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TULUN
O LL
THE JOURNAL OF
TLentcine and Xn pgtene
With which is incorporated “CLIMATE”
G)ropical
Embodying Selections from THE COLONIAL MEDICAL REPORTS.
AND
A BI-MONTHLY JOURNAL. DEVOTED TO MEDICAL, SURGICAL AND
SANITARY WORK IN THE TROPICS
*
*
. D
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.FrLon.; Ap C. M. WENYON, M.B., B.S., B.Sc.
Sm RONALD ROSS, K.C.B., F.R.S., Mason 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,
83.01, GREAT TITCHFIELD STREET, OXFORD STREET, W.
INDEX TO
JANUARY 1 to DECEMBER 15,
AKULA, Sub.Assistant Surgeon T. G., and Liston, Major W.
GLEN, 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 l
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 l Tus
ASHBURN, P. M., VEDDER, E. B., and Genrry, 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,
208; 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
BaARLING, Seymour, M.8., 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-SMITH, 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, 93
Bax and BnRAirLoN.—Hemorrhage late in typhoid fever, 343
Beppvogs, T. P., F. R.C.S.— Psittacosis, 83
BELL, J.—Note of a case of liver abscess treated without
operation, 33
Brirp, FRED T.— Surgery of the subphrenic space, 344
Brat, Col., I. M.S.—Sand-fly fever, 251
BRAILLON and Bax.—Hemorrhage late in typhoid fever, 343
BBEINL, ANTON.— 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
Bruers, CHARLES T., S.M., SrRosG, RicHARD P., M.D., TvzzER.
E. E., M.D., SELLARDS, A. W., M.D., and GASTIABURU,
J. C.—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
| chronic malaria with enlarged spleen, 328 ; 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
CARTEB, R. MankKHAM, I.M.S.—Emetine and ipecacuanha:
their amosbacidal value in pathogenic amabiasis, 153
Casavx, Dr. J.—-Hydatid cyst of the liver, 173
CASTELLANI, ALDO, M.D.—Further case of entoplasmosis, 88 ;
Further researches on combined vaccines, 326; Note on a
case of osteoperiostitis developing after & probable attack
INDEX OF AUTHORS.
VOL. XVII.
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),
118; Notes ou 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 Ancnar-
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'FABBELL,
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
Cumston, 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 Mero, Dr. —Beoriberi in Portuguese India, 125
Duke, H. LynpuHurst, M.D., D.T.M. and H.Camb.— Wild
^ gamo as a reservoir for human trypanosomes, 89
DuTCHER, 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
EscoMEL, E.—Human actinomycosis in Peru, 186
FaARRANT, RUPERT.— Causation, prevention and cure of goitre,
endemic and exophthalmic, 232
FERGUSON, Prof.—Secondary changes due to bilharzia ova in
the spinal cord, 250
Force, Jonn Nivison, M.D., M.S.—An investigation of the
causes of failure in cow-pox vaccination, 201
Force, JoHN Nivison, M.D., M.S., and Gay, FREDERICK P.,
M.D.—Skin reaction indicative of immunity against
typhoid fever, 103
Fraser, Dr., and Stanton, Dr.—Beriberi,
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.. STrRoNcG, HicHaRD P., M.D., TvzzvR,
E. E., M.D., Bruers, CHanrES T., S.M., and SELLARDS,
A. W., M.D.— Verruga peruviana, Oroya fever and uta, 11
the rice theory
Aa83:2272
lv. INDEX
Gay, FREDERICK, P., M.D., and Force, Joun N., M.D.— Skin
reaction indicative of immunity against typhoid fever, 108
Gentry, E. R., ASHBURN, P.M., and Vepper, E. B. —Some
experiments on the inoculation of monkeys with small-
pox, 170
GiRLING, Dr. E. C.— Treatment of yaws and their sequele by
means of salvarsan, 193
Gorcas, 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 spirochætosis, 194; Mollus-
i Jibrosum pendulatum atque elephantiacum (illustrated),
1
HAwTHORNE, C. O., M.D.—Importance of rectal examination,
843
Heuir, Col. P., I.M.S.— Prevention of malaria in the troops
of our Indian Empire, 296
Heiser, 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
HovsToN, Capt., R.A.M.C.—Sand-fly fever in Peshawar, 252
Jack, Rupert W.—Tsetse-fly and big game in Southern
Rhodesia, 315
Kexa, Liu Boon, M.B., C.M.Edin.—Brief note on amoebic
dermatitis, 193; Preliminary notes on entamebiasis, 227 ;
Further notes on entamoebiasis, 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 I.E., I.M.S.—Education and position of the
sanitarian in the Tropics, 250
Kina, Hanorp H., F.E.S.— Observations on the breeding-
places of sand.flies (Phlebotomus 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.8.—Immunity of
certain tracts from plague, 92
Liston, Major W. Grex, 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, GEonRGE 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, GgonaGE 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
Luxis, Hon. Surg.-Gen. Sir Parpey, K. H.S., K.C.S.1., M.D.,
F.R.C.8. —Introductory address, Third All India Sanitary
Conference, 76
LUNDIE, ALEXANDER, M.B.— Detection of trypanosomes in
animals, 22
Macatrian, Dr. A. F.-—Preliminary note on the ankylostomias‘s
campaign in Egypt, 249
McCoNNELL, R. E., B.A., M.D., C.M., D.T.M.—Dracontiasis
or dracunculosis : a review, 337
McDosaGH, J. E. R., F. R.C.S.—Ulcus molle serpiginosum, 41
MacGiLcHnIsT, Major A. C., I. M.S.--Stegomyia survey, port
of Calcutta, 7
McMriLLaAN, JoHN Furss, L.R.C.P.Lond.,
L.S.A. — Asiatic cholera, 354
MAGAREY, A. CAMPBELL, M.S., M.R.C.S.—A_ solitary obso-
lescent pelvic hydatid, 254
MARETT, 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. GoNZALEZz.— Canine babesiasis
Rico, 194
MavNARD, G. D.— Pneumonia on the Rand, 121
MuscRAvE, W. E.—Infant mortality iu the Philippine islands,
167
NELIGAN, A. R., M.D.Lond., M.R.C.S., D.T. M. and H. Cantab.
— Case of Leishmania tropica with a fatal termination, $22
Newman, E. A. R., M.D.Cantab.—Operative treatment of
hepatic absces:, 138
M.R.C.S. Eng
o')
in Porto
O'CoNNELL, MarrHgw D., M.D.— Meteorology of malaria, 97,
821
QO'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), 278
PuHILLIPs, Professor LLEWELLYN P.—Is emetine sufficient to
bring about a radical cure in ameebiasis ? 250 ; Use of liquid
paraftin in enteric fever with constipation, 255
PraTE, Professor Lupwic. — Brief note on Toxoplasma,
Castellani, 1913 (illustrated), 98
PRENTICE, GEoRGE, 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
REvNaUvD, Dr.—Recruiting, 157
Rogers, LEONARD, M.D.—T wo cases of sprue treated by mouth
streptococcal vaccines and emetine hydrochloride hypo.
dermically, 199
Rocers, LkoNARD, M.D., and Price, J. Dopps, M.R.C.S.,
L.R.C.P.—Uniform success of segregation measures ia
eradication of kala-azar from Assam tea-gardens, 55
Royster, HunBERT A.—FElephantiasis and the Kondoleon
operation, 254
SANDES, Joun D., I.M.S.—Treatment of liver abscess, 141
SCHERESCHEWSKY, J. W. —Trachoma in steel mill workers, 107
Scorr, Dr. H. HaroLD. — Vomiting sickness of Jamaica, 959
SELLARDS, A. W., M.D., Strona, HicHaRD P., M.D., TyzzER
E. B., M.D., Bruges, CHARLES T., S.M., and GASTIABURU,
J. C.—Verruga peruviana, Oroya fever, and uta, 11
Yosuipa. — Testicular neuritis following gonorrheeal
epididymitis, 166
SICARD, MoNTGOMEBRY H., M.D.—Trichinosis, with a report of
fifteen cases, 347
Simpson, 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
Stawron, Dr., and FRasER, Dr.— Beriberi, the rice theory and
recent criticisms, 252 |
Strong, RicHaRD P., M.D., Tyzzer, E. E., M.D., BRuEs,
CHARLES T., S.M., SELLAnRDS, A. W., M.D., and Gastia-
BURU, J. C.—-Verruga peruviana, Oroya fever, and uta, 11
STRONG, W. M., M.D., B.C., D.T.M. and H.Camb.—Beriberi
in Papua (British New Guinea), 310 l
Swirr, 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 Young, W. J.—Coastal climate of tropical
Queensland (illustrated), 225
TcHupNowsky, Dr.—Acclimatization in the Tropics, 39
Tvzzkn, E. E., M.D., Strona, RicHARD P., M.D., Bruss,
CHARLES T., S.M., SELLARDS, A. W., M.D., and Gasria-
BURU, J. C.— Verruga peruviana, Oroya féver, and uta, 11
VEDDER, E. B., AsHBURN, P. M., and Gentry, E. R.—Bome
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
SHU
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, Gzonazx 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
WHITE, Mark J.— Examinations for hookworm ova, 103
WooLLEY, Paut G.— Insolation: its prophylaxis and treat-
ment, 230
YATES, A. QG.--Hydatid disease of the lung spontaneously
cured, 186
Younc, W. J.—Study of the nitrogenous metabolism in
chyluria, 242
Youna, W. J., and Tavron, F. 1I.— Coastal climate of tropical
Queensland (illustrated), 225
YovNo, W. McCounBiE.—Segregation and kala-azar, 814
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
—— on a foreign body removed from the liver after
twenty-three years. By Seymour Barling, M.S.,
F.R.C.S., 200 |
A hardy annual, 380
** A human recovery from trypanosomiasis’ (illustrated), 81
A school of Oriental studies, 285
A solitary obsolescent pelvic hydatid, 254 Notes on distribution and habits of stegomyia mosquitoes
A useful prescription in chronic malaria with enlarged spleen, in Madras. By Capt. J. H. Horne, I.M.5., 8
823 ---- on life assurance in Egypt. By Harold Benjamin
Abscess, liver, ease of, treated without operation, 93 i Day, M.D., M.R.C.P., 10
ABSTBACTS ;—
A solitary obsolescent pelvic hydatid. By A. Campbell
Magarey, M.S., M. R.C.S., 254
Acclimatization in the Tropies. By Dr. Tchudnowsky, 89
An investigation of the causes of failure in cow-pox vac-
cination. By John Nivison Force, M.D., M.S., 201
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 and
exophthalmic. By Rupert Farrant, 239
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, 298
Education and position of the sanitarian in the Tropics.
By Col. King, C.I.E., I1.M.9., 250
Elephantiasis and the Kondoleon operation. By Hubert
A. Royster, 254
Emetine and ipecacuanha: their amoebacidal value in
Bes ropenie amebiasis. By R. Markham Carter, I.M.S.,
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,
848
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.8., 92
Importance of rectal examination. By C. O. Hawthorne, 848
Infant mortality in the Philippine Islands. By W. E.
Musgrave, 167
Influence of climate, disease, and surroundings of the white
race living in the Tropics. By Anton Breinl, 267
Insolation: its prophylaxis and treatment. By Paul G.
Woolley, 280
lntestinal 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.O.8.I.,
M.D., F.R.C.S., 76
Is emetine sufficient to bring about a radical cure in
amcobiasis? 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, 58
Manila Bureau of Health report for 1918. 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.
Brock, L.B.C.P. & 8. 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. O. 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 aukylostomiasis 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, 800
Pulmonary attack simulating primary lobar pneumonia.
By Lewis A. Conner, M.D., 104
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., 188
—— —— on sprue. By Dr. P. H. Bahr, 252
Recommendations as to sanitation concerning emplovees 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.O., 252
Secondary changes due to bilharzia ova in the spinal cord.
By Prof. Ferguson, 250
Segregation and kala-azar. By W. MoeCombie Young, 814
Skin reaction indicative of immunity against typhoid fever.
By Frederick P. Gay, M D., and John N. Force, M.D.,
108
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.8., 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, 178
Surgery of the subphrenic space. By Fred. T. Bird, 844
Surgical treatment of colitis and post-dysenteric condi.
tions. By James Cantlie, F.R.C.8., 252
Testicular neuritis following gonorrheal 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.,
141
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
T wo cases of sprue treated by mouth streptococcal vaccines
and emetine hydrochloride hypodermically. By Leonard
Rogers, 199
Ulcus 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. McDonagh,
Vomiting sickness of Jamaica. By Dr. H. Harold Salt,
258
Wild game as a reservoir for human trypanosomes. Bv H.
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 syriuge 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 & radical cure
in? 250
—-, pathogenic, amcoebacidal value of emetine and ipecacu-
anha in, 153
Amosbic dermatitis, brief note on, 193
Anemia, clinical evidence of bi-palatinoid orrefin in, 111
An Indian voluntary aid contingent, 325
An TENOR of the causes of failure in cow-pox vaccination,
1
Animals, acclimatization of, iu the Zoological Gardens, London,
61
—, 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, 880
Antimony in dermal leishmaniasis, 324
Argas and spirochietes, 27
Ascaris in pyopneumothorax, 314
Aseptic hypodermic injections, 218
Balantidiasis, 61
Beriberi in New Jersev, 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
$$ - —— m
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 a means of excluding flies, 185
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 Tropics, 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 Kast 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 i
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, 813
Thread-worms aud appendicitis, 314
Trachoma, 87
Transmission of pellagra from man to monkey, 46
* Traumatic malacea " following fractures, 378
Treatment of enteric fever, 379
—— of infantile diarrhoea 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, fumigatiug 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, 312
Atropine in sea-sickness, 150
Australasian Medical Congress, Auckland, 1914, 64
Australasian Medical Gazette, 13
Australia, British Association meetings in, 165
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 affinities of, 879
——, 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 sleéping 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 amoebic dermatitis, 193
—— on Toroplasma pyrogenes, Castellani, 1913: (illus-
trated), 98
British Medical Association, 80, 228, 247
—— —— —, programme, 158
Association meetings in Australia, 165
Bronchial spirochztosis, 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, 88
—— of Leishmania tropica with a fatal termination, 822
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), 118
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, 84
—— , Mecca pilgrims and, 363
——, 8hip-borne, 25
—— vibrio, recognition of, 182
Chronic ulcers of the leg, treatment of, with frog flesh poultice,
Chyluria, nitrogenous motabolism 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, 368
Comparative diseases of the British West Indian Colonies, 252
Condeosed 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, 852
Kurloff's bodies, 208
Course in venereal disease, 152
Cow's milk, 216
INDEX vii.
Cultivation of a free living filterable spirocheete, 188
—— of Piroplasma canis, 58
Culture of Leishmania from the finger-blood of a case of Indian
kala-azar, 49 Ss
Cyst, echinococcus, of pancreas, 3
———, hydatid, of the liver, 178
, suppurating hydatid, 173
Cystopurin, 30
D
Death following the sting of & scorpion, 199
—— rate, infant, in Burma, 350
Dengue, epidemiology of, 152
Dermal leishmaniasis, antimony in, 324
Dermatitis, amasbic, 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, 363
in the East, distribution and spread of, 293
Disinfecting and fumigating appliauces, 16
Disinfection as practised at the present time by the use of
steam and formol apparatus, and disinfection by means of
‘Clayton ° machines, 174
Distribution and habits of stegomyia mosquitoes in Madras, 8
— and morphology of Spiroclweta duttoni aud S. kochi, 197
—— and spread of diseases in the East, 293
Dracontiasis or dracunculosia: 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 f
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 amoebacidal value in patho-
genic amoebiasis, 153
—— and its value as a therapeutic agent in &moebiasis and
other diseases, 183
———., is it sufficient to bring about a radical cure in amoebiasis ?
250 |
— treatment of dysentery in young children, 16
-Entameebiasis, further notes on, 244
——, preliminary notes on, 227
Enteric fever, 363, 879
——- — —., treatment of, 379
Entericoid fever, 24 ,
Entoplasmosis, a further case of, 83 ie
Epidemic dysentery in the Fiji Islands, 109
Epidemiologic studies of acute anterior poliomyelitis, 51
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, 348
Examinations for hookworm ova, 103
Exanthematic typhus, 59 |
Experiments with malarial parasites aud Piroplasma canis, 72
Exploration, diagnostic, of the right hypochondrium, 182
Extracts from medical papers, 188
a disease associated with a parasite in
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, 187
Flies and disease, 218
—— and public health, 150
——, the geranium as a means of excluding, 185
Food, scarcity of, in war, 812
Foreign body removed from the liver after twenty-three years,
200
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,
84
Fruits and their action, 376
Fulminating gangrene of the genitals, 218
Fumigating and disinfecting appliances, 16
Further case of entoplasmosis, 83
—— notes on entamoebiasis, 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, 185
Germ transformation, 176
Germany and Great Britain, small-pox in, 168
— Western, spas in, 180
Glanders, 176
Goitre, endemic and exophthalmic, causation, prevention and
cure of, 232
Gorgas, Surg.-Gen., address by, on sanitary work in the Panama
Canal, 102
—— ——, dinner to, 99
Great Britein and Germany, small-pox in, 163
Gunshot and bayonet wounds of the stomach, 365
Habits and distribution of stegomyia mosquitoes in Madras, 8
Hemorrhage late in typhoid fever, 348
Helminthemesis, 198
Helminthological investigations, 84
Hepatic abscess, operative treatment of, 138
, see also liver abscess.
Hookworm ova, examinations for, 103
Human actinomycosis in Peru, 186
Hydatid cyst of the liver, 178
, suppurating, 178
— 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 : —
À camphor distillery, 117
Charts illustrating sleeping sickness in the lado of the
Anglo-Egyptian Sudan, 278, 281, 282, 989
—— —— the coastal climate of tropical Queensland, 225
Diagram to show possible relationships of Trichophyton
currit, 262
— illustrating the transmission of Trypanosome brucei
of Nigeria by Glossina nigertense, 373
INDEX
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, 118
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, 318
Infant death rate in Burma, 350
——— mortality in the Philippine Islands, 167
Infantile diarrhoea, 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, 286, 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 amoebacidal value in patho-
genic &moebiasis, 153
Is emetine sufficient to bring about a radical cure in amee-
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, 368
Cow's milk, 216
Dinner to Surgeon-General Gorgas, 99
Discussions at the Trapical 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, 85
International Congress of Trapical 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, 312
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 & case of Indian
_kala-azar, 49
tropica, case of, with a fatal termination, 322
Leishmaniasis, dermal, antimony in, 824
———, natural, of dogs in Algiers, 86
Leprosy, 18, 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, 178
—— abscess, case of, treated without operation, 83
—— —— treatment of, 141
—— ——,, see also Hepatic abscess
Liverpool School of Tropical Medicine, 240
Livingstone College, 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 Puce 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 1918, 105
Mecca pilgrims and cholera, 368
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, 868
Metabolism, nitrogenous, in chyluria, 242
Meteorology of malaria, 97, 321
Midge, new blood-sucking, 48
Milk, artificial, from the soy bean, 176
— ——, supply of, to Indian cities, 318 _
Milks, condensed, keeping properties of, in the Tropics, 46
Mineral constituents of our food, importance of studying the, 85
Miner's phthisis on the Rand, 119
Missile, a new, 369
Molluscum fibrosum, pendulatum atque elephantiacum (illus-
trated), 291
Mortality on tbe 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, 187
Necessity for a women's Indian medical service, 66
Neuritis, testicular, following gonorrhwal epididymitis, 166
New blood-sucking midge, 48 |
geographic locality for Balantidtosis coli, 99
Jersey, beriberi in, 84
malarial parasite of man, 152
missile, a, 863.
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, 69
variety of coffee, 189
Yealand, pellagra in, 168
' Nitrogenous metabolism in chyluria, 242
North Manchurian plague prevention service, 835 |
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, 83
——- —— of osteoperiostitis developing after a probable 1ttack
of '' febris columbensis,’’ 177
—— on a foreign body removed from the liver after twenty-
three years, 200
— on an intestinal protozoal parásite producing dysenteric
symptoms in man (illustrated), 65
Nores AND News :—14, 81, 46, 64, BO, 128, 176, 188, 240, 256,
286, 884, 850, 380
—— on the hyphomycetes found in sprue (illustrated), 305
———, personal, 84, 192, 836, 352
0
Observations on the breeding places of sand-flies (Phlebotomus
spp.) in the Anglo-Egyptian Sudan, 2
Occurrence of certain structures in the erythrocytes of guinea-
pigs and their relationship to the so-called parasite of
yellow fever (illustrated), 369
Operation, early, for gall-stones, 849 i
Operative treatment of elephantiasis scroti, 25
of hepatic abscess, 188
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 l
A useful prescription in ehronic malaria with enlarged
spleen. By James Cantlie, M.B., F.R.C.8., 823
Ankylostomiasis in the North Nyasa district. By A. G.
Eldred, M.R.C.S., L R.C.P.Lond., 209 i
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., 854 Gu
Babesia or piroplasma. By Albert J. Chalmers, M.D.,
F.R.C.S., D.P.H., aud Capt. R. G. Archibald, M.B.,
R. A. M.C., 828
By W. M.
By Dr. T. S.
Beri-beri in Papua (British New Guinea).
Strong, M.D., B.C., D.T.M. & H. Camb., 810
Brief note on amcebic dermatitis. By Lim Boon Keng,
M.D., C.M. Edin., 198 "ic s
—— —— on Toxoplasma pyrogenes, Castellani, 1918. By
Prof. Ludwig Plate (illustrated), 98 |
Bronchial spirochstosis. By Frank S. Hatper, W.A.M.S.,
194 | |
Canine babesiasis in Porto Rico.
Martinez, 194
Case of Leishmania tropica with a fatal termination. By
A. R. Neligan, M.D.Lond., M.R.C.8., 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.
McConnell, B.A., M.D., C.M., D.T.M., 837
By Dr. I. Gonzalez
By 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.
83
—— notes on entamaebiasis. By Dr. Lim Boon Keng, 244
Meteorology of malaria. By Mathew D. O'Connell, M.D.,
97, 321
Molluscum 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 & new geographical locality for Balantidiosis coli.
By Major B. H. Dutcher, 99
—— on an intestinal protozoal parasite producing dysen-
teric symptoms iu 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),
805
Observations on the breeding places of. sand-flies (Pile-
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-
irated), 369
Preliminary note on entamoebiasis.
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, 168
Sleeping sickness in the Lado of the Anglo.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 bruce: of Nigeria by Glos-
sima lachinoides, with some notes on Trypanosoma
nigeriense. By G. H. Gallagher, L.R.C.P. & S.I.
(illustrated), 372
Treatment of chronic ulcers of the leg with frog flesh
poultice. By Lim Boon Keng, M.B. Edin., 84
—— of yaws and their sequele 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 evidenca of bi-palatinoid, in angmia, 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 dysent3ric 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, 304, 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), 853
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 entamoebiasis, 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 i
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, 118
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, 18.
—, 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
Rand, miner's phthisis on the, 119
—— , mortality on the: some of its causes, 119
——, pneumonia on the, 121
————— —— — — M — —— o — — o — ——— — M — — —— —— — €.
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 amoebiasis 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 F'ilaria 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,
342
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., 86
Researches in sprue, 1912-1914, 203
Reviews, 31, 63, 96, 128, 143, 187, 208, 255, 320, 334, 351
Rice, & disease of, 135
—— , Burma, 333
Ringworm yaws, 114
Royal Institute of Public Health, Edinburgh Congress, 198
By Aldo Cas-
Saline injections, treatment of infantile diarrhoea by, 68
Salvarsan in the treatment of yaws, 24
Sand-flies, Beending 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 &nnouncements 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, and 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), 853
Society of Tropical Medicine and Hygiene, 46
Some aspects of surgery in the Tropics, 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, 197
——— and S. kochi, distribution and morphology of, 197
Spirochete, cultivation of a free-living filterable, 138
Spirochsetes and argas, 27
———Ó
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, 298
Sprue, arthritis in, 1
, notes on the hvphomycetes 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, sbip, 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 Tricophyton Malmsten 1845
(illustrated), 289
T
Teff, a valuable tropical and sub-tropical hay crop, 380
Testicular neuritis following gonorrhoeal 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
Toxoplasma 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),
872
"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 sequel: 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
Trypanosonies, detection of, in animals, 99
—— human, wild game as a reservoir for, 89
Trypanosomiasis, 59
——, & human recovery from (illustrated), 81
Tsetse, sleeping sickness-and big game, 91
xli.
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 immunity 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, 342
U
Ulcers, chronic, of the leg, treatment of, with frog flesh
poultice, 34
Ulcus 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 dysenteric 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 aie elephantiacum, face
291
Mürmokiasicsis amphilaphes — Plate T, face p. 129
—— — —— Plate II, face p. 133
—— —— Plate IIl; face p. 135
INDEX OF
INDEX
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, 152
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, 312
, Science and, 325
West Africa, vellow fever in, 14
Wild game as a reservoir for human trvpanosomes, 89
Women's Indian medical service, necessity for, 66
Wu Tien Teh honoured, 64
Y
Yaws, ringwom, 114
-——, salvarsan in the treatment of, 24
——, treatment of, and their sequelae by means of salvarsan, 193
Yellow weyers 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,
ace 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. 117
SELECTIONS FROM COLONIAL MEDICAL REPORTS.*
GENERAL INDEX.
(25) Southern Nigeria, 1
(26) British Honduras, 3
(27) 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, Epwarp.—Grenada, 50
FORDE, 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. Dovaras.—China, 69
HARRISON, J. H. Huen.—British Honduras, 3, 82
* Note to the Binder. —These are to be bound to follow: all the numbers of THE JOURNAL OF TROPICAL "MEDICINE,
(86) British Honduras, 82
(37) Fiji, 85
(88) St. Kitts-Nevis &nd the Island of Anguilla, 102
(39) Durban Corporation, 108
(40) Lahore Municipality, 118
(41) Mauritius, 117
(42) Municipality of Colombo, 119
(43) Cyprus, 181
(44) New Providence, 133
(45) Federated Malay States, 135
AUTHORS.
Ker, J. E.—Jamaica, 31
LamaLEy, W. H., M.D.—Gold Coast, 62
Lyncyu, W. G. A.—Fiji, 17, 85
Murison, P., M.D., B.Sc., D.P.H.—Durban Corporation, 108
NEWZELL, 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
Partir, W. MARSHALL.— Municipality of Colombo, 119
Sansom, CHARLES La4NEÉ.—Federated Malay States, 135
StracHan, H.—Southern Nigeria, 1
— — —
Jan. 1, 1914]
Original Communications.
ARTHRITIS IN SPRUE.
By GrorGeE 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 amebic 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 & 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 diarrhoea (one
or two slight attacks, but not recently).
Present lllness.—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-
rhoea 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 1, Vol. XVII
a
Examination.—Teeth healthy, no sign of pyor-
rhæa, 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. 80%
Differential Number counted Per cent.
Polymorphonuclear 334 oe 66:8
Large mononuclear p 14 2:8
Lymphocytes _... a 126 25°2
Eosinophile pia sai 15 8
Transitional oa uis 11 e 2'2
Mast cells D m 0 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 quickly 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.
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 rheumatic 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 & 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-
{Jan. 1, 1914.
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 HaRorp H. Kine, 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 pupæ in cellars
and similar places among damp bricks and refuse.
Howlett [2 and 8], 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 & number of
larvæ 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.]
soaked with water and cotton seeds planted in it.
On the 17th the jars were netted over and & 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
23rd an adult Phlebotomus papatasii, Scopoli, 1786,
was noticed in one of the jars against the side, about
9 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 pupe
in similar situations in both jars, and for the next
few days fresh pupe 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 pupe
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 larvee 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-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 3
—
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 18, 1918.
REFERENCES.
(The numbers correspond with those in the paper.)
[1] B. Grassi: “Ricerche sui Flebotomi," Memorie della
Socwtd, Italiana della Scienze, Section 8a, t. xiv, pp. 858.894,
1907.
(2) F. M. HowrzErT: ''Indian Sand-flies," Indian Medical
Congress, 1909, Section 8, pp. 289-242.
(8) F. M. Howrzrr : ` The Breediug- places of Phlebotomus,”
Proceedings of the Third Meeting of the General Malaria
Committee, held at Madras, November 18, 19 and 20, 1912.
Abstracted in the JouRNAL or TROPICAL MEDICINE AND
HYGiENE, vol. xvi, No. 16, pp. 255-256.
[4] P. J. MaBETT: ‘ 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. NEw&TEAD: '' The Papataci Flies (Phlebotomus) of
the Maltese Islands," Annals of Tropical Medicine and
Parasitology, vol. v, No. 2, August, 1911. p. 141.
. H. Kina: '*On the Bionomics of the Sand-flies
[6] H
(Phlebotomus) of Tokar, Anglo-Egyptian Sudan."
EE —
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 and Hygiene
JANUARY 1, 1914.
USE OF NEW REMEDIES IN
TROPICAL COUNTRIES.
IT is surprising how speedily a newly introduced
drug or réle of treatment is taken up by medical
men residing in the Tropics; 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
upproved 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 in
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
THE
(Jan. 1, 1914.
—-.-
hands and he has to do his best without in many
cases 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, has 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
Fijians, 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 vaws 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-castes 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.
THE 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 justitication, 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
missicsary, 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.
ee
Ova in Stools.—McNeill, writing in the Journal
of the American Medical Association, November 1,
1918, 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 & 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 th2
method which Dock and Bass recommend, as ıb
requires less time, and there is less residue thrown
down with the ova.
6 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Abstracts.
PAPERS ON THE DISTRIBUTION OF
STEGOMYIA IN INDIA.*
(1) A STEGOMYIA SURVEY OF THE CITY AND ISLAND
OF BOMBAY.
By Major W. GLEN Liston, M.D., D.P.H., 1.M.S.,
AND
Sub-Assistant Surgeon T. G. AKULA.
Bomsay 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
2,358,893 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 cóld 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 Cultcine
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 ol
these mosquitoes to others of this group was 59 per
cent., or about 30 per cent. of ell 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
more open country or suburbs. Stegomyia fasctata
* Proceedings of the Third Meeting of the General Malaria
Committee, held at Madras, November 18, 19, and 90, 19192.
Simla Government Central Branch Press, 1913.
[Jan. 1, 1914.
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 zinc
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 occasionally found in pools und 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 22°5 per cent. of the whole of the
Stegomyta 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
wus generally found breeding in dirty water
coloured brown by organic 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
cattle 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
occasionally met with. On one occasion larve of
Culex mimeticus were collected, und also a mosquito
Jan. 1, 1914.]
e — te — — eg € IM III
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 domestie use, or where it has collected in
disused utensils during rain. The climate and
trade 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 or BOMBAY.
Number of places
Species in which larvæ
wore found
Stegomyia fasciata ... T ius ee ai
Stegomyia scutellaris i as T 5- 56
Scutomyia sugens ... se M a .. 104
Desvoidea obturbans a TE Ns je 29
Culex concolor us s aie ee .. 949
Culex fatigans ioi sss ss - .. 197
Teniorhynchus perturbans T m = 13
Culex mimelicus ... ves a 1
Total breeding places examined gu 922
(2) STEaGoMYrA SurvEy—Port or CALCUTTA.
By Major A. C. MacGiccurtst, I. 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. faaciata 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 Calcutta this mosquito has been
found only in the densely populated parts of Cal-
cutt& 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. fasciuta 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 Calcutta, 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 7
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. fasciuta 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. (This
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 Calcutta 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 coco-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. scutelluris 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 cureumstances 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 un opportunity. Under
8 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ordinary or usual natural conditions,
been caught biting at night.
The species Desvoidea obturbans
was very
common in the Kidderpore Docks and elsewhere. '
It bites to some "
It breeds in foul stagnant water.
extent in the day-time.
Leucomyia gelida was very common in Calcutta
and neighbourhood during August and September;
it breeds readily in earthen pots.
Toxorhynchites.—Two species of these giant
mosquitoes are found extensively in the port of
Calcutta (1) with banded legs, and (2) with un-
banded legs. They are rare in the centre of
Calcutta, 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 Tozorhynchites can kill larve of
Stegomyia three or four times its own size, and
can easily dispose of half a dozen good-sized larvee
of another genus in about half an hour.
(8) NorEs 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 Stegomyta
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,
Ae,
3) Drains, open and underground.
(Jan. 1, 1914.
none havel (3) Wells, surface and deep; both indoor and out-
= door.
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 larvæ 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
‘‘@eep ’’ 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 & 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 & household pest, and it is likely
Jan. 1, 1914.]
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.
(8) 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 scale structure, and resemble it in their vicious
habit of biting by day.
ERADICATION OF MALARIA.*
By C. C. Bass, M.D.
New Orleans.
ERADICATION 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.
———————— a ———— ee
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 9
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
a question of dissemination of a very few very
simple facts and the co-operation of the entire
PoP aton to benefit by the knowledge of these
acts.
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 public 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 public 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 naturally 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 HanRorpD BEgNJAMIN Day, M.D., M.R.C.P.
LIFE 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 ite
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 increasing 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 Officers’
Association on May 7, 1918.
Jan. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 11
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 habite 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
indieator 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
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 RicHagD P. Srrone, M.D., E. E. Tyzzer, M.D.,
CHARLES T. Brugs, S.M., A. W. SzLLARDS, M.D., and
J. C. 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 instruction 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
partieularly 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 1848 to 1871 & 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, & 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
— — ee
* ‘* 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 septicsemia.
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 Bucillus 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 Biff 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, Gastiaburu
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
tvpes 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 earried on in the Municipal Laboratory
of Hygiene, in the hospitals of the city of Lima,
in the mountain towns of Santa Eulalia, San
Bartolomé, Sureo, 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 8
microns 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.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 18
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, &nd 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 ansemia 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 characteristies 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 chromatinic 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-
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, according to the Commis-
sioners, that verruga peruviana represents an
entirely distinct disease, and that it is not a form
of frambeesia or of syphilis. The disease owes its
origin to & 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, 19183.
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 |undred 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.
(Jan. 1, 1914.
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. 374-390) that the diagnosis of
yellow fever could hardly be accepted 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
atypical, probably mild, cases in natives, especially
native children, but exact knowledge of the
character and frequency 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
Africa, 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.
— — —9—— ———
Motes and Mews.
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 class of people. Many
well-dressed men and women are seen with smooth,
perfect skins. Even a coolie is occasionally noted
who gives no visible evidence of having had the
disease, It is stated that the inoculation operation
consists of powdering the scabs of the disease and
blowing the product i to 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 wil 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
ut 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.]
-m ee — o ee e
These marks are called mo:3 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 ot
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 cases,
although the disease is constantly present. |
. As regards foreigners, by far the most cases occur
in new arrivals.. The residents learn to practise
frequent vaceination, 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 eome in contact with these people—the
most favourable conditions. for contracting the
— ———— —— ——— —— M — — a — n
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 15
— — —À — — - ——-l-—.- CUM HE
disease are the result of the entire circumstances.
The beggars and native city distriets 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
cases of small-pox patients having been exposed to
the credulous sympathy and liberality of incautious
foreigners have occurred. Some will consider such
cases 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 which 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 carry the men all over the city and into all
places, going and coming to and from work, would
scem to make all or any intereourse with the natives
dangerous.’
The instinct of economy m 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 pneumatic 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.
Finally, 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 sanipan 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 sears. This
means recent small-pox aboard, and as the infective
agent has great vitality, and as conditions for its
life and propagation are especially favourable on a
sampan, the danger is at once scen to be positive.
If one wishes to use a boat one should be used
whieh 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.
TM T) hein 4a. SP ma qe cmm
REN d
Tue third quarterly number of the Bulletin of
the Imperial Institute, vol. xi (1913), 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 articles 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
subject (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 coucludes with some general notes
and reports of recent progress in agriculture and
the development of natural resources, together with
notices of recent literature.
————_>—_______
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.
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.
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.”
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 CaNTLIE, 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 cæcum—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 instance, 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 mattér 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-stethostope
the limits of the liver can be gaugéd with almost
liair-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
Fic. 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.
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
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-
The sounds heard when the stethoscope is
venient.
Fic. 5.—S. stethosoope applied. @, “loud notes over liver ;
O, faint sounds over heart and stomach.
[Jan. 15, 1914.
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 which 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 a3
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
. *-
«4 2c r
Aæ a KJ p
Y.
e.
lal t
J we
Re ———»-- -e———- we -
es ad t
E PAR
-saa
Fig. 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, &c.). 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 dawer
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 diagnostic 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 the
lower edge of the liver, as in stout people or in
cases of distensions from gas in the intestines or
fluid in the peritoneal cavity, the fork has to be
—— eee —— —
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
Fio. 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). l
An effusion into the pleura is at once detected
by the funing-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
Jan. 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 19
assistance, for neither by percussion, palpation, nor
by auscultation can it be positively diagnosed
whether the dulness or absencé of breath sounds is
`
Ri
»
e
@ loud
S, stethoscope ;
sounds; O, faint sounds,
Fic. 8.— Effusion into pleura,
due to pleuritie effusion, to an abscess of the liver,
or to a liver pushed upwards towards the lung by
abdominal distension, &c.
18. 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 cecum 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
specifie 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. Verane, 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 & marked typhoid state. The patient is very
restless and at times there is & low muttering delirium.
The temperature is high, and may reach 415? 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 &lmost
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 eatalepsy. 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." TYvPHUS-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. 91
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
^" t of a mummy. It is. only a charred piece of
esh. Es
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.—From 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 40'5? 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.
Resptration.—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.
Hypodermic 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.
29 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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 &
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 1s 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.
(Jan. 15, 1914
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THE JOURNAL OF
Tropical Medicine and Hpgiene
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 a
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 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-
fly, 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 1918 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, Scotland, 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, 1913.
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 ha:
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
authorities 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 distinction, and all were
ready to listen to his explanations.
Dr. Sambon was especially struck by th»
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,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 23
—
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. Schwartz, 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 tho
Government authorities, by the medical men he
met, and by the veterinary departments in the
several Colonies he visited.
—— (la
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 rôle 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
medical and scientific investigations.
. As regards the tarbagan the author makes the
following statement, that the only definite proof
24 THE JOURNAL OF TROPICAL MEDICINE ANÐ HYGIENE.
[Jan. 15, 1914. .
that terbagans 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,
d experience which actually oecurred in March of
this vear.
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 28:6
days, as compared with an average stay of 34 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 & similar number of non-
injected cases, the saving effected in dietary alone,
after deducting the cost of the drug used in the
author'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.
—— ee
Entericoid Fever.—Riesman, writing in the
Journal of the American Medical Association (vol.
lxi, No. 25, December 20, 1918), 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, which 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. f
(2) Only that in which the characteristic serologic
and cultural tests for the typhoid bacillus are
obtained should be called typhoid fever.
(3) To the others, which clinically may resemble
typhoid very closely, the term '' entericoid fever ”’
may be applied.
(4) The entericoid fevers are due to different
strains of organisms of the paratyphoid group and
to others morphologically similar (Gärtner’s Bacillus
enteritidis, &c.). |
(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 eases 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-
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
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
specifie 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.
of the
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 bacteriologie 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 publie
health and confidence.
The Operative Treatment of Elephantiusis scroti.
—Taylor, of Yangchow (China Medical Journal,
vol. xxvii, November, 1913, No. 6), describes
a method of his own for operating upon elephant-
lasis 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 drapmg 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 hemor-
rhage by his method.
26 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
As soon as the tourniquet is applied, a long
sagittal incision is made from a point on pubes in
good skin perpendicularly downward through the
preputial opening along the median raphe to a point
in good skin in the perinæum 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 eut 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 & matter of & 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 perinseum 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
cut 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 uf the cover-
ing of the penis. The incision is closed horizontally
across the pubic region down to the penis, and
from here downward vertically, 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 surfaces of the bisected
tumour, which are of course sterile. The -heavy
tumour -has to be lifted very little.
two, it falls apart, and rests between patient’s legs
It is gradually liberated by working
on the table.
As it is cut in
(Jan. 15, 1914.
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 scrotum 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, 1918). The following are
his notes of the case. On September 11 he was
called in to a case of malaria ina 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 shouldbe mentioned that the patient had a
decayed upper bicuspid’ 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
Jan. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 27
Ta
anything to do with the malarial infection per se.
If the patient had been anæmic 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. Marchoux and L. Couvy).—Two
interesting memoirs on the subject of the behaviour
of spirochetes in ticks, by the above-named
authors, have appeared in Nos. 6 and 8 of
the Annales de l'Institut Pasteur, 1918. In the
first of these the authors give an account of the
development of what may be called the granule
theory of spirochetes. Dutton and Todd were the
first to suggest that in ticks the spirochetes 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-
chetes. Leishman some years later drew attention
to the segmentation of the spirochetes 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
larve 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 340-370 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 o1
15°-20° C. after three or four days from their last
feed all spirochstes 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.
Blanc, 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
(coccoid bodies). Incubated at 39° C., these bodies
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 can 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
ticks. 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 is im-
possible to inoculate 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 15° C. the
celomic 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 spirochmtes 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 spirochstes.
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 spirochztes became much finer, so muah
so that they might very readily be overlooked. -Áf
the tick again feeds after starving the spirochetes
commence at once to increase in length and thick-
ness. If, however, the ticks are made to ingest
28 THE JOURNAL OF TROPICAL MEDICINE AND HYGIBNE.
saline solution instead of blood, the spirochsetes 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 eclomie fluid of the tick to contain a few
of these fine spirochetes 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 ca@lomic 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
28° C. for twenty-four hours, it will be noted that
fragmentation occurs. At 379 C. the fragmentation
occurs more rapidly, and it takes place also but
more slowly when the blood is kept in ice.
Similar changes ean be produced by submitting the
spirochetes to the action of specific anti-spirochete
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-spirochete 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 puneturing the dorsum of the tick
‘an intestinal hernia results, and from this, by means
of a fine pipette, intestinal fluid can be drawn off
‘fer examination. After eighteen hours the majority
af 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
nermal, one observes lurge masses of agglutinated
organisms- Spirochwtes may be observed to rest
with one extremity fixed to seme larger object.
During :this period of rest the body of the splrochete
‘appears te-uttraet ‘to itself granules of a refractile
-eharacter- which are- moving in the liquid. These
‘granules attach themselves to the spirochetes, but
ditectly there is the slightest movement on the part
| and perish.
[Jan. 15, 1914.
———s
of the spirochete or the fluid medium the granule
may give one the appearance of escaping from the
interior of the spirochaete. 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 hernie. 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
ure 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
spirochsetes—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 ewlomie fluid is shown
by the following experiments. Ticks were used in
whose ecelomie fluid spirochetes were fairly numer-
ous, but which contained no spirochetes in the
intestinal cæca. The ticks were then. fed on a
healthy animal and the gut tapped daily afterwards,
with the result that spirochetes nevet reappeared
in the gut, as they should have done if they were
able to pass from the eclom. 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, as they do also in the
blood which is kept aseptically in tubes. It seems
that these abnormal forms are produced as & result
of defective nutrition, and fmally, when the. diges-
tive. process is nearly complete, they also agglutinate
The authors then ask the question as to what
Jan. 15, 1914.)
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 379 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 & less extent, at the lower temperature, 15
to 189 C. Thouzh 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 spirochste 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, Hamaphysalis 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 injection of & 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 fact 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
vaceination; ‘while 700 have no’effeet? By the intra-
venous methed 17,000 will produce infection, while
*9-will give immunity. Tables giving the details ‘of
the various experiments are appended. Working
with the very susceptible embryo of the chick while
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 29
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 tiexs 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 cephalie 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 ean be obtained by compression of the tick
is really coelomic 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. | m a
- In addition to spirochetes in the salivary appara-
tus others are constantly present’ in the cephalie
glunds, 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 im the tick. (It was easy to
——Á
—
demonstrate that spirochætes 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 spirochætes 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 spirochsetes in the tick.
(8) 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 ccelom 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.
oe NERA
drugs and Appliances.
‘“ZANA Bartus,” 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 carbonic acid gas is liberated in
the bath. For use in the Tropics the Zana bath
is not only most refreshing at all times, but in many
skin affections, such as prickly heat, in which the
use of soap is deleterious, the Zana Bath is sooth-
ing and curative.
..PEAT Propucrs (SPHaGNOL) in the form of
soap 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
effeacious in relieving the irritation. For dhobie
itech and the skin affections due to excessive per-
spiration, attacking especially the axilla and peri-
neum, Sphagnol in its several forms as ointment,
soap, and sphagnoline (an emollient toilet cream)
i: useful. Peat Products (Sphagnol), Ltd., 18,
30 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE,
and ammonia).
(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),
1918. 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 hypertonic
saline solutions devised and applied by Major
Leonard Rogers. ‘‘ Tabloids " containing suitable
doses of emetine hydrochloride for use in arsenic
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.
HyPoPHYSEN 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.
'** BxuiN " 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. 14; 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.
. Cystopurin.—A. Wulfing and Cò., 12, Chenies
Street, London, have introduced Cystopurin as a
means of treatment for affections of the urinary
tract. It is a modified form of héxamethylene-
tetramine (a compound built up:of formaldehyde
Cystopürin is an: 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 kiled, 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 Oir, PmEPARATIONS.—Messrs. Allen
and Hanburys, 37, 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 which 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-
nificant of the principal ingredients of the combina-
tion; thus: Bynin amara contains nux vomica 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.
—_—_.
Hebrews,
A MANUAL OF PRACTICAL CHEMISTRY FOR PUBLIC
HEALTH STUDENTS. 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 carbolic acid in carbolic 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 public health students
in general and especially for those going in for the
D.P.H. diploma.
Tur MepicaL ^^Wrno's Wao ° rog 1914. Crown
8vo., pp. 812, xxv. 10s. 6d. net. The London
and Counties Press Association, Ltd., 39, King
Street, W.C.
From the preface we learn this i 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.
——————— 9,9 ————— —
Hotes and Mews.
MOSQUITO DESTRUCTION IN
QUEENSLAND.
STATISTICS prepared by the Health Doparümest
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.
39 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Personal Motes.
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.8.; Lieutenant-
Colonel P. B. Haig, I.M.S. ; Captain V. N. Whitamore, I. M.S. ;
Captain S. S. Vazifdar, I.M.8.; Major J. K. S8. Fleming, I. M.S.;
Captain W. S. J. Shaw, I.M.S. ; Lieutenant-Colonel J. H.
Hulbert, I.M.8.; Major D. McCoy, I.M.S.; Captain C. L.
Dunn, I. M.S.
Extensions of Leave.—Lieutenant-Colonel G. Bidie, M.D.,
F.R.C.8. E., I.M.S., 4 d.; Captain J. Woods, I.M.S., 14 d.;
Captain N. N. G. C. McVean, I.M.8., 4 m., M.C.
Permitted to Return.— Captain W. P. G. Williams, I.M.S.
List OF INDIAN 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., 1.8.M.D., to April 30, 1914.
Fleming, Major J. K. S., I. M.S.
Stevenson, Surgeon-General H.
ary 10, 1914.
W., C.S.L, I.M.S., to Janu-
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.
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.8.
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 Staff.
December 4, 1918.
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 appointed Senior Sanitary Officer in Ceylon.
Resignations..—None.
Hetirements. —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.8.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
Officer, 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.Aberdeon, 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.8.
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.8.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.C. 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.S. Lond., M.R.C.S. Eng., L.R.C.P.
Lond., has been selected for appointment as an Assistant
D c UMS and Pathologist in the Medical Department of
amaica.
—— — a ——————
Recent and Current Witerature.
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 Coccid# 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.
_ :»————————
ERRATUM.
OwiNG to a regrettable printer's error '' British
Guinea " was unfortunately inserted for ‘‘ British
Guiana °’ in THE JOURNAL OF TROPICAL MEDICINE AND
HYGIENE, November 15, 1918. 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.
Hotices to Correspondents.
1.—Manusoripts 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.
8.—To ensure acouracy in printing it is specially requested
that all communications should be written olearly.
4. —Authors desiring reprints of their communications to Tur
JOURNAL OP TROPICAL MEDICINE AND HYGIENE should com-
municate with the Publishers.
5.—Oorrespondents should look for replies under the heading
‘ 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, Hony Kong.
A. D., aGep 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
seem to have received the recognition it deserves
(vide JOURNAL OF TRoPICAL MEDICINE AND HYGIENE,
November 15, 1918, p. 345).
We have since had two typical cases of ameebic
liver abscess, both of which have recovered without
any treatment but injections of emetine.
PSITTACOSIS.
By T. P. BEppogs, F.R.C.S.
(Psittacosis—from the Greek word, psittacos, a
parrot.)
IT fell to my lot, in 1898, 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. 2
Both my patiente 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 aecounts 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 Gartner
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 39° 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-
mains 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 cause of death. Partly by direct action,
as well as their effect on the heart and circulation,
they cause a fata] termination in a third of the cases,
with a temperature of 419 C. (105:89 F.) or over,
marked dyspncea 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. EM
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, aerobie and anaerobic, easily
cultivated on the' usual media, not liquefying
gelatine, easily coloured and Gram-negative. Does
34
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
dejecta 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. psilta-
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 Boos 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Feb. 2, 1914.
in sterilized 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 successes indicate that the application stops
bacterial activity and enables the fépaenuve process
to proceed without hindrance.
—————«————— ——
Cholera Bacilli in the Lung.—Greig (Indian
Journal of Medical Research, vol. i, No. 2, October,
t913) reports the cultivation of the comma bacillus
from the lungs in a case 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, and 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 organfsm
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 Publie 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.]
Susiness Rotes.
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Reprints.
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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
caused by placing it along with some substances
calculated to give a gloss, such as paraffin and tale
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.
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 ean 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. |
THE 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-tvphoid 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 case, the explanation given by Dr.
Castellani may be the correct one. The question,
moreover, of local strains of the bacili eomes to
the front in the matter, although scientific pra-
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
(Feb. 2, 1914.
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,» —————
eprint.
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 vaccine—
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. fiir 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. fiir Hygiene, 1902)
that by inoculating 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 inoculated with one germ only. I demon-
strated that even inoculating a rabbit with three
different micro-organisms (B. typhosus B +
pseudo-dysenterieus 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
rubbits inoculated with 4 c.c.
Feb. 2, 1914. ]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 87
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 kslled 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
350 C. These cultures were then heated in a water
bath at 55° C. (dead vaccine), or 509 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 4 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
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 the
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 & 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 inoculated 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
inoculated persons was investigated for presence of
agglutinins regularly once a week, and the results
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-
38 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 ÁGGLUTINATION.
| B. typhosus
Namo Vaccine used for inoculation Weeks after first inoculation
| n E | TO
12 3:415/6|7|8/,9]|11, 18 | 16
DOONOR 5a A a B S A Ba A a d Da
David Mixed * Dead" | O lath | she ats : ata 5 UN |o | vo | do | go | ss
Fernando ... EU. di » O | sis | ado | 360 | ata] ads l ito | sb | a | 35 | as | as
Peter ... Typhoid » a's Iie 300 | ado sóc | 13s | 13» | 140) 130, 6s | sy | 0
Singho .. Paratyphoid A ji 0/,0[/0/0:0/0/0/0/0,0/|01]0
Asson "H d B T 010 d es oe 0|0/,0/0/,0
A. E. de Silva ... Mixed "Live" | jy |n$s| sto abo zov rbo | rào | so | vo | go | dg | 0
D. C. P. Gunesekera "E » O [sho | sło ato sio tbs) — | — 5 — | — | d d
Isaac Ue , Typhoid » O |ils|sbos abs | sbo | abo , 300 ido late | 300 | bo | x
Wellan .. , Paratyphoid A m 0/0; 0 0/0]; 0; 0] 0,0 0/00
Karuppen ... : B - 010 | 0.0/01!0 | 010/0:0101]!—
. B. paratyphosus A.
David Mixed * Dead" | O | d so | v5 vé | co | do | do | s | gs do | 35
Fernando ... T » O | vci so | 30 | ty | ah | so | sv | vo xo | do | zs
Peter Typhoid T 0/0'0/|0/|0/]0 | 0/,0/0/|0/|0/]|0
Singho .. | Paratyphoid A ” Z5 | s0 | 30 | 35 | so | so | 3b | es | 3o | to | a's | O
Asson i ii B j 00/0] 00/0/0100 0lojo
A. E. de Silva Mixed a NO ke ats als cale E ga S S mia 0 | 0
D. C. P. Gunesekera » - UNIES ES tae es eee ee x | e | ab ee
Isaac Typhoid » lololojolololololololo!o
Wellan Paratyphoid A » 0 | rds] so | sto | so | s5 ; au | ok cb | als | oy | abo
Karuppen i B T 0/0'0/0:.0/0:.0/0/0'.0 oi —
| B. paratyphosus B.
David Mixed "Dead" | O | as | Z5 | d | do | sb | to wo |o, 30 | vo | as
Fernando ... uM. » O | 35 | s5 | do | do | as | ab | Js | 35 | ab | zo | ao
Peter ... | Typhoid ji 0|0/0,0/|0/|0..0 | 0,0'0/0]0
Singho Paratyphoid A » ojoļojojoļ]o olojo o'o 0
Asson ” B T 0 so | so | 35 | vo | ab | 26 | 25 | D ts | 0 | 30
A. E. de Silva Mixed "Live"| O | 35 | i5 ab | ao | 35| 0 QUE s |, 0 | 0 : x
D. C. P. Gunesekera R a Qd odisse quibos gre | —|— -$id
Isaac Typhoid 2 0 EXE 30H
Wellan Paratyphoid A » |o|o[ololo!o:o | 0 | 0 | 0:00
Karuppen ... "n" B » O | Jo | do | z5 | 35 | do | nl | To | 0 | 0 | 0 | er
typhoid 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 (53° 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. :
0:86 c.c., or about 10 minims, the first time, and 1°2
c.c., or about 20 minims, the second—induces a
production 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: Zeitschr. für Hyg., 1902.
ii Ceylon Med. Reports, 1904.
p ' Centraibl. fur Bakt., 1909,
2 ` Trans. Bombay Med. Cong., 1910.
S Trans. Soc. Trop. Med., 1912,
i Lancet, 1913.
eer
Abstracts.
p
ABSTRACT OF PAPER ON ACCLIMATIZATION
IN THE TROPICS.*
By Dr. TonupNowskr.
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. x
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, 1918.
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 epidemic, 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
2| —o—— |
———
functions 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 pathological 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 anemia.
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? I 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 cradle of the Malayan race. One must add that
it 1s 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-
40 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 2, 1914.
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 tropical 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
a barrier to fevers and would indicate that the
climate was suitable for Europeans. |
It is clear, then, that in relying only on older
medical statistical figures, or those of explorers,
arbitrary conclusions are arrived 8t 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 miasmatic 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 tropical 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
annophelines.
Dr. Tschudnowsky then proceeds to state
his conviction that malaria is conveved by other
means than by mosquito bites. He cites examples.
of serious outbreaks of malaria in regions where
Feb. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 41
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 epidemics 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 unhygienic 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 American towns. In Curacao
the inhabitants throw all the organic 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 epidemies, 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 acclimatization 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) Methodical 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. McDowaang, F.R.C.8.
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, January, 1914.
the overhanging portion is cedematous 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 ulcers; they were extending above on to the
abdomen and below on to the thighs, and on both
sides they had reached far down in the genito-
crural folds. The ulceration began seven months
before.
Five years before he had had some sores on the
penis (ulcera 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
49 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 pair:
and some in chains, but contrary to what one finda
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
ulcer which spread down over the thigh, so that
when seen practically the anterior surface of the
upper half was one huge ulcer, 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
ulceration had persisted for over five years, and had
not responded to any treatment that had been given.
Unfortunately this patient died before anything
could 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 buho 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 Tropies.
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 uleus molle serpiginosum
have followed an operation on & bubo.
Bacteriology.—In describing Ducrey's bacillus one
must bear in mind the extreordinary morphological
differences which the organism may present. The
following five types are those given by Tomas-
ezewski (‘‘ 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.
(8) Dumbbell forms, which are usually found in
groups.
(4) Forms like diplococci, first described by Unna
es 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
“ Schiffchenformen ” 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 diplococcal 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 diplococci 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
diplococci; 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.
—__$__ ————
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
. on the mid-frontal region.
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
objeets and are laid in & 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
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
larvee ; 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.
elosely adjacent to the first, is very pale, and abuts
on the costa about its centre. The fourth vein
bifurcates about the centre of the wing and the fifth
divides opposite to the extremity of the third vein.
Length 1:5 mm. l
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 whieh 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 in a 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 Mercator’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
[Feb. 2, 1914.
—
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 Republic 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 indicating that
the through traffic via the endemic area to the Kast
will 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
rallways 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 thé route via the Cape
of Good Hope.
The author sums up ‘he 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 traffic 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 trafic 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 north ward
to Japan, but until San Francisco or Honolulu be-
comes infected such & route is not & 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.
(8) 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-
cially, 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 Section 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
ig 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 370 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
cane-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, 1918) 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 picture pre-
sent in the disease in man. They further suggest
that the etiologicál 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.
——— —————
Sotes anb "etos.
THE SOCIETY OF TROPICAL MEDICINE AND
HYGIENE.
Tne Society of Tropical Medicine and Hygiene
has now taken a room from the Medical Society
of London at 11, Chandos Street, Cavendish Square,
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. Camegie 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
Feb. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 47
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-
blance 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. | |
(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 a 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. .— : . 3
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
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 policy the Chamber point to
the refusal to supply Indian Medical Service 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 acquiesce 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 still awaited. The Chamber's letter on
the subject will be forwarded to the Government of
India. : ZEE
We have been requested by Messrs. Butterworth
& Co. (India), Ltd:, Médical 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. - i Lb
48 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 2, 1914.
Memoranda.
DruG 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
cause 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 coast 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 glossinu, 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 connection 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 durk, 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.
————99—————
Personal Motes.
INDIA OFFICE.
From December 18, 1918, to January 10, 1914.
Arrivals Reported in London.—Major T. H. Delany, I.M.S. ;
Major J. N. Walker, I.M.8.; Major L. T. R. Hutchinson,
I.M.8.; Major F. 8. C. Thompson, I.M.8.; Major G. McPher-
son, I.M.S. ; Captain G. T. Burke, I. M.8.; Captain G. McG.
Millar, I.M.S.; Captain J. Morison, I. M.8.
Extensions of Leave.—Major C. R. Pearce, L M.S., 3 m. ;
Major A. B. Fry, I.M.S., 1 d.
List OF Inpran 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. §., I.M.8.
Irvine, Licutenant-Colonel G. B.,
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 18, 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.
, to November 11, 1914.
I. M.S., to October 14, 1914.
List OF INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER CIVIL RULES).
Showing the Name, Province, and Department, and the Period
for, and Daie 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., Bebar and Orissa.
Dunn, Captain C. L., I.M.8., U.P. Sanitary Comm., 6 m.,
November 4, 1918.
Dutton, Captain H. R., I. M.S., Delhi, 12 m. June 8, 19138.
Fayrer, Major F. D. S., I.M.S., 15 m., September 25. 1913.
Haig, Lieutenant-Colonel P. B., I.M.8., 24 m., Ootober 24,
1913.
Hulbert, Lieutenant-Colonel J. G., I.M.S., U.P., 6 m.,
November 12, 1918.
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, 1918.
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., I.M.S., Cent. Prov., 23 m., 29 d.,
October 9, 1918.
Salisbury, Captain F. H., I.M.8., B. Gaols, 6 m., October 20,
1918.
Shaw, Captain W. S. J., I.M.S., Bo., 15 m., November 8,
13.
19
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, 1918.
Walker, Major J. N., I. M.S., U.P., 12 m., October 30, 1918.
Motices to Correspondents.
1,—Manuscripts if not accepted will be returned.
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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 oom.
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.
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. Wexyon, M.B., B.S., B.Sc.
I'rotozoologist 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
leisbmania 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 to
publish the case. d
` ployed.
[No. 4, Vol. X V
of the ear, which had appeared after a journey in
South America. This had persisted for about two
years, and had resisted the various treatments em-
I made smears from scrapings from the base
of the ulcer, as well as from material 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 punctute
wound. Prolonged examination of the various smears
failed to reveal any leishmania, but after an interval
of three weeks flagellates were 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
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 sumall
quantity of the liquid on a platinum loop, place it on
a slide, and examine it with the $ or $ in. objective,
with the condenser down. There is no need to cover
with & 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 eases 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 & 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
50 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
ee 9 =
-—
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 & 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 pathologieal 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
the 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
varying numbers of leishmania. These are known to
be detached portions of the cytoplasm of the large
macrophages, which are themselves filled with leish-
Beb. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 51
mania. In a similar manner the larë 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 distinetly 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 & 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 nie 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.
—— liM —
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THE JOURNAL OF
Tropical dDebícine 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 ag a
rule individually and not as a people. Young men go
59 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914;-
out as members of the great publie 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. à 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 near 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 arother 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-
commonly supervenes; the Shorthorn, Hereford or
black-polled bull is no longer the rampant animal
encountered in British pastures, but becomes tame
and lethargic; and the pusillanimous ram during a
short residence in the Tropics becomes quiet as & ewe.
Even cats sent to the Tropics soon cease to kill rats,
for which purpose they had been specially imported..
In warm climates farmers have 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 tenrperament.
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 {rong a:
cold or temperate climate to the Tropics, it is evident.
that many things have to be taken into considération,
and it may be safely stated that at the presdnt time
we have not sufficient data to go upon to come tó 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 Reg st cat
Park, London, contributes in the recent report 9
Society an interesting account of the death- rates and'
longevity of the animals in the Zoological’ Gardetts*
during the past year. Observations show tliat of? tHe
total number of deaths wellnigh half occur within
the period of six months after the animis were
admitted. This would appear as if it: was: {inpos-.
sible: to: acclimatize, dértiain ‘species of- ‘animals to
the British climate, and that from`that ‘cause many
die. But there &r&'/So many &ide'i$bues which bear
upon the subjeet that" the questióti of acclimatization
is almost ruléd^Gut; Phere 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 a
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 mam it is 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
terhperatüre 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
pathogenie trypanosomes met with when the blood
was examined. In a 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 Vicror G. HEISER. oe
Surgeon, United States Publie'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
maeules 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.
Hypodermic 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 inereased again to the maximum dose. On
October 15, 1911, the patient was microscopically
negative for leprosy. From that date until January
7, 1918, 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
ulcerate. These ulcers gradually healed and by
October, 1911, were entirely scarred over. A final
microscopical examination was made October 80,
1918, 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,
* '* Public Health Reports," vol. xxix, No. 2, January 9,
1914. BG
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. Frost.
. POLIOMYELITIS is due to & 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 distribution 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 epidemies.
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 epidemies, 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 insuseepti-
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 being 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 55
the number of cases without paralysis exceeds the
number of paralytic cases. The occasional develop-
ment of typical paralysis without any distinctive
premonitory or aecompanying 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 contect in large
cities. The same conclusion is again suggested by
the fact that in rural distriets 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. — A MM Lo |
` Yellow fever occurs endemically and perennially
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.8., L.R.C.P.
AND
LEONABD 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
Tropies.'' | : ;
. 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
B Abstract. of a paper in the British Medical Journal,
February 7, 1914. "s
56 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
MM
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
firs& experiment has encouraged other tea-garden
managers and directors to repeat the procedure in
eonnection with ooolie lines infected by kala-azar.
The results obtained during the last sixteen years
have been uniformly suecessful, 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 Indis, and also
throwing considerable light on the probable mode
of infection.
As there have been no material extensions of
the area under tes 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
eoolie 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. s à x
The Amluckie Tea Garden Outbreak of 1806-1904.
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
(Feb. 16, 1914. _
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
about 90 per cent. shows the virulence of the
outbreak.
The Seconee Tea Garden Outbreak of 1908-18.
This garden escaped infection by kala-azar until
some years after the epidemic had died down to a
great extent in the Nowgong district. Nevertheless,
when the disease did break out, it ran an acute
epidemic 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
which 800 healthy people were moved, leaving
behind in the old lines ninety-eight persons with the
infection in their households; all the uninhabited
huts in ihe 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.
| l TM » jo WE USD aisis dc Lam :
Feb. 16, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 57
. s te
-e The Results of Removal. doubtedly due to newly imported coolies sare, cie
"The above two examples demonstrate how simply placed in the old lines, owing to the new ones having
and certainly a Scri cus outbreak of kala-azar ud become filled up. It is thus abundantly clear that
controlled and, within a comparatively short time, thé partial measures adopted in the case of this
completely eradicated from very badly infected estate have failed to eradicate the disease, which has
coolie lines, of tea estates by the measureg advocated. caused’ more deaths during the first eleven months
In fact, it would be difficult to find a more successful of 1918 than in any year since 1899, when the kala-
meth sd of dealing with such a deadly and ruinous 428% camp was in full use. = l »
human disease in the whole range of preventive. | We have ‘here the clearest evidence that as long
medicine. It is particularly worthy of note that’ as fresh material, in the form’ of newly imported
this efficacious measure was worked out as a result) coolies, is introduced into infected lines, so long
of epidemiological studies, at a time (1896-7) when’ will the disease continue to exact a heavy toll in
we were ignorant of the true nature of kala-azar and lives, with consequent serious financial loss. The
its mode of infection; while it was not then even construction of new lines has at length been com-
known how the infection of malaria itself was con- ™enced, into which all healthy families will be
veyed -from ‘one person to another. The facts moved out of the infected lines, as many as possible
collected having established that the infection clung of the old houses in which will then be destroyed
to the houses or their sites, this sufficed to enable and the remaining infected families segregated m
us to evolve a simple plan of dealing effectually Onè of the old lines.
