato
and Yersin in 1894 enabled Childe, of the Indian
Medieal Service, in 1897 to distinguish clearly
between the pneumonic and bubonic types of this
disease. He showed that enormous numbers of
plague bacilli are ejected with the sputum of
patients suffering from plague pneumonia, and he
also drew attention to the infectious nature of this
form of disease. Subsequent epidemics, although
not very infrequent, were always limited, for prompt
and effective precautions were taken to control the
spread of infection; the fact remains, however, that
these pneumonie epidemics arise from time to time
in connection with bubonie eases, taking origin, no
doubt, from bubonie cases which have developed
symptoms of secondary pneumonia.
Meanwhile the connection between rats and the
bubonie form of the disease attracted attention
both in Hong-Kong and in Bombay, but the
relationship between the epidemic and epizootic
was partieularly elearly demonstrated by Ashburton
Thomson during the outbreak of plague in Sydney
in 1900; Thomson also brought forward arguments
to support the view, advanced by Simond in 1898,
that fleas conveyed the infection from rats to men.
The experience of medical officers in charge of
the plague hospitals in Bombay forced upon them
the conclusion that cases of bubonic plague, re-
moved from their homes to the hospital, were
peculiarly non-infectious, for relatives and friends,
ignorant of the very elements of disinfection and
closely in attendance on these patients, never con-
tracted the disease. Bubonic plague thus came to
be regarded as a disease of locality, for infection
appeared to lurk in the homes of the sick, rather
than with the sick themselves. As a consequence
of this view a long series of fruitless attempts were
made by a large number of observers to isolate the
plague bacillus from the floors and walls of infected
houses. Experiments, however, showed that, ex-
posed to the conditions found in nature outside the
body of a living animal, plague bacilli rapidly dis-
appear, so that they cannot for long be recovered
from contaminated soil or clothing placed under
normal conditions.
Major Liston also turned his attention to fleas as
harbourers and transporters of the plague bacillus.
He observed that certain species of fleas readily
took to other than their natural host, especially in
the absence of their natural host, and in 1904 ex-
perimented with guinea-pigs, utilizing these animals
to attract rat-fleas in plague-infected houses, so that
the fleas could be caught in the fur of the guinea-
pigs, when they were chloroformed and examined,
By means of these guinea-pig flea-traps I was able
to show that plague bacilli could be found in plague-
infected houses in the stomach of fleas which had
probably sucked the blood of infected rats; these
rat-fleas readily took to and bit guinea-pigs, which
were used to capture them, so that some of the
guinea-pigs died of plague, the bacilli being con-
veyed by the fleas from infected rats to the guinea-
pigs. In the stomach of fleas the bacilli were
observed to multiply, and it seemed likely that they
could thus be transferred most easily from the blood
of sick to the blood of healthy animals. He proved
also that rat-fleas under certain circumstances could
be captured on men, so that it seemed possible that
plague infection was in this way transferred from
rats to men.
Meanwhile Gauthier and Raybaud had shown in
1908 that it was possible in laboratory experiments
to convey infection from sick to healthy animals by
means of rat-fleas. The Plague Research Commis-
sion in India showed that bubonic plague, whether
in animals or men, must generally (that is, in the
overwhelming majority of cases) be produced by
infection carried by means of rat-fleas from infected
rats. The bubonic type of plague was thus proved
to be not directly infectious.
The International Plague Commission appointed
in 1911 by the Chinese Government to study pneu-
monic plague in Manchouli, a region which has
been associated for years with outbreaks of pneu-
monic and bubonie plague, which have their origin
from an epizootie among tarbagans, spread through
Manchuria, elaiming a death-roll of 50,000 persons ,
during a period of six months. This International
Commission made it abundantly clear that in this
epidemic rat infection played no part. The disease
was spread by direct infection from man to man.
Despite the fact that vast numbers of plague bacilli
were ejected from the sputum of the sick, who were
often huddled together in houses in which rats were
numerous, it is noteworthy that no evidence was
obtained of infection among the rats either acquired
by feeding on the sputum of the sick, or on food
contaminated with sputum, or by feeding on or
gnawing the exposed plague corpses. No evidence
was forthcoming incriminating articles of clothing
as agents in the transmission of the infection, or
proving that houses were infected apart from the
plague patients within them.
Dr. Strong, one of the members of the Commis-
sion working with Dr. Teague in Manila, has shown
that the strains of Bacillus pestis isolated from
pneumonie cases in China in no way differ from
strains isolated from bubonic cases in other parts
of the world. They have shown that plague bacilli
from a pneumonic strain, when injected sub-
cutaneously into animals, produce the bubonic type
of the disease, and that the virulence of these
strains is not greater than the virulence of bubonic
strains.
In discussing the method of infection in plague
274 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
pneumonia, Strong has shown that plague bacilli
are not usually expelled by means of the expired
air during normal or dyspneic respiration by persons
suffering from primary plague pneumonia, but that
during coughing, even when sputum visible to the
naked eye is not expelled, plague bacilli in large
numbers may become widely disseminated into the
air surrounding the patient. He states that the dis-
tance from the patient that the air may become
infected by droplets containing plague bacilli varied
largely with the strength of the cough, the amount
of mucus in the throat and larynx at the time, and
the currents of air in cireulation in the ward. He
omitted to consider the very important influence of
temperature on the distance to which infection may
diffuse, for it is likely that droplets carrying plague
bacilli will float through the air for a longer period
in a cold damp atmosphere than in a hot dry one.
It is for this reason, Major Liston believes, that the
pneunionie type of the disease is more common in
cold and temperate climates than in hot tropical
countries where generally the bubonic form of the
disease prevails.
The International Commission further came to
the conclusion that the chief factor in the decline
of this pneumonie epidemic was probably the pre-
ventive measures, which were adopted either ‘n
accord with scientific methods, or by the efforts of
the people to protect themselves. The widespread
epidemic in China was easily checked when suitable
measures were adopted, as are the small pneumonie
plague epidemics which occur from time to time in
India. But this experience differs entirely from
that obtained in India in regard to bubonic
epidemies, for that type of the disease has been
present there for nearly sixteen yenrs, despite the
most strenuous efforts on the part of Government
to eradicate it.
THE Immunity or Mus RATTUS TO PLAGUE
INFECTION.
When plague broke out in Bombay in 1896 the
disease had been absent from that city since 1702,
a period of 194 years. ‘* These long intervals,"
says Simpson, in his '' Treatise on Plague,”
"seem peculiar to the epidemiology of plague.
Between the epidemic in London in 1348 and that
of 1499 a period of 150 years elapsed, an interval
of seventy years occurred between the epidemic
of 1720 and the previous great epidemie in Mar-
seilles, and in other localities similar intervals
obtained.
Any theory of the method of propagation of
plague must take cognizance'of these phenomena
and be capable of explaining, not only the gradual
decline in the severity of succeeding epidemics, but
also the period of immunity which follows them.
At Bombay Bacteriologieal Laboratory during six
years 701,624 rats have been examined, and 69,191
of that number have been found infected with
plague. "The result of this examination shows that
an approximately close relation is maintained be-
tween rat and human plague, not only in regard
to the onset and decline of the epizooties and
[Sept. 15, 1913.
epidemies, but also in respect to the general course
of each epizootic and epidemic. In 1907, for
example, both epizootic and epidemic steadily
inereased in severity till the end of March and then
repidly deelined; but during the year 1910 both
epizootic and epidemic persisted at a moderate
intensity for some weeks during the months of
March and April.
Granted that epidemics of plague are dependent
on rat epizooties, certain experiments carried out
by the Plague Research Commission in India explain
why succeeding epidemics of plague in an infected
town gradually decrease in severity, and why, after
a succession of epidemics, the disease disappears
and the place remains free from infection for a
comparatively long period of years.
In connection with the epidemiological and experi-
mental researches on plague in India, the Commis-
sion had frequently to bear in mind the possibility
that the immunity or resistance of rats to plague
infection might be a factor of some importance in
the epidemiology of this disease. For example, the
gradual increase in the number of rats immune to
plague might be a factor in terminating an epizootic.
It was noted that the rats which survived an
epizootic, which had been produced by introducing
infection among the fleas in our experimental
godowns (sheds), showed an apparently high degree
of immunity, but it was thought that this immunity
might be explained by supposing that during the
epizootic susceptible individuals had been killed off
and that the more immune had survived, rather
than that the rats had acquired immunity in having
suffered and recovered from the disease. It was
also observed that the rats in Belgaum town were
able to withstand a dose of plague bacilli which
experience had shown would have killed a fair
number of rats caught in Bombay. Rats were
collected in Bombay from several places and a
large number of them infected at one time with the
same dose of plague.
A brief description of the first experiment will
serve to explain the technique adopted in the others.
One hundred rats caught in Madras, and the same
number caught in Bombay, together with seventy-
six caught in Poona, were placed in separate cages,
two rats in each cage. The spleen of a rat which
had died of acute plague was removed aseptically,
and placed in a sterile mortar and ground up with
a known quantity of saline solution. The larger
particles of this emulsion were allowed to settle
and the supernatant fluid was decanted off; to this
emulsion of plague bacilli fresh saline was added
us necessary, so that 1 c.c. of the ultimate solution
contained what we regarded as the equivalent of
one one-hundredth part of a milligram of the
infected spleen. This dose was administered sub-
cutaneously in the majority of our experiments.
Later the technique was improved by ascertaining
the actual number of living bacilli in each cubic
centimetre of the emulsion used by planting out
measured quantities of the emulsion on agar tubes
and counting the number of colonies of plague
bacilli which developed.
Sept. 15,1913. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
The result of the first experiment showed that,
while 83 per cent. of Madras rats died of plague
(the remainder in this experiment having died of
causes other than plague), only 44 per cent. of the
Bombay rats and 30 per cent. of the Poona rats
succumbed to the disease. Madras rats, therefore,
were highly susceptible to plague, while Bombay
and Poona rats were comparatively immune to the
disease.
Now, Madras City has been practically free from
plague, while both Poona and Bombay have suffered
severely, the former more severely than the latter
in proportion to its size.
Rats were caught in other parts of India where
there had been no plague, and we found that rats
from Dacca, Madura, and Banda, for example, all
of which towns had been free from the disease, were
as susceptible to plague as Madras rats were found
to be. These experiments showed :—
(1) That the method of subcutaneous inoculation
of one one-hundredth part of a milligram of a
selected plague-infected rat spleen, or approximately
18,000 plague bacilli, was a more severe test of the
immunity of rats to plague than that which we
were able to bring about by flea infection in a place
like Bombay.
(2) That in a given batch of rats the degree of
immunity was relative to the infecting dose.
(3) That the immunity of the rats was greatest
in places which had suffered most severely from
plague, less marked in those places which had
suffered to a moderate extent, and least in those
places in which epidemic plague had not occurred.
By the nature of this immunity, although the
rats used all conformed to the type Mus rattus, it
was possible to discover special and characteristic
features in specimens from certain places, not as a
rule wholly confined to any one locality, but being
predominant in one place more than another. Thus
the fur of Madras City rats is exceptionally rufous;
rats from the colder northern places had thicker
fur than southern specimens; and Belgaum rats
were on the whole larger than those caught in
Bombay or Poona. But no external difference could
be detected in the rats of Lucknow, Cawnpore, and
Banda, all situated in the United Provinces, yet,
on testing these rats by inoculation, Banda rats
proved to be as susceptible to plague as Madras
rats were, while Cawnpore and Lucknow rats were
both highly immune, the former markedly more
than the latter.
The conclusion, therefore, is that the resistance
of rats to plague is associated with the past pre-
valence of plague. In what manner is this re-
sistance developed ?
It became necessary to ascertain whether the
observed immunity of the rats from the places
tested was an acquired or a natural immunity, using
these terms in the sense usually employed by
bacteriologists; and experiments conducted for this
purpose gave the following results. Adult Madras
rats were tested against young Poona and young
Bombay rats on a number of occasions: the
summed up results of comparative experiments
275
showed that of 500 Madras rats 98 per cent. died of
plague ; of 450 young Poona rats 30 per cent. ; of 450
young Bombay rats 46 per cent. Young rats from
Poona and Bombay, therefore, were only slightly
more susceptible to plague than adult rats from
these places, and were markedly immune as com-
pared with adult Madras rats. These experiments
proved that young rats from Poona and Bombay in-
herited their immunity from their parents, for it was
not acquired by exposure to infection. Further proof
was afforded by testing rats bred in captivity from
Bombay stock, and comparing them with wild
Bombay rats, and with Madras rats. Two hundred
and twelve Madras rats had 208 deaths from plague,
98 per cent. mortality; 248 rats caught in Bombay
had 65 deaths, a mortality of 26 per cent.; while
158 rats bred in captivity from Bombay stock had ,
41 deaths, a mortality of 26 per cent. Hence it
appears that the resistance found is not due to
previous reception of plague bacilli during the pre-
valence of epizootic plague, but to the generation
of an immune progeny by the survivors of epizootics.
Susceptible rats appear to be killed off in the course
of repeated epidemies, while the more immune sur-
vive, transmitting their immunity to their offspring.
Major Liston concluded by saying that the
decreasing severity of epidemics in a particular town
which has suffered from repeated outbreaks of
plague is due to the generation of a race which is
comparatively immune to plague by a process of
selection and survival of the fittest, and it is not
difficult to understand that under these circum-
stances such a place may remain for a time at
least free from epidemies of bubonie plague.
In the experiments he recorded M. rattus was
used, for some recent experiments seem to show
that the conclusions arrived at for M. rattus are
not applieable to M. decumanus.
INVESTIGATIONS AS TO THE RELATION-
SHIP OF THE TARBAGAN (MONGOLIAN
MARMOT) TO PLAGUE.
By Wu Lien Tex (G. L. Tuck), M.A., M.D., B.C.Cantab.
Director and Chief Medical Officer, North Manchurian Plague
Prevention Service; late President of the International
Plague Conference, 1911.
Tur NognrH MaNcHURIAN PLAGUE PREVENTION
SERVICE.
IMMEDIATELY following on the International
Plague Conference, held in Mukden in April, 1911,
the Chinese Government, anxious to carry out the
recommendations of the conference, instituted the
North Manchurian Plague Prevention Service. The
chief of these recommendations were briefly :—
(a) Systematic investigations should be made as
to whether epizootic occurs among tarbagans and
other rodents, and, if such exists, an accurate in-
vestigation should be made of the nature of the
infection.
(b) A general improvement in the sanitary con-
dition of cities and villages, especially with regard
to overerowding, is desirable.
276
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1913.
(c) Education of the publie by lectures and the
issue of pamphlets and handbills, explaining pre-
ventive measures in simple language.
(d) The need for isolation of pneumonie plague
patients being urgent, permanent hospitals should
be available.
(e) Hospital accommodation for suspected cases
of plague should be provided.
(f) Contaet quarantine stations should be con-
structed.
Among the delegates of the International Plague
Conference, Mukden, April, 1911, it was generally
believed that there was a close connection between
plague—or at least the recent epidemie of pneu-
monie plague of Manchuria—and the tarbagan or
marmot (Arctomys bobac, Schreb).
So little was known about this animal and the
grounds for associating it with plague were based
on such slender scientifie evidence that it seemed
to me the first step in the investigation of this
question was to organize an expedition into the
country where the tarbagan abounds, and there to
study its habits and the conditions under which it
lives, and to carry out scientifie investigations as
to the presence of plague among the animals.
For the sake of clearness, it is well to state here
that the tarbagan hunting is divided into two
seasons :—
(1) Spring season, lasting fróm the end of April
to the beginning of June.
(2) Autumn season, lasting from the middle of
August to the end of September.
In the beginning of July rumours were afloat that
a large number of tarbagans were dying in the
neighbourhood of Seharasone —(Transbaikalia,
Siberia).
A correspondent stated that ''the tarbagan
epidemic of Siberia is spreading southwards towards
the Chinese frontier. Dead marmots are now found
as far south as Scharasone, which is only thirty-
five miles north of the Russian-Chinese frontier.
Local measures are sufficiently strict to prevent the
disease from entering Manchuria.”’
Manchouli is situated in Chinese territory at the
junetion of the Chinese Eastern and the Trans-
Siberian Railways, and is about ten miles east of
the frontier between the provinee of Heilungkiang
and Siberia. Here are established the Chinese and
Russian Customs for the examination of goods and
baggage passing along the railway from one country
to the other.
Altogether the population of Manchouli may be
estimated as eonsisting of 8,000 Russian civilians,
customs officials, &e., 3,000 Russian troops, and
2,000 Chinese, most of whom are of the coolie class.
Occurrence of Plague at Manchouli and Surrounding
Districts.
In 1908 Professor Zabolotny was in Mongolia and
found plague in the region he visited. Between this
date and 1905 no reliable information as to the
occurrence of the disease in or around Manchouli
could be got. The outbreaks of plague which had
occurred in this district since 1905 were : —
1905.—Plague occurred in August at Dalai Nor
(14 cases) and in Manchouli (4 cases). Total, 18
cases. Bubonie type.
1906.—Plague occurred in Abagaitui (Russian
territory) (15 cases), and in Manchouli (2 cases).
Total, 17 cases. Pneumonic type.
1907.—One case was imported from Transbaikal
territory into Manchouli. Bubonic type.
1908.—There were no cases of plague in Man-
chouli, but there was reason to believe that the
disease was present among the Mongols along the
Argun River. There is some doubt as to the type
of the disease, but it seems probable that it was
pneumonie.
1909.—No cases reported.
1910.— The last epidemic with 400 cases at Man-
chouli. Pneumonie type.
1911.—End of August, 5 cases at Scharasone,
4 deaths. Bubonic type.
1912.—Beginning of September, near Chita
(capital of Transbaikalia), 3 cases, all fatal.
Evidently pneumonic type (confirmed by P. Haff-
kine).
In considering the occurrence of plague at and
around Manchouli, i& must be borne in mind that
the disease is endemic in the Khirgiz Steppes, and
from time to time this has travelled eastwards,
giving rise to sporadic outbreaks in Eastern Siberia.
Concerning the outbreak of pneumonic plague at
Manchouli in the autumn of 1910, the following
occurs in Dr. Ch'uan Shao-ching’s paper read at
the International Plague Conference :—
'* Observations reported to me by Chinese resi-
dents at Manchouli show that two carpenters who
lived in the house adjoining Wu Kuei-ling’s Inn
died with spitting of blood on October 10. These
two carpenters had been in the service of a foreman
named Chang Wan-shun at Dawoolya (Daurija),
a railway station in Siberia situated some six miles
west of the boundary line. Chang Wan-shun told
me that six or seven of his carpenters had died with
blood spitting in Dawoolya on September 16, and
said he believed that plague had appeared in
Dawoolya before it was known in Mancehouli.
“Later on it was found that nine out of twenty
coolies, who lived in a small room in Wu Kuei-
ling's Inn, were suddenly taken ill with blood
spitting. One of them was sent to the Russian
Plague Hospital, and it was discovered that he
suffered from pneumonie plague. Two died in the
house that same night, but the rest ran away to
different places in the town, and thus disseminated
the disease.’ "
Prohibition of Tarbagan Hunting.
During February, 1911, the (Chinese) Prefect of
Manchouli prohibited the hunting of the tarbagan,
the penalty for disobeying this order being two
. months' imprisonment, and a further order in-
creased the punishment to six months' imprison-
ment. ‘
On August 11, 1911, a general order was issued
by the Russian authorities forbidding trade in mar-
mots, including hunting of animals, preparation of
L
Sept. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
skins, salting of the flesh and fat under penalty of
a fine of 500 roubles or three months’ imprisonment.
Up to 1908 comparatively few Chinese hunted
the tarbagan.: In the autumn of that year and in
the autumn of 1909 several thousand Chinese,
attracted by the high price paid for the fur, were in
the neighbourhood of Manchouli, and in 1910 the
number reached 10,000 hunters.
Owing to the Chinese order prohibiting the hunt-
ing of tarbagans, there were fewer Chinese in Man-
chouli during 1911 than formerly.
The [nns.
There can be no doubt the unhygienic nature of
the inns provided for aecommodating fur hunters
has much to do with the spread of pneumonic
plague.
The inns are of two kinds—those entirely under-
ground and those partly above-ground and partly
underground.
The accommodation in both types of inns is based
much upon the same plan. Two, and sometimes
three, tiers of berths for the lodgers are present,
there being just room enough between the tiers for
a man to sit up. In one house I visited there were
40 berths, the measurements of the room being
only 25 ft. square and 14 ft. high. Even in May
the rooms were ill-ventilated and stuffy. In winter,
when all the windows are closed and the fires are
lighted, the stuffiness must be great. The windows
are closed, and there is a heating stove in the
middle of the room. The usual way of heating
these inns is by means of a k’ang on either side of
the central passage leading from the door. A k'ang
is a horizontal brick flue about 5 ft. wide and 2 ft.
high, at one end of which is an opening where is
lighted a fire of wood or kaoliang (millet) stack. At
the other end of the k'ang an opening is made
through the outside wall of the house, and leads to
a chimney for the escape of the smoke.
They sleep in rows with the head against the wall
and the feet towards the central passage. There is
no partition between adjoining berths, so that they
easily breathe and cough into each other's faces,
From 1908 to 1910 so many people came to the
distriets to hunt the tarbagans that the owners of
the inns packed the men in every available space,
extra tiers being added whenever possible above
those already existing.
Note on the Fur Trade at Manchouli.
The tarbagan hunting is divided into two sea-
sons :—
(1) The spring season, lasting from the end of
April to the beginning of June.
(2) The autumn season, lasting from the middle
of August to the end of September.
The early spring fur, owing to its being lighter
in weight, is more valuable than the heavier fur
obtained in the autumn season. The fur of tha
tarbagan is thick, soft, and very serviceable in
winter; but up to five years ago the export was not
great.
It is estimated that in 1910, however, 9,000,000
277
tarbagan skins in all were exported from Manchouli.
In June, 1913, over 4,000,000 tarbagan skins were
lying at Manchouli ready to be carted by road to
Mazijewsskaia for export to Europe.
Owing to the inereased demand for skins and the
consequent rise in price, large numbers of coolies—
and especially those from Shantung—were attracted
to the spot, and the agricultural peasants left their
fields to become tarbagan hunters. The tarbagan
skins are mostly sent to Leipzig and London to be
cured.
Professor Zabolotny mentioned that a tarbagan
had been caught on June 24-26 near Scharasone on
the Siberian side of the border suffering from
plague; the animal died soon afterwards. From
one of the cultures obtained, Zabolotny inoculated
a healthy tarbagan on the right leg, and produced
two large buboes in the right groin only. The
animal died of septicæmia.
Four other tarbagans were suspected to have died
of plague, but it was found later that none of the
cases were plague.
Work ar BonsJa, JuLy 22-29, 1911.
Borsja (Siberia) is 121 versts west of Manchouli
on the railway, and is the centre of tarbagan hunt-
ing in the Transbaikal district. During our stay
there no hunting was being carried on, as this had
been forbidden, but special permits to hunt were
given to skilled Russian hunters, who were in-
structed to bring in specially any sick tarbagans.
Forty tarbagans were kept for observation in the
cages; when we had satisfied ourselves that they
were perfectly healthy they were released, and
others put in their place. In this way about eighty
tarbagans came under observation.
During the week we spent at Borsja no sick
tarbagans were brought in, and none of those under
observation showed any sign of disease.
On the following morning we got up at 4 a.m. to
see if the tarbagan came out from its hole at dawn
seeking food, as some believe to be the case. But
‘during the next six hours we did not see more than
five tarbagans.
We went out all around the neighbourhood of
! Borsja, and although we inspected many holes, no
trace of a sick animal was found. On July 27 a
dead tarbagan was found four versts away, but did
not reveal any Bacillus pestis.
While at Borsja we performed experiments to try
and ascertain if cannibalism was common among
tarbagans. In one of these an animal was starved;
after some days a dead animal was introduced into
the same cage, but at the end of five days the
eareass had not been mutilated.
Worx iN MoNaorr4, AvavsrT 8-14, 1911.
Tarbagan Ta Hu, 30 li south-west of Manchouli,
August 4, 1011, lies near a small lake of briny water.
Mosquitoes were present in enormous numbers, the
air being black with them. They consisted of culex
principally, and Anopheles maculipennis.
Later I found that the Mongols complained of
fever, and sinee anopheles was present in this
neighbourhood, one presumes the disease they com-
plained of to be malaria.
From inquiries made among Mongols, I learnt
that there had never been any outbreak of disease
resembling human plague in their midst. Nor could
I obtain any word of disease among the tarbagans;
the eountry in which they had lived for many years
past abounds in tarbagans, yet they had never
noticed the animals dying.
In the country around Manchouli, although
plenty of tarbagan holes were met with, few of the
animals were seen, and our traps seldom caught
any. The country had been used for pasturage by
the Mongols and large stretches had been fired.
From this it would seem probable that, when food
becomes scarce in one region, the tarbagans migrate
to regions where food is plentiful.
The Mongols.
At Charbada and Kulun See we camped with
Mongols, and thus had opportunities of studying
them and their habits. The Mongols at Charbada
were apparently quite wealthy, though they lived in
a most primitive way.
The huts are round and domelike, measuring
about 15 to 20 ft. in diameter, and consist of a
series of movable wooden framework 4} by 2 ft. in
size, oblong in shape, and covered by felt-matting
made of camel's hair or sheepskins. On the floor
is laid felt-matting, on which the inhabitants sleep.
The furniture consists of a few wooden chests where
clothes and money are kept, a Buddhist shrine, a
cooking pan and stove, and a box containing dried
cattle-dung, which is used as fuel for cooking.
The Mongols drink a large quantity of cows' and
goats' milk, and they eat, besides mutton, a good
deal of tarbagan flesh, which is only half roasted
before the primitive fire.
The Tarbagan or Marmot (Arctomys bobac,
Schreb.)
The species to which the tarbagan belongs is
known in America as the woodchuck (Arctomys
monaz). The Russians called it ''szuriok," and
the Chinese ''Han T’a’’; but the name most
familiar is the one adopted by the members of the
International Plague Conference, namely, ''tar-
bagan,” a term derived from the Mongols.
The rodents are divided into two
namely :—
(«) The simple-toothed rodents, e.g., squirrels,
rats, mice, and poreupines, and to this group the
tarbagan belongs.
(b) The double-toothed rodents, c.g., hares and
rabbits.
The particular variety of marmot found in Man-
churia and Mongolia is identified as Arctom ys bobac,
Schreb. (or the true marmot). :
The following are some of ita
features :—
The body is stout and the limbs are short. The
tail is bushy and comparatively short, being about
one-half the length of the body. The head is wide
and short, and there are no che The
groups,
distinguishing
ek pouches.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15, 1913.
ears are small and more or less rounded. Of the
five toes, the thumb is rudimentary, being supplied
with a flat nail, whilst the claws of the remaining
four are long and exceedingly sharp. The fur is of
moderate length and of a fine texture. The general
colour tends to change at different seasons of the
year, varying from a light greyish brown in the
spring to a reddish brown hue in the late autumn.
On the back and around the eyes the fur is darker
in colour. The length of the adult animal, exclusive
of tail, varies from 15 to 18 in. (37 to 45 em.), and
the weight of the adult animal varies from 9 to
12 lb. (4,100 to 5,400 grm.), being greater as the
hibernating season approaches.
The temperature of tarbagan taken per rectum
presented wide variations in different animals and
in the same animal at different times—even in
apparently perfect health. Thus, in some it was
found to be 959 F., in others 969 F., in others again
979 F., and so on until in one animal 107:69 F. was
registered. This last ease was particularly interest-
ing in that this temperature was taken soon after
capture. It died, however, twenty. minutes after
the temperature was taken, and sixty-one minutes
after capture. At the post-mortem nothing abnormal
was found. In one of the animals the temperature
varied from 98:59 F. to 104:89 F. within the space
of three days.
Distribution of the Marmot.
The marmot inhabits a wide range, but is con-
fined to the Northern Hemisphere. In North
America the common species is the woodchuck, the
distribution of which is from the Carolinas north-
ward to Hudson’s Bay, and westward from the
Atlantic Coast to Missouri, lowa, and Minnesota;
but other species are met with in the Rocky Moun-
tains and in the north-western parts of America,
even as far as the Arctic Regions.
In the Old World, the best known species are the
bobae (Arctomys bobac, Schreb.) and the Alpine
marmot (Arctomys marmota). The region of the
former extends from the south of Poland and Galicia
over the steppes of Southern Russia and the bare
regions of Siberia to Northern Mongolia, North-west
Manchuria, the Amur regions, and so on to
Kamchatka, whilst it is found in elevated regions
as far south as Cashmere, Thibet, and the Hima-
layas, but the southern limits have not been
defined aceurately.
The Alpine marmot is confined to the higher
regions of the Alps, Pyrenees, and the Carpathians.
A small species (Spermophilus citellus, Linn) is
found in abundance in South Manchuria, especially
around the neighbourhood of Mukden. This species
bears little resemblance to Arctomys bobac.
In the regions where the tarbagan abounds, 1t
can easily be seen either running about on its four
legs or standing on its hind legs. On the approach
of a stranger they let fall the front paws, and imme-
diately retire into the burrows, to come out agam
as soon as they feel the danger is past. The tar-
bagan in captivity is a very fierce animal, using his
front feet freely and biting deeply those who come
Sept. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
279
in his way. With his sharp claws he scratches
effectively when carelessly handled. For dealing
with those we had in cages, strong forceps of con-
siderable length had to be made, each blade curved
so as to give a firm grip on the neck or body. When
placed in a wooden cage, lined with parallel bars of
soft iron, 4 in. in diameter, the animal escaped in
a very short time by bending the iron rods with his
strong jaws and by biting the wood of the cage with
his sharp teeth. This same rod an adult was unable
to bend.
Habitat.
The tarbagan regions of North Manchuria and
Siberia are well seen from the windows of the Trans-
Siberian trains between Hailar and Chita, extending
for a distance of 050 versts. The characteristic
mounds are present everywhere, especially to the
north of the line, and not uncommonly the animals
are visible sitting outside the entrances to their
burrows.
Regarding breeding, there is reason to believe that
the tarbagan is not as prolific as the rabbit—two or
three being the average number of young ones born
each season.
The tarbagan hibernates from October to April.
Indeed, marmots seem to be the most thoroughly
hibernating of all mammals, since their sleep is
apparently unbroken, and they lay up only a small
store of winter food, consisting of grass, roots, and
the seeds of plants. With the return of spring
comes renewed activity on the part of the animals,
and they venture into the open. Hence the hunters
choose the months of April, May, and June for
hunting them. July and August is the breeding
season, and the Chinese authorities forbid trapping
during these months. After August they are again
hunted until the approach of cold weather—about
the end of September.
Method of catching the Tarbagan.
The method adopted by the Cossack and Chinese
hunters for catching tarbagans consists of a piece
of medium-sized iron wire, 24 ft. in length, with one
end twisted in the form of a running loop, whilst
the other end is wound firmly around a rough
wooden peg ł foot long. The peg is driven into the
ground immediately above or on the side of the
entrance to the burrow, and the loop is arranged so
that it fits exactly into the opening.
After capture the animal is killed by a method
called '' breaking the neck.’’ Skinning is performed
by incising the two corners of the mouth, separating
the skin from the soft parts of the jaws and then
pulling the complete skin from before backwards
and from within outwards, i.e., the skin is turned
inside out.
Besides using the fur, the Siberian settlers and
Mongols eat the flesh of the tarbagan. When at
Charbada the members of our party partook of the
flesh, and found it tender and the taste distinctly
good, comparing favourably with the flesh of the
rabbit. Considerable quantities of the flesh are
salted and exported to European Russia.
In addition, the fat, which is plentiful under the
skin of the animal, is turned into a valuable kind of
grease, much used by Russian peasants for pre-
serving leather. They also apply it for the healing
of bruises.
Parasites of the Tarbagan.
In its natural state the tarbagan harbours two
kinds of blood-sucking arthropods, namely, the flea
and the tick. The fleas were more numerous on the
animal when freshly caught than after it had been
in captivity for some time. Most of the fleas were
caught in the groins, but often they were distributed
over the whole body. The ticks were usually
attached to the eyelids, but on one occasion we
found two ticks on the abdomen, and none on the
eyelids. The number of fleas per animal varied
greatly even just after capture. All the fleas were
of the same species, namely, Ceratophyllus silan-
tievi, Wagner, 1898.
Biting Experiments with Fleas and Ticks obtained
from the Tarbagans.
The insects were removed from the tarbagans
directly the animals were caught, and were placed
in test-tubes.
The following experiments were carried out :—
Experiment 1.—When at Charbada, some six fleas
in a test-tube, immediately after their removal from
the tarbagan, were given the opportunity of biting
one of us. Even after several minutes none of them
had bitten.
Experiment 2.—August 10, 1911. Ceratophyllus
silantievi, 1d, starved for three days. Then given
facilities for biting the arm of one of the party. The
insect moved about for some minutes before biting.
It chose a spot in a fissure of the skin, and plunged
its proboscis deep in. While sucking its body was
tilted upwards, and the insect was seen to increase
in bulk. It remained thus for eight minutes, and
then, having withdrawn the proboscis, fell on its
side. Afterwards it began moving around less
actively than before.
The person bitten experienced no pain and very
little sensation, both when the flea pierced the skin
and during the time the insect was sucking. After
the flea had withdrawn its proboscis the site of
puncture was barely visible to the naked eye, and
with the aid of a hand-lens a very slight escape
of blood was seen to have taken place from the
puncture. There was no after-swelling or irritation.
The ticks (sp. Rhipicephalus) were collected in
test-tubes, and similar experiments to those with
the fleas were carried out. In no case did a tick
bite the arm of a human being, although the tick
used in one experiment had been starved for eight
days.
EVIDENCE ASSOCIATING THE TARBAGAN WITH PLAGUE.
The tarbagan has been said to suffer from a
chronic form of plague not unlike the form seen in
rats. From time to time epidemics have been
reported as occurring among the tarbagans, causing
them to die in thousands. It has been said that
280
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 15, 1913.
hunters easily recognize the sick animals—these
often being driven out from their holes to wander
about aimlessly until they die. The piteous state
of these animals has been graphically described.
lf a human being takes plague, and has eaten of
the flesh of the tarbagan—a very common food
among the Mongols and Cossacks—it has been
stated forthwith that this is the source of infection.
Indeed, whenever a ease of ‘human plague occurs
in a remote district of the tarbagan country, it is
stated almost invariably that the disease has
resulted from the eating of tarbagan flesh.
It need scarcely be said that before a diagnosis
of plague is established a complete bacteriological
examination must be made. It has been definitely
established that rats suffer from plague, and from
them the disease is conveyed to man. The chronic
form of plague has been found among the gophers
or ground-squirrels (Citellus beecheyi) of the moun-
tains of Western America by MeCoy. Mice and
guinea-pigs are susceptible to artificial infection
with Bacillus pestis. Strong and Teague, Zabolotny,
Dujardin, Beaumetz, and Mosny have shown that
the tarbagan also is susceptible, and Shibayama has
demonstrated that Spermophilus citellus, the small
species of marmot common about Mukden, is sus-
ceptible to plague, though nót so susceptible as the
rat.
Since these rodents are susceptible to plague, and
since the disease occurs in nature among rats and
ground-squirrels, a priori, it is conceivable that it
occurs among tarbagans in nature. — —
An epidemie among the tarbagans was reported
in July, 1911, and the Russian and Chinese expedi-
tions at once visited the country where this epidemic
was supposed to exist. Not only did the expedi-
tions fail to discover a single diseased tarbagan, but
inquiries made directly from the hunters showed
that they knew nothing of the alleged epidemic. In
the experience of these hunters, not only had no
epidemic ever occurred among the tarbagans, but
they had never even seen sick ones. In Mongolia
the Chinese expedition had similar results, nor could
any news be obtained of disease, past or present,
from the Mongol hunters.
Although the tarbagan hunters dispersed in pursuit
of their business, staying away for one or several
weeks, they usually reassembled at the regular
camps, there to skin the animals captured, yet there
is no history of plague among them. Moreover,
although millions of tarbagan skins were exported
yearly to Europe, and thus handled by hundreds,
perhaps thousands of people, from the hunter and
the railway porter to the factory labourer, no case
had ever been reported of plague infection in human
beings during the transit of such skins. It is also
very doubtful whether plague occurs as a result of
eating plague-infected flesh. As bearing upon this
question, the following may be quoted: ‘ In many
instances during the Manchurian epidemic, the
patient with pneumonie plague must have swal-
lowed enormous numbers of plague bacilli in the
suliva and sputum. Nevertheless, in none of the
necropsies performed during the epidemie were
evidences of primary intestinal infection present,
nor was serious involvement of the intestine encoun-
tered. This fact certainly strongly speaks against
the evidence of primary intestinal plague in man,
and would seem to show that even if the intestines
are sometimes secondarily involved, this condition
in human beings must be also a very rare one"
(Strong and Teague).
The only definite proof that tarbagans in nature
are affected with plague is obtained from the animal
caught by Dr. Issaief, June 24-6, in Scharasone,
and examined by Dr. Zabolotny.
To conclude that a man whose occupation is that
of a tarbagan hunter, and who takes plague, has
been infected from a tarbagan, is comparable to
concluding that a man who sells rice, and who
develops plague, has been infected from the rice.
CONCLUSIONS.
Even though the tarbagan occasionally suffers
from plague the epizootie is never extensive, and
the animal does not play nearly so important a réle
in the spread of plague as does the rat. Indeed,
its direct relationship to human plague may be
considered negligible.
From the writings of Russian authorities, it
appears that plague has existed for many years in
various parts of Siberia, sometimes in the bubonie
form and sometimes in the pneumonic form. These
places may be looked upon as endemic foci.
Other papers and discussions will appear in a
subsequent number of the Journal.
INDIANS, WITH
ENTERIC FEVER IN
SPECIAL REFERENCE TO ITS OCCUR-
RENCE IN THE INDIAN ARMY.
CAPTAIN R. A. Cuampers, I.M.S., in à paper on
Enteric in Indians, stated that it is now an accepted
fact that enteric fever is a common enough disease
amongst Indians. The disease is much rarer in the
Indian Army than among European soldiers, but
there is a marked increase in the prevalence of
enteric fever amongst those classes of Indians for
whom statisties are available, viz., Indian troops
and Indian prisoners.
The mortality amongst Indians appears to be
higher than amongst Europeans either in tropical
or in temperate climates, for amongst European
troops in India the average mortality from 1894-
1911 was 22 per cent., whereas, for natives of
India, Rogers, in his Caleutta series of 50 cases,
had a mortality of 26 per cent., and in my series
of 68 cases the mortality was 28:5 per cent. Unless
the relative. immunity to the disease enjoyed by
Indians be due to attacks during childhood (and the
evidence in favour of such a supposition is conflict-
ing and inconclusive), a low ease mortality might
be expected. From the fact that during the past
four years the case mortality shows a distinet ten-
deney towards deerease both for Indian troops and
Indian prisoners, one is tempted to speculate
whether the ease mortality is not really much lower
Sept. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
281
than the available figures show, and that more
accurate diagnosis, by the inclusion of the milder
cases, is bringing us to a more correct estimate of it.
Captain Chambers’ experience of enteric fever in
Indians is based on 45 cases which were under
his care in the Indian Troops Hospital in Quetta
during a period of four years, and 23 cases under
his colleagues.
Women and children are not treated in military
hospitals for Indian troops. They are treated in
“heir houses, and the absence of hospital facilities,
for continuous observation and bacteriological
diagnosis, probably accounts for the small numbers
of women and children in statistics of the Indian
army, rather than a lesser degree of prevalence.
Mortality.—lifty-two recovered and sixteen died;
a case mortality of 28:5 per cent. No case is
included in the series which was not confirmed by
one or more of the following methods :—
(1) The recovery of the specific bacillus from the
blood.
(2) A positive serum reaction.
(3) The isolation of B. typhosus from the urine
or feces.
(4) Post-mortem examination.
Diagnosis.—(1) The method of blood-culture was
employed in 42 cases; 4-5 c.c. of blood were
obtained by vein puncture, and transferred to the
eulture medium, which consisted in 25 instances
of sterile oxbile, and in 17 instances of 100 e.c. of
a sterile 1 per cent. solution of taurocholate of soda
in water. The latter method gave 16 positive
results out of 17 examined, the former 10 out of 25.
The earlier in the disease the culture method 1s
used, the greater the proportion of positive results.
Seventy-seven per cent. of the cultures examined
up to and ineluding the sixth day were positive,
and of those examined from the seventh day
onwards only 37:5 per cent. were positive.
(2) The serum reaction was carried out in 45
cases. In 6 of these a positive blood-culture had
been obtained.
(3) Isolation of B. typhosus from the feces or
urine. The bacillus was recovered from the fæces
in 5 cases, and from the urine in 2 cases.
(4) A post-mortem examination was made in
3 of the fatal cases, and in each of them peri-
tonitis due to a perforated typhoid ulcer was found.
The intestinal lesions were characteristic. Two of
these cases were definitely diagnosed ante mortem,
but in one the cause of the peritonitis was only
discovered at the post-morlem.
Symptoms.—(1) Onset and prodromal symptoms.
The onset was sudden in 6 cases. Headache of
a severe nature hus been noted in several cases.
Epistaxis has been noted in 13 cases only.
(2) The typical enteric appearance of apathy and
low decubitis has been noted in a majority of the
cases, as also the coated tongue, frequently with
red edges.
Typical spots were observed only thrice.
(3) The pulse. A slow pulse in relation to the
height of the temperature has been frequently
noted.
Dicrotism, during the first week, especially when
assoclated with a slow pulse, is in my opinion of
diagnostic significance. Latterly, a slow dicrotie
pulse with a high continued temperature has always
excited my suspicion, and has been the indication
of the necessity for an immediate bacteriological
examination of the blood. The value of this sign
was especially impressed on me in two cases
admitted with signs of lobar pneumonia. Both had
slow dicrotic pulses, which raised the suspicion of
a typhoid origin. This suspicion was made a
certainty by the recovery of B. typhosus from
the blood in both cases. In the ordinary pneu-
monia a fast dierotie pulse is the common state of
affairs.
Pulmonary complications were of frequent occur-
rence. Bronchitis was noted in 19 cases, or 28 per
cent., and primary pneumonia in 9 cases, or 18:2
per cent., giving a total of 41:2 per cent. for both
conditions. The pneumonia was mainly broncho,
but in 3 cases there was definite lobar consoli-
dation.
Diarrhoea was present at some stages of the
disease in 23 cases, or 36°5 per cent. In 40 the
motions were normal or constipated. In 5 the
condition was not recorded.
Abdominal symptoms are frequently absent. In
16, or 23°5 per cent., of the cases it is definitely
recorded that there was neither pain, distension, nor
tenderness at any stage of the illness. In 21 either
pain, tenderness, or distension was noted. In 10 a
negative abdomen was noted on admission only and
no further observation made, and in the remainder
the condition of the abdomen was not recorded.
According to some observers (Ker, Davidson) the
absence of the superficial abdominal reflexes is
of diagnostic significance. In 23 cases of this series
in whieh they were tested they were absent in only
five.
The spleen was noted to be distinctly enlarged in
20 cases.
PRESENCE OF MALARIA PARASITES IN THE BLOoob.
In the early stages of enteric fever the true
diagnosis is liable to be obscured, and more
especially in those cases with the remittent type
of pyrexia—which are not uncommon—by the find-
ing of malaria parasites in the blood. If, in addi-
tion, the spleen is considerably enlarged and firm,
it is a natural mistake to be satisfied with a
diagnosis of simple malaria, But if these signs
co-exist with a slow dicrotic pulse, and the pyrexia
is not influenced by quinine, immediate resort
should be made to bacteriological methods of
diagnosis.
Of the 45 cases observed by Captain Chambers,
22 per cent. showed evidence of malarial infection.
Kala-azar as a cause of splenic enlargement does
not exist in Baluchistan. Lest it be thought that
the presence of malaria parasites in the blood of
enteric fever patients is an unimportant coincidence,
it should be noted that in 5 of the above 10 cases
the temperature curve was of the remittent type
and not of the typical high continued type. l
989
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1913.
THE TEMPERATURE CURVE.
Duration.—The following table gives the data :—
Under 15 days 15-21 days 22-33 days Over 83 days
CASES
Recovered 6 ... 26 as 15 eis 5
Died B: ok 2 VN 5 S 1
Total 14 ... 28 P 20 ray 6
20:6 per cent. 41:2 percent. 29:4 percent. ^ 8:8 per cent.
The percentage of 8:8 (6 cases) non-fatal cases in
which the pyrexia was under fifteen days' duration
is deserving of note, as such cases are particularly
liable to be overlooked. The percentage of 8:8 cases
with fever lasting over thirty-three days should be
compared with Rogers’s percentage of 20 in
Europeans in India, and also the total percentage of
61:8 of cases in which the duration of pyrexia was
twenty-one days and under, should be compared
with Rogers’s 35/7 in Europeans in India. It is
evident, therefore, that the average duration of the
fever in Indians is much shorter than in Europeans
in India, and corresponds more closely with the
duration in Europeans in temperate climates.
The Type of Fever.—The classical step-like rise
was well marked in 7 cases. It was much
commoner, however, for cases to be admitted with
a high temperature of 1039 or 1049 F., and for the
chart not to show a gradual rise during the first
week.
The Stage of Continued Fever.—Adopting Rogers's
method of describing the types in this stage, high
continued fever was present in the great majority
of the cases, i.e., a temperature keeping persistently
above 1019 F., and not varying over 2° F. for at
least forty-eight hours.
Of the 68 cases 50 had high continued fever, 18
intermittent, remittent, or low continued fever.
Stage of Decline.—The temperature was fre-
quently intermittent during this stage. It was
prolonged in 6 cases only. :
Stage of Convalescence.—In the great majority of
cases the temperature reached the normal line by
lysis, and did not again rise above this point. Re-
lapses occurred in 4 cases only, and were of short
duration.
Complications.—Perforation occurred in 4 cases.
The diagnosis of perforation was confirmed in 3
enses by post-mortem examination, and in 1 ease
during operation. The case operated on died.
Hemorrhage occurred in 5 cases. In
them it was slight, and both recovered.
Thrombosis and phlebitis did not occur in any
of the cases. i i
Captain Chambers’s summary and conclusions
are :—
(1) The mortality is higher than amongst
Europeans either in tropical or temperate climates.
(2) The most valuable method of diagnosis is the
_ early use of the method of blood-culture. It is most
successful if carried out before the seventh day, and
in my series the taurocholate of soda medium has
given the largest proportion of positive results.
(3) A slow pulse, in relation to the degree of
2 of
'Eijman's work), 1900.
pyrexia, is of great diagnostic significance, and early
dicrotism is of importance. Dr. Davidson, of the
Travancore Church Mission, has applied sphygmo-
metry in enterie for the confirmation of the low
blood-pressure. To the trained finger dicrotism
gives almost equally valuable information. I have
never observed dierotism in uncomplicated malaria,
and in pneumonia, not of typhoid origin, the pulse,
though almost invariably dicrotic, is generally 100
to 120 per minute.
(4) Malarial and typhoid infections may co-exist.
The diagnosis may thus be obscured, and the tem-
perature curve may be modified to an appearance
of a malarial infection.
(5) High continued fever is the general rule, but
other types are not uncommon, and in some in-
stances are exceedingly atypical.
(6) Complications are exceptional.
BERIBERI.
PROFESSOR EIJKMAN opened the discussion on
beriberi by a paper giving the history of his own
investigations on beriberi and of those of observers
in various parts of the world.
An illustration of this important paper will appear
in the next issue of the Journal.
SOME RESULTS OF MEASURES TAKEN AGAINST
BERIBERI IN BRITISH MALAYA.
Dr. W. L. Bnappox, M.B., B.S., F.R.C.S.Eng.,
contends that the cause of beriberi is now known,
and gave some details of the successful results of
the practical application of that knowledge.
The first important evidence of the alimentary
origin of beriberi was given by Van Leent in 1880,
Takaki in 1885, and by E. Van Dieren in 1888.
Eijkman’s discovery of polyneuritis of fowls in
1889, due to defect in their food (rice), has proved
the foundation of modern, more precise knowledge
of mode of causation of beriberi.
Further evidence of origin from food as a cause
of:beriberi has been given by Sakaki in 1892; by
Braddon in 1898 and onwards; Grall, Vincent and
Porée, 1895; Vorderman, 1897; Laurent and
Brémaud, 1899; Grijns (confirming and extending
From this date onwards
many observations affording positive evidence of
defect in food, particularly in rice, as the cause has
been contributed by Haynes, Anderson, Saneyoshi,
Littlefield, Uchermann, Pétit, Hulshof and Pol.
None of these observations are, however, con-
vineing. The first complete epidemiological proof
that beriberi (among native rice-eaters) depended
solely on the kind or condition of the rice eaten
was furnished by Dr. Braddon in 1904 and 1907.
The general evidence then given has been con-
firmed later by special experiments, such as those
of Fletcher in 1907; and the experiment with free
coolies in Jelebu, conducted by Braddon, Fraser
Sept. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
283
———————————————————————————MM M HH M MMMM————
and Stanton, wrongly published by the latter two
as their work alone.
The proximate cause has been defined by this
evidence with certainty, and by the efforts of later
investigators directed to isolation from foodstuffs
of protective principles, the absence of which
caused beriberi, according to the observations of
Schaumann, Aron, Chamberlain, Simpson and
Edie, Cooper, Funk, Hopkins, Moore, &c.
The Theory in Practice.—Epidemiologically, and
speaking broadly, among rice-eating natives beri-
beri is due to nothing more or less than the use of
rice which has been deprived of most of its surface-
layer of cells containing aleurone—which has in
fact. become ‘‘ deglutenized," and the application
of this principle by Dr. Braddon’s efforts wholly
bears out the idea.
In PREVENTION OF BERIBERI.
(1) In the Singapore Prison beriberi constantly
prevailed (with a single interval) since 1869. The
disease was abolished for good and all in 1904
simply by substitution of whole (** cured,” or ** un-
polished '’) rice for the white (‘‘ uncured,” or ** un-
polished "') sort formerly in use.
(2) In the prisoners of the Federated Malay
States he obtained the same result.
(3) In the Singapore lunatic asylum beriberi pre-
vailed from its foundation in 1889, attacking three-
quarters of the inmates, and caused the death of
30 per 1,000 annually. This continued, until in
1905 the writer's proposal was adopted, viz., the
substitution of whole for white rice. On this the
disease wholly disappeared.
(4) The Selangor lunatic asylum—an even worse
record. Here the attack-rate was over 150 per
cent., and death-rate fromm beriberi at times 50 per
cent. On the adoption of whole rice the disease
at once disappeared.
Fletcher’s experiment, designed to overthrow
the writer’s ''rice-theory," carried out in this
asylum, afforded a triumphant indication of the
truth of the theory.
In REDUCTION oF CASE-MORTALITY FROM BERIBERI
IN HospiraALS—INSTANCES.
(1) Tan Tock Seng’s Hospital, Singapore.—An
average of about 1,000 admissions for beriberi
annually, death-rate often over 50 per cent. Imme-
diate reduction on adopting whole rice; from 48
per cent. to 174 per cent. Now 10 per cent.
(2) Durian Daun Hospital, Malacca.—About 500
cases annually. Average death-rate formerly 30
per cent.; whole rice reduced it to 0'2 per cent.
(3) Jasin Hospital, Malacca.—Average 113 cases,
average mortality 24 per cent. In year of adoption
of whole rice mortality 41 per cent. Immediate
reduction to 9:2 per cent.
(4) Batu Gajah Hospital, Perak.—Average ad-
missions 450, mortality between 21 and 65 per cent.
Immediate. reduction on adoption of whole rice
from 60 to 16 per cent.
(5) Kampar Hospital,
Perak.—Average admis-
sions 356. Mortality 46 per cent. previous year
reduced to 16 per cent. in year whole rice adopted.
(6) Christmas Island Hospital.—Average 850
cases admitted. Mortality reduced from 10 per
cent. before to 2 per cent. after the introduction
of the whole rice.
In thirteen principal hospitals of Malay admit-
ting some 3,500 cases of beriberi annually and
having the worst mortality, the death-rate has been
brought down from an average of over 30 per cent.
to under 15 per cent., in other words, a saving of
at least 500 lives effected annually.
In every hospital whole rice has now been
adopted with in every case the same marked
results.
A comparison of the Straits Settlements as a
whole with the separate Native States is made, and
results of equal significance noted. In Negri
Sembilan, which has not employed white rice in
the patients’ dietary for the last thirteen years, the
case-mortality has not once reached 10 per cent.
during that period, and generally under 5 per cent.
Some 10,000 cases in all are treated in the Straits
Settlements and Federated Malay States annually.
The reduction in mortality from a former general
average of over 30 per cent. to a present one of
about 10 per cent. means the saving each year of
2,000 lives—the first harvest of the practical appli-
cation of the '' rice-theory.”’
The following resolutions are proposed by the
writer :—
(1) It is recognized by the Congress that among
natives whose food-staple is rice, beriberi is pro-
duced by the continued consumption of the grain
in the form of '' white " rice, or rice which has
been deglutinized or altered by the removal of
essential principles in milling.
(2) Rice in this condition is unfit for use as a
food-staple, and must be in this respect described
as a noxious article injurious to health.
(3) This section urges upon all authorities
responsible for the ,health of native communities
the propriety of restricting or preventing the sale
and use as a foodstuff of rice which has been thus
altered.
(4) In view of the now proved non-infectious-
ness of beriberi this section recommends to all port
and sanitary authorities the propriety of abolishing
quarantine and other restrictive measures at present
operative against the disease.
THE PRESENT STATE OF THE STUDY OF BERI-
BERI IN JAPAN,
Dr. S. Sutpayama, Tokyo, stated that the com-
mission for the study of the cause and prevention
of beriberi, formed in 1908 in consequence of the
fierce epidemic which broke out in the Japanese army
during the late war, deemed it necessary to deter-
mine what relations exist between the two allied"
diseases kakké and beriberi, came to the eonclusion
that they are identical. Since then the commission
284
has issued various reports, which may be classed
as follows: (1) Experimental study of the beriberi-
like disease in birds; (2) prevention of beriberi with
cured rice or a mixed diet consisting of rice and
barley; (3) epidemiological observations.
EXPERIMENTAL STUDY OF THE BERIBERI-LIKE DISEASE
IN Binps.
(1) Fowls, especially hens, pigeons, &c., die of
a beriberi-ike disease when they are fed with
" white” rice, i.e., rice the bran of which is
separated by pounding, so that it presents a semi-
transparent colour, but the administration by the
mouth or subcutaneous injection of rice-bran or its
derivatives, e.g., aleoholie extracts, will cure them.
(2) As to the cause of the beriberi-like disease in
birds that is contracted by feeding on white rice,
the Japanese workers disagree with Schaumann and
Fraser, who advoeate the phosphorus starvation
theory. Though the insufficient phosophoric con-
tents of white rice may cause kindred symptoms in
animals, the true cause is held to be other than
phosphorus itself. Dr. Suzuki, chemist, attributes
the disease to the lack of a material called '' aberic
acid," which he removed from rice-bran by a com-
plicated method; for even a small dose of this acid,
i.e., 0°005 mg. daily, will protect a 300 gr. pigeon
fed with white rice from contracting the disease.
(8) Others hold the zymotie hypothesis. They
attribute the disease to a toxin produced by the
fermentation of white rice, and not to the deficiency
of a certain kind of nutriment. This hypothesis is
based upon the results of an experiment in which
fowls contracted a beriberi-like disease, similar to
that caused by feeding on white rice, from an
injection of a fermentative product of white rice;
they were led to this by the fact that the heart of
a frog will stop in diastole if it is immersed in a
fermentative product of rice produced by a certain
kind of enzyme, just as it will in the milk of a
beriberic woman.
(4) Our Japanese experimenters may be divided
into two schools. One considers the beriberi-like
disease in birds caused by feeding on white rice to
be identieal with human beriberi, while the other
thinks these two diseases are quite independent.
One school points to the fact that clinically the
beriberi-like disease in birds resembles closely that
met with in human cases. The other (the majority)
disagrees with the first on the ground that, although
bird-beriberi may present similar symptoms and
anatomical findings to a certain degree, it does not
always do so. The curative effect of rice-bran and
its derivatives upon bird-beriberi seems to afford
the most interesting analogy to human beriberi, for
it would serve to a large extent to establish the
identity of the two diseases; but many experi-
menters eonsider that these substances do not eure
hüman' beriberi, or at most, they do not think that
they have brought about such a marked improve-
-* weht inéhe human as in the birds’ discase.
*8 «ui we admit the conclusion reached by the latter
sc Bol, We Foe that the study of the beriberi-like
THE JOURNAL OF TROPICAL MEDICINE AND: HYGIENE.
[Sept. 15, 1913.
disease in birds has but little to do with the dis-
covery of the causative agency of human beriberi.
EXPERIMENTAL STUDY OF THE PREVENTIVE EFFICACY
oF CURED Rice AND A MIXED DIET, CONSISTING
oF Rick AND BARLEY, UPON HuMAN BERIBERI.
Experiments to determine these points were
carried out in coal mines where the miners had
been yearly affected most severely and in a fishing
village where the inhabitants had also suffered
severely. In both places the inhabitants were
divided into groups consisting of a certain number
of persons (usually 100); during the beriberi season
seven months from the beginning of April to
the end of October) one group was provided with
cured rice, another with the mixed diet consisting
of rice and barley, while a third was given white
rice as control, the object being to determine which
group provided the largest number of patients. It
was possible to make the main diet uniform, but
unfortunately not the side dishes. The experiment
was earried out twice in each place, and showed
that neither the cured rice nor the mixed diet of
riee and barley is able absolutely to prevent the
disease, though they seem to play some part.
EPIDEMIOLOGICAL OBSERVATIONS IN BERIBERI.
In Japan every year beriberi appears sporadically
like typhoid fever. However, particularly in villages
or on board ship, a severe outbreak often takes
place. Coal-miners, fishermen, railway labourers,
and prisoners are the classes among which the
epidemic rages.
The causative relation which is supposed to exist
between rice and beriberi has been studied most
carefully in many epidemics. Most of these pre-
vailed among people who ate rice, but some raged
among those who took a mixed diet consisting of
four parts of rice and six parts of barley. From
the facts that have been given in the previous
paragraphs, some arrive at the conclusion that rice
is perhaps the cause of beriberi, but they cannot
deny the fact that all the labourers who eat rice
and live in the same surroundings do not contract
the disease. This seasonal prevalence is noticed
in almost all epidemiological observations of the
disease.
RÉSUMÉ.
Those who are studying beriberi in Japan have
not yet been able to arrive at any conclusion. Rice
as well as a monotonous and one-sided diet may
give rise to the onset of the symptoms, but they
cannot be assumed to constitute the cause of the
disease. The symptoms and anatomical changes
seem to develop from intoxication by a poison which
is produced by a certain kind of micro-organism in
the human body, especially the intestine. This
hypothesis may explain the geographical and sea-
sonal prevalence, for if the disease were caused
exclusively by deficiency of a certain kind of
nutriment, we do not see why it should not occur
among other nations as well as the Far Eastern.
Sept. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 285
Discussion.
Proressor Dr. B. Nocut, Hamburg, said: I
fully agree with the excellent historical and
critical résumé of Professor Eijkman on the actual
standing of the beriberi experiments. Therefore,
my remarks. are not really necessary, but as one
will expect to hear my opinion on the matter, I will
add the following :—
I quite agree that Professor Eijkman deserves the
first honours in this latest step in our knowledge of
the etiology of beriberi. “His first experiments on
animals, and the experiments carried out by him
and Vordermann in Java on the feeding of beri-
beri patients, form the starting-point of all further
researches. I am not going to explain how the idea
arose that Eijkman in the first place wished. his
animal and human beriberi to be explained by
poison formation and effect. It is sufficient for me
to-day to note that Professor Eijkman has person-
ally stated that he proposed this poison theory only
to deny it later on.
Grijns was the first man who suggested to me
with the greatest assurance that beriberi was due
to the lack of certain unknown material in the food:
stuffs, i.e., that it is due to a kind of partial hunger.
I would like to note with modesty that I, without
knowing of Grijn's opinions, was the first to order
systematie experiments to be made in my institute
in the search for these lacking substances which I
had suspected. These experiments have been
carried out by Herr Schaumann, and have led to
the formulation of his theory of lack of phosphorus.
This theory has found many opponents, and
Schaumann himself has modified it. At any rate,
Schaumann deserves to be recognized as the first
to have found determinate groups of elements which
come in the consideration of the etiology of beri-
beri. One may differ from his conclusions, but at
any rate the phosphorus question is by no means
worked out, and further experiments are necessary
to show whether phosphorus free foods, which,
according to Funk, are now called ‘‘ Vitamine,” are
not perhaps strictly connected in nature with
phosphorus containing substances, and also whether
the exchange of phosphorus containing food is not
of the greatest importance, at least in certain forms
of experimental beriberi in animals as well as in
man. This we must leave to the physiological
chemists. The clinicians as well as the practical
hygienists must for the present confine themselves
to the fact that phosphorus is the standard by which
they must judge the prophylaxis and the question
of a systematic diet. Further, we must accept as
a fact that there is a surplus of vitamine, whether
phosphorus free or phosphorus containing. In 1909
in my note on the beriberi question, given before
the German Society of Tropical Medicine, I ex-
pressed the opinion that we must accept the fact
that the different forms of beriberi are due to the
lack of certain substances, x, y, Z, &e. At that
time I explained that Schaumann had discovered
the traces of one of these '' x's," and I state that
even Funk's vitamine represents only an “x” in
the mass of lacking material. Vedder and Clark
are also of this opinion. Naturally, these substances
need not be unknown to us; it is sufficient to prove
the importance of the food exchange. Naturally,
it is not excluded that the effect is only indirect and
more complieated than we at first thought.
This last work induces me to say a few words on
the pathological anatomy of beriberi. Vedder's
and Clark's observations coincide with mine. A
general degeneration of the nervous system takes
place, especially in the central organs, similar to
that observed in certain infectious diseases. I point
this out specially, as we should always speak of the
alimentary nerve degeneration in birds and other
experimental animals and in man, and should no
longer speak of polyneuritis. I should also like to
speak of the róle of infective influences in beriberi,
and of the local and seasonal relation to the disease.
It is known that change of weather and fatigue play
an important part in the outbreak of beriberi; the
same may be said of wounds and accidents. We
are also told that intestinal catarrh, which may
often be of infectious origin, very often is an
incipient symptom of the disease.
It has been determined by Rumpf and Luce that
often in mild cases of beriberi advanced nervous
degeneration may be observed, so much so that one
must expect them to have existed long before the
first clinical signs of the disease appear. Vedder
and Clark have observed the same characteristics
in fowl. It may be compared with alcoholic nerve
degeneration. To these occasional predisposing
causes must be added also infectious influences.
That explains how intestinal catarrh may be a cause
of a sudden outbreak of beriberi.
In my opinion the therapeutical use of rice-bran,
yeast, and similar stuffs have been of no use what-
ever, and I think that is also the conclusion come
to by Isuzuki, although this observer fully believes
in his ‘* Antiberiberin.''
It is interesting to note that the mild and early
cases, such as the so-called sailing-ship beriberi,
improve very rapidly by supplementing tinned food
for fresh food without any further special thera-
peutic preparations being employed, whilst the
advanced deformed cases heal very slowly. In our
therapeutical experiments at Hamburg Institute we
have had the same results with fresh food as when
we added rice-bran, &c.
We have no certain results with parenteral appli-
cations. On the contrary, we have had complaints.
We have, however, dealt with no case of fulminant
heart insufficiency. In such cases the parenteral
application with extracts might be successful.
Therapeutically, and according to animal experi-
ments, we would expect in these cases life-saving
results. At any rate, I believe, until I hear of any-
thing better, that raw foodstuffs are more reliable,
and can be used therapeutically in a greater number
of cases than the chemically prepared, sterilized
and isolated vitamine, because a single such vita-
mine represents, in my opinion, only one of the
factors, whilst we need a mixture of several vita-
mines, viz., such as we find in raw food and in the
first extracts from raw food. At present, however,
we are not able to artificially prepare these different
mixtures of vitamine.
286
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1913.
AND SWOLLEN GUMS IN
INDIAN TROOPS.
CoLoneL P. Henir, I.M.8., Assistant-Director of
Medical Services, Burma Division, called attention
to the prevalence of a condition of ulceration,
sponginess, and swelling of the gums met with in
Indian troops; it is frequently associated with some
denudation of the epithelium, of the tongue, small
ulcers, and a greater or less degree of oral sepsis.
One sees some cases of it in almost every Indian
battalion one inspects, and that at all periods of
the year. The pathological state appears to be one
of ulceration with suppuration of the margins and
inner surfaces of the gums, so that, for want of a
better name, one has called it suppurative gingivitis.
Its chief incidence is during the hottest summer and
early autumn months, when men have run down
from the effects of the hot weather, or possibly from
an inadequate supply of fresh vegetables which
occurs at that time of the year. It is specially
common during our Indian Frontier Campaigns,
particularly campaigns lasting over three or four
months. At the end of the Tirah Expedition of
1897-8 some regiments had as many as 40 per cent.
of men afflicted with it. The condition occurs also
in the civil population at the seasons mentioned,
especially during periods of drought and scarcity.
It is not associated with dental caries. Our
European troops are not affected by the malady.
The condition is painless, and, as a rule, the men
do not know anything about having it. At first
sight it has the appearance of pyorrhcea alveolaris,
and one has known at least half a dozen military
medical officers diagnose it as such. But unlike
that very chronic and somewhat formidable malady,
it is curable in a fortnight or so with local appli-
cations, such as tincture of iodine, and antiseptic
mouth washes, without any loss of teeth. In a
Gurkha battalion inspected in September, 1911, one
found 130 cases of it in a severe form, and more
than half the regiment with it in a mild form. In
this instance it took several months’ treatment to
eradicate the malady entirely from the battalion.
In some cases the gums are so swollen that the
teeth appear to be almost buried in them. In such
cases the gums are congested and bleed readily on
pressure. In others the margins of the gums have
atrophied, receded, and exposed the whole of the
crowns and part of the fangs of the teeth, and
present a thin ulcerating margin. Generally a large
area of the gums of both upper and lower jaws is
involved, thus contrasting with pyorrheea alveolaris,
in whieh, exeept in the advanced stage, the disease
is localized to the gum opposite one tooth or a few
teeth. Sometimes the atrophy of the gums will be
found associated with the accumulation of masses
of dirty greyish or cream-coloured tartar on the
outer aspeet of the teeth, rarely on the inner
surface also. Such masses may at times also be
found beneath swollen gums. On scaling off these
masses of tartar we expose an ulcerating gum which
may be very offensive. In these tartar cases the
cleaning of the teeth has been neglected, because
ULCERATED
the patients have found the ordinary process of
using the frayed end of a stick as a tooth-brush
painful. "These blocks of tartar are unlike the small
greenish patches of cretaceous material found
beneath the pockets of the gums in some cases of
pyorrhea alveolaris. In a small percentage of cases
the gums are tender, which renders mastication
difficult and painful. These are the only cases that
seek treatment of their own accord. There is often
slight foulness of the breath, exceptionally a very
offensive odour is given off, due probably to the
presence of miero-organisms which generate indol
in the disease area. In all cases a small quantity
of mixed creamy pus and mucus exudes between
the gingival border and the teeth when the gum is
pressed with the finger. The condition itself, if not
grossly neglected for a long time and masses of
tartar have not formed, does not appear to endanger
the integrity of the dental structures.
Signs of infection of the alimentary canal, such
as ‘‘ catarrhal dysentery ’’ or diarrhea, are common
in men with affected gums.
The chief miero-organisms one has found in
stained smears made from the pus have been strep-
tocoeci and staphylococci, and the ordinary flora
inhabiting the mouth ; in several cases one has seen
an amceba very similar in morphological characters
to Eniamaba coli in association with one or other
kind of the bacterial forms named; this amoeboid
organism was never found to be anything like E.
histolytica; in three cases a short, plump, Gram-
staining bacillus was seen.
The condition is similar in some respects to that
often seen in the incipient stage of land scurvy met
with in the civil population of the poorer classes in
India; rarely it is associated with more positive and
general manifestations of the scorbutie taint, such
as anemia, extravasations into the muscles, rheu-
matic-like pains in the joints, dysenteric symptoms,
&c. Like scurvy, in the large majority of the more
severe cases it yields to anti-scorbutic treatment
and oral antisepties. It seems in India and in
Indian frontier warfare to precede for some time
the appearance of the actual signs of developed
seorbutus. It was very prevalent in Somaliland in
1903-4 before the outbreak of actual seurvy, and
it there, us in India, predisposed to bacillary
dysentery.
It is, as previously stated, remediable. Its pre-
valence in an Indian battalion indicates that there
is something defective in the feeding of the men.
The periodieal examination of the gums of Indian
troops is important, and should be made at all
medical inspections of these troops as to their state
of health.
Colonel Hehir had no theory to advance regarding
the intrinsie nature of this diseased condition of the
gums, and with reference to its etiology the only
fact one can bring forward is its association with a
defective dietary. During the last six years one
has met with over 2,000 eases in thirteen Indian
infantry battalions inspected.
Sept. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
287
THE PROBABLE IDENTITY OF PELLAGRA
AND SPRUE.
Dr. CuanLEs E. Stewart, Battle Creek, Mich.,
U.S.A., drew attention to many points of similarity
between pellagra and sprue. He considers that
sprue and pellagra are so much alike that we are
justified in concluding that there is a very strong
possibility of their having a common etiology. This
conviction has been further strengthened by the
fact that the diet which gives the best results in
cases of sprue, viz., milk and strawberries, in his
hands, also gives equally good results in cases of
pellagra.
In the differential diagnosis of pellagra and sprue
there is only one symptom which calls for serious
consideration, namely, the cutaneous lesions which
are so frequently found in cases of pellagra, and
from which the disease receives its name. From a
study of the literature and from personal observa-
tions of these two diseases, it is apparent that
cutaneous lesions are quite common, and more or
less characteristic in cases of pellagra, while in cases
of sprue, characteristic eutaneous lesions have not
been observed.. Nevertheless, some of our best
pellagrologers describe cases of pellagra-sine-pellagra,
and in 2 cases of sprue, one from Porto Rico, the
other from Central America, there are skin lesions.
In both, the dorsum of the hands was of a dark red
colour, rough and parchment-like ; in one there were
recurring ecchymotie areas such as Hyde described
as occurring in cases of pellagra.
Dr. Charles Begg states that the loss of sub-
cutaneous fat results in visible changes in the skin
and hair; the skin becomes dry and rough, and the
hair loses its lustre, and may become brittle and
fall out.
Authorities on pellagra are by no means unani-
mous in their opinion that pellagra is always
accompanied by cutaneous lesions. Marie has
observed that there are pellagrins in whom there
are no disorders of the skin or of the digestive
organs, and who suffer most from general debility
and motor disturbances, such as vertigo.
Cipriani noted local differences in the symptoms
of pellagra, where the cases were slow and inter-
mittent in their course, and rarely accompanied by
erythema.
Wood, in his recent work on pellagra, writes as
follows: *' We have been told that in the London
School of Tropical Medicine the students are taught
to diagnose pellagra without the presence of skin
manifestations. Certainly such teaching would be
unwise in the southern states, if for no other reason
than because of the fact that in this region there
also occur sprue, Cochin-China diarrhea, and
amcebie dysentery. Sprue especially complicates
the question, for the reason that its symptoms,
except for the absence of skin manifestations, are
almost identical with pellagra. After a careful
study of the two diseases, one is unable to distin-
guish so-called * pellagra-sine-pellagra ' from sprue.”’
He is of the opinion that it is highly improbable
that pellagra-sine-pellagra exists, and that a descrip-
tion of this form owes its existence to the fact that
there are cases of pellagra in which the skin mani-
festations are at times so insignificant as not to
attract attention even from the patient. He has
also observed that the insignificance of the skin
lesions does not necessarily indicate a mild form of
the disease; on the contrary, many of the most
severe and fatal cases of pellagra are accompanied
by very slight, almost inconspicuous cutaneous
lesions. On the other hand, cases with extensive
cutaneous lesions often run a comparatively mild
course, and in some instances end in recovery. The
mildest case, and the one which made the most
satisfactory progress in my series, was a man of 70,
who had pellagra universalis.
Bad food, unsanitary conditions, debilitating
diseases, diarrheeas, pregnancy, uterine disorders,
ankylostomiasis, and ameebiasis have all been given
by various observers as predisposing factors in the
production of both pellagra and sprue. Both are
diseases principally of adult life; no age, however,
is exempt, most cases occurring between 20 and 50;
as age advances the prognosis becoming more grave.
A study of the literature shows that both pellagra
and sprue have been thought by some to resemble
scurvy. Cantlie, in referring to sprue, suggests that
it may have some relation to scurvy, and Manson,
in referring to pellagra, states that ‘‘ the gums may
be swollen and bleed easily, a condition which gave
rise to the name ‘ Alpine scurvy.’ "'
In referring to the most prominent symptoms of
the two diseases under consideration, we believe
we are justified in giving first place to those refer-
able to the gastro-intestinal tract; in fact, as far as
the patients are concerned, these symptoms are so
pronounced that they, in most instances, adumbrate
all others.
Wood, in referring to the gastro-intestinal sym-
ptoms, says that the first indications of pellagra are
found almost invariably in the gastro-intestinal
tract, and that pellagra without an impression on
the digestive apparatus has never occurred in his
experience. He further states that it would be very
questionable in his mind if a diagnosis without these
manifestations would be justified. In an experience
with 400 cases he has never seen a single case of
this kind.
Of the gastro-intestinal disturbances in both
pellagra and sprue, probably the most unvarying
in the constancy of its presence is the stomatitis.
In referring to this in connection with pellagra,
Wood states that ‘‘ when we know more of the so-
called * pellagra-sinc-pellagra ' it is possible that the
stomatitis may be shown to be a more constant
symptom than the erythema. At the present time
it should be placed second in the list of symptoms.”
Dr. Stewart would assign to the gastro-intestinal
symptoms in pellagra the firs& place, and consider
the cutaneous lesions as secondary, as we now so
frequently do in a number of other so-called skin
diseases which have their origin in the gastro-
intestinal tract.
The stomatitis in pellagra and sprue is almost
identical. In both there are dysphagia, salivation,
288
THE JOURNAL. OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1913.
varying degrees of ulceration, denudation of epithe-
lium, marked erythema of the buecal and pharyn-
geal mucosa, smarting and burning of the mouth
and cesophagus. So similar are these lesions that
Wood makes the following statement concerning
them: '' The tongue condition, together with -the
intestinal symptoms in pellagra, has given rise in
some sections of the south to the idea that sprue
is prevalent in that region. "It is very probable
that sprue does occur, and this is one of the best
reasons for hesitation in acknowledging the possi-
bility of ' pellagra-sine-pellagra,’ for the symptoms
of sprue are almost identically those of pellagra
without skin manifestations." He further states
that ''it is not only in regard to the mouth sym-
ptoms that sprue must be considered in connection
with pellagra ; there are many points of resemblance
in all the alimentary manifestations of the two con-
ditions." For himself he can find no satisfactory
points of distinction between sprue and pellagra
without skin manifestations.
: The charaeter of the stools in both of these
diseases is strikingly similar. The macroscopic
appearance of the stools in both diseases is almost
identical. In both the stools were light coloured,
characteristically frothy, acid in reaction, and con-
tained an abnormally large amount of fat and fatty
acids. A bacteriological examination revealed the
presence of large numbers of putrefactive bacteria
in every instance.
Wood, in referring to the diarrh@al features of
these two diseases, writes as follows: '' There are
many things about the diarrhwa of pellagra which
suggest the diarrhea of sprue. The dysenteric
symptoms seen in the early stages of pellagra
gradually give way to the serous diarrhea. This
same thing occurs in sprue.” Amcebe have been
found in large numbers in the stools of both pellagra
and sprue cases. In fact, so similar are the stools
in these two diseases that without further know-
ledge concerning them we should be justified in
suspecting a common cause.
Indicanuria seems universal in both pellagra and
sprue.
The nervous and mental symptoms present in
some cases of pellagra have, we believe, been given
undue prominence, and have sometimes led to an
etroneous classification of the disease as of nervous
origin. While symptoms referable to the nervous
system are quite common in cases of pellagra, they
are by no means constant or characteristic. The
nervous manifestations in pellagra are probably the
result of profound malnutrition and intestinal
toxeinia,
In studying the pathological anatomy of these
two diseases, we are again confronted with a strik-
ing similarity,
Tuczek has found in pellagra an attenuation of
the intestinal wall as a result of atrophy of the
muscular coat, with occasional hyperemia and
ulceration of the lower parts of the canal.
In sprue the mucosa is almost entirely destroyed,
being replaced by a structureless substance con-
taining leucocytes; the submucosa appears much
thickened; ‘fibrous tissue abundant. The
muscular layer is thinned.
Both pellagra and sprue are considered as afebrile
disorders. It is a fact that there are periods in
both in which there may be an increase in the tem-
perature; they are in the main, however, afebrile.
In August, 1911, Dr. Burnett, of Edinburgh,
called attention to some of the principal features
which are so similar in these two diseases, and
concluded his article with the following statement:
“ Bo convinced am I that the two diseases are one
and the same that I feel that I am in duty bound
to put my opinion on record in order that it may
be confirmed or refuted by those who have had
more experience with these diseases.”’
With the possible exception of the cutaneous
lesions which occur in pellagra, the symptomatology
and pathology of the diseases under consideration
are so nearly alike that a careful consideration of
them does not offer sufficient grounds for a positive
differential diagnosis.
' The gastro-intestinal symptoms, which are the
most prominent in both instances, are strikingly
alike, and the results obtained from examinations
of the gastrie contents, stools, blood, and urine,
reveal almost identical conditions.
being
SANITARY ORGANIZATION IN THE TROPICS.
Sirk Ronatp Ross, K.C.B., F.R.S., D.Sc.,
D,P.H., Professor of Tropical Sanitation, Univer-
sity of Liverpool, said he used the word sanitation
in its widest possible sense, to include everything
which tends to reduce the sickness and mortality
of human beings.
The effective prevention and treatment of
diseases implies, above all things, an effective
administrative machinery. Our proper subject
to-day is therefore concerned with the question as
to the best form of machinery which is to be
employed in tropical countries.
Sanitarians are not concerned with most of the
questions which politieians like to consider in con-
neetion with their theories of ideal government.
Whether a country is governed by a despot, or by
an oligarchy, or by a democracy, does not always
appear to them a matter of vital moment. The
point before sanitarians is how administration can
best be directed towards the mitigation of disease.
(1) Unification of the Sanitary Services.—Should
the entire sanitary service be unified, or may it
be split up into different independent departments?
The possible departments into which it may be
divided are: (1) The Medical Department, con-
cerned with the treatment of disease; (2) the
Sanitary Department, concerned with its preven-
tion; (3) the Researeh Department; (4) the Statis-
tical Department; (5) the Engineering Department ;
(6) Subsidiary Departments. The first question `s
whether it is advisable, in an ideal state, to place
all these under one head. I may point out that
in most tropical countries they are at present placed
frequently under almost independent heads. Even
SEPTEMBER 15, 1913.
JOURNAL OF TROPICAL MEDICINE AND HYGIENE,
THE
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—
New Bond Street, from whom copies can be obtained.]
The above photograph is by F. A. Swaine, 106,
Chairman of the Congress.
PHOTOGRAPH OF THE TROPICAL SECTION OF THE INTERNATIONAL CONGRESS oF MEDICINE, Lonpon, 1913.
Inset, Surgeon-General Sir Davip Bruce, C.B., LL.D., F.R.S., R.A.M.C.,
Sept. 15, 1913.]
THE JOURNAL OF TROPICAL. MEDICINE AND HYGIENE.
289
the medical and the sanitary departments are often
practically separate; while sanitary engineering,
especially as concerned with large water supplies
and sewerage schemes, is often divorced entirely
from the sanitary department—which, indeed, is
not even consulted regarding such matters. . Simi-
larly, researches, where they are subsidized at all
by the government, are often practically independent
both of the medical and of the sanitary branches.
Again, the sanitation of municipalities is generally
left entirely to local bodies, which are apt to resent
even the nominal suzerainty said to be exercised
over them by the national or colonial government.
The whole sanitary services of a country should
be unified, and the separation of the various sub-
branches makes only for imperfect administration,
overlapping, and waste of money.
(2) Representation on the Supreme Governing
Body.—The health of a community is of sufficient
importance to require a separate Department of
State. In my own opinion the subject is as impor-
tant as those of Education, the Church, the Law,
Trade, the Treasury, the Army, and the Navy.
There is no reason, for example, why the medical
and sanitary department should be placed under the
education department, as is done in India; nor why
it should be subordinated to various other depart-
ments, as is done in this country. We have
already maintained that there should be a ministry
of publie health in large states, or its equivalent in
smaller states and colonies.
(3) Should the Sanitary Service be Subordinated
to the Medical Service or vice versa?—The present
custom in British possessions is that the sanitary
serviee is always subordinate to the medical service.
The Americans, however, have introduced a new
precedent in the Panama Canal zone, where the
Chief Sanitary Officer is the head of both the ser-
vices and, indeed, of other branches of administra-
tion. Personally I think that the American plan
is the better one. The purely medical branch
properly falls into its place as one, and only one,
of the branches of the general sanitary service; and
I therefore think, personally, that it should be
subordinated to the latter, and not vice versa.
Perhaps the best way out of the diffieulty is to call
the head of the combined department the Director
of Sanitary and Medical Services, without subordi-
nating one to the other.
(4) The Position of Sanitary Engineering.—At
present the head of the medical service sometimes
has a sanitary engineer under him, as in Mauritius;
but this is very exceptional; and if the sanitary
service requires any sanitary engineering done, it
must appeal by a roundabout way to the Public
Works Department, which may or may not adopt
its ideas. Now, effective sanitation is always
requiring small engineering works of one kind or
another, and this procedure leads not only to
unnecessary delay, but to frequent waste of funds.
Naturally the whole subjects of water supply,
sewerage, surface drainage, housing of the poor,
and a large part of town planning should come
into the sanitary service; but, owing to the frequent
neglect of this obvious rule, much waste of money
v
now often occurs. Every sanitarian is acquainted
with many instances in which water supply and
sewerage have been, undertaken, 'at an immense
eost, without proper previous appeal to the sanitary
authorities. I admit that the question is a difficult
one. It means either that the engineers should be
subordinated to the doctors, or that the doctors
should be subordinated to the engineers, or that
both should be independent. As a matter of
fact, however, where there is a proper ministry
of public health, both will be subordinate to the
head of that ministry, and the difficulty would
adjust itself automatically. This merely gives
another argument for the construction of such a
ministry or of its equivalent in colonies. At all
events, if the larger engineering works, such as
water supply and sewerage, be kept distinct from
the sanitary service, the latter should always have
a sanitary engineer for the smaller works which it
so frequently requires.
(5) The Position of Research.—Where medical
investigations are carried out under public funds,
they are now merely nominally placed under the
head of the sanitary or medical departments. In
my opinion, they should be closely incorporated
with the latter.
(6) The Statistical Department.—This | should
include not only all vital statistics, but sanitary
and medical records. At present, no colony that
I know of, except India, perhaps, possesses an
adequate statistical department. Apparently any
one is good enough to collect statistics. As a
matter of fact, the subject is an extremely difficult
one, and requires expert mathematical knowledge.
(7) The Sanitation of Municipalities.—This is a
burning question everywhere. At present, even
small municipalities seem to possess almost un-
limited powers over the lives of the people living
under their rule. However inefficient they may be
the Government of the State is generally unwilling
to interfere with them, on the absurd ground
that they should not interfere with liberty. But
we must draw a careful distinction. Public sanita-
tion requires highly expert knowledge, highly
organized effort, and sufficient funds. Now, these
may be forthcoming in a very large city, such as
the great cities of Britain, which can afford to pay
for proper health officers and the other necessary
experts, but it is unlikely that they can exist in
many of the small towns in the Tropies, which
have, unfortunately, been given municipalities
before they were ready for them. Is it likely that
a small town of under one hundred thousand in-
habitants, consisting mostly of natives or half-
castes, can ever pay for sufficiently expert sanitary
advisers? We are all familiar with such munici-
palities. They appear to be free to entrust their
sanitation to anyone, skilled or unskilled—a local
doctor, a loeal engineer, or a local health committee
consisting of shopkeepers, builders, lawyers, and
others. As a rule, they neglect their sanitary
duties for the sake of local polities, and then raise
an outery when the superior government call them
to account. The whole subject requires careful look-
ing into, at least, with regard to British possessions,
290
All the sanitary work of the smaller munici-
palities and town councils should be subjected to
the scrutiny and discipline of superior governments,
which should not hesitate to take action on the
smallest provocation. The slums, which are such
a blot upon British town administration, really arise
from the defects referred to under this heading.
Popular government deserves to exist only where
it is efficient. Where it is inefficient, as in many
countries which I have personally studied, it should
be either abolished temporarily or forced into better
ways. Under present conditions, the lives of
thousands of people are endangered or lost owing
to our worship of a fetish.
(8) The Management of Epidemics.—Effective
sanitary services should have a proper department
for dealing with epidemics—which, at present, they
scarcely ever possess. Whenever an epidemic
threatens, or exists, the head of the sanitary service
should be able immediately to send expert officers
to the locality in order to investigate, to organize,
and, in case of emergency, to direct the defensive
measures.
(9) Sufficiency of the Local Forces.—There are
some points which still remain to be referred to.
One is the frequent insufficiency of the local
sanitary force of inspectors, sweepers, scavengers,
mosquito-brigade men, and so on. In many
British possessions, hardly any effort is made to
provide sanitary workmen for the villages or even
for the smaller towns. We seem to think that the
only way to improve the sanitation of a country
is to educate the people—that is, to force the people
themselves to clean up their own backyards, and
to remove their own mosquitoes, &c. This is a false
view. The people cannot do this work even if they
wish. It is a work which must be done by the
local authorities, and by means of a sufficient body
of labourers. Sanitary commissioners, health
officers, sanitary engineers, and sanitary inspectors
by themselves are almost powerless. They must
possess a proper working force under them.
(10) Provincial Delegation of Sanitary Authority.
—In a large country or colony the head of the
sanitary service must delegate many of his duties
to subordinate provincial staffs, but decentralization
should only be partial—just as it is in military
affairs. Sanitation is a kind of war, requiring both
local effort and central direction from above. It
is a mistake to give unlimited power to local
sanitary departments, as is often done.
(11) Committee-Government.—One other point
remains to be considered, namely, the efficiency of
committee-government. In my experience, com-
mittees are not of much use in connection with
sanitary matters. Most of the time of the executive
officials is taken up in trying to persuade ignorant
members of the committee to adopt certain lines
of action, the utility of which would be obvious to
persons who know the business. Committees
cannot reason as quickly and as comprehensively
as individuals can, but, on the other hand, they
are sometimes more impartial, and may even occa-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15, 1913.
sionally add information which the individual does
not possess. On the whole, perhaps, the best rule
is that of very small executive committees, consist-
ing of a few paid individuals, who are severally and
jointly responsible to a higher authority.
CoroxEL P. Henr, M.D., F.R.C.P.Edin., I.M.5.,
said that the question as to what is the best form of
sanitary organization for armies in the Tropics is a
subject upon which the opinions of even experienced
military sanitarians are likely to differ, but the
sanitary organization of our army in India at the
present day is the most comprehensive and prac-
tical, and, as the results show, the most efficient
in existence in the Tropics, and may be presented
as a model.
The progressive improvement in the health and
the reduction of mortality in our European and
Indian troops in India during the last thirty odd
years are shown in the following table:—
British troops
Per 1,000 of strength
Indian troops
Per 1,000 of strength
Yeat A.
Constantly sick Death-rate Constantly sick Death-rate
1880 ... 74 e. 24°85 ... 56 .. 8922
1902 .. 66 14°68 24:6 11°16
1905 .. 598 10:05 23:2 8:09
1907 46:4 8:18 21:7 6:27
1909 40°3 6:25 20:8 5°62
1910 31:93 4:66 21:1 4:89
1911 28°81 4:89 19:8 4:48
The improvement in health is brought out even
more conspicuously if we consider the change in
incidence which has taken place in the three infec-
tive diseases, cholera, enterie fever and bacillary
dysentery. Amongst our European troops in 1860
there were over 1,500 admissions and nearly 1,000
deaths from cholera. In 1867 it caused 529 deaths.
In 1869 the European army in India lost from
cholera alone over four times the number of men
it lost in 1911 from all causes put together; in the
same year one battalion of European infantry lost
one-third its total strength from this disease. A
generation ago we had cholera every year at certain
seasons in a large number of military cantonments,
mostly in the form of explosive epidemics due to
specific contamination of water-supplies. In the
years 1910 and 1911 the death-rate from cholera in
both European and Indian troops was only about
1 per 10,000. Corresponding reductions in the
incidence of enteric fever and bacillary dysentery
could be quoted. The lessened prevalence of, and
mortality from, cholera and bacillary dysentery are
equally remarkable in our Indian troops during the
period mentioned.
In the early period of our occupation in India the
death-rate amongst our European troops was 80 per
1,000 per annum. This has been so altered by the
introduction of sanitary and hygienic measures that,
as the foregoing table shows, the death-rate in 1910
was only 4°6, and in 1911, 4:8. This phenomenal
reduction in mortality is shown to be even more
remarkable in the statistics of our Indian troops.
The Director of medical services in India is at
army headquarters and is the chief sanitary
_ Sept. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
291
authority of the army of our Indian Empire. He is
the responsible sanitary adviser of the Commander-
in-Chief in India, and is kept informed as to the
state of the health of every unit through monthly
returns, and special reports in the case of any
serious epidemic disease arising.
Each division has a Deputy-Director or an
Assistant-Director of medical services (principal
medical officer). He has as his staff officer a deputy-
assistant director of medical services (sanitary),
until recently called the divisional sanitary officer,
who is a trained expert in military hygiene and
sanitation, and is provided with a fully equipped
analytical and bacteriological laboratory. These
divisional sanitary officers are appointed from the
Royal Army Medical Corps. All brigades have a
bacteriological laboratory with an executive medical
officer (who is a specialist in bacteriology) in charge
of it.
The divisional sanitary officer is a whole-time
officer, whose duty is exclusively connected with
the practical application of hygiene to the require-
ments of the troops in his division. He is also a
trained analyst and bacteriologist.
Each battalion or unit has a medical officer, who
is the sanitary adviser of the officer commanding the
unit.
The first duty of a medical officer on joining a
unit is to learn everything he has to know about
the barracks and their surroundings and the state
of health of all ranks.
With our troops in the Indian Empire we are at
present inclined to look upon full hospitals as an
indication of some defect in the sanitation of the
barracks and their surroundings, or slackness in
watching the condition of health of the troops in
barracks. Such an inference is, of course, not
universally or invariably justifiable in India or the
Tropies generally; in the early stage of colonization
in the Tropics full military hospitals have always
occurred, and even now we in some years in India
have waves of malarial fevers that fill our hospitals.
The remark, however, holds good generally, and the
experienced sanitarian can as a rule readily discover
the cause of the defect or where the slackness exists.
The medical officer of a unit is primarily the
health officer of the unit, and secondarily the
medical officer for the treatment of the sick and
injured; his highest function is not to treat disease,
but to take steps to ensure that there will be as
little disease as possible in his unit during peace
and on active service. The real executive sanitary
officers of our army in India are the company,
squadron, and battery officers. Through them the
sanitary and hygienic work required is carried out
by all non-commissioned officers and men. It is for
us to bring home to combatant officers that sani-
tation in the army, carried out in its integrity,
means full and healthy ranks in the firing line.
The sanitary work of the army must be part and
parcel of the ordinary routine training. The extent
to which regimental officers realize the great assist-
ance sanitation affords them from a military stand-
point will determine the actual state of the health
of the army. It is our duty to endeavour to ingraft
this fact and to induce them to fully appreciate
their sanitary responsibilities.
All our military cadets have now to pass an
examination in military sanitation before obtaining
their commissions, and all subalterns of European
units are obliged to pass a similar examination
before promotion to captain.
EDUCATION oF Troops IN MILITARY SANITATION IN
INDIA.
Various courses of instruction are given in peace-
time in our army in India as part of the routine
training of the year. The following includes the
more important subjects dealt with :—
Nature and causes of preventable disease in the
soldier in peace and war in our Indian Empire;
preventive measures in connection with enteric
fever, bacillary dysentery and cholera; malarial
fevers, their nature and causes, and the róle of
anophelines as malaria-carriers; hygienic and sani-
tary considerations connected with air and venti-
lation, the cleanliness of barrack-rooms, hygiene of
barrack-room and tent life; water-supplies, their
sources; public water-supplies; purification, distri-
bution, and storage of water for troops in canton-
ments and on field service; food-supply, cooking of
food ; sanitation of kitchens, ablution places, latrines
and urinaries; removal and disposal of excreta—
pail system with trenching, night-soil incinerators ;
dry refuse, its collection and disposal; personal
hygiene, camp sanitation, &c. The practical demon-
strations were conducted by visits to barrack-rooms,
cook-houses, ablution-places, latrines and urinals,
water-supply works and wells, night-soil trenches
and incinerators, regimental institutes, coffee shops,
canteens, aerated water factories, dairies (in which
the possible sources of contamination of milk were
pointed out and the methods of sterilization shown
and explained), and regimental bazaars; the
slaughter-houses were visited, live animals and
carcases inspected, the proper way of disposing of
offal described; bakeries were visited and bread-
making explained, and the dangers through dirty
workmen indicated; laundries and dhoby ghats
visited, and their proper working pointed out; the
breeding-places of mosquitoes and method of deal-
ing with them and the duties of mosquito brigades
gone over, and anti-malarial and anti-mosquito
measures demonstrated; the manner in which flies
breed and the methods of preventing such breeding
shown and dilated on, &e. The non-commissioned
officers and men of the class were also taken into
the field and made to earry out all the work they
would be called upon to do on service in connection
with water-supplies, latrines and trenches, urinaries,
disposal of exereta by incineration or otherwise,
disposal of dry refuse, sanitation of kitchens and
the disposal of water therefrom, and camp sani-
tation generally.
In India the sanitary work of extra-regimental
areas in each cantonment is in the hands of a
eantonment committee.
In non-regimental areas in cantonments—bazaars,
292
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15, 1913.
villages, &c.—there is a regular system of sanitary
inspection, of medical inspection of the people
inhabiting them, and a rigid enforcement of noti-
fication of infectious diseases. The occasional
sporadic and even epidemic cases of plague, small-
pox, cholera, measles, &c., that affect troops are
often initially introduced by the inhabitants of these
areas.
There is a well-considered scheme ready at hand
to meet all epidemic infectious diseases that are
liable to arise in cantonments by importation or
through local infection. Such a scheme is specially
required in connection with enteric and paratyphoid
fever, cholera, plague and small-pox. In this way
no time is lost in dealing with initial cases and
'' contacts.’ It is scarcely possible for any person,
whether soldier or non-combatant, to enter canton-
ments from an infected area without being pre-
viously inspected by a medical officer or medical
subordinate. Everybody concerned knows from
these schemes what one’s duties are when any
epidemic threatens. Copies of these schemes are
in every hospital, brigade office, orderly room, and
cantonment magistrate's office.
A strict and continuous policy for preventing the
importation of infectious diseases from civil com-
munities to cantonments and barracks is adopted.
The sanitary administration of indigenous troops
in tropical countries is invariably a difficult matter,
and in many countries a delicate one.to handle,
especially at its initial stage. In the Tropics
medical and sanitary officers soon learn that they
have to respect the prejudices of local troops, many
of which are associated with religious ceremonial
and the traditions of centuries. We should remem-
ber that in all tropical countries western sanitation
is an importation, and that if not kept in operation
by western sanitarians it would die out in a few
decades. It is not yet ingrafted as part of the
national life of peoples in the Tropics. All western
nations with armies of indigenous troops in the
Tropics have an important responsibility in ineul-
cating the sanitary instinct during military life;
these indigenous troops are dispersed to their village
homes after leaving the service, and if they have
been properly trained they will introduce part at
least of our sanitation and system of preventing
infectious diseases.
THE YELLOW FEVER DANGER FOR ASIA
AND AUSTRALIA, ESPECIALLY AFTER
THE OPENING OF THE PANAMA CANAL.
Dr. J. J. van Locuem, Director of the Institute
of Tropical Hygiene, Department of the Colonial
Institute, Amsterdam, Holland, called attention to
the possibility of yellow fever spreading further,
especially after the opening of the Panama Canal,
as has been repeatedly pointed out ; Manson, in 1903,
read an important paper on '' The Relation of the
Panama Canal to the Introduction of Yellow Fever
into Asia," at the February meeting of the Epidemi-
ological Society.
As the question of the yellow fever danger for
Asia and Australia, considered from the present
point of view, is entirely entomological, we can
restrict ourselves to a study of the distribution and
biology of Stegomyia (Ades) calopus in those
continents.
STEGOMYIA ON Boarp SHIP.
Stegomyia calopus can remain infectious very
long after having bitten a yellow fever patient; so
if the mosquito finds on board the means of keeping
alive there is danger of the disease being carried
over distances. Repeated experience of the occur-
rence of yellow fever among the crew and dock-
labourers during the unloading of ships has proved
this.
In tropieal seas stegomyia not only remains alive
on board ship but sometimes also finds an oppor-
tunity of breeding, as is known from many observa-
tions. .
Dr. Loghem, in a ship on the Java Coast, found
in the cabins stegomyie, and their larve and pups,
in the water-tank of the bathroom, and imagines
against the sides of the tank; larve were also met
with in the bilge water. Dr. Loghem added that
at sea he soon got rid of the mosquitoes in his
cabin; it seems that they are driven from on board
in great numbers by the draught.
The self-cleaning of the ship during its course
is certainly an important point, and the faster the
ship runs and the better it is ventilated the less
chance there is of its carrying yellow fever. On
the other hand, it is clear that the advantages of
the newer ships over the slow-going sailing-ships
—one of the synonyms of yellow fever was ship's
fever—is to a certain extent reduced by their dimen-
sions being larger and their interiors more compli-
eated. And then we are not to forget that the
coast places in tropical seas are also connected by
primitive native ships.
On account of all this it seems certain that as
long as yellow fever occurs in America the chance
remains of infected stegomyie being transported to
Asia and Australia. Should the disease be trans-
ported to Asia and Australia and maintain itself
there?
S. calopus occurs all over the world between
about lat. 40° N. and S. Stegomyie have been
found at all possible places in Asia and Australia
within those boundaries; but we want quantitativo
data about stegomyia in its relation to man, in the
same way as we desire them nowadays about rats
and fleas or about malaria parasites and anopheles
mosquitoes in a scientific treatment of the epidemi-
ology of plague or of malaria, but few data are to
hand on this matter.
Dr. Loghem found that S. calopus is of frequent
occurrence in places along the coast of Dutch East
India and also at a considerable height, 700 and
400 metres above the sea-level.
Dr. Baggelaar, writing from Fak Fak, in New
Guinea, November 30, 1908, says: ‘‘ I hereby send
you some fifteen S. fasciatz. It is swarming here
with these wretched animals. They are only sur-
Sept. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
293
passed in their untiring zeal for biting by the wood
mosquito. In the months of October to December
they are most frequent. The specimens sent all
have the ‘lyre’ intact, having been carefully
selected from dozens of specimens.”
If we compare the temperatures of Dutch India
with the optimal temperature for breeding experi-
ments with stegomyid, one sees that in Asia
throughout the whole year the average temperature
near the Equator is about equal to the temperature
at which yellow fever can prevail in America, and
remains only little below the average temperature
at which the disease becomes a serious epidemic.
If from our observations in East Dutch India,
which can by no means lay claim to completeness,
any conclusion may be drawn, it must be this: it
may be surmised that at various places in Asia and
Australia stegomyia occurs in such numbers and
under such circumstances that yellow fever, once
transported there, will be able to hold its own and
be propagated further.
MEASURES TO BE TAKEN IN ASIA AND AUSTRALIA
AGAINST THE YELLOW FEVER DANGER.
(1) Every ship arriving in the stegomyia zone
from an infected or suspected port must remain at
a sufficient distance from the coast, and be examined
for mosquitoes, larve, and yellow fever patients.
If this examination has a negative result, the ship
shall be given free pratique.
(2) If mosquitoes and larve are found, they are
killed, and yellow fever patients are carried from
the ship in mosquito-nets and nursed in a mosquito-
proof hospital.
But the trouble is that stegomyie may be on
board, hidden in the cargo, without any chance of
their being- discovered by the harbour officials;
among the patients with fever—but not clinically
recognizable as yellow fever—there may be yellow
fever patients; and among the healthy people may
happen to be some in the incubation period of the
disease.
So the conclusion which might be drawn from this
is: That every ship having touched at an infected or
suspected harbour in the stegomyia zone ought to
be fumigated; that the whole (non-immune) crew
ought to be kept in quarantine and observed for
a few days, and that all the fever patients ought
to be taken from on board in mosquito-nets and
isolated in a mosquito-proof hospital.
As compensation for the mistakes that without
doubt will be made in the execution of these
measures, the campaign against stegomyia in the
Asian and Australian ports ought to be started with
all energy.
Tf, then, the ship mosquitoes really make victims
on shore, the condition for spreading further is
lacking.
In order to relieve the local sanitary services in
the harbours of some of their work and responsi-
bility, and to further the rapidity with which ships
in the harbour are controlled, more things ought
to be entrusted to the ships' doctors. I think that
in the future a more important and more honourable
task will be given them than nowadays; more
specially will they be better prepared for their
task. ;
With respect to the above-mentioned recom-
mendations, the question naturally arises whether
it would not be possible to join hands, and through
international co-operation secure the safety that is
not sufficiently guaranteed by the local measures
in the harbours. i
Manson’s idea is confined to the defence of Asia
by cleaning the ships on their voyage through the
Panama Canal; this: hygienic work ought to be
internationally regulated and executed. Gray drew
attention to the fact that yellow fever is endemic
not only on the Atlantic, but also on the Pacific
side of America. He pointed out the irregular
political state in those countries, which does not
guarantee the proper execution of hygienic measures
in the harbours. So Gray wants all ships sailing
from a yellow fever port to an Asiatic one, to be
obliged to first touch at the fumigation station at
Panama. He also thinks that international control
of navigation should be kept there.
At the Congress for Hygiene in Berlin in 1907,
the thought of international co-operation was
uttered by Agramonte, who again clearly showed
what danger the yellow fever centres in Ecuador,
Colombia, Venezuela, &c., have for the whole
tropical zone.
CURATIVE VALUE OF A “ GLYCERINATED
PEST VACCINE ” IN PLAGUE.
R. Row; M.D.Lond., D.Se.Lond., Petit Labora-
tory, Bombay, India, said that the vaccine above
referred: to differs from that previously used by
the author, or that generally employed for prophy-
lactic purposes, in that (1) it is derived from young
first subeultures or the very first cultures on agar
from peripheral blood in septicemic plague cases,
and (2) the plague bacilli are killed with the help
of glycerine instead of with heat or salts, and it is
free from any admixture of antisepties.
The value of employing young first subcultures
depends on the fact (a) that these are rich in a
glutinous globulin-like protein, which is easily taken
up by dilute NaCl solution, and is therefore more
rapidly absorbed when administered subcutaneously,
in contrast with that derived from subsequent sub-
cultures. (b) That owing to the presence of this
globulin-like protein forming, so to say, a light
capsule round the individual bacillus, one obtains
a uniform emulsion of the culture in normal saline
solution, so that on making a smear of the emulsion
on a slide one sees individually dispersed bacilli,
and hardly any clumps such as are seen in a plague
culture emulsion prepared in the ordinary way.
This property, it is needless to say, is well adapted
for aecurate dosimetry.
The object aimed at by the technique is to have
an agency which, while effectively sterilizing the
emulsion, would on one hand allow no clump
formation or production of a precipitate, and yet, on
294
the other, would not lead to the deterioration of the
immunizing principle of the resulting fluid; after
a great many attempts, glycerine added to a salt
emulsion of plague culture, prepared as stated
above, has been found to answer all these require-
ments. Further, it is found that in the presence
of glycerine the enzyme action on the toxic sub-
stances of a crude plague emulsion is not in any
way interfered with.
TECHNIQUE OF DOSAGE AND TREATMENT.
The emulsion above described is stocked in the
strength of one agar tube to 1 c.c. of 50 per cent.
glycerine in normal saline (but it can be stocked in
more concentrated form), and from this stock a
dilution is made to represent the scrapings of one
agar tube to 25 c.c. of the same glycerinated saline
solution, and this is stored for use in small glass
capsules of about à c.c. capacity. When required
i c.c. of this fluid is administered in any part of
the healthy skin subcutaneously, taking the pre-
caution of freely diluting it with normal saline just
before the injection so as to minimize the temporary
smarting caused by the glycerine. The dose usually
employed is 1 to 4 c.c., and therefore corresponds
to the scrapings of ;4, agar tube, and on computa-
tion with various specimens of a two days' growth
on the surface of the usual 3 in. diameter tubes it is
found to contain 85,000,000 to 90,000,000 plague
bacilli. It is possible to make an agar culture at
the bedside from the patient's peripheral blood,
derived, say, from the finger-tip sterilized with
ether alcohol, and this is best done as a part of the
routine of the clinical examination. This way one
ean ascertain roughly if the case which is treated
is of a septicemic or non-septicemic nature; for it
is in the non-septicewmic cases only that any good
can be done. Of 89 consecutive cases treated in
this year's epidemic in Bombay: Septicemic, 47:
all died, no recovery. Non-septicemic, 42: 7 died,
85 recovered, i.e., 83:6 per cent. of non-septicemic
cases recovered.
CONCLUSIONS.
(1) General amelioration of all the symptoms is
noticeable after a period of twelve to twenty-four
hours of the injection.
(2) Gradual subsidence of the bubo and its com-
plete absorption in most cases.
(3) In most of the non-septicemie cases the rapid
termination of acute infection process and uninter-
rupted recovery.
(4) Distinct reaction in the shape of exaggeration
of the already existing symptoms, and a distinct
increase of temperature during the first six to
twelve hours of the injection in all favourable cases.
(5) The freedom from any after-effects or com-
plications.
(6) The possible practicability of applying this
vaccine for prophylactic purposes owing to the sim-
plicity of the technique and the short time required
for obtaining a vaccine, and also because it can be
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Sept. 15, 1913.
obtained as a uniform emulsion of any reasonable
degree of concentration, and therefore well adapted
for reducing the bulk of the injection to even less
than 4 c.c.
————99——————
THE DINNER.
A DINNER was held on August 8, 1913, consisting
of the members of the Society of Tropical Medicine
and Hygiene, together with the members of the
Section of Tropical Medicine attending the Seven-
teenth International Medical Congress. Surgeon-
General Sir David Bruce, C.B., LL.D., F.R.S.,
occupied the chair. Amongst those present were:
Drs. Abraham, Anderson, Ayramonti, Bagshawe,
H. G. Barrie, Fleet-Surgeon Bassett-Smith, Mr.
Norman Bennett, Colonel Birt, Professor Blanchard,
Mr. James Cantlie, Lieutenant Colin Cantlie,
R.N., Dr. Chacin-Utriago, Captain Powell Connor,
Dr. E. de Freitas Crissiuma, Major Cummins, Dr.
J. T. Darling, Dr. C. Noel Davis, Dr. McKenzie
Davidson, Professor Eijkman, Dr. Evers, Dr.
L. G. Fink, Dr. Franchini, Professor Fülleborn,
. Colonel Gimlette, Dr. R. Gonder, Dr. Harford, Dr.
Hata, Colonel Hehir, Dr. Hinke, Major Jackson,
Dr. Lannelongue, Professor Laveran, Dr. Leiper,
Sir W. Leishman, Dr. La Rocha Lima, Major
Liston, Dr. G. C. Low, Sir Patrick Manson, Sur-
geon-General Martini, Dr. Yale Massey, Professor
Minchin, Dr. Murray, Professor Nattan-Larrier,
Professor Dr. Nocht, Dr. Nusia, Professor Nuttall,
Dr. O'Connor, Dr. (Epp, Sir Ronald Ross, Dr.
Sambon, Dr. Sandwith, Professor Schaumann, Dr.
Schilling, Dr. Sehilling-Torgau, Sir David Semple,
Mr. Sheather, Mr. Sheppard, Dr. D. Thomson, Dr.
Tschudnowsky, Mr. J. A. Valentine, Dr. van
Loghem, Professor von Wasielewski, Dr. Malcolm
Watson, Dr. Duncan Whyte, Colonel Wilkinson,
Dr. Wu Lien Tieh.
Sir Davin Bruce, after giving the loyal toasts,
proposed ‘The Progress of Tropical Medicine.”
He began by stating that it was Sir Patrick
Manson's discovery of the part played by mosquitoes
in the conveyance of the disease filaria from man
to man that gave the key to our modern scientific
methods of investigation and research. Manson,
then a lonely practitioner in the distant island of
Formosa, not only framed, but proved the mosquito-
filaria theory, and it is surely one of the most
wonderful pieces of work ever accomplished by any
medical man to whom laboratories were inaccessible
and methods of investigation untaught. M. Laveran,
the doyen of French tropical medicine, by his dis-
covery of the malaria parasite in the blood of man
(1878-79) acquired everlasting fame for himself and
the eternal gratitude of mankind, for his discovery
constituted the fountain to which all modern
tropieal pathology may be traced, and whence our
knowledge of disease flows and gathers strength.
In 1886 the parasite of undulant (Malta) fever was
discovered, and later the part played by goat's milk
in the spread of the disease by Bruce and others.
Sir David stated that this disease was now
Sept. 15, 1913.]
295
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
known to be widespread, and amongst other distant
regions in which undulant fever is known he men-
tioned that he had found it amongst the people
inhabiting the shores of the Albert Edward Lake,
in Africa, and it is interesting to know that these
people drink goat’s milk. `
In 1889 Smith and Kilborne, by their discoveries
and investigations, gave us babesia. Of many
workers in India the name of Lewis will always be
mentioned with respect. Sir Ronald Ross's fame
will go down to posterity as the man who proved
the mosquito-malaria theory (1898), and thereby
showed that the mosquito was the means by which
malaria was conveyed to man. Sir Wm. Leish-
man, in 1903, found the key to that mysterious
disease kala-azar, and introduced us to a new
pathological entity, the Leishman-Donovan body.
The plague bacillus was discovered by Kitasato and
Yersin in 1904, during the epidemic in Hong Kong;
and Simond, Gaultier and others by their investiga-
tions showed that the rat was the alternative host
and that the rat-flea was the carrier of the disease.
The Indian Commission, by its careful analysis of
plague transmission, showed that without fleas the .
transmission of bubonic plague from rats to man
was impossible.
The Chairman paid a cordial tribute to the epoch-
making work on yellow fever by Lazear, head,
Carroll and Agramonte, and to the great practical
issues solved by Colonel Gorgas on the Panama
Isthmus.
The investigations of Eijkman and Braddon in
beriberi, the solution of sand-fly fever in 1909 by
Doehm, and many important additions to our know-
ledge by a host of workers, show how knowledge
is progressing, and Sir David said he gave the toast
of ‘‘ The Progress of Tropical Medicine " with all
confidence.
M. Laveran, in replying to the toast, stated
that for the first time tropical pathology and
hygiene had a special section devoted to them at
the International Congress of Medicine. He hoped
this happy innovation would strengthen the bonds
of these existing societies of tropical pathology.
M. Laveran thanked Sir David Bruce for the
honour he had done him in mentioning his work
in his remarkable speech upon the progress of
tropical pathology; he congratulated Sir David
Bruce upon the great part he had played in its
progress; his work on nagana, upon sleeping sick-
ness and upon undulant fever, constituted an im-
perishable memorial to him. The. men belonging
to M. Laveran's generation eould well appreciate
the immense progress that had been made in
tropical diseases. When they made their medical
studies they were reduced to making hypotheses
upon the nature and propagation of these diseases.
Plague, cholera, dysentery, malaria and yellow fever
were attributed to the emanations from vegetable
or animal matter, and it was supposed that the
infection was produced by the respiratory tract.
To-day can be shown the bacillus of plague,
‘cholera, hematozoa of malaria, amcebe of dysen-
tery, the spirochete of recurring fever, the trypano-
somes of sleeping sickness, and a number of try-
panosomes of animals, organisms of leishmania,
piroplasmosis, &c., and 'often one could see by the
side of a pathogenic microbe the insect which pro-
pagated it, such as mosquitoes, bugs, flies, &c.
The great part played by these blood-sucking
insects in the etiology of tropical diseases is one of
the most interesting facts that have been revealed.
The merit of this revelation rests with Sir Patrick
Manson, who first proved the part that mosquitoes
play in the propagation of filariasis.
It was in studying these works that M. Laveran
was able to verify the statement of the propagation
of paludism by the mosquito, which hypothesis has
been completely verified by the admirable researches
of Sir Ronald Ross. So the most celebrated
aphorism of Chancellor Bacon has been verified,
"* Bene scire est per causas scire.”
The prophylaxis of tropical diseases has made
invaluable progress. Since their etiology was
known plague, cholera, paludism and yellow fever
have become preventable diseases. All who have
contributed to this work deserve great merit on the
side of science and of humanity.
Sir Patrick Manson, in his reply, recalled the
time when he brought the news of filarial periodicity
and of the transmission of filariasis by the mosquito
to London some thirty-three years ago. The
astounding facts he enunciated were neglected or
received with something akin to ridicule. Some
seventeen years later, when he unfolded the mos-
quito malaria, his medical colleagues were not quite
sure of his sanity, and used to tap their foreheads
significantly when he appeared amongst them. Sir
Patrick dwelt upon the necessity of supporting the
Schools of Tropical Medicine, they being the real
foundation for all that is necessary in the fight
against disease in the Tropics.
The toast of ‘‘ The Visitors and Guests’’ was
given by Sir Ronald Ross, F.R.S. In felicitous
terms he referred to the presence of their French
visitors and guests, represented by Laveran,
Blanchard and others; of their German colleagues,
by Nocht, Fülleborn, and others; and drew special
attention to the contributions of Koch to tropical
medical literature; of the great school of Italian
investigators, represented at this meeting by Rho,
the Medical Director-General of the Italian Navy;
of Holland, ably represented by Professor Eijkman ;
and he commented upon the importance of the
presence of Agramonte (Cuba), Kopke (Portugal) ; to
many men of renown from South America; and
lastly, but not least by any means, the representa-
tives of Japan and China, Dr. Wu, of the Chinese
service, taking an active part in the discussion.
The toast was responded to by Professor
Agramonte, Professor Eijkman, Professor Blanchard
and Professor Fülleborn.
Professor BLANCHARD, in his reply, paid a sincere
tribute of respect to Sir Patrick Manson as the
pioneer of tropical medieal studies and the father
of modern tropical medicine. He referred to the
rapid growth of the London School of Tropical
Medicine, which was now capable of accommodating
296
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 15, 1913. _
a large number of students. Miasma as a cause of
disease was now forgotten. Sanitation has enabled
us to master the great scourges of the Tropics, and
the microscope had revealed their causes.
Professor AYRES Kopkr’s name appeared on the
programme as the proposer of the toast of the
“ Health of the Chairman.”
——d———
Annotations.
A Case of Trichinosis.—Bernstein, in the Medical
Record, June 28, 1918, describes a case of
trichinosis, with autopsy.
The patient, an Italian, was admitted to the
Lebanon Hospital under Dr. Mayer. His present
history dated back some ten days, when he had
several severe chills followed by a rise in tempera-
ture, generalized pains, vomiting, and diarrhea.
His physical examination on admission showed
nothing pathological except in his musculature—his
forearms were flexed on his arm, and it was
impossible to extend them passively or actively—
attempts to do so causing excruciating pain. His
mouth could be opened for only about half an
inch, while he was unable to protrude his tongue
beyond the line of his teeth. Pressure over any of
the museles of the extremities, chest, or head
caused severe pains. His temperature ranged
between 1009 and 1049 F., with a pulse-rate of
100 to 112.
Urine analysis constantly gave a strongly positive
diazo-reaction. This test is too often neglected in
the diagnosis of trichinosis, and yet it is a very
valuable help, being almost always positive.
Examination of feces was negative.
A blood examination showed a leucocytosis
averaging about 17,800, with an eosinophilia of 74
per cent. Blood culture was sterile. A careful
search for embryos in the blood was negative, while
animal experimentation, in the attempt to convey
the disease from the patient's blood to guinea-pigs
through feeding, was also without result. Since
these examinations were performed long after the
embryos had left the cireulation, the failure to find
or convey them is not to be wondered at. A section
of the left gastrocnemius muscle, teased in normal
saline solution, showed numerous motile specimens
of Trichina spiralis.
The patient died after sixteen days in the hos-
pital, and the post-mortem examination was per-
formed four hours after death. It revealed no
gross pathological lesions in any of the organs.
Microscopically, the trichine were found in all of
the voluntary muscles, including the intercostals,
psoas, sternocleidomastoid, and diaphragm. They
were, however, most numerous in the musculature
of the tip and base of the tongue. As mentioned
before, the intestinal and heart muscles were nega-
tive, as were also the liver, kidneys, suprarenals,
spleen, lungs, and pancreas.
In conclusion, the author emphasizes the follow-
ing facts in diagnosing trichinosis : —
(1) Examine the urine for the presence of a diazo-
reaction.
(2) Do not expect to find embryos in the stools of
an established trichinosis case.
(8) The parasites are in the circulation for but
three weeks at most.
(4) The embryos are deposited in the voluntary
muscles only.
———— SP ———
Personal Hotes.
COLONIAL MEDICAL SERVICES.
West African Medical Staff.
September, 1913.
Death.—P. F. Foran, F.R.O.S.Ireland, L.R.C.P.Ireland,
Medical Officer, Southern Nigeria.
No transfers.
Resignations.— W. Morrison, M.B., Ch.B.Edin., Medical
Officer, Northern Nigeria; W. Browne, L.R.O.P., L.R.C.S.
Edin., L.F.P.S.Glas., Medical Officer, Southern Nigeria.
Retirements.—OC. T. Costello, B.A., M.D., B.Ch., B.A.O.
Dublin, retires on pension ; M. W. Ruthven, M.B., Ch.B.Edin.,
D.T.M.Liverpool.
New Appointments.—The following gentlemen have been
selected for appointment to the Staff: C. J. H. Pearson,
M.R.C.S.Eng., L.R.C.P.Lond., M.B., B.S.Lond., Northern
Nigeria; B. W. F. Wood, M.B., B.S8.Leeds, Northern Nigeria;
H. North, M.R.C.S.Eng., L.R.C.P.Lond., Southern Nigeria.
Other Colonies and Protectorates.—A. D. Clanchy, L.R.C.P.
and S.Ireland, and Leslie Webb, M.R.C.S.Eng., L.R.C.P.
Lond., have been selected for appointment as Medical Officers,
Uganda; P. F. Nunan, M.D., B.Ch., B.A.O.Dublin, L.M.
Rotunda, J. H. Thomson, M.B., B.Ch.Aberd., G. Dunder-
dale, M.D., B.S.Lond., M.R.C.S.Eng., L.R.C.P.Lond., and
J. H. H. Pirie, M.D.Edin., M.R.C.P., F.R.C.P.Edin., have
been selected for appointment as Medical Officers, East Africa
Protectorate; J. H. C. Greene, B.M., B.S.Dublin, has been
selected for appointment as a Medical Officer, Federated Malay
States.
Business and Other Motices.
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Oct. 1, 1913.]
@riginal Communications.
A REVIEW OF A CLINICAL STUDY OF
MALARIAL FEVER IN PANAMA.
By Joun PErHaM Bates, M.D,
Ancon, Canal Zone, Panama.
y.
ADMINISTRATION OF QUININE IN MALARIA.
A REVIEW of the literature on the subject of the
administration of quinine for the cure of malaria
discloses the fact that the question is far from being a
closed one. The quantity of quinine necessary to
control the malarial attacks is still debated, and the
question as to whether small doses frequently repeated,
or whether larger doses at wider intervals are the
most efficient to control the febrile attacks have their
advocates both pro and “con. The question of the
time in the life phases of the malarial organism when
the quinine is most effective in the destruction of the
organisms, is now settled. This time is accepted by
all to be in the stages of the active development of the
parasites, and all agree that the effectiveness of the
drug continues on the intracellular organism but with
progressively decreasing potency till about maturity,
where it ceases altogether.
With this part of the subject settled, it would
appear that all would at once agree then that quinine
should be administered at the time of the day which
would introduce the drug into the circulation in
greatest concentration during the youngest developing
stages of the organisms, but, as a matter of fact,
clinical experience has proved that such a method
of administering quinine is not at all necessary to
produce quite satisfactory clinical results, and as it
is not always feasible to await a choice of time to
administer quinine, many have come to hold the view
that quinine given in moderate doses frequently
repeated is as a rule the method of choice. The
contention for the effectiveness of what may be
termed small daily quantities of quinine, that is,
15 to 20 gr. as average doses, and 30 to 40 gr. as
maximum quantities, it appears to me, is brought
about by willingness to permit the febrile course of
malaria to continue unchecked unnecessarily long.
It would be well here I think to again call attention
to spontaneous recovery in malaria, in order to
estimate the value of treatment by either small,
average, or large daily quantities of quinine. Most
workers in malaria have for various purposes left off
quinine in cases of ordinary gravity, to find that such
cases usually terminate their course in about ten or
fifteen days with rest and restricted diet. Some of
these cases terminate spontaneously in much quicker
time than this. In a series of cases in which I
refrained from giving quinine, to study the tempera-
ture curve and life phases of parasites, I was surprised
in one case to find the temperature had ceased after
the fifth day from admission, and from the cessation
of the temperature the parasites disappeared to such
an extent that the study of the blood was no longer
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 19, Vol. XVI
profitable. This case was a quotidian infection, and
the blood smears at first were fairly rich in parasites.
It is easy to see in this case what effect small doses of
quinine would have had and what impression this
therapy would have made on the mind of the observer
in this isolated instance. But, on the other hand,
while this study was being carried out, another case
presented itself, a subtertian infection, which appeared
about equal to the first case, and the patient on
admission seemed no more ill, but the illness pursued
no such course as the first one. Instead of the
symptoms becoming milder and milder each day;
as was seen in the first case, they grew worse from
day to day, until on the fifth day from admission the
patient began to show symptoms which made me fear
if he were continued without quinine much longer the
illness would terminate in a pernicious attack ; hence
quinine was beguü at once. The parasites in this
case also behaved differently from the parasites in the
first. They began to increase in number with the
increase in the gravity of the symptoms, and
what is more significant, as I shall show later, their
characteristics began to change; they were now no
longer nearly all the same age and in the ring forms,
but grown forms began to appear in the smears,
presegmenting and segmenting bodies in moderate
numbers, together with occasional crescent forms.
The quinine in this case was given in doses of 10 gr.
three times a day, with satisfactory results.
Here then two cases are shown, in which, from all
appearances at the time of admission which could be
judged from the blood examination and the clinical
symptoms, ought to have pursued a similar course.
Yet some undetermined factor did not permit them
to do so. By contrasting these two cases, it is quite
evident that the same quantity of quinine administered
to each would not have produced a similar result for
each. In the first case, 3 to 5 gr. of quinine a day
would have sufficed to produce satisfactory clinical
results, while in the second case 30 gr. a day was
necessary to do so. Thus, from the study of these
two cases, and many similar ones, the conclusion has
been reached that quinine must be increased in
quantity to meet the gravity of the infection. For
one to undertake to grade the doses of quinine in
proportion to the gravity of the infection in every
case is, of course, out of the question, and in trying
to avoid such a difficult process, the general
experience of all workers has at last arrived at
average doses for the largest majority of all
cases of malaria, which is about 30 gr. a day.
Experience here has proved that the quantity of
quinine that can be administered for short periods of
time without danger to the patient is very much
larger than is generally advised.
The largest majority of all cases of malaria are of
moderate severity, and will terminate their course
spontaneously in ten to fifteen days, or twenty days
at most; this holds good for tropical climates
as well as temperate; thus it is that we find 30 gr.
of quinine a day sufficient to meet the requirements
of the greater number of malarial cases. But in
severe malarious countries a goodly portion of the
298
cases, like Case 2 already noted, do not tend towards
spontaneous recovery, but pass beyond the average
into the grave and pernicious types. In these types
all agree that quinine should be increased in doses
beyond the average of 30 gr. a day, but the
question becomes, to what extent should quinine be
increased to be effective in those types of malaria ?
Craig [1] states that 40 gr. a day should never be
exceeded, while others do not specify any limit, but
very few recommend quantities exceeding 45 gr. a day.
In our hospitals here it has been found necessary to
exceed very greatly these quantities of quinine in the
grave and pernicious types. We first increase the
quinine for the therapeutic tests for differential
diagnosis, and second, to meet the requirements of
the very grave pernicious attacks. The routine
practice is to administer 20 gr. of quinine in solution
when the patient is admitted to the hdspital, and
continue thereafter with 30 gr.a day. For the thera-
peutic test quinine is sometimes increased to 45 gr. a
day for one or two days, and then reduced to the
usual 30 gr.a day. In the grave and pernicious cases
quinine is administered in quantities of from 60 to
90 gr. a day, according to the gravity of the case. In
my individual work I have in many instances exceeded
éven these quantities, and I have administered 120 gr.
in the first twenty-four hours. J do not, however,
continue quinine in these massive quantities for a
period longer than twenty-four hours. Experience has
taught that it is useless to continue quinine in such
massive quantities for a period longer than twenty-
four hours. If quantities such as 90 to 120 gr. in
twenty-fours do not suffice to effect relief, the infec-
tion has already passed the stage where treatment can
be of any avail. In fact, cases of such gravity as to
call for quinine above 80 gr. in the first twenty-four
hours usually prove fatal within this period, and one
rarely succeeds for the lack of time to introduce 90 to
120 gr. of quinine into the system. If quinine has in
this time proved beneficial, the remedy is immediately
reduced to 45 gr. a day, where it is allowed to remain
for the next succeeding twenty-four to forty-eight
hours, when it is again reduced to the usual 30 gr. a
day. In the cases in which I have succeeded in
administering these massive quantities within this
period, I have felt that I had succeeded in saving the
patients’ lives; at least, I have had the satisfaction of
knowing that I did them no harm, for I have seen
no evil results following this method of administering
these large doses of quinine.
There is a small percentage of pernicious fevers in
which I think the quinine ought to bemuch more rapidly
reduced than is stated above, and in some instances
even discontinued for a time. I have already called
attention under the head symptoms of malaria to a
class of pernicious fevers in which the parasites dis-
appear rapidly from the circulation under treatment—
the disappearance of the parasites is not merely from
the peripheral circulation, but it is from the circula-
tion as a whole, as is shown by autopsy smears—yet,
in spite of this fact, the gravity of the symptoms con-
tinues to increase, and death takes place on the fourth,
fifth or sixth day from admission. In this class of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1918.
cases, as the cause of death has not been clearly
ascertained, one can well assume that the quinine
itself may be a contributing factor towards death.
At all events, the quinine has served its purpose, and
there can be no good reason for its continuance, as
experience has proved that continuing the quinine
does not prevent death; therefore, it ought to be
rapidly reduced. The indication for the reduction of
quinine in this class of cases can be easily ascertained
from the examination from time to time of the blood
of the periphery.
Indication for Increasing the Dosage of Quinine.—
The indication for increasing the dosage of quinine is
first noted from the examination of the blood smears.
The gravity of the infection will, as a rule, be indicated
by the number of parasites seen in the smears, though
this rule does not hold good in either direction. Thus,
one may see smears very rich in parasites, yet no
pernicious symptoms will follow, and, on the other
hand, one may see in rare instances only a moderate
number of parasites in the smears, but, nevertheless,
the case will terminate in a pernicious attack in a few
hours. One of the significant indications as to the
gravity of the infection is the characteristics of the
parasites as seen in the smears; that is, the develop-
ing stage of the organism as seen in the peripheral
blood. When full-grown forms, presegmenting and
segmenting bodies begin to appear in the blood of the
periphery, it always indicates that the infection has con-
tinued for some days, as these forms are rarely seen
in the peripheral blood in the quotidian and subtertian
infections, except when the symptoms are grave, or
pernicious symptoms are already present. Another
indication of rapidly oncoming pernicious symptoms
is, when in puncturing the lobe of the ear or finger
for examination purposes, one finds that the blood is
made to exude with great difficulty. In these in-
stances the blood is dark, it clots quickly, and smears
unevenly. This is an indication that the circulation
is already embarrassed in the capillary system from
blocking by the parasites or by the weakening of the
circulatory organs from toxins. The clinical sym-
ptoms may now be correlated with these findings in
the blood examinations for further aid in the indica-
tion for increasing the dosage of quinine. It was
stated under the head of “symptoms in malaria,” that
certain mental aberrations manifest themselves before
the onset of active pernicious symptoms. These
mental aberrations are, the inability for consecutive
thought, difficulty in recollecting events in the illness,
or at times moroseness, or an unwillingness to make
any mental effort, and at other times there will be
vague wanderings away from the bed, and so on.
These clinical symptoms, in conjunction with the
blood findings already noted, such as the richness of
the parasites in the smears, or the presence of sporulat-
ing forms and crescent bodies, always indicate that if
quinine is not pushed, the illness will eventuate in an
active pernicious attack. The absence of these symp-
toms, even with large numbers of parasites, indicates
that the case will probably pursue an average course,
and one may begin the treatment with average doses
of quinine, but ready at all times to increase the dosage
Oct. 1, 1913.]
if untoward symptoms arise; but, on the other hand,
if these mental symptoms are present, although there
may be only a moderate-appearing infection, one should
push the treatment boldly. In these cases with grave
symptoms, though not yet quite pernicious, quinine
should be administered in quantities of 45 or 60 gr.
for the first twenty-four or forty-eight hours. Where
active pernicious symptoms are already present when
the patient comes under observation, the larger doses
of 80, 90, or even 120 gr. are indicated to be given
but only for the first twenty-four hours. In those cases
with the embarrassed circulation, I have always looked
upon this condition as an indication for intravenous
injections of quinine, also in as large doses as can be
given in proper dilution, usually 20 gr. in 10 c.c. of
water. Intravenous injections are now practised by
Dr. W. M. James, in Ancon Hospital, in large dilu-
tions, somewhat after the method of salvarsan injec-
tions. I have had no experience with this method.
The Time of the Day to Administer Quinine.—In
Ancon Hospital it had been a routine practice to
administer quinine in 10-grain doses three times a
day, while in Colon Hospital the practice, as intro-
duced by Brem [2], has been to administer quinine in
15-grain doses at 6 and 11 a.m. Both of these
practices have been equally satisfactory clinically,
but I am nevertheless partial to the twice-a-day
method, with both doses given in the forenoon. It
has the advantage of being less troublesome to the
patient, and as a majority of the cases of malaria
have their paroxysms in the forenoon, the twice-a-day
method has the added advantage of putting the
quinine into the circulation in greatest concentration
at about the time that sporulation most frequently
occurs, thus permitting the quinine to act most effec-
tively on the young organisms. But when it becomes
necessary to increase the dosage to 45 gr. a day, or
more, it is then not feasible to continue the adminis-
tration in twice-a-day doses. Under such circum-
stances I usually administer for the 45 gr.a day
three 15-grain doses during the day, or for the 60 gr.
a day four 15-grain doses. For quantities above this.
quinine is administered in 10-grain doses every two or
three hours as the case seems to indicate.
The Methods of Administering Quinine.—I shall
here discuss briefly the methods of administering
quinine. Such a discussion would hardly require the
space if it were not for the fact that a general impres-
sion seems to prevail, that when quinine is admin-
istered hypodermically it has a like potency, and acts
in the same degree of efficiency as the other highly
soluble drugs such as strychnine or morphine, when
administered in this manner. This assumption thus
makes the hypodermic method of administering
quinine the method of choice when one is desirous of
putting quinine into the system in the greatest
quantity in the least time. I suppose this idea is
deduced from the fact of the prompt and full effect
produced by hypodermic injections of the soluble salts
of the more powerful drugs which can be administered
in minute doses. But with quinine the case is hardly
similar. Quinine is not very soluble at best, and the
quantity administered is enormous when compared to
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
299
the very soluble salts that are usually administered
hypodermically. To a certain extent it is found that
quinine when administered hypodermically follows
the rule of the other soluble drugs when administered
in a like manner, in that it appears in the urine more
quickly than when administered by the mouth, but it
by no means follows that the full quantity of quinine
injected is all absorbed, or, even if it is all absorbed,
that it is absorbed rapidly. In fact, clinical experi-
ence would lead one to infer that when quinine is
administered hypodermically the full quantity is
slowly absorbed, and in many instances scarcely
absorbed at all. Rogers [3] has pointed out by com-
parison of charts that the fever may not be checked
as promptly by quinine administered hypodermically
as when administered by the mouth, and Thayer [4]
notes that a large percentage of the salt is precipitated
in the tissues when it is administered hypodermically.
Indeed, it is a too common experience after a hypoder-
mic administration of quinine for one to be confronted
by patients with deep-seated indurated painful masses
at the site of the injection. These masses may remain
for a week or more to slowly absorb, or finally, a
certain per cent. of them break down by coagulation
necrosis into large sloughing indolent abscesses, and
this untoward event occurs in spite of all aseptic pre-
cautions. Thus, it appears to me that while quinine
administered hypodermically is our sheet anchor in a
great many pernicious cases of malaria, it is neverthe-
less not a method of election but a method of neces-
sity. Therefore, I think when quinine is administered
by the mouth and already in solution, it is even more
efficacious than by hypodermic injection. I make it
a practice to follow the method of administering
quinine by the mouth as long as the patient can be
induced to swallow. Even when vomiting is a trouble-
some problem, a little patience and a little persever-
ance will be rewarded by surprisingly satisfactory
results. By repeating the doses of quinine in
small amounts, 10 gr. or so, after each rejection
by vomiting, with such other symptomatic remedies
as may suggest themselves, a small hypodermic injec-
tion of morphia or hot sinapisms over the stomach
for instance, one will find that the vomiting will cease,
and that the patient can continue to take quinine
with a fair degree of comfort.
Intravenous Administration of Quinine.—Intraven-
ous injection of quinine is, of course, unquestionably
the most rapid and efficient means of administering
the drug, but unfortunately this method is not with-
out danger to the patient. Thayer [5] has reported
a case in which death occurred immediately after the
intravenous injection of quinine, and I have had one
case in which the symptoms became very alarming
just at the close of the operation. In this case
the pulse ceased to be perceptible at the wrist, the
mucous membranes became cyanotic, and the re-
spirations shallow and sighing. On account of the
danger to the patient, I have been timid about adopt-
ing this method, and have not used it except in cases
in which I felt that no other means of administering
quinine could be of any benefit, that is to say, I have
used the method only as a last resort. My results,
300
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 1, 1913.
therefore, have not been satisfactory. All the cases
of pernicious malaria in which I have used intraven-
ous administration of quinine have died in from two
to eight hours after the administration of the drug
in this manner. Nevertheless, I am not condemning
the method, and I think I could have made it perhaps
of use to me if I had made a better selection of my
cases.
McGilchrist [6] has of late brought forward the
method of hypodermoclysis, thus using high dilutions
of the drug. This method has been used by James [7]
in Ancon Hospital, and at first reported favourably,
to be later abandoned. It was attended by too much
pain, and from the exhibition of James's charts,
in which in some the temperature persisted for nine
days, I think that this latter method is not as effica-
cious as even the hypodermie method.
The Prevention of Itelapse.—I am beginning of late
to be inclined to the postulate that malarial parasites
become feebly "fast" to quinine when they are forced
to develop through several generations in weak dilu-
tions of the drug in the circulation. If this then is
true, interrupted periods of administering quinine is
the proper method for preventing relapses. Experi-
ence has taught that interrupted periods of adminis-
tration of quinine has at least this advantage, and
that is, that patients will in most instances persist in
this method of their own accord, when they will not
continue quinine in regular daily doses in quantities
sufficient to be efficacious. It is an old practice to ad-
minister quinine in interrupted periods of about one
week interval. Marchiafava and Bignami[8], so far
as I am able to learn, were the first to adopt the
interrupted method of administering quinine in
relapses, and they insist from their experience that
it is the best method for preventing the recurrences.
I have also found this method very efficacious when
dealing with intelligent patients. I pursue the
method in the following manner: from the last day
of the subsidence of the fever I have the patient
count forward seven days, and make a note of the
date, and each seventh day thereafter is noted for
six weeks, and preferably eight weeks. On the day
before the seventh day the patient is instructed to
begin quinine in full doses, usually 30 gr., and con-
tinue it through the seventh or pivotal day, and con-
tinue it throughout the next day following. Then
discontinue until the next period, and thus continue
the treatment throughout the specified time. As I
have already stated, to obtain results by this method
presupposes intelligence on the part of the patient or
his guardian.
Effect of Quinine in Large Doses —As I have
stated, the quantities of quinine we administer here
in our hospitals are larger than are usually adminis-
tered in any other institutions, and I judge it will be
of interest to make known the effect these quantities
have on the patients. As I have already stated, so
far as I can see it has had no evil effect in any
manner.
If it has been the cause of precipitating black-
water fever, there has been no means of ascertaining
this fact, but apparently it has not done so. It has
left no permanent ill-effects upon the hearing or
sight, and I have seen only one instance of quinine
amblyopia, and this occurred while the patient was
taking 30 gr. a day. In one case quinine in solution
was administered, by accidentally overlooking a
patient, in 30 gr. a day doses for a period of seven
months, at which time no ill effects could be noted,
and the patient stated that he had long since ceased
to be troubled by ringing in the ears or other un-
pleasant symptoms. It was not unusual in my wards
in the press of heavy work to overlook patients in the
manner as stated, and allow them to continue on
quinine of 30 gr.a day for periods of two or three
months. In these instances there was no apparent
ill effect from the drug.
I have in this series of papers stated to the point
of tediousness that if quinine is administered in
malaria in an efficient manner one may always
expect that the febrile course will be checked in
from one to five days. I have herein set forth
what I consider the efficient administration of
quinine. There are several adjuvants to quinine in
malaria which make for the efficiency of the treat-
ment, and to obtain the best results one must insist
upon them. The first of these is rest in bed during
the febrile stage, no matter whether the case is mild
or severe. The second is restricted diet, and the
third is prevention of continuous reinfection of the
patient in his own surroundings. Thus, in our
hospitals here the patient is kept in bed until the
fever is completely controlled, and the diet during
this time is always liquid. After the fever is com-
pletely broken, the patient is allowed to be about the
ward in moderation, and soft diet is allowed during
this time, but it is served at the bedside. After from
two to several days on soft diet, according to the
gravity of the illness, full diet is allowed, and the
patients are permitted then to go about the wards as
they please until discharged. Routine doses of
quinine are of course continued during the entire stay
of the patients in hospital.
In the preparation of these articles I have been
confronted by a paucity of literature and have had to
depend largely on current text-books. On account of
the richness in material and the completeness of the
work, I have drawn very liberally from " Malaria in
the Twentieth Century Practice of Medicine,”
William Wood and Company, New York, by Marchia-
fava and Bignami, to whom I wish to express my
profound obligations. I wish also to continue my
thanks to Colonel W. C. Gorgas, Chief Sanitary
Officer, Isthmian Canal Commission, for permission
to publish these articles, and to thank Major Robert
E. Noble, M.C., U.S.A., Dr. S. T. Darling, and Dr.
W. M. James for encouragement and suggestions.
BIBLIOGRAPHY.
[1] Cnarc, CHas. F. ''The Malarial Fevers.” Wm. Wood
and Co., New York, 1909.
[2] Brem, W. B. ‘ Studies of Malaria in Panama ’’—(1)
** Clinical Studies in the White Race," Arch. Inter. Med., vol. vi,
pp. 646-661, December, 1910.
[3] Rocers, L. ''Fevers in the Tropics,” pp. 232-293,
1908.
Oct. 1, 1913.]
[4] THayer, Wu. S. “On Malarial Fever, with Special
Reference to Prophylaxis," Harvey Lectures, Series 1911-1912.
J. B. Lippincott and Co., Philadelphia.
[5] THAYER, Wm. S. ‘‘Grave Malarial Fever with Few
Parasites in the Peripheral Circulation, Dangers of the Intra-
venous Injection of Quinine," Reprint of remarks made before
the Johns Hopkins Society on October 17, 1909.
[6] McGrucurist, A. C. Paludism, Simla, No. 2, 1911.
[7] James, W. M. “A Preliminary Report on a Practical
Method for Preventing the Development of Pernicious Malaria,"
E rocsedings of the Canal Zone Medical Association, 1911, vol. iv,
art I.
[8] Marcurrava and Bianamr. ‘‘ Malaria,” Twentieth Cen-
tury Practice of Medicine, vol. xix, 1902.
ACQUISITION OF ACID-FAST PROPERTIES
BY A FILAMENTARY ORGANISM CULTI-
VATED FROM AN ANIMAL INJECTED
WITH A CULTURE OF HANSEN’S
“ BACILLUS.”
By J. Martinez SANTAMARIA, M.D.
Bogota.
On June 10, 1911, Dr. Bayon injected 1 c.c. of
a saline emulsion of Kedrowsky's strain of leprosy
intra-peritoneally into a white mouse. The animal
was killed four weeks after; on necropsy numerous
small white nodules were found on the surface of
the various abdominal organs. Fragments of the
spleen were taken with aseptic precautions, the
piece in no case being bigger than a millet seed;
these were placed on glycerine-agar.
The microscopical examination of the inner
organs showed in the liver and spleen deposits of
the acid-fast organisms injected. The tubes so
inoculated were placed in the incubator at 87° C.
and two weeks afterwards a small whitish growth
was noted between the edge of the fragment of
spleen and the culture medium. This was found to
consist of a non-acid-fast, branching filamentary
organism, morphologically identical to the one
cultivated by Dr. Bayon from a case of leprosy.
The spleen particle was removed and the tube
again placed in the incubator. As the culture,
however, did not appear to thrive, it was trans-
ferred to à tube of Dorset's medium on the tenth
day from the first observation of the culture. On
this medium rapid multiplication took place. At
the end of fifteen days the surface of the medium
was covered with a white, creamy, smooth and
moist growth. On microscopical examination it was
found that though the branching, filamentary
organism was absolutely non-acid-resisting, small
granules, such as have been described by Kedrowsky
in his original filamentary culture, could be seen
scattered among the filaments and these granules
had retained the carbol-fuchsin stain; in other
words, we found here an exact counterpart of the
appearances described by Kedrowsky in his original
culture of leprosy.
This examination was repeated fifteen days later
and showed that these acid-proof granules had
apparently increased in number, and, moreover,
short, plump, elongated, acid-fast bacteria had
made their appearance. They were, however, too
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
301
Later on they how-
rods could be
short to be called '' bacilli. ”’
ever grew longer and definite
detected.
Now, fourteen months after the original culture,
the original Dorset medium is reduced to a brown
mass, where, alongside with the acid-fast rods, a
long filamentary and branching absolutely acid-fast
organism is to be found in great quantity.
This series of observations show for the first time
on an artificial medium the cycle of evolution from
a non-acid-fast filamentary, branching organism to
an acid-fast '' bacillus.” Similar results have been
recorded by Kedrowsky, and later by Bayon in con-
nection with the organism of leprosy after injection
into animals, and I consider that these observations
confirm the experiments of these authors, and show
that the failure to cultivate the organism of leprosy
was due to the fact that the cultures obtained from
lepers (branching, filamentary, non-acid-fast organ-
ism, and partially acid-resisting diphtheroids) were
cast aside as contaminations before a complete and
thorough study of their properties had been made.
A FIBRO-SARCOMA IN A NATIVE OF
CENTRAL AFRICA.
By A. Yare Massey, B.A., M.D., C.M.Tor.
Lusambo, Belgian Congo.
In April, 1911, a male native of about 25 years
consulted me for a fungating growth on the vertebral
Native with fibro-sarcoma on his back. Central Africa.
line of the back. He was then in moderately good
health, and said that the tumour had been growing
302
for more than a year. He was kept under observa-
tion for three months, during which time the tumour
increased in size about one-third. It was always
nodular about the everted edges, the centre being
soft, depressed, and bathed in pus, and bleeding at
the slightest touch. The health of the patient
became gradually worse, and when I operated his
weakness was so great that he could scarcely stand.
Under local anzsthesia—eucaine and adrenalin by
infiltration—the tumour was easily removed, and
proved to be superficial to the spines of the verte-
bre. It weighed 900 grm. Skin grafts were un-
successful, but the surface was completely healed
in three months, and in six months the patient was
in robust health. An examination of the patient
eighteen months after the operation revealed no
indication of any return of the tumour.
I am indebted to Dr. Bashford, of the Imperial
Cancer Research, Queen Square, London, for the
following report :—
“‘ Fibro-sarcoma, in parts very cellular, having
typical structure of a spindle-cell sarcoma, probably
of slow growth because of scarcity of cell division. '
I may say that this native was a raw interior
black, never having visited the coast. I believe it
to have been purely a native tumour, and it is the
only one of that character which has come under
my notice during an experience of several years in
Central Africa.
NOTES OF A CASE OF SLEEPING SICKNESS
FOUND ON THE HILLS, TWENTY-TWO
MILES NORTH OF SERENJE, IN NORTH
RHODESIA.
By ALEXANDER Brown, M.B., Ch.B.
Serenje.
History.—A youth, aged about 18 years, born
and brought up in Chimese's village (six miles from
Dr. Livingstone's grave), left his home in 1908 and
came to Serenje. There he was employed by the
assistant magistrate, whom he aecompanied on at
least one journey to the Luangwa Valley. In
1909 he became attached to a mission whose head-
quarters were then at Serenje, and in the month
of August of that year he went with a teacher on
a journey round about his own country, viz., near
Livingstone's grave. In August of 1910 he accom-
panied me on a journey across the Luangwa Valley
to Nyassaland, travelling via Serenje, Kakumbi, and
Fort Jameson. I cannot remember seeing ''fly"
on this journey, though I found them on a sub-
sequent one when travelling the same route. In
July of 1911 he made a journey direct to and from
Broken Hill—a route on which there is no '' fly "'
till near Broken Hill. In the present year he has
been only a few miles from this station (Chitambo,
near Serenje), and not, to my knowledge, in a
'" fly " area. A case with such.a history occurring
on the hills, at an altitude of 4,800 ft. in a fly-free
area, calls for some attention.
The youth, Samuel Ngarande, came to my dis-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 1, 1913.
pensary on April 18, complaining of his left ear.
His temperature was 101:49 F., and he looked rather
ill, but he was a powerful and well-built youth.
His ear had been suppurating. Heart and lungs
were normal. His spleen was very much enlarged.
The blood was negative for malaria. I had at the
time several cases of wstivo-autumnal fever and
suspected his case was the same, though I could
not demonstrate the parasite which was readily
found in the other cases. His ear was syringed,
and improved, and he did not complain of it again.
He was at the same time put on malarial treat- .
ment and his general condition seemed to improve,
though the fever never went away. He now in-
sisted on returning to his work, which he did, but
had to desist. He complained only of want of
strength, but a tonic did not help him. As I
was preparing to go on a journey I put him on to
fresh quinine when just out from home. I was
away almost a fortnight, and when I returned on
May 19 I found him, if anything, worse. The
spleen was distinctly larger. He complained of
deafness, which I attributed to the quinine and
which cleared when the quinine was stopped. I
noticed a peculiar rough appearance on his abdo-
men, which on a white skin might have been a
rash. I had always noted him as a heavy-eyed
youth, but now his upper eyelids were distinctly
puffy. His breathing was rapid. His sublingual
gland was swollen. Decubitus was characteristic of
sleeping sickness. A former examination of neck
glands had aroused no suspicion, now they were
found distinctly enlarged, but not soft. There was
great tenderness over the tibie. There was no
albumin in the urine. He complained of no pain,
but merely of want of strength.
On finding that the quinine had had no effect on
the fever or on the spleen I made a fresh examina-
tion of the blood. The fresh blood showed marked
agglutination, but I found no trypanosomes in it.
Stained specimens, however, very soon revealed the
parasite. This was on May 22, a month after I had
first seen him.
Remarks.—This case seems to me to present
several points of interest:—
(1) The enlarged spleen which at this date (May
28) reaches to the level of the umbilieus, and the
tenderness over the tibie.
(2) The condition of the blood. Over 400 leuco-
cytes were counted. The nuclei of the large and
small mononuclears were frequently indented. The
reduction of the polymorphonuclears was great and
the number of abnormal cells seemed to me to be
large.
Polymorphonuclears $us 5 per cent.
Large mononuclears ge 3$ 40 ^^
Small mononuclears ED sis 42 2
Transitionals... see ET T 10 -
Abnormal i ia 2s iix 10.5 ,,
Eosinophiles ... jx ss. "s 1 a
Mast cells... TS "d T 1 5 (nearly)
In connection with the enlarged spleen, the
microscopical evidence for malaria was so scanty
Oct. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
303
that I am inclined to think that the enlargement
is due to the trypanosomiasis.
(3) The Parasite.—It showed, as usual, variation
in morphology. The most notable difference which
caught the eye at once was the square posterior end.
The percentage was much greater than in any
cases seen previously. Eighty-seven were counted.
Of these, forty-two had the posterior end square,
or nearly square. Thirty-two had various forms,
from a blunt-rounded to a very sharp-pointed
posterior end. Thirteen were doubtful, the ends
being hidden by corpuscles, &e. Some had the
posterior ends of a snout form; some were angular.
A short or absent flagellum, which I have seen in
my previous cases, I have not observed in this.
The blepharoplast was generally some distance from
the posterior end, but sometimes, in the pointed
variety, was quite terminal. The nucleus was
generally about the middle.
(4) The Source of Infection.—The nearest '' fly ”
to us is about twenty miles away. There are four
possible explanations :—
(a) That trypanosomiasis is endemic in the blood
of some people.
(b) That infection occurred in the Luangwa Val-
ley. The length of time since the patient was
there is against the theory of the virulence of
T. rhodesiense, if it is that parasite. (He has not
been in the Valley since 1910.)
(c) That he got it when travelling round his own
home in 1909; but the history of the present illness
is against it being of a chronic nature. If it is
T. rhodesicnse the same argument holds against.
If it is T. gambiense there may be a focus of in-
fection in that region, viz., near Livingstone's
grave.
(d) That he has been infected here.
Against I will only say that biting flies are con-
spicuous by their absence almost all the year round.
But biting flies like Stomozys can always be found
at the cattle kraal.
For a carrier of the infection here, there are, in
addition to the stomoxys, bugs, ticks, and cock-
roaches, &c., as possibilities.
For a possible source of infection we have the
following :—
(1) A dog was kept here for some days which
had contracted trypanosomiasis when crossing the
Luangwa Valley. When this was suspected and
discovered the dog was killed. This was in 1910.
I have re-examined the trypanosome of the dog and
find no resemblance in the parasite to that in the
present case. It is extremely improbable that this
has anything to do with the present case.
(2) The hut in which the boy was living until a
few months ago is close to a cattle kraal. The
cattle, however, have never shown any sign of
sickness, apart from being off colour now and again
for a day or so.
(3) Several individuals have died of sleeping
sickness on this station. One or two of these at
first slept on the station (one, a European, in my
own bed for a week) until huts could be built for
them some distance away. The last sleeping sick-
ness case died in September, 1911. This present
case has never slept in any of the huts in which
these lay.
TREATMENT OF SOME CASES OF HUMAN
TRYPANOSOMIASIS BY SALVARSAN AND
NEO-SALVARSAN.*
By Professor AYRES KOPKE.
Tropical Medical School, Lisbon.
In his first works on the treatment of sleeping
sickness by atoxyl, presented to the Fifteenth
International Medical Congress in Lisbon in April,
1906, Kopke called attention to the fact that try-
panosomes having invaded the cerebrospinal fluid
remained there, notwithstanding the use of atoxyl
in doses of 14 grm. in each injection, and repeated
several times.
Subsequent investigations have confirmed his
ideas. In his aecount at the Congress of 1909 in
Budapest, he concluded, from a long study of
patients, that atoxyl, even when used with other
medicaments, cannot make the trypanosomes dis-
appear from the spinal fluid, and that the patients
die after a period of calm (without symptoms).
Kopke divides the’ patients into two classes:
those who have the trypanosomes in the cerebro-
spinal fluid, and those who have not.
His observations show that the want of result is
due to an insufficient dose of atoxyl or when the
nervous injuries are irreparable.
Professors Laveran and Mesnil think it improbable
that a medicament can extend into all parts of the
system. Professor Kopke had also this doubt, but
persisted because of the good results in the treat-
ment of meningitis by atoxyl.
It was expedient, therefore, to find a medicament
of a greater diffusibility and having a more direct
anti-parasitic power which might operate in cases
having flagellates in the cerebrospinal fluid.
The discovery of salvarsan by Professors Ehrlich
and Hata brought the hope that it might be better
than atoxyl, but neither alone nor with colouring
matter can patients with trypanosomiasis be cured
whose nervous centres have undergone alterations,
neither does it cure all cases in the first period of
infection.
Professor Kopke experimented with salvarsan in
patients in whom the cerebrospinal fluid showed
flagellates, using salvarsan by intravenous injec-
tions. The doses were from °3 to °6 grm., except
in a boy of 10 years, who had a dose of '1.and
"15 grm. The injections were repeated with eight
to ten days” interval, the total number being
generally three. Two patients received seven in-
jections.
Of fifteen patients treated thus ten died. Of the
five living one had two hemiplegic attacks of the
right side with aphasia; the paralytic fits passed off,
but the patient drags the right leg a little and speaks
with difficulty; besides, he has occasional epilepti-
form manifestations; he seems bound to succumb
* Abstract of Paper presented at the International Medical
Congress in London, August, 1913.
304 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1913.
to the illness. Of the four left one has been with-
out symptoms, and no trypanosomes have been
found for one and a half years after treatment. It
would seem that patients who have nervous sym-
ptoms, somnolence, tremblings, &e., do not show
as good results with salvarsan as with atoxyl.
In another patient death followed an injection of
'6 grm. It was an advanced case, with accentuated
nervous manifestations and a precarious mental
state. As no favourable results were obtained with
'8 to ‘5 grm., ‘6 grm. were given. This was
followed by increased trembling; the temperature
was 40:39 C.; epileptic fits were followed by coma
and death twenty-four hours after the injection.
Wilhelm Wechselmann has made a solution of
neo-salvarsan (1°5 the 100) with a maximum dose
of 7 e.c.
Professor Kopke tried a rather advanced case of
sleeping sickness with 10 c.c. of a solution of neo-
salvarsan (1:5 a 100) within the arachnoid by lumbar
puncture. In a few hours afterwards the patient
had trouble in the lower limbs, tremblings, and an
axillary temperature of 389 C.
One patient after injections died four and a half
months after infection.
Another patient had three injections of *45 grm.
of neo-salvarsan; after eleven days he had severe
symptoms, and died—mad—some three months
after the last injection.
As cases treated by neo-salvarsan injection, arach-
noidian only, or followed by intravenous, or by intra
venous alone, have not got better, it seems that the
use of this medicament has been rather prejudicial.
The trypanosomes did not disappear from the spinal
fluid.
CONCLUSIONS.
Salvarsan used in intravenous injections does not
cause the trypanosomes to disappear from the
cerebrospinal fluid in patients suffering from sleep-
ing sickness. Like atoxyl, it makes the flagellates
disappear rapidly from the blood and lymphatic
areas, but it seems too soon to be able to say
whether this disappearance is lasting. i
Injections of neo-salvarsan within the arachnoid
by spinal puncture do not destroy the trypanosomes
under the meninges, and are not exempt from
inconveniences.
————9———— —
THERE are 3,213 women studying in the univer-
sities of Germany; of this total 702 are studying
medicine and 17 dentistry.
OPIUM was grown in China 400 years ago. The
habit of smoking opium made its way into China from
Java by way of Formosa in the 17th century. In
1911, when the British Government undertook to
gradually lessen the supply from India, the Indian
total represented only one-seventh of the amount
consumed in China.
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THE JOURNAL OF
Tropical Medicine and hygiene
OCTOBER 1, 1913.
MANIFESTATION INTERNATIONALE EN
L’HONNEUR DE SIR PATRICK MANSON,
F.R.S., G.C.M.G.
Les magnifiques progrés réalisés, depuis moins
de vingt ans, dans la connaissance des maladies
des pays chauds, sont dus, pour une trés grande
part, à Sir Patrick Manson ou à son initiative. La
eréation des écoles ou instituts de médecine tropi-
cale, ces foyers si actifs et si utiles d'enseignement
et de recherches, est due encore à son action bien-
faisante. En ces questions, il a été un initiateur
de génie.
Les soussignés, persuadés que Sir Patrick Manson
a rendu à la science et à l'humanité les plus
éminents services, ont pensé que l'heure était venue
de témoigner à l'illustre savant anglais leur vive
admiration pour son ceuyre, en méme temps que
leur respectueuse affection pour sa personne. Ils
ont voulu provoquer en son honneur une manifesta-
tion internationale, à laquelle pussent prendre part
tous ceux qui connaissent ou admirent Sir Patrick;
tous ceux qui ont passé par l'Ecole de Médecine
tropieale de Londres, ou par les écoles et instituts
similaires; tous ceux qui, sans avoir été en relations
plus ou moins directes avec lui, savent cependant
l'immense portée de son œuvre et désirent lui
témoigner leur estime et leur reconnaissance,
Dans ce but, il est ouvert une souscription
P
Oct. 1, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
internationale, à l'effet d'offrir à Sir Patrick
une médaille d'or à son effigie. Cette médaille
aura la forme d'une plaquette, mesurant environ
7 centinétres de haut sur 5 de large. Elle sera
l'euvre du Dr. Paul Richer, Membre de l'Institut et
de l'Académie de Médecine, Professeur d'anatomie
à l'Ecole des Beaux-Arts. Tous ceux qui connais-
sent le fin talent et l'élégante exécution de ce savant
médecin, doublé d'un trés grand artiste, peuvent
étre certains que son œuvre nouvelle sera digne, en
tous points, de ses devanciéres et de Sir Patrick.
Les souscriptions sont recues :
1° Chez Mr. JAMES CaxrLIE, directeur du Journal
of Tropical Medicine and Hygiene, 140, Harley
street, à Londres, W.;
1° Chez Messieurs AssELIN et Houzeau, éditeurs
du journal, Archives de Parasitologie, place de
l'Ecole de Médecine, à Paris.
On peut adressser les souscriptions par bon de
poste, mandat postal ou chéque. Aucune limite
n'est fixée.
Tout souscripteur de 25 francs (£1) recevra un
exemplaire en bronze de la plaquette.
Tout souscripteur de 50 francs (£2) recevra un
exemplaire en argent patiné.
En vue de ces envois, dont un grand nombre
devront étre dirigés vers les pays étrangers, les
souscripteurs sont instamment priés d'écrire trés
lisiblement leur nom, leurs prénoms ou initiales,
leur adresse, ainsi que toutes les indications néces-
saires,
[Translation from the French Tezt.]
INTERNATIONAL MANIFESTATION IN HONOUR OF
Sin Parrick Manson, F.R.S., G.C.M.G.
THE magnificent progress made in less than
twenty years in the knowledge of tropical diseases
is due in great measure to Sir Patrick Manson, or to
his initiative. The foundation of tropical medical
schools or institutions, those homes of learning and
energy, is also owing to his beneficent work.
In these matters he showed the genius of the
master.
The undersigned, convinced that Sir Patrick
Manson has rendered the most eminent services to
science and humanity, think that the time has come
to prove to this illustrious British genius their great
admiration for his work and their respectful affection
for himself.
They desire to promote in his honour an inter-
national manifestation, in which those who have
known and admired Sir Patrick can take part; also
those who have passed through the medical schools
of London, or other similar institutions, and those
who, without being closely connected with him,
yet knowing the immense importance of his work,
may desire to show their esteem and gratitude.
For this purpose an international subseription has
been started, with the intention of presenting Sir
Patrick Manson with a gold medal bearing his
effigy. The medal will have the form of a plaque,
measuring about 7 x 5 em. It will be the work
of Dr. Paul Richer, Member of the Institute and
305
Academy of Medicine, Professor of Anatomy at the
Ecole des Beaux-Arts. Everyone is acquainted
with the talents and elegant work of this learned
doctor and great artist. It is certain that this new
undertaking will be ^worthy in every respect of its
predecessors and of Sir Patrick Manson,
Subscriptions will be received by:— .
(1) Mr. James Cantlie, Director of THE JourNnaL
or TRoPrcAL MEpicINE AND HyaikNE, 140, Harley
Street, London.
(2) Messieurs Asselin and Houzeau, Editors of
the Archives de Parasitologie, Place de l'Ecole de
Médecine, Paris.
Subscriptions may be sent by money or postal
orders, or cheque. There is no fixed sum.
As many subscriptions will come from abroad,
it is requested that subscribers write their names
and addresses clearly, giving full postal instructions.
The work of Professor Paul Richer is completed,
but a few months are still required for the final
preparation of the medals. Nevertheless the Com-
mittee did not wish the exceptional opportunity of
the International Congress in London to pass with-
out testifying their respectful sentiments and
admiration for Sir Patrick.
A bronze medal, faithfully reproducing the
original design has been cast, and was presented
to Sir Patrick Manson on August 11, 1918, by
Professor Blanchard at the Tropical Medical Section
of the Congress. The attendance was very large
and the ceremony most striking.
Until the medals destined for the subscribers are
cast and distributed the subscription lists will
remain open and all new subscribers will be gladly
received.
All subscribers of £1 (25 francs) are entitled to
& bronze medal.
All subscribers of £2 (50 franes) are entitled to a
silver-plated medal.
MEMBRES DU COMITÉ D'INITIATIVE.
Col. Arcock, F.R.S., Arthropodologist, London
School of Tropical Medicine.
Sir THOMAS CLIFFORD ALLBUTT, K.C.B., F.R.S.,
University of Cambridge, England.
A. Barrounm, Director-in-Chief of the Wellcome
Bureau of Scientific- Research, Woodcote, Churt,
Surrey, England.
Tu. Barrors, Professeur à la Faculté de Médecine
de Lille.
R. BLANCHARD, Professeur à la Faculté de Méde-
cine de Paris.
Ew. Brumpr, Agrégé à la Faculté de Médecine
de Paris.
Sir T. Lauper Brunton, Bart., F.R.C.P., F.R.S,,
London.
G. N. CarkiNs, Professor in Columbia University,
U.S.A.
Van CAMPENHOUT, Professeur à l'Ecole de Méde-
cine tropieule de Bruxelles.
J. CaNTLIE, London.
A. CASTELLANI, Director of the Clinique of Tropi-
cal Diseases, Colombo, Ceylon.
306
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1913.
A. CELLI, Professeur à l'Université de Rome.
O. Cruz, Directeur de l'Institut Oswaldo Cruz,
à Rio de Janeiro.
FürnLEBORN, Professeur à l'Institut de Médecine
navale et tropicale, à Hambourg.
J. Guiart, Professeur à la Faculté de Médecine
de Lyon.
A. KoPkE, Professeur à l'Ecole de
tropicale de Lisbonne.
Le Dantec, Professeur à la Faculté de Médecine
de Bordeaux.
R. T. Leer, Esq., Helminthologist, London
School of Tropical Medicine.
Sir WILLIAM LEISHMAN,
London.
G. C. Low, Professor of Parasitology, King’s
College, London.
Fr. S. MONTICELLI, Professeur à l'Université de
Naples. `
G. NEUMANN, Professeur à l'Ecole vétérinaire de
Toulouse.
G. H. B. NewnaM, Director of School of Tropical
Medicine, London.
Professeur NicornLE, Directeur de l'Institut Pas-
teur de Tunis.
Professeur Nocut, Directeur de l'Institut de
Médecine navale et tropicale, à Hambourg.
Professor Novy, at the University of Michigan,
Ann Arbor, Mich.
G. H. F. NvurrALL, F.R.S., Professor in the
University of Cambridge, England.
WM. Oster, F.R.S., Professor in the University
of Oxford, England.
Ep. PrRRONCITO,
Turin.
A. PLEHN, Professeur à l'Université de Berlin.
A. RAILLIET, Professeur à l'Ecole. vétérinaire
d'Alfort.
Sir Ronatp Ross, Professor
Tropical Medicine, Liverpool.
E. Roux, Directeur de l'Institut Pasteur de Paris.
Ruce, Médecin général de la Marine, Germany.
L. W. Samson, Lecturer, London School of Tropi-
cal Medicine.
F. M. Sanpwitu, Vice-President of the Society
of Tropical Medicine, London.
A. E. Suiptey, Dean of Christ's College, Cam-
bridge.
W. J. R. Simpson, Professor of Hygiene, King's
College, London.
C. W. SmiLEs, Hygienic Laboratory, U.S. Public
Health and Marine Hospital Service of Washing-
ton, D.C.
A. THEILER, Director of Research in Veterinary
Medicine, Pretoria, Transvaal.
H. B. Warp, Professor in the University of
Urbana, Ill.
Werc, President of the American Medical
Association and Professor in the University of
Baltimore.
C. M. Wrsvos, Protozoologist, School of Tropical
Medicine, London.
H. Ziemann, Médecin d'Etat-major de la Marine
allemande.
Médecine
F.R.S., R.A.M.C.,
Professeur à l'Université de
in the School of
Annotations.
Coccidioidal Granuloma.—Carsons and Cummins
report another case of this interesting condition in
the Journal of the American Medical Association,
July 19, 1913. Clinically the case resembled
typhoid fever and was diagnosed as such. At the
autopsy, however, the true nature of the case was
revealed.
The patient had lived in the San Joaquin Valley
and had presented no skin-lesions to account for
his infection. Although tuberculin reactions were
negative, he was strongly suspected of being tuber-
culous when he was first seen in August, 1912.
Marked hoarseness was then present. Wasser-
mann's reaction was negative. In February, 1913,
he was apparently suffering from typhoid. At
necropsy the lesions appeared to be those of miliary
tuberculosis, the largest lesions being present in the
spleen. For their size, however, the splenic lesions
appeared rather firm for tuberculosis. Micro-
scopically, there was no difficulty in demonstrating
the Oidium coccidioides (Ophüls) in the various
organs. These were most numerous in the spleen.
It was unfortunate that a complete necropsy was
not performed, especially to determine, if possible,
the character of the early laryngeal lesion.
Round Worms simulating Appendicitis.—Kelly in
the Australasian Medical Gazette, June 21, 1913,
reports the case of a boy in whom the presence of
round worms simulated appendicitis. The clinical
signs present were as follows. Temperature on ad-
mission 100°, pulse 106, looking pale and ill, and
complaining of pain in his belly. Tongue coated
but moist, had vomited once. Bowels had been con-
stipated for some time. Heart, lungs and urine
normal. Rigidity of the right rectus muscle with a
very tender spot on pressure in the appendix area.
An operation for the removal of his appendix was
decided on. At this the organ was easily found. It
was slightly reddened, but there were no evidences of
previous trouble. It was removed. As its condition
could not possibly account for the acute symptoms,
further examination was made, and a coil of small
intestine was found to have a peculiar whip-like feel
about it. This was pulled out, and was seen to be
intensely congested and inflamed, and with some flakes
of lymph on it. Three or four round worms could be
felt, and also seen to move init. They occupied about
eight inches of the bowel, and were lying lengthwise
and all together. It did not seem wise to open the
bowel and remove them, nor yet to crush them, as one
could not say what symptoms might follow the
crushing. Had the worms been near the cecum it
would have been an easy matter to push them along
and remove them at the appendix stump, but they
were at least three feet away. The bowel was
replaced, and the abdomen closed. Three days later,
whilst still on a liquid diet, the patient was given lgr.
of santonin and 6gr. pulv. scam. co. followed in six
hours by castor oil, and two round worms, each about
ten inches long were passed. Two days after this,
santonin was again given, and two more worms were
Oct. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
307
passed. Santonin was administered again on the
sixth day, but there was no result. After this the
patient gained weight, and quickly recovered.
Tropical Bubo.—In the Australasian Medical Gazette,
May 10, 1913, Triado writes on the etiology of this
condition. In the last nine years he had seen fifty
cases and admits that he cannot yet give any opinion
as to their etiology. The only distinctive feature he
found in every case was that there had been sexual
connection between aboriginal women and white men.
Also, all the cases have been in white males, no cases
being seen in natives. In every case the man was
single, except one, and this one was living away from
his wife, and admitted sexual connection with native
women. In twenty-seven cases the left inguinal
glands were affected, and in the remaining twenty-
three the right. Thirty-seven out of fifty had had
gonorrhea on some previous occasion and of vary-
ing duration. Two cases had had both gonorrhea
and syphilis, in the past. One case was under
treatment for syphilis, and had a bubo also at the
time of beginning treatment. Six months later all
external signs of syphilis had disappeared, but the
bubo still existed, and was discharging slightly. The
size of the buboes varied at time of removal up to
the size of an ordinary hen’s egg. Fifteen of the
earlier cases .were examined bacteriologically, and
the results failed to show any definite distinctive
micro-organism.
After removal the glands were all distinct, with
distinct softening in the centre of all of them, and
the more superficial ones the most softened. Peri-
adenitis varied according to the length of time that
elapsed since the beginning till their removal. All
the cases had a somewhat similar clinical course.
The earlier cases Triado treated symptomatically by
painting with iodine, a certain amount of rest, and
regulation of general health. The buboes in these
cases, after varying periods from two to six months,
became more painful and tender, and showed signs
of softening, as also did the overlying skin. In
every case the inguinal glands affected were swollen,
slightly tender, but distinct from each other. Sub-
sequently, after varying periods, the most superficial
glands showed signs of softening and a tendency to
burst through the skin.
In the larger buboes patients complained of tight-
ness in the groin, and an inability to walk quite up-
right, without certain, though not much, pain. This
pain was not noticeable if the patient walked with bis
leg slightly flexed on the thigh.
In five of the cases, on which Triado subsequently
operated, the swelling had been in existence over
twelve months; and the swelling in the period had
varied in size. Sometimes during the above time
the bubo was larger, and at other times smaller. In
the above five cases there had been a continual dis-
charge, and after spontaneous bursting through the
skin, of small amounts of pus for over six months.
Periadenitis occurred in all cases which had been in
existence over two months.
The diagnosis of these buboes from syphilitic and
gonorrhoal buboes offers no difficulties, their history
and clinieal course being quite different from gonor-
rhoea and syphilis.
Gonorrheal buboes show early tendency to sup-
puration, and spontaneous bursting through the
overlying skin if not early incised. In syphilis the
bilateral distribution and the characteristic hardness
of the bubo and other signs make the differential
diagnosis easy. In all Triado's cases the tropical or
climatic buboes were unilateral, and up to the present
none have developed any bubo on the opposite side.
After the first few cases the only treatment adopted
has been complete removal in one mass of the whole
of the affected glands, the earlier the better, as the
cavity left in the groin is smaller. Occasionally com-
plete removal in one mass appeared too difficult, so
thorough curettage was adopted. After removal the
whole cavity in the groin is swabbed with pure
carbolic acid. The length of time for the cavity to
fill up varies, according to the size of mass removed,
but never more than five weeks, and this only in the
largest cavities. .
The after-treatment, carried out by the patient,
consists of keeping the parts well washed with soap
and water, and the plugging of the cavity with gauze
changed twice a day. In no case was there any
after-trouble, though all the patients after the first
fortnight resumed their ordinary avocations.
Reports received five years afterwards showed that
the results of the operation had been perfect.
Blackwater Fever.—Lovelace, in the Archives of
Internal Medicine (vol. ii, No. 6, June 15, 1913),
writes on the etiology and treatment of blackwater
fever. He bases his observations upon a study of
514 cases treated by American physicians in the
hospital of the Madeira-Mamore Railway Company,
Porto Velho, Brazil, between January 1, 1908, and
November 27, 1912.
He considers the subject under the following
headings: (1) The relation of the disease or con-
dition to malaria; (2) its relation to a particular
species of malarial parasite; (8) its relation to
quinine; (4) its racial and personal incidence.
Under treatment, he discusses: (1) The results
of treatment with quinine; (2) the results of treat-
ment without quinine; (3) the general treatment of
the condition, and (4) the relation of the quinine
prophylaxis of malaria to blackwater fever.
After an analysis of the 514 cases the author
reaches the following conclusions : —
That there exists a deplorable confusion as to the
cause and treatment of blackwater fever, but as
far as may be indicated by his series of cases,
malarial infection stands in a direct causal relation
to it.
Blackwater fever is not due to a particular species
of malarial parasite.
Quinine, in large or small doses, was, in his
series, an invariable antecedent of the hemoglo-
binurie condition, and under no circumstances
should it be given to a blackwater fever patient
during the period of hemoglobinuria, nor for several
days thereafter. The effect of the paroxysm of
hemoglobinuria is itself that of a drastic, but
308 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1918.
temporary, therapeutic agent, decimating the
malarial parasites in the patient’s blood much as a
single intravenous injection of salvarsan decimates
the spirochetes of syphilis in the lesions of that
disease.
Measures which sustain the blood-pressure are
urgently indicated during the period of hemoglo-
binuria. Of these, normal saline solution given by
the bowel, subcutaneously or intravenously, is the
chief. Digitalis and caffein are of decided value.
The prophylaxis of malaria is the prophylaxis of
blackwater fever.
[Workers on blackwater fever will not fail to
notice that there is nothing new in the above.
The old difficulties remain just as they did twelve
years ago. A perusal of the past literature of the
disease would be of value and instructive to those
about to write upon it in the future. ]
———9——————
Abstract,
THE PROCEEDINGS OF THE SECOND ALL-
INDIA SANITARY CONFERENCE HELD
AT MADRAS, NOVEMBER 11 to 16, 1912.*
Note oN SANITATION IN INDIA.
By CumannLEs N. Manpy.
Executive Engineer, Poona Drainage and Water Supply.
SANITATION ls a science but recently introduced
into India, and is therefore not in a very advanced
state.
Some progress has been made with urban sanita-
tion which presents no great difficulty in carrying
out, but as it entails a considerable increase in the
current rate of taxation in most towns, Government
has to recognize that progress must be slow and
measured by the strength and character of the
public opinion they have to rely on in support of
sanitary measures. In India, therefore, as else-
where, the carrying out of sanitary works is now
much more a question of available expenditure than
of knowledge. Rural sanitation has made no pro-
gress, in fact it barely exists, and is a question of
magnitude and difficulty. As a general rule the
only way to improve rural sanitation is to remove
the sites and construet new villages, laid out on
proper principles with protected water supplies.
The origin of sanitation dates back some seventy-
five years, when an Act was passed in England, and
at a later date in India, about fifty years ago, for
registering births and deaths. From the statisties
thus made available, it was soon made evident that
the annual death-rate per thousand—the most con-
venient standard of expressing the general state of
the publie health—varied considerably in different
localities and under different conditions, and the
fact soon became established that the death-rate
depended broadly on two sets of cireumstances—
circumstances such as climate, clothing, feeding,
local habits and customs, and others which cannot
be brought under direct control by legislation, and
must always be controlled by the individual; and
circumstances such as conservancy, drainage, water
* Simla: Government Central Branch Press, 1913.
supply, prevention of nuisances, &c., which can be
brought under legislative control. It is estimated
by sanitarians, that by the adoption of proper modes
of life on the part of both individuals and com-
munities a great number of existing diseases might
be abolished and the annual death-rate considerably
reduced. Therefore, with this end in view, it has
been found necessary to introduce sanitary legis-
lation.
Modern sanitary legislation is based on the broad
general principle that every member of a com-
munity is entitled to protection in regard to his
health, which protection should be so exercised as
not to interfere with the similar rights of others,
nor be injurious to the community in general, and
has therefore been introdueed to provide for the
co-operation and the combination of communities
to earry out sanitary works in the general interest,
requiring large outlays of capital which could not
be compassed by individuals, and also to guard
against the publie health being endangered by the
action of individuals.
The law has conferred certain well-defined duties
on Munieipal Boards with regard to sanitary works
and the powers necessary to enable them to carry
out these duties. It has also provided an effective
control in these matters and enabled such control to
be exercised by the public and ratepayers as well as
by Government. The passing of sanitary laws,
however, and the granting to a certain department
the power to enforce such laws, will not ensure
good publie health unless the publie at large sup-
ports those laws intelligently. In England very
considerable trouble was experienced in introducing
sanitary measures. Even at the present day num-
bers of convietions take place for neglect of regu-
lations and for positive nuisances in large towns,
and the people still require supervision and at times
coercion to make them attend to their own best
interests. In India, therefore, where the habits
and prejudiees of the people, their religious observ-
ances and apprehensions, and other conditions are
so widely different to what obtain in England, and
Europe generally, it is no wonder that sanitary
reforms and works are looked upon with suspicion
and distrust, and unless some palpable benefit can
be realized and appreciated by these people, the
introduction and carrying out of such reforms and
works is a matter of much difficulty and opposition.
The majority of Municipal Boards in India are
dependent on the advice of Government officials in
sanitary matters, as they have with a few excep-
tions, no independent professional agency to assist
them in the preparation of sanitary projects. In
such cases, the projects are prepared by the
sanitary engineers to the Local Governments, and
after approval by the Sanitary Boards, submitted
to the Local Governments for sanction. To make
these Municipal Boards fully acquainted with the
facts for which they are responsible and to stimulate
them to greater efforts, it is necessary that clear
periodieal statements of the vital statisties of the
locality should be supplied, in the fullest detail.
Programmes of sanitary works should also be pre-
pared under the chief heads of :—
"OUPO Vdor
jo uonoogs oY} jo Buoys ofie[ v qv 'ssoiguo) [VIPO [euorjeuiejuT oqj Jo uoisvooo 944 UO ‘GTGT 'I[ 3sn3ny uo ‘sueqg Jo 'pivqouvwg szosseyorg Aq
Siequiosqus jo eureu OY} ur xoH€eq itg 0} pojuosoid sem [epeur eq, SHBA Jo AY [NV 1ossojoiq Aq pastaop [peut jo osioAo1 PUV os10A4qQ
‘AW CATT "Sara "5 X'O0'0 'NOSNVN MODBILVd HIS OL WIQSTHL IVNOLLVNUALNI
'ÉT6L ‘T WHHOIOO ‘ANHIOAH ANV HNIOIQUK 'IVOIdOHL AO 'IVNHDOOf AHL
Oct. 1, 19138.]
(1) Conservancy, including the removal of refuse.
(2) Filling up of insanitary tanks and cesspools.
(3) Latrine accommodation and public urinals.
(4) Drainage.
(5) Water supply.
(6) The improvement of overcrowded areas and
of buildings with defective lighting and ventilation.
These projects of sanitation should be carefully
prepared with reference to local circumstances and
the resources of the Boards concerned.
The neatness and cleanliness of the appearance
of a town depend on the methods in which the
conservancy is carried out and on the way in which
rubbish is collected by the householders for removal
by municipal carts. In many cities the rubbish is
freely shot out into the street at certain hours, and
the provision of the Municipal Act, with regard to
the establishment of proper depóts for the deposit
of rubbish by house occupiers, has become a dead-
letter.
In most cases, all practical purposes will be met
by providing that rubbish is to be stored outside
the premises at certain hours in baskets or boxes
of suitable size which require simply to be emptied
into carts, which would be sent round once or
twice daily for purposes of removal to either in-
cinerators or depóts outside the city limits. In
small towns with populations below 200,000,
incinerators should, and are likely to be a promi-
nent feature in municipal arrangements; but,
generally, they should be worked as subsidiary to
a tramway project.
Tanks and cesspools constitute one of the most
serious sanitary diffieulties to be met with in many
cities in India. The former are generally holes
filled with surface drainage of inhabited sites, and
the water is more often than not used for domestic
purposes, although absolutely unfit for such pur-
poses. In many cities it will take years of per-
sistent effort and the expenditure of large capital to
fill up these tanks before the population can fully
reap the benefit of sanitary works. In the mean-
time they should, if possible, be connected with
drainage systems and drained to keep down the
subsoil water level.
As regards the cesspool nuisance, the extreme
injury which it infliets on the health of the popu-
lation and the vital necessity of abating that
nuisance are points which should claim more atten-
tion than they do at present. The remedies which
can alone avail are proper systems of sewerage with
effective water supplies. Wherever such remedies
have been applied, enabling the cesspools to be
filled up, statistics tend to show that the death-rate
has been reduced from 20 to 30 per cent.
In most cities there is a large floating population
which cannot be trusted to clean their own privies,
and in such situations public latrines are necessary,
which can be connected with the nearest sewer, or
in the absence of a sewerage system the latrines
should be served by sweepers and the contents
disposed of at the nearest paid depót or trenching
ground.
A proper establishment of urinals is absolutely
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
309
necessary in every city, and without them it is
unjust to enforce prosecution for committing
nuisances which make some localities so offensive.
Every city and town should have a good system
of sewers. In designing a system of sewerage it
should be borne in mind that one which works well
in European cities, owing to climatic and other
conditions, works imperfectly or injuriously in
India. The greatest difficulty in Oriental drainage
lies in quarters where poor populations living in
tiled huts have to be dealt with. It is impossible
in these cases to prescribe either closets or expen-
sive fittings by by-laws which cannot be enforced.
In such cases publie latrines and urinals are
necessary. The huts should have surface drains
connected with a well-flushed collecting drain, con-
neeted with the nearest sewer, and in all areas
liable to receive sullage and foul water impervious
pavements should be insisted upon.
A good water supply is perhaps the most im-
portant sanitary agency in India. But if real
benefit is to be obtained, the source of supply must
be very earefully chosen and special precautions
taken to protect it. It should be out of reach of
the people, and the water should be conveyed to
them in pipes to prevent any possible contamina-
tion. Such special precautions are very necessary
in India where the people of all classes exhibit
extraordinary and perverse ingenuity in defiling
their source of drinking water, by bathing, washing
foul and sometimes infected clothing, and vessels,
eattle, &c., at such sources.
Before embarking on a water supply, chemical,
biological, and microscopical tests are necessary,
but it is necessary to bear in mind that reports
based on the examination of a few samples cannot
be accepted, and no absolute opinion can be formed
at to the true character without a large number
of observations taken at different seasons of the
year, accompanied by a careful examination of the
site and the risks of contamination it is exposed to.
The regulation of buildings in most towns in
India is utterly neglected and the sanitary state of
large cities such as Bombay and Caleutta may be
quoted as examples of the confusion which results
from allowing people to build as they please. The
chief reason why the death-rate is high in over-
crowded localities appears to be that, as a general
rule, they are oceupied by the poorest classes un-
able to pay for sanitary arrangements and the
difficulty of sewering or access for cleaning pur-
poses in such localities. Except on the upper
floors, a large proportion of rooms are insanitary
through various causes, but chiefly through defec-
tive lighting or ventilation. "The high death-rate
and prevalence of epidemic diseases have naturally
turned a considerable amount of publie attention
to the necessity of building regulations and forma-
tion of Improvement Trusts, and it is hoped that
the power to veto the occupation of all ill-lighted
and ill-ventilated buildings and the opening out of
crowded areas, will prove an efficient remedy for
the existing insanitary state of affairs in nearly
every Indian city.
310
(Oct. 1, 1913.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Wherever proper sanitary regulations have been
introduced, statisties show that the death-rate has
practically been reduced by from 20 to 30 per cent.,
and as the very important question of sanitation is
now receiving increased attention from Government
there is no doubt that the results of improved
publie health and the advancement of the standard
of civilization will amply reward them for the efforts
they are making in this direction.
In addition to the above interesting paper the
following are also contained in the report :—
Deseription of the Madras City Drainage Works
inspected by members of the Conference, by J. W.
Madeley, Esq., M.A., M.I.C.E., M.Am.Soc.C.E.,
&c., Special Engineer, Corporation of Madras.
‘* Madras City Drainage Works." J. W. Made-
ley, Esq., M.A., M.LC.E., M.Am.Soc.C.E., &c.,
Special Engineer, Corporation of Madras.
“The Simla Hydro-Eleetrie Scheme." A. S.
Montgomery, Esq., Sanitary Engineer, Punjab.
* Sanitary Problems in Madras." W. Hutton,
Esq., A.M.I.C.E., Sanitary Engineer, Madras.
'** Some Differences between English and Indian
Sanitary Engineering Practice.” G. B. Williams,
Esq., M.LC.E., Sanitary Engineer, Bengal.
“ Note on Dust Prevention." C€. L. Cox, Esq.,
A.M.I.C.E., City Sanitation Engineer, Colombo.
“ The Prevention of Dust in Indian City Roads
and Streets." E. P. Richards, Esq., M.I.C.E.,
M.Inst. M. & C.E., M.I., Mun., E.M.R. San. I.,
F.G.S., &c., Chief Engineer, Calcutta Improve-
ment Trust.
* Experimental Sand and Mechanical Filters,
King Institute, Guindy.” W. Hutton, Esq.,
A.M.I.C.E., Sanitary Engineer, Madras.
“ Madras City Water Supply." J. W. Madeley,
Esq., M.A., M.LC.E. M.Am.Soc.C.E., &c.,
Special Engineer, Corporation of Madras.
“ The Water Supply of Conjeeveram.”’
Nowroji, Esq., B.E., A.M.I.C.E.,
Engineer, Madras Waterworks.
Hormusji
Executive
—— — 9 —————
Hotes and "Refos.
THE UNION MEDICAL COLLEGE, PEKING,
CHINA.
As one goes around and sees the dire need of the
people and the hopeless condition of the present
native practitioner, one realizes how much good
must come to China and her people as a result of
the splendid effort now being made in many centres
to give a medical education to numbers of her young
men. This matter of medical education in China is
one which is occupying the minds of many of our
ablest medical missionaries, and also engaging the
attention of their home Boards. All praise is due
to those Mission Boards which have set their mis-
sionaries free to engage more fully in this work.
The fact that these men are not working as so many
separate units, but in all the large centres are
uniting in their efforts to form Union Medical
Schools, bids fair to secure an ultimate success
which separately they could never hope for.
This union work has resulted in the establishment
of the Union Medical College, Peking, China. The
work there established is very much similar to work
being done, as intimated, in all the large cities in
China. At these schools many young, bright
Chinamen are given a thorough training in practical
medicine and surgery. As men cannot well treat
women in China, because of social practices, work
is well under way, especially at Canton, in the
nature of medical colleges for Chinese women, who
are trained especially in the diseases of women and
children. More than this, there are in China a
considerable number of foreign schooled Chinese
women practising modern medicine. I personally
know of two who are graduates of Ann Arbor,
Michigan. They are doing a most magnificent work
among the women and children, one at Kiukiang,
and the other at the largest city on Lake Poo Yang.
Of course, all this work is under the auspices of the
medical missionaries, upon whom too much credit
and praise cannot be bestowed.
The work of the Union Medical College, Peking,
is of especial interest, as it is not only encouraged,
but partly supported by the ‘‘ Chinese Imperial
Government," This distinction is shared in by but
very few foreign schools. The graduates received
the diploma of the Chinese Imperial Board of Edu-
cation, and these diplomas were presented by the
Grand Councillor. Of the most particular note is
the fact that this is the first instance in history of
the Chinese Government conferring a foreign degree
upon any of her subjects. These facts prove the
awakening of slumbering China, and give evidence
of the confidence the Government places in earnest,
faithful, foreign workers. More than all this, mem-
bers of the Imperial household and high officials are
annually received into the hospital of the college
for surgical treatment. The Chinese place great
faith in the foreigner's surgery. They will rarely
undergo operations on the abdomen, but very
readily submit to other surgical work. In the line
of medicine, a general faith in foreign medicine in
preference to native medicine has not yet been
established in the native Chinaman.
A report of the graduation exercises which took
place at Peking, Friday, April 7, 1911, is given as
follows :—
** What the missionaries of 1901, gathering up the
scattered remains of mission work in Peking, saw
with the eye of faith, we were privileged to see in
actual fact. The ceremony had been long post-
poned owing to the exigencies of the plague work
in which nearly all the graduates were engaged. At
the earnest request of the authorities, it was decided
to arrange matters so that they might continue their
valuable work till the end of March.
“ There being no room in the college large enough
to accommodate the expected guests, a spacious
pavilion was erected, and was made very gay with
decorations in which the flags of China, America,
and England predominated.
** His Excellency Grand Councillor Na Tung, who
Oct. 1, 1913.]
represented the Throne at the inauguration of the
college, was again present to address the graduates
and present them with their diplomas. Hepresen-
tatives of the various Boards and other high Chinese
officials were present, and many others sent good
wishes and congratulations. The International
Plague Conference then in session in Mukden sent
the following message :—
'* * The International Plague Conference unites in
congratulating the Union Medical College on the
graduation of its first class of students to-day.
They weleome the graduates to the membership of
the medical profession, and send them their best
wishes for a successful career.—SZE.'
‘* The various missionary bodies of the city and
neighbouring cities and distriets were fully repre-
sented.
'' Thirteen of the teaching staff of the college
were present on the platform, and made a brave
show in the varied academic costumes of their
respective colleges. The sixteen graduates were
attired in caps and blaek Geneva gowns with facings
of purple satin. The foreign style of headgear
obseured the fact that all but three had sacrificed
their queues to the needs of plague work and the
growing sense of dissatisfaction with the appendage.
Three of them had gone the whole way and were
dressed in foreign style.
'*' The college diplomas were printed in English
and Chinese with a border of green and gold dragons,
and in the centre the Æsculapian sign over the
college seal in red—the effect was quite distinctive
and pleasing to the eye.
‘ The diploma given by the Imperial Board of
Education was quite plain, stamped with the purple
seal of the Board.
** Sir John Jordan, the British Minister, presided
and gave an address, mentioning the difficulties
encountered in the beginning of the school and its
progress, congratulating the students for their good
work, paid tribute to the faithful students of the
college who lost their lives in the work of helping
to stamp out the plague scourge which devastated
Northern China during the past year, and exhorted
the graduates to give their services to the rich and
poor alike. He implored them to assiduously culti-
vate their professional skill and to make it a valu-
able asset in the advancement of the great Empire
whose illustrious Empress laid the foundations of
the Union Medical College.
‘ After other speakers, the American Minister,
the Hon. J. S. Calhoun, followed with an eloquent
tribute to the noble and self-sacrificing work done
by medical men all over the world in the investiga-
tion and combating of disease, which has made it
possible for men to live and work in safety in places
previously devastated by yellow fever, malaria, and
other diseases. He spoke of the doctors of the
college and many of its students having done nobly
in helping to combat the plague in Manchuria,
Tientsin, Peking, and elsewhere.
*' The. Dean, Dr. Thomas Cochrane, made the
following statement during the course of his
address : — i
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
311
'* * We have tried to create a medical nomencla-
ture and a medical literature in the wonderful
language of this country. We are still translating
books, and intend to keep our students abreast of
the times by publishing a monthly medical maga-
zine. We did not adopt the easiest method and
teach our students in a foreign language.’ "'
Much of the school work in China is done by first
teaching English and then teaching science, history
and literature, &c., in English. Even where this
work is conducted in the Chinese language, as it
is done by many of the older men, it is compara-
tively an easy task compared to teaching medicine
in the native tongue. The difficulty lies in the fact
that in Chinese we find no equivalent for the
medical terms. A medical vocabulary must be
manufactured. This also for the names of drugs,
and the same conditions exist largely in all teach-
ing of science. The college already has a con-
siderable number of works on medicine and surgery,
materia medica, &c., translated and a great amount
of translation work is at present under way. A
Chinese medical dictionary represents a feat hardly
to be imagined, but this almost insurmountable
obstacle to medical college. work will soon be a
reality. A monthly medical journal will appear
before the end of 1911.
During 1911, 103 students were in attendance at
the school work. These men came from thirteen
of the eighteen provinces of China, and this fact
again gives evidence of the reputation and renown
of the college. It must be understood that there
are a considerable number of schools and hospitals
attempting medical education of Chinese.
‘As dissection is not allowed in China, naturally
the work in anatomy and surgery is somewhat
crippled, but the deficiency is largely made up by
the employment of excellent models and charts and
clinies.
The course covers about the same work as that
done at the average schools in the States, and pre-
&umes a thorough high school preliminary educa-
tion.
To this college is due the discovery of the first
plague ease in Peking, and the work immediately
started and already under way saved Peking from a
devastation from plague. In fact, the recent work
done by medical men in saving China from extine-
tion by plague has done more to cause the Chinese
people and Government to favour and encourage
foreign medieal work and general missionary enter-
prise than anything else in the history of the past.
Also a much kindlier feeling toward all foreigners
will be a direct result.
The following statement is made relative to the
result of the examination : —
‘In the final examination the results of the
written papers and the oral tests showed a standard
not lower than that attained by the average Euro-
pean graduate, and the Board thinks that the
college authorities have every reason to be congratu-
lated on the class of medical men it has contributed
to the profession.”
The final examinations were conducted by an
312
International Board of Medical Examiners, and at
the examination officials of the Imperial Board of
Education were present.
The following is the list of graduates :—
Wang Chiu-te.
Hsueh Shou-yi.
Ho Sheng-ch’ang.
Shih Chi-yung.
Ma Te-ch’ang.
Tien Chih-yuan.
Li Yu-ch’un.
Wang K'uei-shan.
Ch'u Yung-p'ing.
Hsieh En-tseng.
Hsu Tso-ming.
Wu San-yuan.
Fan Fu-lin.
Wang Huei-Ch'uan.
Liu Yi-te.
Wang Choang-ling.
The following is representative of work done at
a missionary hospital in China. At the Peking
Hospital, during fifty years, over 1,500,000 treat-
ments have been given.
The statistics for 1910 are as follows :—
Out-patients.
First visits, men 13,954
women 5,640
18,894
Return visits, men 20,811
women... 8,525
29,336
—— 48,230
In-patients.
Men ss% $$ E 713
Women ... zi en 143
— .. m AS 856
49,086
Contributed by J. F. Ruperr, U.S.Navy,
U.S. Naval Hospital, Annapolis, Md.
Written in China,
August 15, 1911.
— ———
Brugs and Appliances.
MESSRS. OPPENHEIMER, SON AND Co., LTD., are
now issuing emetine hydrochloride in the form of
hypodermic tablets, each containing } gr. These
tablets are moulded and not compressed, a feature
productive of immediate disintegration and instant
solubility.
This is a highly commendable feature, since hypo-
dermic administration is more often than not an
act of emergency or else performed under circum-
stances in which the usual implements which
facilitate solution are absent. In the treatment of
amæbic dysentery and its attendant complications,
emetine hydrochloride has been found to be prac-
tically a specific.
Ir is, unfortunately, the fact that a large number
of persons cannot take either quinine or cinchona
in the ordinary forms without suffering from well-
marked phenomena of cinchonism. In Vibrona this
great drawback is overcome, and the combination
of the hydrobromate of cinchona with the well-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1913.
matured wine naturally enhances the tonic pro-
perties of the bark. Hence its particular value in
cases where a low vitality has been engendered by
residence in tropical climates. In short, Vibrona
(which is prepared on scientific lines in laboratories
constructed for the purpose, and under regular expert
supervision) may be regarded as a valuable com-
bination of stimulant, nutrient, and tonie which
should prove of much value as a recuperative agent
in malaria and in the convalescent stages.
Numerous medical appreciations have been re-
ceived by Messrs. Fletcher, Fletcher and Co., Ltd.,
of London and Sydney, who make a special feature
of maintaining this tonie wine as a carefully stan-
dardized preparation.
Tug Clayton Fire Extinguishing and Ventilating
Co., Ltd., have been awarded a Grand Prix for their
exhibit of one of their fumigating and disinfecting
machines at the Ghent Exhibition.
— ——X—
Becent and Current Literature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JOURNAL OF TROPICAL MEDICINE AND
HYGIENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
“The Journal of the American Medical Association,"
August 9, 1913.
Salvarsan in Dysentery.—Wadhams and Hill report three
cases of amoebic dysentery treated with salvarsan. Improve-
ment seemed to result from the employment of the drug.
The authors are quite right, however, when they say that
basing deductions on insuflicient evidence and forming
definite conclusions which take into consideration but few
cases is a dangerous tendency which each year is being
more widely realized. So many unreported factors may be
concerned with so-called cures that until large numbers of
observations have been made it is hazardous to attempt a
scientific report on a small number of cases.
* British Medical Journal," August 16, 1913.
The Bionomics of the Hat-flea.—Strickland replies in a
letter to some criticisms made upon a statement of his as
regards the longevity of the rat-flea when fasting. Bacot,
who made these, seems to doubt the accuracy of the times
mentioned. A point, which Strickland believes absolutely
proves his original statement, is that he found Trypanosoma
lewisi in several of the fleas, these being derived from the rats
on which he had fed them eighteen months or more before.
Hotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly,
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publisners.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents,”
Oct. 15, 1918.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 20, Vol. XVI.
Original Communications.
SOME EXPERIENCES OF MOUNTAIN
SICKNESS IN THE ANDES.
By T. H. RaAvENHILL, M.B., B.C.
Late Surgeon to the Poderosa Mining Co., Ltd., Chile, and to
La Compania Minera de Collahuasi, Chile.
IN the following paper I have tried to present
certain facts which came under my observation
while acting as Medical Officer to a mining district
in the Andes, and though I have brought forward
no theories I have ventured to suggest one or two
ideas which seemed to be consistent with the con-
ditions that I found obtaining at the altitude named.
The condition of mountain sickness, known gen-
erally as Puna in Bolivia, and as Soroche in Peru,
is very common in the district I am about toc
describe. These names are given to a train of
symptoms which affect the new arrival at high
altitudes and which tend to pass away as he
accustoms himself to his altered surroundings.
As investigated by explorers and mountain climbers
the subject has of necessity been complicated by
the elements of fatigue, insufficient food, &c.
The district in which I have been able to observe
Calamai
this condition for a period of two years is a mining
region in the Andes, close to the Bolivian frontier
of Chile, situated at a height of from 15,400 ft. to
16,200 ft. The district is serveq by a railway, and
it is by this means that the majority of newcomers
have arrived at the mines. This has given me an
opportunity of observing the effect of altitude un-
complicated, or nearly so, by the elements abovs
stated.
The term ‘‘ Puna ” is used in rather a loose way
by the inhabitants in these altitudes, who use the
word not only to express the illness with which most
people suffer on arrival, but also for the dyspnæa
on exertion which affects everybody who lives there,
no matter how long he has been in the altitudes.
In the following article the term is used in its
former—and proper—sense.
The journey to the mines begins at Antofagasta,
a seaport on the Pacific Ocean, the railway running
first of all over the great desert of Atacama and
rising gradually the whole way to Calama, situated
at a height of 7,441 ft., and about 150 miles from
Antofagasta. If the passenger has decided to make
the journey slowly he will stay the night here,
continuing the next day; if, however, as is more
usual, he travels by the luxuriously equipped
“ Nocturno,” or night train, he arrives at Calama
k----73miles -----
in the early morning and proceeds in the same train.
From Calama the line still rises to Ascotan, 223
miles from Antofagasta, situated at a height of
19,979 ft.—the highest point of the main line.
This latter fact is announced by a notice at the
side of the line, and it is commonly supposed that
a number of cases of mountain sickness begin here,
induced by the sight of this notice in persons
possessed of too vivid an imagination.
From Ascotan the line descends to Ollague, on
the Bolivian frontier, 12,128 ft. high and 275 miles
from Antofagasta. Ollague is reached in the after-
noon, and from here the main line is left, a branch
line taking the passenger to the mines. He leaves
in the early morning of the next day, the mines
being reached about midday—forty-two hours after
leaving Antofagasta if the passenger has come by
the fast Noeturno, or two and a half days if he has
travelled by ordinary trains.
Below is a rough diagram of the route.
Puna or A NORMAL TYPE.
Symptoms.—It is.a curious fact that the sym-
ptoms of puna do not usually evince themselves at
once. The majority of newcomers have expressed
themselves as being quite well on first arrival. As
'
i
1
le
Ascotan,
Sea level
a rule, towards the evening the patient begins to
feel rather slack and disinclined for exertion. He
goes to bed, but has a restless and troubled night,
and wakes up next morning with a severe frontal
headache. There may be vomiting, frequently
there is a sense of oppression in the chest, but there
is rarely any respiratory distress or alteration in the
normal rate of breathing so long as the patient is
at rest. The patient may feel slightly giddy on
rising from bed, and any attempt at exertion in-
creases the headache, which is nearly always con-
fined to the frontal region.
On examination the face may be slightly cyanosed.;
the eyes look dull and heavy, with a tendency to
water; the tongue is furred. The pulse is nearly
always high, being generally in the neighbourhood
of 100 or over. 150 was the highest in my cases.
The temperature is normal or slightly under; not
often is there any rise of temperature at first, though
it may rise towards evening.* There is at times re-
duplication of the pulmonary second sound. The
patient feels cold and shivery.
The headache increases towards evening, so also
does the pulse-rate; all appetite is lost, and the
* Residents at these altituđes have, in health, a slightly
subnormal temperature,
814
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 15, 1913.
patient wishes to be left alone—to sleep if possible.
Generally, during the second night he is able to do
so, and as a rule wakes next morning feeling better;
the pulse-rate has probably dropped to about 90;
the headache is only slight. As the day draws on
he probably feels worse again, the symptoms all
tending to reappear on any exertion; if, however, he
keeps to his bed, by the fourth day after arrival
he is probably very much better, and at the end of
a week is quite fit again.
The most prominent feature in this type of puna
is frontal headache and extreme lassitude. I have
said nothing of epistaxis or other hemorrhages,
dyspnea, or extreme vertigo. These and other
symptoms, however, may all be associated with
puna, and may be so serious and pronounced as to
obscure altogether the usual type of attack, which
I have ventured to call the normal type, and which
is not a very serious condition at the altitude in
question.
There are also wide divergencies from this normal
type, and in my experience these divergent types of
the disease may be conveniently grouped into two
classes :—
(1) Those in which cardiac symptoms, and (2;
those in which nervous symptoms predominate.
Puna or A CARDIAC TYFE
Marked cardiac cases were not common. One of
the worst that I had was the following :—
An Englishman, Mr. V., visited the district in
February, 1911. The weather was snowy and
damp. He arrived in the usual way, by train—
forty-two hours’ journey from sea-level. Three
years before he had lived at the same mine for a
period of three months, had not been ill on arrival,
and had been in good health the whole time. For
some time previous to this latter visit he had been
in the altitudes of Peru, attaining a height of
17,000 ft., and had not been affected. He seemed
in good health on arrival, and said that he felt quite
well, but nevertheless he kept quiet, ate sparingly,
and went to bed early. He woke next morning feel-
ing ill, with symptoms of the normal type of puna.
As the day drew on he began to feel very ill
indeed. In the afternoon his pulse-rate was 144,
respirations 40. Later in the evening he became
very eyanosed, had acute dyspncea, and evident aiv
hunger, all the extraordinary muscles of respiration
being called into play. The heart sounds were very
faint, the pulse irregular and of small tension. Ho
seemed to present a typical picture of a failing
heart. This condition persisted during the night;
he coughed up with difficulty. He vomited at inter-
vals. This condition persisted during the night; he
had several inhalations of oxygen; strychnine and
digitalis also were given. Towards morning he
recovered slightly, and as there was luckily a train
going down to Antofagasta in the early morning, n»
was sent straight down.
I heard that when he got down to 12,000 ft. hs
was considerably better, and at 7,000 ft. he was
nearly well. It seemed to me that he would have
died had he stayed in the altitudes for another day.
The point about this case is the acute heart con-
dition coming on in a perfectly healthy man; a man,
moreover, who had lived in the same place before
and without harm, who had been also in the alti-
tudes of Peru not long beforehand. In addition to
this he was quite well the first day, and had done
nothing liable to bring on such an acute attack. Oi
the weather conditions in which he arrived more
will be said later.
Another case of what I think must have been
cardiac puna occurred in a neighbouring mine. A
young policeman rode up to the district from the
coast (Iquique), a three days’ journey. On arrival
he was said to be markedly collapsed and dyspnoeic.
He was sent down at once on a stretcher, carried
by relays of Indians, but he died at 11,000 ft. on
the way down. I did not see the case at all, as I
was never summoned. In this instance we have
the element of fatigue superadded, as he had had
a nine hours’ journey on ‘horseback.
I had a third case of this nature on July 19, 1911.
I was called to see a young Turk, aged 28. He was
a well-made man, with no previous history of illness,
and had lived in the district for some months
before. He had been below in the port for some
weeks, and arrived again in the district on July 14
late in the day. On the 15th he was getting about,
though he had a slight headache; on the 16th his
headache had increased considerably. The next
day he was really ill, according to his friends’
account, and gradually got worse till the 19th, when
I was called to see him.
On examination he was profoundly dyspneic,
respirations being 60, pulse 144, and hardly per-
ceptible. Air hunger was extreme, he had frequent
shivering fits, and the extremities were icy-cold.
The face was pallid save for the lips and ears, which
were cyanosed. The tongue was very dry, and
covered with a white fur.
The heart sounds were all weak. There were a
few rales to be heard at both bases.
During the night he became unconscious while
making several efforts to get out of bed, and in the
morning he was obviously dying. Death occurred
about 2 p.m.
The history of this case was interesting in that
he was evidently suffering from the normal type of
puna at first, which afterwards developed into a
cardiac attack. Like the first case, he had lived in
the altitudes before. I feel sure that he could have
been saved by being sent down earlier, but from
the time when I was first called to see him there
was no hope of recovery, and he was practically
dead before the next train eame along.
These three cases all occurred in young men, two
of whom I knew to be healthy beforehand, and the
third had a healthy history; these cases were the
worst I saw.
On the other hand, a.great many people with
weak or diseased hearts would fail to show cardiac
symptoms. I remember a case of a woman with a
large aortic aneurism. She had slight dyspncea,
but complained chiefly of headache and profound
prostration. She was sent down at once.
— =
Oct: 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
315.
Puna or A Nervous TYPE.
In this type of puna the nervous symptoms are
most prominent. It is a rare divergence from the
normal,
In its simplest form it consists of a feeling of
nervous excitation and buoyancy; it has been
described to me as a sense of being lifted into the
air as by a balloon. It may precede an attack ot
the ordinary type. There may be a tendency to
twitching of the lips and trembling of the limbs.
Generally it passes off, but the nervous symptoms
may develop to such a degree as to become
alarming.
The most marked case I had was a young Chileno,
aged 19. He arrived at the neighbouring mine in
the usual way; three days later I was called to see
him. He was then unable to speak, there were
violent spasmodie movements of the limbs, and he
resisted examination. The face was blanched, the
lips almost white, the pupils slightly dilated. Tem-
perature and respiration were normal; the pulse
140. He was unable to stand or walk. I was told
that he had been in this condition almost since his
arrival, and that he had been delirious, talking all
sorts of nonsense. I could find nothing organically
wrong on physical examination. He was sent down
the same day; three days later, i.e., by the time
he had reached the coast, he had quite recovered. :
Just before I arrived in the district there had
been another case of this nature. The case was
described to me as being practically the same,
except that the patient—a young Englishman—
had marked convulsions. He also recovered on
being sent down, and on recovery had no recollec-
tion of having been in the place at all.
It may not be out of place here, though not
coming exactly under this heading, to mention a
case under my care in which a typical attack of
delirium tremens was brought on by the altitude.
The patient had had a comfortable journey up, and
had not been exposed unduly to cold. On arrival
he went to his room and took no alcohol. The
attack began two days later, and on the third day
he presented a typical picture of delirium tremens,
when he was sent down.
Vertigo may be a prominent symptom, though it
is rarely very pronounced. I had one very marked
ease in a young Chileno. When lying or sitting in
bed he was quite fit, and made several attempts to
start work in consequence. As soon as he got up,
he was so violently giddy that he had to get back
into: bed. This condition lasted for three weeks,
getting slightly worse, and he was then sent down.
A careful physical examination yielded no evidence
of any organic mischief, and he had a good previous
history. The only other case I saw in which
vertigo persisted to a marked extent was in an
Englishman of 40, with whom it lasted for a week.
The pulse was. not good, however, and the heart
Sounds were weak. i
These are, so far as I have found, the two chief
divergencies from the normal type of puna. There
are two other symptoms usually understood to ba
associated with. mountain sickness—vomiting and
epistaxis. '
Vomiting occurred in about half the cases. It
was never serious, and soon passed off. !
Epistaxis was not common. It occurred in about,
20 per cent. of the cases, and was hardly ever very
profuse. An interesting case was that of a priest
of 34, who had been in the district two months pre-
viously without suffering from the effects of tha
altitude. On his second visit he developed a most
profuse epistaxis, and had to go down again to a
lower level (8,000 ft.), where it stopped. On first
going to the district, on my way up I met an elderly
man who told me that he had once visited the
place, but that he had come down immediately,
bleeding—according to his account—not only from
the nose, but from every mucous membrane of
which he was possessed. In this connection it is
an interesting fact that. while epistaxis was not
common, and stil more. rarely profuse on first
arriving at the altitudes, it was a fairly common
symptom with all those who were living there when
they. became ill, especially with any febrile con-
dition.
My own personal experience of puna was prac-
tically limited to one attack. On my first arrival,
after a long sea voyage, I did not feel anything
except a slight headache on the first morning,
which quickly passed off. . It should be mentioned
that I took four and a half days to make the
journey from sea-level. After living in the district
for eighteen months, I spent a month at ordinary
levels. On returning from the coast in the ordinary
way I felt perfectly well—pulse about 75, às against
my average of 65 on the coast. I went about the
mine, however, instead of keeping quiet. : During
the night I could not sleep, and had a severe feel-
ing of pressure in the chest, especially in the pre-
cordial region. The pulse during the night was
about 180. The respirations were increased, and
I could not take a deep breath. The headache was
only slight, and was soon relieved by aspirin. ‘There
was no vomiting. The next day I gradually got
better, and was quite fit by the third day. I faney
this. attack was of the cardiac type.
It will be seen by the foregoing that the effects
of an altitude of 15,000 ft. vary greatly and are
difficult to reconcile. Some people escape alto-
gether, and some who do not suffer on their: first
visit maybe very ill on their second. j
There is, in my experience, no type of man of
whom one can say that he will, or will not, suffer
from puna.. Most of the cases I have instanced
were men to all appearances perfectly sound:
Young, strong, and healthy men may be completely
overcome ; stout, plethoric individuals of the chronic
bronchitic type may not even have a headache. I
have known several instances of this, even when
the persons jn question have taken no care of
themselves. e
: INFLUENCE oF WEATHER CONDITIONS ON PUNA.
The weather in the district is of three fairly dis-
tinct kinds. In the months of January, February,
316
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1913.
and March it is stormy, and there may be snow,
thunder, and hailstorms any day or every day, with
lightning striking the ground in all directions and
the sky overcast with thunder-clouds. From April
to September the weather is usually much colder,
with strong ‘winds and a clear sky. It is during
this period that the district is liable to be visited
by very severe blizzards, which cover everything
with deep snow and render the avocations of life
very difficult. The thermometer goes down to well
below zero C. each day. -October, November, and
December are usually good months, not too cold,
with clear sky and gentle breezes.
iDuring the first part of the year, i.e., in the
thunderstorm period, puna, in my experience, is
always at ite worst. Most of the bad cases
oecurred during this season, and this, I think, is
what is generally found all-over the altitudes of this
part of the world. I think that the reason that
puna is at its worst during this season is to be
found in the diminished vitality of the body, and
the consequent lessened power of resistance which
this sort of weather causes anywhere. During this
period nobody feels at his best, however long he
has been in the altitudes. Dyspnoea on exertion,
minor illnesses, lassitude, were all more common
with us, and the same influences which affected us
would certainly act on a newcomer.
During the second portion of the year—the cold
portion—puna is less severe than at any other
time. It frequently happens, in this season, that
a man escapes altogether; and the period corre-
sponds to that in which most of the residents feel
at their best. These remarks do not apply in the
case of ‘blizzards, but there is practically no puna
during a blizzard, for the simple reason that it is
impossible for a newcomer to get to the district
at all.
During the third part of the year—the warmer
part—puna is rather worse than during the second
part. In this season the winds are much less
strong, and we frequently had a day with no wind
at al. I noticed that on windless days cases of
puna began sooner and were rather worse; this
again corresponded with ‘the condition of those
living at the mine—everyone felt slack, and less
inclined for exertion on still days than when a slight
breeze was blowing.
The best day for arriving at the altitudes is à
clear, cold, dry day with a fair ‘breeze. The worst
day is the day of snow or hailstorms, with thunder
and the sky overcast. In effect, this is merely an
expression of the influence of weather on the ‘bodily
condition of a man wherever ‘he may be.
INFLUENCE OF ALCOHOL.
Alcohol plays a distinct part in accelerating an
attack and increasing the severity of the symptoms.
If a man takes much alcohol on his journey to the
heights he nearly always suffers more than the
abstemious man. Habitual alcoholics, however.
are not necessarily attacked more severely, ipro-
vided they do not indulge too freely on the journey.
Total abstainers, on the other hand, are not by any
means exempt.
INFLUENCE OF MuscuLAR Work.
Physical exertion also renders & man more sus-
ceptible to an attack. Although most people kept
quiet for the first day or two, puna or no puna,
there were some who, feeling quite well on the first
day, were inclined to scoff at precautions and
would exert themselves in the ordinary way, and
this nearly always meant that they were in bed the
day after.
INFLUENCE OF TOBACCO.
I frequently heard that it was a bad thing to
smoke on the journey to the altitudes. So far as
I could ascertain, in habitual smokers tobacco
exerted no influence either one way or the other.
Most people smoked sparingly or not at all on first
arrival, not only because they probably felt ill, but
also for the reason that tobacco, at this altitude,
does not burn so readily as at normal levels, and it
requires a little practice before one can enjoy it
again.
SEX AND AGE.
It was difficult to form an opinion with regard ta
the influence of sex in puna. The females belong-
ing to the families of the ordinary workpeople did
not commonly seek medieal advice excepting for
severe attacks, and those of a higher station in life
who came to the mine were very few. I think,
however, that on the whole women suffered less
than men.
With regard to age, children under 15 years of
age were less affected than their elders. I do not
remember seeing a really bad ease in a child. [t
should be mentioned that a great many of the work-
people were Bolivian Indians who were born at an
altitude of about 12,000 ft. The Indian does not
suffer, as a rule, from the effects of the altitude
with which I am dealing. 'The children who came
to the mines from the coast were fewer in number.
Above the age of 15 or thereabouts there appears
to be no rule to govern the liability to an attack.
Young or old suffered or escaped indiscriminately.
TREATMENT OF PUNA.
The treatment of the normal type resolved itself
into rest in bed with the window well open, even
for very slight cases, and at least a day of quiet
after all symptoms had disappeared. I found that
aspirin, in doses of 1 grm. to begin with, and 0.5
grm. every four hours afterwards, was of immense
value for the headache, there being an almost
invariable relief after the first dose. Phenacetin
I tried a few times, but the benefit obtained was
not nearly so marked; this, I think, may be attri-
buted to its depressing effect on the heart. I got,
with aspirin, such excellent results in the intense
headache of puna that I was not tempted to try
other drugs for this symptom.
For the rest, light diet and attention to the bowels
were usually all that was necessary, though, as a
Oot. 15, 1918.]
rule, nothing very drastic in the way of a purge was
given, experience showing that free purgation was
not beneficial. In the bad cases, including those
that developed cardiac or nervous symptoms, the
only thing to be done was to treat the conditions as
they arose as well as possible under the circum-
stances, and to send the patients down again as soon
as possible.
There are several herbs in which the Indians of
Bolivia and Peru have great faith for the relief of
puna. ‘Of these, ‘‘ Chacha Como " and '' Flor de
Puna ”’ are the most used, usually in the form of an
infusion. Also a herb called ‘‘ Huamanripu,’’ which
I heard of when I was in Peru. This was given to
my informant at a height of over 18,000 ft. on a
mountain called Sarjantay, in Peru. He told me
that at this height he was seized with profuse bleed-
ing from the nose and vomiting, and that tho
symptoms stopped immediately after chewing a
little of this herb, given to him by an Indian. I
cannot help thinking that this was a case of post
hoc, and not propter hoc.
I once or twice watched the effect of the two first-
mentioned drugs, but could not find that there was
any relief after their use.
I gave oxygen in several cases of puna, but did
not find that it had much effect. One patient said
that his headache was better after each inhalation,
but I think that expectation of relief had in his case
something to do with the improvement. For one
thing I had a very imperfect apparatus, and had to
make my own oxygen by heating a mixture of
KCLO, and MnO,. I think that possibly I might
have obtained better results with a proper apparatus
for eontinued administration and with pure oxygen.
But the difficulty and expense of obtaining these iu
the Andes are, I think, sufficiently obvious.
If the symptoms of puna, however, are solely the
result of lack of oxygen in the inspired air, it appeats
io me that the routine administration of oxygen
would only serve to bring the patient—so to speak—
baek again to lower levels, and that the symptoms
would reappear when the administrations were
stopped. Nor would the gradual diminution in the
amount of oxygen given procure the desired effect.
The patient, in his ascent, has already undergone
this diminution from the normal, and very much
more gradually than one could conveniently bring
it about in the administrations. I think that if
oxygen, given under proper conditions, does do
good in puna, its use will probably be confined to
dangerous cases, to tide over the time till the
patient is able to descend to normal levels.
I gave during the night several inhalations of
oxygen to the first of the bad heart cases described
apes: It did not seem to afford him any relief
at all.
THE QUESTION OF ACCLIMATIZATION.
It is obvious from the cases of puna that I have
quoted that the fact that a man has lived in the
altitudes does not mean that he is immune from
their effects when he revisits them. The question
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
317
avises: is there any tendency to acclimatization,
and can a person, by prolonged residence at a certain
altitude, render himself immune to the effects of a
much higher altitude than the one to which he is
accustomed? A number of experiences bearing on
this:point may first be cited.
Three members of the staff of one of the mines,
the length of their residence at 15,400 ft. varying
from one to one and a half years, made at vari-
ous times explorations on a neighbouring volcano
18,000 ft. high, and in one instance slept not far
from the summit. One resident at 12,000 ft. also
made the ascent on several occasions. The ascent,
an easy one in point of steepness, is made on mule-
back. None of them suffered in any way from puna,
though the first three had all been affected by it on
first arrival at the mine level. It should be noted
that they were all carried up on mules. Incident-
ally, these were not more distressed than usual.
Mr. B., an Englishman, aged 32, paid a visit to
the mine level eleven times in the two years of my
stay there. Of these nine visits were made direct
from the sea coast, and two from Bolivia, at an
altitude of 12,000 ft. On each of the nine occasions
on which he came straight up from port he suffered
from puna. On the two occasions on which he had
already been for some time in the heights he once
escaped altogether, and the other time he had a very
slight attack indeed.
Mr. M., a strong and healthy Englishman, aged
about 42, has the following record: On first visiting
the mine, three years ago, he suffered so badly from
puna that he went down again. On his next arrival,
a year later, when he came to reside at the mine,
he again had a bad attack which lasted for about a
week. During his first year at the mine he made
several descents to port, with corresponding re-
ascents, doing the whole trip in about a week—at
each re-ascent he had a very slight attack of puna.
After a year at the mine he contracted enteric fever
in port, and was away for about three months. He
made a good recovery, and felt in the best of health
at the end of his convalescence. He then made the
ascent to the mine again, and was laid up with a
bad attack of puna for over a week. Later he went
into Bolivia (12,000 ft.) for about ten days; on re-
arrival, no puna.
Mr. 8., an Englishman, aged 38, suffered from
puna on his first arrival. After a year in the alti-
tudes without going down he went away for a
month. -On his return he had a well-marked attack
of puna. Six weeks later he went down to the
coast, and returned five days afterwards—no puna.
Mr. L., an American, aged 26, suffered from puna
on his first arrival. After six months without going
down he went to the. coast, and returned in five days’
time—no puna.
Mr. S., an American, aged 26. On first arrival
from the States he had a bad attack of puna. After
some months without going down he went to the
coast, coming back within five days—no puna. After
nineteen months he went away for a month, never
getting lower than 8,000 ft, On return—no puna.
318
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, .
(Oct. 15, 1913.
These few cases illustrate a very common state.
of affairs, which may be summarized as follows :—
. (1). A certain amount of acclimatization to puna
is conferred on those who live at 15,000 to 16,000 ft.
(2) This acclimatization tends to protect them.
when reaching a higher altitude than the one in
which they live.
(3) The aeclimatization also tends to protect them
on their return from lower levels. Immunity from
puna is the rule for an indefinite period of time for.
descents of 3,000 to 4,000 ft.; it is enjoyed atter
descents to sea-level, provided that only a few days
elapse between the departure from and return to the
altitude.
. (4) This acclimatization wears off after a sojourn
of any length at normal levels, leaving a man just
as prone to an attack as one who has never been in
the altitudes. What length of time is needed for it
to wear away I cannot say, but I think that acclima-
tization is generally lost after about ten days at
sea-level.
The acclimatization mentioned above does not
hold good for everyone, and the above statements
are not intended to be taken as rules, but as prob-
abilities. It must also be understood that they only
apply in cases where no violent physical exertion is
undertaken in the ascent; the cases instanced, for
example, all being those in which men were carried
in some way or other.
If the factor of fatigue is introduced, quite another
set of conditions comes into play. Residence at an
altitude of 15,400 ft., though it may confer a certain
amount of acclimatization to the effects of altitude
as far as this alone is concerned, certainly does not
render a man less liable to the effects of fatigue at
that altitude; rather the reverse. My experience,
and that of most of my fellow-residents, was that
the longer a man lived at a height of 15,400 ft. the
less capable he became of resisting fatigue there;
most of us who had lived there for any length of time
lost weight; dyspnæa on exertion—in going uphill,
for instance—always troubled us; it became more
common for us to have minor illnesses. Possibly
the dyspnea on exertion was a littie less; at the
end of two years I do not think I felt the effects of
walking uphill quite so much, but it was always
there; and any exeessive exertion would often
eause us to have symptoms much resembling the
puna with which we suffered on first arrival. The
subject of physical exertion at high altitudes,
apart from its effects on puna, is rather outside the
scope of this article. The point, however, that
I wish to emphasize is this, that a man who had
lived for some time at a certain height, say,
15,000 ft., and who was carried from this to another
point much higher, say, 20,000 ft., would in all
probability feel the effect of the diminished pressure
very little, and in any ease very much less than
a man who had lived at ordinary altitudes and was
carried to that height from sea-level: but, other
things being equal, he could not climb to that
height nearly so well as the man who was aceus-
tomed to ordinary altitudes.
EFFECT or SLOW or RAPID ASCENT.
Connected with the subject of acclimatization
is the question of the effect of slow or rapid ascent.
As a rule,. persons coming to the district usually
availed themselves of the fast and eomfortable
'" Nocturno,’’ instead of performing the journey in
stages. The workpeople generally came from the port
by the day train, which would get them. up in two
and a half days. When a man took longer cver the
journey—say, a week—he suffered, as a rule, less
from puna than those who came up quickly. On
a certain railway in Peru, which reaches a height
of nearly 15,000 ft. in a few hours, I am told that
puna frequently presents itself in much more
alarming forms than it does on our line, epistaxis
being very common. Very rarely did hzmorrhages
occur during the actual journey in our case, and
I think that this was due, to some extent, to the
faet that it was necesary for everyone (excepting
in rare instances where a special train was chartered)
to spend a night at 12,000 ft.
PuNA MORE COMMON IN CERTAIN PLACES.
It is a well-known fact that in the Andes puna
is worse in certain places than in others of the same,
or nearly the same, altitude. For instance, in
La Paz, in Bolivia, which is situated at an altitude
of 11,965 ft. above sea-level, puna is much more
common than on the high Bolivian Plateau, which
is 12,100 ft. on an average. Perhaps the influences,
previously mentioned, of climate and muscular work
account in some degree for this. La Paz is a city
of steep gradients up which a newcomer has to
walk; the Bolivian Plateau is flat; moreover, the
air movement in the streets of La Paz, lying as it
does in a hollow, is very much less than on the
windswept plateau. In other cases, however, in
which this condition obtains the differences between
the places are not so marked, so that this cannot
be the complete explanation. This condition is
merely stated here as an interesting fact. There
are, indeed, certain valleys in the Cordillera known
as '' puna valleys " from this circumstance.
Errect oF REGAINING NORMAL LEVELS.
In view of the fact that certain symptoms may
be expected when a man ascends to an altitude
such as I have been dealing with, it is not un-
reasonable to suppose that, after living at this
altitude for some time, he would feel some effects
on once more regaining a normal elevation, apart,
of course, from the greater capacity for muscular
exertion. Such is not usually the case, but I have
heard of men being affected by slight headaches and
tinnitus.
I myself twice went down to sea-level. In the
first instance, after eighteen months in the altitudes,
I descended on. mule-back, taking three days over
the journey. On the third day I was conscious of
a very slight feeling as though I had a partially
obstructed Eustachian tube, which soon passed off.
The second time I stayed for three weeks at an
altitude of between 11,000 and 12,000 ft., in Bolivia
Oct. 15, 1913.]
THE! JOURNAL OF TROPICAL ‘MEDICINE AND. HYGIENE.
319
aaaoaeaaS==a—>_—_oa=_—aes>=anj{_eE=|janes=ana=aEee—_—~~y»=~“»_—~—_———__=—_=EE=Eec7__»—_—>»»»~”>—>>>y>>>—=—_—>>—>—>—E—=——_——>————SS——_=
and Peru. I'then went down:to sea-level by train,
doing the journey from 12,000 ft. in twelve hours,
and attaining on the way an altitude of 14,666 ft.
At a height of about 3,000 ft. I began to be troubled
with the sume sensation in the right ear, and this
became quite painful during the same night. The
pain lasted for the whole of the next day, and then
I have never suffered. from any ear
disappeared..
affection before or since.
One man I met, who descended to sea-level
rapidly after a lengthy sojourn at 12,000 ft. and
who was very deaf, attributed his deafness to the
rapid journey, assuring me that it began on his
journey down. This was the only ease of the kind
that I heard of.. A
v9).
: The effect of descent: upon; the‘ pulse-rate; may
here be noted. The pulse-rate increases on arrival
at the. altitudes, remains higher than normal
during residence there, and appears to diminish
simultaneously upon descending. My pulse-rate,
ut rest, for 15,400 ft. was always about 75 to 80.
Usually, for ordinary levels, it is 65 to 70.
It fell to
Previous expe 10,000 ri heights Vomiting Headache Bleeding stead Pulse e
1 |None 24 M. Present Frontal None Normal 96 98:4
Q qos 97 M. None Slight >, z 90 98-4
i frontal
3 | Once before 12,000 ft. ... Slight Frontal |A little from r 114 98:4
nose :
4 | None None 33 None a 104 98:4
5 M »? » rra spi =
6 bi p ise ea ate A little 5 40 104 —
7 ‘Living at mine. Return after None 35 Normal 110 102
leave of absence ` ; à
8 |None: 3 Slight from oa 96 98:4
nose, second y
cA day . i
9 $5 24 M. ys Occipital . None . M 102 . 100
10 a 82 F. A little |Frontaland|. ' |,, 42 128 98:4
occipital à 5. A o: N
11 is 30 M. Present Frontal From nose 24 96 99:8
12 » M. Sn f js None 30 150 101
13 ] 35 M. None * ^ | Normal 110 98:4
14 . Born here 9 M. "m Evident 45 5 96 99
15 | At mine some time before 35. E. | Very slight Frontal From nose 24 104 | 9
very slight ; |
16 | None 40 | M. None 3: None Normal 104. | 100
17 x: Kan oae, Ghee 19 M. si a - m 144 . 98:4
18 | At mine a year before ... 16 F. Present Sy u 24 120 97°6
19 In Peru ... : 83 »M: 55 Occipital a Normal 66 97:8
20 | None 28 M None Frontal | Very slight ys 100 98:4
from nose "
91 |Overa year in mine ~. b 42 M. 3: m None » 96 98-4
22 | Was in the mine before for 25 M. cs is N $s 108 , 98:6
three years i j
93 | Once before 14,000 ft. 55 M. 35 T ait js 108 | 982
94 | None 25 M. Present 55 Slight from » 108 | 994
: : nose i
25 > 26 M. None ji None is 104 98:0
26 5 26 M. Present | Frontal and i » 84 99:2
occipital
97 | Lived here before About 30 M. ; Frontal = 40 144 | =
28 | None 35 M. None 2 dy A Normal =a | —-
29 35 | M. A little S i ie 120 98-6
30 Lived here before. 18 M. None 5 35 » 108 97:8
31 |14,000 ft. and 12,000 ft. 32 M. 5 - rs | Yi 190 91:6
32 | Here before or two years 40 M. Present $$ 53 36 90 | 980
33 | At 10,000 ft.f ux 49 M. None as | Very slight Normal 102 98
from nose
` 384 | None 24 M. Slight is None $$ 104 98:6
35 " 27 M. 5$ n Slight from 3 102 . } 98:4
nose A : |
36 $2 "T an " ET 16 M. Present si None 5 102 | - 98:4
37 » $e T" ais is 40 M, None js N 2 =, =
88 | Living here; return after a 29 M. Ht a 15 80 120 98:4
month at sea level p oe
about this rate after my first descent from the mine
to ordinary levels.
During my second descent it was as follows :—
After three weeks at 11,500 ft.; taken at intervals,
its average was 72.
Then, on my journey to sea-level, on the highest
point of the journey (14,666 ft.), it was still 72.
But at sea-level, eight hours from this point, it
320 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1913.
was 60. Two hours later it was also 60. After-
wards it rose to the normal rate—65 to 70.
NorE.—Later on in Mexico, at 8,086 ft., it was
78. Two companions gave 78 and 72 respectively.
TuE RED BLoop CELLS IN PUNA.
The red blood corpuscles appear to proliferate
very rapidly on arrival at the altitudes. "The usual
number of red cells at 15,400 ft., for Indians as well
as white people, is between 8,000,000 and 9,000,000
per e.mm. The number varies. It is rarely under
7,000,000, and rarely above 9,600,000. My own
count gave nearly always between eight and nine
millions. Once, just before I left, it dropped to
7,120,000. The following counts of my own blood
are of interest, taken after returning from a month's
sojourn at the coast. On the second day I did not
take a count, feeling too ill with puna to have much
interest in it.
On day of return
6,560,000
Third day 7,200,000) Puna
Fourth day rr iss .. 4,840,000
Fifthday ^ .. .. .. 8,940,000
Sixth day XD. 7,440,000
Eighth day o v. T,840,000
Ninth day Se we 8,400,000
Afterwards, counted at intervals, it was always
between eight and nine millions, except in the
instance above quoted.
Mr. B., on day of arrival, February 19, 1911, had
a count of 7,120,000. He had two days’ puna; on
February 24 his count had sunk to 6,360,000. Mr.
B. also gave on his first day of another arrival—May
24—a count of 7,760,000. On that occasion also
he had an attack of puna.
Mr. V.—the bad heart case (see cardiac puna)—
gave on day after arrival 7,840,000.
Mr. D. gave on day of return from a month at
sea-level 8,560,000, which was fairly close to his
normal for the altitude of 8,800,000. He had no
puna.
Mr. E., typical attack of puna, gave-6,880,000 on
day of arrival.
Mr. A., whose blood count was always exception-
ally low, had a bad attack of puna, and gave a count
of 5,400,000 on first arrival. His count, however,
never went above 6,560,000.
The table on p. 819 gives in a concise form the
condition of thirty-eight cases of puna on first
examination. à
Though rather outside the scope of this paper,
which aims chiefly at describing the conditions found
on first arrival at 15,400 ft., the tabulation of some
blood counts, made on myself and others, Indians
and whites, may be of interest, together with, in
certain cases, the hemoglobin percentage.
SELF.
September 5, 1909 ... 8,000,000
» 19,1909 .. 9,600,000
»* 19, 1909 ... 8,800,000
3: 25, 1909 ... 9,600,000
October 12,1909 ... 8,000,000
November 12, 1909 ... 9,600,000
May 6, 1910 ... 2A 8,000,000
February 10, 1911 .., 8,400,000
e (ib. 90 per cent.,
My present count (January 15, 1912), five months
after leaving the altitudes, gives 5,680,000.
OTHERS.
Duration of Red blood
No. residence Nationality corpuscles
1 ... 4 months .. Englishman ... 8,800,000
2 ... 3 months ... Indian 8,800,000
3 ... 2 years 5 months ... American 8,800,000
4 ... Some months .. Indian ... 7,320,000
5 ... Some months .. Indian ... 8.320,000
6 ... Bome years ... Indian 8,720,000
7 ... Some months .. Indian 8,900,000
(Hb. 100 %)
8 ... 2 years . Indian 7,360,000
(Hb. 95 95)
9 ... 4 months ... German 6,610,000
(Hb. 90 %)
10 ... 6 months .. American 5,840,000
(Hb. 90 %
11 ... 2 years .. American 8,800,000
(Hb. 90 o5
12 ... Some months .. Indian 8,640,000
(Hb. 85 %)
13 ... Some years ... Indian 9,680,000
(Hb. 95 95)
14 ... 2 years .. Indian 9,040,000
(Hb. 100 %)
THE DISTRIBUTION OF GLOSSINA LONGI-
PENNIS (CORTI, 1895).
By ALBERT J, Cuatmers, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories.
AND
HanBoLp H. Kine, F.E.S.
Government Entomologist, Wellcome Tropical Research
Laboratories, Khartoum,
Introductory.—We bring forward this brief note
on the distribution of Glossina longipennis (Corti,
1895), in accordance with the promises of one of us
to Major Powell, R.A.M.C., and to Captain Kelly,
R.E., who found the flies in question while explor-
ing, in different directions, the country between the
Nile and Lake Rudolf.
The discovery of G. longipennis in the Anglo-
Egyptian Sudan is interesting, firstly, because it
extends the known distribution of the fly to almost
33° longitude east of Greenwich, and, secondly,
because it strongly supports Balfour's view,
enunciated in 1900, that some day this fly would
be found on the upper reaches of the Sobat.
Balfour's opinion originated after making inquiries
about tsetse flies from the members of Macmillan’s
expedition, which resulted in his suspecting the
region south of Nasser (about 8° north latitude) as
being that in which G. longipennis might probably
exist. Further, the fact that this tsetse is mostly a
night feeder, and is frequently met with in desert
places, has resulted in rather a lack of knowledge
as to its distribution. To-day all species of Wiede-
mann's genus Glossina must be regarded with
suspicion, as the number associated with the spread
of sleeping sickness in mun appears to be slowly
increasing. Thus Macfie has indicated that there
may be a new form of the disease in West Africa,
and has hinted that this may be associated with
some species other than G. palpalis and G. morsi-
tans. It is therefore valuable to know the distri-
Oct.§15, 1913.)
bution of the various species as accurately as
possible;
Historical and Geographical.—Glossina longi-
pennis was first discovered in June, 1898, by :—
(1) Captain Vittorio Bottego on the banks of the
River Welmal in Abyssinia. (This river is-a tribu-
tary of the: well-known River Juba.) The specimen
he found was a male.
(2) In 1894 Greenfield found two males and: one
Boma
Plateau
"ng R
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
GERMAN EAST
AFRICA
female in Somaliland, but did not indieate the
loeality, which makes the exact determination of
the distribution very difficult.
(3) In 1895 C. V. A. Peel found a female in
Western Somaliland in the country between Bur
Furleh and Biermuddo, north of Mount Kuldush
and east of the Daghato River, which is a tributary
of the Webi Shebeli.
(ren
$21
(4) In 1898 Captain Haslam met with one male
on the Sabaki River in British East Africa. The
exact locality was near the junction of the Tsavo
and Sabaki.
(5) In 1908 Captain Greig- captured one male and!
one female near Kibwezi on the: Uganda Railway.
(6) In 1910- Captain Ford discovered one male on:
the shores of Lake Baringo, and: (7) Woosnam one
female on the Tsavo River in British East Africa,
SOMALILAND
INDIAN
OCEAN
MAP
of the
KNOWN DISTRIBUTION.
o
GLOSSINA LONGIPENNIS
CORTI 1895
and in the same year (8) Drake-Brockman drew
attention to its existence on the Juba River.
(9) In 1912 Neave found numbers in the dry,
semi-desert, thorn-scrub of the section of the
Uganda Railway between Voi and Makindu.
Occurrence in the Anglo-Egyptian Sudan.—This
year specimens of male G. longipennis have been
given to us by Major Powell, R.A.M.C., and by
822
“THE JOURNAL OF TROPICAL MEDIOINE AND HYGIENE.
{Oct. 15, 1913:
Captain Kelly, R.E., who found them in the country
between the: Nile and Lake Rudolf.
(10) Major Powell found. his specimen in the
country east of the River Kideppo, i.e., about 5°5°
north latitude and about 33°3° east of Greenwich.
(11) Captain Kelly found his specimen just south
of 6° north latitude and about 34:69 east of Green-
wich, in the country three miles south of Moro
Kinod,
This is the first occasion on which G. longipennis
has been recorded in the Anglo-Egyptian Sudan.
Distribution.—From the above it will be observed
that the known area of distribution of G. longi-
pennis extends, excluding Greenfield's vague locali-
zation, from about 69 north to about 49 south
latitude, and from about 339 to about 479 longitude
east of Greenwich (vide map). This area includes
the following political divisions: British East
Africa, the south and west of Italian Somaliland,
the southern part of Abyssinia, and the south-
eastern portion of the Anglo-Egyptian Sudan. The
localities in which the fly is found are either desert
or semi-desert. When seen in elevated regions it
occurs between the rivers, and not on their banks.
The fact that it is usually a night feeder may explain
the reason why it is seldom reported by travellers,
and perhaps why males have been more commonly
met with than females.
map the places where G. longipennis is found by
means of small (shaded) squares. The numbers
attached to the squares correspond with those
used above in the historical and geographical
section.
Khartoum,
September 6, 1918.
LITERATURE.
(In chronological sequence.)
(1) Austen, E. E. (1903): '*A Monograph of the Tsetse
Flies," London. Page 103 contains all the early literature.
(2) Drake-Brockman (1910): Bulletin of Entomological
Research, vol. i, p. 57.
(3) Austen, E. E. (1911): ‘‘ A Handbook of the Tsetse Flies,”
London, p. 104. :
(4) Simpson, J. J. (1912): Bulletin of Entomological Research,
vol. ii, 4, p. 297. Colour Conventions for Insects and Diseases.
(9) Neave, S. A. (1912): Bulletinof Entomological Research,
vol. iii, 8, p. 308.
————9——— ——
COLONIAL NURSING AS SOCIATION.
Durina the year ending March 81, 1918, the
Association have sent out 76 nurses for work
abroad, 33 as private nurses, and 43 in Government
employ, being the largest number since the com-
mencement of the work of the Association in 1900.
During the year they had 298 nurses at work com-
pared to 276 in the previous year.
Requests for nurses have been received from
Western Australia, and 10 nurses were sent out in
August, 1912. , This most deserving Association
deserves the keenest support of all travellers and
residents in the Tropies.
We have indicated on the
Business Hotices.
1.—The address of the JOURNAL OF TROPICAL MEDICINE AND
HYGIENE is Messrs. BALE, Sons AND DANIELSSON, Ltd., 83-91,
Great Titchfield Street, London, W.
2, —All literary communications should be addressed to the
Editors.
3.—All business communications and payments, either of
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the Publishers.
T. —The Journal will be issued avout the first and fifteenth day
of every month.
THE JOURNAL OF
Tropical Medicine andbhpgtene
OCTOBER 15, 1913.
SIR PATRICK MANSON NATIONAL
PRESENTATION.
Ir is proposed to present to Sir Patrick
Manson, G.C.M.G., the portrait painted by Mr.
Colin Hunter, on the occasion of the dinner of
the London School of Tropical Medicine at
Prince's Restaurant, on Friday, October 24,
1913.
—— eo
SPECIAL DRUGS FOR EACH DISEASE.
Tur ‘‘ Dock AND NETTLE '" IDEA OF THERAPEUTICS.
NomrniNG was perhaps more prominently brought
forward at the recent meeting of the British
Medical Association in Brighton in July, 1913, and
the International Medical Congress in London in
August, 1918, than the announcement, as far at
least as tropical medicine is concerned, of the in-
ability or the failure of special drugs to alleviate
disease or cure persons suffering from tropical
ailments. Most of the authorities who read papers
or spoke on drugs did so usually, not to announce
a cure, but a failure of particular drugs in par-
tieular diseases. It may be, as regards tropical
‘ diseases, that there has not yet been time to evolve
| cures, seeing that our scientific knowledge of these
; maladies is so recent.
Not that scientific investiga-
tion has ever done much in establishing particular
drugs as cures; for our important remedies, mercury,
arsenic, cinchona, ipecacuanha, &c., were evolved
empirieally and before science played any decisive
part. What has been done of recent years in con-
nection with these and other drugs is that the
chemist has given us appropriate preparations of
salts or extracts of these well-known drugs, which
have no doubt advanced our knowledge of thera-
peuties and enlightened us in the ways and means
of treatment. Still it must be confessed that, even
Oct. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
323
at théir best, drugs are all too often disappointing,
and the explanation may or may not be either faulty
diagnosis or misapplied and inefficacious remedies.
In time the former: drawback will no doubt be
removed; methods of precision in diagnosis tend,
and in some instances have attained, to what would
seem finality, and then it will lie with the thera-
peutist to advise what drug to use or what course
of treatment to pursue. It may be that cure is
impossible; this is a contemplation, however, that
does not and should not be allowed to prevail.
More and more do we believe and know that disease
is eaused by an invasion of the body of deleterious
agencies from without, and the growth and develop-
ment of this knowledge would seem to justify the
idea that all diseases may either be prevented, or
that the destructive agencies which generate
them having entered the body can be expelled or
destroyed. Prevention of disease is the ideal to be
aimed at, and it cannot but be said that in Britain
at least it has not proved unreliable or impracticable.
From these islands we have seen several ailments
disappear, or they are kept in check to such a degree
that their effect upon the mortality is infinitesimal ;
amongst these may be mentioned malaria, small-
pox, typhus, typhoid, leprosy, and the outbreaks of
plague and cholera which used at intervals to
devastate the country. The diseases we have with
us preventive medicine has not yet overtaken, and
we have to rely upon nature's effort or drugs to
overcome their consequences. It cannot be said
that drugs have done much as direct agents of cure;
that they help to assist the body to fight against
the evil consequences of the invasion to which the
body has been subjected is undoubted, and in that
view they are of the first importance and of intrinsic
value. The question is: Are we advancing along
the proper lines as regards our uses of drugs? The
spirit that prevails to-day may be summed up as
that of one drug for each disease, a special remedy
for a particular ailment.’ This is an old belief, in
consonance with the idea that nature implanted the
dock alongside the nettle, so that when stung by
the nettle the dock juice may be applied to assuage
the pain. The “ dock and nettle ” principle would
seem to prevail in men’s minds to-day. Poly-
pharmacy is at a discount; the single drug remedy
holds ascendancy; quinine for malaria, mercury for
syphilis, &c., set the example, and the modern
tendency is to find a single drug to deal with
trypanosomes, spirochetes, &c.
It was not so until quite recently. The genera-
tion of medical practitioners before us were poly-
pharmacists, and their prescriptions are viewed with
something akin to contempt, and ofttimes afford
considerable amusement to the younger men of to-
day. We are, moreover, not only using single
drugs, but we are exacting from out of these single
drugs their very essence, such as emetine from
ipecacuanha, morphia from opium, &c., and believe
that a great advance has been made. This may
be so, but no doubt we are apt to be prejudiced by
our present-day discoveries in the course we are
pursuing. That these subjects should be worked
out is most important; it is well to have enthusiasts
for '' salvarsan,’’ for ‘‘ emetine,’’ for '' quinine ’’ in
its several forms, and for the many new remedies
showered upon us. It will be remembered, how-
ever, by practitioners even in their thirties, that
they have seen several loudly proclaimed remedies
fall into abeyance. The '' soured milk *' treatment
is no longer the rage; the treatment of tuberculosis
by tuberculins of sort and several other remedies
and methods of treatment have had their day, and
it is possible that the ''single drug '" remedies of
to-day may be replaced by the poly-pharmaceutical
methods of yesterday. Is quinine alone the most
efficacious method of administering quinine in
malaria? Our immediate predecessors in medicine
used along with it in their “ fever powders ” opium,
arsenic, and mercury; in their prescriptions for
syphilis, opium and other drugs were included,
and if we trace medicines back to ancient times we
know that many concoctions contain a list of
drugs “‘ as long as my arm." That many, in fact
most, of these remedies were inefficacious may be
true, but that they were not included in the
medicine for ‘‘ appearance sake” only may be
believed when it is remembered that the fees
charged were small, that they included the price
of the drugs in the medicine, and that the fewer the
drugs exhibited so the greater would be the
monetary profit on the mixture.
Warburg's tincture, a 4,000 years old remedy,
even at the time that Dr. Warburg, of Vienna,
added quinine to a mixture as old as the time of
Mithridates, and thereby gave us a 23rd substance
to this ancient and well-known remedy for fever.
But Warburg's tincture, in spite of its empirical
nature, still holds its position as a ‘‘ fever remedy,”
a eurious faet at a time when we are extracting the
active principles of drugs from their other surround-
ings and using them. But morphia is not opium,
nor is emetine ipecacuanha, and it would be well to
preserve an even mind in regard to the ‘‘ dock and
nettle " prineiple which is dominating our ideas
to-day. 7. C.
——— M ———
* Bulletin of Entomological Research," vol. iv, part 2,
September, 1913.
Verruga.—Townsend contribuies an interesting paper on
“Progress in the Study of Verruga Transmission by Blood-
suckers.” So far, he says, it has not been possible to secure
sufficient numbers of Phlebotomus for experimentation,
the season for them being apparently on the wane, but such
work will be started at the earliest possible moment. It is
most confidently expected that this work will give prompt
and positive results in verruga infection. Theoretically and
practically, from all points of view, according to the author,
the connection between this Phlebotomus and verruga could
not be more perfect than it is, save for the actual demon-
stration of the transmission. It is practically certain that
the Ceratopogon and other Chironomids cannot carry the
infection. While there is yet time for the acarid trans-
mission experiments to show results, and they will be
carried straight through, it now appears certain that
Phlebotomus is indicated above all others as the agency
concerned in the transmission of verruga.
_
324
Abstract.
A NEW CONCEPTION REGARDING
MALARIA.*
By C. A. BEeNTLEY, M.B., D.P.H.
Special Deputy Sanitary Commissioner, Bengal.
Tue suggestions that have been made from time
to time that our knowledge of malaria is now so
complete that it can be reduced to mathematical
formule and its problems solved by algebraic equa-
tions, point to the danger of research becoming
stereotyped. Already, if we may judge by many
recent text-books and reports, the current idea re-
garding the investigation of malaria appears to be
that it consists essentially in a routine of blood
examination, spleen counting, the capture, indenti-
fication and dissection of anopheles, and the map-
ping out of the breeding places of these mosquitoes.
But although. the brilliant discoveries of Laveran
and Ross have extended our knowledge of the
parasitology of malaria so far that there appears
to be little room for advance in that direction, we
are still ignorant of many of the factors responsible
for the occurrence of the disease, more especially
when it appears in epidemie form among popula-
tions like those to be met with in India; and there
are reasons for believing that until our conception
of infectious diseases in general and malaria in
particular undergoes a radical change, these gaps
in our knowledge may not only remain unfilled but
actually pass unrecognized.
Before proceeding to outline a new and possibly
somewhat startling conception regarding disease,
based. upon the facts that have been ascertained
regarding parasitology in general, and largely those
especially relating to malaria, Bentley believes that
it is necessary to point to certain current fallacies
regarding the latter condition which appear to have
long escaped. recognition, perhaps because of their
very magnitude. In the first place attention must
be ealled to the fact that ever since Laveran’s
discovery of the malaria parasite, medical men have
failed to distinguish between malarial infection and
malarial disease. This want of discrimination has
given rise to much confusion in the past, and in
recent years has led to some heated disputes be-
tween those who asserted that there must always
be a direct relation between the amount of malaria
among a population and the number of anopheles
capable of carrying infection, and those who pointed
to observations in which it was impossible to trace
such a direct connection. There is a wide diver-
gence to be observed between the phenomena of
infection and disease, and as regards malaria not
only do we possess no evidence to show that
morbidity and mortality bear a fixed relation to
the occurrence of infection, but many observations
in all parts of the world support the view that,
under some conditions at least, the amount of
* Proceedings of the Third Meeting of the General Malaria
Committce, held at Madras, November 18, 19, and 20, 1912.
Simla: Government Central Branch Press, 1913,
THE JOURNAL OF TROPICAL MEDICINE AND: HYGIENE.
(Oct. 15, 1913:
malarial disease present in a community. may vary
inversely with the amount of infection present.
Years ago Koch, Stephens and. Christophers, and
others showed that among children of races in-
digenous to Africa and New Guinea, the eecurrence
of almost universal infection with malaria parasites
was associated with little or no evidence of disease ;
and more recently workers in India have pointed
out that the infection index of a population may
remain almost stationary, although at one time
disease might be prevalent and at another time
almost absent. Unfortunately, the significance of
these observations has been largely overlooked and
the word '' malaria ’’ is almost invariably applied to
describe both the condition of infection and the
state of disease which may be associated with it;
moreover ‘‘ malarial infection " and ‘‘ malarial
disease °’ are constantly used as though they were
synonymous terms. But the distinetion is of more
than academical importance. A hundred malaria
infections in Negro children in West Africa repre-
sent a very different condition as regards sickness
to that of a hundred infections in Europeans
resident on that coast; and the morbidity associated
with a 25 per cent. infection-rate among troops in
barracks may be very different to that observable
amongst them when engaged on arduous field
service,
Again in the case of two communities, A and B,
possessing respective infection rates of 10 per cent.
and 100 per cent., it is highly probable that A may
show a larger proportion of cases of malarial disease
than B. Or if we represent the monthly infection
rate of a community by a hypothetical curve and
the morbidity rate by another, there is no certainty
that the two will show any marked relation, except
when we are dealing with non-immunes, in which
case the curves of infection and disease will tend
to be the same. A consideration of these facts
shows that although it may be possible to demon-
strate a definite relation between the “ static
malaria ’’ of a community and the number of
anopheles capable of carrying malaria, it is not at
present possible to show a similar relation be-
tween the number of anopheles and the amount of
disease; and points to the necessity of clearly dis-
tinguishing between ‘‘ infection’’ and '' disease ’’
whenever the investigation of malaria is under-
taken.
The common practice of using as the basis for
conclusions regarding malaria, data obtained almost
entirely from the study of the condition in non-
immunes is also likely to give rise to erroneous
ideas, especially regarding the problems to be faced
in connection with the disease among partially
tolerant races. At present the bulk of the facts
recorded about malaria in current text-books and
medical journals, relate to observations of infection
(usually in cases of disease) among white immi-
grants to the Tropics or those who have returned to
Europe after residence in a malarious country, but
until it has been shown that the reactions between
the parasite and its host in the case of non-
immunes, are similar, at least in kind if not in
Oct. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
325
degree, to those occurring in the case of partially
tolerant races, living usually under very dissimilar
conditions, the conclusions referred to cannot be
accepted as final. There is yet a further point upon
whieh current opinion regarding malaria does not
appear to be in accord with fact. It is commonly
assumed that the occurrence of malarial infection is
an abnormal condition. But although malaria in
a Londoner may be abnormal, the presence of the
parasite in the blood of children in the West Coast
of Africa is as normal a condition as flea infestation
is to a dog.
In order that the significance of this fact may be
properly grasped it is necessary to take a brief
glance at parasitism in general. It is now recog-
nized that parasitism and parasitie infestations ure
natural conditions both of the animal and vegetable
world. Every species of animal harbours not one
but many species of parasites ; and man, in common
with other animals, supports an extensive parasitic
fauna and flora. Parasites are as amenable to the
ordinary laws of existence as other organisms. They
are only found where conditions are suitable for
them, and they increase or decrease just as other
animals or plants do, in proportion as their environ-
ment is favourable or unfavourable to them.
As regards the parasites of malaria, observa-
tions in all parts of the world have shown
that they are to be found in the blood of
man wherever conditions are favourable to their
continued existence and spread, just as drepanidia
oecur in the blood of frogs, trypanosomes in the
blood of rats and halteridia in the blood of birds.
From these observations it would appear reasonable
to assume that infestation by the parasites of
malaria is a natural condition of the life which a
large proportion of the populations indigenous to
malarious countries is accustomed to lead under
circumstances which favour the continued existence
of the organism; and that.it is only to be looked
upon as abnormal when it occurs apart from these
conditions.
It is now possible to outline a hypothesis con-
cerning infective disease in general and malaria in
partieular whieh may prove suggestive in stimu-
lating future research both as regards the origin of
disease and the methods to be adopted for its pre-
vention or control.
Attention has already been drawn to the fact
that parasitism and parasitie infestation are uni-
versal rules of the animal world; and that among
mankind, the more primitive the habit and mode
of life of a race, the more certain it is to be infested
with a multitude of parasites of all kinds. But
like other animals, man becomes adjusted to his
natural parasites and under ordinary cireumstances
suffers little or no inconvenience from their presence.
If we study mankind in relation to the world of
parasites we may note that at one end of the
scale is primitive man, tolerating a large assort-
ment of parasites with impunity, and at the other
end of the scale is the most highly civilized man,
already comparatively free of parasites, and so
highly intolerant of them that he suffers serious
disease when into immediate relation
with them.
Just above the savage in the scale are the races
which having achieved a few steps towards civiliza-
tion are content to pass from century to century
in a condition of stagnation. They, too, like the
savage, support an extensive parasitic fauna and
flora, and like him enjoy a comparative immunity
under ordinary conditions from unpleasant sym-
ptoms, owing to their more or less complete toler-
ance of their parasites. Until comparatively recent
times the bulk of the population of India may be
said to have been in this condition.
It has already been pointed out that highly
civilized man has largely freed himself from para-
sites ; and it would appear that civilization is largely
incompatible with a condition of continued parasitic
infestation. This comparative freedom from para-
sites enjoyed by civilized man has been brought
about by the same process of evolution which has
stimulated his advance in other directions. The
gradual intensification of the struggle for existence
between the individual members of a race or species
produces a rapid development and at the same time
results in the elimination of the most inefficient.
The presence of parasites is a handicap, and a cause
of inefficiency; they consume energy which might
otherwise be usefully expended in work and they
lessen the powers of adaptation of the host to his
environment; and other things being equal a para-
site-free individual or race will always triumph over
a parasite-ridden one. Regarded purely as a
machine turning fuel into energy the civilized man
compares favourably with his primitive brother;
and the result is that the work he can accomplish
is incomparably greater. This is in part due to
the fact that as he has advanced along the path
of civilization he has discarded his parasites along
with other useless burdens.
It must not be forgotten, however, that side by
side with this process of elimination of parasite
curriers und parasites owing to the greater stress
imposed upon mankind by civilized life, another
influence has been at work, assisting to bring about
a condition of freedom from parasites. The
epidemies of disease brought about among parasite-
laden races by the shocks of advancing civilization
have had the effect of stimulating mankind to direct
attaeks upon disease with a view to its control.
And it is natural that this should be the case. So
long as man’s parasites cause him little or no in-
convenience, he tolerates their presence; but when
they disturb his comfort or threaten his existence he
is often aroused to attempt to rid himself of them.
There is little reason, however, to suppose that
the conscious struggle of man against disease, which
has only become effective in quite recent years, has
played a very important part in freeing countries
like Great Britain from parasitic infestations such
as plague, leprosy, typhus fever, relapsing fever,
and malaria, which were at one time prevalent
there. And except in the ease of malaria and
small-pox it is difficult even to guess at the special
causes for the disappearance of these conditions.
brought
826
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 15, 1913.
‘But although there is no direct evidence to show
that malaria disappeared as the result of measures
specially directed against it, it is possible to point
to certain factors which have exerted a marked
influence in bringing about its disappearance. And
foremost among these influences has been improve-
ments in agriculture.
Among the more primitive races of mankind who
seek their living from the soil, the simplest forms
of agriculture are practised. ^ Each family tills a
small plot of land no larger than will suffice for its
few needs, in a manner requiring as little effort as
possible. Land which is most easily cultivated is
selected, the simplest implements are used, no
manuring, no drainage, and only the easiest forms
of irrigation are adopted; and as soon as the soil in
one place is exhausted another site is chosen. So
long as the pressure of population is not very great
these simple methods suffice to supply the wants
of the people in ordinary seasons, and there is no
incentive to improvement in the system of agricul-
ture. But with advancing civilization man’s wants
expand, and to supply them he tills a larger area
than that required merely to provide him with food
and clothing; and by a system of barter exchanges
his surplus crops for other products. Gradually as
communication with outside markets improves, the
demand for all kinds of raw material increases and
under the further stimulus of a system of monetary
exchange, which soon replaces the primitive
methods of barter, agriculture tends to undergo a
rapid process of evolution. ^ As manufacture de-
velops, the demand for all sorts of raw material
expands, and land at one time used for food crops
is turned to other purposes. Partly as a result of
this, and partly owing to the fact that large num-
bers of people who once produced their own supply
of food are now engaged in other industries, the
price of food-stuffs rises, and in sympathy with this
rise, the value of all agrieuftural produce increases.
This brings about increased demand for land, which
in turn produces a rise in land values and a corre-
sponding increase in rents. As land increases in
value owing to the greater demand, areas which in
earlier days were left uncultivated are gradually
brought under the plough, waste land and jungle
are cleared, swamps and low-lying land are drained.
The cultivator also, taught by experience that con-
tinued cropping of the soil produces exhaustion,
learns to make use of manure, to adopt rotation of
crops, selection of seed and advanced systems of
irrigation and agricultural drainage. In other
words, he no longer looks upon the land as a mine
to be worked till exhausted and then abandoned,
but as a machine for turning labour into wealth.
By the time he has reached this advanced state
of development he can obtain from the poorest land
as much or more return than was originally yielded
by the best, and the face of the country has under-
gone a complete change from a waste of forest,
undergrowth, and swamp, broken here and there by
small patches of cultivation, to a wide expanse of
cultivated fields, open pasture, and regulated plan-
tations of useful timber and orchard trees. But it
is not only the surface of ‘the land which undergoes
a change. As soon as the value of agricultural pro-
ducts rises above a certain level, capital is attracted
to the land, and the large farmer enters into compe-
tition with the petty cultivator. And with the rise
in rents, the necessity for using manure, machinery
and other adjuncts of intensive cultivation the com-
petition becomes so severe that the smallholder is
gradually ousted, because he possesses neither the
capital, the knowledge, nor the ability to exact a
full return from the soil. With the elimination of
the small cultivator and the introduction of efficient
machinery the number of people -permanently
engaged in actual cultivation of the soil is greatly
reduced, the rural population diminishes :and that
of the towns increases.
Such changes as have been thus briefly described
signify a tremendous modification in the environ-
ment of a race. And whenever they occur man’s
relation to malaria undergoes a complete alteration;
for the conditions under which he lives are mno
longer favourable to the existence and spread of the
parasite. It has often been stated that malaria has
been eradicated from a country by drainage alone or
by drainage combined with the clearing of jungle.
but it appears more likely that a development, more
or less rapid, of the whole system of agriculture in
a locality, involving not only drainage and clearing
of jungle, but a number of other changes in the
environment of the population concerned, has been
responsible for the reduction or disappearance of
malaria from the country.
Many years ago, while England was still produc-
ing its own food supply, the high prices obtained for
wheat stimulated the exportation of this grain to
Continental ports. This export trade was still fur-
ther encouraged by the offer of a Government
bounty-on every shipment. It is possible that this
chreumstanee was partially responsible for the re-
claiming and cultivation of vast areas in the fen
districts. These districts at one time notorious on
account of malaria subsequently became famous for
their wheat production and stil produce a large
amount of grain. Huge areas of low-lying land m
that part of England, much of it situated below
sea-level, have been reclaimed by a system similar
to that adopted in Holland. The rivers flowing
through that part, which at one time overflowed the
country after every heavy fall of rain, have been
retained within embankments; sluices are used to
regulate flood and tidal water; and ‘to drain the
land a network of low level drains or dykes, to-
gether with high level drains upon embankments,
is employed. Windmills were originally used to
work the pumps required for raising the water from
the low to the high level drains, but these have now
been replaced by steam plant, and the same -plant
which in wet ‘weather removes the excess of water
from the fields is used in time of drought for
irrigating the land from the rivers and high level
water channels.
But although the system of reclaiming and drain-
ing a country in this way has had an immense
influence in bringing about a reduction in malaria,
öt. Kb, 918.)
jt would ‘be a midtake ‘to infer that the same results
"would ‘follow the adoption of: schemes of ‘drainage
‘aimed ‘at ‘the mere reduction:of malaria, rather than
‘the ‘development of agriculture. Attention must
‘lso ‘be ‘called to another important point in this
‘connection. The freeing of the fen districts of
England’ and the greater part of Holland from
malaria has ‘been achieved not by the expenditure
‘of vast sums on sanitation by the State, but by the
'erterprise ‘of private persons. And the farmers
and landholders who have been instrumental in
‘effecting this improvement have been stimulated to
carry out this work not with a view to improve the
‘health of the country, but because they wished to
increase or ‘secure their-own profit.
Turning to India it may be observed that the vast
‘mass ‘of the population is still in a very primitive
‘condition. The coolie, the cultivator, the petty trader
and ‘craftsmen ‘still live a simple life, with few and
easily ‘satisfied wants. They are still mostly with-
out ‘education; and the only ambition they possess
is the wish to live as their forefathers have done
for centuries. In common with other primitive
‘peoples the masses of the ‘population support an
‘extraordinary variety of parasites; and under ordi-
-nary conditions and so long as they have sufficient
food, water, clothing, and shelter, in other words,
so long as their environment remains unchanged,
and ‘their adjustment to it in balance, disease
‘occurs ‘only ‘as a very ‘minor phenomenon amongst
them. But within the past fifty years a series of
extraordinary ‘changes have been going on all over
the country, and the environment of many millions
of the people has undergone enormous modification.
"The construction of many thousand miles of rail-
way, the covering of the ‘country with a network of
roads, and the organization of fast steamer services
around the coast and on the inland waterways have
'simplifred means of communication, and given rise
to sh active export and import trade. Millions of
‘tultivators in Bombay, Bengal, and the Punjab
whose fathers were engaged ‘merely in the produc-
tion of the few necessaries required for their own
families, are now busy supplying not only the
markets of Bombay and Caleutta, but those of the
world, with cotton, jute, and wheat. Side by side
with these larger changes a host of smaller ones has
been ‘brought about, affecting every district. Old
village industries have dwindled; the small weaver,
the oil maker, the lime burner, and a host of other
petty crafts are fast disappearing; trade is now
everywhere conducted through the medium of cur-
rency instead of barter; wages are everywhere paid
in coin instead of in kind. There is not a single
advance towards civilization that has not brought
about a huge modification of the environment of the
people. The development of the tea industry in
Assam, the coal mines of Bengal, the jute mills of
'Oaleutta, and the cotton mills of Bombay has
entirely altered the life of millions. Even the
introduction of a postal and telegraph system, the
laying of cables to Europe, and the construction of
the Suez Canal, have exerted a profound influence
upon the people, for the ‘cultivator in Bombay,
Bengal, and the Punjab has thus been brought into
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
327
direct ‘relation with the markets of the ‘world, and
fluctuations in ‘the price of cotton, jute, or ‘wheat on
the exchanges of Europe may bring him either pros-
perity or adversity.
Partly as a direct result-of all these changes, and
‘partly from other causes, but mainly because India
is now linked up with the world, there has been ‘a
steady and continuous rise in the cost of living; and
the increased price of food, together with a gradual
improvement in the standard -of comfort, is rapidly
effecting a -great intensification in the struggle for
existence among all classes of the community.
Thus in the brief space `of fifty years a change so
vast as to be almost inconceivable has been effected
in the environment of a primitive, parasite-laden
race. And as a -direct result of the ‘successive
‘shocks by which this change has been -brought
about, the balance of life of ‘myriads has been again
and again upset, the delicate adjustment ‘by which
their parasitic infestations were kept in control been
‘broken ‘down, ‘and appalling ‘epidemics of -diseaye
been brought about amongst them at frequent ‘inter-
vals. And the poorest, the most ignorant, the
most parasite-laden and least adjustable classes of
the community suffer most severely at the time of
these epidemics, demonstrating by this fact their
inability to meet the strain of life under the chang-
mg conditions of advancing civilization.
Briefly summarized the ‘conception ‘which ‘has
been outlined in the foregoing pages may ‘be stated
thus :—
Parasitism and parasitic infestation are universal
conditions of life; and man in common with all other
animals is the natural host of many species of
parasites. But civilized man when contrasted ‘with
primitive man is comparatively free of ‘parasitic
infestations, the conditions of his life being less
favourable to the existence of parasite organisms.
‘Under naturel conditions all organisms ‘become
adjusted to their environment, including their para-
sitic ‘associates, and disease as generally understood
‘either ‘does not occur amongst them at all, or only
appears as a very minor phenomenon.
Sudden changes of environment, however, such ‘as
that occasioned by unusual seasons, may upset the
balance of life, and give rise to serious manifesta-
tions of ‘disease, in the course of which the less
resistant members of a race or species ‘perish.
In common with many other parasites the
malarial organism is to be found associated ‘with
man wherever the conditions of his life lend them-
selves to its existence; and as primitive races
generally live under conditions favourable to malaria
they are frequently found to be infested with the
organism.
Primitive man like other animals is normally in
a state of adjustment to his environment, which
includes numerous parasitie infestations, to which
under ordinary circumstances he is tolerant. But
any change in his environment at once modifies his
relationship to these parasites; and in proportion
as it is sudden and severe may lead to a manifesta-
tion of disease.
Primitive man is usually only exposed to such
temporary changes in his environment as those
328
occasioned by exceptional seasons. But the ad-
vance of a race towards civilization is marked by
recurring changes in its environment, often extra-
ordinarily serious in their character.
In the process of civilization individual members
of a race, who fail to adjust themselves to the
changing conditions of life, succumb to the strain,
and fall victims to the attacks of the parasite to
which they have previously been tolerant.
Epidemic disease is a natural accompaniment of
the early stages of advancing civilization; and it is
a beneficent process; because in no other way can
a parasite-laden race so speedily rid itself of its
parasite carriers and parasites.
The phenomenon of epidemic disease is thus
always the result of a change in environment.
When it occurs among primitive races it is usually
due to (a) exceptional seasons, or (b) changes of
advancing civilization. | Under both these condi-
tions, previously tolerated parasites give rise to
disease. But the change of environment producing
disease among a population may itself be the
presence of an unfamiliar parasite. The changes of
environment producing epidemic disease among
highly civilized races appear to be usually of this
character.
Viewed in the light of this conception the problem
of disease takes on a new aspect. Epidemics,
whether of malaria, plague, cholera, and other in-
fective disease to which such races as those occur-
ring in India, China, and Russia are prone, appear
no longer mere isolated, inexplicable catastrophes ;
but as perfectly natural phenomena, fundamentally
related to each other, however profoundly they may
differ in their manifestations.
The investigation of disease becomes essentially
a study of man’s relationship to his environment, of
which parasites form only a part. It follows that
the investigation of the causes of malarial disease
among a population necessitates a consideration
not only of the parasites of malaria and anopheline
carriers which may represent only one factor in the
condition, but an inquiry into every detail of human
environment with a view to determining that special
circumstance which has occasioned the outbreak.
In a country like India, therefore, the more highly
specialized forms of sanitation, such as have been
devised in recent years against yellow fever and
malaria, must be applied with discrimination. They
should be adopted in large cities with enlightened
populations, among troops and jail communities,
and in connection with such industries as tea plant-
ing, mining, &c., for under such conditions they are
most likely to offer a return commensurate with the
expenditure incurred. They are also called for in
rural towns, but more especially for educative
reasons. And in such places on no account should
this educative function be saerificed to the often
futile attempt to obtain immediately obvious re-
sults. No doubt the State, by the deputation of
specially skilled officers and the grant of funds, ean
carry out specific measures against malaria much
more efficiently than the municipal commissioners
of a small town; but the effect of such work when
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1913.
done by Government is to undermine the indepen-
dence of the townspeople, impair their sense of
responsibility, and stifle effort at self-improvement.
And so, though at first municipalities will do the
work very badly, they must be stimulated and
encouraged to undertake it independently of
Government aid.
The attempt to reduce malaria by such measures
as drainage or the clearing of jungle, unless accom-
panied by an extension and improvement in culti-
vation, is foredoomed to failure. Instead of dissi-
pating large sums of money in the vain hope of
reducing the incidence of malaria in a few localities
in rural areas, attention should be concentrated
upon improving the existing methods of agriculture
by every possible means. To this end, not only
should special efforts be directed to educate the
cultivating classes of the population, develop their
intelligence, foster their ambition and independence,
and improve their standards of comfort, but
attempts should be made to induce capitalists to
undertake large-scale agricultural operations wher-
ever possible.
The chief function of the State in regard to
problems of sanitation should be mainly that of
educating the population. And although it may
initiate reforms, the actual carrying out of the
measures should be left as far as possible in the
hands of the people concerned, for without their
intelligent co-operation no scheme of improved sani-
tation can be made effective.
In conclusion it may be pointed out that just as
we can trace the origin of many epidemics of disease
among a primitive people to the changes wrought
upon their environment by advancing civilization,
so it is to civilization carried to a greater length that
we must look for the remedy to these conditions.
And although we shall not in our day see the
elimination of malaria from India, we may rest
assured that it will be accomplished in the future,
as certainly and as completely as it has been
brought about in England.
— e0
Rotes and Mews.
Bovrit, Lrp., have been awarded the Grand
Prix at the Ghent Exhibition, and also a Diploma
for excellence at the Congo Belge Exhibition,
Elizabethville. This double distinction, which
heads a long list of previous awards, is certainly a
high tribute to the excellence of the world-famous
beef beverage.
———————Má——
Hotices to Correspondents.
1,—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
9.— To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL oF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers. / :
5.— Correspondents should look for replies under the heading
« Answers to Correspondents.”
Noy. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 21, Vol. XVI.
Original Communications.
BRONCHIAL SPIROCHASTOSIS.
By ALBERT J. CHatmers, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories,
AND
Captain W. R. O'FARBRELL, R.A.M.C.
Protozoologist, Wellcome Tropical Research Laboratories,
Khartoum.
INTRODUCTORY.
So far as we are aware no one has hitherto noted
the presence of bronchial spirochetosis in the Anglo-
Egyptian Sudan, where it is apparently not un-
common, and this, together with the fact that the
disease has so far been recorded from but few
tropical localities, has induced us to bring forward
the following observations, with the hope that it
may stimulate an inquiry into the causation of
bronchitis and of obscure cases of pseudo-phthisis
in the Tropics and elsewhere.
HISTORICAL.
Some years ago Eichorst found spirochetes in
small numbers in the sputum of cases of bronchitis,
and Bertarelli with Volpino, in 1905, noted forms like
Spirochxta buccalis and Treponema pallidum in the
sputum of a person suffering from heart disease, but
no importance was attached to these researches. In
1905 Castellani saw spirochetes almost unassociated
with other organisms in cases of bronchitis, and
Rona noted the same organisms in cases of gan-
grene of the lungs. In 1906 Castellani, who, with
his usual care, had followed up his cases, came to
the conclusion that there was a specific disease of
the lungs caused by these organisms, and this
disease he named bronchial spirochetosis. His
findings were speedily confirmed in the same year
by Branch, in Kingstown, St. Vincent, but neither
observations seem to have attracted much atten-
tion. In 1907 Mühlens reported the presence oi
spirochetes in gangrene of the lungs, and con-
sidered them to be mouth spirochetes which had
wandered into the lungs. In the same year Küster
described two cases of lung gangrene in which he
found organisms resembling T. pallidum (Schau-
dinn, 1905). He considered it probable that these
organisms were the actual causal agent of the
gangrene. Also in the same year Castellani named
the spirochetes he had found Spirochxta bron-
chialis (Castellani, 1907). Early in 1909 Waters
described typical cases of bronchial spriochetosis
as seen in Tundla, in India. In September of the
same year Castellani gave a fuller description of
the disease in a paper read at the annual meeting
of the Tropical Section of the British Medical
Association. Also, in 1909, Phalen and Kilbourne
described a case of pulmonary spirochetosis in a
Filipino in the Philippine Islands, but considered
that the causal rôle of the organisms was not
proven. In 1910 Castellani gave a detailed account
of the disease in the first edition of the ‘‘ Manual
of Tropical Medicine," written by himself and one
of us, and in the same year Rothwell published
four eases of bronchial Vincent's angina in which
spirochetes were associated with fusiform bacilli;
also in the same year Buvay published histo-
logical researches on gangrene of the lung, in which
he found spirochetes of the nature of S. dentium,
together with Bacillus fusiformis. About this date
Peters, in Cincinnati, reported cases of pneumonia
and fætid bronchitis in which spirochetes, asso-
ciated with fusiform bacilli, were present in large
numbers. In 1911 Chamberlain described two
cases of bronchitis, one with hemoptysis, in the
Philippine Islands, and lastly, in 1913, Castellani’s
latest account appears in the second edition of the
‘* Manual of Tropical Medicine '' mentioned above.
From this historical sketch it will be noted that
spirochetes of various sizes and descriptions have
been seen by several observers in different parts of
the world, associated with inflammation of the
bronchi alone, or together with that of the lung
tissue. It will also be observed that the whole
subject is‘at present open for further research as to
the relationship between the spirochetes and the
various inflammatory conditions in which they are
found.
GEOGRAPHICAL DISTRIBUTION.
Cases have been reported in the temperate zone
and in the Tropies. In the former they have been
mRARA
Fia. 1.— Spiroschaudinnia bronchialis (Castellani, 1907), as
szen by dark-ground illumination. The phase represented is
probably that which occurs just prior to the liberation of the
granules depicted therein. These granules may possibly be the
infective agent. Magnification about 2,000 diameters.
observed in Europe and in the United States. In
the latter they have been seen in Ceylon, India,
the Philippine Islands and the West Indies, and
now for the first time, so far as we know, in Africa
in the Anglo-Egyptian Sudan, and we are privately
informed that it will be reported shortly from
another part of Africa. With regard to the Anglo-
Egyptian Sudan, we have met with ten cases in
the last two months, but medical officers who have
great local experience assure us that it will in all
probability be found to be a very common disease
here. As may be expected, most of our cases have
been found in Khartoum, but one case came from
farther south.
Racran DISTRIBUTION.
The reported cases are in English, Sinhalese,
natives of India (probably very different races),
Arabs, negroes (probably very different races) and
Filipinos.
ETIOLOGY.
In the cases which we have seen in the Anglo-
Egyptian Sudan and in Ceylon we have found large
numbers of spirochetes in the sputum, and
relatively but few bacteria, and no other organisms
such as fungi.
The typical form as seen by dark-ground illu-
mination is depicted in fig. 1, and the various forms
330
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1913
whieh we have observed in stained specimens are
shown in fig. 2.
It is not our intention to describe the morphology
or the life-history of this Spiroschaudinnia, as this
wil be done by Dr. Fantham, the well-known
investigator of spirochetes, who is at the present
moment at work in this laboratory, but we may say
that our observations tend to show that Spiro-
schaudinnia bronchialis (Castellani, 1907) is a good
species, and that the different forms may probably
be closely related to one another as different phases
of growth and division of one and the same spiro-
chete rather than different species of spirochetes.
The question which concerns us here is whether
this spirochete is or is not the cause of the
bronchitis.
Ever since Charles Badham in 1810 introduced
the term bronchitis the list of possible and probable
causes of the disease has been gradually growing
and changing, but in our opinion there is no doubt
that it usually depends upon two factors: (a)
Primary cause; (b) secondary cause.
A
Qa
BE
Fic. 2.—Spiroschaudinnia bronchialis (Castellani, 1907), as
seen in specimens stained by Leishman's method and carbol.
thionin. The various forms depicted probably represent
different stages of growth and division. Magnification about
1,500 diameters.
The essential or primary cause may he physical,
chemical, or parasitic. As far as we know, physical
and chemical causes as primary agents can be
excluded in our cases and experiments, though we
shall endeavour to show later that the physical
secondary causes are of importance.
We are therefore reduced to parasitic causes,
whieh may be divided into the vegetal parasites
and the animal parasites. In the vegetal parasites
there are the fungi and the bacteria to be con-
sidered. With regard to the fungi, Castellani and
others have shown that they may be the cause of
brancho-moniliasis, broncho-nocardiasis, broncho-
aspergillosis, broncho-penicilliosis, broncho-mucor-
mycosis, broncho-sporotrichosis, &e. These can be
definitely excluded in our cases, as we have not
found them in the sputum either by direct examina-
tion or by cultivation.
With regard to bacteria they are not so easily
dismissed, but we have failed to see or to grow
many organisms in several of the cases we have
examined, and in this we support the early findings
of Castellani, who says: ‘‘ They (the spirochetes)
were generally mixed with some bacteria, but some-
times when the sputum was collected in sterile
Petri dishes and preparations made at once they
were practically the only germs present.’
The tubercle bacillus has also been excluded from
all the cases by repeated examination of the
sputum, and by Castellani by the inoculation, of
guinea-pigs, which, at present, are too valuable here
to be expended upon an experiment already per-
formed. :
As neither bacteria nor fungi appear to be the
essential cause, and as spirochetes are in abundance
in the expectoration, it is necessary to consider
them in detail.
Firstly, are they merely mouth spirochetes
which, owing to some secondary condition, have
been induced to wander into the bronchi? Our
answer to this is in the negative, for the following
reasons :—
(1) We have found mouth or throat spirochetes
in some of the cases, but these were morpho-
logieally different from the typical forms of spiro-
chetes in the bronchial mucus, and could be
differentiated.
(2) We do not believe that the disease is caused
by an increase in the number of the mouth or throat
spirochetes and their invasion of the bronchi
because of the following experiment :—
A monkey, which had a small number of fine,
easily recognized spirochetes in the top of its
larynx, was intratracheally injected with some spu-
tum from the case of mixed broncho-spirochetosis
and pneumonia mentioned below. The spirochetes,
which were very few in number, were all dead
before the injection was made. After injection the
monkey was severely chilled by rubbing its chest
with ice and exposing it to the blast of a quickly
running electric fan. The monkey developed a
coryza, and later a broncho-pneumonia, from which
it subsequently died. An immediate post-mortem
was performed, and the pneumococcus was obtained
from the bronchial secretion and the patches of the
lungs. A very few of the laryngeal spirochetes
mentioned above could be found by diligent search
in the bronchial mucus, and they were identical
with those seen before injection.
This experiment tends to show that merely chill-
ing a monkey or injecting it with the pneumococcus
will not lead to marked increase in the number of
the usual spirochetes normally living in the top of
the throat and in the bronchial secretion.
Secondly, if S. bronchialis (Castellani, 1907) is
not a mouth spirochete, what is it? We believe
that it is a specific spirochete, and that it causes
bronchial spirochetosis, because :
(1) The spirochetes are always present in
abundance during the attack, diminish during con-
valescence, and are subsequently either absent or
found with difficulty
(2) The spirochetes of all our cases appear to
belong to S. bronchialis (Castellani, 1907).
(3) The spirochetes found in the Anglo-Egyptian
Nov. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
331
——————————————————————————————————————————————
Sudan appear to be the same as those observed in
Ceylon.
(4) A monkey living in good health in our
monkey house was examined, and found to contain
a small spirochzte in its pharyngeal mucus. This
organism was easily differentiated morphologically
from S. bronchialis.
This monkey was injected intratracheally, and,
unfortunately, owing to a sudden movement on the
part of the animal, also extratracheally with some
expectorated sputum from a well-marked case of
bronchial spirochetosis; after this injection it was
chilled.
In about thirty-six hours it became very ill. It
was unable to eat its food, developed a temperature
of 106°3° F. at night, had a peculiar kind of cough,
and showed a quantity of mucus hanging down from
its muzzle. The mucus from its throat was
examined, and was found to be full of spirochetes
similar to S. bronchialis. In a couple of days the
monkey became very much better, the cough dis-
appeared, it ate its food, and no more spirochetes
could be found, but it still had some fever. It was
then killed, and on post-mortem examination was
found to have a serous anterior mediastinitis due to
the extra-tracheal injection.
This experiment, to our mind, shows that S.
bronchialis can live in the air-passages of a monkey.
That it can produce increased bronchial and tracheal
mucus, because, with the disappearance of the
spirochaetes, the excessive mucus was no longer
present, and that it can at all events assist in the
production of fever, because the temperature was
higher when the spirochetes were present than
afterwards.
Animal experiments are being continued, and
their results will form the subject of a future paper.
(5) A young English scientist arrived in Khar-
toum in January of this year, coming direct from
England, where he had been passed as medically
fit for service in the Sudan. He worked in another
part of these laboratories, but frequently came into
the rooms where patients suffering from spiro-
chetosis were spitting up or had spat up mucus
and where examinations were made. No one is
known to suffer from bronchial spirochetosis in the
house in which he lives, though, of course, there
are several people suffering from the disease in
Khartoum. It must, however, be admitted that
he came in contact with a large percentage of the
known cases while in the laboratory. Moreover,
the heat of the Sudan summer had most evidently
affected his general health.
A few days previously he caught a chill while
sleeping on a covered verandah during a heavy rain
storm, and in about twenty-four hours complained
that he did not feel well, and reported sick thirty
hours after the chill. All his organs were found to
be healthy with the exception of his right lung. The
blood, which appeared quite normal, contained no
parasites. The fluid from his mouth contained no
spirochetes, nor did that from the pharynx. Swabs
from his tonsils, which were quite normal, showed
a Gram-negative diplococcus, which is very common
here. We are well acquainted with the cultural
characters of this diplococcus, as well as with its
pathogenicity, but he showed none of the usual
pathogenic signs produced by this organism.
After washing his mouth and gargling his throat
he expectorated a small quantity of mucus, in which
S. bronchialis was quite easily found. The spiro-
chetes were fairly numerous, though not present in
the enormous numbers which we have seen. Sin-
gularly few other organisms could be found, and no
tubercle bacilli could be detected.
On examination it was found that his tempera-
ture, which at first was 101°6° F., had risen to
1029 F., and that his pulse rate was 90 beats per
minute, while his respirations were 20 per minute.
(Vide fig. 3.) He complained of a sensation of
tightness in the chest. Nothing could be detected
by palpation or percussion, but on auscultation a
few ráles could be heard over the right lung in an
area of about 4 in. in diameter just superior to the
right nipple.
| [157 DAY 2N? DAY
o LAM.| P.M.| AM. | P.M. |
F
Fic. 3.—Temperature chart of the English Scientist,
He was diagnosed as suffering from bronchial
spirochetosis and taken to hospital, where, under
careful nursing, his temperature quickly fell to
normal, a feature we have observed also in native
patients when suffering from acute attacks. He
was treated with arsenic. His chest symptoms
improved, and the spirochetes promptly disappeared
from his sputum, and he was convalescent.
This case appears to us to be as nearly as
possible a case of experimental human broncho-
spirochetosis. It was promptly diagnosed and
promptly treated, and was therefore cut short, but
if it had been neglected it might have developed
symptoms similar to those seen in worse cases in
natives.
As far as we know, this is the first case ever
diagnosed immediately after the onset of a first
attack.
(0) Just as this paper is about to be forwarded to
England one of us has developed a cold in the head
associated with the signs and symptoms of mild
laryngitis and tracheitis, and with the presence of
332
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 1, 191.
Spiroschaudinnia bronchialis in the sputum. This
attack appears to us to be due to direct infection
during the present investigation, with a chill as a
secondary cause. It might almost be classed as
belonging to infections of experimental origin.
To summarize: We believe that Spiroschaudinnia
bronchialis (Castellani, 1907) is the cause of a form
of bronchitis occurring in the Anglo-Egyptian Sudan
because of :—
(1) The appearance of bronchial spirochetes in
one monkey, even though there was such a com-
plication as an anterior mediastinitis of experimental
origin.
(2) The almost experimental infections of the
young English scientist, and one of ourselves.
(3) The presence of S. bronchialis in abundance
in the expectoration of cases during the attack, and
in the experimental monkey during its bronchial
attack.
(4) The apparent exclusion of other causes.
SECONDARY CAUSES.
It is possible that chills may act as secondary
causes, and we are supported in this view by the
history of the scientist mentioned above.
METHOD OF INFECTION.
In our examination of persons having a history
of attacks of probably this disease, but who were
at the time well, we have, after diligent search,
found in the bronchial expectoration perhaps one or
a few spirochetes closely resembling, if not identical
with, S. bronchialis. Also in our patients when
convalescent or recovered we have been able to
find with diligent search one or more spirochetes.
From these few observations, and from the case of
the scientist mentioned above, we would suggest
that the human carrier is the infective agent, and
that probably the disease will not develop unless
the body resistance is lowered by some other cause
such as a chill.
SYMPTOMATOLOGY.
In general the symptomatology of our cases is
that of mild attacks of acute bronchitis, separated
by intervals of good health or of a more chronic
illness closely resembling the early stages of
phthisis, and sometimes associated with slight
hemoptysis. The following case may be re-
corded :—
A male Arab, aged 22 years, born in Kordofan,
where he lived three years, was brought up in
Khartoum, where he lived healthily, as did his
family, till about four years ago, when he was ill
for about twenty-one days with cough and fever.
After his recovery from this attack he remained
quite well for about two years, when he had another
slight attack. After this he was quite well until
this year, when he developed a slight cough and a
little fever which made him feel ill at night, but in
& few days there was a lull in the illness, and he
felt better, though still troubled every day with a
slight cough. After about three weeks he again
became ill with fever, reaching between 1019 to
1029 F. at night, falling in the morning to 999 F.
His cough now became worse, and the expectoration,
which at first was scanty, now became more profuse,
and he complained of pain over the upper part of
the sternum at the level of the fourth dorsal
vertebra.
On examination he was found to be very thin (a
not unusual feature in a young Arab), but all his
organs appeared to be normal. The respirations at
the time of examination were not markedly increased
in number, allowance being made for the excite-
ment over the examination. On palpation some
slight fremitus due to rales could be felt. Per-
cussion revealed no abnormality. His breath sounds
were normal, but a large number of fine rales could
be heard all over the chest, both anteriorly and
posteriorly. The vocal resonance was normal.
His sputum was carefully examined. It con-
tained no tubercle bacilli and very few other bacilli,
but a very large number of forms of Spiroschau-
dinnia bronchialis (Castellani, 1907). His blood was
carefully examined, but no malarial or other para-
sites could be found.
A composite blood examination of this and other
cases gave the following results :—
During attack
Hemoglobin ... 80 per cent.
Red corpuscles 3,648,000 per c.mm....
During interval
100 per cent.
4,400,000 per c.mm.
A marked leucocytosis was present, and the com-
posite differential eount of 2,719 white corpuscles
gave the following percentage :—
Polymorphonuclear leucocytes P e “MOB
Mononuclear leucocytes T iis 6:6
Largelymphocytes .. ni - - 10:6
Small lymphocytes ; 6:6
Eosinophile leucocytes 2:6
Transitional cells iss T "o 02
Mast cells ne aš ER ai es 01
100:0
He improved rapidly under treatment, and when
examined again after an interval of four days was
much better, and only a few rales could be heard,
while his temperature was 999 F., and only a few
spirochetes could be found. After another week
no rales could be heard, the temperature had
become normal, no spirochetes could be found, and
the patient felt quite well. He remained in good
health and apparently free from spirochetes till a
few days ago, when with the advent of rain he
developed a slight cough, and a few spirochetes
appeared in his sputum.
The above history appears to us to be typical of
the cases seen here. It is probable that the other
attacks of illness mentioned therein were also
broncho-spirochetosis. There is, however, another
symptom not found in the above case which we
have met with twice, and this is a pleuritic rub.
The disease as seen here, therefore, consists of a
number of acute or subacute attacks separated by
longer or shorter intervals of fairly good health.
Nov. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
333
Se qo
COMPLICATIONS.
The disease may be complicated by various other
parasites; for example, we have met with a case
complicated with the pneumococeus, and Branch
found one complicated by the tubercle bacillus and
malaria, while Buvay and Peters have met with
cases complicated by the fusiform bacillus. Other
complications may reasonably be expected as the
history of the complaint becomes better known.
COMPLICATION WITH THE PNEUMOCOCCUS.
The following is an account of a case complicated
by the pneumococcus :—
A native of the Sudan was seized with a chill on
June 27, 1913, and complained of pain in the left
side of the chest on breathing deeply.
Second Day.—The temperature rose to 101° F.
in the morning, and remained about that during the
day. No physical signs could be observed.
Third Day.—The morning temperature was 999 F.,
and the evening temperature 1039 F., and there
was increased pain on the left side of the chest.
The frequency of the respirations was not increased,
but the patient coughed up a quantity of blood-
stained sputum. A slight friction sound could be
detected around and below the left nipple.
Fourth Day.—The symptoms remained unabated,
except that the pain was relieved by cupping.
Fifth Day.—The temperature in the morning fell
to 989 F., and in the evening rose to 1019 F. "The
symptoms remained as indicated above.
Sixth Day.—The temperature was 1089 F. in the
morning, and 1029 F. in the evening. During the
day the patient complained of pain on the neck and
occiput. A few sibilant rales were noted over the
left lung, especially posteriorly. The sputum con-
tinued to be blood-stained, and when examined
showed numerous spirochetes, some of which are
demonstrated in fig. 2, and some pneumococci.
The diagnosis of acute bronchial spirochtetosis com-
plicated by broncho-pneumonia was made.
Seventh Day.—The temperature was 102° F. in
the morning, and 1089 F. in the evening.
Eighth Day.—The temperature was 1019 F. in
the morning, and 1049 F. in the evening. He had
severe headache.
Ninth Day.—The temperature fell to 99° F. in the
morning, and was 1009 F. in the evening, and
though the patient vomited he was not worse.
Tenth. Day.—The temperature fell to normal, and
the symptoms subsided.
Eleventh Day.—The temperature was normal.
There were no physical signs, no symptoms, and
the spirochetes had practically disappeared from
the sputunt, but the pneumococci persisted.
DIAGNOSIS.
The diagnosis of broncho-spirochetosis can only
be made by a careful examination of the sputum.
A small quantity of fresh sputum is placed on a
thin, white, clean slide, and covered at once by a
very thin, perfectly clean cover glass, wkich is well
pressed down. The cover glass is then surrounded
by vaseline to prevent evaporation, and the speci-
men is immediately examined by means of the dark
ground illumination, which is quickly and easily
produced by a Zeiss paraboloid condenser, a Nernst
lamp, a 2 mm. apochromatic lens, and a 2 or 4
compensating ocular, or some similar combination
of lenses. Failing this equipment, a film may be
spread on a slide, dried, fixed by heat, and stained
by toluidin blue or carbol-thionin, or simply dried
or fixed wet with osmic acid, and coloured by
Leishman's stain, when the spirochetes are usually
so numerous that they can be found; but this
method of examining stained films is much inferior
to the quicker, surer and simpler method of dark-
ground illumination. The rough diagnosis having
been made, it is advisable to examine the teeth for
caries and to try to find the dental spirochetes ;
then to examine the buccal secretion (collected by
u sterile capillary tube) and the secretion of the
tonsils and pharynx for spirochetes. The patient
should then wash his mouth and gargle his throat
with clean water, and should then cough up his
sputum again into a sterile (or flamed) Petri dish.
The sputum so collected should be examined by the
dark-ground illumination, when it will be noted that
the spirochetes, though numerous, tend to collect
in special areas of the film, and may therefore
require a little search. They are, however, more
numerous than dental or mouth spirochetes, and
this, together with their characteristic appearance,
confirms the diagnosis.
The differential diagnosis has to be made from
acute bronchitis due to other causes and from
incipient phthisis, and less frequently from malaria
and paragonimiasis.
From acute bronchitis due to the influenza
bacillus, pneumococeus, Diplococcus catarrhalis and
other diplococci, as well as to the fungi mentioned
above, it may be differentiated by the absence of
these organisms and by the presence of the numer-
ous examples of S. bronchialis. If one of the above
is present along with S. bronchialis, it is obviously
a double infection.
From incipient phthisis it is differentiated by the
absence of the tubercle bacilli in the sputum, the
absence of tubercular lesions after inoculation of
guinea-pigs, and, if thought necessary, by the
ophthalmo- and cuti-reactions. It must, however,
be remembered that the tubercle bacilli may com-
plicate a case of spirochetosis.
From malaria it is differentiated by the absence
of the parasites in the blood, but again it must be
remembered that malaria can be present as well as
broncho-spirochetosis.
From paragonimiasis by the absence of the
characteristic ova in the sputum, though again no
doubt cases will some day be reported with this
disease as a complication.
PROGNOSIS.
This is good, as the disease appears to be readily
amenable to treatment in its acute phases.
334
‘TREATMENT.
The first essential is rest in bed, good food, and
ventilation. The second is arsenic in some form,
preferably associated with glycerophosphates. These
may be given by the mouth with excellent results,
or intramuscularly as an injection of :—
Sodium cinnamate ... 0°05 grm.
Sodium cacodylate ... 0:10 ,,
Sodium glycerophosphate ... 0:10 ,,
So far we have only tried this injection on one
native patient, but the result was most satisfactory.
PROPHYLAXIS.
We are inclined to think that the disease is spread
by the agency of human carriers from person to
person. The history of a similar attack may arouse
suspicion and cause an examination of the sputum
to be made. Personally we should treat such a
carrier with arsenic.
The secondary causes appear to us to be of great
importance. Prominent among these comes the
chill, but another feature must also be recognized,
and this is the general deterioration of the health
of the European under the effects of tropical heat,
even when living under sanitary conditions in a
tropical town as sanitary as Khartoum.
ACKNOWLEDGMENTS.
It gives us much pleasure to acknowledge the
kindness of Major Forrest, R.A.M.C.; Major
Carroll, R.A.M.C.; Dr. Christopherson, Dr. Atkey,
Captain Buist, R.A.M.C., and Captain Stirling,
R.A.M.C., all of whom have sent us cases for
diagnosis.
Khartoum,
August 20, 1913.
LITERATURE.
(Arranged in chronological sequence.)
[1! ErcuHonsT, Quoted in reference 5.
[2] CasrELLANI (1905). Ceylon Medical Reports.
[3] Rona (1905). Archiv. für Derm. u. Syph., Bd. 74.
[4] BEnTARELLI E VorPrNo (1905). Reale Accademia di
Medicina di Torino, June 16. Also in Centralblatt für Bakt.
(1906), xxxvii, ref. 230.
[5] CasrELLaNI (1906). Lancet, I, 1,884, May 19.
Nu Brancu (1906). British Medical Journal, 1597, Decem-
r l.
[7] CasTELLANt (1907).
(8) MénrxNs (1907).
Bd. 57.
[9] KésrEn (1907).
Dresden.
[10] Waters (1909). Transactions, Society of Tropical
Medicine and Hygiene, 1908-1909, 145, February 19, 1909.
[11] PHALEN and Kivpourne (1909). Report U.S. Army
Board Study Tropical Disease, June 30. á
[12] CasrELLANI (1909). British Medical Journal.
[13] PETERS. Quoted in reference 16.
[14] CASTELLANI and CHALMERS (1910).
Medicine.” 1st edition, 308 and 921.
[15] RorHwELL (1910). Journal American Medical Associa-
tion, vol. liv, p. 1,867.
[16] CHAMBERLAIN (1911). Philippine Journal of Science,
vol. vi, B. Medical Sciences, p. 489.
[17] CasrELLANI and CHALMERS (1913).
Tropical Medicine,” 2nd edition, 402 and 1,283.
Ceylon Medical Reports.
Zeitschrift für Hygiene u. Infektions.,
Versuche Deutsche Naturf. u. Aerzte,
‘Manual of Tropical
* Manual of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1913.
THE APPARENT IDENTITY OF AGCHYLO-
STOMA CEYLANICUM (LOOSS, 1911), AND
AGCHYLOSTOMA BRAZILIENSE (FARIA,
1910).
By Roserr T. LEiPrn, D.Sc., M.B., F.Z.S.
Wandsworth Research Scholar and Helminthologist at the
London School of Tropical Medicine.
In the June issue of the Indian Medical Gazette
Major Clayton Lane records the occurrence of
Agchylostoma ceylanicum as an occasional parasite
of man, and an almost constant parasite of cats
and dogs in Bengal. Through the courtesy of Major
Lane, a portion of the material upon which this
paper was based has been added to the collection
of the Helminthological Department at the London
School of Tropical Medicine. Owing to its close
similarity to A. duodenale I examined the material
with very great interest, and noted specially the
difference in the subdivision of the dorsal ray.
In A. duodenale it will be remembered the elon-
gated dorsal ray is bifurcated near its tip, and
the subdivisions resolve into three small finger-like
branches. In A. ceylanicum, as Lane notes, the
primary subdivisions resolve into two terminal
branches.
Following a long-standing habit, I made a careful
camera lucida drawing of the worm, and it then
occurred to me that the peculiar outline of the dorsal
ray terminals was familiar. On examining the
literature at hand I came across an illustration in
a paper by Gomes de Faria, which obviously formed
the basis of my recollection. This paper, entitled
‘t Contribution towards the Classification of Brazilian
Entozoa III," was published in the Memorias do
Instituto Oswaldo Cruz, vol. ii, 1910, p. 286, and
was annotated as ‘‘a new Ankylostome from Brazil"
by me in the JOURNAL or TROPICAL MEDICINE AND
Hygiene for March 15, 1911. A comparison of
Lane's figures, descriptions, and material with the
paper and illustrations of de Faria lead me to con-
clude that these two species are identical.
As the Memorias do Instituto O. Cruz may not
be available to workers in the Tropies, I reproduce
here the essential portions of Faria’s paper. The
parasites were found commonly in eats and in one
dog. In the latter case of about one hundred
worms a third were A. braziliense, the remainder
A. caninum. ‘* Maximum length is on an average
8:5 mm. in the female, and 7:5 in the male. The
mouth is obliquely projected towards the dorsal
aspect owing to the lateral torsion. The ventral
margin carries on each side of the middle line a
large, strong, triangular tooth, the sharp points of
which are bent down and backwards. In the
superior and internal angle of these teeth a small
accessory tooth is to be seen. ." The
cephalic glands are intimately connected with the
lateral bands, and occupy nearly half of the body
length. The arborescent disposition of the cement
gland in the male genital organs has not been
observed in the other two species (i.e., A. duodenale
Nov. 1, 1913.]
and A. caninum). The spicular apparatus consists
of two very long dark yellow spicula, with a flat-
tened anterior extremity. The spicula are trans-
versely striated in their whole extension, and end
in extremely fine points. The dark yellow, irregu-
larly shaped gubernaculum, or '' accessory piece,”
is visible at the aperture of the cloaca.
In all specimens a prebursal papilla is to be seen
in front of the bursa. In the bursa the median lobe
is distinctly separated from the lateral lobes. ‘‘ The
dorsal ray is much longer, and the lateral rays are
relatively short in comparison to the principal trunk.
‘“ The posterior extremity of the female is com-
pressed transversely behind the anus, and ends in
a very sharp point projecting through the skin. The
anal aperture can be seen in a depression on the
lateral part of the posterior extremity. Next to two
very small caudal papille, a small depression of the
skin can be seen. In a small depression of the
anterior extremity of the posterior third lies the
vulva. The vagina is very short. The ellipsoid ova
were seen with two to four segmentation cells, each
with a very delicate membrane. The eggs measure
n
Dorsa ray of A. ceylanicum vel. braziliense.
on an average 65 microns in length and 32 microns
in breadth."
The common occurrence of the same parasite in
cats and dogs in Bengal and Brazil suggests that the
form will be met with in other parts of the world
also. I have re-examined my collections of anky-
lostomes from cats and dogs mainly from Africa,
but this species is not represented. A study of the
literature suggests, however, that the continuity of
distribution is eastward from India. In Jeffreys
and Maxwell’s ‘‘ Diseases of China " A. duodenale
is recorded as a parasite of dogs, and it is unlikely
that these observers have been misled by A.
caninum. Further, Powell, writing in the British
Medical Journal of June 9, 1900, states that “ A.
duodenale, in all respects similar to that of man, is
occasionally found in dogs in Assam, but very
rarely, as I have had only two cases. A. trigono-
cephalum (i.e., A. caninum) and A. stenocephalum
are very prevalent. I recently showed at the
Lurma Valley Medical Society all three varieties
taken from one bull terrier." He gives the follow-
ing description of the “ A. duodenale ” specimens:
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
335
' A. duodenale varies greatly in size, the female
being from five-sixteenths to three-quarters of an
inch. It tapers towards the head. The teeth are
characteristic—a dorsal pair, one on each side of a
median groove. Four hook teeth, two smaller
median ventral, sometimes hidden by a chitinous
flap, usually with an indentation on the median
edge, two large hooks placed laterally.”
It is to be hoped that workers in China will re-
examine the specimens of A. duodenale reported
from dogs in the light of the new facts now avail-
able. A more careful scrutiny of all ankylostome
material collected from human cases is also desirable
in order to determine the extent of the infection of
man with the newly observed form.
A word may be added with regard to the spelling
of the generic name Agchylostoma. While this is
the actual spelling adopted by Dubini in his original
article, the international rules of nomenclature
admit the correction of obvious errors in typography
and transliteration. The Committee of the Inter-
national Congress of Zoologists, now drawing up a
list of generic names which shall be placed outside
the possible operation of the Law of Priority, has
adopted the spelling Ancylostoma. It is important
to note that the International rules apply solely to
Nomenclature, and that corresponding terms, such
as Ankylostome and Ankylostomiasis, do not come
under their operation, as no ‘‘ Rules of Termin-
ology ’’ have yet been formulated. The spellings
Agchylostome, agchylostomiasis, Ancylostome, and
Ancylostomiasis have no special authority, and may
be discarded therefore as pedantic.
————9—————
Parasites in the Peripheral Blood of Cases of
Mediterranean Kala-azar.—To the August and
September number of Malaria e malattie dei paesi
caldi S. Cannata contributed an interesting paper
on the discovery of Leishmania in the peripheral
blood of seven out of eight cases of infantile kala-
azar. He points out that in India, Donovan,
Christophers and Patton, and in the Sudan, Thom-
son and Marshall, have shown that Leishmania may
be fairly numerous in the peripheral blood of
patients suffering from this disease. Hitherto in
the infantile cases met with in the Mediterranean
districts search for the parasite in blood films has
been generally negative. In eight cases the author
made a most careful examination, searching through
twenty to thirty films in each case. In seven cases
he was rewarded by finding Leishmania in the films.
In one case in one film two parasites were found,
one in a polynuclear and the other in a large mono-
nuclear cell. In a second film from the same case
two parasites were found in a large mononuclear
cell. This was the best result obtained, for in the
other positive cases still fewer parasites were seen.
It would thus appear that though parasites occur
in the peripheral blood fairly regularly they are
present in such small numbers as to make search
for them a most difficult and arduous task.
336
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THE JOURNAL OF
Tropical Medicine andhpgtene
NOVEMBER 1, 1913.
WHEN TO COME HOME FROM THE TROPICS.
NOTES ON ANSWERS TO SCHEDULE SENT OUT.
(See page 337.)
THE remarks of the several contributors to the
queries in this subject are very helpful. The
subject is a difficult one and few care to place their
opinions in writing upon so debatable a theme; all
the more are we indebted to the contributors for
the expression of their opinions.
The best time to reach home is in four of the
replies declared to be the early summer, and Major
Stodart alone recommends the winter. The writer,
when he issued the circular, pointed out the advan-
tages of wintering in Europe for persons who had
been suffering from malaria in the Tropics, especially
when a visit to Switzerland in the month of January
is possible. The writer, and no doubt many others,
agree with Major Stodart as to the advantages of
winter for tropical residents reaching home for
certain ailments, more particularly malaria. Prac-
tical experience has shown the writer the great
benefits derived from residence at high altitudes in
Switzerland during January in malaria, especially
when there is enlarged spleen; no other method of
treatment can reduce a spleen so rapidly as a
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1918.
sojourn at this time of the year in Switzerland or
other countries where similar conditions obtain.
Wintering in England has many drawbacks during
January, February and March, but during October,
November and December the conditions are, as a
rule, quite suitable for tropical residents; when
January comes round Switzerland is highly bene-
ficial and suitable up to towards the end of
February, by which time the usual six months’
leave will be up and the traveller has to return to
work abroad.
Sojourning in the South of Europe.—The idea
that it is necessary to '' gradually cool down '' before
reaching British shores by a sojourn at some place
along the Mediterranean littoral finds two sup-
porters, whilst three deny its benefits. The plan of
getting accustomed to cooler regions before risking
& cold climate is a custom that has the stamp of
time upon it, for it was a proceeding at one time
looked upon as essential. Now the opposite opinion
is commonly held, and the belief that the sooner e
malaria-stricken person gets into colder regions the
better the chance of a more speedy riddance of
infection.
The question of winter sports in Switzerland
is answered by four in the affirmative and by one,
Dr. Villejean, in the negative. As usual, there are
‘‘ pros "' and '' cons ’’ in this as in every other ques-
tion of the kind Where individual idiosynerasies
have to be considered seldom are two cases alike, but
it may be taken as a general rule that in the case of
the younger men or women suffering from malaria
with enlarged spleen the change to Switzerland in
winter is beneficial, and unless anemia is very pro-
nounced they ought to be encouraged to take part
in the ordinary winter sports. Major Graham, very
wisely it would seem, thinks that ''it is beneficial
after a summer, autumn and early winter at home
(in Britain)." He is of opinion that a ‘‘ sudden
transfer to a cold temperature induces relapses.”
Residence by the Sea, Inland, or at High Level
whilst in Europe.—Dr. Villejean considers the sea-
side preferable; Major Stodart recommends the
east coast or dry upland districts; Major Graham
agrees with Major Stodart, and mentions Dornoch,
in Sutherlandshire, Scotland, as particularly suit-
able; Dr. Landsborough is in favour of residence
inland or at a high level; Dr. Chartres prefers an
inland site in place of the seaside. The writer has
for many years been of the opinion that old tropical
residents coming to Britain should avoid seaside
resorts and get to high dry ground in Yorkshire or
Derbyshire, in Aberdeenshire (Braemar and neigh-
bourhood), in the upland districts of Banffshire, or
anywhere in Moray or Nairn, even at the seaside,
for in these two counties the Moray Firth is not
sufficiently wide to influence the lightness of the
air which prevails around the adjacent hill districts
of these counties and the opposite shores of Ross-
shire and Sutherland. All will agree that the west
coast of England, Wales, Scotland or Ireland are
unsuitable for persons suffering from malaria or
from anemia from any cause.
Quinine taking when there are no Malaria Para-
Nov. 1, 1913.]
sites to be found in the Blood.—Major Graham,
Major Stodart and Dr. Villejean are of opinion that
no quinine need be taken when the tropical resident,
who has had malaria and may have been invalided
in consequence, reaches Europe; on the other hand,
Dr. Chartres recommends 5 gr. twice weekly, and
Dr. Landsborough one dose of quinine weekly for
two months. Had the question been made to
include enlarged spleen it is to be presumed all
would recommend quinine to be taken.
The question of the presence or absence of
malaria parasites in the blood cannot be considered
a reliable indication whether the patient is suffering
from malaria or not, unless the examination is done
repeatedly, and perhaps only at times when fever
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
337
tion, and if told no malaria parasites were found he
is satisfied that all is well with him; a subsequent
attack of fever at an early date proves disconcerting,
and the inevitable remonstrance follows to the effect
*' that he was misled by a faulty report." It is un-
fortunate, but nevertheless it is so, that the absence
of malaria parasites from a blood specimen is no
proof that the patient is free from the disease, and
it would seem advisable to administer quinine after
arrival in Britain for some three months. The
periods of administration and the dosage are matters
of choice, but at least 40 gr. per week would seem
the minimum likely to do any good.
Intestinal Ailments.—A subacute or chronic state
of bowel complaint due to residence in the Tropies
ANSWERS TO CIRCULAR INQUIRING WHERE IT IS BEST FOR PERSONS TO GO WHEN LEAVING THE TROPICS FOR THEIR
HEALTH OR FOR CHANGE,
When malaria is present. I
(1) Do you cousider the summer or winter the Summer
better time to reach ** home"' ?
(2) Do you advise & sojourn in South of Europe No
before coming to Britain ?
(3) Do you consider residence, with winter sports, | Beneficial
in Switzerland, beneficial or otherwise ?
(4) Do you advise residence by the sea, inland, or Inland
at a high level whilst in Britain ?
(b) Do you advise continuance of quinine taking | 5 gr. twice
whilst in England if no malaria parasites weekly
are found in the blood ?
When suffering from intestinal ailments.
(1) When intestinal ailments (not acute) are No
present do you advise sojourn in the South
of Europe before coming to Britain ?
(2) Do you consider the seaside, inland, or high | High inland
ground residence the best ? ground
(3) What period of the year should persons with | Late spring
intestinal derangements come to Britain
when the disease is not acute or symptoms
pronounced ?
(4) What do you consider the period of leave| 6 months at
necessary for convalescence when a chronic least
affection of the bowel is gradually im-
proving ?
ll III IV V
Summer Summer Winter Summer
No Yes No Yes, Mediter-
ranean shore
Yes, after a | Likely Beneficial | Not beneficial
spell of resi- |. beneficial
dence at home
Inland and Inland and | East Coast or Seaside
fairly high level) high level dry upland
No 1 weekly dose No No
quinine for
| 2 months
— Yes Yes
— First seaside ?
— Early summer Spring
lyearor 4 to5
months after
symptoms
gone
I—E. A. Chartres, F.R.C.S.I., West African Medical Staff.
II—Major James Drummond Graham, Indian Medical Service.
III—David Landsborough, M.B., C.M., Shoka, Formosa.
IV— Major Stodart, Indian Medical Service.
V— Dr. A. A. Villejean, Hôtel Dieu, Paris.
has actually developed. Of many scores of blood
specimens from patients invalided for malaria, and
many of whom have occasional attacks of malaria
after reaching Britain, examined for me by Dr.
G. C. Low, in only 4 per cent. have malarial para-
sites been found. Enlarged spleens have been
present in 15 per cent. of those examined, yet in
these parasites are absent from the blood as a rule.
The absence may be explained by the patient having
taken quinine recently, but in many instances this
explanation does not hold good. Dr. Low, in his
reports, frequently states ‘‘ the specimen gives all
the indications that it is a malarial blood, but no
parasites are to be found.’’ The patient is always
anxious to know the result of the blood examina-
is the usual form in which intestinal ailments are
met with in Britain. The period at which it is
considered advisable by the contributors for
patients to come home is the late spring or
early summer—April or May; and there seems
little doubt that most observers will agree with this
decision. The question whether the patient should
go inland or to the seaside is replied to by Dr.
Villejean with a ‘‘ query ’’; Dr. Chartres advocates
high inland ground; Dr. Landsborough considers
the seaside beneficial at first. The writer finds that
intestinal ailments, in common with hepatic ail-
ments, are not only not benefited, but are posi-
tively made worse by residence at the sea-level,
and he agrees with the opinion that the patient
338 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1913.
should reside on dry fairly high ground. As milk
by many practitioners is considered an essential
element in treatment, these patients should be
treated in the country, where it is possible to
obtain it before it is '' tampered with ’’ in any way.
The milk in towns is not calculated to benefit
sprue patients or others to whom milk is being
administered.
The length of leave is '' queried’’ by Dr. Ville-
jean; Dr. Chartres considers six months' leave
essential; and Dr. Landsborough advances a plea
for twelve months, or four to five months after
symptoms and signs of the complaint have com-
pletely disappeared. There can be no definite time
fixed for return in intestinal ailments, for the time
it takes to '' cure ’’ is quite impossible to state, and
it is only when several months after signs and
symptoms have disappeared and the patient has
regained his normal weight that he should be
allowed to return to the Tropies.
Many subscribers to the Journal must have the
schedule issued in their hands, and after the replies
received and the remarks made perhaps they will
be induced to contribute their experiences upon this
interesting subject. :
J. CANTLIE.
————— Ó9——————
Abstracts,
ACCOUNT OF AN INVESTIGATION OF THE
PREVALENCE OF ENDEMIC KALA-AZAR
IN THE PLAINS OF ASSAM.*
By Captain T. C. McCompim Youna, I.M.S.
Deputy Sanitary Commissioner, Assam.
TuE author believes that a short account of the
past history of kala-azar in Assam may be of
interest. He therefore recalls the main facts of the
epidemie of the 'eighties and 'nineties. In the Pro-
vince of Assam the disease was first observed in the
Garo Hills in 1869, and in 1882 a severe form of
'" malarial cachexia " was described as affecting
certain areas at the foot of the Garo Hills. This
was believed to have first become operative as a
source of deficiency of revenue in 1875. This fever
was probably identieal with the epidemic of Burd-
wan fever, which devastated the Burdwan division
in the decade 1860-1870, and the district of Rangpur
in 1871-1876; and it was probably a late extension of
this epidemic, which had slowly crept round the
barrier of the Garo Hills, having been imported
from Rangpur. The disease having thus obtained
a footing in Goalpara, then spread up the Brahma-
putra Valley via the grand'trunk road, on the south
bank of the river, through the sub-divisions of
Dhubri and Goalpara to Kamrup, causing the
heaviest mortality in Goalpara during the period
1882-87. Kamrup on the southern bank being in-
fected, the disease then crossed to the north bank
~ * Proceedings of the Third Meeting of the General Malaria
Committee. held at Madras. November 18. 19, and 20, 1912.
Simla: Government Central Branch Press, 1913.
into the Mangaldai sub-division of Darrang, and
thence to Nowgong in 1890. Heavy mortality
occurred, especially in the latter district.
As a measure of the disastrous effects of the
disease, it may be noted that in Nowgong the fever
death-rate rose from about 4,000 in 1891 by regular
stages to 14,000 in 1897, and again declined to about
4,000 in 1902. It is calculated that 54,000 persons,
or one-third of the indigenous population, died in
this district during the epidemic decade, and that
one-fifth of the land went out of cultivation. By
1896 the disease had reached the narrow tract of
sparsely populated country which gives access to
the more open, alluvial plains of the Golaghat sub-
division and the Upper Brahmaputra Valley. Here
stringent measures to prevent infected persons from
traversing this tract of country were put in force;
the epidemic was stayed, and the Upper Assam
Valley was saved from its ravages. Subsequently,
the disease in its epidemie form declined almost to
extinction in the parts first affected, and in 1901 it
was considered that Goalpara and Kamrup were
free from the epidemic, except for a few chronic
cases in parts of the district.
In reviewing the history of the epidemic in
Assam, the author notes that the disease took from
ten to twenty years to go through its epidemic cycle
in a district, and that it spread as far as, and no
farther than, the Golaghat sub-division of Sibsagar.
In the Surma Valley different conditions prevailed.
Although a severe outbreak of fever, with a rise in
the fever death-rate, occurred in 1897, following the
earthquake, the fever death-rate fell to nearly
normal proportions the following year, and the rise
was probably malarial, therein differing from the ten
to twenty year wave-lengths of the epidemic curves
in the districts affected by kala-azar. Further-
more, it had previously been shown that the disease
was endemic in this district. The contrast between
the heavy mortality caused by the disease in the
Brahmaputra Valley and the lightness of its inci-
dence in the Surma Valley is one which is very
striking, and the explanation put forward by Rogers
is of great importance and interest. In this con-
nection Rogers says: ‘‘ The epidemic travelled
through the virgin soil of the northern valley pre-
viously unaffected by the sporadic form of the
disease, and there found a population fully suscep-
tible to its deadly influence, and hence was able to
work such terrible havoc. If this view of the epi-
demic is correct, it is clear that unceasing vigilance
must continue to be exercised to protect the un-
affected upper part of the Assam Valley from the
insidious extension of the disease, while a fresh out-
break may, in the future, be lighted up by some
such extraordinary succession of unhealthy years
as caused the spreading epidemic at the foot of the
Garo Hills in 1875."
The subsequent history of kala-azar in the
province has not been marked so far by any epi-
demic recrudescence, or by epidemic invasion of
hitherto unaffected country. Officers of the Medical
and Sanitation Departments, however, have, within
the last three years, been reporting the existence of
Nov. 1, 1913.]
THE JOURNAL OF TROPICAI. MEDICINE AND HYGIENE,
339
certain areas within which it appears as if some still
glowing embers of the disease, remnants of the
epidemic conflagration, are displaying activity. In
the maintenance of that unceasing vigilance advised
by Rogers, early and careful scrutiny of the condi-
tions attending any such apparent activity is
imperative; and from the first the importance of
doing so has been recognized by the Sanitary
Department.
The author then gives a short account of the
situation in certain of these areas in which the
apparent activity of the disease has attracted atten-
tion, and in which some preliminary work has been
done prior to the commencement of the larger
survey.
Golaghat.—It was in this sub-division of the Sib-
sagar district that the epidemic conflagration burnt
itself out, and it was with regard to this area that
the need for future vigilance has been emphasized.
Beyond this region, amid the higher reaches of the
river, lie the fertile and prosperous districts of
Sibsagar and Lakhimpur. These districts are the
seat of a large and flourishing tea industry. The
protection of this industry, involving as it does very
large financial interests, and one upon whose con-
tinual prosperity the livelihood of a large population
depends, an industry, furthermore, to whose vitality
and energy much of the prosperity and advancement
of the province in the past is to be ascribed, and
in whose hands much of the future industrial pros-
perity of the province lies, is probably one of the
most important problems to be considered by the
sanitary advisers of the Assam administration.
Any suspicious disease activity in a fringe of country
bordering on these hitherto unaffected and populous
districts would give rise to some anxiety. During
the rainy season of 1910, the attention of the Civil
Surgeon, Captain Morison, I.M.S., was directed to
persistent reports of deaths from kala-azar occurring
in the Khumtai Mauza. These had previously been
filed as fallacious and included in the fever mortality
returns. On visiting the affected area, however,
Captain Morison was convinced of the truth of the
reports, and notified the existence of the disease to
the Sanitary Department. Measures for dealing
with the outbreak were drawn up by the Acting
Sanitary Commissioner, and the author was deputed
to investigate the conditions.
His observations confirmed those of the Civil
Surgeon, and the parasite was found in a post-
mortem specimen of the spleen of one of the cases.
Major Christophers, I.M.S., was then deputed by
the Government of India to examine the outbreak.
In the report which he submitted he stated that the
disease had probably been introduced into the dis-
trict ten (or more) years ago, and that it had pro-
gressed irregularly from the original foci, showing
the typical tendency of the disease to cling to
groups of houses and families. He considered that
there was no great tendency for it to assume epi-
demie proportions at present, and he was doubtful
as to whether it was really more prevalent now than
some years ago.
He pointed out, however, that the infection is
maintained by the presence of these secondary foci,
and that so long as these exist it is impossible to
say when the disease may not assume an active
epidemic form.
The results of a survey, which was carefully and
thoroughly carried out under the personal super-
vision of the Sanitary Commissioner, the Civil
Surgeon, and the author of this paper, showed that
the infection was not very widespread, and their
view was that there was no cause for anxiety as to
the present condition of affairs, although the situa-
tion required vigilance.
The measures adopted to deal with the cases are
as follows: When an undoubted case is discovered
in a family, a new house is built for them on
another site at Government expense, and compen-
sation is given for the destruction of presumably
infected belongings before removal under the super-
vision of the Assistant Surgeon in charge. The
infected person is provided with separate quarters
on the new site, but within the compound of the
house, and is prohibited from sleeping or eating
with healthy persons. This degree of segregation
is merely nominal, and, as may be expected, has not
proved effective.
Probably, the author believes, the solution of the
difficulty will be to provide a kala-azar hospital or
dispensary with indoor wards for treatment of
diagnosed cases. The nucleus of such already
exists at Khumtai.
Kamrup.—Another investigation has been in
progress in the district of Kamrup. This district
was involved in the epidemic conflagration and is
known to contain endemic foci. In March, 1911,
the Civil Surgeon, Kamrup, drew attention to the
prevalence of the disease in a village in the thana
of Rangiya in a report suggesting certain measures
to deal with the disease. A Sub-Assistant Surgeon
was placed on duty for a year to carry out the
measures recommended by the Civil Surgeon under
his supervision. He carried out investigations as
to the extent of the infection, and destruction of
infected property was attempted, but without the
thoroughness attending the Golaghat measures.
Fourteen villages were found to be infected out of
sixty-seven examined.
Sylhet.—It was observed that a considerable
number of deaths from kala-azar had been reported
from the Chatak and Sadar thanas of Sylhet in
1910, and the attention of the Civil Surgeon was
drawn to it, and a Sub-Assistant Surgeon deputed
to assist him in the investigation. On looking up
the past history of Sylhet with regard to kala-azar,
it was found that the presence of the endemic form
of the disease had been established by several
observers.
Goalpara.—Attention was drawn to yet another
affected area by the Deputy Commissioner of Goal-
para, who reported that in the Dudnai thana during
the twelve months from March, 1911, to February,
1912, 118 deaths from kala-azar had been reported,
and he remarked that ‘‘ considering the extra-
ordinary virulence of previous epidemics of kala-
azar in neighbouring parts of the district in previous
years these figures are serious.”
Mangaldai.—The Sub-Divisional Officer of the
340
Mangaldai sub-division of the Darrang district has
recently reported the prevalence of kala-azar in the
Ambagaon Mauza, in which the Mauzadar reports
the presence of ninety cases.
From the foregoing account it will be seen that
the presence of endemic foci of kala-azar is tending
to attract attention. There is no reason to believe
that this increased attention is due to any tendency
of the disease to assume again endemic proportions.
But it must be remembered the author states that
the rate of kindling of the epidemic fire is very
slow and the time it takes to burst into flame is
measured by years. Where in other parts of India
the advent of plague or outbreaks of epidemic
malaria are perils to be feared, in Assam kala-azar
is perhaps the greatest potential menace to public
health, for any recrudescence of the epidemic of the
‘eighties and ‘nineties would be a disaster of the
first magnitude in that country.
The situation at present appears to be this—that
in an unknown number of areas in the Lower
Brahmaputra Valley and throughout the Surma
Valley, there are still glowing points of slow-com-
bustion endemic foci. Further more, in the Upper
Assam Valley, which is the main centre of the
important tea industry, there exists a population
so far untouched by the endemic form of the disease,
and hence presumably a rapidly combustible
material for an epidemic fire, and that adjacent to
this inflammable material there exists in Golaghat
an area of combustion of not inconsiderable activity.
The situation, while it cannot be considered to be
fraught with any immediate danger, is one, how-
ever, that requires vigilance.
QUARTERLY REPORT OF BUREAU OF
HEALTH FOR THE PHILIPPINE ISLANDS.
By Vicror G. Heiser, M.D,
First QUARTER, 1913.
HEIser, in the above report, states that it is
satisfaetory to be able to say that during the month
of January there were only 502 deaths, as com-
pared with 698 for the same month of the previous
year; during February there were 445 deaths, as
compared with 611 for the year before; and during
March there were 451 deaths, as compared with 732
for March of last year. When it is remembered
that the population of the city is constantly in-
creasing, it will be apparent that the improvement
is even greater than the numbers indicate. The
above figures also mean that, for the first three
months of the year, all mortality records for Manila
since American occupation have been broken.
The decrease in the number of deaths is largely
attributed to the improved city water supply and
the more general use of the new sewer system, The
many other sanitary reforms which have been
brought about, as, for instance, the proper collection
and disposal of garbage, the reduction in the number
of mosquitoes, the rejection of unwholesome food,
regulation of the milk supply, sanitary houses, the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 1, 1913.
prompt isolation of dangerous communicable dis-
eases, and many other factors, are also no doubt
responsible to a large extent for the improvement
in the public health.
During the quarter there were collected and
transferred to Culion 264 lepers. The majority of
these eame from the island of Cebu, which province
still continues to furnish over half the lepers
encountered, in spite of the fact that it contains
only approximately one-tenth of the population.
A systematie effort to collect all of the lepers
from the Moro Province was also made during the
quarter. The experience there was the same as
that heretofore encountered in other parts of the
Philippines in territory in which the first leper
collection had not yet taken place; namely, large
numbers of persons were brought in as lepers who
on close examination proved to be afflicted with
other diseases. It is satisfactory to report that a
considerable percentage of these cases ean be cured,
and when they return to their homes they will once
more take their places in the community without
being shunned by their fellow-men.
During the quarter human plague continued in
a sporadie manner, there being two cases in
January, four eases in February, and two cases in
March, or a total of eight cases in all.
The infeetion has been confined entirely to that
portion of Manila on the north side of the Pasig
River. In spite of extensive rat catching done on
the south side, no plague rats have been found.
Half of the cases occurred in persons under 16 years
of age, all of whom were boys. 11,579 rats were
caught during the quarter. Of these thirteen only
were plague infected. It is also noteworthy that
with two exceptions all of the plague rats were
found during March in the distriet of Tondo, which
is bounded by the following streets: Peñalosa on
the north, Anloague on the east, Moriones on the
south, and by Manila Bay on the west.
An investigation made of the premises upon which
plague-infected rats were found showed that many
of them were establishments in which straw con-
tainers used for packing bottles against breakage
during shipment are stored. For instance, at No. 319
Estero Cegado it was found that the bottling of
olives, piekles, wines, &c., which came from Spain
in bulk was being done with bottles from Japan,
and that these were shipped in straw containers
that also eame from Japan, and originated in places
where rat plague prevailed. At a soda-water
establishment in Tondo in which plague-infected
rats were found, investigation showed that bottles
packed in straw containers that came from Japan
were used. An investigation made of goods im-
ported into the Philippines shows that rats are not
infrequently brought in in straw matting and in
curios packed in straw which come from Japan and
India.
From the foregoing it would appear not impro-
bable that perhaps Manila has been repeatedly
infected since the original infection was discovered,
during June, 1912.
Nov. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
341
—————— M MM MM HÉ' ÉHLÉM'ÉMÉHL—
Plague at Malolos.
On March 22 a case of plague was discovered at
Malolos. Investigation showed that the victim had
left Manila on or about March 18 and came from
No. 12, Calle Aguila, which is in the vicinity of
Nos. 204 and 232, Calle Concha, where plague-
infected rats had been found. On March 28 another
case, in the person of a girl, who had been ill over
a week, was discovered at Malolos, which came from
the same house in Manila as the first case. The
two were found in widely-separated sections of
Malolos and apparently had no connection with
one another after their arrival in that town. A rat
campaign was immediately begun and has con-
tinued for over a period of two weeks, but so far
no plague-infected rats have been found. Both of
the cases occurred well within the incubation period
of the disease, so that there is every reason to
believe that the infection was contracted in Manila.
In order to combat the rat plague of Tondo the
plan of campaign has somewhat changed. Instead
of the greatest stress being laid upon the actual
catching of rats, the principal thing kept in mind
at present is to destroy rat nests, and then to catch
as many rats as possible and rat-proof the premises.
One gang of labourers composed of about 100 men
is divided into three small sections, each under the
charge of an experienced sanitary inspector, and
these go from house to house and make a thorough
systematic search for rat-breeding places. After
the search of the house proper is completed, the
yards, woodpiles, old junk, rubbish, and everything
likely to harbour rats are moved about so that the
rat nests may be discovered and destroyed. Parti-
cular attention is given to spraying with an insecti-
cide so that the fleas may not escape. In this way
an enormous number of rats are also caught and
the chances of catching those that are likely to be
infected are very much increased. It is thought
that by constantly changing the places of abode
among rats there is less likelihood of the disease
spreading among them, and also that the chances
of plague-infected fleas that have come from rats
dying in rat nests gaining access to human beings
are very much reduced.
In view of the great importance that has been
attached by the Javanese sanitary authorities to
destroying rats in hollow bamboos, special stress
has been laid upon finding similar breeding places
in the Philippines; but in spite of the fact that this
was constantly kept in mind, it was only recently
that rats were actually found in bamboos. In a
house located at 140, Calle Perla a man was found
dead with plague. In a piece of bamboo in which
the partition of the first joint had been gnawed
through a mummified rat that had apparently died
of plague was found. The bamboo was placed
horizontally near the head of the cot on which the
man slept, and it would appear probable that the
plague-infected fleas on the death of their host left
the bamboo and attacked the man.
— f
Annotations,
Experimental Oriental Sore in Mice.—In the
Archiv für Schiffs- und Tropen-Hygiene for June,
1918 (pp. 397-403), Richard Gonder describes the
suecessful inoculation of mice by means of cultures
of Leishmania tropica of Oriental sore. It was
found that infection was most likely to occur when
the parasites were in the flagellate condition, and
the most interesting point of the experiments is
that infection was produced by inoculating the
animals either intra-peritoneally or intra-venously.
A month after such an inoculation Leishmania were
found in the liver by liver puncture. This organ,
together with the spleen, which was also infected,
became much enlarged. In spite of this the
animals remained apparently healthy for about four
months, after which some of them became ill and
died, when large numbers of parasites were found
in the liver and spleen, but not in the bone-marrow.
In other mice which did not die at this stage there
commenced to develop edematous swelling of the
feet, which on puncture exuded a serous fluid con-
taining many Leishmania in pure culture. Later
these. swellings broke down and developed into
necrotic ulcers, while similar lesions appeared on
the tails and about the mouth of some of the
animals. In all these peripheral lesions Leishmania
occurred. In only one case has the author been
able to produce a sore by local inoculation in the
skin of virus obtained from another mouse. With
cultures of L. infantum of Mediterranean kala-
azar injection of the liver and spleen of mice
was produced, but the disease differed in that peri-
pheral lesions did not develop as in infections with
L. tropica. The author suggests that in man
Oriental sore is possibly at first a general infection
as in mice, and that eventually the lesions typical
of the disease develop peripherally on the skin.
The long incubation period of this disease appears
to him to be in favour of a preliminary stage of
general infection which has not hitherto been
recognized,
Dogs successfully inoculated with Leishmania
donovani in India.—In the first number of the
Indian Journal of Medical Research (July, 1913),
both Lieut.-Colonel Donovan and Captain Patton
record the successful inoculation of dogs with
Leishmania donovani from the spleens of cases of
kala-azar. Donovan inoculated a dog intra-hepati-
cally with 3:5 c.c. of splenic blood taken by punc-
ture from a case of kala-azar. Three months later
the dog was killed and Leishmania were only found
in the smears of bone-marrow. Patton inoculated
a large series of animals (3 monkeys, 4 dogs, 2
jackals, 2 guinea-pigs, 2 rabbits, 2 cats, 4 white
rats, 1 young goat, 1 young pig, and a calf) on
two occasions, with an interval of about a fortnight
between the inoculations, large doses of virus being
injected each time. The three monkeys all became
infected and died within two months of the first
342
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 1, 1913.
inoculation. The four d
two dying four months and two about nine months
after inoculation. One of the jackals died nine
months after inoculation and was found infected.
The jackal and two of the dogs became infected
with Piroplasma canis, and this probably hastened
their death. The white rat died two hours after
receiving the second injection, when many parasites
were found in the liver and spleen. It is interesting
to note that in the dogs and the jackal Leishmania
were encountered in the peripheral blood a few days
before death. The successful inoculation of dogs
with the parasite of Indian kala-azar does away
with this supposed difference between Indian and
Mediterranean kala-azar. Patton also records the
examination of the spleens of 1,438 dogs destroyed
in the lethal chambers in Madras from January 29
to November 25, 1912, and the spleens and bone
marrow of 1,821 dogs between November 26, 1912,
and May 16, 1913. In no case was a dog found to
be naturally infected with Leishmania. Dogs in the
endemie centres of kala-azar in India do not appear
to suffer from kala-azar as they do in the Mediter-
ranean distriets.
s also became infected,
The Indian Journal of Medical Research.—This
publication, the first number of which appeared in
July of this year, is to be the official journal of the
Indian Research Fund Association. It is to be
published four times a year, and is to replace
Paludism and the Scientific Memoirs. For-
merly there was in India no periodical devoted
entirely to the publication of research work con-
nected with sanitation and the prevention of disease.
Most of the papers, therefore, on this very wide
range of subjects either remained more or less
buried in the files of the Government offices, found
their way into the general medical or surgical press,
or were scattered over a variety of very specialized
journals in England or Europe. It was long felt
that a periodical which would collect the best of all
this work and publish it in a readily accessible form
would be eminently desirable and meet a real want.
It is to meet this want that the Indian Journal of
Medical Hesearch has been started. The first
number contains 211 pages. Patton (W. S.) and
Cragg (F. W.) contribute two papers on certain
hematophagous species of Musca and a new species
of Philematomyia. Howlett (F. M.), the Imperial
Pathological Entomologist, gives an account of
investigations into the habits of Phlebotomus
minutus, which he shows to be primarily a parasite
of lizards, on which it feeds in preference to any
other animal. Greig (E. D. W.) publishes four im-
portant papers on the subject of cholera, with
reference to the occurrence of the cholera vibrio in
the biliary passages, cholera convalescents and
contacts in India, an epidemic of cholera caused
by a '' carrier," and the occurrence of the comma
bacillus in the urine of cases of cholera. Cunning-
ham (J.) contributes an interesting résumé of our
present knowledge of dysentery, both bacillary and
protozoal; MacGilchrist (A. C.) a paper on the
hemolytic action of quinine and its salts, with
suggestions regarding the etiology and treatment
of blackwater fever; and Acton (H. W.) and
Knowles (R.) one on the diagnosis of latent malaria.
Donovan (C.) discusses kala-azar in reference to its
distribution and probable modes of infection, and
records the successful inoculation of a dog with
Leishmania donovani. Patton (W. S.) records a
series of inoculation experiments in which he
has successfully infected dogs, monkeys, a jackal,
and a white rat with ZL. donovani. Acton
(H. W.) and Knowles (R.) have a paper on the
specific gravity of the blood, Strickland (C.) a
revised list of Malayan anophelines, and Knowles
(R.) and Acton (H. W.) a note on Kurloff's bodies,
in which they give very good reasons for regarding
these structures as cell inclusions of a non-parasitic
nature.
The first number, which is full of interesting and
important matter, is well got up, the paper and
printing is good, and the annual subscription of six
rupees for India and ten shillings for foreign sub-
scribers bears out its claim that the price has been
fixed at a very low rate.
The Life-cycle of Clonorchis. — In the China
Medical Journal, May, 1913, Houghton writes on the
life-cycle of Clonorchis. His paper gives the pre-
liminary results of an attempt to show the direct
source of infection by this parasite.
Houghton states that in Opisthorchis felineus (a
common parasite of man in Siberia), Askanazy is said
to have worked out the post-embryonal development.
According to his researches on cats and dogs, the
first intermediate host for this species is a chub
(Idus melanotus) and a second host the roach
(Leuciscus rutilus). Lühe states more recently that
the details of development are but meagrely known,
and suggests that an encysted larval form found in
north-east Prussia to infect the flesh of Z. idus and
L. rutilus, may be the cercarial stage of this species.
An earlier stage, he thinks, may be passed in the
body of Dreissena polymorpha, a small bivalve
mollusc.
There seems to be no question, however, but that
the final larval stage — the one infective for the
mammalian host—is passed in some species of fish.
The abundance of this parasite in human cases in
areas where fish are not only a staple article of diet,
but are often eaten raw or insufficiently cooked, and
its frequent association with Dibothriocephalus latus,
points significantly to the probable source of infection.
It is likely, considering the close relationship of
the two genera, that Opisthorchis and Clonorchis
have a life-history that follows in general the same
course. In the summer of 1910, in the course of
making some observations on parasites present in the
ordinary foodstuffs of the Chinese dietary, Houghton
noticed the practically constant presence of a larval
trematode in the intestine of a small fish much eaten
in eentral China, and thought of the possibility of its
being some form which might parasitize man, or at
least some mammalian host. The larve were found
lying singly in the folds of the intestinal mucosa
They were best obtained for study by removing
Nov. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
#43
the intestine from the fish, cutting off the upper
and lower portions, and then gently removing the
intestinal contents, by stripping the mucosa from
the gut. The free mucosal elements milked out in
this way, were diluted slightly with normal saline,
and examined under the low power of a microscope.
The larvæ themselves were small distome cercarim,
04 mm. in length, tailless, without cuticular spines,
and showing the anlage of digestive and generative
organs similar to those found in adult fasciolids.
This was the only trematode organism found in these
fish, either in the intestinal canal or encysted in the
flesh.
Three series of experiments were carried out, but
then unfortunately the investigation had to be dropped
for the time being.
(1) In the first series, two suckling kittens were
used, which after forcibly weaning were put into
separate cages. The experimental kitten was fed
for a period of about two months on a diet of boiled
rice, raw fish of the variety under investigation, and
tinned milk. The control was kept on the same diet
minus the fish. At the end of the two months'
period the kittens were killed. On section, the
experimental kitten was found to be infected with
Clonorchis endemicus. The control animal was free
from this parasite. Not satisfied with the technique,
the experiment was repeated under the following
conditions :—
(2) A eat with two suckling kittens was put into
a specially built cage and fed upon sterile food until
the kittens were weaned and able to eat freely of the
boiled rice and tinned milk. The floor of the cage
was covered with sand sterilized previously by baking,
and changed daily. After weaning, the kittens were
removed to separate cages and kept under the same
conditions of sterile food, &c., but the experimental
kitten was fed daily with the intestines of the fish
which were carefully removed from freshly-killed fish
and mixed with rice. Examination of the droppings
at the beginning of the experiment showed absence
of trematode ova, though the eggs of some unidentified
nematode worm were found in both kittens. At the
end of two months both kittens were killed and
sectioned. The control was free from trematode
infection, but on opening the experimental animal
the abdominal cavity was found to be more than
half filled by an enormously large liver. The bile
ducts were so distended as to be easily visible on the
surface of the organ, and the gall-bladder and common
duct were much dilated with thickened opaque walls.
The common duct was very tortuous. Over a
hundred specimens of Clonorchis were allowed to
escape from the cut end of the duct. before tying
it off.
Another finding of interest in this animal, though
not pertinent to the present paper, was a cystic
diverticulum of the stomach wall “connected with
the lumen of the stomach by a minute opening,
which contained twelve specimens of Gw«ithostomum.
(3) <A third series conducted under similar con-
ditions gave a negative result, both kittens dying
of some intercurrent disease at the end of a month’s
time.
While the experjmental work above outlined is too
scanty to form a basis for sound conclusions, the
author, nevertheless, feels justified in saying that
it suggests the probability of infection with Clonorchis .
by a free-swimming cercaria which is to be found in a .
small eyprinidine fish of the genus Notropis. The
fact that fishes of this character are commonly
eaten uncooked in Japan where clonorchiasis is very
frequent, and occasionally eaten inadequately cooked
in China, where in certain areas infection is not
uncommon, and the further fact that about 90 per
cent. of Chinese cats— notorious fish-eaters—harbour
the parasite, all seem to point to the possibility of this
source of infection.
Plugue in Manila.—Goff, writing in the Journal
of the American Medical Association, June 28, 1913,
states that after an absence of six years plague
again appeared in Manila in June, 1912. Between
that date and the present—Marech, 1913—there
have been fifty-five cases, twenty-two of them
having occurred in October.
The way in which the disease entered Manila is not
known with certainty, but as there had been a good
deal of plague in China for some time before June,
1912, it is presumed that an infected rat came
ashore from some boat from the mainland. It is
impossible to guard against this danger absolutely.
In the rat-poisoning and rat-catching operations
which have been carried on, remarkably few
infected animals have been found, which, of course,
accounts for the comparatively few human cases
reported, and leads to the belief that no serious
epidemic will occur in Manila. All of the cases,
except two in the Walled City (Intramuros), have
been on the north side of the Pasig River, which
divides the city; and nearly all of the twenty-two
mentioned as occurring in October originated in an
infected store-house near the station of the Manila
and Dagupan Railroad. This was, of course, at
once thoroughly disinfected and cleared of rats, and
since then no more cases have occurred in that
neighbourhood. It might be mentioned, in this
connection, that arsenic mixed with rice in such
proportion that a few grains of rice constitute a
poisonous dose, is considered to be the best rat-
poison in Manila. The fifty-five cases according to
nationality were divided as follows: In Filipinos
forty-six, Chinese eight, and Caucasians one. Only
ten females were attacked, and the ages of all
patients varied from 16 months to 50 years; shout
one-half being 25 years of age or under.
According to the population the number of cases
was somewhat greater among the Chinese than
among the Filipinos, and among the Caucasians
somewhat less than the due proportion.
All cases of plague are handled at the San Lazaro
Hospital, and every diagnosis is confirmed by
laboratory methods, or by post-mortem, or both.
When a ease is admitted, the bubo, if there be one,
is aspirated, and a smear examined at once, by
which means the diagnosis in typical cases is usually
confirmed. Of course a culture is also made, and
guinea-pigs inoculated. This is done by the
344
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 1, 1913.
Government laboratory. This work of the labora-
tory is particularly useful, from a' practical stand-
point, in doubtful cases of enlarged lymph-nodes.
Many eases are sent as suspected bubonie plague,
with enlarged lymph-nodes, high temperature, &ec.,
which are not plague. It is practically impossible
to be sure of the diagnosis in these instances, for a
day or two, and here the mieroscope is particularly
valuable as giving, at least, negative evidence. Of
course these cases of enlarged lymph-nodes do not
closely simulate typical plague clinically, but many
cases of true plague are not typical
The following is the description of a non-typical
case of plague :—
"A male Filipino, aged 18, was admitted
with a temperature of 104° F., and slight enlarge-
ment of the lymph-nodes in the left axilla. A
lymph-node was aspirated, and nothing was found
indicative of plague in the smear or culture. The
patient was given quinine and calomel, and the
temperature become normal on the day after
admission, and remained practically so for two
days. On the fourth day, however, the tempera-
ture rose again to 1049 F., and a second aspiration
of the lymph-node showed the case to be plague
both in smear, culture, and guinea-pigs. The tem-
perature declined again in a few days, and the
patient recovered. This case was, of course,
bubonic plague in a mild form, but there was
nothing at first to differentiate it from some of the
eases admitted which were not plague, as, for
example, the following :—
* A Filipino child, aged 4, was brought in with
a temperature of 104° F., and a large left femoral
bubo. The lymph-node was aspirated repeatedly,
but nothing could be found in smear, culture, or
guinea-pigs. There was no infection of the foot or
leg to account for the bubo, and according to the
mother there had been fever for some days before
the lymph-node enlarged.”
In the cases observed in Manila the femoral
lymph-nodes have been oftenest primarily enlarged,
followed in frequency by the inguinal; in two cases
the popliteal lymph-nodes were affected, in three
the ppwviaal ond in thvoo tha avillarw Tn onl
ace, ile x ( b i i tthe ly
Opeciinens OL spütiuu were duunia by culiedii
immense numbers of the plague bacillus. These
cases were, of course, in no way genuine pneumonic
plague, all having been of the bubonic type; but as
there was usually more or less coughing, every
person going near these patients was compelled to
wear a mask of absorbent cotton, between double
layers of gauze, over the nose and mouth. In
addition, when practicable, a light towel or piece of
gauze was thrown over the patient’s face when it
was necessary for anyone to remain near him for
any length of time. When individuals reach this
stage they are usually practically unconscious, so
that a light covering over the face causes no
annoyance.
The patients were treated with serum prepared
at the Government laboratory; about 150 c.c. being
given by intramuscular injection as an initial dose,
and from 50 to 75 c.c. three or four times a day
until 500 e.c. had been administered. This treat-
ment had not been used a sufficient length of time
to make any positive statement as to results
possible, but it was believed that it had a beneficial
effect.
Hotes and Hews.
THE SOCIETY OF TROPICAL MEDICINE AND
HYGIENE.
Ar the first ordinary meeting of the Society of
Tropical Medicine and Hygiene for the new Session,
1913-1914, held at 11, Chandos Strect, Cavendish
Square, London, W., on Friday, October 17, 1913,
at 8.80 p.m., the President, Sir R. Havelock
Charles, delivered his Presidential Address on
“ Neurasthenia and its Bearing on the Decay of
Northern Peoples in India," the paper being
followed by an animated discussion.
At a ballot the following candidates were elected
Fellows of the Society :—
Orrock Arnott, M.B., Basutoland.
Daniel Birtwell, L.R.C.P. and S. Edin., Durban.
Captain F. Powell Connor, F.R.C.S., I.M.S.,
Calcutta.
C. Noel Davis, M.B., Shanghai.
Geoffrey Dunderdale, M.D., M.R.C.S., Nairobi.
John Dunlop, M.B., India.
P. V. Early, M.B., Canton.
J. Y. Ferguson, M.D., Ontario.
Henry E. K. Fretz, L.R.C.S., St. Kitts, B.W.I.
Captain J. E. H. Gatt, M.D., R.A.M.C., India.
Captain J. B. Dalzel Hunter, M.B., I.M.S.,
Bombay.
J. L. Keeler, M.D., North China.
Captain Herbert H. G. Knapp, M.D., I.M.S.,
Burma.
J. W. Lindsay, M.B., Paraguay.
Elizabeth N. MacBean Ross, M.B., Tain.
Charles E. F. Mouat-Biggs, M.R.C.S., Babba-
Ts ob i ly AT 13
- Vu nn
Doi WHY Prsia s Narta "waa: Uy. NK, Ea
C. R. Patton, M.B., W.A.M.S., London.
Captain B. B. Paymaster, L.R.C.P. and S.E.,
I.M.8., Bombay.
Alexander Robertson, M.B., Mombasa.
J. A. Valentine, M.D., Ássam.
Aotices to Correspondents,
1.—Manuscripts sent in cannot be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publisners.
5.—Correspondents should look for replies under the heading
‘* Answers to Correspondents."
Nov. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 22, Vol. XVI
aaa a
Original Communications.
HEPATIC ABSCESSES WHICH OPEN
UPWARDS THROUGH THE LUNG.
By James CANTLIE, M.B., C.M.Aberd., F.R.C.S.
Time was when it was considered advisable to
defer operation and to allow a hepatie abscess
situated far back in the liver to open upwards
through the lung. Knowingly for a practitioner to
follow such a line of treatment to-day can be con-
sidered neither more nor less than malprazis, for
the danger incurred, or the long period which must
elapse before possible recovery if it does take
place, is wholly unjustifiable. Yet liver abscesses
finding exit by way of a bronchus are met with, and
in all probability will continue to be so. The reason
for the occurrence is readily understood when the
clinical phenomena are taken into account. The
situation of the pus, at the upper and back part
of the liver, is such as to render exact diagnosis
well-nigh impossible. Neither palpation nor auscul-
tation help much in the localization, nor can direct
percussion be relied upon, for with a hepatitis or
with pus impinging on the diaphragm there is
always a congestion of the base of the right lung,
which renders percussion useless in mapping out
the presumed abscess limit. ‘‘ Presumed "' is said
advisedly, for we have no means of positively
asserting that pus is present when it lies in the
substance of, or far back in, the liver. Neither the
temperature chart, the presence of night sweats,
the history of the case, the character of the cough,
X-ray inspections, nor any one symptom or group
of symptoms are of avail in determining a positive
diagnosis. Finding the pus by a needle is the one
and only fact we can rely upon as indicating that
we are dealing with pus in the parts of the liver
remote from the surface of the body.
That liver abscesses bursting upwards through the
lung will diminish in number is to be hoped for, but
that they will disappear from clinieal practice with
our available means of diagnosis cannot be expected.
Nay, it may be they will inerease, and for this
reason: it has long been a belief that by the
administration of ipecacuanha in large doses, a
hepatitis, associated with or consequent upon
dysentery or a liver abscess may be prevented.
This is a possible and a probable contingency, and
one to be striven after. There is, however, a still
further belief engendered by the suggestions of
recent observers, namely, that even when pus is
forming treatment by ipecacuanha (emetine) may
resolve the ingredients by destroying the amcebe in
the inflamed area. The danger is that this treatment
may be continued unwisely, may be prolonged even
when the abscess, the presence of which is always
obscure, has attained considerable dimensions and
pushed its way beyond the upper surface of the liver
to the interval between the liver and diaphragm,
or may have reached the lung, when ipecacuanha
will be useless.
To the practitioner imbued with the potency of
ipecacuanha and his cherished hope that by its con-
tinuance the much-dreaded (both by the patient
and possibly by the practitioner also) operation for
liver abscess may be put off, it must be remem-
bered that ipecacuanha may fail, and that by the
operation being unduly deferred the pus may
find its way upwards into the lung or pleura. It
is evident that prolonged ipecacüanha treatment is
not without its dangers. The situation may be
summed up as follows :—
(1) That ipecacuanha (or emetine) should be
given in hepatitis associated with dysentery in the
hope of preventing pus forming; it is the only
known means of doing so at our command.
(2) That ipecacuanha may, by destroying ameebe,
actually cause a threatening intra-hepatie liver
abscess to be arrested and to abort is conceivable
and possible.
(8) That ipecacuanha can resolve an established
liver abscess is to be regarded as improbable.
(4) That pus beyond the liver substance—the
supra-hepatie abscess of the writer—situated be-
tween the layers of the broad ligament of the liver,
can be affected by the administration of ipecacuanha
is inconceivable.
(5) The prolongation of ipecacuanha treatment :s
fraught with danger to the patient under conditions
mentioned under (3) and (4).
The transition from the point of safety to that
of danger during the ipecacuanha treatment is
obscure, and perhaps wholly impossible to define or
ascertain. "The point at which a local inflammation
within the liver passes on to pus is impossible to
determine, and it is not until the pus has reached
the surface of the liver and caused a local peri-
hepatitis, or threatens the lung, that a tangible
indieation is presented of the possible presence and
situation of the pus. When a liver abscess is
suspected and a local peri-hepatitis develops the
possibility that pus has actually formed may be
taken as a working diagnosis and steps for its
elimination proceeded with. When the pus takes
an upward course, and reaches the under surface
of the diaphragm between the two layers of the
broad ligament, that is, through the patch on the
liver devoid of peritoneum, the pain may be in-
signifieant, and the pus may find its way upwards
through the diaphragm and gain the lung in à
manner so stealthy that it is only when a cough
supervenes that a real indication of the course it
has taken is presented. The cough attending the
burrowing of pus upwards from the liver to the lung
is characteristic. It is at first trying, inasmuch as
no relief is obtained thereby. It is deep-rooted,
violent, the bouts are frequently repeated, the ex-
haustion of the patient rather than the result
obtained causing some cessation, for the attack
quickly commences again, and the result in the way
of expectoration is, to begin with, nil. After a time,
it may be only half-an-hour or several hours, the
patient may succeed in bringing up a frothy mucus
tinged after a short interval by blood; the sputum
speedily becomes more glairy, and then muco-
purulent and freely stained by or mixed freely with
346
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 15, 1913
‘blood. Finally, pus (liver pus) predominates, and
if the abscess is large it comes away freely. One
has to fall back upon that uncertain, but never-
theless often reliable, element in diagnosis—clinical
experience, in a matter of this kind; this is a poor
factor so far as the beginner is concerned, and it is
he that most wants definite statements and rules to
guide him. j
WHEN Pus HAS FOUND EXIT By THE LUNG.
To the experienced the fact that pus has found its
way into the pulmonary area is often rendered plain
by the character of the cough alone; but when in
addition the sputum is affected the diagnosis should
be less difficult. The expectoration may be in
quantities as much as a pint or two or more in the
twenty-four hours. So voluminous may the pus
become that it well-nigh chokes the patient, and he
has no rest, it may be, for twenty-four hours. The
writer has had on more than one occasion to open
the abscess transthoracically to save the patient
from complete exhaustion and to afford relief from
the distress he suffers and what appears to be
danger of suffocation. In smaller abscesses, cough-
ing up the pus brings instant relief from the tension,
discomfort, and local pain due to the imprisoned pus,
the temperature soon falls, and the patient enjoys
a period of comfort.
All goes well for a time; only a slight cough con-
tinues, and for a week, or it may be six weeks, the
patient believes he is cured. Inevitably, however,
the symptoms recur; fever comes on again; the
appetite is lost; restlessness and insomnia super-
vene; the cough and what slight expectoration. there
may have been disappear, and the patient is in a
state similar to that in which he found himself just
before the abscess opened into the lung. After
three days (as a rule) of this relapse expectoration
returns, at first consisting of froth and blood, to be
shortly followed by pus. This attack passes off.
and again the patient has a relapse. The interval
between the first and second relapse, however, may
be a few months, in place of a few weeks, and the
same process is repeated. If left alone indefinite
relapses may occur, extending over a year or more,
until the cavity is finally emptied. This is what
may be termed a favourable ending, but it is not
one which the practitioner cares to see occurring,
as the patient is not only prevented returning to his
employment, but his life is endangered by the con-
tinued recurrences.
How pores THE Pus FIND ITS WAY TO A BRONCHUS
(1) The post-mortem examination of a lung
through which pus has found its way to a bronchus
is often a disappointment, for there will seldom be
found a channel leading directly from the liver
abscess to a bronchus, but instead the pus would
seem to spread within the base of the right lung
and widely saturate the lung tissue with pus, and
the exact opening into a bronchus it may not be
possible to find. The pus occupies the lung tissue
as water lies in a bog; here and there a piece of
lung tissue crops up amongst a morass of pus. It
is usually necessary to pour water into the bronchus
at the root of the lung and watch its exit through
one of the smaller bronchi to ascertain how the pus
reached the air-passages.
(2) Another tract along which pus may pass
upwards from the liver to the root of the lung is
by way of the ligamentum latum pulmonis. The
pus passes up between the layers of this ligament
where the channel is bounded internally by the peri-
cardium, externally by the lung tissue, and in front
SECTION BELOW Root oF LUNGS SHOWING THE LIGAMENTUM
LATUM PULMONIS.
P., pericardium; R.L., right lang; L.L., left lung; 1 and
2, visceral and parietal layers of pleura; 3, pus from hepatic
abscess between layers of ligamentum latum pulmonis.
P., pericardium; L., lung; Li., liver; 1, pus passing
through diaphragm; 2, pus passing up between lung and
pericardium ; 3, pus entering bronchial tube.
and behind by the layers of the pleura, which con-
stitute the ligamentum latum pulmonis.
(3) Hepatic pus may find its way into the pleura
occasionally by opening directly into the cavity, Or
more frequently after first traversing the lung. On
reaching the pleural cavity the tendency is for the
pus to become localized by setting up a pleuritic
barrier around. When hepatic pus, which is so fre-
Nov. 15, 1913.].
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE:
347
o uM
quently sterile, reaches the pleural cavity directly,
there is less tendency for the pus to become localized
than when it has first traversed the lung, whereby
it becomes germ-laden, and therefore more likely
to be confined by setting up local pleuritis.
(4) Pus which has penetrated the diaphragm
from. the liver reaches most frequently, perhaps,
the space below the pleura and between the dia-
phragm and the ribs, where the loose areolar tissue
alone fills the interval, and where the lymphaties
travel directly between the diaphragm and the chest
wall, and no doubt favours the pus reaching the
chest wall. This explains why, when operation is
delayed, the pus is found directly beneath the ribs
and without the pleura being involved.
OPERATIONS WHEN PUS HAS ENTERED THE THORACIC
CAVITY.
It is a simple matter to find the pus when it lies
immediately beneath the ribs, but it is a serious
matter to reach the channel of its exit when the
tract is close to, or actually in contact, with, the
pericardium.
There is a difference also as regards the course of
the ailment, according as the pus passes through
the lung tissue on its way to the bronchus, or opens
directly between the layers of the ligamentum latum
pulmonis. In the former the pus, being scattered
in the lung tissue, as in a bog.or morass, tends to
hinder the abscess emptying itself thoroughly;
whereas, with a clear channel to the bronchus by
way of the broad ligament of the lung, the pus has
free passage and exit; the result is that in the
former pus will eontinue to appear between the
lung and the liver, and the cavity in the liver will
tend to continue and refill from time to time;
whereas in the latter the aetual abscess in the liver
will tend: to heal, but the test-tube-like channel
between the layers of the ligament of the lung will
persist indefinitely unless it is actually reached and
opened.
(1) When the pus has passed through the lung
tissue the time to operate is during a relapse. As
noted above, the first exit of pus is followed by a
temporary cessation of symptoms, and the patient
seems ''eured." A relapse is well-nigh inevitable
in a week or after several weeks; and it is during
the relapse that there is any hope of reaching the
abscess cavity by operation or of striking pus by a
needle. The first relapse usually takes place whilst
the patient is convalescing and has often left his
doctor's charge for a change. When the symptoms
recur the patient usually lies up for a day or two,
the pus is coughed up, and the fever and all signs
and symptoms again disappear. When this is
reported to the doctor, the patient must be told on
the next recurrence of fever or pain, &e., to report
the matter, and the doctor should at once, whilst
yet the fever and pain are present, make search for
the pus with a needle. It is during this period, and
this period only, that it is possible to strike the
abscess, for it is then that the pus, not finding exit,
is in sufficient quantity to be found at all. During
the intervals the abscess walls are collapsed. and
lie in contact, for the pus has free exit, and there
is no collection. During the relapse there is, as it
were, a cup of pus, whilst during the interval the
cavity is saucer-like only in its thickness, and very
difficult to hit by a needle.
(2) When the pus traverses the chest alongside of
the pericardium and between the layers of the broad
ligament of the lung a difficult problem is presented
to the surgeon.
The writer has had occasion to operate upon two
cases of liver abscess in which the tract of pus was
known to lie between the lung and the pericardium.
The history, of the case, the character of the pus
expectorated, the percussion dulness, and the X-ray
screen views combined to form fairly conelusive
evidence where the pus lay. How to reach the tract
of the pus-in a region of such intricate difficulty is,
and must remain, a serious problem.
In one of the cases a surgeon had attempted. to
reach the pus from the abdomen, hoping to strike
the abscess at the bottom of the tract where the
liver was adherent to the diaphragm; in this he
failed. In another case the surgeon cut down on
the cartilages of the fourth, fifth, and sixth ribs on
right side, and after removing the greater part of
them and ligaturing the internal mammary artery,
attempted to reach the area of the pus. The
adhesions between the pericardium on the one hand,
and the lung on the other, were, however; .so pro-
nounced and so impossible to separate that’ the
operation had to be abandoned. The writer dealt
with these cases as follows :—
Finding it impossible to reach the pus from the
side of the chest by the longest needle obtainable,
44 in., and not considering it safe to introduce a
needle of greater length in case it should break, he
eut away 2 in. of the sixth and seventh ribs im the
axillary line. At the bottom of the wound thus
made a 44 in. needle was pushed onwards through
the lung until a hardened mass of tissue indicated
that the fibrous wall of the tract of pus was reached
close to the pericardium. So close was the needle
judged to be to the pericardium that it required some
courage to push the needle through the mass in the
hope of hitting the pus track. This, however, was
done, pus was found, and along the path of the
needle a large trocar and cannula (Cantlie’s) was
inserted, the stretehed drainage tube was intro-
duced through the cannula, the cannula withdrawn,
and syphonage drainage established. The result in
both cases was complete success, both patients
recovering. The depth of the track from the surface
was 63 to 7 in., the lung was traversed by the
needle, the trocar and cannula, and subsequently
by the drainage tube, yet no damage resulted to the
lung. It is an operation that cannot be lightly
undertaken, but the writer has found in this, as in
other cases requiring penetration of the lung by
trocar and cannula and drainage, as inthe case of
deep-seated hydatid of the lung with sound lung
tissue between the surface and the hydatid, that no
perenne results occur by thus dealing with the
ung.
348
A CASE OF EQUINE TRYPANOSOMIASIS
CHARACTERIZED BY THE OCCURRENCE
OF POSTERIOR NUCLEAR FORMS.
By J. W. Scorr Macriz, M.A., M.B., Ch.B.
West African Medical Staff.
AND
J. E. L. Jounston, M.B., B.S., D.T.M. & H.
West African Medical Staf, The Medical Research Institute,
Lagos, Southern Nigeria.
Sınce Stephens and Fantham [1] first described
posterior nuclear forms in a trypanosome obtained
from a human source the same morphological
peculiarity has been recorded by several observers
in other strains. Wenyon [2], for example, has
described them in Trypanosoma pecaudi from the
Bahr-el-Ghazal, Yorke and Blacklock [8] in T. equi-
perdum, and Blacklock [4] in a strain of T. brucei
from Uganda. In July, 1912, one of us
(J. W. S. M.) [5] observed these forms in a horse
r2
Soe
|
T. brucei (recaudi) from a horse Accra, Gold Coast. x 1,000
infected with T. brucei in Northern Nigeria; but
with this exception, so far as we are aware, the
occurrence of trypanosomes showing this morpho-
logical peculiarity has not been described from West
Africa. We think, therefore, that the observations
recorded in this note may be of interest.
Last July a series of blood slides was sent to the
Medical Research Institute, Lagos, by Dr. Hutton,
from Accra, on the Gold Coast. The blood films
had been taken from two horses infected with try-
panosomiasis. On examining them we found that
the parasites were of the T. brucei (pecaudi) type,
a species of trypanosome that is common through-
out West Africa, and which accounts annually for
a heavy mortality amongst domestic animals. The
one horse had few trypanosomes in the blood, but
in the other they were numerous, and on going over
the slides it was observed that many of them had
i nucleus situated in the posterior half of the
body.
The accompanying drawings have been made from
a film from the latter horse. They were made with
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 15, 1913.
a camera lucida, and the magnification was in each
case 1,000 diameters. The usual long and slender
forms and short and stumpy forms are illustrated,
and in addition sketches are given of several forms
in whieh the nucleus oecupied a more or less
posterior position. No forms were met with in
which the trophonucleus was actually posterior to
the kinetonucleus, although it was not infrequently
seen almost touching it.
As there appeared to be an unusually large
number of forms with the nucleus posterior, a
thousand trypanosomes were examined with a view
to determining the percentage. In doing this the
procedure of Blacklock [6] was carried out. '' Every
trypanosome met with was counted, whether long,
intermediate, or short, dividing or non-dividing.
The number of posterior nuclears was noted, non-
dividing forms only being chosen.’’ The posterior
nuclear forms were also classified, according to his
convention, into his forms A, B, and C. The
results were as follows :—
Posterior nuclear forms
Trypanosomes
enumerated | -
There were thus 4°8 per cent. of the trypansomes
in which the nucleus was definitely posterior. We
do not know on what day of the infection the blood
filas we. examined were taken, but such a per-
centage is certainly a high one. Stephens and
Fantham (loc. cit.) found that in rats infected with
T. rhodesiense these forms might form about 6 per
cent., and Wenyon and Hanschell [7] as much as
72 per cent. of the parasites present.
The occurrence of posterior nuclear forms in the
various species of trypanosomes mentioned above
has been used as an argument against the specificity
of T. rhodesiense [8], and it has recently been
asserted that T. rhodesiense is T. brucei [9].
As it was not possible to examine the animal
reactions of the trypanosome described above we
cannot positively identify the species, but it pre-
sented the same morphological appearances as the
parasite that accounts for a large number of deaths
amongst horses every year in Northern Nigeria,
several examples of which were identified for one
of us by Sir David Bruce as T. brucei [10]. As the
trypanosome is undoubtedly polymorphic, the
species is probably that for which Stephens and
Blacklock have proposed the name T. ugandz [11].
This species and T. pecaudi are by some authorities
considered to be the same.
In Nigeria, and we believe in other West African
Colonies, T. brucei (pecaudi) is a common parasite
of domestic animals. If, on account of the fact
that posterior nuclear forms are common to both,
we are to believe this parasite identieal with T.
rhodesiense, it is a curious fact that human trypano-
somiasis in West Africa appears to differ materially
Nov. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
349
from the disease in Rhodesia. If T. rhodesiense
is T. brucei (pecaudi), we would expect to find cases
of human trypanosomiasis due to T. rhodesiense in
the places where T. brucei was common in the
domestic animals. This is not the case. In Nigeria,
at any rate, sleeping sickness does not present the
acute features it does in Rhodesia. The disease is
endemic, but by no means invariably fatal. The
trypanosome from a case of sleeping sickness in
Southern Nigeria has recently been studied by one
of us. The results have not yet been published,
but it may be of interest to state here that neither
in its morphology, its measurements, nor its animal
reactions does it resemble either T. brucei (pecaudi)
or T. rhodesiense.
REFERENCES.
[1] Proc. Roy. Soc., 1910, Series B, Ixxxiii, No. B 561,
pp. 28-33.
[2] JOURNAL or TROPICAL MEDICINE AND HYGIENE, 1912,
July 1, xv, No. 13, p. 193.
[3] Brit. Med. Journ., 1912, August 31, p. 478.
[4] Brit. Med. Journ., 1912, October 19, p. 1057.
[5] Annals of Trop. Med. and Parasit., 1918, vol. vii, No. 1,
pp. 3 and 16.
(6) Annals of Trop. Med. and Parasit., 1913, vii, No. 2,
05
p. 105.
[7] Journ. Lond. School of Trop. Med., 1912, vol. ii, pt. 1,
. 84.
p [8] Bevan (Lr.): Report on Trypanosoma rhodesiense, dated
March 20, 1913; and Wenyon(C. M.) and HaNscHELL (H. M.):
“A Further Note on Trypanosoma rhodesiense from Three Cases
of Human Trypanosomiasis," Journ. Lond. School of Trop.
Med., 1918, vol. ii, pt. 2, pp. 123-128.
[9] Bruce (Davip), Harvey (Davin), HAMERTON (A. E.),
Davey (J. B.), and Lady Bruce: ‘‘ The Trypanosomes found in
the Blood of Wild Animals Living in the Sleeping Sickness
Area, Nyasaland,” Proc. Hoy. Soc., 1913, Series B, vol. Ixxxvi,
No. B 587, pp. 269-277.
[10] Sleeping Sickness Bureau Bulletin, vol. iii, No. 81,
p. 422, 1911.
[11] Proc. Roy. Soc., B, vol. Ixxxvi, pp. 187-191.
NOTES ON A CASE OF DERMAL LEISH-
MANIASIS IN BRITISH GUINEA.
By E. P. Mıxerr, M.D., D.P.H., D.T.M. & H.
Assistant Government M.O.H. and Bacteriologist.
With Clinical Notes on Treatment by
F. E. Frevp, M.D., D.P.H.
Government Medical Officer, Public Hospital, Georgetown.
THE patient, C. C., aged 47, was admitted to the
Publie Hospital in November, 1912, as a suspected
leper. He is a well-developed healthy man of the
negro race, a native of Barbados, and states that
he has never previously suffered from any illness
whatever. For the last fifteen years the man has
been engaged in bush work of various kinds, prin-
cipally wood-cutting and gold-digging.
There is a history of a chanere on the penis about
six months previous to the onset of the present
disease ; this chancre appears to have been a '' soft "'
one, which promptly disappeared with treatment.
The present condition started when the patient
was up in the Wenamu gold diggings; the man
first noticed a small ‘‘ pimple "' on the left forearm,
there was no pain but intense irritation, causing
him to scratch the pimple very frequently, resulting
in free bleeding. The eruption gradually spread up
and down the left arm, then it appeared on the left
foot und spread up the legs as far as the groin;
the right side was next gradually involved, beginning
on the arm and extending to the legs as on the
right side. The face was the last place to be in-
volved; lesions did not appear on this situation until
the eruption was well developed in the limbs.
The patient states that these '' pimples ” did not
break into open sores until scratched.
The condition has remained practically stationary,
or at most progressed but slowly for the last two
years, in spite of vigorous treatment with a large
number of drugs.
At present the condition is confined to the arms,
legs and face, with two papules on the glans penis.
The fresh nodules are raised, smooth, tense, and
of a lighter colour than the surrounding skin; in
places these nodules have coalesced so as to form
raised pale-coloured plaques with a shiny tense-
looking surface. When further advanced (and as
the result of scratching) they lose their epithelium,
become confluent, and assume first a more or less
granulomatous condition; the final result is a mass
of dried scabs or crusts formed by the drying of the
yellowish exudation. The man states that he suffers
a dull continuous pain from the nodules that are
unbroken, together with intense irritation, but when
the nodules are broken the pain becomes intense.
There are no lesions to be detected on either the
nasal or oral cavities, nor are there any ocular
troubles of any kind. No anesthesia is present
either on the extremities, nasal cavities, or the
nodules themselves; in fact, the man is distinctly
hypersensitive all over.
This man was first suspected to be a case of yaws,
and examinations were made of the nodules with a
view to the detection of a spirochete without success.
The case was then examined for the presence of
Bacilli lepra, but without success on several occa-
sions, and it was during the course of this examina-
tion that the Leishman-Donovan bodies were first
detected.
A further investigation was then made, and mucus
obtained from the juice and blood expressed from
the nodules showed the presence of a large number
of typical Leishman-Donovan bodies, both con-
tained within the endothelial cells and lying free
in the plasma of the fluid. A section taken through
an excised nodule shows the epithelium to be pro-
liferating at the edge, but practically absent over
the surface of the nodule; the true dermis shows
a large amount of small round-celled infiltration,
together with a few polymorphonuclear cells in
patches, giant cells are present at the periphery of
the lesion. The bulk of the nodule itself consists
of fibre plastic tissue, packed with small round cells
and a few lymphocytes; polymorphonuclear cells
are present at the edges of the lesion. A blood
count gave the following results: Red corpuscles,
4,200,000; white corpuscles, 12,380; the hsemo-
globin index working out at 70 per cent.
The differential eount was as follows : Polymorpho-
350
THE, JOURNAL.OF TROPICAL MEDICINE AND HYGIENE. [Nov. 15, 1913.
nuclear cells, 53 per cent.; lymphocytes, 22 per
cent.; large mononuclear cells, 19 per cent.; with
eosinophiles, 6 per cent.
The man states that he was severely bitten by
ticks whilst in the bush, and attributes the infection
to this agency. He also states that several other
men. were similarly infected but recovered.
The Leishman-Donovan bodies have been incu-
bated for some time at 37° C. in citrated blood, and
in blood agar at the laboratory, but so far attempts
to cultivate the flagellate form have been unsuc-
cessful.
All attempts at treatment have been so far use-
less. A long course of treatment with mercury,
both internally and externally, was tried, followed
by a lengthy course of potassium iodide in large
doses. The patient was then treated with nastin,
and finally with salvarsan and neo-salvarsan. At
the present time four doses of salvarsan, 6 grm.,
have been given intravenously during a period
extending over three months. External applica-
tions, such as ung. salicylic, ung. picis, ung.
hydrarg., have failed to make any appreciable differ-
ence. The medical officer in charge of the case has
recently reported as follows: '' The ulcers and
nodules oceupy the identical sites as on admission,
and if improvement there is, it is not apparent.”
The case appears to be undoubtedly one of dermal
Leishmaniasis, commonly called “ boch yaws ” in
Surinam and bush yaws or forest yaws locally,
but as far as can be ascertained the Leishman-
Donovan bodies have not previously been detected,
as present in cases occurring in this colony.
—_—- oo —
Hotice.
THE SOCIETY OF TROPICAL MEDICINE
AND HYGIENE.
A MEETING of the Society will be held at 11.
Chandos Street, Cavendish Square, London, W.,
on Friday, November 21, 1913, at 8.30 p.m.
AGENDA.
(1) A paper (with epidiascope demonstration) on
“The Prevention of Malaria in Rural Districts ”
will be read by Maleolm Watson, M.D., D.P.H.
(Cambridge).
(2) A demonstration upon “ Lupoid Leprosy and
the Results of Treatment of Leprosy by means of
a Cultural Extract " will be given by H. Bayon,
M.D.
—— $9 ——— —
* Journal of the Royal Army Medical Corps," vol. xxi,
No. 4, October, 1913.
Prognosis of Bilharziasis.—Harrison writing on this sub-
ject concludes that it is obvious that bilharziasis is a much
more prolonged disease than we have been accustomed to
think. The earliest period at which we may hope for
recovery is from five to seven years after the onset of
symptoms, and this in only one-tenth of the cases, whilst
it may last without relief for at least thirteen years. The
direct and indirect mortality from bilharziasis among
Europeans removed from the endemic area is probably not
more than about 1 per cent., and there is no reason to
suppose that bilharzial infection increases the tendency to
phthisis,
Business Hotices.
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THE JOURNAL OF
Tropicali Pedicine and Hpagiene
NOVEMBER 15, 1913.
LONDON SCHOOL OF TROPICAL MEDICINE.
ANNUAL DINNER.
PRESENTATION OF PORTRAIT TO SIR Patrick
Manson, G.C.M.G.
THE annual dinner of the London School of
Tropical Medicine was held on October 24, 1913,
at the Prince’s Restaurant, Piccadilly. Dr. F. M.
Sandwith presided, and amongst those present
were: I. Ablett, Esq.; Colonel A. Alcock, C.I.E.,
I.M.S., F.R.S.; Sir John Anderson, G.C.M.G.,
K.C.B.; Algernon Aspinall, Esq. ; Dr. M. Atkinson;
E. E. Austen, Esq.; Dr. C. R. Avari; Dr. A. G.
Bagshawe; Dr. P. Bahr; Major €. R. Bakhle,
I.M.S.; Dr. A. Balfour; Fleet-Surgeon P. W.
Bassett-Smith, C.B., R.N.; Dr. H. Bayon; Sir
Wm. Bennett, K.C.V.O.; Sir E. W.. Bireh,
K.C.M.G.; Dr. H. L. Booth; Sir J. Rose Bradford.
K.C.M.G.; Surgeon-General Sir A. M. Branfoot,
K.C.I.E.; Dr. H. Lynch Burgess; A. B. Bruee,
Esq.; Sir R. Burnet, J.P.; J. Cantlie, Esq.,
F.R.C.S.; Dr. H. Cato; Rt. Hon. Austen Chamber-
lain, M.P.; Dr. A. Chaplin; Sir Havelock Charles.
G.C.V.O.; Rhys Charles, Esq.; Captain A. W.
Clarke; Dr. R. P. Cockin ; Dr. A. Copland ; G. Croll,
Esq.; Major H. M. Cruddas, I.M.S.; Rev. I.
Nov. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
351
Cumming; Dr. C. W. Daniels; Dr. C. N. Davis;
Colonel J. R. Dodd, R.A.M.C.; Dr. H. L. Duke;
Dr. J. Dunlop; Dr. 8. C. G. Fox; Dr. E. M.
Franklin; Dr. J. C. Franklin; Dr. E. J. Garstin;
Fleet-Surgeon A. Gaskell, R.N.; A. P. Hughes
Gibb, Esq.; Dr. F. Grenior; Dr. E. H. Griffin; Dr.
J. G. Hare; A. L. Hetherington, Esq.; Professor
R. T. Hewlett, F.R.C.S.; Commander G. Hodgkin-
son, R.N.; Dr. J. K. A. Hofmeyr; Dr. G. Horner;
Dr. J. M. Joly; J. 8. Joly, Esq.; C. B. Kingston,
Esq.; A. Lampard, Esq.; Dr. Hugh Lawson; Dr.
R. T. Leiper; Colonel Sir Wm. Leishman,
R.A.M.C.; Sir F. Lovell, C.M.G., LL.D.; Dr.
G. C. Low; Sir Chas. Pardey Lukis, K.C.S.I.;
Dr. C. B. Mack; A. G. R. Mackenzie, Esq.; Dr.
J: M. H: Macleod; Sir Patrick Manson, G.C.M.G.;
Surgeon-General A. W. May, C.B., R.N.; Dr. E.
Marshall; Dr. Martley; Dr. H. J. McCaw; Dr.
Campbell McClure; C. C. McLeod, Esq.; Dr.
E. M. Merrins; P. J. Michelli, Esq., C.M.G.; Rt.
Hon. Viscount Milner, G.C.B., G.C.M.G.; Dr.
R. M. Mitchell; Major St. John Moses, I.M.S.;
Dr. C. E. F. Mouat-Biggs; Colonel T. R. Mul-
roney, I.M.S.; Percival A. Nairne, Esq.; Spencer
Nairne, Esq.; Alex. Neilson, Esq.; Dr. H. B.
Newham; Dr. W. P. Norris; Dr. F. W. O'Connor;
Captain D. J: F. O'Donoghue, R.A.M.C.; 0 È
Orford, Esq. ; A. C. C. Parkinson, Esq. ; Dr. A. R.
Paterson; Dr. R.. G. Perkins; J. M. Pirie, Esq. ;
Dr. W. T. Prout, C.M.G. ; Dr. Z. Rajehman; H. J.
Read, Esq., C.M.G.; Rt. Hon. Sir J. West Ridge-
way, G.C.B., G.C.M.G., K.C.8.I.; Dr. J. R. Rid-
lon; B. H. Ross, Esq.; J. D. Ryder, Esq.; Surgeon
G. B. Scott, R.N.; Dr. L. Sells; Dr. R. O. Sibley;
Dr. J. S.. Smith; H. Hamel Smith, Esq.; Dr. D.
Sommerville; Dr. A. Campbell Stevenson; General
The Hon. Sir Reginald Talbot, K.C.B.; Dr. F. E.
Taylor; Sir Wm. Taylor, K.C.M.G.; Sir Wm.
Treacher, K.C.M.G.; Dr. J. A. Valentine; Dr.
H. C. Waldo; Captain G. H. Walker, D.S.O.;
Dr. H. G. Waters; Dr. B. H. Wedd; Dr. C. M.
Wenyon; F. Wilde, Esq.; Colonel E. Wilkinson,
I.M.S.; Dr. H. Williams; Dr. A. C. Wilson.
After the loyal toasts had been proposed by the
Chairman and duly honoured, Mr. A. CHAMBERLAIN,
in proposing the toast of ''* The London School of
Tropical Medicine," said that he supposed it was
entrusted to him beeause it had recently been his
good fortune to be connected from the outside rather
intimately with the fortunes of the School. He
was glad of the opportunity which was afforded him
of saying what had been done with the funds which
had been collected. He accepted the invitation of
Mr. Lewis Harcourt to take the Chairmanship of
the Committee to raise funds for the School for
several reasons. The first reason, he need have no
hesitation in saying, was a filial one, and it was
on the ground of his father’s connection with the
School that Mr. Harcourt appealed to him. That
was not the only reason. The study of tropical
medicine had in the past twenty or twenty-five
years. made giant advances, and in the progress
which it had made Englishmen had borne a dis-
tinguished and a leading part. As the possessors
of the greatest tropical and sub-tropical Empire
sexisting in the world Englishmen had a special
obligation alike to the subject races, of whose well-
being they were the guardians, and to the young
men of their own race who went out to other climes,
carrying with them the honour of England, doing
her work, spreading her civilization, and increasing
her reputation. England owed to them that at
least she should do everything she could to minimize
the risks they naturally had to run, and should show
her appreciation of their work by striving to secure
thorough research into the conditions of health and
the cause of illness, to which their labours rendered
them particularly exposed. It was a matter of
national honour and national pride that in a move-
ment so beneficial Englishmen should be encouraged
to earry on the work and that England should stand
in the forefront of the pioneers and of the new
learning which was being acquired. They set out to
obtain a sum of £100,000, and they had received the
not inconsiderable sum of over £70,000.
ALLOCATION OF THE FUND.
Acting on the adviee of the Committee of Man-
agement of the School of Tropical Medicine and of
the Head of the Seamen's Hospital, they desired,
in the first place, to make a not very large, but an
absolutely necessary extension of the buildings .of
the School. To that they had devoted £15,000; not
an undue proportion of the fund to sink in bricks
and mortar. The second object was to provide a
fund for research. That they had been able to
carry out by the kindness of Sir William Bennett
in allocating to this purpose the legaey of £10,000
which the late Lord Wandsworth entrusted to his
diseretion. This object had been further served by
strengthening the staff of the School. The third
object of the Committee and the subscribers was
to obtain a moderate endowment for the School,
which should place it beyond immediate want and
prevent it being always hampered by lack of funds.
For that purpose there had been already allocated
a sum which would produce an annual income to
the Sehool of about £1,400, and additional funds
had been obtained which would allow of another
£400 a year. The last of the objects was one of
some delicacy. Men sometimes returned from the
Tropies suffering from tropical diseases, but with
means insufficient to secure the attention of those
with special knowledge of tropical medicine, which
was confined to very few. They were anxious,
therefore, to make some provision for cases of that
kind, and owing to the help received from the
authorities at the Seamen's Hospital they had been
able to make arrangements for people of that class.
A large measure of success which had attended the
appeal would never have been obtained but for the
hearty co-operation of numberless people. He had
been moved by the response which had been made
to the appeal from all quarters, and he was particu-
larly touched by letters he had received from many
tropical dependencies of the Crown, in which the
writers sent their humble contributions. He wished
352 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 15, 1913.
to take that opportunity of asking the gratitude of
the company and of recording his own in particular
to the City Committee. Thanks to the London
Chamber of Commerce, in the first instance, and
to the City Committees formed under their auspices,
in the second, the response from companies had
exceeded his most sanguine expectations. It was
unnecessary at that gathering for him to dwell upon
the appreciation which was felt for the work of
the School by those who most immediately bene-
fited by it, and who were best able to judge of
the results achieved. But he might give an in-
stance showing how cordial was the response which
was being made to the invitation issued to some
of those tropical colonies by the Colonial Secretary
for a contribution to their funds. When it was
gently suggested by the Colonial Office to the
Government of the Federated Malay States that in
view of the importance of the School to them they
might be willing to vote £500 of publie money tc
the fund, a telegram was received in reply stating
that in view of the importance of the work to them
the unoffieial members of the Council suggested
that a grant of £5,000 should be made. Those who
subseribed in this country need not, therefore, think
that they subscribed to a work for an ungrateful
few who could not appreciate what the School was
doing. Great as had been the advance which
tropical medicine had made in the last few years,
he believed they had only scratched the soil so far,
and that was a most hopeful and encouraging sign.
The discoveries made were not final or conclusive ;
each opened up a new vista, and new possibilities,
and they were changing the whole of our mental
attitude towards the problems of tropical disease,
health, settlement, and development. Diseases
which were once thought to be the inevitable con-
comitant of that development were now seen to be
preventable.
The CHAIRMAN, in reply, referred to the great
efforts of Mr. A. Chamberlain on behalf of the
fund, and said that it was intended that one of the
wards in the hospital should bear the name of the
* Chamberlain Ward." He was glad to be able
to report that the School was in a fairly flourishing
condition. They had the largest class of students
they had ever had, and the greatest number of
resident students.
PRESENTATION OF PORTRAIT TO Sirk PATRICK MANSON.
Mr. James CaNrLIE said that it was his privilege,
along with Dr. Prout, C.M.G., as representing the
London and Liverpool Schools of Tropical Medicine
respectively, and in the names of many subscribers
to a national presentation to Sir Patrick Manson to
bring his picture before them. They had been
fortunate in obtaining the permission of the Chair-
man on this oceasion— Dr. F. M. Sandwith—to
make the presentation, and they had been enabled
by the co-operation of Mr. P. Michelli, C.M.G., to
do so. The presentation was in the form of a portrait
of Sir Patriek by Mr. Young Hunter, and many
present would remember seeing the painting in the
Royal Aeademy. They were also especially fortu-
, hate inasmuch as they had obtained the consent of
the Rt. Hon. Austen Chamberlain, M.P., to unveil
the portrait. They would all remember that on the
oecasion of the International Medical Congress in
August, 1913, an international testimonial in the
form of a medallion was presented as a world's
tribute to Sir Patrick Manson by Professor
Blanchard, of Paris. Those who took part in that
ceremony were not likely to forget the eloquence
of that address and the moving and glowing tribute
paid to Sir Patrick by Professor Blanchard on that
occasion. It was felt, however, that whilst they
contributed to and took part in the international
testimonial it would be becoming were Sir Patrick’s
countrymen to show their esteem for him and the
appreciation of the work he had done for the British
Empire; and it was accordingly resolved that his
portrait should be presented him. It was this
portrait that was now brought before them, and
Sir Patrick’s acceptance of this tribute of their
regard for him personally and of their gratitude for
the benefits they had received at his hands was
asked. Sir Patrick Manson, after completion of his
medical studies in Aberdeen, went to the Island of
Formosa in the China Seas to take up an appoint-
ment as medical officer in the service of the
Imperial Maritime Customs of China. In that
isolated spot he worked out the part played by
mosquitoes in the spread of filariasis. The great
truth of his discovery and the principles it involved
were beyond the power of man’s intellect to grasp
at the time, and Manson had to wait many years
before men’s minds fully recognized that an entirely
new range of thought was unfolded. Although,
however, this magnificent piece of scientific work
was neglected for a time, it came to light again in
a much wider field of disease, namely, malaria, and
all present were well acquainted with the mosquito-
malaria theory which was evolved as the result of
Manson’s work in Formosa. The effects of this
Formosan discovery will endure until the end of
time. It is one of those strokes of genius which
give a fresh direction to scientific thought and is to
be classed with Jenner's introduction of vaccination,
Pasteur's epoch-making researches, and Lister's
introduction of modern surgical methods. Laveran's
striking discovery of the malaria parasite might
have remained of but academic interest had not
Manson's mosquito-malaria theory been framed.
The consequences already resulting were gigantic,
for there is not a branch of modern medical
research that is not beholden to the principles it
enunciated, nor yet a corner of the earth where
benefits to mankind are not in evidence. Sir
Patrick Manson had retired from active work
amongst them, but he had left behind him a name
that would never perish, a reputation which was
unique in medical history, and an example which
would continue to stimulate and influence scientific
thought for ever.
Dr. Prout, C.M.G., in an eloquent speech, spoke
to Sir Patrick Manson’s attainments which have
had so marked an influence upon the direction of
scientific thought. The practical outcome is shown
Nov. 15, 1918.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
353
in many directions and in none more so than in
the case of the Panama Canal. Disease formerly
prevented its completion, and it was only when
the principles initiated by Sir Patrick Manson were
applied and disease overcome that this great scheme
was rendered feasible.
Mr. A. CHAMBERLAIN, in unveiling the portrait,
said that it was owing to the inspiration of Sir
Patrick Manson that the London and Liverpool
Schools of Tropical Medicine sprang into existence
almost at the same moment. Sir Patrick’s friends
asked him to accept the portrait as a testimony
to their gratitude to him for his help and of their
affection for him. They wished to recognize the
honour he had done his country and the great ser-
vices he had rendered to mankind.
Sir Patrick Manson having suitably acknow-
ledged the gifts, the CHAIRMAN proposed the health
of the guests, to which Sir Joun ANDERSON replied.
Viscount MILNER, in submitting the toast of '' The
Chairman,” paid an eloquent tribute to the value
of Dr. Sandwith’s work in Egypt.
During the evening a message of greeting was
sent to Mr. JOSEPH CHAMBERLAIN, who replied:
*' Thanks for your message. I wish you a pleasant
dinner, and I congratulate you on progress made.”
——9———
Abstract.
SHANGHAI MUNICIPAL COUNCIL HEALTH
DEPARTMENT ANNUAL REPORT, 1912.*
By ARTHUR STANLEYy, M.D., B.S.Lond., D.P,H.
Health Officer.
Tue author states that the past year was not a
healthy one. There was a considerable increase in
the incidence of acute diarrhea, typhoid fever, and
scarlet fever—all preventable diseases, while the
augmented death-rate was, in the case of the foreign
population, due, to some extent, to increased mor-
tality among children from general causes, such as
bronchitis, the incidence being mainly among
Japanese. The increased Japanese population has
introduced a new element into the composition of
the foreign community, which now resembles that
of a home industrial city. In the past the foreign
community consisted largely of people in more rr
less affluent circumstances, but now the greater
number correspond to the poorer class of a European
city, the children of whom contribute extensively
to the death-rate. For this reason, although there
may be a gradual improvement in sanitary condi-
tions, any notable lessening of the death-rate is
improbable until the community has arrived at a
fixed composition.
The Sub-District Health Offices, sixteen of which
are now scattered through the Settlement, have
proved of the greatest value in practical sanitation.
Each section of about 30,000 of the population now
has a Health Office in miniature in charge of a
* Shanghai: Printed by Kelly and Walsh, Limited, Canton
Road, 1918. ;
foreign assistant sanitary inspector, where vaccina-
tion is done at stated times and many other benefits
of modern sanitation are available for the public,
foreign and Chinese. The Chinese are beginning to
voluntarily report cases of preventable disease and
deaths, and, with the general employment of the
medical practitioner educated on modern lines, these
subsidiary Health Offices will make the application
of such modern sanitary measures, as it has not yet
been possible to organize, a comparatively easy
matter. When, for example, small-pox has been
stamped out by bringing free vaccination almost to
the doors of the people, it will be possible to attack
the greatest of all modern health problems, the pre-
vention of tuberculosis. In the near future the
Chinese public will probably learn the necessity for
calling in medical practitioners to recognize cases of
infectious disease, such as scarlet fever and diph-
theria, and may then better understand the need
for isolation in order to prevent these diseases.
Patience is, however, required. The full benefits
of modern sanitation are applicable only to a com-
munity ready to receive them. They cannot be
forced on a reluctant people. The Chinese must be
gradually educated up to the standards of modern
municipal life. The past fifteen years has seen in
Shanghai a gradual building up from very small
foundations of the fabric of modern sanitation, and
the halfway house has now been reached.
The incidence of choleraic diarrhoea affected the
community seriously; for not only were the number
of cases, both among foreigners and Chinese, excep-
tionally high, but the port was declared infected
with cholera by the Japanese authorities. In the
absence of the cholera organism, the disease was
not officially recognized as cholera, but, as the
method of prevention of these maladies is the same,
it matters little by what name it is called. It is
felt that unless more stringent action is taken
against the hawking of fruit, sliced melons and
other foodstuffs which carry the infection, a large
preventable loss of life will be liable to occur
annually. Until the sale of fresh foodstuffs is
confined to municipal markets and licensed shops,
the summer incidence of severe diarrhcea, often
fatal and clinically resembling cholera, is calculated
to kill extensively. The deaths from this trouble
occur chiefly among the very poor, who live from
hand to mouth, deriving much of their sustenance
from itinerant hawkers, whose fly-infected stock-in-
trade is an obvious danger. The need for further
action has been annually pointed out; but there has
been an objection to interfering with the old customs
of the wharf and other coolies, the main sufferers,
who, during the hottest weather, are decimated as
a result of eating fly-infected food bought from the
basket men. These coolies are unable to take care
of themselves in respect to their food, so that it
would appear necessary for the Health Office to be
empowered to safeguard them as far as possible.
The placing of the port in quarantine is a serious
disability to trade, and it appears necessary to face
the question squarely and decide whether it :s
not advisable to deprive the wharf coolies of their
351.
THE. JOURNAL OF. TROPICAL MEDICINE AND HYGIENE. [Nov. 15, 1913..
usual supplies so as to enable them to take their
food under proper sanitary conditions. The pre-
sence of these food hawkers on the wharves, where
they sell infected food to passengers, is also the
main souree of the cases of sickness among the
steerage passengers which are the cause of quaran-
tine restrictions being imposed.
The recommendations of the International
Sanitary Conference at Paris in 1911 have recently
been published. Forty-two countries were repre-
sented at the Conference, including China for the
first time. The following recommendations have
some bearing on the sanitation of Shanghai :—
The first case of cholera, plague, or yellow fever
must be immediately notified.
As regards plague, proposals were made to impose
a compulsory system of periodic rat destruction on
all ships, and even to extend the same to ports.
These proposals were mainly supported by countries
having little or no mercantile marine, but they were
not accepted by the Conference. It was, however,
decided to insert in the new Convention a recom-
mendation that ships should be subjected to periodic
rat destruction at least every six months, and that
preferential treatment should be accorded in ports
of arrival to ships which had undergone the process.
Rat destruction on suspected ships was made com-
pulsory. The period of ten days’ surveillance or
observation, which was imposed at the Paris Con-
vention of 1903 upon all persons landing from
plague-infected ships, was reduced to five days.
This reduction was consequent upon recognition of
the fact that the incubation period of bubonic
plague rarely exceeded five days, and that the
incubation period of pneumonie plague was still
shorter.
As regards cholera, in view of the heavy expense
and vexatious delay upon shipping which a routine
bacteriological examination of passengers and crews
of vessels from cholera-infected ports would entail,
the Conference decided that bacteriological exam-
ination may be applied only in the case of infected or
suspected ships as far as is necessary, that is to say,
amongst contacts or suspected persons. The Con-
ference recommended that research work should be
undertaken with a view to discovering how the
cholera vibrio maintains its existence in countries
where the disease is endemic, and from which the
periodic outbreaks of pandemic cholera have their
origin. Regarding yellow fever, which, when the
Panama Canal is opened, will probably become a
disease for China to guard against, the provisions of
the Washington Convention of 1905 were considered
of too stringent a character. The Conference fixed
a period of six days’ observation or surveillance to
be obligatory in the case of infected ships and
optional in the case of suspected ships. In both
categories mosquitoes were to be exterminated on
the ship, as far as possible, on arrival and before
unloading. If this were not possible, precautions
were to be taken with regard to persons employed
in unloading. Both infected and suspected ships
were to moor, when feasible, 200 metres from shore,
in order to prevent the circulation of mosquitoes
between ship and land. These regulations were
made obligatory in countries only where the
Stegomyia calopus exists, that is to say, in China.
Pustio HEALTH MEASURES NEEDED.
The application of measures for excluding rats
from dwellings throughout the Settlement.
Further amendment of the Chinese Building
Rules so as to secure as far as possible rat-proof
houses.
Amendment of the Foreign Building Rules so as
to secure proper kitchen arrangements and, as far
as possible, rat-proof houses.
Extension of the Health Office and Laboratory
building.
Completion of the Isolation Hospital to include
isolated accommodation for cases of tuberculosis
among foreigners.
Further development of Health Offices in each
sanitary sub-district, including an improved system
‘of death registration.
Dispensaries for Chinese consumptives (in con-
nection with the District Health Offices), a hospital
for advanced cases and a sanatorium for curable
cases of consumption.
A new Land Regulation dealing with Public
Health measures generally.
More small public markets.
The following general Public Health Notices, for
foreigners and Chinese respectively, have been
published during the year.
Pusuic HEALTH NOTIOE rog FOREIGNERS.
The following measures are recommended for the
purpose of preventing those, diseases which, by
means of public sanitation and by individual careful
living, are preventable, such as typhoid fever,
cholera, dysentery, diarrhæa, and other bowel dis-
orders, small-pox, scarlet fever, diphtheria, tuber-
culosis, plague, and malaria.
Public Measures.
Sanitary inspection of houses will be carried out
free of charge on application to the Health Officer.
Persons about to rent houses are advised to ask the
Health Officer for a sanitary inspection and a
certificate of good sanitation before closing with the
landlord.
Conditions dangerous to health should be reported
to the Health Officer.
Isolation of cases of dangerous infectious disease
is provided at the Isolation Hospital, Range Road.
Disinfection of premises after infectious disease
will be carried out free of charge on application to
the Health Officer.
Individual Measures.
Eut and drink nothing that has not been recently
cooked, boiled, or otherwise sterilized.
Do not consume :—
* Fruit, vegetables, salads, melons, &e., which
have not been cooked or sterilized.
fty* Fruit, tomatoes, melons, &c., can be sterilized so that they
can be safely eaten raw, and without spoiling the flayour, by
Nov. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
355
Food on which flies have settled.
* Milk or cream which has not been boiled or
sterilized.
* Water which has not been boiled or filtered
through a Berkefeld filter.
Aerated waters and other drinks unless of best
quality.
Alcoholic drinks during the hot weather.
Ice-cream unless made of boiled materials.
Uncooked oysters.
Fish from June to October.
Kitchen supervision should be thorough because
the preventable diseases specially prevalent in
Shanghai are mostly caused by infected food.
Every house should have a serving-room adjoining
the dining-room and separate from the kitchen.
The serving-room should contain the Berkefeld
filter, ice-chest, table utensils, washing sink, boiled
milk, drinks, bread, butter, fruit, and other cooked
or prepared foods. Cooking or boiling destroys
infection.
Vegetables and fruit grown near the ground, being
watered as a rule with nightsoil, are specially liable
to be soiled with the germs of typhoid fever, cholera,
dysentery, and other bowel diseases, and should,
before cooking, be strictly kept out of the serving-
room and from contact with cooked or prepared food.
Flies carry disease, so they should be excluded
from the serving-room, kitchen, and servants’
latrine by providing spring doors and unopenable
windows screened by perforated zinc, and from the
food on the table by fly covers.
Vaccination should be done on arrival in Shanghai
and afterwards every three years.
Keep rats out of your house. Starve the rats by
providing no food for them in and around your
house. Keep cats. Make your house rat-proof.
Mosquitoes carry malaria. Where mosquitoes
cannot be exterminated by abolishing stagnant
water or by the use of kerosene oil, or by reporting
their presence to the Health Officer, the mosquito
net should be carefully used. A weekly inspection
should be made and no standing water permitted.
Refuse should not be allowed to accumulate, and
a properly covered, easily lifted galvanized iron re-
ceptacle should be provided. Nightsoil buckets
should be kept securely closed, including those in
the servants’ latrines. Proper receptacles for these
purposes may be obtained at the Health Office.
Yards and drains should be kept in a good state of
repair and freely flushed with water.
VITAL STATISTICS.
Population.
The foreign population of the Settlement north
of the Yangkingpang, including the outside roads
and Pootung, at the last census taken on October
dipping for a few seconds into briskly boiling water. Straw-
berries are better sterilized by dipping into boiling sugar syrup.
Milk and cream can be sterilized by placing the bottles in a pan
of cold water and gradually raising to boiling point. The
candle of the Berkefeld filter should .be lightly scrubbed in
running water and then boiled once a week regularly.
15, 1910, was 13,530, and consisted of 6,293 men,
4,172 women, and 3,071 children. The foreign
shipping population, which numbered 1,755, was
not included. The foreign population for the middle
of 1911 was caleulated at 14,000. The census of
the foreign population taken at each quinquennial
period since 1870 shows the following expansion:
1,666, 1,678, 2,197, 3,673, 3,821, 4,084, 6,774,
11,497, 13,536.
The native population on October 15, 1910, was
488,005, and consisted of 227,175 men, 129,924
women, and 130,906 children. The Chinese popu-
lation for the middle of 1911 was calculated at
500,000. The census of the Chinese population
taken at each quinquennial period since 1870 shows
roughly the following expansion: 175,000, 96,000,
108,000, 126,000, 168,000, 241,000, 345,000,
452,000, 488,000.
Deaths.
Deaths among the Resident Foreign Population.
—-During the year 1912 the total corrected number
of deaths registered among foreigners, including
non-Chinese Asiatics, was 343; of this number 294
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,
ealeulated from 294 deaths occurring among the
resident foreign population of 14,000, is 21, as
against 16:8 in 1911. The deaths of 102 children
(persons under 15) have been registered, as against
78 last year; of the deuths among adults, 120 were
men and 72 women; of children, 51 were boys and
51 girls. The mean age at death among the adult
resident population was 41°5.
Small-pox, the most obviously preventable of all
diseases, levied a toll among the unvaccinated.
Scarlet fever, which killed so many in 1902, shows
signs of increased prevalence.
Tuberculosis heads the list of fatal diseases both
umong foreigners and Chinese, and the prevention
of this disease offers a fine field for future work.
Alcohol has been responsible for the deaths of
ten foreign residents during the year.
Lobar pneumonia, which nine years ago assumed
almost epidemic proportions, caused four deaths.
Beriberi is now a frequent cause of death among
foreigners on account of the increased Japanese
population.
Plague-infected rats were found in diminished
numbers.
Among the non-resident population the chief
causes of death were acute diarrhea, drowning,
tuberculosis, small-pox, typhoid fever and dysentery.
Deaths among the Native Population.—9,863
deaths among the Chinese have been reported
compared with 6,799, 8,156 and 8,329 in the three
preceding years.
The death-rate per thousand per annum is 19:8.
There were 124 deaths from small-pox, as against
356
156 last year.
Both scarlet fever and diphtheria
show increased prevalence. Of the deaths, 5,818
were male and 4,845 female. The deaths of 3,993
children (persons under 15) have been registered;
of these, 2,107 were boys and 1,886 girls.
INFECTIOUS DISEASE.
Notification.
In the absence of legal obligation to notify, an
arrangement has been made between the Municipal
Council and the qualified medical practitioners of
Shanghai requiring notification of infectious disease
for the facilitation of preventive measures, in con-
sideration 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, typhoid fever, typhus fever, diphtheria,
scarle& fever, tuberculosis, plague, anthrax,
glanders, leprosy and hydrophobia. Tls. 367 were
paid for notification fees, as against Tls. 885 and
Tls. 110 in the two preceding years.
The system of notification, so far as it goes, has
worked well, and the best thanks of the community
are due to medical practitioners for their co-
operation. Chinese cases are beginning to be
usefully notified by Chinese practitioners educated
according to the foreign standard.
During the year 113 Bills of Health for ships and
cargoes were Issued, as against 147 in the previous
ear.
Weekly returns of infectious disease have been
exchanged so as to get in touch 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, an account of the work
of whieh institution will be found under Hospitals.
Disinfection.
7,122 rooms were disinfected, as against 1,086
and 2,162 in the two preceding years; 108,550
articles have been disinfected by steam, compared
with 80,575 and 107,288 in the two preceding years.
29,704 articles were disinfected by formalin, com-
pared with 24,856 last year. The Disinfection
Station adjoins the Isolation Hospital. Prior to
disinfection each disinfector dons a sterile overall.
The general method of disinfecting in a house after
a case of infectious disease is firstly to remove to
the Station everything that can be disinfected by
steam ; then to spray and wash walls, floors, fittings
and furniture with disinfecting solution (cyllin).
Fragile and delicate ware, such as bonnets, books
and photographs, are disinfected by formalin. In
many cases, such as after typhoid fever or diph-
theria, disinfection of walls, &e., is not considered
always necessary, the washing with disinfectant
being then limited to articles that have been
actually in contact with infected material. After
disinfection, painting or colour-washing of walls and
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 15, 1918.
ceiling is advised to be done by the occupier before
the room is again occupied, without which no
responsibility can be accepted by the Health Office.
Small-poz.
The incidence of small-pox was considerable.
Twenty cases were notified among the resident
foreign community, of which three were fatal.
Among the Chinese there were 124 deaths from
small-pox, as compared with 156, 304, .19, 143 and
863 during the preceding five years.
Small-pox is the typical preventable disease, and
its presence or absence is an index of the hygienic
edueation of a community. In Shanghai the
Chinese are beginning to appreciate the benefits
of vaecination as opposed to inoculation, which they
have praetised with little benefit for hundreds of
years, and which is now illegal in almost all civilized
countries.
Vaccination is done free for all Chinese and
indigent foreigners applying at the Sub-district
Health Offices. Vaccine is also supplied free to the
Chinese hospitals in Shanghai. 6,108 vaccinations
have been done by the Health Offiee during the
year, as compared with 465, 380, 520, 1,418, 4,649,
9,244, 4,008 and 4,938 in previous years.
There is no doubt that vaccination repeated until
it no longer takes always prevents small-pox. The
criterion of efficient vaccination is inability to be
vaccinated. In Shanghai there exists so much
small-pox infection that vaccination should be
repeated every three years until it no longer takes.
Where previous good vaccination is not shown by
white net-like scars, aggregating at least one square
inch in area, particular care should be taken to get
efficiently vaccinated.
Cholera.
Acute diarrhcea of choleraic type was prevalent
from July to September, affecting severely both
foreigners and Chinese. In none of the numerous
cases examined, with the exception of a case intro-
duced from Sungkiang, was the characteristic
cholera organism found after repeated and extended
examination in the Laboratory. Not only were
vibrios of any kind remarkable for their absence
from the stools of these cases, but such as were
discovered showed no agglutination with a specific
cholera serum. Though the disease was not recog-
nized as Asiatic cholera in the absence of the cholera
organism, cases were notified as cholera by prac-
titioners and cases brought to Japanese ports on
ships from Shanghai were declared to be cholera
and quarantine restrictions imposed.
Attention was directed to the need of personal
care in preventing the group of bowel diseases
characteristic of life in Shanghai, which includes
cholera and allied conditions, typhoid fever and
dysentery and allied conditions. The same methods
of prevention apply to all, namely, to eat and drink
nothing that has not been recently boiled or cooked
or otherwise sterilized.
Living in an alien country, the only sure way of
securing purity of food is by sterilization. Steriliza-
Nov. 15, 1913.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
tion means freeing from micro-organisms, especially
the bacteria of disease. Sterilization may be
accomplished best of all by heating to boiling-point,
as by cooking and boiling. The Berkefeld filter
sterilizes water, provided the filter candle be boiled
once a week at least. Canned goods, including
butter, are necessarily sterilized during the process
of canning, otherwise they would not keep. Bottled
beverages of good reputation are practically devoid
of dangerous bacteria. Ice is not sterile and should
not be put into drinks. Fresh fruit, tomatoes,
melons, &c., may be effectively sterilized, without
spoiling the flavour, by immersion for a few seconds
in boiling water, any infection that may be present
being invariably on the surface, provided the fruit
be sound.
lf the simple rule be observed of eating and
drinking nothing that has not been recently cooked
or boiled, or otherwise sterilized, it is practically
impossible to contract any of those bowel troubles
to which the Shanghai resident is especially prone.
When this fundamental fact is grasped, ''chills,"'
"livers " and ‘‘ cholera belts °’ will cease to be
considered matters of importance.
Typhoid Fever.
The incidence of typhoid fever remains an impor-
tant sanitary factor. The fatality of the disease,
now that para-typhoid fever and undulant fever are
less frequently included, approaches the true type.
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
contaminated with infected water, through the air
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
Health Office.
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 vege-
tables are frequently the source of infection with
typhoid fever, cholera, dysentery and other forms
of diarrhea, and particular 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 pantry or serving-room where table
utensils, ice-chest, bread, milk, Berkefeld 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
357
to cooking is an additional precaution that may be
recommended.
Measles.
There was an outbreak of measles, remarkable
for its infectivity and severity, from November,
1911, till April, 1912. There were three fatal cases
among foreigners and 373 among Chinese. As
bearing on this subject it may be noted that a
similar epidemic visited the Philippine Islands
about four months earlier. The severity of the
disease was much greater than usually encountered
and was attributed to the introduction of a new
strain of virus by transports from the United States ;
it was, in fact, decided to make it quarantinable.
Diphtheria,
The incidence of this disease has not been marked,
and the case fatality has been small. Diphtheria
antitoxin is supplied free to indigent patients in
Shanghai on the recommendation of the physician.
In any case of suspected diphtheria, antitoxin should
be given at once, without waiting for the result cf
the bacterial diagnosis.
Scarlet Fever.
The annual admission of foreign cases into the
Isolation Hospital since 1902 has been 84, 7, 11,
11, 20, 70, 25, 9, 32, 22, and 64. Of these 305
cases 54 proved fatal, a case fatality of 16°7 per
cent., as compared with a case fatality in England
of under 5. The case fatality has not markedly
changed since the introduction of scarlet fever into
Shanghai.
Although scarlet fever has hitherto failed to
establish itself firmly in any part of Asia, excepting
Asia Minor, and is practically unknown in the
Tropics, it appears to have come to Shanghai to
stay. Scarlet fever was practically unknown in
Shanghai prior to 1900, when it was probably
introduced by foreign immigrants. As would be
expeeted with a recently introduced disease, against
which evolution has afforded no natural immunity,
scarlet fever has been of a virulent type among the
Chinese. It is probable that the passage of the
disease through the susceptible Chinese has led to
an intensification of the virus, so that it is more
fatal to foreigners also.
Early notification, isolation and disinfection are
especially necessary in dealing with such a fatal
and infectious disease as scarlet fever is in
Shanghai. The commonest mode of infection is
from a previous case either by contact, by proximity,
or by means of infected articles. The infection is
given off by the breath in coughing and speaking,
by the secretions of the mouth, nose, ear and
throat, and later by the peeling skin.
The incidence during the year was sporadic and
indieates need for early isolation and disinfection
to prevent an epidemic recurring among the vast
mass of susceptible material which exists in the
Settlement.
Tuberculosis.
The prevalence of tuberculosis remains at the
same high level. The enormous death-rate is
358
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Nov. 15, 1913.
significant of local conditions of overcrowding,
against which there is at present no legislation.
The prevalence of tuberculosis bears little relation
to climate, but is common wherever man closely
aggregates. The spit of consumptives, being in-
fectious, should only be received into receptacles
which can be burnt or boiled, or the contents
destroyed by strong antiseptics, fire, or boiling
water. It is probable that most cases of tuber-
culosis of the lungs are contracted by breathing
the infected droplets ejected by infected persons
during coughing, sneezing and speaking.
It is hoped, as soon as small-pox is practically
exterminated, to engage in a campaign against
tuberculosis among the Chinese. The establish-
ment of a Tuberculosis Dispensary in connection
with one or more of the Sub-district Health Offices,
where treatment and advice as to preventing the
communication of the disease to others could be
given, would be the first step. As soon as con-
fidence is established and co-operation gained there
would be need of a hospital for advanced cases and
a sanatorium for curable cases.
Plague.
Plague-infected rats were found in December,
1908. A complete plague survey of the Settlement
has been maintained since. During 1912 14,988
rats were found dead and brought to the Laboratory
for examination, and of these 95 were plague-
infected, compared with 187, 249 and 138 during
the three preceding years. During the year nearly
154,000 rats were trapped and burnt. These, with
the rats found dead and examined for plague,
brought the total number of rats visibly aecounted
for to 168,988. In addition to the trapping, close
on six million phosphorus baits were laid, about a
ton of poison being used, which proved a powerful
method in dealing rapidly with infected foci.
Poisoning on so large a seale carried with it certain
risks, but, since using poisoned cubes coloured
bright blue instead of the usual method of spreading
the poison on bread, no cases of adventitious
poisoning have been reported. 1,597 houses, in
plague foci, were temporarily rat-proofed and
pulicidally disinfected; bedding, &e., being passed
through the steam disinfeetor. This temporary
rat-proofing included the plastering up of rat holes,
brieking up and wire-netting places permitting
ingress of rats into houses; the furniture of the
house being removed to permit of thorough examina-
iion for rat holes and runs.
During October special inspection was placed on
a part of the No. 2 Central Sub-distriet where six
plague-infected rats occurred in rapid succession at
a time when the remainder of the Settlement had
been completely free from rat infection for three
months. This same focus was previously infected
in 1909 and 1910. The discovery of a human case
of plague on November 2 was not, therefore, wholly
unexpected, and tended to confirm the extent of
the rat infection and the efficacy of the present
method of plague survey by daily examination for
plague in the Laboratory of rats found dead in all
the areas into which the Settlement is divided for
sanitary purposes. Between November 2 and 19,
seventeen cases of bubonie plague arose within an
area limited by the Nanking, Fokien, Peking and
Shanse Roads. The first cases were discovered »n
the ordinary course of sanitary inspection and the
disease confirmed by laboratory examination. The
Director of the Chinese Publie Isolation Hospital
then offered, according to an arrangement previously
made, to send his staff of Chinese doctors to carry
out house-to-house inspeetion within the infected
area with a view to the discovery of cases, isolation
and treatment. The arrangement was carried out
with cordial co-operation. On the occurrence of
the first human ease of plague the rat-proofing staff
was concentrated on this area, so that by the end
of the year 893 houses in the infected area had been
permanently rat-proofed, over 200 men being, at
one time, employed on this work. The average cost
of rat-proofing these houses was $11. No further
cases were reported in this area subsequent to
December 19. The measures adopted were carried
out with an almost complete absence of that sanitary
hysteria which sometimes characterizes an outbreak
of this dread disease. The inhabitants of the in-
fected area showed no active opposition to the
measures taken, a cireumstanee which was to some
extent due to the leetures which were given in
various parts of the infected area daily explaining
the reason for the measures taken. There were
rumours that the outbreak was one of pneumonic
plague because of the oecurrence of secondary pneu-
monic symptoms in some of the cases, and it was
feared that the epidemic of pneumonic plague which
broke out about this time two years ago in Man-
churia might be repeated in Shanghai. . The out-
break, however, conformed to the usual bubonic
type. The conditions in Shanghai, though not
making the occurrence of an epidemic of pneumonic
plague impossible, through the overerowding which
prevails, are not comparable with the exceptional
conditions obtaining during the Manchurian winter.
A ease of plague occurred on December 10 at
19, Yunnan Road, near the junction of the Yang-
kingpang and the Defence creek, a place where
plague-infeeted rats had from time to time been
found. During subsequent rat-proofing operations
three plague-infected rats were found in hollow
ceilings and two below hollow floors.
As a result of the extensive rat-proofing opera-
tions in the Northern District during the last two
years, some 5,265 houses being done, a gratifying
reduction of plague-infected rats has resulted;
during the last quarter of 1910 there were 126
plague-infected rats found, while during the same
quarter of 1912 only 4 were found. An unsatis-
factory cireumstance at present attending plague
prevention measures lies in the faet that new houses
are being erected in accordance with the Chinese
Building Rules, which, as they contain ceilings,
afford ample facilities for rats to live and multiply
within the houses and become a source of plague.
Indeed, the first cases of the above outbreak
occurred in an alley of new houses with solid ground
Nov. 15, 1913.)
floors but which had ceilings. In the space en-
closed by the lower ceiling, which was subsequently
removed with the permission of the landlord, dead
rats were found which had undoubtedly been the
cause of the plague cases. The hollow space
enclosed by the lower ceiling is a place much
{frequented by rats and one where they are the
greatest danger through proximity to the beds of
the occupants. There can be no question now that
if Shanghai is to be kept free from plague, lower
ceilings in Chinese houses should not be permitted
except in special cases. A very large number of
both upper and lower ceilings have been removed
during the present year from old houses in plague-
infected areas with scarcely any complaint except
in the case of the upper ceiling. Property owners
and architects are respectfully requested to inspect
these houses where ceilings have been removed with
a view to confirming the truth of these statements.
If, as a result of this, the approval is obtained of an
amendment of the Chinese Building Rules to omit
the lower ceiling in the majority of Chinese houses
a sanitary danger of the first importance will be
removed.
The corrugated iron rat-proof barrier against
Chapei erected in August, 1911, was removed in
September, 1912, an effective barrier of rat-proof
houses along the boundary of the Settlement having
been made.
A plague preventive measure of considerable
permanent value has been the erection of rat-proof
house refuse receptacles on Chinese property. A
marked improvement in the cleanliness of alleys
has resulted. It will be apparent that rats will
thus be deprived of a vast store of nourishment and,
us the rat population is to a large extent regulated
by the amount of the available food supply, this
is held to be a radical plague-preventive measure.
Although the initial cost of permanent rat-proofing
is comparatively large, yet, if adequate building
rules are promulgated and new houses built in
accordance with the requirements of modern sanita-
tion, not only will it be possible to gradually reduce
to extinetion the present large plague prevention
staff, but this measure of permanently rat-proofing
houses forms the greatest insurance against plague
in the future, and is, in fact, the only permanent
safeguard. A house permanently rat-proofed is
not only a healthier one to live in, but is an almost
certain guarantee against bubonie plague to the
inmates.
Of the rats examined in the Laboratory, about
70 per cent. were Mus rattus and the remainder
Mus decumanus—rattus being the black or ship
rat, which usually lives in houses; and decumanus,
the brown or sewer rat. Mus rattus largely pre-
ponderated among those plague-infected. Of the
fleas, Xenopsylla cheopis and Ceratophyllus fasciatus
have been identified, the former being the flea
usually associated with the spread of plague from
rat to man.
In formulating anti-plague measures the rat has
been the chief objective, as it is held that the rat
is the essential eause of epidemies, the flea being
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
359
the carrier of infection from rat to rat and from
rat to man, infection from human cases, which is
practically limited to the few pneumonic cases
which usually arise, being comparatively rare.
The dictum ‘‘ No rats, no plague ’’ has been taken
as a working basis, and a house that is rat-proof
has been considered for all practical purposes
plague-proof.
The following is a summary of measures put into
operation :—
Public Measures.
(1) Plague survey by enquiry into the cause of human deaths
and by collection of rats found dead throughout the Settlement
for examination in the laboratory in order to locate plague
infection. (2) Careful daily collection and disposal of house
refuse from every house and storage of house refuse in rat-proof
receptacles so as to deprive rats of means of sustenanco.
(3) Rat-proofing of houses: (a) Temporary, by service of notice
on occupiers asking for co-operation in cleansing, pulicidal
disinfection, demurization aud rat-proofing by minor repairs,
&c.; (b) Permanent, by service of notice on owners requiring
solid ground floors, removal of ceilings and hollow partitions
and stair linings so as to deprive rats of accommodation. (4) Rat
destruction by trapping and poison in infected areas beginning
at the periphery EnA ROMBE towards the centre. (5) Preventive
inoculation with plague vaccine beginning with the sanitary
staff.
Individual Measures.
No rats. No plague. A house that is rat-proof is plague-
proof. (1) Keep cats. (2) Rid your house from rats by trapping
and poisoning. (3) Make your house as rat-proof as possible.
(4) Provide no food forrats. Keep all food in places inaccessible
to rats. Grain and such like food for ponies, towls, &c., should
be kept in covered galvanized iron receptacles. See that your
servants keep their rice bags where rats cannot get. Keep
house-refuse in properly covered galvanized iron receptacles and
see that they are covered, especially at night. Keep the kitchen
and its surroundings very clean; let no refuse lie about.
(5) See that the gratings into the space below the ground floor
keep out rats, and that the brickwork of the basement is imper-
vious to rats. If rats gain access through windows or other
openings on the ground floor keep them out by screening with
wire-netting or perforated zinc. (6) See that all openings into
covered drains are kept in good repair to prevent egress of sewer
rats. Carefully inspect all corners of the house from top to
bottom once weekly, moving furniture where necessary. Do
the same in the stable, fowl-house, and other out-houses.
Arrange for the plastering up of rat-holes or any place that may
afford ingress to rats and mice. (7) All rats trapped or
poisoned should be burnt; other rats found dead in or about
the house should not be touched with the hands, but should be
picked up with tongs, put into Jeyes' fluid and water (1 in 20)
and sent to the Health Officer for examination for plague.
(8) Get vaccinated against plague if exposed to infection.
(9) If you have any difficulty in carrying out the above measures
communicate with the Health Officer in writing.
Malaria.
A comparatively small number of cases of malarial
fever, mostly of the benign tertian type, are con-
tracted in and around Shanghai.
Periodic examination has been made of mosquitoes
colleeted from each of the sanitary distriets into
which the Settlement is divided, and the following
have been found: Myzorhynchus sinensis (malaria
bearing), Stegomyia scutellaris (yellow fever bear-
ing, Culex fatigans (the host of filaria), and
Armigeres ventralis.
The prophylaxis of malaria resolves itself into:
(1) Suppression of mosquitoes; (2) prevention of
infection of man by mosquitoes; (3) prevention of
infection of mosquitoes by man.
Every effort should be made by householders to
do away with all receptacles of stagnant water,
360 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 15; 1913.
e ——————— e
where mosquitoes breed, such as ponds, water-
plants, drains out of repair, abandoned tubs, pots,
tins and what not. The mosquito net should be
assiduously used whenever there are mosquitoes,
and especially.in up-country houseboat trips. It is
doubly necessary to surround a person suffering
from malaria with mosquito netting to prevent
mosquitoes being infected and acting as carriers
of infection. ;
An account of the special mosquito extermination
work will be found later under that heading.
Beriberi.
The incidence of beriberi among the municipal
prisoners has diminished. The cause of this disease
remains under close observation, though up to the
présent wrapt in obscurity. The evidence pre-
ponderates in favour of the disease being an infective
one having no direct relation to food but infective
through body vermin. The recommendations re-
garding the admission of municipal prisoners will,
if carefully carried out, settle the latter point. At
the gaol there were 2 cases as against 27, 34, 134,
0, 0, 2, 2, 2, 1, 5, 78, 16 and 7 in succeeding
years since 1899; such improvement being held to
be attributable to the measures of disinfestation of
body vermin among the convicts.
Dysentery.
Dysentery, with liver abseess as a not infrequent
sequel, continued prevalent. It would appear that,
unlike the type of dysentery prevalent in Japan
which is buacillary in origin, of relatively greater
fatality and unattended by liver abscess, that which
occurs in Shanghai is mostly ameebic in origin and
prone to produce liver abscess. As regards preven-
tion the remarks made under cholera apply with
equal force to dysentery.
Acute Lobar Pneumonia.
This disease, which was rare prior to 1898, has
in subsequent years caused 8, O, 8, 2, 2, 6, 4, 1,
10, 4, 8, 4, 4 and 4 deaths respectively among
resident foreigners.
Rabies.
Ten persons were bitten by rabid dogs within the
Settlement during the year and subsequently under-
went the Pasteur treatment. The virus of rabies
in Shanghai dogs is of an exceptionally intense
character, the period of incubation being shorter
than the rabies met with in dogs in Europe.
Leprosy.
Leprosy is a disease which so seldom concerns
foreigners in Shanghai that its study is somewhat
neglected. Cases are met with occasionally, though
it seldom figures in the death statistics of either
foreigners or Chinese. There appears to be no
urgent call for special preventive measures.
Dengue.
l'rom its home in the Malay Archipelago, dengue
has frequently during recent years spread up the
coust ports to Shanghai. It very rarely kills, but
frequently incapacitates from work a large section
of the community. It is an intensely infectious
disease, spreading in mass like influenza, but
appears not to be spread by contagion.
Relapsing Fever.
‘Relapsing fever again made its appearance among
municipal prisoners. The examination in the
Laboratory of the blood from certain fever cases
has shown that relapsing fever is probably quite
common among the Chinese population and occurs
also to some extent among foreigners. This fever
is much more prevalent in Shanghai than has
hitherto been supposed, a circumstance which may
help in the future to clear up certain obscure cases
of fever.
It is probable that infection is determined by the
presence of body vermin and measures which ensure
their destruction will prevent the disease spreading.
Cattle Plague.
Cattle plague prevailed extensively in the dairies
during the year. The mode of incidence appears to
show that its origin is not irt food, nor is the infec-
tion carried by the coolies, but that insects are the
probable means of spread. Immunization by Koch's
gall method is usually available from the Municipal
Laboratory but is seldom taken advantage of. The
ordinary preventive measures of isolating sick
animals and thorough disinfection were carried out
so tar as possible. :
Kölle and Turner’s simultaneous method of
immunization by virulent cattle plague blood and
immune serum can be recommended as producing
a greater degree of immunity than the gall method,
but its application is more difficult and there may
be some slight loss of cattle as a direct result.
There can be no doubt that were dairymen to have
their cattle thus immunized they would be saved
great subsequent financial loss from epizooties of
cattle plague.
Three cattle were rejected for cattle plague at
the slaughter-house during the year, as against
6, 12, 7, 56, 5 and 8 during the years immediately
preceding.
Other parts of this very interesting report deal with
sanitary inspection, food supplies and cemeteries.
All interested should consult the original paper,
as it is so full and clearly written that it may be
looked upon as a model for sanitary reports in other
parts of the world as well.
Blotices to Correspondents.
1.—Manuscripts sent in cannot be returned.
2.— As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OP TROPICAL MEDICINE AND HYGIENE shouid com-
municate with the Publisners.
5.— Correspondents should look for replies under the heading
“ Answers to Oorrespondents."'
Dec. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 23, Vol. XVI
@riginal Communications.
THE METEOROLOGY OF MALARIA.
By Matruew D, O'CosNELL, M.D.
Betow I give hourly records of meteorological
conditions at Bombay for two complete periods of
Hourly atmospheric conditious at
hourly observation the nearest meteorological con-
ditions which were found, by observation, to raise
body temperature in the Lancashire cotton sheds.
I have added to both the drying power of the air
per 10 cubic feet in order to indicate the rate at
which heat was being lost from the body by evapora-
tion in each atmosphere.
Atmospheric conditions which Degree to which bony tem-
n
Bombay raixed y temperature in the perature was raised in the
cotton sheds of Lancashire cotton sheds
eae ——————
Temperature of Drying Velocity of Temperature of Drying Body tempera- Pulse Respira-
air, F. power of air wind per air, power ofair ture in the tions
per 10 cub. ft. hour per 10 cub. ft. mouth, F.
————
Bombay, 1912 Dry Wet Grains Miles Dry Wet Grains
September 15, 1 o'c. a.m. 78:69 15:49 17 8 78:5° 73°5° 25 99-6? 116 22
” 2 ” 78:6 75:8 17 8 78:5 73:5 25 99:6 116 22
” 8 T 78:3 75:1 14 4 78:5 73:5 25 99:6 116 22
” 4 2 79:0 754 19 4 79:0 73:6 28 100:3 110 24
” 5 ” 78:9 T5:4 18 4 79:0 73:5 28, 100:3 110 24
” 6 ” 787 75:8 18 4 78:5 73:5 25 99:6 116 92
» 7 iy 79:2 75:5 19 4 79:0 73:5 28 100:3 110 24
” 8 » 801 76:6 19 7 80:0 73:0 36 99-2 92 28
" 9 » 81:9 TTT 24 4 82-0 75:0 38 99:2 92 16
Es 10 ” 81:7 77-2 26 4 81:5 75:5 32 100:2 112 31
n 11 ” 81:9 76:9 27 5 82:0 75:0 38 99:2 92 16
AA 12 o'c. noon 88:0 767 85 7 83-0 75:0 43 99:3 92 16
7 1o'c. p.m 84:2 75:9 50 10 84:0 770 89 100:3 84 25
” 2 " 85:0 76:5 47 11 85:0 17:0 45 100:4 120 24
" 3 » 85-0 77°2 44 9 85:0 77:0 45 100°4 120 24
$5 4 » 84:6 761 47 10 84:5 77-0 42 100:6 96 26
, 5 ” 88:5 75:1 46 8 83:5 74:0 50 99:8 116 20
n 6 » 81:9 74:4 40 9 82:0 75:0 38 99:2 92 16
” 7 T 81:2 74:8 36 8 81:0 74:0 37 99:9 120 20
T 8 n 80:8 74:2 35 7 81:0 74:0 37 99:9 120 20
n 9 ” 80:4 73:7 35 7 80:5 13:0 32 99:6 92 20
T 10 ” 80:8 741 83 T 80:5 73:0 32 99:6 92 20
” 11 ” 79°7 73:8 81 8 79:5 74:5 26 100:2 90 24
12 o'c. midnight 79:8 75:0 25 8 800 _ _ 750 27 99:2 92 28
Hourly atmospheric conditions at
Degree to which body tem-
perature was raised in the
cotton sheds
Atmospheric conditions which
raised b dy temperature in the
cotton sheds of Lancashire
SS EUM ET Cpu one nein,
Temperature of Drying Velocity of Temperature of Drying Body tempera- Pulse Respira-
air, F. power of air wind per air, F. powerofair ture ín the tions
per 10 cub. ft. hour per 10 cub. ft. mouth, F.
——— —
Bombay, 1912 Dry Wet Grains Miles Dry Wet Grains
October 15, 1lo’c. à m. 79:59 77:59 11:0 4 79:5* 74:59 26:5 100°2° 90 24
” 2 33 79:0 76:9 11:5 1 79:0 13:5 28:0 100:3 110 24
Š 3 ” 79:0 770 11:0 3 79:0 73:5 28:0 100:3 110 24
ix 4 » 179 9 76:9 12:7 5 79:0 73:5 280 100:3 110 24
» 5 a 78:9 71:0 10:5 4 79:0 73:5 25:5 100:3 110 24
3s 6 33 79:1 76:9 121 4 79:0 73:5 28:0 100:3 110 24
23 7 T 79:83 76:9 127 F 79:5 74:5 28:0 100:2 90 24
" 8 i 80:6 77:5 17:5 3 80:5 73:0 38:5 99:6 92 20
A 9 ” 82°3 778 25:8 1 82-0 76:0 83-0 99-2 88 14
a 10 ss 84:0 79:0 30:0 3 84:0 71:0 39:0 100°3 84 25
$3 11 n 85:6 71:4 47:0 4 85:5 78:0 44:0 100:1 82 22
3: 12 o'c. noon 86:2 80:0 38:2 6 86:0 77:5 49:0 99:2 80 20
T 1 o'c. p.m. 863 79:8 42:8 6 86:5 79:5 42:5 99:2 92 16
£5 2 n 87:5 80:8 42:0 7 87:9 76:0 63:0 100-4 100 20
is 8 at 87:6 80:9 49:1 7 87:2 76:0 63:0 100:4 100 20
” 4 ” 867 80:3 89:4 7 86:5 79:5 42:5 99:2 92 16
ao 5 » 85:6 80:2 33:4 5 855 78:0 44:0 100:1 82 22
ey 6 i 84:1 79:8 28:8 4 840 71:0 89:0 100:3 84 25
a 7 s 83:5 79:0 26:0 4 83:5 71:5 84:5 100 1 100 20
w 8 4 88:1 78:8 24:8 4 83:0 74:0 47°0 99:8 104 21
= 9 is 82:4 78:6 22:0 1 82:0 760 33:0 99:2 88 14
na 10 a 82:0 78:2 22:0 4 82:0 76:0 33:0 99:2 88 14
T 11 » 81:8 767 25:8 8 81:5 75:5 82:5 100:2 112 31
ag 12 o'c. midnight 80:6 76:3 28:5 7 80:5 73:0 88:5 99:6 92 20
twenty-four hours in the season following the rains
when malaria is prevalent. For these records I am
indebted to the courtesy of the Director of the
Government Observatories at Bombay.
For comparison I have placed opposite each
The explanation of the manner in which atmos-
pheric conditions such as the above produce an
intermittent fever, with increased destruction of
red blood corpuscles and enlargement of the spleen,
need not be here repeated. It has already been
362
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Dec. 1, 1913
given in the JOURNAL or TROPICAL MEDICINE AND
HYGIENE of September 1, 1913, with special refer-
ence to Calcutta, and in previous issues of the
Journal with special reference to Lahore, Allahabad,
Madras, Ceylon and Singapore.
REPORT OF EPIDEMIOLOGICAL SURVEY
AND INVESTIGATION INTO PROBABLE
CAUSES OF SICKNESS AMONGST MULES
ON PLANTATIONS BATH, BLAIRMONT,
PROVIDENCE AND SPRINGLANDS,
BRITISH GUIANA.
By E. P. Mryert, M.D.
Assistant Government Bacteriologist.
From the Government Public Health Department, Georgetown,
British Guiana.
HISTORY.
THE first cases appeared to have occurred amongst
the horses owned by a man named Joseph, near
Plantation Bath, who lost four or five horses about
the month of August, 1912, all creole horses and all
bred locally.
The next cases occurred amongst the horses
owned by a man named Ram Persaud in the same
district, near Plantation Bath, in September, 1912.
He lost eight horses, at intervals of about a few
days, out of a total of fourteen animals affected.
The mules on Plantation Bath appear to have been
first affected early in October, 1912, during grinding
operations on the estate; a total of forty-six mules
were affected, of which thirty-five died during a
period of about twelve months; the most severe
cases dying in five weeks and the more chronic ones
taking as long as six months.
On Plantation Blairmont the grinding finished in
February, 1913, and this estate lost three mules and
two horses out of a total of about eight or ten
mules and four horses affected, the total number of
animals on the estate being thirty mules and four
horses. The sickness started early in May, 1913.
The mules had mixed freely with the Bath animals
during the previous six months.
At Plantation Springlands eleven mules were
loaned to Plantation Bath to assist in getting off
the crops of that estate. The mules returned to
Plantation Springlands about the end of March,
1918. The first case of sickness occurred about
April 9, 19183, and of a total of thirteen mules and
two ponies affected four mules and one pony died.
At Plantation Providence sixteen mules were
loaned to Plantation Bath for three months; these
animals returned home in March, 1918; the whole
of these animals were isolated for six weeks after
their return from Plantation Bath. About May,
1918, eight animals appeared to be affected and
were isolated. Of these animals two died in June
and two in July, 1913.
INCUBATION PERIOD.
Very uncertain, but would appear to be a matter
of several weeks in most cases.
DESCRIPTION OF DISEASE.
The accounts of the clinical symptoms given by
the various observers interviewed tally so closely
that there can be little doubt as to the identity of
the disease in each case. The main symptoms
observed were briefly as follows: Loss of condition ;
pyrexia associated with a very slow pulse; progres-
sive anemia; paralysis of hind legs; paresis of hind
quarters; weakness; hemoglobinuria in a small
percentage of the cases (33 per cent. one estate),
in others it appears to have been transient only.
The animals gradually became comatose and died
quietly. No convulsions seem to have been present.
Jaundice was seldom observed. Hemorrhages into
the conjunctiva appear to have been fairly frequent.
Incontinence of urine was present in a fair propor-
tion of cases, and several observers noticed that
after micturition the animals experienced consider-
able difficulty in retracting the penis, and in some
cases the rectal mucous membrane after defecation.
Temperatures taken by me ranged from 98° F. to
1019 F., but I was informed they had previously
been up to 1059 F.
DURATION OF ILLNESS.
The more severe cases appear to have proved
fatal in about three weeks after onset of symptoms,
but the chronic cases ran a course of six months
and over before proving fatal.
MonBID ANATOMY.
Post-mortem examinations have been made in
three cases, and I am indebted to Captain Farrant,
F.R.C.V.S., for particulars of the two carried out
by him; they differ in no important particular from
my own observations.
The internal organs generally were anemic, and
hemorrhages were present under the pleura, peri-
cardium and the serous coat of the intestine. The
kidneys were very pale and anemic, but the
capsules stripped well; a few hemorrhages under
capsule. There were hemorrhages under the cap-
sule of the liver and in one case jaundice was pre-
sent. The spleen did not appear specially enlarged
in any case, a few hemorrhages were present under
the capsule and in the substance also; in one case
old perisplenitis appears to have been present. The
brain, spinal cord, cerebrospinal fluid and meninges
appeared normal in all these cases. In one case a
clot of blood was observed over the optic thalamus.
Microscopic AND LABORATORY EXAMINATIONS.
Fresh blood was examined immediately after
being drawn from the mule. No flagellates were
detected.