With’ the epidemic which was ravaging the Nowgong Rangamati Old Lines.
district and ruining its chief industry.
Here the disease broke out as early as 1894, and
The Indefinite Occurrence of Kala-azar in Coolie has continued ever since—that is, for almost twenty
Lines once Infected if Segregation Measures years—in the old lines, which have not been moved,
are not carried out. although the new lines, only 800 yards distance,
j 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
Solona. kala-azar in infected lines, which have not been
This estate, which contains two coolie lines, called dealt with by removal of the healthy families and
Solona and Borghot, became infected with kala-azar prevention of the admission of newly imported
as early as 1896. The partial measure of removing coolies. This instance is all the more striking from
the-evident and suspected cases of kala-azar from the fact that only 800 yards away is situated the
the infected lines to a segregation camp during the first of the newly constructed lines, from which all
four years from late in 1897 to 1900 had a very bene- — kala-azar cases have been carefully excluded, and
ficial effect in greatly reducing the number of deaths which has remained quite free from the disease for
from the disease subsequently. The kala-azar camp. no less than eighteen years, during the whole of
was broken up at the end of 1900, and two years which period cases have continued to arise yearly
later the deaths. in the old infected lines began to in the old infected lines. Again, we have here
mount onee.more from five in 1901 to fourteen in further proof of the fact that the old acclimatized
1902, while the figure reached twenty-four in coolies, who have lived for years on the estate, many
1904... In 1905 ' à marked decrease again of them having been born and bred there, are
occurred, which lasted for six years: | This sooner or later attacked by the deadly disease, if
decline in the disease coincided with:ithe carry- they continue to reside in infected lines, although
ing out of the following measures. Disinfection they seldom suffer from other serious disease, and
directed towards the destruction of bed-bugs was , form the most valuable and reliable portion of the
carried out in all the infected houses in the Borghot ~ working population.
lines in the hot season of 1905, and it is worthy of | The continued occurrence for from eighteen to
note in this connection that the Borghot lines had twenty years of cases of kala-azar in the only
only about half the number of deaths that occurred , two infected coolie lines in the Nowgong district,
»
in the Solona lines during the following six years, 1 which have not been dealt with by means of the
The following is an account of the disease in two
control lines : —
although the population of the former (850) is con- 4 segregation measures, which we have shown to have
siderably greater than'that of the latter (650). An ? been uniformly successful in the case of the ten
even more important factor was doubtless the con-)4 consecutive lines in which they have been carried
struction of new lines only a few hundred vardet out, furnishes the most convincing evidence possible
from the old Borghot lines, in the cold season ofgg that the complete eradication of the terrible kala-
1905-6, into which all the newly importéd coolies V azar from every garden where ‘this plan has been
were placed. : This new line has remained almost fully put into execution has really been dye to;the
entirely free from kala-azar during the last eight , methods advocated. NE bo
years, the few cases which did occur being due to! T n
carelessness on the part of the manager in allowing}, THE BEARING OF THE Success oF SEGREGATION
admissions of coolies from the infected lines. In” ae hae ities PROBABLE MODE or INFECTION
1901 a distinct. recrudescence of the disease took HR ere |
place in the two old infeoted lines, fifty-two deaths The uniform success of the prophylactic measures,
having occurred within just under three years, un- based on the observation that the infection of kala-
.4 : so!
— MÀ
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 infection 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..
lFumigating 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.
in the houses also failed to prevent subsequent cases
Burning the thatched roofs.
58 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (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 scsotum was the turning point in
the course of the disease.
————,——————
Annotations.
Cultivation of Piroplasma canis.—J. G. Thomson
and H. B. Fantham (Annals of Tropical Medicine
and Parasitology, December 30, 1913) have suc-
ceeded in cultivating Babesia (Pitoplasma) canis in
two out'of four attempts, following the method of
oe using blood and glucose, and incubating at
In one of their cultures, starting with heart blood
containing corpuscles infected with one, two, or,
Feb. 16, 1914.]
THE JOURNAL Of TROPICAL MEDICINE AND HYGIENE. 59.
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 all the 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
cases 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 80, 1913, 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
identical 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 pathogenic for monkeys, dogs,
rabbits, guinea-pigs, rats and mice, while T. nanum
is considered to be incapable of infecting these
blood and intestinal discharges.
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 pathogenicit¥.- In the present state of our know-
ledge they can only conclude that T. congolense and
T. nanum are the same parasite.
Exanthematic 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
results giving the lie to diagnosis. 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 (macula, petechie, marmoriza-
tion). Many acute infectious diseases present a
picture 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 (Miinchener
medizinische Wochenschrift, December 2, 1913) an
episode which tends to bear out Naunyn’ 8 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
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 999 C,
60 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Feb. 16, 1914.
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 fevercurve showed great variation,
but wes of the same type for all. All patients re-
coveréd unharmed, save one left with myocarditis.
_An exanthem is not mentioned, and Naunyn implies
that the existence of one is not indispenseble.
Neither are stupor and apathy mentioned, perhaps
because of the benign character of the episede. 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 saprophytic róle 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 3-5 c.c., approximately
60-80 minims, repeated every three days, and the
eourse 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, 2 3
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, n
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. 07
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, end can bring about the deaths of the
hosts.
(2) Contamination of plants with infected ex-
cremen$ 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.
(3) 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. j
(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 teetse-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. 1487, 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
e —— — —— — M —— o — — — — ——
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 case
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.
(3) 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) Morphologically B. coli suts is identical 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-
&mia with or without punctiform hsemorrhages.
(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.
(13) In those monkeys in which infection took
place, the balantidia entered the tigsues through the
sound intestinal epithelium,
the two animals.
61
(14) B. colt 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 develop 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 réle 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 béfore 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 interrüpted 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
m um 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
In addition a substantial gela-
tinous and hemorrhagic cdema was observed in
the subcutaneous region of the area upon which the
flies were applied in biting. The agar cultures
when injected 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
————— re OS RERO MORE €
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 hsemorrhagic
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 fæces
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.
re LP ere
Drugs 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 a 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
wil 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
carbolic 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
hérd and to fit imperfectly if neglected; they should
he oiled occasionally, when dry, with an antiseptic
62 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
ol. 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 diff-
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 lfttle 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 HYGIRNE. 63
— ——— — — ere — —— ——
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 incou-
venience.
It is desirable that the plunger should be kept
apart from the barrel when not in use, aud 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 he
inserted in the bore of the needle, and kept there
until it is required for use.
—M él ———————
Achiews.
HEALTH PRESERVATION iN West Arrica. By J.
Charles Ryan, L.R.C.P.L, L.M., L.R.C.8.1.,
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
Tropics, 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
auaply rewarded in being better able to fulfil the
conditions of his employment. The watchword of
the book is ‘‘ Attend ta details,”
OUTLINES OF GREEK AND Roman MEDI0cINE. 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
& 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 clinical 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
public 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 understend 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.
SCROFULOSIS. By Professor Dr. G. Cornet, Berlin
and Reichenhall. Translated from the second
German Edition by J. E. Bullock, M.D.,
Assistant Medical Officer, The HEversfield
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 Tubereulosis Classies, 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 become 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 clinical 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.
E cane
Motes and "etos.
WU LIEN TEH HONOURED.
Wu LIEN TEH (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, 1913, 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. have an
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.
e
Personal Mote.
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 81st inst.
Aotices 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.
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 TEE
JouRNAL OP Tropica, MEDICINE AND Hya@mmng should oom-
municate with the Publishers.
5.—Correspondents should look for replies under the heading
'* Answers to Correspondents,”
JOURNAI,
OF TROPICAL MEDICINE AND HYGIENE. MARCH 2, 1914.
Bale & Danielsson, Ltd
From a film stained by Giemsa's method.
To illustrate article by ALDO CasrELLawi, M.D.,
“Note on an Intestinal Protozoal Parasite producing Dysenteric Symptoms in Man."
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 CasrELLANI, M.D.
Mar. 2, 1914.]
——————
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
dysenteric symptoms I have observed a peculiar
large protozoal parasite which most probably was
the cause of the condition. The first case occurred
in 1909, but as «tained preparations of the parasite
were not successful I did not publish the observa-
tion in detail, though I briefly mentioned it ;n
certain of my papers on intestinal diseases.
Symploms.—In all the three cases the clinical
symptoms were those of an ordinary mild type of
dysentery, either amebic 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 eases the microscopie examina-
tion showed absence of léschiz, cereomonata, 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 101° 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 8, in which. slight signs of
hepatitis were present, but rapidly disappeared.
Relapses may occur, apparently, as shown by
Case 3.
Case l.—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 il 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
identieal 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
dysenteric 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
| No. 5, Vol. XVII.
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 described) in fresh and stained prepara-
tions. No léschie were present, nor trichomonata
or eercomonata. Two emetine injections (4 gr.
each) were given, and also every two hours a sodium
sulphate and magnesium sulphate mixture (1 dr.
of cach per dose). The motions became feculent
after a few hours, and the bodies were no longer
present.
Case 3.—Kuropean officer of the Mercantile
Marine. Admitted to the General Hospital of
Colombo with dysenterie symptoms. Gave a
history of two previous attacks of dysentery in
tangoon 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
hepatie 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 freculent. 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 amcebre
were present at any time, nor trichomonata nor
cercomonata. 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
peculiar, 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 amæba,
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
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 scen, nor, apparently, a definite
undulating membrane, nor have I been able to
satisfy myself that there is emission of filiform
pseudopoda.
Stained 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
scen, but in others it is absent. The granules have
the appearanee of coeci; 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.—l am not yet i a position to
state anything on this subject.
Cultivation.—Attempts at cultivation have failed.
Zoological Position of the Parasite.—AÀs I have
already stated, in fresh preparations, the first
impression on seeing these large bodies moving
about, and with aun extremity presenting rapid,
vibratory-like movements, is that one has to do
with flagellates with the flagelli at one end, but on
eloser 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, Paramaba, 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 inelined to consider the parasite
to represent a new genus and species, and as a
temporary generic term I have suggested the term
* entoplusma.''
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 mierophotographs and
drawings.
REFERENCE.
CASTELLANI : '' Preliminary Note on an Intestinal Protozoal
Parasite," Journal Ceylon Branch D. 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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[Mar. 92, 1914.
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THE JOURNAL OF
Tropical gpebtcine andHpgtene
MARCH 2, 1914.
—— ————————— ———
THE NECESSITY FOR A WOMEN’S INDIAN
MEDICAL SERVICE.
ATTENTION has lately been drawn by Sir Charles
~ardey 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 eneumber every
attempt at sanitary enlightenment, and the sus-
picion with which all European methods of proce-
dure in matters of public health are regarded.
House to house visitation and conversations in
the language or dialect peculiar to a district with
——
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 eustoms 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-
struetors be found? We have in England many
schools in which 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
commereial 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 overeome were a sure
prospect of employment held out as an induce-
ment. Sir Charles Lukis shows where women
graduates in medicine ean 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 siek, or even for the purpose of con-
versing with them on sanitary matters. To women
doetors, however, is the privilege granted, and it
is through this channel alone that improvement in
the publie health of India ean 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
medieal publie 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 ehange, 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 scheme 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 as
doctors, nurses, and as missionaries, but the work
must be systematized, the empirical efforts now in
vogue must be organized, and a great women's
Mar. 2, 1914.) 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 ‘‘ ealling’’ 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 sufficient 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 are gitls, 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
eountry 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
Britain should take up this burden and help their
sisters in India in their extremity.
J. C.
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. (8)
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 220 wr.
Mag. chloride 201 ,,
Potass. chloride — ... ne 83,
Mag. sulph. ... gis e. 418 |,
Calcium sulphate... " 82 ,,
Distilled water to 1 pint.
The injections are given with the ordinary pra-
cautions, and the best pluce for introdueing 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.e. (about 22 oz.), but the amount varies from
25 to 150 c.c. (approximately 62 dr. to 51 0z.). 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.
Nunibers Recovered
Method of Treati:ent successful Failures Per cent.
(1) Alexandrian sea-water with
medicines l .. 180 30 81:25
(2) Alexandrian sea-water only 44 ... 10 81:5
(3) Quinton's sea-water e. 84 .. 12 87:5
(4) Artificial (Ringer’s) xs B2. unu El 85:0
(5) Medicine only m im. BB. wu 3 95:1
Medieine 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
(tinct. jodi. jii minims; aqua Loz.) proved success-
ful, à small teaspoonful being given before each
feed.
The most useful drug was found to be calomel
combined with bismuth (calomel } gr., bismuth
carb. 24 gr.), which gave better results than hvdrarg.
č. 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.
[Mar. 2, 1914.
—-—— — D —— M ———— — —— MM ———
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 diarrhoea.
Quinton’s marine plasma has no definite
^uperiority over artificial saline of the same strength.
Such hypertonic solutions are preferable to weaker
CTS 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 diarrhoea—exceeds the in-
take. They should be given before actual symptoms
of collapse arise.
The sum and substance of the treatment of diar-
rhoa by sea-water hypodermic injections ijs useful
in so far as it replenishes the drain of fluid made
upon the svstem by the diarrhea.
Kalu-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 & valuable
report pointed out that the disease had long been
known in the island under the name of marda tal
biccia. It was Dr. Critien also who discovered that
dogs in this island were liable to suffer from & 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 hus
been the custom to return all cases of enlarged spleen
in children under various naines—splenic anæmia,
Banti’s disease. tc. 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 eases of splenic enlargement in children
accompanied by emaciation, anemia and fever, in this
group of islands are in reality kala-azar. Six such
Mar. 2, 1914.]
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 cases which conformed clinically to kala-azar.
Dr. Critien has shown that during the ten vears 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 identical 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
heen prevalent the children of the native population
form by far the greatest percentage of cases, while
the adult population enjoy a relative immunity. The
introduction of malaria into a hitherto uninfected
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 diseasé 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-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 69
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,
first 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 public 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 a 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 anæmic 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 anwmic and the spleens
10 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Mar. 2, 1914.
small 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 anwmia
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, und 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 from
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
infected 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 which 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 which 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 Hea. 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 fieces 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 floas 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-
inania from a case of kala-azar, in most instances the
parasites can be recovered from the peritoneal exudate
and tissues of the mopse 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 mest probably correct
that all the blood-inhabiting flagellates of the try pano-
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 caten hy the larval flea. Now
when a trypanosome, for instance, has become per-
fectly adapted to a vertebrate host, there is no longer
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 faces 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 oceur 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 infeeted dogs.
He states that in Sicily, 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
Puler 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 à 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, 1915, and 1t 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 microscopic 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
79 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, 1s 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 1s
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
Fast, 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,
Erpceriments with Malarial * Parasites and Piro-
plasma canis.—In a paper, entitled ** Weiteres über
die Ziichtung der Malariaparasiten und der piroplas-
men (Piroplasma canis) in vitro?” (Archiv für Schiffs-
und Tropen-Hygienc, February, 1014), Professor H.
Ziemann describes further experiments. with the
culture of malarial parasites. In this case the
parasites were obtained from a patient who was
infected with the double benign tertian variety, and
' lobes of the cars.
[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 tendency 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, whereus the same tendency was
shown in this case by the same parasites in the
blood of the patient who recovered spontaneously.
In reference to Piroplusma canis culture, multi-
plication 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 cultures of P. canis. Only twice has it been
found possible to inject the animals with old cultures,
even with intravenous injeetion—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
father 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-
vinee, 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
Those especially versed in the
diagnosis of leprosy would probably regard this
reddening as due to leprous dermatitis. Micro-
scopie specimens prepared from scrapings from the
cheek and the septum of the nose were positive for
leprosy.—Victror G. Heiser, M.D., Director of
Health, Philippine Islands, Manila.
Mar. 2, 1914.]
Abstracts.
THE THIRD ALL-INDIA SANITARY CONFER-
ENCE, LUCKNOW, JANUARY, 1914.
President.—The Honourable Sir Harcourt Butler,
k.C.S.I., C.I.E., I.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, 89 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 & recurring grant of 2:06 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 £800,000 sterling per annum, of which 5 lakhs
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 7
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 reeeiving attention. In the
provinces which benefited by the transfer to distriet
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 diff-
eulty in finaneing 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-
researeh, and anti-malarial measures have amounted
approximately to Rs. 4,55,74,000, or £3,038,260 ster-
ling, of whieh Rs. 49,50,000, or £330,000, are recur-
ring and Rs. 4,06,24,000, or £2,708,260, 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 e m 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 Caleutta School of Tropical
Medicine, the foundation stone of
which will shortly be laid by His
Excellency 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 produeing 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 Hs. 1,000 cach to the Bombay Baeteri-
ological Laboratory for a practical experiment
in the disinfection of grain in bulk, and to
Professor MeMahon, of the Canning College,
Lueknow, towards an investigation into the
chemical composition of milk in the United
Provinces.
Since the inception of the Research Fund we have
received in grants. Rs. 186,09,000 and disbursed
hs. 14,385,000, in accordance with the adviee of our
"elentifie 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 aud prevention has
become necessary. This inquiry will, however, be
one of considerable diflieulty, as the disease does not
attaek the elass 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 careful perusal the able
reports by Major James on the protection of India
from yellow fever and on the practieability of
stegomyia reduction in Indian seaports which were
published in the second number of the Journal of
Medical Research, It is gratifving 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 reduce the numbers of stegomyla 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-
myli campaign in Colombo. T deeply regret that
he has now been stricken by serious illness and must
proceed to Envland as soon as he is fit to travel.
I am sure that vou 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 Medical Research has
now appeared and its third number is in the hands
of the delegates. It has met with à most cordial
reception not only in India, Great Dritain and the
Colonies, but also on the continents of Europe and
74 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Mar. 2, 1914.
—
America, and its circulation is already very large
and is steadily increasing. If you will consider the
style of its production, you will understand that at
the low subscription rates now charged it will not
be a finaneial suecess 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
circulation than is possible when they are published
inerely as appendices of an official report. They
will, moreover, be issued immediately after the
conclusion of the Conferenee and will thus be m the
hands of the public 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 researched 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
Serviee—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 vears, and Rs. 20,000 recurring for this object,
and it is hoped that the Local Government will be
able to meet the balanee required to complete the
scheme from provincial revenues. These improve-
ments should be greatly appreciated by many
thousands of pilgrims journeving 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
directly 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 T must allude briefly to a few of them,
and To would first direct) your attention. to the
Mar. 2, 1914.]
—
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, vou will have
opportunities of seeing examples of this in Lueknow
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 whieh are of vital importance in view of the
steady increase of tubereulosis 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 aceumulating
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. 75
veil that hides the secrets of disease and mortality,
but we shall not fully benefit by its discoveries until
the people are edueated 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 $t. 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
domestie 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 tbat 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
bv them on loan 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
abject we can achieve in two ways. The one is
by eneouraging 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
emploving 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.
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 whieh I have mentioned will
lend to a full diseussion of the whole subject, for
I am convinced that if we can succeed in working
out a practical seheme it will have a lasting effect
upon the welfare of future generations, both by
increasing their knowledge of preventive measures
and by improving their general standard of health
and physique.
You will thus reeognize 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
whieh no amount of money can altogether remove.
But we ean 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 sueceed.
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 readilv applicable measure we possess for
measuring the intensity of malaria in a given
localitv. We ean 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
eurying out an extensive experiment of jungle
clearing in the vieinity 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-
[Mar. 2, 1914.
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
ix not in constant cultivation, prevent all circulation
of air, preserve a constant damp, noiome 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 scrub 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
malurial endemieity steadily decreases as you go
farther and farther from the jungle belt. To ex-
plain this he advances the very plausible theory
that the serub 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 serub jungle twice yearly
in, and for a radius of one mile around, every
malaria-strieken 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 malaria!
duty in Madras, may have something to tell us next
venr.
I 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. 77
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 (vellow 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 hy some
insect. :
Turning to the subject of the Spirochatoscs, 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
MeKechnie'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. vestimentorum, 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 nossibility of con-
vevance 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-
eal 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, which appears on the
third or fourth day, is often intense and in severe
cases 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 1,891 dogs destroyed in the lethal cham-
her at Madras and in no case was a dog found to
be naturally infected with Leishmania. It is evident
therefore that, in the endemic 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-
logical interest in the disease is its dependence
upon close personal contact.
| Mar. 2, 1914.
Beriberi is not included in our agenda, but Dr.
de Mello, in his. paper upon "* The Notification ol
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 fact that
during the last year communications have poured
into the medieal 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. MC.
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
diarrhaea 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 diarrhoea,
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 leucoeytosis, nothing abnormal was noted. The
spleen was enlarged to a point about 31n. below the
ribs, and on palpation was of a doughy consistence.
The liver inereased 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 mansoni. 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 readimitted 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
diarrachic symptoms were present. Blood examination
proved negative for malarial or other parasites. The
patient became steadily worse, his condition closely
simulating a case of enteric fever; the faeces 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 fieces was carried out. Neither the ova of
intestinal parasites nor amocbie 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 he
ina 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-cweal 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 lateval-spined ova of Schisto-
SOMUML MUNSONL.
Case 3.—An Egyptian soldier was admitted to
hospital suffering from fever and diarrhoea. He was
somewhat anuunle, 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 toxwmic condition likely to be
attended with fatal results. The diarrhesa was a
feature of the case from the onset. The fæces were
examined, and the lateral-spined ova of Schistosomum
mansonij were found.
The observations made post mortem on the previous
cases suggested the possibility of good results
accruing if vaccine therapy was employed. A
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
— ame ~ — — ——
a
genous vaccine prepared. The patient received a first
dose of 0'5 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 diarrhoea 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, ansemia, 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 u 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 leukemia. 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 mansonii
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
feces was obtained and suitably plated out, and a
bivalvent vaccine prepared from two different types
of coli 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 mansoniz.
(2) This fever is usually accompanied by an enlarge-
ment of the spleen, a varying degree of anæmia, 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.
(b) The possible value of treatment by autogenous
vaccines of intestinal organisms, particularly in the
acute toxie 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 elinical 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.
——— 99 — ————
Brugs and Appliances.
PHYSIOLOGICAL CRITERIA FOR MEDICINAL
SUBSTANCES.
THE testing of medicines constitutes one of the
most important and practical branches of modern
scientifie research work, and deserves even more
attention than has hitherto been accorded to it. It
is a 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 Research 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 o'
data susceptible of accurate measurement, and there
fore suitable for establishing an exact system o
dosage.
80 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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 which have been suggested
for standardizing preparations of the suprarenal
gland are next discussed.
Ádrenine is a notoriously unstable substance, and
neither the optical rotation test nor the chemical
estimation methods hitherto devised have proved
sultable 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 Wellcome
Chemical Research Laboratories. Owing to its svn-
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
[Mar. 2, 1914.
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 physiologieal control of drugs, and it abun-
dantly demonstrates not only the importance of this
work but also the thorough and scientific manner
in whieh it is being carried out at the Wellcome
Physiological Researeh Laboratories.
MÀ nl a
Motes and "Heins.
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 8,
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.
KIGHTY-SECOND ANNUAL MEETING, ABERDEEN, 1014.
President-Elect: Sin ALEXANDER Oaston, K.C.V.O.,
M.D., LL.D.
Section of Tropical Medicine.
President.—Professor William 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.
ee
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 oom-
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.
——À aam m aa o
[No. 6, Vol. XVII.
- Original Communications.
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 eoolies, some of whom she had
nursed.
The ease 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 :—
“A HUMAN
Reds 4,175,000
Whites 3,960
Hemoglobin 86 per cent.
Differential Count :—
Polynuclears — .. 48:5 ,,
Large mononuclears 18:0 ,,
Lymphocytes "t diz oh 30:5
Eosmophiles "m is T tk 80 ,,
Two trypanosomes were found whilst making the
differential count.
Examination of the feces 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
advice of Sir Patrick Manson, who saw the parent
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 lb. 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 2 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.
CON ARARE E EDEA 2a al 2s] 26 or] 2a 2a
fpucse | | | xg *3;
Bowers] "1| rm 11
n du Horns tuat at
CHART A.
and the eye becume 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 diarrhoea; 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 neuralgic 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.
— ———
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, 1999, Dec. 15,1909,
Per cent. Per cent. Per cent.
Polymorphonuclears ... 48:5 46:0 T 43:0
Large mononuclears ... 13:0 An 12:0 iaa 6:0
Lymphocytes , 305 T" 33:0 uA 39:0
Eosinophiles ... ss “oe ^s 9:0 T 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.
March 11, 1910.— Written to, to continue treat-
ment. On April 13 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 1$ 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.
[Mar. 16, 1914.
October 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 tə
desist for some days and begin again with 4j 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.
REA MS PAIN
rocker aa
I
9 8? ZW
i
CHaRT 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, $ 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.]
August 2.—Fourth injection, l'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 à 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 14 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 83
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 dysenterie 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-
scopically 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-like 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 coccus-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.’’
— —Á ———————
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.C.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., Cb. 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-
Bity, Belfast, Sierra Leone; J. McC. Clark, 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.8., L R.C.P.Ireland, has been selected
for appointment as a Medical Officer in the East Africa Pro-
tectorate.
M. Anthony, L.R.C.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.8., 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.
. 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.S.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 & Medical
Officer in the Straits Settlements.
Rotices.
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THE JOURNAL OF
Tropical Medicine and Hygiene
MARCH 16, 1914.
HELMINTHOLOGICAL INVESTIGATIONS.
THE departure of the expedition, under the direc-
tion of Dr. R. T. Leiper, Helminthologist of the
London School of Tropical Medicine, to the Eastern
Tropics 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,
Mar. 16, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 85
: €
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
Tropics.
The intestinal parasites met with in man in the
Tropics 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-
mintic, 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 public 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.
ee
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 surgical 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 hypodermics 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
intramuscular injection is called for are those in
which intestinal absorption may be checked by very
marked intestinal affections, or where patients are
nob 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.
Hypodermic 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.
Annotations.
Natural Leishmaniasis of Dogs in Algiers (Le-
maire, G., Sergent, Ed., and Lhéritier, Revuc
Médicale d’Alger, January, 1914).
In this paper the authors describe the kala-azur
of dogs as it occurs naturally in and around Algiers.
On the subject of the period of incubation no
definite statistics are avalable on account of the
difficulty of making a diagnosis in dogs at the early
stages of the diseuse. 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
eases leishmania can only be demonstrated by
inoculating 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
uppear 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. The
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 & 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
[Mar. 16, 1914.
seem to be actually forced away by the parasites
themselves. Animals suffering from the acute
disease die in a few weeks.
Equine Piroplusmosis in Italy.—1n 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
whieh oeeur in horses in Italy. One is the small
(typus parvum) variety, and named by Franca
(1909) Nuttalli cqui, while the other, belonging to
the large (typus bigeminum) variety, was first
distinguished by Nuttall us Babesia caballi.
Nuttalli equi is very difficult to observe in the
living condition, but this can 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 fuint protoplasma layer round it. Morphologically,
these forms are identical 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,
und 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 equt. 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
amceboid 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
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 cqui.
Trachoma.—1n the Archives de UInstitut Pasteur
de Tunis (iii-iv, 1913), 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
typical 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 32° C. In glycerine the virus 's
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.
Another line of treatment has been adopted and
this is the subconjunctival inoculation of the serap-
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
tuken up directly from the curette in a syringe and
injected immediately under the conjunctiva of the
cul-de-sac of the upper lid. Absorption is very
rapid and never has 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 fur Schiffs- und Tropen-
Hygiene, No. 2, January, 1914, p. 51).—In
malarial distriets the laity are inclined to designate
a '' fever " as malaria, frequently using both words
for identical things, in the same way that, in a
ease of fever with & 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 & 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 390 C. (102°29 F.). At D. the blood prepara-
tion was negative the first afternoon; positive at
night, several medium-sized rings, described as
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 89° 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,
0:5 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 cm. 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., 39° C. (102:29 F.).
June 20.—6 a.m., 86:19 C.; likewise at 8 p.m.;
not taken in the interval during labour.
June 21.—6 a.m., 37°5° C.; 6 p.m., 399 C.
(102°2° F.).
June 22.—6 a.m., 86:49 C.; 6 p.m., 39:59 C.
June 23.—6 a.m., 86:89 C.; 6 p.m., 40:19 C.;
(1049 F.).
June 24.—8 a.m., 37:80 C.; 12 noon, 409 C.
(104° F.); after 0:5 grm. aspirin at 2 p.m., 37:19 C. ;
6 p.m., 39:89 C.
June 25.—6 a.m. and 12 noon, 89:89 C.; 6 p.m.,
40:69 C. after 0'5 grm. aspirin; 10 p.m., 37° C.
(98:69 F.).
June 26.—4 a.m., 89:69 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., 38:80 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 28.—10 a.m., 409 C. (1049 FJ; after
0:5 grm. aspirin at 2 p.m., 97:69 C.; at 4 p.m.,
40°49 C.; at 4.80 p.m., first sublimate injection ;
8 p.m., 86:309 C.; 9.45 p.m., when 37° C. (98:69
F.), second injection of sublimate.
June 29.—2 a.m., 88:09 C.; at 11 a.m., when
38:20 C., third sublimate injection; 12 noon,
[Mar. 16, 1914.
88:69 C.; 6 p.m., 87°49 C.; 8 p.m., when 88:19 C.,
fourth sublimate injection.
June 80.—2 a.m., 88:89 C.; 8 a.m., 36:89 C.;
10 a.m., when 37:29 C., fifth and last sublimate
injection; 6 p.m., 38:89 C; 8 p.m., 36:89 C..
July 1.—6 a.m., 37:69 C.; 8 a.m., 87:29 C.; 12
noon, 38:69 C. ; 6 p.m., 36:89 C.
July 2.—6 a.m., 36:20 C.; 6 p.m., 37:29 C.;
10 p.m., 37:59 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 28, 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
pil 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
tropical parasites were found in the blood at D.,
as well as in hospital later, the character of the
fever and therapeutic 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 = șa gr.
Sod. chloride 0:075 = 14 ,,
Aq. sterilisat. 100 = 2dr.
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. fresh bread was served every day, and preserved
THE ETIOLOGY OF BERIBERI.”
By W. J. J. ARNOLD, 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 conveyed 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. E
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 & 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
*Abstract of paper in British Medical Journal, February 7,
914. ii l
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, &c. Fumigation with
SOs 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 crew 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 cases 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 Spzroshaudinnia dutioni
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 OF LAKE VICTORIA
NYANZA.
By H. LyxpHunsT Duxes, 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
rhodesiense and T. gambiense, has recently
attained great importance. As is well known,
* Abstracted from paper in the British Medical Journaí,
February 7, 1914.
—
a terrible 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 &he 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. gumbiense
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 morpnology 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 chronie. 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
90 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
TM &—————————————————————————o—
[Mar. 16, 1914.
a
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-
genieity 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
44a 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 1903 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 & 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. gumbiense 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. vivaz 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 GEonaxE PRENTICE, 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 politics, 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
crops, 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
vietims 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 ^
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
trented 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, and, having
learnt our lesson in & hard sehool, 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
victims 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 goed
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.
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 &dopt 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-
tinctly 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.
THE 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-
ticular have suffered severely from plague. In
Madras there js a comparatively small trade in
wheat; there is, however, & 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
provinees which has suffered very lightly from
plague, the average number of fleas found upon
rats for many months in the year was larger than
[Mar. 16, 1914.
the number found on rats in any other part of India.
Though the climate is eminently suitable to plague,
harbouring in the houses & 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 Banda, 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 epidemies of plague only oceasionally occur,
than with the people living in the badly plague-
infected Ganges Valley. Nevertheless, Bánda is
situated on a railway line which connects it with the
plague-infected districts of Cawnpore and Allahabad,
and many of the merchants in Bánda 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 (8) 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
assisb 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 & source of danger to the com-
munity.
Captain White, I.M.S., 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 infected 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] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 93
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 public 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. BasseTT-SutiTH, 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 1913, 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, &e. 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 scientific 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.
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
endemie 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 & year cases occurred among those people
associated with the most infected herd, and spread
quickly amongst them when once started. These
people, who lived under bad hygienic 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
-~ mtt S
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 à 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 coccus. 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. (uinea-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,
gouts, cows, sheep, horses, mules, and dogs.
In 1912, Négre and Raynaud [1], while testing
various strains of the mierococcus 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
80 frequently reported.
In 1918, I was able to report & very prolonged
case of fever in a lady, contracted at Hyéres, 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 specific micro-
organism passes out of the body in the urine, feces,
and milk. From the urine and milk more or less
pure cultures ean 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-
teeting 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
reaetions were not obtained in higher dilutions than
| 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.
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
- men a ——ü m M M — M —
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 diagnostic 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 specific 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 57° C. for half an hour and
ane unheated; test each in dilutions of 1 in 40,
1 in 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 specific 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.
(3) The test should always be carried to high
dilutions, up to 1 in 400, to avoid paradoxical re-
actions. |
A second sero-diagnostic 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-
sutisfactory agglutinations.
Vigano has lately brought forward a precipitin
test as a diagnostic procedure, but this is unlikely
to act when the disease cannot be recognized by
agglutination methods.
Clinieal 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 Yo 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 spontancously if the in-
fection is not very severe. In German South-west
Africa intravenous injections of protargol as a germi-
cide were used with success, but it Js not free from
danger, occasionally causing toxic 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 torise at the same time. This method,
therefore, holds out considerable hope in protracted
cases. It is possible that a polyvalent vaccine made
from many strains of the micrococeus 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] N&Gore and RAYNAUD: ‘‘ Melitensis and Paramelitensis,”’
Comptes Rendus Soc. Biol., 1912, vol. lxxii.
[2] VaLLET and RIMBAUD: ‘‘ Agg utinin of M, melitensis,”
Comptes Rendus Soc. Biol., 1918, vol. Ixxiv, No. 7.
(3] MARTEL, TaNoN et CHRETIEN: Press Med., August 20,
1913, No. 68.
4] KENNEDY, J. C.: ''Presence of Agglutinins in Cows'
Milk," Journ. R.A.ALC., Janvary, 1914, vol. xxii, No. 1,
pp. 9-14.
(5] Trorta, G.: ''Suppuration in Malta Fever," Wien.
klin. Wochenschr., 1918, vol. xxvi, No. 85.
{6} Scogpo, F.: ‘‘Therapy of Mediterranean Fever."
Centralbl. f. Bakt., 1912, vol. xvii, No. 3.
[Mar. 16, 1914.
Bebiew.
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 discusses 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.
Tue Annual Court of the Seamen’s Hospital
Society, to which are attached the London School
of Tropical Medicine and the London School of
Clinical 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.]
Original Communications.
METEOROLOGY OF MALARIA.
By MarHEW D. O'CoNNELL, M.D.
THE
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
af a fleet under Sir Richard Strachan and an army
of 40,000 men under Chatham. Chatham landed
at Vlissingen (Flushing) on August 15, and cecu-
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. Oo
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Viissingen (Floshing) in the Island
of Walcheren, Netherlands
(No. 7, V
ol. XVII
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 ean have any effect in producing those
milder forms of fever which still linger there.
The Director-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
A
“Temperature of Dryin Velocity of g Temperature of Drying Move- Body tem- Pulse Respira.
air, F. power ofair wind per air, F. powerof ment perature in tion
per 10 cub. ft. second air per ofair mouth, F. l
10 cab. ft. per
Walcheren, Vlissingen, second
1911 —À — : _—— —
Dry Wet Grains Metres Dry Wet Grains Miles
August 9, 7 o'c. a.m. 7271? €5:6?* 30:7 4:5 12:09 65:0^ 29-0 09:6? Not given
» » 13:2 66 0* 81:0 4-4 73°5 68:0 21:5 100-0 100 26
$5 9 5 75:8 67:7 84:4 3:7 75:5 70:5 24:5 .99:4 132 22
" 10 ,, 78:4 69:4* 41:4 41 18:5 13:5 25:0 99:6 116 22
5 11 5 81:3 69:4 56:3 3:3 81:5 74:0 39:5 99:2 86 20
- 12 o'c. noon 82:4 69:4 61:8 3:6 829-0 75:0 38:0 99-9 99 16
$3 1 o'c. p.m. 84:1 69:4 70:3 4:9 84:0 77-0 39:0 100:3 84 25
n d. ds 84:2 69:4* 70:8 4:9 84:0 77°0 39:0 100:3 84 25
$i 3 3 85:6 69:6 77:2 5:0 85:5 18:0 41:0 1001 82 22
$3 4 € 88-8 69:8 92:6 4:7 89:0 16:0 13:0 99:6 98 18
s Ó 4, 90:5 70:0 101:0 4°7 90:0 75:0 82:0 = 99-8 94 24
$5 0. - 45 89-8 10:2 93:4 4'1 90:0 15:0 82:0 o 99:8 94 24
e 7 s 84:5 70:5* 68:5 4:4 84:5 71:0 420 4 100°6 96 26
56 8 jj 80°4 70:2 49:2 4:9 80:5 73:0 38:5 “ 99°6 92 20
is Joss TT:O 70:0 33:0 44 T1:0 780 200 J 100°1 100 18
T IO. 5 75:9 697 90:5 4:2 76:0 12:0 20:0 5 99:4 88 20
j5 11 ,, 71:0 69:5 35'0 2:6 TT:O 73:0 200 g 100°1 100 18
E 190'c, midnight — 78:7 69:2 90-0 2:8 78:5 68:0 245 9 1000 90 22
August 10, 1 o'c. a.m. 72°6 69:0 17:0 2:6 72:0 65:0 29:0 g 99:6 Not giveu
- 2 4, 72:8 68:8 15:5 2:8 72:0 65:0 200 o 99:6 3 a
" > sy 72:5 68:6 18:1 25+A 72:0 65:0 290 3 99:6 ji oe
T d^ x5 71:6 68:3 18:0 2:8 72-0 65:0 29:0 "3 99:6 »3 s
P ð p 70:8 68:1 12:6 1:2 69:0 65:0 17:0 9 100:0 100 26
di 6 ,, 73-0 67:9 92-4 0:2 73:5 68:0 245 & 100-0 90 22
35 T w 74:0 67:8* 27:8 9:1 74:0 70:0 19:0 & 1000 98 22
)5 8&8 uus 75:2 68:1* 82:4 31 75:0 69:5 26:6 Z 100:2 110 18
Si 9. 5, | 79:8 70:4 42:9 1:5 79:5 74:5 26:5 100:2 90 24
T 10 ,, 80:6 72°7* 40:2 2:5 80-5 73 0 38:5 99-6 116 22
o dM. 44 84-3 72:1 60:6 2:5 84:5 71:0 42:0 100:4 120 24.
$a 12 o'c. noon 79:6 71:6 89:2 4'2 79:5 74:5 26:5 100:2 90 24
13 1 o'c. p.m. 78:8 71:0 38-0 5:9 78:5 73:5 20:5 99-6 116 22
,» 2 y 80-7 70:5 49:5 4:9 80:5 78:0 38:5 99-6 92 20
» 3, 81:6 69:6 01:2 4'l 81:5 74:0 39:5 99:2 86 . 20
» 4. y T3 68:8 45'4 4'4 77:0 73:0 20:0 1001 . 100 . 18
» ó y 14:8 67:9 31:4 4:4 75:0 69:5 26:6 100:2 110 . 18
» 6 ,, 72:8 67:1 29:1 4:7 72:0 65-0 29:0 99-6 Not given
7 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.
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 atmospheric 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 100° 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 69° F. (20°5° C.) and a wet
bulb temperature of 65° F. (18:89 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
sudorifics 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
98 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
——— —— — —
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 sufficient. explanation of the mild intermittent
fevers which still linger there. The more scientific
canalization 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
indicated.
D d
BRIEF NOTE ON TOXOPLASMA PY ROGENES,
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 a
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 Toxoplasma pyrogenes
are without any doubt of protozoal origin and differ
from any other protozoal organism so far described
in man; but no conclusion can 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.]
NOTE ON A NEW GEOGRAPHIC LOCALITY
FOR BALANTIDIOSIS COLI.
By Major B. H. DUTCHER.
Medical Corps, United States Army.
HaviNG 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.R., entered hospital December
25, 1918, complaining of mild dysenteric symptoms
and with a temperature of 101°5° F. The tempera-
ture rose to a maximum of 102:89 F. the sume day,
fell by crisis to 99:49 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 ective 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 uncinaria (gen. et. sp. ?) and Trichuris trichiura.
A differential count on January 5, 1914, showed : —
Lymphocytes
.. 195 per cent,
Large mononuclears ... 6° is
Polymorphonuclears ... 34 i
Eosinophiles m .. 40 y
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.
— la
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-Antarctic 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.’’
THE 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 1s, of course, manifest. The material 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 subject.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 99
Sloticts.
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THE JOURNAL OF
Cropícal MDedtctne and hygiene
APRIL 1, 1914.
————— Á—— —— —Ó— —M À À— —À— A— me
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., E.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, aid .
100
—
the spirit which prevailed was in harmony with the
occasion for which the company had gathered.
The work which Surgeon-General Gorgas began and
earried 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 representativ es 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,
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.$.,
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.8.; 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.
Chatipueys, Bart., M.D.; Sir R. Havelock Charles,
G.C.V.O., M.D.: Sir Williaa Watson Cheyne,
Bart., C.B., F.I.C.S., F.R.S.: Sir Wiliam S.
Church, Bart., K.C.B.. M.D.; Dr. S. Monckton
Copeman, F.R.S8.; Sir Anderson Critchett, Bart.,
C.V.O., F.R.C.8.: Major 8. L. Cummins, M.D.,
R.A.M.C.; Dr. H. H. Dale; Dr. Samuel T. Darling:
Mr. J. Hi Dauber, M.B.; Mr. Robert Donald; Sir
Dyce Duckworth, Bart., M.D.; Mr. Perey Dunn.
F.R.C.S.; Sir Frederic 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.S.:
Dr. Archibald E. Garrod, F.R.S.; Dr. R. A.
Gibbons; Sir James Goodhart, Bart.. M.D.: Mr.
John L. Griffith ; Dr. W. 8. A. Griffith ; Surg.-Gen,
€ ‘Sir William Launcelotte Gubbins, K.C.B., M.V.O.,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Major
[April H, 1914;
— od
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. Wiliam 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.; E
Gen, Sir Alfred Keogh, K.C.B., M. D.; Col. W.
King, C.LE., I.M.S.; Mr. P. P. Laidlaw, BC:
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.S.; Dr. G. C. Low; Mr. J. Y. W. MacAlister;
Mr. Ramsuy MacDonald, M.P.; Dr. Hector
Mackenzie; Surg.-Gen. W. G. Maepherson,
C.M.G., M.B. ; Mr. G. H. Makins, C.B. F.R.C. S.;
Mr. E. Alan Masters, B.Sc. ; Major J. A. Masters,
M.D.; Surg.-Gen. Arthur W. May, C.B., R.N. ;
Dr. N. G. Moore; Sir Shirley IF. 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 Pinch, I.M.S.,
Il. R.C.8.; Dr. G. Newton Pitt; Mr. H. G. Plimmer,
|.H.9.; Sir James Porter, K.C,B., M.D.; Sir
Richard: Douglas Powell, Bart., R.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. Scurfield ; 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., I.M.S.; Dr.
S. Squire Sprigge;
Lieut.-Col. Squier; Dr. Purves Stewart; Mr. J.
Lynn Thomas, C.B., C.M.G., F.R.C.S8.; 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 Wiliams, F.R.C.P.; Mr. Guy E. M. Wood.
M.B.
After dinner the loyal toasts were given by the
Chairman.
Lord Brycr 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 & publie part in political affaire,
nor had he experience of the hustings before he
hecame a candidate for the Presidency, but he was
a conspicuous 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 welcome
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 CHARLES, 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 Americans 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 public 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 panic 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 à banner that may be displayed
because of the truths of sanitary science. _—s_..
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
pestilence walked im 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 of 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
Ross. 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 greit
102
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 Goncas 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
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. l
Sir WirLiAM Oster, Bart., F.R.S., proposed the
toast of '' The Chairman,” to which Sir THOMAS
BarLow fittingly responded.
———— —dQ9—————
ADDRESS BY SURGEON-GENERAL GORGAS
ON SANITARY WORR 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
description 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 district was such that it presented an
ideal breeding ground for mosquitocs. The different
zones of the Canal were divided into sanitary dis-
tricts 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
prophylactic 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.
————É—
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.]
Abstracts.
A SKIN REACTION INDICATIVE OF
IMMUNITY AGAINST TYPHOID FEVER.*
By FREDERICK P. Gay, M.D., and Joun 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
alcohol. 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 ”’ apo there is no Suneulsy
—— me € -— —— -—-— — -— —— m —
* Archives of Internal Medici ine, March, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
103
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. im extreme
diameter and is usually somewhat indurated and
frequently clearly demarcated. In negative cases
there is the same reaction or ebsence 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 im 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.
6 c.c. of water in a small test-tube.
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) ener igate puman i two minutes.
of fæces with 5 or
The centrifuge
inana aie A, a S
* «United States Publie Heulth Report T Poids 20,
1914.
104
(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
identifieation of the blastomeres (oc. 1, ob. 7, and
oC. 4, ob. 4& 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-
taet 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April. 1, 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 distinct 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
iiac. The emboli occur late in the process of
throinbosis and are fortunately rare; but because
of their suddenness and the gravity of their sym-
ptoms, they are the ones to which attention has
been -chiefiy 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
local 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.
(8) 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
infarction, 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-
plieating typhoid fever. NE
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 nt first as to
the correctness of the diagnosis. But the frankly
bloody character of the sputum, which continued
i
—— —À s =, a |
April 1, 1914.]
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 deys after the onset of the pulmonary sym-
ptoms. In this instance the bloody sputum lasted
for’ twenty-one days. Concerning the physical
signs, it is to be noted that the signs of consolida-
tion appeared first in the left lower lobe, and a few
duys 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
firs& 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. l
Case 3 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
infarct 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 end
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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, iu 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
indications 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. T
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 instanees 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 19183, DATED
OCTOBER 20.
By Victor G. Herser, M.D.
Plague.—The editor of the Manila Daily Bulletin,
who had his offiee 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 earrying out the insecticidal and other anti-
plague measures in his office à 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 foünd
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’Hygiene Pub-
lique Conference, resulted in the isolation of the
true cholera vibrio.
The next case came under observation on August
25, and occurred 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-
tuined there was no connection between the two
cases. This person gave a history of having been
ill with diarrhea 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 18. 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 employcd to combat it.—Al cholera
cases were promptly transferred to hospital. Dis-
infection of the premises was made with larvicide
or earbolie acid, partieular attention being given to
the toilets, bed upon which the patient slept, his
clothes, and other articles 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 whieh 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
carried out with respect to tight vaults or other
receptacles into which cholera organisms mignt
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 inortality 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 could he excluded, 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 whieh would compare favour-
April 1, 1914.]
ably with even the healthiest cities of the United
States.
Leper Collection.—Two 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 stil 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 searcely be expected as yet.
Vaccination.—Much difficulty 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.
THE Youngstown Sheet and Tube Co. reported to
the State Board of Health the presence of trachoma
among their employees and & medical officer, sent
by the State Board of Health, examined about
twenty-five men who had been dropped from the
rolls of the Company.
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
* « 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.
MeCampbell), 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 6,872; 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.—EKighty
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.
ments favouring the spread of trachoma, but to
the fact that they employ the greatest percentage
of Roumanians, Croatians and Magyars, who, as
ulready 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 ihe mills. Like most steel
plante, 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
cases 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
[April 1, 1914.
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 14 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 accounted for by the presence among them
of chronic cases, some of which are even now in &
state of acute exacerbation.
(2) The crowded insanitary condition of the
lodging-houses amply accounts for the spread of the
disease.
. (8) 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 difficult or impossible.
In view of the fact that some 60 per cent.
April 1, 1914.
——— ————
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
direetly 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 incur 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 specific measures to be adopted
at the 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 dnd 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
he 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 dailv 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
109
—— ———— — A
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 Kast Youngstown.
Se — — P
A STUDY OF EPIDEMIC DYSENTERY IN THE
FIJI ISLANDS.*
By P. H. Bann, M.A., M.B., D.T.M. & H.Camb.
THE 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 hygienie 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 amebic origin
—that is to say, vegetative amoebe bearing the
characteristics of the Amaba 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
iodidds nationalities — Indian, Fijian, Solomon
* Abstracted foin paper in the British Medical Journal,
February 7, 1914. - |
110 THE JOUR*
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; eases were encountered in which it was
subnormal throughout, others in which it reached
1089 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
TAL OF TROPICAL MEDICINE AND HYGIENE.
[April 1, 1914.
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
can 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
Tropics, 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 & 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 & 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.]
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
the 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-
sequently 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-
dysenteric serum (kindly supplied by the Lister
Institute). A dose of 20 c.c. was given to adults,
10 c.c. or less to children.
In apparently hopeless cases injection of 50 to
70 e.c. of this serum in the first twenty-four hours
after admission was followed by remarkable im-
provement. After such injections no deaths occurred
in 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 106 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 attack 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 antidysenterie
serum by Savage in his El Tor series.
In this instance not only was the average stay in
hospital of cases of moderate severity considerably
shortened, but it was also found that the stools
resumed their normal fecal 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 much more extended series of cases. 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 111
The oral administration of salines and intestinal
antiseptics, 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
encountered 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 faecal matter and thereby to
accelerate 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 multiplication of the dysentery bacilli
and other organisms in the intestinal contents.
It must be borne in mind that a very acute
dysentery of primary ameebic 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 amæbic and bacillary forms.
If the case be not of primary amoebic 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.
—— li ————————-—
CLINICAL EVIDENCE OF BI-PALATINOID
ORREFIN IN ANJEMIA.
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 Tar alaa
March 2, 1913 38 per cent. 2,280,000
» 20,1913 .. 54 a 3,800,000
April 3,1918 ... 548 ,, 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 clinieal effieieney of orrefin over all other
forms of iron both organic and inorganic. 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 eff-
ciency is produced.
The makers, Messrs. Oppenheimer, Son and Co.,
Ltd., London, issue various combinations of orrefin
with laxatives and tonies, 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.
———S$—— ———
Personal Rotes.
Inp1a 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 C. G. Seymour, I.M.S.;
Lieutenant. Colonel C. H. Bowle-Evavs, I. M.S. ; Captain A. F.
Hamilton, I.M.S.; Captain R. Brown, LS.M.D.; Captain
A. C. Munro, LM.S.; Lieutenant- Colonel A. C. Yonnan,
I.M.S.; Major F. L. Blenkinsop, I.M.S. ; Major S. P. James,
I.M.S. ; Lieutenant-Colonel S. E. Prall, IM. S. ; Major W. F.
Harvey, I.M.S. ; Major A. Spitteler, I. M. S.3 Captain H. R. B.
Gibson, I. M.S. ; Captain L. H. IL. Mackenzie, I.M.S.; Captain
F. Stevenson, I. M.8. ; Captain F. S. Smith, I. M.8.
Extensions of Leave. —Lieutenant-Colonel S. H. Henderson,
ILM.8., 10 d. ; Major W. H. Cox, IMS. 6 m., M.C.; Major
J. H. McDonald, I. M.S., 3 m., M.C. ; Major D. McCay, I.M.S.,
3 m., M.C. ; Major A. Murphy, I.M. S., 4 m., 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, 1.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.5.
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.
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., I.M.5., B., Sanitary Comm.,
May 18, 1913.
Gage, Major A. T., I.M.S., B. Med. Dept.,
20 m., March 15, 1918.
Goil, Captain D. P., I.M.S., B., 32 m., April 5, 1913.
Hamilton, Captain A. F., I.M. S., Bo., 12 m., January 1,
1914.
Hepper, Captain E. C., I.M.S., N.P.,
1918.
Hugo, Lieutenant-Colonel E. V., I. M.S., Punj., 14 m. 26 d.,
July 15, 1918.
Hunter, Captain J. B. D., I.M.S., 18 m., January 14, 1913.
Ingram, Captain A. C., L MS., M. Mcd. College, 20 m.,
June 30, 1913.
Jackson, Lieutenant-Colonel J., I.M.S., Bo. Prisons,
April 18, 1913.
James, Major S. P., I.M.S.
Kelsall, Captain R., I.M.S., Burma, 18 m., April 15, 1913.
Lalor, Major N. P., O.G., I.M.S., Burma Sanitary Comm.,
24 m., July 23, 1913.
Leventon, Major A., I.M.S., Assam, 18 m., May 8, 1913.
Lunham, Captain J. L., I.M.S., Bo., 18 m., March 20, 1918.
McConaghy, Captain C. B., 1. M. S., ' India. Foreign, Persian
Gulf, 24 m., April 4, 1918.
ll m. 1d,,
Botanical Survey,
23 m. 26 d., April 27,
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, 1918.
Mell, Major F. O. N., I.M.S., C. P. Gaols, 19 m., March 18,
1913.
Mitter, Lieutenant-Colonel R. K., I.M.8., M., 18 m. 15 d.,
August 6, 1913.
Morison, Captain J., I.M.8., Bo., 6 m., Désettbor 1, 1918.
O'Keeffe, Captain D. S. A., I.M.S., M., 15 m., August 10,
1913.
Penny, Lieutenant-Colonel J., I.M.S.,
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.,
1912.
Rutherford, Captain T. C., I.M.S., C.P. Med., 33 m. 18 d.,
March 5, 1913.
Saigol, Captain R. D.,
1913.
Scroggie, Captain W. R. J.,
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., I.M.S., Punj.
Comm., 21 m., February 18, 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, 1918.
Wood, Lieutenant-Colonel H. S., I. M.S., B., 38 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 C. 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., LM. S., to July 7,
1914.
Durham, Lieutenant W. R., I.S.M.D., to April 30, 1914.
Fox, Lieutenant E. C. R., I.S. M.D.
Gibbs, Major A. A., I. M.S., to April 30, 1914.
Gibson, Captain H. R. B., L M.S.
Haughton, Captain S., I. M. S., to March 5, 1914.
Horne, Captain J. H., I.M.8.
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 us
Ker, Lieutenant- Colonel M. ., I. M.S., to March 19, 1914.
Mackenzie, Major H. M., I. M S., to October 91, 1914.
Mackenzie, Captain L. H. L., I. M.S., to February 2, 1915.
McCowen, Major W. T., I. M.8.
Mehta, Captain S. B., I.M.S,
Mills, Captain P. S., I. M.S., to September 10, 1914.
Moore, Lieutenant-Colonel C. M., I. M.B8., 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 S. E., I.M.S.
Seymour, Captain C. G., I. M.8., 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 F., I.M.S.
Watson, Major C.H, IM. S., to May 6, 1914.
Yonnan, Lieutenant-Colonel A. C uo M. S., to December 18,
1914.
Burma, 16 m.,
I.M.S., Burma, 24 m., November 11,
I.M.S., Burma, 24 m., February 10,
I.M.S., 24 m. 14 d., May 14,
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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, 1913, 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 8, 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 April18. The fever continued of the same type,
namely, intermittent, and the maximum temperature varied from 103° to
105° 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.
Ezamination 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) 80. 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.; eosinophiles, 8 per
cent.
Urine.—Nothing abnormal was noted, except occasionally a faint trace
of albumin.
Course and Treatment.—Quinine was continued in massive doses (30 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 masses of chromatin are present. These bodies, for
114
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
convenience sake, I will indicate es 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
a 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 kugeln.’’ 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 cannot 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, 1918.
[April 15, 1914.
—
among whom Professor Plate, of the University of
Jena; Major James, I. M.S.; 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 toxoplesma.
Personal I am stil 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.
——ÁJ———— ——
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 23,
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., 1912, cxiii, 815; Journ.
Amer. Med. Assoc., May 10, 1913; Castellani and
Chambers’ '' Manual," p. 866).
— il ——
COCOA AND KERNELS.
From being tenth on the list of cocoa-producing
countries in 1908, the Gold Coast attained the lead-
ing position in 1911, and retained this in 1918. 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.
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'uoo[dg 94} ur punoj serpoq jo sydviZorn1mojoyg—'e ‘p ‘g ‘z ‘SBT
'9 “OI CL EGE
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'ÞTGI ‘ST TIUdAV ‘ANHIDAH ANV UANIOIGHW 'IVOIdOHL AO 'IVNSIOOf JHL
FILME JOUICNXE Ob TROPICAL MEDICINE ANP HYGIENE, APRIL 15, 191!
À l:
A Body found in the blood
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B-— Bodies found on tne spicen.
To ilustrate paper by ALDO CASTELLANI MD.,
" Note on Certain Protozoa like Bodies in a Case of Protracted Fever with Splenomegaly.”
April 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
115
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THE JOURNAL OF
Tropical Medicine andhpgtene
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 domestic and
public 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
public 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 rgere fads or opinions, but as
definite laws founded on facts which admit of no
discussion.
Politieally, 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
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
sclence 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 scientifie 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
publieation 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 scientifie medicine as a thing apart
and as one requiring special handling.
$a.
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 ut 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.
Àn unmarried man preferred, and for preference not
over 95 years of age at the outside.—Apply to
Editor, JOURNAL or TROPICAL MEDICINE AND
HYGIENE.
General Article,
THE STORY OF SOME OF OUR COMMON
DRUGS.
I.—CAMPHOR.
THAN camphor no other drug in the pharmacopoeia
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),
April15, 1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 117
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 distriets 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-
Fie. 9.
[By permission of the proprietors of ** The Wide World Magazine," from an article by Mr. F. O. Koch.]
Fig. 1.—A primitive Formosan camphor still in the heart of the head-hunting country.
Fig, 2.—4A camphor distillery near the east coast of Formosa.
118
x — À
gitates 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 & 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 & work of time.
The Japanese are proceeding upon & 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 camphor
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 & 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 distiling 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 it 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 & 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 Tropies, for it is & potent diaphoretic
and it lowers the body temperature in pyrexia; its
aphrodisiac action enhances its value in men's
minds, especially in tropical countries where the
sexual powers for various reasons are wont early to
flag.
As a prophylactic against infectious illnesses, as a
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.
April 15,1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
119
————————————————————————————————M——————
Abstracts.
MINERS’ PHTHISIS ON THE RAND.*
By J. L. AYMARD.
THOUGH water may be freely used in the form of
a spray from tne 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 ia
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. Brocs, 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 & 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 duys 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 8,000 ft. there are no
data to indicate.
—
f From the Lancet, April 11, 1914.
120
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;
3lb. “meat,” 220z. pea nuts, l6 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
assimiluted, 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 20° 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
perinits 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 à 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 : —
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[April 15, 1914.
'* 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 oub the importance of the above remarks.
In the following table the incidence rate for pneu-
monia and the death-rate for phthisis (tuberculosis
and 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.
Pneumonia inci-
dence per 1,000
Phthisis deaths |2:28,2:45/1:23] 4:94| 8:67| 3:63 [1:58/0-87|1:71
per 1,002 (tuber-
culosis and
miner'sphthisis)
ics caused the
or all the three
* The importation of natives from the Tro
very great increase in the rate for this year.
years a good many cases of tuberculosis i 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
N A DUMP MEET nc ————— —————Y ————————— E
L ———————————————————————————MM—ÉHÉÉÉÉÉU
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.
(8) Putting new arrivals to heavy work before
this physiological equilibrium is established (about
three weeks) inereases 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
sufficient 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 of THE SOUTH AFRICAN INSTITUTE FOR
MepicaL RESEARCH. +
‘* PNEUMONIA,’ as used throughout this paper,
means the disease clinically known as lobar pneu-
monia when bacteriologically associated with the
diplococcus 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 clinieal 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
‘‘ crisis ' 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
firs& 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.
(13) 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
prophylactic inoculation has any influence 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.
SYSTEM OF 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
medically 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 & 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
1918, that is, from August to December 81, 1912.
SUMMARY.
(Rates per 1,000 in italica.)
Number of natives recruited, 45,991; 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 cultivation, 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 '' diarrheal
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, 89:9; deaths,
709; death-rate per thousand, 1577; 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, 5:8; 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 districts 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
(3) 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.
‘he natives from the districts 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,
April 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
sufficient evidence to enable any suggestions to be
formulated except in a tentetive manner; that a
marked and persistent difference in the tribal rates
does occur, is, nevertheless, established.
Natives whose physieal 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 physically 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
residence on the Rand, and that thereafter it pro-
gressively diminishes. With our present figures we
can 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 i 526 1:16
5— 9 ii 889 0:86
10—14 814 0°69
15—19 275 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
123
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 ttack-rate
arrival attacked per cent.
0 312 ahi 8°89
1 203 M 2:58
2 155 S 2:00
8 139 si 1:88
4 125 T 1:68
5 89 ee 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 & 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 1918; 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
& 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 flrst Months after termination of first attack monthly
attack rate
occurred 1 2 3 4 5 6
Ist 71 13 43 24 43 38 40
2nd 7 38 33 9 0 — 18
9rd 54 94 38 0 — — 30
4th 40 0 O <= — -- dq jd
5th 26 27 -— — — —- 27
6th 25 — ja a — = 25
41 22 33 13 22 38 28:7
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. : [April 15, 1914.
It will 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 80
4 5
5 sae bei 4
6—10 t " i 17
11—15 bis as a 14
16—20 as T uaa 12
21—30 ius io -— 7
Total ... m 80
The population throughout this period remained
practically constant, and we therefore find a rate of
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. pE 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.—C., 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 edema, 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 Malcompson’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., & soldier from Mozam-
bique, aged between 25 and 30; becomes rapidly
tired after marching; dyspnea 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 cedema ;
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.—AÀn 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
> Abstract of paper read at the All-India Sanitary Congress,
1914. |
of the knee.
near the left knee.
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 gai, very
characteristic; has had considerable cedema, com-
mencing in the neighbourhood of the malleoli; this
has, however, become very much less; reabsorption
of this edema 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 cede-
matous region react very feebly to electricity; in
the popliteal space the tendons present an abnormal
degree of hardness, hindering the free movements
No albumin in the urine.
(6) Confirmed Beriberi.—S. F., native prisoner;
walks as if in water up to his knee, painful malleolar
cedema. A curious fact is that the cedema began
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. C(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 cdema and the cramps or neuritis.
This cedema 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 edema.
At this stage we have not observed any other
organic 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 amcebic dysentery,
which had, howéver, 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 hed 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 Geyet 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 dyspnoea (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 Hio Sado, showed:
Hard edema 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 beribert.
BERIBERI AT GOA BEFORE THE EvripEMIC or 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.
and shortness of breath.
[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
(‘‘ Contribucéo as estudo da etiologia do béribéri ''
por J. C., Provença Braganga). 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
He has edema, 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,
ráles 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 Fresa Epipemic IN 1918, OCCURRING ONLY AMONGST
AFRICAN MEMBERS OF THE EXXPEDITIONARY 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.]
These cereals are usually eaten in the form of
farinaceous cakes. Sometimes, though very rarely,
so rarely that such occasions eun be looked on as
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 of
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, 0:2 litre. In case of scarcity of meat
& box of sardines preserved in olive oil was sub-
stituted.
After the epidemic, on the recommendation of the
Sanitary Officer: Hed rice cured in Mangalore, 0:5
litre; meat, 0°5 litre; potatoes, 0°3 litre; fish, 0:4
lire; various vegetables, 0'2 litre; various beans,
0:2 litre. And in spite of this change of diet beri-
beri continued 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 à disease which exists in Goa
in some endemie form.
(2) That beriberi is à 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-Goa and the infantry bar-
racks in Nova-Géa, and the infection has continued
surreptitiously attacking from time to time soldiers
of the marine.
Since 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
$0 per cent, due oértainly to intense infection with worms iu
the cases examined.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
197
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 close 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 inspeetion, and the servants of the hospital
(Africans) that live in the sume 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 ean then be formu-
lated: (1) Beriberi has not previously existed at
Goa; (2) beriberi actually existing in Góa at the
present time 1s 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 Goa 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 epidemics developed on board
French and Japanese cruisers demonstrate the
existence of a ship beriberi where no hygienic
conditions are lacking.
The theories which attempt to solve this difficult
problem can be classed into five groups: Infectious,
parasitic, toxic, 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 ;
(3) the scorbutic form, due to troubles of nutrition.
$< —___—
Motes and Mets.
LONDON SCHOOL OF TROPICAL MEDICINE.
EXAMINATION RESULT (44TH SESSION, JANUARY-
APRIL, 1914).
J. H. Castro, M.D.(Salvador); S. 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. E Millar
(Capt. I.M.S.), M.B., B.Ch.B., A.O.(Dub.); C. J.
B. Pasley (Colonial Serv ice), M.R.C.S., L.R.C. P.
I. Ridge-Jones, M.R.C.8. Aut ; 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
eonditions 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
efforb will 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 Pacifie 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: 5s. 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 additiu allowed a
personal servant.
—————4»——————
Debiews.
RrexaL DiaGnosis 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
s. 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 inv estigation. 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.
HyaGiexE AND Diseases or Inpia. By Lieut.-Col.
Patrick Hehir, I.M.S. Madras: Higginbot-
hams, Ltd. Pp. 1,000. Price Hs. 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 menual the division into sections is dis-
tinctly 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
Original Conrmunication.
MURMEKIASMOSIS AMPHILAPHES.
By ALBERT J. CHaLMeERs, M.D., F.R.C.S., D.P.H.
Director, Wellcome Tropical Research Laboratories.
AND
J. B. CHRISTOPHERSON, 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
cryptococci (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 ''
(axpoyopSev) 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 " (@vptov) 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 ”’
(uvppnxca) 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 " (puvpym-
kiacpós) to denote the breaking out of warts on
the body.
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, (3) 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
into '' c '' and “ y,” as used to be done in bygone
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 cryptococcus is
130
THE JOURNAL OF TROPICA
the causal 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
into consideration, we are of the opinion that à 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 Nevo-
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
clandular enlargements or metastases could be
found, although the growth is said to have steadily
increased 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 schaceous
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
trihe, celebrated because of its almost total extine-
tion under the Khalifa’s rule.
ETIOLOGY.
After removal the warts were cut vertically and
films made from scrapings of the white central
portion. These films were sometimes fixed with
osmie 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
———$——— ————— —Ó—
L MEDICINE AND HYGIENE. [May 1, 1914.
is characteristic of budding yeasts. It was there-
fore concluded that they were yeasts.
Attempts at cultivation on a large series of media
at 209 C., 379 C. and 40° C. failed to produce any
growth. Inoeulations 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 Kützing 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
eryptococei 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 cryptocoecus and
the wart. We are supported in this view by the
absence of cryptococci: from ordinary warts of the
Sudan, from blastomycotic warts and leishmania
nodules, in all of which it was possible to conceive
that they might have lived parasitically without
being the causal agent.
Cryptococci 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 cryptococcus 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
saccharomycetie diseases and in the mouth and
feces of apparently normal people.
It might therefore be contended that the warty
ervptocoeci 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 cryptococcus, 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-asci and
gymnascales. This sub-order, which contains three
families, the gymnoascer, the exoascee and the
saccharomyceter, 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.
Fic. 1. FiG. 9.
Fic. 4.
Fia. 8.
To illustrate article, ** 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MAY 1, 1914.
PLATE II. :
;
!
ENT n
e
g
TS
TÉ ta.
faa N
- gt eL
Aue
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~
Fic. 6c.
To illustrate article, ** 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.
2222
92422422
92422422
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MAY 1, 1914.
PLATE III.
Fic. 10.
Fic. 11. Fic. 12.
To illustrate article, * 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.
24223229
222422
422232222.
May 1, 1914.]
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, gymnoascez,
exoasceæ and saccharomycetew, which are distin-
guished by the fact that the gymnoasceæ have a
rudimentary perithecium while the exoascee and
sueccharomycetere have no perithécium at all. The
exoascee 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-
myees of Barker, in which conjugation precedes the
formation of ascospores; the schizosaccharomyces
of Beyerinck, in which division, instead of budding,
tukes place and in which an ascus is formed after
conjugation; the saecharomyees 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 cryptococcus of
Kützing, 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 ease, it continued in its eryptococcal
or yeust-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 cryptococcus would become an established
genus, though at present the general tendency is to
view it as merely a provisional genus.
But having defined the systemic position of
eryptocoecus 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 1838 as the generic name for certain
forms of his alge, which he classified as belonging
to the sub-class Malacophycee, tribe Gymno-
spermes, order Eremospermes, sub-order Myco-
phyeege, and family Cryptococcacesm. This family
he defined as: ''Globuli gonimici minutissimi
mucosi in stratum indefinitum aggregati," and in
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
131
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. cerevisie 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
cerevisic became Saccharomyces cerevisia.
Cryptococcus therefore remained for those yeast-
like fungi which do not reproduce by ascospores but
only by budding.
The removal of the species cerevisie 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. ater, 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-
mimosz, 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 eryptococeus was
definitely proved to be the cause of disease was
Busse's case 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 hlastomycosis
in Indo-China.
132
[May 1, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
In addition a number of cryptococci have been
found associated with cancers, sarcomata and in-
nocent tumours, e.g., C. plimmeri Constantin 1901,
C. degenerans Vuillemin 1896, C. corsellii Neveu-
Lemaire 1908, C. hessleri Rettger 1904.
The following have been found in the mouth or
throat: C. sulfureus Beauverie and Lesieur, 1912,
C. lesiewuri Beauverie and Lesieur 1912, C. sal-
moneus Sartory 1911, C. guillermondi Beauverie
and Lesieur 1912, C. rogert Sartory 1911, and C.
linqua-pilosie Lucet 1901.
According to some authors, Histoplasma capsu-
latum Darling 1906, is not an animal but a vegetal
parasite and should be classified as a eryptococcus.
The parasite found in cases of chronic ulcerative
dermatitis in America, and often named Crypto-
coccus dermatitis Gilchrist and Stokes does not
belong to the genus Cryptococcus of Kiitzing but
to the genus Mycoderma of Persoon, 1822.
In our opinion the cryptocoecus which we have
just described does not agree with any of the already
named forms. It certainly agrees with those found
in tumours, as it is associated with a warty growth,
which in its turn is largely composed of adenomatous
sebaceous gland tissue. These warty growths are,
however, innocent and not malignant. Taking
these matters into consideration we feel justified
in naming this organism by the Latinized words—
Cryptococcus myrmecie Chalmers and Christopher-
son 1914.
PATHOLOGY.
It is not possible at present to write fully on the
subject of the pathology of these warts as, in the
interests of the patient, it was deemed inadvisable
to remove more than one wart on the tongue, and
therefore the growths in the mouth and throat were
left for the time being.
The pathology of the skin warts is obviously that
of a hyperkeratosis and an acanthosis (or prolifera-
tion of the prickle cell layer of the epidermis),
associated with a similar process in the germinal
layer of the sebaceous glands. The first two of
these proliferations produce the warty condition,
while the third gives rise to the adenomatous
features of the wart. But the nature of the growth
from the germinal layer of the sebaceous glands
suggests the possibility that in some cases it might
remain as solid strands of cells which do not form
sebaceous material, and perhaps this is the condition
in Lillev's ease. If this were so it would produce
an appearance analogous to the carcinoma.
The pathology of the lingual wart is that of an
“acanthosis '' with some irritation of the mucosa.
The peculiar tendeney to spread suggests the
action of some slowly working causative agent of an
infective nature, while the presence of the crypto-
cocci in the epidermis, the depressions leading into
the hair follicles and, though more rarely, in the
cells of the sebaceous glands, as well as in the
epithelium of the lingual wart, makes their etiologi-
cal influence probable, as in these situations they
may give rise to a mild amount of irritation capable
of producing hypertrophy and incapable of producing
degeneration or cancer formation.
The non-recurrence after removal, the lack of
metastases and the non-implication of the lymphatic
glands, together with the lack of any effect on the
bodily nutrition, show that the process is non-
malignant and are in favour of a local eausal agency,
possibly the eryptococei.
The dark colour of the cutaneous warts is due to
the natural colour of the skin and is absent in the
oral and pharyngeal warts.
MORBID ANATOMY.
The naked-eye appearance of a portion of the
cutaneous growth is that of an ordinary sessile wart
with marked papille separated by sulci, while in the
mouth the warty digitations stand out separately
one from the other.
Under a low power of the microscope (fig. 9)
and in vertical section a cutaneous wart is seen to
be divisible into three portions :—
A superficial layer clearly defined by the wavy
line of the epithelium and containing the epidermis,
with the usual dark pigment granules of native races
and the derma! papille.
An intermediate stratum largely occupied by the
growths from the sebaceous glands but also con-
taining a few rudimentary hair follicles here and
there.
A deep layer composed of the dermis and the fatty
layer (this deep layer is only just visible in the
photomicrograph in fig. 9).
Taking these three layers in their respective order,
the epidermis is seen to consist of a well-defined
stratum germinativum (fig. 5, which should be
examined by means of a lens) lying upon the
dermis without the intervention of any basement
membrane. Superficial to this are three to five
layers of prickle cells forming a well-marked stratum
malpighii. These polygonal cells and their processes
appear to be quite normal. Their nuclei are large,
vesicular, and usually contain a well-defined
nucleolus (plasmosome) and a linen network with
chromatie particles. The down growths of this
prickle cell layer give rise to the apparent elongation
of the dermal papilla. This proliferation is a true
‘acanthosis.’
More superficially the epidermal cells change,
becoming more flattened, while the nuclei become
elongated and flattened and lose their vesicular
appearance, but no granules are to be seen in this
layer and therefore a definite stratum granulosum
'annot be seen. In places, however, a great many
granules, some free and some in cells, may be seen
which may represent this layer.
On the surface of this layer les a very highly
developed stratum lucidum consisting of several
lavers of cells, and superficial to this is the stratum
corneum, which, though poorly represented over the
apices of the papilla, is very well marked in the
depressions, filling them up with a network of
swollen and abnormal horny cells (hyperkeratosis
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
133
May 1, 1914.]
and parakeratosis) among which many eryptococci
nun be seen (fig. 8).
Underneath the epidermis comes the dermis,
composed of rather dense fibrous tissue containing
many blood vessels and spindle-shaped fibroblasts
und a few leucocytes. The dermis is continued into
the papille, whieh may be long and narrow or
broad and short. In places the dermis is absent
and directly under the epidermis lie the growths
from the sebaceous glands. These growths occupy
the middle layer of the specimen and are extra-
ordinarily numerous and so closely packed together
in places as to leave hardly any room for the dermal
connective tissue. Generally well encapsuled in
their own fibrous coat, at times their cells appear
to rest directly upon the fibrous tissue of the dermis.
The germinal layer of the sebaceous growth is
often well defined, but when in this condition it
usually more than one layer deep. Growths from
it can be seen extending into the dermis and forming
little club-shaped masses of cells, the central ones
of which become typical sebaceous cells. At other
places these germinal cells may be observed to be
comected with the outer root sheath of a hair
follicle or even with the epidermis directly. In
many places they form a single layer of more or
less fattened cells with vesicular nuclei.
Inside this layer of cells the sebaceous growth
is mainly composed of large polyhedral cells with a
highly reticulated cytoplasm, the meshes of which
contain oil droplets and here and there cryptococci
can be found. These cells are often completely
broken down into sebaceous material. In places,
however, a number of cells with dense granular
protoplasin can be seen intervening between the
more typical sebaceous cells and the germinal layer,
but these are irregularly arranged and do not pro-
duce the normal appearance of a typical section of
a sebaceous gland.
Here and there degenerate hair follicles can be
seen with or without a malformed hair. In the
depressions leading into the hair follieles erypto-
cocci ean be found. T he deeper dermis is in the
same condition as that deseribed above. No sweat
glands and no tactile or other corpuscles are to be
seen. The blood vessels are very numerous and in
places are markedly dilated. The lymphatie vessels
are also numerous.
With regard to the lingual wart it is seen to be
composed of several separate digitations which,
when examined microscopically by means of a low
magnification, appear to have arisen as a proliferation
of the prickle cells, giving rise to downward growths
which subdivide the mucosal papille, while at the
same time it causes the outward growth of the
epithelium, earrying with it the mucosal papille.
In this way the warty digitation arises as a series
of mucosal papille covered by a thickened epithe-
lium (fig. 11).
The superficial layers of this thickened epithelium
are seen to be composed of flattened cells, the most
superficial of which are cast off from its surface.
No stratum corneum, stratum lucidum or stratum
M ———
granulosum can be seen, the whole epithelium being
composed of nucleated, flattened or polygonal cells.
The mucosal papille contain congested blood
vessels, and a cellular infiltration as well as the
usual connective tissue.
The mucosa shows a certain amount of sub-
epithelial cellular infiltration, as well as dilated
blood und lymph vessels, but is otherwise normal.
Under high magnifications the flattened surface
epithelium is seen to contain some micro-organisms
of various characters, while in the deeper layers,
where the cells are very vacuolated and less flat-
tened, numerous ecryptocoeci of various sizes, with
or without buds, may be observed lving in and
between the epithelial cells. Still deeper the cells
assume tlie typical priekle-cell appearance and are
seen to be resting upon the germinal layer, which
has no basement membrane. In places a few
leucocytes can be seen invading the epithelium.
The papille exhibit the features already described,
as does the mucosa. The cellular infiltration of the
papille and mucosa is composed of polymorphonu-
clear leucocytes, lymphocytes, plasma cells, and
connective tissue corpuscles.
SYMPTOMATOLOGY,
The patient, who was a teacher in a native boys’
school, and aged about 16, appeared in good health
with the sole exception of an extensive warty growth
which had severely injured the right eye. A pecu-
liar sickly musty smell arising from this growth was
very noticeable. He stated that it began shortly
after birth, and though he could not say exactly
where it commenced, he was clear as to its slow
and steady growth.
When first seen (figs. 1 and 2) a considerable
portion of the right side of the neck, face, ear, and
side of the head was covered by a thick, mat-like
growth of sessile warts, which had not merely in-
volved the upper and lower eyelids on the right
side, but had also invaded and destroyed the right
eveball. Reaching the right border of the mouth
the warts had extended into the oral cavity, attack-
ing the right side of gums, the floor of the mouth,
the tongue, the right tonsil, and had grown as far
posteriorly as the “pharynx. The larynx, however,
was not involved, neither was the naso-pharynx.
The patient’s skin was naturally dark brown, but
the a of the warts, though mostly black,
showed brown, green and vellow tints in places.
In the mouth and pharynx this black coloration was
absent and here the warts were of a fleshy tint.
None of them were pedunculated, but all were ses-
sile, painless, firm to the touch, and when handled
felt greasv.
NO lymphatic glands could be found to be en-
laryed and there were no metastases, while the
general health of the patient did not appear to be
in any way affeeted.
No recurrence was found to have occurred in the
area from which warts had been removed as far
back as 1910.
134
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
DIAGNOSIS.
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 ulcerate, but which tend
to slowly spread and to endanger or destroy im-
portant organs.
(b) The proliferation of the germinal layer of the
sebaccous 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 lyinphatic glands, the
uon-formation of metastases and the non-malig-
naney 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 Verruca acuminata, from
Botryomycotic warts, from warty cicatricial
tumours (Marjolin’s ulcer), from non-uleerative
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 histological characters
(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 papillae 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 eryptococci.
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 uleerate (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-ulceratiuve
leish mania nodules it may be diagnosed by the
absence of the smooth pink coloured surface (even
in the black skin), of the itehing 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, diserete 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 ean 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 crest. 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 scars, as well
as by the presence of typical warts in contra-
distinction 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 (Lymphangtoma 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-
logically by the absence 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 reeur during a period of over four years.
May 1, 1914.]
—
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
135
——
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-
ing large areas to be covered in by skin flaps and
by skin grafting. Damaged organs, such as the eye
in this ease, 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, RV. 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.
BRuMPT (1913). ‘‘ Précis de Parasitologie,” Paris, p. 794.
CASTELLANI and CHALMERS (1913). ‘‘Manual of Tropical
Medicine," London, pp. 769-771.
* System of Medicine,”
CELsus. ''De Medicina," Book V, chap. xxviii (Targa’s
edition).
CROCKER (1905). ‘‘ Diseases of the Skin," London, pp. 524,
917 and 921.
KéüTZziNG (1849). ''Species Algarum," Leipzig, p. 145.
LirLEY (1912). British Journal of Dermatology, London,
vol. xxiv, pp. 411-418.
MacLEop (1902). -''Pathology of the Skin," London,
chapters xi, xii, and xxiv.
Mornis (1911). ‘* Diseases of the Skin," London, p. 688.
MnacEE (1904). ‘‘ Handbuch der Hautkrankheiten,” Vienna,
vol. iii, p. 512.
SEQUEIRA (1911). '' Diseases of the Skin," London, p. 434.
ILLUSTRATIONS.
Most of these illustrations may with advantage be examined
by a lens.
Puate I.
Fig. l.—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,
Prate II.
Fig. 5.— Photomicrograph of a vertical section of one of the
warts from Murmekiasmosis Amphilaphes. x 70 diameters.
Fig. 6.—(a) Photomicrograph of Cryplococcus myrmeci«,
stained by Giemsa’s method, as seen in a film made from
a scrapiug of the central portion of a vertical section of a
freshly removed wart from the case of Murmekiasmosis
Amphilaphes. x 1,5€0 diameters.
(b) Photomicrograph of Cryptococcus murmecie, a similar
film stained by Leishman’s method. x 1.500 diameters.
(c) Photomicrograph of Cryptococcus myrmeciev, stained bv
Leishman's method, as seen iu 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 Amphilaphes showing Cryptococcus
myrinecie deeply embedded in the cytoplasm of a cell. x 1,500
diameters.
Fig. 8.— Photomicrograph showing Cryptococcus myrmecice
lying in the cells of the -hypertrophied stratum corneum
filling in the hollows between two papille. Note budding and
non-budding forms. Stained by Gram’s method. x 1,300
diameters.
Prater 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 35 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.
— 4»9—————
The (Geranium as a means of ercluding Flies.—
It is reported that the presence of geranium (pelar-
gonium) plants serves to prevent flies congregating
in a room. It appears thatit 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 1s 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..—Drv. 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 deltaic
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 andHygtene
May 1, 1914.
ARE PLANTS, TREES, AND FLOWERS IN AND
AROUND OUR HOUSES BENEFICIAL OR
DELETERIOUS?
IN the public press in Hneland there is at the
present time considerable interest being taken
eoneerning the effeet 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 rose is accused of causing ‘ rose
fever ":; Tiles 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
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 aet 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-
ing 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 eut 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 object, and
although no doubt decoration of the dwelling-house
has a hygienie influence, its direet bearing is not
so obvious,
Although the scientifie explanation of the part
played by insects in the spread of disease ds the
theme of to-day, the belief in their power to spread
disease has been acted on from time immemorial.
The destruction insects—using the term in the wide
sense—cause to the woodwork of the house, to
clothing, to food, and to almost everything con-
nected with our health, eomfort, and dwellings has
caused man to wage a constant fight against these
destructive pests.
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]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
137
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 effuvia 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 overeome the foul odour inseparable
from the proximity of animals. Many other con-
siderations arise in connection with this subject.
Is it hygienic 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, can be radically
prevented; this raises the whole question of the
hygienic influence of plants, flowers, and trees,
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.
———4QP——————
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 increases 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 Spirocheta
duttoni and S. kochi în 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 the 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
—— — —
in which spirochetes could not be demonstrated, and
further, spirochates 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-museular
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 spirochsete 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 spirochaetes. 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 spirochites in tissues
very clearly.
The Cultivation of a Free-living Filterable Spiro-
chete (Spirochzeta 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:
190 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 and 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 1s able to pass through
Berkefeld "V," “N,” and “W” filters, but not through
Chamberland “ F ” and " B” filters.
In culture the optimum temperature is 30 C.
Growth occurs in colonies on the surface of the
agar or in stab cultures. Morphologically the spiro-
chæte resembles closely the pathogenic spirochetes,
but with it it has been found impossible to infect
animals.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
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 a 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 » h » 9) LEO LE ; LEO
1 » 10th » 90 ,, complete right lobar
pneumonia.
1 » 19th ,, » 92 ,, exhaustion.
1 » 18th ,, » 45 , ss (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-thoracic 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-thoracic 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.]
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 &mount 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 pysemic
nature.
Treatment.— Emetine hypodermically, 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 cedema 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 & colleague he cited a similar experience,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
139:
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 1s
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 1s
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
Two cases out of 27 proved on incision to be sub-
phrenic abscesses. The second case presented himself
&t 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 cedema 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-hepatic 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
thoracic 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 :—
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
(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 guidance 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 &nd
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 calcium 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 aseptie 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, 1$ 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.
—— —
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 cdematous. 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
15 in. in its long diameter.
(3) On no account 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
& separate safety pin placed at right angles to the
wound.
(5) 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
hypodermic 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 anesthesia lasts longer. The
absence of hemorrhage at the time bespeaks care in
hemostasis, or recurrent hsmorrhage may occur
later. All obvious vessels must be clipped and liga-
tured. An incidental advantage of local anwsthesia
is that there is no need for haste.
If a rib has to be resected a general anzsthetic
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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
141
—_ —— ————
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.
I am not a believer in counter-openings posteriorly.
It inereases 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 Jonn D. SaxNpzs, 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.
142
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 à 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-
ig 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 & 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
& cure. During the procedure of aspiration it 1s
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 a few 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 hamorrhage, 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[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 & 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 ansstheties are
better avoided, if possible. I have done the large
majority of my aspirations under local anssthesia,
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 anss-
thetic. I have, to a large extent, given up the in-
jection of quinine into the abscess cavity, as I believe
it 1s unnecessary now that we have emetine at our
disposal. The usual procedure is now, after aspira-
tion, to give an injection of $ 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 cases 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 anses-
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 evacuated 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 &
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.]
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.
a
Rebiews.
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 clinieal 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 nob capable of literal] translation.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ee ——— RR ee
143
There is & very full table of contents, end the
pages are headed with indications of the subject
matter—a boon far too frequently absent from
English publications. E
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. By J. A. Turner, M.D.,
D.P.H., with contributions by others. Pp. 1014.
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 a 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 Tropics 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 the
practical worker.
School hygiene, a subject of even greater anxiety
in the Tropics 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
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 he 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 FooD
AND WATER. By William G. Savage, M.D.
Demy Svo., 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 publie health, with & 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 deductions 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 Daermann 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 amæboid 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,
hut 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 1s 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.
——— —,——————
Becent and Current Literature.
A list of recent publicaticns amd articles bearing on trozical
diseases is giren below. To readers interested in any
branch of tropical literature mentioned in these lists the
Editors of THE JOUBNAL OF TROPICAL MEDICINE AND
HYGIENE will be pleased, when possible, to send, cn apzli-
caticn, 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 Hospitel for Sick
Children.
The special points to which they direct attention are:
(1) The fulininant 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 »nd early operation are necessary
conditions of success in treatment.
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,” whieh 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 red areola sometimes à in. in diameter, the
May 15, 1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 10, Vol XVII
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 vaccinia]
eruption about to be described belonged to two
races of Nilotic 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. l
A few weeks ago a number of Nuers and Nubas
were brought as recruits to Khartoum and were duly
146
vaccinated in two quite separate detachments,
twenty-four on February 10, 1014, and thirty-six
on February 23, 1914. The vaccinia developed well
in all cases, but eleven cases, i.c., 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 bateh. 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 ealf
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 vaecination
took well and developed normally, and in no ease
was there anv sign of septicitv or infection,
A brief summary of the symptoms presented by
these eleven patients is as follows :—
Some seven to nine days after vaceination the
patient complained of a sensation of itching 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, end 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
malarial or other parasites, but there was a leuco-
eytosis 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 cut 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 vesicles apparent to the naked eye were not
examined microscopically.
Etiology.—The general appearance of the erup-
tion before any of the minute vesicles appeared was
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MAY 15, 1914.
Fic. 1.
J
42422225
Fic. 2. Fic 3. "3
Fic. 5.
Fic. 4.
To iliustrate 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.
all.
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.
Inoculations 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, which was taking its normal course; the sus-
picion 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
unaccustomed 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, casily 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 be
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
follieles 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
148
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.
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, TYZZER, and COUNCILMAN (1906). Philippine
Journal of Science, vol. i, p. 242. Manila. .
"CASTELLANI and OHaLMEmns (1913). ‘‘Manual of Tropical
Medicine," pp. 1592 and 1597. London.
CROCKER (1905). ** Diseases of the Skin," p. 472. London.
HiLL and Ross (1910). Journal of Hygiene, vol. x, No. 2,
September 20, p. 137. Cambridge.
KorLE and WASSERMANN (1913). ‘‘ Handbuch der Patho-
genen Mikro-organismen," vol. viii, pp. 725 and 745. Jena.
Monnis (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 Pathogeneu Proto-
zoen,” 2 Lieferung, pp. 122-138, Leipzig.
ScHAMBERG (1911). ‘‘ Diseases of the Skin and the Eruptive
Fevers,” p. 467. Philadelpbia.
ILLUSTRATIONS.
The illustrations are improved if examined by means of a lens,
Fic. 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 & transverse section of a small papule
taken from the case depicted in fig. 1. Note the small vesicle
beginning on the right. x 120.
Fic. 3.
Photomicrograph of small vesicles in the same papule as that
used for fig. 2, but in a different section. x 1,370.
Fia. 4.
Photomicrograph of the larger vesicle from a larger papule
taken from the same case as that depicted in fig. J. = 1,400.
Fic. 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.
Mv time is mainly taken up with the ordinary
routine of « 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 calcttrans, und 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 septic 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
cluripes, and these do not average one a week.
Tsetse are so few that they are probably followers
only.
Siegel fascia 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] -
lived there for twenty-one months without any food
or moisture, thus showing the possible danger of
occupying 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 end 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 heelth conditions.
CULICID.
San Salvador, 1908.
{San Salvador, 1908.
' ( Kimpese, viii.1913.
San Salvador, iii.1913.
Wathen, viii. 1912.
San Salvador, 5.11.1912.
Anopheles costalis, Lw. ...
S00 funestus, Giles
» pitchfordii, Giles
rufipes, Gough M
Banksinella luteolateralis, Theo.
Culex annulioris, Theo. = š xii.1911.
, decens, Theo. E fas -* vi.1912.
xii.1911.
, dQdulitoni, Theo. ... s ath en, viii.1912.
, imvidiosus, Theo. ... San Salvador, xii.1911.
», rima, Theo. m i is xii. 1911.
2" tigripes, Gyp. 9 $3 28.xi.1912.
» tigripes, Gyp., var. fuscus,
Theo. .. ... Wathen, viii.1912.
univittatus, Theo. "var. San Salvador, vi. 1912.
Eretmopodites chrysogast er,
Graham T xii.1911.
Mansonioides uniformis, Theo.. 74 29.xi. 1912.
Ochlerotatus argenteopunctatus,
Theo. t xii.1911.
Ochlerotatus domesticus, Theo... zi ix.1912.
" quasi univittatus,
Theo. ... is xii.1911.
Stegomyia africana, Theo. Kibokolo do Zombo, iv.v.
1911.
yi [1] fasciata, F. San Salvador, iv.1912.
is simpsoni, Theo. En $ iv.1912.
Teæeniorhynchus [2] cristatus,
Theo. .. T T 5i 1908.
TABANID4E.
San Salvador, 1909.
Chrysops longicornis, Macq.
Kibokolo, iv-v.1911.
Tabanus billingtoni, Newst.
» [3] canus, Karsh. San Salvador District, 1909.
T claripes, Ric. ... San Salvador ae Pee a
bes Salvador, 1908.
Kibokolo, iv-v.1911,
San Salvador, ¢ ¢ and 9 9.
Kibokolo, 1 9 , iv-v.1911.
) 9 9,iv-v.1911.
Leopoldville, Belgian Congo,
ix, 1910.
T [3] congoiensis, Ric. ...
S: corax, Lw.
gratus, Lw.
i tanthinus, Surc.
i laverani, Surc.
Leopoldville, ix.1910.
5 ruficrus, P. de B. d sen Salvador, xi.1912.
re thoracinus, P. de B. 2 908.
ji sp. nov. ? near Fulezi River, San Salvador,
nyasæ, Ric. 1 9, xi, 1912.
33 [3] pluto, Walker San Salvador, 1909.
* «The Congo Floor Maggot.” Dutton, Todd and Christy.
British Medical Journal, September 17, 1904.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIPAE
-——— — — aa
149
rn —M— M P— = + =
TABANID® (contd. )—
Hematopota cordigera, Bigot ... San Salvador, 1 9 , xi.1912.
is denshami, Austen... Kibokolo, 1 9, 2.iv.1911.
$3 pellucida, Sure. ... - 1 Q, 2.iv.1911.
(a) 1909, near brunnescens,
Ric.
, b) 3 9, San Salvador, i. 1912
2 Spa noy? É near brunnescens, Ric.
(c) 1 9, San Salvador, 25.x.
1912.
MUSCIDZ., ,
( Universal, San Salvador,
Glossina palpalis, R. D. - Mabaya, Kibokolo,
Ambriz River.
.. San Salvador and Kibokolo.
San Salvador, Kibokolo,
ik | Mabaya.
Slomoxys calcitrans, L. ...
3 ^igra, Macq. ...
CHIRONOMID.F.
Culicoides [4] grahamii, Austen San Salvador, 1909.
TACHINID.E. 5
Salvador, Kibokolo,
Mabaya.
San Salvador, ii1.1911.
Auchmeromyia luteola, F = San
Cordylobia rodhaini, Gedoelst ...
SIMULIDA.
Simulium griseicollis, Becker ... Mabaya, v.1912.
32 damnosum, Theo. Ambriz River, 1.1911.
- pusillum, Fries. var. Ambriz River.
SIPHONAPTEBA.
Sarcopsyllide—
Echidnophaga gallinacea, West poultry and dog.
Pulicide—
Ctenocephalus canis, Curtis man, dog, cat.
_ACARINA,
Argasidie— i
Ornithodorus moubata, Murray ... huts,
Ixodide—
Amblyomma splendidum, Giebel
i tholloni, Neum
trimaculatum, Neum
buffalo, pig.
elephant.
monitor lizard.
Hamaphysalis leachi, Aud dis .. dog.
Rhipicephalus capensis, Koch . buffalo, pig, dog.
5 falcatus, Neum ... .. dog.
T lunulatus, Neum dog and pig.
si sanguineus, Latr. .. dog.
VOCABULARY.
English and Ki-Kongo.
Bug Kinsekwa ; plural, yinsekwa.
Flea Nianzi, plural.
» jigger ; .. Dede.
» » Swollen .. Mumvidi; plural, mimvidi.
: : Mbwanzi plural, San Salvador district.
Fly, generic ... B | Nianzi »» Kibokolo district.
( Evekwa dia nzo, S. Salvador.
» Congo floor . - Ekungu nianzi, Kibokolo.
( Ekulumbwanzi, Wathen.
, horse—-
(1) Hematopota...
(2) Tabanus
Evekwa dia mfwila nitu. `
| Evukunia ; plural, mavukunia.
' | Evekwa dia nzadi, Kibokolo.
pzadi = 4 river.
Ekulumbwanzi.
Kinkufu ; Bimbundia.
{ Mbwanzi, S. Salvador.
, large generic
», sand (Simulium)
» stable ' ( Mbwanzi za lau, Kibokolo.
lau = madness.
Louse ... Nianzi, plural.
» crab Maniata.
Maggot í Mumvidi ; plural, mimvidis
` | Ntunga generic Wathen.
150
VOCABULARY (contd.) —-
| Mumvidi a nzo, sing., of the house.
M. M . | Mimvidi mia nzo, plu., ,, »
Maggot, Congo floor... | Mumvidi a nsi, sing., of the ground.
Mimvidi mia nsi, plu., ,, j
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' & 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."
[4] Ibid : Bulletin of Entomological Research, 1912, vol. iii,
p. 100.
—————— ———— ——
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.
THe 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 stables are filthy, where breeding
places for flies abound, and where the infant sick-
ness maintains a high rate, Dr. Ross carried on a
crusude 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1914.
Rotices.
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THE JOURNAL OF
Tropical Medicine andhpgiene
— -- -r.a rA --— ——
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.]
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, a8 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. In this 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 Colleyes.—The medical colleges
which have been established by the Government are :—
The Peiyabg Medical College, Tientsin.
The Army Medical 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 Japanese staff, the language used being Japanese.
Since 1911 all the teachers have been Chinese, mostly
(Now
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
151
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 Colleges. — 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 & 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 sentali
their medical teaching in eight large cities, where
sufficient staff, equipment, and clinical material are
available.
It was decided &t 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 & 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.
. (8) 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 1912).
(5) The Hong-Kong University (opened in March,
1911). The medical faculty of the University con-
sisted originally of the 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
School at Mukden is controlled and supported by the
South Manchurian Railway Company; while the
Harvard Medical 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 public institution encouraged
and partly supported by the British Government.
These centres are essentially for the purpose of giving
a 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, Kweilin,
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,
Esg., M. R. C.S., L.R.C.P., from Persia, on the medical.
work accomplished . in the several. countries. the
speakers represented. |
E | J. C.
———dQe——— —
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 instruction 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.
. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
—
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 amoeboid, 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.
E pidemiolog y of Dame: —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 aud
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 & detailed account of the
epidemiology of the disease.
Dr. Seidelin condemns the use of the term “ mos-
quito 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 & 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
endemie 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 the disease ;
ahd that these cases are the most dangerous from an
epidemiological point of view.
May 15, 1914.]
It is interesting .in this connection to note that
from Puerto, Mexico, a 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 puneliont
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
flavigenwm, 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. f DAT |
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 which 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 animels 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 & 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 succeeded 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
THU JOURNAL OF TROPICAL MEDICINE AND HYGIENE,
--— - - - iua “soe ——— l2 o - —
A amd of. n spreading the disease. -In
other ‘words, the patient would :be infectiotis™ 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 endemic, in spite of stringent sanitary
ee |
W. S. Clark, West African Medical Staff,
E 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 Culer fatigans, C. tigripes, Stego-
myia fasciata and Culictomyia 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. . |
a S9 ————
Abstracts.
EMETINE AND IPECACUANHA ; THEIR
AMGBACIDAL VALUE IN PATHOGENIC
AMCEBIASIS.*
By R! Manxuam CARTER, LM S.
EMETINE administered hypodermically in doses of
1 to 2 gr. per diem acts rapidly in early cases of un-
complicated ameebic dysentery in Europeans and
Indians.
Emetine is valueless in bacillary dysenteries.
Emetine is a specific in pre-suppurative amoebic
hepatitis, and is of marked value in chronic latent
amcebic colitis which gives rise to the above condi-
tion. The value of emetine in liver abscess is doubtful,
and rational oper ative treatment without the exhibitión
of emetiné gives as good results as it does with the
drug.
If amoebic 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
amoeba-free under seventy-two hours.
Further, such cases of intestinal amcebiasis, even
after & week’ s injections and apparent cure by eme-
tine, have in some cases a tendency to relapse.
The true emetine amoebacidal 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 cases 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 &moeba-laden fæces
Bragnalo in the Npousnes of the ure intestine.
* From the Indian Medical Gazelte, March, 1914.
154
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 4 gr. do harm
instead of good, as I believe they so sensitize the
residual store of undestroyed amcebe in the gut-wall
as to render them emetine proof. Such cases pass
out from the hospital apparently cured, but are
amcebal cyst carriers and sources of infection to
others.
I am fully convinced that acute amoaebic 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 amcebacidal effect of the parent
drug upon the parasites buried in the wall of the
affected intestine by the hypodermic injections of
emetine carried to these by the blood-stream.
THE INFECTIOUS DISEASES: RECENT
ADDITIONS TO OUR KNOWLEDGE OF
THEIR ETIOLOGY.*
By Jogmw 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 1s, 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 stil contain the
infective agent. The sume 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 puni very common during DIOE of polio-
. ^ United States Public Health Report, April 3, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 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 whieh 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 from 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 e per
Disease Deaths 100,000
population
Diphtheria and Ru 11,512 21:4
Measles »i 6 598 12:8
Scarlet fever - 6,955 11:6
Whooping cough ... : 6,148 e. 114
Cerebrospinal meningitis .. 2,272 is 4:2
Infantile paralysis 1,459 — 2-7
In 1911, Anderson and Gulübereer 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] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
were made, without success, to demonstrate the
presence of the infective agent of measles in the
‘“ seales '" 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 infected 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 infeetion. 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
inoculation, 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
constant 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.
TvPHOID FEVER.
Thirty years ago the Bacillus typhosus was
described and isolated in pure culture.
155
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, Metchnikoff, 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 pura
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 specific 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
etiological 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
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-
tieles. 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 thaí
time.
The disease is transmitted by the secretions from
the mouth and throat, and is most infectious in the
early stages.
TypHus 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. l
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 discase clearly in mind, were struck
bv 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
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. 2E
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. i57
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
role 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 which he has heretofore been unaware,
and to be on his guard against a disease that pre-
sumably may at any time assume epidemic 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 à 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 communicable 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 application 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. |
——— —9————— —
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 & mortality
of 17 per cent. per 1,000, and a gross reduction of
50 per cent. in three months. AE CE.
^ .fThe 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 t&king place
at the commencement of winter, and this winter was
&' 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, especialy at & growing age, when
transported into the Tropies 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 diffieult 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 climatic 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 océurrence ;
it happened to the Creole recruits at Marseilles and
elsewhere. | . |
J 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. EE
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 passéngers, 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 & 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 versd, 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 circumstances
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.
—— "I —
THE BRITISH MEDICAL ASSOCIATION.
PROGRAMME OF ABERDEEN MEETING.
THE 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
medieine 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.]
———
which the programme -is still undeeided. 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-
peuties 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 Compnrative 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 '' Muscle 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: (a) 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 Infancy 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 subjects 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; (8) '' 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
159
—— 8.
several subjects that have recently been prominently
before the publie have been arranged. On July 29
the President of the Section, Dr. W S. Lazarus-
Barlow, will open a discussion on ‘‘ The Action of
Radiations on Cells and Fluids,” while another dis-
eussion 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-
peuties 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-care,’’ 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 folowing discussions have been decided on
in the Section of Tropical Medicine: (1) '' The
Training and Position in Administration of the Sani-
tarian in the Tropics,” 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
medicine. |
—e0
160
Personal Hotes.
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. Seton, V.A.S., I.M.S.; Lieutenant-Colonel F. W. Gee,
I.M.8.; Major P. L. O'Neill, I. M.8. ; Lieutenant-Colonel P. P.
Kilkelly, I.M.S8.; Lieutenant-Colonel A. H. Nott, I.M.8.;
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.S.; 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.8.
Extensions of Leave.—Lieutenant-Colonel R. H. Elliott,
I.M.8.,6m., M.C. ; Major E. J. Morgan, I.M.8., 6 m., M.C. ;
Major F. D. S. Farrer, I.M.8., 1 m. 27 d. ; Lieutenant-Colonel
J. Jackson, I.M.S., 3d. ; Lieutenant-Colonel C. M. Moore,
I.M.S., 3 d. ; Captain C. L. Dunn, IL.M.S., 5 m., M.C. ; Captain
G. G. Jolly, I.M.S., 15 d.; Captain G. L. ©. 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.
Permilted to Return. —Captein N. N. G. C. McVean, I.M.S.
Lisr 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.
Childe, Lieutenant-Colonel L. F., I. M.S., Bo., 15 m., January
19, 1913.
Duer, Lieutenant.Colonel C., I.M.S., Home Dept., India,
24 m., May 1, 1912.
Hall, Lieutenant-Colonel E. A. W.,I.M.S., B., 24 m., October
25, 1912.
Nott, Lieutenant-Colonel A. H., I. M.S., 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 oF 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.8., 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.C.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.S.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.S.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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
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.8.
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.Iro.,
D.P.H.Ire. F.R.G.8., 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.8. & P.Ire., Provincial Medi-
cal Officer, Southern Nigeria, to be a Senior Medical Officer
(Grade 1), Nigeria; C. F. Watson, M.R.C.S.Eog., 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.8.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 8),
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.8.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 & 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.
—— d
“Journal of the American mcm Association," April 20,
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.]
Original Communications.
EMETINE TREATMENT OF DYSENTERY IN
YOUNG CHILDREN.
By Captain R. G. ARcHIBALD, 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 Lóschia
tetragena Viereck, 1907 (Entameba tetragena). The
results obtained were interesting, and were considered
worth recording, for in the one case the entamcbe
appeared to have considerable resisting properties
towards the action of emetine, while in the other the
amoebicidal 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 diarrhoea, 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.
À 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
diarrhoea, 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 increase 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. | l
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 $ gr. emetine hydrochloride was
* Houston, M., “ Care of European Children in the
Tropics." 1912,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[No. 11, Vol. XVII.
injected intramuscularly, followed twelve hours later
by a second injection of § gr., and twelve hours later
by a further injection of à 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 entamcebee
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 peristaltic 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 & 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 fluctuating between
100? and 102° F. Another injection of } gr. emetine
was administered, making a total of $ gr. in forty-
eight hours. No further emetine was administered
til thirty hours afterwards, when another $ 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 3 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 entamcehe were found on
the twelfth day following the onset of the illness, nor
were they found again in the examinations carried 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 two
and one-sixth 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 7's 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1914.
was given the following day. Examination of the
stools revealed only a few entamcebe and no cysts.
Two more daily injections of emetine, 7s 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 1s
that some guide may be given to the practitioner 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 entamcebse towards this drug. Even after a
total of 13 gr. of emetine administered intramuscu-
larly, living entamcbse were present in the patient's
stools. Bearing in mind the age of the patient,
this result was hardly to be expected in the light
of what has recently been written regarding the
active amoebicidal 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
&mobic dysentery; in many of these cases the enta-
moebe 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 & case where the patient's dysen-
teric symptoms continued, and entamobse 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 & 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 prophylactic 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 amoebic dysentery which fail to
respond to the action of emetine in the amounts
usually employed. On the other hand, there may be
some stage in the life cycle of Léschia 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 amcebic 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 amoebic dysentery
with emetine one must rely on the evidence obtained
by frequent microscopical examination of the feeces.
One’s experience has shown that failure to find
entamcebe 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 entamcebe 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 4 gr. was thus
given in thirty-six hours with excellent results, caus-
ing a complete disappearance of the symptoms and
the entamcebe and their cysts. There can be little
doubt that this was & true relapse, and not & 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 & period of three months after the patient's
apparent cure.
Leonard Rogers" in his recent work, entitled
“ The Dysenteries," discusses the question of radical
cure of amobic 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 accordance with that of this distinguished observer,
and more evidence is required regarding the permanent
* Rogers, L., ‘‘ Dysenteries," 1918.
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 Entamaebe. — Reference has
already been made to the species of entamæœbæ found
in the two cases described above. The entamobse
were examined in the fresh state, and their cytological
characters studied in preparations stained by Leish-
man, and 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
feces containing active entamoebse. Both kittens
developed dysenteric symptoms with entamcebez 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 fæces of all the immediate contacts were exa-
mined, but with negative results as regards the finding
of entamcebe. 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
local 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 a
well-known English and also Italian firm.
Conclustons.—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 entamoebie dysentery of the Sudan emetine
may require to be given in larger doses than are
ugually employed in other countries.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
163 4d
RECOVERY OF EMBRYO OF FILARIA BAN-
CROFTI FROM BLOOD FROM THE LUNG
DURING DAYTIME.
By Major B. H. DuTcHER.
Medical Corps, United States Army, San Juan, Porto Rico.
A SOLDIER of the Porto Rican Regiment entered
the hospital February 16, 1914, suffering from a
mild attack 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 mucus.
Upon examining as much 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.
AT 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.
SMALL-POX IN GREAT BRITAIN AND
GERMANY.
In 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 distinctly 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, “18
that Germany has more rigid and better adminis-
trated vaccination requirements.’
164
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1914.
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THE JOURNAL OF
Tropical Medicine andhypgtene
SOME ASPECTS OF SURGERY IN THE
TROPICS.
AT the meeting of the Society of Tropical Medicine
und Hygiene, on May 19, 1914, a paper was read by
Mr. Cantlie, on " Some Aspects of Surgery in the
Tropics.” 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, &c. 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
a great comfort to the men who are going out; but
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 difficult
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
case 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 difficult 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 cireumstances. 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 cure 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 statistics 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 chosen 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
€
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 European, 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
angesthetics 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, with 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 18, 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
GONORRHGAL EPIDIDYMITIS.*
By Suu YOSHIDA.
NEURITIS after gonorrhæal inflammation of epidi-
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 33. Suffered from
gonorrhoea 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
prostate. The left spermatic cord was generally
enlarged, and the testicle was hard and the size of
an index finger, but they both had no tenderness.
Finally, the author says that the neuritis may
accompany or follow other diseases of the genito-
urinary system.
eee
SOME CASES OF PELLAGRA OCCURRING
AMONG THE INSANE IN SOUTH AFRICA.} °
By E. W. D. Swirt, M.B., and H. Earrton 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 seuson it is not so likely
to become diseased as elsewhere.
The disease in other countries occurs in the
spring end 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 herpetic 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 and 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 206.—Uleeration has extended over
front of legs and elbows. He is weak and has some
dysenterie diarrhea. Skin of face and limbs is
icthyotic, thickened, scaly and coal black. The
appearance is suggestive of pellagra.
October 8.—Uleeration 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, 1918, 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; m
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 sear.
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-
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 identieal 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 ease 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 crouched 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
dysenteric diarrhoea 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.
June 1, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 167
s ee —— A MÀ —— A — A — — M o — ——— — — — M a — a À—À 'o— .
INFANT MORTALITY IN THE PHILIPPINE
ISLANDS.*
By W. E. MUSGRAVE.
INFANT 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
eountry. 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—ineluding 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
are 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.
|. * From the Philippine Journal of Science, December, 1918.
168 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
— — M
— MÓ— =
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 eonditions 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 clinies, 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 eountry, 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
eauses 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 local problem must bear this point
in mind. The milk production of the Philippine
Islands is practieally 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-
[June 1, 1914.
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
& very high eost 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 policy of
this institution have felt it necessary to sterilize the
milk before allowing its consumption by the babies
under their care. If sterilization still is necessary
after the precautions and expenses incident to the
production of milk by 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 difficulties.
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 $0:005, United States currency.
June 1, 1914.]
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 169
—
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 particulars. 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 caloric 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, 1t
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.
water. In our investigation of the causes of death
of 300 babies, it is found that tap-water, either with
or without boiling, is used as a diluent in most
instances. As & 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 earthenware 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 care 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 product 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
edueation, both by theoretical instruction and, best
of all, by practical demonstration as may be seen
in the wards and clinies 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 a very popular one, and even in older countries
with more advanced civilization it is only within
recent years that conservation of health has been
of much interest to the general public.
Publie opinion is vitally active regarding the
peeuniary 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
cruelty to domestic animals.
However, with regard to the great vital question
of the conservation of the health of its citizens and
the saving and protection 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.
[June 1, 1914.
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
economie 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 public opinion regarding the
economie 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. AsHBURN, 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.—A large male,
that had been successfully vaccinated in October,
was inoculated at six sites on the abdomen on
December 4 with fresh vesicle contents. No local
lesions resulted. There was, however, a moderate
rise of temperature on the third day, followed by
a drop, and & 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, 1913. |
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 ecarifications 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 disturbanoe,
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 parb, 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 28.—A large unvaccinated male monkey
was inoculated December 81 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 Scars 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. l
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 discs
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.
Minen 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 he sick and
to have a high temperature, and on January 19 he
died. Autopsy showed streptococcus septicemia as
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, 80, and 31. 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 seabs 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 seabs.
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
172 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[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
but 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
scabs 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-vaccinated 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 atypical variola inoculata, which
in turn and in further modified form may be passed
to other monkeys.
(8) Active and fresh vesicle contents inoculated
on vaecinated 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 scabs or dises from man or monkey
possess but a low degree of virulence, or very
quickly lose their virulence.
(5) When inoculation of such scabs does result in
the production of infection this may be manifested
only locally at the site of inoculation (Case 24). In
June 1, 1914.]
— +
——MM ——— —
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 exanthemute, 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 toxsemia-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. Casavx.
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 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 173
eee
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 cedema. Dul-
ness was continuous with the liver which extended
to the sixth rib; there was no vibration or tremor.
The stools were of & high colour, constipation had
alternated with diarrhoea.
À 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.
e —
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 $ in. below the costal margin in the vertical
* From the Medical Press, May 13, 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
l 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 still in, but complete
recovery ultimately took place, and was attributable
largely to the persevering drainage and irrigation.
———— e — —
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. Itis 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 à gang who wash the
furniture with & 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 róle 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
microbes directly exposed, but does not reach those
in any way protected, and does not affect the insects.
Another, which reaches the microbes 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.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
175
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 accomplishes 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 Hôpital
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 réle 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 everywhere,
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
articles 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
9 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 eubic 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 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 **
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
Diphtheria closed envelope All destroyed.
| closed envelope All destroyed.
at 1°20 m.
&t 0:50 m.
TERIS in | 'oth 1 thickness
5 thicknesses
| closed envelope
Coli bacillus . All destroyed.
79
at 0°50 m.
on floor .
| at 0:80 m.
at 1:20 m. ; closed cuvelope
Staphylococcus ES ceiling All destroyed.
wrapped in E cloth 1 thickness
T : thicknesses
4 guinea - pigs
show no trace
of tubercu-
ORIB ee
on floor ...
at 1:20 m.
at 0:50 m.
near CUBES Somme
Tuberculosis .
at 0-80 m. Develo p m e nt
Subtilis at 1:90 m. ; closed envelope arce 86
at 0:50 m. hours.
ou ficos Develop ment
Anthrax we E closed envelope —— 24
| closed envelope
Diphtheria
Coli bacillus ...
[ores woollen mattress... | ay). mattress ... | An destroyed
"U » Seaweed es yon
Inside woollen mattress
» seaweed T
Staphylococcus (ma woollen mattress
All destroyed.
All destroyed.
|
» seaweed ,, i» |
Development
Subtilis Inside woollen mattress -" retarded 36
hours.
Develop ment
Anthrax Inside seaweed mattress retarded 24
ll hours.
Inside woollen matt 2 guinea - pigs
Tuberculosis ... l T $ EDE ST | show signs of
tuberculosis.
Me Rca bea oe ate Co Tn ae
N.B.—Seeing that the subtilis and authrax, 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 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 1, 1914.
NR
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-
infecting thoroughly in case 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
————— dàÓ9—— —————
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 hag
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 ¿n 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.
eee amc eee
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 Gonorrhesa; 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.—10-12, Ward Work; 12-1, Dr. Mac-
Cormac, special lecture on Syphilis ; 2-4, Laboratory
Work.
Mac-
Friday.—10.12, Ward Work; 12-1, Dr.
‚popularly known as
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 1913 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,
‘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. 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
NOTE ON A CASE OF OSTEOPERIOSTITIS ’ : l ae
DEVELOPING, AFTER A PROBABLE pe the surgeon had no influence on typhoid. para.
ATTACK OF FEBRIS COLUMBENSIS.”” typhoid A, paratyphoid B, Micrococcus melitensis and
By Arpo CasrELLANI, M.D. B. asiaticus, it agglutinated B. columbensis well.
Director, Bacteriological Institute, and Clinic for Tropical With Dr. de Silva’s kind permission a more complete
iseases, Colombo. : :
bacteriological examination of the case was under-
IN 1905 I deseribed and published a case of fever, taken.
somewhat resembling enteric, due to a germ which I SERUM REACTIONS.
called Bacterium columbense. Later, impressed by The blood examined on four different occasions
the peculiar, somewhat inconsistent, sugar reactions has shown complete agglutination for B. columbensis
of the micro-organisms, I was inclined to consider in a dilution of 1 in 40 and occasional feeble agglutina-
the bacterium no longer a separate species and was tion in a dilution of 1 in 80. The blood agglutinates
inclined to identify it with the Bacillus paratyphosus B- equally well the strain isolated from the first case of
Recently having had an opportunity of isolating the — ''febris columbensis" in 1905, the strains recently
same germ from two further cases and studying it isolated in two cases in 1913, and the strain isolated
more completely, I have been forced to come to the from the pus of the lesions shown by the patient.
conclusion I had arrived at eight years previously,
viz., that the germ is a separate species and the fever PRESENCE OF B. columbensis IN THE PUS.
caused by it a separate entity from either typhoid or The bacteriological examination of the pus by
paratyphoid. These two cases have already been plating, &c., has revealed the presence of the typical
| | ae :
i | mE M'MINI' E
8 3 Š js s il$|s sis NET os E(ElE sjea |£
- e 2227 £, £123 E 2|lg Bza E EZE 2 |
|=) P si Aj * B 218 Fle sle-.5/* 3 =
E a Á y i 2? 5 | = | aos und = |B lz ae $
EET ME e a ia wa mc dees Ge ee 2E RR NES MERGE RE,
B. ‘trig ood +;AVS]|. 0 0 AG! AG| AG! AG! ASGS/0| AG!0/0! AG! AG AG 0 AG!0/ AG 0) AG +1010 2. oe 0: GTP| GTP
[
Mil:
Abbreviations used in the table: A = acid, G -= gas, C = clot, D = decolorized, Alk — alkaline, S = slight, A/Alk = acid then
alkaline, GI = general turbidity, P — pellicle, VS — very slight, 0 = negative result, viz., neither acid nor clot in milk, neither acid nor
gas in sugar media, non-production of indole, non-motile or non-liquefaction of gelatine or serum, as the case may be; + — positive result.
* See remarks in the text.
published and recently I have studied three further B. columbensis as described by me in 1905. As
cases. The complications and sequele of this this germ is yet little known, it may perhaps be of
fever are practically unknown; it may therefore be advantage to give here again its description.
of some slight interest to relate a case recentl
observed of eee osteoperiostitis, due to B. seed CHARACTERS OF B . columbensis (CAST., 1905)
bense, which from the history given by the patient Rods 2 to 5 u in length closely resembling
and his relations must have developed in all pro- the typhoid and paratyphoid bacilli, motile. It is
bability after an attack of “ febris columbensis.” The easily stained by the ordinary aniline dyes, but not
patient, a Singhalese, was admitted to the general by gram.
hospital in December, 1913, and placed in Dr. Marcel u
de. Silva’s surgical ward. He had several sinuses Broth.—Abundant growth with diffuse turbidity :
in the left arm discharging sero-purulent matter. after twenty-four hours to forty-eight hours a delicate
According to the patient and his relations the condi- pellicle is generally present. n"
tion had commenced with painful swellings more Agar.— The growth may be typhoid-like, but
than & year previously, after an attack of continuous generally the germ grows more luxuriantly than is
fever which had lasted six weeks. Dr. Marcel de the case with typhoid.
Silva operated on December 12 and again on Feb- Gelatine.—Growth fairly abundant, medium not
ruary 3, and several spicules of bone in the form of liquefied. E
sequestra were removed. The surgeon suspected the Serum.—Nothing characteristic, the medium is not
condition to be due to previous typhoid and sent a liquefied. l l
sample of blood for Widal's reaction to the Bacterio- Litmus Milk.—It may be said that, in general, it
logical Institute. The reaction was negative. At becomes acid at first and alkaline later, and that
———————— —————— bleacbing of the medium is of very frequent occur-
* The author would be pleased to send a culture of the germ rence, but occasionally the medium is rendered
referred to in this paper to any worker interested in the subject. permanently acid. After three weeks, the medium,
CULTURAL CHARACTERS.
17 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
— À—
—
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 À 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 identical with one of the so-called para-
typhosus D, &c., paracolon bacilli, &., 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 nomenclature the
term Bacillus columbensis (Cast., 1905) would have to
stand, owing to priority of description and name.
[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. columbensts (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 ean 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.
—— 4.» —— —
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 2$ 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 tincture of opium to the
solution to prevent tenesmus and aid retention.
June 15, 1914]. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
sRotices.
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THE JOURNAL OF
Tropical Medicine andhHpgiene
JUNE 15, 1914.
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
SPAS IN
179
-———
—
and that disease. He will in all probability arise from
his study of spas in & 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, anæmia, 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 Tropics 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, anæmic 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
welcome 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 medieal men direct their thoughts when liver
ailments are in question. Thither men from the
Tropies used to go as & 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
180
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 aequainted 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
Tropies 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 à 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 thereonly as dietetie and balneo-
logical " 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 which 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
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.
A 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-
richsquelle. The Hauptstollenquelle is the most
used for drinking and contains :—
Common salt $c 4 per mille.
Chloride of lithium 0:05 :
Arsenate of calcium 0:0007 P
Character of Water.—Temperature 194? 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.—Chronic 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.
EMS.
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:—
Bicarbonate of sodium... 2
Chloride of sodium »
Carbonic acid gas 500 vol. "
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, &c., (2) douches, (3) inhalations, and (4) for
drinking, according 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.
per mille.
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
Chloride of calcium
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; chronic 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 & 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 porphyritic 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 a 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 ] per cent.
Chloride of calcium ] 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,
angemia 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.
1 per cent.
2 per mille.
NEUENAHR,
in Rhenish Prussia, possessing & 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 l per mille.
Bicarbonate of magnesium... 04 p
Bicarbonate 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 M
Sulphate of calcium 0'8 "
Sulphate of magnesium 0°45 A
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 angmia, 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
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.
Bicarbonate of magnesium 0'5 to 13 =
Bicarbonate of iron 0018 to 0'036 ,,
The diseases benefited are largely those of the
urinary organs. The chalybeate springs are useful in
anæmia and debility.
os
Aunotations.
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 anemia 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
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 cross agglutination indicated 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
production 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 physical 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 percussing 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—suprahepatic 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
percussed 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 AMŒBIASIS AND OTHER DISEASES."
By Gxonck C. Low, M.D.
IPECACUANHA has long been known to medicine,
first having been introduced into Europe in the year
1658. It soon became known that the drug exerted
& 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
Tid devices had to be adopted to try to prevent
is.
About this time also our knowledge of dysentery
advanced considerably, the amoebic 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 amc«bie 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
amoebic dysentery seen elsewhere, and the only satis-
factory 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 Soci ici zji
(Therapeutical dd Phatibacoloriceh Benin Dr ie n
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 & brief description of
ipscacuanha 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 Rubiacese. 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 Pharmacopceia
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 175 per cent. of ipecacuanha alkaloids to be
present in these. The alkaloids found in ipecacuanha
root are emetine, cephaeline 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, 405 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
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 amcebe 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 entamcebz may be found in the intestine of
man: (1) the Entameaba coli, supposed to be harm-
less; (2) the E. histolytica—the E. tetragenu—the
cause of amobiasis and am«obie dysentery. These
so far have not been cultivated outside the human
body, so Vedder had to fall back upon cultures of
amoebee isolated from tap-water for his experiments.
It was soon found that fluid extracts of ipecacuanha
were very toxic to these organisms ¿n 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 amce-
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 amæœæbæ ; (3) that emetine
is a powerful amoebacide, killing amcebe 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 amoebe 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 0885 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. OF Tror. Mep. AND Hyc., 1911, p. 149.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(June 15, 1914.
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 amcebex, 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
alhumin 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 Calcutta, 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 diarrhea 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 amobse in
normal saline solutions of this salt, he found that
the pathogenie 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 1in 100,000. He then decided
to try if the alkaloid could be safely given hypodermi-
cally in the treatment of amcebic disease, and having
a suitable case, injected à 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
3 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
juite unable to take ipecacuanha by the mouth, so
& gr. of emetine hydrochloride was injected. This
was rapidly increased to 4 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 amoebiasis, viz., acute and
chronic ameebic 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-
cuanha one of all its terrors and discomforts. By
his observations in these cases Rogers was also able
to definitely decide the matter of dosage. Either 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 3 gr., this
equalling 60 gr. of ipecacuanha. In two cases l-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 amosba 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.
-æ
be given, and so on. Sometimes injections are in-
convenient, and in these instances keratin-coated
"tabloids" may be tried.f 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 4 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 5 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
macroseopie 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 entamcsbe 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.
Amoebic abscesses discharging through the lung or
discharging externally are greatly benefited or even
cured straight away, without surgical interference, by
emetine. When an ameebic abscess is opened and
drained, emetine injections should be started at once
as they will help greatly in the healing process.
Cases of amoebiasis 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 amoebic dysentery
treated by injections of the soluble salts of emetine,
suggested the possibility of the drug being similarly
effective in hsmoptysis. Hight cases of this con-
dition were treated, and in all of these, with the
exception of a galloping case of tuberculosis, the
hsemorrhage 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., 1918, i, p. 1369.
186
gives & 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 hsemorrhages. He quotes Valassopulo, of
Alexandria, and Edham, of Salonica, as having
obtained good results from these in hemorrhage from
& carcinoma of the large intestine, and from a case of
muco-membranous entero-colitis. In his own ex-
perience five cases of severe intestinal haemorrhage,
including hemorrhage due to biliary and hypertrophic
cirrhosis, hzemorrhage 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 hzemorrhage
after typhoid. Renon advises doses up to 9cg.
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 anæmic but otherwise normal; there was slight
dyspncea, 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 rales, but the breath sounds over the dull area
were high pitched and bronchial in character, and
pectoriloquy 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 leucocytes showed 5 per cent.
of eosinophiles: ater 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 afew 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 bronchus 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.f
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, tubercular 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 O., but was able to walk
without pain. The lump on the back became pro-
minent and fluctuated. The expectoration contained
no tubercle bacilli. The tumour was punctured and
a 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.
Incision 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 diaphram 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.
— —— ——— ——-
T Bull. de la Soc. de Path. Exot., 1914, Vii, i. No; 5.
June 15, 1914.]
nr M9 —
R chicks,
TEXT-BOOK OF LOCAL ANASTHESIA FOR STUDENTS
AND PRACTITIONERS. Professor Dr. Georg
Hirschel, Heidelberg, Assistant in the Surgical
Clinie. 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 Anæs-
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but also for therapeutic purposes as “ Trigeminal
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A full account is given of the preparation of the
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A special feature of the work and one of marked
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Though local anesthesia is not as much used by
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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,
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Although there are many books by medical and
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The instructions would prevent the diseases known
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which are not known there,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
187
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
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This " System of Surgery” is especially designed
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It furnishes a clear, detailed, and concise record of
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Where everything is excellent, it is hard to in-
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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-
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Rue de l'Ecole de Médecine, 1914. Prix 6 fr.
This is a distinctly useful and interesting formulary
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given. Thirty-two pages are devoted to diseases of the
eye, the importance of which is very often neglected
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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, cr. 8vo, with 89 plates. 1913.
London, Madras, and Calcutta : Christian Litera-
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The abiding impression of the study of this work
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well balanced suggestive speculation on the causation
and prevention of disease ; the various hypotheses are
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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 lymphatie nodules at the sides of the pharyn-
geal part of the tongue.
(8) Whoever advises non-operative treatment of
. adenoids assumes a tremendous responsibility.
——— — llli ——
Hotes and Slews.
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 vear 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-
[June 15, 1914.
re eg AP A M a A M
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 bas accommodation for about eighty
students, and about 200 pass through the curriculum
June 15, 1914.]
——
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
189
every year, while there is residence in the hostel for
eighteen students.
It 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 1s 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. Medieal men cannot act in that way and
patent their discoveries, nor is it deeirable 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.”
“ 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 applieation 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 research 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
the Chureh 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 case, 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-
cally 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 medical treatment.
They would cut 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
and 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,
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’ Association of
Malaya.--Mr. H. M. Darby.
Jamaica: Sir Sydney Olivier, K.C.M.G.
Trinidad : Department of Agriculture.—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.
June 15,1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Nyasaland : Mr. J. S. J. McCall, Director of Agri-
culture.
Rhodesia: Mr. C. D. Wise, Director of Land Settle-
ment.
Anglo- Egyptian 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.S.,
Entomologist, Ministry of Agriculture ; Mr.
B. F. E. Keeling, Director, Physical Ser-
vice, Survey Department.
Monsieur Perrot, representing the Minister
for the Colonies.
L'Office Colonial, Paris. — Monsieur Vergnes,
Gouverneur des Colonies, Directeur de
l'Office Colonial.
Société francaise de Colonisation et d'Ajricul-
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 Agricultural
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. Fedtchenko, 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’ Agriculture, 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 :
Berlin. — Herr
191
Guatemala : Mr. D. Bowman, Vice-Consul in London.
Venezuela : Dr. G. Delgado Palacios.
Sian: Mr. W. A. Graham, Adviser to the Siamese
Ministry of Agriculture.
Formosa: Dr. Tokuichi Shiraki, Government Ento-
mologist.
SUMMARY OF PROVISIONAL ARRANGEMENTS FOR
THE CONGRESS.
Tuesday, June 23, 10.80 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-
1oon.— Discussion on “Technical Education in
. * 99 6t
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
Tropies."
Thursday, June 96, 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."
Saturday, June 27, and Sunday, June 28.
No sittings of the Congress.
Monday, June 29, 10.30 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, 10.80 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 ut the Imperial
Institute.
a —
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 £1. Applications 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 physiological 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 clinical experience and
extensive knowledge of Dr. Burnet on all matters
relating to public 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 a course
of mercurial inunctions.
192 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[June 15, 1914.
Personal Hotes.
InpIA OFFICE.
From April 18 to June 9, 1914.
Arrivals Reported in Lonton.—Colonel H. Hendley, I.M.S. ;
Lieutenant.Colonel S. E. Prall, I.M.S.; Major H. R. Nutt,
I. M.S. ; Lieutenant-Colonel C. C. Manifold. I. M.8. ; Captaiu
M. F. White, I. M.S. ; Captain J. M. Macrae, Los Lieu-
tenant Colonel W. Young, I. M.S. ; Captain A. J. Lee, 1.M.S. ;
Captain S. T. Crump, I.M.S. ; Major S. H. L. Abbott, I. M.S. ;
Lieutenant-Colonel G. T. Birdwood, I.M.S. ; 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, IL M.S.; Major E. J. O'Meara, I.M.S.;
Captain T. L. Bomford, I. M.S. ; Captain W. M. Jack, I. M.S. ;
Major C. 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, 1.M.S.; Captain A. C. Anderson,
I.M.S.; Captain A. A. McNeight, 1.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., 10days ; Major D. McCay, I. M.S.,
4 m., M.C.; Major J. H. McDonald, I.M.S., 5 m., M.C.;
Captain J. B. D. Hunter, I.M.S., 1 m.; Captain R. Brown.