Fresh Brain-squash.—A fair quantity of pigment
detected in the capillaries.
Fresh Cerebrospinal Fluid.—Nothing of an abnor-
mal character detected.
Stained Spleen-smear.—A large amount of pig-
ment present, with degenerated red blood cells.
Stained Blood-slides.—A general anemia, with
Dec. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
363
fair number of polymorphonuclear and large mono-
nuclear cells present. No flagellates or other pro-
tozoa detected.
The following investigations were carried out on
my return to the laboratory :—
Meningococcus.—Sterile glucose broth inoculated
with cerebrospinal fluid with aseptic precautions as
far as possible at time of post-mortem. Subse-
quently plated out in blood agar plates and colonies
investigated. The remainder of the broth was cen-
trifugalized; part of the deposit again plated in
blood agar; the remainder spread on a glass slide
and examined by Gram’s stain. The presence of
Staphylococcus albus only was detected. The Diplo-
coccus intracellularis meningitidis was not detected.
Cerebrospinal Fluid.—A quantity of cerebrospinal
fluid was obtained from the subdural space with a
sterile pipette and preserved in sterilized normal
saline.
Cultivations failed to show the meningococcus.
Centrifugalized deposit showed the cells present
in normal human cerebrospinal fluid only. No
excess. of polymorphonuclear cells detected. No
meningococci detected in cultivation or deposit.
Blood.—About 5 c.c. of blood was drawn off
during life into sterile sodium citrate solution.
Direct examination of the fluid failed to show the
presence of flagellate forms of protozoa. The cen-
trifugalized deposit suitably stained failed to show
the presence of a meningococcus, a trypanosome or
a piroplasma. Forty blood-smears obtained from
ten mules showing a degree of pyrexia varying from
99° F. to 101:59 F. were microscopically examined.
No trypanosomes were detected.
PATHOLOGY.
Portions of brain, spinal cord, spleen, liver,
kidneys, lung and intestines were preserved in
sublimate alcohol, subsequently prepared, and sec-
tions cut in the laboratory for examination.
The kidneys showed a small amount of cloudy
swelling in the urinary tubules. The spleen showed
a large amount of pigment and degenerated blood
cells present.
The spinal cord appeared normal except for a
small amount of small round-celled infiltration sur-
rounding the blood capillaries. No pus cells were
detected nor meningococci.
A similar condition was observed in a section
taken from the base of the brain.
Tricks.
A large number of ticks were removed from
infected mules. The contents of the intestines of
several which were gorged with blood were examined
for flagellates, protozoa, &c. The ticks examined
were of the sub-family Ixodine (genus Ixodes).
BririNG FLiEs.
The contents of the intestines from several flies
'eaught whilst sucking blood from infected .mules
were examined as above. The flies examined were
of the family Muscide (genus Stomozys) and the.
family Tabanide (genus Tabanus).
SUMMARY.
The failure to detect the presence of the Diplo-
coccus intracellularis meningitidis (Weichselbaum),
together with the normal condition of the cerebro-
spinal fluid, both as regards the absence of the
organism and the character of its cellular elements,
is opposed to the diagnosis of epidemic cerebro-
spinal meningitis. This conclusion is supported by
the microscopic appearances of the spinal cords and
brain examined, apart from clinical symptoms, on
which point I am unable to give an opinion. But
the history of the outbreak, the varying time be-
tween exposure to infection and the onset of sym-
ptoms, together with the marked anemia, and occa-
sional and transient hemoglobinuria, would seem to
point to'an insect-carried disease of a chronic nature.
The clinical symptoms closely correspond to the
disease known as mal de Caderas, and to a lesser
degree to the disease known as Babesiasis equi. The
former disease is caused by Trypanosoma equinum
and is supposed to be conveyed by means of a biting
fly. The latter disease is caused by the presence in
the blood of Piroplasma equi, and is conveyed to
animals by means of the tick.
Unfortunately, I have been unable to demonstrate
either of these organisms as present, but the failure
to do so may possibly lie in the fact that these
organisms are not present in the blood at all stages
of the disease.
PROPHYLAXIS.
Fortunately in all the above diseases the prophy-
lactic measures are identical, and are briefly as
follows :— .
(1) Isolation of infected animals.
(2) Thorough cleaning of stables with crude
paraffin and subsequent lime-whiting with a lime-
wash containing an antiseptic (5 per cent. crude
carbolie acid is suggested).
(3) Thorough burning off of infected pastures.
(4) Adoption of the two or three paddock system
for segregating subsequent cases that may occur.
(5) The systematie and regular use of an insecti-
cide on the animals, especially before crossing pas-
tures suspected to be infected.
A suitable wash for animals is as follows:—
Soft soap i Ib.
Water m is + gal.
Dissolve the soap in the water and add, with
constant stirring, two gallons crude petroleum or
paraffin.
(6) The harness should be treated with a similar
mixture.
I beg to tender sincere thanks for assistance in
this investigation to W. M. B. Shields, Esq.,
Captain Farrant, F.R.C.V.8., and the managers and
overseers of the various estates visited.
SUPPLEMENTARY REPORT ON MuLE AND HonsE
DISEASE IN THE COUNTY OF BERBICE.
A bay creole gelding was certified by Captain
Farrant, F.R.C.V.S., as suffering from the disease
known as mal de Caderas.
364
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1918.
Blood-smears were taken from a recently infected
animal during pyrexia, forwarded to the laboratory
on September 24 and received here September 27.
On examination these slides show the presence of
a large number of trypanosomes, which closely
resemble the description given by Vosges in 1902
of a trypanosome named by him Trypanosoma
equinum, and stated to be the cause of the South
American disease known as mal de Caderas.
The principal characteristics of Trypanosoma
equinum is that the kinetonucleus is extremely
minute; this peculiarity is present in the specimens
sent by Captain Farrant.
The presence of these trypanosomes in the peri-
pheral blood of animals suffering from the acute
stages of the disease is, in my opinion, conclusive
evidence of the disease being undoubtedly mal
de Caderas. The clinical symptoms have already
been shown in a previous report to agree with the
above-named disease in horses, which has been
described in Argentina and Central South America.
This trypanosome was discovered by Elmassian,
and described by Vosges. It can be inoculated
into laboratory animals. Its mode of propagation
is not well known, and seems to bear some relation-
ship to the disease which kills the capybara (Hydro-
cherus capybara); this animal appears to be the
reservoir for the parasite. Dogs may be infected
by eating diseased animals, the infection may then
be spread to horses and mules. The transmitting
agent is stated to be a biting fly, either a tabanus
or stomoxys, or more probably both.
E. P. MrxErT, M.D.
SALVARSAN IN FILARIASIS.
By Epmunp R. BngaNcH, M.B., Ch.B.
Basseterre, St. Kitts, W.I.
For very many years I have been in the habit of
treating cases of filariasis with different preparations
of arsenic, giving it after the febrile stages, and
continuing it on and off for several months. This
treatment has proved successful in many cases to
the extent of seemingly making the attacks much
less frequent. I am, of course, aware that this
treatment has been used by very many physicians
with the same result; but no one has claimed to
have effected a cure by it.
Arsenic no doubt has suggested itself in the past
as a likely remedy for filariasis, owing to its well
established value in chronic fevers and other
obstinate morbid conditions, and as salvarsan has
proved to be a most potent form for the introduction
of arsenie into the human organism in the treatment
of syphilis and frambeesia, the idea that it might be
equally useful in filariasis naturally impresses itself
on the mind. With this idea in view I selected a
case in the Cunningham Hospital in which the two
diseases, syphilis and filariasis, occurred together in
very aggravated forms of long standing. An account
of this case is to be found in the Report of the
Vital Statistics for the Presidency of St. Kitts-
Nevis for the year 1912. I may be excused for
quoting this case here. ‘‘ Filariasis.—There is now
a woman in this hospital who has for several years
been afflicted with tertiary syphilis in various forms.
She is also an exceptionally great sufferer from
filariasis, of which she gets an attack of the usual
febrile type at least once a month. The calf of her
right leg used to measure 16 in. in circumference
when no exacerbation of the disease was present,
and the calf of the left leg had, under similar cir-
cumstances, a girth of 18 in. There were also large
freely suppurating ulcers, two or three in number,
on the right foot. The negroes call these ‘ tubba
sores,’ and consider that they keep down the
increased amount of the interstitial discharge. This
woman has been getting salvarsan injections for the
syphilis and has had 10 gr. of the drug. The
'tubba' sores have dried. There has been no
Photograph of the Case referred to in the text.
filarial fever for several weeks, and the circum-
ference of the right leg has fallen from 16 to 14} in.
I have observed similar improvement in other
syphilitic cases treated with salvarsan, which, as
often happens here, where both diseases are so
common, were afflicted also with elephantiasis.''
From subsequent experience extending over nine-
teen cases during the last year, I have found the
following points specially noteworthy :—
(1) The disappearance after treatment of the
micro-filarie in the blood.
(2) The discontinuance of the febrile attacks.
(3) The healing of ulcers, often of very chronic
and indolent nature, and large size.
(4) The reduction, to the extent in some cases of
many inches, in the circumference of long-standing
and monstrous elephantoid limbs. In a few cases
Dee. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
where only slight swellings from elephantiasis were
present these have entirely disappeared.
(5) The health of the patients in all these cases
has improved notably from the treatment. As
many of these have at the same time been sufferers
from constitutional syphilis, the remarkable im-
provement in their health could not be attributed
only or chiefly to the absence of filarial attacks;
but in other instances, cases, uncomplicated with
syphilis, have shown very marked improvement in
their general health from the treatment by sal-
varsan.
It must be admitted that there have been some
disappointments in the results of the salvarsan
treatment for filariasis. "There have been only two
cases in which I have noted recurrence. In one of
these cases there were no micro-filarie to be found
in the blood for three months after the first injec-
tions. In the first recurrence the febrile attack was
exceedingly mild, and only a few micro-filariz were
discovered. A second treatment by salvarsan has
been resorted to in this case, with no return of a
filarial attack for the last four months. This case
has lasted for many years, and is one in which the
affected parts are monstrous in size and appearance.
I enclose a photograph of it (vide p. 364).
It must be remembered that people who live in
places where filariasis is endemic are constantly
liable to recurrence from fresh invasions of the
parasites.
I take this opportunity of expressing my
indebtedness to Miss Alice Williams, the Matron of
the Cunningham Hospital, St. Kitts, for her able
and zealous assistance in such of these cases as
were treated in that institution.
Relapsing Fever in Chitral.—Smith and Graham
(Indian Medical Gazette, October, 1913) report on
an epidemic of relapsing fever in Chitral with an
account of successful animal inoculations. The
outbreak, which was of epidemic form, first appeared
among some remote Kafir villages on the Afghan
frontier situated at some 7,000 ft. elevation. From
the account of the villagers this appeared to be a
disease which was previously unknown among them.
There were no deaths, and recovery in two or three
months was the rule, neither was there any history
of sequela. None of these cases came to hospital
for treatment, but slides of their blood showed very
numerous spirochetes of a small type.
Inoculations of blood were made into young rats,
the blood being passed into the subcutaneous tissues
direct and not diluted with citrate. On the third
day after inoculation spirochetes appeared in the
blood of all of the three rats injected. The para-
sites persisted for two or three days, but then
disappeared and were not found again. The authors
believe that the success of these inoculations de-
pended upon the three following points:
(1) Young rats were used.
He Species of rat used (Mus ratius) was favour-
able.
(3) No citrate or other chemical was added to
the blood used in inoculation.
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THE JOURNAL OF
Tropical Medicine and Hygiene
DECEMBER 1, 1913.
A REPORT ON PRACTICAL SANITATION IN
A DISTRICT OF CEYLON.
THE interesting and instructive report issued
(1918) on malaria at the Port of Talaimannar, by
8. P. James, M.D., D.P.H., and S. T. Gunasekara,
M.R.C.S., L.R.C.P., should be carefully read by
those practically engaged in the fight against
malaria. Mannar is an island off the north-west
coast of Ceylon, forming part of ‘‘ Adam's Bridge,”
and the importance of the inquiry is that Talai-
mannar, in Mannar, is likely to be the port of the
terminus of the new railway to India from Ceylon.
The locality has always had an evil malarial reputa-
tion; it is, in general, not more than 12 ft. above
mean sea level and mostly consists of a low-lying,
sandy waste, covered here and there by scanty
scrub jungle, palmyra groves, and a few coco-nut
plantations, and throughout the area the subsoil
water is so near the surface that despite the porous
nature of the ground extensive tracts become flooded
during the rainy season and remain so for several
months. In the district the rainfall varies between
22 and 55 inches, and severe droughts may alter-
nate with storms and floods. The variations in the
meteorological conditions render alternate plenty
and poverty possible, and the authors draw attention
366
(Dec. 1, 1913.
to the fact that ‘‘it is usually the case in the
Tropics that abnormal meteorological conditions of
any kind are adverse to the population, and this is
illustrated in the Mannar district by the fact that
years of deficient rainfall are years of scarcity and
hardship, while years of excessive rainfall are years
of much sickness and mortality.” The water
supply of the district is derived from tanks, hollows,
and primitive wells, in which fecal pollution is the
rule. The death-rate compared with the birth-rate
is excessively high, but of this later. The cause
of the sickness and mortality attributed to malaria,
for between 50 and 60 per cent. of all the cases
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
simplify the possibility of dealing with the malaria
problem in any district, for where there are many
known carriers the difficulty and expense of exter-
minating them is great, whereas when war has to
be waged against one species only it is materially
lessened. It must not, however, be imagined
that because carriers are few the infection of the
population is necessarily small, for other factors
enter into the question and perhaps none more so
than poverty. When a community consisting of
ill-fed and badly housed people are malarial, the
effects of malaria are more severe and infection
once contracted persists for a longer time, and a
state of continual infection, known
to Kitchen technically as ‘‘ residual infection,”
BACK is ES obtains, with the result that a very
MA. em few anopheles suffice to maintain a
Aor high degree of parasite infection.
: A EN ^ An interesting point noticed and
p - Beaguito prosf gauze DN, N. _ Mosquito proof gauze ___ proved by the authors is that in
VERANDAN
Store _,
Cupboard `
te, |
VERANDAH
q LA
g
o,
HMosgurto proof goure
VERANDAN
Stop for door
r------------
Tw .
Od C
SA Stop
SRONT
Suggested Type of House (see p. 367),
of sickness are ascribed to malaria or malarial
cachexia, and to this infection may be ascribed such
illnesses as those styled pyrexia, debility, dropsy,
diarrhcea, convulsions in infants, &c.; the mortality
directly due to malaria is stated to be 38 per cent.
of the whole. October to January is the principal
rainy season, and shortly after the onset of the
rains brought down by the north-east monsoon
malaria commences to increase in virulence, the
maximum being reached in January and February,
after which it gradually subsides until it reaches a
low level in May. The chief proved (and it may
be the only) carrier of malaria in the district is
Myzomyia culicifacies, and this fact tends to
SERANOANW
V4 T7 Hasguile prof gaust” ~~
The large openings ave
archways, the small ones
ere windows. —
:
Ge ese villages where the population is
: fixed and permanent, the disease
i is chiefly confined to children, the
; spleen rate among the children in
’ certain instances amounting to as
1 much as 100 per cent. and the
parasite rate to 50 per cent., while
among the adults the spleen rate
was only 15 per cent. and the
parasite rate 8 per cent.—the dis-
crepancy being due, no doubt, to
the fact that the adults have be-
come more or less immune by
repeated and long-continued infec-
tions. On the other hand, the
introduction of non-immune immi-
grants into the community alters
the state of affairs; newly arrived
adults become speedily infected,
i and if their numbers are consider-
! able, fever prevails to an extent
A which deserves the term epidemic,
and this outbreak among non-
immunes may arise at a time when
the number of anopheles are rela-
tively few. The epidemic therefore
becomes “‘ one in which the ‘ human
factor’ rather than the ‘ anopheles
factor’ is the chief influence at
work. 4 s The authors remark that conditions
of this kind make the problems connected
with the employment of outside labour in the
district difficult, prevent colonization, and hinder
progress generally. To the practical sanitarian,
therefore, it naturally is suggested that local labour
in a malarial district recommends itself, even
although the population may be somewhat enfeebled
by lifelong exposure to infection, in preference to
imported non-immune labourers, who are almost
certain to early succumb to the local malarial
infection.
In addition to general sanitary attention to such
subjects as the water supply, latrine accommoda-
Dec. 1, 1913.]
tion, housing, &c., the authors advocate regular
medical inspection of the coolies at least every
fortnight. The medical officer should find out those
suffering from fever, anemia, and enlarged spleen,
and the men thus affected should be treated in
hospital; it is a mistake to allow patients suffering
from malaria to remain in their huts, ‘‘ not only
because to do so is to give many anopheles an oppor-
tunity of becoming infected, but because, as a rule,
in such camps the coolies who are ill are not strong
enough and are too apathetic to prepare their own
food, and they have no one else to prepare it for
them.” Unceared for cases of this kind add greatly
to the mortality list.
The authors give details of the TYPE OF HOUSE,
which should be at once airy, cool, and protected
against the entry of mosquitoes, sufficiently sub-
stantial to resist storms, and proof against white
ants. The house should be raised from the ground,
preferably on an extensive plinth of concrete sur-
faced with cement; this is a most important recom-
mendation, more especially for India and Ceylon,
where the bungalows are built on the ground with-
out elevation or subjacent concrete and the emana-
tions from the earth penetrate the rooms directly
through the ill-jointed flooring. The statement
that ‘‘the whole area of the plinth should be
utilized for the erection of a large mosquito-proof
shed, inside which the house proper should be built,’
must be the last word in the protection of dwellings
from mosquitoes. The description of the house is
so good that it is reported here in detail. ‘‘ The
‘shed’ consists of the following parts: (a) Pillars
of iron, stone, or wood, erected at the corners and
along the outer limits of the plinth to support the
roof; (b) between the pillars a dwarf wall, and upon
it a framework filled in with mosquito-proof copper
wire gauze of 18 meshes to the inch; (c) at two
places in the skeleton walls double doors, mosquito-
proofed, and both opening outwards. They should
be made to close automatically (N.B.—It is essen-
tial to the success of mosquito-proofed houses that
all doors should open outwards); (d) a ceiling of
wood or of asbestos material, resting on and closely
applied to the top framework and girders in such
a manner that the roof is completely shut off from
the remainder of the shed; (e) a sun-proof and rain-
proof roof, which is ventilated, and of which the
eaves project as far as possible beyond the frame-
work and are not provided with gutters—the rain
dripping from them being allowed to fall into a
concrete drain laid all round the house; (f) the
result is a large square mosquito-proof structure
with walls of mosquito-proof wire gauze, a ceiling
of wood; and a floor of cement, and the whole
covered by a roof; (g) all that now remains to be
done is to reserve a broad space all round inside
the structure to serve as a verandah, and then to
partition off the remaining space into rooms. It is
not necessary for these partitions to be very solid
structures, and they should be opened wherever
possible by large arches and windows. Doors to
the arches are not necessary. It is important that
no partition should be built which will cut off a
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
367
E
through draft of air from front to back and from
side to side of the house. (h) The house should be
orientated so as to obtain the greatest advantage
from the winds of the south-west and north-east
monsoons."''
The estimation of the relations of the death-rate
to the birth-rate in almost all British Crown Colonies
is a question fraught with difficulties; the chief
being that the population consists of males out of
all proportion to the females. In the Crown
Colonies imported labour is the rule; the wives
are left at home whilst hundreds or thousands of
coolies flock to plantations abroad. Ceylon is con-
stantly invaded by labourers from the mainland of
India. Hong Kong, Singapore, the African Colonies,
the West Indian Islands, and Guiana, &c., have
a population sometimes amounting to ten men to
one female. When, moreover, a woman becomes
pregnant she frequently returns to her home to have
her baby. Statistics gathered in the ordinary way
from any of the above-mentioned places show a
death-rate so disproportionate to the birth-rate that
it would only require the passage of two generations
to exterminate the inhabitants. The same applies
to the region dealt with in the Mannar district of
Ceylon, and due allowance must be made accord-
ingly. In 1912, for instance, the birth-rate per
mille in the Mannar district was 24:8, whilst the
death-rate per mille is given as 49:5; it is evident
that some interpretation is necessary to explain how
the population is maintained at all; and the refer-
ence to the proportion of males to females in British
Crown Colonies generally affords a clue to the
discrepancy.
——— ÀMÀ
Isolation of Typhoid Bacilli from Faces.—
Browning, Gilmore, and Mackie, writing in the
Journal of Hygiene, vol. xiii, No. 3, October, 1913,
describe a method of isolating typhoid bacilli from
feces by means of brilliant green in fluid medium.
They find that:—
(1) Brilliant green exerts an inhibitory effect on
the growth of bacilli of the coli group commonly
occurring in feces, which is in general more marked
than its action on Bacillus typhosus and paratyphoid
bacilli.
(2) By taking advantage of this property of
briliant green a method has been devised for
isolating B. typhosus from feces. The procedure
adopted is the inoculation of a series of tubes of
peptone-water medium containing varying amounts
of brilliant green, incubating for twenty to twenty-
four hours, and then the inoculation on a suitable
solid medium from each tube.
(3) The reason for employing a series of concen-
trations of brilliant green is that the optimum
concentration for the growth and isolation of B.
typhosus varies from case to case, depending prob-
ably both on the proportion of typhoid bacilli present
and on the number and character of the accompany-
ing bacteria as well as on the organic fecal material.
(4) The method is very easily and rapidly carried
out.
368
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1913.
Abstracts.
SCHOOL QUININIZATION EXPERIMENTS IN
THE UNITED PROVINCES.*
By Major J. D. Granam, M.B., D.T.M., I.M.S,
Special Malaria Officer, United Provinces,
Tue various methods of quinine prophylaxis
employed throughout the malarial world have one
feature in common—their dependence for success
upon some degree of discipline or control in the
community being quininized. Organized communi-
ties such as jails and asylums, labour under such
a considerable advantage in this respect that they
are looked on as eminently suitable for the adoption
of such measures, with a reasonable assurance of
their being carried out in their entirety. When,
however, one comes to deal with the civil com-
munity at large, the adoption of any scheme ot
prophylaxis on a large scale becomes difficult, if
not impossible, both from the point of view of
organization and from that of expense, while the
results accruing are likely to be uncertain. In the
civil community, however, the school organization
comes perhaps nearest in point of discipline to the
examples cited, and the scholars, while they are in
actual attendance, can be controlled just as effec-
tually. The experiment of prophylaxing the
scholars in a selected number of schools in any
district has then as desiderata in its favour the
facts that the community concerned consists of
children or young adults well organized and dis-
ciplined during seven hours of each school day,
who are highly susceptible to malaria, and who
are, moreover, in process of mental moulding,
keenly observant, fairly unbiased, and in a position
to remember any object lessons and perhaps retail
them at home.
The first attempt at school quininization experi-
mentation on systematic lines in the United Pro-
vinces was made in the district of Muttra by Major
Robertson, I.M.8., in the rains of 1909, when the
country was beginning to recover from the heavy
toll that had been exacted by the epidemic of 1908,
Muttra had been the worst affected of all the
districts in the provinces, and the passing of the
epidemic had left its mark on the bulk of the
population under ten years, so the huge spleen
indices, very large spleens, mixed infections and
relapses were the features of the school examina-
tions then undertaken. Though Major Robertson
did not write a report on the experiment, the writer
understands that he systematically quininized a
large number of the worst schools during three
months, and that, at the end of the period, the
results were regarded as eminently satisfactory, and
of sufficient value to suggest more detailed experi-
* Proceedings of the Third Meeting of the General Malaria
Committee, held at Madras, November 18, 19, and 20, 1912.
Simla : Government Central Branch Press, 1913.
ments on similar lines in the future. Such an
experiment was undertaken by the author in the
rains of 1910, in the district of Budaun, a district
which had suffered severely during the epidemic
of 1908, and where the district authorities seemed
specially keen on working at the problem and on
giving every assistance. The results of this experi-
ment have been recorded in a ‘‘ Report ’’ addressed
to Government in February, 1911, and since
published.
In this report is recorded a full and detailed
outline of the whole experiment with the conclu-
sions arrived at, and, as the report. was circulated
throughout the province, every opportunity was
given to the different district authorities to digest
the details, and modify them to suit local require-
ments if they felt inclined. The results recorded
were distinetly satisfactory; but, as the autumn of
1910 had not a severe malarial incidence, it was
thought desirable to attempt on similar lines, in
the autumn of 1911, the quininization of a series of
schools in two badly affected districts, and the
districts of Meerut and Aligarh were chosen. These
districts, which are situated in the Jumna-Ganges
Doab, are highly canalized areas, well supplied with
schools, and very accessible, and have shown over
a long period of years continued heavy mortality
from endemic malaria, as well as very heavy
mortality on occasions from epidemic malaria, so
that they were considered eminently suitable. It
is with this later experiment that the present paper
chiefly deals.
General Arrangements.—In consultation with the
district officers a typical series of school was
selected, embracing practically all the district
climatic peculiarities. Sample head lines of a
quinine attendance register had been previously
distributed throughout the schools to be visited, and
by the time of the author's arrival, all schools had
been provided with identical registers in which the
scholars' names had been entered class by class.
These registers showed columns for class number,
name, sex, age, spleen, general health, dose, dates
of dosage and remarks. Personal examination of
every child in every school at the inception of the
experiment, to note the size of spleen, general
health, and age, and to fix a prophylactic dose
calculated on age and physical development, though
tedious, ean rapidly be overtaken in these days of
motor transit, whilst a similar personal examination
at the termination of the experiment made the data
eomplete and comparatively free from error, which
they would not have been, had this been delegated
to subordinates. Dy
Distribution.—To eliminate as far as possible any
local bias against the drug, its distribution was
entrusted to two sub-assistant surgeons, for whom
a weekly cyclical programme was drawn up,
embracing the majority of the schools in each
district, though a few schools because of their in-
accessibility had to be entrusted to the sub-assistant
surgeons at district dispensaries, whilst in several
instances district sanitary officers assisted. In this
Dec. 1, 1913.]
way the general accuracy of the tabulated results
was ensured, whilst each school was able to be seen
twiee weekly in 1911, a factor of some importance.
Quinine.—Quinine in the form of the sulphate
in 1910, and of the bisulphate in 1911, was issued
throughout all thé experiments in uncoated tabloids
of 4,°2, 8 and 5 gr., given dry, and washed down
with water, and was swallowed without difficulty.
The stock was kept in the 1910 experiment with
the Civil Surgeon of Budaun, but in 1911 with the
respective Distriet Board Secretaries of Meerut and
Aligarh, and was issued as required (usually weekly)
to the distributors. "Throughout the whole period
very few cases of intolerance were reported, and
conscientious objectors, though they existed and
were respected, never established cases really
worthy of consideration.
Dosage.—The question of dosage, the crux of any
prophylaetie experiment, was necessarily experi-
mental, and was fixed as low as possible, and in many
cases too close to the borderland of inefficiency.
The adult dose was fixed at 18 gr. A useful method
was evolved of adding 4 to the age and making this
the denominator of a fraction, the numerator of
which was the age. Thus for a boy aged 6, the
fraction of the adult dose was $ + 4 — 455 or 3, or
about 10 gr. weekly. This was given irrespectively
of evidences of malarial infection, such as enlarged
spleen, general appearance or history. In the 1910
experiment single weekly doses and bi-weekly doses
on successive days and on intervening days, with
8, 9, 10, 12, 15, 16 and 20 gr. weekly were tried,
giving in all eleven bases of dosage; but in practice
this was found by its multiplicity to confuse the
issue. Accordingly, in the 1911 experiments, the
weekly scale was limited to 12, 18 and 20 gr., and
was given twice weekly either on successive days
or with intervening days, giving in all five bases of
dosage.
Girls’ schools, which had been included in 1910,
were excluded in 1911 because of the unreliability
of the registers and the irregular attendance. The
test extended over the three fever months, August,
September, and October, and into November in one
case, the final examination being concluded when
the distribution had ceased.
Throughout the 1910 experiment. continuous
weekly blood examination of proved gamete carriers
was attempted, and gave some interesting informa-
tion; but owing to paucity of gamete infections in
1911 it was abandoned. Local conditions were,
however, considered much more in the 1911 experi-
ment than previously in arranging the programme
of schools, and also influenced to some extent the
basis of dosage. This was attended with benefit.
The choice of schools in both Aligarh and Meerut
was influenced to some extent by a perusal of the
malaria intensity figures for thirty-two years of the
rural circles of the districts, and the schools in both
districts assort themselves into four groups :—
(a) A Khadir group.
(b) A canal or riverain group.
(c) A road group (2 miles at least from canals).
(d) A town or city group.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
369.
-r
It is obvious that dosages only just sufficient to
influence a group such as the city group would be
hopelessly insufficient to prophylax effectively a
group like the Khadir group, when it is remembered
that the spleen indices of the two areas might vary
between 5 per cent. and 60 per cent. An attempt
to cope with this was made by putting all such
highly endemic areas on the high scale of 18 or 20
gr., while the town group were kept on the lowest,
12 gr. In this way results were found to work out
very uniformly.
The results obtained in the three districts were as
follows :—
In Budaun in 1910, 54 schools with 2,881
scholars showed a decrease of spleens due to com-
plete disappearance as measured by palpation of
58°4 per cent.; a control of 247 non-quininized boys
enrolled after the experiment had begun showing
30 per cent. of spleens in November at a time when
the quininized showed 7°6 per cent.
In Meerut in 1911, 45 schools with 2,048 scholars
showed a decrease of spleens due to complete dis-
appearance of 48:8 per cent. ; a control of 702 non-
quininized scholars enrolled after the experiment
had begun showing 15 per cent. of spleens in
November at a time when the quininized showed
T'O per cent.
In Aligarh in 1911, 48 schools with 3,254 scholars
showed a decrease of spleens due to complete dis-
appearanee of 56:8 per cent.; a control of 1,029
non-quininized boys enrolled after the experiment
had begun showing 16:8 per cent. of spleens in
November at a time when the quininized showed
18 per cent.
Briefly the spleen rate of the non-prophylaxed
boys in November was practically the same as was
that of the scholars in July, while the prophylaxed
boys showed a reduction by complete disappearance
of about 50 per cent. This happened with every
basis of dosage, even though only a percentage vary-
ing from 79:7 to 88°3 of the available quinine was
consumed.
Twelve grains in the city were found to produce
much the same percentage of reduetion as did 18
and 20 gr. in the canal and Khadir schools, i.e..
the proportionate reduction was much the same in
all. By grouping the schools according to proximity
of spleen indices in periods of ten units each—i.e.,
schools with spleen index from 0 to 10, 10 to 20, and
so on—one can contrast the dosage effects in com-
parable schools, and this shows that 18 gr. bi-weekly
** intervening,” and 20 gr. bi-weckly “ intervening."
are the most successful; but, as already pointed
out, too much reliance should not be placed on any
deductions one is tempted to make regarding
efficieney of individual dosages, though the figures
indicate that such doses as 18 and 20 gr., when
employed under moderately severe endemic con-
ditions, are of unquestionable utility in the reduction
of individual enlarged spleens, when gauged by
numbers sufficiently large to exclude numerical
fallacies.
Dosage in Relation to Fever Incidence.—The in-
fluence of different dosages on fever incidence is
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1913.
370
another of the primary tests which enable one to
estimate the success of the prophylaxis. The per-
centage number of cases in which fever occurred
during the exhibition of the drug will more than
represent the measurement of failure to prophylax.
In Buduan, in 1910, failure to prophylax occurred
in 10:6 per cent. of the pupils when 80:1 per cent.
of the doses were consumed. In Meerut, in 1911, in
8 per cent. of the pupils with 81:3 per cent. of doses
consumed, and in Aligarh, in 1911, in 9:4 per cent.
of the pupils when 76:5 per cent. of doses were con-
sumed.
In this connection one must allow for:—
` (a) Previous latent infection.
(b) Irregular consumption of dosage.
(c) Defective diagnosis. As pointed out recently
by Ross and Thomson in connection with their
enumeration experiments, it can hardly be accepted,
in the absence of accurate enumeration observations,
that apparent rises of temperature during a period
of quininization are necessarily relapses or even
malaria, and this factor alone would go towards
diminishing the apparent failure.
The point elicited, however, by the figures is that
the author was sailing near the border line of in-
efficient prophylaxis, and further, that the more
thorough the administration the less was the fever
incidence and spleen development. In estimating
the relative values of individual dosages, 18 and
20 gr. bi-weekly ''intervening " would appear to
give the best results, and this, too, when applied
to the severely affected riverain, canal and Khadir
areas. As had been repeatedly pointed out, it is
premature to argue efficacy of a particular dosage
over others, when local conditions vary so greatly.
A careful study of the available figures brings out
clearly the necessity for graduating doses according
to locality, and so making the prophylaxis less
empirical. In the Meerut district a 12-gr. dosage
in the towns does apparently what an 18-gr. dosage
does in the Khadir and riverain tracts. It would
naturally be expected that an 18-gr. dosage would
do more in the towns than a 12-gr. dosage. The
present tests do not touch this, however, but the
figures prove that all dosages are efficacious when
exhibited intelligently.
Bloods.—In Budaun in 1910 the careful weekly
examination of gamete carriers during the exhibi-
tion of the drug disclosed three conditions : —
(1) Gametes or other forms are found right
through the fever season, even in cases where no
absences are recorded, i.e., where all the quinine
available has been consumed. This is especially
marked in malignant infections.
(2) Several infections, mostly benign tertian,
seem to be controlled from the commencement, and
to remain so till the end, even in spite of absences,
and therefore diminished quinine consumption.
(3) Original infection is more or less controlled,
but has a second infection, probably a reinfection,
grafted on to it during the fever season.
Curiously, recurrence of old infeetion does not
always seem to vary inversely as the number vi
doses as one would expect, but other factors, such
as the general health, degree of infection, the
amount of the dose, all enter in to complicate the
issue.
In Meerut and Aligarh in 1911, regular observa-
tion of the blood of gamete carriers on the above
lines was found impracticable. Though these
schools showed spleen rates varying between 8'6
and 69:2 per cent., and 8:1 and 56:7 per cent.,
respectively, the blood infections discovered were
few. Meerut showed 18:4 per cent. in July and
1:9 per cent. in October; Aligarh, 3°4 per cent.
in August and 1 per cent. in November-December.
The malignant parasite predominated. There is
every sign that, despite the rainy season, not only
did recrudescence not take place in the majority
of latent carriers, but that actual infections also
decreased, and it is more than likely that the
quinine exhibited helped towards this result.
Evidence of Temporary Immunity.—Reference to
school registers shows that the percentage absence
due to fever, after quinine distribution ceased, was
much greater than it was during the test—indicating
that a degree of temporary immunity existed during
the test.
Size of Spleen.—In the non-quininized scholars
seen in November, the fresh spleens noted were
proportionately larger than were those in the
quininized scholars (i.e., the increase in the non-
quininized was greater than that in the quininized.
Teachers and Staff.—As the teachers form an
adult community comparable in regard to age in all
three experiments, they have been considered
together. Five hundred and ten teachers in the
three experiments consumed 92°6 per cent. of the
available quinine, and showed only sixteen cases
of fever, four of whom developed. slight spleens.
The average dose received was 14:1 gr. in Budaun,
18:2 gr. in Meerut, and 1677 gr. in Aligarh. The
figures show a high degree of prophylaxis.
Cost.—The expenditure involved in such experi-
ments is a practical point which very often must
decide for or against its adoption. The working
expenses of Budaun in 1910, inclusive of the pay
and travelling allowances of the special distributors,
were approximately Rs. 1,163, or 6'5 annas per
head ; Meerut cost Rs. 1,860, or 6:2 annas per pupil:
Aligarh, Rs. 1,725, or 7 annas per pupil. In all
these instances the expenditure could be reduced
to about one-half by depending on local distributors
entirely ; but in the tests the employment of special
men for the purpose was valuable as ensuring
increased accuracy of work. In the three experi-
ments the District Boards supplied funds up to a
certain amount, beyond which Government made
a grant; but the fact that several District Boards
have since and are at present financing their own
programmes, bears out the author’s contention,
that, practically, the cost can be reduced to one-
half that given, or roughly, to about 8:5 annas per
pupil for the fever season.
Other Points.—It would be helpful in new dis-
tricts first to ascertain the malarial conditions, both
Dec. 1, 1913.]
from malaria intensity figures, if available, and by
a perusal of local statistics, and in this way varia-
tion of dosage to suit locality could be made pos-
sible. As a rule 18 gr. should be the minimum
weekly dosage for the adult male community, and,
given bi-weekly with intervening days, it seems to
afford the best results with the least disturbance;
but, as a working rule, smaller doses could be given
in large towns and dry areas away from canal irriga-
tion. Registers should always be kept, as the mere
fact of having a register makes the distribution
appear part of the school curriculum, and ensures
more care being taken over it.
Objects.—The author classes the objects of such
a crusade under several heads.
(1) Educative Value.—To an active boy nothing
can well be more impressive than an untreated
attack of fever, which lays him low for several days,
weakens him, and keeps him from his games and
from school.
What must be the effect on a group of boys, all of
whom are being quininized with success, when they
see one of the class who has consistently refused the
weekly dose, or who has been absent so often as
to have received little or no prophylaxis, suddenly
struck down or suffering severely from fever while
they escape; yet this object-lesson time and again
was demonstrated in class after class of the various
schools. So marked was it that the masters very
often came to associate frequent absence with
indifferent prophylaxis and regular attendance with
systematic dosage. Moreover, the illness of such
boys must have formed a subject for common
gossip both at home and in the play-ground, thus
impressing the family circle with the value of the
drug. The testimony to the increasing regularity
of the attendances of the children in the rains since
the tests were inaugurated was almost unanimous
on the part of both teachers and parents whom the
writer saw, and quinine and this regularity were
placed in the relation of cause and effect, with some
Justification, by most of them.
(2) Prophylactic and Destructive Aspects.—Fresh
infection or reinfection is thus prevented and
the risks from latent carriers of infection are
diminished. ;
(8) Dosage and Therapeutic Aspect.—Information
regarding the variations of dosage which appear
most efficacious and the local conditions requiring
that these doses should be modified, is thus accumu-
lated for future guidance, while the direct effect on
actual infection by diminution of splenic enlarge-
ment and increased standard of general health is as
important a consideration for children as it is for
adults.
Applicability.—Any scheme on lines similar to
those described can be initiated locally without
such detailed examination as was made in these
tests, and, with the help of the district authorities,
ean be run by an intelligent assistant surgeon or
district sanitary officer, while the transition from a
free issue of quinine in the first year, to, in the
second year, a quinine register, for enrolment on
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 371
which a small inclusive charge for the season could
be exacted, is comparatively easy. This is all in
progress at the present moment. Thus, in 1911,
Budaun on its own initiative, after the success of
1910, carried through a similar experiment, when
& proportion of the cost was borne by the scholars
and the remainder by the District Board, and the
register enrolment was actually greater than in the
year of the test experiment, 1910. Budaun is
again doing the same in 1912.
In addition, Meerut in 1912 is running a similar
experiment with 5,561 boys and 199 teachers, the
greater proportion of the cost of this quinine being
recovered from the boys by a small fee for enrol-
ment on the quinine register. No compulsion is
being used. Another feature of the Meerut experi-
ment this year is a graduated scale of dosage to
meet the potentialities of different localities. This
has been circulated to all headmasters throughout
the district, and, as the distribution is in the hands
of the masters, an attempt has thus been made to
get at Khadir and outlying schools which would
otherwise be beyond a special distributor’s help.
The energetic Secretary of the District Board in
Meerut is responsible for this innovation. Aligarh
and Muzaffarnagar are also carrying out register
distribution on systematic lines this year at their
own expense; while three other districts are running
modified experiments. The popularity of these
measures in severely affected tracts is undoubted,
as on several occasions requests were made to have
the distribution continued for another month after
the date fixed for the completion of the test.
Conclusion.—It will thus be seen that as sickness
from malaria is among the most frequent causes of
irregular school attendance in the rainy season, that
as with reliable uncoated tablets of quinine one has
an elegant and exact means of administering a
preventive and curative, that as during 1910 and
1911 its feasibility was demonstrated in three care-
fully applied tests, school quininization, as a general
measure, has now passed the experimental stage,
and the principle of its applicability for all district
schools of the United Provinces of India and simi-
larly affected areas during the rainy and fever
season should now be accepted. That many dis-
triets may require less than others, and in some
years none at all, is quite intelligible; but, once the
principle has been accepted, individual districts,
with the expert advice of their Civil Surgeons and
others, could easily determine how far the principle
should be applied.
The details of these reports should not blind
district authorities to the fact that the mechanism
is neither complicated nor expensive, that it can and
has been conducted by district authorities for an
entire season without any outside help, and that
to obtain from it the maximum of benefit con-
tinuity from year to year in the same district is
requisite.
[This is a most valuable and instructive paper
and should be carefully studied by workers in other
parts of the world as well as in India.]
372
QUARTERLY REPORT OF BUREAU OF
HEALTH FOR THE PHILIPPINE ISLANDS.
SECOND QUARTER, 1913.
By Victor G. Heiser, M.D.
Director of H2alth ; Surgeon, United States Public Health
Service.
In the above report it is stated that during the
week ending April 26, 1918, there was a sharp in-
erease in the number of plague cases reported in the
city of Manila. Four deaths occurred within a period
of seventy-two hours. These cases were reported from
834 Calle Padre Rada, 1,419 interior Calle Dagupan,
1,364 Calle Sande, and 642 Calle Ilaya, respectively.
On further investigation it was ascertained that all
of these deaths occurred in persons who worked in
a silversmith's shop at 1,364 Calle Sande. They
were all empoyed on the first floor, which was of
cement. Ordinarily such construction would be re-
garded as rat-proof; but, owing to openings being
found near the sides which resembled rat holes, and
cracks across its surface, it was deemed advisable
to tear out the floor, which was done, and several
mummified rats were found underneath it, the death
of which was probably due to plague, although this
fact could not be definitely established. It was
then deemed advisable to inquire into the health
condition of the remaining persons who worked at
this shop. This resulted in finding an employee at
1,492 interior Calle Dagupan with malaise, headache
and fever. He was transferred to San Lazaro
Plague Hospital, where soon after admission many
of his glands became palpable. A definite diagnosis
of plague was made, which was afterwards con-
firmed by autopsy. The foregoing experience illus-
trates in a striking manner the intimate relationship
which exists between rat and human plague and that
so-called rat-proof construction must be kept in good
repair. In this instance there is reasonable ground
for believing that after the rat host of the fleas had
died the fleas made their way through the cracks
in the cement floor and attacked the workers in the
shop. In view of the fact that Javanese observers
have reported that ants attack fleas, it may be of
interest to state that there were large numbers of
ants found under the cement floor. But as ants
are almost invariably found near decaying animal
matter, the dead rats may have attracted them. It
is also of interest to note that these human cases
occurred in a district which was reported a month
previously as showing a decided increase in the
percentage of rat infection. Infected rats are still
being found in this section, but as there have been
no plague cases since April, it is reasonable to infer
that the anti-plague measures have been successful.
There were nine cases of plague during the quar-
ter, of which seven died.
APPARENT CunES OF LEPROSY.
On June 11 there were released from San Lazaro
Hospital two persons who were formerly afflicted
with leprosy and have now been pronounced free
from the disease.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 1, 1918.
C. A., male, Filipino, aged 27, admitted to the
San Lazaro Leper Hospital May 29, 1909. On
admission the case presented thickened reddish
spots on the nose and thickening and discoloration
of the lobe of the right ear. Smears made from
the lesions were positive for leprosy bacilli. Begin-
ning August, 1909, he received vaccine treatment at
intervals for one year, but apparently there was no
change in his condition during this period. From
September, 1910, to November, 1910, he took crude
chaulmoogra oil by the mouth, beginning with daily
15-drop doses and by November reaching 60 drops
per day. The oil was given three times daily in
divided doses. From November he received hypo-
dermie injections of the following mixture :—
Chaulmoogra oil 60 c.c.
Camphorated oil 60 c.c.
Resorcin 4 grm.
Mix and dissolve with the aid of heat on
a water bath, and then filter.
The foregoing mixture was given as follows :—
During November
T December
ii January
2 c.c. every 3 days.
Di. ds Bs
10 6.6. 4; Ej
As this large dose was being borne badly it was
reduced to 5 c.c., which amount was injected every
eight days from February to May. There was
apparently no change in his condition at the end of
the year following the vaecine treatment. During
the treatment with erude chaulmoogra oil by mouth
there was some improvement in his condition. This
improvement continued during the time that hypo-
dermie injections were given, and on May 6, 1911,
all the lesions above described had disappeared and
it was impossible to demonstrate the leprosy
bacillus. All treatment was then discontinued for
a period of one year, during which time he remained
negative microscopically. From August, 1912, to
June, 1918, 2 c.c. were given every ten or thirteen
days until the time of discharge.
The second case was that of G. A., a Filipina
woman, aged 22, admitted to the San Lazaro Leper
Hospital on January 7, 1910. She had a generally
suffused countenance and small red macules on the
cheeks, forehead, and chin. Scrapings from these
lesions were positive for leprosy bacilli. Vaccine
treatment was begun January 15, and continued for
a period of five months. At the end of the first
month there was apparently no improvement in her
condition, and crude chaulmoogra oil was given by
mouth in ascending doses. The initial dose was
30 drops per day and had reached 800 drops at the
end of four months. At the close of this period
there was some apparent improvement, but the oil
was no longer borne well, and the chaulmoogra oil
mixture mentioned in the previous case was adminis-
tered. For the first month 1 c.c. was injected into
the buttocks every eight days. The next month
10 c.c. was injected every four days. Then one
dose of 15 c.c. was given. After that 5 c.c.
was injected every six days. By May 6, 1911,
there was a great improvement in her general
Deo. 1, 1913.]
appearance and she was microscopically negative
for leprosy. During September, 1911, all treatment
was discontinued for one year. Beginning June,
1912, 2 c.c. was injected every eight days. Micro-
scopical examinations were made at frequent inter-
vals and always with negative results. On June 11,
the date of her discharge, all macules had dis-
appeared, but there was still some suffusion of the
countenance.
It is not known whether the vaccine treatment
had any influence in these cures. It may be said,
however, that there are a number of other cases
at San Lazaro Leper Hospital and at the Culion
Leper Colony that have been negative for nearly
two years which presented more marked lesions
than those already discharged, and yet they received
only chaulmoogra oil, no vaccine being employed.
Apparent cures have been reported from time to
time in the past from San Lazaro Hospital, but
unfortunately all such cases relapsed or died from
some intercurrent disease soon after they were
negative for a period of'one year. The cases now
reported have been negative for a period of two
years, and there seems to be ground for hope that
the results may be more permanent.
As soon as the favourable results became gener-
ally known among the lepers there was a great
demand to take similar treatment, and many hun-
dreds are now taking chaulmoogra oil in some form
or other.
Owing to the long period over which the oil must
be taken and the nauseating effect when given by
mouth, experience has shown that few have the
hardihood to take the treatment faithfully over a
prolonged period.
Up to the present time the results have not been
such, Heiser believes, as to warrant the belief that
a specific for leprosy has been found; but it is
thought that if adequate funds were available for
the opening of a laboratory for the study of this
leprosy treatment, and an attached hospital provided
which had facilities for making accurate observa-
tions, at least a way has been indicated which might
eventually lead to success. In order that too great
hopes may not be aroused by the present cures, it
should be remembered that in the experience of
the Bureau one leper has apparently recovered
spontaneously—that is, without any treatment
being administered—and that for a period of over
a year now there have been twenty patients placed
under the treatment mentioned above, but only a
few of them have shown any signs of improvement.
ee
THE Future or TROPICAL AMERICA.—The Tropical
Exploitation Syndicate, Ltd., 28, Mincing Lane,
E.C., have recently published a brochure on the
future of tropical America. This clearly shows how
the opening of the Panama Canal will benefit and
improve all the States and Islands lying within its
immediate range. The brochure is very well illus-
trated with excellent photographs, and should prove
useful as a means of educating the laity in general.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
373
Hotes and Aews.
MEDICINE IN ANCIENT EGYPT.
An EARLY PRESCRIPTION.
Proressor ELLIOTT SMiTH, in a lecture on
October 30, 1913, before the Royal Society of
Medicine, on ‘‘ The Contributions of Ancient Egypt
to the History of Medicine,” said that the influence
of mummification upon the history of medicine had
been most profound, for the practice of embalming
prepared the popular mind to permit the practice
of human dissection. The Egyptians took no
advantage of that training, but the Greeks did, and
thus laid the foundations of true anatomy. In the
past twenty years a number of new documents
dealing with medicine had been discovered, and
one whieh had never been published was as early
a medical document as had ever been found. Pro-
fessor Smith showed on the screen a copy of the
papyrus in question, which dated back to 2000 n.c.
The prescription was for the treatment of a man
suffering from acute mania, and it explained that
its purpose was to weaken a strong man's struggles.
There was no malicious intent, it was added, in
weakening him, but it was done for his good. The
prescription contained fourteen different ingredients,
which were to be made into an ointment. The
patient was to be anointed fifteen times every day
until he was calm.
Professor Smith stated that during his experience
in Egypt he had examined 20,000 bodies. Some of
the prehistorie bodies dating back sixty centuries
were in a marvellous state of preservation, and
even blood-stains could still be seen. He had dis-
covered splints which went back to the time of the
Pyramids. In the earliest cemetery ever excavated
in Egypt they found that all the men had been
circumcised. In the whole of his Egyptian experi-
ence he had found only one case of real gout, and
one instance of leprosy, dating back to the early
Christian period. During his first year's work he
never saw the slightest trace of tubercle, but since
then a few instances had been found, and they had
now accumulated ten cases of evidence of tuber-
cular disease. Only three cases had cropped up
which could by any stretch of the imagination be
described as syphilitic. If syphilis really existed
in ancient Egypt, they had not yet seen any definite
traces of it.
———_
AN APPRECIATION.
In referring to the recent death of Dr. W. H.
Langley, Principal Medical Officer of Southern
Nigeria, the Acting Administrator stated in the
Government Gazette that, apart from great services
Dr. Langley has rendered to West Africa as Deputy
Principal Medical Officer in Northern Nigeria, as
Principal Medical Officer of the Gold Coast Colony,
and recently as Principal Medical Officer to
Southern Nigeria, he can well be said to have
endeared himself, by charm of manner and quality
of mind, to all with whom he came in contact,
whether officials or non-officials, throughout West
Africa.
374
RETIREMENT OF DR. R. M. FORDE.
Dr. R. M. Forpe, Principal Medical Officer,
Sierra Leone, is about to retire from the Colonial
Service, which he entered as an Assistant Colonial
Surgeon of the Gold Coast Colony in the year 1891.
Dr. Forde has had a wide experience of the West
Coast of Africa. He was on special service with
the Anglo-French Boundary Commission in the year
1892, and served as Medical Officer of the Special
Mission to Kumasi during 1894-5. In the latter
year he proceeded to the Gambia as Colonial
Surgeon, and was promoted Principal Medical
Officer of Sierra Leone in the year 1907. He re-
ceived the thanks of the Secretary of State for the
Colonies for his researches into human trypano-
somiasis.
THE SOCIETY OF TROPICAL MEDICINE
AND HYGIENE.
AT a meeting of the Society of Tropical Medicine
and Hygiene, held at 11, Chandos Street, Cavendish
Square, London, W., on Friday, November 21,
1913, at 8.30 p.m., the following candidates were
elected Fellows: Catherine E. Anderson, M.D.,
Colombo; Richard F. La Brooy, L.R.C.P.Edin.,
Ceylon; Michael Elmassian, M.D., Paris; Haldane
C. Gilmour, L.R.C.S. and P., London; Victor
Godinho, M.D., San Paulo, Brazil; S. T. Gunase-
kara, M.R.C.S., Ceylon; George Hay, L.R.C.P.
and S., Ceylon; L. Fabian Hirst, M.D., Colombo;
Alexander J. Mackenzie, M.B., S. Rhodesia; H.
S. MeCulloch, M.B., London; Professor Erich
Martini, M.D., Wilhelmshaven; Lieut-Col. Oliver
L. Robinson, M.R.C.8., R.A.M.C.; George W. Van
Twest, L.R.C.P. and S., Ceylon; Lieut.-Col. E.
Wilkinson, F.R.C.S., I.M.S., Caversham.
—9——————
Reviews.
PRACTICAL BACTERIOLOGY, BLOOD WORK AND ANIMAL
PARASITOLOGY, INCLUDING BACTERIOLOGICAL
Krys, ZOOLOGICAL TABLES, AND EXPLANATORY
CriNICAL Notes. By E. R. Stitt, A.B., Ph.G.,
M.D. Third Edition. Revised and enlarged
with 4 plates and 106 other illustrations con-
taining 513 figures. London: H. K. Lewis,
136, Gower Street, W.C. 1913.
The appearance of a third edition so soon after
that of the second indicates clearly the value
of this little work. The present edition brings the
subject up to date, but.the material that has had
to be added has been so considerable that, even by
the use of a smaller type for many of the paragraphs
and by increasing the number of lines on each page,
the total increase in the book works out at 65 pages
more than that of the second edition. In the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 1, 1913.
revision of the chapter on Protozoa the author 1s
greatly indebted to Minchin’s recent work on the
Protozoa and in those relating to Arachnoids and
Insects to the very practical volume of Colonel
Alcock, entitled ‘‘ Entomology for Medical Officers.”’
The illustrations have been added to, and many,
which did not seem to bring out sufficiently details
of anatomy, have been replaced by others more
satisfactory in that respect. The book, as already
stated in previous reviews, can be thoroughly
recommended to all students of tropical medicine.
COMPENDIUM OF THE PHARMACOP@IAS AND FORMU-
LARIES (OFFICIAL AND UNOFFICIAL), WITH PRAC-
TICAL AIDS TO PRESCRIBING AND DISPENSING.
By C. J. S. Thompson. Fourth Edition.
London: John Bale, Sons and Danielsson,
Ltd., 83, Great Titchfield Street, W.
The compendium has now reached its fourth
edition. It will be found most useful for those
prescribing and dispensing their own medicine. It
forms a handy pocket-book for medical practitioners,
pharmacists and students, and should be in the
hands of all.
Synopsis or Mipwirery. By Aleck W. Bourne,
B.A., M.B., B.C.Camb., F.R.C.S.Eng. Bris-
tol: John Wright and Sons, Ltd. London:
Simpkin, Marshall, Hamilton, Kent and Co.,
Ltd. Toronto: The Macmillan Co. of Canada,
Ltd. 1913.
A useful little work, the objects of which are
explained in the preface. The author there states
that he has written his handbook in order to set
the principal points of obstetrics before students
preparing for qualifying midwifery examinations in
a simple and concise manner.
The book serves as a useful supplement to, and
not as a substitute for, the ordinary text-books.
For men preparing for examinations it will be found
most useful as a means of rapidly revising the
subject as a whole.
It should serve also as a vade mecum for men
abroad who may not have the chance of consulting
the ordinary text-books, and who may wish at times
to refer to different points in the subject.
sciatica. By Dr. Wm. Bruce, LL.D.
Bailliere, Tindall and Cox. 1918.
Price 5s. net.
London :
Pp. 175.
Those who are not already acquainted with Dr.
Bruce's '' theory "' of sciatica would do well to read
his book on the subject. It is the only attempt we
have in all our literature to remove from this tire-
some complaint the shroud of ignorance which has
cloaked its cause and tended to place its treatment
in the hands of unqualified curers of any or all
diseases. Dr. Bruce draws attention to the part
played in sciatica by hip-joint ailments, and the
Dec. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
375
———————————————————————————————MM——M—M— MM MH M HdLÉMÉMW'LÉM'M'ÁWdLMHM—
writer can confirm all Dr. Bruce maintains as to the
relationship.
PREVENTIVE MepicINE AND HyorENE. By Milton
J. Rosenau, Professor of Preventive Medicine
and Hygiene, Harvard, &c. With chapters upon
‘* Sewage and Garbage,” by George C. Whipple,
Professor of Sanitary Engineering, Harvard.
“ Vital Statistics,” by Cressy L. Wilbur.
“The Prevention of Mental Diseases," by
Thomas W. Salmon. New York and London:
D. Appleton and Company. 1913.
This work is a very valuable contribution to the
subject of modern hygiene and sanitation. It will
be found of the greatest use by students of tropical
medicine and sanitation, as well as by those work-
ing at home, because it deals fully and accurately
with the prevention of diseases, such as cholera,
dysentery, ankylostomiasis, insect-borne diseases,
undulant fever, leprosy, kala-azar, &c. Descrip-
tions are also given of fleas, rats, ticks, lice, bed-
bugs, and other noxious insects. The second
section of the work deals with immunity, heredity,
and eugenics, the third section with foods, the
fourth with air, the fifth with soil, the sixth with
water, and the others with sewage disposal, vital
statistics, and disinfection.
The book is well printed, is handsomely illus-
trated, and should form a useful text-book and book
of reference.
MaLaria: ETroLoGy, ParHoLoGv, D1aGNosts, PrRo-
PHYLAXIS AND TREATMENT. By Graham E.
Henson, M.D., United States Army (Non-
active List), with an introduction by Charles
C. Bass, M.D., Professor of Experimental
Medicine, Tulane University. Twenty-seven
illustrations. London: Henry Kimpton, 208,
High -Holborn, W.C. Glasgow: Alexander
Stenhouse, 40 and 42, University Avenue.
1913.
There is not much room at the present day for
further books on the subject of malaria, but
nevertheless this little work on malaria by Henson
will be found useful. The subject is dealt with
in nine chapters, as follows: Chapter I, General
Considerations; II, Etiology: The Malarial Parasite ;
III, Etiology: The Malaria-carrying Mosquitoes;
IV, Etiology: Other Factors; V, Pathology, Com-
plications, Sequele, Prognosis; VI, Diagnosis; VII,
Latency, Recurrences, Chronicity; VIII, Prophy-
laxis; IX, Treatment.
CLINICAL SURGICAL DIAGNOSIS FOR STUDENTS AND
Practitioners. By F. de Quervain, Professor
of Surgery, University of Basle. With 510
illustrations and 4 plates. Translated from
the Fourth Edition by J. Snowman, M.D.
London: John Bale, Sons and Danielsson,
Ltd., 83, Great Titchfield Street, W. 1913.
This is an English translation of the fourth edition
of Quervain’s well-known work, Dr. Snowman being
responsible for the translation. The book repre-
sents specially Professor Quervain’s own experi-
ences, and the illustrations are, with few exceptions,
derived from his own observations. The work is
divided into six parts. Part I—Surgical Diseases
of the Head. Part II—$Surgieal Diseases of the
Neck. Part III—$Surgical Diseases of the Thorax.
Part IV—Surgical Diseases of the Abdominal and
Pelvic Viscera. Part V—Surgical Diseases of the
Pelvis and Spinal Column. Part VI—Surgical
Diseases of the Extremities. The work is splendidly
illustrated, and is undoubtedly a valuable one. Now
being translated into English, it should be available
to a much larger class of workers than previously.
Those interested in surgery may with advantage
consult its pages.
A USEFUL little booklet has just been received
from Messrs. Wm. Dawson and Sons, of Bream's
Buildings. This edition for 1914, consisting of more
than 120 pp., contains a list of all the principal
British publications with subscription rates for
Great Britain, the Colonies, and abroad. In addi-
tion it also gives a large number of American and
foreign newspapers, and the charges for same, with
a mass of other information. This list will be found
invaluable for reference to residents abroad.
—————— $—— ————
Personal Hotes.
Inp1a OFFICE.
From August 4 to November 1.
Arrivals Reported in London. — Lieutenant-Colonel J.
Davison, D.S.O., I.M.8.; Lieutenant-Colonel B. E. M.
Gurdon, C.I.E., D.S.0.; Major W. N. Hay, 129th Bal.;
Captain H. C. Nicolay, 2nd G.R.; Captain E. H. Stocker,
13th Hussars; Lieutenant-Colonel E. V. Hugo, I.M.S.;
Captain P. S. Mills, I.M.S. ; Captain J, G. B. Shand, I. M.S. ;
Major A. Murphy, I.M.S.; Major C. H. Watson, I.M.S8.;
Major H. M. Mackenzie, I.M.S.; Major N. P. O'G. Lalor,
I.M.S.; Major C. G. Webster, I.M.S.; Captain W. A. Justice,
I.M.S. ; Captain A. G. Coullie, I.M.S.; Captain A. E. Grise-
wood, I.M.S.; Captain F. E. Wilson, I.M.S.; Lieutenant-
Colonel R. K. Mitter, I. M.S. ; Captain H. R. Dutton, I.M.S. ;
Colonel R. N. Campbell, C.B., C.I.E., LM.S.; Major C. R.
Bakhle, I.M.S.; Major R. W. Knox, I.M.S.; Captain
H. M. H. Melhuish, I.M.S. ; Major F. D.S. Fayrer, I.M.S. ;
Major E. J. Morgan, I.M.S.; Captain W. D. H. Stevenson,
LM.S.; Lieutenant-Colonel E. V. Hugo, I.M.S.; Colonel
R. N. Campbell, I.M.S.
Extensions of Leave, —Major J. H. McDonald, I.M.S., 6 m.,
M.C.; Captain H. H. Broome, I.M.S., 12 d.; Major W. G.
Hamilton, I.M.S., 20 d. ; Lieutenant-Colonel C. Duer, I. M.S.,
27 d.; Lieutenant-Colonel R. H. Caster, I. M.S., 6 m., M.C.;
Lieutenant-Colonel W. Molesworth, I.M.S., 3 m. 17 d.; Major
G. Y. C. Hunter, I.M.S., 6 m, M.C.; Major W. G. Liston,
I.M.S., 3 w.; Captain J. L. Lunham, I.M.S., 9 m. ; Captain
R. D. Willcocks, I.M.S., 6 m. ; Captain R. L. Gamlen, I. M.S.,
to November 23, 1913; Captain C. H. Barber, I.M.S., 8 m.;
Major S. R. Christophers, I.M.S., 2 d.; Major E. A. C.
Matthews, I.M.S., to December 4, 1913; Major T. Hunter,
I. M.8., 10d. ; Major W. D. A. Keys, I.M.S., 2 m., M.C. ; Captain
L. Reynolds, I.M.S., 10 d.; Lieutenant-Colonel S. H. Hender-
son, I.M.S., 3 m. ; Major A. A. Gibbs, I.M.S., to April 30,
1914; Captain. R. F. Hebbert, I.M.S., 2 m.; Lieutenant-
Colonel J. Penny, I. M.S., 4 m., M.O. ; Captain G. L. C. Little,
I.M.S., 4 m., M.C. ; Captain J. G. B. Shand, I.M.S., 2 im. ;
Lieutenant-Colonel C. Duer, I. M.S., 5 m. 3 d. ; Lieutenant-
Colonel J. T. Calvert, I.M.S,, 6 d.; Major W. E. Scott-
Moncrieff, I.M.S., 8 m. 2d. ; Captain R. F. Hebbert, I.M.S.,
2m.
376
Permitted to Return.—Major W. G. Richards, I.M.S.; Mr.
H. Maloney; Mr. E. L. Moysey, I.C.S.; Rev. W. E. C.
Henry; Mr. S. E. J. Flanagan; Captain W. H. Riddell,
I.M.S.; Major E. L. Ward, LM.S.; Lieutenant-Colonel R.
Bird, M.V.O., C.I.E., I.M.S.; Major F. T. Thompson, I.M.S.
List oF INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CivIL RULES).
Showing the Name, Province, and Department, and the Period
for, and. Date from, which the Leave was granted.
Bakhale, Major C. R., I.M.S., Bo., 18 m., July 10, 1913.
Barnardo, Captain F. A. F., L.M.S., B., 30 m. 8 d., May 29,
1912.
Campbell, Colonel R. N., I.M.S., Assam, 8 m., August 2,
1913.
Dutton, Captain H. R., I. M.S., Delhi.
Gibson, Dr. F. M., LM.S, Director, King Institute of
Preventive Medicine, M., 6 m. 8 d., August 21, 1913.
Gray, Lieutenant-Colonel W. H., I.M.S., U.P., 94 m.,
October, 24, 1911.
Grisewood, Captain A. E., I.M.S., Cent. Prov., 8 m., March
14, 1918.
Hugo, Lieutenant.Colonel E. V., I.M.S., Punj., 14 m. 26 d.,
July 15, 1913.
Ingram, Captain A. C., I.M.S., M. Med. College, 20 m.,
June 30, 1913.
Justice, Captain W. A., I. M.S., M. Sanitary Comm.
Knox, Major R. W., I.M.S.
Lalor, Major N. P. O'G., I.M.S., Burma Sanitary Comm.,
24 m., July 23, 1913.
Lindesay, Major V. E. H., I.M.S., Behar and Orissa, 10 m.,
April 8, 1913.
Lloyd, Captain R. E., I.M.S., B., 24 m., November 16, 1911.
Lunham, Captain J. L., I.M.S., Bo., 9 m., March 20, 1913.
McConaghy, Captain C. B., I.M.S., India Foreign, Persian
Gulf, 24 m., April 4, 1913.
McDonald, Major J. H., I.M.S., Bo., 12 m., Mar. 19, 1913.
Melhuish, Captain H. M. H., I.M.S., 6 m., September 10,
1913.
Mitter, Lieutenant-Colonel R. K., I.M.S., M., 13 m. 15 d.,
August 6, 1913.
O'Keeffe, Captain D. S. A., I.M.S., M.
Penny, Lieutenant-Colonel J., I.M.S.,
December 25, 1912.
Reaney, Captain M. F., I. M.S., C.P., 21 m., July 4, 1913.
oo Captain W. R. J., LM.S., 24 m. 14 d., May 14,
1913.
Burma, 12 m.,
d da Major C. G., I.M.S., M. Hospitals, 24 m., July 99,
1913.
Wilson, Captain F. E., I.M.S., India Foreign, 2 m., May 6,
1913.
Woolley, Major J. M., I.M.S., Port Blair, 8 m., March 30,
1913.
List or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Barber, Captain C. H., I. M.S., to September 4, 1914.
Campbell, Colonel R. N., C.B., C.I.E., I.M.S., to April 1,
1914.
Pra Poole, Captain I. M., S. and T. Corps, to November
' 3.
Coullie, Captain A. G., I.M.S., 1 y., to August 3, 1914.
Crimmin, Lieutenant-Colonel J., V.C., I. M.S., to November
30, 1913.
S AAA Lieutenant-Colonel J., D.S.O., I.M.S., to July 7,
14.
Dawes, Major C. D., I. M.S., to December 24, 1913.
Fox, Lieutenant E. C. R., I.S.M.D.
Gibbs, Major A. A., I. M.S., to April 30, 1914.
Hebbert, Captain R. F., I.M.S., to December 19, 1913.
Ker, Lieutenant-Colonel M. A., I. M.S., to March 19, 1914.
Kerans, Captain G. C. L., I.M.S., 1 y., to October 4, 1913.
Mackenzie, Major H. M., I.M.S., to October 31, 1914.
Matthews, Major E. A. C., I.M.S., to December 4, 1913.
McVean, Captain N. N. G. C., I.M.S., to February 11, 1914.
ja. dE OE Captain 8. H., I M.S., to December 10,
Murphy, Major A., I. M.S., to March 18, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1913.
COLONIAL CIVIL SERVICES.
Dr. W. S. McGowan has been appointed Medical Officer in
charge of the Native Dispensary and Hospital at Belingee,
Southern Rhodesia, in place of Dr. Neville S. Williams, who
has resigned the appointment.
Mr. R. F. de Boissiere, District Medical Officer of Fiji, has
been granted an extension of leave of absence for three and
a half months from November 22.
Dr. H. North, who was recently appointed a Medical Officer
of Southern Nigeria, has assumed the duties of his office.
Dr. C. R. M. Pattison has been appointed a Stipendiary
Magistrate of Fiji.
Dr. P. H. MacDonald, Medical Officer in the Southern
Nigerian Service, has retired.
Dr. J. P. B. Snell has left for Southern Nigeria.
Dr. M. C. Blair left recently for Nigeria,
Dr. E. H. Tweedy, Senior Medical Officer, has returned to
the Gold Coast.
Dr. Victor T. W. Eagles has been appointed Medical Officer,
Grade 3, Federated Malay States, and has taken up his duties.
Dr. J. A. Harley, Medical Officer, Medical Department of the
Colony of tbe Gambia, has left the Colony on leave of absence.
Dr. F. C. V. Thompson has been appointed as an Officer of
the West African Medical Staff.
=e
Becent and Current Literature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JOURNAL OF TROPICAL MEDICINE AND
HYGIENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
* Bulletin of Entomological Research," vol. iv, part 2,
September, 1913.
The following original articles appear in the above
number: ** A Bug attacking Sesamum indicum, L.," by W.
L. Distant; “The Bionomies of Glossina” (a review with
hypothetical conclusions), by William F. Fiske; ** On Three
New Species of Gamasid Mites found on Rats," by Stanley
Hirst; “A New Froghopper from Tobago," by J. C.
Kershaw; “ Notes on a few Photographs illustrating the
Haunts and Habits of Glossina tachinoides in Bornu, N.
Nigeria,’ by Dr. Bernard Moiser; “The Anopheles of
Malaya.— Part I," by A. T. Stanton; “The Myzorhynchus
Group of Anopheline Mosquitos in Malaya,” by C. Strickland ;
* Progress in the Study of Verruga Transmission by Blood-
suckers,” by Charles H. T. Townsend; “On the Chemo-
tropism of Insects and its Significance for Economic
Entomology,” by Dr. Ivar Triigardh.
Hotices to Correspondents.
1.—Manuscripts if not accepted will be returned.
2,—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
9.— To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
5.— Correspondents should look for replies under the heading
** Answers to Correspondents.”
Dec. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 24, Vol. XVI
=ar
Original Communications.
PYOSIS TROPICA IN THE ANGLO-EGYPTIAN
SUDAN.
By ALBERT J. Cuatmers, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories,
AND
Captain W. R. O'FAnRELL, R.A.M.C.
Protozoologist, Wellcome Tropical Research Laboratories,
Khartoum.
Introductory.—Staphylococcal infections of the
skin have been recognized since 1880, when Pasteur
isolated staphylococci from a boil. Since then the
labours of Garré, Bockhart, Zackermann, Bousquet,
Leloir, Unna, Welch, Morris, Macleod, Colcott-Fox
and many others have thoroughly established the
staphylococcal nature of many skin lesions in tem-
perate climates. The result of this work is that
these infections are classified into those of external
origin and those of internal origin. The latter are
skin lesions due to a blood infection. The former
may be subdivided into those of primary and those
of secondary origin. Those of secondary origin are
the staphylococcal contaminations of primary lesions
due to some other cause, such, for example, as
scabies.
The primary staphylococcal infections of external
origin are usually either follicular or perifollicular
inflammations, being connected with the hair
follicles, e.g., follicular impetigo, furunculi, carbun-
culi, sycosis menti, sycosis nuche, dermatitis papil-
laris capilliti, or form abscesses in the dermis, the
hypodermis or the subcutaneous tissues, e.g., infan-
tile multiple abscesses, or give rise to inflammations
of the folds of the nails, causing onychia, and
spreading deeper may enter the tendon sheaths,
thus causing whitlows. None of these descriptions,
however, apply to a non-follicular staphylococcal
skin disease, which is very common in natives and
Europeans in the tropical countries in which we
have worked, and which was first differentiated by
Castellani under the term ‘‘ Pyosis tropica.” As
we have quite recently seen the disease in a
European and a native in Khartoum, we venture
to bring forward the following remarks :—
Hisiorical.—As long ago as 1904 Castellani
differentiated the above-mentioned non-follicular
pyogenic skin lesion under the term *'' Pyosis
tropica ' in contradistinction to the other very
common non-follicular pyogenic skin affection often
called Manson's pemphigus, but more scientifically
named '' Pyosis Mansoni’’ by Castellani.
** Pyosis tropica " is so common in the Kurune-
gala district of Ceylon that it impressed its presence
upon the popular mind and received the appellation
Kurunegala ulcers. Castellani found it to be very
common, not merely in Ceylon, but also in Southern
India, and his publications on this subject may be
found in the Ceylon medical reports from 1904 to
1912, and in the first and second editions of a
‘* Manual of Tropical Medicine’’ by himself and
one of us,
In 1912 Gabbi and Sabella record the diagnosis
of seven cases of Pyosis tropica in Tripoli.
So far as the literature at our disposal indicates,
the above comprise the total original articles on the
subject.
Geographical Distribution.—At present '' Pyosis
tropica’’ is, as far as we know, only definitely
recognized in Asia and Africa. In the former con-
tinent it occurs in Southern India and Ceylon, and
in the latter in Tripoli and the Anglo-Egyptian
Sudan. We are, however, in entire agreement with
Castellani's views that it will be found in many
other tropical countries if looked for.
Racial Distribution.—As far as we know, the
disease has only been reported in Europeans,
Tamils, Singalese, and in the so-called Arab peoples
of Tripolitana.
Body Distribution.—The eruption occurs most
commonly on the legs, next on the arms and, but
rarely, over the body.
Etiology.—The causal organism is a micrococeus
measuring from about 0:35 to 0'7 microns in dia-
meter and often grouped in staphylococcal masses.
This micrococeus is non-motile, Gram-positive,
colours readily with all the ordinary dyes, and does
not possess a capsule.
It grows aerobieally at 379 C., and in so doing
produces a golden-yellow pigment on agar slopes in
forty-eight hours.
It produces acid, but no gas, in the following
media : Sugar-peptone media—(a) Monosaccharides :
glucose, levulose and galactose; (b) disaccharides :
maltose, lactose and saccharose.
It produces neither acid nor gas in the following
media: Sugar-peptone media—(a) Monosaccha-
rides: arabinose; (b) trisaccharides: raffinose;
(c) polysaccharides: dextrin and inulin. Glucoside-
peptone media—Amygdalin. Alcohol-peptone media
—Erythrite, adonite, dulcite, isodulcite, mannite,
sorbite and inosite.
In broth and peptone-water it produces a turbidity
but no indol. In peptone neutral red, when grown
aerobically, it produces no fluorescence.
On blood serum it forms small pin-point glistening
colonies, but it causes no liquefaction.
Systemic Position.—From the above cultural
characters it will be seen that it belongs to the
family Coccacee Zopf, emended Migula, and to the
genus Micrococcus, Hallier, 1866, emended Cohn,
1872.
In this genus it must be classified with those forms
which are Gram positive, which grow on agar and
which form orange-yellow colonies. These facts,
together with its pathogenicity, mark it as belonging
to the species Micrococcus pyogenes variety aureus.
Rosenbach, 1884, which is the same organism as
Aurococcus mollis, Winslow and Rogers, 1908.
It is, however, highly unsatisfactory to leave the
classification at this point, for various reasons,
e.g. :—
(1) The Pyosis tropiea organism does not ferment
mannite.
(2) The Pyosis tropiea organism does ferment
levulose and galactose.
€
378 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(3) The Pyosis tropica organism can be readily
cured by an autogenous vaccine.
(4) Nile boils and allied suppurations in Khartoum
also yield organisms of the M. pyogenes variety
aureus type, differing slightly in cultural respects
from the organism of Pyosis tropica and from one
another, and differing markedly in that a vaccine
prepared from a case of Pyosis tropica did not have
any beneficial effect upon a case of Nile boils.
With regard to the fermentation of mannite, this
is one of the substances recommended by Gordon
in 1905 as being of value in the differentiation of
the so-called staphylococci. Since then the action
of M. pyogenes variety aureus upon this medium
has been ably studied by Dudgeon in 1908, who
found that it was acidified by most strains obtained
from pathogenic sources. Thus in suppurative
cutaneous and subcutaneous lesions he found it
absent only twice in sixteen cases and present in
all suppurative bone lesions. In cultures from
normal skin it was absent once in six isolations.
This test would therefore appear to be of some value
in the differentiation of closely allied cocci.
Lævulose and galactose do not appear to have been
tested by Dudgeon, but they are probably not of
the same differential value as mannite, because they
are fermented by strains from Nile boils and allied
suppurations.
Dextrine was not fermented by the organism of
Pyosis tropica, but it was fermented by a subcu-
taneous suppuration strain of M. pyogenes variety
aureus, but not by one from some Nile boils.
From the above it is quite certain that in Pyosis
tropica we are not dealing with the classical
M. pyogenes variety aureus, but with another
though closely allied form.
The next point for discussion is whether the
Pyosis tropica organism is the same as the organism
named M. pemphigicontagiosi, Clegg and Wherry,
1906, and which they seem to have proved to be
the cause of ‘‘ Pyosis Mansoni.” ;
This organism resembled M. pyogenes variety
aureus very closely, but differed in that it did not
produce indol and that a single human inoculation
experiment produced the typical but abortive
vesicles of Pyosis Mansoni. It often showed
typical diplocoecal appearance and seems to have
been closely related to M. pemphigineonatorum,
Almquist, 1891, differing therefrom by not produc-
ing in human inoculations the typical blisters of
pemphigus contagiosus.
The Pyosis tropica organism differs from the
above, among other points, in the nature of the
skin lesions to which it gives rise.
Taking the above points into consideration, we
are of the opinion that the organism which we have
grown from Pyosis tropica, though closely allied
to the classical M. pyogenes variety aureus, Rosen-
bach, 1884, is slightly different therefrom, and
would therefore suggest the name M. pyogenes
variety tropicus, Chalmers and O'Farrell, 1913, in
order to draw attention to the cultural and patho-
genic differences. If the genus Aurococcus, Wins-
Jow and Rogers, becomes established, and it has
[Dee. 15, 1918.
been supported recently by Kligler, the name of
the pyosis organism would be Aurococcus tropicus.
Method of Infection.—We are inclined to believe
that infection takes place after some slight local
traumatism, especially those caused by thorns, or
after any other condition which lowers the local
vitality, such as an attack of prickly heat.
Symptomalology.—The eruption appears first, as
small, reddish, scarcely elevated papules, which
rapidly become papulo-vesicles and pustules (fig. 1),
which are usually encircled by a zone of hyperemia.
These primary lesions are situate between the hair
follicles, with which they have no relationship, nor
have we noticed any connection with the sweat
glands.
Small pustules coalesce together and bursting
give rise to a serous exudate which, if allowed to
dry in situ, forms the yellow crusts, which are
highly characteristic in appearance. On removal
of a crust an irregular superficial ulcer is laid bare,
with a red granulating surface, a free base, and
edges which are not undermined. In natives the
ulcers are surrounded by a zone of hyperpigmenta-
tion, and in Europeans by a hyperemic area.
When the ulcers heal they usually leave spots of
hyperpigmentation (fig. 3), but otherwise th»
affected skin in our cases returned to normal (fig. 2).
There is considerable pruritus in all cases.
Castellani's infections were severer than ours and
he noticed small flattened or hemispheric nodules
under the crusts in addition to the ulcers, and he
also observed depigmentation on healing and ‘n
chronie eases hyperkeratosis, especially about the
elbows, which we have not observed.
As alrendy stated, the regions of the body most
commonly attacked are the legs and arms.
Diagnosis.—The essential features of Pyosis
tropica are the presence of small pustules placed
between the hair follicles and quite unassociated
therewith. From these pustules M. pyogenes
variety tropicus, Chalmers and O'Farrell, 1913, can
be cultivated.
The differential diagnosis of Pyosis tropica must
be made from the various follicular inflammations
from Pyosis Mansoni, from Pyosis palmaris, and
from Frambcesia tropica.
From the follicular pyoses it can be differentiated
by observing that the initial lesions have no con-
nection whatever with the hair follicles.
From Pyosis Mansoni it may be differentiated by
the absence of the relatively large blebs of this
affection, which, though small at first, soon reach
the size of a small pea, and may be even larger.
Small vesicles are, of course, present in Pyosis
tropica, but these rapidly turn into pustules. It
may also be distinguished by the fact that the
axilla and groins are not specially attacked.
From the rare ''Pyosis palmaris” it may be
differentiated by the fact that it never attacks the
palms, that the pustules are surrounded by a zone
of hyperemia, and that they do coalesce and form
crusts.
From Frambæsia tropica it is easily distinguished
by the fact that the essential lesion is a small
DECEMBER 15, 1913.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE,
Fic. 2.—S4ME CASE AFTER VACCINE AND LOCAL
Fic. 1.—Pyosis TROPICA IN A EUROPEAN. T á
REATMENT.
If this illustration is examined with a hand lens the individual This photoeranh was taken ten daya after the
pustules will be easily seen. fürst. P Bray : y
Fic. 8.—THE HYPERPIGMENTATION OF THE SKIN AFTER AN ATTACK.
This photograph was taken about two months after the eruption
was cured. The hairs on the leg had to be removed in order that
the area of hyperpigmentation might show clearly. It may, with
advantage, be examined by means of a hand lens.
To illustrate paper on *'Pyosis Tropica in the Anglo-Egyptian Sudan,” by ALBERT J. CuarwkRs, M.D., F.R.C.5.,
D.P.H., and Captain W. R. O'FannELL, R.A.M.C.
Dec. 15, 1913.]
pustule, and that on removing the yellow crusts,
which may cause Pyosis tropica to resemble yaws,
the resulting ulcer is quite superficial instead of
being raised and of the typical raspberry appear-
ance. The removal of a little serum from a
puncture of the ulcer and the examination of the
same by dark ground illumination will fail to demon-
strate Treponema pertenue (Castellani, 1905) which
is usually easily found in the typical yaws sore.
Prognosis.—The prognosis is very good if actively
treated by means of local and vaccine therapy.
Treatment.—The treatment we have pursued is
quite simple. Remove the crusts by means of warm
boracic fomentations, then cleanse the sores by a
lotion of 1 in 1,000 perchloride of mereury, and
apply a 1 per cent. carbolic ointment, and dress
the sores twice daily.
In the meanwhile an autogenous vaccine is pre-
pared, and 250 million cocci administered every
third day, and controlled by the opsonie index when
necessary. We have found an autogenous vaccine
to be infinitely better than a stock vaccine, and the
same remark holds good for the other allied pyogenie
infections, such as Nile boils.
Prophylazis.—Very little ean be said with regard
to the prophylaxis beyond general platitudes as to
the necessity for care of the general health, regular
washing oi skin and elothing, and care of the
local skin after a slight injury, such as a blow or a
scratch.
Acknowledgment.—We acknowledge most grate-
fully the valuable help which Major Forrest,
R.A.M.C., has given us in this and other researches
into skin diseases in Khartoum.
LITERATURE.
In chronological sequence.
CASTELLANI (1901-1912). Ceylon Medical Reports.
OrEGG and Wuurry (1906). Journal of Infectious Diseases,
vol. iii, No. 1, pp. 165-171.
DupaEoN (1908). Journal of Pathology and Bacteriology,
vol. xii, p. 242,
CASTELLANI and CHALMERS (1910).
Medicine.” 1st edition, p. 1,069.
Giedr and SapELLA (1912). “ Malaria,” Settembre-Ottobre,
p. 271.
CASTELLANI and CHALMERS (1913).
Medicine,” 2nd ed., p. 1,463.
KLIGLER (1913). Journal of Infectious Diseases, vol. xii,
No. 3, p. 432.
* Manual of Tropical
‘t Manual of Tropical
THE VAGRANT HABITS OF ASCARIS LUM-
BRICOIDES WITH THE REPORT OF A
CASE OF INTEREST.
By T. S. Trrumurti, M.B., C.M.
Assistant Professor of Pathology, Medical College, Madras.
Ir is well known that intestinal worms are very
common in the Tropies, the worms usually met with
being Ascaris lumbricoides (round worms), Tricho-
cephalus dispar (whip-worms), Oxyuris vermicularis
(thread-worms), Ankylostoma duodenale and Necator
americanus (hook-worms). Verminous infections
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
879
are so common in India that a knowledge of these
worms and their ova is absolutely essential to the
medical practitioner. The statisties collected by
me in the general hospital post-mortem room show
that over 50 per cent. of the patients who died of
other diseases harboured round worms. For-
tunately, the round worms cause no serious trouble
in most persons. Usually their numbers vary from
half a dozen to a dozen. Rarely patients harbour
large numbers of them and yet suffer from no
symptoms, but they give rise in many instances to
colic, nausea, vomiting, dyspepsia, and occasionally
severe diarrhea, especially in children. In the
Madras Medieal College Museum is a specimen of
a collection of 857 round worms said to have been
passed in three days by a native girl aged 12.
The patient was admitted to hospital for severe
colic. Two grains of santonine, both morning and
evening, followed by castor oil, caused the expul-
sion of the worms. The girl left hospital cured in
a week.
Cases are recorded by Cobbold where the ascaris
is said to have given rise to cerebral symptoms,
convulsions, epilepsy, and cataleptic fits. Many
cases of convulsions in children are attributed to the
presence of these worms in the intestines. A
tangled mass of round worms may also cause intes-
tinal obstruction. In the third physician's wards,
General Hospital, Madras, Captain Ingram, I.M.S.,
mentions that one of the four patients suffering
from symptoms due to the presence of round worms
under treatment passed ninety-nine round worms
within three days, eighty-two of them in one large
stool after an enema. The symptoms of the patient
were constipation, vomiting, and pain in the
abdomen, so that the picture presented was sugges-
tive of intestinal obstruction.
The normal habitat of the lumbricus is the
jejunum and upper part of the ileum. It often
wanders to different parts of the intestinal tract,
stomach, mouth and anus, and gives rise to no
serious trouble. There are instances in which it
has passed into the larynx from the cesophagus,
causing asphyxia and death. It is also known to
cause diffuse suppurative peritonitis by getting into
the abdominal cavity through ulcerated patches of
intestine, but the possibility of its perforating the
normal alimentary canal is doubted, as, for-
tunately, it is not provided with any kind of boring
apparatus. The large number of cases mentioned
in the literature are probably to be explained by the
supposition that the round worms play only a
secondary part, since they have been observed, after
the death of the host, to make use in their move-
ments of passages caused by ulcers perforating the
intestine. To corroborate this hypothesis the
character of the perforations has been cited, which
looks more like a gradual erosion than the result of a
mechanical force. Leuckart writes, “ Although it
is difficult to decide the question with certainty, I
think that the denial of the presence of these per-
forations is unfounded. That a boring apparatus is
by no means necessary for the perforation of tissues
380
and organs has been decided by modern investiga-
tions, and is indeed sufficiently proved by the
instances which we have collected of wandering
cysticerel."'
Cases are recorded in which the ascarides get into
abscesses in communication with the intestinal
tract. Curiously enough no such communication
was seen in the following case recorded by Major
Niblock, I.M.S., 1st Surgeon, General Hospital,
Madras (1910), of a Hindu girl, aged 12, who was
admitted suffering from an abscess in the right ileo-
lumbar region. As soon as the abscess was opened
two large round worms wriggled out of the wound.
There was nothing to point to intestinal trouble,
nor was there any smell indicating Bacillus coli
infection. The abscess healed up without any
trouble.
Liver abscesses have also been known to result
from the vagrant habits of the ascarides, though
such instances are very rare. Major H. Kirk-
patrick, I.M.S., has recorded the case of a young
married woman who attempted to commit suicide
by throwing herself into the Cooum on account of
severe constant pain in the pit of the stomach, of
which she complained for ten months previously,
except when she had occasional intermissions from
the pain. She had irregular remittent fever and
extreme tenderness in the episgastrium to the right
of the middle line. At the operation a living round
worm 11 in. long was withdrawn from an abscess
in the right lobe of the liver. The lay mind of the
hospital ayahs magnified the worm to a snake,
which the patient was thought to have swallowed
in her temporary abode in the Cooum.
'. Sometimes the lumbricus gets through small
orifices in communication with the alimentary canal,
as into the appendix, giving rise to appendicitis, or
through the ampulla of Vater into the common bile-
duct and gall-bladder. These instances are, how-
ever, distinctly rare. Cobbold mentions that the
third fasciculus of a work illustrating the collection
of morbid anatomy in the Army Medical Museum
at Chatham gives a case of lumbrici oceupying the
biliary ducts and gall-bladder. I can meet with no
case in the literature, however, in which numbers
of them had travelled into the liver along the
hepatic ducts giving rise to biliary obstruction and
formation of biliary calculi in the liver. Hence the
report of the following case will prove interesting : —
The patient was a Hindu girl, aged 12. She was
admitted into hospital suffering from fever. On
examination the spleen was found enlarged, and
signs of pneumonic consolidation of the left lung
were present. She died the day after admission,
and a post-mortem examination was conducted by
Major H. Kirkpatrick, I.M.S., and myself.
The body was that of a poorly nourished girl.
tigor mortis was present. The skin was highly
pigmented. There were cicatrices of uleers over
the thighs and anterior abdominal wall. On open-
ing the abdomen the liver was found enlarged about
three fingers’ breadth below the costal margin in
the nipple line, and five fingers’ breadth below the
ensiform cartilage. The spleen was much enlarged.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 15, 1913.
The veins in the neck were distended. The heart
and the right lung showed no pathological changes.
The whole of the lower lobe of the left lung was a
solid mass, the pleura over which was inflamed.
On section it was found to be of a greyish red
colour, with numerous dark red areas of hsgmor-
rhages in its substance. Out of the cut surface a
thick yellowish fluid escaped. The cut surface was
granular, and the substance friable. The mucous
membrane of the smaller bronchi was reddish in
colour. The bronchial glands were enlarged, caseous
and pigmented.
The spleen was enlarged to about six times its
normal size, soft and flabby. The cut surface had
a glazed look, and was of a chocolate colour. The
substance was moist and friable. The trabecular
markings were obscured. The capsule was thickened
in places.
The kidneys were larger in size than normal. On
section they were moist, congested, and dripped
blood. The cortex was normal in extent, and
streaked with vessels. The capsule was thin,
stripped easily, and left a smooth surface.
The liver was enlarged, and on section of a pinkish
grey colour. The veins were full of blood. The
consistency was normal. The bile-duct had five
round worms distending it. Many lumbrici had
travelled up the smaller bile-ducts, one of them to
very nearly the dome of the right lobe near the
posterior margin. The cut surface of the worms
and several soft irregular gall-stones were found in
the several sections of the liver. The specimen is
preserved in the Madras Medical College Museum.
The mieroscopieal examination of the spleen and
bone-marrow smears showed numerous typical
Leishmania-donovani.
The girl died of kala-azar, in which pneumonia
was a terminal manifestation. History of no sym-
ptoms referable to the verminous infection of the
liver or to the presence of numerous calculi in the
hepatie ducts was obtained.
I am of opinion that the lumbrici had not
travelled up the hepatic ducts after the death of
the patient, but must have done so a long time
before death, as their presence had caused some
amount of obstruction to the flow of bile, thereby
giving rise to the formation of hepatic calculi.
My thanks are due to Major H. Kirkpatrick,
I.M.S., for his kindness in allowing me to make use
of the notes of the case.
REFERENCES.
Catalogue of the Madras Medical College Museum. (In print).
Annual Report and Statistics of the Government General
Hospital, Madras, for the year 1909; Third Physician's wards.
Annual Report and Statistics of the Government General
Hospital, Madras, for the year 1910; First Surgeon's wards.
Annual Report and Statistics of the Government General
Hospital, Madras, for the year 1910; Third Physician’s wards.
** The Parasites of Man." Rudolf Leuckart.
‘Parasites : a Treatise on the Entozoa of Man and
Animals." Cobbold.
The Madras Government General Hospital Post-mortem
Records for the year 1912, P.M. No. 453.
———— 9» —————
Dec. 15, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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~ THB JOURNAL OF.
Tropical Medicine anD-bypgíene
DECEMBER 15, 1913.
ANTI-TYPHOID INOCULATION.
To those concerned in examining men and
women about to proceed to the Tropics the
question of anti-typhoid inoculation is an ever-
present one. There are several factors which
have to be dealt with, all of which need con-
sideration, even to the temporary inconvenience
inoculation may cause; and before touching on the
main question, namely, the efficacy of the protection
afforded, several side issues may be disposed of.
Inoculation is usually performed immediately, say,
the last fortnight, before the candidate leaves home
to go on board ship. This is surely the worst time
possible; it is a period of hustle and hurry, saying
good-bye to parents and friends, getting ready for
the voyage and purchasing an outfit. In the midst
of this comes the question of being inoculated,
involving, as it often does, keeping quiet for two
days out of the fourteen at one's disposal. The
candidate, rather than submit to this, foregoes
inoeulation and starts on his voyage. He may be
told that he ean be done on board ship, and he is
provided with the necessary vaccine, so that he
may be done by the doctor on board ship. Not
infrequently the doctor has never before given an
anti-typhoid injection, and he hesitates to do so,
advising his would-be patient to wait until he gets
381
to the port of his destination. On arrival there he
is at once launched upon work, and frequently
finds that the man he is to '' relieve ’’ has already
gone home and a burden of heavy office work is
laid upon the new-comer, who finds his new sur-
roundings take all his time to become familiar
with. The anti-typhoid inoculation is postponed,
and as the days grow into weeks and months the
inoculation is put off, as there seems nothing wrong
with the climate and the new-comer feels, as most
new arrivals do, very fit. He may or may not
falla victim to typhoid, but the chances are if he
does unfortunately do so it goes hard with him.
Another form of neglect is that the candidate may
before he leaves home have had only one injection ;
he declares he felt so stiff and bad after the first
that he is not going to have a second, as he is too
busy and cannot keep quiet. It is needless to say
that this man is imperfectly protected.
These are some of the reasons for a man or
woman not being protected before leaving home;
frivolous they may seem, but nevertheless none the
less difficult to contend with.
Another question often asked by the candidate
or the firm he is employed by: ''Is it necessary
to be inoculated against typhoid before going to
?” naming some place in the Tropics, the
Far East, South Africa, South America, &e. This
is a difficult, and at times a troublesome question
to answer. Difficult, inasmuch as it is impossible
to know the sanitary conditions of every town or
district in the world outside these shores, for that
is what it amounts to; and troublesome, inasmuch
as if it is insisted upon the health authorities in the
place named may resent the opinion of the medical
man at home, who regards a suggestion, even of
inoculation, as a necessity for '' " as an insult
to the sanitary condition of the particular town or
district of which they are in charge. There are,
however, certain towns and districts which are
notoriously typhoid stricken, whilst there are others
where protection against typhoid is uncalled for.
One would like to mention these, but to give a list
of the safe und unsafe places would only cause
friction, and might terrify unnecessarily intending
candidates or their relatives to the extent that a
refusal to go abroad might be the consequence.
An ‘unhealthy " place does not signify typhoid
infected, but that it is beset by malaria or yellow
fever, &c. There are several so-called unhealthy
regions where typhoid is practically unknown;
perhaps the West Coast of Africa is a typical
example, so much so that, rightly or wrongly, the
writer does not recommend, or, at any rate, does
not insist upon inoculation against typhoid being
done in the case of men proceeding to the '* Coast.’
This, however, is not the case in many countries
nearer home; the writer recommends all young
folk under 21 to be inoculated against typhoid
before proceeding to any and every country bor-
dering on the Mediterranean; and in the case of
boys and girls proceeding to the continent of
Europe to reside in a school, be the country what
it may, to be inoculated before going abroad. We
are so free of typhoid in Great Britain now that
SEA.
ORT pe a ?
382
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1913.
one is apt to forget that other European countries
are not so favourably placed and that the young
are particularly susceptible. Typhoid is so rare a
disease in London hospitals at present that many
a student of two or three years' standing has never
seen a case. On the other hand, the following is
instructive: A party of medical men, accompanied
in some instances by their wives and by five young
folk under 21, twenty-three in all, proceeded a few
years ago to the Mediterranean to take part in the
opening of a large sanatorium, with the result that
four of the five under 21 years of age contracted
typhoid. There would, however, seem to be some
parts of the world where typhoid is unknown, or,
ab any rate, where it has not been diagnosed; it
would be advantageous to know these for many
reasons; and it would appear also that there are,
within the lifetime of the present generation,
regions where typhoid, previously unknown, has
appeared and spread and become endemic.
The geographical distribution of typhoid as it
stands at present is unknown, and it would be
interesting, let alone the practical value ensuing,
to find out what the distribution really is. Can
any of our readers tell us towns, districts or coun-
tries where typhoid is unknown?
The value of anti-typhoid inoculation is generally
recognized, although we have not had sufficient
experience of the trial to pronounce what the value
really amounts to.
We usually allow those who have had typhoid
previously to forgo inoculation before going abroad.
That this is not always satisfactory is proved by
the fact of a civil surgeon who went out to South
Africa in 1901, during the war, contracting typhoid
there, although only twelve months previously he
had an attack of typhoid in London.
The question of different types of the ailment
is raised by such cases as these, as if what was
protection against an English form of typhoid was
not sufficient protection against the South African
form, and vice versd. The question also of inocu-
lation with local types of vaccines arises, and
although this at present is disregarded, it may not
continue to be so.
The main question of the good anti-typhoid
inoculation does remains to be dealt with. Is it
possible for anyone to pronounce upon this? Have
we sufficient statisties to go upon? In the British
Army the pronouncement is distinetly in favour of
anti-typhoid inoculation, and recently the autho-
rities of the French Army have recommended that
anti-typhoid inoculations shall be compulsory. The
United States Army authorities have already made
inoculation compulsory, and legislation in many
other countries is tending in the same direction.
The most recent statistics are the French; the pro-
portion of cases of typhoid amongst the inoculated
^nd non-inoeulated in France and Eastern Morocco
being per mille O to 38:23 respectively. In Western
Moroeeo, where exposure to infection is greater,
there were amongst the inoculated 2°96 cases per
1,000, with 0:09 deaths: against 165:75 per 1,000,
with 21:291 deaths amongst the non-inoculated.
There is no doubt, however, that in war prophy-
lactic measures are difficult and in many instances
impossible, and that typhoid still remains one of
the great scourges of military campaigns in almost
every country. It would appear, therefore, that
there is sufficient evidence to justify medical men
pushing the idea of anti-typhoid inoculation to the
full, more especially in the case of young people
under, say, 25 years of age, who leave these shores
for any country, whether for travel or for prolonged
residence.
It is during the first two years, more pronouncedly
in typhoid-infected countries, that the danger exists,
and it is advisable that inoculation should be carried
out, in the case of all young people proceeding
abroad, before they leave British shores à
J. C.
—— DM
Abstracts.
NEURASTHENIA, AND ITS BEARING ON
THE DECAY OF NORTHERN PEOPLES
IN INDIA.*
By Surgeon-General Sir R. HAVELOCK CHARLES,
G.C.V.O., LMS. (R.).
Sergeant-Surgeon to H.M. King George V.; President of the
Medical Board, India Office.
Tur author said it was difficult to dogmatize on
such a subject; but he thought it possible to argue
from the lessons of history, analogy, and experience.
His work on the India Office Medi«:el Board had
brought before him :—
(a) The unhealthiness from which Englishmen
suffer after a long spell of Indian service. All on
sick leave come before the Board, and one can see
that debility, mental and physical, apart from any
special disease, renders a change to Europe every
four or five years a necessity. This is the explana-
tion of Government and Mercantile leave rules. Jt
is not a spirit of philanthropy that is at the base
of these regulations, but a desire to have the
I;uropean servant at his best.
(b) The condition of physical fitness of men going
to India—as all recruits are passed by the Medical
Board.
(c) The diseases causing ill-health, death, or
invaliding—for the Board inquires into such.
The author said it was not his purpose to con-
sider neurasthenia save as regards its determining
factors, and the influence it must exercise on any
people transported to countries where this affection
is common, and to which disease their conditions
of life would render them easier victims.
In opening a discussion on '' Special Factors
influencing the Suitability of Europeans for Life
in the Tropies ” at the British Medical Association,
London, 1910, he stated his opinion as to the best
health capital to be taken to the Tropies, and said
that the best kind of man was the good ordinary
type of Britisher with a clear head ‘‘ well screwed
on," an even temper, not over intellectual, who can
* A paper read before the Society of Tropical Medicine and
Hygiene, October 17, 1913.
Dec. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
383
take an interest in things around, not unduly intro-
spective, one who can work hard and find pleasure
in it, capable of bearing exposure to the sun; one
who will practise temperance in all things, with
self-control and common sense—meaning that such
a one inherits no liability to that neuropathic dis-
position which requires only a light exciting cause
to develop active mental trouble.
In the Tropics normal persons often experience
symptoms which, when more strongly marked, are
characterized as neurasthenic, whilst those cf
weaker mental calibre become unbalanced. In the
former case the condition responds more readily to
treatment than does the neurasthenia as met with
in Europe, but for its cure a change of climate is
absolutely essential.
Many years ago, when Sir Havelock Charles
began life in India, stationed in the Punjab, he
often heard it said of individuals in the various
services, '* Oh! such and such a one ought to go to
Europe for a bit—he has got, or is getting, Punjab
head." On inquiry he found the signs of this
peculiarity were that an officer, otherwise in every
way a good fellow, had become short-tempered ;
forgetful of names; troubled with sleeplessness;
given to feel his work too much for him ; disinclined
to take responsibility; given to make molehills into
mountains; procrastinating; susceptible on slight
exertion, mental or physieal, to fatigue; and with
a loss of all powers of concentration. In fact, an
irritable man, more or less unequal to his work,
though otherwise fairly fit.
Since that date, during much travel in India and
Burma, and twelve years' work in Caleutta, he
recognized that those peculiarities were the com-
mencing signs of an affection which had been named
neurasthenia.
Amongst Europeans in India it is an affection well
worthy of study. It does not directly kill the
patient, but it '' hampers his work, interferes with
his career, ruins his temper, upsets his friends, and
causes him to be unfit for any position of trust or
responsibility.’’
The primary causes leading to this in the Tropics
are the humidity, and the sun, with its light and
heat. Helping these are the parasitic diseases—
the causal agents of which owe their vigour to the
climate and their preservation to the environment.
An abnormal bodily state is produced by the light,
the heat, and the humidity—a change in body
temperature, a lowered pulse-rate and tension, an
irritable heart, a lessened respiratory function owing
to deficiency of intake and rarefaction of the air,
and a deterioration of the blood. An increasing
perspiration causes a lessening of the kidney ex-
cretion; with the extra work thrown on the liver
there follows a continued congestion, then degener-
tion; an atonie dyspepsia and impaired function lead
to pathological decomposition of protein bodies in
the gastro-intestinal canal, and there ensues chronic
auto-intoxication and its results. Thus the climatic
conditions lower the powers of resistance, and
render the individual more liable to fall a victim
to the attacks of the specific forms of disease.
The author has met with the subjects of neuras-
thenie troubles during twenty-five years in India,
and, in the past six years, on the Medical Board,
India Office. In the latter time there have been
upwards of 150 cases.
The commonest
been :—
Mental.—A lack of confidence, tendency to intro-
spection, loss of energy, want of power of concen-
tration, phobias, insomnia.
Emotional.—Lack of control of feelings, irrita-
bility, depression.
Circulatory and Vasomotor.—Palpitation, head-
ache, sense of giddiness, sweating.
Various Forms of Gastro-intestinal Trouble —
Colitis, dysentery, diarrhea, &c.
Nowhere in the world can be seen a white race,
in a tropical climate, maintaining the original energy
of the people that founded the power. The damp
heat changes the quality of the blood; the muscular
fibre becomes less vigorous; the brain becomes more
irritable; the calm reason, the temperate will, the
foresight, the strength, the skill, the endurance s£
the European, becomes sadly redueed by the tropi-
cal conditions, all acting with their depressing effect
on the nervous system.
In India the European is in a position of trust
and has much responsibility. His work is harass-
ing in nature and entails much mental effort. In
the temperate zone many endure strain and mental
expenditure, working early and late, and keep their
powers unimpaired; but in the Tropies the powers
of resistance to such strain are greatly lowered, and
eventually, in the predisposed, the nerve breakdown
called neurasthenia ensues.
When the normal European goes to India he first
experiences a marked feeling of wellness, his brain
is more active, and his muscle vigour more marked.
He cannot understand either the complaints, or the
warnings, of the old residents. He thinks he has
an inexhaustible capital of health, but he over-
draws, and exhaustion follows. The sleepless
night of fervent heat, noisy with insect life, the
food tasteless and unrefreshing, the loneliness of
the station, the petty worries incidental to the
humdrum of the life, the sun shining all day, bring
about tiredness of mind and body. It is this terrible
nerve exhaustion which has, in the past, been the
most important factor in preventing the Northern
aces settling, and procreating their line, with a full
share of the nerve vigour which the parental. stock
possessed. This is why the invaders of India have
disappeared, and this is the bar to the settlement
of tropical regions by white folk. It has been
written of India that there the European struggles
during the first, dwindles and degenerates durinz
the second, and becomes extinct, as such, during
the third or fourth generation.
One cause, and one only, can keep the European
up to his standard, and that is—frequent change.
However you alleviate, by increasing knowledge,
the conditions of life, the factors of climate remain
—those many and subtle physical agencies so active
towards the human organism in health and disease.
symptoms manifested have
384
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1913
The sun and the moisture gradually sap the body,
the feelings, the mind. The domiciled become pale
and pallid, the prey possibly to ansmia, fever, and
dysentery ; unequal to labour and unfitted for super-
vision, wasted and worn, they leave a strain born
of a neurotic stock.
Finally the author concluded as follows :—
(1) I start from Cuvier's axiom: '' The nervous
system is at bottom the whole animal, and the
other systems are only to serve it.”
(2) My thesis is that the constitution of the
Northern races is developed in temperate latitudes
—that its powers are vigorously affected by the
climatie conditions of the hot zone.
The way in which to establish a theory is to
advance definite facts in its favour.
(i) If you damage the subservient systems you
injure the whole animal, i.e., the nervous system.
(ii) Tropical climates injure the various systems
of the body apart altogether from the dangers of
attack from parasitic enemies.
(iii) The characteristics of dwellers in the Tropics
are distinctive of them and produced by their
environment. :
(iv) The characters of the Northern races are a
thing apart and due to similar causes.
(v) Brain power, or the civilization due to it, did
not arise in the hot zone, for the seats of this
ancient civilization—the old ‘‘ culture zone "—
were in lat. 25° N. to 509 N.
(vi) Modern civilization, with higher brain
development, has gone still further north than the
seat of the '' culture zone,'' and is now found in the
temperate regions.
(vii) The emotional type of brain, when found in
the Northern peoples, is more peculiar to the races
that live in the warmer parts, and they have that
in common with dwellers in the sub-Tropies.
(viii) What has happened to the myriads of
invaders of India? Have they maintained their
power, or have they decayed—Aryan, Greek,
Scythian, Hun, Mongol, Parthian, &c.? Do the
peoples of India preserve the characteristics of these
invaders? Do the descendants of the invaders
preserve the powers of the nations from whence
they sprung, and are they comparable to the peoples
occupying the original homeland ?
(ix) What has been the effect on the descendants
of the European races that have gone to India in
old days—Portuguese, Dutch, French, English ?
To how many generations does the pure blood
survive? What is the character of the degenerated
stock ?
(x) How do the heads of the great merchant
firms in India answer the foregoing question when
employing men for various business posts? The
Eurasian gets a certain pay; the country born gets
double that; the imported European, with his
energy and fresh vitality, gets four times the
amount given to the Eurasian, and twice that given
to the country born.
(xi) The Emperor Baber, in his Memoirs,
makes an interesting note on the depressing effect
of the climate on his followers—a falling off in
energy and initiative. For this he gave them per-
mission to return to the cooler regions to recuperate,
whilst he himself battled with the discomfort of
the sun and the surroundings.
(xii) There is a disease—diabetes—which has
certain relations to the nervous system. That
affection is very prevalent in India, and increasingly
so since the Indians have been foreed to live more
strenuously by their contact with Europeans, the
strain being less easy to bear there than in Europe.
(xiii) What occurs to the various strains of
horses, cattle, sheep, dogs, poultry, and even
vegetables, introduced from Europe to the plains
of India? Do their distinctive characters remain
or deteriorate?
(xiv) Experiment has shown that metabolism in
flowers and changes of colour and structure can be
brought about by insolation—according to the
altitude, seasonal and diurnal.
(xv) What is the meaning of ‘‘ Punjab head,"
‘Bengal head," '' Burmese head," and other
such terms? (? Warnings of neurasthenia.)
(xvi) The conditions affecting the foregoing are
those that have had to do with the formation of
races—climate, food, soil—i.e., environment.
NYASALAND PROTECTORATE:
SICKNESS DIARY.
Part XXI.
By H. Hearsey.
Zomba.
Hearsey states that during the months of May,
June, July and August, 1918, twenty-five additional
cases of sleeping sickness have been notified,
namely, six in May, three each in June and July,
and thirteen in August. Of this number seven
have been discovered by Dr. Morgan in the Marimba
distriet, sixteen by Dr. Conran in the Dowa dis-
trict, and two by Dr. Sanderson in the South
Nyasa district. These twenty-five cases added to
those previously reported now make a total of 153.
As was stated in the last memorandum, a rein-
vestigation of the contiguous fly-infested districts,
to the north and south of the *' Proclaimed Area "'
in the Dowa distriet, was to have been taken in
hand. Funds available for this purpose have not
admitted of an extended seareh being made for
cases, but a period of three months' investigation,
however, was allotted to each of the following four
districts with results as now indicated :—
Marimba District.—Dr. Morgan, who began his
investigations in August, has, as already noted, been
successful in finding seven cases within the month.
Six of these were discovered in the northern portion
of the fly-area, which is here continuous with a
similar area extending to the southern portion of
the West Nyasa district; one case has quite recently
been found in the extreme southern part of the
distriet, where the Marimba and Dowa fly-areas
merge into one another.
Dedza District.—The reinvestigation of this dis-
triet, which began in June and terminated in
SLEEPING
Dec. 15, 1913.]
August, was entrusted to Dr. Davey. After a most
painstaking search no cases were discovered, and,
as in the past, failure has again been attributed
to the unfavourable attitude of the natives and to
an entire lack of co-operation on their part. The
distribution of tsetse-fly in this district is in a
relatively narrower ''belt," which traverses its
entire eastern border along, but at some little dis-
tance from, the Lake shore. As this fly-area in
the north is continuous with the fly-area in the
Dowa district, and with a similar area in the South
Nyasa distriet to the south, whence two cases have
recently been reported, it may quite reasonably be
assumed that the Dedza district also harbours
infected cases, however few in number.
South Nyasa District. —Dr. Sanderson began his
investigations in this district in August and has
succeeded in finding two cases up to the present—
both at the south-west arm of the Lake, that is
to say, in the north-eastern portion of the district.
During the month of September he will devote
attention to its southern boundary.
Upper Shire District. —On the completion of his
investigations in the South Nyassa district at the
end of September Dr. Sanderson will investigate
the Upper Shire district during the months of
October and November, working down to the
extreme southern range of tsetse-fly distribution in
the Blantyre and West Shire districts.
It has generally been assumed, Hearsey says,
that sleeping sickness is endemic, more or less
exclusively, in the Dowa district; the object of
these investigations js to demonstrate that the
disease is to be met with wherever there is tsetse-
fly, and that, therefore, there is no part of the
Protectorate where, in the presence of tsetse-flies,
opportunities do not exist for contracting infection.
In short, an effort is now being made to substitute
facts for what has hitherto been conjecture; with
a view to inducing people living in, or passing
through, fly-areas to appreciate the danger and to
adopt necessary precautions. For, however small
the danger of infection may be, the fact remains
that the disease is invariably fatal within a com-
paratively short period. Dr. Conran, in his monthly
report for August, states in reference to the ques-
tion of personal prophylaxis: ‘‘ A gradual alteration
in the attitude of the natives towards the fly is
noticeable. Missionaries inform me that when
travelling in the area (‘sleeping sickness’) they
overhear quite intelligent discussions as to the best
way to avoid bites, and I notice that many more
natives carry fly-whisks or bundles of leaves when
travelling than was the case last year.”
PREVENTIVE MEASURES.
The following preventive measures are now being
carried out :—
(1) Impressing upon the natives the necessity of
avoiding being bitten by flies.
(2) Clearing for a distance of 300 yards or more
round villages situated in close proximity to fly.
Extending these clearings in many instances so as
to embrace their food gardens also.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
385
(3) Making clearings on each side of roads and
main paths leading from one village to another,
thus uniting groups of villages and enabling the
natives to Journey from one to another with com-
mensurate safety.
(4) Instructing the natives to use this felled
timber for firewood, and to avoid visiting the
adjacent fly-infested woods for this purpose.
(5) Instituting public latrines in all the villages,
to prevent natives from visiting the adjoining woods
for the purpose of defecation.
(6) Prohibition as to the firing of grass till the
month of October, when only it is fit for burning,
so as to ensure as large and as effectively cleared
areas as possible.
(7) Removal, whenever feasible, of
situated in danger zones, to fly-free areas.
To expedite clearing operations axes and heavy
knives have been supplied to natives in the sleeping
sickness area, and during a recent inspection
there was reason to be satisfied that some measure
of protection at all events will be secured from the
bites of tsetse-flies, and the danger of man-to-man
infection possibly considerably minimized.
The supervision of these clearing operations has
been placed in the hands of the Medical Officer’s
patrols and police employed in the area, as also
the construction and general supervision of the
latrines, Dr. Conran making his periodical visits to
see that the work is progressing apace and that
it is being properly carried out. All this work is
being done by the villagers themselves, without
payment of any kind; and on inspection the
author was satisfied that the various headmen whom
he met not only did not regard this labour as an
imposition, but appeared to take an intelligent
interest in the work.
Treatment.—The question of treatment has re-
cently formed the subject of a special communica-
tion, and it has been pointed out that unless
natives are segregated in hospital anything in the
way of systematie treatment, which alone would
be of any value in furnishing reliable data, cannot
be taken in hand. Segregation, partly with a view
to treatment, has been tried in the Dowa district
and found unworkable. It invariably resulted in
the concealment of the sick, and natives seemed
to be convinced that the sick died, not in spite of,
but in consequence? of treatment. The object at
present is to asce;ain the range of distribution of
the disease; any «attempt, therefore, to segregate
the siek, for whatever purpose, would reduce the
number of infected cases now found, already few in
number, to a minimum.
Various treatments have, in the past been given
a trial: (1) Atoxyl alone; (2) atoxyl, with inter-
mediate doses of hydrarg. perchlor.; (3) soamin;
(4) salvarsan; (5) tartar emetic; (6) dye B.S. In
no case was there recovery, and in one or two
instances in which some amelioration of the
patient’s condition was observed the improvement
was merely of a transitory nature. Such slight
improvement in symptoms is, however, occasionally
noted in patients undergoing no treatment.
villages
386
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1913.
Annotations,
Entamebe in Monkeys.—C. Mathias, in a paper
in the Bulletin de la Société Médico-Chirurgicale de
l'Indochine (September 14, 1913), describes two in-
teresting entamebe which he has encountered in
monkeys (Macacus rhesus and M. tchehensis) ot
Tonkin. Various observers have recorded, from time
to time, such organisms, either in the free condition
or eneysted, but they have given no details of struc-
ture or development. C. Mathis has been able to
study two entamab: of the monkeys, and these
are remarkable in that one of them conforms closely
to the Entameba coli of man, producing eystie
forms having eight nuclei, while the other resembles
E. histolytica, the pathogenic form from man,
and, like it, produces infective cysts having a maxi-
mum of four nuclei. There seems very little, if
anything, to distinguish the former from =E. coli,
the non-pathogenic entamaeba of man, but regard-
ing it as a distinct species, the author suggests for
it the name Lóschia legeri, adopting the generic
name Lóschia in place of the name Entameba,
whieh was first given to an organism from the
intestine of the cockroach, which, according to
Chatton and Bonnaire, who created the name
Lóschia, certainly belongs to a genus distinet from
the ameboid organisms of the human intestine.
Similarly, Mathis names the second of his monkey
entameebe Lóschia duboscqi. Here, again, there
appears nothing to distinguish this organism from
the pathogenic entamaba of man, and the author
discusses the possibility of their being the same.
However, on account of the difficulties of establish-
ing this point, he thinks it safer to regard them
as distinct. It is possible that this is the organism
found by Castellani (1908) in pus from an hepatic
abscess in a monkey (Macacus pileatus), and named
by him Entameba nuttalli, but no cystic forms were
deseribed, and it is impossible to decide whether
this is identical with the Lóschia duboscqi described
by Mathis, and which, moreover, was not associated
with any dysenterie condition.
The author also records the culture of amcebe
from the feces of monkeys on the medium of
Musgrave and Clegg. These are always of the
Amaba limaz type, and apparently have nothing to
do with the entamcbe, but are derived from cysts
of free living amcebe which have been ingested with
the food.
Entama bie of Man.—* The Entamcebe of Man
is the subject of a paper by Kuenen and Swellen-
grebel in the Centralblatt f. Bakteriologie for
November 15, 1913. The observations were made
in Medan (Deli-Sumatra), and the authors find that
here, as elsewhere, two entamebr exist: one,
Kntameba coli, non-pathogenic and producing eight-
nuclear cysts; and the other, E. tetragena (E. his-
tolytica), pathogenic and producing four-nuclear
cysts. They describe in detail the development of the
two entamæœbæ. — E. coli varies in diameter from 22
to 88 u. They have not encountered the much
smaller forms which have been described by some
observers. The cysted forms of E. coli vary in dia-
meter from 16 to 25 w, which is a measurement
considerably above that given by most writers. In
the development of the cyst from the uninuclear to
the eight-nuclear stage there is described as a normal
process of development the formation of a large
vacuole, which occupies the greater part of the cyst
during the early stages of development, and which
disappears as the nuclei multiply. It is certainly
true that in many of the cysts of E. coli such a large
vacuole occurs and it has the effect of displacing the
nuclei to the side of the cyst and hindering their
division, but it is doubtful if it can be regarded as
of normal oecurrence. In the normal development
no such vacuole is formed, and the nuclear divisions,
first into two, then into four and eight, proceed
rapidly, so that the early stages in the absence of a
vacuole are only of short duration. As regards the
development of the pathogenic entameeba (E. his-
tolyticu), the authors accept the cycle first de-
seribed clearly by Darling in Panama. There are
two distinet types of free forms, one the histolytica
type, which is the tissue invading form, and is to
be found during the acute dysenteric phase. It
measures from 25 to 30 p, has usually a definite
ectoplasm, a nucleus of 6 to 7 y, with a small karyo-
some surrounded by a clear area limited by a ring
of chromatin granules. Within these forms ingested
red blood corpuscles are often seen. The second
type of free form is seen in patients who have re-
covered from dysenteric attacks and who have for
the time being no indication of intestinal ulceration.
These, which were thought by Elmassian to belong
to a distinct species (E. minuta), have a diameter
of 12 to 16 u. The protoplasm is vacuolated; there
is no clear distinction between ecto- and endoplasm ;
the nucleus measures from 8 to 39:44, and often there
is a good deal of chromidium in the protoplasm.
The minuta forms do not invade the tissues, but
live, as saprophytes, in the feces, as does E. coli.
In this condition they may be present in the stools
for many months without giving rise to any sym-
ptoms. It is the minuta form which produces the
cyst which is responsible for the infection of new
individuals. These cysts measure from 11 to 14 x;
they contain one, two, or four nuclei; and in the
protoplasm there is frequently a large vacuole and
a chromidium in the form of blocks or rods.
Some experiments were conducted on the resis-
tunce of these cystic forms. To test whether 4
cystic form is still living or not dilute eosine solu-
tion was employed, for it has been shown that living
protoplasm will not stain with dilute eosine, but
that staining takes place immediately after death.
Aecordingly the eysts were exposed to various ad-
verse conditions and then tested for half an hour
with the eosine solution. The cysts were killed by
1:1,000 sublimate in four hours, 1:250 ecreolin `i
five to ten minutes, 50 per cent. alcohol and boiling
water immediately. Drying kills the eysts in a
few minutes. Exposure to direct sunlight without
drying kills most of the cysts in about three hours.
Dec. 15, 1913.]
Freezing, on the other hand, for several hours kills
only a small pereentage of cysts. In ordinary water
the cysts survive for three days, after which they
begin to die if the bacterial growth is marked, but
they will survive much longer (up to four weeks)
if they are not killed by overgrowth of bacteria.
In nature the cysts, when washed about by rain-
water, will probably survive a long time, since they
will not be exposed to such bacterial growth as
would kill them.
Some experiments were conducted with house-
flies. In no ease were living cysts recovered from
the gut of flies which had ingested them. Living
cysts in small numbers could be recovered from
the outer surface of the bodies of flies which had
become contaminated with feces, but so soon as
the flies had cleaned themselves and dried then ne
further living cysts could be recovered. Accord-
ingly the authors think that only under exceptional
circumstances will flies be able to carry about living
cysts.
As regards emetin, it was found that the histo-
lytica forms were killed by an hour's exposure to a
solution of 1:10,000. The minuta forms were more
resistant and survived this treatment for over three
hours, while the cysts were most resistant of all,
for of fifty-one cysts only twelve were dead after
a twenty-four hours’ exposure. With a solution of
1:100, after half an hour's exposure, of fifty-seven
cysts forty-four were dead.
“ Experimental Entamebic Dysentery’’ is the
title of a paper by Ernest Linwood Walker with the
co-operation of Andrew Watson Sellards, published
in the August number of the Philippine Journal of
Science (Section B, Tropical Medicine). The
authors give an account of experiments made by
them in Manila on prisoners, who volunteered for
the purpose. The account of the work is divided
into six parts, the first of which is an introductory
review of previous investigations on this subject.
It is mentioned that eighteen species of amceboid
organisms have been described as parasitie in the
intestinal traet of man, and of these at least five
have been definitely stated to be more or less patho-
genie. Some investigators have been led to the
belief that amcebe from water and other non-
parasitic sources are capable, when taken into the
intestine, of becoming facultative parasites, and in
certain enses, at least, of causing dysenterie sym-
ptoms. Reference is made to a former publication,
wherein one of the authors (Walker, 1911) showed
that the amæbæ found in Manila water were dis-
tinct from the entamcebe, and that the amcabe
culturable from the intestine of healthy persons,
as well as dysenterics, were derived from cysts of
ameebe which had been ingested with the food and
water, and were in no way connected with the
entamebe, which are strict or obligatory parasites
incapable of multiplying outside the body of their
host and not culturable in Musgrave and Clegg’s
medium. One non-pathogenic species of Ent-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
387
umeba is recognized, viz., E. coli, which includes
the E. nipponica of Koidzumi. "There is one patho-
genie species, E. histolytica, which includes E.
tetragena (Viereck) and E. minuta of Elmassian. It
is pointed out that dysentery has been produced
experimentally in animals by rectal (Kruse and
Pasquale, Strong and Musgrave), and in one ease
by intravenous (Gauducheau) injections of pus from
liver abscesses containing entamcebe but no cul-
turable bacteria; and, finally, several investigators
claim to have produced a disease in animals, and
in one case in man, having the clinical symptoms
of entamebie dysentery with entamabe in the
stools, and exhibiting the characteristic lesions in
the intestine at necropsy, by feeding or injecting
rectally “‘ pure mixed cultures " of amoebe and
non-pathogenic bacteria, which had been isolated
not only from stools of dysenterie patients, but from
water and other non-parasitic sources. Recog-
nizing the unsatisfactory nature of conducting such
experiments on animals the authors have conducted
a serles of experiments on men in Bilibid Prison
who had long sentences to serve, who had been
under observation for years in the prison, and who
ate cooked food and drank distilled water exclu-
sively. The men have been under complete control,
so that the existence or possibility of a natural infec-
tion with ameeboid organisms has been reduced to a
minimum. The organisms used in these experi-
ments included all the species of Amæba that could
be cultivated from the Manila water supply, from
a variety of other non-parasitic sources both within
and outside the Tropics, from the stools of healthy
persons, and from the stools of cases of entameebie
dysentery ; E. coli from healthy persons and persons
suffering from diseases other than dysentery ;*
cysts of “‘ E. tetragena from '' eonvalescents "’
and ** contact carriers " ; and motile E. histolytica
from acute cuses of entameebic dysentery and from
entamcebie liver abscess. The material was
administered in capsule after mixing either with
powdered starch or magnesium oxides. After
feeding, the stools were repeatedly examined cul-
turally as well as microscopieally for amoeboid
organisms.
In Part II of the paper are deseribed the experi-
ments on inen with cultures of amæbæ. Twenty
feeding experiments have been made with cultures
from eleven different sources, representing thirteen
strains and eight species of Ameba. The amebe
were cultivated on what is essentially Musgrave and
Clegg’s medium (agar 2°5 grm., sodium chloride
0°05 grm., Leibig's beet extract 0°05 grm., normal
sodium hydroxide 2 c.c., distilled water 100 e.c.).
The amcebe were fed for the most part in the
eneysted condition, but in some eases young cul-
tures free from encysted forms were used. A com-
plete protocol of each man used in the experiment«
* The term '*convalescent carrier" is used for a person who
has r covered from an attack of evtamabic dysentery, but who
is still carrying the specific organism ; a contact carrier is one
who has not had dysentery, but who nevertlieless carries the
organism,
388
is given. The amcebe (named species A—H) were
all recovered from the feces by culture (from
the first to the sixth day only) after feeding, with
the exception of species A and C. Species C was
ingested only once, and species A five times in
three different strains. Microscopic examination
of the fæces was always negative as regards amebe,
though in one case E. coli was found in the feces
of one of the men who was known to be harbouring
the entamcba when fed with cultures of the
amoba. On culture of this feces the ameba,
species E., was isolated, while E. coli, which was
found microscopically, was not cultivated. The
authors conelude this section by stating that it has
been demonstrated experimentally that none of
these amcebe are capable of living parasitically in
the intestinal tract of man.
Part III has to do with feeding experiments with
E. coli. The author believes that the E. williamsi
and E. hartmanni of Prowazek and the E. brasi-
liensis of Aragao are really forms of E. coli, which
is the entamceba found commonly in the stools of
healthy persons in tropical and sub-tropical coun-
tries.
In the experiments twenty men were fed with
E. coli, five distinct strains having been used. It
was fed mostly in the encysted condition, the stage
with eight nuclei, and given in the manner described
above for the amæbæ. The results with these
experiments stand in striking contrast to those
obtained by feeding the cultured amebe. Of the
twenty men, seventeen became infected with the
entamcebe which were found microscopically in the
fæces. Culture of the feces was invariably
negative. The period of incubation varied from one
to eleven days, and none of the men have developed
dysentery, though some of them have been under
observation for two years and five months. From
the uniform results it is concluded that E. coli,
unlike the Amæbæ, is an obligatory parasite, and
cannot be cultivated in Musgrave and Clegg’s
medium, and that it is non-pathogenic, and conse-
quently plays no rôle in the etiology of entamoebic
dysentery.
Part IV describes experiments with E. tetragena
and E. histolytica. According to Schaudinn’s
original description of E. histolylica, this organism
is distinct from E. tetragena (Viereck), but most
authorities now believe that the two are identical,
and that the four nuclear cysts of E. tetragena are
the true cysts of E. histolytica. The experiments
here to be recorded confirm this conclusion. Of
twenty men who ingested E. histolytica, seventeen
became infected at the first feeding, one required
three successive feeds before becoming infected, and
two who did not become infected at the first feed
were reserved as controls. Sixteen of these men
ingested E. histolytica, and in fourteen mobile
entamcebe appeared in the stool; four men ingested
mobile E. histolytica (in two cases from liver
abscess), and three of these became infected. The
high percentage infected after ingesting mobile
entamcebe is due probably to the fact that the acid
of the stomach was neutralized with magnesium
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1913.
oxide. Only one of the two men who ingested enta-
mobs from liver abscess became infected. In the
case of six of the men fed with encysted forms no
neutralization was undertaken, and they all became
infected. The entamobs appeared in the feces
from one to forty-four days after feeding (average
nine days). Of the eighteen men who became
infected with E. histolytica four have developed
entamoebie dysentery. It is stated that '' the large
percentage of latent infections (78 per cent.) among
these experimentally parasitized men was some-
what unexpected. "However, the frequent
occurrence of latent infections in entameebic
dysentery has been noted by a number of
authors, and is well known to every clinician
and pathologist working in the Tropics.”
No case of spontaneous entamebic dysentery
occurred in the ward during the period of the
experiments with E. histolytica, so that the results
warrant the conclusion that E. histolytica is a strict
or obligatory parasite, that it cannot be cultivated
in Musgrave and Clegg’s medium, and that it is
the essential etiological factor in endemic tropical
dysentery. As a further result of these experiments
it has been found that men fed with E. histolytica
show ''tetragena ” cysts in their stools, and that
at certain stages of the infection the entamebe
acquire the characters of Elmassian’s E. minuta,
so that one may conclude that E. tetragena and
E. minuta are in reality E. histolytica.
Part V is oecupied with the application of the
results to the diagnosis, treatment, and prophylaxis
of entamebie dysentery. For examination of any
individual for entamæbic infection it is better not
to administer a purge, for in the formed stool
encysted forms are more likely to occur, and these
are much more readily diagnosed than the free living
entamcebe. The differences between the free living
forms of E. coli and E. histolytica are described, but
it is admitted that the differentiation of the two is
sometimes impossible. The encysted forms, how-
ever, present the most distinctive characters for
making a diagnosis. In the matter of treatment it
is most important to make a diagnosis, for E. coli
is very common in the Tropies, and the indis-
eriminate treatment of all persons showing enta-
mobs in their stools is as indefensible as would be
the treatment with diphtheria antitoxin of every
person showing a culture of any bacillus whatsoever
from his throat. On the other hand, diagnosis is
necessary in the case of chronic and latent cases
of entameebic dysentery, for these are sources of
infection in endemic regions, first, because of their
relative prevalence; secondly, because this condition
persists indefinitely ; thirdly, because their infection
is unsuspected; and fourthly, because these
“carriers °’ are constantly passing in their stools,
often in enormous numbers, the resistant, encysted
stage of E. histolytica. '' The knowledge of the
part which these ' carriers’ of E. histolytica prob-
ably play in the spread of entamebic dysentery,
together with the ease and certainty with which
such ‘carriers’ can be detected by microscopic
examination of their stools, makes the prophylaxis
Dec. 15, 1913.]
of the disease relatively simple. It is believed that
it would be possible, were it practicable, to eradicate
this disease from any region by a systematic
examination of stools and the treatment or isolation
of all persons found to be carriers of E. histolytica.
In the absence of such thoroughgoing prophylactic
measures, a sanitary disposal of all feecal matter
should be insisted upon, and household ‘ carriers
of E. histolytica should be eliminated."
In the matter of personal prophylaxis the authors
believe that a monthly examination of the stools
of persons residing in endemie centres would
ordinarily be sufficient to anticipate and prevent
an attack of entamæbic dysentery. The paper
describes the methods for separating and distin-
guishing the pathogenic and non-pathogenic enta-
mæbæ, and concludes with Part VI, which is
summary and conclusions to be drawn from the
foregoing results.
A New Sign in Kala-azar.—The Lancet for August
9, 1913 (p. 392) contains a paper by Dr. R. A. P.
Hill on a new sign in kala-azar which, if found to
be of constant occurrence, should be a great help
in diagnosis. The author has seen eleven cases of
the disease in Pekin during the past two years, and
in only one instance was the patient over 12 or 13
years of age. Further south in China adult cases
appear to be more common. The sign referred to
is a peculiar action of the blood when diluted with
a special diluting fluid which the author uses in
making leucocyte counts. In other diseases the
blood mixes with the fluid quite readily, but in eight
consecutive cases of kala-azar the author has found
that even with the utmost expedition one cannot
prevent the blood from clumping, so that it becomes
impossible to make a blood count with the use of
this fluid. The diluting fluid is made in the follow-
ing way :—
A. (1) Wright's modification of Leishman's stain,
saturated and filtered (presumably in methyl
alcohol), 2 parts.
(2) Pure methyl alcohol, 1 part.
B. 0°1 per cent. solution of sodium chloride in
distilled water.
For use add 1 part of A to 8 parts of B, shake
well, and use within half an hour. If a precipitate
forms or the cells overstain add a little more methyl
aleohol to A. Dilute the blood 1 in 20 or 25, and
mix promptly. If the mixing is done too slowly
lumps may form in any blood, but in kala-azar it is
impossible with the utmost expedition to avoid
lumping. Of the eight cases it was least marked
in one that apparently recovered under big doses of
quinine.
Cerebral Malaria.—Patterson contributes an in-
teresting article upon the cerebral form of
pernicious malaria in the Journal of the American
Medical Association, November 15, 1913. He
recognizes the following types: (1) The comatose
type, (2) the motor irritative type, (3) the motor
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
389
depressive type. Coma is a symptom of all the
types, the associated symptoms varying with the
different types. As a rule, cerebral malaria does
not occur with the first paroxysm, but is preceded
by several. Its onset is always sudden, occurring
with startling swiftness. Cases illustrative of the
different types are given; the conclusions the author
reaches are as follows :—
(1) Cerebral malaria may assume the form of any
brain disease.
(2) It is practically never due to the first
paroxysm but to succeeding ones, and by energetic
treatment of the first paroxysm it may be prevented.
(3) Quinine hypodermically acts specifically, but
the drug must be given for effect—the dose usually
being 9 to 12 gr. every four hours.
(4) Cerebral malaria is a frequent disease in
malarial districts.
Leprosy.—Bayon, in the British Medical Journal,
November 29, 1913, writes on the clinical and
bacteriological aspects of leprosy. He believes that
knowledge of the contagious nature of the disease
is founded on the following substantial observa-
tions :—
(1) That it is a disease due to a definite micro-
organism.
(2) That in Northern Germany, where the disease
had been reintroduced from Russia in modern times,
the infection was found to have spread concen-
trically from the first imported cases.
(3) That the overwhelming majority of cases
originate in countries where leprosy is relatively
common.
(4) That in the rare cases in which the disease has
been contracted in countries where leprosy is not
indigenous, such as England, Holland, and Southern
Germany, we are able in every case to prove the
more or less intimate contact with lepers who in
their turn came to these districts after a more or
less prolonged stay in a leprosy ridden country.
(5) That in countries where leprosy is relatively
rare the disease is found to be bound to definite
foci or families. This has been observed in the
Alpes Maritimes, on the Riviera, and in the Valais
(Switzerland).
(6) That the countries which have carried out
universal segregation have been rewarded by a
gradual and constant diminution of the disease.
(7) That where segregation has been abandoned
or loosely carried out the scourge has attacked an
ever-increasing number of individuals.
The author's statistics seem to show clearly that
contagion or infection through immediate contact
is the usual mode of transmission, and this being
so, it is rather far-fetched to seek an insect carrier
of the scourge. All experiments to prove this mode
of dissemination have so far failed, though it
appears quite probable that the common house-fly
ean suck up the germs of the disease from open
sores, and carry them about for several days. As
regards treatment, nearly every imaginable drug
has been tried, and a great number are still under
390
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1913.
experiment in the hope of discovering a cure for
leprosy; but so far there is no specific and sure
method of treatment.
In its initial stages leprosy affects the general
well-being and appearance of an individual to such
a slight extent that any therapeutic effort which
succeeded in arresting the disease in its early stages
in a fair proportion of cases would practically
amount to a cure.
Spontaneous remissions of the disease and spon-
taneous apparent ‘‘ cures’’ occur, however, in a
small proportion of lepers, and may last for several
years, in some instances as long as fifteen years or
more, but afterwards the disease may again become
virulent and rapidly kill the patient. Therefore any
drug or method of treatment must stand the test
of time, five years or more, and be applied to a
sufficient number of patients. :
Without taking into consideration these impor-
tant initial factors, it is absolutely irresponsible to
speak of cure in a disease so chronic, slow, and
intractable as leprosy is known to be.
For all advanced nodular stages Chaulmoogra oil,
or, better, its refined constituent ''antileprol,"'
injected intramuscularly in doses of 8 to 5 c.c. is
still the best palliative the author knows. The
injections should be repeated every three days, and
the course should last five months or more if the
patient ean stand it. Chaulmoogra oil and antileprol
can also be given internally in small capsules, and
for this mode of treatment antileprol is decidedly
preferable, as it does not cause the gastric disturb-
ances produced by the unrefined oil. Doses varying
between 15 minims and ten times that quantity can
be taken daily.
Cases in the early maeular stage appear to
respond better to other forms of treatment. A
cultural extract has also been prepared from the
miero-organism of leprosy isolated by Kedrowsky en
lines similar to those used in the preparation of
Koch's alt-tuberkulin.
——ÀÀ
Hotes and "etos.
THIRD INTERNATIONAL CONGRESS OF
TROPICAL AGRICULTURE, LONDON, 1914.
Association Scientifique Internationale d'Aqronomie
Coloniale et Tropicale.
[Preliminary General Circular. |
Preliminary Notice.
Tne International Association for Tropical Agri-
culture (Association scientifique internationale
d'Agronomie coloniale et tropicale) has decided to
hold in London, in June, 1914, an International Con-
gress, in which all countries interested in Tropical
Agriculture and Forestry are invited to participate.
The Association has requested the Committee of
the British Section, whose headquarters are at the
Imperial Institute, to make the necessary arrange-
ments for the meeting, in co-operation with the
Bureau of the International Association in Paris.
The Congress will be held at the Imperial In-
stitute, South Kensington, London, S.W. It will
open on Tuesday, June 23, and close on Tuesday,
June 80, 1914.
Order of Business.
In the order of business at the Meeting, the morn-
ing sittings (10 a.m. to 1 p.m) will be reserved for
papers and discussions on subjects of general im-
portance, each morning being devoted to a single
subject; the afternoon sittings (8 to 5 p.m.) will be
reserved for papers and discussions on special
subjects.
Transactions.
Communications intended for the Congress may
be made in English, French, German, or Italian;
but the general language of the Congress will be
English.
The following subjects are suggested for papers
and discussion at the morning meetings. Contribu-
tions on these and similar subjects are invited :—
I. Technical Education and Research in Tropical
Agriculture.
II. Labour Organisation and Supply in Tropical
Countries.
III. Scientific Problems of Rubber Production.
IV. Methods of developing Cotton Cultivation in
New Countries.
V. Problems of Fibre Production.
VI. Agricultural Credit Banks.
VII. Agriculture in Arid Regions.
VIII. Problems in Tropical Hygiene and Preven-
tive Medicine.
Papers for the afternoon meetings are invited on
the following subjects :—
I. Problems relating to Tropical Agriculture and
Forestry.
II. The Cultivation and Production of—Rubber,
cotton and fibres, cereals and other food-stuffs,
tobaceo, tea, coco-nuts, other agricultural products,
forest products.
III. Plant Diseases and Pests affecting Tropical
Agriculture.
Papers recommended for publication and Reports
of Discussions will be published at the close of the
Congress.
Subscription.
The subscription for membership of the Congress
will be £1, entitling members to admis ion to all
meetings and receptions and to receive the volume
of printed papers and discussions on n~blication.
Those desiring to become members of th. Cengress
are requested to fill in a form, whic" may be
obtained from the Imperial Institute, asd return
it to the Organising Secretaries for the Congress, as
soon as conveniently possible, in order ‘nat their
names and permanent addresses may be registered.
Notices.
A General Programme, with the complete
arrangements, will be forwarded to all registered
members before the Meeting.
Arrangements will be made for the accommoda-
tion of members of the Congress at suitable hotels.
Arrangements have been made by the Organisers
of the International Rubber Exhibition and of the
International Cotton, Fibres, and Allied Industries
Exhibition to hold these Exhibitions during the
period of the Congress, at the Royal Agricultural
Hall, Islington, London, N. Members of the
Congress will receive free Season tickets of admis-
sion to the Exhibitions; and special means of
conveyance between the Imperial Institute and the
Agricultural Hall will be provided.
The Organising Committee cordially invite all
who take an interest in Tropical Agriculture and
Forestry to attend the Congress and to make the
contents of the present circular as widely known
as possible.
All correspondence relating to the communication
of papers and the arrangements for the Congress
should be addressed to :—
The Organising Secretaries,
Third International Congress of Tropical
Agriculture,
Imperial Institute,
London, S.W.
WywpHAM R. DUNSTAN,
President of the International
Association and Chairman of the
Organising Committee for the
Congress in London.
F. Heim,
Secrétaire Perpétuel de V Asso-
ciation Internationale, Paris.
T. A. Henry,
H. Brown,
Honorary Organising Secretaries for
the Congress in London.
MEMBRES DU BUREAU INTERNATIONAL DE
L'ASSOCIATION.
PRÉSIDENT EN Exercice 1910-1915:
M. le Prof. Dunstan, Directeur de l'Institut Impérial,
Londres, Membre de la Société royale de Londres.
PRÉSIDENT SORTANT (InE PÉRIODE D’EXERCICE 1905-1910).
M. le Prof. J. L. de Lanessan, ancien Ministre, ancien
Gouverneur Général de l'Indo-Chine.
VicE-PRÉSIDENTS :
Allemagne.—M. le Prof. A. Engler, Membre de l'Académie
des Sciences de Berlin, Directeur des Musée et Jardin botanique
royaux de Berlin, et de la Station botanique centrale pour les
Colonies allemandes.
M. le Prof. Dr. Wohltmann, Conseiller privé, Directeur de
l'Institut agricole de l'Université de Halle sur Saale.
Angleterre. —M. le Colonel Sir D. Prain, Directeur du Jardin
royal, Kew, Membre de la Société royale de Londres.
Indes-britanniques. —M. Bernard Coventry, Conseiller agricole
du Gouvernement.
Belgique. — M. Ch. Liebrechts, Conseiller d'Etat à Bruxelles.
M. E. Leplae, Directeur général de l'Agriculture du Congo
Belge, au Ministére des Colonies à Bruxelles.
M. E. de Wildeman, Directeur du Jardin botanique de
l'Etat.
Brésil. —S.E.M. Olyntho de Magalhaes, Ministre du Brésil à
Paris.
Egypte.—M. G. C. Dudgeon, Directeur général de l'Agricul-
ture au Caire.
Dec. 15,1913] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
391
Equateur.—S.E.M, le Dr. Rendon, Ministre de l'Equateur à
Paris.
Espagne.— M. le Prof. Vincente Arche, Chef des Services de
l'Enseignement et de l'Expérimentation agricoles, au Ministére
de l'Agriculture, à Madrid.
M. E. Gomez Flores, Chef du Service agronomique des
Canaries, à Las Palmas.
France.—M. le Myre de Villers, Ambassadeur, Président
honoraire de la Société d'Acclimatation de France.
M. le Prof. Muntz, de l'Institut national agronomique,
Membre de l'Académie des Sciences de Paris.
M. le Prof. Edmond Perrier, Directeur du Muséum national
d'Histoire naturelle, Membre de l'Académie des Sciences de
Paris.
M. le Prof. Prillieux, de l'Institut national agronomique,
Membre de l'Académie des Sciences de Paris.
M. le Dr. Roux, Directeur de l'Institut Pasteur, Membre de
l'Académie des Sciences de Paris.
M. Tisserand, Directeur honoraire de
l'Académie des Sciences de Paris.
Italie. -S.E.M. le Prof. Nitti, Ministre de l'Agriculture, de
l'Industrie, et du Commerce à Rome.
S. E.M. le Prof. Sanarelli, Secrétaire d'Etat au Ministère de
l'Agriculture, de l'Industrie, et du Commerce à Rome.
M. le Comte Sabini, Attaché commercial a l'Ambassade
d'Italie à Paris.
Mezique.—S.E.M. de Mier, ancien Ministre du Mexique à
Paris.
S.E.M. Olegario Molina, ancien Ministre de l'Agriculture à
Mexique.
Pays-bas.— M. le Prof. H. J. Lovink, Directeur général du
Départment de l'Agriculture, des Indes néerlandaises à
Buitenzorg.
Portugal.—M. le Prof. Freire d'Andrade, Directeur général
des Colonies, au Ministére des Colonies, à Lisbonne.
S.E.M. le Prof. Batalha-reis, Ministre du Portugal à Saint-
Pétersbourg.
M. le Prof. J. Henriques, Directeur du Jardin botanique de
l'Université de Coimbra.
M. le Prof. de Monte-Pereira, ancien Directeur au Ministére
des Colonies, à Lisbonne.
Russie.—M. le Prof. Boris de Fedtschenko,
botanique impérial de Saint-Petersbourg.
Turquie.—M. le Prof. Hassib Bayindirly, Directeur de
l’Enseignment agricole au Ministère de l'Agriculture, à Con-
stantinople.
l'Agriculture de
du Jardin
ADMINISTRATEUR-TRESORIER :
M. $8. de la Rupelle, Secrétaire général de la Société générale
ur favoriser le développement des Commerce et de l'Industrie,
Paris.
SECRÉTAIRE PERPETUEL:
M. le Dr. F, Heim, Professeur a l'école nationale supérieure
d'Agriculture coloniale, et au Conservatoire nationale des Arts
et Métiers.
ORGANISING COMMITTEE FOR THE
LONDON.
CONGRESS IN
CHAIRMAN :
Prof. Wyndham R. Dunstan, C.M.G., M.A., LL.D., F.R.S.
MEMBERS:
Mr. M. Kelway Bamber, Government Chemist, Ceylon.
Mr. J. R Blackwood, Director of Agriculture, Bengal.
Mr. J. R. Bovell, I.S.O., Superiutendent of Agriculture,
Barbados.
Mr. I. H. Burkill, M.A., F.L.S., Director of Gardens, Singa-
ore.
Prof. P. Carmody, Director of Agriculture, Trinidad.
Mr. D. T. Chadwick, Director of Agriculture, Madras.
Mr. B. Coventry, C.I.E., Agricultural Adviser to the Govern-
ment of India.
Dr. C. W. Daniels, Medical Adviser to tbe Colonial Office,
London.
Mr. M. T. Dawe, Director of Agriculture in the Territory of
the Mozambique Company.
Prof. F. Debono, Inspector of Agriculture, Malta.
Mr. G. C. Dudgeon, Director-General of Agriculture, Egypt.
Mr. P. R. Dupont, Curator, Botanic Station, Seychelles.
392
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 15, 1913.
Dr. E. Goulding, Imperial Institute, London.
Mr. E. Ernest Green, late Government Entomologist, Ceylon.
Mr. W. S. Hamilton, Director of Agriculture and Industries,
Punjab.
Prof. J. B. Harrison, C.M.G., Director of the Department of
Science and Agriculture, British Guiana.
Mr. W. Hopkins, Director of Agriculture, Sierra Leone.
Mr. A. E. Humphries, Chairman, Home-grown Wheat Com-
mittee.
Mr. J. A. Hutton, Chairman, British Cotton-growing Associa-
tion.
Mr. W. H. Johnson,
Nigeria.
Mr. C. H. Knowles, Superintendent of Agriculture, Fiji.
Mr. P. H. Lamb, Director of Agriculture, Northern Nigeria.
Mr. L. Lewton-Brain, Director of Agriculture, Federated
Malay States.
Mr. R. N. Lyne, Director of Agriculture, Ceylon.
Mr. A. C. MacDonald, Director of Agriculture, East Africa
Protectorate.
Mr. J. MacKenna, Director of Agriculture, Burma.
Mr. J. S. J. McCall, Director of Agriculture, Nyasaland.
Mr. F. C. McClellan, Director of Agriculture, Zanzibar.
Mr. J. MeSwiney, Director of Land Records aud Agriculture,
Assam.
Dr. E. A. Nobbs, Director of Agriculture, Rhodesia.
Lieut..Col. Sir D. Prain, C.M.G., C.LE., LL.D., F.R.S.,
Director, Royal Botanic Gardens, Kew.
Mr. H. N. Ridley, C.M.G., F.R.S., late Director of Gardens
and Forests, Singapore.
Mr. S. Simpson, B.Sc., Director of Agriculture, Uganda.
Mr. H. Hamel Smith, Editor of Tropical Life, London.
Mr. F. A. Stockdale, Director of Agriculture, Mauritius.
Sir Stewart Stockman, Chief Veterinary Officer, Board of
Agriculture and Fisheries, London.
Mr. W. S. D. Tudhope, Director of Agriculture, Gold Coast.
Mr. W. T. Tutcher, Superintendent, Botanical and Forestry
Department, Hong Kong.
Dr. F. Watts. C.M.G., Imperial Commissioner of Agriculture
for the West Indies.
Dr. T. A. Henry, Imperial Institute, London, | Honorary
Mr. Harold Brown, Imperial Institute, London, | Secretaries.
Director of Agriculture, Southern
————99——————
3rugs and Appliances.
EXPERIENCES WITH ARSEN-TRIFERRIN.
ARSEN-TRIFERRIN was used by Dr. K. Jochem,
Berlin, in thirty-two cases of anwmia, scrofula, and
malnutrition, after nervous exhaustion and debility,
after severe illnesses, and finally in diseases of
tubercular origin. It proved of excellent service in
all the cases. No objection was raised on the score
of taste or agreeableness. The author ordered the
preparation half an hour after meals, three times a
day, children taking one tablet, adults two tablets
at a time. Condiments and fruit must be avoided
while Arsen-Triferrin is being taken. Patients who
had complained of loss of appetite were soon en-
dowed with an increased appetite. In all cases the
author observed an improvement in the general
condition within a short time, as well as an increase
in bodily vigour. The author gave Arsen-Triferrin
to ten children, 6 to 13 years old, after they had
recovered from whooping-cough, in order to com-
pensate for the debility, and the results were
excellent.
Arsen-Triferrin was given to the same number of
young patients, both males and females, varying
in age from 13 to 18 years, because of the debility
and anemia associated with puberty, and the
results were all exceedingly good. For example, a
lad, aged 16, became very anemic owing to exces-
sive growth and premature overstrain, but an excel-
lent result was established after the use of six boxes
of Arsen-Triferrin tablets.
—— —4———————
Recent and Current Xitevaturt,
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of the JOURNAL oF TROPICAL MEDICINE AND
HyaiEne will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
* The Medical Journal of South Africa," vol. ix, No. 3,
October, 1913.
Tuberculosis in the Mines of South Africa.— Allen brings
forward figures which show that tuberculosis is common
amongst native miners in South Africa, Thirty per cent. of
these cases are found in imported natives, forty-two per
cent. being due to infection in the mines themselves. No
local measures, the author states, can be expected to accom-
plish much with such a steady annual influx of fresh cases,
{If all natives imported were thoroughly examined and those
suffering from tuberculosis rejected, the incidence of the
disease would manifestly be reduced.]
* Journal of the Royal Army Medical Corps," vol. xxi,
No. 4, October, 1913.
Phlebotomus Fever in Aden.—Loughnan writing on this
subject describes the habits and species of the sand-
flies found in Aden. He states that four specimens of sand-
flies captured in the beginning of June were sent to the
Royal Army Medical College for identification, where they
were pronounced to be Phlebotomus minutus. The adults
have been found with diffieulty in dark areas of inhabited
barracks, bungalows, native huts, and in caves frequented
by camel men and sweepers. About half an hour before
sunset on calm evenings the sand flies take to flight, and
are attracted by human beings, by burning lamps, by
white articles such as writing paper, tablecloths, shirts and
towels, on which they temporarily rest. These flies are
found sparsely distributed during the colder months, but
increase in numbers with the onset of the monsoon from
the end of May, when the temperature averages 95? F. and
the humidity of the atmosphere is greater than during the
colder months.
After careful searches, the author has never been able to
discover the breeding-places of these flies, although the
geologieal conditions might be considered suitable to the
growth of insect life which prefers slight moisture, dark,
secluded caves, associated with crannies and holes, in the
vicinity of human habitations, particularly where crumbling
lava, pumice, rubble and igneous sand are to be found,
with slightly varying temperatures, from sea-level to a height
of 1,700 ft.
Alotites to Correspondents.
1.—Manuscripts if not accepted will be returned.
2.—As our contributors are for the most part resident abroad
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE snould com-
municate with the Publisners.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents.”
| Jan. 1, 1913] COLONIAL MEDICAL
REPORTS.—SIERRA LEONE... 1
Colonial Medical Reports.—No. 12.—Sierra Leone—
(continued).
SMALL-POX.
THERE was no outbreak of this disease either in
the Colony or Protectorate.
The only authentic case officially notified was
one of the native crew landed from a steamer. This
case was seen by a medical offieer and was imme-
diately isolated, and admitted to the Small-pox
Hospital at Kissy; his comrades on board, who
were also landed, were segregated at the lazaretto
and were immediately vaccinated. There was no
fresh manifestation of the disease.
In the Protectorate there were few cases reported,
and there was no epidemic outbreak.
VACCINATION,
This was kept up fairly regularly during the year
in the Colony and Protectorate. The lymph, still
obtained from the Liverpool Institute of Compara-
tive Pathology, continues to give most satisfactory
results, a high percentage of successes being ob-
tained when it was used within a reasonable time
after its arrival in the Colony. To the use of this
lymph must certainly be attributed the comparative
freedom from small-pox for the past three years.
The total number vaccinated was 7,448, and of
these 6,491 were successful, 430 unsuccessful, and
522 were not seen again, the proportion of suc-
cesses being 87 per cent. of the total done.
QUARANTINE.
Only onee during the year were quarantine
restrictions imposed; this was in the case of the
s.s. '" Addah," which arrived in port with a case
of small-pox on board. As already stated, the case
was immediately isolated and admitted into the
Small-pox Hospital at Kissy, and all other neces-
sary precautions taken to prevent any outbreak or
spread of the disease. New quarantine regula-
tions, more in accord with modern ideas, are being
drawn up, and will be in force at an early date.
The new sanitary station at the Cape, about
five miles from the harbour, chiefly for the segre-
gation of persons during yellow fever, cholera, or
plague outbreaks, was almost completed; it now
requires to be enclosed, with a suitable fence, and
the furniture still remains to be completed. The
station contains the following buildings: One large
European barri (or house on native model); six
large native barris (or houses on native model).
A hospital, dispenser's quarters, a guard house,
kitchens, disinfecting chamber, mortuary, wash-
houses and latrines; all the latter are permanent
stone structures, the seven barris are modified
native houses. Each native barri is enclosed with-
in its own wire fence, so that the occupants of one
barri can have no communication or contact with
those of another. Each is capable of accommo-
dating fifty people. A new disinfecting house for
Freetown has been built; it is situated on the quay
at a convenient distance from the landing-place
and jetties. This chamber consists of four apart-
ments; a Clayton's disinfecting machine is placed
in one which communicates by a small opening,
for the passage of the tubes of the machine, with
two of the other rooms, the remaining room is in-
tended for a store for disinfected articles awaiting
shipping. With the completion of the sanitary
station, and the disinfecting chamber fitted with a
Clayton's machine, this Colony may be considered
fairly well equipped for fighting any outbreak, or
introduction from shipping, of infectious disease.
SANITATION OF FREETOWN.
During the year the sanitation of the city was
curried on as usual by the Sanitary Department of
the City Council. The scavenging was under the
direct control of the same department, with the
result that the work was done more efficiently and
more economically than when it was let out to con-
tractors.
The following returns show some of the work
done by the sanitary inspectors during the year
in the prevention of nuisances: Number of sum-
monses, 32; number of convictions, 26; amount in
fines, £6 2s. 1ld.; amount received from owners of
neglected lots cleaned by the Sanitary Department.
£6 9s. 2d.; persons arrested for committing nuis-
ances, 50; number of warning notices for abatement
of nuisances served, 2,280; number of warning
notices re cesspits, 142; number of dead animals
found and buried, 38; amount of diseased meat
found and destroyed, 1,613 lb.
During the year the following minor sanitary im-
provement works have been carried out by the
Government: Incinerators (for ordinary refuse
matter, new ones built, slightly modified in shape
from the first one built in 1908), 4; dust-bins of
the new covered type, 11; publie laundries, 4,
bringing the totals of each up to—incinerators, 5;
dust-bins, 20; public laundries, 6.
It is hoped that by the end of 1910, if the pro-
posed programme of minor sanitary improvements
be carried out, that a sufficient number of the above
will be provided to meet the present requirements
of the town.
A cattle market has also been provided, the land
being granted by the Government to the City
Council.for the purpose; it is situated at the north
end of Hagan Street on high ground, close to the
beach, from which a good road has been made up
the cliff. This market does away with the great
inconvenience and risk to the public formerly ex-
perienced by the driving of cattle through the
streets, and holding the market in one of the princi-
pal thoroughfares, this going on at all hours of the
day. The new market is being railed in and
drained and suitable stalls for tethering cattle are
being provided.
The incinerators mentioned above, the first in-
troduced by me in 1908 having been found to work
so satisfactorily, are now being adopted as the type
of rubbish destructor for general use in Freetown;
they are cheap in construction, economical in
2 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1913.
working (no special fuel being required), and efti-
cient in action, and a great improvement in every
way on the burning pits and rubbish shoots for-
merly in general use throughout the town, and
which were at once so unsanitary and so unsightly.
During 1910 the following programme of sanitary
improvements are proposed to be carried out: (1)
Incinerators, 4; (2) dust-bins, 12; (8) laundries, 4;
(4) draining public stand-pipes; (5) levelling up of
streets; (6) continuation of general drainage
scheme; (7) repairs of streets; (8) a fish market to
be provided.
There is one mule and one bullock cart in use at
present in connection with the scavenging of the
town, but a few more are very much needed in
the large scattered area to be dealt with.
The question of the disposal of excreta, and some
modification in the way of improvement in the
present cesspit system, are still under considera-
tion.
THE TEACHING OF HYGIENE IN FREETOWN.
Elementary hygiene continues to be taught regu-
larly in all the secondary schools, the sum of £180
being voted by the Government for distribution in
prizes to the schools and scholars as an encourage-
ment for the study of the subject. At the annual
examination held in December a hundred pupils
entered, thirty-two more than the previous year,
with the following results :—
1 obtained over 90 per cent. marks
2 80 and under 91
» ” ”
9 ^» ” 70 , ” 81
T s» » 60 ,, » 71
17 a” ” 50 ” ” 61
22 ” ” 40 ” ” 51
20 » ” 41
The five schools represented received £20 each,
the candidate who received highest marks received
s NH the seven next best candidates received £2
each.
So far as I can judge, the teachers and scholars
continue to take a keen interest in the subject.
SANITATION IN THE PROTECTORATE.
During the year a scheme was outlined by which
medical officers were enabled to assist and take an
interest in the sanitation of towns in the Protec-
torate. The scheme was energetically taken up
by Drs. Jackson-Moore and Murphy in the Ronietta
and Koinadugu districts respectively, and their
reports showed that the Chiefs and their people were
on the whole eager to carry out any suggestion
made in regard to the improvement of their towns,
it seemed to be quite the exception to meet with
opposition or indifference to the advice given in
these two districts; it may be truthfully stated that
the Protectorate sanitation scheme has so far
worked satisfactorily, so far as these two districts
are concerned. In the Koinadugu district, Dr.
Orpen reported that the people were decidedly
indifferent, but there is no reason to fear that, with
a little persistence, they will in time come round to
see the advantages of cleanliness in their immediate
surroundings and see the good in the white '' medi-
cine man's '' advice.
Unfortunately, in several districts patrolling for
any purpose is not always possible, owing to local
medieal duties. Medical officers in the Protectorate
are now called upon to carry out the following
varied duties as well as their ordinary purely
medical work, viz.:—(a) To patrol their districts
and instruct the natives in sanitation; (b) to patrol
for purposes of vaccination; (c) to assist in the study
of entomology; (d) to study the prevalence, &c., of
such diseases as syphilis, leprosy, sleeping sickness,
&e; (e) to select and inspect sites for quarters and
report on water supplies; (f) to make special study
of blood-sucking flies as to their prevalence and
localities; (g) to specially report on each of these;
(h) to act as Deputy District Commissioners.
Taking into consideration the various duties
medieal officers are now called upon to perform in
connection with the practice of their profession in
the Protectorate, I think it is high time that they
should be completely exempted from taking any
part in purely administrative duties. As to Deputy
District Commissioner's duties, it now frequently
happens that a medical officer has to give up most
of the time that he could have given, with much
more benefit to the country, to some of the other
and more congenial subjects with which he is
expected to deal.
ANTI-MALARIAL SANITATION IN FREETOWN.
(1) Anti-malarial sanitation has now become an
essential part of general sanitary measures, and
any observations on general sanitation in reference
to a town or a Colony in Tropical Africa must be
interpreted as including in their scope—and a very
important portion of them—measures directed to
the alleviation of malaria generating conditions.
In this Colony the following anti-malarial sani-
tary measures were practised during the past year—
1909 :—
(2) In Freetown the regular collection of refuse,
likely to act as breeding haunts for mosquitos, i.e.,
old tins, bottles, calabashes, and such-like useless
articles, from compounds and houses and their final
disposal either by dumping into the sea, or by
burial. A special look-out was kept up by the
Sanitary Inspectors for the presence of mosquito
larve in water receptacles in compounds, the
importance of this subject being periodically
impressed upon them. During the rainy season the
rapid growth of weeds and grass was kept down as
effectively as possible, so that they did not form
haunts for mosquitos and other insect pests. A
minor sanitary improvement which was appre-
ciated and taken full advantage of by the poorer
inhabitants was the free supply and distribution of
rubble, small stones, and sand, from the Govern-
ment quarry; this was conveyed by the railway to
convenient centres in the town, the people being
duly notified, and the material taken by them to
their own homes for the purpose of filling up and
levelling their compounds and yards where neces-
Jan. 1, 1918.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 3
sary, which measure was the means of preventing
the formation of stagnant pools of water, during
the rainy season, in many premises which formerly
provided numerous mosquito breeding pools.
(3) The following sanitary works, which should
rightly be considered as within the sphere of anti-
malarial sanitation, were carried out during the year
by the Publie Works Department, at an outlay of
£1,698 17s. 3d., namely:—(1) New drains and
concrete gutters constructed, 8,850 lin. ft. ; (2) Non-
masonry drains, i.e., drains cut in laterite or soil,
10,000 lin. ft.; (3) Lengths of streets ballasted and
levelled up, 7,000 lin. ft.; (4) Area of stone paved
roads laid, 4,500 sq. ft.; (5) Culverts repaired and
cleared, 87 sq. ft.; (6) New culverts constructed,
25 sq. ft.; (7) Public open air laundries built,
4 sq. ft.
The laundries are constructed, where possible, in
the course of existing streams, and their connection
with anti-malarial sanitation is that their presence
will do away with the necessity or excuse for the
damming up of the watercourses by the washer-
women in order to form pools for washing clothes
in. These washing places are very much appre-
ciated by the people; they consist of rows of
masonry butts, lined with cement, each butt having
a supply tap and a waste pipe, the waste water
being conveyed into the neighbouring drains or
streams.
(4) The improvement of the drains and streets
will be continued by the Government during 1910,
and one very important drainage reform is now
being taken in hand, namely, the provision of
suitable masonry drains from all the public stand-
pipes. These stand-pipes have been, up to now, a
constant source of insanitary conditions in their
immediate neighbourhood, owing to the presence of
stagnant pools fed by the waste water from them,
there being no proper drainage to carry it off. With
such a glaring defect in the present drainage system
of the town it becomes a delicate and a difficult
matter for the sanitary authorities to attempt to
enforce by the police court compliance with the
Public Health Ordinance, especially in regard to
anti-malarial sanitation.
(5) The death-rate of Freetown for the year was
19 per 1,000; this compares very favourably with
the two previous years, and is, in fact, the lowest
recorded death-rate for the city, as the following
yearly death-rate per 1,000 shows :—
1897 ... 26 1900 ... 26 1903 ... 23 1906 ... 23
1898 ... 25 1901 ... 27 1904 ... 26 1907 ... 21
1899 ... 27 1902 ... 24 1905 ...*29 1908 ... 22
1909 ... 19
* Severe small-pox epidemic,
The deaths recorded as being due to malarial
fevers numbered 119, a marked decrease as com-
pared with the two previous years, as shown
here:—1907, 202; 1908, 150; 1909, 119.
The number of Europeans resident in the Colony
during the year was estimated at 620, and there
were five deaths among them, as follows:—
Officials, 2; military, nil; commercial, &c., 8.
Hint STATION.
From a climatic point of view I think the good
name of Hill Station may be said with truth to
have been maintained during 1909. There were in
all fifty-four residents during the year, of whom
thirty were temporary, mostly military men and
their wives, who were permitted to rent bungalows
of officials on leave. There were sixteen admissions
on sick list, five of which were due to climatic
causes, viz.:—Remittent fever, 4 cases; dysentery,
1 case. Of these, two were officials, and of the
remaining three cases two were cases of remittent
fever contracted on the Hill, so far as I could judge,
as neither patient ever remained a night out of Hill
Station. One of these, the wife of an Army officer,
had not used a mosquito net for six or eight weeks
previous to her attack, and the remaining case was
one of dysentery contracted in the Protectorate. —
The two officials belonged to the Audit and Rail-
way Departments respectively, and no doubt their
cases resulted from infection during duty trips in
the Protectorate.
The chief characteristics of Hill Station from a
climatic and health standpoint are :—(a) Its marked
freedom from mosquitos and most other winged
insect pests, these being only very occasionally seen
or heard; (b) Its cool and pleasant breezy atmo-
spheric conditions, especially at night; (c) Its restful
quiet at night as compared with residence in or near
a native town, in which night is made hideous by
the barking of dogs, the beating of tom-toms, and
the stupefying stuffiness of the atmosphere, which
is only disturbed by the persistent attentions of
mosquitos. :
During the year some defective surface drains
were put in order and extended well away from the
quarters. .
Many of the compounds still remain unfenced,
much to the annoyance of residents, who try to
improve their surroundings by laying out gardens
for the growing of flowers, fruit, vegetables, &c.
The interest of residents in their quarters is still
very noticeable by the care and skill shown in the
arrangements of the compounds.
A residence for the General in command of the
Garrison was built during the year. This is a very
substantial stone building, the advantages of stone
over wood being very marked in the greater cool-
ness of the apartments as compared with a wooden
house.
The sanitary arrangements were carried out
satisfactorily during the year. The sanitary trench-
ing ground was condemned owing to a possible
contamination of the Freetown Water Supply
catchment area, and a new ground selected for the
purpose, which is more central and equally suitable,
and quite free from any risk of contaminating water
sources. One of the outstanding drawbacks in Hill
Station cantonment as a residence is the, at pre-
sent, great liability to a water famine in the dry
season, owing to the defective condition of the
reservoirs, which are incapable of holding water for
any time after the rainy season ends, when we are
4 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Jan. 1, 1913.
— —
compelled to depend on a constantly diminishing
streamlet that barely fills the small dam above the
reservoirs, and from which our quarters are directly
supplied. Even with every precaution against
waste Hill Station water supply for two months or
more in the year is at present very critical and
uncertain. This unsatisfactory state of things is all
the more deserving of adverse criticism, when we
know that with well-constructed receptacles an
ample supply of water could be provided, as in the
rainy seasons an unlimited quantity could be col-
lected.
There is another sanitary defect which requires
attention, and that is the surface drains on each
side of the roads around the station. These are at
present mere gutters excavated in the soil, which
are being year by year washed away, resulting in
the formation of deep holes along their courses,
which, owing to the stagnation of water in them,
must in time become insanitary and lead to some
of the malarial conditions found in Freetown.
These drains should be attended to, and be laid
down with the egg-shape drain-pipe sections now
being laid in Freetown drains; and I would point
out that the sooner this is done the less it will eost,
as every rainy season washes more of the existing
gutters away.
At the end of the year the temporary prison and
the twenty to thirty prisoners accommodated there-
in were removed, and the sanitary gang of labourers
were as a consequence increased from twelve to
thirty-two. The chief work of the twenty extra
labourers will be clearing and rooting the bush
around the bungalows, the ordinary sanitary duties
being performed as usual.
METEOROLOGICAL RETURN FOR THE YEAR 1909.
TEMPERATURE
Saar Mini ade Shade EU
Sala A €
matiman ou eaea, D Eros Range Mean
January ... 137.4 ... .. 98.4 ... 70.0 ... 23.4 81.7
February ... 142.0 .., 65.8 ... 99.4 ... 70.6 ... 28.8 85.0
March . 146.8 ... 69.0 ... 95.6 ... 68.0 ... 27.6 ... 81.8
April . 147.0 ... 69.4 ... 94.4 .. 69.0 ... 25.4 ... 81.7
May .. 151.4 ... 69.8 ... 94.4 ... 68.2 ... 26.9 ... 81.3
June .. 150.2 ... 68.0 ... 93.6 ... 67.6 ... 96.0 ... 81.6
July ..149.4 ... 68.0 ... 87.4 ... 67.0 ... 20.4 ... 82.5
August . 148.4 ... 67.0 ... 81.8 ... 67.8 ... 14.8 ... 74.4
September... 152.4 ... 69.0 ... 93.4 ... 67.2 ... 96.9 ... 80.3
October . 153.4 ... 69.0 ... 94.0 ... 67.6 ... 26.4 ... 80.8
November... 145.0 ... 68.4 ... 94.6 ... 69.0 ... 25.6 .., 81.8
December... 140.4 ... 63.4 ... 92.2 ... 68.8 23.4 ... 80.5
RAINFALL Wisp
PEE eer
Amount Degree of General Average
in inches humidity direction force
January ss 0:30. i4 08- .. NW az 1
February 0.33 64 NW 2 57
March 3.26 66 NW... 1
April ... 3.18 64 N 1
May .. 10.37 73 N 1
June ... 21.04 78 C 1
July ... 28.79 81 NW 2
August 38.96 84 NW 2
September 16.45 83 W 2
October 12.62 79 NW 1
November 5.70 74 WwW 1
December 0.86 72 C 1
Total 141.42
HOSPITALS AND DISPENSARIES.
COLONIAL HOSPITAL, FREETOWN.
(By Dr. D. Burrows.)
The Hospital was administered from the begin-
ning of the year until April by Dr. Burrows, and
from then until the end of October by Dr. Kennan,
the Senior Medical Officer, and from then until the
end of the year again by Dr. Burrows.
Improvements and Alterations.—In the building,
a new latrine for the exclusive use of out-patients
was erected. A new room was added to the nurses’
quarters attached to the female wards. This will
be productive of greater comfort to the nurses and
also ensure their more effective control. A new
kitchen is in process of construction, and this will
be productive of greater comfort to the junior male
staff, under whose rooms the old kitchen was very
assertive.
The Out-patients’ Department has been renovated
and painted with oil-paint, thus making it capable
of more efficient cleaning and also more attractive
and wholesome looking.
While these additions are steps in the direction
of improvement, they are at the best patchwork,
and as the prospect of a new hospital is now within
sight, further comment is withheld. But the fer-
vent hope is expressed that the Outpatients’
Department in the new scheme will be so arranged
as to ensure its complete isolation from the other
parts of the Hospital, the lack of which arrange-
ment now entails much vexation of spirits, loss of
time and, presumably, of material, to say nothing
of the almost impossible task of maintaining dis-
cipline.
The improvements noted last year in the direc-
tion of clothing stores for each ward have more
than justified their inception. "The inventories of
all departments have, in eonsequence, been main-
tained at a surprisingly aecurate level. I would
draw attention to the gratifying increase in the
total amount of work done, and feel safe in assert-
ing, after due experience in the working of this
Hospital, that the limit of its utility has been
reached. This statement is by no means meant to
suggest that more work will not be done, but that
more cannot be done without the provision of
greater accommodation and necessarily of an in-
erease in the medical and nursing staff of the
Hospital.
The average number of patients in Hospital per
diem was fifty-five during the year under report.
During 1908 this figure stood at forty-one. When
the maximum accommodation of the Hospital—viz.,
sixty-two beds—is considered, these figures are
highly satisfactory, especially as six beds are re-
served more or less for paying patients, and fur-
ther as certain beds are, when possible, kept
vacant for surgical and midwifery cases, to the
exclusion, unfortunately, of deserving medical
cases.
Jan. 15, 1913.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE.
Colonial Medical Reports.—No. 12.—Sierra Leone—
(continued).
We have again further cause for satisfaetion. Not
only has there been a material drop in the total
number of deaths from 128 to 107, but the pro-
portion of deaths to cases treated *his dropped from
13 to 8 per cent. Of the total, number of deaths
forty-eight were within seventy-two. hours of ad-
mission, and, as usual, these cases were moribund
on admission, so that-of the remaining number of
deaths, viz., fifty-nine, the Hospital may be reason-
ably pleased at the unavoidable mortality being
reduced to barely 5 per cent. of the admissions.
The actual number of cases treated as intern
patients may-not be in excess of any recorded, but
the salient feature of this return lies in the fact that
the accommodation of the Hospital was taxed to its
utmost through every-day of the year. The large
numbers recorded for 1903, 1904, 1905, are
accounted for by the fact that cases were taken in
and accommodated. on the floor, thus overcrowding
the wards. This objectionable practice has rightly
been discontinued. ,
Before commenting on the returns of surgical
operations for the year under report a glance at the
following figures will give some indication of the
progress made in this particular direction.
Number of operations performed, 1902, 44; 1903,
126; 1904, 145; 1905, 179; 1906, 146; 1907, 190;
1908, 136; 1909, 207, other anesthetics, 10; total,
217.
It will be seen that the number of operations
performed in 1909 was 217, and this is greater than
the number for any previous year, and when the
number of deaths after operations, viz., eight, is
considered, these figures are satisfactory from every
standpoint. The range of operations was extensive,
and the success attendant on them is highly eredit-
able to the after-care and attention bestowed.
Owing to the. limited staff of the Hospital it is
found convenient to perform operations on: only two
days a week. These operations are more or less
of an urgent nature, and the eonsensus of opinion
of all medical officers who have been attached to
the Colonial Hospital is, that this number could be
easily doubled, and that surgery of the relieving
order, such as for deformities, diseases of the eye.
&e., could be practised with considerable effect if
the medical and nursing staff of the Hospital were
adequately increased. Surgery under existing con-
ditions involves a degree of preparation and after-
anxiety out of all proportion to the severity of the
operations; and until a distinet surgical side—not
merely a würd as at present, and even this at times
is utilized for medical cases—is provided, the pre-
sent unsatisfactory method must unfortunately con-
tinue. In the meantime we wait, but our efforts
and their results we, may justly urge as a plea
for improved accommodation . and: an increased
staff. A
Paying Out-paliehts—We commented. on the
insignifieant sum of £10 which was received last
year in return: for rélief afforded in the Out-patients’
r
-Sa
Department. We have an increase of over 5,000
olit-patients for 1909, and, sad to tell, the receipts
have fallen to the deplorable amount of £6 185. Od.,
. or, to put it in à. more convincing light, the 27,474
out-patients contributed 4t
the treatment received. .
The amount received for the dispensing of private
prescriptions of medical officers was £16 10s. 10d.,
this amount including moneys paid for trusses,
syringes, bandages and other appliances. These
prescriptions numbered 360.
It may not be out of place to record that apart
from making up of the prescriptions for 27,474 out-
patients the daily average of fifty-four in-patients,
the number of prescriptions sent by Government
officers, for themselves and their families, num-
berede2,246 during the year.
This- involves no light task on the Resident
Dispenser and his Assistant, who have incidentally
to supervise the dispensing done by the juniors
undergoing training. x
Clinical Laboratory Report.—This Department
has more than justified its inception, and though
conducted at some personal inconvenience, has been
productive of results-which urge the necessity for
greater facilities being granted to continue and ex-
pand its utility. We do not pretend that research
work ean be essayed with the present limited staff
of medical officers attached to the Hospital, but
much could be done to secure more efficient clinical
results, and, more important still, in the matter of
securing material and collections of parasites for
the Schools of Tropical Medicine in England. In
the daily routine of work, opportunities come to
hand of seeuring material which the Schools would
greedily assimilate, and which are invaluable to
the special training in tropical medicine insisted on
in the case of candidates for the West African
medical staff, but which, perforce, cannot be taken
advantage of owing to the lack of time and of the
necessary number of trained medical officers.
The number of recorded cases subjected to
microscopic examination. was 196. This by no
means represents tbe full number of cases examined
us unfortunately a large number were not entered,
and this is exelusive of the work done on a tour
through the Colony by Dr. Burrows, for the pur-
pose of obtaining information as to the prevalence
of yaws, syphilis, and towards preparing a malarial
index of the Colony. .
The following table shows some. of the results
obtained :— Ut
of a penny euch for
Nature of subject examined | Results Remarks
Malaria—benign tertian y ER , $
iv sub-tertian 14 .., No crescents found.
ás quartan hil o... :
ne negative 45 .. Thus including malarial
infection.
Filaria—mature male F. loa ... — 1 ...
xi „ female F. loa.. 2... All from same case.
Vide appendix.
ie M.F. diurne :
Sputum— B. tuberculosis 6... Specimens taken in-
: discriminately.
i Negative “un IS 43
6 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 15, 1913.
Return or DisEAsES AND Deatas IN 1909 AT THE
Colonial Hospital, Sierra Leone.
GENERAL DISEASES.
is 2 ggl
5S 8 822 G DrsEAsES— continued.
z= à Bog Td) Tabes Mesenterica
E s q ‘ (e) Tuberculous Disease of Bones
‘Anthrax nh, = Other Tubercular Diseases
Beri-beri M. aay cwm a Gel dh ee WE MU £i
Bilbarziosis és "c e oe Sa 1 — 1 Su ug x
AEN "E a - E. # Yellow Fever ..
Cholera — — x
Choleraic Diarrhoea is — == E LOCAL DISEASES.
Congenital Malformation — = =
Debility ; 36 — 37 Diseases of the—
Delirium Tremens — = a Cellular Tissue. .
Dengue .. — = Circulatory System
Diabetes Mellitus = — = (a) Valvular Disease of Heart
Diabetes Insipidus ar Y o> — = (b) Other Diseases .. s
Diphtheria js s $^ * e — = = Digestive System—
Dysentery .. T ^is js oe .. 399 7 3 (a) Diarrhoea M
Enteric Fever... vis ss s = oe (b) Hill Diarrhea ..
Erysipelas . . JA Dé u ie — — = (c) Hepatitis f,
Febricula .. 12 — 12 Congestion of Liver
Filariasis .. 1 -- 1 (d) Abscess of Liver
Gonorrhæa E 60x 5 (e) Tropical Liver ..
Gout E SS om = (f) Jaundice, Catarrhal
Hydrophobia — — = (g) Cirrhosis of Liver
Influenza .. 2 = 2 (h) Acute Yellow Atrophy
Kala-Azar Exp f as (i) Sprue à a
Leprosy .. — — -— (j) Other Diseases ..
(a) Nodular. = = = Ear a
(b) Ansesthetic .. — = = Eye 3 vs
(c) Mixed 7 ys T sis e — = -A Generative Sy stem— Sui
Malarial Fever— -a is e RS - vez = Male Organs
(a) Intermittent " is 2s 2 — 2 Female Organs
Quotidian .. ami" dem — Lymphatic System
Tertian 9 - 9 Mental Diseases
Quartan zm umm = Nervous System
Irregular .. 65 2 66 Nose .. à
Type undiagnosed — = Organs of Locomotion
(b) Remittent .. s $5. s2 36 Respiratory re
(c) Pernicious .. aay = EL Skin— :
(d) Malarial Cachexia. . = 4 5 (a) Scabies
Malta Fever ne = = : (b) Ringworm Š
Measles : az ès ais js 1 1 (c) Tinea Imbricata
Mumps... «à a Ac T | — — — (d) Favus A
New Growths— .. 35 2 ie M — =- — (e) Eczema .. i
Non-malignant a em c ( f) Other Diseases ..
Malignant — — = Urinary System
Old Age 5 3 5 Injuries, General, Local—
Other Diseases 24 2 25 (a) Siriasis (Heatstroke) 3
Pellagra .. e Nun aos (b) Sunstroke (Heat Prostration)
Plague = (c) Other Injuries
Pyæmia = ae Parasites— bs
Rachitis T ss = Ascaris lumbricoides ..
Rheumatic Fever CE = Oxyuris vermicularis .
Rheumatism ^ 72 1 73 Dochmius duodenalis, ər Ankylostoma duo-
Rheumatoid Arthritis r ow 5 denale a
Scarlet Fever =" a Filaria medinensis (Guinea: worm)
Scurvy zc P ee. Tape-worm
Septicemia 3 2 3 Poisons—
Sleeping Sickness a —< Snake-bites
Sloughing Phagedena e Zs = Corrosive Acids
Small-pox .. oe Goiri == Metallic Poisons
Syphilis .. 2t Zs = Vegetable Alkaloids
(a) Primary D. = 5 Nature Unknown
(b) Secondary .. 1 — 1 Other Poisons
P Tertiary — .. 13 1 16 Surgical Operations —
) Congenital .. — — — Amputations, Major ..
M Rus E 4 = = Minor ..
Trypanosoma Fevei er 3 1 3 Other Operations
Tubercle— 22 24 Eye
(a) Phthisis Pulmonalis
(b) Tuberculosis of Glands *
(c) Lupus
(a) Cataract.
(b) Iridectomy e bie
(c) Other Eye Operations. Pm oe
|
=l
Deaths
LELE Esne RTT kl os PP PP Eet LT I bead | a0
Total
Cases
Treated
|
119
LlTTLttse
i wl | co
Jan. 15, 1913.] COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 7
eee D EA BAE TS A ane Remarks actually in their own wards or at the houses of
denale i v^ Government officials. The administration of the
5 Ameba coli... BD MER Hospital, and the serutiny of the various books
y Lambia intestinalis 1... concerned, is no light task, and finally the extra
” rss renga coli we 2. work thrown on the other two, when one of the
e gative and other RA :
cofhmon ovs 23 .. three is ill, robs all other work of professional
Night-blood films for Dr. Prout,
Liverpool School AT ... 100 ... Results not known.
A Table of the '' Malarial Index " of the more
important towns in the Colony is given at the end of
these Reports. The splenic enlargement was taken
as the indication, and in the large proportion of the
bloods examined of the same cases the sub-tertian
malarial parasite (ring forms only) were invariably
found.
The total number of out-patients for the year is
27,474, or an increase of 5,875 over the number for
1908. This return gives the most striking proof
of the expansion of the Hospital work, and it is
only fair to suppose that, had the accommodation
been available, the number of intern patients would
have increased in direct proportion.
The following list of out-patients treated during
the past ten years speaks for itself :—
1900, 7,653; 1901, 7,864; 1902, 9,321; 1903,
records missing; 1904, 9,9038; 1905, 8,374; 1906,
15,257; 1907, 18,008; 1908, 21,599; 1909, 27,474.
General. Conclusions.—It will be now patent to
those who read that the work of the Hospital in
the year under review has increased in every direc-
tion. It is still more so to the working staff of the
Hospital, whose resourees and time have been
taxed to the utmost to attain this level. Apart
from the actual practice of medieine and surgery,
there are other duties which are lost sight of by the
publie, in the management of an institution of the
pretensions of the Colonial Hospital. We have a
large staff of untrained material to deal with, and
their instruction, both practical and theoretical,
forms part of the duties of the Hospital staff. The
examinations for their admission and promotion to
higher grades, held twice a year, occupy consider-
able time and labour. The druggist examination
has been ruled to form part of the ‘‘ expected ”
duties of the medical officers; the examination of
candidates for Government service, such as the
police, post office, boatmen, and warders also
takes time. In a large community like Freetown
lunacy is a serious item, and examination of lunatics
is necessarily a tedious and trying ordeal. It fre-
quently happens that two medical officers are in
attendance at either the supreme or police court
together; their work at the Hospital is therefore
at a standstill during the most busy time of the day.
One medical officer is also ‘‘ Medical Officer ’’ of
Prisons, and he is liable to be called up at any
hour, in addition to his routine duties in the
Hospital, and in the Prison Infirmary. One medical
officer is generally engaged for two or three months,
according as he can spare the time, on the annual
Board of Survey on the medical institutions of
the Colony. Two medical officers are con-
stantly on emergency duty for midwifery cases
and casualties at any hour of the day or
night, in addition to the urgent calls to cases
pleasure.
I have represented these matters at length, and,
though wishing to make no invidious comparisons,
cannot refrain from stating that the amount of work
done, and the responsibilities placed on medical
officers attached to the Hospital, are out of all pro-
portion to the individual work which medical
officers in more favoured hospitals and institutions,
not necessarily in Sierra Leone, are called upon to
perform. The experience gained is invaluable, but
the overtaxing of energy is detrimental to both
mind and body, and we may justly claim that we
have demonstrated to the last degree the working
possibilities of the Hospital during the year 1909.
Report of the King-Harman Maternity Ward of the
Colonial Hospital for the Year 1909.
During the year ninety-seven
admitted for treatment.
The number of admissions into the wards during
the year was larger than at any other period, and
this, in my opinion, was largely due to the fact
that we had continuously in charge a responsible
European matron, thereby maintaining the con-
fidenee of the people in the institution.
Admissions during the past eight years were:
1902, 47; 1903, 29; 1904, 61; 1905, 74; 1906, 46;
1907, 60; 1908, 57; 1909, 97; total, 471.
Puerperal fever is one of the principal causes of
death among the ereole population of the Colony,
but it is infrequent among the aborigines. It is
due to the following causes: (a) The use by the
lower classes of any sort of rags that might have
been kept for months during the period of preg-
nancy to be used on the day of parturition. (b)
The attendance of ignorant practising druggists and
half-educated creole grannies or midwives, who are
largely patronized by the people, and in my opinion
constitute an even more potent source of infection,
in that, with a view of showing and impressing
upon the relatives of their patients their knowledge
as well as of inspiring confidence, these druggists
and grannies make frequent vaginal examination
with unclean hands, and even when a pretence is
made of washing their hands this is done insuffi-
ciently. Infection is also conveyed by some of
them by means of instruments such as syringes and
forceps, which some of the druggists and others
use, and which may not be thoroughly sterilized
and rendered aseptic.
Among the aborigines puerperal fever is far froin
being common, in fact it is rare. The old women
in attending to their patients do not make any
vaginal examination at any period during the stage
of parturition; their examination is wholly carried
out on the external abdominal surface, and there-
fore they do not convey sepsis by their hands per
vaginam.
Among the Timnes, Mendis and other tribes
patients were
8 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 15, 1913.
labour is conducted outside the house; the patient
is taken to the Bundo bush or sacred grove, not far
from the village or fakai, w hich is carefully cleared
of bush, swept and rubbed and whereon a new mat
is laid for her use. Here the head of the Bundo
women, an old woman who must be a mother her-
self, attends to the patient, and everything con-
nected with the labour takes place. After labour
is over the patient is bathed with native herbs
already prepared, after which she leaves the bush
and returns home to her friends to commence her
daily duties. This generally happens on the same
day, or within twenty-four hours after delivery.
Thus, from first to last the patient runs no risk of
suffering from puerperal fever.
The gynecological section of the King-Harman
ward has increased in the number of attendances
during the year, and this is due to the fact that
the people were encouraged to attend and were
specially looked after. In the ‘eighties the Colonial
Hospital had a very large gynecological practice,
which was under the immediate charge of the late-
lamented Dr. Hume Hart, Colonial “Surgeon. On
his decease the attendance as a special section of
the Hospital entirely fell away, and there was no
public institution where the poor women of Free-
town could obtain regular attendance. This was
given by the general practitioners at their houses,
but not satisfactorily. On the opening of the
Prineess Christian Cottage Hospital, now called the
Princess Christian Mission Hospital, women of all
classes flocked there for treatment, and that institu-
tion had the monopoly of these cases. After the
opening of our King-Harman ward, the executive
officer did not encourage the creation of this special
department, owing to "the inerease of Government
officers in every department of the service, and the
consequent increasing demands made upon the
time of the two medical officers stationed at Free-
town beside himself. Notwithstanding this, a large
number of cases were seen and treated among
others in the Out-patients’ Department.
During the year under review this section of the
work has been better organized and received greater
attention, owing to the fact that the number of
medical officers temporarily resident in Freetown
Was increased from two to three.
Although all cases are seen and attended to daily
in the Out-patients’ Department, yet the medical
officer in charge of King-Harman ward sees and
treats apart, on Tuesdays and Fridays, all patients
suffering from diseases peculiar to women. This
has served to induce and encourage the shy and
delicate to attend for treatment, and been a means
of increasing the number of attendances.
It is indeed very surprising to see the large num-
ber of women of all classes, especially among the
creoles, now coming up for treatment who are suffer-
ing from subiny olution, endometritis, fibroid growth,
salpingitis, ovarian tumour, uterine polypus, gonor-
rhea, disorders of menstruation and other condi-
tions, which is itself a manifestation of confidence
by the people in this branch of hospital work.
To enable the medical officer in charge to cope
with this increasing class of cases, and to give the
much sought for relief, it is necessary that the
equipment available for.use should be increased,
and every facility given for the vigorous prosecution
of the work. From a ^humanit: wian anil social
point of view this is urgently necessary, for there
has been occurring for several years among the
descendants of the liberated Afrienhs and original
settlers an increasing death-rate, ^a falling birth-
rate, a diminution in the number of families umong
the married people, and an increase in sterility.
The inerease of the population of the Colony proper
is not among these two sections, but is due to the
large influx of the aborigines, Mendis and. Temnes,
who are becoming residents in the villages and
towns.
It is proposed to open a special Out-patients'
Registration of Diseases Book, which would enable
more accurate statistics to be kept of the diseases
treated, and show the amount of work done in this
particular branch.
Nursing Home.
There were fifty cases admitted during the year,
an increase of eight over the previous year.
The number of patients treated during the past
seven years, with the numbér of ‘deaths, was as
follows :—
1003 1904 1005 1906 1907 1008 1909
Cases 2 76 90 79 59 66 42 50
Deaths ... nil nil 3 2 4 3 1
The patients were derived from the following
classes :—
Government Railway Department 104 13
employés Other officials s 91
Commercial firms ... 23
Shipping 9
Missionaries .. if ay, * 3
No occupation dee is d xe 2
50
The diseases met with were as follows: Alco-
holism (delirium tremens), 1; blackwater fever, 4;
carbuncle, 1; debility, 1; dysentery, 2; enterie
fever, 1; fracture (of arm), 1; hernia (scrotal), 1;
gastritis, 2; gunshot wound, 1; insolation, 1;
lachrymal fistula, 1; malarial fever (exclusive of
blackwater fever) m neurasthenia, 1; pleurisy, 1;
ptomaine poisoning, 1 ; whitlow, 1. There was one
death due to blackwater fever.
It will be seen that the firms and shipping con-
tribute well. over half the number of patients
treated in the Home, Government officials a little
over a third of the number. The latter are chietly
second-class railway employees, platelayers, drivers,
fitters, &e., their illnesses being, in the majority
of cases, due to greater exposure and more irregular
habits of living than others. During the year the
European Nursing Staff had. some very arduous
times as it frequently happened that several critical
cases were admitted about the-same dates, but I
am pleased to report that they at all times per-
formed their duties cheerfully and efficiently, and
to the satisfaction.of all.concerned.
Feb. 1, 1913.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 9
Colonial Medical Reports.—No. 12.—Sierra Leone—
(continued).
The Jail.
The daily routine has been carried out as in
former years. The average number of prisoners
both male and female was 209. During the quarter
ending June 30, there was a slight epidemie of
beriberi, which attacked six prisoners; four died
of the disease and two recovered.
Owing to a prisoner being sent from an out-
station, namely, Waterloo, and developing chicken-
pox during his stay, two of his cell companions
were infected with the disease.
These were the only epidemies that occurred
during the year.
À number of prisoners are suffering from diseased
hearts and therefore are only able to do light
labour.
Ten deaths occurred during the year from the
following diseases: Beriberi, 4; heart disease, 2;
strangulated intestine ‘‘ volvulus,” 1; tuberculosis,
2; general debility, 1.
Eleven executions took place; the great number
of the condemned prisoners were sent from the
Protectorate.
The general sanitary condition of the jail, such
as cells, compounds, &c., has been kept up to the
standard of former years, the jail compounds,
quarters for warders, and yards have been kept
scrupulously clean.
During December quarter the cells and out-
buildings have been whitewashed.
The chief diseases treated were: Dysentery, beri-
beri and heart diseases.
The food supplied by the contractor on the whole
has been good, and the water supply is also good.
The attendants' and warders' health has been
good, very few have been ill.
A temporary block of cells has been built on a
new site at the western end of the town, on which
à new permanent prison is to be built. It is now
occupied by over 100 prisoners and thereby has
greatly relieved the old prison, which lately has
been at times dangerously overcrowded.
J. S. Pearson.
Kissy Institutions.
Lunatic Asylum.—There were 118 inmates at the
beginning of the year and thirty admissions during
1909, a total of 143 under treatment. Of these,
seven were relieved and discharged to the care of
their friends, one not relieved was transferred to
the West Indies, and twenty-six deaths occurred,
leaving a total of 109 at the end of the year. From
the number of admissions it will be seen that there
was an increase of five above the previous year.
Four patients were placed under observation, but
as they exhibited no mental trouble were dis-
charged. There was no case of accident during the
year; only one instance of cruelty by a female
attendant, to an inmate, occurred ; this was brought
to the notice of the Principal Medical Officer and
the attendant was suitably punished. None of the
inmates absconded during the year; I attribute this
to the great care exercised by the staff.
One case of trypanosomiasis was admitted, the
cervical glands were enlarged and there was found
no puncture to certain trypanosoma, bodily condi-
tion on admission was very poor and the patient
died a few weeks after. The remainder of the
deaths were due to epileptic exhaustion, pulmonary
tuberculosis, general dropsy, asthenia, angina pec-
toris, anemia, exhaustion, strangulated hernia,
phthisis, intestinal obstruction, enteritis, paralysis
of the insane, paralytic exhaustion,, apoplexy,
dysentery and Bright’s disease. =>} >
A number of male lunaties, who are lucid and
physically fitted, are employed in attending to the
vegetable garden and do sanitary work. All rub-
bish heaps are removed and the rubbish disposed
of by burning or burial, excreta being dealt with
in a trenching ground in a suitable site outside the
buildings. The female lunatics who are mentally
fitted do the washing and mending of the clothes
of the patients in the asylum.
Both male and female lunaties are always in
charge of reliable attendants.
Female Incurable Hospital.—At the beginning of
the year there were thirty-six patients, fifty-one
were admitted during the year and forty discharged,
and there were eighteen deaths, due chiefly to ex-
haustion, old age, and syphilis. This hospital is
very old and requires reconstruction. A nurse is in
charge of the inmates and the general cleaning and
sanitary work is done by two labourers.
The Garden.—During the year the garden was
not very profitable, owing to insects destroying the
plants.
Vegetables soll amounted to £4 9s. 1d., as
against £7 19s. Od. the previous year.
Male Incurable Hospital.—This old building was
occupied by seventy-eight patients during the year,
there were seventy-five admissions, the total number
of deaths was 45, chiefly from old age, syphilis,
paralysis and exhaustion. Thirty-seven patients
were discharged, seventy-one remaining in hospital.
There were six lepers at the beginning of the
year and two admissions during 1909, making a
total of eight under treatment. The varieties are:
Nodular form, 4; anesthetic form, 4.
Lazaretto.—During the year thirty Kroo boys
were admitted and placed under observation for
seven days owing to an outbreak of small-pox on
board the s.s. ‘‘ Addah.’? No outbreak of the
disease occurred during their detention. I attribute
this to the prompt and energetic measures adopted
by the Principal Medical Officer in sending the
Public Vaccinator to vaccinate the whole of the
Kroomen, and special constables on duty at the
Lazaretto, and which have had such satisfactory
results.
The whole of the men were vaccinated success-
fully.
Small-poxr Hospital.—During the year there were
eleven cases of chicken-pox and one of small-pox
admitted. There were no deaths, all discharged
cured.
Vaccination.—During the year under review 157
children were vaccinated, 127 successful, nineteen
unsuccessful, eleven not seen.
Dispensarics.—During the year there were 1,445
out-patients seen at the Kissy Dispensary, as
against 1,223 the previous year; subsequent attend-
unces coming up to 1,298.
Six hundred and forty out-patients were seen at
the Wellington Dispensary, as against 517 the pre-
vious year; subsequent attendances coming up to
540. The prevailing diseases were rheumatism,
constipation, ulcers, bronchitis, diarrhea, and
malarial fever (benign tertian).
Both at Kissy and Wellington there has been a
marked increase of attendances, but unfortunately
the people are very poor and most of them can
ill afford to pay the small fee of 3d. The amount
collected during the year is £2 5s. 3d.
Sanitary Conditions of Wellington Village.—The
sanitary condition of this village is exactly as it has
been for years, no improvement has taken place.
No attention is paid to sanitation, neither in dwell-
ings nor their surroundings, conditions that to the
intelligent mind should be pregnant factors in eaus-
ing and disseminating disease. In the interest of
the public safety I would suggest that the headman
be asked to see that the village is kept clean. The
sanitary condition of the village leaves a lot to be
desired, and to this state of affairs the headman’s
attention might be drawn.
Thé total number of attendances of all classes of
Government officials residing at Cline Town, Kissy
and Wellington during the year are as follows:
Kuropeans, 51; natives, 86; total, 137.
Six European officials of the Sierra Leone
Government Railway were sent to the Nursing
Home, Freetown, during the year: One for inter-
mittent fever (benign tertian); one for septic wound
of thumb; one for phthisis; one for diarrhea and
debility ; one for pleurisy ; one for blackwater fever.
Cline Town.—I would respectfully submit for your
kind eonsideration the work at Cline Town, which is
increasing year by year; at present there are not
less than twenty-one European officials of the Sierra
Leone Government Railway residing there, besides
several native officials with their families; for the
safety of their lives in urgent cases demanding
immediate medical attendance it is necessary that
a medical officer should reside at Clines. The pre-
sent arrangement, whereby the medieal officer at
Kissy is made responsible for the health of the
officials at Cline Town, involves a good deal of risk
and delay in treatment owing to the distance
between Kissy and Clines. Further, the medical
officer at Kissy may be engaged in such duties as
would prevent him from responding to urgent calls
from Cline Town, or he may be on duty at Welling-
ton, or attending Coroner's inquests in any part of
the district.
W. F. CAMPBELL.
Sherbro.
The health of the European officials has been
good. The health of the native officials has not
10 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 1, 1913.
been as good as last year. The attendances for
treatment numbered 210, as against 140 last year,
or un excess of 70.
Non-Official, Europeans.—On an average about
twenty-five Europeans are employed by the mer-
:antile firms here, and on the whole they enjoy good
health considering the time they are kept in this
country. One of the white assistants died up river
in the early part of the year from sequele of
extravasation of urine.
Hospital Buildings.—The hospital buildings have
been kept in a fair state of repair during the year,
with the exception of the dispenser's quarters,
which are in a rather dilapidated state. The provi-
sion of a detached ward, connected with the main
building by a covered way, is necessary owing to
the number of cases of a syphilitie nature presenting
themselves. The capacity of the reservoir has also
proved inadequate this year owing to the foundations
of the same being carelessly laid. It would be well
were a well sunk in the hospital compound as a
source of reserve supply.
Operations.— There were nine operations per-
formed during the year under review as follows:
Amputation of elephantoid serotum, 2; reduction of
a dislocated wrist, 1; seraping a tuberculous gland,
1; radical cure of inguinal hernia, 2; removal of
epilus, 1; amputation of leg for syphilitic ostitis, 1;
amputation of middle finger of left hand, 1.
There were no deaths resulting therefrom. .
In-patients.—There were 232 admissions of in-
patients during the year, i.e., 47 in excess of last
year.
Out-patienls.—The out-patients numbered 2,652,
or 157 more than last year, with old cases.
Deaths.—There were ten deaths in hospital,
classified as follows: Tubercle, 2; unclassified, 2;
digestive system, 2; circulatory system, 1; nervous
system, 1; connective tissue, 1; parturition, 1.
No cases were admitted to Small-pox Hospital
during the year.
Epidemics.—With the exception of a mild
epidemie of whooping-cough during the latter part
of the year, there have been no epidemies. 102
cases of the above disease sought treatment.
Vaccination.—During the course of the year 1,289
vaccinations were performed, of which 1,285 proved
successful. A particularly good record, I consider.
The Jail.—The yard and cells of the jail are
kept clean, but, as in former years, the cell accom-
modation proved totally inadequate at times.
Bi-weekly visits ure paid.
Official — Visits.—His Excellency the Acting
Governor visited the hospital on November 30, and
the Bishop of Sierra Leone on September 4, the
Principal Medical Otticer visited the hospital on
May 18, 1909. ;
Sanitation. — The sanitation of the town is
attended to by the Port of Sherbro Municipal Board,
and on the whole they keep the town fairly clean,
though lately I have noticed a laxity on the part of
the official inspectors,
All meat is inspected by the Medical Officer both
before and after slaughter.
Feb. 1, 1918.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 11
Hospital Fees.—Hospital fees totalled £33 9s. 3d.,
or an increase of £8 10s. 2d. over last year.
J. F. Warp.
Protectorate District Reports.
KARENE DISTRICT.
Headquarters—Bathanu.
The headquarters are situated near the Hiver
Mabole on rising ground surrounded to a varying
extent by swampy ground according to the season
of the year, i.c., wet and dry season; mosquitoes
and tsetse flies abound more or less throughout the
year. Owing to the configuration of the country in
the immediate neighbourhood, the current of the
river is very sluggish, hence the tendency in the
rainy season to the overflowing of its banks and the
formation of swampy areas with stagnant pools.
The question of the prevention of these pools is a
difficult one to solve, and it would certainly be an
extensive undertaking. There has been a fairly
large area of bush clearing done lately with marked
benefit in the way of lessening the number of mos-
quitoes and tsetse flies which were formerly more
numerous. A continued clearing of bush around
the station has been arranged for with the Chief,
together with the ordinary sanitary measures as
regards the cleaning of compounds and removal of
rubbish, &e.
The water supply is very unsatisfactory, being
obtained from the river, which is known to be liable
to eontamination by the neighbouring towns and
villages; however, all precautions as to purification
by filtering, boiling, &c., are invariably taken by the
Europeans who have to use it. A new prison has
been built at Batkanu during the past year, which
is a well-built and well-contrived building, con-
taining the usual cell and out-office aecommodation.
The court messengers' barracks and prison are
inspected weekly, and are kept in a fairly good
sanitary condition. The hospital and dispensary
building is in good condition. There were only five
in-patients treated during the year, with one death,
due to pyemia; this small number is accounted for
by the sparsely populated country around the
station. There were 1,110 out-patients treated,
being 189 more than the previous year.
There have been no cases of serious illness among
the seven Europeans who were resident for varying
periods during the year, and only a few mild attacks
of fever were recorded.
The court messengers, prison warders, &c., have
suffered from the usual troubles of natives to a lesser
degree owing to their more regular life and healthier
surroundings. Foot sores in the rainy season, and
respiratory diseases, especially in the Harmattan
season, are the principal diseases suffered from,
Rheumatic pains are also fairly common.
The sum collected from out-patients was £8 5s. 9d,
Medical comforts sold, £2 3s. 7d. Total receipts,
£10 9s. 4d.
Number of Europeans on sick list, 1; native
admissions on siek list, 60.
The chief diseases of the district are rheumatism,
respiratory diseases, syphilis.
Only three cases of leprosy were reported in the
district. No case of trypanosomiasis was met with
during the year, but the neighbourhood of Batkanu
is full of tsetse flies, and the whole district appears
to be a suitable place for their increase. Owing to
the large area of the district, approximately 7,500
square miles, and the fact that the Medical Officer
has to remain at Headquarters in order to perform
administrative duties (Deputy District Commis-
sioner) for nearly six out of the twelve months, it
is impossible for him to visit more than a small
portion of the District during a tour. The country
is full of rivers, and all those I know, as a result
of my patrols, are infested with tsetse flies, a large
number of which I have collected and sent to the
British Museum and other places. I hope that
the much-needed clearance of bush around at least
the main ferries will soon be taken in hand according
to the instructions issued by the District Commis-
sioner on my advice.
There were 303 successful vaccinations performed
during the year; these were the cases actually
inspected after vaccination, but owing to a large
number not coming in for inspection probably a
much larger number were successful, as the lymph
supplied was of excellent quality, and more persons
would have been vaccinated; but owing to the per-
formance of administrative duties at Headquarters,
as already stated, I was unable to. patrol the District
for this as well as other purposes.
J. C. Murpny.
RONIETTA DISTRICT.
Headquarters—Moyamba.
Moyamba is situated on the railway line 76 miles
from Freetown. The District now includes the
Timne portion of the Central District (abolished),
although administered by an Assistant District
Commissioner, The duties of the Moyamba Medical
Officer include aid to all railway officials from Songo
to Bo, a distance of about 100 miles, including the
tram lines.
European Officials.—Average number was 9. The
number on sick list was 6, with an average of 3}
days; this is quite a satisfactory record.
Native Officials.—Number on sick list was 25,
with an average of 9 days, also satisfactory.
Deaths.—There were none during the year
amongst officials, or any serious sickness neces-
sitating invaliding.
Out-patients are recorded at 3,563, in comparison
to 2,008 in the previous year.
In-patients as 38, in comparison to 16 in 1908.
The principal ailments complained of by the out-
patients were malaria, rheumatism, worms, con-
stipation, ulcers, diarrhea, bronchitis, and vague
pains.
It has been said that a nominal charge for medi-
12 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 1, 1913.
cines in the dispensary would lessen attendance;
this in my experience is incorrect, and is not borne
out by statistics. It has been my principle to
request some payment, except when there is
evidence of visible poverty, in order to imbue the
natives with a spirit of independence and self-
reliance; very few of the hinterland natives cannot
afford threepence to a shilling for medicines; it is
only too often eropping up that extortionate fees
are paid to the cunning native quack.
Hospital Compound.—About 1} acres in area, is
situated on the right-hand side of the main road to
the town, opposite the jail and adjoining the Court
Messengers’ new barracks; it contains two hospitals,
mortuary, kitchen, and latrine house. The Govern-
ment hospital is a wooden structure, roofed with
corrugated iron, divided into a ward capable of
holding four beds, medicine room, store, and con-
sulting room. This building is raised about two feet
off the ground, and, as a hospital, is not viewed with
favour by the native community owing to the
thermic changes—scorchingly hot and stuffy in the
day time and chilly during the early hours of morn-
ing. Under such circumstances this type of hospital
is not a success, even the drugs are subjected to the
same variation of temperature. The second hospital
is of a round native type, capable of holding com-
fortably six beds; it was built and presented by the
sub-chiefs of Moyamba to myself, as a recognition
of services rendered to their people for sugicial work
done after my arrival here. It is the only instance
I have known of native gratitude to be shown in this
manner. This hospital has been of great aid in the
treatment of post operation cases; it is easily kept
clean, inexpensive, not subjected to great variation
of temperature, and as near as possible resembles
their own dwellings; in fact, it meets the present
requirements of bush surgery.
Operations.—The number of operations performed
was fifty-two, of which twenty were major; this in-
cludes eighteen scrotal elephantoid tumours. The
tumours varied from 20 to 110 oz., and four were
complicated by hernia. There were four deaths
following these operations, one from shock, one from
alcoholic liver and spleen, two from mental derange-
ments. The mental symptoms began in one six
days after operation, with hallucinations, twitchings,
and muscular spasms, in the other case symptoms
appeared four weeks after in the form of melan-
cholia; in both cases the testicles were left intact.
I am of opinion that great services could be
rendered to the Protectorate tribes by erecting a
central hospital or hospitals for surgical work,
thereby benefiting a class of deserving primitive
people, capable of showing gratitude.
European Officials’ Quarters.—That of the Dis-
trict Commission is overlooking the railway station
and town on a favourable site. The barrack-like
quarters, formerly occupied by officers of the
Frontier Force, is now utilized by the Assistant-
Distriet Commissioner and Medical Officer, with
the central rooms as a rest house.
This building has been condemned for some years
past and is in great need of repairs. Owing to the
position of site, unprotected verandahs, heavy and
damp sub-soil, I consider it one of the most un-
healthy quarters in the Protectorate.
The quarters occupied by the European Staff of
the Sierra Leone Government Railway have nothing
special to recommend them. The question of
better accommodation for European officials at
Moyamba deserves the Government's attention.
Rest House.—The fact that this rest house is
situated between residential quarters, with common
verandahs, is scarcely fair to those stationed there.
It excludes privacy, and has, during my time, been
the cause of looting by strange carriers entering
what might be termed a private compound. This
arrangement has other drawbacks.
Burracks.—Messengers’ quarters. In consequence
of unfavourable surroundings and overcrowding, a
new barracks on the opposite side of the main road
has been erected. The site and type of houses are
satisfactory.
Water Supply.—The town has a plentiful supply,
which is very liable to contamination owing to
dwellings and the habits of the Mendi people. This
supply is used by all except the European staff and
hospital.
The latter received a daily supply from a moun-
tain spring about three miles from town; it is con-
veyed in aluminium jars and affords an excellent
supply of pure water. This arrangement came into
force about six months ago. This water is dis-
tributed for the most part by prison labour, and
when the Government can afford to lay pipes a great
boon will be conferred on the entire community.
Sanitation.—The pail system is in foree in the
European and Sierra Leone Officials’ quarters and
works wel. The native town, with the exception
of a few sunk closets, has no system. Sanitation
in the Government lines is carried out by the
prisoners, whose duties this year have been excep-
tionally heavy owing to blasting operations for the
new gaol.
Moyamba Town had been allowed to become
greatly neglected, presumably due to the fact that
the paramount chief is a chronic invalid ; all animals
were permitted to roam about and work great havoc
in the town, gutters unkept, refuse deposited within
the town, and no clearing of bush around it. After
a period of six months’ persistency I have en-
deavoured to stimulate the sub-chiefs into activity;
all the animals have been dealt with, old gutters
closed or repaired and new ones made, the streets
have been seen to, all refuse removed and burnt,
clearing of bush around the town for a distance
ranging from thirty to sixty yards has just been
completed; also a road 6 ft. wide has been con-
structed on the outskirts of the clearing; this road
enables the inhabitants to walk round the entire
town. They have promised to fulfil health require-
ments by allowing no refuse or dirt to remain within
this circular road.
His Excellency the Acting Governor has kindly
promised twelve sanitary bins in order that all refuse
may be cleared from within and burnt or destroyed
at convenient centres,
Feb. 15, 1913.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 18
Colonial Medical Reporis.—No. 12.—8ierra Leone—
(continued).
I am convinced that with a little supervision and
encouragement, Moyamba in a short time will be a
creditable Mendi town. At first some of the resi-
dents brought forward objections, which, after
explanations, were overruled by the sub-chiefs; and
now the people are glad and realize the great benefits
derived from this sanitary scheme. Undoubtedly
the native mind is conservative, but one is struck
by their practical minds and quickness to grasp an
idea or scheme which will benefit them.
Burial Grounds.—I pointed out the unhealthy
atmosphere produced by graves in near proximity
to dwellings; this they admitted, and have carried
out the sanitary scheme even in these areas. They
have also promised to bury their dead at greater
distances from habitations, and as long as the
sanitary belt and circular road remain it will be an
easy matter to carry out.
Vaccination.—During the year 811 persons have
been vaccinated, 728 successfully; this excellent
result is due to active lymph and careful preparation
and scratchings.
Sanitary Reports.—Four have been forwarded by
me to Freetown. They covered a fairly wide por-
tion of this district, and briefly the procedure was
as follows: In the town Barri, in the presence of
the chief and as many of the people as possible, I
lectured in simple language for a period of half to
three-quarters of an hour on sanitation, vaccination,
general sickness, leprosy (isolation), elephantiasis
operations, blood-sucking flies, and disease.
Then followed a tour of inspection of the entire
town, pointing out sources of sickness and issuing
all possible suggestions for the benefit of town and
people.
I am convinced that this is the best policy to
ensure success, and the more people who hear what
the Government doctor has to suggest for their
health, the better probably will be the results.
In conclusion, it would be hard to estimate the
enormous benefit to these primitive inhabitants by
the successful carrying out of the Government
sanitary scheme, a unique opportunity for the West
African Medical Staff officers, in corfjunction with
the District Commissioners.
I discovered a singular abnormality in an
elephantiasis scroti, namely, two testicles firmly
adhered together and both cords passing up through
the right inguinal canal, and in a second patient
ante-mortem decomposition in spleen with scirrhotic
liver, in twenty-four hours after operation for
elephantiasis scroti.
J. JACKSON-Moore.
Kornapvuca DISTRICT.
Headquarters—Kaballa.
The health of the officials has been very good,
none of the European officials being placed on the
sick list; with the exception of one ex-Court mes-
senger, whe died of heart disease, after leaving the
hospital against the medical officer’s wishes, there
was no serious illness amongst the native officials.
A large number of patrols have been undertaken
for the purposes of vaccination, leprosy investigation,
and attending to the general sanitation of the towns.
There is no doubt that the greater cleanliness of
many of the larger towns is due to these patrols.
There were 448 vaccinations performed, but 329
were not seen a second time; still, as there were
only three unsuccessful cases amongst the 114 cases
seen a second time, one naturally supposes that
there were over 400 successful. This number is only
about one-tenth of the number that should be
vaccinated yearly, except that the district is, owing
to the appalling epidemics of from four to six years
ago, more protected than other districts in the Pro-
tectorate. Coming from the Mendi or Timne
country one notices what a much greater proportion
of Kurankos, Limbas, and Yalunkas are pock-
marked. The longer dry season, accompanied by
stronger winds, is probably a cause of greater fre-
quency of small-pox in this district than in the
country near the sea. However, apparently, no
cases have occurred in the district during the past
three years.
One ease of sleeping sickness was observed, and
though tsetse flies are common, bites from these
are apparently innocuous. Leprosy is freely pre-
valent, but these have been dealt with recently in
a report from Dr. Orpen.
Referring now to Kalabia, the headquarters of
the district, the chief item of interest is the removal
in November of the Company of the West African
Frontier Force to the Moa River. This was mostly
brought about by the diffieulty in feeding an alien
population of over 300 in & country which is not
thickly settled, which produces little rice and no
palm oil. The latter, largely used as a food neces-
sary, of valuable anti-scorbutie power, has to be
imported from the Timne country.
The water supply, always one of the best in the
Protectorate, has been further improved by fences
and surface drains which have been cut on the
ground level.
A slaughter-house and meat barri, with inspection
by the Medical Officer, are innovations of this past
year. This has prevented the old noxious plan of
slaughtering animals on ground often highly con-
taminated, and the keeping of the carcase in an
ordinary dwelling house. It has largely contributed
to the abatement of the fly nuisance. Another
reason for fewer flies is that in Kaballa, as well as
in several of the other large towns, the people are
beginning to realize that proper cow-sheds, erected
at some distance from the town, are better than
the old plan of tethering the cows in the main
streets. This, however, is still the custom in all
the smaller towns.
Hospital and Dispensary.—These are situated
between the clerks' houses and the barracks, and
since the latter have been untenanted it is difficult
to get sick persons to come into hospital.
The in-patients numbered fifty-seven during the
year, an inerease of six over the previous year, the
14 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 15, 1913.
only death being the case of Trypanosomiasis,
already referred to. The out-patients numbered
968, a decrease of 455 over the previous year; this
is partly due to the better health of the ‘‘ Fron-
tiers," but also to the fact that the native town of
Kaballa has been throughout the year about half
the size as formerly, the Kurankos who occupied
this portion of the Limba country having gone back
to the place from which they originally came.
Amongst the non-officials an increase of over 100
per cent. in subsequent attendances tends to show
that the natives are becoming more appreciative of
European treatment.
Meteorological observations have been kept
throughout the year; the highest maximum shade
temperature registered was 99° F. in February, and
the lowest minimum of 409 F. in January. The
average “ Relative Humidity " at 5 p.m. was
81.6 per cent., this is probably too high, owing to
the wet bulb not being properly adjusted. The rain-
fall of 185.2 in. was quite 30 in. above the annual
average.
C. H. ALLAN.
RAILWAY DISTRICT.—STATIONS—DARU AND
KENNEMA.
Daru.—Headquarters of the W.A.F.F.
Attendance at Hospital.—Out-patients, 1,522, in-
cluding 780 subsequent attendances during the
year.
In-patients.—137, with two deaths, due to pneu-
monia and pulmonary tuberculosis respectively ;
both patients were Frontiers. On the whole the
health of the troops has been fairly good; the
greater number of cases treated in the Out-patients'
Department and in Hospital being due to inter-
mittent fever, rheumatism, gonorrhea, digestive
disorders and minor wounds. l
Hospital Accommodation.—The present native
structure suffered severely during the past rainy
season; on two occasions it was uprooted in the
middle of the night and the patients drenched in
their beds. As new barracks are at present being
erected for the reception of two more companies of
100 men each, the present condition of affairs will
become impossible unless a start is made shortly
with the proposed permanent building.
Health of Officials.—This has not been particu-
larly good, due I think to the excessive prolonged
and severe rainy season; eight European and four
native officials were placed on the sick list for a
total period of cighty-five and forty-eight days
respectively. One European officer was invalided
home three weeks before the end of his tour suffer-
ing from malarial fever.
Vaccination and Small-poz.—No cases of small-
pox were observed throughout the year; 253 persons
were vaccinated. The lymph was always of good
quality.
Sanitation of Barracks.—This has been satis-
factorily attended to, the men's latrines regularly
inspected, non-combustible rubbish disposed of in
pits, and bush undergrowth well cleared. Two cess-
pits (condemned as insanitary by the P.M.O. on
his visit of inspection) formerly in use by the
officers have just been done away with and four
pail elosets substituted; these are emptied twiee
daily and disposed of for the present in the men's
cesspit, but a small pier is to be built into the river
at a suitable spot to enable the sanitary gang to
empty the pails directly into a strong current.
The Water Supply has been satisfactory through-
out the year.
IXENNEMA.,
Health of Officials.—There was no case of sick-
ness among European officials during the year;
there was no ease of serious illness among native
officials, but there was a good deal of anemia and
debility arising from the extraordinary difficulty of
obtaining fresh food of any description during the
greater part of the year. One court messenger was
invalided suffering from hemiplegia.
Water Supply.—Excellent. Pipes have been laid
on to the District Commissioner's bungalows, the
gaol, clerks’ and court messengers’ quarters.
Gaol.—The new stone gaol has been completed,
with accommodation for fifty prisoners. Kitchen,
bath and lavatory arrangements are all satisfactory.
Two deaths occurred, one from dysentery and the
other from peritonitis. Altogether 478 cases were
treated, mostly of minor ailments which would
never have been reported had not the patients been
in confinement at the time. No epidemic occurred
during the year; sanitary precautions were carefully
and regularly attended to.
Attendances at Hospital.—2,203, including sub-
sequent attendances and those from the gaol. -
Scarcity of Fresh Food.—Considering the size
and importance of Kennema it is difficult to explain
the famine-like conditions that obtain there at all
times of the year. Two native officials have
assured me that for two days they could obtain no
fresh food except cassava leaves. Once, it is true,
three cows were killed in quick succession, The
dispenser's suspicions were aroused, and he iu-
formed me that when he inspected the third cow
it was a mass of disease. Acting on his informa-
tion I drew up a set of regulations to be observed
in future slaughterings, but matters immediately
relapsed into their old groove.
W. A. ALEXANDER.
Sration Bo.
The number of officials in and about Bo is:
Europeans, 13; Sierra Leoneans, 44; natives, 209:
and schoolboys, 110; a total of 376. The health
has been good, only 180 days being lost through
sickness by the permanent staff.
Out-patients.—The number of out-patients for
the year was 1,158, an inerease of 318 over last
year.
In-putients.—The in-patients numbered fifty-two.
being twenty-four less than last year; there was
one death from perforation of the intestine.
Feb. 15, 1913.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 15
Hospital Accommodation.—The hospital accom-
modation is still very poor, there being only one
mud native house, which is very dark and has
seven wooden beds. The patients have to bring
their own beds, clothes and food, and also some-
body to cook for them. These conditions are a
deterrent to most natives, especially the poorer
ones, from obtaining hospital treatment.
Operations.—There were ten operations under
chloroform, these included: Inguinal hernia (radi-
cal cure), 3; elephantiasis scroti, 1; dilatation of
urethra, 1; cireumeisions, 2; opening abscess, 2;
tapping bladder suprapubically, 1; dermoid cyst
removal under local anesthesia, 1.
A portion of the dispensary, a wood and iron
building, has two iron beds in it, which were sent
here to form a ward for Europeans, but as there is
no latrine or kitchen, or any provision made for
feeding the patients, it is obviously unsuitable as a
hospital, even leaving out of account the fact that
it is the only place where the surgical instruments,
dressings, poisons and books can be stored, and
also that it is used for the clerical work of the
dispensary.
Professor Simpson, accompanied by Dr. Kennan,
paid a visit to Bo, and was not very favourably
impressed with the bungalows of the officials and
the water supply. The bungalows, he says in his
report, are unfit for human habitation, much of the
flooring and joists of the houses have dry rot and
need repairing. The water supply is still very bad;
the tanks, with a total capacity of 10,600 gallons,
now that the Railway Department have supplied
each of the houses occupied by railway officials with
a tank, are obviously inadequate for the use of the
officials, especially as the trading firms have also
a right to be supplied with water by the Govern-
ment. To increase the supply of water, eighty
aluminium water carriers of 5 gallons capacity
have been sent here, and during the dry season
they are to be sent to Kennema by train to be
filled with water and returned to Bo. This will be
done three times a week for perhaps three months,
and will no doubt be expensive. The sanitary
arrangements here consist of outside earth closets,
which ure emptied every night in a trenching
ground near the railway. There is a sanitary gang
of eleven men and one headman, who empty the
latrines and keep the European compound clean.
The sanitary inspector and carpenter were dis-
missed at the latter end of the year, on the recom-
mendation of His Excellency the Acting Governor,
as being a needless expense.
The children at the Bo school are healthy, and
are increasing in numbers. Their houses in their
own compound are too near the European quarters,
being much less than 200 yards from the nearest
European official’s house. The children obtain
their water from a well at the head of a swamp,
and if the coming dry seuson be prolonged, I doubt
if the supply will be large enough for their needs,
They have two swimming baths, built in the line
of the bed of the swamp.
Vaccination.—Has been carried out diligently, the
total number vaccinated in the year being 1,221.
The natives round about Bo seem to be a little less
afraid of vaccination, and to realize its object and
benefit.
Meteorological Observations.—The total rainfall
for the year has been 119.27 in.: the rainiest
months being August, June and July. The highest
recorded témperature by the shade thermometers
was 99.29 in March, the lowest 59.20 in December.
The mean maximum shade temperature for the
year was 88.29. Flies have been sent to both the
British Museum and the London School of
Tropical Medicine.
H. E. ARBUCELE.
WuLADE AND KaNRE-Lanus, W.A.F.F., Our-
STATIONS.
R. M. Fompr, Principal Medical Officer.
I was in medical charge of Wulade during the
year, paying regular monthly visits to Kanre-
Lahun. At Wulade two European officials were on
the sick list for ordinary fever and congestion of
the liver, and five native officials for malarial fever.
There is a hospital with four beds, and during the
year a total of 231 patients were treated, the most
prevalent diseases being rheumatism, gonorrhea,
diarrhoea, intestinal worms, malarial fever, bronch-
itis and dysentery.
The water supply is satisfactory, being obtained
from springs close to the camp.
Vaccination was continued during the year with
success.
There was one death in the Company from tuber-
culosis.
Kanre-Lahun.—I made regular monthly visits to
this out-station during the year. The number of
European officials was four, one of whom was on
the sick list for fever. Their general health and
that of the Frontiers was satisfactory.
There was no death. The chief diseases treated
being: Rheumatism, gonorrhea, orchitis, inter-
mittent fever, diarrhea, ulcers, minor injuries to
feet, and bronchitis.
The water supply is good, and the general sanitary
state of the camp is kept in a satisfactory condition.
DisPENsARY DISTRICTS IN THE PENINSULA.
The usual simple ailments were met with,
serious cases being sent to the Colonial Hospital
on the dispenser’s advice. There were treated:
New cases, 1,485; old, 2,047; total, 3,532.
Vaccination was performed during the year; 139
persons, chiefly children, were vaccinated. The
sanitary condition of the villages was fairly satis-
factory, and shows signs of improving. The water
supply is good, and is obtained from mountain
streams running near the village.
Goderich.—This branch dispensary was visited
weekly by the dispenser at Regent. There were
2,742 cases treated. The sanitary condition of the
village is fairly good.
Waterloo.—This has now become the centre of
[Feb. 15, 1913.
16 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
the new headquarters distriet, and there is con-
sequently an inerease in the number of Govern-
ment employees in the town. The health of all
officials was fairly good during the year; of these
336 were treated, and there was no death. The
total number of non-officials treated was 8,780. The
sanitary condition of the station continued satis-
factory. During the year the sergeant of police
was appointed Sanitary Inspector for the district.
There was one suspected case of small-pox; strict
measures were taken to isolate the case, and there
was no further outbreak.
Vaccination was carried out during the year.
The water supply was considerably improved by
an increase in public stand-pipes in the town, the
source being a spring on an adjoining hill.
The Gaol.—The health of the prisoners was fairly
good, there was no serious sickness among them;
There was no outbreak of epidemic diseases to
record during the year.
Vaccination was steadily performed, 171 persons
having been vaccinated with a large number of
successes.
The sanitary condition of the town was good.
Dublin (Bananas Islands).—There were 2,492
cases treated, the most prevailing diseases being:
Fever, yaws, tertiary syphilis, rheumatism, and
diseases of the digestive system.
Tertiary syphilis is present in various forms.
The public water supply is obtained from wells,
and is not good. A masonry tank has been pro-
vided at the dispensary in which rain-water is col-
lected. The sanitary condition of the towns has
improved; they are not so overrun with pigs as
formerly. There was no case of small-pox during
the year.
MALARIAL INDEX OF COLONY.
SPLEENS EXAMINED IN ALL CASES (AND PARASITES FOUND IN ALL CASES TESTED FOR CONFIRMATION).
|
Enlarged | Normal
Number of Percentage
ms chilaron, | "secas | spices | iurelin suns
Waterloo 100 69 | 81 | 69 The ages of children examined were from a few months to
| nine years. ;
Hastings 35s ..| 100 66 34 64 Many slides were taken in each place, and all such slides
gave positive results. 7
Dublin ) p, , 50 25 25 50 The parasites of malignant tertian malaria were most in
! Bananas avidoncs
Ricketts ) Islands 34 M4 20 I 41 Benign tertian was found in a few cases and mixed
! infections of both varieties in others. No crescents were
found ; no case of quartan fever either. :
York ... «es n 50 30 20 | 60 Many childien were found with strong fever while at play
| and while in school.
Kent ... T zs 31 25 6 80 Period of examination, April 8 to 20, 1909.
Tombo S age 25 19 6 76
Colonial Hospital, Sierra Leone, April 25, 1909.
the compound was kept in a proper sanitary con-
dition.
Hastings.—This dispensary was visited bi-weekly.
The total number of cases treated was 2,383. The
general health was good. There was no outbreak
of any infectious disease. Only ordinary simple
diseases were met with. Two new stand-pipes
were fixed in the town, thus increasing the supply
of good water. The sanitary condition was fairly
satisfactory. Vaccination was carried out steadily
through the year. There was no case of small-pox.
York.—The water supply is from wells in the
village, and is not wholesome.
The total number of vaccinations was 66. The
lymph supplied was good. Only emergency visits
were made to the neighbouring village of Sussex.
The number of cases treated was: New cases,
1,182; old, 421.
Rheumatism, yaws, dyspepsia, constipation and
uleers were met with in large numbers.
Mano Salija.—There were 1,612 cases treated
during the year. The health of the district was
fairly good.
Average for 7 towns, 62.8 per cent.
ee
D. Burrows, W.A.M.S.
Vaccination was carried on, forty-five children
were vaccinated ; the people do not seem very much
in favour of vaccination.
Tombo.—The sanitary condition of the villages
in the distriet is fair, the prevailing drawback to
cleanliness in them being the presence of pigs,
which are allowed to roam about.
The water supply is obtained from a stream that
flows through the town.
The cases treated numbered 1,475.
Vaccination was carried on, there was no small-
pox heard of in the district.
The following is a return showing the number of
cases treated free and those cases entitled to
medical attendance, with paying patients; the two
latter are given in one figure :—
Officials and paying patients ... $e MP 11,654
Paupers or non-paying patients a m. 60,906
Total troated 72,560
Actual amount expended on medicines, &c. ... £1,378 1 7
Amount received from paying patients (natives) 7l "7
Mar. 1, 1913.]
COLONIAL MEDICAL R
EPORTS.—BRITISH GUIANA. 17
Colonial Medical Reports.—No. 12.— Sierra Leone-—
(continued).
The rule is, that all patients who, in the opinion
of the Medical Officer, can afford to pay for medi-
cine must pay according to his or her means the
sum of 8d., 6d., or 1s. for medicine prescribed.
The actual medieal work done by the Depart-
ment during the year shows an increase of 1,618
in the total number of cases treated. This increase
occurred chiefly in the Colonial Hospital, where
there was an inerease of 5,875 cases in the out-
patients, and 277 in the in-patients treated, over
those of 1908,
Surgical operations at the same institution have
also considerably increased in number—from 148
in the previous year to 222 in 1909.
Sleeping Sickness.—Though medical officers were
on the look-out for this disease during the year,
only one case was met with; this was Kaballa, in
the Koinadugu district. Dr. Orpen reported on the
case, the patient dying after prolonged treatment.
Gland puncture and microscopical examination
were not generally practised, so I am not in a
position to state with any precision whether the
disease is more prevalent in the Protectorate than
the finding of only one undoubted case would lead
me to expect, but the fact that the Glossina palpalis
is found in pretty well all parts of the Protectorate
leads to a strong suspicion of its greater prevalence.
There were 436 cases of syphilis treated; this is
below the annual average, which for the previous
five years has been 610.
From the reports of medical officers leprosy does
not seem to be very prevalent, though occasional
eases are met with throughout the country.
Only two cases of small-pox were reported
during the year. The regular vaccination practised
in the Colony and Protectorate, and the continued
efficiency of the lymph obtained from the Liverpool
Institute of Preventive Medicine, largely account
for the almost entire absence of this malady.
Four cases of malignant new growths were
treated and specimens of them sent to the Cancer
Research Committee. Yaws (Frambeesia) does not
seem anything like so prevalent in this Colony as
in other parts of West Africa; during the year
151 cases were met with.
W. A. Ogumrre-TAyLor.
Colonial Medical Reports.—No. 13.—British Guiana.
MEDICAL REPORT FOR THE YEAR 1909-1910.
By J. E. GODFREY.
Surgeon-General.
Pusiic MEDICAL INSTITUTIONS.
Public Hospital, Georgetown.
Tuts Institution has accommodation for 291 males
and 245 females.
11,263 patients were admitted during the year,
and with the 400 patients remaining in hospital on
April 1, 1909, make a total of 11,663 patients
treated.
The number of out-patients treated was 43,556.
There were 1,237 deaths. This gives a death-rate
of 10.6 per cent. of the total number treated.
Of the total deaths, 283, or 22.8 per cent., died
within twenty-four hours, and no less than 40 per
cent. died within seventy-two hours after admission.
The Resident Surgeon states that these cases
were all dving on admission and past all human
aid.
There were 475 births in the maternity ward.
Nursing Stuff.—I again desire to draw attention
to the excellent work done by the Nurse Superin-
tendent and her assistants in maintaining the high
standard of training and teaching the nurses. She
has, I venture to say, brought the nursing in this
hospital to a very high state of efficiency, and it
compares favourably with the nursing in the
hospitals of Great Britain. That this has been
appreciated by the patients and the community
generally, we have ample testimony. In losing her
the hospital has lost a very valuable officer and one
whose place it will be hard to fill. :
I regret to have to report that the Junior
Divisional Nurse was compelled to resign her
appointment through ill-health ; during the time she
was attached to the hospital she performed her
duties faithfully and efficiently.
During the year 122 lectures and practical demon-
strations in the wards were given by the medical
officers, the Superintendent of Nurses, and
divisional nurses.
The following examinations for nurses were
held: Probationers.—In September, 1909, twenty-
four entered and thirteen passed; in February, 1910,
seventeen entered and twelve passed. Nurses
(Final).—In March, 1910, when ten passed out of
sixteen. Midwifery—In October, 1909, when
seven passed out of twelve; in April, 1910, when
five passed out of twelve.
The following return shows the number of opera-
tions performed and the revenue derived therefrom.
Number of operations (major) 705
Revenue from paying patients $7,744.18
Revenue from operations 800.00
Miscellaneous receipts 890.53
18 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Public Hospital, New Amsterdam.
This Institution has accommodation for 96 males
and 54 females.
There were 3,349 patients admitted, and with 134
remaining on April 1, 1909, make a total of 3,488
patients treated.
The number of out-patients treated was 21,863.
There were 399 deaths, which gives a death-rate
of 11.4 per cent. of the cases treated.
Of the total deaths 90, or about 23 per cent., died
within twenty-four hours of admission.
There were 81 births in the maternity ward.
The training of nurses at this Institution has, I
regret to say, been suspended, as owing to ill-health
the Superintendent of Nurses had to relinquish her
post ; her place has not yet been filled.
Public Hospital, Suddie.
This Institution has accommodation for 54 males
and 26 females.
There were 1,430 patients admitted, and with the
70 remaining on April 1, 1909, make a total of 1,500
patients treated.
The number af out-patients treated was 5,889.
There were 198 deaths, which gives a death-rate
of 18.2 per cent. of the cases treated.
Of the total deaths no less than 188 died within
seventy-two hours of admission,
There were 18 births, of which 5 were stillborn.
Public Hospital, Bartica.
This Institution has accommodation for 24 males
and 11 females.
There were 277 patients admitted, and with the
6 remaining on April 1, 1909, make a total of 283
treated.
. The number of out-patients treated during the
year was 1,012.
There were 25 deaths, which gives a death-rate
of 8.8 per cent. of the cases treated.
Of the total deaths 14 died within seventy-two
hours of admission.
^ There were one birth and three still-births during
the year.
Public Hospital, Morawhanna and Arakaka Ward.
(1) There is accommodation for 14 males and 11
females,
There were 422 patients treated and 25 deaths,
which gives a death-rate of 5.9 per cent.
Of the total deaths 7 died within seventy-two
hours of admission. f
There were 1,570 out-patients treated.
(2) Arakaka Ward.—There is accommodation for
12 males.
There were 173 patients treated and 6 deaths,
giving a death-rate of 3.5 per cent.
Of the deaths two died within seventy-two hours
of admission.
There were 756 out-patients treated.
Lunatic Asylum,
There were 462 males and 274 females in the
Asylum on April 1, 1909. During the year 76 males
(Mar. 1, 1913.
and 65 females were admitted, 86 males and 31
females were discharged, and 42 males and 33
females died. The percentage of mortality on the
total number treated was 8.6.
Leper Asylum.
On April 1, 1909, there were 806 males and 125
females in the Asylum. During the year 78 males
and 29 females were admitted, and on March 31,
1910, there were 287 males and 126 females in the
Asylum. There were 98 deaths, 73 males and 25
females, giving a death-rate of 18.3 per cent.
The conduct of the inmates was satisfactory.
Absconding still oceurs, but not to such an extent
as in previous years.
The farm produced 43,404 lb. of provisions, con-
sisting of: Plantains, 22,706 lb. ; cassava, 19,104 Ib.:
greens, 1,177 lb. ; sweet potatoes, 417 lb. The value
was $481 15.
The majority of the inmates keep their cottages
and grounds neat and tidy. They are given small
plots of ground in which during their spare time
they are allowed to grow vegetables and these are
either used by themselves or sold to the store for
consumption within the Asylum.
The produce from these plots was: Plantains,
25,548 lb.; cassava, 7,191 lb.; greens, 1,228 lb.;
eddoes, 444 lb.; sweet potatoes, 534 lb.; valued at
$398 81.
PUBLIC DISPENSARIES.
Georgetown.
There are three dispensaries in the city :—
No. 1 Dispensary at the Police Station, Broad
Street.
No. 2 Dispensary at the Almshouse.
No. 3 Dispensary at the Public Hospital.
Jountry.
There are seven country dispensaries, situated as
follows :—
(a) Demerara River.—At Akyma.
(b) Berbice River.—At Ida Sabina.
(c) Upper Pomeroon.—District extends from the
Tapacooma Lake to and inclusive of Urua,
(d) Lower Pomeroon.—The district extenda from
but exclusive of Urua, to the mouth of the
Pomeroon River, and includes the Wakapoa Creek
and its tributaries.
(e) Moruca River.—The distriet extends from the
mouth of the Moruea River up to Kamwatta, in-
cluding all the tributaries and settlements.
The dispensers in charge are provided with corials
for the purpose of paying periodical visits to the
different grants, homesteads, and missions.
(f) Potaro.—About eleven miles from the Potaro
Landing, and provided with six beds for the recep-
tion of urgent cases.
(9) Albouystown.—On account of the very large
number of cases seen at No. 1 Dispensary, which
originally included Albouystown, it was decided to
open a separate one there, and thus relieve the
pressure on No. 1,
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA.
1913.]
RETURN or DISEASES AND Deatus IN 1910 AT THE FOLLOWING Posuic HOSPITALS :—
Georgetown, Berbice, Suddie, Bartica, and North-Western District, British Guiana.
GENERAL DISEASES.
Ex
EL
FE
Alcoholism 14
Anemia 181
Anthrax —
Beriberi =
Bilharziosis à =
Blackwater Fever 2
Chicken-pox 2
Cholera —
Choleraic Diarrhoea 3 523
Congenital Malformation —
Debility T : 174
Delirium Tremens --
Dengue .. 3
Diabotes Mellitus 8
Diabetes Insipidus - - ie S
Diphtheria Ae F oe m se 8
Dysentery .. 5s Se fit ae $6 cm
Enteric Fever ne E st s» "EE:
sipelas .. be ae as y oe 15
Febricula .. n Ma EA sis 2s 5
Filariasis .. AS HM és x p a=
Gonorrhcea we di ia .. 199
Gout . Be Ys vs $4 = —
Hydrophobia
Influenza .. js A" t oe .. 194
Kala-Azar S A als a Fa
Leprosy .. vs f M^ a e =
(a) Nodular - = ae sio SR WAR
(b) Anesthetic .. 23 "n js ee
(e) Mixed zs " aa ys oo
Malarial Fever— a4 an ie =
(a) Intermittent es 2,369
Quotidian .. e» o] d oo
Tertian we Jh aa re
Quartan .. oe "n $6 oo
Irregular .. 2s " e. —
Type undiagnosed on wa © —
(b) Remittent . a e s "4
(c) Pernicious .. ET s ia #189
(d) Malarial Cachexia. oy o ge 195
Malta Fever A : Se sı ae -
Measles .. gi Da “a ss a 9
Mumps .. as a m e 256€
New Growths— ..
Non-malignant $ sx T 4 B
Malignant c is 45 2: e0 0905
Old Age $5 10
Other Diseases T ats T at 4
Pellagra .. +: 55, X^ $5 wu "ems
Plague ne es vs s "P TEE
Pyemia .. de ie aft es En 9
Rachitis E —
Rheumatic Fever 55 ef: es -—
Rheumatism Ré af - A .. 805
Rheumatoid Arthritis - 3s s
Scarlet Fever — .. m V. sa ve 1
Scurvy .. N vs 8 2. "PES
Septicemia T vis sk ss so 0056
Sleeping Sickness 7s SA Vs TI
Sloughing Phagedicna y sa Bh
Small-pox .. 2s 2i = d 6a 1
Syphilis .. 3 à ga Se e —
(a) Primary .. $4 $4 -— 2s 15
(b) Secondary .. es S v5 `. 899
d Tertiary PE is ad ix ias ae
(d) Congenital .. T x js .. 28
Tetanus .. e “8 sf vo. "95
Trvpanosoma Fever E. as oo
Tubercle— aks - z 66
(a) Phthisis Pulmonalis £
(b) Tuberculosis of Glands .. iv Tae ov
(c) Lupus Fic T an e —
— | Deaths
oo
ire
SRE e 1 |
hre
N
be ow)| i
i
i
4
1
157
|
2
| S basis!
—
-3
-
19
2 a z 4:2
5 8 388
e
ii i EB
GENERAL DisEASES—continued.
(d) Tabes Mesenterica . es © — -
(e) Tuberculous Disease of Bones -=
Other Tubercular Diseases - "
Varicella .. $ si ip — — =
Whooping Cough EN T s es 6 — 6
Yaws > ; $3 n Ss 0084 1 94
Yellow Fever. E zi ac Sa 1 1 1
LOCAL DISEASES.
Diseases of the—
Cellular Tissue.. 695 92 695
Cireulatory System x. ELT za
(a) Valvular Disease of Heart 98 17 98
(b) Other Diseases .. 167 59 167
Digestive System— — — =
(a) Diarrhoea BA 506 60 506
(b) Hill Diarrhea .. <> S
(c) Hepatitis à 13 1 13
Congestion of Liver D. a 5
(d) Abscess of Liver 14 3 14
(e) Tropical Liver .. 3 1 3
(f) Jaundice, Catarrhal 34 6 34
(g) Cirrhosis ‘of Liver 90 33 90
(h) Acute Yellow pi A 3) eee Ex
(i) Sprue .. 1 A
(j) Other Diseases .. e. Ms .. 881 82 881
Ear ES $a ss m a BO. =: 50
Eye b i3 na ve .. 991 — 99
Generalities Sy: stem— .. is we $e = = XP
Male Organs 495 2 495
Female Organs 1,312 64 1,812
Lymphatic System 190 2 190
Mental Diseases 128 1 128
Nervcus System ys Vg .. 924 57 994
Nose .. i es EM SQ 92 — 99
Organs of Locomotion. 351 7 851
Respiratory BIRON V An .. 1,897 544 1,897
Skin— ` La m Ji Was ee as ans
(a) Scabies .. X ts $i ae 109 02
(b) Ringworm ` T ee e — :
(c) Tinea Imbricata ša T yy om
(d) Favus .. e we 2 e mL x =
(e) Eczema .. rt éa 2 ve 249 = 29
( f) Other Diseases .. v: a 964 964
Urinary System E as Sia .. 979 296 979
Injuries, General, Local— T .. 703 121 708
(a) Siriasis (Heatstroke) a va e — =- x
(b) Sunstroke (Heat Prostrationij T ub c = =
(c) Other Injuries T ie TS =
Parasites— Os a e. zs BF 13 917
Ascaris lumbricoides .. ae ae oe, eee E
Oxyuris vermicularis .. =
Dochmius duodenalis, or Ankylostoma duo-
denale 337 50 387
Filaria medinensis (Guinea worm) = =
Tape-worm oe we T e — €
Poisons-- y čs tis T pe - - -
Snake-bites is ae és AA Y. 6 1 6
Corrosive Acids x T P E 1
Metallic Poisons A os FE < 2 — 2
Vegetable Alkaloids .. T aa EE ea M
Nature Unknown An E "P s å = = 7
Other Poisons we ie 36 6 12 1 12
Surgical Operations — .. 5 m .. 5,223 48 5223
Amputations, Major ..
Minor .. = -
Other Operations = + E
Eye .. — Ll
(a) Cataract or xs s o_o — =
(b) Iridectomy .. x so 48 — 48
(c) Other Eye Operations
[Mar. 1, 1913.
20 _ THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
The following table shows the number of persons
treated :—
——M ————————————?
Dispensary | RUNE | iouis Paupers | Total
m mbi -——— —
Nod. eu Cus .| 805 | — = 11,622 |11,927
Albouystown aad zo 205 | — 25,077 | 25,282
No. 2 d Lis 325 = 6,964 | 7,289
No. 3 102 | — 10,670 |10,772
Potaro oe hau 1,709 | 116 112 1,937
Demerara River ... ae 228 24 524 776
Berbice River ... T 443 —- 416 859
Upper Pomeroon As 155 18 779 952
Lower Pomeroon 5s 367 46 638 1,051
Moruca ... ST its 22 1 84T 870
Total 3,861 205 57,649 | 61,715
al
pO—-—-———————————————— — — AE —
Prison HOSPITALS.
The following table shows the number of
prisoners admitted and the number of deaths in
these hospitals during the year :—
Admitted to Hospital Died in Hospital
Institution — ——Á —— Le,
M. F. T. M. F. T:
H. M. P. Settlement so164 5. ;: Odin 4o R}
Georgetown a »41416 5s BO 186: aa 3. ee ng d
New Amsterdam 84,5. Mb ate.) AD, 1 1
Suddie E 98 giv. ray 955. — —
Total ... ..947 .. 88 ... 380... 6..—... 6
ONDERNEEMING INpUSTRIAL SCHOOL FOR Boys.
The general condition of the Hospital and its
surroundings have been satisfactory. There were
411 in-patients with no deaths.
Orphan Asylum.—The Medical Officer to the
Almshouse has the medical charge of the inmates.
The sanitary arrangements are satisfactory, and the
children continue to enjoy good health.
Almshouse.—The infirmary wards attached to
this Institution are under the medical charge of à
private medical practitioner, who is also in charge
of No. 2 Dispensary, Georgetown. A large number
of cases of chronic disease, unable to maintain
themselves and not likely to benefit by hospital
treatment, are sent from the hospitals to this
Institution.
Sugar Estates.—The estates’ hospitals at Planta-
tions Ma Retraite and Cornelia Ida were elosed. A
new female ward was added to the hospital at
Plantation Albion, and the accommodation of tlie
hospital at Plantation Mara increased from 48 to
72 beds.
At the close of the vear there were 39 estates’
hospitals with a total of 2,490 beds.
58,340 patients were admitted to the estates’
hospitals, and there were 1,386 deaths, which gives
a percentage of 2.8 deaths to admissions. :
It is interesting to report that there was an
appreciable decrease in the number of cases of
infantile convulsions, and the Medical Inspector, in
commenting on this, mentions that Dr. Ferguson
found that there had been a marked decrease in the
Peter’s Hall district since he began the regular and
systematic distribution of quinine.
There were 1,563 fewer cases of malarial fever
treated than in the previous year, which, I think,
shows that the general improvements in sanitation
and the adoption of antimalarial methods on the
estates are bearing fruit. The Medical Inspector
adds that. ‘‘ rice cultivation has accounted for a
very considerable increase in this disease, nullifying
to a great extent the benefits we otherwise would
have gained from improvements in general sanita-
tion." He also points out that there were serious
outbreaks on a number of estates at the time of
rice-reaping, and adds: “ My belief is that these
outbreaks would have been more severe and more
general had it not been for the prophylactic
measures undertaken early in the year" ; the
measures he refers to being the regular daily
administration of quinine to all employees.
Dr. Kennard, the Medical Officer of the Port
Mourant district, addresses the following interesting
and instructive minute to me on the increase of
malarial fever on the estates in his district :—
'" I consider the increase of malarial fever on
these estates, which is especially marked at Albion,
to be due to the following causes, all aiding each
other: (1) The settlement of the people in or
adjoining the rice fields; (2) in consequence of not
having the usual showers, the rice required more
irrigation and much of it was cut when the fields
were still partly swamped; (3) the abnormal condi-
tion of the weather, no rain, excessive heat, little
breeze.”
Regarding (1), we notice yearly at Port Mourant
the amount of fever cases that come from the settle-
ments of Miss Phoebe and Ankerville, which are
situated at the rice fields. At Albion the increase
of malarial fever was first noticed in August, the
cases coming mostly from a new settlement in a
place among the rice fields aback, called the '* Long
John "; it was so severe, and I understand prac-
tically everybody there got it, that most of the
people left this place; following shortly on these
cases came in many people from the '* Guava
Bush," also a practically new settlement in the
rice fields; then more cases from the ‘‘ Sand Reef,"
which is an old settlement in the rice fields on one
side of the ** Guava Bush " and nearer the estate
proper; then we got more cases from the estate
proper yard.
Regarding (2), usually light showers fall for the
ripening rice so that the fields are not kept swamped,
the ground is dry and the facilities for mosquito-
breeding is not so marked as this year.
tegarding (3), the weather has kept abnormal,
hot, dry and close, and the ordinary breeze has
been mostly absent; the people work night and day
when reaping their rice, sleeping frequently in the
fields at night, and working in the swampy fields
under these conditions has diminished their natural
resistance more so than usual,
Mar. 15, 1913.]
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 21
Colonial Medical Reports.—No. 13.—British Guiana—
(continued).
In spite of quinine having been given out freely
to the people, especially at Albion, where the dis-
penser put on to give it out visits also the ‘‘ Sand
Reef,” ‘Guava Bush” and school daily with
quinine, conditions (1) and (3) remaining the same
with the increased amount of people becoming in-
fected has kept up the number both for October
and this month as well.
I think the unusually large proportion of free
people admitted to hospital supports my opinion, as
they mostly live outside the yard proper.
VACCINATION,
Glycerinated lymph is imported for the use of
publie. vaeeinators, to whom it is supplied free of
charge. There were 2,082 successful vaccinations
during the year.
HEALTH OF THE COLONY.
Death and Birth Rates.
It is satisfactory to report that the colony has
been free of any dangerous, infectious, or contagious
diseases.
During the year 9,367 deaths occurred, or 14 less
than last year. This represents a death-rate of
30.0 per 1,000, compared with 30.8 per 1,000 for
the year previous.
There were 8,947 births, or 648 more than in the
past year, representing a birth-rate of 29.3 as against
27.3 for 1908-9.
The deaths exceeded the births by 420 this year;
last year there was an excess of deaths of 1,082.
It is of interest to note that during the year under
review, there has been an appreciable increase in
the birth-rate, while, on the other hand, the death-
rate shows a very slight decrease.
Infantile Mortality.
The mortality amongst children under 1 year, it
is to be regretted, continues to be high; in 1909
there was 1,872 deaths, or 209 per 1,000, which is
an increase on the previous year's figures, 1,644
deaths, or 198 per 1,000; but still less than in 1907,
when the figures were 2,202, or 256 per 1,000. The
mean rate for the past five years is 210 per 1,000.
Tuberculosis.
During the year, tuberculosis was the cause of
5.9 per cent. of the total mortality of the colony,
and in Georgetown 8.8 per cent.
The Society for the Prevention and Treatment of
Tuberculosis has continued its good work during
the year. I know, from being in close touch with
the working of this Society, that the scope of its
work is being gradually extended, but the want of
funds stands in the way.
Malarial Fever and Anti-Malarial Measures.
There has been considerable activity and a pro-
nounced interest is taken by the publie generally
in the question of the prevention of malarial fevers,
On the sugar estates, the screening of water
receptacles, the abolition of other breeding grounds
of mosquitoes, the cutting down of useless bush and
trees, and the free distribution of quinine to their
labourers, have continued throughout the year.
In the eity of Georgetown an attempt has been
made to enforce the regulations with regard to vat-
screening.
In the town of New Amsterdam, I regret to say
that nothing has been done.
In the country districts generally, no active steps
have been taken. I am afraid that no real solid
work will be done with regard to the abolition of
the breeding grounds of mosquitoes until a law,
which I have advocated, is passed and put in
force. To the different local authorities in the
villages and country distriets we must look for help
in pushing on and educating the people to take a
greater interest in diminishing preventible diseases.
During the year, as Chairman of the Local Govern-
ment Board, I addressed a circular to the different
local authorities calling attention to the matter.
It is gratifying to report that the sale of quinine
at cost price at the different Post Offices, which
was introduced in December, 1906, is steadily
increasing, and is being appreciated and taken
advantage of by the people.
Leprosy,
Professor Deycke's Nastin treatment was con-
tinued at the Leper Asylum during the year under
the supervision of the Bacteriologist. I stated in
my last report that no definite pronouncement could
yet be made as to whether Nastin is a cure for
leprosy. In some of the cases there has been
undoubtedly considerable improvement which it is
hoped will ultimately be permanent,
ANCHYLOSTOMIASIS,
On the sugar estates steady progress was made in
the measures which have now for some time been
advocated by this department, viz.:—
(1) The erection of latrines.
(2) The systematic examination of all newly-
arrived immigrants and of all persons suffering
from anemia or showing the least sign of being
infected with the anchylostome parasite.
(3) The treatment and constant observation of all
known infected cases.
In this connection it is gratifying to report that
every estate is now supplied with latrines. There
has been a very marked diminution of the number
of cases, particularly of those severe cases which
were so common a few yeurs ago, and it has been
found practical and advisable to treat the milder
infected cases as out-patients.
The introduction every year of a large number of
anchylostome-infected East Indian immigrants is
a very serious faetor in preventing not only much
better results, but also the cradication of the
disease. Last season no less than 74.4 per cent. of
the new immigrants were found to be infected.
DRINKING-WATER.
The matter remains in very much the same
position as it was when I wrote my last report. As
I have said before, the storing of drinking-water in
open trenches and ponds is indefensible. I have
advocated, and I still advocate, the adoption of the
system in use at Plantation Blairmont, that is, the
erection of tanks for storing the water,
QUARANTINE.
During the year there was :—
(a) Yellow fever in Barbados, Martinique, and
Venezuela.
(b) Plague in Trinidad and Venezuela.
(c) Small-pox in Grenada.
The precautions against infection permitted by
the Quarantine Regulations were enforced in each
case, and happily the colony escaped infection.
The disinfecting machines were tested at regular
intervals and. found to be in good working order.
SUBSIDIZED NURSE-MIDWIVES IN DISTRICTS.
During the year twelve women were qualified as
nurse-midwives. Of this number eleven were
trained at the Public Hospital, Georgetown, and
one at the Publie Hospital, Berbice. Four students
received subsidies amounting to $112.02 to assist
in maintaining themselves whilst undergoing train-
ing at the Publie Hospital, Georgetown. The
examination for these certificates is very much more
difficult than formerly. In addition to certificates,
sign plates are now given to those women who are
certified by Government examination. Midwives’
outfits are obtained from the Medical Supply Asso-
ciation, and supplied, without charge, to certain
nurse-midwives to enable them to be in a position
to properly perform their duties. I look forward to
the day when every village will have a qualified
nurse-midwife.
In July, 1908, a scheme was started for the pur-
pose of providing the poor women in the city of
Georgetown who, for one reason or another, do not
care to go to the maternity ward of the Publie
Hospital, with the assistanee of trained and certified
nurse-midwives. Two midwives were specially
attached to the maternity ward for this purpose,
their duty being not only to attend to the mothers
at their homes, hut to give advice as to the feeding,
&e., of the infants. The Nurse-Superintendent, in
her annual report, writes that this scheme has
prospered beyond our hopes. There is no doubt
that it has proved a great boon to the poorer classes,
22 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 15, 1913.
and should in time prove a very important factor
in reducing our high infantile mortality. Seventy
cases have been delivered during the year, and
1,172 visits paid. Cases are always on the books
and visits have to be paid to these, in addition to
the daily routine visits.
I am glad to say that the Combined Court has
made provision for the appointment of two more
midwives during the present financial year.
There are four subsidized nurse-midwives in the
following outlying districts: Mahaicony, Pomeroon,
Moruea, and North-Western.
BACTERIOLOGICAL DEPARTMENT.
In consequence of the increase of work the
Combined Court sanctioned the appointment of an
Assistant Bacteriologist, and shortly before the
close of the year information was received that Dr.
E. P. Minett had been selected to fill the post.
There is no doubt now that the necessity for this
department has been borne out by results. The
assistance rendered by the Bacteriologist not only
to the staff of the publie hospitals, but to private
medical practitioners, in assisting in the diagnosis
of difficult and doubtful cases is well known, and,
I am sure, fully appreciated. It is interesting to
note that out of a total of 2,553 specimens examined
during the year, no less than 1,290 were sent by
private medical practitioners.
The City of Georgetown.—In consequence of
statements made that there was an outbreak of
virulent fever in the city, and also that it was due
to the screening of vats against mosquitoes, the
acting Health Officer, the Government Bacteri-
ologist, and myself, were asked by the Government
and Town Council to investigate and report.
It was conclusively shown that while there had
been a certain number of cases of diphtheria and
enteric fever, in neither case were they sufficient to
say that the disease was either of an epidemic or
virulent character. In my opinion, the opposition
to the enforcing of the vat-sereening regulations was
chiefly the cause of the rumour, and, as it had been
said that the screening rendered the water unfit for
drinking purposes, in our report we took the oppor-
tunity of making a definite statement that no
deleterious effects nor disease properties of any
kind are produced or increased in water by screening
water-containing receptacles against mosquitoes.
In this connection I would particularly draw
attention to the Government Bacteriologist's re-
mark: '' The water in unscreened vats contains on
an average 1,031 micro-organisms per cubic centi-
metre, and that in vats which have been sereened
for a year or longer the average is only 534.8 per
cubie centimetro,''
Mar. 15, 1913.]
COLONIAL MEDICAL REPORTS.—BENGAL. l 23
Colonial Medical Reports.—No. 14.—Annual Returns of the Lunatic Asylums
in Bengal.
MEDICAL REPORT FOR THE YEAR 1909.
By COLONEL R. MACRAE, M.B., V.H.S., I.M.S.
Inspector-General of Civil Hcspitals, Bengal,
THE number of lunatics on January 1, 1909, was
865; 196 were admitted during the year (including
19 re-admissions), 106 were discharged, 47 died, and
908 remained under treatment at the end of the
year against 865 in 1908. The proportions per cent.
of criminal lunatics to the total population on
December 31 of each year were 39.87 and 41.15,
respectively.
The daily average number resident was 717.72
males and 168.82 females, the maximum number
confined in any one night was 742 males and 177
females, while the accommodation available was
for 761 males and 202 females, so that the asylums
were not overcrowded during 1909. There was,
however, some stress of accommodation at certain
times of the year either in the criminal division,
pauper wards, or on the male side of the asylums,
which was met by readjustment of class accom-
modation. Judging from the total daily average
number of patients, viz., 827.08 in 1906, 849.29 in
1907, 851.33 in 1908, and 886.54 in 1909, and also
the total population on December 31, which was
836, 852, 865 and 908 in those years, respectively,
there is a marked tendency towards increase in the
number under confinement, and within another year
or two at the present rate of increase the question
of increased accommodation will be pressing. This
is being dealt with separately.
Admissions were greater by 9, being 177 against
168 in the previous year. Patna had 12 more, and
the number sent to Berhampore from Caleutta and
the 24 Parganas increased by 5, the figures being
61 against 56 in 1908.
Re-udmissions numbered 19 against 17 in the
previous year. Most of them were, as usual,
criminal lunatics returned to the asylums after
trial. Two had relapses in jails—one was a re-
covered lunatic who was sent back to the asylum
after fourteen days only, and the other, who had
been undergoing sentence, was returned to the
asylum after six months and four days. Of the
six non-eriminals, in one instance the lunatie, who
had been sent for trial, was discharged and made
over to the care of his friends by the trying
magistrate. He was, however, received back after
ten months. Another, a eriminal lunatie, who had
been made over to his friends under the orders of
(Government, was returned to the asylum after about
eight months.
The number discharged from the asylums was
106 against 107 in 1908, Of these, recoveries are
represented by 69 and 65 cases, respectively; the
percentages calculated on the daily average number
in residence being 7.78 against 7.64 in the previous
year. At Berhampore a large number of favourable
male cases were admitted during the year 1909,
which mainly increased the number of recoveries
from 26 in 1908 to 40 in 1909, and the percentage
on the daily average number resident from 4.28
to 6.43. It is remarkable that at Patna the recovery
rate amongst the females was as high as 20.91 per
cent. against 8.92 in 1908, although their cases are,
as a rule, the most intractable.
Sickness and Mortality.—Taken collectively the
health statistics of the asylums show a marked
decrease in sickness, the total admissions to hos-
pitals being 655 against 746 in 1908. The slight
increase in daily average sick, 115.72 against 101.31
in the previous year, was mainly due to the treat-
ment of some chronic cases and to the placing on
the sick list of lunatics with slight temperature to
prevent further development during the severe
monsoon. The latter circumstance chiefly accounts
for the increase in fever cases, which numbered 248
against 149 in 1908. There were two cases of kala-
azar, one ending fatally. Bowel complaints
(dysentery and diarrhea) were fewer, viz., 48
against 48 in the previous year. Thirty patients
were admitted for tubercular phthisis against 33 in
1908. The number of deaths from this cause was
also fewer, 13 against 17 in 1908. The total
mortality was 47 against 65 in 1908, and the death-
rate was strikingly low, it having been 5.30 per cent,
against 7.63 in 1908. This is, indeed, very satis-
factory.
The rate of mortality in Bengal for 1909 was
much less that what obtained in that year in the
United Provinces (9.41), Madras (7.09), Punjab
(18.43) and Bombay (13.1), and Eastern Bengal
and Assam (13.51).
Criminal Lunatics.—The number on the books on
January 1, 1909, was 356; 75 were admitted against
81 in 1908, and 13 were readmitted, the same
number as in the previous year. The number dis-
charged fell from 121 in 1908 to 64 in 1909, the
decrease being chiefly due to the fact that whereas
in 1908, 63 old chronic patients charged with trivial
offences were transferred to the non-criminal list
under the special sanction of Government, the
number so transferred in 1909 was 8 only.
Etforts were continued during the year under review
to find out the relatives of harmless insanes whose
94 THE JOURNAL O
TROPICAL MEDICINE AND HYGIENT.
(Mar. 15, 1913.
crimes were not serious in order that they might
be induced to take charge of them, and the results
were successful in some cases. There were 18
deaths against 20 in 1908.
Most of the admissions, viz., 118, or 60.20 per
cent., were cases of mania. As such cases are more
amenable to treatment, recoveries amongst them are
generally largest, as was the case in the year under
review, viz., 45. Melancholia furnished 46 cases,
or 23.47 per cent., with 19 recoveries. There were
8 admissions in 1909 from delusional insanity,
four Europeans and four Indians. There was one
case of general paralysis of the insane, a rare type
in this country. The patient, a native of Sambalpur,
was a criminal lunatic, a Hindu (Sahara), who was
received into the Berhampore Asylum. The Super-
intendent reports that the case was of the convul-
sive type of general paralysis. The lunatic died.
Dementia accounted for 7 admissions in 1909.
It is remarkable that under its epileptie form there
was one recovery. The patient was under treat-
ment at Bhawanipur.
Ninety-nine, or 50.51 per cent., of the number
admitted owe their mental breakdown to physical,
and 13, or 6.63 per cent., to moral causes, while in
42.86 per cent. of the cases the cause of insanity
was unknown. In 8 cases the mental aberration
was attributed to hereditary influences, in 42 to
abuse of ganja, in 11 to intemperance in drink, and
3 to other intoxicants, viz., toddy. There was a
distinct increase, viz., 11, in the number of ganja
cases at Berhampore during the year under review.
The Superintendent states that the antecedents of
these cases, where the medical history sheets were
defective, were verified by communications with the
relatives of the patients and the police. It is re-
ported that the medieal history sheets of the lunaties
who were sent to asylums were prepared with
greater care during the year under review, but that
there is yet mueh room for improvement in this
respect. In the revised rules for the management
of lunatic asylums, which are about to be adopted,
this form and its heading have been altered, so that
there may be no mis: ipprehension or mistake on the
part of those concerned as to who are responsible
for filling it in and for their correctness and com-
pleteness, which are matters of much importance.
Injuries and Accidents.—The catalogue of these
was large at Berhampore, but almost all were of a
trivial nature and need not, therefore, be detailed.
There were two cases of snake-bites, which were
treated with antivenine. The patients recovered.
There was, however, no record of the kind of snake
inflicting the wounds. Every effort was made to
rid the asylum of these reptiles. At Patna a
criminal lunatic who had been under treatment. in
the hospital for dysentery was found by the overseer
to be bleeding and evidently seriously injured, the
base of his skull having been found fractured. He
died shortly afterwards, The Magistrate who in-
quired into the case was unable to say whether the
injuries were self-inflicted or otherwise. The
warder on duty disclaimed any knowledge of the
circumstances under which the injuries were re-
ceived, but the Superintendent punished him by
dismissal for suspected remissions. Another warder
of this asylum was also dismissed for assaulting a
lunatic.
Escapes.—Two lunatics escaped from the Ber-
hampore Asylum; one was recaptured and brought
back to the asylum. The other, a criminal lunatic,
was at large up to the end of the year. "The warders
through whose negligence these men escaped were
duly punished.
There was no important change in the establish-
ment attached to the asylums.
The manufacturing department yielded a net
profit of Rs. 7,213-7-7. At Patna the profits were
greater when compared with the previous year,
owing chiefly to the garden having been more pro-
ductive and to a lower price having been paid for
raw materials. The net earnings from manufac-
tures at Berhampore fell off in the year under
review, chiefly because the sale of garden vegetables
to the outside public was restricted to meet the
requirements of a larger population in the asylum.
The garden itself did not fare well during the
cyclonic disturbances. Altogether 56.72 per cent.
of the lunatics were employed on various industries
in 1909 which were judiciously selected, the prin-
cipal object being to keep them employed on some
sort of congenial work, which is essential in the
treatment of the insane. A bakery was started at
Berhampore through the exertions of the Deputy
Superintendent. It was most useful to the asylum
and to the public. The system of rewarding hard-
working and well- behaved lunaties was continued
during “the year under review. The dairy at Ber-
hampore, which is a valuable part of the asylum,
also showed a profit.
General Remarks.—Despite the unsuitability of
some of the buildings in which the asylums are
located and their unhealthy surroundings, the death-
rate among the lunatics showed a further reduction
in the year under review. This admits of one con-
clusion, viz., that the sanitary conditions in the
asylums have been much improved and that much
personal attention on the part of the superior staff
was bestowed on the details of asylum management.
The infirm system was maintained with
advantage to the we: ikly and debilitated patients.
Prophylacties were issued to the lunatics in all the
asylums during the unhealthy seasons of the year.
The Superintendent at Berhampore states that but
for this cases of malarial fevers would have been
more numerous. The lunatics were treated to various
kinds of amusements, and were provided with pet
animals, and musical Nietrufde nts to keep them
lively and eheerful. The total amount spent on
amusements was Rs. 452-4-6. Thus the physical
and mental welfare of the patients received due
attention,
I have pleasure in stating that the management
of the asylums during the year’ has been entirely
satisfactory, and that much credit is due to the
superior staff,
gung
April 1, 1913.]
Colonial Medical Reports.
COLONIAL MEDICAL REPORTS.—WESTERN AUSTRALIA. 25
No. 15.—The Medical and Health Departments of
Western Australia.
MEDICAL REPORT FOR THE YEAR 1909.
By JAMES W. HOPE, F.R.C.P.Ed., L.S.A., D.P.H., R.C.P.& 8.1,
Principal Medical Officer.
VITAL STATISTICS.
Population.
Mean population of the State, 1909 ... 274,755
Mean population of the State, 1908 ... 268,347
Inerease ... 6,408
Births.
Numbered |... is as i As 7,6001
Being at the rate per 1,000 population 27.66
Illegitimate, per cent. total births — ... — 4.55
Deaths.
Numbered ... 2,706
Being at the rate per 1,000 population
Natural inerease per 1,000 of population — 17.
Infantile Mortality.
Per 1,000 births A EP aby SR
Deaths from typhoid, 83; percentage total deaths,
3.07; per 1,000 population, .30.
Deaths from diphtheria, 81; percentage total
deaths, 3.04; per 1,000 population, .29.
Deaths from phthisis, 188; percentage total
deaths, 6.95; per 1,000 population, .68.
Deaths from tubereular diseases, all other, 43;
percentage total deaths, 1.48; per 1,000 population,
Abs
Deaths from maternity, 46; percentage total
deaths, 1.74; deaths of mothers to births, .61.
Marriages.
Total 1909: Per 1,000 of population ... 7.27
With one exception during the past ten years the
marriage rate has steadily declined, as the following
figures show :—
1899 1900 1901 1902 1003 1904 1905 1906 1907 1908 1909
9.92 10.06 9.66 9.83 9.32 8.53 8.48 8.70 8.06 7.50 7.97
Life in this State gives no excuse for this, in-
asmuch as there is no poverty, but there may be
some paucity of the females in comparison to males.
It, however, follows the conditions which are
observed in some parts of the Empire, where mar-
riages are not so frequent proportionally as in the
past. The tendency seems to be to delay marriage
until later in life than heretofore. Women are more
employed in many walks of life, which give them
an independent existence.
Births.
The following table shows a decline in the birth-
rate of 3.04 per 1,000 of the population during ten
years :—
1899 1900 1901 1902 1003 1904 1005 1908 1907 1008 1909
30.70 38.3 80.36 30.29 30.27 30.34 30.30 30.02 29.24 28.63 27.66
Illegitimates.
1800 1900 1901 1902 1903 1904 1905 1906 1907 1908 109
4.99 4.82 3.88 3.96 4.70 4.36 4.19 4.78 8.89 4.35 4.55
In consequence of the continued low birth-rate,
the corresponding low death-rate permits of a satis-
factory natural increase being recorded, for 17.8 in
this State bears favourable comparison with the
other States, and is better than in England and
Wales, and most European towns, at least for the
five years 1901-5.
Net annual increase
per 1,000 popniation
Germany ... 14.3
Denmark ... 14.1
Sweden 10.6
Switzerland ; .. 10.4
Franee ies es 2 e 1.6
Italy 10.7
Belgium 10.7
Norway 10.7
Spain 9.2
STATES TABLE.
Net annual increase
State Year per 1,000 population
New South Wales 1909 15.19
Victoria 1908 12.12
South Australia 1908 15.01
Queensland 1908 16.48
Tasmania 1908 19.18
New Zealand 1909 17.88
Western Australia 1909 17.81
England and Wales, 1901-5... 12.1
England and Wales, 1908 11.8
To every square mile of country in 1907 there
lived in Victoria, 14.20 persons; Tasmania, 7.02
persons; New South Wales, 5.06 persons; Queens-
land, .81 person; South Australia, .43 person;
Western Australia, .27 person, which shows that
plenty of elbow room will exist for awhile.
Deaths equalled per 1,000 of the population, 9.85.
This is an improvement upon past years.
In 1899, with a population of 170,651, there died
2.324, equal 13.79 per 1,000 population.
In 1909, with a population of 274,755, there died
2,882, equal 9.85 per 1,000 population.
26 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
During the past ten years the rate of mortality
was :—
1809 1900 1001 1902 1903 19M 1905 1906 1907 1008 1909
13.79 12.65 13.37 13.71 12.60 11.91 10.82 11.87 11.17 10.74 9.85
Infant Mortality.
Almost as many children die during the first year
of life as die during the next thirty years.
Thus in the first year of life there died 593, while
from one year to thirty years there died 612.
The deaths under one year numbered 593, equal
to 78 per thousand births. Of this number no fewer
than 160 died under one week, mainly from con-
genital malformations and debility (which causes
were responsible for 138 deaths). In these 160 cases
the infants really had no chance of life, and if they
be excluded from the ealeulations the mortality rates
are reduced to 57 deaths per thousand births, or 7.24
per thousand of population.
Percentage of deaths under one year to births
during period :—
1809 — 1000 1901 1902 1008 1904 1005 1906 1007 1905 1900
13.99 12.61 12.89 14.20 14.12 11.30 10.42 11.0 9.77 8.17 7.80
Further improvements may be made and consider-
able saving of life effected.
From 1899, when the rate per cent. was 13.99, to
1909, when the rate was 7.80, is very encouraging,
and shows that the care of infants is better under-
stood, and their environment improved. Disturb-
ances of the alimentary tract, as usual, cause the
chief loss.
Enteritis is recorded as causing deaths in 140 cases
out of a total under one year of 593 deaths.
That there may be less loss of life from ignorance
of young mothers how to nurse their offspring is
probable.
It has been the custom for some years to present
to everyone registering a birth a few printed in-
structions and advice, the salient point being that
breast feeding is the essential element of success,
adding to the child's chance of living, of growing up
strong, healthy, happy, and thus repaying the
mother by some freedom from anxiety, expense for
treatment, disturbance of domestic happiness, and
broken rest.
Where artificial feeding is necessary, so much
additional care must be exercised in protecting the
food from contamination by dirty utensils, dust and
insects, and keeping milk cool. In many cottages
the latter can be effected by using a canvas cooler
kept damp. Freedom from contamination can
always be got with care. Fifteen babies artificially
fed die to one that is breast fed. The fate of a
nation rests in the lap of the mother,
Typhoid,
Number of cases notified " s 0641
The death percentage of total deaths in 1908 = 2.65
1909.—Denths 83 — per 1,000 population ... .80
Percentage of total deaths 3.07
The chief places contributing to the outbreaks
were :—
[April 1, 1913.
Metropolitan Area.
Perth and Suburbs 208
Leederville — ... "s .. 83
Subiaco es "A so 128
— 264
Fremantle $i. or PA su AQ
Midland Junction ... any 9
Guildford VN M is 7
West Guildford ioe ES 5
— 81
Claremont T T d ius B9
Vietoria Park ... id ce vus TI
392
Goldfields and Country.
Kalgoorlie se 545 e. 084
Kalgoorlie Road District ... 26
Boulder -— P .. 28
— 88
Meekatharra (Murchison) ... ... 15
Southern Cross pa se ies T
Menzies 4 Ww zat T 12
Ravensthorpe ies 45 4o d
128
The balance were scattered over the different
parts of the State.
The environments of cases indicate that careless-
hess existed in carrying out reasonable precautions,
notwithstanding that printed leaflets giving advice
have been circulated by the Central Board of Health
to all Locai Boards.
In some cases the origin is difficult to locate, and
whether due to carriers or not is uncertain.
That ‘‘ carriers ’’ are the cause in many outbreaks
is a well-established fact, and beyond the care
exercised at the time of sickness it is important that
all who have been attacked should have impressed
upon them the danger they may be to others for a
considerable time, and periodical examinations of
the urine and excreta for some months should be
the rule.
No person should ever be employed in a dairy or
handling foodstuffs who has had typhoid, until such
proof is forthcoming after bacteriological examina-
tion that no harbouring of the bacilli continues. As
long as the germs are in the system such persons
ure likely to pass them from time to time, and
thereby be a fresh focus for infection.
So far no royal road has been discovered for
certain to eliminate the whole of these bacteria from
the system, therefore one has to provisionally con-
sider that ** once a carrier always a carrier.”
Every private place and all publie places should
have water and a towel in them. A little dis-
infectant in the water will add to its usefulness.
The whole of the State at present, it may be
said, is subject to the '' pan "' system in closets,
and as regards the danger from flies, which are
important factors in carrying diseases, the '' pan ”
is more dangerous than the old dark and deep cess-
pits. The pans are in the light, and they are
April 1, 1913.]
usually not darkened by closing the lid of the seat.
The users but rarely thoroughly cover up the con-
tents. The door is more often open than closed.
The building is near the kitchen, so the flies are
permitted free access between it and the closets,
from which they carry great numbers of harmful
bacteria to the kitchen, where exposed foodstuffs
are, and must leave these germs scattered on what-
ever they walk over. These facts are unpleasant to
contemplate, but are not often considered. The
prevention is easy if people would think, and im-
press upon children and others a habit they should
themselves rigorously follow.
Diphtheria.
Number of cases reported 1,221
Mortality 81.— Percentage total deaths ... 3.04
Per 1,000 population — ... .29
Notified Places.
Metropolitan Area ... a .. 518
Agricultural Areas |... as .. 861
Goldfields 342
The bulk of cases notified came from Perth, Fre-
mantle, Northam, Geraldton, York, Kalgoorlie, and
Meekatharra.
This shows a wide distribution, and has caused
considerable interference with school life. In many
isolated places and where population is scattered,
assistance has been rendered by the Central Health
Department. One of the Medical Officers, Dr.
Cumpston, or a qualified nurse from the Depart-
ment, has gone and acted with the local medical
man, where there is one, or alone in other parts,
and carried out complete measures for the control
of the outbreak.
Where no resident medical man was available,
antitoxin was administered by the nurse to each
detected carrier.
The measures included examination by swabbing
of a large number of the inhabitants. Wherever a
clinical case or a carrier was detected the whole
household was immediately isolated and kept so
until everyone was found to show two consecutive
negative results. During isolation, treatment by
spraying the throat of each affected person was
earried out daily by the nurse.
Before the household was released, disinfection
of all articles was carried out as far as was prac-
ticable.
All swabs from suspected cases are examined at
the Health Department laboratory for anyone free.
This disease was first mentioned as occurring in
this State in the sixties, and caused death from
time to time, but outbreaks were not of any serious
character.
During the last five years it has been epidemic in
one or other parts. It has occupied much time of
the officers of the Health Department, both by the
travelling and controlling at different parts, and the
examination of a large number of swabs, so as to
interrupt work in other directions, such as syste-
matic examination of school children, which had
been taken up. Such opportunities as offered were
COLONIAL MEDICAL REPORTS.—WESTERN AUSTRALIA. v 27
availed of by Dr. Cumpston to go through the
schools in the vicinity.
Although certain animals are known to be
attacked by diphtheria, the chief cause of spread
is by personal contact. The presence of the bacillus
in apparently healthy individuals is undoubted, and
ranges from 5 to 20 per cent. These carriers convey
the bacillus to those who are in a receptive state,
and unless detected, isolated, and treated, may
account for many cases. Some of those who have
had the disease may retain the bacillus in the
throat, nose, and other parts for some months and
be the cause of fresh cases.
In all cases treatment should continue until two
consecutive swabs show negative results.
Phthisis.
Number.—Males iis ... 120
Females... i .. 68
188
Percentage total deaths, 6.95 per 1,000 popula-
tion, .68. Other tubercular diseases, 43. Percent-
age total deaths, 1.60 per 1,000 pop., 145. From
all forms of tubercular disease there died in this
State 231. From all causes, 2,706, which is equal
to 1 in every 11.
The number suffering in proportion to those who
died has been differently computed by observers as
from ten times to twice, but a mean of these figures
seems reasonably accurate. What does it mean to
this State, where 1,500 of the inhabitants are in
some stage of this disease, especially when it is the
young who are afflicted and those approaching
middle life who die ?—
In males between 25 and 45; in females between
20 and 35.
They are either bread-winners, or have the re-
sponsibility of a family to look after, and where
another twenty-five to thirty years of useful citizen-
ship may have been possible.
There is also the risk that many are the active
sources of infection to others. From close investi-
gation made in this Department by Dr. Cumpston,
during the last three years, 33.8 per cent. can be
fairly traceable to infection from human beings.
The early recognition and treatment are of first
importance, as it gives the afflicted the best chance,
and the danger of infection to others is removed.
Many cases of tubercular infection are discovered
post mortem. These cases have had sufficient
resistance to limit the infection, suppress and
destroy it, but it may be that continued exposure
or an unusually large dose may exhaust the in-
herent power of the body, and this is likely to occur
where the actively tuberculous patient is in close
contact with those whose heredity may be a pre-
disposing cause.
Hence the necessity for strenuous efforts to wipe
out the scourge from our midst, and it should be
individual and collective: Government, societies,
combinations, and individuals. It will be a financial
success, for it is to the State's advantage to keep
people alive and healthy.
98 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Benefit societies’ funds are depleted by calls of
sick members suffering from tuberculosis. This
view has been made the subject of a memorandum
to lodges throughout the State.
The feeling in this direction was so strong that
towards the end of last year the Government
decided to have a Royal Commission appointed to
make investigations as to the extent of miners’
phthisis.
This Royal Commission has for its object, accord-
ing to the terms of reference—
(a) The prevalence amongst miners of pulmonary
diseases; (b) the nature of such diseases; and (c)
the extent to which they are associated with or
consequent on mining.
The necessity for combined action is recognized in
other parts of the world.
Scarlet Fever.
During the year there were 340 cases of scarlet
fever notified in the State. The chief weeks pro-
ducing this total occurred in the second, third, and
fourth, and the 45th, 46th, 47th, 48th, and 49th
weeks of the year. There was then a slight decline
until the last week in the year, when a further rise
took place.
One hundred and twenty-nine of these cases
occurred in the Metropolitan area, 43 in the country
districts, and 168 in the Goldfields area, chiefly
Kalgoorlie and Boulder.
Measles.
Measles is not a notifiable disease, but there has
been a considerable visitation of it in different parts
of the State most of the year. The number of
eases is impossible to ascertain. The deaths
reported from this scourge during the year were
nine.
The ages of the deaths are as follows :—
Between 6 and 12 months 2 cases
Between one and two years ... us 2
Between two and three years l ease
Between five and ten years ... aa) ET,
Between thirty and thirty-five years 1 ,,
Between thirty-five and forty years 1 ,,
Between fifty and fifty-five years I
Total ... 9 cases
The elimatie conditions here are quite favourable
to there being a low death-rate in this complaint
when it only attacks young children.
There are many months (about 8) of sunshine,
which limits to a large extent the lung complica-
tions which are so often the cause of fatality in
colder, wetter climates.
Whooping-cough.
Whooping-cough has also oceurred during the
year, and is a continuation of the outbreak whieh
has been present here for some vears,
Jt has eaused three deaths, the ages being
Between one and two years 2 deaths
Between two and three years ... 1 death
Total... 3 deaths
[April 1, 1913.
Dysentery.
Dysentery caused the death of 19 persons. This
complaint is as a rule sporadie. Cases occur in
different parts, and are often the cause of death
amongst children in outlying districts, where treat-
ment is not understood, appropriate dietary is not
obtainable, and where medical assistance is not
available.
Chicken-pox.
Chicken-pox has also been present in many parts
during the year.
Influenza
is a frequently recurring complaint. The periods
of the year during which it is most troublesome are
the late autumn and the early spring. It accounts
for 24 deaths.
Plague.
Fortunately there has been no local outbreak of
plague in this State since 1906.
Two cases were imported into the Port of Bun-
bury by a vessel seventeen days out from Bombay
and Madras. The patients recovered, and the fumi-
gation of the vessel by the Clayton process when
she was loaded resulted in 40 rats being found, of
which seven were infected with plague.
Precautions continue to be taken by the respective
local authorities in the destruction of rats, and large
numbers of baits are laid in the principal parts and
observations taken from time to time as to the
prevalence of rodents.
In Perth there have been 36,379 baits put down
for the year, 13,202 taken, and 2,252 rats caught.
In Fremantle there have been 81,587 baits put
down for the year, 6,990 taken, and 392 rats caught.
The difference in the number of rats caught in
Perth and Fremantle can be somewhat accounted
for by the fact that in Perth the dead bodies of
rodents are paid for and in Fremantle they are not.
Close investigations of dead rats caught are con-
stantly made, and during the year no plague-
infected rat has been discovered other than those
above referred to.
?rysipelas.
A notifiable disease. Forty cases were reported
and one death.
Septicemia.
Fourteen cases were notified, of which nine were
puerperal,
Beriberi.
One hundred and twenty-nine cases were re-
ported, all from Broome. This town is the head-
quarters of the Pearling Industry in the Nor’-West,
where a large number of boats are annually con-
gregated in this work. This disease is the chief
cause of sickness amongst the coloured crews, whe
are chiefly Japanese, Malays, and Manillamen.
Although no deaths from beriberi appear to have
been reported, yet from diver's paralysis nine deaths
were notified. This paralysis has been very care-
fully thought out by the late District Medical
Otticer, Dr. Blick.
April 15, 1913.]
Colonial Medical Reports.—No. 15.— Western Australia.—
(continued).
His view of these cases is: ‘‘ That there is a
certain teasing of the spinal cord about the fifth
cervical vertebra. It looks as if one had stippled
this with a fine knife or needle. With this con-
dition is nearly always associated hemorrhage of
greater or less extent, and although the divers
started about March 4, no paralysis occurred before
September, and then to the end of the working
season (November) cases came in almost daily.
"' It is difficult to elucidate the cause of this, but
in an autopsy, signs of scurvy were found. There
is a simple explanation of this amongst men who
live for months on small boats, eating salted and
tinned foods, till the blood-vessels have been some-
what weakened, as we know happens in scurvy.
Acting on this knowledge, I preached an anti-
scurvy crusade, and noticed in fleets where my
advice was taken and extra vegetables and other
precautions used, there was & very considerable
reduction in the number of cases of paralysis.”
Small-poz.
One death from small-pox occurred, which was
an imported ease landed at Broome from a vessel
coming from Singapore.
This vessel caused a further outbreak, but the
cases were segregated and treated at Fremantle.
This disease was also introduced into the Port of
Bunbury by a vessel from Caleutta.
No spread from either of these sources resulted.
Leprosy.
An occasional case of leprosy has been discovered
in this State chiefly amongst Asiaties in past years.
In August a case was discovered by the Acting
District Medical Officer at Roebourne, and was con-
firmed bacteriologically. Another case was found
in the 45th week, one in the 50th week, and another
in the 52nd week.
Although no deaths occurred during the year,
some of the cases proved fatal shortly afterwards.
All the above cases came from the same portion
of the Roebourne district.
It is difficult to account for the origin, but it is
reported that a Chinaman, who was a cook on one
of the stations, was known some years ago to have
a certain skin disease, which was remarked upon
by men seeing him, in a jocular manner, that he
(the Chinaman) was ‘‘ turning into a white man.”
Whether this was so and caused the disease to occur
amongst natives is hard to say, but it must have
had some such starting point.
At present these cases are segregated on a Penin-
sula, and are being looked after.
Malaria.
Malaria is prevalent north of the 20th parallel.
No cases have keen known to arise south of this,
although the anopheles mosquito has been found in
these parts. From malaria, four deaths occurred.
COLONIAL MEDICAL REPORTS.—WESTERN AUSTRALIA. 29
The Kimberley is really a mualarious region,
having heavy tropical summer rains, bringing down
rivers in flood for some time, and afterwards con-
sisting of pools and lagoons, which form good breed-
ing grounds for mosquitoes.
Instructions have recently been issued to Local
Boards of Health, and if action were taken good
results would ensue.
Dengue
Is an epidemical outbreak in the hot parts of this
State, and causes considerable suffering, but no
deaths.
Vencreal Diseases.
This class of disease is one which the public
scarcely realize the ravages which it causes, in its
different forms. Unimagined disaster follows in its
train.
There is no other form of disease which is so
baneful in its results and by which others are
doomed to suffer innocently.
The knowledge of the disease is common; its
eradication most difficult, its havoc is appalling,
and the sufferers are condemned to long periods of
anxiety and ill-health.
No other disease is more inimical to the public
health, and its ramifications deteriorate the stamina
of the nation.
Good results are likely to be obtained by more
general knowledge of the serious consequences of
these diseases.
The diminution of these will ensue if free treat-
ment is afforded at hospital to all voluntarily seek-
ing relief, who declare their inability to pay. To
effect this, strict privacy for patients must be the
rule.
It is especially necessary to teach young men that
chastity and continence are not injurious, but that
these virtues are necessary_and beneficial.
Naturally the only absolute prevention is purity
of living.
Maternity.
There were born 7,601 children, and the deaths
of mothers recorded were 46.
In 1899, it was one death in 165.2 births. In
1898, it was one death in 143 births. In 1897, it
was one death in 167 births.
One-fifth of these at least are notified.as due to
puerperal septicemia.
It unfortunately becomes public knowledge each
year that certain deaths occur through illegal opera-
tions and unskilled interference, coupled with dis-
regard of the cleanliness necessary to safeguard the
patient from infection through dirt and careless-
ness.
Ankylostomiasis.
Mining.—This industry is important and likely to
be continued for many years in this State. With
the immigrants coming in may be some who are
from places where ankylostomiasis is common. It,
therefore, is very necessary— l
30 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1913.
(1) For ordinary reasons of decency and clean-
liness.
(2) To prevent the propagation of the trouble
caused by ankylostoma, if it should be introduced,
that every care be taken to provide plenty of
sanitary accommodation for underground miners,
surface workers, and others, and to see that regular
and frequent removals take place, that each person
quite covers with earth and uses a disinfectant after
every use of the closet, that the accumulation be
ultimately disposed of by burning or trenching, and
that drinking water and food places be carefully
protected from fecal contamination.
Vaccination.
Only about 10 per cent. of those born in recent
years in this State have been vaccinated; this
should be a sufficient reason for trying to remedy
such a state of things rather than of using it as
an argument against the continuance of compulsory
vaccination.
Alcohol.
Alcoholic consumption continues to account for
an enormous outlay of money.
During the past four years it has been as
follows: 1905, £9 12s. per head; 1906, £9 2s. 7d.
per head; 1907, £8 8s. 54d. per head; 1908,
£8 3s. 61d. per head.
The eonsumption of spirits, wines, and beer per
year per head of the population between 1901 and
1906 was as follows :—
New Zealand.—Spirits, .785 gal.; wines,
gal.; beer, 9.309 gal.
New South Wales.—Spirits, .81 gal.; wines, .57
gal.; beer, 9.76 gal.
Victoria.—Spirits, .70 gal.; wines, .85 gal.; beer,
12.04 gal.
Queensland.—Spirits, .82 gal.; wines, .29 gal.;
beer, 10.58 gal.
South Australia.—Spirits, .40 gal.; wines, .27
gal.; beer, 9.15 gal.
Tasmania.—Spirits, .53 gal.; wines,
beer, 9.15 gal.
United Ningdom.—Spirits,
gal.; beer, 29.5 gal.
Western Australia.—Spirits,
1.08 gal.; beer, 24.74 gal.
W.A., 1908.—Spirits, 1.10 gal.; wines, .94 gal. ;
beer, 18.92 gal.
In the quinquennial period above quoted, we are
far in excess of the other States in spirits and beer.
It is to be hoped that the decrease which is now
taking place will become more rapid.
.144
.27 gaul.;
1.17 gal.; wines, .66
1.49 gal.; wines,
Milk Supply.
In 1908 the Central Board inaugurated the veter-
inary examination of dairy cows, and this was
carried on by the Board with satisfactory results up
to the close of that year.
The examination of dairy herds has been steadily
prosecuted by the Stock Department, and a con-
siderable number of cows have been eliminated.
The inspection of dairy premises by the inspecting
staff of the Central Board and by the various local
authorities has been continued, and generally
speaking these premises are found in a creditable
and sanitary condition, and show a marked improve-
ment upon the conditions of a few years ago.
The Local Boards of Health are responsible for
safeguarding the purity of the article supplied to
the consumers. This duty is carried out in many
cases with commendable regularity, but in remote
parts where analysts are not available it is more
difficult and almost impossible to take any such
steps. '
The following points are useful in the sterilizing
of milk :—
(1) Use a double milk saucepan. If this cannot
be obtained, put the milk in an ordinary covered
saucepan, and place it inside a larger vessel con-
taining water.
(2) Let the water in the outer pan be cold when
placed on the fire. —
(8) Bring the water to the boil, and maintain
it at this point for four minutes, without removing
the lid of the inner milk pan.
(4) Cool the milk down quickly by placing the
inner pan in one or two changes of cold water,
without removing the lid.
(5) When cooled down, aerate the milk by stir-
ring with a spoon.
In all circumstances it is most advisable that
every vendor of milk should have it kept cool
and served to all eustomers in bottles instead of by
open means. It would not cost much more.
Abattoirs.
In the metropolitan area private abattoirs are in
use where all killing is done. At Kalgoorlie the
same custom prevails, but here a large Government
abattoir has been built.
At the commencement of the year under review
there were but three inspectors on duty in the
metropolitan area, but owing to an increase in the
nuinber of slaughter-houses in other parts of the
area it became necessary for the Government, on
the reeommendation of the Board, to appoint two
additional inspectors, whose duties comprised regu-
lur inspection of the slaughtering of the yards
previously unsupervised,
The result of this increase in the metropolitan
meat inspection service is that the whole of the
slaughtering at licensed slaughter-yards is super-
vised, and the carcases carefully inspected with a
view to the condemnation and destruction of all
carcases or parts found to be diseased or unwhole-
some.
During the year power was given to the Central
Bosrd to make regulations providing for the brand-
ing of meat passed by its inspectors, and to levy
charges therefor. The regulations came into force
on August 1; a form of brand was decided upon and
the following scale of charges made :—
lor the carcase of every ox, cow, bull,
heifer, or steer as 0d.
April 15, 1913.]
ee
vo
COLONIAL MEDICAL REPORTS.—ST. VINCENT. 31
l'or the carcase of every calf of 300 Ib. '
weight or over... es id es 10d
For the carcase of every calf under 300 lb.
weight T ii iis 2 .. Id.
For the carcase of every sheep, or lamb,
or goat Ss S M T sia Ads
For the carcase of every head of swine ... 2d.
It will be understood that the appearance of the
Board's brand upon a carcase is a guarantee that
at the time of slaughter the particular carcase was
free from disease.
The quantity of meat which was inspected and
branded in this manner amounted to:—
Cattle, 29,678; calves, 297; sheep,
pigs, 126,697.
While the whole of the slaughtering within the
metropolitan area is subject to inspection, some
meat enters the area, both by rail and road, from
beyond the commonly recognized boundaries of that
area. This quantity is comparatively small, but
while any portion of the supply remains uninspected
the position cannot be regarded as perfect.
In the country parts it is impossible, where small
amounts are manipulated, to have inspectors, but
each slaughter-house has to be licensed and the
Local Boards of Health, where such exist, supervise
their cleanliness.
198,638 ;
Fish.
This is easily procured and is plentiful on our
coast. It is a very necessary article of diet; one
which would afford considerable variety and
pleasure to the poorer classes, but which is almost
out of their reach in consequence of the high prices
charged. It may be that the fisheries are controlled
so as to always keep up a fixed price, or that the
catchment is not sufficient to offer to the general
public at a price within their reach, but whatever
the cause, the fact remains that it is a luxury even
for the well-to-do.
Sanitation.
There is no system of sewerage anywhere, but one
is in course of construction in Perth and Fremantle,
which will take a considerable time yet before it is
completed. This will be a great improvement upon
the sanitation of these places.
A few private houses and some institutions arc
providing themselves with septic tanks. These give
fairly satisfactory results when carried out m proper
detail.
Laboratory.
A well-equipped laboratory is attached to the
Central Board of Health, where all bacteriological
investigations are made, both on behalf of the
Board and private practitioners, for diagnostic
purposes.
Tuberculosis and diphtheria specimens are treated
free. For other matters and pathological work a
scale of charges is in operation.
Colonial Medical Reports.—No. 16.—St. Vincent.
MEDICAL REPORT FOR THE YEAR 1909—1910.
By CYRIL H. DURRANT, M.B.,
Medical Officer, Kingstown District.
Tne estimated population of the Kingstown Dis-
trict, which comprises the town of Kingstown, is
5,000. There were 162 births and 81 deaths,
giving a birth-rate of 32.4 per 1,000, and a death-
rate of 16.2 per 1,000.
Sickness was more prevalent during the first
quarter of the year under review, i.e., from April
to June, 1909; and this period also assumes the
highest death-rate, pulmonary tubercle, and gastro-
enteritis in infants, claiming the largest number of
victims.
The relation of gastro-enteritis to the high infant
mortality has been under consideration, and efforts
have been made to educate the mothers and
guardians of infants in the subject of ‘ Infant
Feeding " with the hope of reducing the high
mortality. The method adopted consists in furnish-
ing each mother or guardian, when registering the
birth of an infant, with an attractively printed card,
stating in simple words the way in which the infant
should be fed; und endeavours to teach them to
abolish the faulty and unwholesome diet that is
administered to those of tender age.
It is gratifying to be able to note that the year
under review was not marked by any general dis-
turbing influences affecting the public health of the
district. There was no disease of epidemic
character present during the year. Catarrhal fevers
and amebice dysentery were prevalent during
August, September and October, but they did not
affect the death-rate to any material extent.
Malarial fever was rather less common than is usual
in the October-December quarter. Syphilis in its
various manifestations, frambæsia or yaws, and
intestinal parasites (Ascaris lumbricoides and anky-
lostoma duodenale) are the conditions which the
District Medical Officer is most commonly called on
to treat. Pulmonary tuberculosis, already referred
to, still claims its share of victims.
The sanitary condition of the district has been
32 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1913.
satisfactorily maintained during the year. The
principal streets and thoroughfares of the town of
Kingstown have been kept in a fairly presentable
state, and efforts have been continuously made by
the Kingstown Board and its sanitary inspectors in
anti-mosquito measures. The district immediately
surrounding the town, however, deserves attention
in a similar way; the Richmond Hill and Sion Hill
quarters, which immediately overlook the town,
being a fruitful source of supply of mosquitoes,
owing to the habits of the villagers storing drinking
water in open barrels, tubs, &c., and it is difficult
to be able to suggest the remedy without being able
to supply these villages with a proper and efficient
water supply.
Vaccination has been regularly performed each
week throughout the year, the total number of
successful vaecinations recorded being 132. This
number out of a total number of 162 births points
to a satisfactory condition of protection against
small-pox in the district.
Report OF THE MEDICAL OFFICER, NO, 1 District.
Population. —12,000 estimated.
Births.—141 to December 9, including Calliaqua ;
68 after December 9, excluding Calliaqua. Total,
209.
Deaths.—65 to December 9, including Calliaqua ;
39 after December 9, excluding Calliaqua. Total,
104.
From April onwards through the hot weather
epidemic diseases of children and dysentery prevail.
During January and February there was more
rheumatism to be treated.
During February and March there was a large
number of irritative eye troubles caused by dust.
Relative Mortality in Different Seasons.—Quarter
ending June, 32 deaths; quarter ending September,
20 deaths; quarter ending December, 22 deaths;
quarter ending March, 30 deaths, showing approxi-
mately a 50 per cent. increase of mortality during
the first half of the calendar year.
The following gives the distribution of deaths for
the different months: April, 14; May, 6; June, 12;
July, 9; August, 7; September, 4; October, 4;
November, 9; December, 9; January, 8; February,
12; March, 10.
Since December 9 the only effect of weather
noticeable has been the irritative effects of dust in
dry weather on eyes, throat, and nose.
Gastro-intestinal diseases, including those caused
by intestinal worms, are particularly prevalent.
Yaws and syphilis, widely spread, are the cause
of most of the uleers, and indirectly cause much
disease, such as anemia and debility. The primary
diseases themselves are not a source of much con-
cern to the patients. It would be difficult to say
which causes most harm—yaws, syphilis, or intes-
tinal worms as a class.
General Sanitary Condition.—Any place outside
a house seems to be considered suitable for the
deposit of excreta.
The houses in the villages are reasonably far
apart,' though the houses themselves are over-
crowded.
There are few heaps of domestic rubbish about
these houses.
There are comparatively few pools of water in
and around the villages, except at Clare Valley,
where a brackish lagoon probably keeps the numer-
ous erab holes supplied with water; but the crab
holes as well as the lagoon are at about sea level.
There are occasionally accumulations of rain
water in grass-grown roadside ditches, but the latter
are cleaned periodically.
Drinking water is obtained from rain barrels;
springs are, however, preferred; streams also form
a source of water supply, according as to whether
they do or do not dry up in dry weather.
Stand-pipes are provided in some localities, and
are much to be recommended. It would be most
advantageous should it be possible to extend this
mode of supply.
Forty-three vaccinations were certified successful.
During the four months I have been stationed in
Distriet No. 1 I have seen very little malaria.
That which I have seen has mostly been im-
ported; for instance, severe cases of malaria occur
in the island of Bequia; but the inhabitants con-
stantly travel up and down the Grenadines to and
from Grenada, spending the nights in all sorts of
places, and developing '' Grenada fever," as they
call it, on their return.
The only other part of my district that has houses
üt sea level is Clare Valley; so far malaria has not
been evident there. They expect it in the hotter
weather, when, possibly, the heavy rains supply the
crab holes with fresher water than that which
filters in from the sea, thus affording a breeding
ground for an Anopheline which prefers these holes
—the Cellia.
Anophelines are rare in the distriet as a whole;
surface fishes and water striders probably devour
the larve. I have searched in the grassy edges of
many streams, typical Anopheles breeding grounds,
without finding larve.
The anti-malauria measure, accordingly, required
in District No. 1 is to fill up erab holes, a task of
very considerable magnitude considering the very
slight incidence of malaria, most of which, as stated
above, is imported.
Anti-mosquito Measures as applied to Stegomyia.
An Ordinance will shortly come into force with
regard to harbouring larve in and about houses.
This should entail no hardship on those who use
stand-pipes, deep well springs, and streams for
their water supply.
For those who depend on rain barrels a rigorous
system of inspection would be needed.
There is no doubt that stegomyia could be
abolished in the more densely populated districts,
and with them would go all danger from the im-
portation of yellow fever. Yellow fever is mainly
a town disease, and a few stray stegomyia in
isolated houses outside towns and villages could
practically be disregarded,
May 1, 1913.]
COLONIAL MEDICAL REPORTS.—ST. VINCENT. 7 33
Colonial Medical Reports.—No. 16.—8t. Vincent.—
(continued). ;
Quarantine.—During my term of office no vessels
were quarantined. The few passengers or crew
reported sick by the captain of the vessel concerned
were examined, and found not to be suffering from
quarantinable disease.
In February one case of plague oceurred in
Trinidad; Dr. Durrant, during my absence in
Bequia, fumigated two vessels on this account.
These had not been fumigated at Port of Spain, as
this was not an '' infected port.”
At the end of March Grenada was declared to be
*' infected "" owing to an outbreak of small-pox ; no
vessels arrived from Grenada before April 1, 1910.
Venezuela has been considered '' infected " for
some time, but no vessels came from any port in
that country.
Kingstown and St. Vincent have been '' healthy ”’
since my appointment. I have issued no bills of
health.
H. B. Dopps.
Report oF THE MEDICAL OFFICER, No. 2 District.
Population.—The estimated population of the
district is 11,337.
The number of births were 342, and the number
of deaths 155. Still-born children 19, giving a birth-
rate of 30 per 1,000, and a death-rate of 13.6 per
1,000.
There is a good deal of sickness in this district,
chiefly syphilis, yaws, dyspepsia, and intestinal
parasites. During the rainy season malarial fevers
and dysentery were more prevalent in certain parts,
viz., the Buecament and Cumberland valleys.
The prevalence of any particular disease has not
varied in the different seasons to a marked degree.
Relative Mortality in Different Seasons.—There
is very little difference in the mortality during the
different seasons. The quarterly returns were:
To June 30, 40 deaths; to September 30, 88 deaths;
to December 31, 41 deaths; to March 31, 1910, 87
deaths,
The mortality for each month during the year was
as follows: April, 1909, 18; May, 11; June, 11;
July, 10; August, 19; September, 9; October, 18;
November, 6; December, 17; January, 1910, 10;
February, 8; March, 19.
Malarial fevers and dysentery are endemic in
several parts of this district, particularly the Bucca-
ment and Cumberland valleys, but during the rainy
season the number of cases were increased. The
cases of malaria were of a mild type as a rule, but
some of the cases of dysentery were very severe.
` Two cases of diphtheria occurred during the year,
one case at Layou and one at Chateaubelair. The
usual precautions were taken with regard to isolation
and disinfection, and no fresh cases occurred. -
Yaws, syphilis, and ulcers are common in the
district. ^ Uleerous rhino-pharyngitis occurs in
isolated cases, and is probably. a late manifestation
of severe syphilis. It is common in coolies of a
poor class. $
Ulcers of a specific and non-specific nature are
common; they are generally in a bad state by the
time they come for treatment. Progress is very
slow, and treatment in the people's homes not
satisfactory.
Enteritis in children, in most cases due to im-
proper feeding, is commonly met with.
The general sanitary condition of the district is
fairly good.
The number of successful vaccinations performed
during the year was 282.
In the small towns of Layou, Barrouallie, and
Chateaubelair a sanitary inspector was appointed
for eaeh town. His duty was to inspect the different
houses and yards to see that no water was allowed
to accumulate where mosquitoes might breed, and
to report the result once a week to the Town
Wardens.
A number of patients were sent from this district
to the Colonial Hospital in Kingstown during. the
year. They were chiefly cases of chronic uleers and
diseases requiring proper diet and nursing, which
they were unable to get in their homes.
The number of deaths in children under two years
from gastric and intestinal diseases is high. - This
is due in a good many cases to improper food, and
treatment is very unsatisfactory owing to the
difficulty of getting the people to carry out in-
struetions, &c. ‘
Tuomas H, Massey.
Report OF THE MEDICAL OFFICER, No. 3 Districr.
Population—The estimated population of this
district is about 10,000. No census has been taken
for about 20 years, and, therefore, any figures giving
the proportion of births and deaths per 1,000 are
not reliable.
The total births for the year were 398, 198
legitimate and. 200 illegitimate. Of the 15 still
births, 9 were legitimate and 6 illegitimate. Assum-
ing that the total population for the district is
10,000, this gives a. birth-rate of 39.8 per 1,000.
The population can be roughly calculated from
the birth-rate, which is usually about 36 per
1,000 amongst the people of these islands.
The total deaths for the year were 147, which
gives a rate of 14.7 per 1,000. 94 of these were
deaths of children: under 5 (—04 per cent.) 69
34 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1913.
were deaths of children of one year and under
(=47 per cent.); 15 of these 69 deaths were still-
births. A eeolie woman died aged 105. In 56 of
the 94 children under 5 the cause of death is given
as gastro-enteritis, or diarrhoea, probably caused by
bad feeding, ignorance and neglect, or teething. In
4 of the total of 147 deaths no cause was given.
Presumably, these cases were reported to the
Coroner.
According to the report of the Registrar-General
for Jamaica for the year ending March 31, 1909,
the figures were: Birth-rate 37.6; death-rate 22.4
per 1,000. 29.4 per cent. of deaths were those of
children under 1, and 42.2 per cent. were those of
children under 5. In 76.6 per cent. of the deaths
the cause was not medically certified.
The Barbados death-rate is given as 29, British
Guiana 36.9, Antigua 29.98, Trinidad 22.6, Bermuda
18.7, St. Vincent, 18.34, St. Lucia 19.4.
In London, for the first quarter of 1910, the birth-
rate was 24.5 per 8,000; death-rate 14.3 per 1,000;
the average for 10 years, 18.4 per 1,000.
Infant mortality, measured by the proportion of
deaths amongst children under 1 year to registered
births, was 101 per 1,000.
In 76 of the largest English towns for the first
quarter of 1910, 0.8 per cent. of the deaths were not
certified either by a registered medical practitioner
or by a coroner.
In Birmingham the proportion rose to 3.4, in
Preston 4.4, in St. Helens 5.2, and in Gateshead
5.5. (Extract from the British Medical Journal
Supplement.)
From the figures given, the infant mortality of
this district, measured by the proportion of deaths
of children under 1 year (69) to registered births
(398), was 173 per 1,000; and 8 per cent. of the
deaths were not medically certified. This is gener-
ally due to the fact that the doctor is called at the
last moment, and the patient dies before he arrives.
This district, on the whole, is healthy, and the
only serious diseases which appear to visit it are
dysentery, malaria fever, gastro-enteritis or diar-
rhea, and yaws. Generally speaking, the pre-
valence of sickness depends on the rainfall. After
rain, one may expect dysentery and diarrhea, and,
in dry weather, malaria fever. Pools flushed by
rain in wet weather breed mosquitoes in dry
weather.
Yaws is endemic, and cases could be found in
most villages, but they are never brought to the
doctor, and do not appear in the returns. Accord-
ing to these, there were 4 cases of dysentery in
April and May, and three cases in June and
December, 1909, and January, 1910. Malaria fever
showed 3 cases in December, 1909, 4 in January
and March, and 7 in February, 1910. An outbreak
of yaws occurred at Argyle in September, 1909;
there were 7 cases. Diarrhæa and worms head the
list of diseases.
The deaths were distributed as follows :—
April 28, May 11, June 11, July 14, August 14,
September 8, October 8, November 14, Decem-
ber 15. 1910.—January 5, February 18, March 11.
Cases of malarial fever are few and far between.
They are usually of a mild character.
Tuberculosis is also rare, but is usually imported,
and always fatal.
Yaws.—Cases are concealed in the villages, and
rarely come to the doctor. It is futile to attempt
to deal with yaws until & place is provided where
these contagious cases can be compulsorily sent.
Syphilis is prevalent, but apparently not so bad
as in Kingstown and the Leeward District.
Ulcers are numerous, mostly untreated, and
usually due to syphilis or yaws.
Dyspepsia is common, as is to be expected from
the amount of starchy and badly cooked food eaten
at irregular hours.
Owing to their poverty, women feed their children
on arrowroot or ‘‘ what they have '' instead of milk;
the result is a high infantile mortality of gastro-
enteritis.
There are two chief kinds of worms, the common
round worm, which 90 per cent. of the children
have, and the, hook-worm, causing ankylostomiasis,
of which the chief symptom is anemia from loss of
blood. Comparatively few ankylostomiasis cases
have been met with in this district.
A simple test for ankylostomiasis is to pull down
the lower eyelid and notice if the inside is red or
white.
Schoolmasters should send all children with sores
or white eyelids to the medical officer at once, and
on no account allow them to attend school, for they
are contagious.
The general sanitary condition of the district is
good.
There were 194 successful vaccinations during the
year. The total births were 398, so that apparently
204 children have escaped vaccination in this
district. Some died before vaccination.
The bush was kept cut in the villages, and the
sand bar at the mouth of the river at Calliaqua was
cleared when required. Most houses in these
villages have uncovered water butts, which breed
plenty of mosquitoes. In the absence of any law
providing a penalty for harbouring mosquito larve,
it is difficult to see how this state of affairs can be
remedied. This district cannot be regarded as
malarious, except at a few places such as Calliaqua.
In Antigua, certificated nurses, trained at the
May 1, 1913.]
COLONIAL MEDICAL REPORTS.—ST. VINCENT. 35
Government Hospital, were appointed to the
various villages, and proved most able assistants to
the Medical Officer. A similar arrangement can be
made here, as the Government provides free train-
ing and outfit at the Colonial Hospital for suitable
candidates, who, after five months’ instruction, are
duly examined by the Medical Board and given
certificates.
The women in the country districts run consider-
able risk when not attended in their confinements
by trained nurses. The penal clause of the English
Midwives Act of 1902, which came into force on
April 1 last, provides that ‘‘ any woman acting (as
midwife) without being certificated shall be liable,
on summary conviction, to a fine not exceeding ten
pounds, provided that this section shall not apply
to legally qualified medical practitioners or to any-
one rendering assistance in case of emergency.”’
G. B. Mason.
Report oF THE MEDICAL OFFICER, No. 4 DisTRICT.
Population.—Estimate 12,000.
Births.--30. — Still-born, 4.
Deaths.—26.
Having been in this district for so short a period,
as far as I can judge the season has been normal
with regard to health.
The number of deaths certified by me were dis-
tributed as follows :—
December, 7; January, 7; February, 5; March, 7.
Total, 26.
During the period under review the weather was
dry with occasional showers. In the early part of
March the sun was very hot, with a cold breeze from
north-east. This caused several cases of bronchitis
and allied throat affections.
Ascaris was the most common complaint treated,
149 cases being treated.
Gastro-enteritis or infective enteritis was also
frequently met with, 34 cases with 10 deaths. One
case of infantile convulsions was treated with
success.
Amongst adults, 50 cases of dyspepsia were
treated. No deaths. 41 cases of ulcer were also
treated. 12 cases of amebic dysentery were
treated, with 4 deaths. These cases did not occur
as an epidemic, but were isolated cases from
different parts of the district and at different periods.
10 cases of inflammation of the conjunctiva and
cornea were treated; these were in my opinion due
to the dust. 26 cases of old age were treated with
3 deaths. There was one case of accidental poison-
ing from an excessive use of iodoform on ulcer, not
under medical advice.
General Sanitary Condition of District—The
sanitary condition of the district was satisfactory.
I found no difficulty in gétting the owners of the
property to obey my directions.
The number of successful vaccinations was 50.
The lymph and the supply were both excellent.
There were no cases of malaria or other mosquito-
borne disease met with, nor did I hear of any such
cases having occurred in the district. The district
is generally a healthy one. In some parts the
villages are rather overgrown with bread-fruit trees
and banana plants, but the health of the inhabit-
ants appears about the average of the rest of the
district.
P. GRAY-MARSHALL.
Report or THE MEDICAL OFFICER, No. 5 District.
Population.—The estimated population of No. 5
District may be said to be 7,500. The number of
births for the year was 161, and the number of
deaths 51. The birth-rate per thousand was 21.4,
and the death-rate 6.8.
Regarding the prevalence of sickness in the
different seasons of this year influenza broke out in
the month of April. The cases were very few and
mild in type, and responded readily to treatment;
many of the cases began in the previous month and
lasted on to April. Also in the months of December,
1909, January and February, 1910, a few cases of
influenza occurred, most of them having resulted in
& bronchitis, but none eventuating fatally.
I am glad to mention that while yellow fever and
plague were in neighbouring islands this district was
quite free of these epidemics. ^ Passengers who
arrived from infected ports were subjected to strict
surveillance, and no case was found to exist here.
There was nothing of an epidemic nature. No
zymotic disease occurred.
Throughout the district or districts that I had
charge of, among children, diarrhea, intestinal para-
sites, and congenital syphilis were the chief ail-
ments and the chief causes of death.
This diarrhea of the infant was in most cases
attributed to and found to be the result of the in-
judicious and improper feeding of the infants by the
mothers.
Intestinal parasites, too, were the results of the
unclean way the mothers kept their children, and
the ignorance of and disregard for hygiene.
In the adult the cases which commonly came to
me for treatment were those of dyspepsia, uncin-
aria, valvular disease, Bright’s disease, anemia,
rheumatism, debility, chronic tertiary
gonorrhea, bronchitis, ulcers, and
ordinary constitutional disorders.
Chronic tertiary syphilis, the commonest if not
the only form of this disease met with in the dis-
trict, enters largely in the monthly Returns; and in
this district and colony this is a common ailment
syphilis,
some other
36 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 1, 1913.
The primary syphilis or hard
ever, brought to my
among the labourers.
chancre was seldom, if
observation.
A few cases of pulmonary tuberculosis were
treated; some of them ended fatally. Here I may
mention a disregard many have for hygiene observ-
ances—chiefly overcrowding and exclusion of fresh
air.
Malaria fever is almost unknown in this district.
About half a dozen cases were treated which
seemed to have been of a chronic type.
Some cases of tetanus were treated among
infants, and most of them ended fatally. This
condition is found in the newly-born, and traced to
the ignorance and gross negligence of the so-called
midwives of this colony.
The following is the distribution of deaths in the
different months, and this also includes some in the
No. 4 District: May and November, each month,
14 deaths; October, 11 deaths; July, August, Sep-
tember, March, 10 deaths in each month; April and
December, in each month, 8 deaths (No. 5 Dis-
trict); September, 7 deaths; January, 4 deaths;
February, 4 deaths.
During the year there were frequent downpours
of rain which constantly threw the roads of this dis-
trict out of order; the road to Owia and the Fancy
having been impassable on occasions.
Beyond a few cases of influenza which occurred
at different times of the rainy season, and a few
cases of malaria, there is no particular disease which
occurred during the year.
The general sanitary condition of the district was
excellent, and so was that of No. 4 District during
the time I acted there.
Georgetown, the chief town on the Windward
coast, may be regarded as a very healthy place. It
is provided with an excellent water supply, and is
always kept in a clean and sanitary state.
The sanitary conditions are good. Generally
throughout the district the inhabitants depend on
their water supply from the large and voluminous
rivers which flow in most parts of this district.
The water proved wholesome. There were no
cases of dysentery; but there were a very few cases
of diarrhea.
The number of vaccinations successfully carried
out was 118 in the No. 5 District, and 125 in No. 4
District. The lymph supplied was good, and gave
satisfactory results.
P. F. Cremona, M.B., Ch.B.
REPORT OF THE MEDICAL OFFICER, No. 6 District.
This district consists of the Southern Grenadines,
the three chief of which are the islands of Canouan,
Mayreau, and Union, and the medical attention they
receive consists of quarterly visits. These are really
visits for inspection and vaccination, as the interval
between the visits (three months) is too great to
permit of anything like adequate medical relief to
the patients in these islands. I regret to say that
these quarterly visits were not regularly possible
during the past year owing to hard pressure of work
consequent on an epidemic of enteric fever in
Carriacou. This failure, however, applies only to
Canouan, as Union and Mayreau received weekly
visits for a limited time, and this on account of
enterie fever in these islands.
Population.—The population is estimated at about
1,600 souls, and the social and sanitary conditions
are of the most primitive. Each island is owned
by a single proprietor.
Notwithstanding the entire absence of any sani-
tary measure, these islands are very healthy and
enjoy a remarkable immunity from diseases, which
are endemie in the neighbouring islands, e.g.,
malaria fever, dysentery, &c.
The outstanding feature of the year was an out-
break of enteric fever in Union and Mayreau ; four-
teen cases occurred, each of which was removed
and treated in the Carriacou Hospital, and the
house and surroundings of the patient at once
efficiently disinfected.
The disease was most severe in the village of
Ashton, Union Island, and knowledge of the sani-
tary conditions of this village, which can only be
described as ‘* huddled terraces of filth,’’ compels
one to attribute the stamping out of the disease to
the mercy of Providence.
At one time the whole island stood in imminent
danger, in that the only shopkeeper of the only shop
died somewhat suddenly of enterie fever in the
building in which the shop is kept. However, it is
gratifying to record that efficient disinfection and
other precautionary measures were at once adopted
with satisfactory results.
As to the source of the disease there can be no
doubt that infection was introduced from Carriacou,
where an epidemic prevailed almost throughout the
year,
That water played no part in the further spread
of this disease has been fully demonstrated, as the
chief source of water in Ashton Village is from a
very filthy well which is quite unprotected from
contamination; how filthy the well was may be
proved by the fact that cleaning out the well and
purification with permanganate of potash raised a
violent storm around my person, the older inhabi-
tants declaring that the well had not been cleaned
for seventy years, and the present innovation was
a menace to the lives of the inhabitants: The well
was effectually cleansed.
No disease calls for particular mention.
DvNBAn Hucues, M.B., C.M.
May 15, 1913.]
COLONIAL MEDICAL REPORTS.—FIJI. 97
Colonial Medical Reports.—No. 17.—Fiji.
MEDICAL REPORT FOR THE YEAR 1909.
By G. W. A. LYNCH,
Chief Medical Officer,
THe estimated population of the Colony at the
end of 1909 amounted to 183,881, and was made
up as follows :—
Race. Males, Females, Total,
Europeans and other whites ... 2,060 1,333 3,393
Aboriginal Fijians 45,659 41,731 87,390
East Indian immigrants |
(ineluding their chil. - 23,067 12,339 35,406
dren born in Fiji)
Melanesian immigrants 2,639 365 3,004
Natives of Rotuma T 1,047 1,150 2,197
Half-castes and other degrees ... 946 908 1,854
All others ... a EN 944 243 587
Total 75,762 58,069 133,831
These figures show an increase of the total popu-
lation during the year of 2,765, of whom 1,557 were
males, and 1,208 were females.
There is an inerease in all races except Rotu-
mans; it is diffieult to account for the apparently
very small increase in the European population,
except that at the end of the year there is apt to
be a large exodus of Europeans to more temperate
countries, and that this exodus may have been
larger in 1909 than usual; the increase among
Fijians is appreciable.
Particulars of births, deaths, and marriages which
took place among the various races are shown in
the table below :—
Races and Births. Deaths, Marriages,
Nationalities. M
M. F Total. M. F. Total.
Europeans 49 44 93 23 12 35 39
Fijians . 1,736 1,732 3,468 1,653 1,539 3,192 987
Indians ... 102 667 1,369 343 285 578 494
Melanesians 7 13 20 34 3 37 7
Rotumans.., 46 4T 93 47 55 102 30
Half-castes 41 34 75 11 4 15 17
Others k.. 3 1 4 1 3 4 12
Totals 2,584 2,538 5,122 2,112 1,851 3963 1,516
The total number of births registered exceeded
those in 1908 by 214; the registered deaths were
106 fewer. The marriages registered show a con-
siderable falling off, being 180 fewer than in the
previous year. The birth-rate calculated on the
mean total population for the year was 38°19 per
mille, against a rate of- 37:79 for 1908, and the
death-rate was 29°61 against 31°39 in the former
year.
SEASONAL PREVALENCE OF DISEASE.
The subjoined table shows the number of admis-
sions to the Colonial Hospital during the year; the
admission rate for the twelve months of 1909 is
higher than that for 1908, the highest quarter being, .
as is usually the case, the first quarter of the year,
and the lowest the third.
Europeans iv Zi. fs 194
Fijians E TE n 597
Indians Re i v 790
Melanesians p & ie 174
Others Ba T ess 68
Total 1,823
The number of admissions to the seven provincial
hospitals and the native hospital at Rotuma were
3,236, the number of deaths 86, being 23:5 per
mille.
ENTERIC FEVER.
There continues to be cases of enteric fever in
some of the out-districts, and more of these cases
are found in the Rewa district and its surroundings
than elsewhere. The spread of the disease is
favoured by the presence of small free coolie settle-
ments with insanitary surroundings, poor water
supply, and latrine accommodation of the most
primitive character, and the consequent need for
sanitary inspectors in some of the larger of the
coolie distriets is shown to be great. Hitherto, how-
ever, it has not been found possible to provide these
inspectors, and it is to be feared that until they are
provided, such preventable diseases as enteric fever,
the spread of which is due to the dirt and ignorance
of Indians and natives, must remain a menace to
the general health of the community.
In the free coolie settlements it is a matter of
extreme diffieulty to enforce sanitary regulations,
the inhabitants seldom use latrines (in any case,
these would be of the cesspit order), but prefer to
use the surrounding scrub as a latrine. This applies
to both Indians and Fijians, though in the case of
the latter efforts have been, and are being made,
to compel the erection and use of a simple form of
latrine. It is hoped that when the new Public
Health Ordinance comes into force it will be found
possible to appoint two, or perhaps three, of these
district sanitary inspectors to work under the dis-
triet medical officers and give them early notice of
cases of infectious disease, so that early and proper
isolation preeautions may be taken.
Thirteen cases were treated in the Colonial Hos-
pital with one death. In every case these patients
were brought into Suva from an outside district,
most of them being from the Rewa.
DYsENTERY.
A total of 305 cases of dysentery were treated
during the year at the Colonial Hospital with
25 deaths; a total of 191 cases at the provincial
66 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1913.
of the town has been supplied with a bin, and the
condition of these yards has noticeably improved.
The erection of three incinerators—two of which
are in use, at convenient places—saves much labour
and considerably expedites the removal of rubbish.
The incinerators are of simple construction in brick,
and many loads of refuse are destroyed quickly,
instead of being taken a long distance to the swamp,
to disintegrate slowly in an unsightly manner.
Another advantage is that the ashes are useful for
filling in depressions.
The water supply of Bathurst is still unsatisfactory
and very insufficient. From the grant of £1,000,
thirty-five 400-gallon tanks were imported, and these
have been purchased by persons who are refunding
the cost by instalments.
Unless some large scheme for a water supply is
taken in hand, I am of opinion that the distribution
of water tanks should be encouraged and persevered
with. Many of the poorer classes would avail them-
selves of this method of storing rain water for drinking
purposes, if the Government would import the tanks,
and accept repayment by small instalments.
The public wells are gradually being fitted with
Jonot's elevators ; six have been done in the course of
a year; they are very efficient in preventing further
pollution of the water.
I should point out that the measures suggested, and
that are being adopted, to improve the water supply
of Bathurst are very inadequate, and never can be
regarded as satisfactory; a comprehensive scheme
should certainly be carried out when funds are avail-
able.
The surface drainage of the town is still in an
unsatisfactory state. In the Half Die area a tram
line was temporarily laid down to the beach to enable
people to bring sand to their yards, for the purpose of
raising the level of them, and to some slight extent
it was used.
During the heavy rains a large area of Bathurst is
flooded, and impossible to deal with except by filling
in.
A new plan of Bathurst is being prepared, and
among other things, it will indicate the areas that are
low and impossible to drain. The positions of cess-
pits and surface wells will also be shown which will
be of immense assistance to the Board of Health.
The swamp at Half Die, some ten acres in extent,
has been cleared of all mangrove trees, and there is
now no cover for tsetse-flies in this part of the
town.
Rank vegetation is cut down at regular intervals,
and during the rains an extra gang of labourers is
taken on for this purpose.
LECTURES.
Two courses of lectures were delivered to school
teachers during the year, but the attendances were
irregular, and after the examination it was found that
no candidate had gained sufficient marks to obtain a
first class certificate, and until elementary hygiene
and sanitation is made a compulsory subject for the
children to be taught at school I do not anticipate
this subject will be taken up seriously by the teachers,
or that a useful knowledge of it will ever be obtained
by the children.
The filling in and reclamation of large areas of
Bathurst, and a water supply, I regard as the two
most important and essential requirements from a
sanitary point of view.
The appointment of a sanitary officer solely for
the Gambia becomes a necessity, if sanitation in the
Protectorate is to receive serious attention.
Meteorological observations have been regularly
made at Bathurst and McCarthy Island. It may be
of some interest to remark that the average minimum
and maximum temperature for the year in Bathurst
was two degrees higher than last year, and that in
comparison with the records taken at McCarthy
Island, some 150 miles up the river, the average range
of temperature is 33 and 40'6 F. respectively.
THE VICTORIA GENERAL HOSPITAL, BATHURST.
All the buildings have been kept in good repair ; the
walls have been coated with calcarium and the wood
work painted.
On aecount of the occurrence of yellow fever in
Sierra Leone it was considered desirable to mosquito-
proof three of the wards, and we are now in a position
to segregate, at a moment's notice, twenty or more
patients, in the event of yellow fever breaking out at
Bathurst.
The mosquito-proofed wards are much appreciated
by the patients when mosquitoes are prevalent in the
rains, and I hope eventually to see all the wards of
the hospital treated in the same way.
In the Out-Patient Department, 7,440 new cases
were attended to, and 669 new cases were admitted to
hospital this year, compared with 7,324 and 666
respectively in the previous one.
The number of deaths in hospital have fallen off, but
this probably is due to old and decrepit patients being
transferred to the Home for Destitutes.
THE HOME FOR THE AFFLICTED AND DESTITUTE.
During the year four men and four women were
admitted into the Home, making a total of eighteen
with the ten remaining over from the previous year.
Every care and kindness are shown to the inmates
by the attendant in charge, but the number of deaths
has been high.
Of the four that were discharged two refused to
remain in the Home, one was taken away by relatives
to be eared for, and the other, who was suffering
from dementia, was sent to the Lunatic Asylum in
Sierra Leone.
The food supplies have been ample and suitable,
and were prepared at the Victoria Hospital.
The two 400-gallon tanks for the storage of water
is insufficient, especially as the well water is so
brackish ; the addition of a couple more tanks at
least is necessary.
The sanitation of the Home is well attended to by
the Board of Health.
June 2, 1913.) COLONIAL MEDICAL REPORTS.— BAHAMAS.
= —
RETURN or DisEASES AND DEatuHs IN 1910 at
New Providence, and the Alexandra Hospital, Bahamas.
GENERAL DISEASES.
$ 32
E EE GENERAL DisEASES— continued.
Alcoholi * (d) Tabes Mesenterica . -
A OSOE (e) Tuberculous Disease of Bones
Pr me se as Other Taberoulas Diseases
Be ‘bert Varicella .. «
riberi Whooping Cough
Bilharziosis . Yaws
Blackwater Fever | Yellow Fever A
Chicken-pox
Cholera
Choleraic Diarrhea. LOCAL DISEASES.
Congenital Malformation
Debility f Discases of the—
Delirium Tremens Cellular Tissue
Dengue .. Circulatory System ..
Diabetes Mellitus (a) Valvular Disease of Heart
Diabetes ae gon (b) Other Diseases ..
Diphtheria Digestive System—
Dysentery .. (a) Diarrhoea ws
Enteric Fever . (b) Hill Diarrhoa ..
a2 hep eg ss . (c) Hepatitis è
Febricula .. P Congestion of Liver
Filariasis .. om (d) Abscess of Liver
Gonorrhea s (e) Tropical Liver ..
Gout : vs (f) Jaundice, Catarrhal
Hydrophobia es e" Cirrhosis of Liver `
Influenza .. - vs ) Acute Yellow Amophy:
Kala Azar (i Sprue "
Leprosy
(a) N odular
(J) Other Diseases $e
Ear LE
Admis-
sions
UPPRDbER
LETETI
PloalllSalS! ll) lawl
Deaths
PLT ET Pele tt ttl mt aol TET TPT Phi tt lel lee
Total
Cases
Treated
ha SM I
Lleol lI Rol&Sll il lowlSSiakl ael ll III TI Ili Sl isë
(b) Anesthetic .. Eye sre T
(c) Mixed Generative System— .
Malarial Fever— Male Organs
(a) Intermittent Female Organs
Quotidian .. Lymphatic System
Tertian Mental Diseases
Quartan Nervous System
Irregular .. f Nose ..
Type undiagnosed Organs of Locomotion —
(b) Remittent .. . Respiratory System
(c) Pernicious .. : Skin— >
(d) Malarial Cachexia. . (a) Scabies
Malta Fever ^. (b) Ringworm ‘
Measles e Tinea Imbricata
Mumps è ) Favus ss
New Growths— .. (e) Eczema .. v
Non-malignant ( f) Other Diseases .
Malignant Urinary System
Old Age Injuries, General, Local—
Other Diseases a) Siriasis (Heatstroke) !
Pellagra .. (o) Sunstroke (Heat Prostration)
Plague (c) Other Injuries
Pyemia Parasites— T
Rachitis ‘ Ascaris lumbricoides ..
Rheumatic Fever Oxyuris vermicularis .
Rheumatism . Dochmius duodenalis, or Ankylostoma duo-
Rheumatoid Arthritis denale , . .
Scarlet Fever Filaria medinensis (Guinea worm)
Scurvy Tape-worm ` .
Septicemia vs Poisons—
Sleeping Sickness Snuke-bites
Sloughing Phagedena e Corrosive Acids
Small-pox .. os T ar Metallic Poisons
Syphilis "m T s Vegetable Alkaloids
(a) Primary .. Nature Unknown
(b) Secondary .. Other Poisons
(c) Tertiary Surgical Operations — ..
(d) Congenital . Amputations, Major ..
Tetanus Minor ..
Trypanosoma Fever Other Operations
Tubercle— Eye
(a) Cataract
(b) Iridectomy .. À
(c) Other Eye Operations
(a) Phthisis Pulmonalis Ut
b) Tuberculosis of Gandy es
(à Lupus A
ISl VB E H teda Ee REE T PEE PEL eel LEP Lee
I118IlagSalsllesllellitiielegITILEEI EIL ii allaellalstillesil!l!tilllllllco OR
Ili3lle88.Ilslleesllalllili-sis&8Illlltilllllallesllol-8SIlles!llliSil!l!llllzo sos
LEVEL NP TEL CPI
bp TTE dS T Eq yop T. 7
Ep be trsLTTEITA E I
68 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1913.
THE PRISON.
The daily average number of prisoners was 23°78
during the year.
The health of the prisoners remained good, and only
seven were admitted to the infirmary this year, com-
pared with twenty-one in the previous year. Quinine
has been administered to each prisoner regularly every
week, and there were only three cases of malaria
and attends all who come for medical aid, and each
year he finds the natives show greater appreciation of
his services: 1,002 patients received treatment and
twenty-three minor operations were performed.
A little over two years ago a dispensary, with a
small ward for three beds,was established at McCarthy
Island, some 150 miles up the river from Bathurst.
The medical work there is increasing yearly, and it
has been considered necessary to make further pro-
METEOROLOGICAL RETURN FOR THE YEAR.— BATHURST.
Temperatures
Min. on grass Shade max. Shade min. Ran ge Mean Rainfall in inches Secon secto
January 51 rr 93 E: 57 aaa 36 75:0 — eae East
February 53 . 101 - 62 e 39 86:5 — North
March ... 54 .. 100 w 62 ne 38 81:0 -- »
April 56 .. 104 TT 62 sa 42 83:0 = ”
May 60 im 91 - 64 27 T5 — ”
June 60 95 70 25 82-5 115 Variable
July... 64 93 70 23 81°5 11:98 a
August .. 60 93 62 31 775 16°60 $5
September 55 90 60 30 15:0 11:52 $5
October 60 92 79 22 81:0 2715 js
November 55 95 68 27 81:5 — East
December 47 93 62 31 T5 — ”
44:00
METEOROLOGICAL RETURN FOR THE YEAR.—McCartuy ISLAND.
Temperatures
Shade max. Shademin. Range Mean Rainfall in inches Gone E eid
January 101 ET 52 i 49 d 76:5 -— N.W.
February 105 TM 55 aa 50 us 80:0 — wi
March XT kai T gå ine 110 A 60 ; 50 TT 85:0 — $5
April Ae Y dis AT ot 111 w 63 48 87:0 — Sk
May ... ius tas abs Th ane 110 Se 61 49 85:5 — $
June... ads - b PE ii 108 Ni 69 39 88:5 2:88 Variable
July ... ein 102 s 68 ee 34 T 85:0 9:43 N.
August M 91 Y 68 X. 23 ome 79:5 10:72 $5
September ... 95 Y 68 "e 27 ins 81:5 9:86 $5
October D 95 MN 63 Vue 32 dys 79:0 2-20 T
November ... 98 T€ 55 Ur 43 sis 76:5 a Variable
December ... 99 ks 55 T 44 Ass 77:0 — $$
35:09
amongst the prisoners during the past twelve
months.
The sanitation of the prison is carefully attended
to, and the food and water supplies are of good quality
and sufficient.
THE PROTECTORATE.
During the eight months of the dry season, the
Protectorate Medical Officer travels from town to town
vision with the view of a resident medical officer
being stationed there. During the year a suitable
hospital of brick to accommodate two Europeans and
ten natives has been built. This will meet a long felt
want,and has given great satisfaction to the merchants,
who are obliged to maintain factories, with numerous
Europeans and native clerks, at points many miles
from Bathurst.
Sept. 15, 1913.|
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 69
Colonial Medical Reports.—No. 23.—Straits Settlements.
MEDICAL REPORT FOR THE YEAR 1911.
By W. GILMORE ELLIS,
Principal Civil Medical Officer, S.S.
THE actual population according to the census
taken on March 10, 1911, was 714,069, an increase
on the census figures of 1901 of 24°78 per cent.
It should, however, be borne in mind that Labuan
was not part of the Colony in 1901 and the census
of that year did not include Labuan as it did in
1911. This but makes a small difference so far as
the rates of increase are concerned owing to the
smallness of the additional population.
On comparing the estimated population for the
year with the actual census figures it was found
that there was an under-estimate of 49,000. This
shows that in a population such as that of the
Colony the ordinary system of computation in
vogue for finding the population of inter-censal
years is unreliable. In the circumstances the ques-
tion arises as to the advantage of having a rough
quinquennial census taken without the many
abstruse statements which form a special feature
of the decennial census. Such an additional census
is the more advisable on account of the ever-
changing populace of Singapore town, with its large
immigration and emigration of adult males not only
by large steamships but also by small native craft
and by rail. i
The number of births registered throughout the
Settlements during 1911 was 18,069, as against
18,012 in 1910. This gives a ratio per mille of
population of 25°38, as against 27°55 in 1910.
The death-rate for 1911 was 46°46 per mille, as
compared with 41°88 in 1910 and 37°40 in 1909.
The death-rate for the last ten years gives an aver-
age rate of 40°74 per mille of population. The
death-rate for 1911 cannot but be regarded as ex-
tremely high, more particularly as the taking of the
census in this year precludes any possibility of
error. A great variation in the monthly death-rates
was noticeable. February showed the lowest (31
per mille), June the highest (87 per mille). In this
latter month but four short of 4,000 deaths were
registered in the Settlements. The weekly rate in
Singapore reached 95 per mille for the week ending
June 10. The rate, as is usual, began to rise in
April, was at its highest in June, July showed the
beginning of the fall which continued throughout
August. "There was a second sharp rise in October
which was of short duration. Malaria, for many
years past, has headed the list as the cause of the
greatest number of deaths. During the epidemic in
April, May, June and July, deaths from phthisis,
dysentery and beriberi also showed a marked in-
erease, rising and falling week by week, nearly
similarly. I cannot explain this.
The weekly average number of deaths from
malaria from January 1 to April 30 was in Singa-
pore 41, Penang 17, Malacca 21. The maximum
numbers in any one week in the year was, Singa-
pore 127 for the week ending June 10, 1911; Penang
43 for the week ending July 1, 1911; Malacca 74
for the week ending June 10, 1911.
The weekly average death-rate from all causes
from January 1 to April 30 was in Singapore 38°47,
Penang 34°59, Malacca 53°44. The maximum
weekly rate was Singapore 94°54 for the week end-
ing June 10, 1911; Penang 61°58 for the week
ending July 22, 1911; Malacca 87:04 for the week
ending June 10, 1911.
The influx of sick labourers from outside the
Colony is well known as a contributory factor in
swelling our death-rate. In addition to the malaria
outbreak we have had small-pox practically through-
out the year in all Settlements. Cholera also broke
out in Singapore and Penang, but these epidemics
were in no sense severe. The diseases chiefly affect-
ing our death-rate are dealt with below in detail.
Of the number of deaths registered in 1911,
5,242 deaths were among infants under one year
of age, representing a percentage of 15°85 of the
total, against 18°47 in 1910 and 19:7 in 1909. The
infantile death-rate per mille for 1911, after exclud-
ing the births of children born outside the Colony,
was 270°47, against 268°93 in 1910 and 263°67 in
1909. Three thousand six hundred and thirty-five
deaths were returned as being due to convulsions,
this heading probably covering many different
causes.
In the hope of lowering this -large death-rate
among infants, female inspectors have been attached
to the Municipal Health Department and visit
houses to advise mothers concerning the care of
infants. A daily list of births is sent from the
Registrar of Births’ Office for their information.
With a similar hope it is proposed to license native
midwives, when a sufficient number have qualified,
under a special Ordinance to be framed for the pur-
pose to the exclusion of the present unlicensed and
untrained practitioners. Under the scheme for
midwives referred to in my report for last year, 6
women were in training during the year, of whom
4 obtained certificates of competency.
Plague.—Of the 35 cases reported all occurred in
Singapore Island, 83 being within municipal limits;
of these 82 ended fatally.
Cholera.—In Singapore cholera broke out in
March, reached its highest in October and had
entirely disappeared by the end of the year. Total
cases 296, of which 270 ended fatally.
In Penang there were 64 cases, of these 55 ended
10 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
[Sept. 15, 1913.
fatally. Fifty-seven of these cases occurred on the
west side of the island, chiefly inhabited by fisher-
men. The infection evidently came from Kedah
through these fishermen who have dealings with
that district. ` À
In Province Wellesley there were 19 cases-with
6 deaths. The disease was evidently imported from
Penang.
Small-poz.—There were outbreaks of small-pox in
all the three Settlements, Malacca showing the
largest number of cases, viz,, 558, and Province
Wellesley next, 357 out of a total of 1,281 cases.
In Singapore the cases increased in prevalence up
to June with a decrease in the second half-year. In
all 241 cases occurred in Singapore with 98 deaths,
against 414 with 152 deaths in 1910. In Penan
the outbreak was a continuance from 1910. Total
109 cases with 36 deaths, as against 894 with 239
deaths in 1910. In Malacca the disease occurred
in various districts at different times. Alor Gajah
District was most affected. School teachers were
taught how to vaccinate. A fee of 20 cents was
paid to them for each successful vaccination. The
results were satisfactory, one feature being that
the natives who hitherto evaded vaccination wil-
lingly came forward. to. be operated on by fellow-
countrymen. In the whole of Malacca 558 cases
with 173 deaths were reported.
Diphtheria.—Five cases were treated in the hos-
pitals of the Colony with one death, compared with
8 cases and 3 deaths in 1910. In all 14 cases were
notified to the Health Department, compared with
20 in 1910. The total deaths from this cause were
7. All the cases reported occurred in Singapore.
Enteric Fever.—One hundred and seventy-five
eases were admitted to the hospitals for treatment,
11 remained from the previous year, giving a total
treated of 186. Of these 102 terminated fatally.
There were 113 cases with 47 deaths in 1910. . The
reason for this exceptionally high mortality rate is
that the large majority of cases are brought in only
in the later stages of the disease and when very
dangerously ill, hopelessly so fréquently.
Beriberi.—The deaths from beriberi were 2,056,
as compared with 1,737 in 1910. The use of cured
rice in the different institutions of the Colony has
lessened the death-rate from this cause so. far as
those treated in hospitals are concerned. Although
the actual cause of the disease still awaits elucida-
tion, there can be little doubt that the consumption
of over-milled rice is a factor in its incidence. This
subject is being carefully watched and it may be
possible in the future to induce mill owners to some-
what vary their process of milling. The disease is
on the increase in Malacca, where the number of
deaths from this cause was 443 for 1911, against
267 in 1910 and 219 in 1909. This rise of beriberi
in ‘Malacca coincides with the diminishing cultiva-
tion of padi, natives there. finding it more profitable
to work for rubber-planters or to cultivate rubber
themselves. At the Beriberi Hospital at Pasir
Panjang, Singapore, of 521 cases treated for this
disease, but three deaths out of 16 are attributed
to beriberi.
Venereal Diseases.—The admissions to all hos-
pitals in 1911 were 2,591 with 40 deaths, as com-
pared with 2,299 with 42 deaths in 1910. These
numbers represent but a small proportion of those
admitted to hospitals with venereal diseases, a large
number being returned under other headings.
Several cases of syphilis were treated with salvarsan
both intravenously and intra-muscularly; all did
well. Lengthy observation of these patients was
impracticable owing to the impossibility of inducing
Chinese coolies, when once recovered, to return for
observation. Wassermann reactions were performed
by the Pathological Department at the end of the
year for the first time and should prove of material
assistance in diagnosis.
Phthisis.—Deaths registered from this cause were
2,907, against 2,571 for 1910 and 2,659 in .1909.
Improvement in the death-rate from this disease is
hoped to be. shown in a few years, when time is
given for the sanitary conditions of the bigger towns
to improve by the gradual construction of back-lanes,
improved drainage, more cubic space, and less over-
crowding, more air and sunlight, &c., in tenement
dwellings, matters now being taken in hand by the
municipalities.
Dysentery.—The deaths from this cause totalled
2,035, the figures for 1910 being 1,892 and for
1909 1,241. A large addition to the water supply
of Singapore will soon be completed, improvement
to the water supply of other districts is under con-
sideration, and it is trusted that progress on these
lines may tend to lessen the incidence of the disease.
The number of cases treated in the hospitals show:
Remaining, 1910, 62; admitted, 1911, 2,206; total,
2,268; but 4 short of 1,000 of these cases ended
fatally, patients so frequently only coming to hos-
pital for treatment when jn the last stage of their
disease. In 1910 the total treated. was 1,643 with
689 deaths. It is astonishing that so many of these
patients remain so long alive with but remnants of
mucosa in the lower bowel.
Malaria.—There was a widespread and exceptional
increase of malaria throughout all Settlements. An
inerease of this disease has been steady and pro-
gressive for several years as shown by the hospital
admissions.
An epidemie of the disease commenced towards
the end of April, was at its highest in May and
June, and steadily fell throughout July and August
to our normal rate, a rate though that must be
considered far too high. About these same months
in Penang and Malacca (not so seriously in the
former) similar conditions prevailed. In Malacca
places where malaria was formerly little known had
several cases of locally contracted disease.
The death-rate from this cause also shows cor-
responding inerease, a conspicuous feature being the
number of cases of a malignant type. The deaths
from malaria in all Settlements, including Labuan,
were 5,821, compared with 3,300 in 1910 and 2,589
in 1909.
The total admissions to hospitals were 11,815 with
1,014 deaths, as against 7,483 with 690 deaths in
1910 and 5,083 with 431 deaths in 1909.
Sept. 15, 1913.)
Out of 7,173 children examined for enlarged
spleen, 854, or nearly 12 per cent., were found
affected.
Works are being carried out in this connection.
The Municipal Ordinance is being revised in toto
&nd sections are to be added dealing with the breed-
ing of mosquitoes, prevention of malaria, &c. In
the middle of the year a Malaria Committee was
formed in Singapore and a preliminary sum of
$20,000 was granted for expenditure upon malaria
prevention. A pathologist is being procured from
England to relieve Dr. Finlayson, the Government
.Pathologist, so that the latter officer may be
seconded for special duty in this connection, and he
will begin work almost immediately with the view
of formulating some considered scheme for the
stamping out of all anopheline breeding-places with-
in Singapore municipal limits. A start has already
been made with one of the worst districts in Singa-
pore; later other portions of the Settlements are to
be taken in hand. Throughout the year minor
works have been undertaken by the Health Depart-
ment of all municipalities as well as the clearing of
drains and oiling of pools. In Singapore and
Malacca all the sanitary inspectors had petty anti-
mosquito works ineluded in their daily rounds. In
Penang 68 men (daily average) were specially em-
ployed on such work. Four thousand nine hundred
grains of quinine were distributed gratis in Singa-
pore by the municipality. Five hundred grains
were distributed in the schools, an uncertain quan-
tity to coolies and others in Penang and about
44 lb. were distributed in Malacca. There is
no doubt that one of the causes of this
large increase in the incidence of malaria is
the opening up and clearing of new estates in all
parts of the Peninsula with the consequent large
influx of coolies whose tendency when ill or unfit for
work is to flock into the towns for treatment,
bringing the means of disseminating the disease
with them.
In Labuan an inspector was appointed by the
Sanitary Board and improvement in the general
condition of the town is already reported. The
Estate Labourers (Protection of Health) Ordinance
was passed during the year and a special medical
officer was asked for as a preliminary step. I am
of opinion, however, that one medical man will not
be able to properly supervise the large number of
estates in the three Settlements and additional men
will no doubt be needed later. This special staff,
with a few subordinate officers, will form the nucleus
of a Health Department so that eventually an effi-
cient body should exist to deal not only with estates
but with village sanitation and all infectious cases
occurring outside municipal limits. A considerable
amount of work has been done by the municipali-
ties. In Singapore the building of a new Infectious
Disease Hospital was started and should be com-
pleted next year. A new sewage scheme was
adopted for Singapore and will be taken in hand
shortly. An up-to-date incinerator at Alexandra
Road has been completed. The Kallang reservoir
water supply was made available and is an addition
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 71
of 24 to 34 million gallons per day to the town
supply. There was further progress with the '' back-
lanes " and ''improvement schemes " and lands
are being acquired in several quarters of the town.
The Kampong Kapur Scheme was dealt with, low-
lying land being filled up and streets and back-lanes
laid out. Sultan Ali's estate was also dealt with by
improving the buildings and demolishing insanitary
areas. The Rochore Canal is to be improved at the
joint eost of the Government and municipality.
Three dairy farms were started during the year
under European management.
In Penang the municipality employed a regular
anti-malaria gang of coolies throughout the year. In
several localities insanitary houses were demolished.
Swampy lands were filled up in places and new
streets formed. Many back-lanes were completed
and others arranged for. Additional land for the
catehment area of the water supply is being gradu-
ally acquired.
A Medical Mission was opened in Malacca during
the year and is in charge of two lady doctors. Good
work has been done by this mission, especially
amongst Malay females, who ordinarily reject
Western methods of treatment and never come to
our hospitals.
Ankylostomiasis.—There were in all 586 cases
admitted to hospitals which with the 33 remaining
give a total treated of 619. Among these there were
150 deaths. There were doubtless additional cases
in the estate hospitals, but no accurate details of
these can be obtained. The largest number of
admissions (371) were returned by the Malacca
hospitals. Under the Estate Labourers Ordinance
type latrines are now being insisted upon for all
estates.
The first class wards of the General Hospital,
Singapore, were frequently full and on several
occasions patients had to be treated in second class
wards awaiting accommodation. The native wards
were often overcrowded so much so in the middle
of the year that over 100 patients had to be trans-
ferred to the Beriberi Hospital, Pasir Panjang,
where a ward was placed at their disposal. "These
native wards are of antiquated type and the erection
of a more up-to-date structure with suitable
operating theatre has been proposed and submitted
to Government. An electric light and fan installa-
tion for Penang General Hospital was completed
early in the year. A similar installation for the
General Hospital, Singapore, will be completed in
1912.
The admissions to the Tan Tock Seng's Hospital
increase yearly, the opening of the Chinese Free
Hospital, with some 230 beds, not having
diminished the rate. The total treated at Tan
Tock Seng’s Hospital was in 1909, 8,858; 1910,
9,978; 1911, 13,398.
A special blind ward was erected during the year,
the building being the gift of Mr. Ong Kim Wee,
of Malacca. This ward has accommodation for fifty
and only those ineurably blind are admitted.
In Penang the admissions to the District (Pauper)
Hospital rose from 3,435 to 3,886. Electric light-
72 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS. [Sept. 15, 1913.
ing was extended to the female Distriet Hospital,
a much needed improvement. The Honorary
Ophthalmie Surgeon, Dr. Kirk, was in charge of
the special eye ward, where 52 out-patients were
treated in addition to the in-patients, who num-
bered 140.
The total admissions to the Malacca Hospitals
were 8,559, compared with 4,618 in 1910 and 2,833
in 1909. The existent hospital staff and accommo-
dation in this Settlement will be insufficient if the
large increase of patients just noted persists, but it
is probable that the exceptionally unhealthy year
is the cause of the influx and that a quick return
to the normal rate is to be expected. The staff was
increased permanently during the year by two
dressers and six servants. The rebuilding of
Jasin Hospital upon a healthier site is to be under-
taken.
The total treated and deaths in the hospitals of
the Colony for some of the more important diseases
are shown in the subjoined table :—
Total treated Deaths
Malaria fever 12,029 1,014
Dysentery ... 2,968 $3 996
Diarrhea ... 1,146 ET 832
Beriberi 2,152 zal 242
Phthisis TE m adr 1,095 T 576
Enteric ... Ee is ase 186 T 102
Ulcers Y 4,359 $i 8
Venereal diseases > ots 2,789 T 40
Ankylostomiasis ... T RT. 619 ve 150
Lunatic Asylum.—The total number treated was
558 patients, 26 less than in 1910. The recovery
rate based on the admissions was 36°81 per cent.,
compared with 40'79 per cent. in the preceding
year. The death-rate was 24°30 per cent. on the
average daily number resident. Cholera for the
second year in succession broke out, on this occa-
sion in the wards at Pasir Panjang, and the patients,
including those from the adjoining beriberi wards,
were sent to the Quarantine Camp on St. John's
Island.
Beriberi Hospital, Pasir Panjang.—One hundred
and fourteen patients remained over from 1910, 407
were admitted during the year, making a total
treated of 521, all natives. The total treated in
1910 was 487. Some of the wards in this hospital
were used as overflow wards for patients from the
General Hospital during June, July, and August.
Of the sixteen deaths which occurred in this hospital
only three were certified as due to beriberi. It is
gratifying to note that the marked usefulness of
this hospital continues. The change of diet from
over milled to parboiled rice is doubtless the main
factor, but the daily sea bathing, massage and
exercise, insisted upon in nearly all cases, appears
to largely benefit the patient and quicken the rate
of recovery.
Police Force.—-In Singapore there were 5,800
attendances of out-patients, compared with 5,796 in
1910 and 3,924 in 1909. Of the patients 773 were
sent to the General Hospital for treatment, 25
being Europeans and 748 natives. The force
suffered somewhat severely from malarial fever.
Of 189 recruits 147 were passed as fit for serviee
and 42 rejected.
Estates.—The number of estates and conse-
quently the number of labourers have considerably
increased. During the year two legislative
measures were passed dealing with estates, the
Estate Labourers (Protection of Health) Ordinance
and the Supervision of Labour Ordinance.
There are as yet only 27 hospitals and dispensaries
on estates. The admissions and attendances at
these hospitals were ascertained to be about 27,478.
A number of type plans for coolie lines, latrines and
wells were distributed during the year.
Outdoor Dispensaries.—Twenty-eight thousand
seven hundred and eighty-two patients were treated
at the eleven outdoor dispensaries of the Colony,
against 29,764 in 1910. A change from the old
Outdoor Dispensary, Singapore, to the new build-
ing in North Canal Road was made on June 17;
a decrease in the number of patients attending
occurred in consequence, as was to be expected. A
second outdoor dispensary for Singapore is to be
built, and will be commenced next year.
Vaccination.—Seventy-four thousand five hun-
dred and twenty-five vaccinations were performed
during the year, compared with 20,990 in 1910.
This large increase was due to the special vaccina-
tion called for by the presence of small-pox which,
as stated before, was prevalent in the three Settle-
ments. Some of the ‘‘ Gurus” (Native school-
masters) in Malacca were instructed in vaccinating
and did good work; they were paid 20 cents for
each successful ease. These men did 8,241 vaccina-
tions, of which 5,522 were successful, and some of
the natives otherwise un-get-at-able were thus dealt
with. The Vaccination Ordinance needs amend-
ment, as it does not work with sufficient thorough-
ness. Early attention to this matter is to be given.
It is also found difficult to get in correct returns;
undoubtedly many vaccinations are never regis-
tered. During this, as in past years, a circular
was sent to all private practitioners requesting
particulars of their vaccination work, but with
few exceptions no returns have been made by
them.
Quarantine.—The number of passengers and crew
examined on arrival in Singapore was 427,409 and
110,882 respectively, against 364,720 and 108,148
in 1910. The disinfecting launch Hygeia was in
use throughout the year. During the year a regula-
tion (Government Notification No. 1 of January 6,
1911) was passed fixing a scale of charges for the
disinfection of ships, the minimum charge being
$25. The collections under this notification
amounted to $5,017.50. The quarantine station at
St. John’s Island was occupied throughout the year.
A total number of 53,961 contacts were landed,
compared with 85,062 in the previous year. The
maximum number on any one day was 4,892, taxing
the accommodation to its utmost. A new inspection
shed was added during the year, as also a new
sulphur generator.
Oct. 1, 1913.]
Colonial Medical Reporis.—No. 23.—8traits Settlements.—
(continued).
In Penang.—Two hundred and fifteen thousand
eight hundred and fifteen passengers and 61,336
crew were examined on arrival during the year, as
against 168,216 and 49,751 in 1910, these large
inereases being mostly due to additional immi-
gration from India, several extra vessels having
been put on the run by shipping agents. The new
quarantine station at Pulau Jerejak was taken over
and oecupied on April 6. The old quarantine
station was also in occupation throughout the year
owing to the unusually large number of immigrant
coolies, combined with the occurrence of several
outbreaks of cholera, amongst those landed. Ex-
tensive structural alterations, especially to latrines,
have since been undertaken to suit the class of
person usually landed. 134,957 passengers were
detained for observation and treatment, against
71,876 in 1910. The largest number on the island
on any one day was 11,738 in the old and new
combined stations; with better facilities now being
carried out for isolating contacts in smaller batches,
it is to be hoped such a number will never be
reached again.
Government Analyst's Department.—The De-
partment in Singapore was short-handed during
nine months of the year on account of officers on
leave; a considerable amount of revenue-producing
work had to be refused in consequence.
Medical | School.—Twenty-two new students
entered the school, 16 of whom had passed the
Senior Cambridge local examination. "Ten students
passed out of the school as Licentiates, making a
total of 28 men qualified sinee the opening of the
sehool. At the end of the year 78 students were
on the books as studying for the L.M.S., and
24 taking the prescribed course for Hospital assist-
ants. The new library and pathologieal museum
with offices, the gift of the late Mr. Tan Teck
Guan, referred to in a previous report, was com-
pleted and taken over in June; a brass tablet has
been affixed to the building in his memory. The
standard of teaching is now on a higher scale than
when the school was established, and with the
addition of a second assistant to the Principal, to
be paid for from the King Edward VII Memorial
Fund and a surgical lecturer, both shortly to be
appointed, one hopes that improved results will
gradually ensue.
Pathological Department.—Two thousand three
hundred and thirty-eight autopsies were performed
during the year as compared with 1,748 in 1910.
On August 19 Dr. Finlayson paid a visit to Kelantan
to inquire into a disease called by the natives
‘“ Kudis Sabuter," which, it was supposed, had a
causal connection with plague. He returned on the
31st idem.
Medical Department, Labuan.—The death and
birth-rates were 27:07 and 28°87 respectively.
The population at the census 1911 was found to
be 6,545, against an estimated population of 8,199
in 1910. There has been a considerable decrease
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 73
owing to the closing down of the coal mines early
in the year. The chief causes of death were fever
(97), tuberculosis (23), debility and old age (16),
beriberi (10) and dysentery (6). No epidemic
disease occurred during the year. Malaria is still
prevalent, 118 out of 276 admissions to the Civil
Hospital being for this disease. Nine hundred and
fifteen out-patients were attended to during the
year as against 1,180 in 1910. Two hundred and
ninety-six patients were treated in hospital as
against 338 in 1910 and 307 in 1909. Seven
patients were Europeans.
Miscellaneous.—Forty-three medical practitioners
were registered, making a total of 252 names
standing on the Register. Of these, 184 are in the
service of the Straits or Federated Malay States
Governments.
There were seven mectings of the Hospital Board
held in Singapore during the year. The Hospital
charges to wives and children of Government
Medical Officers have been reduced by Government
and are now the same as the rates for officers
themselves. A Commission was appointed to
inquire into the working of the Quarantine and
Prevention of Diseases Ordinance in the Settle-
ment of Singapore and commenced sittings on
September 11.
Singapore.
GENERAL HOSPITAL.
Report BY Dr. W. H. Fry, SENIOR MEDICAL
OFFICER-IN-CHARGE.
An additional six bedrooms were provided for
nurse probationers with a bath and lavatory for
same.
Part of the swampy ground at the back of the
European block was drained by the Sepoy Lines
Golf Club to the great benefit of the hospital.
Twenty mosquito nets on wire frames were pro-
vided in the first native ward during the year.
The noises in the vicinity of the hospital still
continue, these being most noticeable round the
maternity block, sisters’ quarters and first-class
wards, and arise from the traffic on the road passing
between these buildings. I consider this road
should be closed by a gate; the constant shouting
of hawkers and the passage of 'rikishas, motors
and carts interferes considerably with the sleep
of the nurses engaged on night duty, and is a
source of danger and annoyance to patients in a
critical condition. Previous attempts to close this
road have failed on account of legal difficulties.
It is to be regretted that the majority of house
surgeons arrive with no knowledge of tropical
diseases; this, combined with unavoidable ignorance
of native languages, forms a serious hindrance to
their work and sometimes militates against the
satisfactory treatment of patients, time which might
profitably be spent in acquiring the latter being
devoted to learning the former.
There is an increasing amount of work in this
74 -COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
hospital, and a Supernumerary Medical Officer has
been detailed here for duty when available. A
third house surgeon is being asked for.
During the year no less than seven sisters and
six nurse probationers were admitted to hospital,
exclusive of those whose temporary illness was not
sufficiently serious to justify their being treated as
in-patients; five of the above admissions were due
to malaria.
As the total nursing staff is 10 sisters and 18
probationers this represents a very high percentage
of sickness, particularly when it is remembered
that all the staff are selected for physical fitness
and that none of the sisters have been over two
years in the Colony.
It is unfortunate that not a single Chinese
dresser is available for this hospital; the great bulk
of the patients (excluding police) are of Chinese
nationality, the dressers without exception being
alien in language, ideas, sympathy and nationality
to the majority of the patients they are required to
attend. Attempt is being made to obtain and train
a few.
The senior students of the Medical School have
been of considerable assistance, under the direction
of the Principal, in the microscopic diagnosis of
malarial fevers and other minor laboratory work.
Constant changes took place among the servants
of the hospital, fifty-six new servants being taken
on during the year. The work, particularly in the
native wards, is exacting and the hours often long ;
many servants merely use the hospital as a training
ground.
A large number of the servants were attacked
with malarial fever during the year, and 43 were
admitted to hospital chiefly for this disease. Pre-
liminary surveys were undertaken towards the end
of the year with a view to diminishing the swampy
ground in the vicinity of the hospital by drainage
and reclamation ; one large swamp has been filled in.
During the second and third quarters of the year,
when malaria was most prevalent, quinine mixture
was served out daily to the menial staff, who were
required to drink it in the presence of the steward
at the morning roll call.
One death oceurred in hospital among the hospital
ward boys from Bright's disease.
The use of an efficient Róntgen rays apparatus is
badly needed. The existing instrument, which has
been in use for several years, is praetieally useless
for diagnostic purposes, while no provision is avail-
able for photographie work.
First AND SECOND Chass Warps.
The first class wards haye been frequently over-
crowded during the year, such overflow patients,
while awaiting their turn for admission, having to
be treated in the ** Seamen's ” wards.
The chief diseuses for which patients sought ad-
mission to the first and second class wards were as
under, a comparison with the past four years being
shown. Patients in these wards, it should be said,
include Europeans and better class natives :—
(Oct. 1, 1913.
3011 1910 1900 1908 1907
Malarialfever... 289 ... 211 ... 9Ul .. lil .. 78
Venereal disease 67 ... 80 ... 55 .. GO .. 063
Injuries i (66 uu 4B ou 44... 55 .. 45
Dysentery sie: OE Ser 038 BO casa, 27 va 94
Alcoholism ... 14 .., Tia. B "19 ap 28!
Enteric fever ... 14 ... Ü. x. 4A. ne 22-5 23
Phthisis vig LB aay, X5 qo Ll we 14. 4. M
Appendicitis ... 16 ... Be our snb ausos SAAN uus c
Liver abscess ... 6 .. Du aa, 909 s dos. oi:
Other diseases of interest were: Blackwater fever,
3, as compared with one case in 1910—two of these
eases were Europeans and 1 Chinese, all contracted
the disease in Johore, and all had had several pre-
vious attacks of malaria; burns, 6; beriberi, 7;
cardiac diseases, 11, with 2 deaths; sprue, 2;
hepatitis, 7, with 2 deaths; kidney diseases, 9, with
2 deaths; fractured base of skull, 3. No deaths
where not so stated.
Dengue elaimed 8 admissions in 1911 as compared
with 12 in 1910.
The chief causes of death were: Enteric fever,
5; phthisis, 3; dysentery, 3; sub-tertian malaria,
tetanus, alcoholism, hepatitis, peritonitis, liver
abscess, acute miliary tuberculosis and nephritis,
2 each.
The nationalities of those admitted to the first
and second class wards included 521 Europeans, 95
Tamils and other Indians, 69 Eurasians, 33
Japanese, 31 Chinese, 11 Jews and Eurasian Jews,
and 7 Malays.
Operatious in the first and second class wards
numbered 75 under general anesthesia, numerous
minor operations being performed under local
anesthetics.
The chief operations comprised: Liver abscess
with excision of ribs, 6; operations on rectum, 9;
amputations, 3; removal of glands, 6; appen-
dicectomy, 2; and ligature of thyroid, tracheotomy,
ruptured urethra, laparotomy, radical cure of
hernia and mastoid operation, 1 each.
Malarial fever admissions show a higher number
than in any previous year, the increase during the
past years being continuous and persistent. A
great proportion of these were of the sub-tertian
variety.
Several of the patients admitted to the first class
wards with malaria were engaged in planting in
Johore, Negri Sembilan and Malacca.
Venereal disease admissions are higher than
during past years, and more than double the number
admitted in 1910. The numbers shown, moreover,
represent but a small proportion of those admitted
with this complaint, many cases being returned
under rheumatism, arthritis and other diseases of
a venereal origin.
A few patients were treated with salvarsan in-
jection, some intramuscularly, others intravenously.
All did well, though lengthy observation of the
patients was impracticable owing to their leaving
hospital shortly after the injection.
Wassermann reactions were performed by the
Pathological Department at the end of the year for
the first time, and should prove of material assist-
ance in the diagnosis of venereal disease.
Oct. 1, 1918.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
75
Return oF Diseases AND Deatus IN 1911 AT THE FOLLOWING INSTITUTIONS :—
General Hospital; Prison, St. John's Island; Tan Tock Seng's Hospital;
Beriberi and Lock Hospitals; and Lunatic Asylum, Singapore, Straits Settlements.
GENERAL DISEASES.
Alcoholism
Anemia
Anthrax
Beriberi
Bilbarziosis T
Blackwater Fever
Chicken-pox
Cholera
Choleraic Diarrhoea .
Congenital Malformation
Debility : *
Deliriuzn Tremens
Dengue ..
Diabetes Mellitus.
Diabetes Tampidus
Diphtheria .
Dysentery ..
Entero Fever
Rrysipelas:,
ebricula .
Filariasis ..
Gonorrhea
Gout $
Hydrophobia
Influenza ..
Kala Azar..
Leprosy ..
(a) Nodular
(b) Anesthetic ..
(c) Mixed
Malarial Fever—
(a) Intermittent
Quotidian ..
Tertian
Quartan
Irregular ..
Type undiagnosed
(b) Remittent ..
(c) Pernicious ..
(d) Malarial Cachexia..
Malta Fever x
Measles
Mumps ; Ss
New Growths— ..
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra ..
Plague
Pysemia
Rachitis í
Rheumatic Fever
Rheumatism ‘
Rheumatoid Arthritis
Scarlet Fever
Scurvy
Septicæmia ae
Sleeping Sickness
Sloughing Phagedena .
Small-pox .. .
Syphilis
(a) Primary
(b) Secondary ..
(c) Tertiary
(d) Congenital .
Tetanus .
Trypanosome Fever
Tubercle—
(a) Phthisis Pulmonalis
(0) Tuberculosis of Glands 2s
(c) Lupus
Admis-
T
aol |I Zel] && sions
eo
122
= Deaths
lee lI IIS! e181 Se
or
oo
md.
co |
LIStr Srl IRI T I
mn
-1
t2
PisllollPllaelaill||iealSanul tll) 18!
139
GENERAL DisEasEs— continued.
(d) Tabes Mesenterica
(e) Tubereulous Disease of Bones ..
Other Tubercular Diseases
Varicella $
Whooping Cough
Yaws ; E
Yellow Fever
LOCAL DISEASES.
Diseases of the —
Cellular Tissue
Circulatory System
(a) Valvular Disease of Heart
(b) Other Diseases ..
Digestive System —
(a) Diarrhoea ne
(b) Hill Diarrhea ..
(c) Hepatitis :
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver ..
(f) Jaundice, Catarrhal
g Cirrhosis of Liver
) Acute Yellow BOER:
(i) Sprue
(j) Other Diseases ..
Ear
Eye às es
Generative Sy stem— ..
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervcus System
Nose .. ;
Organs of Locomotion
Respiratory System
kin— . .
a) Scabies
b) Ringworm v^
(c) Tinea Imbricata
(d) Favus .
(e) Eczema .. T
( f) Other Diseases ..
Urinary System :
Injuries, General, Local—
(a) Siriasis (Heatstroke)
(b) Sunstroke (Heat Prostration)
(c) Other Injuries
Parasites— ne
Ascaris lumbricoides AG
Oxyuris vermicularis .
Dochmius duodenalis, c or Ankylostoma duo-
denale
Filaria medinensis (Guinea worm) |
Tape-worm
Poisons—
Snuke-bites
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids
Nature Unknown
Other Poisons
Surgical Operations —
Amputations, Major
Minor .
Other Operations
Eye ..
(a) Cataract.
(b) Iridectomy ..
(c) Other Eye Operations
Admis-
sions
loll 111
Br ey eben ee Piet LI
Sul eElel ol RSI bach prp "estes
m
pl ZSsseal// a4!
LCLETEEL TE EIE EF al? & IIZlil8Zolllliiğ
Quarantine Camp; Leper,
874
»| Sool 8128
-
e
to
Sol
IILLĜILIIIIS]l æg I1È!1]
m
[e
76 -COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
(Oct. 1, 1913.
Dysentery -and appendicitis
increase over previous years.
The admissions for phthisis remain fairly con-
stant. :
show a marked
NATIVE WARDS,
LI
These wards were greatly overcrowded during the
months of April, May, June and July. The
maximum number on any one day was 233 on
June 13, the full number of beds available in the
general ward being 160 without overcrowding.
Owing to this overcrowding 147 cases of various
diseases in convalescent stages were at different
times transferred to the Beriberi Hospital, Pasir
Panjang.
The chief diseases treated with*a comparison of
former yeurs are as under (the numbers including
all native ward patients, whether police or other-
wise):—
1911 1910 1909 1903 1907
Malarial fever 1,616 ... 1,117 .. 736 ... 858 .. 619
Injuries .. 805 ,.. 889... 768 ... 80) ... 448
Venerealdisease ... 278... 371 ... 246 ... 284 ... 215
Dysentery ... 4. — 149 .. 119... 180 ... 158 ... 128
Enteric fever Sis 76 ... 42 ... 69 ... 101 ... 145
Beriberi ,.. € 68 ... 9)... 80... 126... 68
Tuberculosis SS 48 .., 86:55; 108.4... 91 4. 70
Pneumonia "T 83 ... — ... 54... 98 .. 929
Cholera as ss 13 ... A ma Da Boas CO
Plague ras rn T e a (2b ae oem
Small-pox ... $e 2... y Soe lence “ages OS
Other cases included heart disease, 30, with 11
deaths; Bright’s disease, 20, with 2 deaths; anky-
lostomiasis, 23, with 3 deaths ;,meningitis, 11, with
8 deaths; myelitis, 2, both fatal; fractured base
of skull, 10, with 6 deaths; ruptured spleen, 7, all
fatal; liver abscess, 5, with 8 deaths; cut throat, 3,
with no deaths; ruptured bladder, 2, with 1 death;
and hare lip, 1.
The chief causes of death were: Malaria, 111;
injuries, 42; enteric, 42; dysentery, 66; pneumonia,
20; beriberi, 28; phthisis, 24; peritonitis, 13;
broncho-pneumonia, 12; empyema, 8; tetanus, 7;
and cholera, 6.
As regards malarial fever, it will be noticed from
the above table that the increase in the number of
cases has been steady and progressive. In 1906 the
number of patients treated was 401, and in 1905,
369.
This disease has considerably swollen the number
of deaths during the year, and frequently caused
serious overcrowding of the wards from the number
of cases admitted. Of the total number of deaths
in the native wards 23 per cent. were caused by
malaria, compared with a percentage of 11:20 from
this disease last year.
It has been obvious also from the autopsies per-
formed that a large number of those dying from
other complaints had had their constitutions en-
feebled and health wrecked by previous or existing
malarial fever.
From records kept during such periods as malaria
was most prevalent, it was found that very few of
the admissions for this year were those of persons
residing outside municipal limits.
In all wards blood films were taken on admission
of all suspected malarial fever cases, a feature of
the microscopic examination of the blood of these
patients being the large number in which sub-tertian
or malignant parasites were found, these exceeding
ull other varieties. :
lt has been a mutter of general comment that
the number of mosquitoes in the vicinity of the
hospital has greatly exceeded the numbers met
with in previous years. This was particularly
noticed during the second and third quarters of the
year.
To all natives, irrespective of race, parboiled rice
only was issued, save in a few rare instances, when
Siam rice was supplied as an extra to non-beriberi
patients. Fs
NATIVE POLICE.
Seven hundred and forty-eight police were
admitted, as compared with 648 in 1910 and 529 in
1909.
The chief diseases treated were; Malarial fever,
venereal disease, no disease discoverable and malin-
gering, ulcers and boot-bite, bronchitis, dysentery,
synovitis, conjunctivitis, phthisis.
Eight deaths occurred among the police:
Malaria, 4; dysentery, 2; and anæmia and perni-
cious anæmia, 1 each.
The admissions for malarial fever were largely
in excess of previous years, 219 being admitted in
1910, and 193 in. 1909. *
The chief nationalities of those admitted were
Sikhs, 297; Tamils and other Indians, 225; Malays,
164; and Chinese, 62.
MATERNITY WARDS.
The total admissions were 233 as compared with
199 last year, 173 in 1909, and 143 in 1908.
The nationalities of those admitted included:
Europeans, 60; Eurasians, 12; Chinese, 61; Tamils,
30; Japanese, 14; Sikhs, 12; Eurasian Jews, 9;
Malays and Javanese, 8. ,
A number of the European patients admitted
came from Malacca and the Federated Malay
States; the remainder were from Singapore Island.
The deliveries comprised 59 European infants,
being 33 males and 26 females; the. native infants
were 58 males and 84 females.
The average weight of the European infants was
7 lb. 43 oz.; that of the native infants 61 Ib.
Two European infants and 19 native infants were
stillborn.
There were no denths among European mothers,
but 5 among native women. These were 1 within
twenty minutes of admission from cardiac failure,
l cach from dysentery, placenta previa, and rup-
ture of the broad ligament, and 1 shortly after
admission undelivered.
Oct. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 77
Colonial Medical Reports.—No. 23.—Straits Settlements—
(continued).
REPORT ON THE HEALTH OF THE POLICE
FORCE IN SINGAPORE FOR 1911.
Revort Bv Dr. W. S. SHEPPARD, POLICE SURGEON.
There were 5,800 attendances at the out-patient
room during the year as compared with 5,796 in
1910, and 3,924 in 1909.
There are some constables who hardly ever let a
week pass without reporting sick, however trifling
their ailment may be, and it is partly on this
account that the number of attendances recorded
is so large.
The majority of these attending the sick-room are
men suffering from slight indisposition or perhaps
in some cases merely from ergophobia.
Seven hundred and seventy-three cases were
admitted to the General Hospital. Of these 25
were Europeans and 748 were natives.
There were 8 deaths. The number of malarial
and other fever cases is the highest ever recorded.
PRISON HOSPITAL.
Report BY Dr. W. S. SHEPPARD, MEDICAL OFFICER.
There were 1,041 admissions to hospital, the
daily average of sick being 50°7, against 1,061 and
47:05 respectively in 1910.
The health of the prisoners has not been satis-
faetory, owing chiefly to the prevalence of three
disorders, viz., colitis, eczema and neuritis.
Colitis (with whieh I group dysentery and some
cases of intractable diarrhoea) is an old scourge. In
1911, 261 cases were recorded as compared with 315
cases in 1910, and 278 in 1909.
The careful supervision of the food and water
supply would seem to leave no loophole for the
entrance of these disorders. Nevertheless, they
recur year after year. Many cases are undoubtedly
relapses.
Eczema scrotum is a trifling malady in itself, but
it causes discomfort and incapacity for the hardest
kind of work. The cause is probably imperfect
personal cleanliness, this in turn being due to too
short a time being allotted to the bathing of the
prisoners and, in some instances, perhaps, to in-
sufficient cleansing of infected clothing. Better
care is now taken in both these matters.
Neuritis has probably been prevalent in the gaol
for some years past, but it has escaped detection.
During the year my attention was directed to it,
and I was able to compile a list of 75 cases; all
were affected but slightly. The lower extremities are
the parts commonly affected. Experiments con-
ducted at the Kuala Lumpur Researen Institute and
at the Singapore Prison tend to show that parboiled
rice when cooked under a 40-50 lb. steam pressure
in a closed vessel is not protective against beriberi
and neuritis—as was opce believed.
Patients suffering from neuritis are, therefore,
now fed on rice cooked in an open pan, and the
other prisoners on rice cooked in steamers with an
air inlet.
Beriberi.—Six cases occurred, 4 in long sentence
prisoners, 1 in a short sentence prisoner, and the
sixth case was admitted to prison with the disease.
The long sentence prisoners undoubtedly contracted
the disease in the prison. There were no deaths.
The percentage of deaths to total treated was 3:8,
and to the total prison population 0°63. Besides
these deaths in hospital 3 occurred in long sentence
prisoners, who died suddenly in their cells, the,
cause of death being heart failure from disease of
the heart.
TAN TOCK SENG'S HOSPITAL.
Revort BY Dr. T. D. Kennepy, ActinG MEDICAL
OFFICER.
The average daily sick was 608°81, against 519°77
in 1910.
The average stay in hospital of the total treated
was 16°59 days, while that of those who died was
11:57, of those who were discharged 18:80, and of
those remaining at the end of the year 90°78.
The percentage of deaths to total treated was
14:88, against 15°71 in 1910.
There were 1,920 deaths. Of this number no
less than 337 died within twenty-four hours of
admission, and 145 within forty-hours. Eliminating
those dying within twenty-four hours, the death-
rate would be 12:12 instead of 14°33, and eliminating
those dying within forty-eight hours 10°73.
The admissions have been the largest number
on record—12,820— being an increase over the pre-
vious year of 3,924. Notwithstanding the opening
of the Kwong-Wai-Shiu Free Hospital, where the
patients average daily about 200, there has been
no falling off in the numbers seeking admission here.
The principal diseases treated were: Malaria,
ulcers, venereal ‘diseases, dysentery, beriberi,
phthisis, injuries, abscess, pneumonia, bubo,
Bright’s disease, rheumatism, seabies, bronchitis,
hepatic cirrhosis, enteritis, enteric fever, ankylos-
tomiasis and corneal ulcer.
Malaria.—Among the diseases treated malaria
again formed the bulk of the admissions; the
number of cases being 5,022 with 476 deaths,
against 3,150 cases and 377 deaths in 1910, and
1,922 and 260 deaths in 1909.
The localities from which malaria cases came
were chiefly Johore, Bukit Timah, Tanjong Pagar,
Kampong Malacca, Upper Serangoon, Kampong
Kapur and Thomson Road.
Ulcers.—There were 1,719 cases of ulcer, against
770 in 1910. Two wards are devoted solely to the
treatment of uleers and they are not enough.
There are many cases distributed throughout the
other wards. The wastage from this simple cause
is lamentable. From ignorance and neglect on the
part of the patient, he frequently seeks admission
to hospital so late that the only means of saving
life is amputation of a limb.
Venereal Diseases.—They were made up as fol-
lows: Primary and secondary syphilis, 889; gonor-
rhæal and syphilitic arthritis, 222; gonorrhcea, 100.
There were 26 deaths from secondary syphilis and 3
from arthritis.
78 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS. [Oct. 15, 1913.
A few cases of syphilis, specially selected, were
treated for the first time with ‘‘ 606 "" with excellent
results. Thirty were treated by intramuscular
injection, and 20 by intravenous.
Dysentery.—The total number of cases treated
was 900, as compared with 642 in 1910; of these
444 died, giving a mortality of 48'4 per cent.,
against 52:49 per cent. in 1910. As in former
years this high percentage is largely due to the
hopeless condition of patients when they are
admitted to hospital. Thirty-one died within
twenty-four hours of admission to hospital.
Beriberi.—VFour hundred and eighty-five patients
were treated, 66 died, a mortality of 18:5 per cent.
Of these 66, 36 died with twenty-four hours of
admission, reducing the death-rate to 6:18. This
shows a gratifying decrease from the previous year,
when 590 cases were recorded, with a mortality of
19°67 per cent. One hundred and ninety-seven
chronic cases were transferred to the Beriberi
Hospital at Pasir Panjang.
Pulmonary Tuberculosis.—Grouped under phthisis
were 385 cases, of these 215 died, giving a death-
rate of 55°84. Under general tuberculosis were
74 cases with 36 deaths.
Pneumonia.—One hundred and sixty-nine cases
were treated with 81 deaths, and 22 cases of
broncho-pneumonia with 18 deaths.
Enteric Fever.—Sixty-two cases with 36 deaths.
Ankylostomiasis.—Sixty-seven cases with 29
deaths, 7 of these died with twenty-four hours of
admission.
Lunacy.—One hundred and thirty-seven patients
were sent for observation, of whom 87 were certified
as insane and transferred to the Lunatic Asylum.
Medico-legal.—Seventy-two bodies were sent for
Coroner's inquest, in addition there were the usual
inquests on those who died in hospital from acci-
dents and injuries. Five hundred and thirteen
police eases were sent in for treatment.
The total number treated in the European ward
was 420, with 14 deaths from the following causes :
Enterie fever, 2; cerebral hemorrhage, 2; liver
abscess, 2; malaria, 1; beriberi, 1; phthisis, 1;
cystitis, 1; blackwater fever, 1; sprue, 1; diabetic
coma, 1; senility, 1. The diseases were chiefly
malaria, venereal diseases, alcoholism, phthisis and
bowel complaints.
The surgical work done during the year has been
greatly in excess of that done in any former year.
Cholera.—One hundred and two cases were
admitted during the year. There were 71 deaths,
giving a mortality of 69°6 per cent. During the
latter part of September to the end of October
there was an outbreak of cholera, when 65 cases
were admitted. Forty patients died, giving 38 per
cent. recoveries. Roger’s treatment by intravenous
injection of hypertonic saline was tried for the first
time and gave encouraging results. Forty-six
cases were injected one or more times and 27 of
them recovered. The percentage of recoveries of
those injected was 58 per cent.; of 19 uninjected
only 2 recovered, a percentage of 10 recoveries.
Plague.—Eleven patients were admitted, of
whom 5 died, giving a mortality of 45°45 per cent.
In bubonic cases secured in the early stages of the
disease, free incision or the enucleation of the
enlarged glands favourably influenced the future
course of the disease.
Small-poz.—The number of cases treated was
231. Of these 65 died, giving a death-rate of
28:13 per cent. Of 124 with evidence of past
vaccination but 14 died compared with 51 deaths
occurring in 101 unvaccinated cases.
LUNATIC ASYLUM.
Report py Dr. H. J. GIBBS, MEDICAL
SUPERINTENDENT.
One hundred and ninety males and 30 females
were admitted in 1911, making a total treated for
the year of 452 males and 101 females.
Of the above 13 males and 1 female were second
admissions.
The recovery and death-rates on the total treated
for 1911 were 14°65 and 15°75 respectively. The
death-rate for 1911, based on the average number
resident, was 24°30 per cent. Cholera, dysentery
and tuberculosis are largely answerable for this
high rate. The recovery rate calculated on the
admissions was 36°81 per cent.
The number of deaths occurring in those with
under a month’s residence indicates the greatly
impaired physical condition of many of the patients
on admission.
Amongst the main causes assigned malaria again
ranks highest with 62, thus contributing 28°18 per
cent. of the admissions as against 14°04 of the
previous year. The Asylum shared with the rest
of the town and country in the epidemic. So bad
was it here that but few of the staff escaped. At
one time both dressers, the steward, clerk and the
matron were seriously ill with the disease. Of the
many patients who suffered 9 died.
Venereal disease is assigned as the cause of 21
cases of mental breakdown, it is doubtful if these
figures are correct in more than 3 per cent. of the
cases,
Alcohol, pulmonary tuberculosis, previous attacks,
old age and hereditary influences yielded, respec-
tively, 17, 16, 17, 9 and 7 cases.
Alcohol, as a factor in the causation of insanity,
shows a slightly higher rate than it did for 1910.
Beriberi.—One patient was admitted in August
with the disease from Singapore, otherwise the
Asylum has remained free. The experiment of
feeding the patients with under-milled Siam rice
commenced on December 21, 1910, was continued
with two or three short breaks from want of such
rice until November 30, 1911, when it had to be
abandoned owing to the Government of Siam re-
fusing to export any on account of the rice famine.
During the period the patients were so fed no beri-
beri occurred.
Cholera.—I regret to have to again record an
outbreak of this disease amongst the patients at
Oct. 15, 1913.]
. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 79
Pasir Panjang Asylum. The first case occurred on
August 17. Three days after the commencement
of the outbreak all patients were removed to the
Quarantine Station on St. John’s Island.
There were no cases amongst the beriberi patients
in the adjoining wards at first, but within three
days the disease also broke out there and the
patients were removed to St. John’s on August 23.
During their stay, on the Quarantine Station
11 deaths from cholera occurred amongst the insane,
2 amongst the beriberi patients, and 1 hospital
servant, a toty, died. S4
One of the Bengali attendants was also attacked
with cholera on St. John's; he recovered.
It is diffieult to account for this outbreak at
Pasir Panjang, five miles from town, although cases
of cholera were being reported in Singapore at the
time.
© A few days before the outbreak the municipal
water supply was noticed to be offensive and dirty,
the water having become stagnant. Arrangements
were at once made for the more frequent flushing
of the main. It is hardly probable that this water
was in fault or a far bigger and more general out-
break must have occurred.
An interesting case to note is that of a malarial
patient with an enlarged and diseased spleen, who
ruptured his spleen by violent vomiting and died
within two hours
BERIBERI HOSPITAL, SINGAPORE.
Report BY Dn: H. J. GiBBs, PHysICIAN-IN-CHARGE.
Four hundred and- seven patients were admitted
in 1911, a total treated of 521 during the year. Of
these, 94 were discharged recovered, 184 relieved,
l not improved, 9 were transferred to the General
and Tan Tock Seng's Hospitals for diseases other
than beriberi, 120 absconded and 16 died, leaving
under treatment at the end of 1911, 97 patients.
Owing to the occurrence of. cholera amongst the
neighbouring male and female insane patients on
August 19 and of a case on August 22 amongst the
Tan Tock Seng’s Hospital beriberi patients the
whole of the General Hospital overflow patients
then in residence were, with the beriberi patients,
removed to the Quarantine Station on St. John's
Island on. August 23.
During their period of quarantine two fatal cases
of cholera occurred among the General Hospital
patients, the first on the 23rd and the second on
the 31st August, they both died on the 31st.
Of the beriberi patients the patient attacked on
the 22nd died on the 23rd, and at St. John's one
other was attacked but recovered.
I regret to have to report the death of the toty
of the Beriberi Hospital from cholera. He became
infeeted while in attendance on the patients on
August 29 and died the following day.
PENANG.
Report sy Dr. R. Dane, SENIOR MEDICAL OFFICER.
“Settlement " includes Penang, Province Wel-
lesley and Dindings. i
The estimated mean population of the Settlement
for 1911 was 278,811 (Penang Island, 141,893;
Province Wellesley, 129,340; Dindings, 7,578).
Births.—The births in the Settlement during
1911 were 7,358. This is an increase of 481 on
1910. Penang Island, 3,871; Province Wellesley,
3,789; Dindings, 198.
Deaths.—The number of deaths in the Settle-
ment in 1911 was 10,231 (6,973 males, 3,258
females) which shows an increase on 1910 of
713.
The death-rate of Penang Island alone was 41°46,
an inerease of 8°36 per mille on 1910.
Beriberi.—Parboiled rice is exclusively used in
all Government institutions and in them no fresh
cases have occurred.
Malarial Fever.—What I found at Glugor Village
is typical of some other places. Over an area of
about half a square mile there are streams, ditches,
big puddles, tiny puddles,:small ponds and hoof
prints. To level and drain this area would cost a
large sum, besides a large amount annually to keep
it in order.
My recommendations for treatment now are:—
(1) The distribution of tabloids of quinine at cost
price. Tabloids; because the peasant, and others
too, will not take the bitter solution, or the powder;
and at cost price because what is given free is not
valued, and because if given free it would be
cornered by some rogues.
(2) Instruction of the boys at school to recognize
mosyuito larve; ocular demonstration that these
larve become mosquitoes. I think it likely that
the rising generation may thus be induced to help
themselves to kill off the mosquito larve.
(3) ‘A labour party, under direction of the Senior
Medical Officer, to go round, under control of a
sanitary inspector.
General Diseases.—The admissions to the various
hospitals in the Settlement were 12,873, against
10,368 in 1910.
Smaull-poz.—The 1910 outbreak in Penang con-
tinued up to October, 1911; 109 cases and 82 deaths.
The 1910 outbreak, Province Wellesley, continued
up to the end of 1911; 357 cases with 78 deaths.
Dindings began in March and ended in July; 14
cases with one death.
Cholera.—An outbreak occurred on the west side
of Penang Island. There were 60- cases and 52
deaths. A special report has been sent in.
The question of enlarging the accommodation for
Europeans at the General Hospital has been under
consideration since October. On several occasions
there was no room in the seamen's ward and some
patients were temporarily put into the officers’
ward. Besides, admissions had to be refused on
several occasions.
The new Quarantine Station was opened on
April 6. Latrines had been provided which if
properly used would have been ideal. Experience
showed that the Tamil eoolie would not and could
not use them properly, as a consequence the camp
became insanitary. These facts not being known
publicly false conclusions were drawn.
. COLONIAL MEDICAL REPORTS. FeBERATPS, BEETHBMENTS.
Return oF DisEAsES AND DEATHS IN 1911 AT THE FOLLOWING INSTITUTIONS :—
General, District, Lock, Prison, Quarantine Camp, Jelutong, Balik Pulau, Leper Hospital, Pulau
Jerejak, Lumut, Female Leper Ward, Jelutong, and Female Ward, District Hospital and New
Quarantine Station, Pulau Jerejak, Penang, Straits Settlements.
GENERAL DISEASES.
Alcoholism
Anemia .. 3 i
Anthrax .. e ni
Beriberi "S" ia "s
Bilharziosis P vx X:
Blackwater Fever
Chicken-pox T
Cholera .. vs ae
Choleraic Diarrhoea e ve
Congenital Malformation es =
Debility .. 3 vs $e -
Delirium Tremens ie od S
Dengue .. os .. oe
Diabetes Mellitus - hey
Diabetes uid ví oe
Diphtheria s ee R
Dysentery .. . T F
Enteric Fever sis ay s c g
rysipelas .. >% ae ee ee z
ebricula .. ; Ns Ts $
Filariasis .. »s Sh B E
Gonorrhea 3
Gout as T
Hydrophobia "n
Influenza .. T e es e.
Kala Azar .. os rs T os
Leprosy .. T ^ A £s
(a) Nodular .. > ‘
(b) Anesthetic ..
(c) Mixed x.
Malarial Fever— se 23 os
(a) Intermittent ne m «5
Quotidian .. as e oe
Tertian 3
Quartan
Irregular .. oe sie
Type undiagnosed es T
(b) Remittent .. Ya
(c) Pernicious .. . 5s
(d) Malarial Cachexia. . «x is
Malta Fever «s au oe T
Measles m T -
Mumps .. Ee T T T
New Growths— .. $$ T
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra ..
Plague os a sre ve
Pyæmia .. os oe os a
Rachitis :
Rheumatic Fev er. is sv
Rheumatism $e D te M
Rheumatoid Arthritis : be
Scarlet Fever ae ae S. E^
Scurvy
Septicemia 2
Sleeping Sickness
Sloughing CUN
Small-pox . è me os T
Syphilis .. Em > oe ee
(a) Primary v. es š
(b) Secondary .. as 34
(c) Tertiary »
(d) Congenital .
Tetanus
Trypanosome Fever wa
Tubercle— es
(a) Phthisis Pulmonalis T
(b) Tuberculosis of Glands ..
(c) Lupus
2
i$}
$| | 1 S| BI Deaths
(fbb tuk te oe up Pbi
E:
18
elilils$asli!lHl181III ISI I st
bo is]
Silica
—
g8lleaS81ll-l
A
(b) Iridectomy .. s
(c) Other Eye Operations
& Lj
Es
4 n
GENERAL DisEasEs—continued,
(d) Tabes Mesenterica s —
(e) Tuberculous Disease of Bones .. . —
Other Tubercular Diseases 2 |. —
Varicella .. . ws a w? w =
Whooping Cough "e ES xe e —
Yaws à "a ate és e —
Yellow Fever ee ee ve "n oo
LOCAL DISEASES.
Diseases of the —
Cellular Tissue ^e ae ae .. 192
Circulatory System .. ss —
(a) Valvular Disease of Heart rs .. 88
(b) Other Diseases .. os S ve 29
Digestive System — .. i "s oo
(a) Diarrhoea 3a as os .. 455
(b) Hill Diarrhea .. ` - ek —
(c) Hepatitis ae ile «fe we 1
Congestion of Liver .. oe e —
(d) Abscess of Liver VS T 5
(e) Tropical Liver .. hate v =
(f) Jaundice, Catarrhal .. HS a oS
(g) Cirrhosis of Liver vs vs v» AS
(h) Acute Yellow Atiophy, ee ww —
(i) Sprue .. oe . os ee 2
(j) Other Diseases .. m oe .. 409
Ear xA ss T <a ss c VA
Eye ia M. a T .. 190
Generative System— oe Fey A woos
Male Organs ds T T se 297
Female Organs s% .. . 191
Lymphatic System .. vs es .. 168
Mental Diseases zs SA ES e —
Nervous System . e ae .. 118
Nose .. ` ee aT. oe 7
Organs of Locomotion EN T +» 80
Respiratory Spem fie oe as .. 430
Skin— .. . as ee os . —
(a) Scabies .. s s E se 195
(b Ringworm . Fi 25 a B
(c) Tinea Imbricata Eo Ee ear cem
(d) Favus .. FP 2a ate &e =
(e) Eczema .. vs as ws .. 85
( f) Other Diseases .. a6 ra 1,077
Urinary System z 55 ks .. 161
Injuries, General, Local— ss ss .. 484
a) Siriasis (Heatstroke) es e| —
b) Sunstroke (Heat Prostration) | —
(c) Other Injuries .. T a Si =
Parasites— ws oe T _ =
Ascaris lumbricoides .. an E y=
Oxyuris vermicularis .. —
Dochmius duodenalis, or Ankylostoma duo-
denale p ša z5 ‘2
Filaria medinensis (Guinea. -worm) = 3
Tape-worm Ps zs ue ss vs 2
Poisons— $3 vs nA rs s =
Snake-bites — .. ve ee PP m 1
Corrosive Acids as es X © —
Metallic Poisons T T 2s af 1
Vegetable Alkaloids F --
Nature Unknown . —
Other Poisons E a ss E 1
Surgical Operations — .. as ae .. 201
Amputations, Major .. ee æ =
Minor .. ss . ex =
Other Operations v xs x wooo
Eye .. m ee . 7 =
(a) Cataract. F ba : ©. —
.
Deaths
FETTE
_
oll li lll leelallell!lSlwkle
m
Pl) bbl eset TPs
IT] 2 p EP Eats
[Oct. 15, 1913.
to
Oeo
nei ESI Et
Nov. 1, 1913.|
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 81
Colonial Medical Reports.—No. 23.—8traits Settlements—
Ci
(continued).
QUARANTINE CAMP.
Report BY Dr. R. DANE, SENIOR MEDICAL OFFICER.
Of infectious diseases there were 61 cases re-
maining at the beginning of the year (viz., small-
pox 51 and chicken-pox 10) and 150 were admitted
during the year.
Three hundred and eleven contacts and 87 obser-
vation cases were admitted. Of them 90 were
vaccinated for the first time on arrival in the camp,
113 had vaccination marks but were re-vaccinated.
Ninety-five having been recently vaccinated and 13
having obvious marks of previous small-pox were
not vaccinated.
Nineteen cases of small-pox died during the year,
17 of whom bore no vaccination marks. The two
cases who acquired small-pox in the camp and died
were vaccinated on admission to the camp. They
were both infants. They had been in contact with
small-pox some days before admission.
Eleven deaths occurred amongst patients ad-
mitted for observation, viz., acute dysentery, 2;
acute diarrhoea, 7; chronic diarrhea, 1; acute
cholecystitis, 1.
GENERAL HOSPITAL.
Report BY Dr. J. S. WEBSTER, SURGEON-IN-CHARGE.
During the year 1911 there have been 276 patients
admitted to the European wards and 1,593 to the
native wards as compared with 271 and 1,227,
respectively, during 1910. This shows an increase
of 371 patients, i.e., 24°7 per cent. The mortality
excluding deaths within 24 hours of admission was
2:82 for the European wards and 8°07 for the native
wards, as compared with 2:95 for the Europeans
and 4:22 for the natives in the former year. The
cause of this increase in the number of deaths
occurring in the native wards is easily found in the
number of Tamil coolies who have been admitted
to hospital in a moribund condition.
On several occasions all the beds in the European
wards have been occupied and patients have either
had to be refused admission, or else others, only
pártiug recovered, discharged to make room for
them.
The principal diseases treated: Malaria, 899 with
18 deaths; tuberculosis, 28 with 8 deaths; dysen-
tery, 84 with 30 deaths; venereal, 102 with no
deaths; beriberi, 15 with 5 deaths.
Beriberi.—Fifteen cases were treated during the
year, as compared with 25 in 1910 and 15 in 1909.
No case occurred amongst patients admitted to
hospital for other diseases.
Operations.—One hundred and thirty-three opera-
tions were performed during the year as compared
with 108 in 1910.
PRISON HOSPITAL.
Report BY Dr. R. DANE, SENIOR MEDICAL OFFICER.
The sanitary condition of the prison was good,
and the health of the prisoners satisfactory.
Six hundred and fifteen patients were admitted
during the year. The average daily sick was 31°15.
The prominent diseases causing admission were:
Diarrhea, 101; anemia, 40; dysentery, 28; phthisis,
13.
Mortality.—Of the 25 deaths 20 were certainly
due to disease acquired before arrival in prison, 15
of them being sent straight into hospital.
From October to the end of the year I arranged
with the Superintendent of Prisons that all prisoners
should be kept in their cells for the first twenty-four
hours after admission so that we could discover
any who were suffering with diarrhea or dysentery
on arrival. Since this has been done a large number
of cases of diarrhea has been so detected.
DISTRICT HOSPITAL.
Report By Dr. J. S. WEBSTER, MEDICAL OFFICER.
8,886 patients were admitted during the year as
against 3,485 in the previous year.
The average daily sick was 331:18 as compared
with 289°73 in 1910.
There were 516 deaths during the year (mortality
13°30 to total treated) as against 527 deaths in the
previous year (mortality 14°05). Forty-five patients
died within 48 hours of admission. The percentage
of deaths to total treated, excluding those dying
within 48 hours of admission, was 11°35.
Operations.—Sixty-three operations were per-
formed during the year, nearly all of a minor
nature.
Malarial Fever shows an increase over those
admitted in the three preceding years. Beriberi
shows a marked decrease of cases treated. No
cases occurred amongst patients in hospital. Par-
boiled rice was exclusively used in the hospital as
in recent years.
Dysentery.—One hundred and seventy-nine cases
were treated during the year with 77 deaths (mor-
tality 43:02).
Diarrhea.—Acute and chronic accounted for 232
cases treated with 91 deaths (mortality 39°22).
The high mortality among diarrhoea and dysentery
cases is accounted for by the fact that most of the
cases when brought in were in a practically mori-
bund condition.
Phthisis also shows a high death-rate as in pre-
vious years. There was a slight falling off in the
number of admissions.
Venereal Diseases accounted for 613 admissions
with 6 deaths.
EYE WARD, DISTRICT HOSPITAL, PENANG.
Report BY Dr. J. Kirk, Honorary VISITING
OPHTHALMIC SURGEON.
There were 140 cases of eye disease treated in
this ward during the year as in-patients and 52
attended as out-patients.
There were also 20 cases of subconjunctival injec-
tion performed. This method of treatment has had
encouraging results in many cases of pannus and
corneal opacity.
82 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
[Nov. 1, 1918.
BALIK PULAU HOSPITAL.
Report BY Dr. R. DANE, SENIOR MEDICAL OFFICER.
During the year 328 patients were admitted.
The daily average number of sick was 36.
The principal diseases were: Ulcers, 119; malarial
fever, 839; injuries, 20; rheumatism, 16; anemia, 14;
diarrhea, 12; phthisis, 11; chancroids, 13; syphilis,
10.
There were 39 deaths during the year, giving a
mortality of 10°86 of those treated. The causes of
death were: Phagedena, 6; phthisis, 6; diarrhea,
6; chronic Bright's disease, 5; dysentery, 3;
anemia, 3; valvular disease of the heart, 3; malaria,
2; pneumonia, 1; septicemia, 1; syphilis, 1; cellu-
litis, 1; enteritis, 1.
There was an outbreak of cholera—60 cases
occurred with 52 deaths, the first case was reported
on May 4, and the last case on May 28.
LUMUT HOSPITAL, DINDINGS.
Report BY Dr. R. DANE, SENIOR MEDICAL OFFICER.
Four hundred and seventy-seven cases were
admitted during the year, 12 remained from the
previous year, making a total of 489 cases treated.
The principal disease treated was malarial fever
178 (104 cases from Sitiawan and 74 cases from the
District of Dindings). The average daily sick was
13
There were 56 deaths during the year, of this
number 19 died within 48 hours of admission.
The causes of death in the 56 fatal cases are:
Malaria, 12; anemia, 12; dysentery, 10; beriberi,
5; phagedena, 3; phthisis, 8; acute nephritis, 2;
debility, 2; chronic malaria, 1; tuberculosis, 1;
chronic bronchitis, 1; broncho-pneumonia, 1;
enteritis, 1; abscess of the liver, 1; and Bright's
disease, 1. The percentage of deaths to total
treated was 11:45. "The percentage to total treated,
excluding those dying within 48 hours of admission,
was 7°87.
Fourteen cases of small-pox occurred in the dis-
trict with 1 death.
The general health of the population in Lumut
has been satisfactory.
LEPER ASYLUM, PULAU JEREJAK.
Report BY Dr. J. C. C. Forp, MEDICAL OFFICER-IN-
CHARGE.
The average daily number of inmates was 412.
The percentage of deaths was 26:12. One Chinese
leper (Perak) committed suicide by hanging.
Official visits were made during the year by His
Excellency the Governor; the Honourable Resident
Councillor, Penang; the Honourable Principal Civil
Medical Officer, S.S.; the Honourable Colonial
Engineer. Other visitors were the Bishop of
Malacca and Dr. R. Romer, of Deli (Sumatra).
Towkays Goh Taik Chee and Goh Soon Cheng
presented each leper with a small sum of money
at the Chinese New Year; this amount was supple-
mented by a donation from the Anti-Mendicity
Fund.
FEMALE DISTRICT HOSPITAL.
Report BY Dr. J. S. WEBSTER, MEDICAL OFFICER.
Throughout the year all the patients in this
hospital have been lodged in a ward on the lower
story of the Female Ward. It is proposed to
cement the floor of this ward during the coming
year since many of the patients have very filthy
habits. New latrines were erected for this ward,
together with two new bathrooms, and they are .
connected with the building by means of a covered
way. Electric light has also been installed; it is
a great improvement.
During the year there have been 247 admissions
with 52 deaths. Many patients arrived in a mori-
bund condition. The patients have consisted
almost entirely of Tamils and Chinese, especially
the former.
PROVINCE WELLESLEY.
Report By Dr. E. D. WHITTLE, MEDICAL OFFICER.
On an estimated mean population of 129,341 the
birth-rate in 1911 was 29°28 and the death-rate
30°76 per mille.
The admissions to the three Government hospitals
numbered 3,099, as compared with 8,046 in 1910
and 2,696 in 1909.
The death-rate per cent. was 12:19 as against
11:65 in 1910 and 12:68 in 1909.
The publie health throughout the year was good,
with the exception of an epidemic of small-pox in the
Central Province which cos* 58 lives.
The spread of the epidemie was facilitated by the
concealment of small-pox patients. About half a
dozen convictions were obtained for this offence.
A similar epidemie occurred later in the year
amongst the waterside labourers of the Prye River.
The accompanying table shows the relationship
of the case mortality throughout the Province during
the year to the presence or absence of vaccination
marks :—
Cases Deaths Per cent.
Vaccinated T zago LON am cd! we B5]
Unvaccinated ... as LBI 45 08 40:12
Total .. 85b .. 78 22:08
The water supply from Bukit Seraya has been of
good quality. The reservoir is being enlarged.
The analyses of the water from Bukit Panchor are
very definitely condemnatory. A filter scheme of
Jewell type is being prepared.
BUTTERWORTH HOSPITAL.
The principal diseases treated during the year
were: Abscess, anemia, beriberi, bronchitis, diar-
rhea, dysentery, injuries, malarial fever, phthisis,
pyrexia, uleers, venereal diseases.
Among the more important operations were the
following: Amputation, arm; circumcision, explora-
tory laparotomy, extraction of teeth, extraction of
cataract, for cut throat, forceps delivery, incision
abscess, paracentesis abdominis, reduction of dis-
Nov. 1, 1918.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Return or Diseases AND DEATHS IN 1911 AT THE FOLLOWING INSTITUTIONS :—
Butterworth, Bukit Mertajam, and Sungai Bakap Hospitals, Province Wellesley,
Straits Settlements.
GENERAL DISEASES. ii
is 2 yeg Ei
52% 8 8g GeNeRaL Diseaszs—continued.
4 * A E (d) Tabes Mesenterica bx —
Alcoholism 7 1 T (e) Tuberculous Disease of Bones .. —
Anemia 48 10 50 Other Tubercular Diseases —
Anthrax ~ n Varicella ; als es —
Beriberi 51 3 55 Whooping Cough c:
putant = = = «Xawe : 2
Blackwater Fever — — — vi pars
Chicken-pox ee 10 — 10 Yellow Fever
Cholera 4 3 4
Choleraic Diarrhoa — . — — — LOCAL DISEASES.
Congenital Malformation — — —
Debility A — — — Diseases of the—
Delirium Tremens — — — Cellular Tissue 68
Dengue .. — — — Circulatory System —
Diabetes Mellitus - — — — (a) Valvular Disease of Heart 57
Diabetes Iperpidos — — — (b) Other Diseases .. 7
Diphtheria . es —— = Digestive System— —
Dysentery .. : vs 190 75 191 (a) Diarrhea is 87
Enteric Fever 9 6 9 (b) Hill Diarrhea .. =
Trei pelaa T 2 1 3 (c) Hepatitis E 1
Febricula .. — — — Congestion of Liver 1
Filariasis . — — — (d) Abscess of Liver —
Gonorrhea 5 — 55 (e) Tropical Liver .. =s
Gout . - - — (f) Jaundice, Catarrhal 7
Hydrophobia - — — g Cirrhosis of Liver : 33
Influenza .. - — — ) Acute Yellow M —
Kala-Azar.. — — -- ti) Sprue : : =s
Leprosy .. 14 1 14 (j) Other Diseases .. 120
(a) Nodular — — — Ear es 5
(b) Ansesthetic .. — — — Eye $ 47
(c) Mixed - — — Generative System— . «s es
Malarial Fever— — — — Male Organs 100
(a) Intermittent — — — Female Organs 13
Quotidian .. — — — Lymphatic System 58
Tertian 198 — 124 Mental Diseases —
Quartan — — — Nervous System 59
Irregular .. . 14 8 14 Nose .. . —
Type undiagnosed - — — Organs of Locomotion 62
(b) Remittent .. i — = = Respiratory System 177
(c) Pernicious .. « 165 33 165 Skin— .. se —
(d) Malarial Cachexia. 1 50 1 53 (a) Scabies 31
Malta Fever . — — — b) Ringworm è 6
Measles l4 — 15 W Tinea Imbricata —
Mumps .. os — — — d) Favus s . —
New Growths— . — — — id Eczema .. 3s 17
Non-malignant 3 — 4 ( f) Other Diseases .. 407
Malignant 18 2 18 Urinary System A 50
Old Age — — — Injuries, General, Looal— 193
Other Diseases 93 13 94 a) Siriasis (Heatstroke) E —
Pellagra .. — — — (o) Sunstroke (Heat Preetcéon] —
Plague — — — (c) Other Injuries 41
Pysemia 2 — 2 Parasites— vs —
Rachitis — — — Ascaris lumbricoides .. —
Rheumatic Fever - — — — Oxyuris vermicularis . —
Rheumatism . 36 1 38 Dochmius duodenalis, or Ankylostoma duo-
Rheumatoid Arthritis — — — denale 127
Bcarlet Fever — — — Filaria medinensis (Guinea worm) 3
Scurvy — - — Tape-worm —
Septicemia — — — Poisons— —
Sleeping Sickness a — — — Snuke-bites 2
Sloughing Fomina E 27 1 27 Corrosive Acids —
Small-pox . . as 72 14 78 Metallic Poisons —
Syphilis .. — — — Vegetable Alkaloids —
a) Primary 26 — 26 Nature Unknown —
b) Secondary . 188 — 192 Other Poisons 6
c) Tertiary 15 — 17 Surgical Operations — 235
Congenital . — - — Amputations, Major .. —
Tetanus 1 1 1 Minor .. —
Trypanosome Fever — — — Other Operations -=
Tubercle— — — — Eye .. —
(a) Phthisis Pulmonalis — .. 1 4 17 (a) Cataract. 6
i Tuberculosis of Glands .. — — = (b) Iridectomy .. . 1
Lupus af - — = (c) Other Eye Operations 1
Deaths
i
Lt lelloRIl LIT LP IRL Sl eol lI allalll tll RI ol e PI EIP Gg
WA ER y AUI d p ril
Total
Cases
Treated
bil E11]
x
eo
gI 223) SaBl | Sal len] 8I aZI
S| Be |
m»
Sanalla
EMEN
_
--
o
b
reall || &al! lloll æ
84 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
(Nov. 1, 1918.
located hip, scraping ulcers, skin grafting, spinal
injection, suture of wounds of abdominal wall.
A microscopical examination of the blood in all
fever cases has been carried out throughout the
year. The stools of a large number of patients
have been mieroscopically examined.
Vaccination.—Four thousand two hundred and
thirty-three cases vaccinated during the year, of
which 2,164 were emergency cases. The percentage
of failures was 90°9.
Twenty-two autopsies were performed during the
year on the bodies brought by the police. The
Assistant Surgeon had also to inspect bodies with
the Coroner at their respective places of death on
several occasions.
Medical evidence was required in different courts
about fifty times during the year.
Out of 1,806 vaccinations performed in all, 887
were emergency vaccinations for the epidemic. Of
these 1,708 were inspected, with the result that
81:85 per cent. were perfect and 10°53 per cent.
failed.
The epidemic of small-pox of last year continued
for the major portion of this year. There were 231
cases in this district with 54 deaths. Of these 159
occurred from January to April, 2 in May, 7 in
June, 55 in July and August, 2 in September, nil
in October, 5 in November, and 1 in December.
SUNGAI BAKAP HOSPITAL.
Work Done.—Remaining from 1910, 35; admitted
during 1911, 902; total treated, 937; average daily
number of sick, 39°48; discharged, 767; transferred,
0; absconded, 5; died, 181; percentage of deaths
to total treated, 13:98; percentage of deaths to total
treated, excluding those dying within 48 hours of
admission, 10:54.
There were 79 cases of malarial fever, with S
deaths, and 37 cases of pulmonary tuberculosis, with
14 deaths.
Diagnosis in all cases being verified by micro-
scopic examination. Eight cases of beriberi with
no deaths. All cases of beriberi contracted the
disease from outside the hospital.
The total treated is 120 less than in 1910.
Operations.—There were 62 cases of major and
minor operations with 4 deaths. No death occurred
under general anesthesia.
ESTATE AND ESTATES HOSPITALS.
There are now some thirty estates to be visited by
the Medical Officer, Province Wellesley, a task only
possible while the service car is in good order. Im-
provement in the care of the coolies is noticed on
most of the estates. Some are slow to move.
Bertam and Batu Kawan are the most progres-
sive. The dressers, working under certain dis-
advantages, have done their duties well.
Bertam Estate.—Good progress has been made
in the re-housing of the coolies in permanent lines
of improved type.
The drinking water is served by taps from a tank,
the supply from which is pure, but of small
quantity.
The precincts of the lines are polluted; latrines
are to be provided.
Average number of coolies resident on estate in
1911: Tamils, 792; Javanese, 24; and Chinese, 717.
Malakoff Estate-—A new hospital and a new
coolie line have been built on this estate. Drinking
water is obtained from bricked wells by dippers.
Average number of coolies resident on estate in
1911: Tamils, 623; Javanese, 312; and Chinese, 58.
Prye Estate.—The coolies have been re-housed in
lines of improved type.
Latrines are now provided. Care has been taken
in the upkeep and improvement of the hospital.
Water supply by taps from a hill reservoir.
Average number of coolies resident on estate in
1911: Tamils, 740; Javanese, 407; and Chinese, 96.
Batu Kawan Estate.—A new hospital has been
built, and the coolies in the great part re-housed in
lines of improved type. Ingenious latrines are
installed to the great betterment of the health of
the coolies. Drinking water from taps supplying
sand filtered water from a hill reservoir and in part
from rain water collected in properly screened
tanks.
Average number of coolies resident on estate in
1911: Tamils, 651; Javanese, 423; and Chinese,
482.
Val d'or Estate.—The new hospital was occupied
early in the year; its infectious ward fell down later
The health of the estate is fair. The water supply
is by dippers from tanks that contain water too
hard to be palatable. Water is imported in casks
and collected from the trees during rain storms.
Water holes are dug wherever there appears an
opportunity of obtaining a palatable supply. This
estate must tackle this problem next year.
Average number of coolies resident on estate ‘n
1911: Tamils, 119; Javanese, 186; and Chinese, 41.
Bakap Plantation.—The health of this estate has
improved during the year. The water supply is
from shallow wells of poor design.
Average number of coolies resident on estate in
1911: Tamils 292.
Caledonian Estate.—Some general improvement
in the condition of the coolie lines of this estate
has been shown during the year. Latrines are
improved.
The water supply from Nibong Tebal reservoir
has given rise to many complaints.
A new hospital has been started on a fresh site.
Average number of coolies resident on estate in
1911: Tamils 2,277, Javanese 714, and Chinese 699.
Byram Estate.—Some new and improved lines
have been erected. The diminution in the number
of cases of bowel disorders last year anticipated by
Dr. Sheppard from the installation of tap water
supply has been remarkable; 279 cases in 1911 as
compared with 509 in 1910.
Average number of coolies resident on estate in
1911: Tamils 461, Javanese 672, and Chinese 262.
Noy. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. | 85
Colonial Medical Reports.—No. 23.—Straits Settlements—
(continued).
MALACCA.
Report BY Dr. A. H. Keun, MEDICAL OFFICER.
The total number of births registered in 1911 was
3,942 (males 1,993, females 1,949), showing a
decrease of 513 to 1910, when there were males
2,839, females 2,116. This, with the population
obtained at the last census taken on March 10, 1911,
shows a birth-rate of 31:77 per mille, compared
with 45:04 per mille in 1910, and 41:08 per mille
in 1909.
Death-rate.—The number of deaths recorded in
1911 was 7,159 (males 4,981, females 2,178) as
contrasted with 5,188 in 1910 and 4,085 in
1909.
The general health of the Settlement, judging by
the statistics given above, was most satisfactory.
Last year was a record year for unhealthiness and
for epidemics of malaria and small-pox. Severe
outbreaks of malarial fever occurred throughout the
Settlement, and estates which had never had
malaria before showed a severe incidence. March,
April, May, June, July, August and September saw
the disease at its worst. During these months the
admissions into the Government hospitals were
greatly increased. The outbreak was general in
town as well as country. Streets where malaria
was formerly little known, e.g., Heeren Street,
Fort Terrace, Jonker Street, had several cases of
locally contracted disease. With the view of
destroying the breeding places of mosquitoes, the
sanitary inspectors were instructed tu pay particu-
lar attention to receptacles for water and to instruct
householders to destroy or remove tins, vessels,
broken bottles, &e., likely to hold stagnant water.
With frequent inspections the mosquito pest
gradually decreased, and it is now part of the
ordinary routine of the sanitary inspectors to
examine all likely breeding places of mosquitoes.
From 123 admissions for malarial fever into Durian
Daun Hospital in February, it rose to 146 in March,
228 in April, 278 in May, 272 in June, 267 in July,
196 in August, 188 in September. These figures
are quoted to show that the increased admissions
to hospital would imply increased prevalence in the
Settlement. The great majority were of the malig-
nant type. Coma and dysentery were frequent
complications. Free quinine distribution was
adopted. Gurus and police stations were supplied
with quinine with instructions as to the quantity
to be used. Small spoons to hold 5 gr. were given
to all gurus, &¢. Quinine was also supplied free
of charge at the different dispensaries.
During the year small-pox continued throughout
the Settlement, occurring sporadically in different
districts at different times. In all 558 cases were
reported with 173 deaths, giving a percentage mor-
tality of 31:00, which compares favourably with
death-rates from similar epidemies in other places.
As in 1910, the majority of cases occurred in the
Alor Gajah Distriet, viz., 252 cases with 60 deaths
(i.e., a percentage of 23:80). The Central District
had 213 cases with 84 deaths (39:48 per cent.). The
Jasin District 93 cases with 29 deaths (31:18 per
cent.) In several districts severe outbreaks
occurred.
It is interesting to note that the several out-
breaks showed a higher mortality among unvac-
cinated people. The fact that it was the unvac-
einated or not recently vaccinated people who
were chiefly affected led to our vaccination cam-
paign being more successful. In most cases the
Malays themselves realized this and begged for the
operation to be done on them.
With the view of pushing on the vaccinations
among the Malays, who were the people chiefly
affected with small-pox (Malays 416 cases, Chinese
95, Tamils 26, Eurasians 19, Burmese 1, Sikh 1),
Gurus in vernacular schools were taught to vac-
cinate and were provided with lancet, lymph, &c.,
for vaccinating in their respective districts. Re-
turns of their results were submitted monthly,
while cases vaccinated by them were inspected by
some of the medical staff. Twenty cents were
given for each successful case. The frequent in-
spection kept the returns accurate. In all some
8,241 vaccinations were performed by them with
5,522 successful ones. These results are very
satisfactory as they reach a class of people who are
very difficult to get at, as nearly all Malays have
a dislike to vaccinations, whieh they accuse of
bringing on several diseases and even of producing
small-pox, besides incapacitating them from work
from the vaccination complications, e.g., fever,
inflamed arms and glands, &c. As most of the
vaccinations were done in open streets, market
places, common lodging-houses, &c., they were
unable to be examined afterwards.
The number of births within municipal limits
was 627 (males 319, females 308), as against 659
(males 337, females 322) in 1910.
The number of deaths was 1,223 (males 924,
females 299), as against 879 (males 571, females
308) in 1910. The infantile mortality was 238 in
children under one year of age, giving a percentage
mortality of 37:95 to the total births.
PAUPER HOSPITAL.
Malarial fever accounted for the greatest number
of admissions, viz., 2,252 with 139 deaths, giving
a percentage of 6:17. "The microscopic examination
for malarial parasites in all cases of fever, whether
admitted for it or developing while under treatment
for other diseases, was continued.
Dysentery showed a great increase, viz., 250
cases with 118 deaths. The very high mortality
from it ean only be attributed to the cases being
admitted in an advanced stage of the disease, in
most cases the patients being admitted to die in
hospital so as to obtain free burial.
Beriberi accounted for 765 admissions with 75
deaths, or 9:80 per cent.
“86: COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS. (Nov. 15, 1913.
Rerurn or Diseases AND DEATHS IN 1911 AT THE FOLLOWING INSTITUTIONS :—
General, Pauper, Contagious Disease, Leper, Prison, Alor Gajah, and Jasin Hospitals,
Malacca, Straits Settlements.
ay E az
GENERAL DISEASES. is 3 iH
1 x -= Të A ZE
23 8 4383 , E
se 8 £ & * GENERAL DrskEASES— continued.
: DM a (d) Tabes Mesenterica ; ss — —
Alcoholism wi oe ee S "s 2. — 2 (e) Tuberculous Disease of Bones .. S 0I rer
Apemia .. và is . . .. 98 16 105 Other Tubercular Diseases a
Anthrax . . — — = _ Varicella ; Y v es e —— —
Beriberi C . . 810 90 902 Whooping Cough 2 s re eS =
ilbarziosis E © — = — Yaws ` A E x ee EOI Sof Mp
Blackwater Fever (0— = o Yellow Fever = Ss, uL
Chicken-pox ate 32 — 34
Cholera Sis a ay e — — —
Choleraic Diarrhoea v " Ps e — = — LOCAL DISEASES.
Congenital Malformation s A = — —
Debility .. À ex PE : — — Diseases of the —
penums Tremens Ais ie 3 — = Cellular Tissue 99 4 101
Dengu s es ; — — = Circulatory System - - —
Diabetes Mellitus ` ae A š — — — (a) Valvular Disease of Heart 4 2 4
Diabetes iod a6 as ^ - — = (b) Other Diseases .. oa es 1 1 1
Diphtheria : nt : — — — Digestive System— 2s è — - —
Dysentery .. sts .. 978 177 391 (a) Diarrhoea es 285 138 290
Enteric Fever . we e & i — — — (b) Hill Diarrhea .. = = =
bim nn oe HE T oe ` 3 1 3 (c) Hepatitis ; Vs vg = = =
ebricula .. T La ás ve - — — — Congestion of Liver .. as vs 1 — 1
Filariasis .. M — — — (d) Abscess of Liver es Ac 2 1 2
Gonorrhea ; e 9 — 81 (e) Tropical Liver .. re ae TEE E = =
Gout s ai ©. — — = (f) Jaundice, Catarrhal .. a6 30 6 1 7
Hydrophobia nt A e SO — (9) Cirrhosis of Liver (à is .. 41 320 43
Influenza .. we ins - — — (h) Acute Yellow Atrophy ate a = = —
Kala-Azar.. WR. E a (i) Sprue .. và ase T vs 1 1 1
Leprosy .. vs i»: 110 3 11 (J) Other Diseases .. ve a d = = =
(a) Nodular .. a = = = Ear = ats vis : 2 — 2
(b) Anesthetic .. s $s e — = — Eye nM Y - we .. 98 1 101
(c) Mixed 2s ia vs m = = Generative Sy stem— .. SE = eS S
Malarial Fever— A : .. 262 2 270 Male Organs T = +. - 9 1 92
(a) Intermittent š 86 1 86 Female Organs an T T z% 8 1 8
Quotidian .. $ T 2 5. i 6 Lymphatic System 5d ad 41 — 44
Tertian .. ss v ae 3 — — — Mental Diseases sis E >$ sa m = =
Quartan .. - T "e š — — -— Nervous System - T ae .. 69 10 71
Irregular .. ; az n se See Es Nose .. 23 À 1 — 1
Type undiagnosed i — — = Organs of Locomotion T 3 ss eB 1 36
(b) Remittent .. . i 122 26 122 Respiratory Byster as is T .. 979 97 288
(c) Pernicious .. 2292 195 2331 Skin— .. Se ex wi — — =~
(d) Malarial Cachexia. . 23 m ^ ENT he Ll (a) Scabies .. Se i ss .. 97 — 100
Malta Fever ae . T m a = = = (b) Ringworm . ee oe 4 — 4
Measles .. - we e - ve 5 — 5 Wi Tinea Imbricata : . — - =
Mumps ws r 10 — 10 (d) Favus xm umm =
New Growths— .. T s 2 a| — = — (e) Eczema .. Y T 387 — 88
Non-malignant os sis EM si 5 — 6 ( f) Other Diseases .. "T Ss .. 1161 1 1200
Malignant as os ite «s ws. 10 4 12 Urinary System te a is .. 66 21 73
Old Age .. = a — m ae Injuries, General, Local— ; ie .. 159 4 165
Other Diseases s 156 35 158 (a) Siriasis (Heatstroke) as $e e — — —
Pellagra .. . — — — (b) Sunstroke (Heat Posten) m = =
Plague m T oe a — — (c) Other Injuries 2s — — =
Pyæmia .. và "E as . — — Parasites— ss — — —
Rachitis $3 A à — > = Ascaris lumbricoides .. 1 — 1
Rheumatic Fever à — — Oxyuris vermicularis . — — =
Rheumatism ET E" 51 — 53 Dochmius duodenalis, or Ankylostoma duo-
Rheumatoid Arthritis f: — — — denale .. 971 87 383
Scarlet Fever — .. s$ oe — — — Filaria medinensis (Guinea worm) d 4 — 5
Scurvy na rv i xS ex 1 -- 1 Tape-worm ae í T © — — —
Septicæmia a Ro AN "s A 1 1 1 Poisons— oe ve ei oe e — = —
Sleeping Sickness E" é — — — Suuke-bites — .. Pr e. m ©. — — —
Sloughing Phagedæna Ss ; 73 48 78 Corrosive Acids T e + == =
Small-pox .. be 2: 1 es .. 468 105 482 Metallic Poisons "T ig ae — — —
Syphilis .. į ex 2 46r ar 77 Vegetable Alkaloids .. F T 10 — 10
(a) Primary .. oe m oe . — — -— Nature Unknown ae ae ee — — —
(b) Secondary .. "i FA y " => =< = Other Poisons SA 4$ «3 ya — — —
(c) Tertiary — .. ie i F = + — Surgical Operations — .. sè un . 15 — 15
(d) Congenital .. ` — — — Amputations, Major .. ss oe — — —
Tetanus ; 2 2 a Minor .. F oe T — — —
Try panosome Fever ^ — — — Other Operations es m T ya 55 — =
Tubercle— : = = — Eye .. T zh - 1 — 1
(a) Phthisis Pulmonalis os ` — — — (a) Cataract $ d — — —
(b) Tuberculosis of Glands . $2 2 T (b) Iridectomy — — —
(c) Lupus
(c) Other Eye Operations s% a
Nov. 15, 1913.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 87
JASIN HOSPITAL.
The year 1911 was notorious for unhealthiness
and in consequence the hospital was often over-
crowded. A large number of the admissions were
estate coolies, chiefly from Bukit Asahan, Jasin,
Rim, Kemendore, Bukit Kajang, Ayer Panas and
Garing. In all some 1,042 estate coolies were
admitted.
There was a great increase in the number of
females treated in hospital, rising from 70 in 1910
to 105 in 1911. The total number of cases treated
was 1,628, showing an increase of 575 as compared
with 1910, with a daily average of 95°63.
Malarial fever, as usual, claimed the largest
number of admissions, viz., 497 cases with 63
deaths, or 12°67 per cent. Dysentery and enteritis
came next with 176 cases and 63 deaths, or 35°79
per cent. Beriberi had 187 admissions with 15
deaths, or 10:95 per cent. Ulcers 169 with no
deaths. The death-rate for the year was 12°69
per cent., but deducting deaths occurring within
48 hours of admission it was 8°63 per cent. Pul-
monary phthisis showed the highest mortality, viz.,
46:84 per cent., dysentery 42°73 per cent., small-
pox 20°54 per cent. As most cases are admitted
into hospital in a very grave or advanced stage of
the disease this high mortality is not surprising.
Small-pox continued throughout the year in the
Jasin District, and it became necessary in 1911 to
erect a new temporary shed in the Quarantine
Camp. One hundred and thirty-four cases of
small-pox, chicken-pox, measles, and observation
were treated in the Camp with a death-rate of
11:19 per cent. Of the 1,623 admissions, Tamils
were 830, Chinese 540, Malays 243, and Indians 10.
ALOR GAJAH DISPENSARY.
This year was a memorable one in Alor Gajah
District for the continuance of the epidemic of
small-pox, which started in 1910 and lasted
throughout 1911, causing 252 reported cases, 228
being admitted into the Quarantine Camp for treat-
ment. There were 60 deaths, of which 43 occurred
in the Camp. With the view of suppressing the
disease Assistant-Surgeon de Cruz was stationed
at Alor Gajah from December 13, 1910, to May 8,
1911, Dresser R. Lazaroo from April to June,
Dresser M. Danker from April to May, while
Dresser Nonis was sent to Sungai Bahru. Vaecina-
tions were pushed so that there were 7,808 vaccina-
tions done in 1911.
GAOL HOSPITAL.
There were 23 cases treated, with 1 death. The
larger number of admissions this year was due to a
number of vagrants being arrested by the police
and sent to prison. These men were for the most
part broken down, debilitated and diseased indi-
viduals. Of the 23 admissions, 8 were for diar-
rhea, 5 for malarial fever, 4 for anemia, 3 for
dysentery, 1 mumps, 1 colic, and 1 abscess.
ESTATE HOSPITALS.
Bukit Asahan Central Hospital.—This hospital
has seen may changes in its staff. The present
Estate Medical Officer joined early in the year and
the hospital at once showed signs of improvement.
There is a good supply of drugs and instruments,
while the dietary is very carefully attended to.
The returns of these hospitals show an increase
in the admission with a high death-rate. This was
the result of an unfortunate experiment made of
introducing Tamil labour, care not being taken to
see that only agricultural labourers and healthy
people were selected. As these coolies were likely
to be a drag on the estates besides filling the
hospitals and increasing the death-rate, the Com-
pany arranged to repatriate all who desired it and
so several hundreds were sent back to India. The
heavy mortality, viz., 10°6 per cent., amongst the
Tamil coolies was due to malaria and dysentery.
As prophylactic measures for the former, quinine
was served out to all coolies, and ravines drained
as far as practicable. Certain lines proved regular
malarial haunts and had to be abandoned, the
coolies being removed to other and healthier lines.
As this estate, like all Malacca itself, has swamps
and jungle belts all over it, the question of the
eradication of malaria is a difficult if not hopeless
one. Great improvements, however, can be made
and are being now done. Dysentery accounted for
466 admissions with 117 deaths. The dirty habits
of the Tamils, their partiality for polluted water,
their ignorance of cleanliness and care in dietary
for bowel disorders, and, above all, their quick
depression and home sickness, all tended to produce
a high mortality. Careful dietary is the prime
factor of treatment, and this cannot be secured
among a people who clamour for curry and rice
and who manage to get unwholesome and deleterious
food-stuff smuggled in to them when under treat-
ment in hospital.
During the year 8,025 in-patients were treated
in the Central and Divisional Hospitals with 396
deaths, giving a percentage mortality of 4:9. The
daily average number of coolies, including all
nationalities, was 6,000, thus the estate had a
death-rate of 66 per mille. Out of 896 deaths 263
oceurred among Tamils, and as recruiting from
India has now been stopped and as several sanitary
measures are in progress, there is every prospect
of Bukit Asahan becoming healthier.
PENANG PAUPER WARD.
Report BY Dr. J. S. WEBSTER, MEDICAL OFFICER.
During the year the patients have been placed in
the upper storey of the Female ward.
A new latrine connected to the ward by a covered
way has been erected and is used only by these
patients; two new bathrooms have also been built.
There have been 266 admissions with 15 deaths,
against 148 admissions in 1910 with 12 deaths,
which shows an increase of 79 per cent. in the
number of patients and a decrease of 25 per cent.
in the mortality.
88 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
[Nov. 15, 1913.
The majority of patients were Chinese. The
chief cause of death was phthisis.
QUARANTINE.
Report BY Dr. G. E. Brooke, Port HEALTH
OFFICER, SINGAPORE.
During the year 2,100 visits were paid to vessels,
which included the examination of 110,882 crew and
427,409 passengers.
Of these ships, 75 were infected: Small-pox, 40;
plague, 4; cholera, 31.
The s.s. Hygeia was used for disinfecting pur-
poses on 208 occasions, and was also used 19 times
for transport of police and heavy stores to St. John’s
Island.
The extra amount of work done by the s.s. Hygeia
this year is accounted for by the declaration of
Singapore as an infected port (plague) by the Dutch
Government.
To oblige the shipping firms, therefore, all out-
going steamers for Dutch ports were disinfected
prior to departure, as is always done for the Austra-
lian ships. The Dutch Government have now
established a plant at Pulau Samboe which has
greatly relieved the pressure.
In a large and busy port like Singapore a second
disinfecting launch is almost a sime quá non; the
matter of providing for this is now under con-
sideration.
By courtesy of the Marine Department a Health
Certifieate Form was presented to the surgeon or
master of 5,700 vessels which, being not in quaran-
tine or not from an infected port, are not boarded
by the Port Health officials. These certificates
represented 292,896 crew and 306,654 passengers,
of whose health the Port Health Department was
thus immediately informed.
Cases of deaths occurring on steamers or sampans
in the port numbered 46. Of these, 39 were allowed
ashore for burial and 7 suspicious corpses were sent
to St. John's for post-mortem examination and
burial.
Nineteen visits were paid to the Government
Marine quarters. Two cases of cholera occurred in
the engineers’ quarters during the year. The con-
tacts were promptly removed to St. John's and no
further cases occurred. The house was vacated
after disinfection. The origin of the cases was not
traceable. The health of the staff has been on the
whole fairly good.
Quarantine Station.—The station was occupied
every day of the year. The total number of pas-
sengers landed was 53,961, as compared with 35,062
the previous year. The maximum number on any
day was 4,892.
The total sick treated in hospital was 1,612; the
daily average being 41:2 and the maximum number
on any one day being 150. The number of deaths
totalled 887, giving a death-rate of 24 per cent.
The rainfall was 60:84 in.—an exceptionally dry
year.
Vaccinations were done on the station to the
number of 1,972.
During the year the distilling plant worked well,
942,450 gallons of water being produced.
Cholera having broken out at Pasir Panjang
amongst the lunaties and beriberi patients, 146 were
removed to St. John's on August 19, 2 more on
August 21, and 87 on August 24. Five cases
oceurred on admission, 9 subsequently, and also 2
amongst the attendants, making a total of 16 cases,
of whom 14 died. There were also 3 deaths from
other causes. The remainder were discharged on
September 19, with the exception of a few con-
valescents in hospital. The disease appeared at
first to be spreading rapidly, and I attribute its
speedy decline to the administration of eucalyptus
oil as a prophylactic, and to the perpetual insistence
on hand-washing before eating. General cleanliness
and fly prevention seem to be of slight avail unless
accompanied by these two precautions.
The Public Works Department have erected a
sample latrine on a plan with which I furnished
them. This has not yet had a trial. The model
is one evolved, after some thought, as a suitable
one for estates, &c., where no water system is
available. The principle is that of two rollers with
an endless canvas belt. The lower portion of the
belt is perpetually immersed in a tank containing
a thin solution of tar. The upper portion forms
the fecal catchment area and is the sole floor of the
building—the squatting bars being raised above it.
A few turns of the roller suffice to remove the
fæces into one collecting box, and at the same time
a freshly-tarred surface is replaced for use.
If foul the belt can easily be removed and burnt
and a new one inserted. It should ensure a maxi-
mum of cleanliness and a minimum of scavenging
labour.
Only two prosecutions were undertaken during
the year. One was in the matter of the s.s. Curonia,
a Russian vessel, which brought coolies from Amoy
and Swatow. A cholera epidemic had occurred
during the voyage and the report of this was sup-
pressed by the officials. As the ship was then
apparently healthy the coolies were all released and
came ashore in Singapore. The result was a small
epidemic in the town, which fortunately did not last
many weeks. The master was discharged and the
doctor fined $500.
The other prosecution was that of some Tamils
who had buried their dead small-pox child beneath
the floor of their kitchen at Siglap. In this case
there was a sentence ef $50 or three weeks imposed.
PENANG.
Report sy Dr. J. C. C. Forp, MEDICAL OFFICER.
During the year 1,144 vessels were visited and
61,836 crew units and 215,815 passengers were
inspected.
During the cholera epidemie in Kedah particular
attention was directed to junk traffic from Kedah
ports. In the months of February, March, April,
May and June 310 junks with 1,500 members of
crew and 19 passengers were detained in quarantine
and released after disinfection of water tanks, &c.
Dec. 1, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 89
Colonial Medical Reports.—No. 23.—Straits Settlements—
(continued).
Under the Pilgrim Ships Ordinance 8 vessels were
inspected and cleared for Camaran and Jeddah.
The number of pilgrims embarking at this port was
1,882. Small-pox infection occurred on 7 out of the
13 vessels carrying Hadjis returning from the
Hedjaz. One vessel was infected with bubonic
plague as well.