I.S.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 CIVIL 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, LM.S,,
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, 80 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.LE.,
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., I.M.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.
List or INDIAN MILITARY OFFICERS ON LEAVE.
Showing the Name, Regiment, or Department, and the Period
for which the Leave was granted.
Anderson, Captain A. C., 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., * M.S., to November 11, 1914.
Hyderabad,
I.M.S., Be.
Hendley, Colonel H., 1.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.
McNeight. 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. 4, 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.8.
July 1, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (No. 13, Vol. XVII.
Original Communications.
THE TREATMENT OF YAWS AND THEIR
SEQUEL/E BY MEANS OF SALVARSAN.
By Dr. E. C. GIRLING.
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 &ny 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 & 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
case 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 sequele 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 antiseptic 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 ulcers 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 & simple
case of tertiary syphilis. No Wassermann’s reaction
was done. 7
A BRIEF NOTE ON AMCGBIC DERMATITIS.
By Lima Boon Kene, M.B., C.M. Edin.
Singapore.
DERMATITIS CAUSED BY GROWTH OF ÁM(EBA4E
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. Amosbee
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.—It 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-
plications have resulted from extension of the disease.
The discharges appear to be singularly free from
micro-organisms except the amcebe.
The Parasite.—From fresh papules, only small
amobse with fine granules may be seen, but from
the large sinuses, large &mobse with conspicuous
granules, vacuoles, and amceboid movement are easily
seen; these appear indistinguishable from the Enia-
mba histolytica. The parasite is never seen de:
stroyed by phagocytosis in a progressive case; but
after the injection of emetine chloride, the amabe
ean be seen degenerating amidst the agglomerated
194
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 1, 1914.
masses of the leucocytes. After & 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.
sulphurid. 'The usual antiseptic remedies may also
‘be tried, but the above are the best. For the com-
plications, appropriate treatment for each condition 1s
required
BRONCHIAL SPIROCHATOSIS.
By Frank S. HABPEB, 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 axille. 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 & 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, & 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 & 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 tegiek having to publish this case i
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. GonzaLez 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 epizootic
diseases and for hydrophobia. |
The disease was suspected in several cases. In
two instances the diagnosis was confirmed micro-
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.
ee
Reo Preparation.
SECWA is & 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, enteric fever and other
intestinal diseases. It is also of much servisé 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-products of milk. The medical profession can
prescribe it for their patients with every confidence.
July 1, 1914.]
Hotices.
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THE JOURNAL OF
Croptcal Medicine and ppgiene
JULY 1, 1914.
INTERNATIONAL CONGRESS OF TROPICAL
AGRICULTURE.
THE important Congress which assembled at the
Imperial Institute, London, on June 28, 1914, and
continued its work until the 30th, had many important
subjects to consider. |
Apart altogether from the direct questions of the
cultivation 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 direct bearing this subject had upon
the supply of labour in the Tropics. 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
ineficiency 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, anæmic 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 anseemic and malaria infected
native; disease has the upper hand and he has not
the strength to rise against it. Remove 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
io
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 geographical 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.
À 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.
À preliminary test examination before entering the
school in subjects appertaining to the matter in hand
wil be a necessity, otherwise the pupils will be
turned out with à 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 and
Tobacco,” ‘ The Karakul Sheep."
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July-1, 1914. |
Discussion on
Cultivation.”
Papers on “ Cotton,” “Jute and Hemp Fibres,”
and ` The Fibre Industry of British East Africa.”
“The Improvement of Cotton
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.]
——— a -
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
Tropical Medicine in connection with this Hospital
was largely due to the conception and foresight of Sir
Patrick Manson.
many millions of mosquitoes their deaths, to Sir
Patrick’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 l
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 success became almost an embarrassment, for
six years later more accommodation 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, Seulptor.
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.
Many men owed their lives, and:
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 197
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 statistics 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
a 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 recorded.
In recognition of their splendid services he would
presently proceed to unveil the medallions.
Mr. AUSTEN CHAMBERLAIN, who was loudly
cheered, said that he felt deeply embarrassed to find
words to thank Mr. Nairne and the Committee of the
Seamen’s Hospital for the kindly thought which had
198
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
& 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 Medieine.
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, Oryuris 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 which 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'mauy patients whose symptoms cannot be
correlated with any definite diagnosis, might i in Tehran
almost be dubbed malpraxis !
A case of helminthiasis the like of which I have not
read of nor seen again, was & 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 aol 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: By Surgeon
D. A. Mitchell, 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.,
The Congress ‘Secretary’ s office is at 45, Guseti
Street, Edinburgh, until the opening of the Congress.
After the opening the "entes office will i in
the University.
July 1, 1914.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
199
Abstracts.
ON A CASE OF DEATH FOLLOWING
THE STING OF A SCORPION.*
By R. McC. LixNELL, L.R.C.P.
NOTE
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 109'8? F.
No malarial parasites were found. A blood count
gave the following percentages : polymorphonuclears,
758; mononuclears, 081; lymphocytes, 9'68 ; transi-
tionals, 5°64; 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 :—
" À portion of the lumbar cord 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 porion Clarke's
column had been destroyed. The perivascular sheaths
were crowdéd 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. _
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 diarrhoea 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 diarrhæa, 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,
1913, 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 pyorrhea 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 diarrhoea ceased, after having been con-
tinuously present for nine years before the new
treatment was commenced. She has no dyspeptic
symptoms, and can digest all ordinary food. She is
— s
* Lancet, June 6, 1914.
200
—
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 diarrhoa 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,
1918, 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 vaccine 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 diarrhcea 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
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 1, 1914.
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 Baguina, 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 accom-
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, exactly 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 occasion. 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 included{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,
July 1, 1914.]
The abdomen was then opened through the right
linea semilunaris, just below the costal margin. On
introducing 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 & large cyst 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 hsemorrhage. 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 25 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 hemorrhage
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. t 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 JoHN Nivison Forog, 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 &mount adhering to & flat-ended toothpick dipped
into glycerinated virus was sufficient for the inocula-
* Prom the Journal of the American Medical Association,
May 9; 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
201
tion of the three scarified spots constituting a
vaccination.
A gauze square was then applied to the wound and
was secured by four strips of adhesive tape. Verbal
instructions were given the person regarding the
protection 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 antiseptics,
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 application of a compress, kept moist
with 50 per cent. aleohol. 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 practice 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-por.
—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-
cinations 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 areolæ of
immediate reactions, it occurred to me that this
reaction might be used as a test of those failures
o e RT o —-— —— MÀ — MÀ — e— 9
* Jenner: *'An Inquiry into the Causes and Effects of Variole
vaccinise, 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 & general application of the test was not made
until the opening of the academic year 1913-1914.
Previous to January, 1918, only the unscarred
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
unscarred 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, it 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 & 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, 1918, 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 unscarred 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.
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 30. 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 2.—P. A., entrant, never vaccinated, was
vaccinated October 1, 1913.
October 6. No reaction.
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 areols 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 scarification, the same virus being
used which had fatled 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. Areols almost faded.
This case 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
[July 1, 1914.
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 i .h 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. Bags, M.A., M.D., D.T.M. & H.Cantab.
IN sprue, a disease obviously of an intestinal origin,
so chronic 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.
. ltis necessary to refer shortly to the disease known
as hill diarrhoea, 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 thé diarrhea, 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
epidemics, 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.
203
—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 a 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 directly 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 & 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 18, 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.
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 varred 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,
und 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 1n this category are included eases 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-
cluded a number of cases with the typical diarrhoea,
but without any affection of the mouth and tongue,
and also a large series of diarrhceas, 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 diarrheea 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 typical tongue and mouth symptoms are present,
though the disease process does not appear to have
spread beyond the buccal cavity.
Typical or Complete Sprue.—The earliest symptoms
varied widely in different patients; in the majority
the onset was insidious; in only four cases 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 aphthæ 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
angmia, 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 diarrhea corresponding to the hill diarrhoea. 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 & negative Wassermann
reaction, indicating that specific disease plays no part
in the production of these tongues.
Although I am inclined 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
papillz is found in other diseases, especially those
characterized by anemia, chlorosis, ankylostomiasis,
and chronic malaria.
The process of destruction-of the papille 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 papille 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 papille in
the anzmic 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 immediatety before death and
July 1, 1914.]
also in the acute diarrhæœic 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 fecal 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 fæces,
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 & 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 anemia 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
205
THE MORBID ANATOMY AND PATHOLOGY OF
SPRUE.
It is necessary to eliminates all factors conduemge
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
(1$ 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
&bdomen 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 & film of thrush; only the base of
the fungiform papille 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 Teatures,
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 & 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
liver and spleen only calls for special attention. The
cells of the former have undergone fatty degeneration
and contain & few granules of free iron, though this
reaction is by no means so well marked as in per-
‘niclous 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 I 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 anemia,
lymphatic and splenomedullary leucocythemia, kala
azar, trypanosomiasis, filariasis, amcebic 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 structure 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 structures represent & hyaline degeneration,
and therefore cannot be regarded as representing
a 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
. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
admixture of saliva has
[July 1, 1914.
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 i 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
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 physical signs in their
chest. m
In fresh preparations of the frothy, acid stoóls
passed during the early stages of the disease I saw
cells and some mycelial threads bearing & 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 eulture 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 ameebic dysentery stools treated in this manner ;
by cultural 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 terminal stages
of the disease they are at least the most prevalent
July 1, 1914.]
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 & 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 termeil 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
8 baker's yeast; out of these 112 cultures 106 could
be classified in the genus Mon:lia, that is, that they
reproduced by spore and myocelial 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 whén symptoms have
gubsided.
(2) 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
207
- m —— — — — — ——Ó oa
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.
(8) The desquamation of the epithelial cells, accom
panied by subacute inflammation of the tongue and
of the cesophagus, 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 anæmia, 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) Diarrhea, 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 coeliac diarrhea, 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.
T—————————————————M—HÉ————————ÓM
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.
(8) 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 & protozoal, rather than of & fungoid or bacterial,
origin of the disease.
CONCLUSIONS.
(1) Sprue is & 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
w hole, in favour of rather than opposed to this view
———— dp ——
A eiefo.
TROPICAL DISEASES : A PRACTICAL HANDBOOK. By
H. C. Lambart, M.A.. M.D., &c. 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.
————— áp ————
Correspondence.
KURLOFF’S BODIES.
To the Editor of THE JOURNAL OF TROPICAL 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 spirochsstes, 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 last,
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 hardly 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.]
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 flat 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
‘these villages.
ing action has been taken :—
[No. 14, Vol. XVII.
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 sanitary
precautions are taken by the people generally; for
if these are neglected, reinfection will almost cer-
tainly take place, the condition of things becomes as
bad as before, and time and money have only been
wasted. Consequently, the only efficient way to deal
with the question is to systematically work through
each village, examining every individual in it, treating
the infected ones and at the same time establishing
proper latrines and sanitary reforms generally in
With this object in view the follow-
(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.
210
(2) Difficulties in the way of affecting a rapid Im-
provement over a large Area.—It 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 & few of the difficulties that are to be encoun-
tered in dealing with such a disease as ankylosto-
miasis in & 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 fæces 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 & 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
complain 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 microscopic 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
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 & 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 & 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.
(b) Areas dealt with.—In view of these facts the
following procedure has been adopted :—
À 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 cases they refuse to
accept re-treatment, their symptoms being slight or
nil, but in order to try and induce them to do so a
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 tə examine
the whole population for ankylostomes.
July 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
211
———————————————————————————— M eT ae
(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 & 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,
and are 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
& 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 are
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, a 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 eievation 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 (7.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,
diarrhoea.
The changes in the tongue were found just as
commonly in the uninfected native.
Diarrhess, when complained of, was said to take
an intermittent form, lasting & few days, and then
disappearing for weeks or months.
Dysenteric.—ln most instances, when blood was
actually found in a specimen, in a case of ankylos-
tomiasis, bilharzia ov& 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 rheumatie pains in various joints. Joint
pains are, however, so often complained of by un-
212
infected natives that this symptom is not regarded
as possessing much value.
Anzxmia.—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 anmmia.
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
ajregular or constant practice, and probably bears
very little, if any, relation to ankylostome infec-
tion.
Signs of Severe Infection, General idema, Extreme
Anemia, Muscular Wasting, &c.—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 anæmia, 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 VIII.—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.—lndividuals, 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 cireulatory 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 JOURNAL OF TROPICAL'MEDICINE AND HYGIENE.
[July 15, 1914.
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 capacity 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 ansemia,
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 & 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, &n immunity to the severe effects of
ankylostome infection was established.
July 15, 1914.]
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 anemia. |
Table XIII shows the spleen and ansemia-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 ansmia, 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 & 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 & very bad last as workers. It is evident that
this cannot be due to ankylostomes, and it would
appear to be & 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
218
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 anæmia, 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 & 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.
w ——————————————M—Á————————M——————————————————————
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 fæces 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 exainined infected Percentage
44 lake
Ankylostom m im f
nky one e 1,500 650 | 16 hills
Bilharzia .. Vide Tables IL and III 245 ... 16
Ascaris ... "S » 25 is 91 ... 6
Trichocephalus .. :: $3 su T —
Total helminths " as .. 894 ... 55
TABLE II.
. SINGLE INFECTIONS.
Ankylostome Bilharzia Ascaris Trieocephalus
Per cent. Per cent. Per cent. Per cent.
32 ee 8 Sas 1:7 sa 0:5
DOUBLE INFECTIONS.
Aukyloston:e, Ankylostome, Ankylostome, Oxyuris, Bilharzia,
bilharzia uscaris trichocephalus ascaris ascaris
Per cent. Per cent. Per cent. Per cent. Per cent.
72 x 83 .. 26 .. O01 0 O03
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.
" Ankylosto ilharzi
Village percentane” Soren:
1. Mabuluki ... 7 56 per cent. 18 per cent.
2. Kasoti .. "T 97 ,, us Ud a
3. Kaiyune .. vs 9T. y de JE. I4
4. Kanyol ... "E 37 » we 22 ss
5. Mwahimba T 46 ,, "OU; Y
6. Mwawembe des 60 ,, Se B us
7. Mwanjawalo m 39 ,, ue “ED 3,
8. Mwafilaso... "P 98 ,, ty 24 n
9. Mwakasungula ... 97 y m l4
10. Mwangulukulu ... 90 ,, i. 4B us
11. Mpata,Chungu,&c. 40-60 ,, 4 20 ,,
12. Simapoma gs 40 ,, zx 40. y
13. Vua i "d 97 35 Ls —
Henga Valley ... - 24 ,, 3 Cs,
TABLE IV.
PERCENTAGE IN VARIOUS TRIBES.
Ankonde Awemba Ahenga Swahili Nyachusa Hill Henga
Per cent. Per cent. Percent. Percent. Per cent. Per cent.
38-60 ... 60 ... 37 .. 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
MÀ —ÁM T Cea
Lake Villages Wells and
Parasite shore a mile or Lake Rivers water
villages more inland holes
Ankylostome .. 40 48 40 45 53
Bilbarzia oe 12 27 12 28 35
TaBLE VII (ExcrusivE OF CHILDREN.)
Denying
Gastro- Anæmia illness, and
intestinal and one showing no
exclusive — Dysen- Circu- Joint or more Anemia symptoms to
of teric latory pains of pre- only be attri-
dysen- ceding buted to
teric symptoms ankylostome
infection
Per cent. Percent, Percent. Percent. Percent. Percent. Per cent.
18 3:5 15 T5 20 27 81:5
TABLE VIII.
Mouth Number examined Percentage infected
June is 192 a 40 per cent.
July... - 456 w 02 ,,
August i 312 5 63 ,,
September ... 200 9 46 ,,
October in 210 2$: 49 ,,
TABLE IX.
After one course
uf treatment with
beta-naphthol
After one course
of treatment with
eucalyptus and
chloroform mixture
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 per cent.
TABLE XI.
Percentage of individuals
showing one or more of the
General development
symptoms detailed below
l l G
a: : Gastro- :
. Good Fair Bad ae Anemia H vs Tongue
Per Per Per Per Per Per Per Per
cent. cent. cent. cent. cent, cent, cent. cent.
Infected ... 70 28 1°5 17 34 20 5 18
Non-infected 68 81 1:0 18 97 11 6 17
TABLE XII (CHILDREN).
Percentage of children
showing one or more of the
General developments
symptoms detailed below
getto uniti, * .
Circn- Gastro- Anemia, with or
Good Fair Bad lator intes- without enlarge-
Y tinal ment of spleen.
Per Per Per Per Per | Per
cent. cent. cent. cent. cent cent.
Infected ... 64 32 4 8 28 58
Non-infected 66 32 2 4 12 62
TABLE XIII.
Enlarged spleen Enlarged spleen, Spleen normal, Spleen normal,
and anemia no anemia anemia no anwmia
Per cent. Per cont. Per cent. Per cent.
38 dus 21 er 20 ous 21
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.—Very 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
July 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
215
are nearly twice 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 &
totally distinct variety from the human hookworm,
and no such ov& 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.
(2) Notes on some of the Prevailing Diseases in the
North Nyasa District.
Small-pox.—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
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
diarrhess, 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 a relative racial immunity.
—— 39 ———— —
FLIES AND DISEASE.
Anti-fly work has not reached the precision which
one would desire. The house-fly, as a transmitter
of diarrheal 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
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THE JOURNAL OF
Tropical Medicine anb bypaiene
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-Tropics, the earth may be covered with a
green verdure, but it has not the sustenance of
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
&xiom 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
“doctored.” 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 & 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.
dried in & 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 a&t 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 :
& 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
217
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 [sles 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 fact itis 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.
—— — —————
THE PRODUCTION OF SENNA IN THE
SUDAN.
THE senn& 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
& 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 statistics 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[July 15, 1914.
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
tincture 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
injection 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 & composite of various
clinical entities which pursue analogous or identical
courses. Now and then we can hardly avoid the
conclusion that & true venereal propagation has
occurred, while in other cases & simple injury from
coitus has become inoculated with a germ of great
virulence. The fact that in a recent case of this
sort & salvarsan injection terminated the condition
suggests that the spirochste 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 Lohe 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 & gangrenous fluid.
The patient was anssthetized, 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 surgical 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 lymphatic 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.
Abstracts.
RECOMMENDATION AS TO SANITATION CON-
CERNING EMPLOYEES OF THE MINES
ON THE RAND MADE TO THE TRANSVAAL
CHAMBER OF MINES.*
By W. C. Gonaas, 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 1s 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 1397. 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.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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 & 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 & 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
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 9 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. iue
The actual number of deaths from tuberculosis for
the year 1912 among 156,534 natives is probably a
total of 1,709.
This gives & 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 &
matter of fact considerably higher than 565 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 885 per thousand.
In 1912 we have a rate of 10°87 per thousand. For
the future, present conditions continuing, tuberculosis
will 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 medical 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 1s 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 particles 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 a 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
& 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 3mall-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
epidemie pneumonia is prevailing among the men,
and that the French sanitary authorities attribute the
epidemic pneumonia to this overcrowding.
The scattermg 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 sani-
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.
THE JOURNAL OF TROPICAL MEDICINE AND. HYGIENE.
July 15, 1914.]
The economy of this method of housing native
labourers might be emphasized by calling attention to
the fact that recruiting men costs 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
æ 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.
221
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 & 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.
À commendable effort is being made generally to
correct this condition by cleaning up, taking out
refuse, deatroying 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 a few 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.
222
The two chief components of the daily ration are 92 lb.
of mealie meal and 54W5 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 tneal might be reduced, and the meat
and other articles increased.
A soldiers 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 meul 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 15, 1914.
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 inan 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 fecal 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.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
228
d
" 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 feecal 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
81Z0. i
It has been objected that there would be leakage
through cracks in the rock from 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 fecal matter, and the necessary fouling and
disagreeable odours that go with such à 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-
ever cooked food, or food, such as fruit, that is eaten
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 & 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 ig
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 infected with both pneumonia 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 &bout fifty-four mines, each entirely independent
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. Noneof 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(July 15, 1914.
D,
——— TR EP E na
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
&n 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 a minimum. 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 & 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
introduction 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
could 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 1874 in 1906 to 0°42 for the
first eight months of 1918. During one month in
1906, it was higher than it has ever been on the Rand
for & 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 & year or
two he would acquire immunity, and would then be
on the same footing as & 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 & 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
particular 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. TayLor and W. J. YOUNG.
From the Australian Instilute 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
031 and O01 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, 1918, 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.
DAY OF MONTH
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.
296 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
TABLE I.
1913 1914
-—e— e—a — q———M MÀ —
| 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 | 777 : 880 | 822 | 824 | 818 | 805 | 79:9
(degrees) | | | i :
Mean wet bulb, 9 a.m. | 700 61:6 | 599 . 602 | 61:2 | 658 | 68:7 | 733 . 75:6 | 75:6 | 745 | 755 | 740
(degrees) ; | | |
Mean dry bulb, 3 p.m. | 761 | 752 | 72955 ' 798 | 732 | 77-5 | 791 | 84:1 | 84:6 | 84:8 | 84:0 | 824 | 821
(degrees) | |
Mean wet bulb, 3 p.m. , 72:9 | 69:6 | 63:9 | 639 | 636 | 669 | 69:4 | 74:7 | 767 | 761 | 761 | 764 | 749
(degrees) | |
Mean dry bulb, 6 p.m. ; 76:9 , 69:8 | 68:0 | 68:2 | 69:2 | 727 | 750 | 801 | 811 | 816 | 805 | 795 | 787
(degrees) | | i
Mean wet bulb, 6 p.m. | 71:2 | 63:4 62:2 | 62:3 | 62:2 | 65:9 | 681 ; 732 | 754 | 752 | 74:7 | 74:9 | 729
(degrees) | |
Mean maximum ,, 83:2 71:4 | 74-4 | 75:8 | "76:4 80:4 82:2 | 87:5 | 868 | 868 | 861 84:5 | 84:3
Mean minimum ,, 73:1 | 62:0 | 605 | 57:5 | 57:5 | 64:2 | 68-7 | 75:4 | 762 | 75:9 | T44 | 74:0 | 72(9
Maximum recorded ,, | 88'7 | 84:2 | 805 | 7838 | 81:17 | 847 | 88-9 | 99:5 | 91:2 | 91°3 | 923 | 87-4 | 862
Minimum recorded ,, ' 65:3 | 49°7 48:7 46:5 49:0 57:5 61:0 70:1 68:2 71:9 71:0 70:6 68:9
Mean daily range ,, | 13:8 | 15:3 | 13:9 19:8 18:5 | 157 19:8 | 121 107 | 109 | 11:6 | 10:5 11:4
Extreme daily range 21:0 | 2277 | 25:8 | 34:9 | 250 | 262 | 908 | 24:3 | 171 18:8 | 17:8 | 150 | 161
(degrees) ! |
Extreme monthly range! 23:4 | 34:5 31:8 | 81:8 | 32:7 | 272 | 27:9 | 99:4 | 280 | 194 | 21:3 | 168 | 17°3
(degrees) : | |
Mean maximum solar | 134:5 ,125:3 | 120:2 | 127:9 ; 129:6 | 136-7 | 140:8 | 147:1 |146:9 | 144:0 | 146°7 | 14071 | 189°2
(degrees). | | | |
Total rainfall (inches) .. 7:75 | 164! 054; — i — — | 031 A 01, 688! 14:39} 561| 1376, 525
Number of wot days ..: 6 T , 4 j} —' — — 3 18 15 13 16 8
Average fall on wet days; 1:29, 023: 013 | — == — 0:10 " 01| 036| 096| 0-41; 0°86} 0°67
(inches) : |
Greatest fallin 24 hours’ 396| 084! 0°25; — — — 0:19) 0-01 1:60! 6553, 238, 275! 2°35
(inches) | |
Mean monthly relative | 70:9 : 68:3 | 62:8 | 60:5 | 60:6 | 602 | 632 | 64:5 | 72:6 | 718 | 706 | 777 | 787
humidity (per cent.)
Highest daily relative; 95:0 | 95:0 | 940 | 750 , 800 | 730 | 770 | 79:0 | 87:0 | 95:0 | 860 | 950 | 950
humidity (per cent.) :
Lowest daily relative 51:0 | 820 | 29:0 | 45:0 | 88:0 | 190 | 410 | 880 | 58:0 | 570 | 590 | 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.
Mean ;
| tem perature Maximum Minimum b Rd
Degrees Degrees Degrees Per cent.
Townsville (19°8' S). 19:6 81:9 68:3 67:0
yearly average | |
Townsville. Novem- | 80:4 860 | 747 72:0
ber to April | |
Townsville, May to ; 69:8 71:8 61:2 | 62-0
October
Colombo, Cey ici 81:1 87:1 75:9 81:1
(6? 56' N.). yearly ' | |
average | | |
Bombay (18° 54' N.). 794 | 950 610 | —
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 & similar manner in
other places, and which have been published in the
Philippine Journal of Science [4].
TABLE III.--MoNTHLY AVERAGE OF THE PERCENTAGE OF
OxaLic ACID DECOMPOSED PER 1 Hour.
|
Month Average Maximuin Minimum Clear days
= — "Tl
1918 ` Per cent. Percent. | Per cent.
March : 15:4 21: d 12 out of 29
April : 17:8 21.6 4:0 22 ,, 30
May S05 158 21:4 2-9 15.5. Sh
June 15:4 21:4 4'1 19 „ 29
July 18:4 21:0 15:7 18 ,, 81
August : 18:2 20:7 12:9 16 , 31
September 19:3 20:7 16:8 21 ,, 30
October .. 18:2 21:1 8:5 20 ,, 3891
November 18:8 20-9 15:7 18 ,, 30
December... 18:4 21:9 4*0 12 „ 29
1914
January 17:5 21:1 2:9 16 „ 29
February .. 18:8 21:4 8:5 16 ,, 28
March 15:8 9:6 18 ,, 29
22:0 |
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.—COMPABISON OF THE AVERAGE PERCENTAGE OF
OXALIC ACID DECOMPOSED PER HOUR.
Date
Place Maximum| Minimum Period
|
Average
LUN
| | Per cent.
| Per cent. | Per cent. Months
Townsville, 19*8'8. | 1918-14 | 17:5 . 220 2:1 | 18
Manila, 14? 86’ N. | 1910-11 | 194 17°8 l1 : 15
Kuala Lumpur, | 1911 15:3 181 9:0 T
3* 10' N. | |
Honolulu, 21°18 N., 1911 13:8 | 20:8 3:5 10
Bagino (Philip.] 1911 | 142 ! 206 69 4
pines) | |
Khartoum . (Sou. | 1911 | 17:5 | 20:8 14:8 , 3
dan), 15° 86’ N. |
Washington, 38° 59’! 1910-11 | 10:9 | 19-1 17 | un
N.
REFERENCES.
(1] CasrELLANI and CHALMERS. ''Manual of Tropical
Medicine," 1918.
[2] Hann. “Handbuch der Klimatologie," 1910.
(8) Philippine Journal of Science, 1912, vii, Section B, p. 1.
[4] Ibid.
PRELIMINARY NOTES ON ENTAM@GBIASIS.
By Liu Boon Kena, 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 entamcebe 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 entamoebiasis without qualification, as at
present it is not yet possible to say that the general
disease is solely due to the Entamebe 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 amabic dysentery as a rule, or it may be
located in the biliary passages without giving rise to
apy 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 entameaebic 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
entamcebic fever may occur without a previous
history of dysentery. Morerarely 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 .entamosbic 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 entamoebic infection
may be summarized as follows :—
PRIMARY INFECTION.
Hepatic Passages —Toxemia, entameebic fever,
entero-colitis.
Intestinal Canal.—Acute amoebic dysentery.
SECONDARY MANIFESTATIONS (infection spreading
from entero-hepatic foci).
Skin Eruptions.—Urticaria, bullous eruption and
ulcers, multiple abscesses.
Bronchitis (chronic).
Hepatitis and Hepatic abscess,
aches, neuralgic pains.
Entamebic Cachexta.—Aneemia, 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 notice
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 entamobie 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, ansemia, 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.
[August 1, 1914.
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THE JOURNAL OF
Tropical dpebtcine and hygiene
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 & 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 lineof research as well as à 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 Tropics 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 tropical
students are familiar with the great advances and
additions to our knowledge that have followed and
August 1,1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
which we owe to the labours of Leishman, Druce,
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 tothat 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
229
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
eredit for these and other achievements and the im-
provement elfected among the small European com-
munities in the Tropies, the fact 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 heen 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 and a 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 & 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 cultural tests.
———— SQ ————
Abstracts.
INSOLATION : ITS PROPHYLAXIS AND
TREATMENT.’
By PauL 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
causes—the heat and water content of the air about
the body, the condition of the peripheral vascular
circulation, &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 18, 1914.
Sunstroke has been attributed to exposure to sun-
light, more particularly 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 which 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.
August 1, 1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
231
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 he 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 he
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 physical 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 Se Us bs £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 a is 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
usod :—
Sodium chloride oe s as 14 grm
Sodium carbonate (crystallized) .. 10 ,,
Water 1,00. c.c
This also should be given very slowly.
The effect of these solutions upon the secretion
of urine is remarkable, and as à 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 1s
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
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.
TOX-EMIAS ean 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 cause 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 ona 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 toxæmia liable to exacer-
bations. As death occurred in these cases soon after
the occurrence of hyperthyroidism, a complete picture
was obtained of the toxemias 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 toxsemins 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 toxwmias into four
groups, according to their situation: they are usually
in the mouth, nose, , lung, or intestine.
'! 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-
tococcus, staphylococcus, and pneumococcus, 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 organisins 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 exophthalmic 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, pyorrhca, 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 pyorrhcea 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.
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 heen
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-
thalmic goitre, which again subsided after some
months.
A second toxemia 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 toxxmia.
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 exophthalmic 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 pyorrhcea; the
nasal septum was deviated, but there was no evidence
of tuberculosis.
In this case the effect of toxsemias on the thyroid
appeared to be, from the history, that the pyorrhcea
organism caused a condition of hyperthyroidism.
The deviated septum rendered him liable to recurring
nasal infection: the intermittent toxsemia from this
(? Bacillus catarrhalis) caused & further thyroid
change; the last acute attack of this toxcemia 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
233
that cause them are: B. catarrhalis, Friedlander’s
bacillus, B. influenzæ, 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 pyorrhea. 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
Scanes Spicer.
The following examples serve to illustrate the
occurrence of hyperthyroidism and exophthalmic
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 lb. in eight days and died. A post-mortem examina-
tion was refused. "Thyroid hyperplasia was caused
by the well water, and the exophthalmie goitre from
the fresh toxeemia 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
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THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 1, 1914.
of exophthalmie goitre associated with pyorrhcea and
chronic rhinitis, with perforation of the septal
cartilage. Hyperthyroidism was caused by the teeth
infection and exophthalmic 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.
lamination showed pyorrhoa, a deflected nasal
septum, with chronie hypertrophie rhinitis.
Case 8.—M. C., female, aged 39. A case of similar
nature, but exophthalmie goitre developed after
chronie sinusitis.
Lung.
The common infection found in the lung is that due
to D. 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. $., 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. Pyorrhoea was present,
aud signs of tuberculosis at the right apex, with
tubercle bacilli present in the sputum.
Case 11.—B. S., female, aged 43. Presented a mild
type of exophthalmic goitre, associated with pyorrhcea
and chronic phthisis. From her history she appeared
to have developed symptoms of hyperthyroidism from
pyvorrheea, the supervention of phthisis caused an
exacerbation which gradually developed into exoph-
thalmie 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 toxic 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. McCarrison 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 fæces 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-colz series, which
may be subdivided into the B. typhosus, B. enteritidis,
and the B. col? groups. It is proposed to trace these
from the B. typhosus towards the B. coli. Infection
with B. typhosus does not cause & thyroid hyper-
plasia. The result of infection with B. alcaligenes
has not been examined. B. dysenteri# 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 feeces 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. colz
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. coli 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.
acid and gas from glucose, lactose, dulcite, maltose,
&nd 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 cases 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 Medium.
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 Ferces.
Feces of Goitrous Patients.—-Bacteriological ex-
amination of the fæces 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. colt 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 feces were not necessarily the
same as those found in the water.
235
—
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 fæces 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. colt is a normal inhabitant of the guinea-pig in-
testine.
Septicemia.
Guinea-pigs received intraperitoneal inoculation
with typical B. coli and with B. coliformts to cause
a septicemia. The thyroids showed an acute hemor-
rhagic hyperplasia.
Toxemia Subacute.
Guinea-pigs were fed with bread and milk con-
taminated with fresh cultures of typical B. coli,
B. paracoli, 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-
æmia causes a change similar, both microscopically
and macroscopically, to endemic goitre, which is most
marked with B. coliformis. Endemic goitre can be
artifieially induced in guinea-pigs. The complete
cycle, commencing with water contamination, and the
presence of the mutants of D. 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 B. colt 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
are present in the fæces 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 12.—G. F., female, aged 13. At the age of 10 she
went to reside in a goitre district 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 Toxremias acting on a Thyroid
already in a condition of Endemic Goitre.
Pyorrhea.—The thyroids in cases in which pyor-
rho 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 exophthalmic goitre.
Case 13. BD. 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 faeces. 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 Toweemia 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 exophthalmic goitre. Seen a year
later, the thyroid presented an adenoma of the right
lobe and isthmus, the symptoms of exophthalmie goitre
had largely subsided, pulse 96. In this ease endemic
goitre caused an enlargement of the thyroid; the
pyorrhoea, slight hyperthyroidism; the temporary
acute toxemia of whooping-cough caused exoph-
thalmic goitre, which gradually subsided after its
termination.
In a similar way other toxzemias or combination of
toxæmias can be considered, the chronic toxamias
causing a colloid hyperplasia and the subacute a com-
plete hyperplasia with signs of excessive secretion.
Thus small encapsulated adenomata were found in
a 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 toxssmias—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 exophthalmie goitre, that
is, following a combination of subacute toxsmias.
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 (exophthalmic 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 exophthalmie 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 pyorrhoea, 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 methodical
examination should he 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 toxsemias. In this way a connec-
tion between the causatory toxsemia 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 feces
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 pyorrhea 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 & 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 tvphoid fever and
other water-borne diseases.
CURE.
When & comparison is made between the micro-
scopical appearances of a normal gland and those of
exophthalmic 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 c»lls to 7o. 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 toxzmia 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 toxsemia. 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 toxamia.
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 pyorrhoa. 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 1b.:
pulse 108; exophthalmos had disappeared and the
thyroid had diminished 14 in. It was realized that
the onset of any fresh toxeemia before involution was
completed would cause & 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
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 lb.; 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
antiseptics. In four weeks her neck had diminished
14 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 toxemia
is not always present, but constantly recurs. Removal
of the basal toxæmia causes the symptoms of exoph-
thalmic goitre to subside. After-operations can with
safety be performed on the nose to prevent the
recurrence of the nasal infection and consequent
exophthalmic goitre.
Lung.
From the microscopic appearances 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 exophthalmic 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
pyorrhea. 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 1, 1914.
ee
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 par? 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
toxeemias.
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 exophthalmic goitre. Double exoph-
thalmos, pulse 99. 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 ; exophthalmie goitre developed after an attack
of influenza and pleurisy. She was treated for two
years with drugs and X-rays without effect.
Examination showed a soft even enlargement of the
thyroid, pulse 120, and marked unilateral exoph-
thalmos. The carious teeth and inferior turbinals
were removed and thymol administered. In six
months she increased 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 Ewees:
sive Secretion.
This group may be subdivided into three. (a) Those
caused from the ingestion of the atypical forms of
B. coli (endemic goitre). (b) Those caused by the
combined effect of two toxsemias other than atypical
B. colt 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 faces
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 cachets 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 feces.
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 $ in. diminution.
Group (b).—After the nature of the toxæmias 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 act 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?
August 1, 1914. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE
: 239
Enlargements of the thyroid, whether of the exoph-
thalmic 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. Cysts and adenomata should be
treated along the usual surgical lines.
The symptoms of excessive secretion at 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 sympathetic, 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 toxsmia 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
catarrhalis infection on exophthalmic 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
ansesthesia proved fatal.
Case 23.—V. D., female, aged 25. Developed acute
exophthalmic 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 myxcedema 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 angsthesia.
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 TROPICA
— — ———— 9. —-
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. col; under abnormal con-
ditions in the intestine itself, and lead to mutation
and the temporary appearance of mutants in the
fæces 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 toxsemia.
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 toxæmias capable of inducing a colloid hyper-
plasia.
Exophthalmic Goitre.
Exophthalmie goitre is due to & combination of
toxæmias 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
goltre. 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 & few months.
Exophthalmie goitre can be prevented by the
detection of the early cases of hyperthyroidism and
the consequent removal of the basal toxsemia.
Exophthalmic goitre ean be cured if the causatory
agents be removed before degeneration has occurred
either in the gland or 1n those organs that are affected
by the hypersecretion.
When degeneration has taken place in the thyroid,
removal of the toxæmias causes involution to take
place only in the hypertrophied portion; the adeno-
L MEDICINE AND HYGIENE.
[August 1, 1914.
mata and cysts are left. These require appropriate
surgical treatment, as they to & 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.
_ e
Hotes and JRcfos.
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 Tropical 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 crying for solution,
and which, when they were solved, would bring
untold benefit to mankind."
Original Communications.
A STUDY OF THE NITROGENOUS METAÀ-
BOLISM IN CHYLURIA.
By W. J. Youna.
From the Australian Institute of Tropical Medicine.
Townsville, Queensland.
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. [n 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. i
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 diseom-
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 difliculty experienced in
passing the urine.
On examination no physical signs could be detected.
The patient was & 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 secm 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.
August 15, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 16, Vol. XVII.
The patient left the hospital on April 28, without
showing any improvement as regards the condition
of her urine.
Case 9.— 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 first 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
larvee 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 1n 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 scem to effect any improvement. Ichthyol
in pill form was substituted later, beginning with
75 gr. daily and increasing to 30 gr. As this did not
affect the condition to any appreciable extent, meth y-
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.
An estimation 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
——— ———————— —————— MM — ————————— ——
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 tho 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, 26 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
tlask, 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 cooled, made 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 625. 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,
[August 15, 1914.
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 calcu-
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,
extracting the fat with ether and drying to con-
staney, 6/00 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-Schüfer), 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 & 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.
If 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 creatinine 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
OY -matal nitrogen
Total nitrogen therefore increases as the total
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, AUGUST 15, 1914.
w-
Dr. D. E. ANDERSON, M.D.London,
Lecturer on Tropical Diseases at Mansfield College, Oxford.
]
August 15, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
243
TABLE I.
|
Volume in! . | Tota} | Protein Non-
Date ‘eubie cen. Gravity | nitrogen as protein
, timetres | " |nitrozen| nitrogen {ran
!
1913 | |
April 8 975 ETTE 7°31 | 0:96 | 6:35 4-70
» 9 ..: 1,112 !1012 T21 | 0:94 | 6-27 4:75
„ l0 Q2) 1,113 | 1014 698 ' 100 | 598 | 434
„ 11 ..; 1,220 | 1013 825 | 113 | 7:12 4:98
„ 12 1,070 | 1016 1:59 | 0:60 | 6:92 4°87
„œ 13 990 | 1016 712 ; 144 | 5:68 3:97
ix d 760 pao 6-79 | 0-83 | 5:96 3:87
s 15 730 | 1017 601 | 052 | 519 3:42
a 16 666 | 1016 | 668 | 1:94 | 474 3-00
NE. 890 d 8:16 | 049 | 7-67 | 5:13
„ I8 785 | 1018; 8:68 | 0:62 | 806 | 6-01
S 019 935 | 1012 | 7:22 127 | 595 . 371
SQ 20 610 , 1018; 608 | 082 | 5:26 | 3-10
"o: 930 | 1020 8-79 | 053 | 836 | 6-11
e MEER CONARI MEE ERE PONE UE
Average 7°34 0:95 639 | 442
NITROGEN A8 PER CENT. OF NON-PROTHIN NITROGEN
| i | ! |
Ammonia (Creatinine: Uric acid Urea Ed yc Rr | ML
| | !
|
0:45 0:34 0:13 74:0 T1 | 5:4 | 20 114
0:51 0:40 0:17 75:7 8'1 | 64 27 5:4
0:38 0:34 0:12 72:7 63 | 57 | 20 13:2
0:60 0:39 0:16 69:9 84 | 55 | 23:9 13:9
0:44 0:34 0:15 70:4 63 | 49 . 2:2 16:2
0:36 0:38 0-08 |. 699 | 63 | 67 ' 14 14:9
0:32 . 0:34 0:16 61-9 54 | 57 27 | 213
0:25 : 0:34 0-13 66-0 £8 | 65 | 2:5 20-9
0:35 | 033 0:14 633 | T4 | TO 2:9 19-4
046 | O34 0:18 608 | 60 | 44 | 23 20:8
0:50 0:38 0-19 74:4 0:62 | 4:7 ' 24 12:8
0:36 0:27 0:13 6:4 | GO | 45 22 24-9
0:40 | 0:28 0:11 58:9 TÓ 583. 21 26:1
0:56 | 027 0:15 74:0 | 6:8 | 3:8 | L8 14:2
|
— MIM
0:42 0:34 0:14 69:4 | 66 | 54 | 22 16:9
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 15'4 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.
E r=] 45
D S e Tas
ce) 2 | È | Se | Bel eg | 222g
EI = -— g2 D2 =-= aot
Ze 1 B & | ÆR 55 OS $3gz
G 2 5 |z 5s
[n ` je» 5
1914 | |
Dec. 20 .. 1,865 14:56! 1:90 | 12-66 | 0:48 | 0-21 | 5:4
s, 21 1,120 | 15:25; 1-81 | 13-44 | 0-47 | 0-20 | 5:0
» 22 ..11,765| 13-72; 2-18 | 11:54 | 0-46 | 0-0 4-0
» 23 .. | 1,984 | 15-29 | 3:00 | 12-29] 0-54 | O11 | 5:3
s» 94 2.195 14:18 | 2-96 | 11:22; 042 | .. | 3:8
» 25 ..|1,525|14:21| 8:19 ' 11:09 | 0-48 | 3:9
, 26 ..|1,880]1618| 3:39 |1279] 0-52 — .. 41
4 27 2,110 ! 11:68 | 1:57 Ended 0:37 ' 0-20 5:6
DEC E a, i ea NECS UE pe ng ME
Average ..| .. | 14°38) 249 1189| 046 | 018 46
— —— - = = — | an ee ome | ee — -n a | | LÁ ———À
Dec. 98 .. | 1,640} 12°21 2-80 , 9: 1 | 052 ^ 55
» 29 ..|2,155;11 76 | 2:49 |. 9:34 | 0-51 5:5
» 30 .. | 2,820' 10°58} 2:48 | 8:10 | 0:47 | 5:8
» 981 ..:2,0410; 976| 2-06 | 7-70| 0:48 | 6:2
Jan. 1 ..:3,195, 8:66| 1-93 | 6/73 | 0-44 | 6:6
» 2 .. 1,500; 8-6} 1:96 ; 6:10 | 0:43 7-0
Average | 10°17 | 2:97 | 7:90] 0:47 | 6-1
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 GRM.
n D EES
M —
NITROGEN EXCRETED
Total
Urine
Fieces Balance
14°56 0°95 15°51 — 01
15:25 0:76 16:01 — Q6
13°72 1:20 14:92 + 0:5
15:29 "T 15:29 + 01
14:18 1:11 15:29 + 01
14:21 0:99 15:20 + 0:2
16:18 $a 16:18 — 1:8
11:65 1:45 13:10 + 2:3
+ 077
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 & 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 excreted 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 aud creatine, the former
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
catabolized 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 fuir 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-shect 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 O 7 grm. or about 5 grm. of
protein.
An examination of the figures representing the
quantity of protein passed in the urine in this ease
shows that it was not materially affected by the
nature of the diet. In the first eight days the diet
was chosen ip 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 bas been pointed out
that in both cases filaria larvæ could not be found
in the peripheral blood, neither during the day nor
during the night. This absence, however, does not
prove that the chyluria 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 larvie may have been
previously present in the blood and may have since
disappeared. l
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 ENTAM(C:BIASIS.
By Dr. Lim Boon KENG.
SINCE writing my last paper I have had many
opportunities of examining patients suffering from
various diseases, which elinically 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 urticarious and erythematous
type. The relation of rheumatic pains, erythema
and prurigo with dysentery and hepatic abscess, has
heen noted since the days of Graves and Murchison.
The result of my observations is that all rheumatic
inflammations and rheumatisin 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
lithæmia, 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 amceba,
which has small granules and moves by means of
hyaline pseudopodia. Probably these are similar to
the amoeba deseribed 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 myxam«ba state of the myce-
tozoa. From this plasmodium is developed a fungus-
like thallus with eellulose walls with central 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 1s 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 amobule and flagella, which undergo
August 15, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
development as free amæbæ or agglomerate to form
the plasmodium, aíter pairing and forming the zygote
amoba. This is the propagative plasmodial stage, or
the amcehe may be seen undergoing fission giving
rise to the active forms in which the amaba is phago-
cytic and histolitic. The parasite may then attack
. . . s
all tissues causing dysentery, broncho-pneumonia,
endometritis, orchitis, boils and other serious troubles.
Under unfavourable conditions the ameoehe or
am@bule become eneysted, while some form into
spores with the eyst walls, others evidently remain
in the amooboid 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 1s 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 a&meoboid bodies found in
endomotritis, broncho-pneumonia, and skin sinuses
are not the entamccbe histolitica. 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 lithamie 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 amabe Flatulence, biliousness,
and hepatic congestion,
headache, vertigo, dizzi-
ness, lith:iemia, pyrosis,
nervous symptoms, urti-
caria.
Pharyngeal irritation,
colds and bronchitis.
in the fæces.
(b) Granular amæbæ
also present in
sputum.
(e) Freeamcebe plen- Rheumatism, with arthritis
tiful in fæces, and heart discase, toxze-
sputum and mia, typho-malarial
blood. typo of fever, acute
s A . E"
urticaria, prurigo, bots,
&c., tonsillitis, sciatic:
and gravel.
(II) Multiplicative phase. Acute dysentery, acute
Large granular gastritis and colitis,
amæbæ under-
going fission, schi-
zogamy and bud-
ding by means of
chromidia shed-
ding.
broncho - pneumonia,
bronchiectasis and
phthisis, adenitis metri-
tis and pelvie abscess,
peritonitis, nephritis,
appendicitis, hepatic
abscess, pyæmia.
245
— a amt
Condition of host.
Recovery for the time
being or improvement
in the patient's condi-
tion. Relapse occurs
when the cysts burst
and the parasites resume
the active róle.
Stage in life-cycle.
(IID Eneysted stage.
(IV) Parasites in all Cachexia, anasarca,
stages flourish in anzemia, debility,
the blood in ex- sweats.
tensive areas and
affecting the kid-
neys.
Thus we must note that the variations, relapses
and sequelæ 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 amœbæ 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 Chareot-Leyden
crystals and the so-called “exudation cells,” the last
being, no doubt, the amæœæbæ undergoing degeneration.
In one patient such crystals, together with amabs
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 amœbæ accounts
for the irritative, painful and inflammatory conditions
to which physicians have given different clinical topo-
graphical names. My observations show that these
rheumatie conditions are all related. They differ
-only with regard to the stage of the parasite and
lhe resistance of the patient. We are now able to
derstand 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
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 flagellulee 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 & 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 amcebe 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 antisepties 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 indications present.
The value of emetine in metrorrhagia, gastrodynia,
hemoptysis, melæna, 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
saine specific treatment.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
a i OESE
—————————————————ÁÁÉÁÉÉ—R——————MÉÉÉÉÉÉ———————————
[August 15, 1914.
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
feces of the latter by the fact that subcutaneous
injection of a syringeful of mucus containing live
amoebs produced no effect beyond a transient pyrexia.
Provisionally, we may call it Chlamydosporia
torifera on account of its toxic effect upon man.
—————40»———————
THE WAR AND DRUG SUPPLY.
AT present there is a SHORTAGE of the following
drugs :—
Salieylate 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, &c.; 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 narcotic, 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 alcohol has not been too great. This action
is remarkable and unexpected. It is not at present
explicable.—M. Sulzmann (Archiv. exper. Path.).
————— 8$» ——————
August 15, 1914.]
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THE JOURNAL OF
Tropical gpebícíne and bpgiene
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 29.
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
occasion 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
their
247
i es we ee,
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
rôle 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
& 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 Tropics 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
unsatisfactory condition, and had recently
248
—
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-imalarial 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 timo.
Since 1905 it has been known that leishmaniasis
oecurs 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 & morphological point of view there appears
to be no means of differentiating the parasite as it
occurs 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 (Cimex 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
reservoir hosts. In India none have been demon-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
- - —— - — >
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 can be infected with the Indian virus of kala-azar
under experimental conditions, 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 typanosome
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 (8 to 5 gr.) twice
weekly the parasites eould 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-
inents based on the line of the first two experiments
of Basile and his results were entirely negative. He
therefore thinks that 1t will be necessary to discover
an insect intermediary other than the dog flea.
In the discussion which followed Dr. D. E,
August 15, 1914.]
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.
conformed to the clinical type of case known as
Danti'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 nogative
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-azarit 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
Kitehener, to investigate disease in & 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 ophthalmic 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
He did not consider that they |
249
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 absence 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 scheme 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 alcohol 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 a 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 hæmoglobin 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 hemoglobin 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 chenopodiü. 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 inefticient.
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 educate the populace by means of lectures
and demonstrations, and to prosecute researches into
sodii, f
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 iteh " 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. SANpWITH (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. Macallan, 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 hest 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 caused 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 AMEBIASIS ?
In this short paper Professor LLEWELLYN PHILLIPS
(Cairo) put forward a plea for a much more prolonged
course of emetic treatment in amabiasis (for three
weeks or more) combined with small doses of a suit-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 15, 1914.
able aperient. metine readily destroys the amoebic
or active stages of the parasite, but has no effect on
the cysts; 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 case should be considered cured until after
several examinations, and no cysts of E. histolytica
can be found in the fæces.
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 Kına, 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 Tropics
should be more vigorously prosecuted than in England.
Medical knowledge demanded a profound acquaintance
with certain 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 medical, 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 Tropies 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 ease in point. It was therefore neces-
sary that in & tropical government there should be a
distinct cleavage between the medical and sanitary
August 15, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
branches of the service. Whether the sanitary officer
serves & 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 publie 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 & diagram showing
how under central and provincial governments the
medical and sanitary branches of a publie 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
& 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 Tropics, 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. ij
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, D. minutus and D. perniciosus, all apparently
are capable of conveying the infection.
251
a ee ee eee
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, 36u 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 papatasit.
The second paper on
SAND-FLY FEVER,
By Colonel Birt, 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 diarrhoea, 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. papatasit and P. minutus, both of which
Ás 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
and when it was with some degree of justice dubbed
m ; y
by the populace the fever of the rubbish.”
The fifth paper on the same subject was designated
SAND-FLY FEVER IN PESHAWAR,
By Captain HovsToN, 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
PoOST-DYSENTERIC CONDITIONS
zas the subject chosen by Dr. CANTLIE for discussion.
He described the anatomy, physiological and patho-
logical conditions of the sigmoid = flexure, which,
though so far neglected by the profession, he regarded
as a distinct and important portion of the intestinal
eanal; 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-dysenterie condi-
tions it is always excoriated and ulcerated. For the
diagnosis of pathological 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 carbolic 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 sufhces for
cure in the most severe cases.
Besides being of pathological the sigmoid fulfils
certain physiological functions; the moment fæces
impinge on the sigmo-rectal pylorus an intense
desire to pass stool is experienced.
He was averse to examination by the sigmoidoscope
under general anwsthesia 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
beneficial 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. Ij. 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 scientifie conclusions on such statistics. He
was convinced that diametrically opposite conelu-
sions could be drawn from their study. Hospital
statistics could be no index to the real prevalence or
otherwise of various diseases 1n differont countries.
RICE THEORY AND RECENT
CRITICISMS,
BERIBERI, THE
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 polyneuritis,
a condition which may be induced by à 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-
fieial 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), which 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, i& may occur also in the native, irre-
spective of race or mode of life.
(3) This fact, together with the occurrence of the
disease 1n people closely associated, suggests a local
influence or some communication of the specific cause
from man to man.
(1) Sprue is a 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 toxwmia; 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 avery 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. [n 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
109? F. or it may be normal. Cheyne-Stokes breath-
ing may appear. Nernig’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.
Bacterioloyy.—In 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 coccus has been assigned
by Seidelin the provisional name of Diplococeus
jamaicensis.
Morbid Anatomy.— The most striking features are
enlargement and hypereemia of the lymphatic glands,
subsericardial petechie, submucosal gastric hemor-
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 bacteri:mia.
(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
gastric 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 faets—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 voieing 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, us & graduate of this
University, they were unable personally to have the
benefit of his company at the sixteenth mecting of
the Section of which he was the first President. The
Section wishes to communicate from the city, his
professional birthplace, the testimony of adiniration
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.
Abstracts.
HLEPHANTIASIS AND THE
OPERATION.’
By HUBERT A. ROYSTER.
RONDOLEON
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 aeute 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 dificult 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 feces.
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.
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 heemorrhage occurred,
requirin 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
subeutaneous tissue had been removed, leaving 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,
January 3, 1914, the operation was performed:
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [August 15, 1914.
month afterward further progress was evident: the
leg had diminished in size, the foot was much more
fla& 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
hypodermic 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-
cally, for the purpose of combating the possible
parasitic or mierobie 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 151 in.,
above the ankle 154 in., and foot 131 in. The sound
leg shows the following: Calf 155 in., above ankle
103 in. and foot 10$ in. It will be noticed that very
little decrease has been secured in the size of the
elephantiasie 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.
A SOLITARY OBSOLESCENT PELVIC
HYDATID.’
By A. CAMPBELL MaGarey, M.S., M.R.C.S.
Demonstrator of Anatomy, University of Adelaide.
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
urcters were much dilated, as was the pelvis of each
kidney, and, when opened, there was evidence of
ureteritis and pyelitis respectively. The bladder wall
! From the Australasian Medical Gazette, May 19, 1914.
August 15, 1914.) THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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, us occurs with cancer
cells, to the most dependent part of the peritoneal
cavity.
THE USE OF LIQUID PARAFFIN IN
ENTERIC FEVER WITH CONSTIPATION.
By LrEwELLYN 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 cases in which during former acute illnesses
encmata 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.
———
Dediews,
TROPICAL DISEASES. A Manual of the Diseases
of Warm Climates. By Sir Patrick Manson,
G.C.M.G., M.D., LI.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
1914. 12s. 6d. net.
One can only treat with reverence everything that
issues from the pen of the Nestor of tropical
Melbourne.
found in South America.
255
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 & 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
(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 meyistus. (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 spirochæte closely resembling
that of syphilis. (7) Beriberi, at all events in the
Malay States, is the result of a diet of over-milled
rice, a8 indicated by Braddon, and proved by Fraser
and Stanton. (8) A non-periodic variety of Filaria
bancrofti especially common in the Pacific Islands.
(9) That Schistosomum japonicum is by no means an
uncommon parasite in large districts of China and
Japan which gives rise to a deadly disease, and that
it is acquired by contaet with the water of certain
districts. "These, and many minor discoveries made
within the last few years, testify to the activity in
pathological research into tropical 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 amoebic 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 Fréres, Editeurs, 23, Place de l'Ecole-de-
Médecine, Paris. 1914. Prix 8 francs.
This is & manual upon distinctly novel lines for
all kinds of laboratory workers, especially research
workers. One hundred and sixty-three pages of this
book are devoted to the methods of culture prepara-
tion, isolation of bacteria, microscopie 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 alphabetically, and the table contents
is extremely clear.
The work hids fair to be useful to teachers and
students of baeteriology in human, veterinary and
vegetable pathology, particularly to research workers
out of roach of a very up-to-date library.
-e
Aotes anb Mews.
THE PANAMA-PACIFIC INTERNATIONAL EN-
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-Paeifie 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 achievinent.
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 male possible the Panama
Canal. Modern hospital wards, as conductel 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, civice 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
———— ——
[August 15, 1914.
there will be unexampled health and human welfare
displays by such organizations as the American Steel
Corporation; the General Electric 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-Paeifie. 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 lilueation 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 plastie and mechanical pros-
thesis; orthopedic 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 case of accidents, and
to the wounded on the battle-field; ambulance service;
appliances 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. CHALMEBS, 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
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
Sudan.
draw attention, as it is either entirely or almost
éntirely 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 i in the
second ehapter 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 squamula surgunt,
ezque a cute resolvuntur , : et interdum madent, multo
sepius sicca sunt.”
Bishop Fortunatus, who lived in the sixth century
A.D., uses the name “Tinea” in the following passage :
UE nans 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 scab, 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
"eowrap." 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 bady
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
—————— c ——M uO
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 Tropies 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-
cacese and that Ctenomyces serrata Eidam 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 & considerable number of cases at
São Paulo, and also isolated T. album Sabouraud 1907.
In 1911 Horta discovered M. /lavescens and in 1914
he found & new Trichophyton which was subsequently
described and named T. griseum by Vasconcellos.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 1, 1914.
zs —— ÀÀ — —— ———M——9——
Argentina.—In 1907 Uriburu discovered M. fulvum
and in 1909 T. ersiccatum and T. polygonum.
Central America.—In 1918 Brumpt named a
peculiar parasite, discovered by Darier in & 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 pe with in the section on “ Diagnosis " (which
gee).
In 1909 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. macfadyenz
in Tinea corporis tropicalis, and T. blanchardi in Tinea
sabouraudi tropicalis, a term also used for the disease
caused by T. circonvolutum.
In 1908 he observed T. ceylonense in cases of Tinea
nigro-circinata.
In 1912 he found T. nodoformans in Tinea barbe
tropicalis 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. audouimi Gruby 1848, 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. exsiccatum 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,
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.
found in the
Sept. 1, 1914.]
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 Ánglo- Egyptian Sudan.
Sex, 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, z.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 hyphs, ending
in & chain of the so-called spores or short lengths of
hyphe 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, 2.e., about 90? F.,
we place the watch-glass in the incubator 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 & flame.
(4) Stain with aniline gentian violet solution for
thirty minutes.
(b) Treat with Gram's iodine solution for three
minutes.
(6) Decolorize in aniline oil for half an hour.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
259
(7) Stain with concentrated alcoholic solution of
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 hyphse 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 following are the results which we have
obtained in various media :—
Liquid Media.—lIt 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 hyphe
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 & white skin
under which the blue litmus milk remains untouched.
It forms neither acid nor gas in the following
sugar starch, a!sohol-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 20° 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
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 axea,
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.
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 32° C., the fungus forms a small
white puff-ball in twenty-four hours, which, in two
days, becomes surrounded by a circular whitish area
having & silky appearance. On the third day the
white growth is elevated at its periphery. The fourth
day shows & characteristic appearance, viz., & 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.
a 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, ani 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 Linnseus called Ascomycetes by De Bary, which
includes Brefeld's hemi- -ascom ycetes, 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 Zopf
1885, and to the genus Trichophyton Malmsten
1848, which 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 u in diameter.
(3) In cultures it possesses conidia on short
conidiophores (fig. 11).
(4) It possesses spirally curved hyphe (tig. 9).
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 &ppearance 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 T'ricophyton belonging to
the division Endothrix and arranged chronologically
are :—
(1) T. tonsurans Malmsten 1845.
(2) T. sabouraudi R. Blanchard 1895.
(3) T. violaceum Bodin 1902.
(4) T. sulphureum C. Fox 1908.
(b) T. glabrum Sabouraud 1909.
(6) T. fumatum Sabouraud 1909.
(7) T. effractum Sabouraud, 1909.
(8) T. circonvolutum Sabouraud 1909.
(9) T. regulure Sabouraud 1909.
(10) T. umbilicatum Sabouraud 1909.
(11) T. exsiccatum Uriburu 1909.
(12) T. polygonum Uriburu 1909.
(13) T. sudanense Joyeux 1912.
These may be recognized as follows :—
A. Condition of mycelium in hair not definitely stated,
but probably tbat of the Crateriform subdivision
(see bolow).
(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 y in
breadth, arranged in fairly straight ladder.
like rows . Crateriform subdivision.
(a) Cultures coloured and with craters : Tonsurans group.
(2) Yellow in centre, white at periphery tonsurans.
(3) As ‘‘tonsurans”’ but when old cracked
anddry . effractum.
(4) Orange-red centre, remainder sulphur
coloured . — Ssulphurewum.
(5) Golden yellow convoluted centre becom-
ing crateriform later .
(6) When old of a yellowish brown colour » fumatum.
(b) Cultures white with Craters : Umbilicatum group.
(7) Deeply umbilicated with aureola umbilicatum.
(8) Slow growth, surface cracked with dry
te? appearance . exsiccatuin,
(9) Growth at first roundish and then poly-
gonal . i polyganum.
II. Mycelium in hair iio —"—— T caustic pot- + >
ash, segments rounded 4.7 u in diameter,
not. arranged as a rule in rows, but if a row
is visible it resembles & string of beads and
not a ladder . ; Acuminate subdivision.
. Sudamense.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
261
(a) Without acuminate centre : Violaceum group.
(10) Primary growth violet . violaceum.
(11) Primary growth white . glabrum.
(b) With acuminate centre: Sabouraudi group.
(12) Without duvet when old . sabouraudi.
(18) With duvet when old O0 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 À 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).
(2) Its segments are not rounded (fg. 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 to caustic potash (fig. 6).
(2) Its segments are characteristically quadrangular
Ü eae 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.
(6) 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. 12 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. 19 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 we are dealing with a hitherto not described
species of Trichophyton. We name it after Mr. James
269
——————
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 hyphæ give rise to a dark
grey appearance. Habitat: Hairs of the head and
skin of scalp of Sudanese in the Anglo-Egyptian Sudan.
SA Acuminate Group
€ E
e uf
x!
$
es
Main Endothrix
stem
Common stem
Ancestor non-parasitic on
Animals
Diagram to show possible relationships of Trichophyton currii.
Relationships.—The resemblance of T. currii in
part to the Crateriform and in part to the Acuminate
subdivisions of the Endothrix 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. currit, 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 2).
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,
&nd 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 ..4 Lund the Argen-
(2) Bodin's ringworm
tine.
(8) Castellani's ringworm l EI | Ceylon.
(4) Courmont’s ringworms Not named Senegal.
Brazil, Senegal,
the Western Su-
(5) Gruby’s ringworm .. M. audouini 4 dan and Mada-
gascar.
(6) Joyeux's ringworm .. T. sudanense Western Sudan.
(7) Sabouraud’s ringworm 7T. circonvolutum an: neta and
M. fulvum, T.
(8) Uriburu's ringworms | polygonum ol 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 clinically 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. currii.
(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 can 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 7’. 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 scales.
(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 T'ri-
chophyton endothrix 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. currit 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 hyphe. It
was found exclusively in the hairs. The cultures had
a tendency to cupola formation and 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
typically 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
patches 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 :—
264
(1) Presence in the Anglo-Egyptian Sudan, and
possible absence in the Western Sudan.
(2) Absence of grey scales in the alopecial areas
and presence 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. curri! can be
distinguished by :—
(I) Absence of inflammation.
(II) Microscopical and cultural characters.
(b) From the infections due to T. polygonum and
T exsiccatum 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. Rare species: lesions clinically resembling
those of T. tonsurans.
(1) T. effractum Sabouraud 1909.
(2) T. fumatum Sabouraud 1909.
(3) T. regulare Sabouraud 1909.
C. Hare species: lesions clinically resembling
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 À and D to consider.
(4) Tinea tonsurans.—The lesions caused by T.
currii differ from those caused by 7. 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
(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 &miantacée est ordinairement carac-
térisée par des écailles ou membranules micacées,
luisantes, argentines, qui unissent et séparent les
cheveux par méches, les suivent dans trsjet et dans
toute leur longueur: elles ressemblent beaucoup à ces
pellicules mine:s, fines et transparentes qui engainent
les plumes des jeunes oiseaux, et qu'ils enlévent aveo
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 p
les naturalistes. Cette disposition, par paquets -
tincts ot 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. currii.
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 & 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 Rontgen 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.
(-1rranged. in alphabetical order).
ALIBERT (1832). ‘‘ Monographie des Dermatoses,” i, p. 464.
Paris.
BALFOUR and ARCHIBALD (1911). “Second Review of Recent
Advances in Tropical Medicine," p. 315 (Tobacco-soap). London.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, SEPTEMBER 1, 1911.
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,
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.
2242222
M S s
Sept. 1, 1914.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
265
Bonin (1902).. ‘‘ Les Champignons Parasites de l'Homme."
Paris.
BRuMPT (1913). “ Précis de Parasitologie Exotique,”
pp. 804-848. Paris.
CASTELLANI and CHALMERS (1913). ‘‘Manual of Tropical
Medicine," 2nd Edition, pp. 772-787 and pp. 1484-1485.
London.
OoRRE (1887). ‘‘ Maladies des Pays Chauds." Paris.
CouRMoNT (1896). Archives de Médecine Expérimentale et
d'Anatomie Pathologique, p. 100. Paris.
CouRMoxT (1899). Comptes Rendus del’ Académie des Sciences.
exxviii, p. 1411, and oxxix, p. 128. Paris.
3 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
eontinens," folio 98. "Venice.
HinscH (1885). ''Geographical and Historical Pathology,"
ii, pp. 374 and 875. London.
Horta (1911). ‘‘ Microsporon flavescens.”
Institute Oswaldo Cruz, iii, faciculo ii, p. 301.
JACKSON and McMurtry (1918).
pp. 193-248. London.
JEANSELME (1904).
Paris.
MaTRUCHOT and DassoNviLLE (1901). Bulletin de la Société
Mycologique de France, xvii, 2, p. 128. Paris.
" MaTRUCHOT and DASSONVILLE (1899). Ibid., xv, p. 249.
aris.
A Ed (1913). ‘* Médecins et Médecine en Ethiopie,” p. 91.
aris.
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.
PLaAvT (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 (19010). 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.
“Skin and other Diseases of
London. .
‘ Les Champignons Parasites,” pp. 71-
Memorias do
Rio de Janeiro.
** Diseases of the Hair,”
'Cours de Dermatologie Exotique.”
* 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.—8crapings 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.
FiG. 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.
Fic. 5.—A later stage of infection showing a more diffuse
attack of the vertex. Photograph.
Fia. 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.
Fia. 8.—Trichophyton currii : Growth on carrot at 34° 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. — Trichoghyton currii : Chlamydospore, early stage.
x 8,250. Photomicrograph.
Fio. 11.— Trichophyton currii : Hypha, short conidiophore
and conidium. x 2,620. Photomicrograph.
Fic. 12. — Trichophyton currii: Growth on Sabouraud's
maltose agar for two days at 34? C. Photograph.
Fic. 18.-—— 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
849 C. Photograph.
Fic. 15.— Trichophyton currii : Growth on maltose agar for
five days, but from a different case than figs. 12-14. Photograph.
Fra. 16. — Trichophyton currii: Growth on Sabouraud's
maltose gelatine at 20? C. for five days. Photograph.
Fig. 17. — Trichophyton currii: Growth on Sabouraud's
glucose agar for five daysat 34? C. Photograph.
— eo
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).
ESTIMATE 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
oecurred 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.
TRIPLE ACID PRURITUS OINTMENT.
l grm. (5 gr.).
2 grm. (10 gr.).
3 grm. (15 gr.).
80 grm. (1 oz.
Carbolie acid ...
Salicylic acid
Tartaric acid
Glycerine of starch
Rotices.
BUSINESS AND GENERAL.
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THE JOURNAL OF
Tropical WDedtctne 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 1, 1914.
the parasite as it oceurs 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 & 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 clinical work
during the last year of medical studies would be to cut
off clinical 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-
dysenterie State.” Mr. Cantlie, who opened the
subject, fixes upon the sigmoid flexure as the seat of
post-dysenteric 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.
———9———
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 Tropics 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.
267
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 Tropics, 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, alcoholic 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 can 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 between 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, Khartoum
(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 1°15 during fifteen months’ observation; at
Honolulu the maximum day observed out of ten
months was 2077, the minimum 37°48; Kuala
Lumpur (seven months’ observation) had a maximum
of 181, and a minimum of 90; Khartoum (three
months) gave a maximum figure of 920'8 and a
minimum of 1477. The average was 17:16, or 515
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.
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 auitable 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 sufficient 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 036? 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 986° 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 scantily clad human beings there was, with
rising temperature, a decrease to & 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 m 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.
Kijkman 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., 331 in comparison
with 34 9, a difference which is well within individual
variations, and that the chemical 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
anemia 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 anemic 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
hemoglobin, 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 nad 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-
morphonuclear neutrophile 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 ahasevation 18 — M 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 o.c. are
common, against 1,500 in & 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 & 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 careful 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 & 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 cedematous. 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 aud
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 Tropies than in & 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 Tropics 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
Tropics. Even the smallest and apparently negligible
detail may give rise to serious consequences. One
Sept. 1, 1914.]
— te ——
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, &c. 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 account 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 alcohol, 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 Tropies becomes afraid of work, unable to con-
centrate, and, generally speaking, & 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 &
rule, be only slightly affected by the changed condi-
tions of life and the alteration of his social condition.
Even he will lose & 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
271
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
tropical lands. Although situated within the Tropics,
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 & native population makes the
dealing with disease an easy matter. Modern experi-
ence gained throughout the world has proved that
well and discreetly 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
Tropics 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 districts 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 indicate whether the great
experiment of populating tropical 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.
i
Correspondence.
INTRAMUSCULAR INJECTIONS OF QUININE.
To the Editor of THE JOURNAL or TROPICAL MEDICINE
AND HYGIENE.
SIR, —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 chemieal 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, &nd after the injection there is probably
for & 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 1s 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 efficacious 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 intramuscular 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 8, 1914. Health Officer, Perak South.
Sept. 15, 1914.]
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-Eyyptian Sudan,
AND
Captain W. R. O'FPARRELL, 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 called 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (No. 18, Vol. XVII.
distilled water and transferred into the Giemsa's solu-
tion without allowing the films to dry.
Two Giemsa’s solutions were used, viz. :—
(1) 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 28 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 1s
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 sickness 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 eause—
(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
. ts > œ . )»
conclusion that the original strain’ of human
trypanosomes is lost. This trypanosome was also
named T. fordit Maxwell- Adams 28 March, 1903, and
T. gambia Maxwell-Adams 28 March, 1903; other
synonyms are T. hominis Manson 1903, and T.
nepreut Sambon 1 July, 1903.
In 1902 Castellani found a trypanosome in the
cerebro-spinal fluid of persons suffering from sleeping
sickness in Ugarfda. :
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 trvpanosome 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, T. «gandense."
This name suggested by Castellani, though the
paper was written in April, 1903, would bear the date
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1914.
of publieation in the Proceedings of the Royal Society,
vol. lxxi, 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, 1903, 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. castellani! 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 & 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
(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 TAE 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 Conyo.—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. :
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.
Lastly it may be remembered that, as a rule, a native,
out of politeness or fear, will say anything and agree to
anything he thinks 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 1808 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.
À curious point is to be noted in these old writings,
and that is, the persistency 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, cinq
ans aprés avoir quitté les centres endémiques.”
Sept. 15, 1914.]
Bordier says :—
“On à 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
still 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 1893,
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 Enclave. 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, RK.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).
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
275
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 eustern 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-Iigyptian 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 Abyssinian
frontier.
On the East by the Abyssinian boundary and by
Lake Rudolph to about 3 deg. 30 min. N. latitude.
On the South by & 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 River on
the Belgian Congo frontier.
On the West by the Belgian Congo and Bahr-el-
Ghazal frontiers.
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 oceurred 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.
27.6 IHE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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Sleeping sickness areas.
Glossina palpalis.
Glossina morsitans.
Provincial boundaries as regards Lado Enclave ouly.
MONGALLA PROVINCE
(Sept. 1, 1914.
Sept. 15, 1914.) -
The small original Mongalla Province, 7.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 which sleeping sickness was definitely seen was
carefully marked out, being bounded :—
Kastwards.—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 (7. 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 (7. morsitans.
Captain Drew, R.A.M.C., made a careful examina-
THE JOURNAL OF TROPICAL MEDICINE AND. HYGIENE.
277
tion of the Enclave and wrote a most valuable report
on the sleeping sickness therein, finding 218 cases
in 14,976 examinations and after 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
fact that Kajo-Kaji, in the vicinity of which he had
previously found €. palpalis and G. morsitans,
was threatened with the disease and later in the
vear 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 1913, 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. (ride 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 1913 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 ue p and
inhabited by the Makaraka and the Mundu peoples.
(2) An eastern: adjoining Kajo-Kaji (vide map)
and inhabited by the Kuku peoples.
1t 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,
1913, 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 which 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 faet as 1t indicates the same
source 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).
‘Each of the animals was inoculated subeutan-
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 leugth 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, /.e., 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.
YEI STRAIN.
Graphical representation of 1,000 Trypanosomes from one
monkey. Lasiopuyga callitrichus. (I. Geoffrey, 1851.)
MICR IS
[16 | 17. 18 | 19 120 | [20 2! [22 [23|24 725 [26 [22 |28 [22 [30 | :» [32 133 134139 | 26.
Bi E D D D PEE M B DR E
SETS IOS E
EHR
Percentages
o wo
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 Zrypanosome | 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
Dog | life, more than 40 days, often several
| months.
__. [Incubation about 9 days; average length
Monkey | of life, 355 days.
Gerbil 'Ineubation, 7 days; average length of
pet | life, 146 days.
(3) Immunity —A dog was rendered immune, j.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 Yer in twenty minutes in vitro,
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
279
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Sept. 15, 1914.]
TABLE I,—DISTRIBOTION IN RESPECT TO LENGTH OF 1,000 NON-DIVIDING INDIVIDUALS OF YEI STRAIN OF TRYPANOSOMES
IN A SiNGLE Monkey, Lasiopyga callitrichus (I. Geoffroy 1851).
AVERAGE
IN MICRONS
-M ose e CN nm v MINNA e
CN wo OON D-
CC emo O NAH NMMNANN COO e C32
| |
Aetna AN NN ANN
v4 M CV Q3 H Pow OO aW) C6 CN H m <b
NANO nr i HHN ONAA
TNN ANN a iQ. MN (2 OD AON MD
NON - 6C 058 C4 CN raw HN ne
©. o a c a —— 0$ $9 a $9 $9 > 9 9 òo 9 Á $9 8*9 o o ò >o s ç o č u č ò o o 9 9$ $9 @ > ù ò o X —9^* è è è > X 9*9 o o > o
of 1,000
Average length
is 25'071
a
133 159 |
a
|
|
o
i Eo ots f Soe PERENNE u mE . :
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: os DUE Gar Sar A E = ———M — —-—
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—M————— ——
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—
—M— v€« omm y ~e
Ávp pug
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Aep 44g
MADHID HNNAN n 0 00 un
— ~~ — ——— —— —M r
Asp pig Ávp Wap Aep u4g¢
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——MM———
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&sp 4401
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pamm
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E
TanLE II --SUMMARY OF MEASUREMENTS (IN MICRONS) OF
LENGTHS Or 1,000 INDIVIDUALS OF T. yet STRAIN FROM A
SINGLE MONKEY, Lasiopyga callitrichus.
AVernves Averages Range of
Maximum Minimum — of each of each AVCIUCN
100 . 20 of each 20
1 27 19 22-65
2 27 19 23:55
Ist dav 3 26 20 22714 22:50 1:10
4 26 18 22:45
5 28 20 2:3:55
6 as 18 23 05
T 38 22 24-40
2nd day | 8 — 30 20 — 2414 — 240 2:3
: 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 99 19 24:35
15 28 18 23 10
16 32 19 26:50
17 30 1^ 91:10
4th day 18 31 18 25°05 24:75 2'4
l 19 31 20 91 95
20 20 18 24°95
21 30 20 25:90
22 31 21 25:25
5th dav 23 33 21 25:87 20:35 1:2
i 24 29 18 25:10
25 31 22 26°45
26 31 2) 25:60
27 32 2] 25:40
6th day 28 31 2) 25°51 26 20 1:3
29 29 20 26 70
30 30 2] 25:65
31 31 20 21:55
32 32 22 26:15
Tth dav =3 31 18 25:40 25:50 1:95
34 31 21 26:50
35 30) 19 21:60
36 26 19 22:45
37 30 21 25:15
Sth day 38 28 18 23°69 23°55 2:7
39 39 19 23:55
40 28 20 93°75
41 32 93 206-45
12 31 21 25 64
9th day 43 39) 23 26:31 26:95 1°25
f 44 32 21 26°30
45 30 22 26 90
46 36 24 28:90
4T 35 23 29:1C
lOth day — 458 33 9() 28°05 27:50 1:9
49 32 23 21:20
50 33 24 27 55
Range -- 29°10
22:45
6:65
inoculated into gerbils zmmediately after mixture with
the trypanosomes. ‘The results were as follows: --
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1914.
“An infection resulted from which the
Pome ! animal was recovering when it died
"ef Yei | of heat stroke, on the same day with
: forty-nine other &nimals, z.e., on the
thirty-ninth day after inoculation.
(An infection resulted which killed the
T. rhodesiense; animal on the seventh day after
(inoculation.
When completely immune the serum was taken
and after being in contact with the trypanosomes
(1 c.c. of the serum to 0'1 c.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.
yp sc . . "The gerbil became infected and died
T. rhodesiense, . |
L in ten days.
Trypanosome |
from Yei
TaBLE IIl..-T. yet STRAIN IN WHICH THE TRYPANOSOMES ARE
ARRANGED IN BRvcE's THREE Groups: (a) 18—21 u; (b)
22—24 u; (c) 254 AND UPWARDS.
| | |
Day | l | 2 | 3 | 4 | 5. 68:7 8 | 9 10 | Totals
i l
M NEHME Ks p IMS A MN LUN ES EIU ND
(a) Stumpy, | 32 | 13 / 12 15 | 6 10, 8/19 2 | 1| 118
13 —21 u dn | |
(b) Interme- | 44 | 47 45 . 297 | 26 26 , 291 41 | 19 | 10] 814
diate, | |
22—24 p | >. i |
c) Long, 24 | 40 | 43 | 58 | 68 64 63 40/79! 89! 568
| ' i
-———-——--—-——---—p-4LT-—-—-
Totals |100 100 |100 100 100 100 '100 [100 |100 hoo 1,000
TABLE IV.—IMMUNITY EXPERIMENTS IN VITRO.
Immune serum +}: |
Trypanosome from Yei — |
t
Immune serum +
Animal T. rhodesiense
Dog |
against Trypano- '
some from Yet in
the Lado. | |
Goat immunized ' Trypanosomes alive! All trypanosomes
against T. rho- at end ofone hour. : dead in twenty
destense, original minutes.
strain of Stephens |
and Fantham -
1910.
immunized Alltrypanosomesdead Trypanosomes
in twenty minutes. alive at end of
one hour,
Sept. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
TABLE V.—IMMUNITY ÉXPBRIMENTS IN VIVO.
Immune serum
— — | ee MM ——M—— À—— M a ——À— e I —— á—
Inoculated
From dog par-
tially immunized
against the Try-
panosome from
Yer. The inocu-
lation of the ger-
bils was made
immediately after
mixing with the
immune serum.
From dog com-
pletely immun-
ized (1.6., gerbil
inoculated with
its blood did not
develop trypano-
somiasis) against
the Trypanosome
from Yei. Try-
panosomes left for
thirty minutes
in contact with
serum before in-
jection into ger-
bils.
From goat immun-
ized. against T.
rnhodesiense, ori-
ginal strain. Try-
panosomes left for
twenty minutes
in contact with
serum before in-
oculation into
gerbils.
Did not show
Gerbil inoculated with
immune serum + Trypano-
some from Yei
9.4.14 ;
showed
somes 15.4.14; good |
infection 17. 4.14;
after which try pano-
somes
and the animal was
trypano- |
diminished |
Gerbil inoculated
with immune serum
| + T. rhodesiense
| original strain
| Developed severe
trypanosomiasis
and died on
seventh day
after inocula-
tion.
in apparently good |
health on 17.5.14.
when it died of heat
stroke with forty-
nine other healthy
and inoculated ani. |
mals,?.¢. thirty-nine
days after inocula-
tion.
any
trypanosomes but
was killed accident-
ally two days and
fourteen hours after
inoculation. No try-
panosomes to be
found in internal
organs, but peculiar
bodies in lung cells
identical with those
found by Archibald
in spleens of kala-
azar patients aud of
animals inoculated
with kala-azar.
Developed severe try-
ponosomiasis and
died on fourth day
after inoculation.
|
|
Developed severo
trypanosomiasis
aud died on the
tenth day after
inoculation.
Alive and ap-
parently in its
usual health one
month after in-
oculation, and
has not shown
trypanosomes in
its ^ peripheral
blood. Tho ger-
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.
(b) 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.
28]
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 epidemie charaeter 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 & most
remarkable manner but did not act on heterologous
try panosomes.
(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 0'025 c.c. of the infected blood
with 05 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, &c., 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 trypanolytic 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). M dut and Fantham, 1913.)
t
3
-b
Ç
è
9
N
n.
E
8
7
6
5
4
3
2
I
CHART Il.
(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 Societ y
for 1911.
Comparison with other Trypanosones.—The differ-
ences and the similarities of this trypanosome with
the other known human trypanosomes will now be
discussed in the following order :—
(D T. rhodesiense.
(II) T. nigeriense.
(III) T. gambiense, Congo strain.
(IV) T. gambiense, Uganda strain.
(D T. rhodesiense Stephens and Fantham 1910.
The trypanosome from Yei differs from T. rhodesiense
in that :—
Trypanosome from Yei T. rhodesiense
(1 Maximum length 36 against 34 microns.
(2) Minimum length 18 an 14 ,,
(89) Average length .. 25 " 24 y
(4) Curve of 1,000 Vide Chart I. 5s Vide Chart II.
lengths
(5) Posterior nuclea- Not observed 2 Present.
tion
(6) Animal reactions Less virulent vi More virulent.
(7) Yei immune serum
reactions—
(a) In vitro
Destruction of ^ No destruction.
trypanosomes
(b) In vivo.. Destruction of T Development of
trypanosomes disease and
death.
TRYPANOSOMA NIGERIENSE.
Graphical representation of 1,000 Trypanosomes from one
Guinea. pig.
(Scott Macfre, 1913.)
CBART III.
(II) T. nigeriense Scott-Macfie 1913.
from this trypanosome in that :—
It differs
Trypano«ome from Yei T. nigeriense
(1) Maximum length 36 against 34 microns.
(2) Minimum length 18 " B:- 35
(8) Average length .. 25 $5 21 re
(4) Curve of 1,000 Vide Chart 1 M Vide Chart 3.
lengths
(5) Anterior nuclea- Not marked.. 5 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 36days 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. nigeriense 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 gnt of Stomoxys.
We have thus shown that the trypanosome from
Yei is neither T. rhodestense nor T. nigeriense.
TRYPANOSOMA GAMBIENSE.
Graphical representation of 1,000 Trypanosomes in one Rat
(white). (Stephens and Fantham 1918.)
AN
As
E
EJ
E
E
E
ES
ES
as
ES
Se Mile steel
CHART IV.
(III) T. gambiense, Congo strain.—It is now neces-
sary to compare this trypanosome with & 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 Trypu nosome
, from Yei from Congo
1 Maximum length ... 36 against 36 microns
a Minimum length — ... 16 - 16 i3
(3) Average length .. 25:017 - 24:867 js
(4) Curve of lengths Chart I. - 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
Tryp«nosome | Trypanosome
from Yei from Uganda Difference
(1) Maximum length ... 36 — 8 microns
(2) Minimum length ... 16 13 -8 ,
(3) Average length 25:0 22:1 -3 „n
(4) Curve of length Chart I. Chart V. j
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.8.,1911.)
MICRONS
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 Sir David
Bruce's three classes :—
Long and
Strain Short, stumpy, Intermediate slender, 25
13-21 microns 22-24 microns microns and
f upwards
Uganda strain 51:2 231 we 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 mierons and our maximum 2'5 microns
against Sir David Bruce's 2'5 microns.
We have made & 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 &n excess of long and slender forms and at
other times an excess of short and stumpy forms.
We are inelined to think that inoculations made
from recently infected animals tend to produce
increased 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 he
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 (ey., the compass versus the tangent
method, &c.) may also help to explain the difference.
With regard to animal reactions we scarcely meet
on common 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., Lastopyga
callitrichus (Y. 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 24-12 months
Uganda (Bentmann and 10 ,, 82 davs
Günther)
Yei.. P T V 9 ,, .. 36 ,,
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 T'. 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
categories :— |
(A) Southern sleeping sickness caused by T.
rhodesiense Stephens and Fantham 1910, and spread
by Glossina morsituns Westwood 1850.
(B) Equatorial sleeping sickness caused by T.
castellanii Kruse 1908, and spread by (GG. palpalis
(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 & 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.
284
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 :—
Why are so many of the cases exceedingly chronic,
while others are very acute ?
This question is eapable 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 oecur.
This is supported by evidence given to the writers by
Captain Archibald, R. 3.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 theso points.
Acknowledqments,.——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 Bacteriological Assistant,
for much kind help.
We are much obliged to the Director of Surveys
for the map of the Lado Iinclave.
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.
REFERENCES.
ARCHIBALD (1908). Third Report Wellcome Tropical Research
Laboratories, p. 98, London (1913) ; Journal of the Royal Army
Medical Corps, May number (Granules), London.
BALFOUR (1906). Second Report Wellcome Tropical Research
Laboratories, p. 161, London (1908); Third Report, p. 27,
London.
BLACKLOCK (1913). Annals of Tropical Medicine and Para:
sitology, vol. vii, No. 1, p. 101, Liverpool.
Borpier (1884). ‘* La Géographie Médicale," p. 471, Paris.
Braun and TEICHMANN (1912). '**Immunisierung gegen
Trypanosomen," Jena.
Bruce (1911). Proceedings of the Royal Society. B, vol. Ixxxiv,
p. 327, London; also many papers in the publications of tlie
Royal Society and in the Reports of the Royal Society s
Sleeping Sickness Commission, London.
Bulletin of the Sleeping Sickness Bureau (1909-12), 4 vols.
(numerous most valuable extracts), London.
CASTELLANI (1903). Reports of the Sleeping Sickness Com-
mission, Royal Society, No. 1, London.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Sept. 15, 1914.
CASTELLANI and CHALMERS (1913). ‘‘ Manual of Tropical
Medicine," pp. 16-17, 322-327, 721, 966-985, London.
CORRE (1887). ** Maladies des Pays Chauds,” pp. 255 and
258, Paris.
Exsor (1908). Third Report Wellcome Tropical Research
Laboratories, p. 93, London.
Fry (1911). Proceedings of the Royal Society, B, \xxxiv,
p. 79 (Extrusion of Granules), London.
Fry and Ranken (1913). Proceedings of the Royal Society,
B, Ixxxvi, p. 377, London
Gazette, Anglo- E jyptian Sudan (1909).
Mongalla Proclamation,” Khartoum.
Hinpit (1910). Journal of Parasitology. itt, No. 4, p. 455,
Cambridge.
kKornLE and WasskERMANN (1913). 6S Handbuch der Patho-
genen Micro-organismen, vil, pp. 321-419, Jena.
Knusk (1903). ‘‘Sitzungsberichte der Niederrheinischen
Gesellschaft fiir Natur und Heilkunde,” May 18, Bonn.
LavERAN and MesxiL (1907 and 1912). ‘* Trypanosomes at
Trypauosomiases, Paris.
Manson (1914). JOURNAL OF
HYGIENE, pp. 152-185. London.
Martin, Le Ba:vF, and RovBAUD (1909).
Sommeil au Congo Francais," Paris.
Marquras (1911). Fourth Report of the Wellcome Tropical
tesearch Laboratories, vol A. p. 31, London.
MENSE (1913). ** Handbuch der Tropenkrankbeiten,’’ i, pp.
** Sleeping Sickness
TRoPICAL MEDICINE AND
“La Maladie du
. 900-17, Leipzig.
MESSNIL and Brimont (1909). Annales de UInstitut Pasteur,
vol. xxiii, pp. 129-154 (“ Properties of Scrums in Trypano-
somiasis"' : a very important paper with full history), Paris.
Prowazek (1912). “ Handbuch der Pathogenen Protozoen
(Maver Pathogene Trypanosomen)," Lieferung 3, pp. 301-311,
Leipzig. '
RANKEN (1913).
London.
Reports of the Sleeping Sickness Commission, Anglo-Egyp-
tiam Sudan (1909-1913) ; Reports on the administration of the
Sudan, vol. ii.
RonEuTSON (1913). Philosonrical Transactions, Royal Society
of London, B, cciii, pp. 161-184, London.
Scorr-Macrig (19013). — Annals of Tropical Medicine and
Parasitology. vol. vii, No. 3a, Liverpool; (1914), ibid., vol. viii,
No. 1, p. 29. Liverpool.
SLANE (1852-1856).
et des Dynasties Musulmanes de l'Afrique Septentrionale,
Alger. (Quoted in the Sleeping Sickness Bulletin, vol. ii,
». 112.)
STEPHENS and FawTHAM (1910). Proceedings of the Royal
Society. B, xxxiii, pp. 28-33, London ; (1912), ibid., B, xxxv,
pp. 223-231, London ; (1912), Brit. Med. Journ., November 32,
London.
Tropical Diseases Bulletin (1912-1914).
résumés, London.
WARRINGTON, YORKE and Brackrock (1914). Brit. Med.
Journ., June 6. p. 1234, London; (1914) Annals of Tropical
Medicine and Parasitology, viii, No. 6, p. 1, Liverpool.
WixTEkRBOTrOM (1803). “An Account of Native Africans,"
vol. ii, pp. 29-31, London.
Proceedings of the Royal Society, B, Ixxxvi,
Ibn. Khaldoun, ‘ Histoire des Berbéres
,*
Many very valuable
ILLUSTRATIONS.
(A) Mar or THE [DADO lÉÉNCLAVE BELONGING TO THE
MONGALLA PROVINCE.
(B) CHARTS oF Lk*GTHS OF TRYPANOSOMES.
T. castellanii Kruse 1903.
rhodesivnse Stephens
aud Fantham 1910.
T. nigeriense Scott-Mac-
fie 1913.
Chart L.--- Yei strain of trypanosome
IT-T. rhodesiense made by T.
Stephens and Fantham
„ IH.--T. nigeriense made by
Scott- Macfie
S, IV. T. gambiense made by
Stephens and Fantham
V.—T. gambiense made by Sir
David Bruce, F.R.S. js ši m
9
T. castellanii Kruse 1908.
9)
Sept. 15, 1914.]
THE JOURNAL OF
Tropical spebtitine and Hhygtenc
SEPTEMBER 15, 1914.
ene ee eee —— —— ——9—
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. We were favoured by a 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,
& 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
285
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 a 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 fora 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 presidency 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
& 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 Fast, 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 hecome almost appalled
wt 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 difticulties 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.
M
Motes and Mews.
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
—— re ee ee — ——— M — -—
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[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.
<=
Correspondence.
INTRAMUSCULAR INJECTIONS OF QUININE.
To the Editor of THE JOURNAL OF TROPICAL MEDICINE
AND HYGIENE.
SIR,—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.
— —À
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
665 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
toimagine 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 cases 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 & 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 & 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
* Septeniber 1, 1914.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
287
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 & 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 lin 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
me 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.
THE JOURN AL ( OF TROPICAL
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 [ am inclined to agree entirely with
MacGilchrist when he says that “quinine and its
salts are fundamentally unsuited for hypodermic use.
This mode of quinine administration should, therefore,
be abandoned."
Yours fuithfully,
RONALD Ross.
i —— —
Personal Motes.
INDIA 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, LM.S.; Captain R. S. Town.
send, IL. M.S. : Major C. S. Lowson, I. M.S. ; Lieutenant.Colonel
H. B. Melville, I. M.S. ; Lieutenant-Colonel A. W. Dawson,
I.M.S.; Lieutenant-Colonel A. Coleman, I. M.S. ; Lieutenant
E. J. Greson, I.S. M.D.
FE.rtensions of Leave.-- Major C. W. F. Melville,
August 81, 1914; Major A. Murphy, I.M.S., 4 mo M.C.;
Captain A. N. Thomas, I. M.S., 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,
1 M.S., 6 m.; Captain A. T. Pridham, I.M.S., 6 m., M.C. ;
Captain A. A. McNeight, I. M.S., 1 m., M.C.; Captain C. L.
Dunn, I.M.S.,, 3 m, M.C.; Major E. J. Morgan, I.M.S.,
6 m., M.C.
Permitted to Heturn.—Major H. R. Dutton,
tenant-Colonel J. Penny, I.M.S.
I. M.S., to
I. M.S. , Lieu-
List OF INDIAN CIVIL OFFICERS ON LEAVE (INCLUDING
MILITARY OFFICERS UNDER Civir, RULES).
Showing the Name, Province, and Department, and the Period
for, and Date from, which the Leave was granted.
Abbott, Major S. H. L., T. M.S., Punjab, 24 m., April 23, 1914.
Anthony, Major R. W., TLM.S. , Bombay, Hm., , March 31. 1914.
` Bird, Lieutenant- Colonel R. T. M.S., Bl., 6 m., April 14. 1914.
Birdwood, Lieutenant-Colonel G. T, I.M.S., Und. Prov.,
7 m., March 30, 1914.
Castor, Lieutenant-Colonel R. H.,
November 26, 1912.
Christian, Captain J. B., I. M.5.,
I.M.S., Burma, 24 m.,
Bo., 21 m.. January 15. 1913.
Clemesha, Major W. W., I.M.5.. Punjab.
Cox, Major W. H., D.S.O., LM.S., Burma, 18 m.. April 12.
1913.
Crump. Captain S. T., I.M.S.. Burma Medl.. 6 m. 10 d.,
April 9, 1913.
Dalziel, Major R. M., I. M.S.. Punj., 12 m.,
Delany, Major T. H., I.M.S.,
November 11. 1913.
Drake, Captain H. B., L.M.S., Bo. Mint., 6 m., May 2, 1914.
Drake-Brockman, Lieutenaut-Colonel H. E., I.M.S., 6 m.,
April 18, 1914.
December 10. 1913.
Behar and Orissa, 13 m..
Drake- Brockman, Lieutenant.Colonel V. G., I.M.S , India
Foreign Depart., 7 m. 24 d., May 1, 1914.
Dunn, Cap'ain C. L , I.M.S., U.P. Sanitary Comm., 11 m.,
November 4, 1913.
Dutton, Major H. R., I.M. S. , Delhi, 16 m. 20d., June 3, 1913.
Evans, Colonel A. V., I.M.S , Burma Hospitals.
Fuyrer, Major F. D. S. I.M. S., 16 m. 27 d., September 25,
1913.
Finlayson, Captain W. T., I. M.S., Punjab, 24 m., October 21.
1912.
MEDICINE AND HY GIENE.
[Sept. 15, 1914.
Forster, Major W. H. C
Gloster, Major T. H.,
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.,
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.8., U.P., 6 m.,
November 12, 1913.
Hunter, Lieutenant-Colonel G. Y. C., I.M.S., B.Gaols, 42 m.
26 d., March 80, 1911.
Hutchinson, Major L. T. R., I.M.8., Bo., 12 m., Novem-
ber 15, 1913.
Innes, Major H., I.M.8., Assam., 21 m., February 18, 1914.
James, Major S. P., L.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, 1918.
Knox, Major R. W.,
August 30, 1913.
Lethbridge, Major W.,
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.,
29 d , March 25, 1914.
Macrae, Captain I. 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, 1918.
Newman, Lieutenant-Colonel E. A. R., I.M.S., Bl. Emign.
Dept., 7 m. 15 d., May 15, 1914.
Nutt, Major H. R. E 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, 1918.
Peebles, Captain A. S. M., 1.M.S. BI., 15 m., March 31, 1914.
Penny, Lieutenant-Colonel J., I. M.S., Burma, 21 m., Decem-
ber 25, 1912.
Prall, Lieutenant-Colonel S. E., I. M.S., Bo.
February 18, 1914.
Rainier, Major N. R. J., I.M.8., Cent. Prov., 28 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., 1.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.S., 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.,
Laboratory, 18 m., October 4, 1913.
Thompson, Major F. S. C., I.M.S., B. Gaols, 24 m., Novein-
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., I.M.S., U.P., 12 m., October 30, 1918.
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
, 24 m., October 10, 1918.
LM. $. Bo., Bacteriological Dept ,
Dir. Central
I.M.S., Indian Foreign Dept., 14 m.,
I.M.S., Rajpootana, 23 m. 2 d.,
I.M.S., Mc. Prisons, S m.
I.M.S., Agra Cent. Prison, 18 m.,
Med., 12 m.,
I.M.S., Bo. Bacteriological
Oct. 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (No. 19, Vol. XVII.
Original Coumunications.
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 precipuorum 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 generic 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
publication of the German translation and not the
date of the original Swedish work, the name being
derived from Op«£, hair, and du7ov, 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, Torulace: ; 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 & 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.
Bodin (1899-1909) brought forward views tending
to show that the relationship is complex, some of the
species being allied to Endoconideum Prillieux and
Delacroix 1891 (a genus which lately disappeared,
having become Stromatinia Prilieux 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
Hyphomycetee Martius 1817, the Family Mucedinacee
Link 1809, Subfamily 4merosporee Saccardo 1886,
Tribe Macronemz Saccardo 1886, and Subtribe
DBotrytida 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 1848, 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 Schroter’s more detailed
arrangement of the Ascomycetes be adopted, does not
concern our present purpose as both contain the
family Gymnoascacem (often written Gymnoascez) in
which Matruchot and Dassonville place the genus
Trichophyton. |
Their reasons for this classification are:
(1) Ctenomyces serratus Eidam 1880 is & 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 Ezdamella Matruchot and
Dassonville 1901, calling the given species Etdamella
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 Gymnoascace@ Baranetzky 1872
of the Ascomycetes, but as so great an authority as
290
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 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 classifieation 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 curri? 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,
t.e., in a thin layer of the medium, is examined pos-
teriorly à 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 05 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 & rounded body composed of inter-
locked hyphe 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 hyphe 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-
thecia. 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 Gymnoascacese 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 saphrophytic, 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 T. currii would belong to Bara-
netzky's family Gymnoaseacese which already con-
tains the genera :—
. Amauroascus Schróter 1893.
Arachniotus Schróter 1893.
Ctenomyces Eidam 1880.
Eidamella Matruchot and Dassonville 1901.
Gymnoascus Baranetzky 1872.
Myzrotrichum 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 asoi.
Trichophyton curri! 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 parasitic existence
is indicated by the appearance in the cultures of
T. currit 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. currit 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 & position to make any definite statement,
though we incline rather to the view that they represent
THE
JOURNAL OF TROPICAL MEDICINE AND HYGIENE, OCTOBER 1, 1914.
To illustrate article, “The Systemic Position of the Genus Trichophyton Malmsten 1815," by
ALBERT J. CHarLMEns, M.D., F.R.C.S., D.P.H., and ALEXANDER MARSHALL.
49422322
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, OCTOBER 1, 1914.
—_ UTE. Mor dif T
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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
Gymnoascacee 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 1,800 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. .
Bonin (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.
GEDOELsT (1902). ‘‘ Les Champignons parasites de l'homme,”
p. 71 and pp. 99-101. Brussels.
HALLIER (1866). ‘* Pflanzlichen Parasiten de Menschlichen
Körpers,” pp. 72-78. Leipzig.
MALMSTEN (1845). ‘‘Trichophyton tonsurans Hárskürande
Mógel." Stockholm.
MarcRUCHOT 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 805. Ibid., xvii, 2nd fascicle,
pp. 123-132.
RoBiN (1853). ‘‘ Végétaux Parasites,” pp. 408-409 and 417.428.
Paris.
SABOURAUD (1910).
SACCARDO (1906).
VERUJSKY (1887).
pp. 368-391.
** Manual of Tropical Medi-
“ Les Teignes," pp. 717-724. Paris.
** Sylloge Fungorum,” xviii, p. 833. Padua.
Annales del’ Institut Pasteur, Paris, i, No. 8,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
291
MOLLUSCUM FIBROSUM,
PENDULATUM ATQUE ELEPHANTIACUM.
A SHORT ACCOUNT OF A CASE.
By Dr. F. S. HABPER.
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.
a. MÀ
LONDON SCHOOL OF TROPICAL
MEDICINE.
THE “Duncan 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, &c., 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
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THE JOURNAL OF
Tropical Medicine and Hygiene
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
cases 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
-[Oct. 1, 1914.
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 & 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 & 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 & limited area, is so
great that it is natural that alarm is taken, and as a
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.
Even 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
evacuations 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 Cossacks on their track,
Oct. 1, 1914.]
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 1s 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 choleraic diarrhcea 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
a 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
293
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 Australean 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 Culer 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.
Speculations as to the origin of new epidemics aie
( Oneof the Stewart Lectures of the University of Melbourne,
1913.
204
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-
seribed 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, a disease of world-wide distribution, is
commonly observed in the East. Ameebic dysentery,
caused by a protozoon, occurs 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 1s 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.
[Oct. 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 & 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 & certain extent,
shrouded in mystery. It is a generally accepted
Oct. 1, 1914.]
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 Frambosia 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 filarie 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 larv:e, 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
295
eee ae
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 oedematous 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
later in the Philippines. It is endemic in British New
Guinea, and numbers of cases have been observed in
the coastal districts 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 a 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 anæmia.
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
— €———— —À—À M — -——— 4—- o ee oc
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 diseages 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, & 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 endemic 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
tive months, being fed twice weekly; and it is also
an expert traveller, having proved its qualities by
crossing from Central America 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-
duced into North Queensland, and were able to infect
one person. The diagnosis of yellow fever during the
first three days is extremely difficult, even to the
experienced, and it 1s 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 1, 1914.
a -— ~ - ————
a X ———— M. --— DL 0 L———————M———— ——— s Se
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.
— — ÜÍ— DH
PREVENTION OF MALARIA IN THE TROOPS
OF OUR INDIAN EMPIRE.
By Colonel P. Henrr, 1.M.S.
IN most of the cases which occur in troops and
followers on field service the initial infection is
acquired in cantonments: the large majority are
relapses. One's personal experience is that the
malaria of cantonments is to & large extent bred in
the human oceupants and anopheline population of
cantonments.
In all cantonments and barracks we should make
— —À— —
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—including 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 indez,
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 u 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, exca-
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 & 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 oflicers
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 & 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1914.
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 ; in 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
redueing the breeding places of anophelines is tedious,
exaeting, and requires unremitting attention and
supervision ; in the absence of radical and prohibitively
expensive operations i& 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
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 with quinine for a week
or so and then letting them falt-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 cantonment 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
Oct. 1, 1914]
would be a record to the effect that the preceding
attack was caused by a 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. When a relapse 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 case 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-
cally 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 1, 1914.
giving quinine can 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.
In many stations the mistake is made of not begin-
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
]9uropean 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 diffi-
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-
fines 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.
Oet. 1, 1914.]
for example, infusoria. There are other protozoa
which lead a facultative parasitic existence, in other
words, live symbiotie 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 &moebic 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
become 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
301
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
presence 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, hawever, 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 succumbs 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
be seen in an extremely small number of parasites.
The majority of them undergo disintegration, the
eytoplasm becomes vacuolic, 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, antagonistie 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 & 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 case of sleeping sickness, the faculty of the
host to produce substances which are harmful to the
parasites seems only to be & 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 dependeni 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 Tropics, and
is called spirochwta, 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 spirochætes, 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.
(Oct. 1, 1914.
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 anæmia, 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, anzemia with its accompanying odema, and
with enlargement of the spleen. In many cases,
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, folowed 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 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 toa 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 protozoic 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;
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
303
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, & 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.
304
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 deseription 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 up with the blood by the rat louse, grow larger,
&nd resemble morphologically forms which occur as
“ wild parasites," harmless lodgers in different insects.
The work of the life-history of parasitie protozoa
through the intermediary host is complieated by the
occurrence of other parasites in the respective insects,
which resemble morphologically 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-parasitie 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, T.
gambiense, the sleeping sickness parasite, and -7’.
bruce’, 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 corpuseles 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 parasitic protozoa occur
mostly in tropical climates. The most important
disease 1s malaria, which occurs 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. yambiense, a pro-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 1, 1914.
MÀ re — € ———
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.
Spirochztes 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 amoebie dysentery belong to the
phylum of the protozoa, and show a fairly wide dis-
tribution throughout the Tropics.
—_—____
Personal Motes.
List oF INDIAN MILITARY OFFICERS ON LEAVE.
Shcwing 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., L.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, Captaiu 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. C., I.M.S., to November 20, 1914.
McCarthy, Lieutenant P., I.S. M.D., to November 12, 1014.
McCowen, Major W. T., I. M.S., to December 14, 1914.
MeNeight, 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.5., 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. 8., I. M.S., to May 22, 1915.
Thomas, Captain A. N., I.M.S., to November 9, 1914.
Thomson, Licutenant-Colonel G. S., I.M.S., to March 28,
1915.
White, Captain M. F., I.M.S., to September 30, 1914.
Oct. 15, 1914.]
Original Communications.
NOTES ON THE HYPHOMYCETES FOUND
IN SPRUE: WITH REMARKS ON THE
CLASSIFICATION OF FUNGI OF THE
GENUS "MONILIA GMELIN 1791."
By Arpo 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 & 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. fecalis, &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 diarrhea
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
& very important symptom, the serotine fever, is not
due to the tubercular bacillus, but to the secondary
streptococcal infection.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (No. 20, Vol. XVII.
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
generaly 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 Tropies 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 rhanner that,
till some years ago, the term Bacillus colt 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 dust, &c. It is quite possible that future investigation
purposes the following are sufficient for the identifica- may show that some of the species created cannot
tion of most species: glucose, saccharose, levulose, stand, but I venture to say that my main point, viz.,
galactose, maltose, mannite, lactose, provided the that there is a plurality of species of the so-called
results are considered together with the action of the — M. albicans, or thrush-fungus, will be confirmed.
fungi on litmus milk and gelatine. I have observed I will limit myself to give here a description of
in analogy to what takes place when dealing with ^ monilias found in stools, and only those species which
bacteria that certain well-defined species (for instance, I consider to be good. Some of these species have
M. intestinalis, M. tropicalis) do not change to any already been published, but I will repeat here their
appreciable extent their fermentation properties in description for the reader's convenience.
the course of time; while with other species the For those who may be interested in the compara-
fermentation properties are not constant. I have tive study of these fungi, I annex also a table con-
noted also that strains which do not ferment certain taining species derived from cases of bronchomycosis,
sugars may be trained at times to do so, but this is thrush, tea dust, &c.
the case also with many bacteria. It is well known, Monilia intestinalis, Cast. 1911.—-Microscopically
for instance, that Penfold has been able to change has all the characters of the genus Monzlia ; grows
the fermentative properties of germs of the typhoid abundantly on slightly acid sugar media, giving rise
colon group to a remarkable degree; still no one to large white colonies which soon coalesce into a
denies the validity of the usual fermentation tests in cream-like abundant growth. The growth is com-
differentiating between organisms of this group. posed practically of only globular yeast-like cells,
TABLE I.—INTESTINAL MONILIAS.
| j | ' !
| æ | | 5 à 2 | | | a [ | S t: eis
E |£ S x <i $e 5,2|s sz 5:8 |2| se [sl = [Fie £ $| s 358 T
2.5 ;3;2/8 |e 52 5/58/|8]|£2 3 5 fa "^ jg" "3|* 8 ^| 9 [E Ses
= | | | É | Ei es *
| | | | | | i | |]
NP | | | | eae | | I | | | | | |
M. asteroides,' AC ; A A A A A A A O0 A A O jO; O JA: T |O}../4]..; 0 sefeejeo|e
Cast. 1914 | | | TE | |
M. fecalis,| A |AG |AG i AG;jAGS|AGS|O o loi 0 | 0 | o lO! o 'O| C |CIO-[|O| OB jo A R E [i
Cast. 1911 DPS | | | |
M. insolita,| AS | AG | AG | AG | AG | AG | O | AS o 0,0 | o joj o jo! C |C|0j4|0, OB |O
Cast. 1911 | Alk i | | TUE |
M. intestinalis, | ADS AG | AG AS | A jajo o e o|o |o lol o lo; c Clo[s|o| o lo
Cast. 1911 | | | |
M. rotundata,| AC | A | A | A | A 10 | A! O 0| o o | o |o} o lo! C jcjol+]/o| o jol.. |
Cast. 1911 | . |
M. decolorans, | DFC AGS AG |AGS A | A | 0 | +10] 0 jojo] o jolojajo
Cast.and Low Alk
1913
i
A = acid, G = gas, C = clot (milk), clear (broth and peptone water), D = decolorizel, 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 of
indol, non-liquefaction of serum or gelatine, as the case may be.
As regards the use of immunization, agglutination while in the water of condensation globular cells and
and complement fixation phenomena for the differentia- mycelium may be found together. A little mycelium
tion of monilias, unfortunately these are experiments may be found, however, also in the growth on the
which take a very great deal of time. I may say, slope. Ascus formations are absent, gelatine and
however, that rabbits inoculated subcutaneously with serum are not liquefied, litmus milk is slowly
repeated small doses of cultures of monilias often decolorized, the decolorization starting at the bottom
develop agglutinins in their blood, and these are to of the tube. No clotting. This monilia produces
a certain extent specific, viz., the inoculated rabbit ^ acid and gas in glucose and levulose, acid in maltose,
develops a distinct amount of agglutinins only for the galactose, saccharose, does not ferment lactose,
species with which it has been inoculated. It would mannite, dulcite, dextrin, raffinose, arabinose, adonite,
seem from the experiments made— which, however, I inulin, sorbite.
consider far from being complete—that the classifica- Origin.—Isolated by me in three cases of sprue.
tion data obtained in this way correspond broadly Monilia facalis, Cast. 1911.—Grows abundantly
to those obtained by the action of the organisms on on sugar media, giving rise to white colonies which
milk, gelatine and sugar broths. soon coalesce. Milk is rendered first slightly acid,
Description of Certain Species of Monilias found in then alkaline, gelatine not liquefied. Serum is not
Cases of Sprue.—In previous papers I have given a liquefied; a dark pigmentation often develops on the
description of numerous species of the genus Monilia surface of the medium round the growth; this
as found in stools, sputum, &c., in tea dust, in copra pigmentation may be lost in sub-cultures.
Oct.15,1914] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 307
TABLE II.—' TABLE SHOWING MONILIAS SO FAR FOUND, WITH NAMES IN ALPHABETICAL ORDER.
o
eo
©
©
©
M. tropicalis, | Aor | AG | AG | AG AGS/AGS| O 0» 0 1C}0}+/0/ 0B |O.., .
|
Cast. 1909 |
Clo 4o 0 oli "
= T © | S - 3 Eje |
= = E 3 E s e as |3| * = 5s |sl B Jel & |elyZlzis BE 2/;3|9|/3
= 2) 2/4 5 g' m oh a [3 e|S|s| à E ITE ES,
| à il iof fad d dd ad c E e JE i "qr MEER
| a
— i | EI T1202 1 ~ ‘ "1 sci du FID. xL
M. albicans,| AC | AG |AGS|AGS| AG | AVSI 0 O [0] o 0 0 |0| O |0|CTP/C|0/+/4+/] +510 Ia pe
Robin. 1853 | |
M. asteroides, | AC A A A A A A A O| A A 0 (OLoGstAl "P^. (Oates | | heel ates
Cast. 1914 | |
M. blanchardi,| AVS |AGS| A | A | AlAlQO 0| o | AS| O |OJAVS|O| C |C|0|+|0| O |O e| onde
Cast. 1912 “AIK | | |
M. bronchialis,| O AG | AG | AG 0 |AGSI| 0 0 |0| A | O 0 10| O |0| C |C/0/]-4[0| 0 JO estos
Cast. 1910
M. burgessi,| O |AGS| A |AGS| A |AGS| O | 0 |0| o 0 0 |0| o |0| C |C|0|+|0|0B |O|..| exl EA PF
Cast. 1912 Aik | | | |
M. chalmersi,| AS | AG | AG | AS |AGS| AG! 0 0 10| O AS| O j|Oj[AGSI|O| C |C/0/4+/0/ O |90}..| EE sales
Cast. 1912 Alk |
M. decolorans, | DFC | AGS| AG | AGS| A A} Ot 5 [0| A 0 O |0| o |0| € |€C/0/|2|0, 0 |0/0| 0.|0/0/|AJO
Cast.avd Low | Alk
1913 |
M. enterica,| O0 AG | AG | AG | AG | AG| 0] ASJO|AS)| O O 10| o O| C |C\O}+/0} o |0].
Cast. 1911 Alk | | |
M. fecalis,| A AG | AG | AG | AGS AGS! 0 0 |Ol O 0 ò 10} o [0| C |C/O0lJ--|0/ OB |0]. Je. -
Cast. 1911 DPS | | | |
M.guillermondi,, O AG |AG|AS| A [AG | QO 0.0/0 /|AGSI| O 10| O JO|CTP|C\9/+/9} O |O PESE
Cast. 1910 Alk |
M. insolita,| AS | AG | AG | AG | AG| AG| 0 | AS |OI! 0 0 0 |0| O |0| C /|C/0j]-2-0| OB |O efe
Cast. 1911 Aik | | | |
M. intestinalis, | ADS | AG | AG | AS | A | A | 0] o Oo | O |o 0| O |O| C |C|O0|+|0| O |O ELEME
Cast. 1911 |
M. krusei, Cast. 0 AG AG 0 0 0 0 0 |O! O 0 o |0| 0-10] O |C/0/--|0| O [0] ap,
1909 | | || |
M. tustegt,| AS A AGS/AVS| A |AGS| O 0 |0 . A jAGSI| 0 VOl O TOt C 1010+00 0B /0}.. ete
Cast. 1912 D | |
M. negrii, Cast. | AVS | AG | AG | AS |AGS| AG | 0 0 10) Q0 JAGS! O /O) O*'IO| O 1C1.01+101 0 i BP) pe sr
1911 Alk |
M. nivea, Cast.| 0 | AG | AG |AG | AG |AGS 0| o [0| o | aG| o |O| o |O| C |cloj+jo| o jo
1910 Alk | | | NN | |
M. nitida, Cas. | A | AG | AG} A A A de tu lo AVS AS |} O |0| O 0| CTP OOO} 0. [01]. as [ne [o olea
1910 DG | | | ji | | | | | | |
M. paratropi-| AS | AG | AG | AG | AG | AG | O| O |O,AVS| 0 0 |0| o |[O|CTP(C/O|--|O| O o|..| TE COSE
calis, | Cast. | Alk | | | | |
1909 | | | PA | | |
M. perryi,Cast.| AS | A AGS} A | A |AGS| 0| O |O O | AS| O [OL AVS|O| C |C|O0|+|0| O |O|.. led
1912 | DAIk | | | |
M. pinogi, Cast. | O AG|AG|AG | © | O Oo} sO l0] 9 0 © |0| © /|0, © |0/(0j|/0, O s Messe
1910 | Pd
M. pseudotropi- | ACS | AG | AG O0 |AGS| AG | AG) O 10] O 0 o [dl [9| @ [Oo 0; 0 |0 £5 or]
calis, Cast. | | | |
1909 | NN NM, MEN m
M. pulmonalis, | O AG | AG | AG |AGS| AG | O|AVSIJO, O A |AGS|O| O |O, CTP,C/0O)-,0/ OB |O ..
Cast. 1911 | AlkD | | | | | | l|
M. rhoi, Cast. | AS | AG | AG | AVSIAGS| AG | O 0 |0, O 0 0 0| 0 |0| C “10 -H[0,; O }0|..
1909 Alk | e* NS |
M. rotundata, | AC A- P E T OE a Or ea 3 UT 2 0 0 jO; O jO) C |Cj0|-|O| O JOj..| .. ......-
Cast. 1911 | | | Zi
M.rugosa,Cast.|| A | AS| AS| A8 | ABS | AS| O | o jolo |o | O jolo jol C | jol+lo o jol. =.
1910 PSOS | | | | |
C
V
|
0
0 | | |
M. zeylanica,| AOS | A | A A |A A |AS| O |0| A JAVS| O |[OL, AVS | O
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, 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, or serum, as the case may be, + = positive result, liquefac-
tion of medium; F = fine.
308 THE JOURNAT. OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1914.
i
oe |
^
at View
Wwe
^
>
-
Monilia rotundata.
(Glucose agar.)
Monilia asteroides. (Glucose agar.)
Monilta asteroides.
Fresh preparation from a
glucose agar culture.
Monilia intestinalis. Fresh preparation from a
glucose agar culture.
Oct. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE..
309
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
Fresh preparation from a
glucose agar culture,
Monilia rotundata.
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.—Ilt 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, mieroscopically 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
(3) As I have stated since several years, there is' à
plurality of species of such fungi, and the term
M. albicans has been used in the past to cover &
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 occasional 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. Srrona, M.D., B.C., D.T.M. H.Camb.
Late Acting Chief. Medical Officer, Papua.
THE following account 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 occurs 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 scale 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 lb.; sugar, 4 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1914.
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
cases 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 infection 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 1b.;
biscuits, 3 lb. ; sugar, 1 lb.; meat, 2 to 3 lb.
They also get & small quantity of tea and are
always able to purchase small amounts of other food.
The indentured labourer gets all his pay in & 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 modern
view that beriberi is due to a deficiency of a special
substance (vitamine) in the diet. The Purari natives
livein à 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 cases 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;
o —
* 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
couutry. 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 & 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 character
and with an equal interval between the two sounds.
Death usually took place within twenty-four hours
and was never delayed seventy-two hours. (Edema
did not occur. At that time I regarded beriberi as
essentially & chronie disease, and was very doubtful
if the above were really beriberi. Now I rather 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 & native, working on a
recruiting vessel, was brought to me with acute
symptoms much as described above. The food
deficiency (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 cardiac nerves were seriously involved,
but not permanently injured, and that recovery took
place as soon as the requisite vitamine was supplied
in the milk, &c.
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, hiccough, 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 otber 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 case of the “ wet” form with marked oedema.
In New Guinea multiple peripheral neuritis follow-
ing an attack of bacillary 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 JOURNAL OF
Tropical gDebtcine and Hygiene
OCTOBER 15, 1914.
SCARCITY OF FOOD IN WAR.
THAT a scarcity of food in Kurope 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 &s 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 1s killed. The effect of any tough meat in
producing indigestion, cramps, diarrhoea 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, und consume it freely when it is found.
-— — — --- — - —- — cne —— ml —— 2 s - we — — o L - - ot
Oct. 15, 1914.]
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 all kinds. Cholerain an army, in addition
to the insanitary conditions which obtain, attacks
the ill fed and fatigued to & 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 &nd 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
difficult 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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.
———— A ——— ———
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; 25 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 84 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 (ls. ld. 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 —
96 7 per cent. were clean or nearly clean.
333 ^ » fairly clean.
78 Be „ distinctly dirty.
1'9 T » 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
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 Pyopneumothorar. — R. Blanchard
(Bulletin de Académie de Médicine, Nos. 26 to 28)
describes the case of a robust countrywoman sud-
denly attacked with pleuritic pain; on puncture fæœtid
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 syinptoms may recur even after the removal
of the appendix.
i ——
Abstracts.
SEGREGATION AND KALA-AZAR.
By W. McCOMBIE YOUNG.
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 communication which the inter-
position between these two districts of the Mikir Hills
presents and possibly also by the action of the district
officials 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 eertain 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 discase might not assume epidemie 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 public 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1914.
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 à minimum distance of 50 yurds 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 eautioned 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 perbaps worth residing 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 primå 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 ard 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.
subjoined figures, to some extent confirms our belief
in the usefulness of these measures.
1900 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.—Zndian Medical Gazette,
August, 1914.
Kvla-azar mortality in Nowgong
TSETSE-FLY AND BIG GAME IN SOUTHERN
RHODESIA.*
By RuprERT W. Jack.
IN Southern Rhodesia conditions are better than
in most other parts of Africa for gathering informa-
tion concerning 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 Kuropean 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.
315
— o —
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
geveral herds of warthog, and one herd was lyihg 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 sueculent 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 thiekly 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 & 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
ee + -———
——
European. The only attempt at & 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. As a 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
destruction of the bulk of the game by rinderpest is,
of course, a 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 a 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 district 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 & 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Oct. 15, 1914.
on the verge of extermination. Concerning the factors
controlling the situation we are altogether ignorant.
In the Sebungwe district & 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, still 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 is that 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
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
sulted 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, hywnas, 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-—Felidw, Viverrid#, Mustelidie—
are also practically nocturnal, and from their alert
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Oct. 15, 1914.
and aetive 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 eonnection 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
ease 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 sufficient
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 that
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 Stomorys, Hematopota, Tabanus, &c.,
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 Hippoboscidx, 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 forshooting. 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 tly 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 tsotse at that time—it is quite certain that in
320
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 thé 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 ary 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.
——— S, ——————
ai cbietos,
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., &c. 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE
(Oct. 15, 1914.
——
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 ozeena, including some notes on Friedlànder'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, 1f 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]
pee
Original Communications.
THE METEOROLOGY OF MALARIA.
By MarHew D. O'CoNNELL, 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. 598, 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 Adinissions per 1,000
1904-5 ; a .. 162
1905-6 .. zd e» se 12T
1906.7 .. da T .. 287
1907-8 ss aa £s $4 312
1909-10 .. -€ bx .. 183
1910-11 .. ee X .. 202
1911-12 .. x is .. 148
1912-13 .. iu vs .. 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 :—
HosPITAL CASES OF MALARIA AMONG EMPLOYEES.
Month Total cases Number of employees
July 1,037 48,714
August ju 919 50,305
September PA 433 50,948
October - 301 50,103
November bh 272 52,539
December ah 376 53,810
January NM 499 52,142
February T 591 55,333
March e 433 56,258
April e 231 59,771
May os 177 59,771
June zu 237 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 21, Vol. XVII
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 atmospheric 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, z.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. 244).
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
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. Nevican, 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 ease 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 case of the kind with which I have met in eight
years, and I think it on that account worth describing.
The patient was a little Armenian girl, aged 3. She
had had a salek for eight months. There was a huge
foul ulcer 2 in. in diameter covered with heaped-up
Hourly atmospheric conditions
at Ancon, Panama Canal
(Pacific side)
Degice to which body tem
perature was raised by
exposure in the
Lancashire cotton sheds
Atmospheric conditions which
raised body temperature in
the Lancashire cotton sheds
Ten.perature of Relative. Drying Velocity of Temperature of Drying Move- nm
air, F. humidity powerof wind per air, F. power of ment Body teim- Pulse Respira
of air air per hour air per ofnir perature tion
10 eub. ft. 10 cub. it. per in mouth,
Panama Canal, Ancon, ——- ae hour F.
1913. Dry Wet Per cent — Grains Miles Dry Wet Grains Miles —
August 1, loc. a.m. 76:0? 75:3? 96 9:3 8 76:0? 72:0? 20:0 99-4? 88 20
T 9 39 oe ee ee ee 7 ee ee ee ee ee ee
5 3 F 76:0 15:5 97 2:5 7 16:0 12:0 20:0 99:4 88 20
re 4 ae at s T = 7 x se vs lh Vs và
x 5 " 74:0 13:0 97 2:5 TA 74:0 10:0 19:0 100-0 98 22
" 6 AA ate sa at v 8 gi za P sa vá és
35 T 5 78:0 76:4 86 14-0 7 78 0 73°5 23-0 100:0 100 30
339 8 ik) ees oe se ee 6 ee oe ee se ee ee
»5 9 T 84-0 18:5 74 32:5 3) 81:0 {T'O 39-0 100:3 84 25
:: 10 P" - D ae H 5 E - m zx du "
is 11 - 88:0 80:2 66 47:7 5 88:0 11:9 61:0 100:2 104 20
2 12 o'c. noon si ss 5 Ws T T a T uv
, 1 o'c. p.m. 89:0 81:2 66 48:5 5 89:0 19:0 60:0 100 0 108 24
- 2 is te : hg oe 6 ss ead X T ici es
Y 3 is 90:0 82:5 67 18:0 5 B 90:0 15:0 82:0 99:8 94 24
e 4 5 - E - 5 id x a s T $a
a4 Ó "m 82:0 1671 75 29:2 11 82:0 16:0 33-0 2 99:2 88 14
x 6 " a sea gh 13 A ite = = - sa i
k D 78:0 — 756 87 130 j 18-0 13:5 23-0 3 1000 100 30
s a $a es s P 8 - ss s D he -
: : » 770 75:2 90 9:8 8 77:0 73:0 200 & 1001 100 18
af 1 - "S is e ae 7 sa m pe £a T RS
M 11 js 11:0 1072 90 9:8 9 71:0 13:0 20:0 u 100:1 100 18
n 12 5 ss T 7 ae oe oe & - 2.
August 2, lo'c. a.m. 15:0 73:6 92 1:0 8 15:0 69:5 26:6 ‘6 100-2 110 18
19 2 3 IS s d 8 oe . ee <2 ee oe "um
iy ac g 14:0 72-0 92 7:0 7 74:0 70-0 190 & 1000 98 2
ds 3 - js "a a 69A .. - de z m " d
^ 5o. xx 13:0 T1 91 8:0 6 13:5 63-0 245 £ 100-0 90 22
vi 6 - d see bs a 8 - T . = = oe se
^ : n" 80:6 18:2 91 9-0 7 30:0 79:0 21:0 = 99:2 92 28
x f es aime oo a 9 e as is ^ ss ios ou
vs 9 E 870 83:2 82 24:5 6 87:0 79:0 48:0 100:4 108 24
= 10 m ijs i v 6 "T = ene is jn $a
i 11 i 90-0 83:0 12 45:0 T 90:0 19:0 82:0 99-8 94 24
" 12 o'c. noon $3 - us Sh 6| is T Es ee 2s Pi
A 1 o'c. p.m. 91:0 82:2 63 06:5 6l g 900 15:0 82:0 99:8 94 241
i 3 s 85:0 19:5 64 50:2 ;| 88:0 80:0 49-0 100-0 108 16
$3 4 ,) ee oe oe ee 6 ee ee ee oe ee ee
* ; a 82:0 76:2 19 31:7 8 82:0 76:0 33:0 99:2 88 14
2s ) Y = is Vis 5 7] m $5 s S ee vá
if : és 73°0 76:0 89 11:0 8 A 78:0 19:5 23:0 100:0 100 30
29 39 e . ee we T ee eer ae ee ee ova
3 9 T 16:0 19:8 96 3°3 6 16:0 12:0 20'0 99:4 88 20
$3 11 mo 76:0 15:3 96 3:3 6 16:0 72:0 20 0 99:4 88 20
d 12 o'c. midnight Us : M E
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.]
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 aud 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 forin 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 1s 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 pillow 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 fino needle into the
indurated periphery and base of the sore, repeated
two to three times a week. The dose used has
been 1 cg. 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
323
BABESIA OR PIROPLASMA.
By ALBERT J. CuarwEns, 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 :— l
Schizomycetaceae Naegeli 1857.
Genus Babesia Trevisan 1889.
Definition.—Cocci ellipsoidei, longitudinaliter bina-
tim seriati (diplococci longitudinales) in filamenta
moniliformia, pseudodichotoma nuda concatenati.
Arthrospore macrosoms in apice filamentorum
obvenientes.
Etymology.--Derived from the name of the cele-
brated Roumanian bacteriologist. V. Babés.
Species.—(1) B. xanthopyretica 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
& 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. — Hamatococcus Babes 1888 (nec
Agardh); Pyrosoma Smith and Kilbourne 1893 (nec
Péron); Babesia Starcovici 1893 (nec Trevisan) ;
Anwebosporidium Bonome 1895; Ixodioplasma
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.
Patron, W. H. (1895) **'American Naturalist,” vol.
xxix, page 198.
SaAccaRDOo, P. A. (1889) “Sylloge Fungorum,” vol.
viii. page 1051.
Khartoum,
June 6, 1914.
A USEFUL PRESCRIPTION IN CHRONIC
MALARIA WITH ENLARGED SPLEEN.
By James CaNTLIE, 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
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, anemic
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
asa 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 ipecacuanhe 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 2, 1914.
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;
scientifie 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 :-—
R Quinine Hydrochlorid. .. .. gr. v togr. vii
Acid. Arsenosi ds 2a .. gE qe o5 Er sk
Pulv. Ipecac. Co. .. Ex .. gr. lii „gr. iv
Hydrarg. Subchloridi. .. -. ge. 435 5 gr. 2
Fiat pulv. in cachets.
Sig.: One at 11 a.m., end another at bed-time.
Annotations.
Antimony in Dermal Letshmaniasis.— 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 cedema
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 fo recover.
There have been twenty-eight cases since the out-
break of the infection on June 27.
——— 9 —————
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.
Nov. 2, 1914.]
sRotices.
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THE JOURNAL OF
Tropical WDedtctne andhpgtene
NOVEMBER 2, 1914.
— — — — ———— —— —— M ———— —— — —
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
325
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 & 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 sanitatión 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
fields. 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
railway, &c., &e. Soon after commencing training,
however, the news spread that the Native Ármy of
India was on the way to lZurope, 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
"ereeping 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 the members of the
with whieh
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[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.
eee ——
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 vaccines, basing their preparation
on the experimental work I carried 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
inoculating an animal (rabbit) with three different
germs (Bacillus typhosus B, B. pseudo-dysentericus
No. 1 (Kruse), strain of D. 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 1 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 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.
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. Dakt., 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 Medic d Association, June, 1914.
Nov. 2, 1914.]
and B occur, besides typhoid. The advisability of
using such a vaccine is shown by the fact that I have
scen 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 & 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 after
& 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 ($ 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 pupers,
Viz; =<
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
327
—
(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
inoculated 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 a8 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 carbolized 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 2 parts 2 c.c.