Small-por.—The large majority of the cases were
imported from Jeddah. Out of 96 cases removed
from vessels, 83 were removed from pilgrim vessels.
Thirty-two cases were landed in quarantine from one
vessel alone.
Cholera.—Nine cases were imported: From
Kedah, 1; Negapatam, 7; Asahan (Sumatra), 1.
The cases from Kedah and Asahan occurred
among the crew.
On one occasion, when cholera was epidemic in
Madras, the usual weekly vessel arrived with infec-
tion in the first and second saloons and 'tween decks.
Plague.—One case bubonie plague was removed
from a vessel arriving here from Rangoon.
The number of vessels, junks, &c., which required
inspection on arrival here was larger than usual.
Cholera was epidemie in Kedah, the west coast
of Siam and Lower Perak from February to July.
The increase in immigration from India, through
Madras and Negapatam, necessitated extra vessels
being put on the run during the months of May,
June and July.
PULAU JEREJAK.
The old Quarantine Station was occupied through-
out the year. The new Station at Sungai Panchor,
Pulau Jerejak, was occupied on April 6. It was
intended when the new station was opened to vacate
the old station, but the abnormal rush in immigra-
tion from Madras and Negapatam and the combined
occurrence of cholera among them necessitated the
re-oceupation of the old station. During the last
few months of the year a limited portion only of
the new station was available while structural
alterations and additions were being carried out.
The number of passengers detained for observa-
tion, sickness, &c., from 214 vessels was 134,957,
which ineludes 61,690 immigrant coolies.
The maximum number in detention on a single
day on the combined stations was 11,738; the maxi-
mum numbers at the new and the old stations were
10,126 and 5,963 respectively.
Vaccinations (including re-vaccinations) to the
number of 73,988 were done by the Vaccinator.
One adult male developed small-pox, im a modified
form, eight days after successful vaccination. One
adult female and one adult male, who both bore
good marks of vaccination, done in infancy, and who
subsequently had small-pox, as evidenced by their
pitted appearance, were successfully vaccinated;
the vesicles, however, were not typical.
There was a scarcity of water during the months
of March, April, July and August, and fresh water
was conyeyed to both stations from town in water-
boats. These were months of drought and both
reservoirs ran dry.
Cholera.—The outbreak of cholera, during the
months of June and July, occurred among the
immigrant coolies intended for estate labour, These
epidemics have occurred regularly since 1904, during
the months June to September; this season coin-
cides with the times of want and privation in the
recruiting districts in India, and the subsequent
rush of immigration to the Straits Settlements.
On June 22 no more could be accommodated at
either Quarantine Station, and the Teesta, which
arrived here infected, was sent on to Singapore,
where the passengers were removed to the Quaran-
tine Station on St. John’s Island.
From July the coolies for Selangor Estates were
sent direct to the temporary Quarantine Camp at
Port Swettenham for observation and disinfection
instead of being quarantined in Penang.
As a prophylactic, cholera vaccine was obtained
from the Pasteur Institute, Weltevreden, Batavia,
and 1,176 inoculations were done.
Several cases of cholera had occurred among
coolies. These inoculations were done when the
epidemic had practically ceased, and so it was not
possible to estimate the efficacy of the prophylactic.
However, no further cases occurred among those
inoculated, and it was possible to release them after
the fifth day.
The vaccine was injected subeutaneously into the
skin of the back, inside and next to the top of the
left shoulder-blade; the dose for an adult being
l c.c., for children from 5 to 15 years $ c.c., and
for those from 2 to 5 years 4 ¢.c.; infants in arms
were not inoculated.
Within twenty-four hours there was some reaction
with swelling and tenderness at the point of injec-
tion and very mild indisposition.
The majority of those inoculated on July 21
refused food the next day; this was not noticed
among those inoculated on July 31 and August 1;
this reaction passed away within thirty-six hours;
there were no accidental ill-effocts.
MALACCA.
On October 14 a case of cholera occurred in a
Chinese deck passenger on board the Lady Weld
from Singapore bound for Muar. The steamer
after disinfection was ordered back to Singapore
with the passengers for quarantine.
From that date all steamers coming from Singa-
pore were visited for the inspection of all passengers
and crew. Up to the end of the year 177 vessels
were thus inspected. Six thousand three hundred
and eight passports were issued to passengers per-
mitted to land, and opportunity was taken to get
landing passengers vaccinated. In all 4,610 pas-
sengers were thus vaccinated.
PATHOLOGICAL DEPARTMENT.
Report BY Dr. G. A. FINLAYSON, GOVERNMENT
PATHOLOGIST.
Laboratory.—During the year 895 specimens were
(Dec. 1, 1913.
90 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
examined, as compared with 879 in 1910 and 1,258
in 1909, 744 being sent in from the various Govern-
ment institutions, while 151 were submitted by
private practitioners.
Malaria.—The parasite was demonstrated in 44
blood films, the majority as usual showing a sub-
tertian infection. In 93 instances no parasite was
observed.
Widal Reaction.—In 157 instances, as compared
with 82 in 1910 and 202 in 1909, there was a positive
reaction, this again representing a somewhat lesser
number of cases of enteric fever, as in several cases
the blood was examined on more than one occasion.
The reaction was negative in 424 specimens.
The only noticeable feature is the marked rise
towards the latter part of the year, there being
almost as many positive reactions in the three
months September to November as in the rest of
the year.
Tuberculosis.—In 28 samples of sputa T.B. were
demonstrated; in 67 others none were observed.
Diphtheria.—Six swabs from the fauces of sus-
pected cases of diphtheria were examined, but from
none was the specific organism cultivated.
Gonorrhea.—Twenty smears of urethral or vaginal
discharge were examined; in 8 the diplococci were
noted.
Various.—Other samples included three of urine
for casts, &c., 28 of fæces for amcebe or ova, 6 blood
films for differential count, several pieces of tissue
for microscopical diagnosis, and 2 positive leprosy
smears.
Water: Municipal Supply.—Fifty-two specimens
were examined, the weekly sample being taken
from standpipes scattered over the municipal area.
The standard remains fairly constant, the average
number of micro-organisms per cubic centimetre
being 305 on agar and 280 on gelatine medium, as
compared with an average of 240 on agar in 1910.
In MacConkey's medium °25 c.c. produces gas and
acid within twenty-four hours.
THE MEDICAL DEPARTMENT, LABUAN.
Report By Dr. T. C. CLEVERTON, MEDICAL OFFICER.
Table showing the estimated population, with the
birth- and death-rates, for the years 1909 to 1911 :-—
Year copulation: Births Deaths EI Death e
1909 8,281 183 197 22:28 23:93
1910 8,199 235 267 28°66 82:56
1911 6,545 189 183 28:87 21:97
These figures are according to the returns of the
Census taken on March 10, 1911. The total
number of males was given as 3,932, females as
2,018. The different nationalities were not grouped
and numbered. This is the first year since 1906
that the births have outnumbered the deaths in
Labuan. There are no figures prior to 1906.
. The marked decrease in the population since 1910
is due to the exodus which took place at the time
of the closure of the coal mines at Coal Point early
in January, ;
Of the total number of deaths, 57 were ascribed
to '' fever," 23 to pulmonary tuberculosis, 16 to
debility and age, 10 to beriberi, and 6 to dysentery.
No epidemic disease has occurred during the year.
Two cases of small-pox were isolated in a hospital
building; one of these was taken from the s.s.
Marudu, and the other occurred in Labuan. Both
had been vaccinated a short time previously, and
were mild cases.
Malaria.—This disease is very prevalent. During
the year 118 cases were admitted to hospital out of
a total of 276 admissions, and 479 cases were treated
us out-patients. Fifty-seven deaths were attributed
to '' fever " out of a total mortality of 183, com-
pared with 70 deaths out of a total of 267 deaths in
1910. The type of malaria has been severe during
the year under review, 31 cases being subtertian
as against only 19 in 1910. Practically all new
police become infected within a month of their
arrival in Labuan. Some of these cases may be
relapses, but many of them appear to be genuine
new infections. This was strikingly evident when
a number of police were sent up from Singapore
early in the year.
Beriberi.—Thirty-four cases have been admitted
to hospital, compared with 44 in 1910. The number
of deaths in hospital under this disease was 6, as
against 18 in 1910. Parboiled rice was given
throughout the year except towards the middle of
December, when the supply temporarily failed. The
adoption of parboiled rice may have been a factor
in decreasing the mortality rate of the patients
under treatment, but it was noted that the disease
wus not so far advanced in those admitted as was
seen in most of the cases in 1910.
Venereal Diseases.—Fourteen cases were admitted
during the year.
Pulmonary Tuberculosis.—Eight cases were ad-
mitted to hospital during the year, as against 11 in
1910. Twenty-three deaths were attributed to this
disease, making a percentage of 12:56 of the total
death-rate.
Dysentery and Diarrhea.—Thirteen cases were
admitted to hospital during the year, as against 9
in 1910. Eight deaths were attributed to these
diseases.
Police Force.—The general health of the police
throughout the year was satisfactory except for
malaria. The number of cases of all diseases
amongst the force admitted to hospital was 67 (the
same number as last year), of which 38 were ad-
mitted for malaria. Three deaths occurred amongst
the police, one from cerebro-spinal fever, one from
malaria, and one man was murdered.
Prisoners.—The general health of the prisoners
was excellent throughout the year. No prisoners
died, but there were two deaths in hospital amongst
the vagrants committed to the House of Detention.
Out-patients.—The total number treated during
the year was 915. The number of Malays present-
ing themselves as out-patients for treatment is
steadily increasing.
Sanitation.—An inspector was appointed under
the Sanitary Board at the beginning of the year,
PTR ETE IST exec tee hb Lr
bo dope L4
Dec. 1, 1913.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 91
RETURN or DISEASES AND DEATHS IN 1911 iN THE LABUAN HOSPITAL,
Straits Settlements.
GENERAL DISEASES. ge $3 1i
i: 2 cr ane m
£8 1 ESS GeneraL DisEAsEs— continued.
; e 8 = (d) Tabes Mesenterica : T ce
Alcoholism X ean) te (e) Tuberculous Disease of Bones .. - --
VERE LS 1 Other Tubercular Diseases = =
riders $n s. 7 Varicella .. z iy SS
Beriberi 34 6 4 Whooping Cough a MIS
Bilbarziosis — — = Yaws P : 3 —
Blackwater Fever — — -— Yellow Fever — =
Chicken-pox — — =
Cholera — — —
Choleraic Diarrhæa x Ze S = LOCAL DISEASES.
Congenital Malformation ey Ss =
Debility 6 2 6 Diseases of the—
Delirium Tremens -— — — Cellular Tissue uc
Dengue .. — — — Circulatory System — —
Diabetes Mellitus | — — — (a) Valvular Disease of Heart 2 1
Diabetes aaa ipa - — — (b) Other Diseases .. . — —
Diphtheria è — = — Digestive System — "ER T
Dysentery .. 11 8 11 (a) Diarrhoea os — oem
Enteric Fever —— — (b) Hill Diarrhea .. Se es
Erysipelas .. — — — (c) Hepatitis rm
Febricula .. — — = Congestion of Liver = ex
Filariasis .. e e . ae — = — (d) Abscess of Liver =. =
Gonorrhea és sa T T 1 — 1 (e) Tropical Liver ... vs ris
Gout . — — — (f) Jaundice, Catarrhal =).
Hy drophobia 2 a— at — (g) Cirrhosis of Liver = =
Influenza .. ae e = = — on Acute Yellow Atrophy m
Kala-Azar.. — — -— (à Spre .. . . Ss.) Fe
Leprosy .. — — — . _ (j) Other Diseases .. = =
(a) Nodular — — — Ear 5 z4 E ies
(5) Anesthetic . — = — Eye z e oe si s 3 —
(c) Mixed — — — Generative Sy stem— ie ate 4s os = —
Malarial Fever— — = — Male Organs =n UE
(a) Intermittent NOSE = Female Organs =
Quotidian .. = = — Lymphatic System =) AS
Tertian 81 — 83 Mental Diseases 2. —
Quartan p = 1 Nervous System 5 =
Irregular .. 31 3 32 Nose .. , E TES
Type undiagnosed — — — Organs of Locomotion mS "m
(b) Remittent . als DT Respiratory System 12 3
(c) Pernicious .. — — — Skin— .. ure
(d) Malarial Cachexia . . 5 1 6 (a) Scabies zm
Malta Fever : — = — (b) Ringworm on eX ues
Measles — — -- (c) Tinea Imbricata zc
Mumps . ee — — -— (d) Favus = i.
New Growths— .. — — — (e) Eczema .. e =s. ge
Non-malignant = 2s = ( f) Other Diseases .. —
Malignant . - = — Urinary System . ET
OldAge .. es = = = Injuries, General, Local— = =
Other Diseases 2 1 2 a) Siriasis (Heatstroke) T = =
Pellagra — — — b) Sunstroke (Heat FEGURDUM c ow
Plague — — — (c) Other Injuries dile:
Pyemia — — — Parasites— m =! emm
Rachitis ve — — — Ascaris lumbricoides .. EX =
Rheumatic Fever — — — Oxyuris vermicularis . = ince
Rheumatism . — — — Dochmius duodenalis, or Ankylostoma duo-
Rheumatoid Arthritis — — — denale : SS
Scarlet Fever — — = Filaria medinensis (Guinea- omm) EY em
Scurvy .. = = — Tape-worm P s
Septicemia . 1 — 1 Poisons— n c
Sleeping Sickness. — — — Snake-bites = =
Sloughing Phagedena = = =. Corrosive Acids E. tS
Small-pox .. ys 2 — 2 Metallic Poisons EX ds
Syphilis — — — Vegetable Alkaloids A I
(a) Primary ) — 1 Nature Unknown — —
(b) Secondary .. D ou 5 Other Poisons 5 T v — —
(c) Tertiary LES 1 Surgical Operations— .. Y T — —
(d) Congenital . = = — Amputations, Major .. vi x — —
Tetanus = — = Minor .. és Ar =
Trypanosome Fever — — — Other Operations T is oe Mero gu
Tubercle— — — = Eye . bi es ae "D A
(a) Phthisis Pulmonalis ex — — = (a) Cataract. T zm m i EB ce
(b) Tuberculosis of pande a = — — (b) Iridectomy .. ve "A
(c) Lupus ve Ey ds
(c) Other Eye Operations m ii
92
COLONIAL MEDICAL REPORTS: pA ORTEERN NIGERIA.
[Dee. 1, 1913.
and the appearance and general condition of Victoria
has eonsiderably improved.
Vaccination.—The number of cases vaccinated
was 229, as against 235 in 1910, Seventy-one were
done by a private medical practitioner. Of the total
number vaecinated 205 were successful, 14 were
failures, and 10 were not seen. There were 43
vaccinations done on infants of 3 months and
under, 106 on children of 4 months to one year,
and 80 people of one year and over.
Meteorological.—The north-east monsoon started
about the end of January and lasted to the begin-
ning of April; during this time the rainfall was so
small as to occasion a shortage of water in the
hospital well with total failure in March. The
south-west monsoon blew from the beginning of
April to the middle of October, when the north-
east monsoon set in again, and blew to the end of
the year. The total rainfall was only 99:82 in.,
being the lowest on record for atleast six years. In
1910 the total rainfall was 151:25 in. The wettest
month was October, with 26:18 in. The greatest
rainfall in the twenty-four hours occurred on October
19, when 5:65 in. fell. The highest temperature re-
corded was 949 F. on January 18, and the lowest
temperature was 719 F., which was recorded on
three occasions during the year.
The Hospital.—The total number of admissions
was 276, including 7 Europeans, and the total
number treated in hospital was 296. Eleven re-
mained over in hospital at the end of the year.
Twenty operations were done on in-patients. There
were 22 deaths in hospital, giving à percentage of
deaths to total treated of 748. Seven deaths
oecurred within twenty-four hours of admission.
The chief diseases treated in hospital during the
year were malaria 122, with 4 deaths; beriberi 44,
with 6 deaths; pulmonary tuberculosis 9, with 3
deaths; and dysentery 11, with 3 deaths.
Colonial Medical Reports.—No. 24.—Northern Nigeria.
MEDICAL REPORT FOR THE YEAR 1910.
By J. P. FAGAN.
Acting Principal Medical Officer.
THE general health of both Europeans and natives
in the Protectorate during the year may be con-
sidered as satisfactory when compared with past
years.
The general character of the diseases prevailing
showed little change.
During the year 3,899 paupers were treated at
the expense of the Government.
Appended is a list of cases of blackwater fever :—
Number of cases, 9; rate per 1,000 of average
population, 14°12; number of deaths, 2; case of
mortality per cent., 22:2.
There were 3,942 successful vaccinations per-
formed.
METEOROLOGY.
Detailed monthly reports are submitted from
eighteen stations. They are accepted as reliable
by the Meteorological Society. The medical officer
of each station is responsible for the record.
Highest shade temperature—1149 F. at Geidam,
March 23, and at Maiduguri on March 26. Lowest
shade temperature—39° F. at Sokoto on January 4.
Highest mean shade temperature—84°29 F. at
Baro. Lowest mean shade temperature—70:39 F.
ut Ankpa. Greatest rainfall (annual total), 56:44 in.
at Ankpa. Greatest fal on one day—5 53 in.
on August 6 at Zungeru. Lowest rainfall (annual
total), 16:87 in. at Geidam (no record for May).
Greatest range of temperature—739 F. at Maiduguri
1149—41? F.
There is a European and native hospital at each
of the following stations: European—Lokoja, 12
beds. Baro, temporary for Baro-Kano Railway
construction. Zungeru, 12 beds. Native—Lokoja,
52 beds. Baro, temporary for Baro-Kano Railway
construction. Zungeru, 48.
TABLE SHOWING THE Sick, INVALIDING, AND DEATH-RATES OF EUROPEAN OFFICIALS.
Total number of officials resident
Average number resident
Total number on sick list
Total number of days on sick list
Average daily number on sick list
Percentage of sick to average number resident
Average number of days on sick list for each paheni
Average sick time to each resident EN e
Total number invalided . ess
Percentage of invalidings to total residents ...
Total deaths |
Percentage of deaths t to total residents. Me
yy average number resident ...
Number of cases of sickness contracted away from residence
Official Non-oflicial Total
424 213 637
— 1,089
<= m 163 1
31 17 48
73 T9 7:5
7 6 13
1:65 2:81 2:04
Dec. 15, 1913.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 93
Colonial Medical Reports—No. 24.—Northern Nigeria—
(continued).
At every other station & hospital for natives is
erected if necessary.
In the out-stations Europeans are treated in
quarters.
RETURN OF STATISTICS OF POPULATION FOR THE YEAR.
Europeans
and Whites
Number of inhabitants in 1909 ... sse e. 044
ji births during the year 1910 ... "TOES
21 deaths during the year 1910 ... ws 8
$5 immigrants during the year 1910 ... —
ji emigrants during the year 1910 e —
S: inhabitants in 1910 ... n .. 687
Increase is à ht : 93
SANITATION.
During the year, in the course of touring, I
personally visited a considerable part of the Pro-
tectorate.
In April I inspected the whole length of the
railway from Baro to a point 27 miles beyond
Zaria: partly running line and partly the distal
earthworks with the type-camps.
During July my travelling began at Zungeru, was
continued via Minna along the course of the rail-
way to Zaria and back to Zungeru on August 6.
In the course of this tour I arranged, in associa-
tion with the Resident of the district there, the
laying out of a new town at Minna for the rapidly
growing native population.
I then laid down certain principles to be adopted
in the laying out of new native towns. His Excel-
lency assented to these principles with some
reservation.
The important point is that the principle has been
laid down that, in future, all new towns in the
Protectorate shall be laid out in straight lines with
broad thoroughfares, that a straight lane shall
separate the mutual backs of parallel rows of com-
pounds, that no compound shall front a thorough-
fare less than 50 ft. broad, and that the regularity
of the thoroughfares shall be maintained by the
compounds being kept of a uniform depth.
On arrival at Zaria I found His Excellency
himself there, and he invited my advice on the
laying out of the station there, ‘‘ from the point
of view of sanitation.”
His Excellency expressed his intention to embody
the advice given in the standing instructions for the
laying out of new stations.
While at Zaria, also, I had—in association with
Mr. Resident Withers-Gill and Dr. Porteous, the
Medical Officer—a consultation with the Emir
touching the sanitation of the city of Zaria, and,
incidentally, of the other towns in his emirate. For
an African, the Emir, although an old man for a
native, is wonderfully receptive of and responsive
to new ideas.
The chief points dealt with during the interview
with the Emir were the dangers arising from flies
and mosquitos, and the means of keeping those
insects down; the necessity for utilizing the mud
from broken down walls and ruinous houses for the
filling up of the borrow-pits; the obligation resting
upon him to see that future mud for house building
was brought from a distance, and preferably from
the banks of a stream; the necessity for protecting
wells by parapets and keeping them mosquito-proof ;
and the cause of barrenness and of infantile mor-
tality together with the means of fighting against
them.
At Zungeru, the capital of the Protectorate, great
sanitary improvements have been effected. As a
consequence of this, flies are much less numerous
than they were formerly.
In August I left Zungeru on another tour of
inspection. The first place visited was Lokoja, the
oldest centre of European activity in Northern
Nigeria, and which, with its large native town, has
been, until recently, probably the most insanitary
one in the whole Protectorate.
In the early days of Imperial administration
Lokoja was a large military centre; the medical
staff were largely absorbed by military expeditions
and patrols; the administration had little time or
money to devote to sanitation; and, consequently,
vested interests were allowed to grow up in Lokoja
native town, which every year rendered much-
needed radical sanitary reform more and more
difficult.
I went into the whole matter of the native town
with His Excelleney the Governor, who seized this
opportunity of dealing drastically with the existing
state of affairs. The plan for reform suggested by
me was to the effect that the entire native town
should be transferred to a new site across the Mimi,
a small stream which enters the Niger below Lokoja.
The diffieulty at Lokoja demonstrates the embar-
rassments which are bound to arise. The sanc-
tioned plan of improvement was at once proceeded
with, and is now being gradually carried out.
In the course of the journey up and down the
Benue, Yola, Niuman, Lau, Ibi, Abinsi, Loko, and
Bogana were visited.
At Yola recommendations were made touching
‘the gradual transfer of the station to a better site,
and numerous sanitary questions were discussed.
At Niuman, Lau, Loko, and Bogana nothing
could be done; but notes were taken of the exist-
ing state and more clamant requirements.
At Ibi, the most important town on the Benue
and the headquarters of Muri province, a week was
spent, and the condition of the place was gone into
carefully.
At Abinsi the whole condition of the place was
diseussed with the medical and political officers.
At high river marshes extend along both banks
of the Benue practically all the way from Yola to
Lokoja; and, in the dry weather, along many ex-
tensive reaches. It would be impossible to render
the places bordering the river sanitary, in the
perfect sense of the term. But improvements are
being steadily carried on; material changes for the
better within a reasonable time.
94 COLONIAL MEDICAL REPORTS.—STRAITS SETTLEMENTS.
(Dec. 15, 1913.
The province of Bassa more closely resembles
the Southern Nigerian country above the Delta
than does any other province in Northern Nigeria.
The country is covered by dense forest; the native
towns, as a rule, are buried in forest fastnesses;
tsetse-flies abound and render the constant presence
of horses and cattle—except the small semi-wild
breed of Okpoto cattle—impossible ; and the country
is infested by chiggers.
At present the Bassa pagans are not practically
approachable, from the sanitary point of view ; until
recently each village has been quite independent of
the next one, and with which it has often been at
war, while each village has been—and often still
is—intensely jealous of its petty, parochial inde-
pendence.
After leaving Bassa I proceeded to Baro, the
headquarters and starting point of the railway.
Baro is situated in a horseshoe or amphitheatre.
scooped out of a table-land on the left bank of the
Niger. Most of the Europeans live either on the
table-land or, at least, uphill from the horseshoe.
During the rains tsetse-flies abound, tachinoides
and palpalis in the horseshoe and up the cliff, and
morsitans on the table-land behind. The fly
nuisance has been greatly reduced since the com-
pletion, in 1909, of extensive clearing of trees and
bush by Dr. Chartres.
Several cases of trypanosomiasis in natives have
been discovered at Baro. It is impossible to say
if all or any of these cases were or were not impor-
tations.
On November 25 I left Zungeru on a long tour
of inspection, and the end of the year found me
at Naraguta, less than half-way through that
tour.
The first objective was Kateri, a Kadara village.
Kateri had been reported to be the centre of an
outbreak of sleeping sickness, and I went thither,
accompanied by Dr. Simpson, Entomological Expert
for West Africa, by Dr. Scott-Macfie, and by Dr.
Porteous, who came in the dual capacity of local
medical officer and as representative of the Resident,
who could not come.
Kateri is situated in the midst of a dense kurumi,
and the surrounding country is dotted all over with
kurumis, nearly every one of which conceals a
village.
A kurumi is the Hausa term for a piece of marshy
ground, covered by dense forest and scrub. Drs.
Simpson and Seott-Maefie found palpalis in every
kurumi examined.
On arrival at Kateri all its inhabitants, eighty in
number, were apparently well—all the sick having
died before our arrival. The whole eighty people
were examined, and blood films were taken from
ull; thirty-four showed enlargement of the cervical
glands. In none of the cases was the cervical
enlargement well marked; in fact, it was made out
with diffieulty in some of the cases, and in a few
of them was confined to one side. Dr. Scott-Macfic
discovered a trypanosome in the blood of one of
the women, but careful examination failed to dis-
cover the parasite in any other case.
At several other villages in the distriet blood was
taken from people who exhibited slightly enlarged
cervical glands, but in all cases without any positive
result. The blood films were all carefully re-
examined at Zungeru, but again the parasite was
only seen in one—to wit, that from the woman at
Kateri.
The Kadaras wear very little clothing. This,
combined with their inveterate love of living in
kurumis and the wide distribution of Glossina
palpalis in their country, renders them peculiarly
vulnerable to the eause of sleeping sickness.
On December 7 I marched to Naraguta. The
country in the neighbourhood of Naraguta is full of
good sites. I selected what I considered the best,
His Excellency approving the selection.
Steady efforts are being made to secure the
universal principle of surrounding wells with
parapets to prevent their contamination.
Mosquito-borne, fly-borne, and tick-borne dis-
eases, water-borne diseases and leprosy need to
have constant war waged against them. But in the
Mohammedan part of Northern Nigeria—by far
the most important area of the country—venereal
diseases work more havoc than do all the diseases,
mentioned above, put together.
Syphilis and gonorrhea account for a larger
number of the numerous cases of blindness, gener-
ally ascribed by the natives and non-medical
Europeans to small-pox; syphilis causes an enor-
mous amount of abortion, stillbirth, and infantile
mortality; and it is no exaggeration to say that,
outside of the pagan country, one half of the women
of child-bearing age are barren on account of early
gonorrhea. This state of affairs tends to keep the
population stationary, or even decreasing.
Steps have also been taken to initiate the estab-
lishment of segregation camps for lepers throughout
the country.
By an Order under the Infectious Diseases Pro-
elamation 1908 (section 4), the provisions of the
Infectious Diseases Proclamation were applied to
yellow fever.
During the year 254 Europeans and 1,892 natives
were treated for malarial fever, of whom one
European and 13 natives died. These figures refer
to the number of cases treated, and do not neces-
sarily mean 1,646 separate individuals.
In Lokoja, Baro, and Zungeru, puddles which
cannot be effectively drained or filled up are
regularly oiled; and the same prineiple is applied
at bush stations when possible. Watereourses are
kept clear, as far as the supply of labour available
permits.
The Cantonment Magistrate at Lokoja arranged
to let out the whole waste land within that canton-
ment, without rent, to cultivators, on the condition
of cropping the entire surface of their holdings
with short crops. If this seheme work, the canton-
ment will be kept thoroughly clear without extra
expense.
Borrow-pits. are either drained or filled up; no
new borrow-pits are permitted to be made within
the confines of stations; the wells in stations are
Dec. 15, 1913.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Return or Diseases AND Draras IN 1910 rw
Northern Nigeria.
GENERAL DISEASES.
Alcoholism .. "is
Anemia ..
Anthraz n^
Beriberi 2 es Vs
Bilharziosis T 2s
Blackwater Fever .
Chicken pox : Fa
Cholera vis Pr
Choleraic Diarrhaa 3
Congenital Malformation
Debility . E
Delirium Tremens 5
Dengue s 3%
Diabetes Mellitus . a
Diabetes Insipidus -
Diphtheria .. es
Dysentery ..
Enteric Fever
Erysipelas ..
Febricula
Filariasis
Gonorrhea .
Gout.
Hy drophobia.
Influenza
Kala-Azar ..
Leprosy ..
(a) Nodular
(b) Anesthetic ..
(c) Mixed
Malarial Fever
(a) Intermittent
Quotidian..
'Tertian 2
Quartan .. es
Irregular ..
Type undiagnosed
(b) Remittent ..
(c) Pernicious ..
(d) Malarial Cachexia .
Malta Fever $ she
Measles
Mumps
New Growths— ss
Non-malignant .. $
Malignant
Old Age ix T
Other Diseases ..
Pellagra a M
Plague T Ss T
Pyæmia $a 2
Rachitis .. 5 m
Rheumatic Fever . m $
Rheumatism à
Rheumatoid Arthritis
Scarlet Fever s
Scurvy ae oe T
Septicemia . .
Sleeping Sickness .. .
Sloughing Phagedena ..
Smallpox día 9
Syphilis x dm
(a) Primary Re mm
(b) Secondary
(c) Tertiary
(d) Congenital
Tetanus i
Trypanosome Fever
Tubercle— ..
(a) Phthisis Pulmonalis
(b) Tuberculosis of Glands
(c) Lupus s. V
Europeans
————
i: 3
M i
53 —
1 <=
9 2
10
22 1
ANE e
a
250 1
j ae
2 2
l4 —
Natives
]
EE S T IL dad eee Deaths
Pl) te! |
Pl Ll deb pea
| e
rare
LL fowl mel | lel iol
leollSll i BeSlttitlli i
e
leli Il Emani lS]
e
Surgical Operations —
-95
Europeans Natives
Ss 2 #2 2 >z
55 3 53 3 ii
GENERAL Diseases -contmued. — 4^ À q^ à BOE
(d) Tabes Mesenterica .. — — — = —
(e) Tuberculous Disease of Bene. uA duh ex um —
Other Tubercular Diseases 1 — 8 3 10
Varicella .. A s e — = — — —
Whooping Cough . a — — 2 — 2
Yaws $4 . ss oe — — 9 — 91
Yellow Fever — — — — —
LOCAL DISEASES.
Diseases of the—
Cellular Tissue .. gx T 21 -- 604 — 057
Circulatory System— .. - — — — =
(a) Valvular Disease of Heart — — 28 9 28
(b) Other Diseases 7 1 30 4 37
Digestive System— Es - - — — —
(a) Diarrhoea E e 36 — 893 13 931
(b) Hill Diarrhæœa — = — — —
(c) Hepatitis . 4 -= 9 2 13
Congestion of Liver 8 — 6 6 15
(d) Abscess of Liver . - - - — —
(e) Tropical Liver — — — —
(f) Jaundice, Catarrhal 2 — 6 — 9
(g) Cirrhosis of Liver ic — = -—- = —
(h) Acute Yellow Atrophy te - - — — —
(i) Sprue bs a — = — — —-
(j) Other Diseases .. .. 207 — 2657 9 2875
Ear sy at Sy 16 — 142 — 158
Eye $5 ju = 8 738 — 754
Generative System — i s 20 — 321 6 347
Male Organs .. és ne - — - =
Female Organs 2d A — = — - —
Lymphatic System ale «e 16 — 212 — 282
Mental Diseases H3 sic 24 — 265 2 292
Nervous System f ^" 4 1 15 2 21
Nose . zs is 9 — 39 — 48
Organs of Locomotion $ 22 — 1128 — 1138
Respiratory Systeam a T 44 — 1191 13 1264
Skin— .. ew vx - = — — —
(a) Scabies — — 10 — 10
(b) Ringworm Pe T — 48 — 57
(c) Tinea imbricata .. — — — — —
(d) Favus os 55 - - — — —
(e) Eczema .. *^ ifs 4 — 48 — 59
(f) Other Diseases .. = 77 | — 1965 3 2154
Urinary System s ts — — — — —
Injuries, General, Local— ee 64 15942 17 5897
(a) Siriasis (Heatstroke) 4 — 1 1 5
(b). Sunstroke (Heat Prostration) 9 — 4 1 13
(c) Other Injuries — - — = —
Parasites— 9 — 988 1 1011
Ascaris lumbricoides — = — = -—
Oxyuris vermicularis — — — — —
Dochmius duodenalis, or Ankylo-
stoma duodenale .. — — — — —
Filaria medinensis (Guinea- s
worm) .. as EM i3 — — 70 — "4
Tapeworm — = = = —
Poisons— .. —
Snake-bites — 9) — 21
Corrosive Acids .. — — —
Metallic Poisons 1 — 3
Vegetable Alkaloids — — —
Nature Unknown — — —
Other Poisons 51 1 55
Amputations, Major
Minor e.
Other Operations. ws 2
Eye.. .. - oe
(a) Cataract |
(b) Iridectomy .. s
(c) Other Eye Operations
ek PE das Ead. |
kept covered when this is possible, but up country
it is often impossible to secure efficient covers; in
such cases the well is usually further distant than
a mosquito’s flight from any European residence.
During the last three years more attention has
been paid to the wells than was ever done before,
and their condition is being steadily improved.
The use of the mosquito net is universal among
the European community, while quite a consider-
able proportion of native servants, soldiers, police,
and other native employees, together with a good
many African non-natives, also habitually use it.
During the year eight cases of trypanosomiasis
were noted and seven were treated. One of the
cases ended fatally. One of the people affected
went to his own country on the coast; one, at
Kateri, was left in her own village; the remainder
were sent to the neighbourhood of Zaria.
In July a circular was sent all over the country
from the Secretariat, warning Europeans of the
danger of wearing ''shorts °’ on account of the
large amount of skin exposed thereby to biting flies.
Small-pox is endemie, but takes the epidemic
form somewhere every year. Forty-three cases, all
of them in natives, were treated, and three were
fatal. 3,942 successful vaccinations were performed
during the year.
Small-pox is essentially a dry-weather disease,
every outbreak going down with the onset of the
rains.
Dysentery is endemic and is observed all through
the year; but is generally most common, taking the
country as a whole, when the rains begin to flush
the dry watercourses.
Leprosy is found everywhere and the number
affected is very large, particularly in the north.
Steps are being taken, as already mentioned, to
establish segregation camps, and the medical and
politieal officers all over the country are collecting
statistics of lepers.
Yaws is observed from time to time, and some-
times it appears to assume an epidemic form; fur-
ther observations will have to be accumulated before
this can be stated as a matter of fact.
Tuberculosis is an exceedingly rare disease among
the natives; but it is not at all uncommon among
African non-natives from the coast.
Pneumonia often appears to assume epidemic
form, when, during the cold weather, the natives
huddle together in ill-ventilated huts for mutual
warmth.
Rheumatism is a very common disease, and car-
diac complications, very often aortic, are frequently
observed.
Intestinal worms are very common every-
where, and the average native, of whatever race,
takes them pretty much as a matter of course, re-
garding them with the same indifference as the
European does a common cold.
96 COLONIAL MEDICAL REPORTS.—NORTHERN NIGERIA.
[Dec. 15, 1913.
Bilharzia is fairly common, especially in the pro-
vinces of Yola and Bornu.
Guinea-worm is common everywhere. The reason
for this is that it is much more prevalent among
those who travel than among those who are always
sitting down in one place, and most of the people,
particularly the Hausas, are born traders.
Where medical officers are stationed slaughtering
grounds and meat markets are regularly inspected,
and in this way Europeans and some of the natives
are protected.
No water system for the disposal of sewage exists.
Earth closets and latrine trenches are the methods
used for the disposal of excreta at all stations. The
system of direct trench latrines is gradually being
abolished, in favour of the universal use of earth
closets, at all stations where the local resources are
sufficient for the purpose. In most native towns
every compound has one or more tumburis. Tum-
buris are piriform pits, from 4 ft. to 18 ft. deep,
with the end at the top. They are a kind of septic
pit, not rendered in brick and cement and sur-
rounded with puddled clay. They are practically
never cleared out. The danger in connection with
them is the pollution of wells.
Disposal of Refuse.—At Lokoja part of the com-
bustible refuse is disposed of by burning, and the
remainder is thrown into the Niger. At Baro,
Zungeru, and all other stations in the country com-
bustible rubbish is burnt daily, and the non-
combustible rubbish is buried. In Zungeru station,
as distinguished from the native town, a sufficient
number of incinerators, at suitable spots, were
erected during the year to dispose of all the com-
bustible rubbish. They have proved a great success.
The natives themselves, in their own towns, are
gradually in increasing numbers adopting our
method of burning and burying their refuse.
The water supply of Lokoja is derived from the
Niger and from wells; of Baro, from a reservoir at
the back of the amphitheatre, where the water
oozing from the face of the plateau is intercepted ;
and at Zungeru, from the Dago, which flows through
the cantonment. At the stations in the country
the water supply is derived from streams or from
water-holes in the dry beds of streams or from wells
or from springs, and at a considerable number of
stations the normal supply is supplemented by
roof-water collected in iron tanks. At most stations
the drinking water for Europeans is condensed, and
a sufficient supply is issued to each European daily.
In many parts of the country, particularly during
the dry season, the water is of very inferior quality.
Drainage.—The soil over most parts of the country
is light and porous and percolation is free and rapid.
Surface drainage is effected by natural water-
courses and by artificial trenches. There are very
few stations which do not stand sufficiently high to
permit the escape of their surface water.
THE JOURNAL OF
S
(D topital ui ebttine and À)rgine
With which is incorporated "CLIMATE"
AND
Embodying Selections from THE COLONIAL MEDICAL REPORTS.
A BI-MONTHLY JOURNAL DEVOTED TO MEDICAL, SURGICAL AND
SANITARY WORK IN THE TROPICS
EDITED BY
JAMES CANTLIE, M.B., F.R.C.S.; W. J. R. SIMPSON, C.M.G., M.D., F.R.C.P.; ALDO
CASTELLANI, M.D.Fror.; anp C. M. WENYON, M.B., B.S., B.Sc.
Sır RONALD ROSS, K.C.B., F.R.S., Masor I.M.S. (Honorary Adviser to the Editorial Staff)
VOLUME XVII
JANUARY 1 TO DECEMBER 15
1914
LONDON
JOHN BALE, SONS & DANIELSSON, Lr.
83-91, GREAT TITCHFIELD STREET, OXFORD STREET, W.
LONDON
JOHN BALE, SONS AND DANIELSSON, LTD.
83.91, GREAT TITCHFIELD STREET, OXFORD STREET, W,
INDEX TO
JANUARY
1 to DECEMBER 15,
VOL. XVII.
1914.
INDEX OF AUTHORS.
AKULA, Sub.Assistant Surgeon T. G., and LisroN, Major W.
GrEN, M.D., D.P.H., I.M.S.— Stegomyia survey of the
city and island of Bombay, 6
ANDERSON, Dr. D. E.—Comparative diseases of the British
West Indian colonies, 252
ANDERSON, JOHN F.— The infectious diseases; recent additions
to our knowledge of their etiology, 154
ARCHIBALD, Capt. R. G., M.B., R. A. M.C.—Emetine treatment
of dysentery in young children, 161; Intestinal schisto-
somiasis in the Sudan, 78
ARCHIBALD, Capt. R. G., M.B., R.A.M.C., and CHALMERS,
ALBERT J., M.D., F.R.C.S., D.P.H.— Babesia or piro-
plasma, 323
ARNOLD, W. J. J., B.A., M.B., D.P.H.— Etiology of beriberi,
89
ASHBURN, P. M., Vepper, E. B., and Grenrry, E. R.—Some
experiments on the inoculation of monkeys with small-pox,
170
AYMARD, J. L.—Miner’s phthisis on the Rand, 119
Baur, P. H., M.A., M.D., D.T.M. & H.Cantab.—Recent
researches on sprue, 252; Researches in sprue, 1912-1914,
203; Study of epidemic dysentery in the Fiji Islands, 109
BALFOUR, ANDREW, C.M.G., M.D., and Wenyon, C. M., M.B.,
B.S., B.Sc.—The so-called Plasmodium tenue (Stephens)
(illustrated), 353
BanLiNG, Seymour, M.S., F.R.C.S.—Note on a foreign body
removed from the liver after twenty-three years, 200
Bass, C. C., M.B.—Eradication of malaria, 9
BassETT.SMrTH, Fleet-Surg. P. W., M.R.C.P., C.B., R.N.—
Kala-azar and allied conditions, 248; Recent research
relating to undulant or Mediterranean fever, 98
Bax and BRAILLON.—Hæmorrhage late in typhoid fever, 343
Beppogs, T. P., F. R.C.S.— Psittacosis, 33
BELL, J.—Note of a case of liver abscess treated without
operation, 33
Birp, Fren T.—Surgery of the subphrenic space, 344
Binr, Col., I.M.S.—Sand-fly fever, 251
BRAILLON and Bax.—Hiemorrhage late in typhoid fever, 343
BnEINL, ÁNTON.—Distribution and spread of diseases in the
East, 293 ; Influence of climate, disease and surroundings
on the white race living in the Tropics, 267 ; Protozoa and
disease, 300
Brock, B. G., L.R.C.P. and S.Edin., D.P.H.—Mortality on
the Rand : some of its causes, 119
Brown, H. EcERTON, M.D., and Swirr, E. W. D., M.B.—
Some cases of pellagra occurring among the insane in
South Africa, 166
Bruges, Cnanrxys T., S.M., Srrone, RICHARD P., M.D., Tyzzer.
E. E., M.D., SELLARDS, A. W., M.D., and GASTIABURU,
J. O.—Verruga peruviana, Oroya fever, and uta, 11
Byam, Capt. W., R.A.M.C., and CHALMERS, ALBERT J., M.D.,
F.R.C.S., D.P.H.—Vaccine lichen in natives (illustrated),
145
CANTLIE, JAMES, M.B., F.R.C.S.—A useful prescription in
chronie malaria with enlarged spleen, 323 ; Surgical treat-
ment of colitis and post-dysenteric conditions, 252; The
use of the tuning-fork in diagnosing the outlines of solid
and hollow viscera in the chest and abdomen, and of
certain pathological conditions (illustrated), 17
Carter, R. MankHaM, I.M.S.—Emetine and ipecacuanha:
their amo bacidal value in pathogenic amebiasis, 153
Casaux, Dr. J.—-Hydatid cyst of the liver, 173
CASTELLANI, ALDO, M.D.— Further case of entoplasmosis, 83 ;
Further researches on combined vaccines, 326; Note on a
case of osteoperiostitis developing after a probable attack
of * febris columbensis," 177; Note on an intestinal pro-
tozoal parasite producing dysenteric symptoms in man
(illustrated), 65 ; Note on certain protozoa-like bcdies in a
case of protracted fever with splenomegaly (illustrated),
113; Notes on the hyphomycetes found in sprue; with
remarks on the classification of fungi of the genus ‘‘ Monilia
Gmelin, 1791"’ (illustrated), 305; Typhoid-paratyphoid
vaccination with mixed vaccines, 36
CHALMERS, ALBERT J., M.D., F.R.C.S., D.P.H., and ARCHI-
BALD, Capt. R. G., M.B., R.A.M.C.—Babesia or piro-
plasma, 323
CHALMERS, ALBERT J., M.D., F.R.C.S., D.P.H., and Byam,
Capt. W., R.A.M.C.—Vaccine lichen in natives (illustrated),
145
CHALMERS, ALBERT J., M D., F.R.C.S., D.P.H., and CHRISTO-
PHERSON, J. B., M.A., M.D., F.R.C.P, F.R.C.8.—
Murmekiasmosis amphilaphes (illustrated), 129
CHALMERS, ALBERT J., M. D., F.R.C.S., D.P.H., and MARSHALL,
ALEXANDER.— Systemic position of the genus Trichophyton
Malmsten 1845 (illustrated), 289; Tinea capitis tropicalis
in the Anglo- Egyptian Sudan (illustrated), 257
CHALMERS, ALBERT J., M.D., F.R.C.S.,D.P.H., and O'FARRELL,
Capt. W. R., R.A.M.C.—Sleeping sickness in the lado of
the Anglo-Egyptian Sudan (illustrated), 273
CHRISTOPHERSON, J. B., M.A., M.D., F.R.C.P., F.R.C.S., and
CHALMERS, ALBERT J., M.D., F.R.C.S., D.P.H.—Murme-
kiasmosis amphilaphes (illustrated), 129
CLARK, Jackson.—Suppurating hydatid cyst, 173
Conner, Lewis A., M.D.—Pulmonary attack simulating
primary lobar pneumonia, 104
Cumsron, CHARLES GREENE, M.D.—Gunshot and bayonet
wounds of the stomach, 365
Day, Harotp BENJAMIN, M.D., M.R.C.P.—Notes on life
assurance in Egypt, 10
De MELro, Dr. —Beriberi in Pórtuguese India, 125
Duxe, H. LvspHunsT, M.D., D.T.M. and H.Camb.— Wild
game as a reservoir for human trypanosomes, 89
DvrcHER, Major B. H. —Note on a new geographic locality for
Balantidiosis coli, 99; Recovery of embryo of Filaria
bancrofti from blood from the lung during daytime, 163
ELDRED, A. G., M.R.C.S., L. R.C.P. Lond.— Ankylostomiasis in
the North Nyasa district, 209
EscoxEL, E.—Human actinomycosis in Peru, 186
Farrant, RuPERT.—Causation, prevention and cure of goitre,
endemic and exophthalmie, 232
FERGUSON, Prof.—Secondary changes due to bilharzia ova in
the spinal cord, 250
Force, Joun Nivison, M.D., M.S.—An investigation of the
causes of failure in cow-pox vaccination, 201
Force, Joun Nivison, M.D., M.S., and Gay, FREDERICK P.,
M.D.—Skin reaction indicative of immunity against
typhoid fever, 103
Fraser, Dr., and Sranron, Dr.—Beriberi, the rice theory
and recent criticisms, 252
Frost, Wape H.—Epidemiologic studies of acute anterior
poliomyelitis, 54
GABBI, Prof.—Sand-fly fever in Italy, 251
GALLAGHER, G. H., L. R.C.P. & S.I. —Transmission of Trypano-
some brucei of Nigeria by Glossina tachinoides, with some
notes on Trypanosoma nigeriense (illustrated), 372
GAMBLE, Mercier, M.D.—A list of blooding-sucking arthro-
. pods from the Lower Congo, with vocabulary, 148
GASTIABURU, J. C., Srronc, RicHaRD P., M.D., TvzzkmR,
E. E., M.D., Bruers, CHARLES T., S.M., and SELLARDS,
A. W., M.D.—Verruga peruviana, Oroya fever and uta, 11
iv.
Gay, FREDERICK, P., M.D., and Force, Joun N., M.D.— Skin
reaction indicative of immunity against typhoid fever, 103
Gentry, E. R., AsHBURN, P.M., and VEDDER, E. B.—Some
experiments on the inoculation of monkeys with small-
pox, 170
GIRLING, Dr. E. C.— Treatment of yaws and their sequelæ by
means of salvarsan, 193
Goncas, W. C., M.D.— Recommendations as to sanitation
concerning employees of the mines on the Rand made to
the Transvaal Chamber of Mines, 218
GRAHAM, Capt., I. M.S.— Sand-fly fever in Chitral, 251
Harper, Dr. FRANK S.— Bronchial spirochetosis, 194; Mollus-
cum fibrosum pendulatum atque elephantiacum (illustrated),
291
HAWTHOBŠB, C. O., M.D.—Importance of rectal examination,
43
Heuir, Col. P., I.M.S.— Prevention of malaria in the troops
of our Indian Empire, 296
Hetser, Victor G., M.D.—Leprosy, 53; Manila Bureau of
Health Report for 1913, 105
Horne, Capt. J. H., I.M.S.— Notes on distribution and habits
of stegomyia mosquitoes in Madras, 8
Houston, Capt., R.A.M.C.—Sand-fly fever in Peshawar, 252
Jack, Rupert W.— Tsetse-ly and big game in Southern
Rhodesia, 315
Kena, Lim Boon, M.B., C.M.Edin.—Brief note on ameebic
dermatitis, 193; Preliminary notes on entameebiasis, 227 ;
Further notes on entamebiasis, 244; treatment of chronic
ulcers of the leg with frog flesh poultice, 34
Kerr, Dr. T. S.—‘ A human recovery from trypanosomiasis ”
(illustrated), 81
Kina, Col, C LE., I.M.S.—Education and position of the
sanitarian in the Tropics, 250
Kinc, Harotp H., F.E.S.—Observations on the breeding.
places of sand.flies (PAlebotomus spp.) in the Anglo-
Egyptian Sudan, 2
LINNELL, R. McC., L.R.C.P.— Note on a case of death follow-
ing the sting of a scorpion, 199
Liston, Major Gren, C.I.E., M.D., I.M.S.—Immunity of
certain tracts from plague, 92
Liston, Major W. Gren, M.D., D.P.H., I.M.S., and AKULA,
Sub-assistant Surgeon T. G.—Stegomyia survey of the city
and island of Bombay, 6
Low, Georce C., M.A., M.D., C.M.— Arthritis in sprue, 1;
recent researches on emetine and its value as a therapeutic
agent in ameebiasis and other diseases, 183
Low, GEoncE C., M.A., M.D., C.M., and Wenyon, C.M., M.B.,
B.S., B.Sc.— Occurrence of certain structures in the ery-
throcytes of guinea-pigs and their relationship to the so-
called parasite of yellow fever (illustrated), 369
Lukris, Hon. Surg.-Gen. Sir PanpEv, K. H.S., K.C.S.1., M.D.,
F.R.C.S.—Introductory address, Third All India Sanitary
Conference, 76
LUNDIE, ALEXANDER, M.B.—Detection of trypanosomes in
animals, 22
Macauxan, Dr, A. F.—Preliminary note on the ankylostomias!s
campaign in Egypt, 249
McCoNsNELL, R. E., B.A., M.D., C.M., D. T. M.— Dracontiasis
or dracunculosis : & review, 337
McDonaaeu, J. E. R., F.R.C.S.—Ulcus molle serpiginosum, 41
MacGiccurist, Major A. C., I.M.S.—Stegomyia survey, port
of Calcutta, 7
McMintan, JoHN Furse, L.R.C.P.Lond., M.R.C.S.Eng.,
L.S.A.— Asiatic cholera, 354
MAGAREY, A. CAMPBELL, M.S., M.R.C.S.— A solitary obso-
lescent pelvic hydatid, 254
ManETT, Capt. P. J., R.A.M.C.— Economies of the Maltese
phlebotomi, 251
MARSHALL, ALEXANDER and CHALMERS, ALBERT J., M.D.,
F.R C.S., D.P.H. — Systemic position of the genus
Trichophyton Malmsten 1845 (illustrated), 289
Martinez, Dr. I. GoNZzALEZ.—Canine babesiasis in Porto
Rico, 194
MAYNARD, G. D.— Pneumonia on the Rand, 121
MUSGRAVE, W. E.—Infant mortality in the Philippine islands,
167
NEr1GaN, A. R., M.D.Lond., M.R.C.S., D. T. M. and H. Cantab.
— Case of Leishmania tropica with a fatal termination, 322
Newman, E. A. R., M.D.Cantab,—Operative treatment of
hepatic abscess, 138
INDEX
O'CONNELL, MatrHew D., M.D.—Meteorology of malaria, 97,
321
O'FARRELL, Capt. W. R., R.A.M.C., and CHALMERS, ALBERT
J., M.D., F.R.C.S., D.P.H.—Sleeping sickness in the lado
of the Anglo-Egyptian Sudan (illustrated), 273
PniLniPs, Professor LLEWELLYN P.—Is emetine sufficient to
bring about a radical cure in amebiasis ? 250 ; Use of liquid
paraffin in enteric fever with constipation, 255
PraTE, Professor Lupwia. — Brief note on Toxoplasma,
Castellani, 1913 (illustrated), 98
PRENTICE, GEOonGE, L.R.C.P. and S., D.T. M.— Sleeping sick-
ness, tsetse and big game, 91
Price, J. Dopps, M.R.C.S., L R.C.P., and ROGERS, LEONARD,
M.D., I. M.S.— Uniform success of segregation measures in
eradicating kala azar from Assam tea-gardens, 55
Reynacp, Dr.—Recruiting, 157
Rogers, LEONARD, M.D.—Two cases of sprue treated by mouth
streptococcal vaccines and emetine hydrochloride hypo-
dermically, 199
Rocers, Leonarp, M.D., and Price, J. Dopps, M.R.C.S.,
L.R.O.P.—Uniform success of segregation measures in
eradication of kala-azar from Assam tea-gardens, 55
Royster, HuBERT A.—Elephantiasis and the Kondoleon
operation, 254
SANDES, JoHN D., I. M.S.— Treatment of liver abscess, 141
ScHERESCHEWSKY, J. W.—Trachoma in steel mill workers, 107
Scorr, Dr. H. Hanorp. — Vomiting sickness of Jamaica, 253
SELLARDS, A. W., M.D., SrRoNG, RicHanDp P., M.D., Tyzzer
E. E., M.D., Brues, CHARLES T., S.M., and GASTIABURU,
J. C.—Verruga peruviana, Oroya fever, and uta, 11
Yosuipa. — Testicular neuritis following gonorrhæal
epididymitis, 166
Sicanp, Montcomery H., M.D.—Trichinosis, with a report of
fifteen cases, 347
Smrpson, W. J., M.D., F.R.C.P., C.M.G.— A plea for a wider
and more organized application of sanitary methods in the
Tropics, 228
Sraxrton, Dr., and Fraser, Dr.— Beriberi, the rice theory and
recent criticisms, 252
SriRowG, RıcHaRrD P., M.D., Tyzzer, E. E., M.D., BRUES,
CHARLES T., S.M., SELLARDS, A. W., M.D., and Gasrta-
BURU, J, C.—Verruga peruviana, Oroya fever, and uta, 11
Strona, W. M., M.D., B.C., D.T.M. and H.Camb.—Beriberi
in Papua (British New Guinea), 810
Swirt, E. W. D., M.B., and Brown, H. EcERTON, M.D.—
Some cases of pellagra occurring among the insane in
South Africa, 166
TayLor, F. H., and Youna, W. J.—Coastal climate of tropical
Queensland (illustrated), 225
TcuupxowsKY, Dr.—Acclimatization in the Tropics, 39
Tyzzer, E. E., M.D., SrRoNG, Ricard P., M.D., BRUES,
CuanLES T., S.M., SkEtrARDS, A. W., M.D., and Gasta-
BURU, J. C.—Verruga peruviana, Oroya fever, and uta, 11
Vepper, E. B., ASHBURN, P. M., and Gentry, E. R.—Some
experiments on the inoculation of monkeys with small-pox,
170
VERGNE, R., M.D.—‘' Epasmo tropical," a peculiar disease of
great malignancy, associated with a parasite in the blood,
20
Suv
Wenyon, C. M., M.B., B.S., B.Sc.— Culture of Leishmania
from the finger blood of a case of Indian kala-azar, with
some remarks on the nature of certain granular bodies
recently described from the disease, 49
Wenyon, C. M., M.B., B.S., B.Sc., and BALFOUR, ANDREW,
C.M.G., M.D.—The so-called Plasmodium tenue (Stephens)
(illustrated), 353
Wenyon, C. M., M.B., B.S., B.Sc., and Low, GEonoE C., M.A.,
M.D., C.M.—Occurrence of certain structures in the ery-
throcytes of guinea-pigs and their relationship to the so-
called parasite of yellow fever (illustrated), 369
Wuite, Mark J.— Examinations for hookworm ova, 103
WoorLEYy, Paut G.—Insolation: its prophylaxis and treat-
ment, 230
Yares, A. G.—Hydatid disease of the lung spontaneously
cured, 186
Youxao, W. J.—Study of the nitrogenous metabolism in
chyluria, 242
Youna, W. J., and Tavron, F. H.— Coastal climate of tropical
Queensland (illustrated), 225
Youna, W. McComprr.—Segregation and kala-azar, 314
GENERAL INDEX.
A ABSTRACTS (continued.)
Note on a case of death following the sting of a scorpion.
By R. McC. Linnell, L.R.C.P., 199 A
—— on a foreign body removed from the liver after
twenty-three years. By Seymour Barling, M.S.,
F.R.C.S., 200
Notes on distribution and habits of stegomyia mosquitoes
in Madras. By Capt. J. H. Horne, I.M.S., 8
- on life assurance in Egypt. By Harold Benjamin
Day, M.D., M.R.C.P., 10
A hardy annual, 380
‘t A human recovery from trypanosomiasis” (illustrated), 81
A school of Oriental studies, 285
A solitary obsolescent pelvic hydatid, 951
A sare prescription in chronic malaria with enlarged spleen,
Abscess, liver, case of, treated without operation, 33
ABSTRACTS :—
A solitary obsolescent pelvic hydatid. By A. Campbell
Magarey, M.S., M.R.C.S., 254
Acclimatization in the Tropics. By Dr. Tchudnowsky, 39
An investigation of the causes of failure in cow-pox vac-
cination. By John Nivison Force, M.D., M.S., 901
Beriberi in Portuguese India. By Dr. de Mello, 125
——, the rice theory and recent criticisms. By Drs. Fraser
and Stanton, 252
Bionomics of the Maltese phlebotomi. By Capt. P. J.
Marett, R.A.M.C., 251
Causation, prevention and cure of goitre, endemic aud
exophthalmic. By Rupert Farrant, 232
Comparative diseases of the British West Indian colonies.
By Dr. D. E. Anderson, 252
Distribution and spread of diseases in the East. By Anton
Breinl, 293
Education and position of the sanitarian in the Tropics.
By Col. King, C.I.E., I.M.S., 250
Elephantiasis and the Kondoleon operation. By Hubert
A. Royster, 254
Emetine and ipecacuanha: their amcebacidal value in
pathogenic amebiasis. By R. Markham Carter, I.M.S.,
153
Epidemiologic studies of acute anterior poliomyelitis.
By Wade H. Frost, 54
Eradication of malaria. By C. C. Bass, M.D., 9
Etiology of beriberi. By W. J. J. Arnold, B.A., M.B.,
D.P.H., 89
Examinations for hookworm ova By Mark White, 103
Gunshot and bayonet wounds of the stomach. By Charles
Greene Cumston, M.D., 365
Heemorrhage late in typhoid fever. By Braillon and Bax,
343
Human actinomycosis in Peru. By E. Escomel, 186
Hydatid cyst of the liver. By Dr. J. Casaux, 173
—— disease of the lung spontaneously cured. By A. G.
Yates, 186
Immunity of certain tracts from plague. By Major Glen
Liston, C.I.E., M.D., I.M.S., 92
Importance of rectal examination. By C. O. Hawthorne, 343
Infant mortality in the Philippine Islands. By W. E.
Musgrave, 167
Influence of climate, disease, and surroundings of the white
race living in the Tropies. By Anton Breinl, 267
Insolation: its prophylaxis and treatment. By Paul G.
Woolley, 230
Intestinal schistosomiasis in the Sudan. By Capt. R. G.
Archibald, M.B., R.A.M.C., 78
Introductory address, Third All-India Sanitary Conference,
By Hon. Surg.-Gen. Sir Pardey Lukis, K.H.S., K.C.S.I.,
M.D., F.R.C.S., 76
Is emetine sufficient to bring about a radical cure in
amebiasis? By Prof. Llewellyn Phillips, 250
Kala-azar and allied conditions. By Fleet-Surg. P. W.
Bassett-Smith, C.B., R.N., 248
Leprosy. By Victor G. Heiser, 53
Manila Bureau of Health report for 1913. By Victor G.
Heiser, M.D., 105
Miners’ phthisis on the Rand. By J. L. Aymard, 119
Mortality on the Rand: some of its causes. By B. G.
Brock, L.R.C.P, & S. Edin., D.P.H., 119
Operative treatment of hepatic abscess. By E. A. R.
Newman, M.D.Cantab., 138
Papers on the distribution of stegomyia in India. By
Major W. Glen Liston, M.D , D.P.H., I.M.S., and Sub-
Assistant Surg. T. G. Akula, Major A. C. MacGilchrist,
I.M.S., and Capt. J. H. Horne, I.M.S., 6
Plea for a wider and more organized application of sanitary
measures in the Tropics. By W. J. Simpson, M.D.,
F.R.C.P., C.M.G., 228
Pneumonia on the Rand. By G. D. Maynard, 121
Preliminary note on the ankylostomiasis campaign in
Egypt. By Dr. A. F. Macallan, 249
Prevention of malaria in the troops of our Indian Empire.
By Col. P. Hehir, I. M.S., 296
Protozoa and disease. By Anton Breinl, 300
Pulmonary attack simulating primary lobar pneumonia.
By Lewis A. Conner, M.D., 104 n
Recent research relating to undulant or Mediterranean
fever. By Fleet-Surg. P. W. Bassett-Smith, M.R.C.P.,
C.B., R.N., 93
—— researches on emetine and its value as a therapeutic
agent in amoebiasis and other diseases. By George C.
Low, M.D., 183
—— on sprue. By Dr. P. H. Bahr, 252
Recommendations as to sanitation concerning employees of
the mines on the Rand made to the Transvaal Chamber
of Mines. By W. C. Gorgas, M.D., 218
Researches in sprue, 1912-1914. By P. H. Bahr, M.A.,
M.D., D.T.M. & H.Cantab., 203
Sandfly fever. By Col. Birt, I. M.S., 251
-— —— in Chitral. By Capt. Graham, I.M.S., 251
—— —— in Italy. By Prof. Gabbi, 251
—— —— in Peshawar. By Capt. Houston, R. A. M.C., 252
Secondary changes due to bilharzia ova in the spinal cord.
By Prof. Ferguson, 250
Segregation and kala-azar. By W. McCombie Young, 314
Skin reaction indicative of immunity ene typhoid fever.
By Frederick P. Gay, M.D., and John N. Force, M.D.,
103
Sleeping sickness, tsetse, and big game. By George
Prentice, L.R.C.P. & S., D.T.M., 91
Some cases of pellagra occurring among the insane in South
Africa. By E. W. D. Swift, M.B., and H. Egerton
Brown, M.D., 166
— experiments on the inoculation of monkeys with
small-pox. By P. M. Ashburn, E. B. Vedder, and E. R.
Gentry, 170
Stegomyia survey of the city and island of Bombay. By
Major W. Glen Liston, M.D., D.P.H., I.M.S., and Sub-
Assistant Surg. T. G. Akula, 6
, port of Calcutta. By Major A. C. MacGilchrist,
I.M.S., 7
Study of epidemic dysentery in the Fiji Islands. By P, H.
Bahr, M.A., M.B., D.T.M. & H. Camb., 109
Suppurating hydatid cyst. By Jackson Clarke, 173
Surgery of the subphrenic space. By Fred. T. Bird, 344
Surgical treatment of colitis and post-dysenteric condi-
tions. By James Cantlie, F.R.C.S., 252
Testicular neuritis following gonorrhæal epididymitis. By
Shu Yoshida, 166
The infectious diseases: recent additions to our knowledge
of their etiology. By John F. Anderson, 154
vi. INDEX
ABSTRACTS (continued).
Third All-India Sanitary Conference, 73
Trachoma in steel mill workers. By J. W. Schereschewsky,
107
Treatment of liver abscess. By John D. Sandes, I.M.S.,
Trichinosis, with a report on fifteen cases.
gomery H. Sicard, M.D., 347
Tsetse-fly and big game in Southern Rhodesia. By
Rupert W. Jack, 315
Two cases of sprue treated by mouth streptococcal vaccines
and emetine hydrochloride hypodermically. By Leonard
Rogers, 199
Uleus molle serpiginosum.
F.R.C.S., 41
Uniform success of segregation measures in eradicating
kala-azar from Assam tea gardens. By J. Dodds Price,
M.R.C.S., L.R.C.P., and Leonard Rogers, M.D., I.M.S.,
55
Use of liquid paraffin in enteric fever with constipation.
By Llewellyn Phillips, 255
Verruga peruviana, Oroya fever, and uta. By Richard P.
Strong, M.D., E. E. Tyzzer, M.D., Charles T. Brues,
S.M., A. W. Sellards, M.D., and J. C. Gastiaburu,
11
By Mont-
By J. E. R. MeDonagh,
Vomiting sickness of Jamaica.
253
Wild game as a reservoir for human trypanosomes.
Lyndhurst Duke, M.D., D.T.M. & H. Camb., 89
Acclimatization in the Tropics, 39
—— of animals in the Zoological Gardens, London, 51
Acetyl-salicylic acid in the treatment of asthma, 342
Actinomycosis, 380
——, human, in Peru, 186
Acute anterior poliomyelitis, epidemiologic studies of, 54
Address by Surgeon-Gen. Gorgas on sanitary work in the
Panama Canal, 102
Administration of drugs, use of the hypodermic syringe in the,
286
Aftermath of war, disease, 292
After-pain of quinine injections, limitation of, 342
All-India Sanitary Conference, Third, 73
America, new regulations for federal meat inspection in, 350
——, pellagra in, 59
Amoebiasis, is emetine sufficient to bring about a radical cure
in? 250
—-, pathogenic, amoebacidal value of emetine and ipecacu-
anha in, 153
Amoebic dermatitis, brief note on, 193
Anemia, clinical evidence of bi-palatinoid orrefin in, 111
An Indian voluntary aid contingent, 325
An investigation of the causes of failure in cow-pox vaccination,
201
Animals, acclimatization of, in the Zoological Gardens, London,
51
By Dr. H. Harold Salt,
By H.
——-, detection of trypanosomes in, 22
Ankylostomiasis campaign in Egypt, 249
—— in the North Nyasa district, 209
ANNOTATIONS :-—
A new missile, 363
Acetyl-salicylic acid in treatment of asthma, 342
Actinomycosis, 380
Antimony in dermal leishmaniasis, 324
Argas and spirochetes, 27
Ascaris in pyopneumothorax, 314
Aseptic hypodermic injections, 218
Balantidiasis, 61
Beriberi in New Jersey, 34
Cholera bacilli in the lung, 34
Cultivation of a free-living filterable spirochete, 138
of Piroplasma canis, 58
Diagnostic explanation of the right hypochondrium, 182
Disappearance of typhus, relapsing fever and plague from
civilized countries, 342
Differential skin reaction in variola and varicella, 380
Disease of rice, 135
Distribution and morphology of Spirocheta duttoni and
S. Kochi in experimentally infected ticks, 137
Early operation for gall-stones, 342
Echinococcus cyst of pancreas, 3
ANNOTATIONS (continued).
Entericoid fever, 24
Epidemiology of dengue, 152
Equine piroplasmosis in Italy, 86
Exanthematic typhus, 59
Experiments concerning the filterability of Spirocheta
duttoni, 137
with malarial parasites and Piroplasma canis, 72
Free malarial parasites, 182
Fulminating gangrene of the genitals, 218
Geranium as & means of excluding flies, 135
Helminthemesis, 198
Insect transmission of anthrax, 61
Intravenous injections of sublimate for tropical malaria
with latent sepsis, 87
Kala-azar in Malta, 68
Keeping properties of condensed milk in the Tropies, 46
Leprosy after two-year incubation period, 72
Limitation of the after-pain of quinine injections, 342
Malaria in infants, 178
Malnutrition in adults, 379
Mecca pilgrims and cholera, 363
Natural leishmaniasis of dogs in Algiers, 86
Nature of the Kurloff body, 137
New blood-sucking midge, 43
—— malarial parasite of man, 152
type of typhus iu East Asia, 59
Notes on French medical service, 377
Operative treatment of elephantiasis scroti, 25
Ova in stools, 5
Parotitis and malaria, 26
Pathogenicity of Nosema apis to insects other than hive
bees, 60
Pathological affinities of beriberi and scurvy, 379
Pellagra, 46
in America, 59
Plague in Manchuria, 23
—— in New Orleans, 324
Post-typhoid cholelithiasis, 377
Practical points in abdominal surgery, 378
Protection of India from yellow fever, 44
Protective ferments in serum of pellagrins, 342
Rat-bite disease, 60
Recognition of the cholera vibrio, 182
Ringworm yaws, 114
Salvarsan in the treatment of yaws, 24
Ship-borne cholera, 25
Supply of milk to Indian cities, 313
Thread-worms and appendicitis, 314
Trachoma, 87
Transmission of pellagra from man to monkey, 46
** Traumatic malacea ” following fractures, 378
Treatment of enteric fever, 879
—— of infantile diarrhcea by saline injections, 68
of leprosy, 60
of tetanus, 378
Trypanosomiasis, 59
Yellow fever in West Africa, 14
Announcements, scientific, in the lay press, 115
Anthrax, insect transmission of, 61
Antimony in dermal leishmaniasis, 324
Antityphoid vaccine, 36
Appendicitis in children, 144
———, thread-worms and, 314
Appliances, fumigating and disinfecting, 16
Are plants, trees, and flowers in and around our houses
beneficial or deleterious ? 136
Argas and spirochetes, 27
Army, the, and mental disease, 368
Arthritis in sprue, 1
Arthropods. blood-sucking, from the Lower Congo, list of, 148
Artificial milk from the soy bean, 176
Ascaris in pyopneumothorax, 314
Aseptic hypodermic injections, 218
Asiatic cholera, 354
Asthma, acetyl-salicylic acid in the treatment of, 342
Atropine in sea-sickness, 150
Australasian Medical Congress, Auckland, 1914, 64
Australasian Medical Gazette, 13
Australia, British Association meetings in, 165
INDEX vii.
Babesia or piroplasma, 323
Babesiasis, canine, in Porto Rico, 194
Bacilli, cholera, in the lung, 34
Balantidiasis, 61
Balantidiosis coli, note on a new geographic locality for, 99
Bayonet wounds, gunshot and, of the stomach, 365
Bengal Medical Bill, 47
Beriberi and scurvy, pathological affiuities of, 379
——, etiology of, 89
—— in New Jersey, 34
—— in Papua, 310
—— in Portuguese India, 125
——, the rice theory and recent criticisms, 252
Big game, tsetse, and sleeping sickness, 91
—— —— and, in Southern Rhodesia, 315
Bilharzia ova in the spinal cord, secondary changes due to, 250
Bionomics of the Maltese phlebotomi, 251
Blood-sucking arthropods from the Lower Congo, list of, 148
Bombay, stegomyia survey of the city and island of, 6
Breading places of saud.flies (Phlebotomus spp.) in the Anglo-
Egyptian Sudan, 2
Brief note on ameebic dermatitis, 193
—— —on Toroplasma pyrogenes, Castellani, 1913 (illus-
trated), 98
British Medical Association, 80, 228, 247
, programme, 158
Association meetings in Australia, 165
Bronchial spirocheetosix, 194
Bulletin of Entomological Research, 32
of the Imperial Institute, 16
Burma, infant death-rate in, 350
— rice, 333
Burroughs Wellcome & Co.'s exhibition of drugs, 30
** Bynin ” amara, 30
C
Calcutta, port of, stegomyia survey, 7
Camphor (illustrated), 116
Canine babesiasis in Porto Rico, 194
Care of syringes, 62
Carriers, typhoid, 160
Case, a further, of entoplasmosis, 83
of Leishmania tropica with a fatal termination, 322
Casualties in European war, estimate of, 265
Causation, prevention and cure of goitre, endemic and exoph-
thalmic, 232
Causes, some of the, of mortality on the Rand, 119
Certain protozoa: like bodies in a case of protracted fever with
splenomegaly (illustrated), 113
Chair of tropical medicine in the University of Naples, 341
Chamberlain portraits unveiled (illustrated), 196
Children, appendicitis in, 144
China, medical education in, 150
—— , small-pox in, 14
Cholelithiasis, post-typhoid, 377
Cholera, Asiatic, 354
bacilli in the lung, 34
———, Mecca pilgrims and, 363
———, ship-borne, 25
—— vibrio, recognition of, 182
Chronic ulcers of the leg, treatment of, with frog flesh poultice,
Chyluria, nitrogenous metabolism in, 242
Clinical evidence of bi-palatinoid orrefin in anemia, 111
Coastal climate of tropical Queensland (illustrated), 225
Cocoa and kernels, 114
Cod.liver oil preparations, 31
Coffee, a new variety of, 189
Combined vaccines, further researches on, 326
Common diseases in time of war: enteric fever, 363
Comparative diseases of the British West Indian Colonies, 252
Condensed milks, keeping properties of, in the Tropics, 46
Contagion carried by textiles, such as cotton, wool, rags, &c., 224
CORRESPONDENCE :—
Intramuscular injections of quinine, 272, 286, 336, 352
Kurloff's bodies, 208
Course in venereal disease, 152
Cow's milk, 216
Cultivation of a free living filterable spirochete, 138
—— of Piroplasma canis, 58
Culture of Leishmania from the finger-blood of a case of Indian
kala-azar, 49
Cyst, echinococcus, of pancreas, 3
, hydatid, of the liver, 173
, Suppurating hydatid, 173
Cystopurin, 30
Death following the sting of a scorpion, 199
—— rate, infant, in Burma, 350
Dengue, epidemiology of, 152
Dermal leishmaniasis, antimony in, 324
Dermatitis, ameebic, brief note on, 193
Destruction of mosquitoes in Queensland, 31
Detection of trypanosomes in animals, 22
Diagnostic exploration of the right hypochondrium, 182
Diarrhea, infantile, treatment of, by saline injections, 68
Differentiation of streptococci, 230
Dinner to Surgeon-General Gorgas, 99
Disappearance of typhus, &c., from civilized countries, 342
Discussions at the Tropical Section of the British Medical
Association, 266
Disease aftermath of war, 292
-— of rice, 135
——, protozoa and, 300
Diseases common, in time of war: enteric fever, 368
—— in the East, distribution and spread of, 293
Disinfecting and fumigating appliances, 16
Disinfection as practised at the present time by the use of
steam and formol apparatus, aud disinfection by means of
“& Clayton " machines, 174
Distribution and habits of stegomyia mosquitoes in Madras, 8
—— and morphology of Syirocheta duttoni and S. kochi, 137
and spread of diseases in the East, 293
Dracontiasis or dracunculosis : a review, 337
Droitwich, 334
Drugs and appliances, 16, 30, 62, 79, 352
Drug rashes, 48
Dysentery, epidemic, in the Fiji Islands, 109
—— in young children, emetine treatment of, 161
Early operation for gall-stones, 342
Echinococcus cyst of pancreas, 3
Education and position of the sanitarian in the Tropics, 250
Egypt, life assurance in, 10
Elephantiasis and the Kondoleon operation, 254
— —scroti, operative treatment of, 25
Elimination of the narcotic action of alcohols by fats, 246
Emetine and ipecacuanha: their amcebacidal value in patho-
genic amebiasis, 153 , M
——— and its value as a therapeutic agent in amoebiasis and
other diseases, 183
—, is it sufficient to bring about a radical cure in amoebiasis ?
250
—— treatment of dysentery in young children, 16
Entamoebiasis, further notes on, 244
——, preliminary notes on, 227
Enteric fever, 363, 379
, treatment of, 379
Entericoid fever, 24
Entoplasmosis, a further case of, 83
Epidemic dysentery in the Fiji Islands, 109 A
Epidemiologic studies of acute anterior poliomyelitis, 54
Epidemiology of dengue, 152
Equine piroplasmosis in Italy, 86
Eradication of malaria, 9
Errata, 32, 336
“ Espasmo tropical " :
the blood, 20
Estimate of casualties in European war, 265
Etiology of beriberi, 89
Examination, rectal, importance of, 343
Examinations for hookworm ova, 103
Exanthematic typhus, 59 , c
Experiments with malarial parasites and Piroplasma canis, 72
Exploration, diagnostic, of the right hypochondrium, 182
Extracts from medical papers, 188
a disease associated with a parasite in
INDEX
F
Failure in cow-pox vaccination, an investigation of the causes
of, 201
Fever, enteric, 363, 379
———, entericoid, 24
——, sand-fly, 251
—, yellow, in West Africa, 14
—— ——, protection of India from, 44
Fibre from the water hyacinth, 291
Filaria bancrofti, recovery of embryo of, from blood from the
lung during daytime, 163
Filterability of Spirocheta duttoni, 137
Flies and disease, 218
—— and public health, 150
——, the geranium as a means of excluding, 135
Food, scarcity of, in war, 312
Foreign body removed from the liver after twenty-three years,
2
Formaldehyde. pharmacology of, 265
Fourth International Congress of Surgery, 80
Free malarial parasites, 182
French medical service, 377
Frog flesh poultice, treatment of chronic ulcers of the leg with,
34
Fruits and their action, 376
Fulminating gangrene of the genitals, 218
Fumigating and disinfecting appliances, 16
Further case of entoplasmosis, 83
—— notes on entameebiasis, 244
——— researches on combined vaccines, 326
G
Gall.stones, early operation for, 342
Gangrene, fulminating, of the genitals, 218
Geranium as a means of excluding flies, 135
Germ transformation, 176
Germany and Great Britain, small-pox in, 163
Western, spas in, 180
Glanders, 176
Goitre, endemic and exophthalmie, causation, prevention and
cure of, 232
Gorgas, Surg.-Gen., address by, on sanitary work in the Panama
Canal, 102
—— ——, dinner to, 99
Great Britain and Germany, small-pox in, 163
Gunshot and bayonet wounds of the stomach, 365
H
Habits and distribution of stegomyia mosquitoes in Madras, 8
Hemorrhage late in typhoid fever, 343
Helminthemesis, 198
Helminthological investigations, 84
Hepatic abscess, operative treatment of, 138
———, see also liver abscess.
Hookworm ova, examinations for, 108
Human actinomycosis in Peru, 186
Hydatid cyst of the liver, 173
, suppurating, 173
—— disease of the lung spontaneously cured, 186
Hyphomycetes found in sprue, notes on (illustrated), 305
Hypodermic injections, aseptic, 218
—— syringe, use of, in the administration of drugs, 286
Hypophysin extract, 30
ILLUSTRATIONS : —
A camphor distillery, 117
Charts illustrating sleeping sickness in the lado of the
Anglo-Egyptian Sudan, 278, 281, 282, 283
—— —— the coastal climate of tropical Queensland, 225
Diagram to show possible relationships of Trichophyton
currii, 262
—— illustrating the transmission of Trypanosome brucei
of Nigeria by Glossina nigeriense, 373
ILLUSTRATIONS (continued).
Figures and diagrams illustrating the use of the tuning
fork in diagnosing the outlines of the solid and hollow
viscera of the chest and abdomen and of certain patho-
logical conditions, 17, 18, 19
Map illustrating sleeping sickness in the lado of the
Anglo-Egyptian Sudan, 277
Monilia asteroides, 308
intestinalis, 308, 309
—— rotundata, 308; 309
Primitive Formosan camphor still, 117
Temperature charts from a case of human trypanoso-
miasis, 81, 82
—— of case of protracted fever with splenomegaly,
showing certain protozoa-like bodies, 113
Toxoplasma pyrogenes, Castellani, 1918, 98
Immunity of certain tracts from plague, 92
Importance of rectal examination, 343
—— of studying the mineral constituents of our food, 35
India, protection of, from yellow fever, 44
Indian cities, supply of milk to, 313
Infant death rate in Burma, 350
—— mortality in the Philippine Islands, 167
Infantile diarrheea, treatment of, by saline injections, 68
Infants, malaria in, 178
Influence of climate, disease, and surroundings of the white
race living in the Tropics, 267
Injections, subcutaneous, of quinine, 85. 87, 218, 272, 986, 336,
342, 352
Insect transmission of anthrax, 61
Insolation: its prophylaxis and treatment, 230
International Congress of Tropical Agriculture, 195
Intestinal protozoal parasite producing dysenteric symptoms
in man (illustrated), 65
—— schistosomiasis in the Sudan, 78
Intramuscular injections of quinine, 272, 286, 336, 352
Intravenous injections of sublimate for tropical malaria, 87
Introductory address, Third All-India Sanitary Conference, 76
Investigations, helminthological, 84
—, pellagra, 22
Ipecacuanha and emetine: their amcebacidal value in patho-
genic amoebiasis, 153
Is emetine sufficient to bring about a radical cure in ame-
biasis ? 250
K
Kala-azar and allied conditions, 248
— in Malta, 68
——, Indian, culture of Leishmania from the finger-blood of a
case of, 49
———, segregation and, 314
———, uniform success of segregation measures in eradicating,
from Assam tea gardens, 55
Keeping properties of condensed milks in the Tropics, 46
Kernels, cocoa and, 114
Kurloff's bodies, 208
—— —, nature of, 137
L
LEADING ARTICLES :—
A school of oriental studies, 285
Acclimatization of animals in the Zoological Gardens,
London, 51
An Indian voluntary aid contingent, 325
Antityphoid vaccine, 36
Are plants, trees, and flowers in and around our houses
beneficial or deleterious? 136
Chair of Tropical Medicine in the University of Naples, 341
Common diseases in time of war: enteric fever, 363
Cow's milk, 216
Dinner to Surgeon-General Gorgas, 99
Discussions at the Tropical Section of the British Medical
Association, 266
Disease aftermath of war, 292
Fruits and their action, 376
Helminthological investigations, 84
Importance of studying the mineral constituents of our
food, 35
International Congress of Tropical Agriculture, 195
INDEX ix.
LEADING ARTICLES (continued),
Medical education in China, 150
Necessity for a women’s Indian medical service, 66
Pellagra investigations, 22
Scarcity of food in war, 819
Science and war, 325
Scientific announcements in the lay press, 115
Some aspects of surgery in the Tropics, 164
Spas in Europe for tropical residents, 179
—— in Western Germany, 180
Subcutaneous injections of quinine, 85
The use of new remedies in tropical countries, 4
Legislation, South African, 128
Leishmania, culture of, from the finger-blood of a case of Indian
kala-azar, 49
tropica, case of, with a fatal termination, 322
Leishmaniasis, dermal, antimony in, 324
, natural, of dogs in Algiers, 86
Leprosy, 13, 53, 60, 72
—— after two-year incubation period, 72
——, rat, in North Queensland, 13
—, treatment of, 60
Lichen, vaccine, in natives (illustrated), 145
Life assurance in Egypt, 10
Limitation of the after-pain of quinine injections, 342
Liquid paraffin in enteric fever with constipation, 255
Liver, hydatid cyst of the, 173
abscess, case of, treated without operation, 33
—— — — treatment of, 141
—— ——,, see also Hepatic abscess
Liverpool School of Tropical Medicine, 240
Livingstone Gollege, 5, 189
London School of Clinical Medicine, 176
London School of Tropical Medicine, 128, 291
Lung, cholera bacilli in the, 34
Malaria and parotitis, 26
, chronic, with enlarged spleen, a useful prescription in, 323
———, eradication of, 9
—— in infants, 188
—— , meteorology of, 97, 321
———, prevention of, in the troops from our Indian Empire, 296
, tropical, intravenous injections of sublimate for, 87
Malarial parasites and Piroplasma canis, experiments with, 72
, free, 182
Malnutrition in adults, 379
Malta, kala-azar in, 68
Maltese phlebotomi, bionomics of, 251
Manchuria, plague in, 23
Manila Bureau of Health report for 1913, 105
Mecca pilgrims and cholera, 363
Medical education in China, 150
Medicine and medical customs in Egypt, 47
Mediterranean or undulant fever, recent research relating to, 98
Memoranda, 48
Mental disease, the army and, 368
Metabolism, nitrogenous, in chyluria, 242
Meteorology of malaria, 97, 321
Midge, new blood-sucking, 43
Milk, artificial, from the soy bean, 176
——, supply of, to Indian cities, 318
Milks, condensed, keeping properties of, in the Tropies, 46
Mineral constituents of our food, importance of studying the, 35
Miner's phthisis on the Rand, 119
Missile, a new, 363
Molluscum tibrosum, pendulatum atque elephantiacum (illus-
trated), 291 P
Mortality on the Rand, some of its causes, 119
Mosquito destruction in Queensland, 31
Murmekiasmosis amphilaphes (illustrated), 129
N
Narcotic action of alcohols, elimination of, by fats, 246
Natural leishmaniasis of dogs in Algiers, 86
Nature of the Kurloff body, 137
Necessity for a women's Indian medical service, 66
Neuritis, testicular, following gonorrhcal epididymitis, 166
New blood-sucking midge, 48
geographic locality for Balantidiosis coli, 99
Jersey, beriberi in, 34
malarial parasite of man, 152
missile, a, 363,
Orleans, plague in, 324
preparations, 194
regulations for federal meat inspection in America, 350
remedies, use of, in tropical countries, 4
type of typhus in East Asia, 59
variety of coffee, 189
Zealand, pellagra in, 163
Nitrogenous metabolism in chyluria, 242
North Manchurian plague prevention service, 335
Nosema apis, pathogenicity of, to insects other than hive
bees, 60
Note on a case of death following the sting of a scorpion, 199
—— —— of liver abscess treated without operation, 88
—— —— of osteoperiostitis developing after a probable attack
of “ febris columbensis,’’ 177
—— on a foreign body removed from the liver after twenty-
three years, 200
— on an intestinal protozoal parasite producing dysenteric
symptoms in man (illustrated), 65
Nores AND News :— 14, 81, 46, 64, 80, 198, 176, 188, 240, 256,
286, 884, 850, 380
—— on the hyphomycetes found in sprue (illustrated), 305
———, personal, 84, 192, 336, 352
0
Observations on the breeding places of sand-flies (Phlebotomus
Spp.) in the Anglo-Egyptian Sudan, 2
Occurrence of certain structures iu the erythrocytes of guinea-
pigs and their relationship to the so-called parasite of
yellow fever (illustrated), 369
Operation, early, for gall-stones, 342
Operative treatment of elephantiasis scroti, 25
of hepatic abscess, 138
Oriental studies, a school of, 285
ORIGINAL COMMUNICATIONS :—
A human recovery from trypanosomiasis.
Kerr (illustrated), 81
A list of the blood-sucking arthropods from the Lower
Congo, with a vocabulary. By Mercier Gamble, M.D.,
148
A useful prescription in chronic malaria with enlarged
spleen. By James Cantlie, M.B., F.R.C.S., 323
Ankylostomiasis in the North Nyasa district. By A. G.
Eldred, M.R.C.S., L R.C.P.Lond., 209
Arthritis in sprue.. By George C. Low, M.A., M.D., 1
Asiatic cholera. By John Furse McMillan, L.R.C.P.
Lond., M.R.C.S.Eng., L.S.A., 354
Babesia or piroplasma. By Albert J. Chalmers, M.D.,
F.R.C.S., D.P.H., and Capt. R. G. Archibald, M.B.,
R.A.M.C., 323
Beri-beri in Papua (British New Guinea). By W. M.
Strong, M.D., B.C., D.T.M. & H. Camb., 310
Brief note on amebic dermatitis. By Lim Boon Keng,
M.D., C.M. Edin., 193
—— —— on Toroplasma pyrogenes, Castellani, 1913. By
Prof. Ludwig Plate (illustrated), 98
Bronchial spirochetosis. By Frank S. Harper, W.A.M.S.,
194
Canine babesiasis in Porto Rico. ‘By Dr. I. Gonzalez
Martinez, 194 :
Case of Leishmania tropica with a fatal termination. By
A. R. Neligan, M.D.Lond., M.R.C.S., D.T.M. & H.
Cantab., 322
Coastal climate of tropical Queensland. By F. H. Taylor
and W. J. Young (illustrated), 225
Culture of Leishmania from the finger-blood of a case of
Indian kala-azar, with some remarks on the nature of
certain granular bodies recently described from the
disease. By C. M. Wenyon, M.B., B.S., B.Sc., 49
Detection of trypanosomes in animals. By Alexander
Lundie, M.B., 22
Dracontiasis or dracunculosis: a review. By
McConnell, B.A., M.D., C.M., D.T.M., 397
By Dr. T. 8.
R. E.
x. INDEX
ORIGINAL COMMUNICATIONS (continued).
Emetine treatment of dysentery in young children. By
Capt. R. G. Archibald, M.B., R.A.M.C., 161
“ Espasmo tropical": a peculiar disease of great malig-
nancy, asscciated with a parasite in the blood. By R.
Vergne, M.D., 20
Further case of entoplasmosis.
88
— notes on entamebiasis. By Dr. Lim Boon Keng, 244
Meteorology of malaria. By Mathew D. O'Connell, M.D.,
97, 321
Molluseum fibrosum pendulatum atque elephantiacum.
By Dr. F. S. Harper (illustrated), 291
Murmekiasmosis amphilaphes. By Albert J. Chalmers,
M.D., F.R.C.S., D.P.H., and J, B. Christopherson,
M.A., M.D., F.R.C.P., F.R.C.S. (illustrated), 129
Note of a case of liver abscess treated without operation.
By J. Bell, 33
of osteoperiostitis developing after a probable
attack of “febris columbensis.” By Aldo Castellani,
M.D., 177
— on certain protozoa-like bodies in a case of protracted
fever with splenomegaly. By Aldo Castellani, M.D.
(illustrated), 113
— on a new geographical locality for Balantidiosis coli.
By Major B. H. Dutcher, 99
—— on an intestinal protozoal parasite producing dysen-
teric symptoms in man (illustrated). By Aldo Cas-
tellani, M.D., 65
Notes on the hyphomycetes found in sprue; with remarks
on the classification of fungi of the genus ‘ Monilia
Gmelin 1791.” By Aldo Castellani, M.D. (illustrated),
305
Observations on the breeding places of sand-flies (Phle-
botomus spp.) in the Anglo-Egyptian Sudan. By Harold
H. King, F.E.S., 2
Occurrence of certain structures in the erythrocytes of
guinea-pigs and their relationship to the so-called para-
site of yellow fever. By C. M. Wenyon, M.B., B.S.,
B.Sc., and George C. Low, M.A., M.D., C.M. (illus-
trated), 369
Preliminary note on entameebiasis.
227
Psittacosis. By T. P. Beddoes, F.R.C.S., 33
Recovery of embryo of Filaria bancrofti from blood from
the lung during daytime. By Major B. H. Dutcher, 163
Sleeping sickness in the Lado of the Anuglo-Egyptian
Sudan. By Albert J. Chalmers, M.D., F.R.C.S.,
D.P.H., and Capt. W. R. O'Farrell, R. A.M.C. (illus-
trated), 273
So-called Plasmodium tenue (Stephens). By Andrew Bal-
four, C.M.G., M.D., and C. M. Wenyon, M.B., B.S.,
B.Sc. (illustrated), 353
Study of the nitrogenous metabolism in chyluria. By
W. J. Young, 242
Systemic position of the genus Tricophyton, Malmsten,
1845. By Albert J. Chalmers, M.D., F.R.C.S., D.P.H.,
and Alexander Marshall (illustrated), 289
Tinea capitis tropicalis in the Anglo-Egyptian Sudan. By
Albert J. Chalmers, M.D., F.R.C.S., D.P.H., and
Alexander Marshall (illustrated), 257
Transmission of Trypanosome brucei of Nigeria by Glos-
sina tachinoides, with some notes on Trypanosoma
nigeriense. By G. H. Gallagher, L.R.C.P. & S.I.
(illustrated), 312
Treatment of chronic ulcers of the leg with frog flesh
poultice. By Lim Boon Keng, M.B. Edin., 34
— — of yaws and their sequelie by means of salvarsan.
By Dr. E. C. Girling. 193
Use of the tuning-fork in diagnosing the outlines of solid
and hollow viscera of the chest and abdomen, and of
certain pathological conditions (illustrated). By James
Cantlie, M.B., F.R.C.S., 17
Vaccine lichen in natives. By Albert J. Chalmers, M.D.,
F.R.C.S., D.P.H., and Capt. W. Byam, R.A.M.C.,
(illustrated), 145
Oroya fever, verruga peruviana and uta, 11
Orrefin, clinical evidence of bi-palatinoid, in anemia, 111
Osteoperiostitis, note on a case of, developing after a probable
attack of *' febris columbensis," 177
Ova in stools, 5
By Aldo Castellani, M.D.,
By Lim Boon Keng,
Panama Canal, sanitary work in the, 102
— Pacific International Exposition at San Francisco in 1915,
256
Pancreas, ecchinococcus cyst of, 3
Papua, beriberi in, 310
Parasite, intestinal protozoal, producing dysentaric symptoms
in man (illustrated), 65
, new malarial, of man, 152
—— of the sugar-beet, 176
Parasites, free malarial, 182
Pardah and early marriages, 217
Parotitis and malaria, 26
Pathogenicity of Nosema apis to insects other than hive bees,
Peat products (Sphagnol), 30
Pellagra, 22, 46, 59, 163, 166
— in America, 59
—— in New Zealand, 163
—— investigations, 22
—, some cases of, occurring among the insane in South
Africa, 166
—,, transmission of, from man to monkey, 46
Pellagrins, protective ferments in serum of, 342
Pelvic hydatid, a solitary obsolescent, 254
Personal notes, 32, 48, 64, 84, 112, 160, 192, 288, 804, 336, 352
Pharmacology of formaldehyde, 265
Philippine Islands, infant mortality in the, 167
Phthisis, miners’, on the Rand, 119
Physiological criteria for medicinal substances, 79
Pilgrims, Mecca, and cholera, 363
Piroplasma or babesia, 323
— — canis and malarial parasites, experiments with, 72
——— ——, cultivation of, 58
Piroplasmosis, equine, in Italy, 86
Plague, &c., disappearance of, from civilized countries, 342
, immunity of certain tracts from, 92
— in Manchuria, 23
- in New Orleans, 324
Plasmodium tenue (Stephens), the so-called (illustrated), 353
Plea for a wider and more organized application of sanitary
measures in the Tropics, 228
Pneumonia on the Rand, 121
——, primary lobar, pulmonary attack simulating, 104
Poliomyelitis, acute anterior, epidemiologic studies of, 54
Post-typhoid cholelithiasis, 377
Practical points in abdominal surgery, 378
Preliminary note on entamcebiasis, 227
Prescription, a useful, in chronic malaria with enlarged spleen,
323
Prevention of malaria in the troops of our Indian Empire, 296
Production of senna in the Sudan, 217
Protection of India from yellow fever, 44
Protective ferments in serum of pellagrins, 342
Protozoa and disease, 300
Protozoa-like bodies, note on certain, in a case of protracted
fever, with splenomegaly, 113
Pruritus ointment, triple acid, 265
Psittacosis, 33
Public health, flies and, 150
Pulmonary attack simulating primary lobar pneumonia, 104
Pyopneumothorax, ascaris in, 314
Q
Queensland, mosquito destruction in, 31
——., North, rat leprosy in, 13 '
—, tropical, coastal climate of (illustrated), 225
Quinine injections, limitation of after-pain of, 342
— —., intramuscular injections of, 272, 286, 336, 352
——, subcutaneous injections of, 85
R
Rand, miner's phthisis on the, 119
— —, mortality on the: some of its causes, 119
—, pneumonia on the, 121
INDEX xi.
Rashes, drug, 48
Rat leprosy in North Queensland, 13
Rat-bite disease, 60, 192 .
RECENT AND CURRENT LITERATURE, 13, 32, 144, 160
—— research relating to undulent or Mediterranean fever, 93
—— researches on emetine and its value as a therapeutic agent
in ameebiasis and other diseases, 183
—— —— on sprue, 252
Recognition of the cholera vibrio, 182
Recommendations as to sanitation concerning employees of the
mines on the Rand, 218
Recovery, a human, from trypanosomiasis (illustrated), 81
—— of embryo of Filaria bancrofti from blood from the lung
during daytime, 163
Recruiting, 157
Rectal examination, importance of, 343
Regulations, new, for federal meat inspection in America, 350
Relapsing fever, &c., disappearance of, from civilized countries,
Remedies, use of new, in tropical countries, 4
REPRINTS :—
Army, the, and mental disease, 368
Further researches on combined vaccines.
tellani, M.D., 326
Typhoid-paratyphoid vaccination with mixed vaccines.
By Aldo Castellani, M.D., 36
Researches in sprue, 1912-1914, 203
Reviews, 31, 63, 96, 198, 143, 187, 208, 255, 320, 334, 351
Rice, a disease of, 135
. Burma, 333
Ringworm yaws, 114
Royal Institute of Public Health, Edinburgh Congress, 198
By Aldo Cas-
Saline injections, treatment of infantile diarrhcea by, 68
Salvarsan in the treatment of yaws, 24
——-, treatment of yaws and their sequele by means of, 193
Sand-flies, breeding places of, in the Anglo-Egyptian Sudan, 2
Sand.fly fever, 251
Sanitary work in the Panama Canal, 102
Scarcity of European medical officers in Burma, 47
of food in war, 312
Schistosomiasis, intestinal, in the Sudan, 78
Science and war, 325
Scientific announcements in the lay press, 115
Seamen's Hospital Society, 96, 188
Sea-sickness, atropine in, 150
Secondary changes due to bilharzia ova in the spinal cord, 250
Segregation and kala-azar, 314
——— measures, uniform success of, in eradicating kala-azar
from Assam tea gardens, 55
Senna, production of, in the Sudan, 217
Ship surgeons, 128
Ship-borne cholera, 25
Sir Ronald Ross’s work, 189
Skin reaction indicative of immunity against typhoid fever, 103
Sleeping sickness, 91, 273
—— —— in the lado of the Anglo-Egyptian Sudan (illus-
trated), 273
— — —, tsetse, aud big game, 91
Small-pox in China, 14
-— in Great Britain and Germany, 163
, some experiments on the inoculation of monkeys with, 170
So-called Plasmodium tenue (Stephens), the (illustrated), 353
Society of Tropical Medicine and Hygiene, 46
Some aspects of surgery in the Tropies, 164
cases of pellagra occurring among the insane in South
Africa, 166
—— experiments on the inoculation of monkeys with small-pox,
170
South African legislation, 128
Soya bean, artificial milk from the, 176
———, uses of the, 335
Spas in Europe for tropical residents, 179
in Western Germany, 180
Spirocheta duttoni, filterability of, 137
——— and S. kochi, distribution and morphology of, 137
Spirochete, cultivation of a free-living filterable, 138
Spirochetes and argas, 27
Spirochetosis, bronchial, 194
Splenomegaly, note on certain protozoa-like bodies in a case of
protracted fever with splenomegaly (illustrated), 113
Spread and distribution of diseases in the East, 293
Sprue, arthritis in, 1
———, notes on the hyphomycetes found in (illustrated), 305
——, recent researches on, 252
———, researches in, 203
Steel mill workers, trachoma in, 107
Stegomyia mosquitoes in Madras, distribution and habits of, 8
—— survey of the city and island of Bombay, 6
, port of Calcutta, 7
Stools, ova in, 5
Story of some of our common drugs— camphor (illustrated), 116
Streptococci, differentiation of, 230
Study of the nitrogenous metabolism in chyluria, 242
Subcutaneous injections of quinine, 85 :
Sublimate, intravenous injections of, for tropical malaria, 87
Subphrenic space, surgery of the, 344
Sugar beet parasite, 176
Supply of milk to Indian cities, 313
Suppurating hydatid cyst, 173
Surgeons, ship, 128
Surgical treatment of colitis and post-dysenteric conditions, 252
Surgery of the subphrenic space, 344
, some aspects of, in the Tropics, 164
Survey, stegomyia, of the city and island of Bombay, 6
stegomyia— port of Calcutta, 7
Syringes, care of, 62
Systemic position of the genus T'ricophyton Malmsten 1845
(illustrated), 289
T
Teff, a valuable tropical and sub-tropical hay crop, 380
Testicular neuritis following gonorrhceal epididymitis, 166
Tetanus, treatment of, 378
The infectious diseases: recent additions to our knowledge of
their etiology, 154
Third All-India Sanitary Conference, 73
—— International Congress of Tropical Agriculture, 190
Thread-worms and appendicitis, 314
Tinea capitis tropicalis in the Anglo-Egyptian Sudan (illus-
trated), 257
Toroplasma pyrogenes, Castellani, 1913, brief note on (illus-
trated), 98
Trachoma, 87
in steel mill workers, 107
TRANSLATIONS :—
Disinfection as practised at the present time by the use
of steam and formol apparatus, and disinfection by
use of “Clayton ’’ machines, 174
Recruiting. By Dr. Reynaud, 157
Transmission of pellagra from man to monkey, 46
— — of Trypanosome brucei of Nigeria by Glossina tachinoides,
with some notes on Trypanosoma nigeriense (illustrated),
372
''Traumatic malacea " following fractures, 378
Treatment of chronic ulcers of the leg with frog-flesh poultice,
34
—— of infantile diarrhoea by saline injections, 68
of leprosy, 60
—— of liver abscess, 141
—— of yaws and their sequelze by means of salvarsan, 193
—— ———, salvarsan in the, 24
—, operative, of elephantiasis scroti, 25
Trichinosis, 347
Tricophyton Malmsten 1845, systemic position of the genus
(illustrated), 289
Triple acid pruritus ointment, 265
Tropical countries, use of new remedies in, 4
— malaria, intravenous injections of sublimate for, 87
—— medicine, chair of, in the University of Naples, 341
residents, spas in Europe for, 179
Tropics, acclimatization in the, 39
Trypanosomes, detection of, in animals, 22
—— human, wild game as a reservoir for, 89
Trypanosomiasis, 59
—, a human recovery from (illustrated), 81
Tsetse, sleeping sickness and big game, 91
xii. INDEX
MÀ a
Tsetse and big game in Southern Rhodesia, 315
Tuning-fork, use of the, in diagnosing the outlines of solid and
hollow viscera of the chest and abdomen and of certain
pathological conditions (illustrated), 17
Two cases of sprue treated by mouth streptococcal vaccines
and emetine hydrochloride hy podermically, 199
Typhoid carriers, 160
fever, hemorrhage late in, 343
; skin reaction indicative of immunivy against, 103
——, paratyphoid vaccination with mixed vaccines, 36
Typhus, exanthematic, 59
—, new type of, in East Asia, 59
———, relapsing fever and plague, disappearance of, from civi-
lized countries, 942
U
Ulcers,- chronic, of the leg, treatment of, with frog flesh
poultice, 34
Uleus molle serpiginosum, 41
Undulent or Mediterranean fever, recent rescarch relating to, 93
Ungt. **cycloform "' Co., 30
Uniform success of segregation measures in eradicating kala-
azar from Assam tea gardens, 55
Use of the hypodermic syringe in the administration of drugs,
286
—— of new remedies in tropical countries, 4
—— of the tuning fork in diagnosing the outlines of solid and
hollow viscera of the chest and abdomen and of certain
pathological conditions (illustrated), 17
Uses of the soya bean, 335
Uta, verruga peruviana, and Oroya fever, 11
LIST OF
Bodies found in the blood and spleen of a case of protracted
fever with splenomegaly (coloured), face p. 113
Dr. D. E. Anderson, M.D., London, face p. 247
Intestinal protozoal parasite producing dyseuteric symptoms in
man (film stained by Giemsa's method), face p. 65
London School of Tropical Medicine group, face pp. 32, 96, 216
Microphotographs of intestinal protozoal parasites producing
dysenteric symptoms in man, face p. 66
Molluscum fibrosum pendulatum atque elephantiacum, face
. 291
Mvcenakinanadaia amphilaphes —Plate I, face p. 129
——— —— Plate II, face p. 133
——— ——— Plate III, face p. 135
Y
Vaccination, typhoid-paratyphoid, with mixed vaccines, 36
Vaccine, anti-typhoid, 36
—— lichen in natives (illustrated), 145
, combined, further researches on, 326
Variola and varicella, differential skin reaction in, 380
Venereal disease, course in, 157
Verruga peruviana, Oroya fever, and uta, 11
Virol, Limited, 192
Vomiting sickness of Jamaica, 253
W
War and the drug supply, 246
——, disease aftermath of, 292
—, scarcity of food in, 812
—, science and, 325
West Africa, yellow fever in, 14
Wild game as a reservoir for human trypanosomes, 89
Women’s Indian medical service, necessity for, 66
Wu Lien Teh honoured, 64
Y
Yaws, ringwom, 114
, salvarsan in the treatment of, 24
———, treatment of, and their sequele by means of salvarsan, 193
Yellow fever in West Africa, 14
—— ——-, protection of India from, 44
Z
** Zana baths," 30
PLATES.
Occurrence of certain structures in the erythrocytes of guinea-
pigs and their relationship to the so-called parasite of
yellow fever, face p. 370
Photomicrographs of bodies found in the spleen of a case of
protracted fever with splenomegaly, face p. 114
Systemic position of the genus T'ricophyton Malmsten 1845,
face p. 290
The so-called Plasmodium tenue (Stephens), Plate I, face p. 353
—— — — — Plate II, face p. 854
Tinea capitis tropicalis in the Anglo-Egyptian Sudan, Plate I,
face p. 264
—— ——— ——— —— - —, Plate Il, face p: 265
Vaccine lichen in natives, face p. 147
INDEX OF SELECTIONS FROM
COLONIAL MEDICAL REPORTS.*
GENERAL INDEX.
(25) Southern Nigeria, 1
(26) British Honduras, 3
(97) Sierra Leone, 5
(28) Leeward Islands, 15
(29) Fiji, 17
(30) Ceylon, 19
(31) Jamaica, 31
(32) British Guiana, 41
(33) Grenada, 50
(34) Gold Coast, 62
(35) China, 69
INDEX OF
CLEVELAND, RoBERT O.— Cyprus, 131
CULMER, J. J.—New Providence, 133
Denman, R.—Mauritius, 117
Drayton, EDWARD. —Grenada, 50
FonpE, R. M.—Sierra Leone, 5
Fretz, W. H., L.R.C.P., L.R.C.S. Edin.—8t. Kitts-Nevis and
the Island of Anguilla, 102
Goprrey, J. E.— British Guiana, 41
Grey, Dr. DovGras.—China, 69
Harrison, J. H. Hvan.— British Honduras, 3, 82
(36) British Honduras, 82
(87) Fiji, 85
(38) St. Kitts-Nevis and the Island of Anguilla, 102
(39) Durban Corporation, 108
(40) Lahore Municipality, 113
(41) Mauritius, 117
(42) Municipality of Colombo, 119
(43) Cyprus, 131
(44) New Providence, 133
(45) Federated Malay States, 185
AUTHORS.
Ker, J. E.—Jamaica, 31
LawGLEYy, W. H., M.D.—Gold Coast, 62
Lyncu, W. G. A.—Fiji, 17, 85
Morison, P., M.D., B.Sc., D.P.H.—Durban Corporation, 108
NEWELL, Dr. A. G.—Lahore Municipality, 118
Norris, FREDERICK L.—M.B., C.M.—Leeward Islands, 15
Perry, Sir ALLAN, M.B., D.P.H:—Ceylon, 19
Parr, W. MarsHaty.— Municipality of Colombo, 119
Sansom, CHARLES Lane.—Federated Malay States, 195
STRACHAN, H.—Southern Nigeria, 1
* Note to the Binder,—These are to be bound to follow
all the numbers of THE JOURNAL OF TROPICAL MEDICINE,
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 1, Vol. XVII
Original Communications.
ARTHRITIS IN SPRUE.
By GrorcE C. Low, M.A., M.D.
Lecturer, London School of Tropical Medicine.
ARTHRITIS is recognized as a complication of
dysentery, certainly of the bacterial form, though it
is not so clear if it follows the ameebie or other
forms of that disease. When one turns to the liter-
ature of sprue, however, there is little or no mention
of such a condition occurring in that disease.
Carnegie Brown, in his work '' Sprue and its Treat-
ment," writes as follows: '' Myalgia is a frequent
accompaniment of sprue throughout the whole of
its course, and especially prominent in the later
periods. In the secondary stages the muscles are
soft, flabby and atrophied, the effects of failure of
nutrition being most apparent in those of the upper
arm and calf. With the pain and wasting of the
muscles, there is often intense lassitude and weak-
ness, and fatigue is induced by the slightest exer-
tion. The joints, too, are stiff and apparently
deficient in synovial fluid, for the patient assumes
an arthritic posture, and walks with a prematurely
decrepit gait. In the advanced stages of the
disease, muscular atrophy is still more general and
profound.”’
The same author has also met with two examples
of peripheral neuritis of the lower extremities com-
plicating sprue. Other writers (Manson, Daniels,
Castellani) do not mention arthritis or arthritic pos-
tures as complications of the disease, and personally,
though having seen myalgias and other obscure
rheumatic-like pains, I cannot remember off-hand
having seen a definite arthritis—unless the one I am
about to describe now is one—in the many cases of
sprue I have seen and examined.
In the case just mentioned certain joint lesions
have appeared, and it is difficult certainly not to
associate them in some way or other with the
disease, especially so as no other detectable cause
has been made out for them. Firstly, however, I
shall describe the case in detail and shall then return
to the discussion of this point later.
Mr. H., aged 48. India.
History.—Over eighteen years in India. During
that time having resided in many different parts of
the country.
Previous Illnesses.—Enteric (many years ago),
simple continued fever, diphtheria (five years ago),
pneumonia (in 1905), mild dysenteric diarrhea (one
or two slight attacks, but not recently).
Present Illness.——The sprue condition came on
insidiously, the first trouble being a flatulent dis-
tension of the abdomen; the tongue next became
irritable and somewhat bared ; smoking and drinking
making it very painful. After six weeks a little diar-
rhæa began in the mornings, stools pale, white, and
frothy. Dieted himself, but things did not improve.
The stools remained loose in the mornings, and the
patient also noticed that he had lost considerably in
weight.
Ezamination.—Teeth healthy, no sign of pyor-
rhea, tongue not specially bare, a good amount of
epithelium still existing upon it, no sores present in
the mouth or on the buccal mucosa on day of exami-
nation—July 3, 1912. Evidence of loss of weight
marked. All the other systems—lungs, heart,
&c.—were normal. The abdomen was flabby with
very soft walls, no pain on pressure. Liver: 6-7,
and costal margin: not diminished in size. Spleen:
9-11. Nervous system: nil. Urine: normal.
Stools: semi-solid, very pale in colour. Typical
sprue character.
Two days after my examination the patient was
seized with a severe pain in the abdomen. This
began first in the upper segment, and the patient
described it as if his stomach was burning. The
pain was bad enough to make him roll about, and
continued all night; by the next morning the burn-
ing sensation had ceased and the patient had more
or less regained his ordinary health, though his
abdomen on pressure still remained somewhat
tender. A strict milk diet was then prescribed, and
improvement was noticeable at once. No further
pain was complained of in the abdomen, and the
stools gradually became solid, and well-formed,
though still deficient in bile. About this time a
blood examination gave the following count :—
R. 3,970,000
W. 6,200 | No parasites of any kind seen.
Hb. 8095
Differential Number counted Per cent.
Polymorphonuclear «es 884 us 66:8
Large mononuclear Seta 14 ny, 29:8
Lymphocytes ... EA 126 "T 25:2
Eosinophile m tus 15 xs 8
Transitional ves EN 11 T 2:9
Mast cells es sis 0 it 0:0
500 100:0
Slight irregularity in the size of the red cells. No
poikilocytosis worth mentioning. No basophilia. No
nucleated reds.
Progress.—For some time everything went on
satisfactorily, but then for no very apparent reason
a relapse took place (October, 1912). Strict diet
again soon got rid of this, but any slight chill or
getting cold quiekly brought about a renewal of the
symptoms. Another well-marked relapse took place
in the summer of 1918. The bowels became loose
again with soreness of the tongue and the other
typical signs of sprue. From that time until the
present the patient has remained more or less in
statu quo, not having become much worse, but on
the other hand not becoming as well as he was
before the last relapse.
About the end of May, 1913, slight pains resem-
bling rheumatism began in the right shoulder-joint.
By the beginning of November these had become
very marked, and the movements of the joint
quickly became limited. He saw a surgeon for this
about that time and the latter diagnosed that he
had adhesions in the shoulder-joint due to septic
absorption from the intestine, and advised that these
should be broken down under chloroform. This
2 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1914.
was not done at once, and the joint quickly became
worse, pain being experienced in it even when
unmoved, though there was nothing acute visible,
e.g., redness and swelling. Movements also had
become distinctly more limited, and the case
was one evidently for active interference. Chloro-
form was given and the adhesions were broken
down, the patient at the same time being
placed on a lactic acid milk diet by the wish
of the surgeon. This did not affect the sprue
adversely, but on the other hand made no mani-
fest improvement in the joint condition. Pas-
sive movements are now being adopted to prevent
the adhesions re-forming, and it will be interesting
to see whether these do so or not.
Apart from the affection of the right shoulder-
joint there have been no other rheumatie pains in
the muscles (myalgia), but the patient has certainly
been walking lately slightly bowed and with what
might be termed an arthritic or decrepit gait.
Easily produced fatigue has also been a prominent
feature during the course of his illness, the muscles
being soft, flabby, and tending to atrophy as has
been so well described by Carnegie Brown. As re-
gards the sprue, that condition would seem to be
more or less stationery.
It is not perhaps quite correct to term the lesion of
the patient's shoulder-joint a pure arthritis, because
as far as one can judge the internal arrangements are
still in good working order. The changes that have
developed would appear to be in the fibrous tissues
about and around the joint, namely, in the capsular
tissues, and the tendon-sheaths of the different
muscles. In these there would seem to have been
inflammatory changes of a subacute or chronic
nature resulting in the formation of adhesions with
a strong tendency to go on increasing and to become
progressively worse.
As to the cause of the condition the patient has
never suffered from definite rheumatism of any sort
before, never rheumatic fever, he is not as far
as he knows gouty, there are no signs of tubercle,
his teeth are in good condition, no pyorrhea or
any septic lesions existing in the mouth, he has
only suffered from gonorrhea once, long ago in
his youth, and at present does not suffer from
any form of urethritis, nor are there any signs of
syphilis. So far, only the one joint has become
affected, though it is quite within the bounds of
possibility that others may ultimately become in-
volved as well. The surgeon who broke down the
adhesions, as already stated, was of the belief that
the trouble had resulted from the bowel condition,
he being largely led to this belief by the similarity
of the lesions to others he had seen in non-tropical
cases of chronic auto-intoxication from the bowel.
The idea of an alimentary toxemia as the cause
of the shoulder condition seems a fairly plausible
one, the fact that such lesions follow dysentery
favouring this, though on the other hand the ap-
parently extreme rarity of such a condition in sprue
is rather against it.
Whether this be so or no, I do not know; but I
have reported the case as it seems a specially inter-
esting one, and may. help in the elucidation of the
etiology of this obscure disease.
Since writing the above I have again seen the
patient. His sprue condition is much improved,
the tongue now having a good coating of epithelium
and the bowels only moving once a day. The stools
are solid though still deficient in bile. Weight is
increasing again and he feels better.
The joint condition is improved since the opera-
tion, movements being freer, but pain is still
present, and on rotating the arm there is slight
grating within the joint, evidently indicating some
involvement of the cartilages. Upon inquiring into
the history again carefully, I find that the patient
suffered from tonsillitis in his youth, and once did
have some rheumatic kind of condition of one of
his knees. This might indicate therefore a rheu-
matic diathesis, but the present condition of the
shoulder-joint is certainly not an ordinary rheu-
matic one nor is it rheumatoid arthritis. As far
as one can see, therefore, one must consider it
connected in some way with the alimentary con-
dition.
OBSERVATIONS ON THE BREEDING
PLACES OF SAND-FLIES (PHLEBOTO-
MUS SPP) IN THE ANGLO-EGYPTIAN
SUDAN.
By Harotp H. Kıya, F.E.S.
Government Entomologist, Wellcome Tropical Research
Laboratories, Khartoum.
Introductory.—Notwithstanding the investigations
on the bionomics of the so-called sand-flies, which
have been carried out during the last few years,
we as yet know comparatively little of the breeding
places of these tiny blood-sucking insects. Grassi
[1] in Italy found a few larve and pupe in cellars
and similar places among damp bricks and refuse.
Howlett [2 and 3], working at Pusa, has taken
larve and pupe in a number of situations, with but
one exception always associated with either stones,
bricks, tiles, or cement. Marett [4] and Newstead
[5], at Malta, obtained a few larve and Pups in
caves and in crevices in stone walls.
Anglo-Egyptian Sudan.—The writer, working in
the Anglo-Egyptian Sudan, has unearthed a single
larva from soil in a cotton field at Tokar [6] and
now wishes to record the taking of a number of
larve in soil in Khartoum, and the ultimate emer-
gence of the adults under abnormal conditions.
On May 10 of this year, soil was taken from
between rows of orange and lime trees, growing in
the garden of the Gordon College, and placed in
glass museum jars, diameter 8 in. These trees are
irrigated by means of water-channels, running from
tree to tree down the rows, which are about three
yards apart. The soil in the jars was thoroughly
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 3
soaked with water and cotton seeds planted in it.
On the 17th the jars were netted over and a number
of adults of the cotton-flea beetle (Nisotra uniformis,
Jacquart) introduced. By the 21st the soil had
dried out, so it was again soaked with water and
more cotton seeds sown, the seedlings from the last
sowing having been killed by the beetles. On the
28rd an adult Phlebotomus papatasii, Scopoli, 1786,
was noticed in one of the jars against the side, about
3 in. below the surface of the soil. It had newly
emerged and the empty pupal case was close to it.
Examination revealed the presence of several pups
in similar situations in both jars, and for the next
few days fresh pups and adults were continually
being observed. On the 27th, and for several suc-
ceeding days, larve were seen. They were mature,
and had apparently been attracted to the sides of
the jars by the light. Five larve and four pup:
were dug out and preserved and between fifteen and
twenty adults emerged. The pupal period as
observed in two cases was nine days.
It is obvious that immature larve must have been
present in the soil when it was placed in the jars
on May 10, as the first adult was seen only thirteen
days later.
As noted above, in Italy, Malta and India the
immature forms of sand-flies have almost invariably
been taken in association with rocks, stones, or
some kind of masonry, and it is generally considered
that the female fly prefers such situations as these
for the act of oviposition. Doubtless many sand-
flies in the Anglo-Egyptian Sudan breed out under
these conditions, but the writer is of the opinion
that an equally favourite, if not the more normal,
breeding place is the soil. He has taken adult
sand-flies in crevices in rocks in the beds of streams,
and in holes in trees, in the Bahr-el-Ghazal Pro-
vince and the district formerly known as the Lado
Enclave, and in caves in rocky hills some two
hundred miles south of Khartoum, but in the
northern desert provinces they are sometimes met
with in myriads, sufficiently far from any building
or rock to preclude the possibility of their having
come from it. Tokar is a good example of this.
The town of Tokar is the centre of a cotton-growing
area of from 30,000 to 40,000 acres watered by a
river which comes down in flood during the months
of July and August and spreads over the plain.
There are usually a few heavy rainstorms in October,
November and December. In the town itself one
is told that sand-flies are not noticed, but in the
cultivation one may find as many as fifteen adults
hiding under a single clod of earth. In such
numbers do they exist in that locality that anyone
who has been there always associates the word
‘“‘ Tokar ° with sand-flies. The writer has endea-
voured to sleep in the desert, outside the town of
Berber, by the dry bed of a small khor (rain-water
channel), and found that sleep was rendered well-
nigh impossible by Phlebotomus spp.
Prophylazis.—By observations made in these and
other localities in the Anglo-Egyptian Sudan the
writer is led to believe that in devising any scheme
for the destruction of the breeding places of sand-
flies one will have to take into consideration all
tracts of soil containing a certain amount of mois-
ture and cracks. It is improbable that sand-flies
can breed in loose sandy soil which does not crack
on drying, as, in the absence of cracks, the pregnant
female would be unable to descend to lay her eggs
on the damp earth below the surface.
Khartoum,
September 13, 1913.
REFERENCES.
(The numbers correspond with those in the paper.)
[1] B. Grassı: “Ricerche sui Flebotomi," Memorie della
Sociwtá Italiana della Scienze, Section 3a, t. xiv, pp. 353-394,
1907.
[2] F. M. HowrzrT: ''Indian Sand-flies," Indian Medical
Congress, 1909, Section 3, pp. 239-242.
[3] F. M. HowrzrrT : ** The Breediug-places of Phlebotomus,”
Proceedings of the Third Meetiug of the General Malaria
Committee, held at Madras, November 18, 19 and 20, 1912,
Abstracted in the JOURNAL or TROPICAL MEDICINE AND
HGiENE, vol. xvi, No. 16, pp. 255-256.
[4] P. J. Margert: * Preliminary Report on the Investiga-
tion on the Breeding of Sand.fly in Malta," Journal of the
Royal Army Medical Corps, September, 1910, xv, 8, pp. 286-
291.
[5] R. NEwsTEAD: '' The Papataci Flies (Phlebotomus) of
the Maltese Islands," Annals of Tropical Medicine and
Parasitology, vol. v, No. 2, August, 1911. p. 141.
[6] H. H. Kina: ''On the Bionomics of the Sand-flies
(Phlebotomus) of Tokar, Anglo-Egyptian Sudan."
— eoe
Echinococcus Cyst of Pancreas.—A case of this
rare condition is described by Phillips from the
Colon Hospital, Canal Zone (Journal of the American
Medical Association, vol. lxi, No. 22, November 29,
1913). The author gives an idea of the incidence of
the condition by a brief review of-the literature on the
subject. Bergmann dismisses the subject with the
statement that ‘‘ echinococcus cysts of the pancreas
have been mentioned, but they occur with great
rarity.” In Keen is found the following: ‘‘ Hydatid
cysts of the pancreas are extremely rare. Masseron
was able to collect the records of only five cases.
These were first recognized on the post-mortem
table. Graham, of Sydney, writes: ' The hydatid
is sometimes found in the pancreas. I have ob-
served it as a cyst about 3 in. in diameter replacing
the head of the organ.’ Tricomi states, without
giving references, that 'seven cases have been
recorded.’ ’’
So it may be stated that heretofore the condition
has been observed seven times, and that at least
five of these were found on the post-mortem table,
and there was no reference made concerning the
other two cases.
In Phillips’s case the cyst—in the upper part of
the body of the pancreas—was found accidentally
when operating for a duodenal ulcer. It was
drained, and then the cyst wall came away with-
out any trouble. A slight pancreatic fistula per-
sisted for five weeks, but otherwise recovery was
uneventful. The patient was a Russian, and in all
likelihood got the infection in that country.
4 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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THE JOURNAL OF
Tropical Medicine andbhygiene
JANUARY 1, 1914.
THE USE OF NEW REMEDIES IN
TROPICAL COUNTRIES.
Ir is surprising how speedily a newly introduced
drug or róle of treatment is taken up by medical
men residing in the Tropies ; and it is frequently the
case that the more distant the colony and the more
solitary the doctor is as regards medical neighbours.
the more speedily does he begin to use the most
recent introductions. When far away from the
centre of things medical, the reports of new
remedies in the medical journals seem to indicate
to the man overseas that “‘ all the world '' is using
the remedy and that he must not fall behind in
the adoption of new and approved agents. In
many instances these may be new, but not quite
approved except by the individuals who lustily advo-
cate them; still, one finds, in distant parts of
the Empire, advanced therapeutic methods are
being used long before the general mass of the
medical profession at home have even begun to
employ them. The fact is that the medical man iu
isolated regions is on the alert to a degree scarcely
understood by ''stay-at-homes.'" His responsi-
bilities are great, grievously great at times; he has
no one to call into consultation it may be, and his
only guide and counsellor is the medical journal he
happens to ''take in." Valuable lives are in his
(Jan. 1, 1914.
hands and he has to do his best without in many
eases the consolation of being able even to share
responsibility with a fellow practitioner, and cer-
tainly without the privilege of expert advice in
particular ailments. It is no wonder, therefore,
that he flies to the new remedies he reads of, and
visitors to the districts find the ''local doctor"
using remedies freely which were only being whis-
pered about at home. When antipyrin, anti-
febrin, &c., were first brought into use, travellers
were surprised on reaching, say, the Far East to
find that the up-to-date remedies with which the
medicine cases they carried were equipped were
already extensively in use there.
Salvarsan is the latest of our important new
remedies to be tried, and in every quarter of the
Empire the drug is being employed for a variety of
ailments. It is right that it should be so, although
apparently neither time nor experience teaches any
of us moderation in regard to the remedial possi-
bilities and uses of the most recently introduced
remedies. Salvarsan, for instance, lias been exten-
sively and wisely used in Fiji in the treatment of
yaws, and the Report for 1912, by Dr. G. W. A.
Lynch, the Chief Medical Officer, contains a state-
ment by Dr. P. T. Harper, under the heading of
* Salvarsan Treatment,” in which it is recorded :—
“ Salvarsan Treatment.—Fifty cases of yaws and
syphilis were treated by salvarsan during the year;
the number treated by me during 1911 was fifty-one.
Of the fifty cases treated during 1912, nineteen were
Fijans, thirteen of whom were affected with
secondary yaws and six with tertiary yaws. One
of these former (an infant, and one of twins), though
apparently cured of yaws by the salvarsan, caught
dysentery from her elder sister, aged 9, who was
admitted to hospital for dysentery, and died of that
disease. The death occurred some weeks after
treatment with salvarsan, and was not, in my
opinion, due to the drug. The twins at the time of
treatment were aged about 10 months, and were
both in a most advanced stage of yaws cachexia and
wasting, and neither of them had a square inch of
unaffected skin on their body. The salvarsan cured
them in a few weeks. The other Fijians were all
cured or much improved by the treatment. Two
half-eastes and two Samoans were similarly treated
for yaws ; of one of these nothing further was heard.
The other three were cured. Twenty-eight Indians
were treated by this drug for yaws or syphilis; one
of these, an adult female with rupial syphilis,
derived no benefit from the treatment, but got
steadily worse. No treatment was of any avail;
mercury was tried in many forms and large doses
of quinine were given; she died two months after
her last dose of salvarsan; my opinion is that in her
case the giving of salvarsan was prejudicial. It was
given intramuscularly and, in all, she received
3 grm., the first dose being ‘6 grm. and the
six subsequent doses being *2 grm., spread over
a period of over two months. Possibly this was an
instance of anaphylactic reaction. The others all
did well. Two of these Indians were suffering from
syphlitic keratitis which had obstinately resisted
other lines of treatment. They completely recovered
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 5
after the salvarsan. All of the above cases of
yaws and syphilis which were treated by sal-
varsan received the intramuscular injection except
one, a very bad case of secondary syphilis with an
extensive papulocrustaceous eruption, to whom an
intravenous injection of ‘6 grm. was given; he
was cured. As a routine treatment of syphilis I
have now adopted a full two years’ course of mer-
cury, given by the method of the late Colonel
Lambkin, preceded, as a rule, by the intramuscular
injection of salvarsan. A number of the Fijian sal-
varsan cases were treated by native medical practi-
tioner Eroni Buresova, with occasional advice from
me. The hospital superintendent at Nausori Hos-
pital was taught to prepare the drug both for intra-
muscular and for intravenous administration. For
the former, various oily emulsions were tried and
discarded in favour of the aqueous solution. With
proper dosage the risks seem minimal. The risks
of giving the drug are certainly not so great as the
risks of withholding it in suitable cases. One other
case was treated with salvarsan, a case of simple
psoriasis; there was no improvement.”’
The judgment, precision, scientific acumen and
attention to practical detail displayed in this report
show how our medical brethren abroad keep abreast
of the times, and how in the very farthest off of our
colonies the ailments of both Europeans and natives
are being treated in a manner that bears supreme
testimony to the knowledge which our tropical
medical schools have served to diffuse and to spread
to the most distant parts of the Empire.
J. C.
LIVINGSTONE COLLEGE.
Tue Annual Report of the College, issued in
November, 1918, shows that this most useful
institution continues to do good work. It is twenty
years since the College opened and the number of
missionaries attending the College has steadily in-
creased. Men from many different denominations
and nations have taken out the course of instruc-
tion, and as years accumulate the most gratifying
tributes are being paid by the old students who
have returned to tell the value of the knowledge
they had acquired at Livingstone College before
going to the mission field. The course of medical
and surgical instruction provided by the College
extends over a period of nine months, and a better
chosen syllabus it is impossible to conceive; and it
surely needs no advice to the various religious
bodies in our country to see to it that they allow
no missionary to go to the mission field in warm
climates without first having gained the knowledge
which may be the means of saving their own lives
and those dear to them; and most certainly will be
found to prove the most ready and efficient means
of gaining the goodwill and the confidence of the
uncivilized heathen folk amongst whom missionaries
are to labour.
Many of the religious bodies in Britain plead that
they cannot afford to send their intending mis-
sionaries to the College before going out; this dis-
plays a short-sightedness and a throwing away of
golden opportunities for which there is and can be
no justification, and involves a waste of capital in
life and treasure for which the only apology is
ignorance. Religious fervour and devotion all men
admire when it is properly directed; but to send
out a person to almost certain failure, inasmuch as
the natives cannot understand that any emissary
of a religious cause is not also a ‘‘ medicine man,’’
is a mistaken policy and one fraught with danger
to the cause he has at heart, let alone the attendant
loss of health and life which is almost certain to
accrue to the missionary, his family, or- those
amongst whom he may be cast. :
The authorities of the College are endeavouring
to raise a Livingstone Memorial Fund of £10,000; a
small sum, surely, when it is considered that some
£12,000,000 annually are subscribed by the religious
communities in this country towards foreign mis-
sions. Church buildings are but so much material;
without the presence of the clergyman or the mis-
sionary they are mere bricks and mortar and must
fall into disuse unless the vivifying influence of the
pastor is there to advise and help the people. A
good deal of money is spent upon an outfit for the
missionary, but the best outfit a missionary can
be provided with is a knowledge of the kind pro-
vided by the Livingstone College.
Dr. Charles F. Harford, the Principal of the
College, has declared his intention of resigning his
post. This must prove a great loss and is increased
to a manifold degree by the fact that Mrs. Harford,
the kindly and devoted matron, is also withdrawing
from the position she has so long filled with the
greatest benefit to the College. Worthy successors
will no doubt be forthcoming, but seeing that Dr.
Harford was the responsible founder and first
Principal, and that the institution has grown and
developed under Dr. and Mrs. Harford’s devoted
attention, their departure is, from an historical and
a practical point of view, greatly to be lamented.
—————————
Ova in Stools.—McNeill, writing in the Journal
of the American Medical Association, November 1,
1913, describes an improved method of extracting
ova from stools. His technique, which is a slight
modification of Yavita's method, is as follows :—
A particle of the stool, about the size of a cherry,
is placed in a test-tube. To this are added 5 c.c.
of a 25 per cent. mixture of antiformin. This is
mixed well and warmed over a flame, but not boiled.
Five cubic centimetres of ether are then added and
the whole shaken well. It is then filtered through
one layer of gauze and centrifuged one minute
(water centrifuge). Four layers are formed. In the
lower layer the eggs are found.
This method is excellent, also, when dealing with
a fluid or semifluid stool. McNeill has found it
valuable in detecting hookworm ova in stools, the
capsule of the egg not being injured in the least by
the mixture, and he believes it is superior to th
method which Dock and Bass recommend, as it
requires less time, and there is less residue thrown
down with the ova.
6 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1914.
Abstracts.
PAPERS ON THE DISTRIBUTION OF
STEGOMYIA IN INDIA.*
(1) A SrEGOMYIA SURVEY OF THE CITY AND ISLAND
or BOMBAY.
By Major W. Gren Liston, M.D., D.P.H., LM.S8.,
AND
Sub-Assistant Surgeon T. G. AKULA.
Bowzav City, the capital of the Presidency and
the principal seaport of Western India, is situated
on an island in 189 55' N. and 729 54' E. The
island is for the most part flat, and is some eleven
miles long by two or three broad. The distribution
of the population over the island is irregular, the
greatest concentration being found in the south,
while the northern portion is sparsely populated.
Large docks extend along the greater part of the
eastern shores. During the year 897 vessels of
2,858,893 tons burthen engaged in foreign trade
entered the harbour. The bulk of the imports are
supplied by the United Kingdom, but there is con-
siderable trade between Bombay and the Far East.
The climate of Bombay throughout the year is
strikingly uniform, there are no extremes of heat
and cold. The climate may be said to be temper-
ate, but is oppressive owing to extreme saturation
of the air with moisture during the greater part of
the year. The cold season is short, lasting from
December to March. The hottest months are May
and October. The average rainfall is about 80 in.,
though there is a considerable variation from year
to year with a minimum of about 35 in. and a maxi-
mum of a little over 100 in. The rainfall is almost
wholly confined to the monsoon months June and
September.
The Culicine survey of the island was begun in
the end of July, 1912, and the present review covers
the period August and September of that year.
The work was undertaken by the authors in co-
operation with the Municipal and Port Trust
Officers, Drs. Turner, Shroff, and Mr. Lythe.
The larve of mosquitoes of the sub-family Culicine
were collected and identified from 922 breeding
places where they were found. As will be seen
from the accompanying table about 51 per cent. of
these mosquitoes belonged to the genus Stegomyia
and the allied genera Scutomyia and Desvoidea.
The species belonging to these genera were Stego-
myia fasciata and S. scutellaris, Scutomyia sugens
or a species closely related thereto, and Desvoidea
obturbans. By far the most common mosquito of
this group was Stegomyia fasciata. Its breeding
places were found 273 times. The proportion of
these mosquitoes to others of this group was 59 per
cent., or about 30 per cent. of all Culicine found
in the city. The breeding places of this mosquito
were distributed all over the island, in the most
densely populated part of the city as well as in the
Committee, held at Madras, November 18. 19, and 20, 1912.
Simla Government Central Branch Press, 1913.
showed special preference for certain kinds of breed-
ing places, being found 106 times in wooden tubs
containing water, so that this type of breeding
place constituted 39 per cent. of the whole. Other
selected breeding places and their relative propor-
tion to the whole were cisterns 11 per cent., iron
vessels, tin pots, &c., 9 per cent., wells 8 per cent.,
wooden barrels 8 per cent., cattle troughs 4 per
cent., masonry, garden tanks, cesspits, and zine
baskets 3 per cent. The larve of S. fasciata
were more rarely found in the following situa-
tions: Broken pots, cups, lily-pots, fire buckets,
earthen drinking pots, hollows in iron girders, and
other odd receptacles, as shells or antiformicas. In
every instance the breeding places were found in
what may be called artificial collections of water
associated with human habitations. The water in
almost every case was clean and free from putre-
fying material; in this respect this mosquito differs
from those described below.
The larve of Stegomyia scutellaris were found on
fifty-six occasions. This species of mosquito con-
stituted 12 per cent. of the Stegomyia group, and
6 per cent. of all Culicine met with. It was not
found, like S. fasciata, evenly distributed
over the island, but was met with in the urban
parts only where the houses were surrounded by
gardens, and where shade and shelter were avail-
able. This mosquito was more commonly found in
the suburbs of the city. Like S. fasciata, its
favourite breeding places were wooden tubs and
iron pots; such breeding places constituted about
48 per cent. of the whole. As compared with
S. fasciata this mosquito exhibited rather a prefer-
ence for iron vessels. Less frequent breeding
places of the S. scutellaris were wells, cattle
troughs, and occasionally the larve were found in
such places as broken bottles, cups, flower pots,
fire buckets, and antiformicas. It was rarely
though oceasionally found in pools and ditches filled
with rain water.
Scutomyia sugens, or a species closely related to
this mosquito, was met with in different parts of
the island, especially in the neighbourhood of the
new docks. The breeding places of this mosquito
constituted 29:5 per cent. of the whole of the
Stegomyia group.
The breeding places of Desvoidea obturbans were
found on twenty-nine occasions, forming thus 6'2
per cent. of the Stegomyia group. This mosquito
was generally found breeding in dirty water
coloured brown by organie matter in solution. The
larve are most commonly found in drains, which
are often connected with stables. They have also
been found in wooden tubs and hollows containing
rain water, in iron girders, and in disused
machinery. More rarely they have been found in
eattle troughs, masonry tanks, fountains, buckets,
cesspits, and roof gutters.
Of the other Culicine encountered in our survey
Culex concolor and fatigans were the most com-
monly found. Teniorhynchus perturbans was also
oceasionally met with. On one occasion larve of
Culex mimeticus were collected, and also à mosquito
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 7
of unknown genus; unfortunately the specimens of
this mosquito were so much damaged as to make
it impossible to describe or identify them.
It has been clearly established that Stegomyia
fasciata is widely distributed in the Island of Bom-
bay. It breeds in places closely associated with
human habitations where water has been accumu-
lated for domestic use, or where it has collected in
disused utensils during rain. The climate and
irade relations of the port of Bombay are such as
to favour the spread of yellow fever should the
ports of the Far East become infected with the
disease on the opening of the Panama Canal.
THE BREEDING PLACES OF CULICIN® FOUND IN THE
CITY AND ISLAND OF BOMBAY.
Number of places
Species in which larvæ
wore found
Stegomyia fasciata ... et. m ut .. 278
Stegomyia scutellaris 75 "n 3:5 PES 56
Scutomyia sugens ... oh a bef .. 104
Desvoidea obturbans dr «Ss SA y 29
Culex concolor oat ED 2 ae .. 949
Culex fatigans wr «2s ER ca 197
Teniorhynchus perturbans i je PN 13
Culex mimelicus ... Fe M A sus 1
Total breeding places exainined ait 922
(2) Stecomyra SurvEY—Porr or CALCUTTA.
By Major A. C. MacGiccurist, 1I. M.S.
Only two species of Stegomyia (fasciata and
scutellaris) were met with in the Port of Calcutta.
It is noteworthy that S. fasciata is found only in
densely populated areas. For this reason the term
'' domestic " as applied to it is not quite appro-
priate; it is too wide a term. S. fasciata is a town
or city mosquito; it is not content to live in small
villages such as occur on the banks of the Hooghly.
In the Port of Caleutta this mosquito has been
found only in the densely populated parts of Cal-
cutta and Howrah, and in a small area in Garden
Reach. In Calcutta it is a very common mosquito
in the northern part of the city, i.e., north of
Dhurumtollah Street, including not merely the
Indian residential quarter, but also the European
commercial quarter and Government Secretariat
buildings. By Paiva it has been found common
also in the ‘‘ fringe area ’’ of Calcutta and especially
in that part of the ‘‘ fringe area’’ adjoining the
northern part of the city, i.e., east of Upper Cir-
cular Road. It was not found in the villages on
the banks of the Hooghly below Garden Reach.
S. scutellaris is exceedingly common throughout
the port; it has no objection to either rural or city
life. It does not object to live near a solitary
isolated hut, so long as that hut is inhabited. While
S. fasciata is seldom found breeding more than a
few yards away from inhabited houses, S. scutel-
laris is often found breeding some 100 yards away.
If, in Caleutta, a mosquito is found biting in the
day-time, it is almost sure to be one of these two
species. The only other species of mosquitoes
observed to bite in the day were those of Desvoidea.
Only in rare instances have S. fasciata and S.
scutellaris been found in the same receptacle, and
at first it was thought they might be antagonistic
to each other. Their larve, however, when placed
together seem to live quite peaceably; the adults
emerge side by side.
Favourite breeding places for both species of
Stegomyia are the broken earthen pots, containing
rain water, which are found so commonly around
houses.
S. fasciata has been found on the third floor of
a house in the northern part of Calcutta in a very
congested area. The larve are found whenever
water can collect inside and in the immediate
vicinity of dwelling houses. This species of
Stegomyia seems to prefer small collections of
water; the eggs can resist drying for months. The
larve have been found in receptacles holding only
a couple of drachms of water, which would all
evaporate in a very few days. The following
breeding places were noted :—
(1) Earthen pots of all shapes and sizes.
is the commonest.)
(2) Cement and masonry work (next common-
est)—
(a) Water cisterns about 4 ft. square.
(b) Ornamental structures, e.g., in Dalhousie
square gardens for holding flower pots.
(3) Metallic vessels—
(a) Galvanized iron cisterns, 4 ft. x 4 ft. x 5 ft.
(b) Old tin box, 24 ft. x 13 ft. x 1 ft.
(c) Condensed milk tins—hung up as traps.
(d) Kerosine tins.
(e) Iron girder placed on its side, water being
retained between the flanges.
(4) Household utensils—
(a) Enamelled iron bowl.
(b) Porcelain flower pot.
The author thinks it strange that he has not dis-
covered S. fasciata breeding in wooden receptacles,
but this is possibly due to such receptacles not
being in very common use in Caleutta for holding
water. S. scutellaris seems to prefer wooden
receptacles next to earthen pots; it was found in—
(a) Wooden tube.
(b) A hole cut in a log of wood, about 2 in. square.
(c) Hollows of bamboo stumps.
(d) A eoco-nut shell.
Both species lay their eggs singly either on the
surface of the water or on the sides of the vessel.
The eggs of S. scutellaris are only about two-thirds
the size of the eggs of S. fasciata. Some eggs of
S. fasciata were dried and kept on blotting paper
in an almirah for,a month (October-November).
When after that period the eggs were placed in
water, larve made their appearance in less than
forty-eight hours.
The larval stage lasts for seven or eight days.
The differences between the larve of S. fasciata
and S. scutellaris are minute.
The pupal stage lasts two or three days.
Under ordinary curcumstances both bite only in
the day-time and are most active in the afternoon
from about 4 p.m. till it is quite dark. If kept
caged all day and fasting they bite at night,
even midnight, if they get an opportunity. Under
(This
8 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ordinary or usual natural conditions, none have
been caught biting at night.
The species Desvoidea obturbans was very
common in the Kidderpore Docks and elsewhere.
It breeds in foul stagnant water. It bites to some
extent in the day-time.
Leucomyia gelida was very common in Calcutta
and neighbourhood during August and September;
it breeds readily in earthen pots.
Tozorhynchites.—T wo species of these giant
mosquitoes are found extensively in the port of
Caleutta (1) with banded legs, and (2) with un-
banded legs. They are rare in the centre of
Caleutta, but are common in the suburbs—a
probable reason for their avoidance of the city being
the absence of succulent trees; they are vegetarians
and do not suck blood. They are plentiful on the
banks of the Hoogly below Calcutta. As with
Stegomyia their favourite breeding places are
earthen pots; there is usually mud or sand at the
bottom of the pot. Their larve are seldom found
in the same receptacle along with larve of other
genera; they are usually found alone and generally
in very small numbers—only from one to four
specimens in each receptacle. The reason is that
the larve of Tozorhynchites are carnivorous and
eat up the larve of other genera, and in the absence
of larve of another genus they eat one another, the
largest and strongest larve surviving. The adults
apparently do not bite man or suck blood.
A larva of Toxorhynchites can kill larve of
Stegomyia three or four times its own size, and
can easily dispose of half a dozen good-sized larve
of another genus in about half an hour.
(8) Notes on DISTRIBUTION AND HABITS OF
STEGOMYIA MOSQUITOES IN MADRAS.
By Captain J. H. Horne, I.M.S.
The following notes were based on a three weeks’
survey undertaken in order to find out, for the pur-
poses of the Conference, the species, distribution,
and habits of Stegomyia mosquitoes in the town of
Madras. The original scheme for a Stegomyia
survey of the main Madras ports has not yet been
sanctioned, and these notes cannot be taken as in
any way representing the results of a complete
survey.
Species.—Two species of Stegomyia occur here,
viz. :—
(1) Fasciata.
(2) Scutellaris.
Fasciata is the more widespread of the two, and
is essentially a house mosquito; Scutellaris is
common where there are trees, and is, in Madras
at least, apparently an outdoor mosquito.
I. Stegomyia fasciata.—Its breeding places may
be classed as follows :—
(1) All sorts of receptacles containing water, e.g.,
earthenware gurrahs (by far the commonest), tins,
tubs, flower pots, fire buckets, pails, mill stones,
&c.
(2) Drains, open and underground.
[Jan. 1, 1914.
3 (3) Wells, surface and deep; both indoor and out-
oor.
In receptacles they were usually -found along with
Stegomyia scutellaris, Scutomyia sugens, and N.M.
rossi; less often with Culex fatigans and Tenio-
rhynchus. As a rule these receptacles were lying
about in compounds, but were sometimes in very
exposed places, e.g., flower pots on the roof para-
pets of two-story buildings.
It is only in the harbour that the larve have been
found to occur in drains; and here the mosquito is
so abundant as to constitute a serious hindrance to
work in the offices and goods sheds.
The larve were taken—
(1) In an open cement drain round the goods
office.
(2) In a covered underground drain round a load-
ing shed.
The latter drain was roofed over with stone slabs,
between which were numerous chinks and spaces
permitting easy access to the water below.
No Stegomyia larve have so far been got in the
drains in the town.
Their presence in wells was first detected in a
‘Heep’ house well in Georgetown, so dark that
the surface of the water could only be seen with
difficulty. Further search revealed them in an
outdoor well (''deep ") in a neighbouring com-
pound ; and again in a surface well in an open space
in another part of the town. The chances are that
their presence in such wells is widespread. The
first well was in use, the others were not.
In these wells they were found along with Neoc.
'' stephensi '' and Culex fatigans.
Stegomyia fasciata larve were not found in open
pools, ditches, or bamboo stumps.
The adult S. fasciata were almost all caught inside
houses and always in the close vicinity of a breeding
place. Only a very few were caught in sheds,
stables, and gardens. Their presence in huge
numbers in the harbour goods ‘‘ sheds ’’ seems at
first to contradict this statement, but these sheds
are closed buildings and contain large numbers of
coolies during the day.
As regards their well-known habit of biting by
day, coolies in the harbour sheds said that the
worst time was from about 9 to 12 in the forenoon,
and that after that they gave little trouble.
In the Madras Club the author himself has been
bitten between 7 and 10 p.m.
II. Stegomyia scutellaris has been found breeding
in—
(1) Receptacles containing water, e.g., earthen-
ware gurrahs and flower pots.
(2) Bamboo stumps, and always close to trees.
They have not been taken in drains or wells or
open pools.
Not a single adult has been caught inside a house
or hut of any sort, even when their larve were
within 6 ft. of the door.
In gardens, both large and small, they are fairly
common, and here are easily captured owing to the
persistence with which they attack one. In Pusa
this species was a household pest, and it is likely
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 9
that, though here they apparently keep closely to
gardens, they venture into houses for blood. Still
it is worthy of note that in one Paracheri where they
were very numerous the inmates made no com-
plaint whatever of mosquitoes biting them.
In addition to Stegomyia the following were
found :—
(1) Desvoidea, the larve of which were found
together with Culex fatigans in a surface well near
the sea. Adults were taken in neighbouring houses.
(2) Scutomyia sugens, whose larve were found
in earthenware gurrahs together with Stegomyia
scutellaris.
(3) A genus of mosquito which appears to be a
Reedomyia, but this requires confirmation.
Adults of these genus were taken in a wood in
Nungambakam; its larve were not discovered.
These three genera are closely related to Stegomyia
in seale structure, and resemble it in their vicious
habit of biting by day.
ERADICATION OF MALARIA.*
By C. C. Bass, M.D.
New Orleans.
ErapicaTion of malaria from the United States
would not appeal to those who have not given the
subject special thought as within the bounds of
possibility, but Bass is confident that many at a
meeting recently held in Norfolk, Virginia, left with
the conviction that it was quite possible and actually
could be accomplished in a short time. Though
such an undertaking would require considerable
funds, there is no doubt that this would be
promptly offered by some philanthropist, if the
facts or possibilities were known to him. It is quite
possible that, properly undertaken, a great deal
more could be accomplished in the saving of lives
and resources of the country, that are now wasted
by this important disease, than in the instance of
the less destructive hookworm disease.
Bass then recounts some of the suggestions made
by those who addressed the Conference. Before
doing so he states some of the fundamental prin-
ciples and facts relating to the transmission and
treatment of malaria. These are well known to
those familiar with the subject and need not be
repeated here.
All that is required for the complete eradication
of malaria in the United States is for everybody
who has malaria during a warm season to take the
proper amount of quinine on each of two consecu-
tive days in each of six consecutive weeks during
the following cool season.
If this statement could be brought with sufficient
authority to the attention of all the people, and ‘f
the importance of everybody's co-operating could
be emphasized, the writer's belief is that a vast
majority of the malaria carriers would follow the
advice given.
Regardless of the most thorough dissemination
* Insterstate Medical Journal, vol. xx, October, 1918, No. 10.
of this information and the most perfect co-opera-
tion, no doubt a few cases of malaria would occur
during the warm season. These cases are not a
source of infection to mosquitoes until the disease
has existed about two weeks. It is very important
that thorough and successful treatment of such
cases should be applied before they become infec-
tious. Six weeks of proper taking of quinine would
ensure the harmlessness of these cases. It is
important that the laity and also the medical pro-
fession should know these facts. Eradication of
malaria becomes in fact, therefore, a question of
education. Perhaps it may be better said to be
& question of dissemination of a very few very
simple facts and the co-operation of the entire
population to benefit by the knowledge of these
facts.
The laity is generally ready to accept and fully
appreciate such information provided it is simply
stated and not overdone or exaggerated.
A very large part of the population could be
reached through the publie schools. The important
facts relating to the prevention and treatment of
the disease could be stated on one, two, or thre:
pages of some text-book, like, for instance, the
Third or Fourth Reader. This could be prepared
in the form of a lesson. It should also meet the
approval of some such authority as the Commission
for the Study and Prevention of Malaria of the
Southern Medical Association. The lesson could be
simple enough to be within the grasp of all students
above the fourth or fifth grade.
If funds were available and the co-operation of
the superintendent of the publie schools of a state
was given, he would forward to each teacher in
the state the necessary copies of the lesson, and
direct (not suggest) that each student be taught the
lesson thoroughly, just as other lessons are taught.
It should be taught in all grades above a certain
limit and probably should be reviewed during
each term. Teachers would naturall learn the
lesson by teaching it. Many of the children would
carry the lesson home to their parents and talk
about it at home. No doubt many children and
families would take pride in having carried out the
instructions and in not being a source of infection.
Another way by which a great deal could be
accomplished is through corporations and employers
of labour, such as railroad companies, plantation
and manufactory managers, &c. Personal and
financial interest in such instances would be suffi-
cient to lead to important results if the real truth
was known to those concerned. If a plantation or
mill manager realized the menace to the health of
his employees and even to himself and family, and
the actual financial loss from insufficient service that
might result from a single case of malaria, his
interest would be excited. He would likely see that
the person took proper treatment, if he knew what
it was. He could require that proper treatment be
taken to protect the balance of the force.
The medical profession would be supposed not to
require further education on so simple a subject as
malaria; but actually it does. It is true that all
10 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1914.
the best medical schools in the South now give
their students fairly thorough instruction in malaria,
but it must be remembered that a good many
members of the medical profession in the South
were educated in Northern or other schools, and
that the majority were educated several years ago
when instruction in all branches was inferior to
what it is now. No doubt co-operation of schools
in malarial sections could be secured to the extent
that all would in the future thoroughly instruct
their graduating men in the diagnosis and treatment
of malaria. They should all know that it is an
important duty to their malarial patients to instruct
them that, in order to become completely cured and
to prevent infection of others or relapses in them-
selves, they should take quinine properly for six
weeks.
Medical licensing boards could materially assist
in ensuring proper training in malaria, by regularly
asking, on examination for licence to practise medi-
cine, a comprehensive question on malaria. It
might be well if it was generally known that such
& question or questions would be asked on every
examination. An applicant would then be sure to
prepare himself on the subject.
This proposition to give special prominence to
this one disease by medical schools and medical
licensing boards in the South is justified by the
fact that malaria is perhaps the most common and
important disease they will meet in practice.
Because of its great prevalence it is to be con-
sidered and, therefore, diagnosed or proved absent
in almost all cases of fever and in many other
conditions.
Effort to eradicate the disease along the educa-
tional lines suggested would meet with two serious
obstacles. First, there would be a few infected
people who would not follow the advice given either
because they think they know more about the
disease than the scientists who have studied it for
years, or because they have not enough concern
and care for the health and life of themselves and
others to take proper treatment. The question
would arise whether such persons should not be
managed as those who have small-pox, yellow fever,
diphtheria, &c. They should be segregated until
they are no longer a menace to the life and health
of others. The second important obstacle would be
the importation of cases of malaria from other
countries. In the event that America should get
sufficiently free from the disease there would be
the same reason for preventing others from bring-
ing infection into the country as there is for
quarantine regulations against introduction of yellow
fever, trachoma, &c. As a further protection to the
reintroduction of malaria from nearly all tropical
countries it might be possible to carry the pro-
paganda of education against malaria to these
countries, and thus assist them materially to check
the ravages of the disease. The danger of importa-
tion into the United States would thus be very
much reduced.
NOTES ON LIFE ASSURANCE IN EGYPT.*
By Hanorp BENJAMIN Day, M.D., M.R.C.P.
Lire assurance is gaining increasing popularity in
Egypt with the spread of European institutions and
the establishment of local offices offering terms as
favourable as those in .Europe.
Proposers are of all nationalities, and present very
different problems to the medical examiner. Four
main classes may thus be distinguished :—
(1) The Western European.
(2) The native of Southern Europe.
(3) The Eastern races, chiefly composed of
Syrians and Armenians.
(4) The native Egyptian.
The risks of the Egyptian climate nowadays to
British residents are often no greater than those
encountered at home.
The only serious endemic diseases that attack
the European resident are typhoid fever, with its
congeners, and dysentery. The possession of
' trained servants and the habitual observance of due
precautions are necessary safeguards against oral
infections, while the rapidly growing practice of
typhoid vaccination has diminished the incidence
and virulence of this disease. It follows that the
man stationed in Cairo or in one of the large towns
is a better risk than an inspector, for instance,
whose work takes him to distant villages. In
general, therefore, the average British resident is a
good risk.
(2) The largest assurance business done by British
offices in Egypt is among foreigners of more or less
mixed nationality. As a general rule, the purer
the nationality the safer the risk. Such persons
are readily acclimatized, but are less careful of their
health than the average Englishman.
(3) The more Egyptian type, such as the Syrian,
may be classed as intermediate between the fore-
going and the native Egyptian.
(4) The native Egyptian forms the smallest, but
an inereasing proportion of those seeking life
assurance. The difficulty of accepting such lives
in the past has been considerable, and most offices
will not offer whole-life policies.
The proposer may be ignorant of his real age,
or may be unable to offer any proof of it. This
difficulty may be solved by offering insurance for
a limited term. Alcoholic intemperance is very
rare among all classes of Egyptians—Christians as
well as Moslems. As a set-off, however, sexual
excess and immoderate cigarette smoking are com-
mon, although not so prevalent as formerly.
The common diseases of Western Europe are
equally important in Egypt. Of these, rheumatic
fever, tuberculosis, and syphilis—the three most
important for life assurance—are as frequent as
at home. In contrast with the European resident,
the native adult has little susceptibility to typhoid,
since he is commonly protected by an attack during
infancy or childhood. Appendicitis and carcinoma
* Paper read before the Life Assurance Medical Officer.’
Association on May 7, 1913.
Jan, 1, 1914.]
are still relatively uncommon compared with their
incidence in England; diabetes is certainly more
frequent.
Most '' tropical ’’ diseases are endemic in Egypt,
but are largely avoided by personal cleanliness and
sanitation. Ankylostomiasis, pellagra, spleno-
megaly (Banti's disease), relapsing fever, and
typhus, although common among the peasantry,
rarely attack a member of the upper classes.
In boyhood, bilharziasis is often contracted, but
the severe cases are only seen in those workers
who are exposed to repeated reinfection. A slight
lesion of the bladder wall, accidentally revealed on
microscopical examination of the urine, but without
obvious hematuria, does not endanger nor shorten
life, provided the risk of a fresh infection be ex-
cluded. If all the ova seen be calcified, proof is
at once afforded that the disease is of old standing.
Should blood be present in sufficient amount to
cause albuminuria, it is safer to refuse the life,
since the amount of hematuria is roughly propor-
tional to the intensity of the infection. After the
lapse of two or three years such a case may lose
his symptoms and become insurable. The danger
of bilharziasis is the risk of septic complications,
hence all cases showing intestinal symptoms should
be refused. Attacks of renal colic in Egypt are
frequently due to bilharzial disease of the ureters,
without the presence of calculi, and may be the
sole symptoms of this infection. Provided the
attacks have not recurred since early manhood, and
no signs of bilharzial disease remain, such cases
may be accepted.
The question arises: Are the prospects of
longevity the same for the native Egyptian as for
the average European? Judged by the standard
of hygiene and sanitation, all Eastern countries,
including Egypt, fall much below the British
standard. Ignorance and superstition not only levy
a heavy toll on infant life, but are prejudicial to
the health and longevity of adults. Illness is often
mismanaged until effective treatment is difficult,
while skilled nursing is rarely requisitioned. A
great change, however, in the habits and health
of the native population is already apparent in the
upper classes, due to the spread of European ideas.
Education and sanitation are rapidly extending their
influence from the pupil to the home, and the best
native families are the equals in health of the
European.
For practical purposes, therefore, we may take
the infant mortality in the proposer's family as a
useful index of health. In this connection it is
more important to inquire after the history of each
child born to the proposer (since he is generally a
married man) than to trace the family history of
his brothers and sisters, for records of early deaths
are often unobtainable. Such facts are a ready
indicator to the hygiene of his house, and therefore
to the prospects of his longevity—a point to which
sufficient importance has not been attached in the
printed report. A proposer, then, in good health,
whose education has been sound and way of living
satisfactory, and whose children are successfully
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 11
reared, may be accepted for a whole life on Euro-
pean terms. On the other hand, a man of Eastern
race whose life does not conform to the European
standard of hygiene is best offered a fixed term.
VERRUGA PERUVIANA, OROYA FEVER
AND UTA.*
By RicHarp P. Srrona, M.D., E. E. Tyzzer, M.D.,
CHaRLEs T. Brues, S.M., A. W. SgLLARDs, M.D., aud
J. U. GASTIABURU.
THE expedition was undertaken for the purpose of
investigating certain obscure forms of tropical
disease in South America, particularly verruga peru-
viana, as well as with the idea of collecting material
to be used for the instruetion of students in the
various courses of tropical medicine to be inaugu-
rated at Harvard University in November of the
present year. After proceeding to Colon and
Panama the members of the Commission continued
down the west coast of South America to Buena-
ventura, Colombia, and thence to Guayaquil.
From Guayaquil they proceeded to Peru, where at
Lima, and in a number of the mountain towns in
the interior, the major portion of the work of the
expedition was carried on. In Peru the diseases
particularly investigated were verruga peruviana,
Oroya fever and uta.
VERRUGA PERUVIANA AND OROYA FEVER.
From the remotest historical times the inhabitants
of Peru are said to have suffered severely from this
obscure disease. Over four centuries ago, during
the reign of Inca Huayna Capac, thousands of lives
were swept away, supposedly from this malady;
and it is related that during the sixteenth century a
quarter of the army of Francisco Pizarro perished
from it. References may be found to the disease
in Peruvian writings of the seventeenth and
eighteenth centuries, and from 1843 to 1871 a num-
ber of additional papers relating to it were published,
among which may be particularly mentioned those
of Odriozola in 1858, and of Dounon in 1871. In
1870 a severe outbreak of fever took place among
the workmen building the Central Railway between
Lima and Oroya, and it is estimated that at least
seven thousand lives were lost in the verruga zones.
At this time the complaint received the name of
'' Oroya fever,” although it appears that it was not
contracted in Oroya itself. In 1906, out of a force
of two thousand men employed in tunnel work for
the Central Railway, two hundred are known to
have died of the disease. Previous to 1885 there
ensued some discussion as to whether Oroya fever
and verruga were related to one another, or whether
the latter was a distinct disease. On August 27,
1885, Carrion, a medical student in Lima, and a
native of Cerro de Pasco, Peru (a town situated in
the mountains far above the localities in which the
* ** Preliminary Report of the First Expedition to South
America from the Department of Tropical Medicine of Harvard
University," Journal of the American Medical Association,
vol, lxi, No, 19, November 8, 1913.
12 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
disease abounds), attempted to solve this problem
by vaccinating both his arms with blood from a
verruga tumour. It is related that twenty-three
days later he began to suffer from Oroya fever, from
which he died, October 5. From this experiment
the conclusion was drawn by Peruvian physicians
that verruga and Oroya fever were only different
stages of the same disease, and this is the opinion
which has been held by practically all of them up
to the present time. In honour of Carrion's
attempt to throw light on the nature of the disease,
the febrile condition which has been regarded as the
first stage of the malady is now generally known in
Peru as '' Carrion's fever." Although it has been
stated that Carrion during his illness kept notes,
and gave a minute description of his symptoms to
his companions, unfortunately it appears that none
of these were preserved and published. No accurate
record of Carrion’s case is available, and no
necropsy was performed. It has been asserted
since that he died of typhoid fever or of a more
acute form of septicemia.
In 1901 and 1902 Barton performed extensive
bacteriologic investigations, and concluded that in
the blood and organs at necropsy of persons dying
from Carrion's fever a bacillus was present which,
though similar to Bacillus coli communis, could be
distinguished from it. The organism was said to
cause either a fatal septicemia in animals, or a
verruga-like eruption of the skin. Biffi and Carbajal
and Tamayo and Gastiaburi investigated this
bacillus, and reported that it was present constantly
and in abundance in persons suffering from Carrion's
fever, and was agglutinated by their serum, but was
absent from persons suffering from verruga peru-
viana without fever, whose serum also showed no
agglutination of this bacillus. They were unable to
confirm Barton's results as to the production of a
skin eruption by the bacillus, and concluded that it
was not the specific agent in Carrion’s disease, but
was a secondary invader in verruga, and gave rise
to the symptoms of a form of typhoid fever, which
disease constitutes the fiebre grave of Carrion. In
1903 Biffi and Gastiaburü noted in stained prepara-
tions of the blood the presence of granules in the
red blood cells which stained readily with the basic
aniline dyes. The form and structure of these
bodies was that of a coccobacillus or of irregular
granules. In 1905 Barton described in the red
blood cells of two persons sick with severe malig-
nant fever elements similar in morphology to bacilli.
In 1909 he noted the presence of these elements in
stained blood specimens in fourteen additional cases
and expressed the belief that they were protozoa
and probably the specific agent of the infection. In
1909 Gastiaburü and Rebagliati observed the same
bodies, and stated that they were probably protozoa,
and might be regarded as the pathogenic organism
in Carrion's disease. Later, Mayer, Gastiaburü
and Rebagliati, Monge and others have been
inclined to believe that the bodies described by
Barton were products of cell degeneration.
According to the generally accepted opinion
among the physicians of Peru at the time of the
Commission’s arrival in Lima, the disease verruga
(Jan. 1, 1914.
peruviana in the severe type begins with an initial
stage known as the fiebre grave of Carrion, which is
characterized by a fever which lasts from fifteen to
thirty days, profound anemia, prostration, and a
high mortality. If the patient does not die in this
stage the fever begins to abate, and the eruptive, or
verruga, stage commences. If the eruption is
generalized and abundant, then it is stated that the
patient is sure to recover. In the chronic or mild
type of the disease, which is said to comprise the
great proportion of the cases, there is moderate fever
of intermittent or remittent type, and pains in the
joints are common; more or less anemia is also
present. The eruption is said to be the culminating
phase in both forms, and it appears under various
types which, according to the special characteristics
they reveal, are termed '' miliary,” ‘‘ nodular,” or
" mulaire."'
The investigations of the Commission concerning
the etiology of verruga peruviana and of Oroya
fever were carried on in the Municipal Laboratory
of Hygiene, in the hospitals of the city of Lima,
in the mountain towns of Santa Eulalia, San
Bartolomé, Surco, Cocochacra, and Matucana,
and in the vicinity of these towns. From these
investigations it was concluded that verruga peru-
viana and Oroya fever represent two distinct
diseases. The former is due to a virus which may
be transmitted to animals by direct inoculation, and
which produces definite lesions in them, whereas
the latter is due to an organism parasitic in the red
blood corpuscles sufficiently distinct from the other
hematozoa to be placed in a new genus. So far
this organism has not been successfully transmitted
to the lower animals. The parasite which is the
cause of Oroya fever produces in man fever and in
severe infections a rapid and very pernicious form
of anemia, which results in extreme prostration and
frequently in death. At the necropsy of a case, in
addition to the evidences of a very severe anemia,
the spleen was enlarged and showed hemorrhagic
infarctions. No other organism to which death
could be ascribed was found present. In this un-
complicated case there was no eruption of verrugas.
Both intravenous and intratesticular inoculation of
rabbits, as well as intravenous inoculation of a
monkey, with large amounts of defibrinated blood
from severe Oroya fever cases did not produce any
noticeable results; and the parasites observed in the
blood in the cases in man were not found in the
blood of the inoculated animals. The parasites
were observed in the blood in the cases in man both
in fresh and in stained preparations.
Fresh Blood Preparations.—Although in fresh
blood preparations the organisms are frequently
difficult to detect, and at times appear to lie deep
in the substance of the red blood cells, nevertheless
with good illumination and an oil-immersion apo-
chromatic objective, they may at times be distinctly
observed. In form they are rounded or rod-shaped,
though the rods are not always straight in outline.
The rods measure approximately from 1:5 to 3
mierons in length, and the rounded bodies from 0:5
to 1°5 microns in diameter. In severe infections, red
corpuscles in almost every field of the microscope
Jan. 1, 1914.]
are invaded by the parasites, and numbers of
both rounded bodies and bacillary forms are fre-
quently observed in a single cell. The organisms
are endowed with definite motility, which amounts
to slow transition, and is totally distinct from that
of pedesis. The rod-shaped forms have been
observed to glide slowly in the direction of their
long diameter, and to exhibit a slight bending. On
account of their small size the rounded bodies are
more difficult to describe in fresh specimens, and it
can only be stated that they change their position
within the cell.
Stained and Fixed Preparations.—The rod-shaped
forms measure approximately from 1 to 2 microns in
length and from 0:2 to 0°5 microns in thickness.
They are usually curved, and occur singly or end
to end in pairs, or in chains of three, four and five.
V forms, probably representing dividing organisms,
are frequent. When numerous they often lie
parallel to one another. Cross forms are rare and
may be due to organisms being superimposed; Y
forms are also infrequent but not numerous. The
ends of the rods in stained preparations are intensely
coloured. Single free rods show a deep red or
purplish granule which may be of the nature of
chromatin and gives the appearance of a swelling
at one extremity, the rest of the rod having a more
bluish tint, sometimes deepest at the opposite end.
Other rods may be blue throughout or have the
deeply stained granule at both ends, while others
are beaded with blue or deep reddish granules.
The rounded forms are roughly from 0°3 to 1
micron in diameter, the larger ones being consider-
ably thicker than any of the rods. The greater
proportion of these, although rounded, are slightly
oval or pear-shaped; some are considerably larger
than the rods, and the deeply stained granule is
proportionately larger and is likewise differentiated
from the more blue-tinted cytoplasm. They occur
singly or in groups which suggest previous division.
The red cell may contain from one to as many as
thirty of the above-described elements. Nucleated
red cells at various stages of development may also
be found infected. From the anemia which occurs
in this infection, it is to be presumed that the red
cells containing the parasites are ultimately
destroyed.
The authors believe that the organism possesses
some of the characteristics described for the Ana-
plasmata or of the Theileria, but also differs widely
in some respects from the characteristics described
for each of these genera. The rounded bodies re-
semble the Anaplasmata in their form and size and
in the fact that they apparently consist entirely or
almost entirely of chromatinie substance. Although
the bacilliform or rod-shaped bodies predominate,
their appearance and staining reactions are con-
siderably unlike those of the rod-shaped bodies
observed in the Theileria, and cross forms have not
been observed. Moreover, their movements are
unlike those of the Piroplasmata. While the
organism at first sight may be regarded from its
morphology alone as a species of bacterium, this
idea is not supported by further study, It is essen-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 18
tially a parasite of the red blood cell; attempts to
cultivate it on various culture mediums have been
unsuccessful and the inoculation of large amounts
of blood from a severe case of Oroya fever has failed
to infect a monkey or rabbits.
From the present evidence it would appear that
the organism in the blood in Oroya fever belongs to
a group of micro-organisms intermediate between
the protozoa and the bacteria, just as perhaps the
spirochetes form another such group, and the
authors propose the name of Bartonia bacilliformis
for it.
VERRUGA PERUVIANA.
Verruga peruviana is a disease particularly
characterized by an eruption on the skin and
occasionally on the mucous membranes of the
mouth and throat. The lesions present great
variations in appearance. The distribution of the
cutaneous eruption resembles somewhat that seen
in yaws; but in many other respects the lesions
of the disease are entirely distinct. In uncompli-
cated cases, neither the parasites of Oroya fever
nor those of malaria are present in the blood ; though
as verruga peruviana is contracted in regions in
which Oroya fever and malaria are common diseases
among the inhabitants, and visitors are likely to
contract such maladies, it is not surprising that
concomitant infections with these parasites fre-
quently occur.
It is quite evident, aceording to the Commis-
sioners, that verruga peruviana represents an
entirely distinct disease, and that it is not a form
of framboesia or of syphilis. The disease owes its
origin to a virus which produces characteristic local
lesions in rabbits’ testicles. The incubation period
varies in rabbits from ten to twenty-two days. So
far fifteen rabbits have been successfully inoculated,
and the virus is now in its third transplant in these
animals. In dogs and monkeys, cutaneous and sub-
cutaneous, and sometimes intraperitoneal inocula-
tion has given rise after from eleven to seventeen
days to localized lesions, which sometimes resemble
closely those observed in man.
Uta.
Uta is a disease which has existed in Peru since
prehistoric times. It has been stated by various
authorities that the disease represents a form of
syphilis, or one of prehistoric leprosy, or a special
form of lupus vulgaris. The Commissioners were
able to show, however, that the disease is really due
to a species of Leishmania.
——
* Australasian Medical Gazette,” vol. xxxiv, No. 18,
November 1, 1913.
Rat Leprosy in North Queensland. —Priestly states that
rat leprosy has been shown to be present in the rats in
Townsville, North Queensland. The disease presents the
same features which have been described as occuring in
other parts of the world. Two hundred and twenty rats
were examined, and twelve found infected. Six of the rats
showed the lymphatic form and six showed the musculo-
cutaneous form of the disease. The percentage of rats
presenting the musculocutaneous form is very much greater
than has been described in other parts of the world.
14 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Annotation,
Yellow Fever in West Africa.—The Yellow Fever
Bulletin, vol. iii, No. 1, states that the recent out-
breaks of yellow fever in the Gold Coast Colony
and in Southern Nigeria have again called attention
to conditions in West Africa. Investigations are
now being carried out by the Colonial Office, and
_ it is to be hoped that some definite results will be
obtained which can be universally accepted, but it
must necessarily be an arduous task, and probably
a question of years of observation to get to the
bottom of the matter. It has been pointed out in
the abstract of the West African Fever Report
(Bull. II, 4, pp. 374-890) that the diagnosis of
yellow fever could hardly be aecepted in all the
cases included in the Report. The Report, how-
ever, contained exceedingly interesting material and
important evidence of the endemicity of yellow fever
in various parts of West Africa. The problem of
the way in which intervals of outbreaks of the
disease are bridged over remains in statu quo. All
available evidence points to the occurrence of
atypieal, probably mild, cases in natives, especially
native children, but exact knowledge of the
character and frequeney of such cases is still lack-
ing. If this problem can be satisfactorily solved,
a very great step forward will have been made in
our knowledge of yellow fever.
Since the late Sir Rubert Boyce started the dis-
cussion on yellow fever in West Africa in 1910 it has
never been dropped, and it is natural to hope that
the investigations which have been taken up with
renewed vigour in the British Colonies will be
followed by similar investigations in the French and
German possessions. Thus it might perhaps be
possible to solve the problem for the whole of West
Afriea, and to open the way for mutual agreements
with regard to anti-yellow fever campaigns to be
conducted on uniform lines and with the least
possible inconvenience. Anti-mosquito campaigns
are being conducted in all the West African posses-
sions with more or less vigour, but no satisfactory
arrangements have, however, been obtained with
regard to quarantine regulations.
—— À—.
Hotes and Hews,
SMALL-POX IN CHINA.
SMALL-POx obtains in China the year round. The
practice, until very recently, of inoculating all
infants with small-pox is giving way to vaccination,
especially among the better elass of people. Many
well-dressed men and women are seen with smooth,
perfect skins. Even a coolie is occasionally noted
who gives no visible evidenee of having had the
disease, It is stated that the inoculation operation
[Jan. 1, 1914.
consists of powdering the scabs of the disease and
blowing the product into the nostrils of the child
through a quill. Some state that some irritating
substance, such as camphor, is mixed with the in-
fection before it is used. The idea seems to be,
that as the disease is so certain to be contracted,
perhaps after years, in which event.the parents will
be put to considerable expense and labour, it will
be better to have the child take the disease at once
and either die or be rendered immune by having
had it. Among the poor, the responsibility of
raising a child is a great burden, even though the
expense will amount to only a dollar or two gold
per year.
The influence of the missionaries, especially
medical missions, and a certain leaven of education
and enlightenment which is creeping into China,
is beginning to give evidence of its existence.
I am told that when the word is passed among
the people that the missionary doctors will vac-
cinate, hundreds will present themselves for the
operation. This work is often done by the Chinese
"boy," many of whom are connected with the
medical work.
In connection with missionary enterprise, when
we inquire, we learn that from 5,000 to 25,000 or
more people annually receive treatment at these
philanthropic institutions, either in hospital or
at dispensary, together with instruction which is
given in their own tongue in matters relative to
health and sanitation, and the great influence for
improvement is at once made noteworthy.
The extent of this work in China is surprising.
Not only does the medical work have a direct
influence, but the missionaries instruct the people
in habits of cleanliness and the eradication of filth
and disease. Especially, the schools for girls and
women’s colleges will have the greatest influence
for good. Foreign Government schools also assist
in the general awakening of slumbering China.
As the foreigners secure more and more freedom
in China, and as China awakens to her perils and
needs more and more, especially in health matters,
so the more do we note the result. It is not un-
common now for Chinese officials, of higher or lower
rank, to issue proclamations, instructing the people
and exhorting them to do what they can in their
own behalf. The time when Chinese rather con-
sidered plagues and starvation as an act of Provi-
dence, in clearing out many poor people to make
room for others, is passing. The late plague in
Manchuria and starvation in the Central Provinces
is now considered rather an affliction and injury to
the progress of the nation.
A crude method of vaccination is also practised,
especially arnong the poor people. A child is vac-
cinated at many spots, and when the typical
vesicles have developed, the pus is used to vaccinate
the children in wholesale lots by natives at a most
trivial expense. A '' boy ’’ at the hospital told the
Sister that many native ‘‘ doctors ’’ used a method
of mixing this pus with human milk before use. It
is now very common to see Chinese with vaccination
marks, usually at any or several places on the body.
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 15
These marks are called moxa marks. A common
place is on the legs.
The Chinese make no effort to conceal the disease
or prevent its spread or to avoid it, so far as I have
been informed. Disinfection and treatment of
infected clothing is unknown.
They do not fear the disease, and seem to con-
sider it one of the circumstances incident to an
existence. I have been told that a red cloth is used
to cover the face of the afflicted infants, but on
inquiry I have not heard this report confirmed.
The disease is not very fatal among the people.
Mortality rate is very low. This is probably due
to a racial immunity, incurred through centuries of
exposure.
Very few adult Chinese take the disease. By far
the greatest number of cases occur in infants and
very young children. The adult people will not
quit their usual employment as a rule, unless too ill
to drag their limbs about, and the children are given
their liberty as they wish. Nevertheless, it is stated
that they have made some attempt at treatment
which, however, consists in doing nothing. The
people are confined in the dark, if such place is
available, and their huts usually answer the purpose
admirably. Further treatment consists in allowing
no cleansing water to touch the body until the scabs
have well formed. This results in severe pitting,
and a worse sequel is most serious eye disease. A
Sister at the mission hospital states that this prac-
tice is responsible for much of the blindness. The
Chinese as a rule do not favour the use of water for
any purpose other than the necessities of life. The
foreigners are often referred to as '' soap wasters, '
I am told. A fire hose turned on to a mob in a
riot has proven more effective to dispel ambition for
ruin than the sight of rifles and pistols. The
Chinese at the hospitals are very refractory to treat-
ment as regards disinfecting baths. Not only per-
suasion, but also force, is required when this part of
the treatment is given.
As an example of the indifference of the people
to this common disease, the incident of a man pre-
senting himself at the hospital door with a well-
developed case, stating that he thought something
was the matter with him, is related. He had been
going about his work until someone told him that
the missionaries would take care of him, which
information he wanted to verify for himself. Upon
being placed in the isolation ward and given daily
baths he remonstrated most decidedly, not consider-
ing his state so serious as to warrant such drastic
treatment.
Winter and spring furnish the most
although the disease is constantly present.
As regards foreigners, by far the most cases occur
in new arrivals. The residents learn to practise
frequent vaccination, and learn to avoid the most
certainly infected regions. As in all diseases in
which filth and insanitation play the leading part
—and as this condition obtains universally with the
poorer classes of natives, and as visiting foreigners
will only come in contact with these people—the
most favourable conditions for contracting the
cases,
disease are the result of the entire circumstances.
The beggars and native city districts and any native
hut may prove a concentrated source of infection.
A certain morbid curiosity in some, to examine
closely (so as to have something to relate aboard
ship or in letters home) all filthy, diseased beggars,
presenting ghastly anomalous lesions, is a practice to
be condemned and discouraged by all possible
means. It seems reasonable to suppose that actual
eases of small-pox patients having been exposed to
the credulous sympathy and liberality of incautious
foreigners have occurred. Some will consider such
eases leprous or syphilitic, but experience teaches
to shun such unfortunates like the plague, for they
are equally dangerous. If philanthropy insists on
being satisfied, the range and skill of the baseball
accomplishment should be brought into requisition
in bestowing the alms.
Foreign missionary workers are often smitten,
especially those engaged in school work for children.
I know of two Catholic priests having taken the
disease at the same time at the same school.
At present more and more missionary work
among the natives is being done by native preachers
and teachers, who have been trained at schools in
the large ports by the missionaries, so it occurs
that the disease is not now so much encountered as
formerly. However, many of the long resident
foreign missionaries and other foreigners have taken
the disease, while others more fortunate are likely
less susceptible to the illness. |More than that,
after short residence in China the attraction of
visiting Chinese filth and degradation gives way to
disgust and a desire to avoid many places and
conditions.
In the port cities the ‘‘ washaman "' business has
offered vent to Chinese industry and avarice, and
the business in many instances has been developed
to a perfect sanitary status, using modern steam
methods. In former days, and also at the present
time in the small outlying towns, no washmen
being available, such work was done by families
with water drawn from the river. The danger of
contraction of the disease from infection in washed
clothing from infected huts, handled by infected
hands, was most positive.
The practice of some foreigners of housing their
servants in their own compounds, and giving their
quarters close attention, together with instruction
in this matter, is an experiment whieh has proven
satisfactory in reducing incidence of the disease
among foreigners.
The conditions, as they exist in China at present,
are well represented in the following paragraph,
extracted from an article on ‘‘ The Prevention of
Infectious Disease in the Yangtse Valley," by the
writer, as follows: ‘‘ So, in a country like China,
where the natives understand so little of the nature
of infectious disease, especially its method of exten-
sion, and care less, and actually are antagonistic to
efforts put forth to discover disease among them and
prevent its spread, special danger exists. More-
over, by centuries of contact they have developed a
degree of tolerance which foreigners do not possess,
16 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1914.
and because of this may carry disease about with
impunity. Also, their habits and customs, their
living together in most crowded and insanitary con-
ditions; their communication with each other over
large districts, because of industrial pursuits, which
will earry the men all over the city and into all
places, going and coming to and from work, would
seem to make all or any intercourse with the natives
dangerous. ”’
The instinct of economy in Chinese leads them
to patronize the Chinese rickshaws with the iron
tyres, in preference to the pneumatic tyred vehicle.
In view of this fact, it is advised that all foreigners
employ rather the pneumatice tyred rickshaws.
Thorough bathing daily and immediate washing
of the hands after coming in from the streets should
be practised.
While the disease is worse during the winter
months, the state of the temperature will cause all
to remain indoors when possible to do so. In the
summer time, when people naturally spend more
time on the streets and in the open air, danger of
contact would seem more likely. However, the
greatest danger occurs during the spring months,
when the people break out from the winter huts to
enjoy the sunshine after a period of disease and
confinement. At such time, especially, the most
strict precautions should be practised.
Furs and clothing from native shops should be
disinfected before use. The material and place of
workmanship can. very possibly be infected.
All Chinese rags should be avoided. Chinese
women, sewing in a pile of rags, are often encoun-
tered on the streets frequented by foreigners, even
in cities as large as Shanghai. Avoid most care-
fully such places. The rags are almost certainly
infected. Women who solicit jobs of sewing from
house to house should be driven away, as they
may also carry disease and usually belong to this
class.
Final, a danger constantly present is the
sampan (row boat) with a family living aboard. As
certain as children are born, so certain are the
poorer ones of being given the small-pox. An
infant in a sampan means certainly a case of small-
pox aboard during the year. Infants and children
just able to walk or older are often seen with their
faces covered with recent pigmented scars. This
means recent small-pox aboard, and as the infeetive
agent has great vitality, and as conditions for its
lite and propagation are especially favourable on a
sampan, the danger is at once seen to be positive.
If one wishes to use a boat one should be used
which has no family aboard and one only patronized
by foreigners, if possible. The Sisters of a mission
at Hankow told me that when they wished to cross
the river to Wuchang, they used only the sampans
as described above, and as an additional precaution
had the boats washed before the trip was made.
J. F. Rupert, U.S. Navy,
U.S. Naval Hospital, Annapolis, Md.
Written in China,
June 26, 1911.
Tur third quarterly number of the Bulletin of
the Imperial Institute, vol. xi (1918), No. 3, pub-
lished in the beginning of October by Mr. Murray,
contains, among the reports of recent investigations,
the results of examination in the laboratories of the
institute of a large number of samples of cotton
from Uganda, of new Colonial and other tanning
materials, and of essential oils from various
Colonies. Among the special artieles is one of
exceptional interest and value by Dr. Walter Busse,
of the German Imperial Colonial Office, who outlines
the organization of experimental work in agriculture
in the German colonies, with special reference to
tropical possessions in Africa. An article on the
coal resources of Canada, based on official sources
of information, gives a comprehensive survey of the
subjeet (together with a bibliography) which will
be new to most readers, in so far as the large output
in British Columbia and Alberta is concerned, as
compared with that of Nova Scotia. The increasing
demand for wood oils should direct attention to an
illustrated article by Mr. Ernest H. Wilson, the
well-known traveller and collector, on Chinese
wood oils, the production of which in various parts
of the British Empire is strongly recommended.
The Bulletin concludes with some general notes
and reports of recent progress in agriculture and
the development of natural resources, together with
notices of recent literature.
=ó
Drugs and Appliances.
FUMIGATING AND DISINFECTING
APPLIANCES.
As usual, the Clayton Fire Extinguishing and
Ventilating Co., Ltd., has been busy throughout the
past year equipping vessels with their fire-
extinguishing and disinfecting machines. The Com-
pany, moreover, has supplied machines for dis-
infecting and fumigating purposes to all parts of
the world, including several of their largest types
of machines for Kilindini, Mauritius, Fiji, Lagos,
Singapore, and Uganda, to the order of the Crown
Agents for the Colonies, in addition to machines for
Foreign Governments.
Blotices to Correspondents.
1.—Manuscripts if not accepted will be returned.
2.—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers, i
5.—Correspondents should look for replies under the heading
“ Answers to Correspondents.”
m
Jan. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 2, Vol. XVII
Original Communications.
THE USE OF THE TUNING-FORK IN DIA-
GNOSING THE OUTLINES OF SOLID
AND HOLLOW VISCERA OF THE CHEST
AND ABDOMEN AND OF CERTAIN
PATHOLOGICAL CONDITIONS.
By James Cantus, M.B., F.R.C.S.
(Being an account of a demonstration at the London
School of Tropical Medicine to members of the
International Medical Congress, August, 1913.)
For some years I have used the tuning-fork in
conjunction with the stethoscope as a means of
ascertaining the exact outlines of the liver and
other organs. My desire, in the first instance, was
to ascertain more accurately than is possible by
palpation and percussion the area occupied by the
liver and spleen, as these are the chief solid organs
affected by tropical diseases; but I found that the
hollow viscera—the stomach and the cecum—lent
Fic. 1.—Examining liver in front of axillary line,
standing on right side of patient.
themselves to the tuning-fork-stethoscope method
of ascertaining their dimensions. Further, I ex-
tended the same method to the organs of the
chest, and found that by its means several con-
ditions are more readily and precisely ascertain-
able than by the means of diagnosis in use here-
tofore. To gauge the exact area occupied by the
liver, for instanee, by percussion alone can never
be more than approximately accurate; whilst, at
times, it is difficult and occasionally impossible,
owing to pain, distension, &c., to define its outline
with any degree of precision likely to prove useful
for clinical purposes. Palpation is applicable to the
lowest strip of the liver only, and even in healthy
states it is more a matter of opinion than an actual
clinical fact where the lower border of the liver
lies; when, on the other hand, the liver is tender
or the abdomen tense from distension or there is
ascitic fluid present, the lower limit of the liver is
still more.obscure. By the tuning-fork-stethoscope
the limits of the liver can be gauged with almost
hair-breadth precision.
The principle involved in the use of the tuning-
fork-stethoscope method is that when the stetho-
scope is placed over an organ, be it a solid organ
such as the liver, spleen, heart, &c., or a hollow
organ such as the stomach or cecum, and the
vibrating tuning-fork is made to impinge on the
surface of the body over one or other of these organs,
the note of the tuning-fork manifests by its loud-
ness the limits of the organ being examined, and
the moment the limits are passed the note becomes
faint, distant, or is altogether inaudible.
Fic, 2.~-Examining liver in axillary line, standing on
left side of patient.
The Tuning-fork.—I have tried many forms and
kinds of tuning-forks; some with high-pitched, some
with low-pitched notes; some forks with flattened
or button-shaped, and some with pointed ends. The
best results are obtained by a fork made for the
writer by Messrs. Mayer and Meltzer, 75, Great
Fia. 3.—A tuning-fork with hammer attached.
Portland Street, London, W. The note is G-sharp,
and the end of the fork is not flattened, but pointed
rather. The fork may be struck against anything
hard, the heel of the boot if nothing else is available,
and whilst loudly vibrating the end of the stem is
pressed lightly but firmly upon the skin.
18 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1914.
In fig. 3 a tuning-fork with an arrangement
whereby the fork is made to vibrate by an attached
hammer is portrayed. It is a convenient but not
TT d
Fic. 4.—Liver, vertical dimensions. S, stethoscope; 6,
tuning-fork loudly heard; O, tuning-fork on lung and gastro-
intestinal tract faintly heard.
at all a necessary arrangement, as the ordinary fork
is easily set vibrating by striking anything con-
venient. The sounds heard when the stethoscope is
D
\
Fic. 5.—S, stethoscope applied. €, loud notes over liver :
O, faint sounds over heart and stomach,
placed on the skin over any of the organs mentioned
seem to proceed from the point where the
fork impinges on the skin, but when the fork passes
from off the organ over whieh the stethoscope is
placed the sound is not only fainter, but it seems
to proceed from the free or distal end of the
fork, and not from the point where it touches the
skin. By a little practice this peculiarity becomes
more evident and is a useful adjunct to the mere
loudness or faintness of the sound in the matter of
diagnosis.
The practical application of the tuning-fork-
stethoscope method, applied, say, to the liver, is as
follows: Place the stethoscope (binaural) on the
lower part of the chest wall just above the lower
part of the right true rib cartilages about one inch
Fic. 6.—Tuning-fork track along outlines of liver. S,
stethoscope ; 6, loud sounds of tuning-fork over liver; O, faint
sounds beyond outlines.
behind a line drawn downwards from the right
nipple (see S, figs. 4, 5, &e.). The tuning-fork is now
made to travel from the region of the chest midway
between the sternum and the nipple line (fig. 4)
downwards over the liver. The note heard (if heard
at all) when the tuning-fork is over the lung is faint
or distant, but the moment it reaches the area of
the liver the note is loudly heard; when the lower
limit of the liver is reached and the tuning-fork has
other abdominal organs beneath it, the sound sud-
denly fades away to a faintly distant hum. The
degree of pressure necessary for diagnostie purposes
varies; over the chest the end of the fork has only
to be gently pressed against the skin; but when a
careful search has to be made for the limits of tha
lower edge of the liver, as in stout people or in
cases of distensions from gas in the intestines or
iluid in the peritoneal cavity, the fork has to be
Jan. 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE
. 19
pressed fairly deeply at times, so that the piece of
intestine may be pushed aside or the fluid between
the abdominal wall and the liver displaced.
Fig. 5 shows the application of the tuning-fork
over the heart, liver, and stomach, and it is at once
evident from the diagram that along the middle line
of the body the loud sounds are over the liver, and
the faint sounds are over the heart above and the
stomach below.
Fig. 6.—The upper and lower limits of the liver
may be quickly and accurately ascertained by
rapidly passing the tuning-fork all around its pre-
sumed borders, when any divergence from the
regular outline is at once perceptible, and any dis-
crepancy between the relative sizes of the two sides
of the liver at once brought to light.
At times it is well-nigh impossible by palpation
or percussion to know where the liver ends on the
left if the spleen happens to be enlarged as well,
and vice versa, for the two organs may be actually
Fia. 7.—When liver and spleen touch. S, stethoscope over
liver distinguishes 6, loud sounds over liver, and O, faint
sounds over spleen.
in contact. The tuning-fork-stethoscope method
at once settles this point, for if the stethoscope is
over the liver the sounds may be wholly inaudible
when the spleen is beneath the tuning-fork.
Similarly, when the stethoscope is over an enlarged
spleen the tuning-fork, when superimposed on the
liver, is inaudible or faintly heard (fig. 7).
An effusion into the pleura is at once detected
by the tuning-fork (fig. 8). As the diagram ex-
plains, the tuning-fork is heard only over the liver
when the stethoscope is superimposed over that
organ, and only faintly heard or is wholly inaudible
over the lung, the effusion, and the abdominal con-
tents below the liver. This is of great clinical
assistance, for neither by percussion, palpation, nor
by auscultation can it be positively diagnosed
whether the dulness or absence of breath sounds is
Pleuritic
effusion
Fic. 8.— Effusion into pleura, S, stethoscope; @, loud
sounds; O, faint sounds.
due to pleuritie effusion, to an abscess of the liver,
or to a liver pushed upwards towards the lung by
abdominal distension, &c.
\
1G. 9.— With stethoscope placed anywhere over stomach.
@, loud sounds heard ; O, faint sounds heard.
20 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Passing now from the solid viscera to a hollow
viseus, the stomach, as in fig. 9; here, again, it will
be found that the tuning-fork answers true. The
dimensions of the stomach are definable with pre-
cision, and the writer has tested the accuracy of the
method in question compared with that of the
X-ray screen or photographs. The dimensions of the
cecum can also be accurately told, and the difficulty
at times found to be certain whether the full and
movable cæcum or colon is not really a movable or
dropped right kidney is at once settled. The track
of the large bowel can also be followed for some
distance, for when the stethoscope is placed upon
the cecum, the vibrating tuning-fork can be heard
as it is carried along the ascending colon and across
the body along the transverse colon as far, at least,
as the middle line. In several varied abdominal
conditions the tuning-fork method of diagnosis
may be of service, and has proved so in the writer’s
hands. The dimensions of a pregnant uterus, of
an ovarian cyst, or a uterine fibroid can be gauged
by the tuning-fork-stethoscope method. A distended
gall-bladder felt as a tumour through the abdominal
wall can be isolated by sound from the liver, or other
adjacent organs.
In Fractured Bones.—When a thigh bone or any
of the large bones of the limbs are fractured any-
where along the shaft, the stethoscope placed
over one end—say, over the great trochanter of the
fractured femur—the vibrating tuning-fork, placed
on the lower end of the bone just above the knee,
cannot be heard so well as on the sound side.
In the case of a fractured rib, when the stethoscope
is placed far back on the shaft and the tuning-fork far
forward, it is easy to detect the difference of the
note in the fractured rib or ribs, from that over the
sound ribs above and below. A doubtful fracture of
the sternum, collar-bone, &c., can be detected in the
same way.
The Heart.—The dimensions of the heart are
readily and precisely ascertainable by the tuning-
fork-stethoscope method.
The method here described has many other
possible forms of application. I have been making
observations on the different tones which are
specific to different affections of the liver; that a
fatty liver gives out tones distinct from a cirrhosed
liver there is no doubt, and so with other ailments;
but as yet sufficient evidence has not been collected
to tabulate the sounds peculiar to each.
N.B.—In applying the tuning-fork it is better
not to drag it along the skin, but to raise it and
“dab” it on the skin at short intervals.
As the upper limit of an organ is made out, the
forefinger of the hand adjusting the stethoscope can
be kept at the spot where the notes pass from loud
to faint until the spot is marked by a pencil, and
the same can be done when the lower limit of the
organ is reached.
(Jan. 15, 1914.
“ESPASMO TROPICAL”: A PECULIAR
DISEASE OF GREAT MALIGNANCY,
ASSOCIATED WITH A PARASITE IN THE
BLOOD.
By R. Veraxe, M.D.
Health Officer, Barceloneta, Porto Rico.
FOR years this disease has been known to exist
in Porto Rico, but it has never been investigated.
Since the brilliant studies of Major Bailey K. Ashford
on uncinariasis, however, the medical profession of
Porto Rico is awakening to the fact that proper and
well carried out investigations will show that we have
here many unknown tropical diseases.
“ Espasmo tropical" is the name given to a disease
which appears under two different forms. We shall
first describe the one form, which may be benign or
malignant in character, according to the symptoms.
Form "A."
(1) Benign Form.
There is apparently no period of incubation. The
person attacked has previously been feeling quite well,
when suddenly he notices that he cannot open his
mouth. In other words, he has trismus. Shortly
after he loses consciousness, at the same time the
temperature rising to 40° C. After a period of from
eight to fourteen hours, under a stimulating treatment
the patient comes out of the profound stupor and
recovers. This takes place in the majority of cases.
(2) Malignant Form.
In this form we have, in addition to the trismus,
a deep cerebral invasion from the beginning. There
is a marked typhoid state. The patient is very
restless and at times there is a low muttering delirium.
The temperature is high, and may reach 41°5° C.
Vomiting of a dark greenish material is very common.
The pulse is weak and rapid. The attack lasts for
two or three days, when death supervenes in almost
all the cases. The difference between the two forms
lies in the cerebral symptoms. In the benign form
there is loss of consciousness, but the patient is very
quiet, as in a condition of catalepsy. The sense of
pain is abolished, reflexes are absent. In the malignant
form there is the marked typhoid state, the reflexes
are increased, the patient is very restless, and the
sense of pain is preserved. In both cases there is
constipation.
FORM "B." TYPHUS-LIKE FORM.
This is always malignant. It is characterized by
a very short period of malaise, during which time the
patient goes about as usual. Suddenly he vomits,
falls to the ground and becomes unconscious. In
these cases the temperature remains stationary at
37? C. during the first seven or eight hours. Then
it goes up to 40° C. and 41? C. The period of
almost complete unconsciousness lasts for three or
four days, to be followed by one of great cerebral
irritability, which later is accompanied by convulsions
of extreme violence. Then it develops into a state
Jan. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 21
of relative tranquillity, if it does not terminate by
death. Those who survive become insane during a
period of from two to three weeks, after which they
completely recover if properly treated. In addition
to the above symptoms, there is a spasm of the
muscles of mastication and deglutition, obstinate
constipation, dilatation of the pupil and weak and
rapid pulse.
In the majority of cases there is no prodromal
period. The patient is seized by a very high fever
and soon passes into a state of profound stupor
accompanied by a low muttering delirium. The
facies are very characteristic, the patient’s appearance
assuming a dull, agonized expression. The pupil is
contracted but expressionless. The mouth twitches,
and the whole face is haggard.
There is no vomiting at any stage of the disease.
There are no convulsions. There is obstinate con-
stipation.
There are two cardinal symptoms which at a
glance disclose the very malignant character of this
type of the disease.
The Tongue.—This is pathognomonic. From the
beginning the tongue is very dry. From the third
day it takes on its characteristic appearance. I
shall describe it with just one word. The tongue
is that of a mummy. It is only a charred piece of
flesh.
The Eruption.—This is also pathognomonic. Right
from the start of the disease there appears an erup-
tion, which in the majority of cases is localized in
the abdominal region. It begins by very small, dark
spots with raised edges, and which do not disappear
on pressure. They remain thus until the third day,
when they turn to a red colour and become some-
what umbilicated. By the fifth or sixth day they
change to-a bluish colour which is permanent to the
end of the disease.
Other Symptoms.—Throughout the whole course
of the disease there is scanty, dark-coloured urine.
At times there is complete suppression of urine.
Near the end, just before death, the patient sweats
and urinates profusely, recovers his power of speech,
his eyes take an intelligent look, and then he dies.
The Temperature.—F rom the first day the tempera-
ture rises up to 40:5? C. and 41° C., and remains
so until the fifth day, when there is a morning drop
to 36:5? C. But very soon it rises again to 405" C.,
and remains stationary during seven or eight days.
In those very rare cases who recover the temperature
begins to drop gradually by the tenth to the fifteenth
day.
The Pulse.—From the beginning there is a very
weak and rapid action of the heart, which is not
markedly improved by the injection of the various
heart stimulants. There is an intense weakening of
the heart muscle. The pulse varies from 125 to 140.
Respiration.—The respirations are very little in-
creased.
Abdominal Organs.—The spleen is invariably en-
larged and hard to the touch. The liver is congested.
The intestines are normal. In regard to the alimen-
tary tract and in connection with its functions, the
patient shows a great aversion to taking food or
medicines. He will take a few mouthfuls, retaining
them inside the mouth for a few minutes and then
spitting them out.
Complications.—The usual complication is broncho-
pneumonia. Its symptoms appear by the fifth day.
Acute endocarditis is the actual cause of death.
Findings in the Blood.—In twelve cases suffering
from this disease the blood has shown what appears
to be a parasite. This is a little oval body, which is
mainly extracellular, measuring from 2 to 3 microns.
It may occur, however, within the red cells, situated,
when single, near the periphery of the cell. When
multiple it is situated in the very centre of the
corpuscle, arranged in a sort of mosaic work. They
are very small, and difficult to detect. Stained with
Wright's stain they are seen to consist of a nucleus
situated towards the pointed extremity and which takes
on the acid dyes; the protoplasm, which is abundant,
stains blue. These bodies are not numerous, and the
specimen has to be searched for very carefully in order
to find them. When extracellular, they are seen in
clusters.
In the fresh blood they are seen to possess an
amceboid movement. When in clusters they appear
to form an elongated mass which after a short while,
by a to-and-fro movement, becomes spherical.
There is no leucocytosis. One of the striking
features of the blood is the great differential increase
of the large mononuclears. The polymorphonuclears
present belong to the neutrophilic variety.
Autopsy.—In a case of three days’ duration a post-
mortem disclosed the following pathological changes :
Spleen.—The spleen was greatly enlarged, of a hard
consistence, and of a brown mottled colour. Stained
specimens showed a large number of bodies, like those
seen in the blood; what appeared to be flagellated
bodies were also seen. Liver.—The liver was a little
enlarged, of a dark red colour and extremely friable.
Stained specimens showed a few bodies. Intestines.
—These were normal. No ulcerations. Heart.—The
organ was very full of blood. There were signs of
endocarditis. ^ Lungs.—These were congested; nor-
mal colour. Brain.—Not examined. Glandular
system.—A general enlargement of the glands was
present.
Treatment.
The treatment of espasmo is purely symptomatic.
Hypodermie injections of strychnine, or caffeine and
camphorated oil may be given to stimulate the heart.
Physiological salt solution may be injected into the
veins. Hypodermic injections of quinine give no
results.
Mode of Transmission.
The disease may possibly be conveyed to man by
insects. The fact that near a place where five cases
have occurred there were several breeding places of
anopheles, makes it just probable that a mosquito
belonging to this family might be the transmitter of
the disease.
22. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1914
THE DETECTION OF TRYPANOSOMES IN
ANIMALS.
By ALEXANDER Lunpig, M.B.
Gold Coast, West Africa.
THE detection of trypanosomes in animals is often
a matter of difficulty, but in cases where plenty of
blood can be obtained I have found the following
method yield very good results.
When an animal is to be slaughtered for food, or
when one of the big game has been shot, blood is
allowed to pour directly from the cut throat into a
test tube containing 5 gr. of potassium citrate, dis-
solved in 5 c.c. of sterile water. The tube, of course,
and its plug have been carefully sterilized beforehand.
When three-quarters full the tube is plugged, and the
contents are mixed by rolling. The preparation is
then set aside till time can be found to examine it.
Within half an hour there is always a little clear
fluid on the top of the blood, and if there are any
trypanosomes at all in the blood they will certainly
be found there, seeming to be more abundant
on the surface than lower down. They are, moreover,
much more easily detected in the clear fluid, and films
made with it allow of the preparation of magnificent
Specimens when stained by Giemsa's method. Of
course, one never stains the specimen until the living
trypanosomes have been detected, so a great deal of
time is saved by this method, and it yields a larger
number of positive results than any other that I
know of.
Another advantage of this method is this, that it can
be used for the study of the development of trypano-
somes. The preparation is simply left alone till all
the red corpuscles have settled down, which takes
about three days, or the top layer can be siphoned
off into another sterilized tube, and set aside for
study. Latterly I have been in the habit of taking
a quantity of twenty ounces of blood at a time, and
making several culture tubes from it in this way,
and I have easily got crithidial forms thus. It seems,
in fact, far more rational than attempting to develop
the parasites in the water of condensation of a
culture tube, as it is scarcely credible that such
drops of condensation are anything very different
from distilled water.
To study the life-history of trypanosomes in tsetse
flies, one can imitate the chemical change in the fly's
stomach fairly well by mixing the fresh blood, with a
sufficient volume of hydrochloric acid, diluted so as to
contain 0'02 per cent. by weight of hydrochloric
acid. When the requisite proportion is added, the
blood at once becomes brown in colour, and sets
into a jelly, which exactly resembles the congealed
blood that can be squeezed out of a fly that has drunk
blood. The addition of a digestive ferment to the
mixture would no doubt complete the culture medium
quite successfully. The matter of temperature is
simple, as the fly cannot possibly incubate its
ingested blood at a temperature much higher than
that of the air. Experiments in this direction promise
a certain amount of success, and are certainly different
from what have hitherto been in vogue.
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THE JOURNAL OF
Tropical Medicine and Hygiene
JANUARY 15, 1914.
PELLAGRA INVESTIGATIONS.
Dr. L. W. Samson, after a sojourn in the United
States of America, in the West Indian Islands, and
in British Guiana, returned to London on January 6,
1914. This is the third expedition made by Dr.
Sambon in order to investigate the etiology of
pellagra. The first field of his study was in Italy
and the Tyrol, the second comprehended practically
the whole of the South of Europe from the Black
Sea to the Atlantic, and the third—now just accom-
plished—has been devoted chiefly to the central
area of the Western Hemisphere.
It will be remembered that the original reason
for these expeditions was the doubt thrown upon the
accepted cause of pellagra, namely, eating of
diseased maize, by Dr. Sambon. So well did he put
his case that a few believers in the necessity for his
opinion being investigated formed themselves into à
committee, entitled The Pellagra Investigation Com-
mittee, and after collecting funds chiefly through
the columns of the Times and by the liberal help of
the Colonial Office, sent Dr. Sambon to Italy to
inquire more fully into the etiology of this obscure
ailment. The report of this expedition brought a
new idea to scientific men in countries more
especially where pellagra was known to prevail, and
led to much discussion on the subject. Meantime,
— ~
Jan. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 23
the subject of pellagra was attracting a great
amount of attention in the United States, for it
was found that the disease was attaining a wide-
spread hold upon many of the States in the Union.
Dr. Sambon, whilst doubting the part played by
maize in the production of the disease, formulated
his belief in the etiology and brought forward the
suggestion, amounting on his part to almost a settled
conviction, that pellagra was an infectious disease,
and that it was conveyed by a biting fly. He incul-
pated the Simulium, a fly popularly termed a sand-
tly, but really scientifically distinct from that group
of insects; and wherever Dr. Sambon went in
Europe he found that pellagra was associated with
the presence of Simulium.
In 1913 a still further and most interesting factor
came into prominence. It was no other than that
pellagra was discovered to be fairly widely spread
within the British Isles. This fact, now well
established, had long been suspected by Dr.
Sambon, although he had no clinical proof that such
was the case. It was, however, by his description
of pellagra in the medical journals of this country
that the disease was unearthed, and it has now been
incontestably proved that in England, Seotland, and
Wales cases of pellagra are met with in our lunatic
asylums and elsewhere.
The growing importance of the subject led to yet
a third expedition to the West Indies, where, under
the auspices of the Colonial Office, the Pellagra
Investigation Committee, and by the liberal assist-
ance of Mr. H. S. Wellcome, he was enabled to
proceed to the West Indies in August, 1918.
When it was known that Dr. Sambon was pro-
ceeding to the Western Hemisphere, the Pellagra
Commission in the United States invited him to visit
them and to exchange views on the subject of
the disease. A cordial reception awaited him, and in
Spartanburg, Columbia, and Charleston he delivered
addresses to the medical societies in those cities.
Captain Siler, of the United States Army, the chief
of the American Pellagra Commission, who hal
previously travelled with Dr. Sambon in his pellagra
expeditions in Europe, again joined him in part of
his journeys, and he was accompanied also by Mr.
Jennings, of the Entomological Bureau, Washing-
ton, U.S., and by these scientists every help and
assistance was given.
In the United States Dr. Sambon found the
nuthorities keenly alive to the presence of pellagra
in their midst, and anxious to confer with him upon
the subject of the etiology of the disease. His
theory of the causation of pellagra was favourably
entertained by men of distinetion, and all were
ready to listen to his explanations.
Dr. Sambon was especially struck by the
excellent work being done by the Thompson-
MacFadden Pellagra Commission in South Carolina.
After leaving the United States, Dr. Sambon visited
the Panama Canal Zone at the invitation of Colonel
Gorgas, and was astonished at the sanitary and
preventive work which had been done there, whereby
the work of the Canal had been made possible. On
reaching the West Indian Islands he visited Jamaica,
Barbados, Trinidad, Grenada, and St. Vincent, and
proceeded thence to British Guiana. It is well
known that pellagra is present in these regions, and
of this fact Dr. Sambon had convincing proof.
With an activity and enthusiasm peculiar to him-
self, Dr. Sambon devoted attention to many other
matters of medical interest besides pellagra, and he
has returned with a wealth of material in the way
of notes on such subjects as blackwater fever,
filariasis, leprosy, &c., and with photographs num-
bering well over a thousand. Dr. Sambon was
accompanied by the artist, Mr. E. Sehwartz, who
worked with him throughout the trip, and we look
forward with interest to the published report in the
near future.
Dr. Sambon cannot speak too highly of the
courtesy and kindness he received wherever he
went, and of the facilities granted him by the
Government authorities, by the medical men he
met, and by the veterinary departments in the
several Colonies he visited.
————— —————
Annotations.
Plague in Manchuria.—In a very interesting
report concerning the North Manchurian Plague
Prevention Service, published in the Journal of
Hygiene, October, 1918, Wu Lien-Teh (G. L. Tuck)
reaches the following conclusions :—
(1) That even though the tarbagan occasionally
suffers from plague the epizootic is never extensive,
and the animal does not play nearly so important
a role in the spread of plague as does the rat.
Indeed, its direct relationship to human plague may
be considered as negligible. Moreover, the mode of
living and habits of the tarbagan are very different
from those of the rat; for example, while the rat
is a more or less domestic creature in close contact
with man, the tarbagan is the reverse.
(2) That from the writings of Russian authorities
it appears that plague has existed for many years
in various parts of Siberia, sometimes in the bubonic
form, sometimes in the pneumonic form. These
places may be looked upon as endemic foci. In
1910 it is believed that pneumonic plague appeared
in the Russian Ural District long before it made
its appearance at Manchouli, and developed into
the great Manchurian epidemic. During the latter
half of 1911 this form of plague was present in
the Kirghiz settlements. In these districts from
October, 1911, to February, 1912, over 200 cases
of plague occurred. No case of plague, in man
or animal, has occurred in Manchuria since the
epidemic of 1911.
(3) That from this report it is obvious that state-
ments of the occurrence of plague among men or
animals should be believed only when they come
from responsible sources—that is, after proper
medieal and scientifie investigations.
As regards the tarbagan the author makes the
following statement, that the only definite proof
24 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1914.
that tarbagans in nature are affected with plague
is obtained from the animal caught by Issaief in
June, at Scharasone, and examined by Zabolotny.
To conclude that a man whose occupation is that
of a tarbagan hunter, and who takes plague, has
been infected from a tarbagan, is comparable to
concluding that a man who sells rice and who
develops plague has been infected from the rice.
In the latter case it is possible that the rice through
the rat flea was the source of infection; but if,
without some proof that this were so, the statement
was made, such a conclusion would be at once con-
demned as unjustifiable. From the above it seems
a pity to the author that responsible authorities and
medical men should be so obsessed with the unes-
tablished idea of the great infectivity of the tarbagan
as to place hindrance in the way of transporting by
rail live, healthy tarbagans for important scientific
research at the headquarters laboratory at Harbin,
an experience which actually occurred in March of
this year.
Salvarsan in the Treatment of Yaws.—Cockin, of
Grenada, West Indies, writing in the Lancet
(December 6, 1913), gives the results of a series
of forty-five cases of yaws treated by intramuscular
injections of salvarsan. The method of preparing
the salvarsan for injection was in all the cases a
slight modification of that suggested by Taege, and
is as follows. The salvarsan was received from the
ampoule containing it into a sterilized and dry test-
tube, and there emulsified by the addition of
10 to 12 minims of pure glycerine. Sufficient hot,
chemically pure, sodium chloride solution (0°5 per
cent.) was added to make the bulk up to 10 c.c.
and get the salvarsan into solution. The solution
was then received into a sterilized all-glass syringe
and so injected. The syringe and needle were
sterilized by boiling for each injection, and the skin
at the site of injection was painted with a 10 per `
cent. solution of tincture of iodine.
The point chosen for injection was in all cases
that at the junction of the middle and upper thirds
of a line drawn from the tuber ischii to the anterior
superior iliac spine. After injection the puncture
was at once sealed with collodion. The patients
were kept in their beds for three days subsequent
to the injection, and a four-hourly record of the
temperature was made during this period and until
the end of the week. A milk diet was given for
two days following the injection, after which a full
or half diet was allowed. The results of the treat-
ment are shown in a table.
The inference that preliminary treatment with
mercury and iodides expedites the action of the
salvarsan is not supported by observations made
upon cases where these drugs were administered for
long periods in the treatment of syphilis, and where
salvarsan was subsequently given. The average
duration of stay in hospital after injection was 23°6
days, as compared with an average stay of 33 to 4
months of the patients not injected. Owing to the
difficulty in returning children to their parents the
average duration of stay is longer than it otherwise
would be, and in this connection, with one excep-
tion, every case remaining in the hospital for longer
than thirty days after injection was under 12 years
of age.
From an administrative point of view the
advantages of this form of treatment are obvious,
since, in comparison with a similar number of non-
injected cases, the saving effected in dietary alone,
after deducting the cost of the drug used in the
nuthor's series, was £75. Still more important, the
possibility of completely eradicating the disease from
those places in which it exists appears nearer
attainment than ever before. This, however, in-
volves the proper segregation of all infective cases,
the compulsory notification of the disease, an
efficient medical examination of school children, and
the refusal to admit cases of yaws into the ports of
entry other than through the Yaws Hospital. These
measures, Cockin believes, in conjunction with the
salvarsan treatment, would aid materially in com-
pletely eradicating the disease from any community,
and the time occupied in completing the process
would depend upon the size of the country and
the efficiency with which the measures suggested
were enforced.
Entericoid Fever.—Riesman, writing in the
Journal of the American Medical Association (vol.
lxi, No. 25, December 20, 1913), calls attention to
certain fevers which simulate both typhoid and
paratyphoid fever, but which apparently are
different. He proposes that the term ‘‘ entericoid
fever ” should be applied to these.
His conclusions, whieh give a summary of his
paper, are as follows :—
(1) The term ‘‘ typhoid fever," as commonly
used by physicians, includes more than one variety
of disease. E
(2) Only that in which the characteristic serologic
and cultural tests for the typhoid bacillus ar?
obtained should be called typhoid fever.
(3) To the others, which clinically may. resemble
typhoid very closely, the term ‘‘ entericoid fever
may be applied. l
(4) The entericoid fevers are due to different
strains of organisms of the paratyphoid group and
to others morphologically similar (Gärtner’s Bacillus
enteritidis, &e.). '
(5) The source of infection is chiefly food derived
from unhealthy animals.
(6) Food (including drink) may become con-
taminated through contact with diseased meat,
through rodents, birds, or through the discharges of
carriers, &c.
(7) So-called second attacks of typhoid fever are
probably entericoid (paratyphoid) fever, provided,
of course, the first was genuine typhoid fever.
(8) In all cases of typhoid-like character careful
search should be made for the source of infection,
and blood-cultures and other tests for the deter-
mination of the infecting agent.
(9) By combined clinical and laboratory investi-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, JANUARY 15, 1914.
LONDON SCHOOL OF TROPICAL MEDICINE.
43rd Session. X October— December, 1913.
Back Row.— Judson C. King, E. B. Pearson, B. McCullough, R. J. R. Mecredy, E. H. Griffin, E. Zavattari, D. L. Graham (Cant. I. M.5.), J. R. Ridlon
U.S. Pub. Health Ser.), C. R. Bakhle, (Maj. 1.M.8.), C. S. Harwood, C. R. Avari, W. Lethbridge (Maj. I.M.8.), M. F. Reaney (Capt. I.M.8.),
T. P. Fraser, R. F. Steel (Capt. I. M. 8.), W. H. Kauntze, D. T. Mitchell, E. J, H. Garstin, G. Warren (Lab, Asst.), R. V. Khedkar, K. Ghosh.
Third Row Standing.—H. M. Cruddas (Maj. 1.M.S.), R. Dow, A. L. Piper, J. H. Goodliffe, R. M. Mitchell, R. Kelsall (Capt. I. M.S.), B. Sefton, D. S. Bryan-
Brown, W. E. Masters, J. H. Bennett, P. A. Clearkin, R. Drummond, A. S. Burgess, S. Shepheard, J. Moncrieff Joly, L. M. Bisvas,
R. G. Perkins, R. O. Sibley (Demonstrator), W. McDonald (Lab, Asst.), Robert (Lab. Asst.).
Second Row Sitting.—L. G. Fink, B. H. Wedd (Bacteriologist), F. W. O'Connor ,(Demonstrator), P. Bahr (Demonstrator), R. G. Ball, H. B. Newham (Director),
Miss M. I. Balfour, J. R. Dodd (Col. A.M.S.), Col. A. Alcock (Medical Entomologist), Dr, F. M. Sandwith (Lecturer), Miss J. E. Hoffman,
Dr. G. C. Low (Lecturer), C. M. Wenyon (Protozoologist), Miss J. E. Crozier, Miss J. Marsh, F. Troconis, E. Piedrahita, G. V. Fiddian.
On the Ground.—H. W. Furnivall, L. Mascarenhas, G. R. Vohra, J. Atkinson, C. B. Mack, A. C. Wilson, N. Seppelt (House Surgeon), G. Verspyck-Mynssen,
L. R. Sharples, T. B. Marshall, J. K. A. Honey, A. R. Paterson.
Absent.—R. T. Leiper (Helminthologist), Miss M. Plum, J. Urwin (Maj. I. M.S.), E. M. Merrins, A. I. Jackson, G. Rollason, J. S. Smith, H. Ellis,
A. C. Rendle, H. C. Hodgson, G. D. Carpenter, v. Kennedy, W. P. Beal, H. E. Shortt (Capt. I. M.5.).
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON),
Under the Auspices of His Majesty's Government,
CONNAUGHT ROAD, ALBERT DOCKS, EF.
In connection with the Albert Dock Hospital of the SEAMEN'S HOSPITAL SOCIETY.
THE SEAMEN'S HOSPITAL SOCIETY was established in the year 1821 and incorporated in 1833, and from time to time
has been enlarged and extended. It now consists of the Dreadnought Hospital, Greenwich, to which is attached the
London School of Clinical Medicine; the Royal Victoria and Albert Docks Hospital; the East and West India Docks
Dispensary; and the Gravesend Dispensary.
Over 30,000 Patients treated annually. Of this number many are Cases of Tropical Disease.
The School buildings are situated within the grounds of the Royal Victoria and Albert Docks Hospital.
MEDICAL STAFF OF THE HOSPITAL AND LECTURERS IN THE TROPICAL SCHOOL.
JAS. CANTLIE, Esq., M.B., F. R.C.S., D.P.H. Professor R. TANNER HEWLETT, M.D., F. R.C.P. | Col. E J. noH I.M.S., F.R.C.8.
L. VERNON CARGILL, Esq., F. R. C.5. G. C. LOW, Esq., M.A., M.D. UL; SAMBON, Esq., M.D.
E. TREACHER COLLINS, Esq., F.R.C.S. J. M, H. MACLEOD, Ésq., M. D., M.R.C.P. ' FLEMING MANT SANDWITH, Esq. dS D., F. R.C.P.
C. W. DANIELS, Esq., M.B., M.R.C.P., M. R.C.S. | Sir PATRICK MANSON, G.C.M. G.. F.R.S., LL.D., Professor W. J. SIMPSON, C.M.G., , F. R.C.P.
KENNETH W. GOADBY, Esq., D. P.H.(Camb.), M.D., F.R.C. P. | H. WILLIAMS, Esq., M.D., M.R.C.P., D.P Hicamb.)
M.R.C.S., L. R.C.P., L.D.S. R.C.5.
Dean—Sir F. LOVELL, C.M.G., LL.D. Arthropodist— Colonel A. ALCOCK, I.M.S., C.I.E., F.R.S.
Helminthologist—R. T. LEIPER, Esq., D.Sc., M.B., Ch.B., F.Z.S. Protozoologist—C. M. WENYON, Esq., M.B., B.S., B.Sc.
Director—H. B. NEWHAM, M. R.C. S., LR. C P., D.P.H., D.T.M. & H. (Camb.). Secretary—P. J. MICHELL I, Esq., C.M.G.
LECTURES AND DEMONSTRATIONS DAILY BY MEMBERS OF THE STAFF.
There are three Sessions yearly of three months each, viz., from October lst to December 31st, from January 15th to
April 14th, and from May 1st to July 31st inclusive. Women Graduates are received as Students.
Certificates are granted after Examination at the end of each Session, and the course is accepted by Cambridge University
as qualifying for Admission to their Examination for the Diploma in Tropical Medicine and Hygiene, and by London University
as Study for the M.D. in Branch VI. (Tropical Medicine).
Fee for course £16 16s.; shorter periods by arrangement.
Students can be provided with Board and Residence, or partial Board, at the School.
Medical men requiring posts in the Tropics may apply to the Secretary at the School, where a Register mL
A syllabus, with the general course of study, cau be had on application to the undersigned, from who ur
information may be obtained. STATE
Students of the London School of Tropical Medicine, who join the London School of Clinical Medicine, wi TE C;
an abatement on their fees and vice verså.
Chief Office—SEAMEN's HOSPITAL, GREENWICH, S.E.
P, WARD.
. JVERSITY.
v
Jan. 15, 1914.]
gations it should eventually be possible to distin-
guish, according to their specific etiology, the
various entericoid diseases now grouped together,
Ship-borne Cholera.—Craster (Journal of the
American Medical Association, vol. lxi, Decem-
ber 20, 1913) writes on '' the sea as a factor in the
transmission of Asiatic cholera."
He states that during June, July, and August,
1911, ten cholera-infected ships arrived at quaran-
tine, New York, from Mediterranean ports, bringing
a total of 5,411 passengers and 1,789 members of
ship's crews having been exposed to cholera. Six
patients arrived sick, and four were convalescent
from the disease. Twenty-four cases were treated
at the isolation hospital on Swinburne Island, with
thirteen deaths. Two cases occurred among re-
leased passengers in New York City and State, and
one member of a ship's crew. One fatal case
occurred among the quarantine employees. Thirty-
one cholera carriers were detected by routine exami-
nations; these were isolated and treated as cholera
patients. Four of these gave definite histories of a
recent sickness with diarrhea. During the four
months of routine examination of passengers from
infected ports for cholera carriers, 26,678 persons
were bacteriologically examined.
Over one hundred non-cholera vibrios were
isolated during the routine examination. Many of
these resembled the vibrio of cholera so closely that
no difference was perceptible, except the negative re-
action with the specific serum. In cholera,
cases of fluctuating rectal temperature of a degree
above or below normal persisted for some days after
all clinical symptoms had subsided, and after the
specific organism had ceased to be demonstrated in
the stools. The cholera carriers with no subjective
symptoms could be infective up to fifty-four days.
The cholera cases remained infective by the pres-
ence of the comma bacillus in the stools for one to
two weeks after all symptoms had abated, excep-
tionally for longer periods.
Time and length of voyage from infected districts
does not confer any special immunity against the
occurrence of Asiatic cholera in this country. The
well-established existence of the cholera bacillus
carrier has altered considerably the aspect of cholera
prevention, for we have to deal not only with real,
but also with potential agents of infection. The
high efficiency of present-day quarantine procedures
has rendered the possibility of spreading infection
from cholera cases extremely slight. The real dan-
ger to the public is not alone the person sick with
the disease, but also the person infected with the
specific organism and presenting no apparent sym-
ptoms of illness. In typhoid carriers the gall-bladder
is known to be the storehouse of the infecting
organism. That a similar condition may exist with
cholera carriers is suggested by the observations of
Greig, who demonstrated by cultural methods the
presence of the cholera vibrio in the gall-bladder
eighty-one times out of 271 cases of fatal cholera.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 25
In the prevention of cholera, besides the effective
isolation of the sick, there has developed in the
author’s experience at quarantine the necessity
of extreme caution in the release of contacts or
fellow passengers from detention, before a routine
bacteriologie examination has proved them free from
the cholera vibrio, and even after such a routine pro-
cedure there remains always a possibility of the
escape of a bacillus carrier who may have been
examined during a negative interval of an inter-
mittent discharge of the infecting organism.
When sporadic cases of cholera occur in any com-
munity (the so-called cholera nests) it would seem
that the bacteriologic examination of drinking-water
and of food, although advisable always, is not of the
same importance as a diligent search for the true
source of infection, the ‘ infected, presumably
healthy person, the proper means for whose detec-
tion, although involving a State in great outlays of
money and time, are of necessity justified in emer-
gencies for the proper preservation of the public
health and confidence.
The Operative Treatment of Elephantiasis scroti.
—Taylor, of Yangchow (China Medical Journal,
vol. xxvii, November, 19183, No. 6), describes
a method of his own for operating upon elephant-
iasis of the scrotum. As the method is a new one
and not mentioned in the usual text-books of
tropical medicine, it may with convenience be given
here. The procedure is as follows :—
Every endeavour is made to get the surface of the
tumour clean. A one per cent. solution of lysol in
hot soap water is applied vigorously with a brush,
care being taken to get the cracks and crevices as
clean as possible. This is repeated on the second
day, and then the parts left in dry sterile dressing
till morning of operation. While the anesthetic is
being given, the skin to be removed is rubbed with
Harrington’s Solution, which is essentially a strong
solution of perchloride in acid alcohol; after this
dries the whole region is painted with tincture of
iodine. Should one fear the official tincture, whicb
is seven per cent. in the U.S.P., to be too strong,
it may well be diluted with alcohol to one-half.
This coat of iodine is allowed to thoroughly dry
before the draping is done. The tumour is now
examined, and the limits of the elephantoid tissue
are determined. A long rubber tube is wound
tightly around the base of the tumour and fastened
either by sterile bandages to a belt around the
waist, or is held from slipping by towel clamps in
the skin, one anteriorly in the pubic region, one in
front of the anus, and one on each side, all, of course,
being clamped below the tourniquet. The author likes
this method of holding the tubing much better than
the figure of eight around the waist, as it is neces-
sary to unloosen this after the tumour is removed
before finally closing the wound, and it is hard to
prevent soiling of the wound while the helpers are
doing this. He has had perfect control of hæmor-
rhage by his method.
BEURY P. Y ARD,
| STAT
* “ITY,
26 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1914.
As soon as the tourniquet is applied, a long
sagittal incision is made from a point on pubes in
good skin perpendieularly downward through the
preputial opening along the median raphe to a point
in good skin in the perineum in front of the anus.
This incision is first deepened over the canal where
one expects to find the buried penis, until the pre-
putial mucous membrane is found. As soon as this
is reached, a circular cut separates the prepuce from
the outer layers of elephantoid tissue. There is a
line of cleavage running right down around the penis
to its root, and it is a matter of a few moments
only to thoroughly isolate the penis with its elon-
gated mucous membrane canal forming a kind of
foreskin deprived of its outer cutaneous layer. This
mucous membrane is all carefully preserved, as it
will be very useful in making flaps for the penis.
The next step the author finds is one that makes
the whole procedure safe and easy. Keeping care-
fully to the mid-line, the tumour is boldly bisected
and each half laid over on its respective side. The
testicles are approached from the median aspect,
rather than from primary perpendicular incisions
from the outside as usually recommended. They
are nearer the median line than they are to the
external surface, and the tissue here is far easier
to work in. Carefully going in, the testicles and
cords are one by one isolated, any hydrocele present
being attended to, and then the two testicles are
turned upwards along with the penis till the tumour
is removed. The tumour tissue is separated well
from these three structures, and then working out-
ward towards the skin surface, the elephantoid
tissue is cut away from the perinzum till the skin is
reached. The author thinks that one is able to
tell better, working from inside outwards, where the
skin incisions must be, and as soon as the tumour
is cleared away from the mid-line from the pubes
anteriorly to the anus posteriorly one is ready to
eut through the skin, thus releasing the whole
tumour mass. The author has found it well to usea
large number of clamps, and to clamp first, then
cut.
As soon as hemostasis is complete, the preputial
mucous membrane is slit up as much as is necessary
to turn it back, and is used for a part of the cover-
ing of the penis. The incision is closed horizontally
across the pubie region down to the penis, and
from here downward vertieally, making a T-shaped
closure. The testicles are placed in as normal a
position as possible, and covered over with the flaps
saved from the sides of the tumour. The everted
mucous membrane is stitched to the edges of the
skin, and the normal appearance of the organs after
the operation is surprising.
This method of approach has these advantages.
A minimum amount of work is done from the exter-
nal surface of the tumour inward, and danger of in-
fection is thus lessened. A large part of the work
is done from the mesial surfaees of the bisected
tumour, which are of course sterile. The heavy
tumour has to be lifted very little. As it is cut in
two, it falls apart, and rests between patient’s legs
on the table. Tt is gradually liberated by working
from the mid-line externally, and from before back-
wards, with the tissues to be cut in plain sight, with
good opportunity to clamp every bit of tissue before
cutting, if desired, so that one should have to lose
very little blood. The testicles are easily reached
by blunt dissection with little danger of injury, and
the cords are quickly isolated up as high as desired.
Drains are desirable in cases of this kind where
there is a certainty of much oozing, and abundant
dressings will tend to prevent subsequent infection.
The administration of a urinary antiseptic such as
hexamethylentetramin may help to prevent infec-
tion from spilled urine, and will do no harm. It is
very convenient to have the bowels tied up for
several days after operation.
Before attempting operation it is well to satisfy
one's mind that there is no hernia present. If there
should be, it may be attended to in the usual way
before the serotum is touched, and if there is
reason to hope that the testicle on the other side is in
good condition it is wise to ligate the cord high up
in the ring, remove as much as possible through the
hernial incision, make a tight closure of the
inguinal canal, and finally remove the testicle with
the stump of the cord through the scrotal opening.
It will be very difficult to pull up the testicle from
an elephantoid scrotum through the incision for the
herniotomy, though one may often do this where
castration is desired in other cases.
Parotilis and Malaria.—Myers, of Dominica,
West Indies, describes a case of suppurative paro-
titis in a malarial subject (British Medical
Journal, December 27, 1913). The following are
his notes of the case. On September 11 he was
called in to a case of malaria in a woman. It was of
mixed quotidian and tertian infection, and ran a
fairly high temperature (up to 105° F.). On Septem-
ber 17 the spleen was felt for the first time, and on
the same day the courses came on, but lasted only
one day. On September 20 the right parotid be-
came suddenly inflamed, and remained so, some-
times worse, sometimes better, until October 2,
when the pain, in spite of poultices and other ano-
dyne treatment, became markedly more acute.
There was no fluctuation as usual, and the swel.
ling was definitely confined to the gland. On the
same day, under cocaine (and strychnine) anesthe-
sia, he cut down on to the gland capsule, and
opened the abscess with sinus forceps, evacuating
about 4 oz. of ‘‘laudable’’ pus, and inserted a
drainage tube 14 in. long. The cavity drained well,
and was practically healed by October 10. Mean-
while, under treatment with quinine and arsenic,
the fever ran its usual course.
It should be mentioned that the patient had a
decayed upper bieuspid tooth on the right side,
which may have acted as an exciting cause. The
left parotid showed a very slight inclination to be
troublesome, but this soon subsided.
[There is no evidence that the suppuration had
anything to do with the malarial infection per se.
If the patient had been anemic and cachectic these
conditions might have acted as predisposing factors,
but no mention of these is made in the note. The
two conditions were simply coincident, and the
diseased tooth was evidently the focus from which
the septic infection originated, and passed to the
parotid. ]
Argus and Spirochetes. The Granules of Leish-
man (by E. Marehoux and L. Couvy).—Two
interesting memoirs on the subject of the behaviour
of spirochætes in ticks, by the above-named
authors, have appeared in Nos. 6 and 8 of
the Annales de UlInstitut Pasteur, 1913. In the
first of these the authors give an account of the
development of what may be called the granule
theory of spirochætes. Dutton and Todd were the
first to suggest that in ticks the spirochætes might
have a developmental cycle comparable with that
of certain protozoa. They showed that in Ornitho-
dorus moubata the Spirocheta duttoni fragmented
into granules which eventually appeared in the
Malpighian tubes as small bodies having a diameter
of 1 to 3 microns. They were of opinion that they had
been able to trace the development of these granules
into comma forms which vaguely resembled spiro-
chætes. Leishman some years later drew attention
to the segmentation of the spirochætes in the ticks.
The resulting granules were found in the gut and
cells of the Malpighian tubes. They occurred in the
ovaries and in all the developmental stages of the
tick from the egg to the full-grown adult. In the
larvæ and embryos they occurred in those cells
which were destined to give rise to the Malpighian
tubes. If the ticks are incubated at a temperature
of 849-370 C. the granules elongate, and at the end
of 8-10 days spirochetes appear in the Malpighian
tubes and ceca. The inoculation of mice with the
tissues of ticks, which contain no spirochetes but
only granules, gives rise to an infection of spiro-
chetes. Balfour pointed out that in Argas persicus,
Sp. gallinarum underwent a similar development,
with the result that all the organs of the ticks
became charged with granules which were specially
numerous in the Malpighian tubes. Incubation at
370 C. for a few days was enough to cause the
granules to transform into spirochetes. If, how-
ever, the ticks are maintained at a temperature of
159-209 C. after three or four days from their last
feed all spirochetes have disappeared. Balfour
was successful in producing infection by inoculating
the organs of ticks which contained only granules.
Fantham was able to confirm Leishman’s observa-
tions, and gave a like explanation of the granules.
Blane, however, did not believe the granules to
have any relation with the spirochetes. Hindle
described a cycle for Sp. gallinarum in Argas. After
ingestion by the tick the spirochetes passed through
the gut wall into the body cavity, and thence made
their way to the salivary glands and reproductive
organs. In these organs, as also in the Malpighian
tubes, the spirochetes segmented into granules
(ecorenid bodies). Ineubated at 399 C., these bodies
Jan. 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 27
became transformed into spirochetes. The authors
of the present memoir describe ‘in detail the char-
acters and distribution of the granules in Argas
persicus. In the larval tick they are found in the
Malpighian tubes, and in the adult in these tubes,
and also in the ovaries and in the genital ducts of
both the male and female ticks. The granules are
always intracellular. In the fresh condition a
portion of Malpighian tubes is seen to give out from
its cells, if these are broken, small granular spherical
masses. Coloured in vivo by thionin, methylene
blue, or gentian violet, the substance of the
spheres hardly staining, while the granules are
intensely coloured. These granules are the granules
of Leishman. In dried smears fixed in alcohol the
substance of the masses stains blue with Giemsa
stain, while the granules stain red, but it is in
sections that one ean best study the distribution of
the granules. In the cells of the Malpighian tubes
one notes that the granular spheres replace almost
the entire cytoplasm, leaving, however, the nucleus
uninvolved. In the epithelial cells of the genital
ducts the granules are less numerous. In shape
these are more or less ovoid, but may be bacilliform,
or curved rods, two of which may be arranged
together to form a kind of ring. It is these granules
which are supposed, by the authors quoted above,
to originate from the spirochetes ingested by the
tieks. The authors referred to believe they have
proved this: (1) By infecting animals by inoculating
them with tissues containing only granules; (2)
by tracing the forms connecting the granules with
fully formed spirochetes; and (8) by showing that
the granules are present in all infective ticks.
Marchoux and Couvy have examined these points
and have shown in the first place that it 1s im-
possible to inoeulate granules without at the same
time inoculating spirochetes. In examining for
spirochetes if one relies on Giemsa staining, they
may be apparently absent owing to the lack of in-
tensity of the stain. By employing gentian violet,
the authors have shown that even after a fast of
eleven months at a temperature of 159 C. the
ccelomie fluid of ten ticks still contained spirochetes,
which were, however, very much finer than those
originally ingested.
The experiment was varied by keeping ticks at
changing temperatures (on ice and at laboratory
temperature) for five months. In this case five
ticks still contained spirochetes. An attempt was
made to get rid of the spirochetes by feeding the
ticks on a fowl which had been rendered hyper-
immune to this particular spirochete, but after a fast
of nine months the ticks still contained spirochetes.
No better result was obtained by injecting the
hyper-immune serum directly into the body cavity
of the tick. Thus all attempts at freeing the body
cavity fluid of the ticks from spirochetes were
failures. It was noted that with starvation of the
ticks the spirochetes became much finer, so much
so that they might very readily be overlooked. If
the tick again feeds after starving the spirochetes
commence at once to increase in length and thick-
If, however, the ticks are made to ingest
liess,
28 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 15, 1914.
saline solution instead of blood, the spirochetes do
not change, so that the growth is evidently a matter
of nutrition. It has also been shown that the fine
spirochetes are infective. It is only necessary for
a drop of cælomic fluid of the tick to contain a few
of these fine spirochietes for a typical infection to be
produced when injected into a susceptible animal.
The authors thus prove that in the experiments
quoted above wherein it was supposed that only
granules had been injected, in reality some of these
fine spirochetes had been responsible for the
infection produced.
As regards the passage of spirochetes from the
gut, it has been shown that twenty minutes after a
feed on infected blood numerous normal spirochetes
are present in the cclomie fluid, drawn off by
cutting across one of the limbs of the tick. "Those
spirochetes remaining in the gut undergo a change
whereby the chromatin core becomes segmented.
Contrary to the views held by other writers, the
authors regard this as a purely degenerative change
and not the first stage of reproduction in the tick.
If spirochete blood is kept aseptically in a tube at
289 C. for twenty-four hours, it will be noted that
fragmentation occurs. At 379 C. the fragmentation
oecurs more rapidly, and it takes place also but
more slowly when the blood is kept in ice.
Similar changes can be produced by submitting the
spirochetes to the action of specific anti-spirochste
serum outside the body of the host, and also occur
when spirochetes are ingested by invertebrates other
than their true transmitting host. The granules
into which the spirochetes disintegrate have no
great affinity for the stains, while the granules of
Leishman stain intensely. The authors have never
been able to obtain any evidence that these granules
transform themselves into spirochetes under any
conditions. Further, they do not agglutinate, as do
the spirochetes, when subjected to the action of an
anti-spirochzte serum. In injecting the tissues of
ticks which are heavily charged with granules, in-
fection does not always take place, so that the
authors are led to believe that in those cases in
which an infection has followed, it has not resulted
from the granules, but from spirochetes which have
not been seen.
In tracing the changes undergone by the spiro-
chetes in the intestine of the tick, the authors have
found that by puncturing the dorsum of the tick
an intestinal hernia results, and from this, by means
of a fine pipette, intestinal fluid can be drawn off
for examination. After eighteen hours the majority
of the spirochetes have still their original activity,
though some stain rather faintly and others show
some indication of fragmentation. In twenty-four
hours, in addition to spirochetes still apparently
normal, one observes large masses of agglutinated
organisms. Spirochetes may be observed to rest
with one extremity fixed to some larger object.
During this period of rest the body of the spirochete
appears to attract to itself granules of a refractile
character which are moving in the liquid. These
granules attach themselves to the spirochetes, but
directly there is the slightest movement on the part
of the spirochete or the fluid medium the granule
may give one the appearance of escaping from the
interior of the spirochete. The movements of
many of the spirochetes at this time cease entirely,
and one may observe a veritable lysis of the
organisms. Stained preparations show that at this
period there are many spirochetes with fragmented
chromatin. After the lapse of forty-eight hours the
number of normally motile spirochetes has still
further diminished, but the majority have the frag-
mented chromatin. A great many are evidently
degenerate, and on the bodies of some there are
little swellings like hernia. After three days prac-
tically all the spirochetes are immobile. Some
have still intermittent motility, and some have
entered the red blood corpuscles (of the bird), and
are seen to swim around the nucleus like fish in an
aquarium. In stained preparations one sees numer-
ous scattered granules, some undoubtedly derived
from the spirochetes, but others from the dis-
integrated red cells, so that it is not possible to be
sure of their origin.
After four days the blood ingested has been almost
completely hemolysed, and there are seen abnormal
spirochetes—some fine, others short and stumpy
and very motile, while the spirochetes of normal
dimensions are quite motionless and all frag-
menting. After five days the number of motile
abnormal spirochetes has increased. After six days
the abnormal spirochetes are still present, but show
some tendency to agglutination. In seven days
very few spirochetes are present, while on the
eighth day they have generally disappeared entirely
from the gut. Sometimes, however, the complete
disappearance may not take place till the twelfth
day. After this they never reappear in the ceca
of the gut.
Similar changes in the spirochetes have been
shown to take place in bugs and leeches, which are
not the true hosts of the spirochetes. The spiro-
chetes fragment as they do in the tick, but the
Leishman granules never appear.
The authors then. go on to explain the presence
of the abnormal spirochetes which appear in the
gut after the fourth day. That they have not
returned to the gut from the coelomic fluid is shown
by the following experiments. Ticks were used in
whose ccelomic fluid spirochetes were fairly numer-
ous, but which contained no spirochetes in the
intestinal ceca. The ticks were then fed on a
healthy animal and the gut tapped daily afterwards,
with the result that spirochetes never reappeared
in the gut, as they should have done if they were
able to pass from the celom. The abnormal forms
met with in the gut are thus the result of the
digestive process on the normal spirochetes. During
the process of digestion in the bug and leech similar
abnormal spirochetes appear, us they do also in the
blood which is kept aseptically in tubes. It seems
that these abnormal forms are produced as a result
of defective nutrition, and finally, when the diges-
tive process is nearly complete, they also agglutinate
and perish.
The authors then ask the question as to what
==
— a 3
Jan. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 29
are the granules of Leishman which stain so in-
tensely in contrast to the granules produced by the
fragmentation of the spirochetes. The granules of
Leishman certainly vary in form with the change
of temperature of the tick. At 37° C., after a few
days, many of the granules become rod-like and
may have a length of 2 to 4 microns. After five days
at this temperature no further change takes place,
but some of them have the form of vibrios with a
length of 9 to 11 microns. These changes, which
are produced most readily by warmth, occur also,
but to a less extent, at the lower temperature, 15
to 189 C. Though the granules change in this way
and even show elongation with undulations, it is
impossible to confuse them with spirochetes, into
which they never become transformed. The
granules, whether kept at a low or high tempera-
ture, are not agglutinated by a specific serum, nor
is infection produced in susceptible birds by their
injection, the apparently positive results being ex-
plained by the presence of unrecognized spirochetes.
Though in bugs and leeches the spirochete fragmen-
tation takes place as in the tick, repeated feeds on
infected animals never give rise to the Leishman
granules. Further, these granules exist in many
other animals, and have been found in Argas vesper-
tilionis, Rhipicephalus sanguineus, Dermacentor
reticulatus, Hemaphysalis concinna, Amblyoma
variegatum, Ixodes ricinus, and Lelaps echidninus.
The authors find it difficult to admit with Hindle
that in all these invertebrates the granules have
really originated in spirochetes taken up by these
animals from their vertebrate hosts. They discuss
the possibility of their having a bacterial nature, but
do not favour this view. It is possible they are
mitochondria or pre-secretory granules.
In the second memoir the authors describe ex-
periments undertaken to test the infectivity of the
ticks. It was found that the inoculation of a bird
with the crushings of two infected argas sometimes
produced a typical spirochete infection, but most
usually produced an immunity without infection.
Sometimes the injcction of a minute portion of a
tick is sufficient to render the bird immune to sub-
sequent inoculation. It might be suggested that
this immunity was produced by the injection of
antibodies present in the tick, but this was shown
not to be so by the fact that after filtration through
a porcelain filter the material no longer produced
immunity. This is due to the removal of spiro-
chetes, as is also shown by the feet that the
exposure of the crushed organs of the tick to a
temperature of 55° C. deprives it of its infecting or
immunizing power in the same time as virulent
infected blood loses its infectivity under the same
conditions. The immunity results from a vaccina-
tion, for, working with infected blood, the authors
have found that the intramuscular injection of
20,000 spirochetes will produce infection, 1,700 a
vaccination, while 700 have no effect. By the intra-
venous method 17,000 will produce infection, while
70 will give immunity. Tables giving the details of
the various experiments are appended. Working
with the very susceptible embryo of the chick while
still within the egg it was found that the injection
of thirty spirochetes into the egg produced certain
infection. In the light of these results it was easy
to explain the varying results obtained by the in-
jection of crushed ticks. By a counting method
it was shown that, as with the blood, the result
obtained varied with the number of spirochetes in
the crushed ticks employed. The authors then
examined the method of infection by the tick. In
the Argas, apart from the glands connected with
the sexual organs, there exist two pairs—the
salivary glands and the cephalic glands. The
former open by a duct at the base of the hypostome.
The cephalic glands exist only in the female tick,
and serve to lubricate the eggs at the moment of
laying. The duct opens at the base of the rostrum.
In the Argas coxal glands are absent, and the fluid
which can be obtained by compression of the tick
is really cclomie fluid which has filtered through
a thin chitinous plate. Leishman's view was that
in Ornithodorus moubata at ordinary temperatures
the salivary glands are not infected, but that in-
fection is produced by the secretion from the coxal
glands contaminating the wound. Hindle believed
that neither the salivary nor coxal glands were
responsible, but that infection resulted from. regur-
gitation of gut contents or soiling of the wound with
excreta diluted with the fluid from the coxal gland.
Hindle also showed that spirochetes were present
in the salivary glands six hours after a feed, but
that the spirochetes rapidly disappeared from them,
and were never found after a long fast.
Marchoux and Couvy record experiments whereby
they infected birds by means of ticks which certainly
neither passed excreta nor fluid from coxal or other
gland while feeding. Examining salivary glands of
ticks, they found that only exceptionally were
spirochetes present after a fast of two weeks. But
by careful isolation of the salivary duct they have
discovered that spirochetes are always present in
this, and can be readily seen both by staining or
by the ultra-microscope even after prolonged starva-
tion. If, however, before dissection the tick is
allowed to feed it will be found that practically all
the spirochetes have disappeared from the salivary
duct. A few days later, however, spirochetes
become numerous in the acini of the gland. They
again disappear from the gland and pass into the
salivary duct, where they accumulate and attain
their maximum on the tenth to fourteenth day.
By repeated feeding the number of spirochetes
increases, so that a tick in whose salivary duct there
may have been too few spirochetes. to produce
infection at the first feed with multiplication of
these the tick may become infective at a subse-
quent feed, for, as already shown, the result
depends directly on the number of spirochetes
injected.
In addition to spirochetes in the salivary appara-
tus others are constantly present in the cephalic
glands, the secretion from whieh lubricates the
eggs at the time of laying. It was thought that
herein was an explanation of the hereditary trans-
mission of spirochetosis in the tick. It was easy to
demonstrate that spirochetes could pass through the
egg membranes by plunging freshly laid eggs into
infected blood, so that egg infection is most prob-
ably produced by the infected fluid from the cephalic
glands. This would account for the irregularity in
the egg infections. The spirochetes in the eggs are
often very fine and difficult to see. Injected into
birds twenty eggs were able to produce immunity,
but not infection; but two eggs injected into the
more susceptible embryo chick produced infection.
By a most careful examination of eggs it was found
that two out of five contained each more than
thirty spirochetes. The authors believe that within
the egg, as in the cclomic fluid, there exist beyond
the spirochetes that are visible others that are still
finer and invisible.
The conclusions are as follows : —
(1) The injection of a uniform quantity of crushed
tick gives sometimes infection, sometimes im-
munity.
(2) The infecting power depends on the number
of spirochetes in the tick.
(3) It is possible to measure the various doses—
infecting, vaccinating, inactive.
(4) All the, organs of the tick are invaded by
spirochetes.
(5) The spirochetes pass from the cclom into the
acini of the salivary glands, and thence into the
salivary duct.
(6) The salivary fluid is the vehicle of infection.
(7) Spirochetes occur in large quantity in the
cephalic glands, and are able to pass through the
chitinous membrane of the egg.
(8) The eggs of Argas contain spirochetes. A
single one may contain as many as thirty.
——— 9——————
Drugs and Appliances.
“Zana Barus,” prepared by immersing the
aerating cushions supplied by the Hygienic Com-
pany, Ltd., 36, Southwark Bridge Road, London,
S.E., are an excellent substitute for the Nauheim
Bath. Nascent earbonie acid gas is liberated in
the bath. For use in the Tropies the Zana bath
is not only most refreshing at all times, but in many
skin affections, such as priekly heat, in which the
use of soap is deleterious, the Zana Bath is sooth-
ing and curative.
Peat Propucrs (SPHaAGNOL) in the form of
soup and ointment, have proved useful as a
preventive and a means of alleviating prickly
heat. For the bites of mosquitoes, sand-flies, and
other tropical pests of the kind the preparations are
efficacious in relieving the irritation. For dhobie
itch and the skin affections due to excessive per-
spiration, attacking especially the axilla and peri-
neum, Sphagnol in its several forms as ointment,
soup, and sphagnoline (an emollient toilet cream)
is useful. Peat Products (Sphagnol), Ltd., 18,
80 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 15, 1914.
Queenhithe, Upper Thames Street, London, E.C.,
supply these preparations.
Uner. '' CycLororm ’’ Co. (Bayer), supplied by The
Bayer Co., Ltd., 19, St. Dunstan’s Hill, London,
E.C., is a derivative of benzoic acid and extract of
witch-hazel, possessing anesthetic, antiseptic, and
astringent properties. It is useful in pruritic affec-
tions of the vulva, whether due to old age or diabetes,
and has a beneficial effect on congested and painful
piles. In excoriations of the anus, and in the irrita-
tions of the anus and rectum associated with
dysentery and the later stages of sprue, the oint-
ment helps to allay the agony which frequently
obtains.
Messrs. BurrouGHs WELLCOME AND Co.'s ex-
hibition of drugs was a prominent feature at the
Congress of the Far Eastern Association of Tropical
Medicine, held at Saigon, in November (8 to 15),
1913. Especially noticeable was the equipment
for the treatment of cholera, consisting of a com-
pact and thoroughly practical outfit adapted to
carry out the method of transfusion of hypertonie
saline solutions devised and applied by Major
Leonard Rogers. ''Tabloids ” containing suitable
doses of emetine hydrochloride for use in dysentery,
hepatitis and threatened liver abscess, and a sterile
solution—‘‘ Vaporole °’ emetine hydrochloride in her-
metically sealed containers ready for immediate
injection—engaged the close attention of those prac-
tising medicine in the Tropics. A variety of
‘tabloid °’ medicine chests and cases and first-aid
equipments proved attractive to travellers and
others in the Far East.
Hypopuysen Extract (Schering), a preparation of
the fresh glandular substance of the infundibular
part of the pituitary gland, made up in ampoules
containing 8 and 15 minims each, for hypodermic
use, is efficacious in several uterine derangements.
In insufficiency of labour pains, in post partum
hemorrhage, and as a hemostatic in menorrhagia,
hypophysen acts promptly and efficaciously.
Schering’s preparation is obtainable from A. and M.
Zimmermann, 8, Lloyd’s Avenue, London, E.C.
“ BysiN "" AMARA, the well-known preparation by
Messrs. Allen and Hanburys, 37, Lombard Street,
London, E.C., must especially commend itself to
practitioners in the Tropics in cases of convalescence
after illness and on recovery from an attack of
malaria. Its composition: Quinine phosphate,
gr. 13; iron phosphate, gr. 2; nux vomica alkaloids
equal to strychnine phosphate, gr. 1-16th; and
'" Bynin " liquid malt, 1 oz. Dose: a dessert to a
tablespoonful thrice daily before meals.
CvsTOPURIN.—A. Wulfing and Co., 12, Chenies
Street, London, have introduced Cystopurin as it
means of treatment for affections of the urinary
tract. It is a modified form of hexamethylene-
tetramine (a compound built up of formaldehyde
and ammonia). Cystopurin is un addition product
of hexamethylene-tetramine and sodium acetate
in the proportion of 1: 2—a molecular hydrated
combination. It is put up in 15-gr. tablets.
Jan. 15,1914.) -
THE JOURNAL OF.TROPICAL MEDICINE. AND HYGIENE. 31
It is claimed for Cystopurin that it ‘clears up
cloudy and offensive urines; bacteria in the urine
are killed, and gonorrhea and its complications
are. beneficially affected. We can endorse the
claims put forward for Cystopurin by practical
clinical experience of this remedy. |:
Cop-Liver’ Or PmrPARATIONS.—Messrs. Allen
and Hanburys, 87, Lombard Street, London,
E.C., issue special. circulars concerning their
preparations of. cod-liver oil. The excellence: of
these is well known. The plain cod-liver oil is
made as nearly tasteless as possible; the Allenburys
malt and cod-liver oil preparation known as ''Bynol"'
is an elegant combination of these two most nutri-
tive agencies in whieh the taste of the oil is com-
pletely covered; and '' Bynin " emulsion contains,
in addition to oil and malt, hypophosphites of lime
and soda. ‘‘ Bynin ” is a. liquid malt preparation,
and Messrs. Allen and Hanburys have combined it
with many drugs and assigned a name to each sig-
nifieant of the principal ingredients of the combina-
tion; thus: Bynin amara contains nux vomiea in
suitable dosage; B. cascara contains cascara sagrada
and rhamnus frangula; B. formates, formates of
iron, lime and soda; B. glycerophosphates include
iron, lime, potash, magnesia and soda glycerophos-
phates. Besides these we find Bynin Hemoglobin ;
B. hypophosphites; B. lecithin; B. pancreatin; B.
pepsin; B. phosphates; B. plasma and others.
Each and all of these preparations have their
several uses in individual cases of illness, and all
have proved efficacious and reliable compounds.
——À M
Hebviews.
A MANUAL OF PRACTICAL CHEMISTRY FOR PUBLIC
HraALTH Srupents. Especially arranged for
those studying for the D.P.H. By Alan W.
Stewart, D.Sc., Assistant Demonstrator of
Chemistry at the Royal Institute of Public
Health, London. 3s. 6d. John Bale, Sons
and Danielsson, Ltd., Oxford House, 83-91,
Great Titchfield Street, Oxford Street, W. 1913.
Practical chemistry being one of the most
important subjects for public health students, it is
essential that they should possess a suitable manual
on the subject. Dr. Stewart has therefore designed
a little book to supply in a concise manner the '
necessary practical chemical exercises for D.P.H.
students. It has been his aim to produce a cheap
book which shall also be as complete as is required
by students for the D.P.H., for whom it has been
especially written. Though a manual, it contains
all that is required, as the table of contents shows.
Part I deals with acidimetry and alkalimetry. Part
II with air analysis, estimation of oxygen in air,
estimation of carbonic acid in air, the detection of
poisonous gases. Part III, with water analysis,
sewage and sewage effluents. Part IV with
analysis of foods and beverages, analysis of milk,
butter, coffee and chicory, flour, beer, spirits.
Part V with disinfectants and preservatives, esti-
mation of carbolie acid in carbolie powder, esti-
mation of salicylic acid in‘ lime juice, tests for
disinfectants: and preservatives.. Part VI with
microscopical work; and then there are remarks on
useful data and examination questions.
The book should certainly prove useful to the
class of student for whom it.is intended. The in-
formation is well put together, and as the manual
is small it`can. easily be carried about in the pocket
and used as opportunity arises.
It is unfortunate that there is such a large list
of errata, no fewer than nine of these, some very
important, appearing before the first chapter.
These, of course, will be suitably dealt with when
the book runs to a second edition, which we have
no doubt it will soon do. The manual may be
thoroughly recommended for publie health students
in general and especially for those going in for the
D.P.H. diploma.
Tne MEpicAL '"* Wno's Wuo" For 1914. Crown
8vo., pp. 812, xxv. 10s. 6d. net. The London
and Counties Press Association, Ltd., 89, King
Street, W.C.
From the preface we learn this is the third issue
of this bulky volume, and it may therefore be
assumed it has filled a niche and found a recognized
place on the shelves of many professional and non-
professional people. In addition to much of the
information which appears in Churchill's Medical
Directory, it contains various other particulars, such
as speciality, recreation, clubs, &c., and in some
cases a short résumé of work done and posts occu-
pied. We judge the volume contains somewhere
about 7,000 names; if the whole 40,000 names, or
thereabouts, of the members of the profession are
included, as we infer the publishers are prepared
to do, unless something is done to keep the informa-
tion within bounds the bulk of the volume will be
appalling.
——9Ó—————
Hotes and "Reus.
MOSQUITO DESTRUCTION IN
QUEENSLAND.
Sratistics prepared by the Health Department
show that during the week ended October 11 the
mosquito squad oiled some 39,110 square yds. of
natural breeding places. These included 10
swamps and 13 other collections of water; 317
houses were inspected, with the result that only
68 properly screened tanks were found; 277 tanks
were not screened; 2 pools of water were found
to be breeding mosquitoes on private premises;
92 houses were re-inspected, and 55 tanks found to
have been screened, 4 wells drained, and 6 tanks
removed.
32 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Personal Hotes.
INDIA OFFICE.
From November 8 to December 13.
Arrivals Reported in London.—Lieutenant-Colonel G. B.
Irvine, I.M.S. ; Major W. H. C. Forster, I. M.S. ; Captain F. H.
Salisbury, I.M.S.; Captain J. O'Leary, I.M.S.; Lieutenant-
Colonel P. B. Haig, I.M.S.; Captain V. N. Whitamore, I.M.S. ;
Captain S. S. Vazifdar, I.M.S.; Major J. K.S. Fleming, I. M.S.;
Captain W. S. J. Shaw, I.M.S.; Lieutenant-Colonel J. H.
Hulbert, I.M.S.; Major D. McCoy, LM.S.; Captain C. L.
Dunn, I.M.S8.
Extensions of Leave.—Lieutenant-Colonel G. Bidie, M.D.,
F.R.C.S.E., I.M.8., 4 d. ; Captain J. Woods, I.M.S., 14 d.;
Captain N. N. G. C. MoVean, I.M.S., 4 m., M.C.
Permitted to Return.— Captain W. P. G. Williams, I.M.S.
List OF InpIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Heriz-Smith, Lieutenant G. V., I.M.S., to October 5, 1914.
Irvine, Lieutenant-Colonel G.B., I. M.S., to October 14, 1914.
Nauth, Lieutenant-Colonel B., I.M.S.
O'Leary, Captain J., I. M.S.
Pilgrim, Lieutenant-Colonel H. W., I.M.S., to May 10, 1914.
Roe, Colonel R. B., I. M.8.
Salisbury, Captain F. H., I.M.S.
Shand, Captain J. G. B., I.M.S., to January 24, 1914.
Shortt, Captain H. E., I.M.S.
Veale, Lieutenant P. J., I.M.S., to June 8, 1914.
Vazifdar, Captain S. S., I.M.S., to October 19, 1914.
Whitamore, Captain V. N., I.M.S.
Durham, Lieutenant W. R., I.S.M.D., to April 80, 1914.
Fleming, Major J, K. S., I.M.S.
Stevenson, Surgeon-General H. W., C.S.I., I. M.S., to Janu-
ary 10, 1914.
List oF ĪNDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULES).
Showing the Name, Province, and Department, and the Period
for, and. Date from, which the Leave was granted.
Crossle, Captain H., I.M.S , N.-W. F. Prov.
Fayrer, Major F. D. S., I. M.S.
Forster, Major W. H. C., I. M.S., 24 m., October 10, 1913.
Haig, Lieutenant-Colonel P. B., I.M.S.
Morgan, Major E. J., I. M.S.
Pridmore, Lieutenant-Colonel W. G., I.M.S., Burma, 24 m.,
December 11, 1912.
Rainier, Major N. R. J., I.M.S.
Stevenson, Captain W. D. H., I.M.S,, Bo. Bacteriological
Laboratory.
Shaw, Captain W. 8. J., I.M.S.
COLONIAL MEDICAL SERVICES.
West African Medical Staf.
December 4, 1913.
Deaths.—None.
Transfers.—K. McGahey, L.R.C.S. & P.Edin., L.F.P.S.
(Glas.), D.P.H.Ireland, Medical Officer, Northern Nigeria, has
been appoiuted Senior Sanitary Officer in Coylon.
Resignations,—None.
Retirements.—P. H. Macdonald, M.B., C.M, Edin., Medical
Officer, Southern Nigeria, retires on pension; R. C. Hiscox,
L.R.C.S. & P.Edin., L.F.P.S.Glas, M.D., C.M.Toronto,
D.T.M.Liverpool, Medical Officer, Southern Nigeria, retires on
pension; M. W. Manuk, M.B., C.M.Edin., D.T.M.Liverpool,
retires on pension; J. D. Finlay, M.B., C.M.Glas., Medical
Ofticer, Southern Nigeria, retires with a gratuity,
New Appointments.—The following gentlemen have been
selected for appointment to the Staff: W. E. Glover, M.B.,
Ch.B.Aberdeen, D.T.M. & H.Camb., Southern Nigeria; H.
H. Stewart, M.B., B.S.Edin., Southern Nigeria; W. E. S.
(Jan. 15, 1914.
Digby, M.R.C.S.Eng., L.R.C.P.Lond., Northern Nigeria;
J. W. B. Hanington, M.D., C.M. McGill Univ., M.C.P.S.
Newfoundland, M.R.C.S.Eng., L.R.C.P.Lond., Northern
Nigeria; C. R. Patton, M.B., Ch.B.Edin., Gold Coast; H.
McC. Hanschell, M.R.C.S.Eng., L.R.C.P.Lond., D.T.M.Liver-
pool, D.T.M. and H. Cambridge, Gold Coast; R. H. Miller,
M.R.C.S.Eng., L.R.C.P.Lond., M.R.O. V.S. Edin., Gambia.
Other Colonies and Protectorates.—R. F. Russell, M.B., B.Ch.
Aberdeen, has been selected for appointment as a supernumerary
medical officer, Jamaica.
W. Tudhope M.B., Ch.B.Glas., E. N. Russell, M.B., B.C.,
B.A. (Cantab), M.R.C.S.Eng., L.R.C.P.Lond., H. H. V. Welch,
M.B.,B.S.Lond., M.R.C.S. Eng., L.R.C.P. Lond., and F. Collar,
M.R.C.S.Eng., L.R.C.P.Lond., have been selected for appoint-
ment as temporary medical officers, East Africa Protectorate.
H. W. Catto, M.B., B.8. Lond., M.R.C.S. Eng., L.R.C.P.
Lond., has been selected for appointment as an Assistant
Paotoriologiek and Pathologist in the Medical Department of
amaica.
— — ———
Recent and Current Literature.
A list of recent publications and articles bearing on tropical
diseases is given below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of THE JOURNAL OF TROPICAL MEDICINE AND
HyGiENE will be pleased, when possible, to send, on appli-
cation, the medical journals in which the articles appear.
Bulletin of Entomological Research.—The November
number of the Bulletin (vol. iv, Part 8, pp. 151-254) contains
the following papers: * A Proposed Method of Controlling
the Ravages of Leaf-eating Caterpillars,” by G. C. Dudgeon.
* New Synonymy in Oriental Culicide,”’ by F. W. Edwards.
“A List of Uganda Coccide and their Food.plants," by
C. C. Gowdey. ‘Entomological Pests and Problems of
Southern Nigeria" (Plates xxiii-xxviii), by A. D. Peacock.
“Entomological Research in British West Africa—IV.
Sierra Leone " (Plates xviii-xxii and map), by J. J. Simpson.
———— 9 —————
ERRATUM.
OwriNG to a regrettable printer's error '' British
Guinea " was unfortunately inserted for '' British
Guiana '' in THE JOURNAL OF TROPICAL MEDICINE AND
HyeiENE, November 15, 19018. The title of Minett
and Field's paper should therefore have read:
" Notes on a Case of Dermal Leishmaniasis in
British Guiana," and not in '' British Guinea.”
Dr. Wise, of British Guiana, has written pointing
out the error as being misleading and unfortunate.
Hlotices to Correspondents.
1.—Manuscripts if not accepted will be returned.
2.—4As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4,—Authors desiring reprints of their communications to THE
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers,
5.—Correspondents should look for replies under the heading
tt Answers to Correspondents."
Feb- 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 3, Vol. XVII.
Original Communications.
NOTE OF A CASE OF LIVER ABSCESS
TREATED WITHOUT OPERATION.
By J. BELL.
Superintendent, Civil Hospital, Hong Kong.
A. D., acep 26, European, was admitted to
hospital suffering from fever. He had had a slight
attack of dysentery two months previously.
His liver was considerably enlarged, especially
upwards, with tenderness on pressure, and pain in
the right shoulder.
The temperature continued for several days, and
was of the hectic type.
As there was no improvement in his condition,
Dr. Moore, Assistant Superintendent, examined the
liver with an aspirating trocar, and the first punc-
ture showed pus of the typical kind.
Nothing further was done, but the patient was put
on a daily injection of emetine $ gr., and under this
treatment all the symptoms cleared up rapidly, and
the patient is now—six months afterwards—well
and at work.
Remarks.—This case is reported as the emetine
treatment of dysentery, and liver abscess does not
scem to have received the recognition it deserves
(vide JOURNAL oF TROPICAL MEDICINE AND HYGIENE,
November 15, 1913, p. 345).
We have since had two typical cases of amebic
liver abscess, both of which have recovered without
any treatment but injections of emetine.
PSITTACOSIS.
By T. P. BEpposs, F.R.C.S.
(Psittacosis—from the Greek word, psittacos, a
parrot.)
Ir fell to my lot, in 1893, to be called in consulta-
tion to an aunt and niece with symptoms of pneu-
monia. The history was that the brother of the
younger patient, an officer of a tramp steamer, had
brought home a parrot, which had been with other
parrots under the care of the sailors. One sailor
was said to have been sent to hospital at Bordeaux
with supposed typhoid fever. A second had been
admitted to hospital at Liverpool with supposed
typhoid.
The account given was that, on arriving at the
house a fortnight before, the parrot seemed out of
condition, but never at any time likely to die.
When the two patients became ill, a week before,
the bird was killed and the body disposed of. This
was done because the two sailors had been sent to
hospital from the ship and other sailors were out of
health on arrival. Also, the ship’s officer believed
that disease could be carried from parrots , to
humans.
Both my patients had symptoms of pneumonia,
slight expectoration, not prune-juice-tinted or blood-
tinged. The special feature of the case was the
marked prostration. The aunt, aged about 70, died;
the niece, aged 30, recovered.
The only bacteriological examination was for
tubercle, not found.
The evidence that it was an infection from a parrot
caused me to watch for all accounts of similar cases.
At various times epidemics of psittacosis have been
described in Continental literature; the causative
bacillus, B. psittacosis, discovered by Nocard in
1892, is known to English pathologists. (Hewlett,
** Manual of Bacteriology,” Second Edition, p. 381;
Hayes, vol ii, p. 271.) It belongs to the Gärtner
group of paratyphoid bacilli.
A good account of the disease is that of Gilbert
and Fournier, in ‘‘ Nouveau Traité de Médecine et
de Thérapeutique,” in the volume devoted to
‘ Diseases Common to Man and Animals." These
authors isolated the bacillus from humans in Paris,
in 1897, during an important and fatal epidemic
resembling typhoid fever, with early and rapidly
developing severe lung complications. Cases are
recorded of transmission of the disease from man
to man.
The average incubation period is eight or nine
days. The onset occurs with weakness, shivering,
loss of appetite, nausea, intense headache, vomiting,
bleeding from the nose and slight diarrhea. Sore
throat and membranous stomatitis have been
noticed.
In four or five days, sometimes as early as
forty-eight hours, the temperature reaches 399 C.
(102-29 F.) to 419 C. (105:89 F.) and remains at that
level with but slight morning remission.
Thirst, nausea and. vomiting persist; intestinal
troubles are often almost absent; the abdomen re-
muins flat, there is no gurgling in the iliac regions,
constipation is marked. The urine is scanty, highly
coloured, and often contains a large amount of
albumin. The patients are distinctly prostrated,
with either stupor or more commonly muttering, or
continued delirium.
In the lungs there is general bronchitis with basic
congestion, broncho-pneumonia, pneumonia with or
without pleurisy. These symptoms are early and
constant. By their intensity and extent they are
the main eause of death. Partly by direct action,
as well as their effect on the heart and circulation,
they cause a fatal termination in a third of the cases,
with a temperature of 419 C. (105:89 F.) or over,
marked dyspnoea and terminal coma occurs usually
in the second or third week. The prognosis is
always serious, especially in the aged, and when
there is pre-existing heart or kidney trouble, obesity
or diabetes.
Diagnosis of psittacosis is difficult clinically in
cases without a history of association with parrots,
except in epidemics. It is apt to be confused with
influenza having pulmonary complications and with
other paratyphoid infections.
The bacillus is short, with rounded ends, motile
with 10 to 12 flagella, aerobic and anaerobic, easily
cultivated on the usual media, not liquefying
gelatine, easily coloured and Gram-negative. Does
[Feb. 2, 1914.
34 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
not coagulate milk or produce indol.
gelatine and on potato.
One drop of culture is fatal to parrots in ten to
twelve hours. Mice, rabbits and pigeons are equally
susceptible; guinea-pigs and dogs are more resistant.
Parrots are easily affected by placing in their cages
the wings of those that have died of the disease,
and by moistening their food with infected culture
media. The bacillus long retains its vitality and
virulence in dead animals and in culture media.
Infected parrots sit huddled up and motionless
on their perches, with their feathers ruffled and
wings drooping. They suffer from diarrhea, refuse
their food and are in a constant state of drowsiness.
In parrots the bacillus is found in the blood,
viscera, in the intestine and bone marrow. The
dejeeta are especially dangerous, on account of the
number of bacilli they contain. In man it is found
post mortem in the heart blood. The agglutinating
power in man is feeble (1 in 10 to 1 in 60), it varies
with the stage of the disease and soon disappears.
It is more marked in animals slightly affected.
Typhoid serum slightly agglutinates the B. psitta-
COSIS.
The treatment should be conducted on general
principles, as in other typhoid conditions, especial
precautions being taken to guard against pulmonary
complications.
It grows on
TREATMENT OF CHRONIC ULCERS OF THE
LEG WITH FROG FLESH POULTICE.
Note by Lim Boon Kena, M.B.Edin.
IN a tropical practice, especially in connection with
mining or planting operations, the rapid treatment of
ulcers of the legs assumes an economic importance
not to be neglected. For many reasons neither the
coolies nor the employers of labour like the rest in
bed which is so conducive to rapid recovery. Ex-
perience teaches that as soon as pain has subsided
most coolies prefer to return to work, with the result
that simple ulcers become chronic and callous and
take months to heal.
The present writer has treated quite a number of
chronic ulcers with a cold poultice made from the
flesh of freshly killed frogs. Pain and irritation sub-
side in a couple of days, and new skin and healthy
granulations grow rapidly. Even the chronic ulcers
of tubercular leprosy yield to this simple treatment:
in one case reported by me fifteen years ago to the
local branch of the British Medical Association, the
leprous sores on the malleoli of both legs healed up
completely in three or four months after having
resisted antiseptic and other treatment for years at
the hands of the élite of the local profession. Rest
was not insisted on in any of my cases.
The Procedure.—Thoroughly cleanse the ulcer with
sterilized water so as to exclude the possibility of a
claim that antiseptics used may have an effect on the
future cure.
Kill two or three large frogs (Rana esculenta), re-
move the skin, having previously washed the animals
insterilized water. Remove the head with the mouth,
pharynx and intestinal organs with stout scissors and
remove the flesh from the femora and back. Pound
the flesh in a clean mortar and spread on muslin and
apply to the sore. Sometimes I have used the bones
too.
The Rationale.—The explanation of the clinical fact
has not been worked out in detail. What part the
frog serum or the white cells of the frog blood play in
the healing process I have not had time to investigate;
but the suecesses indicate that the application stops
bacterial activity and enables the reparative process
to proceed without hindrance.
———— Á9————
Cholera Bacilli in the Lung.—Greig (Indian
Journal of Medical Research, vol. i, No. 2, October,
1913) reports the cultivation of the comma bacillus
from the lungs in a ease of cholera. This, as the
author states, supports the view that the blood is
invaded by the cholera germs in a certain percentage
of cases of that disease. After invasion of the blood
the distribution of the cholera vibrio in the tissues
becomes extended greatly, und consequently the
possible channels of escape from the body will be
increased. The latter circumstance makes it all
important particularly from the point of view of
prevention of cholera to collect as much information
as possible in regard to blood infection by the cholera
vibrio. It may be mentioned, in support of the
proposition that a blood infection occurs in cholera,
that the comma bacillus is eliminated by the
kidneys and leaves the body in the urine. It was
shown recently by the author that the cholera vibrio
occurs in the urine of a certain number of patients
suffering and convalescent from cholera. In the
present case sections of the kidneys were made and
the presence of an organism having the mor-
phological characters of the comma bacillus was
demonstrated in them.
As Greig has previously shown, the cholera vibrio
is found frequently in the bile of fatal cases of
cholera. In the present cases a culture on ordinary
agar was made from the bile, with aseptic pre-
cautions, and the cholera vibrio was shown, by the
usual tests, to be present. The discovery of the
cholera vibrio in the bile of this case raises the
interesting questions as to whether the organism
reached the bile via the blood-stream, or whether
it gained access to it from the alimentary tract, via
the bile-duct. In a future communication dealing
with his experimental and historical researches on
the gall-bladder and biliary passages in cholera
Greig will refer to this important question again.
Beriberi in New Jersey (Medical Record, January
17, 1914).—A report from Surgeon-General Blue, of
the Public Health Service, shows that during the
last three years there have occurred in the county
jail at Elizabeth, N.J., twenty-two cases of beri-
beri. The investigation showed that at one time
all of the inmates of the jail who were serving sen-
tences of over sixty days had contracted the disease.
Feb. 2, 1914.]
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THE JOURNAL OF
Tropical Medicine and Hpgtene
FEBRUARY 2, 1914.
IMPORTANCE OF STUDYING THE MINERAL
CONSTITUENTS OF OUR FOOD.
MINERAL substances in our foodstuffs have been
neglected in their importance for the organic sub-
stances, such as proteids, fats, &c., yet there is
little doubt that they are as' important as are their
organic associates in the dietary of man and animals.
The tendency is—nay, it is the rule—that our food-
stuffs are tampered with in some fashion by manu-
facturers and traders, and if this interference with
natural food is to continue, which to all appearances
it must, it behoves us to determine in what way the
artificial food is to prove most satisfactory. Rightly
or wrongly beriberi, for instance, is ascribed to rice,
but at any rate it does seem proved that the sub-
stitution of unhusked rice for polished rice acts as
a preventive or a cure.
We may also cite the present condition of wheat
flour in our markets. Some twenty-five years ago
the producers of flour substituted the '' rolling ” in
place of the old ''milling'"' process, and whilst
thereby helping to add to the whiteness of flour, the
flour was detrimentally affected in its nutritive value
by the exclusion of important mineral constituents.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 35
This desire for white flour has even gone further,
and much of the '' fine white ’’ flour exposed for sale
has had its value as a food agent impaired by a
process of bleaching by such agents as the trader
may select. Inferior rice also has its defects
eaused by placing it along with some substances
calculated to give a gloss, such as paraffin and talc
in specially constructed revolving drums. It is
easy to enumerate other detrimental processes
applied to almost every food and drink on our tables,
including sweets, jams, wines, &c., so that, whether
by omissions of useful ingredients from our food,
or by the addition of unwholesome substances or
salts, soluble or insoluble in their nature, the sins
of omission and commission of present-day traders
are many and widespread. Proteins, fats, and
carbohydrates in the lists of manufacturers’ adver-
tisements are given due prominence, whilst the salts
necessary to their digestion are neglected for the
most part, or when salts are added it is more than
doubtful that they are selected on any real scientific
basis, but rather in an empirical fashion, for which
there is but little or no justification. Yet the im-
portance of the minerals in our food, be it fluid
or solid, is incontestable. Experiments show that
certain bacteria require special media for cultivation,
that certain marine animals can thrive only in
certain places of the ocean, and that by depriving
the sea water of particular salts of, say, potas-
sium the animals die. Deprive the child of certain
salts and rickets ensue; supply the necessary
ingredients and the condition disappears. In the
same way the power of resisting disease, be it in
temperate or tropical climates, is largely dependent
upon the food supplied, and the salts necessary for
the maintenance of health play a part as important
as any other constituent. To no section of the
community is this question of '' composite '" food
of more importance than to the European in the
Tropics. In many parts tinned foods are the sole
diet, and in several parts of the West Coast, what
are called the unhealthy parts, is this the case; and
there can be no doubt that the unhealthiness is
largely due to the loss of the resisting powers being
lowered by the deprivation of some ingredient in the
food supplied. What that is we have to rely
upon experience rather than upon chemical know-
ledge owing to want of investigation of the salts
necessary. Why one tribe of natives attains
dominance over its neighbours is usually attributed
to disease, and quite rightly so when the matter
is studied superficially; but were the matter sifted
more deeply the supremacy would be found to be
due to the powers of a certain tribe to resist disease,
and this power may as often as not be due not so
much to the presence of certain carriers of disease,
but to the presence of certain qualities of their food.
The soil, therefore, has to be studied, the soluble
salts in the water, the fruits and the vegetables
have to be sought for if truly scientific conclusions
are to be arrived at to account for the geographical
distribution and prevalence of disease. This inquiry
need not in the first instance be a world-wide
inquiry; for the individual inquirer, the practitioner
36 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 2, 1914.
in the Tropics can even within a restricted area be
able to give us valuable information; an even
cursory inspection of the difference in the soil,
water, food, and fruits used by adjacent peoples who
show one the proclivity to excel and the other to
degenerate would advance this subject and help to
place it on a basis from which more extended
inquiry could be made. We are now aware that
disease accounts for the disappearance of the
physical and mental efficiency and supremacy of
any race or nation, but let us go further and try to
determine if the inroad of that disease was not due
to some change in their power of resistance, be it in
soil or food; and this can only be accomplished by
endeavouring to find what constituent is wanting
and how it can be scientifically supplied to prevent
the physical deterioration consequent upon its de-
ficiency. In our day we have seen the teeth of the
peoples of Northern Europe, at any rate, decay in
a manner which is certain to end in disaster; for no
nation can rear a healthy race with decayed teeth
in their jaws; directly and indirectly they lead to
ill-health, to a digestion which is faulty, and which
means to succeeding generations a physical decay
which must lead to loss of supremacy in the affairs
of the world. What constituent in our food is
wanting to induce decay in teeth it is the réle of our
physiologists to tell us; for dentists seem taken up
too much with patching up the effects of decay to
deal with the matter scientifically and to help us
to apply preventive measures for this serious
calamity of our generation.
Tur reprint of Dr. Castellani’s methods of pre-
paring and administering anti-typhoid vaccine is
more than justified ; for those of us who have been
giving anti-typhoid vaccine to young men and women
proceeding from Britain to the Tropies have been
disappointed to hear at a subsequent date that those
who have been considered sufficiently protected
against the disease have been attacked by typhoid
with more or less severity. Young men proceeding
to India to take up appointments in the Indian
Civil Service are all *' protected ' nowadays against
typhoid, yet it not infrequently occurs that these
men are attacked by a ‘‘ four-week fever” within,
say, one to six months of their arrival in India. They
are popularly considered to have suffered from an
‘initial’ or ‘* baptismal ”’ fever.” Itis not popularly
regarded as either typhoid or malaria, the sym-
ptoms being irregular, and the febrile attack takes
a course characteristic of neither disease. One is
free to surmise, although there is no definite proof
to hand, that it is a modified typhoid or paratyphoid
that produces the '' initial " fever referred to, and
such being the ease, the explanation given by Dr.
Castellani may be the correct one. The question,
moreover, of local strains of the bacilli comes te
the front in the matter, although scientific pro-
nouncements for the moment are against it. In a
recent issue of this Journal the question of local
strain was referred to, and mention was made of
the fact that men who had had typhoid fever in
England did within twelve months of their going
to South Africa during the war contract the disease
there, indicating that a recent attack of typical
typhoid did not afford protection against the South
African strain. The question cannot rest where it
is, and we would welcome reports from medical
men in different parts of the world as to their
experiences of typhoid or '' typhoid-like ’’ infection
amongst the young men or women who have been
inoculated by true typhoid vaccine or with a mixed
typhoid and paratyphoid vaccine before leaving
British shores.
—————J,9————
Reprint.
TYPHOID-PARATYPHOID VACCINATION
WITH MIXED VACCINES.
By ALpo CASTELLANI, M.D.
Director Government Clinic for Tropical Diseases, Colombo
(Ceylon).
ConsIDERING the fairly frequent occurrences of
paratyphoid A and paratyphoid B in tropical
regions—at least in Ceylon and India—I have since
several years advocated the use of a mixed vaecine—
viz.: Typhoid + paratyphoid A + paratyphoid B—
instead of the usual simple typhoid vaccine. Notes
on the subject of mixed vaccines may be found in
my old publications in the Centr. für Bakteriologie
(1909), in the Transactions of the Bombay Medical
Congress (1909), in the Ceylon Medical Reports,
and in various recent communications.
My belief in the possibility of an efficient mixed
vaccine being produced was based on the experi-
ments I carried out in Bonn, while working under
Professor Kruse, during the years 1901 and 1902.
I demonstrated then (see Zeit. für Hygiene, 1902)
that by inoeulating an animal with two different
bacteria at the same time, the blood produced
agglutinins and immune bodies for both, and that
provided a sufficient minimum quantity had been
inoculated, the amount of agglutinins and immune
bodies for each germ was about the same as in the
animals inoeulated with one germ only. I demon-
strated that even inoculating a rabbit with three
different micro-organisms (B. typhosus B+
pseudo-dysentericus No. 1 (Kruse) + strain of
B. coli communis, the amount of agglutinins and
protective bodies elaborated for each germ was
nearly the same as in animals respectively
inoculated with one germ only. During the course
of these experiments I was able to confirm that
when the immunization is obtained by a single
inoculation, provided the minimum dose sufficient
to obtain the maximum immunization be given, the
amount of agglutinins and immune bodies
elaborated by the inoculated animals is not in pro-
portion to the amount of cultures injected. A series
of rabbits inoculated with 2 c.c. of typhoid culture
will give the same average agglutination limit and
the same amount of immune bodies as a series of
rabbits inoculated with 4 c.c.
Feb. 2, 1914.]
Since 1905 I have experimented with several
mixed vaccines in man, of which the principal ones
are a typhoid + paratyphoid A + paratyphoid B
vaccine; and a typhoid + dysentery (Kruse-Shiga)
+ dysentery Flexner vaccine. I will limit my
remarks to the typhoid paratyphoid B vaccine; but
I may be allowed to note that anyone wishing to
experiment with mixed dysentery vaccines should
be careful always to use pepton-water cultures, as
broth cultures of dysentery give rise to an extremely
painful infiltration at the point of inoculation.
Method of Preparation of the Mixed Typhoid
Paratyphoid Vaccine.
The mixed vaccines as prepared by me are either
dead vaccines, the cultures being killed in the usual
way by heating at 53° C., or live attenuated
vaccines, by heating the cultures at 50° C. for an
hour. During recent years I have used rather
extensively both the dead mixed vaccine and the
live attenuated one.
At first I used to prepare the vaccine as follows:
Several tubes containing 10 c.c. of broth each were
inoculated with two loopfuls of an agar culture of
typhoid forty-eight hours old; other tubes with two
loopfuls of paratyphoid B, and others with two
loopfuls of paratyphoid A. All the strains I used
were non-virulent, but rich in antigen, as shown
by animal experiments. The inoculated tubes were
kept for twenty-four hours in the incubator at
35° C. These cultures were then heated in a water
bath at 55° C. (dead vaccine), or 50° C. (live
attenuated vaccine) for an hour; they were then
mixed together in certain proportions in sterile Petri
dishes—two tubes (20 c.c.) of typhoid, one tube
(10 c.c.) of paratyphoid B and one tube (10 c.c.)
of paratyphoid A. The mixed vaccine consisted
then of two parts typhoid, one part paratyphoid A,
and one part paratyphoid B. I used to give 10
minims of the mixed vaccine at the first inoculation,
and 20 or more at the second and third. At the
present time the vaccine is standardized by count-
ing the germs before mixing.
The mixed vaccine I use at the present time con-
tains per cubic centigramme 500 millions typhoid,
250 millions paratyphoid B, and 250 millions
paratyphoid A, and is prepared either from broth
cultures or emulsions in physiological salt solutions ;
a little lysol is added (0'2 per cent.).
Dose and Method of Vaccination.—As already
stated, the mixed vaccine I now use contains per
cubic centigramme 500 millions typhoid, 250 millions
paratyphoid A, and 250 millions paratyphoid B. I
give 0°6 c.c. the first time, and double the dose
a week later, and whenever possible a third dose
two weeks from the first. In some cases, however,
I give only 3 c.c. the first time, and 1 c.c. the
second. Whenever possible I give a third inocula-
tion two weeks after the first—the dose being the
same as for the second. Very thin delicate indivi-
duals and young women receive a little less.
Children between 8 and 15 get 1 to 4 the adult dose.
The inoculation of the mixed vaccine is followed by
a local and general reaction which, as a rule, is not
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 37
distinctly severer than after the inoculation of
simple typhoid vaccine. Three or four hours after
inoculation the region on the arm where the injec-
tion has been made becomes painful and red, and
fever may supervene, which, as a rule, does not last
longer than twenty-four to thirty-six hours, and
does not in most cases incapacitate one for work.
As I do not believe that the immunization given
by bacterial inoculation lasts, in man, very long,
I generally advise people to be vaccinated once
every two years, or even once a year.
=
Innocuity of the Mixed Typhoid-paratyphoid
Vaccine.
The mixed vaccine, whether the dead one or the
attenuated live one, is innocuous, as proved by
several thousand inoculations done to date in
Ceylon. Professor Browning, the Director of the
Ceylon Government Chemical Institute, has to date
received thirty-five inoculations of mixed live
vaccine at one or two weeks’ intervals, in addition
to twenty-nine inoculations of simple typhoid live
vaccine. He has always remained in very good
health.
Remarks on the Immunization obtained in Man by
the Mixed Vaccine.
Lack of time has prevented me studying tho
amount of all protective substances produced in
inoculated individuals. The investigation, therefore,
has been limited to studying comparatively the
amount of agglutinins produced in some individuals
inoculated with mixed and simple vaccines.
Two natives, David and Fernando, were inocu-
lated with mixed (dead) vaccine, 0°6 c.c. the first
time, 1:2 c.c. after a week.
One native, Peter, was inoculated with simple
typhoid vaccine (dead) 0°6 c.c. the first time,
1:2 c.c. after a week.
One native, Baba Singho, was inoculated with
simple paratyphoid A vaccine (dead), 0:6 c.c. the
first time, 1:2 c.c. after a week.
One native, Asson, was inoculated with simple
paratyphoid B vaccine, 0'6 c.c. the first time,
1:2 c.c after a week.
Two natives, A. E. de Silva and D. Gunesekera,
were inoculated with 0:6 c.c. mixed live (attenuated)
vaccine, and with 1:2 c.c. after a week.
One native, Isaac, was inoculated with 0°6 c.c.
live (attenuated) typhoid vaccine, and with 1:2 c.c.
after a week.
One native, Wellan, was inoculated with 0°6 c.c.
live (attenuated) paratyphoid A vaccine, and with
1:2 c.c. after a week.
One native, Karuppen, was inoculated with
0'6 c.c. live (attenuated) paratyphoid B vaccine,
and with 1:2 c.c. after a week.
All the inoeulated persons were healthy young
natives who volunteered for the experiment. They
were inoculated on the same days, first inoculation
taking place on June 14, 1918, and the second on
the 21st of the same month. The blood of all the
inoeulated persons was investigated for presence of
agglutinins regularly once a week, and the results
38
are. collected in the following table, for the com-
pilation of which I am indebted to Mr. Burgess.
From the table it will be seen that agglutinins
seldom appear before the seventh day, and that the
individuals inoculated with a mixed typhoid para-
THE. JOURNAL OF TROPICAL MEDICINE AND HYGIENE. ([Feb.2, 1914.
inoculated individuals, the results did not differ
much; if anything they were rather in favour of the
mixed vaccines. Although of course one cannot
gauge the actual immunization obtained, by simply
studying the agglutination, there can be no doubt
LIMITS OF AGGLUTINATION.
B. typhosus
Name Vaccine used for inoculation Weeks after first inoculation
1/2|8/4|5|6|7]|8]|9 |1t|18 |15
———— YS E Epp SSS SSS SS eS
David Mixed “Dead” | O late] cbv| abel ste] 2. | so | oe | ab | te | oe | us
Fernando ... bon ” O |350| atol 330| sto] sbo do] 35 | so | æ | oe | as
Peter ... Typhoid » Po | zo| xbv | udo | sbo | rdv | io | iio | tio | do | ao | 0
Singho ... Paratyphoid A š 0/0|0,0/,0/]0/,0/|0,0/,0/0/,0
Asson — .. T B " 0|0|0/,0/|0/|0|0/0/,0,0/|0/]0
A. E. de Silva | Mixed “Live” | gy [slo | bc [ado | abe | rbv | rbv | abs | vo | a's | | 0
D. C. P. Gunesekera à n 35 0 |xie| sio atol arol rie | — | — | — | — | dg | s
Isaac , Typhoid » 0 |z% sto | sto | sbo | sbo | 300 | ado | sto | sto | bv | 3
Wellan Paratyphoid A a 0|0/|0,0/]0/|0/,0[|0/0/|0]|0/|0
Karuppen ... » B x 010/10/0/0/0/0/01/0/0/01—
B. paratyphosus A.
David Mixed *Dead"| O | d | sv | æ |rbo| e| go | | v | oy | ts | ob
Fernando ... ” ” O | so | ay | to | d | | d | sv | do | 3o | as | ae
Peter Typhoid 5 0/,0/,0/0/0/|0/0/0/0/,0/0/,0
Singho Paratyphoid A » EET | to | ao] do | sb | dv | as | ao | ao | as | 0
Asson e B A 0 0/0/00 0/0/01 O 0/00
A. E. de Silva Mixed "Live"| 0 | Alas | ao | aot os | os Alw w00
D. C. P. Gunesekera Pe T 0} A | Ad a | a | a ee ee en [us a | ode
Isaac Typhoid i 0/0/0/]0/0/]0/,0/0/0|0 0,0
Wellan Paratyphoid A » O |xbs| do | sv | so | go | aw | oh | Er | do | | as
Karuppen 2 B 2s olotolololo!lolo!o!loio!—
B. paratyphosus B.
David Mixed “Dead”! O | a's | zo | db | do | ab | do ido | go | as | ay | 1o
Fernando ,,. ” » 0 | æ | æ | d | do | do] 35 | æ | 35 | db | as | vs
Peter Typhoid id 010|0/0|0|0/0|0|0|0'0|0
Singho Paratyphoid A ^ ojojojojojojojojo o [0,0
` Asson ” B ” O | ds | de | sb | vo | sb | ds | th | ay | ay 0,5
A. E. de Silva . | Mixed "fgg xl. duoi |olo, o o0
D. C. P. Gunesekera ty ut K l Uus | added Sa dee] iie Lom dro
Isaac .. | Typhoid » 0|0|0/0|0|0,0j0|0/0,0'0
Wellan Paratyphoid A ii 0|0[|0/0|0|0/0/.0/]0/0,0/0
Karuppen ... ” B ” 0 | 25 | do ELSE $5 59090. 0 —
.typlioid A paratyphoid B vaccine, produced agglu-
-tinins for all three germs, and that on the average
the amount of agglutinins produced for each germ
‘was not much smaller than in individuals inoculated
with one germ only, although the latter had a much
larger dose of the germ. As regards the length of
‘time during which agglutinins were present in the
that to a certain extent agglutination is a rough
index for immunization. It seems to me that these
results are decidedly in favour of the advisability of
using a mixed typhoid paratyphoid A paratyphoid B
vaccine, in countries where all three diseases are
“met with. .
Conclusions.—(1) The use of the mixed typhoid
Feb. 2, 1914.]
+ paratyphoid A + paratyphoid B vaccine, either
the dead or the live (attenuated) one, is harmless.
As there is such a general objection to the use of
live vaccines I now recommend for routine use the
mixed dead vaccine, which consists of an emulsion
of typhoid and paratyphoid A and B bacilli, killed
by heat (539 C.) in the usual way and standardized,
so that 1 c.c. contains approximately 500 millions
typhoid bacilli and 250 millions each of paratyphoid
A and B.
(2) The inoculation of such vaccine in human
beings in the doses mentioned in this paper, viz.:
0*6 c.c., or about 10 minims, the first time, and 1:2
c.c., or about 20 minims, the second—induces a
produetion of agglutinins for all three germs:
Bacillus typhosus, B. paratyphosus A, and B. para-
typhosus B. The amount of agglutinins elaborated
for each germ seems to be practically the same as
in individuals respectively inoculated with typhoid
vaccine only, paratyphoid B vaccine only, para-
typhoid A vaccine only.
(3) In countries where besides typhoid there
occur paratyphoid A and paratyphoid B, a mixed
vaccine should, in my opinion, be used, instead of
the simple typhoid vaccine. This has been done in
Ceylon for the last five years, with good results.
I desire to express my indebtedness to Mr.
Burgess, Assistant Bacteriologist, for the very
valuable assistance rendered.
REFERENCES TO PREVIOUS PAPERS ON MIXED VACCINES.
CASTELLANI: Zeilschr. für Hyg., 1902.
js Ceylon Med. Reports, 1904.
" Centralbl. für Bakt., 1909,
A Trans. Bombay Med. Cong,, 1910.
3i Trans. Soc. Trop. Med., 1912.
$6 Lancet, 1913.
————9——— — —
Abstracts.
ABSTRACT OF PAPER ON ACCLIMATIZATION
IN THE TROPICS.*
By Dr. TcHupNowsky.
I po not presume to wish to decide in the limits
of a paper this vast. and complex question of
acclimatization. I only hope to be able to deal with
certain elements of the matter, to analyse the
ideas accepted at the present day, and contrast
them with the results of my personal observations,
based on a medical practice of twenty-one years in
these parts. i
CLIMATE.
To determine the quality of the climate in a-given
tropical region, we must know not only the meteoro-
logical facts, but also the degree of permeability of
its subsoil and the forests which cover it, and
which protect the soil from the direct rays of the
sun. It would be more scientific to say climate is
* Translated from a Paper read at the International Medical
Congress (Tropical Section), August, 1913. ,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 39
the sum of the meteorological, geological, topo-
graphical and social elements of a given region. The
angle at which the rays of the sun fall enable us to
divide the surface of the earth into three zones, but
we shall only occupy ourselves with the acclimatiza-
tion of the man proceeding from the temperate zone
to tropical regions.
ACCLIMATIZATION.
Acclimatization is the innate faculty of every
organized being, thanks to his nervous system, of
being able to adapt his life to the changed con-
dition of climate different from that in which he
lived previously. The displacement of a man from
one place to another in the same isothermic band
says nothing for the character of his acclimatization.
Thus a Parisian who moves from the central parts
to the suburbs may during the first years be affected
by the change; the children especially may become
more liable to febrile disturbance, sore throats,
eruptive fevers, &c. This is due probably to the
unhealthiness of certain parts, caused by the ground
being of a clay subsoil, and being in the neighbour-
hood of watercourses infected more or less during
certain seasons; whereas the same man, moving
from Paris to the Reunion or to Martinique into
another isothermic band, was in no degree affected
by these illnesses.
In like manner I may refer to the interesting
report of A. Moreau de Journy to the Institute
of France in 1817 that the Caraibes and the
colonists of St. Vincent and Martinique who fled
there in 1793. and 1796, the first to Guatemala
and the second to Saint Dominique, almost all
perished by a fatal epidemie, although their new
nabitation was only seven leagues from their homes,
and there was no sensible difference in the soil or
the water or vegetation of these two volcanic islands.
Let us now consider this question: Whether it is
possible for the man of the temperate zone to
acclimatize himself in the tropical?
The history of acclimatization of the last cen-
turies, gathered from the voyages of Columbus and
the celebrated Portuguese, Spanish, Dutch, and
English captains in the East and West Indies, gives
no scientific basis for a direct reply to the question.
The purely economic and religious struggle carried
on by them against the natives excluded all possi-
bilities of acclimatization.
The positive facts of the success of the acclima-
tization of the French in the ‘‘ Ile de Bourbon,” the
English in the Barbados, the Spanish and Portu-
guese in Cuba and the high tablelands of Central
America, and the Dutch in Guiana, are of little
value by reason of their small numbers and by an
enormous series of negative facts, which appear to
prove that the tropical zone is fatal for the tem-
perate zone men. It followed that the history of
colonial wars and the colonization in the regions
created conceptions against the possibility of this
acclimatization. We will divide the arguments into
physiological and pathological.
(1) Physiological_—The arguments are based on
the pernicious influence of temperature on the
40 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 2, 1914.
funetions of the brain and skin of the white man,
the result of absorption by the thermic and sudorific
centres. "There follows an irritation of the central
nervous system, a diminution of energy, and this
leads in two or three generations by slow degrees to
degeneration in mind and body.
(2) The pathologieal arguments are based on the
fact of the predominance in the tropical zone of
fatal diseases, fatal for the white man, as paludism
in all its pernicious forms: cholera, dysentery, beri-
beri, yellow fever, not to speak of the fatal diseases
peculiar to the soil. On the other hand, the white
man may die of tropical angmia.
Let us consider these arguments from the post-
mortem accounts at our disposal.
The first are based on the difference in the pig-
mentation of the skin and the volume of sebaceous
glands in the negroes, although the skin apparatus
is in general the same in men of all colours, yet
these slight differences may account for the differ-
ence between white and coloured in the matter of
sunstroke, tropical meningitis, &c.
The difference ought to be, as Dr. Eychmann has
said, one of ‘‘ Neurogenes art,” and is the effect of
the accommodation of the nervous system of the
native. Measurements of temperature in the white
man in a sound state have never been able to prove
the fact of the accumulation of heat. Is this accu-
mulation proved by the facts of insolation, or so-
called sunstroke, or tropical meningitis? 1 cannot
reply directly, but I may say I have never seen the
tangible proof of this assertion. I must say that
during twelve years’ experience in the two hemi-
spheres of the tropical zone, among soldiers,
planters, sailors, and labourers I have never ob-
served a single case of insolation or sunstroke.
Sudden or slow death is always explained sufficiently
by a sharp illness, and the high temperature is only
an accident before death due to one of the causes
enumerated.
As to the absorption of colour by the brown,
yellow, or black pigment, I do not think this is of
much importance, as the following fact will show.
In the region of Pajacombo, on the west coast of
Sumatra, I have seen native Malay women, not
accessible to contact with Europeans, as white in
skin as women of North Europe or America. The
Equator passes through this region; that is to say,
the sun's rays are very strong; yet this is considered
the eradle of the Malayan race. One must add that
it is the woman who works in the fields and is
directly exposed to the sun's rays. Thus one may
have a white skin and belong to an ancient race of
the torrid zone.
Can one say that the high temperature causes
the intellectual degeneration. I dare to say that
facts prove the contrary, if the manners or moral
of a race are the expression of its superior brain
power. The intellectual and moral level of the
Javanese is superior to certain peoples of Europe,
as also are the Hindoos and even the negroes con-
sidered as a whole population.
The present generation of creoles in the Ile de
Bourbon, whose ancestors settled there in the six-
teenth century, have a decided leaning towards
literature, and the country has produced a great
number of lawyers and professors. This applies
also to the creoles of the Antilles and Central
America. The cradle of the philosophies and
religions was in the tropieal parts of Central Asia.
The degeneration of the white man in the tropical
zone is a theoretic supposition, based in no degree
upon positive facts. On the contrary, the history of
humanity teaches us that the warm rays elevate
and refine the brain power of man. If the white
man does degenerate, it is due to cerebral atrophy.
due exclusively to the inaction and to the want of
exercising the brain.
Dr. Tschudnowsky, in his paper, proceeds to
enumerate several examples of serious epidemics
occurring on plantations where coolies died in num-
bers, and where soldiers from Holland, shortly after
landing in the Dutch Indies, were well-nigh exter-
minated. He shows that this was due to mental and
moral depression, bad housing, bad food, detrimental
environment, and to diseases such as malaria, beri-
beri, and dysentery, and not to climate per se. On
the other hand he shows how planters of Deli
in Sumatra, from all parts of Europe, gain their
living in a flat, alluvial but drained and cultivated
region during many years, and they are quite accli-
matized and prosperous. They live a life in harmony
with the exigencies of tropical countries; that is,
a life of physical activity under burning rays in the
fields. This normal way of living cannot but offer
& barrier to fevers and would indicate that the
climate was suitable for Europeans.
It is clear, then, that in relying only on older
medieal statistieal figures, or those of explorers.
arbitrary conclusions are arrived at without great
value from a scientific point of view.
It is an admitted fact that the germs of tropical
diseases are transmitted in the same way, with a
few exceptions, all over the world. It follows.
therefore, that the high temperature and humidity
of the tropical zone will tend to the quicker develop-
ment especially of those germs of the zoophytic
and protozoan kind, and consequently to a more
rapid course in the human organism.
The impermeability of the subsoil and the alluvial
regions especially produce bogs and marshes, the
luxuriant vegetation in virgin forests, and the sun's
rays cause a pestilential air and miasmatie exhala-
tions (which are not the exclusive lot of the tropical
zone) characteristic of many unhealthy regions.
I only mention here the paludism which forms the
chief base of our tropieal pathology. The physical
character of the malaria parasite is not yet known,
but it would seem certain it settles in these regions
and develops there. The impermeable subsoil and
the virginal forest form the natural laboratories
for the growth of these protozoans and they infect
man by direct inoculation following on the bite of
anophelines.
Dr. Tschudnowsky then proceeds to state
his conviction that malaria is conveyed by other
means than by mosquito bites. He cites examples
of serious outbreaks of malaria in regions where
Feb. 2, 1914.]
é ,
anophelines are few and where the ‘‘ miasma ’
alone can be the infective power. He believes in
the existence of the malaria parasite in the swamps
and forests and accounts for sudden epidemies by
these parasites being carried in the air by winds,
independently of mosquito bites altogether. He
then proceeds to show how the sun's rays serve to
protect unhygienie regions and cities from prevalent
maladies and states that the high temperature and
the direct sun's rays do not provoke a tropical
malady. On the contrary, they kill the pathological
germs, as in the following instances :— ,
At Canton, in China, a town of about a million
inhabitants, with a large population dwelling in
boat-houses, all the filth and the corpses of animals
are thrown into the streets, as in many Chinese
central towns, and nevertheless epidemic diseases
are rare. The same thing happens in Curacao and
in most of the Central Ameriean towns. In Curacao
the inhabitants throw all the organie and culinary
waste into the canals or the streams before their
houses.
In many parts, as the islands in the Indian
Ocean, Mauritius, Ceylon, and other tropical places,
there is no fear of epidemics, the germs do not live.
This is because the forests where the germs thrive
have been destroyed or cultivated by man. It then
follows that the base of the arguments proving the
impossibility of aeclimatization are scientifically
wrong in their practical application.
Conclusions.—Doctors Cazalis and Carry wrote
in the Moniteur Algérien in 1854 that they
were convinced of the possibility of the acclimatiza-
tion of the white man in all the warm countries.
This fervid conviction, which ought to have been
destroyed by the sad results of the first expeditions
and trials at colonization in North Africa, became a
true reality in our days.
The acclimatization of the man of the temperate
zone in the Tropics is therefore possible theoretically
and practically.
I will formulate as a conclusion in the following
rules on which depend the perfect success of this
acclimatization :—
(1) Systematic and methodical culture of the soil
of the neighbouring forests, especially those in the
direction of the trade winds.
(2) Methodieal physical exercises in the open air
as in the temperate zone.
(8) Methodical and systematic intellectual exer-
cises as in the temperate zone.
ULCUS MOLLE SERPIGINOSUM.*
By J. E. R. McDowaau, F.R.C.S.
THE primary lesion is a furuncle, the edges of
which become blue, bluish-white, and then break
down until a distinct ulcer is formed.
The base of the ulcer is fleshy, uneven, and
secretes freely. The edges are ragged, look as if
they had been gnawed, and are deeply undermined ;
* The British Journal of Dermatology, J anuary, 1914,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 41
the overhanging portion is edematous and bluish-
white in colour; external to this the colour becomes
purplish, and still further out, and spreading for
some distance into the healthy tissue, one sees the
red colour of inflammation. The inflammatory zone
is most marked where the ulcer is spreading, as it
invariably spreads in one part more than another;
in fact, one pole may heal while the other is steadily
advancing. A very favourite route for one tongue
of the ulcer to take is down the genito-crural fold.
Occasionally such a process reaches as far back as
the anus.
Case 1.—A man, aged 25, had been four years in
the East and only really ill with malaria during the
first year. Ten years ago he had albuminuria follow-
ing typhoid fever.
The only drug which seemed to do the least good
was potassium iodide given internally. When the
salt was pushed up to 200 gr. per-diem and the
sores washed with perhydrol and then dusted with
iodoform, the ulcers, after several weeks, completely
healed.
Several films and cultures were made with nega-
tive results; these were again repeated when the
ulcers secreted more freely, and every time a pure
culture of proteus resulted.
Vaccines made therefrom stopped the discharge
and removed the fearful odour it gave rise to, with-
out in any way causing the ulcers to heal. The
proteus was Proteus vulgaris; it was Gram-negative,
very motile, and the bacilli varied in length. It
gave acid and gas in glucose and lactose and clotted
peptonized milk. It rapidly liquefied gelatine. A
rabbit which was injected died in forty-eight hours
from acute septicemia.
Pieces of tissue were removed and injected into
a rabbit, a guinea-pig and a mouse intravenously,
intraperitoneally, and subcutaneously respectively.
Only the mouse died a fortnight later, and in spite
of a thorough examination of all its organs nothing
abnormal was discovered.
The bloods of the rabbit and guinea-pig were
tested from time to time with negative results.
In the most superficial layer of the undermined
portion strepto-bacilli were to be found. The bacilli
were Gram-negative, usually in pairs, and never in
chains of more than five or six. No intracellular
organisms were to be found.
Several attempts were made to culture the
organism on both rabbit’s and human blood-agar,
but failed.
Case 2.—A man, aged 27, who had spent several
years in the Malay States. In both groins were
several uleers; they were extending above on to the
abdomen and below on to the thighs, and on both
sides they had reaehed far down in the genito-
crural folds. The ulceration began seven months
before.
Five years before he had had some sores on the
penis (uleera mollia), which healed up without any
complications arising therefrom, such as bubo, &c.
In November the patient fell over a log of wood,
with the result that two days later a swelling
appeared in the skin in the inguino-scrotal folds on
42 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
both sides. The swellings behaved like boils, so
were lanced, and from that time onwards they be-
came ulcers, which rapidly tended to increase in
size. As no local application was of any use, the
patient was put under an anesthetic, and the ulcers
were well scraped, with the result that they spread
quicker than ever.
When first seen the patient could not walk owing
to the pain caused by the ulcers; the ulcers dis-
charged freely, and had that peculiar indescribable
odour noticed in every case seen.
Films from secretions from under the over-
hanging portion of skin in the region where an ulcer
was spreading showed Ducrey’s bacillus. Separate
streptobacilli were to be seen, also many in pairs
and some in chains, but contrary to what one finds
in ordinary soft sores many of the leucocytes were
crammed with a different form of Ducrey’s bacillus.
To prove that the ulcers were due to Ducrey’s
bacillus the patient’s arm was inoculated, and after
the usual incubation period, a typical soft sore
formed from the same bacillus was isolated.
Treatment consisted in gradually increasing doses
of iodides until the patient took 200 gr. per diem;
the maximum was maintained for one week and
then gradually decreased, and so on until the ulcers
had completely healed, which they took three and
a half months to do.
Locally the ulcers were painted with camph-
phenol and then dusted with iodoform.
Case 3.—A man, aged 32, who had spent the last
few years in Ceylon, had an ulceration in his groin
and upper part of the thigh. The ulceration started
in the groin as a little furuncle three years after he
had had some sores on his penis (ulcera mollia).
He had never had a bubo. The furuncle became an
uleer which spread down over the thigh, so that
when seen practically the anterior surface of the
upper half was one huge uleer, although the
superior part had commenced to heal. The ulcer
had persisted for two and a half years, and in spite
of having had every kind of treatment imaginable,
nothing did any good. From this ulcer the intra-
cellular form of Ducrey’s bacillus was found. The
treatment consisted in iodides internally, camph-
phenol and iodoform externally, and in addition the
patient had five intravenous injections of tartar
emetic every four days, 0'1 grm. in 100 c.c. saline,
with the result that in three weeks the ulcer had
completely healed.
Case 4.—A man, aged 36, a native of India, had
an ulceration of both thighs almost down to the
knees, and above the groin practically the whole of
the lower third of the abdomen was involved. The
uleeration had persisted for over five years, and had
not responded to any treatment that had been given.
Unfortunately this patient died before anything
conld be done.
Case 5.—A man, aged 34, who had spent some
years in the tropical part of Australia, consulted
me for a chronic ulceration of one groin. The
patient had had a soft sore and a bnho resulting
therefrom, which had to be incised. The soft sore
healed rapidly, but the edges of the bubo became
[Feb. 2, 1914.
ulcerated until a typical picture of ulcus molle ser-
piginosum presented itself. This ulcer rapidly
healed under potassium iodide internally, camph-
phenol and iodoform externally, and tartar emetic
intravenously.
It is a peculiarly chronic form of ulceration which
at varying periods invariably follows a soft sore
appearing independently of a bubo or after a bubo
has been incised. It is further characterized by
the fact that in every case the patient had lived in
the Tropics.
It is quite clear that any operative procedure
makes matters very much worse, and that unless
exactly the specific treatment is prescribed nothing
is of any avail.
The best treatment appears to be to give potas-
sium iodide internally, to apply camphphenol and
iodoform externally, and healing can be hastened
by giving injections of tartar emetic intravenously.
Either the antimony acts specifically or its action is
due to freeing the iodine, which has undoubtedly a
specific action. This is suggested because, after
every injection of antimony, the patients always
had a violent fit of coughing, which lasted for about
twenty minutes—a cough resembling that which
might be produced by inhaling iodine.
A bubo should never be opened until the dire
necessity arises, and even then only a nick with a
bistoury should be made, not the 2 to 3-in. incision
which is usually practised.
Nearly all the cases of ulcus molle serpiginosum
have followed an operation on a bubo.
Bacteriology.—In describing Ducrey’s bacillus one
must bear in mind the extraordinary morphological
differences which the organism may present. The
following five types are those given by Tomas-
czewski (** Handbuch der Geschlechtskrankheiten, ''
vol. ii, p. 631):—
(1) Short rods which are difficult to distinguish
from cocci, being 0'4 micron long and 0:3-0:35
micron wide.
(2) Longer rods with rounded ends; the bacilli
are usually isolated—length 1:5-1:7 microns, breadth
0:4 micron.
(3) Dumbbell forms, which are usually found in
groups.
(4) Forms like diplococci, first described by Unna
as the '' Doppelpunkt bacillus " and by Ducrey as
the ‘‘ Achterform.’’ Length 1:0-1°5 microns,
breadth 0°3-0°4 micron.
(5) The ‘‘ en navette ’’ form of the French or the
“ Sehiffehenformen "' of the Germans, rods which
have an unstained point in the centre; length
1:1-1:5 micron, breadth 0:5-0:6 micron.
The '* en navette ’’ type is rare in soft sores, but
extremely common in ulcus molle serpiginosum;
the short rods and diplococeal forms were also found,
but they were always extracellular, while the '' en
navette "" form, although found extracellularly, was
most often and in enormous numbers found intra-
cellularly situated.
Hitherto no attention has been paid to this intra-
cellular habitat of Ducrey’s bacillus, but it doubt-
less accounts for the chronicity of the lesions and
Feb. 2, 1914.]
the way in which they resist anything but specific
treatment.
In ulcus molle, Ducrey’s bacillus is extracellular ;
in the complication ulcus molle serpiginosum,
which is one of the most chronic ulcers known, the
organisms have become intracellular.
The so-called Granuloma venereum or Granuloma
inguinale is an allied condition to ulcus molle serpi-
ginosum, and this opinion is backed up by Flu’s
description of intracellular diplocoeci which he
found in the first-named condition. Flu says that
in some cells there are diplococci which stain violet
with Giemsa and have an unstained capsule. If
strong Giemsa stain is used the capsule stains a
bright red. Some of the organisms are bacilli, not
diplocoeci; only a few are to be found extra-cellular.
Flu cultured some of these and obtained plump
bacilli which morphologically resembled Ducrey's
bacillus, and they were, moreover, Gram-negative.
There must be some climatic circumstance
which favours the intracellular habitat of Ducrey’s
bacillus.
Not infrequently the lymphangitis of the penis
which follows a soft sore may become adherent to
the skin and ulcerate, producing an even-cut, freely
discharging ulcer, which heals very quickly under
treatment. While the soft sore and bubo are still
present the patient may develop on the scrotum,
the thigh, or the abdomen one or more ulcers which
differ in appearance only slightly from the ulcus
molle serpiginosum. The edges are scarcely un-
dermined, they have not the blue appearance of
venous congestion, the surrounding inflammation is
not so marked, and the base of the ulcer is not so
deep. Such ulcers heal very rapidly under local
applications of camphphenol and iodoform, and the
Ducrey's bacillus is always found extracellularly
situated.
— AJ
Annotations.
A New Blood-sucking Midge.—Patton, writing in
the Indian Journal of Medical Research (vol. i, No.
2, October, 1913), describes a new Indian blood-
sucking midge. Professor Kieffer, to whom speci-
mens were sent, stated that it was a new species
of Culicoides. Patton has therefore named it
Culicoides kiefferi.
The genus Culicoides, Latrielle, which belongs to
the sub-family Ceratopogonine, contains a number
of small midges, the females of which are, as a
rule, voracious blood-suckers; in many parts of
India and Africa they attack man and animals in
swarms and are great pests. The majority do not
measure more than 1 mm. in length and are nearly
always of a dark brown colour, sometimes yellowish,
rarely whitish. They may be distinguished from the
species of Ceratopogon, another group of small
midges to which they bear a superficial resemblance,
by the rudimentary nature of the empodium, which
in the latter genus is well developed and as long as
the claws.
As far as is known at present, no species of
Culicoides is even suspected of being the invertebrate
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 43
host of any pathogenic parasite, and as they are
difficult to study, due chiefly to their small size,
very little is known regarding their habits and
life-histories.
The eggs of the new species are extremely minute
objects and are laid in a mass in the vicinity of
water, usually on some green algal growth which
collects at the edges of small pools and where water
trickles over the ground. The larva will be found
buried in the green algal matter and may be recog-
nized by its slender body and its rapid vibratile
movements, which closely simulate those of a giant
spirochete. It consists of twelve segments (includ-
ing the head), all of which are smooth and almost
entirely devoid of hairs. Unlike the larve of
all the other known species of Chironomide, that
of Culicoides has no pseudopods on the ventral sur-
face of the first thoracic segment. The head is well
developed, and the eyes are kidney-shaped; the
dorsal surface and sides are furnished with several
small hairs, the two most prominent being situated
on the mid-frontal region. The antenna consists of
a single minute segment with a delicate hair at its
apex. The mandibles are stout curved rods of
chitin and are armed with two teeth. The last
segment has four pairs of appendages which are
deeply bidentate and can be extruded and with-
drawn at will into the segment. These structures
correspond to the tracheal gills of other aquatic
larve ; true stigmata are wanting.
The pupa is very characteristic. Its surface is
almost entirely devoid of bristles, but it has well
developed spines at the sides, and knob-like
processes on the dorsal surfaces of the abdominal
segments. There is a pair of long breathing trum-
pets arising from the sides of the mesothorax, the
stalks of which are very narrow and armed with
several minute blunt knobs; the trumpets end some-
what like those of culicid larve. There are in
addition several protuberances with hairs and
spines at their extremities, and minute processes
on the thorax. The pupa, which never has the
larval skin attached to it, anchors itself by two
prominent terminal spines; or it may float on the
surface. The flies hatch in three days.
The female shows the following characteristics.
Head, palpi, and antenne light brown. Thorax
light brown with a median dark band extending
from the anterior end to about the centre, where it
divides into two short branches; in addition there
are several dark spots and indistinct bands, par-
ticularly at the sides. Abdomen light brown with
faint dark bands and spots. Legs brown with light
bands at the middle of the femora most prominent
on the hind legs; fore metatarsi equal in length to
the three succeeding joints; empodium small and
indistinct. Wing white, the surface clothed with
fine hairs, and in parts with longer ones; a well-
marked fringe borders the wing. There are two
large dark brown spots, one about the centre of the
costal border covering the entire third long vein;
the other which is also on the costa is nearer the
apex of the wing; there are in addition several
lighter spots. The third longitudinal vein, which is
44
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 2, 1914.
closely adjacent to the first, is very pale, and abuts
on the costa about its centre. The fourth vein
bifureates about the centre of the wing and the fifth
divides opposite to the extremity of the third vein.
Length 1:5 mm.
The male is in most respects very similar to the
female, but throughout it is lighter. Both sexes
may be caught in large numbers on window panes
in the laboratories of the King Institute, Madras.
The females bite in the early morning and may then
be caught in large numbers on the shaved abdomens
of calves. The flies disappear about April when the
hot weather begins, and reappear in November.
“ The Protection of India from Yellow Fever" is
the title of a Report by Major S. P. James, appearing
in the October, 1913, number of the Indian Journal
of Medical Research. The author commences by
remarking that, “ yellow fever has not yet appeared
in India, but the abundant presence of the mosquito
Stegomyia fasciata, which transmits it, the suscep-
tibility of the population, and the general conditions
in the chief seaports are very favourable to its exist-
ence and spread, and it is believed that the intro-
duction of the virus would be followed by devastating
epidemics which would be exceedingly difficult to
control. In 1903 Sir Patrick Manson drew prominent
attention to the risk that the commercial develop-
ments which will follow the opening of the Panama
Canal may lead to the introduction of the disease
into Asia, and in June, 1911, the danger was dis-
cussed in an important paper by Major E. F. Gordon
Tucker, I.M.S., Professor of Pathology in the Grant
Medical College, Bombay." Major James was
deputed by the Indian Government in October, 1911,
to ascertain the conditions ina portion of the endemic
area in Central America, and in the principal seaports
between that country and India. The present report
is the outcome of this investigation.
The first ideas that come to one’s mind on examin-
ing a map of the world or of the Pacific Ocean,
prepared on Mercator's projection, are that the
Panama Canal will provide a direct route to Asia and
India from Europe, the United States and the
endemic area of yellow fever, and that after the canal
is open for traffic there will be a danger of yellow
fever being conveyed to India by direct shipping to
that country from or by way of ports in the endemic
area on the Atlantic side of the canal. But charts
on Mereator's projection give a distorted view of the
features of the earth and a wrong impression of the
shortest distances between most ports, so that in
order to ascertain whether our first ideas are tenable,
and to enable the problem with which India is con-
cerned to be accurately stated, it will be convenient
to begin the attempt to estimate the risk with a record
of the actual distances between certain ports. In the
report the distances are set forth in tabular form.
It will be seen that :—-
(1) The opening of the Panama Canal is not likely
to be followed by direct traffic from Europe through
the endemic area to India, for the distance between
London and India is, on an average, 10,500 miles
longer by the new route than by way of the Suez
Canal. This is important, because most of India's
seaborne trade is with Europe.
(2) It is not likely to be followed by direct traffic
from the United States through the endemic area to
India, for New York is, on an average, 6,800 miles,
and New Orleans 3,200 miles nearer to India by way
of the Suez Canal than by way of Panama.
(3) It is not likely to be followed by direct traffic
from the endemic area via Panama to India, for
much the shortest routes to that country from the
West Indies, Mexico, the Central American Republics,
the Panama Canal zone, Colombia, Venezuela and
Guiana will still be by way of Suez, and from Brazil
the shortest route is by way of the Cape of Good
Hope. Major Tucker, in the paper already mentioned,
suggests that Jamaica may be a place from which
there will be direct traffic to India, but if this were
to happen the route would surely be by way either
of the Suez Canal or the Cape of Good Hope; the
distance from Jamaica to Bombay by the Suez route
is about 1,500 miles shorter than by way of the
Panama Canal. In this connection it is noteworthy
that the Republie of Panama already imports Burmese
rice which goes by way of Liverpool or Hamburg to
Colon.
(4) It is believed that the opening of the canal will
result in a great increase of trade in the Pacific Coast
ports of South America, and it might be conjectured
that direct trade between those ports and India will
follow. For many reasons this is very unlikely to
happen, but even if there were direct trade between
say, Peru or Chile and India, the best route would be
from Callao and Valparaiso, via the Straits of Magellan
and the Cape of Good Hope; for the distance from
Valparaiso to Bombay by that route is nearly 4,000
miles shorter than by the trans-Pacific route.
Distances of course are not the only factors to be
considered in attempting to foretell future trade
routes; but in the present case the conclusions to
which their study leads are supported by other con-
siderations, and, on the whole, it seems clear that
the spread of yellow fever to India, if such happens,
will not be the result of direct trans-Pacific shipping
to that country from, or through, the endemic area in
Central or Southern America.
If the same line of inquiry is applied to ports
farther East than India, it will be found that be-
yond Singapore the conclusions are, with one im-
portant exception, the reverse of those arrived at
concerning India; in general the distances to Japan,
China, Australia, and the East Indies will be much
shorter by the new route than by the present ones,
and for this reason direct traffic to those countries
through and from the endemic area may be expected.
The exception is with regard to the distances between
Europe and the countries named above; it will be
seen that for trade between Europe and these coun-
tries the Panama Canal will not provide a shorter
route than the present one by way of the Suez Canal,
and this is, of course, important as indieating that
the through traffic via the endemic area to the East
wil not be so great as has sometimes been anti-
Feb. 2, 1914.]
cipated. If we judge by the factor of distance alone,
it is clear that the through traffic to the East by the
new route will be confined to traffic from the United
States, and even as regards that traffic it must be
noted (a) that the Panama Canal route has to com-
pete with the routes by way of the trans-continental
railways of Canada and the United States, and the
inter-oceanic railways of Mexico, Guatemala and
Costa Rica; (b) that for the trade from New York
to Hong Kong, the Panama Canal route will have to
compete with the present one via the Suez Canal, for
the gain in distance is not much more than 200 miles.
Major Tucker suggests that the direct trade between
England and Hong Kong will be greatly facilitated
by the opening of the canal, but this view is not sup-
ported by the facts that the new route from London
to Hong Kong will be about 4,400 miles longer than
the present one via the Suez Canal, and will even be
about 1,000 miles longer than the route via the Cape
of Good Hope.
The author sums up ‘She conclusions resulting from
the inquiry by saying that the danger is a direct
danger only as far as Hong Kong, and that the spread
of yellow fever to the Straits Settlements and to
India by the route which has been considered cannot
result except as a secondary event subsequent upon
the infection of ports in Japan, China, the East
Indies, or Australia.
There is then given an account of the existing
trans-Pacific steamship traffic of the New World, and
it is shown that the chief conclusion to be drawn
from it is that at present most of the traftic to the
East starts from ports such as Vancouver and San
Francisco, which are not now, and are not likely to
be in the future, infected with yellow fever, but that
there is also (and has been for some years) a moderate
amount of traffic from ports, especially on the
Mexican Coast, which at least must be regarded with
suspicion.
As to the new problems that will arise when the
Panama Canal is open for traffic, the author is by no
means sure that the risk of the spread of yellow fever
will be increased to the extent anticipated, for the
situation on the Atlantic side of the canal, and in the
canal zone itself, is very different from what it was
in 1903, when Sir Patrick Manson first drew atten-
„tion to the dangers now under consideration. Since
that time measures have been taken which have gone
far to cause the disappearance of yellow fever from
places which were formerly severely affected. Panama,
Colon, Havana and other Cuban ports, New Orleans,
Rio de Janeiro, and nearly all the West Indian
Islands are at present free from the disease, and as
regards ports on the Atlantic side of the canal which
are likely to be engaged in trans-Pacific trade, none
are believed to be endemically affected at present.
Further, every possible precaution has already been
taken, and will doubtless be continued, to prevent the
canal from being a route by which disease may spread,
and it is very improbable that the United States will
in future neglect their great responsibility in regard
to this matter.
Ships leaving America for the trans-Pacific voyage
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 45
to the East from San Francisco and more southerly
ports, use the Hawaiian Islands as the first place
of call. The conditions in these islands are through-
out the year favourable to the existence of yellow
fever, but up to the present the disease has been
effectually excluded. The authorities fully appreciate
the danger, and very thorough precautions are taken,
so that the author thinks that the port affords a
strong protection against the infection of Asia and
the East Indies. On the usual route to Hong Kong
the ships, after leaving Honolulu, pass northwards
into latitudes, not as a rule, favourable to the life of
mosquitoes, and the remaining ports of call are Yoko-
hama and other Japanese ports, and Shanghai. The
climate of Hong Kong is favourable to the existence
of yellow fever, but no definite data as to the existence
or not of Stegomyia fasciata there are forthcoming.
The route from San Francisco via Honolulu to the
Philippines does not necessarily take ships northward
to Japan, but until San Francisco or Honolulu be-
comes infected such a route is not a cause of anxiety.
On the whole, the author concludes that the present
routes are not very favourable to the infection of
Asia, and it only remains to foretell whether future
routes will be more so.
Section II of the report is concerned with recom-
mendations, for though the considerations summarized
in the first part of the report lead to a modification
of opinion regarding the degree of danger of spread
of yellow fever to the East and India, it cannot be too
strongly urged that they do not justify the conclusion
that little or no activity is at present necessary.
(1) In the first place it is important to obtain con-
tinuous first-hand information regarding the yellow
fever situation in the endemic area, the actual ship-
ping traffic from and through that area to the East,
and the measures that are taken to prevent ships
from carrying the infection. This can be accomplished
by appointing a medical officer in the Panama zone
whose duty it would be to supply regularly such
information. Supplementary to this measure it
would be highly advisable to appoint a second medical
officer with Hong Kong as a centre, and possibly a
third whose headquarters would be at Singapore.
(2) In the second place it must be recognized that
there is little or no knowledge, not only upon the
subject of a sure method of diagnosing yellow fever,
but upon such subjects as the presence or absence
and distribution of S. fasciata in eastern colonial
and other ports, the problem of whether the very
widely distributed and abundant species Stegomyia
scutellaris carries the disease or not, the bionomics
of those species and many other matters of prime
importance in connection with etiology and preven-
tion; and that should occasion arise to deal with an
irruption of yellow fever in a new territory, this want
of knowledge would greatly hamper and delay efficient
and enlightened action on the part of the authorities
concerned. Therefore, the second recommendation
is that the study of the subjects named, and of other
subjects of which a complete knowledge is essential to
a successful combat against the disease, be adequately
taken up.
46 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(3) If the above recommendations are accepted,
India should take a prominent part in the matter by
offering to give financial or other assistance towards
the appointment of the intelligence officers, the
establishment of the central Intelligence Bureau, and
the institution of any scientific inquiry which may
be carried out under the auspices of the Royal
Society.
Also India must proceed with the systematic in-
vestigation of the Stegomyia problem, and in general
with the carrying out of such measures as are of
permanent value in reducing the breeding places of
stegomyia mosquitoes, while the problem of the
possible spread of yellow fever by way of the Cape
of: Good Hope calls for inquiry on the part of India.
(4) It is advisable to strengthen the line of sanitary
defence for our eastern colonies, and for India espe-
eially, in Hong Kong and by the establishment with-
out delay of a modern quarantine station adequate to
the needs of a shipping centre of such importance, for
it is not at present clear what steps could be taken
if a ship infected with yellow fever were to arrive at
that port.
In Seetion III the author gives a general descrip-
tion of the conditions in most of the ports visited by
him, dealing with only such conditions as are of
importance in connection with yellow fever.
The report is illustrated by a large map giving the
shipping routes, several plans and tables of distances,
and will be found of utmost interest to those concerned
with the possible spread of yellow fever to the East.
The Keeping Properties of Condensed Milks in the
Tropics.—Beveridge (Journal R.A.M.C., January
1914), from a careful investigation of this important
matter, comes to the following conclusions: The
change in colour in certain kinds of condensed milks
is presumably due to brown colour being developed
by reducing sugars in solution at certain tempera-
tures, and is likely to be more marked with an
increase of acidity due to bacterial fermentation;
the presence of iron in the ferric state also plays
a part in the production. In sterile condensed
milks, chiefly found among those brands that contain
no added sugar, changes are not noticeable. Sterile
uncondensed tinned milk shows no change after
incubation at 37° C. for many months. The in-
crease in acidity is brought about by bacterial
activity resulting from the increased temperature,
and hydrolysis of the sugar follows. The bacteria
concerned in the change are spore-bearing bacilli,
which produce an acid fermentation of the proteins.
In milks containing only Gram-positive staphylo-
cocci a brown colour is not produced. It would seem
that the depth of the brown colour is dependent on
the amount of reducing sugar produced or of iron
present, and is likely to be more intense in sweet-
ened milks, owing to the reduction of the added
eane-sugar. The increase in consistency noticed in
connection with the brown coloration in sweetened
milks is due also to bacillary fermentation, and
some of the protein is consequently rendered in-
soluble. For service use in tropical climates there
(Feb. 2, 1914.
is no doubt that to obtain better value, and to
obviate the risk of such a change occurring, especi-
ally when milks have to be stored for considerable
periods, only those brands of unsweetened milk
which have been proved to be sterile should be
selected.
The Transmission of Pellagra from Man to
Monkey.—W. H. Harris (New Orleans Medical and
Surgical Journal, November, 1913) reports two ex-
periments on monkeys, and in closing his recital of
these says it would seem that pellagra may be
transmitted to the monkey (Macacus rhesus) by
means of a Berkefeld filtrate derived from the
tissues of the human patient; at least, the animals
develop all the essential clinical signs and sym-
ptoms, together with the pathological pieture pre-
sent in the disease in man. They further suggest
that the etiological factor of pellagra may be a
member of a large group of Berkefeld filter passers,
such as fowl plague, vaccinia, foot-and-mouth
disease, molluscum contagiosum, poliomyelitis, &c.
Pellagra (Journ. Amer. Med. Assoc., January 17,
1914).—J. F. Siler, P. E. Garrison, and W. J.
MacNeal conclude from their investigations that the
supposition that the ingestion of good or spoiled
maize is the essential cause of pellagra is not sup-
ported. Pellagra is in all probability a specific in-
fectious disease communicable from person to
person by means at present unknown. The authors
have discovered no evidence incriminating flies of
the genus Simulium in the causation of pellagra,
except that these flies are universally distributed
throughout the area studied. If pellagra is distri-
buted by a blood-sucking insect, Stomozys calcitrans
would appear to be the most probable carrier. The
authors are inclined to regard intimate association
in the household and the contamination of food
with the excretions of pellagrins as possible modes
of distribution of the disease. No specific cause of
pellagra has been recognized.
—— J————
Hotes and Mews.
THE SOCIETY OF TROPICAL MEDICINE AND
HYGIENE.
THe Society of Tropical Medicine and Hygiene
has now taken a room from the Medical Society
of London at 11, Chandos Street, Cavendish Sauare,
London, W., for its permanent quarters. Fellows
will now, therefore, be able to use this room, from
10 a.m. to 5 p.m. daily, both for reading and for
the examination of microscopical specimens. A
certain number of exchange publications lie upon
the table, and the late Dr. Carnegie Brown's
bequest of books forms the nucleus of a small
library. These works can also be consulted.
It is hoped that Fellows upon arriving home from
abroad will make use of the room and also record
their home addresses there. -By so doing men from
TI
Feb. 2, 1914.]
different colonies will be able to come into touch
with each other and so exchange ideas. Up to the
present time the lack of such accommodation has
been felt by many, and the Society hopes, now it
has been able to get permanent quarters, that this
want will be suitably met.
MEDICINE AND MEDICAL CUSTOMS IN
EGYPT.
(1) The Hearst Papyrus.—The latest addition to
our knowledge of medicine in ancient Egypt is
contained in the '' Hearst Papyrus ” discovered by
United States explorers working in Egypt. The
period of its publication is presumed to date between
the years 2400-1600 s.c. There is little in the text
except prescriptions, but what these are for it is
difficult to judge, for the diseases, as they are pre-
sented, are unrecognizable. There is a close resem-
blanee between the '' Hearst'' writings and that
contained in the '' Ebers Papyrus.” In fact, the
Berlin, the Ebers and the Hearst papyri seem to
have been a collection of prescriptions employed by
doctors of the period mentioned and originating from
some standard text. i
(2) Rectrictions concerning Circumcision under
the Romans.—Recently discovered papyri in Egypt
throw fresh light upon circumcision and castration
in that country, especially whilst it constituted a
province of the Roman Empire. In the time of
Hadrian the system of having à number of eunuchs
in the households of the rich became so prevalent
that there was a danger of a diminution of the popu-
lation, and castration had to be prohibited by law,
and especially enforced during the reign of the
Emperor Antoninus.
Circumcision was also denounced by Hadrian,
although the reason does not seem quite clear,
except perhaps it was for political purposes, seeing
that the Jewish population in Egypt practised the
rite. The Jews, who gained to their ranks many
Roman citizens, insisted that the converts to their
religion and the slaves in their household should
all be circumcised, and it was probably to prevent
secession from the ranks of Roman citizens that the
law was made. In the time of Antoninus the
regulation was promulgated that although Romans
might adopt the Jewish religion, it was illegal for
the Jews to circumcise their converts or their non-
Hebrew slaves. Jews and Egyptian priests were
allowed to practise circumcision, but it was held
to be a criminal act to circumcise the laity. The
question, therefore, seems to have become not a
hygienic, but a political measure of some impor-
tance.
These matters are dealt with in a paper by Joseph
Orford, published in the Proceedings of the Royal
Society of Medicine, April, 1918.
BENGAL MEDICAL BILL.
THE European Defence Association has addressed
the Bengal Government on the provisions of the
Bengal Medical Bill, 1913, and while approving of it
so far as it goes, regrets that its provisions are not
more drastic and comprehensive. Complaint is made
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 47
that the Bill in no way deals with the question of
persons practising the European system of medicine
and advertising themselves as holders of degrees and
diplomas which are unrecognized by the Medical
Council of Great Britain. The Association suggests
in default of legislation to prevent this practice, such
persons should be deprived of power to recover
charges for services by legal proceedings in courts.—
The Homeward Mail.
SCARCITY OF EUROPEAN MEDICAL
OFFICERS IN BURMA.
The Homeward Mail of December 27 says: The
Burma Chamber of Commerce in a long letter call
the attention of the local Government to the inade-
quate provision of European medical officers in the
province, which is aggravated by the medical policy
laid down in the Secretary of State's despatch dated
December, 1908. In other Indian provinces with an
organized European medical service, the practice of
Western medicine has been encouraged where there
is no material for the recruitment for a native
independent medical service. As examples of the
Government's medical poliey the Chamber point to
the refusal to supply Indian Medical Serviee officers
to growing trades centres, the understaffing of the
Rangoon General Hospital. and the slow development
of the Burma Medical School. It is contended that
by the refusal to meet the need for medical aid in
rapidly growing commercial towns, many valuable
lives have been lost and commerce has been checked.
The policy of repression of the Indian Medical Service
is detrimental to the commercial progress of this
young province. The Chamber heartily aequiesce in
the views of the European Defence Association in
their representation to the Government of India on
medical attendance for Europeans, especially women
and children in out-stations. Finally, Burma, it is
urged, has no confidence in medical assistance except
that dispensed by Europeans or Burmans. The local
Government replied and sympathized with the view
that it was desirable to post Indian Medical Service
officers as civil surgeons in the Dumber districts, but
say that they have not now any available. The need
for more such officers in Burma has often been
represented to the Government of India, whose
orders are stil awaited. The Chamber's letter on
the subject will be forwarded to the Government of
India.
We have been requested by Messrs. Butterworth
& Co. (India), Ltd., Medical Publishers and Book-
sellers, to state that they have been appointed sole
agents in India for all the medical and surgical works
of Messrs. John Bale, Sons & Danielsson, Ltd. As
the latter firm are so well known for their numerous
publications dealing particularly with the diseasss of
tropical and sub-tropical climates, and are also pub-
lishers of the JOURNAL OF TROPICAL MEDICINE AND
HYGIENE, we would advise those seeking information
as to the latest editions of such works to write Messrs.
Butterworth at 6, Hastings Street, Calcutta, for a copy
of their catalogue.
48 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 2, 1914.
atlemorandn,
Drua RAsHEs.
Antipyrin causes round or .oval erythematous
patches, succeeded by pigmented areas if the drug
is withheld.
Alkaline bromides and iodides induce acne; the
points may fuse and a lesion resembling a carbuncle
results.
Arsenic at times brings out a brown pigmentation
of limbs when its exhibition is protracted.
Antimony, aconite, beiladonna, iron, morphia,
phenacetin, quinine, salicylates, sulphonal, usually
eause an erythematous rash or urticarial patches.
SLEEPING SICKNESS IN PRINCIPE ISLAND AND
ANGOLA, WEST AFRICA.
In the Portuguese Island of Principe (marked in
most British maps as Prince’s Island), Surgeon
MeCowen, R.N., found in 1911 that sleeping sick-
ness prevailed to an alarming extent. The island
is in the Gulf of Guinea, some 120 miles off the
African eoast and south of the Spanish island of
Fernando Po. More than half the deaths in the
island are due to sleeping sickness. Glossina pal-
palis is the prevalent glossina, but G. palpalis well-
mani (Austen) and G. medicorum (Austen) have
also been found in Principe and Angola. It is in-
teresting to note that the natives quite appreciate
the connéetion between the bite of the tsetse-fly
and trypanosomiasis; the houses of the more in-
telligent natives in Principe have finely meshed
wire gauze over their windows and doorways, and
do not venture out for pleasure until dark, when
the fly becomes inactive The tsetse-fly especially
attacks the back of the neck and the natives have
a habit of continually passing their hands over this
part when walking out of doors. There are plenty
of wild animals in the small island to act as alterna-
tive hosts for the tsetse-fly, and Dr. Mendes, of
Angola, recommends as a mode of freeing the
island from the disease, that all wild animals should
be killed and all the natives and Europeans should
leave the island for twelve months, by the end of
which time trypanosomiasis would probably be ex-
terminated. This is a rigorous plan of campaign
which, however, there is little hope of being fol-
lowed. The notes are taken from Proc. Roy. Soc.
Med., April, 1913.
——.9——————
Personal Hotes.
INDIA OFFICE.
From December 13, 1918, to January 10, 1914.
Arrivals Reported in London.—Major T. H. Delany, I.M.S. ;
Major J. N. Walker, I.M.S.; Major L. T. R. Hutchinson,
I.M.S.; Major F. S. C. Thompson, I.M.S.; Major G. McPher-
son, LM.S.; Captain G. T. Burke, I. M.8S. ; Captain G. McG.
Millar, I.M.S. ; Captain J. Morison, I. M.S.
Extensions of Leave.—Major C. R. Pearce, LM.8., 3 m. ;
Major A. B. Fry, I.M.S., 1 d.
List or INbpraN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Burke, Captain G. T., I.M.S.
Fleming, Major J. K. S., I.M.S., to November 11, 1914,
Irvine, Lieutenant-Colonel G. B., I. M.S., to October 14, 1914.
M'Pherson, Major G., I.M.S.
McVean, Captain N. N. G. C., I.M.S., to June 11, 1914.
Millar, Captain G. McG., I. M.S., to November 25, 1914.
Nauth, Lieutenant-Colonel B., I. M.S., to October 14, 1914.
O'Leary, Captain J., I. M.S., to October 13, 1914.
Pearce, Major C. R., I.M.S., to June 15, 1914.
Roe, Colonel R. B., I.M.S., to May 14, 1914.
Shortt, Captain H. E., I.M.S., to April 9, 1914.
Stewart, Captain 4. D., I. M.S., to October 1, 1914.
Whitamore, Captain V. N., I.M.S.
Woods, Captain J., I. M.S., to February 13, 1914.
List OF ĪNDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Crossle, Captain H., I.M.S , N.-W. F. Prov., 6 m., October 6,
1913. :
Delany, Major T. H., I.M.S., Behar and Orissa.
Dunn, Captain C. L., I.M.S., U.P. Sanitary Comm., 6 m.,
November 4, 1913.
Dutton, Captain H. R., I. M.S., Delhi, 12 m. June 8, 1913.
Fayrer, Major F. D. S., I.M.S., 15 m., September 25. 1913.
Haig, Lieutenant-Colonel P. B., I.M.S., 24 m., October 24,
1913.
Hulbert, Lieutenant-Colonel J. G., I.M.S., U.P., 6 m,
November 12, 1913.
Hutchinson, Major L. T. R., I.M.S., Bo., 12 m., Novem-
ber 15, 1913.
Knapton, Major H. A. F., I.M.S., Bo. Sanitary Comm.,
12 m., October 15, 1913.
Knox, Major R. W., I.M.S., India Foreign Department,
14 m., August 30, 1913.
McCay, Major D., I. M.S., B. Med., 7 m., September 1, 1913.
Morgan, Major E. J., I. M.S., U.P. 6 m., October 1, 1913.
Rainier, Major N. R. J., LM.S., Cent. Prov., 23 m., 29 d.,
October 9, 1913.
Salisbury, Captain F. H., I.M.S., B. Gaols, 6 m., October 20,
1913.
Shaw, Captain W. S. J., I.M.S., Bo., 15 m., November 8,
1913.
Stevenson, Captain W. D. H., I.M.S., Bo. Bacteriological
Laboratory, 13 m., October 4, 1913.
Thompson, Major F. S. C., I.M.S., B. Gaols, 24 m., Novem-
ber 15, 1913.
Walker, Major J. N., I. M.S., U.P., 12 m., October 30, 1913.
Blotices to Correspondents.
1.—Manuscripts if not accepted will be returned.
9, —As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
4,—Authors desiring reprints of their communications to THE
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers,
5.—Correspondents should look for replies under the heading
** Answers to Correspondents,”
Feb. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[N o. 4, Vcl. 3 V
Original Communication.
THE CULTURE OF LEISHMANIA FROM THE
` FINGER-BLOOD OF A CASE OF INDIAN
KALA-AZAR, WITH SOME REMARKS ON
THE NATURE OF CERTAIN GRANULAR
BODIES RECENTLY DESCRIBED FROM
THIS DISEASE.
By C. M. Wenyon, M.B., B.S., B.Sc.
i Protozoologist to the London School of Tropical Medicine.
THE possibility of obtaining cultures of leishmania
from the peripheral blood of cases of kala-azar was
recently demonstrated by Mayer and Werner upon a
case of Indian kala-azar,' which was under treatment
in the Institute for Tropical Diseases in Hamburg
(“Kultur des Kala-Azar-Erregers (Leishmania dono-
vani) aus dem peripherischen Blut des Menschen.”
Deutsch. med. Wochenschrift, January 8, 1914). These
observers inoculated one dozen tubes each with three
to five drops of blood. Four tubes became contami-
nated, but on the twenty-ninth day the eight tubes re-
maining were all growing flagellates.’ This interesting
observation I attempted to repeat upon a case of kala-
azar from Calcutta, which was admitted under the care
of Dr. F. M. Sandwith, in the Albert Dock Hospital."
Repeated examinations of the peripheral blood had
failed to reveal any parasites, though these had pre-
viously been demonstrated by liver puncture. On
January 20 six tubes of N.N.N. medium were inocu-
lated, each with two to three drops of blood, obtained
by pricking the sterilized finger of the patient. The
tubes were then incubated at a temperature of
23°-25° C. Examined on the sixth and eleventh
days no growth of flagellates was noted in the tubes,
though one was contaminated with bacteria. The
tubes were again examined on the eighteenth day, and
in each of the five tubes free from bacteria flagellates
were present in such numbers as to be easily seen
with the low power objective. It is unfortunate that
the peripheral blood of the patient was not examined
for leishmania on the day the tubes were inoculated,
but the long time intervening between the inoculation
of the tubes and the appearance of flagellates in these
in sufficient numbers to be detected proves that the
leishmania must have been present in the blood in
very small numbers. This development and multipli-
cation of the leishmania in the test-tube is a practical
demonstration of the possibility of the true invertebrate
host becoming infected from the peripheral blood of
cases of kala-azar.
Some time ago I was able to obtain a culture of
flagellates from a case of aural ulceration, which was
under the care of Professor W. J. Simpson. The
patient, an Englishman, had an ulcer on the margin
* I am indebted to Dr. Low, under whose care the patient
was when these observations were made, for permission
publish the case, :
of the ear, which had appeared after & journey in
South America. This had persisted for about two
years, and had resisted the various treatments em-
ployed. I made smears from scrapings from the base
of the ulcer, as well as from materlal obtained by
puncture of the red margin. At the same time the
red raised skin forming the edge of the ulcer was
sterilized with alcoholic iodine solution. This was
punctured with a needle, and material was obtained
for inoculating three tubes of N.N.N. medium by
inserting a fine glass pipette through the puncture
wound. Prolonged examination of the various smears
failed to reveal any leishmania, but after an interval
of three weeks flagellates wére present in one of the
tubes inoculated, thus proving that leishmania had
been present in the ulcer, and confirming the suspicion
that the case was one of dermal leishmaniasis.
The culture method on N.N.N. medium can thus
be used as a means of diagnosis in leishmania diseases,
especially in cases of kala-azar, where spleen or liver
puncture cannot be undertaken, and where one has
failed to find leishmania in the peripheral blood. In
some cases, as in the case of Oriental sore just men-
tioned, a diagnosis was made in this way alone. In
animal experiments it is now a fairly common expe-
rience to obtain a culture from organs which have
failed to reveal leishmania in stained smears. In
many of these cases a more prolonged and careful
examination of stained films might reveal the organism,
but one rarely has time to devote many hours to such
a search. In N.N.N. medium a single parasite may
become a flagellate, and multiply in the course of a
week or two till many thousands are present. In
such cases the actual time spent on' making the dia-
gnosis is comparatively small. The only difficulty is
with the N.N.N. medium, which may be a hindrance
to anyone not accustomed to work with it. "The
medium itself is easy enough to prepare, and can be
made by any laboratory assistant versed in bacterio-
logical technique; 14 grammes of agar, 6 grammes of
salt, and 900 c.c. of distilled water are dissolved in
the usual manner, and distributed without filtering in
test-tubes (1 inch in each tube). The tubes are plugged
and sterilized in the autoclave. A rabbit is killed
with chloroform, and tied out on its back. The
thorax is painted with solution of iodine, and the
heart exposed with sterile instruments. A sterile
20 c.c. syringe, with large needle, is used for drawing
the blood directly from the heart. The agar tubes,
which have been cooled to below 50? C., and in which
the agar is still liquid, are held and opened by an
assistant, and into each is introduced about 1 c.c. of
blood, which has just been drawn from the rabbit's
heart. The tubes are rolled in the hand to mix the
still liquid agar and blood and sloped. When solid
they are incubated at 37 C for twenty-four hours, to
determine their sterility, when they are ready for use.
Inoculation is made into the water of condensation
which has collected in the tubes. They are then
incubated at a temperature of 22°-25° C., after being
covered with a rubber cap to prevent evaporation.
By drawing the blood from the heart of a killed
animal it is possible to obtain sufficient to make
50 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
dozen to twenty tubes of medium. If, however, the
operation is performed while the animal is still alive
under anesthesia, much more blood can be obtained,
as the heart is still pulsating, and fills with blood
after each quantity drawn off. In this case it is
better to transfer the blood to small flasks containing
beads for defibrination before distribution in the agar
tubes. In order to watch the progress of the growth
in the tubes, all that is necessary is to remove a small
quantity of the liquid on a platinum loop, place it on
a slide, and examine it with the 3 or $ in. objective,
with the condenser down. There is no need to cover
with a cover-glass, as with a little experience the
flagellates can easily be seen swimming about with
the $ in. objective. Care must be taken to prevent
bacteria gaining access to the tubes.
In cases of kala-azar and Oriental sore, in which
prolonged search for leishmania in stained films has
been negative, and in which the culture method has
given a positive result, are we to suppose that the
culture has resulted from some stage of the parasite
not hitherto recognized, or from leishmania them-
selves, which have been present in numbers too small
to be detected? In theSudan, Archibald (Journal of
the Royal Army Medical Corps, May, 1913) discovered
in the spleen and liver of a case of kala-azar blue stain-
ing protoplasmic masses containing purple staining
granules in varying number, but no leishmania. A
monkey inoculated from the organs developed kala-
azar with definite leishmania in its organs. It was
suggested that the granular masses seen in the human
subject might represent some hitherto unrecognized
stage of the leishmania. More recently Statham and
Butler (Journal of the Royal Army Medical Corps,
December, 1913) have described similar bodies from
the liver of a case of splenic enlargement in West
Africa, and they suggest that they possibly represent
the schizogonic stage of some protozoon, and in the
light of Archibald’s observation that kala-azar may
exist in West Africa, and that these bodies are
developmental stages of leishmania. The typical
leishmania, however, could not be found in the
smears. In the same journal Smallman describes
similar bodies from the liver of a case of Mediter-
ranean kala-azar. At this time no leishmania were
found in the eight smears, though previously they
had been found, so the author inclines towards the
view that some stage in the development of leishmania
is represented.
It might, therefore, be urged that it is some such
a stage which is responsible for the appearance of
flagellates in cultures when examination of smears
has been negative. A very strong argument against
this view is the fact that in all these cases it requires
a long interval of two to three weeks for the flagel-
lates to appear in the tubes in sufficient numbers to be
detected. When the leishmania inoculated into the
tubes are numerous, flagellates are present in great
numbers in less than forty-eight hours, so that for
any individual leishmania to reach the flagellate stage
this length of time is necessary. The flagellates then
multiply and increase in numbers. When the
leishmania introduced are very few it may safely be
[Feb. 16, 1914.
assumed that they also become flagellates in about
forty-eight hours, but that it is only after two or
three weeks of multiplication that they are in sufficient
numbers to be recognized.
Now, as regards the bodies which have been
described by the various observers just quoted, no
evidence whatever has been produced to prove their
parasitic nature. Because protozoa consist of proto-
plasm and chromatin, it must not be forgotten that
the cells of the higher animals consist of the same
two substances, and in smears stained with Roma-
nowsky stains the cytoplasm, whether of a proto-
zoon or the cell of a higher animal, tends to stain
blue, while the chromatin (and other granules also)
stains varying shades of red and purple. And because
certain stages of some protozoa are cytoplasmic
bodies, containing many chromatin granules, it must
be remembered that any portion of cytoplasm con-
taining granules may give the same appearance if
treated and stained in the same manner, for proto-
plasm is essentially the same wherever it occurs.
Such simulation may give rise to error, and one must
not be too hasty in concluding that appearances of
this kind in smears of organs are produced, or are most
likely to be produced, by parasitic protozoa.
For some time I have been working with experi-
mental leishmaniasis in animals, and have been in the
habit. of performing liver punctures on these. On
several occasions, in both dogs and rats, I have
encountered in these liver smears the bodies described
by the authors mentioned above. The bodies vary con-
siderably. Sometimes they are exact reproductions
of Archibald’s coloured plate, at others they cannot
be distinguished from those figured in the papers of
Statham and Butler, and Smallman. I was at first
surprised at this, though I did not think it possible
that they represented any stage of development of
leishmania. Accordingly, I checked the result by
examining in the same manner the livers of other
uninoculated dogs and rats. I found that exactly the
same bodies might occur in these, so that any possi-
bility of their being connected with the leishmania
was at once done away with. The uninoculated
animals were in perfect health, as, indeed, were most
of the others which had been previously inoculated
with leishmania, so that I doubt very much if the
protoplasmic bodies with staining granules are of
any pathological significance whatever. After careful
examination of many films, I am quite convinced that
the bodies in question are merely detached portions
of the cytoplasm of large cells which are themselves
charged with granules. The exact staining of the
cytoplasm varies very much, and depends largely on
lthe extent of disintegration of the cells and the
amount of flattening to which they have been sub-
mitted in the process of film making. The detached
portions of cytoplasm, being much thinner and more
spread out, often stain differently to the cytoplasm of
the intact cell. In cases of actual kala-azar spleen
smears often show cytoplasmic masses, containing
lvarying numbers of leishmania. These are known to
lbe detached portions of the cytoplasm of the large
macrophages, which are themselves filled with leish-
l
Feb. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 51
mania. In a similar manner the large granular cells
of any organ may be broken in film making, giving
rise to detached portions of cytoplasm containing
granules which stain by Romanowsky stains. This is
what has occurred in the case of the animals I have
examined, and what I feel sure has happened in the
cases described by Archibald, Statham and Butler,
and Smallman. It may be that in some cases the
granules represent a degeneration of some of the liver
cells, but one must never forget that they may repre-
sent a purely physiological process, and be connected
with digestion, in which the liver plays such an
important part. The fact that in perfectly healthy
animals such bodies occur is distinctly in favour of
this view. Another point which must not be for-
gotten is that many kinds of material other than
chromatin are coloured red with the Romanowsky
stain and its modifications, so that one must not be
too hasty in jumping to the conclusion that every
red staining granule is chromatin. In the case of the
bodies now under discussion it seems to me that the
red staining granules they contain are probably
deposits of some substance quite different from chro-
matin. But, whatever be the nature of the granules,
the bodies themselves certainly represent no stage of
schizogony of a protozoal organism, since they are
derived from large cells from which they have become
detached. Therefore, in Archibald’s case mentioned
above, in which these bodies occurred, and from which
a monkey was inoculated and developed kala-azar, I
think the only possible conclusion is that the monkey
became infected from actual leishmania, which were
present in the human being in numbers too small to
be detected microscopically. This supposition is sup-
ported by the fact that the patient recovered without
any treatment, so that the infection was, at any rate,
a mild one. If the granules had represented leish-
mania, the liver must have been heavily infected.
Similarly in the case of dermal leishmaniasis from
which I obtained a culture, the flagellates resulted
from leishmania actually present rather than from
any granular stage undetected by me. Of three
tubes of medium inoculated from the sore, it}{was
only in one that flagellates appeared, and this after
an incubation of three weeks.
It might have been advisable to illustrate in a
coloured plate the bodies found by me in the livers
of the animals, but this would have meant nothing
more than a reproduction of the admirable plates
accompanying the papers of the authors, who have
described the bodies from human cases. A reference
to these plates will show the bodies which I have
found in the liver smears of both the healthy and
experimental animals. They are certainly not para-
sites, and are derived from large cells, as already
explained ; but on the exact nature of the red staining
granules in these cells I am not in a position to
pronounce a definite opinion, though I do not think
anyone could urge that they themselves are parasitic.
—————9——————
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THE JOURNAL OF
Tropical Medtctne and Hygiene
FEBRUARY 16, 1914.
THE ACCLIMATIZATION OF ANIMALS IN
THE ZOOLOGICAL GARDENS, LONDON.
THE subject of acclimatization of Europeans in
tropical countries is discussed far and wide, and has
been a question which has attracted scientific and
other observers for a century or more. The reverse
side of the problem, however, is seldom or ever referred
to, namely the effect upon persons who belong to
warm climates taking up their abode in temperate or
cold climates. Migration of peoples northward or
southward is a slow and very gradual process extend-
ing over hundreds or thousands of years; for there is
really no recorded history of the sudden transmigration
of any race of people of unmixed blood from one sphere
to another where the climate is so markedly distinct
as to stamp it equatorial on the one hand and cold on
the other. The Europeans who go abroad go as a
rule individually and not as a people. Young men go
52 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
out as members of the great public services military
or civil, to merchants’ offices or to banks, as engineers,
miners, &c., but they remain, as a rule, from say a few
years to as many as thirty years or over, when they
return to their native land. The question therefore is
acclimatization not of a race but of individuals for a
period of their lives only. It may be said Australia
affords an example of a white race settling in a warm
climate, and no doubt this is so, but the chief centres of
activity in Australia are as far south as possible, that
is, in & climate as neàr that of the motherland as the
continent of Australia can afford. The equatorial
provinces are not sought after and, except for one or
two towns on the Eastern shore of Queensland where
the heat is modified by the temperature of the sea,
there is but little attempt at colonization of the
tropical tract. The tendency of peoples to migrate
to colder climates we can find no recent example of.
The West African negro thrives well in Equatorial
America and in the southern provinces of the United
States, but northwards from there we meet individuals
only, just as we find white men in the Tropics engaged
for a time in their commercial or other pursuits. The
fact is we have insufficient data to go upon to deal
with the acclimatization of races, be it a northward or
a southward migration.
When the scientist cannot find sufficient material
amongst human beings whereby to settle any point he
may be inquiring into, be it physiological or patho-
logical, he falls back upon observations to be obtained
from animals. It may therefore be of some advantage
to discuss what little has been observed upon the accli-
matization of animals, although here again the migra-
tion has been not a natural one, unless we go back to
prehistoric times, but rather an artificial one, inasmuch
as man has been the factor in this transmigration
as against the natural movement of the animals
themselves. We know that dogs, cattle, horses and
sheep are taken from Europe, especially Britain, and
transplanted to tropical or sub-tropical climates; and
vice-versa we attempt to bring animals native to the
Tropics to our shores to fill our Zoological Gardens,
and occasionally for other purposes. The information
to be gathered from animals taken from Britain to the
Tropics is not encouraging as an argument in favour of
the possibility of acclimatization. In most instances
disease intervenes in animals, as in the case of man, to
annul the evidence. In the case of dogs, for instance,
sent from England to the Tropics, disease is rife:
they suffer so readily from parasitic infection of the
intestines and of the blood that few live more than
a year or so. ^" Worms in the heart” (Filaria
immitis) is a constant danger in regions where the
Filaria prevails ; hydatids, intestinal worms, and a host
of parasitic infections are ever at hand to shorten
their lives, and the propagation and continuance of
their species becomes well-nigh impossible.
In addition to disease amongst dogs and other
animals, there is another factor that would appear to
be due to climate alone. It is a curious fact that
stallions, bulls and rams, taken from Britain to warm
climates, lose their verve and ferocity. The pure-bred
stallion degenerates in spirit, and impotency not un-
[Feb. 16, 1914,
commonly supervenes; the Shorthorn, Hereford or
black-polled bull is no longer the rampant animal
encountered in British pastures, but becomes tame
and lethargie; and the pusillanimous ram during a
short residence in the Tropics becomes quiet as a ewe.
Even eats sent to the Tropies soon cease to kill rats,
for which purpose they had been specially imported.
In warm climates farmers háve continually to bring
out fresh males from Britain, be they bulls, stallions
or rams, to replenish their breeds, which otherwise
would tend to dwindle in physique and temperament.
It may be that disease has caused this change in
temperament, and, on the other hand, it may be
“climate” alone. “Climate” must, however, be
taken in the widest sense, for, apart from the heat
of the atmosphere, the vegetation peculiar to the
climate may be the cause of much of the loss of
verve, &c., in animals; for the pastures of the Tropics
are not the meadows of England; cut grass or hay of
a warm ‘climate has not the sustenance of English
hay, nor are the root crops of the quality which
obtains in Britain. In discussing the acclimatization
of men and animals suddenly transplanted ‘from a
cold or temperate climate to the Tropics, it is evident
that many things have to be taken into consideration,
and it may be safely stated that at the present time
we have not sufficient data to go upon to come to any
scientific conclusion one way or the other.
Dealing now with the other aspect of this vexed
question, we have to consider the sudden transference
of animals from warm climates to British or northern
European shores. Our Zoological Gardens are really
the only available sources of information on the
subject; it is only since the work at the Zoological
Gardens, London, has been conducted scientifically
that any reliable information has been forthcoming.
Mr. H. G. Plimmer, F.R.S., the pathologist at the
Zoological Society's collection of animals in Regent's
Park, London, contributes in the recent report of the
Society an interesting account of the death-rates and
longevity of the animals in the Zoological Gardens
during the past year. Observations show that of the
total number of deaths wellnigh half occur within
the period of six months after the animals were
admitted. This would appear as if it was impos-
sible to acclimatize certain species of animals to
the British climate, and that from that cause many
die. But there are so many side issues which bear
upon the subject that the question of acclimatization
is almost ruled out. There is the journey down
country to the port of embarkation, the trials of a
sea journey, the transference from ship to shore and
to the Gardens to be thought of; the weakness of
the animal when caught, its age whether very old
or quite young, and the fact of captivity, each and
‘all bring about a state of health which is apt to prove
detrimental to the newly arrived animal. Yet, allow-
ing for this, it is difficult to believe but that change
of environment, of temperature, of food and water,
and all that appertains to so-called climate, plays 4
considerable, if not the largest, part in the death-rate.
After the first six months the mortality markedly
lessens, until in mammals it amounts to but 16 per
Feb. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 53
cent. of the total, in birds 10 per cent., and in reptiles
13 per cent. Amongst animals passing suddenly from
the south to the north the danger to life is during the
first few months, so in man passing from north to south
it is in the first twelve or twenty-four months that he
is most likely to be attacked severely by the prevalent
diseases of the region of sojourn. In man it ig usually
after the first few months, when the initial stimulus
of heat has worn off, to be succeeded by a corre-
sponding depression, that illness declares itself. The
powers of resistance have declined, and pathological
agents gain the upper hand.
The chief infectious diseases amongst the animals
in the London Zoological Gardens are tuberculosis,
mycosis and pneumonia. Tuberculosis prevailed
mostly amongst small creatures living in one of
the warmest houses of the Gardens, in which the
temperature is maintained at an even level. Snakes
suffered more from pneumonia than any other section
of the animals; it was found that increased heat in
the reptile house caused a greater activity amongst
the snakes, but brought about a prevalence of pneu-
monia, which was most pronounced. Although many
of the animals from Africa were collected in places
where sleeping sickness prevails, in no instance were
pathogenic trypanosomes met with when the blood
was examined. Ina mouse from the Sudan, and in
eight birds and two frogs, trypanosomes were seen,
but of a kind non-pathogenic to man.
It must be remembered that wild animals are ren-
dered more liable to capture by three conditions: a
tender age, old age, and disease; it is one thing to
secure a very young or a very old animal, quite a
different thing to secure a healthy animal in its prime.
To infancy and old age belong certain ailments, which
may hasten death when transferred to the unnatural
environment of captivity and the trying effects of an
altered climate, however warm their dwelling may be
kept. Disease also facilitates capture; a monkey in
health may baffle pursuers, whereas if it is the subject
of illness its inability to escape renders it liable to be
caught by man or other animals. A snake finds diffi-
culty in capturing a healthy, active monkey, whereas
the same animal, when hampered by disease, falls an
easy prey. It is possible, therefore, that the animals
captured for our Zoological Gardens may be either
too young or too old to be suited for the experiment
of emigration from a hot to a cold climate, and that
disease in some form being present at the time of its
capture, thus rendering the animal more liable to be
secured, may increase the mortality rate of new
admissions over and above the direct effects of
climate merely.
The circumstances recounted above, to which many
more could be added, serve to show that it is difficult
to ascertain whether in mankind or in animals it is
possible to say how much climate per se has to do
with the illness and mortality in the question of
acclimatization.
J.C.
Abstracts.
LEPROSY.*
By Victor G. HEISER.
Surgeon, United States Public Health Service, Chief Quarantine
Officer and Director of Health for the Philippine Islands.
TREATMENT OF Two CASES WITH APPARENT CURE.
Two lepers, in addition to those previously re-
ported as successfully treated with hypodermic in-
Jections of chaulmoogra oil and resorcin, have been
discharged from San Lazaro Hospital, Manila, after
having been free from leprosy for a period of two
years. The principal interest in these cases is in
the fact that, unlike the two preceding cases, which
were reported as having been released as apparently
cured, the cases here reported received no vaccine
treatment. They were also very mild cases. The
history is briefly as follows :—
F. A., female, aged 11, a native of Zamboanga,
Moro Province, was admitted to the San Lazaro
Hospital, January 5, 1911. She had large leprous
macules over the outer surfaces of both legs, extend-
ing from the malleolus almost to the knee, and
similar large leprous macules upon the forearm.
The diagnosis was microscopically confirmed. The
use of chaulmoogra oil by mouth was begun, January
7, 1911, in ten-drop doses three times a day, with
one-sixtieth of a grain of strychnine. By February
15 the nausea became so great that the patient
refused to take any more of the oil by mouth.
Hypodermie injections with the formula composed
of chaulmoogra oil, resorcin, and camphorated olive
oil was started on February 15, 1911, in 1 c.c. doses.
The injections were repeated at weekly intervals
and gradually increased in quantity until they
reached 12 c.c. per dose by April 20. The dose was
then gradually reduced in the same period as it was
increased until 1 c.c. was reached and then gradu-
ally increased again to the maximum dose. On
October 15, 1911, the patient was microscopically
negative for leprosy. From that date until January
7, 1913, the patient absolutely refused to take any
form of treatment. Microscopical examinations
made from time to time during this period resulted
negatively. From January 7, 1913, until October
30, ascending and descending doses of the chaul-
moogra oil mixture were administered as before. A
few months after the original hypodermic injection
of the oil was begun the leprous macules began to
uleerate. These ulcers gradually healed and by
October, 1911, were entirely scarred over. A final
microscopical examination was made October 30,
1913, and no leprosy bacilli could be found nor was
there any clinical evidence of the disease. The only
signs observable were the scars where the leprous
lesions had previously existed. The patient was
discharged October 30, on probation, as being appa-
rently cured.
The other case is that of C. A., Filipino, aged 40,
* **Publie Health Reports," vol. xxix, No. 2, January 9,
1914.
54 THE JOURNAL OF TROPICAL. MEDICINE AND HYGIENE.
who was admitted to the San Lazaro Leper Hospital
on May 4, 1911, with the diagnosis of leprosy, which
‘was microscopically confirmed. He had a large,
dark, pigmented leprous macule, approximately
5 by 10 cm. in outline, on the outer side of the leg
above the malleolus. He had a similar lesion, but
somewhat smaller, which involved the area above
the left ear and some infiltration of the lobe of the
left ear. Upon admission to the hospital the chaul-
moogra oil mixture was injected into the buttocks at
weekly intervals, with an initial dose of 1 c.c.,
which was gradually increased to 5 c.c. When
efforts were made to give him larger doses he suf-
fered from severe palpitation of the heart and a
precordial distress. The leprous macules began to
improve a few weeks after the treatment was started
and had entirely disappeared by August 25, upon
which date the leprosy bacillus could no longer be
found. After August 25 he refused further treat-
ment. He was then placed under observation in
non-leprous quarters. Microscopic examinations
were made from time to time, all of which resulted
negatively. He was microscopically examined on
November 4, 1918, with negative results, and has
been discharged from San Lazaro Hospital on proba-
tion, the same as other cases.
EPIDEMIOLOGIC: STUDIES OF ACUTE
ANTERIOR POLIOMYELITIS.*
By Wape H. Fnosr.
PoLioMYELITIS is due to a specific infective agent,
of which the only demonstrated natural sources are
infected human beings, who may be divided into
the following groups: 'The recognized sick, con-
valescents, the sick not recognizable as polio-
myelitis cases, and passive virus carriers apparently
in good health. The infective agent is known to be
discharged from these sources in the excretions of
the respiratory and digestive tracts; it is known to
be fairly resistant to the destructive agencies
encountered in nature outside of the human body,
and to be capable of gaining access to the tissues
of monkeys and causing infection through the
apparently uninjured mucous membrane of the
nose; also, though less constantly, through the
digestive tract and through the agency of certain
biting insects of wide distribytion in nature.
The disease is, in nature, of widespread though
rare sporadic or endemic occurrence. In epidemics
it has occurred in recent years over a large part of
the world, the outbreaks being sometimes discrete,
at other times spreading rapidly, but irregularly over
wide areas. Such epidemics characteristically run
a rather rapid course in a given community, declin-
ing after a few months or less, after having attacked
(so far as is evident) only a small proportion of the
total inhabitants, usually not more than one in a
thousand; and do not recur in the same locality for
a period of at least two years. In epidemic foci
children under 5 are attacked much more often than
* Bulletin No. 90, Hygienic Laboratory, United States Public
Health Service.
(Feb. 16, 1914.
are older persons, the whole adult population
remaining virtually immune in some epidemics.
The rapid spread of epidemics over wide areas,
their spontaneous decline after only a small pro-
portion of the inhabitants have been attacked, and,
above all, the preponderating incidence in young
children have not been satisfactorily explained by
any hypothesis other than that the infective agent,
during epidemics, is widespread, reaching a large
proportion of the population, but only occasionally
finding a susceptible individual, usually a young
person, in whom it produces characteristic morbid
effects.
The conclusion that susceptibility to poliomyelitis
is comparatively rare, and that the incidence of the
disease is limited chiefly by a general immunity
rather than by the dissemination of the virus, is
reached primarily by exclusion, since no other
hypothesis yet advanced satisfactorily explains the
epidemiological peculiarities of the disease. The
conclusion is, however, greatly strengthened by
direct evidence, namely, the demonstration of the
virus in the secretions of healthy persons. Obviously,
the fact that these persons, though carrying the
virus in their secretions, have developed no clinical
evidence of infection, is proof of their insuscepti-
bility. Should passive carriers be shown to be
actually more numerous than clinically recognizable
cases of poliomyelitis, then it will be proven that
immunity to this infection is more general than
susceptibility.
The only definite conclusion, then, which is drawn
from the epidemiological studies of poliomyelitis is
that the infective agent is, during epidemics at
least, quite widespread throughout the population
affected, the incidence of the clinically recognizable
disease heing limited by the relatively rare suscep-
tibility to the infection. This conclusion, in the
light of our present knowledge, holds equally well
whether it is assumed that the route of infection
is through contact, through insects, or through
dust; whether the ultimate sources of infection are
human beings or lower animals.
As to what constitutes susceptibility or the con-
verse—immunity—practically nothing can be de-
duced except that age is obviously a factor of
importance, susceptibility being generally greatest
in the first half decade of life, thereafter progres-
sively diminishing until in adult life there is a very
general immunity to natural infection.
The reason for this is at present a matter of
speculation. Conceivably the greater immunity of
adults may be due to a non-specific resistance,
developing naturally with maturity, without refer-
ence to previous exposure to or infection with the
specific virus of poliomyelitis.
On the other hand, there are certain facts which
suggest that the very general immunity of adults
may be specific, acquired from previous unrecog-
nized infection with the virus of poliomyelitis. The
facts which suggest this are as follows :—
(1) Poliomyelitis is known to occur in forms quite
difficult to recognize clinically. There is, indeed,
good reason to believe that even during epidemics
Feb. 16, 1914.]
the number of cases without paralysis exceeds the
number of paralytic cases. The occasional develop-
ment of typical paralysis without any distinctive
premonitory or accompanying constitutional disturb-
ance illustrates how insidiously the disease may run
its course. It is obvious that such cases, without
the development of paralysis, which may perhaps
be considered as a complication or accident, would
never be recognized as poliomyelitis.
(2) The perennial occurrence of sporadic cases
shows that the infection is and has been endemic,
at least in this country, for a number of years. The
morbidity returns for the last few years indicate that
the disease is constantly present, especially and
most constantly in the large cities.
(3) The spontaneous decline of epidemics in
localities where only a very small percentage of the
population have been attacked, and the subsequent
immunity of these localities while the epidemic
spreads in contiguous localities suggests that a
population may be immunized by an epidemic
giving rise to only one recognized case of polio-
myelitis among several hundred or several thousand
inhabitants. The immunity of the third ward in
Buffalo during the time that the adjacent wards
were suffering most severely is an excellent illus-
tration of this apparent immunization of a large
group of people. A much more striking illustration
on a large scale is afforded by the history of the
Swedish epidemic of 1911, sparing, as it did, the
localities chiefly affected in 1905, while attacking
most severely localities immediately contiguous.
(4) From admittedly imperfect statistics the
immunity of adults appears to be, in this country
at least, relatively greater in large, thickly populated
cities than in smaller towns, especially greater than
in rather remote rural sections. This is deduced
from the comparative age incidence in rural and
metropolitan epidemics, it having been noted that
in large cities cases during epidemic outbreaks are
confined more exclusively to children aged under 5
years. This suggests that persons residing in densely
populated large cities have been more generally
immunized in early life than have those living in
more remote rural sections, as would be expected,
considering the greater chances for contact in large
cities. The same conclusion is again suggested by
the fact that in rural districts the total incidence
of epidemic poliomyelitis is characteristically higher
than in large cities.
(5) While it seems at first almost inconceivable
that a disease like poliomyelitis could be very gener-
ally endemic without being more often recognized,
the hypothesis that it may be so is supported by
some fairly close analogies. For example, typhus
fever, though not believed to be widespread nor
common, undoubtedly did exist endemically in New
York and other cities for a number of years without
being recognized, notwithstanding that numerous
cases came under the most careful clinical observa-
tion. The same is probably true of pellagra and
undoubtedly true of uncinariasis in the United
States.
Yellow fever occurs endemically and perennially
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 55
in some places almost unnoticed, the cases being
apparently confined to newcomers and young
children, and in the latter being often, if not
usually, unrecognized, early attacks being in fact
deduced chiefly from the general immunity ex-
hibited by these people in later life.
Measles, though not occurring commonly in un-
recognized form, furnishes an analogy of a disease
which in communities where communication is free
is almost exclusively a disease of children, ap-
parently for the reason that the adult population
have been immunized by previous attacks. When
introduced into territory that has long been free
from the infection, measles attacks adults and
children alike.
THE UNIFORM SUCCESS OF SEGREGATION
MEASURES IN ERADICATING KALA-
AZAR FROM ASSAM TEA GARDENS.*
By J. Dopps Price, M.R.C.S., L.R.C.P.
AND
Leonard Rocers, M.D., I.M.S.
In 1906-7 we investigated together the problem of
the epidemiology of kala-azar on tea gardens in the
Nowgong district of Assam. In 1895 new lines
were built for a number of freshly imported coolies
arriving on the Rangamati tea estate. Rogers com-
menced his investigations in the Nowgong district
in April, 1896, and as the result of detailed inquiries
he independently arrived at the conclusion that the
infection was a house one, as fully recorded in his
original report of 1897 and in ‘‘ Fevers in the
Tropics.”
On investigating together, in 1897, the effects of
bringing into use the new lines at Rangamati, it
was found that no case of kala-azar had occurred
among 150 coolies who had then resided there
for two years. Yet out of fifty coolies of the same
batch who had been living in the old infected lines,
for want of room in the new ones, no fewer than
16 per cent. were already dead of kala-azar, while
others were suffering from the disease, and that in
spite of the fact that the new lines were situated
only 300 yards from the old ones.
It was therefore decided to ascertain if the disease
could be stamped out of already infected coolie lines
by moving out all the healthy persons into newly
built lines, and segregating the remaining infected
families. As it was then impossible to diagnose the
disease in its early stages from ordinary malarial
fever (kala-azar being at that time regarded by us as
a peculiar severe epidemic form of malaria), it was
decided to move into the new lines no person in
whose household any cases of kala-azar had occurred,
lest some of them might already be suffering from an
early stage of the disease, and thus carry the infec-
tion with them. At the Old Solona out-garden lines
of the Rangamati estate the infection was so severe
* Abstract of a paper in the British Medical Journal,
February 7, 1914.
56 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
in this community that no fewer than 144 out of 240
souls had cases of the disease in their households,
so that only the remaining ninety-six people could
be moved, while five of these had to be sent back
very soon after on account of developing fever. The
new line was filled up with freshly imported coolies,
who now number 800 workers, and to this day—that
is, for sixteen years—they have remained absolutely
free from kala-azar. Of the ninety-six people who
had to be left in the old infected lines nearly all con-
tracted the disease and died of it during the next few
years. Moreover, the kala-azar spread to a contigu-
ous line with sixty healthy coolies, who had worked
for years on the estate, and who refused to move
into new lines. One-third of them died of the disease
within the next fifteen months, and the rest nearly
all succumbed or left the estate during the few
succeeding years. Their huts have now ceased to
exist, and with them the dread disease has disap-
peared from that neighbourhood. Nevertheless, the
new lines—which have now remained free from
kala-azar for sixteen years—are only 400 yards from
the old ones, which continued to suffer so severely
for several years after the new lines were inhabited.
The remarkably successful result obtained in this
first experiment has encouraged other tea-garden
managers and directors to repeat the procedure in
connection with coolie lines infected by kala-azar.
The results obtained during the last sixteen years
have been uniformly successful, and absolutely
prove the soundness of the measure, thus rendering
this measure one of the first importance in dealing
with the most terrible disease of India, and also
throwing considerable light on the probable mode
of infection.
As there have been no material extensions of
the area under tea in the Nowgong district
during the period of time dealt with owing to the
difficulty in increasing the labour force, the present
working population of the coolie lines is much the
same as formerly. Kala-azar has been stamped out
of a labour force of nearly 7,000 workers, after it
had caused a mortality within a few years of 207 per
mille, and although, subsequently to moving the
coolie lines, over half of the infected households
which had to be left behind on the infected sites
died of the disease. As it costs from £7 to £14 to
recruit a coolie, and the average duration of the ill-
ness is at least seven months, during which food and
treatment costs £4, it is clear that, in addition to
the great saving of life and suffering, the financial
aspect of the case to the tea industry is of great
importance.
The Amluckie Tea Garden Outbreak of 1896-1904.
The mortality from kala-azar in 1899 and 1900
amounted to no less than 128 and 106 per mille,
while in the previous two years it had also been very
high, although unfortunately the exact figures are
not now available. The sudden drop in 1901, after
the new lines had been occupied, to under 9 per
mille deaths from kala-azar, and the complete and
lasting eradication of the disease within a year after
the completion of the new lines, are conclusive in
regard to the effectiveness of the measure. It is
not too much to say that this fine estate was saved
from very great loss, if not ruin, by the measure
under consideration. The high case mortality of
&bout 90 per cent. shows the virulence of the
outbreak.
The Seconee Tea Garden Outbreak of 1908-13.
This garden escaped infection by kala-azar until
some years after the epidemie had died down to a
great extent in the Nowgong district. Nevertheless,
when the disease did break out, it ran àn aeute
epidemie course with a high death-rate, thus show-
ing that tea-garden coolies, who are mainly recruited
from parts of India where kala-azar is comparatively
rare or totally unknown, are liable to severe out-
breaks of the disease, should the infection once
gain a footing among them. The number of deaths
to October, 1913, has been 151, the complete re-
coveries amount to twenty-one, while two cases are
still under treatment. Omitting the last two, whose
condition is still doubtful, the case mortality has
been 87:8 and the recovery rate 12:2 per cent., or
a little over that of the Amluckie outbreak of ten
years earlier, thus showing no appreciable diminu-
tion in the virulence of the disease.
In May, 1911, new lines were constructed, into
whieh 300 healthy people were moved, leaving
behind in the old lines ninety-eight persons with the
infection in their households; all the uninhabited
huts in the old lines were destroyed. Of the
ninety-eight people left in the infected lines
twenty-three have died within the ensuing two
and a half years; being nearly one-fourth of the
whole labour force of the estate. The new lines
are situated some 600 yards from the old site, but
on higher ground. It is also worthy of note that,
owing to no water being obtainable in the new lines
except by digging a deep well, the old well was
exclusively used during the first year after the new
lines were opened, and it is still used during the dry
cold and early hot weather months, when the supply
in the new well runs short. Nevertheless, the kala-
azar rapidly died out after the lines were moved,
only two cases now remaining. Only one of these
had lived in the new lines, and he was a bungalow
servant, who used also to visit the neighbouring
villages and markets. At Seconee, then, there was
no change in the drinking water, which can there-
fore be excluded as being in any way associated with
the incidence of the disease. Segregation was
adopted here earlier than in the former cases,
although not until very serious loss of life had
occurred from kala-azar. It was very noticeable at
Seconee, as in all former outbreaks on tea gardens.
that it was the acclimatized coolies, who had worked
for years on the estate, who succumbed to kala-azar.
Their loss is particularly serious from the labour
point of view, as it is now impossible to replace
them by an equally good class of workers, and as
they are very rarely sick they form the backbone
of the labour force.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 57
Feb. 16, 1914.]
The Results of Removal.
The above two examples demonstrate how simply
and certainly a serious outbreak of kala-azar can be
controlled and, within a comparatively short time,
completely eradicated from very badly infected
coolie lines of tea estates by the measures advocated.
In fact, it would be difficult to find a more successful
method of dealing with such a deadly and ruinous
human disease in the whole range of preventive
medicine. It is particularly worthy of note that
this efficacious measure was worked out as a result
of epidemiological studies, at a time (1896-7) when
we were ignorant of the true nature of kala-azar and
its mode of infection; while it was not then even
known how the infection of malaria itself was con-
veyed from one person to another. The facts
collected having established that the infection clung
to the houses or their sites, this sufficed to enable
us to evolve a simple plan of dealing effectually
with the epidemic which was ravaging the Nowgong
district and ruining its chief industry.
The Indefinite Occurrence of Kala-azar in Coolie
Lines once Infected if Segregation Measures
are not carried out.
The following is an account of the disease in two
control lines :—
Solona.
This estate, which contains two coolie lines, called
Solona and Borghot, became infected with kala-azar
as early as 1896. The partial measure of removing
the evident and suspected cases of kala-azar from
the infected lines to a segregation camp during the
four years from late in 1897 to 1900 had a very bene-
ficial effect in greatly reducing the number of deaths
from the disease subsequently. The kala-azar camp
was broken up at the end of 1900, and two years
later the deaths in the old infected lines began to
mount once more from five in 1901 to fourteen in
1902, while the figure reached twenty-four in
1904. In 1905 a marked decrease again
oceurred, which lasted for six years. This
decline in the disease coincided with the carry-
ing out of the following measures. Disinfection
directed towards the destruction of bed-bugs was
carried out in all the infected houses in the Borghot
lines in the hot season of 1905, and it is worthy of
note in this connection that the Borghot lines had
only about half the number of deaths that occurred
in the Solona lines during the following six years,
although the population of the former (850) is con-
siderably greater than that of the latter (650). An
even more important factor was doubtless the con-
struction of new lines only a few hundred yards
from the old Borghot lines, in the cold season of
1905-6, into which all the newly imported coolies
were placed. This new line has remained almost
entirely free from kala-azar during the last eight
years, the few cases which did occur being due to
carelessness on the part of the manager in allowing
admissions of coolies from the infected lines. In
1901 a distinct recrudescence of the disease took
place in the two old infected lines, fifty-two deaths
having occurred within just under three years, un-
doubtedly due to newly imported coolies being again
placed in the old lines, owing to the new ones having
become filled up. It is thus abundantly clear that
the partial measures adopted in the case of this
estate have failed to eradicate the disease, which has
caused more deaths during the first eleven months
of 1918 than in any year since 1899, when the kala-
azar camp was in full use.
We have here the clearest evidence that as long
as fresh material, in the form of newly imported
coolies, is introduced into infected lines, so long
will the disease continue to exact a heavy toll in
lives, with consequent serious financial loss. The
construction of new lines has at length been com-
menced, into which all healthy families will be
moved out of the infected lines, as many as possible
of the old houses in which will then be destroyed
and the remaining infected families segregated in
one of the old lines.
Rangamati Old Lines.
Here the disease broke out as early as 1894, and
has continued ever since—that is, for almost twenty
years—in the old lines, which have not been moved,
although the new lines, only 300 yards distance,
have remained free since they were built in 1895.
Here, again, we have a clear illustration of the
continued occurrence for an indefinite period of
kala-azar in infected lines, which have not been
dealt with by removal of the healthy families and
prevention of the admission of newly imported
coolies. This instance is all the more striking from
the fact that only 300 yards away is situated the
first of the newly constructed lines, from which all
kala-azar cases have been carefully excluded, and
which has remained quite free from the disease for
no less than eighteen years, during the whole of
which period cases have continued to arise yearly
in the old infected lines. Again, we have here
further proof of the fact that the old acclimatized
coolies, who have lived for years on the estate, many
of them having been born and bred there, are
sooner or later attacked by the deadly disease, if
they continue to reside in infected lines, although
they seldom suffer from other serious disease, and
form the most valuable and reliable portion of the
working population.
The continued occurrence for from eighteen to
twenty years of cases of kala-azar in the only
two infected coolie lines in the Nowgong district,
which have not been dealt with by means of the
segregation measures, which we have shown to have
been uniformly successful in the case of the ten
consecutive lines in which they have been carried
out, furnishes the most convincing evidence possible
that the complete eradication of the terrible kala-
azar from every garden where this plan has been
fully put into execution has really been due to the
methods advocated.
THE BEARING OF THE Success oF SEGREGATION
MEASURES ON THE PROBABLE MODE OF INFECTION
OF KALA-AZAR.
The uniform success of the prophylactic measures,
based on the observation that the infection of kala-
58 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
azar clings to the houses and their sites, is a fact
of great importance in considering the probable mode
of infection of the disease. As it has been proved
that a distance of a few hundred yards—not more
than 300 to 400 in certain instances—suffices for the
permanent protection of coolie lines, provided no
infected person is allowed to reside in them, we may
exclude any mode of infection through such flying
insects as mosquitoes. Moreover, malarial fever
soon becomes as rife in the new lines as in the old
ones, a malarial infection rate among children of
about 80 per cent. in both old kala-azar infected lines
and in a new one which had been free from the
latter disease for several years, so there could have
been no lack of mosquitoes in the new lines. This
high endemic index accounts for the number of
kala-azar patients found to be infected with malarial
parasites in 1896, that is, several years before the
frequent malarial infeetion of apparently healthy
people was known.
Indications for a Non-flying Insect Carrier, most
probably the Bed-bug.
It will be evident that a considerable number of
people may live for several years in the same lines,
or even, as often happened, in the same house as
other persons infected with kala-azar, and yet
entirely escape the disease. The further fact that
if people go on living long enough in such infected
houses or lines the great majority of them do even-
tually contract the disease, so that after a number
of years almost the entire population of a set of
contiguous huts may die of kala-azar, appears to
show that the slowness of infection is not due to
any lack of susceptibility to the disease, and that in
the very same lines every soul is likely to contract
malaria over and over again within the same period
of time. It would appear from these facts that, if
even one bed-bug in a hundred was capable of carry-
ing the infection of kala-azar, every person in an
infected house would rapidly develop the disease.
Moreover, the comparative rarity of the parasites in
the peripheral blood, as compared with malaria,
alone accounts for much of the difficulty in experi-
mental and natural infection of the insects. It
would be quite sufficient for bed-bugs only very
rarely to become capable of conveying the infection,
under conditions an exact knowledge of which is not
yet available, to enable them to be efficient carriers
of the disease.
In this connection we may refer to the
experiment carried out with a view to ascertaining
if measures directed against the bed-bug would
prove effective in freeing houses from infection.
Fumigating the houses with sulphur, disinfecting
the beds with solution of corrosive sublimate in
boiling water, and burning old clothes were followed
by the disappearance of the disease from a row of
badly infected coolie huts for several years, but
this measure was found to be troublesome and
expensive. Moreover, cases reappeared in other
parts of the lines, and the disease was. not com-
pletely stamped out. Burning the thatched. roofs
in the houses also failed to prevent subsequent cases
(Feb. 16, 1914.
occurring in them. The mud walls of these houses
were over 2 ft. in thickness, and the flames died
down long before the whole thickness of the walls
could have been sufficiently heated to destroy all
the bed-bugs within their crevices, so that the failure
of this measure can easily be understood. It is also
known that bed-bugs can live for many months
without food, so that the clinging of the infec-
tion to houses harbouring them is not surpris-
ing. Were it not for the facts now known regarding
the life-history of the parasite, the evidence would
go far towards incriminating the actual soil as well
as the houses; but on the whole the bed-bug theory
best accounts for all the known facts, including a
few instances of infection of Europeans through
cohabiting with native women suffering from kala-
azar. The development of the parasite into the
flagellate stage in bed-bugs obtained by Patton goes
very far towards establishing this theory.
The success in ten consecutive tea gardens where
the segregation methods have been carried out is
sufficiently convincing evidence of the infectiousness
of the houses, and possibly of their sites, to enable
this theory to be safely acted on until such time as
the problem is completely and finally solved. Un-
fortunately, the measures which can be adopted in
tea-garden coolie lines cannot be so easily carried
out in the case of infected villages or isolated
sporadic cases, although the principles remain the
same in either case, and further efforts in this
direction are much to be desired.
The Permanency of Recoveries from Kala-azar.
Scepticism is not rarely expressed as to whether
undoubted kala-azar is ever recovered from. In
hospital practice it is only exceptionally possible
to follow up patients for a sufficiently long time
to prove the occurrence of complete and lasting
recovery. Several European children have not only
recovered but have remained quite well for a number
of years. During twenty years’ experience in
Assam, in upwards of 2,000 cases from first to last
on tea estates, there were over 150 complete and
permanent recoveries, in which the patients: con-
tinued to do full work for years. In the tea-garden
cases the recoveries have not followed any special
line of treatment, but not infrequently occurred
most unexpectedly. It sometimes followed on a
septie infection, as in one of the cases, in which
gangrene of the scrotum was the turning point in
the course of the disease.
—— 9 —————
Annotations.
Cultivation of Piroplasma canis.—J. G. Thomson
and H. B. Fantham (Annals of Tropical Medicine
and Parasitology, December 80, 1913) have suc-
ceeded in cultivating Babesia (Piroplasma) canis in
two out of four attempts, following the method of
Bass, using blood and glucose, and incubating at
379 C.
In one of their cultures, starting with heart blood
containing corpuscles infected with one, two, or,
Feb. 16, 1914]
exceptionally, four piroplasmata, they succeeded in
obtaining a maximum of thirty-two merozoites in a
corpuscle. Various types of Babesia were seen
in their cultures, namely, pyriform, ameboid,
rounded and oval parasites. Division of rounded
forms was observed, following the method of gem-
mation with chromatinic forking. There was
evidence, in stained specimens, of direct binary
fission. Hemolysis occurred in allthe culture tubes.
A puppy was successfully inoculated from a
forty-one hours’ culture, and succumbed to
piroplasmosis on the fifth day.
The authors find that Babesia canis is not so
easily cultivated by Bass’s method as the malarial
parasites of man.
Pellagra in America.—Gehring (in the New York
Medical Journal, December 20, 1913) reports three
eases of pellagra seen in Oxford County, Maine,
during the past spring and summer.
These cases, together with others recently
reported by Lee, of Boston, and McDonald, of the
Danvers State Hospital, fail to establish the etio-
logy of the disease, but they confirm the belief,
becoming every day more general, that pellagra is
not a disease peculiar to tropical regions. These
patients had never been out of the State and had
lived continuously in Oxford County, where they
had been born. All had gastro-intestinal symptoms
and typical skin lesions, but as yet only two have
presented mental abnormality. In two, mental
symptoms preceded those of the gastro-intestinal
tract and skin, whereas in the third, although the
skin looked as if painted with iodine, and diarrhea
had been a distressing symptom; as heretofore
stated the mind had not become affected.
One's home was crowded and dirty; the others
lived in clean, sanitary dwellings, but all had spent
their days in one of the garden spots of the earth—
Oxford County, Maine.
Trypanosomiasis.—Blacklock and Yorke, writing
in the Annals of Tropical Medicine and Parasitology,
December 30, 1918, discuss the probable identity of
Trypanosoma congolense (Broden) and T. nanum
(Laveran).
In a paper published by them on the identification
of the more important mammalian trypanosomes,
T. dimorphon (sensu Laveran and Mesnil), T. con-
fusum (Montgomery and Kinghorn) and T. pecorum
(Bruce) were regarded as synonymous with T. con-
golense, which was first described by Broden in
1904. In the same year Laveran described a
similar parasite found by Balfour in the Sudan,
under the name of T. nanum. These parasites are
identieal morphologically in that they are both short
aflagellar trypanosomes measuring 8 to 19 microns
in length. The sole distinguishing feature is their
effect on small laboratory animals, T. congolense
being described as pathogenie for monkeys, dogs,
rabbits, guinea-pigs, rats and mice, while T. nanum
is considered to be incapable of infecting these
results giving the lie to diagnosis.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 59
animals. The object of the present paper was to
examine the evidence upon which this distinction
is based and to decide whether it is sufficient to
warrant such a differentiation.
As the result of their investigations and of those
of the authors mentioned above, Blacklock and
Yorke can see no evidence which would justify them
in distinguishing one from the other on the ground
of pathogenieity. In the present state of our know-
ledge they can only conclude that T. congolense and
T. nanum are the same parasite.
Ezanthematic Typhus.—Naunyn (Deutsche medi-
zinische Wochenschrift, December 4, 1913) believes
this to be a collective term, which indicates several
distinct members. Naturally we could not form a
distinct conception of this affection until abdominal
typhus had been thoroughly dissociated from it. In
fact, our knowledge of the spotted typhus as an
entity dates only from 1849, and is not necessarily
the terrible typhus of the Napoleonic wars. The
two new diseases were studied side by side. In the
author's time they were badly confused, autopsy
Critically speak-
ing, there are no post-mortem appearances which
characterize typhus. Much stress was laid on the
quality of the rash intra vitam, and this exhibited
great fluctuations (macule, petechie, marmoriza-
tion). Many acute infectious diseases present a
pieture not unlike typhus, as Weil's disease, certain
cases of malaria, Brill’s disease, Manchurian
typhus, &c. Brill's disease is especially instructive,
as illustrating the impossibility of separating it
wholly from true typhus, tabardillo, &c. In times
of great epidemics typhus and the bubonic plague
behave in much the same manner. Indeed, judg-
ing only from this behaviour one might decide that
they represent one and the same epidemic. This
view was expressed by Murchison many years ago,
who added that spotted typhus played the very
same réle in the temperate zone that bubonic plague
did in the Tropics. We have not yet found the
germ of any of the typhuses; and when we do,
should not be surprised to find several of different
sorts. In any case, the author feels confident that
ultimately ‘‘ typhus exanthematicus ” and ‘‘ fleck-
fieber ’’ will disappear from our nomenclature.
A New Type of Typhus in East Asia.—Furth,
who is stationed in China, reports (Münchener
medizinische Wochenschrift, December 2, 1918) an
episode which tends to bear out Naunyn’s recent
claim that typhus is more a syndrome than a disease.
In the group of six cases treated, the exciting cause
appeared to be the usually saprophytic Bacillus
fecalis alkaligenes. Ordinary typhoid was readily
excluded. The bacillus just named was found in the
blood and intestinal discharges. The patients were
sailors on the same vessel. The symptoms which
ushered in the attack were violent headache and
pain in the limbs with great fatigue. Fever of 39° C.
60 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Aside from a slight pharyngeal congestion there
were no local symptoms whatever. The pulse was
accelerated, but the heart and blood-picture un-
altered. There was barely a leucocytosis. The urine
gave a positive diazo reaction, but nothing further
abnormal. The fever curve showed great variation,
but was of the same type for all. All patients re-
covered unharmed, save one left with myocarditis.
An exanthem is not mentioned, and Naunyn implies
that the existence of one is not indispensable.
Neither are stupor and apathy mentioned, perhaps
because of the benign character of the episode. The
febrile period extended between three and four
weeks, and two patients had a relapse. Naturally
the B. fecalis alkaligenes may have been associated
in the blood with an invisible causal germ, and may
have simply played a saprophytie réle save that its
liberated endotoxins may have modified the disease
picture.
Treatment of Leprosy.—In the Report of the
Surgeon-General of British Guiana for 1912-18, the
Medical Superintendent of the Public Leper
Asylum, Demerara, Dr. F. W. Wills, states that
in view of the unfavourable reports that have been
made of the value of nastin in the treatment of
leprosy, nastin is not now supplied for routine treat-
ment at the asylum; he adds that in four cases
-discharged as cured by nastin all returned later to
the asylum showing evidence of the disease; but he
remarks that the treatment was completely dis-
continued when the lepers left the asylum. Of
eleven cases of nodular leprosy treated by one of
three strains of leprosy bacilli extract prepared by
Dr. Bayon, of the Lister Institute, no clinical
effects were noticed. The injections were made
every third day, the cases carefully watched, and
the temperature taken frequently. Owing to the
absence of any apparent effects, treatment by
bacterial extracts was discontinued after twenty
injections owing to the material appearing inert.
Treatment for wounds and ulcers in lepers by a
2 per cent. solution of iodine, which has been
favourably spoken of, did not fulfil the expectations
hoped - for, although fairly satisfactory results
obtained as a rule. The chief cause of death in
-the leper asylum was muco-enteritis, indicating a
direct result of the lepra bacillus on the intestinal
wall. Chaulmoogra oil, or its refined constituent,
antileprol, is the remedy that dominates the
therapeutic field so far as leprosy is concerned.
The antileprol is preferable, as it causes less gastric
disturbance than the unrefined oil when given by
the mouth. The dose of antileprol given internally
varies from 15 minims, and ten times that quantity
can be taken daily. Antileprol may be injected
intramuscularly in doses of 8-5 c.c., approximately
50-80 minims, repeated every three days, and the
course continued for some five months. In the
early muscular stage of leprosy a cultural extract
prepared from the organism isolated by Kedrowsky
has given fairly satisfactory results, but not in the
advanced nodular forms, l
[Feb. 16, 1914.
The Pathogenicity of Nosema apis to Insects other
than Hive Bees.—Fantham and Porter contribute
a very interesting paper to the Annals of Tropical
Medicine and Parasitology (Series T. M., vol. vii,
No. 4, December 30, 1913), on Nosema apis, a
micro-sporidian parasite of hive bees. Their re-
searches show that this parasite may attack other
insects as well as bees, the importance of this being
evident. l
Their conclusions give an excellent summary of
the paper, and are as follows :—
(1) Nosema apis has been proved pathogenic to
Hymenoptera other than bees. It can multiply in
the food canals of humble bees, mason bees and
wasps, and can bring about the deaths of the
hosts. l
(2) Contamination of plants with infected ex-
crement occurs in the neighbourhood of badly
infected hives. Such contaminated food is patho-
genic to the larve of cabbage white butterflies,
cinnabar moths and gooseberry moths, in which
Nosema apis produces destruction of the tissue of
the food canal in the same way as in bees. Both
imagines and larve of these insects became infected
with microsporidiosis when supplied with food con-
taminated with Nosema spores.
(8) Calliphora erythrocephala, the blow-fly, be-
comes infected naturally by ingesting Nosema spores
contained in the sweet excrement of bees. This in-
fection has been repeated experimentally. Crane-
flies may also become infected.
(4) A member of the Hippoboscide, Melophagus
ovinus, has been infected successfully with
Nosema apis, which is pathogenic to the sheep ked.
The authors suggest that research be made by com-
petent observers among the Glossine for Micro-
sporidian parasites allied to the Nosema of bees, and,
possibly, equally pathogenic to the tsetse-flies that
may harbour them. :
Rat-bite Disease.—From time to time accounts
of a febrile condition induced by the bite of a rat
appear in the literature. It is an old story the
evils that may possibly ensue on bites from rats, but
it is only recently that the signs and symptoms have
been systematically described. In 1899, H.
Miyake described the disease in the Mitt. a. d.
Grenzgeb. d. Med. u. Chir., vol. v, No. 2, p. 281.
In the British Medical Journal, 1912, part ii,
p. 1437, Professor Cruickshank reports a case of the
kind. Professor R. Tanner Hewlett and Dr. G. H.
Rodman, in the Practitioner of July, 1918, relate a
case of rat-bite disease which occurred in 1904.
In the Tropical Diseases Bulletin, vol. i, 1918,
No. 7, an excellent summary of what is known of
this disease is given. The period of incubation of
the disease is from five to eight weeks; during the
incubation the wound caused by the bite gives little
or no trouble and generally heals over. Invasion
occurs with rigors followed by a febrile state, with
marked intermissions, the temperature being up
for three days, reaching a maximum of about 105°,
followed by a three-days’ interval, in which the tem-
Feb. 16, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 61
perature is below the normal. An eruption in the
form of an erythema is frequently present. The
glands in direct association with the line of lym-
phaties leading from the seat of the bite get en-
larged and a general glandular enlargement in
axilla and groin may be found. In the ease
recorded by Hewlett and Rodman the patient re-
covered after a period of febrile and afebrile attacks
lasting seventeen weeks.
The mortality is stated to be about 10 per cent.
of those attacked, the later stages of the fatal
form of the malady being associated with general
cedema, albuminuria, and mental symptoms. Ogata
states that he has found a protozoan parasite, but
his observation has not been confirmed.
Balantidiasis. —Walker contributes an interesting
paper upon '' Experimental Balantidiasis " to the
Philippine Journal of Science, vol. viii, Sec. B,
No. 5, October, 1918. His summary and conclu-
sions are as follows :—
(1) Parasitization of man with Balantidium coli
is relatively common in the Philippine Islands.
(2) The balantidia appear in the stools of
parasitized individuals only at irregular intervals,
and consequently infections, unless accompanied by
clinical symptoms, may frequently be overlooked.
(8) A large proportion of the pigs in and about
Manila are parasitized with balantidia.
(4) Balantidia are passed in the resistant encysted
stage more or less constantly in the stools of
parasitized pigs.
(5) Morphologieally B. coli suis is identieal with
B. coli hominis.
(6) Forty per cent. of five monkeys fed or in-
jected with B. coli hominis became parasitized.
(7) Seventy and five-tenths per cent. of seven-
teen monkeys fed or injected rectally with B. coli
suis became parasitized.
(8) Monkeys parasitized with either B. coli
hominis or B. coli suis show the parasites in the
stools only at infrequent intervals.
(9) Only a small proportion of the parasitized
monkeys became infected. Of two monkeys
parasitized with B. coli hominis, one, and of twelve
monkeys parasitized with B. coli suis, one, showed
the parasites in the tissues post mortem.
(10) The early lesions of the intestine of monkeys
infected with B. coli consist only of a slight hyper-
emia with or without punctiform hemorrhages.
(11) Histological examination of the tissues of
monkeys recently infected with B. coli show
changes, notably vascular dilation, minute hemor-
. rhages, round-cell infiltration and eosinophilia,
which distinguish them from lesions of bacterial
origin.
(12) B. coli was never found entering the tissues
through the lesions in ten parasitized monkeys
having a colitis or ulcerations due to bacteria or
other causes.
. (18) In those monkeys in which infection took
. place, the balantidia entered the tissues through the
sound intestinal epithelium.
(14) B. coli can produce bacteriologically sterile
abscesses in the submucosa of an infected intestine.
(15) B. coli is the primary etiologic factor in the
symptoms and lesions of balantidial dysentery.
(16) The latency prevalent in balantidiasis of man
is due chiefly to the fact that the patient, although
parasitized, is not infected with B. coli, but in part
to the chronicity of the ulcerative process in
infected cases.
(17) Every person parasitized with B. coli is
liable sooner or later to deci balantidial dysentery.
(18) B. coli suis is identical with B. coli hominis.
(19) The domesticated pig is the chief source of
infection in the balantidiasis prevalent in the
Philippine Islands.
(20) Therefore, efficient prophylactic measures
against balantidiasis in the Philippine Islands should
be directed against these animals, which should
be confined and not allowed to run in yards and
dwellings. -
Insect Transmission of Anthraz.—M. Bruin Mitz-
main, Veterinary Entomologist, Government of the
Philippines, records, in Public Health Reports, xxix,
2, for January 9, 1914, a preliminary note of a large
number of experiments on the róle of suctorial
insects in the dissemination of anthrax. The ex-
periments were tried with an artificially infected
guinea-pig, which died of the disease upon the third
day. The flies were applied two and a half hours
to a few minutes before the death of the blood
donor. Guinea-pigs were used to receive the infec-
tive bites of Stomozys calcitrans and Tabanus
striatus. Each animal was placed in a gauze sack
strapped to an individual board and the flies were
induced to feed when applied from separate test-
tubes. S. calcitrans was used as the porter in two
experiments and T. striatus in a single experiment.
With both species the infection was successfully
transferred by the direct method in which the flies
were interrupted while feeding on the sick animal.
The stable flies were transferred to the healthy
animal in one trial with only a few seconds' interval
after biting the infected host, and in the other in-
stance an interval of ten minutes elapsed between
the feedings. A total of twenty flies were used in
the first experiment and thirty flies in the second
trial.
The exposed animals died in both cases during the
evening of the third day. Typical pictures of
anthrax infection were presented at the necropsy of
the two animals. In addition a substantial gela-
tinous and hemorrhagic cedema was observed in
the subeutaneous region of the area upon which the
flies were applied in biting. The agar cultures
when injeeted reproduced the disease with fatal
results in guinea-pigs used in later experiments.
Similar results were obtained in all essentials
when horse-flies were employed to transfer the
disease from the sick to a healthy guinea-pig. Three
flies were used to carry the infection, with only a
few seconds’ interval from infected to healthy host.
The latter died on the fourth day after the flies
62 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
were applied. The autopsy was made a few minutes
after death. As in the other instances, there was
no rigor mortis. The site of fly-biting was not much
involved; only a slight gelatinous hemorrhagic
edema. The subcutaneous injection also was slight
in effect. The spleen was greatly enlarged and
extremely friable. Vigorous growth characteristic
of the anthrax bacterium was obtained on agar, and
later the disease was reproduced in a horse from a
saline suspension of the agar culture. Typical
organisms were seen in the feces of horse-flies at
various intervals up to forty-eight hours from the
time the infected animal was bitten. The feces
of the stable-fly were likewise found to be infected
up to twenty-four hours after obtaining blood from
a sick animal.
A series of experiments is at present being con-
ducted with anthrax in cattle and horses. Guinea-
pigs or other rodents will in every instance be
employed as blood donors, as experience has shown
that it is difficult in large animals to time the pro-
bable invasion of the peripheral circulation by the
anthrax organisms so as to render insect transmis-
sion practicable. An attempt will be made to
determine the limits of infection in flies acting as
carriers of contaminative material.
— AG——
Brugs and Appliances.
THE following useful suggestions as to the care of
hypodermic syringes and needles have been issued by
Messrs. Parke, Davis and Co., London.
To test the syringe do not draw out the piston
under à vacuum and allow it to recoil, as this will
most probably result in fracture of the barrel. The
best way is to draw out the piston, then place a finger
firmly on the nozzle, and push the piston home as far
as possible; on discontinuing the pressure the piston
will recoil, provided the vacuum and syringe are satis-
factory, without risk of breakage.
A safe and efficient test is to fill the syringe with
water, then affix the needle and insert the point of
the latter into a good cork; on pressing the piston it
will soon be seen if the plungers and washers are
satisfactory.
Syringes fitted with leather plungers and washers
should not be sterilized by boiling, as this destroys
resiliency of the leather. The syringe itself will
seldom need sterilization, particularly if in frequent
use, as many of the solutions employed are antiseptic.
If it has been used to aspirate a cavity containing
purulent matter, however, a germicidal solution should
be drawn into and expelled from the instrument
repeatedly; it should then be rinsed thoroughly with
sterile water, filled with a 5 per cent. solution of
earbolic acid or lysol, and laid aside for an hour,
after which it should be rinsed repeatedly with sterile
water.
Leather plungers and washers are liable to become
hard and to fit imperfectly if neglected; they should
be oiled occasionally, when dry, with an antiseptic
oil. The plunger, if loose, may be tightened by
drawing out the piston to its full length, so that the
small nut on the upper end of the plunger engages in
a socket in the cap of the syringe; the piston is then
turned gently to the left—to loosen, turn to the right,
The plunger should not be expanded more than is
absolutely necessary, else it will not work smoothly,
and the leather packing may be injured.
There. should be no need to unscrew any part of
the syringe except the needle and cap, or to remove
the barrel or plungers.
Syringes fitted with rubber plungers and washers
may be sterilized by boiling water or by steam, all
parts being separated for the purpose. They may
also be sterilized by carbolic acid or any such agent,
in which case the syringe must be rinsed with sterile
water before using with serums, otherwise the serum
may become coagulated. For this reason also, syringes
should be rinsed after use with serums before they
are sterilized by any method.
Rubber packings become hard in course of time,
but they can be replaced readily by unscrewing the
top of the syringe, and replacing the old packing
with a new one; see that the convex end of the
packing fits well into the end of the small cup. The
packing will last much longer if it is contracted when
the syringe is not in use; this is accomplished by
drawing the piston out to full length and turning it to
the right, reversing the process before use. If any
lubricant is considered desirable, a little glycerine
should be employed, not oil.
Physicians who have become accustomed to leather-
packed syringes may disapprove of the rubber packing
if the difference in action is not taken into account.
Dry rubber clings to dry glass, so that the piston
does not then work smoothly; but when wet no diffi-
culty is experienced. To test these syringes, adopt
the second method suggested in the general rules
above. The packing, being cone-shaped, allows air
to pass it readily; but when the syringe is filled with
fluid it will be found practically impossible to force
this past the packing. Fill the syringe very slowly,
preferably by means of the filling needle supplied
with the serum syringes.
All-metal syringes—i.e., syringes without leather or
rubber plungers and washers—may be sterilized most
satisfactorily by boiling, the syringe being taken apart
for the purpose. Afterwards the metal plunger should
be lubricated with a little antiseptic oil.
It is most essential that these syringes, after each
using, should be rinsed free from any sediment or
unexpelled fluid; also care should be taken to prevent
any foreign matter finding its way into the barrel, as
such is liable to fix the plunger, and may render the
syringe permanently useless. If the plunger is not
kept apart from the barrel, when not in use, it should
be smeared with a little glycerine to prevent fixation.
The all-glass syringes may be sterilized by boiling;
they must be taken to pieces and placed in cold or
warm water, then heated to boiling point, and kept at
this temperature for five minutes. Sufficient water to
cover the syringe must be maintained in the vessel.
Before the parts are fitted together after sterilization,
Feb. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 63
each section should be dried thoroughly. Lubrication
is unnecessary.
Great care should be exercised to cleanse the all-
glass syringe after use; the parts must be separated,
and each rinsed thoroughly in cold water, and, pre-
ferably, with alcohol afterwards. The neglect of
these precautions is almost certain to result in incon-
venience.
It is desirable that the plunger should be kept
apart from the barrel when not in use, and most of
the cases in which these syringes. are supplied are
provided with separate springs or spaces for this
purpose; when this is not done, the plunger should
be smeared with a little glycerine to prevent fixation.
The syringe should never be held perpendicularly
without holding the piston, as the weight of the
latter is, in itself, sufficient to expel the fluid. A com-
bined finger-grip and stop is supplied, by means of
which the piston is prevented from dropping out of
the barrel, and a better control of the syringe is
afforded.
The serum syringes are supplied with a filling
needle, in addition to the ordinary needles. The use
of this will greatly facilitate the filling process, espe-
cially from bulbs of vaccine or serum, and will obviate
the risk of blunting the ordinary needles.
All needles should be sterilized before and after use,
either by boiling or by heating in a flame; the latter
process, however, tends to destroy the temper of steel
needles. After use the needle should be cleared of
every drop of fluid by forcing air through it from the
empty syringe.
To prevent needles becoming rusty and clogged
whilst not in use, they should (subsequent to sterili-
zation) be wiped with a piece of wool or lint saturated
with an antiseptic oil, and a greased wire should be
inserted in the bore of the needle, and kept there
until it is required for use.
—_—_@—__—_
Achiets.
HEALTH PRESERVATION IN West AFRICA. By J.
Charles Ryan, L.R.C.P.I., L.M., L.R.C.S.I.,
L.M., late M.O. West African Medical Staff;
with an Introduction by Sir Ronald Ross,
K.C.B. London: Bale, Sons and Danielsson,
Ltd. 1914. Price 5s. net.
Many books have been written on health in the
Tropies, and in West Africa in particular. The
present manual is in all respects up-to-date. The
rapid commercial and Government development
requires a practical account of health matters.
Despite much improvement, West Africa is, and
from the nature of things must always be, a most
unhealthy country for the white race. But a
healthy man who makes up his mind to pay detailed
attention to preventive measures against ill-health,
in spite of the trouble this may cause him, will be
amply rewarded in being better able to fulfil the
conditions of his employment. The watchword of
the book is ‘‘ Attend to details,”
OUTLINES OF GREEK AND Roman Mepicine. By
James Sands Elliott, M.D., Ch.B.Edin.,
Editor of the New Zealand Medical Journal.
Illustrated. London: Bale, Sons and Daniels-
son, Ltd. 1914. Pp. 165 + xii. Price 7s. 6d.
' net.
This work appeals to doctors, to medical students,
pharmacists and others who are interested in the
history of the progress of human thought and know-
ledge, and who realize that the investigation of
the body and mind, in health and disease, has been
one of the most important features of the evolution
of humanity.
Everyone is acquainted with various items of the
history of medicine, but few have a comprehensive
knowledge of the story of their art. Without such
a knowledge to bind together the consecutive events
science cannot really come into its kingdom.
The book commences with early mythological
Homan history, then goes on to early mythological
Greek medicine, and next describes the commence-
ment of the earliest records of medicine. The
various modes of thought and clinieal descriptions
of disease and treatment by drugs, baths, and
exercises, are given in interesting detail.
Coming to the time of full and authentic records,
the origin, progress, and decline of the various philo-
sophical schools of thought are explained; their
results on practical medicine and the lives of the
publie being graphically dealt with.
Not least interesting is the connection at
various periods of the physicians, surgeons, and
specialists, the relations between medicine and
religion, and the points at which they coincide and
diverge. A special chapter is devoted to the
' Influence of Christianity on Altruism and the
Healing Art." The death of Galen marks the begin-
ning of the decline of medical science in ancient
times, and this we can well understand when we
are told that he regarded his work as '' a. religious
hymn in honour of his Creator, who has given proof
of His omnipotence in creating everything perfectly
conformable to its destination. ”’
What we conceive would be most interesting to
our readers is the progress of the primitive mind of
man in matters relating to health, which explains
many facts in folk-lore, and accounts for views held
both abroad and at home.
An excellent index facilitates reference; the book
is light to handle, the print is good, and the whole
worthy of an author from ‘‘ down-under’’ and a
London publisher.
ScnorvLosis. By Professor Dr. G. Cornet, Berlin
and Reichenhall. Translated from the second
German Edition by J. E. Bullock, M.D.,
Assistant Medical Officer, The Eversfield
Chest Hospital, St. Leonards-on-Sea. London:
Bale, Sons and Danielsson, Ltd. 1914.
Pp. 515 + xiii. Price 15s. net.
This is a translation of one of the series of the
German Tuberculosis Classics, issued on the advice
and under the direction of Egbert Morland, M.D.,
B.Sc,
64 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
The book commences with a historical survey,
beginning with the derivation of the word scrofula
as known to the Latins and Greeks. According to
Virchow, it signifies a young pig, from the resem-
blance which the neck, enlarged by the swollen
glands and forming a continuous outline with the
lower jaws and shoulders, bears to the full contour
of the pig's neck.
Various views are given of clinical conditions,
which are embraced within the term scrofulosis,
and may be paraphrased as an independent disease
due to a certain predisposition, that in its course
often presents tuberculous complications.
The book describes all possible pre-tubercular
conditions and other causes of ill-health, particu-
larly those affecting the lymphatic glands.
Having discussed heredity, social, and other
factors which favour infection, morbid anatomy is
then dealt with.
The third section of the book, from p. 180 to
p. 218, deals with symptoms in the skin, in the
mucous membranes of the nose, mouth and
pharynx, ear, eye, and other mucous membranes,
showing how morbid processes may originate in
them and beeome differentiated.
The third group of symptoms relates to the
lymphatic glands, the external ones of the neck,
groin, and armpit, and then the bronchial and
mesenteric glands.
After due consideration of bone and joint affec-
tions the general symptoms are discussed.
The fourth section describes the course and
duration of scrofulosis and tuberculous scrofulosis,
as well as mixed infection.
A special section is devoted to prognosis, followed
by one on diagnosis, both clinieal and laboratory.
About 250 pages are well spent in consideration
of prophylaxis, therapeutics, including open-air,
medicinal, and local treatment of the skin, mucous
membranes, respiratory organs, ear, eye, affections
of the glands, bones, and joints.
A detailed bibliography occupies 74 pages,
followed by an index, as well as separate index of
authors.
_ 9 ——————
Rotes and "Retos.
WU LIEN TEH HONOURED.
Wu LiEN TzR (G. L. Tuck), M.A., M.D.Cantab., the
Director of the North Manchurian Plague Prevention
Service, has had the honour of being granted the Chia
Ho (third class) Decoration. This is the highest rank
ever conferred upon a medical man by the Government
of China; the Chia Ho Decoration ranks with those
conferred on the heads of departments in the Chinese
Foreign Office, to which Dr. Wu Lien Teh is the
Medical Officer. Dr. Wu, better known in this country
by his adopted name of G. L. Tuck, took a prominent
part in the Tropical Section of the International
Medical Congress in London in August, 1918, and gave
_an interetsing and comprehensive account of plague in
Manchuria and of the part presumed to be played in
the spread of the disease by the tarbagan.
We congratulate Dr. Wu Lien-teh upon the well
deserved honour bestowed upon him, and it augurs
well for the future of modern medicine in China that
the Government recognize the important position
Medicine and Hygiene occupies in the welfare of the
State.
AUSTRALASIAN MEDICAL CONGRESS,
AUCKLAND, NEW ZEALAND, 1914.
MESSRS. BURROUGHS WELLCOME AND Co. havean
interesting display of medicinal preparations and
surgical requisites on view in connection with this
Congress.
Among the most recent results of this firm’s experi-
mental work is '" Epinine,” which possesses the thera-
peutic effect (active principle) of the supra-renal gland,
is a synthetic preparation, and not only exercises a
more sustained effect than the natural active principle
but retains its activity longer. There are, further,
“Ernutin,” a clear palatable fluid, containing the active
principle of ergot of rye; and “ Vaporole ” “ Infundin,”
an extract of the infundibular substance of the pituitary
gland. The respective actions of these three products
on living organisms are indicated by kymographic
tracings.
A “Tabloid” case of medical equipments, a “‘ Soloid ”
Bacteriological Case, a Blood Test Case, a Water
Analysis Case, “ Wellcome” Sera, Vaccines and Tuber-
culins, and the “Tabloid ” animal substance products
were also on view.
The “Tabloid” Adjustable Head Dressing, “Tabloid”
Bismuth Gauze, non-toxic and inodorous, as well as
a series of beautiful photographs illustrating the
cultivation of medicinal plants on the “ Wellcome”
Materia Medica Farm, Dartford, render this display
wonderfully complete and interesting.
—eo
Personal Hote.
Dr. H. B. Dodds, Medical Officer of St. Vincent, has been
transferred to the service of the Straits Settlements as a
Medical Officer of that Colony. Mr. Dodds left St. Vincent on
the 24th ult. for England, and will be on half-pay leave from
that Colony until the 31st inst.
Hotices to Correspondents.
1.—Manuscripts if not accepted will be returned.
9. —As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
8.—To ensure accuracy in printing it is specially requested
that all communications should be written clearly,
4.—Authors desiring reprints of their communications to THE
JousNAL or TRopicaL MEDICINE AND HYGIENE should com:
municate with the Publishers.
5.—Correspondents should look for replies under the heading
** Answers to Correspondents,”
Mar. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 5, Vol. XVII.
Original Communication.
NOTE ON AN INTESTINAL PROTOZOAL
PARASITE PRODUCING DYSENTERIC
SYMPTOMS IN MAN.
By ALDO CASTELLANI, M.D.
Director, Government Clinic for Tropical Diseases, Colombo,
Ceylon.
In three cases of mine in Ceylon presenting
dysenterie symptoms I have observed a peculiar
large protozoal parasite whieh most probably was
the cause of the condition. The first case occurred
in 1909, but as stained preparations of the parasite
were not successful I did not publish the observa-
tion in detail, though I briefly mentioned it in
certain of my papers on intestinal diseases.
Symptoms.—In all the three eases the clinical
symptoms were those of an ordinary mild type of
dysentery, either amæbic or bacterial. The onset
was rather abrupt with severe abdominal pain,
tenesmus and diarrhea, with stools containing
muco-pus and blood. The motions soon lost any
trace of fecal matter and consisted only of muco-
pus and blood. In all cases the microscopic examina-
tion showed absence of löschiæ, cercomonata, tricho-
monata, balantidia and ova of worms; instead
several large motile parasitic bodies were seen,
which will be described presently.
The general condition of the patients was never
very serious. Fever was present at the onset in
Cases 2 and 3, but did not exceed 1019 F., and
lasted only a day or two. The dysenteric symptoms
disappeared very quickly after a few doses of saline
mixture or castor oil Complications were not
observed except in Case 3, in which slight signs of
hepatitis were present, but rapidly disappeared.
Relapses may occur, apparently, as shown by
Case 3.
Case 1.—Cingalese man. Admitted to the
Clinie for Tropical Diseases in January, 1909,
suffering from an epiphytic skin disease. After four
days in the clinic, during which time he received
no treatment of any kind, he one morning was
taken ill with very severe abdominal pains, with
muco-pus and blood in the stools. The stools were
examined microscopically, and large bodies were
seen which I believe to have been absolutely
identical with those found later in Cases 2 and 8
presently to be described. Two films were made,
but unfortunately the staining by Giemsa's was
not successful. A dose of castor oil stopped all
dysenterie symptoms the same day, and in the
stools which were passed later no bodies were
found.
Case 2.—European passenger. Had lived in
Southern India and Burma for several years.
While in Colombo (April, 1913) on his way to
England was taken ill with dysenteric symptoms
at one of the hotels. When I saw him the tem-
perature was 1019 F.; he complained of nausea and
of very severe abdominal pains with severe straining.
The motions contained blood and muco-pus and the
microscopic examination showed the bodies (to be
presently deseribed) in fresh and stained prepara-
tions. No léschie were present, nor trichomonata
or cercomonata. Two emetine injections (4 gr.
each) were given, and also every two hours a sodium
sulphate and magnesium sulphate mixture (1 dr.
of each per dose). The motions became feculent
after a few hours, and the bodies were no longer
present.
Cause 3.—European officer of the Mercantile
Marine. Admitted to the General Hospital of
Colombo with dysenteric symptoms. Gave a
history of two previous attacks of dysentery in
Rangoon and Bombay. ‘Temperature on admission
1009 F., pulse 90; the patient complained of severe
abdominal pains and tenesmus with bloody stools
for three days, also of severe pain in the
hepatic region. The tongue was coated. Examina-
tion of the chest revealed nothing abnor-
mal. Palpation of the abdomen induced pain,
especially on the sigmoid region and hepatic region.
The liver was slightly enlarged and tender, spleen
normal. The usual sodium sulphate and magnesium
sulphate mixture was given and within twenty-four
hours the stools became feculent. Before starting
the mixture the stools contained many bodies
identical to those of Cases 1 and 2. They quickly
(disappeared after a few doses of the mixture, even
before the stools had become feculent. No amcebie
were present at any time, nor trichomonata nor
eercomonata. The bacteriological examination of
the stools for bacilli of the dysentery group gave a
negative result.
DESCRIPTION OF THE PARASITE.
Fresh Preparations.—In fresh preparations and
hanging drops of the stools, one sees large, rather
elongated motile bodies, which on a superficial
examination give the impression of being very large
flagellates moving about. On close examination,
however, no flagella can be detected. The para-
sitic bodies are large, elongated or oval; one
extremity, the one which in stained preparations
appears mammillary, is, so to speak, shaken by a
peeuliar, extremely frequent, vibrating movement,
which makes one suspect the presence of flagella or
an undulating membrane or cilia. Neither in fresh
preparations nor in stained preparations have I been
able to detect flagella or cilia. The protoplasm has
the same appearance all over the body of the para-
site, presenting numerous roundish vacuoles, none
of which are contractile. No distinct nucleus is
evident, and there is apparently no distinct differen-
tiation between ectoplasm and endoplasm. The
parasite does not emit pseudopoda like an ameba,
in fact, the changes in shape of the body of the
parasite are slight, and very similar to those slight
changes in the shape as found in flagellates, such
as Trichomonas hominis.
Motility.—The parasites move about fairly
rapidly, though not so quickly as cercomonata or
trichomonata ; how motility is produced it is difficult
66 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 2, 1914.
to say. No pseudopoda are protruded and the body
of the parasite shows only slight changes in shape.
The anterior portion, as already stated, shows
extremely rapid vibratory movements, but no
flagella nor cilia are seen, nor, apparently, a definite
undulating membrane, nor have I been able to
satisfy myself that there is emission of filiform
pseudopoda.
Stamed Preparations.—All my preparations were
stained with Giemsa and Leishman. The typical
parasites have a peculiar flask-like appearance (see
microphotograph), but round forms are also found;
the maximum diameter varies between 45 and 55
microns. The protoplasm is stained blue and
presents numerous non-stained roundish vacuoles
regularly distributed all over. In certain parasites
a large mass of chromatoid roundish granules are
seen, but in others it is absent. The granules have
the appearance of cocci; but probably they are
chromatine granules representing a diffuse nucleus.
In one specimen the chromatine granules were bacil-
lary in shape. In none of the bodies were flagella
seen nor cilia, nor any evidence of any undulating
membrane. Of course, it is possible that by using
special methods, in place of Giemsa or Leishman,
such structures may possibly be put in evidence.
Reproduction.—_I am not yet in a position to
state anything on this subject.
Cultivation.—Attempts at cultivation have failed.
Zoological Position of the Parasite.—As I have
already stated, in fresh preparations, the first
impression on seeing these large bodies moving
about, and with an extremity presenting rapid,
vibratory-like movements, is that one has to do
with flagellates with the flagelli at one end, but on
closer examination no flagella are ever seen either
in fresh or stained preparations. The parasite,
therefore, apparently is not a flagellate. It cannot,
in my opinion, be placed in any of the genera
Lóschia, Entamaba, Vahlkamfia, Parameba, as
pseudopoda are not protruded, and the changes in
the shape of the parasite while moving are
slight. It cannot belong to the genus Chlamydo-
phrys, as there is no shell. It cannot belong to the
genus Colpoda, Uronema, Nyctotherus, Balanti-
dium, as cilia, at least in fresh specimens and in
preparations stained with Giemsa and Leishman, are
not evident. I am inclined to consider the parasite
to represent a new genus and species, and as a
temporary generie term I have suggested the term
** entoplasma.”’
I wish to express my indebtedness to Dr. Fer-
nando, First House Physician to the General Hos-
pital, and to Mr. E. Burgess, Assistant Bacteriolo-
gist, for much assistance rendered, and to Mr.
M. J. de Silva for the microphotographs and
drawings.
REFERENCE.
CASTELLANI : “ Preliminary Note on an Intestinal Protozoal
Parasite," Journal Ceylon Branch B, M.A., May, 1918.
[Owing to the proofs not having been returned
from Ceylon, this paper has unfortunately been held
over till the present date.]
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THE JOURNAL OF
Tropical Medtctne and Hygiene
MARCH 2, 1914.
THE NECESSITY FOR A WOMEN’S INDIAN
MEDICAL SERVICE.
ATTENTION has lately been drawn by Sir Charles
Pardey Lukis, Director-General, Indian Medical
Service, to the need of fully-trained medical women
in India. His clear exposition of the domestic life
peculiar to the native households of that country
makes it evident that by women doctors, and
women doctors alone, can we hope to raise the
people of India from the prejudice against inno-
vations, the superstitions which encumber every
attempt at sanitary enlightenment, and the sus-
picion with which all European methods of proce-
dure in matters of publie health are regarded. i
House to house visitation and conversations 1
the language or dialect peculiar to a district with
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. MARCH 2, 1914.
Microphotographs of the Parasite from a preparation stained with Giemsa.
To illustrate a ** Note on an Intestinal Protozoal Parasite producing Dysenteric Symptoms in Man,”
by ALDO CasTELLANI, M.D.
Mar. 2, 1914.]
the women of the household will do more to bring
about sanitary improvements than by official
circulars which they cannot read, or by edicts which
they cannot understand. Teaching the young in
schools will help no doubt; but school instruction,
whether at home or in India, is one thing, the life
and customs of the home are quite another. Just
as the language used in school, church, or theatre
in Britain is that of English more or less '' pure "'
in type, whilst the language of the home is a dialect,
so is publie instruction in matters of health to those
which use and wont have set up in the environment
of the home. The knowledge must be implanted
at the source, namely, the home, and as here the
mother is supreme, it is only by instructing her that
permanent and immediate good can be brought
about. This endeavour would imply an army of
women doctors amounting to many thousands 'in
number, and the question is: can sufficient in-
structors be found? We have in England many
schools in whieh women are trained as doctors, but
the numbers are not markedly increasing; in fact,
in many schools the number of women medical
students is diminishing. Supply and demand
control the medical output of doctors just as the
same principle holds good in every profession or
commercial pursuit. The demand for women
doctors at home is not calculated to stimulate
women selecting medicine as a livelihood; for the
course is strenuous and the expense heavy, yet
would these be cheerfully overcome were a sure
prospect of employment held out as an induce-
ment. Sir Charles Lukis shows where women
graduates in medicine can find employment, where
they can do work for the Empire, and where their
work would be appreciated to the full.
Indian custom forbids to women the freedom
granted to them in Britain of having male doctors
to enter their homes for the purpose of treating
them when sick, or even for the purpose of con-
versing with them on sanitary matters. To women
doctors, however, is the privilege granted, and it
is through this channel alone that improvement in
the publie health of India can be hoped for. It
lies with the Government of India to undertake this
great work. There are rumours abroad that changes
of a radical kind are entertained in the greatest
medical public service of our Empire, namely, the
Indian Medical Service. Those who know even
something of this service know how efficiently the
work has been done hitherto; but times change, and
modern India demands changes to fit the times.
What these changes may ultimately result in is
known to but few, or it may be that no seheme has
been as yet fully thought out, but whatever is done
it is hoped that the necessity for fully-trained
medical women may be considered, and that an
Indian Medical Service for women may be placed
upon a satisfactory basis. Many British. women
in India are at present doing excellent work aa
doetors, nurses, and as missionaries, but the work
must be systematized, the empirical efforts now in
vogue must be organized, and a great women's
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 67
public sanitary service be made a department of
the Indian Medical Service. Should the medical
and sanitary service be divided as some contem-
plate, it should be seen to that no third service,
namely, one for women under a separate command,
be set up, otherwise there will be overlapping,
friction, and discontent. The necessity is imme-
diate; the opportunity for development is well-nigh
limitless, for until the three hundred millions of
India are provided for there should be no halt.
In Britain schools for mothers are rapidly multi-
plying; motherhood is a ‘‘calling’’ which the
modern world is only beginning to realize; the
rearing of children is the foremost duty of the
woman; the continuance of the species is the
primary object of every living thing. In Britain it
is found that, late as the age of marriage is com-
pared with the early age at which women become
mothers in India, ignorance prevails to an extent
which seems inexplicable. If, then, training of
mature women in Britain is necessary, how much
more so is the case in India, where girls of 15 or
16 become mothers? The child suffers, the mother
suffers; infant mortality is high, and the dangers
of childbirth are manifold. Primitive methods of
midwifery are almost universally in vogue, and it
is evident that, as teachers of native midwives,
women doctors would be serving a great humani-
tarian purpose.
Under the Dufferin Association a great work has
been accomplished, and the Indian Government
has acted wisely and generously in the recent grant
of £10,000 to the Association. We should like to
see the work of the Association extended, and the
service of medical women organized and developed
into a great public service worthy of the Empire
and sufheient for the needs of India.
Attention has lately been called to a peculiar
feature in the numerical relations of the sexes in
India. It is stated that the men outnumber the
women in many areas. This statement is at
variance with that observed in all the older coun-
tries, and especially perhaps in Britain, that the
announcement is astonishing rather. We know
that there are more boys born in this country than
there ure girls, but soon the excess disappears, and
in adult years the women outnumber the men by
something like two millions. We can account for
it by the fact that for one woman leaving the
country twenty men go abroad; but in India,
although a certain number of men do go abroad,
yet does the male population exceed the female.
It is stated that the Chinese drown a certain number
of the female infants; improbable as this assertion
is, especially in a country where polygamy prevails,
yet it suggests an excess of females over males
born. The cause of the disproportion in India may
be due to the number of deaths which occur at child-
birth; it is known that this number is large, and if
it is due to this cause there is surely a ‘* white
woman's burden’’ imposed, and the women of
Dritain should take up this burden and help their
sisters in India in their extremity.
J. C.
68 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Mar. 2, 1914.
Annotations.
The Treatment of Infantile Diurrhwa by Saline
Injections.—In the Practitioner of July, 1918, Pro-
fessor H. B. Day, of Cairo, gives his experience of
the treatment of infantile diarrhcea by subcutaneous
injections of diluted sea-water, termed marine
plasma. The solutions used in the treatment are:
(1) Quinton's marine plasma, which consists of
sea-water collected in sterilized vessels at a sufficient
depth and distance from land to ensure purity, is
diluted with sterilized distilled water to make an
isotonic solution. (2) Sea-water, 3 parts to 7 parts
filtered distilled water, put up in sterilized bottles,
and heated in an autoclave to ensure sterility. (3)
Ringer's solution is the best artificial saline. The
composition of an artificial saline in grains—when
figures are '' rounded off ""—consists of :—
Sodium chloride 229 gr
Mag. chloride 25$ ,,
Potass. chloride — ... vus 8$ ,,
Mag. sulph. ... "m ous. 3 EB: 1.35
Caleium sulphate 8$ ,,
Distilled water to 1 pint.
The injections are given with the ordinary pra-
cautions, and the best place for introducing the
needle is the side of the abdomen, but they can be
given anywhere; in the back if the child is obstre-
perous. The quantity given as a rule averages
60 c.c. (about 2% oz.), but the amount varies from
25 to 150 c.c. (approximately 6% dr. to 51 oz.). The
amount given at a time depends on the rate of
absorption, which is judged by the speed with which
the lump formed by the fluid is dispersed.
In eases of moderate severity one injection a day
may suffice, but where the circulation is failing large
quantities may be given two or three times a day.
Results.
Numbers Recovered
Method of Treatinent successful Failures Per cent.
(1) Alexandrian sea-water with
medicines A se 1800 55, 30 81:25
(2) Alexandrian sea-water only 44 ... 10 81:5
(3) Quinton's sea-water nd Bis $3. 19 87:5
(4) Artificial (Ringer’s) an 523^ a, di 85:0
(5) Medicine only T Se. (DBM lun. lB 95:1
Medicine only seems to give better results than
any form of saline,
When vomiting is present and medicines cannot
therefore be retained, treatment by hypodermic
injections are a useful stand-by.
To allay the vomiting a dilute solution of iodine
(tinet. lodi. iii minims; aqua 1 oz.) proved success-
ful, a small teaspoonful being given before each
feed.
The most useful drug was found to be calomel
combined with bismuth (calomel } gr., bismuth
carb. 23 gr.), which gave better results than hydrarg.
€. creta. In addition to the powders, a little car-
minative mixture was given, with the addition of
rum if the child showed signs of collapse. In several
such cases injections were urged, but refused; these
recovered on medicinal treatment.
When the presence of mucus and blood in the
stools showed the large intestine to be chiefly in-
volved, salines (sod. sulphat. or phosphat.) were
prescribed with success. The addition of a little
tinet. opii in bad cases was beneficial.
It would appear from the report by Professor Day
that saline injections alone, without drugs, are capa-
ble of curing most cases of infantile diarrhea.
Quinton's marine plasma has no definite
superiority over artificial saline of the same strength.
Such hypertonic solutions are preferable to weaker
(‘75 per cent. or less).
The administration of medicine is preferable to
injections of saline as a routine treatment of in-
fantile diarrhoea. ;
Disregard of dietary instructions is the commonest
cause of failure of out-patient treatment.
Injections are valuable in proportion as the loss
of fluid—by vomiting and diarrheea—exceeds the in-
take. "They should be given before actual symptoms
of collapse arise.
The sum and substance of the treatment of diar-
rhea by sea-water hypodermic injections is useful
in so far as it replenishes the drain of fluid made
upon the system by the diarrhoea.