Plague »i =s Vus ALIS. M un
Typhoid 5 js er d] ue 5
Paratyphoid A ,, is ssl Eus
Paratyphoid B ,, v5 se doma lias
The mixed vaecine will therefore contain per cubic
centimetre :—
Cholera KA 1,000 million
Plague . “6 - Be "5 nds 250 4, ©
Typhoid Ps Vs bs T 250 ,,
Paratyphoid A T" M - 195 ,,
Paratyphoid B 95 és ps 125 ,,
Method of Vaccination.
The inoeulation is made subcutaneously in the
in the same manner as when using simple
typhoid vaccine. In strong adults I give 1 c.o. the
first time, and 2 c.c. a week later; in adults who do
not appear to be very strong, or in individuals who
arm,
328
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 & 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 & 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 inoculated 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.
Immunization
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
& certain extent agglutination is & rough index for
immunization. The results. are collected in the
tables on pages 399-332.
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 2, 191
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 05 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. wil 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-
tensis. 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
approxunately two thousand million typhoid. The
same technique is used to prepare the paratyphoid A
and paratyphoid B vaccines, each of these being
standurdized to contain one thousand million. The
same technique is used to prepare the Malta fever
vaccine, but this vaccine is standardized in such a
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 is vá 6s .. 600 million
Paratyphoid A T P .. 250 e:
Paratyphoid B T à .. 250 -
Malta fever end . 1,000
Nov. 2, 1914.] THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 329
MM M—————————————————————————————————————————————————————ÉÉÓÉ———.c
TABLE I.—CoMBIiNED TypHOID + PARATYPHOID A + PAaRATYPHOID B + CHOLERA + PLAGUE VACCINE.
(Two inoculations, 1 c.c. the first, 2 c.c. the second.)
Limits of agglutination. Weeks after first inoculation
Individuals Blood tested
inoculated against
| 1 2 4
1/40 . 1/1900 | 1/300
1/20 . 1/300 | 1/250
| B. typhosus
1/200
D. paratyphosus A
=
bo
e
d
—
Š
Kuppaswamy- | B. paratyphosus B
V. cholere i 1/20 , 1/20 1/40
B. pestis .. T 0 1/20 0
B. typhosus ..' 1/40 1/1000 | 1/300
| B. paratyphosus A |. 1/20 1/250 1/250
Perivaswamy 4| B. paratyphosus B! 1/20 1/150 1/80
| V.cholere — ..| 1/20 | 1/800 | 1/200
D. pestis .. s Q 0 1/20
5 7 | S 9 10 11
oe CURES. CERE -~ =- ———— —— | —— ——— | — — + aaan
1/150 | 1/100 | 1/60 1/100 | 1/ 1/40
1/150 | 1/50 | 1;CO 1;/60 | 1/40 1,90
1/100 | 1/500 | 140 1/60 | 1/20 1/20
1/30 0 | O0 0 0 0
0 | 0 0 0 0 0
}
1/200 | 1/100 1/100 | 1/150 1/100 | 1/40
1/150 į 1/100 | 1/40 | 1/60 | 1/20 1/20
1/150 | 1/50 | 1/40 | 1/60 | 1,20 0
1/150 | 1/150 | 1/40 | 1/90 0 0
1/20 0 | 0 0 0 0
TABLE II.—VACCINATION WITH COMBINED PLAGUE + CHOLERA VACCINE.
(Two inoculations, 1 c.c. the first, 2 c.c. the second.)
Limits of agglutination. Weeks after first inoculation
Individuals Blood tested
inoculated | against d
| 1 2
; (| B. pestis d 0 1/20
Tamil coolie No. 3 1, V.cholere — ..| 0 1/40
ee a j . D. pestis | 0 . 1/20
Tamil coolie No. 4 V. choler 1/20 1/40
| B. pestis 0 0
Tamil coolie No. st Vi cholerae 0 | 3/20
3 4 5 6 n
| i l METS ESETE E TE
| ; |
| 0 D ds 2 0 0
140 ; O p = 0 0
120 , 0 0 0 0
1/80 | 1/60 0 1/20 0
0 0 0 0 0
1/80 ; 1/60 1/60 0 1/26
TABLE III.—VACCINATION WITH SIMPLE PLAGUE VACCINE.
(Haffkine— one inoculation of 4 c.c.)
i Limits of agglutination for B. pestis.
Individuals | Weeks after first inoculation
inoculated
1 2]383 4 s elr] a
|
Tamil coolie No. 6 O 1/20 1/20 | 0 |} -- |
Cingalese No.1 0 0 aa tee? cad ae
TABLE IV.--VACCINATION WITH SIMPLE PLAGUE VACCINE.
(Lustig— three inoculations.)
A LEE E LIAC a I II M MM M URN KR I RE NT GEI IU FI ITS TS SISTED)
| Limits of agglutination for B. pestis.
Weeks after first inoculation
[undividuals
inoculated
| are NL Serer mn l -
| l 2 | 8 4
i. 5 | 6
Tamil coolie No. 7 | 0 0 | 1/20 | 1,20 | — 2
Tamil coolie No. 8 0 1/20 . t 1/20 | 0
Tamil coolie No. 9 | 0 0 | 9
ee E MU MU MORE Nol. ME ON
TABLE V..—VACCINATION WITH SIMPLE PLAGUE VACCINE.
(Carbolized —two inoculations: 1c.c. the first, 2c.c. the second.)
| Limits of agglutination for B. pestis.
Weeks after first inoculation
Individuals inoculated
Cingalese No. 2 T sek Oe 0
Tamil coolie No. 10.. ~» | 1/20) 1/20|1/20) O {1/20} O | O
TanLE VI.—VACCINATION WITH SIMPLE CARBOLIZED CHOLERA
VACCINK.
(Two inoculations: 1 c.c. the first, 2 c.c. the second.)
OR ERU NT ED EES a ECY C NELGUII——IvAE RC NGN COMMI T CN CU E ETT EN CHA LE
| Limits of agglutination.
| Weeks after first inoculation
Individuals inoculated IN
——— ne — A M— —— — | e ee-
|
Tamil coolie No. 11 1/20 1/40 ! 1/20 | 1/20| 0 0
— —— -| —— —
|
Tamil coolie No. 12' 0 | 1/40 | 1/40] O | 1/20
— | 1/60 | 1/20
Tamil coolie No. ad 1/20 | 1/80
330
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
TABLE VII. —VACCINATION WITH SIMPLE TYPHOID VACCINES.
(Two inoculations: 0°6 c.c. the first, 1:2 c.c. the second.)
Individuals inoculated
| Limits of agglutination for B. typhosus.
' |
2 3 4 5 6
Weeks after first inoculation
1 7 S | 9 |
ISen vm — — cr dn T REI ERE a ee ten demeure en —— — | —_- —_—_——S — — —
i !
Cingalese No. 3 (carbolized vaccine) 120 1/800. 1/300 1,200 2;7200| — '1/100| — | 1/060 1/60. 1/60
| | |
Cingalese No. 4 (ordinary heated vac- 1/20 | 1/500 | 1/500 . 1/200 M 1/150 | 1/150 | 1:150 | BN — 1/60
cine}
| | i | i
TABLE VIII.—VACCINATION WITH SIMPLE PARATYPHOID A VACCINE.
(Two inoculations: 4 c.c. the first, 1 c.c. the second.)
|
Limits of agglutination for B. paratyphosus A. Weeks after first inoculation
Individuals inoculated
1 2 9 : 4 5 6 7 | S 9 10 ll
; : = aac ae ee EAN — eee etree Seen eee eee
Tamil (Singho) ' 1/20 1/80 | 1/20 | 1/40 | 1/60 | 160 | 1/60 | 1/60 | 1/40 | — 1/40
Cingalese (Wellar) O 1/100
[Nov. 2, 1914.
(1/100: 1,00 | 1/60 | 1/80 1/80 | d 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 L. peratyphosus B. Weeks after first inoculation
Individuals inoculated |
i
i | l | 7 l
1 2 3 4 5 6 7 g | 9 | 10 | 11
| |
2 = EEE cup re: Ain ME Lee i Sole Neel eee eee
: | | i
Cingalese (Asson) .. 0 | 1/80 1/60 1/60 1:80 | 1/60 | 1/20 , 1/20 | 1/20 ge | 1/20
! | | | |
Tamil (Karuppen).. |. 0 | 1/20 1/80 1/80 | 1/60 ' 1/20 | 1/20 | 1/20 0 | 0
TARLE X. — VACCINATION WITH ''TyPHorD + DPaRATYPHOID A + PARATYPHOID B + MALTA 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
Individuals Ag inati
aeaii Agglutination for , | | |
| 2 | 3 4 ) 6 | 7 g
DDOE See a a T: EE BE NE REO ha lS ig Acai tac uc
| B. typhosus.. is 0 1/400 1/400 | 1/400 1:200 : 1:200 1/150 1/150
Ha ' D. paratyphosus A 0 1;200 | 1,150 1 150 1/150 — 1;100 | 1/100 1/100
"(c0 B. paratyphosus B 0 1.300 1/100 ] 100 1:100 1:80 1/80 1/80
| Mf. melitensis 0 1:30 | 1/40 . 1;100 | 1;150 1/80 | 1/100 | 1/100
| |
í |, D. typhosus.. T 0 1/600 | 1/500 , 1,500 1/300 , 1/200 | 1/200 | 1/150
Wellan No. 2- | D. paratyphosus A 0 1,209 1/200 1/100 1/100 | 1 Bü 1/80 1:80
. ! D. paratyphosus B 0 1,200 | 1/150 1/109 1/100 | 1/100 1/80 1-50
| M. melitensis 0 1/20 1/60 180 | 1/100 | 1/100 | 1/80 1/80
|
Nov. 2, 1914.]
Of this vaccine 0'5 to 0'6 c.c. is injected subcuta-
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 D 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.)
Limits of agglutination for M. melitensis.
Weeks after Hirst injection
Individuals inoculated ` : ]
O | 1.20} 1/40! 1/60 1/80 ' 1/80 | 1/60| 1/60
?
Suppen (Tamil)
(
Mr. S. (European) O | O |1/40|1/120| 1/150, 1/100) 1/80] 1/100
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
331
stated in previous paragraphs and standardized as
follows :— |
Typhoid .. 2,500 million per cubic centimetre
Paratyphoid A .. 1,000 T T »
Paratyphoid B 1,000 p » T
D. asiaticus 1,000 » » »
B. columbensis 1,000 ” » »
These vaccines are mixed together in equal parts so
that each cubic centimetre of the combined vaccine
will approximately contain :—
Typhoid .. .. .. 500 million
Paratyphoid A .. N "T 200 5
Paratyphoid B .. 200 j3
B. asiaticus i 200 i
B. columbensis .. 200 :
Of this combined vaccine 05 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.
TaBLE XII.—TvPHoID + PanaTrYPeHOID A + PaRATYPHOID B + MALTA FEVER + B. columbens s +
B. asiaticus.
(Two inoculations: 0'6 c.c. the first, 1:2 c.c. the second.)
Individuals inoculated Agglutination for ls
Paratyphoid A
Paratyphoid B
| Malta fever... A
Subetheris (Cingalese)
B. columbensis
B. asiaticus
Typhoid :
Paratyphoid A
Paratyphoid B
Malta fever
B. columbensis
B. asiaticus
Mr. D... (European)
bá
Ocooococouwcocoooooc
e
Limits of agglutination. Weeks after first inoculation
2 | 3 | 4 | 5 | 6
|
|
1/600 1/5CO | 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
1320 | 1/20 1/80 1/100 1/100
| 1/100 1/100 i 1/80 1/40 0
1/80 1/100 | 1/100 1/80 1/60
1/500 1/500 = ae 1/400
1/400 1/400 za: e 1/200
1/400 1/400 in | 1/200
0 120 x E 1/80
1/150 1/80 = 0
| 1/300 1/200 Mis "= | 1/60
COMBINED “ TYPHOID + PARATYPHOID A + PARA-
TYPHOID B + B. columbensis + D. asiaticus”
VACCINE.
There being in Ceylon cases of fever due to 7.
columbensis and B. asiaticus, I have prepared a com-
bined vaccine containing these two germs also. This
vaccine consists of an emulsion in carbolized (4 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. colwmbensis
V ACCINE.
(Two injections : 0:6 c.c. the first, 1:2 c.c. the second.)
EE ET ES LE IDOE TE a I a ITT GEI ROMA C ITI DU RE DE ELEME
: Limits of agglutination, Weeks after first injection
Todividual inoculated Ne ee eee x VOR RES
a | 2 [ox Xd e a
pP FH) ial pont xut aie ey
Tamil Coolie No. .. | 1/20 | 1/100 | 1/80 | 1/80 | 1/40 | 1/20
Tamil Coolie No. .., 0 1/100 ! 1/100 1/40 | 140 | ©
| :
!
332
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 2, 1914.
COMBINED “TYPHOID + PARATYPHOID A + PARA-
TYPHOID B + M. melitensis + B. columbensis
+ D. asiaticus ” VACCINE.
This vaccine consists of an emulsion in carbolized
(+ 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 cubic centimetre :—
Typhoid . ; ja .. 2,400 million
Paraty phoid A. 2 .. 1,000 Gs
Paratyphoid B . .. 1,000 ‘3
B. asiaticus 1,000 ^"
B. columbensis .. 1,000 és
Malta fever 4,000 i
These vaccines are inised in p parts. The
combined " six diseases " vaccine will therefore con-
tain per cubic centimetre :—
Typhoid .. Ss T 400 million
Paratyphoid A .. id .. 166 ,, (about)
Paratyphoid B .. 2. a 166 » -
B. astaticus "T - — 166 o
D. columbensis .. a SA 166 2
Malta fever oy 666 -
I have md numerous persons with this
combined vaccine, 0 5 to 0'6 c.c. the first time, and
1 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 D. columbensis
were produced in fairly large quantity but soon dis-
appeared. This, however, is apparently the case
also with control individuals inoculated with simple
B. columbensis and B. asiaticus vaccines.
TABLE XIV. —VAGCINATION WITH SIMPLE B. asiaticus
VACCINE.
(Two inoculations: 0*6 c.c. the first, 1:2 c.c. the second.)
Limits of agglutination for B. asiaticus.
Weeks after first infection
Individual inoculated
1/20 | 1/200 | 1/150. 1/100 | 1/80
Tamil Coolie No.
1/60
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-baeillus, & 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...
Paratyphoid A bacillus 1
Paratyphoid B bacillus fe ul
Shiga-Kruse bacillus iet T 1
1
4,000 million
,000
,000 9
000,
,000 93
,000 39
Flexner bacillus
Hys Y bacillus
Flexner-like No. 1. 1,000 n
Flexner-like No. 2 . 1,000 $5
These vaccines are unen in NER parts so that
1 e.c. of the mixed vaccine will contain :—
Typhoid zs T - bi 200 million
Paratyphoid A T - m 125 — ,,
Paratyphoid B = ei s 125 24
Shiga-Kruse cs T K 125 "
Flexner ET ER i oe 125 see
Hys Y 5 - 125 5
Flexner-like No. 1 . " - 125 33
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 1'2 c.c. after & week.
The reaction is somewhat severer as & 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
($ 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 cubic centimetre :—
Cholera ae ES .. 4,000 million
Plague p e m .. 1,000 2
Typhoid 2s .. 1,000 ,,
Paratyphoid A 1,000 ,,
Paratyphoid B 1,000 ,,
Malta fever .. 4,000 "T
These vaccines are | hecether: in the following
proportions :—
Cholera .. vaccine 2parts .. 2c.c.
Plague .. T bae UA iun Ku. as
Typhoid "Y " Vue e ons vy us
Paratyphoid A.. .. lpart .. 1 ,
Paratyphoid B.. 5 vv ob. 3 ev d 3$
Malta fever M .. 2parts .. 2 ,,
Nov. 2, 1914]
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.
RÉSUMÉ 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. asialicus + 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-
tvphoid A + paratyphoid B vaccine.
(9) Cholera + plague + typhoid + para-
typhoid A + paratyphoid B + Malta
fever."
(3) The inoculation 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 vaccines 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. carbolic 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
333
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
case 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.
- (1909). Centralblatt für Baktertologie.
» (1909). Transactions of the Bombay Medical
Congress.
» (1912). "Transactions of the Society of Tropical
Medicine.
n (1913). The Lancet.
British Medical Journal.
Centralblatt fir Bakteriologis.
——— $9 ————
BURMA RICE.
Although Burma has only ten million acres under
rice, as compared with fifty million acres in Bengal,
i& 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 &nnum, 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. McKerral 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,
Foobs AND OTHER SUBSTANCES. By J. E.
Purvis, M.A., University Lecturer in Chemistry
and Physies as applied to IIygiene and Public
Health, St. John's and Corpus Christi Colleges,
Cambridge, and T. R. Hodgson, M.A., Publie
Analyst for the County Boroughs of Blackpool
and Wallasey, formerly of Christ's College,
Cambridge. Demy 8vo. Pp. vin. + 228.
Cambridge University Press. 1914. Price Qs.
net.
This book is one of a series about to be brought
out by the syndics of the Cambridge University Press,
upon a scientific basis, owing to the increasing
importance of the study of hygiene and various
matters connected with public 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 effluents,
foods, disinfectants, &c. There is no doubt that
analysts and others engaged in public 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 eflluents. The whole question is
gone into very carefully and exhaustively, a con-
giderable 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.
BrvnsATI. Memoirs of the Department of Agriculture
in India. Major J. 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 research work which
lead him to believe that bursati is a mycosis due to a
sporotrichum in that it closely resembles the sporo-
trichosis of horses and mules described 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 feilocks 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 insuflielent. 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 hand,
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. beurmani,
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
evidence before definitely placing this disease among
the sporotrichoses.
H. G. ADAMSON.
—— i ——————
Motes and Mews.
DROITWICH.
AMONGST Anglo-tropical 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 & 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 1s desirable to bear 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.
Nov. 2, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
335
I M HÜÜ À "ANM ERMMMMÜÜÜÓ€ MEE
——————————————————————————————M————————————————————————M——————————
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 has been 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 eooked 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 produets 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, which 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
& 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 & 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.
£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 oflicers 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 pneumonie 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 ease 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 thc
presence of an extremely acute septicæmic 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-
emia. They are satisfied that this was an instance
of a septicemia 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
subject the local reaction of the tissues and the bubo
may prevent the extension of the bacteria, especially
336
——————————— aM
if the dose is small and the septicemic 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-
semia once develops it is evident that the internal
organs will be affected in much the same way as they
are in pneumonic 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 bacilli 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 overcrowded 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.
————— Sá —— —————
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 idiosyncrasy 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 hypodermics 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 2, 1914.
Personal Rotes.
CoLONIAL MEDICAL SERVICES.
West African Medical Staff.
Dealhs.-—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.
tarstin, 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., 13.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.C.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. Hüuschell, M.R.C.8.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. S. 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. 8. 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. & S.Ire,,
Sierra Leone.
Other Colonies and Protectorates.
J. R. Dodd (Colonel, R. A. M.C.) has beon selected for appoint-
ment as Medical Officer in charge for Ankylostomiasis work in
Trinidad.
C. G. H. Campbell, M.R.C.8.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. S. Taylor, M.R.C.S. Eng., L.R.C.P.Lond., M.B., B.C.
Cantab., has been selected for appointment as & 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 Modical 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.
—— i —
ERRATUM.
INADVERTENTLY the name of Dr. H. Harold Scott
was printed as H. Harold Salt on p. 953 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. MoCoNNELL, 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. zethiopica, 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 192 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
13 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
ceecally. The vulvar orifice is placed externally to
the papille. 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 papille.
The embryo is a short flattened body some gs in.
long and about bv 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 antenne,
the anterior the longer, and both acting as natatory
organs; (3) & 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 adults are in the
found
338
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, & 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,
+ 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 16, 1914.
into the adult worms. No other mode of infection is
now countenanced by investigators.
Manson has indeed reported that four European
officers, 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 cm. 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 & 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 set up by virtue of its qualities as a foreign
Nov. 16, 1914.]
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 & 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 & month later,
although there had been & 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 & 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, 1913, 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 $ 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 & small sore, surrounded by painful
extensive inflammation, appeared on the other leg,
near the ankle. He attributed this to an infected
scratoh, the onset being so dissimilar from that of the
other Guinea-worm that the idea of its being & second
one was dismissed. He could not put his foot to the
ground. The inflammation on rest subsided, leaving
a crater-shaped depression, at the bottom of which
a Guinea-worm presented. In the course of a week
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
339
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, hut 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 & 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
occasion 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 wil 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 eannot hope to induce native communities to
adopt such radical measures.
Fortunately, simply straining through cotton is
effective, and tbere 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 asafcetida
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. l
CASTELLANI and CHALMERS. ‘‘ Manual of Tropical Medicine,’’
CLEMOW. ''The Geography of Disease,’ 1903.
CoBBoLD. ‘‘On Human Entozoa.”’
Davipson. ‘‘ Tropical Hygiene.”
DupGEon, L., and CHILD, F. J. JOURNAL OF TROPICAL MEDI-
CINE AND HYGIENE, August 15, 1903.
FAULKNER. Brit. Med. Journ., 1888.
Fox, F. ‘‘ Skin Diseases.”
GraHaM, W. M. JOURNAL oF Tropical MEDICINE AND
HYGIENE, December 1, 1908.
Idem. Brit. Med. Journ., 1905.
Lereer. Brit. Med. Journ., January 6, 1906.
Idem. Ibid., January 19, 1907.
LEÉuckKART. ‘‘ Die menschlichen Parasiten,’’ 1876.
Manson, Sir P. J. Brit. Med. Journ., July, 1908.
Idem. ‘‘ Lectures on Tropical Diseases," 1905.
Idem. ‘‘ Tropical Diseases."
NEevEux. Rev. de Med. et d' Hyg. trop., 1908.
PowzgLL. Brit. Med. Journ., January 9, 1904.
Roux, F. ''Maladies des Pays chauds."
SIıBERRY, Capt. E. W. Journ. Roy. Army Med. Corps, 1904.
re ef —À
Nov. 16, 1914.)
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
341
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THE JOURNAL OF
Tropical Medicine 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 & 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 4nd on the high-
w&y of the Mediterranean affords opportunities that
render it & 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 & 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. l
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.
——— —p— ——
Arunotations.
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 $ gr. of quinine and urea hydrochloride
compound. The points to be noted are: (1) A $ 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 cases 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 rodentwum,
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. Ina 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.]
E — — —— a,
-—— o o—— —À— e — 9
^ Abstracts.
TL
H#MORRHAGE LATE IN TYPHOID FEVER.
By BRAILLON AND Bax.*
WE distinguish this disease from intestinal hemor-
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 28 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 lin 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 hemorrhage
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 hsemorrhage from the bowel. The
patient was in & 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 cc. 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
hematemesis 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 Hóp.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
343
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
given. 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 hemorrhages 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. HaAwrHORNE, 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; no 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 2: Symptoms of " Colitis," in a Woman, aged
28, due to a Malignant Growth in the Rectum ;
Abdominal Examination Negative.—4A woman, though
only aged 28, was the victim of & 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 3: Diarrhoa 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.— À 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 settled 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 physical 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. Brrp.
THE level of the subphrenic 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., & 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
syphilitics 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 will 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.
Nov. 16, 1914.]
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 a 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 lymphatic 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
hsemorrhage 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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
subcutaneous 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 tube to 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 manceuvres, 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-
cumspectly, and, boring through the hepatic 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 anssthetized 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 eysts, 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 areu
behind, by possible help from the screen, and by the
presence of an eosinophilia. Fortunately, in addition
346
- — + ET —— —
to the chance of & 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 Jower 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 sequelg 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.
Pyogenic infections of the subphrenic space are
difficult, 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.j., 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-
HE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Nov. 16, 1914.
—————— —À ———— M———————MM——————M—————M -——
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
anatomical 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 umbilicus, 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
a very septic case I 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
& number of pathological conditions which cause
invasion of its integrity by simple direct extension,
but it may be caused, l believe, through infection
carried by the portal system ; thus the case of & 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 fully
developed abscess wil 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 & 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 neglect 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.
Either 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, & 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.
947
——_
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 oover 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 Montgomery H. SicARD, 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 larvas in
the centre of it. H. Williams, of Buffalo, found
trichina in 51 per cent. of 505 indiscriminate
examinations.
* From the Medical Record, August 15, 1914.
THB JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Nov. 16, 1914.
—————————————————————M—————————————
Hotes and Sens.
INFANT DEATH-RATE IN BURMA.
IN Burma during the year 1913, 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 ;.
(9) 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
cysts 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)
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-
ease, which are freo 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 & 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. Asa 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 trichinæ, 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
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.
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.
—————————
ebietv.
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:
THEIR COMPLICATIONS AND TREATMENT. By
Colonel Louis A. Lagarde, United States Army
Medical Corps (retired). London: John Bale,
Sons and Danielsson, Ltd., 1314. 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 precige, 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.
The rules also explicitly:
How THEY ARE INFLICTED,
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:
& 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.
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 & distinct need. Practitioners
obtain a fellow-practitioner’s view of recent physio-
logical investigations. Still more valuable, it gives
THE
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.
2?
Drugs and Appliances.
Lactic Acid, in the treatment of erosions of the
cervix uteri, cervical or vaginal leucorrhaa, 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
baeteria flora is changed to one of a fermentative type.
——— iie
Correspondence.
INTRAMUSCULAR INJECTION OF QUININE.
To the Editor of Taz JOURNAL oF 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
McGrigor gave him hypodermics of the same salt
three times a day for two days, and then one injec-
tion daily for a 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 the 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 ≪ 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 injections are really beneficial. Proof of this
can only be obtained after a most searching investiga-
tion of a large 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
—because 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.
——— $9 ————
Personal Motes.
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.8., 8 m., M.C. ;
Lieutenant-Colonel H. B. Melville, I.M.S., 4 m., M.C. ; Major
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Dr. G. R. T. Ross; Lieutenant-Colonel H. E. Drake. Brockman,
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S. E. Prall, I.M.S.; Lieutenant-Colonel J. H. McDonald,
I.M.S. ; Captain A. A. M. Neight, I.M.S.
List oF INDIAN 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.8., 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 Inpian Civirn 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., I. 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., I.M.S., M.S.
Robb, Major J. J., I. M.S., Ms. Jails Dept.
Dec. 1, 1914.]
———À MÀ a Se — —— —
Original Communications.
THE SO-CALLED PLASMODIUM TENUE
(STEPHENS).
By ANpREW Barroun, C.M.G., M.D.
Director-in-Chief,
and C. M. Wenyon, M.B., B.S., B.Se.
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 & careful study of
his paper we must confess that we are somewhat
surprised that so distinguished an ,authority on
tropical medieine as Dr. Stephens should have com-
mitted himself to such & 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 amceboid 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 Wellcome Tropical 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 2 23, Vol. XVII.
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 amceboid 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 amoeboid
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 amoeboid activity,
and the latter by a want of it. The degree of
amoeboid 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 & 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 assume, as we seem justified in
doing, that the amoeboid 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 techniquo, 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
he describes always assumed the amachoid 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 if 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
Erotique of November 12, 1913. Mention is here
made of Billets and Ziemann's descriptions of
curious forms of the quartan parasite, and attention
is ealled 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, as in Dr. Stephens's case.
The film exhibits amcboid forms in large numbers,
and a reference to Plate II À will show that
they are identical in every respect with those
figured as P. tenue by Dr. Stephens. In addition
to the amaboid 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 case was one of
sub-tertian malaria due to P. falciparum, the young
parasites of which are particularly amoeboid for some
reason not clearly understood.
The second ease 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
(Plate II B, 4th row). Ordinary rings of the sub-
tertian variety were very numerous, and, in addition,
there were present irregular amoeboid 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 case 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 corpuseles showed Maurer's
dots (Plate II B, end of 3rd and 4th rows). There-
fore, in this ease, 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 amoeboid 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. It
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.
—— P Ü—MAÜQ!
ASIATIC CHOLERA.
By Joun Furst McMirzaN, 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 & better position—
from perhaps their longer course of study forced upon
them 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, DECEMBER 1, 1914.
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To illustrate paper, ‘‘ The so-called Plasmodium tenue, by ANDREW Barroun, C.M.G., M.D., and
C. M. Wenyon, M.B., B.S., B.Sc.
Dec. 1, 1914.]
Thomas Watson in Medicine have left on record that
they were in à measure obliged to eschew specialism,
the former specifically when the question of excision
of joints versus amputation of the limb came to the
fore, and the question of diagnosis of disease occurred ;
and the latter general in his. lectures on the
principles and practice of physic. But, at the same
time, Sir Thomas Watson is so far a specialist that
when he comes, or rather should come, to speak of
the plague, he dismisses the matter in a word by
saying that he has not seen a case. So that for one
who has had experience of Asiatic cholera, one must
not look within the British Isles, or in fact in Europe
or America, but to India, the home of the disease.
And there the profession is divided into four classes:
the Indian Medical Service, military and civil, the
Royal Army Medieal Corps, and civilian practitioners ;
and inasmuch as the former service deals mainly with
natives, and the latter is stationary in one place, it
stands that an officer of the Royal Army Medical
Corps, located now in cantonment, then on the line
of march and in camp, in medical charge of European
troops, has a far better opportunity of studying
Asiatic cholera than others.
The occurrence of Asiatic cholera in Galicia,
Hungary, and Austria brings the matter near home,
so that one need offer no apology for writing a mono-
graph such as will be a guide to prevention, diagnosis
and treatment, as concerns a disease that leaves one
little leisure for either when it is actually at hand.
It is a well-established fact that a horse turned out
to grass returns to work with the greater ardour, and
so the author trusts will be his case.
Cholera is endemic to India—hence its name Asiatic
—about the low alluvial country bordering on the
Ganges. By endemic is meant that there is the
. home of the disease, and whatever may have been
its primary cause in the history of the world, the first
recorded epidemic is that which occurred at Athens,
known as the Pestilence, and described by Thucydides ;
and in a measure it is & typical &ccount, although
the great Greek historian lived in the fifth century
D.C.; &nd it is well to remember that he suffered from
the disease himself. The author has translated the
portion of the History, and it reads as follows :—
" In such à way were his! funeral rites carried out
that winter, &nd with his decease the first year of
the war came to an end. At the very beginning of
the first month of summer the Peloponnesians with
their allies divided into two parts, and the first as it
were led by Archidamus, the son of Zeuchidamus,
first overran, then settled down, and ate up the
country. And not many days after their presence
in Athens the pestilence first made its appearance
amongst the Athenians, perhaps it would be better to
s&y broke out on all sides, both around Lemnos and
in other countries. Never before does any man
remember to have happened such a pestilence and
consequent? mortality. At the commencement the
physicians were unable in their ignorance to find a
! Pericles.
* Bk. 2. Secs. 47 to 53 and part of 54.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
eure, but themselves’ died in great number, and so
fast as they came forward, nor was other human skill
of avail, so that they thronged to the temples in
supplication, or sought comfort in their need from
philosophies and such like; all without profit; until
at last they desisted from them, conquered by the
scourge.
"It came, in the first place, it is said, from Ethiopia"
by Upper Egypt, and thence extended down to Egypt
and Libya, and so to the country of the Great King.‘
It suddenly addressed itself to the city of Athens,
and in the first place fastened on to the maritime
population of the Piræus,” so that it was said by
them that the Peloponnesians had poisoned the wells,
for they were no longer sweet. Next it reached the
upper city, and there died many more, rapidly. So
it was concerning it that each knew, both physician
and layman, what likelihood there was of its happen-
ing to him, and considered, whatever the causes were
of this evacuation, it to be curable, and he able to
withstand it. I will speak of such as occurred, and
about what one could see, when and how it seized
one, especially how one having a foreboding should
not ignore it. Such will I make clear as one who
has been smitten, and as one who has seen others
suffer. The year in which it happened, as all grant,
was markedly free from other sickness, and if there
was any it was quite differentiated from this. With-
out any apparent cause, of a sudden, whilst in good
health, suffusion of the eyes, and cramp seize one.
The intestines, the throat, and tongue quickly become
inflamed, the breath short and ordure is discharged.
Thence, as the result, sneezing and hoarseness are
produced; then as the disease progresses, this is
succeeded by a marked huskiness, and as soon as it
settles in the stomach it turns the latter so that its
contents are cleansed of bile; such as are treated by
the physicians fail to recover, as also those who are
not; under the great bodily suffering a fruitless retch-
ing occurs in most, abating in some at this stage, in
others and the most, continuing longer. And the
body of those lasting on was not very hot, nor was
it yellow, but reddish, livid, carried to the point of a
sore; the inside is parched up, so that altogether the
walls of the gut which is like fine cloth is cast off, so
that they become empty, whilst pleasantly as cold
running water, they empty themselves, and many
careless men run to the water tank, oppressed by the '
never-ending thirst, and it stands to reasor that the
water is polluted and depreciated for drinking purposes.
And the distress of it never keeps away, but lasts
throughout. And the body at such time as themalady
may reach its climax does not wither away, but holds
out against expectation in such misery. So that
most are either unconscious about the ninth or
seventh day from the fever within, still retaining
vitality, or should it escape from the passing of the
3 Ethiopia in the fifth century controlled one side of the
Red Sea, and was in free communication for purposes of trade
with India.
! Persia.
3 Seaport five miles from Athens, with which it was connected
by a fortified wall, open to carts.
356
disease down to the intestines, extensive ulcerations
proceed from it, and the contents of the bowels
running out like pure water, most sink at last
through asthenia due to this. But it may pass
through the whole body commencing from above,
the head being the primary source of the malady,
and if anyone possessed of great bodily strength
happen to linger on, then the disease may attack
his extremities. For it may fall like a flash on the
pudenda, or the extremities of the fingers or feet,
and many of those stricken lose these, whilst to
others the eyes are lost; again others when con-
valescent suffer from loss of memory, and fail to
recognize themselves, others, or even their attendants.
That which we saw of the pestilenee beggars all
description ; it was difficult to deal with and attacked
without distinction all of the human race; and beyond
dispute i& was shown that birds and beasts such as
prey upon man, many of whom remained unburied,
either did not venture, ór tasting perished. The
disappearance of these birds proves the dictum, for
they did not fly away, nor did they vanish in any
other manner ; the dogs also gave man to understand
what was the matter when they made a meal
together. Therefore often, but sometimes not, the
disease presents an extraordinary nature, for instance
anyone may catch it and give it to another, or at
least such was the general belief; and somehow it
cast its sorrow in its own way, 1n obedience to no
custom, as to how it might come, or when it might
cease. Some died without treatment, others with all
medical attendance possible. As concerns it there
was no remedy, so to say, that proved of any benefit,
for if it works well with this man it injures that.
No frame was able to struggle against it, strong or
weak, all were swept away, and every diet was tried.
The most terrible part of the whole malady was the
despondency, so that anyone in the way of sickening
brought the disease upon himself (for when they lost
hope the mind speedily became unhinged, and they
made matters much worse for themselves by not fight-
ing against it) ; one after another they filled themselves
up with medicine,’ and died like cattle, and it did for
most of the debauchees. But still although no one
aware of the danger went near others, lonely
dwellers perished, and houses were wholly emptied
Írom lack of treatment; for those attending perished,
and especially those displaying valour: those affected
dirtying themselves went among their friends, and so
the relations of those about to die, as they were
carried away, were unmanned by their lamentations,
and quite subdued by this epidemic. But above all
those who escaped death and overrode their trouble,
knew by experience what the disorder was, and were
in good heart, for the same person did not suffer from
the disease twice; just as if it were killed, and they
felt themselves blest above all others, and amidst this
present joy nourished a light hope for the future, that
they should never afterwards be attacked by any
disease. The conveyance of provisions from the
' Wine entered extensively into the Greek and Roman
Pharmacopceias,
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
country to the city brought many in contact with
the pestilence when it fell, and the latter did not
spare the newcomers. It did not commence in
private houses, but in stifling huts, at its height in
the middle of summer, it is judged the murrain
obeyed no order. The dead bodies were heaped one
upon another, and those stricken lay rolling by the
way, and around the wells in their desire for water.
The temples in which they camped were full of
corpses. The pestilence exceeding all bounds, and
numbers dying of it, and men not knowing what to
do took to blaspheming things both sacred and pro-
fane alike. Order was broken by those whose
business it was to keep it, in the first place about
the burial places, so each dug as his strength per-
mitted, and many had recourse to very indecent
modes of interring; from the scarceness of conveni-
ences what one goes to the thicket for remained
about them, and they bungled in placing the accumu-
lations on the artificial fires; some laying a corpse on
a fire, which sat up of its own accord; whilst others
threw up some of those bearing the corpse and went
their way. |
“ When the pestilence first cropped up somewhere
in the city there was no lawlessness. But the
disease spreading some were brave enough to conceal
the fact, and would not forgo their pleasure, until
noticing the sudden change caused by the disease in
other pleasure seekers, their speedy deaths, and that
they were slain without any warning, immediately
mended their ways; yet, nevertheless, some quickly
altered and again turned towards pleasure, acting
so that their affairs suited the ephemeral nature of
their bodies. Indeed to continue any longer in
pursuit of the Ideal no one was ready, considering
that, as before such a point could be attained death
would overtake them, for the present pleasure in all
its surroundings to be to their profit; so this stood
for both the Ideal and Material. Neither the fear of
God nor the laws of man pertained, men judging it to
be the fact that, whether they honoured the gods or
not, from what they saw around them on all sides
their destruction would be equally certain, no one
expecting that judgment would be prolonged till
judgment should take effect, and he receive the
punishment of his offences; nay, they supposed
that a far heavier judgment already denounced
against them hung over their heads; and before it
fell upon them they thought it right to snatch
some enjoyment of life.
“Such was the misery that alighting upon the
Athenians settled upon them, men dying within the
city, whilst the country outside was visited by it, all
that 1s reasonable concerning which in all its details
the Elders remember and say that they were satiated
with it.’”
The author has translated the foregoing passage
from Thucydides without consulting any other trans-
lation, because most of those who have attempted the
matter before work on the more or less preconceived
lines of a certain word meaning such and such, so
-— —
? Text and notes (Bloomfields).
Dec. 1, 1914.]
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 sesthetics, 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
epidemics 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 epidemics 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
357
ee
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
epidemics 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
endemic 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 epidemics radiating
from the endemic 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 Asiatic cholera of our own time, and there are
many stories told of how the inhabitants of densely
populated districts 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
etiology 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 atmospheric conditions in the epidemics 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 & tainted port to & 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 their families. 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 epidemic 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 ns 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 escaping. 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 setiology 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
& comma. 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
peccans, 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 & time the school that viewed
climate as forming the chief cause of dissemination
held the field, but then as i& 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 officer 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 cramps, 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 fecal matter; or again
it may be that the attack was of the nature of those
Dec. 1, 1914.]
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 ono 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 oeeasion 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
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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 aífected. He
appears either to suffer to a terrible degree, or only
in & 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 difficulty 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 infliction whilst the
man himself remained under treatment. This case
is interesting and instructive as showing how a
carrier 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 deseription of
Asiatic cholera.
The soldiers were either suddenly knocked out,
experienced premonitory diarrhoea, 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 diarrh@a 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
was reached the cramps of the limbs subsided and
there ensued a most violent thirst and desire for
water, following & 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 communieating branches with the sympathetic.
So that there is little untoward to be feared per se
from & 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
uræmia, coma and death, occur. If, however, there
be & rally, then may Bright's disease in one of its
forms occur as a sequela. Again, reaction may be
partial or become suspended, when as a sequela
gangrene may oceur. Under normal conditions, how-
ever, this seldom happens in Europeans, whose diet
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 & gangrenous hand from one native
and a leg from another, sequela 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 treatinent 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
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
eause of premonitory disturbance of the digestion,
accompanied by diarrhea 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 from a
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 sutfering from excessive beer drinking
were also admitted to hospital and died within
twenty-four hours, gastric disturbance and diarrhea,
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 amcebic dysentery, the other
bacillic; the former tropical and dependent upon the
presence of the Amba 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
Amaba histolytica not only in the body but in the
test-bube," 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;
Deo, 1, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 361
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 occurs in an epidemic form amongst
lunatics, and the author, having had much experience
of them, expresses the opinion that inasmuch as
when a gaol andalunatic 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 hyperssthenia 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 endemic, like cholera on the Ganges,
becomes epidemic, and doctor and nurse and atten-
dant become affected ; and a predisposing cause may
be errors of diet or constipation, to both of which
lunatics 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 follicles. The general aspect of
Peyer's patches gives us the impression of & secretor
or excretor surrounded by a lubricant in the shape of
the follicles ; 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
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 Asiatic 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 1896, 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 Macnamara 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 Pharmacopoeia. 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, i& 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
— — — —— — — —.
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 eatheter. 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 flicker of pulse, or shadow of heart
beat, persevere as he would in a case of ordinary
shock with collapse. Electricity, either galvanic or
faradic, 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. VA - mxv.
Sp. wth. chlor. ns di e MX.
Sp. wth. nitrosi as bs .. 088.
Tinct. hyoscyami .. s mxv.
Aq. ad. 5i, as required.
If not readily retained the sal volatile may be
omitted, and perhaps sp..s&th. sulph. substituted.
In the course of the epidemic at Camp Gharial the
author, judging from the fact that ipecacuanha is &
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 a coloeynth
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 1t is possible to do so to one company,
when the latter underwent isolation, prevented further
investigation and the experimenting with pills of
hyoscyamus and coloeynth, hyoscyamus and aloes.
But the author is convinced that here lies a
remedy if not a specific for the disease. And at the
present moment in his cupboard are colocynth and
hyoseyamus pills, Pharmacopoeia strength, and others
of half strength, colocynth and aloes with the 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-
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
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 1t
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 & small soda, is perhaps the best, as & 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
instincts 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 crust 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 choleraic diarrhoea,’ 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 controversy.
It may be mentioned that Colonel Cunningham, of
the Indian Medical 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 efficacy of the serum as a pro-
phylactic, such as Jenner’s vaccination lymph, and
typhoid serum, or an anti-scrum 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-
rhaa, or other disturbance of the intestines, the
bacilli thrive and multiply in the mucous membrane
! Celsus describes this, if not Asiatic cholera.
De 1, 1914.]
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.
—— ill —————— —
Annotations.
A New Missile. — Surgeon Johannes Volkmann
(Münch. 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 pənetrated 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.—Ed. rent and L.
Négre (Bulletin de l'Office International d' Hygiène
Publique for August, 1914) examined thirty-six
pilgrims returned to Algiers from Mecca and thirty-
one to 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
363
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THE JOURNAL OF
Eropical Medicine 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 Furope 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
bacillus of Lberth, 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 a useful aid in that
direction; but it is no more than an aid, for it is
not invariably confirmatory, for or against. The
microscope cannot always settle the matter, for the
resemblance 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
a 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 b2 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
madeo by taking, say, three tablespoonfuls of rice in
14 pints of water, boiling for half an hour or moie
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
and then straining off the partiales 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, 335 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 s 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 diarrhoea.
Of the many complications, nose-bleeding, pneu-
monia, hemorrhage from the bowel, perforation of
the intestine, phlebitis, kidney troubles, bed-sores,
each and all call 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 hzmorrhage 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.
——— 9, ———— ——
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 force. 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,
914.
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, pancreas, 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
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
a 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 act should be
reduced to the minimum, simple incision to
let 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
indications, 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, which 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 subcutaneous 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 1, 1914.
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 haemorrhage, 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 &
much better exploration can be made and the lesions
found. The lesions which cause the hemorrhage 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,
panereas, 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 subphrenic region. Should more
space be required during the operation a medium
incision can be advantageously added.
The exploration of the anterior surface of the
Dec. 1, 1914.]
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 s unfolded and the
perforation brought to ligkt 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. Lxtragastric exploration
is & 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
367
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 endogastrie 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—contusion of the posterior gastric
wall from the projectile. This lesion is uncommon,
but it is often the cause of hamorrhage 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
hzematemesis 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 canal. 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 involved, 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 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 ean 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
can 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 indieated for intra-abdominal
hemorrhage, as more lives will be saved under the
circumstances by a careful conservative treatment.
M (li —
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 & 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 &
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
i rS. -—- —À -.— - ——
! 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 1, 1914.
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 præcox 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 prscox.
The report gives a clear, concise outline of the
modern conception of dementia preecox, 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 &rmy 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 spbere—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.
ei
Dec. 15, 1914.] | THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [No. 94, 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. Wenyon, M.B., B.S., B.Sc.
Director of Research in the Tropics to the Wellcome Bureau
of Scientific Research.
AND
GEgonRGE 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 corpuscles of yellow fever cases and
ealled 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.
Aecordingly 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
identieal 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 à minimum we
have reproduced a coloured plate of red blood cor-
puscles 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
will 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
nucleated corpuscle, 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 init. 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 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 1s 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 1t 1s 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 &
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 & 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
THB JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[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 deseribed 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 hodies 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 Sehiling-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.]
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 carriers 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
children were not suffering from any 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,
@ 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 suffered 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 vellow
fever bodies, is forced to diagnose yellow fever where-
ever he sges his parasite, and this has led hin into
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
371
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, Macfie 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 hama-
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 orgunism 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 tho fact that these may
372
be merely physiological or degenerative cell granules,
broken bits of tissue cells, or even parasites of &
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 basophilic 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
subjected 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 anzemia or severe toxzmia. 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 à 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.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
(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. Jeurn. of Path. and Bact., January, 1911, vol. xv, p. 282.
ScHILLING-TorGAU, V. Arch. f. Schiffs u. Trop. Hyg., 1912.
Beih. 1, pp. 87-100. (Verhandl. d. Deutsch. Tropenmed.
Ges., Vierte Tagung, September, 1911.)
SEIDELIN, H. Ibid., June, 1912. vol. xvi, No. 11, pp. 371-872.
ScHILLING-TorGAL, V. Ibid., 1912, pp. 273-376.
AGRAMONTE, ARISTIDES. Medical Record, March 30,
vol. Ixxxi, No. 18, pp. 604-607.
SEIDELIN, H. Ibid., May 18, 1912, No. 20, p. 951.
CABTAYA, J. Sanidad y Beneficencia, March-April, 1912, vol.
vii, Nos. 3-4, pp. 309.319. (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 8 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.
Macrix, J: W. Scort, and Jonnston, 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.
SgipELIN, Hanarp. Yellow Fever Bureau Bull., September 30,
1914, No. 8, pp. 203-207, with 1 plate.
1912,
THE TRANSMISSION OF TRYPANOSOMA
BRUCEI OF NIGERIA BY GLOSSINA
TACHINOIDES, WITH SOME NOTES ON
TRYPANOSOMA NIGERIENSE.
By G. H. GarraaHER, L.R.C.P.S.I.
Medical Officer, West African Medical Staff.
(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,
glossinm 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 OF TROPICAL MEDICINE AND HYGIENE, DECEMBER 15, 1914.
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Relationship to the so-called Parasite of Yellow Fever," by C. M. Wenyon, M.B., B.S., B.Sc.,
and GEORGE C. Low, M.A., M.D., C.M.
Dec. 15, 1914.]
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
373
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
Trypanosomu 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. ;
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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. bruce? which this paper refers to
was obtained by feeding 198 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.
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
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Black line is constructed from 1,000 individuals from is II, III, IV and V.
500 t
Rat V.
Rata II and III.
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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 increased, 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 T. rhode-
stense, the relative proportions of posterior nuclears
to the other types show marked variations. For
instance, counting a thousand trypanosomes on
374
on ee ee ee —
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 124 to 32 u, while the greatest number measure
20 to 21 u.
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 accounted 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 identieal, 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 & glance at the animal
reactions given below.
l
| i
Dateandhow Date when | Dateof | Dura.
| Animal inoculated | AUS | death tion
! Days
| Guines- pig II | G. tachinoides 2) May 2) July 25 +85
T IV| Guinea pig II, (?) Sept. 1: ee 11 j| 110
at death |
Rat I . | Guinea-pig IV, kí T Sept 14| 14
| Sept. 1
| IH . | Rat Ì, Sept. 10 i , 16/Oct. 14| 35
| » HI i. d II, Sept. 16- „ 21: „ 14, 29
og LV R is III, Sept. u (?) Nov. 18, 60
n V .. | 4, LIL, Oct. 14: Oct. m 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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
ae (peer cg, Sa ee
[Dec. 15, 1914.
The inoculation period varied from six to thirteen
days.
Discussion as to the Identity of the Parasite.
In morphology and animal reactions 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. bruce: 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 tbat 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. bruce:
is at present monomorphic, it has yet to be proved
that it has always been so. The curves from this
Nigerian T. bruce: differ somewhat from those given
by Ogawa for T. pecaudi [4]. Ogawa's figures accord
the largest percentage of trypanosomes a length
of 25 u to 26 a. Now, if absolute reliance is
to be placed on curves, one might be lead to the
deduction that T. pecaud: and T. bruce: 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. pecaudi 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. brucei
(Nigeria) and T. pecaudi (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 15] ), 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. uganda.
I will conclude with & 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. bruce: 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.—Z'ypanosoma nigeriense. (SCOTT-
MACFIE 1913.)
This strain was brought home in two animals, viz.,
& 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 à 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, 7.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
9 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.
379
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 curve 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. pecaudt.
(3) That the polymorphie trypanosomes T. brucei
(T. ugandx) 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 7. 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 Wellcome Bureau of Scientific Research, for
placing 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.
Proceedings of the Royal Society, Series B, vol. Ixxxvii,
No. B, p. 598.
[4] Annals of Pasteur Institute, t. xxviii, Juillet, No. 7.
[5] Bouvet, G., ct RouBAUD, E. Annals of Pasteur Institute,
1910, t. xxiv, pp. 664 and 667.
Idem., Soc. de Path. Exot., 11 Octobre, 1911.
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THE JOURNAL OF
Tropical MDedtctne and hygiene
DECEMBER 15, 1914.
—— — — — — ee —— — ee — + ——À nee ee
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Dec. 15, 1914.
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 which 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, &e. It is from this crude tartar
by crystallization that the potassse tartras acida of
the British Pharmacopceia 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 carborate, 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 act 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 canal 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.
Dec. 15, 1914.]
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 a 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 mercury 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 action and then followed a direct
purgation by the exhibition of the saline. |
Liquid evacuations may be produced by drugs in
several 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
377
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 oxalie 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;
tomutoes 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 weeks, recording
378
what is seen by the microscope in the way of crystals.
This is not & erudite nor thorough investigation,
as every item of diet, both food and drink, ought to
be noted, and & chemical examination, both quanti-
tative and qualitative, ought to accompany the micros-
copie 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
medieal 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
conecrements 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. . Hiematuria 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 18, 1914)
studied the phenomena seen in the vertebre after
violence (Kümmell's kyphosis), in the neck of the
femur, and especially in the small bones of the wrist
and foot. Kohler'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 a primary macular lacuna clearing up.
At a later period more serious deforming altera-
tions occur and such conditions as traumatic coxa
vara, Kiimmell’s 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 penetrate as far as
possible.
Medicinally, there is nothing to equal :—
Quinine sulphate n ‘ gr. ij
Dilute sulphuric acid.. zs n 90 miv
Liquor hydrarg. perchlor. .. vi .. 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 sulphurie acid and sulphate also tends to
diminish the risk of hemorrhage.
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 & 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 eflicient 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 oedematous 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 ; hmmorrhagic extra-
vasation into muscles of both legs, left forearm, and
left psoas muscles, involving the muscle fascia between
muscles, old and recent; subperiosteal haemorrhage,
shaft of left femur ; hemorrhage into left knee-joint ;
old subcapsular hemorrhage (knee-joint) ; ulcerative
gingivitis with haemorrhages ; separation of mandibular
periosteum; anzmia 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-
549) 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
bevond the effect. of these measures is systematic
flushing out of the bowel with a hypotonic solution
through a duodenal sound. This clears out the bowel,
draws out toxic 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 ureemia
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 ansemia, in
‘ presclerosis," 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 119 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 scrap of contents 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Dec. 15, 1914.
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
clinically 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
visihle to the naked eye consist of felted streptothrix.
——————Uá—
Hotes and Aews.
A HARDY ANNUAL.
“ WELLCOME” Photographic 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 encyclopedia 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.
TEFF, A 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 autumm
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.
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, 7,362; 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 districts of the Province
36 cases of small-pox were treated.
At Bende, Aro-Chuku and Ahoada, epidemics 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 vaceinated Successful
Western Province 75,691 43,981
Central s 12,902 6,935
Eastern - 47,054 37,663
135,647 88,579
There was an increase of 18,780 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 stil escape
vaccination.
The percentage of successfuls for the three
Provinces was 65:8.
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 larvæ
of Stegomyia fasciata, Culex tigripes, var. fusca, C.
duttoni, C. dissimilis, and others.
Adult stegomyie 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
expect 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 :—
2 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Swamp reclamation; the regular use of quinine
as & 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
eget 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 0O 8... 1,206,000 grains
» T » fever 157 11 8... 916,900 ,,
Eastern an » prophylaxis 389 6 04 215,671 ,,
T » 21 5 9.. to natives
(125,000 grains
to Europeans)
Central Province for prophylaxis 28 7 9... 140,582 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 Forcades, 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 vernacular, 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 1,364 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 2,597 patients
were treated.
There was a diminution in the number of native
(Jan. 1, 1914.
ne € — à
out-patients, but an increase in the number of
European cases.
In the Ibadan Dispensary 2,831 native patients
were treated, including 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-patiente, 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,
27,991; Central Province, 19,748; Eastern Pro-
vince, 22,515.
At the Calabar European Hospital 189 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 5,400 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, with 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 Lunatic Asylum at Calabar twenty-six
patients were treated, with three recoveries and two
deaths.
During the year 529 cases of guinea worm were
treated in Southern Nigeria, viz.: 312 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]
_—— — — ——— —— ——— ee
COLONIAL MEDICAL REPORTS.—BRITISH HONDURAS.. | 3
— Hü€€— M MÀ a— € Ra P —MÀ——— M M MÀ —— ——— — M — i ——
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°3.
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, 1910 .. 59
Admitted during 1910 ths .. 18
— 72
Discharged during 1910 e. 4
Died during 1910 oe sek e 65
° — 9
Remaining on December 81, 1910 .. 68
One death occurred from phthisis and recently
this year three others have occurred. This is not
very satisfactory owing to the cvercrowding, but
every precaution is taken to keep such patients
isolated.
Poor House.
Number of inmates remaining on January 1,
1910 :—
Males .... abs s br. .. 16
Females ... ET iss . 9
` 25
Admitted in 1910 dos Ha .. 15
— 40
Discharged in 1910 : e. 4
Died in 1910 ... m E .. 5 5
Remaining on December 31, 1910 .. 31
QUARANTINE.
Vessels boarded: Ships of war, 4; steamships,
949; schooners, 160; motors, 37; 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 48 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
REeTURN or Diseases AND Degatus IN 1910 ın THE BeLIze HOSPITAL,
GENERAL DISEASES.
Alcoholism
Ansemia
Anthrax
Beriberi
Bilharziosis s
Blackwater F'ever
Chicken-pox
Cholera
Choleraic Diarrhea
Admis-
Congenital Malformation
Debility ,
Delirium Tremens
Dengue...
Diabetes Mellitus -
Diabetes Sampin?
Diphtheria
Dysentery ..
Enteric Fever
Erysipelas..
Febricula ..
Filariasis ..
Gonorrh@a
Gout í
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
Measles
Mumps... eu
New Growths— ..
Non-malignant
Malignant
OldAge .. $5
Other Diseases
Pellagra ..
Plague ..
Pyemia .. os
Rachitis .. .
Rheumatic Fever
Rheumatism :
Rheumatoid Arthritis
Scarlet Fever ..
Scurvy... ks
Septiceemia i
Sleeping Sickness
Sloughing Phagedsena D
Small-pox.. és
Syphilis .. es
a) Primary...
[: Secondary ..
c) Tertiary ..
vl Congenital `
Te tanus .. e
Try penne Fever
Tubercle—
(a) Phthisis Pulmonalis T
i Tuberculosis of Sand: Js
Lupus m
Illgillillii<idiltiS&ILEiEigIalllitisesSI-SI LLL Lieb ELI SEL Peal EET EBLE TL T l |wi ouo sions
British Honduras.
Fh Sarr ies ln etna) ices 2I E TIAA ETA IAT E A T Eer A Fa GARD E a
Total
Se LIST eS iS el i e essasi Ti el LEi eT Tel P3: ele
GENERAL DISEASES— continued.
(d) Tabes Mesenterica
(e) Tuberculous Disease of Bones ..
Varicella .. ;
Whooping Cough.
Yaws f :
Yellow Fever
LOCAL DISEASES.
Diseases of the—
Cellular Tissue
Circulatory System
(a) Valvular Disease of Heart
(b) Other Diseases ..
Digestive System —
(a) Diarrhoea -
(b) Hill Diarrhea ..
(c) Hepatitis
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver ..
( () Jaundice, Catarrhal
Cirrhosis of Liver
A Acute Yellow Atrophy
(a Sprue .. A
(j) Other Diseases ..
Ear n
Eye ; s%
Generative System— à
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervous System
Nose .. ;
Organs of Locomotion
Respiratory m
kin— .
a) Scabies xa
b) Ringworm T
c) Tinea Imbricata
(d) Favus m
(e) Eczema .. aid
( f) Other Diseases ..
Urinary System
Injuries, General, Local—
a) Siriasis (Heatstroke) "T
2 Sunstroke (Heat PINO)
(c) Other Injuries
Parasites— as
Ascaris lumbricoides Se
Oxyuris vermicularis ..
Other Tubercular Diseases
sions
Admis-
[Jeol to |
Dochmius duodenalis, or Ankylostoma duo-
denale
Filaria medinenais (Guinea. -worm)
Tape-worm .. 2s .
Poisons— sá
Snake-bites
Corrosive Acids "E
Metallic Poisons e
Vegetable Alkaloids ..
Nature Unknown
Other Poisons zu
Surgical Operations— ..
Amputations, Major .,
Minor ..
Other Operations
Eye ..
(a) Cataract.
(b) Iridectomy
(c) Other Eye Operations
a ee VR ea
lool lI SSL LL ak Bol Rl eaSaianSllalleleI SI 1) ae
Deaths
PEt dp bolt Pt tt tabbotl tli balileatititlialltal Sige oe
Lad Re BE DT eee Ped
Wai an. A, 1914.
biwlliZ$lIlllllsa&toelS8l!l»s*el»-Zllali-l-2lsllIl&5o
| gb ba
!
|
Lao d TE 4 34 d
Jan. 1, 1914]
—————À ———M——
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
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 5
———————— ae — —ÀÀ——M— M — —
-—
in June, and, strange to say, the lowest numbers
were in August and December.
lNSPECTION.
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 34,010.
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 Europeans, 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; 1908, 471; 1904, 388; 1905, 461;
1906, 434; 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 831.
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; pernicious 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-pox.—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 18 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 i 8
Native bs 8 Nil... 25 Nil
Syrian A 2 zi " EN 1 bá: 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
cases in the Colony. From the reports of medical
officers I am inclined to think that human trypano-
somiasls 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
officers 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 districts, 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 & 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
urisen 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]
ee
ee a ———— m
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-
tucles 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 ut present only just
sufficient to meet the ordinary requirements during
the dry season. 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
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 7
— u — ——M — o — —À
in the reservoir itself. Where an unlimited quan-
tity of water could be colleeted 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 public 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 '' larve '' 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 Nicol 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 *o
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 flaw 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-sacs 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 80,000,000 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
weather flow, and consequently the supply, may
dwindle down during drotghts. 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,
9
r 9 50 99 60 )
15 - 5 40 „ 50 »
17 j " 30 „ 40 Ys
23 ss i 20 , 30 5
37 9? 29 10 99 20 79
4 e 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.
HILL 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 increase in the European staff lately
several additional bungalows are now required, and
8 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Jan. 1, 1914.
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. Davsos, 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.
Jan. ; 14, : 1914. ]
SS —ÓMÓMMÓ—Ó ——
Colonial Medical Reports.—No. 27.—Sierra Leone—
(continued).
Between the beginning of June and the end of
September 14 patients were admitted, their illness
being diagnosed as follows: Yellow fever, 3; 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. | B
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 éncourages patients to
come. , "
The number of out-patients treated has increased
from 27,474 last year to 31,795 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 cardiac 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. : ANE NN. |
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. z T ME
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.
KING-HARMAN’S MATERNITY WARD OF THE COLONIAL
HosPrTAL.
(By Dr. Ww. RENNER.)
Of instrumental labours there were ten. .
The average stay of patients in the ward was
eight days. x | Ve ^s
Of patients with complications on admission there
were fifty-nine. |
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. 9
Following are the particulars of cases which
resulted in death :—
(a) Admitted in unconscious condition. First
child born at home; second in & hammock on the
way. Had frequent fits after admission; temper-
ature went up to 1089 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. U B »
The admissions during the year have steadily
increased. pi ,
| THE Nursina 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 £288 5s., being
£64 18s. 2d. more than the previous year.
THE GAOL.
(By Dr. Davson.) | |
Throughout the year the prisoners have bee
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 prisoner&'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 diarrhea. 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, t.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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
aor Ó—M—M——— ———————MBÓ———— ——————ÉÉáÉÉ—— ——
aS
(Jan. 15, 1914.
RETURN OF DISEASES AND DEATHS IN 1910 IN THE COLONIAL HOSPITAL, FREETOWN,
Sierra Leone.
GENERAL DISEASES.
Alcoholism
Amemia is
Anthrax
Beriberi
Bilharziosis ..
Blackwater Fever Pa
Chicken pox .. M $5
Cbolera 5 vs .
Choleraic Diarrhoea -
Congenital Malformation Vs
Debility d : x bs ex
Delirium Tremens .. "E - RET
Dengue.. an
Diabetes Mellitus es
Diabetes Insipidus .. eu T
Diphtheria .. ba vs -
Dysentery aes ia
Enteric Fever..
Erysipelas
Febricula
Filariasis
Gonorrhea...
Gont .. is
Hydrophobia ..
Influenza x MS T A
Kala-Azar Be a v2 A d
Leprosy bs
a) Nodular..
a) Anesthetic
c) Mixed
Malarial Fever a ie si e
(a) Intermittent .. T is =
Quotidian aa T? cg
Tertian
Quartan
Irregular i
Type undiagnosed
(b) Remittent ys
(c) Pernicious `
(d) Malarial Cachexia
Malta Fever
Measles wi Vs js
Mumps , es s ET
New Growths . i E i s
N on-malignant T T ss T
Malignant .. s T Fs
Old Age..
Other Diseases
PeHagra va si - di
Plague. va i^ x af
Pysmia ‘ ja "" ch
Rachitis
Rheumatic Fever
Rheumatism .. i
Rheumatoid Artbritis
Scarlet Fever . :
Scurvy . id
Septiceemia T
Sleeping Sickness...
Sloughing Bnet
Bmallpox : ou Ae -
ilis vs id as be vs
(a) Primary
(b) Secondary
(c) Tertiary ..
(d) Congenital T s 2
Tetanus ii = js ds
ee Fever ..
(e) Phthisis Pulmonalis .
b) Tuberculosis of Glands T"
te) Lupus .. T e -"
Admis-
sions
=
| &
Fiddles!
vDlas i lel i ET Sl [i IS i!ll]
to
Qo
I|
Liit æi ELI RIEŠILI II ie S] Ea
Illil$2seallllikttiellitt!lititselbtiltilbtilkbthilkelltwllitlillw'llioallll!&!t!!l!w!|: Dess
Total
Cases
lel SIIL LS8IL LP i Stil bel St Ea teated
p igascsqe. ee eRe pac pera ame dd ET 4s sr
GENERAL DI8EASES—CcOninued.
(d) Tabes Mesenterica
(e) Tuberculous Disease of Bones
Other Tubercular Diseases
Varicella ; s
Whooping Cough
Yaws .. :
Yellow Fever ..
LOCAL DISEASES.
Diseases of the —
Cellular Tissue .. - ‘in T
Circulatory System
(a) Valvular Disease of Heart
(b) Other Diseases . a
Digestive System ..
(a) Diarrhea .
(b) Hill Diarrhaa
(c) Hepatitis ..
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver
(f) Jaundice, Caterrhal
(g) Cirrhosis of Liver ..
(k) Acute Yellow ai ad
(i) Sprue .. ;
(j) Other Diseases
Har .. oe
Eye .. ;
Generative System.
Male Organs
Female Organs ..
Lymphatio System
Mental Diseases ..
Nervous System
Nose.
Organs of Locomotion
Respiratory System
Skin. Sa vis
(a) Scabies
(b) Ringworm
(c) Tinea imbricata
(d) Favus.. $a
(e) Eczema "n
(f) Other Diseases
Urinary System...
Injuries, General, Local ..
(a) Siriasis (Heatatroke) -
b) Sunstroke (Heat Prostration)
to Other injuries ..
Parasites ;
Ascaris umbricoides.
Oxyruis vermioularis oe
Dochmius duodenalis, or Ankylostoma
duodenale ;
Filaria medinensis (Guinen- worm)
Tapeworm .. ]
Poisons .
Snake- bites .