Kala-azar in Malta, with some Remarks on the
various Leishmaniases.—This was the title of a paper
read by Dr. C. M. Wenyon before the meeting of the
Society of Tropical Medicine and Hygiene on Friday,
December 19, 1913. The paper was based on in-
vestigations which had been undertaken by the author
in Malta during the summer of 1913. Kala-azar in
the infantile form was first shown to exist in Malta
in the year 1910 by Dr. Critien, who in a valuable
report pointed out that the disease had long been
known in the island under the name of »narda tal
biccia. It was Dr. Critien also who discovered that
dogs in this island were liable to suffer from a form
of leishmaniasis which is most probably caused by
the same organism as that producing the infantile
disease. The disease had, of course, previously been
discovered in both children and dogs in other parts
of the Mediterranean.
The author's results in Malta during the past
summer are mostly confirmatory of Dr. Critien's find-
ings, and it would appear that kala-azar is quite a
common disease in children in this group of islands.
Though this is a fact the disease is not recognized
officially chiefly because of the difficulty in making
an absolutely certain diagnosis without the actual
finding of leishmania, which is only done easily by
performing liver or spleen puncture, an operation
which the general practitioner, for various reasons, is
not anxious to undertake. Asa result of this it has
been the custom to return all eases of enlarged spleen
in children under various names— splenic anemia,
Banti's disease, kc. In Malta malaria does not exist,
so that the chief cause of error in the diagnosis of
kala-azar is removed. It results, therefore, that
practically all cases of splenic enlargement in children
accompanied by emaciation, anzmia and fever, in this
group of islands are in reality kala-azar. Six such
Mar. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 69
cases were seen by the author, and in five of these
spleen puncture was performed and leishmania dis-
covered in each case. The sixth case was one of
twins, the other of which was shown by puncture to
be a case of kala-azar, so there is no doubt that the
sixth case was also one of the disease. Thus of six
suspected cases all turned out actually to be kala-azar.
In making returns of disease in the island a far greater
degree of accuracy would be attained by returning as
such all eases which conformed clinically to kala-azar.
Dr. Critien has shown that during the ten years 1899
to 1908, 744 children under 5 years and 41 above
this age died of diseases which were probably in
reality kala-azar.
As regards the question as to whether the Indian
and Mediterranean types of kala-azar are identieal or
not it was pointed out that though kala-azar in the
Mediterranean districts chiefly attacked children, this
is by no means always the case, as adults occasionally
suffer from the disease. Again, since the first dis-
covery of kala-azar in North Africa, Italy, Sicily,
Greece, Malta, and other parts of the Mediterranean,
this Western endemic centre is gradually being linked
up with that of India. Quite recently cases in both
children and adults have been described by Gurko
from the Caucasus region of South-east Russia.
Further East cases in children and adults have been
recorded from Tashkent, so that there seems to be
every probability that with further discovery the
endemic centres of India will be linked up with that
of Southern Europe. The disease also exists in both
children and adults in Northern China, and here,
again, it is conceivable that connecting centres will
eventually be discovered uniting this focus with those
of India and Europe.
It has been suggested that kala-azar has existed
in Greece in ancient times, and it may be that
the disease has spread from an original European
centre, and this might account for the fact that in
the original centre infantile cases form a greater per-
centage of the total than they do in more recently
established centres farther east. There is some
analogy in the subject of malaria, for it is well known
that in those countries in which malaria has long
been prevalent the children of the native population
form by far the greatest percentage of cases, while
the adult population enjoy a relative immunity. The
introduetion of malaria into a hitherto uninfeeted
district, or the introduction of non-immunes into one
already infected, leads at once to a great increase in
the percentage of adult cases. Such may be the case
with kala-azar, and the difference in the percentages
of adult and infantile cases may vary with the length
of time the disease has existed in any locality. In
India, the fact that the disease spread up the valley of
the Brahmapootra in epidemic form, largely amongst
the adult population, a few years ago, may be an
indication of its more recent introduction.
A difference appears to exist in that in the Medi-
terranean districts dogs are liable to kala-azar,
whereas most prolonged search in the Indian endemic
centres has failed to reveal the natural canine disease.
In Colombo, Castellani claims to have found leish-
mania in dogs, but as he suggests that the dogs may
have been imported dogs (presumably from some
canine kala-azar centre) it is evident that he himself
doubts whether the native dogs suffer from the disease
as they do in the Western centres of infantile kala-
azar. Castellani’s claim is all the more remarkable
in that Colombo is not an endemic centre for human
kala-azar.
It was thought for some time that dogs could not
be infected with the virus of Indian kala-azar, though
it had been repeatedly shown that they could be
infected with the leishmania from Mediterranean
kala-azar. Quite recently Donovan and Patton have
successfully inoculated dogs with Indian kala-azar
virus, and at the Albert Dock Hospital the author has
successfully inoculated an English dog with leish-
mania from the spleen of an Indian case which died
in the hospital. "Therefore, since we know that dogs
can be infected experimentally with virus, both from
Indian and Mediterranean cases, this supposed
difference no longer exists. If then we have regard
to the symptomatology, morphology of the parasite,
infection of animals and distribution of the disease,
it can hardly any longer be maintained that kala-azar
as it exists in India is a disease different from that in
other localities in China, Europe, Africa, and even
South America, from which the first case of kala-azar
has recently been described.
On the subject of the etiology of the disease, it was
pointed out that Basile had claimed to have trans-
mitted kala-azar from dog to dog by means of fleas.
A similar experiment had been conducted by the
Sergents, L'Heritier and Lemaire, who fed fleas,
firs& on an infected dog and then on a dog which was
previously tested for leishmania by liver puncture.
The dog became ill but eventually recovered. It was
killed and leishmania were found in the spleen and
marrow but not in the liver. As liver puncture had
been done to prove it free from leishmania before
experiment, it may have been that even then the
spleen and marrow were infected. Realizing these
fallacies the author conducted an experiment in Malta
with dogs sent out from India. The experiment was
described in these words :—
“ Realizing these fallacies, I attempted to conduct an
experiment in Malta in which they were eliminated.
I had four young dogs sent out from England, and at
once upon arrival they were removed to the roof of
the publie health laboratories, where two of them
were enclosed in a mosquito-proof cage and two in an
unprotected cage about 15 yards distant. Over 300
fleas were captured from & dog known to be infected
with leishmania, and these were transferred to. the
two dogs in the protected cage. After about three
weeks the two dogs on which the fleas had been
placed were showing signs of illness. From this date
they became more and more anemic and emaciated,
and eventually, between five and six weeks after the
commencement of the experiment, both dogs died
within a few days of one another. It was found that
the fleas first introduced had multiplied enormously,
so that the dogs were covered with them. Post
mortem, all the organs were anemic and the spleens:
70 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 2, 1914.
sinall and very pale in colour, and quite different in
appearance from the spleens of dogs suffering from
kala-azar. A careful examination of smears of the
liver, spleen and bone marrow failed to reveal any
leishmania, nor did any flagellates develop in tubes of
N.N.N. medium inoculated from these organs. It
was thus fairly evident that the dogs had not died of
kala-azar, but from the condition of profound anemia
produced by the thousands of fleas which infested
them. Thetwo control dogs in the neighbouring cage
remained perfectly healthy. This experiment—which
had every chance of succeeding—has proved a negative
one, and thus lends no support to the flea trans-
mission hypothesis."
The flea transmission hypothesis was examined by
the author from another point of view.
It has been claimed by Basile, Alvarez, and others
who have investigated this question, that fleas taken
from kala-azar dogs are much more liable to a
flagellate infection of the gut than are fleas taken (rom
healthy dogs. Now, if this be true, there would be a
great probability that the flagellates—in some, at any
rate—of the fleas taken off the kala-azar dogs were
developed from leishmania taken up from the blood
of the dog. It is well known that flagellates almost,
if not quite, indistinguishable from cultural forms of
leishmania exist in fleas in countries in which canine
kala-azar does not occur, so that in kala-azar countries
this same flagellate would be expected to exist also.
But the claim is that fleas are much more likely to be
infected if taken off kala-azar dogs, so that it might
be assumed that in a batch of fleas taken off an
infeeted dog some would harbour a flagellate identical
with that found in fleas in other countries, while some
would harbour another flagellate—perhaps morpho-
logically inseparable from the former—which had its
origin in the leishmania with whieh the dog was
infected.
To test this point, the author carried out a careful
dissection of fleas taken off healthy and infected dogs,
with a result quite the reverse of that claimed by
other observers. Of a series of 274 fleas taken off
dogs, the spleens and livers of which were examined
post mortem, and found to be free from leishmania,
23 were found to harbour flagellates in the hind gut ;
while of 200 fleas off dogs whieh were known to
harbour leishmania, only nine were infected with
flagellates. In this series, therefore, it happens that
the percentage of fleas infected off apparently healthy
dogs was twice as great as the percentage of fleas off
dogs known to be suffering from kala-azar; there is,
therefore, no evidence that any of these flagellates
were derived from the leishmania, and it only serves
to prove how irregular is this flagellate infection of
fleas. Had the results been the reverse of what they
were, it would have been very easy to fall into the
error of concluding that the excess of infections was
due to the fleas having taken up leishmania from the
dogs.
That the leishmania are not themselves very resistant
is shown by the following experiments made by the
author. As has already been pointed out, fleas may be
naturally infected with a flagellate which is hardly to
be distinguished from the various forms of leishmania.
In the flea, infection is produced by the larval fleas
feeding upon the fæces of infected adult fleas. In
this flea fæces, which consists of partly digested blood,
there are passed numbers of small bodies which are
very like the leishmania found in kala-azar. It is
these small leishmania forms which produce infection
when ingested by the larval flea. Some of this flea
fæces was collected on sterile cover glasses and spread
into a thin film and allowed to dry. It was found
that even after twenty-four hours drying, a culture of
flagellates could be obtained by dropping the cover
glass into N.N.N. medium, thus proving that the
small leishmania forms passed in the flea fæces will
withstand a considerable amount of desiccation. This
experiment was repeated with the spleen of a kala-
azar dog, but it was found that the leishmania in the
spleen would withstand no drying whatever, as no
culture could be obtained on N.N.N. medium after
drying the spleen smears. The leishmania as they
occur in the tissues of vertebrates are much less
resistant structures than the morphologically very
similar forms passed in the faces of fleas infected
with their natural flagellates.
In this connection some very interesting experiments
have been recorded recently by Laveran and Franchini.
These investigators, working in Paris, have found that
here, as elsewhere, the fleas from dogs may harbour
this flagellate, and they have attempted to infect mice
by injecting them intraperitoneally with the contents
of the guts of infected fleas, with the result that they
have found that the leishmania forms of the flagellate
could be recovered from the peritoneal exudate blood
and organs of the inoculated animals some weeks
after injection. This proves that the leishmania
forms of the flea flagellate will at any rate survive
a considerable time in the body of the mouse. If
now a mouse is injected intraperitoneally with leish-
mania from a case of kala-azar, in most instances the
parasites can be recovered from the peritoneal exudate
and tissues of the mouse for a considerable time after
inoculation, but usually they disappear after a vary-
ing interval without producing any recognizable
disease. In fact, the injection of leishmania from
a case of kala-azar into the mouse produces a con-
dition somewhat comparable to that arising from an
injection of the leishmania forms of the flea flagellate.
This of course does not prove that the flea flagellates
and the leishmania are one and the same thing, but
it has suggested to the author that in dealing with the
parasites of the leishmania group one may have to do
with an insect parasite which is just adapting itself
to a vertebrate host. It is most probably correct
that all the blood-inhabiting flagellates of the trypano-
some group were originally parasites in the insect
gut alone. Before they were adapted to a vertebrate
host, the individual insects became infected from one
another by the small eneysted leishmania forms
which were found in the fæces. This happens with
the flea flagellate, for the leishmania forms are found
in the fæces and are eaten by the larval flea. Now
when a trypanosome, for instance, has become per-
fectly adapted to a vertebrate host, there is no longer
JOURNAL OF TROPICAL MEDICINE AND HYGIENE. MARCH 2, 1914.
Bale & Danielsson, Lt?
From a film stained. by Giemsa's method.
To illustrate article by Arpo CasrkLLAwi, M.D.,
‘Note on an Intestinal Protozoal Parasite producing Dysenteric Symptoms in Man."
Mar. 2, 1914.]
any necessity for the arthropods to infect themselves
from one another by means of leishmania forms
passed in their fæces, though as far as one knows
some of them may still do so, because they can more
certainly take up the parasites which now maintain
themselves on the blood of the vertebrate. But it
is quite conceivable that a flagellate of an insect like
the flea, which naturally passes from insect to insect
directly, may become adapted to a vertebrate host, so
that the insect in question may be able to infect itself
by feeding on the blood of an infected vertebrate, or
by eating the feces passed by an already infected
insect. It is possible that the leishmania diseases
are of this type, and that one has to do with a flagel-
late of an insect which naturally passes from insect
to insect directly, but occasionally obtains a footing
in the human body, producing the disease of kala-azar
and Oriental sore. The experiments of Laveran and
Franchini could be explained in this way.
The author drew attention to the fact that many
observers, especially Basile, seemed to think that every
case of infantile kala-azar must necessarily be asso-
ciated with some infected dog.
It is quite true that human and canine cases
exist side by side in a manner which cannot better be
illustrated than by the instance quoted by Sergent
Lombard and Quilichini, where, in an isolated farm
outside Algiers, they found a child, a dog and a kitten
all suffering from the disease. The most reasonable
assumption is that these three unfortunate victims
either infected one another or all became infected at
the same time. But it has been repeatedly shown
that cases of infantile kala-azar occur quite apart
from dogs.
In Malta the author came across an interesting
case in which twins about two years of age both
suffered from kala-azar. As one commenced to be
ill some time after the other it is probable that the
first child infected the second. The home, a laundry,
in which the family lived, was some distance outside
Valetta, and here two dogs were kept. A careful
inquiry showed that the .dogs had never had any
illness and at the time they appeared perfectly healthy.
Liver puncture was performed on the dogs with nega-
tive result. The author expressed it as his opinion
that the eanine and human diseases were the same,
but that he did not think there was any evidence to
warrant the conclusion that a human being must
necessarily be infected from a dog. An infected child
is dangerous, not only to any other children with whom
it may come in contact, but also to dogs in just the
same way as an infected dog is dangerous to other
dogs and children.
Knowing that the human flea, Puler irritans,
is the one which most commonly attacks man, while
the dog flea Ctenocephalus canis, attacks dogs, in order
to explain his hypothesis Basile realized that if the
disease is to pass from dogs to children it would do so
more rapidly if the human flea fed upon infected dogs.
He states that in Sieily, where most of his investiga-
tions were undertaken, the human flea is quite a
common ecto-parasite of dogs. In Malta this was
certainly not the case, for of over a thousand fleas off
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. "1
dogs examined by the author not a single one was
Pulex irritans. The human flea is, however, very
common in Malta, so that there was every opportunity
for them to get on to the dogs.
On the subject of canine kala-azar the author stated
that he had examined 46 stray dogs for evidence of
natural leishmania infection. In order to test the
accuracy of liver puncture as a means of diagnosis
this operation was performed before the animals were
killed, after which the spleen and bone marrow was
examined. Unfortunately, liver puncture proved quite
unreliable as a means of diagnosis, for in no case were
leishmania found in the liver smears before examina-
tion of the spleen after the animals were killed. Of
the 46 dogs examined six were found infected by
examination of the spleens post mortem. The exami-
nations were made in the months of June, July and
August, 1913, and it is interesting to note that the
percentage of infections was approximately the same
as that found by Dr. Critien in Malta during April and
May, 1910. An important point to note is that the
great majority of dogs examined were in perfect health,
and it was only amongst the few that were evidently
ill and in bad condition that the cases of infection
were found. Canine piroplasmosis does not exist or
is very rare in Malta, so that the commonest disease
of dogs in this island appears to be kala-azar. It
would, therefore, be fairly easy to insist that all
unhealthy dogs should be removed from the neigh-
bourhood of human beings, or, preferably, killed. It
is just as important also to prevent children, who
show symptoms pointing to kala-azar, from coming
into contact with other children or dogs.
In connection with the diagnosis of kala-azar and
also Oriental sore, it is well known that it may be
impossible to find the parasites by microscopic ex-
amination. In such cases the culture method may
be of some assistance. It has happened several times
in connection with examination of experimental
animals, that the inoculation of tubes of N.N.N.
medium from the organs has given rise to a culture
of flagellates, while mieroscopie examination of smears
from the same organs has been negative.
The author was asked by Prof. W. J. Simpson to
see a case of ulceration on the margin of the ear.
The disease had apparently been contracted in
S. America. Smears from the base of the ulcer, as
well as from the swollen red margin, failed to reveal
any leishmania, though the condition was suspected
as dermal leishmaniasis. By puncture of the red
margin of the ulcer after sterilization of the skin with
alcoholic iodine solution, material was obtained for
the inoculation of these tubes of N.N.N. medium.
After three weeks flagellates began to appear in one
of the inoculated tubes, thus proving that leishmania
had been present in the lesion, though in numbers too
small to be detected by ordinary microscopic examina-
tion. This is the first instance in which the culture
method has been used as a means of diagnosis in this
disease.
As regards the relation of kala-azar to Oriental
sore, some recent experiments are of great interest.
Gonder has shown that mice may be infected with
72 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
leishmania from kala-azar and Oriental sore, and that
in each case a general infection is produced, with
enlargement of the liver and spleen, in which the
parasites may be very numerous. One difference,
however, becomes evident, in that the mice infected
with the Oriental sore virus eventually develop
peripheral lesions on the feet, tail and head, and in
these lesions leishmania are readily found. In the
case of mice infected with the kala-azar virus no such
peripheral lesions appear, so that Gonder is led to
suggest that Oriental sore, like kala-azar, is really a
general infection, the earlier stages of which have
been overlooked, and that it is only in the later stages
that peripheral lesions develop on the skin.
The exact method of infection with Oriental sore is
not known, but the author stated he had inoculated
the virus directly in four human beings and in every
case after an incubation of some months a typical
sore appeared at the point of inoculation, or close to it.
If the infection during the period of incubation,
which is a long one, had been of a general nature one
would at least expect some sores to appear elsewhere
than at the site of inoculation.
The author had the same experience in the inocu-
lation of monkeys, cats and dogs with the virus of
both Eastern and South American sores. The author
attempted to test the relationship of Oriental sore to
kala-azar by inoculating a dog which had recovered
from Oriental sore with a large dose of virus from the
spleen of a case of kala-azar. The dog did not appear
to have contracted the disease, so was killed between
three and four months after injection. No leishmania
could be found in the organs.
As regards the cutaneous leishmaniasis of S. America
it was pointed out that the condition leading on to
extensive involvement of the nasal and buccal cavities
might be very different from the Oriental sore of the
East, though recently Castellani had described some
cases of oro-pharyngeal ulceration from Colombo in
which leishmania had been discovered.
Working with virus from South American sores the
author had not been able to find any features, either
morphological or cultural, to distinguish it, nor were
any differences noted in the infection of animals. It
still remains a fact that clinically in man the South
American disease may be very different from that of
the East, so that the question of the identity of the
parasites must be left for future research.
In summing up the author suggested that kala-azar,
whether in children or adults, in all parts of the world
is caused by the parasite, Leishmania donovani, while
Oriental sore is caused by Leishmania tropica in the Old
World and probably also in South America, though
this cannot be regarded as finally settled.
Experiments with Malarial Parasites and Piro-
plasma canis.—In a paper, entitled ** Weiteres über
die Züchtung der Malariaparasiten und der piroplas-
men (Piroplasma canis) in vitro ” (Archiv für Schiffs-
und Tropen-Hygiene, February, 1914), Professor H.
Ziemann describes further experiments with the
culture of malarial parasites. In this case the
purasites were obtained from a patient who was
infected with the double benign tertian variety, and
(Mar. 2, 1914.
who recovered naturally from the attack without
special treatment. The development of the para-
sites in the culture tube was controlled by examina-
tions of the parasites as they developed in the blood.
It was found that—
(1) Without dextrose the parasites would not
develop in citrated blood, but quickly degenerated.
(2) In the dextrose culture the female gametocytes
were the most persistent forms, and lasted longest
in the culture, as in the patient’s blood. Active
nuclear change took place in the gametocytes during
the early stages of culture.
(3) Just as in the blood of the culture, the para-
sites showed no active multiplication, though there
was a tendency for a longer persistence in culture
than in the blood.
(4) In the culture, together with many de-
generating forms which are often seen in the blood
of cases with a tendeney to spontaneous recovery,
there are other parasites which appear quite normal.
(5) Just as in the blood of such cases, the para-
sites tend to disappear spontaneously, so in the
cultures from these cases subculture is not possible.
Unless the progress of events in the cultures had
been controlled by parallel examinations of the
blood, it might have been thought that the tendency
of the parasites to die off in the tubes was an
abnormal event, whereas the same tendency was
shown in this case by the same parasites in the
blood of the patient who recovered spontaneously.
In reference to Piroplasma canis culture, multi-
plieation takes place much more readily than in the
case of human malaria, for corpuscles are seen con-
taining as many as sixteen to thirty-two merozoites.
Attempts have been made to inject fifty-two dogs
with eultures of P. canis. Only twice has it been
found possible to inject the animals with old cultures,
even with intravenous injection—once with a six-
teen-day culture and once with a twenty-day culture.
These cultures had apparently been maintained at
room temperature (189 C. to 229 C.).
Leprosy after Two-year Incubation Period.—The
futher of the patient, V. T., now aged 81, Filipino,
native of Laguna Province, was admitted to the
Culion Leper Colony, August 10, 1908, with the
clinical diagnosis of tubercular leprosy, micro-
scopically positive. The mother of the patient,
G. T., Filipina, now aged 37, native of Bataan Pro-
vince, was admitted to the Culion Leper Colony,
February 10, 1910, with the clinical diagnosis of
mixed tubercular and anesthetic leprosy, micro-
scopically positive. The patient, a girl born at
Culion, May 15, 1911, an inmate of that institution
to date, when examined, June 80, 1918, presented
no clinical evidences except slight reddening of the
cheeks over the malar bones and reddening of the
lobes of the ears. Those especially versed in the
diagnosis of leprosy would probably regard this
reddening as due to leprous dermatitis. Micro-
scopic specimens prepared from scrapings from the
cheek and the septum of the nose were positive for
leprosy.—Vicror G. Herser, M.D., Director of
Health, Philippine Islands, Manila.
Mar. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
| T3
Abstracts.
THE THIRD ALL-INDIA SANITARY CONFER-
ENCE, LUCKNOW, JANUARY, 1914.
President.—The Honourable Sir Harcourt Butler,
K.C.S.I., C.I.E., 1.C.S., Member of the Governor-
General's Council, in charge of the Department of
Education.
PRESIDENT’S ADDRESS.
GENTLEMEN,— The year’s retrospect shows steady
advance in many directions. We may not—we
must not—be satisfied with the present rate of pro-
gress, but there are no short cuts to the ends which
we have in view. We have arrayed against us the
habits and prejudices of centuries. We cannot in
the land of the ox-cart get the pace of the motor-car.
If ardent spirits are fretful at the rate of progress,
they should at least realize that there has recently
been greatly accelerated achievement and that there
is a sanitary awakening which none can justly gain-
say. In both hygiene and research the results give
ground for hope.
In regard to the sanitary services, four appoint-
ments of Deputy Sanitary Commissioner have been
added to the eight new appointments sanctioned in
1912. The twelve new appointments have been
allotted as follows: Three to Bengal; two each to
Madras, the United Provinces, and Bihar and
Orissa ; and one each to the Punjab, the North-west
Frontier Province and Burma.
Of these appointments, three are reserved for the
present for officers of the Indian Medical Service,
and the remaining nine are open to medical men re-
cruited in India, of whom eight—all Indians—have
already been appointed. In addition, 39 first-class
and 104 second-class health officers are to be
appointed to the municipalities. In order to assist
local governments in organizing the service without
delay a recurring grant of 2°66 lakhs of rupees has
been sanctioned from Imperial revenues in addition
to a grant of Rs. 25,560 per annum to the North-
West Frontier Province. The Government of India
are meeting the cost of the new appointments of
Deputy Sanitary Commissioner on the scale sanc-
tioned for Indians, and are giving a subvention
amounting to half the pay of first- and second-class
health officers. Special attention is also being paid
to the training of sanitary inspectors. The neces-
sity of enlarging the bacteriological department has
also been recognized, and the Secretary of State
has already been addressed on the subject. I
hope also that the Secretary of State will soon be
addressed regarding an increase in the sanitary
engineering staff.
As to the disposal of the grants for sanitary and
anti-malarial schemes, the non-recurring grants for
the purpose of urban sanitation in 1913-14 amounted
to 150 lakhs, or £1,000,000 sterling, exclusive of a
sum of 132 lakhs for special schemes in the North-
west Frontier Province, Delhi, Bangalore, Indore,
Quetta and Mercara. The recurring grants for
sanitation in the same year amounted to 45 lakhs
or £300,000 sterling per annum, of which 5 lakhs
was reserved for research and anti-malarial projects.
The remaining 40 lakhs recurring and the non-
recurring sum of 150 lakhs have been distributed
amongst the different provinces in lump sums.
Schemes for the improvement of rural sanitation
are not yet sufficiently advanced to justify Imperial
grants, but they are receiving attention. In the
provinces which benefited by the transfer to district
boards of the entire net proceeds of the land cess
to the amount of some 82 lakhs, or over
£546,000 sterling a year, there should be no diffi-
culty in financing sound schemes of rural sanitation.
It is hoped that considerable sums will be set aside
for the improvement of rural water supplies, for
anti-malarial measures, for the protection of grain
stores, and for general sanitation.
Since the new department was formed in January,
1911, Imperial grants made for sanitation, re-
research, and anti-malarial measures have amounted
approximately to Rs. 4,55,74,000, or £3,038,266 ster-
ling, of which Hs. 49,50,000, or £330,000, are recur-
ring and Rs. 4,06,24,000, or £2,708,266, are non-
recurring.
During the year the following grants have been
made by the Research Fund for anti-malarial
measures :—
Rs.
(1) Part contribution to anti-malarial
measures at Palwal in the Punjab 14,000
(2) To complete schemes at Saharanpore,
Nagina and Kosi ae nis 2,00,000
(3) For similar purposes in Ennore 58,700
Total 2,72,700
No grant has yet been made for the Meerut and
Kairana schemes, which are still under considera-
tion. Other grants made from the Research Fund
have been :—
Rs.
(a) For equipping research laboratories of
the Calcutta School of Tropical
Medicine, the foundation stone of
which will shortly be laid by His
Excelleney Lord Carmichael ... 1,00,000
(b) For improving the laboratories and
teaching accommodation at the
Central Researeh Institute, Kasauli 16,000
(c) For an elaborate experiment in water
filtration at Benares 1,50,000
(d) A grant of Rs. 2,000 to Captains Patton and
Cragg to assist them in producing a treatise
on medical entomology, which is now in the
press.
(c) A contribution of £500 per annum for a period
of three years to the Imperial Bureau of
Entomology for the investigation of noxious
insects.
(f) Grants of Rs. 1,000 cach to the Bombay Bacteri-
ological Laboratory for a practical experiment
in the disinfection of grain in bulk, and to
Professor McMahon, of the Canning College,
Lucknow, towards an investigation into the
chemical composition of milk in the United
Provinces.
74 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 2, 1914.
* —
Since the inception of the Research Fund we have
received in grants Rs. 16,00,000 and disbursed
Rs. 14,835,000, in accordance with the advice of our
Scientific Advisory Board.
The actual work carried out during the year under
the auspices of the Indian Research Fund Associa-
tion and of the various provincial administrations
has been considerable. There are at present nine
medical officers working on special malarial in-
quiries in seven provinces. You will also be glad
to hear that the Secretary of State has sanctioned
the establishment of a Pasteur Institute at Ran-
goon, the director of which will combine bacteri-
ological and serological research with his routine
work.
As regards the immediate future it is proposed
to institute at Poona an investigation with reference
to the fixation of bacteriological standards of purity
for drinking water. Inquiries will also be made
into the etiology of diabetes, leprosy, and the fevers
of uncertain origin. Although diabetes is not,
strictly speaking, a '' tropical ’’ disease, it leads to
the death of so many valuable lives in India that
an inquiry into its causation and prevention has
become necessary. This inquiry will, however, be
one of considerable difficulty, as the disease does not
attack the class of people who come to hospital for
treatment, being confined almost exclusively to the
richer and more intellectual classes, especially those
who lead sedentary lives. In addition we intend
to carry out at Benares an elaborate practical
experiment in water filtration, with the object of
ascertaining the best methods of silt removal and
determining the relative merits under varying con-
ditions of the different types of mechanical filters
and of sedimentation both with and without the
addition of chemicals.
I recommend to your eareful perusal the able
reports by Major James on the protection of India
from yellow fever and on the practicability of
stegomyia reduction in Indian seaports which were
published in the second number of the Journal of
Medical Research. It is gratifying to learn that in
Major James’s opinion there is no immediate danger
of importation of infected mosquitoes in India after
the opening of the Panama Canal. At the same
time Major James urges that this does not justify
inaction, and points out that a continuous water
supply is an essential preliminary to any attempt
to reduee the numbers of stegomyia mosquitoes in
our seaports. During the last year Major James
has been on deputation with the Ceylon Govern-
ment and has carried out an extensive anti-stego-
myia campaign in Colombo. T deeply regret that
he has now been stricken by serious illness and must
proceed to England as soon as he is fit to travel.
I am sure that you will all join with me in wishing
him a speedy recovery and a quick return to the
scene of his useful labours.
The new Indian Journal of Medieal Research has
now appeared and its third number is in the hands
of the delegates. It has met with a most cordial
reception not only in India, Great Britain and the
Colonies, but also on the continents of Europe and
America, and its circulation is already very large
and is steadily increasing. If you will consider the
style of its produetion, you will understand that at
the low subscription rates now charged it will not
be a financial success unless our subscription list
is considerably increased. It is at present financed
by the Indian Research Fund Association, but we
have no right to count on such support for an in-
definite period. I trust, therefore, you will all do
your best in increase its circulation. Here I may
mention that all the papers presented to the Con-
ference have been printed in such form as will
enable them to be issued as supplements to the
Journal. In this way they will secure a far wider
cireulation than is possible when they are published
merely as appendiees of an official report. They
will, moreover, be issued immediately after the
conelusion of the Conferenee and will thus be in the
hands of the publie many months sooner than was
possible under our previous arrangements.
I attach great importance to the work of the
provincial pilgrim committees with whom the Sani-
tary Commissioner with the Government of India
is zealously co-operating. The great pilgrim centres
are foci of epidemic disease and sanitary improve-
ments in them will add much to the health and the
comfort of the general population. In this connec-
tion I may note the important bearing of Major
Greig’s researches into cholera. During the winter
of 1912-13 the Pilgrim Committee toured exten-
sively in the United Provinces. Their report is now
under consideration. One of the most important
recommendations of the Committee was the im-
provement of the great Badrinath Pilgrim Route,
regarding which a most interesting report has been
written by Mr. G. Adams, of the Indian Civil
Service—it will be found in the January number of
the Journal of Indian Research. The Government
of India have made a grant to the Local Govern-
ment of 6 lakhs non-recurring to be spread over
five years, and Rs. 20,000 recurring for this object,
and it is hoped that the Local Government will be
able to meet the balance required to complete the
scheme from provincial revenues. These improve-
ments should be greatly appreciated by many
thousands of pilgrims journeying from all parts of
India.
I now turn to the proceedings of the Conference.
The only change in procedure this year is that for
administrative convenience; malaria is now dealt
with in the research section instead of our holding
a separate malarial conference.
An analysis of the agenda paper is interesting.
There are no less than twelve contributions on prob-
lems in connection with malaria. No subject has
attracted so much attention. Urban and rural
water supplies are treated of in seven valuable con-
tributions and milk supply in six. Four papers deal
direetly or indirectly with town planning, and four
also with the important subject of vital statisties.
The range covered by these papers is very wide, and
time will not permit of my dealing with them in
detail; but I must allude briefly to a few of them.
and T would first direct your attention to the
Mar. 2, 1914.]
«4 ,
three important papers on '' Bonificasione,’’ which
are on the agenda for discussion this morning.
This method is said to have given good results
in Italy, and the papers, which, as you know, were
presented to Government some years ago, are repro-
duced here in order that the question as to how far
the method is applicable to India may be thoroughly
ventilated and discussed.
Another important subject for discussion is the
question of the milk supply. It is obvious that we
must fix standards of purity with reference to the
Food and Drugs Act, but the question is compli-
cated by the fact that milk in India is often a
mixture of cow's and buffalo's milk. There are,
moreover, administrative difficulties in connection
with religious and caste prejudices and with the
possibility of raising the price beyond the means of
the poorer classes.
As regards town improvement, you will have
opportunities of seeing examples of this in Lucknow
before the discussion on this subject takes place.
You have also before you a technical and elaborate
paper by Mr. Orr, which throws much light on the
difficult subject of the regulation of light and air—
points which are of vital importance in view of the
steady increase of tuberculosis amongst the urban
population.
Then you have three very important papers on
the subject of plague. Those of Captain Kunhardt
suggest a possible new departure in our plague
policy. In one of our resolutions last year we
directed attention to the necessity for carrying on
active anti-plague measures in certain selected
villages during the quiescent period. Captain Kun-
hardt’s present report shows us how to select the
villages which require special attention. His sug-
gestions are now under consideration, and it is
possible that we may decide to carry out an experi-
ment of this nature on a large scale under the
auspices of the Research Fund. The paper from
Parel on grain disinfection reports the results of
the experiments for which we gave a grant of
1,000 rupees. These experiments are of consider-
able value in view of the rapidly accumulating
evidence as to the part played by grain in the
introduction and spread of plague not only in India,
but also in Java, Manila and the Straits Settle-
ments.
Another paper, to which I would draw special
attention, is that of Major Cook Young on the
“Incineration of Rubbish and Night Soil in Delhi
City." Those of us who live in the vicinity know
what a wonderful effect this has had in mitigating
the fly nuisance. Our experience in this matter
illustrates in a practical manner how large a portion
of the discomforts which we suffer and the dangers
to which we are exposed in India are due to defec-
tive scavenging.
Lastly, I wish to refer to the lantern exhibition
of type-designs from all the different provinces,
which, it is hoped, will afford a valuable opportunity
for exchanging views and discussing local pecu-
liarities and difficulties.
Research in all its many branches is lifting the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 76
veil that hides the secrets of disease and mortality,
but we shall not fully benefit by its discoveries until
the people are educated to receive them. In a
resolution, dated February 21, 1913, the Govern-
ment of India commended to local governments a
thorough inquiry into the teaching of hygiene in
schools and colleges and attention to the personal
hygiene of the students—a subject upon which
Rao Sahib Ganesh Nagesh Sahasrabudhe and Rao
Bahadur Gopal Das Bhandari have written instruc-
tive papers. We are also most anxious to enlist
private co-operation, and have reason to hope that
the Indian Council of the St. John Ambulance
Association will come to our assistance. Practical
details of any scheme eventually adopted will be
worked out when the reports of the provincial com-
mittees of inquiry have come in. At present the
general idea is to impart instruction in first aid and
domestic hygiene in certain schools and to encourage
active workers of the Association to afford assistance
in the inspection of pupils and the school premises.
It has also been suggested that special training in
hygiene should form part of the curriculum for
teachers. Any such scheme, however, will leave
the adult population untouched. In order to reach
them it is proposed to organize, under the auspices
of the Indian Research Fund Association, a Central
Bureau, where a sufficient number of good lantern
slides, models, pictures and skeleton lectures could
be stocked. These would be issued to the several
provincial sanitary commissioners to be distributed
by them on Joan to health officers and medical men
for the purpose of popular lectures to the staff at
the differnt fairs and to the staff of travelling dis-
pensaries. With the sanction of the Government
of India, the United Provinces Government has
recently created and financed 26 additional travel-
ling dispensaries in the United Provinces and the
employment of three officers of the Indian Medical
Service to supervise them at an estimated cost of
89,000 rupees per annum. Small exhibitions might
also be organized and bacteriological leaflets be
distributed at religious melas. Nor can we stop
here if we wish to achieve complete success.
Colonel Firth speaking before the United Services
Institution at Simla, and, simultaneously, Sir
Pardey Lukis delivering the inaugural address at
the London School of Medicine for Women—the
one from the military, and the other from the civil
standpoint—expressed their strong conviction that
we shall never make any real advance in domestic
or personal hygiene until we have convinced the
women of the country as to its necessity. This
object we can achieve in two ways. The one is
by encouraging medical women to preach the gospel
of health inside the zenana and to organize purdah
parties at which they will give lantern demonstra-
tions, for which purpose we shall be glad to lend
them the necessary apparatus. The other method
is by a cautious development of the system of
employing nurse district visitors and sanitary in-
spectresses. You have before you an excellent
paper on this subject from Madras, where the
experiment has been in progress for the last six
76 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 2, 1914.
months, and I understand that similar useful work
has been inaugurated in Bombay by Dr. Turner,
who, I am glad to learn, is giving us the benefit
of his great experience in a work on sanitation in
India which is shortly to be published. I trust
that the two papers which I have mentioned will
lead to a full discussion of the whole subject, for
I am convinced that if we can succeed in working
out a practical scheme it will have a lasting effect
upon the welfare of futuro generations, both by
inereasing their knowledge of preventive measures
and by improving their general standard of health
and physique.
You will thus recognize that essential and far-
reaching systems of sanitary education are now in
the air. I hope that we shall soon be able to pub-
lish a resolution on general sanitary policy and
address local governments with a view to the
working out of definite schemes. We have before
our eyes the remarkable achievements on the mili-
tary side by the service so ably directed by Sir
Arthur Sloggett. The military conditions are not
comparable to those with which we have to deal.
We have to handle, not small numbers of adults
under military discipline in sanitary surroundings,
but many millions of men, women and children
living in most unsanitary surroundings under little
or no control. We have to carry the people with
us, and there are limits to the powers of education
which no amount of money can altogether remove.
But we can do much, and I know this—that you
will press forward patiently, but persistently, with
long vision and high sustaining hopes, and, believe
me, gentlemen, you will succeed.
INTRODUCTORY ADDRESS.
By the Honourable Surgeon-General Sir PARDEY LUKIS,
K.H.S., K.C.S.I., M.D., F.R.C S.
Director-General, Indian Medical Service.
THE first paper on the subject of malaria to which
I wish to allude is the contribution relating to the
incidence of enlarged spleen among school children
in London, for which we have to thank Sir Ronald
Ross and Majors Christophers and Perry. Its chief
interest and importance are in view of the fact that
an estimation of the spleen-index of children is the
most readily applieable measure we possess for
measuring the intensity of malaria in a given
locality. We can now continue to use this method
of measuring malaria with increased confidence in
its value and fewer doubts as to its validity, except
perhaps in districts where kala-azar is prevalent.
With regard to jungle clearing, last year the
Indian Research Fund proposed to allot to Bengal
a considerable sum of money for the purpose of
carrying out an extensive experiment of jungle
clearing in the vicinity of inhabited areas. There
has been considerable delay in starting this experi-
ment, owing to the fact that the Provincial Malarial
Committee of Bengal do not consider that the
evidence put forward by us of the connection be-
tween jungle and malaria has borne the test of
further investigation. They are of opinion that
extensive jungle clearing in Bengal villages is im-
practicable. It appears to me that this decision is
due to a misapprehension of the intentions of the
Scientific Advisory Board. The Provincial Com-
mittee, acting upon the reports of Major Fry and
Dr. Bentley, take the term '' jungle " to mean all
vegetation, including fruit trees and bamboos. We
never intended any such wholesale destruction of
valuable property; all we aimed at was the eradica-
tion of rank undergrowth and scrub and useless
trees. The condition of affairs round a Bengal vil-
lage was ably described by Buchanan one hundred
years ago as quoted by Bentley himself in the
November number of the Indian Medical Record.
He says '' the great variety of lofty flower and fruit-
bearing trees and the luxuriant bamboos by which
the cottages are shaded would render their situation
delightful, did not rank weeds and bushes, which
shoot up with increasing vigour in every corner that
is not in constant cultivation, prevent all circulation
of air, preserve a constant damp, noisome vapour
and harbour a great variety of loathsome and per-
nicious animals.’ This is the condition we want
to remedy. Dr. Bentley, in the last paragraph of
his able paper ‘‘ On the Reaction of Mosquitoes to
Artificial Light,’’ alludes to the generally accepted
theory that a sereen of trees is beneficial as a pro-
tection against malaria and mosquitoes. The ques-
tion here, however, is not one of a screen of trees;
it concerns the eradication of serub or undergrowth.
We have moreover in Major Marjoribanks’ sugges-
tive paper on ‘‘ Malaria in the Island of Salsette,"
striking evidence of the deleterious effect of jungle
around the village site. He shows that it is pos-
sible to map out a series of '' isoplens "'; that the
most malarious villages are those at the foot of the
hills, where the jungle is densest, and that the
malarial endemicity steadily decreases as you go
farther and farther from the jungle belt. To ex-
plain this he advances the very plausible theory
that the scrub and jungle afford shelter and
humidity to the female mosquito, thus enabling her
to live on into the dry season and inereasing the
period of her infectivity towards man. Major
O'Gorman Lalor, too, in his recently published
report on '' Malaria in the Katha District '’ advo-
cates as a measure of practical utility the cutting
down and burning of all scrub jungle twice yearly
in, and for a radius of one mile around, every
malaria-stricken centre of population.
Another matter upon which we require further
information, and which formed the subject of one
of our resolutions last year, is as regards the precise
conditions under which wet cultivation is, or is not,
likely to be harmful from the point of view of
malaria. ‘So far, with the exception of a brief allu-
sion in Major Marjoribanks' paper, no reports on
this subject have reached us, though we trust that
Captain Hodgson, who is now on special malarial
duty in Madras, may have something to tell us next
year.
` DI will now pass on to a report on certain important
observations which has been published by Wade-
Brown in the Journal of Experimental Medicine for
July last. In this article the author, after referring
Mar. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. Ti
to his previous experimental work on hematin-
intoxication in the rabbit, produces evidence to
prove that the anemia, the hemoglobinemia, the
high percentage of large mononuclear leucocytes,
the destruction of platelets and the tendency to
hemorrhage in malaria are all influenced by the
malarial pigment ‘‘ hematin.’’ He gives it as his
opinion that hematin is probably the hitherto un-
known circulating toxin to which malarial anemia
has been attributed and he points out that the
hemoglobin, converted to hematin by the malarial
parasite, is not readily available for the regeneration
of the red cells and the blood is thus rapidly depleted
of hemoglobin and iron. In a later report Wade-
Brown deals with the renal complications in
hematin intoxication, but his investigations throw
no light on the problem of hemoglobinuria.
On the subject of blackwater fever the most recent
work appears to endorse the opinion that without
malaria there is no blackwater fever; but it is still
by no means certain that they stand towards one
another in the relation of cause and effect. Not-
withstanding the fact that Balfour and most other
observers are disposed to doubt the parasitic nature
of Leishman’s cell inclusions and the suggestion
that they might be of the nature of chlamydozoa, or
that they play any part in the causation of black-
water fever, Leishman still inclines to his original
view. In a recent article on the etiology of black-
water fever he discusses the usually accepted hypo-
thesis as to its causation and admits that there is
at present no actual proof of the existence of a
specific virus. He argues, however, that the
chlamydozoal hypothesis is not inconsistent with
well-established points. Thus the association of
blackwater fever with malaria is comprehensible if
it is assumed that the chlamydozoal virus is trans-
mitted either by mosquitoes or by some different
insect whose geographical distribution is similar,
and he points out that mosquitoes transmit at least
four diseases, two of which (yellow fever and
dengue) are due to filter-passing viruses. He urges,
moreover, that neither the immunity of natives in
endemic areas nor the fact that immunity to malaria
appears to go hand in hand with that of blackwater
fever can be regarded as being inconsistent with the
new hypothesis; whereas, on the other hand, the
well-known discrepancies in the geographical dis-
tribution of the two diseases may be explained by
assuming that some insect, resembling the mos-
quito in its life habits, transmits the specifie virus,
and that, in those intensely malarious regions in
which blackwater fever does not occur, this insect
may be either less numerous or not so widely dis-
tributed. In conclusion he suggests another pos-
sible connection between malaria and blackwater
fever, namely, the possibility of the malarial para-
site being itself subject to disease. Another theory
worth remembering is a suggestion put forward by
Balfour that blackwater fever may be caused by the
injection of a highly virulent hemolysin by some
insect.
Turning to the subject of the Spirochatoses, Major
Bisset confirms Mackie’s original discovery that
Pediculus vestimentorum is the carrier of the disease,
and also Nicolle’s observation that relapsing fever
is transmitted by the accidental crushing of the lice
during scratching, the mere bite being innocuous.
He is, however, inclined to the belief that infection
is transmitted, not so much as the result of actual
scratching, but that it is due to the prevalent habit
of killing a louse by crushing it between the finger-
nails. As regards preventive measures, he points
out that there must be an active crusade against
lice and that the present method of killing them
must be discouraged. The importance of the
crusade against lice is emphasized by Major
McKechnie’s report on his investigation into a
mysterious fever occurring at Bhim Tal. This fever
he believes to be true typhus, the carrier of which
Nicolle suspects to be P. restimentorum, though
Patton, Husband and MeWalters incriminate
Cimez lectularius, at any rate so far as Indian jails
are concerned. Captain Brown, who has also in-
vestigated relapsing fever in the Meerut district,
confirms Bisset’s findings both as regards lice and
the ease with which they may be killed by the
exposure of clothes and bedding to direct sunlight.
He suggests, however, that the possibility of con-
veyance of infection by Bragada picta, one of the
harvest bugs, is deserving of investigation. It is
obvious that we must not regard P. vestimentorum
as the only carrier of spirillar fevers in India.
Jukes has reported cases of spirillar fever occurring
in the Darjeeling district, in which the temperature
is irregular and shows no resemblance to that of
relapsing fever. In all these cases jaundice was a
marked symptom and there was a high rate of
mortality. Jukes is inclined to regard the fever as
hitherto undescribed, but in my opinion it is identi-
cal with the biliary remittent fever of Vandyke
Carter. This, however, is merely an academic
question: the important point is that lice and bugs
from the infected houses were dissected and in no
instance were spirochetes found in these insects.
In this connection I must mention that during
the past three or four years a peculiar fever, accom-
panied by jaundice, has been noticed in the Anda-
man Islands. The jaundice, whieh appears on the
third or fourth day, is often intense and in severe
eases there are petechial hemorrhages, bleeding
from the gums and delirium. The mortality is
40 per cent. Hitherto this fever has been regarded
as malarial, but no malarial parasites are found in
the blood and treatment by quinine is of no avail.
Major Woolley thinks this fever may be classed as
a separate entity. I suggest that it may possibly
be spirillar.
Patton has examined both the spleen and bone
marrow of 1,321 dogs destroyed in the lethal cham-
ber at Madras and in no case was a dog found to
be naturally infected with Leishmania. It is evident
therefore that, in the endemie centres of kala-azar
in India, dogs are not infected as they are on the
Mediterranean littoral. We have, moreover, the
evidence of Mackie that the main point of epidemio-
logieal interest in the disease is its dependence
upon close personal contact.
78 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 2, 1914.
Beriberi is not included in our agenda, but Dr.
de Mello, in his paper upon '' The Notification of
Disease,'' expresses the opinion that beriberi cannot
be attributed to rice. On the contrary, he believes
it to be infectious and contagious. That he is not
alone in this opinion is evidenced by the faet that
during the last year communications have poured
into the medical press, notably from the Amazons,
Brazil, Southern Nigeria and Shanghai, in all of
which the authors express grave doubts as to the
accuracy of the “deficiency °’ theory, and I am
informed by Colonel Blenkinsop, R.A.M.C., that,
when he was in Sierra Leone, he had under his
care several British officers suffering from clinical
beriberi. A few months ago, moreover, there was
an outbreak of peripheral neuritis closely resembling
beriberi amongst the British troops at Lebong.
None of those attacked were rice-eaters and the
majority of them were total abstainers.
INTESTINAL SCHISTOSOMIASIS IN
SUDAN.*
By Captain R. G. ARCHIBALD, M.B., R.A.M.C.
THE
SCHISTOSOMIASIS exists as a common parasitic
infection among the inhabitants of Egypt, and it is
mainly due to the excellent researches that have been
carried out by different observers in that country that
our knowledge of the disease has been obtained.
There are, however, particular aspects of it as met
with in the Sudan that merit a certain amount of
attention, inasmuch as the disease is responsible for
a clinical picture that often presents some difficulties
to the diagnostician.
The cases, described in this paper representing the
intestinal type of schistosomiasis, are examples of
some of the so-called pyrexias of uncertain origin
met with in the Sudan. The patients affected have
usually been well-nourished adults admitted to hos-
pital with fever, headache, furred tongue, and
frequently enlarged spleen. As will be seen from
the clinical histories of a few of the cases, neither
diarrhæa nor tenesmus form constant symptoms;
indeed, they are frequently absent.
Case 1.—An Egyptian soldier, admitted to hospital
in a weak condition with fever and an enlarged
liver and spleen. Diarrhoea was not present. Six
months previously, while in an _ out-station, the
patient had suffered from an attack of diarrhea,
with blood and mucus in his stools, but since
then had been free from similar symptoms. The
peripheral blood was examined, and, apart from
a leucocytosis, nothing abnormal was noted. The
spleen was enlarged to a point about 3in. below the
ribs, and on palpation was of a doughy consistence.
The liver increased in size, and in view of the
leucocytosis present an exploratory operation was
carried out, but no sign of an abscess could be found.
Quinine injections failed to influence the temperature.
No examination of the fæces was carried out owing
* Abstract of paper in British Medical Journal, February 7,
1914.
to the absence of intestinal symptoms. The patient
became weaker, and died on the seventh day after
admission.
Post-mortem examination showed that there was
extensive ulceration of the large intestine. Smear
preparations from the base of the ulcers revealed the
lateral-spined ova of Schistosomum mansonii. Adult
worms were present in the iliac and portal veins.
The liver was fatty and cirrhotic and the spleen
congested and enlarged.
Case 2.—A powerful-looking Egyptian soldier was
admitted to hospital suffering from pyrexia. His
blood was examined for malarial parasites, but with
negative results. The temperature fell to normal on
the third day after admission, and he was discharged
from hospital at the end of a week. Five days later
he was readmitted with high fever, and looked very ill.
He complained of headache and rigors. The tongue
was thickly furred and the spleen slightly enlarged.
The abdomen was distended but not rigid. No
diarraehie symptoms were present. Blood examination
proved negative for malarialor other parasites. The
patient became steadily worse, his condition closely
simulating a case of enteric fever; the fæces were
rather fluid in character and of a pea-soup colour.
Two days later he was passing almost pure blood per
rectum. A rapid enlargement of the liver was
observed, but no jaundice was noted. Examination
of the fæces was carried out. Neither the ova of
intestinal parasites nor amcebe were found. A daily
increased enlargement of the spleen was then ob-
served, and the organ eventually reached a point
level with the umbilicus. The patient appeared to be
in a state of acute toxemia, and died on the seventh
day after admission to hospital.
Post-mortem examination showed very extensive
ulceration throughout the large intestine as high up
as the ileo-cæcal valve. In this area there was a
small intussusception, with ulcers present in that
portion of the gut forming the intussusceptum.
Smear preparations taken from the base of the ulcers
showed the existence of lateral-spined ova of Schisto-
somunm MUNSON.
Case 3.—An Egyptian soldier was admitted to
hospital suffering from fever and diarrhoea. He was
somewhat ansmie, and the spleen was slightly
enlarged. Blood examination for malarial parasites
proved negative. After admission the patient's con-
dition quickly became worse. He lost flesh rapidly,
and his whole appearance was one of extreme lassi-
tude, suggesting a toxæmie condition likely to be
attended with fatal results. The diarrhea was à
feature of the case from the onset. The faces were
examined, and the lateral-spined ova of Schistosomum
mansonii were found.
The observations made post mortem on the previous
cases suggested the possibility of good results
accruing if vaccine therapy was employed.
sample of the patient's stools was obtained and
plated out on suitable media. The plates were care-
fully examined, and contained for the most part two
different types of B. coli colonies. Their cultural
characters were worked out, and a bivalvent auto-
Mar. 2, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 79
genous vaccine prepared. The patient received a first
dose of 05 c-c., representing 250 million organisms,
followed five days later by a dose representing
500 million. The result obtained was striking. After
the first injection the patient stated he felt much
better. A marked and rapid improvement in his
condition set in. The diarrhea ceased, the tem-
perature fell, and a week after the second dose he
was discharged fit from the hospital.
Case 4.—The patient was a woman of about 24 years
of age, who had never been out of Khartoum. She
was admitted to hospital with fever, anemia, and
debility, and a very enlarged spleen extending to the
umbilicus. Examination of the peripheral blood was
negative for malarial parasites, and a careful search
for evidence of malarial pigment was attended with
negative results. The red blood corpuscles showed a
certain degree of poikilocytosis and microcytes, and
a few normoblasts were present. In addition, there
were found oval and circular cells about 3°5 » in
diameter, whose cytoplasm stained a delicate blue
with Leishman stain. Some of these cells contained
a few granules showing a chromatin tint. Myelocytes
were not in evidence, nor did the blood films suggest
lymphatic leukeemia, The red blood cells numbered
2,250,000 per cubic centimeter, and the white blood
cells 8,000 per cubic centimeter. Blood culture was
carried out, but yielded no results as regards the
presence of a septicemia. Puncture of the spleen
was then resorted to. This organ was very firm,
and resisted considerably the entrance of a fine
hypodermic needle. Several smears were carefully
examined, but neither Leishman-Donovan bodies nor
malarial parasites were ever found.
As the spleen continued to enlarge and the patient's
condition showed no improvement, the operation of
splenectomy was decided upon, and successfully carried
out by Dr. Atkey, of the Sudan Medical Department.
The operation wound healed satisfactorily, but the
patient's temperature continued to rise steadily, and
was in no way influenced by quinine administered
hypodermically. An examination of the fæces was
then carried out after a purge had been given; it may
be mentioned that since her admission the patient had
not shown any signs of intestinal irritation. After a
prolonged search the ova of Schistosomum mansonit
were found.
The patient’s physical condition did not improve,
and it was noticed that the liver was now commencing
to enlarge rapidly. As a possible line of treatment
vaccine therapy was suggested. A sample of the
fæces was obtained and suitably plated out, and a
bivalvent vaccine prepared from two different types
of colt organisms isolated. An injection of 250
million was given as an initial dose, followed four
days later by an injection of twice the number of
micro-organisms, and a similar number a week
following the last dose.
The patient’s temperature after the third injection
became consistently lower. Another sample of fæces
was obtained, and almost a pure culture of a proteus-
like organism obtained. A fresh vaccine from this
was prepared, two injections were given, and at the
end of a week the patient had improved considerably,
and a week later was discharged from hospital with
practically a normal temperature. Her liver, which
had previously extended to a position almost level
with the umbilicus, had now retracted to a point 1 in.
below the costal margin.
CONCLUSIONS.
The main points referred to in this paper may be
briefly summarized.
(1) There exists a specific fever in the Sudan, acute
or chronic in type, dependent on an infection with
Schistosomum mansonit.
(2) This fever is usually accompanied by an enlarge-
ment of the spleen, a varying degree of anemia, a
polymorphonuclear leucocytosis, a large lymphocytosis,
and an absence of eosinophilia. In the more chronic
cases the liver becomes enlarged.
(3) Intestinal symptoms may or may not be present.
(4) The importance of a careful examination of the
fæces in all cases of pyrexia of uncertain origin.
(5) The possible value of treatment by autogenous
vaccines of intestinal organisms, particularly in the
acute toxic types of intestinal schistosomiasis, and in
cases of splenomegaly due to no apparent cause.
Thanks are due to Captain A. G. Cummins, R.A.M.C.,
for the clinical notes of Cases 1, 2, and 3, and to Dr.
Atkey and Dr. Christopherson, of the Sudan Medical
Department, for facilities given in the treatment of
Case 4. Mr. Newlove, of the Khartoum Civil
Hospital, also rendered kindly assistance.
—————————
Drugs and Appliances.
PHYSIOLOGICAL CRITERIA FOR MEDICINAL
SUBSTANCES. :
THE testing of medicines constitutes one of the
most important and practical branches of modern
scientific research work, and deserves even more
attention than has hitherto been accorded to it. It
is à task which has been shown by experience to pass
outside the self-imposed limits of ordinary analytical
chemistry, and it is therefore especially interesting to
note the contributions which have been made, during
recent years, to this branch of study, by specialists in
physiology and bacteriology.
The pamphlet recently issued by the Wellcome
Physiological Researeh Laboratories under the above
title admirably epitomizes current practice and gives
some extremely interesting reports, illustrating the
progress made towards the ideal of precise physio-
logical standardization of potent medicines.
In choosing a physiological test, the method pur-
sued at the laboratories has been to select one
definitely related to the therapeutic effect of the drug,
or, when the active principle is known, to use that
one of its actions which produces an easily measurable
effect. A rise of blood-pressure, or the minimal lethal
dose for animals of uniform weight, are examples of
data susceptible of accurate measurement, and there-
fore suitable for establishing an exact system of
dosage.
80 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 2, 1914.
The application of the lethal dose method to the
digitalis series is described in some detail. The test-
ing of tincture of digitalis is carried out by means of
the common English frog (Rana temporaria), the
heart of a medium sized specimen coming to a com-
plete systolic standstill within three hours when the
frog is injected with a dose of 0'0075 c.c. of the
standard tincture per gramme of body weight. Theo-
retically equivalent specimens of tincture and other
preparations of digitalis, as ordinarily purchased on
the market, have been found to vary in activity in
the proportion of 1 to 4, when tested by this method,
and the extreme importance of maintaining a physio-
logical standard in regard to so potent a drug is there-
fore obvious. The frogs used should be freshly
caught; healthy males of about 25 grm., during the
months of July and September, give the most uniform
results. The curious fact is noted that the toad,
which Shakespeare described as “ugly and venomous,”
possesses a secretion of the skin, digitalis-like in its
action. Being remarkably resistant to the drugs in
this series, toads are unsuitable for testing the
activity of digitalis. Some interesting tables show-
ing the results of doses of the tincture of digitalis,
squill and strophanthus upon frogs of known weight
are given, and the method of deducing an average
minimal lethal dose is indicated.
Cannabis indica being a drug of very variable
activity, of which the active principle, although
known, does not lend itself to chemical methods of
standardization, has furnished another field for
physiological research.
The various methods whieh have been suggested
for standardizing preparations of the suprarenal
gland are next discussed.
Adrenine is a notoriously unstable substance, and
neither the optical rotation test nor the chemical
estimation methods hitherto devised have proved
suitable for routine standardizing purposes. It has
remained for the physiologist to devise a test, and
this has been done by measuring the rise of arterial
blood-pressure produced upon an animal organism as
the result of an intravenous injection. Pithed cats
under artificial respiration are utilized for this pur-
pose, and the method, as stated by an observer, is
found to be capable of the mechanical accuracy of a
chemical balance. Some instructive diagrams illus-
trating this part of the subject are given.
A noteworthy example of the fruitful alliance
between chemical and physiological methods in the
examination of medicinal substances is to be seen
in the production of "epinine," which was the out-
come of independent investigations at the Welleome
Chemical Research Laboratories. Owing to its syn-
thetic origin and the fact that its salts are readily
erystallizable, this substance can be prepared in a
state of uniform purity which precludes the necessity
for the constant repetition of physiological tests. In
its therapeutic effects it closely resembles the supra-
renal active principle.
Pituitary (Infundibular) Extract, which has at-
tained in recent years a wide therapeutic importance,
is a preparation, the chemistry of which is:by no
means in so advanced a state, and here the need
for exact physiological criteria is specially apparent.
Such data are obtained at the Wellcome Physio-
logical Research Laboratories by measuring the
action of a batch of pituitary extract upon the
isolated uterus of a virgin guinea-pig, suspended in
warm oxygenated Ringer's solution, a method which
excludes the errors due to tolerance of successive
doses in animals.
The remainder of the book is devoted to the
elucidation of the complex but deeply interesting
problems connected with ergot and its standardization.
“ Physiological Criteria" should be read by all
who desire to obtain an insight into modern methods
of the physiological control of drugs, and it abun-
dantly demonstrates not only the importance of this
work but also the thorough and scientific manner
in which it is being carried out at the Welleome
Physiological Research Laboratories.
——— 9 —— ———
Hotes and Hews.
FOURTH INTERNATIONAL CONGRESS OF
SURGERY.
THe Fourth International Congress of Surgery
meets at New York, U.S.A., from April 13 to 18 in
the Hotel Astor. The s.s. Imperator, of the Ham-
burg-America Line, leaves Southampton on April 3,
reaching New York on the 9th. Special rates are
being charged for delegates proceeding to the
Congress by this ship, a 25 per cent. reduction being
allowed off the tariff rates. Tickets are available
for the return journey up to May 15 from New York.
BRITISH MEDICAL ASSOCIATION.
EiGnTy-sECOND ANNUAL MEETING, ABERDEEN, 1914.
President-Elect: Stk ALEXANDER OGston, K.C.V.O.,
M.D., LL.D.
Section of Tropical Medicine.
President.—Professor Wiliam John | Ritchie
Simpson, C.M.G., M.D., 31, York Terrace,
Regent's Park, London, N.W.
Vice-Presidents.—Daniel Elie Anderson, M.D.,
F.R.S.E., 26, Harley Street, London; John Mitford
Atkinson, M.B., 37, Welbeck Street, London, W.;
Henry Fraser, M.D., Kuala Lumpur, Federated
Malay States.
Hon. Secretary.—George Alexander Williamson,
M.D., 15, Forest Road, Aberdeen.
Botices to Correspondents.
—
1.—Manuscripts if not accepted will be returned,
2.— As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
3.—To ensure accuracy in printing iv is specially requested
that all communications should be written clearly.
4.—Authors desiring reprints of their communications to Tug
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
5.—Correspondents should look for replies under the heading
‘* Answers to Correspondents.”
Mar. 16, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(No. 6, Vol. XVII.
` Original Communications.
“A HUMAN RECOVERY FROM TRYPANO-
SOMIASIS.”
By Dr. T. S. KERR.
Late P.C.M.O., Straits Settlements,
To the list of recoveries from trypanosomiasis
the following case may now I think be added:—
Mrs. G., aged 45, seen with Dr. E. I. Spriggs
for the first time November 5, 1909.
The patient had just arrived from an upstation in
Portuguese Loanda, where she had lived for fifteen
years, coming home occasionally to Europe.
During the earlier years of her stay she suffered
much from malaria. She remembers specially
being bitten by a tsetse-fly some time in June, 1909,
after which she had a wetting followed by a fever
.on which quinine had no effect. Later a rash
appeared all over the body in circular patches, vary-
ing in size from a sixpenny piece to a half-crown,
which the Portuguese doctor called eczema: it dis-
appeared after a time.
Getting no better she left for England, arriving
in London October 28, 1909.
On examination patient states she does not feel
well but is not sleepless nor irritable, and has now
no fever, but is much depressed. She is pale and
has an anxious look, but there is no marked anemia
nor emaciation. On the left side of the neck
several glands are palpable, one markedly so in the
posterior triangle. The axillary and inguinal glands
are enlarged. The spleen is palpable. There is an
indistinct mottling on the left upper arm, the
patches being irregular in shape and of a reddish
tinge.
There is an eczematous condition of the skin of
the left leg where formerly there had been an ulcer.
Deep hyperesthesia (Kerandel’s sign) is well
marked. There had been much sleeping sickness
among the estate coolies, some of whom she had
nursed. `
The case was diagnosed provisionally as one of
trypanosomiasis, and this was confirmed by the
finding of trypanosomes in the blood.
A blood examination made on November 5 was
as follows : —
Reds 4s Sis 235 ». " 4,175,000
Whites... PR A - "a 3,960
Hemoglobin ai ; : 86 per cent.
Differential Count :—
Polynuclears 48:5 ,,
Large mononuclears 18:0 ,,
Lymphocytes Ses s oy 8055 ,,
Eosinophiles V A or e 80 ,,
.Two trypanosomes were found whilst making the
differential count.
Examination of the fæces was negative.
Treatment.—Intravenous injections of tart. antim.
were proposed, but as the effect of these was
then little known-the following treatment on the
adviee. of Sir Patrick Manson, who saw the patient,
was adopted.
(1) Intramuscular injections of soamin every
fourth day beginning with one grain, increased
gradually to three grains.
(2) Sodium antim. tart., 4 gr. in 10 oz. of
water to be taken in the twenty-four hours mixed
with her food, the amount to be gradually increased
to 2 gr. in the twenty-four hours.
(3) Plain food, cod-liver oil, and open-air exer-
cise daily short of fatigue. She was admitted to
Netley House, November 14, 1909, and treatment
was commenced on the 15th. Her weight was
then 9 st. 11 Ib. There was only a very slight rise
of temperature (see chart), but the pulse was rapid
and easily excited.
On the 16th she developed a cyclitis and iritis
of the right eye, and subsequently severe conjunc.
tivitis which gradually yielded to a lotion of zine
sulph. and atropine. By the 24th she was having
3 gr. injections of soamin and daily $ gr. of sodium
antim. tart., which occasioned no inconvenience;
she was also feeling much better then, had a good
appetite, and had been out for a drive. The rash
was almost inappreciable, the glands diminished
NOV.
[DATE | 5 | i6 | i7 | I8]
MEMEME
rai N
? [5 X
[Purse |
[Bowers 1;
CHART A.
and the eye became much better. She complained
only of occasional fleeting pains in the forearms and
calves of the legs.
By the 28th she could take 1 gr. of the antimony
salt daily and was able to go out for a walk, was
more cheerful, ate and slept well; had crampy feel-
ings in the hands, though very evanescent; eye
now quite well. Left the home November 29.
By December 14 she was taking 2 gr. of the
antimony salt but complained of occasional nausea,
griping pains, and diarrhea; felt much stronger.
Of the eruption there was now no trace, and
some of the enlarged glands had entirely disap-
peared; others were barely palpable. No trypano-
somes could be found in the blood. The antimony
was decreased for a day or two and then resumed. :
A week later she complained of fleeting pains of
a neuralgie character about her temples, cheeks,
arms, legs, ankles, and had frequent flushings.
December 29, beyond fleeting. pains in legs and
about hands, and these less than formerly, had
nothing to complain of; the heart’s action was not
so rapid, the spleen was no longer palpable, nor
82 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 16, 1914.
could the glands, except those in the left axilla, be
felt.
Differential blood counts made on November 5
and 26 and December 15 gave the following :—
Nov. 5, 1909, Nov. 26, 1909. Dec. 15, 1909.
Per cent. Per cent. Per cent.
Polymorphonuclears ... 48:5 46:0 43:0
Large mononuclears ... 13:0 12:0 T 6:0
Lymphocytes ... e. 30:5 33:0 39-0
Eosinophiles ... 2. 8:0 sa 9:0 12:0
The patient left for West Prussia in the beginning
of January, 1910.
On March 5 she wrote saying she had had three
attacks of fever recurring every forty-eight hours;
they were similar to others experienced on returning
from Africa on previous occasions. From the de-
scription these appear to have been of a malarial
nature, so quinine was ordered.
Blood films taken just after the fever and
examined by me on the 8th showed neither malarial
parasites nor trypanosomes.
The glands she stated had quite disappeared, but
occasionally she experienced tingling sensations
about the face and irritation about the neck,
shoulders and upper arms, but '' felt well in mind,
healthy in spirits and really enjoyed life." Weight
10 st.
Mareh 11, 1910.— Written to, to continue treat-
ment. On April 18 she wrote, ‘‘ I suddenly seem
unable to stand my antimony; I have been taking
regularly two '' tabloids ” (2 gr.) in 10 oz. of water,
but for the last two weeks have suffered much dis-
comfort and feel generally unwell, sickness, pains
in the stomach, and diarrhoea."
'* The continued discomfort pulls me down very
much. I have also queer pains in my hands,
wrists and ankles, but no other symptoms that
cause me uneasiness and no return of the malaria.”’
April 20.—Written to, to omit antimony for ten
days, then to begin again with 1 gr. to 10 oz. of
water, to be gradually increased to 2 gr.: to con-
tinue soamin injections.
All disagreeable symptoms passed off on stopping
the antimony for ten days. In four blood slides
taken after stopping the antimony no trypanosomes
were found.
Patient returned to London, June 1, 1910. Stated
she felt very well but had stiff feelings about the
knees after sitting for a long time, and six weeks
ago had a mild attack of conjunctivitis. With
occasional variations has now taken daily 12 gr.
of antimony and soamin injections 3 gr. every fourth
day for five months. No eye symptoms, spleen
not palpable, no enlarged glands, heart’s action
still a little rapid, eczema of the left leg quite
disappeared.
Patient looked well, colour and complexion good.
On her return to Germany on June 16 I suggested
she should see Prof. Schilling at Berlin, to whom I
sent an account of her case. She saw him on
June 20.
She reported that her eyes had been examined by
a specialist and that they were quite normal. Is
getting fatter daily and in the best of spirits, though
still troubled occasionally by the antimony.
Oetober 8, 1910.—Patient again in London.
Has continued the injections of 3 gr. of soamin
every fourth day since November 15, 1909, and
the sodium antim. tart. daily (500 1-gr. ‘‘ tabloids "'
in all).
She has had occasionally to vary the amount
taken, for when the dose reached 2 gr. a day it
induced pain, nausea and diarrhea, and she had t5
desist for some days and begin again with 4 gr.
doses.
Lately has experienced dull feelings in the head
after the injections, which, however, soon pass off.
Unless when taking the antimany in large doses,
the bowels kept regular and she was free from pain.
No extraordinary sensations, eyes normal, no en-
larged glands, weight 10 st. 13 lb.
Injections were then reduced to 3 gr. every five
days, antimony to 3 gr. daily.
In April, 1911, when in Germany, signs of an
eruption again appeared. Treatment was therefore
stopped for three weeks, the temperature was taken
daily, and at the end of this period 20 c.c. of the
patient's blood was injected into a monkey, by
Professor Schilling.
The monkey died, and at the post-mortem ex-
amination showed a much enlarged spleen with
JULY AUG
| DATE [24|25|26 [zz | ze[2e [oo] un | i [2] S[ 4[5[6[7] 8]
vere
"EH fiuit Wort
Feel ree toel bal elan [ee] “rele "rol ao “eel S. ae
aw ELS
CnanT B.
Temperature chart while having the antimony injections.
trypanosomes present there and in the bone
marrow. Sub-inoculated rats also acquired the
disease. At this time the patient wrote to me
saying, '' I have not been so strong for years; can
play six sets of tennis of a morning and take a walk
in the afternoon.”
On July 17, 1911, the patient returned to London
and, in view of Kerandel's experiences just then pub-
lished, it was decided to try intravenous injections
of tartar emetic, beginning with 4 gr. doses to 6 oz.
of saline every third day until seven injections in all
had been given, gradually increasing the dose and
resuming the soamin injections as formerly.
These injections were given by Dr. E. L. Hunt,
and considerable difficulty was experienced in giving
them owing to the very small calibre of the veins.
The first injection, à gr., was given on July 24,
1911, and was followed by no symptoms. Injec-
tion of soamin.
The second on the 26th was unsuccessful, but on
the 28th 1 gr. was injected; this was followed by
cough and a slight rise of temperature lasting two
to three hours.
July 31.—Third injection,
symptoms: soamin 1 gr.
1:25 gr. No after
Mar. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 83
August 2.—Fourth injection, 1°5 gr. No after
symptoms.
August 4.—Fifth injection, 1°5 gr., followed by
slight cough. The patient stated that after each
injection she experiences a curious taste in her
mouth, like that of blood.
August 6.—Sixth injection, 1°75 gr. It was
intended that 2 gr. should be given, but when 1°75
gr. had been injected coughing began. This injec-
tion was followed in about two hours by neuralgic
pains in the shoulder and arm of the side injected,
but these soon passed off.
August 8.—Soamin injection, 2 gr. Feels well.
Weight 11 st.
August 9.—Seventh injection, 1°75 gr. This
was followed by coughing and some hours later by
dreadful feelings of heaviness and pains in the arms
and legs so that she had difficulty in moving, but
by mid-day of the following day they had quite
disappeared and she was able to go home.
On August 23, fourteen days after the last in-
jection, six white rats were injected intraperi-
toneally, each with 1} c.c. of the patient's blood.
On September 24 one of the rats died suddenly
from no assignable cause, but no trypanosomes were
found in its blood or spleen.
When seen on October 9 patient stated, ‘‘I am
very well and enjoy life thoroughly ; am able to take
any amount of exercise without fatigue, eat well and
sleep splendidly. Have occasionally neuralgic feel-
ings about eyes. Weight 11 st. 10 1b.”
The 3 gr. injections of soamin which had been
continued every fourth day since August were dis-
continued on October 14 as there was some redness
around the eyelids and irritation of the skin, par-
ticularly of the parts lain upon.
On November 13, 1911, patient complained of
pains in eyebrows and at back of ears radiating down
the neck and felt very nervous in consequence.
Examination of her blood was negative and there
was neither eruption, enlarged glands nor other
symptoms attributable to trypanosomiasis.
She then returned to Germany again and saw
Prof. Schilling at Berlin. He found her well but
apprehensive of a return of the disease.
He inoculated a second monkey with 20 c.c. of
the patient’s blood on November 27, 1911. This
monkey, which remained well, was killed on January
12, 1912, and no evidence of trypanosomes in the
blood or organs either in fresh or stained prepar-
ations were found.
Another monkey was inoculated in the beginning
of March and died in about four weeks quite sud-
denly, but the autopsy showed nothing that would
point to a trypanosome infection. Further treat-
ment was then abandoned.
Since that time the patient has remained well
ever since, and wrote on August 20 and again on
December 23, 1913, saying that she was in perfect
health.
The points of interest in the case are—
(1) The high eosinophile count, not usual in
trypanosomiasis, though helminths were absent.
(2) The extraordinary good health enjoyed by the
patient in spite of the persistence of the infection.
On June 16, 1911, two years after the initial infec-
tion, she was playing tennis daily. This was, I
think, attributable to the tonic effect of the soamin.
(3) The large amount of antimony taken inter-
nally.
(4) The curative effect of the intravenous injec-
tions of tartar emetic.
(5) Whether the course of soamin injections and
antimony by the mouth during eighteen months
rendered more effective the subsequent intravenous
injections of antimony is a matter for conjecture;
unquestionably they did her much good, but there
ean I think be little doubt that the intravenous
injections were the active remedial agent and caused
the disappearance of the trypanosomes.
(6) Symptoms having now been absent for so long
point, I think, to a real recovery from the disease
and not merely to an arrest of its progress.
A FURTHER CASE OF ENTOPLASMOSIS.
By ALDO CASTELLANI, M.D.
Director Government Clinic for Tropical Diseases,
Colombo (Ceylon).
IN a paper published by me in THE JOURNAL OF
'TRoPICAL MEDICINE AND HYGIENE, March 1, 1914, I
described a peculiar protozoal organism found in
three cases of dysenteric colitis in which amcbe
and bacilli of the dysentery group were absent.
Since then I have come across another case, a
passenger from Burma.. The patient complained
of severe griping pains and diarrhea, with muco-
pus and blood in the stool. These symptoms
had started two days previous to my seeing
him on board ship. The temperature was 1009 F.,
general condition good ; the stools contained a large
amount of mucus, practically no fecal matter. I
prescribed a saline mixture, and directed the patient
to pass a stool into a large sterile Petri dish with
which I supplied him. This was examined micro-
scopieally thirty minutes after having been passed,
and protozoal bodies identical to those described in
my previous report were found. There is no neces-
sity to give a full description of them again here, but
I may mention that the bodies were actively motile
with the body showing only slight changes of shape
while moving and no pseudopodia and with the
anterior portion extremely shaken, so to speak, by
very rapid vibratory-lihe movements, making one
suspect at once the presence of flagella. On closer
examination no such structures were found, either
in fresh or stained preparations. In this case, in
addition to the Giemsa method of staining, I
employed the Heidenhain Iron Hematoxylin, with,
of course, previous wet fixing. One preparation so
stained came out beautifully, showing clearly that
the group of granular or coecus-like bodies observed
in preparations stained with Giemsa is a nucleus, this
confirming Professor Mesnil's and my own opinion.
No flagella or cilia were visible. Of course, I do not
deny that such organs may be present, but so far
in none of my preparations have I been able to
detect them, nor have any of my colleagues to
whom I have shown the slides and the fresh
preparations. How to classify this organism?
84 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 16, 1914.
Professor Mesnil and some other authorities who
have seen it consider it a new organism, but differ in
the zoological position which should be given to it.
Personally, I consider it to represent a new genus,
for which I proposed in my previous paper the term
“ Entoplasma.”’
————3»—————
Personal Hotes.
COLONIAL MEDICAL SERVICES.
West African Medical Staf.
March, 1914.
No Deaths. No Transfers.
Resignations. — A. Hipwell, L.R.C.S., L.R.C.P.Ireland,
D.P.H.Liverpool, D.T.M.Liverpool, Medical Officer, Nigeria ;
F. G. Thompson, M.B.Lond., Medical Officer, Gold Coast.
Retirement. —G. C. Walker, M.D., Ch.B. Vict., M.R.O.S.Eng.,
L.R.C.P.Lond., L.S.A.Lond., D.P.H.Lond., D.T.M.Liverpcol,
Sanitary Officer, Gold Coast, retires on pension.
New Appointments. — The following gentlemen have been
selected for appointment to the Staff: W. Telfer, M.B.,
Ch.B.Glasgow, Gold Coast; J. F. Corson, Ch.B., M.D.Man-
chester, D. P.H.Cantab., Gold Coast ; H. Fleming, M.B., B.Ch.,
B.A.O.Dublin, Sierra Leone; W. Allan, M.B., Ch. B. Aberdeen,
D.P.H., Sierra Leone; W. H. Kauntze, B.A.Vict., M.B.,
B.Ch.Vict., M.B., B.S.Lond., M.R.C.S.Eng., L.R.C.P.Lond.,
Nigeria; A. R. Paterson, M.B., Ch.B.Glasgow, Nigeria; R. G.
Ball, B.A.Dublin, M.B., B.Ch., B.A.O.Dublin, Gold Coast;
E. J. H. Garstin, B.A.Dublin, M.B., B.Ch., B.A.O.Dublin,
Nigeria ; P. A. Clearkin, M.B., B.Ch., B.A.O.Queen’s Univer-
sity, Belfast, Sierra Leone; J. McC. Olark, M.B., B.Ch. Aber-
deen, D.T.M.Liverpool, Sierra Leone; J. Atkinson, M.B.,
Ch.B.Glasgow, Gold Coast.
Other Colonies and. Protectorates.
J. L. Pawan, M.B., Ch.B.Edin., and H. C. Swertz, M.B.,
B.Ch., B.A.O.(R.U.I.), have been selected. for appointment as
Supernumerary Medical Officers in Trinidad.
T. H. Massey, L.R.C.S., L R.C.P.Ireland, has been selected
for appointment as a Medical Officer in the East Africa Pro-
tectorate. .
M. Anthony, L.R.O.S., L.R.C.P.Ireland, has been selected
for appointment as Second Assistant Medical Officer, Lunatic
Asylum, Jamaica.
A. H. B. Pearce, L.R.C.S., L.R.C.P.Edin., L.F.P.S.Glas-
gow, L.M.Dublin, Medical Superintendent of the Holberton
Hospital and Health Officer, Antigua, has been selected for
appointment as Colonial Surgeon in the Falkland Islands.
J. F. Hoare, M.R.C.S., L.R.C.P., has been selected for
appointment as a Medical Officer, Gilbert and Ellice Islands.
J. G. Watson, M.R.C.8.Eng., L.R.C.P.Lond., has been
selected for appointment as Medical Officer for Grand Cayman.
W. S. Mitchell, M.R.C.S., L.R.C.P.Lond., L.S.A., has been
selected for appointment as Assistant Resident House Surgeon
at the Colony Hospital, Grenada.
J. T. Duncan, F. R.C.S.Ireland, has been selected for appoint-
ment as a Medical Officer in the Straits Settlements.
G. V. Fiddian, M.B., B.C.Cantab., has been selected for
appointment as an Assistant Medical Officer in British Guiana.
J. M. Mackinnon, M.B., Ch.B. Edin., has been selected for
appointment as a Temporary, Medical Officer in the East Africa
Protectorate.
B. C. N. O'Reilly, M.R.C.S. Eng., L.R.C.P.Lond., and E. E.
Wilbe, L.S.A.Lond., have been selected for appointment as
Medical Officers in the Gilbert and Ellice Islands.
S. D. Stewart, M.B., Ch.B.Edin., has been selected for
appointment as & Supernumerary Medical Officer, Trinidad.
G. H. Lewis, M.D.Edin., and C. W. L. Cassel, M.B.,
Ch.B.Edin., D.T.M. Liverpool, have been selected for appoint-
ment as Assistant Medical Officers, British Honduras.
H. B. Dodds, L.R.C.P., F.R.C.S.Ireland, Medical Officer,
St. Vincent, has been selected for appointment as a Medical
Ofticer in the Straits Settlements.
Rotices.
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may commence at any time, and is payable in advance.
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8.— The Journal will be issued avout the first and fifteenth of
every month.
TO CORRESPONDENTS.
9.— Manuscripts if not accepted will be returned.
10,—As our contributors are for the most part resident abroad,
proofs will not be submitted to those dwelling outside the United
Kingdom, unless specially desired and arranged for.
11.— To ensure accuracy in printing it is specially requested
that all communications should be written clearly.
12.—Authors desiring reprints of their communications to THE
JOURNAL OF TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
13,— Oorrespondents should look for replies under the heading
** Answers to Correspondents.”
REPRINTS.
Contributors of Original Articles will be supplied with
reprints, “the order for these, with remittance, should be
given when MS. is sent in. The price of reprints is as
follows :—
50 copies of four pages, TE ie 5/-
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If a printed cover is desired the extra cost will be, for 50
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THE JOURNAL OF
Tropical Medtctne and hygiene
MancH 16, 1914.
HELMINTHOLOGICAL INVESTIGATIONS.
Tue departure of the expedition, under the direc-
tion of Dr. R. T. Leiper, Helminthologist of the
London School of Tropical Medicine, to the Eastern
Tropies is an event which must prove of considerable
scientific importance. Accompanying Dr. Leiper is a
medical officer seconded by the Admiralty, Surgeon
E. L. Atkinson, R.N., who, since his return from the
Scott Antarctic Expedition, has been working at the
London School of Tropical Medicine upon patho-
logical specimens he brought back from South
Polar regions. The personnel of the expedition is
further perfected by the presence of a zoologist,
— a | — —
Mar. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 85
T ———————————————————
Mr. A. Cherry-Garrard, who served as Assistant
Zoologist in the late Antarctic Expedition. The
funds necessary for the investigation have been
found partly from the bequest of the late Lord
Wandsworth to, and now under the control of, the
London School of Tropical Medicine, and partly
they have been contributed to by the Tropical
Diseases Research Fund of the Colonial Office.
The primary object of the expedition is to ascer-
tain the mode of spread of the trematode diseases
of man.
Facilities for investigation have been afforded by
several countries, and in Sumatra the United
States Rubber Co. have specially invited the expedi-
tionary party to study the helminths as they affect
the workmen on their rubber estates.
In a previous leader in this Journal we drew
attention to the solidarity of scientific investigation,
citing as an instance the bearing Arctic and Ant-
arctic pathological and zoological findings had on our
geographical knowledge of the spread of disease, and
of the limitations or otherwise of pathological germs
by heat and cold. The association of experts with
a first-hand knowledge of these subjects in the
frigid zones is of particular interest on the occasion
of this the most recent scientific expedition to the
Tropies.
The intestinal parasites met with in man in the
Tropies might well be termed legion, and no medical
practitioner who deals with tropical ailments at
home or abroad can afford to do aught as a first
and stereotype item of practice but to administer
an anthelmintic, or at least a simple purge, so as
to ensure that there is no worm or its ova compli-
cating the symptoms of any one of the intestinal
derangements that may come to him for treatment.
How often even the most skilful doctor in the
Tropics has had cause to repent the non-observance
of this practical axiom. Intestinal fluxes ascribed
to dysentery, acute, chronic or intermittent some-
times prove intractable to the customary remedies
for dysenteric lesions, and the cause of the resistance
to their action is not detected until the patient goes
to another doctor, who, administering an anthel-
mintie, clears up the mystery, to the chagrin
of the aforesaid and the loosening of the unflattering
tongue of the sufferer. Apart, however, from the
mere Clinical aspect of the good this expedition may
do, there are larger and more important factors to
be considered, namely, the publie health and the
commercial points of view. These are intimately
associated. The good health of the workers in a
mine, on a rubber, tea or coffee plantation, or on
any commercial undertaking where men are em-
ployed in large numbers, affects the commercial
value of the undertaking they are engaged upon to
the extent that it may have to be abandoned by the
capitalist owing to the monetary losses ill-health
entails. Such a state of things affects the whole
world by the fact that many necessary articles of
food become dearer not only locally, but universally,
and the tea, coffee, cocoa, sugar, rice, tapioca,
sago, &c., of our ordinary diet is enhanced in price.
Thirdly, the scientific advance likely to ensue from
the expedition may be hoped to be great and lasting.
The men engaged upon it have a high scientific
reputation and their work is sure to be sound and
reliable. It is to be hoped that our knowledge of
bilharziosis will be advanced, that ankylostomiasis
will be rendered more capable of being controlled,
and that the flora of the intestine generally will be
placed on a surer footing than obtains at present.
SUBCUTANEOUS INJECTIONS OF QUININE.
THE condemnation of relying upon hypodermic
injections of quinine in the treatment of malaria
has been from time to time insisted upon in the
pages of this Journal; the surgieal disadvantages
were frequently brought prominently forward, and
the therapeutic value was decried. Time was, and
that but a few years ago, when a practitioner of
medicine who refused to give hypodermies of quinine
in severe malaria was looked upon as old-fashioned
and not in harmony with the scientific advances
of the day. After a lack of wisdom in these
matters there is nowadays a general outcry against
quinine being so given. Captain MacGilchrist,
I.M.S., in an article published in the Scientific
Memoirs by Officers of the Medical and Sanitary
Departments of the Government of India, as long
ago as 1911 (No. 41 Memoir) stated ‘‘ that quinine
and its salts are fundamentally unsuited for hypo-
dermic use." In No. 48 of the same Memoirs,
1911, Colonel Sir David Semple, R.A.M.C., brought
home to us the danger of tetanus occurring from
these injections; and now Sir Ronald Ross, K.C.B.,
F.R.S., states that ‘‘ I really do not know why this
form of medication is continued in malaria." He
further states (Medical Times, March 7, 1914):
* It appears to me that the only cases in which
intramuseular injeetion is called for are those in
which intestinal absorption may be checked by very
marked intestinal affections, or where patients are
not to be persuaded to take the drug by the mouth
at all. For severe cases, to judge by the experi-
mental evidence, the subcutaneous injections are
much worse than useless, because the patient may
really not be absorbing any of the drug just at the
critical moment when it is necessary that he should
absorb a large quantity; and I fancy that a con-
siderable number of the fatal cases are due to this.
Where the drug cannot be given by the mouth in
very severe cases, the intravenous injection in
extreme dilution seems to be much preferable to
the intramuscular one. I am aware that opposite
opinions have been cited, but do not think that their
weight is sufficient to convince us.”
Surely, therefore, we shall hear no more of quinine
being given hypodermically by British practitioners.
Hypodermie medication for many complaints has
come to us from France, and we cannot hope to
find that the French practitioner will recede from
his position, but let us hope that experience will
teach us to give up a method of administering
quinine which never had anything to recommend it.
86 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 16, 1914.
Annotations.
Natural Leishmaniasis of Dogs in Algiers (Le-
maire, G., Sergent, Ed., and Lhéritier, Revue
Médicale d'Alger, January, 1914).
In this paper the authors describe the kala-azar
of dogs as it occurs naturally in and around Algiers.
On the subject of the period of ineubation no
definite statistics are available on account of the
difficulty of making a diagnosis in dogs at the early
stages of the disease. The disease is described as
occurring in three types—the benign infection, the
infection of medium intensity, the acute infection.
Benign Infection.—Dogs show no wasting and
to all appearance are in good condition. In smears
of the organs leishmania either cannot be detected
or are present in very small numbers. In some
cases leishmania can only be demonstrated by
inoeulating bone-marrow into tubes of N.N.N.
medium.
It is not an uncommon thing to find, in and about
the homes of cases of human kala-azar, dogs which
have at some time or another emaciated and lost
their fur, but which later have recovered and
appear quite healthy again, save that in certain
cases there remain lesions of the eyes, and ulcera-
tions about the eyes, nose and ears. It may be quite
impossible either by microscopic examination of
smears or by culture in N.N.N. medium to demon-
strate leishmania, yet the authors feel convinced
that such cases are really ones of canine kala-azar
of a mild type, and that a complete recovery is
usual.
Medium Infection.—This is the most common
type and generally ends in death after a year or
sixteen months. Animals in this condition show a
progressive emaciation, there is great muscular
weakness, especially of the hind limbs, as shown
by the unwillingness of the animal to stand.
The fur is lost in patches and may come off so
completely that the body is denuded. Ulcera-
tions at the angles of the mouth and eyes and on
the nose are common, while keratitis with opacity
of the cornea is fairly frequent. The animal's
appetite is good till near the end, which is often
preceded by a period of hypothermia and several
attacks of diarrhea. In these cases post-mortem
the spleen may be soft and hypertrophied or more
firm and hard, according as to whether the animal
has or has not lived long enough for a terminal
sclerosis to develop. A similar sclerosis of the liver
may occur at a later stage of the disease. Tho
bone-marrow is always red in colour. Keratitis, as
already stated, is common in the canine kala-azar,
and this is a form of intestitial keratitis due actually
to a development of leishmania in large cells in the
cornea itself.
Acute Infection.—In this type of disease there is
a rapid emaciation without any other sign to lead
one to a ‘diagnosis, which can only be made by the
actual finding of the leishmania in the organs.
The leishmania: occur in extraordinary numbers, so
much so that the normal cells of the organs infected
seem to be actually forced away by the parasites
themselves. Animals suffering from the acute
disease die in a few weeks.
Equine Piroplasmosis in Italy.—In the Central.
blatt für Bakteriologie for February 11, 1914,
Matteo Carfano has two papers on equine piro-
plasmosis in Italy.
In the first of these are described two piroplasms
which occur in horses in Italy. One is the small
(typus parvum) variety, and named by Franca
(1909) Nuttalli equi, while the ather, belonging to
the large (typus bigeminum) variety, was first
distinguished by Nuttall as Babesia caballi.
Nuttalli equi is very difficult to observe in the
living eondition, but this ean best be done by means
of dark-ground illumination.
In stained preparations various types are seen.
Granule Forms.—These consist of a chromatin
mass 0:5 to 1 micron in diameter, with or without
a faint protoplasma layer round it. Morphologically,
these forms are identieal with anaplasma ring forms.
They vary in size from 1 to 2 microns, and are round
or oval in outline, and consist of protoplasm with
central vacuole, and one, or even two, chromatin
masses of varying size.
Pyriform Forms.—These are pear-shaped and of
varying size, and may be arranged in pairs in the
red cells. They can, however, always be distin-
guished from the pyriform individuals of Babesia
caballi.
Amaboid Forms.—Others are irregular in shape,
and may have several long, thin pseudopodia resem-
bling flagella.
Reproduction takes place in the blood corpuscles
by a division of the parasite into four merozoites
after four chromatin masses have been produced.
This division gives rise to a characteristic cross
appearance produced by the four merozoites attached
by their pointed ends.
Babesia caballi, the large piroplasm of the
bigeminum type, is less frequently encountered than
Nuttallia equi. Morphologically, it very closely
resembles Babesia bovis of cattle and Babesia canis
of dogs, and is characterized by its large size and
the constant occurrence of pyriform parasites
arranged in pairs in the red cells. Round and
ameeboid forms are also commonly seen, while
reproduction occurs by division in two. Cases of
multiple infection of the red cells appear to be due
to repeated transverse divisions.
In Italy horses are infected with two ticks—
Rhipicephalus bursa and Boophilus annulatus,
which are probably responsible for the transmission.
That these two piroplasms of horses are distinct
can be proved by inoculating with one an animal
which has recovered from and become immune to
the other.
In the second of the papers the author describes
the artificial culture of these parasites in blood
mixed with a solution of sodium chloride and sodium
citrate. In this medium Babesia caballi survives
alive for for many days, but does not appear to
—— aa
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MARCH 16, 1914.
LONDON SCHOOL OF TROPICAL MEDICINE.
44th Session. January—April, 1914.
Back Row.— D. Stocker (Lab. Asst.), D. S. O'Keeffe (Capt. I.M.S.), I. Ridge-Jones, G. G. Jolly (Capt. I.M.S.), A. L. Fitzmaurice, N. S. Williams, C. J. B.
Pasley, S. Colyer, G. Warren (Lab. Asst.), E. Gibson, L. C. Brohier, J. J. S. Pillay, S. F. Chellappah, J. Marmion, W. McDonald (Lab, Asst.),
N. E. Seppelt (House Surgeon), R. Wolfendale.
Middle Row.—F, W. O'Connor, (Demonstrator), F. E. Wilson (Capt. I.M.S.), G. M. Millar (Capt. I.M.S.), J. M. Stenhouse, C. Burnham, J. H. Castro,
B. Haigh, A. Murphy (Maj. I.M.8.), V. St. John Croley, R. C. Lawrenz, P. B. Haig (Lt.-Col. I.M.S.), T. Ryan, R. O. Sibley (Demonstrator),
C. E. F. Mouat-Biggs (House Surgeon).
Front Row.—B. H. Wedd (Bacteriologist), Dr. H. Williams (Lecturer), Col. A. Alcock (Entomologist), H. B. Newham (Director), Dr. G. C. Low (Lecturer), Dr.
C. W. Daniels (Lecturer), Dr. D. Rees, P. Michelli, Esq., C.M.G. (Secretary), Mr. J, Cantlie (Lecturer), Comdr. G. Hodgkinson, R.N. (Member
of Committee), Miss C. J. Crawford, Miss J. M. F. Drake, Miss E. N. Ross, C. M. Wenyon (Protozoologist), R. T. Leiper (Helminthologist),
Robert (Lab. Asst.), Surg. E. L. Atkinson, R.N.
Absent. —A. L. Piper, I. M. Millar, A. Schokman, W. M. Wade, D. T. Mitchell.
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON),
Under the Auspices of His Majestys Government,
CONNAUGHT ROAD, ALBERT DOCKS, =.
In connection with the Albert Dock Hospital of the SEAMEN’S HOSPITAL SOCIETY.
THE SEAMEN’S HOSPITAL SOCIETY was established in the year 1821 and incorporated in 1833, and from time to time
has been enlarged and extended. It now consists of the Dreadnought Hospital, Greenwich, to which is attached the
London School of Clinical Medicine; the Royal Victoria and Albert Docks Hospital; the East and West India Docks
Dispensary; and the Gravesend Dispensary.
Over 30,000 Patients treated annually. Of this number many are Cases of Tropical Disease.
The School buildings are situated within the grounds of the Royal Victoria and Albert Docks Hospital.
MEDICAL STAFF OF THE HOSPITAL AND LECTURERS IN THE TROPICAL SCHOOL.
JAS. CANTLIE, Esq., M.B., F.R.C.S., D.P.H. Professor R. TANNER HEWLETT, M.D., F.R.C.P. | Col. J. J. PRATT, I.M.S., F.R.C.S.
L. VERNON CARGILL, Esq., F.R.C.S. G. C. LOW, Esq., M.A., M.D. L. W. SAMBON, Esq., M.D.
E. TREACHER COLLINS, Esq., F.R.C.S. J. M. H. MACLEOD, Esq., M.D., M.R.C.P. FLEMING MANT SANDWITH, Esq., M.D., F.R.C.P.
C. W. DANIELS, Esq., M.B., F.R.C.P., M.B.C.S. | Sir PATRICK MANSON, G.C.M.G., F.R.S., LL.D., | Professor W. J. SIMPSON, C.M.G., M.D., F. R.C. P.
KENNETH W. GOADBY, Esq., D. P.H.(Camb.), M.D., F.R.C.P. H. WILLIAMS, Esq., M. D., M.R.C.P., D.P. H.(Camb.
M.R.C.S., L. R.C.P., L.D.S. R.C.8.
Dean—Sir F. LOVELL, C.M.G., LL.D. Arthropodist— Colonel A. ALCOCK, I.M.S., C.I.E., F.R.S.
Helminthologist—Hh. T. LEIPER, Esq., D.Sc., M.B., Ch.B., F.Z.S. Protozoologist—C. M. WENYON, Esq., M.B., B.S., B.Sc.
Director—H. B. NEWHAM, M.R.C.5., L.R.C.P., D.P.H., D.T.M. & H.(Camb.). Secretary—P. J. MICHELLI, Esq., C.M.G.
LECTURES AND DEMONSTRATIONS DAILY BY MEMBERS OF THE STAFF.
There are three Sessions yearly of three months each, October 1st, January 15th, and May 1st. A Course in Tropical
Sanitation and Hygiene is held in the October and May Sessions. Women Graduates are received as Students.
Certificates are granted after Examination at the end of each Session, and the course is so arranged as to equip men for the
D.T.M. Camb., the D.T.M. Eng., and the M.D. Lond., and by London University in Branch VI. (Tropical Medicine).
Fee for course £16 16s.; shorter periods by arrangement.
Students can be provided with Board and Residence, or partial Board, at the School.
Medical men requiring posts in the Tropics may apply to the Secretary at the School, where a Register is kept.
A syllabus, with the general course of study, can be had on application to the undersigned, from whom further
inforration may be obtained.
Students of the London School of Tropical Medicine, who join the London School of Clinical Medicine, will be allowed
an abatement on their fees and vice versa. S
Chief Office—SEAMEN's HOSPITAL, GREENWICH, S.E.
Mar. 16, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 87
reproduce. On the other hand, Nuttallia equi re-
produces as in the blood by division, and ultimately
leads to the formation of the small anaplasma
forms which are to be regarded as stages of resist-
ance, and occur in other forms of piroplasma also.
It is to these forms that the author ascribes the
frequent relapses which occur in infections with
Nuttallia equi.
Trachoma.—In the Archives de l'Institut Pasteur
de Tunis (ii-iv, 1918), Nicolle, Cuénod and Blaizot
give an interesting and important review of work
that has been conducted in their institute upon the
subject of trachoma.
In experimental work of this kind the great essen-
tial is to have some animal which is susceptible to
the disease. For a long time the only one which
would contract the disease was the chimpanzee, an
animal difficult to procure. They discovered, how-
ever, that the monkey of Algeria—Macacus inuus—
was also susceptible, and with this animal experi-
ments were undertaken. Inoculation is best made
by searifying the conjunctiva with an instrument
which has been contaminated with a virulent virus.
For eight days after this there is no noticeable
change in the eyes. Then the conjunctiva becomes
red and cdematous, and on the fourteenth day
typieal granulations appear on the upper lid near
the border of the tarsal cartilage. Thence the in-
jection spreads and eventually involves the lower
lids also. During the third and fourth weeks the
appearance is quite typical of the disease. After a
period during which no change occurs the condition
improves till finally after three months a complete
recovery has resulted. It is possible to inoculate
from one monkey to another.
Bertarelli and Cecchetto succeeded in infecting
a Macacus cynomolgus by means of a virus filtered
through a Berkefeld filter. This experiment the
writers of the paper under review have repeated
upon two Macacus inuus in one experiment and
upon a chimpanzee and another Macacus inuus in a
second. In each case a positive result was obtained,
so that they are justified in concluding that the
agent of trachoma is a filtrable microbe which is in-
visible, since most careful microscopic examination
has failed to reveal it.
By an exposure of the virus to a temperature of
50° C. for thirty minutes it is destroyed, and
similarly it ceases to be inoculable after drying for
thirty minutes at 329 C. In glycerine the virus is
still virulent after seven days in the ice-chest.
By a series of inoculations it has been shown that
the virus is virulent from whatever stage of the
disease it is taken, and that the smallest particle
of conjunctival tissue, or even the tears, are able to
reproduce the disease in susceptible animals. The
onset of trachoma is insidious and is unaccompanied
by any inflammatory condition of the conjunctive
or secretion in its early stages.
One attack of the disease confers upon the
monkey an immunity against subsequent injection,
and further there is some evidence to show that
repeated intravenous injections of virus may render
a Macacus inuus immune to subsequent con-
junctival inoculation. As a result of these experi-
ments upon the monkey, attempts have been made
to treat human beings by intravenous injections of
the virus. This was done in ten cases with no
result in three, improvement in five, and decided
beneficial action in two, which was all the more
marked in one of these since the case had been
most resistant to other treatment. j
Another line of treatment has been adopted and
this is the subconjunctival inoculation of the scrap-
ings of the infected eyelids of the patient himself.
From November 15, 1912, to May 15, 1913, this
treatment was carried out in 154 cases, and since
then it has been the routine treatment at the clinic
in the Rue Larkoum. The details of these cases
wil be published later. They have been most
encouraging and have given better results than any
form of treatment hitherto adopted. The treat-
ment is easily done. The products of curetting are
taken up directly from the eurette in a syringe and
injected immediately under the conjunctiva of the
cul-de-sac of the upper lid. Absorption is very
rapid and never bas any bad consequences. Several
injections are given to each case.
Intravenous Injections of Sublimate for Tropical
Malaria with Latent Sepsis (Dr. L. Deppe, Civil
Surgeon, Tanga, Archiv für Schiffs- und Tropen-
Hygiene, No. 2, January, 1914, p. 51).—In
malarial districts the laity are inclined to designate
a '' fever '" as malaria, frequently using both words
for identical things, in the same way that, in a
case of fever with a positive parasitic finding, it is
difficult for the medical man to ascribe it to any
cause other than malaria. And, even when one
considers that the various manifestations of malaria
have not yet by any means been cleared up, malaria
may accidentally accompany a disease from which
it is frequently difficult to separate it. It is only
subsequently that perchance some change in treat-
ment may bring conclusive evidence or confirmation
of another diagnosis. In this sense a case which
was not cleared up may perhaps be of interest.
Mrs. T., aged 30, had measles, scarlet fever, and
meningitis as a child, and a nervous breakdown at
18, which only responded to treatment after six
months’ sojourn in an institution. She had been
ten months in the Tropics and had escaped malaria.
Was supposed to have carefully followed prophy-
lactic measures, but acknowledged, after detailed
inquiries, that she had had frequent slight attacks
of fever, always about midday, but had felt
relatively well during them. When in D., three
weeks previously, she suffered from acute
rigor and fever and went into hospital The
'* fever '’ appeared generally about 4 p.m., as is in-
dicated by the fever-curve. Temperature rose daily
to over 899 C. (102-20 F.). At D. the blood prepara-
tion was negative the first afternoon; positive at
night, several medium-sized rings, described as
Borm
Kara
nai TRE!
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
tropical parasites, being found; later, the blood find-
ing was never positive again. The hospital superin-
tendent wrote: ‘‘ That it was surprising and incon-
ceivable that, despite the continued use of quinine,
there was no fall of temperature; no cause for the
fever could be found. Finally, thinking it might be a
case of quinine fever, the drug was discontinued.
Although the fever still persisted, the observation
time was too short to come to any definite conclu-
sion." The patient spent the following week at
home, without remission of fever, although quinine
had been suspended. As Mrs. F. was near her con-
finement and very run down, her husband sought
medical advice for the persistent fever on June 18.
He was recommended to bring her into hospital at
once.
June 19.—Patient admitted at 4 p.m.; tempera-
ture 899 C. (102:29 F.); pulse 120. No organic
abnormality detected, specially no splenic enlarge-
ment. Urine free from albumin and sugar. Hemo-
globin content 80 per cent. The blood preparation
showed rings claimed to be tropical. Slight pains
set in at 7 p.m., which soon became stronger and
more frequent.
June 20.—Waters broke 10.45 p.m. Head had
entered pelvis. As the pains had become weaker,
0:6 grm. pituitrin administered at 4 a.m. without
noticeable result.
June 21.—0:5 grm. pituitrin again administered iu
the morning without result. As the child's heart
tones only registered ninety beats, even in the
intervals between the pains, the patient was
delivered with forceps at noon during narcosis.
Perineum not ruptured. Living child, 3,500 grm.,
51 em. Back of head drawn forward as in face
presentation. 0'2 grm. ergotin twice.
The temperature range was as follows :—
June 19.—4 p.m., 399 C. (102-29 F.).
June 20.—6 a.m., 36:19 C.; likewise at 8 p.m.;
not taken in the interval during labour.
June 21.—6 a.m., 37:50 C.; 6 p.m., 399 C.
(102-29 F.).
June 22.—6 a.m., 36:49 C. ; 6 p.m., 39:59 C.
June 23.—6 a.m., 36:89 C.; 6 p.m., 40:19 C.;
(1049 F.).
June 24.—8 a.m., 87:89 C.; 12 noon, 409 C.
(104° F.); after 06 grm. aspirin at 2 p.m., 37:19 C.;
6 p:m., 39:89 C.
June 25.—6 a.m. and 12 noon, 39:89 C.; 6 p.m.,
40:69 C. after 0°5 grm. aspirin; 10 p.m., 379 C.
(98:69 F.).
June 26.—4 a.m., 39:69 C.; 12 noon, 409 C.
(104° F.); 6 p.m., 39:39 C.; after 0'5 grm. aspirin
at 8 p.m., 37:19 C.
June 27.—6 a.m., 98:89 C.; 12 noon, after
0:5 grm. aspirin, 37:49 C.; 4 p.m., 39:69 C. ; 6 p.m.,
after 0:5 grm. aspirin, 38:29 C.
June 98.—10 a.m., 409 C. (1049 F.); after
0:5 grm. aspirin at 2 p.m., 37:69 C.; at 4 p.m.,
40:49 C.; at 4.30 p.m., first sublimate injection ;
8 p.m., 36:309 C.; 9.45 p.m., when 379 C. (98:60
F.), second injection of sublimate.
June 29.—2 a.m., 38:60 C.; at 11 a.m., when
38:20 C., third sublimate injection; 12 noon,
(Mar. 16, 1914.
38:69 C.; 6 p.m., 37:49 C.; 8 p.m., when 38:1? C.,
fourth sublimate injection.
June 30.—2 a.m., 88:89 C.; 8 a.m., 36:89 C.;
10 a.m., when 87:20 C., fifth and last sublimate
injection ; 6 p.m., 38:89 C; 8 p.m., 36:89 C.
July 1.—6 a.m., 87:69 C.; 8 a.m., 37°29 C.; 12
noon, 38:69 C.; 6 p.m., 36:89 C.
July 2.—6 a.m., 36:20 C.; 6 p.m., 87:29 C.;
10 p.m., 87:50 C., and so on, the highest morning
temperature being 36:49 C., and the highest evening
37:50 C.
Besides frequent packings and drugs on June 19
and 23, patient was twice daily given an injection
all at one time of 0°5 grm. dihydrochlorate of
quinine (Merck), and from June 28 one esanophele
pill thrice daily instead of quinine. The tempera-
ture also fell suddenly after aspirin ; 0:5 grm. veronal
per os was given a few times, and digalen injections
per os.
Patient recovered, and was discharged on July 19.
Patient's recovery from the confinement was
normal, except that the catheter had to be passed
up to July 10. The fever, therefore, could not be
due to the confinement, and was indeed present
three weeks before labour commenced; its genesis
is of the greatest interest. Although isolated
tropieal parasites were found in the blood at D.,
as well as in hospital later, the character of the
fever and therapeutie ineffectualness of quinine
practically ruled out the possibility of tropical
malaria being the sole cause, especially as ‘‘ quinine
fever ’’ could not be admitted.
The progress of the disease and type of fever
were far more indicative of a septic process. No
certain support for this assumption could be
obtained, however, despite repeated exhaustive
researches. The cerebrospinal fluid was not
examined, but no symptoms pointed to cerebro-
spinal disease such as the patient was supposed to
have had in her youth. Even Staff-Surgeon M.,
who was called in at the request of the patient’s
husband, could find no cause for the fever, and
could only fall in with the supposition of latent
sepsis. We therefore decided to try intravenous
sublimate injections, recommended by Baccelli, of
Rome, for '' acute infections with doubtful diagnosis
and latent infection carriers." The formula adopted
in his clinic was used :—
Hydrarg. bichloride 0°01 = ;5gr.
Sod. chloride 0:075 = 14 ,,
Aq. sterilisat. 100 = 2} dr.
Instead of repeating the dose up to three times
in twenty-four hours, as Baccelli does, the patient
was given two injections daily, five altogether being
given in three days. An undesirable secondary
effect observed was profuse intestinal activity for
a week—seventy-three ‘‘ sublimate stools ’’ within
seven days.
The result was surprising, as is evidenced from
the fall of temperature, which at once set in (see
above). The effect of the ‘‘ therapy of despair,”
as it were, was specially noticeable in the almost
immediate resuscitation of the patient, whose life
was almost despaired of.
Mar. 16, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 89
Abstracts.
THE ETIOLOGY OF BERIBERI.*
By W. J. J. AnNOLD, B.A., M.B., D.P.H.
, St. Helena.
IN view of the widespread tendency to accept as
proved that beriberi is due to the eating of decorticated
rice, it behoves those whose experience contradicts
this theory to express their opinions. Dr. Mac-
Gilchrist, writing from Bengal, has quite recently
given an instance of its occurrence on board ship
where diet was not at fault, but everything pointed,
in his opinion, to an infectious origin. Dr. Stanley,
writing of fifteen years' experience of Shanghai and
other places, is convinced that beriberi is infectious,
and probably eonveyed by parasites.
The epidemic which occurred on this island in 1901
amongst the Boer prisoners of war was certainly not
attributable to diet. Rice formed no part of the diet,
which was in every particular a liberal one. Prior to
the appearance of the disease there had been much
overcrowding in the Boer encampment. Groups of
the prisoners, linked by ties of kindred or friendship,
had built for themselves small huts made from old
biscuit tins, the floors and bunks being of wood. Into
these they packed themselves like sardines in a box.
The Boers were the reverse of cleanly. Here, there-
fore, were two factors usually associated with out-
breaks of beriberi. The disease is not unknown in
South Africa, and was probably imported with the
prisoners of war.
I have long been impressed with the probably in-
fectious nature of the disease. In such a case as the
following it is difficult to avoid this conclusion.
In July, 1903, an American whaling brig, 411 tons
burthen, put into Jamestown for medical aid. The
captain reported that seven men had died of some
illness during the past three weeks, and that many of
the men on board were apparently suffering from the
same disease. He did not know what it was, but
thought it must be beriberi from what he had heard
of it in other ships. The deaths of the men had
taken place suddenly while they were at work on
deck.
On examining the ship's company I found eleven
men in varying stages of beriberi. Several were in a
serious condition, and one man was in the last phase
of heart failure. He died the following day in hospital.
This vessel had a crew of thirty all told. Nineteen
men slept in the small forecastle, ventilated only by the
companion way, and lighted by a small glass oblong
let into the deck. The cubic space available for these
nineteen men involved gross overcrowding, and there
was a lack.of even average cleanliness. I did not
find that the diet varied substantially from that found
on board most sailing vessels. No doubt salt beef
and pork as the staple article of diet is not ideal, but
fresh bread was served every day, and preserved
vegetables and lime-juice were issued at regular
intervals. Rice was not eaten. A monotonous fare
made up largely of preserved provisions may be
looked upon as a predisposing cause of ill-health, but
there are no grounds for going further in the present
instance.
After the removal of those seriously ill to hospital,
measures were taken thoroughly to disinfect and
cleanse the quarters of officers and men, together
with all bedding and clothing, &e. Fumigation with
SO and the liberal application of 1 in 1,000 mercury
perchloride solution was carried out on three or four
separate occasions, the men meantime sleeping on
deck. After remaining in port for three weeks this
vessel, taking those of the erew who had recovered
and some fresh hands, put to sea, and did not touch
land till she returned to St. Helena at the end of six
months. The crew had kept in perfect health, and
no fresh cases of beriberi had appeared.
Since 1903 every ship calling at St. Helena with
beriberi eases on board has been subjected to very
thorough disinfection and fumigation of the quarters
of the sick. In endeavouring to trace the connection
of any case on board ship with previous cases of beri-
beri, I have never failed to find one at least of three
circumstances: (a) The existence of beriberi on the
ship on a previous voyage; (b) the presence on board
of a member or members of the crew who had
previously had beriberi; or (c) some member of the
crew who had recently sailed on a ship where beri-
beri prevailed though he had not then had the disease
himself.
There is a great deal that points to the conveyance
of the disease by parasites. The bug is more likely
than lice to harbour the possible germ. The bug
clings more to places—the chinks and crevices of
floors and bunks, &c., and its eggs are difficult to
destroy. The organism may even develop in the
latter, as in the case of the Spiroshaudinnia duttoni
in the ova of the tick. Before the etiology of beri-
beri can be finally settled, the part, if any, played by
parasites must be thoroughly investigated by modern
methods.
WILD GAME AS A RESERVOIR FOR HUMAN
TRYPANOSOMES.*
An ANALYSIS OF THE AVAILABLE EVIDENCE FROM
THE NORTHERN SHORES or LAKE VICTORI\
NYANZA.
By H. LyxpHunsr DuxE, M.D., D.T.M. & H.Camb.
THE question whether the wild game of the sleep-
ing sickness areas of Africa are acting as reservoirs
for the human trypanosomes, Trypanosoma
thodesiense and T. gambiense, has recently
attained - great importance. As is well known,
bstract of paper in British Medical Journal, February 7,
1914.
* Abstracted from paper in the British Medical Journal,
February 7, 1914.
[Mar. 16, 1914.
90 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
a terribe epidemic of sleeping sickness devas-
tated this part of the Uganda Protectorate
in the years 1899-1909. The disease was presum-
ably introduced by caravan porters from the Congo,
where trypanosomiasis has long been known to the
natives. In 1908-9 the native population of the
lake shore of the mainland and of the neighbouring
islands was removed inland, away from the fly.
Since this measure the disease has practically died
out in this part of the Protectorate. In spite, how-
ever, of the removal of the natives from contact with
the wild lake shore Glossina palpalis, a certain pro-
portion of these flies are still (1912) capable of
infecting monkeys with a trypanosome. The mor-
phology and general behaviour of this organism are
indistinguishable from those of T. gambiense.
Again, in September, 1911, an exactly similar
trypanosome was obtained from the blood of two
situtunga antelope shot on Damba Island, about
nine miles from the mainland. The point to be
decided is: Are these “ wild fly °’ and “‘ situtunga "'
trypanosomes descendants of the T. gambiense
which caused the recent epidemic, or are they
merely parasites of the antelope, and not capable of
surviving in a human host?
For convenience, the trypanosome obtained from
Damba situtunga will be referred to as the ‘‘ Damba
trypanosome.” The organism pathogenic to mon-
keys and derived from wild flies will be called the
“ wild fly trypanosome.”’
(a) There is no reason to doubt the identity of
the ‘‘Damba’”’ trypanosome and the '' wild fly ”
trypanosome.
(b) There is evidence that the trypanosome of
the fly on the mainland and island coasts of
Northern Lake Victoria Nyanza is derived from
antelope, rather than from hippos, reptiles, or birds.
(c) There is evidence that the trypanosome of the
fly is not derived from truant natives.
(d) There is no good evidence to show that the
Damba and fly trypanosome is not identical with
T. gambiense, but that there is a certain amount of
evidence to show that it is identical.
The morphology and animal reaction of these try-
panosomes correspond closely with what is known
of T. gambiense. They cause a more or less chronic
disease in monkeys and rats, and are unaffected by
human serum.
The data relating to the animal reactions of the
human strain of trypanosome obtained from Uganda
natives by the Royal Society's Commission at
Entebbe show that the disease at the first inocula-
tion was slightly more chronic. Thus white rats
lived for three or four months, paralysis of the hind
quarters being observed before death in some, but
not all, experiments. In four uncomplicated monkey
experiments, in which the animals were inoculated
directly from human beings, the average duration
of the disease was 184 days—the maximum being
250 days, the minimum 107 days. In four monkey
experiments with the Damba trypanosome the corre-
sponding figures were 172, 207, and 144 days.
Four monkeys experimentally infected with the
"wild fly " strain (1910-11) lived for an average of
114 days (maximum 147 days, minimum 85 days;
this last monkey was an old emaciated animal at
the commencement of the experiment, and cannot
therefore be looked upon as a fair test of the patho-
genicity of the trypanosome). A single monkey
experimentally infected with wild fly trypanosomes
at Entebbe, in 1904, lived 214 days.
A white rat subinoculated from a rat infected with
human blood by the Entebbe Commission died in
two months and a half without any paretic sym-
ptoms. The average duration of the disease in six
white rats inoculated with the ‘‘ Damba trypano-
some ’’ was 61 days (maximum 74 days, minimum
44—a very young animal). Similar figures were
obtained with rats inoculated with the ‘‘ wild fly ”
strain. It should be noted that the trypanosomes
in these Mpumu rats had in each case undergone
previous passage through monkeys. Some of the
rats showed paralysis of the hind quarters before
death, others did not.
It will thus be seen that the general behaviour of
the Damba and “wild fly” trypanosomes in
monkeys and rats resembles that of the T. gam-
biense obtained in 1908 directly from infected
natives. Guinea-pigs were more refractory to the
human than to the two recent lake shore strains.
It must be remembered, however, in this connection
that when originally tested by Bruce and his colla-
borators T. pecorum was non-inoculable into these
animals, though it subsequently proved pathogenic.
If such a modification can occur in a trypanosome
in the course of a few months at the laboratory,
much stress cannot be laid on this difference. For
if the human trypanosome were excluded from the
blood of man for several years, it might be expected
to show a change in its behaviour towards other
hosts.
(e) Wild antelope of the species frequenting the
lake shore are inoculable with the human trypano-
some, and the parasite persists for any length of
time in their blood, or is rapidly fatal.
Given a number of fly and antelope in a district,
there is nothing to prevent the infection with
T. gambiense being kept up indefinitely.
(f) The evidence available on the subject of the
infectivity of the wild fly to the ‘‘ wild fly '" try-
panosome is such as would lead to the conclusion
that this trypanosome is an antelope parasite, a
descendant of the T. gambiense which caused the
recent epidemic.
(g) There is in Uganda no species of trypano-
some, other than T. gambiense, with which the
" Damba " and '' wild fly '" trypanosome can be
identified.
(h) There is no evidence that a mammalian
trypanosome could persist in wild flies for years
without some mammalian intermediary.
(i) In the prohibited lake shore area the propor-
tion of island antelope which is infected with
T. vivax or T. uniforme is 14:2 per cent., and of
mainland antelope 10 per cent.
Mar. 16, 1914.]
SLEEPING SICKNESS, TSETSE, AND BIG
GAME.*
By Greorce Prenticz, L.R.C.P. & S., D.T.M.
Nyasaland.
THOSE on the spot attribute the enormous in-
crease of tsetse-fly during recent years entirely to
the great increase of big game. The increase of
game we attribute entirely to the protective
measures employed by the governments. The laws
were passed with a view to protecting the wild
fauna of this part of Africa, and they have succeeded
beyond the wildest dreams of those who were
responsible for bringing them into being. The wild
animals have been preserved, but domestic animals
have been sacrificed, and now we are paying a heavy
penalty in human lives for having interfered with
the balance of Nature.
In a district in which the natives owned 200 head
of cattle an incursion of tsetse took place following
upon the herds of buffalo that came into it. Within
two years the natives owned only eighty head.
Under normal circumstances there should have been
an increase of 50 per cent. per annum—300 head
in all, instead of eighty.
In another district where the people were rich
in sheep, goats, and cattle, a recent investigation
revealed the presence of only four dogs, and these
recently imported. Besides having lost their stock,
the people are now being killed off by Glossina
morsitans. Yet with all this going on the people
are not allowed to act in self-defence. Game laws
which would turn any Government out of power
if imposed at home are forced upon a primitive
people here who have no means of redress.
To those of us who take an interest in polities, it
is not a little amusing to find the Chancellor of the
Exchequer posing in the matter of game as the
friend of the down-trodden peasant at home;
whereas a member of the same Government, in
the person of the Colonial Secretary, carefully pro-
tects the huge animals that eat up the native's
crops, kill off his cattle, and carry in their blood
the disease germs of certain death to human beings,
and that notwithstanding a promise we believe he
made to a deputation representing all the missionary
societies at work here—that on evidence being
adduced that game was responsible he would not
fail to act. His replies to Dr. Chapple in the House
of Commons have already been referred to in the
Journal. Not only do elephants destroy the mealie
erops, they this year (1918) fought the owners for
possession of the gardens. In my hospital at
Kasungu I had recently four patients at one time
who had been mauled by wild animals. Three of
them had been hurt by elephants in the gardens.
There is one aspect of this question to which I
have sought to draw attention. The infant mor-
tality in this country is appalling; so, too, is the
mortality among adults from diseases of the ali-
mentary tract. The native has no sick-room cookery
* Abstracted from paper in the British Medical Journal,
February 7, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 91
worthy of the name. We have sought to teach him
the value of milk as a diet for infants and during
disease. But along comes tsetse, and this potential
food supply in sickness is cut off. Thus indirectly
by destroying the food supply and directly by carry-
ing the deadly trypanosome does tsetse kill off the
population. When we speak of the population
being killed off we mean what we say. The disease,
both in Rhodesia and Nyasaland, is much more
serious than certain reports make it out to be. The
first cases I had in my hospital here were from a
district where sleeping sickness was not known to
exist. Reports reached me of a very fatal disease
having broken out among the natives, who spoke
of it as a virulent form of measles. A lad in our
employment entered the district and got badly
bitten by tsetse. He became very ill, and was
carried back to my hospital. I thought he had tick
fever, and proceeded to examine his blood for spiro-
chetes; I found trypanosomes. So far as my
knowledge goes, that was the first case for which
G. morsitans was held responsible by a medical
man. The Government sent a medical officer into
the district and other cases were found. The
virulent form of ‘‘ measles °’ had carried off many
victims before the real nature of the disease was
diagnosed. It has carried off many more since.
We believe that the disease should never have
existed here, and that it can be, and ought to be,
eradicated. We believe that for the time being a
severe onslaught must be made upon the wild
animals until these are driven back from human
settlements and from the public highways. Until
the present danger is past, all wild animals capable
of acting as a reservoir of trypanosomes should be
treated as vermin and destroyed or driven out just
as rats are destroyed during an outbreak of plague.
I, for one, would welcome an outbreak of rinder-
pest such as swept this country in 1893 and 1894.
It would leave us with a clean country, ànd, having
learnt our lesson in a hard school, we should be
slow to impose laws protecting game. We cannot
cure the disease when once it has taken hold of
human beings. Only those who have seen the
vietims can realize the horror and the hopelessness
of it. We can starve out tsetse by depriving it of
its supply of warm blood, and at the same time
we can remove the natural reservoir of the disease
by driving out or destroying the game. It has been
asserted that tsetse can and does exist where it
cannot possibly depend upon game for its susten-
ance, game being absent. This does not hold good
of G. morsitans in Nyasaland and Rhodesia.
Instances cited by the Colonial Secretary do not
stand the test of investigation.
Again, we are told that if game is driven out
tsetse may attack man and his domestic animals
more vigorously than at present. In that case,
when rinderpest killed off the game tsetse ought to
have betaken itself to the nearest villages to feed
upon the people. But it did not. It disappeared
or remained only in small patches among the foot-
hills, where small herds of game escaped the rinder-
pest. Similarly, in South Africa, when the Boers
92 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 16, 1914.
-shot off the wild animals tsetse ought to have re-
mained behind to feed upon man and his domestic
stock. But it did not. There is ample proof that
wherever game is killed off by disease, or hunted
out, G. morsitans disappears. There is no
proof to the contrary. I hold that the time for
experimenting has passed, and that we ought at
once to adopt such measures as may be necessary
to save the people here from further risk and loss.
Traders, farmers, planters, transport riders, and
missionaries ask for permission to act in self-
defence, permission to save their interests from
ruin and themselves and their people from danger.
If we make a mistake we suffer for it, and can
blame no one but ourselves. But why should we
be called upon to suffer for the fads and mistakes
of people at home? We hold that further tem-
porizing, in the light of our present knowledge, is
nothing short of criminal folly.
With reference to Dr. Neave’s suggestion that
the game within a certain area should be impounded
and destroyed, I may say that this suggestion was
made fully two years ago. We asked, when the
first epidemic broke out in Nyasaland, to have the
game destroyed. This was refused, on the grounds,
among other reasons, that the outbreak was dis-
tinetly localized, and that any interference with the
game might cause the animals to spread out and
carry disease into clean districts. On the strength
of this statement I suggested to the Acting
Governor that he should impound all the animals
within the area mentioned, and once and for all
stamp out the disease by exterminating the animals.
To this proposal I got a reply that while His
Excellency appreciated my good intentions he did
not regard the proposal as practicable.
In conclusion, I should like to express my appre-
ciation of and gratitude for the work of the Liverpool
Commission, which has settled once and for all many
hitherto hotly disputed points, and also my grati-
tude to the British Medical Journal for the publicity
it is giving to the work of Dr. Warrington Yorke.
IMMUNITY OF CERTAIN TRACTS FROM
PLAGUE.
Tue BomBay BACTERIOLOGICAL REPORT FOR 1913.
By Major Gren Liston, C.I.E., M.D., I.M.S.
CAPTAINS KuNHARDT and Taylor worked in Madras
while Captains Gloster and White undertook the
observations in the United Provinces.
In India large centres of the wheat trade in par-
tieular have suffered severely from plague. In
Madras there is a comparatively small trade in
wheat; there is, however, a considerable trade in
rice. It may be that infection is more readily
conveyed in wheat than in rice.
In Bánda, a town situated in the Bundelkhand
division of the United Provinces, a division of these
provinces which has suffered very lightly from
plague, the average number of fleas found upon
rats for many months in the year was larger than
the number found on rats in any other part of India.
Though the climate is eminently suitable to plague,
harbouring in the houses a very large rat popula-
tion as susceptible to plague as Madras rats are,
Bánda town has entirely escaped plague though
the disease occurs year after year with considerable
virulence in the comparatively adjacent town of
Cawnpore, which is distant from Bánda, in a direct
line, only some seventy miles. The facts are:—
(1) Very little grain is imported into Bánda while
considerable quantities are exported from the place.
This grain is often stored in pits where rats and
even insects cannot survive owing to the develop-
ment of carbon dioxide gas which accumulates in
the pits. The gas is produced by the living grain
which consumes oxygen and gives off carbon dioxide
gas.
(2) The people of the Bundelkhand are more
closely associated with the peoples of Central India,
where epidemics of plague only occasionally occur,
than with the people living in the badly plague-
infected Ganges Valley. Nevertheless, Banda is
situated on a railway line which connects it with the
plague-infected districts of Cawnpore and Allahabad,
and many of the merchants in Banda pay frequent
visits to both these towns, especially the former,
for the purpose of transacting business. Also
during a severe outbreak of plague in a district to
the south of Banda many refugees found shelter in
Banda.
The facts so far collected indicate that the places
which have escaped plague infection during the
seventeen years this disease has been present in
India owe their freedom from infection, not because
the prevailing conditions are such that plague could
not become established in them, but rather to a
combination of circumstances which are unfavour-
able for the importation of infection into them.
These circumstances may be either (1) a very small
import trade in grain, (2) remoteness from im-
portant trade centres, or (3) climatic conditions
which are unsuited for the prolonged existence of
the rat-flea when separated from the natural host.
The import trade in grain can be controlled to
assist in making a tract less vulnerable to plague.
The investigations have shown that the grain trade
may be largely responsible for the spread of plague
in India; it is important therefore that some action
should be taken to regulate this trade so that it
will no longer be a source of danger to the com-
munity.
Captain White, I.M.8., from a study he has made
of the trade returns of the United Provinces,
strongly supports the view that towns intimately
associated with the collection and distribution of
grain run not only great risk of becoming infected
with plague, but when infected are important centres
from which infection is disseminated to distant
places by means of trade. His observations, in
fact, have brought into prominence the urgent
necessity for taking measures to protect grain from
contact with infeeted rats. This is a line of action
which up to the present has been little followed by
the authorities who are responsible for the preven-
Mar. 16, 1914.]
tion of the spread of plague. The proper storage
of grain, so that it does not become infested with
rats, is a measure which should be the more easily
carried out because it is well known that rats con-
sume and destroy considerable quantities of grain;
the cost of excluding these animals from grain stores
for this reason would to some extent be met by a
decrease in the loss of grain during storage. But
the greatest advantage which would accrue from the
enforcement of this measure would be the lessened
opportunity for the transport of plague infection.
The majority of the owners of buildings in which
large quantities of grain is stored are wealthy men
who can well afford to keep them in better repair.
The presence of ramshackle rat-ridden grain stores,
situated often in the midst of the most densely
populated parts of towns and in the neighbourhood
of which large weekly markets are held, attracting
buyers from the surrounding towns and villages,
is a serious menace to the publie health. The
presence of such buildings in the most populous
parts of towns should be regarded as a public
nuisance.
RECENT RESEARCH RELATING TO UNDU-
LANT OR MEDITERRANEAN FEVER.*
By Fleet-Surgeon P. W. Bassetr-SmitH, M.R.C P.. C.B., R.N.
Since the Commission of the Royal Society re-
ported on the etiology of this disease in 1906, the
International Congress of Medicine, in 1918, dis-
cussed the nomenclature question and agreed that
the term Undulant fever was the most satisfactory.
It does not limit the distribution of the disease, it
draws attention to one of the most frequent clinical
signs, is euphonious, and is easily applicable to any
language.
The fever occurs on the islands and shores of the
Mediterranean as well as in the interior of Spain,
France, Italy, Greece, the Levant, Egypt, Tripoli,
Tunis, Algeria, and is present in most of the islands,
Sicily, Cyprus, Candia, Sardinia, Corsica, &c. It is
not only casual inhabitants that are affected in these
places, as believed by Shaw, but it is endemically
present in most of them. During the past few years
the extension of the disease into districts far from
the sea has been shown to exist. In Spain by de
Cottes, Durán, Ramon y Cajal, and Suarez. In
France by Cantaloube and Wurtz. In Italy by
Sangiorgi and Golini. In Portugal by Bettincourt.
This extension inland is a most important epidemi-
ological factor, and is in agreement with the findings
of the Commission and the view long held by
Zammit that inland villages may be as heavily in-
fected as those near the sea.
In the East it is endemic in Northern India, in the
Punjab. There is no doubt that cases occur in
China which are probably of endemic origin, but
very little real scientifie work has been carried out
there, at least that I know of, to prove the means
* Abstract of paper read at Society of Tropical Medicine and
Hygiene, February 20, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. - 93
of infection, for milk as an article of diet is but little
used except at Hong Kong and Shanghai, where the
dairies are well supervised. Most of the cases have
been reported from the Yangtse region. In the
Philippines many cases have been recognized, and
the disease conveyed by the sick soldiers to the
United States of America.
In Africa cases have been reported from the
Sudan, Blue Nile, Lake Chad, and Uganda. During
and after the Boer War the disease became very
prevalent in South Africa, the Transvaal, and
Orange Free State, that is, when the cattle were
few and more goats’ milk was used. German
South-west Africa is now included in this large
endemic region.
In America there appears to be a true endemic
centre in Texas, of considerable antiquity, extending
into New Mexico. There is probably also a small
centre of infection in Peru.
Wherever the disease is found, goats are prac-
tically always present, and distribute the disease in
Italy, India, South Africa, and America.
Besides goats, other ruminants may carry the
disease, and the products of milk are often in-
fective. The view that other methods of infection
are frequent is steadily gaining ground, and may be
summed up in the words that in urban areas the
infection is generally through ingestion of the in-
fected milk, but in rural districts the disease is
commonly spread by direct infection or inoculation
of infected soil or milk. In Corsica it is dis-
seminated by a few. infected goats to others when
they pasture in the hills; these goats infect the dogs
and goat-men with them. And when the goats are
brought down to the towns at certain seasons they
are milked mostly by women; these women become
infected through the hands by the organisms in the
milk, and the greater part of the milk is converted
into cheese which is eaten fresh, and in which the
miero-organism will retain its vitality for fourteen
days.
An epidemic near Rome showed how one infected
goat gradually spread the disease in the local herds,
how after a year cases occurred among those people
associated with the most infected herd, and spread
quiekly amongst them when once started. These
people, who lived under bad hygienie conditions,
did not consume the milk, but acquired the disease
by inoculations or direct contact with the sick.
A further point is the danger caused by ambulant
human cases; these may be passing out the micro-
organism in the urine, infecting the soil and out-
houses, and conveying the disease to those em-
ployed in these places.
As in typhoid, one must look to the three F's,
food, fingers, and flies, as possible carriers of the
organism. Children at the breast are rarely in-
fected directly ; but infants do sometimes show signs
and give positive serum reactions, as shown by
Longo at Catania, and Lunia, of Palermo; in fact,
the latter thinks that cases are more common than
are reported through not being recognized. As the
Micrococcus melitensis has been shown to be present
in the milk of infected mothers this is probable.
94 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
At Kléber, in Algeria, a small but interesting
human epidemic occurred. In one family four out
of five were attacked; these had no goats, and drank
only boiled milk from an uninfected source. All
the members, including the goatherd, of the family
which had lived in the house previously had suf-
fered from the fever. The infection was believed
to be purely local, due to contamination of the house
and sheds before the owners took possession.
In descriptions of the infecting micro-organism
there is again much discrepancy. Hiss and Zinsser
go so far as to call it the Bacillus melitensis, others
call it a cocco-bacillus, some say it is motile and
describe flagella as being present. From a very
large number of examinations I believe the
organism to be a true coccus, often under cultural
conditions seen as diplococci, due to the division
of the coecus. In old cultures bacillary forms are
common ; these are involution forms and favoured by
different media. Where growth is vigorous, long
chains tend to be present, made up of diplococci;
this streptococcic character is like that which occurs
in the culture of the pneumococcus. The Micro-
coccus melitensis is able to produce a toxin which
acts as a hemolysin.
Pathogenicity.—Monkeys and goats, horses, dogs,
rabbits, guinea-pigs, rats and mice can be experi-
mentally infected. Rabbits, after subcutaneous in-
oculations with living cultures of the M. melitensis,
will give a serum having a high agglutinating power,
but a true septicemia does not appear to be pro-
duced, as the organism cannot be recovered from
the circulating blood; these animals were found by
Eyre to die in about six months. Two animals I
have used for this purpose reacted up to 1 in 2,000,
but have gradually lost these agglutinating reactions
and have made complete recoveries. Guinea-pigs
are not generally affected, unless the pathogenic
power of the organism is raised and the injections
given intra-cerebrally. In rats and mice antibodies
are formed in small amounts or not at all.
The infection may be naturally acquired by man,
goats, cows, sheep, horses, mules, and dogs.
In 1912, Négre and Raynaud [1], while testing
various strains of the micrococcus in Algiers, found
one that, though it gave the morphological and
cultural characters of the type, yet it was able to
agglutinate only with very low dilutions of serum,
rich in antibodies for the type. On working this
out it was found that animals injected with this
strain produce a serum rich in antibodies for itself,
but which only agglutinated other strains in low dilu-
tions. It is also possible to remove the antibodies
from one without affecting the other, as shown by
absorption tests. This variety, which had been sus-
pected by Zammit, is therefore distinct from the
type in its serum reactions, and is described by
Négre and Raynaud as M. paramelitensis. The
strain had previously been known as M. melitensis
Br. It is a curious fact that this strain had been
originally isolated by Bruce, and had been kept,
without its peculiar characters being recognized, in
the laboratories of Algiers and Tunis, from which
places subcultures had been widely distributed to
(Mar. 16, 1914.
other laboratories in Europe—thus probably causing
many of the errors in diagnosis which have been
so frequently reported.
In 1913, I was able to report a very prolonged
case of fever in a lady, contracted at Hyères, in
which, though the symptoms were those of undulant
fever, no positive reactions could be obtained. The
serum was tested in many laboratories, and by
different experts; when the blood was tested with
the paramelitensis strain it reacted up to 1 in 400.
Human infections therefore exist, as well as animal.
In the routine examination of goats in Algeria,
out of 490 tested, in only twenty were positive lacto-
reactions obtained; nine of these were with the M.
melitensis, nine with M. paramelitensis, and two
with both; most of the infected goats had been re-
ceived from Spain. The frequency of the infection
of goats by the paramelitensis strain is of great im-
portance.
Diagnosis.—The methods for animals and humans
must be separately considered. In diseased animals
there is a general infection of the blood, spleen, liver,
kidneys, as well as in the lymphatic system especially
affecting the deep glands. The specifie micro-
organism passes out of the body in the urine, feces,
and milk. From the urine and milk more or less
pure cultures can be frequently obtained, thus
giving definite evidence of the disease. The lacto-
reaction as introduced by Zammit and Horrocks is
the most ready and generally used method for de-
tecting the infected goats, and this could always be
controlled by serum reactions or other more certain
methods.
Recent work tends to show that in many of the
infected goats there is a localization of the organism
producing a mammitis without general septicemia.
Some experiments carried out by Vallet and Rim-
baud [2] found that with healthy guinea-pigs
reactions were not obtained in higher dilutions than
1 in 20; in rabbits it rose to 1 in 50, and in twenty-
one healthy dogs eighteen reacted in dilutions vary-
ing from 1 in 20 to 1 in 400. Heating the serum
always prevented these reactions.
Martel, Tanon and Chrétien [3] state that heating
the serum does not always prevent chances of error.
and that it is indispensable to carry the serum
agglutination test for goats up to 1 in 100. Also
that reactions with milk are too variable to be used
for diagnosis.
The author carried out a series of experiments
which confirm Kennedy’s [4] results. To avoid errors
in testing cows’ milk, which in some cases appears
to have a natural tendency to agglutinate the M.
melitensis, the heated milk should be very
thoroughly centrifugalized, a dilution of not less
than 1 in 20 should be employed, using distilled
water instead of saline solution, and for preference
the microscopic method with a one-hour limit, rather
than sedimentation.
Kennedy found that these agglutinins were also
obtained with the milk whey, but were held back
by filtration. 1
The apparent widespread occurrence of cows’ milk
in London agglutinating the M. melitensis, and the
Mar. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 95
absence of any evidence of endemic undulant fever
there, in itself is strong evidence against a true in-
fection of the cows.
In man diagnosis is made with most certainty by
cultivating the organism from the blood; this is
generally successful in early cases with well-marked
fever, when an advanced cachectic condition is
present this procedure will often fail. From 1 to
5 c.c. should be drawn off and distributed into two
flasks of nutrient broth from which subcultures into
agar can usually be obtained about the third day.
The agglutination reaction with the serum is the
most common diagnostie method, either observed
microscopically or by means of sedimentation tubes.
Using unheated serum, Carrieu and Anglada found
that with certain strains of M. melitensis non-
specific reactions may occur in dilutions from 1 in
10 to 1 in 200, but with specifie sera these variations
with different strains were very slight; they there-
fore recommend that for diagnosis a serum should
be tested with many strains before a conclusive
opinion can be formed. This is not the author's
view. Given a good strain of known agglutinable
power, and using all precautions, errors will be very
few with a 48-hour agar growth. From this a
strong emulsion is made, allow any auto-clumps to
settle, and pipette off part for use. Have two tubes
of serum, one heated to 579 C. for half an hour and
one unheated; test each in dilutions of 1 in 40,
1 im 100, 1 in 400 microscopically and by the sedi-
mentation method. The latter tubes are left in the
hot incubator for two hours and then read off; they
are then set aside in the cold for twelve hours and
a final reading taken. For controls a known specific
serum and a normal blood should always be used.
Out of sixty-five control sera used by myself,
tested with five strains of M. melitensis, in only one
was there a positive reaction. In a series of 150
sera from patients in Haslar Hospital, in 1907, suf-
fering from all kinds of diseases, four gave positive
reactions; in these four a careful history showed
that they had been under treatment at Malta Hos-
pital or had previously suffered from the fever.
Ronchése states that Widal, in his laboratory,
caused an emulsion killed with formalin (2 drops
to 5 c.c.) to be used; this was safer and acted quite
satisfactorily, keeping well for over a year. Thirty
sera of cases suffering from febrile conditions, other
than undulant fever, were tested with this emul-
sion and all gave negative reactions.
When carrying out the reaction the following
points should be remembered :—
(1) The culture to be used should be proved to be
active with known specifie sera and should not
agglutinate with other sera. The use of a para-
melitensis strain would fail to agglutinate in high
dilutions with a true undulant fever serum and give
rise to a negative error.
(2) As recommended by Négre and Raynaud, the
heated and unheated serum should be tested, the
former cutting out the non-specific agglutinations
and preventing a positive error in non-undulant
cases.
(8) The test should always be carried to high
dilutions, up to 1 in 400, to avoid paradoxical re-
actions.
A second sero-diagnostie method which can be
used is that of complement fixation. This has been
employed extensively by Misseroli and others, and
I have found it to give good reactions; it acts as a
very efficient control to the agglutination test, but
the value of different strains of M. melitensis as an
antigen shows often great variations. Cases may
sometimes fix the complement well and give un-
satisfactory agglutinations.
Vigano has lately brought forward a precipitin
test as a diagnostic procedure, but this is unlikely
to act when the disease cannot be recognised by
agglutination methods.
Clinical diagnosis is difficult owing to the irregu-
lar character of the symptoms, the long duration of
the disease, and the presence of certain abortive
forms. This is noted particularly in country dis-
tricts of Spain, Italy, and Africa, where the disease
is but little known. Cases are frequently dia-
gnosed as typhoid, para-typhoid, septic and gastro-
intestinal infections; among young children these
errors in diagnosis are most common. Trotta [5]
and others have shown that the micrococcus may
occasionally act as a pyogenic organism causing
suppurative arthritis and local abscesses. As in
typhoid infections, node-like swellings on the ster-
num and ribs have long been known to occur in
undulant fever, due to a tissue necrosis caused by
the micrococcus. Chronic cases are easily mis-
taken for early conditions of infective arthritis de-
formans. In Texas and New Mexico the disease
has been known as mountain or '' slow fever "' for
at least twenty-five years, and is always found
among people employed in goat rearing, the cases
being most common after the kidding season during
April, May, and June. In German West Africa
the disease is now fairly common, but the cases are
frequently diagnosed as malaria.
Treatment.—It is most important to remember
that we have a very long and tedious disease to deal
with; as this is not associated with ulceration of
the bowel, it is therefore necessary to conserve the
patient’s strength as far as possible, and to give
as much food as he can assimilate, being guided
mostly by the condition of the tongue and the height
of the fever. As cardiac irritability is a common
condition, antipyretic drugs for reducing the fever
are generally harmful and hydrotherapy is to be
preferred. Insomnia is such a trying and common
characteristic that it requires treatment; the patient
should never be allowed to pass sleepless nights.
Trional or other hypnotics should be given, or, if
pain is severe, morphia may be used. Stimulants
are not generally required in the early stages, but
when cachexia is pronounced they often do great
good. Preparations of yeast are useful, both to
increase the number of the polynuclear white cells
and hence assist in destroying the infecting micro-
organism, and also to reduce the tendency to the
development of the neuritis which is so common in
the later stages of the disease.
Seordo [6], experimentally, has obtained very good
96 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
results by treating artificially infected goats with
intravenous injections of perchloride of mercury,
which gave rise to an increase in the corpuscular
elements in the blood, raising the numbers of the
red cells and the hemoglobin, also producing a
polynuclear leucocytis and sterilizing the blood,
thus cutting short the fever; if this can be accom-
plished in man the method will be of great value.
Some good results are stated to have been obtained
in animals with '' 606,’’ but these require confirma-
tion, as rabbits may recover spontaneously if the in-
fection is not very severe. In German South-west
Africa intravenous injeetions of protargol as a germi-
cide were used with success, but it is not free from
danger, occasionally causing toxie nephritic sym-
ptoms and suppression of urine. Trambusti and
Donzello, by inoculating goats with a nucleo-proteid
derived from the M. melitensis, have prepared a
serum which is stated to have given satisfactory
results when used early, but other serums have
always failed. Vaccines may be used with good
results, particularly in subacute cases, both for
melitensis and paramelitensis infections. The
general improvement as shown by an increased
feeling of comfort and a steady gain in weight is
often very marked in these cases, and the opsonic
index is seen to rise at the same time. This method,
therefore, holds out considerable hope in protracted
eases. It is possible that a polyvalent vaccine made
from many strains of the micrococcus might give
better results. The use of sensitized vaccines also
requires trial.
For prophylaxis it is now generally recognized in
endemic areas that the disease should be made
notifiable, that local disinfectant methods should
be carried out, that the importation of infected goats
must be stopped, and that regular examinations of
animals by competent persons must be periodically
made. In France, Italy, and Northern Africa legis-
lative action is strongly urged; this has been taken
in France and Algeria with good results.
In conclusion, we should recognize that though
the disease has been practically eradicated from the
Naval and Military services, where protection of the
food can be properly carried out, yet the disease is
still rampant in very many endemic areas; also that
the source of infection is by no means limited to
ingestion of contaminated milk, but is frequently
brought about by direct inoculation, particularly
in rural districts, and that all cases, ambulant and
otherwise, should be looked upon as potential
carriers of the disease necessitating the thorough
disinfection of excreta and contaminated articles.
LITERATURE,
[1] Ntare and Raynavp: ‘‘ Melitensis and Paramelitensis,”
Comptes Rendus Soc. Biol., 1912, vol. Ixxii.
[2] VannLET and RiMxBAUD: ''Agg utinin of M. melitensis,”
Comptes Rendus Soc. Biol., 1918, vol. Ixxiv, No. 7.
[3] ManrEL, Tanon et CunETIEN: Press Med., August 20,
1918, No. 68.
[4] Kennepy, J. C.: ‘Presence of Agglutinins in Cows’
Milk," Journ. R.A.M.C., January, 1914, vol. xxii, No. 1,
pp. 9-14. f
[5] Trorra, G.: “Suppuration in Malta Fever,” Wien.
klin. Wochenschr., 1913, vol. xxvi, No. 35.
[6] Scorpo, F.: ‘Therapy of Mediterranean Fever."
Centralbl. f. Bakt., 1912, vol. lxvii, No. 8.
[Mar. 16, 1914.
Redich.
Beriberi. By Edward B. Vedder, A.M., M.D.,
Illustrated, pp. 427. John Bale, Sons and
Danielsson, Ltd., Oxford House, Great Titch-
field Street, London, W. Price 18s. net.
This book is by a particularly well-qualified author
who was officially engaged for two years in examin-
ing and sifting the literature and facts relating to
beriberbi, besides having been long engaged in
tropical work. It is one of the few books on the
subject and deals with all information, recent and
remote, bearing on the disease.
The extensive index, list of authors, and biblio-
graphy makes reference to all previous works par-
ticularly easy. The book is a distinct landmark in
a most important study. It clearly enunciates the
vitamine theory attributing the causation to a
deficient diet and faulty metabolism.
The author maintains a judicious impartiality
with regard to the infantile, ship and epidemic
varieties, for although the disease is due to faulty
metabolism, usually associated with deficient diet,
this does not exclude the occasional origin from
epidemic causes and even associated parasitic in-
fections.
The book should be essentially useful to tropical
workers and all dietetists in other parts of the world,
for it is the one disease above all others which is
capable of prevention.
The author fully diseusses the distribution and
prevalence of the disease, which may occur any-
where and at any time. The pathology is particu-
larly useful for those wishing to refresh their know-
ledge. The chapter on symptomatology will per-
haps be more useful to those whose experience of
beriberi is limited and is more theoretical than
practical.
The handy format of the book is not one of its
least attractive features, and the well-chosen and
well-reproduced illustrations render the book dis-
tinctly pleasant reading.
SEAMEN'S HOSPITAL SOCIETY.
Tne Annual Court of the Seamen's Hospital
Society, to which are attached the London School
of Tropical Medicine and the London School of
Clinieal Medicine, was held on Thursday, March 12,
1914. H.S.H. Prince Louis of Battenberg, Presi-
dent of the Society, took the chair. The Prince
brought home to the large audience present the
high claims the Seamen’s Hospital had upon the
people of the British Empire.
The other speakers were Lord Hugh Cecil, M.P.,
Vice-Admiral Sir Arthur M. Farquhar, K.C.B.,
C. V.O. ; Mr. Perceval A. Nairne, Chairman of Com-
mittee; Mr. William Turner, F.R.C.S.,; and Mr.
C. F. Leach.
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 7, Vol. XVII
Original Communications.
THE METEOROLOGY OF MALARIA.
By MarBEW D. O'CoxNELL, M.D,
IN the minds of Englishmen, the Island of
Walcheren, in the Netherlands, will ever be asso-
ciated with the grave outbreak of malarial fever in
the British Force which was despatched there in
the autumn of the year 1809. The Force consisted
of a fleet under Sir Richard Strachan and an army
of 40,000 men under Chatham. Chatham landed
at Vlissingen (Flushing) on August 15, and occu-
pied Walcheren, South Beveland, and Schouwen.
Of the troops landed on fever-stricken Walcheren,
7,000 died and 15,000 were disabled between the
date of landing and December 23.
Flushing, like the whole Island of Walcheren, was
very unhealthy until the second half of the nine-
teenth century. Better canalization of the island has
so far improved its hygienic state that the proverbial
Zeeland fever, which very often killed, especially
Hourly atmospheric conditions at
Vlissingen (Flushing) in the Island
of Walcheren, Netherlands
visitors, has disappeared. The milder form of
malarial fever continues there, but is now confined
to certain localities at certain seasons of the year.
So even at the present day it is of interest to note
the atmospheric conditions at Walcheren in order to
see if they can have any effect in producing those
milder forms of fever which still linger there.
The Direetor-General of the Meteorological
Institute of the Netherlands at De Bilt has kindly
furnished me with the meteorological conditions at
Flushing for August 9 and 10, 1911, as far as he
was able. The dry bulb temperatures of the air
are given hourly for a continuous period of thirty-
six hours. The velocity of the wind is also given
hourly for the same period. Hourly readings of the
wet bulb temperature were not available, and there
is no registering hygrograph there, so only the term-
readings at five fixed hours, viz., 7, 8, and 10
a.m. and 2 and 7 p.m., were procurable. From
these I have roughly estimated the hourly wet bulb
temperatures at Flushing for the same period of
thirty-six hours in the following table. The actual
wet bulb records I have marked with an asterisk.
Degree to which body tem-
perature was raised by
exposure in the cotton sheds
of Lancashire
Atmospheric conditions which raised
body temperature above normal in the
Lancashire cotton sheds
———
“Temperature of Drying Velocity of T Temperature of Drying Move- Bodytem- Pulse Respira-
air, F, power ofair wind per air, power of ment perature in tion
per 10 cub. ft. second air per ofair mouth, F.
lOcub,ft. per
Walcheren, Vlissingen, second
1911 —— — —
Dry Wet Grains Metres Dry Wet Grains Miles
August 9, 7 o'c. a.m. 72:7? 65:6^* 30:7 45 12:09 65-0? 29-0 99-6? Not given
ve) gt. 73:2 66 0* 31:0 44 73:5 68:0 24:5 100:0 100 26
- OF may 75:3 67:7 34:4 37 75:5 70:5 24:5 99:4 132 22
5 10. 5; 78:4 69:4* 4l'4 41 78:5 73:5 25:0 99:6 116 22
33 Ir. j 81:3 69:4 56:3 3:8 81:5 74:0 39:5 99-2 86 20
K 12 o'c. noon 82:4 69:4 61:8 3:6 82:0 75:0 38:0 99:2 99 16
3 lo'c. p.m 841 69:4 70:3 49 84:0 77:0 39:0 100:3 84 25
3$ 2:5 84:9 69:4* 70:8 49 84:0 77:0 39:0 100:3 84 25
y» S- ji 85:6 69:6 17:2 5:0 85:5 78:0 44:0 1001 82 22
3; ICS 88:8 69:8 92:6 4:7 89:0 76:0 73:0 99:6 98 18
5 De i 90:5 70:0 101-0 47 90:0 75:0 820 5 998 94 24
a By 5 89:8 70:2 93:4 4l 90:0 75:0 82:0 o 99:8 94 24
PA T^ S 84:5 70:5* 68:5 44 84:5 77:0 420 4 100°6 96 26
Ja By 5 80:4 70:2 49:9 4:9 80:5 73:0 385 = 996 92 20
35 9'- 71:0 70:0 33:0 4'4 77:0 73:0 200 ., 1001 100 18
33 10 ,, 75:9 69-7 30:5 4:2 76:0 72:0 200 8 99:4 88 20
5 dd <5 77-0 69:5 35:0 2:6 77:0 73:0 200 § 1001 100 18
p - 12 o'c. midnight 787 69:2 20-0 2:8 78:5 68:0 245 2 100:0 90 22
August 10, 1o'c. a.m. 72:6 69-0 17:0 2:6 72:0 65:0 290 3 99:6 Not given
E. Q^ as 79:8 68:8 15:5 2:9 72:0 65:0 290 F 996 WV. AN
y S 12:5 68:6 18:1 25.A 720 65:0 290 Æ 996 A i
s: 4 35 71:6 68:3 13:0 2:8 72:0 65:0 290 3 996 S d
+ 9. » 70:8 68:1 12:6 12 69-0 65:0 17:0 E 100-0 100 26
$5 $5, 73:0 67:9 22:4 0:2 73:5 68:0 245 5 100:0 90 22
37 7 ú 74:0 67:8* 27:8 8:11 74:0 70:0 19:0 & 1000 98 22
jì B oy 75:2 68:1" 32:4 311 75:0 69:5 26:6 E 100-2 110 18
" D. 4 79:3 70:4 42:2 1:5 19:5 74:5 26:5 100:2 90 24
$i I0- «5, 80:6 TATS 40:2 2:5 80:5 730 38:5 99:6 116 22
$5 11 33 84:8 72:1 60:6 2:5 84:5 71:0 42:0 100:4 120 24
2: 12 o'c. noon 79:6 71:6 39:2 42 79:5 74:5 26:5 100:2 90 24
y; 1o'c. p.m. 78:8 71:0 38:0 5:2 78:5 73:5 20:5 99:6 116 22
53 2 31 80:7 70:5 49:5 4'9 80:5 73:0 38:5 99:6 92 20
» BP Gs 81:6 69:6 51:2 4'1 81:5 74:0 39:5 99-2 86 20
5i Ael 17'3 68:8 454 44 77°0 73:0 20:0 100:1 100 18
$3 5 , 74:8 67:9 31:4 44 75:0 69:5 26:6 100:2 110 18
3$ D. n3 72:3 671 23:1 4:7 72:0 65-0 29:0 99:6 Not given
As ss 69°6 66:3* 14:2 5:2 69-0 65:0 17:0 100:0 100 26
Conditions which cause pyrexia bracketed A in above table.
* Actual wet bulb observations at Flushing.
98 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
In line with the meteorological conditions at
Flushing so obtained, I have given, for comparison,
the nearest meteorological conditions which were
found, by actual observation, to raise body tempera-
ture in the Lancashire cotton sheds, and I have
added to both the drying power of the air to indicate
the rate at which heat was being lost from the body
by evaporation.
Comparing the atmospheric conditions at Flush-
ing with those which were found to raise body
temperature above normal in the Lancashire cotton
sheds, as given in the table, it becomes clear that
the conditions at Flushing from 11 p.m. on August
9 to 7 a.m. on August 10, 1911, were such as must
cause pyrexia in many, for (a) the wet bulb tem-
peratures of the air during this period at Flushing
were higher than the wet bulb temperatures of the
air which raised body temperature in the cotton
sheds; (b) the difference between the dry and wet
bulb temperatures of the air at Flushing during the
same period was, at each hour, less than the differ-
ence between the dry and wet bulb temperatures
of the air in the cotton sheds with which they are
compared; and (c) the conditions which so raise
body temperature at Flushing persisted for seven
hours continuously, whilst those whose body tem-
perature was raised in the cotton sheds were in
no instance exposed to the atmospherie conditions
which raised their body temperature for more than
four hours continuously, and in many of the obser-
vations for considerably less. In one observation
in the cotton sheds the body temperature of a
weaver (female) was raised to 1009 F. (87:89 C.),
the pulse to 100, and the respirations to 26 in forty
minutes by exposure to an atmosphere having a dry
bulb temperature of 699 F. (20:50 C.) and a wet
bulb temperature of 659 F. (18:39 C.).
Any pyrexia so caused by the night atmospheric
conditions at Flushing must gradually subside during
the following day period as the difference between
the dry and wet bulb temperatures of the air
increases from the early morning until the late
afternoon at Flushing as elsewhere; or it may be
rapidly reduced by producing sweating either by
sudorifies or by covering the body with blankets.
If similar or nearly similar atmospheric conditions
recur on the following night the pyrexia so produced
must recur also; that is, it is obviously intermittent.
In the above observations I have not referred to
the rate of movement of the air which must, from
its effect on loss of heat from the body by con-
duction and connection, modify any increase of
body temperature so caused. During the period re-
ferred to at Flushing, viz., from 11 p.m. on August
9 to 7 a.m. on August 10, the velocity of the wind
did not exceed 2°8 metres per second, and even fell
as low as 0'2 metre per second at 6 a.m., whilst
during the following day the velocity of the wind,
which was only 1:5 metres per second at 9 a.m.,
reached 5:2 metres per second at 1 p.m. and at
7 p.m.
In the cotton sheds it is said that no movement
of the air was perceptible, but it was stated in the
evidence that the weavers frequently complained
of draughts, and even at times surreptitiously closed
the ventilators of the sheds to stop the draughts of
which they complained, so there must have been at
least some movement of the air in the cotton sheds.
From such considerations I conclude that the
night atmospheric conditions at Walcheren in
August, even at the present day, are such as afford
a suffieient explanation of the mild intermittent
fevers which still linger there. The more scientific
eanalization which has so improved the health of
the island would considerably reduce the dampness,
i.e., increase the drying power of the air there, and
this, by its effect in increasing loss of heat from the
body by evaporation, affords an explanation of the
disappearance of the graver form of the disease,
such as the fatal Zeeland fever, if it is but a graver
form of one disease, caused in the manner I have
indieated.
BRIEF NOTE ON TOXOPLASMA PYROGENES,
: CASTELLANI, 1913.
By Professor Lupwia PLATE.
Professor of Zoology in the University of Jena.
I HAVE examined Dr. Castellani's preparations
made from the spleen of a case of long-standing
fever terminating fatally in Colombo. The pre-
parations were stained by Giemsa, and the bodies to
which he has called attention were quite evident.
I am absolutely convinced that these bodies are not
degenerated red cells, nor degenerated blood plate-
lets, nor degenerated tissue of any kind. The free
bodies are especially characteristic, most of them
being pear-shaped, crescentic, or lanceolated ; 24 to
6 microns in maximum diameter and possessing à
well-developed nucleus, either in the middle or at
one pole, which may at times be vacuolated; none
of the bodies contain any pigment. Occasionally
these bodies are agglomerated together in large
groups. In my opinion the bodies described by Dr.
Castellani with the name of Tozoplasma pyrogenes
are without any doubt of protozoal origin and differ
from any other protozoal organism so far described
in man; but no conclusion ean as yet be come to
as regards their being toxoplasmata or not; in fact,
no conclusion can be arrived at as regards their
exact zoological classification.
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 99
NOTE ON A NEW GEOGRAPHIC LOCALITY
FOR BALANTIDIOSIS COLI.
By Major B. H. DUTCHER.
Medical Corps, United States Army.
Havine been unable to find in the literature to
which I have had access any record of the occur-
rence of Balantidiosis coli in the West Indies, I
desire to record a case from San Juan, Porto Rico.
The patient, a native Portoriquefio, aged 22, born
in Barranquitas, P.H., entered hospital December
25, 1913, complaining of mild dysenteric symptoms
and with a temperature of 101:59 F. The tempera-
ture rose to a maximum of 102:89 F. the same day,
fell by crisis to 09:49 that night, reached normal on
December 27, and did not rise above 98:89 F.
thereafter.
He was given a tablespoonful of a saturated solu-
tion of magnesium sulphate every three hours, with
a liberal and nourishing diet for some days, and
either by reason of or in spite of this treatment
the stools became macroscopically normal within
the next ten days.
The day after his admission active Balantidia coli
were found in the bloody mucus, and continued to
be found in the stools until January 28, 1914, when
they disappeared. The stools contained also ova
of uneinaria (gen. et. sp. ?) and Trichuris trichiura.
A differential count on January 5, 1914, showed :—
Lymphocytes 19:5 per cent,
Large mononuclears ... 65 FF
Polymorphonuclears ... 34 $5
Eosinophiles T .. 40 E
A count made on February 6, 1914, showed almost
identically the same percentages.
Up to the present time, March 4, 1914, he has
been doing full duty, and has been having normal
bowel movements. A dose of magnesium sulphate,
however, will reveal the presence of numerous
balantidia.
oro ————
PRESIDING at the annual general meeting of the
Bovril Company, held in London, February 10, 1914,
Lord Erroll told the shareholders that Sir Ernest
Shackleton had selected Bovril as the only concen-
trated beef food to be taken by him on the forth-
coming Imperial Trans-Antaretie Expedition, and
that,.in writing to his agent on the subject, Sir
Ernest had said: ''I consider the question of con-
centrated beef supply is most important."
Tue Second Edition of Professor Carl Mense's
well-known work on tropical diseases, ‘‘ Der
Handbuch der Tropenkrankheiten,’’ published by
Messrs. J. A. Barth, of Leipzig, has now been
commenced, and the first part containing chapters
upon Arachnoidea, Hexapoda, Hemiptera, Myria-
poda, and Insekta, &c., is now to hand. Dealing
as it does with insect carriers of disease, its import-
ance is, of course, manifest. The inaterial con-
tained in the text is accurate and well up to date,
whilst the diagrams are excellent and well executed.
In addition to this the literature is treated very fully
and should be very valuable to any one studying
the subjcet.
Hotices.
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THE JOURNAL OF
Tropical Medicine andHpgtene
APRIL 1, 1914.
THE DINNER TO SURGEON-GENERAL
GORGAS.
On Monday, March 23, 1914, there assembled at
the Savoy Hotel a representative collection of many
of the most distinguished personages in the Church,
in the Law, in Medicine, and in Science, to do
honour to Surgeon-General W. C. Gorgas, M.B.,
Surgeon-General, Medical Department, United
States Army.
Sir Thomas Barlow, Bart., K.C.V.O., F.R.S.,
President of the Royal College of Physicians of
London, occupied the chair.
The reception previous to the dinner and the
whole evening's entertainment were characterized by
a heartiness and cordiality which is the exception
rather than the rule at proceedings of this kind, and
100
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
the spirit which prevailed was in harmony with the
occasion for which the company had gathered.
The work which Surgeon-General Gorgas began and
carried out in Panama has been the talk of the
whole world for some years past, and the visit of
Gorgas to England gave British folk the opportunity
of showing how highly they held in estimation the
giant work he had accomplished.
As might be expected, men interested in tropical
medicine and hygiene were present in large
numbers, but there were present others who,
although not workers in that field of science,
gathered together to pay their tribute to a great
man.
His Grace the Archbishop of Canterbury, His
Excellency the American Ambassador, Lord Chan-
cellor Haldane, the Rt. Hon. Lord Bryce, O.M.;
the Rt. Hon. Lord Moulton; the Directors-General
of the Army and Navy Medical Departments; the
President of the College of Surgeons, England; the
President of the Royal Society of Medicine; Sir
William Osler, Bart., Oxford; the Master of Down-
ing, Cambridge; several Members of Parliament,
and representatives of several medical societies took
part in the proceedings, bearing testimony by their
presence to the deep interest all professions took in
doing honour to Surgeon-General Gorgas.
Along with the principal guest two of his
colleagues in Panama were present, namely, Major
Robert N. Noble, General Inspector Department of
Sanitation; and Dr. Samuel T. Darling, Chief of
Research Laboratory, both members of the Panama
Canal Commission.
Amongst those present we observed: Dr. P. S.
Abraham; Dr. T. D. Acland; Col. A. Alcock, I.M.S.,
F.R.S.; Dr. D. E. Anderson; Mr. C. A. Ballance,
M.V.O., M.S.; Mr. Arthur E. Barker, F.R.C.S.;
Sir James Barr; Dr. E. F. Bashford; Fleet-Surg.
P. W. Bassett-Smith, C.B., R.N.; Mr. James
Berry, F.R.C.S.; Sir Anthony A. Bowlby, C.M.G.,
F.R.C.S.; Mr. Stanley Boyd, F.R.C.S.; Sir John
Rose Bradford, K.C.M.G., M.D., F.R.S.; Mr.
Horace E. Broadbent; Sir John F. H. Broadbent,
Bart., M.D.; Dr. J. Mitchell Bruce; Mr. W. Deane
Butcher; Dr. E. Farquhar Buzzard; Dr. Guthrie
Caley; Mr. A. W. C. Cameron, M.B.; Mr. James
Cantlie, F.R.C.S.; Mr. A. J. Carter and three
guests; Dr. A. K. Chalmers; Sir Francis H.
Champneys, Bart., M.D.; Sir R. Havelock Charles,
G.C.V.O., M.D.; Sir William Watson Cheyne,
Bart.. C.B., F.I.C.S., F.R.8.; Sir William 8.
Church, Bart., K.C.B., M.D.; Dr. S. Monckton
Copeman, F.R.S.; Sir Anderson Critchett, Bart.,
C.V.O., F.R.C.S.: Major S. L. Cummins, M.D.,
R.A.M.C.; Dr. H. H. Dale; Dr. Samuel T. Darling;
Mr. J. H. Dauber, M.B.: Mr. Robert Donald; Sir
Dyce Duckworth, Bart., M.D.; Mr. Perey Dunn,
F.R.C.S.; Sir Frederie Eve, F.R.C.S.; Dr. John
Eyre; Sir David Ferrier, M.D., F.R.S.; Sir James
Kingston Fowler, K.C.V.O., M.D.; Dr. H. Andrew
Foy, D.P.H. ; Surg.-Lieut.-Col. P. J. Freyer, M.8.;
Dr. Archibald E. Garrod, F.R.S.; Dr. R. A.
Gibbons; Sir James Goodhart, Bart., M.D.; Mr.
John L. Griffith; Dr. W. S. A. Griffith; Surg.-Gen.
Sir William Launcelotte Gubbins, K.C.B., M.V.O.,
M.B.; Dr. A. J. Hall; Dr. F. de Havilland Hall;
Dr. W. H. Hamer; the Rt. Hon. Lewis Harcourt,
M.P.; Dr. C. F. Harford; Mr. H. F. Heath; Dr.
G. William Hill; Mr. Harvey Hilliard; Dr. W.
Ainslie Hollis; Dr. William Hunter; Dr. T. B.
Hyslop and his guest; Sir John Jackson, C.V.O.,
M.P.; Major S. P. James, I.M.S., M.B.; Surg.-
Gen. Sir Alfred Keogh, K.C.B., M.D.; Col. W. G.
King, C.LE., I.M.S.; Mr. P. P. Laidlaw, B.C.;
Sir Arbuthnot Lane, Bart., M.S.; Dr. Arthur
Latham; Dr. H. A. Latimer; Mr. J. B. Lawford,
F.R.C.8.; Dr. T. M. Legge; Mr. C. B. Lockwood,
F.R.C.8.; Dr. G. C. Low; Mr. J. Y. W. MacAlister ;
Mr. Ramsay MacDonald, M.P.; Dr. Hector
Mackenzie; Surg.-Gen. W. G. Macpherson,
C.M.G., M.B. ; Mr. G. H. Makins, C.B., F.R.C.S.;
Mr. E. Alan Masters, B.Se.; Major J. A. Masters,
M.D.; Surg.-Gen. Arthur W. May, C.B., R.N.;
Dr. 8. G. Moore; Sir Shirley F. Murphy,
F.R.C.S.; Sir George Newman, M.D.; Dr. Arthur
Newsholme, C.B.; Dr. H. A. Alford Nicholls,
C.M.G. ; Major Robert E. Noble; Dr. E. S. Pasmore ;
Mr. Herbert S. Pendlebury, F.R.C.S.; Dr. George
Pernet; Capt. A. E. Hayward Pineh, I.M.S.,
V.R.C.8.; Dr. G. Newton Pitt; Mr. H. G. Plimmer,
F.R.8.; Sir James Porter, K.C.B., M.D.; Sir
Richard Douglas Powell, Bart., K.C.V.O., M.D.;
Mr. W. T. Prout, C.M.G.; Dr. Edwin Rayner;
Sir James Reid, Bart., G.C.V.O., K.C.B., M.D.;
Mr. L. Reyersbach; Lieut.-Col. O. L. Robinson,
R.A.M.C.; Major Sir Ronald Ross, K.C.B., F.R.S.:
Prof. William Russell, M.D.; Dr. Louis W. Sambon ;
Dr. H. Seurfield; Dr. Seymour J. Sharkey; Prof.
W. J. R. Simpson, C.M.G., M.D.: Col. B. M.
Skinner, M.V.O., A.M.S.; Dr. F. J. Smith; Dr.
H. Lyon Smith: Surg.-Gen. Sir Lionel Spencer,
K.C.B., M.D., LM.S.; Dr. S. Squire Sprigge:
Lieut.-Col. Squier; Dr. Purves Stewart; Mr. J.
Lynn Thomas, C.B., C.M.G., F.R.C.8.; Mr. C. J. S.
Thompson: Mr. David Thomson, M.B.; Mr. J. G.
Thomson, M.B.; Sir StClair Thomson, M.D.; Dr.
H. H. Tooth, C.M.G.; Sir Frederick Treves, Bart.,
G.C.V.O., C.B., F.R.C.8.; Sir John Tweedy,
F.R.C.S.; Mr. T. Jenner Verrall; Dr. F. Parkes
Weber; Dr. Samuel West; Dr. W. Hale White; Dr.
Dawson Williams, F.R.C.P.: Mr. Guy E. M. Wood,
M.B.
After dinner the loyal toasts were given by the
Chairman.
Lord Bryce proposed the toast of ‘‘ The President
of the United States," and referred to the sym-
pathy President Wilson extended to science, and
particularly to applied science, as a means of
improving the health of the people. The Presi-
dent had not taken a publie part in political affairs,
nor had he experience of the hustings before he
became a candidate for the Presidency, but he was
a conspieuous example of how a student of the
history of peoples and nations, a man deep read in
the motives that dominate mankind throughout
the ages is fitted, provided he is endowed with
judgment and clear-sightedness as the President is.
to conduct the affairs of a great nation. Lord
Bryce drew attention to the campaign against anky-
lostomiasis, which had been successfully conducted
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
101
in the United States, and to the formation of the
International Health Commission, which was ex-
tending to the rest of the world, especially to
British colonies and possessions, the experiences
which had been acquired in the United States. The
Commission, under Mr. Wickliffe Rose, was on its
way to investigate ankylostomiasis in Egypt, Ceylon
and the Malay States. The Commission was estab-
lished by the Carnegie and Rockefeller Institutes,
and the members had been given a cordial weleome
by the Colonial Office authorities in Great Britain.
His Excellency the AMERICAN AMBASSADOR, in
responding to the toast, thanked the assembly for
the cordial way in which the toast to the President
of the United States had been received. He
looked upon the principle of action which seems to
guide the President as one which he might style the
scientific method of administration, and nowadays
scientific methods must be the foundation of every
undertaking, whether it be the work of governments
or of investigators in the realms of disease.
Sır HavELock CnanLEs, G.C.V.O., in proposing
Surgeon-General Gorgas's health, said: As Presi-
dent of the Society of Tropical Medicine and Hygiene
I rise to propose the toast of the evening, '' The
Good Health of Surgeon-General Gorgas." Our
guest has been doubly fortunate in his past:
(1) He has had on two occasions great opportunities
to show his powers; (2) he has successfully demon-
strated, on both those crises in his career, by his
grit, his knowledge, and his tact, the wisdom of the `
great man who selected him for such arduous tasks.
The best was chosen, and, to give that best his
chance, full powers and single responsibility were
conferred upon him. There was the wisdom! It
is not right to allow the energy of a man worthy of
a great task to be used up in contesting with the
quibbles of red tape, envy and ineptitude. Place
upon such a one the whole responsibility, and,
having done so give him a free hand. Havana,
for centuries the hot-bed of yellow fever, was cleared
by our guest of that scourge in nine months. The
greatest labour, though, of this son of Alkméné has
been at Panama, where his effective organization
put an end to the pestilence that, by means of the
mosquito, had defeated that most gifted nation, the
French, without their ever having dreamt of the
source of the attack! The conquest of Panama was
the conquest of the mosquito. The Amerieans suc-
ceeded, but the success was not due to superiority
over the French in engineering skill, but to the
thoroughgoing application by Surgeon-General
Gorgas of the principles of scientific preventive
medicine. The pessimists, of whom, in this land,
we have more than enough, allow us no ground for
boasting of our achievements in science more than
in any other line. We can, though, on this matter
that made Surgeon-General Gorgas's feat possible,
put in a claim for credit, in that the discovery of
the transmission of disease by the mosquito was due
to our countrymen, Manson and Ross. Sir Ronald
is here to-night, and, in congratulating our guest,
we, I think, shall not be wrong in calling to mind
Sir Ronald Ross's achievement, for the publie is
ever ready enough to accept the benefit conferred
by science, but is too prone to ignore the benefactor.
You all doubtless remember the old story of the
city in dire peril about to be destroyed, but it is
said, '' Now there was found in the place a poor
wise man, and he, by his wisdom, delivered the
city, yet no one remembered that same poor man."
As it was in the beginning, even so it is now.
Surgeon-General Gorgas stamped out yellow fever
and plague and controlled malaria. He abolished
the panie of fear and the terror by night that these
inspire. He proved that, by taking the necessary
precautions, selected aliens could live in the Canal
Zone, for a time, with but little more risk than at
home. He inspired, in both his confréres and staff,
confidence by his words, and enforced it by his acts.
He has shown that tropical disease is subject to
human control, and has thus given to sanitarians
the world over a banner that may be displayed
because of the truths of sanitary science.
What was the scene of his labours?—the common
grave of past failures and worn-out reputations.
As our Johnson has said of Scotland of the old days,
it was a place where a man would rather choose to
travel in than to live, and where he would find more
to observe than to desire. Its neighbourhood has,
for us, a great interest. May I recall to you that
Nelson, as a captain, led there an expedition of
200 men—of that 200 but ten returned! Nelson
himself long subsequently bore in his person marks
of the illness contracted there. It gives one
furiously to think how different might have been
the history of the world had the hero fallen a victim
to the diseases of the Panama belt that killed so
many of his brave comrades.
Again, in more recent times, our Consul-General
at Panama; survey party of twenty (Germans and
English); Consul-General offered to accompany;
was refused; insisted ; went; in three days returned
alone! The twenty were dead! Of what? Of the
endemie diseases of Panama! Of those of which
our guest has made a conquest !
It has been estimated that in the construction
of the railway across the isthmus that for every
sleeper laid down on the permanent way a man died
of disease. Truly, sirs, this is the country where the
pestilenee walked in darkness and destruction by
noonday, where at the side of the survivor a thou-
sand fell and at his right hand 10,000 died.
Surgeon-General Gorgas will have a place in the
esteem af posterity, as a man of will as well as of
inauguration, of reason as well as of art, of diplo-
matic tact as well as of warm-hearted impulse. To
his own natural gifts of insight he has added every-
thing that modern preventive science can confer.
In a great work it is the man that is everything.
Truly it has been said that genius is the yeast that
makes the dough of knowledge to rise. His genius
applied with unequalled success the doctrines of
yellow fever prevention—promulgated by the
Havana Yellow Fever Commission. His genius
utilized to the full the discoveries of Manson and
That great people, the Ancient Romans, had
a proverb: '' The man lives unworthily through
whom no other person lives." Sirs, how many are.
now alive who would have died in this great
Ross.
102
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(April 1, 1914.
engineering feat had it not been for the labours of
our guest? As the Romans would have said of him,
we say of Surgeon-General Gorgas, he has lived
worthily.
As Britishers we congratulate our kinsmen across
the seas in the successful accomplishment of that
magnificent work, the Panama Canal.
As medical men we congratulate a confrére for
rendering possible the carrying out of that arduous
undertaking—an undertaking that, in the past, was
rendered impossible by the scourge of tropical
disease ; an undertaking that, in spite of engineering
skill, would even now have been impracticable but
for the intelligent application by our guest of the
recent discoveries of scientific medicine, which,
sirs, made that Herculean labour feasible!
As his hosts this evening we honour ourselves
in doing him courtesy.
We wish him the work in the future which his
merit deserves. But we do not wish for him rest,
for '' joy's soul lies in the doing.”
Sirs, I ask you to drink to the health of our guest
—Surgeon-General Gorgas !
Surgeon-General GorGas replied to the toast,
which was enthusiastically received, in the modest
terms characteristic of the man. He stated that,
of the 60,000 labourers engaged in the construction
of the Canal no fewer than 45,000 were coloured
subjects of the British Empire. The men hailed
from the West Indies, and almost all belonged to
the Church of England; whether this accounted for
their good behaviour or not he could not say, but
better behaved or more orderly and willing workers
it would be difficult to find, and in comparison with
the negroes in other parts of the world they seem
altogether exceptional. One or two amusing things
happened in connection with their employment;
so marked was their religious fervour that when they
left the Bibles, which had been provided for their
use, disappeared with them. They, moreover,
claimed the Panama Canal, lock, stock and barrel,
as their doing, and certainly their arduous labours
were most commendable. On one occasion the
faith of the men in the British Empire faltered; this
was owing to a change in the method of payment
that was adopted without due notice: it was sud-
denly arranged that instead of paying cash to the
men that they should be paid in postal orders
payable at the Post Office in Barbadoes, from whence
most of the negroes came. The sudden call upon
this office of many thousands of orders to be cashed
taxed the resources of the office so severely that
because the money was not immediately obtainable
the report got about that the British Empire was
bankrupt. By another week, however, provision
was made for these payments, und confidence in the
British Empire was restored. He appreciated
highly the kindness with which Major Noble, Dr.
Darling, and himself had been received everywhere
in England, and referred to the pleasure he had felt
on this, his first, visit to London to see places,
streets and buildings with the names of which he
was perhaps more familiar than he was with places
and streets in New York, and he forbore to describe
his feelings when he found himself in Westminster
Abbey, St. Paul’s Cathedral and other places which
were heretofore mere names to him, and actually
walk along streets where Dickens’s and Thackeray's
heroes had trod.
Sir WinLiAM Oster, Bart., F.R.S., proposed the
toast of ' The Chairman," to which Sir THomas
Barrow fittingly responded.
—— 9À—————
ADDRESS BY SURGEON-GENERAL GORGAS
ON SANITARY WORK IN THE PANAMA
CANAL.
On Monday, March 23, Surgeon-General Gorgas
addressed a large meeting at the Royal Society of
Medicine. The President of the Society, Sir Francis
Champneys, Bart., occupied the chair.
In his address, Surgeon-General Gorgas gave a
deseription of the area along which the Canal was
constructed. The length of the waterway is about
50 miles, and it runs almost due north and south.
Two-thirds of the extent was mountainous, or rough
broken uplands, whilst one-third of the length was
through a low, swampy district. The moisture and
warmth of the distriet was such that it presented an
ideal breeding ground for mosquitoes. The different
zones of the Canal were divided into sanitary dis-
triets in charge of specially appointed officers.
Drainage was the stable method employed to keep
down the mosquitoes. The ''drains ' were of
different kinds, according to circumstances; some
were ditches, some were surface drains, but what-
ever their nature they had to be kept clear, for
ditches get grass-grown quickly; but the best of
all was one made of subsoil tiles. The grass on
either side of the Canal, for a distance of 200 yards,
had to be kept cut close, otherwise the mosquitoes
sheltered in the long grass from the sun and wind,
which are destructive to their existence. Where
drainage is impossible oil is useful, and for a time
as many as 1,000 barrels a month were being used
for this purpose. Quinine also was given freely
during the construction, but drainage is the great
prophylaetie against malaria and yellow fever.
As examples of the efficacy of the measures
adopted, Surgeon-General Gorgas stated that where-
as in 1906 not fewer than 820 out of every 1,000
persons engaged in the Canal were admitted into
hospital with malaria, in 1913 the number dropped
to 47 per 1,000. The death-rate amongst negroes
in 1906 amounted to 45 per 1,000, in 1913 it was
reduced to 5 per 1,000. Amongst whites the death-
rate fell from 11 per 1,000 in 1906 to 2:5 per 1,000
in 1913.
Major Noble showed a series of lantern slides of
the work in the Canal in its several phases. The
cost of the sanitary work, over which Surgeon-
General Gorgas presided, amounted to about
£80,000 a year, from 1904 to 1913.
——dp———
Ox March 18 Surgeon-General Gorgas was enter-
tained at dinner by the Director-General of the
Army Medical Service and the officers of the Royal
Army Medical Corps, in their mess at the Royal
Army Medical College, London.
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
103
Abstracts.
A SKIN REACTION INDICATIVE OF
IMMUNITY AGAINST TYPHOID FEVER.*
By Freperick P. Gay, M.D., and Jonn N. Force, M.D.
CERTAIN of the antibody tests, particularly the
agglutination reaction and the reaction of fixation,
are of recognized value in the diagnosis of typhoid
fever; they are, however, of no certain significance
as measuring actual resistance to typhoid infection.
We have simply to mention that a high agglutina-
tion reaction affords no assurance of protection
against a relapse in the disease, and, on the other
hand, that it is well recognized that those who have
recovered from typhoid fever soon fail to give the
reaction in the majority of cases, although they are
usually protected for life from a recurrence of the
disease.
TECHNIQUE.
The method of applying the typhoid skin test is
a modification of the von Pirquet method of tuber-
culin testing. It consists in producing an abrasion
of uniform size and depth designed to cut just
through the epidermis of the arm without drawing
blood. This abrasion is produced by a complete
twist of a chisel with straight edge (measuring
2°25 mm.) and square corners, supplied on specifica-
tion by the Cutter Analytic Laboratory, and so
tempered as to resist sterilization by burning
aleohol. The skin is prepared by cleansing with
95 per cent. alcohol. Various preparations of the
typhoid bacillus have been tried with varying
success, and the one actually chosen as the most
efficient is prepared in a manner similar to the one
employed in producing Koch’s old tuberculin:
250 c.c. of 5 per cent. glycerin bouillon was inocu-
lated with Bacillus typhosus (Dorset Army Strain
No. 5) and incubated for five days. It was then
reduced without filtration to one-tenth of its original
volume by evaporation over a 56 acetone bath for
about eight hours. A control solution of sterile 5 per
cent. glycerine bouillon was evaporated at the same
time to equivalent volume.
Two uniform abrasions are produced on the upper
arm or forearm of each patient tested, and the con-
trol solution gently rubbed into the inner spot with
a sterile toothpick, and the ‘‘ Typhoidin ’’ solution
similarly applied to the outer spot. The reactions
are observed six and twenty-four hours later, and
more rarely at subsequent periods. In a very few
instances the six-hour period shows in positive cases
an accelerated reaction which diminishes or actually
disappears within twenty-four hours. Not infre-
quently, however, a positive test persists for a week.
In the majority of cases the control spot shows a
2 mm. healed abrasion not surrounded by an areola ;
in the minority of cases a slight zone of traumatic or
irritative redness may occur about the abrasion.
In these latter cases when there is a positive re-
action in the ‘‘ Typhoidin ”’ spot there is no difficulty
* Archives of Internal Medicine, March, 1914,
in noting and measuring the differences between its
areola and the control redness. We have arbitrarily
chosen a difference of 2°5 mm. between the two
areolas as indicative of a positive reaction. The posi-
tive spot measures from 4 to 12 mm. in extreme
diameter and is usually somewhat indurated and
frequently clearly demarcated. In negative cases
there is the same reaction or absence of reaction
in the control and ‘‘ Typhoidin’’ spots. In the
routine examination, as a rule, twenty or more cases
representative of the various categories were tested
at a time, after history-taking, and to avoid pre-
judice, the nature of the reaction decided on before
the history was referred to.
CONCLUSIONS.
A preparation of the typhoid bacillus (‘‘Typhoidin’’),
in all respects similar to Koch's old tuberculin,
produces a clear-cut cutaneous reaction by the von
Pirquet method in 95 per cent. of cases that have
recovered from typhoid fever (20 cases positive out
of 21). Two of the cases had suffered from the
disease forty-one and thirty-three years before,
respectively. The reaction is negative in 85 per
cent. of individuals without history of typhoid fever
(41 cases tested). The 9 per cent. of these sup-
posedly control individuals that gave a distinct
positive reaction may be suspected of having had
& mild and undiagnosed attack of typhoid fever.
Of fifteen individuals vaccinated by the Army
method from four and three-quarter years to eight
months previously, nine gave a positive skin re-
action. Twenty-five individuals vaccinated by the
Gay-Claypole sensitized vaccine for from one to
eight months previously gave uniformly a positive
reaction.
It is suggested that the test is of presumptive
value in indicating protection against typhoid fever
whether acquired by recovery from the disease or by
artificial immunization against the disease. The
test may eventually be used as an indication for
re-vaccination in the individual case.
EXAMINATIONS FOR HOOKWORM OVA.*
By Mark J. WHITE.
TECHNIQUE FOR THE EXAMINATION OF FRESH MATERIAL
AND FOR MAKING PERMANENT MOUNTS OF THE
SPECIMENS.
(1) Agitate about 0:5 grm. of feces with 5 or
6 c.c. of water in a small test-tube. The centrifuge
tube is suitable.
(2) Strain through two layers of gauze to remove
the too consistent particles of feces, and wash the
residue with a sufficient quantity of water so that
the total filtrate will properly fill a centrifuge tube.
(3) To the tube of filtrate add and diffuse therein
five drops of a 1 per cent. solution of '' Toluidin-
blau '"' in a 2 per cent. aqueous solution of carbolic
acid.
(4) Centrifugate sufficiently, two minutes.
* «United States Public Health Report," February 20,
1914.
104
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
(5) Decant all supernatant fluid.
(6) Place two loops of the sediment on a slide
and spread by gentle pressure with a cover-glass.
(7) Magnify 105 times in a subdued light (oc. 4,
ob. 3 Leitz).
The dye imparts blue and purple tints to the
fecal material and a light-brown tint to the egg-
shells. This polychromatic effect greatly facilitates
the locating of the eggs, which are then magnified
370 and 1,000 times for the purpose of more definite
identification of the blastomeres (oc. 1, ob. 7, and
oc. 4, ob. jy oil Leitz).
These stained specimens may be satisfactorily
mounted by rimming with melted paraffin. In
such mounts the complete development of the egg,
including the first embryonic stage, may be watched.
As the egg becomes mature and the shell disin-
tegrates, the embryo, whether dead or alive, takes
on a purple colour, as the result of coming in con-
tact with the small quantity of unattached stain
present in the mount. As long as the egg-shell
remains intact its colour is light brown, but as soon
as it permits the unattached dye to come in contact
with the contained embryo the colour of the egg
changes, so that instead of a light-brown egg there
is a purple egg.
In some instances the embryos entirely escape
from their egg-shells and lie free in the field, but
dead, having taken a beautiful purple colour. In
others they remain coiled up dead in the egg-shells.
This change increases the value of permanent
mounts, as some of the eggs may remain brown,
while others show the embryos stained purple. It
is necessary to avoid pressure on these mounts, as
the embryos are very fragile, and the movement of
the surrounding air-bubbles is likely to cause frac-
ture and displacement.
A PULMONARY ATTACK SIMULATING
PRIMARY LOBAR PNEUMONIA, CAUSED
BY PULMONARY EMBOLISM AND IN-
FARCTION FROM A LATENT VENOUS
THROMBOSIS.*
By Lewis A, Conner, M.D.
(1) In the common forms of venous thrombosis,
such, for example, as is seen as a complication of
typhoid fever, and such as so often supervenes after
childbirth and after certain surgical operations,
there is regularly a period of days or even weeks
during which the course of the thrombosis is either
altogether latent or is indicated only by slight and
equivocal symptoms; and the classical signs of
phlegmasia alba dolens appear only late in the pro-
cess, or may indeed be lacking altogether. More-
over, the formation of the primary or white thrombus
is the result of the gradual deposition of blood
platelets on the walls of the still patent vein, layer
on layer, in a manner somewhat comparable to the
* Presented at the Section on Medicine of the Seventeenth
International Congress of Medicine, London, 1913. From The
Archives of Internal Medicine, March, 1914.
formation of a bar by the deposit of silt in a flowing
stream. There is reason to believe that the charac-
teristic local signs of thrombophlebitis appear only
after the occlusion of the vein has become complete,
and after more or less periphlebitic inflammation has
been added.
(2) Pulmonary embolism and infarction is a much
more frequent complication of venous thrombosis
than is commonly supposed. It occurs in two
quite distinet forms, which differ much in their time
of appearance, their clinical course, and their prog-
nosis. There is first the massive and usually fatal
embolus caused by the separation and mobilization
of a large fragment of a thrombus, occupying and
occluding some such large vein as the femoral or
iliac. The emboli occur late in the process of
thrombosis and are fortunately rare; but because
of their suddenness and the gravity of their sym-
ptoms, they are the ones to. whieh attention has
been chiefly directed. The second form of pul-
monary embolus is of much more frequent occur-
rence. It appears early in the process of throm-
bosis, often, indeed, days or even weeks before the
loeal signs of thrombophlebitis are recognizable, so
that frequently it is the very first manifestation of
that condition. Its symptoms are usually mild and
are often interpreted as those of an ordinary pleurisy
or pneumonia. These small, early emboli almost
certainly arise from the separation of tiny particles
from the primary, mural thrombus while the blood
is still flowing in the affected vein. "This thrombus,
as has been said, is formed by the gradual deposit
of agglutinated blood platelets, and it is easy to see
how such freshly deposited clumps of platelets
should be separated from the thrombus and carried
away in the blood-stream to be lodged finally in the
lung capillaries.
(3) Venous thrombosis occurs not so very rarely
in individuals who are apparently in good health,
or who at least are not obviously sick. The litera-
ture contains many instances of such thrombosis in
girls with simple chlorosis, in men with gout, in
cases of varicose veins of the legs, and even in
persons who seem to be quite well. In some of
these latter cases syphilis seems to be the under-
lying cause of the trouble.
The evidence furnished by the four cases will, it
is believed, be found to be convincing that the cases
were actually instances of pulmonary embolism and
infaretion, and were not examples of primary pneu-
monia, as they at first appeared to be. Unfor-
tunately the evidence of this fact is purely clinical,
as the cases all recovered ; but this is true also for
most of the cases of early pulmonary infarction seen
with the venous thrombosis which complicates
typhoid fever. Nevertheless, in these latter cases
the clinical evidence is overwhelming. The present
cases are analogous in every respect to those com-
plicating typhoid fever.
In Case 1 the onset was exactly like that of a
primary pneumonia, except for the absence of a
rigor, and no doubt was entertained at first as to
the correctness of the diagnosis. But the frankly
bloody character of the sputum, which continued
|
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
105
day after day, soon raised a suspicion of the true
nature of the condition, and we were able to predict
with some assurance the ultimate appearance of the
venous thrombosis, which gave its first local signs
seven days after the onset of the pulmonary sym-
ptoms. In this instance the bloody sputum lasted
for twenty-one days. Concerning the physieal
sigus, it is to be noted that the signs of consolida-
tion appeared first in the left lower lobe, and a few
days later in the right lower lobe, and that gradually
these signs changed so as to give the impression
that there was present more or less fluid in both
pleural cavities, although the aspirating needle failed
to show any.
In Case 2, a luetic man, the physical signs were
those of a small area of consolidation near the lower
angle of the left scapula, which disappeared within
two or three days. In this case also the sputum
was composed chiefly of blood and bore no resem-
blance whatever to the rusty, tenacious sputum of
pneumonia. On questioning the patient, the fact
was elicited that several days before the appearance
of pulmonary symptoms he had had, for a day or
two, some pain in the calf of his right leg. When
first seen by me, toward the end of his illness, a
distinct indurated cord could be made out in the
left calf, which did not correspond to any of the
normal structures there, and which seemed to me `
clearly to represent a thrombosed and thickened
vein. A very interesting feature of this case was
the appearance of sudden and severe pain in the left
side of the neck and in the suprasternal notch,
which came on some thirty-six hours before the
advent of pulmonary symptoms. The peculiar
location of this pain is characteristic of irritation of
the central portion of the diaphragmatic pleura, and
in this instance the pain suggests that there had
been a small infarct somewhere on the central
portion of the lower surface of the lung before the
occurrence of the larger infarct, which gave the
more characteristic symptoms and signs.
Case 8 was that of a man with fairly marked
chronic nephritis, which, however, did not prevent
him from carrying on his daily work—an occupation
that required him to be constantly on his feet. In
this instance the diaphragmatic location of the
infaret is seen by the fact that the symptoms (pain,
tenderness and muscular rigidity) were at first
abdominal rather than thoracic. In this case (the
only one among the four) the sputum was very
scanty and was at no time bloody. The signs of
consolidation lasted only about two days. The clue
to the true diagnosis came only when signs of
phlebitis appeared some days after the pulmonary
signs. Then was elicited the fact that, for several
weeks before his illness, he had had dull pain and
soreness in the right calf, with some local swelling.
In Case 4, the interesting features were the
character of the. sputum, and the fact that two
weeks after the subsidence of the first pulmonary
attack there were indications of the occurrence of a
small embolus in the other lung.
To recapitulate, then, we have in three of the four
cases sputum which consisted chiefly of liquid or
clotted blood, and in no case sputum which bore any
resemblance to the characteristic sputum of pneu-
monia; in every case the physical signs differed in
some respect from those usual in pneumonia—in
two cases by the short duration of the signs of
consolidation, in one by the absence of frank signs
of consolidation, and in one by the anomalous and
protracted pleural signs; in all the cases there were
indieations that the pulmonary lesions were mul-
tiple; in none of the cases was there an introductory
rigor; in three of the four cases the temperature
chart bore little resemblance to the usual chart of
pneumonia, and, finally, in three of the four cases
there were points in the history to indicate that
venous thrombosis existed before the onset of the
pulmonary symptoms.
No one of these facts alone would be entitled to
much weight in the attempt to differentiate these
cases from those of primary pneumonia, but taken
together they form a mass of evidence sufficient, I
think, to warrant the conclusion that all of these
cases were instances of pulmonary embolism and
infarction.
That it may be quite impossible at times to say
positively whether the venous thrombosis, which
declares itself after the appearance of the pulmonary
trouble, is the cause or merely the result of this is
freely admitted, but in most cases a careful study
of the symptoms and a patient inquiry into the
history of the case will, I believe, provide one with
sufficient data to clear up the uncertainty.
MANILA BUREAU OF HEALTH REPORT FOR
THE THIRD QUARTER OF 1913, DATED
OCTOBER 20.
By Victor G. Heiser, M.D.
Plague.—The editor of the Manila Daily Bulletin,
who had his office in the Stewart Building, was
taken violently ill on September 19 and on Septem-
ber 20 his case was definitely diagnosed as one of
plague. On September 22 he died. The diagnosis
was completely confirmed by laboratory methods.
While carrying out the insecticidal and other anti-
plague measures in his office a mummified rat was
found in a drawer of his desk. There were also in
the drawer a number of live fleas, one of which
was captured and identified as the rat-flea (Pulex
cheopis). Stained specimens from this flea showed
bipolar staining organisms that were identical with
those of plague. The mummified rat or large mouse
which was found in his desk was ground up, and
inoculations made from it into healthy laboratory
rats produced typical cases of plague in them.
During the examination of the storehouse of the
grocery store, the kitchen of the restaurant, and
other rooms which are on the first floor of the
building in which the offices of the Manila Daily
Bulletin are located, four other dead rats were found
that had all appearances of having died of plague.
It was also learned that on September 20 a
Chinaman who was employed in the grocery store
had died very suddenly and been quickly buried.
106
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
On account of the suspicious circumstances the
body was exhumed. There were enlarged glands
and other lesions, however, which indicated that
death might have been due to plague, but on
account of the advanced state of decomposition
which had set in it was impossible to confirm the
diagnosis biologically.
Cholera.—After an absence of over two years a
case of cholera was discovered in the city of Manila
on August 24 and another on August 25.
The first case occurred in the person of a Filipino
who worked as a carpenter in one of the local hotels,
but was said invariably to have taken his meals and
slept at his residence. On Saturday evening, August
23, he left his place of employment apparently in
good health. About noon the next day he was
seized with violent pains in the stomach, which
later in the afternoon increased in severity, and in
addition marked pains began in the muscles of the
calves and forearms. Though there was no diar-
rhea, the case presented many of the clinical sym-
ptoms of cholera and the patient was ordered to be
transferred to the cholera hospital. The man was
in a moribund condition when he arrived at about
10 p.m., and died a few minutes later. At the
autopsy which was held on the morning of August
25 the typical pathological lesions of cholera sicca
were present. The lower bowel contained a large
amount of hard, formed feces. A liquid rice-water-
like fluid was found in the ileum, cultures from
which, prepared in accordance with the procedure
recommended by the Internationale d'Hygiéne Pub-
lique Conference, resulted in the isolation of the
true cholera vibrio.
The next case came under observation on August
25, and oecurred in the person of a Filipino who
was employed as a cook to a British family in a
suburb of Manila and a number of miles removed
from the first case, and so far as could be ascer-
tained there was no connection between the two
cases. This person gave a history of having been
ill with diarrhoea and cramps in the muscles of the
extremities for a period of about a week. It was
at this time that he came under observation and
was transferred to hospital. He was found to have
rice-water stools, cramps in the muscles of the legs,
suppression of urine, husky voice, subnormal tem-
perature, and other well-recognized clinical sym-
ptoms of cholera. Cultures made from his stools
resulted positively for the cholera vibrio.
No further cases of the disease were discovered
until September 13. The first eight cases occurred
in widely separated sections of the city and the
most faithful investigation failed to trace any con-
nection whatsoever between the cases. After that,
however, there have been a number of instances
of contact infection. Since the beginning of the
outbreak on August 24 to October 20 there have
been seventy-two cases, of which forty-five died.
A most noteworthy fact in connection with this
outbreak is the frequency with which true cholera
vibrio carriers are found among the contact groups
of the true cases of cholera.
Of seventy-two contact groups examined forty
were vibrio carriers of some kind and twenty-nine
were true cholera carriers. These results show the
desirability of having adequate laboratory facilities
for examining large groups of the population in
order to ascertain to what extent infection exists
among them.
The first case discovered was in a person who had
not been out of Manila for many months previous
to his illness, nor did he associate with persons
from foreign parts or eat imported food in a raw
state. At the hotel at which he worked no guest
from a foreign country had registered for over seven
days prior to the date on which the cholera occurred.
As far as known there has been no cholera anywhere
in the Philippines since October, 1911, and careful
investigation fails to show that the disease was
introduced from a foreign country by food or per-
sons. The importation of vegetables or other food,
which might be eaten in a raw state, from any
country except Australia and the United States is
prohibited. From the foregoing it is apparent that
the origin of the present cholera outbreak cannot be
definitely traced. There is considerable evidence
from an epidemiological standpoint that cholera
carriers are always present in the Philippines and
under certain circumstances they are capable of
transmitting the disease.
As in former outbreaks, prior to true cases of
cholera having been found, at intervals of a few
weeks a number of deaths occurred which were
attributed to acute nephritis and were in persons
who had the symptoms of ptomaine poisoning.
Similar experience had in former outbreaks sug-
gests the belief that these cases may perhaps in
some way be associated with cholera outbreaks in
the Philippines.
Measures employed to combat it.—All cholera
cases were promptly transferred to hospital. Dis-
infection of the premises was made with larvieide
or carbolie acid, particular attention being given to
the toilets, bed upon which the patient slept, his
clothes, and other artieles and things that might
have become infected with cholera discharges. All
contacts were required to wash their hands in a
disinfecting solution. In addition, a stool specimen
was taken from each one of them, and in all cases
in which they were found to harbour the cholera
vibrio they were transferred to hospital for observa-
tion and detention. In sections of Manila in which
cholera occurred general disinfecting measures were
sarried out with respect to tight vaults or other
receptacles into which cholera organisms might
have been deposited and from which there might
be any danger that flies, roaches, or other insects
might carry them to food supplies.
Mortality Record.—In_ spite of the fact that
cholera appeared during the latter part of the
quarter—a mortality of 22:08 per 1,000 per annum
for the quarter, which is lower than that for many
cities of the United States, and if the high infant
mortality eould be exeluded, or, in other words, if
comparisons were made of deaths that occur among
persons over 1 year of age—Manila would be found
to have a death-rate which would compare favour-
April 1, 1914.]
ably with even the healthiest cities of the United
States.
Leper Collection.—T wo hundred and seventeen
were collected and transferred to the Leper Colony,
making the number of inmates 3,350.
As the police system in the Philippines gradually
improves it becomes more and more apparent that
there is still a considerable number of cases of
leprosy of long standing at large, so that the rapid
reduction in the number of new cases of leprosy
which had been hoped for after the segregation of
the lepers was supposed to have been completed
can scarcely be expected as yet.
Vaccination.—Much diffieulty is experienced in
impressing upon local health officers the necessity
for carrying out these instructions rigidly, and their
failure to do so has in a number of instances been
responsible for outbreaks of small-pox among the
unvaccinated.
Typhus Fever.—Several cases of a disease re-
sembling typhus fever were reported. One of the
cases occurred in an American, and his clothing
and other effects were most carefully examined in
order to ascertain whether the Pediculus vestimenti
could be found, but all of these efforts were nega-
tive, and it is reported by the Bureau of Science
that up to the present time it has not been possible
to find this insect anywhere in the Philippine
Islands. On account of the fact that the P. vesti-
menti is regarded as the only intermediate host,
there is considerable reluctance to make a positive
diagnosis of typhus fever in these cases.
Cerebrospinal Meningitis.—During May a case of
cerebrospinal meningitis occurred in a sailor who
worked on a lighter. The case was treated in
hospital and the diagnosis was confirmed by autopsy
and the Meningococcus intracellularis was found.
During June and July eight cases were reported
at a railway camp. The examinations made of the
cerebrospinal fluid in two of the cases revealed the
M. intracellularis. Since that time three additional
cases have occurred.
TRACHOMA IN STEEL MILL WORKERS.*
By J. W. ScHERESCHEWSKY.
Tue Youngstown Sheet and Tube Co. reported to
the State Board of Health the presence of trachoma
among their employees and a medical officer, sent
by the State Board of Health, examined about
twenty-five men who had been dropped from the
rolls of the Company. l
At the time the disease was discovered at the
plant the community had become considerably
excited over the danger. The cases were collected
and segregated in the town gaol. They were dis-
charged later, and what became of the patients
could not be learned, though some of them had been
returned to work by the Company.
The eyes of as many as practicable of the factory
personnel were examined, therefore, in order to
* u United States Public Health Report," March 6, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
107
establish the rate of trachoma prevalence, and an
inspection of the sanitary conditions of East Youngs-
town was made (previously stated to be bad by Dr.
McCampbell), in order to determine the extent of
the disease in that community, outside of the mills,
and to note the general sanitary conditions and the
existing opportunities for the spread of trachoma in
schools and lodging-houses.
The writer acknowledges the cordial co-operation
of the Youngstown Sheet and Tube Co. in this
investigation, and the assistance rendered when
examining the mill operatives in other ways.
Number of Employees.—The full complement is
about 8,500 hands. At present only about 80 per
cent. are at work, the number on the pay rolls at
the time of investigation being 6,372; 5,962 em-
ployees, about 95 per cent., were examined, 410
being office employees, those unwilling to be ex-
amined, or others on continuous night duty not
accessible for examination.
Nationality of Employees.—According to Mr.
D. W. McClure, of the Company's Employment
Bureau, representatives of twenty different races and
nationalities are employed at the works. Table 1
sets forth the percentage of each nationality when
the Company was employing 7,518 persons. The
percentages given are approximately correct for the
present force; 28:5 per cent. of the employees are
Americans, 71:5 per cent. belonging to various
foreign nationalities. Slovaks, Croatians, Rou-
manians and Poles form 63 per cent. of the alien
representation.
Prevalence of Trachoma among the Employees.—
Examination revealed 76 cases of trachoma, a
rate of prevalence of 1°3 per cent. In addition, 19
cases of suspicious conjunctivitis were observed in
individuals presenting inflammatory eye symptoms
of recent origin, suggestive of the onset of trachoma,
but positive diagnosis was impossible at the time
of examination.
Racial Distribution of Trachoma Cases.—Eighty
per cent. of the cases of trachoma found were in
three races—Roumanians, Croatians and Magyars—
who form only 28 per cent. of the total number
examined.
Severity and Duration of the Infection.—The
observations are thought sufficiently reliable to
justify the inference that the disease has for some
time been slowly increasing among the factory
personnel, seeing that in some 42 per cent. of the
cases infection was recent, certainly less than six,
and in several instances less than three months in
duration. The inference as to gradual increase is
further strengthened by the cases of '' suspicious ''
conjunctivitis previously mentioned.
Length of Residence of Trachoma Cases in the
United States.—With but few exceptions the disease
was probably contracted subsequent to landing in
the United States, and in the great majority of
instances while these individuals were in the employ-
ment of the Youngstown Co.
Trachoma is most prevalent in the tube mill and
in the yard and construction gangs. This does not
seem due to any special conditions in these depart-
108 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(April 1, 1914.
ments favouring the spread of trachoma, but to
the fact that they employ the greatest percentage
of Roumanians, Croatians and Magyars, who, as
already shown, present the highest incidence of the
disease.
Dissemination of Trachoma in the Mills.—It is
not probable that dissemination of trachoma is more
than occasionally effected by the washing facilities
used in common at the mills. Like most steel
plants, there are practically no washing facilities
provided by the Youngstown Sheet and Tube Co.
except for the office force. They have paper towels,
which are destroyed after being used once.
The workmen either go home without washing,
use their buckets, or the troughs where tongs and
similar tools are cooled off after handling hot metal.
The amount of trachoma observed in skilled work-
men was not significant. The relative absence of
the disease among the more highly paid skilled con-
tingent who do wash up before leaving showed that
the disease has not been extensively transmitted
by the use of common towels and washing utensils
at this plant.
In addition to the conditions just discussed some
eases of trachoma may have been acquired at the
plant through the practice of removing foreign bodies
from each other’s eyes. While the regulations of the
Company require all workmen to go for relief to the
Emergency Hospital maintained by the Company, if
the foreign particle consists merely of dust or cinder,
the workmen frequently have recourse to each other
for assistance. It is possible for a trachomatous
individual, using his presumably infected fingers or
handkerchief for the purpose, to infect the eyes of
a fellow-workman, or, conversely, a trachomatous
subject, believing from the ocular sensations caused
by the disease that he has a foreign body in his
eye, similarly to infect the fingers or handkerchief
of the workman who undertakes to remove it.
The impression gained was that conditions favour-
ing the spread of trachoma could not prevail in the
steel plant to the same extent as in the workmen's
homes and lodging-houses; therefore attention was
directed to the sanitary conditions and their relation
ta the dissemination of the disease.
Sanitary Conditions in East Youngstown.—As the
majority of alien employees are either single, or
their families are in Europe, they live mostly in
lodging-houses in East Youngstown. The sanitary
conditions there were most unsatisfactory. In
lodging-houses they were such as not only to facili-
tate the spread of trachoma or of any communicable
disease, but to cause wonder that the disease is not
even more prevalent.
A river is close to the plant of the Youngstown
Sheet and Tube Co. Many streets are practically
ungraded and sidewalks are, for the most part,
absent. Though a line of sewer has been laid
almost all the houses are still unconnected.
The garbage is dumped in the rear of houses
where it is apt to remain until disintegrated by the
elements. A water company has laid pipes in the
town, but only a few houses are supplied. The
great bulk of the water is derived from shallow
driven wells, each house having its pump. Sanitary
conditions are practically nil, and many of the wells
are exposed to pollution.
As workmen of the same race often live in the
same section of town the lodging-houses exhibited
many instances of extreme overcrowding. In one
case there were twenty-three lodgers in a four-room
house, and it was not uncommon to find a single
room occupied by from eight to twelve workers, who,
for the most part, slept two in a bed. In some
houses, where the men work on both ‘‘ day and
night turns," the occupation of the beds is almost
continuous, the night men taking, during the day,
the places of those sleeping at night.
The beds themselves were usually old, filthy, and
destitute of linen, the covers consisting of old bed-
quilts. The washing facilities consisted of buckets
or hand basins, used in common by all the occupants
of a room. The houses themselves were built close
together, the rooms dark, and very few of them
susceptible of thorough ventilation. All windows
were found carefully closed and the temperature
was still further raised by small stoves.
Examination of the East Youngstown Schools.—
All the pupils (652 in number) in the East Youngs-
town schools and teachers were examined, with the
result of finding ten cases of trachoma, a rate of
prevalence of 1°53 per cent.
The greatest number of cases of trachoma existed
in one school; with 270 pupils, or about 41 per cent.
of the entire number examined, there were eight
cases of trachoma, 80 per cent. of the total cases
of the disease found among the scholars. This
school is situated in that district having the greatest
number of lodging-houses. No cases were found at
the school located at the extremity of the town
nearest Youngstown. The sanitary conditions are
better here, the houses less closely spaced, and the
proportion of Americans higher.
While the rate of prevalence of the disease among
the East Youngstown school children is not very
high, being about 13 per cent., the disease is, never-
theless, present, and some action on the part of the
local authorities is needed to prevent its further
dissemination.
CONCLUSIONS.
(1) The origin of the prevalence of trachoma is
readily aecounted for by the presence among them
of chronic cases, some of which are even now in a
state of acute exacerbation.
(2) The crowded insanitary condition of the
lodging-houses amply accounts for the spread of the
disease.
(3) The presence of recent cases of trachomatous
infection shows that under existing conditions the
disease is gradually being spread. Unless measures
are now undertaken for its control the disease will
gradually gain such headway as to prevail in
epidemic form.
(4) It seems evident that so long as the present
insanitary conditions obtain the control of trachoma
will be diffieult or impossible.
In view of the fact that some 60 per cent.
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
of the taxes of the town are paid by the Com-
pany, and that 60 to 70 per cent. of their
personnel, including nearly all the foreign element,
live there, it would seem the Company is more
directly interested in the sanitary conditions than
anyone else.
The efficiency of its employees is affected, not
only by their environment when at work, but also
by that of their homes. When workmen are ex-
posed to insanitary surroundings during their period
of rest, not only do they ineur the danger of con-
tracting communicable diseases, but their ability to
recuperate from their previous labour is adversely
affected by the prevailing unhealthful conditions.
Any effective treatment of the situation must
necessarily include specifie measures to be adopted
atthe mills and also the betterment of the sanitary
conditions if permanent results are to be secured.
The recommendations made were twofold; first,
the treatment of the situation at the mills; and
secondly, the sanitation of East Youngstown.
Besides calling the attention of the Company to
the usual means for preventing trachoma, such as
avoiding the use of the common towel and hand-
basin and the same bed by two or more individuals,
the following special recommendations were made
to put into effect at once :—
(1) No time should be lost in securing a com-
petent physician on full time, at an adequate
compensation, who should perform the following
duties : —
(a) Make a complete mental and physical ex-
amination of persons applying for employment with
the Company.
(b) Give competent treatment to any individuals
found to be afflicted with trachoma or other com-
municable diseases.
(c) If the necessary arrangements could be made
this physician could also be the health officer for
East Youngstown and supervise its sanitary con-
dition.
(2) A competent graduate trained nurse should be
secured who would be able to administer treatment
to trachoma cases under this physician's direction.
(3) All individuals suffering from trachoma should
be segregated, preferably in some building con-
trolled by the Company, and given competent
medical treatment until such time as the infectious-
ness of the disease has been removed. They could
then be allowed to return to work conditionally upon
their reporting daily to the hospital for inspection
and treatment.
(4) All persons suffering from trachoma, including
those segregated in the manner referred to, should,
upon their return to work, be required to report for
inspection and treatment twice daily at the hos-
pital. It was suggested that these persons secure
their time cards at the hospital and the fact of their
having there reported, on going in and out, be
attested by a special stamp kept at the hospital.
(5) In order to prevent the development of sub-
sequent cases, foremen, or those in charge of gangs,
should be required to submit semi-weekly reports
as to the appearance of the eyes of men under their
109
control. Such reports should not be perfunctory,
but state affirmatively or negatively whether they
have observed any cases of reddened or sore eyes
in any of the men under their charge. Whenever
this was seen such workmen should be sent at once
to the hospital for examination.
The following recommendations as to the im-
provement of the sanitary conditions were made,
their realization to constitute part of the future
policy of the Company, as an equivalent for the
large taxes paid by the Corporation :—
(1) The provision of an adequate and pure water
supply.
(2) The installation of a water-carriage sewer
system.
(3) The abolition of insanitary privies.
(4) The installation of catch basins and sewers for
disposal of storm waters.
(5) The installation of a system of garbage col-
lection and disposal, with ordinances as to the use
of sanitary garbage cans with tight-fitting covers.
(6) Restriction of overcrowding in lodging-houses
and regulation of their sanitary condition by a
system of licensing and inspection.
(7) Numbering of houses and grading of streets.
(8) Physical supervision of the children in the
schools.
(9) The appointment of a properly qualified phy-
sician as health officer.
(10) Establishment of a hospital and dispensary
in East Youngstown.
A STUDY OF EPIDEMIC DYSENTERY IN THE
FIJI ISLANDS.*
By P. H. Bang, M.A., M.B., D.T.M. & H.Camb.
Tue observations recorded in this paper were
made in the Fiji Islands during the year 1910.
In former days these dysentery epidemics were
of great virulence; the newly imported Solomon
Island labourers were specially attacked; thus
Daniels reported one such epidemic in which the
death-rate was 48 per cent,
At the present day, probably owing to better
medical service and hygicnic conditions, the case
mortality from dysentery of all kinds is not nearly
so high as formerly, and amongst the Fijians,
according to the official records, is about 16 per
cent.
During the year 1910 some 170 well-marked
dysentery cases were studied in detail at the
Colonial Hospital, Suva, the capital of the group;
of these only 11 were found to be of ameebic’ origin
—that is to say, vegetative amcbe bearing the
characteristics of the Amæba histolytica of Schau-
dinn were found in the stools. In the dysenteric
discharges of the other 159 cases no amcebe were
ever found.
The epidemic dysentery affected members of the
various nationalities — Indian, Fijian, Solomon
* Abstracted from paper in the British Medical Journal,
February 7, 1914.
110
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
Islanders, Europeans, and half-castes—to.an equal
degree as far as could be ascertained.
In Fiji, as in more temperate zones, epidemic
dysentery is an institutional disease; some 53 per
cent. of the patients under observation were
prisoners undergoing sentences in either of the
prisons of Suva.
Clinical Observations.
Cases from which the dysentery bacilli were
isolated varied greatly in their clinical manifesta-
tions—from a mild catarrhal condition, in which
the stools were solid and coated with a small
amount of blood and mucus, to a fulminating one,
in which the call to stool was incessant, and in
which the patient, overwhelmed with pain, physical
exhaustion, and toxic absorption, would succumb
in from two to three days from the commencement
of the attack. The temperature also varied within
wide limits; cases were encountered in which it was
subnormal throughout, others in which it reached
103° F. and over. No special dysentery bacillus
was found to be associated with any clinical type
of case.
No hepatic symptoms in life or suppurative lesions
of this organ post mortem were ever encountered in
this infection.
Epidemiology.
In studying the epidemics of dysentery which
have occurred in Suva in recent years, one is struck
by the fact that the maximum incidence of the
disease occurs during the months of December,
January, February, March, and April, the period
of the highest mean temperature and of the largest
rainfall.
In searching for an explanation of this fact, I
was led to inquire into the possible sources of the
bacillary infection.
From what we know of the bacteriology of acute
dysentery, it is right to assume that as the bacillus
escapes from the body in the stools these, as in
the case of typhoid, act as the primary source of
infection, and, further, that the alimentary route
is probably the one by which a fresh infection takes
place. The water supply of the town of Suva is
beyond reproach, therefore any suspicion of its
contamination by infected fecal matter can be
dismissed.
There is, in addition, no evidence that the direct
infection of food-stuffs plays any part in the spread
of the disease, since acute dysentery occurs amongst
all races in Fiji, though their respective dietaries
are entirely dissimilar. The Fijians for the most
part live on cooked farinaceous foods, such as the
yam and the dalo (Calocasia esculenta), whilst the
Indian subsists, as elsewhere, on bciled rice and
pulse; the Europeans on a mixed diet, in which
fresh meat plays an important part.
In considering the indirect methods by which
infection could be conveyed to food-stuffs suspicion
fell on the house-fly (Musca domestica). They
swarm in the bush and on the roadside, covering
the traveller from head to foot. In the houses
every article of food must be protected from their
attentions, and it is a common occurrence during
meals to place a fly-paper on the table in order to
draw away the flies from the meal. In the kitchens
they are specially abundant.
The abundance of flies in the cultivated districts
ean probably be explained by the fact that numer-
ous favourable breeding places are afforded by heaps
of decomposing sugar cane, and in the uncultivated
districts by the fecal accumulations which generally
mark the proximity of native villages.
There can be little doubt that in Suva, at any
rate, there is a definite seasonal variation in the
number of house-flies, and that this season corre-
sponds with the conditions most favourable for their
propagation, that is the season of highest rainfall
and atmospheric temperature, and it is just during
these months that the maximum number of cases
of acute dysentery occur.
Experiments on the transmission of the dysentery
bacillus through the intestinal tract of the house-fly
were undertaken at the London School of Tropical
Medicine. They were conducted in a glass house
in which the temperature approached that of the
Tropies, reaching as high as 91° F. in the daytime.
Before experiments were commenced the house was
thoroughly washed out with lysol, and all stray flies
and other insects were rigidly excluded. The flies
were bred and hatched in captivity under as sterile
conditions as possible. The pups were washed in
dilute mercury perchloride solution (1 in 1,000) and
placed in a sterile cage till the flies emerged. They
were then transferred in batches of twenty in sterile
test tubes to sterile bottles fitted with a gauge
sleeve in the manner recommended by Graham-
Smith, and fed with an emulsion of sterile bread
and water introduced into the bottles by means of
a sterile spoon. The flies were infected by means
of bread soaked in a broth culture of the dysentery
organism. Over forty experiments were conducted
in this manner, but for some reason or other not
all were successful.
Two strains of bacilli belonging to the non-acid
and the acid or Flexner group were used for infect-
ing the flies—that is, the true Shiga-Kruse bacillus
and the Y bacillus—bacilli which, after frequent
testing and subeulture over a period of nine months,
had given constant fermentation reactions with the
sugars. The infected material, after being left in
contact with the flies for twenty-four hours, was
removed and sterile food was given as before.
At varying periods batches of flies were dissected,
and the contents of the lower intestine were plated
out in the manner described above, with the result
that neither of these organisms could be recovered
from the flies' intestines after the fifth day. The
bacilli were recognized by the usual tests.
Lately Tebbutt, in a series of experiments in
which larve were fed with cultures of B. dysen-
terie, found that the organism could only be
recovered from the pups and imagines in a small
number of cases, but concluded that the possibility
of infection of flies by these organisms in their
breeding grounds may be considered a very remote
one,
April 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 111
Treatment of Acute Dysentery.
In a disease characterized by clinical forms of
such varying severity, especially in native patients
belonging to races differing widely in physique and
disease-resisting powers, it is difficult to compare
tlie results of various forms of treatment. In every
series, however selected, there will necessarily be a
number of mild cases in which the constitutional
disturbances are so slight as to cause the minimum
amount of inconvenience, and which, if untreated,
would recover in a few days. The only reliable
method would seem to be to compare the results of
treatment by different methods of a parallel series
of consecutive cases all approximately of equal
severity.
The first fifty-three consecutive cases, of which
41 per cent. had marked constitutional symptoms,
were treated by the routine treatment of the admin-
istration of sodium sulphate in drachm doses given
every hour for the first twenty-four hours, and sub-
scquently every four hours. The case mortality in
this series was 13:2 per cent.
The next series consisted of 106 cases, of which
42 per cent. had marked constitutional symptoms.
Some thirty-four of these were treated by salines
combined with cyllin in gelatine capsules (pala-
tinoids) in doses of twenty to thirty in the twenty-
four hours (60 to 90 minims of pure cyllin); the
remaining seventy-two cases received in addition to
this intravenous injections of a polyvalent anti-
dysenterie serum (kindly supplied by the Lister
Institute). A dose of 20 c.c. was given to adults,
10 e.c. or less to children.
In apparently hopeless cases injeetion of 50 to
TO c.c. of this serum in the first twenty-four hours
after admission was followed by remarkable im-
provement. After such injections no deaths occurred
iu a series of five cases, in whom the disease was
of the severest type, as evidenced by the passage
of gangrenous stools and the toxie condition of the
patient.
In this series of I06 cases there were only two
deaths—a mortality rate of 1°8 per cent. Neither
of these deaths could be ascribed to the dysenteric
lesion—one, a Fijian child, succumbed to an inter-
current attaek of broncho-pneumonia ; the other, an
Indian woman heavily infected with ankylostomes,
died in uremic convulsions. Attention has been
drawn to the occurrence of death from nephritis
after massive doses of a polyvalent antidysenteric
serum by Savage in his El Tor series.
In this instance not only was the average stay in
hospital of eases of moderate severity considerably
shortened, but it was also found that the stools
resumed their normal fieeal consistency in a much
shorter average space of time—that is, after five
days, as compared with eight on the sodium sulphate
treatment alone. "These favourable results have
been confirmed by Willmore and Savage working
with a mueh more extended series of eases. "The
case mortality rate of dysentery in Egypt seems to
have been abnormally high (70 per cent.), but under
antiserum treatment in 1912 to 1913 it was reduced
to 12 per cent.
The oral administration of salines and intestinal
antisepties, together with the intravenous injections
of antiserum, appears to me to rest on a rational
basis when the following facts are considered :—
The lesions of acute dysentery are confined to the
large intestine, and from it the dysenterie toxins
are absorbed; it is probably the absorption of these
toxins which is responsible for the collapse so often
eneountered in this affection, especially in children.
To counteract the deleterious effects of this toxin
antiserum is injected. The administration of
sodium sulphate is a necessary measure to cleanse
the lower bowel of fecal matter and thereby to
aecelerate the repair of the ulcerated mucous mem-
brane. The administration of cyllin, on the other
hand, in such large doses must certainly tend to
inhibit the multiplieation of the dysentery bacilli
and other organisms in the intestinal contents.
It must be borne in mind that a very acute
dysentery of primary amebic origin, associated with
the passage of gangrenous stools, in which amebe,
though present in the intestinal lesions post mortem,
cannot be found in the stools in any numbers during
life, is also sometimes met with. In Fiji I encoun-
tered one such case. Therefore, in any given case
of an apparently desperate nature, and in which
there is no time to make a diagnosis by cultural
methods, it is advisable to combine the specific
treatment of both the amobie and baeillary forms.
If the case be not of primary ameebie origin, the
hypodermic injections of emetine, if inefficacious,
is completely harmless.
The combined emetine and antiserum treatment
in any case of doubtful origin is therefore the most
rational to adopt in the circumstances.
eo
CLINICAL EVIDENCE OF BI-PALATINOID
ORREFIN IN ANÆMIA.
Some interesting clinical details have recently
come to hand from an eminent Canadian physician
concerning bi-palatinoid orrefin medication. The
patient, a young lady, exhibited stubborn chlorosis
which had previously resisted every form of iron
treatment both organic and inorganic. Bi-palatinoid
orrefin with arsenic and strychnine were ad-
ministered from March 2, 1913, until April 3, 1913,
with the following remarkable results :—
Condition of blood Hemoglobin Rare
March 2,1913 ... 38 per cent. 2,280,000
» 20,1913 ... 54 st 3,300,000
April 3,1913 .. 78 T 4,160,000
The remarkable increase in the percentage of
hemoglobin and number of erythrocytes in the
blood-stream during the comparatively brief period
of thirty-two days strikingly demonstrates the
superior clinical efficiency of orrefin over all other
forms of iron both organie and inorganie. Such is
due to the patented twin construction of bi-
palatinoids whereby chemical action is deterred until
the immediate zone of absorption is reached, when
112
nascent ferrous carbonate with its inherent effi-
ciency is produced.
The makers, Messrs. Oppenheimer, Son and Co.,
Ltd., London, issue various combinations of orrefin
with laxatives and tonics, and will be pleased to
supply practitioners with detailed literature and
liberal free samples upon application to any of
their agents mentioned in the advertisement of this
issue.
~~».
Personal Motes.
INDIA OFFICE.
From January 10 to March 7, 1914.
Arrivals Reported in London.—Major W. T. McCowen,
I.M.S.; Major R. M. Dalziel, I.M.S.; Major W. E.
McKechnie, I.M.S.; Captain ©. G. Seymour, LM.S.;
Lieutenant. Colonel C. H. Bowle-Evans, I.M.S.; Captain A. F.
Hamilton, I.M.S.; Captain R. Brown, I.S.M.D.; Captain
A. C. Munro, I.M.S.; Lieutenant-Colonel A. C. Yonnan,
1.M.S.; Major F. L. Blenkinsop, LM.S.; Major S. P. James,
I.M.S.; Lieutenant-Colonel S. E. Prall, LM.S. ; Major W. F.
Harvey, I.M.S. ; Major A. Spitteler, LM.S. 5 Captain H. R. B.
Gibson, I.M.S. ; Captain L. H. L. Mackenzie, I.M.S. ; Captain
F. Stevenson, I.M.S. ; Captain F. S. Smith, I. M.8.
Extensions of Leave. —Lieutenant-Colonel S. H. Henderson,
I.M.S., 10 d. ; Major W. H. Cox, I.M.S., 6 m., M.C.; Major
E pe McDonald, I. M.S., 3 m., M.C. ; Major D. McCay, I.M.S.,
,M.C.; Major A. Murphy, I.M. S., 4m., M.C. ; Lieutenant-
Colonel G. Y. C. Hunter, I.M.S., 6 m., M.C.; Captain F. H.
Salisbury, I.M.S., 3 m., M.C.; Lieutenant-Colonel R. H.
Castor, I. M.S., 6 m., M.C. ; Lieutenant-Colonel C. M. Moore,
I.M.S., 2 m.
Permitted to Return.— Major W. D. A. Keys, I.M.S ; Captain
H. E. Shortt, I.M.S.; Lieutenant-Colonel L. F. Childe, I.M.S.
List oF Inpran CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Bakhale, Major C. R., I.M.S., Bo., 18 m., July 10, 1913.
Bourke, Lieutenant-Colonel J. J., I.M.S., Assay Master,
India, 24 m., February 3, 1913.
Campbell, Colonel R. N., I.M.S., Assam, 8 m., August 2,
1913.
Cox, Major W. H., D.S.O., I.M.S., Burma, 12 m., April 12,
1913.
Dalziel, Major R. M., I. M.S.
Elliot, Lieutenant-Colonel R. H., I. M.S., M., 13 m., April 19,
1913.
Fry, Major A. B., L.M.S., B., Sanitary Comm.,
May 18, 1913.
Gage, Major A. T., I. M.S., B. Med. Dept.,
20 m., March 15, 1913.
Goil, Captain D. P., I. M.S., B., 32 m., April 5, 1913.
Hamilton, Captain A. F., LM S., Bo., 12 m., January 1,
1914.
Hepper, Captain E. C., I.M.S., N.P.,
1913
Hugo, Lieutenant-Colonel E. V., I. M.S.,
July 15, 1913.
Hunter, Captain J. B. D., I.M.S.,
Ingram, Captain A. C., I.M S.,
June 30, 1913.
Jackson, Lieutenant-Colonel J.,
April 18, 1913.
James, Major S. P., I.M.S.
Kelsall, Papin R., I.M.S., Burma, 18 m., April 15, 1913.
Lalor, Major N P., O.G., L.M.S., Burma Sanitary Comm.,
24 m., July 23, 1913.
Leveuton, Major A., L.M.S., Assam, 18 m., May 8, 1913.
Lunham, Captain J. L., I. M.S., Bo., 18 m., March 20, 1913.
McConaghy, Captain C. B., I.M.S., India Foreign, Persian
Gulf, 24 m., April 4, 1913.
11 m. 1 d,,
Botanical Survey,
23 m. 26 d., April 27,
Punj., 14 m. 26 d.,
18 m., January 14, 1913.
M. Med. College, 20 m.,
I.M.S., Bo. Prisons, 14 m.,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
McDonald, Major J. H., I.M.S., Bo., 12 m., March 19, 1913.,
McKechnie, Major W. E., I.M.S., U.P., 24 m., December 16
1913.
McKendrick, Major A. G., I.M.S., 24 m., February 24, 1913.
Mél Major 'F. O. N., L.M.S., C. P. Gaols, 19 m., March 18,
19
Mitter, Lieutenant-Colonel R. K., I.M.S., M., 18 m. 15 d.,
August 6, 1913.
Morison, Captain J., I.M.S., Bo., 6 m., December 1, 1918.
O'Keeffe, Captain D. S. A., I.M.S., M., 15 m., August 10,
1913.
Penny, Lieutenant-Colonel J., I.M.S., Burma, 16 m,
December 25, 1912.
Pereira, Lieutenant-Colonel F. C., I.M.S., M., 14 m., April
15, 1913.
Reaney, Captain M. F., I.M.S., C.P., 21 m., July 4, 1918.
Ross, Captain W. C., I.M.S., B. Med. Dept., 19 m. 21 d.,
April, 16, 1913.
Rost, Major E. R., I.M.S., Burma, 24 m., November 11,
1912.
Rutherford, Captain T. C., I.M.S., C.P. Med., 33 m. 18 d.,
March 5, 1913.
Saigol, Captain R. D., I.M.S., Burma, 24 m., February 10,
1913.
Scroggie, Captain W. R. J., I.M.S., 24 m. 14 d., May 14,
1913.
Stewart, Lieutenant-Colonel T. W., I.M.S., Burma, 24 m.,
December 14, 1912.
Tuke, Major A. W., I.M.S., Bo., 9 m., May 22, 1913.
Urwin, Major J. J., I.M.S., Behar and Orissa, 18 m., May 14,
1913.
Webster, Major C. G., I.M.S., M. Hospitals, 24 m., July 29,
1913.
Wilkinson, Lieutenant.Colonel E.,
Comm., 21 m., February 13, 1913.
Wilson, Captain F. E., I.M.S., India Foreign, 24 m., May 6,
1913.
Windsor, Major F. N., I. M.S., B., 19 m. 29 d., May 9, 1913.
Wood, Lieutenant-Colonel H. S., I. M.S., B., 33 m., February
18, 1913.
List oF INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Blenkinsop, Major F. L., I.M.8., to July 27, 1914.
Bowle-Evans, Lieutenant- Colonel O.-H., I. M. S., to December
31, 1914.
Brown, Captain R., I.S. M.D., to July 8, 1914.
Burke, Captain G. T., I.M.S., to October 26, 1914.
Coullie, Captain A. G., I. M.S., 1 y., to August 3, 1914.
Cruddas, Major H. M., I.M.S., to March 81, 1914.
Davidson, Lieutenant-Colonel J., D.S.O., I.M.S., to July 7,
1914.
Durham, Lieutenant W. R., I.S. M.D., to April 30, 1914.
Fox, Lieutenant E, C. R., LS. M.D.
Gibbs, Major A. A., I. M.S., to April 30, 1914.
Gibson, Captain H. R. B., I. M.S.
Haughton, Captain S., I.M.S., to March 5, 1914.
Horne, Captain J. H., I.M.S.
Inman, Captain H. M., I.M.S., to February 17, 1914.
Jolly, Captain G. G., I. "M. S., to } May 8, 1914.
Kennedy, Captain R. S., I. M. S.
Ker, Lieutenant- Colonel M. A., I. M.S., to March 19, 1914.
Mackenzie, Major H. M., I.M.S., to October 31, 1914.
Mackenzie, Captain L. H. L., I. M.S., to February 2, 1915.
McCowen, Major W. T., I. M.S.
Mehta, Captain S. B., LM. S,
Mills, Captain P. S., LM.S., to September 10, 1914.
Moore, Lieutenant-Colonel C. M., I. M.8., to April 3, 1914.
Munro, Captain'A. C., I.M.S., to January 12, 1915.
Murphy, Major A., I. M.S., to July 18, 1914.
Ozzard, Lieutenant-Colonel F. R., I. M.S., to May 9, 1914.
Prall, Lieutenant-Colonel 8. E., I.M.S.
Seymour, Captain C. G., I. M.S., to December 16, 1914.
Shortt, Captain, H. E., I. M.S., to April 9, 1914.
Smith, Captain F. F. S., I.M.S.
Spitteler, Major A., I.M.S., to February 3, 1915.
Stevenson, Captain B1. M.S.
Watson, Major C. H., LM.S., to May 6, 1914.
Yonnan, Lieutenant-Colonel A. C., I.M.S., to December 13,
1914. A
I.M.S., Punj. Sanitary
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Fic. 1.
April 15, 1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 8, Vol. XVII
Original Communication.
NOTE ON CERTAIN PROTOZOA-LIKE BODIES IN A CASE OF
PROTRACTED FEVER WITH SPLENOMEGALY.
By ALDO CASTELLANI, M.D.
Director, Clinic for Tropical Diseases, Colombo, Ceylon.
AT a meeting of the Ceylon Branch of the British Medical Association,
held in Colombo on May 31, 1918, I read a preliminary note on some peculiar
bodies found in the spleen of a case of splenomegaly with fever of long
standing, terminating fatally. It may perhaps be of interest to give here
a few more details on the case and the bodies found.
The patient, Andreas, was a Sinhalese boy, aged 14. He was admitted
to Dr. Grenier’s Ward, General Hospital, on March 30, 1913, with history
of fever of several years’ duration. According to his relations the boy, when
aged 3, had several attacks of malaria which yielded easily to treatment.
The present fever started (always according to the parents) when the boy
was aged 9, and not having yielded to native and European treatment, the
boy was brought to the General Hospital, Colombo.
The fever, while the patient was in hospital, was generally intermittent
and did not respond to quinine given in massive doses by the mouth and by
intramuscular injections. The boy was transferred, by kind permission of
Dr. Grenier, to the clinic on April 18. The fever continued of the same type,
namely, intermittent, and the maximum temperature varied from 103° to
1059 F. The attacks of fever did not start with shiverings and defervescence
was not accompanied by sweatings. The spleen was much enlarged and
hard, the liver slightly enlarged, neither organ was tender on pressure.
All other organs were normal. No enlargement of the lymphatic glands.
The patient became emaciated towards the end of the disease.
Examination of the Blood.—Three counts were taken; the average was:
the red blood corpuscles were reduced to 220,000, leucocytes 5,200, hemo-
globin (Fleish) 30. A few nucleated red cells were present, basophilia and
chromatophilia both very marked. Serum reactions for Malta fever, typhoid,
paratyphoid, always negative. Laveran's parasites always absent. No
pigment. On two occasions peculiar bodies—to be described later—were
found.
Leucocytic Differential Count.—Polymorphonuclears, 50 per cent.; lym-
phocytes, 40 per cent.; large mononuclears, 7 per cent.; eoemophiles, 3 per
cent.
Urine.—Nothing abnormal was noted, except occasionally a faint trace
of albumin.
Course and Treatment.—Quinine was continued in massive doses (80 gr.
and 40 gr. daily) by the mouth and intramuscularly without any effect. The
general condition of the patient became gradually worse and the boy became
greatly emaciated. Death took place on May 26. Three days before death
the temperature fell to normal.
Post-mortem.—The post-mortem examination was held three hours
after death. Body greatly emaciated, all the organs of normal appearance
except the spleen, which was greatly enlarged, smooth, not very hard, not
slate-coloured; the cut surface was of reddish colour. The examination of
many films revealed absence of any malaria parasites, but a few granules of
a rather light yellowish pigment were present. The presence of these rare
granules of pigment does not make me consider that the case was one of
malaria; the presence of a few granules of pigment is found practically at
the post-mortem of nearly every child in Ceylon, whatever the disease
causing the death; the boy, like most children in Ceylon, had merely
suffered from malaria when very young, as stated by his parents.
DESCRIPTION OF THE BODIES FOUND.
Bodies found in the Blood.—These are extremely rare. They are
roundish or pear-shaped, with a maximum diameter of 7 to 12 microns,
most of them are vacuolated. The protoplasm by Giemsa stains a pale
blue and several large magses of chromatin are present, These bodies, for
114
convenience sake, I will indicate as bodies of Type 1.
One such body is depicted in the coloured plate A.
Bodies found in the Spleen.—Two types are
found; some, of extreme rarity, are identical to
those found in the blood (Type 1); others, the
enormous majority, are different. The latter, which
for convenience sake I will term bodies of Type 2,
are roundish, oval, or crescentic bodies, 24 to 6
microns in maximum diameter, with protoplasm
staining blue, and generally one large roundish mass
of chromatin at one pole or in the middle. In one
instance the faintest appearance of a flagellum
seemed to be present. Occasionally the bodies are
larger, roundish or pear-shaped, and have two
chromatin masses, one at each pole or close to-
gether. The bodies are generally free; only in one
specimen did I find some contained in a leucocyte.
Those which have two chromatin masses have quite
& different appearance from the Leishman's bodies,
being larger and more spherical, and give the impres-
sion of being either parasites preparing for division,
or fusion forms.
Nature of the Bodies found.—The bodies of the
type present in the blood (Type 1) do not seem to
be merely degenerated basophile cells with nuclear
remnants ; in such degenerated erythrocytes the dots
staining red are, in my experience, generally small,
much more scattered, and when stained by Giemsa
they are generally of a peculiar red—lighter and less
purplish than true chromatin. The bodies have
none of the appearance of any kind of leucocytes
or of blood platelets. I was inclined at first to
consider them to be related to Koch's bodies, or
“ Plasma kugceln." These, as well known, are
roundish, oval, or somewhat irregularly shaped cells,
8 to 12 microns in diameter, found by Koch in Africa
in cattle affected with East Coast fever. Koch’s
bodies have recently been put in connection, by
Gonder, with piroplasmata; in fact, this author
believes them to represent a stage in the life-cycle
of Theileria parva. Against the hypothesis that the
bodies of Type 1 are Plasma kugeln would be the
fact, in my case, that they were found in the blood
and were practically absent in the spleen, and the
chromatin masses contained in the bodies were
much larger than those found in typical Koch '' blue
bodies.' As regards the bodies found in the spleen
(or bodies of Type 2), even on superficial examina-
tion they eannot be confused with nucleated baso-
phile red cells nor with varieties of Leishmanias.
There is no doubt, it seems to me, that morpho-
logically, as I stated in my previous papers,* they
closely resemble toxoplasmata, but for the fact that
very rarely, only on one occasion, they were intra-
leucocytic. Further investigation is necessary to see
whether the bodies of Type 1 I found in the blood
are connected with those of Type 2 found in the
spleen, and which I am inclined to believe to be
related to toxoplasmata, in some similar manner as
Koch's Plasma kugeln are connected with theilerias.
I may add that I have shown the bodies found
in the spleen to several medical men and zoologists,
* I suggested the term toxoplasma pyrogenes (May, 1913),
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
among whom Professor Plate, of the University of
Jena; Major James, I. M.8.; Major Harvey, Director
of the Kasauli Research Institute; Dr. Georgina
Sweet, Lecturer on Protozoology at the University of
Melbourne; Major Gaudicheau, and several others.
They all agree that the bodies are parasitic and of
protozoal origin, but greatly differ as regards their
classification. Major Gaudicheau considers them to
be toxoplasmata, and Major James is inclined to
come to the same conclusion. Professor Plate sug-
gests that these bodies may represent a develop-
mental stage of a coccidium; others place the bodies
in a new genus closely allied to the genus Leish-
mania; several colleagues are of opinion that they
are piroplasmata, while others consider them to be
anaplasmata; and the opinion has also been ex-
pressed that it may have been a case of mixed
infection, piroplasma or anaplasma and toxoplasma.
Personally I am still inclined to consider the
bodies found in the spleen to be toxoplasmata,
though I quite admit that the appearance of some
of them give the impression of their being ana-
plasmata or piroplasmata which have infected
basophile red cells.
———d———
Annotation.
Ringworm Yaws (H. C. Clark, Journal of Cutane-
ous Diseases, January, 1914).—The case described
and illustrated is that of a male negro, aged 28,
who had been resident for three years at Panama.
An eruption on his trunk and limbs had been
diagnosed and treated as Tinea circinata. Failing
to respond to treatment, the patient was admitted
to hospital. The lesions had elevated, indurated
borders and increased pigmentation, with central,
dry, yellowish-white exudate, suggesting a mycrotic
growth. Smears showed large numbers of Tre-
ponema pertenuis. The Wassermann test was
positive, as it was in nine out of eleven other cases
of yaws. References are given to other pictures
(Howard Fox, Journ. Cutan. Dis., February, 1908;
Arch. f. Dermat. u. Syph., 1012, exiii, 315; Journ.
Amer. Med. Assoc., May 10, 1918; Castellani and
Chambers’ ** Manual," p. 866).
———— 9 ————
COCOA AND KERNELS.
From being tenth on the list of cocoa-producing
countries in 1903, the Gold Coast attained the lead-
ing position in 1911, and retained this in 1913. The
latest figures available, show an export of 39,200
tons, valued at £2,484,218. It is a triumph of
Imperial tropical agriculture that over one-third of
the world's product of cocoa is produced under the
British flag. The industrious Nigerian natives, to
have exported 184,625 tons of kernels in 1912, must
have cracked 190,237 million single nuts, not far
short of 200,000 millions, and each nut cracked
singly between two stones,
April 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
115
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THE JOURNAL OF
Tropical Medtctne andhHpagiene
APRIL 15, 1914.
SCIENTIFIC ANNOUNCEMENTS IN THE LAY
PRESS.
Tae lay press in Britain has lately taken notice
of ''things medical” to an extent hitherto un-
known. During the past twelve months, especially,
nothing is more noticeable than the seeming im-
portance to the journalist of all that appertains to
medicine. The development of this phase of
journalism may have its good points, but it is a
feature of modern medical life which is new to us
as a profession. The reason for the seemingly
sudden interest taken by the daily newspapers in
this field of work it is difficult to gauge, for it may
be due not to any one cause, but to a number of
circumstances. Without discussing the oft-repeated
legend that, at modern dinner parties and afternoon
teas, the subject of the operations performed upon
those present or their friends is for ever uppermost,
and a wealth of detail given of how much was
removed, what was left, and what it cost, there is
a better side to this publicity which is not regret-
table.
When the history of medicine during the
past quarter of a century comes to be written,
the one outstanding feature of the period will be
shown to be ''the part played by insects in the
spread of disease," and the application of this
knowledge as a practical hygienic factor. Vermin
have been '' detested, shunned by saint and sinner,"'
since the creation of man, but the reason for the
abhorrence has only been proved of late years. That
the mosquito can carry malaria, yellow fever, and
filaria ; and that the bed bug, the louse, the flea, the
fly, the blackbeetle, the tick, the itch insect, and
other vermin are agents in the transmission of a
given disease is now common knowledge. This in-
formation has placed the subject of domestie and
publie hygiene and sanitary endeavour on a sure
foundation, and given a stability to preventive
measures hitherto unattainable. It is one thing to
recommend a measure which it is believed to be
‘good for” the individual or the community, and
quite another thing to advocate and enforce laws
which are known to be essential to the personal and
publie safety and welfare.
Important as the health of the people is—and it
ought to be the first consideration—the fact that
the knowledge obtained has become of high com-
mercial value appeals very directly to business men
and to statesmen. The fact that the health not
only of the Europeans engaged in commercial and
other pursuits in tropical and sub-tropical countries
has a direct bearing upon the financial aspects of
the concern, but that the freedom from disease of
each individual native or coolie labourer on the tea
or rubber plantation is an apparent and an im-
portant factor when drawing up the yearly balance
sheet, has caused business men to listen to the
teaching of science to a degree wholly impossible a
few years ago. Hampered by hesitation whilst yet
empiricism reigned, the doctor had difficulty in
getting business men to listen to his advice as
regards sanitary affairs; but now that cause and
effect can be definitely demonstrated, when the con-
sequence of the neglect of following the principles
laid down can be shown and balanced on opposite
sides of the day-book and ledger, the doctor can
speak with the conviction accruing from actual
knowledge, and his recommendations can no longer
be brushed aside as mere fads or opinions, but as
definite laws founded on facts which admit of no
discussion.
Politically, as well as commercially, the work of
Gorgas and his colleagues on the Panama Canal
brings home to statesmen the meaning and import-
ance of modern knowledge in regard to the spread
of disease and the practical application of the lessons
learned therefrom. That this is the real reason for
the public notice now taken of medical matters
nA H tt, ALUA
STATE TY TV ESET e x
116
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
there is little doubt; and that the spread of this
knowledge is wise is incontestable. There is,
however, a tendency to ‘‘ journalize’’ medical
science in a way which is questionable. Any
announcement, be it a new drug, a newly devised
operation, a suggested hygienic measure, or some
one of the many laboratory experiments now in
vogue, is taken up as a matter of journalism very
often to the detriment of the scientific worker, who
finds his discovery publicly announced whilst yet
it is but in the stage of development or experimenta-
tion. There is a great difference between the
journalism of the newspaper and that which obtains
in medical journals. Newspaper journalism means
publication at once; delay until to-morrow might
mean that other papers might. become acquainted
with the matter, and anticipate the ‘‘ exclusive ”’
information which is to hand. The substance of the
information may perhaps be supervised by a
medical man on the staff; but the hurry to publish
may not admit of this, or the medical man con-
sulted may not be familiar with the expert matter
being dealt with, for no one nowadays is competent
to advise in every branch of medical science. We
know that the ‘‘ newspaper men ” despise medical
journalism; they declare that ‘‘ were we to conduct
our paper on the lines of the medical journal we
would not exist a week." They then proceed to
advise how the doctors ought to conduct their
journals and how to be up to date. It is to be
hoped that this desire for '' copy ” will never per-
meate medical publications. Art is long, and science
cannot be hurried in its findings; the ephemeral
cures and discoveries in the past are many, and the
scrap heaps of blunders cumber the field. If our
newspapers are to announce the efforts of research
in medicine, we would beg of them not to make too
great haste to obtain unfinished ‘‘ exclusive ” copy,
but to consider scientific medicine as a thing apart
and as one requiring special handling.
——9———— ——
MEDICAL OFFICER REQUIRED
for Tin Mines in Bundi—Province Kemaman—
State of Tringganu, Malay Peninsula, North-East
Coast, about four days from Singapore, Straits
Settlements.
There are about 400 natives, mostly Chinese,
and about half a dozen Europeans.
No private practice.
Terms.—Three years’ agreement, passage paid
out, and at completion of agreement paid home.
Salary £400 per annum; free living quarters pro-
vided by the company at their expense.
Servants and food not provided by the company.
The medical officer must be well up in tropical
medicine, and must be able to do his own dis-
pensing.
The vacancy has to be filled at once, and the
selected party must be ready to sail on short notice.
An unmarried man preferred, and for preference not
over 85 years of age at the outside.—Apply to
Editor, JouRNAL oF TROPICAL MEDICINE AND
HYGIENE.
General Article,
THE STORY OF SOME OF OUR COMMON
DRUGS.
I.—CAMPHOR.
THAN camphor no other drug in the pharmacopeia
is obtained with so great difficulty, danger, and blood-
shed. The chief source of our supply is Formosa,
and the history of the island is one continuous fight
to defend the camphor trees from invading forces.
Many nationalities have attempted to subdue them,
including Dutch, Portuguese, Spanish, Chinese, and,
lastly, Japanese, and even the British have in the
course of the last two centuries had cause to repent
approaching Formosan shores.
One little thinks that a vegetable product could be
so troublesome to obtain, and when the fact of the
great annual sacrifice of life—amounting to hundreds
in the course of the year—is brought home to us we
are apt to wonder if camphor really is so precious as
to justify the expenditure ?
In our student days we cannot remember that
our teachers laid great stress on the uses of camphor,
and to our everyday thoughts the value of the drug
is rather of an indefinite quantity. The fact is
that camphor has no specific effect upon any one of
our specific ailments; it is used now as a carminative,
now as a liniment, as a general stimulant to the
cardiac, respiratory, and nerve centres, or as an
insecticide for domestic use in our wardrobes.
Like our daily food, procured from the butcher, the
baker, and the grocer, we give no thought to its source
or the difficulties attending its transference from its
source to our tables; so we get our drug from the
chemist without a thought as to how it reached its
labelled bottle or its hypodermic tube. It may be
truly said of camphor, as it is of the “caller herring,”
" wives and mothers, maist despairin’, call them lives
of men,” for camphor is bloodstained to a degree, and
it is said that every particle of camphor costs its
quota of blood. The present great source of camphor
is Formosa; not so long ago Japan supplied us with a
good deal of our camphor, but the camphor trees of
Southern Japan, imported no doubt at one time from
Formosa, have to a great extent been destroyed,
owing to the regulation, at one time in force, that no
tree should be cut unless another were planted,
having been neglected. It is to Formosa then that
all eyes are turned for our supply of camphor, and
the difficulty of reaching the area of supply entails so
much danger and expense that the natural product is
apt to be neglected for the artificial or synthetic. It
has been known for many a year that the Chinese
run great risks in obtaining the crude camphor, but it
was thought when the Japanese took over the island
from the Chinese after the China-Japanese war, in the
‘nineties of the last century, that the difficulties of
obtaining the drug were over, and that natural
camphor would flood the markets. This, however,
has not proved to be the case, and for the following
reasons: The camphor tree (Cinnamomum camphora),
April 15, 1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 117
Fie, 1,
Fie. 2.
[By permission of the proprietors of ** The Wide World Magazine," from an article by Mr. F. 0. Koch.)
or, as it used to be called, the camphora officinarum,
belongs to the laurel group of plants (nat. ord.
Lauracez). It grows in Formosa, but unfortunately
i& is found only in the mountainous districts of the
interior of the island, occupied by tribes of savages,
who, quite aware of the value of their possession, care-
fully guard the virgin forests in which the camphor
trees thrive. The savages are fierce and are said to
be “addicted to head hunting,” a pastime which has
cost many lives through several centuries, and even
to-day renders attempts to seize the forests by the
Japanese anything but an easy task, for head hunting
is a religion with the native savage. The penetration
of the country occupied by the savages is well nigh
impossible, so long as armed opposition is in force,
for the area is mountainous to a degree, reaching in
height in some places to some 8,000 ft.; the valleys
are covered with tall grass in which various plants
intertwine, forming a dense jungle.
The loss of life of late years has been high, but in
‘as recent a period as 1905 and 1906 no fewer than
600 camphor workers were killed, as well as 150
lumbermen and labourers. Treachery and bush-
fighting combine to form the obtaining of camphor a
dangerous task, and one which can only be carried on
by high pay to those,engaging in it. Camphor is
expensive, and no wonder. The elaborate military
organization of the Japanese in their endeavour to
keep the savages in check and to gradually narrow the
limits of their territory, consists of making a path,
6ft. wide, around the area which passes through
forests and over
the high moun-
tains. Atevery
120 yards there
is a guard-
house, and
every fourth or
fifth guard-
house is con-
structed as a
minor fort,
capable of re-
sisting attack
and protected
by wire en-
tanglements
and entrench-
ments; the
houses are in
telephonic com-
munication
with each other,
and at certain
strategic points
mountain and
field guns have
been set up.
The gradual ad-
vancement of
the line neces-
FiG. 1.—A primitive Formosan camphor still in the heart of the head-hunting country.
Fig. 2,—A camphor distillery near the east coast of Formosa.
118
sitates other sets of stations and forts, bringing forward
guns, &c.; and as since 1903 this line has been
pushed forward on 70 different occasions, the enor-
mity of the work can be, to a certain extent, under-
stood. And all for what ?—To obtain camphor.
The island is nearly as big as Scotland, and one-
half its area is in the possession of the savages, and
to rout them from their stronghold is a work of time.
The Japanese are proceeding upon a systematic plan
of campaign. A guard line has been drawn all along
the mountainous district, with small military outposts
at regular intervals in order to protect the camphor
gatherers, and the danger attending the task may be
understood when it is stated that during 1912 as many
as 187 gatherers were killed and 190 wounded. It is
computed that there are about 1,000,000 camphor
trees in the country, and to meet the demands of the
world’s camphor market as many as 10,000 trees
have to be cut down annually. So that without any
afforestation precautions there are sufficient trees in
Formosa to supply the demand for the next hundred
years. With careful afforestation, such as the
Japanese are sure to introduce, the supply of
camphor will become practically inexhaustible. The
world’s supply at present is met by about 3,000,000 Ib.
of camphor and some 2,000,000 lb. weight of camphor
oil.
Formosa supplies these amounts now, and with
greater facilities for collection the quantities could
be increased if necessary. The value of the camphor
industry to Japan is considerable, but it cannot be got
complete control of until the savages have been either
subdued or exterminated. Thenumber of the savages
is estimated at only 120,000, yet with all their dis-
parity in population Japan had to vote £1,000,000
sterling to conduct operations against them and to
send a large number of troops to the island. It is
not likely we shall see a fall in the price of campbor
until the campaign against the savages, which, it is
estimated, will last about another twelve years, is
terminated.
The method of procedure at present followed in
preparing the camphor is as follows: The trees are
felled, then chopped into chips, and it is by the
distillation of these chips that the crude camphor
is obtained. It is plain, therefore, that as the trees are
cut down, unless replanting is practised, the supply
in time dwindles, although as seen above, this may be
delayed for a long period. Camphor in Formosa is
not obtained as it is in Borneo and Sumatra, where
in the clefts of the Dryobalanops camphora it is
obtained in its concrete form, and therefore the
initial expense of distillation is not necessary, for
Nature has performed the process, and produces the
concrete camphor ready to hand. The process of
distillation adopted by the natives was described in
1869 by Mr. E. C. Taintor, in a trade report of the
district of Tamsai, a town in the northern part of the
island. The method is somewhat as follows: A
wooden trough, dug out from a tree trunk, is lined
with a coating of clay. Into the trough is poured a
quantity of water, the hollow of the trunk is covered
by a board- perforated by a number of holes into
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
which the chips of camphor wood are inserted, the
trough is now placed over a roughly constructed
furnace, and as the heat is generated the steam from
the water in the trough passes through the piece of
camphor wood placed in the holes in the board, and
the steam which issues is impregnated with the
camphor distillate, which is received in inverted
earthenware pots placed for that purpose over the
holes and chips.
In the upper part of the pots the steam condenses
in the form of whitish crystals. The crystals are
subsequently collected and stored in vats to await
exportation. Whilst in store camphor oil exudes,
and is sold for use in many directions in commerce
and in medicine. When the crude camphor is brought
to the towns on the coast or to Japan and elsewhere,
it is refined by sublimation, and collected into glass
jars of peculiar form, to the upper part of which the
sublimate adheres.
The pictures of camphor distilling printed by
permission of the proprietors of the Wide World
Magazine, shows the crude process of distillation in
its primitive form. The vapour when condensed is
deposited as crystals on bamboo screens, whence ij is
gathered and sent to the factories in the towns on
the coast. So numerous are these that there are
said to be no fewer than 8,000 stills in the island.
Of the uses of camphor it is unnecessary here to
dilate. Camphor is one of the few substances which
can pass through the unbroken skin, hence its presence
in so many of the liniments ordinarily prescribed ;
similarly camphor is absorbed through the mucus
membrane, and it reaches the blood unchanged by
either route. Camphor is not known to be a specific
for any ailment, but it acts on almost every organ and
system of the body: the circulation, the respiration,
the digestion and the nervous system are each and all
affected by its use. In febrile states it is much sought
after in the Tropics, for it is a potent diaphoretic
and it lowers the body temperature in pyrexia; its
aphrodisiac action enhances its value in men's
minds, especially in tropieal countries where the
sexual powers for various reasons are wont early to
flag.
As a prophylactic against infectious illnesses, as 4
moth and insect destroyer, in the preservation of furs,
skins, &c., of naturalist specimens, and for a host of
domestic and medicinal purposes, camphor is in use,
and will continue to be used. Yet is the acquisition
of this article of common use bought with more
expenditure of blood than any other known substance ;
and whilst the housewife places her campholine balls
amongst her winter clothing when summer approaches,
or the doctor prescribes tinc. camph. co. in his expec-
torant mixture, or includes camphor in his liniments,
they little think that this vegetable product is only
obtainable at great sacrifice of life, and that the
popular saying that every particle of camphor costs
its weight in blood has some justification.
J. C.
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April 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
119
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Abstracts.
MINERS’ PHTHISIS ON THE RAND.*
By J. L. AYMARD.
THouGH water may be freely used in the form of
a spray from tae moment the drill hits the rock
to the end of a 4-ft. or longer hole, there is a time
when it does not effectually destroy the finest dust.
This period is when the drill is hammering and chip-
ping away at the rough uneven surface of the rock
in order to gain a start for the hole. This process is
termed '' collaring the hole." More frequently than
not no water is used during this process, which
provides abundance of the deadly dust. Another
dufficulty to be faced is the constant breaking down
of water-supplies; these for the most part are avoid-
able and due to too great pressure, corroding of
unprotected pipes, &c. Almost all these difficulties
could be overcome. The continuous forced passage
of dust-laden air through places where men are
working can be of little advantage, if any. The
dust must be rendered harmless as much as possible
at its point of origin. If the fine dust is entirely
produced by blasting, then it should be all carried
out of the mine before the men re-enter to work.
The fact remains that sufficient of the really fine
fatal dust (irrespective of blasting) is produced by
the rock drills to account for the whole of the
silicosis on the Rand. Before the strike the miners,
through their union, endeavoured to limit the
number of machines each man should supervise;
upon the whole they were fairly successful. To-day
there is no limit, and no limit means no control as
regards the keeping down of dust produced by rock
drills. If the mining houses and the Government
(which are practically one) were honestly sincere
in their efforts to stop this curse, they would surely
insist on the efficient control of every drill. This by
no means implies that one miner is necessary for
every drill when one or more are placed together,
but, with few exceptions, one miner only can super-
vise one drill properly when working any distance
up a raise. The production of the finest dust from
a rock drill means, when circulating as it freely
does, the death element to everyone working in the
mine.
Miners’ phthisis was well known not many years
ago in ganister mines near Sheffield. It has now
practically ceased. The Home Government
insisted upon the fine dust produced in ganister
mines in England being kept down by the use of
steam, when miners’ phthisis ceased.
The fact that steam has eradicated miners’
phthisis in the ganister mines points to the fact
that in order to attract the very finest and most
deadly dust the water must be in a much finer state
of division, and this can only be produced by steam.
Steam therefore appears to be not only the only
hope, but by-experience elsewhere the only sensible
* From the Lancet, April 11, 1914.
solution left. Steam could be introduced after the
cessation of drilling through the compressed air
pipes. The question at what depth this would be
impracticable, if at all, remains to be seen. Any-
how, it would only seem common sense to gradually
work down from level to level. Something more
must be done to prevent this awful waste of life,
and that at once.
THE MORTALITY ON THE RAND: SOME OF
ITS CAUSES.t+
By B. G. Brock, L.R.C.P. & S. Edin., D.P.H.
THE diseases chiefly responsible for the abnormal
mortality are pneumonia and tuberculosis; the
following remarks therefore apply more especially
to these. It has been shown that 80 per cent. of
the natives coming to work on these fields suffer
from a constitutional ‘‘ taint '" which renders them
peculiarly susceptible to contract both pneumonia
and tuberculosis in a virulent form.
ALTITUDE.
In the case of natives coming from the coast or
other place of low altitude to the Rand great changes
occur in the blood. The normal number of red
cells per cubic millimetre at sea-level is roughly
5,000,000, while on the Rand, 6,000 ft. above sea-
level, it is from 7,000,000 to 7,500,000. It takes
from fourteen to twenty days after arrival on the
Rand for the blood to reach this standard. During
this time the oxygen-carrying capacity of the blood
must be below normal, and the tissues, receiving
an insufficient supply, must be thereby reduced in
disease-resisting power.
These facts would appear to supply the ex-
planation of the oft-repeated observation that
“boys” are much more liable to contract pneu-
monia and tubercle during the first two or three
weeks of their stay on the Rand than later. Some
hold that the greatest number of cases of sickness
occurs in the first twenty-four hours, but the fact
that the mass of native workers come off a long
and tiresome journey, without the opportunity of
getting any rest, and are drafted at once to their
various destinations, along the '' Reef," suggests
that many of these '' first twenty-four hour ’’ cases
are probably due to simple exhaustion. It has
further been found that there is a direct propor-
tional relation between the amount of hemoglobin
and the amount of immune substances in the blood.
It seems therefore probable that if special care were
taken of the '' boys °’ during the transitional period
it might materially aid in reducing the sickness-rate
and increase the chances of escaping pneumonic and
tuberculous infection. What amount of injury
results to the blood, if any, from the men spending
half the day at an altitude of 6,000 ft. and the
other half at from 1,000 to 3,000 ft. there are no
data to indicate.
1 From the Lancet, April 11, 1914.
120
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
CONDITIONS OF LIVING on A MINE.
The standard native ration is: 20 oz. mealie meal,
8 oz. wheat bread, and 4 oz. beans (dried) per day;
91b. ‘“ meat,” 220z. pea nuts, 16 oz. treacle, and
40 oz. vegetables per week. This ration is added to
in some of the mines. There seems to be a good deal
of difference of opinion as to the suitability of this
ration. It is a ration built entirely on its calorie
value, it is not a toothsome diet, there is a con-
siderable waste in unconsumed food, and there is
& considerable amount that is not digested or
assimilated, while the manner of cooking may
influence the value of a diet. The compilation of
an efficient diet is undoubtedly difficult and can
only be attained by direct experiment. A ''boy's"'
clothing usually consists of a blanket—often a mere
rag—a pair of trousers, and a shirt. His bed—
plain wooden boards without bedding. The '' com-
pound ’’ room in which he eats and sleeps is a
large draughty barn, under-heated and over-
ventilated, always dusty, often dirty and verminous.
Comfort there cannot be, and under the conditions
warmth and restful sleep are well-nigh impossible.
Add to this that the native is extremely sensitive
to cold, and that in winter there may be as much
as 209 F. between the wet and dry bulb ther-
mometers, and the least imaginative will realize
that the most robust constitution is liable to break
down under such treatment. How are those who
are constitutionally susceptible to pneumonia and
tuberculosis to pass through such an ordeal
unscathed? They cannot and do not. These are
the places where, and the conditions under which,
pneumonia and tuberculosis spread, flourish, and
destroy.
Is it lack of knowledge, simple thoughtlessness
and lack of sympathy, or downright callousness that
permits such conditions to exist? Probably some
of each. The '' great expense ” has been a reason
against any change. But when the problem is
examined carefully one cannot help thinking that
all the necessary changes would not only not raise
the '' working costs '' of a mine, but would prove to
be an investment that would return a handsome
dividend.
WonkING CONDITIONS.
Little need be said on these. Dust, carbonic
oxide, and nitrous fumes should, of course, be
reduced to a minimum by improved ventilation and
increased care; but no matter how stringent regu-
lations may be, in the nature of things they will
still exist in all the mines to some extent, and the
two latter probably continue to do some harm, the
carbonic oxide by putting some hemoglobin ‘ out
of action," and the fumes by causing some bron-
chitis, thereby lowering the resisting power against
bacterial attacks locally and generally.
The dust that might remain in a well-ventilated
mine would be of little account. Oliver, in his
'* Diseases of Occupations,” p. 298, gives an excel-
lent illustration of this. He quotes from a report
by Dr. Brembridge on the Kolar gold mines to the
following effect : —
“* On the Kolar gold mines in India there are 40,000
coolies employed; the rock is hard. Yet there is
no evidence of miners’ phthisis, except in men who
came from the Transvaal. Although no precautions
are taken in the Kolar mines to throw water on the
surface to diminish the dust after the use of
explosives, and the men work hard, the miners,
native and white men, keep good health. There is
plenty of dust in the Kolar mines; it is hard quartz
rock that is blasted, and without such precautions
as the spraying of water. A large percentage of
miners die from pneumonia, due not so much to
the dust as to the fact that the men, after working
hard for eight hours, are obliged to climb ladders
to a height of 2,000 ft. in a state of fatigue and
when perspiring, and thus become chilled. The
proof that this has had much to do with the
prevalence of pneumonia has been demonstrated by
the fact that since a skip, whereby the coolies can
ride to the surface, has been introduced into one of
the mines from which the largest number of cases
of pneumonia came, the number of cases of acute
lung disease has considerably diminished."'
Here, too, this cause of pneumonia to some extent
exists, but here the '' boys °’ come from the warm
moist mine into an exceedingly dry and cold air—
indeed, it may be compared to putting them into a
freezing chamber.
The ‘‘rates’’ for Germiston district help to
bring out the importance of the above remarks.
In the following table the incidence rate for pneu-
monia and the death-rate for phthisis (tuberculosis
&nd miners' phthisis) for three years are given for
three races then working on the mines. Under-
ground they all worked under the same conditions
and were exposed to the same dangers, save that the
native was less well protected against chills on
coming to the surface than were the other two races.
Whites
JHE
JHE
Pneumonia inci- 2:302:54/3:4
dence per 1,000
Phthisis deaths aa :38| 4°94) 3:67, 3:63 [1:58]0-87]1:71
per 1,000 (tuber- |
culosis and
miner's phthisis), |
* The importation of natives from the Tropics caused the
very great increase in the rate for this year. For all the three
years a good many cases of tuberculosis in natives came under
this head.
These figures show that the natives suffered more
than the other races. In the case of whites and
natives the figures for '' phthisis’’ are very much
below what actually existed on account of the
whites going and the natives being sent out of the
district when they became unfit for mine work.
Nevertheless, the Chinese, although the full rates
are recorded, show lower figures than black or
white. The Chinese occupied the same compounds
April 15, 1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
121
as the natives occupy now. The Chinese had better
food and it was well cooked, while their sleeping
quarters were conspicuous for their apparent clean-
liness and the great care taken to procure personal
comfort, good warm bedding and bed clothes, and
plenty of these. They did not consume their food
in their sleeping quarters, and were not in the habit
of indulging to excess in intoxicating drinks as the
other races were. The figures speak eloquently in
favour of sufficient food, sufficient warmth, and
sufficient rest. There are others that might be con-
sidered, but those dealt with seem to me to be the
outstanding causes which lead up to a death-rate
unparalleled in any civilized country, and the
bringing clearly into view the framework on which
they rest discloses the means by which they may be
removed or modified and this death-rate brought
more into line with those obtaining for similar
industries in other parts of the world.
CONCLUSIONS.
(1) The '' Reef” population is, as a whole,
abnormally susceptible to pneumonia and to tuber-
culosis, and constitutionally badly prepared to with-
stand the attacks.
(2) The change from a low to a high altitude
disturbs the physiological equilibrium of the blood
of new arrivals on the Rand, and renders them
extremely susceptible to disease until this equi-
librium is re-established.
(3) Putting new arrivals to heavy work before
this physiological equilibrium is established (about
three weeks) increases the sick lists and raises the
death-rate.
(4) The great dryness of the air in winter causes
much pneumonia, especially in those coming '* off
shift," unless effective protective measures are
provided and enforced.
(5) The natives are underclad and do not receive
suffieient rest or sleep, and their food requires in-
vestigation as to its physiological efficiency and
proper cooking.
(6) The causes which are responsible for the
abnormal death-rate are capable of removal in large
measure, and the chief supports of these are—false
economy and callous inefficient administration.
PNEUMONIA ON THE RAND.*
By G. D. MAYNARD.
Memoir I Or THE SOUTH AFRICAN INSTITUTE FOR
Mepicat RESEARCH. +
'" PNEUMONIA," as used throughout this paper,
means the disease clinically known as lobar pneu-
monia when bacteriologically associated with the
diplococeus of Fraenkel.
* From the Medical Journal of South Africa.
+ ‘An Inquiry into the Etiology, Manifestations, and Pre-
vention of Pneumonia amongst Natives on the Rand, Recruited
from Tropical Areas.” By G. D. Maynard, F.R.C.S.E., Statis-
tician and Clinician to the South African Institute for Medical
Research.—From the returns of the Witwatersrand Native
Labour Association and its hospital records and reports.
CONCLUSIONS ARRIVED AT.
(1) The attack-rate and death-rate from pneu-
monia amongst ‘‘ tropical natives °’ living on the
Rand are influenced by the country of origin from
which the natives are recruited.
(2) The case mortality is apparently independent
of the country of origin. :
(3) The highest pneumonia attack-rates are found
among the gangs which—judged by the number of
‘detentions " and ''rejects "—have the lowest
physique.
(4) The greatest incidence of pneumonia occurs
immediately on the arrival of the natives on the
Rand, and decreases as the period of their residence
increases.
(5) The case mortality so far as can be judged
from a six-months' record is apparently uninfluenced
by the length of residence on the Rand.
(6) Pneumonia is most prevalent during the cold
season.
(7) The clinical signs and symptoms of pneu-
monia among ''tropical natives '" do not differ
essentially from those among Europeans.
(8) The length of the febrile period of the disease
is probably somewhat shorter among these natives
than among Europeans in the Northern Hemi-
sphere.
(9) While the methods of the termination of the
pyrexial stage are similar to those observed else-
where, the percentage of cases which terminate by
'' erisis'"" is, among these natives, lower than the
percentages recorded for Europeans in other
countries.
(10) There does not appear to be any essential
difference in the clinical characters of the attack,
nor in the length of the convalescence, whether the
fever terminate by ''crisis"" or by ''lysis."'
(11) “ Second attacks '" of pneumonia are most
common immediately after the termination of the
first attack, and become progressively more rare
as the period after the first increases.
(12) The rate of ''second attacks'' among the
population of the previously attacked is higher than
the primary attack-rate among the whole population.
(18) The case mortality of ‘‘ second attacks ” is
probably lower than that of '' first attacks.’’
(14) Pneumococcal meningitis as a complication
of pneumonia appears to be considerably more
common among “ tropical natives’’ than among
Europeans.
(15) Amongst the natives it is more common to
find two or more lobes involved in the pneumonic
process than amongst Europeans.
(16) The stage of hepatization of the lung, as
observed at the post-mortem, bears no constant
relation to the length of the illness before death.
(17) The most common day for death to take
place in pneumonia is the fourth day of illness.
(18) There is no evidence from the data examined
that pneumonia spreads from case to case.
(19) Or that this disease is infectious.
(20) Prophylactic inoculation with a pneumo-
coccal vaccine, when employed immediately on the
arrival of these natives on the Rand, appears to
122
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
reduce the incidence of pneumonia for a limited
period.
(21) The protective value is greatest immediately
or shortly after inoculation, and progressively
diminishes.
(22) Its effect does not appear to last for more
than about four months.
(23) In these records there is no evidence that
prophylactie inoculation has any inffuence on the
case mortality, except possibly for a very short time
after the injection.
(24) The experimental treatment of cases with
pneumococcal vaccine does not favourably influence
the mortality from the disease.
(25) There is some evidence to suggest that treat-
ment with pneumococcal vaccine of cases which had
recently received a prophylactic injection of a
similar vaccine was harmful.
SvsrTEM or RECRUITING.
On their arrival in Johannesburg ‘‘ tropical
natives '" are sent to the W.N.L.A. Association's
compound, where they remain under close medical
supervision for a further period of at least three
weeks. At the end of this time they are again
medieally examined, and if deemed fit for work are
allotted to the mines, but if found to be unfit they
are either returned to their homes or detained for a
further period.
A native not allotted to a mine at the end of
three weeks with the gang to which he belongs is
called a ‘‘detention’’; if he be sent home a
“reject.” It is considered inadvisable to bring
natives from tropical districts on to the Rand during
the winter, and, therefore, no recruiting is carried
on in these areas during the four months April to
July. The summary given below shows the numbers
recruited, with the repatriations, detentions, and
deaths in the Johannesburg compound. The figures
are obtained from the total number of natives
arriving in the seasons 1910 to 1911, and 1911 to
1912, and one-half of the recruiting season 1912 to
1913, that is, from August to December 31, 1912.
SUMMARY.
(Rates per 1,000 in italics.)
Number of natives recruited, 45,291; detention,
8,817 (194:7); repatriation, 1,286 (28:4); deaths in
compound, 1,449 (32-0).
The rates vary considerably with the areas from
which these natives are recruited; and there is a
high correlation between the number of '' deten-
tions ” and the number of deaths.
The head recruiter reports that in the districts
where the natives with the highest death-rates are
recruited the natives are exceedingly lazy, do very
little eultivation, and are often, therefore, in a half-
starved condition. The differences in the general
death-rates are largely due to variations in the
prevalence of pneumonia, and from 44 to 82 per
cent. of the total death-rate is due to the mortality
from this disease. Excluding the group ‘‘ diarrhceal
diseases,’’ cerebro-spinal meningitis is second to
pneumonia in importance as a cause of death during
the period of residence of these natives in the
W.N.L.A. compound in Johannesburg.
Figures relating to tropical natives recruited by
W.N.L.A. during the period August, 1910, to
December, 1912, inclusive :—
Number of recruits, 45,291; total deaths, 1,449;
death-rate per thousand, 32°0. Pneumonia: Cases,
1,809; morbidity rate per thousand, 39:9; deaths,
709; death-rate per thousand, 15:7; per cent. of all
deaths, 49; case mortality per cent., 39:2. Other
deaths, 740; death-rate per thousand, 16:3. Cerebro-
spinal meningitis: Cases, 356; morbidity rate
per thousand, 7:9; deaths, 242; death-rate per
thousand, 5:3; ease mortality per cent., 68:0; death-
rate per thousand minus pneumonia and cerebro-
spinal meningitis, 11:0.
The treatment of the natives in regard to methods
of recruiting, housing, feeding, &c., is practically
uniform, except that the varying distance of their
homes from the coast necessitates in some cases a
lengthy march to the port of embarkation. That
this is not a critical factor, however, is shown by
the fact that the areas which yield the worst death-
rates are not those farthest from the coast. Speak-
ing generally, it appears that the natives from the
inland distriets are, when residing on the Rand,
less prone to the disease than those from the coastal
areas. In the United States, when allowances are
made for the fact that pneumonia is more prevalent
in urban than in rural districts, we find that persons
residing in the coastal districts are less subject to
this disease than those living inland. In regard to
these natives we do not know whether in their homes
a similar condition obtains, but if further inves-
tigation were to show that this be so, a possible
explanation of the reversal of this condition on their
arrival on the Rand would suggest itself; namely,
that there had been a less rigorous selection amongst
the natives from the coastal areas.
Among other possible causes of these differences
are :—-
(1) That a general want of physique is correlated
with a predisposition to all diseases.
(2) That certain tribes are particularly susceptible
to pneumococcal infection, or
(8) That some factor favouring the spread of
infection may be more marked in some groups than
in others, but there is no evidence that a factor of
infection has any influence in causing the variation
in the death-rates.
The natives from the distriets which show the
highest death-rates from pneumonia are, in respect
to cerebro-spinal meningitis, among the best. The
fact, however, that the numbers in these groups are
smaller, must not be overlooked. Excluding these
two diseases, the territorial distribution of the
death-rate for all medical diseases gives a picture
very similar to that of pneumonia. It is possible,
then, that the distribution of cerebro-spinal men-
ingitis may be due to some peculiarity in method of
spread, or in a special constitutional liability, and
that general want of physique may still explain the
variation in the death-rates from other diseases.
We have not, however, at the present time,
THRE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, APRIL
A --Body found in the blood
[ 4 e S) $j
e $
B— bodies found in the spleen.
To illustrate paper by Arno Casteran MD.,
“ Note on Certain Protozoa-like Bodies in a Case of Protracted Fever with Splenomegaly."
15,
19114
April 15, 19314. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
123
———————————————M— MM ÉHHÉHÉHM M LL nnn
sufficient evidence to enable any suggestions to be
formulated except in a tentative manner; that a
marked and persistent difference in the tribal rates
does oceur, is, nevertheless, established.
Natives whose physical condition is poor are
detained in the W.N.L.A. compound beyond the
average twenty-one day period, and, as before ex-
plained, are termed ‘‘ detentions.” If their condition
is so bad that they are not likely to be fit for allot-
ment to the mines within a reasonable time, they are
returned to their homes, and are termed “‘ rejects.”
The physical condition of these natives also varies
from season to season, and at different times during
the same season; the number of '' detentions °’ and
“rejects ’’ from any group reflects, therefore, to a
certain extent the condition of the whole group.
By correlating either the general death-rate, or the
pneumonia death-rate, with the number of '' deten-
tions '' or ‘‘ rejects,’’ the author finds that in gangs
where physically inferior ''boys " preponderate,
both the total and the pneumonia death-rates are
higher than where the reverse condition exists.
The figures are of interest because they show, that
the physieally inferior gangs have both a higher
general death-rate and a higher pneumonia death-
rate than those arriving in better condition; and the
results, even interpreted on a racial basis, show that
racial susceptibility is associated with a degree of
physical unfitness.
The prevalence of pneumonia—taking the death-
rate as a measure of the prevalence—is greatest
amongst natives during their first month of
residenee on the Rand, and that thereafter it pro-
gressively diminishes. With our present figures we
ean consider this problem as it relates to new arrivals
during their first few weeks of residence in
Johannesburg. With the exception of loss by
death, the population in the W.N.L.A. compound
is stationary for all ‘‘ tropical natives” for ap-
proximately three weeks. Dividing the first
nineteen days into five-day periods, the number
attacked in each period out of a total of 45,291
natives, is as follows :—
TABLE I.
Day after Number Attack-rate
arrival attacked per cent.
0— 4 254. 526 Six 1:16
5— 9 E 389 0:86
10—14 Ax 814 0:69
15—19 PH 275 0°61
The period of greatest risk is that immediately
following arrival, the greatest number of cases being
admitted to hospital on the first day. Thus, the
liability commences suddenly and immediately after
arrival, and decreases subsequently from day to day.
It will be observed that the start is within the first
twenty-four hours. The actual number of cases
recorded is greater in the second twenty-four-hour
period, but this is due to the fact that the first
period is not really one of twenty-four hours,
because the first day as determined from the com-
pound books is often a period of only twelve hours,
or even less. The marked reduction in attack-rate
with the length of residence is a fact which must
not be overlooked when we consider the evidence
as to the probability of case to case infection. That
this fall continues after the natives are removed to
the mines is also shown by other figures at our dis-
posal, In the experiment conducted with 8,123
natives, which is subsequently referred to as the
“8,000 experiment," the attack-rate month by
month was recorded, and is here given :—
TABLE II.
Month after Number Attack-rate
arrival attacked per cent.
0 312 vs 9:89
1 208 "us 2:58
2 155 aug 2-00
3 139 or 1:88
4 125 ths 1:68
5 89 1:22
This table also shows that amongst natives re-
cruited in ‘‘ tropical areas °” the maximum attack-
rate occurs immediately on their arrival on the
Rand, and gradually falls as the period of residence
increases. The influence of season in producing
variations in the attack-rate does not in any way
enter into the problem in regard to the figures given
in Table I; and it is probably not of importance in
Table II, because the natives composing the popu-
lation dealt with in this table were recruited over a
period from August to the middle of November,
that is, from the coldest time during which recruit-
ing from these districts is undertaken, up to and
well into the warm season.
The influence of season and climate must now be
considered in so far as the available data permit.
Taken in monthly groups, there is a high correlation
between cases and deaths; or in other words, the
death-rate will serve as a close guide to the attack-
rate,
In the season 1911 to 1912 the rate was highest
in the colder months, and fell very noticeably in
December and January, thus agreeing with an
opinion quite commonly held that pneumonia is
more prevalent during the colder months. In the
season 1910 to 1911 the rate was highest in March
and April, but no marked variations occurred from
August to February. In the season 1912 to 1918
the maximum rates occurred during the warm
weather, a reversal of the condition so marked in
the season of 1911 to 1912. If we assume that
other predisposing factors remained approximately
the same, then from this evidence it would be diffi-
cult to state that season had any constant influence
on the prevalence of the disease, although the ten-
dency of the figures as a whole suggests that the
prevalence decreases in the warmer months.
We have no right, except hypothetically for the
purpose of a first approximation, to assume that
other factors have remained unaltered. For
instance, owing to a dry season in tropical Africa
in 1911 to 1912, there was a consequent shortage
of crops, and it is possible that this factor may have
had an influence on the natives arriving in the
season of 1912 to 1913; again, a large proportion of
124
natives who arrived between November, 1911, and
November, 1912, were receiving prophylactic
inoculations of pneumococcal vaccine.
The monthly fluctuations in the native distri-
butions are not so marked as in Europe, and natives
from British territory show a greater seasonal varia-
tion than those from Portuguese territory. Never-
theless, all show lower rates during the warmer
months. No new arrivals are being allotted to the
mines from May to nearly the end of August, and
this factor in itself will, as we have seen, tend to
reduce the death-rate observed in these months.
Monthly fluctuations among ‘‘ tropical natives "'
are, however, much more marked; this is partly
accounted for by the fact that the rates are
calculated from smaller numbers.
Summing up the whole of this evidence, we may
conclude that pneumonia tends to be definitely
more prevalent during the colder months. Fluc-
tuations due to other causes, more especially
amongst the '' tropical natives,” may, however, to
a large extent mask the effect of season when small
groups are dealt with. Further, the effects of
season are probably dependent on the meteorological
conditions with which they are associated; for in-
stance, the temperature or rainfall of the May of
one year might correspond more closely to that of
the June than the May of a preceding or following
year. The agreement, therefore, between the rates
and changes in meteorological conditions might be
greater than that observed in the monthly charts.
Alterations of weather conditions are, no doubt,
highly correlated with season; these facts, never-
theless, must be borne in mind when attempting to
interpret the meaning of the foregoing data. Cold
or a fall in temperature is the constant factor of
the winter season in all parts of the world. In the
interior of South Africa the winter season is the dry
and dusty season, but in Northern Europe it is the
damp season.
A comparison of attack-rate and case mortality
shows no close relationship; an increase in the
attack-rate does not seem to be associated with an
increase of the case mortality.
CLINICAL AND PATHOLOGICAL ASPECTS OF PNEUMONIA.
The question of second attacks is of particular
interest. All cases in which the temperature rises
after it has been normal for twenty-four hours or
more, when the rise is accompanied by a reappear-
ance of the signs and symptoms of pneumonia,
are '' second attacks,” or recrudescences of the first
attack,
TABLE III.
Rates PER THOUSAND
Month after
arrival in Average
which first Months after termination of first attack monthly
attack rate
occurred 1 2 8 4 5 6
lst 71 13 43 24 43 38 40
2nd 7 38 33 9 0 — 18
8rd 54 24 38 0 — — 30
4th 40 0 0 — -— — 14
5th 26 27 -- — — -- 21
6th 25 — — — — — 25
41 22 33 13 22 38 28°7
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. : [April 15, 1914.
It wil be noticed that there is apparently a
tendency for the rates to fall as the length of resi-
dence on the Rand increases, a phenomenon also
observed for first attacks. Further, although the
rates are irregular, owing to their having been cal-
culated from small numbers, there seems to be a
tendency for second attacks to become less common
as the interval after the first increases.
Out of 1,129 natives who recovered from pneu-
monia in the W.N.L.A. Compound Hospital, eighty
had a ‘‘ second attack ” within thirty days after the
termination of the pyrexial period of the first attack;
the distribution in days after first attack is shown
below :—
TABLE IV.
Day after termination of Number of cases
fever of first attack of ‘* second attacks”
0 1
1 4
2 12
3 4 s0
4 5
5 Vi 339 i
6—10 XA ws 47 17
11—15 E a om 14
16—20 ive vi iid 12
21—30 oak aes sae T
Total ... cad 80
The population throughout this period remained
practically constant, and we therefore find a rate ot
seventy per thousand for second attacks occurring
within thirty days of the end of the first attack, as
against a rate of forty per thousand for primary
pneumonias originating within about a month from
the date of arrival of the natives in Johannesburg.
These figures, showing that amongst ‘‘ tropical
natives’’ in the W.N.L.A. Compound “ second
attacks '’ amongst the attacked are more frequent
than “first attacks ’’ among the whole population,
may indicate that one attack predisposes to a second;
or that we are dealing with a particularly susceptible
population selected as such by the first attacks. The
question is one of considerable difficulty, and in con-
sidering it one must not lose sight of the fact that
** second attacks ’’ appear to become less common as
the period after the first increases; if this be a rule
then it would lend support to the suggestion that
the first attack actually predisposes to the second.
The mechanism of recovery would, however, be
difficult to understand on the basis of modern
theories of immunity, unless we may accept the
suggestion that real differences in strains of pneumo-
cocci do occur, and are of pathological significance.
Out of sixty cases of second attacks occurring
over a period of six months in the group of 8,123
“ boys ” (the ** 8,000 experiment ’’) there were thir-
teen deaths, giving a case mortality of 21°7 per cent.,
as against a case mortality of 82:1 per cent. for first
attacks in this group. Out of eighty second attacks
occurring in the W.N.L.A. Compound Hospital
twenty-six died, giving a case mortality of 32:5 per
cent., as against 89:2 per cent. for first attacks
occurring in the same group. Thus in both groups
we see that there is an apparent reduction in the
April 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
125
case mortality from second attacks; at any rate,
when they occur within a comparatively short period
after the first. It must be remembered that the
numbers are small and the probable errors, there-
fore, large.
BERIBERI IN PORTUGUESE INDIA.*
By Dr. pn: MELLO.
First EPIDEMIC oF BERIBERI IN 1912.
In February, 1912, intimation was received of the
outbreak of an epidemic of beriberi amongst the
soldiers of the African Company and at the same
time several soldiers who were attacked entered the
military hospital. The doctors declared that beri-
beri was an imported disease unknown before 1908.
OBSERVATIONS IN THE MILITARY HOSPITAL OF
Nova Goa.
(1) Beriberi, Confirmed, Mixed Form, Subacute
in Type.—O., a soldier of the Province of
Mozambique; strong constitution; age about 20-25
years. The gait was not characteristic; painful
cedema of the legs; general cedema, myalgia of the
calves; neuritis of the tibial nerve trunks. Altera-
tion in the tactile and thermic sensation; enfeebled
reaction of the muscles of the leg to electrical
stimulation; abolition of knee-jerk and plantar
reflexes. Painful spot of Gayet; epigastric bar.
Emybrocardia or Maleompson’s sign incomplete;
carotid pulse from 120-185 pulsations a minute.
Other organs were without any apparent abnor-
mality. Urine contained neither albumin nor
casts.
(2) Early Beriberi.—J., a soldier from Mozam-
bique, aged between 25 and 80; becomes rapidly
tired after marching; dyspnoea after any exertion;
tachycardia; wasting of the muscles of the leg;
reflexes, sluggish; diminished sensation; pain on
pressure over the course of nerve trunks; no edema ;
organs normal.
(3) Early Beriberi.—S., cdema most marked
in the region of the internal malleolus; tibial
neuritis; weakness of the muscles of the leg.
But apart from these patients sent to the hospital
with the diagnosis of beriberi there were several
African soldiers with other diseases. These were
also examined because some of them had been com-
plaining for some time of pain in their legs which
local applications often succeeded in relieving. One
more beriberi patient was discovered in this manner.
(4) Early Beriberi.—An African soldier suffering
from an inguinal hernia, tibial neuritis, painful
cedema in the legs, weakness, tachycardia, &c.
Diagnosis forced itself upon one at a glance; we
eould not, however, rest there. Sometime before,
beriberi had appeared in a disguised form amongst
the garrison of the gunboat Rio Sado, and sailors
serving in this Province had been invalided home
to Portugal. As the natives captured by our
troops during the revolt had been shut up in the
a Abstract of paper rend at the All-India Sanitary Congress,
4.
gunboat the patients in the gaol infirmaries were
examined and three indigenous beriberi cases found.
(5) Confirmed Beriberi.—N. G. G., a native of
the province of Satary, Portuguese India; of feeble
constitution, aged between 30 and 40; prisoner
in the gunboat Rio Sado. Trembling gait, very
characteristic; has had considerable cedema, com-
mencing in the neighbourhood of the malleoli; this
has, however, become very much less; reabsorption
of this cedema gives to the skin a dry, hard consis-
tency like a plank of wood. Reflexes and sensation
almost normal, but they were at the beginning very
feeble. Even at present the muscles of the œde-
matous region react very feebly to electricity; in
the popliteal space the tendons present an abnormal
degree of hardness, hindering the free movements
of the knee. No albumin in the urine.
(6) Confirmed Beriberi.—8S. F., native prisoner;
walks as if in water up to his knee, painful malleolar
edema. A curious fact is that the edema began
near the left knee. There is no albumin.
(7) Confirmed Beriberi.—B. C., a native prisoner.
Trembling gait; painful spots of Gayet; beriberi bar,
sensation and reflexes diminished.
As observed in Goa, the disease has always begun
with pain; this pain is first a simple sensation of
fatigue following a march; it soon becomes mus-
cular weakness certainly depending on vasomotor
disturbances. Later, without being able to definitely
define the period, the painful symptoms change
their character, becoming true pains, at the same
time the muscles develop a certain degree of flabbi-
ness; they tire very quickly under electrical stimu-
lation and fail to respond altogether after three or
four rapid stimulations. After walking it is no
longer weakness, but painful cramps that supervene.
Pressure over the course of the tibial nerves gives
rise to pain, often most acute. It is noteworthy
that these latter painful phenomena are often
localized in the region of the knee-joint, giving rise
at first to a suspicion that the case may be rheu-
matism and which only subsequent history has con-
firmed as beriberi. (Edema is the second sign in
the chronological order and follows the muscular
weakness. One is, however, unable to state what
degree of cause and effect or coincidence there is
between the cedema and the cramps or neuritis.
This edema has special characteristics; it begins
behind the internal malleolus, but it may appear in
other situations, for instance, the knee; it is painful
and to the touch the skin feels like a board, this
hardness becomes very noticeable after the absorp-
tion of the cedema.
At this stage we have not observed any other
organie change, not even gastro-intestinal troubles,
which are declared to be a precursory symptom of
beriberi.
It is quite true that some natives suffering from
beriberi have been attacked with amebic dysentery,
which had, however, nothing to do with their actual
disease. Remarkable above all is the absence of
albumin from the urine, a sign which continued
negative even in a serious case of cedematous infil-
tration which we had under observation.
126
It is very important to diagnose the disease at
this stage because beriberi in its early stages is
readily curable by means of simple hygienic
measures and symptomatic treatment. Later all
the symptoms described in books supervene.
Our observations having been few in number
we are unable to compile a more complete list of
symptoms. However, all the cases of beriberi in
Goa have been of the mixed type and have pre-
sented the following symptoms: Anesthesia involv-
ing, in a serious case, the thighs and the lumbar
region. The patient does not feel the prick of a
needle in the anesthetic areas. Thermic sensation
is less affected, although between the two conditions
of abolition and slight diminution of sensation, every
possible intermediate condition is met with. There
is a zone of anesthesia and hyperesthesia; reflexes
are diminished or abolished. The following are
some of the painful symptoms observed in beriberi
patients that have passed the first stage of the
disease: Myalgia, spontaneous or easily provoked;
a painful bar in the epigastric region, complete or
incomplete; the painful spot of Gayet between the
second and third dorsal vertebre and at the point
of origin of the eleventh dorsals; it may be noted
that the second point of Gayet is situated between
the ninth and eleventh dorsals.
Other organs are usually normal. In advanced
stages dyspnea (dyspnea after exertion is also
observed in the earlier stages) and cardiac lesions,
embryocardia on Maleompson’s sign, congestion of,
and sometimes pain in, the liver supervene.
The post-mortem examination of M. P. M.,
originally in the gunboat Rio Sado, showed:
Hard cedema in the legs, on the right leg a very
tight cord, possibly applied to relieve pain; conges-
tion of the lungs, congestion being more marked in
the left lung; fatty degeneration of the heart, large
ante-mortem clot; hemorrhagic effusion in the peri-
cardial cavity, the liver granular and showing fatty
degeneration. The lesions found in the heart ex-
plain the sudden death, and that beriberi was the
disease from which the deceased had suffered.
We can then declare, without any fear of contra-
diction, that the disease which in February, 1912,
prevailed amongst the African soldiers and the
native prisoners was indeed beriberi.
BERIBERI AT GOA BEFORE THE EPIDEMIC OF 1912.
The first case of beriberi was seen in 1908. Some
sailors in the gunboat Rio Sado were attacked by it
and sent back to their country; one or two died
during the voyage. In 1910 beriberi was hardly
spoken of, but a short time after evident signs of
it were again seen in the Naval Hospital.
Our colleague, Sousa Machado, on duty in the
gunboat, has often had an opportunity of studying
beriberi, and one of us has several times been on a
medical board to examine patients with a view to
sending them back to Portugal. A student at our
Medical School submitted in his thesis a typical
description of beriberi of the mixed variety, and his
very suggestive recommendations as to the accom-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
modation of sailors in the barracks of the town have
been published in the second and third numbers of
the Boletim Geral de Medecina e Pharmacia, p. 181
(‘‘ Contribucüo as estudo da etiologia do béribéri "'
por J. C., Provença Bragança). All the doctors who
examined the sick sailors have been in agreement
with the diagnosis, and we can affirm: The sailors
of the gunboat ‘‘ Rio Sado "' were in 1910 and 1911
infected with beriberi.
On May 11, 1912, a prisoner, B. C., aged 56, was
admitted to hospital with a history of malarial fever
and suppuration of the external ear. Otherwise has
enjoyed very good health; the patient made some
long marches without having experienced any fatigue
or swelling of the feet; not alcoholic. His actual
illness started in the gunboat where he was im-
prisoned and where his work was washing down the
decks.
His feet are swollen and the swelling extends up
to the legs and thighs, making walking difficult on
account of the pain and fatigue that he experiences
at present. In addition he complains of a dry cough
and shortness of breath. He has cedema, tibial
neuritis, and atrophy of the left leg; cutaneous
sensation abolished in the lower third of the leg
and diminished in the upper two thirds; absence ot
the plantar reflex, abolition of sensation to pain as
high as the lumbar region; slight tricuspid murmur,
rales scattered over the lungs; enlargement of the
spleen. The patient recovered under treatment.
The boat was placed under medical observation
in order that prisoners with signs of beriberi could
be placed under treatment at an early stage of the
disease. As a local defensive sanitary measure the
order was issued that no prisoner would be allowed
to proceed to his destination without a previous
medical examination.
A FnEsnH EPIDEMIC IN 1918, OCCURRING ONLY AMONGST
AFRICAN MEMBERS OF THE EXPEDITIONARY FORCE.
After August 15, 1913, a fresh epidemic began
amongst the African troops; forty, fifty, sixty
soldiers, a whole company went down with it, and
at the moment of writing (October 18) there are
still patients suffering from it in the beds of the
infirmary.
The clinical form is the same and, what is im-
portant, many soldiers who had been attacked in
February have relapsed again. I have good reasons
for believing that the disease was resting in a dor-
mant form in the people previously attacked and
the germ (let us again use the word, although it has
not yet been discovered) again became virulent.
facilitated by the condition of exceptional suscepti-
bility that African races possess towards this
disease.
It is important to remark that no native in the
neighbourhood of the fortified posts occupied by the
African garrison has contracted the disease.
The native of Satary lives on nachinim (Eleusina
indica Roxburgh), pacol (Paspalum scrobiculatum
Linneu), orió (Paspalum miliaceum), rice (Orysa
sativa Linneu), and sanvon (Panicum cruz-galli),
April 15, 1914.| THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
127
These cereals are usually eaten in the form of
farinaceous cakes. Sometimes, though very rarely,
so rarely that such occasions can be looked on us
festivals, the food of the native of Satary is supple-
mented with coco-nut, palm sugar, lentils, setaria
italica, and a little fresh fish. Not a single case ot
beriberi has ever been seen.
The rations of the African soldier before the
epidemic were: White rice, 1 litre; white haricot
beans in butter, 0'2 litre; coco-nut oil, 0:25 litre;
beef or fish, 02 litre. In case of scarcity of meat
a box of sardines preserved in olive oil was sub-
stituted.
After the epidemic, on the recommendation of the
Sanitary Officer: Red rice cured in Mangalore, 0:5
litre; meat, 0'5 litre; potatoes, 0°3 litre; fish, 0'4
litre; various vegetables, 0'2 litre; various beans,
0:2 litre. And in spite of this change of diet beri-
beri eontinued amongst the African company of the
Expeditionary Force.*
WHAT IS THE ORIGIN OF BERIBERI AT GOA?
This question is a very complicated, delicate and
difficult one to answer. Let us see what light our
studies can throw on its obscurity. In the first
place we are up against two distinct opinions :—
(1) That beriberi is a disease which exists in Goa
in some endemic form.
(2) That beriberi is a disease that has been im-
ported into this country and at a relatively recent
date.
The first cases of the disease made their appear-
ance among the sailors of the gunbot Rio Sado,
during the time of the rains, in a barrack which ‘is
used as a depot for materials of war. It was said
that the infection on the gunboat began with a
sergeant of marines, who contracted the disease at
Lourenco Marques, and who probably came to India
without having completely recovered from the
disease. Here he underwent a second attack
exactly like the first, or perhaps a re-infection, and
the naval Sanitary Authorities sent him back to
Lisbon. Soon after various officers and soldiers of
the gunboat contracted beriberi and were isolated
in the convents of Velha-Góa and the infantry bar-
racks in Nova-Góa, and the infection has continued
surreptitiously attacking from time to time soldiers
of the marine.
Sinee this first appearance there have been two
recrudescences each time after the rainy season.
At first sight it was thought that beriberi might have
come from the barracks or from houses situated in
the near proximity. Superficial appearances seemed
to justify this hypothesis, but more mature con-
siderations immediately destroy these first impres-
sions. Indeed, that portion of the barracks where
the sailors stayed was used formerly as a store for
salt for the long period of twelve years, and not a
single case occurred in Góa during these twelve
* Nearly all the patients are very anemic. An examination
fotheir blood has shown eosinophiles, often amounting to
80 per cent, due certainly to intense infection with worms ia
the cases examined.
years, although all the inhabitants of Góa consumed:
the salt that came out of these godowns.
For one year the regiment of artillery was quar-
tered in the same place. "These barracks were used
by the infantry and the band, and not a single man
of them ever contracted beriberi. In the same line
and forming part of the same building, and on the
same level, is the European infantry barracks; and
quite elose are some houses belonging to rich
Hindus, and no one living therein has ever suffered
from a complaint which was in any way suspected as
being beriberi.
Suggestions put forward that beriberi originated
from some houses of prostitutes have not been any
more fortunate. These women are submitted to
medieal inspection, and the servants of the hospital
(Afrieans) that live in the same quarter have never
evidenced the slightest trace of beriberi.
All this is worth reporting, and our attention
ought to be specially directed to those cases which
were due to infection contracted in the gunboat as
well as in the fortress of Aguada.
The following conclusions can then be formu-
lated: (1) Beriberi has not previously existed at
Goa; (2) beriberi actually existing in Góa at the
present time is an imported disease; (3) although
nothing can be definitely stated as to the origin of
infection, one can say, however, that the primary
focus developed in the gunboat Rio Sado; (4) one
cannot state definitely whether the African soldiers
contracted the disease at Góa or brought it from
Mozambique. However, my opinion inclines me
to believe the first hypothesis, the place where they
would have contracted beriberi would be the gunboat
Rio Sado, where these soldiers had for some days
been on sentry duty ; (5) judging from our experience
in Góa it can be affirmed that beriberi is an infec-
tious disease.
ETIOLOGY AND PATHOLOGY OF BERIBERI.
Beriberi enjoys a vastly extended geographical
distribution which can perhaps be subordinate to
four important foci.
Asiatic focus, from which radiations starting from
the extreme east of Asia have reached the Malay
Islands, Australia, New Caledonia, and nearly all
the Oceanic Islands, which constitute the Oceanic
focus, African focus, American focus.
Europe has been free from endemic beriberi, but
slight epidemics are not rarely seen in the ports of
Western Europe. One cannot say so much about
ship beriberi, because epidemies developed on board
French and Japanese cruisers demonstrate the
existence of a ship beriberi where no hygienie
conditions are lacking.
The theories which attempt to solve this difficult
problem can be classed into five groups: Infectious,
parasitie, toxie, alimentary, and symptomatic. Let
us begin the discussion of these by taking first into
consideration the least likely.
THE Symptomatic THEORY.
Nocht and Durek maintain that „beriberi is a
syndrome which develops in different circumstances
128
and under the influence of various causes. Nocht
divides his hypothesis and imaginary syndrome into
three groups: (1) The infectious form, of which the
cause and mode of transmission are unknown; (2)
the alimentary form, due to imperfect foodstuffs ;
(8) the scorbutic form, due to troubles of nutrition.
—9—————
Hotes and "etos.
LONDON SCHOOL OF TROPICAL MEDICINE.
EXAMINATION RESULT (44TH SESSION, JANUARY-
APnIL, 1914).
J. H. Castro, M.D.(Salvador); 5. F. Chellappah,
M.R.C.S., L.R.C.P., L.M.S.(Ceylon); S. Colyer,
M.D.(Lond.), M.R.C.P.; V. St. John Croley,
L.R.C.P. & S.(Edin.); A. L. Fitzmaurice (Colonial
Service), M.B., B.S.(Lond.), M.R.C.S., L.R.C.P.;
E. Gibson (Colonial Service), L.R.C.P. & S.(Edin.);
Bernard Haigh, M.R.C.S., L.R.C.P.; G. G. Jolly
(Capt. I.M.S.), M.B., Ch.B., D.P.H., with distinc-
tion; J. Marmion, L.R.C.P. & S.I.; G. M. Millar
(Capt. I.M.S.), M.B., B.Ch.B., A.O.(Dub.); C. J.
B. Pasley (Colonial Service), M.R.C.S., L.R.C.P.;
I. Ridge-Jones, M.R.C.8., L.R.C.P. ; Miss E. N. M.
Ross, M.B., Ch.B.(Glas.); N. S. Williams (Colonial
Service), M.R.C.S., L.R.C.P., with distinction.
SOUTH AFRICAN LEGISLATION.
THE South African correspondent of the Lancet
of March 28, 1914, states that: ‘‘ So far as the
intentions of the Government have been announced,
it is only proposed to ask Parliament to pass an
Indemnity Bill and necessary financial measures
during the present session. It is expected, how-
ever, that the medical members will insist upon the
conditions on the mines being brought under review,
and particularly the working of the Miners' Phthisis
Compensation Act, which has been responsible for
much criticism. Also it would seem likely that an
effort wil be made to get the Government to
establish a definite Medical Department responsible
for health conditions on the mines, and also for the
medical treatment of mine natives. . . . It is
felt that the State should step in without further
delay and establish a sound organization to take
control and enable the workers on the mines to
feel that Government is rendering their calling
less dangerous and striving to reduce the present
appalling death-rate.''
SHIP SURGEONS.
THE conditions of service of ship surgeons in the
P. and O. Company are now as follows. On all
boats, with the exception mentioned, the rate of
remuneration is £15 a month, with the right to
charge first and second saloon passengers 5s. and
2s. 6d. respectively for each consultation. On boats
engaged on station duty the rate of pay is £20 a
month, with the same right to charge passengers
for medical services. All drugs and instruments are
found by the Company. Surgeons’ cabins are now
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
in all cases outside ones, and in all ships there is,
in addition, a surgery and hospital cabins.
The rate of remuneration of ship surgeons on the
South American mail steamers of the Royal Mail
Steam Packet Company and the Pacific Steam
Navigation Company has been fixed at £12 10s. per
month ; on the Royal Mail Steam Packet Company's
West Indian, Canadian, and ‘‘ D ” Class steamers
to South America the pay is now £14 10s. per
month. In addition to this pay they are allowed
to charge fees for professional attendance on pas-
sengers as follows: Os. a visit to first-class and
2s. 6d. a visit to second-class passengers. Surgeons
on the Company's steamers have a private cabin
and a surgery set aside for their use, and there is
also a hospital fitted with every modern conveni-
ence. Hospital attendants are carried on the mail
boats, and doctors on the Royal Mail Steam Packet
Company's mail steamers are in addition allowed a
personal servant.
—————4—— ———
A efictos.
RENAL DiaGNnosis IN MEDICINE AND SURGERY. By
Dr. Victor Blum. Translated by Wilfred B.
Christopherson. Pp. vi + 144. London: John
Bale, Sons and Danielsson, Ltd. 1914. Price
Ts. 6d. net.
This book describes the work of functional renal
diagnosis with examples chosen from clinical experi-
ence. Renal surgery owes many of its advances and
extensions for and against nephrectomy and nephro-
tomy to functional renal investigation. Not the
least valuable are the methods of treatment of the
various forms of renal complaints due to new
methods of investigation.
The book is divided into renal physiology, renal
competency and incompetency, renal functional
diagnosis, topical diagnosis, and the significance of
these in surgical and medical treatment. An excel-
lent description is given of the interpretation of
renal skiagrams and conditions liable to cause
confusion.
Despite the fact that the author omits to refer
to a certain amount of recent work in England and
America, yet an up-to-date record of German and
most French research work more than compensates,
especially as a full bibliography and table of contents
are given.
HyaIENE AND Diseases or InpiA. By Lieut.-Col.
Patrick Hehir, I.M.S. Madras: Higginbot-
hams, Ltd. Pp. 1,000. Price Rs. 6.8, or
8s. 8d.
The third edition of this well-known work will be
welcomed by all residents in India and medical men
about to settle there. As a comprehensive elemen-
tary textbook it amply repays careful study. As
a popular manual the division into sections is dis-
tinetly useful, for everyone in the Tropics is bound
to study not only personal, but also general hygiene,
as well as the diseases of India. A book of this
description should always be at hand in case of
emergency.
May 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 9, Vol. XVII
TM —M———M—M—M———————————
Original Communication.
MURMEKIASMOSIS AMPHILAPHES.
By ALBERT J. CHatmers, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories.
AND
J. B. Curisropuerson, M.A., M.D., F.R.C.P., F.R.C.S.
Director, Khartoum and Omdurman Civil Hospitals.
INTRODUCTORY.
QUITE recently we have met with a peculiar form
of cutaneous wart characterized by an extraordinary
facility for growth, causing it to spread and to occupy
practically the whole of the right side of the face
and neck, involving the external auditory meatus,
destroying the right eye and even invading the
mucous membranes of the mouth, gums, tongue and
throat, and thus giving rise to the condition depicted
in figs. 1 and 2.
Microscopically the points of interest about this
curious warty mass are the presence of numerous
eryptococci (figs. 6 and 8), and the fact that the
cutaneous warts are largely composed of an adenoma
derived from sebaceous glands (figs. 5 and 9), which
feature is absent in those on the tongue (fig. 11).
As the disease is readily curable by operation this
demonstrates the necessity for a knowledge of its
symptoms in order that an early diagnosis may be
made before terribly extensive operative proceed-
ings become necessary or before the warts invade
the mouth and pharynx, from which positions it is
impossible to eradicate them.
This disease may possibly have been seen in
England, as Lilley described a somewhat similar
warty growth, but he does not mention the presence
of eryptococci or any connection of the cellular part
of the growth with the sebaceous glands, and the
name Naevo-carcinoma, which he gives to the
growth, scarcely agrees with the clinical description,
while the very slight account of the morbid anatomy
leaves some doubt as to what the real condition
may be. Lilley’s case, however, will be described
in greater detail further on in this paper, and if it
eventually proves to be an analogous condition will
tend to show that the geographical distribution of
the disease is not limited to the Sudan.
HISTORICAL.
Several varieties of warts were known to the
ancient Greek writers. They mention a type which
was slender at the base and more expanded on the
surface, and to this the name '' Akrochordon ''
(axpoyopdmv) was given.
The second type included warts which were easily
divisible into parts and were apt to bleed, and to
such a wart the term '' Thymion " (Oúptov) was
applied because it was considered to resemble a
piece of thyme.
The third type was broad and sessile and occurred
on the palms and soles. It gave rise to sensations
resembling those caused by insects creeping over
the body and was therefore called '' Murmekia "'
(uppýria) from the Greek name for an ant-hill.
The above classification was adopted by Celsus
in the fifth book of his ‘‘ De Medicina.” Pliny,
however, altered the nomenclature by applying the
Latin name for a height—'' Verruca "—to the
description of a wart, and since his day this has
remained the commonly accepted name, although
the Grecian names are older and more original.
Galen, however, used the term Murmekia and
coined a new word, '' Murmekiasmos "' (uvpum-
ktagpos) to denote the breaking out of warts on
the body. 3
This early classification remained practically un-
altered until Alibert, in 1825, attempted to add two
new forms, ‘‘ Les Fics” and “ Les Verrues de
Cicerón,” but these did not become established, and
indeed, in 1911, Whitfield only recognizes (1) the
common flat-topped wart, (2) the filiform and fungi-
form warts, and (8) the senile or seborrheic wart.
In general, modern authors, such as Crocker and
Sequeira, recognize: (1) Verruca vulgaris, (2) V.
filiformis, (8) Vacuminata, (4). V. plana juvenilis,
(5) V. plana senilis, (6) V. plantaris, and (7) V.
digitata.
The definition of a wart as given by Crocker is:
A small papillary growth with a horny covering
variable in size, shape, and consistency—and the
individual elements of the peculiar condition which
we are about to describe agree with this definition.
When, however, the morbid anatomy of the
growths is studied, it is seen that there is a marked
proliferation of the sebaceous glands associated with
the wart and the question arises whether the whole
condition should be looked upon as merely an
adenoma of these glands. We think that this is
not the view to be taken, but that the real clinical
feature, judging by the warts on the tongue, is the
presence of a wart which slowly spreads, covering a
relatively large area, and that this wart, when
cutaneous, is associated with a proliferation of the
sebaceous glands, the whole possibly depending
upon the cryptococcal invasion.
The most important clinical feature of the disease
is the wart, and therefore we propose to name this
apparently new human disease ‘‘ Murmekiasmosis
Amphilaphes,’’ using Galen's term for the ‘‘ break-
ing out of warts " on the body, together with the
Greek adjective for ''spreading," and adding to
Galen’s word the termination ‘‘ is '' in order to bring
it into accord with modern nomenclature. In choos-
ing the spelling of these words we have been in-
fluenced by the modern tendency to use the Greek
letters “k” and “u ” instead of converting them
and '' y," as used to be done in bygone
«c ”
into “c
years.
It may be contended that we should have used
the term ‘‘ Cryptococcomycosis ’’ for this condition,
believing as we do that the disease in its active
form may possibly be due to a cryptococcus (fig. 6,
a, b, and c), but firstly we have failed to transmit
the disease to monkeys and dogs by inoculation, and
have therefore failed to reproduce the warts and
therefore have not proved that the eryptococeus is
Jamiii d l5;
S TVET,
ime o
«s i
130
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
the eausal agent. Secondly, as we shall show later,
the genus Cryptococcus of Kützing is probably only
retained because we do not know the full life-history
of the species; therefore, taking these two points
mto consideration, we are of the opinion that a name
which describes the clinical condition without
advocating any theory is the best, and therefore
we prefer the name ‘‘ Murmekiasmosis Amphi-
laphes." We believe we are the first to describe
this condition, unless Lilley’s case of Nævo-
Carcinoma (Melanotic) of the scalp proves on further
examination to be the same disease.
Lilley published a paper entitled “‘ Notes on a
Case of Nevo-Carcinoma (Melanotic) of the scalp
in a boy aged 19," in the British Journal of
Dermatology for December, 1912.
The history which he gives of the onset of the
disease and the excellent photograph with which
he illustrates his paper suggest strongly to our minds
that he was dealing with a condition like the one
we are about to describe.
The term Nevo-Carcinoma is peculiar as no
glandular enlargements or metastases could be
found, although the growth is said to have steadily
inereased from the patient's fifth to his fourteenth
year, and to have then remained quiescent until a
few months prior to being seen, when it began to
grow rapidly.
Again, the fact that, from the date of the opera-
tion in March or April until December, 1912, no
sign of any recurrence could be found also militates
against the view of the malignant nature of the
disease, but the pathological description is so ex-
ceedingly meagre as to leave it open to question
whether the two conditions may not be variations
of the same disease, i.e., a warty growth associated
with a proliferation derived from the sebaceous
glands.
GEOGRAPHICAL DISTRIBUTION.
Our case occurred in a boy who came from
El Damer, a town situate on the Nile north of
Khartoum.
RACIAL DISTRIBUTION.
The boy was an Arab belonging to the Jaalin
tribe, celebrated because of its almost total extinc-
tion under the Khalifa’s rule.
ETIOLOGY.
After removal the warts were cut vertically and
films made from serapings of the white central
portion. These films were sometimes fixed with
osmic acid and treated by the moist method, and in
other cases were simply fixed by drying. After
fixation they were coloured by Leishman’s or
Giemsa’s stain, when they were found to contain a
number of roundish bodies with a definite double
contour. These bodies in the fixed and stained con-
dition vary in size, some measuring about 1:4 and
others about 2:1 microns in diameter (fig. 6).
They contained no visible nucleus or differentiated
cellular eontents. Some of them (fig. 6, a, b, and
c) appeared to be forming buds, thus giving rise to
the well-known cottage-loaf-like appearance which
is characteristic of budding yeasts. It was there-
fore concluded that they were yeasts.
Attempts at cultivation on a large series of media
at 20° C., 379 C. and 40° C. failed to produce any
growth. Inoculations into monkeys and dogs failed
to reproduce the disease and sections of the warts
stained by various methods failed to show any other
form of reproduction beyond that of gemmation,
and therefore it was concluded that these bodies
belonged to the genus Cryptococcus Kiitzing 1833.
Examinations of sections coloured by Leishman's
stain, by Gram's method, by iron hematoxylin and
by the Oxford method reveal the presence of these
cryptocoeci lying among the superficial horny cells
(fig. 8), deep in the recesses between the papillary
processes of the wart. Further examinations show
the same bodies in the epidermis, in the depressions
leading to the sebaceous glands, and in the sebaceous
glands (fig. 7), as well as in the epithelium and in
scrapings from a lingual wart (fig. 6c).
This extensive distribution, together with the pre-
sence of the organism in perfectly fresh specimens,
has induced us to believe that there may be some
causal relationship between the eryptococcus and
the wart. We are supported in this view by the
absence of eryptocoeci from ordinary warts of the
Sudan, from blastomycotie warts and leishmania
nodules, in all of which it was possible to conceive
that they might have lived parasitically without
being the causal agent.
Cryptocoeci are not uncommon in the Sudan and
we propose shortly inviting attention to another skin
disease in which they apparently play a causal part;
but this eryptococcus appears to us to be quite
different from the one we are dealing with at pre-
sent because it can be cultivated and because it is
associated with quite different pathological features.
Yeast-like bodies can be found in the scrapings
of apparently normal skin of persons suffering from
saccharomycetic diseases and in the mouth and
fieces of apparently normal people.
It might therefore be contended that the warty
cryptococci were simply living harmlessly in the
morbid tissues, but we are not in favour of this view,
though we are unable to advance any proof abso-
lutely contrary to it, and though we have been un-
able to find or to grow any other organisms beyond
those usually present in normal skin or in the
mouth.
We are inclined to believe that this is a new
species of eryptococeus, because we have failed to
meet with any literature referring to any species of
this genus associated with warts. There is, how-
ever, so much confusion with regard to the genus
eryptococcus that a brief review of the subject
appears to us to be necessary before finally naming
what we think to be a new species. :
The order of the fungi called ascomycetes contains
a sub-order established by Brefeld and variously
named hemi-ascomycetes, hemi-asci, proto-asei and
gymnaseales. This sub-order, which contains three
families, the gymnoascem, the exoasces and the
anccharomyocetesm, is looked upon by many authori-
ties as a link between the phycomycetes and the true
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MAY 1, 1914
PLATE I.
Fia. 1.
Fic. 3. FiG. 4.
To illustrate article, ** Murmekiasmosis Amphilaphes," by ALBERT J. dcn. M.D., F.R C.S., D.P.H., and
J. B. CunisTOPHERSON, M. A ., M.D., F.R.C.P., F.R.C.S.
May 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
131
ascomycetes, and indeed its founder, Brefeld, be-
lieved that in process of evolution the sporangium
of the phycomycetes had been converted into the
ascus of the ascomycetes.
The hemi-ascomycetes may be provisionally
defined as: ‘‘ Fungi, parasitic or saphrophytic,
mostly minute, with asci, without or with only a
rudimentary perithecium, and having often a vari-
able number of spores.”
This definition covers three families, gymnoascer,
exoascee and saccharomyceter, which are distin-
guished by the fact that the gymnoascee have a
rudimentary perithecium while the exoascee and
succharomycetee have no perithecium at all. The
exoasceæ are parasitic on living plants and their
asci form a continuous layer on the infected stratum,
while the saccharomycetee consist of single cells
which reproduce by budding or division and are
known in some genera to form ascospores inside an
ascus. They may be parasitic or free living.
The saccharomycetee contain the zygosaccharo-
myces of Barker, in which conjugation precedes the
formation of ascospores; the schizosaccharomyces
of Beyerinck, in which division, instead of budding,
takes place and in which an ascus is formed after
conjugation; the saecharomyces of Meyen, in which
reproduction takes place by budding and by ascus
formation without conjugation, the spores being
round or irregular; Willia, in which reproduction
takes place by budding, the spores being pileiform
or limoniform and ridged; and the eryptococcus of
Kiitzing, which was renamed atelosaccharomyces
by de Beurmann and Gougerot in 1909, and in which
only reproduction by budding is known, ascus
formation not having been observed.
It is obvious that as only reproduction by budding
is known, cryptococcus must be looked upon either
as a specialized or degenerate form of saccharomyces
or as merely a provisional genus in which to place
yeast-like forms, the full life-history of which is
unknown.
The fact that when grown for several generations,
as in Busse’s case, it continued in its cryptococcal
or yeast-like form is in favour of the view that
some, at all events, of the species have become
highly specialized and have lost all other modes of
reproduction except budding. If this is correct,
then eryptococeus would become an established
genus, though at present the general tendency is to
view it as merely a provisional genus.
But having defined the systemie position of
cryptococcus we are unfortunately only at the be-
ginning of the difficulties which beset the species
of this genus, and to understand the present state
of our knowledge it is necessary to review their
history.
The name ‘“‘ Cryptococcus " was introduced by
Kiitzing in 1833 as the generic name for certain
forms of his alge, which he classified as belonging
to the sub-class Malaeophycesm, tribe Gymno-
spermee, order Eremospermer, sub-order Myco-
phycee, and family Cryptocoecacesm. This family
he defined as: ''Globuli gonimici minutissimi
mucosi in stratum indefinitum aggregati," and in
this family he placed three genera, Cryptococcus,
Ulvina, and Spherotilus. The genus Cryptococcus
was characterized as: ‘‘ Globuli gonimici in stratum
amorphum diffusum aggregati." In this genus he
gathered no less than thirteen species, all described
by himself and mostly found in water or in phar-
maceutical preparations.
His twelfth and thirteenth species were, how-
ever, more interesting, as they were called Crypto-
coccus cerevisiz and C. vini.
In 1838 Meyen (usually misspelt, being written
Meyer) separated C. cerevisiw from the genus
Cryptococcus, because it reproduced by ascospores
as well as by budding, and to this new genus he
gave the name Saccharomyces, so that Cryptococcus
cerevisix became Saccharomyces cerevisiz.
Cryptococcus therefore remained for those yeast-
like fungi which do not reproduce by ascospores but
only by budding.
The removal of the species cerevisiae from Crypto-
coccus was not recognized by Charles Robin, and
with it he grouped the fungus found by Remak
in 1845 in the biliary passages and intestines of
rabbits, and to which in 1847 he gave the name
Cryptococcus guttulatus. Later, however, it was
also shown to belong to the genus Saccharomyces.
In 1873 Rivolta noticed peculiar bodies in a form
of lymphangitis in horses, and in 1883 he and Micel-
lone named this organism Cryptococcus farci-
mimosx, but another view is that this so-called
cryptococcus is not a fungal but an animal parasite,
which is referred to Gasperini's genus Lymphospori-
dium.
During this period one or two organisms had a
temporary resting-place in this genus, e.g., Fre-
senius's Cryptococcus glutinus.
The first case in which a cryptococcus was
definitely proved to be the cause of disease was
Busse's ease of cystic swellings of the tibia in a
woman, aged 31.
The bodies in question were first seen by Buschke,
but it was Busse who first proved that they were
the true cause of the disease and showed that they
were pathogenic to animals.
These yeast-like organisms were found at the
autopsy some thirteen months later to occur in
sarcomatous-like growths consisting of young granu-
lation tissue and giant cells, not merely in the cysts
but also in the lungs, kidneys, spleen, and in a
vesicle on the cornea.
The organism grew well on potato and in acid
media. It fermented glucose and was specially
pathogenic for rats. It only reproduced by budding
and no endospores or mycelium were ever seen. It
was this that induced Vuillemin to give it the name
Cryptococcus hominis 1901.
Including C. hominis, and after excluding several
wrongly classified forms, there are about fourteen
species parasitic in man which can at present be
referred to the genus Cryptococcus, e.g. :—
Cryptococcus breweri Verdun 1912, described in
an abscess of the vertebral column; C. tonkini
Legendre 1911, found in two cases of blastomycosis
in Indo-China.
Judd is
à
ihe o
134
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
Diacnosis.
The leading diagnostic features are :—
(a) The presence of a warty growth the individual
members of which are painless, firm, do not readily
bleed, and do not readily uleerate, but which tend
to slowly spread and to endanger or destroy im-
portant organs.
(b) The proliferation of the germinal layer of the
sebaceous glands in the cutaneous warts (we can
well imagine a condition in which the proliferation
would produce a carcinomatous and not an adeno-
matous appearance) with the absence of this feature
in the lingual warts.
(c) The non-involvement of lymphatie glands, the
non-formation of metastases and the non-malig-
nancy of the growth.
(d) The non-recurrence after removal.
(e) The fact that the warts grow on healthy skin
and not on cicatrices, and. do not grow at first in
any special relationship to mucous openings or
moist areas of skin.
The differential diagnosis requires to be made from
ordinary warts, from Verruea acuminata, from
Botryomycotic warts, from warty cicatricial
tumours (Marjolin’s ulcer), from non-ulcerative
leishmania nodules, from Brooke's Epithelioma
adenoides cysticum; from Balzer’s Adenoma seba-
ceum, from Blastomycotic dermatitis, from Pem-
phigus vegetans, from Acanthosis nigricans, and
from lymphangiectodes.
From ordinary warts it can readily be distin-
guished by the history, the mat-like growth, and
in the early stages, when perhaps only a single wart
might be present, by its histologieal charaeters
(figs. 9 and 11), and by the presence of the crypto-
coccus.
From Verruca acuminata (so-called Venereal
Warts) it can be classified by not appearing isolated
around mucous openings and on moist areas of skin
and by its histological structure. The lingual wart
shows more cellular infiltration in the papillæ and
in the sub-epithelial mucosa than is present in
Verruca acuminata.
From Botryomycotic (in the tropical sense of the
word) warts, a condition met with in the Sudan, but
as yet not described, it can be differentiated by the
absence of any enlargement in the neighbouring
lymphatic glands, and histologically (compare figs.
9, 11, and 10) by the absence of the thickened
vessel walls, the dense fibrous tissue, the eosino-
phile fatty bodies, and by the presence of a pro-
liferation of cells derived from the sebaceous glands
in the cutaneous warts and by the cryptocecci.
From warty cicatricial tumours it is recognized
by the fact that the warts do not occur on cicatrices,
are not arranged in parallel rows, do not show a
tendency to ulcerate (this ulcer is sometimes called
Marjolin’s ulcer and is usually epitheliomatous),
and do not involve the lymphatic glands.
From Balfour and Thomson’s non-ulcerative
leishmania nodules it may be diagnosed by the
absence of the smooth pink coloured surface (even
in the black skin), of the itching on exposure to the
sun, and the pain when pressed, as well as by the
different histological structure (compare figs. 9 and
12). The nodule shows many large cells with
vesicular nuclei and cytoplasm full of leishmania
bodies and vessels with hypertrophy of the endo-
thelial layer. There is much proliferation of the
prickle cell layer and some cell nests.
From Brooke's Epithelioma adenoides cysticum
(synonyms: Perry’s adenoma of the sweat glands;
Fordyce’s multiple benign epithelioma; Jarisch’s
hemangio-endothelioma tuberosum multiplex, and
Unna's Acanthoma adenoides cysticum) by the
absence of the symmetrical arrangement, and of the
small, firm, discrete tumours which can be felt to
be embedded in the skin and are often so thickly
clustered together as to form lumpy patches, which
are at first of the colour of the skin, but later of a
white bluish-yellow or pearly colour (in the white
skin), and by the presence of typical warts. Histo-
logically by the absence of solid coil-like masses of
cells derived from the rete mucosum and hair fol-
licles, and by the presence of the structure given
above, but it must be noted that Pick’s case
showed a proliferation of the germinal epithelium
of the sebaceous glands.
From Balzer's type and from Pringle’s type of
Adenoma sebaceum it may be separated by its
warty condition, but Hallopeau and Leredde's type.
being warty, requires further differentiation, and
this can be effected by noting that the Adenoma
sebaceum warts are found in the middle third of
the face, especially the naso-labial folds, and by the
fact that they are often accompanied by vascular
nevi, by pigmented moles, and by a flat fibroma
above each iliac erest. The histological characters
of Adenoma sebaceum are more of the type of an
epithelioma derived from the epidermis, which is
certainly not the case in Murmekiasmosis.
From Blastomycotic dermatitis it may be sepa-
rated by the absence of ulceration, of epidermal or
other abscesses, and of soft, smooth sears, as well
as by the presence of typical warts in contra-
distinetion to the warty patches.
From Pemphigus vegetans it may be recognized
by the absence of the history or the presence of
bulle on the skin and in the mouth before the
appearance of the warty growths; by the absence
of constitutional disturbance.
From Acanthosis nigricans it can be diagnosed by
the absence of cutaneous roughness, of the partial
symmetry of the lesions, of the cachexia, and in
the white skin by the absence of bronzing. _
From Lymphangiectodes (Lymphangioma circum-
scriptum. cutis) it may be differentiated by the
absence of vesicles giving rise to a warty appear
ance, by the presence of true warts, and histo-
logieally by the absenee of dermal cysts.
PROGNOSIS.
The warts do not appear per se to endanger life.
but they destroy organs such as the eye, and when
they enter the pharynx there is danger of the
larynx becoming involved. | Where removed they
did not recur during a period of over four years.
— ——
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MAY 1, 1914.
PLATE II.
Fic. 6c.
Fic. 5.
Fic. 6a.
Fic. 8.
Fic. 7.
To illustrate article, ** Murmekiasmosis Amphilaphes," by ALBERT J. CHALMERS, M.D., F.R.C.S., D.P.H. and
.C.P., F. R.C.S.
4, M.D, E.R
M.A
N
J. B. CHRISTOPHERSO
May 1, 1914.]
TREATMENT.
The only effectual treatment is removal by means
of a series of large dissecting operations, when the
whole growth comes away like mats of warts, leav-
iug large areas to be covered in by skin flaps and
by skin grafting. Damaged organs, such as the eye
in this case, must be removed.
The patient made an excellent recovery after each
of his operations, though, of course, there was a
considerable amount of scar tissue at the site of
the growths (fig. 4). No recurrence of warts
appeared on the scar.
However easy removal may be on the surface of
the body it is quite another matter when the warts
invade the oral cavity, the tongue, and the pharynx.
In this position complete removal is quite im-
possible.
PROPHYLAXIS.
The only prophylactic measure we can suggest is
the prompt removal of any suspicious-looking wart,
that is to say, any persistent wart dating from
early years of life and any wart with a tendency
to spread.
ACKNOWLEDGMENTS.
We have much pleasure in acknowledging the
kind suggestions given us from time to time by
Captain Archibald, R.A.M.C., and the help we have
received from our assistants, Mr. Marshall and Mr.
Newlove.
Khartoum,
March 9, 1914.
LITERATURE.
ALIBERT (1912). ‘‘ Monographie des Dermatoses,” Paris,
vol. ii, pp. 700-708.
ALLBUTT and RoLLESTON (1911).
London, vol. ix, pp. 573-577.
BnuwPT (1913). ‘‘ Précis de Parasitologie,” Paris, p. 794.
CASTELLANI and CHALMERS (1913). ‘Manual of Tropical
Medicine," London, pp. 769-771.
CELsus. ‘‘De Medicina," Book V, chap. xxviii (Targa's
edition). :
Crocker (1905).
917 and 921.
Kérzina (1849). *'Species Algarum,” Leipzig, p. 145.
LinrEv (1912). British Journal of Dermatology, London,
vol. xxiv, pp. 411-413.
MacrEgop (1902). :'Pathology of
chapters xi, xii, and xxiv.
Morais (1911). ** Diseases of the Skin," London, p. 688.
Mrackk (1904)
vol. iii, p. 512.
SEQUEIRA (1911).
“System of Medicine,"
** Diseases of the Skin," London, pp. 524,
the Skin," London,
‘* Diseases of the Skin," London, p. 434.
ILLUSTRATIONS,
Most of these illustrations may with advantage be examined
by a lens.
Prater I.
Fig. 1.—Photograph giving a general view of the warty
growth as seen from the front. Note invasion of the eyelids,
Fig. 2.— Photograph showing the lateral extension of the
growth and the invasion of the oral cavity.
Fig. 3.— Photograph showing warts on the lips and tongue.
Fig. 4.—Photograph of the patient after the operations
showing the scar tissue. Note the absence of any recurrence
or of the formation of any growth on the cicatrices.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
* Handbuch der Hautkrankheiten,” Vienna,'
135
PrarE II.
Fig. 5.— Photomicrograph of a vertical section of one of the
warts from Murmekiasmosis Amphilaphes. x 70 diameters.
Fig. 6.—(a) Photomicrograph of Cryptococcus myrmeciv,
stained by Giemsa’s method, as seen in a film made from
a scraping of the central portion of a vertical section of a
freshly removed wart from the case of Murmekiasmosis
Amphilaphes. x 1,500 diameters.
(b) Photomicrograph of Cryptococcus myrmecia, a similar
film stained by Leishman’s method. x 1,500 diameters.
(c) Photomicrograph of Cryptococcus myrmecia, stained bv
Leishman's method, as seen in a film made from a scraping
of a digitation of one of the lingual warts from the case of
Murmekiasmosis Amphilaphes. x 1,400 diameters.
Fig. 7.—Photomicrograph of a section through a sebaceous
gland from Murmekiasmosis Ampbilaphes showing Cryptococcus
myrmecie deeply embedded in the cytoplasm of a cell. x 1,500
diameters.
Fig. 8.—Photomicrograph showing Cryptococcus myrmeciv:
lying in the cells of the hypertrophied stiatum corneum
filling in the hollows between two papille. Note budding and
non-budding forms. Stained by Gram’s method. x 1,800
diameters.
PraTE III.
Fig. 9.— The same photomicrograph as fig. 5, but only
magnified by 30 diameters,
Fig. 10.—Photomicrograph of a botryomycotic wart in the
Sudan. x 935 diameters.
Fig. 11. — Photomicrograph of vertical section of a wart from
the tongue in Murmekiasmosis Amphilaphes. x 30 diameters.
Fig. 12. — Photomicrograph of a non-ulcerative Leishmania
nodule in the Sudan. x 30 diameters.
e
The Geranium as a means of excluding Flies.—
It is reported that the presence of geranium (pelar-
gonium) plants serves to prevent flies congregating
in a room. lTtappears that it does not matter whether
the geranium is of the scented variety or not. It is
a trite observation and one which serves to explain
the usefulness of plants in a room and the craze there
is for loading a sick room with cut flowers. That the
cut flowers can have much virtue either as an insect or
germ protector is perhaps dubious, but that the cut
flowers amongst city folks are representative of plants
growing in pots in country houses and in villages
there can be no doubt. The custom of having plants
in the window may be hereby explained.
A Disease of Rice.—Dr. E. J. Butler, in the annual
report of the Board of Scientific Advice for India
for 1912-13, gives an account of a disease of inun-
dated rice which has broken out in the deltaie
districts of Eastern Bengal. Locally it is known
as ufra. Investigation has shown that it is caused
by a minute parasitic nematode worm of the genus
Tylenchus. The parasite, which has not hitherto
been described, attacks especially the deep-water
winter rice, and the dumage done by it is so serious
that frequently the affected fields are not con-
sidered worth harvesting. The disease seems to
be spreading. The parasite appears to be entirely
restricted to rice. The apex of the shoot, the young
leaves, and the young ear are the parts most open to
attack. It passes the period between successive crops
coiled up, in a resting condition, in the stubble, and
can stand drying in this state for over a year.
136
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THE JOURNAL oF
Tropical Medicine and Hpgiene
May 1, 1914.
ARE PLANTS, TREES, AND FLOWERS IN AND
AROUND OUR HOUSES BENEFICIAL OR
DELETERIOUS?
Ix the publie press in England there is at the
present time considerable interest being taken
concerning the effect of plants and flowers in
causing peculiar and, in many instances, quite
specifie symptoms in many people. The plane
trees so plentifully seen in London streets and parks
are considered by some contributors to the press
as being the cause of a peculiar irritation of the air
passages; the aeeused of causing
fever ''; lilies of a particular kind are excluded
from dwelling rooms, as they are believed to bring
about a state of faintness and a disturbance of the
rose is “rose
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
circulation. A long list of similar accusations
against plants and flowers might be enumerated
until one marvels that not only are flowering plants
tolerated in our dwelling rooms, but even in
proximity to our dwellings at all. The inscrutability
of the phenomena of '' hay fever " is immediately
suggested by these observations, and it would seem
time that some serious attention was paid to the
question of the part played by plants and flowers
in domestic economy.
The custom of loading our hospital wards, our
nursing homes, and the sick room in our dwellings
with flowers has become so prevalent that one feels
rather ashamed to pay a visit to a friend or relation
in any one of these without bringing some flowers
to present to the patient and to ‘* decorate " the
room. The custom seems to be universal and to
have continued from the earliest times. The reason
for this fashion of '' helping ° our fellow-beings in
their illnesses is not so easily explained as it might
appear. The custom is so deeply rooted that it
cannot be due to mere courtesy, to an act of kind-
ness, or to bringing something pleasant for the
patient to look at. None of our so-called decora-
tions were introduced for merely decorative pur-
poses. The curtains to our windows were meant
when first used to keep away flies and other pests;
our mantelpieces and the niches in our walls, over-
mantels, cabinets, &e., were intended as convenient
places to store the household gods, and when
these became too numerous a higher shelf or frieze
was run round some little distance below the ceil-
img to accommodate the surplus. The gardens
around our houses, so beloved of all mankind, had
originally a utilitarian purpose, and so, no doubt,
had the plants and cut flowers in our dwellings.
What purpose do these, or rather, did these serve,
for there is no doubt we have wandered away from
the utilitarian ideas of the past and reached the
stage when mere decoration is all that is thought
of? The bases of all customs of the kind that
survive had protection against disease and the
maintenance of health as their primary objeet, and
although no doubt decoration of the dwelling-house
has a hygienie influence, its direct bearing is not
so obvious,
Although the scientific explanation of the part
played by insects in the spread of disease is the
. theme of to-day, the belief in their power to spread
disease has been acted on from time immemorial.
The destruction inseets—using the term in the wide
sense—cuuse to the woodwork of the house, to
clothing, to food, and to almost everything con-
nected with our health, comfort, and dwellings has
caused man to wage a constant fight against these
destructive pests. i
The box on the window-sills of our rooms filled
with plants is beloved of all classes of people, and
is found in the palace and the cottage. In the
cottage the plant esteemed above all others is the
geranium, although mignonette is a lusty rival.
This collection of flowers in our windows was not
put there for mere decoration, but as a sereen to
exclude flies and insects of all kinds, and the plants
May 1, 1914.]
chosen were those that by some effluvia or other
virtue were repulsive to these pests. The geranium
is a plant of this nature, for insects systematically
avoid it; the choice of the geranium cannot be a
coincidence surely, for many plants are prettier.
many smell more sweetly, and in the matter of
flower it seems a negligible quantity, for it is
not always the flowering geranium that is chosen.
Whilst some flowers are chosen for their inherent
quality of repelling insects, others have the power
of attracting them; these are never placed in our
rooms, but in the garden. The garden trees and
plants were also chosen for utilitarian purposes,
some for their edible qualities, such as fruit and
vegetables, some, as flowering plants, as food for
bees, and several for their medicinal properties.
Of the latter chamomile was grown by our grand-
mothers, and is still cultivated for the purpose of
flavouring more especially that ill-tasting salts and
senna compound so frequently in use. Valerian,
marsh-mallow, rhubarb, and many other plants with
real or assumed medicinal virtues grew in all gardens
up to recent years, but they have been gradually
displaced, and the chemist's products have replaced
the home-grown ''simples," and not even our
kitchen gardens contain them. Decorative annuals,
the sweet pea, and hybrid products of the green-
house have largely replaced the useful plants, and
gardens have become divided into two classes: the
purely decorative and the kitchen garden. Of the
latter we seem rather ashamed, for it is hidden
away behind high hedges, or even removed at a
distance from the house. All these changes are
interesting, and point to an evolution which no
doubt is consistent with necessity.
The original dwelling of mankind was at a home-
stead with adjacent farm buildings for the accom-
modation of cattle; but the presence of cattle meant
an adjacent midden, sometimes the manure was
heaped up against the house or placed within a few
yards of the dwelling-house, oftentimes the door
opened on to a pathway which passed through the
centre of the midden. The manure heap was a breed-
ing-place for flies, and its effluvia was at times objec-
tionable. To keep out the flies plants repulsive to
them were placed in the window-sill, and strong-
smelling plants, such as musk or mignonette, were
made use of to overcome the stench of the midden.
The dried rose leaves kept in an open bowl scented
the guests' rooms for the same purpose, and on
every hand we find that the original idea of flowers
and plants in and around our dwellings were
intended to prevent or cure disease or to act as de-
odorants to overcome the foul odour inseparable
from the proximity of animals. Many other con-
siderations arise in connection with this subject.
Is it hygienie to have vegetation near our dwellings
at all? Modern teaching would seem to denounce
their presence. It is only by cutting down the
trees, undergrowth, and even the rank grass for
some two hundred yards around our dwellings that
mosquitoes, and thereby malaria, ean be radically
prevented; this raises the whole question of the
hygienie influence of plants, flowers, and trees,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
137
whether it be the cut flowers in our sick rooms,
the plants in pots in our windows, the ivy on the
walls, the roses peeping in at the cottage casement,
or the garden, whether flower or vegetable, adjacent
to our dwellings. Man is pictured in the Bible as
having originally dwelt in a garden, but the in-
fluence of that environment had evidently an evil
effect morally, and it may have been for his moral
and physical welfare that he was compelled to
leave it. J.C.
Se ——_—
Annotations.
Experiments concerning the Filterability of Spiro-
cheta duttoni (J. L. Todd and S. B. Wolbach, Journal
of Medical Research, March, 1914) have shown that
S. duttoni can be filtered through even the least per-
meable of Berkefeld filters by means of a pressure of
from 50 to 90 lb. to the square inch; and that an
infective form of S. duttoni could not be filtered by
the force supplied by atmospheric pressure.
The Nature of the Kurloff Body.—In the Indian
Journal of Medical Research for January, 1914,
Acton and Knowles have a further paper "On
the Nature of the Kurloff Body." In 1898 Kurloff
first drew attention to the fact that the mono-
nuclear leucocytes of the guinea-pig contained large
spherical bodies of the nature of cell-inclusions.
He considered these bodies to be vacuoles containing
secretory products. Ehrlich, in 1908, expressed a
similar opinion as to their nature. E. H. Ross, in
1912, described Kurloff's bodies as parasites (lym-
phoeytozoa) inhabiting the mononuclear leucocytes.
They eventually give rise to spirochetes which escape
into the blood plasma. In the present paper the
authors point out that the body is nothing more than
a stage in the development of the eosinophile leuco-
cyte. Material is given off as a granule from the
nucleolus of the nucleus. It escapes into the cyto-
plasm, and there inereases greatly in size and eventu-
ally contains a long coiled thread which segments into
a large number of granules which become the eosino-
phile granules when distributed through the cytoplasm.
The various stages in this developmental process are
illustrated by an excellant plate. Kurloff's bodies,
moreover, are not peculiar to guinea-pigs, but occur in
the bone marrow of widely different animals, birds,
amphibia, and mammals. Normally, the development
of the eosinophile granules takes place only in the
bone marrow, but under the influence of helminthic
infections the Kurloff bodies being immature eosino-
phile leucocytes appear in the peripheral blood.
The Distribution and Morphology of Spirochata
duttoni and S. kochi in experimentally infected Ticks
(Ornithodorus moubata).—As a result of their in-
vestigations the authors support the conclusions of
Marchoux and Couvy, that the granules in tho epi-
thelial structures of the tick are not concerned with
the life cycle of the spirochete. These granules are
abundant in epithelial structures of non-infective ticks,
138
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
in which spirochetes could not be demonstrated, and
further, spirochetes do not invade epithelial cells for
purposes of multiplication. The only type of tissue
in which spirochætes were found in sufficient abund-
ance to warrant the assumption of multiplication
having occurred, was that of the connective tissue
type. Tissues of this type are the fibro-muscular
layers of the gut, the peritracheal fat tissue, and the
delicate strands of connective tissue uniting the organs
of the tick. The power of the spirochete to migrate
through the tissues explains the invasion of all the
organs. It seems probable that infection may be
conveyed by a variety of channels. The finding of
spirochetes in the lumen and cells of the salivary
glands, in the coxal glands, and in the wall of the gut
proves the possibility of infection by any of these
routes. No evidence has been obtained which
supports the infective nature of the granules derived
from the ticks. Certain larger granules are derived
from spirochetes, but they are quite different from
the “infective” granules of Leishman, Balfour and
others. "The transmission of infection for the period
of time studied does not need the assumption of any
other form than spirochetes. The evidence that the
granules and granule clusters are a stage in the life-
history of the spirochetes is purely morphological.
These observations were conducted on sections of the
organs of ticks removed from the chitinous covering
en masse and stained by a modification of the Giemsa
method which demonstrates the spirochetes in tissues
very clearly.
The Cultivation of a Free-living Filterable Spiro-
chæte (Spirocheta elusa ; new species).—A preliminary
report, by S. B. Wolbach and C. S. L. Binger
(Journal of Medical Research, March, 1914). Water
from Jamaica Pond, Boston, after being filtered
through a Berkefeld " V ” filter, was found about one
month later to contain a spirochete in culture. After
much experimentation it was found that the organism
would grow in a hay medium prepared as follows:
120 gr. of hay are soaked in one litre of water for
half an hour. To the decanted water is added 1 per
cent. dextrose. The medium is rendered neutral
to phenolphthalein aud is then sterilized by filtration
through the Chamberland " F ” filter and tubed. The
reaction of the hay infusion is then about '2 per
cent. acid to phenolphthalein. A solid medium was
also prepared by mixing equal parts of 3 per cent.
agar and the hay dextrose medium. The mixing is
better done when the agar has cooled to 50? C.
The liquid medium is heavily clouded by growth in
forty-eight hours, and with these cultures it has been
demonstrated that the organism is able to pass through
Berkefeld " V," “N,” and “W” filters, but not through
Chamberland " F ” and " B” filters.
In culture the optimum temperature is 380° C.
Growth oecurs in colonies on the surface of the
agar or in stab cultures. Morphologically the spiro-
chute resembles closely the pathogenic spirochietes,
but with it it has been found impossible to infect
animals.
Abstracts.
THE OPERATIVE TREATMENT OF HEPATIC
ABSCESS.*
By E. A. R. Newman, M.D.Cantab.
THIS paper is chiefly based on a series of 29 cases
which have been admitted under my care during the
past eighteen months, with a provisional diagnosis of
hepatic abscess. Of these 29 cases, 2 proved to be
instances of sub-phrenic abscess entirely unconnected
with the liver. One was a large right empyema dis-
placing the organ downwards, and another was a
breaking down gumma in & female, which was dia-
gnosed from her past history and which cleared up
quickly under iodides. The case was interesting as it
presented all the physical appearances of a localized
abscess pointing in the eighth intercostal space.
Excluding these, 25 cases of true hepatic abscess
remain.
Of these 25 cases all but 2 were operated on. Of
these one was admitted in a moribund state and died
in a few hours, and in the other the abscess was
already discharging through the lung, and he left
hospital at his own request a few days later.
Of these 23 cases, 15 were discharged cured after
an average stay of thirty-five to forty days in hospital
and 8 died. The case mortality is therefore 35, or
one in three cases. This mortality is an expression
of the extremely advanced and neglected condition of
these cases on admission; the majority were prostrated,
some extremely so.
Cause and date of death are given in the following
table :—
2 died within 24 hours, aged 50 and 35, from shock and
hyperpyrexia respectively.
1 died on 5th day, aged 45, from shock and exhaustion.
1 40
6t ” LEJ ” ” 39
1 , 10th ^ 3930 , complete right lobar
pneumonia.
1 5. IAN. 5, » 529 ,, exhaustion.
1 » 18th ,, EAE NET à (2 operations).
1 » 42nd day, aged 28, from sepsis.
Exhaustion was thus the commonest cause of death,
complicated by shock in 3 if not 4 cases. Sepsis was
definitely the cause of death in one case only. The
death due to lobar pneumonia cannot be directly
ascribed to the local condition, which was steadily
improving, but must in strict fairness be included.
The one striking fact, which might have been antici-
pated, is that 5 deaths out of the total occurred in
patients aged over 40.
Topographically, a trans-thoraeie incision was made
in 8 cases, and an epigastric or abdominal incision in
12 cases. In one instance an incision was made
at two distinct operations, and in two I could find
no record in the notes. In one case treated by
trans-thoraeie incision no adhesions existed, and
partial resection of a rib or cartilage was only per-
* From the Indian Medical Gazette, March, 1914.
May 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
139
formed three times ; in two cases treated by epigastric
incision no parietal adhesions existed.
Symptoms and Diagnosis.—Late or advanced cases
present less difficulty in diagnosis than incipient or
intermediate ones, the local appearances pointing con-
clusively to the existence of pus, though it may not
always be easy to be sure of its exact situation. The
great majority of my cases were of this class. The
only points worthy of note are: (1) That the tem-
perature on admission is often subnormal and rarely
above 100° F., and (2) that jaundice is usually absent,
or if present does not amount to more than a faint
icteric tinge of the conjunctive. The treatment
adopted may be summarized in four words—free in-
cision and drainage, combined, of course, with emetine
hypodermically. Incipient and intermediate cases
present the greatest difficulty in diagnosis and con-
sequently in treatment. Again I do not propose to
consider the differential diagnosis, but I would lay
stress on two points: (1) Repeated careful local ex-
aminations for any cedema of the integument no matter
how slight, and (2) a leucocyte count. Of jaundice my
experience is that it is usually absent or very slight. If
jaundice is definitely present it is a positive contra-
indication of the probability of a true abscess of the
organ and is an indication of inflammation about the
biliary tract. Two cases in point: both were suffering
from enlargement of the liver and marked jaundice,
and in both pus was found in small quantity only
by aspiration. In one of them an autopsy revealed
the presence of multiple small abscesses of pysmic
nature.
Treatment.— Emetine hypodermieally, of course,
which may settle the diagnosis by effecting a cure.
Locally leeches may be advantageously applied accord-
ing to the patient’s circumstances. Counter-irritants,
including iodine, are as certainly contra-indicated, as
they will produce cdema and redness of the skin and
obscure the local condition.
I now come to the crux of the whole question, viz.,
the diagnostic use of the aspirator.
The circumstances under which I am considering
its use must be borne in mind. There is pain, tender-
ness, and enlargement of the liver. There is a slight
to a well-marked leucocytosis. There is no definite
cedema of the integuments. Are we justified in
immediate aspiration for the purpose of making a
diagnosis ?
A few years ago I should have answered this
question in the affirmative. With further experience
I should qualify this considerably.
I am convinced that the aspirator has been a much
misused instrument, and since the perfection of an
aseptic technique, the occasions for its use are
becoming increasingly rarer. The chief danger of
aspiration is, of course, internal hemorrhage. Some
fourteen years ago I lost a patient after exploratory
puncture of a much enlarged liver. Two hours after
the operation he suddenly became collapsed and died
in less than an hour. The autopsy confirmed what
was already only too obvious, and I had not even the
mitigation of finding an abscess. On talking this case
over with a colleague he cited a similar experience,
and told me he had also heard of another within a
short time. We have all heard of these cases, but it
is obvious that the majority find no permanent record.
The only safe conclusion for guidance in practice is
that the danger of internal hemorrhage after explora-
tory puncture of the liver is greater than authority
would lead us to suppose. A further argument
against the use of the aspirator in my experience is
its unreliability. I have more than once extracted
sufficient pus to induce me to cut down on the organ
only to find an insignificant cavity. Per contra, I
have also failed to extract pus when it was present in
large quantity. I do not mean I have missed the
abscess cavity, though this is always a possibility, but
that I have actually failed to aspirate pus through the
cannula inserted into the abscess. Case No. 3 of my
series was a striking instance in point. Aspiration
trans-thoracically revealed pus and a small abscess
was opened and drained. At the same sitting the left
lobe which was much enlarged was punctured and
aspirated in two places through the epigastrium,
without effect. The patient was but little better for
these measures, and five days later I again aspirated
the left lobe without effect. This time I was not
deterred by the negative result, but cut down and
drained a large abscess full of typical liver pus. The
patient died on the thirteenth day after the second
operation, and I regret that I relied too much on the
aspirator and too little on my clinical observation.
This is by no means a solitary experience, and such
instances have led me to regard the aspirator as an
aid to diagnosis with great distrust.
Another danger is an anatomical one. I refer to
the risk of exploratory puncture through the ab-
dominal wall in the epigastric or hypochondriac
regions. The danger of puncturing other hollow
viscera is not great if the puncture is strictly confined
to the limits of a definite swelling. But abscesses in
these regions may originate in the gall-bladder or be
confined to the lesser omental cavity as the result of
duodenal or gastric perforation. Or, further, a true
hepatic abscess may exist on the under surface of the
organ at some distance from the surface, and, of
course, without the existence of parietal adhesions.
In the absence of adhesions the pus, under con-
siderable pressure, may leak alongside the cannula, or
through the puncture wound when withdrawn, and
there is a definite risk of infecting the peritoneum.
The presence of the cannula is further a hindrance to
a clean incision, and when the parietes are divided
the difficulty of packing off the general peritoneal
cavity with pus oozing from the abscess is consider-
ably enhanced.
If, on the other hand, the abdominal wall is incised,
with a sand bag placed under the loins, and no
adhesions are found to exist, an excellent and un-
interrupted field of operation is obtained. Preliminary
packing is carried out with precision and certainty,
and the abscess is evacuated and drained with com-
parative ease. Supposing no abscess of any kind is
found the exploratory incision can be closed without
danger or risk to the patient, and much yaluable
diagnostic information may be obtained.
140
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
Two cases out of 27 proved on incision to be sub-
phrenic abscesses. The second case presented himself
at the Out-patient Department, complaining of severe
epigastric pain. Nothing more was seen of him for
one month, when he came up looking very ill and
emaciated, with a tense, bulging swelling in the epi-
gastric region and the liver palpable for two fingers'-
breadth below the costal margin, continuous with the
swelling. It looked exactly like a typical abscess of
the left lobe, but the event proved that the collection
of pus was entirely distinct from the liver. As exten-
sive parietal adhesions were present, the aspirator
would have done no harm, but would not have been
of the slightest assistance.
Three other cases well illustrate the possible
dangers of indiscriminate epigastric puncture ; in none
of these cases did parietal adhesions exist. In one
case the patient, an elderly man, appeared to be
suffering from hepatic abscess. The organ was
enlarged and the margin palpable for two or three
fingers’-breadth below the costal margin, while there
was an indefinite boggy swelling in the epigastrium.
There was no edema of the integuments. As the
physical signs were not very definite, I cut down
through the right rectus instead of using the aspirator,
and, finding no parietal adhesions, opened the abdo-
minal cavity. A digital examination revealed the free
healthy margin of the right lobe, and some 2 in. away
from it the commencement of an abscess sac sub-
imposed on the under surface of the organ. While
performing an autopsy some years ago I met with an
almost exactly similar case of a sub-hepatie abscess
unrecognized during life, and wondered at the time
how such a case would be dealt with in actual prac-
tice. When confronted with a similar state of affairs
in the case recounted, the peritoneal cavity was packed
off with gauze with some little difficulty on account
of the depth, and the abscess opened by Hilton’s
method. A drainage tube was inserted and the soiled
pack replaced by a clean one, which was removed
on the third day. An uninterrupted convalescence
followed.
Now in both these instances the abscess could
only have been aspirated by traversing not less than
3 in. in thickness of healthy liver in addition to the
abdominal wall, and I have grave doubts if it could
have been reached at all. Supposing it had been, the
danger of hemorrhage in the first place, and of
pushing the drainage tube through the thin: abscess
wall in the second, and so infecting the general peri-
toneal cavity, would have been considerable. These
cases have convinced me that the use of the aspirator
is contra-indicated if the abdominal wall has to be
traversed, unless the parietes are obviously adherent.
In the case of exploratory puncture through the
thoracie wall the anatomical conditions are different.
Here there is no question of the possibility of punctur-
ing any other organ but the liver. Further, by reason
of the unyielding character of the thoracic wall,
incision has no advantage over puncture from a
diagnostic point of view while it has obvious dis-
advantages.
Objections to the Diagnostic Use of the Aspirator :—
(1) Danger of internal hemorrhage.
(2) Unreliability.
(3) The obscuration of the field of operation by
pus if no adhesions exist.
(4) The danger of an intraperitoneal leak, if no
adhesions exist, when passed through the abdominal
wall.
Having thus reviewed its limitations I may
formulate rules for guidanee in its use for diagnostic
purposes only.
(1) The aspirator, as & means of diagnosis of
hepatic abscess, should never be employed until all
other diagnostic methods have been fully tried and
have failed ; they include repeated careful local
examinations, a leucocyte count, and emetine hypo-
dermically.
(2) Its use is only justifiable then on the condi-
tions that (a) the patient has been prepared by the
administration of caleium salts in full doses for
twenty-four hours beforehand ; (b) that the puncture
is only made through the thoracic wall and never
through the abdominal parietes unless they are ob-
viously adherent ; and (c) that preparations have been
made beforehand to incise and drain the abscess at
the same sitting, in the event of pus in any quantity
being found. This condition applies with even greater
force to exploration and aspiration of the pleural
cavity.
(3) After its use with negative results a firm body
roller must be applied and the patient kept as quiet
as possible, while the administration of calcium salts
is continued for twenty-four hours longer.
The Use of the Aspirator as a Therapeutic Agent.—
On its introduction, many years ago, the dangers of
general and local infections consequent upon an open
operation were imminent and real, but with the strides
made in aseptic technique this is no longer the case.
To advocate its continued use on the former grounds
appears to me to largely overlook the radical changes
in the conditions under which modern surgery is
practised. But to advocate its use on the grounds
that infection from the atmosphere, or secondary
aerial infection, is an imminent danger following
incision and drainage, is to wholly disregard the
classical experiments of Tyndall and others, which
were accepted by Lister himself twenty-five years
ago, and strikes at the root of aseptic surgery as it
is now practised. Secondary aerial infection is a
chimera, and everyday experience proves that it is so.
There is no denying the possibility of secondary
infection after incision and drainage, but when it does
occur it is either due to direct infection from the skin
or to infection conveyed by the hands, instruments,
or dressings, &c., and is consequently largely pre-
ventible. There is far greater danger in the con-
tinuous drainage of an hepatic abscess by a compara-
tively small cannula than by a free incision. With
a small localized, and consequently quiescent, abscess
to deal with, it matters little what you do. Relieve
the pus tension and Nature will do the rest. Such
cases are certainly the exception in native hospital
practice. When there is pus in any quantity in the
liver the proper procedure is still to cut down and
May 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
141
drain the abscess freely, with strict aseptic precautions
of course.
The Operation.—(1) Cut down over the most pro-
minent part of the swelling ; if the skin is not actually
inflamed it will often be found cedematous. In the
absence of such localizing signs, ascertain the most
tender point and make the incision over it. The skin
incision should never be less than 3 in., and should be
parallel to the rectus in the epigastric region, to the
costal margins in the hypochondriac region, and to
the ribs in the thoracic region. The muscles should
be split and not divided with the knife.
(2) If adhesions do not appear to exist, cautiously
explore with the forefinger, but on no account break
down any there may be. If none exist, pack the
space between the organ and the parietes with a strip
or two of plain gauze, leaving an elliptical area about
14 in. in its long diameter.
(3) On no aecount explore the liver with the knife,
but plunge a pair of Lister's forceps into it with a
boring motion by Hilton's method. If the capsule
offers great resistance it may be punctured, and the
forceps then inserted.
(4) After the excess of pus has drained away,
insert two good sized rubber drainage-tubes eyeletted
at intervals, lumen % in. in diameter. One should
extend to the full depth of the cavity, the other may
be shorter to act as an air vent. Transfix each with
a separate safety pin placed at right angles to the
wound.
(b) Next evacuate as much residual pus as possible
with Bier's suction cup, or by turning the patient on
to his face.
(6) Reduce the size of the skin incision by one or
more silkworm gut satures suitably placed, and pack
round the tubes with gauze.
Anesthesia.—In very prostrate cases with large
abscesses the rapid induction of shock under chloro-
form is striking, and in eight out of my last nine cases
I discarded general in favour of local anesthesia. I
use P. D. & Co.’s eudrenine, 1 c.c. or an ordinary
hypodermie syringeful, and dilute it with five or six
syringefuls of sterile saline and inject the whole
quantity. In one case following Crile, I used a
solution of quinine and urea hydrochloride for the
deeper parts, as the anssthesia lasts longer. The
absence of hamorrhage at the time bespeaks care in
hemostasis, or recurrent hemorrhage may occur
later. All obvious vessels must be clipped and liga-
tured. An incidental advantage of local anesthesia
is that there is no need for haste.
If a rib has to be resected a general anesthetic
must be given, and speed is an important factor under
these conditions. A good pair of rib shears is much
to be preferred to a saw and bone-cutting forceps.
Rib resection, which is advocated as a routine
measure when the thoracic wall is traversed, is in
my experience comparatively rarely necessary, three
times in eight cases; and I am satisfied it is better
avoided when possible and held in reserve for special
cases. There is usually ample room for two medium
sized drainage tubes in the eighth or ninth inter-
costal spaces in the mid-axillary line, and the incision
can usually be placed here,
When parietal adhesions are absent (pleural or
peritoneal), the practice of suturing the serous layers
before opening the abscess is extremely unpractical.
It is always difficult, sometimes insuperably so. It
takes much valuable time, and even when successfully
performed the stitches are very likely to cut out with
the alteration of the relative position of the parts
coincident upon the opening of the abscess. Gauze
packing is the proper method to adopt; not only can
it be rapidly performed, but it adapts itself auto-
matically to alterations of position and is, therefore,
much more reliable.
Drainage.—Two tubes should always be used if
possible. With two tubes and due attention to
posture after operation, there should not be the
smallest difficulty in securing free and uninterrupted
drainage through an anterior or a lateral wound.
Iam not a believer in counter-openings posteriorly.
It increases the severity of the operation enormously.
I have seen cases with tubes sticking out of them in
three or four situations. The scars left are often very
painful. Such a state of affairs appears to me to be
a confession of failure to secure proper drainage at
the primary operation. Secondary sepsis, too, may
be responsible for later counter-openings—a con-
fession of failure in another direction. Suction with
Bier’s apparatus is a great help nowadays, but pos-
ture and the use of the double drainage tubes are
our sheet-anchors.
Strict asepsis is, of course, absolutely essential, both
at the time of operation and during the after-treat-
ment. The superficial dressings must be changed
frequently at first, and later irrigation with a weak
iodine lotion promotes healing. Bismuth paste or
gauze packing will shorten the closure of subsequent
sinuses. Emetine hypodermically should always be
given as a routine measure.
TREATMENT OF LIVER ABSCESS.*
By Joun D. Sanpes, I.M.S.
Medical College Hospital, Calcutta.
THIRTY-TWO cases of liver abscess were operated
on in the last twelve months. The statistics are
somewhat misleading, as they seem to show that
opening and drainage is a more successful method
of treatment than simple aspiration. All the most
serious cases were treated, in the first instance at
least, by aspiration—indeed, the condition of many
of them would not allow of any more prolonged inter-
ference. Those treated by incision and drainage
include all the cases of abscess of the left lobe, which
class of abscess, as a rule, is smaller and less serious
than abscess of the right lobe ; twenty-one cases were
treated by aspiration alone, and of these six died. This
seems a high proportion of deaths, and so it is, but
when we consider the conditions under which many
of these cases were done and the extent of the mis-
chief, I do not think the mortality at all great. A
majority of my cases are operations of emergency,
* From the Indian Medical Gazette, March, 1914.
142 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
done at all hours of the day and night immediately
on arrival of the patient. Many of the cases are in
an emaciated and some in a moribund condition, and
it is almost questionable if any operative interference
at all is justifiable in some, even although one is quite
aware that there is a liver full of pus waiting to be
tapped. I have, however, always aspirated these
cases, however bad, as it gives the only chance of
recovery. Aspiration alone is permissible in these
cases, and this no doubt swells the mortality of the
cases under this heading. All the cases of large right
lobed abscesses in which there was no definite point-
ing were also treated by this method. Again, under
this heading are included those cases in which the
abscess had burst into the pleura. Many of the cases
required more than one aspiration—one or two as
many as four—as in Case 19 of my series, in which
90 oz., 48 oz., 40 oz., and 36 oz. were respectively
drawn off at four successive aspirations and recovery
followed. Case 29 was the biggest abscess I have
ever seen; at the first operation 126 oz. of pus were
aspirated, and a few days later another 40 oz. The
patient was in an extremely low condition from the
start and finally died. Of those that died, it is often
noted in the notes that they are “ weak and ema-
ciated,” and there is little doubt that a fatal result
would have ensued no matter what treatment was
adopted. A solution of quinine of strength 10 gr. to
the 1 oz. water was injected into the liver cavity after
aspiration in a number of the cases, and before the
emetine treatment was adopted as routine, was an
important method of treatment, and especialiy valu-
able in those abscesses of medium size containing
about 20 or 30 oz. of pus. In these cases one
aspiration followed by quinine injections often effected
a cure. During the procedure of aspiration it is
noticeable that the pus flows steadily out through the
aspiration needle until the majority of it has been
removed, then it comes more slowly in thick drops,
and finally there is often left afew ounces of thick
residual pus that defies extraction by the aspirator.
For these cases I adopt the very useful procedure of
forcible aspiration by means of a strong metal syringe.
The syringe is connected with the aspirating needle by
means of a short stout piece of rubber tubing, and by
exercising forcible suction as much as 10 or 15 oz.
of very thick ropy pus can often be withdrawn in
addition to what has been taken off by the aspirator.
There is perhaps a slight tendency for this forcible
aspiration to cause some hemorrhage, and if much
blood enters the syringe the procedure must, of course,
be given up, but in my own experience I have never
come across a case that has given rise to any anxiety
in this way. I consider this is a most useful sub-
sidiary method of treatment, and I also think that it
is in these cases that the injection of quinine is most
useful. Very large abscesses almost always need a
second and even a third aspiration, and I do not think
these injections of quinine have as much effect in
these cases until the second or third occasion, when
the abscess cavity has contracted down considerably.
The point of aspiration depends, of course, upon the
position of the abscess, but in the many cases in which
(May 1, 1914.
there is no actual pointing, but only general enlarge-
ment of the right lobe of the liver, I have found the
posterior axillary line as high up as possible and con-
sistent with safety to be the most satisfactory place.
There is a tendency for right lobed abscesses, which
form the large majority of all cases, to bulge down-
wards towards the abdominal cavity, and if these are
aspirated too near the costal margin, there is a
tendency as the aspiration proceeds for the abscess
to retreat upwards towards the diaphragm, and the
needle thus becomes tilted and at times obstructed.
If pus is not reached at the first puncture, it should
be repeated, and if necessary many punctures in
various directions made. General anesthetics are
better avoided, if possible. I have done the large
majority of my aspirations under local anesthesia,
and I have uo doubt that in those grave cases of
large right lobed abscess it has helped to bring
about a successful termination of some of the cases.
If ethyl chloride is used to freeze the skin and a
slight notch then made with a knife, the procedure
of aspiration is, to all intents and purposes, painless ;
certainly no more painful than tapping an ascites for
which nobody ever thinks of giving a general anws-
thetie. I have, to a large extent, given up the in-
jection of quinine into the abscess cavity, as I believe
it is unnecessary now that we have emetine at our
disposal. The usual procedure is now, after aspira-
tion, to give an injection of 4 gr. or 1 gr. on the table
(hypodermically), this dose being repeated daily for
six days. This single daily injection is better than a
smaller dose morning and evening, as the latter, on
account of the number of punctures, tends to cause
soreness of the skin.
Six eases were treated by incision and drainage
with one death. Most of these cases were small left
lobe abscesses, some were pointing abscesses without
any very marked enlargement of the liver, in which it
was often difficult to say whether they were liver
abscesses or merely superficial parietal abscesses. In
either of the above cases aspiration is not a suitable
procedure. The incision is made over the pointing
portion, and when pus is reached a finger is inserted
and the abscess cavity explored. Drainage tubes are
inserted, and the pus encouraged to drain into pads
of sterile wool. The difficulty is to keep these cases
free from pyogenic contamination. A general anes-
thetic is necessary in these cases, and thus a new
danger added that can be avoided in the method by
aspiration. About 30 oz. of pus is the largest
amount I have evaeuated by this means.
Finally, four cases were treated by aspiration,
followed at a later date by incision. All of these
recovered. This method of treatment is a most use-
ful one as a certain number—luckily not very many—
fill up rapidly even after repeated aspiration. The
patients often improve much after aspiration, and by
the time incision and drainage is performed are in a
better condition to bear the operation. I have no
doubt this continual drainage is necessary in some
cases, and it has its particular use in those cases of
large abscess which have been improved, but not
cured, by, aspiration.
May 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
143
In conclusion, then, aspiration is the method of
choice, and should always be attempted even in appa-
rently desperate cases. The puncture should be made
in the posterior axillary line as high up as possible.
No general anesthetic should be given, and 1 gr. of
emetine should be injected hypodermically while the
patient is in the theatre. Incision and drainage
should be performed for the abscesses of the left lobe,
and abscesses that are pointing, particularly if there
is no great general enlargement of the liver. Free
drainage by large rubber tubes should be provided.
A combination of these methods is indicated when
aspiration has not effected a cure.
—9————
A: ebicfos,
DEFENSIVE FERMENTS OF THE ANIMAL ORGANISM.
By Emil Abderhalden. Translated by J. O.
Gavronsky and M. F. Lanchester. Pp. xx +242.
London : John Bale, Sons and Danielsson, Ltd.,
1914. Price 7s. 6d. net.
An English translation of the Third Edition of the
work of this distinguished German physiologist is
most welcome, considering the large number of
articles that appear in English and American
journals in which his methods are discussed.
Although Abderhalden's technique for the detec-
tion of pregnancy is the best known, in the same
way that the Wassermann test is the most fre-
quently used form of complement fixation, his lines
of investigation are both numerous and of extreme
promise. These new methods of research for testing
the function of organs and the differential diagnoses
of various diseases by essentially physiological
methods are mainly of physiological interest, their
performance being vastly more elaborate than the
Wassermann test. The defensive ferment reaction
localizes, as far as possible, the diseased parts and
often also the character of the lesion. It is of use
in investigating the dystrophic lesion of the genital
glands in dementia precox, epilepsy and other
mental conditions; diseases of the blood, as perni-
cious anemia, may also be usefully investigated.
Joint diseases, as gout, rheumatism and rheumatoid
arthritis, may be traced to their primary causation.
German books and translations are proverbially
difficult to understand, and, in this instance, several
hours’ deep concentration and study will be required
before the reader is able to thoroughly appreciate
and reap the benefit of this line of investigation,
but the labour will be amply repaid. In the past
medicine has received many benefits from physi-
ological studies, and in the future the line in ques-
tion bids fair to confer great benefits on practical
medicine. For this end to be attained, it is only
fair that clinical workers should inform themselves
of it and put themselves in a position to co-operate
with physiologists. __
Several of the terms used are given in a new
sense, as the words ''fundaments " and ‘‘ sub-
strate," ‘‘ harmony " and ‘ disharmony,’’ which
are not capable of literal translation,
——
There is a very full table of contents, and the
pages are headed with indications of the subject
matter—a boon far too frequently absent from
English publications.
The methods consist, first, of the dialysation
process, and, secondly, of the optical method
requiring elaborate apparatus.
Embracing, as the work does, the borderland of
physiology and medicine, the book is of equal
importance and interest to both.
SANITATION IN INDIA.
D.P.H., with eontributions by others.
Bombay: Times of India Press, 1914.
Although the title of the book is “Sanitation in
India," a second title might well be “ Tropical Sanita-
tion," as all subjects relating to hygiene of the Tropics
are dealt with. The practical application and prin-
ciples of sanitation are gone into very thoroughly.
The subject is so arranged as to facilitate reference
to the matters dealt with, and the various types used
for headings are & great help to the reader.
After a comparison of the sanitary administration
in England and India, the circumstances connected
with cities and ports are then dealt with. Collection,
removal and disposal of town refuse are followed by
consideration of sewage matters; the important
subject of water, such as sources, hardness, storage,
distribution, examination, composition. The con-
sideration of food and' milk has particular attention
paid to it, especially as regards the parasites in water,
meat, fish and other food-stuffs. The parasitic diseases
of animals, as well as the bacteria of milk and the
preservation of meat, milk and vegetables by various
methods, are described and explained.
An especial feature of the book is the attention
paid to all the minute details connected with the
prevention of tropical diseases.
Although considerable space is devoted to the
description of cholera, plague and typhoid, subjects
which are apt to escape the notice of the student at
home receive due attention. For example, the house-
fly, its habits, life history and means of extermination
are so interestingly discussed that the reader can
imagine that he hears the buzzing of their wings,
and feels inclined to consign them to their traditional
father.
With regard to malaria and mosquitoes, of which
everyone in the Tropies reads so much, the subject is
condensed into a clear account occupying a little over
sixty pages.
Native habits and customs, dangerous and offensive
trades and occupations, disinfection and cleansing, are
considered in a way that show the hall mark of thc
practical worker.
School hygiene, a subject of even greater anxiety
in the Tropies than at home, to both doctors and
teachers in schools of all grades, is sympathetically
discussed.
The housing problem shows that the editor and his
collaborators are masters of their craft, and have an
open mind as regards comfort.
Vital statistics and meteorology, which have a
By J. A. Turner, M.D.,
Pp. 1014.
144
bearing in India on famine and its consequences,
often only too tardily appreciated by lay adminis-
trators, are by no means the least important portions
of the work that claim the attention and interest of
the reader.
A pleasing feature is the introduction of a number
of interesting photographs of native scenes.
The type and correct printing are quite up to
European standard, and far beyond the average of
tropical printing.
BRITISH RED Cross SocIETY HYGIENE AND SANI-
TATION MANUAL. By Lieutenant-Colonel S.
Guise Moores, R.A.M.C. Five coloured plates
and 73 illustrations, pp. 183. London: Cassell
and Co., Ltd., 1914. Price 1s.
Although this work is mainly intended for residents
in England, it can be confidently recommended for
tropical residents, who, for their own sake and those
dependent upon their supervision, must have a know-
ledge of the subject. Many useful hints are given
upon house and camp sanitation. The well-designed
illustrations, which facilitate the understanding of
somewhat technical matters, the format of the book,
its well-rounded edges, light weight and an excellent
index, all contribute to its ready use in all parts of
the world.
MEDICAL ANNUAL, 1914. A Year Book of Treat-
ment, and Practitioners Index. A Dictionary
of Modern Therapeutics, a Dictionary of New
Treatment. 32nd Year, 1,000 pp., illustrated in
colour and black and white. Published by John
Wright and Sons, Ltd., Bristol. Price 8s. 6d. net.
This well-known work thoroughly maintains its
reputation, and can be confidently recommended to
all who are not in close contact with a good medical
library. During the preceding twelve months so
much original work has been produced that it is
difficult to select special items of interest, but it is
satisfactory to note that not only is the information
of the whole medical literature of the world epitomized,
but also that the writers are resident in the chief
centres of Europe, Asia, and America—as Frankfort,
Vienna ; from Leeds there is an article furnished by
Sir Berkeley G. A. Moynihan; from Fall River,
Mass., Dr. Richards writes upon Diseases of the
Ear; Dr. Gruner (Montreal) upon Clinical Pathology ;
Dr. Tucker (Virginia) upon Pellagra ; and by no means
of least interest is the article by Major Leonard
Rogers, of Calcutta, upon Tropical Diseases.
THE BACTERIOLOGICAL EXAMINATION OF Foop
AND WATER. By William G. Savage, M.D.
Demy 8vo., pp. x + 174, with 16 illustrations.
London: Cambridge University Press. Price
Ts. 6d. net.
This work, which will be of considerable assistance
to all bacteriologists, makes a special claim upon
members of public health sanitary committees. That
large body of educated, intelligent people interested
in problems of public health, with a moderately care-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
ful study of this volume, will be able to appreciate
the difficulties of bacteriological examinations and
the deduetions to be drawn from the data obtained.
The methods described are of practical value and
proved utility, and the reasons given why the con-
clusions are arrived at may be used as a basis of
administrative action.
Chapters are devoted to water, air, soil and sewage,
milk and meat. The appendix contains the method
of preparation and standardization of the most ap-
proved culture media.
ATLAS TROPISCHER DARMKRANKHEITEN. By Dr.
Gustav Baermann and Dr. Otto Eckersdorff.
Published by Johann Barth, Leipzig, 1913.
Price 80 marks.
This is an exhaustive work on the subject, dealing
with all tropical diseases of the intestine. There
are fifty-seven coloured plates, including photomicro-
graphs. Particularly noteworthy is the consideration
of dysentery, both ameboid and bacillary. It em-
bodies the results of a long and careful study in the
Dutch West Indies. We are in the habit of seeing
beautiful illustrations of macroscopic and microscopic
pictures produced by this well-known Leipzig firm,
but the illustrations in this work are equalled by few
and surpassed by none.
Although the work primarily deals with tropical
diseases, it will be of interest to all workers on the
functions of the intestines. The picture of mercurial
enteritis is of special importance to those interested
in medical jurisprudence.
In spite of the work being somewhat large for a
private library, there is all the more reason why it
should find a resting place in every up-to-date medical
library.
— e
Becent and Current Xiterature,
A list of recent publications and articles bearing on tropical
diseases is given belcw. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of TBE JOURNAL OF TROPICAL MEDICINE AND
HYGIENE will be pleased, when possible, to send, cn appli-
cation, the medical journals in which the articles appear.
“ British Medical Journal,” February 21, 1914.
Appendicitis in Children.—H. M. W. Gray, F.R.C.S.,
and Alex. Mitchell, M.Ch., contribute an analysis of 200
cases of appendicitis in children under thirteen years of age
operated on in the Aberdeen Royal Hospital for Sick
Children.
The special points to which they direct attention are:
(1) The fulminant nature of appendicitis in children. We
have had several cases of diffuse peritonitis with stinking
effusion where the children had been playing in the street
within twelve hours before admission to hospital.
(2) Diffuse peritonitis, contrary to the usually expressed
opinion, is common in children. (3) Abdominal pain and
sickness requires careful inquiry and examination of the
region of the appendix. (4) Diarrhea is an untoward
sign. (5) Frequent micturition combined with pains
coming on suddenly suggests the possibility of appendicitis.
(6) Early recognition and early operation are necessary
conditions of success in treatment.
May 15,1914]. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 10, Vol. XVII
Original Communications,
VACCINE LICHEN IN NATIVES.
By ALBERT J. CHALMERS, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories,
AND
Captain W. Byam, R.A.M.C.
Senior Medical Officer, Khartoum District, Egyptian Army.
Introductory.—Much has been written on the
appearance of vaccination rashes of all descriptions
in the white skin, but, as far as the literature at our
disposal here indicates, very few observations have
been made on the same conditions as seen in the
black skin of African natives.
Skin eruptions as depicted in illustrations of
diseases occurring in white people seldom appear
applicable to the black skin because some of the
signs, for example, those indicating inflammation,
and especially the redness seen in the white, are
with difficulty observed in the black skin.
We therefore are of the opinion that any contri-
bution which attempts to depict an eruption as
seen in dark-coloured peoples may possibly be of
help to other workers who, like ourselves, may have
encountered considerable difficulties in making
diagnoses of skin rashes.
Historical.—There appears to be a dearth of
descriptions of vaccinial rashes as seen in the
African native, but there are references to septic
and syphilitic rashes following vaccination, and
there is an excellent paper by Hill and Ross on
“ Epidemic Generalized Vaccinia,” as seen in Natal.
These authors say that ‘‘ the occurrence of a general
cutaneous eruption consequent upon vaccination is
a possibility generally recognized, but the meagre
literature on the subject and the scanty and brief
references in the present-day text-books of medi-
cine indicate that the condition is only occasionally
encountered. ”’
They, however, proceed to give an account of a
rash quite unlike that which we have met with:
In fact, only Crocker has described an eruption
which appears to be in any way similar to that
which we have seen. He says that he has notes
of over twenty cases of the so-called '' vaccine
lichen,’’ which he describes as follows :—
** It may be papular, papulo-vesicular or pustular,
very rarely bullous. It comes out from the fourth
to the eighteenth day, most frequently on the
eighth; begins on the arms in half the cases, and
on the trunk, neck or face in the rest, and then by
successive crops it may spread over a considerable
part or the whole of the body, pretty evenly distri-
buted and sometimes tending to form circles or
segments of circles.
** The papules are acuminate, pin-point-sized and
bright red, and these characters may be preserved
to the end. They usually remain discrete, but
sometimes coalesce into patches, but as a rule
a good proportion of the papules. are crowned
with. small vesicles and pustules and have
a Ted areola sometimes 1 in. in diameter, the
vesicles or pustules being generally small. In a
moderate number of cases the eruption, as a whole,
is vesicular or, rather, papulo-vesicular, but it is
rarely entirely pustular,
“In ordinary cases when the small vesicles dry
up they leave the base as a flat shining papule,
like lichen planus.
'' There is rarely any constitutional disturbance
and usually only moderate itching, but occasionally
it is severe.
'"' The rash lasts from a few days to a week or
two."
The above description is taken verbatim from
Crocker's book on '' Skin Diseases," merely omit-
ting his references to the bullous and the vesiculo-
pustular forms of the eruption, which do not con-
cern us. None of our cases showed pustules or
bulle, but the rest of his description, as we shall
show later, agrees with the eruption which we have
seen.
Norman Walker, in plate 7 of the 1904 Edition
of his '' Introduction to Dermatology,” depicts a
condition apparently analogous to that which we
are about to describe, but in the brief reference to
it in the text he considers the condition to be a
vaccinial eruption of septic origin, a statement with
which we cannot agree. Moreover, he calls it an
erythema, but his illustration shows elevated
papules which must be identical with those of
Crocker’s eruption and our own cases. According
to Schamberg, vaccine lichen is excessively rare.
Very excellent summaries of vaccination rashes are
given by Acland in Allbut and Rolleston's '* System
of Medicine,’’ 1906, and Morris in his ‘‘ Diseases of
the Skin,’’ 1911, the latter’s classification being :—
(1) Eruptions due to the vaccine virus.
(2) Eruptions due to the vaccine virus together
with an additional virus.
(3) Sequele of vaccination.
Acland’s classification is much the same :—
(1) Eruptions peculiar to vaccination.
(2) Eruptions not peculiar to vaccination.
(3) Complications.
The eruption which we are about to describe is
easily classifiable under these systems, but, strange
to say, neither of the above authors includes a de-
scription which agrees with what we have seen.
Racial and | Geographical Distribution. — The
natives among whom we have found the vaccinial
eruption about to be described belonged to two
races of Nilotie negroes of the Anglo-Egyptian
Sudan, viz., Nuers and Nubas.
The Nuers are a powerful race, living in the
Upper Nile and Bahr-el-Ghazal Provinces, just
north of the well-known Dinka tribes, to whom
they are apparently allied. The skin of both
Dinkas and Nuers is quite black.
The Nuba tribes live in the hills of Southern
Kordofan, a name probably of Nuban origin. The
skin of these natives is very dark, being almost
black. Both Nuers and Nubas are devoid of cloth-
ing in their natural condition.
A few weeks ago a number of Nuers and Nubas
were brought as recruits to Khartoum and were duly
146
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
vaccinated in two quite separate detachments,
twenty-four on February 10, 1914, and thirty-six
on February 28, 1914. The vaccinia developed well
in all cases, but eleven cases, i.e., eight Nuers and
three Nubas, developed a peculiar eruption. Of
these the eight Nuers belonged to the first batch
and the three Nubas to the second batch. It will
thus be observed that the eruption appeared in two
quite distinet races of Nilotie negroes in two quite
distinct batches, but all vaccinated with the same
supply of glycerinated lymph derived from one calf
obtained from the laboratories of the Egyptian
Public Health Department in Cairo.
Sex and Age.—All the patients were young,
strong males about 18 to 20 years of age.
Symptomatology.—In every case the vaccination
took well and developed normally, and in no ease
was there any sign of septieity or infection.
A brief summary of the symptoms presented by
these eleven patients is as follows :—
Some seven to nine days after vaccination the
patient complained of a sensation of itehing in
various parts of the body, but most commonly at
first on the forearms. "This was followed in a few
hours by an eruption of dark-coloured macule,
which quickly became papules. They appeared
first upon the backs of the hands and forearms,
then on the back of the neck, then on the face,
chiefly on the forehead, the chest and back, coming
out in successive crops. The number of these
papules varied considerably in different cases from
a few dozen to several hundred.
When fully developed the skin eruption consisted
of well-defined small papules (fig. 1) or papulo-
vesicles, because even those which showed no
vesicles to the naked eye produced a hard, shotty
sensation on palpation, and on microscopical
examination (figs. 2, 3 and 4) were each found to
contain several minute vesicles.
These papules or papulo-vesicles were raised
some 3 mm. above the surrounding skin, which as
a rule appeared normal, though in some of the
cases it was distinctly congested, and in one case
there was such marked swelling of the whole arm
as to partially obscure the papules until it subsided.
Some of the papules showed small vesicles at the
periphery or on the summit, but these easily seen
vesicles were relatively few and no pustules or
bulle were ever observed.
In size a fully-developed papule was comparable
to a large pin's head, and in appearance it was
rather flatly acuminate or, perhaps more correctly,
sharply dome-shaped.
In every case the onset of the eruption was
heralded by a mild attack of fever, the temperature
rising as high as 1029 F. in some of the cases, but
this febrile attack subsided as the rash developed
and the temperature did not again rise above normal.
During the febrile attack some of the patients
suffered from a dry cough, which became worse as
the eruption developed and then slowly disappeared.
There was no vomiting, diarrhea, or other symptom
worthy of record, while the progress of the local
vaccinia was quite normal, The blood showed no
malarial or other parasites, but there was a leuco-
cytosis and a marked relative increase in the mono-
nuclear leucocytes and in the eosinophile cells.
After lasting some four to five days the rash
slowly disappeared, but this was associated with a
well-marked desquamation where the papules had
been present (fig. 5).
When the rash disappeared and, indeed, for some
time previously, the patients were not merely in
good health, but indignantly well, wishing to return
to their work.
Morbid Anatomy.—In order to study this condi-
tion more carefully a biopsy was performed and two
papules were carefully removed from the forearm
and at once fixed with Schaudinn's fluid and eventu-
ally eut into serial sections and stained by means
of hematoxylin and eosin by Gram's and by Leish-
man’s methods.
On microscopical examination by the aid of a
low power magnification (about 100 diameters) the
most obvious pathological features are an increase
in the depth of the stratum corneum and the pre-
sence of small vesicles lying, as a rule, between
the stratum corneum and stratum lucidum on the
one hand, and the stratum granulosum on the other.
It was also remarked that the whole stratum
corneum and a part of the stratum lucidum showed
a tendency to separate from the rest of the
epidermis.
The small vesicles or cavities varied in size from
a vacuole visible only with higher magnifications
to a vesicle easily visible with a magnification of
much less than 100 diameters. The larger vesicles
were always situate laterally in the section (laterally
in the papule).
In places, with the sole exception of the thickened
stratum corneum, the section appears to be quite
normal. The stratum lucidum in these places is
normal, and so are the strata granulosa, malpighii
and germinative. The papille and dermis also
appear to be quite normal and there is no leucocytic
invasion of the rather thick, prickle cell layer. The
principal pathological changes appear to be asso
ciated with the stratum granulosum and the parts
external to this. In a superficially lying cell of the
stratum malpighii one may see a minute clear, round
eosinophile body lying in the cytoplasm. In
another cell more properly belonging to the stratum
granulosum it may be observed that the degenerat-
ing nucleus is lying in a vacuole, while a larger clear,
round eosinophile body lies in the cytoplasm. This
body appears to contain several dark staining spots.
In the stratum lucidum the cell (the nucleus having
disappeared) may be reduced to a vacuole in which
one or more of the clear round bodies may be seen.
but at one part of the stratum lucidum several cells
have evidently combined to form a minute vesicle,
containing a number of eosinophile round bodies
and a large number of granules.
Only two biopses were made and therefore papules
with vesieles apparent to the naked eye were not
examined microscopically.
Etiology.—The general appearanee of the erup
tion before any of the minute vesicles appeared was
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MAY 15, 1914.
Fic. 1.
Fic. 2. Fic 3.
Fie. 4. Fic. 5.
To illustrate article, ‘ Vaccine Lichen in Natives,” by ALBERT J. CHALMERS, M.D., F. R.C.S., D.P.H.,
and Captain W. Byam, R. A.M.C.
May 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
that of a lichen, but it did not agree with any of
the ordinarily described types of the disease.
Scrapings of the papules examined after treat-
ment with 40 per cent. caustic potash failed to
reveal any fungal hyphe or spores, and subsequent
staining by Adamson's and by the Oxford method
also failed to show any trace of fungi.
Inoeulations of various nutrient media with por-
tions of a papule, after skin sterilization by means
of absolute alcohol, failed to grow bacteria or fungi
even after four weeks, except one or two obvious
skin contaminations.
Animal inoculations were not performed, as the
true nature of the eruption was not at first recog-
nized.
Suspicion was later aroused that the eruption
might in some way be connected with the vaccina-
tion, whieh was taking its normal course; the sus-
pieion was strengthened when an identical eruption
appeared in a second batch of vaccinated Nubas.
Inquiries made from the Egyptian Public Health
Department, where this vaccine was prepared,
elicited the fact that it had produced no such
eruption in Egypt. No septic nor infectious
diseases were found to follow the use of this vaccine
in Egypt nor in the Sudan, with the sole exception
of this rash in two sets of Nuers and Nubas vac-
cinated at quite different times.
But the fact remained that the rash did appear
in these Nuers and Nubas, who are people quite
unaceustomed to vaccination, though small-pox and
a so-called chicken-pox, some of which may be
alastrim, because it is said to closely resemble
small-pox, may occur in African tribes. People just
recovered from typical alastrim are, of course,
susceptible to Jennerian vaccination.
Moreover, the time of the appearance of the rash
after vaccination was. suggestive that it was a
vaccinial eruption. The type of the eruption also
was very like that described by Crocker in the
twenty cases already mentioned. It was therefore
concluded that the eruption was vaccinial in nature,
i.e., was a generalized vaccinia.
The morbid anatomy, the finding of small
vesicles, their method of evolution and the peculiar
granules which they contained all supported this
view.
The granules in question, however, require
further discussion. They are obviously not arte-
facts, and they resemble closely the bodies called
chlamydozoa by von Prowazek in 1907, i.e., there
are minute granules, free or enclosed, in an eosino-
phile cloak. They increase in number as the vesicle
increases in size, but whether this is a true multi-
plication or an addition to the number already
existing by the rupture of a neighbouring cell cannot
be stated. When compared. with photomicro-
graphs, illustrations and descriptions of Guarnieri
bodies, some of them are found to closely resemble
the forms depicted and described. Further, Guar-
nieri bodies are associated with vaccinia and variola.
Taking all these points into consideration, we be-
lieve that some of these are Guarnieri bodies, which
are thought by many authorities to be parasitic, and
147
by others to be cellular degenerations, but both
agree that they are to be found in the lesions of
vaccinia.
We therefore are of the opinion that these bodies
support the clinical diagnosis that the rash was
vaccinial, but we have not applied the crucial test
of attempting to vaccinate another person or animal
from one of these lesions, as the true nature of the
eruption was not apparent to us at first.
Further, the observation that the lymph did not
produce untoward symptoms in a number of vac-
cinations nor in an inoculated monkey points to the
certainty that pure lymph was used.
Very elaborate experiments on variola and vaccinia
in quadrumana, together with an extensive review
of the literature, have been made by Brinckerhoff,
Tyzzer and Councilman in Manila. These observa-
tions are so complete and are so much in agreement
with other investigators’ work that it did not appear
to be in accordance with the present clinical paper
to repeat their experiments.
To summarize, we are of the opinion that the
etiological factor in producing the rash was pure,
uncontaminated calf lymph which for some reason
became disseminated in small quantity throughout
the body and produced a generalized eruption of a
much milder type than that usually described under
the heading generalized vaccinia, but one which
can be included under Heading I. of either of the
classifications given above.
Diagnosis.—A papular eruption in the years that
are gone would have been defined as a lichen in the
sense of the word used by Willan, but not in its
more restricted sense as used by Hebra, because
many of the papules became vesicles. The present
eruption is, therefore, easily differentiated from any
of the lichens used in the restricted sense of the
word for eruptions which remain as papules during
their whole course.
This particular form of lichen, in the broad sense
of the word, is a papular and papulo-vesicular erup-
tion, commencing with fever some eight days after
vaccination.
From the description given by Crocker of his
twenty cases and the record of our own cases we
would suggest the following diagnostic points :—
A papular or papulo-vesicular eruption beginning
about eight days after vaccination and heralded by
slight or no constitutional disturbance, but with
moderate itching, and usually commencing on the
arms, is most probably this eruption which may
be called a vaccine lichen, but which would he
better termed a papulo-vesicular vaccinia.
The diagnosis should be confirmed by attempts at
vaccination of a monkey from a papule or a vesicle.
The differential diagnosis may be made from :—
Lichen acuminatus by the fact that the hair
follicles are not attacked.
From craw-craw (in the restricted sense of the
word) by the absence of the horny consistency, and
by the smaller size of the vaccinial papules.
From lichen convex by being non-follicular and
by being an acute and not a chronic eruption.
From an ordinary generalized vaccinia by the
148
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(May 15, 1914.
E ee eee eee
Å—a oT: rr _OW —————M
main lesion being a papule and by the usually. small
size of the vesicles.
Prognosis.—This is invariably good, as all our
cases and apparently most of Crocker's cases re-
covered very quickly without any scarring or pig-
mentation. Crocker has pointed out that it may
go on to vesiculo-pustular formation, and in some
of these cases fresh crops may continue to appear
for months, or the vesicles may enlarge and become
herpetiform or bullous; but it is possible that these
exceptional forms are due to secondary infections
and not solely to the lymph.
Treatment.—The essential treatment is rest and
quiet. We gave all our patients quinine by the
mouth and an antiseptic ointment, i.e., carbolic
ointment, for the skin, and on this treatment they
rapidly recovered. ej
Prophylazis.—We can offer no explanation why
eleven out of sixty persons vaccinated by the same
lymph and belonging to the same African tribes,
living under similar conditions, and about the same
age and of the same sex, should develop an eruption
while others did not. We are therefore unable to
suggest any prophylactic measures.
REFERENCES.
‘« Anglo-Egyptian Sudan Handbooks” (1911 and 1912), vols.
iandii. Bahr-el.Ghazal and Kordofan.
BRINCKERHOFF, TvzzER, and COUNCILMAN (1906). Philippine
Journal of Science, vol. i, p. 242. Manila.
CASTELLANI and CHALMERS (1913). ''Manual of Tropical
Medicine," pp. 1592 and 1597. ndon.
Crocker (1905). ‘‘ Diseases of the Skin," p. 472. London.
Hirn and Ross (1910). Journal of Hygiene, vol. x, No. 2,
September 20, p. 187. Cambridge.
OLLE and WASSERMANN (1913). “ Handbuch der Patho-
genen Mikro-organismen," vol. viii, pp. 725 and 745. Jena.
Monnizs (1911). ''Diseases of the Skin," p. 254. London.
Norman WALKER (1904). ‘‘ Introduction to Dermatology,”
p. 66 and plate 7. Bristol.
PROWAZEK, v. (1911) :'Handbuch der Pathogenen Proto-
zoen,’’ 2 Lieferung, pp. 122-138. Leipzig.
ScHAMBERG (1911). ‘‘ Diseases of the Skin and the Eruptive
Fevers," p. 467. Philadelphia.
ILLUSTRATIONS.
The illustrations are improved if examined by means of a lens,
Fie. 1.
Photograph of the right arm of a Nuer, showing the fully
developed vaccine lichen. A scar of previous origin also shows
in the photograph.
Fic. 2.
Photomicrograph of a transverse section of a small papule
taken from the case depicted in fig. 1. Note the small vesicle
beginning on the right. x 120.
i Fic. 3.
Photomicrograph of small vesicles in the same papule as that
used for fig. 2, but in a different section. x 1,370.
FIG. 4.
Photomicrograph of the larger vesicle from a larger papule
taken from the same case as that depicted in fig. 1. x 1,400.
Fia. 5.
Photograph of the left arm of the same case as that of fig. 1,
howing the desquamation.
A LIST OF BLOOD-SUCKING ARTHROPODS
FROM THE LOWER CONGO, WITH A
VOCABULARY.
By Mercier GAMBLE, M.D.
The B.M.S. Hospital, San Salvador do Congo.
My time is mainly taken up with the ordinary
routine of a Medical Mission with a dispensary
attendance of 30,000 per annum, but in addition,
because of their medical interest, I have collected
the following arthropods. The majority have passed
through the Imperial Bureau of Entomology, and
I have pleasure in recording my thanks to Mr. Guy
Marshall for much courteous help.
I have been located at San Salvador,* in the Portu-
guese section of the Lower Congo Basin. It is
about ninety miles south-east of Matadi, the port
of the Belgian Congo, and is on the crest of a hill
with an altitude of 1,840 ft. in an undulating grass-
covered country. Even close to the town the grass
grows to the height of 15 ft., and the stems are used
for building the walls of the huts.
Stomoxys is our most common fly, nigra more
than calcitrans, and is a great pest in the hot wet
season from March to May. It causes large sores
on the ears of our dogs and annoys the poultry,
especially those with double combs. It drove me
on my arrival to take my siesta under a mosquito
net, a habit I wish my colleagues would adopt.
It is also no doubt one of the many flies that feed
on the discharges from septie wounds and unpro-
tected ulcers, and I wonder if, in addition to being
the most likely carrier of pellagra in the United
States, it is the carrier of Filaria perstans, which we
see so frequently when examining the blood of
patients.
We see few Tubanids, except congoiensis and
claripes, and these do not average one a week.
Tsetse are so few that they are probably followers
only.
Stegomyia fasciata is common in the wet seasons,
and on more than one occasion the Government has
sent round the town-crier ordering the destruction
or burial of old tins and calabashes.
The Eretmopodites chrysogaster were bred from
the larve found in an old tin.
We seldom see Anopheles; in fact, I had to send
my boys down the hill to the streams in order to
obtain the larve. !
Culicoides grahamii is common at sunset in April
and May; the bite is more painful but less per-
sistent than that of Stegomyia.
Ornithodorus is common in the sandy towns of
Kibokolo,* Ndamba and Mabaya.* Our local
natives dread the bite and the subsequent fever, and
so I have supplied some of them intending to travel
to infected districts with a preventive lotion of
naphthalene, creosote, castor and paraffin oil.
They have reported favourably on the effects.
Some Ornithodorus placed in a small cardboard box
* « Geographical Notes." JOURNAL OF TROPICAL MEDICINE
AND HYGIENE, February 15, 1912.
_ May 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
149
lived there for twenty-one months without any food
or moisture, thus showing the possible danger of
oecupying even a very old camp site.
Our house-dogs are much infected with ticks, even
though twice weekly we have them washed in disin-
fectants and have the ticks removed with the aid
of a pair of forceps.
I have not seen a fowl-tick, though from 500 to
1,000 fowls are brought to the station yearly. The
ticks collected have been determined by Professor
G. H. F. Nuttall and Mr. C. Warburton, and I
desire to thank them; as also Rev. R. H. C.
Graham for his help with the vocabulary.
Kimpese is on the railway about half-way between
Matadi and Thysville, and Wathen* or Letete is to
the north of it, a few miles south of the River Congo.
I had been requested to visit our stations at these
places and report on the health conditions.
CULICIDÆ.
... San Salvador, 1908.
(San Salvador, 1908.
' | Kimpese, viii.1913.
San Salvador, iii.1913.
Anopheles costalis, Lw. ...
» 00 funestus, Giles
"t pitchfordii, Giles
rufipes, Gough Wathen, viii.1912,
Banksinella Meuaciatena ir Theo. San Salvador, 5.ii.1912.
Culex annulioris, Theo. v. 3; xii. 1911.
s» decens, Theo. T: Vr 5 vi.1912.
> xii.1911.
» ditions, Theo. = watheh, viii,1912,
; invidiosus, Theo. ... San Salvador, xii.1911.
» rima, Theo. ds vis ^ xii.1911.
» tigripes, Gyp. s 35 28.xi.1912.
» tigripes, Gyp., var. fuscus,
Theo. .. Wathen, viii.1912.
univittatus, Theo. var. ... San Salvador, vi. 1919.
Eretmopodites chrysogaster
Graham 5» xii.1911.
Mansonioides uniformis, Theo.. ie 29.xi. 1912.
Ochlerotatus argenteopunctatus,
Theo. ... "E i T xii.1911.
Ochlerotatus domesticus, Theo.... 5 ix.1912,
$5 quasiunivittatus,
Theo. .. is xii.1911.
Stegomyia africana, Theo. Kibokolo do Zombo, iv.v.
1911.
d [1] fasciata, F. .. San Salvador, iv.1912,
simpsoni, Theo. — ... z iv.1912.
Teeniorhynchus [2] cristatus,
Theo a s F 1908.
TABANIDÆ.
San Salvador, 1909.
Kibokolo, iv-v.1911.
San Salvador District, 1909.
(1? ,ix.1910.
San Salvador (14189,1912.
San Salvador, 1908.
ciboketo, iv-v.19I1.
San Salvador, g g and 9 9.
Kibokolo, 1 9 , iv-v.1911.
Chrysops longicornis, Macq.
Tabanus billingtoni, Newst.
5 [3] canus, Karsh.
= claripes, Ric. ...
35 [3] congoiensis, Ric. ...
" corax, Lw.
Pe gratus, Lw.
31 tanthinus, Surc. 9 9,iv-v.1911.
i laverani, Surc. Leopoldville, Belgian Congo,
ee 1910.
A Leopoldville, ix.1910.
ud ruficrus, P. de B. T Salvador, xi.1912.
x thoracinus, P. de B. $5 1908.
5 sp. nov. ? near Fulezi River, San Salvador,
nyase, Ric. 1 9, xi, 1912.
B [3] pluto, Walker San Salvador, 1909.
* * The Congo Floor Maggot." Dutton, Todd and Christy.
British Medical Journal, September 17, 1904.
TABANIDE (contd.)—
Hamatopota cordigera, Bigot San Salvador, 1 9 , xi.1912.
5 denshami, Austen... Kibokolo, 1 9 , 2.iv.1911.
A pellucida, Sure. ... 95 1 Q, 2.iv.1911.
(a) 1909, near brunnescens,
ic.
(b) 3 9 , Sau Salvador, i.1912
" 8p. nov. 7 near brunnescens, Ric.
(c) 1 9, San Salvador, 25.x.
1912.
MvscibE,
(Universal, San Salvador,
Glossina palpalis, R. D, Mabaya, Kibokolo,
Ambriz River.
.. San Salvador and Kibokolo.
San Salvador, Kibokolo,
: { Mabaya.
Stomoxys calcitrans, L. ...
) nigra, Macq. ...
CHIRONOMID.E,
Culicoides [4] grahamii, Austen San Salvador, 1909.
TACHINID2.
Salvador,
Mabaya.
San Salvador, iii.1911.
Auchmeromyia luteola, F. ‘4 Ban Kibokolo,
Cordylobia rodhaini, Gedoelst...
SIMULIDÆ.
Simulium griseicollis, Becker ...
» damnosum, Theo.
n pusillum, Fries. var.
Mabaya, v.1912.
Ambriz River, i.1911.
Ambriz River.
SIPHONAPTERA.
Sarcopsyllidze—
Echidnophaga gallinacea, West
Pulicide—
Ctenocephalus canis, Curtis
poultry and dog.
man, dog, cat.
ACARINA,
Argasidie—
Ornithodorus moubata, Murray .. huts,
Ixodidiee—
Amblyomma splendidum, Giebel buffalo, pig.
M tholloni, Neum ; elephant.
trimaculatum, Neum monitor lizard.
Haemaphysalis leachi, Aud we .. dog.
Rhipicephalus capensis, Koch .. ... buffalo, pig, dog.
“i falcatus, Neum ... ss Og.
ki lunulatus, Neum .. dog and pig.
» sanguineus, Latr. .. dog.
VOCABULARY.
English and Ki-Kongo.
Bug .. Kinsekwa; plural, yinsekwa.
Flea Nianzi, plural,
» jigger .. $ Dede.
» 9, swollen .. Mumvidi; plural, mimvidi.
P Mbwanzi plural, San Salvador district.
Fly, generic ... — .. i Nibnd . 2. "Kibokolo distat
( Evekwa dia nzo, S. Salvador.
» Congo floor Ekungu nianzi, Kibokolo.
“i Ekulumbwanzi, Wathen.
, horse—
(1) Hæmatopota...
(2) Tabanus
Evekwa dia mfwila nitu.
| Evukunia ; plural, mavukunia.
' | Evekwa dia nzadi, Kibokolo.
nzadi — a river.
Ekulumbwanzi.
Kinkufu ; Bimbundia,
( Mbwanzi, S. Salvador.
,, large generic
, Sand (Simulium)
n stable ' | Mbwanzi za lau, Kibokolo.
lau — madness.
Louse ... Nianzi, plural.
» crab Maniata.
Maggot f Mumvidi ; plural, mimvidi.
' | Ntunga generic Wathen.
150
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
VOCABULARY (contd.)—
| Mumvidi a nzo, sing., of the house.
A Mimvidi mia nzo, plu., ,, $
Maggot, Congo floor... vnl & nsi, sing., of the ground.
Mimvidi mia nsi, plu., ,, T
Midge (Culicoides)—
Morning biter — Menemene.
Evening biter — Masikasika.
Mite, as of poultry ... Mbwengene.
Mosquito .. Mbu, collective plural; usual form.
lubu, sing. ; tubu, plural.
Tick, dog Nkuba.
» house Kinkwambanda.
(Ey)ata, sing. ; Ma(y)ata, plural.
Kibokolo.
Tsetse ... Evekwa ; plural, mavekwa.
For teaching purposes I have adopted and found useful the
following compound words :—
Menga = blood.
Kimpadi = a small fast-swimming fish.
Therefore—
Kimpadi kia menga = a trypanosome.
Yimpadi ya menga = trypanosomes.
Kimpiatu = a caterpillar generic.
Therefore—
Kimpiatu kia maza ; plural, yimpiatu ya maza, a caterpillar
of the water = a larva.
Yimpiatu ya mbu = mosquito larve.
Kinkete = a chrysalis.
Therefore —
Kinkete kia lubu — a single mosquito pupa.
Nioka — a snake.
Niok' a moyo — an intestinal worm.
Therefore —
Niok' a menga — a blood worm.
REFERENCES.
[1) Boyce: Bulletin of Entomological Research, 1910, vol. i,
p. 256.
[2] Epwarps: Ibid., 1912, vol. iii, p. 26.
[3] Austen: ‘‘ African Bloodsucking Flies."
ea Bulletin of Entomological Research, 1912, vol. iii,
p. ;
— o
ATROPINE IN SEA-SICKNESS.
As a means of allaying irritation of the vagus nerve—
the presumed cause of sea-sickness—atropine in doses
of 1 mgr. is advocated.
FLIES AND PUBLIC HEALTH.
Tne belief as to the part played by flies in the
transmission of disease has been practically acted
upon by Dr. E. H. Ross, of New York. In one of
the most insanitary quarters of the city, where
rubbish of all sorts is allowed to accumulate, where
the houses and the stubles are filthy, where breeding
places for flies abound, and where the infant sick-
ness maintains a high rate, Dr. Ross carried on a
crusade against flies, trapping them in the court-
yards, waste places and stables, and destroying the
breeding places. In a few weeks the sickness rate
was markedly reduced. The area thus dealt with
showed 110 cases of sickness in children under 5
years of age, whereas in an adjacent unprotected
area the rate of sickness amounted to 165.
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THE JOURNAL OF
Tropical gpebícíne anb-bpgíene
May 15, 1914.
MEDICAL EDUCATION IN CHINA.
AT the meeting of the medical department of the
Church Missionary Society held in the Queen's Hall,
London, on May 8, 1914, at which over 2,000 people
were present, the part played by the medical
missionary was prominently set forth by the
Chairman, Mr. James Cantlie, F.R.C.S. The Chair-
man stated that there was a prevalent belief amongst
all and sundry that the " medical missionary ” or the
" missionary doctor ” belonged to a separate grade of
the profession to those who engaged in private
practice at home, or who staffed our hospitals. Some-
how, most folk believe, they manage to slip through
a modified medical career so that they are not so
highly qualified, as far as training, degrees, or diplomas
May 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
151
go, as the other members of the profession in the
British Isles. He assured the large audience--and he
wished to be able to pronounce it from the housetops
so that all the world should know—that this belief
is untenable and untrue. He assured the lay
audience that there was one way, and one way only,
of gaining degrees or diplomas in this country,
namely a five years’ course, and passing examinations
at one of the recognized examining boards. In the
subsequent practice of their profession medical
missionaries had proved themselves capable and
proficient in their profession at all points, and had,
moreover, as observers, as original workers and scien-
tific investigators, held their own with any one of
our great public services. To the recognized public
services of the country—the Naval, Military and
Colonial services—the Chairman said he should
like to add another, namely, the Medical Missionary
service, which was recruited from the same ground
as the others, was organized to a higher degree, and
possessed men as proficient in their work both
scientifically and clinically as those met with in the
services or in public and private positions in civil life.
The chairman next dealt, by request, with the
question of medical work in China. This he did by
referring to the present facilities for medical educa-
tion. Inthis he was guided by the statements made
by Dr. Wu Lien-Teh, M.A., M.D. (Cantab.), Medical
Officer to the Foreign Office of the Chinese
Government. The ‘Memorandum on Medical
Education in China” (published in the China
Medical Journal, March, 1914), drawn up by Dr.
Wu, presents an admirable account of the past and
present state of medical education in China and the
hopes for the future. The summary presented by
Dr. Wu, of the centres of medical teaching in China
runs as follows :—
A) Government Colleges.— The medical colleges
which have been established by the Government are:—
'The Peiyang Medical College, Tientsin.
'The Army Medieal College, Tientsin.
The Army Medical College, Canton.
abolished.)
(1) The Peiyang Medical College was founded
twenty years ago by the late Viceroy, Li Hung Chang.
In its early years the management of the institution
was in the hands of a British staff, but this work
was handicapped from the beginning by inadequate
equipment and by an insufficient number of teachers.
Instruction was given in the English language, the
students coming mostly from Hong-Kong and Canton.
Since 1901 the management has been in the hands of
French professors who continue teaching in English.
The number of students graduating from this college
since its foundation in 1893 has totalled 106.
(2) The Army Medical College, Tientsin, was founded
nearly ten years ago by Viceroy (now President)
Yuan Shih Kai to train medical officers for the newly
organized modern army of Chihli Province. Since
1909 the Board of War, Peking, has taken over the
control of the college. The work was at first entrusted
to a Japanesé staff, the language used being Japanese.
Since 1911 all the teachers have been Chinese, mostly
(Now
graduates of the College, and Chinese has been the
language used. From this College about fifty students
have-graduated annually and have been drafted mostly
into the Army.
(3) The Canton Army Medical College was estab-
lished some years ago to prepare medical officers for
the southern army, and the work was entrusted to
a staff of Chinese and Japanese teachers. Owing to
insufficient staff and equipment, however, the work
was never satisfactory, and the College was abolished
recently.
(B) Missionary Colleyes.— Many of the larger
centres have founded medical colleges for the purpose
of training competent assistants to help them in their
work. Diplomas are, as a rule, given after four to
five years’ training, and a considerable number of
these men may now be found practising western
medicine in different parts of China. The language
used to teach the students has in most cases been
Chinese.
The tendency in late years has been to centralize
their medical teaching in eight large cities, where
sufficient staff, equipment, and clinical material are
available.
It was decided at the triennial Missionary Medical
Conference held in January, 1913, that these cities
should be Mukden, Peking, Tsinanfu, Chengtu,
Hankow, Nanking (or Hangchow), Foochow, and
Canton.
The following resolutions were also passed :—
(1) That the sole object of establishing medical
colleges in China is to bring blessings to Chinese
people and to give a thorough training in medicine
and surgery to young men and women so that they
may be of better service to their country.
(2) That they have no desire to make these institu-
tions permanently foreign, but to hand them over
ultimately to the Chinese themselves.
(3) That they desire to bring their teaching work
into line with the regulations of the Minister of
Education and to always co-operate with the Govern-
ment of the Republic in medical education.
(C) Other Colleges.—Besides the above-mentioned
colleges there exist the following institutions con-
trolled by foreign Governments or corporate bodies
where Chinese students can obtain their medical
training :—
(1) The German Medical School, Shanghai (started
in 1908).
(2) The German Medical School, Tsingtau (opened
in June, 1911).
(3) The Harvard Medical
(opened in 1912).
(4) The Japanese Medical School, Mukden (estab-
lished in 1919).
(5) The Hong-Kong University (opened in March,
1911). The medical faculty of the University con-
sisted originally of ihe College of Medicine, Hong-
Kong, established in the year 1887—the pioneer
medical college in China.
Of these five institutions, the German Medical
Schools at Shanghai and Tsingtau are supported by
the German Government; the Japanese Medical
School, Shanghai
152
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(May 15, 1914.
School at Mukden is controlled and supported by the
South Manchurian Railway Company; while the
Harvard Medieal School is an offshoot of Harvard
University in America. The Hong-Kong University,
of which the Medical Faculty is the oldest and the
most important, is a publie institution encouraged
and partly supported by the British Government.
These centres are essentially for the purpose of giving
& sound medical training to Chinese youths, the
language employed at the German Schools being
German, that at Mukden Japanese, while at the
Harvard Medical School and at Hong-Kong University
the medium is English. As they are independent
institutions it is not known what part they may
take in co-operation, but the colleges established
by the missions are willing to co-operate with the
Chinese Government, and their attitude towards this
question should receive careful consideration.
Dr. Wu suggests that a Central Medical Board be
established in China to control, to centralize and
direct the teaching of medicine in China.
During the meeting at the Queen's Hall, Dr. C. F.
Harford read the annual report of the Medical Depart-
ment of the Society, which was illustrated by a series
of excellent lantern slides dealing with many of the
countries in which the Society's work is being carried
on. These included such widely spread centres as
the Afghan frontier, Srinagar, Peshawar, Quetta,
Amritsar and several other places in India. In China
mention was made of the Union Medical College at
Foochow, of Hinghwafu, Ningpo, Taichowfu, K weilin,
Pakoi, Yunnanfu, &c. In Arabia, Palestine, Persia,
Egypt, East Africa, Uganda, and West Africa, the
Society have hospitals in which assistant and native
nurses are being trained.
The meeting was deeply interested in the addresses
given by Dr. E. N. Cook, M.B., B.S.Lond., from
Uganda; by Dr. H. Gordon Thompson, M.D.Liv.,
F.R.C.S., from Pakhoi, China; and by H. White,
Esq., M.R.C.S., L.R.C.P., from Persia, on the medical
work accomplished in the several countries the
speakers represented.
J.C.
———9—— —— —
COURSE IN VENEREAL DISEASE.
AT the London School of Clinical Medicine at the
Seamen's Hospital, Greenwich, a course of instruction
in venereal disease has been arranged. The first
course will commence on Monday, May 25, 1914.
We beg to congratulate the hospital authorities upon
their publie spirit in coming forward to supply a
course of instruetion which is much in demand at
present. At no other hospital are better opportunities
obtainable for the study of this branch of medicine,
for in the hospital some thirty-five beds are specially
assigned to cases of venereal disease. To officers in
the Public Medical Services, to doctors on board
ships, and to practitioners proceeding to the Tropics,
the course will prove especially useful. From the
evidence before us, it is plain that the classes will be
well attended. The clinical material is plentiful, and
the teachers who are to give the lectures and labora-
tory instruction are all well equipped.
Annotations.
New Malarial Parasite of Man.—In the Proceed-
ings of the Royal Society of April 8, 1914, is
published a paper by J. W. W. Stephens, on “A
New Malarial Parasite of Man." This parasite was
seen by the author in a single blood slide which
had been made from a child in Pachmari, Central
Province, India. Its characters are somewhat like
those of the parasite of sub-tertian malaria, but it
differs in being extremely amceboid, as indicated by
great irregularity in shape, the cytoplasm is very
scanty, and the chromatin out of proportion to the
volume of the cytoplasm.. Pigment granules were
not detected. The parasite is illustrated in a coloured
plate. The author proposes to call this parasite Plas-
modium tenue, believing it to be distinct from the
ordinary parasite of sub-tertian malaria.
Epidemiology of Dengue.—Dr. H. Seidelin under the
heading " Epidemiological questions " (Yellow Fever
Bureau Bulletin, April, 1914) remarks that our know-
ledge with regard to the epidemiology of dengue and
pappataci fever is very limited, and it is only during
the last few years that serious attention has been
drawn to them. He further states that although we
have & working hypothesis on which to base our
knowledge of the epidemiology of Yellow Fever it
will not be possible until the parasite has been
observed, and its prevalence investigated in both man
and the mosquito, to give a detailed account of the
cca dd of the disease.
. Seidelin condemns the use of the term “ mos-
iene fever " for the various short fevers met with in
tropical climates.
A letter from Dr. Juan Guiteras, of Cuba, pub-
lished under the heading of '" Endemicity of Yellow
Fever," discusses Dr. H. Seidelin's report on “ Vomit-
ing Sickness," published in the November number of
the Bulletin. The discussion rages around a sporadic
case of illness in a Chinaman in Jamaica, which Dr.
Seidelin diagnosed as yellow fever. Dr. Guiteras
doubts the diagnosis on the ground that Chinese are
believed to be practically immune; that no fever was
present; that the jaundice was slight and doubtful ;
the pulse-rate was high, 90 instead of about 70; and
that the greenish fluid with coffee-ground-like mucous
streaks found in the stomach after death is an un-
usual condition. Dr. Seidelin replies to the criticisms
and upholds the diagnosis he had previously made,
and points out the diagnosis of mild cases of yellow
fever is a matter of some difficulty at times. The
bearing of this discussion is important as regards the
endemic prevalence of yellow fever. Dr. Seidelin
maintains that yellow fever apparently disappears for
years, and, without any evidence of re-introduction,
reappears in virulent form. He holds that during the
end an endemic infection continues in an attenuated
form, causing mild and atypical cases of tbe disease;
and that these cases are the most dangerous from an
epidemiological point of view.
May 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
153
It is interesting: in this connection to note that
from Puerto, Mexico, à number of cases resembling
yellow fever, occurring simultaneously with a few
typical cases, have recently been reported. There
seems little doubt that yellow fever may declare
itself in mild or atypical form, or as a more severe
type, resembling yellow fever, or in a virulent form ;
that the virulent form occurs at intervals, but that
the infection is kept alive during the intervals and
causes mild attacks, and that yellow fever may there-
fore occur apparently spontaneously in a community,
that is, that it breaks out in an endemic area without
reintroduction from without.
Dr. J. W. Scott and Dr. J. E. L. Johnston con-
tribute a paper to the Bulletin, describing their
experiments and observations in yellow fever. They
declare that at Lagos, Southern Nigeria, where an
epidemic of yellow fever prevailed in 1913 (and
continued at the time of writing), they met with
typical cases of yellow fever, but that many natives
presented a mild type of the disease only.
Drs. Scott and Johnston found the Paraplasma
flavigenum, described by Seidelin, in all the cases
of yellow fever they examined ; and the experiments
they made upon guinea-pigs, dogs, and rats, showed
that inoculations of these animals by blood from
yellow fever cases showed that this parasite was
present in the red blood corpuscles of the inoculated
animals.
Summary of Conclusions : In 1909, Seidelin de-
scribed bodies in the blood of yellow fever patients
which he believed to be the parasite of the disease.
On commencing our investigations at Lagos we
were first at a disadvantage, as we had not seen
specimens of these bodies. It was not long, how-
ever, before we discovered in the red corpuscles
bodies whieh we believed to be identical with the
P. flavigenum. [These have since been declared to be
P. flavigenum by Seidelin.] We have found these
elements in practically every case of yellow fever we
have examined, and also in guinea-pigs, dogs, and
rats that had been inoculated from human cases.
We have found guinea-pigs the most susceptible of
the animals with which we have experimented, and
we have succeeded in conveying the Paraplasma-
bodies by sub-inoculation.
These Paraplasma-bodies are by no means always
scanty. They are as a rule sufficiently numerous to
be a valuable aid in diagnosis, as we have already
experienced, and further, an assistance in the study
of yellow fever. Thus we have found them in the
blood some days after the subsidence of the fever,
when the patient was apparently convalescent, and
we have suceeeded in infecting guinea-pigs by inocu-
lations made as late as the eighth day.
Now, in natives, yellow fever is often a mild,
almost trivial, illness, and patients often insist that
they feel well after but one or two days in hospital.
In their own homes they would, no doubt, go about
freely at this stage of the disease, whilst the Para-
plasma-bodies are still to be found in the blood. If,
as we believe, these bodies are the parasites of yellow
fever, these patients should be capable of infecting
mosquitos and of further spreading the disease. "In
other words, the patient would be infectious for
longer than the generally ascribed period of three
days.
"The successful inoculation of dogs and rats suggests
a possible subsidiary means by which the disease
may be kept endemie, in spite of stringent sanitary
regulations.
Dr. W. S. Clark, West African Medical Staff,
reports upon “Cases resembling Pappataci Fever,"
observed at Jballan, Southern Nigeria. The patients
were British residents : three had sharp attacks,
whilst two had but mild illnesses. The attacks re-
sembled those described as peculiar to Pappataci
fever. The mosquitos met with in the bungalows
of the patients were Culex fatigans, C. tigripes, Stego-
myia fasciata and Culiciomyia sp.; no anophelines
were observed at that time of the year. Of the six
British residents five were attacked, Dr. Clark him-
self was the only one of the six who escaped the
illness.
——— 9————
Abstracts.
EMETINE AND IPECACUANHA ; THEIR
AMCEBACIDAL VALUE IN PATHOGENIC
AMGBIASIS.*
By R. MARKHAM CARTER, I.M S.
EMETINE administered hypodermically in doses of
lto 2 gr. per diem acts rapidly in early cases of un-
complicated amoebic dysentery in Europeans and
Indians.
Emetine is valueless in bacillary dysenteries.
Emetine is a specific in pre-suppurative amcabic
hepatitis, and is of marked value in chronic latent
&mobie colitis which gives rise to the above condi-
tion. The value of emetine in liver abscess is doubtful,
and rational operative treatment without the exhibition
of emetine gives as good results as it does with the
drug.
If amoebie dysentery has lasted for a week or more
we find that emetine injections destroy the vast
majority of the amoebal trophozoites in the first
twenty-four hours, but the stools rarely become
amoba-free under seventy-two hours.
Further, such cases of intestinal amoebiasis, even
after a week's injections and apparent cure by eme-
tine, have in some cases a tendency to relapse.
The true emetine amoabacidal effect is delayed in
patients who are confirmed opium eaters, and experi-
ence has shown me that in spite of vigorous emetine
treatment, it is from the slaves of opium that we get
our eases of rapidly fatal acute gangrenous dysentery.
I believe this is due, not to an antagonistic neutraliza-
tion of the action of emetine by one of the many
opium alkaloids, but to the effect of opium on the
intestinal contents whereby the amceba-laden fæces
stagnate in the pouches of the large intestine.
* From the Indian Medical Gazelte, March, 1914.
o — —M
ETT,
154
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
In the treatment of human amoebiasis the doses of
emetine for an adult should be at least 1 gr. per
diem, and in severe cases the drug should be pushed
without hesitation. Minute doses of $ gr. do harm
instead of good, as I believe they so sensitize the
residual store of undestroyed amobg in the gut-wall
as to render them emetine proof. Such cases pass
out from the hospital apparently cured, but are
amobal cyst carriers and sources of infection to
others.
I am fully convinced that acute amoebic dysentery
requires, as well as the exhibition of the alkaloid
emetine, the entire root with all its alkaloids in
powdered form. My standard daily dosage for an
adult is 90 gr. pulv. ipecacuanhe in 5-gr. pills salol
coated and 1 gr. emetine hydrochloride hypodermic-
ally. In the former we ensure the intestinal contents
are thoroughly permeated with the drug; in the
latter we reinforce the amoebacidal effect of the parent
drug upon the parasites buried in the wall of the
affected intestine by the hypodermie injections of
emetine carried to these by the blood-stream.
THE INFECTIOUS DISEASES: RECENT
ADDITIONS TO OUR KNOWLEDGE OF
THEIR ETIOLOGY.*
By JoHN F. ANDERSON.
POLIOMYELITIS.
In 1909 the disease was transmitted to monkeys
by inoculation with an emulsion of the spinal cord
from a child who died on the fourth day of an
attack of infantile paralysis.
The disease may be transmitted by inoculation to
monkeys and occasionally to rabbits. The disease
belongs among the filterable viruses; that is, its
virus is capable of passing through earthenware
filters and is so minute that it probably cannot be
seen except by the use of special methods, even
with the highest powers of the microscope. It has
been shown that the virus is present in various
organs of human beings dead from poliomyelitis
and that the tonsils of monkeys five months after
the acute stage of the disease still contain the
infective agent. The same is probably true of
human beings, and such persons might well become
sources of infection.
Poliomyelitis may be produced in monkeys by the
inoculation of filtered washings from the mouth and
nose, from the trachea, and from the small intes-
tine, collected at autopsy from cases of infantile
paralysis dying in the early stages of the disease.
The virus of the disease is found in the buccal
and intestinal secretions of persons who gave no
history of recent illness, but who have come into
intimate contact with other persons in their fami-
lies sick with poliomyelitis. Such virus carriers are
most likely very common during epidemics of polio-
* United States Public Health Report, April 8, 1914.
myelitis, probably exceeding the number of persons
with clinically recognizable infections.
The stable-fly is sometimes, not usually, the
factor by which the disease is transmitted.
Flexner and Noguchi cultivated from the central
nervous tissues of human beings and monkeys the
subjects of acute poliomyelitis, a peculiar minute
organism, and with such cultures produced the
symptoms and lesions of poliomyelitis.
The micro-organism consists of globoid bodies of
extremely small size arranged in pairs, chains,
and masses, according to the conditions of growth
and multiplication. They were unwilling to ex-
press themselves as to the place among living things
to which the bodies belonged, but stated that the
cultural conditions necessary are those applying
more particularly to the bacteria. They were able
to produce typical poliomyelitis in monkeys by
inoculation with the twentieth generation of cul-
tures froin the originally infected animal.
We are still without definite knowledge as to the
methods of spread and prevention of the disease.
MEASLES.
Measles was the cause of 44,080 deaths in the
registration area for deaths of the United States
during the period 1900 to 1910. The number of
deaths as compared with those of certain other
diseases in the registration area for deaths during
1910 is shown in the following table :—
Deaths per
Disease Deaths 100,000
population
Diphtheria and qum 11,512 214
Measles A 6 598 12:83
Scarlet fever 6,255 11:6
Whooping cough 6,148 4e d
Cerebrospinal meningitis .. 2,272 ee 42
Infantile paralysis 1,459 27
In 1911, Anderson and Goldberger showed that
the monkey is susceptible to infection with measles
by inoculation with blood from human cases of the
disease. The apparent insusceptibility of the mon-
key to infection with measles is largely due to a
limitation of the period of infectivity of the blood
to the very early stages of the disease before or
shortly after the appearance of the eruption. Thirty-
six hours after the first appearance of the eruption
the infectivity of the blood for the monkey becomes
greatly lessened and rapidly decreases. Studies on
the nature of the virus as it exists in the circulating
blood showed that the infective agent is capable
in a certain proportion of cases of passing through
a Berkefeld filter and therefore is included among
the filterable viruses.
Nasal and buccal secretions from human cases
collected within the first forty-eight hours after the
appearance of the eruption are infective for mon-
keys by subcutaneous inoculation; this would cor-
respond to about the fourth and sixth days of the
disease.
Experiments made to determine the duration of
the infectivity of these secretions strongly suggested
a reduction if not a total loss of their infectivity
with the approach of convalescence. Attempts
May 15, 1914.]
were made, without success, to demonstrate the
presence of the infective agent of measles in the
‘scales ' collected from human cases of the
disease from four to seven days after the appear-
` ance of the eruption.
Koplik spots have been reported in monkeys ex-
perimentally infeeted with measles.
The results of these studies on measles gave the
first definite information, based on carefully con-
trolled laboratory experiments, as to the nature of
the virus, its means of exit from the body and the
probable avenue of infection. The experimental
observations on the duration of infectivity of the
secretions are in accord with previous clinical ob-
servations, that cases of the disease are, as a rule,
not infective after convalescence is well established.
The great importance of having definitely deter-
mined this point, and the further one as to the
non-infectivity of the ‘‘ scales,’’ from a public health
aspect can readily be appreciated.
SCARLET FEVER.
In 1911 scarlet fever was produced in the lower
monkeys, using as a source of infection lymph
glands, blood, pericardial fluid, and scrapings from
the tongue of scarlet fever patients. A febrile re-
action was obtained, attended with an eruption,
appearing after a variable incubation period and
followed by desquamation of the skin.
Just about the same time chimpanzees were
infected with scarlet fever by various methods of
inoeulation, using blood, emulsion of lymph glands,
and deposits from the tonsils of cases of scarlet
fever. In two out of four experiments the chim-
panzees developed a reaction very striking in its
resemblance to scarlet fever in the human being.
In the other two chimpanzees the inoculations were
followed only by angina without any cutaneous
manifestations.
These experimental researches show that the in-
oculation of material from scarlet fever patients into
monkeys is followed sometimes by a morbid syn-
drome which resembles more or less that of scarlet
fever in human beings. Amongst the monkeys the
anthropoids appear to present a susceptibility more
eonstant than the lower monkeys.
The disease produced experimentally seems to be
caused by the specific virus of scarlet fever, and the
streptococcus does not appear to bear any etiological
relationship to the disease. If we admit the scar-
latinal nature of the infection, which appears very
probable, it is then permissible to conclude that
the virus of the disease exists in the deposits on
the tonsils and tongue, in the blood, the lymphatic
nodes, and perhaps in the pericardial fluid. As to
the nature of the etiological agent of scarlet fever
we are still almost totally without knowledge. It
is hoped that further experimental work will result
in more definite knowledge as to the etiology and
mode of transmission of the disease than that which
we have already accumulated.
TypHorD FEVER.
Thirty years ago the Bacillus typhosus was
described and isolated in pure culture,
155
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Grunbaum, in 1906, made attempts to infect
chimpanzees with typhoid fever by feeding them
pure cultures and also by feeding a portion of the
stool from a case of typhoid fever; but his results,
while very suggestive, were not conclusive.
In 1911, Metehnikoff, having in mind the history
of hog cholera, instead of using pure cultures of the
typhoid bacillus endeavoured to infect a chim-
panzee with the feces of a case of typhoid fever
containing an abundance of typhoid bacilli. The
chimpanzee, eight days after ingestion of the fecal
material mixed with food, developed typhoid fever.
The appearance of diarrhea, the presence of typhoid
bacilli in the blood, and the development of specific
agglutinins in the blood serum, left no doubt as to
the result and clearly showed the susceptibility of
the chimpanzee to infection with typhoid fever by
feeding.
Apes could not be infected by the feeding and
injection under the skin of the fluid obtained by
the filtration of typhoid stools. The typhoid bacil-
lus, and not a filterable virus, is the etiological
agent in typhoid fever. Lower monkeys are only
exceptionally susceptible to typhoid fever, and
rodents, such as the rabbit and guinea-pig, are not
at all susceptible to infection by feeding.
Neither killed cultures nor their autolysates pro-
tected chimpanzees against infection with typhoid
fever, but vaccination with living cultures produced
an immunity apparently as definite as from an
attack of the disease. Vaccination with non-
sensitized cultures produced an intense local and
general reaction, while sensitized cultures caused
only a feeble local and almost no general reaction;
both appeared to confer equal immunity to infec-
tion. The work fulfils the postulates of Koch as to
the etiological relation of the B. typhosus to typhoid
fever, discredits the theory of a filterable virus in
the disease, shows the possibility of absolute pro-
tection by vaccination with living cultures, and
emphasizes the importance of not relying upon
vaccination with killed cultures alone to the ex-
clusion of all other precautionary measures.
W HOOPING-COUGH.
In 1900, Bordet reported the observation, in
sputum from whooping-cough cases, of a small
bacillus, which was not obtained by him in pure
culture until six years later, and gave certain
reasons in support of his opinion that the bacillus
discovered by him was the cause of whooping-
cough. Among these reasons was the fact that the
bacillus described by him was found only in cases
of whooping-cough and was always present in the
earliest stages of the disease; another reason being
that it was found that the patient’s blood serum
contained an antibody which was specifie for this
organism and which could be demonstrated by the
complement fixation test.
More recently Mallory has confirmed and ex-
tended the findings of Bordet in regard to the
etiologieal relationship of whooping-cough to the
bacillus described by the former workers. Mallory
found that the primary single lesion in whooping-
cough consists of the presence of masses of minute
156
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
bacilli between the cilia of the epithelial cells lining
the trachea and bronchi. Their action is chiefly
mechanical by interfering with the normal move-
ments of the cilia by causing them to stick together,
and in this way furnishing a continual irritation,
which results in the symptoms peculiar to the
disease. Sputum from cases of whooping-cough
and pure cultures of an organism corresponding in
every way with that described by Bordet produce
the same characteristic lesion in young animals and
the organism is obtained again in pure culture from
those animals.
The action of the bacilli in the respiratory tract
would seem to be largely mechanical by their
presence in such large numbers that they must
interfere with the normal ciliary action and thus
with the removal of secretion and of inhaled par-
ticles. At the same time, the organism probably
produces a mild toxin, which is evidenced by the
production of the well-recognized lymphocytosis,
and by the production of an antibody which is found
present in the blood.
The organism is most abundant and most easily
demonstrated in the early stages of the disease.
This corresponds with the clinical observation that
the disease is most readily communicable at that
time.
The disease is transmitted by the secretions from
the mouth and throat, and is most infectious in the
early stages.
Typus FEVER.
The last appearance of typhus fever in the United
States in epidemic form was in New York in 1891-92.
Since then, except for an occasional case at some
of our large seaports, it has been believed that the
disease had been eradicated from this country.
It has been a source of wonder to health autho-
rities that, in spite of the occasional arrival in this
country of immigrants sick with typhus and of
many persons from endemic foci of the disease,
typhus fever apparently did not gain a foothold in
the United States.
As far back as 1896 Dr. Brill began to notice from
time to time among his typhoid cases in New York
types that were distinguishable from typhoid and
paratyphoid fevers because of the short duration
of the fever, the presence of a distinctive eruption,
and the absence of specific agglutination reactions.
He continued his observations on this type of fever
and published two papers based on the study of
255 cases observed up to December, 1910.
About the time that Brill’s second paper appeared,
Anderson and Goldberger were engaged in the study
of the typhus fever of Mexico, and having the
picture of that disease clearly in mind, were struck
by the very marked clinical resemblance between it
and the disease described by Brill.
In September, 1911, they saw a well-marked case
of Brill’s disease at New York. Blood drawn from
the arm vein of this patient was used for the inocula-
tion of monkeys, one of which, nine days after
inoculation, developed a fever, which reached its
maximum six days later, The fever lasted for
eleven days, when it terminated by rapid lysis.
Blood was drawn from this animal at the height of
its fever and successfully used for the inoculation
of other monkeys. Monkeys that have recovered
from one attack are immune to subsequent infec-
tion. Since then the infection has been carried
through twenty-two monkey generations by inocula-
tion of blood, and is now being continued by passage
through guinea-pigs.
Having established the susceptibility of the
rhesus monkey to inoculation with defibrinated blood
from cases of the disease described by Brill, it
became important to determine the relationship of
that disease to typhus fever, and for this purpose
they proceeded to Mexico City, taking monkeys that
had recovered from infection with the virus originally
obtained from Case No. 1 of Brill's disease, as well
as fresh animals for controls.
Brill's disease confers immunity to subsequent
infection with Mexican typhus and, conversely, an
attack of typhus confers immunity to subsequent
infection with Brill’s disease. To put it in a
simpler way: Brill’s disease, so called, and typhus
fever are identical.
During the progress of the work necessary for the
demonstration of the identity of the so-called Brill's
disease and Mexican typhus, attention was given
to various problems relative to the mode of trans-
mission. It was found that the New York disease,
as also the typhus of Mexico, may be transmitted
from monkey to monkey by the bite of body lice
that had been allowed to feed on monkeys sick with
the disease. These results were in harmony with
and confirm those previously reported by them and
by others.
They were unable to transmit the disease by the
bite of bed bugs or by the inoculation of the buccal
and pharyngeal secretions from a human case of
typhus. They were also convinced that the only
way by which typhus is transmitted is by the bite
of the body louse and possibly by that of the head
louse.
Now that it is shown that typhus fever is identical
with Brill’s disease and that Brill’s disease has been
endemic in the city of New York for a great many
years, there is good reason to believe that what is
true of New York is true also of other large American
and Canadian cities. In fact, since this first work
appeared cases have been reported from several
cities.
When one recalls how frequently the mild forms
of even the familiar infectious diseases are over-
looked, it need occasion no surprise that the benign
form of a disease, usually thought of as an exotic
disease, or at least, perhaps, as a medical curiosity,
should fail of recognition. That this is not appli-
cable to typhus alone is strikingly shown by the
history of pellagra and of hookworm disease in the
United States.
The recognition of these mild forms of typhus
is a rational explanation of what Osler has well
characterized as a ‘‘ remarkable feature '' of typhus,
namely, the occurrence of a few cases at long in-
tervals of time from any other outbreaks and at
May 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
157
great distances from any known foci of the disease.
In other words, these mild forms constitute the
missing epidemiological link between so-called
sporadic cases or outbreaks. In the propagation of
typhus this mild form plays somewhat the same
rôle that the ‘‘ missed '' or the '' carrier °’ cases do
in such diseases as diphtheria and typhoid.
The demonstration of the endemic presence of
typhus fever in the United States requires the
American sanitarian to recognize the existence of a
problem of whieh he has heretofore been unaware,
and to be on his guard against a disease that pre-
sumably may at any time assume epidemie pre-
valence and virulence.
Future advances in our knowledge of the acute
infections would seem to depend to a large extent
upon the discovery of new methods of staining the
etiological agent and of new methods of culture.
It is a singular and regrettable fact that in spite
of the large and important additions to our know-
ledge of the cause and means of transmission of
many of the communieable diseases the application
of this knowledge in the control and eradication of
the diseases has not kept pace with its acquisition.
With a few notable exceptions, such as the control
of yellow fever through mosquito eradication and of
bubonic plague by rat campaigns, health authorities
have been slow to apply the great mass of informa-
tion now available to them by reason of the re-
searches of the last few years.
What is most needed at the present time is a
more general applieation of the results already at
hand. Research should, of course, be encouraged
and developed; the laity should be impressed with
the importance of using the information already
available, and very important it is that law-makers
should also be made to see that it requires money
to carry out the measures for the control of diseases
along the lines which have been pointed out so
convincingly by laboratory studies.
——»————
Translation.
RECRUITING.
THE OLD COLONIAL CONTINGENTS IN FRANCE.
By Dr. REYNAUD.
(Le Caducée, April 4, 1914.)
THE young Creoles from the West Indies, Guiana
and Réunion were incorporated at the end of 1913
with the Colonial troops in garrison in France. Of a
total of 1,560 recruits 386 men of the 1912 class
arrived towards the end of October to join 150
recruits of the 1913 class.
On January 8, 1914, at Marseilles 182 out of 386
West Indian recruits were rejected two and a half
months after arrival. On January 18, 17 men of
those effective had died in hospital, in other words in
less than three months a mortality of 48 per 1,000,
and a loss of 50 per cent. ; the total deaths were more
than twenty.
In the middle of January of the total Creoles in
France, 1,560 recruits, 28 had died, and 781 were
rejected (809 remained), in other words a mortality
of 17 per cent. per 1,000, and a gross reduction of
50 per cent. in three months.
The rest of the Creole recruits were then sent to
Algiers. This considerable loss of Creole recruits in
France on their arrival is due partly to it taking place
at the commencement of winter, and this winter was
a particularly severe one. No doubt Creoles of 20
years of age suddenly brought into France at the
commencement of the cold season suffer physiological
troubles to adapt themselves tc a new climatic situa-
tion ; similar to the physiological troubles encountered
by Europeans, especially at a growing age, when
transported into the Tropics at the commencement of
the hot and rainy season. These troubles of them-
selves do not create specific diseases, but create a
predisposition, a state of receptivity for sporadic and
epidemic infectious diseases existing in the country.
It is not difficult to understand young Creoles be-
coming easy. prey to infectious diseases pre-existing
or introduced into the garrison towns where they are
stationed.
This predisposition of young organisms transported
to a new station is combined with the fatigue insuper-
able with the initiation of, military service. The ob-
servation impresses itself upon all military hygienists
that the existence of specific infectious germs in the
situation where young soldiers are transported is not
the sole cause of development of infectious diseases.
The inevitable fatigues of the early instruction of the
soldier, the digestive disturbances resulting from the
modification of the usual diet, the physiological dis-
turbances of adoption to a town situation, aggravated
in the case of the Creole conscripts by the disturbances
of-climatie adaptation and season adaptation, create
that state of least resistance which is above all things
the suitable ground for the growth of infectious germs.
When troops with this predisposition are introduced
into a town where there are typhoid fever, influenza,
eruptive fevers, when they are lodged in barracks,
where there is a crowding, without being excessive,
these favour contamination and epidemic diseases
which attack young adults. This is a daily occurrence ;
it happened to the Creole recruits at Marseilles and
elsewhere.
At Marseilles the mortality was particularly severe
because, notwithstanding every care, the Creoles
were exposed to the numerous diseases which attack
civilians and soldiers on arrival in this town. Amongst
the causes of death were noticed numerous cases of
influenzal pneumonia, typhoid fever, perhaps small-
pox, or even meningitis.
As regards typhoid fever, one can state without
comment that this disease prevailed amongst all the
population. The steamer Roma arrived at Marseilles
from New York at the beginning of January, 1914,
with passengers, 263 of whom were quarantined,
because typhoid fever had appeared amongst them.
But what is more surprising still is that the Creole
conscripts were sent to Marseilles to be there stationed
at the very moment when the regiment of Hussars
158
was sent from the town because it was attacked with
typhoid fever. Recruits (French) destined to be
garrisoned in the town were temporarily sent to other
neighbouring towns to wait for more favourable
circumstances, and there to undergo anti-typhoid
vaccination. The Creole recruits alone, most suscep-
tible of all, were sent and kept at Marseilles. Can
one conclude from this that these men had not the
qualities of physical endurance and moral energy
which go to make good soldiers? This quest deserves
attention when new classes of recruits are about to
be called up.
It is only fair and just to remember that during the
Mexican expedition the Creole companies of the West
Indies and the Creole sailors, who form a large portion
of the guard and escort in hot climates—centres of
malarial and yellow fever—performed their function
perfectly.
Besides in Madagascar in 1895 a battalion of Ré-
union Creoles hastily raised as soldiers were incor-
porated in the so-called Colonial regiment alongside
of a Madagascar battalion and Haoussa battalion.
This regiment, excepting the marines, showed the
lowest mortality (154 per 1,000), and nevertheless the
soldiers of this troop suffered formidable fatigues.
The Chasseurs had 632 deaths per 1,000 men effective.
The line regiment had 391 deaths per 1,000 men
effective.
The Creoles of the West Indies and of Réunion have
no doubt qualities of endurance which render them
favourable for service in hot climates. In the con-
dition of the French birth-rate and of the absolute
necessity of employing by preference natives of hot
climates in tropical expeditions and garrisons, the
advantage of the increase of available forces by Creole
recruits equivalent to three effective regiments cannot
be ignored. How is it possible to utilize to the best
national advantage and to safeguard the interests of
these contingents? This is a problem which colonial
and military hygienists cannot disregard, and facts
which justify an expression of opinion upon the
question.
Starting with a long established principle that
natives of hot climates (meaning the men of the
annual levies and not the long service men) give the
best return in-hot climates, where they serve with a
minimum of loss and are employed so as to profit by
their native adaptability to hot climates and certain
immunity which adults possess against endemic and
epidemic diseases such as yellow fever and in certain
conditions malaria (having their centres in the
countries of which they are natives). Thus for
example the West Indian Creoles are better qualified
to serve on the West coast of Africa than the Creoles
of Réunion which has never been a centre of yellow
fever. These are the services which Creole recruits
are able to render while freeing a corresponding
number of white colonial troops. But to obtain these
services it is necessary that these recruits should be
incorporated in the colonial army and not in the
Zouave regiments, where they are lost to the properly
called colonial service; without considering the case
of a European war and general mobilization, when they
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
would be required to make a campaign perhaps in
winter either on the north-east frontier or on the
south-east. Natives of hot climates belonging to the
annual levies should be separated from the European
regiments.
The utilization of black troops in European wars
would be dangerous from a sanitary point of view.
Are colonial troops, not having garrisons in Algeria,
where the recruits should be collected to have their
first year of military instruction, to be finally concen-
trated for service in hot climates ?
To avoid the test of a winter so fatal to them in the
south of France and even in Algiers, according to the
last information, it is necessary to distribute the
recruits in the colonial infantry regiments nearest
their country of origin. From Martinique to Guade-
loupe and vice versi, from Réunion to Diego-Suarez.
After the first six months of military training the West
Indians could, at the commencement of April, be col-
lected without sanitary risk in the colonial regiments
in the south of France to finish their military instruc-
tion in profitable contact with other army corps and
from there to be sent to Morocco or West Africa. As
regards natives of Réunion, according to cireumstances
and financial needs they could also be sent to Europe
to complete their instruction before going to Morocco,
or at Diego-Suarez before going to form a garrison in
Madagascar.
For reasons apart from hygiene it appears that mili-
tary instruction for recruits cannot be completely
effective in the immediate neighbourhood of their
families.
These proposals, somewhat undeveloped, take account
of the variety and conditions of the stations and the
needs of the Colonial army. Other solutions can be
suggested before hastily starting new experiments or
adopting too radical measures which would deprive
the colonial army of its important features, but at the
same time it would be able to safeguard the sanitary
interests of the Creole contingents and thus lessen the
effective white troops in hot and unhealthy areas.
eS Ceci
THE BRITISH MEDICAL ASSOCIATION.
PROGRAMME OF ABERDEEN MEETING.
Tur annual meeting of the British Medical Asso-
ciation will be held on July 28 and the three
following days at Aberdeen. The proceedings will
be opened by the President (Sir Alexander Ogston),
who will deliver the presidential address. It is
expected that there will be about 1,500 members
and visitors present. The popular lecture will be
delivered by Professor J. Arthur Thomson on the
subject, '* Vis Medicatrix Nature.’’ The address in
medicine will be delivered by Dr. Archibald E.
Garrod, and the address in surgery by Sir John
Bland-Sutton.
SECTIONAL MEETINGS.
The scientific business of the meeting will be con-
ducted this year in sixteen sections, in several of
May 15, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
159
which the programme is still undecided. In the
Section of Dermatology a discussion will be opened
by Dr. Norman Walker on ‘‘ The Need for some
Method in the Conflict with Lupus and Ringworm.”
In connection with the Section of Electro-thera-
peutics and Radiology, Professor Leduc is again
attending the meeting of the Association, and will
deliver an introductory address on '' Cerebral Gal-
vanization." The first day's meeting will be devoted
to this and to a discussion on ‘‘ The Therapeutic
Uses of High-frequency Currents.” On July 30
Dr. W. Dean Butcher and Dr. John Macintyre will
open a discussion on '' The Comparative. Value of
X-rays and Radium in the Treatment of Malignant
Growths,'" and Dr. Agnes Savill and Dr. W. F.
Somerville will open a discussion on ‘‘ Electro-
therapy in Neurasthenia "; there will also be a
demonstration on '' Musele Testing by Means of
Condensers.’’ For the last day of the session dis-
cussions have been arranged on “‘ X-ray Diagnosis in
Gastro-intestinal Conditions," and with the Section
of Medicine on ''The Diagnosis of Chronie Pul-
monary Tuberculosis.”
In the Section of Medical Sociology the follow-
ing subjects have been set down for discussion :
(1) ' State Medical Service or Panel System? ’’;
(2) “ The Responsibility of the State as regards
Venereal Disease '"; (3) ' The Duty of the State
towards the Early Environment of the Child ’’; and
(4) Medical Certification: («) Generally (except
Lunacy Certification); (b) Under the National
Health Insurance Act.
In the Section of Medicine the joint discussion on
** The Diagnosis of Chronic Pulmonary Tuberculosis
in Infaney and Childhood "' is expected to arouse a
good debate. The openers are Dr. Barty King, Dr.
Clive Riviere and Dr. Ironside Bruce. Sir William
Osler, Professor v. Pirquet, Dr. Frank Eve, and, it
is hoped, Professor Baginsky, Chief Physician to the
Kaiserin Wilhelm Children's Hospital, of Berlin,
will take part. The discussion on '' Artificial Pneu-
mothorax in Pulmonary Tuberculosis " is to be
opened by Dr. Rist, Physician to the Laennec Hos-
pital, Paris. Dr. Clive Riviere is taking part in this
discussion, and it is expected that Professor Brauer,
of Hamburg, will also contribute.
In the Section of Naval and Military Medicine and
Surgery the following subjeets have been arranged :
(1) “ The Treatment of the Wounded in Naval War-
fare," to be opened by Fleet-Surgeon D. W. Hewitt;
(2) " Gangrene in War,” to be opened by Captain
C. Max Page; (3) '' Salvarsan in the Treatment of
Syphilis '"; and (4) “ Common Ailments in Camp,
their Prevention and Treatment,” to be opened by
Captain Cecil Johnson.
Three discussions have been arranged provisionally
in the Section of Ophthalmology. The first, on
“ The Choice of Cataract Operation,” will be opened
by Mr. E. E. Maddox; the second, on ‘* The
Hygiene of Reading and Near Vision," will be
opened by Mr. J. Herbert Parsons; and the third,
on ‘‘The Teaching of Ophthalmology to Medical
Students,” will be opened by Dr. Maitland Ramsay.
In the Section of Pathology and. Bacteriology
several subjects that have recently been prominently
before the publie have been arranged. On July 29
the President of the Section, Dr. WS. Lazarus-
Barlow, will open a discussion on '' The Action of
Radiations on Cells and Fluids," while another dis-
cussion on the same day on '' The Importance of
Biochemistry in Immunity Reactions ’’ will be
opened by Dr. Carl Browning.
On July 81 there will be a joint discussion with
the Section of Pharmacology, opened by Dr. Thomas
Lewis, on '' The Pathology of Heart Function, in-
cluding the Experimental Pharmacology and Thera-
peutics of Pathological Conditions of the Heart.”
On the third day of the meeting Dr. W. J. Penfold
will introduce the subject of ‘‘ The Importance of
Variability among Bacteria and its Bearings on
Diagnosis.”
In addition to the joint discussion with the Section
of Pathology on the Heart function, arrangements
have been made in the Section of Pharmacology for
discussions on ‘‘ Recent Advances in the Relationship
between Chemical Constitution and Pharmacological
Activity," and on ‘‘ The Pharmacology and Thera-
peuties of the Animal Extracts, exclusive of Thyroid
Extract."
In the Section of State Medicine and Medical
Jurisprudence the subjects suggested for discussion
are as follows: (1) “ The State Organization of
Medical Service "’; (2) “ The Legal Investigation
of Cause of Death and Possible Reforms ’’; (8)
'* Modern Views regarding the Period and Duration
of Infectiousness in the Commoner Zymoties '';
(4) “ Certification of Births and Deaths ''; (5) “ The
Administrative Treatment of Tuberculosis, especially
in regard to After-eare," in connection with which
a paper on ** Garden Cities for Consumptives ” will
be read by Dr. J. E. Esslemont; (6) ** Malingering:
its Extent and Control," to be opened by Sir John
Collie; and (7) “ Unqualified Practice: Medical,
Obstetrical, and Dental.’
The Section of Surgery at one of its meetings will
consider a subject to which considerable prominence
was given at the recent International Medical Con-
gress under the title ‘‘ Anoci-Association, or the
Evolution of the Shockless Operation,’’ the opener
being Mr. H. M. W. Gray. Other discussions are
to be opened by Mr. Robert Jones on ‘‘ The Surgical
Treatment of Arthritic Deformities," and hy Mr.
W. G. Spencer on ‘‘ The Etiology and Treatment
of Carcinoma of the Tongue."
The following diseussions have been decided on
in the Section of Tropical Medicine: (1) '' The
Training and Position in Administration of the Sani-
tarian in the Tropies," to be opened by Colonel
King; (2) “ The Surgical Treatment of Colitis and
Post-dysenteric Conditions," to be opened by Mr.
James Cantlie; and (3) ** Kala-azar and Allied Con-
ditions.” Papers on '' Sprue,"' *' Sand-fly Fever,"
and '* Beriberi ’’ have been promised, and others are
being arranged for, while a special sub-section of the
Museum is being reserved for exhibits in tropical
medieine.
or —————
160
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
Personal Rotes.
INDIA OFFICE.
From March 7 to April 18, 1914.
Arrivals Reported in London.—Lieutenant-Colonel J. G.
Hajel, I.M.S.; Major W. H. Leonard, I.M.S.; Brevet. Colonel
B. G. Soton, V.H.S., 1.M.S.; Lieutenant-Colonel F. W. Gee,
I.M.S.; Major P. L. O'Neill, I. M.8. ; Lieutenant-Colonel P. P.
Kilkelly, I.M.S. ; Lieutenant-Colonel A. H. Nott, I.M.S.;
Captain S. C. Pal, I.M.S. ; Major H. Innes, I.M.S ; Captain
F. F. S. Smith, I.M.S.; Lieutenant-Colonel B. J. Singh,
I.M.S.; Major W. H. Dickinson, I.M.8.; Major M. H.
Thornely, I.M.S. ; Captain A. S. Pridham, I.M.S.; Captain
J. Forrest, I.M.S. ; Lieutenant-Colonel V. B. Bennett, I.M.S.
Extensions of Leave.—Lieutenant-Colonel R. H. Elliott,
I.M.S., 6 m., M.C. ; Major E. J. Morgan, I.M.S., 6 m., M.O. ;
Major F. D. S. Farrer, I.M.S., 1 m. 27 d. ; Lieutenant-Colonel
J. Jackson, I.M.8., 3 d. ; Lieutenant-Colonel C. M. Moore,
I.M.S., 3 d. ; Captain C. L. Dunn, I. M.S., 5 m., M.C. ; Captain
G. G. Jolly, I.M.S., 15 d.; Captain G. L. OC. Little, I.M.8.,
2 m., M.C. ; Captain L. Hirsch, I.M.S., 20 d.; Lieutenant
P. J. Veale, I.M.S., 5 m., M.C.
Permitted to Return. —Captain N. N. G. C. McVean, I.M.S.
List or Inpran CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CivinL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Childe, Lieutenant-Colonel L, F., I. M. S., Bo., 15 m., January
19, 1918.
Duer, Lieutenant-Colonel C., I.M.S., Home Dept., India,
24 m., May 1, 1912.
Hall, Lieutenant-Colonel E. A. W.,1.M.S., B., 24 m., October
25, 1912.
Nott, Lieutenant-Colonel A. H., I. M.8., B., 24 m., January
9, 1914.
Steel, Captain R. F., I.M.S., Bo., 24 m., Aug. 2, 1912.
Dickinson, Major W. H., I.M.S., Bo., 18 m., March 1, 1914.
Singh, Lieutenant-Colonel B. J., I.M.S., B. & O.
Thornely, Major M. H., I.M.S., B. & O.,8 m., February 8,
1914.
List or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted,
Gee, Lieutenant-Colonel F. W., I.M.S., to October 22, 1914.
Gibson, Captain H. R. B., I. M.S., to October 5, 1914.
Jolly, Captain G. G., I.M.S., to May 28, 1914.
Leonard, Major W. H., I.M.8.
Mehta, Captain S. B., I. M.S., to November 30, 1914.
Moore, Lieutenant-Colonel C. M., I. M.S., to June 6, 1914.
Pal, Captain S. C., I.M.S.
Seton, Colonel B. G., I.M.S.
COLONIAL MEDICAL SERVICES,
West African Medical Staff.
Deaths.—D. Mackinnon, M.B., Ch.B.Edin., D.P.H.Edin.,
D.T.M. & H. Cantab, Medical Officer, Nigeria ; C. B. Hunter,
M.B., C.M.Glas., Senior Medical Officer, Gold Coast.
Transfers.— G. F. Forde, L.R.O.S., L.R.C.P.Edin., L.F.P.S.
Glas., Medical Officer, has been transferred from the Gold Coast
to Nigeria; J. A. Harley, M.B., Ch.B. Edin., and S. L. Brohier,
M.R.C.S.Eng., L.R.C.P.Lond., Medical Officers, have been
transferred from the Gambia to the Gold Coast ; J. C. Franklin,
L.R.C.S, & P.Edin., L.F.P.S.Glas., Medical Officer, has been
transferred from the Gambia to Nigeria; G. Rollason,
L.M.S.8.A.Lond., Medical Officer, has been transferred from
Sierra Leone to Nigeria.
Resignations.—A. Lundie, M.B., Ch.B.Edin., B.Sc. St.
Andrews, Medical Officer, Gold Coast; E. J. Wyler, M.D.,
B.8.Lond., L.R.C.S.Eng., L.R.C.P.Lond., Medical Officer,
Nigeria; A. Hutton, M.B., Ch.B.Aberdeen, D.T.M. & H.
Cambridge, Medical Officer, Nigeria.
Retirement. — A. Bremner, M.B., C.M.Edin., D.T.M. Liver-
pool, Medical Officer, Sierra Leone, retires on pension.
New Appointments.—The following gentlemen have been
selected for appointment to the staff: T. P. Fraser, M.B., Ch.B.
Aberdeen, D.P.H.Cambridge, Nigeria: A. S. Burgess, M. R.C.S.
Eng., L.R.C.P.Lond., M.B., B.C.Cambridge, Gold Coast.
Promotions.— The following promotions in the staff have
been made since January 1, 1914: T. Hood, M.R.C.S.Eng.,
L.R.C.P.Lond., Principal Medical Officer, Nigeria, Southern
Provinces, to be Director of the Medical and Sanitary Service of
Nigeria; E. A. Chartres, F.R.C.S.Ire, L.R.C.P., L.M.Ire.,
D.P.H.Ire. F.R.G.S., Senior Medical Officer, Gambia, to be a
Senior Medical Officer (Grade 1), Nigeria; C. R. Chichester, M.B.
Dublin, L.R.C.P. & S.Ire., D.P.H.Ire., Provincial Medical
Officer, Southern Nigeria, to be Senior Medical Officer (Grade 1)
Nigeria; W. H. G. H. Best, L. R.C.S. & P.Ire., Provincial Medi-
cal Officer, Southern Nigeria, to be a Senior Medical Officer
(Grade 1), Nigeria; C. F. Watson, M.R.C.S.Eng., L.R.C.P.
Lond., D.P.H.Ire., D.T.M.Liverpool, Senior Medical Officer,
Northern Nigeria, to be Senior Medical Officer (Grade 2), Nigeria ;
W. H. A. Gordon-Hall, M.B., C.M.Edin., Senior Medical Officer,
Northern Nigeria, to be a Senior Medical Officer (Grade 2),
Nigeria; W. I. Taylor, M.R.C.S.Eng., L.R.C.P.Lond., Senior
Medical Officer, Northern Nigeria, to be a Senior Medical
Officer (Grade 2), Nigeria; H. P. Lobb, M.R.C.S.Eng., L. R.C.P.
Lond., D.P.H.Ire., Medical Officer, Northern Nigeria, to be a
Senior Medical Officer (Grade 3), Nigeria; M. E. O'Dea, M.B.,
Ch.B.Edin., Medical Officer, Southern Nigeria, to be a Senior
Medical Officer (Grade 3) Nigeria; W. W. Claridge, M.R.C.S.
Eng., L.R.C.P.Lond., Medical Officer, Gold Coast, to be a
Senior Medical Officer (Grade 3), Gold Coast ; A. E. Horn, M.D.,
B.Sc. Lond., M.R.C.S. Eng., L.R.C.P.Lond., D.T.M. & H.Cam-
bridge, Personal Assistant to the Principal Medical Officer,
Southern Nigeria, to be Senior Medical Officer (Grade 3),
Gambia; J. M. Dalziel, M.D., C.M.Edin., B.Sc. Public Health,
Edin., Medical Officer, Northern Nigeria, to be a Sanitary
Officer, Nigeria.
Other Colonies and Protectorates.
N. S. Williams, M.R.C.S.Eng., L.R.C.P.Lond., has been
selected for appointment as a temporary Medical Officer in
Uganda,
J. H. Paterson, M.B., D.P.H., has been selected for appoint-
ment as a Supernumerary Medical Officer in Jamaica.
C. H. Sills, M.R.C.8.Eng., L.R.C.P.Lond., has been selected
for appointment as a Supernumerary Medical Officer in the
Leeward Islands.
S. Vassallo, D. M. & S.Malta, has been selected for appoint-
ment as a Supernumerary Medical Officer in the Leeward
Islands.
W. A. S. George, L. R.C.P. & S. Edin., has been selected for
appointment as a District Medical Officer in St. Vincent.
H. P. Hacker, M.D., B.S., B.Sc.Lond., has been selected for
appointment as a Supernumerary Medical Officer in the Feder-
ated Malay States,
COLONIAL MEDICAL SERVICE.
Dr. K. McGahey, Medical Officer of Nigeria, Northern Pro-
vinces, has been transferred to the Medical Department of
Ceylon.
Dr. H. L. Duke, Medical Officer in the Uganda Civil Service,
has taken up the duties of Bacteriologist in the Medical Depart-
ment,
Dr. C. H. Sills has been appointed Supernumerary Medical
Officer in the Leeward Islands, to be stationed in Dominica
until further orders,
Dr. A. C. N. McHattie, Chief Medical Officer, Bahamas, has
become Acting Colonial Surgeon of that Colony.
Dr. G. Rollason, Medical Officer, Sierra Leone, has been
transferred to the Government of Nigeria.
—————9————
“Journal of the American Medica! Association,” April 20,
1913.
Typhoid Carriers.—Removal of the gall-bladder and
cystic duct as a method of clearing up chronic typhoid
carriers, by Dr. Leary, although founded on a basis of a
certain degree of scientific justification, has not widely
recommended itself.
June 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 11, Vol. XVII.
Original Communications.
EMETINE TREATMENT OF DYSENTERY IN
YOUNG CHILDREN.
By Captain R. G. AncurBALD, M.B., R.A.M.C.
Pathologist, Wellcome Tropical Research Laboratories,
Khartoum,
NUMEROUS papers have lately been published
referring to the therapeutic value of emetine in
amoebic dysentery affecting adults, but few cases,
however, have so far been described recording the
use of the drug in the treatment of this disease in
children.
The writer has recently had the opportunity of
employing emetine in two cases of amoebic dysentery
in young children, where the causal agent was Léschia
tetragena Viereck, 1907 (Entameba tetragena). The
results obtained were interesting, and were considered
worth recording, for in the one case the entamcebe
appeared to have considerable resisting properties
towards the action of emetine, while in the other the
amcebicidal properties of the drug were well shown.
Case A was an English girl, aged 2 years 4 months.
Shortly after her arrival in Khartoum she had an
attack of diarrhea, vomiting and pyrexia.
The stools were pale and pultaceous in character,
and contained a little mucus, but no blood.
Microscopical examination showed the presence
of large numbers of bacilli, but no entamcebe were
found. Portions of the stools were plated out with
negative results as regards the presence of organisms
of the Bacillus dysenteriz group.
A grey powder was administered, and the patient's
diet limited to albumen water. The symptoms quickly
abated, and the child was soon well again. Ten days
later she became ill with fever, abdominal pain and
diarrhea, and passed a large amount of blood and
mucus in her stools. A specimen of the latter was
examined microscopically and found to contain large
numbers of active entamcebe. These, on further
examination, were proved to be E. tetragena. Plating
of the stools on suitable media showed that no
organisms of the B. dysenteri# group were present.
Examination of the peripheral blood of the patient
eliminated a malarial infection, although it was noted
that there was an inerease of the large mononuclear
leucocytes. A dose of castor oil was administered,
followed two hours later by a grain of Dover's powder.
The latter was given every hour till six doses had
been given.
The symptoms, however, did not abate, for the
child passed twenty-three motions during the next
twenty-four hours. Minute doses of perchloride of
mercury were then administered, as recommended by
Houston,* but without beneficial result, and it was
then considered justifiable to employ rectal lavage
with 1 in 10,000 quinine solution. This had no effect
in alleviating the symptoms.
In the evening 3 gr. emetine hydrochloride was
*.O Houston, M., in the
* Care of European Children
Tropics.” 1912,
injected intramuscularly, followed twelve hours later
by a second injection of 3 gr., and twelve hours later
by a further injection of 4 gr. The patient's symp-
toms showed no signs of improvement, for twenty-
nine motions, containing a large amount of blood and
mucus, were passed in the twenty-four hours. Ex-
amination of the mucus showed that active entamcebe
were still present.
As the emetine appeared to have no effect in
limiting the number of motions, half a minim of
Battley's solution was administered by the mouth,
with the hope of checking the peristaltie action of
the bowels. To a certain extent this was successful,
but in the meantime the patient's condition had
become somewhat grave, and there was danger of
heart failure. Three ounces of sterile normal saline
were injected into the intracellular tissue of the
thorax, with a marked beneficial effect; for the pulse
and general condition of the patient rapidly improved.
Thirteen evacuations occurred during the next twenty-
four hours; some of these were examined, and still
found to contain blood mucus and living entamcebe.
The patient's temperature remained fluctuatingbetween
100? and 102° F. Another injection of i gr. emetine
was administered, making a total of 3 gr. in forty-
eight hours. No further emetine was administered
till thirty hours afterwards, when another i gr. was
given.
The temperature continued to fall, and the patient's
stools showed some improvement in character. Very
few entamcebe were found, and these were chiefly in
the form of cysts.
It was considered advisable to administer a purge
for the mechanical removal of these cysts, and then
follow this up by injections of 2 gr. emetine within
the next twenty-four hours, and subsequent daily
injection of & gr. The patient suffered no after-effects,
the temperature, apart from two slight evening rises,
remained normal, and the frequency of the motions
was daily lessened. No entamæœbæ were found on
the twelfth day following the onset of the illness, nor
were they found again in the examinations earried out
for the fourteen days.
Apart from a slight rise of temperature on the
twentieth day, which was combated by § gr. emetine
given in a single injection, the patient made an
uninterrupted recovery, and soon regained her usual
health.
The total amount of emetine administered during
the course of her illness and convalescence was (wo
and one-sirth grains.
Case B was a girl, aged 8 months, the younger
sister of the above described case. For two days
this child had suffered from colic, and on the third
day a small amount of blood and mucus was passed
with a loose and yellow stool. There was no pyrexia.
Microscopical examination showed large numbers
of E. tetragena present. A dose of castor oil was
administered, and two hours afterwards rs gr. emetine
injected intramuscularly. The number of stools
passed that day was six, and most of them contained
mucus and a little blood.
Another injection of the same amount of emetine
162
was given the following day. Examination of the
stools revealed only a few entamcebe and no cysts.
Two more daily injections of emetine, js gr., were
administered. Examinations of the stools from this
patient were carried out for several successive days,
with negative results as regards entamcebe or their
cysts. She made an uninterrupted recovery and
regained her usual health.
Remarks.—Reference has already been made to the
paucity of literature dealing with the use of emetine
in the treatment of amcebic dysentery in children,
and the main object in recording these two cases is
that some guide may be given to the practitiorer in
the Tropics regarding the dosage of this specific drug
for very young children. Case A was a severe infec-
tion, and was illustrative of the delayed effects of
emetine, and the extremely resistant properties of
the entamcebe towards this drug. Even after a
total of 13 gr. of emetine administered intramuscu-
larly, living entamcebe were present in the patient's
stools.
this result was hardly to be expected in the light
of what has recently been written regarding the
active amcebicidal properties of this drug, and one
draws the conclusion that in such a severe case the
amount of emetine administered in the early stage of
the illness was too small. Instead of a destructive
effect being exercised on the entamcebe, the latter
may have become to a certain extent " emetine fast"
as the result of insufficient dosage. During the last
six months several opportunities have occurred of
noting the effect of emetine in adults suffering from
amcebic dysentery; in many of these cases the enta-
mcebe were often found in the fæces even after the
total amount of emetine administered had equalled
five or six grains, and recently the writer has had
under observation a case where the patient's dysen-
teric symptoms continued, and entamcebe were present
in the fæces after a total amount of 10 gr. of emetine
administered hypodermically in doses of 1 gr. per diem.
That no other causal organism was present to account
for this was proved by the fact that the fæces were
frequently plated out so as to eliminate the possi-
bility of a concomitant infection with either Shiga's
or Flexner's bacillus. This patient eventually left
hospital, having received a total amount of 14 gr. of
emetine.
Malaria may also be cited as a disease where the
causal plasmodium frequently exhibits considerable
resistant properties towards its specific drug. For, in
the Sudan the writer has known of cases where, to
all intents and purposes, the plasmodium has shown
a considerable degree of immunity towards the ordi-
nary methods of quinine administration. "These have
invariably occurred in individuals indulging in in-
sufficient prophylactie doses of quinine prior to their
illness. This insufficient prophylaxis doubtlessly held
the symptoms of malaria in abeyance, and instead of
destroying the causal parasites rather assisted their
resistant properties towards quinine. Such a view,
of course, is purely hypothetical, but appears applicable
to those cases of amoebie dysentery which fail to
respond to the action of emetine in the amounts
Bearing in mind the age of the patient,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 1, 1914.
usually employed. On the other hand, there may be
some stage in the life cycle of Loschia which is
particularly susceptible to the action of emetine, and
this may account for the somewhat inconsistent
results that have occurred with the use of this drug
in the treatment of amoebic dysentery in the Sudan.
Further research requires to be carried out to
ascertain the dosage limitation of this drug. From
observations made the writer is inclined to consider
that the dosage ordinarily employed is too small. It
may be that in the Sudan a particular resistant strain
of entamceba is met with, certainly the common
pathogenic species usually encountered corresponds
to the description of E. tetragena.
From what has been said it is quite apparent that
in order to efficiently treat a case of amcebic dysentery
with emetine one must rely on the evidence obtained
by frequent microscopical examination of the feces.
One's experience has shown that failure to find
entamoebe on the first examination does not preclude
the possibility of their being present. Their detection
is readily assisted by a preliminary purge being given
to the patient. Further, an absence of pyrexia is no
contra-indication to an examination of the feces
being carried out. This point was well illustrated in
Case B, where the temperature remained normal
during the patient’s illness.
More information is required regarding the length
of time that emetine should be administered in order
to prevent dysenteric relapses occurring. This, no
doubt, will be forthcoming when a further knowledge
of the life cycle of the entamcebe is gained.
Case A remained fit and well for a period of nine
weeks, during which no emetine was administered.
In the tenth week, however, some mucus was passed.
Microscopical examination of this showed that large
numbers of entamosbe and their cysts were present
together with a slight amount of blood. A dose of
castor oil was administered, followed four hours later
by an initial injection of $ gr. emetine, and this in-
jection was repeated again in twelve hours, and again
in another twenty hours. A total of gr. was thus
given in thirty-six hours with excellent results, caus-
ing a complete disappearance of the symptoms and
the entamæbæ and their cysts. There can be little
doubt that this was a true relapse, and not a fresh
infection, and in view of this the writer is inclined to
suggest that emetine should be continually adminis-
tered either once a week or once a fortnight for at
least a period of three months after the patients
apparent cure.
Leonard Rogers* in his recent work, entitled
" The Dysenteries," discusses the question of radical
cure of amcebic dysentery by emetine injections, and
states that " the evidence, as far as it goes up to the
time of writing, points to the conclusion that we have
in the emetine treatment a permanent as well as a
rapid curative procedure.”
One's experience in the Sudan has not been wholly
in aecordance with that of this distinguished observer.
and more evidence is required regarding the permanent
* Rogers, L., ** Dysenteries," 1913.
June 1, 1914.]
results obtained by the use of this drug. The question
is one of paramount importance, as it is closely
associated with the “ carrier " problem.
Characters of the Entamebe. — Reference has
already been made to the species of entamcebe found
in the two cases described above. The entamcebee
were examined in the fresh state, and their cytological
characters studied in preparations stained by Leish-
man, aud by the iron hematoxylin method. They
corresponded in detail to E. tetragena. Two healthy
kittens were injected per rectum with 3 c.c. of fresh
fæces containing active entamoebse. Both kittens
developed dysenterie symptoms with entamoebs in
their stools, and died within four days. Their large
intestines showed signs of enteritis. In one kitten
the liver was intensely congested, but no evidence of
abscess formation was present.
Source of Infection. —Contaminated water is appa-
rently the chief source of infection. In spite of the
excellent water supply in Khartoum, Europeans are
occasionally infected, probably as the result of par-
taking of uncooked vegetables washed in contaminated
water or handled by infected individuals. In Cases A
and B it was difficult to trace the source of infection.
The faces of all the immediate contacts were exa-
mined, but with negative results as regards the finding
of entamebs. One may here refer to an important
preventive measure rarely adopted in the Tropics,
viz., the advisability of having the fæces of all native
servants examined before taking them into employ-
ment. This is particularly desirable where young
children are concerned.
Method of administering Emetine Hydrochloride.—
The writer’s experience has been entirely limited to
the intramuscular and subcutaneous methods of in-
jection. Of the two, the former appears to be more
preferable, particularly in patients whose vitality has
been somewhat lowered. Recently, in one case, a
loeal and painful fibrosis developed over the sites of
subcutaneous injections, and in another instance a
local necrosis occurred. A point of interest noted in
some of the blood of these dysentery cases treated by
emetine hydrochloride was the appearance of an
eosinophilia. It may be as well to state here that the
brands of emetine employed have been prepared by &
well-known English and also Italian firm.
Conclusions.—The main point in this paper may be
briefly summarized. .
(1) Young children are extremely tolerant of the
drug emetine. In severe cases of entamoebic dysentery
it is advisable to commence with an initial dose of $ gr.
for & child of 2, and repeat this dose every twelve
hours, till a total of $ gr. has been given.
(2) The total amount of emetine administered
should be controlled by the evidence obtained by
microscopical examination of the stools, a procedure
which should also be carried out at intervals during
convalescence.
(3) In order to avert relapses, the continued treat-
ment by emetine after the patient's apparent recovery
from dysentery would be advisable.
(4) In entameebic dysentery of the Sudan emetine
may require to be given in larger doses than are
usually employed in other countries.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 168
RECOVERY OF EMBRYO OF FILARIA BAN-:
CROFTI FROM BLOOD FROM THE LUNG
DURING DAYTIME.
By Major B. H. DuTCHER.
Medical Corps, United Slates Army, San Juan, Porto Rico.
A SOLDIER of the Porto Rican Regiment entered
the hospital February 16, 1914, suffering from a
mild attaek of whooping cough, then prevalent.
Between 9 a.m. and 10 a.m., February 20, 1914,
during a paroxysm he coughed up a small quantity
of pure blood, embedded in mueus.
Upon examining as mueh of this blood as I could
disentangle, probably the equivalent of a small
drop, I found that it contained five or six
moderately active microfilarie. In lifting off the
cover slip in order to preserve the specimen all
were lost but one. The slide with the survivor is
now in the collection of the Army Medical Museum
at Washington.
While this is not surprising in view of our know-
ledge of the diurnal habitat of Microfilaria nocturna,
it is, I believe, the first time that the worms have
been obtained from the lungs in the living subject.
PELLAGRA IN NEW ZEALAND.
Ar the recent session of the Australasian Medicai
Congress in Auckland, Dr. G. B. Sweet exhibited
a child, aged 4, from Westport, which was sup-
posed to be a case of pellagra, though it is stated
the diagnosis was not definitely confirmed. Dr.
C. E. Maguire reported a female patient, aged 44,
who was suffering from pellagra. These are the
only two known cases of the disease in New
Zealand at the present time, and no cases had been
previously reported in that Dominion.
HENRY B, WERD.
GENE UET,
SMALL-POX IN GRÉATeRRITAIN AND
` GERMANY.
Ix the twenty years from 1889 to 1908 England
and Wales had seven and a half times the small-pox
mortality of Germany, and proportionate to the
population thirteen times; and this in spite of the
fact that England is distinetly in advance of Ger-
many in the matter of general sanitation, as proved
by the fact that her general death-rate has been,
and still is, considerably lower; that the special sani-
tary measures for the suppression of small-pox, viz.,
the notification, isolation, quarantine of contacts,
and disinfection, are more rigorously carried out in
England than in Germany, and that England, by
her insular isolation, enjoys a great advantage over
Germany, which is bordered by several countries in
which small-pox is almost always present. ** The
only reasonable solution," says the report of the
Pennsylvania State Medical Commission, which has
just finished a two years' study of vaccination, " is
that Germany has more rigid and better adminis-
trated vaccination requirements. ”’
164 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (June 1, 1914.
Rotices. a great comfort to the men who are going out; but
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THE JOURNAL OF
Tropical Medtctne andhypagtene
JUNE 1, 1914.
SOME ASPECTS OF SURGERY IN THE
TROPICS.
AT the meeting of the Society of Tropical Medicine
and Hygiene, on May 19, 1914, a paper was read by
Mr. Cantlie, on " Some Aspects of Surgery in the
Tropies." The subject of surgery in tropical work
is one that is apt to be neglected in the over-
whelming interest in, and attention paid to, the more
fascinating subjects of new discoveries of many kinds
in the field of bacteriology, helminthology, proto-
zoology, kc. We send the young medical man to the
tropical field nowadays equipped in laboratory work
in a way which is a credit to the medical schools and
the prospect of having to undertake major operations
straightway on taking up duties abroad, is often but
little short of a nightmare to a young man of say,
four-and-twenty who has never had the opportunity of
doing serious operations before leaving England. How
to overcome this shortcoming in training is a diflicult
problem to solve. A “clinical school of operative
surgery," as Mr. Cantlie intimates, may be theoreti-
cally an excellent idea, but the practicability of its
establishment is another matter. Practising on the
dead body, no doubt, helps much, and such stereo-
typed operations as amputations, excision of joints,
ligature of arteries, &c., may be fairly well learned
thereby, but even these very operations on the living
body is a very different matter. Muscles do not retract
in the dead body when cut, hemorrhage does not
confuse, the skin remains flabby, and the expert
teacher on the dead body may himself be an unskil-
ful operator clinically. How much more is this the
ease when less “set” operations, such as those
demanded in abdominal or brain troubles, have to
be done. The answer usually to all this is that every
man before going abroad to practise should have been
a house surgeon in a hospital. This may be impos-
sible, for there are more candidates than vacancies
for these appointments, and, moreover, the house
surgeons, especially in our large hospitals with medical
schools attached, seldom or never get any of the
operations to do that come to the table in the operat-
ing theatre. This is a pity, no doubt, but it is in-
evitable, and the house surgeon at the end of the
time may have been trained to become a first-rate
dresser, but untrained to take the responsibilities of
operation upon his own shoulders. However, as
pointed out in Mr. Cantlie's paper, the records of
recoveries after operations in tropical hospitals, under
European, or European trained medical men, compare
satisfactorily and in some cases advantageously with
those results published by the hospitals in Britain.
It is ditfieult to compare the two seeing the differ-
ences in environment, in the racial peculiarities, in the
matter of the option of selection of cases, and many
other eireumstanees. Two sets of operations were
selected, not so much as a test of skill, but as a means
of estimating the care devoted to asepsis. In the
matter of the radical eure of hernia (not strangulated
hernia) the returns from twelve tropical districts
ranging from the West Indies to the Far East in one
year 226 cases of hernia were operated upon with
one death; whilst in one of the largest London
hospitals 441 cases were operated on with three
deaths. That statisties of the kind are apt to mislead
we well know, for in the same London hospital in the
year following the one from which the record above
stated was ehosen in over 400 cases no death took
place. Yet the results show that asepsis is quite
readily accomplished in tropical hospitals where the
nursing is often entrusted to natives and sterilizing
is therefore more likely to be dubious. All the
more credit, therefore, is due to the assiduous
care taken by the surgeons in the Tropics. The
mortality after amputations was the other surgical
5
June 1, 1914.]
test applied by the writer of the paper in question,
and it showed that in twelve widely apart tropical
countries, of 665 major and minor amputations,
including 76 through the thigh, performed in tropical
countries there were only 15 deaths, whereas in
twelve years in hospitals in Britain there were 580
amputations performed, including 63 thighs, with
182 deaths. Here again statistics are dubious as
tests of efficiency, for in the home hospitals amputa-
tions through the hip-joints were numerous, whereas
this operation is not mentioned in tropical hospital
returns. Another factor which annuls accurate
comparison is that in Britain amputations are often
called for in cases of accidents which afford but a
slender chance of recovery compared with those
performed for disease. In the tropical colonies
where railway, tramway, and motor accidents are few ;
where factories, mining, ship building and dock-
ing are comparatively infinitesimal compared with
British industries, the accidents are therefore usually
more trivial than those met within Britain. However,
the good results recorded in tropical countries show
that successful surgery is possible, and therefore
encouraging to the young surgeon about to take up
work there.
The racial differences were pithily summed up by
Mr. Cantlie in his statement: “In the case of the
native the danger is on the operating table; in the
case of the European it is after the operation that
danger arises." He explained that the native suffers
from shock to a greater extent than the Eüropean, con-
sequently the effect of the operation is more serious
in his case; but the European, owing perhaps to a
more plethoric constitution induced by several causes,
suffers “constitutionally” later on. As regards
anzesthetics it would seem that they do not cause the
surgeon the anxiety they do in Britain. Chloroform
is the favourite anesthetic in warm climates and
there seems no reason to think that it will be sup-
planted. A sufficiency of air is the chief necessity
for the safety of chloroform-giving, and in tropical
operating theatres or rooms there is plenty, for we
find ourselves practically in the open air. In Europe
owing to the present dread of the entrance of "septic"
air, the operating theatres are close and deaths from
chloroform are not unheard of. Other anesthetics in
the Tropics are less convenient; the old method of
administering ether with its indiarubber bag and
other rubber appurtenances are at a discount, not on
account of the gas itself, but on account of the serious
effects of a tropical climate and the rubber materials ;
the recent method of giving ether by the open
method is not in vogue to any great extent in the
Tropics, owing to the difficulty of getting the patient
under, due to the rapid evaporation of the ether,
and the necessity of stopping the punkah or shutting
several windows to lessen the freedom of the current
of air. Not only does the heat necessitate open
windows, but also the presence of the punkah over
the operating table; this causes annoyance, as it
delays the patient's going under the anesthetic, and
is also apt to cause chilling of the contents of the
abdomen if a laparotomy is being performed; on the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
165
other hand, should the punkah be stopped, the
operator is horrified to find the sweat from his face
dripping into the peritoneal cavity of the abdomen he
has opened. These and many other points arise in
operating theatres in tropical countries which show
that there are environmental difficulties which at first
seem alarming but which soon disappear.
Mr. Cantlie dealt also with liver abscess operation,
with the surgical possibilities in the case of diseases
of the colon, with splenectomy as a rational method
of treatment in certain ailments connected with the
spleen, and brought forward in each instance, practical
examples of the difficulties the medical man in the
Tropics has to encounter, more especially when
single-handed.
THE BRITISH ASSOCIATION MEETINGS IN
AUSTRALIA.
Tue eighty-fourth annual meeting of the British
Association for the Advancement of Science will be
held in Australia during July and August. The
arrangements include visits to all the States, ex-
cepting Tasmania. An advance party, limited in
number, will visit Western Australia for scientific
field work. They are expected to arrive at Perth on
July 21 or 28, and, after a reception at Government
House and an evening discourse by Professor Herd-
man, F.R.S., they will visit the goldfields and other
districts, in the interests of the various sections—
geology, zoology, and botany. The main party is to
arrive at Fremantle on August 4, and, wifh the
Western Australian contingent, will proceed to
Adelaide, where, on August 10, after two days of
receptions and sight-seeing, Sir Oliver J. Lodge
(Retiring President) will deliver his address. Sec-
tional meetings (geography and agriculture) will be
held on August 12, at which Sir Charles P. Lucas,
K.C.B., and Mr. A. D. Hall, F.R.S., will deliver
addresses. On Thursday, August 13, Melbourne is
to be reached, where the party will be received by
the Commonwealth Government, as well as by the
city authorities. On the evening of the 14th, Pro-
fessor W. Bateson, F.R.S., will assume the Presi-
dency of the Association, and will deliver the first
part of his address, the second part being given at
Sydney on the 20th. Arrangements are being made
for receptions and excursions in all the States, so
that the members of the Association may have
the opportunity of meeting representatives of the
various governments, the municipalities, the univer-
sities, the churches, and the societies interested in
education, art, and science throughout the Common-
wealth.
Abstracts.
TESTICULAR NEURITIS FOLLOWING
GONORRH@AL EPIDIDYMITIS.*
By SHU YOSHIDA.
Nevritis after gonorrhceal inflammation of spidi-
dymis occurs a few days or weeks after subsidence
of inflammation.
It may appear in various forms: A feeling of
testicular distension, a feeling of carrying a foreign
body, a feeling of pricking pain, lumbar pain, a
pain along the inner side of thigh. These pains
may come continually or at intervals, and may
disappear without any treatment, but in many cases
it appears after a temporary cure and is generally
caused by connection or travelling.
Among the author’s cases, the most remarkable
was one in whom the pain continued at intervals
for six years.
History of the case: Male, aged 83. Suffered from
gonorrhea with left epididymitis six years ago and
was completely cured in six weeks. Since that
time he suffered from pain two or three times every
month, and it was generally severe the day after
connection or after travelling. Three children were
born after that time. This year he again suffered
from gonorrhoea and was completely cured, but the
pain still continues. Urine was quite clear with
only one or two flakes, and no gonococcus was recog-
nized. Per rectum, the prostate had two bean-
sized nodules on the right side and the patient was
said to have a comfortable feeling on massaging the
prostatt®. *, T8é left spermatic cord was generally
enlaige edge, the testicle was hard and the size of
an mde&'fingér, but they both had no tenderness.
Finally, the author says that the neuritis may
accompany or follow other diseases of the genito-
urinary system.
SOME CASES OF PELLAGRA OCCURRING
AMONG THE INSANE IN SOUTH AFRICA.*
By E. W. D. Swirr, M.B., and H. Eazrron Brown, M.D.
Bloemfontein,
We have frequently seen cases of a recurrent
hemorrhagic superficial eruption on the backs of the
hands and shins of natives, which, on healing, left
a glazed or cracked surface, but these were looked
upon as an erythema due to the effects of the sun.
Some of these were cases of mild pellagra. The
cases we report in this article are of a much more
severe type and typical of the disease as described
in Italy and America.
Dr. M. M. MacFarlane, Leribe, Basutoland,
states that he attended five cases of pellagra among
Basutos in 1906-07, and he ascribes the cause to
the maize being reaped that year in very rainy
weather, and having to be stored in a damp con-
dition.
* From the Sei-i-Kwai Medical Journal, March 10, 1914.
t From the Medical Journal of South Africa, March, 1914.
166 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1914.
One would imagine that, as the staple diet of
the South African native is maize, this disease
would be extremely common among them, but
possibly owing to the grain being usually reaped
and stored during the dry season it is not so likely
to become diseased as elsewhere.
The disease in other countries occurs in the
spring and reaches its height in summer. In this
country we have noticed its appearance in the late
autumn and winter.
Patient S. M., Basuto, aged 40, admitted on
August 18, 1912. Physical examination on ad-
mission showed the patient was poorly nourished ;
the skin of the face was darkly pigmented and dry,
and there was a herpetie eruption on the lips; the
gums were swollen and spongy; the knee-jerks were
exaggerated, and slight ankle clonus was obtained.
Mentally he was morose ànd unsociable, often rest-
less at nights; hallucinated, stating that people,
whom he is unable to see, come into his room and
strike him.
The following notes occur in the Case Book,
September 19, 1912: Developed some superficial
ulcerations of flexures of elbows and front of legs.
September 20.—Uleeration has extended over
front of legs and elbows. He is weak and has some
dysenterie diarrhea. Skin of face and limbs is
iethyotie, thickened, scaly and coal black. The
appearance is suggestive of pellagra.
October 8.—Ulceration is healing.
October 25.—Uleers have healed, but he has again
become excited and deluded; conversation is in-
coherent, and he is restless at nights.
The above attack showed the majority of the signs
and symptoms of pellagra and the recurrence which
occurred this year practically placed the diagnosis
without doubt.
On June 5, 1913, it was noticed that the skin
in front of shins had assumed a more glazed appear-
ance; this also appeared to a lesser extent on the
skin of chest and, very slightly, of face. A few
days afterwards the skin of legs began to become
very dark, practically as black as coal; this was
followed by cracking, the cracks only extending
down to the true skin. By the 16th bulle had
formed with a fair amount of serous exudation; in
places a few pustular areas could be seen, these
being probably due to some external infection. This
was followed by desquamation, and sores developed
extending down only to the upper layers of true skin ;
in fact, the front of the leg was one large superficial
sore. That the true skin was not affected was
proved by these healing without leaving any scar.
About this time the neck and chest became affected
and went through exactly the same stages as the
above. About six weeks after the first bulla formed
the eruption gradually .healed, leaving pigmented
areas.
The other physical signs were diarrhea of a
typhoid nature which improved under quin. sulph.
5 gr. t.i.d. His reflexes were markedly increased,
those of the facial area being most marked, a tap-
ping in front of ear led to a spasmodic reflex of that
side of face, twitching of mouth and nostril by tap-
- = M — ns
June 1, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 167
ping under zygoma and on gently striking face the
corners of mouth twitched. His legs became much
atrophied and the plantar reflex tended to be
extensor.
The history of the disease as gathered from the
patient was as follows: The eruption appeared
about four years ago when he was in Basutoland.
It was identical with, only not so serious as, the
above described. It was preceded by a period of
headache and general lassitude, pain in abdomen
and diarrhea. Mouth and throat felt dry, and this
was followed by the eruption which affected his
arms, legs, face and chest (parts exposed to the
sun). After about two months the eruption passed
off and he felt much better, but he noticed that his
arms and legs were thinner and weaker and that
he had some difficulty in walking. The above is
his fourth attack, all of which have occurred in late
autumn or winter. This has been the case in all
our patients, and appears to be a point of difference
between pellagra occurring here and in other coun-
tries: in the latter it is a disease of spring and
summer,
Another case was that of a Zulu, aged about 30,
admitted to the asylum in February, 1909. The
mental condition of this patient was one of pro-
nounced dementia. He was apathetic and unable
to give any information about himself and showed
no initiative or interest in his surroundings. He
remained in this state with occasional temporary
exacerbations until his death in April of this year.
It was impossible to obtain any history of his illness
owing to the patient’s mental condition.
May 12, 1910.—Has developed an erythematous
rash on left side of neck and front of chest. This
is desquamating and discoloured in parts and
appears similar to the rash which occurs in pellagra.
Hands and legs show some edema. Gums pale but
firm, knee-jerks exaggerated. Patient is profoundly
stupid and dirty in his habits.
July 12, 1910.—The skin has desquamated over
above rash, leaving a dark stain. Always slobber-
ing, wet and dirty; lies erouched up in bed and
res'sts any movement, active or passive: is pro-
foundly demented. Provisional diagnosis pellagra.
Subsequent notes describe the recurrence of a
similar condition of the skin and an attack of
dysenterie diarrhaa in the winter of 1912.
The distribution of the rash was confined to the
exposed parts of the skin. It appeared first in
patches of hyperemia followed by desquamation
and, in parts, by superficial ulceration exposing the
cutis vera. The hyperemia and ulceration gradu-
ally subsided leaving a dark-coloured pigmentation
of the affected areas, more pronounced at the
margins, and the skin in an atrophic and inelastic
condition.
During the last eight years about six cases pre-
senting similar symptoms have been observed among
the native patients in the Bloemfontein Asylum.
The characteristic appearance of the skin, includ-
ing the subsidence and subsequent recurrence of the
rash, has usually been accompanied by attacks of
diarrhoea and progressive debility of mind and bcdy.
INFANT MORTALITY IN THE PHILIPPINE
ISLANDS.*
By W. E. MUSGRAVE.
IxFANT mortality in Manila is greater than it is
in any other city from which we have records. This
excessive mortality is not due to a single cause,
and it is not due to natural conditions of the
country. It is due to a multiplicity of artificial
causes that may be classified into: Predisposing
causes, pre-natal and post-natal, and immediate or
active causes.
A thorough study of the predisposing causes of
infant mortality necessitates careful investigation
of the mentality, financial responsibility, sccial and
political economy of the people, the sanitary condi-
tions—including character and quality of medical
attendance conditions of childbirth, general
hygiene, personal hygiene, habits, vices, and cus-
toms of the race. In this connection, also, must be
considered the influence of heredity, with particular
reference to tuberculosis, syphilis, and other
diseases transmitted directly or indirectly through
generations—in other words, the eugenic estimate
of the race.
Of the more direct influences bearing upon the
prospects of the child after birth, there must be
considered the environment, the character and
method of feeding, and the influence of disease.
Foop SITUATION.
The under-developed and under-nourished condi-
tion of the great masses of the Filipino people is
due to a number of causes, the principal one being
insufficient quantity and injudicious variety of food-
stuffs employed. The cause of the enormous in-
fluence of the faulty nutrition of the mothers upon
infant mortality, directly and indirectly, is one of
the most important subjects within the scope of
any investigation of this character.
The mortality in breast-fed children is higher than
it is among children artificially fed. This condition,
so far as we know, is peculiar to the Philippine
Islands. The logical, and we believe the correct,
explanation of this is the deficiency in quantity and
quality of mothers’ milk. So far as ordinary
analysis shows the breast milk of Filipino mothers
is of satisfactory quality for nutritional purposes.
However, certain diseases (particularly infantile
beriberi) are generally believed to be caused by some
abnormality of mothers’ milk. In a considerable
number of cases studied from the clinics of the
Philippine General Hospital, deficient quantity has
been a rather constant finding. When these facts
ane considered, together with the under-nourished
condition of the majority of the mothers due to the
ravages of disease, we must conclude that faulty
nutrition of the mothers is one of the principal fac»
tors in the enormous mortality of breast-fed
children. The correction of this condition resolves
itself into a discussion of methods for the improve-
ment of the quantity and quality of mothers’ milk
and of the artificial feeding of babies.
E From the Philippine Journal of Science, December, 1918.
168
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 1, 1914.
In individual cases and to meet the immediate
demands, satisfactory artificial feeding offers the
obvious solution of the question. However, such a
policy applied to the whole country would, even-
tually, lead to conditions more unwholesome than
are those of the present time, and the ultimate
solution of the problem, therefore, must depend
upon improvement in the nutrition of the race.
There are not in history more pathetic examples of
unavailing self-sacrifice than are daily seen in our
large clinics, of poor, half-starved, under-nourished
mothers attempting to supply from their breasts
food for one or more children, when their own
metabolisms are in a starved condition. When
asked the direct question as to the supply of food-
stuffs, these mothers almost invariably state that
they have plenty to eat, and the pathetic part of
the story is that they believe that they are stating
facts. These abnormal premises are the result of
a peculiar unexplainable psychology that is of very
wide application in this country, that the adminis-
tration of food is more to satisfy hunger than to
produce flesh and blood, and that the cheapest way
in which hunger may be satisfied produces a satis-
factory form of existence. It has been stated re-
peatedly that Filipinos do not care for foods other
than fish and rice, with a few condiments and
vegetables, but investigation tends to show that
this is not a fact, and that these people have the
same appetites and desire for fat and heat-producing
foods as have people of other countries.
INFANT FEEDING.
Good milk is the only satisfactory food during
infancy. Mothers’ milk, under normal conditions,
is the ideal food, and next, because of its physio-
logical adaptability and because it is the only class
of milk it is possible to produce in quantities suffi-
cient to meet the world’s needs, is cows’ milk.
With the conditions discussed above, showing the
causes for deficiency in the quantity of mothers’
milk, together with the well-known fact that fresh,
clean, raw cows’ milk is not obtainable in large
quantities in the Philippine Islands, and that the
prospect for a sufficient local production seems very
remote, there is shown a new problem in infant
feeding.
In considering the physiological requirements for
the production of satisfactory baby food, it must
be remembered that milk is just as essential an
article of diet for the nursing mother in cases of
breast feeding as it is for the baby in cases of
artificial feeding, and recommendations for the
solution of our loeal problem must bear this point
in mind. The milk production of the Philippine
Islands is practically nil when considered in relation
to the requirements of the country. The principal
supply consists of carabaos’ milk and goats’ milk,
with a few dairies located in the larger cities, mak-
ing a business of supplying cows’ milk. We have
gone rather carefully into the question of the quality
of these milks, it being impossible in the time
allowed to do anything regarding the correct estima-
tion of the quantity produced. Nor is this neces-
sary, because investigation of the quality leads to
but one conclusion, and that is that practically all
fresh milk produced in this country is dangerous to
health, in whatever manner used, and the market-
ing of these products should be interdicted by law.
Carabaos’ milk and goats’ milk, when obtained from
healthy, clean animals, properly fed, and under
proper sanitary surroundings, are excellent milks,
but the requisite conditions do not obtain in the
Philippine Islanls, and with possibly one or two
exceptions the conditions regarding the local supply
of cows’ milk are equally unsatisfactory. Nor is
this all, for by no method of reasoning can we
foresee a time when it will be practicable to produce
satisfactory surroundings consistent with an ample
supply of fresh milk at a reasonable price. The
present custom of collecting, transporting, and
using the local milk supply is unbelievably filthy,
insanitary, and consequently dangerous, and a con-
tinuance of the present practice with the facts
before us should fix criminal responsibility for the
loss of life.
The milk sold on the streets of Manila—and pre-
sumably in other cities as well—is from twenty-six
to thirty hours old; has been diluted with tap-
water, or worse; has been collected and transported
in dirty receptacles; has been milked by unclean
persons from unclean animals; and both chemical
and bacteriological examination, of course, shows
this milk to be just about as bad as it is possible
to make it. We have not seen a single sample
that would even approach the margin of safety for
its use by human beings, and in many instances
evidences of sewage contamination and the pre-
sence of extremely dangerous bacteria are found in
samples of milk bought in the open market. The
same is true, to a less degree, of so-called fresh
cows’ milk sold in Manila. Under special condi-
tions, which are obtained only at the expense of
a very high cost of production, surroundings have
been produced by which clean milk could be mar-
keted. Notable in this respect is the very excellent
work at La Gota de Leche, which by careful super-
vision of model dairies has been able to produce
good milk; but even under these circumstances,
which raise the cost of milk to 50 centavos* a litre,
the distinguished officials controlling the poliey of
this institution have felt it necessary to sterilize the
milk before allowing its consumption by the babies
under their eare. If sterilization still is necessary
after the precautions and expenses incident to the
production of milk hy La Gota de Leche, the
problem of furnishing raw, fresh milk in quantities
sufficient to influence infant mortality in this archi-
pelago would appear to be one surrounded by im-
passable diffieulties.
Taking all the evidence into consideration, a raw,
fresh milk supply, sufficient to meet the absolute
requirements of the country, does not seem to be
within the bounds of possibility—at least within a
reasonable length of time. All authorities acknow-
* One centavo equals $0005, United States currency.
June 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 169
ledge that raw milk contains elements of nutritional
value not found in any sterilized milk, and so
far as we are informed the only differences to be
found between sterilized milks are differences in
chemical composition. Therefore, in all probability,
sterilized milk of local production has no advantage
over imported sterilized milk. The question, then,
resolves itself purely into one of financial considera-
tion. Other things being equal, the cheapest milk
should be the one adopted for our general use.
PASTEURIZATION.
So much has been written recently regarding the
methods of Pasteurization of milk in tropical coun-
tries that a very brief consideration of this subject
seems pertinent. Formerly, Pasteurization was
considered an efficient method of preparing milk for
human consumption, because of the destruction by
this method of dangerous disease-producing bac-
teria. We now know that the so-called pathogenic
organisms are not the only, even if they are the
most dangerous, bacteria in milk. Pasteurization,
of course, does not destroy spore-bearing bacteria,
and, therefore, any milk not kept below a tempera-
ture of from 20° to 22° C. after Pasteurization acts
as a culture medium for those germs not destroyed
by the low degree of heat used in the method of
Pasteurization. Intrinsically, most of the bacteria
of this class are not considered pathogenic, but as
a result of their multiplication the chemical com-
position of the milk is altered, and as by-products
of this alteration there are produced dangerous
chemical poisons which are very important factors
in the morbidity results produced by the ingestion
of milk. Conditions for the growth of bacteria in
the Philippine Islands are ideal, and with a very
limited ice supply and without much prospect of
improving this condition the after-care of either
fresh or Pasteurized milk becomes impossible for the
vast majority of people. Actual experimentation
has shown that the multiplication of bacteria in
Pasteurized milk is so rapid that within a few hours
after Pasteurization such milk is almost as danger-
ous as if this process had not been employed.
We come, then, to completely sterilized milk as
being the only variety of this life-giving food prac-
ticable of extensive employment in this country, at
least at the present time.
Fortunately, conditions are not so bad as they
would appear at first sight. Sterilized milk when
used under proper conditions is a very satisfactory
food for infants, and is just as satisfactory for all
other purposes as is raw milk; and another fortunate
circumstance is that the Philippine Islands enjoy
a splendid market of imported sterilized, natural,
and condensed milks of excellent quality at very
reasonable prices, so that the milk supply of the
Philippine Islands compares very favourably with
that of many other countries and cities. It is a
fact that sterilized milks are a little more indigesti-
ble than are raw milks, and there are certain meta-
bolism conditions, for example, scurvy, that may
be incurred as a result of the use of sterilized food.
However, both the indigestibility and the meta-
bolism-disturbing qualities of such milk are easily
and satisfactorily controlled by simple methods well
known to the medical profession. These methods
are so successful that in one series of records of
more than 1,000 babies born in the Philippine
Islands, and fed entirely on these sterilized foods,
there has not been a single case of metabolism
disturbance nor a death from disease of importance
that could be justly attributed to the use of such
food.
It may be of interest to note that there was
imported into the Philippine Islands during the
fiscal year 1912 an equivalent of between 18 and
20 million kilogrammes of milk, at an approximate
valuation of 7,500,000 dollars.
METHODS OF ARTIFICIAL FEEDING.
The methods employed in the artificial feeding of
infants among the poor people of Manila are faulty
in many partieulars. In the first place, notwith-
standing the accessibility of a very good milk
supply, the foods supplied to children in a majority
of cases are those of condensed, sweetened,
skimmed milk of the cheapest varieties, and con-
sequently poor in quality. The apparent economy
in the use of this food, figured from a financial
basis alone, is not a true economy, because milk
compounds of this class contain from 50 to 65 per
cent. of ordinary sugar. When the calorie value of
the actual milk contained in these tins is figured
at the current prices, and this price subtracted from
the total price of a tin of one of these mixtures, it
is found that the people pay an average of from
50 to 75 centavos a kilogramme for ordinary sugar,
which they can buy in a shop for 11 centavos a
kilogram.
It is, of course, unnecessary to dwell upon the
undesirability of the use of this class of foods, and
it only remains to point out that it is bad in princi-
ple, and what apparently, heretofore, has not been
recognized, that it is a more expensive method of
feeding than would be necessary by the employ-
ment of good qualities of milk.
It should be stated that there is one favourable
feature in the use of sugar-preserved milk com-
pounds, and that is that the excessive amount of
sugar preserves the food from the time of the open-
ing of the tin until the food is entirely consumed.
This is, of course, an important problem with poor
people who cannot afford the ice necessary for the
preservation of any pure milk, whether sterilized
or not, after the tin is opened. However, this
should not be a serious obstacle in the adoption of
the use of a better grade of milk, because the
method that is used to a greater or less extent
among the poorer people of the United States, in
which a number of neighbours who have nursing
children alternate in the opening of the tins of
food, so that each tin when opened is consumed by
a number of babies in a few hours, might well be
adopted here. Another solution of this problem
that already is being employed by some manufac-
turers consists in marketing milk in much smaller
tins.
The next most important faulty custom consists
in the dilution of milk compounds with unsafe
170 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1914.
water. In our investigation of the causes of death
of 800 babies, it is found that tap-water, either with
or without boiling, is used as a diluent in most
instances. As a majority of the houses of these
people are at considerable distances from the nearest
faucet, the water is carted by water carriers and
kept in carthenware jars or other vessels, under the
most unsanitary conditions; in many instances
whatever safety might be secured by boiling the
water is destroyed by the subsequent manipulations
and eare of the water and by the methods employed
in making the dilutions of the milk mixtures. The
proof that these mixtures are dangerous to the
health of the baby, on account of the introduction
of bacteria, is shown by the analyses of the contents
of a number of nursing bottles already prepared for
consumption by the baby. These analyses of the
finished produet of food just before administration
show dangerous contamination in practically every
instance, and this has been found particularly true
in cases of children dying from gastro-intestinal
disturbances.
Other faulty methods which need not be dis-
cussed at length here are the almost universal
custom of feeding babies with the greatest irregu-
larity in time, quantity, and strength of food
administered.
The remedy for these conditions, obviously, is
education, both by theoretical instruction and, best
of all, by practical demonstration as may be seen
in the wards and clinics of the hospitals and La
Gota de Leche, and, as has been recommended
by the Committee for the Investigation of Infant
Mortality, by the establishment of nursery maids,
training schools and day nurseries.
The remedy controlling the character and quality
of foodstuffs employed, however, lies in the hands
of the legislative body, and the question should be
treated by discriminating high import duty on un-
satisfactory milk compounds and by allowing free
entry to the better qualities.
In order to solve the infant mortality question in
this or any other country, the first essential is to
secure the influence of a favourable and interested
publie opinion.
The attitude of public opinion in health matters
is à very popular one, and even in older countries
with more advanced civilization it is only within
recent years that eonservation of health has been
of much interest to the general publie.
Publie opinion is vitally active regarding the
pecuniary interests of the country, as exemplified in
commercial activities and improvements, and even
in the health and protection of draft animals and
in the comfort and well-being and protection from
eruelty to domestic animals.
However, with regard to the great vital question
of the conservation of the health of its citizens and
the saving and proteetion of the lives of infants,
there exists a curious indifference that only springs,
periodically, into activity as the result of some
spectacular catastrophe, and dies down again with
the restoration of the usual equilibrium,
The great Taal voleano eruption destroyed some
two thousand lives and a great deal of property,
and its results sent waves of horror throughout the
world. There are more lives uselessly sacrificed to
tuberculosis in the Philippine Islands every month
than were destroyed by the Taal eruption; and the
economic loss to the country by decrease in poten-
tial energy and earning capacity of its citizens, to
say nothing of the actual loss of life, costs the
country daily many times the value of property
destroyed by Taal.
The recent catastrophe in Cebu and other
southern islands sent a wave of horror over the
country and called out Government and private
reserves to meet the requirements of the situation.
The loss of life and health is greater from criminal
obstetrical practices in the Philippine Islands every
day of the year than was the loss of life at Cebu.
The financial drain upon the resources of the coun-
try as a result of these preventible and criminal
practices is a greater daily drain than the total value
of the property destroyed by this unavoidable
calamity.
In older and more experienced countries there is
at last an awakened publie opinion regarding the
eeonomie consideration of health problems, and one
of the most important questions for us is to secure
the support of this valuable weapon in our cam-
paign for the conservation of the lives of the
potential citizens of this country.
SOME EXPERIMENTS ON THE INOCULA-
TION OF MONKEYS WITH SMALL-POX.*
By P. M. AsnBuns, E. B. VEDDER, and E. R. Gentry.
(1) EXPERIMENTS WITH VESICLE CONTENTS FROM A
CASE OF DISCRETE SMALL-POX.
On December 4 the case of a Dutch traveller who
had contracted small-pox in China came under
observation. This case was a very typical discrete
small-pox in a man whose general condition was
excellent and who had been successfully vaccinated
in childhood (about 1884) and revaccinated with
doubtful result about 1900. At the time of admis-
sion he was moderately covered with discrete
lesions, those on the upper part of the body being
good vesicles, those on the feet and legs not quite
mature. He was in the eighth day of the disease.
Vesicle contents drawn into capillary tubes was used
to inoculate five monkeys. Other vesicle contents
in capillary tubes was preserved for later use.
Experiment with Monkey No. 5.—4 large male,
that had been successfully vaecinated in October,
was inoculated at six sites on the abdomen on
December 4 with fresh vesiele contents. No local
lesions resulted. There was, however, a moderate
rise of temperature on the third day, followed by
a drop, and a second rise on the sixth day, with
almost continuous elevation to the seventeenth day.
We call attention to the probability of this rise being
due to variola sine eruptione, the eruption being
* From the Philippine Journal of Science, December, 1918.
-—
June 1, 1914.]
absent because of the protection afforded by the
vaccination in October.
Summarizing the experiments with fresh vesicle
contents, we may say that inoculation with it, by
way of scarifications of the skin: (1) caused variola
inoculata in two unvaccinated monkeys, the primary
lesions, secondary lesions, and temperature curves
being alike in the two instances and probably char-
acteristic ; (2) caused in a vaccinated monkey (No. 5)
a fever very similar to that produced in variola
inoculata, but gave rise to neither primary nor
secondary skin lesions. This fever might well be
the manifestation of variola sine eruptione. Placed
free on the mucous membranes of the conjunctive,
nares, and mouth, the virus caused no disturbance,
or, if any, so little as to be insufficient for interpre-
tation as an evidence of infection.
Of the fresh vesicle contents tubed and not used
on the above monkeys, the greater part, probably
twenty tubes, was used for the inoculation, by
scarifications and intravenously, of two horses.
Neither animal showed symptoms or signs that
could be interpreted as small-pox. The remainder,
which was partly clear vesicle contents and partly
contents drawn on December 7 and showing slight
turbidity, was kept in an ordinary ice-chest for
twenty-four days and was then used to inoculate
two monkeys.
Monkey 23.—A large unvaccinated male monkey
was inoculated December 31 at several points on the
abdomen with 24-day-old vesicle contents. On
January 6 five points and lines of induration, swell-
ing, and slight redness were noted about inserts,
and the temperature was elevated.
By the 8th the induration, redness, and swelling
were all beginning to diminish. Dry scabs covered
the points of insertion. No secondary lesions de-
veloped. On January 7 some of these scabs were
raised and the beds on which they rested scraped.
These scrapings and the triturated scabs were used
to inoculate monkeys 8 and 16.
Summarizing these experiments we may say that
vesicle contents, capable when fresh of causing
variola inoculata in monkeys, so loses its virulence
by being kept for twenty-four days in the ice-chest
as to be no longer capable of producing the typical
disease with prolonged fever and primary and
secondary lesions. It did produce an ephemeral rise
in temperature in both instances after an incubation
period prolonged beyond the ordinary length, and in
one of the two instances it gave rise to abortive
and atypical primary lesions. In neither instance
did secondary lesions or severe disturbance result.
The above finding would indicate that a working
and satisfactory small-pox prophylactic might be
secured by storage and attenuation of virulent vesicle
contents, but prophylaxis by vaccination as prac-
tised is so safe, satisfactory, and efficient that the
pursuit of the clue appears at present unnecessary.
(2) EXPERIMENTS WITH Scans or “ Discs ”
THE ABOVE CASE OF SMALL-POX IN MAN.
As the lesions on the person of the Dutch traveller
matured and the scabs fell or were picked off, they
FROM
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
171
were all collected and saved; one-half of them were
placed in glycerine and one-half were placed dry in
a sterile test-tube.
On December 19, the patient’s sixteenth day in
the hospital and about the twenty-third day of his
sickness, some of each lot of scabs were triturated
in saline solution and some with the serum of a
vaccinated monkey, so as to make thick suspen-
sions. With these suspensions monkeys 28, 22, 26,
27, and 29 were inoculated, five or six insertions
being made on the belly of each.
Monkey 28.—This monkey received scabs pre-
served in glycerine and triturated with vaccinated
monkey’s serum. No local lesions developed. On
the eighth and tenth days the monkey showed sharp
rises of temperature. He thereafter appeared well.
The sites of inoculation were first reddened on
December 8; on the 10th the redness and induration
were very marked, as in monkey 19. On the 11th
small vesicles or pustules marked the insertions,
and two of them were ruptured. The next day the
swelling and redness had begun to subside and the
lesions were scabbed. On the 13th small secondary
lesions, papules, were seen on the legs and about
the anus. On December 15 a profuse eruption of
small vesicles and pustules, more numerous than in
monkey 19, was present on the palms, arms, legs,
face, and scalp. The abdominal lesions were sub-
siding, and the inflammatory process in the ab-
dominal wall was almost gone. On the 17th the
belly wall was more inflamed and indurated and the
swollen ridges were black on top; apparently
secondary infection had occurred. All the secondary
lesions were either pustules or scabs. On Decem-
ber 18 the tops of the swollen ridges on the belly
sloughed, leaving extensive ulcers, and it may here
be stated that these ulcers were not: completely
healed until the end of the month. Numerous pus-
tules of the secondary lesions were yet unscabbed,
but by December 21 all had become so, and des-
quamation was completed by the 26th, the com-
pletion being delayed on the palms, where the dises
were held down by thickened epidermis, and on the
legs, where entanglement of hairs in the scabs
doubtless delayed it.
This case we also regard as one of variola inocu-
lata in the monkey, characterized by fever and signs
of local inflammation on the fifth day; by primary
and secondary eruptions, the latter appearing on, or
escaping notice until, the tenth day; and continued
fever until the fifteenth and possibly the nineteenth
day.
Monkey 12.—A medium-sized unvaccinated mon-
key was given a drop of fresh vesicle contents in
each eye, each nostril, and each side of the mouth
on the morning of December 5. The virus was
placed free on the mucous surfaces. No local
lesions resulted, and no systemic disturbance other
than a trifling rise of temperature on the sixth,
seventh, and eighth days, and we are unable to
affirm that any infection occurred.
On January 16 he was again found to be sick and
to have a high temperature, and on January 19 he
died. Autopsy showed streptococcus septicemia as
172 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
the cause of death. That the sharp rises in tem-
perature on December 26 and 28 were related to the
septicemia that caused death three weeks later,
notwithstanding the interval of apparent health and
normal temperature, is possible.
Four monkeys inoculated with dry scabs triturated
in 0°85 per cent. saline solution; these monkeys
showed no reaction, either local or general.
On December 24 two monkeys were inoculated
at six points on the belly with dried scabs, and one
monkey with both dry and glycerinated scabs. None
of them showed general or local disturbance.
(3) EXPERIMENTS WITH ScABS FROM A CASE OF
RECOVERED VARIOLOID ON THE SIXTEENTH Day.
In addition to the case of small-pox above men-
tioned, the United States Army transport Sherman
arrived in port on December 1, 1912, with a naval
recruit in his sixteenth day of modified small-pox,
which he had contracted in San Francisco and de-
veloped after leaving Honolulu. The attack had
been mild, the lesions abortive, and at the time of
his arrival here the man showed only a few small,
dry, brown scabs. These were all collected, and on
December 2 were triturated in sterile 0'8 per cent.
salt solution and used to inoculate three monkeys,
Nos. 6, 17, and 18.
Monkey 6.—This animal had been successfully
vaccinated in October. No lesions followed inocu-
lation with the scabs. The animal had an irregular
temperature from the first and was sickly. On
December 18 it was killed, in order to get vaccine
immune serum.
Monkey 17.—A medium-sized female, unvacci-
nated, showed no disturbance and no lesions as a
result of the inoculation.
Monkey 18.—A small unvaccinated male showed
neither lesions nor systemic disturbance as a result
of the inoculation. He was later (December 24)
successfully vaccinated.
(4) EXPERIMENTS WITH SCABS FROM VARIOLOUS
MONKEYS.
While two monkeys were suffering from their
variola attempts were made to obtain vesicle con-
tents from them, but the vesicles were so small and
so soon ruptured by the animals that it was found
impracticable. Scabs were collected, however, as
the lesions dried, and these were used to inoculate
monkeys 24, 25, 30, and 81. The results in all of
these animals were quite negative, with the excep-
tion of monkey 24.
Monkey 24.—A medium-sized female was inocu-
lated, December 19, with scabs from monkeys. No
general or febrile disturbance resulted, but on
December 26 there was swelling, redness, and
marked induration of three points of insertion and
their surroundings. The lesions formed dry scabs.
The induration persisted about ten days, and the
monkey remained well,
Whether or not the above monkey suffered from
modified primary lesions of small-pox we cannot
know positively, but it seems probable. At any
[June 1, 1914.
rate, all of the above experiments with small-pox
scabs or discs from man and monkeys indicate that
such material has but feeble virulence and that such
as it has is speedily lost.
On January 7, 1913, the scabs were lifted from
the lesions on monkey 23 (see above), the under-
lying tissue curetted, and the pulp so obtained used
to inoculate monkeys 8 and 16.
Monkey 8.—A monkey that had been vaccinated
in October with the vaccine scab from a pig, atypical
hut supposedly successful ‘‘ takes’’ having been
obtained, showed redness and slight swelling at the
points of inoculation with pulp from No. 23, but
nothing at all characteristic or strongly suggestive of
small-pox or vaccinia.
Monkey 16.—This monkey had been unsuccess-
fully inoculated in November with vaccine triturated
in 1 per cent. phenol in 0°85 per cent. saline solu-
tion and so kept for two weeks, no '' take ’’ result-
ing. Inoculated with '' pulp ” from the lesions of
monkey 23 on January 7, the animal had a rise of
temperature beginning the sixth day.
Beginning on the seventh day after inoculation,
the animal showed marked induration and some
cedema of and about the sites of inoculation and
thick dry scabs formed. The induration was deep.
On January 16 (tenth day after inoculation) the
seabs were lifted, the areas beneath curetted, and
the pulp so obtained used to inoculate monkeys
25, 19, 28, and 3, the first three of which have been
discussed, and the last being a monkey vaccinated
in October. None of them showed general or local
disturbance.
This experiment indicates that the virus in vesicle
contents, although attenuated by storage and fur-
ther attenuated by passage, was still recognizably
active in this animal, but not sufficiently so to sur-
vive another passage.
SUMMARY.
(1) Fresh vesicle contents from a case of human
variola is capable, when inoculated into abrasions
or scarifications on non-vaecinated monkeys, of pro-
ducing variola inoculata in those monkeys, the
disease being marked by fever and by primary and
secondary lesions.
(2) Such vesicle contents kept at ice-chest tem-
perature for twenty-three days loses most of its
virulence, but may still, in a proportion of instances,
produce a mild and atypieal variola inoculata, which
in turn and in further modified form may be passed
to other monkeys.
(3) Active and fresh vesicle contents inoculated
on vaccinated monkeys may produce a fever closely
resembling that of variola inoculata in the monkey
and a condition permitting of interpretation as
variola sine exanthemate in the monkey.
(4) Small-pox seabs or dises from man or monkey
possess but a low degree of virulence, or very
quickly lose their virulence.
(5) When inoculation of such seabs does result in
the production of infection this may be manifested
only locally at the site of inoculation (Case 24). In
June 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 173
other words, the '' B '' part of small-pox virus sur-
vives longest in scabs.
COMMENT.
We admit that this small series of experiments
affords but little proof of the correctness of our
hypothesis as to the relationship of variola and vac-
cinia. On the contrary, we do not see that it affords
any evidence in disproof. The case of monkey 5,
although of little value standing alone, is certainly
susceptible of being cited as an instance of variola
sine exanthemate, as an instance of separation of
the elements of small-pox virus (the pock-producing
or "B" part having acted on the monkey in Octo-
ber; the toxemia-producing, pyrogenic, or “A ”
element in December), and as proof that vaccina-
tion protects against the pock-forming element of
small-pox rather, or to a greater degree, than
against the whole disease. We feel justified in re-
stating our hypothesis that small-pox is due to a
dual and divisible virus, one part of which is the
cause of vaccinia and the pock stage of small-pox,
the other part being necessary for the production
of the highly contagious, febrile, general disease
with an initial stage and preliminary rashes.
HYDATID CYST OF THE LIVER.*
By Dr. J. Casaux.
Case 1—A woman, aged 36, with a six years’
history of digestive disturbance and inability to take
fatty foods, with a feeling of weight in the region of
the liver where later swelling was noticed.
The tumour gradually became larger; there was
no epistaxis nor urticaria, but persistent pruritus,
especially at night. The patient was very thin and
emaciated.
There was marked swelling in the right hypochon-
drium. The thorax was distended, the ribs raised and
the last intercostal spaces approximated. The tumour
extended five fingers’ breadth below the costal margin
and transversely as far as the mid-line. It felt soft,
distinctly fluctuating, without bosses. There was no
vibration or tremor, there was no local cedema, no
sensation of friction, no pain. The dulness extended
upwards to the fourth rib, below this limit back and
front the chest was dull. There was no vesicular
murmur except at the upper part of the lung. In the
base behind there were light superficial frictions.
Breathing was embarrassed. A
A 4-in. incision was made in the most prominent
part of the tumour parallel to and 1 in. below the
costal margin. Upon opening the peritoneal cavity
. the tumour was seen of a brownish colour, very tense
‘to digital examination. A trocar was introduced,
when a rupture occurred and some fluid went into
the peritoneal cavity. The lips of the tear were
seized in forceps, the interior of the cyst was scraped
with the finger to remove the gelatinous debris and
large flakes of viscid membrane. It was then dried
* From the Bulletin de la Société Médico-Chirurgicale de
l'Indo-Chine, April, 1914,
with mops, the cavity being very extensive in all
directions. The cyst was stitched to the lips of the
incision and the cavity washed with 1 per cent.
formalin. The contents were at first clear, then green
and thick ; when collected they amounted to 12 litres.
After the operation the pulse was very weak (108)
and caffein and camphorated oil were injected.
There was vomiting, distension of the abdomen, which
was painful to pressure. Notwithstanding injections
of serum and collargol the patient became continually
worse and died on the fifth day.
At the post-mortem there was no peritonitis and no
fluid in the peritoneum.
Case 2.—A man, aged 48, with a three years’
history of digestive disturbance and loss of appetite,
and a distaste for fatty foods, and with so rapid a
debility that at the end of a few months the appetite
was extremely bad, with nausea and vomiting. From
time to time he had jaundice. For two years a
swelling of the right hypochrondrium was noticed
and heavy pain in the back, especially in the right
shoulder. Inspection showed an oblong swelling
most prominent above and to the right of the
umbilicus; the costal margin was unaffected. The
swelling followed the respiratory movements.
Except for jaundice the skin was normal. The
tumour was felt to extend horizontally a little above
the level of the umbilicus, and mesially it extended
behind the external edge of the rectus. It descended
with inspiration. There was no local edema. Dul-
ness was continuous with the liver which extended
to the sixth rib; there was no vibration or tremor.
The stools were of a high colour, constipation had
alternated with diarrhoea.
A transverse incision was made 1 in. below the
costal rib, the swelling was punctured, emptied and
injected with formalin solution. The fluid which
came away was perfectly clear. After suture of the
lips of the cavity to the parietal incision the interior
of the cyst was wiped and a white transparent
membrane extracted. The patient remained in a
poor condition, but insisted upon leaving a month
after operation, although the wound still required
irrigation and dressing. He died somewhat later.
SUPPURATING HYDATID CYST.*
By Jackson CLARKE.
THE patient, a woman, aged 44, had a four years’
history of dull, continuous, aching pain in the epigas-
trium and right hypochondrium, which was not in
any way related to the absorption of food. She had
occasional attacks of vomiting lasting weeks at a
time. She had lost flesh for eighteen months and
had had jaundice for fourteen days. On admission
she was emaciated and cachectic and markedly
jaundiced. There was tenderness over the liver and
epigastrium ; the lower border of the viscus was
palpable 4 in. below the costal margin in the vertical
* From the Medical Press, May 18, 1911.
174 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
nipple line; the edge of the liver was very hard.
The gall-bladder was enlarged and distended
Temperature 103° F., pulse 128. The patient had pre-
viously been twice operated on. On the present
occasion a bullet probe was passed up the existing
sinus, which was about 5 in. in length; its orifice
was near the mid-line of the abdomen. The walls of
the sinus were felt to be remarkably indurated. Some
2 in. of the right eighth rib were resected between
the anterior and posterior axillary lines. The point
of the probe, which had been left in situ, was now
felt under the area of the resected rib, where it was
exposed. A rubber drainage tube was inserted into
the new opening and passed along the sinus to within
1 in. of the opening of the sinus on the anterior
abdominal wall No drain was left in the anterior
wall of the abdomen. Daily irrigation with iodine
solution (a drachm to a pint of water) was carried out,
but great difficulty was experienced in keeping up
free drainage. The patient was discharged to a con-
valescent home with the tube stil in, but complete
recovery ultimately took place, and was attributable
largely to the persevering drainage and irrigation.
—— 9—————
Translation.
DISINFECTION AS PRACTISED AT THE PRE-
SENT TIME BY THE USE OF STEAM AND
FORMOL APPARATUS, AND DISINFECTION
BY MEANS OF “ CLAYTON ” MACHINES.
How to prevent the spread of disease has been, in
all ages, one of the most serious problems. From
the earliest times disinfection has been strongly
recommended, and one of the favourite methods was
sulphur fumes, produced by the combustion of sulphur
in pots. Investigations and experiments carried out
under scientific supervision, possible only since the
marvellous discoveries of that great benefactor of
humanity, Pasteur, have recently shown that the
means selected empirically by the ancients are, in
effect, the best available at the present time.
In all civilized countries disinfection is now obli-
gatory. It is a delicate operation, complicated as now
used, and the application is attended with numerous
difficulties. The great majority of the public accept
it readily only in case of epidemics ; consequently, the
measures employed too often meet with opposition
more or less open. Even those who recognize the
necessity of it submit with a bad grace, and complain,
not without reason, of the inconvenience caused, the
length of the operations, and the damage done to
their personal effects, inevitable with the methods
actually employed. The sanitary staff is not sup-
ported by the very people who would benefit most by
its efforts, and one cannot be surprised if the im-
patience of the public affects the staff and injures the
quality of its work.
This impatience, however, is quite comprehensible.
A bereaved family, mourning the loss of one of its
members, sees people arrive who demand the bedding,
[June 1, 1914.
linen, effects and articles of all sorts used by the dear
lost one, as well as of everything that may have been
contaminated during the illness (and very often this
represents nearly all the family effects). All are
carried away to be dealt with at a disinfecting station,
and after a more or less long delay the articles of all
kinds are returned mixed together, damp and partially
deteriorated. The Assistance Publique of Paris have
every year very large sums to pay for damage caused
to articles disinfected at these stations, but these pay-
ments are far from representing the total loss. In
many cases the poor people have to put off going to
bed until their only mattress is brought back, which
is too often returned to them in a very wet condition
when the disinfection has not been followed by
efficient drying. It is useless to dwell upon the results.
While these articles are being thus disinfected the
dwelling-place is handed over to a gang who wash the
furniture with a solution of sublimate, or perhaps
introduce steam and formol or some of its derivatives.
After both processes everything remains in a damp,
comfortless condition, and the disinfectant in addition
leaves an extremely disagreeable smell, which lasts for
days, in spite of ventilation.
One can conceive the real sufferings involved in a
present-day official disinfection, and one can quite
understand the opposition incurred to the declaration
of a disease after which such a method of disinfection
is imposed.
Of course, a thorough disinfection cannot be carried
out without inconvenience, but this should be reduced
to the strictest minimum.
To be efficacious, a disinfection should be carried
out promptly, and in such a manner as to avoid the
risk of spreading the disease; it should reach all
pathogenic microbes, not only those found on clothes,
linen, &c., or in the bedding, but also those which
may have settled on furniture or in carpets, on the
floors and walls of the dwelling; it ought also to
destroy all insects whose rôle of propagators of
disease is universally acknowledged.
At present, as we have seen, several different opera-
tions are carried out which only give incomplete
results, for no single one of the methods actually
employed suffices in itself. One process, applied on
the spot without handling the articles, destroys
mierobes directly exposed, but does not reach those
in any way protected, and does not affect the insects.
Another, which reaches the mierobes whether ex-
posed or protected, necessitates handling the articles,
bedding, &c., and removing them from the contami-
nated place. There are certain articles in common
use capable of transmitting infection which cannot be
exposed to either one or the other process.
If it were possible to abolish the removal of clothing,
&c., and their disinfecting at a station, the risk of spread-
ing the infection would be avoided, the articles would
not be damaged, and the families would be spared the
grief of having to assist at such measures, which cannot
fail to shock feelings entitled to every respect. If it
were possible, by a single operation, to disinfect the
infected premises with all the contents, our means of
defence against disease would be strengthened, the
June 1, 1914.]
inconveniences diminished and, consequently, the oppo-
sition of the public lessened.
Is it possible to attain this result? The “ Clayton "
system is the only method we know of at the present
day that aceomplishes this end.
For the destruction of all kinds of vermin this
system has been employed for years throughout the
whole world, and in this respect its superiority is
incontested and incontestable. Modifications and
improvements recently added to the machines, and
to the manner of using them, now allow of the same
excellent results being obtained in disinfection as in
deratization and destruction of insects.
The annexed table furnishes the proof. It shows
the results of a disinfection carried out at the Hopital
de la Pitié at Paris, under the supervision of a Com-
mission of the Conseil Supérieur d’Hygiéne Publique
de France.
The possibility of destroying pathogenic microbes
by the “Clayton” process once established, its
superiority over others becomes evident.
&& The “Clayton” apparatus suffices in itself. Not
only does it fulfil the róle of the disinfecting station,
but it renders unnecessary all additional operations.
The complete disinfection of the premises and of
all the contents is carried out in a single operation,
which at the same time destroys all the insects and
their eggs.
There is no danger of spreading the disease; the
centre of infection is reached on the spot.
All articles remain in their respective places. No
handling is necessary, the gas penetrates every where,
therefore it is not necessary to unfold garments, to
open parcels of soiled linen, beds, cupboards, &c., nor
to disturb carpets, curtains, furniture. Furs, articles
in leather and skin (shoes, gloves), india-rubber, silk,
velvet, &c., as well as furniture, are not damaged by
the action of the gas. Needless to say, many of these
artieles would be absolutely ruined if treated at the
ordinary disinfecting station.
“ Clayton ” gas is dry, and is introduced into the
premises to be treated at the temperature of the air,
consequently there is neither humidity nor condensa-
tion, and the smell quickly disappears after aeration
carried out by means of the machine itself.
The gas diffusing itself under the action of a
powerful blower, the machines can be used to dis-
infect at a single operation the most extensive pre-
mises, whilst by the usual method it is possible to
treat only a certain number of articles limited by the
dimensions of the apparatus, the capacity of which
is always restricted. There are several types of
these machines, all equally efficient, but of different
capacity, from the smallest which weighs only about
3 cwt., and is suitable for the disinfection of small
places of about 500 to 700 cubic feet, to the largest
which weighs 5 tons, delivers about 750 cubic feet
of gas per minute, and is capable of disinfecting the
largest ships.
The motive force employed to operate the blowers
may be either steam, electricity, petrol, or oil; the
motor varies from $ h.p. to 15 h.p., according to the
type of machine.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
175
The only material necessary to produce “ Clayton
gas is roll sulphur, which has been employed, as we
have seen, from the earliest times ; it is cheap, can be
obtained everywhere, and lasts indefinitely. Conse-
quently, the operations are simple and inexpensive.
Clayton system officially authorized for disinfection by the
Conseil Supérieur de Santé de France after the following
results obtained at a disinfection of an amphitheatre of the old
“ Pitié” Hospital, Paris, situated in the Michou building,
and having a cubic capacity of about 425 cubic metres, by a
Clayton machine type ** H."
on floor ...
at 0:80 m.
at 0:50 m.
near ceiling
at 1:20 m.
on floor ...
Typhoid bacillus 4 at 0:80 m.
near ceiling)
at 1:20 m.
at 0:50 m.
Xie in | 'oth 1 thickness
E thicknesses
AII destroyed.
Diphtheria closed envelope
| tose envelope — All destroyed.
| closed envelope
Coli bacillus . All destroyed.
on floor AT
at 0:80 m. i
at 1:20 m.
closed envelope
at 0°50 m.
Raik one | All destroyed.
Staphylococcus
wane in cloth 1 thickness
a 2 thicknesses
|
|
:
n
at 0-80 m. Develo p m ent
Subtilis at 1:20 m. ;closed envelope retarded 36
at 0:50 m. UM
evelopment
Anthrax ja pee Dg } closed envelope retarded 24
hours.
fer floor ... 4 guum. pigs
‘ at 1:20 m. show no trace
Tuberculosis .. at 0-50 m. pee envelope of tuberous
(near ceiling losis.
Diphtheria Inside woollen mattress... ! AIL destroyed
aj i
seaweed -
. qm Inside woollen mattress
Coli bacillus . AII destroyed.
seaweed ,,
Inside woollen mattress
Staphylococcus
seaweed ,,
| All destroyed.
$^ (Develop m ent
(
Subtilis Inside woollen mattress retarded 36
hours.
Development
Anthrax Inside seaweed mattress retarded 24
hours.
(2 guinea - pigs
' 4 show signs of
tuberculosis.
Tuberculosis. «. Lo woollen mattress
„ seaweed ,, e
—Á RTT REED
N.B.—Seeing that the subtilis and anthrax, exposed under
different conditions, were both retarded for the same length of
time, it is evident that something abnormal took place for two
out of the six guinea-pigs to show signs of tuberculosis.
Every maritime station which possesses type “ B,"
of these machines, for the destruction of vermin on
board ship need only add others of smaller type,
specially adapted for the disinfection of cabins, crews'
quarters, &c., with all their contents, to avoid having
to carry away belongings and bedding to the stoves,
as is done at the present time, and while the holds
are being disinfected with the “B” machine, the
small spaces are treated by the others.
176
Every ship provided with a " Clayton " apparatus
for the extinction of fire possesses at the same time
the means of getting rid of all vermin and of dis-
infeeting thoroughly in ease of disease on board, and
the maritime sanitary authorities grant special
favours to vessels so equipped. Delay in quarantine
is also reduced thereby, and in fact sometimes
entirely avoided
LL €—
Hotes and Melos.
GERM TRANSFORMATION.
MME. VICTOR HENRI, working in Dr. Roux's
laboratory, has, in a communication read before the
Academy of Science in Paris, announced that under
the influence of the ultra violet rays, a bacillus has
been transformed into a coccus. The experiment was
made with the anthrax bacillus, which after prolonged
exposure to the rays developed into a microbe of quite
a different character. This is an interesting step in the
evolution of bacteriology, and what has been found to
hold good in vitro may in time be found to be capable
of being extended to changes in living tissues. We
are getting accustomed to the idea that the apparent
specific differences of germs are but stages in develop-
ment, starting from some common source, and that
soon the present-day divisions founded upon shapes,
&c.-—bacilli, cocci, flagellated bodies, comma bacilli,
&c.—will become obsolete as a basis of classification.
LONDON SCHOOL OF CLINICAL MEDICINE.
COURSE ON SYPHILIS.
This course, referred to in our last issue, is arranged
as follows :—
Monday.—10-11, Ear, Nose, and Throat Complica-
tions of Syphilis, Mr. Biggs; 11-1, Ward Work, in-
cluding the taking of case notes, doing of dressings,
injections, &c.; 2-4, Laboratory Investigations and
the practising of Laboratory methods of diagnosis,
Wassermann tests, Luetin tests, and the staining of
Gonococci, &c.
Tuesday.—10-12, Ward Work; 12-1, Diseases of
the Skin, including many due and analogous to
Syphilis ; 2-4, Laboratory Work, with tuition and
supervision from Dr. Davies; 4.15, on alternate
Tuesdays, Skin Diseases, Sir Malcolm Morris.
Wednesday.—10.30, the Eye Complications of
Syphilis and Gonorrhcea; 11.30-1, the Cerebral,
Spinal, and Nervous Complications, by Dr. Gordon
Holmes or one of the other physicians; 3-4, Ward
visit with Mr. C. C. Choyce, F.R.C.S.
Thursday.—10-19, Ward Work; 12-1, Dr. Mac-
Cormac, special lecture on Syphilis; 2-4, Laboratory
Work.
Friday.—10.19, Ward Work ;
19-1, Dr. Mac-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1914.
Cormac, Clinique for Skin Diseases; 2-4, Laboratory
Work, under the tuition and supervision of Dr.
Davies.
GLANDERS.
THE latest number of the Monthly Bulletin of the
New York Health Department states that in the
Borough of Manhattan in 1918 there were dis-
covered 589 glandered animals among approxi-
mately 65,000 horses, or about nine out of every
1,000. The disease is found to be most frequently
transmitted through blacksmith shops and public
drinking troughs. In the city of New York there
were in 1909 three deaths from human glanders; in
1910, four; in 1911, three; in 1912, five; and in
1918, one.
ARTIFICIAL MILK FROM THE SOY BEAN.
IT is reported from Bockenheim, Germany, that an
artificial milk is being made from the soy bean—the
well-known product of North China. So-called butter,
cheese, and other alimentary products are being made
and finding a ready sale in the area around Bocken-
heim. It is reported that the works already estab-
lished can produce 11,000 gallons daily of artificial
milk which, it is said contains 4 per cent. of fatty
matter. There is no end to the degradation to which
the modern chemist will drag down his profession;
it is not mere substitution but a prostitution of chem-
istry that is going on at the present day in many
departments of our food supplies.
THE SUGAR-BEET PARASITE.
Aphis enonymi, a species of green-fly, is the chief
enemy of the sugar-beet in Europe. The life-history
and development of this insect, which is the pest of
several plants, is interesting.
Starting from the egg, the larve in a short time
become wingless females, which soon produce vivi-
parously (without an egg stage) another generation
of unwinged as well as winged insects, some of
which fly away to found fresh colonies on other
plants. Towards autumn, egg-laying females are
developed, who deposit their eggs in the axils of the
buds and other parts of trees or shrubs. Males,
some of whom are winged and some wingless, are
also produced at this time, and are responsible for
the fertility of the eggs. The wingless insects,
popularly known as '' plant lice," are by far the
most numerous. They have a beak or sucking tube,
with which they pierce the skin of the plant and
suck up the juice. This is the cause of the crumpled
condition of the leaves and other parts of the plant
attacked.
—————
June 15, 1914.] THE JOURNAL OF TROPICAL
MEDICINE AND HYGIENE. (No. 12, Vol. XVII.
Original Communications.
NOTE ON A CASE OF OSTEOPERIOSTITIS
DEVELOPING AFTER A PROBABLE
ATTACK OF “FEBRIS COLUMBENSIS."*
By Arpo CasrELLANI, M.D.
Director, Bacteriological Institute, and Clinic for Tropical
Diseases, Colombo.
In 1905 I described and published a case of fever,
somewhat resembling enteric, due to a germ which I
called Bacterium columbense. Later, impressed by
the peculiar, somewhat inconsistent, sugar reactions
of the micro-organisms, I was inclined to consider
the bacterium no longer a separate species and was
inclined to identify it with the Bacillus paratyphosus B.
Recently having had an opportunity of isolating the
same germ from two further cases and studying it
more completely, I have been forced to come to the
conclusion I-had arrived at eight years previously,
viz., that the germ is a separate species and the fever
caused by it a separate entity from either typhoid or
paratyphoid. These two cases have already been
Motility
Lactose*
Saccharose
Dulcite
Mannite
Glucose
Maltose
Dextrin
Raffinose
Arabinose
Adonite
|
Litmus milk*
the Bacteriological Institute all bloods sent for Widal's
reaction are also tested for Malta fever, paratyphoid
A, paratyphoid B, B. columbensis, B. asiaticus. We
found out then that while the specimen of blood sent
by the surgeon had no influence on typhoid, para-
typhoid A, paratyphoid B, Micrococcus melitensis and
B. asiaticus, it agglutinated B. columbensis well.
With Dr. de Silva’s kind permission a more complete
bacteriological examination of the case was under-
taken.
SERUM REACTIONS.
The blood examined on four different occasions
has shown complete agglutination for B. columbensis
in a dilution of 1 in 40 and occasional feeble agglutina-
tion in a dilution of 1 in 80. The blood agglutinates
equally well the strain isolated from the first case of
" febris columbensis" in 1905, the strains recently
isolated in two cases in 1913, and the strain isolated
from the pus of the lesions shown by the patient.
PRESENCE OF B. columbensis IN THE PUS.
The bacteriological examination of the pus by
plating, &c., has revealed the presence of the typical
Inosite
Salicin
Inulin
Erythrite
Amygoalin
z
o
>
=|
Sorbite
Galactose
|
Broth
Peptone water
|
B. columbensis +| AVS O 0 AG AG) AG! AG! ASGSO AGO
(Cast., 1905) | | Alk | or |
| |AGVS| |
Abbreviations used in the table: A — acid, G — gas, O = clot, D
alkaline, GT = general turbidity, P — pellicle, VS — very slight, 0
gas in sugar media, non-production of indole, non-motile or non-liquefaction of gelatine or serum, as the case may be; +
0| AG in ah N
| | | |
| | |
0| AG|0| AG -|0|0|0 0/0,0 GTP| GTP
vs
j
decolorized, Alk alkaline, S — slight, A/Alk — acid then
negative result, viz., neither acid nor clot in milk, neither acid nor
* See remarks in the text.
published and recently I have studied three further
cases. The complications and sequele of this
fever are practically unknown; it may therefore be
of some slight interest to relate a case recently
observed of chronic osteoperiostitis, due to B. colum-
bense, which from the history given by the patient
and his relations must have developed in all pro-
bability after an attack of “ febris columbensis." The
patient, a Singhalese, was admitted to the general
hospital in December, 1913, and placed in Dr. Marcel
de Silva’s surgical ward. He had several sinuses
in the left arm discharging sero-purulent matter.
According to the patient and his relations the condi-
tion had commenced with painful swellings more
than a year previously, after an attack of continuous
fever which had lasted six weeks. Dr. Marcel de
Silva operated on December 12 and again on Feb-
ruary 3, and several spicules of bone in the form of
sequestra were removed. The surgeon suspected the
condition to be due to previous typhoid and sent a
sample of blood for Widal’s reaction to the Bacterio-
logical Institute. The reaction was negative. At
* The author would be pleased to send a culture of the germ
referred to in this paper to any worker interested in the-subject.
B. columbensis as described by me in 1905. As
this germ is yet little known, it may perhaps be of
advantage to give here again its description.
CHARACTERS OF B. columbensis (CAST., 1905).
Rods 2 to 5 pm in length closely resembling
the typhoid and paratyphoid bacilli, motile. It is
easily stained by the ordinary aniline dyes, but not
by gram.
CULTURAL CHARACTERS.
Broth.—Abundant growth with diffuse turbidity :
after twenty-four hours to forty-eight hours a delicate
pelliele is generally present.
Agar.—The growth may be typhoid-like, but
generally the germ grows more luxuriantly than is
the case with typhoid.
Gelatine.—Growth fairly abundant, medium not
liquefied. ‘ s
Serum.—Nothing characteristic, the medium is not
liquefied.
Litmus Milk.—It may be said that, in general, it
becomes acid at first and alkaline later, and that
bleaching of the medium is of very frequent occur-
rence, but occasionally the medium is rendered
permanently acid. After three weeks, the medium,
positive result
178
if tubes are capped with rubber caps, may occasion-
ally become thickened, or even real clotting, though
of rare occurrence, may take place.
Sugar Broths and Action on. Lactose.—The sugar
reactions are collected in the following table. Some
remarks may be made on the action of the germ on
lactose: when the germ is freshly isolated from the
stools or urine it has no action on lactose, but after
several transplantations it may very slightly ferment
this sugar at times, while it does not touch it at other
times, using the usual technique with Durham tubes.
The experiment has been repeated many times and all
precautions have been taken to avoid mistakes as far
as possible.
It is notable that on MacConkey’s lactose red agar
the colonies are always permanently white.
Biological Tests—All strains of B. columbensis
have been repeatedly tested with typhoid serum,
paratyphoid A serum, paratyphoid B serum derived
from patients suffering or convalescent from such
diseases, as well as from hyper-immunized animals,
always with absolutely negative results, the result
being always negative, even using a dilution of 1 in
20. The strains have been tested also with very
powerful paratyphoid A, paratyphoid B, sera obtained
from the Berne Institute, with the same result, viz.,
no agglutination whatever is observed. The absorp-
tion tests completely confirmed the agglutination
tests. There cannot be any doubt, therefore, that
the germ is neither paratyphosus A nor paratyphosus
B. The germ has been tested also with various coli
and coli-like sera I have prepared, always with
negative results.
BOTANICAL POSITION OF THE BACTERIUM.
This bacterium is difficult to classify owing to its
inconstant action on lactose. As already stated,
though all precautions to avoid a mistake have been
taken, the conclusion arrived at is that the same
strain while at times it is a non-lactose fermenter, at
other times it feebly ferments lactose with very slight
production of gas. When it does not ferment lactose
its reactions are practically identical to those of
B. paratyphosus B; when it ferments lactose it is
more closely related to B. coli. Agglutination and
absorption tests clearly show that the germ is a
separate species, as it is never agglutinated by para-
typhoid A and B sera, even powerful ones, as those
imported from the Berne Institute, nor from any
coli and coli-like sera I have prepared. Bacterium
columbensis cannot be identified with B. paratyphosus
C of Uhlenhuth, as the latter is culturally identical to
B. suipestifer, and in man at least is apparently not
pathogenic.
It cannot, of course, be excluded that B. columbensis
may be identieal with one of the so-ealled para-
typhosus D, &c., paracolon bacilli, &c., isolated by
certain authors, as I have not in my hands the whole
series of such germs to enable me to carry out com-
parative researches: even if such were the case,
however, according to the rules of nomenclatare the
term Bacillus columbensis (Cast., 1905) would have to
stand, owing to priority of description and name.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 15, 1914.
CONCLUSION.
In a case of chronic osteoperiostitis developing after
an attack of continuous fever said to have lasted six
weeks, a micro-organism has been isolated from the
pus with all the characters of B. columbensis (Cast.,
1905). The blood of the patient agglutinates the
strain isolated from the pus as well as all the strains
of B. columbensis kept in the laboratory, including
the original one isolated in 1905.
There can be little doubt in my opinion that this
germ has been the cause of the osteoperiostitis, and
that the fever from which the patient states he suffered
before the periostitis developed, was, according to all
probabilities, an attack of "febris columbensis."
I wish to express my indebtedness to Dr. M. de
Silva, 2nd Surgeon, General Hospital, for allowing
me to investigate the case, and to Dr. E. C. Spaar for
assistance rendered.
——— e———À
Malaria in Infants (W. Weston, Archives of
Pediatrics, New York, April, 1914).—If seen during
the early part of the paroxysm a hot mustard bath
is given, ice cap applied to the head, and if the infant
is having convulsions give bromide of soda and
antipyrin also. If the infant is in this stage, frequent
tepid spongings give great relief. The bowels should
be promptly and freely opened by the use of frequent
small doses of calomel. Other medicinal treatment
consists in the administration of quinine, preferably
bisulphate, in aqueous solution. The stomach of
an infant suffering from malaria is almost invariably
very irritable, and it is therefore important that
quinine should be given only at those times when it
will be most effective in destroying the parasites.
Weston advises that in benign attacks no quinine be
administered for at least three hours after the tempera-
ture becomes normal. Then administer 2 gr. bi-
sulphate in aqueous solution every two hours day
and night for twenty-four hours, then 2 gr. in
solution every four hours for twenty-four hours, then
3 gr. morning and evening for three weeks. It absorbs
more readily when the stomach isempty. If difficulty
is found in retaining the bisulphate, euquinine or the
tannate may be tried. In pernicious malaria quinine
hypodermically is the only method to be relied on.
The best salt of quinine for injection in Weston’s
opinion is the bimuriate. The tablets of bimuriate of
quinine and urea are convenient and reliable. The
3 gr. tablets contain about 25 gr. of the quinine salt.
The tablet should be dissolved in distilled water or
merely sterilized water. The needle and syringe
must be sterile and the skin sterilized. The solution
is then injected deep into the muscles. This pro-
cedure may be repeated every six hours. Finally the
rectal administration of quinine may be resorted to.
Here the bimuriate in doses three times as large as
would be given by the mouth or intramuscularly
should be given in 2 oz. of warm water. This injec-
tion should be given high up in the rectum. It is
well to add 5 drops of tineture of opium to the
solution to prevent tenesmus and aid retention.
June 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
179
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11.—To ensure accuracy in printing it is specially requested
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‘* Answers to Correspondents.”
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iven when MS. is sent in. The price of reprints is as
ollows :—
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ET Vp ais Gs ja 6/-
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One page of the Journal equals 3 pp. of the reprint.
If a printed cover is desired the extra cost will be, for 50
copies, 5/6; 100 copies, 6/6; 200 copies, 7/6.
JUNE 15, 1914.
SPAS IN EUROPE FOR TROPICAL
RESIDENTS.
THERE is no more common question put to the
doctor in warm climates, when tropical residents
intend going to Europe, than “ What spa should I go
to on reaching home?” for Europe means “home”
in a general sense to all Europeans abroad. More
often than not the medical adviser has to “ reserve
his decision," for a confession of his complete ignor-
ance of spas and the treatment given there is neither
to his benefit nor does it help the patient. In his
moments of leisure the doctor may turn to what
sources of information he has at hand, and try to
unravel the rival claims of spas as specific for this
and that disease. He will in all probability arise from
his study of spas in a mind yet more confused, for
every spa seems to “cure” every ailment mentioned
in the category of disease. Catarrh of every tract of
the human body, and each individual organ in those
tracts, is specially mentioned in almost every spa
prospectus. Heart ailments, organic and functional ;
blood circulatory troubles ; respiratory ailments, from
the nose to the bronchi ; kidney and bladder troubles,
rickets, scrofula, anzemia, gout, rheumatism, syphilis,
skin diseases —a comprehensive term—brain affections,
and paralysis, infectious diseases—whatever that term
implies—disorders of the pelvic organs of women, and
last, but not least, “Tropical diseases.” The last
named is perhaps the most wonderful of all; and the
doctor in the Tropics, gauging the claims of a spa to
cure other diseases on the same magnificent grouping
as that of tropical diseases, is quite justified in
throwing his guide to spas aside and coming to the
conclusion that it matters not where his patient
should go. This, however, is not politic practice, and
he advocates this or the other spa as the one calcu-
lated to specifically benefit the constitution of the
individual he may be advising.
Where, however, with all the knowledge of the
balneologist, would he advise tropical patients to go?
The fact is the uses of waters of European spas were
settled as means of "cure" before patients with
“tropical diseases ” came into the field for such treat-
ment. The spas were instituted for diseases met with
in Europe, not in the Tropics; but seeing that tropical
residents seeking change in Europe have become
within the past five-and-twenty years more numerous,
provision had to be made for them in the advertise-
ments, under the heading “ and tropical diseases."
Having been in the Tropies folks assume that it is
the liver that requires treatment, and therefore the
"reducing ” treatment at spas must be the form of
"eure" required. But the doctor in the Tropics is
cognizant of the fact that tropical liver conditions
are in a different category to the hepatic troubles met
with in Europe. The European with a liver con-
gested and enlarged from a plethora of rich food and
rare wines is one thing, and requires the stinted régime
which is the feature of most spas; but the tropical
resident coming home, after a lengthy spell in a trying
climate, anemic and played out, accustomed to food
which is not rich, who has had "tropical chickens ”
as his main article of diet, and tinned food as a
weleome change, does not surely require a reducing
régime but the opposite. When one speaks of spa
treatment for liver, one thinks of some Bohemian or
other spa where the treatment is severe, where
dietetic discipline is rigid, and where both the laity
and medical men direct their thoughts when liver
ailments are in question. Thither men from the
Tropies used to go as a matter of course when they
came "home." Many went: some were not appar-
ently injured by the treatment, some returned and
repented going, some never returned. Wiser counsels
prevail to-day ; the famous spas in Bohemia and else-
where are not frequented as of yore by old tropical
residents; the fashion took some time to stem, but
HENRY B, WARD,
STATE UNIVERSITY,
180
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 15, 1914.
the medical men have not spoken in vain. Again, the
custom long in vogue, when a tropical resident on
returning to Britain consulted a doctor, was for the
doctor to prescribe a cure at a Continental spa as a
necessary part of treatment. The patient often re-
sented the advice, saying, " That is all very well, but
here am I come home on leave to my native country
after a long spell abroad, and the first thing you do
is to send me out of it." The man has had enough
of foreign countries, and would prefer to take his
chance in his native land. Moreover, there is no
necessity for anyone for whom spa treatment is
necessary to go out of Britain to get it.
British spas, whether as regards the variety or the
quality of the waters, are as potent as anywhere in
the world; the appointments and the appliances of
several British spas compare favourably with the
best on the Continent of Europe. The doctors at
home are as well acquainted with the requisites of
a spa as the professional spa medical “ attendants”
on the Continent. Much might be said concerning
the treatment of tropical ailments at these spas by
men who have never studied the subject and whose
information consists of what the patient from the
Tropics tells him of the signs, symptoms, and treat-
ment of his or her disease. “ And tropical diseases "
at the end of the list of ailments for which any
particular Continental spa is recommended requires
no further comment; it is a legend which cloaks an
ignorance of depths so profound that the practitioner
in the Tropics may well say, " Oh! go to any spa you
like." That a spa does good to almost all visitors is
undoubted; so does a visit to the hills by a dweller
in the plains, and the seaside benefits the inland
residents in any country. A change is necessary for
many animals, as evidenced by bird migrations and
by the necessity for fresh blood from a distance
amongst stock, whether horses, cattle or sheep. So
in the same way a spa benefits; it is a change in
environment, a change in the mode of living, and
taking the waters does good, both physiologically
and mentally, through the discipline incurred. But
that a tropical resident must be sent abroad to get
the “cure” is not true.
The term " cure ” always sounds odd to English ears.
Is the cure so certain? Do they guarantee cures
at these spas? If so, then is the ailment trivial or
imaginary altogether? Certain it is the spas are not
meant for the treatment of serious illnesses, and it
behoves really sick folk to avoid them. Moreover,
no one wants them there. The visitors do not want
to see sick folk sitting about; it depresses them, they
say. The doctors are there only as dietetic and balneo-
logieal " experts," and are not practitioners in the
accepted sense, and certainly not experts in tropical
ailments. The spa, on the Continent especially, is a
place at whieh entertainments are a primary feature
of the attractions, the water drinking being an ad-
dendum merely and often regarded as rather a bore
by many. In Britain there are more sick folk about
the spas than are to be seen on the Continent ; enter-
tainments are less considered or altogether absent;
and the doctors are more clinicians than dietetic
experts, and actually treat diseases as practitioners of
medicine. The British spas, consequently, will com-
mend themselves to tropical residents who seek spa
treatment as a necessity, not as a luxury, and who do
not wish to spend their leave away from home, but
only go to a spa for relief from illness.
SPAS IN WESTERN GERMANY.
BADEN-BADEN.
À WATERING-PLACE in the Grand Duchy of Baden,
with a population of some 22,000 inhabitants, is
situated in a wide valley of the Black Forest. The
town, surrounded by well wooded mountain ranges,
rises in a succession of terraces on a hill side, and is
not only beautifully placed but is also in a sound
sanitary state. Some twenty mineral springs exist in
the neighbourhood, of which the largest is the Fried-
riehsquelle. The Hauptstollenquelle is the most
used for drinking and contains :—
Common salt se d
Chloride of lithium 0'05 E
Arsenate of calcium — 0'0007 53
Character of Water.—Temperature 124° to 150° F.
The water may be classed as a thermal water of
weak mineralization. The use made of the springs
takes the following forms: (1) Baths, in the various
forms of hip-baths, natural mineral running-water
baths, natural steam baths, douche massage and so
on; (2) drinking water cure; (3) inhalations (garg-
ling) ; and (4) the use of the radium emanatorium.
Diseases Benefited.—Chronie gouty and rheumatic
affections of bones and joints, certain skin affections,
catarrhal affections of digestive organs in which mild
treatment is indicated.
Season: May 1 to October 30.
EMSs.
Ems is situated in Nassau, midway between
Cologne and Frankfort-on-the-Main. The town
occupies both banks of the river Lahn, which here
runs through a well wooded narrow valley.
There are several springs in use, the chief con-
stituents of which are :—
per mille.
Bicarbonate of sodium... 2 per mille.
Chloride of sodium "
Carbonic acid gas 500 vol. 5
The Ems hot springs are the only acidulous springs
in Germany which are alkaline and muriatic.
Character of Water.—Temperature 80° to 120° F.,
and is described as thermal muriatic alkaline water.
The waters of Ems are used for (1) baths in the
form of simple thermal baths, aerated carbonic acid
baths, &e., (2) douches, (3) inhalations, and (4) for
drinking, aecording to the ailment for which they are
prescribed.
Diseases Benefited.—Catarrh of the air passages
including nose, larynx, and bronchi; catarrh of
stomach and intestine ; catarrh of the urinary passages
and uric acid deposits.
Season: May to October.
June 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
181
KREUZNACH.
Kreuznach in Rhenish Prussia stands on the banks
of the river Nahe ten miles from its junction with the
Rhine. The part of the town known as Bad Kreuz-
nach is adjacent to, but separate from, the old-world
town of Kreuznach itself.
The waters contain :—
Chloride of sodium 1 per cent.
Chloride of calcium . 2 per mille.
Bromide and iodide of
sodium e -. minute quantities
Character of Water.—Cold springs; the outstand-
ing feature of the water is that it produces radium
salts from its own material. Kreuznach was the
first German health resort in which scientific experi-
ments on the use of radium emanation were carefully
studied.
At the spa are given inhalations, baths (including
air and sun), drinking waters and douches.
Diseases benefited.—Rickets and chronic tuber-
cular ailments of all sorts; catarrh of the throat,
nose, larynx and bronchi; chronie catarrhal and
inflammatory conditions of the female generative
organs, and various skin affections are some of the
chief affections for which the spa is patronized.
Radium treatment is a special treatment of the
Kreuznach spa. At the Radium Brine Baths are
provided radium baths, radio-electric air baths, &c.
At the new Radium inhalatorium strong radium
emanations issue from the crevices of the radium
cave—a porphyritie gallery of two hundred metres in
extent.
Season: May 1 to September 30.
NAUHEIM.
Bad Nauheim, in the Grand Duchy of Hesse, lies at
the foot of the hills of the Taunus range. Although
held in estimation as & health and spa resort for a
long time it is only during recent years, by the
scientific work of the brothers Schott who introduced
the system known as "voluntary movements with
resistance," that Nauheim has risen to high rank
amongst spas.
The drinking waters are classed as belonging to the
group “ common salt or muriatic waters.”
The drinking water contains several varieties of
salts. The Kur-Brunnen and the Karls-Brunnen are
tepid waters containing :—
Chloride of sodium 1 per cent.
Chloride of calcium 1 per mille.
Free carbonic acid gas effervescent.
Bath water (temperature 82° to 95° F.) contains :—
Chloride of sodium .. 2 to 3 per cent.
Chloride of calcium 2 to 3 per mille.
Bicarbonate of iron A trace.
Free carbonic acid gas effervescent.
Diseases Benefited.—Heart affections and arterio-
sclerosis, local blood disturbances, rheumatic affec-
tions, gout, nephritic ailments, in diseases of women,
anemia and digestive disorders. Under the direction
of the Drs. Schott baths are graded and exercises
charted to suit individual cases.
Season: May 1 to September 30.
NEUENAHR,
in Rhenish Prussia, possessing a thermal alkaline
water (75° to 104° F.) is situated in the Ahr valley,
a short distance above the town of Bonn, in the
Siebengebirge mountain district. The Neuenahr
springs are the largest alkaline hot springs in
Germany, and of recent years have been much fre-
quented. The waters are classified as “ simple alka-
line," and contain :—
Bicarbonate of sodium 1 per mille.
Bicarbonate of magnesium... 0'4 5
Biearbonate of calcium 03 »
Bicarbonate of iron... 004 ,
The waters are used as drinking waters, baths and
douches; here also the usual balneo-therapeutic
means of treatment are in use.
Diseases Benefited.—Catarrh of respiratory pas-
sages, catarrh of digestive tract, catarrh of the urinary
passages, affections of the female sexual organs, diseases
of the blood, gout, diabetes mellitus, &c.
PYRMONT,
in the Waldeck-Pyrmont principality, lies in the
valley of the river Emmer, and has many methods of
administering spa treatment. The waters are classed
as chalybeate, and contain :—
Bicarbonate of iron 0°07 to 0'03 per mille.
Bicarbonate of calcium 1 ^
Sulphate of calcium 0'8 "
Sulphate of magnesium 0'45 2
Carbonic acid ... .. Free.
Besides the chalybeate there are muriated water
springs containing from 7 to 32 per mille of common
salt.
The waters are used as baths and drinking water ;
and also mud, moor and peat baths are extensively
used. The diseases benefited are anzemia, the catarrh
of various tracts, gout, rickets, rheumatism, female
sexual ailments, and functional nervous affections.
WIESBADEN,
in the Hesse-Nassau province is famous as much for
its desirability as a resort as for its thermal springs,
which contains common salt. The water is classed as
" muriated.”
The water issues at a temperature of from 100° to
156° F. and contains chloride of sodium 7 per mille.
In the waters used for baths there is a faint odour of
sulphuretted hydrogen. Baths, drinking water, and
the usual multiplicity of applications for electricity
and radium are to be had here.
The diseases for which the springs are recom-
mended are catarrhs of all tracts, " tropical diseases,"
heart and circulatory troubles, rheumatism, gout,
female sexual organs, &c.
WILDBAD
is romantically situated in the Black Forest, in
Wiirtemberg, in the Enz valley. The waters rise
through borings in the primeval granite, and as
the baths themselves are built around the mouths of
these borings the water can be used directly it issues
from the ground. The water is classed as “indifferent
182 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
thermal" The water issues at a temperature of
from 91? to 104? F.
Here the usual balneological appliances are in vogue.
Diseases benefited are mostly of rheumatic and gouty
types.
BAD WILDUNGEN,
in the Cassel—Frankfort-on-the-Main district, is in
the principality of Waldeck. Its reputation as a
surgical spa distinguishes it from others. The waters
are classed as “earthy and calcareous.” The cold
gaseous springs contain :—
Bicarbonate of sodium 0°5 to 1°3 per mille.
Bicarbenate of magnesium 0'5 to 1'8 T
Bicarbonate of iron 0'018 to 0'036 ,,
The diseases benefited are largely those of the
urinary organs. The chalybeate springs are useful in
anæmia and debility.
— ó
Annotations.
Free Malarial Parasites (Mary R. Lawson,
Journal of Experimental Medicine, June, 1914).—The
malarial parasite is extracellular throughout its life
cycle and migrates from red corpuscle to red corpuscle,
destroying each before it abandons it; in the brief in-
tervals between, the parasite is free in the blood serum ;
it does not remain long free, but almost immediately
attaches itself to another red corpuscle by means of
delicate pseudopodia. The compact form of the
tertian parasite is the type of free parasite most often
observed; in this form the parasite may be seen
not only in migration, but after quinine and in
the cadaver. I believe the compact form to be
the normal resting form of the parasite, all other
forms being assumed in order to secure attachment
and to obtain food. Care must be taken not to
confound free parasites having protoplasmic pseudo-
podia ready for attachment with the sexual flagellating
parasites, whose flagella are composed of chromatin.
The malarial parasite can live for some time free in
the blood serum, though under normal conditions
there is no reason why it should remain free for any
length of time, and there are certain periods in the
life of the parasite when it must be admitted that it
is free from the corpuscle and survives. If the
parasite is, as I believe, attached to the external
surface of the red corpuscle, it is constantly exposed
to the action of the patient's serum. The destruction
of more than one red corpuscle by each parasite would
readily account for the severe and early anæmia occur-
ring in malarial infections. Long continued treat-
ment with quinine will eventually cause the death
of all malarial parasites.
Recognition of the Cholera Vibrio (C. V. Craster,
Journal of Experimental Medicine, June, 1914).—
Cholera-like non-agglutinating vibrios are invariably
found in the intestinal contents of healthy persons,
and frequently in the water of wells and rivers, during
epidemics of cholera. Although many of these
saprophytic vibrios are indistinguishable in morpho-
logy and cultural properties from the cholera vibrio,
the negative reaction with an anti-cholera serum has
readily differentiated them from the Asiatic vibrio.
The biological polymorphism of the cholera vibrio has
been suggested by the development of agglutination,
by special methods of culture, in cholera-like vibrios.
Confirmatory Pfeiffer reactions have not been obtained,
as a rule, in these instances, probably because of the
low virulence of the vibrio culture, although positive
bacteriolysis in vitro (Bordet's test) was observed
in some, and in others positive complement fixation
and eross agglutination indieated the cholera nature
of the vibrios in question.
Although it cannot as yet be definitely proven,
we are justified in suspecting that cholera-like vibrios
which eventually develop agglutination properties are
of a true cholera nature. It is probable that the
produetion of agglutination antibodies in the serum
brings about the development by the bacterial cell :
of defensive anti-agglutinins, resulting in the dis-
appearance of agglutinating power. In the case
of the water vibrios, changed physieal conditions
could bring about a similar alteration in biological
properties.
It may be said that the absence of agglutination
in a vibrio isolated’ from a suspected source does
not define conclusively its non-cholera nature. In
all probability among a number of cholera-like vibrios
isolated from suspected sources a certain percentage
will eventually be found to develop agglutination
either during laboratory cultivation or by means
of animal passage, and until subjected to a pro-
cedure that will induce the return of agglutination
no vibrio can be regarded with assurance as of a
truly saprophytic variety.
Diagnostic Exploration of the Right Hypochondrium.
-—F. Lejars (Presse Médicale, April 25, 1914) describes
three methods for diagnosing large hydatid cysts of
the upper segment of the liver. The first consists in
placing the left hand under the right side of the
thorax of the recumbent patient and with the right
hand pereussing with short strokes the anterior wall
of the thorax as well as the epigastrium. Transmis-
sion of waves or vibrations to the left hand through
the thorax indicates. the presence of cystic disease.
In another procedure—suprahepatie ballottement—
the left hand is placed on the anterior aspect of the
thorax at the level of the second and third intercostal
spaces, while the right is made to hook round the
lower margin of the liver and attempt to drive it
upward by a series of sharp pulls. At each pull the
left hand perceives, in cystic disease, a slight impulse
transmitted up toward it. The third sign—trans-
thoracic hydatid fremitus—is elicited with the patient
in the erect posture. The left hand, placed across
the back below the lower angle of the left scapula,
perceives, in hydatid disease, a series of light un-
dulatory vibrations when the fifth or sixth rib is
pereussed anteriorly with the right index finger.
June 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
183
Abstracts.
RECENT RESEARCHES ON EMETINE AND
ITS VALUE AS A THERAPEUTIC AGENT
IN AMGEBIASIS AND OTHER DISEASES.*
By GEonakE C. Low, M.D.
IPECACUANHA has long been known to medicine,
firs& having been introduced into Europe in the year
1658. It soon became known that the drug exerted
a beneficial influence on some forms of dysentery,
and physicians practising in India used it from time
to time in varying doses for this condition. Docker,
in Mauritius, in 1858, increased the single dose up
to as much as 60 gr. of the powdered ipecacuanha root
and, according to Rogers, reduced the death-rate of
the dysentery prevailing there from a former annual
rate of 10 to 18 per cent. to only 2 per cent.
For some reason or other the popularity of the
drug waned, the explanation of this probably being
due to the fact that ordinary catarrhal and bacillary
forms of dysentery are not in any way influenced by
ipecacuanha, and, as at that time all forms of dysen-
tery were looked upon as the same, many of this
category must have had the ipecacuanha treatment
with, of course, no beneficial effect. Sir Patrick
Manson was largely responsible for its revival, the
results obtained at the Branch Seamen’s Hospital at
the Albert Docks from 1900 onwards being excellent,
and in some cases even marvellous. Large doses
were given, the initial one being 30 gr. the first night,
and then for subsequent ones a reduction of 5 gr. per
night. The great difficulty in this treatment was,
however, the vomiting these large doses excited, and
mod deviees had to be adopted to try to prevent
this.
About this time also our knowledge of dysentery
advanced considerably, the amcabic forms being
definitely differentiated from the bacillary, helminthic,
and other varieties, and the reason of the uniform
success obtained in the cases just mentioned was un-
doubtedly due to the fact that they belonged to the
first group. Still, even though this knowledge was
widely diffused and always strongly supported by
Rogers and others in India, the Americans after their
occupation of the Philippine Islands decried ipeca-
cuanha, and said it was useless. So emphatic were
they upon this point that one almost became forced
to the belief that the amcbic dysentery met with
there was different to that seen in other parts of
the world, and by us here in London: our cases
chiefly coming from India. We now know, however,
that the Philippine dysentery is the same as the
amobie dysentery seen elsewhere, and the only satis-
faetory explanation that one can suggest for the
different results obtained in treatment in those days
is, that the Americans did not give the ipecacuanha
in the proper manner or in proper doses, or were using
inferior brands lacking in alkaloid. It is interesting
* Proceedings of the Royal Society of Medicine, 1914, vol. vii
(Therapeutical and Pharmacological Section), pp. 41 to 49.
also that one of them— Vedder—should have dis-
covered that the alkaloid emetine is the potent part
of the ipecacuanha, and so should have paved the way
to a greatly improved and simpler method of treat-
ment. Before giving a short résumé of his work it
may not be out of place to give a brief description of
ipecacuanha and its alkaloids.
Ipecacuanha, ipecacuanhe radix, or ipecacuanha
root, is the dried root of Psychotria ipecacuanhe,
a South American plant belonging to the natural
order Rubiacew. Several varieties are used in medicine
—namely, one from Rio de Janeiro, one from Minas,
Brazil, another from Colombia (Carthagena ipeca-
cuanha), and what is known as Indian ipecacuanha,
this being the South American plant grown in the
Straits Settlements, where it has been introduced.
In the United States Pharmacopeia the Brazilian
plant is named Cephaélis ipecacuanha, while the
Colombian one is said to belong to another species,
Cephaélis acuminata. The British Pharmacopaia
only describes the Rio root, and this is not required
to yield any definite percentage of alkaloids. The
United States Pharmacopoeia includes both the Rio
and Carthagena roots, and further requires the pre-
sence of 1°75 per cent. of ipecacuanha alkaloids to be
present in these. The alkaloids found in ipecacuanha
root are emetine, cephaéline and psychotrine, and
give in the Brazilian variety a percentage of from
2 to 2'2 per cent. The relative percentage composi-
tion of these in Brazilian and Colombian ipecacuanha
is, according to Paul and Cowley, as follows: Brazi-
lian— emetine, 72°14 per cent. of the total alkaloid ;
cephaéline, 25°87 per cent.; psychotrine, 199 per
cent. Colombian—emetine, 40°5 per cent.: cephaé-
line, 56'8 per cent. ; psychotrine, 2'7 per cent. It will
thus be seen that Colombian root contains much less
emetine than Brazilian, and, as will be pointed out
later, its use may have contributed to the diversity
of views regarding the efficacy of the drug in the
treatment of dysentery. Selangor (Straits Settle-
ments) ipecacuanha approximates to the Brazilian,
also containing more emetine than cephaéline.
The name emetine used to be applied to an impure
extractive containing the mixed alkaloids of ipeca-
cuanha ; this impure mixture is now termed emetine
(extract).
Emetina (more usually spoken of as emetine) is a
colourless white powder, darkening on exposure and
slightly soluble in water, though it is readily so in
alcohol, ether, chloroform and benzine; two salts of
it are in medical use—namely, the hydrobromide and
hydrochloride. The drug is a powerful emetic and
expectorant, but to get these results must apparently
only be given by the mouth.
Cephaéline is also colourless, but crystalline, and
darkens on exposure to light. It is less soluble in
ether than emetine, but is readily so in caustic
alkaline solutions. One salt is known, the hydro-
chloride. Its medical properties are similar to those
of emetine, it being a stronger emetic, but a less
powerful expectorant.
On February 6, 1911, Captain Edward B. Vedder,
Medical Corps, United States Army, read a paper
184
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 15, 1914.
before the Manila Medical Society, entitled '" A Pre-
liminary Account of Some Experiments undertaken
to test the Efficacy of the Ipecacuanha Treatment of
Dysentery."^ After some preliminary remarks on
the divergence of opinion as to the value of this drug
in dysentery Vedder passed on to a description of his
experiments. These were undertaken with a view
of determining: (1) Whether ipecacuanha has any
decided action against either the bacilli of dysentery
or such amobe as can be cultivated: (2) if such
action be present, to determine how the drug com-
pares with other remedies that have been used in the
past, such as quinine and silver nitrate; and (3) to
determine to what constituents of the ipecacuanha
this action is due. As regards dysentery bacilli it
was found that a 2 per cent. fluid extract of ipeca-
cuanha inhibited their growth, but this was not
a specific action, as it was also obtained with
other bacteria, while other drugs, such as hydrastis
and digitalis, acted in a similar manner. Shiga’s
bacillus was more susceptible than Flexner’s.
Two entamcebe may be found in the intestine of
man: (1) the Entamæba coli, supposed to be harm-
less; (2) the E. histolytica—the E. tetragena—the
cause of amobiasis and amoebic dysentery. These
so far have not been cultivated outside the human
body, so Vedder had to fall back upon cultures of
amcebe isolated from tap-water for his experiments.
It was soon found that fluid extracts of ipecacuanha
were very toxic to these organisms in vitro, dilutions
of 1 in 50,000 or even in some instances higher ones,
killing them off very rapidly. Emetine was next
tried and was found to be still more toxic, dilutions
of 1 in 100,000 being sufficient to cause death of the
organisms. Vedder finally concluded from this part
of his work (1) that ipecacuanha is a powerful amo-
bacide, since the weakest preparation used (with the
exception of the de-emetized) killed in a dilution of
1 in 10,000; (2) that different preparations of ipeca-
cuanha on the market vary greatly in their ingredients
and in the power of killing amcebe ; (3) that emetine
is a powerful amabacide, killing amcebex in dilutions
of 1 in 100,000, which is double the dilution that
was amcebacidal when fluid extract of ipecacuanha
was used. The author, further, was of the belief
that the power of any specimen of ipecacuanha to
kill amcebe was directly dependent upon the pro-
portion of emetine contained in it, though he could
not absolutely prove this owing to the presence of
the other alkaloid, cephaéline, He thought, however,
that if the latter was at all active it would be possible
to judge of the amcebacidal properties of a prepara-
tion by estimating the total alkaloidal content, but
apparently no such activity was present, because
a sample of ipecacuanha with a total alkaloid content
of 0'885 appeared to be fully as powerful as another
containing 1'8 total alkaloid. Further, it was noted
as a clinical fact that the Brazilian root— which, as
I have already pointed out, contains much more
emetine than the Colombian—was much more potent
than the latter in the treatment of dysentery, and
* Journ. or Trop. Mep. AND Hye., 1911, p. 149.
Vedder concluded—a conclusion afterwards proved to
be correct—that this was due to the larger amount
of emetine contained in it. Other constituents of
ipecacuanha root, such as resins, gums, or ipeca-
cuanhic acid, were proved to be absolutely inert, as
was also ipecacuanha from which the emetine had
been extracted (ipecacuanha sine emetina). Experi-
ments were also conducted with quinine and silver
nitrate. Quinine in a dilution of 1 in 20,000 killed
the amæbæ, but failed in higher dilutions. Silver
nitrate was more powerful even than emetine, killing
in dilutions of 1 in 300,000. In actual practice,
however, irrigations of the latter quickly lose their
strength because of the union of the salt with the
albumin and NaCl in the mucous membrane of the
intestine. Vedder also tried the action of ipecacuanha
on a species of paramcecium and a balantidium
isolated from tap-water. Both of these forms were
killed by ipecacuanha in a dilution of 1 in 50,000
and by emetine in a dilution of 1 in 100,000. This
experiment was suggested to him by the report by
Duncan of a case of balantidial dysentery in man
treated by ipecacuanha with prompt recovery.
It fell to the lot of Rogers, in Caleutta, to put
Vedder's experimental work to the clinical test—
namely, by treating cases of amoebic dysentery in
man by emetine. This was not, however, the first
time that this drug had been used for such a condi-
tion, Bardsley, in 1829, employing it in some forms
of dysentery and diarrhcea with excellent results,
while Walsh tried it in 1891 combined with mercuric
iodide by the mouth, also with good result. Rogers,
on learning of Vedder's work, tested the effect of the
soluble emetine hydrochloride on the Entameba
histolytica in dysenteric stools. On placing pieces
of mucus containing numerous active amæœbæ in
normal saline solutions of this salt, he found that
the pathogenic organism is immediately killed and
materially altered in its microscopical appearances by
a 1 in 10,000 solution, while after a few minutes
they are rendered inactive and apparently killed by
as weak a solution as 1 in 100,000. He then decided
to try if the alkaloid could be safely given hypodermi-
cally in the treatment of amabie disease, and having
a suitable case, injected $ gr. of the hydrochloric of
emetine, this equalling 15 gr. of ipecacuanha. No
local irritation followed the injection, nor was any
nausea or vomiting produced. Four hours later
4 gr. was injected, again with no ill-effects, not even
temporary depression of the pulse. The patient's
symptoms quickly disappeared and recovery took
place. In the second case the patient was greatly
emaciated and was passing over twenty foul-smell-
ing stools of pure mucus and blood daily. He was
quite unable to take ipecacuanha by the mouth, so
¢ gr. of emetine hydrochloride was injected. This
was rapidly increased to $ gr. twice daily. On the
second day the blood had disappeared from the stools
and fecal matter reappeared in them. Here, again,
no discomfort of any kind followed the injection of
the emetine. In another case the dose of the drug
was increased up to $ gr. to 45 gr. of ipecacuanha—
with no untoward results.
June 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
185
In a subsequent paper" Rogers gave details of
another twelve cases of amebiasis, viz., acute and
chronic amoebic dysentery, acute hepatitis, and
amoebic abscesses of the liver and spleen. These
were all treated by emetine injections, the abscesses
at the same time being aspirated. The records of
the cases showed that in the hypodermic use of
emetine a valuable method of treatment had been
discovered—a treatment which robbed the old ipeca-
euanha one of all its terrors and discomforts. By
his observations in these cases Rogers was also able
to definitely decide the matter of dosage. Hither the
hydrochloride or the hydrobromide salt can be used,
but as the first is-more soluble in water it is the one
chiefly employed. At first 4 gr. was used, but later
this was increased to $ gr., or even up to § gr., this
equalling 60 gr. of ipecacuanha. In two cases 1-gr.
doses were injected, but such a quantity is only
required in extremely acute cases. The salts can be
safely boiled for a very short time, but Rogers believed
that it was better to dissolve them in sterile saline,
or to boil the solution first and then add the emetine
salt. They are generally obtainable in sterile ampoules
now. As a result of his observations, Rogers con-
cluded that in emetine we have a specific treatment
for amoebic hepatitis and amoebic dysentery.
Confirmation of these results were quickly obtained.
The drug was given a trial at the Seamen’s Hospital,
Albert Docks, and proved equally satisfactory.
Chauffard introduced it into France, and since that
time a large literature has sprung up about it, many
people recording their treatment of cases by it.
An analysis of these cases with one’s own experi-
ences of the drug enables one to come to certain
conclusions. Emetine is not a specific in the sense
that it completely sterilizes the body from amcbe.
Relapses after its use occur, and these are by no
means infrequent. The drug may be compared with
mercury and salvarsan in syphilis and quinine in
malaria, where, again, even after long periods of
treatment, relapses or recrudescences are met with.
Protozoal infections are always very difficult to
eradicate, and when anything detrimental to the
parasites causing them happens, forms arise which
are specially resistant, and though remaining quiescent
for long periods of time are capable, under circum-
stances favourable to themselves, of giving rise to the
disease again.
In ameebic dysentery the amæbæ become encysted,
and then apparently the emetine cannot kill them,
this stage being a very resistant one. At later periods
these become transformed into the living forms again,
and so produce relapses. Treatment, therefore, for
amoebiasis must be conducted on similar lines to that
of malaria by quinine. Suitable doses must be given
and kept up for prolonged periods of time. I there-
fore give $ gr. doses of emetine hydrochloride until
10 gr. in all have been taken. Then, if all symptoms
have abated the drug is stopped and the patient kept
on a strict diet. Some cases, even after this, re-
lapse, and then a second course of the emetine has to
* Brit. Med, Journ., 1912, ii, p. 405.
be given, and so on. Sometimes injections are in-
convenient, and in these instances keratin-coated
“ tabloids ” may be tried.t My experience of these is
that some patients can take them without vomiting
or any unpleasant symptoms ; others are sick for the
first day or two, then tolerate them; while a third
group keep on being sick each time they take them.
In this latter class injections must be substituted.
The dose by the mouth is 4 to 3 gr., and if not
vomited is quite as effective as injections. As
regards the latter, it is more satisfactory to inject the
drug intramuscularly than subcutaneously. Some
stiffness may even then result, so it is well to vary
the site of the injection. Some cases do not do so
well with emetine as others. I recently saw a case
where the stool still showed blood and mucus after
twenty 4 gr. injections, and another whose stool was
teeming with cysts after a short course of the drug.
The efficacy of the treatment is tested by frequent
macroscopic examination of the stools to see if all
blood and mucus has disappeared, by the number of
motions passed per day, and by microscopic examina-
tion for the entamebs from time to time; these
usually disappear very quickly from the stools after
the first two or three doses have been taken.
In addition to the emetine treatment a milk diet
first and then later a milk and white meat diet must
be insisted upon, and no alcohol in whatever shape
or form is to be allowed. The patient should remain
a teetotaller for a year or more after all signs of the
disease have disappeared.
' Ameebic abscesses discharging through the lung or
discharging externally are greatly benefited or even
cured straight away, without surgical interference, by
emetine. When an amobie abscess is opened and
drained, emetine injections should be started at once
as they will help greatly in the healing process.
Cases of amebiasis without signs of dysentery or
hepatitis or abscess have also been met with. In these
there is a high temperature, this quickly falling, how-
ever, and all other signs disappearing on the adminis-
tration of emetine.
Balantidiasis: The part played in this disease by
ipecacuanha and emetine has already been described.
In addition to its use for dysentery, injections of
emetine have lately been tried in the treatment of
hemoptysis and intestinal hemorrhages. Flandin, in
France, impressed by the prompt disappearance of
blood from the stools in cases of amcebic dysentery
treated by injections of the soluble salts of emetine,
suggested the possibility of the drug being similarly
effective in hemoptysis. Eight cases of this con-
dition were treated, and in all of these, with the
exception of a galloping case of tuberculosis, the
hemorrhage was definitely arrested, the bleeding
stopped immediately. No bad symptoms, such as
nausea or depression, followed the administration of
the drug. In some cases, though all traces of blood
may disappear from the sputum, blackish clots may
remain for some time. If, after one injection, there
is a tendency for the hemorrhage to return, Flandin
+ Brit. Med. Journ., 1913, i, p. 1369.
186
gives a second injection twelve hours later, and again
on the following day. His dosage was 0'04 c.c. of
emetine hydrochloride dissolved in 1 c.c. of distilled
water. The arterial pressure was taken both before
and after the administration of the drug, but no
change was noted either in it or in the coagulation of
the blood, or in the blood count. These results were
confirmed in twelve other cases by other physicians,
while Renon also succeeded in obtaining the dis-
appearance of blood from the sputum in two cases of
lung carcinoma by the same treatment. The latter
observer later tried emetine injections for serious
intestinal hemorrhages. He quotes Valassopulo, of
Alexandria, and Edham, of Salonica, as having
obtained good results from these in hemorrhage from
a carcinoma of the large intestine, and from a case of
muco-membranous entero-colitis. In his own ex-
perience five cases of severe intestinal hemorrhage,
including hemorrhage due to biliary and hypertrophic
cirrhosis, hemorrhage after typhoid and ulcerative
entero-colitis and chronic nephritis, were treated
with rapid and excellent results. He finally states
that Raymond also was successful in dealing with
hemorrhage of the stomach from a single ulcer and
from a neoplasm, with severe intestinal haemorrhage
after typhoid. Renon advises doses up to 9eg.
These results would seem to indicate that in
emetine we have a useful means of arresting
hemorrhage. Why this should be is not altogether
clear, but as it has been stated that the drug exerts
a powerful local constricting effect upon blood-vessels
it is possible that this is the explanation of its action
in these cases. .
HYDATID DISEASE OF THE LUNG
SPONTANEOUSLY CURED.*
By A. G. YATES.
THE patient, a married woman, aged 26, first came
under observation in June, 1913. She had never
lived abroad, and until the onset of her illness had
enjoyed good health. Her first symptom was a
sudden attack of hemoptysis which was not profuse.
Cough and some pain in the chest persisted for a
week, and then passed off. She had no further
symptoms for a month, when she again coughed up
blood and with it a quantity of membrane. When
examined a few hours afterwards she looked some-
what anemic but otherwise normal; there was slight
dyspnoea, but no fever. Examination of the chest
revealed a small area of dullness in the first left
intercostal space close to the sternum ; it extended to
the left for 2 in. There was a dilated vein running
up to this region from the left breast. "There were
no ráles, but the breath sounds over the dull area
were high pitched and bronchial in character, and
pectoriloguy was well marked.
The expectoration contained no tubercle bacilli,
but the membrane showed a characteristic laminated
structure, and there were numerous hooklets. A
differential count of the leucoeytes showed 5 per cent.
of eosinophiles. After bringing up the membrane all
* Brit. Med. Journ., June 13, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
symptoms rapidly subsided, and in a few days she was
apparently well.
When seen again, nearly a year after the first onset
of symptoms, she was perfectly well; the dullness
and bronchial breath sounds were no longer present,
and there were no abnormal signs in any part of the
chest. Askiagram of the whole chest showed nothing
abnormal. Examination of the liver and other organs
revealed nothing.
It is clear that the condition was a small cyst
which ruptured into the left bronchuüs and was
expelled. The symptoms at the time of rupture were
extremely mild, there was no suppuration, and down
to the present time there has been no evidence of
recurrence.
HUMAN ACTINOMYCOSIS IN PERU.t
By E. ESCOMEL.
HUMAN actinomycosis, very rare in Peru, has
never previously been recognized in Arequipa. This
is the first recorded case in Peruvian literature with
a definite microscopic diagnosis.
A man, aged 19, in May, 1912, contracted broncho-
pneumonia with gastro-intestinal relapses causing
delayed convalescence. In the expectoration there
were no Pfeiffer bacilli, tubereular bacilli, or mycelium.
At length the patient was sent to Cuzco where he
rapidly convalesced and was occupied in packing hides
for Europe. In the department of Arequipa, actino-
mycosis has not previously been recognized, while at
Cuzco it is often present.
While at work the cough returned, the patient
lost weight, was feverish and felt a pain at the right
posterior inferior area of the thorax at the level of the
eighth intercostal space.
He returned to Arequipa on November 23, 1912,
with a temperature of 39'6 C., but was able to walk
without pain. The lump on the back became pro-
minent and fluetuated. "The expectoration contained
no tubercle bacilli. The tumour was punctured and
& thick, gelatinous, chocolate-coloured fluid was ob-
tained, which contained no tubercle or recognizable
microscopic organism. Inoculated into a guinea-pig
the animal was found normal when examined four
weeks later.
Ineision of the tumour produced reddish pus
resembling hepatic pus. A finger passed through the
diaphragm into a cavity in the liver. Irrigation of
the wound caused the patient to cough and spit up
some of the irrigating fluid. The abscess involved
the basis of the right lung, the pleura passing through
the diapliram to the liver.
Two days later the pus from the wound contained
granular bodies the size of a pin's head which, under
the microscope, freshly stained by Giemsa, showed
actinomycosis. A new abscess formed and infiltra-
tions were noticed under the abdominal wall. Finally
invasion of the kidneys caused death more than a year
after the commencement of the disease. Iodide of
potassium was given from 3 grm. up to 12 and 15 grm.
daily for two months without producing any effect
and without producing iodism.
+ Bull. de la Soc. de Path. Exot., 1914, vii, No. 5.
June 15, 1914]. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
187
A eviehs,
TEXT-BOOK OF LOCAL ANJESTHESIA FOR STUDENTS
AND PRACTITIONERS. Professor Dr. Georg
Hirschel, Heidelberg, Assistant in the Surgical
Clinic. With an introductory preface by Pro-
fessor Dr. Wilms. 103 illustrations in the text.
Translated by Ronald E. S. Krohn, M.D.Lond.
London: John Bale, Sons, and Danielsson, Ltd.,
83, Great Titchfield Street, W. 9s. net.
Although much has been written on “ Local Anes-
thesia ’’ this is an essentially up-to-date description
of “infiltration-angsthesia " mainly for operations,
but also for therapeutic purposes as “ Trigeminal
Neuralgia.”
A full account is given of the preparation of the
patient, instruments and drugs used. The second
section of the book. is devoted to ‘‘ Regional Anæs-
thesia," for cranial operations, operations on the face,
dental operations, anesthesia of the neck, chest and
breast, kidney and abdominal operations.
A special feature of the work and one of marked
utility is the use of infiltration anesthesia for
abdominal operations and also extradural anesthesia
through the sacral canal.
Though local anesthesia is not as much used by
English surgeons, yet there is a large field for its use
both at home as well as in the Tropics, so that a well
translated exposition of the most recent information
will be found to supply a need felt by both surgeons
and ‘dentists.
HINTS FOR RESIDENTS AND TRAVELLERS IN PERSIA.
By A. R. Neligan, M.D., M.R.C.S., D. T. M.Cantab.,
Physician to His Majesty's Legation at Tehran,
with map. 1914. London: John Bale, Sons and,
Danielsson, Ltd., 83, Great Titchfield Street, W.
5s. net.
Although there are many books by medical and
other travellers on Persia, with jottings and hints on
medical matters, this is the first one exclusively
devoted to medicine for travellers and residents in
that country, which perhaps is not to be wondered at
considering that many parts of Persia are distinctly
healthy and afford a pleasing holiday to Anglo-Indians
and in former times was a much frequented road
home. Although the work is mainly intended for
the rich, able to supply themselves with comforts
and luxuries, yet it is a booklet that should be found
amongst the light baggage of all who go to Persia,
and not least those with families whose lot it is to
reside there, as they will find it not only an aid to
health but also conducive to-comfort. The strong
binding and rounded corners will enable the book to
stand much use and wear.
The instructions would prevent the diseases known
to prevail in Persia; but what is more important to
timid travellers, should allay all dread of diseases
which are not known there.
A SYSTEM OF SURGERY. Edited by C. C. Choyce,
B.Sc., M.D., F.R.C.S., and J. Martin Beattie,
M.A., M.D., C.M., Pathological Editor. 3 vols.
48 colour plates, 80 black-and-white plates,
950 illustrations in the text. Waverley Book
Company, Ltd., 7, 8 and 9, Old Bailey, E.C.
£3 3s. Cassell and Co., London, New York,
Toronto and Melbourne.
This " System of Surgery” is especially designed
for the practitioner who wishes to keep himself
abreast with the most modern surgical teaching, and
for the student who aims at a sound comprehensive
knowledge of present-day surgery.
It furnishes a clear, detailed, and concise record of
modern surgery. The special feature of this book,
written by various authors, is that it is all practical
and there is no over-lapping.
Where everything is excellent, it is hard to in-
dividualize, but one may remark that the results of
most recent work are given, as details connected with
new growths and tumours, examination of blood and
cerebro-spinal fluid, yaws, leprosy and other tropical
diseases.
It is only fair to mention that the plates and
illustrations are of a very high order
FORMULAIRE DE THERAPEUTIQUE CLINIQUE. Par
le Dr. L. Pron, Membre de la Société de Théra-
peutique, avec la Collaboration du Dr. A. Can-
tonnet, Ophtalmologiste des Hópitaux de Paris
(Hôpital Cochin). Deuxième Edition, refondue
et augmentée. Paris: Librairie Maloine, 27,
Rue de l'Ecole de Médecine, 1914. Prix 6 fr.
This is à distinctly useful and interesting formulary
by an Algerian. The diseases are treated alpha-
.betieally, and appropriate descriptions and directions
given. Thirty-two pages are devoted to diseases of the
eye, the importance of which is very often neglected
by students, until too late they meet cases that refuse
to react to the usual remedies.
A TEXT-BOOK OF MEDICAL ENTOMOLOGY. By
Walter Scott Patton, M.B.Edin., I.M.S., and
Francis William Cragg, M.D.Edin., I.M.S. Pp.
764 + xxxiii, er. 8vo, with 89 plates. 1913.
London, Madras, and Calcutta : Christian Litera-
ture Society for India. £1 1s. net, or Rupees
15.2 net.
The abiding impression of the study of this work
is that it will be most useful to all interested in
medical entomology, both as a text-book as well as
work of reference, and it is to be hoped will attain
success both in the Tropics and elsewhere. The
authors deal with all entomologieal details connected
with insect-borne diseases. The methods of recog-
nizing insects, their method of collection, the manipu-
lation of insects in the laboratory, natural and
artificial methods of breeding. Copious illustrations,
both original as wellas those obtained from the most
recent authorities, are characteristic of the work.
All the most recent information on the subject is
enumerated. The authors have accomplished the by
188
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
no means easy task of condensing the information
supplied by the standard works of Austen, Nuttall,
Graham Smith and others. In addition there is
well balanced suggestive speculation on the causation
and prevention of disease ; the various hypotheses are
well supported by facts. The essential features of
this encyclopedic work are clear, anatomical descrip-
tions and well balanced theories.
BOOKS RECEIVED.
TROPICAL DISEASES. By Sir Patrick Manson. Fifth
Edition, enlarged. Cassell and Company, Ltd.,
London, New York, Toronto and Melbourne.
THE PRACTICE OF SURGERY. A Text-book. By
Russell Howard, M.S., F.R.C.S. London:
Edward Arnold, 41 and 43, Maddox Street, W.
Extracts from Medical Papers.
(1) Recent opinion is inclining to the supposition
that influenza, tonsillitis, acute rheumatism, and
appendicitis are all related and of almost identical
origin.—W. Wilson, Practitioner, June, 1914, p. 773.
(2) Status lymphaticus can be diagnosed by enlarge-
ment of lymphatic nodules at the sides of the pharyn-
geal part of the tongue.
(3) Whoever advises non-operative treatment of
adenoids assumes a tremendous responsibility.
———— a ———
Hotes and lets.
SEAMEN'S HOSPITAL SOCIETY, ALBERT
DOCK HOSPITAL.
UNVEILING BY THE SECRETARY OF STATE FOR THE
COLONIES OF BRONZE PORTRAIT RELIEFS,
JUNE 23, 1914, ERECTED BY THE COMMITTEE
TO COMMEMORATE THE SERVICES RENDERED
BY Mr. JOSEPH CHAMBERLAIN AND MR.
AUSTEN CHAMBERLAIN TO THE ALBERT Dock
HOSPITAL AND THE LONDON SCHOOL OF
TROPICAL MEDICINE.
Mr. Perceval A. Nairne, Chairman of the Com-
mittee of Management, will receive Mr. and Mrs.
Lewis Harcourt, Mrs. Joseph Chamberlain, Mr. and
Mrs. Austen Chamberlain, and other visitors at
4 o'clock. Mr. Lewis Harcourt will then unveil the
Bronze Portrait Reliefs, designed and executed by
Mr. F. W. Doyle Jones, and will address the meet-
ing. He will be followed by Mr. Austen Chamber-
lain. The Hospital and the School will be open
to inspection, and various pathological and other
specimens connected with tropical diseases will be
shown under the microscope. Tea will be served
at 5 o'clock.
The Seamen's Hospital Society was founded in
the year 1821, for the care and treatment of ill and
injured sailors of all nations. Until 1870 the sole
hospital maintained was the old three-decker “ Dread-
nought” moored in the river off Greenwich; but in
that year the whole establishment was moved ashore
to the old Infirmary of Greenwich Hospital.
In the year 1889 it became clear that the vast area
of the Port of London could not be served by a single
hospital, and it was decided to build a small hospital
in the Albert Dock. The foundation stone was laid
by H.M. King George, then Duke of York, on July 15,
1889, and the wards, containing twenty beds, were
opened by King Edward VII and Queen Alexandra,
then Prince and Princess of Wales, in the following
year. From this small beginning the present hospital
and school have sprung.
Early in the year 1898 a letter was received from
Mr. Joseph Chamberlain, then H.M. Secretary of
State for the Colonies, suggesting the enlargement
of the Albert Dock Hospital and the establishment
of the London School of Tropical Medicine, in order
that newly appointed medical officers of the Colonial
Service might receive systematic training in tropical
diseases.
Sir Patrick Manson, one of the Physicians of the
Albert Dock Hospital and Medical Adviser to the
Colonial Office, supported Mr. Chamberlain’s applica-
tion, which was sympathetically received by Mr.
Perceval A. Nairne, then, as now, Chairman, and by
the Committee of Management. Mr. Chamberlain’s
suggestions were adopted, and he presided at a dinner
in the year 1899 when £15,000 was subscribed, a
sum which made it possible to establish the first
tropical school with accommodation for twelve
students.
In the year 1905 Mr. Chamberlain again presided
at a Banquet, which resulted in £10,000 being re-
ceived. On this occasion the Hospital was enlarged
to fifty beds and the accommodation in the School
doubled.
Various additions were made subsequently, until
two years ago, when Mr. Lewis Harcourt, Secretary
of State for the Colonies, invited Mr. Austen Chamber-
lain to carry on the work so ably and successfully
initiated by his father. He suggested that a fund
should be raised to place the School in a sound
financial position by providing money for the enlarge-
ment and endowment of the School, for research, for
a hostel for the accommodation of students, and for
the endowment of hospital beds.
To this end Mr. Austen Chamberlain issued his
appeal and a sum of £73,000 was received. Of this
amount £52,000 has been invested for endowment
and research, £15,000 has been spent upon buildings,
and £6,000 upon the endowment of six beds in which
officers and others suffering from tropical disease
whose means are limited may come to this country
to be treated under the most favourable conditions.
At Mr. Chamberlain’s special request arrangements
have been made whereby patients who can afford it
are admitted on payment of a reasonable sum for
maintenance and treatment.
At the present time the hospital has fifty beds, of
which about half are available for tropical diseases.
The school has accommodation for about eighty
students, and about 200 pass through the curriculum
June 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
every year, while there is residence in the hostel for
eighteen students.
: [t is with the hope of conveying some expression,
however slight, of their gratitude for the great services
rendered by Mr. Joseph Chamberlain and his son to
the Albert Dock Hospital and the London School of
Tropical Medicine that the Board of Management of
the Seamen's Hospital Society erect these portraits.
A NEW VARIETY OF COFFEE.
FROM the Congo a variety of the coffee plant Coffea
robusta, discovered by Emile Laurent in 1898, is
gradually finding its way into coffee-growing
countries. The name given to the plant is to dis-
tinguish its robust characteristics, inasmuch as it is
less liable to be attacked by disease than either of the
two older varieties, C. arabica and C. liberica. In fact
the C. arabica is going out of cultivation in Java,
Guadeloupe and elsewhere owing to the uncertainty
of the crops on account of disease, but the immunity
possessed by the C. robusta is making the plant a
favourite every where.
SIR RONALD ROSS’S WORK.
SIR RONALD ROSS'S action in forwarding a petition
to the Chancellor of the Exchequer, asking Parliament
for some recognition of his discoveries as to the mode
of infection of malaria has been commented upon as
follows by Professor W. J. R. Simpson, C.M.G. “I
am certainly of opinion," he said, "that those men
who have benefited the British Empire and humanity
by their researches should have some chance of being
placed in fairly easy circumstances. Consider, for
instance, what has happened with regard to Dr.
Haffkine’s prophylactic for plague in India. He is
engaged by the Government of India as one of its
officers, and his prophylactic is used both in that
country and elsewhere. The Government of India
actually makes money by selling it, but apart from
his salary and the fact that he will probably event-
ually retire on a small pension he gets no benefit out
of his discovery. The medical man is placed in a
very different position from that occupied by the
engineer. Lord Kelvin’s discoveries were of immense
value to the world, but by patenting them he received
a large revenue, and died a rich man. The same can
be said of the discovery of wireless telegraphy, and so
forth. Medical men cannot act in that way and
patent their discoveries, nor is it desirable that they
should, for it would lead to quackery. The fact
remains however, that they spend an enormous
amount of time on their investigations, make their
results public, and get the credit of the discovery,
but nothing further. What reward, for instance, has
Sir David Bruce ever received for the investigations
that cleared Malta of what till recently was known
as ‘Malta fever’? Sir Patrick Manson, again, who
was the pioneer in connection with the mosquito
and malaria by his researches on the way in which
the filaria were spread by the mosquito in filariasis,
received no grant in recognition of the value of his
work."
189
"In the article published in the Morning Post
I notice that you have indicated the great benefit
to India of Sir Ronald Ross's work. Its value, of
course, extends far beyond India. The Panama
Canal could never have been constructed if that
work had not been done. The knowledge that} the
mosquito carried malaria led to the American work
on yellow fever, and the application of the results
obtained enabled General Gorgas to make the Panama
zone so healthy that the American engineers could
carry out their magnificent work. The French en-
gineers would have been quite capable of doing the
engineering feat, but they lost 50,000 men while they
were engaged on it, and had to abandon it, simply
because their attempt was made before Sir Ronald
Ross had done his work. For this reason one feels
that the nation should look on his work as being of
an exceptional character, and should recognize it. At
present nothing is given. Everything is left to be
done by the man personally, often at very consider-
able expense. To this general statement I should
make the qualification that the Colonial Office is
beginning to adopt a rather different attitude, and
some money is being set aside to send out com-
missions of inquiry and to enable investigations into
the causes of disease to be undertaken. It should be
remembered that discoveries of the sort that demand
signal recognition from the nation are not many, the
work done on sleeping sickness by Sir David Bruce
and Dr. Castellani having to be added to the other
examples I have mentioned. "That adequate rewards
should be given for researeh is to my mind of very
great importance. The fact that there are no such
rewards is having a very bad effect on medicine in
this country, for the younger men will not undertake
research. I have not given much consideration to
the question as to what would be the best method of
arranging that the rewards should be available,
whether by Nobel prizes, by petitions to Parliament,
or otherwise, but in the present case of Sir Ronald
Ross, I think that he is doing a publie service in
presenting a petition to Parliament on the same lines
as those followed in the case of Jenner.”
LIVINGSTONE COLLEGE.
SATURDAY, June 13, 1914, was Commemoration
Day at Livingstone College.
The Bishop of Chelmsford, in the Chair, expressed
his great pleasure in being present. He desired to
bear testimony to the work of his old friends, Dr. and
Mrs. Harford, at Livingstone College, whom he had
known intimately through the fact that Livingstone
College carries on the St. James-the-Less Medical
Mission in Bethnal Green. As one who travelled
throughout the world he recognized the immense
importance of medical knowledge to a missionary,
and whilst it might be said that "a little knowledge
is a dangerous thing," yet he felt that it was abso-
lutely essential that men going abroad should have
such training as was carefully given at Livingstone
College.
Dr. Ernest Cook spoke as a medical missionary of
190
the Church Missionary Society from Central Africa,
and he gave an instance of a case where a Living-
stone College student had saved the life of a Roman
Catholic Father in Uganda who was suffering from
blackwater fever in a place where no doctor could be
obtained. He spoke of the many dispensaries that
are scattered through the Uganda Protectorate, where
immense benefit is conferred upon the people of the
country, who are without any medical knowledge, and
for such work missionaries needed training such as
was given at the College.
Rev. E. W. T. Greenshield, an old student of the
College, is well known for his heroic labours among
the Esquimaux. His dental experience had stood
him in good stead not only in helping the Esquimaux,
but actually in his own ease, and he told how he had
had to pull several of his own teeth. On one occasion
he had no proper dental forceps, and he had practi-
ealy to dig out the offending tooth, but he was
suffering very keenly not only from toothache but
from hunger, so that he was compelled to remove the
tooth even though he took half an hour to do so. By
means of his medical knowledge he had been able to
gain the confidence of some of the rough crews with
whom he had sailed in the Arctic regions and who had
thought little of the parson until they found what he
could do for their bodies, when he gained their
confidence and respect.
The Esquimaux were absolutely ignorant of the
most elementary knowledge of medieal treatment.
They would eut open an abscess with the foulest
knife and put on a dressing of raw seal-skin. It was
therefore a tremendous boon to these people to treat
them by proper surgical measures. He paid a very
warm tribute to the help which he had received from
his college training.
Rev. E. H. Clark, a Missionary of the London
Missionary Society from Tanganyika, stated that the
training he had received had not only benefited him-
self and his family, but had been of the greatest use
to the people of Central Africa amongst whom he
worked. He was in a place where there were swarms
of anopheles which carry malaria which he knew
must breed in a swamp. He found out the swamp
an:l was able to drain it, and by that means he had
benefited the whole countryside, and what was
formerly a most malarious region was now entirely
a different place.
At the conclusion of the meeting, the Treasurer, in
the name of the Committee and Staff, and Students,
past and present, made a presentation to Dr. and
Mrs. Harford of a silver rose-bowl, an album con-
taining photographs of the groups of all old students,
and a cheque for £100.
Rev. H. H. Heaton, senior student of the College,
also spoke as representing present and past students
who had contributed to the testimonial.
Dr. Harford expressed the very hearty thanks of him-
self and Mrs. Harford for the handsome gift which had
been given to them, and his earnest appreciation of
the good wishes of his colleagues on the staff and on
the committee, and of past and present students.
The Bishop, in response to the vote of thanks,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
referred to the great financial needs of the College,
which are set forth in the Year-book, in which an
appeal is made for £10,000. Towards this sum £789
is available from contributions that have already
been given. The Bishop hoped that the amount
might be fully met. He then closed the meeting
with the Benediction.
THIRD INTERNATIONAL CONGRESS OF
TROPICAL AGRICULTURE, IMPERIAL
INSTITUTE, LONDON, S.W., JUNE 23-30,
1914.
Patron.—His MAJESTY THE KING.
President.— Professor Wyndham R. Dunstan, C.M.G.:
LL.D., F.R.S., President of the International
Association for Tropical Agriculture, Director of
the Imperial Institute.
REPRESENTATIVES AND DELEGATES.
United Kingdom: Board of Agriculture.—Sir Sydney
Olivier, K.C.M.G., Permanent Secretary to
the Board.
British Cotton-Growing Association. —Mr. W. H.
Himbury, Mr. C. M. Wolstenholme, Mr.
R. W. Brown and Mr. J. Percival.
International Federation of Master Cotton Spin-
ners’ and Manufacturers’ Associations.—Sir
Charles Macara, Bart, and Mr. Arno
Schmidt.
London Chamber of Commerce.—Sir Owen
Philipps, K.C.M.G., Mr. J. H. Batty, Mr.
W. Soper and Mr. C. E. Musgrave.
India: Dr. C. A. Barber, Sc.D., F.L.S., Government
Sugar-cane Expert.
United Planters’ Association of Southern India.—
Mr. R. D. Anstead, B.A.
Ceylon : Department of Agriculture.— Mr. R. N. Lyne,
Director of Agriculture.
Ceylon Agricultural Society.—Dr. H. M. Fer-
nando, M.D., and Dr. W. A. de Silva.
Low Country Products’ Association.—Mr. J.
Peiris, B.A., LL.M.
Federated Malay States: Planters’
Malaya.—Mr. H. M. Darby.
Jamaica; Sir Sydney Olivier, K.C.M.G.
Trinidad : Department of Agrieulture.—Professor P.
Carmody, Director of Agriculture.
Agricultural Society of Trinidad.—Lieutenant-
Colonel Collens, V.D.
British Guiana: Mr. G. E. Bodkin, B.A., Economic
Biologist in the Department of Science and
Agriculture.
Leeward Islands : Mr. H. A. Tempany, B.Sc., F.I.C.,
Superintendent of Agriculture.
Nigeria: Department of Agriculture—Mr. W. H.
Johnson, Director of Agriculture, Southern
Provinces.
Gold Coast: Mr. W. S. D. Tudhope, Director of Agri-
culture, and Mr. T. F. Chipp, Assistant Con-
servator of Forests.
Sierra Leone : Mr. A. C. Hollis, Colonial Secretary,
and Mr. W. Hopkins, Director of Agri-
culture.
Association of
June 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 191
Nyasaland : Mr. J. S. J. McCall, Director of Agri-
culture.
Rhodesia: Mr. C. D. Wise, Director of Land Settle-
ment.
Anglo-Eyyptian Sudan: Mr. H. P. Hewins, Director,
Commercial Intelligence Branch, Central
Economic Board, Sudan Government.
Egypt: Mr. G. C. Dudgeon, F.E.S., Consulting Agri-
culturist, Ministry of Agriculture ; Monsieur
Victor Mosseri, Member of the Egyptian
Institute; Dr. L. H. Gough, Ph.D., F.E.8.,
Entomologist, Ministry of Agriculture ; Mr.
B. F. E. Keeling, Director, Physieal Ser-
vice, Survey Department.
Monsieur Perrot, representing the Minister
for the Colonies.
L'Offiee Colonial, Paris.— Monsieur Vergnes,
Gouverneur des Colonies, Directeur de
l'Office Colonial.
Société francaise de Colonisation et d'A,ricul-
ture Coloniale.— Dr. Heim, Secrétaire per-
pétuel de la Société.
Institut Colonial, Marseilles.— Monsieur Baillaud,
Secrétaire-General, and Monsieur Stieltjes.
Madagascar : Monsieur Perrot.
French West Africa: Monsieur Prudhomme, Direc-
teur du Jardin Colonial, Nogent-sur-Marne.
French Equatorial Africa : Monsieur Rouget, Sous-
Chef de Bureau, Administration Central des
Colonies.
Tonkin : Chamber of Commerce, Haiphong.—Mon-
sieur Brousmiche, Vice-President of the
Chamber.
Germany: Dr. Bucher, Government
Inspector, Cameroons.
Deutsche Kolonialgesellschaft,
Schultz.
Kolonial Wirtschaftliches Komitee.—Prof. Dr.
Warburg, Herr F. Hupfeld and Dr. W. F.
Bruck.
Kolonialinstitut, Hamburg.—Professor Dr. Voigt.
Italy: Commendatore Carlo Rossetti, Director of
Colonial Studies, Rome.
Dr. Oberto Manetti, Vice-Director, Istituto
Agricolo Coloniale Italiano, representing the
Minister of the Colonies.
Russia : Mr. B. A. Fedtehenko, Principal Botanist,
Imperial Botanical Garden, St. Petersburg.
Austria-Hungary: Museo Commerciale, Trieste.—
Professor Giulio Morpurgo.
Netherlands and Netherlands East Indies : Dr. C. J.J.
van Hall, Director, Government Institute
for Plant Diseases and Cultures, Depart-
ment of Agriculture, Buitenzorg, Java.
Koloniaal Institut, Amsterdam.— Dr. J. Dekker.
Belgium : Monsieur E. Leplae, Directeur-Général de
l'Agrieulture, representing the Ministry of
the Colonies.
Greece : Monsieur Cosmeto Phoca Cosmetata.
Cuba: Dr. Rafael Martinez Ortiz, Cuban Minister
in Paris.
Mexico: Chamber of Agriculture, Yucatan.—Senor
don Auguste L. Peon.
France:
Agricultural
Berlin. — Herr
` noon.—Discussion on
Guatemala : Mr. D. Bowman, Vice-Consul in London.
Venezuela : Dr. G. Delgado Palacios.
Siam: Mr. W. A. Graham, Adviser to the Siamese
Ministry of Agriculture.
Formosa : Dr. Tokuichi Shiraki, Government Ento-
mologist.
PROVISIONAL ARRANGEMENTS FOR
THE CONGRESS.
Tuesday, June 23, 10.30 a.m. to 6 p.m.
Morning.—-Meeting of General Committee : General
Meeting of the Congress: Reception of Delegates and
Representatives ; Address by the President. After-
“Technical Education in
Tropical Agriculture”; Paper on “ Work of the
British Cotton-Growing Association."
Wednesday, June 24, 10.30 a.m. to 6 p.m.
Morning.-—General Meeting of the Congress: Dis-
cussions on "Sanitation and Hygiene on Tropical
Estates ” and " Legislation against Plant Diseases."
Afternoon.— Papers on " The Fertility of Soils in the
Tropics.” :
Thursday, June 26, 10.30 a.m. to 6 p.m.
Morning.—(General Meeting of the Congress: Dis-
cussion on “The Factors which determine variation
in the properties of Plantation Rubber, with special
reference to its uses for manufacturing purposes.”
Afternoon. —Papers on “ Rubber" (Section 1) and
on “ Cereals and Sugar ” (Section 2); Paper on “ The
Utilization of Sun Power for irrigation and other
purposes in Tropical Agriculture."
Friday, June 26, 10.30 a.m to 6 p.m.
Morning. —General Meeting of the Congress: Dis-
cussions on “ Agricultural Credit Banks and Co-
operative Societies" and “The Organization of
Agricultural Departments in relation to Research."
Afternoon.—Papers on "Oils and Oil-seeds " (Sec-
tion 3) and on ‘ Cocoa and Tobacco” (Section 4);
Paper on " The Caracul Sheep.”
SUMMARY OF
Saturday, June 27, and Sunday, June 28.
No sittings of the Congress.
Monday, June 29, 10.80 a.m. to 6 p.m.
Morning.—General Meeting of the Congress : Dis-
cussion on "The Improvement of Cotton Cultivation."
Afternoon.— Papers on" Cotton” (Section 5) and on
“Jute and Hemp Fibres " (Section 6); Paper on “The
Fibre Industry of British East Africa.”
Tuesday, June 30, 10.30 a.m. to 6 p.m.
Morning.—General Meeting of the Congress :
Papers on “ Cotton ” (Section 5) and on “ Miscellan-
eous Subjects ” (Section 7). Afternoon.—Meeting of
the General Committee; General Meeting of the
International Association ; Closing Meeting of
Congress.
RECEPTIONS.
Tuesday, June 23, 9.30 p.m.—His Majesty's
Government will hold a Reception for the Delegates
and Members of the Congress at the Imperial
Institute.
192 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1914.
Wednesday, June 24, 9 p.m.—The Royal Colonial
Institute will hold a Reception at the Natural History
Museum, Cromwell Road, South Kensington, S.W.
The subscription for membership of the Congress
is £l. Applieations for membership and all corre-
spondence should be addressed to :—
The Honorary Organizing Secretaries,
Third International Congress of Tropical Agriculture,
Imperial Institute,
London, S.W.
VIROL, LIMITED.
SUCCESS OF THE LABORATORY SCHEME.
THE fourteenth annual general meeting of Virol,
Ltd., was held on June 5.
The Chairman, in moving the adoption of the
report and accounts, said that the opinion held of
Virol in medical circles had been still further raised
by the remarkable series of investigations into the
action of the white blood cells in destroying disease
germs. These investigations proved that the adminis-
tration of Virol greatly increased the germ-combating
power of the blood cells. "The scheme for the estab-
lishment of the Virol Research Laboratories had been
carried into effect. Premises were secured in Bedford
Square, and equipped on the most up-to-date lines,
with the result that the Virol laboratories were now
amongst the finest in the kingdom. Their primary
objects were to furnish the medical profession with
all possible scientific data in regard to the bio-
chemical and physiologieal action of Virol in the
various conditions of health and disease, and to in-
vestigate all scientific questions in connection with
the business. They had decided to extend the services
of the laboratories to the medical profession for the
investigation of clinical questions, and although the
laboratories were only opened in March last, public
health authorities, hospitals and sanatoria all over
the country had availed themselves of the exceptional
facilities thus placed at their disposal. They had
secured as director of the laboratories the services of
Dr. Edward Burnet, who combined with the highest
scientific qualifications a very intimate knowledge of
the technique and organization of this class of work,
and he felt sure that the wide clinieal experience and
extensive knowledge of Dr. Burnet on all matters
relating to publie health would prove an important
factor in the success of the scheme.
Mr. Arthur E. Canney (Managing Director) seconded
the motion, and after a few remarks by Dr. Edward
Burnet it was unanimously adopted.
RAT-BITE DISEASE.
OGATA (Mitteilungen a. d. med. Fakultät d. k.
Univ. Tokyo, April, 1914) considers that a fungus,
with which the individual is inoculated when bitten
by the rat, is the cause of rat-bite disease. The
fungus seems to be of the aspergilus family and
to be readily destroyed by mercurial inunctions,
improvement and complete cure following on à course
of mercurial inunctions.
Personal Rotes.
Inp1a OFFICE.
From April 18 to June 9, 1914.
Arrivals Reported in London.—Colonel H. Hendley, I.M.S.;
Lieutenant-Colonel S. E. Prall, I.M.S.; Major H. R. Nutt,
I.M.S.; Lieutenant-Colonel ©. C. Manifold. I.M.S.; Captain
M. F. White, I.M.S. ; Captain J. M. Macrae, I.M.S.; Lieu-
tenant.Colonel W. Young, I.M.S. ; Captain A. J. Lee, I.M.S. ;
Captain S. T. Crump, I.M.S. ; Major S. H. L. Abbott, I.M.S. ;
Lieutenant-Colonel G. T. Birdwood, I.M.8.; Major R. F.
Bard, I.M.S.; Major G. King, I.M.S.; Major E. F. G.
Tucker, I.M.S.; Captain A. S. M. Peebles, I.M.S.; Captain
W. Tarr, I. M.S. ; Lieutenant-Colonel R. Bird, I. M.S. ; Major
W. W. Clemesha, I.M.S.; Major E. J. O'Meara, LM.8.;
Captain T. L. Bomford, I.M.S. ; Captain W. M. Jack, I.M.S.;
Major ©. W. Melville, I.M.S. : Colonel C. C. Manifold,
I.M.S., T.G., Civil Hospital; Major S. P. James, I.M.S.;
Captain T. J. C. Evans, I.M.S.; Captain A. C. Anderson,
I.M.S.; Captain A. A. MeNeight, I.M.S. ; Captain F. J. Kola-
pore, I.M.S.; Captain G. W. Maconachie, I. M.S. ; Lieutenant-
Colonel V. G. Drake-Brockman, I.M.S.; Captain R. B. S.
Sewell, I. M.S.; Lieutenant-Colonel S. Browning Smith, I.M.S.;
Lieutenant-Colonel E. A. R. Newman, I.M.S.; Colonel R.
Robertson, I. M.S. ; Captain G. A. Jolly, I.M.S.
Extensions of Leave.—Lieutenant C. Duer, I.M.S., 6 m.;
Major F. O. N. Mell, I.M.S., 10 days; Major D. McCay, I.M.8.,
4 m., M.C.; Major J. H. McDonald, LM.S., 5 m., M.C.;
Captain J. B. D. Hunter, I. M.S., 1 m. ; Captain R. Brown,
I.8.M.D., 4 m., M.C. ; Captain G. L. C. Little, I.M.S., 4 m.,
M.C.
List oF INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER Civi, RULES).
Showing the Name, Province, and Department. and the Period
for, and Date from, which the Leave was granted.
Abbott, Major S. H. L., I. M.S., Punjab.
Baird, Major R., I.M.S., U.P.
Bennett, Lieutenant-Colonel V. B., I.M.S., Hyderabad,
12 m., March 18, 1914.
Birdwood, Lieutenant-Colonel G. T., I.M.S.
Crump, Captain S. T., I.M.S., Burma Medl.
Duer, Lieutenant-Colonel C., I.M.S., Home Department,
India, 30 m., May 1, 1912.
Forrest, Captain J., I. M.S., M., 18 m., February 14, 1914.
King, Major G., I. M.S.
MacLeod, Lieutenant-Colonel J. N., C.I.E., LM.S., Be-
loochistan, 10 m., February 5, 1914.
Maconachie, Captain G. W., I.M.S., Ms. Prisons.
Macrae, Captain I. M., I.M.S., Agra Cent. Prison.
Manifold, Colonel C. C., I. M.S., U.P.
Nutt, Major H. R., I.M.S., U.P.
Prall, Lieutenant-Colonel, S. E., I. M.S., Bo. Med.
Singh, Lieutenant-Colonel B. J., LM.S., B. & O., 8 m.,
March 7, 1914.
Tarr, Captain W., I.M.S., C.P.
Tucker, Major E. F. G., I. M.S., Bo.
Young, Lieutenant-Colonel W., I. M.S., U.P.
Lisr or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Anderson, Captain A. ©., I.M.S., to December 2, 1914.
Drake-Brockman, Lieutenant.Colonel V. G., I.M.S.
Evans, Captain T. J. C., I. M.S., to April 12, 1915.
Fleming, Major J. K. S.. I.M.S., to November 11, 1914.
Hendley, Colonel H., I.M.S.
Kolapore, Captain F. J., I.M.S.
Lee, Captain A. J., I.M.S.
Manifold, Colonel C. C., I. M.S., to October 18, 1914.
MeNeight, Captain A. A., I.M.S.
Melville, Major C. W., I.M.S.
Pearce, Major C. R., I. M.S., to June 15, 1914.
Pridham, Captain A. S., I. M.S., to July 5, 1914.
Sewell, Captain R. B. S., I.M.S.
Seymour, Captain C. G., I.M.S., to December 16, 1914.
Thomson, Lieutenant-Colonel G. S., I. M.S.
White, Captain M. F., I.M.S.
July 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 13, Vol. XVII.
Original Communications.
THE TREATMENT OF YAWS AND THEIR
SEQUEL BY MEANS OF SALVARSAN.
By Dr. E. C. GrnLING.
Bolobo, Belgian Congo.
IT is, I believe, generally admitted that the treat-
ment of yaws before the introduction of salvarsan
was very unsatisfactory. Here at Bolobo our efforts
were very seldom followed by any marked degree of
success. The treatment was tedious and often painful,
and there could be no certainty as to prognosis.
Natives of this part of Africa are impatient, and will
not usually submit to a prolonged treatment for any
disease.
Salvarsan, however, has revolutionized the whole
question of the treatment of yaws, and it can
undoubtedly be looked upon as a specific remedy for
the disease. We have treated actually about fifty
patients in various stages of the disease, and in every
ease recovery has been rapid and complete.
We usually give an intravenous injection of
0'01 grm. of salvarsan per kilo body weight of the
patient. We have been successful lately with a
much smaller dose, viz., 0075 grm. per kilo. In small
children the intravenous injection is sometimes diffi-
cult, and the drug is injected into the muscles of the
gluteal region. One injection has, up to the present,
proved sufficient. We have had no deaths from these
injections for yaws.
The patients experience relief from the pain and
discomfort of the disease within forty-eight hours,
and the eruption is dry within a week, and has dis-
appeared by the end of fifteen days.
Some of the patients treated had been suffering
for more than a year. Four were treated for crab
yaws on the soles of the feet; all these four were
adults, and their crab yaws had persisted for a
number of years. Two of these had received inter-
mittent treatment here for their condition for four
years without any permanently good result. All
four recovered after one injection of salvarsan, but
the recovery occupied a longer period of time.
Two patients were especially interesting in relation
to the persistent nature of some of the sequel of
yaws. As the two cases were very similar, I will only
cite one.
M., a lad, aged about 16, presented himself for
treatment in 1908. He stated that about five or six
years previously he had been infected with yaws.
The typical eruption had disappeared, but there
remained large granulomatous ulcers on the forehead,
occiput, and on the backs of the hands. He was
treated with simple antiseptie dressings and iodide
of potassium, mercury and arsenic internally. The
ulcers healed but constantly recurred. We employed
him in the hospital and continued the treatment
assiduously for four years without establishing a
permanent cure. He also received 24 injections
of atoxyl and 10 injections of tartar emetic (corre-
sponding to 8 grm. atoxyl and 1 grm. tartar emetic
in all). All our efforts were without avail In
December, 1912, he still had two large uleers over his
occiput and an ulcer on the back of his hand. He
then received 0°50 grm. of salvarsan intravenously,
and in three weeks he had completely recovered, and
he has had no recurrence since. The improvement
in his general health has been wonderful. It is of
course difficult to exclude syphilis in this case, but
one would have expected an improvement from the
iodide and mercury he received had it been a simple
ease of tertiary syphilis. No Wassermann's reaction
was done.
A BRIEF NOTE ON AMCBIC DERMATITIS.
By Lim Boon Kexa, M.B., C.M.Edin.
Singapore.
DERMATITIS CAUSED BY GROWTH OF AMŒBÆ
IN THE TISSUES OF THE SKIN.
Characters.—It begins as minute papules, red and
hard, discrete and very suggestive of variola, but
there is no fever. A clear fluid appears in a day or
two. The vesicles may attain the size of a small
pea. The discharge is a serum which forms a crust
like that of vaccinia. Each papule ultimately breaks
down and then may heal up or leave a depressed
ulcer. Rarely the parasites spread widely and cause
diffuse spreading erythema with pus in the subcu-
taneous tissues. When opened, the fresh pus may
show white thick creamy pus, which contains large
granular amcebe, closely resembling the Entamæba
histolytica. The skin around the healed ulcers may
become deeply pigmented. The Chinese of Swatow
recognize the papular form as the “black blotch ” or
bleb (= 0-pha). The ulcers are depressed. They
may present a smooth cut surface or may be covered
with a yellowish-white exudate. The surrounding skin
is thickened and red. The ulcer enlarges or tends to
heal. The disease is very itchy and contagious, but
tends to heal itself, and spreads to a new site. Amcebe
are generally found in the stools. Patients may or
may not have had dysentery. In the majority of
cases the disease first appeared in the vicinity of the
anus.
Situation.—lt may occur anywhere, but mainly
in the buttocks, and spreads hence to the back, the
limbs, face and trunk; no site seems exempt.
Complications.—If extensive, blood poisoning may
be the result. Abscesses, cachexia, and renal com-
plieations have resulted from extension of the disease.
The discharges appear to be singularly free from
micro-organisms except the amæbæ.
The Parasite.—From fresh papules, only small
amæœbæ with fine granules may be seen, but from
the large sinuses, large amcebe with conspicuous
granules, vacuoles, and amoeboid movement are easily
seen ; these appear indistinguishable from the Enta-
meba histolytica. The parasite is never seen de-
stroyed by phagocytosis in a progressive case; but
after the injection of emetine chloride, the amcebe
can be seen degenerating amidst the agglomerated
194
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1914.
masses of the leucocytes. After a week of repeated
injections with emetine parasites disappeared from
the discharges in a very severe case, where the
sinus extended from the lumbo-sacral region to the
neck, on the dorsum of the body.
Treatment.—Injections of emetine chloride hypo-
dermically are required in extensive invasions of the
skin and subcutaneous tissues. Superficial ulcers
may be treated by ung. hydrarg. ammon. and ung.
sulphuris. The usual antiseptic remedies may also
be tried, but the above are the best. For the com-
plications, appropriate treatment for each condition is
required
BRONCHIAL SPIROCHJETOSIS.
By Frank S, Harper, W.A.M.S.
Tamale, Northern Territories, Gold Coast, West Africa.
T., A COOK in the service of a European Govern-
ment official, aged about 35, Fantee, came to the
dispensary, Tamale, Northern Territories, Gold
Coast.
He complained of cough, wasting, profuse expec-
toration which had never been blood-stained, and
had been ill about six months.
Physical examination revealed no prominent phy-
sical signs in the chest. There were no rales,
rhonchi or crepitations to be heard, there was no
dulness on percussion anywhere but I noticed that
the vocal resonance was markedly increased all over
the chest. There was in addition a very marked en-
largement of the lymphatic glands in both triangles on
both sides of the neck, in the region of the supra-
sternal notch, and in both axilla. The glands were
nearly all as big as walnuts, and were not tender on
pressure but seemed somewhat soft in consistence.
The patient informed me that he had had a gland in
the region of the cricothyroid membrane incised for
symptoms of suppuration six months before and that
the wound had never healed. Neither the liver or
spleen were enlarged, and the heart was normal.
I procured a specimen of the gland juice from the
axilla. It was easily obtained, was clear, non-puru-
lent and watery in appearance. I could see no
organisms I could ideutify in a specimen stained with
methylene blue. The sputum was very similar to the
gland juice in appearance, was very thin and watery,
contained very little mucus, a very few pus cells, and
was extremely profuse. A specimen stained with
methylene blue showed numerous spirochetes. These
were very thin and delicate, and were of the com-
monest type mentioned by Castellani and Chalmers
in their book on tropical diseases. I could only
identify one species.
Examination of the blood revealed only such con-
dition as would be found in a case of moderately
severe anemia. The patient had no temperature the
only time he presented himself for examination.
In my opinion this was certainly a case of chronic
bronchial spirochetosis which had followed an acute
attack.
I very much regret having to publish this case with
such insufficient clinical data, but I could not induce
the patient to enter the local hospital, as he wished
to continue his journey with his master who was
going home on leave.
I believe that this is the first case of this condition
reported from West Africa.
CANINE BABESIASIS IN PORTO RICO.
By Dr. I. Gonzavez MARTINEZ.
Dr. I. GONZALEZ MARTINEZ writes under date of
February 28, 1914, announcing the important dis-
covery of Canine Babesiasis (piroplasmosis) in the
course of routine examinations of dogs for epizootie
diseases and for hydrophobia.
The disease was suspected in several cases. In
two instances the diagnosis was confirmed miero-
scopically with Leishman's stain, which showed " the
characteristic pair of schizonts of Babesia or Piro-
plasma canis within the red corpuscles." With
Giemsa's stain diluted with distilled water, in the
same proportion as is employed to stain the Tre-
ponema pallidum; and thanks to this procedure
beautiful preparations were obtained in which the
parasite appeared pyriform, as a rule, with the cyto-
plasm stained a sky blue and the trophonucleus red.
There was also visible in all of them without excep-
tion a large vacuole, and in the greater number of
cases occupying the same corpuscle were two
schizonts, united at their thinner extremities by a
slender filament. In other fields could be seen
three, and sometimes four, schizonts in the same
erythrocyte. On one occasion two schizonts were
observed within the protoplasm of a large mononu-
clear cell.
The schizonts encountered in the examination of
the smears of blood obtained from the liver and spleen
were larger than those found in the peripheral
circulation, nearly all of them measuring close to
four microns long.
This is an interesting observation, showing the
wide distribution of Babesiasis.
o Ó——nÜ C:
Aw Preparation.
SECWA is a new departure just brought out by
Messrs. Casein, Ltd., Battersea, and is the last word
in dry milk products. It contains a larger percentage
of soluble whey albumins than any other known
preparation on the market, and is to be thoroughly
recommended as useful for ailing infants, con-
valescents from dysentery, enterie fever and other
intestinal diseases. It is also of much service to
the aged and debilitated, when ordinary foods cannot
be assimilated.
Secwa, which is literally dry curds and whey.
contains all the ingredients of fresh milk, except the
casein and the fat, and is one of the most valuable
by-produets of milk. The medical profession can
prescribe it for their patients with every confidence.
July 1, 1914.]
Hotices.
BUSINESS AND GENERAL.
1.—The address of THE JOURNAL OF TROPICAL MEDICINE AND
HyGrEeNE is Messrs. BALE, Sons AND DANIELSSON, Ltd., 83-91,
Great Titchfield Street, London. W.
2.—Papers forwarded to the Editors for publication are under-
stood to be offered to THE JOURNAL OF TROPICAL MEDICINE AND
HYGIENE exclusively.
3.—All literary communications should be addressed to the
Editors.
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THE JOURNAL OF
Troptcal Medicine and Hygiene
JULY 1, 1914.
INTERNATIONAL CONGRESS OF TROPICAL
AGRICULTURE.
THE important Congress which assembled at the
Imperial Institute, London, on June 28, 1914, and
eontinued its work until the 30th, had many important
subjects to consider.
Apart altogether from the direct questions of the
eultivation of the soil, the production of rubber,
afforestation, and the more commercial aspects of
agriculture there were many "side" issues which,
however, are entitled to be regarded as not only
important, but perhaps the basis of all future tropical
ventures where the production of the soil is concerned.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
195
The greatest of these, the " Hygiene of Tropical
Estates," was early brought forward and, on the sug-
gestion of Sir Ronald Ross, who occupied the chair
at the time, the whole question of sanitation and
hygiene in tropical estates was referred to a standing
committee.
Sir Sydney Olivier followed this up by a pointed
reference to the direet bearing this subject had upon
the supply of labour in the Tropies. The physical
efficiency of the labourer has directly to do with the
price of food: for when sickness prevails in districts
where the population is sparse, sufficient labour can-
not be obtained, and the various harvests are un-
gathered; but even where labourers are plentiful the
enormous numbers that have to be engaged owing to
wastage from sickness detracts from the commercial
resources of the employer and may wreck his
finances.
Short of actual sickness there is moreover the
physical deterioration of the population, a factor
which implies inability of the men to perform a fair
day’s work, and entails the engagement of an additional
amount of labour which thwarts success perhaps
even more effectually than acute illness. The ex-
planation of the apathetic disposition of tropical
natives of the working classes, so frequently ascribed
to their down-trodden condition under tyrannical
rulers, is rather to be sought for in their physical
inefficiency due to hereditary, or early acquired,
diseases. To this cause may be assigned also the
use of the lash in times gone by, when "lazy"
labourers, anemic and easily fatigued, failed to
please their masters or overseers.
Malaria is, of course, the greatest of these scourges,
and were that disease alone eliminated or even
lessened, the Tropics would lose their evil name as
a hotbed of disease, and the value of the land and
all upon it would be enhanced tenfold. That this day
will come is assured; when it will come depends
on the education of Governments, of masters and
employers, and perhaps most of all of the labourers
themselves. Malaria immunity is a matter of pro-
tection merely, and theoretically anyone who becomes
infected has only himself to blame. Individual pro-
tection is difficult owing to personal carelessness, and
to the dread of derision of one’s neighbours at the
precautions taken; but protection of the community
is a different matter. Drainage is the only real
remedy; until the swamps are ditched and channelled,
the reedy river shallows cleared, paddy fields removed
to a safe distance from the dwellings, malaria will
prevail. This must be done by the European; the
task is too great for the anemic and malaria infected
native; disease has the upper hand and he has not
the strength to rise against it. Kemove the cause
and he will gain energy and strength to keep the
scourge in check in future. The task is Herculean,
but not impossible; by teaching practical hygiene to
the people, and by insisting on its laws being obeyed
the miracle of delivery can alone be performed. The
question of the best place at which to establish a
school of tropical agriculture was frequently brought
up at the Congress. From what one gathers this is
196
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1914.
a question which the advisers of the British Govern-
ment have inquired into, and perhaps settled the
matter. Ceylon is put forward as the most con-
venient spot to locate the school, and this is due as
much to the geographieal situation of Ceylon as to
the flora of the country. Placed on the high road of
the eastern seas it is readily reached from India,
China, and the Malay Peninsula, East Africa and the
great group of islands of the Archipelago.
A twelve months’ course is spoken of, but this must
be altogether inadequate if serious work is to be
done. A fairly good knowledge of entomology,
chemistry and bacteriology, in addition to a scientific
and accurate acquaintance with botany in all its
branches cannot be acquired in twelve months unless
the pupil has had previous teaching in these subjects.
A preliminary test examination before entering the
school in subjects appertaining to the matter in hand
will be a necessity, otherwise the pupils will be
turned out with a smattering of knowledge merely.
Young men can be trained in this country before join-
ing the School. An agricultural college curriculum
should be attended in this country before the young
men proceed to Ceylon. Just as tropical medicine is
but a branch of general medicine so is tropical agri-
culture but a branch of general agriculture; the
pupils in each case must have a general training
before proceeding to specialize. A candidate, before
going from this country, ought to satisfy a board of
examiners that he is fitted to fully benefit by taking
out the Ceylon course of instruction. We hope to
see this College of Tropical Agriculture speedily
established in Ceylon, and it is to be hoped that the
agricultural service will be dealt with scientifically,
that the students allowed to enter are not the fools
of the family who are no good but to “learn farming,"
and so are sent thither to give them something to
do.
Dr. Harford's advocacy of the suppression of the
sale of alcohol to natives is also a hygienic measure
of deep import to the welfare of labourers in the
Tropies, but as yet neither the imperial nor the local
government have legislated in the matter.
Amongst the important papers and discussions
held at the International Congress of Tropical Agri-
culture were :—
Discussion on “ Technical Education in Tropical
Agriculture."
Paper on " Work of the British Cotton-growing
Association."
Discussions on “Sanitation and Hygiene on Tropical
Estates ” and “ Legislation against Plant Diseases.”
Papers on " The Fertility of Soils in the Tropics.”
Discussion on “The Properties of Plantation
Rubber, with Special Reference to its Uses for
Manufacturing Purposes.”
Papers on "Rubber," “Cereals and Sugar," and
" The Utilization of Sun Power for Irrigation and
other Purposes in Tropical Agriculture.”
Discussions on “ Agricultural Credit Banks and
Co-operative Societies" and “The Organization of
Agricultural Departments in relation to Research.
Papers on "Oils and Oil-seeds,” “Cocoa
Tobacco,” “ The Karakul Sheep."
and
Discussion on “ The Improvement of Cotton
Cultivation.”
Papers on “ Cotton, Jute and Hemp Fibres,”
and " The Fibre Industry of British East Africa."
CHAMBERLAIN PORTRAITS UNVEILED.
To commemorate the distinguished services of Mr.
Joseph Chamberlain and Mr. Austen Chamberlain to
the London School of Tropical Medicine, bronze por-
trait reliefs of the two statesmen have been placed in
one of the wards of the Seamen’s Hospital at the
Royal Albert Docks, the headquarters of the School.
The ceremony of unveiling was performed on June 23
last by Mr. Lewis Harcourt, M.P., Secretary of State
for the Colonies. Mr. Joseph Chamberlain was pre-
cluded by the state of his health from attending, but
Mrs. Joseph Chamberlain and Mr. Austen Chamber-
lain were present. Among others at the ceremony
were Mrs. Lewis Harcourt, Mrs. Austen Chamberlain,
Mrs. Endicott, Sir John Anderson, Sir David and
Lady Bruce, Sir William and Lady Bennett, Sir
M. M. Bhownaggree, Sir Henry Burdett, Sir George
and Lady Dashwood, Sir George Denton, Sir James
K. Fowler, Sir Thomas and Lady Holderness, Sir
Frederick and Lady Lugard, Sir Francis and Lady
Lovell, Sir Thomas and Lady Robinson, Sir Reginald
and Lady Talbot, Sir William and Lady Treacher,
Major and Mrs. H. Bryan, Dr. C. J. Martin, Sur-
geon-General and Mrs. Godfrey, Dr. Ronald Brinton,
Mr. H. J. Read, Professor W. J. Simpson, Dr. and
Miss Sandwith, Mr. and Mrs. James Cantlie, Professor
R. T. Hewlett, Dr. and Mrs. Low, Dr. C. W. Daniels,
Dr. H. B. Newham, Dr. and Mrs. Bahr, Dr. F. W.
O'Connor, Dr. Lynch Burgess, and Mr. Perceval A.
Nairne, Chairman of the Seamen’s Hospital Society
and of the London School of Tropical Medicine.
Mr. PERCEVAL NAIRNE explained that the Presi-
dent, Admiral Prince Louis of Battenberg, who took
the deepest interest in the institution, was unable to
be present owing to his having to fulfil a long-standing
official engagement.
COLONIAL SECRETARY'S APPRECIATION.
Mr. LEWIS HARCOURT, M.P., said that he deemed
it a distinguished honour to be permitted to perform
the ceremony. He owed this, of course, in the first
place, to his official position, but he hoped he might
confidently attribute it in some degree also to his
life-long friendship with Mr. Chamberlain. Political
differences occupied their proper, but not, he hoped,
exaggerated, place in public life, but they never had,
and never could, blind him to the great services ren-
dered in other spheres by those to whom he might
happen to be politically opposed. It was pleasant
to meet on the neutral and illuminating territory of
applied research. Seldom could it have happened to
two men—father and son—to have their great ser-
vices jointly recorded, and, happily, in the lifetime of
both, and never was an honour more abundantly
deserved. During his eight years’ tenure of the office
July 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
197
of Colonial Secretary, Mr. Chamberlain became pain-
fully aware how great a factor in Imperial administra-
tion were the problems and the prevalence of tropical
disease. Had he been present on this occasion, Mr.
Chamberlain would, he was sure, have been the first
to acknowledge that the initiation of a School of
Tropieal Medicine in connection with this Hospital
was largely due to the conception and foresight of Sir
Patrick Manson. Many men owed their lives, and
many millions of mosquitoes their deaths, to Sir
Patriek's suggestive and alleviating discoveries. It
was now fifteen years since Mr. Chamberlain, realiz-
ing the necessity for further openings for research,
observation, and treatment, suggested the institution
of a new School of Tropical Medicine in association
with this branch of the Seamen's Hospital The
reasons for his
selection were
obvious ; its con-
tiguity to the
docks and Port
of London ren-
dered it a fre-
quent resting-
place for many of
those who had
contracted, and
not recovered
from, those very
diseases which it
was desired to
destroy. It was
one thing, and an
easy one, to sug-
gest a school: it
was quite another
to endow it.
With character-
istic energy Mr.
Chamberlain did
both. In May,
1899, he raised
at a banquet a sum of £15,000, and by October of
the same year laboratories had been built and the
School opened.
This suecess became almost an embarrassment, for
six years later more aecommodation became impera-
tive, and at a second banquet Mr. Chamberlain raised
a further sum of £10,000. This equipped a library,
a museum, and special tropical wards, which brought
the number of beds up to fifty. The total capital
expenditure up to date had amounted to £50,000,
and the annual expenditure was £3,000, which latter
amount was, however, nearly met by the students’
fees. Grants, not ungenerous in amount, had been
made by the Treasury and other publie departments,
and an annual contribution of £850 was made by
the Crown Colonies as a token of their gratitude for the
advantages they enjoyed from the institution, while
many private benefactors had added to its funds.
Experimental work was done in the laboratories, and
the students had spread themselves over half the
habitable globe in pursuit of further knowledge.
F. W. Doyle-Jones, Sculptor.
SEAMEN'S HOSPITAL SOCIETY.
Bronze Portrait Reliefs erected in the Albert Dock Hospital to commemorate the
services rendered by the Rt.Hon. Joseph Chamberlain, M.P., and the Rt. Hon. Austen
Chamberlain, M.P., to this Hospital and to the London School of Tropical Medicine,
1914.
Malaria, sleeping sickness, guinea worm, sprue,
dysentery, and ankylostomiasis had each in their
turn been subjects of their inquiries. Nothing had
been more remarkable in the modern progress of
medical science than the great and sometimes unex-
pected results which had accrued from the meticulous
industry of individuals in apparently objectless record
and investigation. The microscopic application in
the dissection of facts and the observation of pheno-
mena brought into a creative focus by such schools
as this materially served the health and happiness
of humanity. The number of students had grown
steadily from 70 in the first year to nearly 200 in
the last. The number who had passed through the
School was now close on 1,800, and he was glad to
say that nearly 700 of these had entered the Colonial
Medical Service.
It | was only
those at the
centre, like him-
self, with the
vital statisties of
the Colonial Ser-
vice always be-
fore them, who
could appreciate
what those men
had done to ease
the pain and
modify the dan-
gers of tropical
life. The West
Coast of Africa,
once regarded as
& death - trap,
would soon be
looked upon as a
sanatorium.
Duringthe period
to which he had
referred, the
death-rateamong
British officials had been reduced from 28 per 1,000
to 8 per 1,000, and the invaliding rate from 62 to 28.
Mr. Joseph Chamberlain, speaking fifteen years ago,
said: " The man who shall make the Tropics livable
for white men, who shall reduce the risk of disease
to something like an ordinary average, will do more
for the world and more for the British Empire than
he who adds a new province to the wide dominion
of the Queen. All those who co-operate in securing
this result, whether by their personal service or by
some pecuniary sacrifice, will be entitled to shar®
the honour and to add their names to the golden
record of the benefactors of mankind." On that
record there was no doubt that both father and
son were entitled to have their names recorde
In recognition of their splendid services he wou
presently proceed to unveil the medallions.
Mr. AUSTEN CHAMBERLAIN, who was loud
cheered, said that he felt deeply embarrassed to fi
words to thank Mr. Nairne and the Committee of the
Seamen's Hospital for the kindly thought which had
> o —
|
4
)
4
A
SE
x»
y
19 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1914.
led them to suggest this memorial, and Mr. Harcourt
for the very kind words in which that gentleman
had spoken of the services of his father and himself.
To tell the truth, he felt that he himself in this
matter was nothing but an accident, though he hoped
a happy one. His father entered on his term of office
as Colonial Secretary with a double programme of
work, one part of which was to do all that in him lay
to bring closer together the self-governing Dominions
of the Empire, and the other to promote the un-
developed resources of the tropical and semi-tropical
Dependencies and Crown Colonies of the Empire.
The first step towards their development, it seemed
to him, would lie in an improvement in the health
of their white administrators because such improve-
ment would give greater attractions to their life,
more people would take it up, and progress would
be more rapid. The improvement in the health of
the whites was necessarily linked with consideration
for the health of the native inhabitants, who, though
they were not to the same extent victims of many of
the diseases that were fatal to white men, yet had
their own peculiar troubles, for which peculiar
remedies were needed.
Very early in his career at the Colonial Office his
father ascertained that the man who could best
advise him and co-operate in combating tropical
diseases was Sir Patrick Manson. Sir Patrick had
felt the need of such an institution as this ; in fact, he
had suffered from that need, and the suggestion for
its foundation came from him. No sooner was the pro-
posal set forth than the late Sir Alfred Jones set about
founding the Liverpool School of Tropical Medicine.
The Liverpool and London Schools, therefore, came
into existence almost simultaneously, and since then
they had worked in perfect amity or with a rivalry
that had never been anything but healthy and
friendly. Already they had done much, and it was
apparent that they could do infinitely more. To his
father and to Sir Patrick Manson, then, the institution
owed a great deal. He himself was brought in much
later in the day, when the present Colonial Secretary
invited him to accept the Chairmanship of the Com-
mittee. Such an invitation he could not decline, and
he had done all he could to make the undertaking a
success. In this connection he would like to say a
word of acknowledgment with regard to the great
assistance he had had from the Committee of the
Seamen's Hospital, and its Secretary, Mr. Michelli;
from Mr. Read, of the Colonial Office; and from the
Committee which had been formed in the City of
London under the auspices of the London Chamber
of Commerce, as well as others in the City of London
who were interested in tropical and semi-tropical
countries. For himself, he could only say that he
humbly accepted his share of the honour done to his
father and himself. He most heartily thanked them
for having recorded on the walls of that Hospital the
association of his father with a work in which he
had taken and still took a deep interest.
The Colonial Secretary unveiled the memorial,
which is by Mr. F. W. Doyle Jones, and represents
the two statesmen facing each other.
Annotations.
Helminthemesis (A. R. Neligan, Lancet, June 6,
1914.)— Every Persian is infected at one time or
another in the course of his life, and a large proportion
of Europeans fail to escape. The common worms
in the North of Persia in the order of frequency are
Ascaris lumbricoides, Oxyuris vermicularis, and Tenia
saginata.
Vomiting of a round worm is very often accom-
panied by serious general disturbance. The first case
of grave illness to whieh I was called after arriving
in Tehran was that of a child aged 4 who was uncon-
scious, with high fever, a rapid irregular pulse, and
Cheyne-Stokes breathing. Meningitis was my
diagnosis, but within twenty-four hours the child
vomited a round worm and promptly got well. Cases
of obscure and apparently grave illness, both in adults
and children, terminate by the vomiting of a worm;
I should say round worm, for I have never seen a
tapeworm expelled from the mouth. To omit to give
santonin in most cases of gastro-intestinal disturbance,
and to many patients whose symptoms cannot be
correlated with any definite diagnosis, might in Tehran
almost be dubbed malpraxis !
A case of helminthiasis the like of which I have not
read of nor seen again, was a child aged 7, wasted to
skin and bone, face drawn with pain, fever, irregular
bowels, and occasional vomiting. Abdomen full of
lumps, some as big as hen's eggs, and tender.
Diagnosis: tuberculous peritonitis. Prognosis: hope-
less. Treatment: calomel and santonin in small
doses, as a beginning. In three days the child was
brought back looking a different creature and the
lumps in the abdomen gone; scores of round worms
must have been expelled.
THE ROYAL INSTITUTE OF PUBLIC HEALTH.
EDINBURGH CONGRESS.
Wednesday, July 15, to Monday, July 20, inclusive.
The papers to be read at this Congress bearing
upon tropical medicine are :—
(1) The Treatment of Trypanosoma Diseases with
Antimony Preparations, especially with Irixidin: By
Professor W. Kolle, M.D., Berne.
(2) The Control of Rat Plague: By W. E. Harker,
M.D. and Major R. W. Jackson, M.D.
(3) The Decline of Enteric amongst British
Troops in India: By Lieutenant-Colonel N. Faichnie,
R.A.M.C.
(4) Some effects of Damp Heat:
D. A. Mitehell, R.N.
(5) The Struggle against Mosquitoes: By Surgeon
D. H. C. Given, R.N.
(6) Sanitary Progress in British Guiana: By K. S.
Wise, M.B., B.S.
The Congress Secretary’s office is at 45, Queen
Street, Edinburgh, until the opening of the Congress.
After the opening the Secretary's office will be in
the University,
By Surgeon
July 1, 1914.]
Abstracts.
NOTE ON A CASE OF DEATH FOLLOWING
THE STING OF A SCORPION.*
By R. McC. LiNRELL, L.R.C.P.
THE patient, a coolie, aged 20, was admitted to
hospital, Kuala Lumpur, on January 25,1914. He
had been working regularly until two days previously,
when he was stung by a scorpion in the left heel.
For the cure of the sting the other coolies had made
him eat the head of the scorpion. On admission to
hospital the patient complained of "things creeping
all over the body." The temperature was 102'8?F.
No malarial parasites were found. A blood count
gave the following percentages : polymorphonuclears,
75'8; mononuclears, 0'81; lymphocytes, 9°68 ; transi-
tionals, 564; mast cells, 0'81 ; and eosinophiles, 7°26 ;
The heart and lungs were clear and the urine was
normal, but the fæces contained ankylostoma ova.
On the fourth day after receiving the sting the patient
had paralysis of the legs, and on the fifth day motor
paralysis to the umbilicus, sensation being unaltered.
On the sixth day there was retention of urine, and
on the ninth day sugar was present in the urine
(between the third and ninth days the urine was not
examined). On the thirteenth day the patient became
comatose, but could be roused to eat and drink. The
temperature on the following day fell below 95? F., and
the patient was still comatose. Death intervened on
the fifteenth day.
The patient had seemed to be able to feel as long
as he was conscious. The sugar had persisted in the
urine from the ninth day to the end. The patient's
relatives had very strong objections to a post-mortem
examination being held, but I finally persuaded them
to allow me to remove a piece of the spinal cord.
Dr. W. Fletcher, Pathologist to the Institute of
Medieal Research, Kuala Lumpur, kindly examined
this and reported as follows :—
" A portion of the lumbar eord was received for
examination. It had been hardened in alcohol, so
that no pathological changes could be recognized in
the myelin sheaths. Paraffin sections stained with
Heidenhain showed that the cord was affected with
acute disseminated myelitis. In one part there was
acute destruction of the anterior horn and an infiltra-
tion of round cells. In another portion Clarke's
column had been destroyed. The perivascular sheaths
were crowded with small round cells and the meninges
were congested. Some of the cells of the anterior
horn were swollen and the nuclei eccentric; chroma-
tolysis had occurred in many of them."
Although scorpion stings are fairly common in the
Federated Malay States, yet deaths following them
directly must be extremely rare, the above case being
the only one which I can trace. The scorpion was a
small brown specimen, which the natives declare to
be the most vicious and deadly of all. What appears
to be an unusual feature in the case was the appearance
of sugar in the urine.
= Lancet, June 6, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
199
TWO CASES OF SPRUE TREATED BY MOUTH
STREPTOCOCCAL VACCINES AND EME-
TINE HYDROCHLORIDE HYPODERMI-
CALLY.*
By LEONARD ROGERS.
CASE 1.—A Mohammedan woman, aged about 40,
in October, 1905, had commenced passing a number of
large light-coloured loose, frothy stools, said to be as
many as twenty daily, and accompanied by obstinate
dyspepsia. She was then a stout woman weighing
14 st., but her weight soon became reduced to 10 st.
During the following year the diarrhea was less,
with only about five stools daily, but she was never
free from it. In November, 1908, there was a recru-
descence, with numerous loose stools, nausea, and
flatulence. She stated that this condition had con-
tinued ever since, and that for nine years she had
never been free from diarrhea, although she had
been treated by a number of medical men, both
European and Indian, in Bombay and Calcutta.
She lived in Bombay from June, 1911, to December,
1918, but was worse there than when in Calcutta.
At that time she used occasionally to become giddy
and even faint, having several times been found
collapsed on the floor at night on her way back from
the bathroom. During the eighteen months she was
in Bombay her gums were ulcerated and they bled
freely, and she was told by a dentist that this con-
dition could not be cured until all her teeth had been
removed, which she declined to allow.
Present Condition.—When first seen, on Decem-
ber 6, 1913, she was passing about twelve large,
loose, pale, sprue-like stools daily, accompanied by
flatulent dyspepsia. I failed to find any amcebe in
the stools. There was marked pyorrhoa alveolaris,
so I made cultures, and obtained large numbers of
streptococci, from which a vaccine was made.
Progress.—Half-grain doses of emetine hydro-
chloride were injected hypodermically every other
day, and were soon increased to 1 gr. doses. After
two or three injections, and before the vaccine had
been commenced, the stools became much less fre-
quent and of better consistency and colour. After
eight injections the evacuations had become healthy
and only one or two a day. In the meantime the
streptococcal vaccine was begun, 50,000,000, soon
increased to 100,000,000, being injected once a week.
The discharge of pus from the gums rapidly de-
creased, and in a few weeks completely disappeared,
and has remained absent for the last four months.
No teeth were removed. Some superficial soreness
and redness of the tongue subsequently appeared,
from which a streptococcus was also cultivated. A
vaccine made from this removed the unhealthy con-
dition of the tongue within a few days.
On May 3 last, except for slight redness of the tip
of the tongue, she was quite well; almost five months
since the diarrhea ceased, after having been con-
tinuously present for nine years before the new
treatment was commenced. She has no dyspeptic
symptoms, and ean digest all ordinary food. She is
* Lancet, June 6, 1914,
200 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1914.
now free from the giddiness, faintness, and neuralgia
which she used to suffer from, and her general
health has greatly improved. She has not been
weighed regularly, but has put on some flesh and has
gained much in strength. The only trouble with her
bowels is a slight tendency to constipation, necessita-
ting an occasional dose of castor oil.
CASE 2.—A woman, aged about 40, had had
very severe diarrhea in Calcutta, in August,
1909. She had also been treated twice in Eng-
land, twice in Hong Kong, in Berlin, as well as
making two voyages to Japan. On December 17,
1913, she was in a very emaciated and weak condi-
tion, and passing several large, pale, typical sprue
stools daily. Emetine hydrochloride was given in
$ gr. doses two or three times a week, and later in-
creased to 1 gr. doses. She slowly improved during
the next three weeks, but on January 14 last she had
a severe relapse with frequent copious stools. Her
mouth had now become very painful, with numerous
small shallow ulcers on the tongue and_ buccal
mucous membrane, while the temperature rose every
afternoon for about a week. She was very prostrated
and too weak to stand or even sit up, while the pulse
was fast and irregular. Cultures from the mouth
ulcers showed in some tubes a pure growth of a strepto-
coccus. I therefore made a vaccine from it and
commenced with 50,000,000, increased later to
100,000,000, once a week. After the second dose
of the vaecine both the mouth and the bowel sym-
ptoms rapidly improved. Towards the end of Janu-
ary she was put on a milk diet, beginning with 6 oz.
and gradually increasing it to 120 oz. daily by the
end of three weeks. The emetine injections were
continued twice a week. The diarrhoea now stopped,
the mouth lesions healed, the vaccine being con-
tinued once a week. Up to this time the patient
was being carried from her bed to a couch for a
few hours daily. She now rapidly improved, and on
. March 4 was able to be moved to Bangalore, a three
days' railway journey, for the hot weather.
On March 20, the patient reported that she had
had no signs of diarrhoea since February 5. The
mouth was quite well. She had gained just over a
stone in weight in four weeks, before which she had
become reduced to 6 st. 9 lb., or to under half her
original weight. She was now able to walk a quarter
of a mile and do everything for herself. She was
continuing the vaccine once every eight days and the
emetine injections once in ten days. On April 9, she
reported continued improvement. She could now
digest eggs, semolina, and toast and butter. When
I last heard from her, on April 28, she remained free
from all signs of sprue and continued to gain weight
steadily.
The success attending the use of a vaccine made
d s : :
from the streptococci which were found present in
practically pure culture in the mouth lesions is very
significant, and opens up the interesting and sugges-
tive question as to whether this class of organism
may not be the cause of the disease, at least in
some cases. The rapidity with which the disappear-
ance of mouth ulcers under the influence of the
vaccine was in the second case followed by cessa-
tion of the diarrhea certainly suggests a causal
relationship between the organism and the disease,
and affords some hope of the new treatment prov-
ing to be of a specific nature and thus an important
advance in dealing with this intractable and distress-
ing disease. Even in cases where no mouth lesions
are present there may still be a streptococcal infec-
tion of the digestive tract, and possibly cultures may
be obtainable from the stools which might prove of
service in the form of a vaccine.
NOTE ON A FOREIGN BODY REMOVED
FROM THE LIVER AFTER TWENTY-
THREE YEARS.*
By Seymour Baruine, M.S., F.R.C.S.
IN September, 1911, a healthy married woman,
aged 26, came up to the out-patient department at
the General Hospital, Birmingham, complaining of
pain shooting down the right side of the abdomen
into the groin. The pain was intermittent, had been
present on and off for about a year, and was aceom-
panied by some tenderness in the right iliac fossa.
Examination of the urine was negative, and a radio-
graph of the kidney and ureter showed no abnormal
shadow. The condition was diagnosed as due to
chronic inflammation of the appendix. At the sub-
sequent operation a long appendix, somewhat kinked
at its root, was found and removed. This was con-
sidered sufficient to account for the patient's symptoms.
The patient again presented herself in October,
1913. She still complained of her old pain, which
had been little, if at all, relieved by the operation.
It now seemed higher up, near the right costal
margin, and was distinctly worse when she was up
and about than when lying down. On closely
questioning her as to her past history, it was as-
certained that twenty-three years ago she was carrying
a bottle of beer up some steps when she stumbled and
fell, cutting herself just over the lower margin of the
chest. She was very ill after this, and was confined
to her bed for nearly six months. On examination a
scar was found 3 in. long, exaetly parallel to the
interval between the sixth and seventh costal cartilages
on the right side. This had previously been over-
looked owing to a pendulous breast.
Another radiograph was taken somewhat higher
up than on the former oceasion. This revealed an
opaque body, about 3 in. by 1 in., lying across the
tenth and eleventh ribs just external to the upper end
of the right kidney. It had been just missed by the
first radiograph, which ineluded;the kidney area only.
As a lateral view could not be taken satisfactorily,
it was difficult to determine the exact depth of the
foreign body. An incision was therefore first made in
the subcutaneous and muscular tissues over the lower
part of the thorax posteriorly. Nothing, however,
could be detected there.
* From the Archives of the Roentgen Ray, June, 1914.
July 1, 1914.]
The abdomen was then opened through the right
linea semilunaris, just below the eostal margin. On
introdueing the hand into the sub-diaphragmatic
space it was found that a large mass of adhesions
filled the interval between the under surface of the
diaphragm and the right lobe of the liver. Good
access was given to this region by cutting through the
right rectus muscle. When the adhesions had been
broken down a large eyst with whitish fibrous walls
was found, partly in the sub-diaphragmatic space and
partly in the substance of the liver.
When this was punctured a dark fluid issued, and a
freer opening of the cyst yielded something over a
pint of this fluid, dark in colour and evidently the
residue of an old hemorrhage. Deep in the cyst
were the fibrous remains of an old blood clot, and
embedded in this could be felt some sharp-edged
foreign body, which cut the gloved finger when
endeavours were made to dislodge it. Eventually
a piece of thick green bottle glass was removed,
measuring 2$ in. by 14 in., triangular in shape. It
was curved, and was evidently a portion of an
ordinary bottle, the edges and corners being as sharp
as those of recently fractured glass.
The cyst was packed with gauze, as the haemorrhage
was somewhat free, and a drainage tube was stitched
into the wound. The patient made an excellent
recovery, and left hospital in three weeks. There is
still a sinus, discharging a slight amount of pus, but
this is gradually closing.
The case is of interest as showing the length of
time such a dangerous object can lie dormant in a
vascular organ like the liver. It also shows the
importance of a complete radiographic examination as
an aid to diagnosis.
AN INVESTIGATION OF THE CAUSES OF
FAILURE IN COW-POX VACCINATION.”
By Jonn Nivison Force, M.D., M.S.
THIS paper is the record of an investigation of the
causes of failure in the cow-pox vaccination of persons
entering the University of California with no visible
evidence of a previous vaccinia. All entrants not
showing a vaccination scar were vaccinated. Failure
to “ take ” resulted in a repetition of the vaccination
twice during the first term, and once every succeeding
term during residence at the University.
Technique.—The arm was scrubbed with soap and
sterile water, rinsed with alcohol and dried with
cotton.
Scarification was made by means of a chisel with a
carbon steel point which could be dipped into alcohol
and flamed without affecting the cutting edge.
Application of Virus.—The virus was applied to the
scarified spots by means of a sterile wooden toothpick.
The amount adhering to a flat-ended toothpick dipped
into glycerinated virus was sufficient for the inocula-
* From the Journal of the American Medical Association,
May 9, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
201
tion of the three searified spots constituting a
vaccination.
A gauze square was then applied to the wound and
was secured by four strips of adhesive tape. Verbal
instruetions were given the person regarding the
proteetion of the arm, and return for the renewal
of dressings.
The return date (five days after vaccination) was
stamped on the adhesive tape. A printed card of
instructions regarding the care of the vaccinia replaced
the verbal directions formerly given. No antisepties,
salves or shields were used. On the ienth day, when
area formation normally occurs, a few persons com-
plained of soreness in the arm. This was much
relieved by the applieation of & compress, kept moist
with 50 per cent. alcohol. The inflammation subsided
in twenty-four hours. In the absence of large scarified
spots there were no “ bad” arms.
Area formation on the tenth day is evidence that
the growth of the colony of vaccine organisms has
been arrested by the antibodies which have been
formed by the stimulation due to the organism, or, in
other words, that immunity has been established.
The praetice of destroying the colony by opening
the vesicle and applying phenol (carbolic acid) before
area formation occurs naturally results in a reduction
of the size of the dose of vaccine organisms. Immediate
revaccination in the cases in which the dose has been
insufficient would produce a vesicle. Revaccination
when a condition of active immunity exists would
only result in the reaction of immunity as hereinafter
described.
Investigation of Alleged Immunity against Cow-poz.
—By attention to the technique and virus, the failures
in unscarred persons have been reduced from 21 to 16
per cent. There remains still the question of alleged
natural immunity to cow-pox vaccination.
A small-pox epidemic at the opening of the second
term of the academic year 1912-1913 gave opportunity
of observing the course of revaccination in persons
with scars of various kinds who reported for vaccina-
tion " to be on the safe side."
The experience gained in over one thousand revac-
einations observed at that time confirmed the observa-
tions of Jenner,” v. Pirquet and others regarding the
difference between a true primary vaccinia and the
condition produced by revaccination, which the French
authors call " vaccinoid."
In general a vaccinia observed five days after
vaccination is characterized by a yellowish vesicle
surrounded by a narrow red areola, while the vaccinoid
of the same age has a comparatively smaller vesicle
surrounded by a wider areola. When no vesicle
develops and the areola appears and subsides early we
have the immediate reaction of v. Pirquet, which was
first described by Jenner as “ sudden efflorescence.”
The Test of Immunity.—During the course of some
observations and measurements of these areole of
immediate reactions, it occurred to me that this
reaction might be used as a test of those failures
* Jenner: **An Inquiry into the Causes and Effects of Variole
vaccinir, 1798."
202
which persisted each year in spite of our best efforts
with uniform technique and cold virus. In a previous
paper some of the characteristic cases were described,
but a general application of the test was not made
until the opening of the academic year 1913-1914.
Previous to January, 1913, only the unsearred
entrants had been vaccinated. Certain changes in
the State vaccination law caused the regents of the
university to issue an order that, in addition to
unsearred entrants, all other entrants showing a scar
over seven years old must be vaccinated. This order
gave an excellent opportunity for the following
application of the test of immunity :—
If a student had an old or otherwise unsatisfactory
scar, he was vaccinated in two spots on the arm, a
control spot being scarified and rubbed with the
glycerine diluent used in the preparation of vaccine.
Observations were made at twenty-four, forty-eight
and seventy-two-hour periods after vaccination. If
either of the vaccinated spots showed an areola of
5 mm. or over (with or without papule) at the end
of twenty-four hours, which areola (or papule) had
decreased at the time of the seventy-two-hour observa-
tion, i& was considered a reaction of immunity due
to the presence in the blood of the individual of
antibodies against vaccine virus. The student was
excused from further vaccination. If either of the
vaccinated spots showed an areola at the end of
twenty-four hours which developed into a small
vesicle, maturing on the fifth or sixth day and then
rapidly subsiding, the reaction was considered a
vaccinoid.
If there was no change until the third day, and
then a small areola began to form, the case would be
vaccinia. If there was no change by the fifth day,
the failure was charged to technique and the experiment
was repeated. If a case was not seen until the fifth
day, and there were no signs of a recent local reaction,
the vaccination was repeated, and daily observations
were made, for all signs of the reaction of immunity
may be gone by the fifth day.
Results of the Application of the Immunity Test.
—Out of 589 persons vaccinated during the semester
August-December, 1913, complete records have been
obtained from all but two. In all doubtful cases a
revaccination has produced one of the characteristic
reactions.
(1) Of three previously unvaccinated entrants giving
the reaction of immunity, one had a definite history
of small-pox, one had a history of recent chicken-pox
(which might have been small-pox), and the third
denied having had either small-pox or chicken-pox.
(2) Sixteen unsearred old students and ten unscarred
entrants gave the reaction of immunity. This would
imply the presence of antibodies against vaccine virus,
due to repeated doses of a virus in each instance
incapable of growth, but capable of producing
immunity; that is, analogous to a bacterial vaccine
made from a killed culture.
(3) The highest percentage of reactions of immunity
occurred in persons having well-pitted scars.
(4) No natural immunity against vaccine virus was
discovered. Such a person would have no history of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1914.
vaccinations nor would he give a specific reaction of
immunity to vaccine virus.
The following cases serve to illustrate certain points
which must be considered in the application of the
test :—
CASE 1.—G. R., entrant, vaccinated just before
entrance with no result, was vaccinated September
22, 1913.
September 26. No reaction.
September 29. Revaccinated with same virus, in
two spots with a control scarification.
September 80. No reaction in vaccinated spot.
October 1. No reaction.
January 5, 1914. Revaccinated with fresh virus in
two spots with a control scarification.
January 6. No reaction in vaccinated spots.
January 7. Areole, 7 mm. in diameter, around
vaccinated spots.
January 10. Vesicle in vaccinated spots, but areole
20 mm. in diameter in place of the ordinary small
areola hardly larger than the vesicle.
CasE 9.—P. A, entrant, never
vaccinated October 1, 1913.
October 6. No reaction. s
October 13. Revaccinated with same virus in two
spots with a control scarification.
October 14, 15, 16 and 20. No reaction in vac-
cinated spots.
October 27. Revaccinated with a fresh virus, two
spots, and a control scarification.
October 21. No reaction.
November 3. Vesicles on both vaccinated spots,
but areole larger than normal for primary vaccinia.
These two cases were stragglers vaccinated during
the month following the general vaccination of
entrants. The repeated vaccinations with an inert
virus probably served to sensitize them. This
accounts for the large areolee occurring in conjunction
with the formation of vaccinia vesicles.
CASE 3.—L. S. H., old student, vaccinated between
ten and twenty years ago. Had scar 15 mm. in
diameter very well pitted, the type of scar from
which we obtain the highest percentage of immunity
reactions. Vaccinated November 19, 1913, in two
spots with a control searification, the same virus being
used which had failed twice with Cases 1 and 2.
November 20. Areole 10 mm. in diameter with
slight papule around both vaccinated spots.
November 21. Same condition.
November 25. Areole almost faded.
This ease shows that virus incapable of growth may
produce the reaction of immunity in a person well
supplied with antibodies. It is suggested that repeated
inoculation with a virus inactivated by heating, or
sensitized by serum from an animal immune to vac-
cinia, might stimulate antibody formation without the
necessity of first growing the colony of vaccine organ-
ism on the skin as a culture-medium.
If by the fifth day no reaction whatever occurs in a
previously unvaccinated person, the virus is probably
inert. Signs of activity produced by vaccinating a
previously vaccinated person with the same virus
should not be considered proof to the contrary. In
vaccinated, was
July 1, 1914.]
the absence of natural immunity, one of the three
reactions must occur.
CONCLUSIONS.
(1) Any one of the typical reactions against vaccine
virus must be regarded as an evidence of immunity.
(2) If antibodies against virus are present in the
blood of the individual the immediate reaction occurs,
characterized by the formation of an areola around the
vaccinated spot usually within the twenty-four hours
succeeding the vaccination.
(3) If antibodies are not present but the power of
forming them exists through previous vaccinations,
the growing vesicle is aborted sooner than in a pre-
viously unvaccinated person, which accounts for the
small size of the vesicle and the early appearance of
an areola larger than in the case of a vesicle of the
same age.
(4) The technique described is an aid to exact observa-
tion subsequent to revaccination.
(5) Physicians’ certificate of immunity should
be based on an observed reaction and not on the
failure of two or three vaccinations, unobserved
until the fifth day after the insertion. These
"failures" may not have been due to immunity
but to inert virus.
RESEARCHES IN SPRUE, 1912-1914.*
By P. H. Baur, M.A., M.D., D.T.M. & H.Cantab.
IN sprue, a disease obviously of an intestinal origin,
80 chronie in its course, exhibiting such powers of
latency, in fact so definite and unsatisfactory a sub-
ject for investigation from every point of view, it
is not surprising that the conclusions reached
from work in Ceylon are somewhat indefinite and
unsatisfactory.
It is necessary to refer shortly to the disease known
as hill diarrhea, which has been inextricably con-
fused with sprue. Hill diarrhea is a flatulent dyspep-
sia accompanied by nausea and vomiting, and by the
passage of large, pale, liquid, and fermenting stools.
A distinctive feature of the diarrhoa, apart from the
peculiar colour of the stools, is the tendency to be
passed in the early morning. The tongue and mouth
are never involved. The disease is apt to occur in
epidemies, especially in the Indian hill stations. "The
attack is generally acute, and in the majority of cases
promptly subsides on leaving the endemic area for the
plains, and is attended by little or no mortality, but
in a few instances diarrhoea persists for some time
and may develop into genuine sprue. The facts so
far known suggest some functional disturbance of the
digestive organs as the most probable etiological basis ;
against this supposition is the fact that since the
sanitation and water-supply of the Indian hill stations
have been improved, the incidence of hill diarrhea
has apparently decreased.
Sex.—In the thirty-six European cases the majority
* From the Transactions, Society of Tropical Medicine and
Hygiene, April, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
208
—nineteen—occurred in females; the especial liability
of the female sex to infection is strengthened when it
is remembered that the proportion of European males
to females in Ceylon is as two to one.
Age.—The oldest man I saw suffering from sprue
was à burgher aged 76, the youngest a Eurasian boy
aged 13.
THE INFLUENCE OF IMMEDIATE ENVIRONMENT.
Housing.—There is a prevalent and popular idea
in Ceylon that sprue most commonly originated in
dry-rot bungalows, which are notoriously unhealthy ;
the dry-rot is a sawdust-like powder which filters from
the beams, emitting a disagreeable smell and giving
rise to symptoms of pharyngeal and nasal irritation.
The evidence seems to negative the suggestion that
dry-rot is direetly connected with sprue, save that an
unhealthy environment of this sort may predispose to
its development by reducing the normal vital resist-
ance to the disease.
DISEASES WHICH PREDISPOSE TO SPRUE.
The development of some chronic infection, such as
dysentery, is regarded as the most important predis-
posing factor; some observers have gone so far as to
suggest that the condition known as sprue is actually
the ultimate result of a chronic dysentery, others that
the development in the intestinal canal of the sprue
germ is favoured by frequent dysenteric attacks.
Amongst my cases the occurrence of previous
dysenteric attacks is noticeable, but it is open to
doubt whether this connection is merely incidental,
seeing that the majority of residents have, at one time
or other, been subject to such attacks. In one half
of the cases the disease arose de novo ; there are ample
grounds, therefore, in regarding sprue as a primary
specific infection, but that, as in all other chance
infections — such as tuberculosis — any debilitating
cause may lower the vital resistance and render the
alimentary tract more liable to attacks of the specific
sprue germ.
SPRUE REGARDED AS AN INFECTIOUS DISEASE.
The occurrence of sprue in Ceylon in all classes of
the community, irrespective of age, sex, race, or
environment, are facts suggestive of the communi-
cability of the disease from man to man. The con-
tagion theory has already been advanced. In my
experience cases of this nature in persons closely
associated were far too frequent to be of a purely
accidental occurrence. There were six instances of
the disease occurring in one or more closely asso-
ciated members of the same family, such as mother
and son, father, sister and daughter, husband and
wife, mother and daughter, &c. In the first case
quoted there was more or less definite evidence of a
direct infection. The mother, a Eurasian, was, while
lying very ill, in the habit of feeding her son, a boy
aged 13, with her own spoon; a few months before
she died the boy developed symptoms. All my
attempts to convey the disease directly to the
lower animals, rabbits and monkeys, by inoculating
204
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1914.
T———————————————
scrapings of sprue tongues and by injecting sprue
stools into the alimentary canal, failed.
SYMPTOMS OF SPRUE.
The symptoms of the disease and its manifesta-
tions varied so considerably that the only satisfactory
classification was one which rested upon the hypo-
thesis that the disease process affects the various
regions of the intestinal canal to an unequal degree,
and thus gives rise to symptoms according as one or
other rogion is specially affected.
Under the heading of “typical or complete sprue "
are included all those cases exhibiting the two cardinal
symptoms—the characteristic tongue and stools—but
even in this category are included cases of all degrees
of severity, which I considered myself justified in
regarding as mild, acute, and chronic manifestations
of the same disease.
Under the heading of ‘incomplete sprue ” are in-
eluded a number of cases with the typical diarrhea,
but without any affection of the mouth and tongue,
and also a large series of diarrhaas, mostly in young
male Europeans, accompanied by emaciation, flatu-
lence and dyspepsia, which I regard as early cases of
sprue and not as cases of hill diarrhea as described
by Indian authorities. Finally, I include, as a further
division of incomplete sprue, under the name of
“ tongue sprue,” cases occurring in all races, in whom
the typieal tongue and mouth symptoms are present,
though the disease process does not appear to have
spread beyond the buccal eavity.
Typical or Complete Sprue.—The earliest symptoms
varied widely in different patients; in the majority
the onset was insidious; in only four eases could I
elicit the occurrence of an acute diarrhoea, merging
later into a more chronic form. In eleven cases
tongue symptoms, in two persisting for three years
before the commencement of the diarrhea, were the
only two indications of the onset of sprue.
It is important to notice the absence of any history
of the occurrence of buccal aphthe in four cases, two
of which were seen daily during the terminal stages
of their illness.
In advanced stages of the disease, in which there
was also marked anemia, curious pigmentations of
the skin, consisting of brown patches of irregular out-
line, were present, and were situated on the forehead,
temples, cheek, on the abdomen, and once on the legs.
Apparently this pigmentation is associated with the
anemia, as the patches disappeared on treatment and
directly an improvement in the general condition of
the patient set in.
Incomplete Sprue.—In seven cases, four in men and
three in women, the stools were typical, but in no
single instance could any abnormal appearance of the
tongue be detected. In one patient these symptoms
had persisted for twelve years. Twenty-one cases
had chronic diarrhea with large, bilious, frothy
stools, but no tongue symptoms. Cases of this
description occurred in old residents as well as in
new arrivals to the colony, and originated in all parts
of the island. I was quite unable to find epidemics
of diarrhæa corresponding to the hill diarrhaa of
India.
Tongue Sprue.—A quite distinct and definite disease
of the tongue is met with in Ceylon. The changes,
atrophy of the papille, and superficial fissuring
observed in these tongues are characteristic of the
sprue tongue. I met with seven such cases in the
Europeans who had for many years suffered with
these mouth symptoms alone, and who had ‘never
had any diarrhea. As a further evidence of regard-
ing this condition as being a local manifestation of
sprue, I can quote four cases in which the sore
tongues developed while the patients were living in
close association with typical cases of the disease.
This condition is also found in the burgher com-
munity, where I met with numbers of cases occurring
in the same family, and also commonly among the
Singhalese prisoners and the Tamil estate coolies; the
majority of cases tested gave n negative Wassermann
reaction, indicating that specific disease plays no part
in the production of these tongues.
Although I am inelined to regard this "tongue
sprue ” as being a distinct affection of the tongue and
of the same nature as the typical disease, yet one
must bear in mind that an atrophy of the lingual
papille is found in other diseases, especially those
characterized by ansemia, chlorosis, ankylostomiasis,
and chronic malaria.
The process of destruction of the papillae can easily
be watched in the sprue tongue, after the subsidence
of a localized inflammation, but should the case run
a favourable course and recovery ensue, the papille
are regenerated, as I actually observed in one case.
As a result of these studies, and basing my con-
clusions on clinical grounds, the evidence suggests :
a) that the destruction of the papillz in sprue and in
these sore tongues is of the same nature and caused
by some active process, probably by some specific
micro-organism, a view supported by pathological
evidence, whereas (b) the atrophy of the papilla in
the anemic diseases previously mentioned is of a
passive nature, engendered by some general nutritional
change common to these diseases, a view also borne
out by pathological evidence.
INVESTIGATION ON THE CLINICAL PATHOLOGY
OF SPRUE.
The typical colour, or lack of colour, of sprue stools
is to be ascribed partly to the farinaceous diet on
which the patients are fed, partly to a colourless
reduction product of hydrobilirubin—called leuco-
urobilin—and partly to the abnormal percentage of
fat they contain.
The conversion of hydrobilirubin, the normal fecal
pigment, to leucourobilin (Nencki) is apt to take place
in the absence of the normal pancreatic juice, and
therefore also occurs in malignant disease of the
pancreas, and also, according to Mayo Robson, in
chronic pancreatitis, in which disease the stools
resemble both in size and colour those of sprue. The
alcoholic extract of a colourless sprue stool soon
becomes oxidized to a yellow colour on exposure to
sunlight, and when this change has occurred the
typical hydrobilirubin spectrum becomes visible. In
the liquid stools passed immediately before death and
July 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
205
also in the acute diarrheie stools I was able to
demonstrate unaltered biliverdin; besides, the gall
bladder in all the six sprue post-mortems I performed
was filled with normal amber-coloured bile; any
abnormal chemical change in the composition of the
bile pigments must therefore take place during the
passage of the fæcal matter through the intestinal canal.
I need hardly say that the size of the sprue stools
requires a little explanation; that it is due to the
lack of absorption and digestion of certain bodies,
such as fats and carbohydrates, there can be little
doubt, as is evidenced by the immediate progressive
diminution in the size of the stools which take place
immediately a progressive increase in the patient's
body-weight is noted.
The fat absorption, that is, the proportion between
the fat ingested and the amount excreted in the feces,
was found to vary in my cases between 70 to 90 per
cent., whereas in milk-fed normal subjects it is over
95 per cent.
The complete absence of any traces of pancreatic
ferments, such as trypsin, which is found in normal
stools, is a further peculiarity which I ascertained to
occur.
All these various characteristics of the sprue stool,
their acid reaction, large size, high proportion of un-
digested fats and carbohydrates, absence of pancreatic
ferments, their similarity to those of ascertained
pancreatic disease, indicate either an inefficiency
or a complete absence of the pancreatic ferments in
sprue.
Observations on the urine showed little of import-
ance. The somewhat rough estimations on the pro-
teid content of ingested milk indicate that the urea
in sprue is of exogenous and not of endogenous origin,
that is to say, not derived from any excess of tissue
metabolism. An indicanuria in sprue has been
advanced as a diagnostic point, but it is to be ex-
pected, seeing that its presence is dependent on the
amount of intestinal putrefaction. Cammidge’s re-
action, on which great stress has been laid of recent
years by Cammidge himself and by Begg as indicating
some pancreatic lesion in sprue, was performed in
twenty-seven sprue urines, but always with a negative
result.
The saliva was found to be invariably acid and,
especially in cases with acute tongue lesions and
those in the last stages of the disease, with a visible
growth of thrush in their mouths.
It was interesting to note that the reaction of any
individual inflamed fungiform papilla was invariably
acid to litmus paper.
The gastric juice has been investigated by Van der
Scheer, who found a hyperchlorhydria in the majority
of cases, a hypochlorhydria in others. I had only
one opportunity of making such an analysis, and
found free hydrochloric acid present to the extent of
4 per cent.
Blood.—A grave degree of angmia was only found
in the most advanced cases. I have recorded a fatal
case in which the number of red cells never fell below
3,900,000 per c.mm., and at the autopsy a hemoglobin
percentage of 80 was found.
THE MORBID ANATOMY AND PATHOLOGY OF
SPRUE,
It is necessary to eliminate all factors conducing
to post-mortem changes, especially in such a delicate
structure as the intestinal mucosa. In the Tropics,
in the absence of any suitable refrigerating apparatus,
post-mortem changes made themselves apparent, more
especially in the intestinal tube, with disconcerting
rapidity. In making the two autopsies described in
this paper, every precaution has been taken to ward
against post-mortem decomposition. The tissues were
removed as soon after death as possible (two hours
at the maximum) and immediately fixed in 4 per cent.
formalin.
The bodies presented the external appearances of
starvation ; there was a complete absence of subcu-
taneous and body fat; the muscles were dark brown
in colour; the heart small, dark, and atrophied; in
fact all the organs exhibited the same proportional
degree of wasting, and weighed less than half their
normal weight; this is especially the case with the
liver (24 oz.), the spleen (14 oz.), and the pancreas
(14 oz). The liver was yellow and fatty, bile-stained
in one case; the gall-bladder full of bile.
There was a great absence of fat in the great and
small omenta, and appendices epiploice; in the
abdomen the most noticeable feature was the trans-
parent and distended ileum; no intestinal ulceration
was found; the whole of the intestinal canal was
covered with a layer of ropy mucus; the tongue was
covered with a film of thrush; only the base of
the fungiform papilla could be distinguished; the
esophagus was covered with a yellowish substance
resembling a diphtheritic membrane, composed almost
entirely of yeast fungi; the bone marrow was dark
red in colour and exhibited no peculiar features,
either macro- or microscopically.
In smears of the liver from one post mortem a few
yeast cells were seen, and in preparations of the
intestinal mucus, stained by Gram’s method, from
every part of the intestinal tube, great numbers of
cells and branching mycelium were found—in fact
they were by far the most abundant organisms.
Yeasts were grown in glucose broth from every
part of the intestinal canal, also in one case from the
liver and spleen, and from the kidneys in the other,
but in addition to these, cultures (made by means of
a syringe) from the heart’s blood yielded a growth of
B. coli, apparently of two varieties, most probably
denoting a secondary and terminal infection. Great
interest centres in the microscopical structure of the
intestinal canal; the stomach appears normal, but
the remainder of the intestinal tract from duodenum
to rectum exhibited chronic inflammatory changes ;
in the small intestine the villi are quadrangular in
shape and shrunken; the columnar surface epithe-
lium is for the most part preserved, but the cells
stain badly, and the nuclei can with difficulty be
distinguished ; it is possible that a certain amount
of epithelial destruction took place during the last
few days of life, as both patients were comatose for
ten days or more before death.
Of the other organs examined, the condition of the
206 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1914.
liver and spleen only calls for special attention. The
cells of the former have undergone fatty degeneration
and contain a few granules of free iron, though this
reaction is by no means so well marked as in per-
nicious anemia; in the spleen there are certain
hyaline bodies, probably of a degenerative nature,
in the swollen endothelial cells of the venous sinuses,
which I believe to be pathognomonic of sprue. I
would impress on you that this is a well considered
statement, as 1 found these bodies in all the six sprue
spleens I have examined, but not in those of other
diseases, of which I have examined forty-three in
all, of ankylostomiasis, malaria, pernicious ansmia,
lymphatic and splenomedullary leucocythemia, kala
azar, trypanosomiasis, filariasis, amoebic and bacillary
dysentery, &c., as controls.
The bodies are of a small size and show no affinity
for fuchsine, and are Gram-positive. By Giemsa they
attain different shades of pink, violet, or blue; the
cells in which they are situated are swollen almost
to bursting point, and their nuclei cannot be dis-
tinguished ; the absence of any differentiation in
their strueture and the lack of surrounding tissue
reaction negatives their parasitic origin. As to their
exact nature, I have been unable to reach any definite
conclusion, but I am inclined to regard them as being
possibly produced in response to the extensive yeast
infection found in sprue. In support of this view I
can adduce but one fact, namely, that bodies giving
the same staining reactions were present in the
capillary endothelium of a rabbit's liver after intra-
venous injection with yeast isolated from a sprue
saliva, but a similar degeneration of the spleen could
not be produced by these means.
These bodies must be distinguished from other
Gram-positive but acid-fast bodies, identical with
Russell’s bodies, which are commonly found both
lying free and in the interstitial cells of the sprue
issues, especially in the alimentary canal, but this
is not their only situation, as they are found in many
other organs; nor are they to be regarded as distinc-
tive of sprue, as I found them commonly in anky-
lostomiasis, malaria, and tubercular tissues. Russell’s
bodies were at one time considered to be protozoal
organisms and the cause of tumour growth, but they
are of further interest to the tropical pathologist as
they have been described as an organism—Botromyces
ascoformans (Bollinger, 1869)—and have been described
by Archibald in botromycosis, an actinonyeotic disease
of horses and camels, sometimes found in man. My
investigations on this subject certainly suggest that
these struetures represent a hyaline degeneration,
and therefore cannot be regarded as representing
& parasitic organism.
EVIDENCE OF ASSOCIATION OF THE THRUSH
FUNGUS WITH THE SYMPTOMS OF SPRUE.
Intracellularly situated yeast cells and mycelial
elements were found in scrapings of the inflamed
tongues during the acute stage, and could be cultivated
in glucose broth from 50 per cent. of sprue tongues,
but only from 17 per cent. of normal tongues; in the
saliva they were commonly found in numbers by
direct microscopical examination in twenty-four
sprue cases, and could be cultivated in 55 per cent.,
but only in 35 per cent. of normal cases.
These observations on the abundance of yeasts in
the saliva are of importance in another direction. In
the last few years Castellani has published a number
of papers on a tropical respiratory disease termed
by him, variously, tropical bronchomycosis, broncho-
blastomycosis, bronchoidiosis, and bronchomoniliasis.
The subjects of this infection are said to exhibit
symptoms of a subacute bronchitis, resembling tuber-
culosis, and called by him “tea factory cough”; he
has, however, failed to find tubercle bacilli, but has in
some cases found numbers of yeast cells in the sputum
on microscopical examination. In others in which
they were less numerous he was able to isolate them
on culture. So far he has adduced no evidence,
either by post-mortem or microscopical examination,
that any invasion of the bronchi or the lungs by these
yeasts has, in cases presenting these symptoms, in
reality taken place during life.
My observations on this subject certainly indicate
that these fungi are common saprophytic organisms
in the saliva of Europeans and natives in the Tropics,
and it therefore follows that their presence in any
given sample of sputum to which necessarily an
admixture of saliva has taken place does not
necessarily denote a pathogenic action on their part;
certainly none of my sprue patients on whom these
observations were made were suffering from “tea
factory cough" or had any physieal signs in their
chest.
In fresh preparations of the frothy, acid stools
passed during the early stages of the disease I saw
cells and some mycelial threads bearing a great re-
semblance to yeast cells and exhibiting an affinity for
iodine; there is no doubt that they are by far the
most predominant form of micro-organism in the
stools passed shortly before death, as I have found
them in great numbers in simple smear preparations,
and on culture yeast colonies formed 75 per cent. of
all organisms ; in the centrifuged deposit of sprue
stools, stained by Gram's method, a great number of
yeast cells were found in 72 per cent., but they were
only found in small numbers in 25 per cent. of normal
and amcebic dysentery stools treated in this manner;
by eultural methods yeasts were cultured from 58 per
cent. of sprue stools as against 29 per cent. of control
cases.
These figures by no means indicate the prevalence
of yeast cells in sprue stools, as in patients under
treatment I found I was unable to cultivate them once
the stools had become solid, though I was able to
do so from every case during the acute diarrhea
stage.
Although it is difficult, in view of the uncertain
nature of the whole subject, to draw any definite or
positive conclusions, yet I submit that these observa-
tions indicate that not only can yeasts be cultivated
from the majority of sprue stools and salivas, but
that in the acute as well as in the termina] stages
of the disease they are at least the most prevalent
July 1, 1914.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
207
organism in the tongue lesions, salivas, and stools of
victims of the disease.
Cultures from Aphthe—I can advance cogent
reasons for disregarding these buccal ulcers as being
an essential lesion of the disease. My reasons for so
doing are, firstly, that they are not present in every
case, not even in the two I observed which terminated
fatally; and secondly, that similar lesions are found
commonly in perfectly normal subjects presenting
no sprue symptoms whatsoever. I examined the
organisms found in these lesions, both in scrapings
and cultures, in ten instances; in these I found yeast
cells, but no mycelial elements; the Staphylococcus
pyogenes aureus and the Streptococcus brevis were the
commonist organisms found, and similar organisms
were isolated from buccal aphthe in normal subjects.
I consider, therefore, that they merely represent
a secondary and localized pyogenic infection of a
mucous membrane, the resistance of which has
already been lowered by the cachectic state of the
patient, or by a primary infection of the thrush
fungus.
A STUDY OF THE YEASTS FOUND IN SPRUE LESIONS
AND ATTEMPTS TO CLASSIFY THEM ON A
RATIONAL Basis.
The blastomyces, or yeasts, are distinguished from
the true fungi by their peculiar method of reproduc-
tion by gemmation. Some kinds, under adverse cir-
cumstances, reproduce by means of spores called asco,
or clamydospores, and they can be classified into two
main groups: (1) the Saccharomyces and (2) the
Torule, according to whether they form spores or not.
Amongst the former of these groups a third method
of growth by means of mycelial threads may also
arise, and according to the presence or absence of
this mycelium formation the Saccharomyces may be
divided into two sub-groups, the first of which may
be termed the Saccharomyces proper and the second
the genus Monilia, and it is to the latter that the
thrush fungus belongs.
In my attempts to classify the yeast fungi found
in sprue, and in order to compare them with other
yeasts, I examined 112 cultures obtained in Ceylon
from various sources; five were cultivated from
thrush lesions in infants, and were compared with
others from the mouths, stools, and post-mortem
tissues of sprue, and also with cultures obtained from
the air, from cow dung, from fruit, milk, and from
a baker’s yeast ; out of these 112 cultures 106 could
be classified in the genus Monilia, that is, that they
reproduced by spore and mycelial formation.
Evidence in favour of regarding Sprue as a
Blastomycotic Infection.
(1) Yeast cells and mycelial elements are found in
scrapings of the tongue lesions at an early stage of
the disease, and cannot be found at a later stage in
scrapings of the same structure when symptoms have
subsided.
(9) Yeasts are the only organisms found in the
deep layers of the tongue in microscopical sections ;
the evidence that this infection is not one of recent
date receives support from the chronic inflammatory
changes in the corium of the papille, and from the
presence of Russell's bodies in this situation.
(3) The desquamation of the epithelial cells, accom -
panied by subacute inflammation of the tongue and
of the esophagus, are changes such as would be
expected from a study of the mode of growth of the
thrush fungus and of its low order of virulence.
(4) A general infection of the intestinal mucus with
yeasts was found in sprue post-mortems, but no such
general infection in twenty-six cases of other chronic
wasting diarrhceas.
(5) The stools of sprue, their frothy and gaseous
character, are such as one would expect in such a
blastomycotic infection of the intestinal canal.
(6) The relapsing nature, the chronicity and latency
of the disease, are such as one would expect from the
life history of the blastomyces, their periods of
attenuated growth and powers of sudden recru-
descence.
(7) There is no evidence in favour of regarding the
sprue yeast fungus as being otherwise than incidental
with the thrush fungus (Monilia albicans), an organ-
ism possessing a very low pathogenic power, but it is
possible that under certain conditions, as for instance
in the tropics, this power may be greatly augmented.
In support of this view I may add that it is a well-
recognized fact that there are endless varieties of
yeasts employed in brewing beer and in making wine,
and the predominance of one variety in certain dis-
tricts imparts to the local wine its characteristic
flavour, which, though differing widely from each
other in their powers of growth and fermentation,
yet resemble each other minutely in their morpho-
logical and cultural characters. May it not be that
their pathogenic as well as their other properties
are capable of being altered by local conditions ?
(8) Wasting and anemia, both symptoms of sprue,
can be produced by continuous intravenous injections
of small doses of a broth culture of a pathogenic
yeast; moreover, a degeneration of the hepatic
capillary endothelium, apparently similar to that
found in the sprue spleen, may be produced in these
animals by the same means.
(9) Diarrhoea, atrophy of the lingual papille as in
sprue, digestive disturbances, and an aphthous ulcera-
tion of the mouth are commonly found in infants, the
subjects of thrush infections in temperate zones.
(10) It is possible that obscure diseases of the
alimentary canal in children in temperate zones, such
as Gee's cceliac diarrhoea, are of the same nature as
sprue in adults in the tropics. A hypothesis of this
sort would explain the occurrence of sporadic cases of
sprue in temperate zones.
(11) The local affection of different portions of the
digestive tract with this fungus would best explain
the varying clinical manifestations of sprue.
(12) To maintain such a hypothesis it is necessary
to stipulate for a third factor, a predisposing cause,
which may exist in the local tropical climatic con-
ditions, which favour a more precocious and luxuriant
growth of all the fungi, a matter of common observa-
tion to all laboratory workers in the Tropics.
208
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1914.
ee a a ee Te? Ee ee
T M —————MH—M———————————————————————
Evidence against regarding Sprue as a Blastomycotic
Infection.
(1) The thrush fungus (Monilia albicans) is a
terminal, though uncommon, infection in other chronic
wasting diseases, such as phthisis, cancer, diabetes, &c.
(2) General infections of the alimentary canal with
this fungus have been reported in temperate zones.
(3) If the geographical distribution of sprue be
eventually found to correspond with that of other
typical tropical diseases, such a fact alone is in favour
of a protozoal, rather than of a fungoid or bacterial,
origin of the disease.
CONCLUSIONS.
(1) Sprue is a specific disease of tropical and sub-
tropical countries, though it is possible that cases
occasionally originate in temperate zones.
(2) It is a disease prevalent in Ceylon, especially
amongst the Europeans, but contrary to the opinion
hitherto held, it may also occur in the native, irre-
spective of race or mode of life.
(3) This fact, together with the occurrence of the
disease in people closely associated, suggests a local
influence or some communication from man to man.
(4) Sprue is a variable disease; it may occur in a
mild or in a particularly virulent form, and in common
with many other serious diseases, it is sometimes
liable to sudden remissions and latent periods.
(5) There is evidence that the disease may occur
as distinct and specific clinical forms according to the
portion of the alimentary canal attacked.
(6) Researches on the composition of the stools
point either to a complete absence or insufficiency of
the intestinal digestive ferments.
(7) Researches on the blood and urine are in
favour of regarding sprue as an alimentary toxemia.
(8) The pathological findings are also in favour of
this supposition and point to an infection with the
thrush fungus (Monilia albicans) as being the organism
concerned in its production; the evidence is, on the
whole, in favour of rather than opposed to this view
ENS eS |
Review.
TROPICAL DISEASES: A PRACTICAL HANDBOOK. By
H. C. Lambart, M.A., M.D., &e. With 6
coloured plates and 82 other illustrations. Pp.
xv + 324. London: Charles Griffin and Co.,
Ltd., Exeter Street, Strand. 1914. Price
8s. 6d. net.
This book is intended as a manual for medical men
and students, and is so arranged alphabetically that
it shows at a glance the diagnosis and treatment of
the principal tropical diseases. The subjects are
treated in the simplest manner possible, the pages
being nowhere encumbered with disputed points or
unsolved theories, its main object being to supply
the readiest reference.
The author has spent many years in the Tropics
and has evidently made the most of his time.
Although the descriptions of the various diseases are
brief, they are to the point and cannot but be of
great assistance to any practitioner who is just
starting work in the Far East.
Aids to diagnosis, bacteriological methods, special
diets, eye diseases, geographical distribution, fevers
and skin diseases are grouped under separate sections
and special attention is given to treatment. The
therapeutic index, with prescriptions and lines upon
which treatment should be based, has been brought
up to date.
The type is good and clear, and the illustrations,
many by the author himself, satisfactory. This little
manual can be thoroughly recommended to anyone who
has to get up a working knowledge of tropical diseases
within a limited time; especially those who want a
purview of the subject when commencing a course
of lectures.
—— Sg
Correspondence.
KURLOFF'S BODIES.
To the Editor of TRE JouRNAL or TnoPICAL MEDICINE.
SiR,—I beg to correct two misstatements about me
that were published in THE JOURNAL OF TROPICAL
MEDICINE of May 1 and May 15 last respectively.
In your issue of the former date it is stated that two
workers in India have shown that Kurloff's bodies
are granules, &c. The article implies that this dis-
proves my recent work on the subject which shows
these bodies to be parasites. Such an implication is
untrue. The parasitic nature of these bodies has
now been proved. They have been transferred
naturally through several generations of guinea-pigs,
develop into spirochetes, and pass through the
placenta. An allied species of parasite produces
disease in rabbits, has been passed artificially from
rabbit to rabbit, and has been inoculated into
monkeys, producing death. The same parasites have
been recovered in the monkey. And thus Koch's
postulates have been fulfilled showing these bodies to
be disease-producing parasites.
In your issue of May 15, it was stated that I have
been conducting a campaign against house flies in
New York. This is incorrect. I have never been to
New York. The statement originated in a letter of
mine published in The Times of January 31 laste
This letter pointed out that a successful campaign
bad been conducted in a part of New York by Dr.
Donald Armstrong, of the New York Association for
Improving the Conditions of the Poor. Apart from
this letter, I have had no hand in the campaign.
I beg that you will publish this correction so that
justice to the real organizer of this excellent work
may be done. Yours faithfully,
E. HALFORD Ross.
The John Howard McFadden Researches
at the Lister Institute.
[It is bardly likely that “E. H. Ross, of New
York," should be taken as meaning Dr. Halford Ross,
of the Lister Institute of Preventive Medicine,
Chelsea Gardens, S. W.— Ep. T.M.!
We hear with great regret, as we go to press, of the
death of Mr- Joseph Chamberlain. -
July 15, 1914.1] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 14, Vol. XVII.
Original Communication.
ANKYLOSTOMIASIS IN THE NORTH NYASA
DISTRICT.
By A. G. ELDRED, M.R.C.S., L. R.C.P.Lond.
Medical Officer, Karonga, Nyasaland.
DURING the latter part of the year 1911 a severe
case of ankylostomiasis was reported from Vua, in
the North Nyasa district. This particular helminth
had previously been recorded in various parts of
Nyasaland, but there were no general statistics of the
percentage of natives infected, &c.
In view of the fact that Vua was expected to
become the centre of the cotton growing industry
in the North Nyasa district, and that ankylosto-
miasis might prove to be the reason for the difficulty
in obtaining efficient local labour, it was decided to
investigate the matter more thoroughly.
During the few weeks that I was stationed in
Karonga, early in 1912, there was no time for a
thorough investigation, but the cases I found then
led me to suggest that the infection was not limited
to Vua, and that probably a systematic examination
of the general population would show a large pro-
portion to be infected.
A report by the Medical Officer of Karonga in
1912 (Dr. Conran) showed that at least 41 per cent.
of the population were infected. It was decided to
continue the investigation, and to enforce such pro-
phylactic measures as were practicable.
A total of 1,500 natives have been examined during
the past seven months, all infected individuals given
treatment one or more times, and such prophylactic
measures as were practicable and possible under
existing conditions carried out.
(A) DESCRIPTION OF DISTRICT.
(1) Physical Features.—North Nyasa consists of
two distinct portions: (1) A narrow strip of almost
entirely fla& country at the lake level (1,500 ft.),
about 10 miles in width and 70 miles long, bounded
on the east by the lake and on the west by the
mountains. Directly on the lake shore, and for a mile
or two inland, there are numerous villages, but as the
hills are approached the population becomes scanty,
except near the larger rivers. Along the lake shore
and often for half a mile or more inland the soil con-
sists of pure sand, and more inland of more or less
sandy earth. On this sand or sandy earth the
majority of the villages are built. There are numerous
rivers and streams, but all except four or five are dry
in this area for at least nine months in the year.
There is no thick forest, but a profusion of small
trees and scrub scattered about on the grassy plains.
In and around the villages are thick banana groves.
During the rainy season (December to April) this
flat country is in many places waterlogged, and during
this period the population in such areas move a short
distance away to some slightly higher and drier spot,
returning to the original site after the rains. The
people derive their water supply from either the
lake, the rivers, or from water holes and wells.
(2) A mountainous portion composing the remainder
of the district, thinly populated, well wooded in many
places, and with a soil consisting largely of coarse
gravel.
The percentage of ankylostome infection has been
shown by Dr. Conran to be highest in the lake
level area.
(2) Inhabitants.—The great bulk of the population
at the lake level consists of Ankonde, or allied people.
There are also settlements of Henga, a hill tribe, of
Awemba, originally from Rhodesia, and some so-called
Swahili. The principal hill tribes are the Henga, in
the southern portion of the district; the Poko, on the
Nyika plateau, and the Misuku, in the north-west
portion. The Ankonde, the original inhabitants of the
lake level area, are a peaceful, cattle-breeding race;
their one purpose in life appears to be the well-being
of these cattle. Their food consists principally of sour
milk and bananas, possibly a valuable diet in an emer-
gency, but as staple articles of food not calculated to
produce a race of virile workers.
There appears to be no doubt that the Ankonde are
inferior to the Ahenga, Awemba or Swahili as workers,
and it was thought that ankylostome infection might
be the reason.
(B) PROCEDURE ADOPTED.
(1) It has been shown that the usual route of
infection in hook-worm disease is through the skin,
infection being acquired by walking over infected
ground containing embryos which have developed
from the ova voided with the fæces. It is therefore
evident that any campaign against such a disease, to
be permanently successful, must be very thoroughly
carried out; treatment of a small percentage of the
infected individuals in one local ty, though tem-
porarily benefiting a few, will noti go far towards
eradicating the disease in the community, nor is
treatment of much avail unless very efficient sa
precautions are taken by the people generally ; *fo
if these are neglected, reinfection will almost X.
tainly take place, the condition of things becomes es
bad as before, and time and money have only beén
wasted. Consequently, the only efficient way to deal ,
with the question is to systematically work throug
each village, examining every individual in it, treating
the infected ones and at the same time establishing
proper latrines and sanitary reforms generally in
these villages. "With this object in view the follow-
ing action has been taken :—
(a) The chiefs and headmen of the various villages
have been called in before the Resident and Medieal
Officer, and the nature of the disease and the pre-
ventive measures to be adopted explained to them.
They have been shown the type of latrine that should
be adopted.
(b) A systematic examination of every individual
in the surrounding villages is being carried out.
(c) Printed notices in the Wankonde and Ahenga
languages, explaining in simple terms the nature of
the disease, and the precautions to be adopted, have
been printed and circulated.
"1
\
p
210
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 15, 1914.
(2) Difficulties in the way of affecting a rapid Im-
provement over a large Area.—lIt has, I understand,
been suggested that a 25-mile radius from Karanga
should be taken, and this area dealt with first.
I should like to take this opportunity of pointing
out a few of the difficulties that are to be encoun-
tered in dealing with such a disease as ankylosto-
miasis in a native population, and without a large
staff of workers and especially in such a district as
this, where the population is extremely scattered, and
where, owing to this and to the nature of the district,
travelling takes up a large amount of time. These
difficulties are caused by :—
(3) Time involved in Diagnosis and Treatment.—
The diagnosis and treatment of ankylostomiasis
necessitate the following procedure:
(a) A microscopic examination of the feces for ova.
(b) A clinical examination of infected individuals.
(c) Anthelmintic treatment of these individuals.
To be thorough re-examination and, if necessary,
further treatment should be undergone in a week or
two. In regard to (a) I am at the present time
examining slides at the rate of 20 to 24 per diem, and
find that this is the maximum average that can be
maintained by one worker if each slide is thoroughly
examined and when various other duties are included,
such as the clinical examination and treatment of the
infected individuals, and inspection of villages.
As the sphere of action widens, the time taken up
in travelling and inspecting will probably lower the
above average, but, assuming that one worker could
continue to examine slides at the rate of 400 to 500
a month, and the population of the whole of North
Nyasa being over 38,000, we get the following
results :—
One worker would take over seven years to com-
plete the examination of the whole district, and over
three and a half years to complete the examination of
the inhabitants of the 25-mile radius where the popu-
lation is estimated at nearly 19,000.
(b) is merely a question of time involved, but is
advisable.
(c) is important for the following reasons :—
The curative treatment of hook-worm disease does
not consist in merely handing out a dose of medicine
to each individual who is infected, but requires four
separate administrations of two or more rather un-
pleasant and in some cases dangerous drugs ; during
which period of administration it is necessary that no
food, very little liquid, and in the case of thymol or
beta-naphthol no alcohol, should be taken. Moreover,
& large proportion of the infected individuals only
eomplain of minor symptoms, and many deny having
any symptoms at all; consequently it is probable
that they will seldom follow out the above treatment,
except under supervision.
An alternative method of treatment would be to
dispense with the mieroscopie examination, and to
dose every individual who complained of symptoms
that might be due to ankylostomiasis. This could be
fairly rapidly done by training several natives in the
prominent symptoms to be sought for, and in the
method of administering the anthelmintic; such a
haphazard course is open to obvious objections, and
many cases would be missed.
(4) The Existing Type of Villages.—The main
population of North Nyasa is not contained in a
series of large villages or towns, but scattered over
the 4,000 odd square miles which comprise the
district are a multitude of tiny settlements, often
consisting of only a hut or two, separated from
neighbouring ones by several hundred yards, while
possibly sixty, eighty, or more of these huts go to
make up one of these so-called “ villages." There
are of course a certain number of large and compact
villages, but these are in the minority. As long as
these villages remain as they are it will not be possible
to establish a satisfactory system of public trench
latrines, for it is certain that in such a scattered
community they would not be used by the majority,
and the present alternative is a latrine for almost
every house, rendering the work of inspection much
more difficult, and the probabilities of the ground
near the huts becoming infected much greater.
(5) Areas dealt with—In view of these facts the
following procedure has been adopted :—
A small area has been taken in hand, with the
object of thoroughly dealing with it. This area
consists of a strip extending inland from Karonga
for about 10 or 12 miles, and for about 15 to 20
miles north and south. This strip contains roughly
14,000 people in an area of 400 square miles, or
35 inhabitants to the square mile, whereas a 25-mile
radius from Karonga contains about 19,000 people
in an area of 1,000 square miles, or only 19
inhabitants to the square mile. In this way a small
area can be fairly satisfactorily dealt with, and at the
end of a year re-examination would show whether
sufficient improvement had resulted to justify a
campaign on a large scale.
(C) CURATIVE MEASURES.
Practically all the people in the immediate vicinity
of Karonga have now been examined and treated, and
also as many cases as possible in the area mentioned
under C. Stray cases in the dispensary, and such as
have been found while inspecting the district, have
also been treated. All infected individuals have been
given one course of treatment, either with beta-
naphthol or eucalyptus oil It was obviously im-
possible to re-examine every case, but from nearly
100 cases that I was able to re-examine it is evident
that one course of treatment is frequently inadequate.
(See Table IX.)
Very little desire is shown by these people to come
up for treatment, and in most eases they refuse to
accept re-treatment, their symptoms being slight or
nil, but in order to try and induce them to do so à
ticket has been given to every case of ankylostomiasis
found, and the recipient informed that on presenting
this ticket at the Karonga Dispensary free treatment
is available. It is possible that in this way any
cases which at some future date may develop severe
symptoms may be got hold of and cured. As has
already been shown it would take years to examine
the whole population for ankylostomes.
July 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
211
a ——X——
(D) PREVENTIVE MEASURES.
These have been conducted on the lines detailed
under (C), (1), (a), (b), and (c).
Notices have been sent to all the chiefs and head-
men in the area, and to a great number in the rest of
the district.
I have inspected a large portion of the district and
it is now possible to say that latrines have been built,
andare at present being used, and the sanitary con-
dition of the villages is in general better. As several
people have said, it is now possible to camp outside
a village on sites that were before impossible owing
to the insanitary and promiscuous habits of the
inhabitants.
In the Henga Valley, and in other parts of the
hill district, the latrines either had been built or were
built before I left the village, but opportunities for
the inspection of villages 100 miles or more away &re
naturally rather rare. With regard to the type of
latrine that has been adopted, not only is the shallow
trench latrine not advisable, but it is very difficult to
induce the native to adopt any form of public latrine,
nor are the villages at present adapted to such a
thing. Consequently, nearly every family has its
own little private latrine, & pit about 4 to 6 ft. deep,
with a thatched roof. Until the villages are concen-
trated it will be advisable to allow those private
latrines to be used, but with a properly planned-out
native village, the best arrangement would be one or
more deep trench latrines for each village, according
to requirements. The Village Ordinance of 1912 is
now applied to the North Nyasa District, and this
will certainly render it easier to insist on sanitary
measures being adopted.
(E) RESULTS OF INVESTIGATIONS.
(To be read in conjunction with the tables.)
Tables I and II.—The 1,500 people examined were
of all ages and both sexes, from all parts of the lake
level area, and from a portion of the hill area.
The primary object of the investigation was the
finding of ankylostomes, and as a rule other helminths
were merely noted when seen; consequently, as will
be observed by reference to Dr. Conran's Report, the
actual percentage of other helminths therein noted is
higher than appears in these tables.
In certain villages, to be enumerated later, the
correct bilharzia percentage was taken, and the
bilharzia percentages given in Table VI are correct.
Strongyloides are not included, as in many cases
by the time the specimens were examined the stools
were from four to six hours old, and though rhabdite
embryos were sometimes seen, it was always in
association with ankylostome ova; so it is possible
that those embryos were those of ankylostomes.
Trichocephalus appears to be most prevalent in the
north-east part of the district, in the Songwe River
area, and a very large number of the cases of ascaris
infection were also found in this part (32 per cent. in
one village). The Songwe is the rice growing area.
Table III.— Villages 1, 2, 3, and 13 are built
almost directly on the lake shore, 4 to 9 and 12 are
from one to three miles inland, 10 is about six miles
inland in the marshy country near the Songwe River,
and 11 are villages about eight miles inland near the
foot-hills.
The Henga Valley is in the southern part of the
district at an elevation of about 3,000 ft.
The Bilharzia percentage is correct for numbers
1, 3, 4, 5, 7, 8, and 12.
Table IV.—With the exception of the hill Henga,
the tribes mentioned were living at the lake level.
The relatively low percentage in the Ahenga living
at lake level is in part due to the comparatively small
number examined, and the fact that they lived in an
area where the percentage for other villages was low.
Table V.—This shows the liability to infection at
various periods of life. Owing to the usual route of
infection, through the skin of the feet or legs, it is
only natural that in actual infancy (i.e., before the
child can walk) the percentage of infection should be
low. Once infancy is passed the age of the indi-
dividual has very little influence on the liability to
infection, and the same holds good in regard to sex.
Table VI.—The soil of the lake level area is, in
and around most villages, either pure (in the geo-
logical, not the sanitary sense) sand or sandy earth,
as already mentioned. Now the percentage for
villages in general directly on the lake shore is
40 per cent., and for villages a mile or so inland is
48 per cent., so that at first sight it would appear
that soil and water do, in the lake area, influence
the percentage slightly. But on reference to Table
III, we find villages Nos. 1 and 3, both built on
exactly similar sites, directly on the lake shore, and
on sand, with such widely different percentage as
56 per cent. and 27 per cent. It would appear that
soil and water supply have not much bearing, one
way or the other, at the lake level. It is probable
that the lower percentage in the hills is due in some
degree to the totally different nature of the soil.
Table VII is an analysis of the symptoms usually
met with. The various symptoms enumerated were
found to occur either singly, or two more in
conjunction.
Gastro-intestinal.—Including pigmentation of or
purple streaks on the tongue, colic, epigastric pain,
diarrhea.
The changes in the tongue were found just as
commonly in the uninfected native.
Diarrhoea, when complained of, was said to take
an intermittent form, lasting a few days, and then
disappearing for weeks or months.
Dysenteric—In most instances, when blood was
actually found in a specimen, in a case of ankylos-
tomiasis, bilharzia ova were present.
Circulatory.—Irregular action of the heart, palpita-
tion, hemic murmurs, and in some cases evident
organic lesions, the latter probably not associated
in any way with the presence of ankylostomes.
Dilatation of the heart was very seldom seen.
Joint Pains.—The pain in the sternum, mentioned
by various writers, was sometimes complained of,
and often rheumatic pains in various joints. Joint
pains are, however, so often complained of by un-
212
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 15, 1914.
infected natives that this symptom is not regarded
as possessing much value.
Anaemia.—There were no facilities for obtaining
the true hemoglobin percentage in these cases, and
only a rough-and-ready test of anemia, by examining
the conjunctiva, could be applied. In a great number
of cases all symptoms were denied, and the only sign
of departure from normal that could be attributed to
ankylostome infection was a mild degree of anzemia.
Other symptoms, not included in Table VII:—
Ground Itch.— No reliance can be placed in any
past history of this in a native, who suffers from so
many lesions of the skin of the feet and legs; no
typical ground-itch rash was ever seen in a native,
though in the case of a European the presence of
the typical rash on the ankles gave the clue to the
disease.
Earth-eating, or Geophagy.—A small percentage
of both infected and uninfected acknowledged to this
practice, and it is probably quite a common one in
fact, though often denied. It does not appear to be
a regular or constant practice, and probably bears
very little, if any, relation to ankylostome infec-
tion.
Signs of Severe Infection, General Gidema, Extreme
Anemia, Muscular Wasting, dc.—Very few really
severe cases were seen, and no cases of arrested or
retarded development were observed. All the cases
seen during the last six months are being kept sight
of as far as possible, and up to now only one is
recorded as having died, a boy of about 8, with
extreme anemia, chronic diarrhoea, and edema. He
also had chronic malaria.
Examination of Specimens.—The number of ova
found was almost always small, often only one in
the whole slide, and very seldom more than four or
five. The number did not appear to bear any relation
to the severity or otherwise of the symptoms. The
specimens were examined by direct admixture with
water, as time did not permit of the centrifugal or
other methods being employed.
Table VILI.—From June to the middle of December
the rainfall is practically nil in this district, conse-
quently one would expect, as is the case, very little
variation in the percentage during these months.
Table IX has already been discussed under
Curative Measures.
Table X.—Explanation of terms :—
Carriers.—Individuals, usually of good physique
(for the native of this locality), denying illness, and
apparently in good health, and either showing no
symptoms due to ankylostome infection, or at most
a mild degree of anemia.
Mild Cases.—Of good or fair physique, in some
cases anæmia, and showing in a mild degree one or
more of the symptoms detailed in Table VII.
Moderate Cases.—Accentuation of the symptoms
found in the “mild ” cases, and including cases show-
ing evidence of circulatory changes, and obvious bad
health that might be due to ankylostome infection.
Severe.—In which there is every probability of a
fatal termination, with such symptoms as extreme
anemia, wasting, cedema, &c.
The remaining tables will be considered in the
concluding portion of the Report.
(F) REASONS FOR ASSUMING THAT THERE IS, IN
THIS PART OF THE PROTECTORATE, A RACIAL
IMMUNITY TO THE SEVERE EFFECTS OF
ANKYLOSTOME INVASION, AND THAT THE LACK
OF EFFICIENCY, AS LABOURERS, CANNOT IN
THE ANKONDE BE ASCRIBED TO ANKYLOSTOME
INFECTION.
In clinically examining every day a number of
natives whose fæces on microscopical examination
had shown ankylostome ova the mildness or even
absence of symptoms and the remarkable rarity of
severe cases soon became apparent, and made one
wonder whether ankylostomiasis was seriously affect-
ing the health of these natives as a community, or
even in the majority of cases as individuals, and also
whether the inefficiency of the Ankonde as a worker
could really be attributed to ankylostome infection.
It seemed advisable to attempt to settle the ques-
tion, both to avoid disappointment in the possibly
anticipated improvement in the working eapacity of
the Ankonde, and also because to deal thoroughly
with ankylostomes in such a district, and among such
a community as this, would be an exceedingly costly
and lengthy undertaking.
The method adopted has been to examine both
infected and non-infected individuals, noting their
general development, symptoms possibly caused by
ankylostomes, other diseases, mode of life, sur-
roundings, &c.
Table XI is for adults, and shows the results of
this comparison of infected and uninfected individuals.
Under general development they have been divided
into good, fair, and bad ; good indicates good develop-
ment and physique as represented by the native of
this district, and not of Africa in general. No one,
I imagine, would call the North Nyasa native a fine
type, as compared with other tribes and races. Of
course exceptionally fine men are seen from time to
time, but as a general rule, both intellectually and
physically, the type is anything but high.
Referring then to Table XI it is seen that as far
as general development is concerned, the presence of
ankylostomes has no effect. Again, with anemia,
circulatory changes, and joint pains, just as many
uninfected people show these changes, and so many
other diseases may produce these symptoms, for
malaria, yaws, syphilis, leprosy, and a host of chronic
ulcerations, all exist in this district. The pigmented
condition of the tongue is just as common in the
uninfected native. The presence of ankylostomes
evidently does affect the gastro-intestinal tract in
these people, but here again it must be remembered
that many of these cases are complicated by bilharzia,
and that digestive troubles are very common in the
uninfected native.
Tables XII and XIII.—It might be suggested that
the children were the sufferers, as is the case with
malaria in the native, and that, as adult life was
approached, an immunity to the severe effects of
ankylostome infection was established.
July 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
213
Table XII shows that this can hardly be the case,
and that malaria, the great factor of ill-health in
native children, has also to be taken into account.
Now, enlargement of the spleen, in children especially,
may fairly be ascribed to malaria, as ankylostomiasis
produces no special changes in the spleen, and
malaria causes ansmia.
Table XIII shows the spleen and ansmia-rate in
infected children; the deduction being that 59 per
cent. of children with ankylostomes are also infected
with malaria, 21 per cent. are normal, and the re-
maining 20 per cent. are suffering from a certain
degree of anæmia, probably not due to malaria, and
possibly due to ankylostome infection.
Other Facts.—As has been said, the average type
of native here is not particularly well developed, but
occasionally exceptionally fine men, comparing favour-
ably with the best type of African one could pick out,
are seen. Such men on being examined have in most
cases been found to be harbouring ankylostomes, and
it certainly could not be said that their health was
affected.
Thirty carriers were taken on a journey of 300
miles, and the capability of each individual as a
worker was noted. They were all examined for
ankylostomes, and 50 per cent. of them were found
to be infected; intestinal bilharzia was found in
33 per cent. The infected ones worked just as well,
and appeared to have just as much stamina as the
uninfected. Five of these thirty men were decidedly
better than any of the rest as workers, and three of
the five had ankylostomes.
The percentage of infection is just as high in some
other parts of the country. In the South Nyasa
district, for example, it is 44 per cent. and there is
there,as far as I know, no complaint about the
inefficiency of the native as a worker.
With regard to the Ankonde, reference to Table IV
shows that the percentage of infections is no greater
in them than in any other tribe. Moreover, they are
of no worse physique than the other local tribes, nor
do they show any more evidence of suffering from the
effects of the infection.
The capabilities of the various tribes as workers,
in order of merit, and their staple diet, are shown in
the following table :—
Tribe Staple diet
Awemba Maize, cassawa,
Ahenga Maize, millet, cassawa.
Swahili Rice, and occasional maize.
Ankonde Sour milk, bananas.
According to local employers of labour, the Ankonde
come a very bad last as workers. It is evident that
this cannot be due to ankylostomes, and it would
appear to be a purely racial reason, not due in any
way to disease. As has been suggested food may be
a possible factor. There is no special endemic area,
but ankylostomes are found in over 60 per cent.
(actual) of the inhabitants of the lake level area,
irrespective of locality or tribe.
The infection is no worse among the Ankonde than
any other local tribe, and the inferiority of the
Ankonde as workers cannot possibly be ascribed to
ankylostome infection. Of the infected individuals in
this district 31 per cent. show no departure from
health due to harbouring ankylostomes, and 27 per
cent. only a mild degree of anemia, that may or
may not be due to ankylostome infection; that is to
say, nearly 60 per cent. can fairly be classed as
“carriers.” Another 37 per cent. have only mild
symptoms, and though it is probable that they have
been harbouring ankylostomes for years, are not
suffering any serious inconvenience on that account.
Severe cases are extremely rare, for if existing in
any number, they must certainly have come to notice
in examining such a large number of people.
To put it in another way, if 1,000 infected natives
were examined, 580 would be found to be unaffected
by the presence of the parasite; 370 would hardly
know that they were affected, owing to the mildness
of their symptoms, forty-five would complain of ill-
health, though itis possible that this ill-health would
in many cases be due to other causes; and five would
be in a really bad state of health. In short, in spite
of over 60 per cent. of them being hosts of this worm,
very few seem much the worse for it. In other
words, there is here a very high relative racial
immunity.
However, there is no doubt that the native would
be better without his ankylostomes, and though it
does not appear to be necessary to enter upon a costly
and extensive campaign, much may be done on the
lines suggested by Dr. Conran in his Report. There-
fore, the aim should be to improve sanitary conditions
on the lines already suggested, and to treat such cases
as are obviously suffering from the effects of ankylo-
stome infection: in this way it is possible that a
gradual improvement will be effected; but to examine
and treat all the people in this district who harbour
ankylostomes would, unless about a dozen doctors
or microscopists were employed, be a most lengthy
business, and not of much value unless one could
ensure that reinfection would not occur. Before any
real and permanent sanitary improvement can be
effected there should be provided: concentration of
the villages, and sanitary inspectors to see that the
standard is maintained, that villages are built on
proper lines, and that the latrines are maintained and
used. These inspectors are, I understand, to be supplied
next year.
With regard to the concentration of villages, this
is one of the most important points, and, in every
instance where new villages are contemplated the
chief or headman should be required to notify the
resident, who, with the advice of the Medical Officer,
would give instructions as to site, type of village,
spacing of huts, water-supply, &c. A definite set of
rules for the planning-out of new villages might well
be drawn up.
The fact that a general exodus is unusual, the
inhabitants of the village drifting away a few at a time,
appears to be one reason for the scattered nature of
the villages, and may prove one of the difficulties to
be encountered in getting a better type of village
adopted. The existing type has been described, and
it is obvious that such a type can never be maintained
214
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 15, 1914
in a sanitary condition unless the inhabitants are
sanitary enthusiasts, which these certainly are not.
Unless otherwise stated, percentages refer to
ankylostome infection. “Infected” means ankylo-
stome ova found in the faces on microscopical exami-
nation. The percentages stated are the actual
percentage in which ankylostome ova were found,
and 20 per cent. should be added for error.
The slight difference in the percentages under
similar heads in Tables VII and XI is due to the
fact that about 100 of the people examined to com-
pile Table VII were not examined for Table XI.
TABLE I.
Number of people Nuniber
Parasite reader p infected Percentage
{44 lake
Ankylostome 1,500 s OBO? uL. 116 hills
Bilharzia .. Vide Tables II and III 245 ... 16
Ascaris e" iz 5s T 91 ... 6
Eae barton E ” ” Me Ah ask y d
Total helminths n 26s nip IDA "itio Da
TABLE II.
SINGLE INFECTIONS.
Ankylostome Bilharzia Ascaris Tricocephalus
Per cent, Per cent. Per cent. Per cent.
32 is 8 TT 17 f 0:5
DOUBLE INFECTIONS.
Ankyloston.e, Ankylostome, Ankylostome, Oxyuris, Bilharzia,
bilharzia ascaris trichocephalus ascaris ascaris
Per cent. Per cent. Per cent. Per cent. Per cent.
T2 ay CBB uu RO ar, OL v, 098
TRIPLE INFECTIONS.
Ankylostome, ascaris, Ankylostome, ascaris, Ankylostome, bil-
bilharzia trichocephalus harzia, trichocephalus
2:6 per cent. 0:2 per cent. 0:06 per cent.
TABLE III.
: Ankylostomo i
Village Wirtantaoe reuera
1. Mabuluki ... 56 per cent. 13 per cent.
2. Kasoti Wc 87 j es n:
3. Kaiyune .. aa 217-5, ioe dhe "x
4. Kanyol .. T 97 ,, sedg. 1
5. Mwahimba Vir 46 (Cs, 25 =,
6. Mwawembe itt 60, $a t ld
7. Mwanjawalo sis 39 ey .. 26 2
8. Mwafilaso... ads 93 ,, wet, dé 35
9. Mwakasungula ... 37 y, Ko di x
10. Mwangulukulu ... 50 (Cy, sex. Do. Jg
11. Mpata,Chungu,&c. 40-60 ,, e 430 2;
12. Simapoma an 40 ,, nz 40 .45
13. Vua $e "E 37 s$ "A —
Henga Valley ... ves 24 yy 9-5,
TABLE IV.
PERCENTAGE IN VARIOUS TRIBES.
Ankonde Awemba Ahenga Swahili Nyachusa Hill Henga
Per cent, Percent. Per cent. Percent. Percent. Per cent.
98-60 .. 60 .. 87 .. 56 .. 50 .. 24
TABLE V.
Infancy Childhood Adult life Old age
12 per cent. 47 per cent. 51 per cent. 41 per cent,
TABLE VI.
Percentage in relation Percentage in relation
to soil, vegetation, &c. to water supply
hee
Lake Villages Wells and
Parasite shore s mile or Lake Rivers water
villages more inland holes
Ankylostome .. 40 48 40 45 53
Bilharzia T 12 27 12 28 35
TABLE VII (EXCLUSIVE oF CHILDREN.)
Denying
Gastro- Anemia illness, and
intestinal and one showing no
exclusive — Dysen- Circu- Joint or more Anwmia symptoms to
of teric latory pains of pre- only be attri-
dysen- ceding buted to
teric symptoms ankylostome
infection
Percent. Percent, Percent. Percent. Percent. Percent. Percent.
3:5 15 T5 20 27 31:5
TABLE VIII.
Month Number examined Percentage infected
June ... iis 192 si 40 per cent.
July... 456 sis 52 ,,
August 312 $ 583 ,,
September 200 <3 46 ,,
October 210 263 49 ,,
TABLE IX.
After one course
of treatment with
eucalyptus and
chloroform mixture
After one course
of treatment with
beta-naphthol
Percentage still showing 42 per cent. 33 per cent.
ova on re-examination
TABLE X.
Carriers Mild cases Moderate cases Severe cases
58 per cent. 37 percent. 4'5 percent. 0:5 percent.
TABLE XI.
Percentage of individuals
showing one or more of the
symptoms detailed below
General development
————
A Gastro-
Circu- n Joint
Fair Bad latory Anemia se pains
Per Per Per Per Per Per Per Per
cent. cert. cent. cent. cent. cent, cent. cent.
Infected ... 70 28 15 17 34 20 55 18
Non-infected 68 31 10 18 37 11 6 17
TaBLE XII (CHILDREN).
Percentage of children
showing one or more of the
symptoms detailed below
Good Tongue
General developments
———
Circu. Gastro- Anemia, with or
Good Fair Bad lato intes- without enlarge-
TY tinal ment of spleen.
Per Per Per Per Per Per
ceut. cent. cent. cent, cent cent.
Infected ... 64 32 4 8 28 58
Non-infected 66 32 2 4 12 63
TABLE XIII.
Enlarged spleen, 1 Y
and anemia no anemia anemia no anemia
Per cent. Per cont. Per cent. Per cent.
38 sts 21 est 20 $$ 21
Enlarged spleen Spleen normal, Spleen normal,
ADDENDA.
(1) Helminthic Disease in Domestic Animals.
As a matter of interest, various domestic animals
have been examined, and a helminth allied to the
human ankylostome was found to exist in a large
percentage.
Sheep.—Of thirteen sheep from various parts of
the district, ankylostome-like ova were found in 51
per cent. These ova differed from the ova of the
human ankylostome as follows: larger, slightly more
ovoid, with a larger space between capsule and
nucleus; segmentation was further advanced than in
the human ankylostome.
Cattle.—Nery similar ova found in 10 per cent. of
ten cattle examined.
Donkeys.—Ova found in 80 per cent. of five
donkeys examined. Mature worms from a donkey
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, JULY 15, 1914.
LONDON SCHOOL OF TROPICAL MEDICINE.
45th Session. May —July, 1914.
Top Row Standing.—A. M. Williams, J. M. Stenhouse, C. T. Sibley, A. G. McPhedran, L. S. Holmes, N. S. Deane, C. K. arise D- E. Jones, G. L. Ritchie,
SES "m t Chellappah, D. R. Robert, W. J. Dixon, T. Bragg, E. F. Wills, D. P. “Goil (Capt. “LM. S.), A. G. Fletcher, O. H. Pinney,
main
Second Row Standing.—Robert McKay (Lab. Asst.), K. B. Dastur, R. B. Jackson, B. H. Wedd (Bacteriologist), C. Bonne, W. M. Strong, W. O. Pou
H. G. Waters, J. C. Watt, C. H. Bariow, W. Russell, H. K. Ward, N. Malon, W. M. Shepherd, A. C. Munro (Capt. I.M.S.), I. I. ‘Abdel
Rahman, D. C. de Fonseka, D. M. Gibson, G. Warren (Lab. Asst.)
Third Row Sitting.—J. S. Webster, A. C. eene (Capt. I.M.S.), P. Zachariae, R. K. Mitter (Lt.-Col. I.M.S.), G. W. Maconachie (Capt. I.M.S.),
C. Robson, H. B. Newham (Director), P. J. Michelli, Esq., C.M.G. (Secretary), Dr. C. W. Daniels (Lecturer), Sir Francis Lovell, C.M.G.
(Dean), Col. A. Alcock (Medical Entomologist), Miss O. N. Walker, F. W. O'Connor (Demonstrator), R. Roper, R. U. Sibley (Senr. Demonstrator).
Sitting on Ground.—S. Elias, J. Baeza, C. Sivasithamparam, J. V. Shirgaokar, M. C. Thavara, D. Stocker (Lab. Asst.).
Absent.—Miss M. I. Balfour, J. A. Beattie, J. H. Fenn, A. G. Eldred, M. F. Reaney (Capt. I. M.S.), D. Duff.
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON),
Under the Auspices of His Majesty's Government,
CONNAUGHT ROAD, ALBERT DOCKS, E.
In connection with the Albert Dock Hospital of the SEAMEN’S HOSPITAL SOCIETY.
THE SEAMEN’S HOSPITAL SOCIETY was established in the year 1821 and incorporated in 1833, and from time to time
has been enlarged and extended. It now consists of the Dreadnought Hospital, Greenwich, to which is attached the
London School of Clinical Medicine; the Royal Victoria and Albert Docks Hospital; the East and West India Docks
Dispensary; and the Gravesend Dispensary.
Over 30,000 Patients treated annually. Of this number many are Cases of Tropical Disease.
The School buildings are situated within the grounds of the Royal Victoria and Albert Docks Hospital.
MEDICAL STAFF OF THE HOSPITAL AND LECTURERS IN THE TROPICAL SCHOOL.
JAS, CANTLIE, Esq., M.B., F.R.C.S., D.P. H. EN MEE R. TANNERHEWI, DET. M.D., F. R.C.P. | Col. we J. PRATT, I.M.S., F.R.C.S.
M.
L. VERNON CARGILL, Esq., F.R.C.S. G. LOW, Esq., M.A., M.D. |; L. W. SAMBON, Esq., D.
E. TREACHER COLLINS, Esq., F.R.C.S. J. M. H. MACLEOD, Esq., M. D., M.R.C.P. | FLEMING MANT SANDWITH, Esq., M. D., F. R.C. P.
C. W. DANIELS, Esq., M.B., F. R.C.P., M.R.C.S. | Sir TA: MANSÓN, G.C.M. Gi F.R.S., LL.D., | Professor W, J. SIMPSON, C.M. :G., M. D., F. R.C.P.
KENNETH W. GOADBY, Esq., D. P. H.(Camb.), M.D., F.R.C.P. | H. WILLIAMS, Esq., M. D., M.R.C.P., D.P. H.(Camb.
M.R.C.S., L.R.C.P., L.D.S. R.C.S. |
Dean—Sir F. LOVELL, C.M.G., LL.D. Arthropodist— Colonel A. ALCOCK, I.M.S., C.I.E., F.R.S.
Helmintholo; ogist—R, T. LEIPER, Esq., D.Sc., M.B., Ch.B., F.Z.S. Protozoologist—C. M. WENYON, Esq., M.B., B.S., B.Sc.
Director— B. NEWHAM, M.R.C.5., LRC P., D. b. H., D.T.M. & H.(Camb.). Secretary—P. J. MICHELL I, Esq., C.M.G.
LECTURES AND DEMONSTRATIONS DAILY BY MEMBERS OF THE STAFF.
There are three Sessions yearly of three months each, October 1st, January 15th, and May 1st. A Course in Tropical
Sanitation and Hygiene is held in the October and May Sessions. Women Graduates are received as Students.
Certificates are granted after Examination at the end of each Session, and the course is so arranged as to equipment for the
D.T.M. Camb., the D.T.M. Eng., and the M.D. Lond., and by London University in Branch VI. (Tropical Medicine).
Fee for course £16 16s.; shorter periods by arrangement.
Students can be provided with Board and Residence, or partial Board, at the School.
Medical men requiring posts in the Tropics may apply to the Secretary at the School, where a Register is kept.
A syllabus, with the general course of study, cau be had on application to the undersigned, from whom further
information may be obtained.
Students of the London School of Tropical Medicine, who join the London School of Clinical Medicine, will be allowed
an abatement on their fees and vice versâ.
Chief Office—SEAMEN's HOSPITAL, GREENWICH, S.E.
July 15, 1914.]
are nearly twiee the size of the human hookworm,
but in essential details very similar. A drawing of
the male caudal bursa is shown in the illustrations.
While there is no doubt that this helminth is a
totally distinct variety from the human hookworm,
and no such ova were at any time found in humans
examined here, at the same time it is reasonable to
consider the possibility of humans becoming infected
by it; for if such infection occurred, the difficulties
ef prophylaxis would, in view of the large number of
cattle in this district, be enormously increased.
(9) Notes on some of the Prevailing Diseases in the
North Nyasa District.
Small-poz.—No cases of small-pox have been seen,
nor any outbreak reported. A good many cases of
blindness ascribed to small-pox are seen, and one fre-
quently sees natives, adults mostly, bearing the marks
of small-pox. A vaccinator is at work in the district,
and the natives are keen on being vaccinated.
Pneumonia.—These natives appear able to bear a
great deal of exposure without ill-effects, but quickly
succumb once they are attacked with pneumonia.
Tetanus.—One fatal case in a woman; no history
of previous injury or confinement.
Leprosy.—Several cases, mixed variety,
from the north end of the district.
Malaria.—Common. Anopheles mosquitoes are
found in all low-lying parts of the district, and the
nature of the country is most favourable for their
production. The spleen rate for children under 12
is, for the district in general, 60 per cent.
Tick Fever.—The tick, Ornithodorus moubata, is
found in the Henga Valley and near Fort Hill, and
probably occurs in other parts.
Syphilis.—Secondary and tertiary lesions are
observed, but no case of primary sore has been seen,
probably because the native does not appreciate the
need for treatment. There are many forms of dubious
ulcer that may be syphilitic, but a definite diagnosis
is often difficult.
Yaws.—This disease is fairly common, and typical
cases are seen, with definite primary and secondary
stages. Iodide of potassium appears to be the most
effective drug.
Filariasis.— Most of the cases seen have come
from the Songwe River area.
Eye Diseases.—A form of acute catarrhal conjunc-
tivitis is very common here in November and
December, and is probably infectious. Interstitial
keratitis is often met with. Cataract is hardly ever
seen.
Ear.—Otitis is very common in children, and is
very possibly a mycosis in many instances.
Digestive.—A severe ulceration of the gums and
mucous membrane of the mouth, leading to gangrene
in some cases, is fairly frequent. A spirillum and
various bacilli are found in the discharge. Various
intestinal disturbances are of course common, and
though in some cases evidently due to helminthic
infection often bear no relation to this, and are pro-
bably due to the diet of the native and to drinking
polluted water.
mostly
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
215
Skin.—Scabies and the various tinea are common ;
eczema, especially in children, and many varieties of
ulcer, including ulcus tropicum, ulcerating yaws,
specific ulcers, and ulcers due to neglected cuts and
scratches.
(3) Bilharzia Infection.
This infection, in the intestinal form as a rule,
is found in varying percentages all over the district,
especially at the lake level, but, unlike ankylostomiasis,
it is obviously affected by the nature of the water
supply. This is clearly shown in Table VI. Urinary
bilharzia was comparatively seldom seen.
An examination of the various water supplies, lake,
wells and rivers, failed to reveal anything in the
nature of an intermediate host. Two or three varie-
ties of lake and river fish on examination were also
negative. An illustration is given of a helminthic
parasite, found free or in the folds of the mucous
membrane in the intestinal canal of fishes. The
body cavity would appear to be one large ovary, and
oviposition proceeds at a great rate when this parasite
is placed in water, an enormous number of eggs being
laid. The symptoms produced by rectal bilharziosis
are not as a rule severe in these natives. Dysenteric
diarrhea, of an intermittent form is the usual
symptom complained of, and in many cases they
deny any symptom. Here again it would appear that
there is & relative racial immunity.
——— ey —
FLIES AND DISEASE.
Anti-fly work has not reached the precision which
one would desire. The house-fly, as a transmitter
of diarrhceal troubles, especially amongst infants
during hot weather in cities, is at present regarded
with suspicion, and in some instances actual proof
of the incrimination has been brought home. The
Department of Social Welfare, U.S.A., has endea-
voured to show the difference between an area
protected from fly infection and one in which no
protective measures were attempted. The means
adopted to get rid of flies from dwellings are: screens
to windows and doors, fly trapping, fly papers, disin-
fection of breeding places with iron sulphate, clean
streets, clean houses, courtyards, yards, and stables.
Flies caught in houses and their surface washings
plated for bacteriological counts were found to differ,
according as these flies were collected from clean or
dirty houses, thus: (1) Cultivations on agar from
clean houses showed a count of 13,986 to 1,106,017
in dirty houses; whilst (2) cultivations on Conradi
plates in clean houses showed 4,489 to 292,117 in
dirty houses. The cultivations on Conradi plates
indicate fairly accurately the number of intestinal
organisms in the surface of the flies.
It is interesting to note that amongst the flies dealt
with, such as house-flies, blue-bottles, flesh-flies,
&c., the house-fly Stomoxys calcitrans formed 1 per
cent. of the whole, and as the S. calcitrans is con-
sidered to be a means of spreading infantile paralysis
the prevalence of flies allowed to proceed unrestrained
tends to propagate several serious ailments in tem-
perate climates.
216
Rotices.
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THE JOURNAL OF
Tropical Medicine andHpgtene
JULY 15, 1914.
COWS’ MILK.
IF one were to state shortly the geographical dis-
tribution of the use of milk it might be summed up
by saying that it is used less and less as the equator
is approached. The reasons for this are several, but
under the heading “ climate,” in the widest sense,
explanations are mostly grouped. In the first place
northern pastures are necessary if the cow is to give
a profitable supply of milk; and not only so but
cattle cannot exist in arid districts where water is
scarce and green food at a minimum, or even wholly
unobtainable. Even in many parts of the Tropics
or sub-Tropies, the earth may be covered with a
green verdure, but it has not the sustenance of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
northern pasture grass and in many instances it is
not edible, both cattle and sheep avoiding it. '' No
suitable food, no good cows' milk," is therefore an
axiom readily understood.
Again, even in places where cows exist, their milk
is frequently not used as milk pure and simple, but
"prepared" in some way for consumption. We
know it as cheese and butter; in India ghee is more
elaborate in its preparation than our butter made as
it is by merely churning fresh cream. In many parts
of South-Eastern Europe and in Western Asia, milk
is consumed after being submitted to a method
recently made kuown to Western Europe by Professor
Metchnikoff. The lacto-bacillus employed is taken
from the Bulgarian preparation; besides which there
is the " Yaourt” method so largely employed in
Western Asia. The “ Yaourt” soured milk is placed
upon the market by the Société du Yaourt d'Orient
Ltd., and is advertised as “ Vardy's Curdled Cream,"
for which advantages over the Bulgarian plan are
claimed. These several preparations may have
advantages, but they are not cows' milk, only prepara-
tions of the same. The reason for advocating these
manipulations is usually ascribed to a beneficial
agency developed in the milk itself, and various
health-giving properties are claimed for the milk thus
" doetored." The fact is that all such methods are
employed because milk is so speedily changed and
soured in hot weather that it becomes undrinkable.
This is anticipated by the addition of the lacto-
bacillus, be it the Bulgarian or the Yaourt method.
The action, moreover, of the lacto-bacillus fermenta-
tion tends to kill out other germs such as those of
tubercle, typhoid, scarlet fever, &c., which may be
present, and the " souring " of the milk therefore is at
once a hygienic agent and a convenient preservative.
Milk is so “touchy” a fluid that the possibility of
its use in towns in the pure state becomes more diffi-
cult as towns increase in size, and milk has to be
imported in larger quantities, and the failure of ensur-
ing sweet milk in hot weather is an important matter
for the supplier and a serious inconvenience, let
alone other drawbacks, to a community.
Preservatives of various kinds are used in most
countries. Formalin, boric and salicylic acids, &c.,
are in vogue to-day and yet others will succeed them
in the future.
None of these, however, supply the community
with untampered milk, and the addition of bacilli or
chemicals is not above suspicion.
Pure milk, therefore, so all important a factor in
our food, seems an impossible article to obtain in
towns of any size, and a great problem lies before
every community. What is the probable and possible
solution of this all-important question? Condensed
milk, prepared as it is at present, does not and never
will give us what we want; it is needless to give the
pros and cons for this statement, as they are well
known to every one. Pasteurized milk put up in tins
and bottles is satisfactory in a way, but it also has
many drawbacks, as we know. The solution would
seem to lie in the direction of a “dried milk,” pro-
vided this is carefully prepared and packed. Milk
July 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
217
dried in a scientific way coincides more strongly to
theoretical requirements than any other process known
to us at present. Of course “dried milk" is not
" natural" milk, but whether any essential element of
nutrition is lost to the milk, or converted so as to be
rendered useless for nutritive purposes by the process
of drying, has to be inquired into and these possible
detriments removed if such can be accomplished. Dried
milk is being used in several directions at present,
but the matter wants further investigation before it
can be pronounced a success. Something must be
done, otherwise milk will largely cease to be used at
home and in British over-seas dominions and colonies :
a calamity indeed, for the race would suffer in conse-
quence, if it has not already seriously suffered, by the
detrimental measures adopted of late years to dis-
tribute milk in a “natural form” in Britain.
Dried milk, if it can be proved a satisfactory
substitute for natural cows' milk, has theoretically
much to recommend it. The bulk is reduced, and,
therefore, the carriage being cheapened, milk would
be obtainable at a lower price, a most important
factor. There is less handling necessary, and instead
of being transmitted in big cans for railway carriage,
poured into receptacles of doubtful cleanliness, trans-
ferred thence to milk jugs, &c., exposed to in-
fection by flies and dust at every turn and during
every transmission from vessel to vessel, the packet
of dried milk could pass from the farmhouse to the
consumer’s table without having seen the light of
day on the journey. The drying process means the
use of heat, the cost of which must be taken into
account; and it means also the addition of boiled
water, again involving cost for firing. A convenient
method by which the process of drying can be carried
out it is surely possible to devise, so that the farm
kitchen fire can be utilized for the purpose. To
require milk to be sent to a collecting or co-opera-
tive station to be dried would continue many of the
dangers of infection, souring, &c., which prevail at
present; and it only requires a little ingenuity to
devise an apparatus whereby the farmer can dry the
milk in his own house and by the fires in ordinary
use. For “board ship” use dried milk would be a
great gain, and were its consumption confined to
this sphere alone it would have an extensive market
It is certain something has to be done; we cannot
continue as at present; and it is surely within the
power of man’s ability to devise some method where-
by cows’ milk can be supplied, if not in its natural
state, at least in some form which does not negative
its nutritive qualities.
One may answer to the whole question, Is milk
after all a necessity? In many parts of China and
other countries milk is not used at all, and yet nearer
home we are accustomed to the French and people of
other western European nationalities speaking in
derogatory terms of milk and condemning its use,
even for children. Diluted red wines are advocated
instead, and the English belief in milk for children
decried. I do not believe British folk, either at home
or abroad, will agree to this doctrine now or in the
future. The demand for milk grows, and England
is being converted into pasture-lands and the plough,
and wheat-growing is neglected, so that the demand
of the cities may be met. This demand will not
cease in England so long as English pasture-lands
remain; for there are no pastures such as we meet
with in the British Isles elsewhere in the world and,
consequently, there is no milk possessing the high
qualities we are accustomed to. This is an important
factor to remember, for once dried milk is adopted it
can be conveyed to these shores from any part of the
world. This faetitis well to bear in mind, for British
milk, in whatever form it reaches our homes, has
a nutritive value altogether superlative to any
produced elsewhere. We understand that several
important companies are dealing scientifically with
the matter of dried milk in this country and it is
to be hoped their efforts may be successful.
Other milks—goats’, mares’, asses’ and buffaloes’—
are utilized in many parts of the world, but the dangers
of their uses and their unsuitability for human con-
sumption compared with cows’ milk are such that
these will never prove a substitute for cows’ milk
so that we cannot look beyond the cow for supplies.
J.C.
——
THE PRODUCTION OF SENNA IN THE
SUDAN.
THE senna exported from Egypt is gathered from
shrubs growing wild in the Sudan and the Red Sea
littoral of Arabia. The Sudan variety is the Cassia
acutifolia, which furnishes what is known as
Cassia angustifolia, which supplies the senna called
Mecca, Arabian or Indian. Senna is gathered once
a year, in October, the size and quality of the crop
depending on the abundance of the rainfall. The
leaves and fruit are allowed to dry on the branches.
The product is classified in four grades as follows:
Whole leaves, half leaves, broken bits, and fruit (bean).
Suez is the collecting point for both Sudan and Mecca
senna. Arabian statisties are not available, but dur-
ing the year 1912 senna from the Sudan was exported
to the value of nearly £10,000, and in the first half of
1913 to over £6,000.—Journ. Roy. Soc. Arts, June 10,
1914.
PARDAH AND EARLY MARRIAGES.
ACCORDING to a Hindu writer, the original cause
of the establishment of early marriage and the
pardah system among the Hindus was due to the
protection of their young females from Mahomedan
raiders. The Mahomedans used to raid the various
parts of India from time to time, plunder the people,
and take away by force the Hindu maiden girls to
their own country, convert them into Mahom-
edanism—by force, of course—and marry them.
The Hindus, at that time, in order that their young
girls might be spared by the raiders, began to marry
their children when they were far too young, for the
Mahomedans would generally take away unmarried
girls, though many married Hindu women used to
meet the same fate. The objectionable conduct of
the Mahomedans is also responsible for the evil
custom of the pardah system in India.
218
Annotations.
Aseptic Hypodermic Injections (M. Loiselet, of Bey-
routh, Revue de Médecine et d'Hygiène Tropicales,
vol. xi, No. 1).—The needles are kept in 5 per cent.
carbolized liquid paraffin, which prevents rust and
does away with flaming which makes the needles
blunt and brittle. At the time of injection the needle
is taken from the oil, fixed on the syringe, and
chloroform is rapidly pumped up and down. The
skin is disinfected by placing upon it a drop of
tineture of iodine, through which the puncture is
made before it has time to spread or evaporate, so
that the needle passing through the drop carries in
with it some of the iodine solution. After the
injeetion the needle and syringe are cleaned as
before in chloroform. The needle is replaced in the
carbolized oil and the syringe in its box. Several
thousand injections have been thus made, the majority
of quinine, without the slightest trouble.
Fulminating Gangrene of the Genitals (Editorial,
Medical Record, June 20, 1914).— This mysterious
affection is usually regarded as a composite of various
clinical entities which pursue analogous or identical
courses. Now and then we can hardly avoid the
conclusion that a true venereal propagation has
occurred, while in other cases a simple injury from
coitus has become inoculated with a germ of great
virulence. The fact that in a recent case of this
sort a salvarsan injection terminated the condition
suggests that the spirochete of syphilis, or at least
some spirochete, was the pathogenic agent.
This affection has received a great deal of study
at the hands of French writers, and is in fact
known by Fourniers name. A very large morbid
material has been collected and analysed. It is,
therefore, of interest to mention a case recently
reported by Lóhe before the Society of Physicians
of Charité Hospital, Berlin (Berliner klinische Wochen-
schrift, May 4). The patient, à man aged 61, under
treatment for a genital affection not named, suddenly
developed an enormous swelling of the penis which
extended centralwards. The organ was of the size of
a man's forearm, while the scrotum swelled to the
dimensions of a child's head. Only at a later period
did blebs develop, giving exit to a gangrenous fluid.
The patient was anesthetized, and free incisions
made, the prepuce being split. In this manner
100 c.c. of the same fluid was evacuated. The
patient recovered under a combined surgieal and sup-
porting plan of treatment.
The author, like others in the past, seems to regard
this affection as practically an erysipelas, in which
intense inflammation brings about lymphatie stasis
and gangrene. Such a theory hardly accounts for
the majority of these cases, for the initial lesions may
be gangrenous vesicles. In the present case con-
stitutional disease (diabetes) and urinary infection
could be excluded, despite the coincidence of enlarged
prostate.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
Abstracts.
RECOMMENDATION AS TO SANITATION CON-
CERNING EMPLOYEES OF THE MINES
ON THE RAND MADE TO THE TRANSVAAL
CHAMBER OF MINES.*
By W. C. Gorgas, M.D.
Washington, D.C.
THE reports of the Native Affairs Department
show that for natives employed in mines and
industrial works in the proclaimed Government
district of the Transvaal during the year 1903 the
death-rate was 71°7 per thousand. This high death-
rate has been steadily dropping till the present time.
During the year 1912, for about 300,000 employees
in the same area, the rate was 26.84. This rate is
still very much too high, as we are considering men
in the prime of life.
The death-rate among the negro employees work-
ing on the Panama Canal during the same year was
only 10. Still this drop from 71 per thousand to
26 per thousand in the course of nine years is most
encouraging.
Pneumonia varies very greatly in the different
mines. It also varies greatly as to the locality
from which the natives come. Among natives
from the British Nyasaland Protectorate it is
highest : among the natives from the Cape Province
it is lowest.
PNEUMONIA.
The pneumonia rate varies widely also in different
localities. Among natives not working in mines in
the city of Johannesburg, the rate was 1°20 per
thousand for the year 1912. In the new Goch mine,
the rate among natives was 1671. In the Municipal
Location at Klipspruit, the rate among 750 natives
over 18 years of age, extending over a period of three
years, was 1°37. This isthe same class, and also age,
as the men in the mines.
For the year 1912 the 21,000 tropical natives had
a death-rate from pneumonia of 26.30; but the
199,000 non-tropicals had a rate of 8. In general,
the tropical is the non-civilized native who has had
little contact with the white man’s diseases, and the
non-tropical the native who has had more or less
contact with civilization—and the white man’s
diseases.
In general, therefore, a community which has had
a large proportion of tropical natives will have a high
pneumonia death-rate, and a community with a large
proportion of non-tropical natives will have a low
pneumonia death-rate.
During the first few years on the Isthmus, we
housed our negroes in barracks containing about
eighty-four men each, and of such dimensions as to
give them about 30 ft. of floor-space. This is
ordinarily considered very crowded. In 1907 we
allowed our negro labourers to scatter out along the
line of the Canal, build each man his hut, with a
small cultivable piece of land, and bring over his
* From the Journal of the American Medical Association,
June 18, 1914.
July 15, 1914.]
family. In 1910 our negro force was 37,000. Of
this force, only about 7,000 lived in barracks; the
other 30,000 lived in their own establishments. To
this fact of scattering I attribute the disappearance
of epidemic pneumonia. I explain it in this way :—
It is a well-recognized fact in military hygiene that
overcrowding of a barrack is coincident with inflam-
mation of the upper respiratory passages, which at
times become epidemic. This was the case on the
Isthmus of Panama, and doubtless is the case on the
Rand. Non-immunes crowded into barracks would
in the same manner develop inflammation of the
upper respiratory passages, in many cases due to the
pneumococcus, which inflammation would afford a
portal of entry for the pneumococcus resulting in
some persons in lobar pneumonia and in others in a
certain amount of immunity. If we have eighty-five
men in a crowded barrack, and the pneumococcus
gets in, the probabilities of its spreading to the other
men are considerable. If the pneumococcus
establishes itself in a man living in a hut alone,
or with his family, it is not apt to spread to the
men with whom he works, and with whom the con-
tact is not intimate. The scattering of our negroes
was the chief cause of our sudden and permanent
drop in pneumonia on the Isthmus.
Other causes no doubt contribute to it. The next
most important, we think, is acquired immunity, such
immunity as the old boy would have as compared
with the new boy. It is self-evident that the propor-
tion of old boys to the new was much larger in the
force in 1909 than it was in 1906.
The question of immunization for pneumonia as
recommended by Sir Almroth Wright should be more
carefully looked into. It would be useful to continue
the experimental inoculation against pneumonia,
using the different strains of pneumococci.
Persons recovering, or having recovered, from
pneumonia may, and usually do, carry virulent
pneumococci in their mouths and respiratory passages
for long periods, and may infect others indirectly by
means of their sputum, or by infecting the drinking
or eating utensils used by several persons in common,
or by infecting the common water-tap or cup. It has
been observed that natives when drinking from the
water-tap place it in their mouths, and in this way
may leave a moist film of infected spittle on the tap
to be taken up by the next person using the tap. In
the mines, one tap has to serve for many labourers on
the level, and personal observation has shown the
facility with which a line of thirsty natives may
become mutually infected.
Not only are pneumococci transferred in this way
from persons who have recovered from pneumonia,
but it is most probable that pneumococci are acquired
similarly from persons suffering from the “common
cold," tonsillitis and other forms of inflammatory
disease affecting the upper air-passages.
It is highly desirable, therefore, that means should
be used to prevent as far as possible such conveyance
of infection as is indicated above. This might be
done effectively and economically by means of some
of the well-known types of “ bubbling” fountain, or
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
219
protected taps. These taps prevent the dissemination
not only of pneumonia, but also of tuberculosis and
syphilis.
TUBERCULOSIS.
Tuberculosis is far too high among native miners.
The report for 1912 shows that the total rate for all
native miners was 5'65 per thousand for pulmonary
tuberculosis. The rate at Panama, for the same class
during the same year, was less than 1 per thousand.
The rate for London, total population, men, women,
and children, was 1'03 per thousand for 1911, and for
New York, 1°67 per thousand for 1911.
In addition to the deaths of natives from pulmon-
ary tuberculosis, there is a high percentage of deaths
from other forms of tuberculosis among the native
labourers, as tuberculosis of the intestines and
abdominal viscera.
The actual number of deaths from tuberculosis for
the year 1912 among 156,534 natives is probably a
total of 1,702.
This gives a death-rate for tuberculosis in all its
forms of 10'87 per thousand per annum, of the aver-
age working force of 156,534 natives, so that the
death-rate from tuberculosis in all its forms is as a
matter of fact considerably higher than 5'65 per
thousand for 1912, and 4'80 per thousand for 1913,
as shown by the reports supplied by the Chamber
of Mines.
Estimating the deaths from tubereulosis we find
that in 1910 we had among natives a total of 1,520,
which would give a rate of 8'85 per thousand.
In 1912 we have a rate of 10°87 per thousand. For
the future, present conditions continuing, tuberculosis
wil cause more trouble among natives than does
pneumonia at present.
Overcrowding plays just as important a part in the
spread of tuberculosis of types other than pulmonary
tuberculosis as it does in the pulmonary type. The
same measures for its control are applicable.
Careful routine medieal examination should be
made of the sick, and when a man is found to have
tuberculosis he should be excluded from the mines.
As far as the native is concerned, the most important
single measure is that recommended for pneumonia,
that is, scattering, and in the same way as recom-
mended for pneumonia.
Disinfection in the dwellings of the tuberculous is
useful and important, and should always be resorted
to.
Tuberculosis is a disease that can be particularly
combated by fresh air, sunshine, cleanliness and
roomy quarters.
MINERS’ PHTHISIS.
This disease has so far been steadily increasing
on the Rand. The reports for 1903 show a rate of
0'05 per thousand, and that for 1912 a rate of 0°10
per thousand. The disease is essentially a silicosis,
and is caused by partieles of silica getting into the
lung-tissue, through respired air, causing chronic
inflammation, the tissue thickening until finally a
considerable portion of the lung is destroyed for
respiratory purposes. This condition of the lung
brings about & low state of local vitality, so that an
220
organism like the tubercle bacillus easily finds lodg-
ment. At present on the Rand most persons with
miners’ phthisis die from an incidental tuberculosis
implanted on a silicized lung, rather than from
silicosis itself. The hygiene of this disease is obvious,
that of laying the dust, so that the particles of silica
will not be floated in the air where they can be
breathed. Some form of water-spraying apparatus
is now very generally used on the Rand. If such
measures be generally and carefully enforced and
extended, they will soon reduce miners’ phthisis to
a minimum.
CEREBROSPINAL MENINGITIS.
Cerebrospinal meningitis is a disease that at times
causes considerable mortality among native miners
on the Rand. This is an infectious disease whose
organism, so far as we know at present, is spread
from person to person by crowding and contact.
Scattering would also be the most effective sanitary
measure against this disease, in addition to the general
measures of cleanliness, air and light already referred
to. Disinfection is probably more useful in this
disease than in either of the diseases previously
discussed.
TYPHOID FEVER.
During the last four years 310 men on an average
died from typhoid fever. Typhoid fever by vacci-
nation is as preventable as is small-pox. This death-
rate could be entirely wiped out at once. With the
present organized force of medical men it would be
neither difficult nor expensive. The vaccination itself
causes nothing like the trouble to the person vacci-
nated as does the vaccination for small-pox. In
general, there is almost no reaction, soreness or effect
of any kind.
HOUSING THE NATIVE.
The most serious sanitary defect in the mines on
the Rand is the manner of housing the native. The
quarters are much too crowded. He has in general
200 cubic ft. of air-space, which would give him 14 ft.
of floor-space. The general objection is that it causes
the respired air to become vitiated. Such crowding
forces the occupants into close personal contact, and
therefore largely increases the spread of any infectious
disease. This applies particularly to pneumonia, tuber-
culosis and cerobrospinal meningitis.
In the French army they allow about 50 ft. of
floor-space to a man. Recently they have largely
increased their army, which has caused crowding in
their barracks. It is stated in the newspapers that
epidemic pneumonia is prevailing among the men,
and that the French sanitary authorities attribute the
epidemic pneumonia to this overcrowding.
The scattering from large barracks into single huts
and small rooms was the important measure in its
effects on pneumonia on the Isthmus. For the sani-
tation of pneumonia I would urge a similar measure
onthe Rand. Place your negro labourers in individual
buildings, and bring in, and place with them, their
families. This measure would result with you as it
did with us. In the course of about a year it reduced
our pneumonia death-rate from 18'40 per thousand to
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
2 per thousand. It would probably reduce your
present rate of 15 per thousand (the highest pneu-
monia monthly rate for 1913) to 2 per thousand.
What is at once feasible is to extend your family
locations. At present all the mines have such a
location where the native lives with his women and
children. Into these locations the pneumonia rate
and the general death-rate are low. They are always
among the very best class of native rates on the Rand.
At the City Location at Klipspruit, about 2,800 natives,
men, women and children, live in neatly constructed
single dwellings, more or less separated, from 50 to
200 ft. apart. The whole village, both inside and outside
the dwellings, were well policed, and presented a clean
and attractive appearance. For the past three years,
with an average of 750 male natives over 18 years of
age, the pneumonia death-rate had been 1°37 per
thousand, while the native rate for pneumonia in
the mines on the Rand for the same year (1913) was
10°05.
It is a very striking coincidence that whenever we
find the native on the Rand living as he does on the
Isthmus of Panama, his health-rates are approximately
as good as they are on the Isthmus. When the
negro on the Isthmus lived in large barracks, as does
the native in general on the Rand, his health-rates
were fully as bad as those on the Rand. Wherever I
have inquired, the compound manager has told me
that he has more applicants for married quarters than
he can accommodate, and that if he had more build-
ings he could fill them. Let each mine therefore put
up cheap but comfortable buildings, as they find they
have need for them. The native hut strikes me as
being excellent. It has a circular wall with thatched
roof. In this type of hut, concrete floors and glazed
windows I consider quite unnecessary.
At the Arcturus mines these huts were attractive
and neat in appearance, complied with the needs of
sanitation, and were economical in construction. In
extending locations, it would be better, from a sant-
tary point of view, to erect huts rather than to extend
the present buildings.
In extending these locations an eye should be had
to the future. They should be laid out in streets and
blocks with a view to eventually putting in a water-
borne sewerage system.
Eventually, in this way, a considerable portion of
the force could be placed in these villages, and the
barracks mainly used for the unmarried men. This
would begin at once to give more room in the bar-
rack for the highly susceptible new boy. As the
barracks ceased to be needed for the unmarried native,
they could be slightly rearranged for native married
families. This was very satisfactorily done at Panama.
As we ceased to need the barracks for our unmarried
negro labourer, we transformed them economically
into comfortable married quarters.
A native labour force living with families near the
mines would be more stable and contented than the
present force. They would be old and experienced
men and, therefore, more efficient, and from all points
of view more economical and satisfactory to the mine
manager than the present force.
July 15, 1914]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
221
The economy of this method of housing native
labourers might be emphasized by calling attention to
the fact that recruiting men eosts about $5,000,000
(£1,000,000) per annum. The greater part of this
expense can be saved by the construction of loca-
tions—such as Klipspruit—or building huts of the
general type of those erected by natives at their kraals.
A force of married men living in such a location
would be a permanent force of skilled workmen,
always available as a source of labour for the mines.
A nominal charge for such huts should be made,
such a charge as would pay for the hut, say in ten
years, and also keep the huts in repair. Such a
location would be self-supporting and would correct
the unsatisfactory health conditions of the compounds
by giving more floor-space per capita to those who
continue to live in them.
Public sentiment will not approve the keeping of
a large body of semi-savage labourers in the commun-
ity in such conditions as obviously to foster sexual
crimes. Both the public and the labourer will insist
on the native having his women and children. If the
labourer cannot have his family with him at the mines,
he will, as the country develops, seek other employ-
ment where he can have them.
On the order of the Government, recruiting among
the tropical natives ceased last March. If we were
considering the sanitation of the tropical native alone,
I should still more strongly urge scattering, as much
as possible, as the proper sanitary measure for him
against pneumonia. This dispersion I should bring
about, if possible, by putting him in a hut with his
family. If this were not possible, I should put him
in huts without his family, arranged so as to give
him 50 square feet of floor-space. If huts were not
possible, I should put him in barracks with the small-
est rooms I had, arranged so as to give him 50 square
feet of floor-space. .
In general, the care of the compound yards showed
everywhere neatness, cleanliness and commendable
care and discipline; but when we came to examine
the interior of the native living-quarters the very
opposite was the case.
Food was always present in dirty and unkempt
vessels in considerable quantities; old clothing and
wearing-apparel of all kinds, soiled and dirty, was
littering up everything, and litter of all kinds was
stowed away under the sleeping-platforms. I was
told that discipline and cleanliness were not enforced
in the sleeping-quarters from the fact that the authori-
ties did not wish to interfere with the natives to such
a degree as to make them dissatisfied. This is a very
good general rule, and a population of the class of the
ignorant native miner should not be worried with too
many and exacting sanitary regulations. Indeed
not much in the way of correction could be done,
even if the native co-operated, in the present
crowded condition of the barracks. But give each
man 50 ft. of floor-space, and he can have an indi-
vidual bed and box of some kind in which he could
keep his personal belongings. It would then be no
hardship to require him to keep his belongings to his
own bed and in his own box.
If a number of small sheds, inexpensive in con-
struction, and convenient to the sleeping-rooms, were
erected around the compound, it would be no great
hardship to require him to eat his food under this
shed. In the receiving compounds at Johannesburg,
the native is required to eat his food on a concrete
platform, and no food is allowed in the living rooms ;
there is no particular objection on the part of the
natives.
If the sanitary necessity of keeping the barracks
in a cleaner condition was considered, the details
could be worked out gradually so as not to interfere
to any great extent with the habits and customs of
the natives.
A commendable effort is being made generally to
correct this condition by cleaning up, taking out
refuse, destroying bugs, whitewashing, &c. But this
must be done (in the nature of things) very often.
In the best-kept quarters this is done about once
a month, but in afew days conditions are as bad as
ever. It is not feasible to make any considerable
improvement in present conditions as long as the
barracks are as crowded as they are, and as long as
the men are allowed to eat and keep food in their
sleeping-quarters.
I recommend that each native be allowed 50 square
feet of floor-space; that he be furnished with an
individual bed, and an individual box in which to
keep his belongings ; that the barracks be divided into
smaller rooms to contain not more than from twelve
to fifteen men; that no food or utensils of any kind
be allowed in the dormitories, and that eating-sheds
be erected about the compound, located conveniently
to the dormitories. A good many of the men at
present keep their food from meal to meal and con-
sume it between times. They also use the mealie
porridge for making fermented drinks. If it is neces-
sary to allow this, to each native who asked for it, a
locker in the eating-shed could be assigned. The
expense of such changes would not be large. The
increase in floor-space would cause a large expenditure,
if the force were as full as it was a year ago. If you
encourage your married locations, some room would
be gained in the barracks in this way. The reforms
could be carried out gradually. Those compounds
could first be selected in which the death-rate was
high. There are a considerable number of compounds
in which the death-rate has been low for a number
of years. They are frequently the old compounds
which the native prefers, and therefore they contain
a larger number of old boys. In all the cases the
crowding there was not so great.
These two conditions, namely, the lesser crowding
and the greater proportion of old boys, generally
explain the better health-rates. In this way gradual
improvement could be brought about at no very large
yearly outlay.
DIET OF THE NATIVES.
The ration is another thing that has impressed me
very strongly in inspecting the various mines. I have
never seen so large a proportion of the ration supplied
by one article as is here supplied by mealie meal.
999 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
The two chief components of the daily ration are 2 Ib.
of mealie meal and 5455 oz. of meat. This is a
great deal too large a proportion of the carbohydrates
for men doing the hard manual labour that the natives
do. The mealie meal might be reduced, and the meat
and other articles increased.
A soldier's ration in the British Army is 16 oz.
of bread, 12 oz. of meat, and also an allowance of
threepence per day for vegetables, and other articles.
A miner does very much harder labour than the
soldier. His diet should be at least as good.
On the Isthmus we had a great deal of trouble as
to rations. There was no particular disease among
our labourers that we could attribute to diet, but they
seemed to be underfed, and there was constant com-
plaint. The whole matter of food was satisfactorily
settled both for the negro and ourselves when the
families came and when we established commissaries
for the sale of food at cost. The negro then bought
what he liked in such quantities as he wished, and
his wife cooked it in the manner to which they had
been accustomed. At the Premier mine they have
three systems of feeding going on at once. The
native can either eat his food at the regular mess,
buy such cooked food as he liked, or buy food and
cook it himself.
At the Kimberley mines the system of food-supply
is altogether that of allowing the native to buy his
own food. It seemed to be very satisfactory. This
would be an excellent system of feeding to adopt
generally, although I prefer our system on the
Isthmus, where food is supplied the native at cost.
The object of this measure is to give him an abundant
food-supply in such a way that he can vary it as
his tastes suggest. If you attempt to make a profit
on food, you by so much defeat the object of your
measure.
I am inclined to attribute scurvy to the large amount
of mealie meal in the ration. It has been found that
beriberi is caused by making polished rice the almost
exclusive article of diet. It is due not to the rice
itself, but to the fact that the rice is polished. In
polishing, the pericarp is rubbed off, and this pericarp
contains substances that are necessary in the body
economy. Mealie meal, as used on the Rand, has a
similar outer coating removed in the process of mill-
ing: "There is strong evidence to prove that scurvy is
due to having such a large proportion of the diet con-
sist of the bolted mealie meal. If this is the case, it
can be corrected easily and economically by having
the meal properly prepared. This question should be
investigated further.
On the Isthmus of Panama in 1906, each man
bought his own food from a poorly supplied market,
at a very high price, and cooked it himself. In 1908
he bought from a well-stocked market, at cost price,
and had someone to prepare his meals.
We first started having each man take care of
himself as far as food was concerned. Each labourer
bought his uncooked food from the nearest native
vender, and cooked it himself between working-hours.
This proved very unsatisfactory for several reasons.
The labourer did not have time to collect his food and
cook it between working hours. He was also too
much fatigued to do it properly. Our force increased
so rapidly that we consumed everything that there
was in the country. We then put up stores along
the line, supplying food at cost, and also kitchens
where it could be bought cooked at a reasonable price.
This proved a distinct improvment over former con-
ditions, but the matter of feeding was put on an
entirely satisfactory footing, both to ourselves and to
the negroes, by bringing the families over, and allowing
each man to put up a hut for himself and his family.
Since that time we have had no trouble as to food
for the negro, or dietetic diseases among them. Each
negro now gets such food as he likes at cost, and his
wife cooks it for him in the manner and quantities
which he likes best. Present conditions as to food
are entirely agreeable to both parties. The establish-
ment of stores by the commission and selling at low
price in no way interfered with opening of stores by
private persons. Such stores existed in considerable
numbers at all towns and were prosperous.
SEWERAGE AND WATER SYSTEMS.
Another sanitary improvement completed at about
this time was the introduction of sewerage and water
systems. One of the prominent causes of death
among our predecessors had been dysentery. Indeed,
this disease is generally prominent in tropical countries.
Typhoid fever is another disease that we knew we
should have to reckon with. In the hope of protect-
ing ourselves against these two diseases we put in
eight different water systems along the fifty miles of
canal. Generally, for getting water, we dammed the
small streams near their source in the mountains, and
piped the water down to the cities and villages along
the line of the canal. About twenty sewer systems
were put in at these villages. The sewerage systems
were limited to the villages.
Several things happened about the time of the dis-
appearance of our epidemic of pneumonia.
The men were scattered from crowded barracks to
individual huts in the hills, and houses in the towns.
An insufficient, poor, expensive food-supply, badly
cooked, was replaced by one abundant in quantity
good in quality, cheap, and very well cooked.
Water-supplies and sewerage systems were every-
where installed.
It is an obvious axiom of both hygiene and economy
that no unnecessary tax should be placed on the
strength of the native labourer. With these objects
in view, he should be conveyed to his place of labour,
and away from it, with as little delay and as little
exertion to himself as possible.
The present bucket system of disposing of night-
soil should be replaced by a water-borne system.
This is possible everywhere on the Rand above sur-
face. This bucket system promotes the breeding of
flies, and the transference of diseased faecal matter by
these insects. The water-borne system would be
economical as compared with the present bucket
system. Several of the mines have at present partial
water-borne systems. I commend particularly that
of the Crown mines.
July 15, 1914.]
Where a water-borne system is not feasible, a
properly constructed, fly-proof closet is preferable to:
the present bucket system. It is more sanitary and
less expensive.
Underground a water-borne system seems to be
impracticable from a mechanical point of view. A
vault system would be a decided improvement on the
present bucket system, both from a sanitary point of
view and from the point of view of economy. I mean
by a vault system the excavating of a small vault and
placing on it a fly-proof seat wherever a closet is
needed. I should use no water whatever. Allow
only in the vault fecal matter and urine. When the
vault is filled, close the vault and move the seat to a
new location, or empty the vault with an odourless
excavator. I should empty the vault or move the
seat as seemed most convenient and economical.
Vaults that were located on the outer workings, and
that were to be used less than a year, I should think
could be more economically closed than emptied.
Vaults that were located near the centre of the work-
ings, and were to be used for several years, might be
emptied when filled. This should be determined
purely from the point of view of expense.
There would be some sanitary advantage in closing
a vault rather than emptying it. I think that from
an administrative point of view it would be found
more economical to close a vault and build a new
one, rather than to empty it. The length of time
that a vault would last would be determined by its
size.
It has been objected that there’ would be leakage
through cracks in the rock ftom these vaults into
the mine below. There would be so little fluid, the
urine only, that I do not believe this would be the
case. If the deposit were found to be too fluid, this
condition could easily be remedied by the use of dry
earth or some similar drying material. I have seen
this system used on a large scale in cities with little’
objection as to odour or inconvenience. The great
sanitary objection to the present bucket system is
against the daily handling and carrying through the
mines of feecal matter, and the necessary fouling and
disagreeable odours that go with such a system. The
great sanitary advantage of a vault system in such
locations as the mines is that the excreta are per-
manently disposed of as soon as deposited.
The economical disadvantage of the bucket system
lies in the considerable expense of daily transporting
the buckets to the surface, emptying, cleaning and
returning, as well as the expense of plant. The only
expense of the vault system would be that of originally
digging the vault and then of closing it.
A system of septic tanks might be considered, if it
should be found more economical than the vault. I
think that such a system could be planned so that
there would be no objection to the effluent passing
into the general drainage system.
THE FLY NUISANCE.
I commend the effort at some of the mines to
abate the fly nuisance by trapping and otherwise.
All eating-houses, kitchens, dining-rooms, or where-
THE JOURNAL OF TROPICAL MEDICINE. AND HYGIENE.
228
ever cooked food, or food, such as fruit, that is esten
uncooked, is exposed, should be well screened as a'
protection against these insects. In addition traps,
fly-paper and such devises as tend to destroy flies
that have gained entrance to these places should be
used. The present crusade against fly-breeding should’
be encouraged in every way. Such a movement is one
of the best educators.
The disposal of garbage is generally satisfactory.
It is in general dumped at some out-of-the-way place
sufficiently removed from the mine so that the odours
and the flies are not troublesome. I should recom-
mend, however, the general use of crematories. The
crematory system is generally more satisfactory than
the dump, from the fact that it does away with fly-
breeding and disagreeable odours. In many cases it
is more economical from the fact that the haul is
much shorter in the case of the crematory.
THE LIQUOR QUESTION.
Alcohol for the native is an unmitigated evil. It is
in no way necessary for his health; in fact, it is
always hurtful. I believe that it would be best for
the native on the Rand to have no alcohol at all.
That alcohol is not a necessity for the native is
evidenced by the condition of affairs at the De Beers
mine. There they have compounds that are kept
rigidly: closed: Neither kaffir beer nor any other
alcohol is given him. Yet he’ remains in perfectly
good health and seems contented. He likes the life
at Kimberley better than he does that on the Rand.
This is evidenced by the fact that their force is
always full, yet they do not have to recruit, whereas
on the Rand the opposite is the case!
One cannot see these mines, or look over their
statistics, without being struck by the many advan-
tages a closed compound has in the management of
these semi-civilized natives.
MEDICAL SERVICE.
Attention should be given to the methods at present
in vogue of getting the East Coast boy from his home
to the mines. There is opportunity here of the
native’ becoming infectéd with both prieumonia and
tuberculosis before he reaches the mines.
In any case some machinery is needed for carrying
out a system of sanitation. On the Rand there are
now about fifty-four mines, each entirely independént
as to the sanitation and care of the sick. About
thirty-eight physicians are employed by these mines.
Each is doing the same work as the other. Sixty-two
hospitals treat 2,150 patients. None of these hospitals
is equipped or manned in a first-class manner. In
general, the larger the hospital the better manned
and equipped. The nursing force in native hospitals
is made up of natives who have neither the intelli-
gence nor training for such work. If a combination
could be effected, a much higher state of efficiency
could be brought about at no increase of cost. If all
the sick could be brought together into one hospital,
they could be cared for at less cost than in sixty-two
hospitals. You could afford to equip such a hospital
with first-class surgical appliances of every kind at
224
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(July 15, 1914.
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a less cost than the moderate supply at present given
to the sixty-two hospitals now in use. The same
could be done on the medical side.
In the Bacteriological Institute you already have
an institution and personnel that could be used for
the pathological work, and the patient could be brought
to hospital by the railroad, which connects with all
the mines, and by motor ambulance and wagons.
With 200 white trained nurses, male and female,
in such an institution, you could select your sub-
ordinate native nurses from the more intelligent and
better educated natives, and thus secure a first-rate
nursing force.
In a large hospital of this kind you could keep in
better touch with the character of disease affecting
the employees, which is in itself a considerable
sanitary advantage.
You could select the men best fitted and place
them in charge of the sanitary work. These men
should devote their whole time to their work, and be
in thorough and constant touch with the sanitary
conditions of all the mines. One-man should be
chief, and on the staff of the Chamber of Mines; he
should be responsible to the Chamber of Mines, and
entirely independent of the management of the
individual mines. If you had had for the past few
years a sufficient force constantly devoting their whole
time and attention to sanitation, you would have by
this time reduced pneumonia to aminimum. If it were
adopted now, at the end of a few years pneumonia
would be reduced to a minimum. If it were feasible
to adopt the whole scheme as outlined, which is the
scheme that we used at Panama, the results should
be the same, the rapid reduction of pneumonia to a
minimum. Your native labour force is evidently
undergoing a gradual process of immunization. In
1903 and 1904, your total rate from pneumonia was
25'31 per thousand. For the first nine months of
1913 this had fallen to 8'8 per thousand per annum.
The fall has been more rapid during the last months
of this period, on account of the stoppage of the
introduetion of the more susceptible native from the
tropical regions north of latitude 22. This process
will continue going on for several years till the whole
of the native labouring population reaches the state of
immunity that the Cape native has now. This, I
take it, is the maximum that the native is capable of
reaching under your present sanitary conditions. This
eould be still further reduced by the sanitary improve-
ments suggested. I base this opinion on our experience
on the Isthmus, where the negroid pneumonia rate
has been reduced from 18°74 in 1906 to 0°42 for the
first eight months of 1913. During one month in
1906, it was higher than it has ever been on the Rand
for a similar body of men, and for & similar period,
43°41 per thousand. Meanwhile, if you introduce the
native from the non-immune regions, your rate will
go up. This could in great part be prevented by
housing the tropical native in huts as suggested, and
by furnishing him with cooked or uncooked food to be
purchased as he liked. In the course of a year or
two he would acquire immunity, and would then be
on the same footing as a boy from the South.
Of these sanitary recommendations, that of increas-
ing the floor-space to about 50 ft. is the most im-
portant and pressing, and by far the best way of
doing this is the village hut system and the intro-
duction of families. If this particular method cannot
be carried out, effort should be made to come as near
it as feasible.
Second in importance I consider improvement in
the hospital system and care of the native sick. This
can be best carried out by a central hospital. If a
central hospital is not feasible, such concentration of
hospitals as is possible should be made.
The third in importance is the establishment of a
central sanitary bureau or department under the
Chamber of Mines, the head of this department to
represent the mines on all sanitary questions.
The present regulations regarding matters of sani-
tation should be revised so that the sanitation of the
mines might be accomplished by the authority of one
official, government or municipal, instead of with five
different interested parties, as is now the case.
CONTAGION CARRIED BY TEXTILES SUCH
AS COTTON, WOOL, RAGS, ETC.
A REFUTATION.
A WRITER in the Journal of the Royal Society of Arts
(June 10, 1914) deals with the question of the trans-
mission of disease amongst workers in factories who
handle wool, cotton, rags, &c. This much discussed
question receives a partial confirmation, but a more
complete refutation when the broad outlines of the
matter are considered. On the question of the con-
veyance of small-pox by raw cotton which is believed
to have recently occurred it appears that the out-
break of small-pox in a Lancashire mill has been
attributed, upon circumstantial evidence, to contagion
carried by raw cotton, and the mill-owners have been
prevailed on to destroy their stock of cotton-waste.
Cotton has been accused in a similar way in at least
one other instance, but there has been no proof
absolute such as is obtainable in respect of anthrax
from wool. English mills use well over 2,000 million
pounds of raw cotton annually, and import it from
countries where small-pox is always more or less rife.
It may therefore be held that were the transmission
other than the rarest of occurrences the spread of the
disease must have arrested attention long ago. The
partieular cotton suspected is Mexican, and may
actually be a portion of the produce seized by the
insurgents, for which the rightful owners have not
been paid. In view of the quantities of material
involved, and their concentration upon certain centres,
the impressive fact about the importation of textile
materials is the extreme rarity of cases of infection
with any zymotic disease. If one material more than
another might be expected to carry disease, that one
should be rags, yet the advices from the rag centres
are most reassurring. The last published reports from
these districts say that zymotic diseases are about
the only ones of which rag-sorters never die.
August 1, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 15, Vol. XVII.
Original Communications.
THE COASTAL CLIMATE OF TROPICAL
QUEENSLAND.
METEOROLOGICAL OBSERVATIONS TAKEN AT
TOWNSVILLE.
By F. H. Taytor and W. J. Youna.
From the Australian Institute of Tropical Medicine, Townsville,
Australia.
FROM the commencement of April, 1913, daily
observations of the local meteorological conditions
have been taken at the Australian Institute of
Tropical Medicine, Townsville, North Queensland,
and the records obtained are summarized in the
following tables.
The instruments employed were supplied by the
Commonwealth Bureau of Meteorology, Melbourne,
and were of the standard pattern in use at the various
weather stations throughout Australia.
These observations extending over thirteen months
show two distinct seasons, each of six months’ dura-
tion, the cooler season commencing towards the end
of April, and the hotter season towards the end of
October. The averages of the temperature records
during May were markedly lower than those of the
previous months, whilst during June and July the
temperature still decreased, but the fall was much
more gradual. Simultaneously with the fall in
temperature the relative humidity of the air showed
an analogous decrease, most pronounced between April
and May.
The wet season proper finished about the end of
April, only light rains occurring in May and June to
the extent of 1°64 and 0°54 in. respectively, whilst
from July until the middle of December only 0°32 in.
were registered.
Between October and November a marked rise was
observed in the averages of the readings of the maxi-
mum, minimum, wet and dry bulb thermometers.
The hot season thus commenced towards the end of
October and the high temperature continued from
then, with no great variation, until the end of April,
1914. The relative humidity did not rise corre-
spondingly in November, due to the fact that the
thunderstorms and rain, which usually occur on the
coastal area of North Queensland in October and
November, did not commence until December. Only
0°31 and 0'01 in. of rain were recorded in October
and November respectively, whereas from the records
kept in Townsville for the past forty-two years
the average rainfall for these months is 1°39 in. and
1°70 in.
The heavy rains commenced in December, and
45/59 in. were registered from then until the end of
April, 1914.
This division into two seasons is readily seen from
the accompanying graphs (fig. 1), in which are
plotted the means of the average temperature, the
maximum, minimum and wet bulb (3 p.m.) readings
for each month.
For the sake of comparing the conditions at Towns-
ville with those prevalent in other parts of the tropics
where the climate is more generally known, in Table II
are given the averages for Townsville for the whole
year (May, 1913, to April, 1914), for the two periods of
six months corresponding to the two seasons, and the
yearly averages for Colombo, Ceylon [1]. For further
comparison the temperatures for Bombay [2] are in-
cluded in the table, since both Bombay and Towns-
ville are situated in monsoon districts where the chief
rains occur during the warmer months. It will be
observed that during the hot season, November to
SUNLIGHT OBSERVATIONS .
%
x
E
t)
Ur
HOURLY DECO)
BLACK LINE = MARCH 1913
DOTTED LINES SEPT.1913; ^
Fic. 2.
April, the meteorological conditions in Townsville
are approximate to those which obtain throughout
the whole year in Colombo. In Colombo, however,
the temperatures do not vary to any great extent ; the
rainfall is much greater and is distributed over the
whole year.
In addition to the foregoing, daily observations
were made of the intensity of the sunlight, as regards
those rays in the violet and ultra-violet portions of
the solar spectrum. "The method employed was that
recommended by the late Paul Freer, of the Bureau of
Science, Manila [3]. This depends upon the photo-
catalytic decomposition of oxalic acid into carbon
monoxide, carbon dioxide and water in the presence
of a uranium salt, a reaction which is brought about
solely by the rays in question.
By this method daily determinations are made of
the decomposition which takes place in a standard
mixture of these substances when exposed in standard
vessels to the sunlight during a definite interval, and
the figures thus obtained may be compared with
those found under identical conditions in other parts
of the world.
226 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
TABLE I.
1913 1914
SS amaaa ———A——
———— ——————— —————M———— ———— ———
April May June July August | Sept. Oct. | Nov. Dec. Jan. Feb. March , April
Mean dry bulb, 9 a.m. | 76:6 | 69:2 | 66:8 | 66:9 | 69°5 | 75:2 | 7717 | 88:0 | 82:2 | 82:4 | 81:8 | 8055 | 799
(degrees)
Mean wet bulb, 9 a.m. | 70:0 | 61:6 | 59:9 | 602 | 61:2 | 658 | 687 | 78:83 | 75:6 | 75:6 | 74:5 | 75:5 | 74:0
(degrees)
Mean dry bulb, 3 p.m. | 76:1 | 752 | 72:5 | 78:3 | 73:2 | 77:5 | 79:1 | 841 | 846 | 848 | 840 | 824 | 821
(degrees)
Mean wet bulb, 3 p.m. | 72:9 | 696 | 68:9 | 68:9 | 68:6 | 66:0 | 69:4 | 747 | 767 | 761 | 761 | 764 | 749
(degrees)
Mean dry bulb, 6 p.m. | 76:9 | 69:8 | 68:0 | 68-2 | 69:0 | 727 | 750 | 801 | 81:1 | 8L6 | 805 | 795 | 787
(degrees) |
Mean wet bulb, 6 p.m. | 71:2 | 68:4 | 62:2 | 62:3 | 62:2 | 65:9 | 681 | 73:2 | 75:4 | 75:0 | 74:7 | 74:9 | 729
(degrees) |
Mean maximum ,, 83:2 TT:4 T4:4 75:8 | 76:4 804 | 822 | 87:5 | 868 | 868 | 861 84:5 | 84:3
Mean minimum ,, | 78:1 | 62:0 | 605 | 575 | 575 | 64:2 | 68:7 | 75:4 | 762 | 75:9 | 74:4 | 74:0 | 729
Maximum recorded ,, 88:77 | 84'2 | 805 | 783 | 81:7 | 847 | 88-9 | 99:5 | 912 | 91:3 | 923 | 87-4 | 862
Minimum recorded ,, 65:3 | 497 | 48°7 | 465 | 490 | 575 | 61:0 | 701 | 68:2 | 71:9 | 71:0 | 706 689
Mean daily range ,, 13:3 | 153 | 18:9 | 193 | 185 | 157 | 13:8 | 12:1 | 107 | 10:9 | 11:6 | 105 | 114
Extreme daily range 21:0 | 927 | 25:8 | 349 | 25:0 | 262 | 208 | 24:3 | 171 | 19:8 | 17:8 | 15:0 | 161
(degrees)
Extreme monthly range | 23:4 | 34:55 | 31:8 | 81:8 | 327 | 27-2 | 27-9 | 29-4 | 93:0 | 19:4 | 21:3 168 | 173
(degrees)
Mean maximum solar|134:5 |195:3 | 120-2 |197:9 |199:6 | 186°7 | 140°8 | 147-1 |146:9 |1440 | 146-7 | 140-1 |1392
(degrees)
Total rainfall (inches) .. 775) 164| O54) — — — 031, 001| 658| 14°39) 561| 1376| 5%
Number of wet days ..| 6 7 4 — — — 3 1 18 15 13 16 8
Average fall on wet days| 1:29, 0:23, 013, — — — 010, 0-01) 036| 096| 041| 086| 067
(inches) |
Greatest fallin 24 hours | 3:96| 0:84| 025| — — — 0:19| 0-01 1:60| 553| 238 255, 235
(inches)
Mean monthly relative| 70:9 | 63:83 | 62:8 | 60:5 | 606 | 60:2 | 63:2 | 64:5 | 726 | 71:8 | 70:6 TU | 797
humidity (per cent.)
Highest daily relative | 95:0 | 95:0 | 94:0 | 75-0 | 800 | 730 | 77:0 | 790 | 870 | 950 | 860 | 950 | 950
humidity (per cent.)
Lowest daily relative| 51:0 | 32-0 | 29:0 | 45-0 | 88:0 | 19:0 | 410 | 380 | 58:0 | 570 | 59:0 | 660 | 670
humidity (per cent.) | | |
The determinations were carried out under the
exact conditions recommended, and the standard
flasks used were supplied by the Manila Bureau of
Science. Mixtures of 5 c.c. 10 per cent. oxalic acid,
5 c.c. 1 per cent. uranyl acetate and 20 c.c. water
were exposed daily from 9 a.m. until noon, and the
oxalic acid remaining estimated by titration with
standard potassium permanganate.
TABLE II.—COMPARISON OF TOWNSVILLE WITH OTHER
TROPICAL PLACES.
| ee E Maximum Minimum Sarii
|
Degrees Degrees Degrees Per cent.
Townsville (19°8' S). 79:6 819 | 683 67:0
yearly average
Townsville, Novem- 80:4 86:0 TET 72:0
ber to April
Townsville, May to, — 69:8 71:8 61:2 62:0
October
Colombo, Ceylon 811 871 75:9 811
(6° 56' N.). yearly |
average |
Bombay (18? 54' N.). 79:4 | 95:0 61:0 —
yearly average |
On every occasion duplicate determinations were
made and the mean figures taken.
The results are embodied in Table III, the figures
representing the percentage of oxalic acid decomposed
per one hour. As this method only gives a com-
parative measurement, figures are given in Table IV,
which have been obtained in a similar manner in
other places, and which have been published in the
Philippine Journal of Science [4].
TABLE III. .-MOoNTHLY AVERAGE OF THE PERCENTAGE OF
OXALIC ACID DECOMPOSED PER 1 Hour.
Month Average Maximum Minimum Clear days
1913 Per cent. Percent. | Per cent.
March ie : l: 1 12 out of 29
April 2] = 11978) 21.6 4:0 22 ,, 30
May 15:8 91:4 2:9 15 4, "9l
June 15:4 21:4 41 19. 4. 39
July 18:4 21:0 15:7 18- 5: "8l
August 18:2 20:7 12:9 16 , 31
September 19:3 207 16:8 21 , 9
October 18:2 211 8:5 20). s; 8.
November 18:8 20:9 15:7 18 , 39
December .. 18:4 21:2 4'0 12. 33, 2
1914
January 17:5 21:1 2:9 16 ,, 9)
February .. 18:8 91:4 8:5 16 „ 38
March vi 15:8 22:0 3:6 18 ,, 29
In the accompanying graphs (fig. 2) are given
the daily variations during two months—one, March,
1913, in the wet season with a low average, and the
other, September, 1913, in the dry season with a high
average.
These results show that the sunlight in Townsville
is extremely rich in these rays. The maximum
decomposition, 22 per cent., is higher than any of those
August 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
227
recorded elsewhere, whilst the average is higher than
that recorded at Kuala Lumpur, a place almost on
the equator. The figures also demonstrate that there
is no difference between the hot and cool seasons as
regards the maximum intensity, and that the lower
averages which are obtained during the hot wet
season are really due to the fact that during this time
there are a number of days when the sun is obscured
by clouds, which results in a low decomposition.
The high yearly average is accounted for by the long
dry season with its continuous sunny weather.
TABLE IV.—COoMPARISON OF THE AVERAGE PERCENTAGE OF
OXALIC ACID DECOMPOSED PER HOUR.
| !
Place Date | Average | Maximum| Minimum | Period
Per cent. | Per cent. | Per cent. | Months
Townsville, 19°8’S. | 1918-14 | 17:5 22:0 2-1 | 18
Manila, 14° 86’ N. |1910-11| 12:4 17:8 l1 > 15
Kuala — Lumpur, | 1911 15:3 18:1 9:0 7
3" 10' N. | |
Honolulu, 21°18 N.| 1911 18:8 20:8 9:5 | 10
Bagino (Philip. | 1911 14:2 20:6 69 | 4
pines) |
Khartoum (Sou.| 1911 17:5 20:8 14:8 3
dan), 15° 36' N.
Washington, 38° 59' | 1910-11 | 10:9 19:1 17 11
N.
|
REFERENCES.
[1] CASTELLANI and CHALMERS. ''Manual of Tropical
Medicine," 1913.
[2] Hann. “Handbuch der Klimatologie," 1910.
[3] Philippine Journal of Science, 1912, vii, Section B, p. 1.
[4] Ibid.
PRELIMINARY NOTES ON ENTAMCEBIASIS.
By Lim Boon Kese, M.B., C.M.Edin.
Singapore.
_ As a result of a systematic examination of the
evacuations of all fevers which are not amenable to
quinine and are not typical of enteric fever, I have
found that infection with the entamcbe is quite a
common disease with a most complex and variable
syndrome, entitling it to rank in point of poly-
morphism along with syphilis. We may call this
infection entamcebiasis without qualification, as at
present it is not yet possible to say that the general
disease is solely due to the Entamebex histolytice.
Entameebiasic is then an infection of man by any
species of pathogenic amoeba. So far in my observa-
tions the Entamebe histolytica, or some form closely
allied to it, is the cause cf symptoms here described.
The primary infection generally occurs by the way
of the intestinal canal. It gives rise to the well-
known amoebie dysentery as a rule, or it may be
located in the biliary passages without giving rise to
any intestinal sign or symptom, except gastric irrita-
tion in the form of nausea and vomiting and pain in
the epigastric region. This hepatic infection is often
characterized by an irregular fever which corresponds
to that which was described by physicians in India
as typho-malarial. This fever, which Rogers clearly
recognized, should be called entamcebic fever. It may
closely resemble an ague or remittent fever. Under
quinine it may even assume a tertian or quartan type,
but tends to become remittent. Sometimes it soon
shows intestinal signs in the shape of flatulence and
diarrhoea, and then is easily mistaken for tropical
enteric fever. The urine may show the diazo-reaction,
which is not quite typical, inasmuch as the froth is
coarse and not pink. The stools are charged with the
entamcebe in one form or another.
Sometimes the hepatic infection is very acute and
then we have symptoms of toxemia characterized
by severe urticaria, gastric or hepatic pain, vomiting,
choleraic symptoms, collapse, with more or less fever.
Until complications set in the pulse is unusually slow
(75 to 90 per minute). Both the toxemia and
entamacebie fever may occur without a previous
history of dysentery. More rarely multiple abscesses
may be the first indication of illness, and as a result
there may be developed a distinct form of dermatitis.
The abscesses lead to the formation of enormous
sinuses and fistule in the subcutaneous tissue.
Hepatitis and hepatic abscess is the late manifest-
ation of the entamoebic fever, which may be the
primary disease, or which may arise as a sequela of
amcebic dysentery. Multiple abscesses may develop
under the skin or in the brain or elsewhere.
The protean features of this entamcebic infection
may be summarized as follows :—
PRIMARY INFECTION.
Hepatic Passages —Toxemia, entamebic fever,
entero-colitis.
Intestinal Canal.— Acute ameebic dysentery.
SECONDARY MANIFESTATIONS (infection spreading
from entero-hepatic foci).
Skin Eruptions.—Utticaria, bullous eruption and
ulcers, multiple abscesses.
Bronchitis (chronic).
Hepatitis and Hepatic abscess,
aches, neuralgic pains.
Entamabic Cachexia.— Anemia, anarsaca, albumin-
uria, profuse sweats, debility.
Peritonitis, Ascites, Typhlitis (?)
Relapses are very frequent, and one form may pass
into another. The primary infection may escape notiee
altogether. Death may result from hyperpyrexia and
exhaustion or coma, or from asthenia and cachexia.
Treatment.—The only remedy is emetine chloride
by intravenous, intramuscular, or subcutaneous in-
jection. The maximum doses should be given. One
grain intramuscularly one to three times a day may
be given, and may be repeated until the parasite
disappears from the stools. Burroughs Wellcome and
Co.’s vapurols have been used throughout.
The emetine chloride given by the mouth, even
when keratin coated, gives rise frequently to severe
vomiting unless the patient lies in bed and avoids
drinking large quantities of fluid.
The entamabic fever is cured as quickly and
effectively as the dysentery. The temperature may
come down by crisis with sweating and collapse.
With quinine the fever becomes irregular.
Symptomatic treatment for the collateral complica-
tions as a result of abscess, anemia, debility, &c., is
always necessary.
Sleeplessness is troublesome. Profuse sweating calls
for treatment and is easily amenable to atropine.
obscure head-
228
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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| THE JOURNAL OF
Tropical Medicine andhpgiene
AUGUST 1, 1914.
BRITISH MEDICAL ASSOCIATION.
SECTION OF TROPICAL MEDICINE.
Introductory Address by the President, W. J. Simpson,
M.D., F.R.C.P., C.M.G.
A PLEA FOR A WIDER AND MORE ORGANIZED
APPLICATION OF SANITARY MEASURES IN
THE TROPICS.
GENTLEMEN,—Dr. Williamson, our Secretary,
reminds me that the papers to be read are numerous
and our time is limited. It will accordingly be neces-
sary that the introductory remarks I propose to make
should be few and as concise as possible.
My first duty is to welcome the members of the
Section and to hope that we shall have a successful
and profitable session.
When considering what I should say on this
occasion my thoughts turned to the first meeting of
the Section of Tropical Diseases of the British Medical
Association held in Edinburgh sixteen years ago, and
the great advances in tropical medicine that have taken
place since that time. It was a memorable meeting.
Sir Patrick Manson, the father of modern tropical
medicine, was president of the section and by special
invitation he delivered a lecture entitled " An Exposi-
tion of the Mosquito Malarial Theory and its Recent
Developments.” The exposition consisted of two
parts: the first was a résumé of Sir Patrick Manson’s
important observations on the behaviour of the
malarial crescent outside the human body and its
evolution into sphere and flagellated bodies, and of
his own far-reaching deductions drawn from them
concerning the nature and probable further develop-
ment of the parasite in the mosquito based on his
former remarkable and original work on the life cycle
of filaria in the mosquito; the second part was an
account of the brilliant discoveries of Sir Ronald Ross
on the development and migrations of the malarial
parasite in the mosquito and its transference when
mature from the mosquito to another host. Ross's
observations and experiments not only proved and
established the accuracy of Manson's views concerning
the existence of a life-cycle of the malarial parasite
in the mosquito, but they also led to the epoch-making
discovery that the mosquito by its bite actually
transferred to another host the malarial parasite after
its life cycle had been completed. Those who were
present on that occasion will remember the enthusiasm
which ensued when Manson mentioned he had
received a telegram from Ross announcing his success
in infecting sparrows with proteosoma by having them
bitten by mosquitoes which had fed on birds that
contained proteosoma and which had been kept a
sufficient time for the parasites to pass through their
life cycle and find their way to the proboscis of the
mosquito. It was felt that the master key had been
found to open the door behind which lay revealed the
secrets and mysteries hitherto connected with the
prevalence and prevention of a widespread and
destructive disease, and so it has proved to be.
Time has shown the accuracy of Ross’s observa-
tions. A new line of research as well as a new method
of conveyance of disease was unfolded to the pro-
fession by the work of Manson and Ross, which has
caused a revolution in our ideas as regards the trans-
mission of protozoal diseases and given a powerful
weapon in the hands of sanitarians such as Colonel
Gorgas and others in the Tropies to deal with diseases
established to be insect borne. It is not too much to
say that the world owes a debt of gratitude to Man-
son and Ross. The immediate effect of their work
was that men’s minds, which had been occupied since
the discoveries of Pasteur, Koch and Lister with the
all-absorbing study of bacteria as the causal agents
of disease and of the vehicles by which these bacteria
were conveyed into the human body, were now
diverted to the study of protozoal organisms and the
role of insects in the dissemination of disease. That
study has been exceptionally fruitful and all tropieal
students are familiar with the great advances and
additions to our knowledge that have followed aud
August 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
229
which we owe to the labours of Leishman, Bruce,
Low, Castellani, Dutton, Daniels, Rogers and a host
of other workers. Some of these advances are indi-
cated by the new names that have secured a place
in the literature of tropical diseases such as Leish-
maniasis, trypanosomiasis and phlebotomus fever.
The interest aroused by the British workers and
schools in tropical medicine has created among the
medical profession in all parts of the world a greater
activity than before in the domain of medical research,
and the results are bound to be of the most far-
reaching character. Although, with the exception of
Sir Alfred Jones and some of the Liverpool merchants,
our wealthy men in Great Britain have not awakened
to the fact that endowments for the prevention of
disease are as important as those for hospitals, and
we cannot boast of similar magnificent endowments
for scientific research which Rockefeller and other
men of wealth have placed at the disposal of Americans
for tropical work, yet we live in hopes that encourage-
ment of the same kind may still fall to the lot of our
tropical schools and universities. In the meantime
the demand for carrying on research work is slowly
and partially being met in our own possessions by
the establishment of laboratories in India and the
colonies staffed by medical officers and other scientists.
But the distinction between ordinary routine work
required for clinical and public health purposes
and that necessary for investigations of new problems
which may arise on account of that work or uncon-
nected with it does not seem to be sufficiently recog-
nized. Hence the great danger threatening these
laboratories is the swamping of research by ordinary
routine work because of an inadequate financial and
administrative provision for both classes of investiga-
tion.
While a more liberal encouragement of scientific
research is advocated, it is necessary not to lose
sight of its main purpose, viz., to increase our know-
ledge in order to assist in the diagnosis, treatment and
prevention of disease. There is no risk of the main
object being lost sight of in medical practice, but it is
not the same as regards applied hygiene,in which it is
necessary to beware of laboratory work absorbing
attention to the neglect of the adoption of practical
measures based on knowledge already at our disposal.
Medical knowledge of hygienic value, whether it
relates to that vast amount of information acquired be-
fore or during the present bacteriological and parasito-
logical era, is not of much value unless applied. We
should not be satisfied with its application to the
hygienic protection of Europeans in the Tropics. I
would put in a plea for a wider and more continuous
application of existing knowledge to improve the
health conditions of communities in the Tropics and
a more scientific and organized service than we now
possess to prevent control and suppress disease.
Let us at least have a period of scientific and practical
application following one of scientific research or,
better still, let them go hand in hand.
No doubt many instances can be cited of brilliant
results obtained from the practical application of
existing knowledge. There is the stamping out of
yellow fever in Havana and the Panama Canal, the
abolition of malaria in Ismailia, Durban and Clairfond,
in the Mauritius, and its reduction and improvement
in Panama, Hongkong and many spots and localities
in India, Algiers, Italy, West Africa and the Malay
States, Egypt and the Sudan. There is the reduction
of typhoid fever in the Army in India, and of cholera
in some of the Eastern towns. But allowing full
credit for these and other achievements and the im-
provement effected among the small European com-
munities in the Tropies, the faet still remains that
comparatively little has been done in the Tropics in
this direction. Tuberculosis, cholera, plague, malaria,
dysentery, and other tropical diseases over which so
much time and labour have been expended on dis-
covering their causation and method of transmission,
prevail at one time or another according to the situa-
tion of the locality. It is not that they exist be-
cause of a want of knowledge as to their prevention,
but because well-known preventive measures have not
been taken to prevent them.
What do we generally see on a visit to the Tropics
in that quarter of the town occupied by the inhabit-
ants for whose welfare we are responsible? Water
supplies open to pollution, absence of or defective
drainage, nuisances connected with latrines or absence
of latrines; rank undergrowth and vegetation close
to houses and huts, bad conservancy, and numerous
flies, pools, puddles and marsh land breeding mos-
quitoes, bad housing—which is not so surprising, for it
is unfortunately bad at home, both in town and country,
among the labouring classes—houses closely built
together without order or plan. Many of these
housing conditions may be old and represent a period
before the causes of disease were understood, but this
does not apply to the new ones springing up and
rapidly forming unhealthy areas. It is under these
conditions that death-rates are high and preventible
diseases are rife. Many instances could be given of
the need of organized sanitary service to fight against
tropical diseases, but I shall content myself with one.
Colonel W. G. King, C.I.E., recently showed that
the death-rate in India is more than double that of Eng-
land, that in 1911 feversclaimed 4,207,000, of which one
million (1,000,000) at least may be ascribed to malaria;
plague nearly three-quarters of a million (733,000),
cholera 354,000, smallpox 58,000, and that in sixty-
four large towns the death-rate varied from 30 to
70 per 1,000 of the population, and that the expecta-
tion of life at birth of the Indian male is only 22°59
years against 46°04 for English males, or in other
words, the Englishman has the expectation of being a
citizen at the most useful age for a period of twenty-
three anda half years more than the male Indian. The
Indian authorities are slowly waking up to this
unsatisfactory condition and recently have organized a
sanitary service for towns and municipalities which
was advocated just twenty yearsago. Seven hundred
and fifteen municipalities are to have an organized
sanitary service. It is a creditable advance, but it
is not nearly enough, for it has left out the rural
population. It represents provision of a sanitary
service for 10 per cent. of the population of India,
230
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
while it leaves in a defenceless condition against
epidemic and preventible disease the other 90 per
cent. A country which has lost eight million deaths
from plague in sixteen years must have a better
organization than this to protect its people.
THE DIFFERENTIATION OF STREPTOCOCCI.
THE vexed question of the stability of streptococci
derived from different sources when cultivated on
media containing different carbohydrates and allied
substances has been re-studied by C. Floyd and S. B.
Wolbach and published in the Journal of Medical
Research, vol. xxix, No. 3 (new series, vol. xxiv, No. 3),
January, 1914. The conclusions these authorities
have come to is summed up as follows :-—
It is possible to make, more or less arbitrarily,
divisions of streptococci from human sources, accord-
ng to their fermentative properties in media con-
taining the test substances selected by Gordon.
These properties persist after long cultivation on
ordinary media. The agglutination tests and com-
plement fixation tests support the evidence yielded
by eultural tests.
———»9—————
Abstracts.
INSOLATION : ITS PROPHYLAXIS AND
TREATMENT.’
By Paur G. WooLLEY.
THE treatment of insolation has been based upon
the fact that in that condition too much heat has
been produced in the body, and that too little heat
is given off; in other words, that the disease is due
entirely to heat retention. The whole effort in treat-
ment has therefore been to reduce the temperature of
the body by the application of cold, and by encourag-
ing superficial evaporation. But little account has
been taken of the fact that in insolation abnormal
substances are being produced continuously because
of the increased temperature of the body, and that
these abnormal products (or products in abnormal
amounts) are not being eliminated with sufficient
rapidity to insure the body against their deleterious
action, the brain and heart being especially affected.
Lesions of these organs are the main causes of death.
Insolation (siriasis, sunstroke, heat-stroke, thermic
fever) is a term applied to certain symptom com-
plexes, the result of disturbances of heat regulation.
These disturbances arise primarily from physical
eauses—the heat and water content of the air about
the body, the condition of the peripheral vascular
cireulation, &c., but these causes lead to or produce
chemical changes in the organism, which are mani-
fested in the characteristic clinical symptoms.
' M. H. Gordon. Report Local Government Board, London,
1908, p. 85; Lancet, 1905, vol. ii, 1400; Report Medical Officer,
Local Government Health Board, 1905, p. 972; Journ. of Path.
and Bact., January, 1911, xv. No. 3.
* From the New York Medical Journal, June 13, 1914.
Sunstroke has been attributed to exposure to sun-
light, more partieularly to exposure of the head to
the direct rays. But this does not account for the
large group of borderline cases classed as heat exhaus-
tion or prostration, which are encountered among
stokers, laundry workers, and persons who are
crowded together or who live in hot, badly ventilated,
insanitary rooms, buildings, or barracks. Taking the
whole series of cases that may be included in a
group (represented by the classical hyperpyrexial
sunstroke, by the atypical apyrexial heat-stroke, and
the heat prostrations whieh occur in the absence of
direct sunlight), insolation may occur under any
circumstances in which heat accumulates in the body
and in which the body does not rid itself of its
metabolic end-products. Since metabolism increases
under the influence of abnormal heat, it will appear
that symptoms of insolation are imminent whenever
the heat production of the body exceeds the heat
dissipation, and when, at the same time, the excretory
processes are slowed.
Insolation is an auto-intoxication brought about by
substances formed in the body under abnormal con-
ditions of heat retention.
Preceding the onset of the symptoms, the body has
been losing considerable amounts of water, and
at the same time metabolism has been abnormally
rapid. The draining off of the water produces a
relative concentration of the colloids of the tissues
(the protoplasm), and in this state diffusion of meta-
bolites is less rapid than when the colloidal concen-
tration is normal. As diffusion is diminished, the
substances which should be carried off in the cellular
and body excretions tend to accumulate in the cells
and intracellular substance, and tend again to embar-
rass the cellular activities. It is entirely possible
that this embarrassment results in incomplete split-
ting of certain protein substances, so that instead of
the catabolic processes being carried to the physio-
logical limit, they are stopped, in part at least, at a
point where the toxic portion of the protein mole-
cule (Vaughan) remains unbroken and active, and
so the high temperature of the body, which was
primarily produced by external heat, is subse-
quently caused by protein intoxication. In cases of
apyrexial insolation the cause would be an over-
whelming production of the toxic fragment of protein
which causes collapse. The diminished secretion
associated with increased metabolism—which means
in terms of physiological chemistry retention of acid
products (carbonic acid, lactic acid, &c.), accounts for
the fact that the alkalinity of the blood is diminished
in insolation. Tissue acidosis helps to account for
retention of catabolites, for unless a tissue is giving
up water it does not give up its soluble substances,
and in the condition of acidosis protoplasm does not
give up water, but does the reverse.
Since the body cannot withstand a loss of water of
more than 10 per cent. of its weight, an acute loss
of 3 to 4 kilos must necessarily result in grave
disturbances, collapse, or death. Where losses of
water are so great, evaporation is reduced and
refrigeration decreased.
EU ME
August 1,1914. ] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. ^ 931
PROPHYLAXIS.
This consists in preventing the accumulation of
abnormal amounts of heat in the body. To accom-
plish this there are mediate and immediate methods.
The former applies to habits and clothing, or, in
general, to hygienic surroundings at any time, the
latter to habits during severe hot weather.
The skin should be kept clean to allow free evapora-
tion ; the clothes should be loose and light, moderately
absorbent, but thin enough to allow the air to circulate
freely and so assist evaporation. The diet should be
such as not to create unnecessary demands upon the
system. Alcoholic drinks should be tabooed; plenty
of cool water or mild citrous drinks may be indulged
in to advantage, since they serve to keep the excretory
system freely open and to encourage refrigeration by
evaporation. Fatigue, worry, anxiety should be
avoided as far as is possible. Heavy work in the
open should not be done, and even in the shade it
should be limited. Dwelling houses and living rooms
should be open, and the windows should be shaded
in such a way as to exclude the heat rays without
cutting off what breezes may blow. Fans, of any
sort, are often indispensable, and cool (not cold)
baths are infinitely refreshing as well as useful in
keeping the body at ease.
During times of intense heat, and always during
the hot hours of the day, all physieal effort should
be reduced to an absolute minimum. At such times
rest in the shade, with as little clothing as cir-
cumstances permit, should be indulged in. The
Oriental custom of taking a siesta in the middle of
the day is highly commendable. In addition, it is
advisable to suggest a light diet accompanied by as
much water as can be gratefully consumed. Such a
régime will result in quiet of mind and body and
encourage a useful, moderate degree of perspiration
and evaporation which results in a comparatively
mild state of refrigeration. Attention should be paid
to the excretory organs. Citrous drinks encourage
the renal activities and so assist in the cleansing of
the tissues. Much water will assist intestinal elimi-
nation and so assist in preventing intoxication from
fecal stasis. Constipation must be avoided with
as great care as diarrhoea. Any exposure to the
direct sunlight should be avoided as much as possible,
and when such exposure is necessary it should be
brief. An umbrella is a valuable protection.
TREATMENT.
One cannot expect to remove extravasations of
blood in the brain or meninges in a few minutes or
hours, and still less can one expect to restore the
damage produced by the hemorrhages in less than a
very considerable time.
Often residual symptoms remain, such as a tendency
to relapses, to headache, to partial loss of memory, to
loss of sustained attention, to polyuria, even to
glycosuria. There is the further possibility that
insolation, particularly the moderately severe type,
predisposes to meningitis.
Treatment of an attack of insolation is therefore
one that combines refrigeration with elimination,
both active enough to produce good effects, without
embarrassing organs, such as the heart, which are
already damaged. To accomplish the former the
practice is to give ice-cold packs or baths. To
compass the latter recourse is commonly had to
stimulants. This latter seems not to be best, except
as a last resort. Stimulation of an already burdened
organ can do little good and much damage. Hydro-
therapeutic methods are of more value in insolation
than drugs. Ice-packs or iced baths have a great
value, but should not be continued for more than a
few minutes at a time and should be discontinued
when the rectal temperature has reached 104° F.
To replace the water lost to the body before the
attack, and to increase elimination, there is no better
method than infusion of saline solutions. If it is
true that the oxygen content of the body is low and
the acid content high, then such solutions should be
alkaline. Alkaline solutions are extremely efficacious
whether given by rectum or intravenously, in neutral-
izing the acids of the body and increasing water
elimination by the kidneys. The following solution
for rectal use should be prepared as follows :
Sodium chloride ae y ba £0 grm.
Sodium carbonate! (crystallized) .. 20 ,,
1 For intravenous use the alkaline solution should be very
carefully prepared. The carbonate cannot be boiled. The salt
solution should therefore be made and sterilized, after which the
crystals of carbonate may be added. If the crystallized sodium
carbonate is not available and use must be made of the ordinary
dried form of the salt, the amount indicated in the prescription
given above should be divided by three.
Water es č. E 1,000 c.c.
The injection should be given slowly enough to allow
retention. The time consumed in injecting a litre should
not be less than one hour.
For intravenous injection the following solution may be
used :—
Sodium chloride gis 2 s 14 grm
Sodium carbonate (crystallized) — .. 10 ,,
Water .. ea: 1,000 c.c.
This also should be given very slowly.
The effect of these solutions upon the secretion
of urine is remarkable, and as a rule they will make
it unnecessary to use digitalis. When this latter
drug is used, it should be very carefully administered
and its effects carefully watched. The use of
strychnine is not advised in the active stage of the
disease.
Such treatment will dispose of the immediate
danger, and when this has been done treatment
is symptomatic. Headache may be treated with
acetanilid, phenacetin, salicylates. But these drugs
should be used with extreme caution. This is
particularly true of the coal-tar products. Sleepless-
ness may be controlled with bromides, trional, or
other mild sedatives and soporifics.
In apyrexial heat exhaustion external hydro-
therapeutic measures are uncalled for, and treat-
ment should be eliminative and stimulative. The
internal hydrotherapeutic methods should be very
useful in these cases and should be combined with
friction, massage, warm packs with sufficient in-
ternal stimulant medication.
After recovery from an attack of insolation great
caution must be observed by the patient to prevent
Tee
YODLA ra
232
recurrences from subsequent exposures to heat.
He must pay careful attention to prophylactic
measures, and use the greatest precautions in order-
ing his life. It is advisable for all such persons
to arrange their time in such a way that they
may spend the hot seasons at some great altitude
or cool summer resort. Many tropical countries
have what is known as a summer capital," to
which many people go to escape the heat of the
lowlands.
THE CAUSATION, PREVENTION, AND CURE
OF GOITRE, ENDEMIC AND EXOPH-
THALMIC.'
By RUPERT FARRANT.
Surgical Registrar to the Westminster Hospital.
TOXJEMIAS can be divided into three groups accord-
ing to their action on the thyroid. In the first group
are those that have no effect on the gland; in the second
those that eause a colloid hyperplasia; and in the
third those that cause a complete or acute hyper-
plasia. The microscopical appearances of the colloid
hyperplasia are indistinguishable from those seen
in exophthalmie goitre. No definite signs of hyper-
thyroidism are observed in cases affected with a
single toxemia. Neither are they seen in guinea-
pigs after inoculation with two acute toxemias—the
second being injected before recovery was complete
from the first. But hyperthyroidism, as judged by
the occurrence of exophthalmos, was found in a man
in whom an acute toxemia had supervened on a
chronic. The case was one in which miliary tuber-
culosis had developed on a chronic. It was also found
when a subacute toxemia had supervened on a
chronic. Ten out of twelve cases of cirrhosis of the
liver presented exophthalmos. It had also been
described in chronic interstitial nephritis, which may
be regarded as a chronic toxemia liable to exacer-
bations. As death occurred in these cases soon after
the occurrence of hyperthyroidism, a complete picture
was obtained of the toxeemias causing extreme thyroid
hyperplasia and the thyroid hyperplasia causing signs
of hyperthyroidism.
These examples serve to bridge over the gap
between the thyroid changes found post mortem and
the thyroid changes and hyperthyroidism found clini-
cally in either endemic or exophthalmic goitre.
The object of this paper is to record observations
made on 85 cases of goitre (exclusive of simple
hyperthyroidism) between 1909 and 1914 as to the
relationship between toxæmias and diseases of the
thyroid; to prove that cases in which the thyroid is
diseased, the causatory micro-organism or toxemia
can be determined; to show that in this way not
only can diseases of the thyroid be cured, but also
prevented.
CAUSATION.
It is proposed, for the sake of convenience, to sub-
divide the micro-organisms and toxæmias into four
groups, according to their situation: they are usually
in the mouth, nose, lung, or intestine.
1 From the British Medical Journal, July 18, 1914,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
The Mouth.
Pyorrhea and dental caries are associated with
micro-organisms of all kinds; some, such as the strep-
tocoecus, staphylococcus, and pneumococeus, can at
once be eliminated, as they have no effect upon the
thyroid. Any change must, then, necessarily be
determined by some other infection. Observations
were made at Mr. Landon Whitehouse's dental clinic
in 1901 on cases that attended for teeth extraction.
Signs of hyperthyroidism were found in about 7 per
cent. of cases. Bacteriological examination of the
teeth was made in too small a number for the causa-
tory organisms to be determined. The cases were
mostly females between the ages of 17 and 30. The
history given was that of nervousness, with falling
out of the hair and moistness of the palms of the
hands, slight loss of weight. Examination revealed a
fine moist skin, fine glistening hair, tremor, tachy-
cardia of about 110, perhaps slight prominence of
one or both eyes, with or without general fulness
or enlargement of the thyroid. No one of these signs
was sufficiently prominent for any gross thyroid
lesion to be suspected, but taken together they
showed a typical picture of hyperthyroidism. Cases
of dental caries frequently do not attend until they
are suffering from one of the secondary results, as
chlorosis, dyspepsia, or osteo-arthritis. Observations
were therefore extended to such cases. An exactly
similar condition was found in a few of the early
cases of dyspepsia, in a large proportion of the early
cases of osteo-arthritis, and in some cases of chlorosis.
This association of hyperthyroidism and chlorosis
was first described by Chvostek; he thought it was
a forme fruste of exophthalmie goitre. The symptoms
of hyperthyroidism in these cases pass unnoticed, as
they are masked by the other more prominent effects
of the toxemia. There is one exception, that is,
when the case comes to the ophthalmic surgeon with
unilateral exophthalmos. Any one of the symptoms
of hyperthyroidism may become more prominent than
the others. It may affect the hair, skin, vasomotor
or central nervous symptom; the cases being dia-
gnosed and treated for this one symptom, thus
alopecia, hyperidrosis, urticaria scripta, tachycardia,
and hysteria. Examination has shown that in some
of the cases so affected the other signs of hyper-
thyroidism are to be found.
Case 1.—M. L., female, aged 33. A case with
carious teeth, pyorrhoea, dyspepsia, and commencing
pains in her joints associated with hyperthyroidism,
the most prominent symptom of which was unilateral
exophthalmos. There was some slight fulness of the
thyroid.
The exophthalmos diminished after ten weeks; no
treatment or drug of any kind was given, and she
continued her work.
The relation between the pyorrhea and hyper-
thyroidism is nct merely a coincidence, but is that of
cause and effect, as the following shows. After teeth
extraction, for the first week there is some increase
of symptoms ; they then rapidly clear up for two or
three months, but it is usually six months before they
disappear entirely.
August 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
233
Case 2.—M. W., female, aged 32. A similar case,
but with slight bilateral exophthalmos; refused to
have her teeth removed. She was treated for one
year with the following drugs: Iron, arsenic, nux
vomica, belladonna, and aloin, without improvement.
Her teeth were then put in order; the hyperthy-
roidism disappeared in six weeks.
An attempt was made to follow these cases over
a period of five years—letters were written to ten
cases, no answers were received from nine whose
teeth had been removed; the tenth, who had refused
to have her teeth removed, came up for examination ;
the signs of hyperthyroidism had increased, she had
unilateral exophthalmos, marked tremor, and a pulse
of 120. `
The occurrence of some nervous shock causes an
exacerbation of the symptoms, especially those
connected with the nervous system.
Case 3.—M. M., female, aged 23. Carious teeth,
dyspepsia (for which gastro-jejunostomy had been
performed, associated with hyperthyroidism). Her
teeth were removed, but her father died a few days
later, and she developed typical exophthalmic goitre.
This subsided in a few months. She then nursed her
brother, who died, and she again developed exoph-
thalmie goitre, which again subsided after some
months.
A second toxeemia acting on a gland that is already
in a condition of complete hyperplasia from infection
of the teeth causes an enlargement of the gland, with
an exacerbation of the symptoms, the degree of which
varies with the intensity and duration of the toxæmia.
The symptoms may continue for one to two months
after the infection has to all appearances ceased.
Case 4.—A. L., male, aged 30. He had had bad
teeth since a child, a persistent cough three years,
with slight hemoptysis two years ago. Eighteen
months ago he had had a bad attack of influenza.
He stated that he had always been nervous; he first
noticed palpitation two to three years ago. Following
the influenza his eyes became prominent, he lost
weight, and became weak and tremulous. Examina-
tion revealed acute exophthalmie goitre accompanied
by sleeplessness, delirium and mania, persistent
vomiting, and diarrhoea. Amyotonia was so marked
that it was first thought to be a case of myasthenia
gravis. His mouth was foul from pyorrhea; the
nasal septum was deviated, but there was no evidence
of tuberculosis.
In this case the effect of toxwmias on the thyroid
appeared to be, from the history, that the pyorrhoea
organism caused a condition of hyperthyroidism.
The deviated septum rendered him liable to recurring
nasal infection: the intermittent toxeemia from this
(? Bacillus catarrhalis) caused a further thyroid
change; the last acute attack of this toxemia led
to the development of exophthalmic goitre. The
later history of this patient will be noted under the
heading “ Cure.”
The Nose and Nasal Sinuses.
The nose is one of the sites for acute, subacute,
and chronic infections. Amongst the micrc-organisms
that cause them are: B. catarrhalis, Friedlünder's
bacillus, B. influenzx, pneumococcus, staphylococcus,
streptococcus. Of these, the last three can be
eliminated. Of the others B. catarrhalis was found
from inoculation of guinea-pigs to cause a complete
hyperplasia. The rest were not so injected, but as
they nearly always occur in symbiotic combination
with B. catarrhalis these infections may be regarded
as having such an action—if not from their own
power, from the fact that B. catarrhalis is present.
In a normal nose in a normal individual an infection
with a common or " influenzal" cold would cause a
transient thyroid hyperplasia. The gland would
involute to normal soon after the subsidence of the
toxemia. But if the patient were already in a
condition of hyperthyroidism from any other cause
the fresh stimulus from the B. catarrhalis would
lead to an exacerbation of the hyperthyroidism. The
nose may be abnormal, there may be some deformity
leading to chronic infection and thickening or atrophy
of the mucous membrane, polypi may be present, or
chronic sinusitis—conditions likely to cause a chronic
or constantly recurring toxemia. In these, if
B. catarrhalis was present, thyroid hyperplasia with
hyperthyroidism would occur, as has just been
described in cases of pyorrhaea. It, however, should
be remembered that the nose is generally sterile, and
that an original infecting micro-organism frequently
dies out in the presence of an excessive number of
pyogenic organisms.
The association of exophthalmic goitre with nasal
infections has been described by Hack, Semon, and
Seanes Spicer.
The following examples serve to illustrate the
occurrence of hyperthyroidism and exophthalmie
goitre from these causes:
Case 5.—F. H., male, aged 24. Thirteen months
ago was quite well, and weighed over 12 st.; four
months later he noticed an enlargement of his neck
and other symptoms of exophthalmic goitre; these
steadily increased despite all drugs and antithyroid
treatment. On admission to hospital he weighed
7 st. 4 lb.
For some years he had drunk water from a goitre-
producing well without noticing any thyroid enlarge-
ment. Thirteen months ago he began to work with
lime, the dust from which caused a chronic nasal
irritation. Examination showed that he had ulcera-
tion of the middle turbinals with opacity of his antra.
There was only a slight nasal discharge, a swab from
which showed no growth on culture. An extension
of his infection occurred with pharyngitis, laryngitis,
and some crepitations at his right apex. He lost
9 Ib. in eight days and died. A post-mortem examina-
tion was refused. Thyroid hyperplasia was caused
by the well water, and the exophthalmic goitre from
the fresh toxemia acting upon this.
Case 6.—M. J., female, aged 36. Three years ago
the symptoms of hyperthyroidism had developed with
exophthalmos. Her neck enlarged six months ago,
and she lost 14 lb. in weight. She stated that she
had had bad teeth for some years, and a chronic
nasal discharge. Examination showed a mild type
234
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
{August 1, 1914.
of exophthalmie goitre associated with pyorrhcea and
chronie rhinitis, with perforation of the septal
cartilage. Hyperthyroidism was caused by the teeth
infection and exophthalmie goitre by the sequence of
a chronic nasal infection.
Case 7.—M. B., female, aged 31. For eighteen
months she had noticed the gradual onset of the
symptoms of exophthalmie goitre. She had had bad
teeth for some years, and constantly recurring colds.
Examination showed pyorrhoa, a deflected nasal
septum, with chronic hypertrophic rhinitis.
Case 8.—M. C., female, aged 39. A case of similar
nature, but exophthalmie goitre developed after
chronic sinusitis.
Lung.
The common infection found in the lung is that due
to B. tuberculosis. Its action on the thyroid varies with
the degree of the infection ; miliary tuberculosis causes
a complete hyperplasia, whilst the chronic causes a
colloid hyperplasia. The thyroid changes occurring
in a case of tuberculosis can be arranged in a circle
which passes through the stages of both complete
and colloid hyperplasia to a final condition of fibrosis.
The diameter of this circle is dependent on the extent
of the infection. At one stage tuberculosis is associ-
ated with complete hyperplasia, during which stage
signs of hyperthyroidism may become evident.
The onset of exophthalmos has been described
following the onset of miliary on chronic tuberculosis,
and the condition of the thyroid ratified post-mortem.
The following examples serve to illustrate these
points clinically :—
Case 9.—C. F., male, aged 39. Had early chronic
phthisis; exophthalmos was noted temporarily follow-
ing the development of fresh foci.
Case 10.—F. S., female, aged 22. Developed
whooping-cough two years previously, which was
followed by phthisis, which was said to have been
cured. Latterly she had noticed a fulness of her
neck, which she thought was getting bigger. Examina-
tion showed that there was tenderness and slight
enlargement of the thyroid. Pyorrhawa was present,
aud signs of tuberculosis at the right apex, with
tuberele bacilli present in the sputum.
Case 11.—B. S., female, aged 43. Presented a mild
type of exophthalmie goitre, associated with pyorrhaa
and chronic phthisis. From her history she appeared
to have developed symptoms of hyperthyroidism from
pyorrhesa, the supervention of phthisis caused an
exacerbation which gradually developed into exoph-
thalmic goitre.
Intestine.
The intestine may be the site of all kinds of micro-
organisms, and be the medium through which various
poisons are absorbed. The toxie products may be
divided into two main groups—(a) material derived
from the decomposition of the intestinal contents from
the action of the putrefactive anaerobes: (b) toxins
directly derived from the micro-organisms infecting
the tract.
(a) Decomposition of the intestinal contents occurs
especially when any obstruction is present in the
tract. A toxsemia becomes evident in cases of either
acute or chronic intestinal obstruction and in the
more subtle cases of intestinal stasis. Observations
made on the thyroids obtained post-mortem from cases
of acute and chronic intestinal obstruction have
revealed no signs of hyperplasia. Neither has hyper-
thyroidism been observed in cases of intestinal stasis,
nor have cases of hyperthyroidism shown signs of
intestinal stasis, in fact the reverse—frequent action
of the bowels or diarrheea——is a common symptom.
Many thyroids have been obtained from cases in
which intestinal stasis was present. It is concluded
that there is no evidence to show that products of
the intestinal putrefaction have any action on the
thyroid.
(b) The micro-organisms infecting the intestinal
tract. MeCarrison has shown that some organism
living in the alimentary canal of an infected indi-
vidual gives rise to thyroid enlargement. He pro-
duced goitre in goats by giving them water con-
taminated with the feces of goitrous people and by
feeding them with cultures of the organisms grown
on agar. He obtained the same results by using the
fæces of non-goitrous people.
The Micro-organisms present in Feces.
The micro-organisms may be divided into two
groups, the aerobic and the anaerobic. The true
anaerobic have not been examined beyond the B. aéro-
genes capsulatus, which appears to have no action
on the thyroid.
Of the aerobic, the pneumococcus, streptococcus, and
staphylococcus can be eliminated as having no action
on the gland. There is left the typho-coli series, which
may be subdivided into the B. typhosus, B. enteritidis,
and the B. coli groups. It is proposed to trace these
from the B. typhosus towards the B, coli. Infection
with B. typhosus does not cause a thyroid hyper-
plasia. The result of infection with B. alcaligenes
has not been examined. B. dysenteric& causes a com-
plete or acute hyperplasia, judged from the effect of
inoculation of Flexner's and Shiga’s bacilli into
guinea-pigs and from asylum dysentery in man. Of
the enteritidis group, Gaertner's bacillus, as found in
infantile diarrhoea, causes a complete hyperplasia.
These two groups can be dismissed as being causatory
agents in the production of endemic goitre, as they
are not present in the fæces of goitrous individuals.
It is possible to conceive, however, that when they
are present in combination with other micro-
organisms, they might be concerned in causing
thyroid changes and hyperthyroidism. The B. coli
group is still left. Typical B. coli can be eliminated,
as it is a normal inhabitant of the intestinal tract of
normal individuals.
The Effect of Water on the Coli Group.
A good deal of discussion has arisen as to what is
a normal B. coli. In this work the normal B. col: is
regarded as being one that is a Gram-negative, feebly
motile, non-spore-bearing bacillus, that coagulates
and acidifies milk and produces indol; that forms
August 1, 1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
235
acid and gas from glucose, lactose, dulcite, maltose,
and mannite, but not from sucrose.
A bacteriological examination is needed of the water
supply in goitrous districts, and an examination of
the fæces of goitrous persons coming from these
districts. The presence of the mutants of B. coli in
either would suggest that B. coli had somewhere
been placed under abnormal conditions.
Etiology of Endemic Goitre.
It is proposed now to consider the etiology of
endemic goitre from the point of view of infection
with the B. coli group.
The number of eases among people who have
always lived in London is small. It appears that
goitre rapidly diminished in London after the closure
of the wells and the establishment of a pure water
supply. Still London has an advantage that the
cases seen come from all over the world. Those
examined have come from places as far apart as
Cashmere, Central India, Australia, South and West
Africa, and various parts of England. The character
of the water supplied to these individuals has varied
from 48 per cent. of hardness to snow or rain water,
The strata over which it has flowed has varied from
chalk, granite, clay, and limestone. One can eliminate
both the chemical constituents and the soil as being
direct causatory agents of endemic goitre.
Contamination of Water and its consideration as a
Culture Mediwm.
Goitre is common in the valleys of mountainous
districts. Inquiry shows that the water supply in
these districts is of surface origin, and so liable to
surface pollution. Usually it neither passes through
filtering beds nor stands in volume. These two great
safeguards in the removal of surface contamination
and its consequent micro-organisms are absent. The
same applies to surface wells and springs. Rain-
water, though in the first instance pure, soon reeks
with micro-organisms from the methods adopted in its
collection, and the barrels and tanks in which it is
kept. Water derived from snow is also open to
surface contamination, and micro-organisms survive
longer in water at lower than higher temperatures.
Thus in all these instances inquiry shows that there
are factors present which render the water liable to
contamination, and that they may also tend to the
development of or the prolongation of the life of
micro-organisms derived from such contamination.
Examination of Feces.
Feces of Goitrous Patients.—-Bacteriological ex-
amination of the feces of cases of endemic goitre have
been made. One case had left the goitrous district
nine years.
It may be said that water containing members of
the B. coli group has been supplied to individuals ;
these individuals became goitrous, and mutants of
B. coli have been isolated from their fæces. The
mutants found in the fæces were not necessarily the
same as those found in the water.
If there is any causatory relation between infection
with atypical members of the B. coli group and goitre
formation, it should be possible to experimentally
make an exact reproduction of the series of events.
Evidence might also be forthcoming that the organism
is specific to the individual in whose feces it occurred.
Fixation of the Complement.
Blood has been examined for fixation of the com-
plement in three cases of endemic goitre. It was
found that there was no fixation of the complement.
This was only to be expected, as the condition is an
apyrexial toxemia. No confirmation can be derived
from the complement fixation test.
Pathogenicity and Action on the Thyroid of Typical
and Atypical B. coli.
Guinea-pigs were used in these experiments, as
B. coli is a normal inhabitant of the guinea-pig in-
testine.
Septicamia.
Guinea-pigs received intraperitoneal inoculation
with typical B. coli and with B. coliformis to cause
a septicemia. The thyroids showed an acute hemor-
rhagic hyperplasia.
Toremia Subacute.
Guinea-pigs were fed with bread and milk con-
taminated with fresh cultures of typical B. coli,
B. paracolt, and B. coliformis. Those that survived
the longest showed the colloid hyperplasia indistin-
guishable from that seen in endemic goitre. The
glands appeared enlarged, but as they are small in
guinea-pigs no reliable observations on this point can
be made.
Chronic Toremia.
A similar number of guinea-pigs were fed in an
exactly similar manner, except that they received
smaller doses of the cultures given every alternate
day.
It is concluded that these micro-organisms are
pathogenic to guinea-pigs in the following order:
paracoli, coliformis, and coli. An acute toxemia,
either from intraperitoneal inoculation or by feeding
with large doses of broth cultures, causes the thyroid
to undergo a complete hyperplasia A chronic tox-
wmia causes a change similar, both microscopically
and macroscopically, to endemic goitre, which is most
marked with B. coliformis. Endemic goitre can be
artificially induced in guinea-pigs. The complete
eycle, commencing with water contamination, and the
presence of the mutants of B. coli to goitre formation,
can be performed in the laboratory.
It is concluded that endemic goitre, whether it
occurs in isolated habitations or in goitrous districts,
is caused in man by the chronic ingestion of organisms
of the D. coli group.
B. coli are washed away from surface droppings
and contaminate surface waters, and they become in-
gested by man. The coli, being placed under abnormal
conditions, either in the water or in the upper part
of the intestinal tract, undergo mutation. The mutants
236
are present in the feces of individuals affected with
endemic goitre, and when once lodged there may
remain for many years. The pathogenicity of the
mutants appears to vary; some members cause a
colloid hyperplasia of the thyroid with enlargement
and no signs of hyperthyroidism. It is possible te
conceive that some of the varieties may produce a
toxin capable of further stimulating the thyroid to
a condition of complete hyperplasia accompanied by
signs of hyperthyroidism. At present no further
attempt has been made to separate them, as there
are some hundred varieties. The amount of thyroid
change varies with the degree of infection.
The following may be taken as an example of the
induction of endemic goitre :—
Case 19.—G. F., female, aged 13. At the age of 10 she
went to reside in a goitre distriet and drank well water
for seven months. She then returned tc London;
eighteen months later she noticed an enlargement of
her neck. She was seen a year later and found to
have a general enlargement of the thyroid with an
adenoma of the right lobe. The mutants isolated
from the fæces had negative reactions to litmus milk,
lactose, sucrose, and dulcite.
The Effect of other Toremias acting on a Thyroid
already in a condition of Endemic Goitre.
Pyorrhea.-—The thyroids in cases in which pyor-
rhoea coexisted with endemic goitre were softer and
more vascular than that seen in endemic goitre alone.
Signs of hyperthyroidism were present up to a forme
fruste of exophthalmie goitre.
Case 13. B. catarrhalis.—M. W., female, aged 12.
Had drunk water from a well and developed goitre, as
had her grandmother and sister. B. coliformis was
isolated from her feces. She had a deviated septum
and was constantly catching colds. The thyroid was
soft and evenly enlarged, and there were some signs
of hyperthyroidism. Whilst under observation she
caught several colds. After each of these there was
an exacerbation of the symptoms of thyroid excess,
which subsided about a month after each attack.
Case 14. An Acute and a Chronic Toxrwmia super-
vening on Endemic Goitre.—C. G., female, aged 39.
Resided in a goitre district in the Himalayas from the
age of 18 to 31. Her teeth were removed for caries
when she was 32. She developed whooping-cough
when 364. Her neck enlarged about the age of 30,
accompanied with slight symptomsof hyperthyroidism.
After whooping-cough the hyperthyroidisms increased
and she developed exophthalmie goitre. Seen a year
later, the thyroid presented an adenoma of the right
lobe and isthmus, the symptoms of exophthalmic goitre
had largely subsided, pulse 96. In this case endemic
goitre caused an enlargement of the thyroid; the
pyorrhea, slight hyperthyroidism; the temporary
acute toxemia of whooping-cough caused exoph-
thalmie goitre, which gradually subsided after its
termination.
In a similar way other toxiemias or combination of
toxwmias can be considered, the chronic toxæmias
causing a colloid hyperplasia and the subacute a com-
plete hyperplasia with signs of excessive secretion.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 1, 1914.
Thus small encapsulated adenomata were found in
& case of actinomycosis seven months after infection.
An adenoma occurred in one case a year after the
combination of rheumatic fever and mumps.
Formation of Adenomata.
Colloid hyperplasia is found in two other con-
ditions besides chronic toxemias—namely, during the
involution of either the acute or chronic toxsmias.
They are not generally found during the involution
following a single acute toxemia. They are typically
found in the late stages of exophthalmic goitre, that
is, following a combination of subacute toxæmias.
Masses of colloid are formed from the hypertrophied
tissue, which become encapsuled to form adenomata.
Adenomata after the involution of the chronic
toxemias is typically seen in the late stages of
endemic goitre.
PREVENTION.
It is proposed to separate the diseases of the thyroid
into two groups: (a) Those in which the most promi-
nent feature is hyperthyroidism (exophthalmie goitre
type); (b) those in which the most prominent feature
is thyroid enlargement (endemic goitre type). The
methods adopted in preventing these will be considered
separately.
(a) The prevention of exophthalmic goitre depends
entirely on the recognition of the first stage—the
early condition of hyperthyroidism. The presence of
this is usually marked by the occurrence of nervous-
ness, followed by falling out of the hair, sweating,
and slight loss of weight: examination reveals all the
signs of exophthalmic goitre in a minor degree; its
detection necessitates examination of the skin, hair,
and sweat glands, of the muscular tone, the sym-
pathetic nervous, and the cardio-vascular system.
The cases are to be found amongst those diagnosed
as pyorrheea, dyspepsia, early osteo-arthritis, chronic
rhinitis, tuberculosis, cirrhosis of the liver, and
chronic interstitial nephritis, the last two being of
interest rather than of importance. In these cases
the infection and its results are more prominent than
the signs of thyroid excess. The cases are also to be
found amongst the following, in which one symptom
of thyroid excess is more prominent than the other:
Hyperidrosis, alopecia, urticaria scripta, tachycardia,
myocarditis, hysteria, and exophthalmia. These
cases come under notice, not only in general practice,
but also in the special departments. When a dia-
gnosis is made, the case becomes a bacteriological
study ; both the nature and the focus of the infecting
micro-organisms are to be found. A methodieal
examination should be undertaken, the history of any
past illnesses elicited, and the date of onset of each
noted.
The date of the onset of the symptom of thyroid
excess should be compared with the date of the
occurrence of the toxwmias. In this way a connec-
tion between the causatory toxemia and the hyper-
thyroidism can often be elicited. An examination of
the mouth, nose, lungs, &c., must be carried out for
the site of the infection, and swabs and cultures to
August 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
find the causatory micro-organisms. In those cases
in which the micro-oganisms have been constantly
swallowed a bacteriological examination of the fæces
should be made to find if the organisms have become
indigenous in the intestine. When the causatory
micro-organism and its site has been determined,
means should be undertaken for its removal. Some
minor surgical operation, such as teeth extraction,
submucous resection of the nasal septum, removal of
the nasal polypi, suffice to cure the condition, accom-
panied in appropriate cases with intestinal antiseptics
such as thymol. In the cases that have been so
treated the symptoms entirely disappeared in about
six months; no intestinal antiseptics were used, as
it was necessary to determine the exact connection
between the toxemia and the hyperthyroidism with-
out the intervention of drugs. It may be as well to
state that because carious teeth or a deviated septum
happen to be present it is not sufficient to at once
ascribe the cause to them. Only about 7 per cent. of
cases of dental caries exhibit such symptoms. With
a deflected septum there must be a very definite
history of constantly recurring infection. It is also
as well to remember that owing to the general
vaso-dilatation all the mucous surfaces are flushed.
Enlarged tonsils are but an effect, a part of the
disease.
The following example shows the benefit of pre-
vention.
Case 15.—N. B., female, aged 33, was seen with
signs of early exophthalmic goitre, including double
exophthalmos in association with pyorrhcea and
carious teeth and frequent nasal infection. Six
months after the removal of her teeth no signs of
hyperthyroidism were present. Her sister, aged 38,
gave a history of an exactly similar condition, but
after an acute attack of influenza she developed
exophthalmic goitre which after eight years termin-
ated in myxcedema. When seen, her primary
infecting foci were still present.
(b) Prevention of endemic goitre consists in adopt-
ing the precautions for preventing typhoid fever and
other water-borne diseases.
CURE.
When a comparison is made between the micro-
scopical appearances of a normal gland and those of
exophthalmie goitre one is struck by the enormous
cell increase that has taken place. In the solidifica-
tion of the vesicles there are nearly ten times as
many cells per vesicle; the vesicles themselves are
also increased in number, so that when the gland is
doubled in size the secreting area is increased some
forty times. Involution to normal thus necessitates
a reduction in the secreting calls to 43w. It may be
deduced from the length of time taken for the
symptoms of thyroid excess to disappear in the cases
of simple hyperthyroidism that complete involution
of the gland and the disappearance of the symptoms
in exophthalmic goitre would take over six months.
Any incidental toxemia acting as a fresh stimulus
would lead to a recurrence, the extent and duration
of which would depend on the intensity and duration
237
of the toxemia. Observations have been made on
cases following the removal of the infecting agent.
As far as possible, the patients while in hospital
did not rest in bed—they got up early in the morning
and did ward work, no medicinal or other treatment
was given, so that any improvement could only be
accounted for by the removal of the toxemia.
The treatment adopted and the results obtained
necessarily varied with the nature and the situation
of the infecting micro-organisms. The most striking
results were obtained in the very acute cases in which
the infecting process could be completely removed.
The following examples demonstrate the results
obtained from removal of the infection in the four
common situations.
Teeth.
The toxemia derived from this source has but a
preliminary action. It serves as a basis for the action
of another to cause exophthalmic goitre. Only one
example will be given, as it was discussed under
Prevention.
Case 4 (p. 239)—A. L., male, aged 30. Hyper-
thyroidism was present for three years, associated
with pyorrhea. Following an acute infection in his
nose, to which he was rendered liable by a badly
deviated septum, exophthalmic goitre developed, ac-
companied with acute mania; pulse 130, respirations
36, and extreme myasthenia. He was treated with
all the usual medicinal remedies without avail, and
given up as moriturus. His mouth was put in order,
and twenty-one teeth removed under gas and oxygen.
Five days later he became quiet, and slept, and his
three attendants were no longer needed. After
fourteen days he had put on 23 lb. in weight, and at
the end of three months he had put on 344 lb.;
pulse 108; exophthalmos had disappeared and the
thyroid had diminished 14 in. It was realized that
the onset of any fresh toxemia before involution was
completed would cause a recurrence and probable
death; but owing to myocardial degeneration it was
thought inadvisable to attempt to prevent such by an
operation on his nose or to diminish the effect that
such could have by removal of a portion of his thyroid.
It was hoped that complete involution would take
place before the onset of a toxemia. Four months
later he developed another acute nasal infection, his
symptoms rapidly recurred, and he died in another
hospital despite all medicinal measures.
Nasal Cases.
Cauterization of the nose became the standard
treatment for exophthalmic goitre after Hack, Frankel,
Semon, and Spicer recorded cases cured by the re-
moval of nasal polypi and other nasal affections.
This soon dropped into disrepute, as the majority of
cases are not nasal in origin.
Case 16.—E. L., female, aged 27. Gave a history
of the symptoms of hyperthroidism for some years
associated with carious teeth, and constantly recur-
ring colds. Three months ago she had developed
a very bad cold which lasted for a month, when
238
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
exophthalmie goitre occurred. Examination showed
a soft enlargement of thyroid, an adenoma in the
left lobe, with an average degree of symptoms; pulse
120. The teeth were carious, and right nasal septum
and inferior turbinals were adherent. The adhesions
were divided and the teeth removed ; the symptoms
cleared up with the exception of the adenoma in the
left lobe, which was subsequently removed by opera-
tion. It had undergone cystic degeneration.
Case 17.—L. C., female, aged 26. Gave a four
years' history of exophthalmie goitre. She had
drunk water from a goitrous well, and had carious
teeth and a chronic cold. The thyroid was but
little enlarged, pulse (?) 160, marked exophthalmos,
weight 86 lb. She was kept in bed until her con-
dition had subsided from the last nasal infection,
her teeth were then removed and a submucous
resection performed. In nine weeks she weighed
105 Ib.; the tachycardia and exophthalmos were only
present during excitement.
Case 6. — M. J., female, aged 36. Three years’
history of hyperthyroidism in association with carious
teeth. Her thyroid had enlarged six months pre-
viously. Examination: A firm, hard enlargement of
the thyroid with well-marked exophthalmic goitre,
pulse 150, double exophthalmos, weight 87 lb. Her
nose presented a black slough surrounding a perfora-
tion of the septal cartilage and chronic rhinitis. Her
teeth were removed and the nose treated with nasal
antisepties. In four weeks her neck had diminished
1i in. At the end of fourteen weeks she weighed
194 lb, and the exophthalmos was not noticeable.
During the involution an adenoma developed in the
left lobe of her thyroid. Her heart was left in a con-
dition of some myocardial degeneration with dilatation,
and a pulse of 110.
In the nasal cases for the most part the toxamia
is not always present, but constantly recurs. Removal
of the basal tox:emia causes the symptoms of exoph-
thalmie goitre to subside. After-operations can with
safety be performed on the nose to prevent the
recurrence of the nasal infection and consequent
exophthalmie goitre.
Lung.
From the mieroscopie appearanees of the thyroids
obtained from cases dead of tuberculosis it is con-
cluded that only for a period of a few years is the
gland in a hyperactive condition. It is only during
this time that exophthalmic goitre is liable to develop.
In the early cases hyperthyroidism may be a
transient phase which disappears perhaps to return
after an exacerbation of the tuberculosis or the onset
of another toxemia. Observations have been made
on five cases of typical exophthalmie goitre associated
with chronic tuberculosis of the lungs. They were
of a mild type with the exception of one case, which
is quoted below. The basal toxemia in four was
pyorrhaea. The cases were observed for over a year,
during which time the symptoms partially subsided,
and the gland underwent degeneration with the
formation of adenomata.
Case 18—M. R. F., female, aged 22. Gave a
history of constant colds and hemoptysis at 17,
followed by exophthalmie goitre. ^ Examination
showed a pulsating thyroid, pulse 156, double exoph-
thalmos, weight 115 lb., steadily decreasing. The
nasal septum was deviated, and the mucous mem-
brane in a condition of chronic rhinitis. Tuberculosis
was present in the right apex. Partial thyroidectomy
was performed under Crile’s anoci-association. At
the end of a month there was a great reduction in
symptoms, but she had lost a further 9 lb. in weight.
She was sent to the seaside, and her symptoms
cleared up pari passu with the tuberculosis.
The indications for treatment of exophthalmic
goitre associated with phthisis appear to depend on
the extent of the infection, the degree of hyper-
thyroidism, and the condition of the gland. In the
first stage, when the condition is transient, the treat-
ment should be directed to the tuberculous focus.
The same line also may be adopted in chronic phthisis;
the symptoms subside with the cure of the infection
or upon fibrosis of the gland. In the more acute
variety the treatment will depend on the coexisting
toxemia. In ail cases this should be removed or
prevented. Sometimes it is not feasible, as in the
above case, when prevention involves a serious opera-
tion on the nose. Here it seemed preferable to
remove half the thyroid first, and then to complete
the cure by sanatorium treatment.
Intestinal.
Hyperthyroidism and exophthalmic goitre, caused
by the association of a toxemia with that derived
from the presence of coliform organisms in the intes-
tine, are cured by removal of the source of the
toxæmias.
The simplest of these is when endemic goitre is
associated with carious teeth. Removal of the teeth
and the administration of an intestinal antiseptic
cause a rapid disappearance of the thyroid enlarge-
ment and the symptom of hyperthyroidism.
Case 19.—Female, aged 24. Drank well water from
a goitre-producing well until two and a half years ago.
She had had carious teeth for some years. Examina-
tion showed a soft even enlargement of the thyroid,
medium type of exophthalmie goitre. Double exoph-
thalmos, pulse 92. A mutant of B. coli was isolated
from the fæces which decolorized litmus, sucrose,
and produced no indol. Many carious teeth were
present. After teeth extraction and the administra-
tion of thymol the neck diminished 1 in., the pulse
became 78, and exophthalmos was not noticeable,
and she increased 8 lb. in weight in a fortnight. The
mutant of B. coli was not found after seventeen days’
treatment, three days from the last dose of thymol.
Case 20.—A. F., female, aged 25, was in a condition
of hyperthyroidism from endemic goitre and carious
teeth; exophthalmic goitre developed after an attack
of influenza and pleurisy. She was treated for two
years with drugs and X-rays without effeet.
Examination showed a soft even enlargement of the
thyroid, pulse 120, and marked unilateral exoph-
August 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
thalmos. The carious teeth and inferior turbinals
were removed and thymol administered. In six
months she inereased 25 lb. in weight; the exoph-
thalmos was only present on excitement and her
pulse-rate was 84. An adenoma developed in the
right lobe during involution.
Enlargement of the Thyroid without Signs of Exces:
sive Secretion.
This group may be subdivided into three. («) Those
caused from the ingestion of the atypical forms of
B. coli (endemie goitre). (b) Those caused by the
combined effect of two toxemias other than atypical
B. coli that are capable of inducing a colloid hyper-
plasia. (c) During the involution following either the
acute or chronic toxæmias.
(a) Endemic Goitre.—The history of the case is of
great help in making a diagnosis. Every toxemia
from birth upwards and their date of onset should be
noted. The character of the water supply should be
ascertained both in the district in which the patient
was born and in the districts where they have after-
wards resided, with the dates and the time of onset
of the thyroid enlargement. In this way the cases
may be placed into groups according to their cause.
A routine examination should then be made. A
sample of the water should, if possible, be subjected
to a bacteriological examination and the different
members of the B. coli group isolated. The fæces
are similarly examined and the causatory organism
determined. Before treatment is commenced a care-
ful examination of the gland should be made for the
presence of adenomata and cysts. A preliminary
purge is given (castor oil should not be used), thymol
gr. x in eachets is administered two to three times a
day for fourteen days; after a three days’ interval it
is repeated for another fourteen days. A week later
the fæces are again examined. If the organism is
still present another course of thymol is necessary.
(Fats and oils must not be given within two to three
hours of taking thymol.) Under this treatment the
organisms are killed and the gland rapidly diminishes
in size. The following may be taken as an example
of the sixteen cases treated :—
Case 21.— G. F., female. The paracolon and the
B. lactis aérogenes were isolated from the fæces.
Twelve days after treatment with thymol her neck
had diminished 1 in.; at the end of eight weeks it
was of normal size, having diminished 2 in. She
had previously been treated for six months with syr.
ferri iodidi with only 1 in. diminution.
Group (b).—After the nature of the toxemias has
been determined they should be removed, though for
the most part they have ceased to act before the
cases are seen.
Group (c) consists of adenomata and cysts that
have developed in the course of involution. If the
cause be still present it should be removed ; often it
has ceased to aet long before the cases are seen,
though from the history the causatory agent may be
determined even twenty or thirty years after its onset.
The question arises— Up to what point can thyroid
affections be cured by removal of the cause?
239
Enlargements of the thyroid, whether of the exoph-
thalmie or endemic type, entirely subside after
removal of the cause, providing this is done before
the development of adenomata or cysts. Glands
containing these will subside as a whole, but the
adenomata or cysts are left. The administration of
iodine may cause a slight diminution in their size,
but they have not disappeared even after eighteen
months’ treatment. Gysts and adenomata should be
treated along the usual surgical lines.
The symptoms of excessive secretion a£ first rapidly
diminish after removal of the cause, and then more
slowly pari passu with the diminution in the size of
the gland. Any excitement will for the moment bring
these symptoms again into evidence. If the disease
has progressed so far that the various organs have
become degenerated only partial recovery can be
made. The patient may be left with a dilated heart,
permanent albuminuria or glycosuria, or with some
weakness of the nervous system, either central, peri-
pheral, or sympathetie, leading to feeble mentality,
paralysis of a nerve, or some vasomotor disturbance.
These require appropriate treatment.
Acute Exophthalmic Goitre.
These cases arise from the effect of a toxemia act-
ing on a gland that is already hypertrophied and has
led to hyperthyroidism or typical exophthalmic goitre.
The added stimulus gives rise to an acute exacerba-
tion which may rapidly lead to death. Treatment is
a matter of difficulty, as the five cases quoted show.
Medicinal measures may prove unavailing, removal of
the toxemia may be impracticable, and any attempt
to remove a portion of the gland may prove fatal.
Case 4.—A. L., male, aged 30, developed an acute
catarrhalis infection before involution was complete
from exophthalmic goitre, and died in a few weeks
despite all medical remedies.
Case 5.—F. H., male, aged 30. An extension of a
eatarrhalis infection on exophthalmie goitre caused
death in five days despite medical remedies.
Case 22.—S. L., female, aged 28. Developed an
acute catarrhalis infection on medium type of exoph-
thalmie goitre and went rapidly downhill.! An
attempt to remove half the thyroid under Crile’s
anæsthesia proved fatal.
Case 23.—V. D., female, aged 25. Developed acute
exophthalmie goitre on endemic goitre and teeth in-
fection. She lost 26 lb. in weight, but recovered
under medicinal treatment after appearing moriturus
for some weeks. She now exhibits the combination
of myxedema and degeneration of various organs
from exophthalmic goitre.
Case 24.—M. R., female, aged 51. An acute
exophthalmic goitre developed from the effect of acute
catarrhalis on exophthalmic goitre from chronic
catarrhalis and teeth infection. Recovery after partial
thyroidectomy under Crile’s anæsthesia.
CONCLUSIONS AND SUMMARY.
Endemic goitre is caused by the toxins from the
atypical forms of B. coli. The mutants are usually
240
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 1, 1914.
conveyed by water. They become indigenous in the
intestine, and different mutants of B. coli are to be
found in the fæces of cases of endemic goitre. The
mutants are but rarely present in the fæces of normal
individuals, or in the fæces of individuals goitrous
from other causes. It is possible to conceive circum-
stances which place the B. coli under abnormal con-
ditions in the intestine itself, and lead to mutation
and the temporary appearance of mutants in the
feeces of normal individuals.
The mutants set up an apyrexial toxemia, which
stimulates the thyroid, so leading to a colloid hyper-
plasia and eventually to enlargement of the gland.
The whole process can be imitated in the laboratory,
and endemic goitre induced in guinea-pigs by feeding
with small doses of the mutants.
The supervention of a fresh toxemia whilst the
gland is in a hyperactive state causes a complete
hyperplasia, with absorption of colloid and signs of
hyperthyroidism up to a condition of exophthalmic
goitre. This is dependent on the intensity and dura-
tion of the fresh toxeemia.
Endemic goitre is preventible by the avoidance of
water contamination and by the sterilization of con-
taminated water.
It can be cured by the administration of intestinal
antiseptics, the gland returns to normal, providing no
degeneration has taken place. The gland as a whole
involutes to normal, but the adenomata or cysts are
left.
A condition similar to endemic goitre can be caused
by other toxemias capable of inducing a colloid hyper-
plasia.
Exophthalmic Goitre.
Exophthalmie goitre is due to a combination of
toxsemias of an intensity sufficient to cause a hyper-
plasia with absorption of the colloid material. One acts
during a period sufficient to give rise to a complete
hyperplasia associated perhaps with slightly marked
signs of hyperthyroidism without necessarily any
glandular enlargement. The supervention of another
infection stimulates the gland, which usually enlarges,
and the signs of hyperthyroidism become very evident ;
the case develops into one of typical exophthalmic
goitre. A nervous shock may lead to the diagnosis
by suddenly bringing into evidence the symptoms of
hyperthyroidism, especially those connected with the
nervous system.
The severity and duration of exophthalmie goitre
is dependent on the intensity and duration of the
toxemias. If they be of short duration the disease
will disappear in a few months.
Exophthalmie goitre can be prevented by the
detection of the early cases of hyperthyroidism and
the consequent removal of the basal toxæmia.
Exophthalmie goitre can be cured if the causatory
agents be removed before degeneration has occurred
either in the gland or in those organs that are affected
by the hypersecretion.
When degeneration has taken place in the thyroid,
removal of the toxamias causes involution to take
place only in the hypertrophied portion; the adeno-
mata and cysts are left. These require appropriate
surgical treatment, as they to a certain extent keep up
the symptoms of thyroid excess. Surgical treatment
without removal of the cause is followed by recurrence
unless so much of the gland substance has been
removed that hypersecretion is impossible. Degenera-
tion in the other organs partially recovers after
involution of the thyroid; appropriate treatment is
necessary for those that remain. Acute cases of
exophthalmic goitre may present themselves in which
surgical treatment is the only means of saving them,
though the risk of death under the anesthetic perhaps
precludes operation.
L—— idi —— ———
Hotes and Aes.
LIVERPOOL SCHOOL OF TROPICAL
MEDICINE.
ON Thursday, July 23, 1914, the Countess of Derby
opened a new ward at the Royal Infirmary, Liverpool,
to be known in future as the “Sir Alfred Jones”
Tropical Ward. Heretofore the Southern Hospital
in Liverpool had given accommodation to the cases
of tropical diseases, and placed the beds at the
disposal of the Tropieal School authorities; but as
the chairman, Mr. F. C. Danson, remarked, “They
had, however, grown out of the accommodation
generously provided at the Southern Hospital in
Liverpool, and, having regard to the necessity of
having a thoroughly well equipped laboratory on the
spot so as to enable the students to do their work
close to where the patients were lying, it was
apparent that the Royal Infirmary was the best
site for such a ward, because of its proximity to the
School.”
The Earl of Derby said that Liverpool and its
Tropical School had set an example to the world, and
he was glad they were not now going to lag behind.
He had no doubt that science would be much
advanced by that new ward.
TRIBUTE TO THE LATE SIR A. L. JONES.
Sir Thomas Barlow, at a luncheon given subse-
quently in his honour by Mr. Danson, described the
late Sir A. L. Jones as like a comet, having regard to
the vast amount of valuable work he accomplished in
a comparatively short life. In commending the work
of the Liverpool School of Tropical Medicine, he re-
ferred to the fact that they were about to embark on
a third step in bringing the study of tropical diseases
within the curriculum of the medical undergraduate.
“So long as they maintained the Colonies and the
Colonial Medical Service, and their kith and kin went
out there to work, so long surely it was right to
arouse the interest of their medical students in the
fascinating problems which were erying for solution,
and which, when they were solved, would bring
untold benefit to mankind."
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 16, Vol. XVII.
Original Communications.
A STUDY OF THE NITROGENOUS
BOLISM IN CHYLURIA.
By W. J. Youna.
From the Australian Institute of Tropical Medicine,
Townsville, Queensland,
META-
THE condition of the urine in chyluria has hitherto
been studied from the point of view of the fatty
material which it contains, and very little work has
been done on the albuminous matter and other nitro-
genous constituents. In 1913 and 1914 two cases of
chyluria were admitted to the tropical ward of the
Townsville General Hospital, and the opportunity
was taken to examine the urines with regard to the
distribution of nitrogen in them. The cases were in
the charge of Dr. Breinl, who has contributed the
clinical notes.
Case 1.—Mrs. D., aged 42, was admitted to the
hospital on March 12, 1913. She had lived all
her life in North Queensland, mostly in the north-
western portion. According to her own statement
she noticed about twenty years ago that her urine
suddenly became milky in appearance, and clotted into
jelly-like masses if left standing for any length of time.
She did not notice any blood in the urine at the time.
This condition was not accompanied by any discom-
fort and she suffered no pains whatsoever. Within
the last ten years, however, she had experienced dull
aching pains in the small of the back and had
observed at times that the urine was stained with
blood. At no time was any difficulty experienced in
passing the urine.
On examination no physical signs could be detected.
The patient was a tall well-nourished woman and
seemed hardly affected in her well-being by her
condition. The urine had a milky appearance and
when allowed to stand for some time gelatinous clots
formed. The blood of the patient had never been
previously examined for filaria. Samples of the blood
were taken on admission and at varying intervals
both in the day and night time, but it was never
found to contain any filaria larvie.
The patient remained in the hospital for nearly
seven weeks, being treated at first with increasing
doses of oleum terebinthini. As this treatment did
not seem to give any relief it was changed to ichthyol
in capsules.
The bladder was washed out with a solution of
silver nitrate, which was increased from 4 to 8 gr. per
16 oz. Her diet was carefully regulated and all fats
in the shape of milk, butter, &c., were banished from it.
During the whole time in the hospital her tempera-
ture only rose on two days to 99? F. with a corre-
sponding rise in the pulse-rate, but was always normal
otherwise.
On the whole neither the turpentine nor the
ichthyol affected the condition. The urine was
always milky. The washing out of the bladder with
silver nitrate, however, seemed to give the patient
some relief.
The patient left the hospital on April 28, without
showing any improvement as regards the condition
of her urine.
Case 2.—Matthew F., aged 23, a miner, was
admitted to the hospital on December 13. This
patient had spent all his life in North Queensland,
north of Cairns. He noticed firs& about eight years
ago that he had difficulty in passing his urine as it
contained small jelly-like, blood-stained clots. He
noticed further that his urine became milky and
clotted when left standing for some time. At the
same time he had dull aching pains in his back. His
urine then remained milky for about two weeks.
Ever since he had the same kind of attacks periodi-
cally, which lasted only for a short time, the urine
being quite normal in the interval.
Within the last three months, however, his urine
had remained milky continuously, being often very
much blood-stained, and was always more cloudy in
the morning than during the rest of the day. With
the exception of his trouble in passing the urine, and
slight pains in the back, the patient felt quite well.
On admission, no physical signs could be detected ;
there was no swelling in the groin, nor any other sign
of filariasis. His blood was examined repeatedly
at different hours of the day and night, but filaria
larva could never be found. His urine was slightly
increased in amount, varying between 48 and 104 oz.,
the increased quantity being due to the administration
of diuretics. The urine was milky and generally of a
pinkish colour.
The treatment consisted first in the administration
of oleum terebinthini in increasing doses, starting
with 21 minims daily and increasing to 84 minims.
This medication was kept up for nearly three weeks,
but did not seem to effect any improvement. Ichthyol
in pill form was substituted later, beginning with
15 gr. daily and increasing to 30 gr. As this did not
affect the condition to any appreciable extent, methy-
lene blue was administered in gelatine capsules up to
20 gr. daily.
The urine improved slightly, the morning urine
became quite clear for a time, but the daily urine was
still of the same condition as before. The improve-
ment, however, only lasted for a few days.
Diuretics seemed to be the only effective remedy,
as during the time of their administration no retention
took place. The patient was kept in bed on a fat-free
diet.
The temperature remained normal all the time
he was in the hospital.
He was discharged on March 16, 1914, without
showing any improvement in the condition of his
urine.
Both these cases were true chyluria. The urines
always contained fat, which could be extracted with
ether, but the milky appearance could not be entirely
removed in this way.
Anestimation of the quantity of fat in the urine was
only made on one twenty-four-hour sample in each case.
This was done by a modification of Meig's method
for determining the fat in milk. 100 c.c. of urine
were shaken in a stoppered cylinder with a mixture
249
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
of ether (20 c.c.) and alcohol (20 c.c.). The fluid
was allowed to stand for a few minutes and the
ethereal layer removed into a tarred flask, by replacing
the cylinder by a rubber stopper containing the well-
known wash-bottle arrangement of tubes, dipping
down just above the junction of the two layers. This
extraction process was repeated three or four times,
the ether was then evaporated off, and the flask and
contents dried at 100° and weighed. The twenty-
four-hour sample in Case 1 contained 1°8 per cent.
and that in Case 2, 2'6 per cent. of fat.
A quantity of protein was present which showed
the properties of the proteins of the lymph. It
coagulated when the urines were heated to 70 to 75? C.
and contained a globulin precipitated by half satura-
tion with ammonium sulphate, and an albumin
precipitated when the liquid was completely saturated
with this salt.
On standing, large jelly-like masses formed in the
urines, due to the action of the clotting enzymes of
the lymph on the proteins. This could be prevented
by collecting the urines in a vessel containing
potassium oxalate, when the urines remained quite
liquid and free from all clots, and in the analyses
tabulated later this procedure was always followed.
In Case 1 the sediment on centrifugalization con-
tained some leucocytes, a varying but always small
number of red blood corpuscles, epithelial cells and
crystals. After prolonged centrifugalization, or after
standing in the presence of antiseptics for some days,
the fluid became somewhat clearer, but no distinct
separation into two layers could be observed
In Case 2, a separation into two layers was often
observed, a pinkish blood-stained, slimy bottom layer,
containing the sediment, and a second milky layer.
The sediment when examined microscopically con-
sisted of red and white corpuscles and granules.
In neither case was any sugar found in the urine.
In Case 1, a fairly complete analysis of the nitro-
genous constituents of the urine was made daily for a
period of fourteen days. The results are given in
Table I, all the constituents being expressed in terms
of the nitrogen they contain.
The protein nitrogen was determined by adding
20 c.c. of a saturated solution of sodium chloride to
100 c.c. of the urine contained in a 200 c.c. measuring
flask, making faintly acid with acetic acid, and coagu-
lating the protein by immersing the flask in a bath of
boiling water for thirty minutes. The mixture was
then eooled, niade up to the mark with distilled water,
filtered, and the unpreciptated nitrogen determined in
an aliquot part of the clear filtrate by Kjeldahl.
The difference between this non-protein nitrogen,
calculated up to the original volume of the twenty-four-
hour urine, and the total nitrogen of the urine deter-
mined by Kjeldahl, corresponded to the nitrogen
present as protein. "The absolute quantity of protein
may be obtained by multiplying this figure by the
usual protein-nitrogen factor 6'25. "This method is
much simpler than the usual one of weighing the
coagulate, since it avoids the laborious process of
washing and drying to a constant weight. Moreover,
in these urines, fat is carried down with the coagulate.
and this would have to be removed before the protein
could be weighed.
The result by this shorter method is substantially
the same as is seen in the following experiment in
which the protein was determined by both methods
in samples of the same urine. The figures are caleu-
lated for the total volume of urine for twenty-four
hours.
Total nitrogen of urine 1:310 grm.
Uncoagulated nitrogen 6:350 ,,,
Protein nitrogen 0:960 6:00 grm. protein.
By weighing the coagulate after washing, drying,
extraeting the fat with ether and drying to con-
stancy, 6'06 grm. were obtained. In every case the
clear filtrate from the protein precipitation was
tested to see that it was quite free from protein, and
if any was found a fresh determination was made.
The other nitrogenous constituents were determined
in the urine after removal of the protein, urea by
Folin’s potassium acetate method, ammonia (Folin),
uric acid (Folin-Schiifer), creatinine and creatine
(Folin).
The patient was maintained on a diet consisting of
lean meat, bread and potatoes, the nitrogen content
of which was approximately 15 grm. However, the
quantity of food represented by the amount of
nitrogen invariably proved more than that dictated
by the patient's appetite, and some food was always
left untouched.
The weight of the patient was unfortunately
not taken, but she was above medium height and
showed no signs of wasting.
The quantity of protein-nitrogen excreted per
day varied considerably, from 0°49 grm. to as much
as 1°94 grm., the average for the fourteen days being
0'95 grm. per diem, corresponding approximately to
6 grm. of protein.