Corrosive Acids
Metallic Poisons ..
Vegetable Alkaloids ds
Nature unknown .. 3s ah
Other Poisons
Surgical Operations .
Amputations, Major
Minor
Other "Operations -
Eye . i
( Cataract ..
(b) Iridectomy
(c) Other Eye Operations
sions
Admis-
pi bent
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LETTRE
Jan. 15, 1914]
the accommodation of violent female lunatics was
pulled down, and much needed additions and alter-
ations in connection with the asylum were carried
out. These consist of a new block eontaining 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 mest sensible of the
lunaties 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, &e., for their use.
Female Incurable | Hospital.—There were 29
patients at the beginning of the year; during the
year 90 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 syphilitic 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-
huustion, syphilis and paralysis; and 82 patients
were remaining in hospital on December 31. Owing
to the serious nature of the cases, 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 eases of chicken-pox and one of small-pox were
admitted during the year, all aborigines, and ull
were cured. The case of variola was of a mild form;
the patient came from the Protectorate.
Protectorate District Reports.
RONIETTA DISTRICT.
HEADQUARTERS—MOYAMBA.
(By Dr. J. Y. Woop.)
Out-patients.—Total number of attendances. of all
classes was 4,155, an inerease over last year of 592,
showing a steady increase in this department from
year to year. |
In-putients.—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 uleers,
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
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. ii
ay rm t a RATI
symptoms of enlarged glands and. eonstant 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
and serotum, but eases seldom came for treatment,
and operation was almost always refused.
Venereal Diseases.—Gonorrhea 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-syphilitie treat-
ment, are very eommon 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-
tuin 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,
each cesspit being closed when full. 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 bemg 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 &ttention is drawn to insanitary conditions,
paying much less attention to arguments in favour
of sanitation. Bottle borders, a fruitful source of
mosquito breeding places during the rainy season,
are in great favour among them.
Sunitury | Patrols.—During the year extended
patrols were undertaken, and at each town where
a halt was made sanitation, on the lines suggested
in Standing Instruetion No. 5, was explained to
the chiefs and the people as simply as possible, and
all were urged to co-operate in carrying out the
suggestions. | |
I am of opinion that more frequent and more
extended patrolling by medieal 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
cmd Pm
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
. Un. 15, 1914.
The people objected strongly to be vaccinated 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
Kuropean officials was good. Among the native
officials the Court messengers have suffered most.
The nature of their duties entails a considerable
umount 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 toʻa stand-
pipe.
The water supply at Renee 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 und in the prison; the
contents are emptied into a trenching ground by
prisoners every morning.
StaTion—Daru (HEADQUARTERS OF THE W.A.F.F.).
(By Dr. J. C. Murpay.)
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 wo and
seventy-four days respectively.
About twenty Europeans resided in the sation
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 diarrhoea 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 obtained chiefly from
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, JANUARY 15, 1914.
LONDON SCHOOL OF TROPICAL MEDICINE.
43rd Session. 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 (Capt. I.M.S.), J. R. Ridlon
(U.S. Pub. Health Ser.), C. R. Bakhle, (Maj. I.M.8.), C. S. Harwood, C. R. Avari, W. Lethbridge (Maj. I.M.S.), M. F. Reaney (Capt. I. M.8.),
T. P. Fraser, R. F. Steel (Capt. I. M.S.), 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.8.), 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. Hofmeyr, A. R. Paterson,
Absent.—R. T. Leiper (Helminthologist), Miss M. Plum, J. 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, W. Kennedy, W. P. Beal, H. E. Shortt (Capt. I. M.S.).
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON),
Under the Auspices of His Majesty's Government,
CONNAUGHT?) ROAD. -ALCBERT DOCES, .H.
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., 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., 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.
Helminthologist—R. T. LEIPER, Esq., D.Sc., M.B., Ch.B., F.Z.S. Protozoologist—C. M. WENYON, E«q., M.B., B.S., B.Sc.
Director—H. B. NEWHAM, M.R.C.S., 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, viz., from October 1st 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 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 versá.
Chief Office—SEAMEN's HOSPITAL, GREENWICH, S.E.
Jan. 15, 1914]
the Moa River. This river is of considerable width
and force with & rocky and sandy bed. Cataracts
just above barracks tend to make tlie 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.—238 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.
HEADQUARTERS—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 has been
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
cases 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
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
COLONIAL MEDICAL REPORTS.—SIERRA LEONE. MEN 13
noted was 1009 F., end the lowest 519 F. The
rainfall for the year amounted to 89:92 in. The
greatest in one month was 17:66 m.
KARENE DISTRICT.
HEADQUARTERS—BATKANU.
(By Dr. H. E. ARBUCKLE.)
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 conerete 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 occupied 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.
Ex ea EL. nd
en eee eee
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-
rhea, skin affections, rheumatism, bronchitis,
leprosy (from time to time), elephantiasis (leg, arm,
and serotal), and deformities. Ulcers are an every-
dav 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.
BowTuE—SaANiITATION 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
makes a good, firm soil.
The sanitary authority is the Sherbro Municipal
Board, of whom the Medical Officer tor Bonthe ix
un 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 grazs 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
— MÀ M Á—— — A € M M M A
— — — — — A e m m —
scavengers is quite too small. The work done is
done in an insufficient manner, bottles, tins, &c.,
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 & 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 can 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 am informed that some of the
draing are used in the rainy season as places for
washing clothes. Other drains have never been
finished, eonerete 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.
RteGENT, WaTERLOO, Hastincs, York, TOMBO,
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; ulcers; a few
cases of yaws.
Vaecination 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.
Jan. 15, 1914.) COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS. 15
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 64,653 were paupers and
received free treatment and medicine. The actual
MNES i ——— ee eee
wea Se T a
-_oe IL eS ee ee eee MM —— meee -
amount expended for medicines, &c., was £1,278
12s. ld. The amount received from paying out-
patients was £65 2s. lld. 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 36,160. 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 tlie Presidency.
There were 1,184 births, being an estimated rate
of 38:19 per 1,000, against 82:55 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 34:77 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 m 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 m m Een wee OE
Zymotie diseases ... M ue 2
Tuberculosis tes i uus. 17
Diseases of the respiration other
than tubercular ... Pi .. 80
Second Quarter:
Malaria oa s e. 9
Zymotic diseases ... sie ne D
Tuberculosis iss pe su LL
Diseases of the respiration other
than tubercular ... ia ur 28
Third Quarter :
Malaria - dei ue 2
Zymotic diseases ... 5s E. <@
Tuberculosis - -— Sq 15
Diseases of the respiration other
than tubercular ... Sis ne al
Fourth Quarter:
Malaria ; w s sae. d
Zymotie diseases... sus um 9
Tuberculosis aei -— .. 20
Diseases of the respiration other
than tubercular ... bn ws 51
Total:
Malaria pat a ids .. 16
Zymotic diseases... TE e. 14
Tuberculosis "T si .. 68
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
number of births.
with the
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.
down of mosquitoes, which are much fewer this
year.
YAWS.
Compulsory notification of yaws was introduced
towards the end of the year, therefore no definite
The yards in the city were carefully inspected,
and cart-loads of receptacle and rubbish cleared out.
return ean be made of this disease just yet.
There has been no outbreak of any serious in-
Influenza has
fectious disease during the year.
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:
Zymotic (epidemic, endemic, or
contagious) or eruptive fevers ...
Malarial fever
Yellow fever sans ios 22s
Animal parasites, including filari-
asis, ankvlostomiasis, and in-
testinal wornis
(b) Sporadic Diseases :
Cancer and other malignant dis-
eases a. TR
Tubereular disease
Syphilis
Yaws
Leprosy * a e, ix
Diseases of the brain, spinal
marrow, nerves, and senses
other than tubereular ... ea
Diseases of the heart and blood-
vessels ; TT th ies
Diseases of the lungs and other
organs of respiration other than
tubercular " js -
Diseases of the stomach, liver,
and other organs of digestion ...
89
. 118
172
(b) Sporadic Diseases :—(continued.)
Diseases of the kidneys .. 25
Other diseases. of the urinary
organs... is iu 8
Diseases of the womb, &c. —
Childbirth a 3 ma O
Rheumatism, diseases of the
bones, joints, &c. ve .. 2
Diseases of the skin, cellular
tissues, &c. 21
Malformations 1
Premature birth 12
Atrophy 46
Senile decay 85
Sudden - isa "EE
Violence, privation, poison, in-
temperance, &c. ... 6
Stillborn "- ds ... 102
Diseases of uncertain seat,
dropsy, marasmus, &c. 47
Total of deaths for the year ... 989
METEOROLOGICAL SUMMARY, 1910.
Thermometer Dew Point Wind. Aver-
Month
Max. Min. 9a.m. age per hour
January .. 82° .. 66° .. 644 .. T ess
February ... 88 ... 66 .. 687 11:0
March ... .. 86 ... 66 ... 643 6:7
April .. .. 84 .. 68 .. 64:9 7-8
May .. .. 84 .. 70 66:2 9:1
June .., Se BT Zw WI 68:0 10:6
July .. we 8T we 70 69:0 11:9
August... ... 87 ... 69 70:8 9-6
September ... 86 ... 70 70:8 47
October... ew BP wu FL 70:6 8:4
November .. 89 .. 70 704 2:9
December .. 86 .. 68 68:7 5:9
Highest maximum temperature, 89? on November 2.
Lowest minimum temperature, 66? on January 11 and
19, and February 4.
Highest barometer, 80:187 on February 17.
Lowest barometer, 29:890 on October 21.
Greatest rainfall in 24 hours, 2:04 on November 2.
Greatest number of miles run by wind in 24 hours, 875 on
July 5 and 8.
(Jan. 15, 1914.
—_— OO —— —— ee eee. e
Rainfall
. -8°44
1-28
2°55
2°72
1:22
1°34
3°73
3°86
6°18
8°43
4°32
4°40
Earthquakes record, 4—on June 21, October 16 and 29, and
December 24.
Feb. 2, 1914.]
— — ais ES ES en CEC EAT —— m marta Se ——
Colonial Medical Reports.
COLONIAL MEDICAL REPORTS.—EFIJI. 17
-—— ——M—
No. 29.—Fiji.
MEDICAL REPORT FOR THE YEAR 1910.
By G W. A. LYNCH.
Chief Medical Officer.
VITAL STATISTICS.
THE estimated population of the Colony at the
end of 1910 amounted to 185,891, as follows :—
Totals at last
Decennial Census
Race
Europeans and other whites ... 8,402 2,459
Aboriginal Fijians 87,460 94,397
East Indian immigrants (in-
cluding their children born in
Fiji) .. . .. T .. 89,287 17,105
Melanesian immigrants 2,900 1,950
Natives of Rotuma fuo 9 oxi — £s —
Half-castes and otber degrees... 1,850 1,516
All others vis oe "s 492 ... 467
Total 185,391 ... 120,124
These figures show an increase of the total
population during the year of 1,560.
There is a small increase 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 immigrants (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, 37:28 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 far by the general epidemic of dysentery,
which 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 361 admis-
sions and 17 deaths; at the provincial hospitals
there were 847 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
indieation of the disease in the provinces, since so
many sick people refuse to see them on their visite.
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, 31; 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 cases of dysentery admitted, working
in his private laboratory.
Enteric Fever.—Enteric fever again prevailed in
some parts of the Colony, notably in scattered 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.
hospitals for this disease also continue to be numer-
ous, in spite of circulars 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-
ments in the progress of clearing and cultivating the
land.
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.
[Feb. 2, 1914.
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
qualified 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 Mebpicat 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.
Aleoholism, 1; ankylostomiasis, 7; acute yellow
Feb. 2, 1914]
atrophy, 1; bronchitis, 2; broncho-pneumonia, 6;
carcinoma of panereas, 2; carcinoma, 1; cerebral
hemorrhage, 2; cerebro- spinal meningitis, 9; 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
COLONIAL MEDICAL REPORTS.—CEYLON.
19 4
tuberculosis, 8; hemopericardium, 1; inanition, 2;
nephritis, 1; pericarditis, 1; pernicious anemia, 1;
pneumonia, 1; premature birth, 2; pulmonary
tuberculosis, 17; pyæmia, 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.—PoPuLATION: 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,
1,059,854 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
4,124,940, 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 II.—PvuBLic 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 increase
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 .
Simple continued fever .. |
iy nasheed "i 21,906 .. 28,903
Remittent fever |
Ague
Diarrhea ..
Dysentery ..
Dyspepsia ..
Enteritis 18,730 22,932
Obstruction of bowel
Hernia ; gs |
Appendicitis is v
Laryngitis .. vs ds $$
Crou A T ex sé |
erage + 6,810 .. 9,453
Pneumonia.. |
Pleurisy, &c.
Phthisis 3,917 4,195
Diseases of nervous system 13,597 .. 14,477
Tetanus .. à is 646 .. 488
Circulatory system $5 Ps 618 .. 755
Anchylostomiasis .. ee ae 1,592 1,486
Diabetes mellitus.. " v 139 .. 182
Cancer , ; es e 264 .. ° 158
Parangi (yaws) is T js 114... 94
Leprosy Ji is 64 .. 73
Hydrophobia a T x 20 .. 80
Cholera .. is - T 29. .. 8
Suicide e as is ds 221 .. 204
Snakebite .. e T P 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, &c. Under this
heading, in my 1909 Report I stated that there was
no control over such preventible diseases as,
among others, tuberculosis, 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 (4) the
notifieation of phthisis compulsory, and (b) the
highly dangerous carriers of that disease mnocuous
to the publie.
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 2577 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 diarrhoea
2,788, dysentery 2,376, debility 2,108, pneumonia
1,835, 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 1,213, with
15 deaths. 140,592 ounces of quinine were issued
from the Civil Medical Stores at a eost of Rs. 93,133.
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 publie 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
20 THE JOURNAL OF TROPICAL MEDICINE AND HYGIE
[Feb. 2, 1914.
m ———— €
So
hospitals was 3'4 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. Gunasckara 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 sehools, 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 19:43
Average spleen .. a as 1-71
" For five provinces for the first half of 1911
(south-west monsoon) :—
Number examined 84,226
Total enlargement 12,728
Spleen rate T - 15:11
Average spleen .. £5 és T 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
Spleeu 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 8, 1911, a
case of cholera occurred in a coolie who had arrived
on April 29 from an infected area in India; on May
9, 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
3,000 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
= M. — ——M— ——————— ———M ee ee Ce ee ————M—
after a small stumpede, 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 ''infeeted." The rapid spread of
the epidemic was aceounted for as due to three
possible agencies—water, food and thes. The water
tanks were not tly-proof, the food was cooked on the
ground, and there was a plague of flies,
The tanks were disinfeeted 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 3827 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 fer
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 litrine and scavenging coolies favoured
the spread of the epidemic.
I have great pleasure in plaeing 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’ ean 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
cases 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-pox.—There were 356 cases treated, with
62 deaths, during the eighteen months’ period,
which figures are m nearly the sume 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 F'evcr.—816 cases were treated in 40 out
of the 75 hospitals of the Island; 69 per cent. of
the total cases wore 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
hospituls 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; 18 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-
fuctorily 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
29 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 cuses 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 (3°96 per cent. mortality).
In the Colombo gaol hospital alone 1,347 cases were
treated, with 69 deaths (5:1 mortality).
Leprosy.—028 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
publieation 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 & 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 distriets 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 eases the Principal Civil Medical Officer
should be empowered to send an officer to inspect,
report, and make recommendations for combating
the disease. If the Prineipal 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 Prineipal 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
SEM cma WILL m CURAR -—-
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 RHegistrar-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 Hospitel and the
Infectious Diseases Hospital, Colombo, there were
12 cases treated, with 1 death.
Chicken-poz.—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 figuro
Feb. 9, 1914.]
ee — —À—— —M — ———
9,485 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 & 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
inereasing 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
COLONIAL MEDICAL REPORT
— — —MM— —
23
S.—CEYLON.
— M
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
(1.€., carcinomata 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 I ; 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
melanotic, and the remaining 3 occurred in bone.
The carcinomata were distributed through the
various parts and organs of the body, thus :—
Females Males Total
Cheek 26
Cervix
Penis
Breast
Tongue ..
Uterus
Lower jaw
Upper jaw
Lower lip
Upper lip
Hard palate
Larynx ..
Liver
Skin
Glands
Omentum
Pylorus ..
Rectum ..
ex | ‘eo ee an ere elt
po] = | ns mi muam] wr
PETE
ren
M
e
Phthisis.—In the Registrar-General's returns for
1910 3,917 are shown under the heading '' Phthisis,’’
as againat 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 & publie fund was started, and the
publie subscriptions so far collected amount to the
sum of Rs. 150,000, which, with Mr. Campbell's
24 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
generous gift, makes Rs. 300,000. 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 Colambo 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 18,993 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. successful and 8,258 unsuccessful; in
14,497 the results were not known. The percentage
of success in the re-vaccinated was 70°34. 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; bacteriological examination at the time
of collection 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 & 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 medieal 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
[Feb. 2, 1914.
'" healthy," were permitted to work cargo as
'* 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,
und remained foul for many months.
The total number of estate coolies arriving at
Colombo was 152,338, 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.
SECTION ILI.—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 oak
western parts of the island than elsewhere, Se
three patches recording over 200 in. . . .
In former reports the influence of the: pem mon-
soons on malaria has been pointed out; outbreaks of
this disease in the western half of the island .oceur-.
ring after the first rains of the south-west, monsoon,
and a like result in the eastern half after the com-
mcncement of the north-east monsoon. .
. During the period under review severe malaria
w as 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 larvæ.
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.
Feb. 16, 1914.]
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
soil 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 can 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
Infectious 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 80:4 respectively, as
against 25°27 and 80°77 in 1909.
The Rural Medical Officer of Health reports that
COLONIAL MEDICAL REPORTS.—CEYLON.
25
—————MÀ —— ioo AE ey =
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. 8,081:25. 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 thab the sanitation of this town
is slowly improving. During the eighteen months’
period more public latrines have been provided;
cesspite 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.
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, which 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 scavenging 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,
public latrines, and public 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.
9 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[Feb. 16, 1914.
—
————— —M ———— —ü
——— —— —
Badulla.
Cement conerete 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 1
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-
sarics.
The various medical institutions have been well
maintained, and many structural improvements
have been carried out, notably fly-proofing of
kitchens and latrines ond 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-
meneed in September, 1909, and is now nearly
finished. There were 73 hospitals and the lunatic
and leper asvlums, 408 Government dispensaries,
and 250 estate dispensaries in working.
Feb. 16, 1914]
— m. — — ——————
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,
96 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
Excellency 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 3,183,567 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 81, 1909, there were 416 patients
left in hospital, 34 in the paying section and 382
in the pauper section. During the eighteen months
COLONIAL MEDICAL REPORTS.—CEYLON. 27
under review 20,677 cases were admitted, making
a total of 21,098 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 21,098 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°26 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 7°3.
The receipts in the pauper section amounted to
Rs. 207:45, 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 Ks. 113,298, 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. 41,173.
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 (2:9 per cent.). Of
the deaths, 30 were due to accidents of childbirth;
of the number admitted, 1,532 were before delivery,
59 after, and 334 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.
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 hus
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.&S., 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 Memortal 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.
28 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
M — ——M —— ne — — — 9 o—
[Feb. 16, 1914.
— À — Á——Ó e
Police Hospital, Colombo.
The total number of patiente 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 diarrhea, with 133 deaths;
960 cases of dysentery, with 63 deaths; 1,218 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 796 06 88°28 .. 89
Mutwal 300°47 27:52 .. 57
Hulftsdorp 121-08 2°45 .. 6
Mahara . §84°36 48:78 .. 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 Diseases 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 m oe af sis 9 3
Small-pox .. us 5s .. 105 22
Ohicken-pox .. - ; 1,141 1
Measles zs is ni sé 293.45: 2
Acute diarrhoea vs 2e e D ww |
Mumps T T d ag 73 .. —
Whooping cough .. - ae T uw Å 11
Beriberi s is ae 10. —
Diphtheria .. . 4 1
Other cases, including those under
observation .. i vs T
[wi
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 8 died; 74 remained on June 30.
1911.
Bacteriological Institute and Clinic for Tropical
Diseases.
The total number of specimens sent for bacterio-
logical examination was over 3,000, 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 Astalicus.
(6) Observations on some new intestinal bacterin.
(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 .. 1747 10:08
Field 4:62 .. 11°54 5:55
Immigrant 3'65 .. 945 8:24
District 775 .. 19°87 16°18
Asylums .. bi 8:33 .. 10°38 .. 8°38
Other hospitals .. 95 .. 181 .. 1:02
Total .. 7:46 17°98 1088
Hospital Accommodation. .
This was generally sufficient. Some of the
hospitals in the planting districts 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
ae 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. 99
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
diarrhea 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 Medica!
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 students. 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. 805,888°19;
140,592 oz. of quinine were issued, which cost
Rs. 98,183. 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. 38,279:19. 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. 341,898:15, 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.
mom Š iae iae deis - —————— —— —— aae —
1 Director of the De Soysa Bacteriological Institute,
l Assistant Bacteriologist, 1 Professor of Chemistry,
l 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 2,182 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 (89:07)
among the estate labourers occurred in the civil
hospital at Ratnapura, and the lowest (6°35) in the
field hospital at Alutnuwara. The admissions into
the former were 1,464, and into the latter 178.
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. 611,683:48, leaving a deficit of Rs. 473,293°94.
APPENDIX.
The Opium Question.
The question of regulating the traffic in opium in
this island is intimately associated with the name
of Mr. John Ferguson, 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
licensing 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 tihe 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 & system of careful inspection be intro-
duced by the appointment of special officers under
the direction 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, S. C. Obeyesekere, W. G.
van Dort, M.D., Drs. A. J. Chalmers 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
uppointed 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 as vedaralas, should submit a
report on the applications to the Governor.
forc 09 Rm —
Feb. 16, 1914.]
ee ee —À—— — ——— -2
(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
source 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
he 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
31
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,
notification 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 depdts 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 Medical 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:—
During tho Four Quarters tin i ki ium
s ended 3 Quantity ui m ia eer realized Quantity d. Fh neut realized Total realized
Grains 8. c. Grains Rs. c. Rs. c.
December 31, 1910 13,848,433 100,960 71 2,994,398 29,977 34 180,988 5
March 31, 1911 14,898,067 112,084 99 3,147,081 31,456 26 148,541 25
June 30, 1911 15,982,828 119,781 17 9,040,191 80,405 99 150,187 16
September 80, 1911 16,567,981 124,453 53 3,094,954 30,256 81 154,710 34
Total for the year .. 60,736,559 457,980 40 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 81, 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,
sporadic 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 Porb 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
39 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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 larvæ 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. Neisu, Health Officer.
ST. 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 occur. 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
absence of stagnant water.
The houses and their compounds have never he-
[Feb. 16, 1914.
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 insuff-
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 public water supply. This course
will doubtless cause a cessation of the pollution.
The town of Black hiver 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.—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
which 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
— ——
COLONIAL MEDICAL REPORTS.—JAMAICA. 33
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.
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 à 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. SMITH.
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.
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 publie 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 thai 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
ingpectors.
Latrinc..—The ‘‘ pit system '' is in general use in
town. At the public institutions the dry earth
system is in force. The villages have no particular
system but sanitation is enforced by the sanitary
officers.
Malaria—the presence of several breeding places
of mosquitoes 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. Rosis, M.O.H.
ST. THOMAS.
The overerowding 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 concrete
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 eountry districts.
The latrines in and around the town and villages
lack modern improvements for the benefit of
| (Mar. 9, 1914.
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 paris, and come here
with it.
Malaria fever is less prevalent than it has ever
been. There is always, however, & 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 Chureh 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 láws 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
_ Mar. 3, 1914.]
RETURN oF DISEASES
GENERAL DISEASES.
Alcoholism
Anemia
Anthrax
Beriberi
Bilharziosis
Blaokwater Fever
Chicken pox si
Cholera : he
Choleraic Diarrhea 4
Congenital MM OTRAS OR
Debility
Delirium Tremens
Dengue..
Diabetes Mellitus
Diabetes Insipidus
Diphtheria
Dysentery
Enteric Fever ..
Er rye polas
ricula
Filariasis
Kala-Azar
Leprosy :
Nodular..
1e. Anesthetic
c) Mixed -
Malarial Fever
(a) Intermittent
Quotidian
‘ Tertian
Quartan
Irregular s
Type puaiagnoes
(b) Remittent "
(c) Pernicious
(d) Malarial Cacheria
Malta Fever
Measles
Mumps
New Growths .
Non-malignant
Malignant
Old Age..
Other Diseases
Pellagra
Plague ..
Pysemia
Rachitis
- Rheumatic Fever
Rheumatism ..
Rheumatoid Arthritis
Scarlet Fever .
Scurvy .
Septicemia ,
Sleeping Sickness
S ORE Peer
Sma lpox j
is ‘
R Primary
b) Secondary
(c) Tertiary ..
(d) Congénital
Tetanus : a
Trypanosoma Fever ..
Tubercle e
(a) Phthisis Pulmonalis .
(6) Tuberculosis of Glands
(c) Lupus .. 6s
RA pad a
e bed
= | ey ET
L211 S311 lie
| mol | eo |
“1
rN
oo
Wa i
lann 5|] I |
MEL LL IEEE S ITEM m Deaths
COLON IAL MEDICAL REPORTS.—J AMAICA. —
LI—LL——————
AND DEATHS IN 1911-12 IN THE VARIOUS HOSPITALS OF
Jamaica.
mt z3 2
8g z
éd 5.
2 GENERAL DisEASES —cortinued.
327 (d) Tabes Mesenterica —
TN (e) Tuberculous Disease of Bones —
10 Other Tubercular Diseases —
— Varicella í is —
4 Whoopi Cough 1
1 Ya vs 24 255
4 Yellow Fever .. =
pe LOCAL DISEASES.
104 Diseases of the —
1 Cellular Tissue 611
— Circulatory System 665
Es (a) Valvular Disease of Heart —
a (b) Otner Diseases =
= Digestive System .. 1844
186 (a) Diarrhosa ; —
164 (b) Hill Diarrhea —
Ex (c) Hepatitis : —
= Congestion of Liver —
= (d) Abscess of Liver -—
434 (e) Tropical Liver sis —
-" (f) Jaundice, Catarrhal —
— (g) Cirrhosis of Liver .. —
3 (h^) Acute Yellow ANDES —
= (i) Sprue .. —
— (J) Other Diseases es ss des —
9 Ear .. os 23 is 77
1 Eye .. $ PA T .. 808
=e Generative System ss Js $2 —
1 Male Organs .. a T s UAI
7434 Female Organs .. s a .. 257
= Lymphatic System £s se .. 216
=. Mental Diseases .. ey bs as 23
2 Nervous System .. 5a 2s .. 451
T: Nose . i " Es S
— Organs of Locomotion - bs .. 251
327 a id xn ye T —
87 Skia - E .. 4111
15 (a) Scabies is T 7 sa —
1 (5) Ringworm Ge id ‘ia i —
1 (c) Tinea imbricata — .. " e —
5 d) Favus.. ` in —
— (e) Eczema : sh y - —
83 (f) Other Diseases "E T = —
63 Urinary System .. $ m .. 824
= Injuries, General, Local .. 1800
114 lay Siriasis (Heatstroke) e —
— (b) Sunstroke (Heat Prostration) -—
— (c) Other injuries .. A
4 Parasites : es . 24
— Ascaris lumbricoides a A s 9
3 Oxyuris vermicularis —
1528 Dochmius duodenalis, or Ankylostoma
— duodenale E .. 470
-- Filaria mediuensis (Guines- worm) 7
— Tapeworm .. 3 3 s —
19 Poisons 5
— Snake-bites . —
— Corrosive Acids —
=a Metallic Poisons eae - —
— Vegetable Alkaloids A x is —
278 Nature unknown .. i "e p —
168 Other Poisons ; - js T —
181 Surgical Operations .. P a .. 2268
61 Amputations, Major Es T ia —
14 Minor —
— Other ‘Operations -
68 Eye T A
a (a) Cataract -
— (b) Iridectomy Ps =
— (c) Other Eye Operations es
slons
Deaths
T E
| m
'Ililælelætwaal lil lillllitlall&e
GTB Jalan qq
36 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Health all the latrines in the vicinity of the Outram
emptied into the river. I went up one morning in
& 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 & 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.
W. G. FaARqQUBARSON, 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 case 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
[Mar. 2, 1914.
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, i.e., 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 still 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 he
drained.
G. LEcESNE, M.O.H.
RICHMOND.
There has been a marked general improvement
throughout this district in recent years in the
Mar. 2, 1914.]
structure and accommodation of the houses, and
this tends towards better sanitation.
The whole district depends for its water supply
cu 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. MaraBRE, M.O.H.
ANNOTTO Bay.
The houses of the poorer class are for the most
purt 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
if 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.
COLONIAL MEDICAL REPORTS.—JAMAICA. 37
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. RrircurE, M.O.H.
PorTLAND—HOopE 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.
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 cleanliness 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, CROFTS 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. Strupwick, 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 medical 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
[Mar. 2, 1914.
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 cure 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 public
general hospitals during the year under review as
compiled from the nosological returns submitted by
she 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,
7,995; indentured coolie labourers, 17,822; con-
stables, 569; paying patients, 166.
Hookworm 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 case, 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 anemic and debilitated owing to the fact that
they harbour the hookworm.
It may also be a fact and probably i 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—430 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
faces of seven of them.
Dr. TungroN'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 specific 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. 89
eee
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 larceny 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,
oc 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 cases 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 E aaa Jamaica. Quinine.
One dose for a child of 5 years and under 9.
(4) Medical Department, Jamaica. One dose for
child under 5 years.
i ^ THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Mar. 2, 1914.
SALVARSAN.
During the year the remedy known as ''606 "
The
results have been eminently satisfactory, as is shown
by the reports attached under the heading '* Yaws,"
but the injections do not seem howcver to have the
was supplied to 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 :—
‘“ I 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 astonishing degree after one
injection; & month after I suggested a second in-
jection, but the patient absolutely refused in spite
of the. marked the first
injection.”
improvement after
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 1,489, whilst
the daily average number was 1,183. The number
of patients admitted was 268, or 188 men and 130
women; of these 24 were readmissions. 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 discharged amounted
to 150. Of these 144 were discharged recovered,
number of 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 calculated 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.
75 of the
indications the time is
approaching for preventing those who have suffered
from insanity or who have inherited insanify 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-
crowding, 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.
Hereditary influence accounted for
admissions. There are
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.
Surgeon-General.
PuBLIC MEDICAL INSTITUTIONS.
Public Hospital, Georgetown.
Tuis 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 39 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 285 or 18°9 per eent. 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 eonnection 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 femeles. There were 1,258 patients admitted,
and with 55 remaining on April 1, 1910, make a
total of 1,313 patients treated. The number of
out-patients treated was 4,567. There were 197
deaths, which gives a death-rate of 15 per cent. of
the casés treated. Of the total deaths no less than
135 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 11:3- 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’
32 deaths, which gives a death-rate of 6:83 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.
49 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
RETURN OF DiskAsES AND DEATHS IN 1910 IN THE PuBLIc HOSPITALS,
GENERAL DISEASES.
Alcoholism
Anemia
Anthrax
Beriberi
Bilharziosis :
Blackwater Fever
Chicken-pox is
Cholera
Choleraic Diarrhoa
Congenital Malformation
Debility
Delirium Tremens
Dengue...
Diabetes Mellitus
Diabetes i a
Diphtheria
Dysentery ..
Enteric Fever
hat Deps -—
Febricula ..
Filariasis ..
Gonorrhea
Gout :
Hydrophobia
Influenza ..
Kala-Azar..
Leprosy ..
(a) Nodular ..
(b) Anæsthetic ..
(c) Mixed
Malarial Fever—
(a) Intermittent
Quotidian ..
Tertian
Quartan
Irregular ; i
Type undiagnosed l
(b) Remittent ..
(c) Pernicious ..
(d) Malarial Cachexia..
Malta Fever
Measles
Mumps .. e
New Growths— ..
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra ..
Plague
Pysemia
Rachitis
Rheumatic Fever
Rheumatism :
Rheumatoid Arthritis
Scarlet Fever
Scurvy ..
Septiceemia
Sleeping Sickness
Sloughing Phagedena E
Small-pox ..
Syphilis
a) Primary...
b) Secondary ..
(c) Tertiary
(d) Congenital ..
Tetanus
Trypanosome Fever
Tubercle—
(a) Phthisis Pulmonalis i
b) Tuberculosis of Glands ..
c) Lupus
Adinis-
på gi
Cn sions
Em
or)
c
2! lelosal ll | |
-1 O0»
E
N
SllialllSlilselleea
pos
IIIB agas
British Guiana.
as TEE ge pegg | Pees
| o
ipj lweSm2llllwseelllilsSelll&llll
on!
II Èl Goel tel TIS:
no = Total
e
maomaralesl il earl | | $e C
GENERAL DISEASES— continued.
(d) Tabes Mesenterica es
(e) Tuberculous Disease of Bones
Varicella
Other Tubercular Diseases
Whooping Cough
Yaws
Yellow Fever
Diseases of the—
Cellular Tissue
Admis-
sions
LOCAL DISEASES.
Circulatory System ..
(a) Valvular Disease of Heart
(b) Other Diseases ..
Digestive System —
(a) Diarrhoea
(b) Hill Diarrhea ..
(c) Hepatitis
Congestion of Liver
(d) Abscess of
Liver
(e) Tropical Liver ..
Jaundice, Catarrhal
g Cirrhosis of Liver
) Acute Yellow Apa"
1) Sprue
Ear
Eye
(j) Other Diseases . MS
Generative System— e
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervous System
Nose x
Organs of Locomotion
Respiratory m
kin—
(a) Beabies -. T
(b) Ringw
(c Tinea TubHsdis
(d) Favus .. ,
(e) Eczema .. ne
( f) Other Diseases ..
Urinary System
Injuries, General, Local—
(a) Siriasis (Heatstroke) 35
(b) Sunstroke (Heat R
(c) Other Injuries
Parasites—
Ascaris lumbricoides ..
Oxyuris vermicularis .
Dochmius duodenalis, or Ankylostoma duo-
denale
Filaria medinensis (Guinea. worm)
Tape-worm
Poisons —
Snake-bites
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids
Nature Unknown
Other Poisons
Surgical Operations —
Amputations, Major ..
Minor ..
Other Operations
Eye
(a) Cataract
(b) Iridectomy .. .
(c) Other Eye Operations
. Lom
14681 LL 1] 11S ISI
|
Deaths
co
e
IILI ISI iol gI ZG!
[wn
Q Cx
Co + BS OC» OD
sid rr eu
Ld Fie Ea eV |
[Mar. 16, 1914.
Ei
FX YY4 T5 ld-v 4434
Mar. 16, 1914.]
Leper Asylum.
On April 1, 1910, there were 287 males and 120
females in the Asylum. During the year 67 males
and 29 females were admitted, and on March 31,
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 84,916 lb., valued at $349.16
Cassava 23,732 ,, 4 237.32
Greens "T 487 ,, - 2.43
sweet Potatoes 609 ,, 5 6.09
Arrowroot 204 ,, n 1.00
Coco-nut Oil ... 20 galls. _,, 25.20
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.
Georgelown.
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 ut 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.
(5) Moruca River.—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.—114 miles from Potaro Landing and
provided with six beds for the reception of urgent
cases.
(7) Albouystown.
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 43
. ———————— —
The following table shows the number of persons
treated : —
Police
Dispensary patents — patatas Paupers
No. 1 n ads 763 .. — 3,279
Albouystown 2,184 .. — 5,520
No. 2 "T M 610 .. — 4,868
No. 3 e a 567 .. — ... 8,901
Demerara River... 242 ... 22 .. 489
Berbice River 2x 853 .. —— .. 863
Upper Pomeroon ... 133 ... 24 .. 778
Lower Pomeroon .. 3969 ... 47 .. 641
Moruca T 13 .. -— .. 1,221
Total ... . 5,994 93 21,055
The following Missions were supplied with medi-
cines free: Mallali, Chalk Hill, Sand Hills, Orealla,
Suxacalli, Capoey Luke, 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 ... .. 135 .. 15 1
New Amsterdam hu 27 uu 10 —
Suddie ... es sai 19 .. — —
Total .. .. 3907 25 8
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
vear, 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,
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
7,900 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 vaceinations
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
94:4 per 1,000 and the birth-rate 27:5.
The remarks of the Resident Surgeon of the
Publie 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, stil 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 afticted to take advantage of the
tuberculosis ward at the Public 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
44 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. (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
Mahaica 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 be carried
out. When he left his instructions 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 leprae
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 benzovl chloride in 24 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 scale. 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 Deyeke, 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 Deyeke found in the nodules of
lepers. It is combined with benzoyl chloride, 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 effected by the nastin
attaching itself to the leprosy bacillus, after which
the benzoyl acts upon the baeillus, 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE, MARCH 16, 1914.
LONDON SCHOOL OF TROPICAL MEDICINE.
44th Session. January— April, I914.
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.8.), 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 DOCES, 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 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
L. VERNON CARGILL, Esq., F.R.C.S. G. C. LOW, Esq., M.A., M.D. . 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.R.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.S.
Dean--Sır 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., 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, 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 versá.
Chief Office—SEAMEN’s HOSPITAL, GREENWICH, S.E.
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 diseuse, 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 cases
could be regarded as early, or favourable, instances;
only 87 per cent. had had the disease to their know-
ledge for less than two years. Itis 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 etfect 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. 45
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
confess 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.''
Ankylostomiusis.
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 systematie 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 NunsE-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 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 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 Public 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 districts: Mahaicony,
Pomeroon, Moruea, 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 specimens 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
Sehools 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 2} per cent.
and 5 per cent. of benzoyl chloride, 1 e.c. 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 caes 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 inereased to 2 e.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 advaneed
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
ulcer or phlyctenules, treatment was temporarily
suspended until the condition improved.
Experiments are still being carried on; the results
so far may be summed up as follows :—
ll per cent. showed slight or no destruction.
32°8 T P medium destruction.
14:2 5 F advanced destruction.
12:0 M " very few bacilli.
37-1 ae a no bacilli.
4:2 is " died.
The above cases were treated under strict obser-
vation and frequent estimation of the destruction
of baeilli 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 chlorine 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 cases were selected for treatment with
chlorine water, as suggested by Dr. Barnes. Each
case was carefully demonstrated to have a large
number of ankylostome ova present before investi-
gation started.
Of these cases three were treated as follows:
14 oz. liq. chlorine was administered at 4, 5 and
Mar. 16, 1914.]
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 ease 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 sime 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,
l 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 3 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, 4 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-
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. 47
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. Causes 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
cases, 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
e
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. pyocyaneus 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
erows whieh abound in the town to the roofs from
which the water supply of the town is collected.
| E. P. MixrET.
PusBLIC 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 824 on January 10, 1911, and of females
the highest number was 248 on October 24, 1910.
The highest total number of patiente 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 picked 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, 180 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, 1,848. 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 desths 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 499 deliveries in the Maternity Ward
with 18 deaths, 7 of which were due to eclampsia
and 1 to septicemia. There were 73 stillbirths and
39 abortions.
There remained in hospital on March 31, 1911,
976 males and 220 females; total, 496. The out-
door patients for the year were 16,617 males and
25.991 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 32 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. GRAIGEN.
PuBRLIC HOSPITAL, NEW AMSTERDAM.
The Public 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. McKrxnon.
Pusiic HospitaL, SUDDIE.
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 capaciby
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 185 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. SHotto DOUGLAS.
April 1, 1914.]
COLONIAL MEDICAL REPORTS.—BRITISH GUIANA. | 49
Colonial Medical Reports.—No. 32. —British Guiana—
(continued).
PusLic 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,
Ward, 11 beds; total, 35.
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, 9 within seventy-two hours. The
death-rate on the total treated was 11:3.
J. TEIXEIRA.
N.W.D.
The hospital at Morawhanna has accommodation
for 14 male and 11 female patients.
The Arakaka Ward has accommodation for 12
patients.
During the year under review the number of
admissions was as follows, viz.: Males, 838:
females, 149. There remained in hospital from the
-previous year: Males, 11; females, 6.
The number of deuths in the institution during
thé year 1910-1911 was: Males, 26; females, 6.
The principal diseases treated this period were:
e fever, diarrhea, dysentery, anchylostomia-
, pneumonia, and phthisis.
de death-rate on total number treated was:
Males, 7:4 per cent. ; femialés, 9:8 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
l1 female. Of those died within sev enty-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 drinking purposes
for patients in the hospital is liable to frequent and
24 beds; Female
Pusuic HOSPITAL, MORAWHANNA,
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
SV stem, 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 troolic,
whieh presents a similar menace to the anne at
Morawhanna and should be removed.
Regular district 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, anchylostomiasis and gastro-intestinal dis-
turbance were among the chief ailments. Free
medicines have been regularly supplied to the
Mission at St. Bede’s, where many of the
aboriginals congregated. Quinine has bgen 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.
GEO. E. CARTO.
" PusLIc 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 seulleries 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
buekets with covers have done good service and have
worn well; their advantages in rainy weather have
been well demonstrated.
50
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 JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [April 1, 1914.
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 music-
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
uf 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
E E E E
Mon w= LZ a
ONTH PE EE i8 | iE
5 É &- & 4
January 126:0 140:0 69 0 84
February 105:0 | 1410 | 690 | 87
March 138 0 142-0 68-0 90
April 199-0 141:2 71:0 87
May 181:0 | 1420 | 72:0 | 90
June 96:0 140:0 71:0 85
July 110:0 | 1410 | 720 | 86
August 117-0 141 0 74:0 90
September 129:0 | 1410 | 720 | 90
October 121:0 141:0 73:0 | 90
November 113:0 140:0 720 | 8T
ecember 1940 | 1410 | 710 | 86
mo coder EUR WIENER XL A 2
Averages ^| 119: | 1409 | 712 | 87-
Pa R T
RAINFALL WINDA
| 1 g | |
—- bus c =» :
E — eg Ez c | ie be
d o së | E | 86 | gb | i9
| g5 <2 A=z Os i «
1 a
[ams am | | am | 0.4
5:8 *656 5:00 | 720 | N.E. | 159-0
5-0 | -699 277 | 740 | N.E. | 924
77 635 0-96 640 | N.E. | 195:8
6-0 718 1°67 | 700 | N.E. | 1393
5:9 145 941 ` 720 E. 187-1
3-6 ‘801 | 19-36 82-0 E. | 1014
47 "787 5:59 71:0 E. | 1420
44 :819 7:98 75:0 E. 195-6
| 47 898 7-86 77-0 E. 97-7
| 55 :812 3:15 74:0 | S.E. 60-8
| 47 795 5:86 770 | E. 187-5
' 40 ‘746 | 564 77-0 E. 180-4
52 | -752 | 5-76 | 74:2 E. | 1241
* At Richmond Hill Meteorological Station in the South of the Island,
April 1, 1914.]
RETURN OF STATISTICS OF POPULATION FOR THE YEAR 1911.
Pee of Colony at census on April 2,
ET -— M s 66,750
Estimated births from April 8 to December
31,1911 ... eg -— .. 2,024
Estimated deaths from April 3 to
December 81, 1911... Se 905
Increase of 1,119
67,869
Excess of emigration over immigration 21
Estimated number of inhabitants at
December 81, 1911 m e 67,818
CoLony HosPrTAL.
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 ... e. 971 ... 1,081 848
«i m discharged cured 674 627 462
5 5 relieved 169 298 ... 250
- i who died .. 96 .. 97 .. 52
js s remaining De-
cember 81 .. ess Xm vee 92 uu 69 ... 79
Average stay of all patients in hos-
pital... E a te .. 907 ... 302 .. 3062
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
duriny 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 us 1,082
Payment s es ihe 720
Number of Attendances.
Pa-pers ... wile ee 40
Labourers’ children es ste 324
Aged ae m - m a 68
Police constables ve 164
Labourers 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 films.
| R. P. CockIN,
Resident Surgeon.
COLONIAL MEDICAL REPORTS.—GRENADA. 51
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
applicable 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.
St. ANDREW’s District HOSPITAL.
The admissions for the last five years are de-
tailed beneath :—
1907 1908 1900
Admissions 145 166 150
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
Public 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 district dis-
pensary is given beneath as it affords some indica-
tion of malarial fever treated in the district :—
1911
166
1910
165
1907 1908 1909 19 0 1911
13 1b. 4 oz. ... 121b. 8 oz. ... 15 Ib. ... 121b. 8 oz. ... 11 1b. 2 oz.
The reduction in the amount used is due to a
subsidized dispensary in Dr. Whiteman's district,
established in 1910.
N. S. DURRANT.
BELLE Vure HosPiTAL, CARRIACOU, GRENADA.
Seventeen patients remained in from the previous
year and 196 were admitted—making a total of 213
treated for the year.
The average number of patients per day was 20:5.
Two deaths occurred 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.
Return or Diseases AND DEATHS IN 1911 iN THE CoLony, Yaws, St. ANDREW’s AND Carriacou HOSPITALS.
GENERAL DISEASES.
Admis-
| = ions
| | o H5 sions
Alcoholism
Anemia
Anthrax
Beriberi
Bilbarziosis
Blackwater Fever
Chicken-pox T
Cholera
Choleraic Diarrhoea :
Congenital Malformation
Debility Se
Delirium Tremens
Dengue ..
Diabetes Mellitus '
Diabetes ie
Diphtheria
Dysentery ..
Enteric Fever
Erysipelas . .
Febricula ..
Filariasis ..
Gonorrhea
Gout ER
Hydrophobia
Influenza ..
Kala-Azar..
Leprosy .
(a) Nodular.
(b) Ansesthetic ..
(c) Mixed
Malarial Fever—
(a) Intermittent
Quotidian ..
Tertian
Quartan
Irregular ..
Type undiagnosed
(b) Remittent ..
(c) Pernicious .. ,
- (d) Malarial Cachexia..
Malta Fever .
Measles
Mumps *
New Growths— .. bs
Non-malignant a
Malignant
Old Age |
Other Diseases
Pellagra
Plague
Pyzemia
Rachitis .
Rheumatic Fever
Rheumatism ,
Rheumatoid Arthritis
Scarlet Fever
Scurvy
Septicsemia gs
Sleeping Sickness
Sloughing Phagedeena
Small-pox .. 23
Syphilis
a) Primary y
lo) Secondary .. ja
(c) Tertiary 2x
(d) Congenital ..
Tetanus
Trypanosome Fever
Tubercle—
(a) Phthisis Pulmonalis
(6) Tuberculosis of Glands ..
(c) Lupus i
ies
Grenada.
Total
Cases
priest ere
reated
Admis-
sions
GENERAL DisEASES— continued.
(d) Tabes Mesenterica s —
(e) Tuberculous Disease of Boues TI
Other Tubercular Diseases s .. —
Varicella : ; —
Whooping Cough —
Yaws i bs 2
Yellow Fever $e e is "d ooo
LOCAL DISEASES.
Diseases of the—
Cellular Tissue is m is .. 37
Circulatory System .. ha æ. —
(a) Valvular Disease of Heart .. .. 84
(b) Other Diseases .. T Ps .. 34
Digestive System— .. .. zs oo
(a) Diarrhoes - "m gi
—. (b) Hill Diarrhea .. 5 E REO —
(c) Hepatitis — . oe vs = 4
Congestion of Liver .. m e m
(d) Abscess of Liver 1
(e) Tropical Liver .. - a oo
(f) Jaundice, Catarrhal .. T T 1
9) Cirrhosis of Liver Sa i 5
) Acute Yellow Auto o>
Là Sprue .. id : a 0 ==
(j) Other Diseases .. fs - .. 83
Ear m T vs bs és 4
Eye - "T zs .. 48
Generative System— X Ra P ee --
Male Organs we T. 2s .. 85
. Female Organs i% M ES .. Of
ps System .. is ex se 17
ntal Diseases 2 - = - 5
Nervous System se ale d .. 20
Nose vs ; ay bá dá 7
Organs of Locomotion ja " .. 90
Respiratory iiis = ba 2 .. 92
Skin— `.. in - s oo
(a) Scabies .. es ere iu e. —
(b) Ringworm dd Vu e —
(c) Tinea Imbricata T T oo
(d) Favus .. - s one o>
(e) Eczema .. = - - sce 3
( f) Other Diseases ..
Urinary System : is 2s .. 64
Injuries, General, Local— Js e —
(a) Siriasis (Heatstroke) Bs 1
(b) Sunstroke (Heat gg. —
(c) Other Injuries .. | T: .. 82
Parasites — oe T i i 3
Ascaris lumbriooides .. 2
Oxyuris vermicularis . 1
Dochmius duodenalis, or Ankylostoma duo-
denale ; i . 108
Filaria medinensis (Guinea. worm)
Tape-worm i T i
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 .. š
(c) Other Eye Operations
elwlS-selll-lllz-l
Deaths
Lleol tl lil
ILleslllitlil2eelw!ewelllelletltitl!llhsawlc
[April 1, 1914.
m
M»
t2
c Oo
OD =
40
el reed E teh we
pė
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.
Ulcers 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 We tts, M.B.,
Medical Officer, Carriacou District.
Lunatic ÁsYLUM, hicuMoND 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.
Lucia having been stopped, on account of the over-
crowded state of the asylum.
The year opened with 184 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
ES —— —À — ———— M —
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.—ST. 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 pieta ọver 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 (2,853)
legs 300 to Woburn and 200 under section 5 .. 1,853
Excess of births over deaths from April to Dec. 31... 48
Total ... TN .. 6,687
Population m s e es .. $6,687
Births during the year saa ae: i bou ed 182
Deaths during the year.. a F a ais 97
Birth-rate per 1,000 - Ds UY A .. 27°42
Death-rate per 1,000 14:61
The population return for the previous year was
given as 7,511, but I &m inclined to regard that as
excessive and to place more reliance on the present
figures. No account is taken in this calculation 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 epidemic of influenza; this epidemic 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.
the year would be instrumental in determining the
increased amount of sickness recorded for that
period.
Particular Diseases that have occurred 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 118 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
uttributed to it was 4, all being among children
from 2 45 years and under; the fatal result in three
cases 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 case of black-water fever, seen in
a child aged 5 years, occurring at Grand Mall,
outside this district; 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 case 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 class. |
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
treatinent 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.
[April 1, 1914.
—————— TIENE meee,
Typhoid Fever (Enteric).—Two cases were seen
for the year; of these only one originated in the
distriet, 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 occurs among the poorer class of
patient.
Ankylostomiasis.—During the year, of twenty-
seven cases seen and recommended for hospital
treatment, only five originated in this district; two
in town, two at Grand Anse, and one at Woodlands
the remaining twenty-two came from differen
localities over the island. This district can be con
sidered to suffer very little from this disease; at any
rate, it is rare to come across a ease that exhibits
the characteristic anæmic appearance which stamps
those that harbour, to à 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 angmia, or, indeed, symptoms of any descrip-
tion whatever. One must be careful, therefore,
to avoid concluding that the ankylostomum is the
cause 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 can be ascertained to have originated here;
I naturally conclude that in this case the infection
took place in Trinidad.
The general sanitary condition 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
cases 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 year 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]
—— —- - --— —— . - —
meen — a — o M ——-
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-vaccination 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 passengere ex-
amined daily during periods of surveillance, 865;
the number of Bills of Health issued was 176.
G. W. PATERSON,
Medical Officer, No. 1 District.
District No. 2.—RicnMoNp HILL.
The estimated population is about 4,500, and
includes one of the most desirable residential dis-
triets 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,
whieh 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
eases, 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
L REPORTS.—GRENADA. 55
— — — pms EA —
long distances, and is deficient both in quantity and
quality. A fuir 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. Harton,
Medical Officer.
District No. 3.—St. GEORGE’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
increase in this district. Formerly it was prac-
tically 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 District 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.
T. C. Onronp,
Medical Officer, No. 3 District.
District No. 4.—GovYvavE.
The general heelth 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 epidemic of pertussis, and in the latter
part of the year the general health of both adults
and children was disturbed by an epidemie 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 1s 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
cases 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 stil 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.
Ana mia.—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 Ordinance, 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. district, without control or supervision, and
so the vicious cycle is established and the expendi-
ture for the eradication 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
possihle prophylactic measure was carried out in the
first place by me, and subsequently by Mr. Saunders,
disappear to a great extent.
[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 casc
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:—
Ist quarter os E E e. 55
9nd ,, a Eus A igh. 299
3rd ,. iud is XT ... 40
4th ,, mea . 39
Sanitation and Anti-malarial Misa: 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,
whieh is very prevalent in this neighbourhood, will
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, wil have to be very
vigilant in order to prevent any ill-effects, 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; a
total of 258 cases (successful) were performed and
the district continues well protected against small-
pox. The lymph continues to give satisfactory
results. |
R. D. O'’NFALE.
April 15, 1914.]
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; 3rd 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, occurred 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
year.
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. 2S
Nothing is heard nowadays from the dwellers in
COLONIAL MEDICAL REPORTS.—GRENADA. 57
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 on 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. | nar
. H. BrisHoP,
Medical Officer, No. 6 District.
District No. 7.—St. Patrick's.
The estimated population based on the census of
April last is 6,897. 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 n m 2 D 18
February ; T at 24
March .. 19
April 12
ay T
June 5
July . 9
August 11
September 9
October 15
November 11
December 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
= ——— ee
— =. re pa a ————— LL VL
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
certificate 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 certificate several other members assist
in making or selling the bread without so doing.
The Ordinance is a good one, and in the interest
cf 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. " District.
58 THE JOURNAL OF TRO MEDICINB AND HYGIENE.
[April 15, 1914..
District No. 8.—ST. ANDREW'&.
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 ^ 1810 1911 -
Birtbs 661 EM 731 d 660 4. . 695... 703
Deaths 831 .. 400 .. 422 .. 459 . 869
About a third of the children born in this parish
die before passing their fifth year—see figures given
below :—
1909 1910 ` 1811
Births .. ... 660 ... 695 ... 705
Deaths of children 5 y cars old and under ... 985 ... 956 ... 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—
. 1000 1910 1911
60 is ob T 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 lust Three Years.
Deaths .. i 1,250
Less children under 5 years.. is ... 709
l | 541 |
Deaths at 60 years and over... T sus 168
Deaths between 5 and 60 years im .. 878
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 panerai 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.
1908 1911 1909 1906 1910 ,
1907
Rainfall 61:27 ... 71:2 ... 84:82 ... 91-57 ... 98:16 ... 11270
Deaths 831 ... 400... 869... 422... 444... 459
Remarks on Particular Diseases that have occurred
during the year.
Malaria.—The deaths attributed disestiy 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]. .
—
—————— n
COLONIAL MEDICAL REPORTS.—GRENADA.. . 59
—————— À—— —— - a áád— —
PREVALENCE OF SICKNESS AND RELATIVE MORTALITY IN THE DIFFERENT SEASONS,
DgaATBHS DUE TO DISEASES OF
: Labourers in
T Heint j | i | their e
Mt. i TE spi : Other preecr
Horne | WW LT | Taca moma | Tor
January 4:83 18 15 5
February 5:96 18 11 | 6 |
MAE S 2-97 8 9 , 2 |
April ... 2:98 8 1 | 4 |
May 4:56 4 4 1 |
June ... 15:69 5 4 | 2
July -... 4-91 4 8 | 9 |
August 8:24 11 2 2
Beptember 13:49 11 6 2
October 5:56 9 4 9
November 10-02 11 7 9 |
December 6-28 11 8 | 8 |
| 84:82 118 79 | 33
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.--Gonorrheea 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 diarrhcea.
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 agricultural cultivation in certain defined areas
of the town should be under sanitary jurisdiction
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.—I regret the slaughtering of cattle is
still a public 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.
Vaceinations.—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 (809) 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 aceurate 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.
Malarial fevers were the chief causes affecting the
publie health; there were no serious epidemie
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-
metically sealed with rags, &c., to keep them out.
Vaccination was very thoroughly performed in
this district 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,
especially, 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 gonorrhcea
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;
but as the local authorities are now offering more
convenienees and inducements to the publie, 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.—S-r. 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 eannot 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, diarrhea, malarial fevers, dysen-
tery, &c., but none assumed epidemic proportions
and none deserves special mention.
The cases of yaws met witu were sent to the Yaws
Hospital. Several cases of this malady were dis-
covered and reported to me by the police and district
sanitary 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 publie health standpoint, that
is nearly as useful or urgent.
À 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
calls 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.
——————
——— ——— ——— M —M— ——— -——
COLONIAL MEDICAL REPORTS.—GRENADA. 61
ee ee
CanBIACOU DistricT.—BELAIBR, 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, 35°4 per 1,000;
death-rate during 1911, 18:21 per 1,000; number of
stillbirths, nine.
The birth-rate was higher than the previous year,
35°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 13°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 diarrhea, 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.
Sporadic 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 zs, M.B.,
Medical Officer, Carriacou District.
62 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Aem
_ 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.
-Is Ashanti and the Northern Territories the rains
commence earlier and end later, with à break
during July or August, which is more marked the
farther north. the observations are taken. In the
Golony this break is less noticeable, and the rainy
season as a Whole is shorter.
Malaria begins to rise slowly soon after iiei rains
set in, and reaches its greatest height in August.
There is then a fall, and a second but smaller rise
im 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 und these pools
remain for longer periods that the great rise in the
malarial rate takes place. The smull 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 fulls must also be
attributed to some extent to increased vigour in the
prosecution of prophylactie meusures.
. 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 partieles
of sand it carries. The later rise from July onwards
is accounted for by the general dampness and the
frequency 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
due 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
decrease in the number placed on the sick list, there
was a considerable increase in the number of days
during which officials were ill, and there was also
a slight increase 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-
creasing year by year; that of the others, however,
varies considerahly, and much difficulty is experi-
enced in obtaining as accurate figures regarding it
as ure available in the case of Government officers.
The system in vogue 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 un 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.
i 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.
Guols.—The general health of convicts was not
good. Although the number undergoing sentences
wis 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
cases 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.
H
RETURN or Diseases AND DEATHS iN 1911 1N
Ashanti, Northern erent: Gold Coast Colony.
SENERA: DISEASES.
Alcoholism
Anemia...
Anthrax ..
Beriberi
Bilbarziosis ii
Blackwater Fever
Chicken-pox ae
Cholera l
Choleraic Diarrhoea i
Congenital Malformation
Debility ; b
Delirium Tremens
Dengue ..
Diabetes Mellitus
Diabetes Ionipidus
Diphtheria i
.Dysgentery ..
Enteric Fever M ae Am
Erysipelas . . "AES es ai
Febricula .. n
Filariasis .. .. T ds m «à
Gonorrhea s T sa zs
Gout - .
Hydrophobia sa
Influenza .. vd vi
Kala-Azar..
Leprosy ..
(a) Nodular...
(b) Anesthetic ..
: -(e) Mixed
Malarial Fever—
(a). Intermittent
Quotidian ..
. Tertian .. s T
Quartan: .. v T i T
" Irregular . T iux — qu
Type adinin.
(b) Remittent $4 gs
. (c) Pernicious ..
. (d) Malarial Cachexia . .
-Malta Fever ;
Measles ,
Mumps .. F
New Growths— .. ki
. Non-malignant ga
.., Malignant
OldAge .. a x V i
Other Diseases .. is sä oe
Pellagra. ..
Plague
Pyemia |
Rachitis ..
Rheumatic Fever T e ;
Rheumatism - M M A
Rheumatoid Arthritis |
Scarlet Fever
Scurvy
Septicemia fa
‘Bleeping Sickness
Sloughing Phagedena
Bmall-pox.. vs
‘Syphilis .. En
2 Primary ..
b) Secondary .
(c) Tertiary ..
d) Congenital ..
‘Tetanus ..
anosome Fever -
rcle—
(a) Phthisis Pulmonalis
i. Tuberculosis of Senet i oe cas
-Lupus | ;
co
ITE E d ast d d
on
e
f , | i Deaths
PE bolt TL oat bet Beil] osii] Ef mallei Peco ie ILII E eit egiii bell.
co
em pos
DO wn
[Salli !llSlaiec
GENERAL DisEASES— continued,
(d) Tabes Mesenterica vs
(e) Tuberculous Disease of Bones ..
Other Tubercular Diseases
Varicella .. i i.
Whooping Cough
Yaws A ‘ T T
Yellow Fever "m Vs T
LOCAL DISEASES.
Diseases of the—
Cellular Tissue
Circulatory System ..
(a) Valvular Disease of Heart
(b) Other Diseases .. i
Digestive System —
(a) Diarrhoea e
(b) Hill Diarrhea ..
(c) Hepatitis T
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver ..
(f) Jaundice, Catarrhal
ip) Cirrhosis of Liver
) Acute Yellow AGODA.
(à Sprue i
(J) Other Diseases ..
ng m ae
Kye id
Generative System— .
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervous System
Nose .. T
Organs of Locomotion e.
Respiratory. prem e ks
Skin— .. e vs vs
rm
Tinea Imbricata
(à Favus .. bi
(e) Eczema .. "m
( f) Other Diseases . T
Urinary System ET
Injuries, General, Local— $5
a) Siriasis (Heatatroke)
(b) Sunstroke (Heat Prostration)
(c) Other Injuries... T
Parasites — me is
Ascaris lumbricoides .. es
Oxyuris vermicularis ..
Dochmius duodenalis, or Ankylostoma duo. |
denale vis
Filaria medinensis (Guinea. worm)
Tape-worm , ;
Poisons— is
Snake-bites ..
Corrosive Acids vs
Metallic Poisons
Vegetable Alkaloids
Nature Unknown us s
Other Poisons $5 is
Surgical Operations— .. T
Amputations, Major ..
Minor ..
Other Operations .
. Eye .. 2"
(a) Cataract T
(b) Iridectomy .. S aA
(c) Other Eye Operations. e
508
i |
*
[|
oa ie ee |
llel! lasl i FILIS S= owl l IIITIEITILI E Ssa]
T
948
TES | re
es ii ae
^ — tos.
64 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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 precincts of bush and weeds, carrying water
and collecting firewood. 3,930 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,
29,293, 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. a
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 Hospitel 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 & 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-pox.—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 nof 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.
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 haye 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.
THE NORTHERN TERRITORIES.
MEpDIcAL REPORT.
OvT 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 causes; 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; accident (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. "E
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
——M — ——
——— —— -
The average number of days spent on the sick
list shows a large increase on last year, this being
caused by the length of time some of the patients
had to remain in the Northern Territories before it
was eonsidered advisable to allow them to undergo
the long journey to the coast.
Native Troops.—The company of the Gold Coast
hegiment 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 distriets.
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. TwEEDY,
Provincial Medical Officer.
DEG eae NTRS —— ———
SANITARY REPORT.
Trypanosomiasis.—During 1910, about fifty cases
of sleeping sickness 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.
66 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(May 1, 1914.
- 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 314 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
occurred 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
124 mile camp.
The Cape Coast Town Council passed some excel-
lent by-laws with & 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 Ordinance 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 cases 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 17:05 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 statistics 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.
25,399 vaccinations were performed throughout
the Colony during: the twelve months; of these,
14,069 were successful, and 11,880 unsuccessful.
In the previous year 13,614 individuals were vac-
cinated. l
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 vacoinators 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 end
for the introduction of small-pox into fresh villages.
Dysentery.—The records of the various hospitals
show that 470 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 expect, for many yeurs 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 & 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 Tania 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
difficulé 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 à 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 public 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 88 carts are in addition
in daily use. About 21 loads of tin cans and other
incombustible 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-
6 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 1, 1914.
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) boaste 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 rein-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. Ina short time there will
be but few that have not similarly been dealt with.
Drainage.
There is little or no sub-soil drainage. About
8,6084 yds. of masonry drains were constructed
during the year, and 6,041 yds. of ditches dug and
graded.
Extensive drainage schemes ere 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 of 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 4,581,749 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 obtai-
able from the Director of Education.
May 1, 1914.]
an —— —— —— — —— M 2. —
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, &c., 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 ab
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 epidemics 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 medical 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
thousand years ago. |
At the same time there has to be noted a steady
annual inerease 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-
70 THE JOURNAL OF TROPICAL DH AND HYGIENE.
culosis, diarrhoea 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 i 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.
Typhotd 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 Fever.—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
breught 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 has followed
the expert management of the Nile should be a
_ {May 1, 1914.
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-poz.—ln 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. |
Mularia.—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 Spiralis.—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 alcoholism 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.)
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
Hailway, populous centres (e.g., Hankow, Peking,
and Tien-tsin) will be brought within & few days of
Canton, which is an endemic 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 epidemic was afforded by the
Manchurian 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
ineubation 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 485 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
COLONIAL MEDICAL REPORTS.—CHINA. 71
a E E es —— +
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 diarrhoea, 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. Moorneap, 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, which 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 epidemie 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 epidemie in May the approximate number
of deaths was estimated at 200 per diem.
It is impossible, Dr. Davenport says, under
79 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
existing circumstances 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
increased 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
tropics.