Table I shows a low grade of nitrogenous meta-
bolism. The non-protein nitrogen representing
protein actually utilized in metabolism was very
small in quantity, the average twenty-four hourly
excretion being 6°39 grm. This represents approxi-
mately only 40 grm. of protein catabolized.
lf the protein nitrogen be left out of account the
other constituents of the urine show a normally
balanced nitrogenous metabolism. When considered
in percentages of the total non-protein nitrogen they
are of the same order as those given by Folin (Ameri-
can of Journal Physiology, xiii, p. 70) for similar
levels of catabolized protein. Thus the urea rises and
falls with the total non-protein nitrogen representing
on the average 69'4 per cent. of this nitrogen, whilst
the ammonia corresponded to 6'6 per cent. and the
uric acid to 2°2 per cent. The quantity of creatinine
nitrogen excreted is rather low, the average being
only 034 grm. per diem, or 55 per cent. of the
non-protein nitrogen. The ereatinine in the urine of
normal individuals represents the tissue or endo-
genous metabolism, and is independent of the
quantity of nitrogen in the diet. The percentage of
the total nitrogen which is excreted as creatinine
Creatinine x 100
or iii ATL
“Total nitrogen therefore increases as the total
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, AUGUST 15, 1914.
Dr. D. E. ANDERSON, M.D.London,
Lecturer on Tropical Diseases at Mansfield College, Oxford.
— eee ee ee ee
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
243
TABLE I.
| NITROGEN A8 PER CENT. OF NON-PROTEIN NITROGEN
Volume in | | Protein Non-
Date cubic cen- Gravity Biel as protela | PUES
| timetres | nitrogen | nitrogen Urea | Ammonia Creatinine| Uric acid | Urea Econ Oinati: br Misa di
1918 |
April 8 975 | 1014 T31 0:96 6:35 40 | 045 0:34 0:13 74:0 Tl 54 | 20 11:4
via 1,112 | 1012 7:21 0:94 6:27 4°75 0:51 0:40 0:17 7577 81 6:4 2:7 5u
»» 10 1,113 | 1014 6:98 1:00 5:98 4:34 0:38 0:34 0:12 72:7 6:3 567 | 20 13:3
yy lH 1,220 | 1013 8:25 1:13 1:12 4:98 0:60 0:39 0:16 .69:9 8:4 5:5 2:28 13:9
x 44 1,070 | 1016 7:52 0:60 6:92 4:87 044 | 0:34 0:15 70:4 6:3 4:9 2:2 16:2
» 18 990 | 1016 7:12 | l44 5:68 3:97 0:36 0:38 0:08 69:9 6:3 67 | l4 14:2
n 14 760 | 1017 6:79 | 0:83 5:96 | 3:87 0:32 0:34 0:16 64:9 | 54 577 2:7 21:3
» 15 730 | 1017 6-01 0:82 519 | 842 0:05 | 0:34 0:13 66:0 | 48 65 | 2:5 20:2
>» 16 666 | 1016 , 6:68 1:94 4:74 3:00 0:335 | 033 0:14 63:3 T4 7:0 2:9 19:4
s d 890 | 1018 | 8:16 0:49 7:67 5:13 0:46 | 034 0:18 668 | 60 44 2:3 20:8
; 18 785 | 1018 | 8:68 0:62 8:06 6:01 0:50 0:38 0:19 74:4 | 62 47 | 24 12:3
» 19 935 | 1012 | 7:22 1:27 5:95 3°71 0:36 0:27 0:13 62-4 6:0 45 | 2:2 24:9
5» 20 640 | 1018 | 6:08 0:82 5:26 3:10 0:40 0:28 0:11 58:9 76 | 53 | 24 26:1
» 21 930 | 1020 | 8:79 0:53 8:26 6:11 0:56 0:27 0:15 74:0 6:8 39:3 | 1:8 14:2
Average .. its as T34 0:95 6:39 4:49 0:42 0:34 0:14 69:4 6:6 54 | 2:9 16:9
— —— H— — nl —o——€— MÀ i —Àá a Eee
protein catabolized decreases, and at a protein level
corresponding to that of the patient this ratio is
normally somewhat higher than was observed in this
case.
Case 2.—In this experiment the patient was kept
on two different diets. During the first eight days
the diet consisted of lean meat, eggs, and bread care-
fully weighed out and equal in quantity to 154 grm.
of nitrogen per diem, whilst in the succeeding six
days a diet of eggs, milk, bread and butter was
partaken of which was uncontrolled as regards
quantity.
TABLE II.
— ——————
2 z =] its
zÉ È x a E" ee £83.
ez | & z eB | FE | £5 | 2088
Eg 3 | £ | g2| 22 | 53 $325
S £ E q^ S PS
o
1914 | |
Dec. 20 1,865 | 14-56 | 1:90 | 12:66 | 0-48 | 0-21 | 5:4
» 21 .. | 1,120) 15:25 | 1-81 | 13:44 | 047 | 020| 50
» 2 1,765 | 13°72 | 718 | 11:54 | 0-46 | 0-0 4:0
» 98 1,984 | 15-29 | 3:00 |12-99| 0:54 | 0-11 | 5:3
» 24 2.195 | 14-18 | 2:96 | 11-92 | 0-49 | .. 3:8
» 95 1,525 |14:-931| 8:12. | 11:09 | 0:43 | .. 3:9
s 26 1,880 | 16-18 | 3:39 |1279 | O-52 |... 41
s Bm 2,110 11:68 | 1:57 10:08! 0:37 | 0-20, 5:6
“Average .. |14:38| 249 | 1189| 0-46 | 018 46
Dec. 2€ .. | 1,640 12-21} 2-80 | 9:1 | 0:52 7 Ba
» 29 .. | 2,155 | 11-76] 2-42 | 9:34 | 0-51 555
» 30 ..|2,820|10:58| 2:48 | 8:10 | 0-47 5:8
s 31 ..|2,040| 9-76 | 2-06 | 7-70 | 048 6-2
Jan. 1 ..|8,195| 866) 1:93 | 673 | 0-44 | 66
» 2 1500 806| 1:96 | 610| 0-43 7-0
Average .. | (1017| 297 | 7-90] 0-471 .. | 61
————————————————————————p
The analyses of the urine are given in Table II.
It will be noticed that the volume of urine passed
varled very considerably, the two extremes being
1,120 c.c. and 3,195 c.c. in twenty-four hours.
The daily loss of lymph proteins as determined by
the albumin passed in the urine was much greater
than in the previous case, the daily average for the
fourteen days being 2'40 grm. of nitrogen, equivalent
to 15 grm. of protein. It varied from 10 grm. to as
much as 215 grm. per diem.
TABLE III.
NITROGEN CONSUMED IN FOOD, 15*4 ORM.
NITROGEN EXCRETED
Fieces
Urine Total Balance
14°56 0:95 15:51 — 01
15:25 0:76 16:01 — 06
13:72 1:20 14°92 + 0:55
15:29 oe 15:29 oe + 01
14:18 1-11 15°29 oe +01
14°21 0:99 15:20 +02
16:18 zs 16:18 — 18
11:65 1:45 13:10 + 2:3
4-07
During the first eight days the protein catabolized
daily, as represented by the non-protein nitrogen,
averaged 11'89 grm., approximately 74 grm. of protein,
which is quite a normal figure. The patient consumed
the whole of the food given, and did not find the
amount excessive. In the second period, however,
when the diet was controlled only by his appetite, the
quantity of nitrogen exereted decreased gradually and
steadily the non-protein nitrogen falling as low as
6'1 grm. per diem, corresponding to only 38 grm. of
protein catabolized, a figure below normal. Moreover,
it had not reached a minimum, but was still decreasing
when the experiment ceased.
The only other constituents of the urine which were
estimated were the creatinine and creatine, the former
244
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (August 15, 1914.
being quite normal in amount, the percentage ratio to
the total nitrogen normally increasing as the protein
eatabolized decreased. The second diet had the
advantage of being practically free from creatinine
and creatine, so that the creatinine present in the
urine during this time should give a fair picture of
the tissue metabolism. Creatine was occasionally
present in the urine when the patient was on a meat
diet, but was always absent when the food was
creatine-free.
It seemed of interest to ascertain whether a patient
losing so much protein was maintaining nitrogen
equilibrium, and during the first period when a definite
amount of protein was eaten a balance-sheet was
made out between the nitrogen intake and that
excreted. The total nitrogen in the urine and fæces
was determined in the usual manner, and a sample
of each food was analysed as regards its nitrogen
content. During this experiment the food was care-
fully weighed and the whole quantity was eaten.
Table III embodies the results of this experiment
and shows that the patient was practically in nitrogen
equilibrium, the result of the whole eight days being
a nitrogen retention of 0'7 grm. or about 5 grm. of
protein.
An examination of the figures representing the
quantity of protein passed in the urine in this case
shows that it was not materially affected by the
nature of the diet. In the first eight days the diet
was chosen in accordance with the usual treatment
and was almost free from fat, whereas in the second
period the diet was rich in fat. The quantity of
protein excreted remained on the average practically
the same, and the urine was not altered in appearance
by the change.
Both cases were true chyluria, the urines containing
fat and lymph proteins. It has been pointed out
that in both cases filaria larve could not be found
in the peripheral blood, neither during the day nor
during the night. This absence, however, does not
prove that the ehyluria was not of filaria origin as it
is well known that definite symptoms of filariasis
may be observed in patients, even when repeated and
careful examination does not reveal the presence of
the parasites. Moreover, filaria larvæ may have been
previously present in the blood and may have since
disappeared.
The general protein metabolism was not affected
by the continued loss of lymph. In the first case
the level of protein catabolized was very low, but the
relative quantities of ammonia, urie acid and
creatinine were of the same order as those in normal
urines with similar protein levels of metabolism.
In the second case, when the diet was constant in
amount and of normal protein content, nitrogenous
equilibrium was more than maintained.
The quantity of chyle in the urine as measured by
the proteins excreted was, on the average, the same
whether the diet was free from fat or rich in fat. The
usual practice of reducing the fats to a minimum
does not appear to be justified by this experiment.
The quantity of proteins present in the urines is
the best guide to the condition of the patient in
chyluria, since these are the substances which clot to
jelly-like masses, to which is due the difficulty of
passing urine often experienced.
FURTHER NOTES ON ENTAMCQGBIASIS.
By Dr. Lim Boon KENG.
SINCE writing my last paper I have had many
opportunities of examining patients suffering from
various diseases, which clinically we have been in the
habit of associating with one another, such as rheu-
matism with sciatica, pleurisy, asthma and sundry
skin affections of the urtiearious and erythematous
type. The relation of rheumatie pains, erythema
and prurigo with dysentery and hepatic abscess, has
been noted since the days of Graves and Murchison.
The result of my observations is that all rheumatic
inflammations and rheumatism as seen in Singapore,
are associated with a protozoon organism, whose
characteristics and life-eycles I propose to sum-
marize briefly, leaving to a later occasion to bring
forward clinical and other data to substantitate my
conclusions.
The organism is found in the intestinal canal in
many persons, but mainly in those suffering from
lithemia, rheumatism, bronchitis, asthma, an irregular
remittent fever, various inflammations, sciatica, lum-
bago, urticaria, erythema marginatum, erythema
nodosum, prurigo, impetigo herpetiformis, lichen rubra
acuminata, and chronic gastrodynia. One patient had
painful micturition as if passing gravel, the urine
being red and having a brick-dust deposit. In many
of these patients, the organism is also found in the
sputum, the urine, in the blood and in the skin
eruptions.
As the life-cycles are somewhat complicated, we
may begin with the small free trophozoite amæba,
which has small granules and moves by means of
hyaline pseudopodia. Probably these are similar to
the amoeba described by Noe. They form a plas-
modium, and are embedded in a large mass of mucin-
like substance into which the cells discharge numerous
rounded oval or spindle-shaped granules. This stage
corresponds with the myxamaba state of the myce-
tozoa. From this plasmodium is developed a fungus-
like thallus with cellulose walls with eentral venation.
which sends off branches. The veins are filled with
a mucin-like mass of fibrils, many of which are twisted
round. The substance of the thallus is divided into
many cylindrical cells. The walls are perforated so
that the chambers communicate with one another.
In the substance of the thallus in proximity to the
vein, a crystalline core is developed, there being two
kinds of crystalline bodies, colourless phosphatic and
brownish-red urates. Around these the cells of the
plasmodium grow and build up the crystals, and the
bodies called sori, which develop in the chambers of
the thallus, between the soral masses, which appear
like pieces of indian corn thrown together in a syste
matic way. These are oval or round cysts. From
these grow amcebule and flagelle, which undergo
245
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
development as free amcebe or agglomerate to form
the plasmodium, after pairing and forming the zygote
amceba. This is the propagative plasmodial stage, or
the amcebe may be seen undergoing fission giving
rise to the active forms in which the amceba is phago-
cytie and histolitie. "The parasite may then attack
all tissues causing dysentery, broncho-pneumonia,
endometritis, orchitis, boils and other serious troubles.
Under unfavourable conditions the amabx or
amcebule become encysted, while some form into
spores with the cyst walls, others evidently remain
in the amoeboid stage and creep out when the cyst
ruptures.
It is my impression that we have to deal with
more than one species. At least two distinct species
(that producing dysentery, liver abscess and their
inflammations; and that giving rise to rheumatism
and its allies) may be clinically admitted although
it is possible that in dysentery we have to deal
only with a special phase of the multiplicative stage.
This question of the relationship between dysentery
and the rheumatic states cannot yet be settled. It
is almost impossible at times to say from microscopic
examinations that the ameceboid bodies found in
endometritis, broncho-pneumonia, and skin sinuses
are not the entamcbe histolitiea. And the different
diseases named are often found in persons who have
had an attack of dysentery, although the greater
number of those rheumatic and lithæmic patients
have never had dysentery.
The association of the parasite with the different
diseases is shown by the following table :—
Stage in life-cycle. Condition of host.
(I) Fungus-like plasmo- Constipation.
dium.
(a) Few free ameebe Flatulence, biliousness,
in the fæces. and hepatic congestion,
headache, vertigo, dizzi-
ness, lithamia, pyrosis,
nervous symptoms, urti-
caria.
(b) Granular amceebe Pharyngeal irritation,
also present in colds and bronchitis.
sputum.
(c) Free amcebe plen- Rheumatism, with arthritis
tiful in fæces, and heart disease, toxæ-
sputum and mia, typho-malarial
blood. type of fever, acute
urticaria, prurigo, boils,
&c., tonsillitis, sciatica
and gravel.
Acute dysentery, acute
gastritis and colitis,
broncho - pneumonia,
bronchiectasis and
phthisis, adenitis metri-
tis and pelvic abscess,
peritonitis, ^ nephritis,
appendicitis, hepatic
abscess, pysemia.
(II) Multiplicative phase.
Large granular
amcebe under-
going fission, schi-
zogamy and bud-
ding by means of
chromidia shed-
ding.
Condition of host.
Recovery for the time
being or improvement
in the patient's condi-
tion. Relapse occurs
when the cysts burst
and the parasitesresume
the active róle.
Stage in life-cycle.
(III) Eneysted stage.
(IV) Parasites in all Cachexia, anasarca,
stages flourish in anemia, debility,
the blood in ex- sweats.
tensive areas and
affecting the kid-
neys.
Thus we must note that the variations, relapses
and sequelx of dysentery and rheumatism are due to
the combination of stages as well as to the resistant
character of the cysts, spores and fungi-like state.
The persistence of these diseases is thus explained by
the organism causing them undergoing metamorphosis
and remaining as a harmless saprophyte in the skin
or alimentary canal. When the host suffers from
the influence of cold, worry, or other depressing
causes the trophozoite amcebe assume the multipli-
cative form, and then invade the tissues by attacking
red blood corpuscles or dissolve tissues by means
of a liquid derived from special granules secreted
by their protoplasm. Such liquid causes toxemia,
urticaria, and ephemeral eruptions.
In the thallus are found white crystals probably of
a phosphatic nature, and around the central crystalline
core are amorphous reddish mineral substances in-
distinguishable from amorphous urates. Coiled round
the venation and making impressions on the mineral
core, are spirals of cellulose or mucin. As the thallus
has been seen by me in cases of chronic bronchitis,
asthma, and bronchiectasis, I feel sure we have now
in these the explanation of the origin and presence of
Curschmann’s spirals and of the Charcot-Leyden
crystals and the so-called “exudation cells,” the last
being, no doubt, the amcebe undergoing degeneration.
In one patient such crystals, together with amœbæ
and fragments of the thallus in the urine, give rise to
symptoms such as are due to gravel. If the red
amorphus mineral is proved to be really urates the
difficulty of accounting for the uric acid in rheumatism
and allied conditions is thus also explained. In any
case, in all the patients examined, the presence of
crystals, parts of the thallus and the amcebe accounts
for the irritative, painful and inflammatory conditions
to which physicians have given different clinical topo-
graphical names. My observations show that these
rheumatic conditions are all related. They differ
only with regard to the stage of the parasite and
the resistance of the patient. We are now able to
understand why the benzoates, salicylates, and
aromatic oils are useful in all these conditions. The
value of potassium iodide in asthma, bronchitis,
chronic rheumatism, and enlarged glands is also
explained. The curative influence of arsenic is no
longer a mystery.
Therapeutic Note.—The details of the life-cycles of
the parasite have yet to be studied, but so far the
246
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 15, 1914.
changes observed by me explain why our treatment
has, so far, been so unsatisfactory. Emetine hydro-
chloride, the salicylates, and benzoates have no effect
upon the cyst and upon the glutinous covering of the
thallus. Consequently, treatment has to be continued
till the flagellulze and amcebule are formed. When the
organism continues to exist in holophytic fusion by
means of chromatophores and pyrenoid granules
these drugs can no longer influence them.
The latest form of the entamceba is thus unaffected
by the drugs which are rapidly fatal to the amoeboid
organism.
I have, therefore, devised a form of treatment
calculated to deal with the parasite in any stage
of its metamorphosis. In mercurial preparations,
phenol, urotropine, and chlorine or other halogen
gases, we have effective remedies which can destroy
the vitality of the fungi-stage of the parasite. In
the olden days mercury was the treatment for rheu-
matism and doubtless the evil effects were due to the
salivation and mercurialism ; thanks to this humoral
pathology of the time.
But we sbould not administer mercury to the stage
of salivation. For acute dysentery I prescribe grey
powder and salol with pulv. cinnamom. co. and
Dover's powder, followed or preceded by a dose of
castor oil. In severe cases, at least 1 gr. of emetine
chloride should be injected intramuscularly twice
a day at first, and then once daily till no amasbex are
observable in the stools. This stage coincides with
the appearance of formed stools. Then the cysts
and the thallus begin to appear. The thallus stage
is recognized by the presence of granules chromato-
phores, cellulose cell wall, opaque cysts, spirals, and
crystals.
In this condition the antiseptics are required.
I think grey powder with bismuth salicylate or salol
and aromatic chalk the best preparation for this
stage. The carminative waters are useful excipients
or adjuvants even when cachets or powders are
prescribed. In an obstinate case, Yeo's chlorine
mixture for a week is an effective if unpleasant
remedy. In chronic lithemia and bronchial cases
I have found Dr. Carle’s method of administrating
potassium iodide 30 gr. after breakfast and a table-
spoonful of Yeo's mixture after lunch, the latter
mixture being repeated two or three times in the
afternoon at intervals of an hour—a good and certain
way of acting on the parasite.
In nearly all the rheumatic conditions named,
I have since my discovery of the mycetozoan para-
site, treated with emetine, chlorine water or grey
powder with almost better results than the salicylates,
but it is best to combine these remedies according to
the indieations present.
The value of emetine in metrorrhagia, gastrodynia,
hemoptysis, melwna, sciatica, pleurisy, bronchitis,
asthma, urticaria and prurigo is, in my practice,
absolutely established. This fact alone goes far to
prove that these diverse states are due to one cause.
Syphilis affords us the best parallel of a pleomorphic
disease and all forms of which are amenable to the
same specific treatment.
Nature and Name of the Parasite.—As far as I can
make out the parasite is a mycetozoon, and is a
form of chlamydomysca. The fungus stage closely
resembles a mycetozoa I have found in house drains
and is almost indistinguishable from a parasite in the
intestinal canal of fowls. I was led to examine the
fæces of the latter by the fact that subcutaneous
injection of a syringeful of mucus containing live
amob:e produced no effect beyond a transient pyrexia.
Provisionally, we may call it Chlamydosporia
toxifera on account of its toxic effect upon man.
——dÁg———
THE WAR AND DRUG SUPPLY.
AT present there is à SHORTAGE of the following
drugs :—
Salicylate group: Salicylate of soda, salicylic acid,
salicin, and aceto-salicylic acid; bromides (sodium,
potassium, ammonium, &c.); potassium salts: bi-
carbonate, acetate, and citrate; acid tartrate of
potash (cream of tartar), tartrate, and sulphate:
chlorate of potash and permanganate of potash:
glycerophosphates ; liquid paraffin; synthetic benzoic
acid and salts (the following preparations which con-
tain benzoic acid should also be sparingly used:
tr. camph. co., tr. opii ammoniata). N.B.—There is
no reported shortage of benzoin itself and conse-
quently none of tr. benzoin co. (Friar’s Balsam).
Of the following drugs, the supply is NOT TOO
ABUNDANT :—
Citric acid, tartaric acid; synthetic products:
phenazone, acetanilid, phenacetin, &e.; ergot; for-
maldehyde and its derivatives; hexamethylenetetra-
mine and allied compounds ; and gentian root.
ELIMINATION OF THE NARCOTIC ACTION
OF ALCOHOLS BY FATS.
The harmful narcotic action of alcohols of the fatty
series may be eliminated or greatly modified by
administering simultaneously fixed oils or fats. In
the case of amylene hydrate or of paraldehyde, if fat
be introduced into the stomach at the same time, the
narcotic action of these hypnotics may be entirely
eliminated so that doses which, by themselves, would
be powerfully narcotie, are rendered quite inactive.
With ethyl alcohol, the simultaneous administration
of fat has also a very marked action in diminishing
the narcotic effect. It is even possible to obtain a
cessation of the effects of alcoholic intoxication in cats
by administering cream to the animals, provided the
dose of aleohol has not been too great. This action
is remarkable and unexpected. It is not at present
explieable.—M. Sulzmann (Archiv. exper. Path.).
caen
August 15,1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
247
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THE JOURNAL OF
Tropical Medtctne and Hygiene
AUGUST 15, 1914.
BRITISH MEDICAL ASSOCIATION MEETING,
ABERDEEN 1914.
President, Professor R.T. Simpson, C.M.G. (London).
Secretary, Dr. C. A. Williamson (Aberdeen).
First Day. Wednesday, July 99.
OPENING ADDRESS.
THE President, Professor R. T. SIMPSON, G.M.G.
(London), made the opening address, in which he
feelingly referred to the first meeting of this section
held in Edinburgh only sixteen years ago under the
presidency of Sir Patrick Manson, G.C.M.G., on which
oceasion he had unfolded his mosquito-malaria theory
and the remarkable confirmatory discoveries of Sir
Ronald Ross. The immediate effect of their work
was that men’s minds, which had been occupied since
the discoveries of Pasteur, Koch and Lister with the
all-absorbing study of bacteria as the causal agents
of disease and of vehicles by which these bacteria
were conveyed into the human body, were now
diverted to the study of protozoal organisms and the
role of insects in the dissemination of disease. This
study had been exceptionally fruitful and all students
are familiar with the great advances and additions to
our knowledge that have followed, and which we owe
to the labours of Leishman, Bruce, Low, Castellani,
Dutton, Daniels, Rogers, and a host of other workers.
Some of their advances were indicated by the new
nomenclature of disease which was rendered necessary,
such as leishmaniasis, trypanosomiasis, and phlebot-
omus fever. With the exception of Sir Alfred Jones
and some of the Liverpool merchants, the wealthy
men of Great Britain had so far not wakened to the
fact that endowments for the prevention of disease
are as important as contributions to the large hospitals.
It was necessary that the profession should be alive
to the great danger threatening laboratories by the
swamping and research by ordinary routine work
—while a more liberal encouragement of scientific
research should be advocated, it was necessary not to
lose sight of the main purpose, viz., to increase our
knowledge in order to assist in the diagnosis, treat-
ment and prevention of disease. He issued a plea for
a wider and more continuous application of existing
knowledge to improve the health conditions in the
Tropics, and for a more scientifically trained and
organized service than we now possess to prevent,
control and suppress disease.
Many instances could be cited of the brilliant
results obtained from the practical application of our
existing knowledge, such as the stamping out of
yellow fever in Havana and from the Panama Canal,
the abolition of malaria from Ismailia, also at
Clairfond in Mauritius, its reduction in Panama,
Hong Kong, India, Algiers, Italy, West Africa, Malay
States, Egypt and the Soudan. There is also the
reduction of typhoid fever in the army in India, and
of cholera in some of the eastern towns. While
allowing full credit for these and other achieve-
ments, the improvement effected among the small
European communities in the Tropies is still insignifi-
cant. Little has so far been done in the reduction of
the ravages of tuberculosis, cholera, plague, malaria,
dysentery and other tropical diseases over which so
much time and labour have been expended on dis-
covering their cause and mode of transmission. The
quarters of tropical towns occupied by the natives
for whose welfare we are responsible are generally in
a most insanitary state. According to Colonel King,
C.I.E., the death-rate in India is more than double
that of England; in 1911 fevers claimed 4,207,000
deaths, of which at least one million could be ascribed
to malaria, nearly three-fourths of a million to plague,
and 733,000 to cholera; in sixty-four large towns the
death-rate varied from 30 to 70 per mille; and the
expectation of life of the Indian male at birth was
only 22°59, against 46°04 years for English males.
The Indian authorities were slowly waking up from
their unsatisfactory condition, and had recently
248
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
organized a sanitary service for towns and munici-
palities, a measure advocated just twenty years ago.
It was essential that a country which had lost eight
million lives from plague in sixteen years should
have a better organization to protect its peoples.
KALA-AZAR AND ALLIED CONDITIONS,
By Fleet-Surgeon P. W. BASSETT-SMITH, C.B., R.N.
The author applied the term Leishmaniasis to cover
all forms of disease dependent etiologically on the pre-
sence of peculiar protozoal organisms known as Leish-
mania donovani, L. infantum, and L. tropica. These
diseases may be divided clinically into two main groups.
The first in which the diffusion of the parasites is wide-
spread in the body and in which the constitutional
symptoms are severe ; the second in which the parasite
causes but a local and superficial lesion without any
constitutional symptoms.
He proposed to confine himself mainly to the first
group. Kala-azar in India has spread in epidemic form
up the Ganges Valley to the foot hills of the Hima-
layas and has devastated the tea plantations of
Assam. It is now known that many irregular fevers
previously diagnosed non-malarial remittents are in
truth kala-azar. The extension of the disease east-
ward through Thibet into China is now recognized,
the most heavily infected region being in the north-
eastern part between the Yangtse and the Peiho rivers.
To the west the disease extends from India to
Southern Europe by way of Arabia, Persia and the
Caucasus, though endemic areas are present in Central
Africa, Abyssinia, the Blue Nile, Sudan and Egypt,
where it has probably existed for a very long time.
Since 1905 it has been known that leishmaniasis
occurs in Southern Italy and throughout the whole
Mediterranean basin in a form which is particularly
liable to attack young children. In the western
hemisphere, so far there has been but one authentic
record of kala-azar.
From a morphological point of view there appears
to be no means of differentiating the parasite as it
oceurs in India, China, or in the Mediterranean.
The frequency of the parasite in the peripheral blood
appears to vary in different endemic areas; for in-
stance, in Madras the percentage of positive results in
the hands of Patton and Donovan has been very high.
The examination of blood films being a lengthy
process, cultivation of the parasites in N. N.N. medium
presents a much more reliable method of demon-
strating their presence. It was their frequency in
the peripheral blood which led Patton to believe that
the bed-bug (Cimer rotundatus) was the definitive
host of the parasite, though his discovery that inges-
tion of a second feed of blood within a limited time
tends to cause the destruction of the multiplying
organisms in the digestive tract rather seems to
negative this suggestion.
The recent paper by Rogers and Dodd suggested
that the infection in Assam is to a large extent a
house infection. Other vertebrates in some of the
endemic areas are liable to infection and serve as
reseryoir hosts. In India none have been demon-
strated so far, but in the Mediterranean area it has
been shown that dogs not infrequently harbour a
similar parasite and it has been suggested by Lemaire,
Sergant and Basile that fleas convey the infection
from the dog to man, but the supposition is contro-
verted by Wenyon's work. There is no doubt that
dogs ean be infected with the Indian virus of kala-azar
under experimental eonditions, yet apparently as has
been stated, natural infection does not occur. As
regards the flagellates normally inhabiting the in-
testinal tract of fleas and other insects and which may
be mistaken for a stage in the development of leish-
mania, Bassett-Smith is inclined to agree with Wenyon
that all blood-inhabiting flagellates of the ty panosome
group were originally parasites of the insects’ gut
alone, but some have adapted themselves to a para-
sitic life in warm-blooded animals.
There is little doubt now that the virus of the
Indian and of the Mediterranean forms are identical.
There is therefore no advantage in retaining more than
one name for the parasite causing the generalized
infection, either in the far East, India, Africa, the
Mediterranean basin, or America. As regards treat-
ment, in a case under Bassett-Smith’s care on
intramuscular injections of atoxyl (3 to 5 gr.) twice
weekly the parasites could no longer be cultivated
from splenic punctures though still demonstrable in
smears. It is possible that this was due to the
continuous action of atoxyl; clinically, however, no
great improvement in the patient’s general condition
had been observed.
In old standing cases spontaneous recovery may
ensue. Injections of salvarsan have so far been
attended by little success.
Professor GABBI (Rome) read a communication of
the transmission of kala-azar. Basile, he said, first
drew attention to the probability of the transmission
of the parasite from dog to dog and to man by the
agency of fleas. He proceeded on the following
lines :—
(1) Healthy and leishmania-infected dogs were
placed together for a space of time.
(2) Fleas removed from the infected were placed
on healthy dogs.
(3) Puppies were inoculated with the intestinal
contents of fleas from an infected dog.
By these means he was materially enabled to convey
the infection to healthy dogs.
Wenyon carefully checked the third experiment
quoted above and arrived at the entirely opposite
conclusion; this was also the experience of Marshall.
This anomaly Wenyon explains by the fact that Basile
made his experiments in centres where spontaneous
canine leishmaniasis is common and that he omitted
the cultural and microscopical examination of their
bone marrow before pronouncing the dogs free from
infection.
Professor Gabbi related at some length two experi-
ments based on the line of the first two experiments
of Basile and his results were entirely negative. He
therefore thinks that it will be necessary to discover
an insect intermediary other than the dog flea.
In the discussion which followed Dr. D. F.
249
August 15,1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ANDERSON (London) remembered that uta, a curious
disease in Peru, is none other than nasopharyngeal
leishmaniasis. Dr. P. H. BaHR (London) drew
attention to the remarkable absence of both canine
and human leishmaniasis from Ceylon, a country so
closely related both geographically and zoologically
to parts of India.
Professor FERGUSON (Cairo) said that the existence
of leishmaniasis in Egypt had so far not been sub-
stantiated. In Cairo they were familiar with an
interesting form of febrile splenomegaly, in which the
clinical picture resembled kala-azar, though no parasite
could be demonstrated in the tissues either during life
or post mortem. He did not consider that they
conformed to the clinical type of case known as
Banti’s disease.
Dr. G. A. WILLIAMSON (Aberdeen) confirmed
Professor Ferguson’s statements; the disease he
referred to was extremely frequent in Cyprus.
Captain MARSHALL, R.A.M.C., said in his experience
the leishmania commonly disappeared from the spleen
in the terminal stages of kala-azar, a fact he was quite
unable to account for. All the experiments with insect
intermediaries, including lice, had so far given negative
results.
Professor GABBI (Rome) also admitted familiarity
with this disease in Sicily; they were certainly not
examples of Banti's disease which was non-febrile.
He himself had formerly acted as assistant to Banti
and was quite familiar with the symptoms of the
disease which bears the name of this distinguished
Italian physician. Before pronouncing a diagnosis on
kala-azar it was necessary on many occasions to examine
splenic punctures and even the red bone marrow as
well. It was his experience also that the parasites
were apt to disappear from the tissues in fatal cases.
Patton’s experiments on the transmission of the
parasite by Cimez rotundatus required ample confirma-
tion.
PRELIMINARY NOTE ON THE ANKYLOSTOMIASIS
CAMPAIGN IN EGYPT.
In this paper Dr. A. F. MACALLAN (Cairo) outlined
the recently organized campaign inaugurated in that
country.
Up to a few months ago no serious effort to check
the ravages of this disease in Egypt had yet been
made.
A beginning was made in September, 1913, by the
Department of Public Health on the initiative of Lord
Kitchener, to investigate disease in a temporary
annexe attached to the general hospitals. Subse-
quently it was determined to convert it into a
travelling hospital in tents with beds for 100 patients,
the organization of which was on lines similar to
those of the travelling ophthalmie hospitals, in which
the treatment is dispensed gratuitously.
In February of 1914, the director-general of the
International Health Commission founded by Mr.
Rockefeller, visited Egypt; as a direct result of his
visit the commission has granted £6,000 per annum
on the condition that a similar amount would be
contributed by the Egyptian Government.
It has been decided to commence operations in the
province of Shargina with a population of 879,000.
The scheme is to include one large and four smaller
travelling hospitals each capable of dealing with
100 patients. Up to April 30, 1914, 1,011 anky-
lostomiasis cases had been treated ; of these 628 have
been cured and 383 relieved. The absences of worms
or ova from the fæces on the second day after the last
dose of thymol is taken as the definition of a cure.
The seheme has been hampered so far by the lack
of a skilled staff, though they will now be able to
employ two medical men with a proper tropical
training, and who in addition to this work will be
able to pursue investigation into all aspects of this
disease.
The course of treatment as outlined lasts a week.
The first day is the day of admission after the
discovery of ova in the excreta. No food is
allowed after the midday meal. In the evening
1 oz. of sodium sulphate is given which empties the
intestines. On the second day 60 gr. or 4 grm. of
finely powdered thymol 1s given in cachets. Three
hours after the thymol a second dose of aperient
salts expels the worms stupefied by the drug. No oil
or aleohol is allowed and only one good midday meal
during treatment.
A similar line of treatment is pursued on the third
and fourth days. The fifth and sixth are days of
rest during which the patient has three meals a day ;
stools are examined for ova on the sixth morning,
should they be present & second thymol course is
recommenced.
By these means 70 per cent. of cases may be cured
by one course of thymolization in lightly infected
places; in heavily infected areas the results are not
so good by 20 to 30 per cent.
The hemoglobin percentage in the non-infected
fellah varies from 40 to 80 per cent.; the average
rise of hemoglobin after treatment was 19 per cent.
in one locality and 9 per cent. in another.
Out of 1,291 patients in whom the hamoglobin was
estimated, 65 had a percentage of 10 or under.
It is proposed to make an extended trial of Dr.
Ferguson's method in British Guiana, by means of
small repeated doses of 10 gr. of thymol on six days
in the week until 100 doses have been given. This
line would appear to be eminently suitable for the
eradication of the disease from prisons, schools and
labour gangs, but unsuitable for the treatment of a
free and untrammelled adult population.
Other anthelmintics employed are
naphthol and oleum chenopodii. The action of the
former is similar to, but less efficacious than
thymol, whereas oleum chenopodii, given in doses of
45 minims on sugar and followed by castor oil and
chloroform, was inefficient.
It is proposed to make as time permits an anky-
lostomiasis survey of one province at a time in order
to determine the existence or absence of endemic
centres, to elucate the populace by means of lectures
and demonstrations, and to prosecute researches into
sodii, £
250
many aspects of the disease. The common method
of inspection in Egypt either by the oral or dermal
route still remains to be determined. It is a remark-
able fact that no cases of “ground itch” have been
observed.
It is hoped that this preliminary note will at any
rate demonstrate that every endeavour is being made
by the Egyptian Department of Public Health, under
the distinguished directorship of Sir David Semple, to
make the campaign a success.
Dr. F. M. SANDWITH (London), in congratula-
ting Dr. Macallan, described his visit to Egypt in the
spring of the year. He was impressed with the
interest that Lord Kitchener took in this important
work. It gave him great pleasure to take part in the
inauguration of a campaign which he himself (Dr.
Sandwith) had suggested some years ago to Dr.
Harpur in charge of a Church Missionary Society
hospital in Cairo. In his experience pellagra was an
extremely common disease amongst these ankylos-
tome-stricken patients, having found that almost
50 per cent. showed obvious signs of this disease.
Dr. Maeallan, though professionally an oculist, was
undoubtedly the right person to direct the work in
Egypt. His knowledge of the language, habits, and
customs of the country were invaluable. He expressed
surprise at the failure of oil of chenopodin as a vermi-
fuge in Egypt; he understood that Dr. Schaffner, in
Sumatra, considered it superior to any other, a view
also held by two of his correspondents, Dr. Nicoll
and Dr. Linnell, in the Malay States. He suggested
that perhaps the oil of chenopodium supplied to Egypt
was not of the same quality as that employed in the
Malay States.
Professor LLEWELLYN PHILLIPS (Cairo) said he
had had good results from a mixture of eucalyptus
oil, castor oil, and chloroform. From every point of
view thymol and eucalyptus oil were the best vermi-
fuges in his estimation.
A PRELIMINARY NOTE ON SECONDARY CHANGES
DUE TO BILHARZIA OVA IN THE SPINAL CORD
was the title of a short paper by Professor FERGUSON
(Cairo). Bilharzia ova were found widely distributed
throughout the body—in the central cortex, heart,
lung, liver, spleen, and kidneys, as well as in the
reproductive organs. In natives of Egypt who had
exhibited during life anomalous nervous symptoms,
such as mono- and paraplegias, and incontinence of
urine, he had found great accumulations of ova in the
posterior columns and surrounding the central canal
of the spinal cord, where they eaused great destruc-
tion of the nerve elements. Professor Ferguson
showed some microscopic specimens to illustrate his
paper.
Is EMETINE SUFFICIENT TO BRING ABOUT A
RADICAL CURE IN AMU:BIASIS ?
In this short paper Professor LLEWELLYN PHILLIPS
(Cairo) put forward a plea for a much more prolonged
course of emetic treatment in amoabiasis (for three
weeks or more) combined with small doses of a suit-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(August 15, 1914.
able aperient. Emetine readily destroys the ameebic
or active stages of the parasite, but has no effect on
the eysts; hence the patient remains a carrier and a
source of danger to others, while he himself is further
liable to complications and relapses. The following
line of treatment is suggested: hypodermic emetine
for at least ten days or longer, followed by oral
administration of the same drug. This to be followed
by subsequent courses at increasing intervals by
similar injections interspersed with frequent doses
of calomel and thymol.
No ease should be considered cured until after
several examinations, and no cysts of E. histolytica
can be found in the feces.
Drs. SANDWITH and BAHR fully concurred with
Professor Phillips in his views.
Thursday, July 30.
THE EDUCATION AND POSITION OF THE SANI-
TARIAN IN THE TROPICS.
This paper, by Colonel KING, C.I.E., I.M.S. (ret.),
was read, in the inevitable absence of the author, by
Dr. Cantlie. The prevention of disease in the Tropies
should be more vigorously prosecuted than in England.
Medical knowledge demanded a profound acquaintance
with eertain defined sciences largely evolved by and
peculiar to medicine; it deals with man as an in-
dividual. Sanitary knowledge, on the other hand,
whilst possessing a substratum of medical science,
was a compound of all sciences affecting man.
The evolution of the sanitarian in Great Britain
and his adaptation by special education and qualifying
examinations was the result of the natural tendency
to specialism of the profession. In the Tropics, on
the other hand, the sanitarian was largely the out-
come of special epidemic diseases and local conditions,
in which the large areas to be administered and the
sparsity of the European official staff had to be taken
into consideration. At the present day the civil
medical officer in India was a man who had qualified
as a medical practitioner after five years’ study,
though subsequently he may study public health
matters. Such a man in the Tropics had to deal
successfully with mixed medical and sanitary
functions. As the country concerned makes economic
progress, a cleavage occurs in their duties, and a
certain number form a branch of the service dealing
entirely with medieal, others with sanitary matters.
No attempt had yet been made to produce the type
of man wanted as a whole-time sanitarian in the
Tropics, although the London School of Tropical
Medicine recently had by modifications in its curricu-
lum suitably approached the subject.
In the Tropics the sanitarian had not at his dis-
posal experts in the various branches of science he
utilizes.
Already proof was available as to the advantages
of giving the sanitarian in the Tropics a free hand ;
the success of Surgeon-General Gorgas in the Canal
Zone was a case in point. It was therefore neces-
sary that in a tropical government there should be a
distinct cleavage between the medical and sanitary
LÀ — uae — o
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
branches of the service. Whether the sanitary officer
serves a municipality, a district, province or empire,
if he be responsible for giving advice affecting public
funds or interests, he should be subordinate to no
other authority whatsoever than the public body or
government which pays him. There should be no
reason, whatsoever, why the sanitary officer should
be subordinate to the chief medical officer, whose róle
should be curative medicine.
The paper was illustrated by a diagram showing
how under central and provincial governments the
medical and sanitary branches of a public health
service can be worked. In it the several depart-
ments should be independent of each other, though
co-related so as to work under a special branch of
the Government termed the Ministry of Public Health
and Economics. This scheme also provides for an
expert sanitary engineering staff and also provincial
sanitary boards, dealing in consultation with the chief
sanitary officer of provincial governments with major
sanitary works in urban and rural areas.
Professor R. T. SIMPSON, C.M.G., agreed to many
of the points raised in the last paper, but was strongly
opposed to the complete separation of a sanitary from
a general medical education. He considered a primary
medical training to be absolutely essential.
Dr. CANTLIE proposed and Colonel WOOLBERT,
I.M.S., seconded the following resolution, which was
put to the meeting and passed by unanimous con-
sent :—
" Whilst agreeing with Colonel King in his admir-
able scheme for the creation of separate curative and
preventive medical departments in the Tropies, this
meeting considers that there should be no interfer-
ence with the general education of medical students
but that specialization in hygiene should be entirely
a matter of post-graduate training and work."
Dr. BRUCE Low (London) was of the opinion
that without the assistance of properly trained sani-
tary inspectors it would never be possible to build
up and maintain an organized sanitary service in the
Tropics.
There were no fewer than five separate papers
dealing with different aspects of sand-fly fever.
THE BIONOMICS OF THE MALTESE PHLEBOTOMI,
A Paper by Captain P. J. MARETT, R.A.M.C.,
illustrated by numerous microscopical specimens, was
read by the Secretary.
The habits of the sand-fly larva, previously little
understood, were dealt with in detail. They are
devoid of eyes and live in dark places amongst
rubbish ; their food consists for the most part of the
excreta of woodlice, lizards and bats. The requisite
and optimum temperature for these developments is
above 70 F. A certain amount of moisture appears
to be essential. These necessary physical conditions
are found in the interior of rubble walls, crevices of
caves, and especially in Malta in the interior of the
old bastions.
Three species of phlebotomus have been described
by Newstead as occurring in Malta, Phlebotomus
papatasii, P. minutus and P. perniciosus, all apparently
251
capable of subserving as definite hosts for the virus
of sand-fly fever. In Malta the flies appear about
the middle of May in small numbers and gradually
increase in number to the middle of June; by July
fewer are to be seen, but from the middle of August
to the middle of September they swarm again. The
life-span of the adult fly is but a short one, on an
average about seven days. The eggs, 364 X 12 u are
white, but rapidly become darker and are marked
with distinct patterns ; on hatching the minute larve
are of a dull white colour, the head and the two tail
hairs being a shiny black. Increasing rapidly in size
they moult once and assume two pairs of tail hairs.
When about 4 mm. long they become motionless,
empty the intestinal canal and pupate.
The pupa is obtectate and of a dull white colour.
The imagines become sexually mature within a few
hours of emergence ; the maximum distance of
flight in a horizontal direction is about fifty yards,
though the powers of ascending vertically are
limited. They are commonly attacked by an ecto-
parasite a small red mite, and internally by a fungus
Empusa papatasii.
The second paper on
SAND-FLY FEVER,
By Colonel Brrt, A.M.S.,
was also read by the Secretary. He dealt mainly
with the clinical symptoms and laid stress on the
conjunctival injection, and the post-ocular pain,
epigastric distress, intermittent diarrhea, epistaxis
and slow pulse. The blood shows a leucopenia with
a relative decrease in the polymorphonuclear and
eosinophile elements. The lethargy which ensues
after defervescence is a remarkable feature.
In the majority of cases the attack lasts but two
days; occasionally, however, the febrile period may
extend over seven days or more.
After the attack a high degree of immunity is
developed. Second infections in the same individuals
may occur, though they are of extreme rarity.
SAND-FLY FEVER IN CHITRAL,
By Captain GRAHAM, I.M.S.,
was the title of the third paper. The three-day fever
of Chitral originally described by Macarrison in 1906,
tallies in every particular with the disease in the
Mediterranean basin. In the mountainous district of
which the paper treats it never occurs at an elevation
above 7,000 ft. The phlebotomus is represented by
two species, P. papatasii and P. minutus, both of which
are capable of conveying the infection. As regards
racial susceptibility the Gurkhas of the hill country
are more prone to contract the fever than are the
natives from the hot plains of the Punjab, the majority
of whom have previously suffered.
SAND-FLY FEVER IN ITALY.
Professor GALLI (Rome) read a short communication
on sand-fly fever in Italy, where the disease appeared
suddenly after the great Messina earthquake in 1908,
252
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
and when it was with some degree of justice dubbed
by the populace " the fever of the rubbish."
The fifth paper on the same subject was designated
SAND-FLY FEVER IN PESHAWAR,
By Captain Houston, R.A.M.C.
The facts recorded agreed in the main with those
dealt with in the previous papers. The commonest
species of phlebotomus in Peshawar is P. papatasii.
Friday, July 31.
THE SURGICAL TREATMENT OF COLITIS AND
Post-DYSENTERIC CONDITIONS
was the subject chosen by Dr. CANTLIE for discussion.
He described the anatomy, physiological and patho-
logieal conditions of the sigmoid flexure, which,
though so far neglected by the profession, he regarded
as a distinct and important portion of the intestinal
canal; in addition to this it was one of the narrowest
portions and the point at which it was joined to
the rectum was by far the narrowest portion of the
tube. This aperture, which was as well marked as the
os uteri, he had designated the sigmo-rectal pylorus,
a favourite situation of cicatricial contraction as well
as of malignant disease. In post-dysenteric condi-
tions it is always excoriated and ulcerated. ^ For the
diagnosis of pathologieal changes in this part the use
of the sigmoidoscope was absolutely essential, any
change in the mucosa of the sigmoid could thereby be
readily seen. Dr. Cantlie's local treatment consists
in freely applying carbolie acid, subsequently injecting
a solution (1 dr. to 6 oz. water) of collosol argentum
(Crookes) daily for a week and subsequently twice
weekly, if necessary. Usually one week suflices for
cure in the most severe cases. i
Besides being of pathological the sigmoid fulfils
certain physiological functions; the moment faces
impinge on the sigmo-rectal pylorus an intense
desire to pass stool is experienced.
He was averse to examination by the sigmoidoscope
under general anesthesia and was convinced that the
patient's own sensations were the best guide in the
precaution of any accidental laceration of the bowel
wall during examination. He considered the passage
of the sigmoidoscope in itself as being distinctly
benefieial as it tended to dilate the sigmo-rectal
pylorus and thereby promote healing,
COMPARATIVE DISEASES OF THE BRITISH
WEST INDIAN COLONIES
THE
was the title of a paper read by Dr. D. E. ANDERSON
(London) in which he compares the hospital statisties
of the various West Indian Islands compiled from
the Colonial Office Reports.
Dr. BAHR (London) thought it inadvisable to base
any scientific conclusions on such statistics. He
was convinced that diametrically opposite conclu-
sions could be drawn from their study. Hospital
statistics could be no index to the real prevalence or
otherwise of various diseases in different countries.
BERIBERI, THE RICE THEORY AND RECENT
CRITICISMS,
was the title of a printed communication from Drs.
FRASER and STANTON (Malay States). Amongst
writers on the etiology of beriberi during the
last few years, they declared, there are not a few
who have been unable to accept the rice theory,
or as it is sometimes called the “deficiency ” theory,
because they believe it to be incompatible with their
clinical experience. It has been stated that the diets
consumed by peoples among whom they have observed
outbreaks of beriberi were physiologically perfect, but
it has been shown conclusively that a diet, which as
estimated by the methods generally in use is physio-
logically perfect, can cause disease by reason of the
fact that it is lacking in substances the nature and
composition of which have up to the present not been
determined. The evidence so far adduced in favour of
regarding beriberi as a place disease, as an infection
by some micro-organism, or even as an insect-borne
disease could easily be disposed of. The paper
terminated with an appeal to fellow-workers who as
physicians have to deal with outbreaks of beriberi,
and whose experience is opposed to the view that the
disease arises through a defect in diet, to consider
that after all beriberi is but one form of polyncuritis,
a condition which may be induced by a variety of
causes, and that their observations do not necessarily
invalidate the conclusions arrived at in regard to the
origin of the disease elsewhere. Facts rather than
surmises are now necessary if they would combat
effectively a theory the application of which in
practice has been attended by widespread and bene-
ficial results amongst the rice-eating people of the
Orient:
Dr. SANDWITH and Professor SIMPSON regarded
beriberi as the result of a one-sided diet, but thought
that more attention should be paid to diseased con-
ditions of the rice grain itself in producing the disease.
RECENT RESEARCHES ON SPRUE
was the title of a paper read by Dr. P. H. BAHR
(London), whieh was illustrated by a number of
macro- and microscopic specimens. As a result of his
researches which were conducted in Ceylon he con-
cluded that :—
(1) Sprue is a specific disease of tropical and of
sub-tropical countries, though it is possible that
cases occasionally do originate in temperate zones.
(2) It is a disease prevalent in Ceylon, especially
among the Europeans, but, contrary to the opinion
hitherto held, it may occur also in the native, irre-
spective of race or mode of life.
(3) This fact, together with the occurrence of the
disease in people closely associated, suggests a local
influence or some communication of the specific cause
from man to man.
(4) Sprue is à variable disease: it may occur in a
mild or as a particularly virulent form, and in common
with many other serious diseases of intestinal origin,
it is sometimes liable to sudden remissions and latent
periods.
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
253
(5) There is evidence that the disease may occur
as distinct and specific clinical forms according to the
portion of the alimentary canal attacked.
(6) Researches on the composition of the stools
point either to a complete absence or inefficiency of
the intestinal digestive ferments ; researches on the
blood and urine are in favour of regarding sprue as an
alimentary toxemia.
(7) The pathological results of the investigation are
also in favour of this supposition and point to an
infection of the alimentary canal with the thrush
fungus (Monilia albicans) and consequent absorption
of its toxins as being concerned in the production of
this toxemia; the balance of evidence collected is on
the whole in favour of rather than opposed to this
view.
THE VOMITING SICKNESS OF JAMAICA
was the subject of an important paper by Dr. H.
HAROLD SALT, Government Bacteriologist, Jamaica,
which was read by the Secretary.
The disease is of exceptional interest, as it appears
to be limited to the island. Amongst other features
it has a peculiar seasonal prevalence, a tendency to
attack children only, and a very high death-rate.
Since 1905 there have been several outbreaks: in
1907, 1910, 1911 and 1913. During 1913 to 1914
though only twenty cases came to Dr. Salt’s notice
over the whole island all but two died, a 90 per cent.
mortality.
During recent years it has been suggested that it
is but an undefined form of yellow fever, though this
view is not shared by the local medical men.
Symptoms.—The patient, usually a child, is suddenly
taken ill during the night with vomiting followed by
epigastric pain and further vomiting. In a very short
time convulsions ensue, soon passing into a state of
coma and death. The total duration of the illness is
short, the average being about twelve hours, though
in rare instances the whole duration may only be
half an hour. The temperature may reach 101° or
102° F. or it may be normal. Cheyne-Stokes breath-
ing may appear. Kernig’s sign may or may not be
present. The pupils are equal and moderately dilated,
and if the coma is not deep, react normally. "There
may be photophobia; delirium is uncommon.
If recovery ensues the child who has been seriously
ill may be sitting up in bed after twenty-four hours
and up and about again in another forty-eight.
The vomit is never “ black " as in yellow fever.
Bacteriology.—1ln the majority of cases cultural
attempts of blood and cerebrospinal fluid yield negative
results, though occasionally a diploeoecus which in
some respects does not tally with the meningococcus
can be cultivated. This coceus has been assigned
by Seidelin the provisional name of Diplococcus
jamaicensis.
Morbid Anatomy.—The most striking features are
enlargement and hyperamia of the lymphatic glands,
subsericardial petechiw, submucosal gastric hamor-
rhages, necrotic foci in the pancreas, liver and kidneys,
marked hyperemia of the spinal and cerebral pia mater
and intense engorgement and hemorrhages into the
parenchyma of the kidneys, liver, spleen, lymphatic
glands and heart muscle. Cultures of large quantities
of blood drawn from a vein during life have always
proved sterile. As a result of his researches Salt
made the following careful deductions :—
(1) That, in view of the sudden onset in apparently
perfect health, without any prodromata, and the
absence of any bacterial findings in a typical case under
favourable conditions, the weight of evidence is
against the disease being due to a bacteriwmia.
(2) That the rapidity of progress of symptoms
with early fatal termination, or in rarer instances
an equally rapid and complete recovery without
deleterious after-effects, rather indicates the action
of a poison.
(3) That in view of the early symptoms being
gastrie and cerebral, this poison is probably produced
in and absorbed from the stomach; the gastric and
duodenal congestion present tends to support this.
(4) That, since feeding experiments have proved
negative and chemical tests have revealed none of the
organic or inorganic poisons, the poison (if such it be)
may be of the nature of a glucoside.
(5) That the poison spreads rapidly throughout the
whole body, as is evidenced by the hemorrhages and
other changes present in almost every organ and
tissue.
(6) That it produces its effects mainly upon the
liver, as is evidenced by the extensive fatty changes
found in that organ.
(7) That considering the enormous death-rate
(90 per cent. of the cases reported this year), the
first indication for treatment which can be deduced
from the above lines—for it is little more than theory
and conjecture based on observed facts—until the
poison is isolated and its antidote found, is to wash
out the stomach at the very earliest opportunity.
Dr. SANDWITH proposed and Dr. CANTLIE
seconded the following congratulatory message, which
was despatched by the meeting and greeted with
applause by all present :—
“The Section of Tropical Medicine assembled in
Aberdeen in connection with the British Medical
Association Meeting, July, 1914, sincerely regrets
that, owing to his state of health, it was impossible
for Sir Patrick Manson, G.C.M.G., F.R.S., to be
present. Members of the Section feel that they
would be voicing the opinion and desire of medical
men attending the Conference were they to communi-
cate to Sir P. Manson their deep regret at the cause
of his absence, and also that, as a graduate of this
University, they were unable personally to have the
benefit of his company at the sixteenth meeting of
the Section of which he was the first President. The
Section wishes to communicate from the city, his
professional birthplace, the testimony of admiration
for the great benefits Sir P. Manson has, by his work,
conferred upon humanity, and hopes that he may
very soon be restored to vigorous health, and may
long be spared to guide by his advice the advance of
tropical medicine."
The proceedings terminated with a vote of thanks
to the President, Professor R. T. Simpson, C.M.G.,
and the energetic Secretary, Dr. G. R. Williamson.
254
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
Abstracts.
ELEPHANTIASIS AND THE KONDOLEON
OPERATION.’
By HUBERT A. ROYSTER.
A MULATTO, aged 23, born in Virginia. Later he
moved to South Carolina, his present home. During
the summer of 1911 his right leg and foot began to
swell, following an acute attack, accompanied by
pain, redness and fever. In the winter months the
condition improved, but each summer the swelling,
pain and fever returned. The leg has steadily in-
creased in size until it seriously interferes with his
occupation. Locomotion is difficult and wearing of
ordinary trousers impossible.
The enlargement was confined to the right leg and
foot and did not extend above the knee. The cir-
cumference at the calf was 22 in., above the ankle
18 in. and of the foot 14 in. The skin was exceed-
ingly hard, thick and rough; in some portions it was
scaly, in others horny; at the bend of the ankle there
was a wide fold which prevented proper motion of
the joint,
Detailed investigation elicited the following: The
Wassermann reaction was negative; repeated study
of the blood, taken at various hours of night and day,
and continued over several weeks, showed no filariæ ;
at one time a decided eosinophilia (11'2 per cent.)
was present; the urine was normal. The eosinophilia
was most probably due to an accompanying hook-
worm infection, as the eggs were found in the fæces.
It was decided to do the Kondoleon operation.
For four days previous the man was put to bed; each
day the leg and foot were scrubbed in a strong
mercuric chloroid solution, bandaged tightly with
a Canton-flannel roller and kept elevated on pillows.
As a result of this, the leg was reduced in size about
2 in. January 3, 1914, the operation was performed
as follows: A long incision was made through the
skin on each side of the leg, extending from knee
to ankle. Wide retraction of the integument was
secured by dissecting it back freely from each edge of
the incision. Going from above downward, the deep
fascia to the width of three fingers was dissected off
the muscles and cut away in one piece of the length
of the wound. Also, the same area of subcutaneous
tissue was removed by splitting it off the skin. The
muscles were laid bare and free hemorrhage occurred,
requiring many ligatures. The skin was stitched
back in position, dressings applied and the leg
bandaged without a splint.
One week later the first dressing revealed primary
union, except at the lower third of the incision on the
outer side of the leg, where sloughing of the skin
edges had occurred. Undoubtedly too much of the
subcutaneous tissue had been removed, leaying the
skin at that point thin and poorly nourished. The
whole leg was very much smaller (17 in. at the calf)
and the ridge across the ankle had disappeared. One
| From the Journal of the American Medical Association,
May 30, 1914.
month afterward further progress was evident: the
leg had diminished in size, the foot was much more
flat and the patient could walk with comparative
ease. At the present time (April 23, 1914) the
improvement is still evident ; there has been no going
back. The patient is able to get about and will
probably take up his work in a short while.
The auxiliary treatment consisted, first, in the
hypodermie administration of thiosinamin (fibrolysin)
every three days over a period of two weeks while
the patient was in bed. On two occasions a marked
reaction resulted from an ordinary dose and it had to
be given in smaller quantities. Then on April 10, an
intravenous injection of salvarsan was given empiri-
eally, for the purpose of combating the possible
parasitic or microbic origin of the disease, in spite of
our inability to demonstrate the presence of any infec-
tive organism. Since the injection the eosinophiles
have reduced to 6 per cent. It is too early to predict
the final result.
Kondoleon's operation was evolved from the idea
of Lanz, of Amsterdam, who referred to his procedure
as a “ deep lymphatic derivation." But Lanz s opera-
tion is technically difficult, while the operation method
offered by Kondoleon is simple. The principle in-
volved is that, by removal of the deep fascia, there is
brought about an anastomosis between the deep and
the superficial lymph-spaces. The operation is new
and has not been performed in a sufficient number of
cases to warrant any definite opinion; Kondoleon
himself has done it but six times, and, though his
reports were favourable, only two months had elapsed
since the last operation.
Now, more than three months after the operation,
the measurements of the affected leg are; Calf 15tin.,
above the ankle 154 in., and foot 134 in. The sound
leg shows the following: Calf 15} in., above ankle
10} in. and foot 105 in. It will be noticed that very
little decrease has been secured in-the size of the
elephantiasic foot, and a similar operation in that
region is proposed as the next step, provided it could
be done without damage to the tendons. The skin
over the whole leg is much smoother and quite
movable over the underlying tissues.
OBSOLESCENT PELVIC
HYDATID."
By A. CauPBELL Magarey, M.S., M.R.C.S.
Demonstrator of Anatomy, University of Adelaide.
A SOLITARY
A MALE anatomical subject was aged 67 at time
of death. There was no information concerning
symptoms during life.
When the abdomen was opened the bladder was
seen to be distinctly enlarged and thickened, and a
hard tumour observed situated in the middle fossa of
the pelvis, between the bladder and the rectum. The
ureters were much dilated, as was the pelvis of each
! From the 4 ustralasian Medical Gazette, May 19, 1914.
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
255
was considerably thickened, and the inner aspect
showed marked sacculation.
The dimensions of the tumour were: antero-
posteriorly, 2+ in.; vertically, 2+ in.; transversely,
3% in. The tumour was slightly larger on the left,
though it extended across the pelvis. The prostate
was not enlarged; the rectum was dilated above the
tumour.
Though a routine complete anatomical dissection
was made, no further evidence of hydatid disease was
discovered. When opened, the tumour was found to
consist of a thick ectocyst with intramural calcareous
deposits, and within this membranous folds of
gelatinous consistency, between which folds lay the
typical caseous material, characteristic of a dead or
dying hydatid.
The point of particular interest in this case is the
occurrence of a solitary cyst in the lowest part of the
peritoneal cavity, and it would appear to be either
the sole survivor of a multiple infection, which has
escaped destruction by the tissues, or else an instance
of a single infection through the wall of the alimentary
canal, which has gravitated, as occurs with cancer
cells, to the most dependent part of the peritoneal
cavity.
THE USE OF LIQUID PARAFFIN IN
ENTERIC FEVER WITH CONSTIPATION.
By LLEWELLYN P. PHILLIPS.
IN Egypt it is the exception to see cases of typhoid
fever with diarrhoea. Constipation is the rule, and
this constipation is often very difficult to manage.
In eases in which during former acute illnesses
enemata have acted with the greatest difficulty,
paraffin, if an enema is necessary, acts easily and
painlessly, and both my patients and the nurses have
been more than satisfied with the result. It seems
absolutely free from risk and, further, it probably acts
as an emollient dressing to the typhoid ulcers. The
only disadvantage from its use during typhoid fever
has been a little occasional leakage per anum.
The dose is half an ounce at night and, if this be
not sufficient, a dose of half an ounce in the morning
as well; it is best taken floated on the top of a little
soda-water. With such dosage enemata are often
unnecessary, though still often the bowel has to be
washed out so as to remove as much toxic material
as possible.—Lancet, July 25, 1914.
————————— —
eviews.
TROPICAL DISEASES. A Manual of the Diseases
of Warm Climates. By Sir Patrick Manson,
G.C.M.G., M.D., LL.D.(Aberd.), &e., with 12
colour and 4 black-and-white plates and 239
figures in the text. Fifth Edition, revised
throughout and enlarged. Cassell and Co., Ltd.,
London, New York, Toronto and Melbourne.
1914. 12s. 6d. net.
One ean only treat with reverence everything that
issues from the pen of the Nestor of tropical
medicine. This, the fifth edition and fourteenth
reprint, contains the most recent points in tropical
medicine, and to mention a few of the recent advances
one can enumerate: (1) The discovery that kala-azar,
especially the infantile form, is a not infrequent
disease in the countries surrounding the Mediter-
ranean Sea, and also elsewhere in tropical and sub-
tropical countries, that it is intimately associated in
many of these countries with the dog, and that
peculiar forms of dermal leishmaniasis are to be '
found in South America. (2) The transmission of
Trypanosoma gambiense by Glossina palpalis is not,
as was supposed, a simple mechanical process, but,
as Kleine has shown, involves a necessary biological
evolution in the insect. (3) That a peculiarly virulent
form of the trypanosome occurs in Rhodesia, which
is transmitted by G. morsitans. (4) There exists in
South America a form of trypanosomiasis which is
transmitted by Lamus megistus. (5) A specific form
of three-days' fever is caused by an unknown germ
introduced into the human subject by the bite of a
phlebotomus. (6) As Castellani has pointed out,
yaws is produced by a spirochete closely resembling
that of syphilis. (7) Beriberi, at all events in the
Malay States, is the result of a diet of over-milled
rice, as indicated by Braddon, and proved by Fraser
and Stanton. (8) A non-periodie variety of Filaria
bancrofti especially common in the Pacifie Islands.
(9) That Schistosomum japonicum is by no means an
uncommon parasite in large distriets of China and
Japan which gives rise to a deadly disease, and that
it is acquired by contact with the water of certain
distriets. "These, and many minor discoveries made
within the last few years, testify to the activity in
pathologieal research into tropieal disease, and the
necessity for a thorough revision of the manual.
The author points out that, whilst tropical
pathology has been so actively and successfully
studied, the prevention and treatment of tropical
diseases have not been neglected, and in the case of
more than one disease investigation in these direc-
tions has had most gratifying results. To mention
but a few, he points to the prevention and treatment
of beriberi on the lines indicated by the discoveries
of Braddon, Stanton, and Fraser; the treatment of
yaws and relapsing fever by salvarsan ; the treatment
of trypanosomiasis by antimony ; and, perhaps the
most important of all, the substitution of emetine for
crude ipecacuanha in the diagnosis and treatment of
amoebic dysentery and amaebie abscess of the liver.
One cannot criticize the print or illustrations of
the work, but might suggest that in the next edition
of over 1,000 pages it should be divided into two
volumes and perhaps the pages made a little larger.
MANUAL OF DIAGNOSTIC BACTERIOLOGY. Manuel
Pratique de Diagnostic Bactériologique et de
Technique Appliquée à la Détermination des
Bactéries. Par R. le Blaye et H. Guggenheim.
Vigo Frères, Editeurs, 23, Place de I’ Kcole-de-
Médecine, Paris. 1914. Prix 8 franes.
This is a manual upon distinctly novel lines for
all kinds of laboratory workers, especially research
256
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
workers. One hundred and sixty-three pages of this
book are devoted to the methods of culture prepara-
tion, isolation of bacteria, microscopic investigation
and inoculation.
A special feature of the work is its forty-seven
tables on the plan of those used in practical chemistry,
which, as a new departure in bacteriology, should be
as useful as the practical chemistry tables them-
_ selves.
The fourth part consists of those bacteria which
up to the present have been incompletely investigated.
Fifty pages are devoted to the index with an extremely
full bibliography alluding especially to each prepara-
tion arranged alphabetieally, and the table eontents
is extremely clear.
The work bids fair to be useful to teachers and
students of bacteriology in human, veterinary and
vegetable pathology, particularly to research workers
out of reach of a very up-to-date library.
————9—————
Hotes and Mews.
THE PANAMA-PACIFIC INTERNATIONAL EX-
POSITION AT SAN FRANCISCO IN 1915.
THE completion of the Panama Canal is as much
a monument to the science of medicine and sanitation
as it is to that of engineering. It is therefore fitting
that the Panama-Pacific International Exposition,
which opens its gates on Saturday, February 20, 1915,
to celebrate this event, should accord signal honours to
the science and practice of medicine.
The Medical Corps, under Lieutenant-Colonel W. C.
Gorgas, made the building of the canal possible. The
engineering corps headed by Colonel George W.
Goethals completed the achievment.
Among the 227 congresses and conventions which
will meet at the Exposition, the American Academy
of Medicine, the National Hygiene Commission and
the International Association of Nurses, with 6,000
delegates, will occupy commanding positions.
General Loynaz Castillo, Cuban Commissioner to
the Exposition, announces that his government in
1915 will show how the experience of the United
States Army in Cuba made possible the Panama
Canal. Modern hospital wards, as conducted in the
tropics, will be an important part of the exhibit in
the Social Economy Section. A mosquito as large
as an ostrich will be in the Cuban exhibit intended to
demonstrate the dangers of the mosquito. This
exhibit, upon which Cuba will spend more than a
quarter of a million dollars, is to be prepared by
Philip Rauer, probably the world’s greatest manu-
facturerer of wax and glass models and a scientist of
great learning.
Argentina, Japan, France, Germany, the Philip-
pines and thirty other countries will be well represented
and the most important of the welfare, civic and
health exhibits from the Lyons Urban Exposition,
1914, will be brought to San Francisco, as well as
the entire British exhibits shown at Ghent last year.
In addition to the governmental and state exhibits
there will be unexampled health and human welfare
displays by such organizations as the American Steel
Corporation ; the General Electrie Company, with
appliances for conserving the health of factory
employees; the Rockefeller Foundation, which will
concentrate on the measures to eradicate the hook-
worm; the Russell Sage Foundation, Carnegie Insti-
tutions and the Social Survey.
The American Academy of Medicine, the National
Commission of Mental Hygiene, five organizations of
eye, ear, nose and throat specialists, various societies
for the elimination of tuberculosis, cancer, and other
diseases will be a few of the many to meet in San
Francisco next year.
The Panama-Pacific Dental Congress will bring
more than 3,000 delegates with a clinie of more than
thirty chairs. The Red Cross Association of America,
the American Nurses’ Association, and the National
League of Nurse Education will meet with their
thousands of delegates, as well as the International
Congress of Nurses and the National Organization of
Public Health Nurses, which will bring an elaborate
series of exhibits including late hospital equipment,
model wards, a Florence Nightingale exhibit and
a model mortuary as developed in Europe.
One of the interesting features to surgeons and
medical men and women will be the model emergency
hospital. This has been in operation for many weeks
and constitutes one of the many working exhibits.
It is in charge of Dr. R. M. Woodward, of the United
States Marine Hospital, San Francisco.
The hospital includes model automobile ambulances,
a sterilizing room, X-ray room, library, operating
chairs, surgical instruments and equipment and a
drug room. It isin the service building of the Exposi-
tion, at the entrance to the grounds. P. Blakeston
and Son, Meiecke and Co., D. Appleton and Co.,
Schiedel Western X-ray Company, Bausch and Lomb
Optical Company, N. B. Saunder and Company,
American Sterilizer Co., and the Victor Electric
Company have all given their wares for the use of the
hospital.
In the Palace of Liberal Arts, medicine and surgery
will be treated in thirteen separate classes, instru-
ments for work in anatomy, histology and bacteriology,
apparatus for sterilizing instruments and wound-
dressing appliances will be shown. Other features
in this line will be: instruments for special and
general medical research; instruments and appa-
ratus in therapeutics, surgery and dentistry; X-ray
apparatus; electric sterilizers and ozonizers ; appli-
ances for the use of the infirm, of invalids and of
lunatics; apparatus for plastic and mechanical pros-
thesis; orthopwedie apparatus; apparatus for hernia;
instruments and apparatus used in the practice of
dentistry; chests and cases of instruments and
medicines for the use of army and naval surgeons;
appliances for rendering aid in ease of accidents, and
to the wounded on the battle-field; ambulance service:
applianees for rendering aid to persons apparently
drowned or asphyxiated; instruments and appliances
for veterinary surgery; and equipment used by
druggists and pharmacists.
Sept. 1, 1914.]
Original Communications. —.
TINEA CAPITIS TROPICALIS IN THE ANGLO-
EGYPTIAN SUDAN.
By ALBERT J. Cuatmers, M.D., F.R.C.S., D.P.H.,
Director, Wellcome Tropical Research Laboratories,
AND
ALEXANDER MARSHALL.
Senior Bacteriological Laboratory Assistant, Wellcome Tropical
Research Laboratories, Khartoum.
Introductory.—So far as we are aware no researches
have hitherto been made to differentiate the form of
Tinea capitis tropicalis found in the Anglo-Egyptian
Sudan. Thanks to the kindness of Mr. James
Currie, C.M.G., Director of Education, Mr. M. F.
Simpson, the Assistant Director, and other officials
of the Department of Education of the Anglo- Egyptian
Sudan, we have been able to begin the study of this
rather complicated subject, to which we desire to
draw attention, as it is either entirely or almost
entirely omitted in works on tropical medicine.
Up to the present we have found only one species
of the genus Trichophyton and, as this appears to
differ somewhat from those usually described, we
venture to bring forward the following remarks.
History of Ringworm in the Tropics.—Celsus in the
second chapter of the sixth book of his " De Medicina "
gives an account of ringworm of the head under the
name “ Porrigo.”” His words are: “ Porrigo autem
est, ubi inter pilos quedam quasi squamule surgunt,
esque a cute resolvuntur; et interdum madent, multo
sepius siccae sunt.”
Bishop Fortunatus, who lived in the sixth century
A.D., uses the name “ Tinea” in the following passage:
" Lavans capita egenorum, defricans quicquid erat,
crustam, scabiem, tineam nec purulentam fastidiens.”
In the tenth century Ali ben Abbas (often written
Haly) who lived in Persia, described the complaint
under the terms “ sahafati ” and " alvathim.”
The Anglo-Saxons applied the word “ teter ” to any
kind of skin disease which itched, and in this form
it was used in middle English. In the fourteenth
century Guy de Chauliac wrote a work on surgery
in which he used the word “ teigne,” deriving it from
" tenir."
With the advent of printing it was called “ tetters "
in England (vide Langham's " Garden of Health,”
1633), but in or before the sixteenth century the word
" Ringworm” (vide Levins or Levens, “ Manipulus
Vocabulorum," London, 1570) had appeared for the
disease Tinea circinata. In 1695 Willis in his
"London Practice of Physick " devoted a chapter to
the subject of the running seab, tetter or ringworm.
With a history such as this it is not astonishing
that the early English writers on tropical medicine
refer to the same disease as seen in tropical countries.
Thus in 1766, in his work on the diseases of
Barbados, Hillary says that it was noticed by the
first voyagers to the West Indies, and that it probably
is the same disease as that called by the natives
““cowrap.” He gives a good clinical description of
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 17, Vol. XVII.
Tinea circinata as he saw it in Barbados, and he is
supported by Wright ("Essays on the Malignant
Fever of the West Indies"), who stated that it was
common in Jamaica.
Winterbottom in 1803, under the term ‘ Herpes,"
describes the disease in Sierra Leone, calling it
serpigo, ringworm or tetters, and distinguishing it
from kra-kra.
So far it would appear as though only the body
ringworm or Tinea circinata was meant by the terms
"tetters" and “ringworm,” but in 1817 Bateman,
the pupil of Willan, who completed his master's great
work on skin diseases, published an atlas on the same
subject, in which Plate XXXIX induces Sabouraud
to believe that he recognized the identity of the two
conditions. In 1824 Plumbe showed that inoculation
of ringworm of the scalp would cause ringworm of
the body and vice versa.
These publications appear to have stirred the
practitioners of the Tropics to study the disease,
as it was described in India by Young, in 1826, and
in the Malay Archipelago by Lesson, in 1829.
In 1832 Alibert published the first edition of his
celebrated “Monographie des Dermatoses," which
stimulated the continental medical mind of the day,
as is reflected by Smith's description of the disease in
Peru, in 1840, and Pruner's in Egypt, in 1847.
In 1842 Gruby, who had already repeated
Schoenlein’s observations on the parasite of Favus,
discovered a new cryptogam in Tinea barbs, which
was an Ecto-Endothrix.
In 1843 he found Microsporum audouini, and six
months later, on April 1, 1844, he described an
endothrix as the parasite of Herpes tonsurans. It
is, however, but just to state that, without Sabouraud’s
generous treatment, much of Gruby’s work might
have been permanently overlooked.
In 1845 Malmsten gave the name of Trichophyton
to the parasite of Tinea tonsurans.
It is asked that the reader will kindly observe the
spelling of the names of these two genera. Gruby
called the one Microsporum, not Microsporon, and
Malmsten named.the other Trichophyton, not Tricho-
phytum.
These researches naturally aroused much interest
and in 1855 Heymann showed that the disease
existed in the East Indies, but it is noticeable that
he makes no mention of observing a parasite in the
affection.
In 1874 Blanc described the occurrence of the
disease in Abyssinia where Merab states that it is
very common, and where it is treated by the juice
from the fruits and leaves of Bryonia deoica and by
tobacco powder as well as by sulphur ointment.
In 1872 the Army Sanitation Commission induced
the British Government to instruct Tilbury, Fox and
Farquhar to obtain a better knowledge of the endemic
skin diseases of India, and to bring about an agree-
ment between the profession in India and England as
to nomenclature, typical characters, varieties and
probable causes of these diseases. Thanks to the
interest of Lord Granville, Lord Kimberley and Sir
Alexander Armstrong, this inquiry was extended to
258
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1914.
China, Japan, Egypt, Algeria, the West Indies and
Honolulu, and the finished report was published in
1876.
The net result of this inquiry as far as ringworm
was concerned was unfortunate, as it led to the
dogmatic assertion that the ringworm of the body
in the Tropics was the same as that of temperate
climes.
In 1873 van Leent drew attention to the large
number of cases of ringworm of the head in Chinese
in the Island of Banka, in Malaysia.
In 1878 Corre gave a description of the disease and
its parasite as seen in Nossi-Bé.
From 1890 the possibility of plurality in the species
of Trichophyton was raised, but it was not until
Sabouraud in 1892 began those brilliant researches
which he has carried on to the present day that this
was definitely established. In this year he showed
that ringworm of the scalp could be divided into two
main groups, viz., those with small spores belonging
to the genus Microsporum Gruby 1843, and those with
large spores belonging to the genus Trichophyton
Malmsten 1848. The large-spored fungi of the scalp
he divided into five species which were afterwards
named T. crateriforme, T. acuminatum, T. gypseum,
T. violaceum and T. rosaceum.
In 1893 he further divided the Trichophytons into
two groups which he named Endothrix and Ecto-
Endothrix (Ectothrix) and which corresponded with
Gruby’s two divisions. His researches were speedily
confirmed by many observers, among whom may be
mentioned Adamson, Colcott-Fox, Malcolm Morris,
White and Mibelli.
In 1900 Matruchot and Dassonville showed that
the Trichophytons were closely allied to the Gymnoas-
cacew and that Ctenomyces serrata Fidam 1880 when
injected into animals produced a Trichophyton-like
mycelium and eruption.
The further history may perhaps be better discussed
according to the countries :—
Brazil.—The history of ringworm in Brazil appears
to date from the appearance of Silva Araujo's " Atlas
des Maladies de la Peau," which contained an account
of Favus and of a Trichophyton causing Sycosis, both
supported by microscopical observations.
Later Fernando Terra grew <Achorion schoenleini
from an atypical case of Favus and some form of
fungus from a case of Tinea capitis tropicalis which
was traceable to infection from a cat and was there-
fore probably T. felinewm. The sixth Brazilian
Congress of Medicine and Surgery, held in 1907, is
remarkable for the appearance of papers on ringworm
in which the parasitic fungi were studied according to
Sabouraud's classical methods. It was at this meet-
ing that Rabello announced that he had found
T. violaceum, M. audouini and M. lanosum.
In 1909 Lindenberg reported the presence of
T. sabouraudi. Horta announced that M. felineum
had been found in a considerable number of cases at
Sao Paulo, and also isolated T. album Sabouraud 1907.
In 1911 Horta discovered M. flavescens and in 1914
he found a new Trichophyton which was subsequently
described and named T. griseum by Vasconcellos.
Argentina.—In 1907 Uriburu discovered M. fulvum
and in 1909 T. ersiccatum and T. polygonum.
Central America.—In 1913 Brumpt named a
peculiar parasite, discovered by Darier in a Derma-
tosis resembling Pinta, T. carateum. This disease
was found in Central America.
Africa.—In 1896 Courmont described two forms of
Tinea capitis tropicalis seen in Senegal, but these will
be d with in the section on ‘ Diagnosis ” (which
see).
In 1902 Bodin found T. violaceum in North Africa.
In 1904 Jeanselme announced that Courmont had
found M. audouini among the negroes of Senegal and
that Sabouraud and himself had found a Trichophyton
(subsequently named T. circonvolutum by Sabouraud
in 1909) in white people returning from the Western
Soudan.
In 1912 Joyeux discovered T. soudanense in the
Western Soudan.
Ceylon.—In 1905 Castellani discovered T. violaceum
var. decalvans in Tinea capitis tropicalis, T. macfadyeni
in Tinea corporis tropicalis, and T. blanchardi in Tinea
sabouraudi tropicalis, a term also used for the disease
eaused by T. circonvolutum.
In 1908 he observed T. ceylonense in cases of Tinea
nigro-circinata.
In 1912 he found T. nodoformans in Tinea barbe
tropiealis and in Tinea ciliorum.
Tropical Queensland.—In 1914 Priestley discovered
M. scorteum in Tinea corporis tropicalis.
This brings the history of the parasites found in
Tinea capitis tropicalis and the allied diseases of Tinea
barbæ tropicalis and Tinea corporis tropicalis down to
the present day.
The fungi at present recognized to be causal agents
of Tinea capitis tropicalis are :—
Genus Microsporum Gruby 1843.
(1) M. audouini Gruby 1843, found in Brazil,
Senegal, the Western Sudan and Madagascar.
(2) M. fulvum Uriburu 1907, found in the
Argentine.
Genus Trichophyton Malmsten 1848.
(1) T. circonvolutum Sabouraud 1909, found in the
Senegal and Dahomey.
(2) T. ersiccatum Uriburu 1909, found in the
Argentine.
(3) T. polygonum Uriburu 1909, found in the
Argentine.
(4) T. sabouraudi R. Blanchard 1895, found in
Brazil.
(5) T. soudanense Joyeux 1912, found in the
Western Sudan.
(6) T. violaceum Bodin 1902, found in North Africa.
(7) T. violaceum varietas decalvans Castellani 1905,
found in Ceylon.
In addition Courmont's two ringworms found in
Senegal, but with unnamed, and at all events in one
case, imperfectly differentiated parasites must be
remembered.
It may, perhaps, be advisable to state that the
Western Sudan is quite different geographically from
the Anglo-Egyptian Sudan. The Western Sudan, as
used here, refers to the Haute-Guinée.
Sept. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
259
Geographical Distribution.—The variety of Tinea
capitis tropicalis which we are about to describe has
only been observed by us in Omdurman and Khartoum
in the Anglo-Egyptian Sudan.
Ser, Age and Racial Distribution.—So far we have
only observed it in boys and youths about 10 to 16
years of age. All our patients have been Sudanese.
Etiology.—If the head of a patient is examined it
will be observed to show one or more white patches
(figs. 1, 2 and 5). If one of these be investigated
it will be noticed that it is composed of white scales,
of normal hairs, and of hairs broken off about a
millimetre above the surface of the skin (if a lens is
used and fig. 2 is examined, these features will be
seen).
If now one of these broken hairs is removed and
soaked in 40 per cent. caustic potash for some hours,
it shows very distinctly rows of so-called spores
(fig. 6) inside the shaft of the hair; but none are to
be seen in the sheath or the cortex of the hair.
These so-called spores are arranged in regular ladder
or ribbon-like chains (fig. 6) which resist the action
of caustic potash and, therefore, this mycelium may
be termed resistant. This arrangement can be well
seen by making a lateral fracture of the hair (fig. 6)
as well as by examining the shaft. The individual
spores are usually quadrangular in shape, double
contoured, with an average measurement of about
4'2 microns in breadth.
The rows of hyphal segments (so-called spores)
divide dichotomously, a condition which can be readily
seen if the hair is teazed out or broken across.
Sometimes the hair is quite filled with longitudinal
rows of these hyphal segments which project beyond
the broken end of the shaft as clear whitish quad-
rangular spore-like bodies in chains which may show
the commencement of dichotomous division, thus
producing rather a pretty effect with the black hair.
When scrapings from the scalp, t.e., the white
scales, are treated with caustic potash and stained by
Adamson’s method chains of so-called spores may be
seen (fig. 3) and more rarely elongated hyphæ, ending
in a chain of the so-called spores or short lengths of
hyphz with elongated cells.
In our experience the best method of colouring
fungi is by vital staining, but, failing this, Adamson's
or the Oxford method is excellent, the latter being
preferable for spores.
We use Adamson's method of staining rather
differently from the original; our plan is as follows :—
(1) Soak the scales or hairs in 40 per cent. caustic
potash solution in a covered watch-glass for some
hours. In Khartoum cold weather, i.e., about 90? F.,
we place the watch-glass in the ineubator at 40? C.
(2) Transfer the specimens to another watch glass
with 15 per cent. alcohol for half an hour.
(3) Transfer to a slide and, after evaporation of the
spirit, dry over a flame.
(4) Stain with aniline gentian violet solution for
thirty minutes. 4
(5) Treat with Gram’s iodine solution for three
minutes.
(6) Decolorize in aniline oil for half an hour.
(7) Stain with concentrated alcoholie solution ot
eosin for one minute.
(8) Wash off the excess of eosin with aniline oil, or,
in the case of hairs, preferably with clove oil.
(9) Treat with xylol.
(10) Mount in Canada balsam.
By this method the hyphe and spores may be
Gram positive if young and Gram negative if old.
The so-called spores (hyphal segments) show up
well in the superficial layers of the epithelium of the
scalp, or inside the shafts of the hairs.
With regard to obtaining pure cultures, we found
that the best method was to apply absolute alcohol
to the scalp and to allow this to evaporate and then
to remove an infected hair, or to make a scraping
from a white patch. The hair or scraping was then
placed in beer wort, when puff-balls, which could
easily be subcultured, quickly began to appear.
On only one occasion were we able to grow the
fungus absolutely pure by direct inoculation of a solid
medium from the scalp; generally some coccus or
bacillus appeared along with the fungus when grown
in this manner.
The Trichophyton grew well aérobically at 20°
and 34? C. and quickly at 37? C. but not so well at
40? C. It did not grow under anaérobic conditions.
The folowing are the results which we have
obtained in various media :—
Liquid Media.—]lt is advisable to begin cultivation
in an acid liquid medium such as beer wort, and later
to subculture into glucose peptone containing 4 per
cent. of sugar and 1 per cent. of peptone, or in
ordinary bouillon with — 10 reaction.
In all of these media it grows in the form of puff-
balls with a distinct centre from which the hyphx
radiate. At a very late stage of the growth, the
white hyphe often form a layer just below the surface
of the medium.
Milk is not coagulated nor is acid produced, but a
growth forms on the surface which bleaches litmus
milk in that situation, giving rise to a white skin
under which the blue litmus milk remains untouched.
It forms neither acid nor gas in the following
sugar starch, alcohol-peptone media: Monosaccha-
rides: glucose, levulose, galactose, mannose, ara-
binose and xylose; disaccharides: maltose, lactose
and saccharose ; trisaccharide: raffinose; polysaccha-
rides: dextrin, inulin, starch and glycogen; gluco-
sides: amygdalin, salicin, helicin and phlorrhizin;
alcohols ; | tetrahydric : erythrite; pentahydric:
adonite; Aerahydric : dulcite, isodulcite, mannite,
sorbite and inosite.
Solid Media.—It is not easy to work with gelatine
in a place with a daily maximum air temperature
varying from 108? to 110? F. and rising at times to
115? F., but, by the aid of the native burma, i.e., a
large earthen vessel which allows water contained
therein to evaporate freely, thus producing an internal
temperature of 90? C., we have been able to use
gelatine of 30 per cent. strength. In removing a tube
for examination, it is necessary to place it immediately
in a glass vessel containing cool water, from which it
is only taken for a few moments at a time.
260
It is extremely difficult to obtain photographs of
these gelatine cultures and hence only one (fig. 16) is
shown, and this is only five days old. The technique
is to first prepare the whole photographic apparatus,
the focusing being performed by means of a similar
agar growth. The gelatine culture, which has been
kept for some time in ice-cold water, is rapidly placed
in position, the final focusing is speedily performed
and the photograph taken as quickly as possible.
We give these practical details because, in every
tropical climate we have lived in, we have been able,
so far, to use gelatine successfully.
On Sabouraud's maltose proof gelatine at 20? C. a
minute white knob appears at the end of one day,
which, at the end of two days, has became larger, and
in three days has developed into a well defined round
knob, which in four days is surrounded by a white
plate. On the fifth day (fig. 16) the knob becomes
more acuminate and resembles a little hill on a white
plateau ending in a slight fringe.
On the seventh day the only point to be remarked
is the increase in area of the growth, which, on the
eleventh day, reaches the margin of the tube, after
which it grows up and down the medium and attempts
to extend on to the glass.
The growth on Sabouraud's glucose proof gelatine at
20° C. resembled the above except in minor details;
thus, when at its best, it showed a small central knob
situate on a white area which had two very slightly
elevated rings, one external to the other, and then a
broad radiation.
On Sabouraud’s maltose agar it grew very well at
34° or 37? C., but much more quickly at the latter
temperature. It began as a white knob, which
rapidly increased in size and was surrounded by a
white plateau in two days (fig. 12). In four days the
only changes were the larger central knob and the
appearance of an elevated ring (fig. 13) and a slight
outer fringe. In seven days the growth was much
larger and two concentric rings were visible. The
portion internal to the inner ring and surrounding
the central knob had become thinner and the dark
coloured medium showed through the white area,
which therefore appears rather darkish (fig. 14). The
whole area is surrounded by a very slight fringe.
For comparison we reproduce in fig. 15 a similar
growth of five days’ duration on Sabouraud’s maltose
agar, but grown from another case and with atmo-
spheric temperatures about 112° to 115° F. It
resembles figure 13, but is slightly more advanced.
It shows a central knob with indications of the two
concentric rings and the slight fringe.
After seven days the growth extends to the margin
of the flask or watch-glass. When this occurs, or
slightly earlier, four or more slight grooves and ridges
may appear running outwards from the central knob.
These grooves and ridges are shown beginning in fig. 15.
In old cultures, chlamydospores, intercalary
(fig. 10), and terminal can be seen, as well as lateral
conidia (fig. 11) which are situate at slight distances
from one another and on either side of the hypha.
They are not very numerous. Septate spindle bodies
can be found, but require to be looked for.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
On Sabouraud's glucose agar it forms a central
knob, a white plateau with a slight circle, and a small
fringe (vide fig. 17), which is a five days' growth.
With regard to the photographs on maltose and
glucose agar we have found it convenient to use the
apparatus shown in fig. 7, viz., half a sterilized Petri
dish carrying an originally sterilized watch-glass con-
taining the inoculated medium, which is covered by
an ordinary sterilized filter funnel fixed to the Petri
dish by means of sterile vaseline and with its terminal
aperture closed by a sterile cotton-wool plug. If care
is taken the watch-glass can be removed and photo-
graphed and replaced without contamination occur-
ring, and therefore, the same growth can be easily
photographed at different stages.
On carrot at 82° C., the fungus forms a small
white puff-ball in twenty-four hours, which, in two
days, becomes surrounded by a cireular whitish area
having a silky appearance. On the third day the
white growth is elevated at its periphery. The fourth
day shows a characteristic appearance, viz., a small
central white elevation surrounded by a larger dark
area depressed into the substance of the carrot. This
area is surrounded by an outer white line (fig. 8).
On potato it forms in twenty-four hours at 32° C.
& slight stain, rather difficult to see, which, when
examined by means of a lens, shows a central inocu-
lated area from which branching hyphe are extending
in all directions. In two days the area is more
distinct and white or greyish-white in colour; later,
the greyish-white growth becomes more distinct and,
finally, it covers the potato with a growth which
gradually becomes greyish-black.
On beet-root it forms a white growth, without
characteristic appearances.
On Buchanan's medium and Loeffler’s blood serum
it also grew, but only very feebly, showing a small
white central elevation surrounded by a white
plateau.
Animal Inoculations.—In regard to animal inocula-
tions, we have obtained negative results with inocula-
tions direct from a patient’s head into a monkey,
a cat, a dog, and a white mouse, and also with
inoculations of cultures into another series of animals
of the same species.
Classification.—For reasons which we hope to deal
with in another paper, we have come to the conclusion
that this fungus belongs to the class of the Fungacee
of Linnæus called Ascomycetes by De Bary, which
includes Brefeld's hemi-ascomycetes, unless this is
taken as a separate division, in which case the fungus
in question would belong to this division.
It also belongs to the family Gymnoascacee Zopt
1885, and to the genus Trichophyton Malmsten
1848, whieh Matruchot and Dassonville have already
demonstrated to belong to this family. It comes
under Malmsten's genus Trichophyton because—
(1) It is parasitic in hairs and in the skin.
(2) Its hyphal segments (so-called spores) are
large, 4°5 4 in diameter.
(3) In cultures it possesses conidia on
conidiophores (fig. 11).
(4) It possesses spirally curved hyphe (fig. 9).
short
-x — M Mn — M — — ——À
Sept- 1, 1914.]
It belongs to the division of the genus Trichophyton
called Endothrix because it develops solely in the
interior of the hair and does not cause suppura-
tion. It therefore does not belong to the Neo-
endothrix group because :—
(1) We have never seen spores or mycelium on the
outside of the hair shaft.
(2) It differs from the known Neo-endothrix
parasites T. flavum Bodin 1902 and T. plicatile
Sabouraud 1909 because in culture it has neither
the crater nor the convoluted appearance of these
fungi.
It also does not belong to the Endo-ectothrix
division because :—
(1) The fungus is found exclusively inside and does
not occur on the outside of the hair shaft.
(2) The infected hairs are broken off near the
scalp.
(3) It is not associated with inflammatory lesions.
It therefore cannot be confused with T. griseum
Vasconcellos 1914, which is an Endo-ectothrix of
the Gypseum group.
The species of the genus Tricophyton belonging to
the division Endothrix and arranged chronologically
. tonsurans Malmsten 1845.
. sabouraudi R. Blanchard 1895.
. violaceum Bodin 1902.
. sulphureum C. Fox 1908.
. glabrum Sabouraud 1909.
. fumatum Sabouraud 1909.
. effractum Sabouraud, 1909.
. circonvolutum Sabouraud 1909.
. regulare Sabouraud 1909.
. umbilicatum Sabouraud 1909.
. ersiccatum Uriburu 1909.
. polygonum Uriburu 1909.
T. sudanense Joyeux 1912.
These may be recognized as follows :—
A. Condition of mycelium in hair not definitely stated,
but probably that of tbe Crateriform subdivision
(see below).
(1) In cultures very convoluted . circonvolutum.
B. Condition of mycelium in hair definitely stated.
I. Mycelium in hair resistant to caustic potash,
segments characteristically quadrangular in
shape, with double contour, 4 to 6 u in
breadth, arranged in fairly straight ladder.
like rows ; i A . Crateriform subdivision.
(a) Cultures coloured and with craters: Tonsurans group.
(2) Yellow in centre, white at periphery . tonsurans.
(8) As “ tonsurans" but when old cracked
S
HHHHHH
~
-11
—
MM
es
=
SSAA
anddry . s : À E d effractum.
(4) Orange-red centre, remainder sulphur
coloured sulphureum.
(5) Golden yellow convoluted centre becom-
ing crateriform later . 4 : . sudanense,
(6) When old of a yellowish brown colour . fumatum.
(b) Cultures white with Craters : Umbilicatum group.
(7) Deeply umbilicated with &ureola umbilicatum.
(8) Slow growth, surface cracked with dry
Be appearance és . i exsiccatum,
Des? a(9) Growth at first roundish and then poly-
gonal . A . . , , polyganum.
II. Mycelium in hair not resistant to caustic pot- « +
ash, segments rounded 4.7 u iu diameter,
not arranged as a rule in rows, but if a row
is visible it resembles a string of beads and
not a ladder . A Acuminate subdivision.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
261
(a) Without acuminate centre : Violaceum group.
(10) Primary growth violet A . violaceum.
(11) Primary growth white glabrum.
(b) With acuminate centre: Sabouraudi group.
(12) Without duvet when old . a
(13) With duvet when old
sabouraudi.
pilosum.
Courmont's parasites cannot be easily classified,
except as belonging to the Endothrix division (vide
section on “ Diagnosis ").
It is quite obvious that the present fungus does not
belong to the A division, because the condition of the
mycelium in the hair is known and the cultures are
not convoluted.
It is equally obvious that it does not belong to
B sub-group II, i.e, to the Acuminate subdivision,
because :—
(1) Its mycelium is resistant to caustic potash
solution (fig. 6). i
(2) Its segments are not rounded (fig. 6).
(3) They do not appear as a string of beads (fig. 6).
It belongs to B sub-group I, t.e., to the Crateri-
form subdivision, because :—
(1) Its mycelium is resistant tocaustic potash (fig. 6).
(2) Its segments are characteristically quadrangular
(s de with double contour, 4 to 5 » in breadth
fig. 6).
(3) Its segments are arranged in fairly straight
ladder-like rows (figs. 4 and 6).
(4) Its rows show dichotomous branching, but it
differs from the known members of the Crateriform
subdivision in the appearance of its cultures in that :—
(1) A crater is never developed even in the
oldest cultures.
(2) The characteristics of a culture are :—
(a) Very quick growth.
(b) White colour until old, when it turns
dark.
(c) Central white knob on a white plateau
marked by one or two slightly
elevated rings and bordered by a
slight fringe (figs. 19 to 17).
(d) Absence of “duvet” even in the oldest
cultures.
In its cultures it approaches the Acuminate sub-
division, but differs from the various members of that
subdivision because :—
` (1) Its primary growth is not violet but white.
(2) It has not the granular appearance of a
T. glabrum culture, nor has it the characteristic
markings, nor is its surface moist.
(3) It differs from T. sabouraudi in not forming
conical growths, in the absence of the central plumes,
of the yellowish or pinkish rings, of the dark pinkish
colour, and of the powdery surface as seen in old
cultures. In fact the cultures of T. currii have quite
different appearances (figs. 12 to 17) as compared with
those of T. sabouraudi.
(4) It differs from T. pilosum in the absence of the
dense white duvet in old cultures and in the differences
just given above to differentiate it from T. sabouraudi.
Nomenclature.— We are therefore forced, by con-
sideration of the above paragraphs, to the conclusion
that WaNRY Mpa yith a hitherto not described
ss io. -' We name it after Mr. James
262
Currie, C.M.G., Director of Education in the Sudan,
without whose aid it would have been impossible
to have conducted this research, Trichophyton currii
Chalmers and Marshall 1914.
The etymology of this term is sufficiently obvious.
Definition.—The definition of this new fungus would
be—Trichophyton: Endothrix with mycelial seg-
ments in hairs resistant to caustic potash solution,
quadrangular, on the average 4 to 5 ^ in breadth,
arranged in fairly straight ladder-like row:. Grows
aerobically but not anaerobically on most ordinary
liquid and solid media. On Sabouraud's proof media
it produces a white growth with a knob-like centre on
a white plateau with or without two concentric rings
and with a slight fringe. In old cultures no duvet
appears, but the greyish hyphe give rise to a dark
grey appearance. Habitat: Hairs of the head and
skin of scalp of Sudanese in the Anglo- Egyptian Sudan.
S Acuminate Group
Main Endothrix
stein
Common stem
Ancestor non-parasitic on
Animals
Diagram to show possible relationships of Trichophyton currii.
Helationships.—The resemblance of T. currii in
part to the Crateriform and in part to the Acwninate
subdivisions of the Endothrir division of the genus
Trichophyton, together with some other features
which we will deal with in another paper, suggest
that it is allied to a common ancestor of the two sub-
divisions and is on the whole nearly related to the
main line of Trichophyton evolution. Our views
as to the relationship of the new Trichophyton
may be gathered by a study of the attached phylo-
genetic diagram.
Pathology.—We have never seen the temporary
primary ecto-endothrix stage of T. currii, but there
can be no doubt that this stage exists. So far we
have only seen it growing down the hair to near the
bulb and up the shaft to a broken end, out of which
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
it may project in the form of chains of quadrangular
segments, which must be one method of its spread
from man to man. Eventually this growth destroys
the hair, the shaft of which early breaks off close to
the scalp.
In addition the parasite grows in the superficial
cells of the epidermis of the scalp, which it elevates
in the form of white scales, but there is never any
inflammatory reaction either here or around the hairs.
We have failed to find T. currii in animals infected
with ringworm in Khartoum.
The disease is not very contagious, the percentage
of infected cases in a school not being large. It,
however, appears to be well known to the sharper
small boys of a school, who call it “ gouba."
As far as our observations go it does not affect
adults, but a better knowledge of the complaint might
alter this opinion.
Morbid Anatomy.—An infected hair is broken off
close to the scalp and when pulled out appears to be
whiter than natural. The white elevated scales of
the patches can be easily seen.
Symptomatology.—The length of the incubation
period is unknown, but the early stages of the disease
are readily recognized as white scaly patches
scattered among the dark hairs of the head
(figs. 1 and 9).
When such a patch is examined it will be seen to
be more or less devoid of hair shafts, which will be
noted to be broken off close (about one millimetre) to
the skin of the scalp.
These broken ends may appear as darker spots on the
black skin, thus giving rise to an appearance somewhat
like the black-dot ringworm of Europe. More usually,
however, the end of the hair is covered by a few scales
which form a minute whitish mound, but the area
being covered by the white scales of the epidermis
this black dot appearance is masked.
Usually the patchy appearance is preserved, but at
times it may become slightly diffuse in a part of the
head. We have never observed it on the skin of the
limbs or trunk. Once we observed it on the nape of
the neck just below the hairy scalp. There is no sign
of inflammation or of enlargement of lymphatic glands
to be noted, and there are no subjective symptoms.
All our patients have been boys from 10 to 16 years
of age. The disease is essentially chronic and slow
growing. Apparently it lasts for years if untreated and
slowly spreads in the infected school, and apparently
may leave small permanent alopecial areas.
Complications.—Once we have observed it to be
complicated by a Cladosporium. The spores of this
fungus were apparently living under the elevated
white scales. Castellani, to whom a culture was
sent, considers that possibly this Cladosporium is a
species as yet not described in connection with man.
Diagnosis.—The principal points in the diagnosis
are :—
(1) White scattered scaly patches on the scalp.
(2) When the white scales are cleared away the
black-dot appearance due to the stumps of the broken
hairs is readily seen.
(3) The absence of all signs of inflammation.
Sept. 1, 1914.]
(4) Its habitat in the scalp of natives of the Anglo-
Egyptian Soudan.
(5) Its microscopical and cultural characters.
The differential diagnosis must be made firstly
from the known examples of Tinea capitis tropicalis,
and secondly from the known forms of Tinea capitis
of the temperate zone.
(1) Tropical ringworms :—It must be differentiated
from :—
Parasite.
Name. | Tropical habitat.
(1) Blanchard's ringworm T. sabouraudi ..
Brazil.
Asia Minor, North
| Africa, Brazil (?)
.. T. violaceum *! and the Argen-
(2) Bodin's ringworm
tine.
(3) Castellani's ringworm SOPORE } Ceylon.
(4) Courmont’s ringworms Not named Senegal.
Brazil, Senegal,
Í the Western Su-
(5) Gruby’s ringworm .. M. audouini a dan and Mada-
gascar.
(6) Joyeux's ringworm .. T. sudanense Western Sudan.
uu OM Senegal and
(7) Sabouraud's ringworm T. circonvolutum { Dahomey.
M. fulvum, T.
(8) Uriburu's ringworms | polygonum ni The Argentine.
T. exsiccatum
The only methods of absolute differentiation are
the microscopical and cultural examination of the
parasite causing the ringworm, but in addition to
these some clinical differences may also be noted,
but must not be solely relied upon for the differentia-
tion of the variety of Tinea capitis tropicalis observed
on a patient's head.
The various points useful in making a differential
diagnosis are as follows :—
Blanchard’s Ringworm, which was discovered by
Sabouraud in 1894, is characterized, as a rule, by
small widely disseminated patches or more rarely by
a single extensive area. In these patches scales are
absent and the stumps of the hairs appear as black
dots on the skin of the scalp, hence the name “ black
dot ringworm.”
Other small black points may also be observed
caused by the covering of an infected hair by a
growth from the stratum corneum of the epidermis.
This ringworm is usually found in children from 4 to
15 years of age, and is caused by T. sabouraudi.
Blanchard's ringworm therefore clinieally resembles
the lesions caused by T. currii, which may be
differentiated by noting :—
(1) The presence of the white scales which are the
prominent feature of the lesion of T. currit.
(2) The presence of the black-dot appearances,
which, however, have to be found by removing the
white scales.
(3) The microscopical and cultural characters
already given, which are the principal points of
differentiation.
A very good illustration of Blanchard's ringworm
can be found in fig. 102, page 283, of Sabouraud's
celebrated book “ Les Teignes."
From Bodin’s Ringworm, which is due to T.
violaceum, it ean only be recognized by microscopical
and cultural characters. Bodin’s ringworm is spread
nearly all over the world. Sabouraud thinks that it
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
263
has been disseminated along the Mediterranean basin
by the Jews and from this area to the Tropics e.g.,
perhaps by the Italians to the Argentine.
From Castellani’s Ringworm, caused by T. violaceum
var. decalvans, it may be differentiated by :—
(1) Presence in the Soudan and absence in Ceylon.
(2) Absence of enormous numbers of heaped up
white seales.
(3) Absence of T.
Castellani 1905.
For an illustration of Castellani's Ringworm see
fig. 557, p. 1484, of the second edition of " A Manual
of Tropical Medicine " by himself and one of us.
Courmont's Ringworms.—We have unfortunately
been unable to refer to Courmont's original papers
and have drawn our description from Brumpt and
from Jeanselme (see References).
In 1896 Courmont noted small round patches on the
head of a Senegalese child. On microscopical examina-
tion these patches were observed to be due to a Tri-
chophyton endothrir with the so-called spores en
évidence. The mycelium was resistant and flourished
on various media, producing polymorphic and poly-
chromatic growths, according to the temperature.
On proof media at 20° C. the growths gave rise to
white colonies with rays.
It is obvious that the lesions due to T. currii can
be distinguished from this ringworm by the absence
of the polymorphism, the polychromatism, and of the
rays, as well as by the failure to infect animals, which
Courmont was easily able to do.
In the same year Courmont observed another form
of Tinea capitis tropicalis in Senegal.
It produced severe disseminated lesions on the head
of another Senegalese child. From the lesions he
obtained an atypical Trichophyton belonging to the
Endothrix division, but characterized by showing none
of the so-called spores and only elongated hyphæ. It
was found exclusively in the hairs. The cultures had
a tendency to cupola formation &nd the growths on
peptone gelatine were pale yellow and moist, while on
proof media they were white and dry. This could also
be inoculated into animals.
violaceum var. decalvans
T. currii differs from this most markedly in showing
typiealy the so-called spores in the hairs. The
question naturally arises in one's mind as to whether
Courmont's last parasite really belonged to the genus
Tricophyton.
We do not know whether there are any illustrations
of these ringworms in existence.
From Gruby's Classical Ringworm caused by M.
audouini, which is moderately common in Africa and
South America, it may be differentiated by :—
(1) Absence of large bare patches covered with
slate-grey scales and the presence of small white
patehes with white scales.
(9) Absence of hair stumps broken off 3 to 5 milli-
metres from the skin, and the presence of the black
dots.
(3) Absence of a peripheral erythematous area, or
any sign of inflammation.
(4) Slight degree of contagion.
(5) Microscopical and cultural examinations.
Illustrations of this condition are common.
From Joyeux's Ringworm, due to T. sudanense, it
may be diagnosed by :—
HENRY B, WARD,
STATE UNIVERSITY,
264
[Sept. 1, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(1) Presence in the Anglo-Egyptian Sudan, and
possible absence in the Western Sudan.
(2) Absence of grey scales in the alopecial areas
and presenee of white scales.
(3) Absence of T. sudanense Joyeux 1912.
For illustrations of T. sudanense see Archives de
Parasitologie, tome xvi, No. 3, ler. mars, 1914,
Pl. VII.
From Sabouraud's Ringworm caused by T. circon-
volutum it can only be recognized by its cultural
characters, which are quite different.
The appearance of the cultures is shown in fig. 128
of Sabouraud's " Les Teignes."
Uriburu's Ringworms.—These are caused by three
different parasites, all found in the Argentine.
(a) From the infection due to Microsporum fulvum
Uriburu 1907 that due to T. currii can be
distinguished by :—
(I) Absence of inflammation.
(II) Microscopical and cultural characters.
(b) From the infections due to T. polygonum and
T ersiccatum that caused by T. currii can
only be distinguished by the microscopical
and cultural appearances, as the clinical
aspect produced by these parasites is
unknown.
II.— From the Tinea Capitis of Temperate Climates.
For our present purposes we can differentiate the
disease due to T. currii from the Tinea capitis, due to
species of the genus Microsporum Gruby and of the
divisions Neo-endothrix and Ecto-endothrix of the
genus Trichophyton Malmsten by the clinical, micro-
scopical and cultural characters already described
above. We have, therefore, only the species of the
division Endothrix, which have not so far been found
in the Tropies, to consider.
These may be classified into :—
A. Common species.
(1) T. tonsurans Malmsten 1845.
(2) .T. sulphureum Fox 1908.
B. Hare species: lesions clinically
those of T. tonsurans.
(1) T. effractum Sabouraud 1909.
(2) T. fumatum Sabouraud 1909.
(3) T. regulare Sabouraud 1909.
C. Hare species: lesions clinically
those of T. sabouraudi.
(1) T. glabrum Sabouraud 1909.
(2) T. pilosum Sabouraud 1909.
D. Unique rare species.
T. umbilicatum Sabouraud 1909.
As we have already described the lesions and
differential diagnosis for T. sabouraudi, and as we are
about to do so for T. tonsurans, nothing further need
be noted about groups B and C, so that we have only
groups A and D to consider.
(A) Tinea tonsurans.—The lesions caused by T.
currii differ from those caused by T. tonsurans and
T. sulphureum in that :—
(1) White clean scales are always present.
(2) The hair stumps are black or whitish in colour,
not grey or yellow.
resembling
resembling
(3) The hair stumps are usually very short and are
not twisted into irregular shapes.
(4) The cultural variations are very marked.
(B) T. umbilicatum.—Sabouraud has only seen one
case, which he says resembled “ la teigne amiantacée
d'Alibert.” On turning to Alibert’s account the
following is found :—
La porrigine amiantacée est ordinairement carac-
térisée par des écailles ou membranules micacées,
luisantes, argentines, qui unissent et séparent les
cheveux par méches, les suivent dans trajet et dans
toute leur longueur: elles ressemblent beaucoup à ces
pellicules minccs, fines et transparentes qui engainent
les plumes des jeunes oiseaux, et qu'ils enlévent avec
leur bec, lorsqu'ils sont dans leurs nids, et qu'ils n'ont
point encore acquis la faculté de voler, ou plutót à
cette substance désignée sous le nom d'amiante par
les naturalistes. Cette disposition, par paquets dis-
tincts et cylindriques, et qui donne à cette teigne son
existence spécifique, est aussi constante que la depres-
sion urcéolée qui signale les incrustations du favus,
dont nous parlerons plus bas.
This description together with the characters of the
parasite is sufficient to separate this form of ringworm
from that caused by T. curri.
With regard to these rare temperate zone ring-
worms it is as well to remember that infections which
have been found rarely in Europe have subsequently
been discovered to be common in the Tropics.
Possibly some or all of these rare forms of Tinea
capitis may be found to be common in some tropical
country.
After the infective stage has passed away, small
alopecial patches may be left which require to be
diagnosed from similar patches due to favus, which is
common in the Tropics, and due to Brocq's pseudo-
pelade. The diagnosis can be effected by noting the
absence of small cicatrices.
Prognosis.—As a rule the alopecial patches are
small and not noticeable, and therefore the prognosis
as regards baldness appears to be good in the cases
which we have seen.
Treatment.—We have tried a variety of remedies
which all do temporary and not permanent good. Of
all remedies the nicotiana-seife or tobacco-soap made
by C. Mentzel in Bremen seems to promise best
results for a country such as the Anglo-Egyptian
Sudan, where a Róntgen apparatus is only available
in Khartoum.
Prophylaxis. — Much can be effected by the prompt
treatment of cases, as the disease spreads but slowly
in a school. We recommend the periodical inspection
of all scholars for parasitic diseases, and the prompt
treatment of such cases as are found.
Acknowledgments —We have much pleasure in
acknowledging the kind interest which Dr. Castellani,
of Ceylon, and Captain Archibald, R.A.M.C., of these
laboratories, have taken in this work.
REFERENCES.
(Arranged in alphabetical order).
ALIBERT (1832).
Paris.
BALFOUR and ARCHIBALD (1911). “Second Review of Recent
Advances in Tropical Medicine," p. 315 (Tobacco-soap). London.
** Monographie des Dermatoses,” i, p. 464.
HENRY B, WARD,
UNIViRaryy.
THE
JOURNAL OF TROPICAL MEDICINE AND HYGIENE, SEPTEMBER 1, 1914.
PLATE I.
To illustrate article, ** Tinea Capitis Tropicalis in the Anglo- Egyptian Sudan,” by ALBERT J. CHALMERS,
M.D., F. R.C.S., D.P.H., and ALEXANDER MARSHALL,
CA Ses r
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, SEPTEMBER 1, 1914.
PLATE II.
To illustrate article, ** Tinea Capitis Tropicalis in the Anglo-Egyptian Sudan," by ALBERT J. CHALMERS,
M.D., F.R.C.S., D.P.H., and ALEXANDER MARSHALL.
=e annm
-— —
eed
Sept. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
265
Bonin (1902).
Paris.
Broumpt (1913).
pp. 804-848. Paris.
CASTELLANI and CHALMERS (1913). ‘Manual of Tropical
er tol 2nd Edition, pp. 772-787 and pp. 1484-1485.
ondon.
Corre (1887). ‘‘ Maladies des Pays Chauds." Paris.
Courmonr (1896). Archives de Médecine Expérimentale et
@ Anatomie Pathologique, p. 700. ‘Paris.
CounMoNT (1899). Comptes Rendus de l'Académie des Sciences.
exxviii, p. 1411, and exxix, p. 193. Paris,
^ FouranD (1886) ''Teignes et Teigneux," Histoire Médicale,
aris.
Fox and FARQUHAR (1876).
India and Hot Climates.”
GEDOELST (1902).
114. Paris.
HALY FILIUS ABBAS (1492). ** Liber totius medicine necessaria
continens," folio 98. Venice,
HinscH (1885). ‘‘ Geographical and Historical Pathology,"
ii, pp. 374 and 375. London.
Horta (1911). ‘‘Microsporon flavescens.”
Institute Oswaldo Cruz, iii, faciculo ii, p. 301.
JACKSON and McMunrRY (1913).
* Les Champignons Parasites de l'Homme."
* Précis de Parasitologie Exotique,”
“ Skin and other Diseases of
London.
'* Les Champignons Parasites,” pp. 71-
Memorias do
Rio de Janeiro.
“ Diseases of the Hair,"
pp. 193-243. London.
pecan (1904). ‘*Cours de Dermatologie Exotique.”
aris.
MarRUcHOT and DassowviLLE (1901). Bulletin de la Société
Mycologique de France, xvii, 2, p. 193. Paris.
á MarRUcHOT and DassoNvILLE (1899). Ibid., xv, p. 249,
aris.
Meras (1913).
Paris.
Morris (1911). “Parasitic Skin Diseases," Allbutt and
Rolleston's **System of Medicine," ix, p. 117. London. And
“ Diseases of Skin," pp. 370-391. London.
PravT (1909). Mracek's ** Handbuch der Haut Krankheiten,”
iv, S. 73. Wien and Leipzig.
PLaut (1913). Kolle und Wassermann's
Pathogenen Organismen,” v, pp. 93-107. Jena.
PRIESTLEY (1914). ‘ Microsporon scorteum." Annals of
Tropical Medicine and Hygiene, viii, No. 1, p. 113. Liverpool.
RaEBINGER (1910). Archiv für Schiffs und Tropenhygiene,
xiv, No. 2 (Tobacco-soap). Leipzig.
SABOURAUD (1910). ‘Les Teignes." Paris.
VASCONCELLOS (1914). ‘‘ Trichophyton griseum.” Memorias do
Instituto Oswaldo Cruz, vi, fasciculo i, p. 11. Rio de Janeiro.
** Médecins et Médecine en Ethiopie," p. 91.
* Handbuch der
ILLUSTRATIONS.
Most of these illustrations may, with advantage,
be examined by means of a lens.
PLATE I.
Fic. 1.—Showing white infected areas on the crown of the
head in a case of early infection. Photograph.
Fia. 2.— Occipital region of the same case as fig. 1, showing
the white areas of infection. Photograph.
Fic. 3.—Scrapings from a white area after treatment with
40 per cent. caustic potash and staining by Adamson’s method,
showing the rows of hyphal segments which are shrunken
owing to the staining, &c. x 1,520. Photomicrograph.
Fic. 4.—A hair from an infected patch after treatment with
caustic potash to show the longitudinal rows of hyphal seg-
ments. Fresh preparation. x 1,060. Photomicrograph.
Fia. 5.—A later stage of infection showing a more diffuse
attack of the vertex. Photograph.
Fic. 6.—Similar specimen to Fig. 4, showing a single row of
hyphal segments obtained by rupturing a hair laterally by means
of needles. Fresh preparation. x 1,370. Photomicrograph.
PLATE II.
Fic. 7.—Simple apparatus for growing fungi for photographic
purposes. It consists of: Half a Petri dish, a watch glass and
nutrient medium, and a filter funnel. Photograph.
Fra. 8.— Trichophyton currii : Growth on carrot at 349 C. for
four days. Photograph.
Fic. 9.—Trichophyton currii: Spiral body, early stage,
growth obtained by De Beurmann and Gougerot’s method of
* Lames séchés” and then stained in situ by carbol-fuchsin.
x 2,470. Photomicrograph.
Fic. 10.—Trichophyton currii : Chlamydospore, early stage.
x 8,250. Photomicrograph.
Fic. 11.— Trichophyton currii : Hypha, short conidiophore
and conidium. x 2,620. Photomicrograph.
Fic. 19. — Trichophyton currii: Growth on Sabouraud's
maltose agar for two days at 84° C. Photograph.
Fic. 13.— The same as fig. 12, but four days’ growth at 34°C.
Photograph.
Fic. 14.— The same as fig. 12, but seven days’ growth at
84°C. Photograph.
Fra. 15. richophyton currii : Growth on maltose agar for
five days, but from a different case than figs. 12-14. Photograph.
Fic. 16. — Trichophyton currii: Growth on Sabouraud's
maltose gelatine at 20? C. for five days. Photograph.
Fic. 17. — Trichophyton. currii: Growth on Sabouraud’s
glucose agar for five daysat 34? C. Photograph.
———9———
PHARMACOLOGY OF FORMALDEHYDE.
Experiments with dogs have shown that formalde-
hyde is readily absorbed from the alimentary tract
and lungs, and may also be excreted by these organs.
It is quickly oxidized in the body into formic acid
and carbon dioxide. Large quantities cause inflam-
matory symptoms, though smaller amounts may be
absorbed without such effects. Formaldehyde acts
directly on the heart, producing a lowering of the
blood pressure. It quickens the respiration, and
stimulates the intestines. The author states that
the use of formaldehyde in medicine must still be
restricted to external application. As antidotes in
cases of poisoning, morphine and ammonia are
recommended.—H. McGuigan (Journ. Amer. Med.
Assoc., 1914, 62, 984).
OF CASUALTIES IN EUROPEAN
WAR.
FROM the figures supplied by Dr. Laurent of
Brussels it is possible to form an estimate of the
casualties likely to occur in the present war.
In the late wars between Bulgaria and Turkey,
Bulgaria employed an army of 500,000 men. In the
two wars, 46,000 were killed, one in twelve of the
whole army, and 115,000 wounded, a total casualty
of 161,000, about a third of the army. During one
month, July, 1913, there were 150,000 casualties,
killed and wounded, on the two sides ; 80,000 of these
occurred during the six days, June 30 to July 5.
From the author's estimate, made before the
present war, that in a European war ten times as
many would be engaged and a proportionate increase
in casualties, he estimates not less than 1,500,000
dead and wounded in the course of the first month.
ESTIMATE
TRIPLE ACID PRURITUS OINTMENT.
lgrm. (5 gr.).
2 grm. (10 gr.).
3 grm. (15 gr.).
80 grm. (1 oz).
Carbolie acid ...
Salicylic acid
Tartaric acid
Glycerine of starch
266
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
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THE JOURNAL OF
Tropical Medictne and hygiene
SEPTEMBER 1, 1914.
DISCUSSIONS AT THE TROPICAL SECTION
OF THE BRITISH MEDICAL ASSOCIATION.
THE Section of Tropical Diseases at the recent
meeting of the British Medical Association at Aber-
deen, although no startling discoveries were an-
nounced, was interesting in several ways. Of the
three main subjects put down for discussion, namely,
" Kala-azar," “The Education and Position of the Sani-
tarian in the Tropics,” and “ Treatment of Intestinal
Lesions,” the first-named called forth most discussion.
Fleet-Surgeon P. W. Bassett-Smith, C.B., drew atten-
tion for the most part to Leishmania donovani. The
geographical distribution of the infection is now better
known, due to more accurate diagnosis and not
apparently to the spread of the disease in recent
times. Itis a fact that from a morphological point of
view there appears to be no means of differentiating
the parasite as it occurs in India, China, or in the
Mediterranean ; and there seems little doubt that the
viruses of the Indian and the Mediterranean forms are
identical; hence there is no advantage in retaining
more than one name for the parasite causing the
generalized infection, either in the Far East, India,
Africa, the Mediterranean Basin, or America. The
treatment of the ailment has not, however, advanced
with our knowledge of the disease, and neither atoxyl
nor salvarsan can be considered either efficient or
hopeful means of cure. The spread of the disease
by the bed-bug (Cimex rotundatus), by house infection,
by dogs, by fleas, have all been suggested, but none
have been conclusively proved, as the agents of trans-
mission ; and Professor Gabbi, from a study of Basile
statements, is inclined to think that it will be necessary
to discover an insect intermediary other than the dog-
flea as the channel of transmission to man.
Dr. D. E. Anderson believes that uta, a Peruvian
ailment, is none other than nasopharyngeal leish-
maniasis; and Drs. Bahr, Ferguson and Williamson
drew attention to the absence of leishmaniasis infec-
tions in Ceylon, Egypt, and Cyprus respectively.
Colonel King, C.I.E.,in his paper on “The Education
and Position of the Sanitarian in the Tropics ” insisted
upon the necessity of specializing in sanitation at an
early period of the career of medical men, and con-
siders that even in their student days men should
decide whether they are to follow the clinical or the
sanitary branches of their profession.
That such a decision may have to be arrived at in
future years, owing to the growing bulk of medical
and sanitary knowledge that has to be acquired, may
be considered probable, but it was held by the
majority of those present that the time had hardly
come for that yet. To be a good sanitarian requires
an intimate knowledge of disease, and that can only
be acquired at the bedside; to sidetrack clinieal work
during the last year of medical studies would be to cut
off clinieal education during the only year of study
that afforded the student any grasp of disease at all.
In the medical department of the Army there is
the same question: namely, clinical versus sanitary,
and yet another " versus," viz., executive. The clinical
side is apt to be forgotten, partly because in sanitary
work one wholly avoids the anxieties and constant
worries attendant upon the practice of medicine, and
partly,in home hospitals at least, from the sparsity
of material for study. Again, the clinical department
in Army work ceases as a rule altogether after some
fifteen years, when the officer is promoted and has to
deal with executive work only.
Specialization is a necessity in every branch of
science, and none more so than in medicine; the
question is when should it commence. Colonel King
says in student life, and his claim, although at
present regarded as "too advanced,’ may, and in
all probability will, be listened to and acted upon.
The subject for discussion on the last day of the
meeting was '" The Surgical Aspects of Lesions of the
Large Intestine, more especially those of the Post-
dysenteric State." Mr. Cantlie who opened the
subject, fixes upon the sigmoid flexure as the seat of
post-dysenterie lesions, and chiefly the lower two
Sept. 1, 1914.]
inenes of the sigmoid, that is, just as it joins the
rectum.
The proof that this is the area of the bowel affected
seems to be incontestable, for not only does Mr.
Cantlie show that examination with the sigmoido-
scope by way of the anus supports this, but that,
after opening the sigmoid flexure above the left groin,
the sigmoidoscope, introduced through the opening
and passed downwards to the junction of the sigmoid
flexure and rectum, gives further evidence of the truth
of this statement. Mr. Cantlie contends that the
sigmoid flexure is an entity, a portion of the bowel
with specialized functions, and therefore to be con-
sidered by itself and not as a mere portion of the
large intestine. He has dignified the entrance and
exit to the sigmoid as apertures with marked charac-
teristics and styled them the colo-sigmoid and the
sigmo-rectal respectively. The latter is the more im-
portant clinically.
The treatment of post-dysenteric lesions at the
sigmo-rectal pylorus and lower two inches of the
sigmoid Mr. Cantlie states clearly and definitely
to be: Rest in bed, washing out the bowel with sea-
water (natural or artificial) daily for a few days,
touching the ulcerated surface of the sigmo-rectal
pylorus with pure carbolic acid occasionally ; injec-
tions of colloid silver (Crookes), a teaspoonful (or
more) to 6 oz. water daily. Under this régime the
lesions speedily disappear, even in bad cases, within
a week. Diet is of little consequence in the treat-
ment. In addition, Mr. Cantlie contends that the
mere fact of the passing of the sigmoidoscope through
the seat of the lesion is helpful in the cure, owing to
the fact that there is always narrowing of the bowel
at the seat of the trouble.
—_—_—_@—__—.
Abstracts.
THE INFLUENCE OF CLIMATE, DISEASE,
AND SURROUNDINGS ON THE WHITE
RACE LIVING IN THE TROPICS.
By ANTON BREINL,
Director of the Australian Institute of Tropical Medicine,
Townsville.
THE facility of transport and communication have
brought the Tropies nearer to the temperate zone.
An ever-increasing demand for tropical products for
our daily life has arisen, and many of them have
entered into the constant consumption of every
family in the United Kingdom. Moreover, the
Tropics supply raw material for manufacture upon a
constant supply of which more than twenty millions
of wage-earning inhabitants of Great Britain depend
for means of existence, and, above everything, the
" transplantation of the redundant masses from over-
crowded areas to areas where their services are
urgently required, has become recognized as one of
the highest functions of civilization."
It is perhaps necessary, in the first instance, to
define what we mean by “Tropics.” According to
= * One of the Stewart Lectures of the University of Mel.
bourne, 1913.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 26
-3
the geographical definition, the Equatorial zone in-
cludes the country between latitude 23 deg. 27 min.
north and 23 deg. 27 min. south of the Equator.
As might be expected, however, the geographical
definition is not coincident with the isothermal
charts, and Supan limited the tropical zone ‘to the
region situated between the two mean annual iso-
therms of 68 deg., a temperature which coincides with
the northern and southern limits where palms
flourish—the truest expression of the tropical clime.
Within these limits, however, the meteorological
conditions are so diverse that one is hardly justified
in speaking of a uniform tropical climate, of which,
according to our conception, the main characteristics
should be the highest temperature and the highest
humidity.
These peculiarities of the tropical climate are most
pronounced in regions situated near the coast which
are low-lying, and which, on account of their natural
advantages, are the centres of settlement by Euro-
peans. There the mean temperature is very even,
and tne uniform distribution of temperature involves
uniform pressure distribution.
The great humidity of the air is an outcome of the
enormous extent of the sea, and of the large tracts
covered with dense luxuriant vegetation.
The influence of the tropical climate on Europeans
is an extremely complex subject. Amongst the con-
ditions to which the deleterious and debilitating effect
of the climate is ascribed may be enumerated the
excess of sunlight, the humidity of the atmosphere,
and the equable temperature. It is, however,
extremely difficult to estimate the influence of these
factors upon the white man living in the Tropies, as
" there always enters an element of uncertainty owing
to the absence of absolute means of measurement and
the variability of other hygienic surroundings.”
Among other factors, one may mention the un-
toward effect of unsuitable clothing, housing, im-
proper food, alcoholie excess, and last, but not least,
of the infections with parasites belonging to the
animal or vegetable kingdom which occur in great
abundance, and are, in many instances, confined in
distribution to tropical regions.
Of the three climatic factors the sunlight ean be
the most exactly studied, and Paul Freer, of the
Manila Bureau of Science, was the first to make
comparative measurements of those rays of the
solar spectrum—the violet and the ultra-violet rays
—to which most of the effect of tropical sunlight
is usually attributed.
For this purpose the photocatalytic decomposition
of oxalic acid in the presence of uranyl acetate has
been employed. Oxalic acid, when exposed to the
sunlight in the presence of uranyl acetate, is de-
composed into carbon monoxide, carbon dioxide, and
water, and it has been shown that this reaction is
brought about almost entirely by the rays in the
violet and ultra-violet portions of the spectrum, and
that hetween certain limits the influence of tempera-
ture on the rate of reaction may be neglected. A
comparative measurement of the intensity of sun-
light in those particular rays may therefore be made
by determining the extent of the decomposition in
268
a standard mixture of these compounds, when
exposed to the sunlight under standard conditions.
The Manila authorities have devised such standard
conditions as to hours of exposure, concentration of
solutions, size of vessel, &c., whereby observations
may be made daily over reasonably long periods, and
an average figure obtained for comparison with
similar observations made in different parts of the
globe. Such observations have been made at Manila
and Baguio, in the Philippines, 14 deg. 13 min. north,
Kuala Lumpur (Malay) 3 deg. 10 min. north, Hono-
lulu (Hawaii) 21 deg. 18 min. north, Kbartoum
(Sudan) 15 deg. 31 min. north, and other places.
Daily observations by this method have been
made in Townsville since February, 1913, and the
figures show that Townsville has an exceedingly
high insolation as far as these rays are concerned.
At Manila the maximum was 17'8 and the mini-
mum 115 during fifteen months’ observation; at
Honolulu the maximum day observed out of ten
months was 20°77, the minimum 3°48; Kuala
Lumpur (seven months’ observation) had a maximum
of 181, and a minimum of 9'0; Khartoum (three
months) gave a maximum figure of 20°8 and a
minimum of 147. The average was 1716, or 5'15
higher than Manila. At Townsville during the
seven months a value of 21 was reached on no less
than eight days, much higher than any recorded at
the above places. Curiously enough the figures
obtained in Brisbane, where observations have also
been made during this year, were higher still, the
maximum recorded being 23. Thus, so far as these
particular rays are concerned, tropical Australia
appears to take a high place. s
The animal body is capable, not only of regulating
its heat production from the combustion of food-
stuffs, but also its loss of heat from water evaporation.
Normally the thermal effects of the surroundings
are compensated either by a suitable transference of
heat to the surroundings, or by conservation or pro-
duction of heat within the body, so that, practically
speaking, the body temperature remains the same
within narrow limits.
The higher the temperature of the surroundings,
the less heat will be lost by radiation, and if this
temperature exceeds that of the body, no heat can
be lost in this way and the body temperature would
rise, were it not for the loss of heat occasioned by
evaporation of water from the lungs and from the
surface of the body.
High temperatures alone, therefore, do not change
the body temperature so long as the latter can be
regulated by the loss of sufticient heat through water
evaporation.
The numerous observations as to the body tempera-
ture of Europeans in the Tropics vary slightly in their
results. The consensus of opinion, however, seems
to point to the fact that a slight rise of body tempera-
ture may be noticeable during the passage from a
temperate to a tropical clime, varying between 0°36° F.
and 15? F., but experienced observers, like Plehn, in
the Kamerun, and Eijkman, in Java, have proved
that there is no increase in the body temperature of
acclimatized Europeans whilst resting or taking
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
moderate exercise, the readings in the axilla varying
between 97'9° F. and 991^ F.
The coloured population in the Tropics shows,
according to numerous observations, practically the
same body temperature as acclimatized Europeans.
It is a well-known fact that even in a temperate zone
exercise causes a rise in body temperature, and, as
might be expected, this rise is more exaggerated in
the Tropics, and most marked on a steamy hot day.
A comparative study of the skin temperature of a
white and coloured population in the Tropics has
been made by Aron, in Manila, by means of a specially
constructed thermocouple, which made accurate read-
ings possible to within one-tenth of a degree, and his
results are extremely significant.
It was shown that the naked skin if exposed to the
rays of the sun is warmed very quickly to about 97° F.
If one side be kept in the shade and the other exposed
to the sun, the differences in temperature on the two
sides may amount to as much as 54 F. Above
97° F., with a maximum air temperature of 98'6° F.,
the temperature of the skin no longer increases. On
the contrary, if exposure be continued the temperature
falls more or less coincident with the outbreak of
perspiration—the greater the outbreak of perspiration
the greater the fall in the temperature of the skin.
In comparing the skin of the white man with that
of the brown man, Aron finds that on exposure to the
sun the skin of the brown man absorbs more heat
than does the white skin in the same length of time.
As brown skin absorbs a greater quantity of rays
than white, the point where sweat secretions begin is
reached earlier than in a white skin, and as soon as
this point is reached the skin is cooled by water
evaporation. The regulating apparatus of the brown
man is thus more sensitive, and works more promptly
and successfully than than of the white under similar
conditions.
Aron further points out that at a time when the
white man is perspiring profusely over his entire
body, and the sweat is dropping from his face and
forehead, the brown man shows only a fine velvet-like
layer of very small drops on his skin.
It is thus not the sweat which we see, but the
sweat which we do not see, which exerts the cooling
influence. In other words, the water evaporated, not
the water secreted, is of value.
In case a European is transplanted to a hot climate,
the amount of energy required for the upkeep of the
functions of the body is not increased ; if anything, it
might be expected to be decreased, and as the body
temperature of an acclimatized European is normal,
a priori, the metabolism should be exactly the same
as in a temperate climate.
Amongst the investigations which have been con-
ducted in this direction, mention may be made of
those of Rubner on human beings, and those of
C. J. Martin on animals. In both cases the experi-
ments were carried out under artificial conditions, the
subject being placed in a specially constructed respira-
tion chamber, maintained at varying temperatures
and stages of humidity, and balance-sheets were
drawn up between intake of food, water, and oxygen,
and output of carbon dioxide and water.
Sept. 1, 1914.]
The general results of Rubner's experiments showed
that with seantily clad human beings there was, with
rising temperature, a decrease to a minimum of the
excretion of carbon dioxide, averaging about 75 per
cent. per degree, whilst the excretion of water was
considerably increased.
At lower temperatures water was secreted almost
entirely by the lungs, whilst at higher temperatures
the skin. began to perspire, the evaporation increasing
with rising temperature.
A similar reduction in the output of carbon dioxide
under the same conditions was also observed in
Martin’s experiments on animals.
Eijkman carried out similar experiments in Java
under natural conditions on Europeans and natives.
These experiments, although few in number, seem
to show that the metabolism of an acclimatized
European living in the Tropics does not show any
appreciable difference from the European standard,
that nearly the same number of calories per kilogram
of body weight is required, viz., 33°1 in comparison
with 34'9, a difference which is well within individual
variations, and that the chemieal metabolism of the
organism is not being called upon for the regulation
of body heat to a lesser extent than in a temperate
climate. The experiments related are, however, by
no means conclusive, and a good deal of work is still
required to bring order into the chaos of facts which
have been collected.
Of the organs of the body the blood is suspected to
suffer most under the influence of a tropical climate,
and the term “ tropical anemia” can be found in
nearly all text-books of older date, as an idiopathic
anæmia occurring in the Tropics. With the advance
of knowledge of parasitology cases of this complaint
have become rarer and rarer.
Idiopathic tropical anemia is most probably only
skin deep; in other words, the anæmic looks of many
of the white people living in the Tropics are caused
by the coarseness and dryness of the epidermis.
Eijkman's observations on the number of blood
corpuscles, the quantity of red-colouring matter, the
heemoglobin, and on the specific gravity of blood and
plasma of acclimatized Europeans in the East Indies,
pointed to the fact that the tropical climate, as such,
does not lead to any appreciable change in the quality
of the blood.
Similar observations have been made by the
American workers in the Philippines. The blood
examinations of healthy young American soldiers
(1,418 red cell counts and 1,433 hemoglobin estima-
tions on 702 soldiers) after twenty months of Philip-
pine service gave the same results as those recognized
for healthy young men in the temperate zone.
The observations of the Philippine observers are
extremely interesting, but are lacking in one respect,
viz., the subjects chosen for observation had only
been living in the Philippines for a comparatively
short time, and were especially chosen healthy indi-
viduals, who had to undergo a strict medical examina-
tion before being sent on service abroad. For some
time observations on the same lines have been carried
out in Townsville. The blood of school children has
been carefully examined. This examination has
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
269
proved that there is no appreciable difference between
the blood of children of the second and third genera-
tion as far as the number of formed elements of the
blood is concerned.
We (Dr. Priestley and myself) have, however, been
able to make very interesting observations. Some
time ago Arneth made a careful and systematic study
of a certain class of white blood corpuscles, the poly-
morphonuclearneutrophile leucocytes. The leucocytes,
when stained by different dyes, possess a large irregu-
larly shaped nucleus, sometimes resembling a horse-
shoe, sometimes split up into a number of nuclei or
nuclear fragments, so that in numbers of them three,
four, or more apparently distinct nuclei can be
differentiated.
Arneth observed a definite relationship between the
number of cells possessing one, two or more nuclei,
his relative figures being based, as a rule, on 200
consecutive cells found in a stained specimen. By
adding up the number of cells containing one and two
nuclei, and comparing it with the number of those
showing three and more nuclei, an index was obtained,
usually called after the author “ Arneth index."
He named the conditions when the first and second
class, containing one or two nuclei, were increased
above the normal number, and the third and fourth
correspondingly decreased a shift to the left, whilst
the reverse alteration is a shift to the right. Arneth
considered a shift to the left as a sign of lowered
resistance to disease.
Whilst examining the blood of Filipinos, Chamber-
lain and Vedder found a very marked shift to the left
in Filipinos in comparison with that of normal
Europeans.
Our own observations on the blood of healthy school
children have shown that there is a decided shift to
the left of the Arneth index, and the figures obtained
are nearly identical with the figures obtained in
Filipinos.
This observation is exceedingly interesting, as it is
a change which may be due to climate alone. Care-
ful work will, I hope, throw further light on this
change, whether it is the expression of a lowered
body resistance to certain maladies or without any
marked significance.
Our work as regards the blood-pressure of North
Queensland children shows that it does not differ to
any appreciable extent from the blood-pressure of
normal European children, showing a mean of about
116 mm. mercury.
As might be expected, the climatic conditions do
effect certain changes in the inner workings of the
organism. The excessive perspiration relieves the
kidneys of a part of their work. In a hot climate
the amount of urine decreases correspondingly to the
amount of fluid which is being excreted by the skin.
Daily quantities of urine of only 500 to 700 c.c. are
common, against 1,500 in a temperate zone. The
urine, however, is far more concentrated, and the
smaller quantity contains the same amount of waste
products as the larger volume elsewhere. The high
concentration of the urine might explain the higher
frequency of kidney diseases observed in the Tropics.
It is of common knowledge that, as a rule, the girls
270
attain puberty earlier in life in tropical climates. A
table compiled by Raciborski shows that there is a
distinct connection between the mean yearly tempera-
ture and the age of puberty. In the northern and
central parts of Europe the average age is 15-16
years ; in southern Asia 12 years and ten months is
given as the average age. Glogner’s observations in
the East Indies show that out of twenty-five girls of
European descent, and born in India, in eighteen
cases puberty came at an earlier age than in Europe ;
as a matter of fact, at the same age as in half-caste
girls.
The foregoing observations show that our knowledge
of the influence of the climate in the stricter sense is
very limited indeed. Disconnected facts have been
gathered at ditferent times, and under different and
often very adverse conditions, and, above everything,
the work has up to now not been sufficiently extended
to allow of the formation of definite conclusions,
especially in the direction of investigation of the most
minute physiological functions of the organisms under
tropical conditions.
All changes would be expected to become noticeable
very gradually, and such changes, if taking place,
would be hardly observable in the first generations,
would be more marked in the second and become
apparent to the naked eye in the third generation,
or perhaps even later.
As proof I may quote our own observations on the
" Arneth index." A few observations on Europeans
acclimatizing in the Tropics showed a slight shift to
the left which, however, was still within the indi-
vidual variation. In the third generation, on the
other hand, a distinct and unmistakable shift to the
left was present.
I am convinced that when our work has progressed
far enough to exclude gross changes, that numerous
and eareful observations on the physiology of the
human organism under tropical conditions will show
that certain minute changes do take place, and will
become more marked in succeeding generations.
THE INFLUENCE OF DISEASE.
This influence of parasitism has been more thoroughly
studied, and the advances made within the last fifteen
years in tropical parasitology and bacteriology have
revealed to us host upon host of new and deadly para-
sites, which are solely confined in their distribution
to tropical regions.
Anywhere in the Tropics where white settlers went
malaria formed a formidable barrier. Soon after
their arrival they contracted the fever, and whether
in Africa or South America or New Guinea white
tombstones marked the tracks of the first pioneers
with the inscription that — died of fever.
Numbers of them took flight, and returned to Europe,
often invalided for life, and hardly able to obtain
colours glowing enough to describe the ‘‘ New country
as a devil's paradise."
And the children! It is a pitiful sight to see in an
endemic malarial centre the small children suffering
from chronic malaria. The complexion is ashy grey,
the face is aedematous. They are pot-bellied, and
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1914.
one can often see without palpating the abdomen the
outline of the enormously enlarged spleen.
On considering in a general way the mental and
bodily progress in the course of the whole human life,
it becomes apparent that a child in its early infancy
is capable of assimilating mentally many times the
amount any adult could possibly digest in the same
space of time. If the mental capabilities are curtailed
during infancy on account of chronic malaria or any
other chronic debilitating disease, much valuable time
is lost for the further development, and backwardness,
due to lost opportunities, will become apparent and
more and more pronounced as the child grows older.
Of other diseases yellow fever has been an impor-
tant factor in checking the stream of emigrants to
countries where this particular disease is prevalent.
I remember how one used to look with pitying eyes
on the new-comers in North Brazil, knowing for
certain that nearly 25 per cent. to 40 per cent. of all
would, within a short time, succumb to this disease.
Parasitism, on the whole, is much more common
in the Tropics than in a temperate climate, since the
conditions for the development and spread of animal
parasites are more favourable on account of the humid
and hot temperature. The infections with helminth
are extremely common throughout the Tropics. The
most dreaded of all such infections is agchylosto-
miasis, which is so common and widely spread. The
adverse influence which this infection has upon
children, especially in early years, can hardly be over-
estimated. Many of the infected children are pale,
listless, take no interest in their surroundings, are
very irritable, their night's rest is disturbed, their
appetite is impaired, and the little sufferers show a
perverse craving for all sorts of rubbish, earth, sand,
wood, paper; in fact, there is hardly anything which
can be swallowed which is not eaten at one time or
another by the children suffering from this disease.
In case the patients are not treated at an early
stage of the disease, and the infection becomes
chronic, the children are marked for life, and present
the typical aspect of a degenerate.
When examining school children one is always
able to pick out the children suffering from agchy-
lostomiasis, who are at the same time, as far as
their progress at school is concerned, dull and
obstreperous.
The much-quoted examples of modern sanitation in
the Tropics, such as Ismailia, parts of India, and the
West Coast of Africa, have given conclusive evidence
that a great deal of the deteriorating influence which
has been attributed to climate, as such, is in fact only
due to parasites, and that with the awakening of our
knowledge of parasites, their life-histories and inter-
mediary hosts, the curse which has been lying on
many parts of the Tropies has been removed.
THE INFLUENCE OF SURROUNDINGS.
Personal hygiene, as clothing, housing and food,
are all factors which have an important bearing
upon the personal welfare of white men living in the
Tropies. Even the smallest and apparently negligible
detail may give rise to serious consequences. One
Sept. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
271
example may illustrate this statement. Frequently
children are brought to the hospital, the parents
complaining of the child being unwell, peevish, and
listless. Other children are brought in showing
clinical symptoms of fully developed lead poisoning,
drop wrist, drop foot, blue line in the gum, &e. The
clinical examination of the urine and fæces showed
the presence of lead in the excrementa, sometimes in
considerable quantity. The most obvious explana-
tion, after excluding the water supply, is that given
by previous observers, namely, that the lead paint of
the veranda rail became softened by the heat or
dried up in the sun, and the little mites ingested
enough of the paint by putting their fingers into their
mouth to become seriously ill, and often crippled for
lifetime.
Experience of life during my residence in different
parts of the Tropics may perhaps justify the expression
of my personal opinion. As a rule, when compared
with the overcrowded parts of Europe, the conditions
of life are much easier in the Tropics. The competi-
tion is less on aecount of the sparsity of the white
population, salaries are larger, and in the parts with
a large native population numerous servants can be
obtained for very small wages, so that the proud
white man is not forced to do any menial work, and
his position is that of a supervisor.
The hot sun, the abuse of aleohol, the proud
position into which the average man has been placed
tend to bring forth a considerable change in his
character. The amount of energy required to pro-
duce the necessities of life, which are on the whole
smaller than in a temperate climate, is lessened, and
the healthy, vigorous young man who emigrated to
the Tropics becomes afraid of work, unable to con-
centrate, and, generally speaking, a weakling.
The mental picture I have drawn, however, is
fortunately not the rule, but is only an extreme
example of the influence of the changed surroundings
upon a weakling whose energy in a temperate climate
was only kept up by the fight for his daily bread.
The European with energy and ambitions will, as a
rule, be only slightly affected by the changed condi-
tions of life and the alteration of his social condition.
Even he will lose a certain amount of his energy;
he will feel tempted to succumb to the fascination of
the dolce far niente. A call on his energy will, how-
ever, always be answered, and he will be able to do
nearly the same amount of work bodily and mentally
as anywhere in Europe.
The white woman who emigrates to the Tropics
will be much more affected by the change of surround-
ings than the man. During the hot hours of the day
she is compelled to stay in the house, and as most
of the housework is done by coloured servants for
very small wages, she will have hardly anything to
occupy her mind. The social conditions are altered
in comparison with those in which she has been
reared. The social gaiety of life to which she has
been accustomed is non-existent, and very soon she
will begin to fret, and the lack of outdoor exercise
will accomplish the rest. The woman will soon be
discontented and homesick, and her only subject of
conversation will be the behaviour or misbehaviour
of her native servants. This case again depicts
an extreme. The common-sense, healthy young
woman, with a good deal of esprit de vie, and with
varied interests, will never drift so far, but even she
will suffer now and again from discontent and home-
sickness.
It is said, and nearly everyone agrees on this one
point, that it is essential to send the children as
soon as a certain age is reached (usually between 5
and 8 years) away for their education. One has
to consider that the children are left to a great
extent in charge of native servants; they soon begin
to realize their apparent superiority over the coloured
servants; they become peevish and completely spoiled.
Moreover, the imitative sense is strongly developed ;
the children begin to imitate the ways and habits of
the coloured races amongst whom they are living.
If, now, we consider the application of the fore-
going to conditions prevalent in tropical Australia,
` we find that tropical Australia enjoys, in many
respects, quite a unique position amongst other
tropieallands. Although situated within the Tropies,
it has diversity of climes within easy reach, ranging
from the humid, het, low-lying coastal districts to the
bracing atmosphere of a high table-land. There is
practically no native population, the few surviving
aboriginals are of so little importance that their
influence is not felt.
The absence of a rative population makes the
dealing with disease an easy matter. Modern experi-
ence gained throughout the world has proved that
well and disereetly administered law, in a community
educated in matters of hygiene and in appreciation
of cleanliness, can accomplish even the most difficult
task.
The absence of a native population, furthermore,
does away with many of the social conditions which
prevent a white community in other parts of the
Tropies from gaining a firm foothold.
Most of the factors constituting " surroundings "
can be adjusted and improved in accordance with the
knowledge gained by experience, careful research,
painstaking observations, and scientific collecting of
statistics.
In Northern Australia we have, therefore, only one
factor which might prevent the successful colonization
by a white working population, and that is “ climate.”
Unfortunately, as we have previously seen, our
knowledge of purely climatic influence is still in its
infancy, and the facts and observations collected in
other tropical countries cannot be applied, as is so
often done, to tropical Australia without careful
discrimination.
Years of detailed and minute research carried on
in the populated coastal distriets of tropical Australia,
where a second and a third generation is being reared
at present, will clear up the question of the climatic
influence on the white man in the Tropics, and the
result of this work will indieate whether the great
experiment of populating tropieal Australia with a
white working community can be accomplished.
It would be precarious to express a definite opinion
that a colonization of tropical Australia by a white
population is possible, since statements either way
272
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1914.
cannot at present be substantiated by facts, but are
only the expression of a personal opinion.
It cannot be denied, however, that tropical
Australia offers far more favourable conditions than
any other tropical country for permanent white
settlement.
We are faced here with one of the most far-
reaching experiments of modern times, and experi-
ment which certainly justifies the application of
unlimited effort, as its result is the possession, not
only of the north, but of the whole of the united
Australia by a white community.
— 9 —————
Correspondence.
INTRAMUSCULAR INJECTIONS OF QUININE.
To the Editor of THE JOURNAL oF TROPICAL MEDICINE
AND HYGIENE.
S1r,—In a recent number of your Journal you had
an article inveighing against the intramuscular
injection of quinine, in which you ended up by saying
that you hope that a method of administering the
drug which never had anything to recommend it will
be given up.
You quote authority, including that of Ross, but
it would not be difficult to counter-quote other
authorities with quite as wide a clinical experience ;
and though authority is naturally listened to, when
it runs contrary to the clinical experience of many
it is desirable that the whole argument should be
thoroughly stated.
In this country intramuscular injections are given
very frequently, and many of us would like to know
the whole of the arguments that can be advanced
against them.
We know Semple’s work on tetanus, but many of
us think that the danger is so remote as not to be
worth considering; and if lives can be saved by intra-
muscular injection that cannot be saved otherwise I
do not think that the infinitesimal risk will prevent
men from giving quinine in this way. Tetanus may
be caused after the intramuscular injection either by
bacilli already in the system or by bacilli injected
with the quinine; but it is of no use to mention that
eleven cases occurred during the Madagascar campaign
and that someone has collected another ten cases;
we want to know the percentage of cases of tetanus
to intramuscular injections. The tetanus bacillus
has been found in catgut ligatures: this has not
stopped the use of catgut, but it has produced more
care in its sterilization.
It certainly would be very sad to have a case of
tetanus following the use of an intramuscular injec-
tion; but, unless it can be shown that the risk is dis-
proportionate to the gain, I do not think that the
many who have used the method with so much
benefit will be likely to give it up.
You mention the unsuitability of the salts of
quinine for hypodermic use, which chemically is
perfectly true; but I, and many others with whom
I have discussed this matter, have seen temperatures
come down after intramuscular injections which had
not been touched by quinine by the mouth, and this
not merely in a few cases but very many times. It
is not of much use to talk of chemical incompati-
bility and slowness of absorption if the clinical results
are good, as they have been known to be in perhaps
thousands of cases.
Then the slow absorption is given as a reason
against the method; but it is possible that this is
really in its favour, as the absorption is practically
continuous, and after the injection there is probably
for a long time some quinine in the blood ready to
hit off any sporulating organisms: whereas when
quinine is otherwise administered the whole may be
eliminated before sporulation takes place.
The intramuscular injection of salvarsan is said to
be more lasting in its effects than the intravenous
because of its slow absorption.
It is not necessarily the quantity of quinine that
cures; it is the presence of some in the blood at the
right time that is important, and for this the intra-
muscular injection seems to provide.
Of the other methods the rectal, which does not
seem chemically to be any more reasonable, has been
tried by several of my colleagues and given up because
they did not find it so effieaeious as the intra-
muscular. If you say that it is more easily and
rapidly absorbed from the rectum than from the
muscles the retort is " Possibly! but it does not cure
them so quickly.”
The intravenous is a method that can only be used
by a qualified medical man; it cannot be used by
dressers in estate hospitals miles away from a medical
man; and, though this method may be the quickest
way of getting a large quantity of quinine into the
blood, it is probably the method by which elimination
takes place the most quickly.
On some estates the coolies are so convinced of the
superiority of the intramuseular method that, even
though they cannot be persuaded to take the quinine
by the mouth, they actually ask for the injections.
Many Europeans, after getting tired of a long course
of quinine by the mouth, ask for intramuscular in-
jections and are benefited. It is not uncommon to
hear the expression, “Quinine by the mouth is no
good to me.”
I do not think that either these coolies or these
Europeans would ask for rectal or for intravenous
injections.
Some of us feel that there may be something we do
not know on the subject and would like enlighten-
ment. At a recent meeting of our local medical
society opinion was unanimously in favour of intra-
muscular injections—one speaking of thousands and
another of about 15,000 intramuscular injections
given by him or under his supervision—and we should
be glad to hear of some stronger reasons than those
given in your article, or in the letter by Sir Ronald
Ross in the Lancet, before abandoning a method which
seems to us not "never to have had anything to
recommend it," but potent for good.
I am, yours faithfully,
J. TERTIUS CLARKE,
June 3, 1914. Health Officer, Perak South.
Sept. 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 18, Vol. XVII.
Original Communications.
SLEEPING SICKNESS IN THE LADO OF THE
ANGLO-EGYPTIAN SUDAN.
By ALBERT J. CHALMERS, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories, Member
Sleeping Sickness Commission, Anglo-Egyptian Sudan,
AND
Captain W. R. O'FARRELL, R.A. M.C.
Protozoologist, Wellcome Tropical Research Laboratories,
Khartoum. '
Introductory.—This paper is the first of what it is
hoped will be a series of short notes on sleeping
sickness in various parts of the Anglo-Egyptian
Sudan, giving a condensed account of the known
history and distribution of the disease associated with
an attempt to define the parasite.
The experimental work has been performed in
Khartoum, which is far removed from tsetse-flies
and sleeping sickness. The material has been
obtained by means of animals inoculated from sleeping
sickness patients at Yei in the Lado Enclave of the
Mongalla Province by Captain Ranken, R.A.M.C., and
will be ealled the Yei strain or Yei trypanosome until
the end of the present paper.
The only means available at the present time of
differentiating trypanosomes is by comparative experi-
ments performed as nearly as possible under the same
circumstances of climate, place and time, and this
is the reason why the work was not performed in a
sleeping sickness area, because it was considered
unjustifiable to introduce Trypanosoma rhodesiense
into such area, as with all precautions an accident
might happen the results of which might have been
very terrible.
The strain of T. rhodesiense used was a lineal
descendant of the original strain discovered by
Stephens and Fantham, of the University of Liverpool,
to both of whom we are deeply indebted for so kindly
giving us the living trypanosomes.
Therefore the two strains to be compared in this
present paper have the following origins :—
T. rhodesiense.—Lineal descendant of the original
strain and brought alive from Liverpool in animals.
Yei strain.—Brought alive in an animal from Yei,
the full history of which will be detailed later.
Patients were not brought to Khartoum for two
reasons :—
(a) Danger of spreading the disease by bringing
individuals with trypanosomes in their peripheral
blood through as yet uninfected fly regions.
(b) Desire not to hinder the treatment, which
drives the trypanosomes from the peripheral blood
and at all events temporarily benefits the patients.
The methods adopted for fixing and staining the
trypanosome were as follows :—
All films were fixed wet with osmic acid vapour
for about four seconds and then plunged at once into
absolute alcohol, in which they were kept for two to
five minutes. They were then quickly washed with
distilled water and transferred into the Giemsa's solu-
tion without allowing the films to dry.
Two Giemsa's solutions were used, viz. :—
(4) A solution made up of 1 c.c. of the ordinary
stock stain with 10 c.c. of distilled water and two
drops of a 1 in 1,000 solution of potassium carbonate
in distilled water.
The films were stained in this solution for one
hour or longer and were then rapidly washed in
distilled water and dried.
(B) A solution made up of 2'5 c.c. of the ordinary
stock stain with 100 c.c. of distilled water and five
drops of a 1 in 1,000 solution of potassium carbonate.
The films were stained from five to twenty-four
hours in this solution and then washed in distilled
water and dried.
Historical.—In order to make some of our remarks
intelligible to any one who may read this note, it is
necessary to review the history of the discovery of
the trypanosomes of sleeping sickness as we under-
stand it, and then to pass on to a brief review of the
history of sleeping siekness in the countries adjoining
the Lado.
Human Trypanosomes.—The trypanosomes known
to exist in man may, for our present purposes, be
divided into those which cause—
(a) South American trypanosomiasis (molestia de Carlos
Chagas) caused by Trypanosoma cruzi Chagas 1909.
With this disease and its causal organism we are
not at present concerned.
(b) The African Trypanosomiases, more commonly called
sleeping sickness, with which we are concerned at
present.
In 1901 Forde and Dutton found a trypanosome
which, subsequently, received the name Trypanosoma
gambiense Dutton 1902, in the blood of a man suffer-
ing from a peculiar type of fever on the Gambia.
This trypanosome was, we believe, brought alive to
Europe; but, as after many inquiries we have failed
to trace its present existence, we are forced to the
conclusion that “the original strain" of human
trypanosomes is lost. This trypanosome was also
named T. fordii Maxwell- Adams 28 March, 1903, and
T. gambiz; Maxwell-Adams 28 March, 1903; other
synonyms are T. hominis Manson 1903, and T.
nepveut Sambon 1 July, 1903.
In 1902 Castellani found a trypanosome in the
cerebro-spinal fluid of persons suffering from sleeping
sickness in Uganda.
On page 9 of the First Report of the Sleeping Sick-
ness Commission of the Royal Society Castellani
says :—
“ The trypanosome found in the cerebro-spinal fluid of
sleeping sickness does not, as far as I have been able to
make out, differ materially in size and shape from the
species one finds in the blood of trypanosome fever,
T. gambiense (Dutton), but possibly it is to be differentiated
from this one because in it, as a rule, the micro-nucleus
lies nearer the extremity and the vacuole is apparently
larger. Besides, its movements are not apparently so
active, but this fact might be due to the effects of the
centrifuge. In case it should prove to be a new species,
the trypanosoma I have described might be called from
the country where I have found it first, 7, wandense.”’
This name suggested by Castellani, though the
paper was written in April, 1903, would bear the date
274
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1914.
of publication in the Proceedings of the Royal Society,
vol. Ixxi, 1903, p. 501.
In the meanwhile Kruse, as Castellani points out,
had suggested the name Trypanosoma castellanii in
the "Sitzungsberichte der Niederrheinischen Gesell-
schaft für Natur und Heilkunde zu Bonn," dated
May 18, 1903, because this is the first name to appear
in print, while the name T. ugandense was only read
before the Royal Society on May 14, 1908, and did
not appear in publie print till later. Therefore if, by
any chance, the trypanosome found by Castellani in
Uganda should prove to be different from T. gam-
biense Dutton 1902, its name would be either
T. ugandense Castellani 1903, or, as it appeared in
public print slightly earlier
T. castellanii Kruse 1903.
The differences between these two trypanosomes
is not recognized at the present time because morpho-
logically they seem to be identical.
Matters remained in this position until the year
1910 when Stephens and Fantham advanced the view
that the trypanosomes found in cases of sleeping
sickness in the Loangwa Valley in Rhodesia belonged
to a new species which they called—
Trypanosoma rhodesiense Stephens and Fantham
1910.
Whatever views may be held concerning this
species, no one has ever doubted that it was different
from T. gambiense, in the broadest sense of the word,
and some of the experiments which will be described
below show how very different it is from the
trypanosomes of the Anglo-Egyptian Sudan, Mongalla
Province (Old Lado Enclave), and which, from epi-
demiological and other reasons, is thought, by the
present writers, to be probably the same trypanosome
as that found in the Congo and in Uganda.
In 1913 Scott Macfie described a new trypanosome
in cases of sleeping sickness in Southern Nigeria,
separating it from T. gambiense and T. rhodesiense
by:—
(a) Its morphological features.
(b) The peculiar symptoms of the disease produced
by it.
(c) The slight mortality it causes in animals.
This trypanosome he names :—
Trypanosoma nigeriense Scott-Macfie 1913.
Thus in differentiating a human trypanosome, it
has to be compared with :—
(1) T. gambiense Dutton 1902,) if these are dis-
(2) T. castellanii Kruse 1903,) similar.
(3) T. rhodesiense Stephens and Fantham 1910.
(4) T. nigeriense Scott-Macfie 1913.
To this point we shall return in the discussion of
our observations.
Sleeping Sickness in Countries adjoining the Lado
Enclave.—The countries which adjoin the Lado
Enclave and which are known to be infected with
sleeping sickness are :—
(1) Belgian Congo,
(2) Uganda,
and it is necessary, for the purposes of this paper, to
review the known conditions of the disease in the
parts of these countries which lie in proximity to the
frontiers of the Lado.
(1) The Belgian Congo.—In order to understand
the conditions under which sleeping sickness has
arrived in the Belgian Congo and Uganda it is
necessary to review briefly a few of the known salient
points with regard to the general history of the
disease in Africa.
The reader of this note is asked to observe carefully that
any dates merely signify that those are the periods during
which the disease was definitely recognized at a given place
and do not mean that the disease had just arrived in that
locality. f à
If it is realized how difficult the diagnosis of sleeping
sickness may be and how necessary it is to confirm its
presence, in the early stages, by gland puncture and the
microscopical recognition of the trypanosome it will be
obvious that it could be easily overlooked for years in a
place in which it was present. à
Lastly it may be remembered that, as a rule, a native,
out of politeness or fear, will say anything and agree to
anything he tbinks is required, and hence misleading
evidence may be received as to absence from or the duration
of sleeping sickness in a place.
With these preliminary remarks we will review
what is known of the principal points of the history
of the disease.
The earliest recorded case of sleeping sickness is
the death from lethargy of the King Mansa Djata in
1373-74; at that time, it is stated, the disease was
very common in his country, which was situate in the
bend of the Niger.
In the year 1721 John Atkins, Surgeon in the Royal
Navy, made a journey to the Guinea Coast, touching
at Sierra Leone, places on the Gold Coast, Dahomey
and Cape Lopez.
As a result of his observations he says :—
** Whydah slaves are more subject to smallpox and sore
eyes; other parts to a Sleepy Distemper, and to Wind.
ward Exomphalos’s.”’ :
He also mentions "the Sleepy Distemper" in his
other book entitled " The Navy Surgeon."
In 1803 Winterbottom recognized the disease as
being common in the natives about Sierra Leone and
gave an account of the disease, especially emphasizing
the importance of the presence of enlarged glands in
the neck for early diagnostic purposes.
Sleeping sickness was known to exist on the Congo
when Bordier wrote in 1884.
When Corre wrote his justly celebrated book in
1887 it was recognized to extend from the Senegal
River in the north to the Loango river in the south.
If it is realized that, at that time, hardly anything
was commonly known about West Africa Congo, it
will be apparent that this only indicates the fringe of
the distribution of the disease.
A curious point is to be noted in these old writings,
and that is, the persisteney with which the authors
dwell upon the endemicity of the disease.
Thus Corre says :—
'' Endémie trés limitée, et ne prenant jamais la forme
épidémique.”
Another feature of the disease which appears to have
been missed is its duration.
Again quoting from Corre :— ;
'On aurait vu des individus atteints deux, trois, cing
aus aprés avoir quitté les centres endémiques.”
Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.:
275
Bordier says :—
“On a vu la maladie se déclarer chez les nègres depuis
longtemps (7 ans) débarqués aux Antilles.” :
That is to say, the disease can last longer than
seven years after removal from any chance of infec-
tion, but how much longer? This question we are
stil unable to answer.
From this history it is quite clear that sleeping
sickness was of old standing in the country enclosed
in the bend of the Niger and along the West Coast of
Africa from the Senegal to the Loango. It is, there-
fore, not. surprising when we find that it was recog-
nized at Stanley Falls on the Upper Congo in 1898,
but that by no means indicated that it had just arrived
there, and there is no reason to doubt that, at that
period, the greater part of the Congo valley was
infected, but when the original infection took place
we do not know.
From this source of infection it most probably
spread into the western part of the Lado Enclave,
perhaps by the agency of Belgian troops or perhaps
still earlier.
(2) Uganda.—Towards the end of the eighties of
last century Stanley led a large force from the Congo
to relieve Emin Pasha who was at that time at
Wadelai on the Nile, where it bounds the south-
eastern part of the old Lado Enelave. Christy and
Hodges consider it probable that some of Stanley's
people were infected with sleeping sickness and thus
introduced the disease into that district and infected
Emin's men.
There are several points to support this, viz.: firstly,
at the present time Wadelai is known to be infected
as was shown by Captain Drew, R.A.M.C. ;.secondly,
Captain Archibald, R.A.M.C., pathologist to these
laboratories, travelling northwards from Uganda to
the Sudan in the-early part of 1908, met with sleeping
sickness north of Lake Albert and found G. palpalis
on the road from Murchison Falls to Wadelai and on
the Nile in that region.
Emin’s people subsequently travelled with Stanley
to Kavali on Lake Albert, which is known to be in-
fected at the present time. Later they were moved
to Busoga, known now to be heavily infected. pro-
bably since 1896.. Still later they passed to Uganda
where Mengo, the Sese Islands and the western shores
of Victoria Nyanza became infected.
'This seems to be the probable history of the source
of the infection of Uganda, and seeing that it started
from the southern part of the Lado now belonging
to Uganda or from Lake Albert it is not surprising to
find that there is a heavy infection in the south-
eastern part of the Mongalla Province on the Kiyu
River near Kajo-Kaji and that this infection wipes.
out villages and in general behaves just like the
Uganda and the Congo epidemics. It is, however,
but just to state that it is thought that the Kiyu
epidemic was introduced from Uganda years ago by
Baganda traders.
The Mongalla | Province.—The present Mongalla
Province was acquired for Egypt by Sir Samuel Baker
and was later administered by General Gordon, and
still later by Emin Pasha (Dr. Edward Schnitzler).
At this time the inhabitants were being decimated by
Arab slave traders to an extent that is now incredible.
The Mahdist rising-in the Northern Sudan isolated
this Equatorial Province, and Emin Pasha and his
people were left there until rescued by Stanley’s
expedition in 1888. This is.a memorable date, as it
is believed that sleeping sickness was introduced into
this part of Africa by Stanley’s followers.
After the departure of Emin Pasha and his people
the local inhabitants were left to war with one
another at their own free wills, until during the closing
years of the last century they were controlled by the
Belgians who came from the West, and to whom the
Lado Enclave, a territory extending along the left
bank of the Nile from Albert Nyanza to 5 deg. 30 min.
N. latitude, was leased in order to afford an outlet for
the trade of the eastern parts of the Belgian Congo
via the Nile.
This traffic, which was probably of importance in
the spread of sleeping sickness, was maintained. by
carriers. drawn from the neighbouring regions and
from around the lakes.
After the death of King Leopold the Lado reverted
to the Anglo-Egyptian Sudan in June, 1910. . |
As now constituted, the Mongalla Province is
bounded—
On the-North by the Upper Nile Province and a
horizontal east and west line running from the Nile
at about 7 deg. 40 min. N. latitude to the Apusinies
frontier.
On the Hast by the Abyssinian boundary andi by
Lake Rudolph to about 3 deg. 30 min. N. latitude.
On the South by a line drawn from Lake Rudolph
to Nimule and northward just to the west of the Nile
as far as the Kiyu River, then westwards along the
Kiyu River to near the source of the Kaya Riven on
the Belgian Congo frontier.
On the West by. the Belgian Congo and Bahr-el-
Ghazal frontiers. i
For the most part the western side of the province
is composed of- gently undulating land drained by
numerous streams and inhabited especially in the
Lado by people who are great wanderers. Early
writers mention the existence of tse-tse fly in the
Monbuttu country just south of the Lado, which is
the region of the Mongallo Province to which
sleeping sickness is confined.
The Lado.—The Lado (vide map) is inhabited: by
numerous small tribes who in their natural condition
appear to have been on very poor terms with one
another, consequently little or no inter-communica-
tion occurred until the advent of more stable condi-
tions under the white man's rule. Along the river
there are the Dinkas and the Baris towards the
south. Inland in.the Northern Lado there are the
Nyanbaru and the Morru. The Fajelu, Avokaya and
Kakwa live in the Central Lado. To their west are
the Makaraka and Mundu tribes. The former are an
offshoot of the Azande or Niam-Niams and are a
comparatively recent intrusion in this part. In the
southern part of the Lado‘ there are the Kaliko
towards the west and the Kuku on the plateau near
Kajo-Kaji.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
31!
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Yangwara» Roha
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MAP I r
a J NE Ea
MONGALLA PROVINCE SEIL
LADO ENCLAVE Sawa,
Scale lin 1,500,000
i. Tm
Q----------- Sleeping sickness.
=- æ m m -------- Sleeping sickness areas.
Q----------- ~ Glossina palpalis.
Oss Stee aS as Glossina morsitans.
. Provincial boundaries as regards Lado Enclave ouly.
3/0 Ra: (Sh: Bula Matar
[Sept. 1, 1914.
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Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
277
The small original Mongalla Province, ?.e., the part
of the present province to the west of the Nile and
north of the Lado, was first occupied in 1901, being
placed under the Governor of the Upper Nile Province,
and during this time contained no sleeping sickness.
In 1909 it was felt that there was great danger of
the disease spreading from the south into the little
province, and special regulations were framed with
the view of preventing this.
The Lado Enclave lease to Belgium being due
to terminate in June, 1910, Major Mackenzie and
Yusbashi Yusef Effendi Derwish were sent to in-
vestigate the conditions of sleeping sickness therein,
prior to its being added to the Sudan.
They were met by the late Dr. Errara, who stated
that the presence of the disease had been recognized
in the Lado since 1908, and that it had extended
far northwards along the Yei River (vide map),
westwards along the Torre River, and that it was at
Kiro in the north-eastern corner of the Enclave, but
this was probably only an imported case, as it has
not been reported from there since.
Major Mackenzie and Yusbashi Yusef found it
present in many villages on the upper waters of
Yembi and Kowba Rivers, also in the villages of
Wata, Lasuba, Kambora, Sei, Lua, Morgan, Baraba,
Lugalla (Luba) and at Bringi village near Wande.
They also observed that Glossina palpalis was almost
everywhere and that the tribes were great wanderers,
a fact which tended to spread the disease. The area
in whieh sleeping sickness was definitely seen was
carefully marked out, being bounded :—
Eastwards.— Line from Bangali to Loka.
Northwards.—Line from Loka to Wande, and from
Wande to Ewe.
Westwards.—Line from Ewe along the Bahr-el-
Ghazal frontier to the Congo frontier.
Southwards.—Along the Belgian Congo frontier
through Libogo to Bangali.
Immediately after taking over the Lado from
Belgium schemes were set on foot to cope with the
epidemic; and in January, 1911, a large isolation
hospital was started at Yei, by Captain R. J. C.
Thompson, R.A.M.C.
Later in the same year the Lado was carefully
inspected by the late Colonel Mathias, R.A.M.C.,
P.M.O. Egyptian Army, with Captain Archibald,
R.A.M.C., who reported that the natives called the
disease " Kubeera Na Pongi.” Colonel Mathias came
to the conclusion that the disease had existed for
four to five years, being introduced from Uganda by
Baganda porters or from the Congo Free State by
them on their return journey and by Congolese
soldiers. He also mentions that some villages had
been wiped out by the disease.
In the same year Mr. King, Government Entomo-
logist, made an entomological survey of the Lado and
reported that G. palpalis could be found at any suit-
able place the whole way from M'volo in the Bahr-
el-Ghazal Province to Yei. He also visited the
eastern part of the Lado, and mapped out the dis-
tribution of G. palpalis and G. morsitans.
Captain Drew, R.A.M.C., made a careful examina-
tion of the Enclave and wrote a most valuable report
on the sleeping sickness therein, finding 218 cases
in 14,976 examinations and alter performing 742
gland puncture examinations. He estimates that in
the area inspected he examined about 95 per cent. of
the men, women and children.
In 1912 Captain Stigand drew attention to the
faet that Kajo-Kaji, in the vieinity of which he had
previously found G. palpalis and G. morsitans,
was threatened with the disease and later in the
year it was found to be infected as was Loka and
Wadelai.
In the same year Captain Ranken reported that
up to September 30, there had been 408 cases of
the disease admitted to the isolation camp and
among these there had been 88 deaths. The case
infection of different villages varied very much from
22 to 0'3 per cent. In one set of 695 persons with
enlarged glands in the neck 139 were proved by
puncture to be due to trypanosomes.
Early in 1918, Colonel Bray, R.A.M.C., P.M.O.
Egyptian Army, made a tour of inspection of the
Mongalla Province and found that the area of infec-
tion had become larger, having spread northwards
and eastwards.
The boundaries as described to us in June, 1914,
by Captain Ranken, R.A.M.C. (vide map), are :—
Eastern.—From a little south of Wara through
Loga to Mafi east of Wande.
Northern.—From Mafi to the Yei River and from
this to where Ewe was formerly on the frontier.
Western and Southern.—From Ewe along the
frontier to just south of Libogo and then to a little
south of Wara.
Late in 1918 Captain Ranken found very heavy
infections in the villages of Bulamatari and Jokwat
situate on the Kiyu River, where about 100 cases
were discovered and where it was said that whole
villages had been wiped out. Captain Ranken thinks
that this infection came from Baganda traders long
ago.
The Kiyu River forms part of the proposed boundary
between Uganda and the Sudan.
It will thus be seen that there are two main areas
of infection in the Mongalla Province, viz. :—
(1) A western: centred around Yei (vide map) and
inhabited by the Makaraka and the Mundu peoples.
(2) An eastern: adjoining Kajo-Kaji (vide map)
and inhabited by the Kuku peoples.
It would appear as though these had arisen from
two entirely separate sources of infection, viz. :—
(1) From the Belgian Congo, assisted by Baganda
traders.
(2) From Uganda.
The Parasite—Captain Ranken very kindly in-
jected two monkeys and one dog from sleeping sick-
ness patients at Yei Sleeping Sickness Segregation
Camp. These animals were brought to Khartoum
by Captain Simpson, who left Rejaf on July 21, 1913,
and who arrived in Khartoum on August 10, 1913.
On examination only one monkey was found to be
infected and from this animal the strain called the
trypanosome of Yei was obtained,
278
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1914.
An attempt to forward another strain in December,
1918, was unfortunately not successful, as neither
‘the dog nor the monkey showed any infection on
arrival in Khartoum, so that this present note as
regards the Mongalla Province is written solely from
experiments made on the first strain.
~ Captain Ranken has kindly supplied the following
history of the case from whieh the monkey was
inoculated :—
“The woman was an advanced case of sleeping
sickness coming from Abuddal, a Makaraka village
situate originally on the banks of the Yei River some
twenty miles north of Yei itself, but recently moved
to a distance from the river bank. The Makaraka
area used to be celebrated for its ivory, and ‘many
-Baganda traders formerly visited it and may possibly
have been the original source of infection. It is of
importance to note this fact as it indicates the same
"gource.of infection as that which has wiped out the
villages of Bulamatari and Jokwat (this should be
remembered in reading the aecount of the action of
^human serum on this trypanosome given below).
:'s"* Bach of the animals was inoculated subcutan-
“eously with blood, gland juice, liver blood and cerebro-
spinal fluid in order to ensure infection, as the woman
.was the only untreated case in the camp and the
trypanosomes had disappeared from the peripheral
blood on the day of inoculation."
It is possible that the strain may represent that
"present in Uganda or present on the Congo, but this
hardly matters, believing, as we do, that the Uganda
infection originally came from the Congo.
Itis now proposed to give certain details concerning
this parasite under the following headings :—
(1) Morphology.
(2) Animal reactions.
- (3) Immunity.
(4) Cross immunity.
(5) Cytolytie sera.
` (6) Agglutination.
(7) Other reactions.
(8) Mode of transmission,
(9) Iconography.
(1) Morphology.—The minimum length was 18
microns, the maximum length was 36 microns, the
variation being 18 microns.» The minimum breadth
was ‘about 1 micron, the maximum breadth was
2°5 microns measured across the widest part.
The average length of 1,000 non-dividing trypano-
somes measured in the usual way was 25 microns.
The distribution according to length of 1,000 non-
dividing forms measured by one hundred per diem
from the blood of an infected monkey, Lastopyga
callitrichus (I. Geoffroy 1851), and drawn by means
of a camera lucida at a magnification of 1,000
- diameters and measured by the tangent method, is
set forth in Tables I, II and III, and in Chart I.
The history of the monkey is as follows :—-
It was inoculated subcutaneously on January 8,
1914, with citrated blood of a gerbil, Gerbillus pygargus,
which was in the early stages of the disease. Ten
days later, 7.c.,on January 18, for the first time the
monkey showed a heavy infection and the count was
started and completed on January 27. The monkey
died on February 9.
Yri STRAIN.
Graphical representation of 1,000 Trypanosomes from one
monkey, Lasiopyga callitrichus. (I. Geoffrey, 1851.)
CROMS
[25 T26 [27 [28 [29 [30 [3 [32 [33 [ $4135 136]
t
$
=
$
è
CHART I.
The measured trypanosomes were therefore taken
from the tenth to nineteenth day inclusive of an
infection lasting about thirty-three days.
A posterior nuclear position has, so far, never been
observed by us in this trypanosome.
(2) Animal Reactions.—Briefly it may be stated
that its virulence in dogs, cats, rabbits, gerbils,
jerboas, white rats and monkeys is distinctly less
than that produced by Trypanosome rhodesiense
Stephens and Fantham, but more marked than that
recorded for T. nigeriense Scott- Macfie.
The average duration of life in infections with this
parasite is as follows :—
Ineubation, 12 days; average length of
life, more than 40 days, often several
| months.
Dog
. |Ineubation about 9 days; average length
Monkey l of life, 35/5 days.
Gerbil | Incubation, 7 days;
average length of
life, 14°6 days.
(3) Immunity—A dog was rendered immune, r.e..
its peripheral blood had failed to show trypanosomes
for more than sixty-one days after receiving its fifth
inoculation with the Yei strain. The last tested
gerbil inoculated with this dog's blood failed to develop
an infection.
The serum of the dog, when fully immune, destroyed
the T'rypanosome from Yei in twenty minutes in ritro.
but had no effect on T. rhodesiense, after one hour,
i.e., the serum destroyed the homologous but not the
heterologous trypanosome. In these observations we
confirm the work of Mesnil and Ringenbach as quoted
by Stephens and Fantham.
When partially immune the serum was taken and
Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
279
TABLE I.—DISTRIBUTION IN RESPECT TO LENGTH OF 1,000 NON-DIVIDING INDIVIDUALS OF YEI STRAIN OF TRYPANOSOMES
IN A SrNGLE Monkey, Lasiopyga callitrichus (I. Geoffroy 1851).
IN MICRONS
14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 92 | 23 | 24 | 95 | 26 | 27 | 28 | 29 | 80 | 81 | 82 | 38
— m | p a tac! da E
HA se] 24 955 ES: O ENE SE A Bs} el s |
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|
34 |
AVERAGE
Of each | Of each
20 100
22-65
22:55 |
22:50
22-45
23:55
22-74
23°05
24-40
24-20
23:80
25:25
24°14
24°40
24°10
24-00
24°35
23°10
23:99
26:50
24:10
24°75
24 95
24°95
25-05
25:90
25:25
26:85
25:40
26 45
25:87
25:60
25:40
96-920
24°70
25°65 |
25°51
24°55
26:15 |
25°50 |
26:50
24°60
25°46
22-45
25:15
23:55
23:55
23°75
23°69
26°45
25°65
26°25
26°30
26°90
26°31
28:90
29:10
27:50
21:20
27:55
28°05
1! Average length
of 1,000
is 25:071
TABLE II —SUMMARY OF MEASUREMENTS (IN MICRONS) OF
LENGTHs OF 1,000 INDIVIDUALS OF T. yei STRAIN FROM A
SixarLE Monkey, Lasiopyga callitrichus.
Averages Averages Range of
Maximum Minimum of each of each averages
100 20 of each 20
1! 27 19 22-65
2 | 27 19 22°55
Ist day 3 26 20 22°74 22°50 1:10
: 4| 26 18 92:45
5 28 20 23:55
6 28 18 23:05
7 28 22 | 24:40
2nd day 8 30 20 24:14 24:20 2:9
9 28 19 23:80
10 30 23 25:25
11 20 20 24°40
12 29 20 24°10
3rd day 13 28 18 23:99 24:00 1:3
14 28 | 19 24:35
15 28 18 23:10
16 32 19 26:50
17 30 18 21:10
4th day 18 31 | 18 25:05 24°75 2:4
19 31 20 21:95
20 29 18 24:95
21 30 20 25°90
22 31 21 25°25
5th day 23 33 21 25:87 20:35 1:2
24 29 18 25:10
25 31 | 22 26:45
26 31 20 25:60
27 32 21 25:40
6th day 28 31 20 25°51 26 20 1:3
29 29 20 26 70
30 30 21 25:65
31 31 20 24:55
32 32 22 26:15
Tth day £3 31 18 25:46 25:50 1:95
34 31 21 26:50
35 30 19 24:60
36 26 19 22:45
3T 30 21 25:15
Sth day 38 28 18 23°69 23°55 27
39 29 19 23°55
40 28 20 23°75
41 32 23 26:45
; 42 31 21 25 65
9th day 43 30 23 26:31 26:25 1:25
44 32 21 26:30
45 30 22 26 90
46 36 24 | 28:90
47 | 35 23 29:10
10th day 48 33 20 28-05 27°50 19
49 32 22 27:20
50 32 24 27 55
Range = 29:10
22:45
6:65
inoculated into gerbils immediately after mixture with
the trypanosomes. The results were as follows :—
T. rhodesiense
T. rhodesiense i
(a) Stumpy, | 32
(c) Long, 24
25—36
280 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Sept. 15, 1914.
¿An infection resulted from which the
animal was recovering when it died
of heat stroke, on the same day with
forty-nine other animals, 7.e., on the
thirty-ninth day after inoculation.
An infection resulted which killed the
animal on the seventh day after
inoculation.
!
Trypanosome
of Yei
|
(
When completely immune the serum was taken
and after being in contact with the trypanosomes
(1 c.c. of the serum to 0'1 e.c. of infected blood, both
infections being as nearly as possible of the same
apparent strength) for thirty minutes, was inoculated
into gerbils :—
/No trypanosomes seen in the peri-
pheral blood of the inoculated ger-
bil, but the animal was accidentally
killed two days fourteen hours after
inoculation. It showed no trypano-
| somes in the internal organs, but
peculiar bodies were seen in the cells
of lung smears, comparable with the
granules found by Archibald in the
spleens of kala-azar patients and of
animals inoculated with kala-azar.
These granules are quite different
from the infective granules described
by Fry and Ranken.
{The gerbil became infected and died
in ten days.
Trypanosome |
from Yei |
TanBLE IIL— T. yei STRAIN IN WHICH THE TRYPANOSOMES ARE
ARRANGED IN BRUCE’S THREE Groups: (a) 18—21 u; (b)
22—24 u; (c) 25u AND UPWARDS.
Day | 1 2 | 3 4 5 6,1 8 9 , 10 {Totals
13/12 15| 6 10! 8/19, 2 1| 118
13—21 u | |
26 26|2|41 |19 | 10 | 814
(b) Interme- | 44 | 47 | 45 | 27
diate, 4 |
22—24 u i |
40 | 43 | 58
68 ial ical W 568
Totals |100 100 100 100 |100 100 100 100 |100 |100 |1,000
TABLE IV.—IwMUuNITY EXPERIMENTS IN VITRO.
|
Immune serum +-
Trypanosome from Yei
Immune serum +
Animal | T. rhodesiense
Dog immunized , Alltrypanosomesdead Trypanosomes
against Trypano-| in twenty minutes. alive at end of
some from Yei in | one hour.
the Lado. |
Goat immunized Trypanosomes alive | All trypanosomes
against T. rho- | atend of one hour. |
desiense, original
strain of Stephens
and Fantham
1910.
M s e a s n RR e e s a
dead in twenty
minutes.
Sept. 15, 1914.)
TABLE V.—IMMUNITY EXPERIMENTS IN VIVO.
T |
Gerbil inoenlated with | Gerbil inoculated
immune serum + Trypano- with immune serum
some from Yei | +T. rhodesiense
original strain
Immune serum
From dog par- | Inoculated — 9.4.14; | Developed severe
tially immunized | showed trypano- trypanosomiasis
against the Try- | somes 15.4.14; good, and died on
panosome from | infection — 17.4.14; | seventh day
Yei. The inocu- | afterwhichtrypano-| after inocula-
lation of the ger- | somes diminished | tion.
and the animal was |
in apparently good
health on 17.5.14. |
when it died of heat |
stroke with forty-
nine other healthy
and inoculated ani-
mals,i.e.,thirty-nine
days after inocula-
tion. |
bils was made
immediately after
mixing with the
immune serum.
From dog com- |Did not show any | Developed severo
pletely immun- | trypanosomes but} trypanosomiasis
ized (i.e., gerbil | was killed accident- | and died on the
inoculated with | ally two days and| tenth day after
its blood did not
develop trypano-
fourteen hours after| inoculation.
inoculation. No try-
somiasis) against | panosomes to be
the Trypanosome | found in internal
from Yei. Try-| organs, but peculiar
panosomes left for | bodies in lung cells
thirty minutes | identical with those
in contact with
serum before in-
jection into ger-
bils.
found by Archibald
in spleens of kala-
azar patients and of
animals inoculated
with kala-azar.
Developed severe try-
ponosomiasis and
died on fourth day
after inoculation.
From goat immun-
ized against T.
rhodesiense, ori-
ginalstrain. Try-
panosomes left for
Alive and ap-
parently in its
usual health one
month after in-
oculation, and
twenty minutes has not shown
in contact with trypanosomes in
serum before in- its peripheral
oculation into blood. The ger-
gerbils. bil was now
killed and films
made from the
lungs, spleen and
liver, but no try-
panosomes were
found.
(4) Cross Immunity.—The immunized animal was
used for a cross immunity experiment which we
propose to detail in a subsequent paper.
(5) Cytolytic Sera.—We have tried the effect of
normal human blood serum upon several strains of
trypanosomes.
The technique used was to take 0'5 c.c. of the serum
and to add to it 0'025 of the infected blood containing
as far as possible equivalent numbers of trypanosomes.
The experiments were conducted at room temperature,
i.e., 102° F.
The results may be summarized briefly by saying
that no trypanolysis, worthy of record, took place
with two strains of mule trypanosomes, with T.
rhodesiense original strain, or with the Trypanosome
from Yei which we are considering.
The human serum certainly slowed the movements
of T. rhodesiense but it was not observed to destroy
any during the space of one hour.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 98]
It did not appear to be beneficial to the mule
strains.
With regard to the Yei strain the human serum
appeared to have a distinctly beneficial action, as at
the end of one hour's microscopical examination in
vitro the trypanosomes were in excellent condition
and more active than at the commencement of the
experiment.
This beneficial action of human serum on the Yei
strain of trypanosome may perhaps explain, at all
events in part, the epidemic character of the attack
in the Eastern Lado as well as the high mortality in
that region.
The only sera which we have observed to produce
trypanolysis have been strongly immune sera which
destroyed the homologous trypanosomes in a most
remarkable manner but did not act on heterologous
trypanosomes.
(6) Agglutination. — We have observed strong
though incomplete agglutination of a strain of
trypanosomes from a gerbil and derived originally
from a mule by mixing 07025 c.c. of the infected blood
with 0'5 c.c. of normal human blood serum.
If this is admitted it is obvious that agglutination,
as a specific test, is useless for the recognition of a
trypanosome.
(7) Other Reactions. — We have not used such
methods as phagocytosis, attachment, complement
deviation, &e., as other observers have found them to
be unsuitable for the purpose of the differential
diagnosis of a trypanosome. We have only performed
a few experiments with trypanolytie drugs and quickly
came to the conclusion that this form of research
would not help our present purpose.
(8) Mode of Transmission.— We have made no
experiments under this heading, nor are, in our opinion,
any necessary if we are correct in our recognition of
the species of trypanosome (vide infra) which we have
received from Yei as the brilliant discoveries of Sir
David Bruce and his co-workers have sufficiently
proved that it is spread by Glossina palpalis (Robineau-
Desvoidy, 1830).
TRYPANOSOMA RHODESIENSE.
Graphical representation of 1,000 Trypanosomes from one Rat
(white), (Stephens and Fantham, 1913.)
à
9
8
7
6
5
4
3
2
D
CHART II.
(9) Iconography.— We give no photomicrographs
of this strain as we believe it (vide infra) to be the
282
same as the Uganda strain which has been so
beautifully depicted by Lady Bruce in plate 13 of
vol. 84, series B, of the Proceedings of the Royal Society
for 1911.
Comparison with other Trypanosomes.—The differ-
ences and the similarities of this trypanosome with
the other known human trypanosomes will now be
discussed in the following order :—
(I) T. rhodesiense.
(II) T. nigeriense.
(III) T. gambiense, Congo strain.
(IV) T. gambiense, Uganda strain.
(I) T. rhodesiense Stephens and Fantham 1910.
The trypanosome from Yei differs from T. rhodesiense
in that :-—
Trypanosome from Yei T. rhodesiense
(1) Maximum length 96 against 34 microns.
(2) Minimum length 18 Si 14 si
(3) Average length .. 25 PA Bi 5.
(4) Curve of 1,000 Vide Chart I. SA Vide Chart II.
lengths
(5) Posterior nuclea- Not observed m Present.
tion
(6) Animal reactions Less virulent i» More virulent.
(7) Yei immune serum
reactions—
(a) In vitro Destruction of F No destruction.
trypanosomes
(b) In vivo.. Destruction of " Development of
trypanosomes disease and
death.
TRYPANOSOMA NIGERIENSE.
Graphical representation of 1,000 Trypanosomes from one
Guinea-pig.
(Scott Macfie, 1913.)
TAN [|
TTA LIVE MALIA |
REA +H FERN
ECE
Ltt HHH HH- YT I NI
"i71 | HEREDES
Omarr III.
(II T. nigeriense Scott-Macfie 1913.
from this trypanosome in that :—
It differs
Trypanosome from Yei T. nigeriense
(1) Maximum length 36 against 84 microns,
(2) Minimum length 18 T 8. "5
(83) Average length .. 25 $i v AE
(4) Curve of 1,000 Vide Chart 1 Vide Chart 3.
lengths
(5) Anterior nuclea- Not marked.. S Marked in small
tion forms.
(6) Animal reactions More viru- i Less virulent ;
lent; mon- monkeys alive
keys die in and well on an
about 36 days average 127
after inocu- days after in-
tion oculation.
In making these comparisons decimal figures have not been
considered,
We have found no records of immunity and trans-
mission experiments with T. migeriense except two
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1914.
observations by Scott-Macfie, indicating a possible
development of T. nigeriense in the gut of Stomoxys.
We have thus shown that the trypanosome from
Yei is neither T. rhodesiense nor T. nigeriense.
TRYPANOSOMA GAMBIENSE.
Graphical representation of 1,000 Trypanosomes in one Rat
(white). sg and Fantham 1913.)
la
papis Tre [17 [i6 Tig [20T2! | ree [25 T28 27 [25 [25 36 9: [SETS S [34
||
|_|
L]
L|
|J
y |
[HH
JERR eR
| |
m
L|]
|_|
|
J
a
| |
L|
CnaRT IV.
(III) T. gambiense, Congo strain.—It is now neces-
sary to compare this trypanosome with a known
strain of T. gambiense (sic) and this can be done by
taking the strain ably described by Stephens and
Fantham in the "Annals of Tropical Medicine and
Parasitology," 1913, vol vii, No. 1, p. 27, which,
according to Professor Stephens, was obtained from
Professor Mesnil in 1905 who, according to Dr.
Fantham, obtained it from a case of sleeping sickness
from the French Congo.
Trypanosome Trypanosome
7 from Yei from Congo
(1) Maximum length — ... 36 against 36 microns
(2) Minimum length jv SRO ji 16 X
(3) Average length 25-017 3 24:867 ^n
(4) Curve of lengths Chart I. M Chart 4
Mesnil and Ringenbach have demonstrated that the
immune serum protects against the homologous but
not against the heterologous trypanosome when
T. gambiense (sic) is compared with T. rhodesiense and
vice versa, With regard to their immunity experi-
ments it is not definitely known whether the strain
of T. gambiense (sic) used was the same as that
described by Stephens and Fantham.
It is concluded that the trypanosome from Yei is
not dissimilar from the trypanosome of the French
Congo.
(IV) T. gambiense, Uganda strain.—With regard to
the trypanosome found in Uganda, it is not possible
to compare the measurements exactly, as the 1,000
trypanosomes measured by Surgeon-General Sir
David Bruce, F.R.S., were taken from man, chim-
panzees, monkeys, oxen, antelope and rats, whereas
our measurements were made from a single animal
on ten successive days of its infection.
Notwithstanding this, there is a curious similarity,
the proportions being the same, only there is every-
where a difference of 3 microns and the curves very
much resemble one another,
Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
283
nosome x
“From Fe ende Difference
(1) Maximum length ... 33 — 3 microns
(2) Minimum length ... rt 13 -383 ,,
(3) Average length 25:0 22:1 -8 ,
(4) Curve of length ChartI. Chart V. as
One cannot help being surprised at the remarkable
similarity of the result, considering the very different
manner in which the two sets of results were
obtained.
TRYPANOSOMA GAMBIENSE.
Graphical representation of 1,000 Trypanosomes in man and
various animals. (Surgeon-General Sir David Bruce, F.R.S. ,1911.)
MICRONS
[25 [26 [27 [28 [29 [30 [31 [32 [23 [2]
CHART V.
The explanation of the systematic smaller size of
the Uganda trypanosome is obtained by comparing
our results with those of Sir David Bruce and
Stephens and Fantham when divided into PSI David
Bruce's three classes :—
Short, st I edi 7 t X^
Strain ISSi microns’ 33-24 microns anlerons'and
upwards
Uganda strain 51:2 231 25°7
Congo strain 18:2 27:0 54:8
Yei strain 11:8 31:4 56:8
It is seen that Sir David Bruce's strains have a
preponderance of short stumpy forms but in our
opinion this does not prevent them from being the
same trypanosome as that examined by Stephens
and Fantham and by ourselves, and we are supported
in this view by the measurement of the breadth, our
minimum being about one micron against Sir David
Bruce’s 1'5 microns and our maximum 2'5 microns
against Sir David Bruce's 2'5 microns.
We have made a preliminary study of the varia-
tions in length of a given trypanosome and, with all
reserve, we have provisionally come to the conclusion
as the result of our observations that the same
trypanosome in the same animals may show at
times an excess of long and slender forms and at
other times an excess of short and stumpy forms.
We are inclined to think that inoculations made
from recently infected animals tend to produce
inereased numbers of long and slender forms while
inoculations made from late infections tend to produce
short and stumpy forms; we also consider that it may
require more than one passage to produce the result.
If we are correct in this, it might partially explain
the uniform discrepancy in the measurements given by
Sir David Bruce, and a further explanation might be
the number of different hosts used by Sir David Bruce,
as compared to one host used by Stephens and Fantham
and by ourselves, and lastly perhaps the difference in
technique (e.g., the compass versus the tangent
method, &c.) may also help to explain the difference.
With regard to animal reactions we scarcely meet
on eommon ground, as the conditions under which
our animals live must be very different from those
under which the Uganda animals lived. Besides this,
we can only find one common animal, viz., Lasiopyga
callitrichus (I. Geoffroy 1851). The duration of
infections observed in this monkey may be tabulated
as follows :—
Strain Incubation period Duration of life
Uganda (Sir D. Bruce) .. 9-40 days 23-12 months
Uganda (Bentmann and 10 ,, 82 days
aM].
Yei. i as v Bs 4 86 ,,
In other words, the incubation of the disease more
or less agrees, but the trypanosome from Yei appears
to be more virulent. This, however, may be only
apparent and not real, being simply due to the trying
climatic conditions under which the animals were
compelled to live in Khartoum.
We cannot find records of immunity and cross
immunity experiments in which the Uganda strain
(definitely stated) is compared with strains from other
regions.
Conclusions.— We consider we have brought forward
sufficient evidence to show that the trypanosomes
which we found in the infected animal sent by Captain
Ranken, R.A.M.C., and the Congo strain are the
same, and that in all probability they and the Uganda
strains are also the same. There being no data, that
we know of, to compare these strains with 7'. gambiense
Dutton 1902, we are of the opinion that at all events
provisionally it would be safer to keep the name
“ Trypanosoma castellanii Kruse 1903 "
for these strains until more light is thrown upon the
complicated problem of “What is T. gambiense
Dutton 1902?”
It would appear to us as though the sleeping sick-
ness of Africa could be divided into the following
eategories :—
(A) Southern sleeping sickness caused by T.
rhodesiense Stephens and Fantham 1910, and spread
by Glossina morsitans Westwood 1850.
(B) Equatorial sleeping sickness caused
castellanii Kruse 1903, and spread by G.
(Robineau-Deavoidy 1830).
(C) Northern sleeping sickness which may be caused
by as yet imperfectly known trypanosomes named—
(a) T. gambiense Dutton 1902,
(b) T. nigeriense Scott-Macfie 1913, and perhaps
also by some as yet unknown trypanosomes.
With regard to Sir David Bruce’s method of
measuring and charting a large number of trypano-
somes our observations support the view that this
method, if carefully carried out, of comparing these
parasites one with another is probably of distinct
value and not merely a matter of coincidence as has
been maintained recently by Yorke and Blacklock.
Laveran and Mesnil's methods of differentiation by
immunization and cross immunization are also, in
our opinion, of distinct value.
by T.
palpalis
284
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 15, 1914.
Further Investigations.—There is, however, a com-
plication to be remembered with regard to the Lado
Enclave which, stated in the form of a question, is as
follows :— i :
Why are so many of the cases exceedingly chronic,
while others are very acute ?
This question is capable of being answered in two
ways :—
(a) Because the disease has been for some time
endemic in the western part of the Lado in which the
chronic cases are found and more newly introduced
into the part on the east where the acute cases occur.
This is supported by evidence given to the writers by
Captain Archibald, R.A.M.C., and Captain Ranken,
R.A.M.C., and is probably the solution.
(b) Because there are two different forms of sleeping
sickness. This is not so likely.
Steps have already been taken to enable work to be
done to attempt to elucidate these points.
Acknowledgments. —We wish to draw attention to
the fact that it would have been impossible to have
done the work contained in this paper without the
generous help of Lieutenant-Colonel Bray, R.A.M.C.,
Principal Medical Officer of the Egyptian Army and
President of the Sleeping Sickness Commission of
the Anglo-Egyptian Sudan, and Captain Ranken,
R.A.M.C., of the Sleeping Sickness Commission, to
both of whom we are much indebted.
We desire to express our gratitude for the kindness
which we have received from Captain Drew, R.A.M.C.,
in supplying us with epidemiological data and giving
us other kind assistance. We also desire to thank
Captain Archibald, R.A.M.C., Pathologist to these
Laboratories, for many kind suggestions, and for
checking our experiments, Mr. Grabham, Government
Geologist, for his kind interest in this paper, and Mr.
Alexander Marshall, Senior Bacteriologieal Assistant,
for much kind help.
We are much obliged to *he Director of Surveys
for the map of the Lado Enclave.
Finally, we desire to express our indebtedness to
Dr. Bagshawe and his collaborators in those valuable
publieations— The Bulletins of the Sleeping Sickness
Bureau and The Tropical Diseases Bulletin —without
which the task of writing this short note would have
been rendered much more difficult.
Khartoum, July 12, 1914.
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BrackLockK (1913). Annals of Tropical Medicine and Para-
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BonbrER (1884). '* La Géographie Médicale," p. 471, Paris.
Braun and TricHMANN (1912). ‘‘Imimunisierung gegen
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Bulletin of the Sleeping Sickness Burean (1909-12), 4 vols,
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Fry and Ranken (1913). Proceedings of the Royal Society,
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KonnLE and WassERMANN (1913). *'Handbuch der Patho-
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Kruse (1903). ‘Sitzungsberichte der Niederrheinischen
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RaNKEN (1913).
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et des Dynasties Musulmanes de l'Afrique Septentrionale,’
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Tropical Diseases Bulletin (1912-1914). Many very valuable
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“ Sleeping Sickness
“La Maladie du
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Ibn-Khaldoun, ** Histoire des Berbéres
'
ILLUSTRATIONS,
(A) Mar or THE LADO ENCLAVE BELONGING TO THE
MoNGALLA PROVINCE.
(B) CHARTS or LE*GTHS OF TRYPANOSOMES.
T. castellanii Kruse 1908.
rhodesirnse Stephens
and Fantham 1910.
T. nigeriense Scott-Mac-
fie 1913.
Chart I.— Yeistrain of trypanosome
IL— T. rhodesiense made by T.
Stephens and Fantham
,IIL—T. nigeriense made by
Scott. Macfie
» IV. T. gambiense made by
Stephens and Fantham
V.—T. qambiense made by Sir
David Bruce, F.R.S. "
T. castellanii Kruse 1903.
"t
» "
———9————
Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
285
THE JOURNAL OF
Tropical Jediene and Hygiene
SEPTEMBER 15, 1914.
A SCHOOL OF ORIENTAL STUDIES.
IN early summer of the current year a considerable
amount of interest was taken in the formation of a
school of Oriental studies—in other words Oriental
languages—in London. Wewere favoured bya circular
at the time drawing attention to the need of funds to
supplement what had already been promised by the
Home Government, by the Government of India, and
by the Education Committee of the London County
Council. That the establishment of the school met
with the approval of Government was evident, and
substantial sums, amounting in all to £7,250 yearly,
had been promised towards the total of the £14,000
stated to be the annual sum necessary to keep the
school going. Attention is drawn to the fact in the
circular, that whilst in Germany, France, Russia and
Italy schools of this kind are in being, and supported
financially in every instance by their several States,
in Britain nothing of the kind is attempted. This
statement does not quite represent the state of
affairs, for there is scarcely a university in the realm
in which the teaching of an Oriental language is not
provided for. Hebrew professors or lecturers are
attached to the divinity faculty of our universities,
and in 1887 a serious attempt was made by the
Imperial Institute to establish teaching centres of
Oriental languages at the Institute itself, and at
University College and at King’s College, London.
At the colleges teaching still is conducted, but for
some reason the interest seemed to flag. It is hoped
by the establishment of “the School of Oriental
Studies " now advocated to contribute “a new pillar
of Empire and Commerce " to the advantage of this
country.
The fresh attempt has H:M. the King as its patron,
2 departmental committee appointed by the Secretary
of State for India, and a city executive appeal
committee composed of men of position and influence.
The school is to be housed at the London Institution,
Finsbury Circus, London, E.C., and it is intended to
commence teaching in 1915.
The difference between the new and past attempts
to advance interest in Oriental languages is that
heretofore the subject has been dealt with as one of
academic or political interest merely, the devotees to
which have been and must necessarily be limited,
whereas it is now intended to regard the matter as
one of commercial importance, having wide and direct
interests and immediate monetary value. So keen
is commercial competition to-day that the leading
bankers and merchants in Britain feel that their
representatives are handicapped in comparison with
men from several other countries, inasmuch as they
are ignorant of the languages of the peoples they are
brought into contact with, whilst their rivals have
been taught to speak and read these languages.
Gradually has this belief grown up amongst us, being
enforced by loss of trade to the country and decline
of prestige. The attempts made to meet the condi-
tions of modern commerce have been few, and from
want of encouragement and opportunity our young
men go abroad badly equipped for their duties. So
acutely was the situation felt that, to quote from the
papers, “in 1907 the Prime Minister, who was ther
Sir Henry Campbell-Bannerman, appointed à com-
mittee, with Lord Reay as chairman, which put for-
ward certain recommendations of great value and
importance. Then, in 1910, three years afterwards,
Lord Morley, who was at the time Secretary of State
for India, appointed a Departmental Committee to
organize a scheme for a School of Oriental Languages
upon the lines recommended by Lord Reay's com-
mittee. Finally, on May 6 in the present year, the
scheme was supported by a large and representative
meeting of Members of Parliament, City merchants,
and scholars, held under the presideney of the Lord
Mayor, at the Mansion House. At last, Great Britain
seems to have realized the greatness of her need.
And how do matters stand? In the first place, a
site for the new school has been found in the buildings
of the London Institution, secured for the school by
Act of Parliament. His Majesty the King has
graciously consented to be the patron of the school,
which is to be attached to the University of London,
under the terms of a Royal Charter. The Govern-
ment has also promised the sum of from £20,000 to
£25,000 necessary for alterations and repairs, and
the building of a new block of class rooms. As we
said just now, in order that the school may have its
full efficiency, we require an annual income of £14,000
a year. How is this sum to be made up? The
Government have promised £4,000, the Government
of India £1,250, and the Education Committee of the
London County Council have recommended the con-
tribution of £2,000 a year under certain conditions.
What is still required is something like £6,700 a year,
and it is for this sum that an appeal is now being
made—an appeal for annual grants, subscriptions,
and so forth—in order that an endowment fund of
not less than £100,000 should be raised. No words
of ours are necessary to recommend so beneficent a
project to the practical sympathies of the nation at
large. Commercially, there can be no doubt of the
value of a knowledge of Eastern languages. How is
a trader to compete with his rivals, how is he to
develop his own business, unless he knows how to
converse with the natives, not merely through an
interpreter, and unless he succeeded in imbibing some-
thing of the spirit of the East? But our Imperial
responsibilities touch wider issues. Since the time
when the merchant adventurers, the founders of the
great commercial houses connected with the East, and
the bankers, generally, recruited from the city of
London itself, went forth in the spacious times of
Queen Elizabeth and her successor, James, British
power and influence have grown into so huge and
colossal a structure that we become almost appalled
at the vast and intricate series of relations which
unite this island with the teeming millions of the
286
East. That we should any longer allow the develop-
ment of our Empire to be presided over by chance
and accident, is an unthinkable proposition. We
must know the spirit and temper of the peoples with
whom we have to deal, and for this purpose it is
absolutely necessary that we should know their lan-
guages. On both grounds, commercial and imperial,
a school of Oriental Languages in London is one of
the most imperative needs of our time."
It is to be hoped the stimulus given to the acquire-
ment of Oriental languages by the commercial com-
munity will be ably supported by the banking and
commercial firms dealing with the East. At present
the candidates seeking employment in banks, com-
mercial firms, rubber and tea estates, &c., are required
to be able to produce a leaving school certificate,
and to know typewriting and shorthand: accomplish-
ments not demanding either much education or mental
abilities of a high order. It remains to be Seen whether
the employees will be given time to acquire a language
whilst they are being trained in their ordinary clerking
work in the London office of the firm. They are
fairly hard worked as it is, as the majority who join
are quite young lads and not physically quite up to
standing the strain put upon them at present, and to
add the acquisition of one or two languages in addi-
tion may prove a tax upon their time and strength
which might be detrimental. Moreover, Oriental
languages are many, and young men in banks and
firms abroad are changed frequently from place to
place—now in Calcutta, later in Burmah, or the
change may be to Siam, China, Japan, Malay States,
Manila, and to places and districts in these countries
where dialects are spoken which require a separate
study altogether. The firm may not know in what
country, of the many they are interested in, a vacancy
may crop up and the clerk will not know which
language to study. All these are difficulties which
have to be met if our young men are to be equipped
as they should be; in course of time they will no
doubt, be overcome; necessity will demand it unless
the British merchant consents to allow himself and
his country’s trade to disappear from the world’s
markets.
——9—————
Hotes and Mets.
USE OF THE HYPODERMIC SYRINGE IN
THE ADMINISTRATION OF DRUGS.
DR. J. TERTIUS CLARKE's letter addressed to the
Editor on this subject, which was published in the
September 1 number of this Journal, is a valuable con-
tribution to the use of quinine when given by intra-
muscular injection, and we do not regret having pub-
lished the statements made, seeing we have drawn
forth a reply from so well-known an authority as
Dr. J. Tertius Clarke.
The occurrence of tetanus did not occur to us as
a prominently dangerous feature of administering
quinine by intramuscular injection, but it was rather
[Sept. 15, 1914.
to the uncertainty of absorption, and especially to the
local and general disturbances created, that we referred.
Experiences of different individuals vary evidently on
this subject, and each individual can only go by his
own results. Moreover, the references to the dangers
and inconvenience of intramuscular injections to
which Dr. Clarke takes exception were not made
anent giving quinine intramuscularly in desperate
cases, for that would be removing a method of
treatment which has, in most people’s hands having
any experience of the matter, had beneficial effects
well-nigh miraculous in their action. Not to inject
quinine hypodermically, intramuscularly, or intra-
venously when febrile attacks are otherwise uncon-
trollable is to bring a serious accusation against the
medical man who neglects so potent a remedy. The
writer of the article referred to had evidently in his
mind the present-day practice of so many doctors,
especially those who have had a Continental training,
of using the hypodermic syringe on every possible
occasion. It has come to this, that many medical
men look upon a colleague who gives quinine by the
mouth as old fashioned, or, in other words, that he
is not doing his duty by his patient; and as with
quinine so with other drugs. The doctor is tending
to become more a skilled mechanic with his “ each
disease its own drug” theory, and that administered
by what has been termed an “unnatural channel."
To many the evil consequences of quinine, antimony,
salvarsan, &c., given hypodermically is a regrettable
memory; not from tetanus but from the local
troubles engendered: abscess, sloughing, necrosis of
bone, fistulous tracts lasting for a year or more or
until dealt with, chronic blood poisoning, hectic and
death traceable directly to the use of the hypodermic
injections of one or other of these drugs.
We thank Dr. Clarke for his letter, and feel that
men who have had unfortunate experiences with the
administration of drugs by the hypodermic needle
may console themselves that, although they have to
lament the death of a patient in consequence of
following this method, mankind generally has bene-
fited; and as it is, after all, the greatest good to the
greatest number that counts, so the drawbacks had
better be “ censored ” and the syringe allowed to
hold its sway.
—— 9 ———
Correspondence.
INTRAMUSCULAR INJECTIONS OF QUININE.
To the Editor of THE JOURNAL oF TnoPICAL MEDICINE
AND HYGIENE.
Sik,—The case against intramuscular or sub-
cutaneous injections of quinine may be summarized
as follows: The behaviour of quinine administered in
this manner, and also by the mouth, has now been
carefully studied by a very large number of thoroughly
capable observers, especially more recently, by Kleine.
Jacoangeli, Mariani, Modigliana, Giemsa, Schaumann,
Gaglio, Schmitz, Megaw, MacGilchrist, and others.
Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
287
It has been clearly shown ‘that in vitro a large
amount of quinine is precipitated in the presence of
various albumins, especially when the solution of
quinine is a strong one.
Mariani injected a 1 in 5 solution into the leg of
a rabbit. When this was killed seventeen hours later
66'5 per cent. of the quinine was still present at the
site of injection.
By very numerous and complete quantitative
estimations of the quinine eliminated in the urine
after both injection and oral administration, it has
been clearly shown that the absorption by the mouth
is much more rapid and also greater in total quantity
than absorption from subcutaneous and intramuscular
injections. ;
From a consideration of these facts, it is difficult
to imagine what theoretical advantage injection can
have over oral administration, at least in ordinary
cases. True, if the injected quinine is in very weak
dilution more of it is absorbed, but this necessitates
the injection of large quantities of fluid. Moreover
injections often give rise to considerable local trouble
and occasionally to severe local inflammation and
even to tetanus. ;
It has, however, been suggested by D. Sandro that,
by injecting quinine, absorption through the liver is
avoided; but this does not prove much, because we
have no reason for supposing that the drug is
destroyed in its passage through that organ. In fact
centuries of administration by the mouth, as well as
the numerous estimations of quinine in the urine,
show that quinine remains effective in spite of such
passage.
A priori, therefore, there appears to be no case at all
for preferring injections to oral administration, except
in rare Gases where, owing to gastro-intestinal troubles,
oral absorption is much prevented or delayed ; and in
patients who cannot or will not take quinine by the
mouth; and perhaps for prophylactic use where it is
advisable to establish a “ quinine depot” in the body
for the. purpose of giving a continual supply of the
drug to the blood in persons who will not take it by
the mouth.
The only plea in favour of the injections is that
given by several observers who maintain that their
clinical experience proves the injections to be superior.
But anyone who has considered the extreme difficulty
of obtaining clear proof by such clinical evidence will,
to be frank, doubt such conclusions in face of the
strong a priori case against the injections. For
instance, Dr. Tertius Clark says in your current issue"
that he and many others have seen “ temperatures
come down after intramuscular injection which had
not been touched by quinine by the mouth, and this
not merely in a few cases but very many times."
Now the salient peculiarity of malarial fever is that
it "comes down" by itself, while mere rest in bed
and good food will, especially as proved by Caccini,
tend to ameliorate the fever by themselves. The
malaria chart is so discontinuous and interrupted that
* September 1, 1914.
the longest and most careful researches are required
before it can be established that benefit is in any way
caused by treatment. The only evidence which
would be passed by statisticians as amounting to
proof would lie in counting the parasites before and
after treatment in a very large number of cases. On
the other hand, the statements that are made by some
clinicians upon this point belong to the class of
unproved opinions, and I doubt whether in a single
case any clinician has ever made out a good statistical
and scientific proof. of the theorem that injections
are in any way better than, or as good as, oral
administration—at least in ordinary cases.
` The a priori objections are so strong that clinicians
who wish to establish the utility of injections must
be asked to prove their case, not by obiter dicta, but
by very careful statistical evidence. In the meantime
therefore I, for one, fail to see that they have even
established a prima facie case in favour of the con-
tention. And our doubts are increased when we
observe that such writers often appear not to have
studied the literature thoroughly.
They must establish not only that injections may
be useful, but that they are of superior efficacy to
oral administration. Injections cause much destruc-
tion of tissue, and MacGilchrist has shown that such
destruction occurs even when the solution is as weak
as l in 150. Unless, therefore, there is some very great
advantage in the injections over oral administration,
the former can scarcely be properly utilized, except
in certain special cases; and the advocates of injec-
tion must prove that they possess such great advan-
tages, which they have certainly not done up to the
present. The final test for effectiveness in any line
of treatment of malaria is that it shall completely
extirpate the parasitic invasion. Do injections attain
this end more quickly than oral administration? No
proof of this has yet been given.
While writing this letter, I have two cases under
treatment which have [been subjected to injections of
quinine without effecting anything like permanent
cure. One of these tells me that he was given
altogether fourteen injections distributed over three
weeks, but that three days after the last injection he
suffered from what he described as the worst attack
he had ever had. This was a fortnight ago, and he
still has a large tumour about three inches in diameter
on his hip, where the injections were made, and informs
nie that the inflammation formerly spread all up one
flank. Some time ago I saw a child in a Greek
hospital, who was so covered with painful lumps
caused by innumerable injections that she shrieked
whenever she saw a doctor, and: I judged that the
fever from which she still continued to suffer was
probably due rather to the injections than to her
malaria.
I do not deny that injections may be called .for in
a few special cases, or that they may be of some
utility when quinine cannot be otherwise given ; but
I think that in view of the -slow absorption from
injections and the necrosis caused by them, they are
not likely to be nearly so effective as oral administra-
tion, and should not be used as a routine measure.
288 THE JOURNAL OF TROPICAL
MEDICINE AND HYGIENE. [Sept. 15, 1914.
It is, however, quite possible that some improvement
might be made by which injections may be rendered
more effective and less damaging to the tissues; but
in the meantime I am inclined to agree entirely with
MacGilchrist when he says that “quinine and its
sults are fundamentally unsuited for hypodermic use.
This mode of quinine administration should, therefore,
be abandoned.”
Yours faithfully,
RONALD Ross.
——— AJ ———
Personal Hotes.
Inp1a OFFICE.
From June 16 to July 28, 1914.
Arrivals Reported in London.—Lieutenant-Colonel V. G.
Drake-Brockman, I.M.S.; Colonel J. Crimmin, I.M.S.; Major
T. B. Kelly, I.M.S.; Colonel A. O. Evans, I.M.S. ; Lieutenant-
Colonel R. J. Macnamara, I.M.S.; Major C. B. Harrison,
I.M.S.; Captain G. F. Graham, I. M.S.; Captain R. S. Town-
send, I.M.S. ; Major C. 8. Lowson, I. M.S. ; Lieutenant-Colonel
H. B. Melville, I.M.S. ; Lieutenant-Colonel A. W. Dawson,
1.M.S.; Lieutenant-Colonel A. Coleman, I.M.S. ; Lieutenant
E. J. Greson, I.S. M.D.
Extensions of Leave. —Major C. W. F. Melville, I.M.S., to
August 31, 1914; Major A. Murphy, I.M.S., 4 m., M.C.;
Captain A. N. Thomas, I. M.8., 3 m., M.C.; Major Lethbridge,
I.M.S., 1 m., M.C. ; Captain M. F. White, I.M.S., to Novem-
ber 30, 1914 ; Major H. R. Dutton, I.M.S., 1 m., M.C.; Major
E. J. O'Meara, 1.M.S., 3 m., M.C ; Captain R. Kelsall,
I M.S., 6 m.; Captain A. T. Pridham, I.M.S., 6 m., M.C. ;
Captain A. A. MeNeight, I.M.S., 1 m., M.C.; Captain C. L.
Dunn, I.M.S., 3 m, M.C.; Major EK. J. Morgan, I.M.S.,
6 m., M.C.
Permitted to Return.—Major H. R. Dutton, LM.S.; Lieu-
tenant-Colonel J. Penny, I.M.8.
List or INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER Civit, RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Abbott, Major S. H. ..,1.M.S., Punjab, 24 m., April 23, 1914.
Anthony, Major R. W., I. M.S., Bombay, 8 m., March 31, 1914.
Bird, Lieutenant-Colonel R., I. M.S., Bl., 6 m., April 14, 1914.
Birdwood, Lieutenant-Colonel G. T., I.M.8., Und. Prov.,
7 m., March 30, 1914.
Castor, Lieutenant-Colonel R. H., I.M.S., Burma, 24 m.,
November 26, 1912.
Christian, Captain J. B., 1.M.S., Bo., 21 m., January 15, 1913.
Clemesha, Major W. W., I.M.S.. Punjab.
Cox, Major W. H., D.S.O., LM.S., Burma, 18 m.. April 12,
1913.
Crump, Captain S. T., IL.M.S., Burma Medl., 6 m. 10 d.,
April 9, 1913.
Dalziel, Major R. M., I. M. S.. Punj., 12 m., December 10, 1913.
Delany, Major T. H., I.M.S., Behar and Orissa, 13 m..
November 11, 1913.
Drake, Captain H, B., I.M.S , Bo. Mint., 6 m., May 2, 1911,
Drake-Brockman, Licutenant-Colonel H. EB., I.M.S., 6 in.,
April 18, 1914.
Drake-Brockman, Lieutenant.Colonel V, G., I.M.S , India
Foreign Depart., 7 m. 24 d., May 1, 1914.
Dunn, Captain C. L , I.M.5., U.P. Sanitary Comm., 11 m.,
November 4, 1913.
Dutton, Major H. R., IL. M.S., Delhi, 16 m. 20d., Junc 3, 1913.
KEvaus, Colonel A. V., I.M.S., Burma Hospitals.
Fayrer, Major F. D. S., I.M.S., 16 m. 27 d., September 25,
1913.
Finlayson, Captain
1912.
wW .
T., I. M.S., Punjab, 24 m., October 24,
Forster, Major W. H. C., I.M.S., 24 m., October 10, 1913.
Gloster, Major T. H., I.M.S., Bo., Bacteriological Dept,
12 m., June 13, 1914.
Haig, Lieutenant-Colonel P. B., I.M.S., 24 m., October 24,
1914.
Harvey, Major W. F., I.M.S., India Misc., Dir. Central
Research Inst.. Kasauli, 24 m., February 5, 1914.
Hayward, Major W. D., I.M.S., M., 15 m., March 27, 1914.
Hojel, Lieutenant-Colonel J. G., I.M.S., Bo. Med. Dept.,
12 m., November 16, 1913.
Hulbert, Lieutenant-Colonel J. G., I.M.S., U.P., 6 m.,
November 12, 1913.
Hunter, Lieutenant-Colonel G. Y. C., I.M.S., B.Gaols, 42 m.
26 d., March 30, 1911.
Hutchinson, Major L. T. R., I.M.S., Bo., 12 m., Novem-
ber 15, 1913.
Innes, Major H., I. M.S., Assam., 21 m., February 18, 1914.
James, Major S. P., I.M.S., India Sanitary and Medl., 9 m.
10 d., January 23, 1914.
King, Major G., I. M.S., Behar and Orissa, 14 m., February 18,
1911.
Knapton, Major H. A. F., I.M.S., Bo. Sanitary Comm.,
12 m., October 15, 1913.
Knox, Major R. W., I.M.S., Indian Foreign Dept., 14 m.,
August 30, 1913.
Lethbridge, Major W., I.M.S., Rajpootana, 23 m. 2 d.,
October 13, 1913.
Lowson, Major C. S., I. M.S., Bombay Jails.
Macnamara, Lieutenant-Colonel R. J., I.M.S., Ms. Prisons,
9 m., May 17, 1914.
Maconachie, Captain G. W., I.M.S., Mc. Prisons, S m.
29 d , March 25, 1914.
Macrae, Captain I. M., I.M.S., Agra Cent. Prison, 18 m.,
March 1, 1914.
Manifold, Colonel C. C., I.M.S., U.P., 6 m. 20 d., March 29,
1914.
McCay, Major D., I. M.S., B. Med., 14 m., September 1, 1913.
McDonald, Major J. H., I.M.S., Bo., 20 m., March 19, 1913.
Morgan, Major E. J., I.M.S., U.P., 12 m., October 1, 1913.
Newman, Lieutenant-Colonel E. A. R., I.M.S., Bl. Emign.
Dept., 7 m. 15 d., May 15, 1914.
Nutt, Major H. R., I.M.S., U.P., 8 m., March 31, 1914.
O'Meara, Major E. J., I.M.S.. Und. Prov.
O'Neill, Major P. L.. I.M.S., M., 18 m., March 23, 1913.
Peebles, Captain A. S. M., 1.M.S. Bl., 15 m., March 31, 1914.
Penny, Lieutenant-Colonel J., I. M.S., Burma, 21 m., Decem-
ber 25, 1912.
Prall, Lieutenant-Colonel S. E., L M.S., Bo. Med., 12 m.,
February 18, 1914.
Rainier, Major N. R. J., I.M.S., Cent. Prov., 23 m. 29 d.,
October 9, 1913.
Ross, Captain H., I.M.S., U.P., 24 m., November 20, 1912.
Saigol, Captain R. D., I.M.S., Burma, 24 m., February 10,
1913,
Salisbury, Captain F. H., I.M.S., B. Gaols, 13 m., October 20,
1913.
Scott. Moncrieff, Major W. E., I.M.S., N.-W.F. Prov., 32 m.
7 d., November 19, 1911.
Seton, Brevet-Colonel B. G., I.M.S., 9 m., March 2, 1914.
Shaw, Captain W. S. J., I. M.8., Bo., 15 m., November 8, 1913.
Smith, Lieutenant-Colonel S. B., I.M.S., Punjab, 18 m.,
April 29, 1914.
Stevenson, Captain W. D. H., I.M.S., Bo. Bacteriological
Laboratory, 13 m., October 4, 1913.
Thompson, Major F. S. C., I.M.S., B. Gaols, 24 m., Novem-
ber 15, 1913.
Townsend, Captain R. S., I.M.S.
Vaughan, Lieutenant-Colonel J. C. S., I.M.S., Behar and
Orissa.
Walker, Major J. N., L.M.S., U.P., 12 m., October 30, 1913.
CoLoNiAL MEDICAL SERVICE.
Dr. T. Hood has assumed duty on appointment as Director of
Medical and Sanitary Services, Nigeria.
Leave of absence granted to Dr. Macphail, Medical Officer,
No. 1 District, St, Lucia, has been extended for one month.
The post of Government Veterinary Surgeon of British
Guiana has been filled by the appointment of Mr. A. S. Milne,
M.R.C. V.S.
Oct. 1, 1914.]
Original Communications.
THE SYSTEMIC POSITION OF THE GENUS
TRICOPHYTON MALMSTEN 1845.
By ALBERT J. CHALMERS, M.D., F.R.C.S., D.P.H.,
Director, Wellcome Tropical Research Laboratories,
AND
ALEXANDER MARSHALL,
Senior Bacteriological Laboratory Assistant, Khartoum.
Introductory.—As a rule no mention of the genus
Tricophyton is to be found in the larger works
on Fungi, or if it is found it is used. only as a
synonym. Thus Saccardo, in vol. xviii of his “ Sylloge
Fungorum," has an Index Universalis Cohortium,
Familiarum, Subfamiliarum, Generum, Subgenerum,
atque Synonymorum pracipuorum in toto opere (vol. i,
xviii) erpositorum, in which, on p. 833, is printed :—
Tricophyton Malmst = Sporotrichum Link.
When so great an authority as Saccardo publishes
a statement of this nature in the year 1906, no further
excuse is necessary for bringing forward any facts which
may elucidate thesystemic positionof Malmsten's genus
Trichophyton.
Historical.—In 1844 Gruby discovered the para-
site of ringworm, and this was verified in 1845 by
Malmsten, who proposed two generie names for the
new fungus, i.e, ' Trichophyton ” or “ Trichomyces,”
and one specific name " Tonsurans.” The first generic
name has become established and the genus, the
systemic position of which we are about to review,
is now known as Trichophyton Malmsten 1845 ; very
often the date given is 1848, which is that of the
publieation of the German translation and not the
date of the original Swedish work, the name being
derived from Opí£, hair, and $vróv, a plant.
Malmsten believed the genus Trichophyton to be
closely related to the genus Torula Persoon 1801, and
especially to the species T. olivacea Corda 1837 and
T. abbreviata Corda 1837.
This relationship was adopted by Charles Robin in
his celebrated work “ Histoire Naturelle des Végétaux
Parasites,’ published in 1853. His classification
is as follows: Fungi: Division, Arthrosporei ;
Tribe, Torulacei ; Genus, Trichophyton Malmsten.
We have been unable to refer to Malmsten's original
paper, but it is not difficult to understand the reason
why, in 1845, he believed Trichophyton to be allied to
Torula Persoon 1801.
In 1886 Hallier regarded the relationship to be
closely allied to the genus Penicillium Link 1809.
In 1875 Grawitz made a new assertion, claiming
that the relationship was with Oospora Wallroth 1833,
a view which was adopted by Baumgarten in his
“ Pathologischen Mykologie" in 1890.
Later researches by Duclaux in 1886, by Verujsky
in 1887, and still later by Sabouraud, indicated that
some of the species should be classified near to
Sporotrichum Link 1809, which suggestion has been
adopted by Saccardo in his " Sylloge Fungorum,”
though he goes further, making Trichophyton merely
a synonym of Sporotrichum.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (No. 19, Vol. XVII.
Bodin (1899-1902) brought forward views tending
to show that the relationship is complex, some of the
species being allied to Endoconidium Prillieux and
Delaeroix 1891 (a genus which lately disappeared,
having become Stromatinia Prillieux 1897) while
‘other species were held to be more closely related to
Acladium Link 1809 and to Haplaria Link 1809.
These views are based upon a study of the sporula-
tion and indicate that Trichophyton is a genus belong-
ing to Fuckel’s Class Fungi Imperfecti, and, adopting
the older methods of classification, to the Subclass
Hyphomycetex Martius 1817, the Family Mucedinacee
Link 1809, Subfamily Amerosporee@ Saccardo 1886,
Tribe Macroneme Saccardo 1886, and Subtribe
Botrytida& Saccardo 1886.
Vuillemin's recent classification places the genus
under the Order Thallosporales, Suborder <Arthro-
sporales Vuillemin 1910, and allies it with Mycoderma
Persoon 1822, Madurella Brumpt 1905, Indiella
Brumpt 1906, Epidermophyton Lang 1879, Micro-
sporum Gruby 1843, Achorion Remak 1845, and
Trichosporum Behrend 1890.
In June, 1899, Matruchot and Dassonville published
a paper entitled "Sur la position systematique des
Trichophytons " and followed it later in the same
year by another paper entitled " Sur le Ctenomyces
Serratus (Eidam) comparé aux Champignons des
teignes." Briefly stated, their view is that the
genus Trichophyton Malmsten 1845, belongs to the
Ascomycetes of De Bary if this is taken to include
Hemiascomycetes of Brefeld. In either case, whether
these classifications or Schréter’s more detailed
arrangement of the Ascomycetes be adopted, does not
coneern our present purpose as both contain the
family Gymnoascacee (often written Gymnoascex) in
whieh Matruchot and Dassonville place the genus
Trichophyton.
^ Their reasons for this classification are :
(1) Ctenomyces serratus Eidam 1880 is a fungus
found on the feathers of birds which, when
cultivated on Sabouraud’s proof media, produces
growths strikingly analogous to those of species of
Trichophyton.
(2) Ctenomyces serratus, when inoculated into
animals, gives rise to lesions resembling a Trichophyton
eruption in which it appears in a filamentous form.
(3) A fungus closely resembling a Ctenomyces,
which they found in a ringworm in a dog, when
cultivated gave rise to perithecia. For this fungus
they created a new genus Hidamella Matruchot and
Dassonville 1901, calling the given species Eidamella
spinosa Matruchot and Dassonville 1901.
Against this view Sabouraud has pointed out that
in the cultures of this fungus they found intercalary
chlamydospores, but neither fusiform bodies nor the
conidia usually seen in Trichophyton cultures, and
therefore he considers their demonstration to be still
incomplete.
To summarize, Matruchot and Dassonville have
brought forward considerable evidence to support the
view that the genus Trichophyton Malmsten 1845
belongs to the family Gymnoascaceg Baranetzky 1872
of the Ascomycetes, but as so great an authority as
290
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 1, 1914.
Sabouraud does not accept their proofs as final there
is obviously an opening for further observations,
especially as no proof of such a classification has, up
to the present, been brought forward with regard to
a Trichophyton obtained from man.
Trichophyton currit.—In a previous paper published
during the present year in this Journal we have
given an account of a Trichophyton Endothrix which
we found to be the common ringworm on the heads
of schoolboys in Khartoum and Omdurman and to
which we gave the name Trichophyton currii Chalmers
and Marshall 1914.
In this paper we gave photographs of the parasite,
its cultures and the disease which it produced, and
therefore do not consider it necessary to repeat that
which we have so recently written and depicted,
except to state that in liquid media the conidia are
formed in masses.
It will be seen by reference to our previous paper
that the growth formed by T. currii on Sabouraud's
maltose agar is white, but if the culture is kept for
several months it gradually becomes black.
If the growth produced at atmospheric temperature
(average about 100° F.) in one of Kitasato’s flasks,
i.e., in a thin layer of the medium, is examined pos-
teriorly a number of small black dots may be seen.
These dots resemble in size the head of a fine entomo-
logical pin, that is to say about 0'5 mm. on the
average (vide fig. 1) although some few appear to
be larger.
When a small one is separated out and examined,
it shows the appearance depicted in fig. 2, where it
will be seen to be a rounded body composed of inter-
locked hyph with thickened greenish-black walls.
On section the structure shows the appearance
depicted in figs. 3 and 4, on examination of which it
will be noted that there is an outer wall composed of
the interlocked hyphs mentioned above, while the
contents show hyphe and cells the spaces between
which are filled, in the fresh condition, with a fatty
material.
If a black dot is teased or broken and examined in
a fresh state it will be observed how easily the outer
. wall is separated into its component hypha and also
that the contents are simply fatty material and ovoidal
bodies (vide fig. 5) composed of a double contoured
wall and clear hyaline cytoplasm.
The black dots appeared first when the cultures
were about two months old, a length of time probably
equal to a year’s growth at atmospheric temperature
in Europe, but at the time of writing they are nearly
seven months old and consist of only the outer wall,
the contents having all disappeared.
When they, in their younger condition, with some
of the surrounding hyphe were planted on Sabouraud's
or other media, typical trichophytic growths were
produced apparently indistinguishable from those
originally obtained from the hair. Inoculated into
animals they gave no better results than that pro-
duced by inoculations direct from a patient's head or
from fresh cultures.
Such in brief is the description of the bodies the
nature of which we are now about to discuss,
Discussion.—The structure and appearance of the
black dots confirm us in the view that they are Peri-
lthecia. Further, the fact that they are simply com-
posed of interlocked hyphe indicates that the fungus
giving rise to them belongs to the Hemiascomycetes
and to the family Gymnoascacere Baranetzky 1872.
Their origin appears to us to be simply thickened
hyphe wrapped around other hyphæ which break up
into fatty bodies and the ovoidal bodies mentioned
above. These ovoidal bodies are, in our opinion, asci
which have failed to produce ascospores, nor is the
reason of this difficult to understand, as it is simply
a stage of the adaptation from the saphrophytie, or
the parasitic, existence on a plant to the more perfect
parasitic condition on a man.
Classification.—If we are right in our conclusions
given above then T7. currti would belong to Bara-
netzky's family Gymnoascacee which already con-
tains the genera :—
Amauroascus Schróter 1893.
Arachniotus Schróter 1893.
Ctenomyces Eidam 1880.
Eidamella Matruchot and Dassonville 1901.
Gymnoascus Baranetzky 1872.
Myzotrichum Kunze 1823.
Moreover, our observations and deductions remark-
ably agree with, confirm and support the admirable
researches of Matruchot and Dassonville with whom
we are in entire concord.
Evolution.—We. are further of the opinion that
Eidamella spinosa of Matruchot and Dassonville 1901,
indicates the least specialized form of Trichophyton
known, in that it develops ascospores in the asci.
Trichophyton currii appears to us to have advanced
a step further along the line of parasitic adaptation
in that it has ceased to develop the ascospores, and,
moreover, has begun to develop fusiform bodies and
spiral loops.
In the evolutionary tree depicted in our previous
paper we indicated that T. currii was closely related
to the main stem of the Trichophytons, and this was
one of the reasons of our doing so, though we did not
mention it in that paper. Moreover, in the same
paper we gave reasons for considering that T. currii
was closely related to a possible parental form of
the Crateriform and the Acuminate groups of the
Endothrix division of the genus Trichophyton.
In our opinion a step further in parasitie existence
is indicated by the appearance in the cultures of
T. currii of a very few spindle-shaped bodies and a
few spirals. In our opinion the spirals indicate an
attempt to form a perithecium. In this view we
differ from other observers who consider them to
represent merely ornaments on the outside of the
perithecium. Our contrary opinion is based on the
fact that the perithecia of T. currii do not show
ornamentation, and we therefore consider the spiral
bodies to represent not merely the ornamentation but
the whole wall of the perithecium.
With regard to the septate spindle bodies we are
not in a position to make any definite statement,
though we incline rather to the view that they represent
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
291
Oct. 1, 1914.]
an attempt to form asci than that they are related
to the chlamydospores.
If we are right in our opinions then some of the
peculiar features of Trichophyton morphology are
explicable.
Conclusion.—We believe that the genus Tricho-
phyton Malmsten 1845 belongs to the family
Gymnoascacez Baranetzky 1872 which is included
in either Brefeld's Hemiascomycetes or De Bary's
Ascomycetes, according to the form of classification
adopted by the reader.
Khartoum,
July 18, 1914.
LIST OF ILLUSTRATIONS.
These illustrations are much improved if examined by means
of a lens.
Fig. 1.—Photograph of a culture of Trichophyton currii
Chalmers and Marshall 1914, about seven months old, on
Sabouraud’s maltose agar in one of Kitasato’s flasks and taken
from the back. Note the small black dots. Fresh preparation.
Natural size.
Fig. 2.—Photomicrograph of one of the small black dots as
seen in fig. 1, but taken from a culture when only two months
old. Surface view of a fresh preparation. x 1,300 diameters.
Fig 3.—Photomicrograph of a section of one of the small
black dots as depicted in fig. 1, but taken from a culture
about four months old and preserved so as to show the fat
bodies in situ. Unstained. x 1,570 diameters.
Fig 4.—Photomicrograph of a section of one of the small
black dots shown in fig. 1, but with the fat dissolved out of
the specimen. Stained by the Oxford method." x 800
diameters.
Fig. 5.—Photomicrograph of one of the ovoidal bodies
obtained by teasing out the contents of a black dot and
staining by the Oxford method. x 1,140 diameters.
REFERENCES.
Arranged in alphabetical order.
BAUMGARTEN (1890). ‘‘ Pathologischen Mykologie,’’ ii, pp. 905-
907. Brunswick.
Boprn (1902). ** Les Champignons parasites de l'homme." Paris.
Brumpt (1913). “ Précis de Parasitologie,” pp. 804-805, 809-810.
Paris.
CASTELLANI and CHALMERS (1913).
cine," p. 772. London.
CHALMERS and MARSHALL (1914). JOURNAL OF TROPICAL MEDI-
CINE AND HYGIENE, xvii, p. 257. London.
ENGLER and PrantL (1897). ‘* Pflanzenfamilien,” Teil I, Ab-
teilung 1, pp. 293-296. Leipzig.
GrpoELsT (1902). ‘‘ Les Champignons parasites de l'homme,"
p. 71 and pp. 99-101. Brussels.
HALLIER (1866). *''Pflanzlichen Parasiten de Menschlichen
Kórpers," pp. 72-73. Leipzig.
MALMSTEN (1845). :'Trichophyton tonsurans Harskirande
Mégel.” Stockholm.
MarrucHot and DassoNvILLE (1899) Comptes rendus de
l'Académie des Sciences, Paris (1899), June 5.; Bulletin
de la Société mycologique de France, Paris (1901), xv,
4th fascicle, pp. 240 and 305. Ibid., xvii, 2nd fascicle,
pp. 123-132.
Rosin (1853). '' Végétaux Parasites,” pp. 408-409 and 417-428.
Paris.
SABOURAUD (1910).
Saccardo (1906).
Verugsky (1887).
pp. 368-391.
“ Manual of Tropical Medi-
“ Les Teignes," pp. 717-724. Paris.
** Sylloge Fungorum," xviii, p. 833. Padua.
Annales de l' Institut Pasteur, Paris, i, No. 8,
MOLLUSCUM FIBROSUM,
PENDULATUM ATQUE ELEPHANTIACUM.
A SHORT ACCOUNT OF A CASE.
By Dr. F. 8. Harper.
West African Medical Staff, Tamale, Northern Territories,
Gold Coast, West Africa.
PATIENT, Falimata, female Dagomba, aged about
40, has lived for six years in a village near here.
She was born in Yendi on the German boundary and
came to reside here six years ago. She had no
brothers but two sisters, who grew up and were
married, but who have had no children. Patient
herself has had four children of whom three, all girls,
died within a year of their birth. The fourth, a
male, is alive and healthy and shows no signs of the
disease. She says that she was born with the
disease, but my opinion is that it probably came
on just about the time when she could begin to re-
member; in any case her memory does not carry her
far enough back to the time when she was without it.
Her mother and father both stayed at Yendi and
died there. She is positive her mother had the same
sickness; she does not remember her having seen
anybody else with the same sickness except her
mother. It is interesting that, according to patient's
history, her mother presented the same three types
of the disease as patient herself, even to the pendulous
tumour (see photograph) which was on the same
spot on the same side of the face, viz., the left.
Patient does not think that the disease has pro-
gressed since her childhood, she says that the
pendulous tumour was long when she was a girl.
It is interesting that the left side of the face, trunk,
and legs show more marked manifestations of the
disease—e.g., there is a large tumour on the left
knee-joint over the quadriceps tendon, and the left
leg is more elephantiasic in type than the right, also
patient cannot see out of her left eye. She is per-
fectly healthy otherwise. Neither of her female
children showed any signs of the disease when born.
The excellent photographs were very kindly taken
for me by Dr. J. J. Simpson, of the Entomological
Research Society.
—— —ÁQ———
LONDON SCHOOL OF TROPICAL
MEDICINE.
THE "Dunean Medal," awarded to the student
who obtains the greatest aggregate of marks during
the Session, has been gained by Captain A. C. Munro,
I.M.S., in respect of the Forty-sixth Session, May
to July, 1914.
Captain Munro has also gained the Medal in
recognition of having attained the greatest aggregate
of marks during the medical year 1913-14.
PROFESSOR PERROT, of Saigon, has succeeded in
producing fibre suitable for making ropes, twine,
coarse thread, bags, &e., from the stalk of the water
hyacinth, so well known in China. As a substitute
for jute the fibre of this plant possesses certain
advantages,
292
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct- 1, 1914.
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THE JOURNAL OF
Tropical Medictne and Hygiene
OCTOBER 1, 1914.
THE DISEASE AFTER-MATH OF WAR.
THE threat of cholera amongst the armies on the
Russo-Austrian frontier is causing some disquietude
in Europe, and naturally so. In a normal state of
affairs, however, it is a neighbourhood where a few
eases of Asiatic cholera occur well-nigh every year,
but during recent times nothing further develops. At
the present moment, however, with an army moving
about from place to place, a few cases of cholera may
infect many water supplies, and in place of a few
sporadic cases an epidemic may break out. The
disease is reported chiefly amongst the defeated
Austrian armies, but as they retreat the Russians
advancing over the ground evacuated may speedily
become infected. A force retreating before its
pursuers cannot follow even the rudiments of sanita-
tion, with the consequence that not only are the
soldiers themselves exposed to disease, but they leave
behind amongst those following them and amongst
the civil population a condition of things which is
calculated to generate and to spread disease. The
soldiers of a retreating army seek shelter in and
around the farm-houses of the district they are pass-
ing through, and in Galicia the sanitary arrangements
of these dwellings are at the best of times primitive. A
single case of cholera defecating on the ground near
the house may pollute the well, and a focus of infec-
tion is thereby set up which becomes a danger to all and
sundry. In well appointed camps a soldier who goes
several times to the latrine in twenty-four hours is
reported to the medical officer, and precautionary
steps are taken to isolate him, to disinfect all his
stools and to watch his symptoms closely ; in the con-
fusion of a routed army all these routine precautions
are impossible and disease is allowed to spread
uncontrolled. The danger, therefore, of cholera spread-
ing, once it breaks out in even a limited area, is so
great that it is natural that alarm is taken, and asa
means of prevention it is urgent that the alarm be
sounded far and wide. Nor will the danger diminish
with the advent of wet weather, for then the surface
water finds its way into the unprotected well situated,
all too frequently, in the compound of the farm dwel-
lings and near by the midden where the cholera stools
may have been deposited, either by the patient stool-
ing there or by the evacuations passed in the house
being thrown out on the ground adjacent to the
dwelling-house.
Eyen in the depth of winter when snow lies all
over the country the cholera germ may remain active.
In Southern Russia cholera not infrequently continues
through the winter months. The belief that frost and
snow curtails the continuance of cholera is not true.
The hygiene of a Russian farm-house, bad as it is
in the light of Western town-experienced sanitarians,
is rendered rather worse than better in the winter.
Huddled together in the one room where the stove is
kept going, infection is easily spread; but in the case
of cholera it is not so much the household conditions
as the water supply that is the channel of transmission.
Fecal evacuations are as a general rule thrown out
around the house on the top of the snow, where they
lie until the spring or until they are buried by a fresh
covering of snow. But with wells frozen and buried
in a snow drift the people take their water not from
the well, which may be inaccessible, but by gathering
the snow near by the house and melting it. As the
evaeuations are as a rule thrown out in a haphazard
way around the house there is a danger that the
stools of the cholera infected may be collected in the
snow used from melting for drinking water. In this
way cholera and other diseases, especially typhoid and
dysentery, may be spread, to the danger of the
immediate household, and also to neighbours who
come to visit.
What can be done to prevent cholera spreading?
In Austria at the present moment where disaster
prevails, when, with the Cossaeks on their track,
Oct. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
293
oo a e a a
people are fleeing from their homes, when food is
scarce and shelter from the elements impossible, little
can be done to check the disease. It therefore lies
with the surrounding countries to take all possible
precautions. At the present moment the autumn sun
is hot, flies abound, and owing to the cold nights the
flies seek shelter in the warmth of the house; there
is therefore a danger beyond mere water contamina-
tion. Soon, however, the flies will disappear, but the
water pollution remains. When those precautions
can be taken around Galicia where cholera is reported
it is difficult to state, for Russia, Servia, Germany and
and Austria are all at war, and precautions which
might be taken in times of peace are set at nought
in times of war. The rumour, therefore, of cholera
in the Austrian Army is enough to cause alarm,
for the chances of the spread of the disease are many.
The alarm, it is to be hoped, will not eventuate in
an epidemic and there are several experiences to
justify a hopeful conclusion that it may not do
so. In the recent Balkan war cholera was reported
in certain places, many cases occurred, but the
disease never became epidemic, although the circum-
stances in the Balkans favoured its development
even more than that prevailing in the Carpathians.
The Italians did not suffer in their Tripoli campaign,
although cholera always lurks around in that part of
Africa.
Another comfort may be taken that perhaps the
cholera spoken of in Austria is not Asiatic cholera.
Intestinal flux with sudden collapse is likely to be
present amongst soldiers and civilians when meals are
irregular and meagre, where water is drunk from any
source however polluted, by the exhausted soldiery ;
when the quality of food is wretched and food from
“blown” tins is all too common in-the rations
supplied by the Army contractor. Under these con-
ditions intestinal flux is prevalent always, and it is
to be hoped, and it is just possible, that what is pro-
nounced as cholera is nothing of the kind; it may be
a choleraie diarrha@a only, for unless the comma
bacillus characteristic of Asiastic cholera has been
proved to be present we may well take comfort in the
hope that a true cholera outbreak need not be antici-
pated.
It is needless to enter into other questions; with
the Belgian, French and German hordes in the
western part of the campaign, and Russia where it
frontiers with Austria and Germany littered with
dead bodies amounting to hundreds of thousands im-
perfectly buried, the subsequent dangers to the troops
and to the countries engaged in war are manifold.
The course of the campaign in the west especially
is fraught with serious dangers from this cause; for
the retreat into France and then the advance from
around Paris to the German border was well-nigh
over the same ground, so that it has been thickly
strewn with corpses of men and horses which neither
& rapidly retreating nor a rapidly advancing army
has had time to bury, but merely to cover over in
shallow haphazard graves. Curiously enough tetanus
' has not been much referred to, but the disease is not
unknown in these districts and should it once appear
the chances are that it will continue long after the
war is over.
Typhoid has scarcely had time to declare itself, and
it may be that the precautionary measures of inocu-
lation adopted for all soldiers in Western Europe may
be capable of preventing the disease gaining a serious
hold.
Of other ailments pneumonia will no doubt be the
chief; already it has claimed a considerable number
of victims amongst Territorials encamped at home, and
we are prepared to hear that as the winter advances
the armies in the field will suffer also.
——————————
Abstracts.
THE DISTRIBUTION AND SPREAD OF
DISEASES IN THE EAST.*
By ANTON BREINL.
Director of the Australian Institute of Tropical Medicine,
Townsville.
DENGUE is a fever of very wide distribution in
the East; it gives rise to the most diverse symptoms.
The onset is sudden; the body temperature rises with-
out any premonitory symptoms. The patient com-
plains of severe pains in the head, in the lumbar
regions, and in the bones; hence the popular name
of “ break-bone fever.”
According to Ashburn and Craig’s experiments, the
hitherto unknown parasite of dengue fever is trans-
mitted by Culex fatigans, the common house mos-
quito, which is ubiquitous throughout the Tropics,
and it is due to the enormous prevalence of this
particular mosquito that the disease has become so
widely spread.
Dengue fever occurs throughout the East, assuming
now and again a pandemic character. It has been
observed in Formosa, Tropical China, the Philippines,
the Dutch East Indies, New Guinea, and has invaded
most of the islands of the Eastern Archipelago. Ac-
cording to records, it was introduced into Queensland
as recently as 1894, probably much earlier, as I was
informed that in 1879 a fever epidemic with hardly
any mortality appeared in Townsville. Since then
it has swept over the populated parts of Queensland
and the northern parts of Western Australia into the
Northern Territory. One attack of dengue fever con-
fers only a transient immunity, and in consequence
every now and again the whole population of the
northern towns has to pay its tribute to the un-
welcome guest.
The appearance of a dengue fever epidemic is
always a serious matter, since it invalids the sufferer
completely for about two weeks, and leaves the con-
valescent patient in a singularly depressed state for
weeks afterwards, so that after a severe dengue
epidemic the number of suicides is always above the
average. è
Speculations as to the origin of new epidemics are
* One of the Stewart Lectures of the University of Melbourne,
1913.
294
fascinating. Does the dengue fever parasite lie
dormant in the mosquito, its intermediary host, for
months, and even years, and suddenly become again
conscious of its virility when the acquired transient
immunity of the populace has passed away, or is
always a fresh case of the disease introduced from
outside giving rise to the new epidemic? This latter
conception is more likely, since one can, as a rule,
see the spread starting from one centre, from street
to street, and from town to town.
Malta Fever, a far more serious complaint than
dengue, has not yet been able to gain a firm foothold
in the East. This fever comes on gradually with
headaches, bone-aches, and lassitude. The patient
is very ill for months, and often slight improvements
and relapses follow each other at irregular intervals.
China is the only eastern country where cases of
Malta fever have been known; but itis not improbable
that in the near future some of the hitherto unde-
scribed fevers will be diagnosed as Malta fever.
Plague and Cholera are bacterial diseases more
or less endemic in the East.
Plague is propagated by means of infected rats,
and the bacilli are transmitted to a human being by
the bite of the rat fleas. According to the conclusions
of the Indian Commission, the spread of plague is
not so much due to the migration of rats as to the
presence of infected rats on ships, and the introduc-
tion of infected fleas in merchandise. We have,
therefore, in plague a disease which might at any
time be introduced again into Australia.
Cholera, an epidemic disease, characterized by
violent gastro-intestinal symptoms and collapse, has
in all probability originated in the East. Symptoms
corresponding to this disease have been described in
the most ancient Indian literature, and it was recorded
in Java as far back as 1629. After an epidemic in
Calcutta, which lasted till 1823, cholera began to
spread eastwards to Malacca, Penang, Singapore, and
Manila.
The possibilities of the introduction of this scourge
into Australia are very great, and its advent can only
be prevented by the strictest quarantine regulations.
Dysentery, & disease of world-wide distribution, is
commonly observed in the East. Amocebic dysentery,
caused by a protozoon, oecurs endemically throughout
Japan, China, the Philippine Islands, and the Dutch
East Indies. Bacillary dysentery has made its
appearance in New Guinea within the last two
decades, and has been responsible for a great number
of deaths amongst the natives. It has been spread
by dysentery carriers—natives who have apparently
recovered from the disease, but harbour numberless
fully virulent bacteria in their intestines. Indentured
labourers who have survived an attack of dysentery,
carry the infection to their village, thus causing on
their return an outbreak of the epidemic. It is cer-
tainly the most important disease in New Guinea
from an economic point of view.
In Northern Australia dysentery is a comparatively
rare complaint. On more than one occasion, how-
ever, it has been introduced into Thursday Island by
labourers recruited from New Guinea.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 1, 1914.
Another intestinal complaint peculiar to the East,
and of uncertain etiology, is Sprue (tropical aphthae),
of which disease a catarrhal inflammation of the
mucous membrane of the intestinal tract is the main
symptom, giving rise to chronic diarrhea. The
motions are large, of greyish colour and frothy, the
patient emaciates, the skin becomes dry and dark, so
that the complexion of an advanced case is of an
ochre colour.
Cases are found in Japan, in China, in the Philip-
pines, Malaya, Sumatra, Java, New Caledonia, and
the Fiji Islands. In Australia the occurrence of
sprue is confined to the coastal belt between Mackay
and Cairns, most of the cases originating in Bowen,
Ingham, and Innisfail districts. No cases, or even
records of cases, have been obtained from New Guinea.
Leprosy.—Cases are seen more or less frequently
in the Philippines, Dutch East Indies, and especially
in New Caledonia, where it has been introduced
within the last fifty years. In New Guinea lepers
are met with in small numbers along the coastal
districts. A number of cases were diagnosed in the
Mekeo district, west of Port Moresby, and on Tro-
briand Island, situated off the north-east coast. On
the other hand, districts west of the Vailala River,
where the oil fields are situated, seem singularly free
from this disease.
Leprosy is fortunately comparatively rare in
Australia. Amongst the aboriginals in the far north
lepers are found in small numbers, whilst now and
again a case is discovered in a white man.
In New Zealand in the olden times leprosy was
widely distributed.
Beriberi is perhaps of the greatest economic
importance of complaints which are most probably
of purely eastern origin, and have spread far and wide.
References to this disease, under the name of
“ Kake,” occur in Chinese literature of 200 B.C., and
these manuscripts contain unmistakable descriptions
of beriberi. In a Chinese book written about the
tenth century, the dry and wet forms of beriberi are
already differentiated, and descriptions of this disease
also occur in Japanese medical literature of the ninth
century. Without a doubt, however, other complaints
causing dropsical conditions of the legs have been
confused with true beriberi.
Beriberi occupies a large and anxious share of
Eastern diseases. It is prevalent in Japan, Indo-
China, and China. Frequent cases occur in the
Philippines, in the Malay States, and in Dutch East
Indies. A number of cases have been observed among
the native labourers in New Guinea, whilst numerous
cases originated among the coloured crews of the
pearling boats in Thursday Island, filling the hospital
at certain seasons of the year to its utmost capacity.
A small epidemic is said to have occurred in Western
Australia, and a few cases have been described from
Western Queensland, whilst quite recently this disease
has appeared in some of the Pacific Islands, especially
Fiji and New Caledonia.
In spite of the large amount of work done on the
etiology of this disease, it is still, to a certain extent,
shrouded in mystery. It is a generally accepted
Oct. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
295
opinion that the disease is due to a deficient diet, to
the exclusive use of highly polished rice; in other
words, rice of which the husk has been completely
removed. It is very probable, however, that even at
present several different, but closely allied, diseases
are classed under “ beriberi.”
Yaws, or Frambesia Tropica is another disease of
.very wide distribution in the eastern Tropics. Yaws
is purely a tropical disease, closely resembling syphilis
in its clinical manifestations. It is accompanied by
an eruption, which may attack any part of the body,
and is most frequently found on the hands and soles
of the feet.
Yaws is very common in India, the Malay Peninsula,
in Siam, Java, and in the Philippine Islands, and
throughout the Pacific Islands. In Fiji every child
is said to contract the disease in infancy. In China
cases of yaws are only rarely encountered, and
then mostly in coolies returning from the Straits
Settlements.
A mild form of yaws prevails in the Torres Strait
Islands, where nearly every child examined had some
sign of a past or present attack.
It also occurs amongst the aboriginals of the
Northern Territory, and many of the aboriginal
children were infected.
In New Guinea, as far as visited, the disease is
rampant. A large percentage of the children in the
coastal villages suffer from yaws in the different stages,
and many of the adults have the curious scar formation
around the mouth, the result of a past infection.
Europeans, on the whole, do not contract yaws, as
this disease is only propagated by contact.
Filariasis and Elephantiasis in the East are of
special interest as regards their distribution.
In Japan, filariasis and elephantiasis are known
to occur, but it is only the most southern part of the
great island which is affected by the disease. Through-
out China, filariasis is common, and it was in China
where Sir Patrick Manson made his discoveries on the
life-history of the parasite.
Filariasis is common in the Philippine Islands, in
Guam, it is present in the Malay Settlements, in the
Dutch East Indies, New Guinea, Queensland, and the
Northern Territory, and it is very widely distributed
in most of the Pacific Islands.
It is probable that all the filarize of the different
eastern countries belong to one and the same species,
although attention has been drawn lately to the fact
that the typical nightly presence and daily absence of
the parasites from the peripheral blood is not common
to all the larvae, but in some cases they are to be found
whenever sought, day or night.
The Chinese microfilaria is a nocturnal filaria (from
this peculiarity hails the name Microfilaria nocturna).
The Philippine microfilaria, as well as the microfilaria
in the blood of some of the New Guinea natives, is of
the non-periodical type. The nocturnal filaria, how-
ever, was found to exist in New Guinea as well.
In some of the Pacific Islands, as, for example, Fiji,
the non-periodical filaria exists, and, according to
Bahr’s observations, Stegomyia pseudoscutellaris acts
as intermediary host. This same species of mosquito
is prevalent in Eastern New Guinea, and it is possible
that the distribution of the non-periodical filaria may
be coincident with the presence or absence of this
species of mosquito.
In Queensland the microfilaria show,
exception, the typical periodicity.
Filariasis is very irregularly distributed in Queens-
land. The disease is more prevalent in Brisbane and
Port Douglas than in Townsville. In Brisbane nearly
17 per cent. of the total admissions to the hospital
show the parasite in their blood ; in Townsville, how-
ever, only 3'4 per cent.
Of diseases which are more or less confined only to
parts of the East, Gangosa offers some interest.
Gangosa, or " Rhinopharyngitis mutilans," is an
ulcerative condition of the nose, palate, and throat,
which begins as a rule as a thick cedematous swelling
on the upper lip, and spreads into the nasal cavity to
the pharynx, and often to the skin of the face and
neck, destroying the greater part of the face and giving
rise to a most hideous appearance.
Cases of Gangosa were first described as occurring
in the Ladrone Islands, Caroline Islands, Guam, and
laterin the Philippines. It is endemic in British New
Guinea, and numbers of cases have been observed in
the ceastal distriets between the Fly River and
Samarai. It has been found in the Torres Strait
Islands, is most common in Murray Island, where it
was referred to as far back as 1822 by Dr. Wilson in
his narrative of a “ Voyage Round the World.”
Juxta-articular Nodules is another typical eastern
disease of limited distribution. In the legs and
arms, as & rule in proximity to the joints, nodules
are found in the subcutaneous tissue of varying sizes,
sometimes as large as hen's eggs, sometimes quite
small and of hard consistency. Sir William Mac-
Gregor, when Governor of New Guinea, pointed out
that the nodules occur mostly on parts which come
in contact with the ground when the native is resting.
The frequency of their occurrence in some of the
villages, their total absence in others, however,
supports the opinion of a parasitic origin, which has
been confirmed lately by the discovery of a fungus in
the nodules.
Agchylostomiasis is, of helminthic infections, per-
haps of the greatest importance from an economic
standpoint. In the tropical parts of China, the
Philippines, throughout the Dutch East Indies, in
British New Guinea, and in Northern Queensland,
hookworm is a frequent and unwelcome guest.
Agchylostomiasis may be caused by two morpho-
logically, but closely allied, nematode worms—
Agchylostoma duodenale and Necator americanus—
both of which give rise to similar clinical symptoms,
namely, a profound anemia.
The first species, Agchylostoma duodenale, is found
in China; the second species, the American hook-
worm, is the more common in the Philippine Islands
and in New Guinea, whilst both species are frequently
encountered in Queensland.
It is very curious that Agchylostomiasis has not
been found in the Australian mines, as it is well
known that the damp heat in mines is especially
without
296 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 1, 1914.
favourable for the development of the parasite.
Experiences in other countries, such as England,
Belgium, and Germany, have shown what serious
consequences might arise from the employment of a
few infected individuals in a suitable mine.
From this short survey of tropical diseases which
occur in the eastern countries, it becomes apparent
that there exists a continuity in the distribution of a
great many of the diseases mentioned, from China
through the Malay Peninsula and the East Indies,
as far as New Guinea and tropical Australia.
Tropical Australia, on account of its insular isola-
tion and its scanty population, has enjoyed, up to
now, a freedom from the inroad of many of these
diseases, although quite a number of them, such as
filariasis, sprue, malaria, dengue fever, yaws and
agchylostomiasis have invaded Northern Australia,
and have found the conditions favourable.
Modern times, with their improved ways and means
of communication, have shortened the distance
between Australia and the surrounding lands, and
thus have brought new and important problems
before the far-seeing sanitarian.
The modern aspect of hygiene is chiefly concerned
with the study of local and general conditions, which
may favour the spread of disease in case it should be
introduced, and at the same time with the framing
and putting into practice of such quarantine regulations
as will prevent their introduction.
A practical example may give a clear idea of this
conception. We are now on the eve of the opening
of the Panama Canal. Ships coming from zones
where yellow fever is endemie can travel without
leaving tropical waters to China, India, and Australia.
Stegomyia fasciata, the yellow fever carrying
mosquito, has a very long life. Female mosquitoes
have been kept alive in captivity in Townsville for
five months, being fed twice weekly; and it is also
an expert traveller, having proved its qualities by
crossing from Central Ameriea to Spain and Portugal,
causing outbreaks of yellow fever on shipboard, and
even in Europe.
In Europe an epidemic could not spread, since
stegomyia cannot live on account of the low tempera-
ture. It is quite a different matter in the East and
in Northern Australia where stegomyia is very
common. It occurs very frequently in Darwin, and
as far south as Brisbane, and a few have been found
in Newcastle. "Thetemperature in Northern Australia,
especially during the summer months, is high enough
to enable the yellow fever parasite successfully to
undergo its development in the mosquito. Suppose,
as an instance, that infected stegomyia were intro-
dueed into North Queensland, and were able to infect
one person. The diagnosis of yellow fever during the
first three days is extremely diffieult, even to the
experienced, and it is during this time that the blood
of the patient is infectious to the mosquito. Numbers
of stegomyia, which occur abundantly in Queensland,
would have an opportunity to take up the virus, and
after twelve days, the time required for the complete
development of the parasite in the mosquito, more
cases of an indefinite but fatal fever would crop up,
and yellow fever would soon become established.
Let us now consider the steps which may be taken
to prevent such a terrible scourge as yellow fever from
entering Australia. It is practically impossible to
fumigate ships so thoroughly as to feel assured that
all the mosquitoes have been destroyed. As an
example of this, I may quote an instance which came
under my own observation whilst living in South
America, in a zone heavily infected with yellow fever.
Several cases of yellow fever had occurred on one of
the steamers, and the port authorities had undertaken
the fumigation of the whole vessel. Just before the
cabins were closed up, I was able to hide a wire cage
containing live mosquitoes under a sheet in one of
the cabins. Hours afterwards, when the ship was
supposed to have been thoroughly fumigated, I
inquired into the welfare of my mosquitoes, and, not
altogether to my surprise, I found that the majority
of the mosquitoes had passed through the ordeal
unharmed.
As the fumigation of ships cannot be depended
upon, there is only one course open, and that is a
thorough and energetic campaign against the mosquito
throughout tropical Australia.
During the yellow fever outbreak in New Orleans,
the Americans have proved that a town can be made
practically mosquito free within a few weeks.
But yellow fever is by no means the only danger
to which Australia is exposed. Many diseases, grim
and terrible in their manifestations, are to be found in
countries which are within easy reach and in constant
communication with Northern Australia. All the
conditions which some of these diseases require in
order to propagate when once they are introduced,
such as climatic and suitable insect hosts, are present,
with one exception, that of a dense population.
Besides human diseases there are many deadly diseases
in stock, which occur in the near neighbourhood of
Australia, and which might be introduced any time
in spite of the most thorough quarantine regulations.
I refer to diseases like surra, a blood disease of horses
occurring in the Philippines and India; rinderpest,
and many others which would cause as much havoc
and mortality as did the introduction of redwater
fever, which came from the East.
Only a careful study of the conditions which favour
the spread of disease, their removal if possible, and at
the same time a strict and discreet quarantine service,
will enable us to preserve tropical Australia from the
inroad of these diseases, which might stunt its
development for years to come.
PREVENTION OF MALARIA IN THE TROOPS
OF OUR INDIAN EMPIRE.
By Colonel P. Hxuin, 1.M.S.
IN most of the cases which oceur in troops and
followers on field service the initial infection 1s
acquired in eantonments: the large majority are
relapses. One’s personal experience is that the
malaria of cantonments is to a large extent bred in
the human occupants and anopheline population of
cantonments.
In all cantonments and barracks we should make
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, OCTOBER 1, 1914.
To illustrate article, “The Systemic Position of the Genus Trichophyton Malmsten 1845," by
ALBERT J. CHALMERS, M.D., F.R.C.S., D.P.H., and ALEXANDER MARSHALL.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE,-OCTOBER 1, 1914.
To illustrate article, ** Molluscum Fibrosum, Pendulatum atque Elephantiacum,” by Dr. F. S. HARPER.
Oot. 1, 1914.) -
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
297
an inquiry into the amount of malaria present in the
troops and other inhabitants, the breeding places of
anophelines (especially the local malaria-bearing
species), and the barracks, bazaars, and buildings
which adult anopheline carriers frequent. We should
use a large scale map and mark on it the extent to
which malaria prevails in different barracks, bazaars,
&c., and the breeding places of anophelines with the
species—ineluding all collections of surface water,
streams, irrigation channels and water-courses gener-
ally, areas under wet cultivation, ponds, tanks, pools,
borrow-pits, artificial collections of water (small and
large), stand-pipes, &c. The terrestrial waters and
possible breeding places are best seen after a heavy
shower. The cantonment should be divided up into
areas, the area of each unit being in charge of the
medical officer of the unit, the non-regimental areas
being similarly subdivided and supervised. In large
cantonments when an officer with expert knowledge
of malaria is available he should, under the senior
medical officer, be in charge of and direct all the anti-
malarial measures that are being carried out. Each
of these officers should have a map of his area, and
keep it up to date as regards prevalence of malaria,
breeding places still in existence, breeding places
removed, fresh ones that have arisen, &c.
The anti-malarial campaign in each cantonment
should be planned after these preliminary inquiries
have been carried out, and then systematically pushed
from year to year.
The most accurate indication as to the prevalence
of malaria in a cantonment is the malarial index.
The most practicable indication is the spleen index,
that is, the percentage of children up to 10 years of
age with splenomegaly due to acute or chronic
malarial infection. . The spleen-rate in troops, except
in highly malarial stations, is in no sense a reliable
estimate as to prevalence or intensity of malarial
infection—troops are usually brought under treatment
and the effects of the malaria checked before the
spleen attains to any great degree of enlargement.
There is a considerable amount of malaria amongst
Indian children in cantonments. Of 3,884 children
in various cantonments examined a few years ago on
the plains in India, in the 7th (Meerut) Division one
found during the malarial season an average of 60 per
cent. with enlarged spleens and 40 per cent. with
malarial parasites in the blood. The children of
cantonments are the chief reservoirs of malarial
parasites, and the source whence a great deal of the
malarial infection of troops spreads from year to year.
Fresh breeding places for anophelines are still being
created in many cantonments—in road-making, by the
removal of earth for new buildings, and in a score of
other ways.
The chief anti-mosquito measures required in
cantonments embrace rough canalization of streams,
irrigation canals and water-courses generally : level-
ling, grading, and embanking of rain-water channels,
ditches and roadside drains ; filling up of tanks, exea-
vations and depressions; covering of disused wells;
covering with mosquito-proof material or periodical
emptying of water cisterns; treating all small collec-
tions of water that cannot be abolished with some
larvicide once a week; preventing (where possible)
excavations for building purposes within cantonments,
and removal of brick factories from cantonment
limits ; and disuse of grass farms within half a mile
of barracks when these are near the breeding grounds
of anophelines. The mosquito gangs of cantonments
who are chiefly used for kerosining collections of
surface water should be employed in carrying out
much of the work. The work should be carried out
systematically, the labour fairly divided amongst the
men, and regularly supervised by the malaria officer,
senior medical officer, and medical officers of units.
The senior medical officer and malaria officer should
be acquainted with all possible breeding grounds of
anophelines in the extra-regimental areas of the
station and allot tasks to the mosquito gangs employed
in these areas, medical officers of units doing the
same in regimental areas.
The sanitary detachment, non-commissioned officers
and men of all our British and Indian units are now
in their annual course of instruction in military
sanitation made familiar with the róle of anophelines
in malaria and the methods employed in reducing
their numbers. "These men might be utilized in the
anti-mosquito measures of all cantonments to a large
extent. With their aid in most cantonments it would
be possible to work out during a single mosquito
season the anophelines in existence and the actual
malaria carriers amongst these. They are, as a rule,
intelligent and keen men. Apart from supervision,
all they require to guide them is a sound and well-
considered anti-mosquito scheme for the areas in
which they are employed.
A great deal of the unskilled labour connected with
the reduction of mosquito breeding places can be
carried out by the troops themselves in their regi-
mental areas. One has seen this done in several
stations with advantage, and we have had several
excellent examples of it in India and Burma during
the last few years. We should remember that it is
our duty to employ all the smaller and least expensive
methods before recommending large schemes.
I believe it is possible to reduce the anophelines
and the malaria in the cantonments of practically all
malarial stations if the matter is taken in hand in
a thoroughly methodical way and a continuous anti-
malarial policy be adopted from year to year. Patch-
work and change of policy are responsible for many
failures.
With the progressive decrease of breeding places of
anophelines in and around cantonments there will be
a corresponding reduction in the amount of quinine
that will be necessary for curative and prophylactic
purposes in garrisons, and the amount of labour
required to keep down the number of breeding places
will become yearly less.
There are many cantonments where this has
actually taken place —stations in which malaria was
prevalent and malignant, but in which the endemicity
is now mild.
As instances of cantonments that have been vastly
improved by persistent anti-malarial sanitation I
298
would mention Agra, Mhow, Belgaum, Hyderabad
(Sind), Quetta, Bangalore, Cawnpore, River Forts
(Rangoon), Mandalay and Lucknow.
In 1909 Agra yielded in our European troops 695
cases, in 1913 only 36, the strength remaining the
same. The excellent anti-malarial work that has
been in progress in Mhow for the last few years has
removed the necessity of issuing quinine prophylacti-
cally; the same may be said of Quetta and several
other stations. There is ten times less malaria in
Belgaum than ten years ago. The River Forts,
Rangoon, used to be notoriously malarial, every man
going to them getting infected; this is not now the
case. Mandalay used to be one of the most malarious
places in Upper Burma ; it has ceased to be so. In
Hyderabad (Sind) in 1908 the malaria ratio was 606
per 1,000 of strength; ian 1913 there were only 29
cases throughout the year.
These instances demonstrate the highly satisfactory
results obtainable by the active co-operation of all the
authorities concerned, combined with an intelligent
scheme of anti-malarial sanitation, and serious atten-
tion to the treatment of cases of malarial infection
both in hospital and subsequently. The work of
reducing the breeding places of anophelines is tedious,
exacting, and requires unremitting attention and
supervision ; in the absence of radical and prohibitively
expensive operations it has to be carried out from
year to year, the work must be uninterrupted ; any
relaxation will result in much of the advantages
gained being lost.
Destruction of adult mosquitoes in barrack rooms
is a by no means negligible defensive agency; the
collective effort of soldiers in barracks in this respect
is capable of greatly reducing the number of ano-
phelines present. Our troops should be encouraged
to do this, and small hand-nets and trap should be
placed in each barrack room during the anopheline
season.
Coolies employed in barracks should invariably be
medically inspected before being engaged and periodi-
cally examined afterwards, and they should get the
same issue of prophylactic quinine as the troops;
these remarks apply equally to all followers who sleep
in proximity to barracks.
The keeping of European troops at non-malarial hill
stations until the malarial season is over is a measure
of considerable advantage to efficiency. The transfer
of men severely infected with malaria to our con-
valescent depots on non-malarial hill stations serves
the triple purpose of eradicating malaria from the
individual, thereby lessening the invaliding rate for
malaria, and removing infected men from malarious
stations in which, through anophelines, they dissemi-
nate malaria. One has made a series of observations
on the children of Indian followers of British troops
moved to hill stations where there was no initial
malaria, and ascertained that a year's residence at
such stations eliminates without any treatment 98 per
cent. of the malarial infections; 97 per cent. of cases
of malarial enlargement of the spleen in children dis-
appear spontaneously in the same period. These con-
clusions were arrived at from observations made on
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1914.
997 Indian followers’ children in seven different hill
stations.
The detection, isolation, and specific treatment of
all infected soldiers are of great importance in the
prevention of malaria. Malarial patients should,
during the anopheline season, be isolated in special
wards and supplied with mosquito curtains. All
known cases of active malarial infection should be
admitted into hospital. This is very necessary, for
if not carried out, the men with malaria on returning
to the barracks infect their comrades and may get re-
infected themselves. The great advantage of remain-
ing in hospital is that all our hospitals are provided
with mosquito nets for malarial cases, whilst nets are
not universally employed in barracks. All discharged
cases of malaria taking quinine curatively should get
their quinine at the hospital or inspection room daily ;
this enables the medical officer to see them regularly.
During malarial infection the object should be, not
only to check the paroxysms, but also to eradicate all
the parasites from the blood by the use of quinine.
Relapses in soldiers, and in all other bodies of men
under discipline, can to a large extent be controlled.
There should be but little residual malaria in troops.
Relapses occur when previous infection has not been
eradicated by proper quinine treatment. All troops
and followers in cantonments known to be infected
with malaria should be subjected to a course of
quinine treatment lasting not less than four months.
Were this universally adopted there would, one
believes, be fewer cases of relapses in the late winter,
spring, and early summer months. The method of
treating malarial fever cases wjth quinine for a week
or so and then letting them fall into line with the men
who are taking the drug prophylactically is one of the
many causes of the continuance of malarial infection
amongst our troops. Under such treatment the cura-
tive administration of quinine is discontinued just at
the time when the patient is most infectious to others
through the gametocytes in his blood. The proper
way to treat malarial fever in our troops’ hospitals in
India is to keep the patient in hospital and under
quinine and mosquito nets until gametocytes are no
longer to be found in the surface blood, then discharge
him to attend daily for his course. Generation after
generation of gametocytes and schizogonic parasites
continue in the spleen and bone-marrow long after
they cease to be found in the peripheral circulation—
it is this recurring multiplication we should aim at
eradicating ; until this is done the infected person is
liable to relapses, that is, to recurring paroxysms
without reinfection, and also through malaria-carrying
anophelines to infect others.
In a malarial eantonment during the malarial season
when fresh infections are constantly liable to occur, it
is practically impossible to decide whether a particular
case is one of reinfection or relapse. A careful scrutiny
of each case with examination of the blood, and a
history of the course of the infection (if any) would
probably give us information upon which we could
draw inferences as to whether it was a reinfection or
a relapse, but such deductions would not be scientifi-
cally reliable. The only indication of a reinfection
a n
Oct. 1, 1914.]
would be a record to the effect that the preceding
attack was caused by & species of parasite different
from the one discovered in the blood during the attack
under investigation, although this does not necessarily
mean a reinfection, as the former infection may have
been a mixed one and one species has died out.
Relapse is one of the most common factors in
malarial infection; and the asexual cycle is that phase
in the life-history of the malarial parasites most fre-
quently associated with the primary infection and with
the relapse; and with one relapse and the succeeding
one. Relapse frequently follows the so-called spon-
taneous cure of malaria, because the asexual cycle in
such a case often persists in numbers that can be
detected by the thick film method in the intervals of
apyrexias. Infections treated with small doses of
quinine will in all probability relapse, because the
parasites of the asexual cycle in the spleen and bone-
marrow are very slightly if at all affected thereby.
Relapse is less likely to occur when the infection is
promptly and vigorously treated, because probably the
older the asexual cycle the more resistant to quinine
it becomes. Whenarelapse occurs with the presence
of parasites in the peripheral blood during the admini-
stration of quinine by the mouth in sufficient doses,
faulty absorption of the drug should be suspected.
These statements are based on the assumption that
the perpetuation of the asexual cycle of malarial para-
sites in the blood, spleen and bone-marrow is the sole
responsible cause of relapses, and that like Trypano-
soma gambiense and other trypanosomes in relation to
atoxyl treatment in the experimental production of
trypanosomiasis in lower animals, the asexual forms
of malarial parasites under certain conditions take on
a relative immunity against quinine. We have so far
absolutely no grounds for believing that relapses are
caused in any other way than by latent asexual forms
of malarial parasites taking on activity and multiply-
ing in the same manner as they did during the stage of
initial infection. Whether the spores of malaria become
immune to the action of quinine under the conditions
stated remains to be proved, but the assumption that
they do gives us a definite and practical line of quinine
treatment in the early initial paroxysms.
The special significance of the hypothesis rests in
its application in the treatment of malaria. Small
doses of quinine even in the slight infections may
simply render the asexual cycle relatively immune, so
that larger doses, if- they had been given early in the
attack might have eradicated the parasites, are later
without effect. It is probable that were larger doses
of quinine given for the first three weeks than those
usually administered during the initial infection, and
progressively decreasing doses continued subsequently
for the remainder of the four months' course, there
would be considerably fewer relapses and reinfections.
These remarks also emphasize the necessity of all cases
of malarial fever reporting sick at once so as to get
infected persons under quinine as soon as possible and
thus prevent the formation of gametocytes. Relapse
cases in cantonments after the real malarial season is
over are very largely responsible for the perpetration
of malaria through anophelines when the latter start
breeding again.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
299
From our reports we can measure the effect of
quinine in cases treated in non-malarial hill stations.
Men are sent up convalescent from malaria for four
to six months, get one relapse, are put under a com-
paratively mild course of curative quinine treatment
for four months, and no further relapses occur; in
98 per cent. of these cases their malaria is eradicated.
In a large proportion of cases the same course of
quinine treatment would not be successful in the
plains, possibly because of reinfections or because the
asexual parasites are more immune to the action of
quinine in the plains during the malarial season, or
for some other yet undiscovered reason.
Our records distinctly show that in those malarious
stations in which curative quinine treatment is most
persistently carried out relapses are decidedly fewer
than in those in which quinine treatment is adopted
in a half-hearted way.
One is in possession of abundance of evidence
pointing to the necessity of more continuous exami-
nation of the blood for parasites in fevers of unknown
origin in malarious stations. One group of facts
supports this statement. In the Burma Division up
to August, 1911, a large percentage of fever cases were
returned as pyrexia of uncertain origin, the practice
being to rely upon a single examination of a stained
blood-smear for malarial parasites. From that month
onwards daily microscopical examinations of the blood
in all cases of undiagnosed pyrexia was carried out,
quinine being withheld until malarial parasites were
found in the peripheral blood. Over 9,000 slides
were examined in connection with 750 infections.
In 1 ease parasites were not found until the eighth
day, in 2 on the seventh day, in 5 on the sixth
day, in 4 on the fifth day, in 11 on the fourth
day, in 43 on the third day, in 127 on the second
day, the remainder on the first day; in other
words, in 25'86 per cent. of proved malarial infections
parasites were absent during the first paroxysm. In
two Indian battalions quartered in Mandalay, which
used to be a very malarious cantonment, six months
after the adoption of this change the place of practi-
eally all the cases of pyrexia of uncertain origin was
taken by malaria in the returns. A similar series of
facts were recorded in the 6th (Poona) Division in the
last quarter of 1913.
The records of our military hospitals show that fre-
quently malarial parasites are not found in the peri-
pheral blood during malarial paroxysms. The chief
reason given for this failure to discover parasites is
that the patients are at the time taking quinine pro-
phylactically. One is, however, quite convinced that
when malarial parasites are in sufficient numbers in
the blood to give rise to malarial paroxysms, they can
in the large majority of cases be found in the peri-
pheral blood, especially if the thick film method is
employed and quinine is temporarily withheld.
The practice of giving quinine tocases where malarial
parasites are definitely known not to exist is unsound
therapeutically. One great disadvantage of giving
quinine in cases of doubtful fever is that after its use
the diagnosis of the case may never be cleared up.
When all evidence shows that there are no malarial
parasites in the peripheral blood, abstaining from
300
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[Oot. 1, 1914.
giving quinine ean do no serious harm to the patient
in the vast majority of cases. It sometimes happens
that the disuse of quinine in such cases for some days
enables the diagnosis to be settled by parasites appear-
ing in the finger-blood. Although we know that quinine
is a specific in malarial infection, the fact that its use
brings about the disappearance of pyrexial phenomena
does not prove that the fever is malarial. Quinine is
an antipyretic, apart from its plasmocidal properties.
I consider that as a routine practice no case of fever
should get quinine until malarial parasites or other
changes in the blood, or definite clinical manifesta-
tions, indicate that the case is one of malarial fever.
Papers have in recent years been published
antagonistic to the prophylactic use of quinine, and
in several annual reports of garrisons of 1913 the
utility of this procedure is questioned. The failure of
quinine as a prophylactic of malaria is due to improper
dosage, defective methods of administering the drug,
postponing its administration too long, or using it in
prophylactic doses when it should be given curatively ;
usually the last named is the cause giving rise to
disappointing results, and the ultimate defect will in
most cases be found to be a want of completeness in
the method of diagnosing actual cases of existing
malarial infection. Prophylactic doses of quinine do
little or no good when malarial infection is already
present; it may possibly be instrumental in creating
resistant strains of malarial parasites which perpetrate
the infection in the individual and thereby through
him lead to dissemination of the infection.
Jn many stations the mistake is made of not hegin-
ning the prophylactic issue of quinine sufficiently
early; for one reason or another this issue is post-
poned until the incidence is seen to be rising rapidly.
Under this circumstance a fair percentage of men in
barracks are already infected, and through anophelines
infect one another. The cases where the infection is
latent do not of course report sick, but they are
reservoirs of the parasites that enable anophelines
to disseminate the malaria. Prophylactic doses of
quinine in such cases are, if anything, worse than use-
less; infection has already occurred and curative
doses are required ; prophylactic doses possibly harden
the parasites to the effects of quinine, and the reputa-
tion of the drug by this mistake suffers in two ways.
When all cases of malaria in units are admitted,
and such admissions reach 2 per cent. of strength, I
consider the prophylactic issue of quinine is justifi-
able. The longer it is delayed after this the higher
will the percentage of fresh infections become during
the malarial season. There are circumstances when
a prophylactic issue should be made irrespective of
the percentage of admissions, e.g., in barracks where
mosquito nets are not in use and when there is a
sudden rise in the malaria of the civil community
around. Assuming a uniform distribution of cases in
barracks, any greater percentage than 2 means that
one man in each barracks is infected, and that through
him in the presence of anophelines malaria will rapidly
spread. If time permitted I could quote several
instances in which five or six men occupying parallel
and consecutive beds in barrack-rooms suffered from
the same type of malarial infection, the other men
escaping; and one instance in which 13 of 24 men in
one room suffered from malignant tertian, the other
11 remaining healthy, and in the adjoining room 9 of
the 24 occupants suffered from benign tertian, the
other 15 occupants being unaffected by malaria in
any form. Under ordinary circumstances in non-
epidemic years, however, such spreading of malaria
does not occur through cases in the barrack-rooms of
European troops, but through the infected anophelines
from married quarters, bazaars, and followers’ huts
invading barrack-rooms.
The effect of the percentage of cases of infection in
influencing the incidence of malaria may be seen in
every endemic malarial station.
One's personal experience is that the best prophy-
lactic dose of quinine during the malarial season where
malaria is comparatively mild is 5 gr. daily ; where it
is severe, 5 gr. daily for six days and 10 gr. on the
seventh day weekly; and where it is very severe, 5 gr.
for six days and 15 gr. on the seventh day weekly.
Many factors interfere with the reduction of malaria
in cantonments—indifference of the persons infected,
want of enthusiasm of those guiding anti-malarial
operations, absence of concentrated effort and of
universal co-operation in the measures, and, especially,
absence of funds necessary to make these measures
radically useful. All who are familiar with the diff-
culties inseparably associated with prevention in
endemic malarial cantonments must allow that it is
always a heavy task from which there can be no
remission.— Indian Medical Gazette, August, 1914.
PROTOZOA AND DISEASE.*
By Anton BREINL.
Director of the Australian Institute of Tropical Medicine,
Townsville.
PHYLOGENETICALLY, the protozoa are placed
between plants and animals, and it is the general
opinion that no one feature separates the lowest plant
from the lowest animals, and the difficulty—in many
cases the impossibility—of distinguishing between
them is clearly recognized.
The protozoa correspond in their anatomical struc-
ture to the units which build up the body of the
multiple-celled metazoa, and, like animals and man,
they consist of cytoplasm or protoplasm, which is
considered to be the carrier of the activities which
constitute life, and of a nucleus or a number of
nuclei to which different functions are attributed.
Morphologically, protozoa do not show any dif-
ferentiation into different organs, but within the con-
tines of the single cell are carried on all the essential
vital functions which characterize the many-celled
animal—nutrition and multiplication are carried on
by the one cell.
There are numerous protozoa all over the world in
water and dust, leading an independent existence, as,
* One of the Stewart Lectures of the University of Melbourne,
1913.
— — —
Oct. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
301
=n
for example, infusoria. There are other protozoa
which lead a facultative parasitic existence, in other
words, live symbiotic in and with their host, without
causing any harmful effects; and there are finally
the parasitic protozoa, which live in the host to its
detriment, and which are of special interest, since
they are the cause of many and varied diseases.
Amongst such diseases caused by protozoa may be
mentioned amæbic dysentery, malaria, Leishmaniosis
(kala-azar, and Oriental boil). They are the cause of
sleeping sickness and of numerous diseases in stock.
There are a great number of species which live in the
blood of wild animals and birds. Others, like the
Coccidia, invade the epithelial cells of the intestine
of different species of animals, and emigrate from the
intestine into the liver, causing extensive and marked
lesions in this organ. Many of the representatives
of another branch—the Neosporidia—cause extensive
skin lesions in fishes and have been found in the
intestines of insects.
The majority of the parasitic protozoa belong to
the large class of Sporozoa, so-called because they
multiply, in one stage or another of their life-history,
by spore formation.
Parasitic protozoa differ in many ways in their
action upon their host from bacteria: Bacteria, as a
rule, multiply within the host until they have over-
come his resisting power and caused his death, or
until the host has been able to form antibodies, a
poison counteracting the bacteria and their products,
in sufficient quantity to retard their further multipli-
cation and to accomplish their annihilation.
Blood protozoa, on the other hand, undergo, as a
rule, a series of definite changes called the life-cycle
in the warm-blooded host, and morphologically dif-
ferent forms are found at different stages of the
disease in varying numbers.
The parasite of benign malaria, for example, enters,
in its youngest stage, the red blood corpuscles of its
host. It has the shape of a signet ring, consisting of
cytoplasm and the nucleus. Soon after the parasite
has entered the blood corpuscles, the whole parasite
increases in size; very soon the chromatin of the
nucleus breaks up into numbers of particles, which
collect a certain amount of cytoplasm around them-
selves, and after a varying period—in benign malaria
about forty-eight hours—the blood corpuscles which
contain the parasites burst open and the young spores
hecome free, and soon afterwards attach themselves
to new red-blood corpuscles, enter them and begin
the same cycle anew.
The parasite of sleeping sickness, Trypanosoma
gambiense, undergoes a developmental cycle analogous
to the malaria parasite. At a given time the peri-
pheral blood of men may contain an enormous
number of parasites. If the blood of the same men
be examined one hour or so afterwards, the parasites
may have disappeared so completely that even the
most diligent search will not reveal the presence of
a single parasite, and it may be days, weeks, and
often months before the parasite can again be found
in the same patient. This negative interval coincides,
as a rule, with a considerable subjective improvement,
All the observations on the life-history of the
pathogenic protozoa seem to prove that there must be
a close relationship between the action of the parasite
on the host and the reaction of the host to the
presenee of the parasite, and open up a wide field for
original work, namely, on the nature of immunity
against protozoa and its relation to the life-cycle of
the parasite. In spite, however, of the strenuous
efforts of a great number of highly skilled observers,
our knowledge has not progressed very far in this
direction.
Protozoic immunity differs essentially in one respect
from bacterial immunity. Bacteria only occur in one
shape and form and stage in the organism. Protozoa,
on the other hand, occur in different shapes and forms
and stages, and whilst at one stage of the infection
the organism has been able to combat one phase of
the parasitic invasion, the parasite is able to undergo
morphological changes in such a way that the body
has to bring forth new efforts in order to counteract
the effects of the parasite in its new phase.
If a small number of trypanosomes be inoculated
into the abdominal cavity of an experimental animal,
multiplication sets in, and after a certain time the
parasites enter the blood-stream of the animal. Even
the most careful examination of the animal's blood
during the first few days does not reveal the presence
of trypanosomes; the animal is in the incubation
period. After a varying interval, which, on the
whole, corresponds to the number of parasites in-
jected, the parasites have become numerous enough
in the peripheral blood of the experimental animal
to be detected by microscopical examination. They
continue to multiply, reaching their first maximum
number after a few days. Suddenly the parasites
disappear, and for days, sometimes weeks, no trace
can be found in the peripheral blood of our animal.
After a varying interval, however, the parasites re-
appear again, at first in scanty numbers, then multiply
and reach a second maximum, which may or may not
be slightly higher than in the first instance. After
this second maximum the parasites disappear again,
and-a second negative phase is observed. This play
and counterplay repeats itself more or less often
until the parasites become so numerous that the
peripheral blood is swarming with them, and at this
stage the animal suceumbs to the infection.
The question of the fate of the parasite during this
negative interval was difficult to solve. Careful obser-
vations of the blood and organs, carried out over pro-
longed periods, revealed the fact that the parasites
undergo morphological changes at the time when the
first maximum in numbers is reached. The parasite
of sleeping sickness, Trypanosoma gambiense, possesses
two nuclei, a small one situated at one end and a
larger one placed in the centre, the former in all
probability controlling the vegetative function of the
cell, the nutrition, and the latter the reproductive
function. At a time when the parasites begin to dis-
appear frcm the peripheral circulation an interaction
takes place between these two nuclear structures, a
chromatin band grows from the smaller nucleus to
the larger one, This phenomenon can, however, only
302
[Oct. 1, 1914.
be seen in an extremely small number of parasites.
The majority of them undergo disintegration, the
cytoplasm becomes vacuolie, and the majority of the
parasites break up, and the fragments are eaten up by
the phagocytes, the policemen of the blood. If we
take the blood serum at this stage of the infection
and mix it with parasites taken from another animal,
but in an earlier stage, then we find that the serum
acts in the test-tube in exactly the same way as in
the body, and we may observe under the microscope
that the parasites are destroyed.
With regard to the smaller number of parasites in
which the interaction between the two nuclear struc-
tures has taken place, a further development takes
place. The cytoplasm of these parasites becomes
denser, the chromatin of the nucleus becomes more
concentrated, and the smaller forms which result,
consisting of a nucleus and a small ring of cytoplasm,
take refuge in the spleen and bone marrow, and there
lie dormant for varying periods awaiting the oppor-
tunity to begin life again and give rise to a new
generation of parasites. These forms have rightly
been termed “ latent bodies," as they are the parasites
of the “latent stage of the disease.”
The observation that the serum taken at the crisis
(that is, at the time when the parasites begin to dis-
appear) causes the destruction of other parasites of
the same species, seems to prove that a formation of
certain immune bodies, antagonistic to the parasite,
and therefore termed "antibody," has taken place in
the serum, and that these are the cause of the dis-
appearance of the majority of the parasites from the
blood. The presence of this immune body in the
serum is unfortunately only of short duration. In
the course of a longer or shorter space of time these
" antibodies " are excreted or broken up, and give the
parasites an opportunity to leave their hiding place
with impunity.
In the ease of sleeping sickness, the faculty of the
host to produce substances which are harmful to the
parasites seems only to be a limited one, since after
several attacks and latent periods the resources of the
animal organism become exhausted, giving the para-
site the freedom to multiply indefinitely and cause
the death of the host.
The foregoing observations show that protozoic
immunity is intermixed with, and dependent on, the
life-history of the parasite, and vice versa; in other
words, in protozoie diseases, the parasites act first
upon the animal:organism, which reacts in a protec-
tive sense, and forces the parasite to undergo a further
development in its life-history.
Similar and analogous changes take place in the
case of infections with the parasite which causes
relapsing fever in different parts of the Tropies, and
is called spirocheta, an extremely small thread-like
body. In cases of relapsing fever active and latent
periods follow each other at varying intervals, clini-
cally characterized by attacks of fever and feverless
periods. The spirochetes, which are present in
enormous numbers in the blood during the fever
period, suddenly disappear completely, only a few of
the parasites coiling themselves up in the cells of the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
liver and spleen, which, as soon as the elements in
the blood serum hostile to the parasites have ceased
to exist, break up into numerous fine particles, out of
which the new generation develops.
Other protozoa, especially the non-pathogenic pro-
tozoa, which live in the host without causing injury—
as, for example, Trypanosoma lewisi, a parasite of the
common wild rat—differ in many respects from the
pathogenic trypanosomata. These parasites, after
they have entered the animal host, multiply slowly,
are present during the whole duration of the infection,
and finally disappear. Even in these cases the multi-
plication during the first stages of the infection differs
from that of the later stage. Whereas in the early
stages the multiplication takes place by segmentation.
one parasite breaking up into a number of smaller ,
ones, in the later stage multiplication takes place
by simple fission, each parasite splitting into two
daughter cells. Morphological differences in the
parasites are well marked in different stages of the
infection, and tend to lead to the ‘conclusion that the
animal body has produced substances which have
forced the parasites to change their tactics and mor-
phology.
Malaria parasites differ in many respects from
trypanosomes. It is a well-known fact that the fever
caused by the malaria parasite (simple tertian form)
is an intermittent fever—fever to-day, a feverless
interval the second day, and fever again on the third
day. During the febrile interval parasites are either
absent from the blood or only present in certain
stages, the sexual stage referred to later. The rise
of temperature always corresponds with the sporula-
tion of the parasites, that is, to the period when the
blood corpuscles break up, setting free numberless
small forms, the schizonts, which attack new blood
corpuscles, develop in them and repeat the same life-
history over and over again. A great number of
these small parasites must perish, otherwise the
human organism would succumb to the number of
parasites at a very early stage of the infection.
In the normal course of malaria, if the patient be
not treated, relapse follows relapse; the clinical
symptoms, such as anzmia, enlargement of the spleen,
and wasting, as a rule, become more marked with
each relapse, a slight improvement taking place during
the interval. After some time, however (several
months), the symptoms reach a fixed limit, and the
patient shows the typical clinical picture of chronic
malaria, anemia with its accompanying cedema, and
with enlargement of the spleen. In many eases,
especially in native children, improvement sets in
after the symptoms have reached the fixed limit.
The relapses lose their regularity, the feverless
intervals become longer and longer, the clinical sym-
ptoms become less marked, but on examination para-
sites can still be found in small numbers in the blood.
Complete recovery may take place, followed by a
partial immunity.
A practical illustration of the condition referred to
can be found in any native community where the
natives live in villages. One of the most constant
symptoms of malarial infection is the enlargement of
Oct. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
303
the spleen. On examining the children living in a
malarial district, from baby to about 4 or 5 years,
enlargement of the spleen may be found in as many
as 90 to 100 per cent. of all the children examined,
and this enlargement becomes less marked in the
older children.
One may often examine a great number of adult
natives in the same village without finding any signs of
latent malaria, and this occurrence proves that the
human organism produces an immunity against the
malaria parasite. In other words, when infection had
taken place, especially in early childhood, the malaria
parasite, which has been a true parasite at first, has
become a saprophyte, and although still present in
very small numbers, does not cause clinical sym-
ptoms. It is, however, remarkable to note that this
equilibrium between body and malaria parasite is
very unstable, and may become easily disturbed.
Any of the conditions which cause the slightest
lowering of the resistance of the human body may
give rise to a typical attack of malaria. There are
cases on record where, even after a fever-free interval
of from four to six years (the person had been living
in a malaria-free country) malaria parasites have
made their appearance again at a time when some
other disease had lowered the vitality of the patient.
This also accounts for the fact that in many instances
malaria fever attacks can often be noticed after the
infected person has left the malaria district. It is of
common occurrence that people returning home from
the West Coast of Africa, after a stay of one or more
years, show the first signs of fever when nearing
Gibraltar, whilst persons who have been resident in
New Guinea for quite a long period have noticed
their first attack on their arrival in Queensland during
the winter.
Similar to the malarial immunity is that produced
in bovine piroplasmosis—tick fever in cattle. It is
well known that the infection of tick fever in cattle
runs a mild course if the parasite invades young
animals, whilst older animals succumb, as a rule, to
the infection. If the infection takes place in a young
animal a permanent immunity is conferred upon this
beast. Parasites can, as a rule, be found for a whole
year after the onset of the disease, if not by direct
microscopic examination, at least by sub-inoculation
experiments of the blood into a susceptible animal.
Protozoic immunity is a very difficult problem
indeed, and the advances made up to now are only
slight. At the same time it is a very important pro-
blem, as an insight into the ways and means Nature
employs to overcome protozoie infections may lead
to the successful treatment of the disease in question,
in the same way as the advances in our knowledge of
the mode of production of bacterial immunity, have
done so much to make diseases such as diphtheria
and lockjaw easily amenable to treatment. The
investigations into protozoic immunity on the lines
of those employed in the case of bacterial immunity
have, up to now, completely failed, and new methods
and modes of reasoning have to be devised to further
our knowledge of this subject.
Protozoa differ in other respects from bacteria in
that they are transmitted by some biting insects,
which act as intermediary hosts, passing through
definite changes within the insect. For example, the
tsetse-fly, Glossina palpalis, acts as intermediary host
to the sleeping sickness parasite; different species of
anophelines as intermediary hosts for the malaria
parasite ; ticks, as Ornithodorus moubata, as inter-
mediary hosts for the African relapsing fever; and
various Boophilus as intermediary hosts for the tick
fever in cattle.
Investigations into the life-history of protozoa
have taught us that the parasites undergo a rejuvena-
tion in the intermediary host, and have shown us
that there are in nearly all protozoa which have been
carefully investigated, two distinct and different life-
cycles—one life-cycle in the body of the host, and a
second quite distinct life-cycle in the intermediary host.
I will give, as an illustration, the life-history of
the malaria parasite, Plasmodium vivax, in its inter-
mediary host, a certain mosquito, an anopheles, of
which only a limited number of species are capable
of offering the malaria parasite a welcome home
for further development. The sexual forms are
taken up with the blood of patients by the female
mosquito. The female gamete, or macrogametocyte,
escapes from the red-blood corpuscles after it has
reached the intestine of the mosquito, and undergoes
changes in some respects analogous to those which
take place in the germ cells of the metazoic organism.
The nucleus divides, and some of the chromatic
particles leave the cell; the nucleus of the macro
gametocyte has undergone reduction division, and
has become a macrogamete.
The microgametocyte, the male element, changes
in a similar way. The chromatin of the nucleus
breaks up into a number of particles which migrate
to the periphery of the cell. Shortly afterwards fine
whip-like filaments called flagella shoot out from the
periphery of the cell, which lash about and show
lively movements. These small filaments finally
break off and form microgametes—the male element.
Each microgamete consists of a filament of cytoplasm,
over which is spread the chromatin in small dots.
Soon after the formation of the microgametes, the
male and female elements conjugate, the nuclei fuse,
and the fertilized parasite, called the ookinete, elongates
and becomes pointed at one end ; the pigment is placed
mostly at the posterior end of the parasite, and is
often thrown out.
At this stage the parasite penetrates the lining of
the stomach of the mosquito and comes to rest on
the outside of the stomach, surrounding itself with
a thin membrane. The parasite now begins to grow
at a great rate, the nucleus divides into a large number
of daughter nuclei, which form the sporoblasts ;
afterwards the chromatin of the sporoblasts divides
into a great number of smaller chromatin particles,
which move towards the periphery and cause
numerous projections. This cyst, which has increased
in size considerably, now bursts, and the contents
escape into the body cavity of the insect and are
carried by the blood-stream of the insect throughout
the whole body, and finally find their way into the
salivary glands. This process in the mosquito takes
ten to twelve days.
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THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oet. 1, 1914.
When the infected mosquito feeds on a second
person, the small parasitic forms pass from the
mosquito into the blood-stream of the person' by way
of the wound, attack the blood corpuscles of the new
host, and begin to multiply.
From this description it is apparent that the
parasites of malarial fever have to undergo compli-
cated changes before being able to enter the new host.
Many of the other protozoa undergo a complicated
development in the intermediary host, but none of
the life-history is as definitely known as that of the
malaria parasite.
Trypanosomes most probably undergo a sexual
development in the tsetse-fly, which, however, is not
yet clearly understood. The life-cycle of one species
of trypanosome, Trypanosoma lewisi, found in the
wild rat, is better known. The trypanosomes are
taken ap with the blood by the rat louse, grow larger,
and resemble morphologically forms which occur as
" wild parasites," harmless lodgers in different insects.
The work of the life-history of parasitic protozoa
through the intermediary host is complicated by the
occurrence of other parasites in the respective insects,
which resemble morphologieally the changed form of
the parasite in question.
For example, two trypanosomes, T. grayi and
T. tullochi, which occur commonly in the tsetse-fly,
resemble closely that of sleeping sickness in some of
its stages.
The fact that parasitic protozoa resemble in many
stages of their life-history other protozoa which live
as harmless commensales in the body cavity of
different insects, is a very suggestive one, as it seems
to point to the conception that parasitic protozoa
have been evolved in the course of time from origin-
ally harmless parasites, which were taken up by
insects and became non-parasitic commensales before
acquiring their parasitic habits.
In the Tropics a great percentage of all the animals,
mammals, birds, and reptiles harbour parasitic pro-
tozoa, which, although morphologically very similar,
often even identical, are specific for the species of
animals in which they occur. For example, 7.
gambiense, the sleeping sickness parasite, and 7.
brucei, causing the tsetse-fly disease in cattle, are
morphologically nearly identical, biologically quite
different. The sleeping sickness parasite only causes
slight and transient infections in horses and cattle ;
the cattle parasite never causes infection in man.
Most of the various blood parasites which inhabit
the blood corpuscles of lower animals and birds are
specific for the species in which they occur, never
being able to live and multiply in any other species.
The diseases caused by parasitie protozoa occur
mostly in tropical climates. The most important
disease is malaria, which oceurs nearly as far as the
Tropics extend. There are at least three different
varieties of the parasite of malarial fever—the
quartan, simple tertian, and malignant tertian parasite.
The quartan sporulates every fourth day, and causes
rise in temperature, rigor, &c.; the simple tertian
sporulates every other day, and the malignant tertian
parasite runs a more or less irregular course.
Sleeping sickness is caused by 7’. gambiense, a pro-
tozoon belonging to the large group of the hæmo-
flagellata. Sleeping sickness has spread throughout
many parts of Africa with a tremendous mortality,
depopulating whole districts. It is a very chronic
disease, characterized in its early stages by a marked
swelling and inflammation of the lymph glands. In
the later stages the brain becomes attacked, and the
round-celled infiltration in the perivascular lymph
spaces gives rise to the mental stupor and drowsi-
“ness from which the disease gets its name.
Kala-azar, a disease due to a micro-organism,
Leishmania donovani, occurs in India. Patients show
a great enlargement of the liver and spleen, and
emaciate to a skeleton. The fever is irregular and
persistent. This disease is always fatal. A morpho-
logically similar parasite is the cause of leishmaniosis
infantum, a form of the disease which attacks mostly
infants, and shows as clinical sign a great enlarge-
ment of the spleen, which is followed by well-marked
emaciation.
Similar parasites cause the lesion known as Oriental
boil, a slowly spreading ulcer on different parts of the
body, occurring in Bagdad, Delhi, Brazil, and other
parts of the world.
Spirochetes are too well known as disease producers.
Syphilis, yaws (a children's disease amongst the black
inhabitants of the Tropics), the different forms of
relapsing fevers— the African, Indian, European,
American— are produced by spirochetes. Parasites
which give rise to amæbic dysentery belong to the
phylum of the protozoa, and show a fairly wide dis-
tribution throughout the Tropies.
—— —4—————
Personal Hotes.
List oF INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment or Department, and the Period
for which the Leave was granted.
Bomford, Captain T. L., I.M.S., to April 3, 1915.
Coleman, Lieutenant-Colonel A., I M.S.
Crimmin, Colonel J., I.M.S.
Dawson, Lieutenant-Colonel A. W., I.M.S.
Graham, Captain G. F., I. M.S., to June 5, 1915.
Greson, Lieutenant E. J., I S. M.D.
Harrison, Major C. B., I. M.S.
Hendley, Colonel H., I. M.S., to October 22, 1914.
Heriz-Smith, Lieutenant G. V., I.M.S., to October 5, 1914.
Jack, Captain W. U., I. M.S.
Jolly, Captain G. A., I.M.S., to February 15, 1915.
Kelly, Major T. B., I.M.S., to March 15, 1915.
Kolapore, Captain F. J., I. M.S., to December 7, 1914.
Leonard, Major W. H., I. M.S., to October 16, 1914.
Little, Captain G. L. O., I. M.S., to November 20, 1914.
McCarthy, Lieutenant P., I.S.M.D., to November 12, 1914.
McCowen, Major W. T., I. M.8., to December 14, 1914,
McNeight, Captain A. A., I.M.S., to September 7, 1914.
Melville, Major C. W., I. M.S., to August 31, 1914.
Millar, Captain G. McG., I.M.S., to November 25, 1914.
Pal, Captain S. C., I. M.8., to December 20, 1914.
Pridham, Captain A. T., I.M.S., to April 5, 1915.
Robertson, Colonel R., I. M.S., to November 7, 1914,
Seton, Colonel B. G., I.M.S., to November 30, 1914.
Stevenson, Captain F., I. M.S., to October 12, 1914.
Thakur, Captain K. S., I.M.S., to May 22, 1915.
Thomas, Captain A. N., I. M.S., to November 9, 1914.
Thomson, Lieutenant.Colonel G. S., I.M.S., to March 23,
1915.
White, Captain M, F., I.M.S., to September 30, 1914.
———à — M a —— ——
Oct. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 20, Vol. XVII.
Original Communications.
NOTES ON THE HYPHOMYCETES FOUND
IN SPRUE: WITH REMARKS ON THE
CLASSIFICATION OF FUNGI OF THE
GENUS “MONILIA GMELIN 1791.”
By ALDO CASTELLANI, M.D.
Director, Government Clinic for Tropical Diseases, Colombo,
Ceylon.
IN the present paper I do not propose to discuss
the etiological róle played by fungi in sprue, but
merely to study the subject from a botanical point of
view.
Historical.—Kohlbrugge, in 1901 (see Arch. f. Schiffs
u. Tropen-Hygiene, 1901, No. 12), found in cases of
sprue a fungus which he identified with the thrush
fungus (Monilia oidium, Endomyces, Saccharomyces
albicans). He made a very complete histological
study of one of his cases which ended fatally, and
emphasized the fact that the fungus in sections of
the tongue, &c., had invaded the deep strata of the
mucosa, the glands, and portions of the submucosa.
He concluded that the thrush fungus, or Monilia
albicans, was the cause of the disease. Kohlbrugge’s
findings were confirmed by many observers, Le
Dantec suggesting for the disease the term Blasto-
mycosis intestinalis.
From 1909, being interested in the subject of
fungi in general, I have studied the hyphometic
intestinal flora of a certain number of typical cases
of sprue, as well as of other conditions and of normal
individuals, and I have come to the conclusion that
there are several different species of intestinal monilias
(M. intestinalis, M. fzcalis, &c.). In my paper on
sprue in the Rivista Critica di Clinica Medica, 1912,
I discussed all the various theories, bringing forward
what had been found in favour of each by myself
and others. I did not express any opinion as regards
the etiological róle of these fungi in sprue, except
that they were probably the cause of the frothy
diarrhea, having noted that this frothy diarrhma
generally improves after strong doses of bicarbonate
of soda. I thought that sodium bicarbonate given in
large doses, by decreasing the acidity of the intestinal
contents, might check the growth of fungi, which, as
is well known, grow better on acid than alkaline
media.
In 1913 Dr. George Low and myself described a
new species of monilia we found in a case of sprue,
and called it M. decolorans. We considered this
monilia and similar ones to be probably the cause of
some of the important symptoms of the disease, such
as frothiness of the stools, &c., but we were not
inclined to consider them to be the primary cause of
the malady; we quoted in analogy the example of
Scabies, in which the main part of the symptoms is
due to the secondary invasion by staphylococci, and
not the primary or real cause, the acarus. We quoted
also the example of pulmonary tuberculosis in which
a very important symptom, the serotine fever, is not
due to the tubercular bacillus, but to the secondary
streptococcal infection.
Recently Dr. P. Bahr has published a report of his
investigation of the malady (Transactions of the
Society of Tropical Medicine and Hygiene, April, 1914),
in which he identifies the fungi found in sprue
with the thrush fungus (M. albicans), completely
supporting Kohlbrugge. Heseems also to be inclined
to agree with Kohlbrugge that M. albicans is the
primary cause of the disease.
Presence of Fungi in Sprue.—In practically every
case of sprue it is easy to put in evidence hypho-
mycetes in the stools and scrapings from the tongue.
The microscopical examination of the frothy motions
will often reveal the presence of spore-like bodies and
mycelial elements typical of the genus Monilia. Even
when fungi are not observed microscopically they can
generally be put in evidence by cultures, inoculating
glucose agar or glucose broth tubes with a particle of
the stools. Though generally in much less amount
it is not rare in the Tropics to find microscopically
identical fungi in stools of patients suffering from
other diseases (dysentery, enteric, &c.), and occasion-
ally in normal people. Microscopically identical
fungi may be isolated also from the air, tea dust,
copra dust, &c.
Botanical Position: Differentiation of Intestinal
Monilias and Monilias in general.—As already stated,
all monilias found in sprue as well as in other condi-
tions, such as bronchomycosis, thrush, otomycosis,
those found in the air, tea dust, copra dust, &c.
have all been considered to be the same species and
identified with the thrush fungus or M. albicans.
Since 1909 in a series of papers I have expressed
the opinion, based on a certain number of experiments,
that the term “thrush fungus,” or M. albicans (oidium,
saccharomyces, endomyces albicans), has been used to
cover a large number of different species (possibly even
different genera) of fungi, in the same manner that,
till some years ago, the term Bacillus coli was used
to indicate a prodigious number of different bacteria,
in the same manner that the term Trychophyton
tonsurans, till fairly recently, covered numerous
different fungi, belonging not only to different species
but to different genera, such as the genera Epidermo-
phyton microsporon, Endodermophyton. This, in my
opinion, erroneous conception of M. albicans has been
due to the classification of such fungi being based
hitherto solely on their morphological and micro-
scopical characters and gross appearances of cultures
on solid media. Since 1908 I have suggested the
classification of such fungi should be based not only
on their morphological appearances, but also, and
principally, on (1) their action on litmus milk and
gelatine; (2) their action on carbohydrates; (3) on
agglutination and immunization phenomena, when-
ever possible.
Action of Monilias on Litmus Milk and Gelatine.—
Some monilias coagulate milk, others do not; some
monilias render it acid without coagulating it; some
strains decolorize the medium. The greatest number
of strains in my experience do not liquefy gelatine,
while a few, including the original M. albicans, sensu
stricto, do liquefy this medium.
Action of Monilias on Carbohydrates.—I have always
306
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1914.
used a very large number of sugars, but for practical
purposes the following are sufficient for the identifica-
tion of most species: glucose, saccharose, levulose,
galactose, maltose, mannite, lactose, provided the
results are considered together with the action of the
fungi on litmus milk and gelatine. I have observed
in analogy to what takes*place when dealing with
bacteria that certain well-defined species (for instance,
M. intestinalis, M. tropicalis) do not change to any
appreciable extent their fermentation properties in
the course of time; while with other species the
fermentation properties are not constant. I have
noted also that strains which do not ferment certain
sugars may be trained at times to do so, but this is
the case also with many bacteria. It is well known,
for instance, that Penfold has been able to change
the fermentative properties of germs of the typhoid
colon group to a remarkable degree; still no one
denies the validity of the usual fermentation tests in
differentiating between organisms of this group.
dust, &c. It is quite possible that future investigation
may show that some of the species created cannot
stand, but I venture to say that my main point, viz.,
that there is a plurality of species of the so-called
M. albicans, or thrush-fungus, will be confirmed.
I will limit myself to give here a description of
monilias found in stools, and only those species which
I consider to be good. Some of these species have
already been published, but I will repeat here their
description for the reader’s convenience.
For those who may be interested in the compara-
tive study of these fungi, I annex also a table con-
taining species derived from cases of bronchomycosis,
thrush, tea dust, &c.
Monilia intestinalis, Cast. 1911.—Mncroscopieally
has all the characters of the genus Wonilia ; grows
. abundantly on slightly acid sugar media, giving rise
to large white colonies which soon coalesce into a
cream-like abundant growth. The growth is com-
posed practically of only globular yeast-like cells,
TABLE I.—INwTESTINAL Moni ias.
ee 1 | | |
| 2 BE v 2 2^] x (4 2 2 5 5 | E: "
EA $ t $ > z 2 B5 2 $ 2 S| « alalz A
2|18$8|/3|8$ £2$là8i|/l8 $ €] 2] 2 lz] € |8 $ |23]85 E
a ME el aye le Sie is E1858] is) 3.3 & aalsa
B e 4$ |-2|43 $ S3|3 |a àá|g3 E z^ 3|^ |S|73|& =
| ü a [e E c 4 Š. c |
RE
- M. a8 Z = = - > | — I I E P VN Aen |
| Pl |
M. asteroides, | AC A “A A A A A A |0| A 0 jO] O JA! T /O}..}4]..
Cast. 1914 | |
M. fecalis, A AG | AG | AG | AGS | AGS| 0 0. 0| 0 0 O| O | C (6/0120
Cast. 1911 DPS | |
M. insolita, | AS | AG | AG | AG | AG | AG| O AS |O| 0 0 0 {0} O jO; C |C|O|+|0
Cast. 1911 "Alk |
M. intestinalis, | ADS | AG | AG | AS A 0 0 Oo! 0 0 o jo! o jo] C |C/|0l-|0O!
Cast. 1911 | |
M. rotundata, | AC A A A A 0O |0| 0 0 0 |0/ o l0! © |C\0)+/0
Cast. 1911 |
M. decolorans, 0|0 0| A 0 o jol o jo; € |cjoj+|0
Cast.and Low
1913
A = acid, G = gas, C = clot (milk), clear (broth and peptone water), D = decolorized, P = peptonized (milk), A/Alk = acid then
alkaline, S = slight, + = positive result, F = fine, 0 = negative result, viz., neither acid nor gas in sugar media, non-production 9:
indol, non-liquefaction of serum or gelatine, as the case may be.
As regards the use of immunization, agglutination
and complement fixation phenomena for the differentia-
tion of monilias, unfortunately these are experiments
which take a very great deal of time. I may say,
however, that rabbits inoculated subcutaneously with
repeated small doses of cultures of monilias often
develop agglutinins in their blood, and these are to
a certain extent specific, viz., the inoculated: rabbit
develops a distinct amount of agglutinins only for the
species with which it has been inoculated. It would
seem from the experiments made—which, however, I
consider far from being complete—that the classifica-
tion data obtained in this way correspond broadly
to those obtained by the action of the organisms on
milk, gelatine and sugar broths.
Description of Certain Species of Monilias found in
Cases of Sprue.—In previous papers I have given a
description of numerous species of the genus Monilia
as found in stools, sputum, &c., in tea dust, in copra
while in the water of condensation globular cells and
mycelium may be found together. A little mycelium
may be found, however, also in the growth on the
slope. Ascus formations are absent, gelatine and
serum are not liquefied, litmus milk is slowly
decolorized, the decolorization starting at the bottom
of the tube. No clotting. This monilia produces
acid and gas in glucose and levulose, acid in maltose.
galactose, saccharose, does not ferment lactose,
mannite, dulcite, dextrin, raffinose, arabinose, adonite.
inulin, sorbite.
Origin.—Isolated by me in three cases of sprue.
Monilia fæcalis, Cast. 1911.—Grows abundantly
on sugar media, giving rise to white colonies which
soon coalesce. Milk is rendered first slightly acil.
then alkaline, gelatine not liquefied. Serum is not
liquefied; a dark pigmentation often develops on the
surface of the medium round the growth; this
pigmentation may be lost in sub-cultures.
Oct. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
TABLE II.— TABLE SHOWING MONILIAS SO FAR FOUND, WITH NAMES IN ALPHABETICAL ORDER.
307
M. albicans,
Robin. 1853
M. asteroides,
Cast. 1914
M. blanchardi,
Cast. 1912
M. bronchialis,
Cast. 1910
M. burgessi,
Litmus milk
Cast. 1912 |
M. chalmersi, | AS
Cast. 1912 | Alk
M. decolorans, | DFC
Cast.aud Low
1913
M. enterica, 0
Cast. 19Ł1 | Alk
M. fæcalis,| A
Cast. 1911 DPS
M.guillermondi,, O
Cast. 1910 Alk
M. insolita,| AS
Cast. 1911 Aik
M. intestinalis, | ADS
Cast. 1911
M. krusei, Cast. 0
1909
M. lustigi,| AS
Cast. 1912 D
M. negrii, Cast. | AVS
1911 Alk
M. nivea, Cast. 0
1910 | Alk
M. nitida, Cast. A
1910 DC
M. paratropi- | AS
calis, Cast.) Alk
1909
M. perryi, Cast. AS
1912 | DAIK
M. pinoyi, Cast. | O
1910
M. pseudotropi- | ACS
calis, Cast.
1909
M. pulmonalis, 0
Cast. 1911 AIKD
M. rhoi, Cast.| AS
1909 | Alk
M. rotundata, , AC
Cast. 1911 |
M. rugosa, Cast.| A
1910 PSOS
M. tropicalis, | A or
Cast. 1909 0
M. zeylanica, | ACS
Cast. 1910
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siiisijiigpiiisimsineitinsiras
£ | i |
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| | | RE
AG |AGS|AGS| AG |AVS| o | o lo 0 | o |o| o |o|CTP|C/O|--4-| 8/0]. ..
| |
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|
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| Alk |
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AG | AG | AG |AGS|AGS| o | o 0 o | o | © |O| O jo] C |C/0}+/0)oB |O].: ois doa
| | |
AG |AG | AS | A | AG| O | o |o o |AOS| o |O| o |O|CTP|C|O|--|O| o jol.
AG AG |aG|aAG|aG|0|48]0 o | o | 0-|O0| o fo] © |CjO|2-|O|OB |o].
| |
AG) AG] as/ A | A | 0/0 0,0 0 | ojojo [O| O [COO o Jol. |
| |
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A |AGS|AVS| A |aGs| 0 | o |O| A lacs| olof ojo] C |C/O|4-|O| OB |O]..
AG | AG | AS |AGS| AG | O | o loj o |aGs| o Jo} o |o| C |c|0|-|0| o Jo}.
AG | AG | AG | AG laGS o | o joj 0 | aG| o |O| o |O| C 1CjO-JO| o jol..
AG | AG| A | A | A|A| A |ojavs|as]| o [0] o [|O|CTP|C|O |O| o lol.
or |
| | 0 | | | | | |
AG | AG | AG. AG | AG | O | O jO AVS| 0 0 |0| O |O|CTP|C/O|H|O | O |0Oj..! .. j..]..]..]--
| | |
| | | | | |
A |AGS| A | A |aas| o| o |O| o | AS | O jJOJ|AVS|O| C |cloj+joj o Jol. hee
| | | |
AG|AG|AG 0 |o;ojo |0 0 |o | O joj o joj CO jojoj+lo| o Jo. CEPR
| | |
AG |AG | 0 |AGS| AG |AG| o |0| o | O | o |O| o |O| C |CjO|-O| o jo}. chis
| | | | | | |
AG | AG | AG AGS) AG | o |AVS|O, O | A |AGS|O, o |o|cTe|c|o|+|0|oB |o]. ooz
| | | | |
AG | AG | AVS AGS| AG | 0| o |o; 0 |o | o joj o |O| C pejo +0 0 jol. | di
| | | | |
A|A|4/|4A4]|0/|4/|0]|o| Oo | 0 | oO Jo} 0 [0| C [O]O|--/.0| O Jol. os
| d | |
aS | as | AS | AS | AS | 0| 0 jojo | 0 | O fo!-o jol O | jo|0| o lol:
AG AG |AG AGS|AGS! o| o jo o | o | o Jo o |O| C |clol+jo oBjo..
A| AA |lA| A las| o [oj a |avs| o |ojavs|o| c [cjo|--|o| o |o...
| |GVS| |
Abbreviations used in the table: A = acid, G = gas, C
= clot (milk), clear (broth and peptone water), CTP = clear at first then
thin pellicle present, D = decolorized, P = peptonized (milk), pellicle (broth), Alk = alkaline, A/Alk — acid, then alkaline, S = slight,
VS = very slight, B = brown pigmentation of the medium, 0 = negative result, viz., neither acid nor clot in milk, neither acid nor
gas in sugar-media, non-production of indol, non-liquefaction of gelatine or serum, as the case may be, + = positive result, liquefac-
tion of medium; F = fine.
308 THE JOURNAI OF TROPICAL
— á E "
TRAC co»
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=
Monilia rotundata.
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(Glucose agar.)
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Monila asteroides. Fresh preparation from a
glucose agar culture.
MEDICINE AND HYGIENE. [Oct. 15, 1914.
Monilia asteroides. (Glucose agar.)
eo oO
o 00C 500
e 99,0
Monilia intestinalis. Fresh preparation from a
glucose agar culture.
Oct. 15, 1914.]
Monilia intestinalis. (Glucose agar.)
Origin.—Isolated from two cases of sprue, one of
enteric, one of ptomaine poisoning; also from a sputum
which had been collected in a dirty receptacle.
Monilia insolita, Cast. 1911.—Colonies on sugar
media white. Milk is first very slightly acid, then
Monilia rotundata.
Fresh preparation from a
glucose agar culture.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
309
alkaline, and becomes slowly decolorized. Gelatine
is not liquefied. The growth on serum dose not
become surrounded by a zone of dark pigmentation ;
the medium is not liquefied. The fungus produces
acid and gas in glucose, levulose, maltose, galactose,
saccharose, produces often slight acidity in mannite
and does not ferment lactose, dulcite, dextrin, raffinose,
arabinose, adonite, inulin, sorbite.
Origin.—This monilia was isolated from the stools,
saliva, and scrapings of tongue, from a case of sprue,
stools of two cases of enteric, and a normal individual ;
also from sputum.
Remarks.—It is probable that this monilia is in
reality merely a variety of M. fecalis.
Monilia tropicalis, Cast. 1900.—On glucose agar
large white colonies appear which later on coalesce.
Gelatine and serum not liquefied ; there is no brownish
or black decoloration of the serum. Litmus milk
is not changed, or is rendered slightly acid: it is
never clotted. This monilia produces acid and gas in
glucose, levulose, maltose, galactose and saccharose,
does not ferment lactose, mannite, dulcite, dextrin,
raffinose, arabinose, adonite, inulin, sorbite.
Origin and Remarks.—Found in the stools of a
case of sprue. This species is the most frequently
met with in Ceylon, in cases of bronchomycosis.
Monilia (?) rotundata, Cast. 1911.—Growth on
glucose agar has a somewhat crinkled appearance.
The colour is yellowish. Milk is rendered strongly
acid and clotted. Serum and gelatine are not liquefied.
This fungus does not produce gas in any sugar
(glucose, levulose, galactose, saccharose, lactose,
mannite, dulcite, dextrin, raffinose, arabinose, adonite,
inulin, sorbite); it produces acidity in glucose,
levulose, maltose, galactose, lactose.
Origin.—Isolated by me from stools of a case of
sprue, a case of enteric, and a case of simple enteritis.
Monilia asteroides, Cast. 1914.—The colonies on
glucose agar have a characteristic, radiating appear-
ance (see photo); hence its name. This fungus does
not clot milk, grows very badly or not at all on serum,
which is never liquefied. Does not produce gas in
any of the sugars used, but produces acidity in
levulose, saccharose, glucose, maltose, mannite,
galactose, lactose, raffinose, dextrin, sorbite.
Origin.—This fungus has been isolated from the
stools of a case of sprue, also from one of those
peculiar cases of pseudo-sprue I have described, which
seem to be in reality chronic infections due to a
Flexner-like bacillus.
Remarks.—It is doubtful whether it is botanically
correct to place this species and M. rotundata in the
genus Monilia. They possibly belong to different
genera, but further researches are necessary on this
point.
CONCLUSIONS.
(1) In practically every case of sprue it is possible
to put in evidence fungi, microscopically or culturally.
(2) These fungi do not all belong to the same species
—the so-called “thrush fungus" or M. albicans, as
stated by Kohlbrugge and all other observers who
have confirmed his findings.
310
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1914.
(3) As I have stated since several years, there is a
plurality of species of such fungi, and the term
M. albicans has been used in the past to cover a
large number of different species and possibly different
genera, in the same manner as in the past the term
Tricophyton tonsurans was used to cover a great
number of different fungi. As a matter of fact,
M. albicans, sensu stricto (M. albicans, Robin 1853,
em. Cast. 1909) has never been observed by me in
sprue cases, as none of the monilias isolated by me in
sprue liquefies gelatine.
(4) The following, probably good species, have been
isolated from the stools or serapings of tongue and
saliva of sprue patients: M. intestinalis, Cast. 1911,
M. fecalis, Cast. 1911, M. tropicalis, Cast. 1909,
M. decolorans, Cast. and Low 1913, M. rotundata,
Cast. 1911, M. asteroides, Cast. 1914. The last two
species of fungi may in reality belong to different
genera. The same case may occasionally harbour
two or more different species. M. intestinalis and
M. decolorans have been found in sprue cases: the
other species have been found in several other
conditions besides sprue.
BERIBERI IN PAPUA (BRITISH NEW
GUINEA).
By W. M. Srrone, M.D., B.C., D.T.M. H.Camb.
Late Acting Chief Medical Officer, Papua.
THE following aecount of beriberi in Papua has
been written at the invitation of Dr. Sandwith and
Mr. Cantlie, of the London School of Tropical
Medicine. I must thank them for the encouragement
they have given me by expressing an opinion that it
was my duty to make known my experience of beri-
beri during ten years' residence in Papua.
Papua is an extensive island lying just south of the
equator to the north of Australia. The British own
about a quarter of the island with an area of some
80,000 square miles, a native population estimated at
about a quarter of a million, and a European popula-
tion of about twelve hundred. Papua is perhaps the
wildest and least known part of the world.
With few exceptions, which will be mentioned
later, beriberi only oecurs in Papua among natives
who are fed on European articles of diet, and who are
not able to vary this on their own initiative. Such
cases of beriberi are found either among the prisoners
in Port Moresby gaol or among natives indentured to
Europeans as labourers. The native living in his
village and feeding on bananas, sweet potatoes, vams
or taro, with very little proteid food, does not get
beriberi.
'The ration seale which such prisoners and labourers
receive has varied slightly from time to time; but it
has never differed much from the following per week:
Rice, 104 lb.; biscuits, 4 Ib.; sugar, 3 lb.; tinned
meat, 1 lb.
An attempt is usually made to replace some of this
rice by fresh vegetables. In Port Moresby and else-
where, however, these are difficult to obtain for the
greater part of the year, and the medical officer has
to exert a good deal of pressure in the matter.
It may be mentioned that natives living on such
a diet are liable to attacks of “sore mouth” from
time to time. In the mildest cases there is only a
little ulceration around the teeth. In more severe
cases the teeth become loose and stomatitis develops,
perhaps with extensive slough formation extending on
to the cheeks. I have heard of even more severe
eases terminating fatally with sloughing of the face,
resembling " noma.”
The condition is readily cured by a simple mouth
wash, and fresh vegetable food or lime juice. I be-
lieve infeetion can be carried by means of eating
utensils, and the pipes the natives use for smoking
and which they readily pass from one to the other,
but there is probably an element of scurvy in the
condition. And scurvy like beriberi is due to the
deficiency of a special substance in the diet. This
condition is not found among village natives or other
natives living mainly on fresh vegetable food.
It is worth noting that the armed native constabu-
lary are not affected with beriberi. The ration scale
of the constabulary consists per week of: Rice, 7 lb.;
biscuits, 3 lb.; sugar, 1 lb.; meat, 2 to 3 lb.
They also get a small quantity of tea and are
always able to purchase small amounts of other food.
The indentured labourer gets all his pay in a lump
sum at the end of his time and has not got this facility.
At the end of 1912 I had occasion to inspect the
native population from Kerema in the Papuan Gulf
as far as the western side of the Purari delta. It
struck me as very remarkable that while cases of
paralysis are extremely rare in the native villages, yet
several cases of atrophic non-spastic paralysis were
seen in the Purari delta. The disease affected the
legs and obviously suggested old cases of beriberi.
Assuming that these were cases of beriberi, the ques-
tion arises as to why this particular group of natives
should be affected. I entirely accept the modem
view that beriberi is due to a deficiency of a special
substance (vitamine) in the diet. The Purari natives
live in a swampy delta where there is practically no
dry land, they hardly make any gardens for the culti-
vation of vegetables and live almost entirely on sago.
May it not therefore be that sago is also deficient in
this anti-beriberi vitamine, and that the cases I saw
were actually old beriberi cases. I am familiar with
the greater part of the country and know that paralysis
is rare elsewhere.*
Two eases which occurred in the Port Moresby
native village early in 1913, while I was acting chief
medical officer there, are worth noting. I have known
the Port Moresby natives on and off since 1903;
* I am aware that several cases of paralysis have been re-
ported by laymen from the Western Division where sago is also
largely eaten, but am not myself familar with this part of the
country. Perhaps beriberi appears also in the Western Division ;
it undoubtedly occurs among the pearling fleet in Jones Straits.
Natives from the Western Division of Papua have for many
years been employed in the pearl fishing. So these cases of
paralysis may only be old beriberi from the pearl fishery. On
the other hand, the western division is swampy and much sago
is eaten there.
Oct. 15, 1914.]
but until 1913 had never seen a suspicious case of
beriberi. In 1903, these natives lived partly on vege-
table food they grew themselves and partly on sago
obtained by trading with Gulf natives. Now the
European settlement has so much increased that
native gardens are almost given up and the natives
live largely on sago and rice, with such other extras
as they can procure. Early in 1913, at a time when
native vegetable food was most scarce and sago
common, two cases of beriberi came to me from the
Port Moresby village. Again it appears that beriberi
can occur on a diet consisting largely of sago.
Having considered the etiology of beriberi in Papua,
I now propose to discuss its clinical aspect.
From 1903 to 1905 a series of cases occurred in
the Port Moresby gaol of a very uniform and severe
character. A prisoner would not seem quite well one
evening and not eat his evening meal of rice. Next
morning he. would be reported to me as seriously
ill. I would find him prostrated and unable to rise.
His pulse would be either absent or barely perceptible.
The heart-beat would be nearly normal in rate, but
very feeble with the two sounds similar in charaeter
and with an equal interval between the two sounds.
Death usually took place within twenty-four hours
and was never delayed seventy-two hours. @Œdema
did not occur. At that time I regarded beriberi as
essentially a chronie disease, and was very doubtful
if the above were really beriberi. Now Irather regard
the cases of beriberi usually seen, not as true beriberi,
but as rather the residual permanent paralyses caused
by past beriberi damaging more or less unimportant
nerves (unimportant as far as life is concerned) beyond
recovery. I remember one typical series of nine cases
of the above-mentioned acute type all occurring within
a few months of each other.
At this time there was no attempt made to supply
the prisoners with either fresh vegetables or lime
juice. The general line of treatment was the giving
of cardiac stimulants, strychnine, alcohol and digitalis.
About 1905 or 1906 attempts to supply native food
were made, and since then such acute cases have
been very rare. In 1911 a native, working on a
recruiting vessel, was brought to me with acute
symptoms much as described above. The food
defieieney (vitamine) theory had just come out, and
I at once fed him on unsweetened tinned milk, bread,
and minced tinned meat (the only available). Alcohol
was also given. I hardly expected him to live through
the first night; but he did, and left me a few days
after with nothing wrong with him beyond some
paralysis of the legs. A few days after a medical
man reported him to me as being apparently quite
well. I cannot help thinking that here was a case in
which the cardiae nerves were seriously involved,
but not permanently injured, and that recovery took
place as soon as the requisite vitamine was supplied
in the milk, &e.
From 1903 to 1906 other cases in the Port Moresby
gaol of not quite such an acute character also appeared,
In these cases pains in the lower limbs and abdomen.
paralysis of the legs, and abdominal symptoms, such
as dilated stomach, hiecough, and vomiting occurred.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
311
The abdominal cases tended to die in a few days,
while those mainly with leg symptoms generally
recovered eventually, sometimes with permanent
partial paralysis. A post-mortem examination on one
case showed nothing abnormal except a little excess
of pericardial fluid.
I have laid stress on these acute cases, not because
the bulk of those seen have been of this character,
but because of the clinical importance of this severe
type. Ordinary cases with some increase in heart-
rate, some paralysis of legs, and loss of knee-jerks
were not uncommon. I remember a batch of nine
natives coming into Port Moresby, and eight of them
going down with this mild type of beriberi.
Since 1906 attention has been paid to native diets,
and now everyone makes some effort to secure native
food for labourers and prisoners. These acute cases
have become very rare, and nothing of the nature of
an epidemic has been reported.
But cases of moderate severity occur from time to
time. I have noticed in sporadic cases, among a
group of natives, that other members of the group
will be found with a pulse-rate of about 100, but
with no other sign or any complaint of ill-health.”
Other cases occur from time to time with a rapid
pulse combined with some vague complaint of ill-
health, or perhaps with a complaint from the
employer that the native will not work. I remember
one case especially. I was visiting a plantation when
the manager complained that two of his labourers
persistently refused to work properly. They both
appeared quite well, except that one had a pulse-
rate just over 100 and the other 96. I diagnosed
beriberi and advised appropriate treatment with
native food, &c., but doubt if the manager was
convinced. I learnt afterwards that one native died
suddenly about a fortnight after, with no other sign
of ill-health. This must have been an instance of
chronic involvement of the cardiac nerves with some
more acute involvement later.
If one reads the text-books on beriberi the im-
pression is acquired that the number of so-called
" wet" cases which occur are at least comparable in
number with the atrophic " dry" form. Such has
not been my experience in New Guinea. Any sign of
cedema is very rare, while I can only remember one
typical ease of the “ wet” form with marked cedema.
In New Guinea multiple peripheral neuritis follow-
ing an attack of bacilary dysentery has not been
very uncommon. The vitamine theory readily
explains this. If an individual is just on the border-
line of vitamine equilibrium, is it not likely that a
disease like bacillary dysentery, where absorption of
all nutriment is almost suspended for a while, may
cause this vitamine equilibrium to be upset with
symptoms of beriberi. If the individual is only
absorbing just the requisite amount of vitamine, when
digestion and absorption are going on normally, is it
not likely that any serious disturbance of digestion
may precipitate an attack ?
* I mean, of course, a permanent pulse-rate of 100 not
caused by recent work or running.
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THE Xon OF ! u
Tropical gpeptctne and Hygiene
OCTOBER 15, 1914.
SCARCITY OF FOOD IN WAR.
THAT a scarcity of food in Europe is probable at no
distant date in some of those countries now at war,
in which importation of supplies must become a
necessity, is evident to everyone. The harvest in
France and Germany has been partly lost from want
of the necessary complement of labourers, and as
both countries have previously to 1914 been import-
ing grain, that is, in times of peace, there would seem
to be, in Germany and Austria at any rate, a certainty
that food must become scarce as the quantity of
home-produced wheat, barley, oats and rye gives out.
In France and Britain, with a sea-board kept open
by the British fleets, there is less danger of shortage ;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1914.
and in that great granary of cereals, Russia, there is
no possibility of famine for the time being. There is
not, and cannot be, any substitute for the ingredients
of cereals ; many things have been tried, but they are
mere adulterations, and therefore, if not actually dan-
gerous to life, valueless as a food. Sawdust has been
foolishly upheld as of nutrient value and introduced
into bread; beans, peas and lentils have been added
with more justification, although they are better used
separately, and not intermixed with flour, as yeast
has little or no-effect upon starch in a form such
as it is met with in such cereals. Potatoes are
frequently mixed with flour in bread-making, but in
times of scarcity an excess is apt to be added, to the
detriment of the digestive qualities of the loaf.
Meat is the staple form of food for the European
soldier, and beef engenders the highest quality of
sustenance. In Britain the beef of the fully matured
animal is used as a rule; on the Continent of Europe,
however, immature meat in the form of veal is more
commonly eaten. If in times of peace slaughtering
calves is the rule, so much more in war will this
prevail, for it takes two years at least for the calf to
reach maturity, and when the land is desolated or
the crops ungathered food for cattle is scarce and the
calf is killed after a few months of life. The economic
fallacy of this is patent at all times, but necessity
drives in war, and at the present moment in Central
and Western Europe there is a possibility of beef and
veal becoming more and more difficult to obtain, for
both old and young cattle are sacrificed to fill the
necessity of feeding the millions of men engaged in
war. The Germans, following their custom in time of
peace of eating horse-flesh, will find plenty of meat of
a kind on their battlefields to satisfy their appetites,
but the nutrient value of horse-flesh is not of the
high quality of well-fed oxen, and whilst the stomach
may be filled the sustenance is inferior. This is due
largely to the difficulty of the human stomach digest-
ing the tough rump steaks cut from the war horse,
and partly to the "unhung" state of the flesh
obtained, for the horse will be eaten immediately
after it is killed. The effect of any tough meat in
producing indigestion, cramps, diarrhosa and colitis
soon becomes apparent, and an army’s strength
and powers of endurance are thereby lessened.
Some one has suggested that the consumption of
horse-flesh accounts for the barbarity of the German
soldier, but whilst this advanced physiological reason-
ing is interesting the idea is calculated to provoke
derision. Yet the cannibal says he finds vigour and
ferocity from eating the heart of his enemy, a theory
which is supported by modern organo-therapy, inas-
much as for a diseased organ the healthy organ of
another animal is prescribed, a form of treatment
stamped with, high scientific authority.
Alcohol is condemned by all military authorities as
being deleterious to the soldier, and with good reason.
Spirits on an empty stomach and in the semi-
starving state soldiers often are in is fatal to a degree
to good work. It is interesting to note that the
Germans search the cellars of all captured towns for
champagne, and consume it freely when it is found.
Oct. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
313
The instinctive selection of this beverage above all
others is due to the saccharine properties of cham- `
pagne and to the instantaneous vigour it imparts.
Sugar is the best and most speedily acting restorative
known, and in champagne we have it in a pleasant
form ; moreover, the German wisely prefers the sweet
champagnes to the “dry” doctored and poisonous
variety preferred in England.
Cheese is the form of food, both theoretically and
practically, best adapted for war rations, and a
relieving force which can throw cheeses over the
heads of the containing force to their friends inside
the beleaguered city will convey a benefit impossible to
be surpassed short of raising the siege. It sounds
fantastic to suggest that Dutch cheeses might be
dropped from aeroplanes or dirigibles into a besieged
city, but than cheese no other form of food is so well
suited to the idea. Other forms of food, however,
could be so conveyed, such as tins of meat, &c., for
if bombs can be thus distributed so can foods.
The scarcity of food in an army is answerable for
illnesses of many kinds. The ill-nourished body,
fatigued with long fighting, lying out on damp ground,
occupation of trenches, and all the trying condi-
tions of warfare, with mud in plenty, lowers the
resisting powers and paves the way for infectious
ailments of allkinds. Cholerain an army, in addition
to the insanitary conditions which obtain, attacks
the ill fed and fatigued to a degree in excess of any-
thing met with in ordinary outbreaks of this disease.
Dysentery, or, rather, acute colitis, which is often
the dysentery of camps and armies, is due to the
damp, chills, and fatigue acting upon insufficiently
fed soldiers. The evils of impure water it is needless
to dilate upon, and the supply to armies, especially
when advancing over the ground evacuated by the
enemy, is invariably in danger of pollution.
The training in times of peace of the Royal Army
Medical Corps is apt to be rendered futile in war, yet
is that training necessary so that the ideal may be
kept in view although it be impossible of attainment.
It is the same in all training in peace for war for
every branch of the service. The Chamberland or
Berkefeld filters, the water-carts, the apparatus for
boiling and cooling water, &c., are apt to appear as
toys of sanitation when the stress of war brings
millions of men into the field. Yet is it well that
these should be practised and explained to the soldier,
for he thereby has an ideal set before him, which
according to his environment will no doubt have to
be modified or set aside, but yet is he imbued with the
idea of the dangers of impure water and does his best
to avoid them under the most adverse circumstances.
The bulk occupied by food is a great consideration
in war; the cereals being more bulky than meat
accounts for the preference for the latter on the part
of the commissariat corps of an army. It is more
diffieult to feed an army with oatmeal, flour or rice,
owing to the bulk these cereals occupy, than when
meat is supplied, owing to the concentrated nature
of the nourishment it presents.
A British regiment can do with fewer wagons to
carry its food than an Indian regiment, with whom
rice is the staple diet. This is a consideration of
prime importance; but the European regiment re-
quires many other accessories that the Indian soldier
does without, and if the latter’s actual food occupies
more bulk the absence of other impedimenta renders
his train of supplies always smaller in consequence.
Biscuits seem to be the ultimate resort of most
soldiers short of food, but whilst they are useful to
maintain life they are not calculated to give the verve
and élan which is the prerogative of an army with
whom meat enters largely into the diet.
——9——————
Annotations,
The Supply of Milk to Indian Cities—H. H.
Mann (The Agricultural Journal of India, Calcutta,
ix, pt. 2, pp. 160-177,), gives an account of the milk
supply of Poona. Milk is produced in 47 villages
which send in about 550 gallons per day: 21 per cent.
comes from villages within a radius of less than
3 miles; 48 per cent. comes from villages within a
radius of 3 to 6 miles; 28°5 per cent. comes from
villages within a radius of 6 to 9 miles; 2°5 per
cent. comes from villages within a radius of over
9 miles.
The supply is brought in by hand in brass pots
slung over the shoulders or carried on the heads of
the milkmen, bullock carts or the train being only
used in a few cases. Nine-tenths of the total con-
sists of buffaloes’ milk, whose content of fat and
solids-non-fat amounts to 5 and 9 per cent. re-
spectively, as against 34 to 85 per cent. in cows’
milk.
Of 51 samples only 10 were pure, even when judged
on a very conservative basis, the remainder being
adulterated with more than 10 per cent. of water.
The price varies with the quality, there being a close
connection between the price and the amount of
water added; for instance, all milk sold at less than
six seers for one rupee (1s. 1d. per gallon) is almost
certain to be adulterated. With regard to the amount
of dirt it contains, this is not nearly so great as would
be expected ; of the 51 above samples —
56°7 per cent. were clean or nearly clean.
33°3 5 » fairly clean.
78 i „» distinctly dirty.
19 a » very dirty.
The milk produced in the city itself is a far more
important contribution to the total supplies than that
brought in from the surrounding country. The milk-
ing cattle of the city consist of 2,688 head, of which
1,532, or 57 per cent., are kept for private use only, and
1,156, or 43 per cent., for sale of the milk. Among
the former class about three-quarters consist of cows
and the remainder of buffaloes, while in the latter
class the proportions are reversed. The cattle kept for
the sale of their milk are housed in small sheds
distributed all over the city; 80 per cent. of these
sheds contain less than ten animals, and their general
conditions of hygiene are very bad. It is estimated
that about 2,000 gallons are produced daily, of which
314
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1914.
about 1,400 gallons are buffaloes’ milk and the rest
cows’ milk; the total daily consumption in the city,
therefore, amounts to 2,550 gallons per day.
Ascaris in Pyopneumothorax. — R. Blanchard
(Bulletin de l'Académie de Médicine, Nos. 26 to 98)
describes the case of a robust countrywoman sud-
denly attacked with pleuritic pain; on puncture foetid
pus was obtained. A purge caused the evacuation of
two worms. As pus continued to be discharged the
pleura was opened, and a macerated ascaris found.
Perfect recovery indicates that there was no opening
from the lung. This is the eighth case recorded.
Thread-worms and Appendicitis.—Aschoff (Berliner
klin. Woch., August 10, 1914) considers it unproven
that oxyuris cause appendicitis. The part they play
in causing pseudo-appendicitis showed the necessity
of attention being paid to them when children have
attacks resembling appendicitis; unless they are
removed symptoms may recur even after the removal
of the appendix.
i —
Abstracts.
SEGREGATION AND KALA-AZAR.
By W. McCounBriE Youna.
DURING the years when kala-azar was epidemic
in the adjoining district of Nowgong, the Golaghat
sub-division escaped invasion, presumably owing to
its separation from the adjoining infected district by
the barrier to free communieation which the inter-
position between these two distriets of the Mikir Hills
presents and possibly also by the action of the district
offieials in refusing admission to infected families
migrating from Nowgong during the epidemic there.
Six years afterwards, in 1909, attention was directed
to the occurrence of the disease in active form in
certain villages of the subdivision.
The outbreak was, in the first place, investigated
and verified by the provincial sanitary department.
The disease was probably imported from Nowgong,
and round these original foci of imported disease other
cases had appeared. The history of the disease
showed extraordinary infectivity, and member after
member of an infected family became infected and
died. The disease had a well-defined tendency to
cling to certain groups of houses and to spread from
them into surrounding areas. It was not showing
any decided tendency to advance, but so long as
these foci exist it would be impossible to say when
the disease might not assume epidemic form, and it
would be unwise to rely, in our ignorance as to the
transmission of the disease, upon conditions possibly
not being so favourable to the spread of kala-azar as
in Nowgong. In view of the caution originally en-
joined upon the publie health administration of Assam,
lest the disease should gain an active footing in the
economically important districts of the Upper Assam
Valley, it was decided to put measures of control in
force. As a preliminary to these a house-to-house
survey of the whole subdivision was carried out in
detail.
. When the number of infected villages, houses, and
persons had been ascertained in this manner, segre-
gation measures were put in force:
These consisted in supplying the infected family
with a new house, at Government expense, upon a
new site at a minimum distance of 50 yards from the
old site, and in most cases at a greater distance.
As no separate isolation hospital for the reception
of sick persons was in existence, nor indeed would
popular opinion have consented to its utilization had
it been available, in many cases it was found necessary
to remove the infected member of the family along
with the uninfected persons to the new site. In such
cases a separate sleeping apartment outside the house
enclosure was provided and the adults of the family
were cautioned to prevent the infected persons from
sleeping or eating with others.
On evacuation of the house in which infection had
occurred it was burnt down, and with it all bedding,
clothing, and other belongings which could presumably
harbour insect parasites were destroyed under the
supervision of an assistant surgeon on special duty for
the purpose. Liberal compensation was paid by
Government for property so destroyed.
Since the commencement of these operations the
work has been continuously supervised by the sani-
tary department and notes as to the condition and
health of all infected or suspected families have been
recorded monthly.
Out of forty infected families removed to new sites
three years ago a recurrence of the disease in a person
not obviously infected upon the old site has occurred
in only one case.
The people appear to recognize the value of the
measures, and are grateful to Government for carrying
them out.
Provided that no new and separate foci of the
disease appear, it is possible that the disease may be
extinct in this subdivision in a few years’ time if these
measures of control are continued.
These results are perhaps worth recording for the
following reasons :—
(1) They appear to show the possibility of applying
with success the same measures of segregation to the
indigenous population as have proved of value in com-
bating the disease among the labour force of a tea
garden.
(2) They show that measures of removal and segre-
gation which, on primá facie evidence, seemed to be
most incomplete, in that they involved the removal
of an infected person to the new site, have been
attended with an unexpected degree of success.
It appears that whatever complicated processes of
disease transmission are covered by the convenient
phrase “ site infection," nevertheless it appears to play
an important part in the propagation of the disease.
Whether the diminution of the disease is due to
our operations, or is in reality due to a natural
decrease in the course of the waxing and waning of
the activities of an endemic disease, it is difficult
to decide, but the fact that the disease is tending
to increase rather than to diminish in the adjoin-
ing district of Nowgong, as will be seen from the
Oct. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
315
subjoined figures, to some extent confirms our belief
in the usefulness of these measures.
19000 1910 1911 1912 1913
140 221 286 308 417
In conclusion, it is not suggested that these opera-
tions have been wide enough in scope or long enough
in duration to afford much evidence as to the vexed
question of the transmission of the disease. The
object of this note is to draw further attention to the
apparent usefulness as a public health measure of
the removal of kala-azar infected families to new
houses on uninfected sites.—Indian Medical Gazette,
August, 1914.
Kala-azar mortality in Nowgong
TSETSE-FLY AND BIG GAME IN SOUTHERN
RHODESIA.*
By Rupert W. Jack.
IN Southern Rhodesia conditions are better than
in most other parts of Africa for gathering informa-
tion eoncerning the distribution of tsetse in the past,
and perhaps even in the present. This is due to a
combination of two factors, namely, that only one
species of tsetse, Glossina morsitans, is found within
our borders, and that the territory, in comparison
with.the Central African States, contains and has
contained a relatively large European population.
The case built up is considered strongly in favour
of a vital association between the prevalence of big
game and the continuance and increase of the fly.
In most cases game is more or less abundant all
the year round in fly-infested country, and that in no
instance is the larger animal life altogether absent,
even during a portion of the year. The point where
the writer carried out certain investigations on the
Gorai River is fifteen miles away from the Hanyani,the
nearest water at the end of the dry season. The grass
is burnt off annually by the natives, and the game
naturally forsakes country which contains neither
grass nor water. Along the banks of the Gorai,
nevertheless, fly is abundant in October and Novem-
ber, whilst on the west bank of the Hanyani, where
the game is normally abundant at this time of year,
fly is scarce. This appears at first sight a strong
argument for the dissociation of tsetse and big game,
but closer investigation of the situation reveals the
presence of other factors.
In the first place, the situation as seen in October
and November is only temporary, being due to the
drying up of the rivers and the burning of the grass.
In the second place, although at the time of the visit
the larger antelopes had all deserted this part of the
country, there were left behind warthog, undoubtedly
capable of yielding sustenance to tsetse. Shot speci-
mens are frequently found abundantly attended by
the fly, and trypanosomes have been found in warthog
blood. These animals either have the power of
burrowing down to water where other animals would
have to thirst, or are constitutionally to a large extent
* Reprinted from the Bulletin of Entomological Research,
September, 1914,
independent of drinking, because they are, like the
duiker, met with in very dry tracts of country where
none of the larger antelopes are to be found. Along
the Gorai River, in November, 1911, the writer saw
several herds of warthog, and one herd was lying on
the very river bank in the shade where the tsetse
congregate, and was probably affording a meal to
numerous tsetse at the time. There was also evidence
of much rooting in the vicinity of the river where the
ground is soft and succulent roots are more abundant
than in the neighbouring bush. In the third place,
the fact of the tsetse not being found associated with
the game at the Hanyani River is probably accounted
for by the nature of the country. Along the Hanyani
where the game was congregated the banks of the
river are very thickly wooded and there is very much
dense undergrowth, whilst this condition gives way
to country in which shade is very deficient. Now
shade is essential to tsetse, but G. morsitans is not, in
the writer’s experience, found in abundance in this
territory in any bush so tangled as to be difficult of
penetration. In addition to this, the neighbouring
forest is unusually open, not affording much shade
even in the wet season when tsetse spreads through
the bush instead of remaining confined to the shady
banks of watercourses and edges of vleis. The Gorai
River affords excellent winter shade, and the sur-
rounding bush is sufficiently shaded during the rains,
so that it is in all respects suitable for tsetse, and it is
not a matter for wonder that the fly has increased
and made its home in this part, whilst it has failed to
do so to the same extent on that part of the Hanyani
River to which reference has been made. In April,
1911, the writer again visited the neighbourhood of
the Gorai River and found that game, including rhino-
ceros, zebra, sable, kudu, eland, impala, &c., was
moderately abundant in the haunts of the tsetse,
which was at that time to be met with throughout
the bush.
The evidence in favour of the necessity of big game
to the tsetse in Southern Rhodesia and adjacent
territory may be summed up under four heads :—
(1) Tsetse retired before the advance of civilization
in the Transvaal, the only known modification of con-
ditions being the destruction of the game.
(2) Tsetse disappeared from large tracts of country
immediately after the rinderpest in 1896.
(3) Tsetse has increased and spread since the
rinderpest only in those parts of Southern Rhodesia
where big game has increased.
(4) Tsetse has greatly decreased of late years in the
Hartley district in those parts where the big game has
been most effectively destroyed or driven away.
(1) Sufficient weight has hardly been attached to
the phenomenon of the retirement of the tsetse before
the advance of the white man, for in conjunction with
subsequent events in this territory and elsewhere,
this is one of the most weighty arguments for the
vital association of the fly with big game. The
advance of settlement was preceded by the wholesale
destruction and driving away of the larger fauna of
the forest, and for many years this was the sole modi-
fication of natural conditions due to the advent of the
316
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct, 15, 1914.
cz m ~—
European. The only attempt at a suggestion of other
changes that might conceivably have had an adverse
effect on the tsetse appears to be that settlement
implies a certain amount of clearing of the forest ;
but it is quite obvious that settlement did not pene-
trate into fly-infested country, but pushed the pest
back before it: that is to say, that farms were not
worked “in the fly," for very natural reasons, and
that therefore, as a general rule, no clearing of any
extent occurred in the forest until the fly had prac-
tically disappeared from it. Asa matter of fact, but
little clearing usually occurs on pioneer farms in
South Africa for many years after occupation, unless
the farmer happens to be a man of considerable sub-
stance and enterprise, bent on developing his farm
agriculturally, attributes hardly characteristic of the
voor-trekkers in the Transvaal, who were primarily
stock-owners.
(2) The total disappearance of the fly from some
parts of Africa and its great reduction in others after
destruetion of the bulk of the game by rinderpest is,
of course, à very strong argument for the dependence
of the fly on game. There is no tsetse now in dis-
tricts in which it used to occur in varying abundance,
according to the reports of early hunters and traders.
In other areas & nucleus of the pest was left, but
large tracts of country were free which are infested at
the present time. The path by which the cattle are
brought down crosses the Zambesi at Feira and the
Hanyani River about six miles below the escarpment.
It was between that river and the escarpment that
the fly appeared. According to native testimony,
however, tsetse existed earlier than this to the east,
about the Gorai River already mentioned, but very
definite information is lacking. After 1902 the spread
of the pest was rapid, and by 1905 at least it extended
as far north as the junction of the Ambi River with
the Hanyani.
The Lomagundi distriet has some special features
of its own. The available information concerning this
district before 1900 is more meagre than in regard to
any other. There appears to be no record of tsetse
at that time, but it was fairly numerous there in 1903.
It is probable, therefore, that a nucleus of fly remained
in this part after the rinderpest. The writer has
received indirect native testimony to the effect that
tsetse never died out altogether. Whether fly was
present below the escarpment to the north-west of
the district at that time can only be conjectured.
There is no doubt, however, that that belt has ex-
tended very greatly of recent years. Between 1905
and 1910 odd specimens of fly were encountered at
a number of isolated spots in this area. Subsequent
visitors have almost always failed to find fly at any
of these spots.
This part of the country has been shot over to a
considerable extent by hunters and prospectors, but
the game has certainly not been reduced to anything
like the same extent as it has in the Suri-suri belt in
the Hartley district. It would seem that the fly in
this part survived the rinderpest in very small
numbers in scattered localities, failed to increase to
any extent, but persisted until recent years, although
on the verge of extermination. Concerning the factors
controlling the situation we are altogether ignorant.
In the Sebungwe district a belt always existed
along the Umniati River, which has, however, only
extended to its present limits within recent years.
The writer has personally noted a south ward extension
of about seven miles since November, 1910, and
according to the testimony of white hunters and
natives there has been a considerable progression to
the north and west.
Owing to the native disturbances and other troubles
which affected Southern Rhodesia in 1896-7 and the
undeveloped state of the country, exact information
concerning the distribution of tsetse between that
time and the year 1900 cannot be expected.
Our information concerning the spread of tsetse in
the Sebungwe district is more detailed tban it is in
regard to other parts. Tsetse was first taken on the
Sengwa in that year, at the junction with the above-
mentioned river, and the writer fixed the southern
boundary in May. The southward movement of the
fly had been very rapid, and had driven away the
only native chief possessing cattle in the district.
This native subsequently moved his cattle back to his
old kraal and lost very heavily from trypanosomiasis,
whilst some Government mules stationed at a kraal
within three miles of the same spot also died about
the same time. The fly is very thick at one spot
close to the Sengwa in this belt.
The Sebungwe area is of special interest because
there have been no white men living in the district
to the west of the Sengwa River, the natives are
practically unarmed, and the processes of nature have
not been interfered with by human agency. Big
game has increased greatly and is now very abundant
in certain parts.
Turning now to the Hartley district we are
confronted with an exactly opposite situation. Here
human agency has been at work for years and natural
conditions have been modified. The heart of the fly-
belt on the railway line, which is the one to which
it is desired to call particular attention, is about the
head-waters of the tributaries of the Suri-suri River.
There is, unfortunately, but little to be learnt from a
comparison between the extent of the belt after 1896
and its extent to-day, because it is nearly surrounded
by mines, and although the heart of the belt was, up
to 1912, stil virgin forest, the bush had been cut
down to supply fuel and timber to a considerable
extent around it, and conclusions, therefore, cannot
be drawn from the fact that the fly has not spread
widely in the district. It may, perhaps, be worth
noting that, in spite of the facts mentioned above,
there have always been channels some miles in
breadth along which the pest might have spread with-
out encountering any modification of its native habitat
beyond the scarcity of game. On the whole, however,
it seems best to leave this side of the matter out
of the question. It should, moreover, be noted that
owing to the large number of cattle used for transport
on the mines and farms, our information concerning
the range of the pest in these parts is exceedingly
good. In spite of farming and mining operations,
Oct. 15, 1914.]
however, there was, until early last year (1913), an
area about 150 square miles in extent in which the
only change: from natural conditions due to human
agency had been the destruction and driving away of
the game. During the past few months a light
railway has been run down to the heart of the belt
to supply timber for certain mines, and, according to
information received, the destruction of the forest has
been very considerable. Events subsequent to 1913,
therefore, have no bearing on the question of fly and
game.
An area embracing the fly-belts in the Hartley
district was first thrown open to free shooting for
three months in the year 1901, but this period was
not extended. Later, in 1905, the Game Laws were
again suspended in respect to this part of the
country, zebra, elephant, rhinoceros, hippopotamus
and ostrich being excluded, however, from the scope
of the notice. The open area was maintained until
1908, but in that year was closed again, only to be
reopened in 1909 on account of heavy losses amongst
cattle. Since that time the Game Laws have
remained suspended with respect to the fly-infested
portion of the district.
The basin of the Suri-suri River, being easy of
access, was shot over to a great extent by residents
in the district, as well as by professional hunters,
and between 1905 and 1908 a considerable reduction
of the game took place. But even in 1909 there
were still small herds of eland, sable, zebra and other
buck to be met with. The destruction has continued
since then, and at the present time the basin of the
river, once one of the more prolific hunting grounds
in the territory, is almost destitute of the larger
fauna, although until last year a few still lingered,
and small herds were liable to pass through at
certain seasons. A few warthog and small buck
were usually to be found. The writer visited this
part first in August, 1909, and there was considerably
more evidence of big game at that time than in the
years following.
The last instance of tsetse having been met with
in considerable numbers in the Suri-suri belt occurred
in 1908, when they were sufficiently thick to con-
stitute a serious personal nuisance: the fly was more
numerous previous to 1909 than afterwards. In
1910, a Cape boy who drove the writer across the
Suri-suri River near its head-waters volunteered the
statement that a few years previously the mules
would have been attacked by a swarm of tsetse.
The very considerable losses of cattle from trypano-
somiasis at the end of 1908 and the beginning of
1909 were largely the cause of the area being again
thrown open to free shooting in March of the latter
year.
The writer paid almost monthly visits to the
Suri-suri belt after August, 1909, and throughout
1910, and never on any occasion met with the pest
in numbers. The greatest number seen in one day
was in October, 1909, when the total was nine.
Usually two or three were encountered, and
occasionally none at all. The belt has been kept
under observation since, and there has been no sign
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
317
of increase. Losses from trypanosomiasis in cattle
have decreased in this part of the district; in fact,
‘until a contractor, persumably emboldened by the
general immunity, actually kept and worked his
spans in the very heart of the fly-belt, they had
nearly ceased, and cattle are now kept and worked
where it would have been fatal to have done so
formerly. Tsetse has not, however, altogether
disappeared. The cases of trypanosomiasis amongst
the cattle working in the heart of the old fly-belt
indicate that a few tsetse are still to be met with.
The presence of cattle in the former haunts of the
game, where fly still persists in very small numbers,
might conceivably have even caused a small increase
of the pest since last year, though the clearing of the
bush would eventually counteract any tendency of
this nature.
The lingering of the fly does not, of course, affect
the broad facts of the situation, seeing that the game
had not been altogether destroyed. The important
fact isthat in this district alone in Southern Rhodesia
has tsetse decidedly decreased of late years, and
here the game has been greatly reduced by artificial
means. In other districts where permanent fly-belts
occur the game has become more abundant and
the fly has increased and extended its range greatly
since 1896. It is interesting also to note that the
greatest and most rapid extension has occurred in
those parts of the territory where game is most
abundant, as in the Sebungwe district and certain
parts of the Zambesi Valley.
We have, therefore, south of the Zambesi River
a very logical chain of evidence, so far as it goes,
suggesting the necessity of big game to the tsetse-fly,
namely, the retirement of the fly before civilization
under circumstances difficult to dissociate from the
effect of game destruction; the general disappearance
or great reduction of the fly coincident with the
general reduction- of the game by rinderpest; the
increase and spread of the fly again corresponding
with the increase of the game; and, finally, the
reduction again of the fly locally coincident with
the removal of the game by human agency in that
particular spot.
The writer is well aware that something more than
these facts will be required before the theory of the
vital connection of the two forms of life is accepted,
especially as some contradictory evidence has been
brought forward elsewhere. On account of the nature
of the problem, however, final proof could only be
constituted of an accumulation of circumstantial
evidence pointing in the same direction, and the
Hartley experiment in this territory appears to be
the first definite effort to obtain direct evidence on
the point. The experiment was not carried out with
the scientific detail that would undoubtedly have
rendered it more valuable, but nevertheless the
result is very significant in conjunction with events
elsewhere. At the present time it may be said that
nearly all the known facts in South Africa either
strongly support the positive theory or are, at any
rate, not inconsistent with it. Years before the
rinderpest it was the general opinion amongst
318
hunters that "the fly would disappear with the
game.” The apparent effect of the rinderpest was
confirmatory to an amazing degree, and subsequent
events have now lent their support. Even to suggest
any other possible explanation of the various pheno-
mena is a matter of difficulty and necessitates an
appeal to the possibilities of coincidence that few
would care to place upon paper.
Apart from the contradictory reports of different
observers, the great obstacle to the acceptance of the
theory of the necessity of big game to the tsetse-fly
is the fact that many other possible sources of blood
than the ungulate mammals exist in the African
forests. By a closer examination of the matter,
however, it seems probable that the vast bulk of these
are not fitted to be relied upon in this respect. Few
will contend that there is any possibility of inverte-
brate animals, such as caterpillars, being a permanent
source of nourishment to the tsetse. Amongst the
vertebrata it also appears that an exclusive diet of
reptilian or amphibian blood, or even a mixed diet of
such blood and that of mammals, is deleterious to
the species. [The researches referred to concerned
G. palpalis and not G. morsitans; moreover, the
later observations indicate that the conclusions cited
are probably erroneous, for they have found reptiles
to be a highly favoured source of food for G. palpalis
under natural conditions.—ED., Bull. Top. Res.) As
a matter of fact, in the case of G. morsitans such a
supply is rarely available, as the fly is not often
found on the banks of the larger rivers where
crocodiles abound, and the belts in the dry season
are frequently far removed from water of any sort,
in which case water-loving reptiles, such as Varanus
and freshwater Chelonia, as well as most amphibians,
are not available. The smaller lizards, including
chameleons, are more likely to make a meal of tsetse
than vice versa, whilst the terrestrial tortoises are too
scarce to be of any account. Amongst the mammals,
certain orders, namely the Insectivora, Chiroptera
and Edentata, are obviously of no service on account
of their nocturnal habits and the seclusion of their
diurnal retreats. Certain rodents, such as hares,
may serve the fly for a meal on occasions, but the
order can be of but little importance on account of
the small size and activity of the majority of its
members and the fact that they are largely nocturnal
in habit. Of the larger species the porcupine
(Hystrir) is entirely nocturnal, but certain squirrels
attain a size not greatly inferior to that of a rabbit
and are of diurnal habit. The larger forms of the
latter family are, however, rarely seen in country
suited to the tsetse. No doubt the larger carnivora
are attacked by tsetse when they enter its haunts,
but their numbers are relatively so small that they
are practically negligible. Lions and, to a lesser
extent, hyzenas, are also dependent on the larger un-
gulates for food, and desert country from which these
have been driven. The hunting dog (Lycaon) is
always migratory, and leopards and jackals, in
addition to their scarcity, lie up during the day. The
smaller carnivora-—Felid:, Viverridæ, Mustelidæ—
are also practically nocturnal, and from their alert
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1914.
and active habits are unlikely to submit to be fed
upon. Anyone may note the intolerance of the
domestic cat to the attentions of Stomoxys in this
connection. It would seem, therefore, that the whole
class of mammalia, with the exception of ungulates
and certain primates, are little fitted to be of service
to tsetse even in the aggregate. The smaller ante-
lopes and Quadrumana must be considered later.
In connection with birds, we are faced with the fact
that tsetse certainly.shows no dislike to avian blood,
as fowls have been freely used to feed the flies (both
G. palpalis and G. morsitans) in confinement, and
evidence has been brought forward to show that species
of Glossina at least occasionally secure a meal from
certain birds in nature. On the other hand, in the
case of G. palpalis, in the presence of other sources
of blood, birds are not laid under contribution to any
great extent. Similar observations do not seem to
have been made with G. morsitans, but it should be
noted that this species has little opportunity of feed-
ing upon the quiescent water-loving birds suggested
as the source of the avian blood found in G. palpalis.
Moreover, the tsetse’s habit of awaiting its prey not
far from the ground renders it probable that the vast
majority of birds come comparatively rarely within
the ken of the fly. Small birds, also, in addition
to their restlessness, activity, and tendency to catch
insects, probably have but little power of attracting
tsetse, for there is some evidence to show that the
size of an animal and the amount of disturbance
created in moving about have a direct influence on
the number of tsetse attracted, at least in the case of
G. morsitans. It would, in fact, seem that the distance
a tsetse is led by scent alone is a comparatively short
one. The writer has frequently had the experience
that when sitting quietly in a fly-belt few tsetse would
be in attendance, but that a movement of only a few
yards brought a considerable accession of numbers,
the newcomers showing a desire to bite that proved
they were hungry. On the other hand, movement
through infested forest invariably attracts a number
of the flies, even when it is as soundless as progress
along a path on a bicycle. The flies in such circum-
stances do not always evince a desire to feed, but on
the other hand they quite commonly do so. From
this it appears that the range of sight is greater than
that of scent, and that large moving bodies constitute
a particular attraction. If this is the main method
by which flies are attracted, the range of attraction
of an animal should, within certain limits, vary in
direct ratio with its size, and one can understand
that, apart from all other considerations, small
mammals, small birds, and small reptiles could on
this account alone form only a casual source of
sustenance. There are, however, certain birds which
live almost entirely on the ground, are of suflicient
size to attract tsetse from some distance by vision,
and are often found in great abundance in the
particular haunts of the fly. These comprise several
species known as game birds, and include Numida,
Pternistes, Francolinus and others. The fact of tsetse
feeding on fowls in captivity would seem to show tliat
attempts would be made to feed on other gallinaceous
Oct. 15, 1914.]
birds in a state of nature, at least when pressed by
hunger. The writer has, nevertheless, found on
entering a limited belt where enormous numbers of
game birds were congregated, the flies were as eager
for mammalian blood as elsewhere, and the collapsed
state of the abdomen showed that they had not fed to
the full for days. At this spot the birds rose from
the grass at almost every step, and if the flies were in
the habit of finding the birds and feeding on them
there was certainly not the least difficulty in every
fly doing so, nor any apparent reason for the presence
of swarms of desperately hungry individuals. There
is therefore some ground for belief that for some con-
stitutional cause, such as their conformation, their
armature of feathers, their activity, their habit. of
pecking at insects, or such causes combined, birds as
a class do not form a very suitable source of sus-
tenance to tsetse. That some such disability exists
in respect to most other bloodsucking flies would
seem to be beyond question, when we consider how
little attention Stomoxrys, Hamatopota, Tabanus, &e.,
pay to fowls, for instance, even in the absence of
larger animals. The only bloodsucking flies that have
made a thorough success of feeding on birds appear
to be some members of the Hippoboscide, which
have developed a parasitic habit and become specially
adapted to moving about amongst feathers. The flat
form of Olfersia is obviously of advantage to it in this
respect, and we can see how ill-adapted the tsetse is
in comparison.
With regard to the smaller antelopes and Quad-
rumana there is no doubt at all that the fly feeds
upon these animals whenever appetite and oppor-
tunity coincide, or that a regular supply of the blood
of these species would serve the fly indefinitely. The
small buck, however, do not run in herds and are
very scattered, and on this account are not fitted to
afford a regular meal to large quantities of tsetse. It
is conceivable that monkeys and baboons, in spite of
the great troops of the latter, also fail to some extent
in this respect. They are also by no means constant
denizens of fly-belts. Dr. R. E. McConnell’s obser-
vations on the actions of his pet monkeys when
attacked by tsetse show that making a meal of
monkey’s blood is not without danger to the fly itself.
In connection with a species to which the prolonged
survival of the individual is of such importance as it
is for Glossina this may not be without significance.
A feasible explanation of the dependence of G.
morsitans on the larger Ungulata seems to be that a
regular supply of blood is essential to the continuance
of the fly, and that this is only afforded by the
presence during the greater part of the year of these
grass-feeding animals. An irregular supply is afforded
by monkeys, baboons, small buck and other animals,
and possibly birds, which may help to tide the insect
over periods of scarcity. It does not appear to be
incomprehensible that a regular supply of food should
be of such importance to the species when we recollect
the great expenditure of substance of the female in
the comparatively slow process of reproduction. The
tsetse is obviously very delicately poised in the balance
of nature, and any retardation of the rate of reproduc-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
319
tion would obviously have a tendency to result in the
failure of the species to maintain itself. When food
is scarce there is no doubt that reproduction is re-
tarded, and in belts where a season of scarcity occurs
annually there will be comparatively few offspring
produced during certain seasons of the year. The
very few pups. found by the writer on the thickly
infested Gorai River supports this view, especially
when compared with. the results obtained elsewhere
in belts not subjected to annual periods of dearth.
During a portion of the time when the flies are con-
gregated in the shade provided by the banks of the
watercourses reproduction is apparently very slow,
and it must be assumed that the numbers of the tsetse
are maintained by the breeding which occurs at other
times of the year. Where, by the removal of the
main source of food, tsetse is subjected permanently
to an irregular supply and also forced to draw this
from sources involving some danger to the fly itself,
reproduction could quite conceivably fail to keep pace
with the death-rate, and the species die out on this
account.
The writer would emphasize the fact that no claim
is made to have explained in the foregoing pages all
the phenomena connected with the disappearance of
tsetse-fly. There are far too many factors affecting
the situation. The sole object in view has been to
point out that the apparent dependence of G. morsitans
on big game is not quite such an inexplicable pheno-
menon as it appears to be at first sight. The position
of tsetse-fly at the present time, in fact, would suggest
some such dependence.
A further experiment in the direction of ascertaining
whether the spread of tsetse can be checked by the
reduction of big game has now been commenced in
the Sebungwe district. A wide belt of. country,
bounded on one side by the Umniati River and on
the other by the Sengwa, has been declared an open
area for shooting. The fly is reported to be spreading
across this area from the west and east, and it is
desired to prevent the two belts meeting and embrac-
ing the Bumi and Sesame Rivers where there is a
considerable number of native kraals. Observations
have been made on the limits and abundance of the
testse, and, provided that the suspension of the Game
Laws results in the destruction of the big game to a
sufficient extent, the experiment should certainly
yield valuable information.
It is urged by those who support the theory of a
special association between tsetse-fly and buffalo that
it was the nearly complete extermination of the
buffalo, apart from other game, by the rinderpest that
was the cause of the great reduction of fly which
immediately followed. If this theory is still tenable,
it must now be urged that the increase of fly has been
due to the increase of this species of animal, unless,
of course, it is suggested that the progeny of the fly
that survived the year 1896 have acquired new habits,
which would be merely a method of admitting that
the theory no longer holds. Whatever may have
beea the position before the rinderpest—and buffalo
blood may have been the most easily obtainable food
of tsetse at that time—it is quite certain that in
320
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE
[Oct. 15, 1914.
Southern Rhodesia to-day the fly is not in any way
dependent upon this species of animal. Buffalo was
at one time, as is well known, extremely abundant in
various parts of the territory, but whatever may have
been the reason the species has never been protected
under the Game Laws, its numbers have not increased
since the rinderpest in the same proportion as the
various species of antelopes. This may be due to the
fact that the reduction of the buffalo was more nearly
complete than that of any species of antelope, or to
some other cause, but at the present time buffalo is
. not generally met with throughout the territory.
Herds occur in certain parts, but as a species it is
distinctly local. Were buffalo of vital importance to
tsetse herds would occur in some abundance through-
out the fly-infested country; but, as a matter of fact,
there are great belts of country infested with fly in
which buffalo is rarely or never heard of, as in the
greater part of the Sebungwe belt lying west of the
Sengwa River, the biggest and most thickly infested
fly-area in this territory.
The converse argument is of little importance, but
one hears so much about fly following the buffalo
that a very striking instance to the contrary may be
recorded. Near Nenyunka’s kraal on the Sengwa
River there is a thick thorn brake, such as is termed
isi-nanga by the natives, in which buffalo is very
abundant, far more so than any other species of game
in the vicinity, but tsetse is not to be found. The
writer penetrated to the heart of the isi-nanga where
the drinking places of the animals were situated and
where the quantity of dung made the place look like
a cattle kraal, and met with no fly. Nenyunka’s
kraal is certainly marked on the edge of the fly-area
in a recent map of the district, but this was on the
strength of one or two having been reported to have
been seen by natives. The edge of the belt to the
south is, on reliable information, from ten to fourteen
miles up the Sengwa from this point, and there is
another belt on the lower reaches of the Sengwa, the
limits of which have not been clearly defined, but
here, in the very haunt of the buffalo, fly is absent.
To sum up the matter rather baldly, it is quite
certain that no one having travelled through the fly-
belts in Southern Rhodesia, as the writer has done
during the past five years, could entertain the idea
that, except in a few localities, the blood of the buffalo
is, even at long intervals, a regular food for the tsetse,
much less that it is an essential one.
—— —9————
Rebdiews,
PRACTICAL TROPICAL SANITATION. A Manual for
Sanitary Inspectors and others interested in the
Prevention of Disease in Tropical and Sub-tropical
Countries. By W. Alex. Muirhead, Staff-sergeant,
R.A.M.C., &e. With illustrations ; pp. xv + 288.
London: John Murray, Albemarle Street, W.
1914. Price 10s. 6d. net.
This carefully written book practically covers the
whole field of tropical sanitary effort, thus filling up
a distinct gap in the literature devoted to this subject.
It should be of value to the sanitary inspector, more
especially when newly appointed, seeing that it gives
innumerable details which are often ignored by
writers as being of too simple a character to deserve
mention. Thus, the singular and plural of certain
nouns used in connection with bacteria are given for
the benefit of readers unfamiliar with them. The
cause of disease is also gone into very thoroughly:
the different channels of infection being described
with exceptional clearness.
In the chapter on Tropical Diseases the part played
by the common house-fly in carrying infection is
graphically shown. Malaria is dealt with very fully,
and a diagrammatic illustration of the connection
between man and mosquito in the spread of malarial
fevers is particularly interesting.
Mosquitoes have a chapter to themselves. It
seems a regrettable fact that insects, upon the investi-
gation of which the indefatigable resources of science
and patience have been brought to bear, should be
such an appalling scourge to mankind. Full details
of the life-history of a mosquito are given, the
complex subject being much elucidated by the
illustrations.
Seeing that this book is specially intended for aid-
ing the sanitary inspector, a considerable portion of it
is devoted to disinfection, air and ventilation, water
and water supplies, food, &c. There is no doubt that
if the rules laid down here are adhered to, they should
be of material aid in stamping out tropical disease in
the near future. A marked feature of the manual is
the way in which an attempt is made to simplify com-
plicated technicalities, so that they may be easily com-
prehended by the layman. In furtherance of this
object there is an excellent appendix, which cannot
but be of great assistance to any candidate for
examination in tropical sanitary work.
Throughout the text there are numerous illustra-
tions, many of which are original, and add considerably
to the interest of the reader. The type is good and
the book of a size convenient for handling. It can be
thoroughly recommended to all anxious to study
tropical matters.
OBITER SCRIPTA. Throat, Nose,and Ear. By A. R.
Friel, M.A., M.D., General Hospital, Johannes-
burg. 1914. John Wright and Sons, Ltd.,
Bristol. Pp. 40. Price 2s. 6d. net.
This little brochure only contains three chapters,
dealing respectively with common conditions in the
throat, nose, and ear; zinc ionization and the treat-
ment of ozena, including some notes on Friedlünder's
pneumobacterium.
The author gives practical advice which would be
a help to the student anxious to obtain a rapid and
brief survey of conditions and operations pertaining
to these branches of surgery. The country practi-
tioner, too, if called upon to resort to drastic measures,
might find it of service in an emergency.
The book is neatly bound and the type good; the
thinness of the volume being compensated for by the
thickness of the paper. There is quite a full index.
Nov. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 21, Vol. XVII.
Original Communications.
THE METEOROLOGY OF MALARIA.
By Maruew D. O'Connett, M.D.
THE work done by the Department of Sanitation
of the Isthmian Canal Commission, under its chief,
Colonel William C. Gorgas, of the United States Army,
has produced a great improvement in the health of
the employees of the Commission and also in that of
the general population of the Canal Zone.
In the Annual Report of the Commission for
1912-13, p. 528, the morbidity rate of malaria is taken
as an index for health conditions on the Isthmus.
The following table gives the admission rate, per
1,000, since 1904, of employees sick with malaria :—
Year Admissions per 1,000
1904-5 .. s z4 .. 162
1905-6 ae os ee er aT.
1906-7 .. 22 re .. 287
1907-8 .. oe m .. 812
1909-10 .. 53 yi .. 183
1910-11 .. dz T .. 202
1911-12 .. $e ws «a 143
1912-13 `.. Pe 25 .. 102
The seasonal incidence of malaria among the
employees is indicated in the following table taken
from p. 554 of the Annual Report for 1912-13 :—
HosPrrAL CasES OF MALARIA AMONG EMPLOYEES.
Month Total cases Number of employees
July 1,037 48,714
August S 919 50,305
September zs 438 50,948
October es 301 50,103
November "e 272 52,539
December T 9376 53,810
January sé 499 52,142
February T 591 55,333
March s 433 5€, 258
April Ss 234 59,771
May "E 177 59,771
June "- 937 58,590
Presumably this admission rate does not include
those cases of malaria among the employees which
were treated in sick camps, and in quarters. Still,
from the figures given in the above table it is seen
that the disease still lingers among the employees to
some extent.
The great reduction in malaria among the em-
ployees has been attributed to the killing of, and pro-
tection from, mosquitoes, oiling pools, clearing brush
and grass, constructing and maintaining ditches for
drainage purposes.
In the Canal Zone during the year 1912-13 no
fewer than 1,063,689 mosquitoes (anopheles and
culex) were killed in houses and barracks; 5,310
breeding places of mosquitoes were found and
oiled ; 277 miles of new ditches were constructed, and
272 miles of old ditches maintained, for drainage pur-
poses; 7,356 acres of grass and brush were cleared.
But in addition to the above measures for the eradi-
cation of malaria, another anti-malarial work of
acknowledged benefit has been slowly progressing
since the commencement of the making of the canal.
I refer to the excavation of the canal itself. For, in
addition to its being a canal for shipping purposes, is
it not also a huge drain cut right through the middle
of the ten-mile wide zone and extending from Ancon
to Colon ?
Such a drain must have a great effect in drying the
soil, and therefore drying the overlying hot atmo-
sphere, for a considerable distance on both sides of it,
In order to ascertain if the atmospheric conditions
of the Canal Zone are, at present, such as would
afford an explanation of the occurrence of an inter-
mittent pyrexia among the employees I have obtained,
by the courtesy of Colonel W. G. Goethals, chairman
and chief engineer of the Panama Canal Commission,
records of meteorological observations at Ancon
(Pacific side), Culebra (Central Station), and Colon
(Atlantic side), for periods of forty-eight hours in the
months of February and August, 1913. In these
records the dry bulb temperature and the relative
humidity are given every two hours and the velocity
of the wind every hour. From the dry bulb tempera-
ture and relative humidity of the air I have added
the wet bulb temperature and drying power of the
air from Glaisher's Meteorological Tables.
In line with each record at Ancon I have placed,
for comparison, the nearest atmospherie conditions
which were found by actual observation to raise the
body temperature, of many of the weavers in the
Lancashire cotton sheds, above normal.
On page 322 are given the atmospheric conditions at
Ancon, from 1 o'clock a.m. on August 1 to 12 o'clock
midnight on August 2, 1913.
From comparison of the atmospheric conditions at
Ancon in August, 1913, with those which raised body
temperature above normal in the Lancashire cotton
sheds, it is, I think, evident that the former by the
greater impediment which they present to loss of heat
from the body, especially during the twelve hours of
the night, must raise body temperature more thau
the atmospheric conditions in the Lancashire cotton
sheds did, i.e., must cause pyrexia in many; and the
meteorological change which takes place from the
night to the day must make any pyrexia, so caused,
intermittent in type, as I have in previous papers
tried to explain.
In the section on Meteorology in the Canal Report
for 1912-13 it is stated that during the year the
rainfall and relative humidity of the air were generally
deficient, whilst the air temperature (dry bulb) and
wind movement were above the average (p. 944).
Thus there was less impediment than usual to loss of
heat from the body by evaporation and by conduction
and connection which would make any pyrexia so
caused, by the atmospheric conditions, less prevalent
than usual.
As regards loss of heat by conduction and connec-
tion, it is stated on p. 232 of the Report that the
anemometer at Ancon is 69 ft. above the level of the
ground and 160 ft. above the sea level.
In less elevated and less exposed parts of Ancon
the movement of the air would be proportionally less
than at the level of the instrument, and therefore
the impediment to loss of heat from the body by
322
conduction and connection would, in such places, be
greater.
In further papers I hope to give the atmospheric
condition at Culebra (Central Station), and at Colon
on the Atlantic side of the Canal.
A CASE OF LEISHMANIA TROPICA WITH A
FATAL TERMINATION.
By A. R. NELIGAN, M.D.Lond., M.R.C.S., D. T. M. & H.Cantab.
Physician to the British Legation, Teheran.
Salek,* the Persian name for Leishmania tropica
or Oriental sore, is so common at Teheran that
natives pay little attention to it, and seldom come
* Sal is the Persian word for ‘‘year” and salek is its
diminutive. Oriental sore takes about a year to run its course.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 2, 1914.
for treatment to European medical men except when
the ulcer becomes grossly infected with pyogenic
organisms. Indeed, apart from the ugly scar which
the sore leaves behind, serious results or deformity
are not common. The case described below, which
died of tetanus and in which no other “ port of entry "
for the bacillus could be discovered than the sore
itself, came then as rather a shock to me. Looking
back now on all the cases of salek with secondary
infection that one has seen, for such a complication
as tetanus to occur would appear to be the simplest
thing in the world. As a matter of fact, this is the
first ease of the kind with which I have met in eight
years, and I think it on that account worth describing.
The patient was alittle Armenian girl, aged 3. She
had had a salek for eight months. "There was a huge
foul uleer 2 in. in diameter covered with heaped-up
Hourly atinospheric conditions
at Ancon, Panama Canal
(Pacific side)
Atmospheric conditions which
raised body temperature in
the Lancashire cotton sheds
Degree to which body tem
perature was raised by
exposure in the
Lancashire cotton sheds
Tem perature of Relative Drying Velocity of | Temperature of Drying Move- ——
air, F. humidity power of wind per air, F. power of ment Body.tem- Pulse Respira
of air air per hour nir per ofair perature tion
10 cub. ft. lOcub.ft. per in mouth,
Panama Canal, Ancon, -m maa hour F.
1913. Dry Wet Percent Grains Miles Dry Wet Grains Miles
August 1, 1lo'c. a.m. 16:0? 75:3? 96 8:8 8 76:0? 72:0? 20:0 99:4* 88 20
es 3 » 76:0 75:5 97 2:5 7 76:0 72:0 20:0 99:4 88 20
h : T 74:0 73:5 97 2:5 TRA 740 70:0 19-0 100:0 98 22
; m 5 ee m 8 no es "m as až ss
E TP. vá 78-0 75:4 86 14:0 7 78:0 78:5 23:0 1000 100 30
3» 8 Pe oe T m 3 6 ee y .. T ws .
Ts 9 n 84:0 78:5 74 32:5 5 81:0 TT:0 39:0 100:3 84 25
+ 10 35 $e ai as a 5 ^ s oe s x es
2s 11 jy 88:0 80:2 66 47°7 5 88:0 77:5 61:0 100:2 104 20
is 12 o'c. noon T m sla «a 5 T ws . £5 ps oe
is 1 o'c, p.m 89:0 81:2 66 48:5 5 89:0 79:0 60-0 1000 108 24
3 Y mm m as m 6 ve ve T "T ak es
ie 3s. es 90:0 82:5 67 48:0 5|, 900 75:0 82:0 99-8 94 u
oy 4 i 22 ee we ar 5 a F e. a as oe
ne 5 $i 82:0 767 75 29:2 11 82:0 16:0 33:0 3 99:2 88 14
n: 6 se ae >s - oe 13 as an D a es ale .
se 7 780 756 87 130 | 78-0 73:5 230 $ 1000 100 3
2» .. LED . oe 8 ee .. .. o =. --
i 9 $ 77:0 75:2 90 9:8 8 77:0 73:0 20-0 E 100:1 100 18
3$ 10 is E a îs af T se oe a £ ae we
$5 s 5 77:0 75:2 90 9:8 9 TTO 73:0 20:0 E 100:1 100 18
5 * 5, En D T 7 2s m "m c oe bs
August 2, lo'c. a.m. 75:0 73:6 92 7:0 8 75:0 69:5 266 S 1002 110 18
ss 2 $i E v d 8 s m I E De e -
* ju ss 74-0 72:6 92 7-0 7 74:0 70:0 190 §& 1000 98 2%
K uai zs e Se X GPA... i tg H i = e
: 2 » 73:0 71:4 91 8:0 6 73:5 68:0 245 È 100-0 90 22
25 3 os Me "s 2n 8 s m os £ a - T
3 T 5 80:0 78:2 91 9:0 T 80:0 75:0 27:0 E 99:2 92 28
+5 e DD m m oe 5 m T sie Z "s ^P
5; 9 i5 87:0 83:2 82 24:5 6 87:0 79:0 48:0 100:4 108 24
: 10 A m of và oe 6 oe we m ee ana Pe
e Hb oa 900 830 72 450 T 90-0 75:0 82-0 99:8 94 A
5s 12 o'c. noon T ws si BE 6 DC T s. ie ate zx
"e 1 o'c, p.m. 91:0 82:2 63 56:5 6 B 90:0 75:0 82:0 99:8 94 24
32 2 RE B i a az 4 as oe $a 15 an se
js 3 y 88:0 79:5 64 50:2 e| 88-0 80:0 49:0 100:0 108 16
25 4 j "^ aa id att 6 s ae m E: - m
3; 1 oA 82:0 76:2 73 31-7 7) 82:0 76:0 33:0 99:2 88 14
2 "E zs "S n way 7 t al m s. es oe
di T ti 78-0 76:0 89 11:0 8|, 780 78:5 23-0 100.0 100 30
5 HS ave z as s. 7 oe rei m oe as 2
x 1 " 76-0 75:8 96 9:3 6 76:0 72:0 20:0 99:4 88 20
53 0 a m vs " sz 7 a ws ry
$5 11 b 76:0 753 96 3:3 6 76:0 72:0 20:0
12 o'c. midnight M f
994 8S 9
m I.
Conditions bracketed A will cause pyrexia in many. Conditions bracketed B will not cause pyrexia in any.
Table to accompany Mathew D. O'Connell's Paper on ** Meteorology of Malaria.”
Nov. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
323
dirty, yellow crusts over the the left malar bone.
Higher up, in the temporal fossa of the same side,
was a similar ulcer, 1 in. in diameter. From under-
neath the crusts pus was oozing, and around the
ulcers there was an area of induration ¢ in. wide
and beyond that again there was cedema of the eye-
lids. The submaxillary and preauricular lymphatic
glands were enlarged and tender. Scrapings from
the base of the larger ulcer showed numerous
Leishman-Donovan bodies.
Fomentations were ordered to be applied with a
view to removing the crusts and cleaning the ulcer
before beginning treatment.
The child was not brought again for nine days.
The ulcers were cleaner and I was on the point of
beginning a series of injections of hectine when
I noticed that the child’s head was a little retracted
and that there was stiffness of the neck. Further
examination showed that there was spasm of the
masseter muscles. On inquiry I found that the
child had had difficulty in opening its mouth for two
or three days. The child died of a very rapidly
progressive form of tetanus two days later.
Unfortunately, I did not have the satisfaction of
finding the tetanus bacillus in the pus or scrapings
from the ulcers. The chain of evidence is not
therefore complete, but a careful search brought to
light no abrasion of the surface of the body other
than the ulcers described, and tetanus is not at all
common in this part of Persia. When it does occur
some very obvious port of entry is found. The
severity and rapid termination of the case goes well
with asite of infection placed so near to the important
nerve centres.
Strictly speaking, it is not correct to say that death
in this case was due to the Leishmania infection, but
at any rate it is permissible to suggest that had not
the child had the sores she would not have got
tetanus and died. The case, I think, points a useful
lesson, and I shall look with greater respect on salek
in future. The ulcer was particularly well placed for
added infections to occur: it must often have come
in contact with the ground as the child tumbled
about in play or slept there, as native children do,
without pilow or mattress.
As to the treatment of Leishmania tropica with
hectine, the use of the drug was suggested to me by
Dr. Gachet, of the French Navy Medical Service,
Professor of Medicine at the Royal University. We
have given it by injection with a fine needle into the
indurated periphery and base of the sore, repeated
two to three times a week. The dose used has
been 1 eg. for each 4 kilos of body-weight. The
results have been good, healing generally taking
place in three weeks to a month, and, what is very
important in an affection which so often attacks the
face, with very little scarring. When the ulcers are
numerous, as they often are, I have found the intra-
venous injection of neo-salvarsan give excellent
results. Arsenical compounds are, undoubtedly, the
most effective remedies for cutaneous leishmaniosis
that I have yet used.
BABESIA OR PIROPLASMA.
By ALBERT J. CHALMERS, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories.
AND
Captain R. G. ArcHiBALD, M.B., R.A.M.C.
Pathologist, Wellcome Tropical Research Laboratories, Khartoum.
WHILE searching through botanical literature in
the course of a certain joint work in connection
with the Fungi imperfecti we chanced upon the
following :—
Schizomycetaceae Naegeli 1857.
Genus Babesia Trevisan 1889.
Definition.—Cocci ellipsoidei, longitudinaliter bina-
tim seriati (diplococci longitudinales) in filamenta
moniliformia, pseudodichotoma nuda concatenati.
Arthrosporæ macrosomæ in apice filamentorum
obvenientes.
Etymology.-——Derived from the name of the cele-
brated Roumanian bacteriologist. V. Babés.
Species.—(1) B. wxanthopyretica Trevisan 1889,
found in people suffering from yellow fever; (2) B.
erysipeloidis Trevisan 1889, found in people suffering
from erysipelas.
It is obvious that as Trevisan applied the name
Babesia in 1889 to a genus containing certain bacteria,
‘this name cannot be used a few years later to name
a genus of the protozoa and, therefore, the name
Babesia Starcovici 1893 cannot be retained.
This brings the nomenclature of the genus of
protozoal organisms discovered by Babés down to
the year 1895, when Patton introduced the word
" Piroplasma."
The synonyms will therefore stand as follows :—
Genus Piroplasma Patton 1895.
Synonyms. — Hematococcus Babés 1888 (nec
Agardh); Pyrosoma Smith and Kilbourne 1893 (nec
Péron); Babesia Starcovici 1893 (nec Trevisan) ;
Amebosporidium Bonome 1895; Ixrodioplasma
Schmidt 1904.
This, we hope, will end the confusion in that some
authors use the name “Babesia” and others
" Piroplasma " for the same genus of protozoal
organism.
REFERENCES.
Parros, W. H. (1895) '*American Naturalist,’’ vol.
xxix, page 498.
SaAccaRDo, P. A. (1889) “Sylloge Fungorum,” vol.
viii, page 1051.
Khartoum,
June 6, 1914.
A USEFUL PRESCRIPTION IN CHRONIC
MALARIA WITH ENLARGED SPLEEN.
By James Cantuiz, M.B., F.R.C.S.
I HAVE used in the treatment of chronic malaria
with enlarged spleen a combination of quinine,
arsenic, opium and mercury for several years with
marked benefit. The ingredients are really those of the
old fever powder which was so largely used by our
fathers in medicine when malaria was ripe in England,
the chief difference being that the mercury was given
324
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 2, 1914.
by them separately in the form of a blue pill, and used
as a purgative. In the first place it is not because of
being a purge that mercury owes its presence in the
powder, but on account of its action as a germicide.
It is given for the same reason as it is given for
syphilis, to destroy the spirillum of syphilis; and
although its action in malaria with hypertrophied
spleen may be less apparent, practical experience
shows it to be beneficial. We know the action of
mercury in trypanosomiasis when combined with
antimony, and we know also that as a preliminary to
the treatment of almost every ailment calomel was
administered in a stereotyped way by physicians in
the middle of last century. Itis not sufficient tosay that
the calomel served as a purge merely, for we know that
for two, three or more days after a purgative dose of
calomel the mercurial salt remains in the system, so
that were the calomel included in my prescription
taken out and given as it used to be given previously
to the “ague powder,” yet in the system would all the
drugs combine and mercury would still play whatever
part is assigned to it, be it given before or with the
other ingredients. I prefer, however, to include the mer-
cury in the powder and not give it in a purgative dose.
The patient home from the tropics with frequently
recurring attacks of fever, with a big spleen, anæmic
to a degree, depressed and worried by illness, should
not be given mercury as a purge. Milder measures
should be used; for the “tropical” liver is not the
" Aldermanic ” liver, it is not overloaded with the pro-
ducts of the digestion of rich food and rare wines, but
one depleted of wholesome blood, flooded with the
toxins of intestinal or blood parasites, functionally
exhausted by climate and from want of the nourish-
ment and stimulus supplied by the fresh meat and
vegetables of British tables. Such a liver does not
do well on calomel nor on any powerful hepatic deriva-
tive. Severe measures are unsuitable, and the less
vigorous the Spa treatment is the better.
The calomel introduced in the prescription, there-
fore, is not placed there for its purgative qualities but
as a germicide. The next ingredient is arsenic, a drug
with many therapeutic attributes and one which is
used in malaria in many countries. In salvarsan
arsenic is a potent factor, and the general application
of the drug seems limitless, if Ehrlich’s idea of its
being a “ sterilizer of the system ” has any truth.
The combination of arsenic with quinine is no
doubt a useful one, more especially in chronic malarial
affections.
Opium in the form of pulvis ipecacuanh:e compo-
situs is introduced into the prescription partly
because of its traditional use in malaria but chiefly
from the writer's experience of the benefits it confers.
The effects of opium are legion and the full measure
of its benefits seem unsearchable and innumerable.
The dose is so minute that it might be deemed in-
capable of producing any therapeutic effect; this
opinion may have theoretical argument, but it has not
clinical experience to support it. Again, opium by
itself is not so valuable as when it is combined as in
Dover's powder. Opium has been used in malaria
since the disease and the drug were known, and their
disassociation is an affair of yesterday. That this
has been a wise step is more than doubtful; our
fathers in medicine believed in the combination, and
their powers of observation were more acute than
ours. Effect was their only test, success was their
sole gauge of usefulness; they had not blood examina-
tion reports to support them in their beliefs nor
laboratory methods to afford suggestions. We pride
ourselves on our one drug for each disease, on the
principle of the dock for the nettle-sting. We have
condemned long prescriptions containing combinations
of several potent remedies as unscientific, until we
have well-nigh lost the art of writing a prescription.
The "dock and nettle” system has had its day;
scientific investigation shows that not infrequently
two remedies are required: one to clear the blood of
the parasite, another to kill the parasite after it has
gained the tissues.
The prescription runs as follows :—
E Quinine Hydrochlorid. .. sa gr. v to gr. vii
Acid. Arsenosi as ws e BU. 48 S QE. oh
Pulv. Ipecac. Co. .. St +. gr.dil ,, gr. iv
Hydrarg. Subchloridi. —.. e EC x55, gr. d
Fiat pulv. in cachets.
Sig.: One at 11 a.m., and another at bed-time.
—— 9———— —
Annotations.
Antimony in Dermal Leishmaniasis.— Vianna
(Annales Paulista de Med. e Cir., ii. 167, 1914)
finds that in Brazil the best remedy for lesions of the
skin and mucous membranes is tartar emetic by
intravenous injection; salvarsan and neosalvarsan
have been entirely unsuccessful in curing the cutaneous
lesions. The maximum dose was 1 c.c. of a 1 per
cent. solution in sterilized normal saline. Generally
smaller does were used, and used in chronic cases for
considerable periods. The intravenous injections were
given to children of 5 and to adults over 60. In two
cases of nephritis the albumin increased and «edema
developed with the maximum dose; on reducing the
dose the trouble disappeared. Symptoms showing
the limit of tolerance are pains in joints and muscles,
or headache.
Plague in New Orleans.— On September 22, two
fresh cases of bubonic plague were reported, one
has since died; the other is expected to recover.
There have been twenty-eight cases since the out-
break of the infection on June 27.
———_—_. >.
WITH the New Zealand Expeditionary Force
coming to Europe are two dental lieutenants. These
gentlemen were senior students at the Otago Uni-
versity, but on the outbreak of war were given special
examinations, and thereafter granted special dental
commissions.
Noy. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
325
Rotices.
BUSINESS AND GENERAL.
1.—The address of THE JOURNAL OF TROPICAL MEDICINE AND
HyGrENE is Messrs. BALE, SONS AND DANIELSSON, Ltd., 83-91,
Great Titchfield Street. London, W.
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THE JOURNAL OF
Tropical Medictne andhpatene
NOVEMBER 2, 1914.
SCIENCE AND WAR.
THAT war has proved wholly detrimental to
human progress is not borne out by historical fact.
In earlier days when transport was slow, when
contact with the peoples of other nations was
restricted almost to an infinitesimal degree, when
the ignorance of the inhabitants of a country of the
customs and ways of their neighbours prevailed to
an extent almost incredible to-day, war was the
only channel by which extensive contact was possible.
The West was made more familiar with the East by
the Crusades in the Middle Ages and long before
the Romans spread light and learning to what was
in their day the “ world.” To come down to more
recent times no farther back than the Crimea, we
are indebted to that war for modern hygiene. The
fact that overcrowding was detrimental to health was
not known, or if known to the few it was not acted
upon practically. That sixteen men could inhabit
a “bell” tent, covered with frozen snow, with no
ventilation of any kind, and to which no fresh air at
any time was admitted except when a soldier had to
open the " door " of the tent to get out when called to
sentry duty, was a common feature of sanitation
even as shortly ago as 1854. That typhus prevailed
was of course inevitable; that dysentery in an
epidemic form ‘found ready victims is readily under-
stood, and that epidemics of cholera prevailed, when
it is remembered that sanitation of camps or of our
own dwellings was primitive in the extreme. The
officers who cut some holes in the top of their tents
through which air could find entrance and exit were
the pioneers of our modern notions of ventilation, and
by the genius of Parkes, of the Army Medical Depart-
ment, the information gathered from war experiences
served to found our knowledge of hygiene, both
military and municipal. It is to the medical depart-
ment of the British Army that the world owes a
debt of gratitude for this world-wide benefit; the
knowledge there acquired has been the basis of pre-
ventive medicine and of our domestic hygiene.
To take a concrete example. In 1866 Cohn-
heim, of the German Army, after the battle of
Sadowa, went to Vienna to visit his friend and
teacher, Stricker, the pioneer of research in many
tields. He found Stricker working at the passage of
the red blood corpuscles through the walls of the
capillaries. Cohnheim was deeply impressed with the
demonstration, and on the way back to Berlin he
thought if the red corpuscles can find their way
through the capillary walls, why cannot the white?
It is unnecessary to relate that he had only to look
to find their passage, a rudimentary fact which is
known to even laymen amongst us to-day. The
war between Germany and Austria brought Cohnheim
to Vienna, and at any rate hastened a discovery
which laid the foundation of modern pathology.
To war, therefore, we can ascribe the acquisition
of modern hygiene and pathology, two branches of
science without which the practice of medicine would
have remained mere empiricism.
AN INDIAN VOLUNTARY AID CONTINGENT.
INDIAN students and a few others resident in
England on the outbreak of war volunteered to go
to the seat of war as dressers, orderlies, and stretcher-
bearers. The difficulty was to affiliate the members
with any organized authority; and only after much
discussion was it decided to form a separate contin-
gent for use where they might be needed, and they
placed themselves under Mr. Cantlie for training in
first-aid, nursing, military hygiene, stretcher drill,
ambulance wagon drill, and mode of carriage by
326
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
railway, &e., &e. Soon after commencing training,
however, the news spread that the Native Army of
India was on the way to Europe, and the problem of
the sphere of usefulness of the Indian voluntary aid
contingent was solved. The delight which thrilled
the members of the contingent when the coming of
their brethren was announced was electrical. Pre-
viously they went to their lectures and drills as if
“creeping like snail unwillingly to school”; but
immediately attention was riveted on every item
of instruction, the text-books were devoured, the
movements on the drill ground became smart to a
degree, they turned out punctually to a second, and
their work orderly to a hair. They had now a definite
mission, and their true worth was disclosed.
There are many in England to-day who envy their
going to the front—men and women who are denied
that privilege; men and women who have been
training for years, and are wearing their hearts out
waiting to be allowed to help. Their petitions are
rejected whilst their countrymen suffer. Not so
the Indian contingent; their desire has been fulfilled,
and they are thankful.
Amongst the members of the contingent are a
goodly number of doctors, men who hold both Indian
and British diplomas. These men sat down in the
classes with the others and learned “ first-aid,” a
noble example which has been followed but by
few medical men in Britain. It is difficult for
doctors to understand that first-aid is a speciality,
not taught in our medical schools to either students
or nurses; it is a distinct branch of surgery—simple
it may be to doctors and nurses, but yet one requir-
ing a short technical training. These Indian doctors
without pretence went through their course of in-
struction, quietly helped their untrained fellow-
members, and emerged at the end of the course skilled
in a special branch of surgery, and fit to teach the
subject because they themselves had wisely submitted
to the necessary instruction, the discipline and the
drill.
After instruction in the essentials of ambulance,
the contingent was taken over by the Government and
placed under the command of Colonel Baker, I.M.S.
(retired), by whom and his officers an efficient
auxiliary medical corps has been given to the Indian
Army.
The war in Europe has been productive of good in
many ways already, and let us hope that the good
will continue. Enmities have been set aside, or, at
any rate, kept in abeyance, political differences at
home and racial prejudices everywhere have col-
lapsed. Never was this more noticeable when, at a
meeting held at the Polytechnic in London, Mr.
Gandhi occupied the chair, whilst H.H. The Agha
Khan delivered an address to the members of the
Indian voluntary aid contingent. Hindu, Moham-
medan, and Brahmin met together, and in speeches
expressing tolerance of other beliefs and other
creeds, and radiant with patriotism to India as part
of the Empire, helped to smooth the road to better-
ment and peace.
The readiness with which the members of the
(Nov. 2, 1914.
Indian contingent acquired efficiency is only remark-
able to those ignorant of the alertness and the
receptivity of the brain of Indian students.
— E— a À——
Reprint.
FURTHER RESEARCHES ON COMBINED
VACCINES.*
By ALDO CASTELLANI, M.D.
Director, Clinic for Tropical Diseases, Colombo (Ceylon).
SINCE 1905 I have prepared and used in man
several combined vaecines, basing their preparation
on the experimental work I earried out in Bonn in
Professor Kruse's laboratory during the years 1901 and
1902. I succeeded then in demonstrating that an
animal (rabbit) inoculated with two different bacteria
produced, at the same time, agglutinins and immune
bodies for both ; and that provided a sufficient mini-
mum quantity had been inoculated, the amount of
agglutinins and immune bodies elaborated for each
germ was about the same as in animals inoculated
with one germ only. Moreover I demonstrated that
inoeulating an animal (rabbit) with three different
germs (Bacillus typhosus B, B. pseudo-dysentericus
No. 1 (Kruse), strain of B. coli communis), the amount
of agglutinins and immune bodies elaborated for each
germ is nearly the same as in animals respectively
inoculated with one species only. In rabbits I found
that by inoculating more than three species of micro-
organisms no good results were obtained, but, in view
of my recent work, if I had used animals of larger
size I might, and probably should, have found that
good results can be obtained even using more than
three species. I showed that when immunization is
obtained by a single inoculation, provided the mini-
mum dose sufficient to obtain the maximum immuni-
zation be given, the amount of agglutinins and
immune bodies elaborated by the inoculated animals
is not in proportion to the amount of cultures injected.
A series of rabbits inoculated with 9 c.c. of typhoid
eulture will give the same average agglutination limit
and the same amount of immune bodies as a series of
rabbits inoculated with 4 c.c.
COMBINED TYPHOID + PARATYPHOID A + PARA-
TYPHOID B VACCINE.
Since 1905 this vaccine has been extensively used
by me with good results. Having already pub-
lished several papers on it (Centr. f. Bakt., 1909 and
1913 ; British Medical Journal, 1913, &c.) I will limit
myself to stating here that my further investigation has
confirmed my previous work, viz., that this combined
vaccine is harmless; that it gives a certain amount of
protection for the three diseases; and that it is
advisable to use it always instead of the simple
typhoid vaccine in countries where paratyphoid A
* Reprinted from the Journal of the Ceylon Branch of the
British Medical Association, June, 1914,
Nov. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
327
and B occur, besides typhoid. The advisability of
using such a vaccine is shown by the fact that I have
seen two cases of persons inoculated with simple
typhoid vaccine before sailing from Europe, developing
paratyphoid A three months after landing in Ceylon:
the diagnosis being made by hemoculture. More-
over, cases of mixed infection, typhoid and para-
typhoid A, or paratyphoid B, do occur, though not
frequently. As a matter of fact I have recently
observed a case which must be extremely rare, of
contemporaneous triple infection: typhoid, para-
typhoid A, and paratyphoid B. I hope to soon pub-
:lish this case in detail, but I do not think there can
be any doubt about the diagnosis, as the stools con-
tained the three germs, the blood gave a strong
agglutination for all three, and the absorption test
showed that there were present specific agglutinins
for.each germ.
In previous papers I have given in detail the tech-
nique for the preparation of such vaccine; it suffices
here to state that the vaccine consists of an emulsion
of typhoid and paratyphoid A and B bacilli, killed
by heat (53° C.) and standardized so that 1 c.c.
contains approximately five hundred millions of
typhoid bacilli and two hundred and fifty millions
each of paratyphoid A: and B. The vaccine may
be prepared also without heating by emulsions
from agar cultures in 0'75 per cent. salt solution
to which 0°75 per cent. of carbolic has been added ;
the presence of 0'5 per cent. carbolic is sufficient
to kill the germs. For the first dose 0'5 c.c. to
0'6 c.c. should be injected with aseptic precautions
under the skin, preferably in the arm. The inocula-
tion is followed after three to four hours by some pain
and tenderness at the site of injection, and in a few
hours later by fever (100° F. or 101° F.) and general
malaise. All these symptoms have usually dis-
appeared in thirty-six hours. A second injection of
from 1 c.c. to 2 c.c. should be given seven to ten clear
days after the first inoculation. It is often followed
by less local reaction. A third injection (the same
dose as the second) may be given with advantage atter
a further interval of seven to ten days.
COMBINED CHOLERA + PLAGUE VACCINE.
On this combined vaccine I will say here only a few
words, having already published papers on it else-
where. Given the presence in Ceylon at the same
time of both cholera and plague, it occurred to me to
prepare a combined plague-cholera vaccine, which
should contemporaneously give a certain amount of
immunization for both diseases. The combined plague
+ cholera vaccine I prepare consists of an emulsion in
carbolized (4 per cent.) normal salt solution, of plague
bacilli and cholera vibrios from three days old cul-
tures, standardized so that 1 c.c. of the emulsion con-
tains approximately one thousand millions of plague
bacilli, and two thousand millions of cholera vibrios.
Of this vaccine, in adults, 1 c.c. is inoculated the first
time subcutaneously in the arm, and 2 c.c. the second
time, a week after the first injection. To date 250
individuals have been so inoculated. I can confirm
the conclusions I came to in my previous papers,
VIZ. u—
(1) The inoculation of the vaccine in the lower
animals induces a production of protective substances
for the plague bacillus and the cholera vibrio.
(2) The inoculation of such vaccine in human
beings is harmless ; the reaction is rather less marked
than after the inoculation of Haffkine’s, but severer
than after Lustig's vaccine.
(3) A small amount of agglutinin both for plague
and cholera appears in the blood of most of the
inoeulated persons. The agglutination for the plague
bacillus is generally very slight (1 in 10, 1 in 20, or
nil), but this is also the case when using a simple
plague vaccine such aS Haffkine’s or Lustig's. The
agglutination for cholera varies between the limits
1 in 20 and 2 in 60 (rarely higher) and is practically
the same as in individuals inoculated with cholera
vaccine only (see tables).
COMBINED TYPHOID + PARATYPHOID A +
PARATYPHOID B + PLAGUE + CHOLERA VACCINE.
This combined "five diseases " vaccine consists of
carbolized emulsion of typhoid, paratyphoid A and
paratyphoid B bacilli, cholera vibrios, and plague
bacilli. The technique of its preparation is as
follows :—
Agar cultures twenty-four hours old are used in the
case of typhoid, paratyphoid A, paratyphoid B and
cholera ; agar cultures three days old are used in
the case of plague, as this germ grows slowly. The
growth of the typhoid agar cultures is washed off
with 0°75 per cent. salt solution containing 0°5 per
cent. carbolic acid; is stored at room temperature
eighteen to twenty-four hours and then tested for
sterility and standardized in such a way that 2 c.c. of
this earbolized typhoid vaccine will contain approxi-
mately one thousand millions of typhoid bacilli. The
same procedure is carried out with paratyphoid A,
paratyphoid B and plague; each of these carbolized
vaccines will contain therefore one thousand million
germs per each cubic centimetre. The same technique
is used to prepare the cholera vaccine, but this vaccine
is standardized in such a way as to make it contain
four thousand million per cubic centimetre. After
having prepared, standardized, and tested for sterility
these five different vaccines, they are mixed together
in the following proportions :—
Cholera vaccine s 2 parts 2 c.c.
Plague i$ T Sian, wae ss Mus
Typhoid js i £s Bagg, 2,4
Paratyphoid A ,, za TR ug. diss
Paratyphoid B ,, = fupd4 Ay 55
The mixed vaccine will therefore contain per cubic
centimetre :—
Cholera 33 1,000 million
Plague .. Ve as ne E 250 a
Typhoid we es d is 260.
Paratyphoid A os Ms et 125 ,,
Paratyphoid B v. dis vs 125 ,,
Method. of Vaccination.
The inoculation is made subcutaneously in the
arm, in the same manner as when using simple
typhoid vaecine. In strong adults I give 1 c.c. the
first time, and 2 c.c. a week later; in adults who do
not appear to be very strong, or in individuals who
328
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 2, 191
fear the reaction, as also in women, I give half doses,
viz., $ c.c. the first time and 1 c.c. the second time.
Children between 10 and 16 years receive one-third
the adult dose. Children below 10 years of age
I have not yet inoculated. The inoculation of the
vaccine is followed in a few hours by a local reaction
(redness and some infiltration) and general reaction
(fever, malaise, rheumatoid pains) which generally
do not incapacitate one for work for more than
twenty-four hours. The reaction may be said to be
as a rule severer than after the inoculation of simple
typhoid, or the mixed typhoid + paratyphoid A +
paratyphoid B vaccine; a little severer also than
after the inoculation with Lustig’s simple plague
vaccine; but certainly somewhat less severe, in my
experience, than after using Haffkine's simple plague
vaccine. It is to be noted that occasionally one
comes across individuals who do not show, practically,
any reaction.
Innocuity of the Mixed “ Five Diseases" Vaccine.
Four persons who have volunteered have been
inoculated nine times, at a week's interval, with 1 c.c.
the first time and 2 c.c. on all the following occasions.
They have remained in good general health, though
two have had somewhat severe general and local
reactions. One person who also volunteered has
been inoeulated with a double strength mixed vaccine
four times—a vaccine which per cubic centimetre
contained double the amount of germs than the one
generally used. Apart from a more severe local
reaction no untoward effects were noted.
obtained in Man by the Combined
(Five Diseases) Vaccine.
Lack of time has prevented the study of the amount
of all protective substances produced in inoculated
individuals. The investigation, therefore, has been
limited to studying the amount of agglutinins pro-
duced in individuals inoculated with the mixed five
diseases vaccine, and comparing the results with
those noted in individuals inoculated with simple one
disease vaccines. Of course, one cannot gauge the
actual immunization obtained by simply studying
the agglutinins, but it is generally admitted that to
a certain extent agglutination is a rough index for
immunization. The results are collected in the
tables on pages 329-332.
From these tables it will be seen that the two
individuals inoculated with the combined five diseases
vaccine produced agglutinins in large amount for
typhoid, paratyphoid A and paratyphoid B; in small
amount for cholera, and in very small amount for
plague.
If we compare these results with those obtained
in individuals respectively inoculated with simple
typhoid vaccine, paratyphoid A vaccine, paratyphoid B
vaccine, cholera vaccine and plague vaccine, we see
that the amount of agglutinins produced in the latter
is not distinctly larger. In the control individuals
inoculated with simple typhoid, paratyphoid A, and
paratyphoid B vaccines, the amount of agglutinins
for such germs does not seem to be much higher; in
Immunization
individuals inoculated with simple cholera vaccine
the amount of agglutinins present is small in in-
dividuals inoculated with simple plague vaccine;
whatever kind of vaccine is used (carbolized, Lustig's
or Haffkine’s) it is also very small or absent.
COMBINED TYPHOID + MALTA FEVER VACCINE.
This vaccine consists of an emulsion in carbolized
(4 per cent.) normal salt solution (0'75 per cent.) of
typhoid bacillus and Micrococcus melitensis. Agar
cultures twenty-four hours old are used in the case
of typhoid ; agar cultures three days old in the case
of Malta fever. The growth of the typhoid agar
cultures is washed off with 0°75 per cent. salt solution
containing 0'5 per cent. carbolic acid, is stored at
room temperature eighteen to twenty-four hours and
then tested for sterility and standardized in such
a way that 1 c.c. will contain approximately one
thousand million typhoid bacilli. The same technique
is used to prepare the Malta fever vaccine, but such
vaccine is standardized so as to contain four thousand
million per cubic centimetre. These two vaccines are
mixed together in equal parts: the combined vaccine
will contain per cubic centimetre five hundred million
typhoid and two thousand million Malta fever. I have
inoculated this vaccine in eleven individuals with no
untoward symptoms. The reaction is hardly severer
than after the inoculation of simple vaccine. I have
not studied the agglutination week by week as I have
done in other combined vaccines, but the blood of
inoculated individuals develops a large amount of
agglutinins for the typhoid bacillus and a certain
amount of agglutinins for the Malta fever.
COMBINED “ TYPHOID + PARATYPHOID B +
PARATYPHOID A + MALTA FEVER VACCINE.”
This vaccine consists of an emulsion in carbolized
salt solution (0°75 per cent.) of typhoid, para-
typhoid A, and paratyphoid B bacilli and M. meli-
lensis. Agar cultures twenty-four hours old are used
in the case of the first three germs mentioned; agar
cultures three days old of Malta fever. The growth
of the typhoid agar cultures is washed off with
0'75 per cent. salt solution containing 0°5 per cent.
carbolic acid, is stored at room temperature eighteen
to twenty-four hours and then tested for sterility and
standardized in such a way that 1 c.c. will contain
approximately two thousand million typhoid. The
same technique is used to prepare the paratyphoid A
and paratyphoid B vaccines, each of these being
standardized to contain one thousand million. The
same technique is used to prepare the Malta fever
vaccine, but this vaecine is standardized in such à
way as to contain four thousand million per cubic
centimetre.
After having standardized and tested for sterility
these four different vaccines they are mixed together
in equal parts. Each cubic centimetre of the mixture
will contain the following :—
Typhoid vs T i : 500 million
Paratyphoid A AY 3 .. 250 $5
Paratyphoid B i a - | 250 h
Malta fever Pa . HOO g
Nov. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
TABLE I.—CounBiNED TYPHOID + ParatyrHorp A + PanATYPHOID B + CHOLERA + PLAGUE VACCINE.
(Two inocalations, 1 c.c. the first, 2 c.c. the second.)
Limits of agglutination. Weeks after lirst inoculation
Individuals Blood tested
inoculated against - rris
| 1 2
——— — —— M—À— M
B. typhosus 1/40 1/1200
B. paratyphosus A | 1/90 1/300
Kuppaswamy, | B. paratyphosus B | 1/20 | 1/250
V. cholere 1/20 1/20
| B. pestis .. 0 1/20
B. typhosus ..| 1/40 1/1000
B. paratyphosus A | 1/20 | 1/250
Periyaswamy 4| B. paratyphosus B| 1/20 1/150
| V. cholere .| 1/20 | 1/300
B. pestis .. --| 0 0
4 5 7 | 8 9 10 11
1/300 | 1/150 | 1/100 | 1/60 1/100 | 1/60 | 1/40
1/250 | 1/150 | 1/50 | 1/C0 1/60 | 1/40 | 1/20
1/200 | 1/100 | 1/50 | 140 1/00 | 1/20 | 1/20
140 | 1/80 0 0 0 0 0
0 0 0 0 0 0 0
1/300 | 1/200 | 1/100 | 1/100 | 1/150 | 1/100 | 1/40
1/250 | 1/150 | 1/100 | 1/40 | 1/60 | 1/20 | 1/20
1/80 | 1/150 | 1/80 | 1/40 | 160 | 1/20 0
1/200 | 1/150 | 1/150 | 1/40 | 1/20 0 0
120 | 120 | 0 | o | 0 0 0
I i
TABLE II.—VaccrNATION WITH COMBINED PLAGUE + CHOLERA VACCINE.
(Two inoculations, 1 c.c. the first, 2 c.c. the second.)
329
| Limits of agglutination.
Weeks after first inoculation
Individuals Blood tested
inoculated against 1 a
1 | 2 3 4 5 6 7
ee SN i as — — — | -— — — — ——— —— — - ———
s : B. pestis 0 1/20 0 | 0 | — 0 0
Tamil coolie No. 3 {| V Cholere |. 0 1/40 140 JJ 0 22 0 0
A B. pestis — .. 0 1/90 1/20 0 0 0
Tamil coolie No. 4 { V^ Porc ||| 1/20 1/40 1/80 | 1/60 0 1/20 0
: z B. pestis 0 0 0 0 | 0 0 0
Tamil coolie No. 5 | | V: cholere 0 | 1/20 180 | 1/60 1/60 0 1/26
I
TABLE III.—VaACCINATION WITH SIMPLE PLAGUE VACCINE.
(Haffkine—one inoculation of 4 c.c.)
|
Limits of agglutination for B, pestis.
Individuals | Weeks after first inoculation
inoculated
"E o|? | 8
E sl — o ——— —
Tamil coolie No.G 0 | 1/20 1/20 | CEES E "Or lp s
Cingalese No, 1 | 0, 0|— | e -— | A P =
: |
TABLE IV.— VACCINATION WITH SIMPLE PLAGUE VACCINE.
(Lustig—three inoculations. )
MÀ M— M M MÀ HÀ À— — M
Limits of agglutination for B. pestis.
| Weeks after first inoculation
Individuals
inoculated Ne | aes
1 2 | 8 | 4 | 5 | 6
= = -— |
Tamil coolie No. T 0 0 1/20 | 1,20 | — | 0
Tamil coolie No. 8 0 1/20 O | 1/20 | 0 0
—- - 0
Tamil coolie No. 9 0 0 O~ d — |
| | |
TABLE V.-—VACCINATION WITH SIMPLE PLAGUE VACCINE.
(Carbolized —two inoculations: 1 c.c. the first, 2 c.c. the second.)
Limits of agglutination for B. pestis.
Weeks after first inoculation
Individuals inoculated |
Cingalese No, 2 zs 25
Tamil coolie No. 10 ..
TaBLE VI.—VaACCINATION WITH SIMPLE CARBOLIZED CHOLERA
VACCINE.
(Two inoculations: 1 c.c. the first, 2 c.c. the second.)
| Limits of agglutination.
| Weeks after first inoculation
Individuals inocufated |
[o] Salts M EARUM
Tamil coolie No, 11. 1/20 1/40 | 1/20 | 1/20 | 0 0
Tamil coolie No. 12 0 | 1/40 | 1/40 0 1/20 | 0
|
Tamil coolie No. 13 | 1/20
|
1/60 | 1/20| 0
330 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Noy. 2, 1914.
TABLE VII. — VACCINATION WITH SIMPLE TYPHOID VACCINES.
(Two inoculations: 0*6 c.c. the first, 1*2 c.c. the second.)
Limits of agglutination for B. typhosus. Weeks after first inoculation
Individuals inoculated ad Eier E 8 | =
1 | 2 g^ I vis "lr cb 6 7 8 | 9 10 | 1
= — oe | - SS À 9 — — - ìi oom
| | ' |
Cingalese No. 3 (carbolized vaccine) .. | 1/20 | 1/800 | 1/300 | 1/200 | 2/200} — |1/100| — | 1/60 | 1/60 | 1/60
| |
Cingalese No. 4 (ordinary heated vac- , 1/20 | 1/500 1/500 | 1/200 | 1/300 | 1/150 | 1/150 | 1/150 | 1/150 | — 1/60
cine} |
i | | | |
TABLE VIII.—VACCINATION WITH SIMPLE PARATYPHOID À VACCINE.
(Two inoculations: 3 c.c. the first, 1 c.c. the second.)
Limits of agglutination for B. paratyphosus A. Weeks after first inoculation
Individuals inoculated | i :
| 1 2 3 | 4 | 5 6 7 | 8 | 9 10 n
Tamil (Singho) .. be 33 ..| 1/20 1/80 | 1/20 | 1/40 | 1/60 | 1/60 | 1/60 | 1/60 | 1/40 | — 1/40
Cingalese (Wellar) Us ys -.| O0 | 1/100} 1/100 | 1/60 | 1/60 | 1/80 | 1/80 | 1/60 | 1/60 | — | 1/60
TABLE IX.—VACCINATION WITH SIMPLE PARATYPHOID B VACCINES.
(Two inoculations: 0'6 c.c. the first, 1:2 c.c. the second.)
——————————————————————————————————————————————————
Limits of agglutination for B. paratyphosus B. Weeks after first inoculation
Individuals inoculated | |
|
1 2 3 | 4 | 5 | 6 7 8 9 10 n
— — es DONO. ea Se — AL P REA. SOS =
Cingalese (Asson).. — .. .. ..| 0 | 1/80 | 1/60 1/60 | 1/80! 1/60 | 1/20 | 1/20 | 1/20) — | 1/90
|
Tamil (Karuppen).. —.. .. ..| 0 f 1/20 | 1/80; 1/80 | 1/60 | 1/20 1/20 | 120| o | — | o
|
TARLE X.—VACCINATION WITH “TYPHOID + PanRATYPHOID A + PanRaTYPHOID B + Matta FEVER”
CoMBINED VACCINE.
(Two inoculations: 0:5 to 0°6 c.c. the first, 1 to 1:2 c.c. the second.)
Limits of agglutination. Weeks after first injection
Individual ;
Snonulated Agglutination for j
| 1 | 2 3 4 5 6 7 8
c (rs e cn cried]. m o exe E aes a ecc
B. typhosus.. — .. — ..| O | 1/400 | 1/400 | 1/400 | 1/200 | 1/200 | 1/150 | 1/150
H | | B. paratyphosus A . 0 1/200 1/150 1/150 1/150 1/100 1/100 1/100
3 B. paratyphosus B O | 1/300 | 1/100 | 1/100 | 1/100 | 1/80 1/80 1/80
| M. melitensis A 0 1/20 1/40 1/100 1/150 1/80 1/100 1/100
( | B. typhosus.. mn 0 1/600 1/500 | 1/500 1/300 1/200 1/200 1/150
Wellan No. 2! ! B. paratyphosus A O | 1/200 1/200 1/100 1/100 1/80 | 1/80 | 1/80
CMBR 10% A) a ER paratyphosus B O | 1/200 1/150 1/109 1/100 1/100 | 1/80 1,50
| | M. melitensis oF O | 1/20 1/60 1/80 1/100 | 1/100 | 1/80 1/80
i | |
_——$———— a
Nov. 2, 1914.]
Of this vaccine 0'5 to 0'6 e.c. is injected subeuta-
neously in the arm the first time, and 1 to 12 c.c.
the second time, after a week.
I have used this vaccine in a fairly large number of
persons. I may say that the reaction was hardly
higher than after the simple typhoid or mixed typhoid
paratyphoid A and paratyphoid B vaccines. The
blood of all the inoculated persons developed a large
amount of agglutinins for typhoid, paratyphoid B and
paratyphoid A, and a certain amount for Malta fever.
The amount of agglutinins produced for each germ
was apparently not distinctly less than in control
individuals inoculated with simple “one disease"
vaccines. (See tables.)
TABLE XI.—VACCINATION WITH SIMPLE MALTA FEVER
VACCINE.
(Two inoculations: 0'6 c.c. the first, 1:2 c.c. the second.)
7
Limits of agglutination for M. melitensis.
Weeks after first injection
Individuals inoculated ~~~ = a "B
|
1 2 8 4 5 6 | T 8
Suppen (Tamil) 0 |120 1/401 1/60 1/80 | 1/80 | 1/60) 1/60
g
Mr. S. (European) 0 0 1/80, 1/100
1/40} 1/120} 1/150 1/100
| |
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
331
stated in previous paragraphs and standardized as
follows :—
Typhoid T .. 2,500 million per cubic centimetre
Paratyphoid A .. 1,000 ” ” »
Paratyphoid B .. 1,000 ” v ”
D. asiaticus 1,000 ” n »
B. columbensis 1,000 ^ i »
These vaccines are mixed together in equal parts so
that each cubic centimetre of the combined vaccine
will approximately contain :—
Typhoid .. . an $5 500 million
Paratyphoid A .. 2% hs 200 ʻi
Paratyphoid B .. T T 200 "
B. asiaticus EM i5 5 200 i
B. columbensis .. 200 or
Of this combined vaccine 0'5 to 0'6 c.c. is inocu-
lated the first time, and 1 to 1'2 c.c. the second
time, a week later. The reaction is not much severer
than after a simple typhoid or typhoid-paratyphoid
vaccination. The inoculated individuals develop a
large amount of agglutinins of typhoid, paratyphoid A
and paratyphoid B practically in the same amount
as control individuals inoculated with simple ‘‘ one
disease" vaccines. Agglutinins for B. asiaticus and
B. columbensis are, however, present in most cases in
not very large amount and may soon disappear.
XII.—TypHom + PanarYPHOID A + ParatypHorp B + MALTA FEVER ma B. columbens s +
B. asiaticus.
(Two inoculations: 0*6 c.c. the first, 1:2 c.c. the second.)
Individuals inoculated Agglutination for
Limits of agglutination. Weeks after first inoculation
|
"| aeyphoia sh |
Paratyphoid A
Paratyphoid B
Malta fever
B. columbensis
B. asiaticus
Typhoid z
| Paratyphoid A
Paratyphoid B
Subetheris (Cingalese)
Mr. D. ....(European) 4 Malta Tavar
B. columbensis
B. asiaticus
Hi
cogoexooocooo
2 8 4 5 6
1/600 1/500 | 1/400 1/400 1/200
1/500 1/500 1/300 1/300 1/300
1/500 1/500 1/500 1/300 1/200
1/20 1320 | 1/80 1/100 1/100
1/100 1/100 1/80 1/40 0
1/80 1/100 1/100 1/80 1/60
1/500 1/500 = c 1/400
1/400 1/400 = — | 1/20
1/400 1/400 = | 1/200
0 1/20 Ere — 1/80
1/150 1/80 = 0
1/300 1/200 z5 1/60
COMBINED “ TYPHOID + PARATYPHOID A + PARA-
TYPHOID B + B. columbensis + B. asiaticus”
VACCINE.
There being in Ceylon cases of fever due to B.
columbensis and B. asiaticus, I have prepared a com-
bined vaccine containing these two germs also. This
vaccine consists of an emulsion in carbolized ($ per
cent.) salt solution (0'75 per cent.) of typhoid, para-
typhoid A, paratyphoid B bacilli, B. asiaticus, and
B. columbensis.
The individual carbolized vaccines are prepared as
TABLE XIII.—VACCINATION WITH SIMPLE B. columbensis
VACCINE.
(Two injections: 0*6 c.c. the first, 1:2 c.c. the second.)
Limits of agglutination, Weeks after first injection
Individual inoenlated =| — ——
ice Pe poe qns
Lac: hee a
Tamil Coolie No. 1/20 | 1/100 - 1/80 | 1/80 | 1/40 | 1/20
Tamil Coolie No. ..| 0 | 1/100 1/00 1/40 | 140 | 0
| | Í
332
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 2, 1914.
oS FT... — 00a
COMBINED “TYPHOID + PARATYPHOID A + PARA-
TYPHOID B + M. melitensis + B. columbensis
+ B. asiaticus” VACCINE.
This vaccine consists of an emulsion in carbolized
(4 per cent.) salt solution (0°75 per cent.) of typhoid
bacilli, paratyphoid A, paratyphoid B bacilli, B.
asiaticus, B. columbensis, typhoid, Malta fever micro-
coccus.
The individual vaccines are prepared as described
in previous paragraphs and standardized as follows,
per cubie centimetre :—
Typhoid .. = aC .. 2,400 million
Paratyphoid A .. as 23 1,000 »
Paratyphoid B .. 1,000 5
B. asiaticus i 1,000 2
B. columbensis .. 1,000 E
Malta fever 4,000 5
These vaccines are mixed in equal parts. The
. bbe . $ . .
combined six diseases " vaccine will therefore con-
tain per cubic centimetre :—
Typhoid .. T se a3 400 million
Paratyphoid A .. eu is 166 » (about)
Paratyphoid B .. m Ki 166 " 5»
B. asiaticus 3e es oe 166 ‘
B. columbensis .. nt S 166 i
Malta fever Fa ae 3s 666 AA
I have inoculated numerous persons with this
combined vaccine, 0'5 to 0'6 c.c. the first time, and
l to 12 c.c. the second time a week later. The
inoculated people have developed a large amount of
agglutinins for typhoid, paratyphoid A, and para-
typhoid B ; in fact, the great amount of agglutinins for
B. paratyphosus A and B. paratyphosus B is indeed
remarkable, being higher than in control individuals
inoculated with simple paratyphoid A and para-
typhoid B vaccines; a certain amount for Malta
fever. Agglutinins for B. asiaticus and B. columbensis
were produced in fairly large quantity but soon dis-
appeared. This, however, is apparently the case
also with control individuals inoeulated with simple
B. columbensis and B. asiaticus vaccines.
TABLE XIV.—VACCINATION WITH SIMPLE B. asiaticus
VACCINE.
(Two inoculations: 0*6 c.c. the first, 1:2 c.c. the second.)
—————————————M—
Limits of agglutination for B. asiaticus.
Weeks after first infection
Individual inoculated
|
1 2 3 4 | 5
1/200 | 1/150 | 1/100 | 1/80 | 1/60
| |
Tamil Coolie No.
COMBINED DYSENTERY + TYPHOID + PARA-
TYPHOID VACCINE.
For the preparation of this combined vaccine broth
cultures should never be used, as broth cultures of
dysentery bacilli give rise to an extremely painful
infiltration at the site of the inoculation. Peptone
water cultures should be used, or better, emulsions
in salt solution, such as I use at the present time.
The combined vaccine I now prepare consists of an
emulsion of Shiga-Kruse, Hys Y bacillus, original
Flexner-bacillus, a Flexner-like bacillus No. 1 isolated
in Ceylon, a Flexner-like bacillus No. 2 also isolated
in Ceylon, typhoid bacillus, paratyphoid bacillus A,
and paratyphoid bacillus B. The individual vaccines
are prepared by making emulsions from twenty-four-
hour agar cultures, in normal salt solution (0°75 per
cent.) to which 0'5 per cent. of carbolic acid has been
added.
The individual vaccines are standardized as follows
per cubic centimetre :—
Typhoid bacillus 4,000 million
Paratyphoid A bacillus .. 1,000 s
Paratyphoid B bacillus .. 2. 1245000 ^4
Shiga-Kruse bacillus a .. 1,000 a
Flexner bacillus .. - .. 1,000 3y
Hys Y bacillus .. 1,000 $5
Flexner-like No. 1 .. 1,000 $5
Flexner.like No. 2 .. 1,000 $»
These vaccines are mixed in equal parts so that
l e.c. of the mixed vaccine will contain :—
Typhoid ; Re i5 dra 200 million
Paratyphoid A 2 P ^ 125 F
Paratyphoid B N s e 125 T
Shiga-Kruse ga s és 195 j
Flexner $e x «s "s 125 is
Hys Y T A E Fit 125 55
Flexner-like No. 1 .. as Po 125 $
Flexner-like No. 2 .. ; 125
Of this vaccine 0'5 to 0'6 c.c. is given hypodermi-
cally the first time and 1 to l'2 c.c. after a week.
The reaction is somewhat severer as a rule than
after the typhoid-paratyphoid vaccine. As regards
amount of protective substances induced by such
vaccine, very little can be said as the agglutination
for the germs of the dysentery group was generally
slight, the agglutination limit seldom being higher
than 1 in 40; it was also very irregular and in-
constant, but the same may be said of individuals
inoculated with simple Shiga-Kruse, Flexner, &c.
vaccines. Typhoid, paratyphoid A and paratyphoid A
and B agglutinins, on the other hand, are produced
in fair amount, though, as a rule, distinctly less than
in control individuals inoculated with simple typhoid,
paratyphoid A and paratyphoid B vaccines. Possibly
the amount of bacteria of each species inoculated
falls below the necessary minimum.
CHOLERA + PLAGUE + TYPHOID + PARATYPHOID A
+ PARATYPHOID B + MALTA FEVER VACCINE.
This vaccine consists of an emulsion in carbolized
(5 per cent.) salt solution (0°75 per cent.) of cholera
vibrions, plague bacilli, typhoid, paratyphoid A and B
bacilli and M. melitensis. The individual vaccines
are prepared as described in previous paragraphs, and
standardized as follows per cubie centimetre :—
Cholera at an -. 4,000 million
Plague oe m F .. 1,000 E
Typhoid . 10000 ,,
Paratyphoid A 1,000 5
Paratyphoid B 1,000 „
Malta fever .. zs En .. 4,000 3»
These vaccines are mixed together in the following
proportions :—
Cholera .. vaccine 2 parts 2 c.c.
Plague .. Vs v es 2H us iq MS as
Typhoid aa x 255 oss;
Paratyphoid A.. " 1 part end
Paratyphoid B.. 3 ic I T ros
Maita fever 9s .. 2 parts r cs
Nov. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
333
Of this mixed vaccine 1 c.c. is inoculated the first
time and 2 c.c. the second, a week later. This vaccine
is still in the experimental stage, having being used
only in six individuals. The reaction is somewhat
severe and similar to that observed after inoculation
of a simple plague vaccine or a combined plague
cholera vaccine. From some observations made it
would seem that the production of agglutinins is very
similar to that observed in individuals inoculated
with one disease vaccines, but the investigation is
still to be continued.
RESUME AND CONCLUSIONS.
(1) The preparation of combined vaccines is based,
I think I may venture to say, on the experimental
work I carried out in 1901-1902 in Bonn, in Professor
Kruse’s Institute, when I demonstrated that in
inoculating an animal with two or three species of
bacteria—provided a sufficient minimum quantity was
given—agglutinins and immune bodies for all the
germs were elaborated, the amount of agglutinins
and immune bodies elaborated for each germ being
nearly the same as in animals respectively inoculated
with only one species.
(2) I have prepared and used in man the following
vaccines :—
(1) Typhoid + paratyphoid A + paratyphoid B.
(2) Typhoid + Malta fever vaccine.
(3) Typhoid + paratyphoid A + paratyphoid B
+ Malta fever.
(4) Typhoid + paratyphoid A + paratyphoid B
+ B. asiaticus + B. columbensis.
(5) Typhoid + paratyphoid A + paratyphoid B
+ B.asiaticus + B. columbensis + Malta
fever.
(6) Typhoid + paratyphoid A + paratyphoid B
+ dysentery Kruse-Shiga + dysentery
Fiexner + dysentery Hys Y + dysentery
Flexner-like No. 1 + dysentery Flexner-
like No. 2.
(7) Cholera + plague.
(8) Cholera + plague + typhoid + para-
typhoid A + paratyphoid B vaccine.
(9) Cholera + plague + typhoid + para-
typhoid A + paratyphoid B + Malta
fever.*
(3) The inoeulation in man of the above combined
vaccines is harmless. The reaction is not severe,
with the exception of the “cholera + plague" and
“cholera + plague + typhoid + paratyphoid A +
paratyphoid B” vaccines, when the reaction is severe,
though apparently rather less so than after Haffkine's
simple plague vaccine.
(4) The combined vaceines I am now using consist
of carbolized emulsions of agar cultures in normal
salt solution without heating. These emulsions seem
to give a less painful local reaction than broth
cultures killed by heat. The presence of 0°5 per
cent. carbolie acid is sufficient to kill the germs.
* The typhoid + paratyphoid A + paratyphoid B vaccine
and the typhoid + paratyphoid A + paratyphoid B + Malta
fever vaccine are now prepared according to my instructions
by the Serum Institute of Berne.
The "typhoid + paratyphoid A + paratyphoid B
vaccine" is, however, also prepared by heating
cultures at 53.
(5) The individuals inoculated with the above-
mentioned combined vaccines generally produce
agglutinins for each species of bacteria, and the
amount for each species is not much less than
control individuals inoculated with simple “ one
disease" vaccines. The only exception though only
to a certain extent—seems to have been in the
ease of the typhoid-dysentery vaccines.
(6) Combined vaccines, when efficient, are of
practical advantage, saving a great deal of time,
and rendering possible a contemporaneous vaccination
for several different maladies.
References to previous papers on mixed vaccines :—
CASTELLANI (1902). Zeitschrift für Hygiene.
" (1904). Ceylon Medical Reports.
3; (1909). Centralblatt für Bakteriologie.
ii (1909). Transactions of the Bombay Medical
Congress.
si (1912). Transactions of the Society of Tropical
Medicine.
5 (1913). The Lancet.
British Medical Journal,
Centralblatt fiir Bakteriologie.
— Qi
BuRMA RICE.
Although Burma has only ten million aeres under
rice, as compared with fifty million acres in Bengal,
it exports no less than 75 per cent. of the total
quantity of rice shipped from India. This is due to
the fact that its population is small in comparison
with the rice acreage, so that there is a large surplus
of rice for export. Though the available area for rice
has now been almost entirely taken up in Burma,
there are still possibilities of increasing the output by
irrigation and by intensive cultivation, so that there
seems to be no reason to expect any falling-off in the
Burmese exports in the near future. Rice is culti-
vated in Burma both in the Deltaic Region, with a
rainfall of 70 to 200 in. per annum, and in the
Central Region with the low rainfall of 25 to 35 in.
per annum. In the second of these areas rice is a
crop of secondary importance, except where irrigation
is possible. Apart from manurial and other experi-
ments having for their object the introduction of
improved methods of cultivation, the Department of
Agriculture in Burma is carrying on experiments for
the improvement of the rice grain. The chief objects
of these experiments are: (1) The elimination of red-
grained and awned varieties of rice; (2) the produc-
tion of grain which shall be free from awns and red
skin, and shall be of uniform size, vitreous in appear-
ance when husked, and spheroidal rather than cylin-
drical in shape; (3) the avoidance of dirt and foreign
seed in shipments of rice. This work is being done
at the Mandalay and Honwabi experiment stations,
and a brief description of the methods followed is
given in a paper read by Mr. A. C. MeKerral at the
Third International Congress of Tropical Agriculture
held in London last summer.—Journal of the Royal
Society of Arts, October 23, 1914.
334
Reviews.
THE CHEMICAL EXAMINATION OF WATER, SEWAGE,
Foops AND OTHER SUBSTANCES. By J. E.
Purvis, M.A., University Lecturer in Chemistry
and Physics as applied to Hygiene and Public
Health, St. John’s and Corpus Christi Colleges,
Cambridge, and T. R. Hodgson, M.A., Public
Analyst for the County Boroughs of Blackpool
and Wallasey, formerly of Christ’s College,
Cambridge. Demy 8vo. Pp. viii. + 228.
Cambridge University Press. 1914. Price 9s.
net.
This book is one of a series about to be brought
out by the syndies of the Cambridge University Press,
upon a scientific basis, owing to the increasing
importance of the study of hygiene and various
matters connected with publie health.
The present volume is intended for the use of
students attending courses of instruction for diplomas
and degrees in publie health, as well as for those
studying the chemistry of water, sewage eflluents,
foods, disinfectants, &c. There is no doubt that
analysts and others engaged in publie health matters
generally will find its contents useful.
The authors do not profess to give an exhaustive
account of all available methods of examination, but
describe those they have tested both in laboratory
instruction and in daily analytical work.
No less than eighty pages are devoted to water,
sewage and sewage effluents. The whole question is
gone into very carefully and exhaustively, a con-
siderable number of typical analyses being introduced
to illustrate variations which may occur in the
composition of the articles themselves.
Such simple, but necessary, foods as milk, cream,
butter, margarine, lard, dripping, suet, cheese, edible
oils, tea, coffee, chicory, cocoa, flour, baking powder,
bread, pepper, mustard, cane sugar, golden syrup,
honey, &c., are all dealt with and analyses of their
nutrient and other contents given. The extent to
which alcoholic beverages can be adulterated is
shown, as well as methods by means of which the
said adulteration can be detected.
There is an addendum giving a table of atomic
weights, alcoholic tables, volumes of oxygen and
nitrogen absorbed from the atmosphere by distilled
water and sea-water, as well as other useful informa-
tion. The index is a good one.
The book is neatly bound and not too heavy to
handle with ease.
Bursati. Memoirs of the Department of Agriculture
in India. MajorJ. E. Holmes, C.I.E. September,
1914. Vol. xi, No. 5, p. 19.
Major Holmes gives an interesting account of this
disease, and the results of some researeh work which
lead him to believe that bursati is a mycosis due to a
sporotriehum in that it closely resembles the sporo-
trichosis of horses and mules deseribed by Carougeau
in Madagascar. Bursati is prevalent in India among
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 2, 1914.
horses during the rainy periods and sometimes in the
hot weather. It invades the skin and subcutaneous
tissue of the angles of the mouth, the prepuce and
glans penis or vulva and the fetlocks and pasterns.
It begins as a subcutaneous nodule which eventually
invades the skin and forms an indolent open sore.
Imbedded in the sore are characteristic yellowish
spherical bodies, larger than a pin’s head, and known
as "kunkur bodies." The disease has been classified,
on insufficient grounds, with summer sore, granular
dermatitis and other similar skin affections. But the
nematode embryos present in these affections are
absent from the bursati sores; on the other band,
bursati sores, like “ leeches,” to which they bear a
clinical resemblance, have been shown to contain
a fungus. Major Holmes describes and pictures
mycelium and spores found in the lesions, and cultures
of the fungus on Sabouraud’s medium. The cultures
are white chalk-like growths which show on removal
a dry opaque skin, and in the opinion of Dr. Butler,
Imperial Mycologist to the Government of India,
resemble Sporotrichum minutissimum. It is note-
worthy that the healing of the lesions was promoted
by arsenical treatment (internally), and also that
cases improved under mercury and iodide of potassium.
As a criticism of Major Holmes’ conclusions it may
be remarked that the description of the cultures is
not readily recognizable as that of S. beurmanit,
which is found in sporotrichosis of humans and
animals, and that mycelium is not found in the
lesions of that disease, but only in cultures outside
the body, so that one must, perhaps, await further
evidenee before definitely placing this disease among
the sporotrichoses.
H. G. ADAMSON.
—— Wi
Hotes anb *ieíos.
DROITWICH.
AMONGST Anglo-tropieal health resorts Droitwich
has an interest of its own. The saline content of its
water is higher than that of any other spa, and it
occupies a prominent position in the treatment of
chronic rheumatism and all the rheumatoid affections.
For sciatica and all forms of neuralgia, from a gouty
and debilitating cause, it holds a unique position.
It has always struck us that the best time to visit
Droitwich is immediately upon return from the
Tropics and other places where the work has been
of an arduous nature, and we feel sure that in these
strenuous times many will appreciate having their
attention directed to Droitwich. We know of no
better place to commence or to complete restoration
to perfect health, to permit return to the strain and
stress which previously have caused incapacity for
arduous toil Particularly it is desirable to hear in
mind that not only are there good railway facilities
from London, but also from the northern, western, and
southern parts as well—from Glasgow, Liverpool,
Brighton and Southampton.
Noy. 2, 1914.]
THE USES OF THE SOYA BEAN.
THE soya bean is only at times used for food by
the Chinese and chiefly when supplies of the usual food
products are scarce. The soya bean hasbeen cultivated
by the Chinese chiefly for its oil and for the residue
known as “ bean cake” for fertilizing the soil.
There are six varieties of beans commonly grown
in China. These varieties are known as the yellow,
the green, the black, the red, the white, and the small
green. Of these the yellow, green, and black are
soya beans, and are distinguished from the others by
their size and ovoid shape. The red bean is used by
the people as food, the beans in their pods whilst
green being cooked and served chopped with oil or
other dressing.
The white bean is used chiefly in the manufacture
of what is known as “bean curd,” one of the most
common food products used by the people of China.
The beans are partially cooked and are then ground
in a primitive stone mill. To these beans as they
are ground a considerable quantity of water is added,
and the ground product is gathered on a tray and
drained of most of the water. It partially solidifies
and when drained it is cut in slices and eaten with
soy sauce, whicli in itself is the fermented liquor of
ground soya beans.
This curd is also dried and made into cakes. When-
ever wheat flour rises in price, beans of various sorts,
including the soya bean, are used as food.
Bean oil is used as food, as an illuminant, and as
a paint. Soy, the Chinese sauce, which is the basis
for most modern tabie sauces, is simply manufactured
by grinding the beans and mixing the meal with
water and a Chinese yeast. The mixture is then
allowed to stand for from three to four months, when
it ia drained off to form the sauce.
THE NORTH MANCHURIAN PLAGUE
PREVENTION SERVICE.*
THE disastrous epidemic of pneumonic plague
which raged in Northern Manchuria in the winter of
1910-11 induced the Chinese authorities to seek the
counsel and assistance of the great Powers in the
prevention of that disease, and incidentally of others.
An international conference was held at Mukden in
April 1911, and the delegates there assembled
unanimously advised the institution of a North
Manchurian Plague Prevention Service.
OBJECTS OF THE NORTH MANCHURIAN MEDICAL
SERVICE.
The staff comprises eight medical men, two of
whom are graduates of Cambridge and one of
Edinburgh University, the others being graduates
either of the Peiyang Medical College or of the Union
Medical College, Peking. The only European member
of the staff, Dr. F. E. Reynolds, acts as bacteriologist
to the department. The annual sum voted for carry-
ing on the service is 78,000 roubles—a little over
* “North Manchurian Plague Prevention Service Reports
from 1911 to 1913." Edited by Wu Lien Teh (G. L. Tuck),
M.A., M.D., B.C.Cantab. Cambridge University Press. 1914.
Pp. 186, with many illustrations.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
335
£8,000 in English money. The headquarters are
at Harbin, where a large hospital has been built in
which 50 plague cases can be isolated as well as 250
contacts. Since its opening in December, 1912, this
hospital has not been needed for plague, and no fewer
than 10,169 patients suffering from diseases of a
general character have been treated in it. Other
hospitals have been built, or are being erected, at
Lahasusu, Taheiho, and Sansing. Dr. Tuck expresses
the hope that eventually the medical officers will
obtain a voice in the direction of local sanitary
affairs, the control of which in Manchuria is at
present entirely in the hands of laymen.
INVESTIGATIONS INTO THE RELATIONSHIP OF THE
TARBAGAN TO HUMAN PLAGUE.
During part of the inquiry he was accompanied
by Russian experts under Professor Zabolotny.
It appears that although the tarbagan occasionally
suffers from plague the epizootic seems never to be
extensive, so that it is natural to assume that this
animal does not play so important a part as the rat
in the spread of the disease. Dr. Tuck regards its
direct relationship with human plague as almost a
negligible quantity. He draws attention to the
occurrence, especially in recent years, of outbreaks
of plague, frequently of the pneumonic form, in various
parts of Siberia, which are now regarded as endemic
centres of the infection. It is thought very probable
that the great Manchurian epidemic of 1910-11 had
its source in infection brought from one of these areas,
and not from the tarbagan, as was formerly believed.
No case of plague in man or animal has actually
occurred in Manchuria since the end of the recent
outbreak, that is, since April, 1911.
THE HISTOLOGY OF THE LESIONS MET WITH IN
PNEUMONIC PLAGUE.
Some material taken from fatal cases of pneumonic
plague in 1911 were forwarded to Cambridge Uni-
versity for examination, the results of which are
embodied in a joint report by Dr. Tuck and Professor
Sims Woodhead, entitled " Notes on the Histology of
some of the Lesions found in Pneumonic Plague.”
The material included portions of the heart muscle,
lung, bronchial glands, liver, spleen, and kidney.
After describing the lesions, it is stated that the
histology of the specimens afforded evidence of the
presence of an extremely acute septicaemic condition.
The authors then go on to observe that their investiga-
tions point to the suggestion that in the Manchurian
outbreak the amount of the infective material gaining
access to the upper respiratory passages was of
importance in determining the character of the septic-
iemia. They are satisfied that this was an instance
of a septicamia or bacteremia resulting from a pul-
monary infection. In warm countries the people live
in the open, and the facilities and channels by which
plague infection is communicated appear to be those
provided by rats and fleas; the plague material is
carried more or less directly from one patient to
another, or from the rat by the flea. In the human
subjeet the local reaction of the tissues and the bubo
may prevent the extension of the bacteria, especially
336 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
if the dose is small and the septicamic condition
occurs at a comparatively late stage, whilst if there is
good reaction of resisting tissues the disease may
never become septicemic. If, however, the septic-
mia once develops it is evident that the internal
organs will be affected in much the same way as they
are in pneumonie plague. In Manchuria, where
plague was at its height in the depth of winter, the
facilities for the inhalation or ingestion of large num-
bers of plague baeilli were far greater than they could
ever possibly be in warm countries, where people live
more or less in the open. The Manchurian patients
lived in overerowded and badly ventilated houses,
with doors and windows tightly closed because of the
intense cold, and, moreover, artificially heated. The
intensely fatal character of the Manchurian outbreak
was due to the massive doses of the infection received
by the patients.
z=
Correspondence.
INTRAMUSCULAR INJECTIONS OF QUININE.
To the Editor of THE JOURNAL OF TROPICAL MEDICINE
AND HYGIENE,
DEAR SrR,— Recently several letters have appeared
in the JOURNAL OF TROPICAL MEDICINE AND
HYGIENE on the question of the advisability or the
utility of hypodermic injections of quinine in malarial
cases.
In the numbers of the Journal which I have read
mention is not made of those rare cases where a
patient has an idiosynerasy to quinine per oram,
and suffers from intense headache, vertigo, nausea,
and a very severe form of urticaria.
This urticaria may be of such intensity as to frighten
the patient from taking quinine in any form.
Recently in Borneo I had such a patient, a surveyor,
who had to tramp and camp in the jungle and native
villages where he had every chance of acquiring
malaria. He had not taken any quinine because he
said " it was poison to him." Having a certain doubt
as to the reality of this poisoning I persuaded him to
take 10 grs. of bi-hydrochloride of quinine by the
mouth. The result was most distressing.
Then I gave him hypodermies of the same salt
three times a day for two days, then one injection
daily for a week. No poisoning took place from these
injections. The patient recovered and felt that at
last he could take quinine and get back to his employ-
ment. Heso appreciated the value of the hypodermic
injections that he purchased a syringe and ampoules
and injected himself twice a week thereafter as a
prophylactic. He had no further attacks of malaria,
and looked and felt a healthier man.
This little experience may be of interest to many of
your readers in tropical practice, where one has to
act promptly in severe cases of malaria fever, and use
any means of introducing quinine into the human
body available. .
Yours, etc.,
H. J. McGRIGOR,
Captain, R.A.M.C. Reserve of Officers.
Aldershot.
(Nov. 2, 1914.
Personal Hotes.
COLONIAL MEDICAL SERVICES.
West African Medical Staff.
Deaths.-—T. P. Fraser, M.B., Ch.B.Aberd., D.P.H.Camb.,
killed in action; J. A. Harley, M.B., Ch.B.Edin.; E. J. H.
Garstin, M.B.. B.Ch., B.A.O.Dub., Medical Officer, Nigeria.
Transfers. —J. H. Collier, M.D., C. M.Aberd., L. R.C.S. & P.,
L.M.Edin., L.F.P.S.Glas., Senior Medical Officer (Grade 3),
has been transferred from Nigeria to the Gold Coast; N. A. D.
Sharp, M.R.C.S.Eng., L.R.C.P.Lond., Medical Officer, has
been transferred from the Gold Coast to Nigeria; A. F. Ken-
nedy, M.B., B.Ch., B.A.O.Ire., Medical Officer, has been trans-
ferred from Gambia to Nigeria; R. W. Orpen, L.R.C.P. & S.,
D.P.H.Ire., Medical Officer, has been transferred from Sierra
Leone to the Gambia; J. W. S. Macfie, B.A.Cantab., B.Sc.
Edin., M.B., Ch. B. Edin., D. T. M.Liv., Medical Officer, has been
transferred from Nigeria to the Gold Coast.
Promotions. —W. H. G. H. Best, L.R.C.P. & S.Ire., Major
R.A.M.C. (Special Reserve), Senior Medical Officer (Grade 1),
Nigeria, to be a Principal Medical Officer in Nigeria; A. C.
Parsons, M.R.C.S.Eng., L.R.O.P.Lond., D.T.M.Liv., Medical
Officer, Nigeria, to be a Sanitary Officer in Nigeria; W. J. D.
Inness, M.R.C.S.Eng., L.R.C.P.Lond., D.P.H.Ire., Medical
Officer, Nigeria, to be a Sanitary Officer in Nigeria.
Resignation.—H. McC. Hünschell, M.R.C.S. Eng., L.R.C.P.
Lond., D.T.M.Liv., D.T.M. & H.Camb.
Retirement.--J. R. P. Allin, L.R.C.P. & S., L.M.Ire, D.T.M.
Liv., retires with a gratuity.
New Appointments.—The following gentlemen have been
selected for appointment to the staff: J. J. Baeza, M.B., Ch.B.
Glas., Gold Coast; N. 8. Deane, L.R.C.P. & S.Ire., Sierra
Leone; J. C. Watt, M.B., Ch.B.Glas., Sierra Leone; J. T.
Watt, M.B., Ch.B.Aberd., Nigeria; T. B. Fraser, M.B., Ch.B.
Aberd., D.P.H.Cantab., Nigeria; A. S. Burgess, M.R.C.S.Eng.,
L.R.C.P.Lond., M.B., B.C.Cantab. Gold Coast; E. Gibson,
L.R.C.P. & S.Edin., Nigeria; C. J. B. Pasley, M.R.C.S.Eng.,
L.R.C.P.Lond., Nigeria; T. Ryan, M.B., Ch.B., B.A.O.Dub.,
Gambia; C. Mackey, M.B., Ch.B.Vict.Univ.Man., D.P.H.,
D.T.M.Liv., Nigeria; J. M. O'Connell, L.R.C.P. & &$.Ire.,
Sierra Leone.
Other Colonies and Protectorates.
J. R. Dodd (Colonel, R. A. M.C.) has been selected for appoint-
ment as Medical Officer in charge for Ankylostomiasis work in
Trinidad.
C. G. H. Campbell, M.R.C.S.Eng., L.R.C.P.Lond., has been
selected for appointment as Assistant Medical Officer for Anky-
lostomiasis work in Trinidad.
A. Kidd, M.B., B.Ch., B.A.O.Dub., has been selected for
appointment as House Surgeon of the Victoria Hospital and
Bacteriologist in St. Lucia.
R. 8. Taylor, M.R.C.S.Eng., L.R.C.P.Lond., M.B., B.C.
Cantab., has been selected for appoiutment as a temporary
Medical Officer in Uganda.
N. Crichlow, M.B., Ch.B.Glas., has been selected for appoint-
ment as a Medical Officer in the Solomon Islands Protectorate.
W. M. W. Shepherd, M.B., Ch.B.Edin., has been selected
for appointment as a Medical Officer in Zanzibar.
A. L. Fitzmaurice, M.R.C.S.Eng., L.R.C.P.Lond., M.B.,
B.S.Lond., has been selected for appointment as a Medical
Officer in Somaliland.
E. H. Black, M.B., Ch.B.Edin., D.P.H.Camb., has been
selected for appointment as a Medical Officer in the Federated
Malay States.
P. W. H. Burne, M.B., B.S.Lond., has been selected for
appointment as a Medical Officer in the Straits Settlements.
—— eo
ERRATUM.
INADVERTENTLY the name of Dr. H. Harold Scott
was printed as H. Harold Salt on p. 253 of the
JOURNAL OF TROPICAL MEDICINE AND HYGIENE
on August 15, 1914, in a report of the discussion
on " Vomiting Sickness of Jamaica" in the Tropical
Section of the British Medical Association.
Nov. 16, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 22, Vol. XVII.
Original Communications.
DRACONTIASIS OR DRACUNCULOSIS: A
REVIEW.
By R. E. McCoNNELL, B.A., M.D.C.M., D.T.M.
Colonial Medical Service.
Definition.—A disease caused by the presence in
the body of Filaria medinensis (synonyms F.
persarum, Dracunculus medinensis, D. persarum, F.
dracunculus, F. xthiopica, Vena medinensis, Gordius
medinensis), commonly known as the Guinea-worm.
History and Geography.—Cobbald, Bartholini and
Kirschenmeister believe that the serpents of fire
spoken of in the Old Testament at the time of Moses
were Guinea-worms. The earliest definite reference,
however, is by Plutarch.. He quotes a writer of the
second century B.C., who reported it as occurring on
the shores of the Red Sea. Later Leonidas, in the
second century A.D., mentions it as occurring in India
and Africa.
It would be difficult to prove whether Asia or
Africa was the original home, although some circum-
Stances point to its being the latter continent.
On the West Coast the disease is indigenous in the
countries extending from Senegambia to the Kameruns,
although in the latter area it is said not to be common.
Clemow states that it is rare and probably not
indigenous in the Congo. Roux says that it occurs
in the Portuguese Colony, Angola. It is found in
British East Africa, and is common in the Nile
Province of the Uganda Protectorate. It occurs in
parts of Abyssinia and is endemic in Kordofan,
Darfur and Nubia. Cases are seen in the countries
bordering on the Mediterranean, but these are believed
to be imported.
In India the disease is very common. It is most
frequently met with in South Eastern India, Rajputana,
Central India and Gujerat; is common in Deccan ;
but not absent from any geographical division of the
Peninsula. It is rare only in the North West Pro-
vinces, in Lower Bengal, and the Coast belts of the
Madras Presidency.
Clemow has stated that in Ceylon it is also of
frequent occurrence, but Castellani and Chalmers,
both resident in this island, say that in spite of
many cases being imported from India, there is no
evidence that it spreads there. W. Carnegie Brown
states that cases are frequently imported into Malaya,
but that the disease is never contracted there.
It is endemic on the southern shores of Persia.
In Arabia the disease is common. Curiously enough
at Medina (which takes so prominent a part in the
nomenclature of the disease) it is said to be com-
paratively rare, while it is especially common in
Arabia Petrea, and the coasts of Hedjaz and the
Yemen. It has also been found in Syria.
In Turkestan it is not common, but in Russian
Turkestan it is more widespread (especially in the
Jisakh and Karshi districts). Castellani and Chalmers
state that it is known in the Fiji Islands.
For the most part cases reported from both North
and South America have been imported, but Osler
reports two cases from the United States, and there
is said to be a small endemic centre in the province
of Feira de Santa Anna, Bahia, Brazil.
The small number of cases reported from Europe
have been without exception imported.
The adult female is a long, smooth-surfaced, milk-
white, cord-like cylindrical worm. Its colour is due
to the mass of embryos it contains amounting to
several millions. On expressing these from any
portion of its continuity it assumes a dull translucent
whiteness. Davidson says that of forty specimens
the shortest was 12% in. and the longest 40 in.;
the great majority have been in my experience from
25 in. to 35 in. in length. The diameter is about
rs in.
At the head end it narrows somewhat and then
ends in an oval-shaped, bluntly rounded surface, the
“ cephalic shield." In the centre of this is a small
two-lipped mouth. Near the buccal opening are two
papille, one dorsal and one ventral, while near the
circumference of the shield are six smaller ones, two
lateral and larger, and four submedian. These are
sensory organs with nerve-endings in a little depression
at the apex of each.
The mouth leads into an alimentary canal which
is straight, atrophies toward the tail end, and ends
cecally. The vulvar orifice is placed externally to
the papilla. A vagina joins it to the uterus which
when distended by embryos occupies practically all
the body cavity and extends almost to the tip of the
tail. -It tapers towards the tail and ends in a small
hook-like process. The male, as recovered from
Leiper’s monkey, is only about 22 mm. long, but is
probably double this length when adult. It presents
five pairs of post-anal papillae.
The embryo is a short flattened body some 35 in.
long and about jo5s in. at its broadest part. The
anterior or head end is rounded while the posterior
end is produced into a very narrow tail. At the
head end is situated the small three-lipped mouth
which leads to a comparatively large alimentary
tract. This extends through about three quarters
the length of the embryo and probably ends cæcally.
Near the root of the tail a little sac is placed on
each side. The body surface is markedly striated.
Cyclops.—It is considered convenient to discuss
this little animal here, as it will be later referred to `
in its capacity as intermediary host. It belongs to
the Phylum arthropoda, order Copepoda. There are
both salt and fresh water forms, the latter alone, as
far as is known, being inculpated in the transmission
of the disease under discussion. It is a small animal
with a cephalothorax, thorax, and abdomen. On the
cephalothorax are: (1) A central eye consisting of
two or more eye-spots; (2) two pairs of antenna,
the anterior the longer, and both acting as natatory
organs; (3) a pair of mandibles; (4) two pairs of
maxille ; and (5) a pair of maxillipeds. The thorax
has five segments, each (or sometimes only the first
four) having a pair of swimming legs. The abdomen
is reduced and has five segments with an anus at
the posterior end.
Life-history. — The in the
adults are found
338
[Nov. 16, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
connective tissue, more particularly that in proximity
to the mesentery. Copulation takes place here and
probably the males die off soon afterwards. The
fertilized female then endeavours to reach the surface,
choosing for the point of exit some part which will
be likely to be exposed freely to water, a phenomenon
which may be called hydrotropism. A worm which
has assumed a subcutaneous position has been
observed to move several inches in a day.
Eventually a funnel-like opening in the skin forms,
l in. to $ in. in diameter, at the bottom of which
lies the head somewhat pushed to one side in order
that the vulvar orifice with its prolasped uterus may
present. If now a little water is poured over this
spot a clear or translucent fluid, which later becomes
more opaque, is seen to exude from the prolapsed
uterus which under the microscope is found to consist
of very many active embryos.
Leiper, whose work on this subject has been most
interesting, says that natural evaporation of their
watery habitat causes immediate death, and that they
cannot be resuscitated.
Leuckart, on the other hand, has stated that unless
complete desiccation has taken place the life processes
may be resumed. Sea and brackish water also kill
the embryos.
Leiper has found that the embryos live from four to
six days in ordinary water, and a day or two longer
in muddy water. A few more days are allotted to
them by some observers. The site of presentation is
usually on or near the foot, so that when the unshod
host enters streams or pools these become polluted.
If the little cyclops exists in such waters it is then
found that the embryos are ingested by it and make
their way from the intestine into the celom. No other
pond animal has been found capable of acting as an
intermediary host. Development then takes place in
the cyclops. In the early days some alimentary tract
changes take place. Between the eighth and twelfth
days it sheds a striated cuticle, gets rid of its long
swimming tail, and in a day or two later, according
to Leiper, a very delicate enveloping covering. They
also become cylindrical in shape.
No further ecdysis occurs, the subsequent changes
consisting of the differentiation of internal structures.
In the fifth week the larva becomes mature. Leiper
kept some two weeks longer but observed no further
change. Some of the cyclops, however, died with
their parasites. Fedschenko has observed that twelve
embryos did not inconvenience the host, but Leiper
found that six brought about death. During the first
two weeks the parasites are quite active, but then
become quiescent. If when the larva is mature the
cyclops is placed in a solution of '2 per cent. HCl, the
equivalent of the acidity of the stomach secretion,
the host dies but the parasite becomes very active,
gains the body cavity, and finally makes its way
through one of the openings (Leiper). Having made
its escape it swims actively about. The next step
then in nature is that man drinks water containing
cyclops with mature larve; these latter escape in the
stomach, make their way through the wall of the
alimentary tract, and in the adjacent tissue develop
into the adult worms. No other mode of infection is
now countenanced by investigators.
Manson has indeed reported that four European
ofücers, who both boiled and filtered the drinking
water, but who bathed in dirty water, contracted the
disease. One frequently, however, gets water in the
mouth while swimming, which forms an adequate
explanation of such cases.
Course of Disease.— The time intervening between
the ingestion of the larva and the appearance of the
mature embryo-bearing female at the surface of the
body is in the neighbourhood of one year. Manson
saw two cases in London in May—the patients had
been shooting together in the Nile Province of the
Uganda Protectorate during the previous May. Powell
reports that sixteen gentlemen and five servants left
Bombay on April 20, 1912. They remained away
two days and drank unfiltered water from a well. On
April 2, 1903, a Guinea-worm appeared in the leg of
one of the gentlemen, and between this date and
May 20, 1903, five other gentlemen and one servant
were attacked, making seven cases in all. The
shortest intervening period in these cases was 345 days,
the longest 435, while the majority of the eighteen
worms which appeared presented in a year and two
or three weeks. Davidson gives the intervening
period as nine to twelve months, but says that it may
be two years. W. Carnegie Brown (Penang) states
that he has seen cases develop in the Malay States
eighteen months after arrival, and remarks that
although cyclops exist in that country the disease does
not spread.. Leiper fed a monkey on bananas smeared
with five weeks’ old embryos contained in cyclops,
and six months later a post-mortem disclosed three
immature unimpregnated females some 30 em. in
length, and two small males 22 mm.
In Guinea-worm districts one occasionally meets
with sudden painful swellings, usually in the lower
extremities, which one is inclined to ascribe to re-
action following the premature emission of embryos.
The worm on reaching the skin does not always
pierce it immediately, but may do considerable sub-
sequent travelling.
Neveux, in referring to worms which do not pierce
the skin, places them under the following categories :—
(1) Those living beneath the skin exhibiting no
desire to emerge; they may live a long time. This
information was gleaned from native sources.
(2) Those dying in this situation and neither being
absorbed nor escaping. He cites a case in which
such a worm had existed for ten years, and was as
thick as & pencil.
(3) Those becoming cysts. These are ovoid, the
size of a hen's egg: some are fluctuant, others hard.
These were observed to follow the appearance of
Guinea-worms. I have never heard of or seen any-
thing suggesting category (3) and I doubt whether
an adequate examination of such cyst has ever been
made.
In making its way towards the surface the worm
bores through the tissue spaces, but adopts another
means of perforating the skin. Either from a re-
action seb up by virtue of its qualities as a foreign
Noy. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
339
body, or (which is more probable) from the secretion
of an irritating substance, the epidermis is raised by
an accumulation of fluid until either its own attenua-
tion or some outside agent causes it to break. It is
not likely that embryos are extruded until expulsion
is incited by contact with cold water. At the apex
of the somewhat crater-like resultant sore the head
of the worm may now be detected.
Symptoms premonitory to the appearance of the
worm are seldom observed in practice. One does not
often see a case before the actual rupture of the skin,
and the patients being, for the most part, in Africa
at least, people of limited intelligence this testimony
is unreliable. My opinion is that premonitory
symptoms are not the rule; nevertheless, they have
been not infrequently described and are probably more
common in Europeans. Dudgeon and Child cite a
case from India where twelve months after exposure
to infection there was pain and swelling in the foot,
but the worm did not present until a month later,
although there had been a small black spot on the
site of presentation some two weeks previously.
Powell states that he found some fever a few days
before the worm was palpable, and in two cases there
was swelling of the face and hands even when worms
presented in the legs. Manson states that there is
sometimes urticaria, and a little fever when it comes
to the surface.
Siberry reports a case in a European where the
foot was swollen for five weeks, there being no pain
or redness or constitutional disturbance: the skin
between two toes then became red hot and tense,
there being no fluctation; next day this burst emit-
ting first a yellowish and then a sanguineous fluid.
On the following day a pale fluid continued to escape ;
the base offered a small punched out appearance, and
then the worm presented.
In my European case he noticed, about December
26, 1913, that a dull ache such as he would have
expected from a varicose vein set in near the right
shin, after playing tennis or undergoing other exertion.
From December 30, 1918, to January 12, 1914, he was
on “safari.” On the evening of the 14th the leg
became very itchy, and before going to sleep a small
blister appeared. He broke this during the night by
scratching, and next day was dressing the resulting
sore when about 4 in. of worm suddenly appeared
which he broke, thinking it was the “core” of an
abscess. Following this numerous small pieces came
away, but he did not lie up. When he judged most
of the worm to be out he went on safari again.
The wound healed, but a few days later great inflam-
mation set in necessitating extensive incisions and
lying up for nearly three weeks.
On March 4 a small sore, surrounded by painful
extensive inflammation, appeared on the other leg,
near the ankle. He attributed this to an infected
scratch, the onset being so dissimilar from that of the
other Guinea-worm that the idea of its being a second
one was dismissed. He could not put his foot to the
ground. The inflammation on rest subsided, leaving
a erater-shaped depression, at the bottom of which
a Guinea-worm presented. In the course of a week
this was gradually extracted piecemeal. About three
weeks later severe inflammation set in in the anterior
tibial group of muscles. It was at this time that I
saw him first. Some ten days’ rest and treatment
left him with a sound member. It was impossible to
place the exact date of infection as he had been
stationed on the Nile Province for over a year, and
had left Gondokoro for Europe on the previous
May 11.
In a great many cases seen in West and Central
Africa I have only recognized two worms above the
knee, one in the thigh and one in the scrotum, and
neither of these had perforated the skin. These were
both palpable for their entire length in their subcuta-
neous position, and were the only two I met with which
admitted of extraction at one sittting. The over-
whelming majority of cases present in foot and ankle.
Manson states that in 85 per cent. of the cases the
presentation is in the feet and legs, but I am satis-
fied this percentage should be larger. Manson also
states that in the few Europeans he has seen they
presented in the body, scrotum and thigh. One
would expect to find among the clothed and booted
Europeans more diversity in the sites of presentation
than among his scantily clad dark-skinned fellow
men, as the worm in its search for an exit likely to
be exposed frequently to water is placed at a distinct
disadvantage among the former.
Presentation in the head has also been known.
Among Indian water carriers it is not uncommon
to find that the worm seeks the back, a clever adapta-
tion on its part to circumstances.
The worm discharges embryos for two to three
weeks, during which time, if uncomplicated, there
should be no constitutional disturbance. If, however,
the worm during extraction is broken as it lies among
the tissues, the internal emission of embryos sets up
a serious reaction, which may go on to abscess forma-
tion. This, of course, is more probable when the
channel in which the worm lies has already become
infected. Among careless natives such suppuration
is very common. The pus very often has both the
consistency and colour of anchovy sauce. In old
suppurative cases the accessible part of the worm
becomes filled with white cells which destroy the
embryos.
As many as fifty worms have been found in one
patient: three to five are by no means uncommon.
Economic Importance.—Death, direct or indirect, is
an extremely rare result, but the disease frequently
lays a heavy hand on village communities, where
nearly every member may be temporarily incapaci-
tated in varying degrees for work.
Manson reports an epidemic which occurred in a
column of soldiers at Old Calabar, in 1904, where
15 per cent. of the men were affected. On this
oecasion it was found necessary to requisition the
service of an additional company of men from Lagos
to carry out the work of the expedition.
Graham reports, from the Northern Territories of
the Gold Coast, that among an average force of 350
men, 57, or 16°28 per cent., suffered from the disease in
the course of a year. The number of days spent in
340
hospital aggregated 1,304, or an average of 22'8 per
patient. More loss of time was caused by this disease
than any other. At one time the Indian Army had
almost 5 per cent. annually affected. Occasionally
the worm enters a joint-setting up an arthritis, which
may limit the usefulness of the member. Rarely,
too, the suppurative inflammation, which not infre-
quently in natives is set up in the immediate neigh-
bourhood of the worm, when extensive enough leaves
troublesome contractures. Such destructive inflam-
mation may also extend to the bones, especially in the
region of the feet.
Periodicity.—In an endemic centre cases are seen
during every month of the year. Nevertheless, there
is relative periodicity which lends itself to explana-
tion. Pools, open wells, and the reeded edges of
streams are the usual sources of infection. Imme-
diately before the rains the pools and wells are at
their lowest, and the streams are sluggiest. It follows
that the cyclops are densest. In addition, these little
animals are usually more numerous near the bottom
of water supplies. As the rainy season in most
tropical countries appears annually with only a negli-
gible variation in the date, one would then expect
the greatest number of cases, taking the average
hidden life of the worm at one year and a few weeks,
to appear about the beginning of the following rains.
This is what actually occurs. Rodrigues and Neveux
in Senegal, say that it always appears there during
the rains. Leuckart, from Indian statistics, has con-
cluded that the disease most frequently manifests
itself in the two months at the end of the dry and
beginning of the wet seasons. But, curiously enough,
Graham’s figures from Gambaga show that in that
region the two months previous to the rains formed
the period of greatest incidence.
Prophylaxis.—It will now be evident that any
preventive measures must be directed towards the
exclusion of cyclops from household water. Boiling
and filtering are certain prophylactic measures, but
one cannot hope to induce native communities to
adopt such radical measures.
Fortunately, simply straining through cotton is
effective, and there is no reason why this should not
be universally adopted among such people.
On the West Coast of Africa communities have
changed the source of their water supply at great
inconvenience to themselves in order to avoid con-
tamination, while others have built new villages at
a distance—a not infrequent custom with some tribes
when they have been visited by any epidemic. Such
measures show wisdom, but infection is too often
carried to the new supply. If the mechanism of the
dissemination of the disease was simply and ade-
quately explained to them, I feel confident that they
could be relied upon to carry out the straining
process. Covered-in wells, properly constructed, would
be an alternative, and probably more reliable measure.
Villages on a reed-free stream with a moderate
current should be exempt.
Treatment.—After emitting embryos for some time,
the worm protrudes slightly. Before this occurs,
unless the worm lies subcutaneously, it is useless in
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 16, 1914.
my experience to adopt any measure other than
frequent application of water in order to hasten
emission of embryos coupled with antiseptic dressing.
Formerly, it is said that in India natives used a
trumpet-shaped tube to suck out the worm in order
to hasten its exit. Horton says that asafctida
kills the worms and prevents inflammation. Fox
in his case combined this with cataplasms, and
in five days found that the worm had come out.
Faulkner sends a current of electricity through it.
After some discharges he claims that the parasite
comes out whole. Others have advocated the injec-
tion of the worm with some poisonous substance,
such as perchloride of mercury. After the partial
protrusion, all native peoples have adopted some
means of exercising traction. Some Arabs have
attached a piece of lead to the worm; in India they
have attached a bunch of leaves or grass to it, after
which they swam or waded about in water. By far
the most universally adopted method among such
people is to wind the worm on a piece of wood, tying
it in a position so that it will not recede, and resum-
ing the pulling process after an interval. The great
danger of such methods in careless hands is the
rupture of the worm in its course among the tissues.
The common measure among European practitioners
in the Tropics is, after thoroughly douching with
water, to combine massage with gentle traction, and
then to apply a moist antiseptic dressing, this opera-
tion being repeated daily until complete extrusion has
occurred. In cases where it lies subcutaneously, one
cuts down on the centre of the worm and by running
a broad tape around it exercises gentle traction. It
is only in such cases that one may hope to secure
a good specimen. Two incisions are sometimes neces-
sitated by the intricate looping of the central position ;
even then a rupture may follow excessive traction.
In this subcutaneous situation, however, it has not
the ugly consequences of a rupture in the deeper
tissues.
BIBLIOGRAPHY.
CASTELLANI and CHALMERS. ‘‘ Manual of Tropical Medicine,"
1910.
Ciemow. ‘‘ The Geography of Disease,'' 1903.
CoBBoLD. *'*On Human Entozoa."’
Davipson. ‘‘ Tropical Hygiene.”
DupGeon, L., and CHILD, F. J. JOURNAL or Tropican MEDI-
CINE AND HYGIENE, August 15, 1903.
FAULKNER. Brit. Med. Journ., 1883.
Fox, F. “Skin Diseases.”
GnaHaM, W. M. JOURNAL or TROPICAL MEDICINE AND
HYGIENE, December 1, 1908.
Idem. Brit. Med. Journ., 1905.
LEIPER. Brit. Med. Journ., January 6, 1906.
Idem. Ibid., January 19, 1907.
LEUCKART. ‘‘ Die menschlichen Parasiten,’ 1876.
Manson, Sir P. J. Brit. Med. Journ., July, 1903.
Idem. ‘* Lectures on Tropical Diseases," 1905.
Idem. ‘‘ Tropical Diseases."
Neveux. Rev. de Med. et d' Hyg. trop., 1908.
PowELL. Brit. Med. Journ., January 9, 1904.
Roux, F. ‘‘ Maladies des Pays chauds."
SIBERRY, Capt. E. W. Journ. Roy. Army Med. Corps, 1904.
——— dS
Nov. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
341
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THE JOURNAL OF
Tropical Medtctne and Hygiene
NOVEMBER 16, 1914.
THE CHAIR OF TROPICAL MEDICINE IN
THE UNIVERSITY OF NAPLES.
Dr. ALDO CASTELLANI has been offered and has
accepted the recently created Chair of Tropical
Medicine in the University of Naples. He has also
been appointed Director to the Royal Clinique for
Tropical Diseases in the City of Naples. The wisdom
of the choice of the University authorities in Naples
will be apparent, for no man at the present day in
any country is better equipped for the high and
important duties attached to a chair of tropical
medicine than Dr. Castellani. The establishment of
this chair is an important event, for Naples is in
touch with semi-tropical and tropical countries in a
way that few other cities in Europe are, and affords an
opportunity of studying tropical diseases in Naples
first hand, as it were, and before the chronic stages
are reached. The other European tropical schools
are far north—London, Liverpool, Hamburg, Paris, &c.;
but Naples being in a warmer zone and on the high-
way of the Mediterranean affords opportunities that
render it a pre-eminent centre for collating those
stricken with tropical ailments, whether Italians or
those of other nationalities. Moreover, Italy with
its North African possessions is kept in immediate
touch with fresh cases of disease frequently of a
tropical character.
When the establishment of a tropical school in
this country was first publicly brought forward by
Mr. Cantlie at the Imperial Institute in 1898, Sir
Joseph Fayrer discussed the question, raised by the
late Dr. Thin, of a tropical school at Rome or Naples.
The suggestion did not find favour at the time, no
more did the establishment of a tropical school
at Calcutta. Now Calcutta has its school and Italy
has its school, the early dreams of the ‘pioneers of
tropical education being thus fulfilled.
Wise in the creation of a school in Naples, the
Senate of the University is to be further congratu-
lated on their forethought and wisdom by dignifying
the department of tropical medicine as a university
chair. In London, with its confusion of medical
organization, with a university which is wholly dis-
similar to that in any other town or country, the
title of professor is not granted to holders of chairs
in any department of tropical medicine; in Liver-
pool, however, where a university on recognized lines
exists, this is the case, and we are glad to see the
Neapolitan authorities have done likewise.
Dr. Castellani’s work, his powers of observation, his
accuracy, his methods and scientific acumen, are well
known to all workers in tropical medicine. His
momentous discovery of the presence of the trypano-
some in sleeping sickness in man and the many, many
additions to our knowledge since he went to Ceylon,
have earned him a world-wide reputation of unassail-
able distinction.
The loss to Ceylon by the departure of Dr. Castel-
lani will be deeply felt. Not only will the college
regret his resignation and feel the serious loss of this
distinguished member of its teaching staff, but the
community of Colombo have on all occasions ex-
pressed publicly and privately the value of Dr. Castel-
lani’s services to themselves individually. Recently
Dr. Chalmers, Dr. Castellani’s valued colleague and
joint author with him of the magnificent “ Manual of
Tropical Medicine,” left Ceylon for the Sudan, and the
departure of these two distinguished men is a loss to
the colony which cannot be easily, if ever, wholly
repaired.
We extend our hearty congratulations to Dr. Castel-
lani upon his appointment, and we sympathize with
the feelings of regret which the community of Ceylon
have expressed at losing him. Dr. Castellani has
made Colombo a centre of skilled medical advice to
all travellers in tropical Asia, and we are convinced
342
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 16, 1914.
that on returning to his native land Dr. Castellani
will make Naples a great centre of scientific and
clinical tropical medicine throughout the Mediterranean
shores and prominent amongst the tropical schools of
the world.
——9————
Annotations.
Note on Limitation of the After-pain of Quinine
Injections.—A. G. Peter, of Prestea, West Africa,
writes (Lancet, October 24), that patients, where
they have any choice, naturally prefer a practitioner
who has not the reputation of advocating this line of
treatment, and so greatly do some people dread the
after-pain of quinine injections that they will resort
to every kind of subterfuge to avoid them. To avoid
this he used quinine and urea hydrochloride tablets,
and found a conspicuous absence of any after-pain
when this drug was used. By trial the smallest
amount required to ensure comfort afterwards was
found to be 4 gr. of quinine and urea hydrochloride
compound. The points to be noted are: (1) A 3 gr.
tablet of quinine and urea-hydrochloride appears to be
sufficient to remove the after-pain of quinine injec-
tions. (2) One tablet is added to the amount of
quinine to be given, between 10 and 20 gr. of bihydro-
chloride, about 2 c.c. of water are then added, and
the boiled solution received into a sterile 2 c.c.
syringe for injection. (3) The solution is equally
efficacious when boiled, but in too concentrated
solution is apt to block the needle if not given at
once.
Early Operation for Gall-stones.—J. C. Hubbard
(Boston Med. and Surg. Journ., June 18, 1914) has
reviewed the conditions found in 108 autopsies on
bodies in which gall-stones were found; some had
been recognized, some suspected, others unrecog-
nized. Gall-stones were found in the gall-bladder
only in 76 cases. Gall-stones caused the death of
nine of these patients by setting up fatal trouble in
the liver or gall-bladder. The causes of death
were: hepatitis, cancer of the gall-bladder, pancrea-
titis, abscess of the liver. Sixty-seven died from
conditions not connected with gall-stones. There
were 32 cases where the stones had passed beyond
the gall-bladder, and were found in the ducts. In
14 of these the cause of death was due to the gall-
stones. The causes were given as abscesses of
the liver, peritonitis, cholangitis, abscess of bladder,
cholecystitis. In 4 out of the 108 cases a stone
was found which had ulcerated through into the
intestine. The relative mortality between gall-stones
in the bladder and those that have passed into the
ducts is of special interest. The mortality from gall-
stones in the gall-bladder is, without operation, 14
per 100; 3 to 5 after operation, increased to 43 per
100 when the stones are in the ducts. The
deduction is obvious that advice for operation should
follow the establishment of a diagnosis before the
stones have had time to set up any secondary
ohanges calculated to lead to a fatal result.
Acetyl-salicylic Acid in Treatment of Asthma. G.
Jepsen (Ugeskrift for Leger, Christiania, August 20,
Ixxvi, No. 34, pp. 1449-1494) has suffered from
asthma himself and has found great relief from acetyl-
salicylic acid, as also a number of patients, as he
describes in detail. The dose was 1 grm. (15 gr.) and
it always helped at once and has served to ward off
impending attacks. Some of his patients have been
thus taking it for two years, one for three. In some
other eases no benefit was apparent from it and only
epinephrin gave relief. All had a vasomotor rhinitis
which suggests that reflex action from the nose may
be an important factor in asthma. Treatment of the
rhinitis is thus an indispensable preliminary to treat-
ment of theasthma. The asthma subsided completely
during acute inter-current diseases in his patients.
Disappearance of Typhus, Relapsing. Fever and
Plague from Civilized Countries (K. Kisskalt, Deutsche
medizinische Wochenschrift, Berlin, August 6, xl,
No. 32, pp. 1601-1648).—The recent discovery that
typhus and relapsing fever are transmitted mainly if
not exclusively by the louse readily explains their
vanishing from a country as habits of cleanliness
exterminate vermin. This also has co-operated in
the disappearance of bubonic plague, as fleas and rats
have been brought under some control. Another
important factor may be the fact that the black rats
have been driven out of Western Europe in the last
century or so by the brown rats which are not so
tame as the black house rat. There is a disease
among rats in Europe which causes chronic lesions
almost identical with those of plague in rats. It is
caused by the Bacillus pseudotuberculosis rodentium,
and this resembles the plague bacillus so closely that
there is much to sustain the assumption that this is
the degenerated descendant of the original bacillus of
virulent rat plague in former centuries, modified by
countless passages through rats.
Protective Ferments against Maize-albumin in Serum
of Pellagrins (Deutsche medizinische Wochenschrift,
Berlin, August 6, xl, No. 32, pp. 1601-1648).—
Nitzescu, of Bucharest, calls attention to the possibility
of early serodiagnosis of pellagra by the presence of
protective ferments against maize albumin—zeinolytic
ferments. The maize albumin or zein seems to have
a toxic action, and the ferments formed to combat
this linger in the blood long after other symptoms
have disappeared when maize is dropped from the
diet. In a recent case a patient with merely nervous
manifestations was shown by the serodiagnostic test
to be suffering from otherwise latent pellagra, and
later other characteristic symptoms developed. The
response was particularly pronounced in eight cases
with predominant gastro-intestinal disturbances. The
reaction was negative in the fifty-eight cases only in
two pellagrins who had been in the hospital for over
two years and had eaten no maize during this time
and had no symptoms left except slight mental
confusion at times. The zein was extracted accord-
ing to Osborne’s directions and the Abderhalden
ninhydrin technique was followed otherwise.
Nov. 16, 1914.]
—$—$———$—$—$— Omaha ——_=
Abstracts.
HJEMORRHAGE LATE IN TYPHOID FEVER.
By BRAILLON AND Bax.*
WE distinguish this disease from intestinal haemor-
rhage due to the specific ulceration of the bowel, and
early severe, malignant hemorrhage, similar to that
which occurs in other infections. The late occurs
during defervescence or convalescence in cases which
have given no indication of unusual severity. It
usually lasts about six to eight days, ending most
frequently in recovery.
A girl, aged 16, was admitted on October 98 to
hospital with a fifteen days' history of illness, without
previous hemorrhage. The temperature was 104? F.,
the pulse 80, the urine was clear, rose spots were
present on the abdomen, and Widal’s reaction was
positive at 1 in 50. On November 7 the temperature
began to fall and convalescence seemed imminent.
On November 11 the urine was slightly red. On
November 13 there was slight bleeding from the
gums, and the urine was more highly coloured. In
the evening epistaxis occurred, and the bleeding from
the mouth and gums continued. A mixture contain-
ing chloride of calcium and ergotine was prescribed.
On November 14 considerable intestinal hamorrhage
occurred, and the oozing from the gums continued.
The urine contained much blood. The temperature
was normal, but the pulse was 120, and very small,
and the skin and mucous membranes were very pale.
She was given caffeine and a hypodermic injection
of serum with 0'04 grm. of emetine hydrochloride.
On November 15 the bleeding from the nose and
mouth continued, as did the hematuria, but there
was no further hemorrhage from the bowel. The
patient was in a state of torpor and appeared almost
exsanguine. The pulse varied from 130 to 140 and
was almost imperceptible, while the temperature had
fallen below 98'6°F. An injection of 500 c.c. of
saline solution was administered subcutaneously. In
the afternoon she was in a precarious condition, and
as hemorrhage continued blood was transfused.
The connection was maintained for forty-five minutes,
by which time the donor had become pale and rather
faint. The patient felt better and showed slight
colour in the cheeks, while her pulse fell to 100,
but was still very small. Next day she showed
marked improvement, the skin and mucous mem-
branes being well coloured, the pulse 90, well filled,
and the temperature 101' F. The bleeding from the
nose and the gums had ceased, and the hematuria
was less marked than before the transfusion. The
bleeding from the gums recurred during the night, and
on the following day the hematuria again increased.
In the afternoon she vomited a large clot of dark
blood. An injection cf 0'04 grm. of emetine hydro-
chloride was again administered. On November 18
hzematemesis recurred, and the oozing from the gums
continued in spite of the application of perchloride of
iron. The hematuria was also very abundant. The
* Abstracted from Bull. et Mém. de la Soc. méd des Hop.
348
forearm at the site of transfusion had become
cedematous, and on exposing the wound a soft clot
protruded. In the afternoon profuse bleeding occurred
from the wound and could not be entirely arrested.
Next day her condition appeared to be hopeless. The
oozing from the wound and from the gums continued,
as well as marked hematuria. The pulse was 160
and almost imperceptible. A slow instillation of
500 c.c. of saline solution containing forty-seven
parts of glucose in 1,000 was given by the rectum.
This was replaced in the afternoon by a saline solution
containing 1 per cent. of gelatine, of which a litre was
given during the afternoon and evening with perfect
tolerance. A hypodermic injection of 10 c.c. of
electrargol and another dose of emetine were also
gven. On the following day the temperature was
100?F. and the pulse 120. The hemorrhages had
ceased suddenly and simultaneously during the night.
The gums were almost normal, and the urine was
clear and free from blood by chemical and micro-
scopical examination. Another 500 c.c. of glucose
solution was given by the rectum. Next day the
improvement was maintained and no further hemor-
rhage occurred. She gradually regained strength, and
left hospital on January 24.
The writers made detailed blood examinations,
including differential counts, and point out the unusual
severity of this rare condition and the failure of the
transfusion of a large quantity of blood to arrest it.
The striking arrest of the haemorrhages by the instilla-
tion of gelatine in saline solution per rectum shows
the value of this method.
THE IMPORTANCE OF RECTAL
EXAMINATION.*
By C. O. HawrHoRNE, M.D.
RECTAL examination ought not to be omitted in
any instance of abdominal tumour or dropsy, per-
sistent or recurring abdominal pain, tenesmus,
obstinate sciatica (especially if bi-lateral), and of
continuing diarrhoea on the one hand or constipation
on the other.
Case 1: Severe and Recurring Abdominal Pain
relieved by Rest; mo Physical Signs in Chest or
Abdomen, but a Malignant Tumour found per rectum.
—A man, aged 40, for many months complained of
dyspeptic symptoms and constipation with, more
recently, severe pains in the lower abdomen. Under
rest these symptoms had been relieved, but on return-
ing to his work as a music-hall performer they
recurred, and the pain in particular had been ex-
tremely severe; at no time had there been any blood
in the stools. Physical examination of the abdomen
showed nothing abnormal, but a considerable malig-
nant growth was readily recognized per rectum.
Case 9: Symptoms of “ Colitis,” in a Woman, aged
98, due to a Malignant Growth in the Rectum;
Abdominal Examination Negative—A woman, though
only aged 28, was the victim of a malignant growth in
the rectum. She had for several months been unde;
* Abstracted from the Polyclinic, August, 1914.
344
treatment for “colitis” (frequent action of the
bowels and some abdominal pain), but hardly regarded
herself as seriously ill. To rest on a diagnosis of
“ colitis " until thorough and repeated attempts have
been made to exclude all gross forms of organic disease
is unsafe.
Case 8: Diarrhea for some months in Man, aged
14; no Obvious Failure of Health and no Physical
Signs in Abdomen ; Rectal Examination Negative, but
Tumour discovered by Sigmoidoscope.— A man, aged
74, for six months had to go to the w.c. some ten to
twenty times a day, the stools containing mucus,
and, at times, a little blood. He had undergone
various methods of treatment for “ colitis," but with-
out benefit. The patient protested that his general
health was " quite good," and denied that he had
lost flesh. He appeared to be a vigorous and hearty
old man. Rectal examination was negative, but with
the sigmoidoscope a considerable growth was detected
in the sigmoid flexure.
A negative rectal examination with the finger is not
sufficient finally to exclude a malignant growth; the
sigmoidoscope is necessary to make such exclusion
absolute.
Case 4: Enlargement of Liver of Doubtful Nature ;
Malignant Ulcer in Wall of Rectum.—A man, aged 52,
had considerable enlargement of the liver. It was
doubtful whether this was due to malignant disease,
cirrhosis, or abscess of the liver. The discovery of
an ulcer with thickened edges and base in the wall of
the rectum settied the question.
Case 5: Ascites without other Evidence of Disease ;
Discovery of Malignant Growth on Rectal Examina-
tion.—A middle-aged woman complained of abdominal
distension which was found to be due to extreme
ascites. The chest was normal. The urine was free
from albumin. There was some cedema of the lower
limbs, but this could be accounted for by the pressure
of the ascitic fluid on the abdominal veins. As for
the abdominal organs, a confident opinion could not
be given as the abdomen was full of fluid. Still,
there is a presumption that ascites in an adult, and
unattended by other evidences of disease, means
cirrhosis of the liver. This view had been accepted ;
but on rectal examination a considerable tumour
could be felt through the anterior wall of the rectum.
After paracentesis several similar tumours were found
in other parts of the abdomen, and the diagnosis was
plainly malignant disease.
Case 6: Obscure Abdominal Pain following Febrile
Attack ; Visible Intestinal Peristalsis; on Rectal
Examination discovery of Impacted Ovarian Cyst.—
An unmarried woman, aged 30, had what seemed to
be some simple febrile disturbance for ten days.
Soon after defervescence she began to lose flesh and
suffered from short but severe attacks of spasmodic
pain in the lower abdomen. It was difficult to bring
these symptoms into relation with the earlier febrile
condition, and no physieal changes could be detected
in the abdomen. But on one occasion it chanced that
she was seen during an attack of pain, and then on
exposing the abdominal wall peristalsis was seen.
This showed that somewhere in the lower intestinal
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 16, 1914.
area there existed some form of mechanical obstruc-
tion. On rectal examination a considerable tumour
was found in the pelvis. It proved to be an ovarian
cyst firmly adherent to the surrounding structures,
and it was afterwards successfully removed. A small
collection of recently formed pus was found, and it
may be that to this the original febrile attack was
due.
THE SURGERY OF THE SUBPHRENIC
SPACE.*
By FreD. D. Binp.
THE level of the subphrenie space alters with
alterations of the diaphragm, and it may be much
raised without our being able to say that there is
anything wrong with it; e.g., I have seen a very large
hepatic hydatid cyst force the diaphragm up to the
level of the third and even of the second rib, without
impairing the integrity of the space. In the opposite
direction the space may be depressed by pleural
conditions, e.g., effusions, empyema.
As a rule the space is at a lower vertical level on
the left side than on the right, but dilation of the
stomach may be so great as to equalize the levels.
The position of the diaphragm is best arrived at by
the aid of the fluorescent screen. The space may
be traversed by tumours and inflammations with but
little harm to it; e.g., a hydatid on upper surface of
the liver discharging into a bronchus, and adhesions
may be present after operation without any dis-
comfort to the owner. I have several times examined
cases after the transpleural operation, and have seen
the shadow of the diaphragm distorted at the site of
the operation. The space on the right side may be
obliterated, wholly or in part by disease, causing
adhesions between the upper surface of the liver and
the under surface of the diaphragm. The commonest
cause of dense adhesions in this position is syphilis.
Gumma of the liver is apt to give rise to adhesions
of the peritoneal surfaces of the space; the recurring
pains over the liver region experienced by old tertiary
syphilities are generally to be interpreted in terms
of adhesions between the liver and the diaphragm.
Nature, as well as the surgeon, occasionally fill up
& portion of the space with fringes of omentum.
Carcinomatous aggregations wil sometimes cause
adhesions by their raised periphery, and the interior
being filled with serous fluid a most puzzling condi-
tion results.
In performing transpleural operations, the nearer
the surgeon keeps to the costal cartilages the more
likely will he be to strike the apposition of the two
pleural surfaces. This has three advantages : first,
that it is technically much easier to enter the
abdominal cavity in this situation; secondly, that no
collapse of the lung can take place; and, thirdly, and
most important, that sepsis is much less likely to
spread into the general cavity of the pleura. Per
contra, the mid-axillary line, unless at the costal
margin, is the worst place in which to open the pleura
* From the Medical Journal of Australia, July 4, 1914.
—-. ll
Nov. 16,1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
345
preparatory to opening the peritoneum. Hydatid on
the upper surface of the liver of size sufficient to
cause symptoms without suppuration, can be attacked
as & rule transpleurally by removing a portion of
costal cartilage or rib adjacent to it. The greatest
importance is attached to this choice of position in
transpleural operations. In pursuance of this I have
on two occasions operated too far forward to hit the
hydatid, which was of moderate size. Except for loss
of time, no harm was done, as it was easy to follow
the rib back a short distance until the place where
the adventitia implicated the subphrenic space was
reached. "Though several times cases have been lost
of liver hydatid operated on abdominally, I have not
yet lost one attacked transpleurally, which is due
largely to a recognition of the value of selecting a spot
where the two pleural surfaces are apposed and will
remain so. Operations should never be performed
without a screen examination, which shows us
definitely the shadow of the cyst.
Transpleural operations are obvious; not so sub-
pleural operations, i.e., access to the diaphragm
behind through an intercostal space without opening
the pleura. It is doubtful whether we can utilize
this route with advantage except occasionally... We
know that disease, notably hydatid and carcinoma,
passes through the diaphragm into the thoracic cavity
by direct extension, by continuity of tissue ; infection
can pass in either direction in this way, but also by
means of the lymphatie system. It is said that the
passage is more facilitated by anatomical disposition
when the invasion is from above than when it is in
the opposite direction. Of course, there is always the
difficulty of negativing the carriage of germ infection
by the blood-stream. Pneumococcic infection of the
peritoneum does not appear generally in the vicinity
of the diaphragm, and the sudden appearance of
infection in the pleure or pericardium in a person
abdominally inflamed can be better explained in
many cases by blood distribution than by direct
lymphatic infection. Great pressure in the space
must interfere with the lymphatie return, and serous
effusion in the pleura is a common accompaniment of
live hydatid of a large size on the upper surface of the
liver. It is to be remembered that pleural effusion is
much more likely to be a concomitant of hydatid
on the upper surface of the liver than of hydatid
of the lung. Inflammatory fluid in the pleura may
be due to abscess beneath the diaphragm, so that we
have a layer of clear fluid or of pus. In a similar
manner great pressure may cause varicosity of the
veins of the diaphragm, which empty mainly into
the musculophrenic in this situation.
A very bad quarter of an hour was experienced by
me once during a transpleural operation for hydatid
on the upper surface of the liver in a person who
showed large subcutaneous veins. After the removal
of a portion of the eighth rib, I plunged a knife in the
space left through into the cyst. Alarming venous
haemorrhage occurred, which a finger in the adventitial
cavity was able to control. It was extremely difficult
to stay in any other manner, even temporarily. A
large tampon of gauze in the cavity, stuffed with the
pledgets and pulled into the wound, eventually
stopped it, but further bleeding took place a week
later on removal of this tampon, and had to be
arrested in the same way. Eventually a good re-
covery was made. I take it that the diaphragmatic
veins were varicose from the same reason as the
subeutaneous ones, and I had partially divided a
dilated vein.
In X-ray examinations the patient should be viewed
face to the tube, and back to the tubeto see in which
position the hydatid is nearest to the screen. Puncture
with a trocar before operation is inadmissible. When
a portion of one rib is removed—and one rib, as arule,
is enough—then the exploring trocar can be used with
advantage. A small one is best, and the objects of
its use are, firstly, to confirm the suspected existence
of the hydatid, and then to determine the distance
between the diaphragm and the cyst. This can
generally be gauged with fair accuracy. If the adven-
titia abuts right on to the subphrenic space there will
be no liver tissue to pass through, so that a knife can
be plunged through two layers of pleura, the subserous
tissue, the diaphragm, and two layers of peritoneum,
into the cavity of the adventitia. At once the left
forefinger should enter and pull up the adventitia into
the wound. Four stitches are now put through these
various tissues (which are now for the surgeon one
single layer), so that looking into the wound we see
right into the adventitial cavity. This method seems
somewhat wanting in care, but as a matter of fact it
is much less risky than more careful manœuvres, viz.,
sewing the surfaces of pleura together, cutting through
the layers singly, opening the adventitia by large trocar,
and so on. We want to avoid soiling of the pleura
and peritoneum by hydatid fluid, and this quick way
is the best manceuvre. If there be a layer of liver
tissue over the cyst then we must proceed more cir-
cumspeetly, and, boring through the hepatie tissue
with the fingers along the track of the trocar is the
best way of dividing it. This can seldom be needed,
as by the time the cyst is discovered in the vast
majority of cases it will have incorporated the serous
membrane with its adventitia. The patient should be
lightly anesthetized so as not to nullify abdominal
pressure, which can be increased by the hand of the
assistant pressing on the integuments below the costal
margin.
There is no need to alter the technique for suppur-
ating hydatids; they need for their treatment the
bolder method more than uninfected ones. I have
the greater respect for infected cysts near the posterior
aspect of the vena cava, of a size that does not cause
them to be accessible. They are a very deadly form
indeed. They tend to burst into the vena cava, and
give rise to fatal hydatid embolism, or hemorrhage.
Even the uninfected cysts may take this desperate
course. Therefore the surgeon, if he can diagnose
such cysts, wishes to reach and remove them, if he
can diagnose them by the pain they cause when
infected, by the septic condition of the patient, by
some increase of heavy dulness in the liver area
behind, by possible help from the screen, and by the
presence of an eosinophilia. Fortunately, in addition
346
(Nov. 16, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
to the chance of a burst taking place into the vena
cava, there is also a tendency greater than the more
fatal one of an infection of the right pleura ensuing.
When this occurs the surgeon’s chances of bringing
the case to a successful termination are much
increased. He opens the empyema by a large
opening, and endeavours to find the track by which
infection has reached the pleura; if he can follow
this it must lead him into the adventitia. I venture
to deprecate the use of the knife in this position ; the
trocar may be employed when the empyema is opened,
but to use the knife in the liver anywhere near the
vena cava is to court disaster. In these very difficult,
though fortunately rare cases, waiting and watching
for an empyema to form is probably the best treat-
ment, although a tragedy may occur on the side of
the vena cava. An unusual form of hydatid, viz.,
the sub-pleural cyst, would give rise to great difficulty
in diagnosis if it were present in the lower part of
the posterior mediastinum. The fluorescent screen
again would be of the greatest assistance. As a rule,
subserous pleural cysts are found higher up, about
the level of the scapula, when, of course, they would
be outside our discussion.
A very trying form of disease, which may implicate
the subphrenic space and its surroundings, may be
found in the sequela of typhoid infection of the ribs.
I have seen a case of this disease where the parts that
I have just described as being stitched together in
hydatid disease, minus, of course, the adventitia, were
thickened to a great degree, and welded into one
tissue more than 1 in. thick. These cases are
incurable as far as I know.
Of actinomycosis in this region I have seen but
one case, and that in the post-mortem room. I
remember thinking that it also was beyond the reach
of surgery.
Pyogenie infections of the subphrenie space are
diffieult, both in diagnosis and treatment. This is
mainly due to, first, the great size of the space;
second, the number of organs from which infection
may originate. The resulting abscess will be small
at first in most cases, and the history, even after the
abscess has been present some time, will be the history
of the cause, e.g., gastric ulcer, or appendicitis in the
majority of cases, but there are exceptions. For
example, the abscess may remain often small; the
cause of the abscess may have no antecedent
symptoms, or may be far away in the body, and a
connection’ between the two is not at first obvious.
Sometimes the subphrenic abscess may be successfully
treated and the cause remain unknown.
The classical limits of abscess in this space have
of late years been enlarged, and abscesses, both under
the liver and those which have reached the surface
on top, are called sub-diaphragmatic. Then, again,
modern surgery, by early operation, has inhibited
many causes from acting, and if the subphrenic space
should have been infected the resulting abscess is
sought for earlier and treated before all its classical
signs and symptoms are present. Following Nature
we can classify abscesses on the upper surface of the
liver by the bisecting lines of the coronary and falci-
form ligaments. This gives four unequal compart-
ments, and where the crossing of the ligaments takes
place a large non-peritoneal space occurs. Abscesses.
large and small, may occur in any of these positions,
and they may be continuous with abscesses on the
under surface of the liver or in the flanks. Certain
anatomieal facts help us to understand the symptoms
and signs of a more or less fully formed abscess in
any of these compartments. Thus the coronary
ligament is set very far back, and pus in the back
part of the right anterior intraperitoneal compartment
will be reflected in symptoms at the back rather than
the front, and it is easily confounded with a patch of
pulmonary consolidation at the base of the right lung.
The liver narrows so rapidly towards the left that
a perigastric abscess from carcinomatous ulcer is
bounded by diaphragm above and stomach below,
the liver entering but slightly into the combination.
The portion of liver uncovered by peritoneum is
considerable, and an abscess in this areolar space can
acquire both size and tension, so that it is more
strictly above the liver than the others, and able to
force the liver downwards, which the other subphrenic
abscesses cannot do, they being forced down by the
liver. It tends eventually to develop along the round
ligament towards the umbilieus, at which it may
point. It is rare, and should be opened high up in
the costal angle, near the xiphoid cartilage. The
right posterior position for abscess, that is behind the
coronary and the right lateral ligaments, is difficult
indeed to diagnose. It arises both from appendicitis
and gall-bladder conditions. I induced one in a
cholecystectomy last year. Getting hemorrhage in
avery septic case J had to plug with gauze far in
under the liver; this eventually produced an abscess
which, associated with the pre-existing sepsis, caused
the patient’s death ten days after the operation.
This abscess was discovered post mortem.
The right anterior intraperitoneal form of abscess
varies much in size and position. It may arise from
a number of pathological conditions which cause
invasion of its integrity by simple direct extension,
but it may be caused, 1 believe, through infection
carried by the portal system; thus the case of a man,
aged 38, with very bad ulcerated hemorrhoids,
who developed an abscess between the liver and the
diaphragm, for which no other cause could be assigned,
seems to bear out my contention. An anterior incision
along the costal margin led to an excellent recovery.
Infection through the portal vein may manifest itself
through the gall-bladder, the substance of the liver,
or the hepatic surface, and all these without
pyophlebitis. Abscess formations in this compart-
ment following appendicitis are the commonest form,
and give the surgeon much anxious mental exercise.
We do not even think of it so long as the patient is
doing well; but if he pauses in recovery, if his
temperature chart assumes a septic character, and
especially if his tongue remains furred, we become
anxious about the subphrenic space. A full
developed abscess will have a tender margin, though
the mass of the abscess may cause neither pain nor
tenderness (X-rays will help but slightly in the smaller
Nov. 16, 1914.]
case). However, tenderness should be sought for
in every suspicious case, especially in the intercostal
spaces and behind. Percussion may give a heavy
feeling of increased resistance to the finger, and be
valuable, but we are driven to consider the exploring
trocar whether we like it or not. It is admissible
before the actual operation, though there must be
danger to the pleura in every case. It is, of course,
inadmissible below the costal margin. If the patient
is very ill he will very probably die if you cannot arrive
at the proper diagnosis; the surgeon is justified in
taking some risk, and if he uses a very moderate-sized
trocar or needle, and keeps as much as he can to the
confines of the pleura, where the layers are in contact,
the risk is small, A large trocar may lead to terrible
results from leakage into the pleura. It is certainly
wise to be ready to go on with the operation if pus
be found, and then, of course, the cannula had better
be left in position. If the danger of sudden flooding
of the pleura be avoided by using a trocar of small
bore, we should be wrong to Yieglect the surest means
of diagnosing pus, viz., the use of the trocar. We
certainly do not wish to enter the liver with the
instrument if we can help it, so it is used warily and
tentatively. Of course, if the patient’s strength is
holding out well, it may be wisest to wait in the
hopes of the abscess showing below the costal
margin, or by fulness of the intercostal spaces.
Barnard draws a firm distinction between abscess in
this compartment of the space due to appendical
inflammation and that of gastric or duodenal origin.
In the former the edge of the liver is apt to adhere
to the diaphragm along the costal margin, thus
preventing the abscess coming into the open. In the
latter the abscess does come below the costal margin,
and is restrained by the round ligament of the liver
to the left and the colon and omentum below.
Hither of these abscesses may be continuous with
collections of pus situated beneath the liver. A
variety of incisions can be used in these cases.
Immediately below the tenth right costal cartilage
is, in my opinion, an excellent one in some cases.
This incision gives good access to the undersurface
of the liver, even to the portal fissure. When the
abscess is fully developed, and consequent on gastric or
duodenal perforation, an anterior incision in the site
of the greatest swelling is to be chosen. In other cases
the transpleural route is a necessity. Two incisions
may in some cases be advisable, and the presence of
an assistant with unsoiled gloves and instruments is
necessary. One incision would be anterior and the
other behind, and the utility appears to be obvious.
To me, however, a counter opening in such cases is
a mistake as a rule. It produces a fresh raw surface
in a person already absorbing much toxic material,
and it interferes with the action of the intra-
abdominal pressure, which is so strong an ally of
the surgeon. A moderate-sized incision into the
abscess, the introduction of drain tube to a moderate
depth, and as little pulling about of the parts as
possible seem to be the requisites of surgical
intervention.
In the left anterior intraperitoneal compartment
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
347
we may find abscesses of varying size. I have seen
three small abscesses in this compartment which
could rightly be termed perigastric abscesses. Around
them existed an efficient rampart of inflammatory
material. Two were opened by myself, and simply
drained with recovery, no attempt being made to
solve the pathology. The third, or rather bigger one,
I saw with a colleague, who made an effort to
ascertain the cause, with the result that a fatal
general peritonitis followed. A good leucocytosis was
present in each of these cases. A count on successive
days must be of the greatest help in cases where
infection of the subphrenic spaces is suspected,
although the result is discounted to some extent
by the antecedent inflammation and by operation.
Perigastric abscesses, which do not come forward,
but which tend to fill the vault of the diaphragm on
the left side, are very generally found in connection
with carcinoma near the cardia, and with mural
cancer under cover of the left cartilages and ribs. If
they are suspected by the pressure of inflammatory
signs and symptoms, a review of the case is very
necessary before operation is decided on, because of
this frequent association with carcinoma. The same
association of carcinoma and abscess is often seen in
the intestine, abscess being not infrequently the first
sign that calls attention to the underlying tumour.
In the subphrenic variety we should stay our hand
from operation if the history of the case suggest
carcinoma. With intestinal cases it is different, and
I have had the good fortune to open the abscess and
eventually to excise successfully the carcinoma of the
small intestine in connection with it.
Abscess in the lesser cavity of the peritoneum
occurs very occasionally, and cannot or should not
be diagnosed at operation. Marsupialization, with
drainage, is the treatment of all collections of fluid
which come forward either between the stomach and
liver or between the stomach and colon; and the
surgeon can surmise at his leisure whether the pus
was in the lesser bag of the peritoneum, or a pseudo-
pancreatic cyst, or a pancreatic abscess, or a pan-
creatic cyst which has suppurated. He is well
content to save his patient without gaining exact
knowledge of the anatomy of the abscess.
TRICHINOSIS, WITH A REPORT OF FIFTEEN
CASES.*
By Montcomery H. Sicarp, M.D.
IN man the infection comes from the hog, which
in turn has eaten infected offal, trichina-bearing
rats, mice, or trichina-bearing meat. The source of
contamination is the encapsulated larva, which exists
in the muscles of the animal. The infection arises
if ham, bologna, pork, sausage, &c., are eaten either
uncooked or cooked insufficiently to destroy the
larve. About 6 per cent. of pork is infected. Boil-
ing ham for three hours did not destroy the larve in
the centre of it. H. Williams, of Buffalo, found
triehina in 51 per cent. of 505 indiscriminate
examinations.
* From the Medical Record, August 15, 1914.
348
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Life-history.—Atter an individual eats infected
meat the larve are freed by dissolution of their
capsules in the gastric secretions, and escape to the
duodenum and jejunum where they develop to adult
life in about two days, and where impregnation of
the female occurs; the females are viviparous, and
in turn burrow into the lymphatics of the intestinal
wall and reproduce, about 1,500 per female. The
embryos wander with the lymph- or blood-stream to
different parts of the body, preferably the striated
muscles, and there become encysted larve again ;
this takes about ten days from the time of infection.
Pathology.— Acute intestinal catarrh and mesenteric
glandular swelling, and sometimes ulceration of the
mucosa are present. During the growth of the
embryo in the muscles (which takes about ten weeks)
degenerative changes occur; inflammatory foci form
which persist until the eighth week; these foci
consist of round cell infiltration, eosinophile cells,
and sometimes hyaline degeneration; after a time
some of these cells are absorbed and the rest are
converted into connective tissue. The encapsulated
larve may live in the muscles for many years;
in the hog they have been observed as long as twenty
years, and in man for twelve years. Ordinarily,
calcification of the capsules sets in after about a year.
Frothingham has demonstrated the embryos in the
blood-stream, and claims that they can break out of
the vessels in the liver, pancreas, and brain, and
cause local destruction of tissue. Lamb reports five
cases in New York, in which parasites were recovered
from the blood, and quotes four more from the
recent literature of the subject. Parenchymatous
degeneration of the liver, myocardium, and kidneys
may occur with embolism.
Opie’s experiments proved interesting; he found
that during the second and third weeks eosinophiles
gathered in the mesenteric glands in such numbers as
to resemble abscesses. Where eosinophiles form as
much as 15 per cent. of the leucocytes the marrow
presents a characteristic appearance, the fat being
replaced by myeloid cells, chiefly those having myeloid
granulations. In the lung the capillaries are much
distended and red cells escape into the alveoli; some-
times fibrin also collects with polymorphonuclear
leucocytes, eosinophiles, and epithelium ; and some-
times new tissue is formed; eosinophiles are so
closely packed that the specimen takes a homogeneous
eosin stain. In the third week trichine are easily
found in the voluntary muscles.
Ingestion is in most cases difficult to determine, as
it is only by close scrutiny that the parasites can be
seen as small white dots resembling miliary tubercles;
when ham or pork eating is much indulged in the
people give it but slight attention, and it is often by
a number of a family becoming infected that we learn
the exact time of infection.
Incubation begins shortly after the ingestion of
the parasites, as the latter require but about two
days for its full development after escaping from the
capsule.
This period of invasion is usually marked by
prostration, nausea, vomiting, severe cramp-like
&[Nov. 16, 1914.
abdominal pains in the epigastric and umbilical
regions, headache, diarrhea, chilly sensations and
a febrile rise. The severity of these symptoms
depends on the severity of the infection, that is the
number of- trichinæ eaten. In some of the cases the
invasion is mild, in others the symptoms of invasion
continue until the time of admission, which is
usually ten days or two weeks after the onset; this
is also the period required for the immature parasite
to attain maturity, reproduce in the intestine, and
for the embryos to reach the muscles of the host.
Many times this entire group of symptoms does not
exist, consequently the differential diagnosis in the
beginning is often difficult. In two of my cases the
onset occurred after an exposure to inclement weather,
so that chilly sensations, fever, muscular pains,
would not be of diagnostic importance except for the
time of appearance of pains, which from exposure
would be early, while from trichinosis it would be
later. An accurate history is often difficult to get.
The invasion with headache, high fever, diarrhoea,
mild abdominal pain, and splenie tumour, closely
simulates that of typhoid fever, and it may be several
days before we can exclude the latter disease by the
appearance of muscle pain, facial cedema, eosino-
philia, together with an absence of the Widal re-
action and the positive blood culture; the onset of
trichinosis is, however, usually more acute than that
of typhoid fever.
Symptoms in detail.—There was one case where
the onset simulated that of malaria. Simple gastro-
enteritis is sometimes the diagnosis, from the sever-
ity of pain, vomiting, and diarrhoea. Fever is one
of the early symptoms, and is ushered in by chilly
sensations sometimes repeated and accompanied by
sweating; in many of our hospital cases the fever
has existed from ten to fourteen days before admis-
sion, so that the whole febrile course may be from
three to five weeks or even longer. All of our cases
showed daily remissions of from two to four degrees,
and these remissions were apt to be accompanied by
sweating; none of these cases showed the high cor-
tinuous fever that Bovaird reports. The temperature
subsides by lysis. The fever curve is sometimes
confused with that of typhoid fever, especially that
of the third and fourth weeks, when remissions
occur. One case of this series had been treated for
typhoid fever for three weeks before admission to the
hospital. Cases are reported of combined trichinosis
and typhoid fever.
Vomiting occurs early: it is usually transient,
but may be protracted for several days; it is
accompanied by abdominal pain, sometimes severe
and sometimes, though not very often, by diarrhea;
in one case diarrhoea and constipation alternated.
No parasites were found in any specimen, although
looked for conscientiously and repeated examinations
were made. (Edema usually appears rather early; it
is situated in the eyelids, across the bridge of the
nose, in the conjunctive, and in no way differs from
the edema of nephritis; it occurred in ten of the
fourteen cases and may have been present in another
who had been sick three weeks before admission.
Nov. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
349
MacKenty reports three interesting cases of cedema
of the glottis, pharynx, and tongue. Thompson
reports cases having cedema of the ankles and swell-
ing around the knees and elbows. Eye tenderness,
photophobia, diplopia, and pain upon motion were
present in one case; conjunctival oedema is common.
Subjunctival hemorrhages have been frequently seen
by W. Gilman Thompson; these hemorrhages lie
external to the iris, are apt to be triangular in shape
with their bases inward next the iris. W. Gilman
Thompson and F. Parker each report a case with
cedema of the retina and optic neuritis. Kratz
observed subcorneal hemorrhage in eight cases during
an epidemic of 264 cases occurring in Hedersleben.
Muscular tenderness, stiffness, and pain upon and
after motion are supposed to occur in practically all
the cases, and are often the complaints for which
patients seek relief, in consequence of which they
usually apply ten to fourteen days after infection (or
after an average of ten days in the present cases).
Muscular weakness and prostration are early sym-
ptoms. Ina number of cases the onset of the pain
cannot be elicited ; eight of the cases complained of
no pain at all, nor was there any tenderness through-
out the course of the disease; two more gave no
history of pain, but were tender upon examination ;
seven had both pain and tenderness. On the other
hand, tenderness is sometimes very acute. In the case
of J. R. H., an intelligent man, muscular pains, ten-
derness, and cedema developed on the third day
and were present upon admission the following day.
The localities chosen seem to be the calves, thighs,
biceps, and neck, in the order of frequency. Thomp-
son has seen cases with tenderness over the diaphragm
and with dyspnoea, signifying a probable invasion of
that structure by embryos. MacKenty in operating
for tuberculous glands of the neck saw minute white
spots in the trapezius muscle resembling tubercles ;
on microscopic examination they proved to be encysted
larvee.
The most characteristic thing in the blood picture
is the eosinophilia; it usually begins early and in-
ereases rapidly; thus in one of the cases presented
it was 5 per cent. on the day of admission, 9 per
cent. on the following day, increasing rapidly to
23 per cent. It evidently remains for a considerable
time, most of the cases having a high count upon
discharge from the hospital. Cases are reported with-
out eosinophilia, while Brown and Bovaird had cases
where it was slight during the first month, but reached
its height during the second month when convales-
cence was established: Thompson also had cases
among his fifty-three where the maximum was
reached after the temperature struck normal. Brooks
had cases with counts as high as 80 per cent.; the
counts sometimes vary considerably from day to day.
High eosinophilia (normal being 3 per cent.) is found
in other forms of intestinal parasites, notably anky-
lostoma; also in bronchial asthma, and in various
skin diseases. There is usually a moderate leucocy-
tosis; my cases ranged from 14,000 to 21,000 per
cubic millimetre, with four cases having no increase.
The proportion of eosinophiles does not seem to have
any relation to the total number of leucocytes, as one
of my eases showed 34 per cent. eosinophiles with
a total of 8,000 leucocytes. There is usually a mild
secondary anemia. j
An eruption resembling that of typhoid occurred
in two cases, and Bovaird reported several such cases
in his series; the spots cannot be differentiated from
enteric spots and only obscure the diagnosis. Erythe-
matous and urticarial} rashes do occur, but I have
not seen them; furuncles also occur from which
trichine may be emptied.
There were no deaths in the present series, but
death sometimes does occur, either from exhaus-
tion and inanition, or from pulmonary infarct and
pneumonia.
Recapitulation.—The disease occurs frequently
enough to be borne in mind where unclassical sym-
ptoms of infection occur, and where the history is
indefinite. The embryos develop to adult life in the
stomach and intestine in about two days, the larve
reaching the muscles in ten days after infection; the
presence of the parasite in the intestinal tract causes
a gastro-enteritis of greater or less violence, according
to the number of larve ingested : the incubation period
then is short, and the invasion usually, though not
always, is well marked. Thetemperature is remittentin
character, varying from 2° to 4°F., and continues from
one to five weeks, according to severity. These long
continued temperatures are not infrequently taken for
typhoid fever, though thedistinct and marked remissions
are not characteristic of the latter disease. A splenic
tumour is sometimes present. Muscle pain and ten-
derness are usually present, though by no means
always; facial cedema is common, and subconjunctival
ecchymosis is present at times; this conjunctival
heemorrhage with facial oedema makes quite a charac-
teristic appearance. The eosinophiles are usually
present in numbers ranging from 15 to 30 per cent.,
or often higher, but it must be remembered that
during the active stage of the disease an increase
may not yet have occurred, and it may come on
during convalescence. It is difficult to find parasites
in the stools, but embryos may be found in the blood-
stream and the larve may be found in muscle section;
this, however, is not necessary where eosinophilia
exists with a good clinical picture. There is often
present a mild albuminuria.
BIBLIOGRAPHY.
Barraar, Jons. N.Y. Med. Journ., Dec. 18, 1913.
BARTLETT, C. J. Yale Med. Journ., 1909.
Bernstein, E. P. Medical Record, June 28, 1913.
BLACKBURN, A. E. Penn. Med. Journ., 1912, vol. xvl, p. 786.
Bovarnp, Davip, jun. Medical and Surgical Report, Presby-
terian Hospital, New York, 1906.
Brown, Tuos. R. Lancet, 1897. Journ. Exp. Med., 1890.
FROTHINGHAM. Journ. Med. Research, 1906, vol. xv, p. 483.
Hepp. Medical News, April, 1905.
Joacuim. Long Island Med. Journ., 1913, vol. vii, p. 354.
Lams. Medical and Surgical Report, Presbyterian Hospital,
New York, 1912.
Lorentz. Die mensch. Erkrank., Wien, 1904.
MacKenty, J. E. Amer. Med., February, 1908.
Opin, EucENE L. Amer. Journ. Med. Sci., March, 1904.
Parker, F. J. Medical Record, August 3, 1907.
ScunEgrPP. Deutsches Archiv für klin. Med., 1904, vol. Ixxx.
SravBLI. ‘ Trichinosis."'
STEINER, W. R. Boston Med. and Surg. Journ., Nov., 1908.
THoMPSON, W. GiLMAN. Amer. Journ, Med. Sci., Aug., 1910.
350
Hotes and "Retos.
INFANT DEATH-RATE IN BURMA.
IN Burma during the year 1918, 316,654 children
were born and 107,967 under 5 years of age died.
In view of this alarmingly high infant mortality
a memorial bearing the signature of a large number
of European and Burmese ladies has been forwarded
to the Lieutenant-Governor, praying that (1) The
cadre of the Government Medical Department be
amended by opening twenty-one of the appointments
of assistant surgeons (twenty-five being vacant on
April 1) tolady doctors: such women of this provinceas
are already qualified and suitable it is suggested should
be employed in some of the twenty-one towns now
without female medical aid, the remaining vacancies
to be filled in the same way as speedily as possible ;
(2) separate wards for maternity cases be provided in
all Government hospitals where such wards do not
now exist ; and (3) all town authorities in large towns
be urged to entertain visiting midwives.
NEW REGULATIONS FOR FEDERAL MEAT
INSPECTION IN AMERICA.
THE new meat inspection regulations governing
the slaughtering of cattle, sheep, swine and goats,
and the preparation of meat food products in in-
spected establishments, were signed by the Secretary
of Agriculture on July 15, 1914. All the regulations
become effective on November 1, 1914, except those
governing imported meats, which go into effect
January 1, 1915.
Packers can sterilize and cook thoroughly certain
classes of meat and sell it in cans or sealed containers,
labelled plainly “Second Class Sterilized.” This
sterilized cooked meat is the meat of portions of
animals the fat of which the old regulations per-
mitted the packers to make into edible lard and
tallow. The process of rendering served to sterilize
the fat and make it entirely hygienic. The new plan
extends the same principle so as to utilize the lean
portions of this meat, which heretofore packers have
not been allowed to sell for food purposes.
This action follows scientific investigations made
by specialists of the department, and by independent
veterinarians and physiologists, which have made it
clear that large quantities of meat which are per-
fectly good food when thoroughly cooked have been
condemned because of the presence of strictly localized
cysts or lesions in animals. This meat is of the type
which the German and Austrian governments have
long permitted their packers to sterilize by cooking
and sell at shops in a cooked condition. This meat
which, cooked, finds ready sale at a lower price than
raw meat in Germany and Austria, consists of por-
tions of the flesh of animals which have localized
eysts or lesions which make the immediately affected
muscle or tissue unsuitable for food, but which do
not affect the remaining flesh of the animal or render
it unhealthful. Portions (usually organs or glands)
THB JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 16, 1914.
containing cysts or lesions are cut away and con-
demned. These cysts and lesions do not come from
any of the highly dangerous diseases, for any indica-
tions of which the regulations require the condemna-
tion of the whole carcase.
Under both the old and the new regulations, in
cases where the diseased condition is trivial and
strictly localized, the unaffected portions of the car-
case, which are free from any suspicion of disease,
are passed for food and allowed to be sold in the raw
state. On the other hand, all carcases and all parts
diseased to an extent rendering them unfit for food
are condemned. Between these two classes lies the
class of meat which may be sterilized under the new
regulations. This consists of parts of carcases be-
lieved to be entirely healthful, but which comes from
carcases affected to a somewhat greater extent than
would allow the passing of these parts for food in the
raw state, because these parts may contain a chance
cyst which, if eaten raw, might lead to tapeworm or
other diseases. These accidental cysts or lesions,
even if present, are rendered entirely harmless by
thorough sterilization in cooking.
While the packers of Germany and Austria for many
years have widely availed themselves of this method
of saving, by cooking, a huge waste of meat, it is not
known how far the American packers will care to
follow the practice. It is believed, however, that if
it is undertaken it will make available a large quantity
of cooked meat which is now wasted.
The provisions relating to the post-mortem inspec-
tion of carcases have been made clearer and more
explicit so as to make the rules under which the in-
spectors pass or condemn carcases or portions of
them exact and in accordance with the latest scientific
knowledge. The regulations governing the carcases
of hogs suspected of hog cholera have been made much
more stringent.
The rules and regulations governing the disposal of
condemned meat and the use and integrity of the
Federal marks have been redrafted to meet fully all
conditions which have developed during the past six
years. As a result, it is made certain that the mark
“U.S. Inspected and Passed” can appear only on
meat that has passed a rigid ante-mortem and post-
mortem inspection at the hands of skilled veteri-
narians.
On account of the danger from trichine in pork and
the lack of any known method of inspection which
affords an absolute safeguard, the regulations pre-
scribe that no muscle tissue of pork shall be allowed
as an ingredient of any article such as summer
sausage, or similar foods which customarily are eaten
without cooking. To be included in articles which
may be eaten without home cooking, the pork must
have been subjected to a temperature sufficient to
destroy all live trichinw, or subjected to some other
approved treatment which may hereafter be dis-
covered.
The regulations governing the sanitary condition of
packing establishments, the cleanliness of employees,
and the care of utensils and instruments have been
redrafted into a series of definite rules. This, it is
— —— apa —— —M
Nov. 16, 1914.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
351.
believed, makes compliance with the rules easier on
the part of the packers and makes detection of
violations simpler for the inspectors. These rules
are very explicit as to the provision of washing and
toilet facilities for the help, as to the condition of
clothing, and as to the cleanliness of the hands of
those handling the meat. The rules also explicitly
prohibit the passing of meat which has been allowed
to touch floors or become contaminated by contact
with condemned meat or knives used in butchering
diseased meat.
———9—————
A ebicto.
THE WHOLE ART OF BANDAGING. By Thekla
Bowser, Fellow of the Institute of Journalists.
With an introduction by James Cantlie, M.A.,
M.B., F.R.C.S. Profusely illustrated. Pp. xii
-- 108. Price 1s. John Bale, Sons and
Danielsson, Ltd., London, W.
This manual makes a welcome appearance at the
present moment, when the care of the sick and
wounded is uppermost in our minds. The author
knows her subject well and has given much time and
energy to the work of the St. John's Ambulance
Brigade.
The main object of the book is an endeavour to
clearly set forth all that is necessary in the appli-
cation of the triangular and roller bandages. The
instructions are given very carefully and simply,
the numerous illustrations helping considerably in
driving home the important points.
The book is of such small compass that it can
easily be carried in the pocket, and its modest price
places it within the reach of everyone interested in
bandaging.
GUNSHOT INJURIES: HOW THEY ARE INFLICTED,
THEIR COMPLICATIONS AND TREATMENT. By
Colonel Louis A. Lagarde, United States Army
Medical Corps (retired). London: John Bale,
Sons and Danielsson, Ltd., 1914. Pp. 398.
Price 18s. net.
The author, the Professor of Military Surgery in the
United States Army Medical School, describes the
experience of surgeons in the Spanish-American,
Boer, Russo-Japanese, and Balkan Wars.
The first five chapters treat of the characteristic
lesions, symptoms and treatment; as to shell wounds,
poisoning from gases given off by bursting shells is
carefully considered. With regard to treatment
emphasis is laid on antiseptics as opposed to aseptics.
Seven chapters are devoted to regional lesions of
the head, spine, chest, abdomen, blood vessels, joints,
and lesions of the long bones.
The writing is clear and precise, the printing and
illustratisns are of a high order, the index excellent.
The book can be highly recommended both for care-
ful study as well as for ready reference in cases of
emergency.
DIETETICS: OR, FOOD IN HEALTH AND DISEASE.
By William Tibbles, LL.D., M.D.Chicago ;
L.R.C.P.Edin.; M.R.C.S.Eng.; L.S.A.Lond.
Demy 8vo. Pp. x + 627. Bailliére, Tindall
and Cox, 8, Henrietta Street, Covent Garden,
W.C. Price 12s. 6d. net.
This volume, dealing with food in health and
disease, applies the theory and principles of dietetics
to the many conditions and circumstances of life.
The author, who has devoted years to the study of
this question, considers that the present work, and a
previous one on “ Foods: their Origin, Composition
and Manufacture,’ form a complete system of
dietetics.
Part I deals mainly with food values, the com-
position, digestion and absorption of foods, metabolism,
&c. Careful tables are compiled setting forth the
amount of food requisite under many circumstances ;
the feeding of infants, children and adults, a special
chapter being devoted to the appropriate diet of old
age. Stimulants (such as alcohol) of all kinds, tea,
coffee, cocoa, are described in great detail, their effect,
good or otherwise, upon metabolism being clearly set
forth.
Part II considers the various affections to which
flesh is heir, such as diseases of the stomach, intestines,
liver, &c.; gout and rheumatism, obesity, diabetes;
diseases of the pancreas, suprarenal, thyroid and
other glands; of the skin, blood, circulatory and
respiratory organs, &c. The nervous system is also
dealt with as well as fevers, and in all these instances
the appropriate diet is given.
A chapter is devoted to vitamines and the deficiency
diseases. It has long been known that various
substances in food have a favourable influence on
the well-being of the organism, their absence tending
to the opposite condition. Amongst these are the
substances known as vitamines. It is a recognized
fact that when fed on some kinds of food animals
grow quicker, larger, and become heavier; whereas
with a monotonous diet—such as rice, maize, white
bread, pickled meat and canned foods— people suffer
and certain diseases are developed. These diseases
are due to the absence of vitamines, and are cured by
the administration of substances which contain them.
The subject has been gone into very thoroughly, the
forms of diet to be taken and avoided both in sickness
and in health being well defined. The index gives
a very good idea of the extent and variety of the
subjects discussed. "The author is to be congratulated
on the skill with which he.has accomplished his
laborious task.
THE NEWER PHYSIOLOGY IN SURGICAL AND
GENERAL PRACTICE. By A. Rendle Short,
M.D., B. Se.Lond., F.R.C.S.Eng. Third Edition,
revised and enlarged. Pp. xi;+!256.% Bristol :
John Wright and Sons, Ltd. 1914. 5s. net.
The fact that there have been three editions and
one reprint in three years indicates that the scope
of the work supplies a distinct need. Practitioners
obtain a fellow-practitioner’s view of recent physio-
logical investigations. Still more valuable, it gives
352
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 16, 1914.
students of physiology an outline of the facts
which appear most important to a practitioner and
examiner. To a careful student it is a key to examin-
ations.
———* ————
Drugs and Appliances.
Lactic Acid, in the treatment of erosions of the
cervix uteri, cervical or vaginal leucorrhcea, or any
form of vaginal catarrh due to non-specific ailments,
has been proved of real value. Parke, Davis and Co.,
have prepared a lactic acid bacteria suppository which
is convenient, readily soluble, and does not stain the
garments ; one suppository introduced at bedtime, at
first nightly, and then every second night, is sufficient.
It is believed that the good lactic acid does in these
circumstances is due to the rapid growth of the lactic
acid bacteria accompanied by the production of lactic
acid and other mild organic acids in a nascent
condition. It is suggested also that the putrefactive
bacteria flora is changed to one of a fermentative type.
or _————
Correspondence.
INTRAMUSCULAR INJECTION OF QUININE.
To the Editor of TRE JOURNAL or TROPICAL MEDICINE
AND HYGIENE.
DEAR SIR,—It appears to me that the facts cited
by Captain H. J. MeGrigor may be interpreted in
a different manner to that adopted by him. In your
Journal of November 2 he mentions a case of malaria
who had not taken any quinine because he said it was
poison to him, and who suffered greatly after a dose
of 10 gr. of the bihydrochloride. Then Captain
MeGrigor gave him hypodermics of the same salt
three times a day for two days, and then one injec-
tion daily for à week. No poisoning took place from
these injections, and the patient recovered and so
appreciated the value of the hypodermic injections
that he injected himself twice a week thereafter as a
prophylactic. He had no further attacks of malaria
(Captain McGrigor does not say for how long.)
It appears to me that this case simply confirms
the view that intramuscular injections are little
absorbed. If they had been absorbed, the patient
should have been as much “distressed " from the use
of them as from thé use of the per oram doses.
There is no proof that the injections cured this case,
because. as we all know, such chronic cases of malaria
are apt to improve for long periods without any treat-
ment at all; and also, quite possibly, the previous
dose of 10 gr. which had affected him so much might
have destroyed vast numbers of his parasites before
the intramuscular injections were commenced.
May I again point out that improvement after a
few such injections in a few cases is no proof that
the injeetions are really beneficial. Proof of this
can only be obtained after a most searching investiga-
tion of alarge number of cases treated with and
without quinine injections. But in the meantime we
know from numerous investigations that injections
are likely to remain unabsorbed and to cause con-
siderable local trouble. As quinine is generally
absorbed readily by the mouth, there seems to be
therefore absolutely no a priori argument in favour
of the injections, and one really wonders why they
are given.
Since writing my letter on this subject published
in your issue of September 15 last, p. 286, I have
had another case of a patient who suffered from the
injections for a month after they were given, and
came to me because he was also suffering from the
continuance of his malaria! In fact, I suspect that
most cases who are considered to have been cured by
injections really relapse a few weeks later; and even
believe that many of the fatal results recorded of
pernicious malaria are due to the use of the injections
—beeause the quinine so given probably remains
unabsorbed in the tissues just when it is most
needed.
Yours faithfully,
RONALD Ross.
18, Cavendish Square,
London, W.
November 10, 1914.
OO
Personal Rotes.
INDIA OFFICE.
From August 19 to October 27, 1914.
Arrivals Reported in London.—Dr. P. P. Phillips; Dr. D. B.
Spooner; Major J. Masson, I.M.S.; Major J. J. Robb, I.M.S. ;
Captain S. T. Crump, I.M.S.; Captain E. P. Armstrong,
I.M.8.; Major W. G. Richards, I.M.S.
Extensions of Leave.—Major W. H. Cox, I.M.S., 3 m., M.C.;
Lieutenant-Colonel H. B. Melville, I.M.S., 4 m., M.C.; Major
H. R. Nutt, LM.S., 3 m., M.C.; Lieutenant-Colonel J. H.
Macdonald, I.M.S., 1 d., M.C.
Permitted to Return.—Major L. T. R. Hutchinson, I.M.S.;
Dr. G. R.T. Ross; Lieutenant-Colonel H. E. Drake- Brockman,
I.M.S.; Major E. J. O'Meara, I.M.S.; Lieutenant-Colonel
S. E. Prall, I.M.S.; Lieutenant-Colonel J. H. McDonald,
I.M.S. ; Captain A. A. M. Neight, I.M.S.
List oF INpIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment or Department, and the Period
for which the Leave was granted.
Armstrong, Captain E. P., I.M.S.
Barber, Captain C. H., I.M.3., to December 3. 1914.
Mackenzie, Major H. M., I.M.S., to October 31, 1914.
Riddell, Captain W. H., I.M.S.
Robb, Major J. T., I.M.S.
Wilson, Lieutenant J. D., I.M.S.
List oF ĪNDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Harrison, Major C. B., I.M.S., Ms. 6 m., June 7, 1914.
Hunter, Captain J. B. D., T. M.S., 19 m., January 14, 1913.
Masson, Major J., I. M.S., Bihar and Orissa, 15 m., August 13,
1914.
Matson, Captain H. S., I.M.S., Burma.
Melville, Lieutenant-Colonel H. B., I.M.S., Delhi, 7 m.
April 1, 1914.
Miller, Major A., I1.M.S., M.S.
Robb, Major J. J., 1.M.S., Ms. Jails Dept.
Dec. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 23, Vol. XVII.
Original Communications.
THE SO-CALLED PLASMODIUM TENUE
(STEPHENS).
By Anprew Batrour, C.M.G., M.D.
Director-in-Chief,
and C. M. Wenyon, M.B., B.S., B.Sc.
Director of Research in'the Tropics, The Wellcome Bureau
of Scientific Research.
IN a comparatively recent number of the Annals of
Tropical Medicine and Parasitology, Dr. J. W. W.
Stephens describes what he believes to be a new
malaria parasite of man. After a careful study of
his paper we must confess that we are somewhat
surprised that so distinguished an authority on
tropical medicine as Dr. Stephens should have com-
mitted himself to such a diagnosis in the absence of
clinical data, and on what we cannot help thinking
to be insufficient evidence. His conclusion is wholly
based on the morphological peculiarities of a malaria
parasite which he found in a single blood film from
a native child in India sent him by Major Kendrick,
I.M.S. After carefully describing the plasmodium,
he proceeds to mention the features which distinguish
it from the malignant tertian parasite and the benign
tertian parasite. We agree with Dr. Stephens that
his parasite is distinct from the latter, and recognize
the validity of his remarks on the differences between
them.
We cannot, however, join issue with him in the
arguments he advances to prove that his parasite is
distinct from the malignant tertian parasite, and we
certainly think that further proof is required before
one can say that this Indian parasite is the type of
a new species (Plasmodium tenue).
Dr. Stephens believes that P. tenue differs from
P. falciparum in (1) its ameeboid activity, (2) the
abundance and irregularity of its nuclear matter.
Further, he states that his parasite was unlike any
malignant tertian parasite that he had ever seen or
could find figured in the text-books or journals.
We would point out that Plate VII of the Third
Report of the Welleome Tropieal Research Labora-
tories (1908), here reproduced as Plate I, represents a
form of malarial parasite very closely resembling,
if not identical with, the so-called P. tenue. One of
us (A. B.) noticed the peculiarity of this parasite and
thought it worth while having it carefully illustrated
in colour. The note regarding it will be found on
p. 110 of the first Review Supplement of the above-
mentioned laboratories }(1908), and is as follows:
“In the blood of a case which had become infected
at Taufikia, on the White Nile, I found the curious
amoeboid forms shown in Plate VII, Third Report. A
parasite closely: resembling a trypanosome will be
observed. It differs from the hemogregarine}forms
described by Billet and, as it was the first parasite
found in the film, proved, for the moment, puzzling,
although clinically the case was one of malaria. On
the following day a few crescents were found.
Quinine soon caused the disappearance of the endo-
globular forms.”
Although morphologically the parasite appeared
peculiar there was nothing in the clinical history
of the case to distinguish it from one of ordinary
tropical malaria, and it will be noted that crescent-
shaped gametocytes were discovered. Special atten-
tion was paid to the blood film on account of the
work of the Sergents, and of Billet in Algeria, a short
account of which will be found in the preceding
paragraph of the above publication.
It must be admitted that the young forms of
the sub-tertian parasite most usually occur as the
typical and well known " rings " which are figured in
Dr. Stephens's Plate VIII, but it is generally recognized
that amoeboid forms of this parasite are occasionally
found, more especially in the late stages of those
eases which have very large infections, and which
often terminate fatally. Ziemann, in his article on
malaria in Mense’s “Handbuch der Tropenkrank-
heiten,” calls attention to such varieties. (First
edition, vol. iii, p. 294.) They not infrequently occur
shortly before death, but whether their presence
implies some diminished resistance on the part of the
host, or some increased activity or metabolism on the
part of the parasite, cannot be stated. It, however,
requires more evidence than that which can be
gathered from a single blood film, showing only one
stage of the parasite, to create for such amcboid
forms a specific name, and thereby to conclude
that under no conditions can the sub-tertian para-
site depart from its more common morphological
characteristics. The simpler forms, such as the
parasite of benign tertian and quartan malaria, are
characterized, the former by its amceboid activity,
and the latter by a want of it. The degree of
amceboid activity of the benign tertian, however,
varies considerably from one case to another, and
similarly one occasionally encounters what are un-
doubtedly quartan parasites with this feature developed
to a high degree. It may be possible to find for these
variations some mechanical explanation. Very
actively amoeboid organisms, unless rapidly fixed or
dried, would tend to shrink towards the spherical
form more quickly than those which are more
sluggish. In this way a parasite which is of irregular
form might contract in the slow drying of a film to the
spherical shape, so that its amoeboid nature would
be masked in the stained film. The amount of
chromatin in the nucleus is also subject to much
variation, and if we assyme, as we seem justified in
doing, that the amceboid activity is correlated with
active metabolism and growth, it is just in such
amoeboid forms of the malarial parasites that we
should expect to find the greatest amount of
chromatin. It is only by a careful study of films
made on many occasions, and under varying condi-
tions of technique, that we can hope to establish the
true nature of such an organism and eliminate
abnormal or unusual appearances from the customary
cycle of development.
Had Dr. Stephens been able to study his case
clinically from day to day and show that the parasite
354
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
he describes always assumed the amceboid form
at that particular stage in its development, despite
varying technique; that in its further growth and
multiplication by schizogony it departed from the
type usually associated with the parasite of sub-
tertian malaria; that the gametocytes presented some
peculiar features; then there might have been some
ground for thinking that the parasite was a distinct
species. Even then it would be doubtful if sufficient
justification existed for the creation of a new species
on a single case, and the introduction of a new name
into the already overburdened literature. An inter-
esting paper by Ed. and Et. Sergent, Beguet and
Pantier on abnormal forms of the sub-tertian parasite
appeared in the Bulletin de la Société de Pathologie
Exotique of November 12, 1918. Mention is here
made of Billet’s and Ziemann’s descriptions of
curious forms of the quartan parasite, and attention
is called to certain elongated young sub-tertian para-
sites with streaked arrangement of the chromatin.
Though these forms are not amoeboid to any great
extent they are interesting in that they show that
the young sub-tertian parasite has been noted to
depart from “the regular, almost monotonous, contour
of the rings."
In addition to the Sudan case mentioned above,
two others which have come under the notice of
one of us (C. M. W.) are of interest in this connec-
tion. The first was from West Africa, and there
is but a single film, às in Dr. Stephens's case.
The film exhibits amceboid forms in large numbers,
and a reference to Plate II A will show that
they are identical in every respect with those
figured as P. tenue by Dr. Stephens. In addition
to the amaeboid forms there occur a considerable
number of ordinary ring forms and, what is most
important, the characteristic gametocytes of sub-
tertian malaria (Plate II A, 4th row). It is only
reasonable to conclude that this ease was one of
sub-tertian malaria due to P. falciparum, the young
parasites of which are particularly amaeboid for some
reason not clearly understood.
The second case was that of an adult Arab who
had contracted malaria in Busra, at the top of the
Persian Gulf, and was seen by one of us (C. M. W.)
at Bagdad in 1910. He was brought into the
laboratory in a dying condition, and only semi-
conscious. A blood film at once showed that he
had an enormous malarial infection (Plate II B).
Several films were made then and an hour later,
just before the man died. The parasites in these
films were recognized as being peculiar, and it was
at first thought that they might represent a distinct
species. However, an examination of the literature
relating to sub-tertian malaria showed that similar
infections were not uncommon. The striking
features, apart from the intensity of the infection,
were, firstly, the presence in the blood of large
numbers of schizonts in all stages of nuclear multi-
plication and with great variation in the number of
merozoites, and, secondly, the occurrence of numbers
of crescents, the developmental stages of which
could be readily traced from the younger forms
(Plate II B, 4th row). Ordinary rings of the sub-
tertian varlety were very numerous, and, in addition,
there were present irregular amocboid forms like
those figured by Dr. Stephens, and which are the
prevailing forms in the West African case already
cited. Furthermore, both in the Bagdad and the
West African ease the quantity of chromatin in the
nucleus was considerably larger than is usually seen
in the sub-tertian parasites. The amoeboid forms
evidently represent the youngest stages of the
parasite, since in them pigment appears to be absent,
but that this form of parasite produces pigment is
clearly shown by its presence in the gametocytes
and schizonts of the Bagdad case.
Another point of considerable importance is that
many of the infected corpuscles showed Maurer's
dots (Plate II B, end of 3rd and 4th rows). There-
fore, in this case, considering the absence of enlarge-
ment of the infected red cells, the presence in them
of Maurer's dots, the occurrence of gametocytes of
the crescent type, schizonts with merozoites varying
in number from half-a-dozen to four or five times
that number, there is complete agreement with what
we know of the parasite of sub-tertian malaria. The
presence of amoeboid young forms with richly
developed chromatin is unusual, but he would be
a bold person who would venture to establish a new
species on this character alone.
Dr. Stephens has named such an amaeboid form
seen by him in a single blood film P. tenue, but has
not produced any evidence to prove that he was not
dealing with an amoeboid sub-tertian parasite. lt
is unfortunate that in his film there existed only the
single stage—neither schizonts nor crescents being
present to help in the diagnosis.
We would express our indebtedness to Messrs.
Richard Muir and George Buchanan, of Edinburgh
University, for their care and skill in executing the
drawings from which the plates illustrating this
paper were prepared.
ASIATIC CHOLERA.
By Joun FunsE McMirrras, L.R.C.P.Lond., M.R.C.S.Eng.
L.S.A.
Late Royal Army Medical Corps.
ON all sides it will be granted, and indeed it would
be folly otherwise, that the heads of the profession
at the various hospitals of the Metropolis, and within
the British Isles generally, are in a better position—
from perhaps their longer course of study forced upon
ihem in order to obtain the higher qualifications, and
so a furthering of their intellect —to specialize, in some
branch or another, whence an individualism or person-
ality is produced that without demur causes any
opinion from such to be received as the crux for those
of more multifarious duties and calling to follow.
Yet, nevertheless, from the very fact of their digging
deep in a circumscribed area of ground, they may
be incognizant of what transpires in a neighbouring
area. This, perhaps, may not be new in any way,
for both Sir William Ferguson in Surgery and Sir
ee |
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, DECEMBER 1, 1914.
PLATE I.
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Reproduced from the Third Report, Wellcome Tropical Research Laboratories, Khartoum.
To illustrate paper, ‘‘The so-called Plasmodium tenue,” by ANDREW Barrour, C.M.G., M.D.,
and C. M. Wenyon, M.B., B.S., B.8c.
—— et
Dec. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
357
that when any attempt has been made to give a closer
name to the common one of pestilence, it has been
that of the plague, and in more recent times typhus
fever. But it should be remembered that a Greek, at
all times somewhat involved in his style, would be
more so when describing such, to him, a nauseating
disease as cholera would be. One can picture a
collection of Greeks assembled, say upon the Acropolis,
suddenly assailed by most violent vomiting and
purging, and the effect it would have on their white
clothing, such that to sstheties, as Thucydides says,
gone was the ideal. Hence we conclude that he uses
ambiguous language. The author proposes to leave
any further elucidation of the question until later,
and to now proceed to give a brief history of such
epidemies as have been recorded since that by
Thucydides.
The authority upon endemic cholera of the last
century is Charles Macnamara,’ who made the disease
his study in the ever infected area, and it should be
remembered that the investigation of epidemic Asiatic
cholera is much more cosmopolitan. Sir Thomas
Watson, the author is of opinion, has given the best
résumé of the cholera epidemies which have reached
Europe and America from India, so that we will take
his word as concerns them. Macnamara informs us
that cholera was known to the ancients, and that
what he calls simple cholera was described by
Hippocrates; but the first epidemic he records is that
of 1817, when cholera, which was prevalent about
the Ganges, rapidly spread over the whole of Bengal ;
extending during the following year over the greater
part of Hindustan, and from thence to Ceylon,
Burma, and China. The disease was carried from
Bombay to the Persian Gulf, and spread over adjacent
parts, but did not extend to Europe.
Now the epidemic of 1817 did not extend to
Europe for a certain reason, and that is because from
Central Asia it worked away east to the north of the
Himalayas. But a point we must impress is the
manner in which it travelled from Bombay to
the Persian Gulf. This, and the word we are going
to employ is not newly coined but one used at the
time, was effected by means of what is known as a
carrier; and it is well to bear this in mind, as the
subsequent history of the investigation of the disease
in a great measure turns upon this word carrier.
From 1817 until 1824 the disease, so far as Europe
is concerned, lay dormant, or at least so the English
authorities would say, whereas Macnamara states
that in 1826 the disease again burst out in Bengal,
and then by way of Cabul, advanced into Europe
through Russia, and thence to America. Sir Thomas
Watson gives a lucid description of the arrival of
this the first epidemic in England. From Russia it
moved on through Germany to Hamburg, whence a
carrier was the means of transferring the disease to
Sunderland; it crossed the Atlantic and devastated
both continents. It then crossed the Channel to
France, where the first points of affection were
certain ports on the northern seaboard, whence it
Was propagated over the whole country.
1 ** Quain’s Dictionary of Medicine,” 1882.
Much speculation, some almost mythical which
would not have disgraced Thucydides, was displayed
as to the cause of such very great methodical move-
ment, but all who had cause to treat cases in this
country were unanimous in the opinion that the
disease was either contagious or infectious, two
words that have caused much confusion in the
appreciation and elucidation of the cause of disease;
some from observation and experience inferring that
contagion applied to the so-called zymotic diseases,
such as variola and typhus, rather than to cholera,
and so they applied the word infectious more
peculiarly to the latter disease, and as at the time the
distinction between typhus and typhoid had not
been clearly worked out, perhaps to Asiatic cholera
the word “infectious” in its true sense was first
applied. This is interesting and important, and will
be found the keynote in the study of all subsequent
epidemies until the present day. And in 1831 this
drawing of a, at the time, crude, if not nice, distinc-
tion between contagion and infection led some of the
profession, who were cognizant of the fact that the
disease was infectious, not only to assume a bolder
attitude themselves, but to induce the laity to
appreciate the fact that there was little to be feared
from contact.
In 1840 during the China War the disease was
carried by native troops or followers from Bengal to
China, where it became epidemic, on to Burma,
thence to Thibet, and thence by way of Kasghar to
Bukhara, Afghanistan and Scindh. In 1845 it
passed through Persia to Russia, and traversed
Europe, to appear in America in 1848.
And now it is well to remember that the cholera
endemie to Bengal might either be dormant, active,
or recrudescent. When dormant there was no know-
ing when it might become active, but once active it
did not readily again become dormant, but assumed
the form of recrudescence, small epidemies radiating
from the endemie area over the rest of Bengal; and
this is what occurred from the years 1845 to 1848,
so that whilst the disease was raging with violence in
America, in 1849, it passed to the Punjab, then to
Bombay, whence a carrier conveyed it to Persia;
thence it spread northwards to Arabia and Russia, on
the one hand, and to Egypt and the south of Europe
on the other. Then, on the heels of the previous
epidemic, it visited the British Isles, and ended its
course in America again, with great violence and
virulence. This is known as the epidemic of 1853-54,
at or about the time of the Crimean War. During
the year 1860 the disease again became active in
Bengal and the Central Provinces; it passed to
Bombay, and then along the shores of the Red Sea,
whence it was carried by pilgrims to Mecca: thence
it gradually found its way to Europe and America
for the fourth time. This is, as it were, the epidemic
of Asiatie cholera of our own time, and there arc
many stories told of how the inhabitants of densely
populated distriets of the Metropolis fled in panic
into the country, so acting as carriers and furthering
the spread of the disease. The author remembers
as a small boy being haunked from Hampstead,
358
whilst the disease was raging in Camden Town, out
of the danger zone.
Sir Thomas Watson is of opinion that the epidemic
of 1840 was the most violent of any, and places the
number of deaths at 70,000. And since the epidemic
of 1826 little fresh light was thrown upon the
wtiology of the disease; indeed some might say that
there was a retrograde movement. Whatever truth
there may be, and there is some as will be seen later,
it was the general consensus of opinion of the pro-
fession that the disease was air-borne and depended
upon atmospherie conditions in the epidemies of
1860-62. Sir Thomas Watson, however, stuck to his
guns, and always held the view that the disease
was "catching," and he agrees with Dr. Body that
" when it travels over great distances, as from one
country or region to another, it uses the vehicle of
human intercourse; but that it may be, and often is,
diffused over smaller places, as from one part of a
town to another, or from a tainted port to a ship
anchored to leeward, by the movements of the atmo-
sphere." And he tells the story how two pilots who
obtained a tow by catching hold of a rope astern of
a vessel with cholera aboard contracted the disease,
and carried it home to theirfamilies. He also quotes
from the Times, October 15 or 16, 1865, how
Gibraltar and St. Roque, five miles distant, weresmitten
by the plague not only on the same day, but at the
same moment. It is well in passing to note that Sir
Thomas uses the word plague in its broader sense as
pestilence, although he well knows, and indeed intends
to be meant, Asiatic cholera, so that only slight
clerical error would seem necessary for confusion to
occur, a point worth remembering as regards Thucy-
dides’s description of the Athenian pestilence. And
that reminds us that Sir Thomas tells the story, how
at Constantinople on the appearance of the disease
the seagulls deserted the Bosphorus, and did not
return until the cessation of the epidemic. Again,
he makes mention of rooks in a rookery near Sligo,
within a day, or at least two, of the appearance of
cholera there, dying off until the remnant flew away,
to return exhausted, and evidently recovering from
sickness, when the epidemie died out.' This tallies
with Thucydides’s description, but the King's College
lecturer seemingly had not studied him, or he would
have noticed the Grecian historian's account of the
wells. But it must be said that Sir Thomas draws
attention to what is known as the Soho cases, where
Dr. Snow proved conclusively that a well contami-
nated by a sewer leakage was the cause of the appear-
ance of the disease in all the houses in streets supplied
by a certain pump. Again, he relates the case of
where an artesian well sunk in the centre of an
infected area caused the neighbouring streets furnished
by the water to stand out like an oasis where the
disease prevailed. Perhaps, however, the most strik-
ing case of the proof that whether—of course we
speak as at the time—-the disease be catching, con-
! Fleming (“Animal Plagues”) bears out this statement ;
33,000 dead rooks were picked up on the shores of a lake,
horses were stricken in Russia, and dogs in India.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
tagious, infectious, air, food or water-borne—neverthe-
less there can be no question as to the latter cause
—is the story credited to Macnamara, where some
dozen natives drank in the evening water that
had been exposed to the sun,in an open vessel,
several of them contracting Asiatic cholera, some
dying, and only a few eseaping. There was much
talk in India at the time of the occurrence, and
although possibly desperate straits necessitated
desperate means, yet, even were they criminals, the
measure was considered a strenuous one.
So much so for the history and general wtiology of
Asiatic cholera, until such time as the author, during
the course of his service in India, came into contact
—in its broadest sense—-with the disease itself, and
so was enabled to draw deductions, inferences, and
conclusions of his own, and that was some few years
after Koch had, in 1884, astonished the medical
world by his reputed discovery of a bacillus which
he, from its resemblance to that point, likened to
acomma. But in the interim between the epidemic
of 1866 and his discovery, workers in India had not
been idle, and it had long been deduced as the result
of research and observation that the propagation of
the disease beyond the endemic area of the Ganges
depended upon a certain materies morbi, materies
peecans, that was called the germ of the disease, and
origo; the latter being terms culled from Celsus and
Paracelsus to denote the origin of disease. So that
it was generally acknowledged that the disease
depended upon a certain specific poison, which was
disseminated by a carrier from the endemic area, and
then either by air, food, or water, by infection. was
propagated. For a time the school that viewed
climate as forming the chief cause of dissemination
held the field, but then as it became dogmatic it was
overborne by the water infection theorists, who in
their turn laughed at the idea of climate and atmo-
sphere playing any part in the propagation of the
disease. During the Burmese War the author was
stationed in medical charge of a section of a field
hospital at Shwebo, in Upper Burma, and one
evening, whilst he and a brother oflicer were returning
from a walk outside the stockade, they were asked by
an officer of the Indian Medical Service if they would
care to see something that possibly they had not seen
before. They answered “ Yes," when they were
ushered into a large bamboo hut—raised on piles—and
the sight that met their eyes was such as Thucydides
describes at Athens. Some twelve or eighteen sepoys
were lying prostrate on their charpoys, or doubled up
upon the floor, suffering from a most violent form
of Asiatic cholera, the symptoms of which will be
described later. And this may seem strange, but it
is true. nevertheless, the author's brother officer was
seized with violent retching, was placed in bed, and
during the course of the night suffered from evacua-
tion with slight eramps, but in the course of the
ensuing day, being a strong man, of athletic frame,
was himself again. Of course it might be said that
contagion was the factor, but it is again possible that
through the lungs he inhaled dry fæcal matter; or again
it may be that the attack was of the nature of those
Dec. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
359
that are classed as sympathetic, and which are
peculiarly allied to hysteria. Perhaps we may pause
for a moment to say that, as regards preparation for
the meeting of the disease in the British Isles, a
study of the workings of small epidemics, such as
occur in India, are of more value than possibly is the
study of the larger epidemics that have occurred of
recent years in Russia and other places; for it is, as
it were, that a seaman at some seaport, such as
Sunderland, will carry the disease to his home,
possibly into a neighbouring village.
Two days after the author’s brother medical
officer recovered from his ambiguous attack, one
morning two European soldiers reported sick, were
detained and diagnosed as cholera, and in the course
of the day two more reported themselves. Two
recovered in a couple of days under treatment, one
died, whilst the third made a slow and prolonged
recovery from reasons to be described hereafter, due
to suppression of urine. The twelve or eighteen
natives it was ascertained were from one company ;
a transport follower had a week before the outbreak
joined from the endemic area in the Ganges, where
the disease had become active, and had extended
to certain neighbouring villages; and now amongst
the natives affected was a non-commissioned officer
who was on friendly terms with one of the soldiers,
whilst the three other soldiers were the latter’s
immediate chums; and employed by the native non-
commissioned officer to do odd jobs was an Indian
native, who cleaned the European soldiers’ rifles, &c.,
for them. With the exception of the one British
soldier and three natives, in ten days’ time there
were no signs remaining of a cholera outbreak. It
should be remembered, however, that although
Indians for the most part profess otherwise, yet
on occasion they will drink, and it is possible that
preceding the outbreak a carouse had taken place,
when shamsu, the Burmese liquor, was imbibed in
quantity by both them and the British soldiers.
The author will now describe an epidemic localized
in India.
In 1885-86 cholera became active in the endemic
area, and suddenly appeared in Cashmere; seemingly
a long jump for it to make, but investigation proved
that Afghan horse-dealers had returned from the
infected area through the Khyber, and cases of cholera
occurred in Afghanistan, whence it was carried to
Cashmere, where there occurred an epidemic of short
but violent duration. And, perhaps, it will be well
to give a brief description of the lie of the country
about the Murree Hills. The summer resort for the
Rawalpindi district in 1885, Murree is situated on a
plateau formed by the flattening out of a spur of the
Himalayas running down to the river Jhelum, across
which is the road into Cashmere, open to dak, the
rough pair-pony tonga of the natives, in which,
however, Europeans travelled. Between Murree,
with the various hill stations situated on the spurs
of the Himalayas running down to it, and the river
Jhelum was situated what is known as Camp
Gharial where a European regiment was stationed
under canvas for the summer. Only one or two
Europeans were attacked in Srinagar, but in every
dak bungalow, between that city and the Jhelum,
here one and there two natives suffered, and per-
haps it may not be out of place here to speak of the
manner in which the native may be affected. He
appears either to suffer to a terrible degree, or only
in a slight measure. Once at a Cavalry camp at
Akhora, near Lahore, the author was asked by a
brother officer in medical charge of a battery of
Horse Artillery to see a native follower. On exam-
ination there appeared little amiss with the man,
and the medical officer in charge, not being over
conversant with Hindustani, had a diffieulty in
understanding what the native was saying, there
being no interpreter, as for some reason the apothe-
cary was absent. The author, however, gathered
from the natives of the Army Service Corps that the
man in question had visited some friends some eight
or ten miles off, where cholera was prevalent, and
they insisted that the man himself had been attacked
on the road whilst returning, so—inasmuch as when
a native takes the trouble to make an assertion, and
has nothing to gain one way or the other, he may
be trusted—there was little doubt that the man was
in what will be considered later the reactionary
stage of Asiatic cholera, with some slight suppression
of urine; isolation, fumigation, disinfection, saved
the majority from, perhaps, an inflietion whilst the
man himself remained under treatment. This case
is interesting and instructive as showing how a
earrier will wander about disseminating the poison,
as long as he himself suffers from no great personal
inconvenience.
Then, to return to Camp Gharial, in June, towards
the end, a case pronounced to be Asiatic cholera
occurred in a native near the dak bungalow by the
Jhelum, and in the first week in July, without any
premonitory warning, two colour-serjeants of the
British regiment were brought to hospital suffering
from most violent Asiatic cholera, which raged for
six weeks, some fifty cases occurring, of which thirty
were of a pronounced type, and some fifteen deaths,
amongst which were two women on the strength.
And now the author will give a description of
Asiatic cholera.
The soldiers were either suddenly knocked out,
experienced premonitory diarrhaa, or, as one soldier
described his feelings, felt “ gummy-headed," by which
he meant that he was suffering from headache and
other symptoms of malaise, with some slight sym-
ptoms of coryza, looking in a measure as if he were
sickening for measles. There might or might not be
vomiting. When a soldier was suddenly and violently
attacked, he was generally assailed by profuse diar-
rhoea, with intense abdominal pain, quickly followed
by violent cramps, rapidly falling into collapse.
Where there was premonitory diarrhoea the same
end might be reached, but on the whole the prognosis
was more favourable than in those in whom there
was premonitory malaise, the latter cases usually and
speedily assuming a virulent form; but practically
there was no great or marked difference between
these two types of cases. As the stage of collapse
360
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 1, 1914.
was reached the cramps of the limbs subsided and
there ensued a most violent thirst and desire for
water, following a desire and appreciation of any
liquid. Whilst the cramps last the skin assumes
a livid hue, gradually turning mottled, and with the
reaching of the latter stage the eyes are sunken, whilst
the tremulous, feeble, moving hands form the only
difference between the cholera-stricken patient and
a corpse. The voice, such as it is, is as though a
child’s squeaking toy has been pricked, respiration
may be accelerated, whilst the pulse is thin and wiry.
The evacuations have been compared, and aptly, to
water in which rice has been boiled, hence the name
commonly applied to rice-coloured evacuations. The
urine is suppressed. And upon the re-working of the
kidneys will depend whether the patient recovers from
the algide state, or gradually passes away from syn-
cope and asthenia. Should the tubuli uriniferi com-
mence to fulfil their functions, then is the prognosis
hopeful, and what is known as the stage of reaction
is reached when the temperature, which throughout
both collapse and algide stages has been below the
normal, will rise, and initially would appear to depend
upon the accelerated functions of digestion, assimila-
tion and nutrition, to the normal, and then will over-
shootit. In other words, Nature temporarily loses her
inhibitory control over the heat-producing mechanism
by the extra work thrown on the vagus nerve, through
its communicating branches with the sympathetic.
So that there is little untoward to be feared per se
from a rise of temperature. Should, however, the
tubuli uriniferi fail to perform their functions involved
in the rise of temperature and consequent fever due
to the extra and sudden strain thrown on to them,
then will partial or complete suppression, followed by
uremia, coma and death, occur. If, however, there
be a rally, then may Bright’s disease in one of its
forms occur asa sequela. Again, reaction may be
partial or become suspended, when as a sequela
gangrene may occur. Under normal conditions, how-
ever, this seldom happens in Europeans, whose dict
is adapted to reaction, but is not uncommon in
natives. The author remembers once, when in the
line of march in India, being requested by a medical
officer of the Indian Medical Service to ride some
ten miles out of his course to assist at the operation
of the removal of a gangrenous hand from one native
and a leg from another, sequelae to cholera. Chest
trouble may occur as a sequela, especially in the aged,
from the impairment of the working of the bronchi
and air vesicles, during the reaction, and chest trouble
such as tubercle may be accentuated. But inasmuch
as impaired reaction is rare in Europeans, so are these
sequel. Bed sores, of course, may arise, be they not
guarded against.
As to the treatment there has been much divergence
of opinion.
The author, as the result of the study he made of
the Camp Gharial epidemic, came to the following
conclusions, remembering that Koch's comma bacillus
was then rather speculative than proved. The
disease was due to a materies peccans that was not
indigenous to the body, but in some manner passed
into the mouth and so found its way into the in-
testines, either through air, food, or water, but that
in most if not all cases there was the predisposing
cause of premonitory disturbance of the digestion,
accompanied by diarrhoea or otherwise. The two
colour-serjeants, the evening before they were
attacked, had together eaten a cured pig’s cheek that
had been presented to them, and which came froma
native porkery ; whilst engaged in this repast one
remarked to the other that the face did not seem
quite up to the mark, to which the other agreed, but
as it was a present he replied he was going through
with it. This they both did, with the result that
they were admitted to hospital the next morning and
died of Asiatic cholera in the night; and inasmuch as
two soldiers suffering from excessive beer drinking
were also admitted to hospital and died within
twenty-four hours, gastric disturbance and diarrhoea,
or what is known as ptomaine poisoning, cannot have
been the cause, but it would appear clear that finding
a suitable nidus to develop in the materies peccans
throve and developed in the intestines.
And now before coming to the treatment it would
be well to discuss the pathology, as the former
depends in a measure upon the latter.
In the Lancet of September 19 and the subsequent
issue, appeared the Lettsomian lectures delivered by
Dr. Sandwith concerning dysentery, wherein he draws
with niceness a distinction between the two divisions
of the disease, one called amaebic dysentery, the other
bacillie; the former tropical and dependent upon the
presence of the Amæba histolytica in the system, less
in the blood than in the mucous membrane of the
intestines ; and the latter, bacillary dysentery, due to
the presence in the intestines of a fibrillated bacillus.
Both these forms of the same disease were known in
the nineties, but there was confusion between the
two; however, at the same time it is well to remember
that a chronic form of dysentery was recognized as
a form of tropical dysentery, the acute form readily
amenable to ipecacuanha and the chronic to ipeca-
cuanha and quinine. And the author remembers an
occasion whilst in medical charge of a train load of
invalids from Upper India to Deolali being held up
outside Delhi by three cases of cholera occurring in
men suffering from what was then called chronic
dysentery, a form of the disease that was seldom if
ever met without malaria as either a predecessor or
concomitant. Dr. Sandwith has been so good as to
inform the author that “ipecacuanha destroys the
Ameba histolytica not only in the body but in the
test-tube," so that so far as the matter in hand as
regards Asiatic cholera is concerned, we will disso-
ciate tropical dysentery with abscess of the liver
from bacillary dysentery, an epidemic disease that is
perhaps allied to enteric fever and Asiatic cholera.
It may be well to state that the author is indebted to
a manual of bacteriology by Muir and Ritchie for the
association of his ideas with the most modern. The
following points the three diseases possess in com-
mon: the main seat of trouble is the intestines;
whilst each has been proved to be due to the presence
of a specific bacillus affecting the mucous membrane;
Dec. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
allthree fibrillated and motile. Mention must now
be made of the Bacillus coli which inhabits the soil,
and is commonly found in the mucous membrane of
the lower large intestines. Dr. Sandwith relates the
story of a body of soldiers in Egypt who, suffering
from thirst, drank from a festering pool, when
most of them developed bacillary dysentery and the
remainder enteric. Can it be that under certain
conditions what are known as staphylococci and
streptococci act upon the Bacillus coli communis of the
soil and so are produced the B. dysentericus and the
B. typhismus ? For only under certain conditions do
epidemies of dysentery and enteric occur. On the
other hand, Asiatic cholera is always with us endemic
about the Ganges, and whether or not the comma
bacillus was formed from the B. coli communis, the
conditions attached would be water contaminated by
the putrefying corpses of Hindus voyaging down the
Ganges, for it is customary for the native to rinse his
mouth on all occasions when he bathes. But bacil-
lary dysentery oecurs in an epidemie form amongst
lunaties, and the author, having had much experience
of them, expresses the opinion that inasmuch as
when a gaol and alunatie asylum are in juxtaposition,
both furnished with the same water supply, the latter
cannot be the cause, and it seems clear that given it
is a change in the B. coli communis that produces the
dysentery bacillus, then must we look to the lunatic
himself, that is to say, the mucous membrane of his
lower intestines, for the place where the B. coli
communis undergoes its change, and remembering
the adage of the ancients that the mechanism of
one organ cannot be impaired without another
suffering to some degree, and that in lunaties,
whether in the form of mania or dementia, the
brain, spinal cord, and nervous system generally are
at fault, either from hyperesthenia or :esthenia,
then may it not be likely that a certain atonicity
of the mucous membrane is caused by brain and
nerve waves affecting the vagus and sympathetic ?
So that under these conditions the B. coli communis,
always ready to undergo a change, may develop into
the bacillary dysentery, and so the disease which is
in a measure endemie, like cholera on the Ganges,
becomes epidemie, and doctor and nurse and atten-
dant become affected; and a predisposing cause may
be errors of diet or constipation, to both of which
lunaties are prone.
It may be remarked that whereas in bacillary
dysentery the lower gut is affected, in enteric the
upper, in cholera the whole is involved, and such of
the mucous membrane as is not shed in the way of
rice-coloured stools peels off after death in flakes, or
the intestines may be found full of fluid.
An unknown factor in the intestinal economy is
the solitary gland of Peyer, agminated and surrounded
by Lieberkuehn's follieles. "The general aspect of
Peyer's patches gives us the impression of a secretor
or exeretor surrounded by a lubricant in the shape of
the follieles ; and may it not be possible that through
Peyer's patches there may be a connection between
the three diseases, their affection being apparent in
enteric with ulceration, but their function merely
361
destroyed in bacillary dysentery and cholera? Do
they constitute a nidus ?
During the epidemic at Camp Gharial the author
experimented with a view to discovering a specific
for Asiatie cholera, and when he contracted the
disease himself essayed the same; but first it may
be well to describe such treatment as practice and
experience has proved to be, if not of the greatest
value, then the less injurious.
At the time of the first epidemic that reached the
British Isles in 1826, opinion was divided as to
whether it were better to check any initial diarrhea,
or at least not to hinder if not to aid the latter.
Charles Maenamara made it his practice to carry in
his waistcoat pocket some dozen acetate of lead and
opium pills (in India at a perhaps later date), whereas
Sir Thomas Watson speedily came to the opinion
that the materies peccans held its nidus in the intes-
tines and was discharged with the evacuation, and
that it also made its home in the blood; therefore,
strenuous and heroic as it may seem, and against all
our modern ideas, the removal of a pint of blood from
the arm in the premonitory or initial stage of the
disease was not so much beside the mark as it would
appear. The drug administered to remove the poison
was calomel, laid on the tongue, and appears to have
been given periodically until the algide stage was
reached. Then, in the later epidemics a mixture of
catechu and chalk, with opium, was employed, to give
way later, in India, to chlorodyne, even before the
latter drug was admitted into the Pharmacopeia. Of
course, rest in bed, with mackintosh sheet, is indicated,
hot-water bottles, blankets, and fomentations as occa-
sion may require; that is to say, so soon as reaction
is imminent, then will they be in request. The thirst
is best alleviated by ice to suck; and it has generally
been found that when the patient has a desire for
chicken broth, milk, and lime water, liquid or solid
jelly, either nitrogenous or saccharine, that the
stomach will retain it; but when he evinces no desire
it is better not to force him with a feeding cup, but
to administer the nutriment by means of a teaspoon.
It may be added, however, that if the patient ex-
presses a desire for beef tea, and there be no Liebig's
available, in certain cases the stomach will retain
ordinary beef tea, or mutton broth without the fat
skimmed off. Mutton broth is sometimes well
retained. Eau de Cologne on a handkerchief applied
to the forehead is soothing, and generally appreciated,
although it may not be by those in attendance. Now
we come to the mainstay of the treatment, and that
is brandy, and its value will depend in a very great
measure upon the use or abuse that the patient has
made of it in his previous life. It is his sheet
anchor, and if he has so accustomed himself to its
use, like the opium smoker, it may be necessary to
administer the alcohol in such great quantities that
when the hoped-for reaction occurs, then will the
suppression of urine be accentuated. And it cannot
be too emphatically expressed that, as the patient
shows signs of returning animation when in the
algide stage, denoted by the general signs of the
recovery from shock and collapse, the stimulation
362
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 1, 1914.
of the kidneys should be encouraged by every means,
such as fomentations, blister, or cantharides ; and if
necessary, owing to atonicity of the bladder, the
urine should be removed from that organ by means
of a catheter. It is surprising the length of time
that may elapse before reaction is fully established,
and the practitioner should never lose heart, but
whilst there is a flieker of pulse, or shadow of heart
beat, persevere as he would in a case of ordinary
shock with collapse. Electricity, either galvanic or
faradie, when available are indicated. Should
reaction not be established then coma and death
ensue.
As regards medicine to be administered internally,
some such draught as the following is desirable,
as evolved by the author through induction :—
R Sp. ammon. co. - ae +. mxv.
Sp. æth. chlor. SA v je ME
Sp. ieth. nitrosi vs oe .. 5ss.
Tinct. hyoscyami — .. ps mxv.
Aq. ad. 5i, as required.
If not readily retained the sal volatile may be
omitted, and perhaps sp. eth. sulph. substituted.
In the course of the epidemic at Camp Gharial the
author, judging from the fact that ipecacuanha is a
specific for dysentery and quinine for malaria, cast
about for one for cholera, and acting on the supposi-
tion that whether a specific be discovered or not, in
agreement with Sir Thomas Watson, it is well to
eliminate the poison, he administered a pill of
colocynth and hyoscyamus, with marked effect, but
whilst he was investigating, one morning between
two and three o’clock, he awakened to find himself
suffering from Asiatic cholera, and he took acolocynth
and hyoscyamus pill, with the result that after being
assisted back to bed by his native servants he was so
far recovered by 7 a.m. the next morning as to beable
to mount his horse and ride to the hospital to attend
a soldier who had cut his throat; and the latter
incident, combined with the fact that the disease was
located as far as it is possible to do so to one company,
when the latter underwent isolation, prevented further
investigation and the experimenting with pills of
hyoseyamus and coloeynth, hyoseyamus and aloes.
But the author is convinced that here les a
remedy if not a specific for the disease. And at the
present moment in his cupboard are colocynth and
hyoscyamus pills, Pharmacopaia strength, and others
of half strength, colocynth and aloes with tho full
amount of hyoscyamus.
It may be mentioned that as a prophylactic
measure a belt of flannel has been much advocated,
but it is well to bear in mind that the object is to
keep the abdomen warm and so prevent a chill, and
that per se it possesses no specific value, such as some
believe to be attached to it after the manner of some
of the popular belts. As a prophylactic, in barrack-
room language, it is well to keep one's pecker up; that
is to say, retain one’s cheerfulness, and eat at or about
the usual Have no fads. Sterilization of milk
—possibly lime-water affects this—and the placing
of meat in tly-proof safes; the avoidance of any-
thing in the remotest degree tainted, with the filtration
and boiling of all water, of course, are indicated, but
the life led should be the normal one, and probably it
is better for the moderate drinker to continue his ways,
the total abstainer his; but should the latter “fancy”
something, then a liqueur glass of whisky, or cognac,
with a small soda, is perhaps the best, as a prophy-
lactic measure against the disease, for when those
liable to be attacked by cholera are in any way
suffering from neurasthenia the not obeying their
instinets may produce insomnia, which prolonged may
render them irresponsible for their actions, when a
debauch or errors of diet may follow. All food should
be well cooked, appetizing, all burnt fragments should
be avoided, as also should the erust of toast—in fact,
anything that is liable in any way to cause intestinal
irritation in any form should be most carefully
eschewed ; for it would appear to be beyond dispute
that anything causing the alimentary tract to become
deranged will predispose towards the disease, and
this in the past has given cause for confusion, and
so every case of intestinal disturbance has been classed
as choleraie diarrhea, which, after all, is not such
a misnomer as it may at first blush appear, as will
be seen in a moment, although the name has given
rise to much eontroversy.
It may be mentioned that Colonel Cunningham, of
the Indian Medieal Service, has succeeded Charles
Macnamara, as far as concerns Asiatic cholera, and
the views of the two coincide as to its endemic
nature about the Ganges. In the epidemic amongst
Europeans at Camp Gharial the author has shown
how the disease reached the Jhelum, and then ap-
peared in camp. In the autumn, whilst chikor shoot-
ing in the khud below the camp, at the side of the
spur running down to the river, he interviewed several
natives, and—the matter concluded, so, therefore, no
detriment likely to accrue to them from disclosures—
the fact was elicited that several villagers had suc-
cumbed to the disease between the last case at the
Jhelum dak bungalow and its appearance in camp
above, where—Gharial being isolated in accordance
with the Indian regulations—the disease was confined,
and no carrier advanced it further. So that isolation
should be practised in all cases, both as regards those
affected, and, when practicable a village in the British
Isles, or even street when feasible and possible. On
all sides it appears to be agreed that Koch's comma
bacillus is the materies morbi, but as to the value
of the serums that have resulted, opinions are
by no means unanimous, and Muir and Ritchie tell
us that it is not at all certain whether the bacillus is
a toxin per se, or causes certain changes. In a word
that either the effieaey of the serum as a pro-
phylactic, such as Jenner's vaccination lymph, and
typhoid serum, or an anti-serum such as Pasteur's
hydrophobia, or anti-tetanus, is non-proven. But
the fact has been determined beyond dispute that,
given certain conditions such as premonitory diar-
rhea, or other disturbance of the intestines, the
bacilli thrive and multiply in the mucous membrane
! Celsus describes this, if not Asiatic cholera.
Dec. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
363
of the intestines. And we have seen the close
relationship between bacillary dysentery, enteric
fever, and cholera, as regards the flagellated nature
of the bacilli; whilst again in enteric fever, Peyer's
patches are affected, and in cholera the whole intes-
tinal tract suffers, it would appear not unlikely that
the prophylactic serum for typhoid in some manner
affects the little known agminate and solitary glands
of the ileum.
To conclude, the bacillus may be air-, food- or water-
borne, prefers a suitable nidus in the alimentary tract
to settle in, develop and multiply, is destroyed by
heat over 55° C., by sulphur fumes, and by chloride of
lime; is affected by cold and frost, but seemingly
only suffers from impaired vitality, and may again
recover motility; is better removed from the body
than checked by astringents; whilst the value of
cholera serums has yet to be determined, and possibly
one of the components of pil. colocynth and hyoscya-
mus may be a specific.
i —
Annotations,
A New Missile. — Surgeon Johannes Volkmann
(Miinch. med. Wochenschr., September 15, 1914)
reports thirteen cases of punctured wounds from
arrows dropped from an aeroplane on September 1.
The missiles were 10 to 15 cm. long, of pressed
steel, about 8 mm. thick and weighing 16 grm. The
lower part was solid, terminating in a needle point.
The upper part of the arrow consisting of a skeletal
arrangement of four thin staves, the whole making
a star-shaped figure in cross section. The men of the
regiment were surprised lying down by sharp sudden
wounds suggesting to some that they had been
prodded by one of their comrades as a practical joke.
The arrows penetrated arms, feet, calves, fingers,
ankles, the cheek, the neck, and in one case, the
skull, the latter furnishing the only fatality. In
some cases the arrows had to be cut out. The
treatment consisted in a sterile bandage, and the
wounds healed rapidly by first intention. Only one
case was treated with tincture of iodine.
Mecca Pilgrims and Cholera.— id. Sergent and L.
Négre (Bulletin de l'Office International d' Hygiene
Publique for August, 1914) examined thirty-six
pilgrims returned to Algiers from Mecea and thirty-
oneto Morocco. Thirteen (10 per cent.) had dysenteric
bacilli of the Flexner type. The examination of the
stools of a number of natives resident in the neighbour-
hood of Algiers who had not been to Mecca gave a
negative result. In three of the returned pilgrims
(4'5 per cent.) cholera vibrios were found in the
intestines, and in two instances the vibrios presented
all the true characters of the cholera vibrio. The
pilgrims were all in good health, and the observations
show that among those returning from Mecca there
are carriers who escape existing sanitary measures.
Motes.
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THE JOURNAL OF
Tropical Medtctne and Hygiene
DECEMBER 1, 1914.
COMMON DISEASES IN TIME OF WAR:
ENTERIC FEVER.
OF the many ailments now coming under treatment
in our camps and military hospitals independently of
shot, shell and bullet wounds, those that stand out
most prominently are enteric, dysentery, rheumatism,
pneumonia, tetanus and occasionally typhus and
cholera; nor is influenza to be forgotten. Amongst
men from tropical countries engaged in Europe at
present the possibility of malaria recurrences cannot
be neglected.
Enteric.—In spite of all methods of investigation
as to the evidence of the presence of the typhoid
364 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
bacillus of Eberth, none are unfailing except the
record of the temperature during the first week.
The classical temperature chart, showing a drop of
one degree in the morning, and the gain of two degrees
in the evening, holds good to-day as it did before
blood tests were in vogue. Widal’s reaction serves
to confirm the diagnosis, and is & useful aid in that
direction; but it is no more than an aid, for it is
not invariably confirmatory, for or against. The
mieroscope cannot always settle the matter, for the
resemblanee of the colon bacillus to the typhoid is
such that even experts may be misled. Again, in
many febrile states besides enteric the sulphanilic
and the diazo-reaction tests hold good, so that one
has to fall back upon the experiences recorded by
Sir William Jenner when he first established the
distinctions between typhus and typhoid.
It is needless to go over the commoner signs and
symptoms, for although recently qualified men,
especially those who have studied in London hospitals,
since the disease has well-nigh disappeared in London,
seldom see cases of typhoid, still, they are well
drilled by their teachers in the subject, for typhoid
was the disease in the student days of the middle-
aged doctor of to-day. Few signs or symptoms occur
in a given case of typhoid which may be said to be
constant. There may be no rash, or it may prove
elusive; the pea-soup stools may never develop, but
an annoying constipation may prevail instead ; beyond
& few vivid dreams at the initiation of the febrile
state, there may be neither hallucinations nor delirium.
The spleen may not be enlarged to so marked an extent
that it can be felt; or if the patient happens to have
been in the Tropics the splenic enlargement may be
due to malaria. The "classical" tongue is imitated
in many fevers; and so with almost every other pos-
sible point to bə observed, there is no constancy. It
comes, therefore, to be a question of a three or four
days’ careful temperature-taking during the initial
phases of the disease to settle the " working diagnosis "
that it is typhoid that we are dealing with.
The treatment of typhoid is stereotyped, and con-
sists of milk and beef or chicken tea—about 3 pints
of the former and 1 pint of the latter during the
twenty-four hours. That this strict routine is wise
is more than doubtful; the whole idea is, of course,
the withholding of any food that has an indigestible
refuse, so that the lower part of the small intestine
and the commencement of the colon may not be
irritated by its passage, and hemorrhage and perfora-
tion avoided. There are, however, many substances
which may be safely administered, which at present
are looked at askance. The patient, if thirsty, may
be given toast-water, rice tea (rice roasted and then
infused in the same way as ordinary tea). Tea itself
may be given if made by holding above the cup a
strainer with a teaspoonful of china tea, pouring
boiling water into the strainer and letting the water
trickle through into the cup; sugar in plenty may be
added to the tea. Home-made lemonade, thin barley
water or rice water may also be given. Rice water
made by taking, say, three tablespoonfuls of rice in
14 pints of water, boiling for half an hour or moie
and then straining off the particles of rice, is an
excellent substitute for milk, inasmuch as it is very
nourishing and it does not coagulate and clot as
milk does. Of more solid substances, junket or curds,
barley (not oat) meal porridge, home-made jellies,
baked custard and so forth are a pleasant change
and at the same time sustaining and harmless to
the bowel.
In regard to medicinal treatment, this may or may
not be required; when the disease follows a normal
course no drug may be needed, but there is no reason
why remedies should not be freely given when
necessity demands. Delirium may be allayed by the
usual remedies ; hyoscine, 13g gr. hypodermically,
is excellent; and so are bromides, sulphonal, adalin
and others given by the mouth. When constipation
is persistent, a glycerine suppository may suffice, or
castor oil in teaspoonful doses, repeated every hour
or two until say 6 drm. are given; or, again, calomel
in minute doses of y gr. every two hours until an
action occurs. When diarrhoea is severe, salicylate
of bismuth, in 10 gr. doses in a simple mixture and
administered every two, three or four hours, is safe
and acts also as an intestinal disinfectant. The
question of disinfectants is a constantly recurring
question in typhoid and other ailments in which
an intestinal flux is a prominent symptom. The
difficulty is to reach the affected part, which is always
low down in the bowel, and coated capsules, said to
be indissoluble in the stomach, are administered with
the intent of carrying the drug to the diseased part.
Of all disinfectants sulphurous acid in 15 to 30
minim doses, given in a wineglassful of peppermint
or dill water every four to six hours, holds a high
reputation.
When temperature is high and rising, the hydro-
chloride of quinine in 3-, 5- or 7- gr. doses,or Warburg's
tincture in tablespoonful doses, especially if malaria
complicates the disease, are safe; but antipyrin,
phenacetin, aspirin, and the like should be avoided
as a rule. Sponging the body with hot water may
serve to lower the temperature, or if it fails cold
water, or equal parts of cold water and spirits of wine
may be employed ; wet packs or even cold baths may
be used, but these necessitate the utmost care and are
only expedient in desperate cases, and then only in
the earlier stages of the disease whilst yet the heart
is able to stand the strain of so drastic a measure
In regard to the use of opium it is not forbidden;
cough may be allayed by some of the simple forms of
cough mixture; a suppository of opium or a starch
and opium enema is useful when there is great
irritability of the bowel from diarrhaa.
Of the many complieations, nose-bleeding, pneu-
monia, hemorrhage from the bowel, perforation of
the intestine, phlebitis, kidney troubles, bed-sores,
each and all eall for watchfulness and care on the
part of the nurse and doctor. Good nursing, and
in that is included accurate observation, is the first
and the last word in typhoid fever. Lung troubles
are to be avoided by frequent change of position, the
patient being gently rolled first on one side and then
the other; the back has to be carefully examined
—
Dec. 1, 1914.]
for threatening bed-sores, the stools examined for
blood, and the state of the bladder as regards reten-
tion attended to. The patient in the height of the
disease must never be left unwatched, for collapse
from hemorrhage or perforation may cause an instan-
taneous collapse.
Vaccine treatment for typhoid has not yet proved
its efficacy, but it may be worth trying. The
surgeon should be called in when perforation is
known to have occurred; and the earlier the better.
— P
Abstract.
GUNSHOT AND BAYONET WOUNDS OF
THE STOMACH.’
By CHARLES GREENE Cumston, M.D.
Geneva, Switzerland.
A BAYONET wound is in all respects similar to
any form of stab wound, but the lesions produced
by the Lebel bayonet present certain special characters
which should be taken into consideration. The Lebel
bayonet has four sharp longitudinal projections,
separated by four corresponding grooves. The wounds
produced in the stomach and intestine are rounded,
with irregular and slightly contused borders. A
soldier who was wounded by this bayonet in the
epigastric region and who died from a wound of the
aorta, showed at autopsy that, although the stomach
was full of food and completely transpierced, no
gastric contents were found in the abdominal cavity.
A young girl, who was wounded in the epigastric
region by a Lebel bayonet, presented distinct sym-
ptoms of gastric perforation but recovered without
operation.
Of gunshot wounds it may be said that to-day the
armies of all civilized countries employ a pointed
projectile of small calibre, having a very great
penetrating foree. The modern projectile is elongated
in shape and of an average calibre of 7 mm.: its
length is equivalent to four times its calibre, and
it weighs about 15 grm. The nucleus is composed
of an amalgam of lead and antimony, which forms a
very hard mass, and is covered at the apex at all
events—and usually also on its entire surface, except-
ing the base—with an envelope of hard metal.
The lesions differ according to the distance at
which the arm has been fired. Beyond 300 metres,
these projectiles produce simple perforations which
are small and circular, the bullet entering the tissues
like a gimlet, spreading them apart, with the result
that the borders of the wound may close together,
producing an almost complete occlusion. The open-
ing of the exit of the projectile is generally somewhat
larger than that of entrance. When the firing dis-
tance is less than 300 metres the lesions vary
according to the state of plenitude of the stomach.
When the organ is empty the wounds present the
! From the Boston Medical and Surgical Journal, October 15,
1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
365
same characters as those just enumerated and the
resulting disturbances will be slight, but the same
cannot be said when the stomach is distended with
food, and the result is a genuine bursting of the
viscus ; it presents large tears and extensive rents.
Gunshot wounds of the stomach are very fre-
quently accompanied with wounds of the neighbour-
ing viscera. When the shot is fired at a moderate
distance the projectile generally transpierces the
subject, passing through the pleura, lung, liver,
spleen, panereas, kidney, or even the pericardium and
heart. The minimum of damage is met with when
the projectile enters in the area of Labbé's triangle,
an area in which the stomach is in direct relation
with the anterior abdominal parietes ; but even here
the organs situated behind the stomach (kidney, pan-
creas) will probably be involved. In other instances
the track of the projectile in the tissues is much
longer, when the bullet follows the axis of the body.
This is met with frequently in soldiers who were in
the recumbent position at the moment they were
shot, and under these circumstances the lesions are
multiple and varied. In one case the point of
entrance was in the anal region, while the point of
exit was found in the left sixth intercostal space in
the mammillary line. The bullet lacerated the hypo-
gastric vein, perforated the small intestine several
times, likewise the colon and mesentery, and also
went through the stomach.
Such cases are of no clinical interest, however,
because death occurs before any help can be offered,
and although such lesions are frequent on the battle-
field, there are fortunate instances in which the
stomach alone is involved, or at least represents the
principal lesion. It is just these cases that we shall
more particularly consider when speaking of the
operative treatment, when this can be resorted to with
the slightest chance of success, as we shall see.
The area of gastric vulnerability corresponds to the
projection of the stomach on the abdominal wall.
Over the anterior abdominal wall this area has an
oval shape with its axis almost vertical, or perhaps it
would be better to say slightly inclined from left to
right and from above downwards, whose greater ex-
tremity occupies the left hypochondrium, while the
lesser is situated to the right of the middle line
corresponding to the pylorus. Its upper limit is
represented by a curved line with its concavity parallel
to that of the diaphragm, whose uppermost point is at
the level of the left fifth rib in the mammillary line.
This point undergoes slight oscillations with the
respiratory movements.
The lower limits vary. When the gastric cavity
is empty they correspond to a transverse line passing
at the point of union of the ninth and tenth rib on
each side. When the stomach is distended it becomes
displaced downwards; the most declivous point of
the full stomach will be found in the neighbourhood
of the umbilicus.
The left lateral limit in the state of complete
distension becomes confounded with the limits of
the hypochondrium. Usually it attains a vertical
line, passing slightly to the outer aspect of the
366 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
nipple. The right extremity corresponds to the
pylorus, which is also subject to variations, but
which in its mean situation is found behind the
eighth rib, this point corresponding to the external
border of the rectus.
Over the posterior abdominal wall the projection
of the stomach affects a shape similar to the pre-
cedent. The culminating point of its upper curved
limit is at the level of the eighth rib in the left
scapulary line. In the middle line, its upper limit,
corresponding to the lesser curvature, obliquely
crosses the spine from left to right and from above
downwards, extending from the left side of the tenth
thoracic to the right side of the first lumbar vertebra.
When the stomach is distended the lower limit reaches
about to the spinous apophysis of the second lumbar
vertebra,
Let it not be understood that a wound whose
orifice of penetration is located outside the limits
of the area here given may not involve the stomach.
With firearms this can perfectly well happen, but in
this case involvement of the stomach is rather the
exception.
Gunshot wounds are the most frequent of any in
battle; lesions from the bayonet are the exception.
Usually the damage done by the projectile within the
abdomen is so extensive that death results at once.
A great number of those thus wounded die before
they are removed from the field; among those
removed a number die from peritonitis, but quite
& large proportion recover without operation, and
almost all submitted to laparotomy die.
Peritonitis is the only late indication for operating,
and in these cases the operative aet should be
reduced to the. minimum, simple incision to
le& out the pus and drain the peritoneal cavity,
without searching for the gastric lesions, which,
unlike wounds of the intestine, have a much more
favourable evolution. However, the existence of
lesions of the neighbouring viscera may create special
indieations, such as hernia of the intestine and,
above all, intra-abdominal hemorrhage. What has
been said of gunshot injuries to the stomach applies
quite as well to lesions from the bayonet, whose
resulting wounds generally have a favourable evo-
lution.
The conservative treatment consists in absolute
rest and, if possible, the subject should not be
mobilized. This latter is the first condition of
conservative treatment. Morphine and opium are
to be administered and an absolute diet maintained
for the first few days, whieh should be continued
just so long as there is any doubt about cicatrization
of the gastric perforation. Usually, feeding by
mouth can be prudently commenced by the fourth
day, but it may have to be postponed for a week or
so. During this time rectal feeding is exclusively
employed, along with the subeutaneous administra-
tion of physiological salt solution.
There are cases which will die from internal
hemorrhage, if not immediately operated on, and
this is the only indication for surgical interference
in abdominal wounds on the battlefield. But since
a laparotomy is undertaken for the control of the
loss of blood, after this has been accomplished, it
is better, perhaps, to do a complete piece of work
since the abdomen is opened, and close gastric or
intestinal perforations when present.
Given a case presenting the classic symptoms of
intra-abdominal hemorrhage, and supposing that the
patient can be transported in sufficient time to the
field hospital, the proper incision to be selected is in
the middle line in gunshot wounds, because by this a
much better exploration can be made and the lesions
found. The lesions which cause the haemorrhage may
be so serious that even splenectomy or nephrectomy
may be required, but wounds of the pancreas or liver
can be sutured. Therefore begin at once to examine
for the sources of bleeding in the left hepatic lobe,
pancreas, spleen and kidneys, because gunshot wounds
of these viscera are detected by the flow of blood.
When this has been found and the proper treatment
applied, one can next proceed to explore the small
intestine for perforations, never forgetting the duo-
denum. Then the stomach is next examined, never
neglecting the examination of the posterior gastric
wall as well.
In bayonet wounds the exploration of the ab-
dominal viscera need not be quite so complete,
because multiple lesions from this cause are infre-
quent; but, nevertheless, the arm may enter deeply
and involve deep-seated structures, such as the splenic
or renal vein. Examination of the small intestine
need not be resorted to, as multiple perforations from
stab wounds are practically unknown. When the
hemorrhage has been controlled and the gastric
perforation found, you will proceed to deal with it.
Thoracotomy in wounds in which the bullet enters
through the thorax into the abdomen is too formidable
an operation to be done in a field hospital.
Gunshot wounds of the stomach usually penetrate
both walls of the organ, and median laparotomy is
the proper incision. Other incisions may be of
advantage in some few cases in civil practice, they
have none in the surgery of war. By the median
incision the left hepatic lobe, stomach, spleen, and
pancreas, likewise the kidneys and intestine, can be
thoroughly explored. But in bayonet wounds median
laparotomy is to be done only when the wound is
in the neighbourhood of the linea alba, otherwise
the incision should be made at the point of abdominal
perforation, since one has not to search for multiple
lesions. When perforation of the posterior gastric
wall occurs it is generally seated directly or nearly
opposite the anterior perforation, so that it can more
readily be discovered by posterior exploration. The
intestine is rarely involved and in the few cases
where this has been the case the transverse colon has
been the organ injured. In cases where the wound
is situated in the left flank the abdominal incision
made parallel with the costal border is to be pre-
ferred, as it gives an easier access to the hypo-
chondrium and subphrenie region. Should more
space be required during the operation a medium
incision can be advantageously added.
The exploration of the anterior surface of the
a egg —À"
Dec. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
367
stomach is usually easy, excepting in the region of
the cardia. The gastric perforation usually comes
into view when the abdomen is opened, but when it
is very small, as is sometimes the case, it must be
searched for with much attention. Occasionally, it
is seen in the form of an ecchymosis, which must be
closely examined in order to discover the perforation.
Sometimes it is hidden by a blood-clot, or it may be
concealed in a gastric fold. In order to expose the
perforation in the latter case, the gastrocolic ligament
is incised, and by introducing the hand behind the
Stomach the anterior surface is unfolded and the
perforation brought to light which would otherwise
escape attention.
The projectile generally perforates both gastric
walls, and the orifice of exit is usually seated in the
posterior wall In bayonet wounds the anterior
perforation is usually the only one, but it must be
recalled that perforation of the posterior wall occurs
in about 10 per cent. of these injuries. Therefore,
the surgeon must not omit exploration of the pos-
terior wall in these cases. Extragastric exploration
is a necessary step in the interference in both gun-
shot and stab wounds, and this is done through the
gastrocolic omentum, but when the perforation
is near the lesser curvature it is, perhaps, better
to go through the gastrohepatic omentum. By
this latter route it is easier to suture a wound
of the pancreas. An incision in the transverse
mesocolon may sometimes be preferred. But these
are not methods of choice, because by the former
the access is difficult and does not allow one to
explore the entire posterior gastric wall, while in
the latter, if the opening is at all large and this is
necessary, there is danger of injuring the vessels of
the mesocolon. It is also better to avoid working
in the lower part of the abdomen, necessitated by this
technique, particularly when the case is one of stab
wound which does not require examination of the
small intestine. Therefore, incision of the gastro-
colic omentum will be the method of choice, and
with a large opening it is sufficient for all operative
work, and involving several of its vessels will not
compromise the vitality of the great omentum.
When the perforation is in the middle or lower
portion of the stomach it can readily be seen and
closed through a relatively small opening made in the
ligament with forceps, but the same does not apply
when the perforation is seated high up on the
posterior wall near the cardia. To accomplish a
good suture here, the stomach must be turned
upwards in order to expose its posterior aspect
thoroughly. The costal borders hinder the opera-
tion, and it is for this reason that several types of
resection of the costal cartilages have been described ;
but I do not hesitate to say that by median laparo-
tomy perforations situated high up can be sutured,
on the condition that the opening in the gastrocolic
omentum is sufficiently large.
It is well to make it extend from the pylorus to
the left angle of the colon, and thus one can quickly
explore the posterior aspect and carry out a careful
cleaning of the retrogastric space. Gangrene of the
greater curvature need not be feared if the opening is
made 2 cm. from the stomach, so as to avoid the
gastro-omental arteries.
In some special cases extragastric exploration will
be sufficient, in which case gastrotomy is to be re-
sorted to, but before doing this a cushion should be
placed under the lumbar region, which may render
the examination easier, and the endogastric procedure
may not be required. However, should this be
deemed necessary, the incision in the anterior gastric
wall should be horizontal, at least 3 in. long, and
made at equal distance from the curvatures. Intro-
ducing the hand behind the stomach, the posterior
wall is made to protrude through the gastric incision.
The mucosa is wiped with compresses, after which
the surface is examined. One may thus discover an
ecchymosis or a perforation which would otherwise
have been overlooked.
This technique, which in gastric ulcer is rather
simple, is less so in traumatic perforation, because in
the former the gastric cavity is apt to be empty,
while very frequently the stomach is full at the time
the gunshot injury is received. This being the case,
the contents must be removed through the incision,
with all due care not to let any of it escape into the
peritoneal cavity. Very few surgeons have resorted
to endogastric exploration in gunshot wounds, and
when it has been done, the incision in the anterior
wall has been timidly made, with the result that the
posterior perforation has been overlooked. In the
case of President McKinley, the anterior perforation
was simply enlarged and the gastric cavity explored
with the finger, and the posterior perforation was
only discovered by a. direct examination of the
posterior wall.
It is true that simple inspection of the outside of
the stomach wall may fail to reveal a perforation,
and this happened in several cases, but it is un-
common. Always remember that the perforation in
the posterior wall may be in the duodenum.
There is one lesion that may require gastrotomy
for its discovery—eontusion of the posterior gastric
wall from the projectile. This lesion is uncommon,
but it is often the cause of hemorrhage and ulcera-
tion. It is also indicated when external exploration
does not reveal any lesion sufficient to explain the
symptomatology; when, for example, there is free
hematemesis due to contusion of the stomach with-
out perforation of the organ. This has been observed
in practice. As can readily be seen, the endogastric
exploration has a limited field of usefulness, but
occasionally it may be required.
The closure of the perforations is the same in gun-
shot wounds as in any perforation of the gastro-
intestinal eanal. When there is much contusion of
the borders an economical resection of the exuberant
mucosa is indicated. When the opening is at the
pylorus or cardiac end of the stomach the sutures
should be placed perpendicularly to the axis of the
portion iuvolved, in order to prevent stricture. If
the loss of tissue is considerable, it is better to suture
the perforation to the skin in order to save time.
When there is a simple abrasion of the outer coat of
368
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 1, 1914.
the stomach it should be buried under a peritoneal
suture in order to avoid future complications.
Free drainage of the abdomen is absolutely neces-
sary, no matter how small the perforation, and should
be established in those regions where liquid is most
prone to accumulate, the left hypochondrium for per-
foration of the greater curvature, the space comprised
between the liver and stomach in perforation of the
anterior gastric surface and lesser curvature.
For posterior gastric perforation the retrogastric
area must be drained with care; the best manner
being through a lumbar incision. It can be done,
however, through an incision in the gastrocolic
ligament. Packing the retrogastric space may be
necessary for controlling slight bleeding from a
sutured pancreatic perforation. Absolute quiet is
essential for the first few days, and feeding by mouth
ean usually be begun on the fourth day, but should
vomiting occur it must be stopped at once and not
again attempted for several days.
Gunshot perforations of the stomach, as met with
in the field hospital, should never be treated surgically
unless laparotomy is indicated for intra-abdominal
hemorrhage, as more lives will be saved under the
circumstances by a careful conservative treatment.
————9—————
Reprint.
THE ARMY AND MENTAL DISEASE.’
THE mental anguish, depicted by the numerous
tales of suicide, madness and desertion among soldiers,
to say nothing of mental frenzy expressing itself in
wanton murder, that have come to us from our ill-
fated friends across the sea, leads us to realize that
there have been made as yet no scientific studies of
the effect of war on the minds of officers and enlisted
men in the army. Fortunately for our nation, there
has been no opportunity to study the effect, on a
large body of men, of short rations, loss of sleep, great
emotionalism, exhausting exposure, excessive physical
exertion, home-sickness, &c.; yet these in combination
produce a strain that might well prove fatal to the
equilibrium of many a mind that in regular routine
would show no weakness. To be mentally sound in
such conditions is of more importance than to pass
the eyesight test, or to be typhoid proof.
In the light of modern psychiatry it is rumoured
that more than one great battle has been lost by a
general who was in the early stage of paresis, and
doubtless dozens of men who have met the fate of
deserters had their doom written in their brains,
could their officers have read the signs of dementia
precox. Although the mental effects of war strain
have not been studied, our War Department has been
carrying on, under the Surgeon-General’s advice,
a very interesting inquiry concerning the mental
status of the army. The studies show that the
! From the Journal of the American Medical Association,
October 17, 1914.
? King, E.: “Mental Disease and Defect in United States
Troops," Bulletin 5, Dept. of War, Washington, D.C.
mentally diseased, and those who are congenitally
or otherwise mentally defective, form an important
problem in armies and navies.
Of all the discharges for disease or external causes,
practically speaking, one-fifth are on account of
mental disease in some form. That is to say, out
of 1,062 men discharged in 1912 on account of dis-
ability from all causes, more than 200 were found to
be mentally diseased or defective during the year;
and these did not include the retirements for neuras-
thenia or hysteria, which, although the patients
are not insane in the accepted sense, are in reality
mental diseases that will seriously affect one's effi-
ciency in time of strain.
Of all the mental diseases, it was found that
dementia precox was by far the most frequent
form; it averaged about 56 per cent. each year of
all the dismissals. In addition to these, there is no
knowing how many cases there might have been
among the soldiers who deserted through the year,
or were dishonourably discharged on account of
" previous convictions by summary court,” or who
attempted suicide. Many of them, without doubt,
had mild or unrecognized cases of dementia præcox.
The report gives a clear, concise outline of the
modern conception of dementia præcox, explaining
the way in which it may appear in the army in
young men who have never shown any of the
symptoms of irresponsibility when sheltered by their
parents or friends, but who cannot " get along" when
they are required to speak, act, and even think in
preseribed and orderly fashion.
The symptoms, with the vivid case descriptions
that follow, will afford the regular army surgeon
much insight into cases that would seem to be
merely undisciplined. In fact, the text of this
bulletin will be of tremendous social value to every
officer, as well as to anyone dealing with large
bodies of men, whether in reform schools, prisons,
factories or mines.
In the same clear, concise manner, paranoid
mental states are treated, also manic depressive
psychoses, general paresis, syphilis of the nervous
system, arteriosclerotic mental disturbance, hysterial
psychosis and the constitutional psychopathic states.
It is interesting to note that the military prisons
frequently turn over men who have been convicted
for desertion, assault, murder, theft, who were prob-
ably at the time suffering from mental diseases that
were not recognized until they became so pronounced
that the prisoners had to be sent to the Government
Hospital for the Insane.
Even despite the advice of experienced alienists,
men are condemned to death by jurors instructed by
lawyers who fail to grasp the significance of these
peculiar disturbances in the emotional sphere— delu-
sions, hallucinations and sexual perversities. The
pages of this bulletin would be excellent reading for
the occupants of the jurors’ box in a criminal law
court; for what holds true of enlisted men matches
up in a pretty fair average to men in general.
-— e
Dec. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 24, Vol. XVII.
Original Communications.
THE OCCURRENCE OF CERTAIN STRUC-
TURES IN THE ERYTHROCYTES OF
GUINEA-PIGS AND THEIR RELATION-
SHIP TO THE SO-CALLED PARASITE
OF YELLOW FEVER.
By C. M. Wesyon, M.B., B.S., B.Sc.
Director of Research in the Tropics to the Wellcome Bureau
of Scientific Research.
AND
GgonaE C. Low, M.A., M.D., C.M.
London School of Tropical Medicine.
(From the Wellcome Bureau of Scientific Research).*
IT has been claimed by Seidelin, and later by
Macfie and Johnston, that certain structures seen in
the red blood corpuseles of yellow fever cases and
called by them Paraplasma flavigenum, are inoculable
into guinea-pigs, and can be passed on by subinocu-
lation from one animal to another. In consequence
of these and other results they consider that they are
dealing with a definite parasite, the etiological factor
of yellow fever.
In inoculated guinea-pigs these bodies are never
present in large numbers, and it occurred to us that,
before accepting these conclusions, it would be well
to make a careful study of the blood of normal guinea-
pigs in a country where yellow fever does not exist.
Accordingly we have made minute examinations of
healthy guinea-pigs of all ages born and bred in
London.
The results obtained in these examinations are of
extreme interest, for they have shown, as we sus-
pected, that the erythrocytes of apparently normal
and healthy guinea-pigs contain in small number
minute bodies, which, as far as we can judge, are
identical with the structures described by the authors
already mentioned in their inoculated guinea-pigs.
Such observations are not altogether new, for Agra-
monte and Schilling-Torgau have already recorded
similar results in their examination of animals. A
brief mention of our examination of normal guinea-
pigs and the discovery in them of these bodies has
already been made (Lancet, May 9, 1914, p. 1357).
The difficulty of describing such minute bodies
verbally has led to contentions as to the identity of
the structures dealt with by the various authors. In
order to reduce such difficulties to a minimum we
have reproduced a coloured plate of red blood cor-
puseles drawn from films of guinea-pigs' blood, stained
by methods practically identical with those recom-
mended by Seidelin, and painted by the same artist
(Miss Mabel Rhodes) who produced the skilful draw-
ings illustrating Macfie and Johnston's paper. The
magnification employed is also the same as that of
the corpuscles in the plate illustrating the last
mentioned paper. If anyone interested in the subject
wil compare our plate with that one, and with
* This work was begun at the London School of Tropical
Medicine, but has since been much extended at the Wellcome
Bureau of Scientific Research,
those produced by Seidelin, they cannot, we think,
but be convinced that we are dealing with similar
bodies.
DESCRIPTION OF BODIES IN NORMAL
GUINEA-PIGS.
The bodies occur most commonly in very young
guinea-pigs, and against their parasitic nature is the
fact of their being in largest number in the newly
born animals, for it will be remembered that the
occurrence of placental transmission is exceedingly
rare in the whole realm of parasitology and does not
occur in piroplasmosis, trypanosomiasis, and other
protozoal diseases. In films of such blood, if suitably
stained, it will be found that nearly every red cell
exhibits one or more small red granules varying in
size and in position in the cell. They are evidently
structural elements of the erythrocyte and are not
found free in the plasma. Some of these resemble
very closely the red granules depicted by Seidelin in
some of his plates. "Their probable explanation is to
be found in the development of the red cell from a
nueleated corpusele, that is to say, they represent
some form of nuclear remnant, an idea suggested by
Schilling-Torgau. As the animal increases in age
the granules diminish in number till eventually they
become difficult to find. The majority of these
granules appear to be perfectly homogeneous and
refractile and have no other structure attached to
them, though in certain focus the appearance of a
whitish halo around them may be detected—this is
probably physically produced. In certain instances
the red granule may show a central more deeply
staining spot, as in fig. 35 of Macfie and Johnston’s
plate of the dog’s blood. A fairly common feature of
the red dot is the association with it of a bluish-grey
material which has the appearance of protoplasm, and
it is to these forms that special attention has to be
directed on account of their close resemblance to
some of the piroplasmata. The exact arrangement
of this substance is variable, and the appearance of
a vacuole may often be noticed in it. The nature of
this blue-grey substance is difficult to determine—
Schilling-Torgau considers it to be the remains of the
central capsule, part of the archoplasmic body of the
immature red cell, but it must be admitted that such
an explanation is hypothetical and somewhat difficult
of proof. It does seem, however, that in some cases
it has a connection with a basophilia of the red cells,
certain of which are seen to be dotted over with
irregularly shaped blue-grey patches varying in
number from a single one to fifty or more. If one
of the red dots, described above, should be associated
with one of these patches of basophilic change there
would be produced bodies which would have a striking
resemblance to minute piroplasmata. It is possible
that some of the bodies are produced in this way,
but the explanation will hardly account for the very
definite appearance of the rod-shaped and ring-like
bodies described below.
In some instances the blue-grey substance leads
away from the dot as a comma-shaped tag (see figs.
land 2), in others it is rod-shaped with the dot in
370
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
the centre or at one end (figs 3 to 8). In the rod-
shaped forms two red dots may be present instead
of one (fig. 9) while the rod itself instead of being
straight may be curved to produce a sickle shaped
body (figs. 10 and 11). Frequently, however, the
blue-grey substance is roughly the shape of a triangle
with its base separated from the dot by a clear space,
the two angles continuing on to enclose the dot
(figs. 16, 17 and 18), giving the appearance of a ring,
very much like a malarial ring in miniature, with the
side opposite the chromatin dot much .thickened.
Sometimes it is impossible to make out any connec-
tion between the red dot and the blue-grey substance
(figs. 14 and 15). This may only be due to the
minuteness of the structures examined, or, on the
other hand, there may be a real lack of such con-
nection owing to the fact that the appearance has
been produced by the accidental association of a red
granule with a blue patch of basophilic change on the
red cell, as explained above. In many cases, however,
ring appearances are produced without any marginal
thickening (figs. 19, 20 and 21), while irregular forms
are frequently seen (figs. 22 to 27), and also more
compact and solid looking bodies (figs. 28, 29 and 30).
From the above description it might be thought
that the chromatin-like part is always a single granule,
but this is not so; sometimes it is a more irregular
chromatin mass which appears to be made up of a
group of small granules (fig. 12).
The forms we have just been considering are very
much smaller than the smallest malarial parasite,
but occasionally larger ones are met with; such a
one is figured in our plate (fig. 13). It is possible
that these larger forms are of a different nature, and,
in fact, the extreme polymorphism of the bodies
suggest that they may not all be produced in the
same manner.
Recapitulating, therefore, the following different
types of bodies may be found in the erythrocytes of
normal guinea-pigs.
(1) The highly refractile red granule which in
certain focus appears to be surrounded by a white
halo and sometimes has a more deeply staining
central dot.
(2) Blue rod-shaped forms with one or more red
granules in the middle or at the ends.
(3) Blue ring-shaped forms with thickened blue
area opposite red dot.
(4) Large and small blue ring forms of more
uniform outline and lateral red dot.
It must be remembered that one is dealing with
extremely minute structures, and sometimes their
differentiation from artefacts is by no means easy
even to those who have specially studied the subject.
Even allowing for this we would insist that the
majority of the bodies are definite structures forming
part of the erythrocyte and are not artefacts which
have become accidentally adherent to these in the
process of film making. Some of them may result
from a degenerative or basophilic change in the red
cells, others may be remains of the red cell nuclei or
other structures which go to make up the com-
plicated ideal erythrocyte of Schilling-Torgau. It
(Dec. 15, 1914.
should not be forgotten that they occur in largest
number in the very young animals whose blood
approaches the embryonal type where developing
erythrocytes appear in the circulation more commonly
than in older animals.
It is to be expected that similar bodies will be
found to occur in the blood of other animals. Macfie
and Johnston have described such for dogs and rats.
This fact must be borne in mind when one is dealing
with animals which are known to be liable to piro-
plasma infection; for this infection in itself, by pro-
ducing a blood change, will tend to increase the
number of pseudo-piroplasmata present. One must
be very careful to distinguish these from true parasites
and must not be carried away by a superficial
resemblance in colour, which is merely an accident
of their chemical nature.
THE SUPPOSED INOCULATION OF GUINEA-PIGS
WITH THE SO-CALLED YELLOW FEVER PARASITE.
Seidelin and those who have followed him have
inoculated guinea-pigs with blood from yellow fever
patients and have found in the red cells of these
inoculated animals bodies which are indistinguishable
from those described by us above. They claim that
these have been inoculated from the patients suffering
from yellow fever and represent the parasite causing
that disease. They made no mention of the fact
that normal guinea-pigs harbour such bodies. It is
evident, therefore, that they have not sufficiently
controlled their results by the examination of normal
uninoculated animals, and their supposed inoculation
of the parasite of yellow fever into healthy guinea-
pigs is thus quite without foundation. We are con-
vinced from our observations on numbers of normal
animals that the guinea-pigs used by them must
have harboured these bodies before they were ever
inoculated, and their mistake has arisen through the
resemblance of these to the paraplasma bodies seen
in yellow fever cases.
THE SO-CALLED PARASITE OF YELLOW FEVER.
In this short paper it will not be necessary to go
into the literature of the. subject of the so-called
parasite of yellow fever in detail as this is sufficiently
well known to students of yellow fever. Suffice it
to say that Seidelin in 1911 showed specimens before
the Society of Tropical Medicine and Hygiene of
small bodies in the red cells of yellow fever cases, and
put forward the idea that these were parasites and
the cause of the disease. Subsequently he published
several other papers elaborating this view. After
this Schilling-Torgau in Germany discussed the
subject and showed that similar bodies might be
demonstrated in the blood of different diseases, and
he finally came to the conclusion that the bodies
were in all probability associated with the develop-
ment of the erythrocyte. Some correspondence took
place between Seidelin and Schilling-Torgau, and then
Agramonte, in Cuba, published a paper on the subject.
In this paper he criticized the bodies very strongly
and brought forward many points against their being
parasites. Other writers in that island, Cartaya,
Guiteras, &c., also demonstrated the presence of
Dec. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
371
what they considered similar objects in the blood of
people not suffering from yellow fever.
Seidelin, however, after examining specimens of
the bodies seen by other observers, concluded that
they were not the same as his. Here the matter
remained for some time, and might have gone on
doing so for ever had not Seidelin gone a step further
and claimed that he had found similar bodies in
guinea-pigs inoculated with yellow fever blood, in
fact, claimed that he had produced yellow fever in
guinea-pigs. Such a statement is, of course, not
only an important one, but a serious one as well, as,
if proved to be true, it means that the lower animals
can suffer from yellow fever and may act as reservoirs
or earriers of the germ. These results of Seidelin
have been confirmed by Macfie and Johnston and
by Seidelin himself working in West Africa. We
have now, however, shown that these authors were
mistaken in supposing that the bodies seen by them
in yellow fever are inoculable and undergo multiplica-
tion in guinea-pigs, and as this supposed transmission
was one of their chief arguments in favour of the
parasitic nature of the bodies, the point now arises
are these structures in yellow fever cases parasites
at all? The bodies we have found are present so
constantly in newly born guinea-pigs that the para-
sitic theory becomes untenable. "Therefore we would
suggest that the similiar bodies found in yellow fever
cases are likewise non-parasitic, this harmonizing
with the findings of Guiteras, Schilling-Torgau and
others who have demonstrated them in diseases
other than yellow fever.
Seidelin's position is this, he describes certain
structures in the red cells of yellow fever cases as
parasites of the disease, and, as Agramonte suggests,
places himself in an unassailable position by assum-
ing that the bodies found by others, who do not
support him, are not identical with his own. Further-
more, in his examination of the children in schools
in Mexico, he demonstrated his bodies, though the
ehildren were not suffering from auy recognizable
disease. Instead of accepting this as affording
evidence against his theory, he argues by analogy
with considerable skill, but without the production
of any proof, that these children are really carriers
of the parasite. Again, in his own case, he suffered
when in Mexico from a very mild febrile attack,
a common enough condition in those residing in
tropical climates. On examining his blood he en-
countered his bodies in larger number than in most
of the severe cases of yellow fever examined by
him. He himself had admittedly sutfered from an
attack of yellow fever some years before, and but for
the finding of the bodies in his blood we are sure
would never have diagnosed his complaint as yellow
fever. Still more remarkable is his most recent
announcement of his reinfection with the yellow fever
parasite by inoculation of blood of a supposedly
infected guinea-pig. If this were true, it would mean
a third attack—a most unlikely occurrence. Seidelin,
having accepted the parasitic nature of his yellow
fever bodies, is forced to diagnose yellow fever where-
evor he sees his parasite, and this has led him into
some difficult positions out of which he tries to
extricate himself by drawing analogies from malaria
and other diseases. For instance, a Chinaman in
Jamaica was diagnosed as suffering from yellow
fever because of the presence of such bodies in his
blood, without there being yellow fever in the island
at the time. He might with more reason have
accepted this case as refuting his theory. Still
further, Mactie and Johnston, finding similar bodies
in the blood of stray dogs, have guardedly suggested
that this animal is a carrier of the disease. In view
of the fact that our bodies are identical with theirs,
we might just as well say that guinea-pigs all over
the world are carrying the virus, and that only in
certain countries are they being conveyed to man
and producing yellow fever, unless one assumes that
guinea-pigs in yellow fever countries harbour the
yellow fever parasite, while in other countries they
have a morphologically identical parasite which is
not the yellow fever one. Such positions no one
would be foolish enough to adopt. The extreme
of the position is reached when it is suggested by
Seidelin that a protective inoculation against yellow
fever should be undertaken by suitably injecting the
blood of supposedly infected guinea-pigs.
THE VALUE OF THESE BODIES AS A DIAGNOSIS
OF YELLOW FEVER.
From what we have already said, and from the
examination of films from yellow fever cases, we are
convinced that these are of no value as a means of
diagnosing this important disease, and this quite
apart from the fact that other observers have found
them in most varied conditions. We would, there-
fore, warn those who have not had many oppor-
tunities of making such minute blood examinations
from accepting the presence of such bodies as a
clinical test of yellow fever. The bodies are so
minute and obscure that a specially trained expert is
frequently in doubt as to whether they are purely
artefacts or not. We absolutely fail to see how it is
possible for Seidelin to detect and identify such bodies
amongst the cellular and granular contents of a
section, especially one stained by the iron hema-
toxylin method. It is perhaps only just to remark
here that the bodies described by Macfie and Johnston
present a much greater uniformity of structure and
appearance than the heterogeneous collection of
structures which Seidelin serves up for our consump-
tion as the organism of yellow fever. Though it is
extremely difficult to depict such bodies even in a
coloured plate a very little experience in blood film
work would convince anyone examining Seidelin's
figures that many of them represent nothing more
than artefacts which have been produced by the
process of film making. We would undertake to find
in the smears of any organ, the stomach included,
bodies which no one could possibly distinguish from
those described from similar situations by Seidelin,
who seems resolved to work into the life cycle of his
hypothetical parasite every particle of blue and red
staining substance he can pick out of films, smears
and sections, regardless of the fact that these may
372
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 15, 1914.
be merely physiological or degenerative cell granules,
broken bits of tissue cells, or even parasites of a
totally different nature.
Seidelin has, however, done one service in showing
that by the expenditure of extreme patience and
laborious care, it is possible to find such bodies in
human blood, and we feel convinced that if anyone
cares to expend a similar amount of trouble in the
examination of diseases other than yellow fever they
will meet with similar reward.
WHAT ARE THE BODIES IN YELLOW FEVER
CASES?
We have already stated, in reference to guinea-
pigs’ blood, that the bodies found there, though
not parasitic, are still definite entities, and cannot
be regarded as artefacts. We believe similarly
that in yellow fever cases many of them have
to do with the development of the erythrocyte
from a nucleated red cell, though in some instances
they may represent basophilie or other degenera-
tive changes. The occasional presence of nucleated
red cells in the blood of yellow fever cases, as
recorded by some observers, seems to indicate that
a change has taken place in the development of the
erythrocytes, a change which is not remarkable in
view of the severe toxemia which exists in this
disease. It is not surprising, therefore, that prolonged
search reveals structures like those described above.
What does seem strange is that the blood, when
subjeeted to such a severe toxin, does not reveal more
evidence of erythrocyte degeneration. It will be
remembered that Guiteras, Cartaya, and Agramonte
found similar structures in diseases where there had
been anwmia or severe toxemia. These conditions
tend not only to stimulate blood production, thereby
increasing the possibility of nuclear remnants occur-
ring in the circulating cells, but the toxic substances
themselves also are likely to produce degenerative
changes by a direct action on the red cells. A further
study of the exact nature of these bodies would be
of interest, with a view to determining whether they
are developmental or degenerative in origin.
CONCLUSIONS.
(1) In the blood of normal guinea-pigs, born and
bred in England, are to be found bodies indistinguish-
able from the so-called Paraplasma flavigenum of
Seidelin.
(2) In most cases these appear to be definite
structures which probably have to do with the
development or degeneration of the red cells.
(3) They are not parasitic because they occur in
the blood of newly born animals, not forgetting even
the possibility of a placental transmission.
(4) The apparent success of the inoculation into
guinea-pigs of such bodies from yellow fever cases is
due to a failure of a sufficient examination of control
animals.
(5) The evidence in favour of the yellow fever
bodies being parasites thus breaks down.
(6) The presence of such bodies in yellow fever
bears, therefore, no diagnostic significance apart from
the evidence of blood alteration.
(7) It is frequently impossible to separate real
bodies from pure artefacts, a fact which renders their
differentiation one of extreme difficulty.
BiBLIOGRAPHY,
SEIDELIN, HARALD, Trans. Soc. Trop. Med. and Hyg., January,
1911; Brit. Med. Journ., January 23, 1911, p. 199.
Idem. Journ. of Path. and Bact., January, 1911, vol. xv, p. 282.
ScuiLLING-ToRGAU, V. Arch. f. Schiffs u. Trop. Hyg., 1912.
Beib. 1, pp. 87-100. (Verhandl. d. Deutsch. Tropenmed.
Ges., Vierte Tagung, September, 1911.)
SEIbELIN, H. Ibid., June, 1912, vol. xvi, No. 11, pp. 371-372.
ScurLLING-ToRGAU, V. Ibid., 1912, pp. 273-376.
AGRAMONTE, ARISTIDES. Medical Record, March 30, 1912,
vol. Ixxxi, No. 13, pp. 604-607.
SuipELIN, H. Ib:d., May 18, 1912, No. 20, p. 951.
Cartaya, J. Sanidad y Beneficencia, March-April, 1912, vol.
vii, Nos. 3-4, pp. 309 312. (English, pp. 415-418.)
SEIDELIN, H. ‘Report of Yellow Fever Expedition to Yuca-
tan," Yellow Fever Bureau Bull., October, 1912, vol. ii,
No. 2, pp. 123-242, with 3 plates and 2 maps.
AGRAMONTE, ARISTIDES. Trans, XVII Internat. Congress of
Med., London, 1913, Sect. XXI, Trop. Med. and Hyg.
pt. 2, pp. 77-81.
MacriE, J. W. Scorr, and JouxsrON, J. E. L. Yellow Fever
Bureau Bull., April 7, 1914, vol. iii, No. 2, pp. 121.144,
with 1 plate.
Low, G.C. Lancet, May 9, 1914, p. 1357.
Sempre in, Harao. Yellow Fever Bureau Bull., September 30,
1914, No. 3, pp. 203-207, with 1 plate.
THE TRANSMISSION OF TRYPANOSOMA
BRUCEI OF NIGERIA BY GLOSSINA
TACHINOIDES, WITH SOME NOTES ON
TRYPANOSOMA NIGERIENSE.
By G. H. GALLAGHER, L.R.C.P.S.I.
Medical Officer, West African Medical Staf.
(From the Wellcome Bureau of Scientific Research.)
DURING my last tour in Nigeria I was placed in
charge of the Sleeping Sickness Camp at Eket. This
district lies in the eastern division of the southern
provinces of that colony. The southern border of
the district abuts on the sea which inundates some
considerable portion of that section of it. No part
of the district is much above the sea level and a
profuse network of streams intersect the centre of it.
As a result of this vegetation is marked, especially
the palm tree and the short thick scrub which grows
so readily during the years the land lies untilled.
Here, as may be conjectured, is the ideal haunt of
the tsetse, and in former days when game must have
been more plentiful than now, the country must have
been a veritable Eden for them. Asa matter of fact,
glossinæ are not very plentiful—at any rate in com-
parison to the well-known fly-belts of the Congo and
East Africa—and rarely is one annoyed by these
pests along the Government road which passes east
and west through the middle of the district.
A few words as regards the distribution of the
tsetse-fly may be of some interest. I have failed
to find any mention in the literature on the
subject of existence of Glossina tachinoides or other
tsetse in the Eket district, though my predecessor,
the late Dr. Foran, in his various reports while he
was in medical charge of the Sleeping Sickness Camp,
THE JOURNAL
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OF TROPICAL MEDICINE AND HYGIENE,
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2R 29
DECEMBER 15, 1914.
20
25
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Bale & Danielsson, Ltd.
To illustrate paper, ** The Occurrence of Certain Structures in the Erythrocytes of Guinea-pigs and their
Relationship to the so-called Parasite of Yellow Fever,” by C. M. Wenyon, M.B., B.S., B.Sc.,
and GEonGE C. Low, M.A., M.D., C.M.
Deo. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
373
-E
repeatedly pointed out that this fly was very preva-
lent there. Later, Dr. Macfie, I believe, sent
home specimens of the fly which have been identi-
fied. Next in order of numbers come G. palpalis
and G. caligenea, though these are more plentiful
nearer the two larger streams to the east and west
of the district.
It was from such ideal surroundings that I obtained
two strains of trypanosomes (a third strain, probably
Trypanosoma nanum, obtained by feeding G. palpalis
on a clean guinea-pig, was lost owing to failure in
sub-inoculating) which were brought home for further
identification and study.
13
4 15 6 17 I8 19 2 el
Description of the Parasite.
The living trypanosomes, though freely motile,
show little translatory power, and the shape and size
of the body, presence of the nucleus and the long free
flagellum (when present), can easily be made out, the
undulating membrane being thrown out in sweeping
waves.
In stained preparations the parasite appears to be
of the classic polymorphic type showing the three
characteristic variations in shape and length, namely,
(1) long and slender, with long free flagellum, (2)
short and stumpy with little or no free flagellum,
MICRONS
22 23 24 25 26 27 28 29 230 3!
32. 33 34 35
—
—
p
(1) Black line is constructed from 1,000 individuals from ID III, IV and V.
500
(2) Broken line n
(3) Dotted line
” n
STRAIN I.— Trypanosoma brucei.
It may be well to state here that what I take to
be T. brucei is a polymorphic trypanosome of the
type consistently figured and described under that
name by Sir David Bruce in his various reports.
The existence of such a trypanosome, showing
posterior nuclear forms, was first mentioned by
Scott-Macfie from Northern Nigeria in 1912 [1]. The
diagnosis of the parasite was based, apparently, on
its morphological character, and a certain number
of inoculations of it into guinea-pigs and rats.
The strain of T. brucei which this paper refers to
was obtained by feeding 128 G. tachinoides on a clean
guinea-pig. This animal was first found infected on
May 2 this year, and died on my voyage home on
July 25. Another guinea-pig was the next day inocu-
lated from it, and when first examined, on Septem-
ber 2, was found to be infected. Since that date the
trypanosome has been maintained in white rats.
250
” n”
Rats II and III.
”
including the posterior nuclear variety, and (3) the
intermediate forms.
These three forms were always present at some
time in the life of an inoculated animal though in
varying proportions. Speaking generally, it was found
that the first few days of infection showed a pre-
ponderance of the long, slender type and that as the
infection grew the numbers of the short stumpy and
of the intermediate forms inereased, so that in some
cases, where the infection became relatively chronic
(as in Rat IV), these forms seem to become the
dominant type. With regard to the posterior nuclear
forms there is even a greater want of correlation
here. One animal may show this type quite early
in the disease, in another their appearance may be
delayed. Again, as pointed out by Wenyon and
Hanschell [2] to be the case with Z. rhode-
siense, the relative proportions of posterior nuclears
to the other types show marked variations. For
instance, counting a thousand trypanosomes on
THE JOURNAL OF TROPICAL MEDIC
INE AND HYGIENE. [Dec. 15, 1914.
approximately the same day and intensity of infec-
tion Rats IV and V gave the following relative per-
centages: Rat IV = 0 per cent, Rat V = 365
per cent. Further prolonged search in the case of
Rat IV revealed only one posterior nuclear form,
though there were approximately 200 parasites
in every field of the microscope. Coincidentally
it may be stated, for the support of those who
look on these forms as an index of virulence, that
Rat V lived thirty-six days, whereas Rat IV lasted
for fifty-nine days, though it would be only fair to
point out that Rat IV was inoculated from Rat III
when only one trypanosome was found by coverslip
examination, whereas Rat V was inoculated from Rat
III after death of the latter, when the trypanosomes
were very numerous.
Curves showing the percentages in length of this
trypanosome show that the parasite varies in length
from 12 u to 32 u, while the greatest number measure
20 to 21 x.
Three curves are given on the previous page—one
in black represents a thousand individuals taken at
odd times and varying numbers from Rats II, III, IV
and V; the second, in interrupted lines, is the curve
of 500 individuals (a hundred being drawn on five suc-
cessive days) from Rat V ; the third, dotted lines, is
the measure of 250 individuals from Rats II and
III. It will be seen that they vary somewhat, there
being a marked difference between the first and second
curves, while the third occupies an intermediate
position. "This marked difference of the second curve
is only to be aecounted for by the extraordinary num-
ber of posterior nuclears in Rat V, which as stated
above reached the high percentage of 36 5.
Comparison shows these curves to be very similar,
if not identical, with those drawn by Sir David Bruce
from his Zululand strain [3]. This similarity in
morphology of the trypanosomes and their respective
curves is not disturbed by a glance at the animal
reactions given below.
| | I
P Data and how Date when | Date of | Dars-
Animal inoculated | Aat lt death tion
| | | Days
1 | Guinea-pigII | G. tachinoides (?)May 2|July 25 4-85
2 ia IV | Guinea pig II, (?) Sept. 1 Nov. 11| 110
| | at death |
3 | Rat I Guinea-pig IV, | » 7; Sept. 14| 14
| |. Sept. 1 | |
4 |^ a XE .. | Rat I, Sept. 10 » 16|O0ct. 14| 35
5, , III | 5, IL, Sept. 16 s L| 42 4] 329
B. sos «| ,, II, Sept. 21 | (?) Nov. 18} 60
Th Ga Y eo» IIL, Oct. 14) Oct. 27) ,, 19] 37
|
|
Animal Reactions.
These have been done only on a very limited scale.
If one may be pardoned for generalizing in the face
of this, it may be said the parasite is very fatal to the
ordinary laboratory animals. The ease and surety
with which these are inoculated is striking and the
multiplication of the parasite is rapidly developed.
The average length of the life of six rats is thirty-
five days, the longest living fifty-nine days, while the
shortest life covered fourteen days.
The inoculation period varied from six to thirteen
days.
Discussion as to the Identity of the Parasite.
In morphology and animal reaetions this strain is
so similar to that of Sir David Bruce's Zululand
strain that I conclude without fear of criticism to
label it undoubtedly T. brucei. I fear, however, in
doing so I shall run contrary to those observers who
claim that the real and original 7. brucei was not a
polymorphic one. I do not wish to enter into the field
of contention, but having read his papers, and being
present at the discussion following Sir David Bruce's
classification of the trypanosomes at the October
meeting of the Society of Tropical Medicine and
Hygiene, suffice it for me to say that I came away
with the impression that the original T. brucei was
a polymorphic trypanosome. For, though the Euro-
pean laboratory strain of this trypanosome which
has been used for so long as a standard of T. brucei
is at present monomorphic, it has yet to be proved
that it has always been so. The curves from this
Nigerian 7. brucei differ somewhat from those given
by Ogawa for T. pecaudi [4]. Ogawa's figures accord
the largest percentage"of trypanosomes a length
of 25 » to 26 uw. Now, if absolute reliance is
to be placed on curves, one might be lead to the
deduction that T. pecaudi and T. brucei are different.
Even if curves and figures were binding, I fear it
would be difficult for me to believe and reason that
two polymorphic trypanosomes so identical in general
morphological details and virulence to animals as
T. pecaudi and T. brucei, one coming from French
Dahomey and the other common in Nigeria, are not
identical. Moreover, both the curves in this paper
and those of Ogawa differ when one compares the
figures for the larger and smaller number. Ogawa
has shown that the average-sized trypanosomes (25 to
26 u) occur in larger numbers in those curves con-
structed from 200 to 300 individuals than in the curves
constructed from 1,000 individuals. In my curves
the opposite condition maintains, there being a larger
number of average-sized trypanosomes (20 to 21 4) in
the curves drawn from 1,000 individuals. Besides,
Ogawa's paper refers to a strain of T. pecaud: of six
years ago, and kept up in the Pasteur Institute during
that time. May not the parasite have changed slightly
its morphology? To revert to the identity of T. bruce!
(Nigeria) and T. pecaud: (Dahomey), it seems likely
that these two trypanosomes, morphologically
identical and capable of transmission by the same
species of glossina, viz., G. tachinoides (Bouet and
Roubaud have shown that tachinoides does transmit
T. pecaudi [5] ), are one and the same. Moreover, it
is not unreasonable to assume that the polymorphic
trypanosome found well-nigh throughout Africa,
certainly from that part mapped out by Senegal to
the Soudan in the north, and British East Africa to
German South-West Africa in the south, are one and
the same trypanosome. The confusion of the whole
subject is regrettable, and it would be kind if the
ruling minds would agree to make easy the path of
the newcomer and beginner by avoiding unnecessary
confusion and retaining for this polymorphic trypano-
Dec. 15, 1914.]
some—transmitted in some places by G. morsitans,
in others by G. tachinoides or G. longipalpis [6],
capable of producing posterior nuclear forms, and
which is so virulent to animals—the name T. brucei,
and thus save him from the brain-racking medley of
synonyms as T. pecaudi and T. ugande.
I will conclude with a reference to the contested
identity of T. rhodesiense and T. brucei, and would
suggest to the powers that be that in such a country
as West Africa, where human trypanosomiasis is not
uncommon, and where also T. brucei is to be found,
that & sufficient number of laboratory animals be
kept at each dispensary in the country to allow of
every human case being inoculated into these
animals. As is well known, those who do not believe
in the identity of these two parasites point out (and
this must bear some considerable weight) that in West
Africa, among other countries, the more virulent
Rhodesian strain is absent. This inexpensive scheme
may lead to a discovery that some of the more fatal
cases of sleeping sickness which have, up to this, for
want of proof to the contrary, been put down as
due to T. gambiense, are really due to what is claimed
to be T. rhodesiense.
STRAIN II.—Trypanosoma nigeriense. (SCOTT-
MACFIE 1913.)
This strain was brought home in two animals, viz.,
a guinea-pig and a monkey. It was obtained in
the following manner. One of the sleeping sickness
patients under treatment developed, on the evening
of March 24, convulsive seizures which ended fatally
in spite of remedies. As a preliminary, eight drachms
of cerebrospinal fluid were withdrawn and collected
in a measure-glass with the idea of reducing tension.
I cannot say this had any marked effect in relieving
the convulsions and, as stated, the patient died next
morning. The same night the upper four drachms of
fluid was injected intra-peritoneally into guinea-pig
No. 1, and the remaining fluid was similarly injected
next morning into a monkey. Both these animals
had been under careful protection and inspection for
over two months. Unfortunately, owing to a bout of
illness, I was unable to examine these animals till
May 3, on which day I found trypanosomes in both.
Since that date the animals were examined every
three days. Never at any time were parasites at all
numerous, and at first it was not unusual for parasites
to be absent on two such examining days, ?.e., for a
period of a week. With this to explain my difficulties
I must state that I have nothing new to record. As
stated by Macfie, who first named the parasite, it is
peculiarly avirulent. The human mortality is under
5 per cent., records of the sleeping sickness camp
which, owing to the short time it has been actually
in existence are probably not reliable for purposes of
deduction, place it round about 3 per cent. It is,
moreover, with great difficulty carried on in laboratory
animals. Since being brought home three guinea-pigs
and a rat were injected from the blood of the original
guinea-pig. Blood examination at the time of inocu-
lation showed parasites to be present in the latter.
Parasites have not been found in the subinoculated
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
375
animals up to date of writing. A mouse was injected
with the cerebrospinal fluid of the monkey. This also
failed.
The parasite on its first appearance is similar to
T. gambiense, i.e., it has the same long, slender body
and a long free flagellum. As stated above, parasites
were never found to be numerous so that I can give
no eurve or other such data.
Since being brought home blood examination of the
infected animals has revealed the remarkable, short,
stumpy forms described by Macfie which led him to
claim for the parasite a specific identity. I have
placed these before competent observers who agree
that they are relatively more abundant than in any
strain of T. gambiense they have worked with.
One, indeed, said, " Were I asked if this were
T. gambiense, I feel sure I would say ‘No. ”
As stated above, I fear I have recorded nothing
here which has added to our knowledge of the
parasite. Before closing, however, I would plead
that the name T. nigeriense be allowed to stand till
further investigation shows it to be identical with
T. gambiense.
CONCLUSIONS.
(1) That a polymorphic trypanosome indistinguish-
able from the Zululand strain of T. bruce? and very
probably, if not actually, identical with it, occurs in
the Eket district of Nigeria and is probably to be
found in all that country in as likely situations.
(2) That this trypanosome is carried in the natural
state by G. tachinoides as has been previously shown
by Bouet and Roubaud who regarded their trypano-
some as T. pecaudi.
(3) That the polymorphic trypanosomes T. brucei
(T. ugandz) and T. pecaudi, found in various parts
of Africa, are identical, though not naturally always
transmitted by the same species of glossina.
(4) That it is desirable that an attempt be made to
demonstrate a posterior-nuclear producing trypano-
some among the more fatal cases of human sleeping
sickness by inoculating every human case into
animals.
(5) There is ground for belief that T. nigeriense
(Scott-Macfie) is not identical with T. gambiense, and
that further research on this parasite is indicated.
Finally, I should like to take this opportunity of
expressing my indebtedness to Dr. Balfour, Director
of the Welleome Bureau of Scientifie Research, for
plaeing the laboratories of that institution at my
disposal; and also to Dr. C. M. Wenyon, of the
above institution, for his help and assistance.
REFERENCES.
[1] Annals of Tropical Medicine and Parasitology, vol. viii,
No. 1, pp. 3-4.
2) * Further Note on Trypanosoma rhodesiense from Three
Cases of Human Trypanosomiasis,” T'he Journal of London
School of Tropical Medicine, vol. ii, pt. ii.
(8] Proceedings of the Royal Society, Series B, vol. Ixxxvii,
No. B, p. 598.
[4] Annals of Pasteur Institute, t. xxviii, Juillet, No. 7.
[b] Bover, G., et RouBAUD, E. Annals of Pasteur Institute,
1910, t. xxiv, pp. 664 and 667.
[6] Idem., Soc. de Path. Exot., 11 Octobre, 1911.
376
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
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FRUITS AND THEIR ACTION.
THE part played by tartaric acid and tartrates
in the economy must be of some considerable impor-
tance seeing that they are met with in many fruits
and their products. Yet the fate of tartaric acid and
other tartrates in the body has not been studied
with the thoroughness that would seem commensu-
rate with their frequent exhibition in our food, drink,
and as medicinal ailments. The grape, of all fruits,
is the richest in tartrates where it exists chiefly in
the form of the acid tartrate of potassium. From the
grape juice in the process of fermentation this salt
is gradually eliminated owing to the fact that the
acid tartrate, but little soluble in water, is less so in
the spirit which is gradually formed during the con-
version of the sugar of the grape juice into alcohol.
The acid tartrate unites in part with the lime in the
grape juice and the two are found lining the vessels
or bottles in whieh wine is kept as crude tartar.
These substances are the plague of the wine merchant,
the cause of the “ bees wing” which necessitates the
filtration of port, &c. It is from this crude tartar
by crystallization that the potasse tartras acida of
the British Pharmacopeia is obtained and from
which tartaric acid and most of the tartrates used in
medicine are derived.
In the blood it is not the acid salt that is met with
but the carbovate, and it is chiefly as the carbonate
that the tartrates are eliminated by the kidney,
although when given as tartaric acid a considerable
amount of this salt unchanged is excreted by the
kidney, showing that tartaric acid given by the mouth
is apparently much more difficult of combustion and
digestion than are most organic acids.
The fact is that the tartrates are mostly got rid of
by the bowel, and only seek exit by the kidney when
the bowel is overloaded; yet, curiously enough, grapes
in which the acid tartrate of potassium is so
plentiful do not serve as a purgative. Bitartrate of
potassium is useful in dropsy; it acts as a purgative
bringing about watery evacuations owing to the fact
that it possesses a low diffusion-power, for this salt is
not freely soluble in water, does not cause much, if any,
irritation of the mucous membrane, and has little
affinity for water in animal textures. It is difficult,
therefore, to set forth on what the purgative action
of this salt depends. The various ways purgative
salts aet may be grouped under several headings.
The tartrates under consideration would seem capable
of preventing the absorption of the secretions of the
stomach, liver, pancreas and intestines; that is, the
fluid secreted by these viscera remains in the ali-
mentary eanal in consequence of the presence of the
bitartrate of potassium. The retention of this fluid
causes an intestinal flux whereby the system is freed
of a plethora of fluid, and, no doubt, of any fermentive
agent or toxin which is present. But the deprivation
of the system of watery fluid determines its replace-
ment; and in dropsy, whether general or local, fluid
is available for that purpose, with the result that the
salt is beneficial in Bright’s disease, inasmuch as it
indirectly lessens the fluid in the tissues and in the
cavities of the body be it derived from the abdominal
thoracic, or the cerebral regions. Indirectly the blood
is benefited, as any poisonous matter present is
allowed freer exit owing to the pathways of elimina-
tion being cleared, and further riddance of poisonous
material facilitated. The kidneys are also relieved, for
the purgative action often leads to a copious flow of
urine, proving the direct and indirect effects of a
salt of the kind in Bright’s disease; primarily by
clearance of the prima via, and secondly by relief of
the kidney vessels.
It must be remembered also that fruits do good
not only as a means of producing watery evacuations,
but also by contributing material to be got rid of.
Dee. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
377
Orange juices may help to benefit constipation, but
the pulp and pith of the orange contributes a quota
of vegetable tissue which it is impossible for any
organ to digest, and therefore leaves a refuse mass to
be got rid of, bringing about & necessary motion.
Sucking an orange before breakfast is disappointing
to most people seeking relief from chronic constipa-
tion, but the efficacy is multiplied tenfold when the
pith of the orange is swallowed as well as the juice;
the latter helps a watery evacuation, the former by
increasing the bulk of the contents of the canal
stimulates peristaltic movements, and the two com-
bined will prove efficient provided a sufficient quantity
of the fruit is taken ; one orange is of little account,
but half a dozen seldom fails to bring about relief
from constipation. Agar-agar has attained its reputa-
tion as a " corrector” of constipation, not from any
salts present in its substance, but merely from the
bulk it attains in the intestinal canal inducing peri-
staltic movements. It is the same with all vegetables
and most fruits. Grapes fail because of the small
amount of vegetable tissue they contain; cabbage, &c.,
succeeds as its stalk cannot be digested; nuts are
taken for the oil they contain, but as a laxative their
efficiency depends on the pulp, which when swallowed
creates a refuse that necessitates evacuation.
The whole question of purgation by salines is
interesting, intricate, and but ill understood. There
is the experience of a doctor who after a “ fish
dinner " consisting of some six or eight courses, spent
an uncomfortable night, took a Seidlitz powder next
morning, passed four copious watery stools and the
fish was afterwards vomited.
The trouble is that our knowledge of the physio-
logical processes within the small intestine, more
especially, are still obscure, although within the past
decade the gain in that direction has been most
satisfactory ; nor is the pathological chemistry by any
means complete, so that still the treatment of fermen-
tive and other lesions is not on a sure basis and
therefore more or less empiric. We are not sure to
what extent the contents of the canal poison the
blood, or whether the blood poisons the contents
during the process of secretion. The older physicians
almost always commenced their treatment of a case
of illness by a purge, which took the form, usually,
of mereury or a mercurial salt followed by sulphate
of magnesia or soda. Experience, never far wrong in
this instance, also bears out scientific teaching; the
germicide action of the mercury accompanied its
indirect purgative aetion and then followed a direct
purgation by the exhibition of the saline.
Liquid evacuations may be produced by drugs in
seyeral ways:—
(a) The drug exhibited may attract water directly
from the blood into the intestinal canal. With this
passage there can no doubt be attracted to (and
thereby expelled from the body) dropsical fluids as
well as toxins, or possibly germs which may exist in
the blood.
(b) The glands in the mucous surfaces may be
excited to action, and therefore pour into the intestinal
canal a large quantity of fluid. It is said that this
does not take place when tartrates are used as
no albuminous substances are to be found in the.
fæces.
(c) By causing the retention of the water naturally
present in the intestine when tartrates as well as
such drugs as sulphate of magnesia, potash and soda
are given, is considered by many observers to be the
true explanation of the passage of liquid stools. How
they produce this retention of the fluids met with in
the intestine is due to their low diffusion-power, in
other words to their very slight tendency to pass from
the intestines to the blood. They hold just the water
in which they are dissolved, and also that which is
met with in the prima via, and hurry these along
the canal, although not producing much peristalsis as
judged by the absence of griping. The fact is, they
are mere eliminators of effete watery elements met
with in the canal. They do not clear the bowel of
solid materials as does castor. oil, and they do not
aid in the elimination of effete matters from the
blood except indirectly.
(d) By drugs causing peristalsis the contents of
the canal are hurried along, but as these may deal
only with the fluid contents always present in the
bowel, they may, or may not (probably do not) to
any significant degree, relieve the blood of toxins and
other deleterious materials.
These and other considerations are of the utmost
importance from the clinical point of view. In the
Tropics, where fruit is in abundance and ripened to
a degree of nicety we can never approach in Northern
latitudes, opportunities to study the effects of fruit
upon the kidneys and bowel are correspondingly great.
To simplify the matter let it be a study of urinary
salts to begin with ; nothing is more interesting than
the microscopic examination of crystals passed, and
much information may be gained thereby. We
recognize usually three diathesis as determined by
the crystalline salts met with in the urine :—the uric
acid, the phosphatic and the oxalic. How these are
affected by mangoes, persimmons, prickly pears, pine-
apples, lychees, &c., we do not know, and are depen-
dent upon popular report often correct although
wholly unscientific. We know that rhubarb is un-
suited to the oxalic diathesis owing to the excess and
size of the oxalate crystals natural to the plant, and
beyond that most is vague; strawberries are said to
be unsuited to the gouty, but why we know not;
tomatoes are condemned in other diathesis, but we
are hazy which ; and so on through hosts of fruit we,
as far as clinical knowledge is concerned, are wholly
at sea.
It would be an interesting investigation, and a
distinct addition to our knowledge, were a doctor to
take up one fruit and work out its behaviour. Some
such plan as the following would seem a practical
one to commence with. Take, say, three healthy
men between 20 and 30 years of age; examine the
urine of each man microscopically for crystals daily
for a month, excluding the fruit intended to be
given and inquired into; then put all the three
on the same fruit along with the ordinary diet. Con-
tinue the examination daily for some wèeks, recording
378
what is seen by the microscope in the way of crystals.
.This is not a erudite nor thorough investigation,
as every item of diet, both food and drink, ought to
be noted, and a chemical examination, both quanti-
tative and qualitative, ought to accompany the micros-
copic observations; but it is a start in the right
direction, and one which is possible for every medical
man to carry out, involving but little expenditure of
time, and one which does not imply the technical
knowledge necessary for chemical research. We
hope to hear of some one of our readers who has
made observations in this direction. In many parts
of the world facilities for work of this kind is possible,
and especially we would draw the attention of the
medical men in the Philippines and the Straits
Settlements to this sphere of study, for in these
places the variety of tropical fruits is, perhaps, greater
than in any other.
——
Annotations,
Notes on French Medical Service. — The Paris
Academy of Medicine has received from Professor
Edward Delorme a report on the condition of the
French ambulance and sanitary service. In order to
prevent gangrene and tetanus from shrapnel wounds
he suggests preventive injections of oxygen, water and
antitetanic serum. Dr. A. Dastre gave details of the
successful use of a powerful electro-magnet for the ex-
traction of splinters of steel and even of rifle bullets.
The use of specially prepared paper underclothing to
prevent cold was also advised.
Post-typhoid Cholelithiasis (P. Ballarin, Gazetta
degli Ospedali e delle Cliniche, Milan, No. 112,
pp. 1217-32).—A girl, aged 16, who had typhoid,
but the temperature did not return quite to normal
for & month after the main typhoid symptoms had
subsided. During this convalescent period she had
several attacks of gall-stone colic and passed two
concrements of pure cholesterin. Typhoid bacilli
were cultivated from the centre of each, but none
was found in the stools during or after convalescence.
Practical Points in Abdominal Surgery.—Dalziel
(Glas. Med. Journ., September, 1914) points out
that neuralgias, especially of the twelfth nerve,
stimulate visceral lesions. Ventral hernia of extra-
peritoneal fat is usually found about 24 in. above
the umbilicus in the median line and is characterized
by attacks of vomiting and regurgitation of bile;
pain is seldom complained of. In the gall-ducts,
stones may grow to considerable size without causing
symptoms, especially when the duct becomes dilated.
Acute inflammation of the kidney may give rise to
symptoms which closely indicate an acute abdominal
condition. Hwematuria may be due to a stone,
ulceration, tumour or tubercle of the kidney; also
to essential hematuria, in which no anatomical lesion
can be found, but which, on section, may show thin-
walled blood spaces near the apex of the pyramids,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
Varicose veins of the bladder also give rise to
hemorrhage, as does the presence of bilharzia.
Marked abdominal discomfort may be caused by the
presence of calcareous glands in the mesentery and
the symptoms may closely simulate appendicitis.
In making diagnosis of stomach conditions, one must
always bear in mind the possibility of spasm of the
pylorus and adhesions.
“Traumatic Malacia" following Fractures.—Gaza
(Münch. med. Wochenschr., October 13, 1914)
studied the phenomena seen in the vertebre after
violence (Kiimmell’s kyphosis), in the neck of the
femur, and especially in the small bones of the wrist
and foot. Kóhler's disease, a term applied to
softening of the scaphoid of the foot after violence,
is one of the best known types. The author has
seen two cases of so-called traumatic malacia in the
semilunar bone of the wrist. In these cases a linear
fracture had been in evidence and the presumption
was that the softening was a result of fracture.
" Kóhler's disease" was not originally traced to
fracture nor was such a traumatism held responsible
for it. Cases of atrophy and softening of certain
bones and parts of bones while traceable to violence,
have not been connected with latent fractures in all.
The author states that in such cases the lesion is a
linear fracture accompanied, perhaps, by some crush-
ing of the adjacent trabecule or followed by a certain
amount of absorption of mineral matter. The skia-
grams show & primary macular lacuna clearing up.
At a later period more serious deforming altera-
tions occur and such conditions as traumatie coxa
vara, Kümmells kyphosis, and perhaps Kohler's
disease. There is often a prolonged period of latency
between the primary and secondary alterations, and
the joint surfaces may become involved.
Treatment of Tetanus.—W. F. Law (Brit. Med.
Journ., November 21) says that wounds of the foot
are responsible for by far the greater number of cases
in British Guiana, a small wound from a splinter of
greenheart being the very frequent history. Some-
times the patient denied any knowledge of injury,
and no wound could be discovered, but it can be
readily understood that natives who go about bare-
footed will frequently sustain an injury so trivial as
to excite no notice. Cases can be divided into two
groups: (a) Those with severe febrile disturbance ; (b)
those with slight or no febrile disturbance. In the
former—unfortunately by far the most numerous—
the temperature quickly ran up to 103° or 104° F.
and even higher, and these cases almost invariably
proved rapidly fatal. In the latter, the febrile
disturbance was slight, up to 101° F., and subsided
very rapidly. In these cases the prognosis was more
favourable.
Routine treatment, after careful attention to the
wound (if any), was to give a very full dose of chloral
hydrate and to follow this up with just sufficient of
the drug to keep the patient constantly under its
influence, and free from spasms. Under this treat-
ment he had quite a fair number of recoveries,
Dec. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
379
including one case of tetanus neonatorum which was
severe at the outset.
The most watchful care is required throughout the
whole course of the case: nourishment must be given
as freely as possible, and some judgment is needed to
give just enough of the chloral and not too much;
the more frequent error lies in too small rather than
too large dosage.
The Treatment of Enteric Fever. — Broadbent
(Brit. Med. Journ., November 21) recommends the
use of an ice-bag in the treatment. It should be
suspended from a cradle over the right side of the
abdomen in the region of the lower part of the ileum.
It is important that there should be nothing between
the ice-bag and the skin but a piece of gauze or butter
muslin, so that the cold may penctrate as far as
possible.
Medicinally, there is nothing to equal :—
Quinine sulphate € es a gr. ij
Dilute sulphuric acid.. bs ss ss MAY.
Liquor hydrarg. perchlor. .. T .. Oss.
every four hours (not within half an hour of food).
If the diarrhea is excessive the sulphuric acid can
be increased, and if there is constipation magnesium
sulphate can be added in sufficient quantity to pro-
duce one or two actions of the bowels a day. The
use of the sulphuric acid and sulphate also tends to
diminish the risk of haemorrhage.
Beddard (Brit. Med. Journ., December 5) in June,
1901, when on the high veldt, had about twenty
patients suffering from enteric fever. The camp had
been surrounded and attacked the whole day, so that
when night fell there was no opportunity for re-
pitching tents, and one had to leave the men, well
wrapped in blankets, out in the open. The night was
intensely cold; in the morning none were dead, and
the most severe cases showed a wonderful improve-
ment, and the whole picture was in striking contrast
with that presented by the same men who had
previously been treated in army tents. Delirium
and restlessness were quieted, temperatures were
lower, tongues and mouths were cleaner and moister,
only attributable to the good effects of the antipyretic
action of the cold air respired by the lungs.
Hydrotherapy has claimed good results; is it not
possible that the persistent inhalation of cold air
might prove more efficient and safer ?
The Pathological Affinities of Beriberi and
Scurvy.—S. T. Darling (Journ. Amer. Med. Assoc.,
October 10, 1914) observed cases of scurvy in
South Africa. Not only has the Rand type of
scurvy affiliations with beriberi, in that cardiac
degeneration and degeneration of the vagus occur in
typical scurvy as well as in beriberi, and by reason
of the appearance of beriberi or neuritic features in
certain epidemics of scurvy, but many of the negro
miners dying of various diseases, at necropsy disclose
slightly edematous calves without any other sign of
scurvy or beriberi. Scurvy has definite affiliations
with rickets, and infantile scurvy, too, for in a case
seen there had been extensive destruction of the
chrondrocostal junction, with depression of the entire
sternum, Three severe cases of scurvy, practically
free from complication (one had a little tuberculosis),
came to necropsy at hospital. The anatomical find-
ings were closely similar and are summarized in a
composite anatomical diagnosis ; hamorrhagic extra-
vasation into muscles of both legs, left forearm, and
left psoas muscles, involving the muscle fascia between
muscles, old and recent; subperiosteal hemorrhage,
shaft of left femur ; hemorrhage into left knee-joint ;
old subcapsular hemorrhage (knee-joint) ; ulcerative
gingivitis with hemorrhages ; separation of mandibular
periosteum; anemia of all viscera; hyperplasia of
femur marrow; cedema of lungs, and scaly desqua-
mation of both legs; hypertrophy and dilatation of
right heart; fatty degeneration of musculature of
right heart; the right ventricular wall is definitely
thickened, of a yellowish colour, and does not
collapse as in the normal heart (this lesion is
pathognomonic of Rand scurvy and brings it into
relation with beriberi).
Conclusions.—The striking eccentric hypertrophy
and dilatation of the right heart with extensive fatty
degeneration of the same musculature, the left heart
remaining apparently normal, and the severe degenera-
tion of the vagus nerve described in several fatal cases
of scurvy from the Rand, furnish new and additional
facts which show the intimate relationship between
scurvy and beriberi as to etiology. The presence of
affinities between these two diseases (scurvy and
beriberi) and certain other cachexias lends emphasis
to the opinion that they are one and all the result of
the continued use of a one-sided and deficient diet.
Malnutrition in Adults.—C. Funck (Archiv fur
Verdauungs-Krankheiten, Berlin, xx, No. 4, pp. 423-
542) considers the trouble is due to the improperly
prepared molecule acting like a poison, setting up a
kind of anaphylaxis. Patients showed a toxic relative
lymphocytosis. The anaphylaxis condition may entail
disturbance in carbohydrate metabolism, and this
disturbance may persist even after the primary cause,
the malnutrition, has ceased to act. This all paves
the way for diabetes and other metabolic diseases.
The improperly prepared alien albumin may get into
the blood from the food or ,from the pathological
product of some gland with an internal secretion—
often as a response to the stimulus from food entering
the bowel. Correction of one may have a favourable
influence on the other. When diabetes is complicated
with gastro-enteritis, the sugar output may often be
reduced to normal merely by curing the stomach
and bowel trouble. As the gastro-intestinal mucosa
becomes less permeable for the alien albumin, and its
normal functions are restored, the functioning of
glands with an internal secretion, the pancreas in
particular, improves with it.
Normal conditions are obtained by modifying the
diet, lavage of the stomach, supplying substitutes for
lacking digestive ferments, and having the patient
drink large amounts of a mineral water. But far
380
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
beyond the effect of these measures is systematic
flushing out of the bowel with a hypotonie solution
through a duodenal sound. This clears out the bowel,
draws out toxie secretions and washes them away,
modifies the bacterial flora and its culture media in
the intestines, while exerting a healing action on the
mucosa and glands in the bowel. He uses three litres
in from two to five hours, or keeps up the irrigation
for sixty hours. In some cases of impending uremia
he rinsed the bowel first with a hypotonic solution
without chlorides, and followed this with an isotonic
diuretic solution, keeping up this enteral drainage for
six hours. The blood-pressure subsided to 35 mm.,
and profuse diuresis followed. Similar prompt and
far-reaching benefit was realized in delayed re-
absorption of effusion and transudates, in anemia, in
" preselerosis," and to promote the elimination of the
products of acute infection. In a case of “ asystolic
toxemia” the pulse was reduced by this enteral
drainage from 112 to 84, the respiration rate from
26 to 18, while the output of urine increased from
950 to 1,750 c.c. in thirty-six hours.
The clinical manifestations of this form of chronic
malnutrition may inelude dyspepsia in its broadest
sense, pruritus, eczema, neurasthenia or neuralgia,
constipation generally of the spastic type, diarrhoea
with all the signs of an enteritis, subjaundiced, greyish
tint, depression, migraine or hypertony. Examination
of the stools throws no light on the absorption of
toxins, but there may be anacidity and defective
pancreas function and motor insufficiency of the
stomach.
Differential Skin Reaction in Variola and
Varicella. — Tiéche (Berlin. klin. Wochenschr.,
September 28) by a test technique, similar to that
of Pirquet’s tuberculin skin reaction, differentiates
small-pox from varicella and other eruptive diseases.
This simple measure is harmless and reliable.
With protective vaccination against varicella when
an epidemic broke out in an institution with 200
children, no local reaction was observed until the
eighth day at the point inoculated with the varicella
lymph. Vaccine lymph, on the other hand, always
induces a prompt local reaction, and generally in
four hours. Tiéche experimented until he had con-
clusively demonstrated that no local reaction was
evident for several days, if at all, after vaccination in
the arm with the secretion or rubbed-up contents of
a varicella pimple. On the other hand, the secre-
tion or serap of eontents from a small-pox pustule
promptly induces a typical early reaction in the skin
at the point of inoculation. He reports constantly
negative results in eighteen varicella cases, and con-
stantly positive in nine variola cases. With seven
new cases suspected to be small-pox, the reaction
was positive in five, and the course of the cases con-
firmed the assumption of variola, while the negative
reaction in the other cases likewise was proved
correct by the further course. The test inoculations
were made on three healthy adults, himself, his wife
and sister-in-law.
To render the secretions harmless, the lymph is
heated to 60° or 70° C. for five minutes before applying
it to three minute scratches on the arm. Variola
lymph, after keeping for eleven months, gave a positive
reaction in one case. A few cases are described in
which everything seemed to indicate small-pox but
this negative local reaction, and on this he based his
diagnosis. One patient stayed at his hotel, thus
saving all concerned great annoyance and trouble,
and the course of the case confirmed that it was
not small-pox, but either varicella or an atypical
erythema multiforme. Public health officials might
be tested with varicella secretions to learn whether
they are especially sensitive to it.
Actinomycosis.—Dressl (Deutsch. med. Wochenschr.,
October 15, 1914) considers this disease to be due
to a trichomyces known as the actinomyces, this
anaerobe being often associated with streptothrix. In
clinieally similar cases there may be only virulent
streptothrix. In recent genuine cases of actinomy-
cosis the pus may contain no granules; these cases
require culture test for differentiation. Granules
visible to the naked eye consist of felted streptothrix.
— eo
Hotes and Mews.
A HARDY ANNUAL.
“WELLCOME” Photographie Exposure Record and
Diary (for 1915) is again with us. To photographers,
both professional and amateur, the Record has for
years proved an essential volume, for with it they are
equipped in a measure wellnigh impossible to attain
by other means. It is a veritable encyclopxdia of
photography, condensing as it does within one pocket-
sized volume clear, simple directions for all possible
purposes. A prominent feature of the volume is the
“Wellcome " Exposure Calculator, the ingenious device
which, by one turn of one scale gives the correct
exposure for any plate or film at any time of day or
year. The Exposure Record and Diary are suitable
for any part of the world; a truly valuable shilling's-
worth.
VALUABLE TROPICAL AND SUB-
TROPICAL HAY CROP.
TEFF (Eragrostis abyssinica) is an annual hay grass,
particularly suitable for use as a summer catch-crop,
and a smother-crop for weeds, owing to its rapid
growth when weather conditions are at all favourable.
If sown with the early spring rains it has been
possible to cut three crops of hay in the season,
giving 24 to 3 tons per acre, and to obtain autumn
grazing from the aftermath. The introduction of
teff grass into South Africa has raised many small
farmers struggling for a living to positions of com-
parative comfort and independence. They are unani-
mously agreed that this introduction alone has repaid
over and over again the whole cost of the Division
of Botany of the Department of Agriculture from its
inception to date.
TEFF, A
Jan. 1, 1914.]
COLONIAL MEDICAL REPORTS.—SOUTHERN NIGERIA. 1
Colonial Medical Reports.—No. 25.—Southern Nigeria.
MEDICAL REPORT FOR THE YEAR 1910.
By H. STRACHAN.
Principal Medical Officer.
During the year 85,237 sick persons were treated
in the three Provinces. Western Province, 34,143;
Central Province, 25,040; Eastern Province, 26,054.
Total, 85,237.
The principal diseases treated were: Malaria,
7,052; dysentery, 1,421; intestinal disease (chiefly
diarrhea), 8,710; rheumatism, 7,862; respiratory,
9,020; diseases of the skin, 2,899; parasitic, 7,723;
filariasis, 39; injuries, 12,398.
SMALL-POX AND VACCINATION.
The satisfactory condition of Lagos Town as re-
gards small-pox continued during 1910; only 17
cases were admitted into the Infectious Disease
Hospital, all of which were infected outside Lagos.
The usual epidemic outbreaks occurred in various
parts of the Provinces, and many cases came over
the border from Dahomey in the latter half of the
year.
The influence of the Priesthood of the Small-pox
God had its usual baneful effect, but during the
year power to deal with these monsters was given
by law.
At Calabar no case of small-pox occurred in the
town, but in the other distriets of the Province
36 cases of small-pox were treated.
At Bende, Aro-Chuku and Ahoada, epidemies of
small-pox occurred and were properly and satis-
factorily dealt with.
In the Central Province 115 cases of small-pox
were treated.
The following figures show the total number vac-
cinated and the number of '' successfuls.''
Total vaccinated Successful
Western Province 75,691 43,981
Central A 12,902 6,935
Eastern A 47,054 37,663
135,647 88,579
There was an increase of 13,780 in the total num-
ber of persons vaccinated; and an increase of 12,215
in the total number of successful cases.
In the Western Province there has been a de-
crease in the number vaccinated in Lagos Town
and a few of the other larger centres, due to some
extent to the diminishing number needing the
operation.
In the Eastern and Central Provinces there has
been an increase in the number; but in all the Pro-
vinces a vast number of persons still escape
vaccination.
The percentage of successfuls for the three
Provinces was 65:3.
Considering the opposition to vaccination on the
part of the majority of the natives, and the effect
of the power wielded by the Priesthood of the Small-
pox God, the results are, as a whole, encouraging.
SANITATION.
Central and Eastern Provinces.
Sanitation has been carried on as previously, and
much good work done during the year.
The Plague scare in 1908, and the Yellow Fever
scare in 1910, led to extra exertion on the part of
the natives in Lagos and other large towns, the
results of which, in regard to cleanliness of com-
pounds, have been maintained.
In Lagos, Calabar, Opobo, and Bonny consider-
able areas of swampy land were reclaimed.
The Sanitary Branch of the Medical Department
was formed in March, and a senior and junior
sanitary officer appointed in July; much is hoped
in the cause of sanitation in West Africa from this
action.
Dr. Connal, who made special study of the mos-
quitoes in Lagos, has reported that the chief mos-
quitoes found are Pyretophorus costalis and Steg-
omyia fasciata (the latter found in the houses in
the day, and the former in evenings, nights, and
early mornings).
In the water pots of the natives were found larve
of Stegomyia fasciata, Culex tigripes, var. fusca, C.
duttoni, C. dissimilis, and others.
Adult stegomyisz were found to be more common
about a week after a shower of rain. They come
from regions outside the town limits, and seem to
replenish the stock exhausted by the warfare waged
in the town itself.
The mosquito index, when anti-mosquito work
was started several years ago, was cent. per cent.
When Dr. Pickels, the Senior Sanitary Officer, made
his summary, early in August, we found it 47 per
cent.; at the end of December it was 15 per cent.
Though, no doubt, this fall was in part due to
the usual effect of the dry season—and we must
expeet a rise when the rains return—it is certain
that much was due to the greatly increased work
that was rendered possible by the grant of £110 per
month for that special object, and it is clear that
there should not be the slightest relaxation of this
most important work.
Water Supply.—The work in the Iju Valley, to
provide a water supply for Lagos Town, was begun
during the year.
The following anti-malarial work has been con-
tinued :—
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 1, 1914.
Swamp reclamation; the regular use of quinine
as a prophylaxis among Europeans; destruction” of
mosquito breeding places by oiling of such water
collections as cannot be drained; use of mosquito
nets, use of wire gauze for rooms and houses, use
of quinine prophylaxis among such natives as are
willing to take the drugs, and teaching and advice
to all.
The quantity and cost of the quinine issued
gratuitously during the year in the three provinces
was as follows :—
£ s. d.
Western Province for prophylaxis 208 0 8... 1,206,000 grains
j » fever 157 11 3... 916,300 ,,
Eastern jo » prophylaxis 39 6 O% 275,071 ,,
s » 21 5b 9.. to natives
(125,000 grains
to Europeans)
Central Province for prophylaxis 28 7 9... 140,532 grains
YELLOW FEVER.
There was an outbreak of yellow fever in May on
the Gold Coast and Sierra Leone.
Special precautions were immediately taken in
Lagos.
ln Forgades, Calabar, and other Southern Nigeria
ports quarantine stations were put in good order;
increase in number of mosquito gangs and of sani-
tary inspectors was sanctioned.
Placards were posted and leaflets distributed in
English and the vernaeular, in which the nature of
the disease and the method of combating yellow
fever by attacking the stegomyia were clearly and
simply explained in the three Provinces, and lec-
tures were delivered to the people on the same
subjects in various centres.
STATISTICS.
In the Lagos Hospital 1,9364 natives and 167
European patients were treated as in-patients, as
compared with 1,519 natives and 122 Europeans in
1909.
The death-rate of Europeans admitted was
3°5 per cent. (six deaths)—6,479 native out-patients
were treated as compared with 5,179 in 1909.
Three hundred and thirty-four major surgical
operations were performed.
The following gives the total number of patients
treated in the dispensaries of Lagos Town and
Ebute-Metta: Massey Street Dispensary, 4,250;
Ereko Dispensary, 7,758; Ebute-Metta, 5,807;
total, 17,185.
The two former are in charge of native medical
officers.
In the European ward, Ibadan Hospital, eighty-
nine patients were treated as in-patients, with no
deaths.
In the native ward 172 patients were treated,
with fifteen deaths.
In the out-patients’ department
were treated.
There was a diminution in the number of native
2,597
patients
out-patients, but an increase in the number of
European cases. :
In the Ibadan Dispensary 2,831 native patients
were treated, ineluding three European patients.
At the Badagry Hospital twenty-two Europeans
were treated as out-patients, forty-five natives as
in-patients, and 1,116 out-patients.
At Epe Hospital ninety-five in-patients and
1,166 out-patients, natives, were treated.
There were twenty-four European out-patient
cases.
The number of natives in Southern Nigeria who
have received medical aid at the public expense
during the year is as follows: Western Province,
27,831; Central Province, 19,743; Eastern Pro-
vince, 22,515.
At the Calabar European Hospital 139 patients
were treated (of these eighty-two suffered from
malarial fever, twenty-one official and sixty-one non-
official).
In the native hospital, Calabar, 1,114 natives
were treated as in-patients and 5,490 were treated
in the out-patients’ department; 119 surgical
operations were performed.
The Calabar prison dispensary: In-patients, 253;
out-patients, 200.
In the New Barrack Dispensary 1,564 patients
were treated, of whom fourteen were Europeans.
At Opobo European Hospital only one in-patient
was treated.
At the European Hospital at Warri fifty-one
patients were treated.
At Onitsha European Hospital forty-one in-
patients (fourteen officials and twenty-seven non-
officials) were treated, with five deaths.
In the native hospital, Onitsha, 369 natives were
treated and 4,550 out-patients, with forty-three
deaths.
Three officials were invalided during the year in
the Western Province, five in the Eastern Province,
and ten in the Central Province.
In the Onitsha Leper Asylum seventy-five cases
were treated, witli six deaths.
In the Yaba Leper Asylum seventeen cases were
treated, with one death.
Treatment with nastin is under investigation: it
is far too early yet to pronounce any opinion on it.
In the Lunatie Asylum at Calabar twenty-six
patients were treated, with three recoveries and two
deaths.
During the year 520 cases of guinea worm were
treated in Southern Nigeria, viz.: 812 in the
Western Province and 217 in the Eastern and
Central Provinces.
A case of sleeping sickness occurred in the
Western Province, that of a little girl infected at
Fernando Po. The case is still under treatment,
but will be fully reported on at its close.
Thirty-nine cases were treated in the whole
Colony, thirty-three in the Eastern Province, five
in the Central Province, and one in the Western
Province.
Jan. 1, 1914.]
COLONIAL MEDICAL REPORTS.—BRITISH HONDURAS. 3
Colonial Medical Reports.—No. 26.—British Honduras.
MEDICAL REPORT FOR THE YEAR 1911.
By J. H. HUGH HARRISON.
Colonial Surgeon.
STATISTICS.
Hospital.
REMAINING at beginning of 1910, 51; admitted
during the year, 648; total, 699.
Discharged: Cured, 436; relieved, 57; not re-
lieved, 25; died, 90; remaining December 31, 40;
total, 648.
Operations, average per week, 4; out-patients,
daily average, 2:8.
By the above figures it will be seen that the
work of this institution was extremely satisfactory,
the admissions being seventy in excess of last year.
Since June, Dr. Mackey has been resident at the
Hospital, a fact by which a great deal of work has
been got through. Lectures were held twice a week
for nurses and an examination came off at the end
of the year. ,
It is hoped that a proper operating room will be
provided; at present it is impossible to carry out
operations in a proper aseptic manner; while the
lighting of the theatre is very faulty.
Lunatic Asylum.
The following is the statistical record for the
year:—
Remaining on January 1, 191 se 59
Admitted during 1910 YE x. 18
— 72
Discharged during 1910 TEE.
Died during 1910 ne ts sx wD
= "9
Remaining on December 31, 1910 .. 68
One death occurred from phthisis and recently
this year three others have occurred. This is not
very satisfactory cwing to the cvercrowding, but
every precaution is taken to Keep such patients
isolated.
Poor House.
Number of inmates remaining on January 1l,
1910:—
Males ... nt fes T .. 16
Females ... FEE Ds we 19
25
Admitted in 1910 sa ass . 18
— 40
Discharged in 1910 z 5s PA
Died in 1910 ... mAs 32 we 0
©
Remaining on December 31, 1910 e Sl
QUARANTINE.
Vessels boarded: Ships of war, 4; steamships,
349; schooners, 160; motors, 87; yawls, 49; sloops,
175; doreys, 164; barges, 2; total, 940.
Number of vessels fumigated, 231; number of
crew and labourers inspected, 18,955; number of
passengers inspected, 4,697. Amount of deposits
collected during 1910: U.S. and B.H. currency,
$3,603.00; Sols, $1,866.00.
Every vigilance is exercised in the matter of
admitting people from the surrounding Republics,
especially Honduras, where an outbreak of yellow
fever occurred on board the U.S.S. ‘‘ Marietta.’’
One death and five cases. Further, owing to the in-
flux of a great number of troops at the northern
ports, such as Puerto Cortez, La Ceiba, Truxillo,
&c., the sanitary conditions cannot have improved.
GENERAL HEALTH OF THE COLONY.
Measles seems to have been prevalent in all the
districts, otherwise no infectious diseases occurred.
The infant mortality in the Colony stands extremely
high.
Corosal.—Out of a death-rate of 140, 64 were
children between the ages of 1-5 years.
Orange Walk.—Out of 157 deaths, 69, or 43 per
cent., occurred in children under 5 years of age.
Stann Creek.—Out of 158 deaths, 86 occurred in
children 5 years old and under, over 54 per cent.
Cayo.—Out of 89 deaths, 42 occurred in children
5 years old and under.
Toledo.—Out of 161 deaths,
children 5 years old and under.
Return of the principal causes of deaths in the
Colony: Malarial fever, 226; dysentery, 46;
phthisis, 59; diseases of nervous system, 44;
diseases of circulatory system, 47; diseases of
respiratory system, 115; diseases of digestive sys-
tem, 127; diseases of urinary system, 31; other
causes, 357; total, 1,052.
Lectures in tropical and personal hygiene were
given during the year to the teachers and pupil
teachers of the schools of the different denomina-
tions. The syllabus consisted of elementary
anatomy and physiology, and the attendance was
fairly good. Those who went up for examination
did fairly well.
Since then I have had a communication from the
Women’s Imperial Health Association of Great
Britain wishing us to co-operate with them in order
to further their good work; I have taken up the
matter seriously and hope that with the assistance
of the intelligent ladies of the town to do much
59 occurred in
(a) Phthisis Pulmonalis
(a) Cataract.
(b) Iridectomy
4 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Wan. iz 1914.
RETURN oF DISEASES AND Deatus IN 1910 iN THE BELIZE HOSPITAL,
British Honduras.
GENERAL DISEASES. is 3 si
n A = se & egf
ef $ sii 4* à È
gg 8 2A $ GeNeRaL Dıseases— continued.
7 s 2 EB (d) Tabes Mesenterica T = = =
Alcoholism 2: — 2 (e) Tuberculous Disease of Bones .. — -= —
Anæmia eS 5 Other Tubercular Diseases — — —
Anthrax — -— -- Varicella .. ; — — =
Beriberi ah = 2 Whooping Cough 2 — 2
Bilharziosis — — — Yaws 3 ` ey. os Ex
Blackwater Fever — — — 1 PN -
Chisken box HR tz = Yellow Fever
Cholera — — —
Choleraic Diarrhaa — .. — — — LOCAL DISEASES.
Congenital Malformation — — =
Debility š š 18 8 18 Diseases of the—
Delirium Tremens — — — Cellular Tissue 8 — 8
Dengue .. = = a Circulatory System .. 16 7 16
Diabetes Mellitus - — — = (a) Valvular Disease of Heart — — —
Diabetes Inu poop — — = (b) Other Diseases .. = = —
Diphtheria . — — — Digestive System — — — =
Dysentery .. 6 1 6 (a) Diarrhea ae 82 7 82
Enteric Fever — — = (b) Hill Diarrhea .. — — —
Erysipelas .. — — — (c) Hepatitis e 1 — 1
Febricula . — — = Congestion of Liver — = —
Filariasis .. == = = (d) Abscess of Liver 1 — 1
Gonorrhea 27 — 28 (e) Tropical Liver .. — = —
Gout è — — — (f) Jaundice, Catarrhal — — —
Hydrophobia — — — y Cirrhosis of Liver . 5 1 5
Influenza .. — — — ) Acute Yellow Aupty — — =
Kala-Azar.. = = = (à Spre .. è . — — —
Leprosy .. 1 — 1 (j) Other Diseases .. 50 5 5l
(a) Nodular — — — Ear 23 is 1 — 1
(b) Anzesthetic .. — — — Eye . a 4 — 4
(c) Mixed — — — Generative System— wis — — =
Malarial Fever— — — — Male Organs 6 — 6
(a) Intermittent — — — Female Organs 17 — 17
Quotidian .. — — — Lymphatic System 4 — 4
Tertian 25 — 25 Mental Diseases — — —
Quartan 1 — 1 Nervous System 25 6 26
Irregular .. A — — — Nose .. i as — — —
Type undiagnosed 80 — 30 Organs of Locomotion 8 — 8
(b) Remittent .. š 10 — 10 Respiratory tvm 18 4 19
(c) Pernicious .. 2 — 9 Skin— . 15 — 15
(d) Malarial Cachexia. . 18 1 19 (a) Scabies .. 6 — 6
Malta Fever ; ? — — — (b) Ringworm š — — —
Measles 12 1 12 Wi Tinea Imbricata — — —
Mumps we — — — ) Favus sis — — —
New Growths— .. — — — (e) Eczema .. $s - — -—
Non-malignant — — — ( f) Other Diseases .. — — —
Malignant 5 1 6 Urinary System s 40 16 39
Old Age — — — Injuries, General, Local— 54 2 5
Other Diseases 82 JT 82 (a) Siriasis (Heatstroke) S — — =-
Pellagra .. — — — (b) Sunstroke (Heat Proma con) — — —
Plague — — = (c) Other Injuries IL. Ss aci
Pyæmia — — — Parasites— 3c 2 — 2
Rachitis — — — Ascaris lumbricoides .. 2 — 9
Rheumatic Fever | — = — Oxyuris vermicularis . — — —
Rheumatism 5 16 — 16 Dochmius duodenalis, or Ankylostoma duo-
Rheumatoid Arthritis — — — denale . — — -
Scarlet Fever — — — Filaria medinensis (Guinea. worm) — — =
Scurvy — — — Tape-worm $ e as — — —
Septicemia . — — — Poisons— oe ee os . —— -
Sleeping Sickness. =a — — — Snake-bites — .. e: - oe - — --
Sloughing Phagedena .. — — — Corrosive Acids — — —
Small-pox .. .. Er — — — Metallic Poisons - = —
Syphilis 15 2 16 Vegetable Alkaloids — - -
(a) Primary è — — — Nature Unknown — - -
(b) Secondary .. — — — Other Poisons - - -
(c) Tertiary — — — Surgical Operations — — - -
(d) Congenital . — — — Amputations, Major — — -
Te tanus — — — Minor .. — —- +
Try panosome Fever — — — Other Operations -- — —
Tubercle— 52 23 55 Eye — — —
(b); Tuberculosis of Glands P
(c) Lupus
(c) Other Eye Operations — .. ..
Jan. 1, 1914.)
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 5
good, especially in the direction of the rapid spread
of tuberculosis and our terrible infant mortality.
Corosal.
The health of this place has been fairly good.
Dysentery still seems to be fairly prevalent, twenty-
six deaths having occurred from that cause. The
death-rate has been rather higher than the previous
two years.
Belize District.
I tried to take the opinions of the general practi-
tioners in the town as to which they considered the
sickliest season of the year, because it was popu-
larly believed that July and August were the worst
months, but opinions of the medical men do not
prove this to be the case. Dr. Gahne thinks that the
sickliest season is during the heavy rains, accom-
panied by land winds. Dr. Davis thinks that
October and November are the most unhealthy in
Belize. Dr. Heusner thinks October, November,
and December. All seem to concur that the land
winds are prejudicial. From our hospital records it
is difficult to make any definite statement on this
point. The highest in hospital under treatment was
in June, and, strange to say, the lowest numbers
were in August and December.
INSPECTION,
The work of the inspectors of nuisances was not
satisfactory. I had to bring this to the attention
of the Government, after which the Screening
Ordinance was better carried out. The following
notices were issued for defective or unscreened
water receptacles :—
Vats, 337; tanks, 60; barrels, 1,251; total, 1,648.
Only six summonses were issued. The people
are very difficult to deal with, but this can be
remedied by an honest and searching inspection by
the inspectors, otherwise such work is useless and
a danger to the town.
VACCINATIONS.
Belize District, 164; Corosal District, 207;
Orange Walk District, 288; Stann Creek District,
70; Toledo District, 58; Cayo District, 45; total,
832.
The above figures show that vaccination is satis-
factorily carried out.
Colonial Medical Reports.—No. 27.—Sierra Leone.
MEDICAL REPORT FOR THE YEAR 1910.
By R. M. FORDE.
Principal Medical Officer.
THE CoLony.
The approximate population of the Colony was
75,051. The deaths registered numbered 1,550 and
the births 1,152, showing a death-rate of 20 per
1,000 and a birth-rate of 15 per 1,000. Registration,
however, is not compulsory, and these figures
cannot be taken as reliable.
In Freetown registration of births and deaths is
compulsory, and therefore-more reliable. From the
Census returns of 1911 it is shown that the popu-
lation of the town has decreased by 489, so that
it must be concluded that the estimated population
for 1909 was too high, and this fact, combined with
the undoubted greater amount of illness, accounts
for the marked difference in the death-rate for 1910.
The population for Freetown, calculated on the
recent Census returns, was 84,010.
The births registered numbered 581, and the
number of deaths was 936; these give a birth-rate
of 17 per 1,000, and a death-rate of 27 per 1,000 of
the population.
The chief causes of death were as follows:
Malarial fevers, 122; nervous system, 156; respira-
tory system, 117; digestive system, 190; circulatory
system, 52; genito-urinary, 23; debility, 80; pre-
mature births, 48; tubercle, 24; unclassified, 42.
There were 10 deaths from yellow fever, viz.,
5 Kuropeans, 3 Syrians, 2 natives, as well as several
suspicious cases that recovered. The first case
occurred early in May and the last on September 22.
Fumigation of houses, screening of patients in mos-
quito-proof cases, and rigorous measures directed
against the propagation of stegomyia were carried
out from the beginning and with success, under the
able direction of Dr. Kennan, who was at the time
Acting Principal Medical Officer.
Of the total deaths registered 214 occurred under
the age of one year, which gives an infantile death-
rate of 368 per 1,000 births, a rise of 24 on that for
the previous year.
The infantile death-rate for the past nine years
was as follows :—
Year 1902, 466; 1903, 471; 1904, 388; 1905, 461;
1906, 484; 1907, 357; 1908, 351; 1909, 344; 1910,
368.
Health of European Residents.
The health of Europeans was not so satisfactory
as in 1909, the death- and sick-rates being decidedly
higher. An outbreak of yellow fever in Freetown
was the chief cause of this. Blackwater fever was
also unusually prevalent, there being nine cases
treated at the Nursing Home, with one death.
6
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Jan. 1, 1914.
The total number of Europeans resident in the
Colony and Protectorate during the year was 881.
There were 15 deaths among these, 18 in Free-
town, and 2 in the Protectorate. These were due
to the following causes: Yellow fever, 5; black-
water fever, 4; pernieious malarial remittent (hyper-
pyrexia), 1; dysentery, 1; drowning, 1; septicemia
(wounds caused by buffalo), 1; heart disease, 1;
debility, 1.
Official Sick-rate.
The total official strength for the year was:
Europeans, 171; natives, 946; total, 1,117.
Among the former there were 83 admissions on
the sick list with 2 deaths, and among the latter
there were 589 admissions with 10 deaths.
Vaccination.—This was carried on fairly regularly
during the year throughout the Colony and Protec-
torate, but not with quite the same success as in
the previous year.
Small-poz.—The Colony and Protectorate re-
mained free from any epidemic outbreak of this
disease during the year. Sporadic cases, however,
occurred at Bo, York and Freetown. In all only
four cases were reported.
Quarantine.—During the year the quarantine
station was opened once for the isolation of persons
landed from suspected ships arriving from Sekondi
during the yellow fever outbreak at that place.
Fifty-one persons were isolated at the station during
the period it was open, and no cases of illness
occurred amongst them.
Yellow Fever.—An outbreak of this disease
occurred. The first case came under observation
in May and the last case in September. There were
in all 13 diagnosed cases with 10 deaths, and 11
suspicious cases with one death.
The nationality of the patients is shown here :—
Diagnosed Cases Suspicious Cases
Deaths Recoveries Deaths Recoveries
European 5 Nil
Native 3 Nil y Nil
Syrian 2 T 1 1
It is quite possible that other cases occurred
among the native population, but such cases not
having come under medical observation no record
of them was possible. I am of opinion that this
disease is of rare occurrence in epidemic form in
the Protectorate.
Sleeping Sickness.—Though medical officers have
been on the special watch for this disease only one
diagnosed case and three suspicious cases were
reported from the Protectorate and three suspicious
eases in the Colony. From the reports of medical
officers I am inclined to think that human trypano-
somiasis is at least not on the increase in Sierra
Leone. Regulations for checking the introduction
of the disease by shipping have recently been
brought into force.
Leprosy.—From the observations of the medical
offücers this seems to' be most prevalent in the
Karene and Kaballa districts, in both of which
several cases were met with during patrols. In
every instance advice was given as to the necessity
for segregation, which the chiefs promised to follow.
Goitre.—This condition is also reported as being
fairly common in certain localities in the Karene and
Kaballa distriets, several cases being met with
during the sanitary patrols of the medical officers.
Syphilis.—This disease is met with throughout
the country, but from the comparatively small
number of cases that come up for treatment I am
not in a position to say that it is prevalent to any
alarming extent.
Three hundred and seventy-one cases were treated
in the various hospitals and dispensaries, chiefly
of the tertiary variety.
Beriberi.—Several outbreaks of beriberi occurred
during the year, and the following number of cases
came under treatment at the different places : —
Colonial Hospital, Freetown, 27; Kennema Prison,
7; Daru Barracks (W.A.F.F.), 10.
In each case the incidence of the disease was put
down to the use of imported (Indian) rice. Owing
to the great scarcity of native rice during a part of
the year (May to September), large quantities of
rice, chiefly Indian, had to be imported, and it is
a notable fact that where this rice was freely used
by the people beriberi symptoms became prevalent,
though beriberi is not, under normal conditions,
often met with here.
. It is also remarkable, as mentioned by Dr.
Davson, that in the gaol, where there was very
little imported rice used, there were no cases of
the disease. These facts tend to the conclusion
that the imported rice contained the germ or poison
of beriberi, though to ordinary inspection it appeared
to be of good quality. ,
Sanitation in Freetown.
The sanitation of Freetown was, as usual, under
the management of the Sanitary Department of the
City Council, to which body the Principal Medical
Officer is Medical Officer of Health. During the
first half of the year there were only 50 labourers
employed for scavenging duties, but later on, owing
to the presence of yellow fever, it was thought
advisable to increase the number to 200, and this
was done at the expense of the Government, as
vigorous anti-stegomyia measures were considered
necessary. A large proportion of the refuse gathered
in the town had to be removed by manual labour,
owing to the insufficient number of carts employed,
viz., two bullock carts and one mule cart. This is
a serious defect in the important work of scavenging
in a large tropical town. Some difficulty having
arisen in the disposal of tin and bottle rubbish by
burial, as was formerly the practice, owing to the
rocky nature of the remaining available sites around
the town, two canoes were provided by the Govern-
ment for the disposal by dumping in the sea of all
such refuse, and this method has proved a great
success.
It is intended to have receptacles of expanded
metal of suitable form placed in the streets for the
collection of old tins and bottles, &c. The new
Jan. 1, 1914.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 7
Fish Market was opened during the year; it affords
a more sanitary method for the disposal of fish by
sale than the former system of exposing for sale this
universal article of food in any vacant bit of road
or footpath in the town. The drawing up of a com-
prehensive plan for the reconstruction of the drains
and streets of Freetown is under consideration, but
this will not be allowed to interfere with the carrying
out of the minor sanitary improvements in drainage,
&c., of the town that are at present considered of
urgent importance, and which will to a large extent
assist in the mosquito extermination campaign now
being fought.
Anti-malarial Measures.—These were followed out
as usual during the year, and consisted of the
following :—
The collection of all waste tins and bottles and
other rubbish likely to act as mosquito breeding
grounds, and their disposal by dumping in the sea
at a suitable distance from the shore, two canoes
being provided for this purpose.
The periodical oiling of stagnant pools.
Regular attention to the various watercourses, to
keep their channels free from obstructions, so as
to prevent the formation of stagnant pools in them.
House-to-house inspection of premises for the
detection of mosquito larve in water receptacles.
This necessary work was placed on a satisfactory
footing by the appointment in October of a Junior
Sanitary Officer, who carried out strict larve inspec-
tions under the Public Health Amendment Ordi-
nance No. 16, of 1910, by which the presence of
larve in any water vessel in a compound renders
the occupier liable to be dealt with summarily,
whether a notice has been served to abate the
nuisance or not.
A new Public Health Amendment Ordinance,
dealing specially with the presence of mosquito
larve in premises, came into force on September 30,
1910. Under this Ordinance there were forty-two
persons convicted for having larve in water recep-
tacles on their premises. Under the Principal
Ordinance (Public Health) there were twenty-seven
convictions for defective mosquito-proof covers to
barrels.
In reference to the removal of tin and bottle
refuse, there were 1,021 canoe loads removed from
the town and disposed of by dumping in the sea,
the capacity of the canoes by measurement being
two tons. This represents 2,042 tons of this variety
of rubbish disposed of during the year.
There are two important points in connection with
the sanitation of Freetown which I consider require
special and early attention, particularly as they are
intimately connected with mosquito extermination
measures :—
(a) Improving the Water Supply.—The water
supply at Freetown is at present only just
sufficient to meet the ordinary requirements during
the dry seuson. The only reservoir is capable
of storing only two days’ supply, so that in
the dry season there is no provision to meet an
emergency such as the bursting of a main, or, more
serious still, the development. of leaks due to cracks
in the reservoir itself. Where an unlimited quan-
tity of water could be collected in the rainy season,
I am of opinion that such an unsatisfactory con-
dition of things as an insufficient water supply in
a large tropical town like Freetown, with all its
attendant insanitary evils, should be remedied at
the earliest opportunity. This defect in the public
water supply bears a close relation to the question
of stegomyia extermination, the importance of
which has lately been vividly impressed upon us by
an outbreak of yellow fever in the town, as it means
the continuance of the presence of wells and of an
insufficient number of publie stand-pipes around
the town, which in its turn means the keeping of
water receptacles by householders. These recep-
tacles, barrels, French jars, drums, tins, &c., have
been proved to be the chief source of mosquito larve
at the present time, resulting in numerous sum-
monses under the new “ larvie '" Ordinance, though
the Government has arranged to assist the public
by the supply of taps and mosquito-proof covers at
cost price (4s. 7d. to those who can pay, but free
to the poor).
(b) Concreting and Canalizing of the Water-
courses.—There are three large streams running
through the town, viz., the George River, Sanders
Brook, and Nieol Brook, with two or three less im-
portant ones; these have very irregular courses, and
run in small ravines varying from a few feet up to
10 ft. or 15 ft. deep. The sides and floors of these
ravines or natural channels are extremely jagged
and uneven, the floor or bed consisting chiefly of
large boulders and loose stones of varying sizes. In
the rainy season these watercourses are frequently
and thoroughly flushed from side to side by the rush
of water down the mountain sides, every pool and
erevice being scoured out; but in the dry season,
when the flow of flood water, owing to the absence
of heavy rain, falls to a negligible quantity, the
total amount of water flowing in them becomes
reduced to a mere trickle, and the numerous cul-
de-saes formed by the boulders and stones become
so many stagnant pools wherein mosquitoes breed.
This is another source of mosquito breeding grounds
that could and should be got rid of. The only
efficient method of doing this would be, in my
opinion, by a thorough scheme of concreting (with
a central channel) of the bed of each stream within
the city boundaries.
It is only during the last two months of the dry
season that there is any actual shortage of water,
but at that time it must be remembered that the
present supply can only be considered a '' hand to
mouth supply."
If an accident happened to either the service
reservoir or mains the city would be without water,
as there is no storage to fall back upon.
A storage reservoir or reservoirs capable of con-
taining singly or jointly about 30,000,000 gallons
should form part of the scheme. The exact requisite
volume of storage cannot be determined at present,
but it is probable that the above-mentioned size
would be ample. Without some storage it is im-
possible to prediet the extent to which the dry
8 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Jan. 1, 1914.
weather flow, and consequently the supply, may
dwindle down during droughts. If, therefore, there
were no storage, interruptions to the supply might
occur, involving the most serious inconvenience,
and danger to health would be the result.
THE TEACHING OF HYGIENE.
This subject is now being regularly taught in the
secondary schools, and at the annual examination
in December the results obtained were as follows :—
Of the 107 candidates who sat for examination
2 obtained between 60 and 70 per cent.
60
9 LEJ ?3 50 ” 31
15 ” ” 40 7» 50 3)
17 ” ” 80 ” 40 ”
23 ” » 20 ” 30 ”
37 » » 10 ,, 20 »
4 pa under 10 per cent.
Mr. Nicholas Taylor, of the Church Missionary
Grammar School, obtained the first prize, £5, and
the seven next best candidates received £2 each.
There were seven more candidates than the
previous year. The five schools received a bonus
of £20 each.
Hirr STATION.
The health conditions of Hill Station have during
1910 continued to be quite satisfactory. There
were during the year 79 residents, an increase of
25 over that for the previous year. With this large
addition to the number of residents it is gratifying
to note that there was an increase of only two in
the number of admissions on the sick list.
The total number of cases on the sick list was 18.
Of these 6 were due to climatic causes: Malarial
fever, 5; yellow fever (suspected), 1.
In three of the cases of malarial fever, infection
was contracted during visits to out-stations in the
Protectorate. Two of the cases occurred in the mili-
tary residents who worked in Freetown daily. The
suspected case of yellow fever occurred in a newly
arrived official who frequently had to remain in his
office overtime, owing to extra work, and was not,
in consequence, able to leave Freetown until late
in the afternoon.
The military residents almost equalled the
officials. This is due to the fact that bungalows
vacated by officials going on leave are immediately
rented to military men, who are always keen to
take advantage of the pleasant climate of Hill
Station with its convenient mountain railway.
This renting of the official quarters at Hill Station
is being overdone, and this was especially so during
the past year, when several Government officers
were compelled to reside in the Rest House in Free-
town for prolonged periods, great personal incon-
venience and discontent being caused thereby, while
several bungalows were at the same time occupied
by temporary tenants. Rest houses are not intended
to be used as quarters, and it is unreasonable to
expect an officer to carry on his duties satisfactorily
under such unsettled and disturbing conditions.
Owing to the inerease in the European staff lately
several additional bungalows are now required, and
the building of some of these should be taken in
hand without delay to meet present requirements.
Water Supply.—The water supply of the Settle-
ment remains in the same uncertain state. For
three or four months between January and May our
position as regards this all-important question is
certainly precarious, owing to the defective storage
arrangements. With the present and prospective
still further increase in the number of residents,
something must be done to make the water supply
more certain and more ample than it is at present
during the dry season. With an annual rainfall of
160 in., it only requires efficient means of storage
to secure an abundant supply during the dry season
for all purposes. This is impossible with the present
defective reservoirs, which seem to have been of
very little use since their construction, and the
periodical patching up which they undergo does not
seem to improve their effectiveness, as this season
our shortage difficulties began earlier than ever.
This serious drawback to living at Hill Station will
certainly deter other Europeans who may desire to
do so from selecting it as a place of residence. The
appearance of the compounds show that the per-
manent residents continue to take an interest in
them. Defects in some of the surface drains and
the waste pipe connections from bath-rooms, &c.,
were pointed out and partly remedied during the
year; many of the latter still remain, however.
Clearing the bush and undergrowth around the
Settlement was carried on steadily during the year
by the sanitary gang, and there is now a fairly
large area cleared of excessive vegetation. The
sanitary arrangements worked satisfactorily during
the year, with the exception of the water supply,
as already referred to above. Means of exercise
and recreation (these may properly, I consider, be
included under sanitation in such a Settlement as
Hill Station), owing to the hilly and rocky nature
of the land in the immediate neighbourhood, are
limited, lawn tennis and croquet being the only
games at present played, with a nine-hole golf
course three miles away at the foot of the hills;
this, however, can only be played on during the dry
season. A third tennis court has been approved of.
A small club house or pavilion is very much
needed near the tennis courts. This would be par-
ticularly useful during the rainy season, as it would
obviate tennis players and others running off to
their quarters whenever a sudden shower or tornado
comes on; this is a rather frequent occurrence
during the rains, and often means a severe wetting
or getting very hot in the run uphill to one’s bun-
galow, which in either case means the risk of a chill.
CoLoNIAL HOSPITAL, FREETOWN.
(By Dr. J. B. H. Davsox, S.M.O.)
Isolation Arrangements.
Owing to the outbreak of yellow fever in the town
during the month of May, it was found necessary
to make arrangements for the isolation of patients
suffering from, or suspected of suffering from this
disease.
p
Jan. 15, 1914.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. : 9
Colonial Medical Reports.—No. 27.—8ierra Leone—
(continued).
Between the beginning of June and the end of
September 14 patients were admitted, their illness
being diagnosed as follows: Yellow fever, 8; malarial
fever, 8; pleurisy, 1; influenza, 1; rheumatism,
1. Of these 9 recovered and returned to work; 4
recovered and were invalided; 1 died (yellow fever).
For the purpose of isolating natives at the
hospital, eleven beds on the male side and five beds
on the female side were provided with mosquito
netting.
Four cases admitted into these beds were dia-
gnosed as yellow fever; three of them died and the
post-mortem examination confirmed the diagnosis.
Cases Treated.—The number of patients admitted
into the hospital this year, i.e., 1,500, is the largest
since the year 1904, when it reached a total. of
1,098. No doubt the presence of trained European
nurses gives confidence and encourages patients to
come.
The number of out-patients treated has increased
from 27,474 last year to 81,795 in 1910.
Beriberi.—Between the months of August and
November twenty-seven cases of beriberi were
admitted to hospital. They were characterized by
the presence of a very marked ataxia, comparatively
slight muscular weakness, and almost entire ab-
sence of sensory symptoms. As.a rule there was
slight cardiae disturbance and no dropsy.
Five of these patients died, and during an autopsy
on one of them, conducted by Dr. Mayhew, a mass
of inflammatory tissue, involving the pancreas, was
found round the pyloric end of the stomach and the
duodenum.
From May onwards till September the supply of
native rice in Freetown fell very short and most of
these people said that from July onwards they lived
wholly or partly on imported rice. There were no
cases in the gaol. . Very little of the imported rice
was used there. e :
Ankylostomiasis.—During the year 1904, and
from time to time since, examinations have been
made of the faces of patients for the purpose of
estimating the degree of prevalence of ankylosto-
miasis among the inhabitants of Freetown. It is,
apparently, often present, but during this year only
seven patients have been admitted to hospital with
serious symptoms that could be attributed to this
infection.
Diarrhea and Dysentery.—The number of ad-
missions for these complaints is about the same as
it has been since 1904. The number of deaths from
them remains much the same.
KiNc-HanMaN's MATERNITY WARD OF THE COLONIAL
HosPrrar.
(By Dr. Wm. RENNER.)
Of instrumenta] labours there were ten.
The average stay of patients in the ward was
eight days.
Of patients with complications on admission there
were fifty-nine.
Following are the particulars of cases which
resulted in death :—
(a) Admitted in unconscious condition. First
child born at home; second in a hammock on the
way. Had frequent fits after admission; temper-
ature went up to 108° F. Patient died eleven
hours and ten minutes after admission.
(b) Ante-partum hemorrhage, . placenta previa.
Was admitted in exhausted condition; collapsed and
died one hour and forty-five minutes after admission.
(c) Admitted in a weak condition seven hours
after delivery. Puerperal nephritis; renal asthma.
Died thirty-six hours after admission. ;
(d) Hemorrhage, placenta previa; had hemor-
rhage twenty-eight hours before admission. Very
exhausted; died an hour and a quarter after
delivery (by forceps). '
(e) Admitted in exhausted condition; head of
child born; shoulders fixed; arms brought down and
child delivered. Died of exhaustion two and a half
hours after delivery. : à
The admissions during the year have steadily
increased.
Tur Nursinc Home.
This institution, for the use of Europeans only,
is managed by European nurses.
There were 60 admissions during the year, 10
more than the previous year. During the past year
the number of patients was 60, with 4 deaths, due
to blackwater fever, 1; yellow fever, 3.
The admissions were ten more than the previous
year. The amount received in fees for admission
and treatment during the year was £233 5s., being
£64 18s. 2d. more than the previous year.
THE GAOL.
(By Dr. Davson.)
Throughout the year the prisoners have been
divided, the majority being kept at the gaol and
the rest (averaging about one hundred) at the tem-
porary building on the site of the new prison. This
distribution of prisoners has tended to promote good
health, except for the fact that those at the Botanic
Station (new prison) appear to be more liable to
attacks of diarrhoea. “As all prisoners have the
same food and water this is probably due to less
perfect supervision enabling them to obtain articles
of diet they should not have.
There are in the gaol several old people and some
others very weakly who suffer from chronic diseases,
such as asthma, heart disease and elephantiasis.
Those have to be employed always on light tasks.
During the year there have been four executions
in the gaol and five deaths from disease, i.e., three
from heart disease and one each from general
debility and phthisis.
Kissy INSTITUTIONS.
(By Dr. W. F. CAMPBELL.)
There has been no epidemic amongst the inmates
throughout the year. During the year the old and
defective building in which cells are provided for
10 THE JOURNAL pF TEONIOAY MEDICINE AND HYGIENE.
(Jan. 15,
RETURN OF DISEASES AND DEATHS IN 1910 IN THE COLONIAL HOSPITAL, FREETOWN,
GENERAL DISEASES.
Alcoholism .. os ès
Anæmia ee we s
Anthrax
Beriberi
Bilharziosis
Blackwater Fever
Chicken pox
Cholera e em
Choleraic Diarrhoea as T
Congenital Malformation
Debility os E^
Delirium Tremens m m
Dengue. s Ss °9
Diabetes Mellitus AN ès an
Diabetes Insipidus .. se Tm T
Diphtheria .. s n $a ie
Dysentery T es we -
Enteric Fever .. a "n
Erysipelas À
Febricula
Filariasis
Gonorrhea
Gout .. D
Hydrophobia ..
Influenza À ae z ne
Kala-Azar vie $3 ng s
Leprosy : E
Nodular..
a) Anæsthetic
c) Mixed
Malarial Fever
(a) Intermittent
Quotidian
Tertian
Quartan
Irregular
Type undiagnosed
(b) Remittent
(c) Pernicious E
(d) Malarial Cachexia
Malta Fever
Measles
Mumps
New rowhá-
Non- malignant oo m oe ee
Malignant .. oe oe a
Old Age.. P M
Other Diseases
Pellagra
Plague ..
Pyemia
Rachitis
Rheumatic Fever
Rheumatism ..
Rheumatoid Arthritis.
Scarlet Fever . i
Scurvy ..
Septicemia
Sleeping Sickness
Sloughing i healed
Smallpox
Syphilis
(a) Primary
(b) Secondary
(c) Tertiary ..
(d) Congenital
Tetanus te
Trypanosoma Fever ..
Tubercle
(a) Phthisis "Pulmonelis .
(5) Tuberculosis of Glands M
(c) Lupus .. m pa T v
Admis-
PPI PlSttl bei Sl Ee
t2
Q
E = TN IG
w
M
Lex ERT TEEST I s LEERS re Lili
111 B.S! lSeal |!
sions
bd Bel MRR pee bel a Pa bs Tae RET eb aed ST RT ne TE ee DIST ee 4 see fy 22359 Debe
Total
Cases
treated
PBL IT] lol I SITIEESILITIESI TIL Sl Site
eb Biol See wee TSP SA I keti Td tS
Sierra Leone.
GENERAL DisEASES—continued.
(d) Tabes Mesenterica
(e) Tuberculous Disease of Bones
Other Tubercular Diseases
Varicella à ie
Whooping Cough
Yaws .. ss
Yellow Fever ..
LOCAL DISEASES.
Diseases of the —
Cellular Tissue .. oe oe >.
Circulatory System vs
(a) Valvular Disease of Heart
(b) Other Diseases
Digestive System .
(a) Diarrhea ..
(b) Hill Diarrhoea
(c). Hepatitis
Congestion of Liver -
(d) Abscess of Liver
(e) Tropical Liver
(f) Jaundice, Catarrhal
g) Cirrhosis of Liver ..
h) Acute Yellow Atopiy
i) Sprue ..
(j) Other Diseases
A e
Eye .. . ee
Generative System
Male Organs
Female Organs ..
Lymphatic System
Mental Diseases ..
Nervous System
Nose.
Organs of Locomotion
Respiratory ee
kin ..
(a) Scabies
(b) Ringworm
(c) Tinea imbricata
(d) Favus..
(e) Eczema 1
(f) Other Diseases
Urinary System ..
Injuries, "General, Local
(a) Siriasis (Heatstroke) .
(b) Sunstroke (Heat Prostration)
(c) Other injuries ..
Parasites
Ascaris umbricoides
Oxyruis vermicularis x
Dochmius duodenalis, or Ankylostoma
duodenale P
Filaria medinensis (Quinea- worm)
Tapeworm .. ;
Poisons s
Snake- bites .
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids
Nature unknown ..
Other Poisons
Surgical Operations . pi oe Tm
Amputations, Major oa se +e
Minor
Other "Operations Es
Eye è và
‘(a Cataract os
(b) Iridectomy
(c) Other Eye Operations
Admis-
sions
al litt
LIL LLL BSB ol TLL) See BeSBSI SHALE] lol EI RI ola
Ed UD teed
Deaths
e]. Tor E 3
PEEL EP ean! TI) LP bonlotmanl Ileal | el dol el ol al o
PPP 1l 1l&el| b: bbb det dl
1914.
Total
Cases
treated
ald] dil
' —
ofli.
&
n j
-
TITEL | eel
-
w
-
Joanos]
-—
LET Ltt SRSESSITILI
TS eT et 34
Jan. 15, 1914]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. ii
the accommodation of violent female lunaties was
pulled down, and much needed additions and alter-
ations in connection with the asylum were carried
out. These consist of a new block containing cells
for violent cases and a hospital ward; a new wash-
house and latrine have also been provided, as well
as separate kitchens for patients and female
attendants. The administrative block has also been
rebuilt giving more ample and suitable aecommoda-
tion for the attendants, and the dispensary with the
medical officer’s office and consulting room.
Only the quietest and most sensible of the
lunatics were employed in laundry and gardening
work. The vegetables grown by the inmates were
sold in Freetown, and the proceeds devoted to the
purchasing of articles such as biscuits, cakes,
coco-nuts, tobacco, &c., for their use.
Female Incurable Hospital.—There were 29
patients at the beginning of the year; during the
year 96 patients were admitted, making a total of
85 under treatment.
There were 26 discharged, 26 deaths, and 33
remaining in hospital at the close of the year.
The deaths were due to syphilitie exhaustion,
senility and paralysis.
Male Incurable Hospital.—Seventy-one cases
were under treatment at the beginning of the year,
136 were admitted during the year, 73 were dis-
charged, and 52 deaths occurred from old age, ex-
haustion, syphilis and paralysis; and 82 patients
were remaining in hospital on December 31. Owing
to the serious nature of the cuses, and the advanced
stage in which many are admitted, the death-rate is
always high.
Infectious Diseases Hospital.—At the commence-
ment of the year there was one case of chicken-pox ;
six cases of chicken-pox and one of small-pox were
admitted during the year, all aborigines, and all
were cured. The case of variola was of a mild form ;
the patient came from the Protectorate.
Protectorate District Reports.
RONIETTA DISTRICT,
HkabQUARTERS—MOYAMBA.
(By Dr. J. Y. Woop.)
Out-patients.—Total number of attendances. of all
classes was 4,155, an increase over last year of 592,
showing a steady inerease in this department from
year to year,
In-patients.—Twenty-four compared with thirty-
eight in previous year, a decrease of fourteen, pos-
sibly acounted for by the frequent change in medical
officers. The number of operations during the year
was six, all being minor cases. The prevalent
diseases during the year in order of frequency were :
Rheumatism, constipation, pulmonary complaints,
wounds and injuries, skin diseases, including ulcers,
venereal disease and malaria.
Dysentery was not very prevalent, and leprosy
seldom seen. There were two cases of bilharziosis,
verified by microscopic observation, and three cases
of suspected trypanosomiasis, all children with
symptoms of enlarged glands and constant sleeping,
one case terminating in death. None were verified
or treated, as the people refused to leave the
children under observation at the hospital.
Elephantiasis is very common, both of the leg
und scrotum, but cases seldom came for treatment,
and operation was almost always refused.
Venereal Diseases.—Gonorrheea appears to be
more prevalent in the outlying parts of the district
than in the neighbourhood of Moyamba. Primary
syphilis is very rarely observed, and but few cases
of undoubted secondaries; but ulcers, very sus-
picious both from situation and appearance, im-
proving or disappearing under anti-syphilitic treat-
ment, are very common in both sexes, although
more frequent in men. I have not seen any definite
case of hereditary syphilis.
Although gonorrhea is commonly recognized by
the natives as venereal under the term '' women
palaver,’’ syphilis is not at all recognized as such,
and secondary manifestations are treated purely as
local.
Water Supply.—This is from two sources, a small
river used by the inhabitants of Moyamba and also
by Europeans for washing purposes, and a moun-
tain spring three miles away used by Europeans for
cooking and drinking purposes. A scheme for con-
veying it in pipes would be of the greatest benefit.
Sanitation.—The pail system, worked by prison
labour, is in use among officials and works very
well; all rubbish is burnt or buried. Among the
Creoles in the town the cesspit system is in use,
eaeh cesspit being closed when tall A few of the
chiefs and wealthier natives are also adopting this
plan. Some of the towns visited on patrol are also
adopting the cesspit system, in some cases even
erecting public cesspit closets. Moyamba town has
been kept fairly clean during the year, the chiefs
usually readily cleaning up any neglected part on
its being pointed out to them. The Creole portion
of the town continues to give the most trouble
owing to there being no one there with sufficient
authority to get things put right. As a rule the
Creole part of the population seem to be much more
careless as regards clean surroundings than the
natives, and are not so ready to clean up when
their attention is drawn to insanitary conditions,
paying much less attention to arguments in favour
of sanitation. Bottle borders, a fruitful souree of
mosquito breeding places during the rainy season,
are in great favour among them.
Sanitary Patrols.—During the year extended
patrols were undertaken, and at each town where
a halt was made sanitation, on the lines suggested
in Standing Instruction No. 5, was explained to
the chiefs and the people as simply as possible, and
al were urged to co-operate in carrying out the
suggestions.
I am of opinion that more frequent and more
extended patrolling by medical officers would lead
to very great improvement in general sanitation and
eonsequently in general health among the natives,
for here, as elsewhere, the two go hand in hand,
the dirtiest towns being always the most unhealthy.
12 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Jan. 15, 1914.
RAILWAY DISTRICT.
Bo AND KENNEMA STATIONS.
(By Dr. J. McConacuy.)
There are 118 schoolboys at the Bo Government
School. Three hundred and five days is the aggre-
gate amount of time lost by the permanent staff
through illness.
The health of the European officials has, on the
whole, been good. Two Sierra Leonean officials
died during the year, one of pneumonia and one of
mitral regurgitation.
The number of out-patients treated at the dis-
pensary during the year was 1,159, being an increase
of just one patient over last year. The amount
collected in out-patients’ fees was £2 2s.
Forty-two in-patients were treated in the hospital.
There were six deaths in hospital, four being due
to cardiac disease, one to pneumonia and one to
diarrhea. There were eight operations performed
under chloroform.
The health of the children at the Bo School has
on the whole been good. There was one death, due
to acute general peritonitis. During the year a
fortnightly inspection of all the boys has been held
with the object of detecting chiggers and skin
diseases.
All the bungalows in the European Compound
are extremely hot during the day. The Medical
Officer's bungalow has been improved by widening
part of the veranda. This addition practically
forms an extra room and is fairly cool in the even-
ings. Charcoal has been placed between the gal-
vanized iron roof and the ceiling. A site for
quarters for an engine driver was chosen in the
European Compound, and the building commenced
before the end of the year. This house is being
built of stone. A new rest house has been built
near the railway station. It contains four rooms,
with a veranda running right round the house.
It is double-roofed, the outer roof consisting of
thatch, and the inner of galvanized iron. The house
is cool, but the outer roof leaked during the rains,
and, as a consequence, the veranda was always
damp during that season. The whole house is built
of mud.
The water supply of Bo is quite inadequate. The
auxiliary supply, which is brought from Kennema
in aluminium bottles during the dry season, obviates
the difficulty of obtaining drinking water, but when
the dry season is advanced, water for general pur-
poses, such as bathing, is scarce. There is a sani-
tary gang of twelve men who empty latrines, remove
household rubbish, &c., and look after the cleanli-
ness of the Compound generally. The question of
sanitation in the town of Bo itself is most un-
satisfactory. In addition to the natives there is a
large Sierra Leonean population. The Chief does
not appear to have much authority over the people,
and it seems to be almost impossible to make the
inhabitants generally realize the importance of
keeping the town clean.
Only 295 vaccinations were done during the year
The people objected strongly to be vaecinated dur-
ing the famine, when they were in a chronic state
of hunger.
A patient suffering from small-pox came to the
dispensary. He was isolated and recovered. It
was found that he had come from Blama. A vac-
cination patrol was made to Blama, and vaccina-
tions performed. Biting flies are not plentiful in
Bo. Those found belong for the most part to the
Tabanide. Ihave not seen any tsetse.
KENNEMA STATION.
The Medical Officer of Bo has paid weekly visits
to Kennema during the year. The health of the
European officials was good. Among the native
officials the Court messengers have suffered most.
The nature of their duties entails a considerable
amount of exposure.
There is no hospital in Kennema and all patients
are treated at the dispensary or at their own houses
when seriously ill. There was one death in the
gaol from pulmonary tuberculosis, and there was
also an outbreak of beriberi in the gaol, seven cases
occurring at the same time. The patients were
isolated in a native house outside the prison. All
the prisoners were accommodated in huts outside
the gaol, and the gaol thoroughly disinfected. All
the patients recovered.
The Court messengers’ quarters are very comfort-
able and situated in well-laid-out lines, with
masonry drainage, and water laid on to a stand-
pipe.
The water supply at Kennema is excellent, as the
water is obtained from an uncontaminated source
on the hills led down in pipes and distributed by
standpipes.
Sanitation.—Pail closets are used by the Euro-
peans and native clerks and in the prison; the
contents are emptied into a trenching ground by
prisoners every morning.
SrATIoN—Danu (HEADQUARTERS OF THE W.A.F.F.).
(By Dr. J. C. Murpuy.)
Since the last Annual Report was written the
general health of the officials has been fair, and
there has not been any very severe sickness amongst
them.
Ten Europeans and eleven natives were placed
on the sick list for a total period of seventy-two and
seventy-four days respectively.
About twenty Europeans resided in the station
for varying periods of a month upwards, others
passed through, staying for a night or so. One
officer W.A.F.F. and one railway platelayer were
invalided to the Nursing Home, Freetown. A fair
proportion of the Europeans residing for long periods
at Daru had suffered from diarrhea with transient
mild symptoms of dysentery, not sufficiently severe,
as a rule, to necessitate placing them on the '' sick
list." The drinking water is obtained from the
rain water collected from the roofs and stored in
tanks. There is a plentiful supply of water for
domestic and other uses; it is obtaimed chiefly from
— ——— 77
Jan. 15, 1914.]
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 13
the Moa River. This river is of considerable width
and force with a rocky and sandy bed. Cataracts
just above barracks tend to make the water turbid
and prevent sediment settling down. On the
whole the sources of water supply are good. Fresh
food is usually obtainable, and adds to the health
of the station.
Vaccination.—288 persons were vaccinated dur-
ing the year; there were only nine failures.
Meteorological observations are taken daily, total
rainfall for the year was 95:40 inches.
Weekly inspection of barracks, latrines, &c., have
been arranged. Cutting of grass in compounds,
also of small shrubs, is from time to time carried out
by fatigue parties, and the station kept clean and
free from excess in vegetation.
KOINADUGU DISTRICT.
HkADQUARTERS—KABALLA.
(By Dr. J. S. PEARSON.)
The general health of the officials and Court
messengers has been good throughout the year. No
deaths or invalidings have occurred among officials.
Extern Department.—There have been 517
attendances. The most interesting case was that
of trypanosomiasis. This patient, a boy, aged 15,
living at a village about a day’s walk from here,
refused to stay in the hospital to be treated.
Intern Department.—Three cases were admitted
into hospital. One was a case of rather serious
contusions to the leg, and two of elephantiasis of
the scrotum. These latter two were successfully
operated upon. They both weighed from 30 to
40 lb. each.
Sanitation.—The compounds around the officials’
quarters and those of the Court messengers have
been kept clean and in good order. The bucket
latrines of the officials were daily attended to by
the prison gang. In the Court messengers’
barracks the pit system is in use. These pits are
periodically filled up and new ones dug, and are
inspected at regular intervals.
Water Supply.—The water supply
excellent.
Patrols.—The different districts around have
been visited fairly regularly. The Chiefs were
spoken to in regard to the cleanliness of their towns,
where to keep their cattle, and in a general way
how to keep down any infectious diseases that may
at any time appear. Vaccinations have been
regularly carried out. A very good percentage of
eases were successful. "There are still some towns
where it is very difficult to get people to agree to
vaccination.
Tsetse-flies.—As far as one can surmise these
are fairly numerous, especially in and around the
towns to the north, north-east, and north-west of
has been
Kaballa. Several specimens have been sent down
to the Colonial Hospital and transmitted to
England.
Meteorological Observations.—The meteorological
observations have been noted carefully daily, and
records have been kept. The highest temperature
noted was 1009 F., and the lowest 519 F. , The
rainfall for the year amounted to 89°92 in. The
greatest in one month was 17°66 in.
KARENE DISTRICT.
HEADQUARTERS—BATKANU.
(By Dr. H. E. ARBUCELE.)
The health of the officials here has not been very
good, two Europeans and 51 native officials being
on the sick list, and four officials being invalided,
including the District Commissioner, Mr. Burra,
and the Medical Officer, Dr. Alexander.
The most prevalent diseases were constipation,
syphilis, bronchitis, and rheumatism.
The water supply is from the Mobile River, and,
although not particularly good, is not so bad as
previous reports would show. The river is big, and
there is no town or farm nearer than at least two
miles above Batkanu. The water is boiled and
filtered before use by the Europeans.
There are two wood and iron bungalows in Bat-
kanu. One is a double one, occupied by the District
Commissioner and his assistant. The bungalow is
raised on concrete pillars about 10 ft. from the
ground. It is divided by a single wooden partition,
and each side consists of a single room, surrounded
on two sides by a closed veranda. The house is
very hot, and to make things worse, many of the
windows must remain shut to keep out bees, of
which there are three swarms in the walls. The
bungalow oecupied by the Medical Officer is raised
only one-third foot, and consists of two rooms, with
a low ceiling; it is very hot, especially in the dry
season, but now the District Commissioner has
given orders for the roof to be covered with grass.
If the bungalows at Bo were deemed not fit for
human habitation by Professor Simpson, much less
are the bungalows in Batkanu. The Court mes-
sengers and clerks live in houses which are within
100 yards of the Europeans' bungalows; the native
village of Batkanu is only about 200 yards away,
and is separated from the bungalows and office by
a belt of bush which is within 80 yards of the
Medical Officer's bungalow and the District Com-
missioner's office. This bush is used as a burial
ground by the town, and also for the deposition of
human excrement; it is therefore very objectionable,
but as it is regarded as sacred by the Chief and his
people, it cannot be touched. On sanitary grounds
it would be most desirable to alter the headquarters
of this district. `
Sanitary patrols into outlying parts of the district
have been undertaken by Dr. Murphy and myself.
The Chiefs seem grateful for the information given
them, and will, I believe, act on the Medical
Officer's advice. On these patrols I carry a stock
of medicines, and after addressing the Chief and
his people on elementary sanitation, out-patients
are given free medicines.
In the rainy season, owing to the annual overflow
of the river, mosquitoes are fairly common, and
their destruction is practically impossible. Glossina
palpalis is, or rather, was, very common, but since
I have been here this year I have not yet come
14 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Jan. 15, 1914.
across any. I found several specimens of the
Glossina morsitans, in December, not far from the
Small Searcies River north of Samaia.
The pail system of closet is in use in all Govern-
ment quarters here, and gives satisfaction. The
pails are emptied in a trenching ground a little
distance away from the Court messenger lines.
The Court messenger lines are inspected every
week and are kept very clean.
A station gardener has been appointed, and his
duties are to plant vegetables and look after them,
so that the officials may have some green vegetables.
which are an enormous boon to the unfortunate
officials stationed in this very '' hungry " station.
The water for the Europeans could be improved
greatly if tanks were built here to catch the rain
from the roofs of the bungalows.
SHERBRO.
(By Dr. R. W. Orpen.)
The health of the European staff during the year
has been good, also the health of the native officials ;
no serious case was seen.
There are about thirty-five Europeans employed
with various mercantile firms in Bonthe; on the
whole the health of these has been good, but I regret
to say that during the year two deaths took place,
the cause of one being blackwater fever, the other
being hyperpyrexia due to pernicious malaria.
The diseases seen in the out-patients' depart-
ment vary greatly. The following are most often
seen: Malaria, syphilis (second and third), gonor-
rheea, skin affections, rheumatism, bronchitis,
leprosy (from time to time), clephantiasis (leg, arm,
and scrotal), and deformities. Ulcers are an every-
day occurrence.
Vaccination.— Vaccination was carried out during
the early part of the year; the number of successful
cases seen was 141.
The gaol has been visited regularly twice a week
and all prisoners examined on admission,
BowTHE—SANITATION Report, 1910.
(By Dr. Orpen.)
The town is roughly cut in two by a large swamp
called Heddle Swamp. This at low tide is an area
of foul-smelling mud; at high tide it is full of water,
being assisted by the stream which flows into the
head of the swamp. A portion of the swamp has
lately been filled in and houses erected, and I note
that there is apparently some further filling in about
to take place. The material used for this purpose
is turf cut from the island opposite Bonthe. It
inakes a good, firm soil.
The sanitury authority is the Sherbro Municipal
Board, of whom the Medical Officer for Bonthe is
an ex-officio member. It employs sanitary in-
spectors, six sanitary police, and two scavengers;
there is also a gang of men, twelve in number,
whose duties are keeping the grass short in the
streets, &e. The duties of the scavengers consist of
cleaning publie latrines, removing nuisances, night
soil, &c.; it is quite obvious that the number of
scavengers is quite too small. The work done is
done in an insufficient manner, bottles, tins, &e.,
are to be seen lying in every street. Three ham-
mocks of the same type as used in Freetown have
been ordered for removing rubbish, as the cart
owned by the Sherbro Municipal Board is a quite
impossible article. The rubbish, &c., is now being
dumped at the head of Heddle Swamp, and an
attempt is being made to fill in some ground.
Water Supply.—This is a question of great im-
portance, owing to the shortage of water in the dry
season. The Government has constructed two
tanks (concrete) with catchment areas. This makes
four tanks of total capacity 64,000 gallons; but I do
not think that the tank of the Government Hospital
should be taken into consideration, as it is used for
hospital purposes, although there is a stand-pipe in
the street in connection with the tanks. I do not
think that these tanks during the dry seasons will
be able to supply the wants of Bonthe. The usual
method of obtaining water here is to dig a well;
water ean be obtained at any point from 3 ft. to
12 ft. There are 116 wells in Bonthe; about two
of them are properly covered; they are usually
situated in a compound in close proximity to a
house, and thus liable to contamination. Ten
pumps are now in process of being erected, but are
quite inadequate for the requirements of Bonthe.
I suggest that twenty more be supplied, and then,
by closing the wells at the various areas where the
pumps are situated, a very large number of places
where mosquitoes breed and flourish would be
removed.
Water does not lodge in the streets owing to the
porous sandy soil. I um informed that some of the
drains are used in the rainy season as places for
washing clothes. Other drains have never been
finished, concrete sections being just placed together
and not jointed; mosquito larve have again been
found there.
Latrines.—There are only three public latrines in
Bonthe, two situated on piers running out over the
water; the other is a dry earth closet situated close
to the District Commissioner’s office, a very bad
situation, and far too close to public and private
buildings.
DISPENSARY DISTRICTS IN THE
PENINSULA.
REGENT, WATERLOO, Hastings, York, Tomeo,
Mano, SALIJA, BANANAS ISLANDS.
The prevailing diseases treated at the above-
mentioned dispensaries were: Chest affections,
chiefly bronchitis; dyspepsia; intestinal worms;
intermittent fever of a mild type; rheumatism,
chiefly muscular; venereal diseases; uleers; a few
cases of yaws.
Vaccination was carried on fairly regularly by
the dispensers with varying success.
Sanitation also received attention from the dis-
pensers, who take every opportunity to bring to the
notice of the people insanitary conditions in their
villages and compounds.
a ————
p
There has been a large increase in the total
number of patients treated by the Medical Depart-
ment during the year, the total number of cases
treated being 87,094.
Of those treated 22,441 consisted of officials, &c.,
who are entitled to free medical attendance, and
paying patients; and 604,053 were paupers and
received free treatment and medicine. The actual
Jan. 15, 1914.) COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS. 15
amount expended for medicines, &c., was £1,278
12s. ld. The amount received from paying out-
patients was £65 2s. 1ld. It is well known that
a large number of people attend the Government
dispensaries and hospitals as pauper patients who
could very well afford to pay for attendance and
medicine, but it is, as in England, a difficult matter
to prevent this abuse.
Colonial Medical Reports.—No. 28.—Leeward Islands.
MEDICAL REPORT FOR THE YEAR 1910.
By FREDERICK L. NORRIS, M.B., C.M.
Chief Government Medical Officer.
VITAL STATISTICS.
THE estimated population on December 31, 1910,
was 386,160. No accurate account has been kept
of the amount of immigration and emigration in past
years. This will be remedied in the report for next
year, as a Census of the population was taken on
April 2 last, and arrangements have now been made
for the keeping of an accurate record of the number
of departures from and arrivals in the Presidency.
There were 1,184 births, being an estimated rate
of 33:19 per 1,000, against 32:55 in 1909.
There were 982 deaths, an estimate of 27°53 per
1,000, as against 27:38 per 1,000 in 1909.
The deaths of children under 1 year were 248,
or 25 per cent.; this is, of course, exclusive of
stillbirths, and I am of opinion that the vital
statistics are really more favourable than they
appear, as the population is probably over-
estimated.
METEOROLOGICAL CONDITION OF THE SEASONS.
The general rainfall for 1910 was 84°77 in., being
10:2 in. below the average for the past thirty-seven
years.
The greatest rainfall was in the third and fourth
quarters of the year.
First quarter 7°22 in
Second ,, 5:28 ,,
Third sty 13°77 ,,
Fourth ,, 12-19 ,,
The highest temperature prevailed in the fourth
quarter of the year, and the lowest in the first
quarter,
The wind travelled at its greatest velocity during
the second quarter of the year.
RELATIVE MORTALITY.
First Quarter:
Malaria Phe 7
Zymotic diseases ... sèi uno
Tuberculosis Fe ei ger SET
Diseases of the respiration other
than tubercular ... es .. 80
Second Quarter:
Malaria lé iM 2 . 8
Zymotie diseases ... ‘a NES
Tuberculosis «as -— nk
Diseases of the respiration other
than tubercular ... iis s. 28
Third Quarter:
Malaria T A NEC
Zymotie diseases ... ngs Ae 3X
Tuberculosis 5 - .. 15
Diseases of the respiration other
than tubercular ... fos s
Fourth Quarter:
Malaria T $e s e 4
Zymotie diseases |... sof e) |
Tuberculosis she "m. .. 20
Diseases of the respiration other
than tubereular ... A ec OL
Total:
Malaria sae e des .. 16
Zymotie diseases... X Aa
Tuberculosis PA $e. .. 63
Diseases of the respiration other
than tubercular ... 130
VACCINATION.
Seven hundred and ninety-six successful vaccina-
tions were performed, which is a decrease from last
year. Probably it is due to children having been so
thoroughly vaccinated the year before.
The number compares favourably with the
number of births.
MALARIA.
There is a marked decrease in the number of
deaths from this disease. "There have been only
16 deaths for the year. Last year there were 46.
This is a very satisfactory state of affairs. In
my opinion, I believe that it is largely due to more
attention being paid to the clearing up of bush and
the cleaning out of streams and ponds and keeping
16 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Jan. 15, 1914.
down of mosquitoes, which are much fewer this
year.
The yards in the city were carefully inspected,
and cart-loads of receptacle and rubbish cleared out.
YAWS.
Compulsory notification of yaws was introduced
towards the end of the year, therefore no definite
return ean be made of this disease just yet.
There has been no outbreak of any serious in-
fectious disease during the year. Influenza has
been present at times during the year.
I attach meteorological summary and mortality
report.
TABLE SHOWING THE NUMBER OF DEATHS FROM EACH
CAUSE DURING THE YEAR 1910.
(a) General Diseases :
Zymotie (epidemic, endemic, or
contagious) or eruptive fevers... 14
Malarial fever si ies s. 16
Yellow fever a wise mem
Animal parasites, including filari-
asis, ankylostomiasis, and in-
testinal worms 36
(b) Sporadic Diseases :
Cancer and other malignant dis-
eases sine Pes atts seer l4
Tubercular disease ae .. 608
Syphilis S Tv ae .. 18
Yaws ds T ade is —
Leprosy m. oe si se 8
Diseases of the brain, spinal
marrow, nerves, and senses
other than tubercular ... aw «Bl
Diseases of the heart and blood-
vessels... sz s .. 89
Diseases of the lungs and other
organs of respiration other than
tubercular T "T ... 118
Diseases of the stomach, liver,
and other organs of digestion ... 172
(b) Sporadic Diseases :—(continued.)
Diseases of the kidneys jus
Other diseases of the urinary
organs... - s Qs
Diseases of the womb, &c.
Childbirth ; AG ET
Rheumatism, diseases of the
bones, joints, &c. bg T
Diseases of the skin, cellular
tissues, &c.
Malformations
Premature birth
Atrophy
Senile decay
Sudden „èz 3:5 Ke
Violence, privation, poison, in-
temperance, &e. ...
Stillborn we a 22s
Diseases of uncertain seat,
dropsy, marasmus, &c.
25
47
Total of deaths for the year
METEOROLOGICAL SUMMARY, 1910.
. 982
Thermometer Dew Point Wind. Aver-
Month Marx. Min. 9am. age per hour Panel
January .. 8299 .. 66°... 644 .. 67 .. 944
February — ... 88 ... 66 63:7 11-0 1:93
March ... .. 86 66 64:3 6:7 2:55
April 84 68 64:9 T:8 9:79
May 84 70 66:2 9-1 1:22
June 87 71 68:0 10:6 1:34
July... Ain B seca LO 69-0 11:9 373
August... ne (BT 355-69 70:8 9:6 3:86
September ... 86 ... 70 70:3 47 6:18
October... ins MOL aus. Vi 70:6 8:4 3:43
November ss 895. 7 70; TO E 2:9 4:32
December we B0. os 08 68:7 5:9 4:40
Highest maximum temperature, 89° on November 2.
Lowest minimum temperature, 66? on January 11 and
19, and February 4.
Highest barometer, 30:187 on February 17.
Lowest barometer, 29:820 on October 21.
Greatest rainfall in 24 hours, 2:04 on November 2.
Greatest number of miles run by wind in 24 hours, 375 on
July 5 and 8,
Earthquakes record, 4—on June 21, October 16 and 29, and
December 24.
Feb. 2, 1914.]
COLONIAL MEDICAL REPORTS.—FIJI. 17
Colonial Medical Reports.
No. 29.—Fiji.
MEDICAL REPORT FOR THE YEAR 1910.
By G W. A. LYNCH.
Chief Medical Officer.
VITAL STATISTICS.
Tue estimated population of the Colony at the
end of 1910 amounted to 185,391, as follows :—
Totals at last
Decennial Census
Race (1901)
Europeans and other whites ... 8,402 .. 2,459
Aboriginal Fijians : . 87,460 ... 94,397
East Indian immigrants (in-
cluding their children born in
Fiji)... js is 39,987 . 17,105
Melanesian immigrants 2,900 1,950
Natives of Rotuma Er iex = =
Half-castes and other degrees... 1,850 1,516
All others ae m Sis 492 .. 467
Total 135,391 120,124
These figures show an inerease of the total
population during the year of 1,560.
There is a small inerease of 70 reported from
the Registrar-General's figures among the Fijians.
The large increase among Indians is due for the
most part to immigration. The actual figures are:
Europeans (increase), 9; Fijians (increase), 70; East
Indians, including their children born in Fiji (in-
crease), 3,881; Melanesian inimigrants (decrease),
104; mixed and miscellaneous (decrease), 99.
The total number of births were less than those
of the previous year, even excluding the Rotuma
figures; there were decreases in European, Fijian,
Melanesian, and half-caste births, the only in-
creases being among Indians and '' others.”
The marriage rate was higher by 117.
The deaths registered were higher in every case.
The total birth-rate (omitting Rotuma) in the
population for the year of all races was 87°12 per
mille; in 1909 the rate was 38:19 per mille.
The European birth-rate was 26°16 per 1,000;
Fijian, 88:61 per 1,000; Indian, 87:28 per 1,000.
The death-rate (omitting Rotuma) was 85:44 for
all races. The rate for Europeans was 19:10 per
1,000; Indians, 25:91; Fijians, 41:24.
The excessive death-rate among Fijians is to be
accounted for by the general epidemic of dysentery,
whieh had specially bad results among native
Fijians.
DISEASES,
Dysentery.—The chief disease for the year was
dysentery, which, after the hurricane in March,
spread almost throughout the whole group, and was
specially virulent among the natives in certain parts
of Vitilevu. The disease also prevailed to an acute
extent in the Suva district—it was again marked
in the gaol, but was prevalent all over the Suva
district, and was also very extensive in the Rewa
district.
At the Colonial Hospital there were 861 admis-
sions and 17 deaths; at the provincial hospitals
there were 347 admissions, with 54 deaths; at the
plantation hospitals there were 1,176 admissions,
with 84 deaths.
The returns from native medical practitioners
are incomplete; moreover, they are not an accurate
indication of the disease in the provinces, since so
many sick people refuse to see them on their visits.
The figures available, however, show that there was
a very large and very general outbreak, which
became very much more marked after the hurricane,
and in consequence of the hardships entailed by its
destruction of houses and by the very prolonged
wet season.
The admissions to the Colonial Hospital by
months were: January, 69; February, 88; March,
16; April, 81; May, 49; June, 40; July, 36; August,
18; September, 17; October, 12; November, 13;
December, 26; showing a fall from January to
March, a rise after the results of the March hurri-
cane were felt, then a gradual marked fall in the
cooler months of the year, with again an inclination
to a rapid rise with the approach of the hot weather. :
The type of the disease has been in some cases
severe, and the majority of cases have been
bacillary in origin.
In regard to dysentery, much investigation work
was carried on by Dr. Philip Bahr, who was sent
out to Fiji on a special mission to investigate the:
origin and cause of the disease in Fiji. Dr. Bahr
was temporarily attached to the Colonial Hospital
as Hon. Pathologist, and carried on his investigation
there on all eases of dysentery admitted, working
in his private laboratory.
Enteric Fever.—Enteric fever again prevailed in
some parts of the Colony, notably in seattered and
far separate parts of the Rewa district; but there
was no great outbreak as there was in this district
in the year before.
There were only seven admissions to the Colonial
Hospital—two Europeans brought from out-
stations, and five Indians in one family brought
from a suburb in Suva; from these latter no spread
was reported—the cases were reported and admitted
to hospital early.
Tuberculosis.—One hundred and twenty cases of
all forms of tuberculosis were admitted to the
Colonial Hospital during the year with a mortality
of 34 cases.
The admissions to the provincial and plantation
18 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 2, 1914.
hospitals for this disease also continue to be numer-
ous, in spite of cireulars and warnings frequently
issued by medical officers and native medical prac-
titioners.
Influenza.—This disease continues to prevail in a
mild form; it appears throughout the Colony and
attacks all races, except in Rotuma. The after
effects are not usually severe; in that island, how-
ever, the death returns are considerable from the
sequele.
Dengue Fever.—Dengue fever still prevails, and
occurs in limited outbreaks, generally in a very mild
type. Forty-two cases were treated at the Colonial
Hospital, of whom 27 were Europeans.
One hundred and eighty-three cases were also
treated in the plantation hospitals. A fair number
of cases, however, were so mild as not to require
treatment, or at any rate not to require hospital
treatment, causing merely two or three days’ incon-
venience.
Tinea Imbricata.—This skin disease continues to
be largely treated in the provincial hospitals and by
native medical practitioners, and very good results
are reported on all sides from the persistent use of
sulphur fumigation, more especially in old standing
cases. This is satisfactory, for it is a far less expen-
sive method of treatment than that by chrysarobin
or the expensive iodine.
Frambesia.—Frambeesia in young children, espe-
cially in the more distant and less frequented parts
of the Colony, continues to be responsible for much
sickness amongst children, and consequent mor-
tality. As natives slowly become more enlightened
they bring their children with more confidence for
treatment; but the process of their education is
discouragingly slow, and meanwhile an increasing
number of Indians become affected.
Leprosy.—The station on the island of Makogai
made some progress during the year, but there
were many delays in the work and many disappoint-
mini in the progress of clearing and cultivating the
and.
There was no material change in the conditions
of the lepers at Beqa—the numbers there remain
about the same as last year.
Ankylostomiasis.—The records of this disease
rather tend to show that it is increasing. Seventy
cases were treated at the Colonial Hospital, while
at the plantation hospitals 404 cases were treated.
VACCINATION.
Vaccination was carried out as usual all through
the Colony.
GOVERNMENT PHARMACY.
The work at this Government Department steadily
increases with the increasing number of medical
stations and native medical practitioners’ stations.
Two natives have been assigned as apprentices, who
assist in packing and sorting of drugs.
BACTERIOLOGICAL LABORATORY.
A new bacteriological laboratory was at the end
of 1910 nearing completion,
COLONIAL HOSPITAL.
The admissions to the Colonial Hospital were
1,973. European admissions increased from 194 to
202.
There were no additions made to the buildings.
It is hoped that the question of a new European
block may have early consideration.
NunsiNG STAFF, COLONIAL HOSPITAL.
The insufficiency of the nursing staff continues,
and it was, in spite of much effort, short through-
out the year.
The shortage is due to two causes: (1) That
nurses leave the hospital as soon as they are
qualifed in nearly all cases, attracted by the higher
remuneration obtainable by nurses in the Austra-
lian Colonies; (2) the difficulty in procuring candi-
dates to fill vacancies as probationers. During the
year two retired from the hospital and two new
probationers were taken on.
The training of native women in obstetrics and
the care and nursing of children continues. Twelve
trained native nurses were qualified and passed out
to districts. In all, 18 native nurses have now
qualified and been sent to districts. Two hundred
and ninety-nine cases have been attended by them
in the provinces, which vary much in their appre-
ciation of the nurses’ services.
NATIVE MEDICAL PRACTITIONERS.
In 1910 seven students were examined and six
passed and were sent to new districts; of these,
three began work in January, 1911. The total
number of native medical practitioners now
employed is 36. The class of students remained
20. The new quarters were built and occupied, and
are suitable for their needs.
Levuka HosPiTAL.
This hospital, with the exception of a few minor
matters, was finished and occupied towards the end
of the year. The hospital consists of two blocks,
one for Europeans, with offices and operating room,
the other for natives. It is under the district
medical officer of Levuka, with a native medical
practitioner as dispenser, and a European nurse and
native nurse in charge.
GAOL AND GAOL INFIRMARY.
The building of the new gaol and gaol infirmary
was deferred to 1911; the patients from the gaol,
therefore, continue to be treated at the Colonial
Hospital for the present.
New Mepicat District.
A new medical district is to be established in 1911
in Vanualevu, with quarters in the Savusavu
district.
RETURN OF DEATHS DURING THE YEAR AT THE
COLONIAL HOSPITAL.
Alcoholism, 1; ankylostomiasis, 7; acute yellow
Feb. 2, 1914.]
COLONIAL MEDICAL REPORTS.—CEYLON. 19
atrophy, 1; bronchitis, 2; broncho-pneumonia, 6;
carcinoma of pancreas, 2; carcinoma, 1; cerebral
hemorrhage, 2; cerebro-spinal meningitis, 2; cardiac
disease, 2; cirrhosis of liver, 1; congenital syphilis,
1; debility, 3; diarrhea, 2; diabetes, 1; dysentery,
16; empyema, 1; enteric fever, 1; epilepsy, 1;
ethelioma, 1; filaria sanguinis hominis, 2; filaria
adenites, 1; filariasis, 1; fractured skull, 1; general
tuberculosis, 8; hemopericardium, 1; inanition, 2;
nephritis, 1; pericarditis, 1; pernicious anemia, 1;
pneumonia, 1; premature birth, 2; pulmonary
tuberculosis, 17; pyemia, 1; pulmonary embolism,
1; sarcoma of ilium, 1; septicemia, 3; syphilis, 1;
tetanus, 2; tuberculous meningitis, 1; tuberculous
peritonitis, 2; tuberculosis of spine, 1; tuberculous
enteritis, 1: total, 107.
Colonial Medical Reports.—No. 30.—Ceylon.
MEDICAL REPORT FOR THE YEAR 1910-11.
By Sir ALLAN PERRY, M.D., D.P.H.
Principal Civil Medical Officer and Inspector-General of Hospitals.
SECTION I.—Po»uraTION: BIRTH AND DEATH RATES.
THE population enumerated at the last Census
(March, 1911) was 4,105,535, and consisted of 7,625
Europeans, 26,857 Burghers, 2,714,616 Singalese,
1,059,354 Tamils, 266,454 Moors, 13,089 Malays,
and 17,540 others, exclusive of the Military and
Shipping; compared with the population at the
Census of 1901, there was an increase of 15°1 per
cent. in the decade. The natural increase by
excess of births over deaths from the date of the
last Census to June 30, 1911, amounted to 10,636,
while the number of Indian immigrants exceeded
the number of emigrants by 8,169. The population,
estimated as on July 1, 1911, was accordingly
4,124,840, an increase of 127,676 persons, or 3:19
per cent., on the population at the end of 1909
estimated on the basis of the previous Census.
Section Il.—Pusiic HEALTH.
Vital Statistics.
I regret that the returns of deaths under their
respective diseases are not available yet for the
period covered by this Report; but for the purpose
of estimating the condition of the public health from
the birth and death returns kindly furnished to me
by the Registrar-General, it may be stated that the
births registered during the eighteen months num-
bered 241,488, and were in the proportion of 39°6
per-1,000 of the population per annum estimated
to the middle of the period. The deaths registered
during the eighteen months numbered 171,194, and
were equal to a rate of 28°0 per 1,000 of the popu-
lation per annum. Compared with the year 1909,
the birth-rate for the eighteen months 1910-11
shows an increase of 2°9 per 1,000, and the death-
rate a decrease of 2:3 per 1,000; compared with the
average rates for the twelve years 1898-1909, the
birth-rate for the eighteen months shows an inerease
of 1:8, and the death-rate a decrease of *5 per 1,000.
I submit herewith the number of deaths regis-
tered under their respective diseases for the year
1910 with those for the year 1909 for comparison :—
1910 1909
Cerebro, including spinal fever ..
Sanpla continued fever .. m |
nteric fever En :
Influenza .. èi ; 21,906 23,908
Remittent fever a's |
Ague si
Diarrhea .. x:
Dysentery .. $s
Dyspepsia .. sé
Enteritis X ..r 18,730 22,932
Obstruction of bowel P
Hernia T
Appendicitis T
Laryngitis .. js
pup så i4 |
ronchitis .. PE
Asthma Ug 6,810 9,453
Pneumonia.. se
Pleurisy, &c. ave
Phthisis a} F ae 3,917 4,195
Diseases of nervous system 18,9597 .. 14,477
Tetanus .. Ys E T 646 .. 488
Circulatory system SA qs 618 .. 755
Anchylostomiasis .. vs 3s 1,592 .. 1,486
Diabetes mellitus.. ss is 139 .. 182
Cancer sa T is i 9264 .. 158
Parangi (yaws) .. on S 114 .. 94
Leprosy .. T . $s 64 .. 78
Hydrophobia ss as Fs 20 .. 30
Cholera... Js Ss nt 22 .. 8
Suicide 22 ar M $5 291 .. 204
Snakebite .. d a8 are 185 .. 189
Of the above sixteen groups of diseases, it is
satisfactory to note that nine groups show a fewer
number of deaths in 1910 than in 1909. In the
seven groups showing a larger number of deaths
are tetanus, anchylostomiasis, cancer, parangi,
hydrophobia, cholera and suicide.
Deaths due to Preventible Diseases.—In 1910 the
total number of deaths registered was 110,195, as
against 122,970 in 1909; of the former number,
14,559 were deaths due to what one may call
preventible diseases, and include such as enteric
fever, phthisis, anchylostomiasis, puerperal fever,
malaria, cholera, hydrophobia, &e. Under this
[Feb. 2, 1914.
90 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
heading, in my 1909 Report I stated that there was
no control over such preventible diseases as,
among others, tubereulosis, anchylostomiasis, and
hydrophobia. It is gratifying to be able to state
that a Bill for the control of anchylostomiasis is
now being considered; that a muzzling regulation
for dogs has been introduced into municipalities
and most local board towns; and it is hoped that
some legislation will be framed to render (a) the
notifieation of phthisis compulsory, and (b) the
highly dangerous carriers of that disease innocuous
to the public.
Infantile Mortality.—The infant mortality in the
thirty-one principal towns for 1910 was equal to a
rate of 241°7 per 1,000 births, as against 257'7 in
1909.
The Health on Estates.—The mean birth-rate on
estates for the four quarters of 1910 was 33:9 per
1,000, and the death-rate 35:9 per 1,000, compared
with 36:6 and 39:6 respectively for 1909. The
principal causes of death in 1910 were diarrhea
2,788, dysentery 2,376, debility 2,108, pneumonia
1,335, anchylostomiasis 1,178, infantile convulsions
947, fevers 489, and phthisis 187. Out of these
eight groups, the numbers were lower in six and
higher in two; the phthisis rate was practically
equal, viz., 188 in 1909 and 187 in 1910. The
estate population was 420,340, based on the Census
figures of 1901.
Principal Diseases.
Malaria.—The total number of persons treated for
this disease in hospitals and dispensaries during the
eighteen months was 877,841, an increase of 72,371
in proportion to the number treated in 1909, which
may be accounted for by the occurrence of an
unusually severe outbreak in parts of the Western,
Sabaragamuwa, and Central Provinces after the
break of the south-west monsoon of 1911 followed
a prolonged drought. In hospitals alone 15,493
cases were treated, of whom 664 died. During the
period under review the Western Province had the
greatest number of cases, next the North-Western,
and then the Southern Province. The number of
admissions into gaols for this disease was 1,218, with
15 deaths. 140,592 ounces of quinine were issued
from the Civil Medical Stores at a cost of Rs. 93,188.
The amount of quinine expended during the
eighteen months in comparison with 1909 was
double. The special yearly report on malaria for
1910 was submitted under cover of my letter No.
936 of June 20, 1911, and for convenience I attach
a copy :—
‘The work in connection with the prevention of
mosquito-borne diseases in Ceylon during the year
1910 was on the lines followed in previous years,
viz., general improvement in the sanitation of
towns, the education of the public by lectures and
pamphlets, and the free distribution of quinine.
Malaria is the most frequent form in which a mos-
quito-borne disease is shown here; the other forms
are absent, or so rare that they may be disregarded.
The deaths from all fevers was ‘52 per cent. of the
population. The deaths from malaria alone in
hospitals was 8:4 per cent. of the admissions for
that disease.
““ As in the former years, no organized campaign
against malaria in any particular town or district has
been attempted, but a beginning in this direction
has been made by His Excellency the Governor,
who in May, 1910, nominated a Committee com-
posed of the Hon. T. B. L. Moonemalle, Dr. A. J.
Chalmers, and Dr. H. M. Fernando to submit a
scheme for the prevention of malaria at Kurunegala,
in the North-Western Province. This town has a
population of 8,000 persons, and covers an area of
four square miles.
'" On August 1, 1911, Government approved of
Dr. S. T. Gunasekara as Superintendent in charge
of the anti-malarial scheme at this town; he
assumed duties on September 5.
“ The spleen census for the six months, January
1 to June 30, 1911, was obtained from a more care-
fully selected portion of the community, viz., male
children attending schools, as against all children
and young adults attending hospitals, dispensaries,
and schools, which was the former practice :—
“For all provinces for the latter half of 1910
(north-east monsoon) :—
Number examined 179,837
Total enlargment 34,935
Spleen rate T ze 19:43
Average spleen .. es os 171
" For five provinces for the first half of 1911
(south-west monsoon) : —
Number examined 84,226
Total enlargement 12,728
Spleen rate 15-11
Average spleen .. 1°56
'''The result of these inquiries shows a smaller
spleen rate and average spleen than that in 1909,
which was:—
Number examined 317,694
Total enlargement ` 66,141
Spleen rate 20°81
Average spleen .. 1:75."
Cholera.—The total number of cases of this
disease treated during the eighteen months was 410,
with 266 deaths. The larger number of these
cases was in connection with a serious epidemic
which occurred within the last three months of the
period at the quarantine coolie camp at Ragama,
where there were 327 cases, with 214 deaths: other
small outbreaks occurred in the Western, Central,
North-Western, Uva, and Sabaragamuwa Provinces.
In nearly every instance the original source of
infection could be traced to South India.
The Outbreak at Ragama.—On May 3, 1911, a
ease of cholera occurred in a coolie who had arrived
on April 29 from an infected area in India; on May
5, 4 other cases occurred, 2 from contacts of the
first case and 2 from among the arrivals of May 1
and 2; on May 6,9 cases occurred among the arrivals
of April 30 and May 3 and 5; there were then about
9,000 coolies in the camp, but further arrivals con-
tinued to be received up to May 9. The disease
spread rapidly throughout the various camps, and
Feb. 2, 1914.]
COLONIAL MEDICAL REPORTS.—CEYLON. 21
after a small stampede, in which the coolies in the
various camps became mixed, there was no
possibility of keeping the divisions separate, and it
was recognized that the whole number had to be
considered as ''infected." The rapid spread of
the epidemic was accounted for as due to three
possible agencies—water, food and flies. The water
tanks were not fly-proof, the food was cooked on the
ground, and there was a plague of flies.
The tanks were disinfected and made fly-proof;
subsequent bacteriological examination proved that
the wells and tanks were free from the cholera
vibrios. It is probable, therefore, that the vehicle
of dissemination was food or flies, or both. The
food was cooked on the ground, and the ground was
seriously contaminated with deposits of human
excreta, much of which was cholera-infected, and,
as I have remarked above, there was a plague of
flies.
There were 327 coolies attacked, of whom 214
died. All the dead were cremated.
The health of the coolies rapidly improved when
the new camp on another site was ready for their
reception: the first batch of removals was made
on May 24; after that date only 20 cases occurred
in the new camp.
The last batch of healthy coolies left Ragama for
their estates on June 19.
Before and during the epidemic an unprecedented
drought occurred; the camp wells ran dry, and
water had to be brought from Colombo, eight miles
by railway. This shortage of water and an insuffi-
ciency of latrine and scavenging coolies favoured
the spread of the epidemic.
I have great pleasure in placing on record the
magnificent work performed by the medical officers,
apothecaries, sanitary inspectors, two religious
sisters, and the attendants and coolies who were
employed by this Department throughout this
serious epidemic. No words can convey their
devotion, unselfishness, and nobleness of conduct.
To their efforts is due the wonderful result achieved
—the epidemic was controlled in a little over three
weeks, and considering that at one time it was
estimated that there were 4,000 coolies in the
camp, that they were panic-stricken, that the water
supply for a large part of the period was insufficient,
that the sanitary force was totally inadequate and
could not be strengthened, it is marvellous that
only 327 coolies were attacked, and that the death-
rate among them was only 65:4 per cent.
Cholera at Ratnapura.—The history of cholera
during the eighteen months from January 1, 1910,
to June 30, 1911, would not be complete without
mentioning an outbreak that occurred at Ratnapura.
A coolie arrived on Nivitigala estate on June 18 from
Tataparai in India; he was attacked with the
disease on the 19th idem. A second case occurred
in a coolie who arrived on the 22nd idem. Seven
eases developed subsequently among old resident
coolies on this estate. Owing to the drought the
inhabitants of Ratnapura were forced to use water
from the river, which was badly smelling, and
which it is assumed was polluted from the washings
of the above-mentioned estate, as there was some
rain during the latter part of June. The first case
in the town was on July 2: 7 cases were reported,
with 6 deaths. On July 9 a coolie was attacked on
Rambukkande estate; he arrived from India on
June 23. There were cases that developed in the
gaol, in the hospital, and in villages as far as eight
miles away. The total number of those attacked
was 49, of whom 31 died. The last case was on
August 11.
Small-poz.—There were 356 cases treated, with
62 deaths, during the eighteen months’ period,
which figures are in nearly the same proportion to
those published for the year 1909. Every Province
(except the North-Central) returned cases; the
Western and Central Provinces were seriously
affected, with 154 and 159 respectively; Kandy
and its surrounding villages suffered most. The
original source of infection in many cases was traced
to Southern India, but in all probability some cases
were connected with the 1909 outbreak. Out of the
154 cases in the Western Province, 105 were treated
at the Infectious Diseases Hospital, Colombo. The
total number of deaths in which previous vaccin-
ation was absent was 37. The epidemic at Kandy
lasted from March 2, 1911, to the end of October
last.
Enteric Fever.—816 cases were treated in 40 out
of the 75 hospitals of the Island; 69 per cent. of
the total cases were in Government hospitals in
Colombo (not including the Jail and Municipal
hospitals). There were 171 deaths, a mortality-
rate of 20°9 per cent. The death-rate in Colombo
hospitals was 17°5 nearly; there were 40 cases
treated in the Kandy hospital, with 14 deaths; 18
cases, with 2 deaths, at Galle; 17 cases and 4
deaths at Kalmunai; 13 cases and 1 death at
Dikoya; 17 cases, with 5 deaths, at Nawalapitiya.
In the 18 hospitals attached to gaols there were 18
cases, with 6 deaths. The Medical Officer of
Health for the suburbs of Colombo reports that the
notification of cases of enteric fever is very satis-
factorily carried out in the villages; notwithstanding,
264 cases were reported to him from between
January 1, 1910, and June 30, 1911, and every one
was seen by him. Pamphlets were left in all the
infected houses with directions as to the precautions
to be taken to prevent the spread of the disease.
Disinfection of premises was carried out and free
disinfectants issued to the poor. It is ominous
that the village most affected was Kirillapone, which
immediately adjoins Narahenpitiya (the Colombo
night soil depót), and that the fly pest was so great
at Kirillapone and Wellawatta that ‘‘ bakers could
not knead their dough in the daytime, and had
to do it after nightfall.”
Dysentery.—This disease is rife in all parts of
Ceylon. 3,710 cases were treated in the various
Government hospitals, with 1,094 deaths. It is
very common in the planting districts and in
Colombo. In the former the water supplies are, as
a rule, indifferent as to quality and liable to pollu-
tion ; in Colombo this same cause is found with those
who use shallow, unprotected wells. But Colombo
22 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 2, 1914.
contains a large number of vagrants, who, as a
class, easily contract this disease. 20°53 of the
total treated were in Colombo hospitals.
There were 18 cases, with 6 deaths, in gaol
hospitals. Most of these cases occurred at the
Mahara and Mutwal gaols.
Dysentery and diarrhea are the commonest
diseases in our gaols. 4,944 admissions were
recorded in gaol hospitals for the eighteen months’
period, with 196 deaths (8:96 per cent. mortality).
In the Colombo gaol hospital alone 1,347 cases were
treated, with 69 deaths (5:1 mortality).
Leprosy.—628 cases of leprosy were treated in
the Government medical institutions during the
period under review, with a mortality of 63. The
present accommodation for lepers is quite inad-
equate.
The question of a leper colony in the Eastern
Province is still under consideration. There are
many lepers at large, who are a source of danger
to the pubic. Until they can be all isolated in a
proper institution it will be impossible to stamp out
this disease. At Hendala Asylum I strongly
recommend that religious sisters should be
employed as nurses.
Anchylostomiasis.—It is gratifying to record that
this disease has received consideration since the
publication of my last Administration Report; as
a result of the Report of a Committee appointed in
1910 to consider this question, the attention of
planters and others has been directed to it, and a
draft enactment is now under consideration. The
recommendations of the Committee above men-
tioned are :—
(1) That all superintendents of estates should
treat new arrivals with beta-naphthol, followed by
tonics.
(2) Where it is known that anchylostomiasis
already prevails on estates, superintendents should
treat the whole labour force in convenient batches
in a similar manner.
(3) The drugs required for the treatment should
be issued at cost price from the Civil Medical
Stores; where estates have dispensaries, we
recommend that the drugs required for beta-
naphthol treatment may be used for Singalese as
well as Tamil labourers.
(4) Medical officers in charge of districts should
report to the Principal Civil Medical Officer, through
their immediate superiors, the prevalence of
anchylostomiasis in a severe form on any estate.
In such cases the Principal Civil Medical Officer
should be empowered to send an officer to inspect,
report, and make recommendations for combating
the disease. If the Principal Civil Medical Officer
approve these recommendations, they should be
communicated to the superintendent with a view
to their adoption. Where these recommendations
have not been carried out, Government shall be
empowered to enforce the Principal Civil Medical
Officer’s recommendations at the expense of the
estate.
(5) With regard to the question of the improve-
ment of sanitation on estates, we recommend that
every set of lines and its immediate surroundings
should be cleaned and swept once every day. All
sweepings should be burnt or buried. At least 12
feet clear of all vegetation must be maintained
round the lines. Stone, brick rendered in cement, or
cement concrete drains should be constructed to
carry off rain from the roofs and from the immediate
vicinity of the lines. The immediate vicinity of the
lines should be on a lower level than the floor of the
lines and slope downwards from them, with the
object of keeping the ground surrounding the lines
as dry as possible, as the hook-worm flourishes
in damp earth. All excreta deposited within 50
feet of the lines should be removed daily and buried
by the sweeper.
(6) At all bathing-places, whether at spouts,
wells, or riverside, there should be stone or paved
platforms with a properly constructed run-off drain
where necessary. Wells for bathing and wells for
drinking water should be kept separate.
(7) To prevent contamination of the water supply
for drinking purposes, closed iron piping is strongly
recommended. Wells should be lined with brick
pointed with cement and have parapet walls, and
a surrounding platform 4 feet wide of stone paving,
cement concrete, or brick cement rendered, and a
surrounding drain to conduct the waste water away.
Wells for domestic and drinking purposes should be
covered and provided with a pump.
(8) We would urge on all employers of labour the
desirability of establishing latrines, especially for
bungalow coolies, factory coolies, school children,
and Public Works Department lines.
(9) The agents, visiting agents, and managers
of estates should be requested to do all in their
power to give effect to the above recommenda-
tions.
I would here repeat the figures showing the
deaths from this disease. The Registrar-General
gives the total deaths from anchylostomiasis for the
whole island for 1910 as 1,592, of which 1,173 were
deaths on estates; this leaves only 419 deaths from
this disease for the rest of Ceylon’s population,
which is significant, and points to the necessity of
taking active measures to prevent insanitary con-
ditions on those estates that favour the propagation
of this disease.
Many planters have improved the conditions
under which their labour force live, and have
carried out sanitary improvements and medical
treatment without waiting to be made to do so by
law, with excellent results as to improved health
among the labourers and a more efficient force.
Diphtheria.—This disease is becoming more fre-
quent, or its symptoms are more easily recognized
by medical men. In the General Hospital and the
Infectious Diseases Hospital, Colombo, there were
12 cases treated, with 1 death.
Chicken-pox.—8,151 cases of this mild affection
were treated, with only 2 deaths.
Parangi or Yaws.—4,777 cases of this disease
were treated at the various medical institutions
during the eighteen months ended June 80, 1911.
This number is less in proportion than the figure
Feb. 2, 1914.]
COLONIAL MEDICAL REPORTS.—CEYLON. 23
8,485 given for the year 1909; the deaths for that
year numbered 18, and for the eighteen months’
period 40. As one of the results of the Durbar
held at Kandy in July, 1910, the question of com-
pulsory treatment of parangi patients was con-
sidered by His Excellency the Governor in Execu-
tive Council, and it was decided in October, 1910,
that an experiment be made in a selected village
or group of villages in order that the improvement
which may be effected by providing a sufficient
water supply and wholesome food should be
observed. The village of Timbirigaswewa, in
Tamankaduwa, about one mile from Habarana, was
selected by the Government Agent, North-Central
Province, in February, 1911, for the proposed
experiment. The Provincial Surgeon visited this
village and submitted a report on April 19, in which
he said the village was a suitable one, but that it
was very insanitary, the houses were filthy and
ill-ventilated, water supply inadequate and pre-
carious. He recommended clearing of the village,
and brushwood to be cut down, &c.
The Principal Civil Medical Officer visited the
village on July 11, and submitted a report to
Government on 27th idem, pointing out that while
the water supply was inadequate, the sanitary con-
dition of the place had improved, the inhabitants
looked fairly well nourished. The people present
on the day of the visit numbered 60, mostly women
and children; the men were said to be away at work.
Only 3 cases of parangi among adults and 3 among
children were noticed, which small number did not
appear to justify a further continuance of the
experiment.
Since the issue of the last Administration Report
of the Medical Department of this Colony an epoch-
making discovery in chemotherapy has been given
to the world by Professor Paul Ehrlich in his pre-
paration called Salvarsan, or 606, which is a specific
for all spirochetal and spirilla infections. Parangi
as a spirochetal infection was discovered by Dr.
Aldo Castellani.
The salvarsan treatment of this disease has been
tried in many countries, with uniformly good
results; in this country Dr. Castellani has treated
a fair number of cases, and the results, after one
injection of the new drug, are nothing short of mar-
vellous. Time alone will prove if this curative
effect will be lasting. If this much-to-be-desired
result is attained, the yearly outcry for special
parangi hospitals in various parts of this colony
will cease. For the purpose of putting this remedy
to a more extended test, a medical officer with
special knowledge of the treatment has been
stationed at Anuradhapura to freat all suitable cases
that may be admitted into that hospital.
Cancer.—Under this heading 264 deaths were
registered in 1910, as against 158 in 1909. From these
figures it cannot be said definitely that the disease is
increasing in this country, because the attention of
medical practitioners has been directed to the sub-
ject through many channels, notably through the
reports published from time to time by the Cancer
Research Fund, and these reminders may have
influenced the correctness of diagnosis, which would
increase the number of deaths certified.
Turning to the records of the hospitals, it is seen
that the reports on the number of cases of cancer
(i.e., careinomata and sarcoma together) in 1910 was
the same as in 1909, namely, 121. The provincial
distribution is as follows :—
Sarcoma Carcinoma
Central Province .. — 7
Northern Province — .. 10
Western Province .. 8 73
Southern Province T ri 15
Eastern Province .. 1 6
Province of Uva . — 5
5 116
No reports were received from the three other
Provinces. Of the sarcomata, 2 were said to be
melanotie, and the remaining 8 occurred in bone.
The carcinomata were distributed through the
various parts and organs of the body, thus :—
Females Males
Cheek .. T id 98555 26:
Cervix .. as as, AQ r6
Penis Sd it
Breast
Tongue .
Uterus
Lower jaw
Upper jaw
Lower lip
Upper lip
Hard palate
Total
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Kee ED HEE DWH DOOR WO
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2| ] asi e pen ea enter ey Ex a] ol & |
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m
Ó
e
Phthisis.—In the Registrar-General's returns for
1910 3,917 are shown under the heading ‘‘ Phthisis,”’
as against 4,195 in the year 1909. During the
eighteen months’ period there were 1,652 cases
reported from the hospitals. In these reports the
notified cases registered at the Municipality are not
included.
On February 1, 1910, His Excellency the
Governor was pleased to appoint a Commission *' to
inquire into and report upon the prevalence and
alleged increase of tuberculous diseases in the
island, and upon the most effective measures for
checking the dissemination of the said disease.”’
The Commission held six meetings, the first of
which was on February 11, 1910, and the last on
June 6, 1910. A large amount of evidence was
recorded, and the report was issued on the latter
date.
A munificent donation of £10,000 had been given
tc Government by the Hon. J. N. Campbell, of
Ceylon, some months previously for the purpose of
fighting tuberculosis.
Subsequently a public fund was started, and the
publie subscriptions so far collected amount to the
sum of Rs. 150,000, which, with Mr. Campbell’s
[Feb. 2, 1914.
24 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
generous gift, makes Rs. 800,000. Mr. A. E. de Silva
has given a large piece of land near Colombo which
is suitable for a sanatorium, and it is hoped that this
institution with a tuberculosis dispensary (largely
contributed by Mr. A. J. R. de Soysa) and a hospital
for chronic cases of phthisis in Colombo will be
established at no distant date.
The education of the public in the question of tuber-
culosis and. how to prevent it-has been attempted
by means of illustrated handbills with letterpress
in the vernacular, and the Principal Civil Medical
Officer has given popular lectures on the subject,
illustrated by lantern views, at many towns between
Jaffna and Galle.
One of the most important measures taken against
this disease has been the regulation made by the
Chairman of the Colombo Municipality, namely, the
compulsory notification of cases of phthisis within
the Municipal limits.
Vaccination.—During the period under review
251,500 subjects were vaccinated, of which 209,160
were primary vaccinations and 42,840 re-vaccina-
tions. Of the former, 185,296 were successful and
9,871 unsuccessful; in 13,993 subjects the results
of the vaccination was not known.
The percentage of successful cases to the total
inspected was 95°45. For re-vaccination cases
19,585 were suecessful and 8,258 unsuccessful; in
14,497 the results were not known. The percentage
of success in the re-vaccinated was 70:84. The
number vaccinated in the eighteen months’ period
are larger actually, and relatively, to the figures of
1909. The successes are much higher in primary
vaccinations, but less good in the .re-vaccination
returns. The quality of the lymph has been greatly
improved; bacteriologieal examination at the time
of colleetion showed the number of extraneous
micro-organisms to be normal.
The buildings and equipment of the establishment
have been much improved by the addition of a new
office, operating-room and lavatory, by new stalls,
and the fly-proofing of the rooms and stables.
The calves were not always of good quality and
physique, and owing to the large amount of small-
pox in parts of the island the number necessary
could not always be obtained. This difficulty was
got over by the foresight of the officer in charge,
who had a good supply of lymph in cold storage.
515 calves were employed for the manufacture of
lymph, and 104,249 tubes of lymph were issued
from the establishment.
Precautions taken against the Introduction of
Infectious Diseases.—During the eighteen months’
period the medical staff at the port consisted of the
Port Surgeon and three assistants. The total
number of vessels calling at Colombo was 4,597
steamers and 633 Indian and native sailing vessels.
The following ports were declared infected:
Bombay, Calcutta, Rangoon, Burma, Karachi,
Tuticorin, Mangalore, Madras, Calicut, Tellicherry,
Bangkok, Batavia, Sourabaya, Samarang, Mauri-
tius, Port Said, Hong Kong, and Penang,
The number of vessels placed in strict quarantine
was: For plague, 4; small-pox, 15; cholera, 4.
1,899 vessels arrived from infected ports, and, being
“ healthy,”
“ healthy in quarantine.’
No case of plague was brought to the port, but
four steamers were placed in strict quarantine,
having suspected cases of this disease on board,
and subsequently allowed to work ‘“‘healthy in
quarantine,” as the cases were proved not to be
plague.
The prevalence of cholera and small-pox in the
south of India gave rise.to much anxiety, because
there is a large number of native passengers arriving
here daily. "Towards the end of 1910 Tuticorin, the
principal port on the Indian side, became infected,
and remained foul for many months.
The total number of estate coolies arriving at
Colombo was 152,333, and 67,574 '' miscellaneous
deck passengers '' ; of the latter, 8,863 persons were
vaccinated on arrival. The estate coolies showing
no marks of vaccination or of small-pox are vac-
cinated at the coolie camp at Ragama. The Plague
Committee held its periodical meetings.
Lunacy.—The total number of patients treated in
the Colombo asylum during the eighteen months’
period was 872 (males 542, females 330). The
number discharged was 126 (males 80, females 46).
The number of deaths was 98 (males 62, females
36). In the House of Observation 292 persons were
treated (208 males and 84 females), of whom 149
(males 95, females 54) were transferred to the
asylum and 122 (males 100, females 22) were dis-
charged. The accommodation provided at the
asylum is inadequate for the numbers treated.
were permitted to work cargo as
Section III.—METEOROLOGICAL CONDITIONS AND
THEIR RELATIONSHIP TO DISEASE.
The rainfall for the eighteen months’ period shows
four areas that were comparatively dry, viz., the
coast line from Kankesanturai to Mullaittivu in the
north, the Mannar and Puttalam Districts in the
west, the Hambantota District in the south, and a
very small patch in the south-east of the centre of
the island.
As usual, more rain fell in the central and south-
western parts of the island than elsewhere, with
three patches recording over 200 in.
In former reports the influence of the two mon-
goons on malaria has been pointed out; outbreaks of
this disease in the western half of the island occur-
ring after the first rains of the south-west monsoon,
and a like result in the eastern half after the com-
mencement of the north-east monsoon.
During the period under review severe malaria
was experienced at the end of a long drought and
after light showers, which is attributed to the preser-
vation of malarial-bearing mosquitoes through the
death of fish that feed on their larve.
Bowel diseases are more prevalent during the
reins. Respiratory diseases are common during the
chilly nights and mornings of the north-east mon-
soon.
Certain meteorological conditions further affect
unfavourably the health of the people as regards
the less quantity of food produced, and in conse-
quence the lowered vitality to resist disease.
eg —— — —r — 7
Feb. 16, 1914.]
COLONIAL MEDICAL REPORTS.—CEYLON. 25
Colonial Medical Reports.—No. 30.— Ceylon— (continued).
SECTION IV.—GENERAL SANITARY CONDITION OF THE
COLONY AND OF THE CHIEF Towns.
THE general sanitary condition of the Colony
leaves much to be desired. Major sanitary works
are very expensive, consequently improvements
under this heading proceed slowly; the tendency is
towards slow improvement, particularly in towns
having a municipality or local board and small
places that are placed under the Small Towns
Sanitary Ordinance. There are many towns with-
out a satisfactory water supply or drainage, and
conservancy, scavenging, and the proper disposal
of refuse are inadequately carried out. The drain-
age and water supplies in some of the large towns
are bad, and overcrowding exists.
Colombo.
As mentioned in last year's report, the water
supply is insufficient, but of excellent quality.
Steps have been taken to lay a larger main in
Colombo where the Labugama pipes discharge,
which it is said will remedy this shortage of distri-
bution. The laying of another main pipe from
Labugama will have to be undertaken in the near
future, not only for present needs, but because of
the recent inclusion of two large areas within
municipal limits.
The extension of the water-carriage system of
sewers has made good progress during the last
one and a half years. The area of those parts of
Colombo that discharge into the harbour has been
sewered and ready for the connections between the
houses and sewers for a year, but very few con-
nections have been made. The collection of night
soll in pails, its transfer to carts in the streets, its
conveyance through the city to a pitting ground on
the outskirts, where it is buried, is unsatisfactory
from a sanitary point of view, but it is carried out
as well as such a system ean be, and it cannot be
changed until the water-carriage system is taken
into use.
A refuse destructor is being erected by the muni-
cipality. The scavenging has been fairly well
carried out, but at times there is a good deal of
dust, and there is not enough watering of streets,
particularly where the roads do not lend themselves
to oiling or tarring.
There is a good deal of overcrowding.
A great improvement has been made by opening
a new road in Slave Island known as Short’s Road.
Another new road to run parallel with Colpetty is
under consideration, and improvements are antici-
pated in the markets. The plans for a Municipal
Inféctious Diseases Hospital are ready.
The compulsory notification of cases of consump-
tion has been proclaimed.
Enteric fever is far too prevalent; there have been
no serious outbreaks of small-pox or cholera.
Average birth- and death-rates per 1,000 of popu-
lation for 1910 were 25:5 and 30:4 respectively, as
against 25:27 and 30°77 in 1909.
The Rural Medical Officer of Health reports that
by-laws have been framed and put in force with
reference to the following: Offensive trades, eating-
houses, dairies, laundries, bakeries, butchers’ stalls,
fish stalls, the keeping of animals, and general by-
laws. The general condition of the towns and
villages outside Colombo has been much improved
since this officer and his inspectors have been
appointed. 264 cases of enteric fever were reported
to the Rural Medical Officer of Health during the
eighteen months. Every report was followed by a
visit by that officer to the infected house, and the
friends were instructed how to deal with the case
so as to reduce the spread of this disease.
There were a few cases of chicken-pox, several
cases of dysentery, and only one case of cholera.
There were 747 prosecutions for offences against the
sanitary by-laws, and 671 convictions. The total
amount of fines came to Rs. 3,031°25. The Rural
Medical Officer of Health recommends that public
markets should be erected in certain suburbs, and
that the Small Towns Ordinance be applied to
Peliyagoda and Veyangoda.
Kandy.
This town was badly affected with small-pox
during a part of the period under review. The
drainage has been improved, particularly in the
direction of Peradeniya and Katugastota, by the
provision of concrete drains. The water supply has
been improved by the inclusion of a new stream to
the catchment area. The supply has been sufficient
and of good quality. The night soil is collected in
pails and conveyed in air-tight drums to the pitting
ground. The scavenging was carried out satis-
factorily. The dairies, laundries, slaughter-house,
and eating-houses were regularly inspected. There
is a good deal of overcrowding and want of sani-
tation in the alleys, which was brought to the notice
of the authorities during the small-pox epidemic.
Galle.
This town employs a small force for carrying out
anti-malarial measures. The water supply has
been improved in quantity by the opening of the
new works at Hiyara. The town is now well sup-
plied. The water from this new source is coloured
brown, and therefore unattractive, but it is in no
way injurious, and will improve as time goes on.
Drainage was improved in the bazaars and fort, and
a new sewer put down in Pedlar Street. The
swamps on both sides of the Pattigala-ela below
Talapitiya were filled in and the ela drained. The
conservancy and scavenging have been carried out
satisfactorily. Dairies and bakeries have been
regularly inspected.
Jaffna.
It may be said that the sanitation of this town
is slowly improving. During the eighteen months’
period more public latrines have been provided;
cesspits are being filled up and closed, and the dry-
eurth conservancy extended. Private compounds
are cleaner, the dairies are inspected and registered,
and by-laws have been passed for regulating them.
b
26
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
The drainage is defective; a complete scheme for
the removal of sewage is required. It is reported
that paddy fields in the heart of the town are being
converted into sites for dwelling-houses. The
water supply is unsatisfactory, both as regards
quality and quantity. The scavenging is satis-
factorily performed. There were too many cases
of small-pox, whieh was introduced from South
India, but there was an absence of cholera, and very
few cases of enteric fever.
Batticaloa.
The sanitary condition of this town is not satis-
factory. Extensive low-lying areas of land in the
town are covered with water for months, and there
are very few masonry drains, and these are seldom
flushed. The water supply is from wells, and there-
fore '' suspicious." A scheme for a water supply
is under consideration. The scavenging is fairly
satisfactory. Conservancy is carried out by the
bucket system in a very limited area. There are
five public latrines; the excreta is buried on the
western shore of the lake. Cesspits are numerous;
the soil of private compounds and shores of the
lake are polluted by the habits of the poorer
inhabitants. There is overcrowding in the Moor
quarter of the town. Laundries, bakeries, aerated
water factories, slaughter-houses, and the public
markets are under the Local Board and satisfactory.
The milk supply is very defective. During the
period of this report there were no cases of small-pox
or cholera, and only seven cases of enteric fever.
There is a fair number of cases of tuberculosis. The
infant mortality is high.
Anuradhapura.
Some attempt was made at anti-malarial work
by the clearing of low jungle in the town and the
keeping clean of the banks of irrigation channels.
Weekly inspections were made by the Acting
Provincial Surgeon of bazaars and tenements. The
water supply is unsatisfactory. A drainage scheme
is under consideration. The hospital has been im-
proved considerably, and mosquito-proof wards for
males and females have been established. The
conservancy of night soil is partially carried out.
The seavenging has been carried out satisfactorily.
Kurunegala.
The water supply is still unsatisfactory. The new
scheme for a better supply has not been arranged
yet. Owing to a drought the present supply almost
failed. A pumping plant to obtain water from the
tank for flushing drains is being put up. Cesspits
are being filled and closed and the dry-earth system
adopted in their place. As mentioned under the
heading of '' Malaria’’ in an earlier part of this
report, this town is the first in Ceylon in which
active measures are being undertaken to combat the
periodical outbreaks of malaria. The scavenging is
satisfactorily carried out. The laundries, dairies,
publie latrines, and publie markets are inspected
regularly by the sanitary officer and are well kept.
The drainage in many parts of the town consists
of earth drains, and is therefore unsatisfactory.
There is some overcrowding in parts of the town.
$
Badulla.
Cement concrete drains are replacing gradually
the primitive type. The water supply is sufficient
in quantity and of good quality. The scavenging
is done satisfactorily, and there is a partial dry-
earth conservancy. Some overcrowding exists.
There are no dairies or laundries. The bakeries are
kept in a good sanitary condition. This year the
Provincial Surgeon, with the help of the Govern-
ment Agent, has been very energetic in trying to
reduce the outbreaks of malaria by the filling up of
hollows, drainage, and the oiling of sheets of water,
and free distribution of quinine. Like many other
towns in Ceylon, Badulla possesses a large area of
paddy fields, in which the malaria-bearing mosquito
is found. It is difficult to ‘‘ oil’’ paddy fields for
two reasons: that the paddy stalks break up the
film, and the water is running. Experiments
carried out by the Director of the Royal Botanic
Gardens at Peradeniya proved that the oil on the
surface of paddy land water disappeared in twelve
hours owing to the large amount of water used for
irrigation. Paddy land in and near towns should
be converted into dry land for some other kind of
cultivation.
Ratnapura.
The water supply is insufficient, and ran dry
during 1911. There was a serious outbreak of
cholera. The drainage is defective; a part of the
town and bazaar became water-logged. Over-
crowding is common. . Cesspits are being replaced
by the dry-earth system.: The number of public
latrines is insufficient. The markets are kept in «
satisfactory condition. The bakeries and eating-
houses are not kept well. The pollution of the
river is marked owing to galas, private houses, and
the hospital, which drain into it. Scavenging is
fairly satisfactory.
SECTION V.—GENERAL.
Medico-legal.
During the period under review the Government
Analyst completed 421 reports; 1,064 samples were
examined in connection with them. The total
number of judicial cases was 285, involving the
examination of 745 productions. There were 127
cases of suspected poisoning. 122 samples of
medicines were sent by the courts for reports.
Besides criminal productions, a hundred samples
were reported upon for various Departments of
Government.
Administrative: Hospitals, Asylums, and Dispen-
saries.
The various medical institutions have been well
maintained, and many structural improvements
have been carried out, notably fly-proofing of
kitchens and latrines and the mosquito-proofing of
wards for malarial cases and of operating rooms.
The building of a new out-patient department in
connection with the General Hospital was com-
menced in September, 1909, and is now nearly
finished. There were 73 hospitals and the lunatic
and leper asylums, 408 Government dispensaries,
and 250 estate dispensaries in working.
Feb. 16, 1914.]
COLONIAL MEDICAL REPORTS.—CEYLON. 27
The following hospitals were opened during the
eighteen months’ period: The Lady Ridgeway
Memorial for children, which contains 47 beds, and
is worked under the administration of the Lady
Havelock Hospital for children. A new Govern-
ment hospital of 50 beds was erected at Muppane.
New dispensaries were built at Nochchiyagama,
Nanu-oya, Galawela, Wattegama, and Wellawaya,
and one at Delft commenced. The new Govern-
ment hospital at Koslanda is nearing completion.
Several other new hospitals are in contemplation,
for which sites are being selected and plans
prepared.
Nursing in Ceylon Hospitals.
The nursing in Ceylon hospitals is undertaken by
fully qualified European trained nurses, by religious
sisters, and locally trained Ceylonese young women.
There are 20 European trained matrons and sisters,
36 religious sisters, 29 locally trained matrons, 36
locally trained nurses, and 35 pupils in training.
The European trained matrons and sisters are
employed mostly at the General Hospital, Colombo,
and in the Kandy hospital. The religious sisters
are employed in the native wards of the General
Hospital and at Kurunegala hospital. Two nursing
schools for the training of local pupil nurses exist
at the Lady Havelock Hospital (Miss Richardson,
matron) and at the Kandy hospital (Miss Hair,
matron). The training course is for two years, at
the end of which time certificates are given to those
who pass the examination. More nurses are
required; hitherto the inducements offered to can-
didates have not been sufficiently attractive. His
Excelleney the Governor appointed a Committee to
inquire into the nursing of Ceylon hospitals and to
report. The latter is now under the consideration
of Government. The nurses are assisted in the
wards by male and female native attendants.
Number of In-patients treated.
The total number of in-patients treated in all the
hospitals and asylums of the Island was 118,024.
The deaths were 12,840, giving a death-rate per
cent. of 10°88 of the hospital population.
Number of Out-patients treated.
At the 408 Government dispensaries 218,645 new
cases were treated, who paid 8,183,567 visits.
Surgical Operations.
Four thousand five hundred and two operations
in general surgery were performed in all the
hospitals, with 155 deaths, a death-rate of 8:22 per
cent.' Operations on the eye, not included in the
above, numbered 604 among out-patients and 509
among in-patients, total 1,118 (at the Victoria
Memorial Eye Hospital).
General Hospital, Colombo.
On December 31, 1909, there were 416 patients
left in hospital, 34 in the paying section and 882
in the pauper section. During the eighteen months
under review 20,677 cases were admitted, making
a total of 21,093 cases under treatment. Of the
20,677 new admissions, 1,180 were admitted to the
paying section and 19,497 to the pauper section.
Of the 21,093 cases under treatment, 18,604 were
discharged, 1,904 died, and 585 remained in hospital
on June 80, 1911. Of the 1,904 deaths, 89 occurred
in the paying section and 1,815 in the pauper
section. The percentage of deaths to cases treated
was 9:20 per cent. (7:3 in the paying section and
9:18 in the pauper section). The daily average
number in hospital was 471°71.
The maximum number of cases in hospital on
any one day was 560 on June 8, 1911, in the pauper
section, and 55 on August 7, 1910, in the paying
section. The minimum number of cases was 313
on April 16, 1911, in the pauper section, and 28 on
February 6, 1910, in the paying section.
During a large portion of the eighteen months’
period there were more patients than beds in the
non-paying section of this hospital. This overcrowd-
ing was seriously increased by having to accom-
modate the patients with chronic complaints from
Ragama (owing to the cholera outbreak), which was
not relieved until temporary cadjan wards were
built for them in the hospital compound. Two
thousand four hundred and fifty-two surgical oper-
ations were performed by the surgeons of the
hospital (2,126 in the pauper section and 326 in the
paying section), with a total mortality of 64, or 2:2
per cent. The percentage of deaths to total treated
in the pauper section was 9:18, and in the paying
section the percentage of deaths to total treated
was 73.
The receipts in the pauper section amounted to
Rs. 2907:45, and the expenditure (not including up-
keep of buildings, equipment, medical attendance,
nursing, drugs, and surgical appliances) was
Rs. 161,271. The receipts in the paying section
were Rs. 113,293, and the expenditure (not in-
cluding medical attendance; upkeep of buildings
nurses, drugs, and surgical material) was Rs. 72,120,
showing a credit balance of Rs. 41,178.
Houses of Observation for Suspected Lunatics.
In addition to those admitted into the houses of
observation at the Colombo Lunatic Asylum, the
numbers admitted into these institutions at Kandy,
Galle, and Jaffna were 57, 77, and 26 respectively.
De Soysa Lying-in Home.
The numbers treated in this institution go up
each year. For the eighteen months' period 1,925
were admitted, of whom 57 died (2:0 per cent.). Of
the deaths, 30 were due to accidents of childbirth ;
of the number admitted, 1,582 were before delivery,
59 after, and 384 before the commencement of
labour.
The seriousness of labour cases complicated with
anchylostomiasis is shown by the fact that 8 out of
12 cases died. The percentage of infantile mortality
was 3°78. It is gratifying to note that 51 patients
were Mohammedans.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
In addition to its useful work in rendering skilled
aid to poor females during their confinements, this
institution is doing good work in training midwives
for practice in all parts of the island. The accom-
modation for these pupils is limited, and the course
of instruction is too short, but no improvement can
be made until more ground is available for building
purposes. The popularity of the establishment is
acknowledged, but its usefulness as regards its
primary objeet and for the training of midwives has
reached its limit unless more accommodation is
provided.
The Lady Havelock Hospital for Women and the
Lady Ridgeway Block for Children.
Mrs. Fysh, M.B., was in charge of the above
institutions until September, 1910, when she went
on leave, and was subsequently invalided. She was
relieved by Miss de Boer, L.R.C.P.&$8., who
acted as Medical Officer in charge until the present
Medical Officer was appointed (Miss Anderson,
M.B.) The number of patients attending at the
outdoor dispensary (in association with the Lady
Havelock Hospital) was 88,925. During the period
under review 1,508 patients were admitted into the
Lady Havelock Hospital, with a death-rate of 6:42
per cent. The number of Mohammedans treated
was 52. There were 122 surgical operations per-
formed, with 9 deaths.
The Lady Ridgeway Block was opened in Sep-
tember, 1910, and from that date to June 30, 1911,
585 children were admitted, of whom 102 died, a
mortality of 17:48 per cent. This high death-rate
is due to the fact that parents will not bring in the
children early in the disease; often they are dying
when admitted, and frequently cases are treated
for weeks by vedaralas before seeking admission.
This institution is very popular; the number of
applicants seeking admission often exceed the
number of vacant beds.
The Victoria Memorial Eye Hospital and Grenier
Outdoor Dispensary.
At the dispensary 12,787 new cases (eye and ear)
were treated, among which were 1,201 cases of
injury. One ‘hundred and ninety persons were
examined as to their fitness for employment in
Government Departments, e.g., the railway. Six
hundred and four operations were performed.
At the Victoria Memorial Eye Hospital 1,008 in-
patients were treated. Five hundred and nine
major operations were performed, 277 of which
were for cataract; 3°24 of these were failures.
To show the popularity of this -institution,
patients came from every Province in this island
and from South India. The accommodation
provided has been found insufficient, and a
new male ward and an enlargement of the outdoor
dispensary are pressing necessities. Owing to the
generosity of Mr. Walter de Soysa, who has given
Rs. 50,000 for the extension of buildings for the
treatment of eye diseases in Colombo, Galle, and
Kandy, a start will be made soon to supply these
wants.
Police Hospital, Colombo.
The total number of patients was 1,276; of those
122 were gaol officers. Of those admitted 4 died,
1 each from dysentery, bronchitis, pneumonia, and
pericarditis; only one case of enteric fever was
admitted. The average daily sick in hospital was
14°72.
Branch Hospitals for Women.
At Colombo 545 were treated for venereal diseases,
with 1 death. At Galle 164 were treated.
Gaol Hospitals and Sick Prisoners.
During the eighteen months’ period 21,749
prisoners were admitted into the different gaols of
the island. The average daily strength of prisoners
was 8,108:12; the number treated in gaol hospitals
was 9,991. The total number of deaths was 347.
The chief causes of sickness and deaths were as
follows: 3,984 cases of diarrhoea, with 133 deaths;
960 cases of dysentery, with 63 deaths; 1,213 cases
of malaria, with 15 deaths; 18 cases of enteric fever,
with 6 deaths; 144 cases of injury, with 2 deaths.
All other diseases totalled 3,672, with 128 deaths.
Colombo Gaols.
Average Daily — Aversge Total
Strength Daily Sick Deaths
Welikada 196-06 38:28 89
Mutwal 800°47 27-52 57
Hulftsdorp 121-08 245 .. 6
Mahara 584:36 43°78 .. 87
Diets.
In August, 1910, 16 oz. of raw rice was sub-
stituted for 16 oz. of bread in No. 1 penal diet in
the Colombo prisons.
Kanatta Infectious Discases Hospital.
One thousand six hundred and forty-six cases of
infectious diseases were treated at the hospital
during the eighteen months’ period. The diseases
included :—
Cases Deaths
Cholera 33 X 8 $e 9. 3
Small-pox $5 105 22
Chicken-pox . P à 1,141 1
Measles Pr RC es .. 188 2
Acute diarrhea «t x ae 2 2
Mumps oe T D - 73 —
Whooping cough... ne $i 7 —
Beriberi a $i d^ 10 .. —
Diphtheria . se M 19 1 1
Other cases, including those under
observation .. a T vt 1
Victoria Home for Incurables.
At this institution 66 remained on December 31.
1909, and 12 were admitted during the period under
review, making a total of 78 cases, of whom 1 was
discharged and 3 died; 74 remained cn June 90.
1911.
Bacteriological Institute and Clinic for Tropical
Diseases.
The total number of specimens sent for bacterio-
logical examination was over 8,000, including the
Ciinic and Seamen's Ward, General Hospital. The
Feb. 16, 1914.]
fees collected amounted to Rs. 1,029. A new clinic
is an urgent need, the present building being un-
suitable. Research work was carried out in the
following subjects by Dr. Castellani :—
(1) Dhoby itch and its fungi (five new species).
(2) The hyphomycetes of Tinea imbricata: their
growth on artificial media and experimental repro-
duction of the disease.
(3) Tropical bronchomycosis.
(4) Anchylostomiasis fever.
(5) Cases of fever due to Bacillus Asiaticus.
(6) Observations on some new intestinal bacteria.
(7) A peculiar trichomycosis.
(8) The treatment of yaws.
(9) Vaccination with live vaccines.
Total Hospital Deaths.
The total deaths were 12,840. A statement
showing the death-rate per cent. in the various
hospitals and asylums (excluding the gaols) is given
below, the death-rates among mixed races and
immigrant Indians being shown separately :—
Hospitals Mixed Races Indians Total
Civil 807 . 17°47 10°08
Field 4°62 11:54 5:55
Immigrant 3'65 .. P45 3°24
District .. 24 T7175 .. 19:87 16°18
Asylums .. 2s 8:33 .. 10°33 .. 8:58
Other hospitals .. 95 ww r81 .. 1:02
Total .. 1:46 17:98 10:88
Hospital Accommodation.
This was generally sufficient. Some of the
hospitals in the planting distriets were overcrowded.
Water for drinking purposes is, as a rule, filtered
before use. Separate bath-rooms are provided for
males and females, but patients who can help them-
selves prefer to bathe in streams when such are
near. The conservancy of the latrines is entirely
on the dry-earth system.
Inspection.
The hospitals and dispensaries were regularly in-
spected by myself and the provincial surgeons of
the respective Provinces. The number of these
visits of inspection is given in the return of each
institution. The books were produced when called
for, and generally were found complete and kept up
to date.
Food Supply.
The provisions for the various hospitals were sup-
plied by contractors approved by Government. The
system works satisfactorily. The food is inspected
by the medical officers of the hospitals before it is
served to patients, and any samples not approved
are rejected. Contractors offering inferior samples
are fined.
The Ragama Camp.
The total number of persons that passed through
the camp during the period under review was
142,045; of these, 64,161 were from cholera-infected
areas in South India, 6,244 from small-pox-infected
districts, and 648 from plague-infected parts, and
the others were Sepoys of the native infantry
COLONIAL MEDICAL REPORTS.—CEYLON. E 29-
regiment stationed in Colombo, who returned from
their homes in India. Forty-six thousand eight
hundred and sixty-two persons were vaccinated at
the camp.
The camp was free from infectious diseases till
May, 1910. From May 5, 1910, to September 10,
1910, there were 11 cases of cholera, with 10 deaths,
and 1 fatal case of acute diarrhea. In 1911 there
were 2 fatal cases of cholera and 1 case of acute
diarrhæa up to May 1. A severe outbreak of
cholera occurred in May, 1911, the first case being
on May 3. The disease spread rapidly, and the
total number of cases of the outbreak was 327, with
214 deaths. The outbreak lasted from May 3,
1911, to June 14, 1911. One case of small-pox only
occurred at the camp during the eighteen months’
period.
Medical College.
The College consists of lecture hall, students’
library, laboratories for chemistry, physiology.
pathology, and biology, a dissecting room, offices,
photographic rooms, museum, the Colonial Medicai
Library, and a separate building for lady students.
There were 243 students in attendance at the end
of June last, of whom 161 were registered medical
students and 82 apothecary santai: Thirteen
students qualified in medicine and surgery; 19
apothecary students passed out.
The work at the College and the number of
students have outgrown the accommodation; the
rebuilding of portions of the premises is sanctioned.
The fees collected during the period amounted to
Rs. 55,720, and the net cost of the institution to
the Colony was Rs. 33,886:69. The net cost to the
Government for the period for each student was
about Rs. 139.
The Medical Council.
Meetings were held regularly. Thirty-five persons
were registered.
The Civil Medical Stores.
The total cost of drugs, chemicals, and instru-
ments during the period was Rs. 305,888:19;
140,592 oz. of quinine were issued, which cost
Rs. 93,183. The cost of repairing surgical instru-
ments was Rs. 919°54. The cost of transport was
Rs. 10,620°07. The sale of medicines to Govern-
ment Departments and others was to the value of
Rs. 4,656°71, and the sale of medicines, &c., to
estates realized Rs. 9,979:19. The sale of un-
serviceable articles realized Rs. 718:22, and the value
of instruments sold, lost, and paid for by officers ot
the Department amounted to Rs. 2,541°77. The
total cost of drugs, instruments, stationery, print-
ing and binding, transport, and other incidental
expenses amounted to Rs. 341,893:15, and the total
income realized by sale of drugs, unserviceable
articles, &c., amounted to Rs. 11,195:89.
Strength of the Medical Department.
The following was the strength of the Medical
Department during the period: 1 Principal Civil
Medical Officer, 1 Assistant Principal Civil Medical
Officer, 1 Registrar of the Ceylon Medical College,
£
30 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 16, 1914.
1 Director of the De Soysa Bacteriological Institute,
1 Assistant Bacteriologist, 1 Professor of Chemistry,
1 Professor of Physics, 1 Government Analyst, 9
Provincial Surgeons, 1 Superintendent of the
General Hospital, Colombo, 1 Superintendent,
Leper Asylum, Hendala, 1 Superintendent, Lunatic
Asylum, Colombo, 3 Medical Women, 30 Medical
Officers, Grade I, including 1 Medical Woman; 37
Medical Officers, Grade II, including 1 Medical
Woman; 66 Medical Officers, Grade III, including
1 Medical Woman, 6 Health Officers, 246 Apothe-
caries, 1 Chief Storekeeper, 9 Inspectors of Vacci-
nation, and 181 Vaccinators.
Estates BRANCH.
During the period there were 2,132 estates
scheduled to 35 districts, with 21 district hospitals
and 29 dispensaries and 18 civil hospitals and dis-
pensaries, to attend to the medical wants of which
the following medical officers were employed:
Medical officers First Grade, 4; medical officers
Second Grade, 11; medical officers Third Grade, 19;
and 68 apothecaries.
During the period 26,854 estate labourers were
treated in the district hospitals and civil constituted
district hospitals. Of these, 5,448 died—a death-
rate of 20°29 per cent. Of the mixed races, 24,861
were treated, of whom 2,271 died—a death-rate of
9°13 per cent.
In the civil hospitals, worked partly as district
hospitals, the death-rate of estate labourers was
21°31 per cent., whilst in the district hospitals it
was 19°87 per cent. The highest death-rate (39°07)
among the estate labourers occurred in the civil
hospital at Ratnapura, and the lowest (6:85) in the
field hospital at Alutnuwara. The admissions into
the former were 1,464, and into the latter 173.
The total number of days the estate labourers
stayed in hospital was 667,587, an average of 24°85
days each; of these, 413,812 were paid for by
estates, the rest being charged to the fund. The
total number of days the mixed races stayed in
district and civil hospitals was 826,872, an average
of 18:12 days.
The total number of estate labourers treated at
the outdoor dispensaries was 111,575. The total
number of estate labourers treated on estates was
59,237.
The total number of births reported from estates
was 26,553, of which 12,942 were males, 12,455
were females, and 1,156 were stillbirths.
The number of deaths reported from estates was
21,258, of whom 10,264 were males, 10,987 were
females, and in 7 cases the sex was not stated.
Medical Aid.
The expenditure under the Medical Aid Ordin-
ance amounted to Rs. 1,084,927:42, and the receipts
to Rs. 611,633:48, leaving a deficit of Rs. 473,993:04.
APPENDIX.
The Opium Question.
The question of regulating the traffic in opium in
this island is intimately associated with the name
of Mr. John l'erguson, C.M.G. A Committee con-
sisting of the Hon. Messrs. S. C. Obeyesekere,
F. C. Loos, and J. Ferguson, C.M.G., and Mr. R.
Morison, J.P., and the Principal Civil Medical
Officer (Chairman), was appointed by Government
in June, 1907, '' to inquire into and report on the
importation, sale, and consumption of opium in
Ceylon, and to state what changes were desirable
in the Ordinances and regulations affecting the im-
portation and sale of the drug." The recommend-
ations of that Committee were—
(a) That the present system of renting and
lieensing be abandoned.
(b) That all opium shops be closed on the
expiration of existing licences.
(c) That the importation, distribution, and sale
of the crude drug be made a Government
monopoly.
(d) That for every opium shop closed the nearest
Government dispensary be made available for the
distribution of the drug to all habitual adult users
of the same who may come forward to register their
names for a certain quantity to be periodically given
out and paid for in cash, and that suitable remuner-
ation be given to the dispensers for the extra work
and responsibility thus cast upon them.
(e) That the use of the drug, except for medical
purposes, should be entirely prohibited after a
definite period.
(f) That a system of careful inspection be intro-
duced by the appointment of special officers under
the direetion of the Principal Civil Medical Officer.
This was followed by the appointment of a Com-
mission in September, 1909, consisting of the Hon.
Messrs. L. W. Booth, 8. C. Obeyesekere, W. G.
van Dort, M.D., Drs. A. J. Ghalmers and H. M.
Fernando, and Solomon Seneviratne, Gate Muda-
liyar, with the Hon. Mr. A. G. Lascelles, K.C.
(Chairman), ''to inquire into and report on the
question of introducing a system of registration of
vedaralas who deal in opium in this country; and
in the event of their being registered, whether the
opium supplied to them should be pure or mixed
with aloes or some other drug." The recommend-
ations of this Commission were—
(a) The registration of vedaralas should be
entrusted to provincial boards consisting of the
Government Agents as Chairmen and such other
members as the Governor may appoint.
(b) Only such vedaralas should be registered as
in the judgment of the Board have gone through
a sufficient course of training, are of good character,
and have an extensive and more than merely local
practice.
(c) Similar boards, if thought desirable, might be
appointed in revenue districts with the Assistant
Government Agent as Chairman.
(d) In order to secure uniformity the Governor
should fix the maximum number of registered
vedaralas to be allowed for each province .or
revenue district. To enable the Governor to do this
in the first instance each Government Agent, after
the Board has received and considered applications
for registration us vedaralas, should submit a
report on the applications to the Governor.
Feb. 16, 1914.]
COLONIAL MEDICAL REPORTS.—JAMAICA. 31
(e) On the registration of a vedarala, the max-
imum amount of opium which he will be entitled
to obtain annually, and the depót from which the
opium will be obtainable, should be recorded, no
vedarala being entitled to obtain opium from any
souree except the depót in connection with which
he is registered. Precautions must, of course, be
taken that no vedarala shall be registered at more
than one depót.
(f) With regard to the quantity of opium for
which vedaralas should be registered, we think that
the maximum should be fixed by the Governor from
time to time. We believe that 8 oz. a year would
be sufficient, if the Government Agent were em-
powered to authorize the issue of larger amounts
for limited periods in special cases or in seasons
when there is an outbreak of any sickness for the
treatment of which opium is necessary.
(g) Opium should be issued only to the registered
vedarala in person.
(h) The vedarala, when registered, should be
required to pay a registration fee to cover the cost
of administration, and to enter into security to issue
opium only for medicinal purposes.
(i) The Government Agents should have power to
cancel registrations, subject to an appeal to the
Governor.
(j) The price at which opium will be issued from
During the Four Quarters Eating Opium
ended Quantity sold Amount realized
Grains Rs. c.
December 31, 1910 13,343,433 100,960 71
March 31, 1911 14,893,067 112,084 99
June 30, 1911 15,932,828 119,781 17
September 30, 1911 16,567,231 124,453 53
Total for the year oe. 60,736,559 457,280 40
the Government depót should be fixed from time
to time by the Governor, and opium should be
issued only against cash payment.
(k) Subordinate provisions would be required
as regards the issue of certificates of registration,
notifieation of change of residence, the books to be
kept, and other matters of detail.
The result of these two inquiries was the passing
of an enactment cited as '' The Opium Ordinance,
1910," in which opium was made a Government
monopoly, with Government opium depots in
various parts of this island for the distribution of
the drug to registered consumers and registered
vedaralas. The Principal Civil Medical Officer was
appointed to control and supervise this new branch
of the Medieal Department. Existing Government
dispensaries were utilized for the majority of the
depóts; in certain places, notably Colombo, houses
were rented for this purpose. Fifty-eight opium
depóts were established and equipped for the sale
of opium by October 1, 1910, since which date the
work has gone along smoothly. At the very busy
depóts specially trained sellers have been appointed.
A staff of examining clerks visit the depóts regularly
and inspect the books.
Statement of Opium sold and the amount realized
during the year October 1, 1910, to September
30, 1911:—
Quantity NAE ME eut realized Total realized
Grains Rs. c. Rs. ë
2,994,398 29,977 34 130,938 5
3,147,031 81,456 26 143,541 25
3,040,191 30,405 99 150,187 16
3,024,954 30,256 81 154,710 34
12,206,574 122,096 40 579,376 8)
Colonial Medical Reports.—No. 31.—Jamaica.
MEDICAL REPORT FOR THE YEAR 1912.
By J. E. KER.
Superintending Medical Officer.
QUARANTINE.
During the twelve months ended March 31, 1912
there were no detentions at the quarantine station.
The following ports continued under proclam-
ation as infected places during the twelve months:
all ports of Brazil, for small-pox and yellow fever.
dated February 6, 1892; all ports of Venezuela, for
small-pox, dated September 29, 1898, and Mazattan
in Mexico, for plague, dated May 26, 1908.
Trinidad was under proclamation as a place
infected with plague for a portion of the year,
sporadie cases having occurred at that place.
Modified quarantine restrictions were also
imposed on ships arriving from New York in con-
sequence of cholera having been imported there
from Italy.
Plague at Port Durban, South Africa, and cerebro-
spinal meningitis at Galveston have necessitated
the detention of arrivals from these ports for report
to the Quarantine Board.
No new works were carried out during the year
at the quarantine station.
Repairs were effected to the valve of the large
circular tank, the telephone, the wire gauze windows
of the hospital and the flag-staff.
A large area of ground of about five acres in
extent, and immediately adjoining the southern
boundary of the quarantine station, was closely
32 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
cropped of dense trees and bush. This has had the
effect of producing a large open space devoid of
bush and trees amongst which mosquitoes might
harbour.
This clearing, having gone through the dense
tangle on the sea-shore, has practically cut off the
access of mosquitoes from this bush and the lagoon
to the quarantine station.
In January after a fall of rain a few larve of
mosquitoes were observed in the lagoon. Minnows
from the reserve tank were put in the pond and
quickly dispersed.
A large bucketful of the water from the lagoon
was taken to the quarantine station and six lively
minnows put in with a view to ascertaining how
long the minnows would live in it, and to gain some
information as to the utility of the minnows in the
destruction of mosquito larve in such a medium.
At the end of two hours all the fish in the bucket
were dead.
These put in the lagoon were not seen again; but
the mosquito breeding that took place was very
limited since no trace of them could be found a
week later.
The remarks of the Quarantine Board in last
year’s report with regard to the necessity of having
an up-to-date Clayton disinfector on a barge or
lighter, with a launch for towing, apply with
unabated force. No confidence can be placed in
the present methods of disinfecting the holds of
ships with the antiquated sulphur pot. The
approaching opening of the Panama Canal renders
it imperative that some more efficient and trust-
worthy means of disinfection should be available.
Should the Canal bring no increased trade in the
shape of ships and cargoes it will also, to a certainty,
expose us to additional risks of the introduction of
diseases into the Island.
D. Nersu, Health Officer.
Sr. ELIZABETH.
Since taking up the duties of Medical Officer of
Health for the Parish of St. Elizabeth on April 1,
1911, and up to March 31, 1912, I have visited
regularly the towns of the parish and a great portion
of the country districts. The only infective disease
which occurred during that period is enteric fever,
of which a slight outbreak took place in the district
of Santa Cruz: there were four cases and the disease
did not spread. There were a few sporadic cases
in Southfield district but not of an epidemic form.
I have found during the past five years that in
every period of drought the people in these parts
drink any and every kind of water owing to the
scarcity of this article, and they have not yet learnt
the absolute necessity of boiling the water for
drinking purposes, and it is at this time that such
cases oecur. There was during the fall of the year
under review the usual malaria fever, but this was
of a milder type than in other years, and not so
extensive, consequent on the severe drought and
nbsence of stagnant water.
The houses and their compounds have never be-
fore the appointment of a Medical Officer of Health
been regularly inspected and consequently were,
among the poorer classes especially, not in a sanitary
condition, but since the putting into operation of
the Health Law and by regular inspections and
personal explanations the people are beginning to
recognize that their premises must be kept sanitary ;
this of course takes time, and I would be averse to
taking legal proceedings against them except in
cases which show no attempt to carry out the orders
of the Local Board of Health.
Water.—The water supply of the parish may be
divided into two main divisions, viz.:—
(a) That portion of the parish which is supplied
by springs and streams tributary to the Black River,
the hills joining the watershed of this river. This
portion comprises the north-eastern and central
divisions of the parish, and has as a rule a copious
and sufficient rainfall, and the people have a fairly
good water supply.
(b) The drought area or south-eastern end, the
western and northern parts with a large population
dependent entirely on wells in the lowlands and on
tanks in the hills, these tanks being quite insuffi-
cient and in a number of cases insanitary; the
catchment of these latter being generally the yards
around the houses. In the south-eastern end of the
parish the people do not seem to have taken advan-
tage of the Tank Loan Law which was passed
recently for their benefit. There are two public
tanks in this end of the parish, but they are quite
inadequate to meet the requirements of the popu-
lation. The Balaclava supply in dry weather is
from the Oxford River, and owing to pollution the
Local Board of Health has recently proclaimed this
stream a source of publie water supply. This course
wil doubtless cause a cessation of the pollution.
The town of Black River is supplied by efficient and
pure water by means of service pipes.
The refuse of the town of Black River is used for
filling and reclaiming swamp-lands; in other places
it is carried out of the villages and used as manure
by neighbouring landowners.
The latrine system in Black River is either
directly into the sea by those householders along
the beach or dry earth closets in other portions of
the town; the duty of the sanitary officer is to see
that these latrines are emptied at least twice a
week and the excreta thrown into the sea. In other
parts of the parish the general system is that of
earth pits or open-air closets which are hardly
sanitary, and it will take some time to educate
people into the dry earth closets system, but already
there are signs of improvement.
The housing of the poor in towns and villages is
fairly satisfactory, but there are several dilapidated
shanties in the villages which will have to be con-
demned during the coming year. In the country
parts the housing is often deplorable, the small
houses being badly built with no flooring, only clay
rammed, and as many as five or six people sleeping
in one small room with very little ventilation ; the
consequence is that the health of these people
suffer, especially during the wet seasons.
Mar. 2, 1914]
: COLONIAL MEDICAL REPORTS.—JAMAICA. : 38
Colonial Medical Reports.—No. 31.—Jamaica.— (continued).
There is no marked pulmonary tuberculosis in
this parish, cases occasionally occurring in the hills
among visitors who go there with this disease in
search of climate.
The local conditions causing malaria are the
usual ones in a tropical country, and after heavy
rains all the holes and depressions retain water
whieh form breeding places for mosquito. This
parish having about one-third of its area almost at
sea-level (and in swamp) it is extremely difficult to
deal with this condition, but by the example of the
Malaria Commission in filling up a large morass near
the town of Black River, there are indications of
the local owners following this good example, and
in the next year the improvement will be more
general as the Local Board of Health is insisting
on these improvements.
The Medical Officer of Health visits as a routine
the-towns and villages which have been declared
places under Law 35 of 1910 at least once a month,
and there are three sanitary inspectors appointed by
the Local Board of Health who report regularly to
that officer on the local conditions of their respec-
tive districts. In Black River, where the Medical
Officer of Health resides, the inspection is daily by
the sanitary officer and the Medical Officer of
Health.
There has been considerable new work done in
the interest of sanitation during the year, notably
the reconstruction of all the stalls in the markets at
Black River and Balaclava, the old insanitary
wooden stalls being replaced by concrete slabs, a
new drainage system. laid down in each of these
markets. Extensive concrete drains have also been
laid throughout the town of Black River.
A. R. Topp, M.O.H.
TRELAWNY.
The sanitary conditions are on the whole satis-
factory, although there still remain many condi-
tions open to improvements, such as removal of
konch shells and empty vessels liable to contain
stagnant water from compounds. Also proper
drainage of streets to carry off waste water and
regular attention to keep such drains clear of
rubbish.
Water Supply.—The town of Falmouth is supplied
through pipes from the Martha Bre River. Some
villages are supplied by ponds and others situated
near the river receive their water therefrom. There
is no adequate means. of protection from water
pollution.
In the town of Falmouth the sanitary carts
remove house refuse. The pit closets exist in most
houses. In so far as I am aware overcrowding
does not exist. The poor are well housed.
Tuberculosis.—Pulmonary tuberculosis is not
very prevalent in this district; there are, however,
a few cases.
The swamps and. ponds in Falmouth do-not in my
experience breed malaria mosquitoes although the
mangrove trees may act as shelters for the
mosquito. l
Dr. A. E. C. Myers.
Duncans.
There has been a change for the better here.
People are beginning to appreciate the benefits of
a clean house and yard.
Water supplies are from ponds in the neighbour-
ing villages. There is no way of preventing
pollution.
` Disposal of Refuse Matter.—This is a matter that
requires the urgent attention of the parochial
authorities—there are no dumping grounds any-
where, and these are absolutely necessary. Until
the local authorities move in this matter I con-
sider it is useless and unfair to prosecute private
individuals for not keeping their yards clean.
F. A. G. Puncnas, M.O.H.
ULSTER SPRING.
The health of the district has been good during
the past year. There have been regular inspections
as to the keeping and cleaning of latrines. Latrines
are not properly kept, sufficient dry earth is not
thrown on the excreta, in the majority of cases no
steps are taken to throw any earth at all. In
another set of cases no arrangements are made for
any latrines; this was so in the house in which
there was the only case of enteric fever in this
district this year.
The houses and compounds are in fairly good
condition. One must remember that the term
“hut” would more justly be applied to the
majority of the buildings not in the immediate
vicinity of villages, and these are most badly built
and poorly ventilated.
Cases of malaria fever and pulmonary phthisis are
few and far between.
Dr. Surrn.
WESTMORLAND.
The sanitary condition of houses and their com-
pounds are in a fair condition. By following the
advice of the sanitary officers, the use of dis-
infectants, and the observance of sanitary measures
hitherto neglected, improvements have taken place.
Sav.-la-Mar is supplied with water from Sweet
River, a distance of about six miles from the town.
A main is laid in the intake and the water is
34 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 2, 1914.
conducted through this main to the town; service
pipes are attached to the main and connected to
each house in the water area, for which a rate is
charged and collected.
The sanitary inspectors visit the public water
supplies regularly, and see that no pollution takes —
place and that the surroundings are kept in a
sanitary condition. I have just recommended to
the Board that springs and wells be covered as a
protection from pollution.
In town the yards and streets are swept daily
by scavengers, and the refuse carted away and
deposited at the depót ground some distance from
the town. In the villages each occupier keeps his
compound clean, to the satisfaction of the sanitary
inspectors.
Latrine.—The “‘ pit system '' is in general use in
town. At the publie institutions the dry earth
system is in force. The villages have no particular
system but sanitation is enforeed by the sanitary
officers,
Malaria—the presence of several breeding places
of mosquitoes—stagnant water, swamps, the want
of concrete drains and other insanitary conditions.
These causes are receiving the attention of the
Parochial Board, and I do most earnestly solicit
from the Malaria Commission a grant to enable the
Board to carry through these important measures.
No prosecutions for non-compliance with the
Health Law have taken place as the people really
carry out the orders of the sanitary officers, more
especially in the country districts.
H. Rosins, M.O.H.
Sr. THOMAS.
The overcrowding of houses among the poorer
classes is very common, but the necessity of keep-
ing their compounds clean is being appreciated to
a marked degree.
The water supply of Morant Bay is good, but a
great deal of hardship is felt among certain villages,
Duckenfield, Dalvey and Bowden, especially during
severe droughts. An epidemic of dysentery
occurred last month at Duckenfield, due to impure
water supply, resulting in one death. The majority
of these districts abound in springs, and their pro-
tection from contamination by solid
enclosures is most urgently needed.
A house-to-house daily disposal of refuse is rigidly
carried out in Morant Bay, and is used to fill up
the Board’s swampy lands; the collection and
burning of refuse being taught to the inhabitants
of the country districts.
The latrines in and around the town and villages
lack modern improvements for the benefit of
concrete
sanitation. There are signs of improving them, and
new ones are only built from specifications sub-
mitted to and approved by the Medical Officer of
Health.
Pulmonary tuberculosis shows an increase in the
number of cases, but the majority of cases coming
under my notice seem to contract the disease in
Central America and other parts, and come here
with it.
Malaria fever is less prevalent than it has ever
been. There is always, however, a number of
cases to be found in the P. G. River district during
the year, and if this district is made a sanitary
district under charge of an inspector of nuisances
a great improvement will result. The Bamboo
River in Morant Bay is the chief source of the
breeding of anophelines.
Daily inspections are made by the Medical Officer
of Health and the Inspector of Nuisances around the
town of Morant Bay, and the Medical Officer of
Health also visits the different sanitary districts at
least once a month.
Many works for the improvement of sanitation
have been done by the Board, including the exten-
sion of concrete drains around the town of Morant
Bay and Church Corner; the concrete drain at
Brown’s Gully, which however is not yet finished,
the establishment of a market at Port Morant.
which has been the means of cleaning and filling up
some of the swampy lands, an absorption pit at the
Alms House with concrete drains around the com-
pounds of the institution. The intelligent execution
of the sanitary laws has given satisfactory results.
F. A. Norton, M.O.H.
St. Mary.
Before a regular and systematic inspection of the
houses and compounds was made, most of the
houses and yards in the town were in a_ highly
insanitary condition. Water was allowed to collect,
broken bottles filled the yards, and the latrines were
never emptied. But these conditions are ceasing
to exist.
The water supply of Port Maria is excellent, and
it is proposed to shortly carry the water by pipes
into Oracabessa and the surrounding districts.
The disposal of refuse, &c., is a matter that is
attracting the attention of the Parochial Board. At
present there is no deposit ground, and until a
suitable place is found this difficulty will always
exist. At present an attempt is being made to
throw all the rubbish, &c., into Warner's Pond with
the idea of gradually filling it up. This has worked
very satisfactorily.
Until the appointment of a Medical Officer of
—— ——— MÀ —
35
Admis-
bo
Sellil
470
7
Mar. 2, 1914.] COLONIAL MEDICAL REPORTS.—JAMAICA.
RETURN OF DISEASES AND DEATHS IN 1911-12 IN THE VARIOUS HOSPITALS OF
Jamaica.
GENERAL DISEASES.
ie 2 323
S8 3$ Zi
se E eM
Alcoholism .. vs xs i 9 — 9 GENERAL DISEASES —continued.
Anemia zs : z 821 7 85 (d) Tabes Mesenterica zz
Anthrax . 7 2 — — = (e) Tuberculous Disease of Bones as
Beriberi A . è 10 — 10 Other Tubercular Diseases h
Bilharziosis i $ — — = Varicella " y
Blackwater Fever z A 4 — 4 Whooping Cough
Chicken pox .. . : 3 t 1 1 Yaws .. . os
Cholera - id é A 4 — 4 Yellow Fever .. 56
Choleraic Diarrhoea .. Sa 3 Š= = oe
Congenital Malformation .. - š — — = LOCAL DISEASES.
Debility sie ais $5 s. . 104 9 104 Diseases of the —
Delirium Tremens ae e á 1 = 1 Cellular Tissue oy we as -
Dengue.. ae ite se s è — = Circulatory System R
Diabetes Mellitus ve Je = = (a) Valvular Disease of Heart
Diabetes Insipidus .. 4 = LA (b) Other Diseases ie wa
Diphtheria Ve s. — = EX Digestive System .. - 4
Dysentery .. a T 186 10 186 (a) Diarrhea — .. .
Enteric Fever .. E 53 164 40 164 (b) Hill Diarrhoea
Erysipelas i4 as at — = (c) Hepatitis A
Febricula ae a — — = Congestion of Li ver an
Filariasis is X — — a (d) Abscess of Liver .. $5 iĝ
Gonorrhea 434 484 (e) Tropical Liver t X P
Gout .. ; — = = (f) Jaundice, Catarrhal i e
Hydrophobia . + — = = (g) Cirrhosis of Liver .. ‘i e:
Influenza 3 — 3 (k) Acute Yellow Atrophý
Kala-Azar ae — = (i) Sprue .. 4
Leprosy — = (J) Other Diseases a 2 s
(a) Nodular.. ct ee 9 9 Ear .. P s bs at
(b) Anæsthetie .. vs T 1 — 1 Eye .. m : we ie Ya
(c) Mixed .. va Es . — — = Generative System 2a $s
Malarial Fever $s js M 1 = 1 Male Organs... z T .
(a) Intermittent .. és T 7434 87 7434 Female Organs .. vs Si $e
Quotidian P os — = == Lymphatic System
Tertian — m x Mental Diseases
Quartan Di Fe — — = Nervous System
Irregular m vie ne — — — Nose.
Type undiagnosed .. ia -— = = Organs of Locomotion
(b) Remittent ve v ia 327 21 327 Respiratory Aytan ie
(c) Pernicious d is 7 : 87 11 87 Skiu .. . m
(d) Malarial Cachexia 15 1 15 (a) Scabies T
Malta Fever 1 = Í (b) Ringworm .. 25
Measles ss 1 — 1 (c) Tinea imbricata
Mumps 5 = 5 (d) Favus..
New Growths . — — — (e) Eczema T
Non- malignant es 83 1 83 (f) Other Diseases
Malignant i ks 63 9 03 Urinary System
Old Age.. iA i. "C T — — — Injuries, General, Local
Other Diseases ius > 114 2 114 (a) Siriasis (Heatstroke) .
Pellagra xe - — — — (b) Sunstroke (Heat Prostration)
Plague .. $5 e» T £c — -= — (c) Other injuries .. Š
Pyæmia a Ss oe 4 — 4 Parasites ve
Rachitis E -- — = Ascaris lumbricoides
Rheumatic Fever 3 — 3 Oxyuris vermicularis
Rheumatism .. vs 1598 — 1528 Dochmius duodenalis, or ` Ankylostoma
Rheumatoid Arthritis. zo os — — — duodenale : T
Scarlet Fever . r a — — =. Filaria medinensis (Guinea. worm)
Seurvy .. RE 2 a T m — -- Tapeworm .. sis a. H^
Septicemia ... es ts oe 19 14 19 Poisons
Sleeping Sickness — — — Snake-bites .
Sloughing Phagedæna PE ae -— ES — Corrosive Acids
Smallpox E oe 25 raf — — — Metallic Poisons Ps ^
Syphilis LA T "n E — — Vegetable Alkaloids M ar
(a) Primary 278 1 278 Nature unknown .. yv +s
(b) Secondary 168 2 168 Other Poisons we - e
(c) Tertiary .. es oe . 181 3 181 Surgical Operations . . Ws
(d) Congenital vs iw us 61 3 61 Amputations, Major
Tetanus - e as 14 10 14 Minor EN
Trypanosoma Fever .. ie NT — — — Other "Operations T
Tubercle $a A: 15 68 Eye T
(a) Phthisis. Pulmonalis ..
(b) Tuberculosis of Glands
(c) Lupus
(a) Cataract
(b) Iridectomy
(c) Other Eye Operations
sions
b dul Deaths
lel
c2 a ; ;
Il141418$8lllllleleloiceellt!tlttlilltlllllsllS8e
-1
36 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 2, 1914.
Health all the latrines in the vicinity of the Outram
emptied into the river. I went up one morning in
a boat, and was appalled at the existing circum-
stances. Since then I have had all the latrines
removed from the river and a dry earth system is
now in vogue, but until a deposit ground is chosen
and the night soil removed by a proper cart
service, I am much afraid that a nuisance will still
exist.
Overerowding exists in Port Maria, which I
suppose is common in nearly all towns in Jamaica.
The yards are being kept more clean, and owing
to the benevolence of the Government, who supply
quinine cheaply to the inhabitants, malarial fever
is certainly diminishing.
Inspections are made daily, and in special cases
yards are visited more frequently, especially in the
case of those who seem disinclined to keep their
places clean.
i W. G. FanqunansoN, M.O.H.
GAYLE.
The sanitary condition of the houses and their
compounds leave much to be desired indeed; in
many districts the conditions are such as appertain
to man in a primitive state.
There has been some improvement in the villages,
as householders are now compelled to keep their
yards clean and abate all nuisances under the new
Health Law. But as this district is a very popu-
lous one and made up of numerous small settle-
ments, the sanitary improvements in the chief
village merely touch the fringe and can only be
regarded as a first step, but it is to be hoped that
the example of the larger centres and the increasing
popular demand for sanitation will compel the
remoter settlements to fall in line.
With the exception of a few better class resi-
dences which are supplied by tanks, rains, &c., the
water supply of the whole district is the simple one
of direct collection from rivers and springs, which
are numerous and never-ending.
In the ease of the springs, while the water is no
doubt pure, it is frequently contaminated by the
washing from the houses above, by the watering of
stock, by water carriers' feet, and other obvious
sources of pollution. "The water is collected chiefly
by children at dusk or in the early morning, and
the condition of the pools at such times can better
be imagined than described. Since my appoint-
ment as Medical Officer of Health of this district
I have brought this matter to the notice of the
Parochial Board, and have suggested the erection
of small impounding dams with supply pipes. I
am glad to say that estimates of cost have been
prepared and submitted for the Saltrum, Derry,
Mount Angus and Windsor Castle springs, and it
is evidently intended to proceed with these as soon
as the necessary rights:have been acquired.
There are no special means for the disposal of
refuse waste or objectionable matter. These are
usually deposited in the nearest banana field or
other convenient spot and time, and our natural
scavenger—the ‘‘ John Crow ’’—does the rest.
The pit closet is the only attempt at a latrine
system in the villages. In some of the better-class
houses and in Government institutions (e.g., police
stations) the dry earth closet is used. For the
district generally the latrine system is that described
under disposal of refuse, iie., the banana fields.
This may have some agricultural benefits to .com-
mend it, but it is certainly objectionable, and in my
opinion is responsible for many intestinal disorders
among the people, and for the small outbreaks of
enteric fever which occur from time to. time in this
district.
Among the facts brought out by the, last Census
was the great increase in the number of good houses
in this parish, and to this end I think this district
has added its fair share. It is certainly refreshing
in certain parts to see the neat little cottages that
have recently been and are stil being erected.
When one considers, too, the high price of lumber
and other building materials in these parts, this is
certainly commendable, and is sure to confer other
benefits as well as those of sanitation. Unfor-
tunately, there are many settlements which are
little better than African villages, with the asso-
ciated insanitary conditions. Overcrowding exists
to a great extent in these settlements, yaws and
other loathsome diseases abound, and the general
health and intelligence of the people are low. That
they live at all can only be explained by the natur-
ally salubrious climate, the high infantile mortality
which ensures the survival of the fittest and the
powerful immunity acquired against many of the
ordinary diseases.
Pulmonary tuberculosis is not prevalent, and,
strange to say, very few are seen from those dis-
tricts where overcrowding exists.
This district is a very hilly one, and there are few
natural conditions favouring the propagation of the
mosquito. There are, however, some stagnant
pools in and around Gayle in which anopheline larve
have been observed by me. These may well be
drained.
G. Lecrsne, M.O.H.
RICHMOND.
There has been a marked general improvement
throughout this district in recent years in the
Mar. 2, 1914.]
COLONIAL MEDICAL REPORTS.—JAMAICA. ` 37
structure and accommodation of the houses, and
this tends towards better sanitation.
The whole district depends for its water supply
on the streams and rivers, in some places on tanks
and ponds, and in a few instances on wells. No
means are taken’ for protecting the water from
pollution, except by the large proprietors who have
the streams on their properties and under their
direct control. There is an absolute disregard of
all the laws passed for the prevention of fouling the
various streams.
In Highgate and Richmond there is some attempt
made to sweep up the refuse twice a week. In
other parts of the district the refuse is simply
allowed to accumulate or thrown in the nearest
banana walk.
There are but few latrines provided in the villages
of the district. Such latrines as exist are either
pits or just built on a slope and exposed to the
elements.
The poorer classes are fairly well housed, and
there is no overcrowding in the usual sense.
Mosquito breeding places exist throughout the
district, viz., ponds, badly graded banana trenches,
the rank vegetation along the banks of most of the
streams, &c. These are all, of course, possible
sources of anopheles and, ergo, malaria.
P. O. Mauasre, M.O.H.
Annorto Bay.
The houses of the poorer class are for the most
part badly ventilated, and overcrowding exists in a
great many instances. The compounds around
some of the dwellings are insanitary and require
cleaning, bushing, &c. Pulmonary tuberculosis is
not very prevalent. In Annotto Bay, as far as I
am aware, agriculture being the occupation of the
labourers, their lives are spent mainly out of doors,
which probably lessens their chances of infection.
The water supply for the town is laid on by pipes
from house to house. The intake is high up in the
Fort George Hills, and though there are no filter
beds the water cannot easily be contaminated. The
quality is excellent and the quantity ample. In
some of the yards small puddles collect from the
drippings from the taps, but on the whole nuisances
from this source are not often noticeable.
The parochial carts remove some of the rubbish
from the town and some is burnt in the yards, but
it is necessary to provide a deposit ground for all
refuse and waste matter.
There is no regular latrine system in the town;
such as there is is in the main most insanitary, and
the accommodation provided appears to be in-
sufficient. The bucket system should be adopted,
buckets being emptied regularly into the sea.
Malaria prevails throughout the district, but the
cases coming under observation have not been so
numerous during the past ten months, due no doubt
to the prolonged drought, but the disease is always
with us. There are large swamps in and around
the town, and on my visits of inspection it has been
quite easy to find the larve of malarial mosquitoes
in abundance. The two swamps in the town known
as the *' Annotto River ’’ and ‘‘ Miss Fords River "'
should have permanent outlets to the sea. If such
outlets were constructed and the water allowed to
drain into the sea, the swampy lands in their neigh-
bourhood would be considerably improved. The
swamp known as '' Miss Fords River ” is the most
prolific breeding place for anopheles mosquitoes in
the town. The swamp has been somewhat im-
proved, the banks are clean, and the water lilies on
the surface removed.
F. A. Rrrcnuig, M.O.H.
PorTLAND—HopeE Bay.
From time to time inspections have been made
of houses, compounds, &c.
Whilst there is still room for improvement, they
have responded very well on the whole. The
sanitary condition of houses and their compounds
have shown distinct signs of improvement, the
yards are kept clear of refuse and waste, and
although in a few instances it was necessary to
issue notices calling the attention of householders
to their negligence, the matter was always promptly
attended to, and no further steps taken to enforce
the regulation.
The water supply of houses is obtained from
springs generally, and in some instances from catch-
ments of rain water in puncheons, &c. There is no
protection for any of the springs, as the water is
taken as it bubbles out of the rocks. The
puncheons, &c., need constant supervision, as quite
frequently some are found with stegomyia; these
are promptly dealt with.
The disposal of refuse and waste and objection-
able matter is carried out by dumping in pits dug
for the purpose outside of the town, and properly
covered up when necessary.
The latrine system is that of the earth closet, and
they also require constant supervision and dis-
infection. In a few instances it was necessary to
condemn the sites and have them removed to more
suitable spots.
I am afraid there is always more or less over-
crowding.
Pulmonary tuberculosis is not by any means
prevalent; the percentage is very small.
The chief local condition causing malaria is a
swamp on the Hope property, adjacent to the town
38 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 2, 1914.
of Hope Bay, and connecting with the sea by a
stream which is always stagnant, except in very
heavy weather, when the mouth is opened into
the sea.
Anopheles abound in this locality, and malaria is
the most prevalent disease in this district. The banks
of this stream are cleared from time to time of weeds,
and the water lilies pulled up as much as possible,
and both the banks and water oiled or disinfected.
I may state here that at the police station, in spite
of its eleanliness inside as well as around its imme-
diate neighbourhood, and in spite of the regular
dosing of the men with quinine, they all suffer a
good deal from malaria, which I attribute to the
quantities of mosquitoes which take refuge there,
and the want of screens on doors and windows.
Not one man has escaped an attack of malaria
during the past two years, and sometimes they are
all on the sick list at the same time.
ARNOLD T. CLARKE, late M.O.H.
CLARENDON, Cnorrs HILL, KELLETS.
The sanitary condition of the district is on the
whole fair.
There were two cases of typhoid fever, both in
December: one at Jincho and the other at Sevens
Ground. The source of infection in the one at
Jincho could not be ascertained with any certainty.
In the case at Sevens Ground, another member of
the family had died a short tirne before from what
appears to have been ambulatory typhoid.
Strict attention was paid to the disinfection of
all infectious material in the cases of typhoid fever,
and no further cases occurred.
A bakery in connection with the house in which
the case of typhoid fever occurred at Sevens Ground
was shut down until all risk of infection from the
patient was past.
H. T. SrRvpwrck, M.O.H.
VACCINATION.
During the past year the vaccine lymph sent
out from England proved for some months to be
very inert, large numbers of children who were
vaccinated failing to show successful results, much
to the annoyance of medieal officers and to the
parents of the children.
The inactivity of the lymph seems to have been
due partly to the extremely hot weather, and partly
due to reinforcing the parent seed through a rabbit
before cultivating it on the calf.
Yaws.
During the year under review a great deal
more attention has been given to this disease than
before. The Yaws Notification Law has given the
medical officers increased facilities for dealing with
and following up the treatment of cases seen in the
bush, and consequently a possible chance of seeing
some results of their work, a thing that in the days
when only one visit was paid to a patient was
absolutely impossible.
Yaws in many parishes of the island exists chiefly
in mountainous localities and where Water is scarce
or not close at hand, and where cleanliness, bathing
and proper sanitary precautions are negligible quan-
tities, consequently treatment of this disease is a
somewhat difficult matter.
Other infective diseases are segregated, and
rightly so, and it consequently seems only right
that this disease should be also isolated.
In view of the success already achieved by the
use of salvarsan in the treatment of this disease,
there is the hope that by taking cases of yaws into
existing hospitals where there is room for them, or
into specially made cheap hut hospitals, and using
that drug, a speedy eure of local symptoms may
take place, and a probable wiping out of the disease
altogether, a thing that the present system can
never lead to.
The total number of patients treated in publie
general hospitals during the year under review as
compiled from the nosological returns submitted by
ane D. M. O.'s were: Cases, 26,091; deaths, 497;
giving a death rate of 1,904. The number of oper-
ations performed were 2,268, with 20 deaths,
showing a death rate of 882 per cent. Among the
number of patients treated in the hospitals were
the following: Patients admitted without charge,
7,895; indentured coolie labourers, 17,822; con-
stables, 569; paying patients, 166.
HookwonM DISEASE.
A consistent and steady examination of short
term prisoners admitted to the Spanish Town Prison
since October 1, 1911, has been made by Dr. Peck,
D.M.O., in medical charge of that institution.
As regards estates, I have no doubt that the
degree of infection varies very much—some estates
being doubtless more infected than others.
Coolies are known to import the disease with
them and to suffer much from ankylostomiasis. In
fact of the first eight coolies from the last batch
landed and examined by Dr. Moseley at Port
Antonio Hospital seven were found to harbour the
worm.
Until recently, however, it has not been generally
recognized that the creole is as badly infected as
seems to be the ease, and much of the supposed
laziness and languor of the labouring classes is
Mar. 2, 1914.]
without doubt due entirely to the fact that they
are anæmic and debilitated owing to the fact that
they harbour the hookworm.
It may also be a fact and probably is, that many
cases of deaths registered as malaria or undefined
fever are due to this parasite. It must be remem-
bered that about 3,000 deaths annually occur from
‘ undefined fever,” nine-tenths of which are buried
without a medical certificate.
It is a great pity that treatment of this disease
cannot be systematically carried out on board the
ships that convey coolies to the West Indies.
The number of worms passed in some of Dr.
Peck’s cases were very large—439 being counted
in one case.
The total number of prisoners examined by Dr.
Peck and his dispenser, Mr. DeLeon, was 428; of
these 313 were found to harbour the disease, and
in 115 no evidence of the worm’s presence was
found.
Owing to the above results of examination and
the fact that many of the Northside coolies who
are infected are now transferred to Spanish Town
Hospital, it becomes a serious question as to
whether the Penitentiary Farm should have the
sewerage from the above institutions run on to it
any longer.
Of the newly arrived immigrants that arrived
recently on an estate Dr. Moseley found ova in
feces of seven of them.
Dn. Turton’s REPORT.
Since he reported three years ago on the preva-
lence of ankylostomiasis in his district it has
become increasingly evident to him that this
disease is responsible for a far greater amount of
disability—of chronic ill-health—among the labour-
ing population of his side of the parish than any
other single cause that he can name. It is the
mild infection that seems to be so insidious in its
effects before the grave and unmistakable symp-
toms show themselves. Over and over again
within the last few years he has seen cases of
chronic *' debility ° without any marked symptoms
clear up and recover rapidly on the discovery of a
very mild infection followed by specifie treatment.
One occasionally sees a whole family affected
in greater or less degree. He writes thus of the
district as only being within his own knowledge.
But he may say that he has examined every child
admitted into the Industrial school during the past
year: these came from every parish in the Island,
and it is a rare thing to find a child from any one of
the country districts that is quite free from this
infection. This is of course the result of the
COLONIAL MEDICAL REPORTS.—JAMAICA. 39
absence of any proper system of dealing with the
excreta, the earth becoming foul, re-infection
occurring, and the disease spreading. Then comes
physical disability, and. so poverty; from this to
predial lareeny is but a step, and the children left
to find for themselves become a curse to their
neighbours by reason of the depredations—for they
must steal or starve. So the vicious circle of
poverty and disease becomes established, with
crime as an incidental. His strong conviction is
that this disease is responsible for much of the petty
crime of the country districts of the Island.
NoTE ON ANKYLOSTOMIASIS IN THE PENITENTIARY.
The investigation into the prevalence of hook-
worm among prisoners received at the penitentiary
has been continued during the year ended March
31, 1912. 232 new prisoners were examined. 167,
or about 71 per cent., were found to contain hook-
worms. The naked-eye method of examination
was employed, so that it is certain that many cases
escaped detection; the more laborious microscopic
or cultivation methods would have yielded a much
larger percentage of infected cases. Coolie pris-
oners are not included in this investigation. Of the
167 infected cases 116 are recorded as having many
worms; in the remainder only a few were found.
Six eases were in the third or most advanced stage
of the disease, a number showed symptoms of
moderate infection. All cases improved greatly
after treatment.
The infected prisoners practically all came from
moist agricultural districts, some had worked in
cane or banana fields.
M. GRABHAM.
QUININE SALE AND DISTRIBUTION.
A great increase in the quinine output has taken
place this year. The system of selling quinine
tablets in farthing packets at the post offices is
developing and more of the 2°3 and 1-grain doses
have been circulated than last year. Each tablet
is wrapped in paper and put into an envelope and
sent in hundreds to the General Post Office when
requisitioned. The farthing envelope packets are
marked as follows :—
(1) Medical Department, Jamaica. Quinine, gr. v.
One dose for an adult. Price one farthing.
(2) Medical Department, Jamaica. One dose for
child of 9 years and under 14. Price one farthing.
(3) Medical Department, Jamaica. Quinine.
One dose for a child of 5 years and under 9.
(4) Medical Department, Jamaica. One dose for
child under 5 years.
40 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 2, 1914.
SALVARSAN.
During the year the remedy known as “ 606”
was supplied to The
results have been eminently satisfactory, as is shown
by the reports attached under the heading ‘‘ Yaws,”
` but the injections do not seem however to have the
various medical officers.
same consistently good and rapid effect on cases of
syphilis as on yaws, perhaps to some extent due to
the fact that the pain resulting from the injection,
and which in some cases is occasionally severe, lasts
for some time, so much so that patients refuse a
second injection.
Dr. Joslen, in a communication dated March 27,
states as follows :—
““T regret to say that patients object to the pain
caused by the intramuscular injection of salvarsan
so much that in some instances they refuse a second
injection. Just recently I have had a case of exten-
sive tertiary syphilitic disease of the vagina which
improved to an degree after one
injection; a month after I suggested a second in-
jection, but the patient absolutely refused in spite
of the marked improvement after the first
injection.”
astonishing
LUNATIC ASYLUM.
The year began with 1,169 inmates under treat-
ment, and ended with 1,195, or an increase of 26.
The total number under treatment was 1,439, whilst
the daily average number was 1,183. The number
of patients admitted was 268, or 138 men and 130
Although
the admissions were 56 fewer than last year, the
total number under treatment was greater, which
left a residuum of 26 to swell our annual increase.
The number of discharged amounted
to 150. Of these 144 were discharged recovered,
women; of these 24 were readmissions.
patients
five discharged relieved, and one not improved, two
patients escaped, one was captured, and the other
left the island assisted by his friends. The rate of
recovery caleulated on the number of admissions
was 53°89 per cent. Forty men and fifty-one
women, or a total of ninety-one died; of these one
inmate committed suicide by strangulation in his
cell, several patients admitted in a moribund con-
dition died within a few hours or days of admission.
With the exception of slight recrudescence of
pellagra among the female inmates the asylum has
enjoyed the best of health, with a marked absence
of malarial fever and gastro-intestinal diseases.
The death-rate of 7'6 per cent. on the average
number resident is one of the lowest in the history
of the institution.
Hereditary influence accounted for 75 of the
admissions. There are indications the time is
approaching for preventing those who have suffered
from insanity or who have inherited insanity on
both sides from marrying. For the sake of future
generations drastic measures are advocated for the
suppression of the unfit. Three admissions were
attributed to ganja smoking, which confirms the
opinion expressed by the Council of Evangelical
Churches that ganja smoking is spreading among
the natives of the island, and that proper steps
should be taken to suppress the cultivation and sale
of the plant.
All the buildings destroyed by the earthquake
were restored during the year, and an additional
ward for the accommodation of 100 female inmates
built. This has given us entire relief from over-
erowding, from which the asylum suffered for many
years.
A rainfall of 15°71 in. for the twelve months was
exceedingly small, and advantage was taken of the
drought to clean the grounds and repair the fences,
at the same time providing healthy occupation for
the inmates in the open air.
Mar. 16, 1914.]
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 41
Colonial Medical Reports.—No. 32.—British Guiana.
MEDICAL REPORT FOR THE YEAR 1910-1911.
By J. E. GODFREY.
Surgeón-General,
PusBLIC MEDICAL INSTITUTIONS.
Public Hospital, Georgetown.
Tuts institution has accommodation for 291 males
and 245 females; 11,059 patients were admitted
during the year, and with the 452 patients remaining
in hospital on April 1, 1910, make a total of 11,511
patients treated. The number of out-patients
treated was 41,908. There were 1,348 deaths.
This gives a death-rate of 11:7 per cent., of the total
number treated. Of the total deaths 290 or 21:5
per cent. died within twenty-four hours and no less
than 526 or 89 per cent. died within seventy-two
hours of admission.
Every year the resident surgeon draws attention
to the large number admitted in a dying condition.
This year he reports: ''A large number of these
would have had a far better chance had they come
earlier, and had the advantage of good nursing.”
He also refers especially to the high death-rate
from pneumonia due to the delay in coming to
hospital and says: ''It is quite a common occur-
rence for cases to be admitted suffering from
pneumonia of six days’ standing."
The deaths amongst children under 5 years of
age were 235 or 18:9 per cent. of the total deaths.
This is very excessive and in commenting on it the
resident surgeon remarks: ''I cannot too strongly
emphasize the fact that it is to a large extent due
to malnutrition consequent on improper feeding.”
There were 492 births in the maternity ward.
During the year 128 lectures were given in con-
nection with the nursing staff, and practical demon-
strations held in the wards in connection with the
various classes.
The following return shows the number of opera-
tions performed and the revenue derived therefrom :
Number of operations (major), 872; revenue from
paying patients, $8,874.55; revenue from operations,
$280.00: miscellaneous receipts, $341.39.
Public Hospital, New Amsterdam.
This institution has accommodation for 96 males
and 54 females.
There were 3,169 patients admitted and with 124
remaining on April 1, 1910, make a total of 3,293
patients treated. The number of out-patients treated
was 22,739.
There were 422 deaths, which gives a death-rate
of 12:8 per cent. of the cases treated. Of the total
deaths, 64, or about 15 per cent., died within twenty-
four hours of admission. There were 65 births in
the Maternity Ward.
The training of nurses at this institution has, I
regret to say, been suspended during the year, as
no provision has been made for appointing a Superin-
tendent of Nurses.
Public Hospital, Suddie.
This institution has accommodation for 54 males
and 26 females. There were 1,258 patients admitted,
and with 55 remaining on April 1, 1910, make a
total of 1,818 patients treated. The number of
out-patients treated was 4,507. There were 197
deaths, which gives a death-rate of 15 per cent. of
the cases treated. Of the total deaths no less than
185 died within seventy-two hours of admission.
There were 17 births, of which 4 were still-born.
Public Hospital, Bartica.
This institution has accommodation for 24 males
and 11 females. There were 267 patients admitted,
and with the 6 remaining on April 1, 1910, make a
total of 273 treated. The number of out-patients
treated during the year was 1,066. There were
81 deaths, which gives a death-rate of 11:8 per cent.
of the cases treated. Of the total deaths 7 died
within twenty-four hours of admission. There were
7 births during the year.
Public Hospital, Morawhanna, and Arakaka Ward.
The Hospital at Morawhanna has accommodation
for 14 males and 11 females, and the Arakaka Ward
for 12 males. There were 504 patients treated and
82 deaths, which gives a death-rate of 6°3 per cent.
of the cases treated. Of the total deaths 5 died
within forty-eight hours of admission. There were
2,924 out-patients treated.
Lunatic Asylum.
There were 460 males and 275 females in the
Asylum on April 1, 1910. During the year 72 males
and 78 females were admitted, 27 males and 29
females were discharged, and 36 males and 25
females died. The percentage of mortality on the
total number of inmates was 6:8.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
RETURN or DisEAsES AND Deatus IN 1910 iN THE PuBLIc HospiTaLs,
42
GENERAL DISEASES.
zx
Alcoholism 15
Anemia Sa es T 166
Anthrax .. $3 zz t --
Beriberi .. - 27 RE di æ =
Bilbarziosis SA as 24 es e. —
Blackwater Fever 2
Chicken-pox ee 6
Cholera .. —
Choleraic Diarrhoea 3 —
Congenital Malformation E
Debility - 258
Delirium Tremens. 1
Dengue .. —
Diabetes Mellitus | 6
Diabetes MUR 9
Diphtheria 6
Dysentery . 514
Enteric Fever 70
Frya polas ass 15
ebricula .. s an d 4
Filariasis .. oe c ae s æ. —
Gonorrhea 127
Gout es iz s xd fi oc —
Hydrophobia T gs i AD M —
Influenza .. ae : X ae . 93
Kala-Azar.. X ms 33 39 —
Leprosy .. <a i "n TS ^ 9
(a) Nodular .. - wa X. ae 1
(b) Anesthetic .. "T 2 s ; 20
(c) Mixed y € —
Malarial Fever— dm "y 44
(a) Intermittent - e oe 1943
Quotidian .. m. S oe =
Tertian .. A M và s
Quartan .. V ara me c=
Irregular .. ed ^ M —
Type undiagnosed 2 gs M —
(b) Remittent .. T 56
(c) Pernicious .. 10
(d) Malarial Cachexia.. . 9
Malta Fever $ a xa --
Measles .. at ae rs ss 2
Mumps .. zè ae T -—
New Growths— .. =
Non-malignant ^ AS m 63
Malignant e. . ee +e 71
Old Age .. ae e ae ba 6
Other Diseases .. 4. và a 12
Pellagra .. a ry ad ^ —
Plague us es ae = m —
Pyemia .. os T e oe 12
Rachitis .. A D^ m —
Rheumatic Fever ER s$ ss —
Rheumatism . Tm is os 297
Rheumatoid Arthritis ae Y "M —
Scarlet Fever E na a’ Sa —
Scurvy .. $e —
Septicemia T 58
Sleeping Sickness T —
Sloughing Phagedena .. —
Small-pox .. m va EC T —
Syphilisstgs Qu. aas dad HRS 30
(a) Primary .. ss ae Tm 11
(b) Secondary .. oe 30
(c) Tertiary F 176
(d) Congenital . 29
Tetanus 16
Trypanosome Fever —
Tubercle— 69
(a) Phthisis Pulmonalis "- |. —
b) Tuberculosis of Glands .. sa æ —
c) Lupus as T T es —
British Guiana.
Las blog Jet Mrs Do (ipo eet
wo
t em Orman
|
Pl b«ell
EMEN
ELITSE 59-11 a
ot
[*7]
[Rati lel ||
tz
os
EM
Total
Cases
€ Created
=
ar
lawl l|
GENERAL DIsEAsES— continued.
(d) Tabes Mesenterica ia
(e) Tuberculous Disease of Bones ..
Other Tubercular Diseases
Varicella .. aN 4s
Whooping PORE
Yaws ne A aa
Yellow Fever T "m
LOCAL DISEASES.
Diseases of the—
Cellular Tissue e
Circulatory System ..
(a) Valvular Disease of Heart
(b) Other Disenses .. 4
Digestive System —
(a) Diarrhoea ae
(b) Hill Diarrhea ..
(c) Hepatitis
Congestion of Liver
(d) Abscess of Liver $3
(e) Tropical Liver ..
(f) Jaundice, Catarrhal
(g) Cirrhosis of Liver
(h) Acute Yellow SUY
(i Sprue .. . e
(j) Other Diseases ..
Ear os ae m
Eye
Generative Sy: stem— 2s
Male Organs n $e
Female Organs E? -
Lymphatic System
Mental Diseases .
Nervous System an
Nose .. :
Organs of Locomotion .
Respiratory siad es
Skin— .. P os
(a) Scabies ..
(b Ringworm
yl Tinea Imbricata
)Favus ..
(e) Eczema .. Hm «s
( f) Other Diseases .. e
Urinary System . es
Injuries, General, Local—
a) Siriasis (Heatstroke) à
b) Sunstroke (Heat Prostration)
(c) Other Injuries .. v.
Parasites— ss n
Ascaris lumbricoides s qs
Oxyuris vermicularis ..
Dochmius duodenalis, or Ankylostoma duo-
denale 4 wi
Filaria medinensis (Guinea. worm)
Tape-worm .. e. T
Poisons— s ..
Snuke-bites
Corrosive Acids e: as -
Metallic Poisons T ix 2x T
Vegetable Alkaloids
Nature Unknown
Other Poisons
Surgical Operations —
Amputations, Major
Minor ..
Other Operations
E si as
Xa) Cataract T m
(b) Iridectomy š
(c) Other Eye Operations
m
—=_-_<_ M P —9Á —À
Deaths
| BuwSall 18!
| 3
noe
[Mar. 16, 1914.
Total
Cases
Treated
ISI!
Lgi j Sel | ogl
eo
t»
o
Mar. 16, 1914.]
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 43
Leper Asylum.
On April 1, 1910, there were 287 males and 126
females in the Asylum. During the year 67 males
and 29 females were admitted, and on March 81,
1911, there were 299 males and 123 females in the
Asylum. There were 87 deaths, 57 males and 30
females. The percentage of mortality on total
number of inmates was 16:2.
The buildings and grounds are in good order.
The farm was kept in good order and produced :—
Plantains 34,916 lb., valued at $849.16
Cassava 23,782 ,, » 237.32
Greens M 487 ,, 33 2.43
Sweet Potatoes 609 ,, 33 6.09
Arrowroot ds 204 ,, cR 1.00
Coco-nut Oil ... 29 galls. ,, 25.26
The majority of the inmates keep their cottages
and grounds neat and tidy. They are given small
plots of ground, in which during their spare time
they are allowed to grow vegetables, and these are
either used by themselves or sold to the store for
consumption within the Asylum.
PuBLIC DisPENSARIES.
Georgetown.
There are three dispensaries in the city with the
following boundaries :—
No. 1 Dispensary at the Police Station, Broad
Street. It includes the following wards: Charles-
town, Werk-en-Rust and Wortmanville. Medical
Officer, Dr. Edmonds.
No. 2 Dispensary at the Alms House. It includes
the Lodge Village and the following wards:
Stabroek, Robb’s Town and Bourda. Medical
Officer, Dr. Massiah.
No. 3 Dispensary at the Public Hospital. It in-
cludes the following wards: Cumingsburg, Albert
Town, Queenstown and Kingston. Medical Officer,
Dr. Wharton.
Country.
There are seven country dispensaries situated as
follows :—
(1) Demerara River.—At Akyma.
(2) Berbice River.—At Ida Sabina.
(3) Upper Pomeroon.—District extends from the
Tapacooma Lake to and inclusive of Urua. The
dispenser resides at Pickersgill.
(4) Lower Pomeroon.—The district extends from
but exclusive of Urua, to the mouth of the Pomeroon
River, and includes the Wakapoa Creek and its
tributaries. The dispenser resides at Marlborough.
(B) Moruca Hiver.—The dispenser resides at
Acqueero and the district extends from the mouth
of the Moruca River up to Kamwatta, including all
the tributaries and settlements. The dispensers in
charge are provided with corials for the purpose of
paying periodical visits to the different grants,
homesteads, and missions.
(6) Potaro.—11}4 miles from Potaro Landing and
provided with six beds for the reception of urgent
cases.
(7) Albouystown.
The following table shows the number of persons
treated :—
Police
Dispensary Shes patients Paupers
No. 1 Es a 7598 .. — 3,279
Albouystown 2,184 .. — 5,520
No. 2 s -— 610 .. — 4,868
No. 3 E mE 567 .. — .. 3,901
Demerara River ... 242 .. 22 .. 489
Berbice River P 858 .. — .. 363
Upper Pomeroon ... 188 ... 324 .. 773
Lower Pomeroon .. 869. 4; AT ni 641
Moruca Hi m 18 — ooa 1,22I
Total ... 5,224 93 21,055
The following Missions were supplied with medi-
cines free : Mallali, Chalk Hill, Sand Hills, Orealla,
Saxacalli, Capoey Lake, Mukumuku; Bedes’ Mis-
sion, Dalgin, Muritaro, Rupununi, Duffryn Mission,
Cabacaburi Mission.
Prison HOSPITALS.
The following table shows the number of prisoners
admitted and the number of deaths in these hos-
pitals during the year :—
Admitted to Died in
Institution Hospital Hospital
M. F. M.
H.M.P. Settlement ... 126 ... — 2
Georgetown ... dng ^195 5^ AB 1
New Amsterdam en b ced LO --
Suddie ... ase ace etl? on = —
Total ... .. 807 25 3
ALMS HOUSE AND ORPHAN ASYLUM.
The medical care of the inmates of these institu-
tions is under Dr. E. S. Massiah, a private medical
practitioner, who is also in charge of No. 2 Dis-
pensary, Georgetown. A large number of cases of
chronic disease, not likely to benefit by further
hospital treatment, are sent from the hospitals to
the Alms House.
SUGAR ESTATES.
The hospitals at Skeldon, La Bonne Intention,
Rose Hall, Melville, Diamond and Nismes were
repaired and painted. The hospital at Springlands
was practically rebuilt and new ranges for the
accommodation of the immigrants were erected on
many estates.
At the close of the year there were thirty-nine
estates’ hospitals with a total of 2,458 beds.
Fifty-two thousand seven hundred and thirteen
patients were treated in the estates’ hospitals, being
a decrease of 5,636 on the previous year. There
were 1,357 deaths, as against 1,386 for the previous
year, which gives a death-rate of 2°5 per cent. of
the cases treated.
It is interesting to report that the decrease in the
number of cases of infantile convulsions mentioned
in my report for last year still continues. For the
year 1910-1911 there were 138 cases and twenty-
nine deaths, as against 195 cases and fifty-seven
deaths for the year 1909-1910. This is, I am sure,
44 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
very largely due to the systematic distribution of
quinine.
In 1909-1910 there were 1,563 fewer cases of
malarial fever treated than in the previous year,
and for the year 1910-1911 there were no less than
7,556 less than 1909-1910, which, I think, shows
that the general improvements in sanitation and
the adoption of anti-malarial measures on the
estates are bearing fruit.
VACCINATION.
Glycerinated lymph is imported for the use of
the Public Vaccinators, to whom it is supplied free
of charge. There were 1,935 successful vaccinations
during the year.
HEALTH OF THE COLONY.
It is satisfactory to report that the colony has
been free of any dangerous infectious or contagious
diseases. The death-rate for the whole colony was
34°4 per 1,000 and the birth-rate 27:5.
The remarks of the Resident Surgeon of the
Public Hospital, Georgetown, as to the excessive
death-rate from pneumonia, on account of the delay
in applying for admission, and among children
under 5 years of age, due to malnutrition, are in-
teresting as they reveal important factors in keep-
ing up the high death-rate of the colony.
Infantile Mortality.
The mortality amongst children under 1 year, it
is to be regretted, still continues far in excess of
what it should be. In 1909 there were 1,872 deaths
or 209 per 1,000, in 1910 there were 1,954 deaths,
or 285 per 1,000. The mean rate for the past five
years was 210 per 1,000.
Tuberculosis.
During the year tuberculosis was the cause of
6:8 per cent. of the total mortality of the colony,
and in Georgetown 8:8 per cent.
The Society for the Prevention and Treatment
of Tuberculosis has continued its good work during
the year. I know, from being in close touch with
the working of this Society, that the scope of its
work is being gradually extended, but the want of
funds stands in the way. Its operations have now
been extended by the appointment of a '' Lady
Visitor ’’ who visits the cases under treatment, gives
advice as to the means to be taken to prevent the
spread of infection to others, and endeavours to
persuade those afflicted to take advantage of the
tubereulosis ward at the Publie Hospital, George-
town.
Leprosy.
A very interesting report on the treatment of
leprosy by nastin at the Leper Asylum by Dr.
Wise, Government Bacteriologist, and widely dis-
tributed, has been published. This report shows
the great care and attention given to this treatment,
and the enormous amount of work it involved, much
of it being of a highly technical and scientific
(Mar. 16, 1914.
character.
here.
'" An important and highly interesting report by
Dr. K. S. Wise, Government Bacteriologist of
British Guiana, has recently been issued by the
Colonial Office on the treatment of leprosy by nastin.
The report gives the results of the extended trial
of this remedy in the Public Leper Asylum at
Mahaiea during the period from December, 1908,
to September, 1910. What makes the report more
interesting is the fact that Professor Deycke, the
originator of this treatment, visited British Guiana
at the end of 1908 at the invitation of the Governor
and with the approval of the Secretary of State for
the Colonies, and remained in the colony for about
six months in order that he might personally direct
the method in which the treatment should he carried
out. When he left his instruetions were carefully
observed and the treatment was maintained strictly
on the lines he had indicated up to June, 1910,
when experience suggested some modifications:
among these was increase of the dose of nastin
hypodermically injected; trial was also made of
intramuscular injections, and single nodules were
injected. In view of the apparent failure of nastin
to cause any change or destruction in Bacillus lepre
in the nasal cavities or in the larynx weekly or bi-
weekly sprayings by means of an all-glass nebulizer
were adopted. Intractable ulcerations were treated
with ointments containing benzoyl chloride in 2} and
5 per cent. strengths. Finally benzoyl chloride in
olive oil is now being used in some patients as an
injection instead of nastin itself. These later
methods have not been sufficiently long in use to
warrant a report upon them being included in the
present one, but it is hoped to give the results at
a future date. So far as we know, although nastin
has been tried by many experts in the treatment
of leprosy, in no instance that we remember has
the test been applied before on so large and ex-
tended a seale. The reports on the former trials of
nastin have been somewhat conflicting, some experts
asserting that marked improvement followed the
use of the remedy, while others of equal standing
reported unfavourably upon it, saying that it had
no apparent effect upon the disease at all. Nastin,
our readers are reminded, was introduced by Pro-
fessor Deycke, a German medical officer in the
service of the Turkish Government, and stationed
in Asia Minor, where he had opportunities of study-
ing leprosy and its treatment. Nastin is a fatty
principle extracted from cultures of a streptothrix
which Professor Deycke found in the nodules of
lepers. It is combined with benzoyl ehloride, and is
made into ampoules with sterilized olive oil. It is
now manufactured by a German firm of chemists at
Biebrich, on the Rhine, for export. The action of
this remedy is said to be effeeted by the nastin
attaching itself to the leprosy bacillus, after which
the benzoyl acts upon the bacillus, damaging it by
the removal of its fat, when the normal fluids of
the body complete its destruction. Nastin is used
in three strengths—BO, B1, and B2, the last being
the strongest. It was nastin B2 which was employed
I cannot do better than reproduce it
Mar. 16, 1914]
throughout in British Guiana. The number of lepers
treated by this remedy in the British Guiana Asylum
during the period in question was 185, of whom 80
suffered from the nodular type of the disease, 24
from anesthetic, and 31 mixed. There was no selec-
tion of cases for the nastin treatment; any leprous
patient asking for it received it. Few of the cuses
could be regarded as early, or favourable, instances;
only 877 per cent. had had the disease to their know-
ledge for less than two years. It is worthy of men-
tion that the majority of the lepers who received the
injections declared that the treatment produced 'a
light feeling all over,' and as a result they were
observed to work harder and more willingly on the
farm or on their own garden plots. It is not pos-
sible to say how much of this tonic effect was due
to the remedy or to the renewed hopes of a cure
inspired by the injections. Dr. Wise, in summing
up the results, says that those of less than eighteen
months’ duration improved considerably under the
nastin treatment, so much so, that they might be
regarded approximately as cured. But, on the other
hand, some early cases got very much worse, though
treated precisely in the same way as the others.
It does not seem possible to foretell which course a
given patient will follow under the treatment until
it has been in progress for some time. The action
of the nastin injections appeared to be that they
initiated, accelerated, or intensified a natural pro-
cess which usually occurs spontaneously in too
small a degree or too late in the course of the
disease to be of any benefit to the patient. It is
claimed by Professor Deycke that nastin is capable
of producing reactions of a general or local kind,
the latter being confined to leprous tissue. On this
point Dr. Wise says that his experience does not
enable him to give a definite opinion; he admits,
however, that such reaction does occur in some
cases. There seem to be great variations in in-
dividual susceptibility and resistance. Probably in
the majority of cases large initial doses are required
to produce reaction; moreover, immunity to the
action of the nastin seems to arise rapidly. As has
already been pointed out, Professor Deycke claims
that the injections cause definite changes to take
place in the B. lepra, which eventually lose their
acid-fast property. In certain cases Dr. Wise found
that there had been a marked and persistent in-
crease in the bacillary changes which occur in every
leprous patient in greater or less degree; in the
majority of the cases treated by nastin a temporary
increase of such changes was observed. In a num-
ber of instances, however, no increase of the usual
natural bacillary changes was noted. Professor
Deycke claims that the injections arrest the pro-
gress of the disease. But Dr. Wise says that some
of the patients undoubtedly got worse under the
treatment, while the majority remained in statu
quo ante; a few improved, and three of them might
be regarded approximately as cured. Dr. Wise’s
conclusion is that since the favourable results are
so few longer and wider experience can alone deter-
mine whether these successful cases were instances
of natural improvement irrespective of the adminis-
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 46
tration of nastin, or whether, on the other hand,
the injections played an active part in effecting the
disappearance of the leprotic deposits. We must
contess that these results are disappointing, for we
had been led to hope that the testing of the nastin
treatment in British Guiana would yield definite and
conclusive evidence of the correctness of Professor
Deycke's contentions on behalf of his remedy for
leprosy. It is possible that if there had been selec-
tions of ' early’ cases for treatment by nastin the
tabular results might have appeared more favour-
able.”
Ankylostomiasis.
On the sugar estates steady progress was con-
tinued in the measures which have now for some
time been advocated by this department, viz. :—
(1) The erection of latrines.
(2) The systematic examination of all newly
arrived immigrants and of all persons suffering from
anemia or showing the least sign of being infected
with the ankylostome parasite.
(3) The treatment and constant observation of all
known infected cases.
In this connection it is pleasing to report that
every estate is now supplied with latrines. There
has been a very marked diminution of the number of
cases, particularly of those severe cases which were
so common a few years ago. It has also been found
practical and advisable to treat the milder infected
cases as out-patients.
The introduction every year of a large number of
ankylostome-infected East Indian immigrants is a
very serious factor in preventing not only much
better results, but also the eradication of the
disease. Last season between 70 and 80 per cent.
of the new immigrants were found to be infected.
QUARANTINE.
During the year there was: (a) Yellow fever in
Trinidad, Venezuela and Grenada; (b) plague in
Trinidad and Venezuela; (c) small-pox in Grenada.
The precautions permitted by the Quarantine
regulations were enforced, and I am pleased to say
there was no case of infection.. The disinfecting
machines were regularly tested and found to be in
good working order.
SUBSIDIZED Nurse-MIpWIVES IN DISTRICTS.
During the year twelve women qualified as
nurse-midwives. Five students received subsidies,
amounting to $137.83, to assist in maintaining
themselves whilst undergoing training at the Public
Hospital, Georgetown. The examination for these
certificates is very much more difficult than formerly.
In addition to certificates, sign plates are now given
to those women who are certified by Government
examination. Midwives’ outfits are supplied with-
out charge to certain nurse-midwives to enable them
to be in a position to properly perform their duties.
I look forward to the day when every village will
have at least one qualified nurse-midwife.
The scheme started in July, 1908, for providing
an out-door Maternity Department has worked very
46 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (Mar. 16, 1914.
satisfactorily and is being largely taken advantage
of by poor women who do not for one reason or
another care to go to the Publie Hospital. For the
year 1909-1910, 70 cases were attended in their own
homes and 1,172 visits paid. For 1910-1911, 134
cases were attended and 2,872 visits paid.
The work of the out-door midwives is supervised
by one of the divisional nurses, but the work has
So grown, and is stil growing, that the time is
approaching when it will be necessary to have a
skilled nurse in charge of this most important de-
partment. There are five subsidized nurse-midwives
in the following outlying distriets: Mahaicony,
Pomeroon, Moruca, North Western, and Enmore.
BACTERIOLOGICAL DEPARTMENT.
The assistance rendered by the bacteriologists not
only to the staff of the publie hospitals, but to
private medical practitioners, in assisting in the
diagnosis of difficult and doubtful cases is well
known, and, I am sure, fully appreciated. It is
interesting to note that out of a total of 4,481
specimens examined during the year, no less than
1,110 were sent by private medical practitioners.
The total number of speeimens examined was
4,481.
During the year specimens of halteridia, proteo-
soma, gregarines, Heterakis braziliensis, Filaria de-
marquayi were sent to the London and Liverpool
Schools of Tropical Medicine. A tapeworm of an
unknown species was sent for classification. A
collection of snakes, lizards, iguanas, &c., was also
forwarded. Pathological specimens are forwarded
from time to time by Dr. Newham, Dr. Leiper,
Dr. Payne and Dr. Boycott.
Since October, 1910, 70 patients have been treated
by injection of benzoyl chloride, which acts as a
solvent on the fatty capsule of the bacillus and thus
leaves it open to phagocytic destruction. The
strength of injections used has been 24 per cent.
and 5 per cent. of benzoyl chloride, 1 e.e. of which
was injected into the muscles of the forearm.
Ulcers have been dressed with the solution, which
has promoted healing, and a nasal spray has been
used for many eaes which showed many bacilli in
the nasal mucous membrane, with a disappearance
of bacilli pro tem. They, however, recur when the
spray is discontinued. The cases treated were not
in any way selected, several cases of the anesthetic
type, in which the bacilli are seldom found, being
included.
In a few cases where no improvement or destruc-
tion of bacilli was noted the injection was after a
few weeks increased to 2 c.e. benzoyl chloride
weekly, and one case then showed marked increase
in bacillary destruction. In many cases where a
smear preparation from the nose showed advanced
or medium destruction, a scraping from a nodule on
the ear, face or limb showed no destruction. In
several cases fresh nodules appeared, chiefly on the
face and ears, during the treatment. In eleven
cases which showed eye symptoms, iritis, corneal
uleer or phlyetenules, treatment was temporariiy
suspended until the condition improved.
Experiments are still being carried on; the results
so far may be summed up as follows :—
17:1 per cent. showed slight or no destruction.
32:8 35 Y medium destruction.
14:2 + 3i advanced destruction.
12:0 53 " very few bacilli.
371 5$ ^ no bacilli.
42 5 3 died.
The above eases were treated under strict obser-
vation and frequent estimation of the destruction
of bacilli made by the bacteriologist. Many cases
treated by the medical superintendent were not
placed under bacteriological observation, although
their clinical condition was closely observed. The
total number of lepers treated was over 200 cases.
Owing to favourable reports on red mangrove bark
treatment of leprosy being recorded in the Leper
Asylum at Trinidad, a supply of the bark was
obtained and six cases of leprosy treated. The
powder was made into an ointment with an inert
base and applied daily to three of the cases. An
infusion was prepared and used in the remaining
three cases as a lotion. Both applications have a
distinctly cleaning action, but no effect on the
nodules, either clinically or bacteriologically, as far
as could be detected in a trial extending over six
weeks. Its action appears to be that of a mild
antiseptic and astringent. Administered internally
it appears to have the effect of a mild astringent.
Chlorine-water treatment of ankylostomiasis. The
lines of investigation we adopted were as follows :—
Enumeration of Ova before and after Treatment.
—The technique was as follows: The total amount
of fæces passed each twenty-four hours was col-
lected, thoroughly mixed and weighed. A known
weight was then taken, the ova present enumerated,
and from the relative proportions the total
number of ova passed in twenty-four hours calcu-
lated. This was done before and after each treat-
ment with ehlorine water and thymol for the purpose
of comparison. In some cases the enormous total
of 585,600 ova was passed in twenty-four hours.
Enumeration of Adult Nematodes before and after
Treatment.—This was carried out in the usual
manner by means of a strainer and was done by
the medical officer personally.
Blood Estimation.—The red corpuscles were
enumerated and the hemoglobin index worked out
before and after treatment with (a) chlorine:
(b) thymol.
Differential Blood Counts were carried out at the
expiration of treatment, a period of a week being
allowed to elapse before taking the blood specimen.
Eleven eases were selected for treatment with
chlorine water, as suggested by Dr. Barnes. Each
ense was earefully demonstrated to have a large
number of ankylostome ova present before investi-
gation started.
Of these cases three were trented as follows:
11 oz. liq. chlorine was administered at 4, 5 and
—— —— — —
Mar. 16, 1914.]
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 47
6 a.m., followed by 4 oz. aperient mixture at 7 a.m.
This treatment was repeated on three occasions at
intervals of a week.
In no case were adult ankylostomes detected in
the stools. The numbers of ova present in the total
stools passed in twenty-four hours remained con-
stant.
These same cases were then treated with thymol
in the following manner: 10 gr. of thymol was
administered at 4, 5 and 6 a.m., followed by 4 oz.
aperient mixture at 7 a.m. The numbers of ova
were carefully noted, also the number of adult
ankylostomes passed in each stool during the twenty-
four hours following the administration of the
thymol and the aperient.
Case 1, numbers of adults in each stool, 290, 30,
20, 15, 12, 4, 0; total for twenty-four hours, 371.
Case 2, numbers of adults in each stool, 11, 20, 20,
11, 9, 23, 16, 0; total for twenty-four hours, 110.
Case 8, numbers of adults in each stool, 0, 14, 2, 2,
0, 0, 0; total for twenty-four hours, 18.
The total numbers of ova present showed a gradual
decrease during the same period.
Three cases were treated as follows: A mixture
of quinine sulph., 5 gr., dissolved in chlorine water,
1 oz., was administered three times daily for a
period of seven days. The result was as follows:
Case 1 passed 2 adult ankylostomes; Case 2 passed
no adult ankylostomes ; Case 8 passed no adult anky-
lostomes. The numbers of ova present in the stool
remained constant during the whole of this period.
Note.—Case 1 refused further treatment and went
out before he could be treated with anthelmintics.
Cases 2 and 8 were then treated as follows:
Thymol, 10 gr., at 4, 5 and 6 a.m., followed at
7 a.m. by 4 oz. aperient mixture.
The numbers of adult ankylostomes detected in
the feces for the twenty-four hours immediately
following treatment were as follows: Case 2,
numbers present in stools, 24, 4, 0, 0, 0; total five
days, 28. The numbers of ova present in the stool
showed a progressive diminution. The patient then
went out.
Case 8 was a very serious one inasmuch as no
treatment was effective in removing the adult anky-
lostomes from the intestines; but the numbers of
ova present in the stool remained constant and very
numerous throughout the investigation. The re-
sults of examination of twenty-four hours’ stools
were as follows: Thymol treatment, 0, 0, 0, 0, 0;
Phillip’s mixture, 0, 0, 0; beta naphtol, 0, 0, 0.
Numbers of ova present remained fairly constant.
The patient died at a later date, and a careful
search revealed a large number of ankylostomes
present in the small intestines, the total number
adherent to the mucous membrane being 156.
Two cases were treated as follows, the same
routine examination being carefully carried out:
Chlorine water, } oz., was administered every two
hours for seven days, an aperient was administered
if a daily evacuation was not obtained.
Case 1 passed one adult ankylostome only. There
were large numbers of ova present during the whole
of the treatment, the numbers showing no appre-
ciable diminution. The patient then went out,
refusing further treatment.
Case 2 passed two adult ankylostomes, and the
fæces showed presence of large numbers of ova.
The patient died before treatment with thymol or
other anthelmintics, and a search at the post-
mortem revealed the presence of 105 ankylostomes
in the intestines.
Three cases were treated as follows, and under the
same conditions as regards examination :—
Chlorine water, 1 oz., was administered every two
hours for seven days, the result being as follows:
Case 1 passed no adult ankylostomes, ova very
numerous; Case 2 passed no adult ankylostomes, a
few ova detected; Case 3, no adults passed, but
patient passed large quantities of blood and mucus,
so treatment stopped. Cases 1 and 2 were then
treated with thymol as before, the results being as
follows :—
Case 1, adult ankylostomes, 66, 52, 5, 5, 0, 52, 0;
total for seven days, 280. Case 2, adult ankylo-
stomes, 59, 1, 0, 0, 0, 0, 0; total for seven days, 60.
No ova were detected in either case.
Blood investigations were carried out in twelve
eases, the red blood corpuscles being enumerated
by the Thoma-Zeiss Hemocytometer and the hemo-
globin estimated by means of Gower's Hemoglobino-
meter.
In many cases large numbers of poikilocytes were
observed, indicating the large amount of blood
destruction present. The blood-counts generally
are very anemic in character, except in a few in-
stances, although the anemia is not of the perni-
cious type. Differential blood-counts were made by
Leishman’s method a week after treatment had
been discontinued.
Pyocyaneus.—This organism, comparatively rare
in England, is of frequent occurrence in British
Guiana. During the last twelve months upwards
of thirty specimens have been isolated from a
variety of cases.
The true B. pyocyancus has been isolated from
vat waters, and in the analysis of sixty samples of
milk its presence was detected in four. Probably
in both milk and water the bacillus was of fecal
origin, being in the latter case carried by the carrion
crows which abound in the town to the roofs from
which the water supply of the town is collected.
E. P. Miner.
PuBLIC HOSPITAL, GEORGETOWN.
The nurses and servants are drilled once a month
in fire practice by one of the senior sergeants of
the Fire Brigade.
The condition of grounds and buildings remain
much the same, only ordinary repairs having been
undertaken by the Public Works Department.
Water Supply and Dietary.—The Lamaha water
is used for bathing and washing, and rain-water,
which is stored in large tanks and vats, for drinking,
cooking, and medicinal purposes. Our total storage
capacity is 207,400 gallons.
The highest number of males in hospital on any
48 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 16, 1914.
day was 324 on January 10, 1911, and of females
the highest number was 248 on October 24, 1910.
The highest total number of patients in hospital on
one day was 561 on January 9, 1911. The lowest
number of males was 254 on May 15, 1910, and
females 149 on March 27, 1911. The lowest total
number, 411, on May 5, 1910.
The death-rate of those who come to hospital too
late for all human aid still keeps high, and shows a
tendency to increase. In all 290 died within twenty-
four hours of admission, which is 21:5 per cent. of
our total deaths.
That practically 40 per cent. of our deaths should
occur during the first seventy-two hours is indeed
discouraging; a large number of these would have
had a far better chance had they come earlier and
had the advantage of good nursing.
Our pneumonia death-rate is considerably higher
than in Europe, the chief reason being undoubtedly
due to the delay in coming to hospital.
It is quite a common occurrence for the ambulance
to bring in some poor patient in a moribund state,
having been pieked up on the side of the street,
suffering from advanced pneumonia of six days’
standing. The sick people do not realize the im-
portance of early hospital treatment, although we
are continually pointing out the dangers they run
by waiting until the last moment.
There were admitted during the year ending
March 81, 1911, 6,450 males and 4,609 females;
total, 11,059. Of these, 130 were unallotted
immigrants, 20 were indentured immigrants from
sugar estates, 855 were free immigrants from sugar
estates, and 1,639 were immigrants from other
places than sugar estates; 65 were Chinese.
There died in hospital 826 males, 522 females;
total, 1,948. This gives a percentage of 12:7 males
and 11:4 females and 12:2 per cent. on the total
number of cases treated to a termination, and is
1:2 per cent. higher than last year.
The average daily number was males 286, females
189; total, 475. The deaths of children under
1 year were males 86, females 75; total, 161. The
deaths of children from 1 to 5 years were males 45,
females 49; total, 94. This makes a total of 235
deaths in children under 5 years of age, or 18°9 per
cent. of our total death-rate.
This number is enormous, and I cannot too
strongly emphasize the fact that this to a large
extent is due to malnutrition consequent upon
improper feeding, producing an enteritis with an
accompanying broncho-pneumonia which rapidly
carries the child away.
There were 492 deliveries in the Maternity Ward
with 18 deaths, 7 of which were due to eclampsia
and 1 to septicemia. There were 78 stillbirths and
39 abortions.
There remained in hospital on March 31, 1911,
276 males and 220 females; total, 496. The out-
door patients for the year were 16,617 males and
95.901 females, a total of 41,908, which is 1,648 less
than for the previous year, 1909-10.
There were admitted into the Phthisical Ward
122 males and 51 females; total, 173. There died
in this ward during the same period 82 males and
15 females; total, 47. And there were discharged
61 males and 48 females; total, 109.
The death-rate from pneumonia for the year was
44:5 per cent.
Practically all these cases were admitted in an
advanced stage, and as pneumonia is a disease
which lasts as a rule about eight days, if only those
suffering from it would come in earlier I am certain
in a very short period we should have our death-
rate down as low as that obtained in European
hospitals.
Typhoid fever shows a large increase for the year;
in all we had 60 cases with 19 deaths, or a death-
rate of 31:6 per cent. There were twice as many
cases as the year before, and ten times more than
five years ago. The disease is certainly increasing
annually and already the numbers are becoming
alarming.
A. J. CRAIGEN.
PuBLIc HOSPITAL, New AMSTERDAM.
The Publie Works Department did the following
repairs: Relaid concrete in No. 1 Laundry and made
new troughs, repaired floors in the wards, relaid
boiler wall and repaired range. The roads and
grounds are in good order.
The pail system is employed, and the excreta
removed daily by the Town Council. A bathroom
and a lavatory is attached to each ward. The
drainage of the grounds is by open drain.
The water supply is of two kinds, viz. : rain-water
for cooking and drinking purposes stored in tanks,
and creek water for bathing and laundry work.
There are 150 beds in the hospital. The highest
number resident was on July 24, 1910, when there
were 101 males and 57 females; total, 158. The
lowest number resident was on April 25, 1910, when
there were 82 males and 33 females; total, 115.
A. A. McKrxnoy.
EN
Nw
Pusuic HospiTAL, Suppie.
Sanitary Arrangements and Drainage.—The con-
tents of the soil buckets are dumped into trenches
in the portion of ground to the south of the hospital.
The drainage is fairly good.
The Water Supply consists of rain-water collected
from the roofage of the hospital and is stored in
three large iron tanks, two of which have a capacity
of 36,000 gallons, and the third a capacity of 25,000
gallons.
The greatest number of patients in hospital on
any one day was 95, on March 9, 1911. The least
number of patients in hospital on any one day was
50, on March 4, 1910.
Of the 197 deaths for the year 135 died within
72 hours of admission. The daily average number
in hospital was 68:199. There were 4,567 out-
patients treated. There were 17 births, of which 4
were stillborn.
J. Snorro Dove as.
April 1, 1914.]
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA.. 49
Colonial Medical Reports.—No. 32.—British Guiana—
(continued).
Pusuic HOSPITAL, Bartica.
The conduct of the staff was satisfactory. Build-
ings in fair order. Sanitary arrangements and
drainage good. Water supply and dietary ample
and good.
Accommodation: Male Ward, 24 beds; Female
Ward, 11 beds; total, 35. 7
The greatest number in hospital on any one day
was 16 (November 2, 1910), and the least number
was 1 (December 29, 1910).
Of those who died: 4 died within twelve hours
of admission, 7 within twenty-four hours, 2 within
forty-eight hours, 3 within seventy-two hours. The
death-rate on the total treated was 11:8.
J. TEIXEIRA.
Pusuic HosPrTAL, MorawHanna, N.W.D.
The hospital at Morawhanna has accommodation
for 14 male and 11 female patients.
The Arakaka Ward has aecommodation for 12
patients.
During the year under review the number of
admissions was as follows, viz.: Males, 388;
females, 149. "There remained in hospital from the
previous year: Males, 11; females, 6.
The number of deaths in the institution during
the year 1910-1911 was: Males, 26; females, 6.
The principal diseases treated this period were:
Malarial fever, diarrhea, dysentery, anchylostomia-
sis, pneumonia, and phthisis.
The death-rate on total number treated was:
Males, 7:4 per cent.; females, 3:8 per cent.
Some of the cases treated came into hospital in a
moribund condition. Of those that died within
twelve hours after admission there were 3 males.
Of those died within twenty-four hours, 2 males.
Of those died within forty-eight hours, 4 males and
1 female. Of those died within seventy-two hours,
1 male and 1 female.
Public Hospital, Morawhanna.—The building is
commodious and well ventilated, the one serious
drawback being the troolie roofing. At present there
is considerable leakage in the operating theatre
owing to the separation of the joint between the
theatre and the main building due to the sinking
of the former. Troolie, as a rule, presents serious
objections, since it constitutes the habitat of the
rat, bat, wood-ants, beetles, fleas, cockroaches and
similar pests. The chief objection to it lies in the
fact that the water collected for drinhing purposes
for patients in the hospital is liable to frequent and
easy contamination, by reason of the dead decom-
posing bodies of the pests enumerated above pass-
ing in minute particles into the water so collected
in the vat. Recently samples of water from vats
within the compound were examined by the Govern-
ment Bacteriologist and the report so far as pro-
ducing disease was concerned was favourable; yet
the troolie roofing is a constant menace to health
statistics of the hospital, and this menace should be
removed.
Hospital Compound, Morawhanna.—The com-
pound has been kept constantly cleaned during the
year. The place continues to be light and cool.
The Village of Morawhanna.—The local sanitary
authority has recently rebuilt the principal thorough-
fare and now it is in fair condition. The drainage
of the village is in a very deplorable state. The
main draining trench and various other small
trenches that empty into it required digging and
cleaning. With regard to the sewage disposal, the
pail system should be substituted for the present
system, which consists of closets over trenches that
are tide flushed.
Arakaka Ward.—The building has accommodation
for twelve patients. It is very well ventilated and
has been tidily kept during the year under review.
Some minor repairs have been done to it and it is
now in very fair condition. The roofing is of troolie,
which presents a similar menace to the roofing at
Morawhanna and should be removed.
Regular distriet visits have been made during
the year. The sanitation is good. Frequent visits
have been made along the Barima-Barama road and
the people found to be fairly healthy.
Barama River.—Regular quarterly visits were
paid to this district. It is not as healthy here
as in other portions of the north-western district.
Malaria, anehylostomiasis and gastro-intestinal dis-
turbance were among the chief ailments. Free
medieines have been regularly supplied to the
Mission at St. Bede’s, where many of the
aboriginals congregated. Quinine has been freely
distributed and it is found to be of decided benefit
to the inhabitants of this district, the number of
fever cases from this part steadily decreasing.
Gro. E. CARTO.
PuBLIC Lunatic ASYLUM, BERBICE.
The grounds have been kept in fair order, free
from weeds, and flower-beds laid out; the drains
have been kept in good order; during the year the
main drainage trench was dug by prison labour.
The sanitary arrangements and drainage continued
to be the same as in previous years; the necessity
of concreting the drains carrying off slop-water from
bathrooms and sculleries continues, but lack of
funds prevents this being done. The excreta are
buried in pits dug for the purpose.
The rain-water in the tanks and vats attached to
the buildings and the creek water from the water-
works have proved sufficient for the actual needs
of the institution; during the year all but two of
the vats and tanks were cleaned internally, and the
date of the cleaning marked on the outside; they
all remained mosquito proof and free from gross
impurities. The quality of the creek water is the
same and its dirty brown colour is specially notice-
able on the days that the fire brigade calls for
pressure.
The dietary of the attendants and patients has
been ample and of good quality; the enamel food
buckets with covers have done good service and have
worn well; their advantages in rainy weather have
been well demonstrated.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
The chief diseases treated were: Intermittent and
remittent malarial fevers, diarrhoea, dysentery, lung
affections and cutaneous eruptions, besides the usual
forms of insanity. There were no cases of epidemic
disease during the year. The usual preventative
dose of quinine was administered weekly to every
attendant and patient during the last quarter of the
calendar year, with satisfactory results.
Employment: In addition to the usual forms of
employment suitable for the patients, the making
of coconut oil for the use of the female patients has
been started; this not only provides employment
for a certain number of females in picking the husks,
but also saves the value of sweet oil for toilet pur-
poses.
There were only two escapes, one male patient
being brought from Smithfield about six hours after
having been missed, and the other a male East
Indian, found a short time afterwards; there were
nine attempts at escape, but in these the patients
did not go beyond the asylum boundaries.
Q. B. DE FREITAS.
PUBLIC LEPER ASYLUM, MAHAICA.
Sanitary Arrangements and Drainage.—The pail
system is in use, the excreta being buried and soiled
dressings burnt. The drainage of the asylum is
perfect. Two concrete drains were built at a very
small cost.
The water supply is sufficient, though there are
a few vats in very bad condition. :
The behaviour of the inmates was good; abscond-
ing continues, but to a very limited extent.
Average daily school attendance: Male,
female, 8. ;
Amusements.—Concerts, dramatic performances,
dancing, cricket and football matches and other
athletic sports and amusements, including magic-
lantern demonstrations, were indulged in by the in-
mates. The harmonium, gramophone and musie-
box are in good condition.
The farm is in excellent condition—everything
grown is turned to account.
The coconuts are now gathered and used for
making oil; the husks are used as fuel in the kitchen.
The death-rate on the total number of inmates
treated was approximately: Males, 15; females,
19:8.
There were four cases—two males and two females
—discharged by order of His Excellency the
Governor, cured, the result of nastin treatment.
The diseases principally treated other than leprosy
were malarial fever, diarrhea, dysentery, bronchitis,
Bright’s disease, and tuberculosis.
The nastin treatment was continued through the
year—judging from the bacteriological reports, the
clinical and physical appearances, a large number
of the inmates have benefited greatly by the treat-
ment. They are most anxious to submit themselves
to treatment. J. S. NEDD.
17;
Colonial Medical Reports.—No. 33.—Grenada.
MEDICAL REPORT FOR THE YEAR 1911.
By EDWARD DRAYTON.
Colonial Secretary.
METEOROLOGICAL RETURN FOR THE YEAR 1911.*
TEMPERATURE RAINFALL WINDS
Montu E AE of 8 2 i5 2$ SP ai £z
BE Bz $8 22 & HE! e$ | $= ES 22
$5 £z FE iz a | “pe EE | BE Hs sé
Us E ae 2s | 85 EE Az ox <
(8
d P3 a.m, a. d. ^ I a.m, y.
January ... 126:0 140:0 69:0 84:0 58 | -656 500 | 720 N.E. 159:0
February 105:0 141:0 69:0 87:0 50 | 699 2:7 740 | N.E. 92:4
March 1380 142:0 68:0 90:0 TT "635 0:96 64:0 N.E. 125.8
April 123:0 141:2 71:0 87:0 6:0 “713 1:67 70:0 | N.E. | 139°3
May 131:0 142:0 72*0 90:0 5:9 "145 3:41 72:0 E, 137:1
June 96:0 | 140:0 71:0 85:0 36 '801 19:36 82:0 E. 101-4
July 110:0 | 141:0 72:0 86:0 4:7 "IST 5:52 | 77:0 E. 142:0
August ^a ..] 1170 | 1410 74:0 90 0 44 '819 7:98 75:0 E. 185-6
September rA ..| 199:0 141:0 72:0 90:0 | 4&7 "823 7°86 77:0 E. | 977
October ... : 121:0 | 141:0 73:0 90:0 55 | 812 3:15 74:0 S.E. 60:8
November 113:0 | 140:0 72:0 87:0 | 47 ! +795 5:86 77:0 E. 137:5
December 124:0 141:0 71:0 86:0 | 40 "146 5:64 11:0 E 1804
Averages... 119:4 140:9 TL2: BTT | 532 "192 576 | 74°2 E 1241
* At Richmond Hill Meteorological Station in the South of the Island,
April 1, 1914.]
COLONIAL MEDICAL REPORTS.—GRENADA. 51
RETURN OF STATISTICS OF POPULATION FOR THE YEAR 1911.
Population of Colony at census on April 2,
1911 iX As se des 66,720
Estimated births from April 3 to December
81,1911 .. ae Vi .. 2,024
Estimated deaths from April 3 to
- December 81, 1911... Sg 905
Increase of 1,119
: 67,869
Excess of emigration over immigration ... Leche 21
Estimated number of inhabitants at ‘
December 31, 1911 sis e 67,848
Cotony HOSPITAL.
The total number of patients admitted to the
hospital during the year was 902, a decrease of
fifty on the numbers of the previous year.
The following table shows a comparison with the
two previous years :—
1911 1910 1909
Number of patients treated ... 971 ...°1,08L ... 843
2$ m discharged cured 674 ... 627 ... 4062
eus H ` 4, relieved 169 ... 298 .., 250
» 25 who died sce BO us 87 .. 52
3» “a remaining De-
cember 31 as en He ip 199 45 69! cx, “FF
Average stay of all patients in hos-
pital ... wa was $53 .. 907 30:2 ... 36:2
Of the thirty-six deaths, twenty were males and
sixteen females; the percentage mortality being
3°7 per cent.
There were fifty-four paying patients and forty-
five constables under treatment in the hospital
during the year.
The number of patients suffering from venereal
disease and ulcers treated in the hospital was 244.
The average stay of these patients was 47°61 days.
Regarding the prevalence of ankylostomiasis in
the island, the number shown under that head in the
list of diseases gives an erroneous impression of its
occurrence. The numbers shown in the list of
diseases enumerate only those cases of ankylosto-
miasis which were uncomplicated. As shown in
the report, 60 per cent. of the sick population treated
were suffering from this disease; and further work
has assured me that that figure is not an exaggerated
one.
The following table shows the attendances in the
Out-patient Department during the year :—
Number of Prescriptions issued.
Free Sas wae ase ; 1,032
Payment Di A "P im 720
Number of Attendances.
Panpers ... 37 ET. Tt a 40
Labourers’ children — ... Sa bs 324
Aged "e" va $e esi DA 68
Police constables sa sss TA 164
Labourers "s $us "m X 723
As bacteriologist I was called upon to inquire
into the nature of the outbreak of anthrax at
Dougaldston Estate, Gouyave; and I wish here to
thank Dr. O'Neale, Mr. Saunders, and Sergeant
Briggs for the assistance given me in the sending
of samples and preparation of blood filma,
R. P. Cockry,
Resident Surgeon.
Yaws HOSPITAL.
The total number of patients treated during the
year was 339, of which number 268 were admitted
during the year.
The number of discharges during the year was
276; of these 178. were males and ninety-eight
females.
Two deaths occurred during the year, one a male,
the other a female. The cause of death in each
case is certified as due to an inter-current malady
and not to yaws.
During the year a limited number of cases have
been treated with salvarsan, and the results ob-
tained have been such as to justify further work
being carried out with this drug. Some cases are
at present under treatment in the institution and
are making good progress.
The remarks made in the report on the Colony
Hospital regarding ankylostomiasis are even more
applieable in the case of yaws than of other patients,
and it is exceptional to examine specimens from
yaws patients with a negative result.
R. P. CockiN,
Resident Surgeon.
Sr. ANpnEW's District HOSPITAL.
The admissions for the last five years are de-
tailed beneath :—
1907 1908 1900 1910 1911
Admissions ... 145 ... 166 ... 150 ... 165 .. 166
No changes occurred in the staff during the year.
No one had either vacation or sick leave. One
Hamilton Joseph was accepted as a student in the
dispensary, with His Excellency's approval, in May.
The birthplaces of those treated in the hospital
were: Barbados, 7; St. Vincent, 8; Trinidad, 3;
India, 4; Africa, 1; Carriacou, 3; Grenada, 140.
The hospital buildings are in good order. The
Publie Works Department has promptly remedied
minor defects whenever reported. The grounds
about the hospital have always been neat and well
kept.
The free prescriptions have increased from 2,606
in 1901 to 6,499 in 1911.
The quantity of quinine used in the distriet dis-
pensary is given beneath as it affords some indica-
tion of malarial fever treated in the district :—
1911
1907 1908 1900 19 0
13 Ib. 4 oz. ... 12 lb. 8 oz. ... 15 lb. ... 121b. 8 oz. ... 11 Ib. 2 oz.
The reduction in the amount used is due to a
subsidized dispensary in Dr. Whiteman's distriet,
established in 1910.
N. S. Durrant.
BsSLLE Vue HOSPITAL, CangRIACOU, GRENADA.
Seventeen patients remained in from the previous
year and 196 were admitted—making a total of 218
treated for the year.
The average number of patients per day was 2075.
Two deaths oceurred in hospital—one from intus-
susception of the bowel, the other from lobar pneu-
monia.
The buildings are in fine order, beautifully
52
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
Return or Diseases AND Dearas 1N 1911 iN THE Cotony, Yaws, Sr. ANDREW’s AND CARRIACOU HOSPITALS.
GENERAL DISEASES.
Admis-
Alcoholism 2. ts os
Anemia .. oe En DX
Anthrax .. v.
Beriberi x
Bilbarziosis i
Blackwater Fever |
Chicken-pox oe
Cholera
Choleraic Diarrhoea zs
Congenital Malformation es $e =
Debility .. s Y ete ae ^
Delirium Tremens T t
Dengue ..
Diabetes Mellitus '
Diabetes Insipidus ss "T
Diphtheria we os .
Dysentery .. "T Ac s
Enteric Fever .. En Té
sipelas .. m
Febricula .. T $$ NE acl
Filariasis .. vs T z3 gs ES
Gonorrhea
Gout 3 EM vs "m v à
Hydrophobia Y ats ys e es
Influenza .. oe a «s ate 5
Kala-Azar..
Leprosy ..
(a) Nodular .
(b) Anæsthetic ..
(c) Mixed oe
Malarial Fever—
(a) Intermittent
Quotidian ..
Tertian .. we
Quartan
Irregular ..
Type undiagnosed
(b) Remittent .. aie ar it
(c) Pernicious .. se vs
(d) Malarial Cachexia. .
Malta Fever és
Measles .. EA "n vs N-
Mumps .. os oe es «e
New Growths— ..
Non-malignant
Malignant oe
Old Age... s
Other Diseases
Pellagra ..
Plague *-
Pyæmia
Rachitis "
Rheumatic Fever
Rheumatism
Rheumatoid Arthritis
Scarlet Fever
Scurvy .. es vs
Septicemia ee ee
Sleeping Sickness
Sloughing Phagedena
Small-pox .. os
Syphilis .. z5
(a) Primary és
(b) Secondary .. 25
(c) Tertiary ita
(d) Congenital ..
Tetanus
Trypanosome Fever
Tubercle—
(a) Phthisis Pulmonalis ‘
(6) Tuberculosis of Glands ..
(c) Lupus PE $s E
sions
m | Deaths
(a) Cataract,
Grenada.
sti
£ 8 1 GENERAL DiskEASES— continued.
= (d) Tabes Mesenterica 3 si
2 (e) Tuberculous Disease of Bones ..
17 Other Tubercular Diseases
a Varicella .. . T ais afe s.
= Whooping Cough is "s i5 zs
S Yaws i st a ae T
1 Yellow Fever č. A Ts € E
s= LOCAL DISEASES.
Diseases of the—
Cellular Tissue ee T ss oe
— Circulatory System .. T ET
1 (a) Valvular Disease of Heart :
-- (b) Other Diseases .. vá ds "
— Digestive System— .. cs T oe
20 (a) Diarrhoea a és a vs
-— (b) Hill Diarrhoea .. 7A és r
(c) Hepatitis vs X oa 2s
— Congestion of Liver .. oe we
— (d) Abscess of Liver es -
11 (e) Tropical Liver .. x 55s H
— (f) Jaundice, Catarrhal .. ot gs
— gi Cirrhosis of Liver T, a
1 ) Acute Yellow d A
-- tà Spre .. cs s
— U) Other Diseases .. s S es
— Ear P Er: Se vi Sx as
—- Eye Y» vs oe ae
— Generative System— ar y m vs
— Male Organs mm es se ..
— Female Organs i ee em v.
— Lymphatic System .. T s ws
100 Mental Diseases T E «e vs
— Nervous System ee T 3S =
— Nose .. : ae S ve
— Organs of Locomotion z: ss we
— Respiratory System .. oe T os
— Skin— .. ox ys de os "
23 (a) NM s an m Er oe rf
— (b) Ringw X fe we
— | Tinea Tabrieata .à ae ae
— o Favus .. s: T es aa
— (e) Eczema .. T we T ae
14 ( f) Other Diseases .. E is p
3 Urinary System Vs DE fa sa
— Injuries, General, Local— "n e Js
— (a) Siriasis (Heatstroke) ba EN
— (b) Sunstroke (Heat Prostration) A
— (c) Other Injuries .. ss T
1 Parasites— ee T ss
-— Ascaris lumbricoides .. ee i
— Oxyuris vermicularis .. A
27 Dochmius duodenalis, or Ankylostoma duo-
— denale T ie
— Filaria medinensis (Guinea. worm)
— Tape-worm oe is T . ‘
-— Poisons— js Tm T Ss os
-— Snake-bites — .. T Se -
-— Corrosive Acids fà ss «e "m
— Metallic Poisons es $e T zs
— Vegetable Alkaloids .. ss «s
2 Nature Unknown «e 35 zs ae
61 Other Poisons Ta id ar c
4T Surgical Operations— .. ps ss sie
5 Amputations, Major .. ae ae ee
1 Minor .. 2s T SH
-— Other Operations a
— Eye .. d ae
(b) Iridectomy A 2d $ 45
(c) Other Eye Operations. E .
wo
~
e% | coves af wel a RE
43
E PI Now
J
elol eel ll ell lawl &
Deaths
Elis E dmol iiiI] enlo! monli ollet IILE i l mele lelllil
b Ese EEEE
—ewezl-|$SS8sclllilgS5aSesSESIS$llse-l-ls&liusl&2lt
all dod asd Lp s
April 1, 1914.]
situated on the top of a hill, they are spacious,
clean, and well kept.
Twenty-two cases of malaria were treated in
hospital. They were admitted chiefly along the
coast-line and especially the district round about
L’Esterre, where the area is covered by swamps.
One case of tetanus was successfully treated by
hypodermic injections of curare. It is perhaps early
to dogmatize on the benefits of this drug in the
treatment of tetanus—the fact remains that the
case referred to was one of more than ordinary
severity and the result was very gratifying.
Uleers are very common in this district and seem
to prevail in the last quarter of the year. A small
amount of cleanliness would prevent the formation
of many an ulcer.
Epwin WErLs, M.B.,
Medical Officer, Carriacou District.
Lunatic AsyLuM, RicuMoNp HILL.
The total number under treatment during the
year was 159, seventy-six males and eighty-three
females; last year the number was 170. This de-
crease in numbers is due to admissions from St.
Lueia having been stopped, on account of the over-
erowded state of the asylum.
The year opened with 134 inmates, sixty-five
males and sixty-nine females.
During the year there were twenty-five admis-
sions, eleven males and fourteen females, including
one male and three females from St. Vincent.
Of the twenty-five admissions, fifteen were ad-
mitted for the first time to an asylum, and ten had
been in this or some other asylum at least once
before.
There were twenty-three discharges, twelve
males and eleven females. Three of the males
belonged to St. Lucia and three females to St.
Vincent, nine males and eight females belonged to
Grenada.
The average stay of the twelve males discharged
was 244 days, while that of the eleven females was
nearly five years; the longer average stay of the
latter was due to the three St. Vincent females
who had been in for many years and were dis-
charged to be sent to the Poor House.
There were nine deaths, six males and three
females.
The percentage of deaths based on the daily
average was 6'91.
The percentage of discharges based on the num-
ber of admissions was 94.
The number remaining in at the end of 1911 was
127; males fifty-eight, females sixty-nine.
There were three cases of enteric during the year,
one among the male inmates and two among the
female. All terminated favourably.
There were a few cases of injury to patients
caused by patients, but nothing of a serious nature.
Seclusion under lock and key was resorted to on
eighty-two occasions, chiefly because the offender
would not keep on his or her clothes. The restraint
belt was used seven times.
A considerable number of the male inmates were
COLONIAL MEDICAL REPORTS.—GRENADA. 53
employed in agricultural work on land belonging to
the asylum, while others were employed as car-
penters, masons, painters, cooks, and scavengers.
The women are chiefly employed in sewing and
washing clothes for this institution and for the Poor
Asylum.
Very little can be done in the way of amusing
the inmates, but the men play ball and marbles;
music is provided and dancing arranged for once or
twice a year.
One or more religious services are held every
week.
A system of water closets is at present being
installed, and should prove a great benefit to the
institution. These closets will discharge into septic
tanks outside the asylum walls.
The attendants and servants performed their
duties satisfactorily throughout the year. The staff
of female attendants was increased by one, to per-
mit of one half of the staff being off duty every
evening.
E. F. HATTON,
Medical Superintendent.
REPORT OF DISTRICT MEDICAL OFFICERS.
District No. 1.—Sr. GEORGE'S.
The probable population of the district for the
year under review would be about 6,637, and is
obtained by adding certain figures calculated from
the census returns to the excess of births over deaths
from April 2 to December 31, viz. :—
Population of town (4,916) less 180 to No. 3 District 4,736
Population of parish sections 1, 2, 3, and 5 (2,353)
less 300 to Woburn and 200 under section 5 1,853
Exeess of births over deaths from April to Dec. 81... 48
Total ... es -. 6,637
Population T A e «ex ig: .. 6,637
Births during the year ... Pes ast dis va 182
Deaths during the year... "e T ive Pr 97
Birth-rate per 1,000 a ae : .. 27°42
Death-rate per 1,000 14:61
The population return for the previous year was
given as 7,511, but I am inclined to regard that as
excessive and to place more reliance on the present
figures. No account is taken in this caleulation of
the effects of emigration or immigration.
There was a good deal of sickness during the latter
five months of the year due to a prevalence of
malarial fever and dysentery and the occurrence of
an epidemie of influenza; this epidemie was wide-
spread, persons of all ages being attacked; the
character of the disease was severe in some cases,
three being complicated with pneumonia, one with
pleurisy and many with severe bronchitis.
Of 624 cases of malarial fever seen during the year
105 were met with during the month of October.
The total number of deaths recorded was 97, repre-
senting a death-rate of 14°61 per 1,000 of the popu-
lation; of this number 22 were of children 1 year
old and under; the mortality was fairly evenly
distributed over the whole year.
The prevalence of rains during the latter part of
54 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
I [April 1, 1914.
the year would be instrumental in determining the
increased amount of sickness recorded for that
period.
Particular Digdases that have jenti during the
Year.
Pulmonary Tuberculosis.—This disease still main-
tains its prevalence; there were more new cases
seen this year than during the last; the same factors
exist for facilitating its occurrence, viz., faulty
domestic hygiene and absence of institutional treat-
ment for arresting the disease during its early
phases and for the segregation of advanced cases
with the object, amongst others, of removing
sources of infection. The contemplated special
hospital for pulmonary tuberculosis is urgently
needed, and by the provision of which much relief
is anticipated.
Yaws.—Of eleven cases of this disease that were
recommended for admission to hospital, seven only
originated in this district, which can still claim a
comparative freedom from this loathsome disorder.
Dysentery.—There were 113 cases with 5 deaths,
as compared with 42 cases and 2 deaths for the
previous year; it will be apparent by the mortality
that the disease was not of a severe type.
Malarial Fever.—The number of cases of this
disease seen was 624, and the number of deaths
attributed to it. was 4, all being among children
from 2.45, years and under; the fatal result in three
eases being directly attributable to convulsions, the
result of high temperatures. The absence of any
deaths among adults testifies to the mild type of
fever.
There was one ease of black-water fever, seen in
a child aged 5 years, occurring at Grand Mall,
outside this distriet; the case gave a history of
frequently recurring attacks of malarial fever which
had only received home treatment.
Leprosy.—One fresh case was seen and recom-
mended for admission to the Pauper Asylum, which
is the only institution at present available for the
sporadic cases that occur. A death took place from
acute laryngitis and bronchitis in a ease of the
disease previously reported.
Syphilis.—Sixty-two new cases of this disease
were seen and were made up as follows: Congenital
22, primary 11, secondary 14, and tertiary 15
Under the last heading a great number of old
acquaintances keep on reappearing, the inclusion of
which would tend to augment these numbers very
considerably. There were four deaths all among
the congenital cluss.
During the year I employed the treatment by
salvarsan (** 606°’) in two cases and in conjunction
with Dr. Mitchell in a third; the method adopted
was the intramuscular injection and the advisability
of following this up with some form of mercurial
treatment was emphasized; the results were satis-
factory; the expense of this form of treatment is,
of course, prohibitive to the many.
The well-recognized difficulty of getting patients
to submit to treatment for a sufficiently long period
is constantly being experienced, and this even among
those of an intelligent class.
Typhoid Fever (Enteric).—Two cases were seen
for the year; of these only one originated in the
district, the other being brought in from St. John's;
it arrived in the town on December 10 and ter-
minated fatally from intestinal hemorrhage on
December 14. An isolation ward at the Colony
Hospital is a necessity for such cases, especially
when the disease oecurs among the poorer class oí
patient.
Ankylostomiasis.—During the year, of twenty-
seven cases seen and recommended for hospital
treatment, only five originated in this distriet; two
in town, two at Grand Anse, and one at Woodlands
the remaining twenty-two came from’ differen
localities over the island. This district ean be con
sidered to suffer very little from this disease; at any
rate, it is rare to come across a case that exhibits
the characteristic anemic appearance which stamps
those that harbour, to a marked extent, the parasite
(Ankylostomum duodenale) of the disorder, for it is
a recognized fact that ‘‘ there may be dozens of
ankylostomers. in the intestine without any appre-
ciable anemia, or, indeed, symptoms of any descrip-
tion whatever. One must be careful, therefore,
to avoid concluding that the ankylostomum is the
eause of every pathological condition with which it
may chance to concur.”
Filariasis.-—One case of filarial disease was seen
and recommended to hospital; the right leg and
thigh were affected, and the disease was present as
lymphangitis, abscess, and some elephantiasis of
the limb in question. The history of the case was
as follows: He lived in Trinidad for seven months
in 1907, when he suffered from his first attack; he
had a second in Grenada a year previous to this, his
third attack. All the cases of filariasis I have seen
here have contracted the disease outside of this
colony; I have never seen a case in which the in-
fection ean be ascertained to have originated here:
I naturally conclude that in this case the infection
took place in Trinidad.
The general sanitary eondition of the district was
on the whole good. The epidemie of influenza
already referred to, in spite of being widespread,
was not responsible for any deaths; nor were the
eases of malarial fever seen, though greater in
number than that of the previous year, severe in
type, as is evidenced by a mortality of only four
and that among children.
I am unable to record any practical advance in
anti-malarial works for the vear under review; a
committee, however, appointed for making recom-
mendations on this subject, has recently sent in an
exhaustive report.
The water supply in the town is plentiful and
good, and the extension of a service to Belmont a
great blessing to residents in that direction.
The very desirable removal of siltings in the
Carenage, it is anticipated, will form part of a
scheme for harbour improvements under contem-
plation by a committee recently appointed for that
purpose. There still exists considerable discomfort
and annoyance from the pollution of the air conse-
quent on the method adopted in the disposal of
night soil; the introduction of an efficient water
April 1, 1914]
sewerage system to remedy this evil is by no means
one of the least necessary improvements to be
envied.
The number of successful vaccinations of infants
was 151; this was less than that of the previous
year owing to the prevalence of influenza among
children during a certain period.
The vaccination and re-vaecination of adults
imposed as a result of travelling regulations assist
with the vaccinating of infants in maintaining a
high standard of efficient vaccination of the com-
munity and thereby a protection from small-pox.
Quarantine restrictions were imposed against
Brazil for plague and small-pox; against Venezuela
for plague, small-pox and yellow fever; against
Trinidad for plague; and against Panama for yellow
fever. The usual precautions of fumigation of ships
and surveillance of passengers were adopted, and it
is pleasing to record that none of these diseases
gained an entrance into the colony. The Quarantine
Station was not occupied for the year.
The following duties, imposed by the Quarantine
and Rats Ordinances, were performed for the year:
Visits of inspection paid to ships, 57; number of
vessels fumigated, 41; number of passengers ex-
amined daily during periods of surveillance, 365;
the number of Bills of Health issued was 176.
G. W. Paterson,
Medical Officer, No. 1 District.
District No. 2.—Ricnmonp Hinr.
The estimated population is about 4,500, and
includes one of the most desirable residential dis-
tricts in the Colony. The greater part of it is
situated on high ground, is well supplied with
water, and is practically free from malaria, but there
are certain localities, such as Woburn and Caliviny,
which are malarial and are badly supplied with
water.
The health of the district was above the average
as compared to previous years, no disease was
epidemic or even more than usually prevalent. The
only disease notified under the Infectious Diseases
Ordinance was enteric, of which there were five
cases, three of them occurring in the lunatic asylum.
Five cases of yaws were sent to the Yaws Hospital.
There were 118 vaccinations performed during
the year.
No special sanitary work was undertaken during
the year, but the sanitary inspector was active and
did some good work.
There is great need of an organized campaign in
sanitary matters, especially in regard to the disposal
of excreta. Latrines are conspicuous by their
absence among labouring classes and small pro-
prietors. The usual method of disposing of excreta
is to throw it on the land, without any pretence at
covering it with earth. It is not therefore difficult
to account for the prevalence of dysentery, diar-
rhea, and ankylostomiasis.
The districts of Woburn and Caliviny are very
badly off for water, being dependent on ponds and
rain water stored in tanks; this has to be carried
-COLONIAL MEDICAL REPORTS.—GRENADA. .- 55
long distances, and is deficient both in quantity and
quality. A fair supply could be given to these
places by laying a pipe from the reservoirs of the
St. Paul's Water Works at Richmond Hill, along
the ridge through Morne Jaloux to'the Main Lower
Road at its junction with the Woburn Byeway,
where it might connect with the pipe of the River
Soulier Water Works continued from Belmont.
Overerowding in the houses of the labourer and
peasant proprietor, especially at night, is responsible
for a great deal of sickness, but it is an evil which
can only be overcome by an increased earning
capacity of the people, and a general improvement
in the standard of living.
E. F. HATTON,
Medical Officer.
District No. 3.—ST. GrORGE’S.
The general health of the district was fairly good
during the year. Malarial fever, however, showed
little diminution on the previous year, there being
443 cases treated as compared with 445 in 1910.
No epidemics occurred during the year.
The mortality was fairly constant throughout,
and apparently did not show the usual increase
during the last quarter. The infant mortality was
much below that of the previous year, the latter
being exceptionally high owing to the epidemic of
whooping-cough.
One further case of beriberi in its convalescent
stage was seen in the early part of the year, the
disease being contracted at Brazil.
I am of opinion that ankylostomiasis is on the
inerease in this district. Formerly it was prac-
tieally confined to Mt. Moritz, Constantine and
Boca, but it seems now to be spreading to all parts
of the district. The time has arrived when active
measures should be adopted for controlling this
disease.
The sanitary condition of the district is good. . No
new anti-malarial measures were carried out during
the year. The drains which were opened in the
Willis Distriet last year have been kept open and
have effected much improvement.
Two hundred and twelve vaccinations were per-
formed during the year as compared with 196 the
previous year. B
T. C. Onronp,
Medical Officer, No. 3 District.
District No. 4.—Govyavr.
The general health during the year was satis-
factory, and no formidable disease was recorded.
During the early months of the year there was a
good deal of sickness amongst children and infants,
due to an epidemie of pertussis, and in the latter
part of the year the general health of both adults
and children was disturbed by an epidemic of
influenza. ;
Malarial fever, dysentery, bronchitis, and gastro-
enteric disorders of children formed the majority
of attendances given during the year.
Malarial Fever.—There were 532 cases of this
disease recorded, showing an increase of fifty-seven
56 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
cases over the preceding year and this increase was
probably caused by the excessive rainfall which
occurred on two or three occasions during the year;
the type of the fever was, however, not malignant.
as is testified by the low death-rate, eleven deaths
only being recorded from this malady.
Dysentery.—One hundred and eighty-four cases
of this disease were attended, of which 189 were
children and infants and forty-five were adults. In
general the disease was of a mild type, but many
eases showed the tendency to recurrence after con-
valescence had well set in, and in a few cases the
disease took on a more or less chronic type.
Bronchitis.—One hundred and seventy cases of
this disease were noted, a good many occurring in
the months of July and August; the majority, how-
ever, obtained during the last few months of the
year and being infectious in type were probably
influenzal in origin.
Pertussis, which commenced towards the close
of the year 1910, continued in epidemic form
during the months of January and February, with
the beginning of the drier weather, and possibly
owing to the want of fresh pabulum, the number
of cases gradually decreased and it ultimately dis-
appeared about the end of May, after having been
in the district about eight to nine months and being
directly responsible for forty-four deaths.
Pulmonary Tuberculosis.—Of this disease four-
teen cases were recorded with a total of seven
deaths. Although every effort is made to disinfect
the sputum and every precaution taken to prevent
the spread of infection, home treatment still con-
tinues unsatisfactory to the patient and dangerous
to the other residents, owing to the small size of
the houses in which the patient as a rule lives.
Anamia.—Seventy-two cases were attended, some
of malarial origin, but a good many of the cases
have been proved to be due to the ankylostomia.
Instruetions have been issued, in accordance with
the Ordinanee, for the provision of latrine accom-
modation at the various schools and estate villages,
but the time allowed for erection has not yet
expired.
Yaws.—Fifty-six cases were sent into the institu-
tion and great vigilance was maintained in attempt-
ing to rid the district of this disease. Beds at the
institution are not always available and there is no
law to compel those who are refused admission to
come up for treatment; as a consequence nuclei
for the infection of new cases continue to exist in
the distriet, without control or supervision, and
so the vicious cycle is established and the expendi-
ture for the eradieation of this disease will ever
continue to be recurrent.
Anthraz.—This disease, of which there had not
been a single case for many years, suddenly made
its appearance again at Dougaldston Estate, the old
and original infected area, and cases subsequently
developed at Loretto Estate and in the town of
Gouyave. Immediate steps for the suppression of
this disease were taken in every case, and every
possible prophylactie measure was carried out in the
first place by me, and subsequently by Mr. Saunders,
2t
wY*.-
[April 1, 1914.
veterinary surgeon, to limit the infection from
spreading, with the result that very few animals
were attacked. It is regrettable that two animals
have again been verified as dying from anthrax
during the present current year and prophylactic
measures have also been taken in these cases, so it
is to be hoped that there will be no further recur-
rence. In connection with this outbreak one case
of external anthrax in man was recorded which
readily yielded to treatment.
The following table gives the relative mortality
for the different quarters of the year:—
1st quarter es nt TO .. 90
9nd ,, ate Dt SE .. 33
9rd ,. nm dis T€ e. 40
4th ,, -— sit ae’ ree!
Sanitation and Anti-malarial Measures. The
drainage of the L’Ance portion of the town of
Gouyave which was begun in the previous year still
remains uncompleted. The Town Board have made
provision, however, for the carrying on of this im-
portant work during the present current year, and
steps are at present being taken for constructing
the second section of the drainage. I have no
doubt that when this is completed malarial fever,
which is very prevalent in this neighbourhood, will
disappear to a great extent. The appointment of a
sanitary inspector has been a step in the right direc-
tion and some good work has been done by the
present officer, who is capable and efficient; as a
result of his energies I am able to report a marked
improvement in the yards of the town and also in
the general sanitation of the rural portion of the
district.
The water supply to the town of Gouyave was
unsatisfactory on two or three occasions; the fault
appears to lie with the intake dam of the reservoir,
from which it seems impossible to shut off the dirty
flood water of the river when heavy rains occur:
on these occasions one feels very disinclined to use
it even for washing purposes.
The delimiting of a pig area in the outer portion
of the town, although it can certainly not be
looked upon as a progressive step in sanitation, will
without dubiety prove a great boon to the poor
inhabitants of the town, of which there are not a
few; the board, however, will have to be very
vigilant in order to prevent any ill-effeets, both as
regards malaria and anthrax. In this line, however,
much cannot be hoped for, as I am unable to say
that the control at present exercised by this body
over other animals permitted in the town is very
creditable, as Gouyave appears to be more a pasture
of some large stock farm, with animals running
loose about it, than a small town with an adminis-
trative body regulating these matters, and this, too,
with anthrax at their very doors of which they are
cognizant.
Under head vaccination the attendance was satis-
factory and only two defaulters were convicted; à
total of 258 cases (successful) were performed and
the district continues well protected against small-
pox. The lymph continues to give sntisfactory
results.
R. D. O'NEALE.
April 15, 1914.]
COLONIAL MEDICAL REPORTS.—GRENADA. ; 57
Colonial Medical Reports.—No. 33.— Grenada — (continued).
District No. 6.—St. Patrick’s.
In view of the changes affecting the population,
satisfactory comparison with the vital statistics of
previous years is impossible. The birth- and death-
rates were normal There was but one factor in
operation during the year which in some measure
increased the sick-rate and mortality, viz., an
epidemic of whooping cough which began in the
previous year and continued during the first quarter.
This was responsible for the higher death-rate
during that period.
Based on the recent census the population of the
new No. 6 District is estimated at 5,500.
The relative mortality in the different quarters is
shown in the following table :—
Number of deaths: 1st quarter, 51; 2nd quarter,
82; 8rd quarter, 21; 4th quarter, 35.
A higher sick-rate was as usual to be noted in
the wetter months.
Malarial fever was rather more prevalent. Four
hundred and fifty cases or nearly one hundred more
than in the previous year were treated. The num-
bers occurring in September and October were about
double the monthly average. As a rule the cases
were mild and yielded readily to treatment. In-
testinal diseases also showed some slight increase.
There were sixty-eight cases of dysentery treated,
but comparatively few of these showed any malig-
nancy.
Forty-seven cases of yaws were seen and, except
those cases occurring in infants, were all referred to
the police for transport to the Yaws Hospital.
There were fifteen cases of pulmonary tubercu-
losis. Gastro-enteritis among children, the result of
improper feeding, oceurred in its usual large num-
bers.
Whooping cough, as above noted, was epidemic
during the first quarter. Few children under
10 years of age escaped an attack. Considering the
widespread character of the epidemic the death-rate
from the disease was comparatively small.
The improvements in the sanitary condition of
the district which followed the appointment of a
sanitary inspector were well sustained during the
ear.
7 Some permanent improvement was effected in the
drainage of the towns of Victoria and Sauteurs by
the laying down of concrete drains. The lower
Marli lands and the Glebe lands in the town of
Sauteurs have been much improved and there is
less vegetation in the neighbourhood of houses
generally. Rank vegetation is however permitted
to remain in the water-logged areas at the mouths
of the Mt. Craven and La Fortune rivers, where
it is most desirable that such growths should be
removed.: Trees and shrubs of no economic value
should all be removed from these pestiferous areas.
They only provide shelter for mosquitoes and any
cultivation permitted should not impede the free
circulation of air.
Nothing is heard nowadays from the dwellers in
Sauteurs of the hardness of the water supply. The
more fastidious palates seem reconciled to the
“ heaviness ’’ and the water is used for every pur-
pose.
Some consideration was given to the question of
a water supply for the town of Victoria. The
Babillon Spring òn the Tufton Hall Estate was
examined and found to fulfil all the requirements
of a good drinking water. The scheme presents no
engineering difficulty and it would be a pity to delay
the accomplishment of a work so very essential to
the sanitation of the town. ;
Two hundred and ninety-four children were suc-
cessfully vaccinated. Parents regularly presented
their infants for the operation and seldom was it
necessary to report defaulters.
No anti-mosquito measure of any magnitude was
undertaken during the year. What the sanitary
inspector effects in the improvement of sanitation
generally must, however, be regarded as tending to
prevent the spread of mosquito-born diseases. As
yet no diminution in the number of cases of malarial
fever has been observed.
H. BrisnoP,
Medical Officer, No.-6 District.
District No. 7.—St. Patrick’s.
The estimated population based on the census of
April last is 6,397. Owing to the recent re-division
it is not possible to give comparative figures, nor
the birth and death-rates.
The usual observation was made that more sick-
ness prevailed during the wet than during the dry
season for reasons well known. But the year as a
whole was one of comparative good health, no
serious epidemic of any kind, with the exception of
the regularly recurring influenza, having occurred.
I am inclined to attribute this improvement ta
the vigilance of the sanitary inspector, whose fre-
quent visits have resulted in an undoubted improve-
ment in the sanitary condition of the villages. This
officer continues to take great interest in his work,
and performs his duties very satisfactorily.
The following table gives the monthly distribution
of deaths :—
Number of
deaths
January 83 53 Ss Pus 18
February set $a de $ 24
March ... T: T. T zn 19
April ... - wes Ey Ss 12
May .. wa sya iss "T 7
June ... T ea ant "T 5
July ... Ms hes ais sh 9
August fe T y tea 11
September ... Zee T gi 9
October de tee ea a 15
November ... bes ds ids 11
December E ade sS E 19
Total 152
The rainfall was seasonable and abundant, and
did not adversely affect health.
The necessity for the establishment of well-
regulated public cemeteries is becoming more and
more urgent, With the increase of population and
LS
sem" cor
CUCINA TWO EDEN
58 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
cultivation there is hardly any room left in the
existing burial grounds, which at their best were
only small plots of land intended for family pur-
poses. So that at the present time great difficulty
is experienced in some of the villages to secure
suitable places to bury the dead.
A great deal would have been achieved in this
direction so far as this district is concerned if a
cemetery were established at Conference, and
another at Mornefendue. These two places would
tap most of the affected villages, and at the same
time a glaring breach of ordinary sanitary precau-
tions would be removed.
The following gives the number of cases of the
more important diseases dealt with during the
year :—
Dysentery, 226; malaria, 989; malignant new
growths, 3; pulmonary tuberculosis, 12; syphilis,
376; tetanus, 8; leprosy, 1; yaws, 47; influenza,
epidemic.
Yaws is as prevalent as ever, and will continue
to be so until more hospital accommodation can be
provided.
Pulmonary Tuberculosis.—Still maintains its
strong position, and it will be a boon indeed to the
poorer classes when the promised special hospital
for cases of this disease has been erected. Imagine
a consumptive being one of the eight occupants of
one of our ordinary labourer's huts, 16 ft. by 10 ft.,
and the horrors of the situation will at once reveal
themselves.
The sanitary condition of the district remains
much the same as in previous years. The work of
the sanitary inspector, however, is beginning to
show fruit in the greater cleanliness in and around
the village houses, and in the fact that all small
collections of stagnant water are at once removed.
And to these improvements I attribute the appre-
ciable diminution in the number of cases of malaria.
The provisions of Section II of the Public Health
Ordinance, 1910, requiring all persons handling
bread, either in its preparation or sale, to secure a
certifieate of health from a medical officer, are excel-
lent, but observation has satisfied me that they are
not rigidly carried out, and so their object must be
defeated. There are still some people baking bread
who have never obtained the necessary certificate.
But the great plan in the execution of the Ordin-
ance is that whilst the head of the family generally
obtains the certifieate several other members assist
in making or selling the bread without so doing.
The Ordinance is a good one, and in the interest
of publie health should be pushed for all its worth,
This will tend to reduce the number of bakeries,
and so the number of people handling this important
article of food, and at the same time better super-
vision will be secured.
The attendances for vaccination have been most
regular, and 292 children under 1 year were success-
fully vaccinated. The lymph supplied, with but
trifling exceptions, gave uniformly good results.
W. A. D. WHITEMAN,
Medical Officer, No. 7 District.
District No. 8.—Sr. ANDREW’s.
The exodus of labourers from Grenada in search
of work in Panama or Brazil has not affected this
parish materially as the births and deaths show :—
1907 1908 1909 1910 1911
Births 661 ... 731 ... 660 .. 695 ... 703
Deaths 331 ... 400 ... 422 ... 459 .. 369
About a third of the children born in this parish
die before passing their fifth year—see figures given
below :—
1909 1910 1911
Births ... DT ive T TA .. 660 ... 695 ... 705
Deaths of children 5 ycars old and under ... 235 ... 256 ... 218
The survivals are mostly a sturdy race who have
defied unsuitable feeding and perhaps `‘ unavoid-
able '' neglect from hard-working parents from
almost infancy.
Longevity of the Population.—The number of
deaths of persons recorded as 60 years old and over
was in—
1900 1910 1911
60 m 55 RA 53
If the children who die under 5 years (from which
age the maximum probable duration of life is
reckoned) are deducted, it will be seen what pro-
portion of the survivors reach 60 years and over :—
Gross Totals last Three Years.
Deaths .. AP sss ae .. 1.950
Less children under 5 years... s o 09
541
Deaths at 60 years and over... ess NA 168
Deaths between 5 and 60 years 5S ex 373
Whereas the chances of any one after attaining
5 years of reaching 60 years are about equal in
England.
The death-rate in a wet year is generally greater
than that of a dry one. Deaths from digestive
respiratory and malarial diseases are all increased,
the little streams which supply drinking water are
contaminated by road and surface drainage, and
enteric troubles become prevalent. This mortality
is fairly well shown if the rainfall and deaths for
the last six years are arranged for comparison.
The deaths this year are still an increase when
compared with 1907. It is, of course, impossible
to trace deaths by the rainfall each month as
children when taken ill linger on several months.
1907 1908 1911 1909 19n6 iste
Rainfall 61:97 ... 71:9 ... 84:82 ... 91°57 ... 98°16 ... 11270
Deaths 881... 400 .. 3869... 422... 444... 459
Remarks on Particular Diseases that have occurred
during the year.
Malaria.—The deaths attributed directly to
malaria were in: 1909, 32; 1910, 59; 1911, 31.
1910 had the greatest rainfall of the last six years
and therefore offered facilities for mosquitoes to
propagate. The deaths enumerated above indicate
a considerable amount of illness.
April 15, 1914.]
COLONIAL MEDICAL REPORTS.—GRENADA.
59
PREVALENCE OF SICKNESS AND RELATIVE MoRTALITY IN THE DIFFERENT SEASONS.
| Rainfall Dearie DUE TO DisEASES OF Iasbonreniu
1911 at | thelr ae
Mt. Harne Digestiv Respiratory Other | Total death preect
antoni, pis ae Malaria. diseases peers month for
—s À — — — —— — — — | L —— | — —— ——— RR - — —
January 4:83 18 15 5 | 14 52 768
February 5:96 13 11 6 | 8 38 571
March 2-37 8 9 2 | 10 29 698
April .., 2-98 8 1 4 | 16 29 700
May 4:56 4 4 1 13 22 751
June .. 15:62 5 4 2 7 18 544
July ... 4:91 4 8 2 14 28 711
August 8:24 11 2 2 16 31 742
September 13:49 11 6 2 13 32 689
October 5:56 9 4 2 12 27 756
November 10°02 11 7 2 13 33 790
December 6:28 11 8 3 8 30 621
84°82 113 79 83 | 144 369 | 8,341
Yaws is decidedly less seen, but the ill-effects on
the constitutions of many often remains.
Intestinal Worms. — Labourers’ children are
almost universally affected, adults very frequently.
It is astonishing how many find a habitat in one
person.
. Venereal Diseases.-—Gonorrhea is very rife. In
both 1910 and 1911 the stillbirths recorded were
forty; venereal diseases may account for some of
these, but illegitimacy and married men working
abroad both operate in compelling women to labour
till too near their confinement.
The sanitary inspector on his rounds calls on the
inhabitants to remedy sanitary defects. In a
mountainous country with roads dug along hill-sides,
as fast as mosquito pools in the drains are filled up
Nature resupplies her progeny with others. Drains
are quickly blocked by earth trickling downwards,
by the rapid growth of weeds obstructing the water
course, or by a heavy rainfall ploughing holes in
the soft soil. The houses of the peasantry are
scattered everywhere along the roadsides except at
extreme heights.
Former cane fields near the coast, now cattle
pastures, swampy after rain, could no doubt be
reclaimed if owners were enterprising and wealthy
enough to await their transition into coco-nut
groves. Such swamps exist at either end of Gren-
ville.
The milk supply is mostly obtained from cattle
tethered on accumulating dung heaps midst the
cocoa (for the sake of the manure) and drawn by
unclean youths. The substitution of condensed
milk with limewater often arrests infantile diarrhea.
The Public Works Department have commenced
a drainage scheme. Flood water is to be drained
into a tank, whence it is proposed to be pumped
into the sea by wind-power.
Rank vegetation, by which is understood bush
and high growing weeds, are prohibited in the town,
but the luxuriant growth of varieties of the banana
plant and coco-nut trees effectually bar sunlight and
circulation of air and keep the soil damp. Floral
and agricultura] cultivation in certain defined areas
of the town should he under sanitary jurisdietion
and a clear space of 30 ft. insisted on round houses.
Cultivation too often is used as dumping place for
household waste and slops.
By-laws for condemning insanitary and struc-
turally unsafe dwelling-houses were passed during
the year. Such quarters were the refuge of unde-
sirable characters from the country, who hindered
sanitary progress. These by-laws will also have a
beneficial effect in compelling owners to keep their
premises in repair or lose their rents.
Abattoir.—l regret the slaughtering of cattle is
still a publie exhibition in unscreened private yards.
Any amateur can painfully slaughter an animal,
and no prior inspection of its fitness as food is made.
The subject has long been under consideration.
Vaccinations.—The lymph supplied gave uni-
formly good results; 210 children were successfully
vaccinated. The little operation is always deferred
from month to month when delicate infants are
brought, and this gives me additional control in
watching over such weaklings.
N. S. DURRANT,
Medical Officer, No. 8 District.
District No. 9.—ST. ANDREW'S.
For the following reasons it is quite impossible
to form any useful estimate of the population of this
district. In the first place, the southern boundary
was changed on November 1 from the Crochu River
to the Great Bacolet River; the changes through
emigration and immigration also add to the difficulty
of getting any correct data. The infantile vaccina-
tions (309) give a fair idea of the number of births,
while the deaths, certified and uncertified, were 202;
but this latter number only refers to my own prac-
tice and does not include those of the two private
medical men. Harford Village, Lower Capitol,
Grand Bacolet and Balthazar all have district boun-
daries running through them, so that even the
registrar of births and deaths is unable to supply
any accurate information on the subject.
January, August, September and October were
the most unhealthy months in my district; while
March, April and June were the most healthy.
60 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 15, 1914.
Malarial fevers were the chief causes affecting the
public health; there were no serious epidemic
diseases to contend with in 1911. The mortality
was highest in January and December, and lowest
in April, June and October, but the range was not
great.
The rainfall, as registered at Bellevue Estate, was
83°28 in.; this was much less than that of the pre-
vious year, which was 111 in. Although the rainfall
was less, the number of malarial fever cases was
larger by 59,-the total number being 619. This is
hard to understand until it is remembered that the
majority of them were persons who were already
harbouring the malarial parasites, and only required
a disturbing chill, &c., to start the fever afresh.
I think that the actual primary attacks were not
more numerous than last year.
One case of typhoid’ fever occurred at La Digue;
the patient was a girl, aged 17, and she recovered
after seven weeks’ illness. The water supply was
not the vehicle of infection in this instance, for she
lived exactly opposite the first standpipe of filtered
water from the public waterworks.
Seventy-six cases of dysentery were treated.
July and August supplied the largest number, twelve
and ten respectively. Nearly all these cases oc-
curred in parts of the district not served by the
St. Andrew's waterworks.
The general sanitary condition of the district was
fairly good, considering that it is a purely rural one
and so did not get much money spent on it for
sanitation purposes. A good deal of useful minor
work was done by the Sanitary Inspector, but it
is very difficult to make the average labourer appre-
ciate the dangers of dirt and stagnant water; deaths
from preventible diseases are always accepted as a
Mohammedan's ‘‘ Kismet.”
Overcrowding is still the great trouble among the
labouring classes, especially as the condition is not
ameliorated by ventilation; it would seem that the
night air is so heavily charged with '' Jumbies ”’
that every door, window and crevice has to be her-
metieally sealed with rags, &c., to keep them out.
Vaccination was very thoroughly performed in
this distriet during 1911. Infants to the number
of 809 were successfully operated on, and a large
number of emigrants also sought its protection.
Observations regarding the Health of the
Inhabitants of the District.
Respecting the health of the inhabitants of No. 9
District, I fear the general tone is low; the children,
especial, are anything but healthy; poor feeding
is the root of the whole trouble. This poor feeding
of the children is easily accounted for, when it is
borne in mind that the average Grenada labourer,
with children, only makes 5s. a week; such a small
sum, without a garden for provisions, is not a
“ living wage." The complaints that the children
suffer mostly from are nearly all connected with the
digestive system, gastro-enteritis and intestinal
parasites being their chief diseases.
The quantity of worms (especially the Ascaris
lumbricoides) that some children can harbour is
something astounding; fifty or sixty ‘‘ round
worms '" from a four-year-old child is a frequent
occurrence.
I know that the ‘‘ Ankylostomum ”’ is the fashion-
able worm in Grenada just now, but I am perfectly
certain that it does not cause half the harm that
the common ''round worm '" does. After thirty
years' medical experience in this colony I cannot
call to mind a single death directly attributable to
ankylostoma, but I have seen many deaths from the
Ascaris lumbricoides; very old people suffer from
them also.
In dealing with ankylostomiasis the treatment
generally commences at the wrong end of the ladder.
When a patient is found to be anemic from anky-
lostoma he is sent to hospital, where he is scienti-
fically treated with thymol, &c.; when cured, he
returns to his home and soon becomes reinfected ;
once more he goes to hospital to be again ‘‘ cured.’’
This process will go on indefinitely until attention
is paid to the environment of the patients; for it is
the soil surrounding their dwellings that requires
the treatment: in many damp localities, where the
houses are encroached upon by cultivations, the
earth is laden with the embryo worms, and any
person walking on it barefooted runs a risk of being
infected. In the old sugar days the soil had fre-
quent chances of getting dried up and aerated, and
so did not afford the worm a suitable nidus for its
eggs and larve; but to-day, under the shade of cocoa
and nutmeg trees, the soil is always damp and ready
for the requirements of the parasite.
If the yards of the dwelling-places, in certain
localities, were kept free from vegetation, allowing
the sun and wind to dry them up, very few people
would require to be specially treated for ankylosto-
miasis; this disease has a natural tendency to cure
itself, and it is the reinfections that cause all the
mischief. Under the present mode of dealing with
ankylostomiasis, hospital beds are in continuous use
for the treatment of this one disease to the exclu-
sion of far more serious cases.
Malignant New Growths.—I am glad to be able
to state that cancer did not appear to be on the
increase; the cases seen were nearly all in women,
and the uterus was the organ most frequently
attacked.
Pulmonary Tuberculosis.—Consumption is still
gaining ground in Grenada, but, as suitable places
for treatment and isolation are soon to be built, I
expect to see some improvement in this direction.
Venereal Diseases.—Both syphilis and gonorrhea
were frequently met with among the lower classes,
but the permanent injury caused by these diseases
is certainly less serious than that experienced by
persons suffering from them in colder climates; it
would appear that free perspiration has a certain
eliminating effect with respect to syphilis.
The want of properly trained midwives has be-
come a most urgent question. I have not granted
a certificate in midwifery for many years; those
women who applied for them were hopelessly
ignorant, and could not even understand the neces-
sity of cleanliness in their special work.
Burials.—More bodies were buried outside the
cemeteries and proper burial grounds than inside;
<r ge
April 15, 1914]
COLONIAL MEDICAL REPORTS.—GRENADA. 61
but as the local authorities are now offering more
conveniences and inducements to the public, I have
every hope that improper interments will be less
frequent in future.
H. J. Lee BENNETT,
Medical Officer, No. 9 District.
District No. 10.—Sr. Davip's.
The estimated population for District No. 10 can-
not be given, as the district includes a large part
of the parish of St. Andrew’s, and a part of the
parish of St. David’s is included in No. 2 District.
For the same reason other figures appertaining to
vital statistics cannot this year be set down here.
For the purposes of a general survey it might be
mentioned that the birth-rate throughout the parish
of St. David’s was of normal standard and the births
numbered 287.
The deaths registered as having occurred in the
parish during the same period amounted to 108.
The death-rate was the smallest recorded for many
years, and that was principally due to the exceed-
ingly small sick list for the year. This parish and
district have never been known to be so healthy for
many years.
The prevalence of no disease was specially accen-
tuated during the year; there was a little of all the
usual yearly troubles, such as gastro-enteritis among
children, influenza, diarrhoea, malarial fevers, dysen-
tery, &c., but none assumed epidemic proportions
and none deserves special mention.
The cases of yaws met witii were sent to the Yaws
Hospital. Several cases of this malady were dis-
covered and reported to me by the police and district
samitary inspector.
Pulmonary tuberculosis is still with us. There
was a movement some time ago of providing an
institution for the isolation and treatment of people
suffering from this dreadful complaint; recently
nothing has been heard of the scheme. It would
certainly be conferring the greatest good on the in-
habitants of Grenada by establishing such a hos-
pital; and, in my opinion, I know of no publie work,
from a sanitary and public health standpoint, that
is nearly as useful or urgent.
A few cases of ankylostomiasis were met and were
treated with thymol with good results. This disease,
as far as I am able to judge, is not gaining ground
in this district.
The general sanitary condition of this district
during the year was exceedingly good and nothing
ealls for special observation.
The vaccinations performed during the year
amounted to 228 and the lymph supplied was excel-
lent in quality and came regularly.
G. N. ALEXIS,
Medical Officer, No. 10 District.
Carriacou DisTRICT.— BELAIR, CARRIACOU.
The population as taken by the last census was
6,886. Births during 1911, 244; deaths during 1911,
ninety-one; birth-rate during 1911, 85:4 per 1,000;
death-rate during 1911, 13:21 per 1,000; number of
stillbirths, nine.
The birth-rate was higher than the previous year,
85:4 per 1,000, as against 27:7 for 1910.
The death-rate was also higher, 10:09 per 1,000
for 1910, as against 18°21 per 1,000 for the year
under review.
Malarial fevers were prevalent in January and
also November and December. One case of black-
water fever was treated in January. The last cases
of an epidemic of whooping cough, which raged at
the end of 1910, were seen in January, forming the
tail end of the epidemic. Several cases of pneu-
monia were seen in February; they were of a mild
type and no death occurred. March was particularly
a healthy month; a few cases of malarial fever were
seen.
Venereal diseases kept cropping up with persistent
regularity as the sloops returned from the south.
The great majority of the nine stillbirths was due
to venereal disease in either one parent or the other.
I regret to report that there are to-day many inno-
cent children who are paying the price of their
parents' dissolute habits.
Gastro-enteritis and diarrhoea, among children and
adults respectively, were fairly prevalent in April
and May and again in August and September. In
children the cause must be due to the manner of
feeding adopted, irregularity in quantity and irregu-
larity in quality.
Tuberculosis of the lungs and other parts of the
body still continues to make an insidious progress
among the poorer classes, and I hope the day is not
far distant when patients so affected may be sent to
an isolation hospital, so as to reduce the spread of
this dreadful malady.
The sanitary condition of the district has been
undoubtedly good during 1911, and very few cases
could be directly traced to insanitation.
Sporadie cases of dysentery were seen, and when
the conditions of the water supply is considered the
natural immunity of the average Carriacouan to
water-borne diseases becomes apparent.
Anti-malarial measures consisted in stocking the
swamps and ponds with ‘‘ millions " fish, the
clearing of brushwood and weed around dwellings,
and a free and liberal use of quinine.
The number of successful vaccinations for the
year was 146. The lymph was of uniform good
quality.
Epwin We ts, M.B.,
Medical Officer, Carriacou District.
62 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914:
Colonial Medical Reports.—No. 34.--Gold Coast.
MEDICAL REPORT FOR THE YEAR 1910.
By. W. H. LANGLEY, M.D.
Principal. Medical Officer,
GENERAL HEALTH.
In Ashanti and the Northern Territories the rains
commence earlier and end later, with a break
during July or August, which is more marked the
farther north the observations are taken. In the
Colony this break is less noticeable, and the rainy
season as a whole is shorter.
‘Malaria begins to rise slowly soon after the rains
set in, and reaches its greatest height in August.
There is then a fall, and a second but smaller rise
in October, followed by another fall.
. The prevalence of this disease is, of course, in
direct proportion to the anopheline rate. It does
not begin to rise until some time after the com-
mencement of the rains, because there has not yet
been time for any great number of mosquitoes to
be bred and become infected. During the heavy
rains, moreover, stagnant pools suited to the habits
of the anopheles are less numerous and constantly
being flushed out by flood water, and it is, therefore,
only when the rainfall is decreasing and these pools
remain for longer periods that the great rise in the
malarial rate takes place. The small secondary
rise after the subsequent fall may be deceptive, but
is possibly due to the nearly equal rainfall from
August to October, which would be sufficient to
maintain many suitable pools at a fairly constant
level. The suddenness of the falls must also be
attributed to some extent to increased vigour in the
prosecution of prophylactic measures.
The great prevalence of diseases of the bronchi
and lungs during December and January is due to
the ehilling effects of the Harmattan wind and the
irritation set up by inhalation of the fine particles
of sand it carries. The later rise from July onwards
is accounted for by the general dampness and the
frequenéy with which the people are drenched by
the rains.
The rise and fall of gastro-intestinal diseases
coincides fairly well with the rainfall, and is mainly
düe to pollution of the water supplies by surface
water from the villages, combined, to some extent,
with lowered powers of resistance to disease during
the unhealthiest season.
HEALTH OF GOVERNMENT OFFICIALS.
The health of European officials was not so good
as in the preceding year. Although there was a
deerease in the number placed on the sick list, there
was a considerable inerease in the number of days
during which officials were ill, and there was also
ü slight inerease in the daily average. Both the
invaliding and death-rates were higher, the former
nearly double that of 1909.
GENERAL EUROPEAN POPULATION.
The general European population consists of: (i)
Government officials; (ii) employés of trading
firms, employés of mining companies; (iii) mission-
aries.
The strength of the first group is steadily in-
ereasing year by year; that of the others, however,
varies considerably, and much difficulty is experi-
enced in obtaining as accurate figures regarding it
as are available in the case of Government officers.
The system in yogue is unsatisfactory. It depends
for its success on the courtesy of individuals; but,
although their courtesy is not called in question,
such a method of obtaining statistics is bound to
prove faulty. A suggestion was recently put for-
ward that arrivals and departures other than those
over the seaboard of the Colony might be regarded
as a negligible quantity, and that what is required
is an accurate record of embarkations and dis-
embarkations. This could be provided by the
agents of the different shipping companies or the
pursers of ships landing and embarking passengers ;
in existing conditions, "the required information is
only obtainable through the courtesy of these
officials. It has been suggested that the question
of some form of legal enactment should be con-
sidered.
GENERAL NATIVE POPULATION.
The subject of compulsory registration of births
and deaths has been occupying the consideration
of the Government.
At the few centres in the Colony where the
system of issuing and recording '' burial permits "'
obtains the number of burials recorded was 2.099,
as against 1,611 in 1909; it may be assumed, there-
fore, that, as regards the Colony itself, the sickness
rate for the year under review decidedly increased.
Gaols.—The general health of convicts was not
good. Although the number undergoing sentences
was less than in the previous year, the sickness and
death-rates were higher.
Lunatic Asylum.—The mortality rate was high,
but the deaths occurred among very old standing
enses or those recently admitted in an enfeebled
condition, the causes being, with one exception,
those usually common in this class of patient, e.g.,
epilepsy, heart failure, inanition, dysentery, and
pulmonary diseases. The number in the latter
group was proportionately small, most of the deaths
April 15, 1914.]
COLONIAL MEDICAL REPORTS.—GOLD COAST.
RETURN oF DisEAsES AND DEATHS IN 1911 IN
Ashanti, Northern Territories, Gold Coast Colony.
GENERAL DISEASES.
2x
Alcoholism 32 v vs $x se^ I.
Anemia .. vs zs vs E .. 182
Anthrax --
Beriberi 38
Bilharziosis —
Blackwater Fever —
Chicken-pox 64
Cholera =
Choleraic Diarrhoea sie —
Congenital Malformation —
Debility ; 372
Delirium Tremens —
Dengue . —
Diabetes Mellitus =
Diabetes re —
Diphtheria s m oe s —
Dysentery .. sj v ee ve .. 505
Enteric Fever A a3 s iè A 3
Erysipelas . . vs >s ie és s. 10
Febricula .. us a is vs .. 948
Filariasis .. £s m A^ vs o_o —
Gonorrhea ay ne ‘ia 2s .. 621
Gout n aia we he = $1 9
Hydrophobia s E es T M —
Influenza .. vis E T és on 6
Kala-Azar.. t T ?. ze | —
Leprosy .. T as T T . 40
(a) Nodular. $ vs —
(b) Anesthetic .. Re oe e —
(c) Mixed "t e Ve EM 2$ —
Malarial Fever— m T —
(a) Intermittent —
Quotidian .. T ae T sa 48
Tertian .. Sa es ee 4 20
Quartan .. vs sa we o_o
Irregular .. Je AA se 18
Type undiagnosed T T .. 1,291
(b) Remittent .. ^n T .. 1,412
(c) Pernicious .. T T as 20
(d) Malarial Cachexia.. x* oe ae 7
Malta Fever N we 2s . e —
Measles .. en B" T oe .. 86
Mumps .. mm m m oe 2T
New Growths— .. a os s “=
- Non-malignant 25 vs oy .. 194
Malignant ae en ka oe Žo 7
Old Age .. sa x is v. =
Other Diseases .. Ji oe om ee te
Pellagra .. ss J 5 Ss DO
Plague T oe bs "n ss M —
Pyemia .. ee es es oe vs 2
Rachitis .. Es pz e ae i 1
Rheumatic Fever s ia T .. 614
Rheumatism 4 si aa FT .. 1,430
Rheumatoid Arthritis .. ei T aa —
Scarlet Fever .. a ss Ss $a 1
Scurvy .. is 55 iy ma Me —
Septicemia 2 "t. P és in, LF
Sleeping Sickness ee ae y e 09
Sloughing Phagedena .. T m e —
Small-pox .. "à s T me .. 208
Syphilis .. in và 3 "T | —
a) Primary .. ee T Se .. 124
b) Secondary .. E Sis oe .. 255
(c) Tertiary ois Pe ds se Se
(d) Congenital .. =
Tetanus 6
Trypanosome Fever et = a. Ss
Tubercle— ME $5 .. 30
(a) Phthisis Pulmonalis ti —
by Tuberculosis of Glands .. —
c) Lupus a —
[t aao Ped Ft IE E Eb een D adc T Mah Pei Ce hit eR EET ded TOL ET putt
ET
EE
GENERAL DrsEASES— continued.
(d) Tabes Mesenterica s es —
(e) Tuberculous Disease of Bones . --
Other Tubercular Dade —
Varicella . —
Whooping Cough -=
Yaws : 508
Yellow Fever 11
LOCAL DISEASES.
Diseases of the—
Cellular Tissue . 1,725
Circulatory System _ =
(a) Valvular Disease of Heart 43
(b) Other Diseases .. 4 231
Digestive System— 8,646
(a) Diarrhoea $e --
(b) Hill Diarrhea .. —
(c) Hepatitis . —
Congestion of Liver -—
(d) Abscess of Liver =
(e) Tropical Liver .. —
Jaundice, Catarrhal —
g Cirrhosis of Liver —
) Acute Yellow Atrophy —
e Spre .. d —
(3) Other Diseases .. + m s >
Ear En ae xs ds .. 587
Eye B as $$ .. 1,529
Generative System— és od ve woo
Male Organs T m T .. 480
Female Organs "^ se 25 .. 948
Lymphatic System .. e. T .. 568
Mental Diseases vs "e E ^. 12
Nervous System "s ša oe .. 861
Nose .. e v 6% .. 104
Organs of Locomotion, n ie .. 1,011
Respiratory System .. «s es .. 4,658
Skin— . m ve m es oo
a) Scabies - e ds vs vi .. 887
b) Ringw 27g» 4» ^: 82
Tinea. [oe EP is a e —
(à Favus .. «s ue P oo
(e) Eczema .. $$ T ve oo 175
( f) Other Diseases .. ar A .. 6,075
Urinary System ee ET T .. 199
Injuries, General, Local— v» sa P —
(a) Siriasis (Heatstroke) .. - eo
(b) Sunstroke (Heat pee) we is 3
(c) Other Injuries .. mm .. 5,990
Parasites— we és «s .. 452
Ascaris lumbricoides .. bs xs =
Oxyuris vermicularis . —
Dochmius duodenalis, or Ankylostoma duo-
denale F ^ os aT
Filaria medinensis (Guinea. worm) .. 948
Tape-worm .. si as T .. 274
Poisons— T
Snuke-bites — ..
Corrosive Acids
Metallic Poisons oe
Vegetable Alkaloids
Nature Unknown
Other Poisons
Surgical Operations— ..
Amputations, Major ..
Minor .
Other Operations
Eye .
Ta) Cataract
(b) Iridectomy .. ait, wi
(c) Other Eye Operations" TP -
‘ T
I| Seelallelt |
Deaths
Sslillil
Feo d ed PEE USE eet ete TI T e Sce «ee
[d Sure bud
LT dues b T oe d OD ES
64 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ee
having occurred during the rainy season. The ex-
ception referred to above was a case of trypanoso-
miasis.
Food and water supplies were ample and of good
quality.
As in previous years, such patients as were fit
to work were employed in gardening, clearing the
asylum precinets of bush and weeds, carrying water
and collecting firewood. 38,930 lb. of cassava were
produced in the asylum gardens.
Laboratory.—The only regular laboratory work
done during the year was examining rats for plague
bacilli. There were occasional analyses of water,
and some microscopical work for purpose of
diagnosis and determination of malarial indices
among children. Excepting a period of six weeks
in November and December it- was not possible to
detail a medical officer exclusively for laboratory
work, but during this period the unavoidably inter-
rupted preparation of small-pox vaccine was gone
on with; the results were encouraging. The first
supply of lymph reached its destination within four
weeks of its manufacture and gave a success per-
centage of 15:09; the second, after a period of six
weeks, gave a success percentage of 98:1. "There is
reason to believe that most of the first supply was
rendered inactive by heat during the process of
sealing the tubes for which at the time there were
no proper facilities.
HOSPITALS AND DISPENSARIES.
The construction of new native hospitals was
completed at Tamale, Tarquah, Akuse, and Winne-
bah; and a special fly-proof hospital was built at
Anum, in the Volta River District, for the treat-
ment of sleeping sickness and the isolation and
observation of '' suspects.’’
The number of cases treated in the hospitals and
dispensaries in the Colony was: European, 900;
native, 26,908; as against European, 1,056; native,
29,298, in 1909.
ACCRA.
The later rains in November and December of
1909 probably account for a rise in the general
sickness and malaria rates which occurred in
January, and the exceptionally heavy rainfall in
June for the later elevation of the malaria rate.
MEDICAL REPORT OF COOMASSIE AND THE
PROVINCE OF ASHANTI.
The health of the Europeans stationed in Ashanti
during the year has been good.
The total number of Europeans on the sick list
amounted to 75.
There was one death of a non-official European
from blackwater fever, who was brought in to
Coomassie from a mine in a moribund condition,
and three were invalided.
The health of the troops during the Camp of
Exercise held in the early part of the year was
good; four officers only suffered from minor com-
plaints.
The European Hospital has been kept in an
[April 15, 1914.
efficient state throughout the year, and has been
much appreciated by patients, who formerly had to
be treated in their own houses in any illness.
The health of the native staff was most satis-
factory throughout the year. One clerk was
invalided, and no deaths occurred.
Drs. Brabazon, Atkinson and Hunt have been in
immediate charge of the native hospital during the
year. The large majority of those who attend for
treatment are soldiers from the regiment suffering
from ulcers of the feet and legs, although there is
a gradual increase of natives from the surrounding
villages as compared with former years. Much
good work has been accomplished.
Prison.—The health of the prisoners has been
very fair; there was one death from bronchitis.
There were 63 cases under treatment in the in-
firmary, the prevailing diseases being febricula,
diarrhea, rheumatism, bronchitis and abscess. The
yard and the cells were kept in a clean and good
sanitary state. The food of the prisoners was
inspected at different times, and found to be satis-
factory.
There were between 80 and 90 known cases of
sleeping sickness in the Province, and an average of
15 have been under treatment with atoxyl injections
at Coomassie; the subjects attend weekly at the
hospital for this. No deleterious effects on the sight
have been observed or complained of, although com-
plaint is made of the pain at the seat of injection
lasting for a number of days. A small isolation
hospital for this disease is in course of erection, and
will be ready for occupation in a month or two.
Small-poz.—'This disease has been prevalent
throughout the year at many places in the Province;
no doubt a good deal of it is due to the native habit
of inoculating direct from persons suffering from
small-pox to healthy people, with the idea that the
disease is produced in a mild form; but whether this
is so or not it is difficult to say, as the chiefs or
their people will give no information as to mortality,
but the custom, no doubt, keeps the disease alive.
During the year there were.37 admissions to the
segregation camp, of whom 11 died. Vaccination
with lymph from Europe has been carried on as
much as possible, but the people do not show
anxiety or readiness to have it done; there have
been 2,881 successful vaccinations done in
Coomassie during the year.
Native Staff.—Instruction has been given to the
hospital pupils and junior staff by the medical
officers and nursing sister in hygiene, dressing of
wounds, and other hospital duties; also, first aid
and stretcher drill, to contingents of soldiers, by the
medical officers.
The sanitation of the town of Coomassie has been
well looked after with a staff of about seventy
scavengers in daily employment. There are now
five incinerators in constant operation, burning the
sweepings and rubbish of the town, and three for
the regimental lines, and the cleanliness of both
town and cantonment may be considered satis-
factory. The burnt refuse from the incinerators is
being used to fill in the swamps below the town.
Lu oc a
May 1, 1914.]
Colonial Medical Reports.—No. 34. — Gold Coast — (continued).
FEw mosquitoes are observed in the town or
cantonments, but constant supervision is required
to prevent the people keeping water standing in
barrels or pots in their houses. The visitation of
houses during the month of December revealed the
presence of larve in a little over 2 per cent. Be-
tween thirty and forty cesspits have been found to
be in existence in the premises of different people
in Coomassie, and which are now being abolished.
The water supply is abundant and good. During
the year eleven wells have been covered and cased
with cement, and hand pumps fitted on to them.
A number of surface street drains have been
completed, and as funds permit these will be
gradually extended, but a lot of work is still neces-
sary in this direction in the town.
Owing to the population of the town being much
increased of late, the present slaughter-house is too
small to meet requirements now, and it is under
consideration to have it enlarged.
The vegetable garden has been most productive,
and the produce much appreciated by the white
officials; it no doubt contributes to the good health
enjoyed by the Europeans stationed here.
Meteorological.—The rainfall for 1910 was exceed-
ingly heavy, 70:89 inches fell, as compared with
55:74 in 1909.
C. B. Hunter, S.M.O.,
Acting Provincial Medical Officer.
NORTHERN TERRITORIES.
MepicaL REPORT.
THE
Our of a daily average European population of
22°37 thirty-four were placed on the sick list. One
invalided and one death occurred; this is a great
improvement on the health of the previous year, in
which 50:99 officials were placed on the sick list
from all eauses; three invalided and three deaths
took place out of an average daily population
of 22:62.
I attach prevalent diseases from which Europeans
suffered: Abscess, 1; colitis, 1; chronic diarrhea, 1;
debility, 1; aecidert (knocked down by bull), 1;
bilious remittent fever, 1; blackwater fever, 1;
boils, 1; acute dysentery, 1; acute orchitis, 1;
enteritis, 2; hepatic congestion, 2; injury to foot,
1; lymphangitis, 1; obscure abdominal inflam-
matory condition, 1; paresis of wrist (result of
injury, 1; ptomaine poisoning, 1; remittent
malaria, 11; remittent malaria and congestion of
liver, 1; tape worm, 1; thecal abscess, 1; wound of
foot, 1.
Non-Official Europeans.—One Catholic Father
died at Navarro from blackwater fever. This Mis-
sionary had been in the country for over five years.
With this exception the health of the European
non-officials was satisfactory.
Native Officials.—The average daily number of
the Government clerks throughout the Protectorate
averaged 50°23; and out of this total twenty-three
were placed on the sick list, three were invalided,
and no deaths took place.
COLONIAL MEDICAL REPORTS.—GOLD COAST 65
The average number of days spent on the sick
list shows a large inerease on last year, this being
eaused by the length of time some of the patients
had to remain in the Northern Territories before it
was considered advisable to allow them to undergo
the long journey to the const.
Native Troops.—The company of the Gold Coast
Regiment was transferred early in the year to the
new headquarters of the North-Eastern Province;
and since their arrival at that station, the health
amongst all ranks has been excellent. Out of a
daily average of 140:46, there was no invaliding, and
no deaths occurred.
Northern Territories Constabulary.—Detachments
of this force were stationed at nine different points
throughout the Protectorate, and from all stations
satisfactory health reports have been received.
During the year five men were invalided and three
deaths took place. When it is considered the duties
these men perform in all weathers these figures are
low. No epidemic occurred amongst Constabulary
or I Company of the Gold Coast Regiment, stationed
in the Northern Territories.
No serious epidemic occurred amongst the natives
of this country during the year. Slight outbreaks
of small-pox took place in several districts, but were
easily dealt with, as the inhabitants now raise very
little objection to having the infected ones isolated ;
and in several cases it was done without any instruc-
tion being given.
In some districts it is the custom, when a case
of small-pox arises in a village, for the Chief or
Headman to inoculate all adults; and sometimes
the inhabitants of a neighbouring village will visit
an infected one, for the purpose of having all the
people inoculated. In this way the disease is kept
up in the outlying districts.
Dr. Beringer, in his report on a tour through a
certain portion of the Southern Province, reported
several cases of sleeping sickness. Throughout the
rest of the Protectorate three cases were under treat-
ment, all of which ended fatally.
Meteorological.—The rainfall was about the aver-
age, 46°21 inches; and except that the Harmattan
set in earlier than usual in the first week of October
there is nothing particular to remark about the
meteorological conditions of the year 1910.
The supply of vegetables in all the gardens has
been well up to the average. The following articles
were procurable during most of the year: Tomatoes,
carrots, lettuce, French beans, and radishes.
The water supply at all stations throughout the
Northern Territories has undergone improvement,
wells being sunk at most of the stations from which
a good supply of pure water is obtained.
Sanitation.—The sanitation of the headquarter
stations and villages in the immediate neighbour-
hood of same is kept in good order. This is only
accomplished by constant supervision; and, if re-
laxed for any length of time, the people soon return
to their filthy habits.
H. Tweepy,
Provincial Medical Officer.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
SANITARY REPORT.
Trypanosomiasis.—During 1910, about fifty cases
of sleeping siekness were treated in the different
hospitals, and eleven deaths recorded. Towards the
end of the year 107 cases were reported under
observation or treatment by the medical officers in
various districts.
Glossina palpalis is universal and widespread in
almost every part of the Colony, from Anum on the
eastern border to Berekum and Sunyani on the
west, extending into the Gonja district, and even
probably as far north as Gambaga. Dr. Kinghorn
reports it pretty universal throughout the northern
and western provinces of Ashanti and the Banda
District. He states that the extent of the disease
in the Western Province bears a strict relation to
the comparative frequency of G. palpalis. In Wenki
5 per cent. of the inhabitants were found to be in-
fected.
On the Togoland border Dr. Claridge states that
the whole district is adapted to the tsetse-fly and
that G. palpalis is present everywhere.
Dr. Beringer points out the widespread prevalence
of this fly throughout the Gonja District, but
whether this be the ordinary G. palpalis or G. pal-
palis var. Wellmani, would appear open to question.
Whole villages in this district are reported to have
been deserted by the natives on account of sleeping
sickness prevalent there.
Dr. Rice has called attention to the prevalence
of the fly all along the Coomassie-Kintampo road,
and it has long been known to be exceedingly plenti-
ful in the Kintampo District. It would appear,
therefore, that G. palpalis is far more widely spread
throughout the Colony and Protectorates than any
other variety of tsetse. It is found almost uni-
versally throughout the whole of the forest and
semi-forest country.
Taking into consideration the widespread distribu-
tion of G. palpalis it seems extraordinary that try-
panosomiasis has not made greater headway or taken
on an epidemic form. Whether human trypanoso-
miasis is endemic and the natives to some extent
become immune, or whether we are dealing in this
Colony with a strain of infection of low virulence,
are hypotheses to neither of which I care to commit
myself.
The seriousness and the possibilities of sleeping
sickness, as far as the Gold Coast is concerned, are
now well recognized, and every effort is being made
to cope with a situation that at first sight strikes
one as being well-nigh superhuman.
It would not appear that the time is yet ripe for
compulsory segregation of the infected. One’s
efforts must be directed for the present to the in-
telligent clearing of bush round villages, fords,
ferries, &c., in fly districts, to the erection of segre-
gation camps and hospitals, and to gaining the con-
fidence of the native, and persuading him and
educating him as to the good to be derived from
attending these hospitals. The Chiefs should be
held responsible for these clearings, and some sys-
tem of compulsory notification of the infected should
be insisted on.
During the year £4,000 was specially voted for
sleeping sickness preventive measures.
Three special service medical officers were ap-
pointed, some excellent work was done, and much
useful information obtained as to the distribution
of the disease and the fly.
It is extremely difficult to start a proper system
of prophylaxis until the distribution of trypanoso-
miasis and G. palpalis are more definitely mapped
out.
A sleeping sickness hospital was completed and
opened at Anum during the early part of the year.
It consists of two mosquito-proofed rooms, measur-
ing respectively 814 ft. by 18 by 12 and 154 ft. by
18 by 12 ft., and capable of accommodating eight
to ten patients. The staff consists of a medical
officer and a dispenser pupil. The attendance was
disappointing. For many months the wards were
entirely empty. The native seems to make light of
the disease, and it is difficult to persuade him to
come for treatment. A sleeping sickness hospital
was also erected at Kintampo. Here there were
eight admissions and three deaths during the year.
A fly-proof room was set apart in the Native Hos-
pital at Coomassie for the treatment of these cases.
There were four admissions and two deaths in the
twelve months.
Slaughter-house Blood Smears.—During the last
half-year 1,181 blood examinations were made of
cattle killed in the various slaughter-houses.
In eighty-seven of these cases trypanosomes
were found—a percentage of 7°36. In twenty-six
cases other forms of parasites were noted. Of cows,
85:07 per cent. were found to be suffering from
trypanosomiasis, sheep 14:54 per cent., goats 15°42
per cent. No trypanosomes were reported to have
been found in pigs.
Yellow Fever.—In the early part of the year there
were ten cases of yellow fever amongst Europeans
in Seccondee, nine of which were fatal. Three
deaths were also known to have occurred amongst
natives. The first notified case of the epidemic
oecurred on April 12, and the last death took place
on May 22.
On July 15 a death from the same cause was
reported from Axim, and on July 18 the last case
of the epidemic was brought into Seccondee from
1293 mile camp.
The Cape Coast Town Council passed some excel-
lent by-laws with a view to obtaining further powers
for dealing with mosquito larve, but these were
disallowed in deference to the Attorney-General’s
opinion that they were '' ultra vires.”
An Ordinanee to provide for the destruction of
mosquitoes throughout the Colony was brought
under the consideration of the Legislative Council.
Filariasis.—Only six cases of elephantiasis were
reported under treatment during the year.
There were three enses of Filaria loa recorded.
Although it cannot be said that any special pre-
ventive measures have been set on foot with refer-
ence to this disease in particular, still the fact has
not been lost sight of that the prevention of
filariasis practically resolves itself into protection
from mosquito bite. A rigorous campaign against
May 1, 1914]
mosquitoes of every variety is at present being con-
ducted.
Plague.—It is pleasant to report that the past
year has been entirely free from this epidemic. The
lessons of the previous year have, however, been
taken to heart. Rats are being regularly and
systematically examined. The Clayton machine is
being periodically used to keep these vermin in
abeyance. A mechanic has been provided for the
Clayton machines, and regular bi-weekly Claytoniz-
ing of warehouses harbouring rats will be carried
on in Accra, Seccondee and Cape Coast.
Small-poz.—One hundred and sixty-two cases are
reported as having been treated in hospital, and
forty-two deaths were recorded—a mortality of
25°09 per cent., as compared with 217 cases and
a mortality of 1705 per cent. in 1909. This repre-
sents but a small porportion of cases that actually
occurred, as a large number are concealed in the
bush and never heard of. At the close of the year
sixty-one cases were under treatment.
In Ashanti there were frequent small and scat-
tered outbreaks, but it is impossible to obtain reliable
information, and statisties are out of the question.
In the Birrim District in August 159 cases were
isolated. Two medical officers were dispatched
there, and some 5,869 vaccinations were performed
and many sanitary improvements carried out in the
district. At the latter end of the year there was a
small outbreak in Tamale.
25,899 vaccinations were performed throughout
the Colony during the twelve months; of these,
14,069 were successful, and 11,880 unsuccessful.
In the previous year 18,614 individuals were vac-
cinated.
Whenever an outbreak has been reported medical
officers have been immediately sent to the district
to take the necessary steps to stamp out the disease,
and native vaccinators have also been sent to patrol
and vaccinate in the district, but the ways of the
native are inscrutable. At times they will flock to
be vaccinated, at others they will stampede and
nothing will persuade them to return.
There can be no doubt that the practice of inocu-
lation carried out by natives in some districts has
been responsible for a large number of deaths and
for the introduction of small-pox into fresh villages.
Dysentery.—The records of the various hospitals
show that 479 cases of dysentery were treated, with
a mortality of 42 — 8'76 per cent., as compared
with 828 cases in the previous year and a mortality
of 4:26 per cent. Amongst European officials there
were eleven cases, none of which ended fatally.
Intestinal affections are very common amongst
the natives, and taking into consideration the great
carelessness displayed in most villages and many
towns with regard to the pollution of the water
supplies the wonder is that intestinal troubles are
not very much more prevalent and fatal. A great
deal of attention has been paid recently, and a large
amount of work done in protecting the water sup-
plies from pollution and contamination. In all the
principal towns the majority of wells have been
COLONIAL MEDICAL REPORTS.—GOLD COAST.
67
protected, and this work is being proceeded with as
rapidly as funds will admit.
One cannot expeet, for many years to come, to
see a proper drainage scheme and a pipe-borne water
supply laid on in these towns—with two exceptions
—but it is hoped that in the course of a few months
there will not be a single well that is not properly
protected—at any rate, as far as the principal towns
are concerned.
Throughout the Colony and Protectorates, at the
end of the year, 34 public wells and 674 private ones
had been protected against surface contamination.
Enteric.—Only four cases were treated in hospital
during the year, and one of these was fatal. Three
out of the four were European officials. No special
preventive measures have been adopted in this
direction, as hitherto enteric has been exceedingly
rare in the Colony.
Ankylostomiasis.—Only eighteen cases of ankylo-
stomiasis were recorded. Ankylostomum duodenale
is known to be prevalent. In 1905 the presence of
Necator americanus amongst the natives of this
Colony was demonstrated. Several cases of
uncinariasis have been reported from the Aburi
district. There is reason to believe that Uncinaria
americana (Necator americanus) is more widespread
than it is generally reported to be, and probably we
shall find that with the more systematic examina-
tion of the stools recently instituted uncinariasis is
by no means an uncommon disease.
The protection of the wells against surface con-
tamination, at present being proceeded with, will
undoubtedly aid in the diminution of this and other
helminthic diseases.
Teniasis.—The hospital records show that 273
cases of cestode infection received treatment. No
other particulars are given, but when one takes into
consideration how universally the pig is kept and
fed upon, it is only reasonable to suppose that the
majority of these cases were cases of Tænia solium.
It is the general opinion than teniasis is very much
more common amongst natives than the above
figures would lead us to suppose.
Until pigs are more or less confined, and the
very primitive methods of ‘‘ conservancy " prac-
tised in most bush villages is improved upon, it is
difficult to see what measures can be taken to abate
this evil. It is a matter that will probably right
itself pari passu with the advance of sanitation in
the bush villages.
Bilharzia.—Only three cases of bilharziosis were
recorded during the year. No special preventive
warfare has been waged against bilharzia hematobia
(Distomum hematobium). The large amount of
work done, however, in protecting water supplies
from contamination must have a good effect in this
direction.
Guinea-worm.—There were 944 cases recorded in
the various hospitals during the year. Many
attempts have been made to trace the sources of
infection, and when successful the infected pools
have been dealt with. As a rule it is not easy to
trace an infection to its source, information is
68 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
difficult to obtain and generally misleading. You
may provide the native with a good water supply,
but you cannot insist on his drinking that water and
that alone. His salvation, as far as guinea-worm
is concerned, rests on his education and his realizing
how he gets the guinea-worm.
Sewage Disposal.
There is no water-borne disposal of sewage in the
Colony. The latrine pans are for the most part
emptied into the sea or trenched. An improved,
more sanitary form of latrine was started during the
year. The floor was raised and graded so as to
allow of the washings being collected in a pan placed
outside, instead of saturating and polluting the
ground around, as was formerly the case. A large
number of latrines have been reconstructed in
accordance with this improved type, and the re-
mainder are being altered as rapidly as funds and
labour will allow.
During the year 72 new publie latrines were
erected, 46 for males and 26 for females. There are
682 private latrines.
Disposal of Refuse.
The common methods of disposal of refuse were :
filling up holes, burning, dumping in the sea, dump-
ing on marked-out dumping grounds.
A large number of incinerators have recently been,
and are being, erected. It is intended that all the
larger towns shall be provided with two or three
incinerators, mostly of the beehive type. In
future, therefore, the greater part of the refuse will
be got rid of by burning in these incinerators.
There are at present 43 destructors and about 195
dustbins in use.
Some 4,329 headloads of rubbish are daily re-
moved by scavengers, and 38 carts are in addition
in daily use. About 21 loads of tin cans and other
ineombustible material are daily removed from
houses and compounds and buried.
Water Supply.
There can be no doubt that one of the crying needs
of the Colony is ‘‘ improved water supply."
Accra and Seecondee have now commenced their
schemes for a pipe-borne supply. It will probably
be some time before other towns are similarly
favoured, but it is imperative in the meantime that
such water as is available should be protected from
contamination. In this direction a large amount of
work has been done during the past year. The
unfortunate outbreak of yellow fever was not with-
out some good results—money was voted and drink-
ing-water sources protected on a scale that would
not otherwise have been possible.
Only one town at present (with the exception of
one or two of the mining villages) boasts a pipe-
borne supply, and that is Obuasi. The town is pro-
vided with twelve stand-pipes, laid on by the mine.
The drinking water in the towns is for the most
part either storage rain-water or water from shallow
wells. In the bush villages the supply is usually
from adjacent streams.
There are 58 public wells in the Colony and Pro-
tectorates, and 1,224 private ones, 130 publie tanks
and 854 private ones, and 3,043 barrels. Of these
various water receptacles 80°50 per cent. have now
been properly protected. In a short time there will
be but few that have not similarly been dealt with.
Drainage.
There is little or no sub-soil drainage. About
8,6083 yds. of masonry drains were constructed
during the year, and 6,041 yds. of ditches dug and
graded.
Extensive drainage schemes are at present under
consideration for Accra, and it is proposed to spend
large sums of money on Seccondee. In both these
cases it will be necessary to complete these schemes
before the arrival of the pipe-borne water supplies
now in course of construction.
Clearance oj Bush.
Owing to the Yellow Fever Preventive Vote
allowed to the different towns and the greater
number of scavengers in consequence possible, more
bush clearing was done during the latter half of the
year than I suppose has ever before been known
in the history of these towns.
Some 4,531,743 square yds. are reported to have
been cleared, but probably this does not represent
anything like the amount of clearing actually done.
In addition to having the interior of the town
cleared, the aim in view is to have the entire out-
skirts also well cleared to the extent of at least
100 yds. This is a fairly large undertaking and
requires time. Many of the towns up to the present
have been well cleared round to the extent of 50 yds.
or more.
Most of the medical officers have during the
course of the year given a series of lectures or de-
monstrations to their dressers. School-teachers and
others outside were at liberty to attend, and in some
instances this opportunity was taken advantage of.
No information on teaching in schools is obtain-
able from the Director of Education.
May 1, 1914.)
COLONIAL MEDICAL REPORTS.—CHINA.
69
Colonial Medical Reports.—No. 35.—China.
General Summary of Medical Reports from His Majesty’s Consulates
in China, for the Year ending September, 1911.
By Dr. DOUGLAS GRAY.
British Legation, Peking.
Tux following short note will explain the principal
objects of these reports :—
The data concerning the presence or absence of
zymotic diseases in different ports will contribute
much, in the light of the latter-day bacteriological
knowledge, to the study of epidemiology, which is
all the more important in view of the rapid and
increased steam-ship inter-port communication and
opening of railways through the Empire.
For those who are in China, or contemplate
coming to it, and for commercial undertakings, it
is well to know the health conditions of the treaty
ports, as also the habits of life, diet, &e., which
experience has shown to be necessary for the well-
being of foreigners during their residence here.
Information can also be gathered from medical
observation of Chinese diseases and method of
treatment.
A general survey of medical matters cannot
fail to be of interest and use to the profession at
home, and will add to the better equipment as
regards knowledge of local diseases to practitioners
in China.
INTRODUCTION,
The general impression gained from a study of
the medical reports sent from seventeen treaty
ports of the health conditions during the year
ending September, 1911, is that, during the period
under review, the public health among foreigners
has been very good, better than for many years
past.
It has also been fairly good among Chinese in the
central ports. But, as regards the Yang-tsze
valley, the inexorable law of nature that ‘‘ pes-
tilence ’’ follows famine has been again observed in
the virulent epidemies of typhus and relapsing fever
which have been very prevalent among the crowded
groups of famine-stricken refugees and wanderers
rendered homeless by the heavy, almost un-
precedented autumn floods from the river and its
tributaries. Starvation, following the destruction
of crops, and its ensuing lowering of resistance to
disease and infection, has caused the deaths of
many thousands. Various reasons have been given
for the immediate cause of the present political
trouble, but one might argue with great reason that
the reflective effect of famine on the mass of the
people with its concomitant circumstances of high
sick and mortality rates is in the highest degree
provocative of general unrest. In an agricultural
Empire such as China is, with 80 per cent. of its
inhabitants tillers of the soil, the vast majority of
them know little and care less for political vagaries,
and as long as crops are plentiful they are willing
and able to pay the usual taxes without troubling
much as to the ultimate distribution of the sums
collected. There can be little doubt but that the
revolutionary outbreak, taking place, as it did, in
the Yang-tsze valley with its ruined crops and con-
sequent rise in the price of rice, the mainstay of
Chinese diet, found, at its beginning, the people
distressed in mind and body, and ready to listen
to the incitements of political agitators.
These remarks may be somewhat beyond the
province of a medical report, but they are prompted
by the observations made so frequently by the con-
sular medieal officers of the apathy and indifference
to public health improvement on the part of the
local authorities throughout the Empire. Tuber-
eulosis is noted as on the increase, and is becoming
a veritable unchecked scourge. Typhus, relapsing
fever, cholera, small-pox, and bubonic plague
appear annually and claim a heavy toll. The
problem of overcrowding in Chinese cities is one
that is very difficult of solution, but that a great
amelioration could be effected by the Chinese
themselves, the efforts, necessarily more or less
limited, of foreign doctors and medical missionaries
in China can be cited as proof.
Efficient drainage, pure water, isolation of
infected cases and their contacts, ventilation of
dwellings: these are the four outstanding factors
requisite to good public hygiene, and they are all
neglected in every Chinese city. The East has
much to learn from the West in this respect, and
it may serve a good purpose to lose no opportunity
in pointing out the need of more active measures.
In most places the lower classes are more ready
to seek foreign medical aid than the gentry and
literati, many of whom, in spite of lessons to the
contrary, are curiously wedded to the Chinese
system of medicine, which, with its superstitious
notions and erroneous ideas, remains in the same
state of unscientific knowledge as it was over a
thousand years ago.
At the same time there has to be noted a steady
annual increase in the demand for foreign medicines,
which is being only partially responded to by
British drug merchants, the most active traders
being the Japanese. Patent medicines are now
extensively advertised and the consumption of them
is yearly growing greater.
Specific Diseases.—Intestinal parasites, tuber-
^ mM b. 6A
EPN TIWIVERS 7
70 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 1, 1914.
culosis, diarrhea and dysentery, malaria, venereal
diseases are endemic and, in the order named,
prevalent all over the Empire.
Pneumonic Plague.— This epidemic, already
reported upon, raged over Manchuria, Shantung,
and Chih-li provinces last winter, resulting in a loss
of over 65,000 lives. The Chinese authorities,
when once they had become alive to the danger,
showed most commendable energy in the way they
grappled with the disorder. A certain amount of
preparation to guard against a similar occurrence
has been made, and it is not probable that another
epidemic of this variety of plague, should it arise,
will be allowed to spread to the same extent as the
last one.
Bubonic Plague during the past year has not
been so prevalent as usual. It appeared in Canton
(200 deaths per diem), Amoy, Pakhoi, Shanghai,
and Foochow, but there is no mention of its having
occurred in any inland ports or in the Yang-tsze
valley.
Cholera.—The past year has been singularly free
from epidemics of this disease. Probably more
accurate methods of diagnosis have resulted in a
clearer definition between choleraic diarrhea and
the more virulent and fatal cholera Asiatica.
Typhoid Fever has been less prevalent among
foreigners owing to the better sanitation of the
various concessions. If every European and
American coming to reside in China where typhoid
is undoubtedly endemic were to first submit to anti-
typhoid inoculation, this disease, which annually
causes a number of deaths, more especially among
comparative new comers, would become much less
of a menace than it at present is. The statistics
of the United States of America Government,
recently published, showing that among 12,644
soldiers vaccinated against typhoid only five cases of
the disease occurred with no deaths, while in the
remainder of the army 418 cases occurred with
thirty-two deaths, are sufficiently good proof of the
preventive power of this vaccine against typhoid
fever.
Typhus Fever and Relapsing Fevcr.—Both these
diseases have been very prevalent and caused an
incalculable number of deaths among the Chinese.
They are the result of bug infection in enfeebled
constitutions, and are rarely met with among
foreigners. The conditions of life under which they
occur are at present beyond the power of medical
science to ameliorate: the question is not one of
cure but of prevention, and this can only be
brought about by public works involving a large
expenditure of money to diminish, or, if possible,
avoid altogether the present uncontrollable flooding
of the Yang-tsze River and its tributaries. Total
prevention seems a counsel of perfection, but it is
mainly a matter of finance as to whether the annual
loss of many thousands of taxpayers’ lives, and the
destruction of good crops do not cost the nation
more than the expenditure of the necessary funds.
The economic progress in Egypt that hus followed
the expert management of the Nile should be a
striking object lesson to China, and is proof enough
of the capabilities of scientific engineering to effect
a great improvement and lessen the appalling loss
of life which is yearly becoming a more pronounced
feature of increasing gravity in the Yang-tsze valley.
No figures are available, though from the accounts
to hand the sickness and mortality caused by typhus
and relapsing fever alone exemplify in marked
manner the urgent need for public sanitation.
Small-pox.—In treaty ports and wherever
foreigners are, the benefits of vaccination are being
made more and more known, and the epidemics of
this disease (which in some places here resemble
those of the middle ages in Europe) are being
correspondingly limited. During 1911 there
appears to have been less small-pox than has ever
been noted before.
Malaria.—All the varieties of this disease are met
with in Mid- and South China. In the provinces
of Chih-li and Shansi, and in Northern Shantung
and Kansu which comprise North China, it is but
rarely found. The question of malaria in China
depends largely on quinine treatment and less on
mosquito prevention, for the paddy fields of the
rice-growing districts form the most suitable mos-
quito breeding grounds that could be devised.
Wherever rice is grown in China, there is malaria
most prevalent.
The foregoing summary refers to diseases most
commonly met with. It may not be without
interest to mention some of the most notable in-
stances of diseases from which this vast Empire is
comparatively free as regards its native popu-
lation :—
Appendicitis.—Very rare. Some doctors of long
standing and wide Chinese medical experience have
never met with a case, though they are occasionally
called to deal with it in foreigners.
Sprue.—Though so frequent among foreigners,
especially in Shanghai, no definite case of this
dangerous disease has ever been recorded in a
Chinese.
Liver Abscess.—Scarcely ever seen among them,
notwithstanding the high dysentery rate.
Trichina Spiralts.—I can find no record of
Chinese human infection, and even among pigs
trichinosis is extremely rare.
Tapeworms.—These worms which have so wide-
spread and common a distribution over the rest of
the globe, are seldom found in Chinese except in
those of them who eat foreign food.
Nervous Diseases.—Locomotor ataxia and chorea
are very infrequent. Having regard to the fact
that syphilis is one of the commonest and worst-
treated diseases in China, the almost total absence
of true tabes dorsalis and general paralysis of the
insane is remarkable. In this connection one might
add that in China aleoholism is very uncommon.
Rickets is scarcely ever noted, probably owing to
the fact that Chinese children are all breast-fed.
Acute Rheumatic Fever in children is likewise
lacking, and this accounts for the noted freedom
from organic heart lesions.
May 1, 1914.]
COLONIAL MEDICAL REPORTS.—CHINA. 71
This list is capable of extension, but I have limited
it to those diseases about which there is unanimity
of medical opinion.
The national extension of Chinese railways may
yet prove to be an important factor in the spread
of disease. By such lines as the Canton-Hankow
Railway, populous centres (e.g., Hankow, Peking,
and Tien-tsin) will be brought within a few days of
Canton, which is an endemie plague centre. An
outbreak of cholera at Hankow which will, when the
railway is finished, be distant only thirty-six hours
from Canton, would thus be made more easily com-
municable than is at present the case. It is to be
hoped that efficient measures of medical inspection
will be devised to meet this new sanitary danger.
A most noteworthy instance of the power of
railways to spread an epidemie was afforded by the
Manehurian lines (during the recent outbreak of
pneumonie plague), which brought down through
the Great Wall into the Northern Provinces many
hundreds of potentially infective coolies during the
incubation stage of the disease, in addition to
numbers already infected.
A new menace to the health of the people has,
during the past few years, appeared in China, and
is annually claiming a greater number of victims.
I refer to schistosomiasis. No specific remedy has
as yet been found for it, but the disease is being
closely observed by carious medical workers. Its
prevalence may be appreciated from the obser-
vations made by Drs. Hart and Houghton (vide the
Wuhu Report), that in the Anhui province there
are some magistracies '' wherein practically every
other one of the farmers is infected." A separate
article at the end of this report, embodying the
studies of Dr. J. A. Thomson, of Hankow, will be
found an important contribution to the scanty
literature of this grave problem.
AMOY.
Population 400,000. .
The report from this port, including the native
city and Kulangsu, the foreign settlement, shows
a much better state of health than that of the
previous year. The same diseases have been
prevalent, but to much less extent.
Although the health officer was obliged to declare
plague to be epidemic, in consequence of the rule
imposed by the Imperial Maritime Customs, that
four cases daily are sufficient for that purpose,
irrespective of the size of the population, it is
doubtful if the declaration was justified. During
August, the weekly returns of plague deaths
diminished rapidly to nil. There has not been a
single case noted since the end of August. From
first to last, beginning on February 12, 1911, there
have been eleven fatal cases on the Island of
Kulangsu, and 435 deaths in Amoy city and its
suburbs.
Considering that the population numbers any-
thing between 200,000 and 800,000, living amid
insanitary surroundings unsurpassed anywhere else
in China, these figures cannot be regarded as
denoting a severe outbreak. Quarantine of ten
days from port to port was imposed on arrivals from
Amoy to Singapore on June 17, but by some over-
sight was not notified in Amoy till July 7. This
might have caused a certain amount of unnecessary
trouble, but shipping arrangements were made to
meet the requirements of the situation.
Cholera.—There has been practically no cholera
in Amoy this summer, the health officer having
personally seen only one case of typical complaint.
There have been quite a number of cases of
choleraic diarrhea, many proving fatal. The same
name ''lao-t-u'' is used for both complaints
indiscriminately.
In spite of Amoy being free from the infection,
the port was declared infected by cholera by the
Straits authorities in consequence of an outbreak
on board the steamship Seang Choon, which
occurred after the ship had arrived at Singapore.
fourteen days after she had left Amoy, though the
period of incubation for Asiatic cholera is from three
to six days. This outbreak was unmistakably due
to the presence on board of Hakkha emigrants from
Swatow. These coolies, whose villages are notable
hotbeds of cholera, for some reason refuse to use
the distilled water supplied them by the ship, and
bring on board with them for drinking purposes en
route chatties full of water from their native places.
This is in a foul condition when they start, and :
becomes worse with keeping.
There have been no other diseases of an epidemic
nature. The health of the foreign community, in
spite of the trying summer, has been on the whole
good, though there was a certain amount of seasonal
gastric trouble.
J. Moonurap, L.R.C.P.
CANTON.
This is the most important Chinese city in the
Empire. It has a population of 2,500,000, and is
about ninety-five miles by river from Hong Kong.
The foreign population lives on Shamien Island,
apart from the native city, whieh is and always has
been very overcrowded. But for the yearly
visitation of plague, the health of Canton may be
considered to have been satisfactory during the past
year. Since the laying of a supply of water a few
years back throughout the native city from the
Canton waterworks, there have been far fewer cases
of enteric, cholera, and dysentery in the city of
Canton.
During the summer of 1911 in the native city
a few cases of supposed cholera occurred at odd
times, but there has not been any epidemic of this
disease.
Bubonie plague appeared in epidemic form in
April and increased during the months of May and
June, and, whereas it has usually subsided and
often entirely disappeared in June in former years,
it continued till July this year. During the height
of the epidemic in May the approximate number
of deaths was estimated at 200 per diem.
It is impossible, Dr. Davenport says, under
72 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
existing cireumstances in Canton, to secure any
accurate statistics. There are always a certain
number of cases of malaria, mostly of the benign
tertian-form, in Canton. A number of Chinese have
been sent into hospitals suffering from malignant
malaria. A considerable number of these were
coolies employed in construction work on the
Canton-Hankow Railway. It is interesting and
pleasing to note that, in spite of the greatly
inereased population of the foreign settlement of
Shamien in recent years, there was far less malaria
and typhoid fever, from which foreign residents
very frequently suffered in the past. Only one case
of typhoid fever (a Japanese subject) occurred
during the past year.
The improved health generally throughout
Shamien may be attributed chiefly to improved
administration and the enforcement of more strict
sanitary regulations, and, in spite of the long
summer, Shamien, the foreign settlement, can now
compare very favourably with any town in the
tropies.
E. C. Davenport, M.B.Lond., M.R.C.S.,
L.R.C.P.; Hermann Bartan, M.D.,
B.S.Lond., F.R.C.S.Eng.
CHANGSHA.
Population 500,000. The capital of Hunan. On
- the Hsiang River.
There have been more cases of illness among
foreigners this year than in the previous year, but
the ailments were for the most part not of a serious
nature. For the first time in several years no case
of typhoid has occurred among foreigners. Dr.
Hume has given twenty-four protective injections
of anti-typhoid vaccine and is advising its use in the
community. There was discomfort only in one
case. Summer diarrhea was the most common
affection. Impure water is the most fruitful source
of infection at Changsha.
Urticaria and tropical boils were noted in foreign
residents, as also two cases of oxyuris vermicularis
infection.
Among Chinese the table of maladies does not
differ from those noted in last year's report to any
great extent. Infections with intestinal parasites,
particularly ascaris lumbricoides, hookworms, pin-
worms, and Trichocephalus dispar, continued to be
common. More cases of infection with Schisto-
80mum japonicum were observed. No genuine
cases of typhus fever, plague, beri-beri, anthrax, or
leprosy were seen during the summer.
Small-pox, an epidemic of moderate severity,
visited Changsha early in spring. Small-pox is
endemic here, and this epidemic was one of the
exacerbations from which the city suffers every now
and then. Dr. Yen quotes the following case to
show how little is yet known by the Chinese as to
the infectivity of the disease. He was called to see
a child supposed to be suffering from measles. On
arrival he found the child had small-pox, and on
inquiring was told another had just died from the
same disease, and one slave girl had just survived
an attack. Another one was in the pre-eruptive
stage, and the mother, who was in the stage of
crustation, was having her hair, which was well
entangled in scabs, dressed by a maid, who, to
Dr. Yen's surprise, had not yet been infected.
Out of 500 surgical cases seen in one division of
the Yale Mission Hospital at Changsha, 83 or 18:8
per cent. had surgical forms of tuberculosis. Dr.
Hume compares this incidence with the figures of
the Johns Hopkins Hospital in Baltimore, U.S.A.,
where only 0°61 per cent. of surgical cases are
tubercular.
A warning is given against foreigners bathing in
the Siang River, as the endemic area of Schisto-
somum japonicum is steadily spreading. It has
now been noted at Siang-yin, forty miles below, and
at Hengchow, above Changsha.
Vaccination is still little practised by Chinese in
this province. Inoculation is extensively carried
out. It is done at childhood, and one inoculation is
said to ensure protection for a lifetime.
E. H. Hume, M.D.; F. C. Yen, M.D.
CHINKIANG.
Population 168,000; 160 miles from Shanghai at
the junction of the Grand Canal with the Yang-tsze
River.
In the first half of the year under review the
health in Chinkiang was '' not at all satisfactory.''
There were six cases of typhoid fever in the small
foreign community, and an epidemic of typhoid
among Chinese, ‘‘ which undoubtedly originated
among the thousands of famine refugees." As the
conditions of water supply were very primitive, food
and milk under no supervision, it was only natural
any slight oversight in individual precaution should
cause the high typhoid rate. Dr. Urbánek makes
the following statement as to infection in dogs :—
‘It is interesting to note that just before the
outbreak among human beings there was an
epidemic among dogs, first among Chinese curs and
then dogs kept by foreigners. I had the oppor-
tunity of making seven autopsies on dogs, and have
been astonished to find quite typical ulcerations in
the bowels (ileum), infiltrated glands in the
peritoneum, big tumour of the spleen, and excessive
parenchymatous degeneration of the heart, liver,
and kidneys. Uleerations and infiltrations were in
the ileum, solitaire follieuli, and Peyer's patehes—
in a few words, the typical pathological picture of
typhus abdominalis. Death in most cases was due
to septicemia, as all but one had perforation and
peritonitis. Clinical symptoms, as far as I could
find out, kept on from fourteen days to three
weeks. I am sorry I neglected to obtain a culture
from the spleen; it would have been of great im-
portance to ascertain whether the bacilli were
identical with the enteric bacilli (Eberth, Gaffky,
Loeffler).”’
Real famine typhus has also been prevalent. A
journey was made along the southern section of
the Tien-tsin-Pukow Railway to Hsu-Chao Fu to
verify rumours that plague had broken out. The
epidemic was due to typhus fever, and there was
a very high death-rate from this disease and
starvation,
May 15, 1914.]
COLONIAL MEDICAL REPORTS.—CHINA. 73
Colonial Medical Reports.—No. 35. —China --(coxtinued).
THE rumour as to plague started on account of
the fact that the starved people, having no resist-
ance, when infected with typhus died in one or
two days, before it was possible to make any
diagnosis. ‘‘ The starving population stripped in
many places the bark from trees, and hundreds of
people have been seen digging out rotting roots of
the earth to satisfy their craving hunger." Two
eases of anthrax and one of cdema malignum
came under notice.
In the second half of the year the health of
the foreign community showed improvement,
though Dr. Balean reports that typhoid, dysentery,
diarrhoea, boils, malaria, and, owing to considerable
and rapid variations in temperature, bronchitis and
catarrhs were all prevalent. One case of beriberi
was noted in a foreigner.
Amongst the Chinese population the mest
numerous affections treated were malaria, dysen-
tery, diarrhea, tuberculosis, beriberi, septic affec-
tions, syphilis, and gonorrhea.
The type of malaria found to be most prevalent
was tertian, and few cases of the malignant type
have occurred. There was marked freedom of the
concession and surrounding country from cholera,
which Dr. Balean attributes to the relative scarcity
of water-melons, very few being obtainable after
July on account of the flooded condition of the
Yang-tzse valley in general. A few cases of
cholera, however, occurred in the native city during
July.
The adoption of surface drainage, which is now
completed in almost all the lots of the concession,
and the care and attention that is being devoted to
scavenging and the removal of nightsoil will do
much to improve the health of the population.
M. Ursdnerk, M.D.
CHENGTU.
In sending the first medical report from Chengtu
district, Dr. R. B. Ewan gives an interesting refer-
ence to the physical features and climatic conditions
of Western Szechuan.
The Chengtu plain is surrounded on all sides by
mountains and hills of varying altitude. Standing
on a spur of the northern range the plain looks in
some respects like a huge basin, through which the
canals of its world-famed irrigation system are seen
to wind like silver ribands as far as the eye can
reach.
The physical appearance favours the usually
aecepted theory that the Chengtu plain was origin-
ally a large inland lake, the waters of which in the
eourse of ages eut their way through the range of
mountains which now form the famous Yang-tsze
Gorges.
One of the first things to strike a new arrival in
this part of Szechuan is the unusual number of dull
and sunless days, and the unexplained humidity
of the atmosphere—in the latter feature resembling
ca Wed:
a seaport rather than a far inland district. There
is no doubt a close relation between the moisture
and the lack of sunshine, but no satisfactory ex-
planation has yet been given. Travellers say that
it is not at all unusual in crossing the pass which
divides Szechuan from Yunnan to find the Szechuan
side covered with mist and fog, while the Yunnan
side is bathed in sunshine. While the thermometer
does not register unusually high, the moisture in
the atmosphere makes the summers very trying to
most foreigners, and all who can spend a month
or six weeks on the hills. Even the Chinese feel
it, and during the hot weather lose energy and
become anzmic. Owing to the flatness of the
country the drainage is poor, and the level of the
'" ground-water ° high. In the wet season it is
not at all uncommon to have the water rise in the
wells to within 2 ft. of the surface. This no doubt
accounts for not a little of the sickness (fever, &c.),
which often breaks out at these seasons.
The diseases of Chengtu and district do not
materially differ from those of Szechuan in general.
Indigenous leprosy is practically unknown, the very
few cases met with invariably hailing from other
provinces. Cholera occasionally breaks out. Small-
pox, malaria, tuberculosis, and venereal diseases in
all their forms are prevalent. In Dr. Ewan’s
experience diphtheria has been a negligible quantity,
though he has heard of an outbreak this year thirty
miles from the capital. He has not in the course
of thirteen years’ practice in Chengtu found a case
among Chinese which he is prepared to diagnose
as typhoid.
Cerebro-spinal meningitis is not uncommon, The
Chinese doctors claim that it prevails every year
during certain winter months. They also recognize
it as an almost invariably fatal disease. It is a
rather noticeable fact that out of five adult deaths
that have occurred in the Canadian Methodist
Mission, since its establishment in West China, two
have been from cerebro-spinal meningitis, one from
typhus, and one from cholera. Anthrax is un-
known.
Measles, rubella, whooping-cough, and influenza
are common, but no scarlet fever has been noted.
There seems to be an unusually large percentage of
enlarged tonsils and adenoids in the children of
foreigners born in this district. Last summer, on
the Kuan Hsien Hills, both foreigners and Chinese
suffered from a somewhat peculiar fever charac-
terized by high temperatures, slow and feeble pulse,
and gastric disturbances. The onset was typhoidal,
but the course shorter, and did not readily respond
to medical treatment. Although Dr. Ewan has
met with several cases of appendicitis among
foreigners, he has. only. seen one case of. mild
catarrhal appendicitis in a Chinese who had been
acting as cook for foreigners during a number of
years.
Dr. Ewan belongs to the Canadian Methodist
Mission, and has been busily engaged in erecting
a large four-storey building, which, when complete,
will accommodate from 135 to 160 patients. There
74 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1914.
is also a fine new hospital, erected three years ago
by the American Methodist Episcopal Mission, with
accommodation for 100 beds. AN
The Roman Catholics, who have occupied
Szechuan for nearly two hundred years, have
recently opened a new hospital. Whilst the wards
are only modified Chinese buildings, the operating
equipment is of the best. The French Government
has also supplied an X-ray plant, which is used
in connection with the training school. I am
indebted to His Britannic Majesty’s Consul-
General, Mr. W. H. Wilkinson, for the following
report of their work :—
The French Mission médicale in Szechuan is
paid partly out-of the ‘‘ allocation spéciale ” for
scientific missions abroad, and that forms part of
the annual vote for the Ministère des Affaires
Etrangères, and partly by the Government of Indo-
China. The total sum from the two Governments
allocated to Szechuan is placed in the hands of the
French Consul-General at Chengtu and distributed
by him.
' There are two establishments (a) for Chungking
(b) for Chengtu. The doctor at Chungking is also
engaged for the Hópital de Tchongking, maintained
by the Catholie Mission at that city, and his chief
work is on behalf of the Catholic missionaries.
At Chengtu there are two doctors and two
‘“ infirmiers "—all four being French. One of the
'' infirmiers ” is paid specially by Indo-China, the
other by the French Ministry of Foreign Affairs.
The doctors are both members of the Army Medical
Corps, and are married.
One of them, Dr. Mouillae, is *' médecin con-
sultant de l'Hópital chinois," a dependency of the
Ecole militaire médicale, where the professor is a
Japanese. He has also the direction of the Catholic
Mission Hospital, receiving a small salary from that
mission. He is allowed private practice, and is
much sought after by the Chinese.
The other, Dr. Esserteau, is to have the direc-
tion of the Institut bactériologique, now in process
of erection on premises belonging to the Catholic
Mission, outside the North Gate. This institute
is a sort of bacteriological laboratory started by
the French Government in accord with the Catholic
Mission, and forming, as it were, a compiement to
their hospital. The funds necessary, and, above
all, the materials, are furnished by the French
Government, notably the vaccine, sent from
Tonquin.
At present the institute will confine itself to
vaccination, though later on other serums, as, for
instance, the antidote to hydrophobia (Pasteur's
serum) will be studied and applied.
‘Should Chengtu be made, a treaty port, the
French Government will either buy out the interest
of the Catholic Mission in this institute or will.
convey their own interest to the mission.
The personnel,.of the institute is to include a
doctor, who must be an expert in bacteriology, an
“infirmier” (a Frenchman), and a number of
Chinese pharmacists,
Opposite to the buildings of the institute is a
hospice, conducted by sisters of mercy. No physi-
cian is attached to the hospice, but one or two
rooms will be reserved for interesting bacteriological
cases. Until his leave is due next year, Dr.
Esserteau from the institute will attend to such
patients.
Both Dr. Mouillae and Dr. Esserteau send in
monthly reports to the French Consul-General,
combining these into annual reports, which are
forwarded to the Governments of France and Indo-
China.
R. B. Ewan, M.D.
CHUNGKING.
Population over 400,000. On the Upper Yang-
tzse, in the province of Szechuan.
The health of the foreign community has been
good. By the end of September the great heat
(999 F. to 102° F. in the shade) ends, and the
foreigners bring back their families from the hills.
A tornado of wind and rain, accompanied by a
severe thunderstorm, breaks up the hot atmosphere,
and after a day or two of more rain the summer is
ab an end. The most prevalent diseases (amongst
Chinese) have been hemiplegia, chronic bronchitis,
cardiac dilatation, and dropsy, especially among
water-carriers (Chungking being very hilly), anemia
in girls and women, phthisis, rheumatism, asthma.
typhoid fever, and gonorrhea. Trachoma is the
commonest eye disease. In noting that tetanus
neonatorum occurs in many children, Dr. Wolfen-
dale says the cause is due to the Chinese practice
of wrapping the placenta and cord around the baby
(and all together in warm clothing) and waiting till
they decay off.
A small epidemic of small-pox occurred in Chung-
king. As drugs can only be obtained once (or at
most twice) a year, with reasonable hope that the
order may arrive safely on account of the Yang-tsze
rapids to West China, I compiled and sent a list
of useful drugs which can be readily obtained in
native medicine shops.
R. WorrENparE, L.R.C.P. & S. Edin.
Foocuow.
Population 650,000. The capital of
province.
No regular reports have been received from this
port, but in the beginning of this year a report
was supplied by me dealing with a part of 1910.
It is, however, included as showing the health con-
ditions prevalent there. There were no cases of
serious illnéss of a remarkable nature among foreign
residents. In spring and autumn there were
numerous cases in the foreign community of
influenza and muscular rheumatism. Diarrhcea
was common during summer, while only cne case
of dysentery was accounted, and for several years
there has been no case of typhoid fever. The
majority of residents migrate in summer to the
Fokien
ao. P
May 15, 1914]
COLONIAL'MEDICAL REPORTS.—CHINA. 75
mountain tops at Kuliang, where the highest
temperature in the shade seldom exceeds 829 F.
The temperature at Kuliang is normally 10° or
15° F. below that in foreign houses in Foochow.
Among Chinese there is a good deal of general
illness, but the only disease of markedly prevalent
nature was Asiatic cholera. Influenza, measles,
mumps, whooping-cough, typhoid fever, and diph-
theria are reported as frequently recurring among
natives.
Plague, which first appeared in 1894 and every
year during July, August, and September, raged
with violence until 1907, has since then been
present in decidedly sporadic form in Foochow city
and its immediate surroundings. During the
summer of 1910 I only came across one case of
plague. Plague has never visited any of the tea
districts. Typhoid fever has proved more fatal
among foreign residents from 1879 to 1910 than
any other disease.
T. Renniz, M.D.
Hankow.
Situated at the junction of the Han with the
Yang-tsze River. In addition to a large foreign
community, this important trade centre, with an
annual trade value of over 1,000,000,000 taels, has
a population of 800,000, all living in narrow, over-
crowded lanes.
The climatic conditions were favourable during
the past year. The summer was unusually cool,
but there were floods which submerged a consider-
able part of the British concession. The native
and foreign health was exceptionally good, the best
in my recollection. An important sanitary improve-
ment has been the introduction of a thoroughly
modern water system constructed by a British
sanitary engineer. The water is taken from the
Han River above the native city of Hankow,
and after sedimentation, aeration, and filtration,
chemical and bacteriological tests show it to be of
a high grade of purity.
No cholera was noted this year, and this freedom
is in accordance with Indian experience that floods
and a high subsoil water-level mean less cholera,
and vice versi. It is seldom that a summer passes
without a more or less extensive cholera epidemic
in Hankow, but during the past summer of rain
and floods there appeared to be a complete absence
of this disease. Plague was also absent; typhus
and relapsing fevers, up to the time of writing the
report, were less prevalent than usual.
Paratyphoid and typhoid-like fevers are of fre-
quent occurrence, and are no doubt eaused by an
organism of the colon group, though the typhoid-
like fevers do not agglutinate with typhoid or para-
typhoid emulsions. They run a mild course.
Several cases were seen of fevers which agglutinated
with emulsions of B. melitensis, although clinically
the symptoms were not very characteristic of Malta
fever. Diarrhea and dysentery are very common.
Of the latter disease, the catarrhal type is most
often met with. Acute bacillary cases are less
common, but amebic dysentery is frequently seen.
Tubereulosis is véry prevalent among Chinese, but
rare in the foreign community. Tetanus often occurs
in accident cases. Anthrax—only one case, in a
foreign patient, has been noted since 1909. Malaria,
formerly very common, has now become rare owing
to the much greater area of land which has been
raised, laid out in streets, and drained. Benign
tertian is the most usual form; quartan is less
common; malignant tertian is variable, raging with
epidemic fury some years and almost absent other
years. Kala-azar is present, but appears to be
sporadic so far, though I think that if splenic
puncture were performed on many of the cases
diagnosed:as chronic malaria, the presence of this
diseasé at out-patient clinies would be more fully
appreciated.
J. A. Toomson, B.Sc., M.B., Ch.B.
ICHANG.
Population 60,000. About 1,000 miles from the
coast up the Yang-tsze River. A port of growing
importance. :
In the first half of the year under review the out-
standing feature was an epidemic of cholera which
was present in the months of November and
December. Two of the three foreigners who
became infected died. Many Chinese were attacked
and the death-rate was said to be very high. The
notable thing about this outbreak is the season at
which it began, and the fact that at such an un-
usual season of the year for the occurrence of such
an epidemic its source could not be determined.
In the latter half of the year cholera was entirely
absent. Small-pox was conspicuous by its absence
during the winter. The Chinese are increasingly
availing themselves in Ichang of the protection
afforded by vaccination. Malaria was exceedingly
prevalent, and a greater number of Chinese have
sought treatment for it during the winter than in
former. years. They are now well aware of the
efficiency of quinine, which is much sold in the
streets. The commonest type is ordinary tertian,
and the next is sstivo autumnal, while quartan
malaria is comparatively seldom seen. "There were
many cases of amcebic dysentery. As for appen-
dieitis, I have never seen a case in a Chinese.
Plague and beriberi were absent.
There has been a severe epidemic of phagedenic
uleers, which occurred mostly among those coolies
who during the spring suffered from relapsing fever.
The history given was usually that of a slight injury,
and in the cases seen early there is a small area
covered with a yellow grey patch of necrosed skin,
while the tissue around is inflamed and swollen.
This rapidly breaks down, and in about seven days
a round, sharply defined sore is formed. This is
covered by a thick slough, and gives rise to a good
deal of foul discharge. The slough separates in
from seven to ten days, and usually the ulcers heal
rapidly. The patients were all anemic.
ALVIS
TYR
LESNAR at
^" XX
be
76 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1914.
Elephantiasis—Two cases of this disease were
treated by the operation of lymphoplasty with fairly
good results. There was marked disappearance of
the swelling.
Phthisis.—This and other forms of tuberculosis in
my opinion are coming more and more into evidence.
What is certain is that the Chinese seem to be an
agreeable soil for the growth of tubercle bacilli,
and what is equally certain is that those in authority
ought to make provision for the treatment of those
cases which are a danger fo the community. I note
on the part of the Chinese an absolute indifference
and inactivity towards this matter.
In Iehang there is a short continued fever last-
ing three to five days, which may probably be
phlebotomus fever due to sand-fly bites. "There
have been several cases noted of ''river fever"
amongst the European population which may prove
to be schistosomiasis, but as yet the positive proof
of the ova in the stools has not been observed by
him.
A. GnanaM, L.R.C.P. & S.
NANKING.
Abstracted from reports by Drs. W. E. Macklin and
M. Urbánek.
Population 400,000.
The reports received do not mention much of
interest with regard to the health of the foreign
community with the exception of the extraordinary
prevalence of malaria, for which the destructive
floods which started so early and kept on so long
are mainly responsible. Dr. Urbánek states that
'' the disease was in Nanking and Pukow practically
universal, and I do not think that any foreigner can
have got off without an attack." The malaria was
a malignant type, and in one district, seventy miles
from Nanking, called Ming Kwan, '' nearly every
case became icterus and even icterus gravis.''
Dr. Macklin says in his report that ‘‘ malarial
fevers are very common. Usually quartan forms
are observed in the winter and carly spring, and
crescent form in the summer and autumn. Fre-
quently a continued fever is seen; that is probably
the cerebral type." There are few, if any, surface
drains in Nanking; they are mostly foul under-drains
that do not run.
The use of quinine is becoming very popular
among the Nankinese. Beriberi has been common
of late. One camp of soldiers who used southern
rice was badly affected. Dr. Macklin notes a case
of fulminant beriberi. Small-pox remains evident,
though the Chinese generally believe in and practise
vaccination, but they use human lymph. Inocula-
tion is now rarely done; ''foreigners usually get
small-pox in a very virulent form—as confluent, or
the hemorrhagic type." With regard to the ques-
tion of prevalence of appendicitis, Dr. Macklin is
of opinion that, while it is not so common as at
home, he has observed cases of this disease among
Chinese. The important affection, schistosomiasis,
has been studied in Nanking for the past three years
by Dr. R. C. Beebe, who finds it fairly common.
Some of his cases came from the north of the Yang-
tsze River. Fishermen were the class mostly
affected. ‘
Famine, typhus, and relapsing fever were the
cause of thousands of deaths in and around
Nanking.
Pakuol.
Situated in the Gulf of Tonquin, this is the
most southerly consular port on the coast of
China.
The health of the town of Pakhoi for the past
twelve months has been, as compared with other
years, undoubtedly good, though there is room for
great improvement were the drainage of the town
given adequate attention.
Small-pox and typhus fever have been entirely
absent. Malarial fevers: the simple benign tertian
is the usual type, though a malignant tertian is
occasionally seen. Malaria is common, and the
anopheles mosquito finds abundant chance of breed-
ing in the open drains of the town. note it as
interesting that the European residents at Pakhoi,
except those who have lived in other parts of China,
do not suffer from malaria, and would point out that
this is probably due to the fact that their houses are
all away from the town on high ground with not
much surrounding vegetation and no pools in the
vieinity. This port is regarded as one of the
‘“ foyers '' of plague in China. It was first reported
here in 1886, and every year since then there have
been a certain number of cases, the year 1910 being
one of the worst on record. No rat or preventive
measures of any kind are taken by the people.
although they recognize that the discovery of dead
rats in a house is very often connected with one
or more of the occupants being attaeked by the
disease. During the past year there have only been
between fifty and sixty cases. At the neighbouring
city of Lienchow, however, for some weeks the
epidemie was exceedingly virulent, as many as forty
to fifty deaths occurring in one day, and the total
number was probably over 1,000. Other isolated
towns and villages suffered badly, notably the town
of Kotah, three miles east of Pakhoi ; though having
only a quarter of the population of the latter, the
number of plague cases was greater there than in
the town.
Beriberi appears to be limited to sporadic cases,
and I have not specially noted it as attacking any
one class. I have not seen a case of undoubted
appendicitis since I eame to China in 1906. Only
a few cases of cholera, not more than twenty, have
been noted this year. "There is a high prevalence of
tubercular cases, phthisis, tubercular joints, and
tabes mesenterica. Venereal affections are very
numerous, both syphilis and gonorrhea in all their
forms. Syphilitic enteritis in children yielding to
hydrarg. cum creta would account for most of the
enses of infantile diarrhoea.
Cases subject to attacks of mania are commonly
seen; melancholia never. T have also never met
May 15, 1914.]
COLONIAL MEDICAL REPORTS.—CHINA. 77
with a case of general paralysis of the insane, though
I have occasionally seen disseminated sclerosis and
locomotor ataxia. The commonest eye affections in
Pakhoi are trachoma, entropion, corneal ulcers, and
pterygium. This observation applies equally all
over China.
Once again one would put on record the conviction
that a simple system of drainage for Pakhoi could
be readily devised and, if adopted, would materially
improve the condition of this town from a health
point of view. It is regrettable that all offers of
assistance made to the Chinese officials have so far
met with no acceptance.
H. GonpoN Tuompson, M.D., F.R.C.S.Eng.
PEKING.
During the year ending September, 1911, the
health of the Chinese and European communities
was, as compared with other years, good. It is
noticeable throughout the city that publie sanitation
is being more efficiently carried out and main drains
are being periodically opened and cleansed. The
wide main streets with their open, bricked side
drains readily carry off the surface waters, and
locomotion is rarely interrupted nowadays during
the rainy season. Municipal scavengers pass up
and down the lanes gathering débris and offal, and
the number of public latrines is annually increasing.
Foreigners.—Intestinal catarrh, due to B. coli
communis, bronchitis and sporadic influenza, were
the most prevalent diseases. Insomnia and neuras-
thenia are not infrequently noted. The health of the
crowded quartier diplomatique shows a steady
annual improvement, mainly due to two factors—
pure water and better drainage. In most of the
legations and business places septie tanks are now
installed, and attention is also being turned to the
supply of pure ice, the lack of which has hitherto
been such a fruitful source of disease.
The past summer was exceptionally cool, and
those residents compelled to remain inside the city
walls were able to do so with less physical discom-
fort than is usually the case.
Chinese.—The epidemie of pneumonie plague last
winter touched Peking very lightly; there were
eighteen cases, which all died. During this time
the sanitary department of the police kept a strict
register of every death, whieh showed an average
of thirty-eight deaths per diem in a population of
700,000. This, however, was at the healthiest
season of the year, and does not inelude child
mortality, whieh remains exceedingly high—over 40
per cent. The number of infant deaths is so great
that it is beyond individual burial, and the small
bodies are simply wrapped in matting and placed in
carts which go through each district collecting the
bundles, which are afterwards thrown en masse in
a hole outside the city gates.
There have been no epidemies beyond the annual
summer outbreaks of diarrhea and dysentery. The
ineidenee of small-pox is gradually diminishing,
largely as a result of the growing popularity of vac-
cination. Numbers of the people suffer during the
summer from febrile attacks lasting from three to
seven days, often longer. In spite of many blood
examinations made by various observers no plas-
modia have been discovered as yet, and the diagnosis
of phlebotomus fever, due to sand-fly bites with
an ultra-microscopical blood germ, is now being
increasingly given to such cases.
It would be difficult to over-estimate the serious-
ness of the tuberculosis scourge. It is the most
important death factor in our midst. Every facility
is given to its spread in a household by the rooted
ideas the Chinese have as to exclusion of fresh air
and the possibility of an affected person '' catching
cold '' from an open door or window.
The intensive system of agrieulture whereby two
crops are raised each year causes a large demand
for nightsoil, which is a valuable commodity. The
Oriental sees no objection to the daily passage
through every lane and street of wheelbarrows and
buekets carrying the ordure to depóts outside the
walls, which explains the efficient, if not esthetic,
manner in which the publie disposal of sewerage is
carried out in this vast city, situated as it is in
the middle of a big plain with no effluent waters
into which drainpipes could be emptied.
G. Dovetas Gray, M.D.Edin.
SHANGHAI.
The annual health report issued by the Municipal
Council differs from those of other treaty ports in
the important respect that more definition is given
to disease rates by the statistics collected by the
Sanitary Department. Notwithstanding the large
extent of its foreign settlement the public health of
Shanghai, no doubt owing to better facilities, is
managed more satisfactorily than in the other ports.
The Medical Officer of Health, Dr. A. Stanley, with
the aid of Drs. A. Moore and Noel Davis, and a staff
of four inspectors and twenty assistant inspectors,
keeps up a systematic examination of the whole
settlement, and is able to carry out prophylactic
measures in a way which is well reflected in the
comparatively low mortality rate when that of other
cities is taken into consideration. In a population
of 18,536 foreigners and 488,005 Chinese the death-
rate from all causes was 20:2 per 1,000 foreigners
and 17:5 per 1,000 Chinese.
Last year there were six human cases of plague
which was ascribed to the increase of rat infection
in one of the sanitary sub-distriets, whieh borders on
a pestiferous district under Chinese control, where
no precautions are taken. The incidence of small-
pox was considerable. Forty-six cases were notified
among the resident foreign community, of which
thirteen were fatal. Among Chinese there were 304
deaths from it, as compared with 143 and 863 the
preceding two years. There were many cases of
choleraic diarrhoea, but no case of true cholera was
found where the diagnosis was confirmed by the
publie laboratory. Typhoid fever remains an impor-
tant sanitary faetor in Shanghai; there were twenty-
78 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1914.
three cases of it, with sixteen deaths. In nearly all
the eases where the origin was investigated obvious
breaches of the rules of health, as laid down in the
publie health notice, were observed. There were no
deaths registered from the Malta fever, and the case
mortality from diphtheria is steadily diminishing,
probably owing to a more general use of antitoxin,
which is now one of the staple products of the
laboratory, and is issued free to any indigent patient.
Searlet fever, practically unknown in the Tropies,
appears to have come to Shanghai to stay since its
introduction by foreign immigrants in 1900. As
would be expected with a recently introduced
disease, against which evolution has afforded no
natural immunity, scarlet fever has been of a viru-
lent type amongst Chinese. It is probable that the
passage of the disease through the susceptible
Chinese has led to an intensification of the virus,
so that it is more fatal to foreigners also. There
were thirty-two cases among foreigners, and a case
mortality of 21:8 per cent. The prevalence of
tuberculosis remains at the same high level, and the
heavy death-rate (669 deaths in all) from this
disease is significant of local conditions of over-
erowding, against which at present there is no legis-
lation. Quite a number of cases of malarial fever,
mostly of the benign tertian type, are contracted in
and around Shanghai. Beriberi has diminished,
sixteen cases as against seventy-eight last year, and
this improvement is held to be attributable to the
measure of disinfection of body vermin among the
prisoners in gaol.
Rabies.—Ten persons were bitten by dogs, and
underwent the Pasteur treatment. The virus of
rabies in Shanghai is of an exceptionally intense
character, the period of incubation being shorter
than the rabies met with in dogs in Europe. Cattle
plague infected the dairies during the year. Immu-
nization by Koch's gall method was offered to all
the Chinese dairies, but almost invariably refused.
The Publie Health Laboratory appears to be a
busy institution; 20,599 specimens were examined
during the year for pathological diagnosis, including
19,599 rats, of which 249 were found to be plague
infected. Over 17,000 glycerinated calf vaccine
tubes were sent out during the year.
A. SrANLEY, M.D., B.S.Lond., D.P.H.
'l'ENGYUEH.
The reports from this treaty port in South-west
Yunnan do not differ materially from those of the
previous year. The health of foreigners has been
good. There were numerous deaths in and round
the town due to dysentery, measles, typhoid and
malarial fevers. Several cases of leprosy came under
treatment. Malignant malaria appears to be very
prevalent, especially among travellers from Bur-
mah. An outbreak of small-pox occurred in Feb-
ruary and March in the surrounding villages.
Vaceination is gaining popularity, but the majority
of the people are still in favour of inoculation.
H. A. Ram Lall Sirear, the Consular Medical Officer,
gives the following description of the practice of
inoculation :—
‘‘ The scabs from small-pox cases are collected
and stored in the form of powder for the season.
This powder is blown up the nostrils of the children
and causes an attack of artificial small-pox, the
viruleney or mildness of which depends on the doses
used and the type of small-pox from which the
scab was taken. When the attack is severe the
result is pitiable, the unfortunate victims sometimes
lose one or both eyes, some become permanently
deaf, and some die of septicemia. Two such cases
came under my treatment lately. One of them had
necrosis of the nasal bones due to multiple septic
abscesses, and the other had lost one eye and had
a big gangrenous ulcer on the right cheek. As they
did not return I presume they both died."'
H. A. Ram Larr SiNcan; H. A. Winrar CHAND.
TIEN-TSIN.
(Population over 1,000,000: The commercial capital
of North China.)
The general health conditions of this important
post remain very good for foreigners and Chinese
alike. There have not been any epidemics. Among
foreigners a few cases of typhoid fever occurred, and
a peculiar feature of each autumn for the past three
years has been the occurrence of sporadic cases of
cerebro-spinal meningitis, mainly British and French
soldiers. No satisfactory account has as yet been
forthcoming as to the etiology of these cases, as all
those affected lived in healthy sanitary surround-
ings. Venereal disease is frequent both among
foreigners and Chinese, and there are also many
native deaths from tuberculosis. The presence of
several thousand soldiers of different nationalities in
Tien-tsin, without any adequate enforcement of pre-
ventive measures against contagious diseases, is a
matter which requires more supervision than it has
hitherto received. In this great wool and hide im-
porting centre, where carding and sorting is carried
on in a large scale in local factories to prepare the
trade for export, it is remarkable that human
anthrax is almost non-existent, though particular
attention has been paid in the past few years to its
possible presence in view of the heavy indictment
against China as the country of origin from whence
the majority of infective skins, &c., which cause
anthrax in England and the continent come. No
bovine anthrax has yet been seen in North China.
TSINAN.
Abstracted from reports by Drs, Med. Kautzsch
and Herrmann.
(Population, 100,000: The capital of Western
Shantung.)
The general state of health in this consular dis-
trict was on the whole unfavourable. The greater
mortality of January, February, and March was
occasioned, on the one hand, by numerous serious
May 15, 1914.]
COLONIAL MEDICAL REPORTS.—CHINA. 79
cases of small-pox, scarlet fever, diphtheria and
typhus and on the other hand by the pneumonic
plague imported into Shantung last January.
During summer there were heavier and more fre-
quent rains than usual. An accumulation of illness
was especially noticeable in August.
Diphtheria appeared specially in February
amongst the Chinese population in a very virulent
septicemic form, which frequently caused death in
two or three days without getting so far as any
distinct membranous formation. Dr. Med. Kautzsch
says that many cases reported as plague were really
diphtheria. Typhus was very common in connection
with the famine in South-west Shantung. It is
probable that the first cases were imported from
Tsingtau, where there was an epidemic of typhus
fever, during which the well-known Dr. Med.
Wunsch died, having been infected whilst treating
a Chinese who recovered. The German doctors
noted that Europeans less frequently survive typhus
than the Chinese. Pneumonic plague was imported
into Shantung in the beginning of January by the
labourers returning every winter from Manchuria
either by land via Techow or by sea via Chefoo.
Dr. Kautzsch adds that ‘‘ the importation of plague
via Techow was doubtless due to the inauguration of
labourers’ trains on the stretch from Tien-tsin to
Tsinan whereby some 60,000 coolies were carried.
Had the railway not been completed at that time
there would have been no plague in West Shan-
tung.''
Cases of typhoid fever have been more frequent
during the past year, and Dr. E. Hermann reports
that the Chinese recover more quiekly from this
disease than Europeans do.
Wunv.
Abstracted from reports by Drs. E. H. Hart and
H. S. Houghton.
(Population, 130,000: On the bank of the Yang-tsze
River. It is the principal river port of Anhui
Province and one of the chief rice exporting centres
of the Empire.)
The health of foreigners in this port has been
excellent, there were no deaths during the year.
Skin affections, malaria, acute bronchitis, and
genito-urinary complaints in the order named were
the chief diseases in the foreign community. Drs.
Hart and Houghton, in the report forwarded, have
made some interesting remarks on the diseases
found in Chinese in Wuhu and the surrounding dis-
trict. It appears that typhoid fever is by no means
uncommon among them, though its virulence is low.
Small-pox is very abundant, but is probably decreas-
ing in actual numbers of cases and in severity of
infection, inasmuch as vaccination with calf lymph
is eagerly sought and practised freely throughout the
prefecture in recent years. Cholera is endemic.
Under favourable conditions it becomes epidemic in
the city and immediate suburbs, but the farming
districts are spared. Dysentery is one of the com-
monest affections in Wuhu. The acute bacillary
dysenteries are very abundant, reaching a climax
in numbers in September. Somewhat less frequent
is amebie dysentery. The dysenteries associated
with metazoal intestinal parasites, such as Schisto-
somum japonicum and Strongyloides intestinalis,
while not seen in foreigners, in certain. parts of this
district and province constitute a serious menace to
the farming classes.
Constant exposure to infection and reinfection
being made necessary by work in the rice-paddies,
there are some magistracies in Anhui wherein prac-
tically every other one of the farmers is infected.
As heavily infected cases usually die in from one to
four or five years, it will easily be seen how grave
a problem it is in some of these places.
Malaria is plentiful, the commonest form being
quartan, next benign tertian, the rarest subtertian.
No cases of pernicious subtertian have been noted
in Wuhu for some years past.
Kala-azar has an abundant distribution towards
the north of. the Province, but local cases have not
been seen. There is, however, a constant stream of
trafic between Wuhu and the infected area in the
north, and imported cases have been found as far
south as Kiangsi, so that the disease will in all
probability reach Wuhu ere long.
Tubereulosis is inereasing in the fertile soil of
insanitary and unhygienic city life, and is the worst
scourge of the city dwellers. All forms—pulmonary,
cutaneous, bone and joint, and laryngeal—are very
common.
Rabies is well known. Scarlet fever, plague, and
diphtheria have not been seen in Wuhu. Relapsing
fever has hitherto been absent, but has been re-
cently introduced from the famine districts in the
north.
Schistosomiasis.
In the first series of these reports some observa-
tions made by Dr. E. H. Hume on this disease
were included, in which he quoted the case of a boy
as being the first European on record to suffer from
infection by the parasite Schistosomum japonicum.
This year Dr. Hume is still more impressed, from
a wider experience, of the danger which foreigners
run, and the possibility of a wider distribution, and
he added in the report his conviction that ‘‘ bathing
by foreigners in the waters of the Siang River
should be forbidden until such time as we have
fuller knowledge of the distribution and life-history
of this treacherous parasite.” Discovered so re-
cently as 1904, first in Japan, by Katsurada, and
a few months later by Catto, in Fukien, it has
become increasingly evident throughout the Yang-
tsze Valley. In some places whole villages seem
infected, and in other places, e.g., at Pingwu, in
Chekiang, it is said to be ''a perfect scourge.”
One is led to think in this connection of trypano-
somiasis (sleeping sickness), which is also a scourge
of recent years. I have passed through populated
and contented agricultural districts in Central
Africa, ten years ago, which are at present devas-
tuted and abandoned owing to wholesale infection
by the trypanosome parasite. It therefore becomes
80 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1914.
important to give every publicity to the work done
to elucidate the growing problem of schistosome
infection in China. In this. year's report from
Hankow, Dr. J. A. Thomson gives notes of three
European cases which are symptomatic of the
initial infection by Schistosomum japonicum.
Case No. 1.—Mr. Ms., an office clerk, arrived in
China, October, 1910. On July 13, 1911, he com-
plained of fever, headache, and general body pains.
There was looseness of the bowels. Four days be-
fore he had been on a bathing picnic and had swal-
lowed water while bathing. He had then noticed a
peculiar pimply eruption on one toe, ‘‘ so peculiar
that he showed it to his companions,” but it had all
disappeared by next morning.
Physieal examination: Abdomen and chest nor-
mal; tongue furred along the dorsum with a thick
slimy coat, edges red but indented; blood examined
for malaria was negative, no notable alteration. By
July 29 the symptoms had become more acute, and
on August 3 giant urticaria appeared on the
abdomen, back, and thighs. On August 5 an
eosinophilia of 36 per cent. was found, and next day
examination of a small piece of mucus adhering to
a constipated stool showed ova of Schistosomum
japonicum. At this time the sigmoid became tender,
rolling under the palpating fingers like a sausage;
the spleen became palpable, and there was consider-
able enlargement of the liver. There was dull pain
on inspiration; this was accompanied by a rising
temperature, reaching its climax of 105°4° F.
on August 7. All these symptoms were quickly
relieved by calomel, after which the temperature
steadily fell, and convalescence progressed slowly but
surely. At the time Dr. Thomson wrote his report
(September 24), ova were still present in the stool,
also the sausage-like and tender thickening of the
sigmoid remained in statu quo, but liver and spleen
were normal in size; eosinophilia 34 per cent. The
patient lost much in weight, but latterly regained
this, and is now only 10 lb. under his normal. The
treatment was purely symptomatic.
Case No. 2.—Mr. H. also came on July 18 for
treatment with symptoms similar to those in Case
No. 1. Eosinophilia 23 per cent. was found, no
ova; but on August 29 they were discovered in
mucus adhering to a constipated stool. Eosinophilia
at this time reached 54 per cent. He also became
convalescent under treatment.
Case No. 3.—Mr. Me., under the care of Dr.
Aird, Hankow. This patient came under observa-
tion on July 10, 1911. He, too, was an office clerk,
who had arrived in China during the present year.
He had similar symptoms, but had no rose spots
or other eruption. It was not until August 7 that
numerous characteristic ova of schistosomum were
found. Liq. arseniealis was prescribed, and he is
now convalescent.
These three men, Ms., H., and Mce., all had a
history of bathing in a lake some twelve to fifteen
miles distant from Hankow.
Ms. is not a swimmer, and consequently his bath-
ing consisted of standing splashing and dipping in
the shallows. Mc. swims a little, but spent most
of his time in the water with his companion Ms.
H. is a better swimmer, but after swimming from
the boat to the shore he sat on the bank dangling
his legs in the shallow water for some minutes.
Altogether there were twelve men in the party;
these three and three others swam to the shore or
paddled in the shallows, and of these latter three,
two had fever with very pronounced eosinophilia ;
the third had eosinophilia without fever or other
symptoms of illness. Taking into consideration the
previous history of these last three and the presence
of pronounced eosinophilia (30 to 40 per cent.) with
no other discoverable cause, it might be justifiable
to suspect them of being ‘‘blind’’ cases of the
disease, that is, cases with infection, but with no
discharge of ova, a condition which is easily con-
ceivable when one remembers the habitat of the
adult worm. The six other bathers, so far as Dr.
Thomson could find out, are unaffected; they swam
in deep water round the boat, and did not go ashore.
In cases of severe infection ova are readily dis-
covered; but in the lesser infections ova are by no
means plentiful, and can be very easily missed,
even after centrifugalizing. It is pointed out that
a much more certain way of finding ova is to get the
patient constipated, and on the surface of the con-
stipated stool small points of mucus, often blood-
stained, will be found, and such mucus pressed
under a cover glass will, as a rule, show several
ova. It is probably an occupational infection, as
practically all the cases reported have been amongst
fishermen, rice farmers, boatmen, and raftmen;
lakeside dwellers are peculiarly liable to the disease.
This would further suggest infection by skin or anal
contact with infected water. No cases have ever
been reported amongst women. In this part of
China women are all ‘‘ small-footed,'' and care of
their feet and feet-bindings is one of their first con-
cerns, and their reason for not wading or working
in paddy fields is obvious. The disease is present
among pointers and other sporting dogs, and mani-
fests itself in them by dysentery and wasting.
Dr. Thomson proceeds : —
' Native patients present themselves at hospital
with a variety of symptoms.
** (1) Ova are found in the routine examination
of stools of patients presenting themselves for some
other disease.
“ (2) Patients with remittent fever, large spleens,
and enlarged livers, with dyspeptic troubles with or
without diarrhoea or dysentery, but with a history
of one or other of these.
“ (3) Like 2, but with moderate ascites.
** (4) With shrunken liver, spleen enlarged or not
enlarged, enormous ascites and extreme wasting.
'" In man ascites is a very frequent accompani-
ment of the disease, but not so in dogs; I have
known of dogs which have suffered severely for
years, but have never known of one to have de-
veloped aseites, but, on the contrary, the abdomen
becomes more and more retracted; dogs. however.
are as a rule destroyed when dysentery and diar-
rhea become so severe that shooting becomes more
merciful than further attempts at treatment.
June 1, 1914.]
COLONIAL MEDICAL REPORTS.—CHINA. 81
==.
Colonial Medical Reports.—No. 35.—China — (continued).
" MoRPHOLOGICALLY the adult worm is developed
to live in a free space, as its suckers can have no
other function. If it is a parasite of the portal venous
system only, how can this explain the escape of
ova from the intestines and ova reaching the lym-
phatic glands in such large numbers? The ova
themselves are passive, and can only travel by being
carried in currents. Those deposited by worms ly-
ing in the large veins anywhere in the portal system
will naturally be carried by the blood-stream until
they reach the small termini of the portal vein
ramifications in the liver, and, there settling, cause
congestion of the organ and interlobular cirrhosis
manifesting itself clinically in enlargement and
tenderness of the liver; in course of time coarser
cirrhosis sets in with shrinking of the liver and
development of ascites. It is conceivable, too, that
adult worms may be lodged in the small radicles
of the portal vein in the intestinal wall—radicles
just big enough to contain the male and female pair;
in such a case the pair of worms would themselves
occlude the channel and cause the ova to accumu-
late behind them until the venous wall liberating
marked feature of this stage; it is rarely the sym-
ptom that the patient will complain of; this stage
stimulates chronic kala-azar, chronic malaria,
dysentery, or chronic diarrhea or alcoholic cirrhosis.
The duration of the disease will depend upon the
number of worms present and upon the question if
they ever die off or not, and it will be a problem
for physicians practising among Europeans in China
to determine what the prospects will be for patients
who have been infected by bathing or wading once
or twice.
‘“ The prognosis is as yet doubtful, for, as regards
Europeans who come early under treatment and
avoid further infection, there are not enough cases
so far upon which to pronounce definitely, but in
their case it is decidedly more hopeful than among
native patients, who are exposed to infection over
and over again.
" In the diagnosis of schistosomum infection (a
recent case), extreme eosinophilia will be the phy-
sician’s first clue: that is, if the blood is examined
as a routine procedure in all fever cases, and in
‘blind’ cases it may be the only clue. Eosino-
philia is very pronounced, and is obvious in the
EXAMPLES OF EOSINOPHILIA.
Poly-
Date morphonuclears.
Per cent,
Mr. Ms. August 13 m 50
3 ase » 27 -— 37
Mr. Mc. SA An 10 igs 48
Mr. H. AE $$ 28 m 27
Mr. F. FF T 13 ies 30
Mr. S. September 10 ET 47
the ova into the tissue spaces, from which some
are carried away in the lymph stream to lodge in
the glands and others get pressed upwards between
the mucus glands to finally escape into the lumen
of the bowel. Escape of the ova into the bowel
would therefore altogether depend upon adult worms
inhabiting very small venous radicles, and is there-
fore not necessarily a feature of the disease. A
marked eosinophilia with a history of bathing in
possibly infected water, with no other reason to
account for such an eosinophilia, even in the absence
of ova, may under certain cireumstances (as in the
three cases mentioned in which ova could not be
found even after many examinations) justify one in
diagnosing schistosomum infection as so-called
‘blind’ cases of the disease.
‘“ Pathologically the disease may be divided into
two stages :—
' (1) Febrile stage of invasion characterized by
pronounced febrile reaction and remarkable eosino-
philia. Clinically this stage has to be differentiated
from fevers such as typhoid, paratyphoid, and
malaria.
'* (2) Ovian embolic stage, during which ova are
settling in the liver and intestinal glands, causing
cirrhosis of these organs. Fever is not, as a rule, a
? Large
ophilia. Lymphocytes. Mast cells,
dio cents Wiper cout. Per cent. oe
36 ti; 11 1 2
34 ate 24 1 4
45 we 5 0 8
54 T 17 0 2
39 M 23 3 5
39 ner, 25 1 4
ordinary examination for malarial parasites even
without a detailed differential leucocyte count.
“ Mr. F. had fever, but no ova were found. Mr.
S. had no fever or other signs of illness, but six
years previously had suffered from an undiagnosed
fever following bathing.
‘“ The mode of entrance into the body is still an
undecided point. Mouth infection is likely, other-
wise there could not be the marked limitation to the
male sex.
'* Ova when put into saline quickly hatch out, and
the pointed ciliated embryo swims about actively
for a time, then comes to rest; cilia are lost and the
embryo enlarges and assumes the sporocyst stage
of the liver fluke, but no further development occurs.
An intermediate host for the development of cer-
caria suggests itself in some fresh-water mollusc,
and it is to be hoped that, with the number of
practitioners now interested in the subject in China
and Japan, a full life-history will soon be forth-
coming.”
Dr. Thomson was able to make a post-mortem
examination of one case, but the results are not
included in this report. Briefly, the liver was
shrunken and cirrhotic, with numerous scattered
ova and sections of what appeared to be portions of
(June 1, 1914.
the adult worm in the cirrhotic area. The peri-
toneal glands were all enlarged, and there were
about thirty pints of chylous fluid. The pathological
findings all pointed to the disease being an embolic
process, ova constituting the emboli. In this case
82 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
no evidence could be found of filarie to account for
the chylous nature of the fluid. Ascites is the
normal ending to all these cases, so far as Dr.
Thomson has yet noted.
Colonial Medical Reports.
No. 36.— British Honduras.
MEDICAL REPORT FOR THE YEAR 1909.
By J. H. HUGH HARRISON.
Colonial Surgeon.
Tux work of the Hospital during the year has been
very satisfactory. Number treated during the year,
629, 96 in excess of last year. The figures for the
pe are as follows: Remaining at beginning of 1909,
8; admitted during the year, 591; total, 629.
This was a good year for surgery, operations
averaging four per week.
Lunatic ASYLUM.
The health of the lunatics was good. The follow-
ing is the statistical record for the year: Remaining
on January 1, 1909, 55; admitted during 1909, 8;
total, 63. Remaining on December 31, 1909, 60.
PoorHouseE.
Number of inmates remaining on January 1, 1909,
36; number admitted in 1909, 4; total, 40.
QUARANTINE.
A suspicious case of yellow fever occurred on board
the s.s. '' Ellis,” from New Orleans, last July. The
case was removed to the Isolation Hospital at Moho
Cay. On recovery, he was sent back to the States.
All passengers were kept under quarantine and the
vessel properly fumigated with sulphur.
The United States have shown their appreciation
and confidence in this Colony by not putting any
medical officer here during the present quarantine
season.
INTERNAL QUARANTINE.
Owing to the outbreak of small-pox at Stann Creek
that place was quarantined against the rest of the
Colony. All persons coming from the town of Stann
Creek were kept under medical surveillance.
Vessels boarded, fumigated, crews and passengers
inspected by Health Officer for the Port of Belize.
Vessels boarded: Bteamships, 267 ; schooners, 167;
awls, 35; sloops, 160; doreys, 210; total, 870.
umber of vessels fumigated, 211; number of
crew and labourers inspected, 19,456; number of
passengers inspected, 3,150.
THE GENERAL HEALTH OF THE COLONY.
Corosal.—The health of this place has been good
during the past year. It is a matter of much con-
gratulation that dysentery was not as rife during the
past year as in previous years. No infectious disease
was reported during the year.
Orange Walk.—The infant mortality was very
high. Out of 131 deaths registered, 58 occurred in
children under 5 years of age. No infectious disease
was reported. Anti-malarial measures were taken by
filling up sundry ponds and low-lying swamps, and
bringing the Mosquito Ordinance into proper force.
Stann Creek.—An outbreak of small-pox occurred
in the commencement of the year. Luckily the
cases were isolated early and general vaccination
resorted to with the happy result that the disease
was soon stamped out. Eight cases occurred, and
of these three died.
Toledo District.—Report for the year was good.
In May of last year, Dr. Mackey proceeded to San
Antonio owing to a rumour that an epidemic was
raging amongst the Indians. Dr. Mackey’s report
is appended, the conclusions of which point to the
prevalence of tuberculosis and the hook-worm, but
the epidemic which caused such a loss of life amongst
the young residents during the early part of the year
was, in my mind, undoubtedly due to pneumonia.
Belize District.—Tuberculosis is still on the in-
crease; twelve deaths were reported from this cause
in the town with seven in the hospital.
Several cases of myasis (screw-worm) were
admitted. They seem to be becoming commoner in
the place; in fact, I have noticed the flies on many
occasions in the hospital, in my own house, and in
the asylum gardens. Cases have been reported to
me by private practitioners in the town. It is
possible for great damage to be done by the screw-
worm.
In one particular case the whole of the nose
together with the right eye was destroyed. It is a
wonder to me that the man survived, as the destruction
to the tissues, not only of the nose but the posterior
nares, was very great. Specimens of the fly were sent
to the British Museum. They are known as the
June 1, 1914] COLONIAL MEDICAL REPORTS.—BRITISH HONDURAS. 88
Sarcophaga chrysostoma instead of what was under-
stood to be the Chrysomyia macellaria.
Another most interesting case due to splenic abscess
occurred in a boy 11 years of age. The actual notes
were lost in the fire, but as far as my memory serves
me the patient was suffering for over nine months.
When admitted he was anemic and haggard, com-
plaining of pain on the left side radiating to the
umbilicus. The abdomen was tense and he had
ascites as well. On palpation you could feel the
spleen right from the back to the left side reaching
nearly to the umbilicus; above this point it showed
a slight bulging which felt soft and pulpy to the touch.
The liver also was enlarged, but the separation between
this organ and the spleen was distinctly felt. I
tapped him and drew off the ascitic fluid; this brought
into prominence the splenic tumour very vividly.
After two or three days I opened the bulging at its
most prominent point and drew off about 6 oz.
of pus which resembled the discharge of hepatic
abscess. However, in spite of the abscess being well
drained the boy died in about a week. I held a post-
mortem and found the spleen nodular, very much
enlarged and cirrhosed. All the other organs were
pale and anemic, otherwise healthy.
Another case of enlarged liver was admitted during
the year. It was a patient of 10 years. The liver
could be distinctly fel& about 4 in. below the costal
margin having a nodular feel to the touch. The
patient was anemic and much jaundiced and there
were some ascites. He died soon after admittance.
Post-mortem examination showed the liver much en-
larged and scattered throughout with what appeared
to be multiple abscesses varying in size from a pea
to that of & small orange. On opening these they
seemed to contain a sort of creamy caseous matter.
The organ was sent to Dr. Stevens. His kind report
was destroyed, but I believe on examination it was
found to be of a carcinomatous nature. This is
interesting from the fact that the patient was only
10 years of age.
ASSISTANT COLONIAL SURGEON Mackey’s REPORT
on Visit TO San Antonio, May, 1909.
I reached San Antonio at 11 a.m., May 28, and
remained there until 7 a.m., June 1. Whilst there
I was fortunate in being able to secure the services
of an intelligent interpreter who rendered me much
assistance.
Situation of the Settlement.—San Antonio seems
to be about twenty-five miles in a north-westerly
direction from Punta Gorda. The surrounding
country is hilly. The settlement is situated on two
neighbouring hillocks with a very shallow stream
running between them. More huts are built on the
higher of the two hillocks which has an easterly
aspect. Some of the houses are so near the stream
that it would appear they must be flooded when the
river is high. The floors of such houses appear damp
even in the dry season.
Dwellings.—The people of San Antonio live in huts
which are roofed with bay leaves, and many have
only one room. This is used for living, sleeping,
cooking and eating. The walls of many of the huts are
of open stockading, others are plastered with mud;
they have earth floors. Very few of the huts are
spacious. The dwellers in the mud-water houses
seem to disregard the need of light and ventilation.
After sundown the windows and doors are closed.
Water Supply.—Water is taken from a shallow
well and also from the river for drinking and other
purposes. The well water appeared very muddy and
there was a copious earthy deposit seen on standing.
The river water seemed to contain much macerated
vegetahle matter.
Food Supply.—There are many Milpas in the
neighbourhood and the people seemed to have plenty
of maize, so much so that the people carry it to Punta
Gorda and San Louis for sale. Eggs and chickens
were cheap in San Antonio. There were many pigs,
and these appeared in good condition, but they were
not kept in styes but allowed to wander about.
Habits of the People.—The people are very dirty
in their habits, and as they appeared to disregard the
common rules of hygiene much avoidable exposure
to infection takes place. They expectorate freely
over the walls and floors of their houses and then
wipe away the residual sputum from their mouths on
to the sleeves of their tunics or on to their hands,
afterwards drying their hand on their trousers. One
finds fæces scattered within the limits of the settle-
ment. This is not due to the dirty practices of the
children only, but also of the adults, some of whom
defacate after nightfall on the ground within the
settlement. The pathways in the bush, those along
the river especially, are used as latrines. One is
struck by the uncleanly condition of the children
and most of the men. Pigs and fowl are allowed to
live in the dwelling-houses, and both are often fed
there.
Population.—This appeared to be about 450.
House to-house Visiting.—I visited each of the 93
dwellings in San Antonio, and examined such sick
people as were met with in that way.
The following is a list of cases seen and examined
with a few remarks added :—
Middle-aged woman said to suffer from “fts.”
She said she had a sick son in Punta Gorda, but
could give no account of his symptoms.
Man, about 45 years of age, with chronic bronchitis.
Child, about 8 years, with acute broncho-pneumonia.
Man, aged 56, has chronic phthisis pulmonalis.
Has been ill for fourteen months. Said he lost his
son one year ago through “ cough and bad chest.”
Child, aged 4. Malarial fever.
Woman, middle aged. Has early signs of phthisis
pulmonalis.
Girl, aged 19. Acute rheumatic arthritis. Cases
VI and VII live in a very small hut along with four
other persons.
Girl, aged 7, has marked phthisis pulmonalis. Said
to have been ill six months. House is spacious, has
open stockading walls. Situated on the top of the
hill. Other occupants appear healthy.
Mother and son sick. Mother has _ phthisis,
duration of illness said to be three years. Son at
Milpa, so could not be examined.
Woman. Senile debility. Son said to have ‘ bad
cough,” but is now away.
Child, aged 5. Pyococcic dermatitis.
84 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 1, 1914.
Woman, aged 25. Acute gastritis (aleoholic).
Child, aged 6. Impetigo contagios.
Old woman. Chronic bronchitis.
Acute arthritis (left knee).
Old woman. Mossy foot (hyperkeratosis). Duration
said to be twenty years.
Old woman. Emphysema.
Boy, aged 12. Uncinariasis.
Boy, aged 6. Advanced uncinariasis.
Man, aged 25. Incipient phthisis.
Boy, aged 10. Marked uncinariasis.
Two girls, aged 8 and 4 respectively, and boy,
aged 9. Uncinariasis.
Boy, aged 18. (?) Early phthisis pulmonalis.
Old woman. Advanced case of mitral regurgita-
tion.
Man, aged 35. Marked phthisis pulmonalis.
Woman, aged 25. Malarial fever. Strong and well
nourished. E
Woman, aged 25. Old spinal caries.
Boy, aged 16. Malarial cachexia.
Man, aged 22. Advanced phthisis pulmonalis.
House has walls of open stockading and is near river.
Had been cupped over left apex by San Antonio
Indian.
Man, aged 56. Emphysema and double cataract.
Girl, aged 7. "Tuberculosis, adenitis and phthisis.
Man, aged 40. Phthisis pulmonalis. Sick for one
ear.
d Man, aged 18. Malarial cachexia.
Man, aged 35. Malarial cachexia.
Microscopical Examination of Stools.—The people
seemed very unwilling to send their stools for examina-
tion, probably due to their habit of using the bush.
Four were examined, and ova of hook-worm found
in one.
Estimation of Prevalence of Malaria.—Forty-two
apparently healthy children were examined and
specimens of their blood taken. These children were
under 9 years of age with one exception, a girl of 12.
Two of this number were slightly ansmiec. Six
showed marked splenomegaly. The spleens of seven-
Child, aged 8.
teen others were slightly enlarged. The malarial
parasite was present in 19 per cent. of the specimens
of blood examined, there was an increase in the
mononuclear cells in 30:9 per cent. Two of the
specimens were spoiled previous to examination.
I inquired of several of the residents if they could
describe to me the signs and symptoms of the young
people who died in the early part of the year. The
several accounts coincided very closely. They said it
was the strong and healthy who were attacked and
succumbed. Their illness lasted from three to five
days, and the symptoms appeared very similar. They
were ''fever, bad cough, shortness of breath, pain in
the chest and hard breathing." It was noticed that
these sick people became bluish before death.
Conclusions.—(1) The people as a whole, especially
the children, presented a healthier, stronger and
less anæmic appearance than many of the Indian
settlements in the western district of the colony.
(2) Pulmonary tuberculosis seems more prevalent
than one would expect in such a community. This
is likely to spread more rapidly than it ought to do
owing to the want of hygiene amongst the people.
(3) Uncinariasis is present, but to a much less
extent than in the settlements in the western district,
or the effects of the hook-worm may be less marked.
(4) The disease which caused such a great loss of
life among the young residents during the early part
of this year might have been acute iufective (creeping)
lobar pneumonia, but from the description given one
cannot form a definite opinion upon the matter.
(5) The ineidence of malaria is high.
Whilst in San Antonio I took the opportunity of
mentioning to the Senior Alcalde, and many of the
people who gathered around in the evening, some of
the more important precautions that the people might
easily adopt, firstly in preventing malaria, secondly
in lessening the risks of the spreading of phthisis and
uncinariasis. They seemed eager to know what
could be done in the matter, and expressed their
intentions to carry out the recommendations.
June 15, 1914.]
COLONIAL MEDICAL REPORTS.—FIJI. 85
= = —- E = ——————á—
Colonial Medical Reports.—No. 37.—Fiji.
MEDICAL REPORT FOR THE YEAR 1911.
By G. W. A. LYNCH.
Chief Medical Officer.
THE estimated population of the Colony at the end
of 1911 amounted to 142,761, and was made up as
follows :—
Totals at last
decennial census
(1911)
Europeans ss 3,734 3,707
Half.castes — .. ae 2,430 2,401
Indians 43,302 40,286
Polynesians 2,991 2,758
Rotumans 1,965 2,176
Fijians 87,229 87,096
Chinese 305 3905 «
Others 805 812
Total 142, 761 139,531
The difference between the numbers at the decennial
census for the year 1911, and the total in December,
1911, is mainly aecounted for by the larger numbers
of Indians ; the inerease here being due, in the main,
to the larger importation of indentured Indians during
the year, and the comparatively small number re-
patriated at the end of their term—there were 3,768
of the former, and 647 of the latter.
The total number of births in 1911 was less again
that in 1910. There was a decrease also in 1910 as
compared with 1909. Total decrease, 304. It is
difficult to account for the heavy drop among Indian
births. The fall amongst the Rotumans is due to the
severe and universal epidemic of measles that swept
through the entire population of this island in the
early part of 1911. The fall amongst Fijians is the
same as is uoted with regularity each year with
a population either falling or stationary. The number
of marriages shows a general increase.
The number of deaths shows a decrease all round
and, on the whole, the comparison with 1910 is good.
There is a total decrease of deaths of the whole
population of 147. In 1910 the increase in deaths
was seen in every class; in 1911 the increase in
deaths is seen only in the misfortune of the Rotuma
epidemic of measles, but for which the total would
have been far more satisfactory.
The birth-rate for 1911 is 32-20 per mille against
31:12 per mille in 1910, and 38:19 per mille in 1909.
The European rate was 24:10 per mille, against 26:16
per mille in 1910; the increase in European population
having been entirely amongst the males, by new
arrivals in the Colony. The Fijian rate was 37:80 per
mille, against 38:61 per mille in 1910. The Indian
rate was 29:35 per mille against 37:28 per mille in
1910.
The great decrease in Indian births and birth-rate
is not easily understood. It may be that registration
is not very perfectly carried out amongst them and
that thereby some births are missed.
The death-rate for 1911 for all races in the
Colony, including Rotuma, was 33:11 per mille,
against 35:44 per mille in 1910; 29:31 per mille
in 1909; and 31:38 per mille in 1908. If the
Rotuman figures are omitted the rate comes down
to 30:10 per mille. The European rate was 12:34 per
mille, against 19:10 per mille in 1910. The Fijian
rate was 37:69 per mille, against 41:24 per mille in
1910. The Indian rate was 18:24 per mille, against
25:91 per mille in 1910.
The European figures are striking for a tropical
country. Account has to be taken of the fact that
a great many Europeans retire from Fiji after &
certain age; but even allowing for that fact, and the
fact that some invalids go away and do not return,
the rate inust be considered a low one. Among
Fijians the heavy death-rate is among children ; and
these die in large numbers from preventible diseases
because of the apathy of parents, adherence to native
remedies, and neglect to take advantage of the various
provincial hospitals provided for their exclusive use in
nine or ten different parts of the Colony.
Seasonal Prevalence of Disease.—From January to
March or April is the season when admissions for
dysentery are expected to be high ; in the last quarter,
and especially in the last month of the year, native
chronic cases do not present themselves in nearly
such large numbers, as they are all most desirous of
getting to their homes at Christmas time.
DISEASES.
Dysentery.—There were a large number of cases
of this disease treated in all the hospitals throughout
the Colony. At the Colonial Hospital, 274 cases,
with 15 deaths; in 1910 there were 353 cases, with
12 deaths. In the provincial hospitals, 220 cases,
with 20 deaths; in 1910 there were 347 cases, with
54 deaths. In the plantation hospitals there were
1,019 cases, with 49 deaths, against, in 1910, 1,156
cases, with 84 deaths.
In addition to these figures, the returns from native
medical practitioners show that they treated in 1911,
621 cases of dysentery, with 33 deaths. The returns
from this source were incomplete in 1910. In look-
ing at these figures for dysentery cases, it must be
pointed out that natives, in the greater majority of
cases, keep their dysentery patients at home if they
can possibly avoid sending them to hospital, and
therefore a great number of dysentery, as well as
other cases, are never reported to the native medi-
cal practitioners or district medical officers, or,
if they are reported, only when the cases are in
extremis and all native remedies have been exhausted.
This is the common and disappointing experience of
86 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
every medical officer who has ever worked amongst
Fijians.
With regard to the death-rate from dysentery
quoted for the provincial (native) hospitals, it must
also be noted that the friends and relatives frequently
insist on removing their sick from hospital if they
consider that the case is hopeless. The rate can
therefore only be considered an approximate one
amongst natives; just as the number of cases treated
is but a small part possibly of those who suffer from
the disease. It appears, however, from the tables
given that the total number of cases is smaller than
in 1910. The total number of deaths is very con-
siderably less; the percentage of admissions for
dysentery throughout the Colony is less; and the
percentage of deaths from dysentery to cases admitted
is also less; from which it may be said that while
there were fewer deaths, the type of cases was milder,
and perhaps more attention was given by natives to
European methods of treatment. Printed circulars,
containing simple recommendations for treatment of
dysentery, have again been issued in English, Fijian,
and Hindustani, and widely circulated in every part
of the group. Some good may have resulted from
these.
Enteric Fever.—At the Colonial Hospital there
were 17 admissions for enteric fever with 3 deaths.
In 1910 there were 6 admissions with 1 death. At
the provincial hospitals there were 15 admissions,
with 3 deaths, in 1911, against 34 cases and 3 deaths
in 1910; at the plantation hospitals there were 11
cases and 4 deaths in 1911, against 2 cases and
1 death in 1910; a total of 43 cases and 10 deaths
in 1911 against 42 cases and 5 deaths in 1910. Most
of these cases occurred at the Colonial Hospital, at
Rewa, Labasa, and Nadroga. Several of the cases
atthe Colonial Hospital were also brought for treat-
ment from the Rewa district, where, for several years
past, there have been more or less serious outbreaks ;
thus, in 1910, 33 cases occurred in this district out
of a total of 42 cases treated in the hospitals of the
Colony. There seems, however, to be no doubt that
this disease has spread and is spreading in the Colony ;
but now that, under the new Public Health Ordinance,
there are increased facilities by law for notification
there should be better means for controlling the disease
by early notification and early isolation, especially of
native cases.
Tuberculosis.—There would appear to be an up-
ward tendency in this disease; and this is especially
the case amongst natives, who fail to realize its
gravity and therefore fail to take advantage of
advice given to them with a view to its check and
prevention. The low percentage in the plantation
hospital patients is due, of course, to the fact that in
these hospitals are treated entirely the indentured
labourers in their first five years; and therefore they
are the pick of the Indians, who should be free from
such diseases, for all doubtful cases are weeded out at
the depót before indenture. At the Colonial Hospital,
on the other hand, are admitted all conditions, and
none are refused. The Indian patients in the Colonial
Hospital may therefore be said to be all those who
have broken down in the Colony. There is a steady
rise in the cases admitted to the provincial hospitals,
due, perhaps, to the fact that the numbers of patients
show a certain steady rise in number for all diseases.
Measles.—A few cases of measles were treated in
the Colony itself. There were cases introduced by
the Indian immigrants in one or two districts. In
the province of Kadavu, however, the disease was
mildly epidemic—the epidemie is referred to in the
report appended by the district medical officer,
Kadavu. In Rotuma, however, measles was intro-
duced early in the year with most disastrous results.
The epidemic was a very severe one and swept
through the entire population with an enormous
mortality, the details of which are fully given in the
report by the district medical officer, Rotuma. The
results of the disease are still showing themselves
amongst the people in the increased mortality from
tuberculosis, ascribed by the medical officer to the
results of the epidemic.
Influenza.—The incidence of this disease is not
great, 10 cases being the total at the Colonial Hospi-
tal, 332 in the plantation hospitals, 154 in the pro-
vincial hospitals, against 34, 988, and 117 respectively
for 1910. In Rotuma, however, there continue to be
yearly outbreaks of this disease, and one of these,
following the measles epidemic in 1911, added very
markedly to the sick-rate, and by its sequel on to the
death-rate of that island.
Dengue Fever.—Eighty-four cases were admitted to
the Colonial Hospital during the year, of which 18
were Europeans—there were no deaths—957 to the
plantation hospitals, and 290 to the provincial
hospitals. For the same disease in 1910, the
admissions were 41, 183, 236. Typical dengue fever
is endemic in the Colony. It must be stated, as
a general rule, that few new-comers escape, that
the disease attacks them with considerable severity
in most cases, and that these attacks are in the
majority of instances quite typical. I do not think
that there can be much doubt that many of the cases
put down as “ febricula ” in hospital returns are, in
reality, mild attacks of dengue fever, for this fever in
Fiji, at any rate, may vary from extreme mildness to
great severity, and even in the extremely mild cases
there may be all the typical signa of dengue fever,
though in a mild degree.
Tinea Imbricata.—A vast number of cases of this
parasitic disease continue to be treated in many parts
of the Colony, both at provincial hospitals and by
native medical practitioners at their stations. The
use of the sulphur fumigation method has been much
extended until, at the present time, practically all
provincial hospitals are provided with the fumigating
apparatus, and many native medical practitioners
also have the use of them. The results reported are
good, and it is hoped that persistent care will now,
in a short time, get rid of the disease altogether. A
difficulty always arises, especially in the remoter
districts, viz., the difficulty of effectual disinfection
of the dwellings of the affected people, for these being
made of native material—grass, reeds, &c.—are good
holding ground for the parasite. Mats and old
clothing can be and are destroyed, but the destruc-
tion of the house is a more difficult matter.
Frambesia.—This disease may be considered to be
slowly and gradually becoming less. The hospital
June 15, 1914]
RETURN oF Diseases AND DEATHS IN 1911 IN THE CoroNian HOSPITAL,
GENERAL DISEASES.
Alcoholism ds is st is
Anemia .. m 2s E
Anthrax .. js
Beriberi $
Bilharziosis
Blackwater Fever
Chicken-pox «e os
Cholera xs
Choleraic Diarrhoa 5
Congenital Malformation
DU. cs MS 1G. ger “an
Delirium Tremens iis
Dengue .. : a $4 ss
Diabetes Mellitus e E s4
Diabetes Insipidus *s bs
Diphtheria ie e
Dysentery .. ` F
Enteric Fever .. a
Erysipelas S^ oe
ebricula .. m s
Filariasis .. 4» pig A zs s
Gonorrhea oe re
Gout è vs Ps
Hydrophobia sä wa
Influenza .. 55 vs
Kala-Azar.. RE
Leprosy .. ae << - >i
(a) Nodular .. i 25 M
(b) Anesthetic ..
(c) Mixed :
Malarial Fever— $5
(a) Intermittent
Quotidian ..
Tertian — ..
Quartan
Irregular
Type undiagnosed
(b) Remittent .. $
(c) Pernicious .. $ ee «4
(d) Malarial Cachexia. . m $5
Malta Fever s E s
Measles
Mumps .. we
New Growths— .. are 3
Non-malignant or e.
Malignant .
Old Age... =
Other Diseases ee
Pellagra .. es oe
Plague +2 re
Pyemia .. ae
Rachitis < oie
Rheumatic Fever ts
Rheumatism * T às ds
Rheumatoid Arthritis i$ ee s%
Scarlet Fever si s sig eie
Scurvy .. vs T wis
Septicemia P vw hd es
Sleeping Sickness 42 aie ys
Sloughing Phagedena ..
Small-pox .. i e oe es
Syphilis .. ae ‘fe ae oe
(a) Primary . dE $e
(b) Secondary .
(c) Tertiary .
(d) Congenital .
Tetanus
Trypanosome Fever
Tubercle—
(a) Phthisis Pulmonalis
n Tuberculosis of Glands 3 A 5
c Lupus s P as oa
eo
to
LIII acl SSL Ii tli dt beltlleolétil
| | | Deaths
LT ATH
Ill bei lL lowe
bra d bt ae Epl
PP bleh
COLONIAL MEDICAL REPORTS.—FIJI. 87
Fiji.
E x £ 3 23
ES 3 #33
sii 3s à esf
£82 Genera Diseases—continued.
= (d) Tabes Mesenterica 2. — — =
6 (e) Tuberculous Disease of Bones ts 1 -- 1
=F Other Tubercular Diseases 108 19 116
EX Varicella 7 T as we © — — —
3 Whooping Cough cS $4 T ie -— —
ES Yaws $ oe ar n ce 216 1 121
Ka Yellow Fever BS — — —
= LOCAL DISEASES.
ms Diseases of the—
— Cellular Tissue Ji ne $2 ia 439 £z 89
84 Circulatory System .. as ome 95 5 27
— (a) Valvular Disease of Heart S e idi <
-- (b) Other Diseases .. — —
— Digestive System — — — —
274 (a) Diarrhoea ae e ric 45 — 45
17 (b) Hill Diarrheea .. i3 xy — — —
— (c) Hepatitis . .. és 2 — 2
109 Congestion of Live .. a6 — = —
— (d) Abscess of Liver $ 1 1 2
35 (e) Tropical Liver .. EM e e = — --
— (f) Jaundice, Catarrhal .. $e sis 4 1 4
— (g) Cirrhosis of Liver . ie 1 1 1
10 (h) Acute Yellow Atrophy 1 1 1
-- (i) Sprue š ` — — —
11 (j) Other Diseases .. 90 — 90
— Ear ES oie X bs 21 — 21
— Eye ae we ae se eS 47 — 47
— Generative Sy stem— ‘ie 7 a3 es -- — —
— Male Organs 31 1 31
3 Female Organs 90 2 94
— Lymphatic System "p e 26 1 28
Mental Diseases sa ES ae — — —
— Nervous System 36 7 37
Nose ee = = —
Organs of Locomotion — 19 1 19
— Respiratory System 124 10 128
- Skin— .. m — —_— —
— (a) Scabies .. 27 — 27
— (b) Ringworm T 4 — 4
36 (c) Tinea Imbricata 1 — 1
17 (d) Favus .. E. os ne ci eap ce —
— (e) Eczema .. fs ws $a 44 2 — 2
4 ( f) Other Diseases .. . as 52 — 52
7 Urinary System se T F 20 4 20
= Injuries, General, Local— 118 2 121
28 (a) Siriasis (Heatstroke) R ea — = —
-—- (b) Sunstroke (Heat Srna hon) 4s 1 — 1
— (c) Other Injuries m — — —
— Parasites — a "3 41. — 49
— Ascaris lumbricoides $* is — —
— Oxyuris vermicularis . — = =
16 Dochmius duodenalis, or Ankylostoma duo-
— denale e «e: 108 5 109
- Filaria medinensis (Guinea. worm) 3 = 3
1 Tape-worm X. T — = —
— Poisons— s oe bs "Y ©. — — —
— Snake-bites — .. >. oa we = = --
— Corrosive Acids e. SS = —
— Metallic Poisons ay ne . 1 — 1
— Vegetable Alkaloids .. sa zs . 1 — 1
6 Nature Unknown E is oe æ = — —
17 Other Poisons zs es 55 $m = —
27 Surgical Operations— .. a5 A e — — —
— Amputations, Major .. oe ©. = = —
3 Minor .. i is ©. = — —
= Other Operations . sis E " — = —
-- Eye .. se T 3 — — —
(a) Cataract . T oe = = —
= (b) Iridectomy .. os OS — —
= (c) Other Eye Operations ve "EL ==
Ay
G6]. EE AWS
88
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1914.
returns, of course, show large numbers of admissions,
but these are, in most cases, the late manifestations
of the disease. The cases of primary framboesia
treated in hospitals are few, as admitted to the
various hospitals; there are, of course, many cases
stil in the villages in all the provinces among the
children. Much benefit has been shown by treating
late cases of framboesia with salvarsan at the Colonial
Hospital. I saw all the cases, and there is no doubt
possible as to the benefit of the treatment. Notable
cases are those of persistent chronic ulceration,
lasting for a period of many years, which showed
considerable results after one injection, and left the
hospital cured in three weeks, and have remained
well since. The use of the drug is now being ex-
tended to the provincial hospitals, from which further
statistics will no doubt be available for 1912.
Filariasis and Filarial Disease.—The results of
filarial infection continue to be seen in all its mani-
festations in most parts of the Colony. This must
remain 80, so long as the country is as it is, and so
long as there are vast areas which cannot be made
mosquito-free, except at enormous cost. In this con-
nection, it may be pointed out that in Suva a certain
amount of work is being done to improve the drainage
condition of the town by canalization and improving
the existing watercourses; and it has been directed
that a fixed sum be applied for in 1913, which is to
be used for making this canalization of a more per-
manent nature. There is no doubt that the areas
treated have been very much improved, but a great
deal remains to be done, and to be done every year,
before any real progress can be made in ridding the
town of mosquitoes, and with that of mosquito-borne
diseases. The present staff for this canalization work
consists of a gang of ten prisoners with a native warder
working, under a European overseer, in the municipal
area of Suva. This small gang works under the
direction of the Medical Officer of Health and Sanitary
Inspector. It is an easy matter to see how large the
work to be accomplished is, and how, with so small
a staff, it must be a very gradual work, even within
the small area of the town of Suva. When the vast
swamps of the whole colony are looked at with a view
to mosquito extermination and consequent ridding the
colony of filariasis and other mosquito-borne diseases,
it must be confessed that without enormous and con-
tinual outlay nothing could possibly be done which
would have any practical effect. All efforts are now
being directed towards the increased and better sani-
tation of native towns and their surroundings, and all
medical officers and native medical practitioners have,
as shown by their reports attached, directed their
efforts towards this end by improvements in latrines,
town and house cleanliness, use of clean mosquito-
screens, and the clearance of bush and scrub for some
distance round each town.
Ankylostomiasis manifests itself in a very great
number of cases of Indians, many of whom bring it
to the colony with them on introduction. A campaign
has been started in a large plantation where the
health from this cause has shown badly. On this
plantation the medical officer has instituted regular
week-end treatment for patients suffering from this
disease with, so far, very excellent results. The
patients for two, three, or four weeks go to hospital
on each Saturday afternoon, and are treated at once
with thymol, returning to work early on Monday
in every case when well enough. The improvement
in the patients on this plantation has been most
marked. Of course, in any case where there appears
to be the least need for so doing, the patient is retained
in the hospital for a term. It is now proposed to
carry out the same methods with regard to the
patients in the Suva gaol, and on other plantations
where the disease is prevalent, and by this individual
inspection and improved sanitary inspection and con-
ditions to eradicate, or, at any rate, materially reduce
the disease.
Leprosy.—-At the end of the year all the lepers
were transferred from the old station at Beqa to the
new one, and were comfortably installed there.
A brief account of the station may be of interest.
Makogai is an island in the central part of the Fiji
group, some eighteen miles north-east of Levuka, and
about seventy miles from Suva. The area is 2,075
acres; length .two and seven-eighth miles, breadth
two miles. Itis nearly circular in shape, and consists
of high land in the centre up to 800 ft., with a series
of flats all round the coast. It is on these flats that
the settlements for the patients are placed, the plant-
ations for food supplies are made, and the cattle
paddocks are built. The island was purchased by
the Government some three years ago. It was
formerly a coco-nut plantation and cattle station.
During the three years, and after many delays, the
station has been at last completed. At the south end
of the island (Nasau) are the quarters and station of
the Medical Superintendent, European warder, and
European mechanic, dwellings for various native
officers and plantation labourers, some paddocks for
cattle, plantations for food supplies, the butchery, and
a cottage hospital and dispensary for the labourers.
This part of the island is about two miles distant
from the main leper stationand is completely separated
from the rest of the island by a high wire fence. The
water supply of this part of the island is from a
spring in the flat and is delivered by pipes to all the
dwellings on the flat, and forced up to the quarters
of the Medical Superintendent by an engine pump.
The supply has, so far, proved amply sufficient.
Latrines (except in the case of the Medical Superin-
tendent, who is provided with a septic tank system)
are pans, which are removed and emptied daily. From
this part of the station to Dalici, the main leper
station, is a fair, rideable tract, which passes through
flats on the coast, where are plantations for food ; and
on a flat called ‘‘ Aro” is the first settlement of houses
for lepers. These consist of two kinds of dwellings—
a series of verandahed wooden cottages for four or
five inmates, and a set of dwellings in one building.
Each set of buildings is provided with kitchen,
bathroom, and latrine, and water is laid on to
each, brought from the main water supply from
the hills at the back of the main station at Dalici.
A hill separates this settlement from the main settle-
ment at Dalici. This is a large bay with good
anchorage, in which is a considerable area of flat
land running thence up the coast to the north end
of the island.
M
July 1, 1914.]
COLONIAL MEDICAL REPORTS.—FIJI. 89
Colonial Medical Reports.—No. 37.—Fiji— (continued).
THERE are many buildings here—hospitals for males
and females; quarters for female European lepers;
quarters for the two native medical praotitioners
and servants; storerooms; a lock-up; and, at a short
distance inland, quarters for the two European
nursing sisters and their two female native assistants.
On the land running hence to the extreme north end
of the island are cottages similar to those at ‘ Aro”
for patients. Water is brought from a stream about
150 ft. above Dalici by pipes, and distributed to the
whole station and up to the north end. The supply
has so far been sufficient and it is estimated that it
will be ample when the station is fully occupied.
Latrines are small movable ones placed over pits.
All patients who can do so, are expected to plant their
own food to some extent, and are allotted some land
for this purpose. The Fijian and Melanesian patients
have begun well in this respect—the Indian not so
well At the extreme north end of the island is a
large flat, which has been converted by the Medical
Superintendent into a series of paddocks for cattle and
sheep—these are doing well and will materially assist
in making the station self-supporting. Pigs and goats
are also kept and bred on the island for food for
patients. The plantations consist of areas planted in
yams, tapioca, sweet potatoes, rice, bananas (the
unfortunate hurricane early in 1912 completely ruined
these). The planting is systematically carried out;
with green manure crops to improve the soil and
frequent and regular ploughing, the crops obtained
will, in time, it is confidently expected by the Medical
Superintendent, supply all the needs of the station.
The energy of the Medical Superintendent in this
respect has been most exemplary; and he has had
many set-backs in the way of the hurricane above
mentioned, destruction of growing crops by rats,
mice, and insects, and very great difficulties in the
way of preparation of the land due to the difficulty of
obtaining sufficient labour for the purpose. The
station is provided with an auxiliary cutter, which
crosses to Levuka, weekly, for stores, mails, &c.
During 1912 it is expected that the majority of the
lepers in Fiji will be taken to the island. In the
matter of certifying and collecting from so scattered
a colony, the question of their transport must involve
certain delay.
The increase in the work of the Government phar-
macy multiplies yearly with the increasing number of
stations to which supplies must be sent. I regret that
there is no report by the pharmacist this year on his
work as analyst, for he has been absent from the
Colony from ill-health since July. The analytical
work which has much increased, has been carried on
entirely by the medical officer of health.
The bacteriological laboratory is now in full work-
ing order, but the time of the bacteriologist, who is
also medical officer of health, is mainly taken up with
his work as medical officer of health, which latter
increases very rapidly.
Admissions to the Colonial Hospital, Suva, increased
from 1,973 in 1910 to 2,120 in 1911. There were 195
European admissions in 1911, against 202 in 1910.
There were 95 deaths in 1911, against 107 in 1910,
The detailed return of cases is appended to this report.
No new buildings were added to the hospital during
the year, but it was approved that quarters should be
erected early in 1912 for the new appointment of
junior medical officer at the hospital under the new
arrangement to bə detailed below. It has not been
possible yet to take steps towards the rebuilding of
the hospital and concentration of the various blocks,
but the need especially for a new European block and
new nurses’ quarters is being more urgently felt as
years go on.
Nursing Staff, Colonial Hospital.—The matron pro-
ceeded on long leave, the appointment of acting
matron being filled by Miss V. Griffiths, a former
pupil at the opita, who returned to the Colony to
take the appointment. The nursing staff was filled
to its full strength during the year by the appoint-
ment of three probationers, who filled the place of
one nurse resigned and two other long standing
vacancies. Seven new native obstetric nurses were
qualified and sent out to new districts. The demand
for these native obstetric nurses increases, and though
they may not be so much used and appreciated by
the natives amongst whom they work as might be
wished, there can be no doubt that their work is
good and that they are more called for as time
goes on.
The number of native medical practitioners in 1911
was 37, employed as follows: 1 as dispenser,
Colonial Hospital; 1 as dispenser, Levuka Hos-
pital; 2 as native medical practitioners, Makogai
Leper Station; 8 as native medical practitioners,
provincial hospitals; 25 as native medical practi-
tioners in twenty-five districts. Five students quali-
fied in 1911. Three new districts were made and
2 filled vacancies. The class of native medical
students is reduced to 15. By many of the native
medical practitioners it may be said that excellent
work is being done ; and special attention is being
given by them to sanitary work in native villages
with, it is hoped, beneficial results. Their struggle
is an uphill one, and they require much encourage-
ment and supervision to prevent their lapsing into
laziness and apathy. Two of the earliest qualified
native medical practitioners retired on the grounds of
age and ill-health.
Lau District.—In the Lau district one of the three
proposed hospitals was begun, at Lomaolma, and
will be complete and occupied in 1912.
The new Gaol Infirmary was begun in 1911, and
will be finished and occupied in 1912, thus relieving
the Colonial Hospital of the treatment of all male
prison patients. The infirmary will accommodate all
male sick prisoners. It consists of a block for patients,
European and native wards, a dispensary, operating
room, and quarters for native medical practitioners in
residence. It will be under the charge of the visiting
medical officer, who is also resident medical officer
at the Colonial Hospital. The site is a good one, on
the larger reclamation in front of the present gaol.
The building is of brick, and is one of the first public
buildings to be made of this material. In spite of
the most constant and watchful care on the part
of the medical officer and gaol authorities, there
was again, in the early part of the year, a very
90
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1914.
considerable outbreak of dysentery in the institution.
Inspections for sanitary improvement are frequent
and thorough ; all suggestions for improvements are
carried out with little delay. The kitchens are
practically fly-proof, and are separated by a con-
siderable distance from the latrines, which lie on the
lee side of the kitchen. Latrines are of the pan
system, daily emptied, and supplied with plentiful
lime for covering evacuations, while they are kept
dark and well covered to prevent the access of flies ;
all drains are flushed out daily and much disinfectant
is frequently used. Notwithstanding these precau-.
tions, and the care with which it is certain that they
are carried out under close European supervision,
there is the same yearly recurrence of dysentery,
beginning usually towards the end of December or
beginning of January and increasing up to the close
of the hottest months, when there is a gradual decline
to practically nothing in the last months of the year.
The outbreak in 1911 was, however, neither so severe
nor so prolonged as that of 1910; the number of
cases were fewer and the type of the disease was
milder. Ninety-eight Indian prisoners, 18 Fijian
prisoners, 3 others, and 1 gaol warder (a total
of 120 cases) were attacked. It is remarkable
to note the disproportion betwecn Indian prisoners
and Fijian prisoners, and the single case of a gaol
warder, while no other member of the staff, either
native or European, was attacked, in spite of the fact
that there is a very considerable staff—Fijian, Indian,
and European—resident in the gaol precincts, with
their families. All medical officers who have been
visiting medical officers to the gaol have been forced
to recognize the fact that the Indians do, undoubtedly,
malinger in some indescribable manner, so as to
produce such irritation of the bowels as to make
them easy victims to the disease. (We have the
well-known case of an Indian prisoner found eating
finely powdered glass in large quantities, and there
are others.) And, although it must not be thought
that any attempt is made to shelve this highly
important matter by such a solution as malingering
to begin with in every case, yet the conclusion is
forced upon one that, in the dysentery season, it
must be responsible for some of the Indian cases,
who thereupon spread it to others. In support of
these conclusions it must be stated that Fijians them-
selves suffer severely from dysentery in all parts of
Fiji, while in the gaol, as compared with Indians,
they cannot be said to so suffer, as proved by the
figures shown above of the number of cases. When
the gaol infirmary is open and in use, and prisoners
can no longer escape discipline by means of a period
of residence in the Colonial Hospital, and when the
new gaol with its single cells in place of the present
large general sleeping apartment is in use, some
amelioration may be hoped for. In other respects,
the gaol produced no more than its average number
of sick.
A new medical district was opened (as noted above)
in the island of Vanualevu. It has been called the
Cakaudrove district, including, as it does, the whole
of that part of the province of Cakaudrove which is
situated on the island named above. It is a large
district, with small plantations, owned by Europeans,
and each employing a few indentured Indians. The
station of the medical officer has been fixed near to
that of the stipendary magistrate at Valeci, in Savusavu
Bay, and sufficient land has been provided for the
future establishment of a provincial hospital, which
is really much needed in this part of the Colony.
The district was opened by Dr. Smartt in the latier
half of the year. This medical officer caused a small
native building to be erected, and with the small
material at his disposal has treated a very consider-
able number of cases both of natives and of indentured
labourers.
There are now sixteen medical districts, including
Rotuma and Makogai, and of these, four medical
officers combine in their districts the duty of medical
officer and stipendiary magistrate, viz., in the districts
of Taviuni, Lau, Bua, and Rotuma.
VACCINATIONS FOR THE YEAR.
During the year, 3,104 vaccinations were performed.
The number is smaller than in 1910.
The number of unsuccessful vaccinations is large
and is accounted for, as usual, by delay in getting
supplies of lymph to distant out-stations, and constant
deterioration.
The lymph used is wholly glycerinated calf lymph,
which is imported twice monthly from New Zealand.
The number of medical officers in out-districts who
vaccinate is 15, and the number of native medical
practitioners who are proyincial vaccinators is 36,
of whom 10 are attached to provincial hospitals and
2 are native medical practitioners, who, though they
have retired, still do some work in the districts in which
they live. The remainder (24) are native medical
practitioners who are stationed in outlying districts
and work under the direction of the nearest European
medical officer, to whom they make periodical reports
of all work done.
G. W. A. Lyycu.
Punnic Lunatic ÁsvnLUM, Suva.
During the year 1911, there were treated at the
Public Lunatic Asylum, 39 patients; 24 remained
over from December 31, 1910; 15 were admitted
during the year; 5 were discharged cured; and 5
died; 29 remained on December 31, 1911. The
patients were 29 males and 10 females. There were
8 Europeans, 12 Fijians, 16 Indians, and 3 others.
The Europeans were 5 males and 3 females. One
of the chronic European cases died suddenly. One
female European admitted during the year was 4
readmission of a patient who had been in the asylum
several times before, and is a sister of the other
chronic European female case. There were 5 deaths.
Since the removal of the native male patients to
their more spacious new quarters, there is a very
considerable. improvement in their general health,
and the services of the resident European female
attendant have had a good effect on the female
patients, especially the Europeans. These being very
chronic cases, it is not to be expected that they will
be cured, but under the care of the attendant there
is constant supervision, and an increased appearance
July 1, 1914]
COLONIAL MEDICAL REPORTS.—FIJI. 91
of well-being. The type of cases admitted is on the
whole a chronic type in nearly all cases.
G. W. A. Lyxca.
Port or Suva.
The health of the port during the year has been
good, and no case of quarantinable disease has
occurred.
Two outbreaks of cholera occurred in Honolulu
during the year. In the first outbreak, between
February 23 and March 14, 31 cases with 26 deaths
occurred. In the second, between April 12 and 25,
8 cases with 7 deaths occurred. During these periods
the passengers and crews of vessels arriving from
this port were inspected, but no cases of cholera
occurred on board.
In April and May, plague was prevalent in Auck-
land, but the epidemic was by no means severe, and
was promptly stamped out. Plague-infected rats
were, however, found in that city during the last
days of May. Inspection of passengers and crews
of all ships coming from this port was carried out,
and mooring restrictions for the prevention of landing
of infected rats were put in force.
In the beginning of February, an effort was made
to reduce the number of rats infecting the wharf and
buildings in the neighbourhood. Traps were supplied,
and the sum of 2d. was offered for each rat caught.
This plan was not, however, a success as the natives
were too apathetic to set traps. In September, there-
fore, a rat-catcher (an Indian) was appointed at a
fixed wage of 30s. per month and 1d. for each rat.
He, working with twelve traps, accounted for 188
rats and 125 mice.
The new Quarantine Ordinance, No. XXII of 1911,
came into force on October 18.
Town or Suva.
Te health of the town during the year has been
good.
Prevalence of Disease.—Measles was present in
mild epidemic form during the year, 121 cases having
occurred in the town between the beginning of
February and the end of the year. In the last
quarter a few cases of rótheln occurred.
Typhoid Fever.—A few sporadic cases occurred
in the district, but this disease was not present in
epidemic form. In all cases, routine measures of
disinfection of houses, bedding, clothes, &c., and the
removal of all cases to hospital were carried out, and
thus the spread of the disease prevented.
Dysentery appears to have been less prevalent than
usual, and the same may be said for dengue fever.
In February, leaflets on ‘‘ The Prevention of Dysen-
tery,” in English, Fijian, and Hindustani, were widely
distributed throughout the Colony, and by familiarizing
the people with the cause of the disease and its dis-
semination by flies and other ways, together with
the enforcement of regulations regarding the use of
dry material in latrines, we feel some result has
already been achieved in the diminished incidence of
the disease. The sanitary inspector (Mr. Chalmers)
has been most assiduous in enforcing the regulations
with regard to the satisfactory sanitation of latrines
and yards. The work of clearing and canalizing the
watercourses in and about the town, which naturally
entails the drainage of swampy land in the ravines,
by the sanitary gang, progresses steadily. Much
difficulty is experienced in some of these watercourses.
The aim is to dig out smooth, shallow, V-shaped
channels on the soapstone surface, so that at no time
can there be accumulations of water in which breed-
ing-places for mosquitoes could be formed. The
irregularity of surface of the soapstone, however,
renders it necessary in many places in the course of
a channel, to build up the bed of the channel in the
pockets of earth where the soapstone surface sinks,
with stone, to form a uniform gradient; again, the
sudden rush of water down the steep slopes in the
heavy showers frequent here, washes away the earth
banks above the soapstone, so that it is necessary in
many places to face the banks with stone.
A. E. InELaND, D.P.H.
LAUTOKA.
The year was a hot one. The wet season was
wetter than the average. The dry season was un-
usually dry, with only 9:21 in. of rain in five months
(August to December). There was little or no cold
weather, and the heat of December was certainly
well above the average, the highest maximum shade
temperature recorded (100° F.) being registered this
month. The mean temperature for January was
79:5? F., the mean for July, 75:3? F., a difference
of less than five degrees.
In spite of the climatic conditions the health of the
indentured Indian immigrants, free Indians, Fijians,
and Europeans was satisfactory during the year. No
fewer than 1,700 cases (Indians) passed through the
plantation hospital, and 55 of them died. The deaths
were mostly infants, from enteritis (27 out of the 55).
Seven died from dysentery out of 106 cases. The
only medical event of the year was an epidemic of
dengue fever, or seven-day fever, which continued
during the months of February, March, and April,
coinciding with the mosquito season. During these
three months, 241 Indians, or nearly one-fifth of the
indentured population, passed through the hospital.
Very many Europeans also suffered, but the number
of cases was not recorded.
It is customary in Fiji to call the fever noted above
“dengue fever," but I believe the fever corresponds
rather with that known as ''seven-day fever" in
India. It has become indigenous in Fiji, and in all
the centres of population occurs sporadically all the
year round. In this district there was hardly a day
this year in which I did not visit at least one patient
suffering from this pyrexia. At certain intervals the
pyrexia appears in epidemie form, as this year.
The type of fever now observed is sporadic ; it lasts
as & rule from five to seven days without the non-
febrile period. There is rarely a rash, and then only
a fugitive erythema. The headache and eyeball-ache
are usually more severe than the backache and limb-
ache, and sequel: are absent.
The sanitary state of the district is satisfactory,
though the water supply of some of the villages might
be improved. There has been nothing special to
note, nothing outside the ordinary routine; no official
92 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1914.
action was taken during the year, but many insanitary
conditions were rectified on attention being drawn
to them by the Local Authority.
During the year, 156 persons were vaccinated.
Almost all the children over a year old are now
vaecinated— Indians, Fijians, Europeans, &c.
H. N. Joynt,
Rewa.
The population, as roughly estimated, is: Huropeans,
300; indentured Indians, 1,900; free Indians, 6,000;
Fijians, 10,000; miscellaneous, 200.
Following on the very unhealthy year of 1910, the
health of the district was, in the early part of the
year, bad, but improved considerably in the latter
half, as the disorganization caused by the 1910 hurri-
cane was remedied. Dysentery was very prevalent.
To the plantation hospitals there were 285 admissions
for this disease—over one-seventh of the whole
indentured population—and the mortality was 59
per cent. of the cases, as against 6:2 per cent. in
1910, and 3:3 per cent. in 1909. The average stay in
hospital of those who died was over 100 days, show-
ing that the cases were of a chronie nature. Only
38 cases (nearly all amongst children) were admitted
to the provincial hospital.
Only 9 cases of enteric fever were seen in the district.
Two of these were connected with each other; the
rest were separate cases, and show that points of
infection are scattered throughout the district. There
was less dengue than in recent years, apart from an
epidemie in June, July, and August amongst recently
arrived indentured Indians.
Ankylostomiasis continues almost universal amongst
the Indian population. There were 279 admissions
for it to the plantation hospital.
All the coolie lines in the district were visited at
least three times during the year. The sanitary
conditions were generally satisfactory.
Plantation Hospitals.—Nausori Hospital was kept
in good repair, and sanitation and the staff of
attendants were sufficient.
Baulevu Hospital. —With this has now been
amalgamated Naitasiri Hospital. The buildings are
good, but the equipment is poor, and serious cases
often have to be taken to Nausori Hospital. The
small hospital at Koronivia supplied the needs of
about 150 indentured labourers sufficiently.
Native Villages.—Few of these have yet been fully
rebuilt since the hurricane of 1910, and many of the
people are still living in small temporary houses.
The water supply of the villages is generally good,
but arrangements for the disposal of sewerage are
very poor.
In the free Indian settlements the water supply is
invariably from surface wells. In places where the
subsoil water is only a few inches from the surface,
the water is extremely bad. Under these circum-
stances also, pit closets cannot be provided, and
excrement is deposited over the surface of the
land.
In March, 1911, the Sub-Inspector of Police was
appointed Sanitary Inspector of the district, and &
beginning was made in improving sanitation. Efforts
were chiefly expended in providing for each house &
closet from which flies could be excluded, and so
situated that wells should not be polluted. Consider-
able improvements were obtained in the immediate
vicinity of Nausori.
Meteorologically, the year was a normal one. The
rainfall was 108 inches. None of the diseases pre-
valent bear any obvious relation to the dry or wet
months of the year. A. MONTAGUE.
Makoaal.
The asylum was opened on November 29, with
20 lepers transferred from Beqa. Another 20
followed on December 7, from the same source. No
other lepers were admitted during the year. A few
minor operations were performed, chiefly removal of
necrosed bone, scrapings, general cleaning up. All
patients were, unless there were contra-indications,
put on chaulmoogra oil, and their sores dressed,
They have greatly improved in general condition.
When in Sydney, on leave, I attended the leper
lazarette. Drs. Ashburton Thompson and Millard
gave me every assistance and placed records of cases
and treatment at my disposal. No treatment, in
their opinion, had been discovered as curative.
Sanitation.—Much has been done to endeavour to
decrease the number of flies and mosquitoes at the
station. The burial of excreta and rubbish in this
sandy soil is, I think, most unsatisfactory. I have
seen the larve of the common fly crawling on the
surface after the faeces infected with its ova had been
buried to the depth of three feet. Burial of excreta with
substances that would inhibit or destroy the growth of
the larvee is expensive and unsatisfactory when under-
taken by natives.
The water supplies at Dalici and Nasau were very
low at the end of December. The slip and wharf
were finished after the asylum was opened.
The general health of all residents has been
excellent. F. Hatt.
LABASA.
The population of this district as shown at the
census taken in April, 1911, was as follows :—
Males Females Total
Europeans ac, 139 ne 65 +» 194
Half-castes T 66 v 57 .. 128
Indians .. . 4,278 .. 2,470 . 6,748
Polynesians... 60 es 1 «s 61
Others .. v 24 ee T Y 81
Total 4,557 2,600 757.
Diseases.
Enteric Fever.—Twelve cases came under observa-
tion and treatment, of which 4 proved fatal. The
first case occurred in February, in the person of a free
Indian woman living on an isolated “ zamin " at the
Bulileka free coolie settlement. She was removed to
hospital and recovered. About the middle of April,
four other free Indians were found to be suffering
from enteric in the Bulileka settlement, and were
removed to hospital. It subsequently transpired that
the woman mentioned in the first case had, on her
discharge from hospital, moved to a '' zamin ” adjoin-
ing those on which these other coolies developed. I
have no doubt that she was still a *' carrier," and that
the disease was conveyed to the others by flies.
July 15, 1914.]
COLONIAL MEDICAL REPORTS.—FIJI.
93
Colonial Medical Reports.—No. 37.—Fiji— (continued).
In April, also, 2 indentured Indians and 1 European
developed enteric fever. Of the former, one lived in
labour lines and may have contracted this disease
during a visit to the patients in hospital. The other
was & woman engaged as hospital nurse and whose
duties included the nursing of some of the enteric
cases. She was carefully instructed and warned as
to the precautions to be taken and the risk of their
neglect, but obviously without avail, as she became
infected and unfortunately died of the disease. I
could not trace the source of the infection in the
case of the European (a young male adult); he also
died. A male half-caste child, living at Malau, also
had the disease about the same time. He was treated
in Macuata provincial hospital, and recovered. Two
other cases occurred among the indentured Indians
in June, and three in September. Of the latter, one
proved fatal. The source of their infection could not
be traced, and there was no apparent connection
with the previous cases. The earlier cases all had
relapses.
Measles broke out in the district in April, the
infection being brought by the s.s. Motusa. It did
not spread widely, there being only seven cases (all
half-castes) in the immediate neighbourhood of
Labasa. A few Fijian cases occurred in outside
districts, and in July there was one isolated case in
an indentured immigrant, from the Naleba estate,
newly arrived in the district.
Varicella.—There was a small outbreak of this
disease among newly arrived coolies in June,
Twenty-one cases occurred in all, and 12 broke
out at the same time on widely separated estates,
8 eases occurring subsequently in July and 1 in
August. Consideration of dates and circumstances
pointed to the steamer Providence A, which brought
the coolies from Nukulau, as the source of infec-
tion.
Dengue fever occurred in epidemic form, commenc-
ing in August and reaching its height in October.
Two hundred and seventy cases were treated among
the indentured Indian immigrants, and it was wide-
spread among other classes of the community. It
still continued at the end of the year, though rapidly
declining.
Dysentery.—One hundred and eight-two cases of
this disease were treated in the Indian plantation
hospital, with 2 deaths; 39 at the Macuata pro-
vincial hospital, with 3 deaths; and 31 in the
gaol. A few cases occurred during the year among
Europeans and a few were treated. The number of
cases was least in April, May, and June, the figures
for the other months being mostly uniform.
Tuberculosis was moderately prevalent; 5 cases
with 2 deaths were treated in the Indian hospitals,
and 6 cases with no deaths at the Fijian Hospital.
Yaws was, of course, general. Twelve early and
142 later cases were treated at the Macuata provincial
hospital.
Syphilis.—Forty cases of the primary disease,
19 secondary, 8 tertiary, and 5 inherited were
treated at the plantation hospitals, and a number of
cases of syphilis were also seen by me privately
among free Indians and Europeans. Treatment by
mercurial injections was systematically carried out
among the indentured Indian patients.
Other Venereal Diseases.—One hundred and fifty-
nine cases of gonorrhea were treated at the plantation
hospitals. Cases of chancroid were fairly numerous
in the district.
Eye Diseases.—Three hundred and thirty-three
cases, chiefly conjunctivitis and secondary keratitis,
were treated among the indentured Indians, and
14 at the Fijian Hospital. Pterygium is common.
Respiratory Diseases. — There were 161 cases at the
plantation hospitals—mostly colds and bronchitis—
and 14 at the Fijian Hospital. Asthma was common,
as in previous years, among Indians in the district.
Diseases of Digestive System.—Under this heading
there were 26 cases among indentured Indians and
14 among the Fijians treated in hospital. Dysentery
is not included. Diarrhoea showed a seasonal pre-
valence similar to that of dysentery, and 15 cases
proved fatal, chiefly among children.
Parasites.—Ankylostomiasis was very common
` among the newly indentured coolies who arrived in
1911, especially those from the second s.s. Sutlej.
Some of the cases were very severe and 7 proved
fatal. I saw no cases among Fijians.
Scabies.—There were 213 cases among indentured
Indians and 11 among Fijians.
Tinea imbricata is enormously prevalent among the
Macuata Fijians, but very few of these cases come to
the hospital.
Filariasis was also, as usual, extremely common
among the Fijians of the province. Thirty cases
were treated at the provincial hospital.
Injuries.—Among the indentured Indians there were
3 fatal cases of injury—one suicidal hanging; one
internal lesions, due to crushing between trucks on
the railway-line ; and one of head injuries, the result
of assault.
The crushing season at the mill was happily un-
attended in 1911 by any serious injury. Twenty-five
cases of injuries, including a large number of fish-
bites, were treated in Fijians at Vuo Hospital.
Plantation hospitals, three in number, in the
Labasa district. There were 2,983 in-patients, with
46 deaths. Except in very occasional cases, I do not
have indentured Indians treated as out-patients, as
the system is, in my opinion, unsatisfactory.
Plantation Lines and Sanitation. — The lines
throughout the district have been kept under fre-
quent supervision, and on the whole were well kept.
The Colonial Sugar Refining Company had allowed
many of the buildings both at the plantation hospitals
and the various lines to fall into disrepair, and dur-
ing the year numerous orders were made for better-
ment. These, which have been carried out, included
the repainting of all three plantation hospitals, repairs
to the buildings of the same, the provision of &
mortuary at Wainikoro Hospital, and of improved
isolation accommodation both there and at the
Labasa Hospital; the closing of the well and opening
of a new one at Tuatua estate; new latrines for
several estates ; and the furnishing of all latrines with
back-flaps and doors at the entrances, to. exclude
flies; the whitewashing and repairing of floors in line
94 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
nurseries; and the provision of fly-proof cupboards;
attention to line drainage, &c.
Macuata Provincial Hospital.—The number of in-
patients treated was 364, with 6 deaths; aud the
number of out-patients was 822. The new arrange-
ment as to native food supply has proved most
unsatisfactory. As I anticipated, no voluntary con-
tributions of native food-stuffs for sale have been
made, and throughout the year the patients, to their
great discontent, have had to subsist on rice, except
for a short time when yams were purchased from a
European on the Dreketi River. The old system of
regular district contributions of food month by month
was infinitely more satisfactory from the hospital
point of view. Under the present system, admission
to the hospital means practically a complete stoppage
of normal diet, with anything but good results.
Native town sanitation has been attended to in
accessible towns by the district medical officer, and
in outlying districts by the native medical practi-
tioner. The Macuta towns are fairly clean on the
whole, though the people themselves are most back-
ward and dirty.
Free Coolie Settlements.—Efforts have been made
by the district medical officer and sanitary inspector
to supervise and improve the sanitary condition of
these. The question of suitable latrines remains a
very difficult problem. A system of pan-closets is
impracticable without regular organization, backed by
law, and cesspits are open to grave objection owing
to the fact that the large majority of the ‘‘ zamins "
have a well water supply. The position remains very
unsatisfactory.
General Sanitary Work.—Much was done in 1911.
At the time of the outbreak of enteric fever, pre-
viously mentioned, I made myself a house-to-house
inspection in the central district, and numerous
orders were made, latrines were all put in order,
garbage receptacles provided, and drainage attended
to. The Colonial Sugar Refining Company's main
water supply was the subject of unfavourable report
by me to Suva, and my opinions were confirmed by
the analysis of the Medical Officer of Health. I
ordered the whole of the surface drains of the
Colonial Sugar Refining Company's lower Labasa
lines to be concreted, owing to the fact that in view
of the central position of these lines and the observed
tendency of the drains in question to become fouled
and to breed flies and mosquitoes they constituted,
in my opinion, a menace to the health of the com-
munity. The work is now nearly completed.
Concrete drains have also been substituted for the
earthen drains through the grounds of Labasa
plantation hospital, which is also in the midst of the
European and general settlement of Labasa. A ship-
ment of frozen mutton, brought to Labasa, was
condemned by me as unfit for food, and destroyed.
I found the cold storage arrangements both at the
local butchery and on the Fiona satisfactory, and
in my opinion the meat was bad when shipped in
Sydney. But even if good when shipped, the neces-
sary exposure and heat in transport up this river at
Labasa renders it a dangerous article of import, in
my opinion, and I advised the Colonial Sugar Refining
Company not to repeat it.
Meteorological Conditions—The rainfall for 1911
was 108-90 inches. Both wet and dry seasons were
unusually prolonged in 1911, the latter commencing
late, but continuing to and beyond the end of the
year. Labasa is probably the hottest big station in
Fiji, and it has amply maintained this reputation
during 1911. E. G. E. ARNOLD.
ROTUMA.
The estimated population of the island at the mid-
year was 1,973 persons, and the actual number ascer-
tained by a census taken on November 27, was 1,983.
The births numbered 79, and tbe birth-rate, calcu-
lated on the number of the people on November 27,
only reached 39:8 per mille. This is a low rate for
this place where rates of 50, 52, 56, and even 59 per
mille have been recorded. Of the total number, one
was a still-birth and five premature, and the cause
of these was infection with measles on the part of the
mothers. About 18 per cent. of the children born
had the blood of the other races in them. Illegiti-
mates numbered 7, or about 8 per cent. of the total.
The male births were seventeen in excess of the
female, and numbered 48, the female only 31.
The deaths numbered 489, and the death-rate
reached the enormous figure of 246:5 per mille. The
death-rate has always been high here, and in former
years the lowest rate I have registered has been
37 per mille and the highest 54. A death-rate of
73 per mille was recorded in the year 1901, when Dr.
Hall visited this place in connection with an epidemic
of choleraic diarrhoea, which had prevailed for some
time before his arrival. When one compares these
rates with a normal one of 17 per 1,000 the con-
trast is great. The explanation of the high rate this
year is, of course, the epidemic of measles which,
allowed to run through the people for the first time,
during my absence on leave, swept them off literally
in hundreds. The female deaths were sixty-five in
excess of the male, and numbered 277, as against 212.
I have shown a return of the age period at which
death occurred, and from it it will be noticed that
death has been most busy among young children and
adults from 20 to 45 years of age. From 5 to 20
years the incidence has not been so heavy, and over
45 years it has been comparatively slight. Among
the causes of death measles leads the way with its
326 victims. The disease, as I have already re-
ported, was in most cases complicated with ileo-
colitis, most likely of bacillary origin; in some with
tubercular disease of the lungs; in a few with yaws,
pneumonia, pregnancy, child-birth, miscarriage.
Phthisis pulmonalis follows next with 26 deaths.
Since the measles epidemic its prevalence has boen
widespread. Acute broncho-pneumonia carried off
twenty children—in most cases the disease might be
put down as an after result of measles. I have
put down twenty-three cases to acute ileo-colitis,
following measles in all cases, but where complete
recovery from the latter disease had taken place.
The marriages numbered thirty-one, giving &
marriage-rate of 15:6 per mille—somewhat higher
than usual, but brought about by couples marrying
either of which had lost a wife or a husband in the
epidemic.
July 15, 1914]
Measles were introduced on January 29, when I
was absent, and on my return, on March 26, 700
cases were reported to me as existing. The epidemic
continued throughout April and May, and finally died
out in June. It caused 50 deaths in March; 198 in
April; 74 in May; and 4 in June. It was accom-
anied by or followed with acute ileo-colitis—a very
atal complication in most cases. Influenza appeared
about the close of April and continued its course
through May. It was unfortunate that it should
have followed so close on the heels of the last-
mentioned epidemic, as it must have undoubtedly
been fatal to many measles convalescents. Mumps
were also prevalent in May, and the swellings in
many cases disappeared very slowly; it was not,
however, very widespread.
The natives have the same objection here as in
Fiji to stay as in-patients, much preferring the society
of their own relations and the privacy of their own
houses when sick. The out-patient department, on
the other hand, is always taken free advantage of. A
great many of course were seen in their homes. The
total number for the year reaches 4,083; and the
large numbers shown in March, April, and May are
connected with the measles epidemic.
The rainfall for the year amounted to 147-04 inches.
The highest fall was recorded in the month of
February, when 26:92 inches fell; the lowest in the
month of July; but the full force of the trades is
felt here. The lowest temperature recorded by the
thermometer has been one of 66° at night, and the
highest 74?. Ninety-seven degrees is the highest
temperature registered by the maximum thermometer,
and 72° the lowest.
The general sanitary condition of the place is good.
All concrete houses have been whitewashed (lime),
inside and outside, at the close of the year and, as
they constitute the majority of the houses, it may be
said that most of them have had their walls at least
disinfected. The concrete tanks, which provide the
water for drinking and cooking purposes, have been
washed out. They now provide a plentiful supply of
potable water for the people. The villages are clean,
in all cases situated near the beach and so open to
the sea breezes, and a wall running more or less
round the island between the villages and the interior
land keeps the pigs from among the houses. Flies
and mosquitoes, however, abound. The latter breed
in swamps, of which a few are in existence here and
which are made use of for taro cultivation ; they also
breed in coco-nuts which have been made use of for
drinking purposes and then cast on the ground. All
the plantations are littered with such and it is im-
possible, in my opinion, to abolish this source of
mosquito production.
Owing to the epidemic already referred to in this
report, only a few vaccinations could be done this
year. The results of vaccinations done are not satis-
factory, but this is due to the age of the lymph when
it reaches here. Lymph, which arrives here from
forty to sixty days after its date of origin in New
Zealand, in most cases is active, but beyond this
period it seems to become inert and yields no results.
H. MACDONALD.
COLONIAL MEDICAL REPORTS.—FIJI. . 95
Bua.
Vital Statistics.
Population. Births. Deaths. `
Europeans "m 38 — —
Fijians ... ye .. 8,560 148 146
Indians... NS un 974 6 5
Miscellanéous ... T 126 1 4
The diseases prevalent during 1911 were of a
general character. The year was singularly free of
epidemic disease and to this fact, chiefly, I attribute
the absence of any decrease in the native population.
Dysentery caused only four deaths throughout the
year. Four cases of enteric fever occurred in the
Bua district. An unusually large number of cases
of pneumonia were observed, due in most cases, I
believe, to the fact that in many villages the Fijians
would not take the trouble to make their houses
weather-proof. Filarial diseases were as common as
ever, and are likely to remain so until something is
done to drain the many swamps to be found in close
proximity to native villages.
SPECIAL Reports.
Plantation Hospitals.—The only one in this district
is a& Wainunu Tea Estate. From other plantations
sick men are sent into the native hospital, and, as
most of the labourers are Fijians, the plan works well.
There were 285 admissions to the Wainunu plantation
hospital during 1911, but the great majority of
admissions were for very trivial ailments. Mild
attacks of fever, muscular rheumatism, and small
ulcers accounted for most of them. Four deaths took
place; three amongst infants.
The plantation lines were kept in a satisfactory
manner, but a good deal of trouble was experienced
by the manager in getting men for latrine work, and
as a result, I could not get all I wished done in the
matter of sanitation.
Native Hospital.— There were 561 admissions to the
native hospital, the majority of cases admitted being
as usual yaws and tinea imbricata. —Filarial diseases
accounted for 28 of the admissions, and for one case
of this disease treated in hospital, I should say
twenty occurred in the district. Nineteen cases of
croupous pneumonia were admitted as in-patients,
most of them coming from villages not far away.
Only five cases of dysentery were admitted during the
year, and but few cases were reported from the
districts. Many people suffering from the ravages of
tertiary yaws received great benefit from their stay
in hospital. The admissions for tertiary yaws number
116. Children suffering from the secondary stage of
the disease numbered 50.
Native Town Sanitation.—I inspected a good number
of native villages during the year, paying particular
attention to sites, water supply, houses, and latrine
arrangements. Where the Buli of the district and
the village chiefs were active men with some power
over their people, I generally found the villages in a
satisfactory state, but one does not find that class of
man all over the province by any means. Swamps
exist about many villages. Talking about mosquito-
borne diseases to a Buli or Turage-ni-koro will often
bring forth the usual Fijian expression of surprise at
the depth of one's knowledge, but in his heart he
96 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [July 15, 1914.
believes it to be nonsense, and he will drain his
swamp when he is made to, but certainly not before.
Latrine Arrangements.—Generally speaking they are
good if the inspection is expected and exceedingly bad
on surprise visits. Buton the whole I believe things
are improving in this respect. Only frequent in-
spections by native officials educated to the work will
keep native villages in a sanitary state in a province
where there is no sanitary inspector. The Roko,
Bulis, native medical practitioners and provincial
officers can all assist; but it is very important that
their notions of sanitation should agree, and I believe
I have brought this state of things to pass. The use
of mosquito-screens has become more general, and
the bad habit of spitting in houses is, I am glad to
say, on the decrease.
Free Coolie Settlements.—Latrines have been insisted
on in the same manner as in Fijian villages. Wells
have been protected to some extent by making fences
around them, and by the use of only one clean bucket
for drawing water at each well.
J. FARRINGTON.
TAVIUNI.
The: total European population of the district is
about 100. Statistics for Indians are incomplete.
The population was about 260, with 10 births and 3
deaths. There are no free Indian settlements. The
Fijian population was 1,300, and there were 69 births,
and 48 deaths, and 19 marriages among them—giving
a birth-rate of 53 and a death-rate of almost 37 per
1,000. The birth-rate is extraordinarily high, but is
supplied from data in the Provincial Office.
Dysentery was prevalent during the early months
of the year among all races.
Influenza was rife all the year through, but in a
mild form only, and caused no deaths.
Tuberculosis is very widespread among the Fijians,
but occurs little among the Indians.
Leprosy shows 16 cases, of whom one is a half-
caste (son of ẹ leprous Fijian mother), three are
Polynesians, and the remainder Fijians.
Frambaesia is, of course, the hall-mark of the Fijian,
and. the number of cases from this disease more than
doubles that from any other. No cases occurred
among the Indians.
The sanitary condition of the native towns is fair.
They are mostly kept well weeded and clean, and
have good water supply. In many instances the
seashore is used as a latrine, and in other cases there
is a small erection put up over a running stream close
to the town it serves.
There are no free coolie settlements. The general
sanitary condition of the district is good. There is
no sanitary inspector.
The year as a whole was somewhat a dry one.
During the first two months large quantities of rain
fell, amounting to more than half of the average fall
of the previous three years ; but the middle and later
months of the year were very dry. The usual strong
and somewhat constant south-easterly wind was
conspicuous by its absence or mildness from May
to October, the months in which it is usually most in
evidence.
A. W. CAMPBELL.
Kapavu.
The population of Kadavu amounted to 6,359
persons in October, 1911, being composed as follows :—
Europeans, 26 ; half-castes, 50 ; Chinese, 18 ; Indians,
7; Polynesians, 2; Fijians, 6,256: total, 6,359.
The above figures, with regard to the Fijian popula-
tion, are approximate only, and were obtained as the
result of a census of native towns made in October,
1911, for the Provincial Council.
Deliberate and wilful neglect to seek European
medical aid caused the deaths of no less than 11
children from whooping-cough alone. The number
of deaths during each quarter of the year were as
follows: First quarter, 66; second quarter, 87;
third quarter, 50; fourth quarter, 43. The first half
of the year was thus much more unhealthy than the
second. The chief causes of mortality during the
first six months were acute dysentery, diarrhwa, and
whooping-cough.
` Dysentery and Epidemic Diarrhaa.—These were very
intimately related, and there is reason to believe that
many so-called deaths from the latter were returned
incorrectly and were really due to dysentery.
Together these two diseases accounted for 59 of the
total 246 deaths—i.e., 24 per cent. of the mortality.
Of these no less than 50 deaths occurred during the
first six months of 1911. That flies play a most
important part iu the spread of the disease must be
admitted by all. My local experience inclines me to
look upon contamination of drinking-water as the
most likely cause. In almost every town in the
province, including the provincial hospital at Vunisea,
the drinking-water, whether obtained from creeks or
springs, is very liable to contamination by decaying
vegetable matter of every kind, which gets washed
into and falls into the creeks, primitive reservoirs, &c.
Owing to the habits of tho natives, who allow their
food, utensils, &c., to be fully exposed to con-
tamination by infected flies, and who use the bush
around their towns in place of closets, the problem of
eradicating the disease is not an easy one.
Whooping-cough.—The disease seems to have been
widely distributed, but I am unable to give the total
number of cases. At the provincial hospital, Vunisea,
161 cases were treated as out-patients, with 2
deaths only. In the Naceva district, the natives
refused to accept European treatment in most towns,
and in consequence no fewer than 11 children died
there. It is safe to say that the majority of the
deaths were entirely due to gross negligence, igno-
rance, and obstinacy on the part of the parents of the
children—all the deaths having occurred among
children.
Secondary Yaws or Coko.—There is no doubt what-
ever that almost all such cases were due to gross
negligence, ignorance, and obstinacy on the part of
the parents, none of whom brought their children to
hospital. I have never seen an uncomplicated case
of coko die, and during my nine years’ experience 1n
Fiji I have personally had several hundreds of cases
under my care at hospital.
August 1, 1914]
COLONIAL MEDICAL REPORTS.—FIJI. 97
Colonial Medical Reports.—No. 37.— Fiji— (continued).
Measles.— This was introduced by a half-caste child
suffering from the disease, who was brought from
Suva to Kadavu in March, 1911. "There have been
186 cases altogether, with 4 deaths. Such disin-
fection as was possible was practised, but this was
very limited, as it is impossible to disinfect the Fijian
houses except by burning down the same. The type
of the disease was mild in most cases, and the deaths
which occurred were all due to secondary dysentery.
T'uberculosis.—There can be no doubt as to the
increasing prevalence of tuberculosis, especially of
the lungs and lymphatic glands, and to a less extent
of abdominal tuberculosis. The filthy domestic
habits of the natives tend to make the spread of the
disease an easy one.
Influenza is epidemic in Kadavu. It was directly
responsible for 15 deaths, or 6 per cent. of the total
mortality. From time to time it breaks forth into
extensive epidemics, disabling whole villages at a
time.
Liver Abscess.—Only one case was seen by me
during the year, and the patient, a Fijian adult, was
sent to the Suva Hospital, where he was successfully
operated on.
Trachoma.—This is very prevalent all over the
group. The dirty habits of the natives and their
indifference to flies combine to make the spread of
the disease a very easy one.
Sanitary Work.--There are no Indian or Polynesian
settlements here, and sanitary work is practically
confined to the Fijians. The towns are badly kept,
overgrown, and rubbish allowed to accumulate. On
learning of the approach of the medical officer the
attempt is often made to hastily clean up the same.
The outskirts of the town were almost everywhere
absolutely neglected and overgrown, and in some
cases used as an “al fresco” closet. The question
of house-building is a complicated one, and, owing to
the communal system, one is powerless to deal with
individuals.
Meteorological Conditions.—No record is kept here
of the same. The first eight months of the year
were unusually wet, and since then we have had very
dry and hot weather, except for a week’s rain in
November.
R. F. pg BOISSIÈRE.
BA.
Tuberculosis.—This disease is accountable for the
majority of deaths, comparatively, but at all events
among the Fijians, who do not comprehend the
seriousness of this malady. Should any cases
admitted become seriously ill, the invariable and
piteous appeal both by patient and relatives for cough
medicine follow, and one has either to grant the
request or run the risk of diminution of applicants
for admission to hospital.
Yaws.—One finds this disease and its sequel
predominating in the returns, but the figures do not
represent anything like the actual number of cases
that are bound to exist. That Bulis and Turaga-ni-
koros fail to interest themselves sufficiently in forcing
cases into hospitals is evinced by the fact that most
of one’s admissions are made after visitation of the
native medical practitioner, and a general round up.
Venereals.— Within the last seven or eight years
one used to find the wards of plantation hospitals
filled with patients, but, nowadays, this disease is
less frequently met with. This is due to systematic
injection treatment and surveillance of all cases met
with.
Plantation Hospitals.—There are two in the medical
district of Ba. Both institutions are well found
and managed, and the sanitary arrangements in
good order.
Native Town Sanitation—In a general way the
sanitary conditions are reasonably satisfactory. To-
wards the latter end of the year there was a distinct
improvement in matters hygienic.
Free Coolie Settlements.— Very little was attempted
towards the betterment of this very necessary and
extensive work. With greater power under the new
Health Ordinance, and with the appointment of a
sanitary inspector, one is in a better position to deal
with the problem.
General Sanitary Conditions—As in most rural
districts where dwellings are self-contained and at
some distance from one another, good sanitary con-
ditions depend to a degree upon the personal habits
of the individual. In a general way, the sanitary
conditions prevailing are satisfactory.
Jous Hannzy, M.D.
LEVUKA.
The European population in the province of
Lomaiviti is approximately 400. The population of
the town of Levuka is about 380 Europeans and 300
half-castes. The Fijian population of Lomaiviti is
estimated at 5,200, as follows: Ovalau and Moturiki,
1,821 ; Gau, 1,421 ; Koro, 1,250; Nairai, 416 ; Batiki,
292. 'The Indians iu this district all live within
the town of Levuka, or within a short distance
of the town boundaries; their number is 120.
They have increased rapidly in the last few years,
and included among them are a number of Tamils.
The number of Solomon Islanders and natives of
New Hebrides living in Levuka is estimated at 220.
The number of natives of other Pacific Islands is
about 100. The number of Chinamen, nine months
ago, was 28, but I am of opinion that this number
was considerably exceeded at the end of 1911. The
statistics available are insufficient to enable me to
give any birth-rate for the different classes of the
inhabitants. The following are the only death-rates
which I can obtain: Europeans, 13°16; half-castes,
13:33. These are good death-rates, but being based
on such a small population they are of no real value.
Diseases Prevalent during the Year.
Dysentery.—Nineteen cases of dysentery were
admitted to the Levuka Hospital during 1911, and
5 of these cases proved fatal.
Enteric Fever.—Only three cases of enteric fever
were recorded during the year; one of these proved
fatal.
Tuberculosis.—This disease is very prevalent among
Fijians. It is, I believe, increasing. Pulmonary
98 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 1, 1914.
tuberculosis is far more frequently met with than any
other form of the disease.
Native Town Sanitation.
Water Supply.—Ovalau is an exceptionally well-
watered island, and there is no town where the
natives cannot get good water, and in most towns
they have but a short distance to go for it. Moturiki
is not at all well watered. The other islands in
Lomaiviti are all fairly well supplied with water.
Latrines.—Most of the houses are on the coast,
and the latrines are built over the sea. A good type
of latrine for natives, but they are not always well
built or kept in good repair.
General Sanitary Work and Sanitary Condition.—
The surface drainage has been in some parts of the
town of Levuka improved by the construction of con-
crete culverts. The removal of night-soil has been
done on the whole fairly satisfactorily, but the present
system can never be considered efficient. It is the
most primitive form of the conservancy system, and
is capable of great improvement, apart from the
installation of a drainage system.
B. M. WirsoN, M.D.
Lav.
The Lomaloma Hospital was only begun at the
close of the year (the previous native reed and thatch
building was in too bad a state to be repaired, and
the commencement of the new building was delayed
far beyond the estimated date), so that all patients
seen were either out-patients at the dispensary or
else visited at their own houses. "This has made the
work more heavy for the year 1911 tban it would
have otherwise been. The population of the whole
district, taken at the April census, was as follows:
Europeans, 76 ; half-castes, 54; Fijians and Tongans,
6,942; Polynesians, 209; Indians, 10£; other races,
14 ; total, 7,399. The people of the islands of Vanua-
balavu, Cicia, Tuvuea, Nayau, and Cikobia, and also
the labourers from the privately owned islands, usually
come to the Lomaloma Hospital for treatment—the
more southerly islanders going to Lakeba or Matuku.
Thus an estimated population of 2,410 is catered for
by the Lomaloma Hospital. Out of this number of
persons 2,029 cases were actually treated in 1911.
The very large proportion of dengue fever cases —242
out of a total of 2,029 cases of all sorts—is notice-
able. This I attribute largely to the presence of the
mosquito breeding swamps on this island, particularly
at Lomaloma, and this is borne out by the fact that
in the dry inonths of May, June, and August (July in
1911 was a wet month), the outlets of this swamp
dried and filled up, so that the water inside stagnated,
the sea-tide could not get in, and mosquitoes were
bred in millions.
Causes of Dysentery.—These, last year, have been
remarkably few. This may be due to the extra pre-
cautions taken as regards enforcement of separate
latrines in the villages.
Respiratory diseases have, as usual, been numerous.
Twenty-nine cases of tuberculosis of the lungs
occurred. This disease is increasing in the Lau
Islands, the cases in the southern islands of the
group would, I am sure, show still higher numbers
if properly diagnosed by the native medical
practitioners.
Diseases of the digestive system have been mostly
of a trivial nature, due chiefly to the eating of im-
proper foods and the drinking of impure water.
Owing to the lack of running water, these tanks are
often kept in a very dirty state, half choked with
leaves and sediment.
The sanitary state of the towns is, on the whole,
good. Latrines are still far from being universal.
A compulsory clearing of all bush for a half mile
radius from all towns would be of enormous benefit
by doing away with the temptation to make use of
the bush for latrine purposes, and would also keep
down the mosquitoes or flies.
T. R. Sr. JOHNSTON.
Nani.
The estimated population of the district of Nadi at
the end of 1911 amounted to 7,260, and was made
up as follows: Europeans and other whites, 127;
aboriginal Fijians, 3,300; East Indian immigrants,
3,800 ; half-castes and other degrees, 23; all others,
10.
Particulars, as far as available, of births and deaths
which took place among the various races in the
district are as follows: European births, 4 (31:5 per
1,000); European death, 1 (07 per 1,000); Fijian
births in six of the eight districts (population 2,550),
104 (40 per 1,000) ; Fijian deaths in six of the eight
districts (population 2,550), 102 (40 per 1,000).
There has been but little change in the prevalence
of disease in the different seasons of the year. The
general health has been excellent throughout and,
with the exception of cases arising among indentured
Indians, very little dysentery.
Eight cases of leprosy (6 among Fijiaus—0:13
per cent.—and 2 in Indians) were existent during
the year. The Fijian cases were all living in isolated
houses away from their towns. There has been no
measles at all in this district during the recent
epidemic elsewhere. Twelve cases of mumps
developed amongst the newly arrived indentured
Indians. They were strictly isolated in a separate
building in the Nadi plantation hospital and the
disease did not spread.
During the months of August and September about
30 cases of whooping-cough developed amongst
Fijian children iu six towns (Nadi and Sikituru
districts). These children were all isolated under the
care of a special attendant. The cases all recovered.
There were two hospitals for indentured Indians
during the year in this district. One thousand eight
hundred and twenty-seven Indians were treated at
these two hospitals during the year, with 43 deaths.
Three hundred and forty-eight surgical operations
were performed.
All the plantation lines were visited at frequent
intervals during the year, and on each occasion were
found in a satisfactory condition.
The thirty-seven native towns were each of them
inspected monthly with very few exceptions. The
water supply, drainage, condition of houses, kitchens
August 1, 1914.]
COLONIAL MEDICAL REPORTS.—FIJI. 99
and latrines, &c., are alike, in most cases,
satisfactory.
The sanitary condition generally of the district is
very good. There is no sanitary inspector at present.
Two hundred and forty vaccinations were performed
during the year, of which 221 were successful.
G. H. HusrmLER, M.B.
very
Navoa.
Diseases Prevalent During the Year.—Amongst the
European population the most prevalent disease has
been dengue fever. Dysentery and diarrhoea have
also occurred at times, chiefly when the supply of
water was scarce, owing to drought. Diarrhoea in
particular was very common during the dry spell of
August and September. With regard to Indians, the
principal diseases, as usual, have been dysentery and
bowel complaints in general. There was a rather
extensive outbreak of influenzal catarrh during the
latter end of the year at Beqa which spread to other
villages.
Tuberculosis does not appear to be prevalent to any
extent amongst the natives of Namosi and Serua.
Yaws is common enough amongst the children, but
during my inspections of the native villages I have
not seen a single case of the extensive and destructive
ulceration which is such a common sequela or
manifestation of the disease in some parts of the
country.
Seasonal Prevalence.—Dengue fever and influenza,
dysentery and diarrhea, were all most prevalent in
the early months of the year—January, February, and
March. The numbers fell very considerably in the
sueceeding months, but are now again on the up-
grade. This appears to be almost invariable, year by
year, the most unhealthy season corresponding with
the hottest and wet part of the year. Periods of
prolonged drought, however, have au adverse effect
on the general health—no doubt from accumulation
of offensive material and from the water in the tanks
becoming stale and more or less unfit for drinking.
Mortality was fairly evenly distributed throughout
the year.
Plantation Hospitals. —'There is only one plantation
hospital in the district, viz., at Tamunua. This also
serves the coolies indentured to estates farther down
the coast, of which there are four or five. The total
number of admissions to the hospital of immigrants
indentured to the Vancouver-Fiji Sugar Company
was 2,432, and the number of immigrants, including
children, in December, was 1,229. The total number
of deaths was 53.
Dysentery accounts for 9:5 per cent. of admissions.
This disease has been very prevalent during the year ;
in the early part more especially at Lobau, and laterly
at Tamunua. The most important of the parasitic
diseases is ankylostomiasis, which is very prevalent
on some estates. The number of deaths in hospital
of indentured immigrants was 53, being 2:17 per cent.
of the admissions. Deaths from dysentery amounted
to 10 (or 4:29 per cent.), and from other diseases of
the digestive system to 14, or 4:4 per cent. of the
admissions for these diseases respectively.
Coolie Lines and their Sanitation. —The lines have
been frequently inspected during the year, more
particularly those yielding the greatest number of
hospital cases, viz., Tamunua and Lobau., With
regard to Tamunua lines, it was decided that certain
improvements should be effected. The Lobau lines
are badly situated on low-lying, swampy ground. No
‘very great or permanent improvement can be expected
until these lines are moved and re-erected in an
elevated position.
Native Towns Sanitation.--The medical district of
Navua includes Namosi and Serua provinces. Na-
mosi: This province has been medically inspected
three times this year (1911). The sanitary condition
of most of the towns is very satisfactory, and the
mountain villages especially have an excellent and
abundant supply of pure running water. All villages
are provided with latrines, but whether used much is
rather doubtful. The towns are well drained, the
grass kept short, and the general appearance at such
times as I saw them was neat. Serua: The towns of
this province have been inspected twice, and some
three times. Their sanitary state is for the most
part satisfactory.
Free Coolie Settlements —These, of which there are
a considerable number in the district, have been
visited from time to time. Their sanitary arrange-
ments are of the most primitive description. The
water is obtained in a great many cases from shallow
surface wells, sunk close to the hut, and liable to
contamination from being unlined and uncovered.
In other cases the river water is used—a filthy and
contaminated supply. The infant mortality is appall-
ing from ignorance and apathy of mothers.
Meteorological Conditions.—There is nothing of
particular importance to record except the prolonged
dry spell in August and September. The rainfall for
the last quarter of the year was considerably below
the average.
J. W. Hunt, M.B.
NADROGA.
Vital Statistics.—Total population at mid-year,
9,511, constituted thus: Europeans, 80; Fijians,
7,265; Indians, 1,940; half-castes, 56; Polynesians,
70; Chinese, 100.
Fijians Population Births Deaths
Nadroga 3,183 ee 152 ee 162
Colo West 4.082 «5 148 Ge 188
The hospital is easily accessible to all parts of
Nadroga. In the district of Sigatoka, the towns
of which are all within a quarter of a mile, there
were 29 deaths; of these 8 were stated to have been
attended, t.e., 27 per cent.
Causes of Death.—Examination of the register has
revealed a serious epidemic of whooping-cough and
typhoid fever (if the diagnosis of the Fijians can be
accepted) in Nadroga, and dysentery in Colo West,
without any previous report to the district medical
officer or native medical practitioner.
Sudden Deaths. —Two cases of sudden death, during
the last two months, where the patient has not been
ill more than one day, have come to my notice. I
was able to perform autopsies and, in my opinion,
100
death was due to poisoning by Fijian medicines. Of
the 162 deaths in Nadroga, there were ‘not ill more
than one day," 18; of these one was ill for thirty
minutes, and others for only one hour. No notice
seems to have been taken of these deaths, and there
appears to be no machinery to deal with such cases.
These figures speak for themselves.
Prevalent Diseases.—Typhoid fever (severe form) :
January to March cases— Europeans, 5 (1 death);
Indians, 6 (1 death); Fijians 2 (1 death). Fijian
returns show an additional nine deaths. Cases were
not reported, and the extent of the epidemic amongst
Fijians is not known. Origin of the disease not
traced.
Whooping-cough : January to March. In Nadroga
the Fijian returns show a total of 31 deaths from
whooping-cough—only 5 were reported and attended
by the district medical officer or native medical
practitioner.
Dengue: January to March. Amongst Europeans,
20 cases.
Fever—of unknown origin. Three to four days
duration was very prevalent amongst Europeans and
Indians, and was most common in the sand-fly
districts.
Plantation Hospitals.—The hospitals at Lomawai,
Nadovi, and Kavanagasau were in use until May,
after which only Lomawai was kept open. Total
admissions, 1,540; deaths, 17; births, 33. Prevalent
diseases: Febricula, 212; gonorrhea, 115; eye
diseases, 102; diarrhoea, &c., 115; diseases of the
skin, 262 ; injuries, 240 ; operations, 80.
Plantation Lines.—Frequent inspections have been
made during the year in all permanent estates.
Water has been laid on by wells and pumps, and
latrines have been concreted. At the end of the year
sanitation was very good.
Native Hospitals.—' Total admissions, 336; deaths,
5; operations, 37; out-patients, 969; daily average,
85 to 90.
Prevalent Diseases.—Ringworm, 115 cases dis-
charged cured; yaws, 49; pulmonary tuberculosis,
10 ; typhoid fever, 7.
General Sanitary Work.—A drainage scheme was
ordered and carried out for the Colonial Sugar Refin-
ing Company’s European settlement. During the
typhoid epidemic four Indian huts were burned, one
store was disinfected, and other steps were taken to
prevent any further infection.
Meteorological Conditions.—There have been 82 in.
of rain during the year. ‘he climate is very dry and
good for this Colony.
J. F. E. PuipEAUX.
Ra.
Population :—
Race Males Females Total
Fijan .. an — 3 6,657
Indian .. ue 827 .. 452 1,279
European " 44 oe I9. ia 63
Half-caste is 24 a 1$. x 41
Total T 5,070
Mam Causes of Deaths.—lhe following are the
diseases mainly responsible for the deaths during
the year, with their relative mortality: Broncho-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 1, 1914.
pneumonia, 11-4; phthisis, 11-1; diarrhea, 13:2;
dysentery, 6:2; weakness, 6:9.
A good supply of instruments has been procured
by the Company. A European hospital attendant
has been procured, and the whole result is an
enormous improvement upon the former insanitary
and inadequate single building. "The water supply
is one 6,000-gallon tank, one 400-gallon tank, and one
well.
Main diseases treated at the hospital were diarrhea,
pyrexia, conjunctivitis, ulcers, dysentery. There is
a large decrease in diseases of the intestinal region.
Main Causes of Deaths.—Diarrhea, 8; meningitis,
2. No other disease was responsible for more than
one death. There was only one death due to
dysentery.
Plantation Lines and Sanitation.—Penang Estate :
The lines are now much better kept than formerly.
A chain of land has been cleared around them and
the grass between the houses kept short.
The Latrines: New latrines have been constructed
according to plans based upon those of the latrines
at Ba. There are twenty-nine such latrines.
Caboni Estate : The lines are very well constructed
and maintained in good order. The site is a good
one, well drained.
Ellington Estate: The lines on this estate, although
adequate for the needs of the labour, have only
recently been altered to conform to the regulations.
The site is a good one and in very good condition.
Native Hospitals.—There is only one native hospital
in this district, which is situated at Nanukaloa. The
hospital consists of the following permanent build-
ings: Male ward, female ward, four small isolation
wards, a dispensary and operating theatre, store, two
bath-rooms, kitchen, and the following native build-
ings: native medical practioner’s house, labourer’s
house, post-mortem room, store room, three houses
for ringworm. A new ringworm house was erected,
and for some time past a sulphur box for treatment
of this disease has been used with good results.
The main diseases treated were yaws, tinea im-
bricata, filariasis, dysentery, broncho - pneumonia,
phthisis.
Hospital Latrines.—The earth-pit type of latrine
has been installed at the hospital on the high ground
behind. Each pit has a separate house. They seem
to be quite satisfactory.
Native Town Sanitation.—The sanitary state of
the town has, I think, definitely improved during the
year. The vast majority of the towns are situated on
quite satisfactory sites. The great majority of the
houses in the towns are clean, although promiseuous
expectoration indoors does not help in this direction.
It is noteworthy that windows are being introduced
into the more recently erected houses. As far as I
can judge, from my own experience, the drinking-
water of the towns, when taken from the source that
is supposed to be used for the purpose, is almost
without exception quite good.
On the whole, the free coolie settlements are far
from sanitary. The site of most of the houses is bad.
The source of water supply is, I think, without
exception, from wells, whieh are dangerous, as
buckets are lowered into them.
101
August 15, 1914]
COLONIAL MEDICAL REPORTS.—FIJI.
Colonial Medical Reports.—No. 37.—Fiji— (continued).
Tue staff of the hospital at Nanukaloa have spent
a considerable amount of time and energy upon the
improvement of the sanitary state of the district.
In all 143 visits have been paid to the towns of this
district. The staff have endeavoured to teach the
natives the part played by flies and mosquitoes in
the transmission of dysentery, diarrhoea, cika, enteric
fever, filariasis, and dengue fever. Drains seem to
be looked upon as the correct place to throw all
rubbish. Efforts have been made to have the drains
kept clean. There is no doubt whatsoever that the
abolition of the closets over streams and sea—which
formerly were one of the main breeding-places of
flies near towns—has improved the sanitary state of
the district, and it is to be hoped that the new closets
will also help in the matter of this improvement.
Considerable improvement in the general level of
cleanliness of the houses has been effected by the
demolition of the oldest ones and the erection of new.
The drinking-water in the towns is almost universally
good, and in the great majority of cases is taken from
& separate stream from that used for bathing and
washing. J. T. SMALLEY.
CAKAUDROVE.
Population (approximately). — European, 110 ;
Indian (free), 119; Indian (indentured) 24; Poly-
nesian and Fijian, not known.
Health of District.—This, I think, may be con-
sidered satisfactory on the whole, i.e., no worse nor
better than other districts.
Dysentery is not common; a few sporadic cases
have occurred. The type observed appears to be of
the bacillary variety. No deaths from this cause
have come to my notice. The Fijian villages appear
to be particularly free from this disease.
German measles is common, in fact epidemic, in
parts of Natewa Bay. It generally affects whole
families, particularly the women and children, and
does not appear to be attended by any bad results.
Phthisis is fairly common. This can, I think, be
attributed to the insanitary system the natives adopt
of sleeping with closed doors on dirty floors, or
herded under dirty mosquito-screens made of close
material.
Tinea imbricata is very common, especially on the
north side of Natewa. The south side of Natewa
Bay is strangely enough almost free of this disease.
In Savusavu Bay, this disease is common in Wailevu
West.
Frambesia is common, especially in Savusavu,
where inoculation is said to be widely practised on
children.
Bronchitis is very common among children and is
probably the most fatal of all diseases, and causes
more deaths among them than all other diseases put
together. In no town I have visited has the pro-
portion of children affected with coughs and colds
been less than 1 to 2 per cent. of healthy children of
the children I have examined. No mortality figures
can be given.
The water supply is stored water in closed tanks
for drinking purposes, and creek water for bathing.
The hospital accommodation is bad, and of latrines
there are none.
On most estates creek water is used for drinking
purposes.
Latrines of any description are unknown. The
danger attending this omission is not so great as
might be, owing to the fact that all the estates are
near the sea and doga swamps. I have not found
anything offensive on any estate which might be
attributed to the absence of latrines.
Native Hospitals.—In October, a temporary bure
was erected on some Government property attached
to the stipendiary magistrate’s station. This has
proved very useful within limits of size and general
convenience. This is the only hospital accommoda-
tion in the district.
Native Town Sanitation.—Creek water principally ;
also conserved roof water from houses with iron roofs.
There are a few cement storage tanks. In some
districts during dry weather, good drinking-water can
only be procured at a distance, and is scarce.
Latrines.—No system of latrines exists in this
district. The bush, shore, tidal creeks, and doga
swamp are used. This is not a great evil, as there
are few large rivers with towns higher up on their
banks, and their water, though open to contamina-
tion, can be used for drinking purposes.
Meteorological Conditions.—These have not been
recorded. The last quarter of the year has been
exceptionally dry, and at times almost amounted to
drought. F. Nance Smartt, M.B.
On THE TREATMENT oF Fijian YAWS AND SYPHILIS
IN Inp1ans By “606” iw 1911.
Dr. P. H. Harper, resident medical superintendent,
Colonial Hospital, says: During the last four months
bl cases of yaws and 15 of syphilis have been treated
at the Colonial Hospital, Suva, with salvarsan (606).
The following table shows the nationality of the
patients treated and the methods employed :—
CaskEs or SYPHILIS Cases OF Yaws
—À
Nationality Male Female Male Female
European .. s. oi a 0 0
Fijian T 2*4. ae? X105 vase SA 0
Indian v 74d Se HO" seer TE 4
Samoan F sS WES a od. ke O 0
Half.caste (Fiji-
European) tx OF rage 2 0 0
Wallis Islander 1^ x 0 0 0
Total vs 20: 54 16 Il .,4 4
After fully reporting his methods and their effects
upon the cases treated, he came to the following
CONCLUSIONS.
(1) The drug did not appear to have a selective
influence on any of the races treated. The greater
liability of Fijians to albuminuria following intra-
venous injection is only apparent and is, in my
opinion, due to the fact that yaws is a more severe
disease than syphilis. But no observations were
made on the effect of salvarsan on the filaria. One
of the Fijians, however, who did not develop albumi-
nuria after intravenous salvarsan, was the subject of
filarial elephantiasis.
102
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
— ——!
[August 15, 1914.
(2) Local treatment of yaws granulomata and
ulcers by scraping, &c., is not called for, as the
unhealthy protuberant granulations at once break
down, to be replaced by healthy red healing granula-
tions. Graft operations and excision of the scars left
after the healing of uleers of many years' duration
are useful in some cases.
3) Local reaction was severe in only one case.
4) The best results were obtained by the intra-
venous method. The intramuscular is preferable to
the subcutaneous method. j
(5) The results of treatment by serum from blisters
obtained on treated patients are doubtful, and the
method was only tried when the debility or age of
the patient was considered a contra-indication to
intravenous injection.
(6) The treatment of yaws by salvarsan is our
most economical line of treatment. In January and
February, 1911, before salvarsan was used the average
stay in hospital of yaws patients was over forty-five
days, although this includes several minor cases
who were in only a day or two. The average stay
in hospital of yaws patients treated by salvarsan
will be under twenty days, probably under eighteen
days.
(7) Cases which were hopeless of cure when treated
by other methods were apparently cured when treated
by salvarsan.
Colonial Medical Reports.—No. 38.—St. Kitts-Nevis and the Island of Anguilla,
Leeward Islands Colony.
MEDICAL REPORT ON THE PRESIDENCY OF ST. KITTS-
NEVIS AND THE ISLAND
OF ANGUILLA, LEEWARD
ISLANDS COLONY.
By W. H. FRETZ, L.R.C.P.,
L.R.C.S.Edin,
Fellow of the Royal Institute of Public Health, London; Fellow of the Society of Tropical Medicine.
Senior Medical Officer.
POPULATION, BIRTH AND DEATH-RATES.
Statistics of Population in the Presidency of St. Kitts-Nevis.
St. Kitts Nevis Anguilla
Estimated number of inhabitants in
1910 .. T a as .. 80,185 14,971 4,894
Estimated number of births during
the year 1911.. » e a 949 545 180
Estimated number of deaths during
the year 1911.. ve o" PEE 749 323 80
Estimated number of inhabitants in
1911 30,385 15,193 4,994
Estimated number of increase
Number of inhabitants at census on
April 1, 1911 .. s
200 222 100
26,283 12,945 4,075
The above table is calculated, as heretofore, on
an estimated population of the previous year and
gives a death-rate as follows :—
St. Kitts.—24-650. per mille against 26:45 per mille
in the previous year.
Nevis.—21:259 per mille against 21:57 per mille in
the previous year.
Anguilla.—16:019 per mille against 19:41 per mille
in the previous year.
The birth-rate estimated on the same basis is as
follows :—
St. Kitis.—31:232 per mille against 32:93 in the
previous year.
Nevis.—36:871 per mille against 37:94 in the pre-
vious year.
Anguilla.—36:043 per mille against 429/70 in the
previous year.
BIRTHS, STILL-BIRTHS AND DEATHS (EXCLUSIVE OF
STILL-BIRTHS IN 1911).
Death-rate
Living Still- Deaths per 1,000
Living birth-rate Still. birth-rate exclusive of inhabi-
births per1,0000f births per 1,000 0f ofstill- tants ex-
inhabitants inhabitants births clusive of
still-births
St. Kitts 849 21:941 100 3-291 649 21:359
Nevis .. 500 32:909 45 2:961 278 18:311
Anguilla 174 34:841 6 1:201 74 14-817
In the previous year (1910) these rates were as
follows :—
Living births Still-births exclusive of
still-births
St. Kitts 30:23 2°79 .. 23-66
Nevis.. 36:13 2:40 x 19-17
Anguilla 40°86 1°85 11:64
The following table of legitimate and illegitimate
births is not without interest, from the invariable fact
that the mortality among the illegitimate is greater
than among the legitimate, and that many of them
are still-born shows clearly how unfavourable their
position is from the first.
LEGITIMATE AND ILLEGITIMATE BiRTH-RATE FOR 1911.
Legitimate [legitimate Legitimate "Illegitimate
births births La my
St. Kitts .. 3999 627 10:507 .. E
Nevis e 22 333 13:953 .. 21-917
Anguila .. 79 .. 161 15:818 .. 20:224
Infantile mortality, considered as the annual
number of deaths of infants under 1 year of age to
August 15, 1914.) COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS.
every 1,000 births, is still high in the Presidency, as
the following table shows :—
Number of deaths Rate per 1,000
under 1 year of births
St. Kitts .. és 260 273°972
Nevis oe es 148 271°559
Anguila .. zs 31 172:2
The causes of infantile mortality are common to the
whole island, and the chief of them is improper food
and methods of feeding, the improper substitution of
farinaceous for milk food; the use of uncleanly bottles
containing milk in an incipient state of putrefaction
is a common source of infantile diarrhoea. Convulsions
are very commonly due to the irritation produced by
improper feeding ; prematurity and congenital defects
in connection with the health conditions under which
the mother lives have an undoubted influence on the
vitality of her progency, and so too have hereditary
tendencies, such as the inheritance of syphilis.
Pusiic HRALTH.
The general health of the Presidency during the
year was good, and there was nothing noteworthy.
No disease of a quarantinable nature visited our
shores, and the Quarantine Station was not requi-
sitioned for such purposes.
Leprosy.—There were 60 cases in the lazaretto on
January 1, 1911. There were 7 admissions during
the year—3 males, 4 females—making a total of
67 treated for the year; of these 6 died. There were
no discharges. Leprosy is spread by direct and in-
direct contagion by persons suffering from the disease.
The possibility that indirect contagion may be effected
by fleas, bugs, lice, &c., has to be borne in mind.
Leprosy is most prevalent under conditions of per-
sonal and domestic uncleanliness and overcrowding,
especially where there is close and protracted associa-
tion between the leprous and non-leprous. The
evidence as to the Nastin treatment of this disease
is conflicting, and we must await the result of ex-
periments on a large scale; Deycke reports its use as
effective in clinical practice. The results of treatment
from it in a leper asylum in British Guiana were
favourable, the swellings in the tuberculous forms
retrograded, and in the nerve cases improvement
seemed good, especially as regards the spots on the
skin and the anesthetic areas ; the drug produced no
ill effects, and the general health of the patients
seemed improved.
Yaws was placed on the notifiable list for part of
the year, and showed no decline in its prevalence,
being endemic in some parts of the country districts.
This disease has been successfully treated with ‘ 606 "
(salvarsan), and from the remarkably successful results
obtained in the Trinidad Hospital it may be looked
upon as a specific in its treatment
Enteric or Typhoid has prevailed during the year,
causing 13 deaths. There were no explosive outbursts
of the disease ; the difficulty of tracing the source of
the infection was very great, and in the majority of
cases could not be arrived at.
The Medical Officers report as follows :—
Dr. Nurse (District No. 1) says:—
During the last two quarters of the year the district
has been fairly healthy.
Cases of diarrheea and dysentery, which are gener-
ally prevalent during the fall of the year, have been
few, especially among the children.
I have had only one case of malarial fever in the
district.
The parish of Trinity has been exceptionally healthy.
Dr. McDonald (District No. 3) says :—
The public health in District No. 3 during 1911 has
been very satisfactory. The death-rate has been
exceptionally low.
There were a few cases of typhoid fever at the
beginning of the year. One of the last cases occurred
in my own hcuse. This was a very severe case, the
fever ranging up to 104? F. and continuing for ten
weeks, the chief symptoms being continued fever,
tympanitis and intense jaundice lasting two weeks ;
during convalescence the patient suffered from paro-
tiditis (mumps), which aecording to the textbooks is
almost always fatal Two of the other cases in the
district showed intense jaundice.
died from a relapse and exhaustion.
T wo new dispensaries were established at Tabernacle
&ud Parson's Ground.
During the year 6,089 patients were attended at the
three dispensaries in the district.
Midwives.—Those instructed by me and supplied
by the Government with materials for carrying on
their work have done very well. There has been a
marked diminution of cases of tetanus in the new-
born, and also in cases of still-births. Tetanus is
almost a thing of the past.
I am very glad to report that the sanitary condition
of District No. 3 is now in a very satisfactory way
and has greatly improved during the year.
In the formation of the District Sanitary Board the
object aimed at was to appoint members who move
a great deal among the people of the district, and
who thus have many opportunities of instructing the
people, and of noticing and correcting any insanitary
conditions.
Each member of the Board has been asked to act
as a kind of sanitary inspector for his own immediate
neighbourhood, to instruct the people in sanitation on
all occasions, to help the people improve their sanitary
conditions, and specially to notice and report any
insanitary conditions in their neighbourhood.
At the start the members realized that there were
three important objects that they must pay particular
attention to :—
Prevention of breeding and destruction of flies ;
Prevention of breeding and destruction of mos-
quitoes ;
The proper disposal of night soil.
There are three sanitary inspectors, one for St.
Mary's, one for Christ Church, and one for Tabernacle
and Stonecastle.
The chief duty of the sanitary iuspectors is to
inspect houses and premises in order to discover and
remove nuisances and insanitary conditions.
The method of inspection is :—
House.—Note anything in surroundings which
might injuriously affect it; whether shut in, and
amount of free air space and light available. Note
any evidence of dampness (under the house or in the
walls), dirtiness or overcrowding, or any collection of
rubbish under the house.
One of the cases
104
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
Yard.—See whether surface drains are in good
repair, whether the yard is damp, whether there is
any collection of rubbish in the yard. Find out if
house refuse is regularly collected and put out, and
whether any animals such as pigs, poultry, &c., are kept,
and how kept. Note any,breeding places of mosquitoes.
Excreted Refuse.—Find out method of disposal, and
note condition as to cleanliness.
Cesspit.—Find out if there is any leakage or
offensive smell.
Pail Closet.—Find out if contents are kept dry, and
how often pails are changed.
Water Supply.— Find out how obtained, and
methods and arrangements for storing.
Note any trade business in the vicinity likely to
cause annoyance or discomfort.
General Remarks. —On account of the persistent
efforts of the members of the Board of Health and of
the sanitary inspectors, the district has been particu-
larly free from mosquitoes. The sanitary officers on
their weekly rounds sometimes find mosquito larve
breeding in water in estate coppers, barrels and other
receptacles. The water is either immediately emptied
out or supplied with ‘ millions.”
The most likely breeding places for mosquitoes in
the district are the mould traps or holes at the sides
of the public roads. The gutters, trenches and holes
at the sides of the public roads are seldom cleaned
out, and often contain stagnant water for months at
a time, thus becoming ideal breeding places for
mosquitoes. I have repeatedly obtained mosquito
larvae from stagnant water in these holes. With a
little expense and trouble these breeding places of
mosquitoes could be easily destroyed.
It is with great pleasure that I record the splendid
results achieved at“ Mansion Estate ” by the manager,
Mr. D. Todd. Mansion Estate is a model of
cleanliness and proper sanitation and an example to
all the other estates. All collections of water that
cannot be emptied are regularly supplied with
** millions," therefore Mansion Estate is always free
of mosquitoes, even in the bad ** mosquito season.”
Dr. Foreman (District No. 4) says :—
There was nothing unusual to report in District No. 4
during the year 1911, except the building of cemented
gutters at Dieppe Bay and at Sandy Point, which were
much needed. It makes a great improvement in the
sanitary condition of these places. "There is no more
stagnant water about the streets and private yards,
and there are certainly fewer mosquitoes.
Iam glad also to report that public latrines are being
erected at Dieppe Bay. I hope that people will make
use of them, and that ankylostomiasis will soon be less
prevalent in that village and its neighbourhood.
I think the notification of cases of yaws has done
some good, as patients above 9 years old were
provided with gratuitous treatment as well as the
younger ones, with the result that most of the cases
were cured. However, there are a few fresh cases
in the villages of Fig Tree and Godwin Gut.
Dr. McPherson (District No. 5, Anguilla) says :—
The health of the district during 1911 has been
fair. An epidemie of typhoid fever occurred during
the latter three months of the year. Up till
December 31, 16 cases, with 1 death, occurred.
All the persons affected lived within & radius of
a quarter of a mile. No obvious source of infection
could be discovered, but i& is undoubtedly the house-
fly which acts as a carrier.
The prolonged drought during the summer months
caused great scarcity of grounds, provisions and
consequent hardship to the poor.
The tota! number of deaths was 78, as compared
with 89 for last year; 27 of the number were under
1 year of age, and of the 27, 7 were still-births.
Malaria, Ankylostomiasis, Yaws, Filariasis have
been entirely absent, excepting a few imported cases
of the first-named.
Dysentery and Diarrhea have been frequent.
Infantile Diarrhea caused 12 deaths of those
under 1 year.
Tuberculosis in various forms is fairly common and
accounted for 9 deaths.
One imported case of Pellagra, which proved fatal,
occurred.
A trained midwife has been at work in the district
for eight months of the year and has been of consider-
able service.
There were 91 successful vaccinations. The
scattered dwellings and bad roads make it difficult
for mothers to carry their children to the places
appointed for vaccination and a certain number
escape from this cause.
Five major operations were performed locally, and
one patient was sent for operation to the Cunningham
Hospital.
Dr. Rat (District No. 6, Nevis) says :—
The health of District No. 6 during 1911 has been
good. There was no general epidemic during the
year. The only departures from the normal were the
prevalence of dysenteric diarrhcea during the last
quarter and the occurrence of three cases of pneu-
monia, in two of which the disease was contracted in
St. Kitts.
One hundred and sixty-four deaths were reported,
45 among children under 1 year of age, 18 among
those of from 1 to 10, 3 among those of from 10 to
15, 1 among those of from 15 to 20, and the rest
among adults.
The largest number of deaths, viz., 35, was due to
diarrhoea. Eleven deaths resulted from malarial
fever, 9 from tuberculosis, and 6 from syphilis.
Ten children died from congenital debility within
a few days of their birth; and among adults 8 from
old age. The remaining deaths were divided among
the several diseases to each of which fewer than 6
deaths are attributed.
There was nothing exceptional in the health of the
adult population except the prevalence of dysenteric
diarrhoea already mentioned. The cases appeared
during the last quarter after a long drought followed
by heavy rains. One of the drudges employed at the
Alexandra Hospital was attacked with this disease,
and, after a relapse, showed signs of liver abscess.
A dome-shaped swelling about 2 in. in diameter at
the base was observed in the epigastrium. It was
exceedingly painful and was attended by continued
fever. It, however, disappeared under treatment
with quinine internally and ichthyol and mercury
externally, without developing pus.
COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS.
Sept. 1, 1914.]
Colonial Medical Reports.—No. 38.—Leeward Islands—
(continued.)
Or the 248 children born in the district, 20 were
stillborn. The mortality among the remainder was
45. This gives a mortality of 19:7 per cent., which
is about 5 higher than the corresponding average
figure for England. As many as 18 died before they
had completed the first month of their existence.
Ten were too feeble at birth to live beyond a few
hours or days, and their deaths are recorded as due
to congenital debility, but some of these must have
been affected with hereditary syphilis. The other
eight died of such diseases as trismus, of which it is
interesting to note that there were only two cases,
convulsions, umbilical hemorrhage, hemophilia,
gastro-enteritis and cellulitis. Diarrhaa, of which
there were 19 fatal cases, was the chief cause of
death. While there were only 5 deaths from it
during the first half of the year, 14 occurred in the
latter half, as many as 12 having taken place in the
last quarter. The diarrhcea which prevailed among
the infants during the last three months was of the
same type as that which affected adults during that
time. It was attended by colic and discharges of
blood and mucus.
The mortality among children under 1 year of age
was due to the following diseases in the following
proportions: Congenital debility 10, diarrhea 19,
syphilis 4, convulsions 1, hemophilia 1, malarial
fever 3, trismus 2, bronchitis 1, umbilical hæmor-
rhage 1, gastro-enteritis 2, cellulitis 1.
METEOROLOGICAL RECORD.
Rainfall in the Presidency in 1911.
St. Kitts Nevis Anguilla
T Can- N R
Buckley's Hermita It New River
Leeward Wind at Gardon Windward Centre of
side of side of side of side of Island
Island Island Island Island
January 5:23 341 6:82 2:23 2:36
February .. 5°79 7:03 3:05 1:87 3°13
March 2:16 3:21 1:33 2:10 0°88
April 1:97 1:09 3:16 2°00 5°34
May 3°65 5°54 3°35 2°80 1'77
June 2:13 2:50 1:224 .. 023 0°46
July 3:97 2-02 268 .. 1:09 0:80
August . 9:04 2:11 8:08 .. 1:96 0°83
September.. 4°64 422 5°70 4:82 0:88
October 4:96 4:69 3°70 4:14 3:61
November.. 3°64 407 .. 2:93 3:118 4:21
December.. 6:73 8:06 7:88 7:10 7:90
Total .. 47:51 48-67 44:92 83°52 82°17
1910 .. 42:15 44:37 41:54 31:85 32:35
METEOROLOGICAL RETURNS FOR 1911.
Montlis Minimum Maximum Range MR Rain fall
January .. sw DB. Ae Bb 23. gue zs. TS. 4:98
February ve B6: 3 “B27 ou 6 76:9 4°51
March .. S. 805 25 8... 18 78.3 2°30
April i oe 40. 25 286 aks 6 81:4 1:36
May $i jw d ua HO. «Bey Ae 81:9 4°37
June 5 iha 49. os SB c. "19 84:1 2:25
July vi oa, AA we, BB Ss, Ft 84:1 3:34
August .. eL fey UE. S ALi 85:7 2:18
September Noe TO: Ss BU. At CIT 84:6 3:49
October .. S4 STB! L4 «90s luy 84:6 4:92
November us TE dm SBB* uova 81:7 3:02
December do Wh ow 86 .. 15 79:6 6:37
Total 81:7 43:09
Mean temperature for year, 817.
GENERAL AND SANITARY.
The Presidency is in a fairly good sanitary con-
dition ; several cemented drains have been introduced
into the parts of the town of Basseterre where there
was no drainage previously, and extension of existing
drains in others. Increase in the number of latrines
must have a sanitary effect. As before reported there
is overerowding in many parts of the town. The
water is good and wholesome. The Mosquito Ordi-
nance has been enforced in the whole Presidency,
and some attempts at the extermination of those
pests have been made, though their destruction is
still looked upon apathetically by the majority of the
people; stocking of ponds and ornamental waters
with the small fish ‘ millions," known as voracious
devourers of the mosquito larve, have had some
effect in reducing their breeding spots. It would be
advisable to cut down more brushwood in the neigh-
bourhood of dwellings, and to fill up hollows and
pools of stagnant water. The method of collection
of night soil is unsatisfactory from a sanitary point
of view. The careful collection and disposal of house
refuse is a measure of primary importance against
the deadly “ house-fly,” and adequate means should
be taken to prevent the access of flies to foodstuff ;
measures should be employed to screen the kitchens
and latrines against them; cleanliness should be
maintained in the house, so as to deprive the insects
of food and breeding places.
INSTITUTIONS.
Dr. Edmund Branch, Medical Officer of
Cunningham Hospital, reports as follows:— -~
There were 838 cases treated in the wards of
Cunningham Hospital and 88 of these ended fatally,
giving a death-rate of 10-5 per cent. which is about
the annual average.
Among the deaths 20 were from old age. This
item, which is owing to the waut of & poor house in
this island, unfairly increases every year the death-
rate of the hospital.
The attendances on out-patients were 2,355.
The operations performed during the year amounted
to 110, giving the low death-rate of 1:8 per cent.
There are a few points in the nosological list
which perhaps deserve brief comments here.
The number of cases (12) of malignant growths
was large comparatively with most of the other
ailments on the list. Papain was administered
internally, as a routine treatment, whether the cases
were inoperable or had been operated on, and the
latter class were instructed to continue to take it
steadily after leaving the hospital. This was done
in accordance with the suggestions contained in
certain articles in the British Medical Journal to the
effect that the extraordinary power of papain, when
injected into the centre of a scirrhus, to digest can-
cerous tissues, encouraged the idea that the drug
might act destructively on whatever constituent of
the blood favoured the genesis and growth of cancer.
I may be excused for mentioning here a case in my
private practice, the more so as it influenced the
treatment of one of the 12 cases above mentioned.
A lady, aged 45, consulted me on her arrival in
St. Kitts. She had been treated in America for
the
106
scirrhus of the breast, first by the Rontgen ray and
then by amputation. She was emaciated to a degree
and presented so extraordinary an appearance that I
am almost afraid to describe it. Every gland in her
body from her neck to her legs was indurated and
could easily be felt. She was undergoing agonizing
pains in all these lumps. Six months had elapsed
from the date of amputation of the breast. I put her
on the internal papain treatment. In six weeks the
cancer nodules and the pain had disappeared. She
died in about two months from the almost sudden
disappearance of her hard lumps, but her death was
an easy one, as from exhaustion. During the last
two months she was free from pain.
Just at this time a woman, whose breast had been
amputated for scirrhus, came into the hospital with
a hard secondary cancer nodule the size of a pigeon's
egg in one corner of the mammary cicatrix. I
intended to remove this cancer, but put her in the
first instance on papain internally. In a week the
tumour was smaller and in about eight weeks she left
the hospital without any trace of it. I saw her three
months after and it had not returned. She took
papain for a long time after leaving the hospital.
The first case operated on in the Leeward Islands
with the help of quinine and urea hydrochloride is
among those mentioned in this nosological list under
the heading of malignant growths. It seems to me
necessary therefore to give a brief description of the
case in these notes. The patient, a white gentleman
aged 77, came from one of the neighbouring islands.
He had an epitheliomatous cancer involving nearly
the whole of his lower lip and another and larger
growth of the same nature on the mucous membrane
of the right cheek. His heart sounds were very
weak, and he was extremely feeble, chiefly from pro-
longed semi-starvation. He had consulted several
doctors, who rightly decided that he could not be
safely put under chloroform. They also thought that
the growths could not be extirpated without leaving
a horrible appearance from the mutilation of his
face. Under these circumstances they all declined
to operate. With the concurrence of my colleagues,
Drs. Fretz and Nurse, I removed the growth and
secured enough flaps from the neighbouring parts to
obviate completely any deformity. Dr. W. J. Branch
kindly managed also to be present at the operation.
The proposed lines of incisions were anesthetized by
numerous hypodermic injections of quinine and urea
hydrochloride. The patient groaned twice during
the operation but remained quite still. The skin was
devoid of sensation, but the mucous membrane over
the part of the buccal growth that projected into the
mouth was still a little sensitive, and he groaned
when the instrument pressed on it. No less than
200 drops of a 1 per cent. solution of the drug were
required to effect the anssthetization. The incisions
were not begun till the lapse of twenty minutes after
the last hypodermic injection. If I had injected some
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1914.
of the drug into the body of the buccal tumour, as
well as round its base, the operation would, I think,
have been perfectly painless. The wound healed by
the first intention. He left the hospital in three
weeks. He was put on the usual internal papain
treatment. I had a letter from his daughter three
weeks ago, that is to say five months after the oper-
ation; no disfigurement of the face resulted from the
removal of the tumour, and there had been no
appearance of a return of the disease up to now. His
general health and spirits are excellent. In spite of
the size and long continuance of these growths, the
glands under the jaw never became affected.
The Cunningham Hospital has had for many years
a sort of traditional good reputation for the successful
treatment of tetanus. The treatment that has always
been relied on by my predecessors as medical officers
of the institution is by chloral, often given heroically.
At any rate chloral was given in tetanus by the
doctors in St. Kitts almost from the time when the
drug was first introduced into medicine. I have been
informed that the late Dr. Dinzey was very successful
in treating with it tetanic cases in his country practice.
This year I include two recoveries out of three cases
of tetanus after wound. All of these were treated
with chloral.
THe Gaor.
Sixteen persons were sent to the Cunningham
Hospital for treatment and 62 were treated in the
institution itself for trivial ailments. There were no
deaths among the prisoners during the year.
The sanitary condition of the entire institution
remains, as usual, excellent, and the whole place is
kept scrupulously clean and tidy.
ALEXANDRA HosPiTAL, Nevis.
Dr. Rat reports as follows:
There were 256 admissions into the wards, of which
109 were males and 147 females.
The deaths numbered 16. Of these, 9 occurred
among the male and 7 among the female patients.
The mortality, according to sex, was, males, 8:2 per
cent.; females, 47 per cent.: The total mortality
was 6:2 per cent.
There has been a marked improvement in the
mortality since the removal of the patients from the
old infirmary in Charlestown, where the average
number of deaths among the hospital patients—not
including the poor house inmates— was 17 per cent.
during the period 1899 to 1906.
The diseases and injuries for which the largest
numbers of admissions were made were malarial
fever, syphilis, elephantiasis, lymphadenitis, heart
disease, pharyngitis, eye disease, genito-urinary
diseases, ulcers, injuries.
There were 36 operations
anesthetics.
performed under
(a) Phthisis Pulmonalis
(b) Tuberculosis of Glands ..
(a) Cataract.
(b) Iridectomy
n
Sept. 1, 1914] COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS. 107
RETURN or Diseases AND DEATHS IN 1911 IN THE CUNNINGHAM HOSPITAL,
Leeward Islands Colony.
D an
GENERAL DISEASES. $88 5 ggg
n n 2 Ed o $
is 3 ggg Aw. ou. PUE
SS $8 £82 GeneraL DisEasES— continued.
d ği A B (d) Tabes Mesenterica =e e — — —
Alcoholism SS ge SS us 12 — d (e) Tuberculous Disease of Bones .. |. — -- —
Anæmia -e E . : 1 1 Other Tubercular Pines a SS Se
Anthrax .. e . . c. ac AS Varicella .. 1 S ae Pío = oes Jim
Beriberi .. s D et — — — Whooping Cough . AME =
Bilbarziosis , j 3 — — — Yaws ! a 3 em, Toe —
Blackwater Fever . . = Yellow Fever .. 3s : ME A re
Chicken-pox TE 3 . — — —
DEDI $5 . s . _ — = —
holeraic Diarrhea ss : B — — —
Congenital Malformation i : =A es FONS DISEASES,
Debility .. ae BE `: . 5 — 7 Diseases of the—
Delirium Tremens ve . oe z — = = Cellular Tissue ae T 24 — 24
Dengue .. 3 . A <. = — — Circulatory System .. as e. -= oe —
Diabetes Mellitus S š . _- — — (a) Valvular Disease of Heart vs és 6 5 7
Diabetes Pi ss A ? a - — —- (b) Other Diseases .. oe i 6 3 7
Diphtheria Y è . = = — Digestive System— .. = ae e. — — —
Dysentery .. Se š 7 4 — 4 (a) Diarrhoea ce 2 25 5 24
Enteric Fever |. š s 5 > = — (b) Hill Diarrhea .. T at - — —
Ervaipalas me se . . d = oS = (c) Hepatitis s We — — —
ebricula .. id . E s l = 1 Congestion of Liver 6 2 8
Filariasis .. x È e = — — (d) Abscess of Liver - — —
Gonorrhcea z . . 14 -- 14 (e) Tropieal Liver .. 4s e. © — — —
Gout è Vi ‘ i $ è =, — = (f) Jaundice, Catarrhal .. : e — — —
Hydrophobia ^ d : r — — — (g) Cirrhosis of Liver a3 is | — — -—
Influenza .. T ^ " x 3 — 3 (h) Acute Yellow Atrophy — — —
Kala-Azar.. à . 6 F. — = — (i) Sprue $ - : — — —
Leprosy .. ʻi . . ee - — — — (j) Other Diseases .. a . 109 1 111
(a) Nodular . . == — Ear Pe EE . . . . 3 — 3
(b) Anesthetic .. š ‘ . — — — Eye oe T s . . W — 24
(c) Mixed s$ . s — — Generative System— A si © -= — --
Malarial Fever— E . = = zm Male Organs ve » 14 — 15
(a) Intermittent . : $e 3 — 3 Female Organs 5 . 15 — 15
Quotidian .. . z eo . — — Lymphatic System m . 3 — 8
Tertian . . T — — — Mental Diseases T 23 — 29
Quartan . 3 ` . = = = Nervous System . . «17 3 21
Irregular .. Š A — — — Nose .. a oe . 1 — 1
Type undiagnosed . . = — — Organs of Locomotion . . 19 — 23
(b) Remittent .. . 2 s = = = Respiratory System . . 2L 2 29
(c) Pernicious .. . . 5 5 Skin— .. zs . . . 22 — 25
(d) Malarial Cachexia. . : x — — — (a) Scabies . k ©. = — —
Malta Fever - «i ; — — — (b) Ringworm " E ©. — — —
Measles oe — = (c) Tinea Imbricata s: © = — —
Mumps... ve i i — — — (d) Favus .. ©. — — —
New Growths— .. T = = — (e) Eczema .. ss ae T" ©. — — —
Non-malignant T. 5 1 5 ( f) Other Diseases .. ? © — = —
Malignant $4 12 — 12 Urinary System ss . . 24 5 25
Old Age .. . + — = — Injuries, General, Local— es v $e 84 4 67
Other Diseases e 66 27 76 (a) Siriasis (Heatstroke) +e dm e — — —
Pellagra .. es — — — (b) Sunstroke (Heat Prostration) .. — - —
Plague — .. os Si — = — (c) Other Injuries és T — — =
Pyemia .. m ang _ — — Parasites— P 59 7 67
Rachitis .. i bs — = — Ascaris lumbricoides .. 1 — 3
Rheumatic Fever os = = — Oxyuris vermicularis . — — —
Rheumatism R P 16 — 17 Dochmius duodenalis, or Ankylostoma duo-
Rheumatoid Arthritis .. z — — — denale . — — —
Scarlet Fever š — — — Filaria medinensis (Guinea worm) . = — --
Scurvy .. .. z — — — Tape-worm . — — —
Septicæmia T A — — = Poisons— ie ae e = = —
Sleeping Sickness à — — — Snake-bites — .. p. ar Ka ©. — — —-
Sloughing Phegodena An — — — Corrosive Acids y © — — —
Smallpox .. 4 sá — — -— Metallic Poisons 3 š 1 — 3
Syphilis .. T — — = Vegetable Alkaloids 3 SS —
(a) Primary 16 — 16 Nature Unknown : ©. — — —
(b) Secondary .. 90 13 103 Other Poisons . è _ — — —
(c) Tertiary . . — — — Surgical Operations — E . e — — —
(d) Congenital .. 4 — 6 Amputations, Major .. P : ©. — — =
Tetanus .. . A 3 1 3 Minor .. : £s + «10 1 10
Trypanosoma Fever — -- Other Operations . `: 93 1 95
Tubercle— 10 27 Eye .. . i= 7
(c) Lupus .
(c) Other Eye Operations s 1
108
Colonial Medical Reports.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
No. 39.—Durban Corporation.
MEDICAL REPORT FOR THE YEAR ENDING
JULY 31, 1911.
By P. MURISON, M.D., B.Sc.,
D.P.H.
Medical Officer of Health.
Durina the past year public health affairs have
been of such a kind as to excite very little public
attention. There has been an entire absence of
epidemics or even serious outbreaks of infectious
diseases. An important aim of public health depart-
ments is to prevent such occurrences; itis only when
this function has not been successfully exercised that
the secondary one of “ fighting it," as the phrase goes,
comes into operation. Plague, smallpox and malaria
have now been absent from this borough for several
years, and unless any one of these diseases should
again appear all reference to these diseases will be
omitted in future annual reports. The only disease
which occasioned any uneasiness was a somewhat
sudden sharp outbreak of epidemic diarrhaa, which
occurred in January, and lasted about five weeks.
It was diagnosed and notified as dysentery by some
medical practitioners, by others it was considered
muco-enteritis.
The number of cases of infectious disease occurring
in the borough during the past year has considerably
increased. The diseases that are chiefly responsible
for this increase are dysentery, enteric, and phthisis.
Diphtheria shows a marked decrease. Each case on
being notified by the doctor in attendance is immedi-
ately visited and kept under close supervision during
the course of the illness and until the process of
disinfection has been carried out.
Since 1907 a considerable change has come over
Durban owing to its development as a health and
holiday resort, which has produced one or more points
demanding notice from a public health aspect. Owing
to the permanent as well as the changing attractions
provided during the winter months, we have a sudden
influx of a European temporary population added to
our own. A very considerable portion of this popula-
tion consists of young children liable to infectious
diseases. When a case of infectious disease occurs
in such places, uneasiness, if not alarm, is produced
amongst other guests, particularly the parents or
guardians of children. The only method of allaying
such alarm is by the immediate removal of the
sufferer to a suitable isolation hospital.
The want of more adequate provision for the
isolation and treatment of cases of infectious diseases
is particularly noticed during the winter and summer
seasons when the borough has its housing capacity
tested to the utmost.
From some considerable personal experience I
would venture to suggest that it would be highly
advantageous both to the borough and visitors if the
municipality would exercise greater control over
accommodation provided for visitors, and more
particularly in the letting of lodgings. It would be
a highly appreciated service if an Information Bureau
for visitors intending to visit Durban could be inaugu-
rated by the Corporation.
Native Location.
When plague and smallpox invaded this munici-
pality these diseases were noticed to spread amongst
our Native population quite as rapidly as amongst
Indians, and quite as many fatal cases occurred
amongst Natives as in any other race, while owing
to their habits and circumstances Natives are
exceptionally active agents in the spread of infectious
disease.
The Corporation during the past year have con-
demned several blocks of buildings, oecupied by their
coloured employees, which were erected ten years
ago, and to accommodate the population so de-housed,
are erecting several blocks of buildings adjacent to
the Magazine Barracks that will serve as models for
all other employers of coloured labour.
In these dwellings, light, ventilation and air space
have received particular attention, and instead of
being the usual back to back wood and iron sheds,
are built of brick and hollow concrete blocks, and
provided with through ventilation.
One half of the total population of this borough
consists of Natives and Indians, and as the weakest
link of any chain determines its strength, so the
health of the European population depends to a con-
siderable extent on the health and sanitary conditions
of those with whom they are brought into contact.
ADDITIONAL PuBLIC HEALTH AND SANITARY
PowERs.
Fairly wide powers are now available for con-
trolling all food-stuffs sent into the Borough, and
more particularly for the examination of all foods
and articles intended for human food, their seizure,
removal, and destruction if found to be diseased,
unsound, or unfit for food of man, and imposing
penalties including imprisonment on conviction of
any person exposing for sale, selling, transmitting, or
depositing for sale, such food or articles. Under
previous legislative powers it was impossible to deal
with persons living outside the Borough who sent
into Durban for sale food or articles unfit for human
consumption. Under powers conferred by this Ordi-
nance such persons can be dealt with in a similar
manner to those whose trading premises are within
the Borough.
Sept. 15, 1914]
COLONIAL MEDICAL REPORTS.—DURBAN CORPORATION.
109
Colonial Medical Reports.—No. 39.—Durban Corporation.
(continued. )
It is recognized that the stabling, shedding and
kraaling of animals in municipalities should be under
more efficient control, and amongst several important
provisions of this ordinance there is one dealing with
the power to restrict the number of animals to be
kept in such places. It is highly undesirable to kraal
animals within the borough unless remote from all
dwelling-houses or work-places.
Powers have also been given for dealing with hair-
dressers’ and barbers’ premises, in order to secure,
amongst other things, protection of customers from
inoculation of cutaneous and other diseases.
GOVERNMENT PRIMARY SCHOOLS.
During 1906 a careful inspection of all primary
schools in Durban was made by this department, the
result of which was to show that in many of these
schools various kinds and degrees of insanitary and
defective conditions existed. On the strength of a
detailed report, the Town Council communicated with
the Education Department and Government on the
subject. It was recognized by all parties that modern
school buildings must be provided, sufficient in num-
ber and size to cope with the wants of this community.
The history of progress in Durban during the past
three years in the direction of school accommodation
can only be regarded as phenomenal.
MEDICAL Inspection or SCHOLARS.
It will be perceived from what has been stated
regarding schools that the Borough of Durban will
shortly be supplied with adequate and proper school
accommodation. However desirable and essential
that provision may be, another important factor
exists requiring careful consideration. It is now
recognized that children attending schools may
require attention for the purpose of discovering any
physical or mental defect capable of prejudicially
affecting a scholar’s physical development or intel-
lectual progress into a perfect citizen. Such defects
may not be recognized by or known to their parents
or guardians.
In considering this question the first point requir-
ing to be settled is: Does the same necessity exist
in Durban for medical inspection of scholars as in
other parts of the world where such inspection has
been found so necessary and advantageous? That
question can only be answered by a trial examina-
tion of a considerable number of mixed pupils. An
application has been made to Government recom-
mending that permission be granted for such trial
examination, and the suggestion has been made that
a medical inspection of the scholars attending a
mixed school would furnish sufficient statistical
facts to answer the above question. I expect to hear
shortly that the Government has sympathetically
considered this proposal.
INFECTIOUS DISEASES.
During the year the Health Officer for the colony
recommended the closure of schools to prevent the
spread of infectious diseases.
This step would only be taken in exceptional cir-
cumstances, and that duty will now be carried out by
this Department. Any action is duly notified to the
Health Officer for the colony, the date of closure of
the school, the reasons for the closure, and the date
of re-opening.
VITAL STATISTICS.
For several years past the Municipality has caused
a census of the inhabitants to be taken, and this
work has been carried out in an excellent manner.
Up to the latest moment of sending in this report
only a preliminary uncorrected census return has
been made, consisting of the total numbers of the
different races as follows :—
Europeans ... 31,903
Natives M zA 2 En 17,750
Indians and other Coloured Races 19,512
Total - ies .. 69,165
In the new method of grouping of races the only
points of possible approximation to correctness in
the above table is the number of natives and the
total population, The preliminary return is not
comparable with any previous censuses in its group-
ing. It will be noticed that St. Helenas, Mauritians,
&e., are classed with Indians. In previous returns
these persons have been grouped into a separate
class, ‘‘mixed and others,” and as these people
adopt European habits, all returns of vital statistics
relating to Natal or Durban have included them in
the European population.
Estimate OF Popunation, 1910-11.
Europeans... A des 31,903
Coloured and Half-Caste 2,497 | 84,000
Natives "a Sas 17,750
Indians 17,015
These figures show that a very healthy increase
has taken place.
NATURAL Increase oF POPULATION OF DURBAN,
1910-11.
Births 952
Deaths 301
651 natural increase of population.
It is of importance in other respects than that of
Public Health to have a census of the population of
a community taken at frequent intervals. To know
whether a population is stationary, increasing or
decreasing, and more particularly if it is increasing,
at what rate, affords valuable information of economic
interest.
TABLE SHOWING MONTHLY DISTRIBUTION OF BIRTHS FOR
Race anD Sex, 1910-11.
TOTALS
pp
Months Europeans Asiatics Natives
1910—August ET ie 5i 75 2
September ... a8 ait 91 50 3
October 85 51 1
November 82 67 2
December 80 34 0
1911 —January ed vit 94 54 3
February ... zi e 85 46 2
March 89 52 0
April ... 91 41 1
May ... 88 74 1
June ... TT 42 1
July .. 84 49 1
Totals .. 1,021 610 17
European birth-rate (gross) T so, 29-77 per 1,000
Ys Y. (corrected) for non-residents 27-7 RA
Indian birth-rate aa ise Se 95:0 M
110
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 15, 1914.
The small number of births of natives occurring in
Durban prohibits the stating of any birth-rate for that
population.
TABLE SHOWING RACE AND Sex DISTRIBUTION OF DEATHS
DURING THE Past YEAR.
Race Male Female Total
European ... Yet fr 176 125 301
Native... p dos 82 27 109
Asiatic... aa sas 172 133 305
Totals ... die 430 285 715
TABLE SHOWING CAUSES OF NON-RESIDENT DEATHS.
x
European Native Asiatic Total
Dysentery ... 4
Enteric fever
Measles
Malaria
Venereal diseases ..
Puerperal fever
Phthisis ...
Tuberculosis, other than. phthisis
Cerebro- spinal po ees
Cancer i
Old age
Diseases of nervous system A
Diseases of heart and ciroulatory
system $ RA ;
Pneumonia
Bronchitis ... A
Other diseases of
system ..
Diarrhea, enteritis and catarrh
Other diseases of alimentary track
Diseases of urinary system
Diseases of child-birth
Accident :
Suicide
Execution ...
m
onaran NNO ANDTOKR EF ROROCWH
T
FOROCOWOOCCCOF
tbo
CcCOrOWONO Oc MAROAWMONOrOCN
m re
0200002 D I tO iR co
m ji
mew Or OAT to nee
Sey
RPOWOrnKHO Oe
Totals ... M er, 40 31
ge
k
Q
e
The above table shows that a considerable number
of people who do not usually reside in the borough
come here to be treated for disease or injuries and
succumb while here.
The deaths amongst the European population of
Durban for the past three years show that there has
been a considerable increase in the number during
the past year as compared with the two previous
years. This increase in the number of deaths is not
confined to the Borough of Durban. Statistics are
available for the first six months of 1911 for the
whole of Natal, and they show an increase of nearly
50 per cent. of deaths as compared with the corre-
sponding six months of the previous year. It has
also to be remembered that our European population
has somewhat increased. It will be noticed that
the deaths from tuberculosis remain practically
steady at an average of twenty European deaths per
annum. It is to be remembered that these twenty
deaths were those of people domiciled in the borough.
Diseases of the intestinal track account for a large
proportion of the inerease of deaths occurring during
the past year. A fair proportion of the increase of
deaths also is due to injury and weakness at birth.
NamrvE DEATHS.
Natives (population, 1911, 17,750).—During the
past year 109 natives have died in Durban.
Adults *Children Total
Males ... T " 54 28 82
Females ... "T Ws 6 21 27
Totals... eae 60 49 109
Asiatic DEATHs.
Indians (population 1911, 17,015).—During
past year 305 Indians have died in Durban.
Adults *Children Total
Males .. ts = 67 105 172
Females ... e TH 43 90 133
110 195 905
* “Child means under 12 years.
INFANTILE MORTALITY.
Male Female Total
Infantile deaths during 1910-11 ane 49 37 86
Registered births ... T iss .. 952
Infantile deaths T zis ie sas B6
This equals 90:3 infantile deaths per 1,000 births,
and represents the ‘‘infantile mortality figure" for
Durban, 1910-11.
YEAR
* iene, x id B a =
$222 22 2
Number of infant
deaths ... .. 112 105 109 67 89 62 41 86
Infant mortality
figures ... . 100:3 88 100 69:2 91:7 67:3 45:4 90-8
ViTAL STATISTICS.
JOHANNESBURG.
EUROPEANS CoLouRRD
Whites Natives PEUT. Asiatics
Population 111,857 95,522 7,749 5,176
Birth-rate per 1 ,000 `. 35°7 x » Pg
Death-rate (crude) 13:8 33:6 91:1 197
Death-rate corrected for age
and sex distribution 15:2976
m
Infantile mortality ... es 110 326 29-5
Death-rate from tuberculosis 0:97 4°74 245 1:15
* Not calculated on account of the very small number of women,
CAPETOWN.
Europeans Coloured
Population ; 30:476 37-055
Birth.rate per 1 ,000 . 24:9 44:34
Death-rate (crude) 14:89 28-76
Infantile mortality ... ; 94:8 206-6
Death-rate from tuberculosis, non-
residents 1:27 5:233
Gross 1:87 5:93
PRETORIA.
Europeans Coloured
Population is “a sax
Birth-rate per 1, 000 . 34:2 17
Death-rate (crude) x ; 10°6 14:1
Infantile mortality ... E 104 244
Death-rate from tuberculosis Cus 0-2 2:4
Sept. 15, 1914.] COLONIAL MEDICAL REPORTS.—DURBAN CORPORATION.
111
BLOEMFONTEIN.
Europeans Coloured
Population . 25 á T 10,968 10,106
Birth-rate per 1.000 ... s ats 32:8 is
Death-rate (crude) ... oye sal 10 34
Pr (corrected) 7:59
Infantile mortality ... 79:2
PLAGUE.
No cases of plague have occurred in Durban or
amongst the shipping in Port Natal during the past
year. Several cases, however, are reported to have
occurred on the West Coast of Africa and Mauritius.
On the latter island, during 1909, 248 deaths occurred
from plague, and during the first ten months of 1910
165 deaths were reported.
SMALLPOX.
No cases of smallpox have occurred within the
Borough of Durban during the past year. The s.s.
* Sultan" arrived on September 28, 1910, having
had a case of smallpox on board during the voyage
in an Indian passenger. The Port Health Officer
informed me that ninety Indian contacts were ready to
be discharged from the ship. Consequently all these
contacts were then removed to and quarantined on
Salisbury Island by the Port Health Department.
VACCINATION.
We still continue to act as a lymph depót for the
convenience of medical practitioners in Durban.
During the past year several complaints have been
sent to the Health Officer for Natal concerning the
lymph supply. I would repeat that the vaccination
laws are not sufficiently administered. The Indian
population is not well vaccinated; the European
population very much less so.
DysENTERY.
Sporadic cases of this disease continue to be
notified from time to time, and from all over the
borough. The cases of dysentery that are now
notified are not to be compared with the cases of
dysentery occurring eight or nine years ago. About
December 20 the number of notifications of dysentery
commenced to slightly increase, and by the beginning
of January it was noticed that in the ten days twelve
cases had been notified. During the five weeks tbis
outbreak existed there were fifty-two cases notified as
dysentery.
ENTERIC FEVER.
The number of cases of enteric occurring in the
borough during 1910-11 was more than double that
for the previous year. The increase was fairly
general all over the borough. There were in two
families three cases, in another two cases, and in
another there was one instance of three cases in a
family and another of two cases. These occurrences
would seem to point to the need for more stringent
measures of isolation than can be obtained in most
of the small houses in Durban. It is therefore
imperative that every person suffering from enteric
should be isolated from all others except those in
attendance on the patient.
In considering the increase it should be borne in
mind that the greater part arose in the area to which
most of our season’s visitors flock for accommodation,
and that many of these visitors are only just con-
valescent from disease. It is certain that some of
them have just recovered from enteric, and some may
not be free from infection.
TUBERCULOSIS.
Dr. Adams on his arrival took over the duties
connected with tuberculosis, and the Tuberculosis
Bureau commenced its operations at the beginning
of May, 1911.
In some of my previous reports attention was
drawn to the fact that although consumption of the
lungs was an infectious disease, the ordinary methods
of dealing with infectious diseases were not reason-
ably applicable in cases of tuberculosis.
It is common knowledge that dirty and insanitary
houses and impure air predispose to the spread of
all communicable diseases. Although great sanitary
improvements have been effected in Durban in
connection with such conditions, and have produced
excellent results as regards many other infectious
diseases, the yearly statistics relating to consumption
clearly show that sanitary improvements have not
produced any practical diminution.
Tuberculosis generally makes its appearance
amongst the occupants of houses where the mini-
mum sanitary conditions obtain, and particularly
where overcrowding and deficient ventilation exists,
still numerous examples can be recorded in Durban
where this disease has invaded homes where, in
addition to the highest comfort, the very best hygienic
and sanitary conditions were maintained.
The European portion of the community has
already taken advantage of the services of tbe
Tuberculosis Medical Officer. The coloured races,
however, have not come to the Bureau in anything
like the numbers anticipated, from statistics of con-
sumption amongst these races spread over many
years. This apparent unwilling or reluctant attitude
on their part may be as yet due to lack of knowledge
or &ppreciation of the existence or purpose of the
Tuberculosis Bureau. Up to the present the great
majority of the Indians who have sought advice
belong to the more intelligent and better class
members of that race.
The leaders of opinion amongst the Indian com-
munity are now beginning to awaken to a knowledge
of the fact that the Tuberculosis Bureau exists for
the purpose of preventing the spread of a dangerous
infection amongst their compatriots, and also to assist
in the cure of those already attacked. A large and
influential committee has been formed by them to
assist Dr. Adams in his work, and by the aid of
this body of volunteers it is hoped to overcome any
objections or apathy on the part of Indians.
Since the inauguration of the Bureau a regrettable,
although very pathetic, feature has occurred, viz., the
immigration to Durban of many persons suffering
from this disease. Some of these sufferers, it was
found, had taken the journey on the recommendations
of their medical attendants.
112
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 15, 1914.
DURBAN MUNICIPAL TUBERCULOSIS
BUREAU.
From the opening of the Bureau to the end of the
municipal year, July 31, 1911 (three months), 302
persons presented themselves for examination.
Many of these tubercular cases attended on more
than one occasion, 152 attendances of these old
cases being recorded. In addition the medical super-
intendent paid 115 visits to them in their homes, the
bureau nurse 247 visits (in two months, as she under-
took her duties on June 1), and the Indian Health
Visitor 61 visits (in one month, as he was appointed
on July 1). The nurse visits European and coloured
patients, while the Indian visits Asiatics and Natives.
Of the 115 cases who attended the bureau, 6
European, 3 coloured, 2 Indian, and 0 native cases
died, and a number have left the borough, while the
remainder are under supervision.
No medicines are given away as at some of the
tuberculosis dispensaries at home, but to a few
tubercular cases only prescriptions were given. The
majority of the patients who attended regularly gained
weight, and improved in health on the advice given.
Many persons attended in whom no signs of tuber-
culosis could be found, whose sputum was examined
with a negative result, and who did not react to von
Pirquet's test. No non-tubercular patients were
allowed to attend after a negative diagnosis had
been made.
The social status of the large majority of European
cases of tuberculosis is very much higher tban that
obtaining at the dispensaries in England, and a large
proportion of cases found to be suffering from con-
sumption are well able to work and are actually
working. A large number came from the surrounding
area—Mayville, Overport, Umgeni, Sea View, South
Coast Junction, while many visitors to the town from
Johannesburg, Harrismith, Volksrust, &c., have con-
sulted the medical superintendent. Among this num-
ber have been found a large proportion of cases of
pulmonary tuberculosis.
The medical superintendent has notified to the
medical officer of health 59 cases of pulmonary tuber-
culosis who bad not previously been notified by the
medical practitioners.
Owing to the work of visitation carried out by the
nurse, Indian health visitor, and medical super-
intendent, it has been possible to keep in touch with
practically all the cases of pulmonary tuberculosis, in
spite of the fact that the Indian popnlation in parti-
cular are frequently moving their residences. The
department of the medical officer of health has been
kept informed of any changes of residence, and any
departures from the borough, and a large number of
rooms with linen, clothing, &c., have been disinfected
when vacated by patients.
The tuberculosis bureau has already got into touch
with a large number of persons suffering from pul-
monary tuberculosis, in spite of the short time since
its opening, and the fact that only for the last month
it has had its full staff.
Durban is the first municipality to establish a
bureau in South Africa, or, indeed, in the British
possessions; consequently it should be a model
scheme, and it is hoped that before long the neces-
sary sanatorium and hospital will be forthcoming.
These need not be expensive structures, nor to
accommodate large numbers, but it would be satis-
factory to provide the required accommodation for
those cases who need it, and thus amplify the work-
ing of the borough.
Basin Apams, M.D.
Tuberculosis Medical Officer.
Oct. 1, 1914.]
COLONIAL MEDICAL REPORTS.—LAHORE MUNICIPALITY.
113
Colonial Medical Reports.
No. 40.—Lahore Municipality.
HEALTH OFFICER’S REPORT FOR YEAR 1911.
By Dr. A. G. NEWELL.
Health Officer.
THE year under report was characterized by a
deficient rainfall. During the whole year the total
rainfall amounted to only 15°57 in., of which 4:01 in.
was in the month of March, which month had
the greatest rainfall. This too was unusual. We
have to go back to March, 1904, to find the same
unusual rainfall in this month, when there was a fall
of 5:37 in.
The months of May, June and July were character-
ized by excessive mean maximum temperatures and
there is no year during the last twelve years which
shows these three months in succession having such
high temperatures. In addition to this the month of
August also had an abnormally high mean maximum
temperature, and during the last twelve years 1911
alone records such a high mean for this month.
VrTAL STATISTICS.
Population.—The population of Lahore, as estimated
by the census of 1911, is as follows :—
Lahore City PA Ae aa 120,436
Civil Station and Anarkali — ... sas .. 68,321
Garhi Shahoo, Thathi Mehteran, Killa Gujar
Singh, Khui Miran ... m zy .. 11,579
Railway Colony ... " e 7,790
Total 208,126
The total number of deaths from all causes during
1911 was 6,681 and this, on the above estimated
population, gives an annual death-rate of 32:0 per
1,000. The annual death-rate for 1910 was 35:3 per
1,000 and the average for the five years 1906 —1910
was 48:4 per 1,000. This shows in comparison with
last year a difference of 3:3 per 1,000 in favour of the
year under report and, in comparison with the five
years’ average, a difference of 16:0.
The total infantile deaths (deaths under 1 year of
age) for 1911 amounted to 2,226, giving & death-rate
of 288'l per 1,000 births, against 222:3 per 1,000
births for 1910. If we deduct the deaths of infants
from small-pox this gives an infantile death-rate of
151:5 per 1,000 births.
BinTHs.
During the year there were 7,729 births registered
as compared with 7,520 for 1910, showing an increase
of 209. This gives a rate of 371 per 1,000 of the
population against a ratio of 40:2 per 1,000 for 1910.
A midwife was appointed on May 10, 1910, and a
dai was appointed on April 6.
One thousand leaflets, informing the public in the
native city about tlie midwife aud dai being available
for free attendance on maternity cases, were dis-
tributed in the city. The total number of cases
attended from May 9 to December 31, 1910, were
166, and for the year under report 171 cases were
attended.
INFECTIOUS DISEASES.
Plague.—There were 39 cases of plague in 1911,
with 19 deaths. Of these cases 32 were imported,
6 were indigenous. This is against 466 cases with
271 deaths in 1910.
The chief measures against plague carried out were :
(1) increased attention to removal of rubbish ; (2) con-
tinuance of rat-trapping during the period of likely
incidence of the disease ; (3) the use of pesterine and
cyllin to disinfect affected houses. Our chief cause of
exemption from a plague epidemic I attribute to the
rat-trapping operations carried out. The total number
of rats caught was 39,776 during four months.
The chief point in the system of rat-trapping is
proper supervision of the gang of trappers. "Two
superintendents proved unsatisfactory and another.
superintendent is now under observation.
Our cases have been of the bubonic type and the
mode of infection is by the agency of the rat-flea.
Pneumonic plague, as has been proved by the recent
experience in Manchuria, can prove extremely fatal
and epidemic. As the bacilli are in the lungs it is
not surprising that aerial infection plays the chief
mode of spread. It is possible for the bubonic form
of plague to terminate in a pneumonic variety, and it
is indeed an open question whether all varieties of
plague do not terminate in pneumonia, and the reason
why such cases do not give rise to other such cases
in the same house may be explainable on the ground
that the patient in the majority of cases is at death's
door before the pneumonia has gained ground, that
the bacilli are not of sufficient virulence to fight against
other bacilli in the lungs or in the air, and. because
the majority of corpses are within a few hours hurried
off to the burial ground. With the danger that bubonic
plague may terminate in pneumonia would seem the
necessity for segregation of cases and disinfection of
infected houses. Whilst primary pneumonie plague
is highly infectious there is evidence, however, that
the secondary pneumonia following on plague is
not so.
Cholera.— During the year there were 6 cases of
cholera with 6 deaths. The first case was reported
on August 27 and the last on October 19. During.
this period there were 7 suspicious cases which were
evidently cases of food poisoning. During this period
there were 11 cases of diarrhoe v. The houses of the
114
cases were all visited and disinfected as well as dis-
infection of clothes. Most of the cases were at
Gowalmandi, and a special raid was made by me on
this quarter by a large staff of sweepers aud bhishtis
and the whole place specially conserved and drains
washed, compounds cleaned and all refuse removed.
Disinfection of houses and disinfection of wells
were carried out and all suspected latrines dis-
infected. An extra gang of sweepers were sanctioned
as well as a special Jemadar and the erection of an
incinerator. The cases at Gowalmandi were around
the highly insanitary land occupied by a large number
of gowalas with their cattle.
Small-pox.—A small-pox epidemic has visited Lahore
every three years, and the year following the outbreak
had usually also a number of deaths from the disease.
The year 1909, however, shows no cases so recorded
and I cannot believe that this year was really free
from any case. Judging from the system of death
registration in vogue and the absence of inquiry into
the causes of deaths it is more likely that cases were
not recorded from the disease and that cases were
concealed; seeing that primary vaccination is also
not as successful as it should be and revaccination
has not been resorted to supports this contention.
There were only 257 revaccinations performed in
1908-9. In 1909-10 there were no revaccinations per-
formed. It is most important for the public to
recognize that the mere operation of vaccination
cannot be regarded as successful if there has been
no evidence left of the operation, and because a vacci-
nation does not “take” it does not mean that that
person is immune to vaccination.
VACCINATION.
This is the only preventive measure against small-
pox and since the Health Officer is concerned with all
preventive measures against any disease the anomaly
of the Health Officer of Lahore not being in charge
of vaccination has already been pointed out.
From September 1 to December 31, 1911, 2,574
notices were issued for the primary vaccination of
infants. Of these 1,564 had been complied with up
to December 31.
There were 3 deaths among 27 vaccinated cases over
ten years, or a percentage death-rate of J1:1; also of
the 66 unvaccinated over ten years there were 28
deaths, or a percentage death-rate of 49-4. From this
we find the advantage of the vaccinated over the
unvaccinated as regards escape from death when
attacked by small-pox was 73:9.
Many children were primarily vaccinated during
the epidemie rather late after exposure to the infec-
tion. They, of course, got small-pox, though the
vaccination in some modified the disease. The
following case is interesting in this respect: A child
had three recent marks of vaccination on the left arm.
The top one was still in its scabby condition when
I saw it. The certificate of vaccination showed that
the vaccination was performed on December 17, and
the child was attacked on December 26 with small-
pox, the rash appearing as usual on the third day
(28th). Thus whilst primary vaccination, performed
on one incubating the disease, nine days before the
symptoms presented themselves, did not prevent the
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1914.
development of the disease, it was successful in
modifying the disease and saving the child's life, as
the child had only a very discrete form of the disease.
Many other instances of such late resort to vaccination
could be cited.
I attribute the present epidemic to the following
chief facts : (1) To the ignorance of the people leading
them to conceal cases; (2) to the worship of the
goddess of small-pox; (3) to the fact that the people
have not resorted generally to revaccination ; (4) to
the failure of a large number of primary vaccinations.
Whilst it is true that the small-pox virus can strike
at great distances—and in a congested city like that
of Lahore it has an easy action in this respect—yet
we must remember that this is only possible when
the community is susceptible—z.e., unprotected by
vaccination. As regards the first of the above reasons,
it is unfortunate that through ignorance the lowest
classes do not know that they should report cases and
that such reporting does not incur any risk to them.
Inquiry elicited that there had been cases of small-
pox in the city before I got information of the first
case, and later in my rounds many cases were dis-
covered which were never reported simply because
the people really did not know. It is true ignorance
of the law is no excuse, yet how can one prosecute
such ignorant people, who can neither write nor read
and who are dependent on their news and their duties
to custom and law, or what perhaps their neighbours
say? Again, through this same ignorance the majority
of the cases in December were only known from the
notifieation of the death. Is it then to be wondered
that with so many cases in existence the disease
spread as it did? Lastly, in going through the city
many children were found with recent marks of small-
pox, and on questioning them and taking down their
names and addresses it was found that many had been
unreported. As regards the second reason, I have
tried to find out what is the actual religious view
concerning this disease. I have not been satisfied
to the extent I wished, but so far I have learnt (I
give my information for what it may be worth) that
(a) about the eighth to tenth day of the disease a
certain amount of religious ceremony is observed with
friends; (b) that an affected person should not be
exposed to the air or public view and so the patient
is kept in the dark ; (c) that no vaccination should be
performed in the same room as the case; (d) that no
one with dark clothes should enter the room ; (e) that
by some it is regarded as inadvisable for the Health
Officer to see the case. If these views are correct,
and there are probably others, it is clear that one's
action is to a great extent limited. As regards the
third cause, it is to be regretted that revaccination
has been in such a deplorable state. To some extent
this is to be attributed to ignorance of the fact that
revaccination is as necessary to protect against small-
pox as primary vaccination. Though I am glad to
record the fact that the various notices issued with
a view to emphasize this fact has resulted in a resort
to revaccination by those willing to act on such
advice, yet I do not hesitate to state that, in my
opinion, the time has come when a law for the com-
pulsory revaccination of all children at 9 years of age
should be enacted. This point is one in which my
Oct. 1, 1914]
COLONIAL MEDICAL REPORTS.—LAHORE
MUNICIPALITY. 115
committee should move Government, and by it alone
can unnecessary epidemics of small-pox and loss of
life be avoided. Further, all Government clerks, &c.,
should only be employed as are revaccinated, as attacks
of this disease cause unnecessary absences from
work from an avoidable disease. With reference to
the fourth cause it was clearly demonstrated to me
that a very large number of children had not been
primarily vaccinated, and the result of this is clearly
shown where children under 10 years of age formed
the greater number to be affected and to die there-
from. This is highly to be regretted from an economic
point of view. Many children were stated to have
been vaccinated in infancy and yet showed no marks.
Granted that the truth was not told in many cases I
have no hesitation in stating that the manner in which
this was said convinced me that these simple people
told the simple truth. Others again likewise impressed
me of the truth of their statement that the vaccination
had been performed but had not taken. To what can
we attribute this insufficient primary vaccination and
its failures? To the former part of this question I
am of the opinion it is due to (a) that vaccinators in
the past have not been doing their duty; (b) that a
certain number of people have not resorted to primary
vaccination; (c) that a certain amount of bribery to
escape vaccination has probably existed; (d) that to
a slight extent people mistake plague inoculation and
vaecination ; and (e) that there is a belief that the
sahib vaccinates with one sort of lymph and the
Indian vaccinator with another. I cannot help re-
marking on this last because i& has actually been told
me, also because in my own visits to do house-to-
house vaccination I have not had the slightest diffi-
culty in getting vaccinations done so far as primary
vaccinations are concerned. Indeed one child actually
cried to get done, although she had been successfully
vaccinated and revaccinated. The only instance in
which primary vaccination was refused was that of
a child who had recently lost its mother. The aunt
who was looking after this child would not have the
child vaccinated because she herself, poor woman, had
recently losta child of herown. Although I promised
to supply good milk for the child for two months from
the best dairy in Lahore this woman said she was
prepared to die rather than have the child vaccinated.
This case, however, must be regarded as exceptional
and as due to a mixture of ignorance and grief from
her recent trouble. As regards revaccination there is
not opposition against it but rather a simple belief
that it is not necessary.
We have been painfully aware of the ravages of
this disease among the inhabitants of the city. Any-
one who has studied the death returns would think
that tuberculosis is a new disease for the city. This
cannot be so. It is only because an endeavour has
been made to find out the causes of death that the
number of tuberculosis cases have mounted up.
Personal observation in the city has shown me that
there were many cases of phthisis. I do not say we
have reached absolute accuracy in this respect—
that is impossible by the present system of death
registration and the absence of reliable investigators.
This disease and others can only be put upon a more
satisfactory statistical basis by getting rid of the
present illiterate moharrirs and substituting for them
some hospital assistants who have received some
medical education.
There are two types of the tubercle bacilli, viz.,
(1) human, (2) bovine. Both these types produce
tuberculosis in man. Thus the sputa of a phthisical
case is infectious to man. On its being dried the
bacilli are conveyed through the medium of the air,
i.e. it is inhaled. The conditions of ill-ventilated
and ill-lighted rooms, together with the moisture from
other immates in the room, are sufficient to afford an
excellent medium for propagation. The bovine type
causes tuberculosis to bovines, swine and to a lesser
degree to children and young adults. The danger
here lies through the ingestion of infected cow's meat,
milk and butter. The meat supply is under super-
vision and the danger of this is lessened. To the milk
supply we must ascribe a more important source of
danger. In the absence of a laboratory, however, we
cannot be certain to what actual extent this danger
does exist in the Lahore milk supply. One thing,
however, is certain, that the tubercle bacillus can
develop and pass through the excreta of a cow even
though that cow be not affected with tuberculosis.
This cowdung, therefore, is a matter for considera-
tion. I am rather of the opinion that more tuber-
eulosis is spread in India through cowdung and
cowdung eakes than through the medium of meat or
milk. This may appear at first a rather startling
statement to make, but our veterinary examinations
have shown that tuberculosis both in cows and
buffaloes is a rare disease. As my experience may
not be regarded as sufficient—though I could not
overlook what has been my personal observation—I
wrote round to the many veterinary authorities in
India to get their opinion on this point and found it
supported my own conclusions.
The milk may be a cause, but the milk is extremely
liable in its process of drawing from the teats, by the
dust in the cowshed, by the brushing of the sides of
the animal by the milker, and by its environment in
an atmosphere of cowdung particles to be infected
with the tubercle bacillus from cowdung. The other
reason why cowdung should be a greater cause than
the milk is that most Indians use heated milk, and
curdled milk is a common drink. Thus in a crowded
city like Lahore “ city " where cattle are too numer-
ously present in many insanitary places, where
cowdung cakes are permitted to be attached to any
wall, and where the light of the sun only enters for a
few hours or not at all, it is not, indeed, to be
wondered if a very large number of the people are
tuberculous, As it is a chronic disease and one in:
which the actual death-rate does not represent its
actual prevalence, it may be taken from me that it
is far more prevalent than our death-rates from
phthisis actually represent.
TUBERCULIN TREATMENT.
This cau be used (1) as a preventive, (2) as a cure.
Tt is with the former I am concerned chiefly, and it is
undersirable, in my opinion, to confuse its use for
these two purposes in the hands of one person or in
one institution. Further, success for the preventive
purpose is only attainable by attention to many
116
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1914.
important factors to which the physician at a dispen-
sary could have no time to attend to or inquire into.
Few people will go to a tuberculin dispensary situated
at any distance from the city, and what is wanted is
the allocation of funds for the Health Officer to use
“ tuberculin ” in such cases as he can after inquiries
from his death returns on people in such infected
houses, and to give it to such physicians who will
furnish him with the returns necessary. Lastly, I
cannot but add that skill and intelligence in its use
are important factors in success. At the same time,
we must remember, in India it will be an experiment,
and so the time is not ripe for any large provincial
dispensary which is likely to be a costly failure.
Considering our returns we find there have been
571 cases of phthisis during the year, of which 386
were among Mohammedans and 185 among Hindus.
Ward III gave the largest number of deaths, viz., 73,
and next to it come wards II and IV, which gave 53
and 46 deaths respectively. As was to be expected,
most of the deaths were recorded in September,
October, November and December—months when
the humidity rises and chances of chill are greater.
When we consider the age periods at which these
phthisis deaths occur we find that no less than 284 of
the 571 occurred between the ages of 15 and 35 years,
and of these 161 between 15 and 24 years, i.e., at ages
of the early bloom of manhood at which ages a com-
munity can least afford its death-rate.
IRRIGATION.
There can be little doubt that irrigation, as it
is practised in Lahore, must be regarded as an
important factor in the prevalence of mosquitoes.
As Lahore becomes more closely related to Lahore
Cantonments by the extension of buildings the danger,
some day, is likely to be more real than it is at
present, since the latter place has long been known
to be malarious, and we shall then have the varieties
of anopheles, there prevalent, invading us. There is
too much over-irrigation in the Civil Station due to
the absence of any definite regulated system and to
the kutcha channels. Most places are flooded rather
than irrigated. A system of payment by volume
would lessen the evil and would necessitate a regulated
system. For this purpose, therefore, it is to be
regretted the irrigation module is not introduced.
Yearly, too, some money might be spent on the
"provision of pucca inverts to the main irrigation
channels.
WaTER SUPPLY.
During the year a special note on the water supply
was submitted by me. The purification of our supply
on & simple and not costly method of mechanical
filtration, as by the Paterson filter, will give us the
requisite purification we want. A laboratory is
necessary to prove the quality of water from time
to time and test the guarantee of efficiency of the
filter. I consider the purification of our water supply
outstands in importance any other scheme.
QuiNINE DISTRIBUTION.
Quinine was again this year distributed among the
poor of the city. In all 106,400 tablets or 5,320
tubes of quinine were distributed. This year the
system was introduced of giving out tubes each
containing 20 tablets of 4 grains each or sufficient
for the treatment of a case of malaria. With each
tube was given a leaflet of instructions in the
vernacular of how to use quinine for an adult or a
child both for prevention and the treatment of malaria.
The people come readily for the quinine.
GENERAL.
From the report it will be seen that but for small-
pox the year has been a healthy one. The only thing
that will save us from a small-pox epidemic and its
results in future is a revaccination law. The death-
rate in comparison with past years and the averages
for past years tells its own tale of the improved
sanitary condition of the city and environments.
The city is now cleaner than it has ever been.
TABLE or METEOROLOGICAL DATA FOR LAHORE FOR 1911.
TEMPERATURE
Relative
Mean Mea ^ 2
Maximum Minimum yee Rainfall
January ... 65:9 48:3 ... 89 2:56
February 74:1 470 ... 76 017
March 76:2 547 ... "9 4:01
April 93:6 64:2 ... 50 0:38
May MOTD. .. 7449 2.297 0:58
June 106:3 ... 81-8 55 2-10
July 106:8 ... 831 58 114
August 104:6 83:9 ... 58 3:50
September 98:9 .5 TT n A 0:30
October ... 965 ... 643 .. 61 0:27
November 76:8 48-5 79 0:60
December 72:0 40:8 81 0:00
-
e
or
-
Oct. 15, 1914. COLONIAL MEDICAL REPORTS.—COLONY OF MAURITIUS.
117
Colonial Medical Reports.—No. 41.— Colony of Mauritius.
REPORT ON THE
MEDICAL AND HEALTH DEPARTMENT FOR 1911.
By R. DENMAN.
Director, Medical and Health Department.
Statistics OF POPULATION.
Tue civil population on December 31, 1911, as
estimated by the Registrar-General and based upon
the Census returns for 1911, with a total of 372,274,
shows that the estimate for last year was too high.
This error extends also to the birth and death-rates
given for 1910. Therefore comparison between the
two years is not possible.
The number of deaths was 12,204 against 12,485
in 1910 and 13,761 in 1909. The whole of this
reduction is more than accounted for by the fewer
number of deaths from plague in 1911. The deaths
for the two years, subtracting those from plague, were
as follows: 1910—11,935; 1911—12,173.
The death-rate was 33 per cent., that for the decen-
nial period 1901-1910 being 37:1 per cent. As I have
stated above this latter figure is not reliable owing
to the error made in calculating the total population.
As regards districts, Port Louis, as usual, gives the
highest, 43 per cent., followed by Black River 38:8,
Grand Port 36:6, Flaeq 34:6, and Pamplemousses
33:0. Plaines Wilhems is lowest with a still too high
rate of 25:8 per cent.
14,584 children were born during the year, giving
a birth-rate of 39:4 per cent., or nearly 4 per cent.
above the decennial average. Riviére du Rempart
again heads the list this year with a birth-rate of
43:9 per cent. Pamplemousses is lowest with 36:1
per cent.
The disease that caused most deaths was malaria—
4,313 deaths being attributed to this disease alone, i.e.,
more than one-third of the total. This figure is not
reliable; “ la fièvre” is a common and easy diagnosis,
and is the cause of death usually given when the
registration is made by the friends of the deceased
and without a certificate from a medical man. The
next highest is pneumonia with 1,186, tuberculosis
836, and debility (ankylostomiasis ?) 802. Adding
the deaths caused by these diseases and subtracting
their sum from the total deaths, we find that 58-5 per
cent. of the people who die in Mauritius die from
diseases that are now looked upon as preventible
ones, and that with proper sanitary precautions it
should be possible to reduce the death-rate of the
Island considerably. As I have said above, the figures
for malaria are not reliable, but considering the
weakening of resisting power caused by repeated
attacks of malaria, we may take it as certain that
though many of the deaths recorded as due to malaria
were not immediately due to that disease, the possi-
bility is that they would not have occurred if the
patient had not been weakened previously by several
attacks of fever during his life.
METEOROLOGICAL STATISTICS.
According to the Director of the Observatory, the
year was characterized by an unusually low average
temperature. The years compare thus :—
Solar max. Grass min. Shade max. Shade min. Rain
1910 '4 s. 401 .. 902 .. 58°61 38:79
1911 150:6 54:1 87:5 61:8 46-28
Twenty-five inches of rain fell in February and
March. The last six months only had 6:56 in.
between them. These are the figures for the Observa-
tory, but the drought of the last six months was equally
felt all over the Island. According to the hospital
returns (the only reliable ones) the malaria curve
followed the rain curve, most fever cases occurring
in the hot months and the fewest in the dry cool
ones—July, August, and September.
PREVALENCE OF SICKNESS AND RECURRENCE OF
PARTICULAR DISEASES.
The usual returns are taken as the basis for this
report. The number of patients admitted to the
various hospitals and asylums in 1911 was 18,074
compared with 18,128 in 1910. 6,783 were treated
as out-patients at these institutions, and 62,384
attended the dispensaries.
Malaria and Hypertrophy of the Spleen.—-2,117 cases
were treated in the hospitals with a death-rate of
0:89 per cent., an increase of 0-01 per cent. over last
year. Splenic hypertrophy fell still further from 561
to 380, showing that malaria is on the decrease.
Dysentery.—566 cases with a mortality of 12:54 per
cent.; a slight decrease in the number and death-
rate of 1910, when the figures were 575 and 13:9 per
cent. respectively.
Enteric Fever.—53 cases were treated in the
various hospitals against 48 in 1910 and 77 in
1909. The death-rate was 22:6 per cent. The total
number of cases notified in the Colony, including the
above, was 182, with a case-mortality of 18:1 per
cent. The diagnoses in most, if not all, of these
cases were verified by Widal's reaction.
Diphtheria.—10 cases were admitted to the hos-
pitals with 4 deaths. There were 28 cases in all with
& mortality of 25 per cent.
Influenza.—1,610 cases, 300 less than last year,
were admitted.
118
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1914.
Pneumonia.—598 cases were admitted to the hos-
pitals during the year with a mortality of 24:5 per
cent. As I have stated above 1,186 deaths occurred
from this disease alone. It was very prevalent among
the estate coolies, especially towards the end of the
year. As the disease took on a quasi-epidemic form
I was at one time inclined to suspect plague. Care-
ful examination of the sputum showed absence of the
plague bacillus and proved that they were cases of
ordinary pneumonia.
Tuberculosis.— This disease appears to be on the
increase and demands more attention. 954 people
were admitted to the hospitals with it and its pre-
valence is shown by the fact that 836 deaths were
due to it alone. It was stated to be the cause of
death in one case out of every fifteen.
Cerebrospinal Meningitis.—No cases were admitted
to the hospitals during the year, but there were 9
deaths in the Island from this disease against 7 in
1910.
Beriberi.—Eleveu cases with 3 deaths were under
treatment during the year. Some cases of “ epidemic
dropsy” resembling beriberi were reported: they
were limited to one family.
Nephritis.—The increase in the number of admis-
sions for this disease was maintained. The figures
for 1910 aud 1911 were 576 and 631 respectively.
- Syphilis.—It is regrettable to be obliged to report
a still further increase in this disease, no fewer than 767
persons having presented themselves at the hospitals
for treatment as in-patients and 9 as out-patients,
whilst 768 were treated at the various dispensaries.
In 1904 the cases treated at the hospitals were only
352 out of an estimated population of 378,745, whilst
this year, with a population of 372,274, the number
has risen to 767.
Leprosy.—No cases were treated at the hospitals
during the year. One hundred and fifty-six people
were treated at St. Lazare. Of these 82 belong to
the general population and 74 are Indians. Thirty-
six were discharged and 25 died, leaving 95 in the
asylum at the end of the year. This does not
represent anything like the number of lepers in
the Colony, and until some method for the regis-
tration of lepers be adopted all reports on the
disease must be confined to those patients treated
at the St. Lazare Asylum. Iam indebted to the Poor
Law Commissioner, in whose charge the asylum is,
for the figures given above.
Erysipelas.—63 cases of this disease were notified
during the year; a reduction of 20, the number
notified in 1910 being 73.
Measles and Scarlet Fever.—92 cases of each of
these.diseases were notified during 1911.
Mental Diseases.—133 cases were admitted to the
Beau Bassin Lunatic Asylum during 1911; 77 of
these were new cases and 56 re-admissions. The
total number of inmates on December 31, 1911, were
456, being 40.in excess of those in the wards on the
same date in 1910. The daily average amounted
to 430:9.
There were 25 criminal lunaties, viz., 21 males
and 4 females, 3 more than during the previous year.
In only 70 of the admitted cases could the absolute
cause of the mental trouble be diagnosed. In all
cases the old sources were found, ganjah smoking
and heredity being the two most common ones.
Seventy-one patients were discharged, the per-
centage of cures being 45:8 to the admissions and
14:4 to the daily average, both figures being consider-
ably lower than in 1910. There are altogether con-
fined and on probation 660 certified lunatics in
Mauritius, viz., 406 males and 254 females. The
ratio to the total population is 1 to 564, the insane
rate of the total population being 3:03 per 1,000.
The Indians, as usual, have a lower rate, viz., 1:21
per 1,000.
Plague.—194 cases were treated in the general
hospitals and 36 in the lazarets against 77 and 243 in
1910. The end of the 1910-1911 outbreak was severe
and abrupt, 86 cases occurring in January, 1911, 22 in
February, 5 in March, and 6 in April, the last case
being declared on the 20th. The next cases reported
were in June (two), and then one on August 27, but
the 1911-1912 outbreak was delayed really until the
end of September, when isolated cases began to crop
up, and up to December 31 only 51 more cases were
reported, making the total for the twelve months 173.
Of these 131 died, giving a death-rate of 75:7.
A short and sharp outbreak attacking 19 people and
kiling 18 appeared in the town of Rose Hill in
November. The first patient came from Port Louis
and was declared on the 18th. Owing to insanitary
surroundings the disease spread rapidly and it was
decided to evacuate and demolish the block of build-
ings infected. This was done with the result that the
last case was declared on December 11, and Rose Hill
has been free from plague up to this.
Out of the 173 cases 36 were on sugar estates.
Race Incidence has increased among the white
population from 1:18 to 2:3, the non-white from
29-1 to 29:5, and amongst the Chinese from 27 to
11:0. It has decreased among the Indians from 66:3
to 57:2.
Age Incidence.— As usual the younger portion of
the community suffered most. Sixty-seven per cent.
of the attacks occurred in those under 30. This
constant drain on the reproducing part of the
population probably accounts in some measure for
the decrease in the total population shown in the last
Census. As regards sex the percentage of attacks
was, amongst males 66:5 and females 33:5 per cent.,
the death-rates, however, being reversed, viz., males
72:2 and females 82:8. per cent.
As regards type, bubonic was the commonest and
femoral buboes were the most numerous and least
fatal. Other types, viz., abubonie, pneumonic and
septicemic, existed in 18 instances and were fatal
in every case.
One thousand six hundred and seventy-three
premises, containing 25,226 rooms, were disin-
fected in Port Louis during the year, leading to
the discovery of 1,195 dead rats and mice, and the
bodies of 32 cats and 70,692 rodents were destroyed
during the year—only 60 of these were brought in by
private parties.
In the country districts 23,258 -rodents were
destroyed by cur rat-catchers and 2,590 were brought
into the police station at Rose Hill. 21,485 of these
animals were examined for plague bacilli, representing
Oct. 15, 1914]
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
119
36:7 per cent. of those caught in Port Louis. The
percentage of infection was 0:66.
The Grand River N.W. Lazaret was used for
36 patients during the year, the only other lazaret
used being the one at Poudre d’Or. Subtracting
those cases that were admitted in a moribund state
the death-rate at this lazaret works out at 32 per
cent. The estate hospitals come next with 59 per
cent., private cases 70:6, and the Civil Hospital 73:5,
the high figures in the last two items being because
most of the private cases are notified after death
and those that go to the Civil Hospital go there
in a dying condition.
Surra.—51 animals are reported to have died from
surra during the year, the figures for the last five years
being :—
1907 1908 1909 1910 1911
306 192 158 50 51
The reduction probably means that most of the
susceptible animals have been inoculated, had the
disease, have recovered from it and are now immune.
The year under consideration has been noticeable
chiefly for the decrease in the number of plague cases.
Excluding this one disease, as I have pointed out else-
where, the total number of deaths is higher than that
of 1910. Malaria is distinctly on the decrease, but
many other communicable diseases are increasing—
notably tubercle and syphilis. Pneumonia with 1,186
deaths is largely responsible for the high total. The
number of inmates of the Leper Asylum is diminishing,
but I do not think that this disease is disappearing.
Means for registering existing cases are necessary
and more perfect supervision is required. Lunacy,
especially among the non-white general population,
is more common than it should be. The cause I
attribute to poverty, drink, ganjah and heredity.
VACCINATION.
Eleven thousand two hundred and ninety children
were vaccinated in 1911, an increase of 878 over
1910. Of these 11,090 vaccinations were successful,
68 were unsuccessful, and the rest were lost
sight of. The proportion of successes to failures
was 98:2 per cent. and the proportion of children
vaccinated to those born was 77 per cent., a com-
paratively small proportion when we come to consider
that this is our only protection against small-pox
and that compulsory re-vaccination is not enforced.
Colonial Medical Reports.—No. 42.—Municipality of Colombo.
MEDICAL REPORT FOR 1911.
By W. MARSHALL PHILIP.
Medical Officer of Health.
1.—INTROoDUCTION.
THE mean temperature of the air during the year
1911 was much the same as the average; but there
was, for the ninth year in succession, a great shortage
of rain recorded, amounting to 24:06 in.
The most noteworthy event of the year was the
taking of the Decennial Census upon the night of
March 10, 1911, when a population of 212,295 was
disclosed, representing the remarkable intercensual
increase of 36:02 per cent. This great increase has
had a most important bearing upon the health of the
town. .
The birth-rate during 1911 was higher than the
average, but owing to the large number of children
of Colombo parents who are born and registered in
distriets outside the town, the birth-rate as recorded
does not afford a true measure of the fertility of the
population, which is undoubtedly great in the case of
the Burghers and the Sinhalese.
The general death-rate during 1911 was rather
above the average, owing to an inereased mortality
amongst Malays, Sinhalese, Burghers, and Tamils.
There was, on the other hand, a reduction in the
mortality amongst Europeans, ‘‘ Others," and Moors.
The increase in the death-rate was confined to two
wards, viz., St. Paul’s and San Sebastian, all the
other wards having a lower rate than the average.
Amongst the principal causes of death, pneumonia
and enteric were the only ones which showed an
increase; but in the case of enteric, the apparent
increase was more than counterbalanced by the
decrease in the number of deaths ascribed to simple
continued and remittent fever, both of which terms
are being to a large extent abandoned by the medical
profession, who now, as the result of improved
methods of diagnosis, prefer to apply the more specific
term of enteric fever. The only exception to this is
in the case of the Malays, a large proportion of whose
deaths from fevers continue to be returned under the
unscientific headings of simple continued and remit-
tent fever. There appears to be little doubt that,
although the Malays have apparently one of. the
lowest death-rates from enteric, they in reality suffer
more from this disease than any other race except
120
the Europeans. The steadily increasing and now
very high mortality from pneumonia is a serious
matter, more especially as it is a difficult disease to
deal with. Its increased prevalence is probably asso-
ciated in some measure with the climatic conditions
which have prevailed.
The mortality from phthisis has shown a note-
worthy improvement during the last two years, which
is very encouraging in regard to the preventive
measures which have been adopted during that period.
The infant mortality, which has been improving so
steadily for a series of years, was higher than the
record low rate of 1910, but was still 22 per 1,000
below the average. The defect in the registration of
births referred to above has the effect of making the
infant death-rate here appear higher than it probably
is in reality.
There was a considerable increase in the number
of infectious diseases notified and dealt with during
1911 compared with the previous year, which was
in a large measure due to phthisis having been made
a compulsorily notifiable disease, and to an improve-
ment in the diagnosis and notification of enteric fever.
There were nineteen cases of cholera and thirty-six of
small-pox reported from the town during the year,
the original infection of each disease having been
imported, as usual, from India, via the Ragama camp
in the case of the cholera and via Tondi in the case
of the small-pox.
The housing problem in Colombo has become very
acute, both as regards the insufficiency of accom-
modation and as regards the existence of unhealthy
areas and unhealthy dwellings, and it is urgently
necessary that something should be done to improve
matters.
The question of the purity of the food supply
in Colombo is one which has long been crying for
better attention, and it is recommended that the
Council should give this matter immediate consid-
eration. Proper food laws are much required.
The admittedly poor quality of the bread in
Colombo is said to be due to the use of inferior
flour, and the bakers assert that their customers will
not pay the price which the use of Trieste flour
renders necessary. The question of improving the
quality of the tinned foods imported into the Island
requires attention.
There has been quite a remarkable improvement
in the matter of milk adulteration during the last
few years as the result of the action taken by the
Public Health Department, the percentage of adulter-
ated samples having dropped from 73 per cent. of
the samples examined in 1907 to 17 per cent. of
those examined in 1911.
The question of improving the quality of the town
water by filtration before distribution has been under
consideration for some time, and the installation of
the Jewell system has been recommended. The
polluted state of the wells in Colombo, particularly
the large publie bathing wells, is & matter which,
although important, cannot be properly dealt with
until there is a sufficient supply of town water perma-
nently available to justify closing these wells and
substituting town water.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1914.
The state of the publie markets remains highly
unsatisfactory. The dairies have been improved,
but are most difficult to maintain in a sauitary
condition. The laundry trade is in à most unsatis-
factory state.
2. —M ETEOROLOGY.
The mean temperature for the year was 80:8? F., the
average for forty-two years being 80:7? F. The total
rainfall for the year was 58:26 in., which is 24:06 in.
below the average.
3.— POPULATION.
The extraordinary increase in the population has
a most important bearing upon the health of the
town, but this is a point which cannot be fully
considered until the report of the Superintendent of
Census, with its attached data, has been published.
The total number of occupied houses at the time
of the 1910 Census was 27,268, which had increased
to 38,667 at the time of the recent Census, the largest
increases being in St. Paul’s, Maradana, and Kol-
lupitiya Wards. It is possible that the system of
enumeration of houses differed at the two periods,
and that these figures are not really comparable.
One point stands out clear, however, and that is that
the erection of new houses has not kept pace with
the increase of the population, all classes of which
are at present keenly feeling the insufficiency of
house accommodation.
4.—Brirrus.
During the year 1911 there were 5,280 births
registered in Colombo, representing a ratio of 247
per 1,000 living, as against the average of 23:1 for
the preceding ten years, an increase of 1:6 per 1,000 ;
623, or 11:8 per cent., of those births were attended
by the Municipal midwives.
That the births recorded in Colombo are far short
of being a complete statement of the children born of
Colombo parents would appear to be beyond all
question, for not only is it well known that an ancient
custom prevails amongst most of the indigenous races,
whereby prospective mothers migrate prior to their
confinement to the homes of their parents, which are
in many instances situated outside the town, but a
comparison of the birth-rates of the several races in
Colombo with those of the same races in the Island
generally shows that the Colombo rates, as recorded,
cannot possibly be accepted as a true measure of the
fertility of the Colombo population. The direct effect
of the migration referred to is to make the infant
death-rate appear much larger tban it really is,
because a large proportion of these children are
brought to Colombo after the mother has sufliciently
recovered, and help to swell the unregistered (in
Colombo) part of the infant population, and to con-
tribute towards the infant death-rate, which is
reckoned upon the population of the infants registered
in Colombo only.
121
Colonial Medical Reports.—No. 42.—Municipality of
Colombo (continued. )
5.—DkaTHS.
During the year 1911 there were 7,234 deaths
(inclusive of deaths of non-residents) registered in
Colombo, representing a ratio of 33:8 per 1,000 living,
as against the average of 33:0 during the preceding
ten years, an increase of 0:8 per 1,000; 631 of these
were deaths of non-residents of Colombo who died in
the hospitals, the death-rate (exclusive of non-resi-
dents) being only 30:9 per 1,000. Further corrected
for age and sex constitution the death-rate was 35:5
per 1,000.
Deaths by Races.
The Malays had the highest death-rate during the
year, viz., 40:1 per 1,000, next come the Sinhalese
(37-1), then the Tamils (33-4), then Moors (29:2),
then Europeans (28-3), then Burghers (27:3), and
lastly the “Others,” who had the unusually low
death-rate for them of 27:3 per 1,000. The rates of
the Europeans, Tamils, and ** Others” are, however,
much affected by fluctuations in their populations, `
and are not therefore very reliable. Comparing these
rates with the average of the preceding ten years, it
is found that the mortality amongst ** Others" was
7:6 per 1,000 below their average, amongst Europeans
it was 1:3 below their average, and amongst Moors it
was 0°5 below their average. The rates of all the
other races were above their average.
It is necessary to bear in mind, when considering
these death-rates, that some of them are seriously
affected by the deaths in hospitals of non-residents
in Colombo.
6.—INrawT MORTALITY.
Deaths, 1,669; death-rate per 1,000 recorded
births, 316; average rate for preceding ten years,
338 ; decrease, 22 per 1,000.
The infant death-rate in Colombo is probably not
so high as it appears, for the following reason. It
is reckoned as a proportion to the infant population
as represented by the number of births registered in
Colombo during the year. If, therefore, any of the
births escape registration in Colombo during the
year, the death-rate will be reckoned on a population
smaller than the actual, and will consequently be
made to appear higher than it really is. This is
actually happening in Colombo, for it is known that
it is the custom amongst the indigenous races for
women to repair prior to their confinement to the
house of their parents, and as many of the Colombo
men are married to country women, many of the
men themselves hailing from the country originally,
it follows that a large number of children of Colombo
parents are born and registered in these extra urban
districts, their births being thus lost to Colombo;
and as such of these children as survive are brought
to Colombo, where their subsequent deaths are
registered, the effect is to make the infant mortality
appear higher than it really is. How far this custom
affects the infant death-rate it is impossible, with any
certainty, to say; but as a result of a rough esti-
mation, I make it that the infant death-rate, instead
of being about 300, is probably nearer 200 per 1,000
births.
The average infant death-rate for each race in 1911
and for each race during the four years 1908-1911, in
respect of which records for the individual races are
available, has been as follows :—
TAS Burgher Sina Tamil Moor Malay “Others'
Average, 1908-
1911 159 200 290 436 410 304 441
1911 182 218 286 413 493 291 408
The persistently high infant death-rates amongst
the Tamils, Moors, and “ Others" demand attention.
A large proportion of the Tamils, and many Moors,
being poor, are compelled to live in unhealthy areas,
such as exist in St. Paul's, New Bazaar, and San
Sebastian Wards, their infants being thereby exposed
to conditions which are invariably associated with a
high rate of mortality. The mothers are, moreover,
very ignorant and careless, and, especially in the case
of Tamils, have to work instead of attending to
their children. The great need in their case is that
sanitary dwellings should be provided for them at
a rental which they can afford to pay. This will
certainly not be done so long as it is left to the pro-
perty owners to carry out, for, the moment a better-
elass house or tenement is erected, even in an insani-
tary area, the rent is raised, and the house is thereby
placed beyond their means. In this connection
reference is requested to the section dealing with the
housing problem.
It is generally admitted that the infant mortality is
the best test of the sanitary condition of a district,
and the statistics in Colombo fully bear us out, as
Shown by the following statement, in which the infant
death-rate in each ward during 1911 and the average
for the preceding ten years are given.
7.—PULMONARY DISEASES.
Under this heading are included phthisis,
pneumonia, and bronchitis.
Deaths, 1,897 ; ratio, 8:24 ; average, 8:11 ; increase,
0:13 per 1,000.
Phthisis shows a decrease of 0:55 per 1,000, pneu-
monia an increase of 0:68, while bronchitis was the
same as the average.
(a) Phthisis.
The improvement in the death-rate from phthisis
which took place during 1910 was continued during
1911, the number of deaths recorded from this cause
being 634, representing a ratio of 2:96 per 1,000, of
which no less than 88 or 13:8 per cent. were deaths
in hospitals of non-residents of Colombo.
As in previous years, there was in 1911 an
extraordinarily high death-rate from phthisis amongst
Mohammedan women (Malays and Moors) compared
with the rates amongst the males of these races, and,
as has previously been pointed out, this is no doubt
in a large measure attributable to their peculiarly
insanitary custom whereby they keep their women
very much confined to their houses, which are often
badly lighted and ventilated. In the case of the
stricter Moors, the women are further deprived of the
benefits of fresh air and sunlight by their insanitary
custom of shutting themselves up in closed carriages,
or wearing heavy veils or cloths over their heads when
122
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 2, 1914.
they go out. It is high time that the more intelligent
of the Mohammedans turn their attention to this
matter. What is required is that their women should
have outdoor exercise, with plenty of fresh air and
sunlight; they should be taught that phthisis is an
infectious disease, aud that they should not go and
unnecessarily sit or sleep in the same room with a
patient suffering from this disease, and that those so
suffering should adopt precautions with a view to
preventing the spread of infection to others. A
female health visitor with a special knowledge of
phthisis could, I believe, do much good by teaching
these people, amongst whom the feeling of family
attachment is strongly developed.
In view of the m € ked improvement in the mortality
from phthisis which has occurred in the last two
years, and the fact that the increasing prevalence of
this disease in the Island generally has recently been
the subject of a Government Commission, it may be
of interest to state what are the preventive measures
now recognized to be necessary, and how far they
have been, or still require to be, adopted in Colombo.
Preventive Measures.— The measures which are
now recognized to be necessary for the prevention of
phthisis may be divided into the three following more
or less distinct groups: (a) direct preventive measures,
(b) indirect preventive measures, (c) relief and educa-
tional measures.
Direct Preventive Measures. — These include all
those which have for their object the prevention of
the spread of the virus of the disease from infected
to non-infected persons, and comprise such measures
as detection, notification, segregation, and disinfection.
Indirect Preventive Measures.—Under this heading
come general sanitary measures which have for their
object the prevention or removal of conditions which
tend to act as predisposing causes of the disease, such
as overcrowding, contamination of the atmosphere,
defective lighting and ventilation, dampness, &c.; in
other words, general sanitary measures. These
measures will include such works as drainage, paving,
dust prevention, cleansing, prevention of overcrowd-
ing, and improvement of unhealthy dwellings and
unhealthy areas, including re-housing of the poorer
classes displaced during the progress of improvement
schemes.
Relief and Educational Measures.—Under this
heading come the erection of sanatoria for the treat-
ment of early and, therefore, presumably curable
cases, providing suitable employment for those who,
although infected, are still capable of doing selected
work, organizing and distributing relief to the families
of bread winners who are incapacitated for work by
the disease, propagating knowledge in regard to the
causes, methods of prevention, and cure of the disease
by popular lectures, by teaohing in schools, and by
the distribution of literature on the subject.
Incidence of Control.—The carrying out of the
direct and indirect measures enumerated above is an
obligation which rests with, and can only be properly
discharged by, the authorities armed with legal
powers, and with sufficient staff and funds at their
disposal.
The organizing and carrying out of relief and
educational measures belongs more properly, at least
in the earlier stage, to the sphere of action of the
voluntary worker and philanthropist, and need not be
further considered here.
Preventive Measures adopted in Colombo.—Although
phthisis has for many years been a steadily increasing
aud, indeed, one of the principal causes of sickness
and deaths in Colombo, it was not until early in 1906
that this was recognized, as the result of working out
and tabulating the rates for a series of years from all
the principal causes of deaths.
At that time, however, and for some time subse-
quently, the attention of the public, and consequently
of the Council and its Public Health Department,
was much occupied by enteric fever, which, although
not nearly such a prevalent disease amongst the
population as a whole as phthisis, is much more
dramatic in its operations, and strikes, as a rule, the
European population more severely than any other
race here.
The prevention of phthisis in common with other
causes of deaths was, however, not neglected, as this
department was constantly engaged in carrying out
general sanitary measures, such as checking over-
crowding, improving the lighting, ventilation, and
drainage of dwellings, teaching the cult of the open
window, cleansing of premises, and such like, all of
which act as indirect preventive measures.
Here it is necessary to point out that the Council
have as yet neither the legal power to enforce
segregation of cases, no matter how dangerously
infectious they may be, nor, even if they had such
power, have they a hospital in which they could
isolate them. It is impossible, therefore, for the
present to do more than strive to improve the methods
now being carried out.
Indirect Preventive Measures.— One has seen it
stated that of all zymotic diseases phthisis has shown
the least tendency to diminution from general sanitary
measures. This is no doubt true as a general state-
ment ; but where, asin Colombo at present, practically
every principle of sanitation is violated, particularly
as regards the insanitary construction and disposition
of dwellings, the irrepressible tendency towards over-
crowding, the lack of proper means of drainage and
disposal of waste, the almost entire absence of
measures for the occlusion of damp in a climate with
an average rainfall of 82°32 inches per annum, and
the ignorance and indifference of the population as
regards sanitary measures generally; under such
circumstances there can be no doubt that the problem
of phthisis prevention in Colombo is intimately
associated with, and to a considerable extent
dependent upon, the carrying out of the indirect
preventive measures enumerated above, and that no
scheme for the prevention of this disease which omits
to provide for the carrying out of these measures
can be considered either complete or likely to be
really effective.
Drainage.— Although, as is known, many miles of
sewers have been laid, and the whole town will in
time be thus served, very few premises have so far
been drained (only 97 out of the estimated number
of 8,000 to 10,000 available at the end of 1911), and
consequently the sanitary condition of the town has
not yet appreciably benefited by this great work;
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
123
Nov. 2, 1914.]
indeed, on the contrary, it has in some respects
suffered in consequence of the breaking up of the
streets, the blocking of existing open side drains, and
such like, all of which are, of course, unavoidable
during the construction stage. Needless to say, the
benefit of the sewers can be reaped by the town at
large only after the connections have been made, and
it is therefore most necessary that, as the City
Sanitation Engineer has recently pointed out, if the
work of connection is to be completed within a
reasonable period, the present rate of progress must
be very considerably augmented.
Paving and Damp-proofing.—There is no legal power
to enforce paving of floors, backyards, or lanes, and
progress in this direction has therefore been very
difficult ; but, as the statement of structural improve-
ments included in each annual report shows, a con-
siderable number of dwellings, backyards, and passages
have been paved at the instance of this Department.
There is no legal power to require the provision of
damp-proof courses, and scarcely a house in Colombo
is so protected. Special powers are urgently required
in those respects.
Dust Prevention.—The practice of road oiling is
now being carried out by the Works Department on
a considerable scale, and has very materially reduced
the dust nuisance. It is, however, not so effective or
so lasting as paving, the initial cost of which, how-
ever, is heavy.
Public cleansing includes scavenging and the con-
servancy of latrines. As regards the scavenging, it
has been enormously improved since the contract
system was abolished, and the work was taken over
departmentally by the Works Department in 1905,
the latest and a most important improvement in this
connection being the establishment of a Horsfall
refuse destructor, with a view to replacing the old
and highly insanitary method of tipping.
The conservancy of latrines was taken over on
September 1, 1911, from the contractor, in view of
the unsatisfactory manner in which the work was
being performed by him, and already one sees signs
of great improvement; but the bucket system can
never, even with the most perfect management, be
anything but highly objectionable and insanitary in
a town of the size and with a population so careless
in these matters as exists in Colombo.
Private Cleansing.— The work of maintaining
private premises in a cleanly condition is one in
respect of which the householders are held responsible
under the Ordinance, and one of the principal tasks
of the sanitary inspectors consists in endeavouring to
keep them up to the mark.
Careless and obstinate although many of the house-
holders are, an enormous improvement has been
effected in the state in which private premises are
kept, as anyone who was acquainted with the back
compounds of Colombo, say ten years ago, and as
they are to-day, must recognize. The records of the
works engineer as regards the output of scavenging
rubbish are the best evidence on this subject.
Overcrowding.— Midnight inspections, with a view
to the detection and prevention of overerowding, have
for years been regularly carried out; but it is a hope-
less task so long as there is the present insufficiency
of house accommodation. The most that can be done
is to get the worst instances abated, aud this is as far
as possible being done.
(b) Pneumonia.
Deaths, 859; death-rate, 4-02 per 1,000; average
for the preceding ten years, 3:34; increase, 0:68 per
1,000. This death-rate has only twice been exceeded
during the decade 1901-1910, viz., in 1908 and 1909.
Forty-six, or 17 per cent., of the deaths from pneu-
monia in 1911 were of non-residents of Colombo who
died in the hospitals. This disease was the principal
cause of death amongst the population of Colombo
during 1911, being responsible for no less than 13
per cent. of the total deaths. It was the principal
cause of death amongst every race except the Euro-
peans. As regards the cause of this disease, all
authorities are agreed that it is an infectious disease;
but there is a divergence of opinion on the extent to
which it is preventible. Parkes and Kentwood, for
example, state that ** so far as has been ascertained,
neither meteorological nor insanitary conditions
appear to exercise any marked influence in the epi-
demic prevalence of pneumonia.” Osler states that
in America it has shown a decided increase, and in
some places, e.g., in Chicago, it has gradually replaced
phthisis as the principal cause of death. He records
the fact that in America it is more fatal amongst
coloured than amongst the white people, au observa-
tion which equally applies to Ceylon. It is more
common in cities, and individuals who are much
exposed to hardship and cold are particularly liable to
it, e.g., the Tamils and '' Others," whilst debilitating
causes of all sorts render individuals more susceptible,
alcoholism being a particularly predisposing factor.
Notter and Firth state that “insanitary conditions,
especially filth, overcrowding, and want of ventilation
act apparently as powerful, though not indispensable,
predisposing causes." It is difficult to see what can
be done to check the spread of this disease here
beyond improving the general sanitary conditions of
the town, as jindicated in the sections dealing with
housing and phthisis prevention.
(c) Bronchitis.
Deaths, 270; death-rate, 1:26 per 1,000; average
for preceding ten years, 1:26 ; increase, nil.
8.—DianRHGaAL DISEASES.
Deaths, 959; death-rate, 4:57 per 1,000; average
for preceding ten years, 9:08; decrease, 1:41 per
1,000.
This group includes diarrhoea and enteritis (which
are for all practical purposes synonymous) and
dysentery.
One of the most noteworthy points in regard to
the mortality from this group is the great preference
which practitioners have of late years shown for the
term “enteritis” rather than that of ‘“ diarrhoea.”
The two terms are for all practical purposes synony-
mous; but whereas ten or fifteen years ago nearly all
these cases were returned as diarrhea, they are now
mostly being returned under the heading of “enteritis.”
During 1901, for example, out of a total of 681 deaths
returned under those two headings, the proportions
124
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 2, 1914.
were diarrhcea 669 deaths, enteritis 12 deaths, where-
as in 1911, out of a total of 696 deaths, the propor-
tions were enteritis 520 deaths and diarrhoea 176
deaths.
(a) Diarrhea and Enteritis.
The persistently high death-rate from this cause
amongst the Tamils is noteworthy. No doubt poverty
and exposure to hardships of the large Tamil beggar
population has a good deal to do with this, as in the
case of pneumonia; the consumption of contaminated
and unwholesome food is an important factor in the
causation of this disease.
(b) Dysentery.
Deaths, 263; death-rate, 1:32; average, 2-07; de-
crease 0°75 per 1,000. The mortality from this cause,
alihough slightly higher than in 1910, has greatly
decreased.
The Europeans, as usual, were the heaviest sufferers
from this disease, dysentery and enteric fever being
the two diseases from which they suffer more than
any other cause.
9.—FEVERS.
Deaths, 490; death-rate, 2:909 per 1,000; average
for preceding ten years, 2°46; decrease 0:17. Of the
total deaths registered from fevers 58, or 11:8 per
cent., were deaths of non-residents of Colombo which
occurred in hospitals. In other cases reported from
the town no doubt the infection was acquired outside,
but developed in or was brought to and reported as
from Colombo, just as no doubt in some cases persons
infected in the town died in the country. The head-
ing ‘‘ Fevers” includes enteric, simple continued,
remittent, and intermittent fever. :
Intermittent fever (malaria), which used to appear
in the returns as a cause of death, has completely
disappeared, there having been no deaths ascribed to
that cause during 1911. Remittent fever (malaria)
has also to a large extent disappeared from the returns.
This bears out what I have frequently remarked, that
there appears to be very little primary malaria in
Colombo. One sometimes hears it stated that “ seven-
day fever," of which there has recently been a great
deal in Colombo, is a form of malaria, but there is no
evidence at present so far as I can gather in support
of this.
(a) Enteric Fever.
Cases reported, 1,149; deaths registered, 396;
death-rate, 1:85 per 1,000; average death-rate for
preceding ten years, 1:18: increase, 0°67; case-rate
per 1,000 living, 5/70; case mortality, 38:9 per cent.
Eight hundred and eighty enteric-infected houses
were disinfected and 185 filthy compounds were
cleansed, while 354 cases with a mortality of 21-7 per
cent. were treated in the enteric hospital.
The case mortality for the town quoted above, viz.,
38:9 per cent., clearly indicates that many non-fatal
cases must have escaped recognition and notification,
for the true case mortality in Colombo is almost
certainly not more, and is very probably less, than
12 per cent. The Europeans, who suffer from this
disease more severely than any other race, and
amongst whom diagnosis and notification of mild
cases are no doubt more accurate and complete than in
any other race, had a case mortality in 1911 of 12-9
per cent. Probably a large number of the unrecog-
nized mild cases occur amongst children.
There can be no doubt that the enteric rates for
most of the indigenous races, but especially for the
Malays, are far from correct.
Owing to the infection being so widely implanted
here, the possible sources are so numerous, and the
channels whereby it may gain access are so obscure
and devious, that it is impossible to state with any
degree of certainty which are the most usual. There
are, however, one or two so well known and so
obvious that they may with certainty be specified.
(1) Direct Contact with an Infected Case.—This
would include contact, not only with those known to
be suffering from the disease, but also with uprecog-
nized cases, and with carriers. The latter two are
the most dangerous by reason of their true nature
being concealed, the result being that no precautions
are adopted.
It is a source which is not by any means confined
to the poorer classes, several instances having occurred
amongst the well-to-do and educated classes, in which
there was more than a suspicion that infection had
been acquired by direct contact with an infected
relation or friend. Noone should be allowed to leave
the room of an enteric patient, whether at home or
in the hospital, without washing and disinfecting
their hands.
(2) Infection from Latrines.—Infection may be
acquired in this manner either by direct contact with
the infected matter in the latrine, or through the
agency of flies which have visited the latrine for the
purpose of laying eggs. The latter is, I believe, one
of the most fruitful sources of infection in Colombo.
It is a source which can only be effectively prevented
by the abolition of the bucket latrine and the institu-
tion of the water-carriage system instead.
The extraordinary indifference and carelessness of
even educated householders in the matter of these
latrines may be gathered from the fact that during
a recent inspection of most of the houses in the
Cinnamon Gardens, although the house latrines were
all right, in only five out of a total of 225 premises
visited was it found that any sort of covering was
used for the contents of the buckets in the servants’
latrines, most of which, be it noted, are situated
within a few paces of the back veranda and of the
house kitchen. It is no wonder, under such circum-
stances, that when the fly season comes round enteric
fever breaks out every now and then and spreads
amongst these houses.
It is of interest in this connection to note that out
of 900 cases of enteric investigated last year, in no
less than 801, or 89 per cent., there were badly kept
bucket latrines on the premises.
(3) Milk.—Contaminated milk is a probable source
of infection in some cases, especially where, as in
Colombo, the milk is known to be frequently adul-
terated. There has, however, been an extraordinary
improvement during the last few years in the matter
of milk adulteration.
Nov. 16, 1914.]
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
125
Colonial Medical Reports.—No. 42.—Municipality of
Colombo (continued.)
Epidemics caused by milk have, as a rule, certain
definite characteristies, none of which have been met
with here during recent years. The only conclusion
one can draw from these facts is that, if the informa-
tion supplied is correct, although milk is a possible
source, especially if used unpasteurized or unboiled,
it is not, as matters stand, a very common source of
enteric in Colombo. On the other hand, as the result
of a good many years’ experience here in the matter
of collecting information, the replies given to the
sub-inspectors as to the use of milk are by no means
reliable, and therefore one must keep an open mind
in regard to the degree in which milk is a source of
infection here, and must omit no precaution in this
respect.
(4) Water.—Another possible source of infection is
through contaminated water, e.g., foul wells and
bathing places. How far infected water from wells
and such like is a source of infection here it is impos-
sible to say, but the town water has been shown by
repeated examinations to be above suspicion.
(5) Dust.—Infeeted dust is a possible, but.a prob-
ably extremely rare, source of infection.
(6) Indirect Contact.— This may be a source of
infection by handling infected clothes, &c., but, erude
although the dhobie's methods are, I do not think
‘he probably often is responsible for the spread of
. enteric.
In conclusion, the chief sourees of infeotion by
enteric here are probably direct contact and badly
kept bucket latrines. The former can best be met
by segregating all cases in hospitals, the latrine source
ean only probably be dealt with by the abolition of
‘tbe bucket system and the introduction of the water-
earriage system, pending which householders must
protect themselves and their neighbours by using
coir dust in their latrines, fly-proofing their kitchens
and latrines, boiling milk, covering up food, and sueh
like.
As it will be many years at the present rate of
progress before the water-carriage will have com-
pletely displaced the bucket system, it behoves those
who are specially susceptible, e.g., newly arrived
Europeans, to further protect themselves by being
inoculated against enteric. In view of the remarkable
results which have been obtained in India and else-
where by this method, it strikes one as little short of
folly not to take advantage of it. It is sueh & trivial
operation, less painful as a rule than vaccination. I
think firms who are responsible for the importation
‘of young Europeans should insist in every instance
upon their being inoculated prior to leaving England.
' Such a policy would probably save æ lot of incon-
venience and money, not to speak of young lives, so
many of which this disease has been responsible for
cutting off in the past.
. E have already recommended that the Council
should adopt such a policy in regard to its own
employees, and I understand the suggestion has been
favourably received.
(b) Simple Continued Fever.
Deaths, 45; death-rate, 0-21 per 1,000; average
rate for preceding ten years, 0:58; decrease, 0:37;
cases notified, 71. It is impossible to say what the
true cause of the 45. deaths ascribed to simple con-
tinued fever was; some of them were probably enteric
fever.
(c) Remittent Fever. !
Deaths, 49; death-rate, 0'23 per 1,000; average
rate for preceding ten years, 0°69; decrease, 0°23.
A quarter of these deaths were in Slave Island, no
fewer than eight of them being amongst Malays.
When it is considered that whereas the term ‘‘ remit-
tent fever" as commonly used implies malaria, and
that Slave Island, where most of the Malays live, is
distinctly a non-malarious district, it is a significant
fact that the Malays should be the only race which
continues to have a high mortality ascribed to this
cause. There can be little doubt that these deaths
were in reality due to causes other than malaria,
many of them being probably due to enteric fever.
(d) Intermittent Fever. 3
This has entirely disappeared from the returns
& cause of death. The great reduction in the
mortality ascribed to remittent fever, and the entire
disappearance of intermittent fever from the returns,
bear out what has been previously. maintained, that
except for small oceasional outbreaks on the out-
skirts of the town, there is practically no primary
malarial infection in Colombo.
(e) Seven-day Fever.
Although this is not a notifiable disease, inquiries
show that there have of late been a good many cases
in Colombo. Its specific cause has not yet been
ascertained; but there appears to be a growing sus-
picion that it may be spread by the bite of & mosquito.
Whether this is so, whether the virus is ingested, or
gains access in some other way, has not yet been
ascertained.
10.—Inrectious DISEASES: NOTIFICATION.
(a) General.
The notifiable infectious diseases are plague, cholera,
smallpox, chickenpox, measles, scarlet fever, diph-
theria, acute or choleraic diarrhoea, enteric feyer,
simple continued fever of seven days’ duration or
over, and, sinee January 1, 1910, phthisis.
(b) Cholera.
Nineteen cases were reported from the town and
two from the port; all proved fatal except two. In
twelve of the cases a bacteriological examination was
made with a positive result in each. The outbreak
commenced at Ragama camp, and spread from there
to the town, the first two cases which occurred in the
town having been employed as sweepers at the camp.
The town cases were spread over a period extending
from May 26 until July 27. All the cases except one
were males. The largest number of cases occurred
at the 20 to 25 age period.
(c) Smallpox.
Sixty-five cases were reported, of which 36 were
from the town, 20 from extra-urban districts, and 9
from the port. There were 8 deaths in all, repre-
196
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 16, 1914.
————————————————————M———M MH —M—————————M—————
senting a case-mortality of 12:3 per cent., which is a
‘low case-mortality, and indicates that the community
is fairly well vaccinated. The first infection was, a8
usual, imported from India, the patient having arrived
as a deck passenger via. Tondi, which was at that time
‘an open port, quarantine having been imposed in the
ease of only Tuticorin and Paumben. ‘
Vaccination.—17,325 vaccinations were performed
during the year, of which 8,310 were primary and
9,015 were secondary. As there were only 5,280
births registered during the year, the figures quoted
above include a number of primary vaccinations of
persons over one year of age; but a proportion of the
discrepancy is no doubt due to the vaccination of
children who, although born of Colombo parents, have
been born in districts outside the town, from whence
they have been brought into Colombo and been there
vaccinated. *
(d) Chicken-poz. |
There were 934 cases reported from the town, 71
from extra-urban districts, and 10 from the port.
‘One death was ascribed—probably erroneously—to
this cause.
t (e) Measles. :
There were 330 cases reported from the town, 17
from extra-urban districts, and 6 from the port. Four
deaths were ascribed to this cause.
(f) Diphtheria.
Twelve cases were reported from the town, there
being 4 deaths, representing a case mortality of 33:3
per cent., which is very high, and probably indi-
-cates that a number of mild non-fatal cases escaped
recognition and notification.
(g) Acute Diarrhea.
Nineteen cases were reported from the town. The
death returns do not discriminate between acute
diarrhoea and simple diarrhoea.
11.—Houvsine.
(a) General.
The problem of housing in Colombo is one which,
as the result of many years of legally uncontrolled
and consequently indiscriminate and insanitary erec-
tion of buildings, has now become so pressing that, in
the interests of public health, action can ro longer be
safely deferred. These remarks have refeie ice not to
the mere insufficiency of house accommodation, which
is being keenly felt by all classes, but to the question
of improving the existing and preventing the creation
`of new unhealthy areas and unhealthy dwellings,
which latter has been for years, and is now, ‘going on
‘go rapidly in Colombo, and is seriously affecting the
health, especially of the poorer and more numerous
section of the population. It is not, however, the
“health of only those residing within these unhealthy
areas which is affected, fot there being constant com-
munication between. the. quarters of the poor and
those of the well-to-do, through servants, tradesmen,
; &c., many of the diseases which are bred and fostered
"jn the poorer quarters—e.g:, enteric, phthisis, -&c.—
cannot be restrained within such limits, but make
excursions from there into the dwellings of the well-
to-do, whose death-rate is also thus maintained at a
‘higher level than it otherwise should be.
' For confirmation of this one has only to look at
-the death-rates of the various races in Colombo,
where it will be seen that the Europeans and Burghers,
“types of two classes who more than any other live
outside the unhealthy areas, have nevertheless had
‘average death-rates during the recent decade of 29-6
and 26:3 per 1,000 respectively—rates which, though
not so high as those of the poorer races, are higher
‘than they ought to be, and higher than they no doubt
would be if a large part of the poorer population were
not living in comparatively close proximity to them in
unhealthy areas. . Action taken, therefore, with a
"view to protecting the poorer classes from the evil
effects of living in unhealthy dwellings and unhealthy
areas would also have an effect in relieving the whole
population from a situation which has for many years
been steadily, and during recent years has been rapidly,
increasing in danger.
; (b) Unhealthy Areas.
- Although thé unhealthy dwelling is the unit of the
unhealthy area, and the two subjects are therefore
‘intimately associated, it is usual to deal with, them
separately, especially in the matter of legislation.
In Colombo there are no laws for dealing. with un-
healthy areas, and consequently practically nothing
nas been done to improve matters in that respect.
It is true that the widening of Churchyard Lane (now
Short's Road) and of Panchikawatta (now part of
Skinner's Road) has effected a local improvement in
these districts; but, as no provision was made for
re-housing the poor people so displaced, as required
'by all modern improvement schemes, these people
have merely been driven from one place to another,
which in turn they have helped to overcrowd and
render more unhealthy. The result cannot, therefore,
be considered a gain to the town as a whole from a
sanitary point of view. These road widepings have
benefited traffic more than sanitation, and were indeed
carried out primarily in the interests of traffic. :
Not only has practically nothing been done to
improve the existing unhealthy areas, but, owing to
the lack of control over the erection of new buildings,
the old unhealthy areas have been steadily increasing
both in size and number, particularly during recent
years, when something of the nature of a building
boom has been in progress.
The whole problem of housing must be carefully
considered, ways and means must be devised, and ‘a
regular programme must be drawn up and followed
out.
- It is my belief that the only practical way to effect
: this is to follow in the footsteps of places like Bombay
and Calcutta, and to create an Improvement Trust
for the city. The longer action in this matter is
deferred the greater will be the cost to the ratepayers.
(c) Unhealthy Dwellings.
This question, as will be seen, is intimately asso-
ciated with the question of unhealthy areas, which
are merely aggregates of unhealthy dwellings. There
:is a vast amount of improvement work urgently
Nov. 16, 1914.]
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
127
requiring -to be carried out in connection with
unhealthy dwellings, and it is in my opinion most
necessary that the staff of the Inspector of Private
Buildings should be increased.
(d) House Accommodation.
The rapid growth of the population of Colombo
during the recent decade, amounting to 36 per cent.,
has resulted in an insufficiency of house accom-
modation, which is being keenly felt by all classes.
The comparatively sudden increase in the prosperity
of the island during recent years has, as might be
expected, been particularly felt in Colombo. Firms
whose business has suddenly increased have had
rapidly to augment their staffs of assistants, clerks,
and servants of all kinds. The increased demand for
labour has in turn been responsible for an increase in
the rate of wages. This again has attracted people
to Colombo, not only from all parts of the island,
but also from India and elsewhere. Not only so,
but during the last few years an extraordinary
number of large public works. have been undertaken
in Colombo, which again have attracted large numbers
of pepple to the town. ^ e
The result of all this is a rather sudden and far
from healthy congestion of population, in conse-
quence of which house accommodation has become
more and more scarce, and rents have gone up, the
result being that every owner of a few feet of land
has been tempted to run up a building in the hope
of sharing in the increased prosperity. Many
obstructive buildings have thus been erected, which,
in the absence of proper building laws, the officers
of the Council have been powerless to prevent,
although they have done their best to do so. Another
effect of this rapid increase of population is that it
has encouraged what has now become an irrepressible
tendency towards overcrowding, especially in the
poorer quarters. All this development of property
would, if it had been controlled by proper, laws, have
greatly improved the condition of the town, instead :
of which, it has been responsible for a steady, and
even rapid, retrogression, the evil effects of which
have been counteracted only by the success of the
efforts of the Council’s departments in other directions.
12.—Foop.
(a) General.
One thousand and eighty-three, or nearly 15 per
cent. of the total deaths registered in Colombo during
the year 1911 were ascribed to diarrhoea, enteritis,
and dysentery — diseases which are known to be
closely associated with the consumption of unwhole-
some and contaminated food, and yet Colombo,
unlike other towns in the East, has no special staff
for carrying on the important work of food inspection.
The town is in exactly the same position in regard
to this matter as i& was ten or for that matter twenty
years ago, all the food inspection having to be carried
out by the sanitary inspectors, who have a multipli-
city of other duties to perform, and can therefore
only give a very limited and entirely insufficient
amount of time to food inspection.
(b) Tinned Food Stuffs.
The huge scale upon which tinned milk is used will
_be seen from the fact that during the twelve months
extending from June, 1910, to July, 1911, 1,732,560
tins were imported into the island. A certain amount
of it is of inferior quality, and far short of fresh cow’s
milk in nutritiousness and digestibility. Some of it
is made from skimmed milk, although that fact is
not declared upon the label, and the directions for
dilution are frequently such that, if carried out, a
mixture will be produced which is far below the
Colombo standard for pure milk. This is most unfair
to the local milk dealer, who is punished every time
he sells milk below the standard.
Not only milk, but also large quantities of butter,
fish, beef, and mutton are also imported in tins, and
I would repeat my recommendation that the date of
filling at the factory should be clearly impressed upon
each tin, failing which it should be liable to seizure.
(c) Bread.
The inferior quality of the Colombo bread is a
frequent source of .complaint, and several bakers
were interviewed on the subject with a view of
finding out if possible what the explanation was.
The following were the facts elicited.
` The quality of bread depends mainly upon two
things, viz., the quality of the yeast and the quality
of the flour. The best bread is made with toddy
yeast, the price of which varies from Re. 1.50 per lb.
during the months of January to April to 50 cents
during the months May to December. It takes
about'l lb. of yeast to make 50 lb. of bread. Bread
.made with hops, yeast and potatoes goes sour very
quickly in the Tropics. The quality of the bread is
often affected by bakers adding various things to the
yeast with a view to economy, but the best bread is
made with pure toddy yeast, which must be fresh.
The cheaper yeasts aré more liquid, have a sour
smell, and a dirty grayish appearance.
The best flour is Trieste flour, which costs Rs. 30
per bag; next comes Bombay superfine at Rs. 15;
then Bombay flour at Rs. 13; and a still cheaper
variety at Rs. 12. The better the flour is the whiter
and better the bread is. Alum does not appear to
be used here as an adulterant. Trieste flour is too
expensive, and none of the bakers use it. It has
been tried, but does not pay, as a one-lb. loaf costs
28 cents, as compared with 14 cents, the price of a
loaf made of Bombay superfine flour. It would not
, pay to use Trieste flour unless 600 lb. of bread per
day were guaranteed. "These are the facts supplied
. to me by one of the leading bakers.
(d) Milk.
The. extraordinary improvement which has been
effected, as the result of the action taken by this
department during the last few years in respect of
the milk supply of the town, is shown by the fact
that whereas in 1907, 73 per cent. of the samples
examined were adulterated, only 17 per cent. were
found adulterated in 1911. The 1911 figures are
based upon the examination of 1,087 samples, which
is the largest number ever dealt with.
“128
13.— WATER.
(a) Town Water.
Although no pathogenie or even suspicious germs
have ever been found in the Colombo water, whieh
has always been pronounced good and wholesome by
the City Analyst, a rather high bacterial count has at
times been observed, and it contains too much
suspended matter, which rapidly deposits upon and
occludes the iron pipes. The Municipal Engineer and
I were deputed by the Council to visit and report upon
the Jewell system of filtration in Bangalore, and as &
result of our inquiries we recommended that it should
be adopted in connection with the Colombo water
supply.
(b) Wells.
The dangerously polluted condition of the wells in
Colombo is shown by the fact that out of fifty-six
samples examined fifty-two were found to be danger-
ously polluted.
Twenty-two wells were closed during the year.
(c) Liquor.
One further point which calls for remark is tbat
copper continues to be found in arrack, sometimes in
large quantities. The whole liquor question is at
present the subject of a Government Commission.
14.—Pusiic MARKETS.
(a) Buildings.
There is little improvement to record in this
respect, the reconstruction of Dean’s Road market
being still far from completion. A large central
market, on the lines of the one at Bombay for
example, is badly wanted.
(b) Administration.
A considerable advance has recently been effected
in this respect by the appointment of assistant market-
keepers and additional coolies. These men took up
duties only on March 1 of this year.
15.—SLAUGHTER- HOUSE.
The sanitary condition of the slaughter-house
buildings, apart from minor defects in the matter of
repairs, is fairly good; but the arrangements for the
disposal of the drainage, which contains much blood,
and creates a fly-breeding nuisance in the neighbour-
hood, remains the same. The extension of the sewers,
so as to receive the liquid waste from the sheds, is the
only satisfactory solution of the difficulty.
_ The returns of animals slaughtered show an increase
of 2,302 in the number of cattle slaughtered, but a
decrease of 331 pigs and 20 sheep or goats. 728
animals were rejected on account of their being too old
and wasted, which is a reduction of 143 compared
with the 1910 figures. The Superintendent has been
instructed to be more strict in this matter, as it was
found that many animals were being passed which
were much too thin to be put upon the meat market.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 16, 1914.
The quality of the meat in Colombo is exceedingly
poor, and it is only by rigorously rejecting old and
wasted animals that it can be improved—a task which,
however, the Superintendent appears to find some
difficulty in carrying out.
16.—REGISTERED TRADES.
(a) Dairies.
The condition of dairy premises in Colombo,
although much improved in some respects, is far
from satisfactory. The fact of the matter is that a
dairy is a very difficult business to conduct properly.
It involves & considerable initial expenditure, and
thereafter incessant supervision over the workmen by
the owner or manager.
The registration of four dairies was cancelled during
the year 1911, and five new premises were registered,
leaving thirty-eight dairies on the register at the end
of the year.
(b) Bakeries.
There were fifty-six bakeries on the register at the
end of 1910, four were discontinued, and four new ones
were registered during 1911, leaving fifty-six on the
ME at the end of the year.
he following are the chief conditions required.
The bakery should not be situated in an insanitary
area, but this cannot be insisted upon so long as the
bakery itself and its immediate surroundings are in
order. It must not be in a position where foul smells
from latrines and such like can reach it. Where the
sewers are available, a latrine must be provided for
the workmen; but where the sewers are not available,
the latrine must be at some distance, and disconnected
from the bakery.
The bakery must be well lighted and ventilated,
particular attention being paid to the ventilation. It
must also be protected as far as possible against undue
heat, as otherwise the workers perspire too freely
when at work. To secure this the oven is where
possible disconnected from the kneading room by an
unroofed yard or space, only an open sided roofed air
passage for the workers being allowed between the
oven and the kneading room.
The floor and the walls to a height of 5 ft. must be
cemented, the rest of the walls being limewashed.
A tap, with a basin, soap, and clean towels must be
provided for the workmen, who must wear clean white
aprons covering the whole of the front of their bodies.
The kneading tables must be kept in good repair, free
from gaps between the boards, and must be kept
scrupulously clean. No unnecessary articles must
be kept in the kneading room. Spitting is strictly
prohibited in the kneading room or on the passages.
Unless not more than one day’s supply of flour is
kept upon the premises, there must be a separate
flour store, with cemented floor and a bench upon
which to keep the flour sacks. This store must be
properly ventilated. The bread baskets must be kept
clean.
These requirements are, upon the whole, well
carried out, the bakers being much better as a class
to deal with than the dairymen,
Dec. 1, 1914.]
TOLONTAN MEDICAL REPORTS. —MUNICIPALITY OF COLOMBO.
129
Colonial Medical Reports.—No. 42.—Municipality of
Colombo (continued.)
(c) Laundries.
There were 235 laundries on the register at the end
of 1910; 25 were discontinued and 63 new ones were
registered during 1911, leaving 273 on the register at
the end of the year.
The laundry trade in Colombo is most unsatis-
factory. There is not a single laundry in Colombo
which can be considered satisfactory. Where pipe
water is used, as in the case of the Racquet Court
laundries, the dhobies are too sparing with the clean
water, batch after batch of dirty clothes being washed
in the same water, until it resembles soup rather than
water. It is true that the clothes are, as a rule,
ultimately passed through clean water, but it is
doubtful whether the filth is thus properly removed.
The clothes frequently look clean enough and white
enough ; but they have seldom the proper clean smell,
which is the test of properly washed clothes. The
clothes which could stand such a process, and most
of the things sent to the dhoby here could do so, are
neither boiled nor even washed in hot water.
The amount of clothes washing which has to he
done in the Tropics is greatly in excess of what is
required in temperate climates, and therefore the rates
must be lower here, unless people are able to afford
a heavier dhobies’ bill. Low rates, on the other
hand, will probably not make it possible to run a
aundry on up-to-date lines.
There thus seems to be no solution of this problem,
except to have two standards, one for the ordinary
dhoby, and the other for first-class dhobies. Here,
however, success is dependent upon the customers,
for unless they are prepared to make it worth the
dhobies’ while to comply with the higher standard,
no dhoby will embark upon the undertaking. A dhoby
once told me that if he were guaranteed a sufficient
number of customers he would undertake to establish
an up-to-date laundry, but he added that a laundry
on Western lines had been tried before in Colombo
and failed through lack of support. Needless to say,
if any guarantee of this sort is to be furnished, it must
be by the customers themselves. I see no hope of
seeing really up-to-date laundry methods being
adopted here, except as the result of private enter-
prise backed up by the residents of the town.
(d) Eating-houses.
A large proportion of the working classes, and many
of the clerks, take their midday meal in eating-houses,
the number of which is consequently large, there
being 287 upon the register at the end of 1911. These
eating-houses demand a great deal of sanitary super-
vision, otherwise they tend to rapidly degenerate, as
the customers are for the most part indifferent to the
conditions under which their food is prepared and
served, and it is consequently not worth the while of
the eating-house keeper to trouble on their account
about the niceties. There are, however, a number of
better class houses, the number of which I am glad
to say is increasing, where a considerable effort has
been made to render them attractive to those with
more fastidious tastes. It is largely a matter of
experience or education. A person who has dined in
a bright clean house will be more likely to notice and
to resent eating in a badly kept one, and consequently
the larger the number of good houses there are the
greater will be the number of those persons who,
having experienced the better conditions, will avoid
the badly kept houses. Some of the eating-houses
are kept in quite a creditable condition.
(e) Offensive and Dangerous Trades.
Under this heading come manure depots, soap
manufactories, hide stores, dyeing houses, cotton
stores, straw depots, timber depots, and aerated water
factories. The supervision over the dangerous trades
enumerated above, with the exception of the aerated
water factories, might more properly be under the
Superintendent of the Fire Brigade than the Medical
Officer of Health.
17.—CRMETERIES.
The whole of the cemetery has now been surveyed
and a new plan prepared, upon which the ground is
marked out in systematic blocks, plots, and paths.
The work of marking in the existing graves, the older
ones of which are not in accordauce with any sys-
tematie method of alignment, is now engaging the
attention of the assistant keeper, who was specially
selected for his knowledge of survey work. All new
graves are being dug in accordance with the new plan,
except in a few instances, where this is impossible
owing to the irregular disposition of old graves. The
head gardener has planted a considerable number of
shrubs and flowering trees, especially flamboyants,
which should in time greatly improve the appearance
of the cemetery. The introduction of a water service
has greatly facilitated the keeping of plants in
condition.
18.— WORK STATEMENTS.
(a) Sanitary Inspectors.
The experience of every year demonstrates the
necessity for employing a Chief Sanitary Inspector,
as is done in other towns. Nowhere is this want
more felt than in the conduct of prosecutions in the
Municipal Court, where many cases are lost purely as
the result of unskilful handling by the inspector.
This is no more than is to be expected, where, instead
of having one trained man to examine, arrange, and
present the evidence in every case, each one of the
thirteen inspectors has to work up and conduct his
own cases. If all the prosecutions were conducted
by cne Chief Inspector, he would in time become an
expert in municipal law and procedure, and the
Council would probably be saved a considerable
amount of money, which they now have to spend in
lawyers’ fees, while the public would be saved from
what are sometimes made to appear as unnecessary
and harassing prosecutions, for a prosecution which
is entered, and as the result merely of unskilful
handling ends in acquittal, does a great deal more
harm than good, and fosters in the minds of those
who have been so prosecuted the feeling that they
have been unjustly dealt with in being prosecuted
at all.
There can be no doubt that the appointment of
130
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
& trained Chief Sanitary Inspector, whose character
should be above suspicion, and who should sift all the
evidence put forward by the Sanitary Inspectors, and
conduct their prosecutions, would go a long way to
improve matters. What is required is a man with
a good moral character, a strict disciplinarian, one
trained in sanitary work, and with no local ties or
connections which might influence him, or be alleged
to influence him, in the discharge of his duties, and
who has not, either rightly or wrongly, been the sub-
ject of suspicion as to his methods of procedure.
(b) Sub-Inspectors.
The work of the sub-inspectors comprises inquiring
into and taking action in respect of enteric fever and
phthisis. During the year 1911 they supervised the
disinfection of 880 fever infected houses and 364
phthisis infected houses, making a total of 1,244
houses disinfected, which, together with the 787 dis-
infected by the Sanitary Inspectors, makes a total of
2,031 houses disinfected during the year.
(c) Enteric Cleansing Gang.
This gang consists of an overseer and four coolies,
whose duty it is to cleanse and disinfect compounds
and latrines which are either enteric infected or are
so filthy that the ordinary procedure of serving notice
upon the occupant cannot be awaited. Four hundred
and forty-seven infected latrines, &c., were so dis-
infected, and 185 filthy compounds were cleansed
during the year.
(d) Ambulance.
The ambulance work was, as hitherto, carried out
by the Fire Brigade, to the Superintendent of which
I take this opportunity of expressing my thanks for
the excellent manner in which the work has been
carried out.
(e) Disinfecting Station.
This is in charge of an overseer, whose duty it is to
receive, pass through the Equifex steam disinfector,
and dispatch infected articles of clothing, &c.
One hundred and eighty-five loads, comprising
5,879 articles, were thus passed through the dis-
infeetor during the year.
(f) Insect Pest Prevention Gang.
This gaug consists of an overseer and two coolies,
whose duty it is to search out and deal with the
breeding-places of mosquitoes and flies. Naturally
such a small gang can only touch the merest fringe of
this work which requires to be done in Colombo; but
they are useful for dealing with complaints from
householders in regard to mosquitoes. During the
year 1911, 2,038 premises were visited, in 1,176 of
which mosquitoes were found breeding, and their
breeding-places were destroyed, the occupants being
instructed how to prevent a recurrence, and warned
that if they failed to do so they would be prosecuted ;
90 notices to abate insect breeding were served; 494
pools, &c., were oiled, the quantity of oil used during
the year being 1721 gallons.
This most useful work of insect pest prevention is
one which to be really effective requires to be taken
up upon a vastly larger scale; but the lack of funds
for other important purposes leaves little hope at
present of the success of a recommendation in this
respect. It is a matter, however, which must be
dealt with before long, and I propose to do so later.
19.—MUNICIPAL Free Dispensary, SLAVE ISLAND.
This, the first of a proposed series of municipal
free dispensaries adopted by the Council, was opened
in Church Street, Slave Island, in February, 1910.
The object of this dispensary is to supply skilled
medical attendance to those who are too poor to afford
the lowest fees accepted by private practitioners; to
search out in their homes cases of sickness which are
not under the care of a medical man; to advise in the
matter of the care and feeding of infants, and in
matters of domestic hygiene generally, with special
reference to the prevention of phthisis; to supervise
the work of the municipal midwife in the district.
The municipal midwife system was established
prior to the establishment of the dispensary ; but the
Slave Island midwife has been attached to the dis-
pensary, and is under the control of the medical
officer, who checks her work, and where necessary
deals with difficult cases.
20.—Municipan Mipwives.
Six hundred and fifteen cases, representing 623
births, were attended by the six municipal midwives
during 1911, there having been eight multiple births.
This is slightly less than in 1910. There were 29
stillbirths and 19 deaths within four days, representing
a death-rate (exclusive of stillbirths) of 2:89 per cent.,
which is slightly in excess of the 1910 rate. The
numbers of male and female children born were 325
and 298 respectively. Burghers show a large excess
of female, and Moors a large excess of male infants;
other races show a fairly equal distribution of sexes.
21.—MonicipaL ENTERIC HOSPITAL.
The Medical Officer reports that the buildings have
been kept in good repair, but complains that the
accommodation for the staff is insufficient, a remark
with which I agree. During the year 1911, 354 cases
were admitted for treatment, there being 77 deaths,
representing a case mortality of 21:7 per cent.
A few minor operations were performed, and five
post-mortems were held during the year.
The Medical Officer draws attention to the large
number of cases sent in as enteric from other hospitals
which are found to be due to causes other than
enteric. This is, however, a usual experience in
enterie hospitals all over the world, and is due to the
great difficulty of diagnosing this disease, especially
in the earlier stages, the usual remedy being a more
frequent use of Widal’s blood test.
Dec. 1, 1914.]
COLONIAL MEDICAL REPORTS.—CYRPUS.
Colonial Medical Reports.—No. 43.— Cyprus.
MEDICAL REPORT FOR 1910.
By ROBT. O. CLEVELAND.
Chief Medical Officer.
l.—PoBric HEALTH.
Tue general health and sanitary condition of the
island have been most satisfactory. There was
no serious outbreak of infectious or contagious
disease. Plague still menaced the island as in
former years, and the outbreak of cholera in neigh-
bouring countries caused anxiety, but fortunately the
island escaped both these serious dangers, as no cases
were reported throughout the year; the year under
report in fact presents no special features, from a
medical point of view, that call for remark.
Epidemic Meningitis.—A marked reduction in the
number of cases of this disease is a pleasing feature.
Eighty-four patients, as against 1,000 the previous
year, are shown in the returns. The cases showed
a milder form of infection, and there is every indi-
cation that the disease has assumed a sporadic form.
Malarial Fever.—Cyprus is unfortunately malarial,
the disease receiving the local name of ‘“ Cyprus
fever" until a few years ago, when the application
of the mieroscope revealed its true nature. The
three types, tertian, quartan and malignant fevers,
were soon proved to exist in the island. The disease
is fairly prevalent during the hot months of the year
and in mild winters, cases are seen all the year
round, their number varying considerably, being
dependent largely on the rainfall, which if heavy
during the warm months provides breeding-places
for anopheles. During the year under report the
disease was less prevalent than usual. There were
6,074 cases returned, against 7,450 in 1909, and
10,746 in 1908. The people are beginning to recog-
nize the value of the various prophylactic measures
recommended ; the use of mosquito nets, improved
sanitation, and quinine is becoming more general.
Typhoid Fever.—Generally speaking of a mild
type, and only occurred in a sporadic form, although
there was an inerease of 66 cases on the returns of
the year 1909, a total of 334 cases having been
reported by the medical officers during the year
under report.
Diphtheria.—Only 9 cases of
recorded during the year.
this disease are
2.—INSTITUTIONS.
Hospita!s.—'The hospitals of the island show an all-
round improvement in attendance and admissions.
The total in-patients treated at the Government
Central Hospital, Nicosia, and the five District
Government-aided Hospitals was 2,201, with 125
deaths -- 567 per cent. There were thus 141
more admissions than in the previous year. The
out-patient departments of these institutions were
also well attended, the patients numbering 23,859,
an increase of 2,058 on the figures of the previous
year.
A total of 298 surgical operations were performed,
being an increase of 83 on the returns of the year
1909. To this total must be added 316 minor
operations among out-patients.
The Central Hospital, Nicosia, the only purely
Government Hospital in the island, has had a most
successful year. The beds of this institution now
number 53 and provide accommodation for men,
women and children. There are wards for the
treatment of both poor and paying patients. Medical,
surgical, maternity, eye, and isolation beds now exist,
and the general utility of the hospital is improving
year by year.
Nearly 200 surgical operations were performed
at this hospital alone. Patients from all parts of
the island received the skilful and careful attention
of an efficient and well trained medical and nursing
staff.
In all the other district hospitals also advance-
ments and important improvements have been made ;
among these the Larnaca Hospital, an institution
built from funds raised by private effort and in great
measure supported in the same manner, is note-
worthy. The number of in-patients treated was 232
against 257 in 1909, and of out-patients 3,603 against
3,156 in 1909. Patients came from many towns and
villages in that district and from others more remote.
Useful structural additions were made during the
past year, and an English nurse’s services were
secured in place of those of a native nurse. The
hospital is well equipped as regards beds, bedding,
instruments, and other arrangements for the comfort
of patients.
The accommodation consists of a male ward of
twelve beds, a ward for women of eight beds, four
private wards, operating room, and the various
offices connected with hospital administration. The
hospital is devoted to the reception and treat-
ment of the sick poor of the town and district
both as in- and out-door patients. In special and
urgent cases patients are admitted from elsewhere,
and, as noted above, private paying patients are
treated.
The returns of the twelve rural medical officers
show that 10,461 patients were treated, a decrease
of 1,354 on the returns of the previous year.
The services of these officers are much appreciated
by the inhabitants of the more remote towns and
villages of the island. x
The Leper Farm.—At the close of the yéar there
were 99 inmates on the farm, and during the year
there were 12 admissions. Fifteen inmates died.
This mortality, although at a higher rate than in
the last few years, is not exceptional in view of the
terrible nature of the malady from which these un-
fortunate people suffer. Their lot has been con-
siderably relieved by a substantial increase to the
grant allowed them by Government.
132 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Return or DiskAsks AND Dgatus iN 1910 IN THE Six GENERAL HosrrTALS, LEPER Farms, AND
GENERAL DISEASES.
Alcoholism X is "E Er
Anemia .. % $5 m is
Anthrax .. "E Sy 3 os
Beriberi
Bilharziosis He cs ae
Blackwater Fever S $5 "E
Chicken-pox oe ve or ia
Cholera bz Sr 3
Choleraic Diarrhoea hs
Congenital Malformatiou
Debility .. . ;
Delirium Tremens
Dengue .. š
Diabetes Mellitus
Diabetes Insipidus
Diphtheria >
Dysentery ..
Enteric Fever
Erysipelas ..
Febricula .. è
Filariasis .. ss «s b s ;
Gonorrhea
Gout i
Hydrophobia Hf
Influenza .. +e is
Kala-Azar..
Leprosy ..
(a) Nodular
(b) Anesthetic ..
(c) Mixed
Malarial Fever—
(a) Intermittent
Quotidian ..
Tertian — .. oe
Quartan
Irregular ..
Type undiagnosed
(b) Remittent .. are
(c) Pernicious ..
(d) Malarial Cachexia..
Malta Fever i
Measles
Mumps 6s
New Growths— ..
Non-malignant
Malignant
Old Age .. $5
Other Diseases
Pellagra .. je ss i" a
Plague ES oe aie $5 ait
Pyremia ee m T es
Rachitis y
Rheumatic Fev er
Rheumatism *
Rheumatoid Arthritis
Scarlet Fever M T. re 25
Scurvy Es $s $i 3% os
Septiciemia 3
Sleeping Sickness es
Sloughing acai is
Smallpox .. T
Syphilis
(a) Primary
(b) Secondary ..
(c) Tertiary
(d) Congenital ..
Tetanus
‘Trypanosoma Fever
Tubercle—
(a) Phthisis Pulmonalis
(b) Tuberculosis of Glands
(c) Lupus "
Admis-
| | ome sions
1 to | po |
= bo
-0
[wn
=
ltl S@lealle
Lunatic WARDS.
Deaths
| nom
PF] dell TPP P dott PPP P til) eee a deol Fill dt
Ae d ees a
I|
Cyprus.
sii
Sa f GENERAL DISEASES— continued.
iret = (d) Tabes Mesenterica zs
1 (e) Tuberculous Disease of Bones ..
12 Other Tubercular Diseases e
6 Varicella .. es ps $a ze m
= Whooping Cough: ‘i Rx T 3
= Yaws z š os zi JE
= Yellow Fever .. . re
= LOCAL DISEASES.
9 Diseases of the—
1
Cellular Tissue es oe
Circulatory System
2 (a) Valvular Disease of Heart
=~ (b) Other Diseases .. A sé és
6 Digestive System— .. as äs Es
26 (a) Diarrhea as S $3 E
53 (b) Hill Diarrhea ..
9 (c) Hepatitis .
37 Congestion of Liver
— (d) Abscess of Liver
36 (e) Tropical Liver ..
— (f) Jaundice, Catarrhal
= Hy Cirrhosis of Liver
78 t) Acute Yellow Atrophy:
-- tà Sprue $5 . ss T
— (j) Other Diseases .. 2 y. a
62 Ed és ae `
52 Eye . e x
— Generative Sy stem— .. a sa
— Male Organs bs Ed os
— Female Organs M " vs
137 Lymphatic System
42 Mental Diseases DE
7 Nervous System
5 Nose .. . es
180 Organs of Locomotion e h^ PE
11 Respiratory PrMem ve ES EC -
3 Skin— .. $$ m HE
= a) Scabies
2 b) Ringworm
— (c) Tinea Imbricata
— (d) Favus .. F
— (e) Eczema .. 5
25 (f) Other Diseases .. AN 5%
18 Urinary System ae T ae
— Injuries, General, Local— E
2 (a) Siriasis (Heatstroke) ^ aia
— (b) Sunstroke (Heat ProatrAtion] sx
= (c) Other Injuries
Parasites— pe E e i
Ascaris lumbricoides .. ne
16 Oxyuris vermicularis .
59 Dochmius duodenalis, or Ankylostoma duo-
— denale 7 A
1 Filaria medinensis (Guinea worm)
— Tape-worm ae A e T
4 Poisons— e z T Y
— Snake-bites — .. $a "T ea
a Corrosive Acids ws a a
= Metallic Poisons x^ és s
s Vegetable Alkaloids .. sa Tm
13 Nature Unknown ats Ar RE
10 Other Poisons ae ia ie R
— Surgical Operations— .. as sis ET
-- Amputations, Major
4 Minor .. ‘ cy X
— Other Operations S. or ee Sie
37 Eye .. "n 25
(a) Cataract is $25 EC
= (b) Iridectomy .. sis
c (c) Other Eye Operations |
sions
Admis-
Ed 34d 141
Si eT hes) ond hed
[Dec. 1, 1914.
Deaths
SFE Veo bh de col tee Pee he ee Ea tt
bey d pop s]
PT Pet ue Hi
f Total
LT TT | „Cases
Treated
|
=
leeSlFl itl
a
ex | w
o m
ex
-
e
t9 w=
ew lade) | Saal 1111
Dec. 15, 1914.]
COLONIAL MEDICAL REPORTS.—NEW PROVIDENCE.
133
Colonial Medical Reports.—No. 43.—Cyprus (continued.)
The subjoined table is of interest as it contains
details regarding the inmates for the past ten years,
and I should like to state, in this connection, that
each year, on account of the extension of the Govern-
ment Medical Service, and the increasing number
of medical practitioners, fewer cases of the disease
escape notice and segregation.
Cases of the three chief classes of this disease are
seen, tubercular, anesthetic and mixed, the tuber-
cular exceeding the anesthetic by 5 to 1.
Inmates in the
Admitted
rl during Deaths Remaining on December 31
Year Inmates the year Moslems Christians Total
1901 110 13 12 24 87 111
1902 111 12 13 23 87 110
1903 110 19 15 28 86 114
1904 114 6 9 28 83 111
1905 111 13 9 28 87 115
1906 115 3 19 24 75 99
1907 99 12 11 27 73 100
1908 100 H 5 28 T4 102
1909 102 11 11 25 7T 102
1910 102 12 15 25 74 99
No birth was recorded during the year. Two
children still remained on the farm, being too young
to be removed from their parents.
One child was admitted to the Home, there being
eleven of both sexes thus removed from the farm,
and it is of interest to report that in no case so far
has any sign of the disease appeared. One death
amongst them is recorded from chronic Bright's
disease. Their education is receiving attention and
they are being taught trades which it is hoped will
place them in a position to earn their living.
The Lunatic Wards.—There were 20 cases of in-
sanity admitted to the wards during the year; of
these 18 were cases of dementia, 4 were suffering
from acute mania, the remainder were cases of idiocy,
delusional and epileptic insanity, and general paralysis
of the insane.
Six inmates died during the year; 20 patients
were sufficiently recovered to be released to the care
of relatives or friends; at the end of the year 56
inmates remained under treatment.
Quarantine Department.—It was not necessary to
impose quarantine during the year. The stations,
and particularly that of Larnaca, were maintained in
an officient condition in readiness to cope with any
emergency should the necessity arise, but nothing
more than a careful medical inspection was imposed,
and this was sufficient to protect the island from the
importation of infectious disease.
Vaccination, although not compulsory, was exten-
sively carried out. Fresh imported glycerinated
vaccine was the medium used, Six thousand three
hundred and thirty-two of these operations were
carried out; of these 6,197 were primary vaccinations,
METEOROLOGICAL RETURN FOR THE YEAR 1910.
|
| TEMPERATURE RAINFALL WINDS
E = |8 ep 2
zz 2 m |€8 |} 88 | 52) 88
| B $a |g |ás|7$5|4
January 58:2 38:4,19:8, 48:4 | 3:59. 80 | W. | 0*6
February 6411 36:3 27:8 | 51:0 082 80 M 0:2
March .. | 63:1 36:4! 2677 /51:1|8773 76 1:0
April 76°0 | 43:9 32:1 60:2,0' 70. 72 $$ 0:2
May 85:6 51:3 34:3 66:9 | 1:02. 68 a 0:2
June .. 925 586 |339 74°4/0°73 62 5 0:4
July xe | 99:0 63:2 35:8 80:4| 0-00 58 5 0:1
August.. ..199:8, 65:8: 34:0 | 83:4 | 0-00 , 54 $$ 0:4
September ..|918|6321,28 77 7T6|1:85| 78 | ,, O'7
October 80:4 | 52-4 | 280 68:2| 1[90 . 68 | ,, 0:8
November .1(71:6,44:3| 2773 58:4 |014 . 76 | ,, 0:8
December .. |63°1 37:1| 26:0 49:4, 2:36 78 F. 0-1
Total mean .. | 78:8 49:2|99:5 64-1 |1684 71 W 0:4
I |
Colonial Medical Reports.—No. 44.—New Providence.
MEDICAL REPORT FOR 1911.
By J. J. CULMER, M.R.C.S.Eng., L.R.C.P.Lond.
Acting Chief Medical Officer.
Tue general health of the Colony throughout the
year was good, no infectious or contagious disease
having been notified to the Board of Health except
nine cases of typhoid fever occurring in New Provi-
dence, with one death, a few sporadic cases of typhoid
fever being reported almost annually.
The street drainage of the city of Nassau continues
in an unsatisfactory condition, and until the drains iu
some of the streets are reconstructed no improvement
can be expected.
The water supply from wells and cisterns has been
plentiful.
The rainfall during the year was 40:15 in., an in-
crease of 14:44 in. over the previous year.
Two hundred and sixty successful vaccinations
were performed in New Providence during the
year, and 2,956 on the various out island settle-
ments.
RETURN OF THE STATISTICS OF POPULATION. FOR THE
YEAR 1911.
Number of inhabitants according to the census on
April 2, 1911 oe 2i de Pe we .. 55,944
Number of births since the last census .. x 1,362
Y» deaths ,, m P vt . t . 867
m immigrants m bz -| Not
5 emigrants F ..j| known
inhabitants in 1911 56,439
495
39
Increase
134 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
Return oF Diseases AND DEATHS IN 1911 IN THE BAHAMA GENERAL HOSPITAL,
New Providence.
GENERAL DISEASES.
Alcoholism
Anemia
Anthrax
Beriberi ..
Bilbarziosis aH
Blackwater Fever
Chicken-pox
Cholera
Choleraic Diarrhoea ;
Congenital Malformation
Debility 3s 3
Delirium Tremens
Dengue .. .
Diabetes Mellitus È =f
Diabetes SCE $s T
Diphtheria . is Kia
Dysentery .. ae oe
Enteric Fever
epus D
Febricula ..
Filariasis .. 2s $e e»
Gonorrhca X ia ss
Gout E e
Hydrophobia
Influenza .. T
Kala-Azar..
Leprosy ..
(a) Nodular
(b) Anesthetic ..
(c) Mixed ds
Malarial Fever—
(a) Intermittent
Quotidian .. E
Tertian — .. ae e
Quartan .. e às
Irregular
Type undiagnosed
(b) Remittent .. »
(c) Pernicious .. ES
(d) Malarial Cachexia. . R
Malta Fever ES xs i
Measles .. a ^ 23
Mumps .. ss p «s
New Growths— .. ae
Non-malignant oe
Malignant s
Old Age .. és a M
Other Diseases .. ae E
Pellagra .. es a sé
Plague oe va es >s
Pyæmia ee T T
Rachitis .. ; ae ie
Rheumatic Fever as p
Rheumatism
Rheumatoid Arthritis ..
Scarlet Fever — .. a
Scurvy .
Septiciemia :
Sleeping Sickness £s
Sloughing Phagedena ..
Smallpox .. as
Syphilis .. -
(a) Primary ;
(b) Secondary ..
(c) Tertiary ..
(d) Congenital .. es P
Tetanus .. ve oe
Trypanosoma Fever
Tubercle—
(a) Phthisis Pulmonalis n
(b) Tuberculosis of Glands ..
(c) Lupus ‘ i3
Admis-
sions
PII 1] He
LL I18SI T 1
Pill ld &Bleel LSi 1 Sl | vasl |
| |
] Tel p Ed. T
loll lest |
| al
Deaths
Een AUS 55 ESE fete
ndo EE ae TT
Total
Cases
Treated
LL tt esl SILI Sl vasli iI ISlibi lll toe
We HE
pet
e
bo
loll lallollIIF
GENERAL DisEASES— continued.
(d) Tabes Mesenterica ye
(e) Tuberculous Disease of Bones
Other Tubercular Diseases
Varicella .. 3 vx
Whooping Cough A se
Yaws . . "T AC
Yellow Fever $» A "n
LOCAL DISEASES.
Diseases of the—
Cellular Tissue is ss
Circulatory System ..
(a) Valvular Disease of Heart
(b) Other Diseases .. à
Digestive System — re
(a) Diarrhea - »*
(b) Hill Diarrhoea ..
(c) Hepatitis >
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver ..
(f) Jaundice, Catarrhal
g Cirrhosis of Liver
) Acute Yellow Annae.
là Spre .. a «
(j) Other Diseases .. EE
Ear 3s T
Eye st
Generative System— :
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervous System a se
Nose .. " oe
Orgaus of Locomotion ys
Respiratory Roe pé
Skin— ..
(a) Scabies
(b) Ringworn :
(c) Tinea Imbricata
(d) Favus .
(e) Eczema .. de
(f) Other Diseases ..
Urinary System
Injuries, General, Local— : 4
(a) Siriasis (Heatstroke)
(b) Sunstroke (Heat Prostration)
(c) Other Injuries
Parasites —
Ascaris lumbricoides .. fe
Oxyuris vermicularis ..
wi Ta. Ta^ NÉ
Dochmius duodenalis, or Ankylostoma duo-
denale
Filaria medinensis (Guinea- -worm)
Tape-worm ee m m
Poisons — Ls T
Snake-bites
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids
Nature Unknown
Other Poisons
Surgical Operations —
Amputations, Major .. se
id Minor ..
Other Operations ee
Hye: ss v e
(a) Cataract Fes
(b) Iridectomy
(c) Other Eye Operations.
15
PiewlliSollllllaalnS
1SlT 1 tl teollt
|
Deaths
PPLE Teoh PLETE bel bool TITEL PPP thi thi tdattal
EV Pe eT EA
1
|
PITTI TIT 8i tks
ISl!
$
o
llellisS8llilllilasSlI -SS8sE
bool tI
PUNE JASKA
| |
Dec. 15, 1914.]
COLONIAL MEDICAL REPORTS.—FEDERATED MALAY STATES.
135
Colonial Medical Reports.—-No. 45.-—Federated Malay States.
MEDICAL REPORT FOR THE YEAR 1911.
By CHARLES LANE SANSOM.
Principal Medical Officer.
THE estimated population of the Federated Malay
States as calculated from the Census returns of
March 10, 1911, was 1,045,947, an increase of 44,690
persons over the number estimated for 1910, which
was 1,001,257.
The total number of births registered was 20,310,
the birth-rate being for the whole of the Federated
Malay States 19:41 per mille of the estimated
population.
Deaths.—The number reported amounted to 38,732,
the death-rate per mille being 37:03 of the total
estimated population.
Malaria caused 45:02 per cent. of the total deaths.
There were 17,440 deaths from this disease, with a
mortality-rate of 16:39 per mille of the living
population.
Dysentery and dievrhw@a accounted for 7,451 deaths
—that is 19 per cent. of the total deaths, with a
death-rate of 7 per mille of the total population.
Thirty-nine per cent. of the total deaths were of
persons in the prime of life—that is between the ages
of 20 and 40.
The infant mortality was 170 per mille; 3,185
children died within twelve months of birth. This
rate compares favourably with those of India and
Burma, the provincial rate of infant mortality for
Burma in 1910 was 233-24 per mille.
The number of in-patients in 1910 numbered
80,824. The death-rate for the year was 9°57 per
cent.
The attendances of out-patients were 232,506, as
compared with 217,407 for 1910.
In the Kuala Pilah district a travelling dispensary
with a Malay dresser in charge was started in June.
The travelling dispensary boat was not at work
for four months, as i& was engaged on cholera duty,
and thus the number receiving outdoor aid was not
so large as in the previous year, a decrease probably
enhanced to some extent by the opening up of estate
hospitals.
Lunaties to the number of 990 were treated in the
asylums ; of this number 162 died ; this includes 94
deaths from cholera.
There were 519 cases treated in the leper asylums ;
130 lepers were trausferred, and the erection of a
temporary ward has relieved overcrowding in the
asylum at Kuala Lumpur.
Every endeavour is made to lighten the burden of
these unfortunate people; tobacco, fishing nets, and
durians, when they are in season, are provided, and
recently they were given a gramophone with records
of Malay tunes, which was much appreciated.
The diseases responsible for the greatest number
of admissions and deaths in the hospitals during
the year are as follows: Malarial fever, beriberi,
dysentery, diarrhma, venereal diseases, tubercular
disease of the lungs, other pulmonary diseases,
ankylostomiasis, skin diseases, injuries, rheumatism.
The death-rate from malaria continued very-high.
There were in all 17,440 deaths in the whole of the
Federated Malay States.
This malady has engaged the attention of all
officers of the department, as well as others in the
Government service. During 1911 the disease was
more prevalent, and unless preventive measures are
successfully carried out it is not unlikely, as the
population becomes larger and traffic between the
carrier and sufferer facilitated, the tendency to
increase will be greater. The mortality figures alone
do not convey a full knowledge of the amount of
harm malaria causes; for instance, comparatively
few Europeans or [iurasians die from it; but, on
the other hand, agreat many are repeatedly attacked,
and not only is vitality lowered and resistance: to
other diseases weakened, but the pecuniary loss to the
individual is considerable, and the total loss to the
community and the Government is very great indeed.
In fact, I do not think I should be guilty of exaggera-
tion in saying that malaria is probably the most
expensive luxury in the Federated Malay States:
During the past few years several men have been
persistently working at the malarial problem in
this country, and sufficient information has been
gathered together to warrant more energetic warfare
against the malady. It has become obvious that
preventive measures here cannot be limited to one
procedure, because several varieties of mosquito
which are carriers exist in various parts, making use
of their own particular breeding-places, and a method
of extermination which would be successful in one
place would be a complete failure in another.
The dissemination of correct information is of no
small importance. It is felt that systematic diffusion
of knowledge regarding this enemy of man, its habits,
the harm it does, and how to exterminate it, will not
only encourage the individual to do his share, but
also facilitate the efforts of local bodies and probably
make them more effectual.
Dr. Freer, Senior Medical Officer, Selangor, Negri
Sembilan and Pahang, reports that malaria is on the
inerease in Selangor, due principally to the continued
opening of rubber estates and to the influx of
immigrants of all nationalities arriving at Port
Swettenham, to the number of 117,200 in 1911 as
136
against 93,544 in 1910. In Selangor and Negri
Sembilan malaria was very prevalent during May,
June and July in all parts, and that the Coast districts
suffered most in September and October.
Dr. Fox, Senior Medical Officer, Perak, reports
three cases of blackwater fever, being the first ever
admitted into the Officers’ Ward at Taiping, one of
which ended fatally. In Selangor there were five
cases of blackwater fever, with two deaths; and in
Negri Sembilan two cases occurred, both recovered.
Seven thousand and twenty-one children were
examined for enlarged spleen, the percentage affected
being 20°19.
In the Kuala Pilah district of Negri Sembilan a
systematic examination of the children for enlarged
spleen was made by Dr. Hennessy in June and
December of the year under review, and out of 1,237
examined in the latter month 305 were found with
enlarged spleen, and of the blood examination of
1,091 children, 115, or 10:54 per cent., had parasites
in their blood while attending school.
Free distribution of quinine to the poorer classes
was continued in all the States during the year. In
Perak quinine in the form of capsules, weighing
181 lb. 11 oz. 5 dr., was distributed free.
There were 6,042 cases of beriberi treated in the
various hospitals, with 695 deaths.
In Perak there is a slight diminution since last
year, but in Selangor and Negri Sembilan an increase
has occurred.
The fact that a diet chiefly composed of white
polished rice causes beriberi has received further
confirmation, and several efforts have been made to
make this generally known. Government has had
under consideration several proposals for preventing
or limiting the use of an unsafe rice, but the matter
is a very difficult one to tackle.
A very important detail, which is part and parcel
of any legislative interference with the sale of rice,
is the effect on prices, and it is probable that no one
could foresee exactly what would be the result if
Government attempted to regulate trade in rice.
Certain ways in which the consumption of a safe
rice might be encouraged have been under considera-
tion, and it is probable that by giving every possible
facility for manufacture, transport, and sale of it
some good may result.
There has been an increase of 2,303 cases of
dysentery and diarrhcea, with higher mortality com-
pared with 1910, the three western States contributing
towards the increase.
Cholera.—A serious outbreak of cholera occurred in
Lower Perak in May, 1911: 342 cases were reported,
with 237 deaths. Measures taken under the direction
of Dr. Clarke, Medical Oflicer, Lower Perak, against
the spread of the disease were effective.
In Krian the outbreak was peculiar, inasmuch as
there were three recrudescences during the year, viz.,
in January, June, and October respectively. Alto-
gether there were 199 eases, with 142 deaths.
Cholera appeared in the Lunatic Asylum, Taiping,
in October, and the last ease on November 15; 25
lunatics were stricken, with 20 deaths. The lunatic
asylum being surrounded by a high fence rendered it
possible to confine the infection within the asylum
m,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
and prevent its spreading. Total cases treated in
Perak were 582, with 411 deaths.
In Selangor, cholera broke out on July 15, with
14 cases, resulting in 12 deaths. Twenty-four cases
occurred on rubber estates in the Coast districts.
Prompt measures prevented any serious outbreak.
Altogether there were 79 cases, with 63 deaths.
On the Island of Tioman it was reported that an
epidemic, the symptoms of which appeared to be
similar to those of cholera, was responsible for 22
cases, with no recoveries. Unfortunately, the medical
authorities were not informed until all was over, the
victims being all Malays.
Small-por.—In Perak there were 81 cases, with
13 deaths. The small-pox epidemic which broke out
in Taiping in August did not finally subside till
February of this year.
In Selangor, 75 cases, with 6 deaths, were reported.
The greater number occurred on rubber estates,
mostly in the Coast districts, and wholesale vaccina-
tion prevented any serious spread. There were 125
cases, with 23 deaths, reported; in Pahang 5 cases,
with 1 death, and at Kuala Lipis 2 cases, the source
of infection being unknown.
Plague.—There were 5 cases reported. One died
in the isolation ward at the District Hospital, Kuala
Lumpur; and of the 3 cases admitted in the hospital
at Seremban all proved fatal.
Chicken-por.—There were 91 cases with no deaths.
Measles.—There were 151 cases reported. Of the
20 patients treated in the hospital there were 3 deaths,
due to broncho-pneumonia, convulsions and fever,
and 1 in Pahang.
Enteric Fever.—In Selangor 15 cases came under
notice. Of the 5 cases admitted in the Kuantan
Hospital, 3 died.
Diphtheria.—There were 2 cases in Selangor. In
Negri Sembilan 7 cases were treated in hospital.
Filariasis.—This disease is comparatively rare in
this country. Out of 700 blood examinations for
filariasis made at the District Hospital, Kuala
Lumpur, the embryos were found in 16 cases, or 2:28
per cent.
At Raub Hospital the blood of 1,034 patients was
examined for the presence of filariasis, with a positive
result in 4 cases only; none showed any symptoms of
filarial disease.
VACCINATION.
The table appended shows the work ‘done and the
results :—
State Successful Failed Not verified Total
Perak 20,992 3,585 24,181 .. 48,758
Selangor .. os 007,198 6,544 .. 12,622 46,894
Negri Sembilan.. 6,636 1,005 .. 177 7,818
Pehang 3,528 .. 821 .. 302 4,651
Total 58.884 .. 11,955 937,282 .. 108,191
Vaccination by gurus (native teachers) is gradually
being introduced in some parts of the State.
Altogether the gurus have vaccinated 2,067 cases,
for which they get 10 cents for every successful
operation.
a eating
pis og
OF TROPICAL MEDICINE HYGIENE
16-17 8 1913-14 =
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