E. C. Davenport, M.B.Lond., M.R.C.S.,
L.R.C.P.; HERMANN BarraN, M.D.,
DB.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-
somum 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
[May 1, 1914.
erustation, 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, 88 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. |
À 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. Á
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. Ulcerations and infiltrations were in
the ileum, solitaire folliculi, and Peyer’s patches—
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]
I—————l————.-
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.
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
cases 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 most
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 i 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. UrsAnek, 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
accepted theory that the Chengtu plain was origin-
alfy a large inland lake, the waters of which in the
course of ages cut 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
A
COLONIAL MEDICAL REPORTS.—CHINA. | 73
"The starving population stripped in,
a seaport rather than a far inlund 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 whieh
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 anemic. 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 tive 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
eatarrhal appendicitis in a Chinese who had been
acting as cook for foreigners during a number of
years. |. — EP"
"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.
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
hus also supplied un X-ray plant, which is used
in conneetion with the training school. I am
indebted to His Britannie Majesty's Consul-
General, Mr. W. H. Wilkinson, for the following
report of their work : —
The French Mission médieale in Szechuan is
paid partly out of the ''allocation spéciale ’’ for
scientific missions abroad, and that forms part of
the annual vote for the Ministere des Affaires
Etrangeres, 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 Hopital 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 "—Aall 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. Mouillac, 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 complement 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
"amnfirmier ". (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. Mouillac 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
(99° F. to 1029 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
at 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. WorrENDALFE, L.R.C.P. & S. Edin.
Foocuow.
Population 650,000. The capital
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 illness of a remarkable nature among foreign
residents. In spring and autumn there were
numerous cases in the foreign community of
influenza and muscular rheumatism. Diarrhea
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
of Fokien
May 15, 1914]
COLONIAL MEDICAL REPORTS.—CHINA. 75
mountain tops at Kuliang, where the highest
temperature in the shade seldom exceeds 82° I.
The temperature at Kuliang is normally 10° or
159 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 ot
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. Rennizt, 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 versa. 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 typhoidslike fevers are of fre-
quent occurrence, and are no doubt caused 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. Diarrhoea 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.
Tuberculosis is very 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
eommon ; 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
disease at out-patient clinics would be more fully
appreciated.
J. A. Tno«sow, B.Se., 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 amebie dysentery. As for appen-
dicitis, I have never seen a case in a Chinese.
Plague and beriberi were absent.
There has been a severe epidemic of phagedenie
ulcers, 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 diseharge. The slough separates in
from seven to ten days, and usually the. ulcers heal
rapidly. The patients were all anemic.
16 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [May 15, 1914.
. 41
Elephantiasis.—Ywo cases of this disease dod
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 to the community. I note
on the part of the Chinese an absolute indifference
and inactivity towards this matter.
In Ichang 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. GRAHAM, 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.
PAKk1IOI.
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. I 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
allaway from the town on high ground with not
much surrounding vegetation and no pools in the
vicinity. 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 attacked 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
epidemic 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 & 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 came 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, ànd
tabes mesenterica. Venereal affections are very
numerous, both syphilis and gonorrhoa in all their
forms. Syphilitic enteritis in children yielding to
hydrarg. cum creta would account for most of the
cases of infantile diarrhoea.
Cases subject to attacks of mania are commonly
seen; melancholia never. I have also never met
May 15, 1914.]
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 TnowPsosN, 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 publie 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 septic 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 pneumonic 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, which 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 include child
mortality, which 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 epidemics beyond the-annual
summer outbreaks of diarrhea and dysentery. The
incidence of small-pox is gradually diminishing,
largely as a result of the growing popularity of vac-
COLONIAL MEDICAL REPORTS.—CHINA. 71
— MA MM —À — € — À À— M MÀ
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-mieroscopical blood germ, is now being
inereasingly 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 agriculture 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
buckets carrying the ordure to depots outside the
walls, which explains the efficient, if not «esthetic,
manner in which the public 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. Dovaraás 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 18,530 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, which borders on
a pestiferous distriet 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 diarrhea, but no case of true cholera was
found where the diagnosis was confirmed by the
public laboratory. Typhoid fever remains an impor-
tant sanitary factor in Shanghai; there were twenty-
78 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
three cases of it, with sixteen deaths. In nearly all
the cases 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,
whieh is now one of the staple products of the
laboratory, and is issued free to any indigent patient.
Scarlet fever, practically unknown in the Tropics,
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 tvpe 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 (660 deaths in all) from this
disease is significant of local conditions of over-
crowding, 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 ineubation 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 Public Health Laboratory appears to be a
busy institution; 20,500 specimens were examined
during the year for pathological diagnosis, including
19,599 rats, of which 240 were found to be plague
infected. Over. 17.000. glycermated calf vaccine
tubes were sent out during the vear.
A. SrANLEY, M.D., B.S.Lond., D.P.H.
TENGYUEH.
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
inalarial 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 Sircar, the Consular Medical Officer,
—————— — ————M—ÓMÀM——— z
[May 15, 1914.
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
virulency 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 LALL SiNcAR ; H. A. WIHAL 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 epidemies. 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 Dra, 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.]
cases of small-pox, scarlet fever, diphtheria and
typhus and on the other hand by the pneumonie
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 quickly from this
disease than Europeans do.
WURU.
Abstracted from reports by Drs. E. H. Hart and
H. S. Houghton.
(Population, 180,000: 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-
irict. 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
COLONIAL MEDICAL REPORTS.—CHINA. 79
—— — o a M
s == —
dysenteries are very abundant, reaching a climax
in numbers in September. Somewhat less frequent
is amcebic 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-
tieally 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 eases 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
traffic 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.
Tuberculosis is increasing 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-
tated and abandoned owing to wholesale infection
by the trypanosome parasite. It therefore becomes
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.18, 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.
Physical 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 105:49 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 13 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. Mc., 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. arsenicalis was prescribed, and he is
now convalescent.
These three men, Ms., H., and Mc., 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 shallaws. Me. swims a little, but spent most
80 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[May 15, 1914.
of his time in the water with his companion Ms.
H. isa 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 (80 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 tho
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 eases 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 diarrhea or dysentery, but with a history
of one or other of these. l
'* (8) 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
vears, but have never known of one to have de-
veloped ascites, but, on the contrary, the abdomen
becomes more and more retracted; dogs, however.
ire 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.—No. 35. —China —(continued).
'"" MORPHOLOGICALLY the adult worm is developed
to live in a free space, as ite 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
COLONIAL MEDICAL REPORTS.—CHINA 81
*
a arm ne pa
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 diarrhoea 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 ell 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 uA 50
$5 ous 3s 27 TE 37
Mr. Me. 5 10 Wi 48
Mr. H. " i 28 js 27
Mr. F. sed 2: 13 i 30
Mr. S. September 10 wea 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 circumstances (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
2 . Large
si hilia. Lymphocytes. Mast cella.
ierit d Per Cen Per cent. NEN
36 11 1 2
34 24 1 4
45 5 O 3
54 17 0 2
89 23 3 5
39 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.
5. 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
39 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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 tu the disease being an embolic
process, ova constituting the emboli. In this case
[June 1, 1914.
no evidence could be found of filurie to account for
the ehylous nature of the fluid. Ascites is the
normal ending to all these cases, so far as Dr.
Thomson has vet noted.
Colonial Medical Reports.—No. 36.—British Honduras.
MEDICAL REPORT FOR THE YEAR 1909.
By J. H. HUGH HARRISON.
Colonial Surgeon,
THE 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
year are as follows: Remaining at beginning of 1909,
38 ; 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.
POooRHOUSE.
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: Steamships, 267 ; schooners, 167;
yawls, 35; sloops, 160; doreys, 210; total, 870.
Number 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]
pardus M MN CC ut ccrurcmiRrratui Spare RENE S lh
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. T held a post-
mortem and found the spleen nodular, very much
enlarged and cirrhosed. All the other organs were
pale and ansmie, otherwise healthy.
Another case of enlarged liver was admitted during
the year. It was a patient of 10 years. The liver
could be distinctly felt about 4 in. below the costal
margin having & 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 a 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;
COLONIAL MEDICAL REPORTS.—BRITISH HONDURAS. 83
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
vegetable 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 tunies 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 Vistting.—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 “fits.”
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 12. 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.
Woman, aged 25. Acute gastritis (alcoholic).
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.
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
year.
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 angwmic. Six
showed marked splenomegaly. The spleens of seven-
Child, aged 8.
[June 1, 1914.
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 angemic 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 infective (creeping)
lobar pneumonia, but from the description given one
cannot form a definite opinion upon the matter.
(5) The incidence 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
ee — ee
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 3,734 8,707
Half-castes 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 305 305
Others 805 812
Total .. 142,761 189,581
The difference between the numbers at the decennial
census for the year 1911, and the total in December,
1911, is mainly accounted for by the larger numbers
of Indians ; the increase 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 noted 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 & 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
epidemie of measles, but for which the total would
have been far more satisfactory.
The birth-rate for 1911 is 32:20 per mille against
91:12 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
T 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 & tropical
country. Account has to be taken of the fact that
& great many Europeans retire from Fiji after a
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 & 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,
&nd 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
——— ——— ee ~
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,
aud 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, 38 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,
86 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [June 15, 1914.
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 epidemic 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 stil 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 & mild degree.
Tinea Imbricata.—A vast numbér 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.
Frambesva.—This disease may be considered to be
slowly and gradually becoming less. The hospital
June 15, 1914]
CODO TAL MEDICALA REPORTS. TEI.
————
RETURN OF DisEAsES AND Dearas IN 1911 IN THE COLONIAL HOSPITAL,
Fiji.
GENERAL DISEASES. E =
| is $ Gi qe
=S € £8 GmanERAL DisgAsES—confinued.
WS um OT (d) Tabes Mesenterica à m.
Alcoholism D. e 6 (e) Tuberculous Disease of Bones
Anemia | o; Other Tubercular Diseases 103
Anthrax EE. ES = Varicella .. ; —
Beriberi iban 3 Whooping Cough —
Bilharziosis vá — — — Yaws . 116
Blackwater Fever — — e Yellow Maver a
Chicken-pox 2 — 2
Cholera — — —
Choleraic Diarrhea — — -— LOCAL DISEASES.
Congenital Malformation — — z
Debility — — — Diseases of the—
pn Tremens fs nm = Cellular Tissue 89
Dengu ; 8i — 84 Circulatory System 25
Diabetes Mellitus — — — (a) Valvular Disease of Heart -—
Diabetes ee — — -- (b) Other Diseases .. —
Diphtheria , — — — Digestive System — —
Dysentery .. 2660 15 274 (a) Diarrhoea s 45
Enteric Fever 17 3 17 (b) Hill Diarrhea .. —
Erysipelas . . — — -— (c) Hepatitis è 2
Febricula .. 106 — 109 Congestion of Liver —--
Filariasis .. — -- —- (d) Abscess of Liver 1
Gonorrhoa 91 1 35 (e) Tropical Liver .. —
Gout : — — — (f) Jaundice, Catarrhal 4
Hydrophobia — — — (g) Cirrhosis of Liver 1
Influenza .. 10 — 10 (h) Acute Yellow se 1
Kala-Azar .. — — -- (i) Sprue . —
Leprosy .. 9 — 11 (j) Other Diseases .. 90
(a) Nodular — — — Ear ze 21
(b) Ansesthetic .. — — — Eye a 47
(c) Mixed — — — Generative System— m --
Malarial Fever— — — — Male Organs 31
(a) Intermittent 3 -- 3 Female Organs 90
Quotidian .. — — — Lymphatic System 26
Tertian — — — Mental Diseases =
Quartan. — — — Nervous System 36
Irregular — — — Nose .. bi —
Type undiagnosed — — — Organs of Locomotion 19
(b) Remittent .. ] — Respiratory oe 124
(c) Pernicious .. — — — Skin— , —
(d) Malarial Cachexia.. — — — (a) Scabies 27
Malta Fever ; ; — — — (6) Ringworm ; 4
Measles 36 — 36 (o) Tinea Imbricata 1
Mumps - 17 — 17 )Favus .. ys —
New Growths— .. — — — (e) Eczema .. p 2
Non-malignant 3 — 4 (f) Other Diseases .. 52
Malignant 7 1 7 Urinary System . 20
Old Age — — — Injuries, General, Local— 118
Other Diseases 28 4 28 (a) Siriasis (Heatstroke) s -—
Pellagra .. — — — (b) Sunstroke (Heat Prost) 1
Plague — - — (c) Other Injuries —
Pyæmia — — — Parasites — T 47
Rachitis oi — — — Ascaris lumbricoides .. —
Rheumatic Fever — — — Oxyuris vermicularis . —
Rheumatism ; l6 — 16 Dochmius duodenalis, or Anky lostoma duo- |
Rheumatoid Arthritis — — — denale : i .. 106
Scarlet Fever — — Filaria medinensis (Guinea. worm) 3
Scurvy -- 1 Tape-worm - m Js —
Septicemia we — — Poisons— =
Sleeping Sickness — — — Snake-bites =
Sloughing ee — — -— Corrosive Acids =
Small-pox . à — — —- Metallic Poisons 1
Syphilis -— — —- Vegetable Alkaloids 1
a) Primary .. 6 — 6 Nature Unknown =
b) Secondary .. 16 — 17 Other Poisons ses
(c) Tertiary .. 27 27 Surgical Operations — =
(d) Congenital .. — — — Amputations, Major .. x
Tetanus .. T 2 2 3 Minor . ai
Trypanosome Fever .. — — — Other Operations a
Tubercle— zc mi E. Eye . ans ais
(a) Phthisis Pulmonalis — — — (a) Cataract a mE
(o) Tuberculosis of Glands . x — — — (b) Iridectomy . e
c Lupus is T — — — (c) Other Eye Operations =
Deaths
Loil
Jes]
poe Ge ask ees ee aes ec NET € a a Peg
PL iti deem Tf
Ll dd td bd T Ees]
88 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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
still 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 so, 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
[June 15, 1914.
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 & 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 station and 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 & 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. |
July 1, 1914]
—— —— — ge
— — —— nS —á—— P— ————ÀM— MÀ — MÀ
———
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 practitioners
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 doso, 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 aud 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.
COLONIAL MEDICAL REPORTS.—FIJI. 89
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 ba 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 Hospital, 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
— ‘a GRECO. auia ee ee er
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 Kuropean—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 latter
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 mugistrate, 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 provincial 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. Lyncg.
PoBLiCcC Lunatic ÁSYLUM, Sova.
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 a
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]
——M -—— —
of well-being. The type of cases admitted is on the
whole a chronic type in nearly all cases.
G. W. A. Lyncg.
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, & 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.
oh 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 oecurred.
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 bas
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
COLONIAL MEDIC
— —— ee
91
AL REPORTS.—FIJI.
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 amooth, 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. InEgraND, D.P.H.
LAUTOKA.
The year was & 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 epidemic form, as this year.
The type of fever now observed is sporadic; it lasts
as a 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 sequels are absent.
The sanitary state of the district is satisfactory,
though the water supply of some of the villages might
be improved. There bas been nothing special to
note, nothing outside the ordinary routine; no official
99 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
vaccinated— Indians, Fijians, Europeans, &c.
H. N. JovNwT.
REWA.
The population, as roughly estimated, is: Europeans,
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—&nd 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 & 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
epidemic 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. es
- 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 a
beginning was made in improving sanitation. Efforts
were chiefly expended in providing for each house a
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.
MAKOGAI.
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 boue, 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 fæces 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 larvæ is expensive aud unsatisfactory when under-
taken by natives. - x:
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. Haut.
LABASA.
The population of this district as shown at the
census taken in April, 1911, was as follows :—
Males Females. Total
Europeans s AZO +44 65 .. 194
Half-castes vx 66 sn 57 .. 123
Indians .. .. 4,278 2,470 .. 6,748
Polynesians .. 60 E 1 - 61
Others .. $a 94 7 31
Total .. 4,557 2,600 7,157
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.]
E —À — — ——— o —— — — A M —
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
&n indentured immigrant, from the Naleba estate,
newly arrived in the district.
Varicelia.—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 cases 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-
vinoial hospital, with 3 deaths; and 31 in the
gaol. A few cases occurred during the year among
Europeaus 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
COLONIAL MEDICAL REPORTS.—FIJI. 93
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 gonorrhoea 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 wascommon,
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 a
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 &nd doors at the entrances, to exolude
fies; the whitewashing aud repairing of floors in line
94 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
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; and 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.
[July 15, 1914.
Meteorological Condstions.—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.
ROoTUMA.
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 & 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 epidemie
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 been
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.
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. Attlee, S. E. Jones, G. L. Ritchie,
J. T. Watt, S. F. Chellappah, D. R. Robert, W. J. Dixon, T. Bragg, E. F. Wills, D. P. Goil (Capt. "I. M.S.), A. G. Fletcher, O. H. Pinney,
M. B. Mitzmain.
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. L Abdel
Rahman, D. È. de Fonseka, D. M. Gibson, G. Warren (Lab. Asst.)
Third Row Sitting.—J. '8. Webster, A. C. Anderson (Capt. I.M.S.), P. Zachariae, R. K. Mitter (Lt.-Col. I.M.S.), G. W. Maconachie (Capt. I.M.S. a
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. O. 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. L. M.S.), D. Duff.
LONDON SCHOOL OF TROPICAL MEDICINE
(UNIVERSITY OF LONDON),
Under the Auspices of His Majestys Government,
CONNAUGHT ROAD, ALBERT DOCES: HH.
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 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. Sh 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. | PLEMING MANT SANDWITH, Esq., M.D., F. R.C.P.
C. W. DANIELS, Esq., M.B., F.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., 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., LLD.S. R.C.8. « |
Dean—Sır F. LOVELL, C.M.G., LL.D Arthropodist— Colonel A. ALCOCK, TMS., CLE, F.R.S.
Helminthologist—R. T. LEIPER, Esq., D.Sc., M.B., Ch.B., F.Z Protozoologist C.M. WENYON, Esq., M.B., B.S., B.Sc.
Director—H. B. NEWHAM, M.R.C.S., LR.CP., 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 lst. 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
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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 versá.
Chief Office.—SEAMEN's HOSPITAL, GREENWICH, S.E.
July 15, 1914]
Measles were introduced on January 29, when I
was &bsent, 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 & few vaccinations could be done this
ear. The results of vaccinations done are not satis-
actory, but this is due to the age of the lymph when
ib reaches here.
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. MacDOoNALD.
Lymph, which arrives here from
COLONIAL MEDICAL REPORTS.—FIJI. 95
Bua.
Vital Statistics.
Population. Births. Deaths.
Europeans ; 38 — —
Fijians ... i .. 8,560 148 146
Indians... 2i es 274 6 5
Miscellaneous ... ae 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 a6
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 at 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 &
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.
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
Bay, 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 disiriot 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
& birth.rate of 53 and & death-rate of almost 37 per
1,000. The birth«ate 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 4 leprous Fijian mother), three are
Polynesians, and the remainder Fijians.
Frambesia 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 instauces the
geashore 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.
[July 15, 1914.
KADAVU.
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, diarrhoea, and
whooping-cough.
| Dysentery and Epidemic Diarrhea.—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 in 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 the 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 brougbt their children to
hospital. I have never seen an uncomplicated case
of coko die, and during my nine years' experience in
Fiji I have personally had several hundreds of cases
under my care at hospital.
August l, 1914]
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. ‘here 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 Ábscess.—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. s
Meteorological Conditions.—No record is kept here
of the same. The first eight months of the year
were unusually wet, and siuce then we have had very
dry and hot weather, except for a week's rain in
November.
R. F. pe 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
— — m - — ——— --— = — —M—Ó—M———————À —— —
COLONIAL MEDICAL REPORTS.—FIJI. 97
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 medicel
district of Ba. Both institutions are well found
and managed, and the sanitary arrangements in
good order.
Native Town Sanitation.—ln 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.
JoHN Hatuey, 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 in 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. Wirsos, M.D.
Lau.
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 than 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, 101; 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 Lomaloina, and this is borne out by the fact that
iu 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.
Cases 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.
NADI.
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 (0/7 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 Fijians—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 in 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.]
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. Hustuer, M.B.
very
NAVUA.
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 intluenzal 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 diarrhoea, were all most prevalent in
the early months of the year—January, February, and
March. The numbers fell very considerably in the
succeeding 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 an 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.
COLONIAL MEDICAL REPORTS.—FIJI. 99
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 cau 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 ns 3,183 .. 152 .. £162
Colo West 4,082 .. 143 .. 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, 2.e., 27 per cent.
Causes of Death.—Examination of the register has
revealed & 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. —T'wo 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 poisoniug 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, aud 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
Fijans 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; gonorrhoea, 115; eye
diseases, 102; diarrhoea, &c., 115; diseases of the
skin, 262 ; injuries, 240 ; operations, 80.
Plantation Lines.—Frequont 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,
9; 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. Piipraux.
Ra.
Population :—
Race Males Females Total
Fijian .. ka —- ah - - 6,657
Indian .. a 827 25 452 1,279
European sy 44 - 19^ X 63
Half-caste sa 24 T If .. 41
Total 5,070
Main Causes of Deaths.—lhe following are the
diseases inainly 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; diarrhoea, 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.—Diarrhoa, 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, & 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 & 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 Santtation—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 promiscuous
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, which are dangerous, as
buckets are lowered into them.
August 15, 1914]
Colonial Medical Reports.—No. 37.—Fiji— (continued).
THE 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, diarrhma, 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.
= Savusavu Bay, this disease is common in Wailevu
est.
Framboesia 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.
COLONIAL MEDICAL REPORTS.—FIJI.
101
——— - —————— ——— —
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.—'T'hese have not been
recorded. The last quarter of the year has been
exceptionally dry, and at times almost amounted to
drought. F. NANGLE Smartt, M.B.
On THE TREATMENT oF FisiAN YAws AND SYPHILIS
IN INDIANS BY “606” iN 1911.
Dr. P. H. Harper, resident medical superintendent,
Colonial Hospital, says: During the last four months
Dl 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 :—
CASES oF SYPHILIS CASES OF YAWS
—\
Nationality Male Female Male Female
European .. sx | 0 0:
Fijian i .. dl 10 .. 0 0
Indian zu exu 4 x 0O .. 11 4
Samoan Pa oe oO. wees b e 0
Half-caste (Fiji-
European) e. 0 2 0 0
Wallis Islander 1 0 0 0
Total $e 0. us 16 2s dH 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 ulcers 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.
(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. 88.—8t. 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 .. . .. .. .. .. 80,85 14,971 4,894
Estimated number of births during
the year 1911.. ard e m" 949 545 180
Estimated number of deaths during
the year 1911.. aT 24 ing 749 823 80
Estimated number of inhabitants in
Vu e s e .. 80,885 15,199 4,994
Estimated number of increase 2 200 222 100
Number of inhabitants at census on
April 1, 1911.. " 26,983 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. Kitís.—31:232 per mille against 32:93 in the
previous year.
Nevis.—36°871 per mille against 37:94 in the pre-
vious year.
Angwuilla.—36:043 per mille against 42-70 in the
previous year.
BIRTHS, STILL-BIRTHS AND DEATHS (EXCLUSIVE OF
STILL-BIRTHS IN 1911).
Death.rate
per 1,000
Livin i
birth-rate exclusive of inhabi-
g Still- Deaths
Living birth-rate
Still-
births r1,0000f births per1,000 of of still- tante ex-
nhabitants inhabitants births clusive of
. still-births
St. Kitts 849 27:941 100 8:291 649 21:859
Nevis .. 500 82:909 45 2:961 278 18°811
Anguila | 174 34:841 6 1:201 74 14°817
In the previous year (1910) these rates were as
follows :—
Deaths,
Living births Still-births exclusive of
still-births
St. Kitts 30°23 2°79 28-66
Nevis.. 36:13 2:40 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.
"- ne Legitimate Illegitimate
L xitimate legitimate birth-rato birth-rate
St. Kitts 322 627 10:507 .. 90:635
Nevis .. 212 333 19-953 21-917
Anguila .. 79 161 15:818 20-994
Infantile mortality, considered as the annual
number of deaths of infants under 1 year of age to
August 15, 1914.]
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 .. vs 260 2173:979
Nevis es és 148 271°559
Anguila .. is 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.
PuBLIc HEALTH.
The general health of the Presidency during the
year was good, and there was nothing noteworthy.
No disease of & 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 & 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 diarrhoea and dysentery, which are gener-
COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS.
103
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 bealth 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 according to the textbooks is
almost always fatal. Two of the other cases in the
district showed intense jaundice. One of the cases
died from a relapse and exhaustion.
T wo new dispensaries were established at Tabernacle
and 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 inspectors 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.
104
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 larvæ
breeding in water in estate coppers, barrels and other
receptacles. The water is either immediately emptied
out or supplied with *' millions." 7
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
& 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 &bout the streets and private yards,
and there are certainly fewer mosquitoes.
I am 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 epidemic of typhoid fever occurred during
the latter three months of the year. Up till
December 31, 16 oases, with 1 death, occurred.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
[August 15, 1914.
— —À M —
All the persons affected lived within a radius of
a quarter of a mile. No obvious source of infection
could be discovered, but it is undoubtedly the house-
fly which acts as a carrier.
The prolonged drought during the summer mouths
caused great scarcity of grounds, provisions and
consequent hardship to the poor.
The total 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 1l year.
Tuberculosis in various forms is fairly common and
&ccounted 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 diarrhos 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
&mong 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 & 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.
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. Diarrhoea, 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 diarrhea 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, diarrhoea 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
ries Can: N R
Buckley's Hermi bier New River
Leeward Windward ra Windward Centre of
side of side of side of sid: of Island
Island Island Island Island
January . 0:93 341 6:82 2°23 2°36
February .. 5°79 7°03 3:05 1:87 8:18
March 2:16 3:97 1:33 2°10 0°88
April 1:97 1:09 9:16 2:00 5:834
May 3:65 5:54 3°35 2:80 177
June 2:13 2:50 .. 1°24 0:23 0:46
July 3:97 2°02 2°68 .. 1:09 0:80
August .. 264 277 .. 808 . 1:96 0:88
September.. 4:64 4'22 .. 570 4:82 0:88
October 4:96 4°69 3°70 4:14 3°61
November.. 3°64 4°07 2:93 3:18 4:21
December.. 6°73 8:06 7:88 7:10 7:90
Total .. 47:51 48:67 44:92 33°52 82:17
1910 .. 42°15 44:37 41:54 31:85 32:35
METEOBOLOGICAL RETURNS FOR 1911.
Months Minimum Maximum Range Soap Rainfall
January .. se 68 .. BI .. 3 .. 778 .. 498
February .. 66 .. 82 .. 16 76:9 4°51
March .. .. 65 .. 83 .. 18 18.3 2:30
April -- .. 70 .. 86 .. 16 81:4 1:36
ay ex ee CE .. 8&5.. 14 81:9 4:87
June e .. 78 .. 86 .. 13 84:1 2°25
July ue .. 74 .. 88 .. 14 81:1 3:34
August .. cs Wk ee! DL ui. 17 85:7 2:18
September pi Wb. Bye BO sar IT 84:6 3:49
October .. .. 03 90 17 81:6 4:99
November .. 04 88 14 817 3:09
December 71 86 15 79:6 6:37
Total 81:7 43:09
Mean temperature for year, 81:7.
COLONIAL MEDICAL REPORTS.—LEEWARD ISLANDS
105
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 overcrowding 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 ees 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, 80 as to deprive the insects
of food and breeding places. |
INSTITUTIONS.
Dr. Edmund Branch, Medical Officer of the
Cunningham Hospital, reports as follows :—
There were 838 cases treated in the wards of
Cunningham Hospital aud 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 want of a 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 & 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
106
scirrhus of the breast, firs& by the Róntgen 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
& 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
& 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 anssthetized 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 GAOL.
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 HospitTaL, 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, 4/7 per cent.: The total mortality
was 6'2 per cent.
There has been & 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
Sept. 1, 1914]
Nd MEDICAL REPORTS. —LEEWARD ISLANDS.
RETURN or DiskAsESs AND Dgatus IN 1911 IN THE CUNNINGHAM HOSPITAL,
GENERAL DISEASES.
Alcoholism
Anemia
Anthrax
Beriberi
Bilharziosis
Blackwater Fever
Chicken-pox $s
Cholera
Choleraic Diarrhoa ts
Congenital Malformation
Debility ;
Delirium Tremens
Dengue...
Diabetes Mellitus
Diabetes e a
Diphtheria
Dysentery ..
Enteric Fever
Erysipelas ..
Fobricula os
Wilarigsig.ctss os ak) eS SW
Gonorrhaa
Gout :
Hydrophobia i
Influenza .. T" T
Kala-Azar..
Leprosy ..
(a) Nodular i
(b) Angsthetic ..
(c) Mixed
Malaria! Fever—
(a) Intermittent
Quotidian .
Tertian
Quartan
Irregular ..
Type undiagnosed
(b) Remittent .. "
(c) Pernicious ..
(d) Malarial Cachexia. .
Malta Fever ;
Measles
Mumps .. m
New Growths— ..
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra ..
Plague
Pysemia
Rachitis as
Rheumatic Fever
Rheumatism :
Rheumatoid Arthritis
Scarlet Fever
Scurvy
Septicemia i
Sleeping Sickness m
Sloughing anre -
Smallpox .. : d
Syphilis
(a) Primary
(b) Secondary .
(c) Tertiary
(d) Congenital ..
Tetanus...
Trypanosoma Fever
Tubercle—
(a) Phthisis Pulmonalis
(b) Tuberculosis of Glands ..
(c) Lupus T T e
Admis-
I RAS unn.
| ME sions
Leeward Islands Colony.
| |
LT |
Floile®lelialllllel
Eee Gab ae ad eer
Lleol lI Et lel
LIITE E&I al |
E
C
LESE TE AES esr T Tesh at a
Ll) Plow! Sali liiiol
| | | Deaths
AS ETERWT
lll Stellel |
Peer ee eet ee eed ohne oth Pagel Pea do
[lI SleelSellliillisi
GENERAL DISEASES— continued.
(d) Tabes Mesenterica ; à
(e) Tuberculous Disease of Bones
Other Tubercular Diseases
Varicella :
Whooping Cough
Yaws :
Yellow Fever
LOCAL DISEASES.
Diseases of the —
Cellular Tissue
Circulatory System
(a) Valvular Disease of Heart
(b) Other Diseases ..
Digestive System —
(a) Diarrhees -
(b) Hill Diarrhosa ..
(c) Hepatitis
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver ..
(f) Jaundice, Catarrhal
(g) Cirrhosis ‘of Liver :
(h) Acute Yellow Atopar.
(1) Sprue .. . :
(j) Other Diseases ..
Ear.
Generative System— is
Male Organs
Female Organs
Lymphatic System
ental Diseases
Nervous System
` Nose .. ‘
Orgaus of Locomotion
Respiratory System `
Skin— . T
a) Scabies
b) Ringworm ;
o Tinea Imbricata
(d) Favus .. ms
(e) Eczema .. os
( f) Other Diseases ..
Urinary System
Injuries, General, Local—
. (a) Siriasis (Heatstroke) ` :
(b) Sunstroke (Heat Prostration)
(c) Other Injuries
Parasites — và
Ascaris lumbricoides ..
Oxyuris vermicularis .
Dochmius duodenalis, or Aukylostoma duo-
denale ` d , T
Filaria medinensis (Guinea worm)
Tape-worm - e
Poisons— se
Snuke-bites
Corrosive Acids
Metallic Poisons
Vegetable Alkaloids
Nature Unknown
Other Poisons
Surgical Operations —
Amputations, Major ..
Minor ..
Other Operations
Eye ..
(a) Cataract
(b) Iridectomy .. DA
(c) Other Eye Operations -
Eye .. ne ee
sions
Admis-
DELETE
LT 4 dd ud
20
Il1lass!lll!i-cilllkil
E
eSlllllia:il&laalé
Deaths
Pfalddwol htt i ddl tet tll db Leld ttt leoi beleal I.
Meee one ie ee ae
—— pS SRS P
Total
Cases
Treated
LITT bof ttl $
111
[xSl 11 S81 11111888.
1 |
PL) 1 akST LT lin
108
Colonial Medical Reports.
THB 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.
During the past year public health affairs have
been of such & 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; it is 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 diarrhoea, 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, occupied by their
coloured employees, which were erected ten years
ago, and to accommodate tbe 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 weakeat
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
PowEns.
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 i& 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]
_ ——— = ———— — — -——— = — —— — e m -
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 & 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 oF 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 & 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.
InrECTIOUS 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
COLONIAL MEDICAL REPORTS.—DURBAN CORPORATION.
109
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 ... 81,903
Natives - nee Wi m 17,750
Indians and other Coloured Races 19,512
Total 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,
&c., 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.
EstTiMaTE OF PoPuraTION, 1910-11.
Europeans... s Ms 81,903)
Coloured and Half-Caste 2,497 j 94,000
Natives d - 17,750
Indians 17,015
These figures show that à very healthy increase
has taken place.
NATURAL INCREASE OF PoPULATION OF DURBAN,
1910-11.
Births ee ... 952
Deaths Tm .. 3901
651 natural increase of population.
It is of importance in other respects than that of
Public Health to have & census of the population of
& 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
m D ———€
Months Europeans Asiatics Natives
1910-—August , on M 75 50 2
September ... i sie 91 50 3
October - td e 85 51 1
November... as 2) 82 67 2
December ... T ut 80 34 0
1911 —January T is Y 94 51 3
February - M 85 46 2
March a ost os 89 52 0
April ... bes Vus du 91 41 1
May ... ae " - 88 14 1
June ... ves ahs E TT 42 1
July ... e ate vus 84 49 1
1,091 610 17
Totals "
European birth-rate (gross) ves en .. 29°7 per 1,000
^ is (corrected) for non-residents 27:7 is
Indian birth-rate "M "T " .. 95:9 F
110
The small number of births of natives occurring in
Durban prohibits the stating of any birth-rate for that
population.
TABLE SHOWING RACE AND S&gx DISTRIBUTION OF DEATHS
DURING THE Past YEAR.
Race Male Female Total
European ... i "T 176 125 301
Native sini soe " 82 27 109
Asiatic... = M 179 133 305
Totals ... Ww 430 285 715
TABLE SHOWING CAUSES OF NON-RESIDENT DEATHS.
European Native Asiatic Total
Dysentery ...
Enteric fever
Measles
Malaria
Venereal diseases ..
Puerperal fever
Phthisis
Tuberculosis, other than phthisis
Cerebro- spinal meningitis
Cancer EA x
Old age
Diseases of nervous system i
Diseases of heart and circulatory
system : n
Pneumonia
Bronchitis ... E
Other diseases of
system
Diarrhea, enteritis and catarrh
Other diseases of alimen tary track
Diseases of urinary system
Diseases of child-birth
Accident
Suicide
Execution ...
m
bo D co Q't2-10€ o m BH Or cor
md
=“—Oonmoowoocrodce
bo
oor OWwWono oc, e O'-coocoonoUvuc-cto
- m ue
"0 Oo Ww OD Le et OO Ma
bd pet
mn Sm OS 7 Ordo t2 onm o9
ipM
wow crn = © O O =
Ondo ck oor bd tb
|
|
|
Totals
-1
e
co
nen
C
[
[uy
e
on
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 increase of deaths occurring during
the past year. A fair proportion of the increase of
deaths also is due to injury and weakness at birth.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
(Sept. 15, 1914.
NATIVE DEATHS.
Natives (population, 1911, 17,750).—During the
past year 109 natives have died in Durban.
Adults *Childréen Total
Males .. T sas 54 28 82
Females ... ds Pu 6 21 27
Totals ... - 60 49 109
ASIATIO DEATHS.
Indians (population 1911, 17,015).—During
past year 305 Indians have died in Durban.
Adults *Children Total
Males .. m Dd 67 105 172
Females ... o " 48 90 133
the
110 195 805
* í Child" means under 12 years.
INFANTILE MORTALITY.
Male Female Total
Infantile deaths during 1910-11 T 19 37 86
Registered births — ... ET = .. 952
Infantile deaths ave m s .. 86
This equals 90:3 infantile deaths per 1,000 births,
and represents the “infantile mortality figure " for
Durban, 1910-11.
YEAR
~ T e rt x 3. = han
n Lej © rf e
2 282 P s = B £
pw = — = -— T re =
Number of infant
deaths ... .. 112 105 109 67 89 62 11 86
Infant mortality
figures ... . 100°3 88 100 69:2 91:7 67:3 45°4 90:8
VITAL STATISTICS.
JOHANNESBURG.
EUROPEANS COLOURED
Fie - Rar
Whites Natives african Asiatics
Population. 111,857 95, 522 7, 749 b, 1176
Birth-rate per 1, 000 .. .. 857
Death-rate (crude) 13:3 33: '6 81: 1 197
Death.rate corrected for age
and sex distribution 15:2976 ...
Infantile mortality ... — ... 110 326 39-5
Death-rate from tuberculosis 0:97 4°74 29:45 1:15
* Not calculated on account of the very small number of women.
CAPETOWN,
Europeans Coloured
Population . 30:476 31:055
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 1:97 5°23
Gross 1:87 5°93
PRETORIA.
Europeans Coloured
Population " we
Birth-rate per 1. 090 . 34-2 13
Death.rate (crude) E ls 10°6 14:1
Infantile mortality... TM 104 244
Death.rate from tuberculosis sick 0:2 2:4
Sept. 15, 1914.]
BLOEMFONTEIN.
Europeans Coloured
Population ... a e Te 10,968 10,106
Birth-rate per 1.000 ... PA gs 32:8 me
Death-rate (crude) ... id pn 10 34
i (corrected) 7°59
Infantile mortality ... pei "T 19:2
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.
Sporadie 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
Deceinber 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 this
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 thau 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
COLONIAL MEDICAL REPORTS.—DURBAN CORPORATION.
111
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 the
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 appreciation 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
iminigration 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 O native cases
died, and & 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 & 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 than 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
Ben a a a
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.
Tbe medical superintendent has notified to the
medical officer of health 59 cases of pulmonary tuber-
culosis who had not previously been notified bv the
medical practitioners.
Owing to the work of visitation carried out by the
nurse, Indian health visitor, &nd 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.
BastiL Apams, M.D.
Tuberculosis Medical Officer.
Oct. 1, 1914.]
Colonial Medical Reports.
COLONIAL MEDICAL REPORTS.—LAHORE MUNICIPALITY.
113
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 sume
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.
VITAL STATISTICS.
Population.—The population of Lahore, as estimated
by the census of 1911, is as follows :—
Lahore City at - ; 120,436
Civil Station and Anarkali ... SP .. 68,821
Garhi Shahoo, Thathi Mehteran, Killa Gujar
Singh, Khui Miran ... oe mo .. 11,579
Railway Colony ... sis des 7,190
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 8:3 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 a death-rate
of 288:1 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.
BinTHSs.
During the year there were 7,729 births registered
as compared with 7,520 for 1910, showing an increase
of 209. This gives à rate of 37:1 per 1,000 of the
population against & 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 the midwife and 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.
| InrECTIOUS 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) inereased 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 aud
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 tbe bacilli are in the lunga 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 pneumonic 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 diarrhasv. 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 and 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-por.— A sinall-pox epidemic has visited Lahore
every three years, and the year following the outbreak
had usually also & 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 publie 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 epidemic 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
notification 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 R
committee should move Government, and by it alone
can unnecessary epidemies 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 nót 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
vaccination ; 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 it 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 lost a 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
EPORTS.—LAHORE MUNICIPALITY.
115
— —— ——
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-
culosis is spread in India through cowdung and
cowdung cakes 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 & 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 can be used (1) as a preventive, (2) as a cure.
It is with the former Í 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.
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
house’, 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 IIT 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.
[Oct. 1, 1914.
et, ees pi T a a ease NE ES ————
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 OF METEOROLOGICAL DATA FOR LAHORE FOR 1911.
TEMPKRATURK
Relative
Mean M gene :
Maximum Minimum Pr nd Rainfall
January ... 65:9 48:8 ... 89 2°56
February 74:1 41:0. ... 76 ... O17
March 76:2 54:7 79 . 401
April 98:6 64:92 50 . 0:88
May 107:1 742 ... 37 ... 0°58
June 106:3 81:8 . 55 ... 2°10
July 106:8 88:1 . 58 . 114
August 104:6 88:9 ... 58 ... 3°50
September 98:0 ... 777 ... "l1 .. 0:90
October ... 96:5 .. 643 . 601 ... 0'27
November 76:8 ... 485 ... 79 .. 0°60
December 12:0 40:3 . 81 . 0:00
rn
on
Q
a]
Oct. 15, 1914.] COLONIAL MEDICAL REPORTS.—COLONY OF
MAURITIUS. 117
—————
—_—— = Pen
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.
IHE 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 19,485
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.
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, Flacq 34:6, and Pamplemousses
93:0. Plaines Wilhems is lowest with a still too high
rate of 25:8 per cent. |
14,584 children wete born during the year, giving
a birth-rate of 39:4 per cent., or nearly 4 per cent.
above the decennial average. Rivière. du Rempart
again heads the list this year with a birth-rate of
43-9 per eent. Pamplemousses is lowest with 36:1
per cent. "E |
The disease that caused most deaths was malaria—
4,313 deaths being attributed to this disease alone, t.e.,
more than one-third of the total. This figure is not
reliable; “ la fièvre ” is à 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-
As I have.
report.
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 168:(4 ... 451 ... 90:32 ... 53°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 60:56 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
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
a mortality of 25 per cent.
Influenza.—1,610 cases, 300 less than last year,
were admitted. |
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. Ag 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 and 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.—2 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 43099.
There were 25 criminal lunatics, 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Oct. 15, 1914.
ee ee iO —
cases the old sources were found, ganjah smoking
aud 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.—124 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 mouths 173.
Of these 131 died, giving a death-rate of 75:7.
A short and sharp outbreak attacking 19 people and
killing 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 2:7 to
11:0. It has decreased among the Indians from 66:3
to 57:2.
Age Incidence.— Às 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., abubonic, pneumonic and
septiceemic, 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
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 & 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. 12.— Municipality of Colombo.
MEDICAL REPORT FOR 1911.
By W. MARSHALL PHILIP.
Medical Officer of Health.
1.—INTRODUCTION.
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 & 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
districts 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 increased 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
aud 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
-—— m —— - - --
the Europeans. The steadily increasing and now
very high mortality from pneumonia is a serious
matter, more especially as it is & 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 & considerable increase in the number
of infectious diseases notified and dealt with during
1911 compared with the previous year, which was
in.à 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, vta 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 heen 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 public bathing wells, is a matter which,
although important, cannot be properly dealt with
until there is a suflicient 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 public markets remains highly
unsatisfactory. The dairies have been improved,
but are most difficult to maintain in a sanitary
condition. The laundry trade is in a most unsatis-
factory state.
2.—METEOROLOGY.
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.—BIrtTHs.
During the year 1911 there were 5,280 births
registered in Colombo, representing a ratio of 24:7
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 than it really is,
because a large proportion of these children are
brought to Colombo after the mother has sufficiently
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.
Nov. 2, 1914.]
^ Colonial Medical Reports.—No. 42.—Municipality of
: Colombo (coptinued.) |
5.— DEATHS.
. During the year 1911 there were 7,934 deaths
(inclusive of deaths of non-residents) registered in
Colombo, representing a ratio of 83:8 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
(97-1), 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. sf
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. l |
6.—Inrant 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 & 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
AE about-300, is probably nearer 200 per 1,000
irths. b jet EC | FO
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
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 :—: JE
l pude Burgher M Tamil Moor Malay ‘Others’
Average, 1908-
1911 159 200 290 486 410 304 441
1911 182 218 286 418 423 291 408
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 ta -
their children. The great need in their case is that
sanitary dwellings should be provided for them at
& 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-
class 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. m :
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 infaut
death-rate in each ward during 1911 and the average
for the preceding ten years are given. | (|
7.—PuLMOoNARY DISEASES.
Under this heading are included phthisis,
pneumonia, and bronchitis. NE
Deaths, 1,897 ; ratio, 8:24 ; average, 8:11 ; increase,
0:13 per 1,000. ao RECTAM
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. p ls
| (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. M
As in previous years, there was in 1911. an
extraordinarily high death-rate from phthisis amongat
Mohammedan. women (Malays and Moors) compared
with the rates amongst the males of these races, aud,
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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENF.
[Nov. 2, 1914.
— — —
SSS TAEAE à
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, and 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 & 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 à 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
owers, and with sufficient staff and funds at their
isposal.
he 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
and, 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;
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
80 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 overcrowding, have
for years been regularly carried out; but it is a hope-
less task so long as there is the present insufficiency
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
————— ———M——————— E
of house accommodation. The most that can be done
is to get the worst instances abated, and 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 & 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, an 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, overerowding, 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, asjindicated 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,—DIARRHGAL DISEASES.
Deaths, 959; death-rate, 4:57 per 1,000; average
for preceding ten years, 5°98; 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 ‘ diarrhaa,.”
The two terms are for all practical purposes synony-
mous; but whereas ten or fifteen years ago nearly all
these cases were returned as diarrhoea, 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
were diarrhoea 669 deaths, enteritis 12 deaths, where-
as in 1911, out of a total of 696 deaths, the propor-
tions were enteritis 520 deaths and diarrhawa 176
deaths.
(a) Diarrhea and Enteritis.
The persistently high death-rate from this cause
amongst the Tamils is noteworthy. Nodoubt 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,
although 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, 2:20 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 &s 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 & 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 & 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
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
- - — — —M—— — —
(Nov. 2, 1914.
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 unrecog-
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.—No. 42. —Municipality of
Colombo (continued. )
Epidemics caused by milk have, as a rule, certain
definite characteristics, 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 bas been shown by
repeated examinations to be above suspicion.
(5) Dust.—Infected dust is a possible, but a prob-
‘ably extremely rare, source of infection.
(6) Indirect Contact.— This may be a source of
infeetion by handling infected clothes, &c., but, crude
although the dhobie's methods are, I do not think
he probably often is responsible for the spread of
enteric.
In conclusion, the chief sources of infection bs
-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
can only probably be dealt with by the abolition of
the bucket system and the introduotion of the water-
carriage 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 such
like.
As it. will be many years at the nsus 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 such a 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 a 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.
: I 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 ;
COLONIAL MEDICAL REPORTS.—MUNICIPALITY OF COLOMBO.
in Colombo.
125
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 proe e 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 & 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 realitv due to causes other than malaria,
many of them being probably due to enteric fever.
. (d) Intermittent Fever.
This has entirely disappeared from the returns as
& 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 occasional outbreaks on the out-
skirts of the town, there is practically no primary
malarial infection in Colombo.
(e) Seven- day Fever.
Although this is hot a notifiable disease, inquiries
show that there have of late been a good many cases
Its specific cause has not yet been
ascertained ; but there appears to be & growing sus-
picion that it may be spread by the bite of a mosquito.
Whether this is so, whether the virus is ingested, or
gains access in some other way, has not yet been
ascertained.
10. —IxrzcTIOUS Diseases NOTIFICATION.
(a) General.
The notifiable infectious diseases are plague, cholera,
smallpox, chickenpox, measles, scarlet fever, diph-
theria, acute or choleraic diarrhoea, enteric fever,
simple continued fever of seven days’ duration or
over, and, since 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 & period extending
from May 26 until July 27. All the cases except one
were males. The largest number of cases s occurred
-at the 20 to 25 age period.
(co) 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-
126
senting a case-mortality of 12:3 per cent., which is a
low: case-mortality,.and indicates that the community
ie fairly well vaccinated. The first- infection: was, as
usual, imported from India, the patient having arrived
as a deck passenger wa Tondi, which was at that time
an open port, quarantine having been imposed in.the
case of only Tutieorin.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 984 cases reported from the town, 71
from extra-urban districts, and 10 from: the port.
One death. was: ascribed—probably erroneously—to
this cause.
(e) Measles.
There were 330 cases reported from the town, lf
from extra-urban districts, and 6 from the pert. Four
deaths were ascribed to this cause.
. (J) Diphtheria.
Twelve cages 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
diarrhea. and simple diarrha@a,
11.—Hovsina.
(a) General,
The problem of housing in Colombo is one whieh,
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 refe;e1ce net 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 bas been for years, and is now, going on
so 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, for 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
‘in- the poorer quarters—6.g., enteric, phthisis, &e,—
‘eanrot be restrained: within such limits, hnt maake
THE JOURNAL OF TROPICAL. MEDICINE AND: HYGIENE:
Nov. 1$, MA. |
excursions from there into the dwellings of, the well-
to-do, whose death-rate is. albo: thus maintained at a
higher level than it otherwise. should be..
For confirmation. of this. one hae 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 highar
than they ought to be, and higher than they no douht
would be if a large part of. the poorer population were
not living.in comparatively. olose 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:bave an effect in. reheving the whole
population from a situation which has for many yeams
been steadily, and during recent. years has.been,rapidly,
increasing in danger.
(b). Unhealthy Areas.
Although.the unhealthy, dwelling is the: uait 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. far 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 Charchyard Late (now
Short's Road) and of Panchikawatia (now part ef
Skinner's Road) has effected a local improvement in
these districts ; bub, as no provision was mada far
re-housing the poor people. so displaced, as. required
by all modern improvement schemes, thase people
have merely been driven: from one placa to another,
which in turn they have helped to overerowd and
render more unhealthy. The result.cannot, therefore,
be considered a gain ta the town as a whole fram a
sanitary point of view. These road widevings 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
beth in size and number, particularly during necent
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 he devised, and. a
regular programme must be drawn up. and followed
ouf.
Ii is my: belief that the only practical way to effeot
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 imtimasely: asao-
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.]
eee — — ——— M ——
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 people to the town. |
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 & few feet of land
has been tempted to run up & 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 earrying on the important work of food inspection.
The town is in exactly the same position in regard
to this matter as it 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
enly give a very limited and entirely insufficient
amount of time to food inspection. Eia
COLONIAL MEDICAL RBPORTS.—MUNICIPALITY OF COLOMBO.
127
IT ——————————————————— — ———————9 i ——
(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 1 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. are 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 & one-lb. loaf costs
28 cents, as compared with 14 cents, the price of &
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.—W ATER.
(a) Town Water.
Although no pathogenic or even suspicious germs
have ever been found in the Colombo water, which
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 a
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 that
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.—Pusriic 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.
À 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,
80 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 & 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. Tho fact of the matter is that a
dairy is a very difficult business to conduct properly.
It involves a 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
register at the end of the year.
The 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.
Dac. 1, 1914] COLONIAL MEDICAL REPORTS.—MUNICIPAL
= ————— — —ÓMMMÓM—— ————————
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
& heavier dhobies' bill. Low rates, on the other
hand, will probably not make it possible to run &
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.
À 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 i8 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
199
ITY OF COLOMBO.
experience or education. A person who has dined in
& 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.—CEMETERIES.
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 accordance with any sys-
tematic 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.—Wonk STATEMENTS.
(a) Sanitary Inspectors.
The experience of every year demonstrates the
necessity for employing & Chief Sanitary Inspector,
as ig 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
eee —-—
Gu re |.
a trained Chief Sanitary luspector, 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 discipliarian, 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 aud
phthisis. During the year 1911 they supervised the
disinfection of 550 fever infected houses and 364
phthisis infected houses, making a total of 1,214
houses disinfected, which, together with the 787 dis-
infected by the Sanitary Inspectors, makes a total of
9,031 houses disinfected during the year.
(c) lEnterie 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. Lour hundred
and forty-seven infected latrines, &c., were so dis-
infected, and 185 filthy compounds were cleansed
during the vear.
(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) Disinfectiny Station.
This is in charge of an overseer, whose duty it is to
receive, pass through the Iiquifex steam disinfector,
and dispatch infected articles of elothing, &c.
One hundred and eighty-five loads, comprising
5,979 articles, were thus passed through the dis-
infector during the year.
(f) Insect Pest Prevention Gang.
This gang consists of an overseer and two coolies, '
whose duty it 1s to search out and deal with the
breeding-places of mosqnitoes 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
vear 1911, 2.058 premises were visited, in 1,176 of
which mosquitces were found breeding, and their
breeding-places were destroyed, the occupants being
instructed how to prevent à 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 oilen, the quantity of oil used during
the year being 172} 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.
NICIPAL 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 domestie 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
Sluve 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.
920.— MuxiICIPAL MIDWIVES.
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.
CIPAL Lanrentc HOSPITAL.
The Medical Officer reports that the buildings have
been kept in good repair, but complains that the
accommodation for the staff is insuflicient, 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-morlems were held during the year.
The Medical Officer draws attention to the large
number of cases sent in as enteric from other hospitals
whieh are found to be due to causes other than
enteric. This is, however, a usual experience in
enteric hospitals all over the world, and is due to the
great difliculty of diaguosing this disease, especially
in the earlier stages, the usual remedy being & more
frequent use of Widal's blood test.
2
Dec. 1, 1914.!
- ———— e ————
COLONIAL MEDICAL REPORTS.—CYRPUS.
131
— SS e MN e z ——— — —
Colonial Medical Reports.—No. 43,—Cyprus.
MEDICAL REPORT FOR 1910.
By
ROBT. O. CLEVELAND.
Chief Medical Officer.
1.—Pusnic Hearta.
Tux general health and sanitary condition of the
island have been most satisfactory. There was
ho 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
reporb 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. ‘Ihe 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 microscope revealed its true nature. The
three types, tertian, quartan and malignant fevers,
were soon proved to exist in the island. T'he 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. Tuere were
6,074 cases returned, against 7,150 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, aud quinine is becoming more general.
Typhoid Fever.—Generally speaking of a mild
type, and only occurred in a sporadic form, although
there was an increase of 66 cases on the returns of
the year 1909, a total of 334 cases having been
reported by the medical oflicers during the year
under report.
Diphtheria.—Only 9 cases of this diseise are
recorded during the year.
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 =- 5:67 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 vear. 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 eflicient and well trained medical and nursing
statt.
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 agaiust
3,156 in 1909. Patients came from many towns and
villages in that district and from others nore remote.
Useful structural additions were made during the
past year, and an Bnglish nurse's services were
secured in place of those of a native nurse. The
hospital is well equipped as regards beds, bedding,
iustruments, 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
oflices 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.
The Leper l’arm.—At the close of the year 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
Return oF Diseases AND DgaTHS IN 1910 IN THE Six GENERAL HOSPITALS, LEPER FARMS, AND
GENERAL DISEASES.
Alcoholism
Anemia
Anthrax
Beriberi
Bilbarziosis
Blackwater Fever
Chicken-pox
Cholera
Choleraic Diarrhoea
Congenital Malformation
Debility
Delirium Tremens
Dengue .. ;
Diabetes Mellitus
Diabetes EOS
Diphtheria ;
Dysentery ..
Enteric Fever
Erysipelas ..
Febricula ..
Filariasis ..
Gonorrhea
Gout :
Hydrophobia -
Influenza .. és (e
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 .
Measles
Mumps vs
New Growths— ..
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra ..
Plague
Pysemia
Rachitis ;
Rheumatic Fever
Rheumatism ;
Rheumatoid Arthritis
Scarlet Fever
Scurvy
Septicwmia $^
Sleeping Sickness ka
Sloughing eae nà ..
Smallpox .. -
Syphilis
(a) Primary
(bL) Secondary ..
(c) Tertiary
(d) Congenital .
Tetanus
Trypanosoma Fever
Tubercle—
(a) Phthisis Pulmonalis "m
(b) Tuberculosis of Glands ..
(c) Lupus $a
Admis-
sions
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.
Lunatic WARDS.
Deaths
Cyprus.
FE
ESS GENERAL DisEASES—COnLinued.
(CR (d) Tabes Mesenterica ‘
1 (e) Tuberculous Disease of Bones
12 Other Tubercular Diseases
6 Varicella .. ; E i
HT Whooping Cough
= Yaws . T EN
D Yellow Fever - 25 T
E LOCAL DISEASES.
9 Diseases of the—
1 Cellular Tissue
= Circulatory System
2 (a) Valvular Disease of Heart
-- (b) Other Diseases ..
6 Digestive System —
26 (a) Diarrhea s4
53 (b) Hill Diarrhea ..
9 (c) Hepatitis i
37 Congestion of Liver . T
— (d) Abscess of Liver í4 ais
36 (e) Tropical Liver .. : js
=i (f) Jaundice, Catarrhal
— (g) Cirrhosis of Liver
78 (h) Acute Yellow Atropb y
-- (2) Sprue .. va ‘
— (j) Other Diseases ..
62 Ear vs
52 Eye - T
= Generative System— T
— Male Organs
Female Organs
1 37 Lymphatic System
42 Mental Diseases
7 Nervous System
5 Nose ..
180 Organs of Locomotion —
11 Respiratory Sem
3 Skin— .. ,
= a) Scabies ..
2 b) Ringworm :
— (e) Tinea Imbricata
— (d) Favus .. s
— (e) Eczema .. T
95 ( f) Other Diseases ..
18 Urinary System
= Injuries, General, Local—
2 (a) Siriasis (Heatstroke) T
si (b) Sunstroke (Heat epu
= (c) Other Injuries
— Parasites — ex
m Ascaris lumbricoides ..
16 Oxyuris vermicularis ..
59 Dochmius duodenalis, or Ankylostoma duo-
— denale À
1 Filaria medinensis (Guinea worm)
— Tape-worm vs ats ; i
4 Poisons— ix
— Snake-bites
— Corrosive Acids
— Metallic Poisons v Ja -
= Vegetable Alkaloids .. 24 T
13 Nature Unknown T js
10 Other Poisons
-— Surgical Operations —
— Amputations, Major
4 Minor ..
Other Operations
Eye
(a) Cataract
(b) Iridectomy ..
(c) Other Eye Operations.
Admis-
sions
LT Ed
wn
m= bo OS
ProlPT TEE Rebel eeedol PPP LIETI ed dd
Deatha
Ph ew 4
m
bo
M
i ee TETE Et fled
‘Dec. 1, 1914.
Total
Cases
Treated
"ELSE
516
Dec. 15, 1914.]
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 &ccount 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, ansesthetic and mixed, the tuber-
cular exceeding the anssthetie by 5 to 1.
Inmates in the -
Admitted
T 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 t) 28 87 115
1906 115 3 19 24 15 99
1907 99 12 11 27 73 100
1908 100 T ð 28 T4 102
1909 102 11 11 25 17 102
1910 102 12 15 25 11 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 írom 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.
COLONIAL MEDICAL REPORTS.—NEW PROVIDENCE.
133
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 vot 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
huudred and thirty-two of these operations were
carried out; of these 6,197 were primary vaccinations.
METEOROLOGICAL RETCRN FOR THE YEAR 1910.
i
TRMPERATURE ' RAINFALL WINDS
Ni ba p m
z = > Sh | eg ;
3 = ! 4 AZ i79 4
Jauuary . 9872 3954 19:8.48:4: 3:59. SO | W. OG
February .. 6411 363 218/510:082 80 | , 02
March .. .. 631 364/3267 5111373 76 | , 1:0
April . TGO 43:9 32:1 60:2;0"70 72 ds 0:2
May .. .. 856 51:3 34:3 066:9/,1:02 68 s 0:2
June .. 925 586 33:9 T4'4|0'73 62 i3 0:4
July 99:0 63:2 35:8 804000 58 | ,, O1
August.. 99:8 65-8 34-0 8:3:410-00 54 | ,, 04
September 91:8 63:1. 287 71:61:85 78 , 07
October | 80:4 52-4| 28-0 68°2/1:90 68 5 0:3
November 71:6 44:3, 27:3 58:4 O14 76 ,, 0:8
December : 63:1 37:1 26:0 49°4) 2°36 78 | S 01
Total mean 78:8 49:9 i 29:5 64:1 116-84 71 | W. 04
Colonial Medical Reports.—No. 44.
New Providence.
MEDICAL REPORT FOR 1911.
By J. J. CULMER, M.R.C.8.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 in
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.
SrATISTICS OF POPULATION FOR THE
YRAR 1911.
RETURN OF THE
Number of inhabitants according to the census on
. .. 55,944
April 2. 1911 ; es vis oe
Number of births since the last census .. 1,362
» deaths » » 867
" immigrants Not
35 emigrants zs .. | known
s inhabitants in 1011 .. 2d b 56,439
Increasc ʻi zs s T si - - 495
134 THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. [Dec. 15, 1914.
——M— — — — — M — ———— ———— —9
n —— —— M MM ———— M — — —À — € Ó—
RETURN OF DISEASES AND DzEaTHS IN 1911 In THE BAHAMA GENERAL HOSPITAL,
New Providence.
GENERAL DISEASES. be É ane
~ 85 € 383%
d e Z ax Gs D oa?
= Z z ees q? À RO
29 à S&S Generar DisEASES—continued,
i ! (d) Tabes Mesenterica Sa — — —
Alcoholism 8 — 8 (e) Tuberculous Disease of Bones — ž -- —
Anemia 1 E 1 Other Tubercular Diseases — — —
Anthrax ze Seek ees Varicella .. : T : — — —
Beriberi — i TEES — . Whooping Cough — —
Bilharziosis ‘ — — -- Yaws . TEM AE
Blackwater Fever — -- --- Yellow Haver T _
Chicken-pox —- — . =--
Cholera — —
Choleraic Diarrhoa - — -— LOCAL DISEASES.
Congenital Malformation -— Et
Debility : 33 36 Diseases of the—
Delirium Tremens — = Cellular Tissue A - i .. 19
Dengue .. : --— Circulatory System .. T EE
Diabetes Mellitus (a) Valvular Disease of Heart
Diabetes ix d (b) Other Diseases ..
Diphtheria Digestive System —
Dysentery .. (a) Diarrhoea
Les Fever
sipelas ..
Febricula ot
Filariasis ..
Gonorrhea
Gout :
Hydrophobia
Influenza ..
Kala-Azar..
Leprosy ..
(a) Nodular
(b) Ansesthetic ..
(c) Mixed
Malarial Fever—
(a) Intermittent
Quotidian ..
Tertian
Quartan
Irregular .. F
Type undiagnosed
(6) Remittent .. ‘
(c) Pernicious .. ;
(d) Malarial Cachexia..
Malta Fever " ;
Measles
Mumps .. m
New Growths— ..
Non-malignant
Malignant
Old Age
Other Diseases
Pellagra ..
Plague
Pyeemia
Rachitis 5k
Rheumatic Fever
Rheumatism
Rheumatoid Arth: ritis
Scarlet Fever
Sl d asmellil
iT Ld] beled bi
(b) Hill Diarrhea ..
(c) Hepatitis .
Congestion of Liver
(d) Abscess of Liver
(e) Tropical Liver ..
(f) Jaundice, Catarrhal
o) Cirrhosis of Liver
) Acute Yellow AOPE
(a Sprue .. Es
(j) Other Diseases ..
Ear T
Eye
Generative System— P
Male Organs
Female Organs
Lymphatic System
Mental Diseases
Nervous System
Nose .. ;
Organs of Locomotion
Respiratory SS
Skin— .
(a) Scabies
(b) Ringworm ;
(c) Tine& Imbricata
)Favus .. £5
(e) Eczema .. s
( f) Other Diseases ..
Urinary System
Injuries, General, Local—
(a) Siriasis (Heatstroke) sa
(b) Sunstroke (Heat CERE
(c) Other Injuries
Parasites— x
Ascaris lumbriooides ..
Oxyuris vermicularis .
Dochmius duodenalis, or Ankylostoma duo-
denale ; í j
Filaria medinensis (Guinea- worm)
Ssc&luellllilltllilliSgSil&te
lleilliSelllll!esi-
IeelliliilillwllseellklilitiIllli!lllli!lal Lal
llolli
ERES
(a) Phthisis Pulmonalis i4 e wo - - (a) Cataract
(b) Tuberculosis of Glands .. a e —
— b) Iridectom
(c) Lupus E T ja oo PA bcd
— (c) Other Eye Operatious
Scurvy — = Tape-worm m sa RU
Bepticremia je. 5 8 Poisons — as T ps T 2 — 2
Sleeping Sickness s — — Snake-bites — .. T s T — — --
Sloughing roue ix — — Corrosive Acids : — — —
Smallpox .. (s yx si e| = — Metallic Poisons ene fmm —
Syphilis .. a js x: T e o — — -- Vegetable Alkaloids pu Mem =
(a) Primary... - T T wo — Nature Unknown — — —
(b) Secondary .. T bá T e 904 — 37 Other Poisons — — —
(c) Tertiary .. js T m ; 21 7 26 Surgical Operations — 99 — 99
(d) Congenital .. T và ae n 9 2 9 Amputations, Major .. — — —
Tetanus .. an $s is m 2 1 2 Minor .. — ig c mS
Trypanosoma Fever. - vs ee Other Operations = s
Tubercle— “8 Ki .. 59 26 69 Eye .. em cem
EE
Dec. 15, 1914]
———— ———— ee — ——
COLONIAL MEDICAL REPORTS.—FEDERATED MALAY STATES.
135
deu S oe ee 2€ ———S A, €
Colonial Medical Reports.—No. 45.— Federated Malay States.
MEDICAL REPORT FOR THE YEAR 1911.
By CHARLES LANE SANSOM.
Principal Medical Oficer.
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.
Ihe 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.—Ths 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 diarrhoea 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 it 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.
Lunatics to the number of 990 were treated in the
asylums; of this number 162 died ; this includes 24
deaths from cholera.
There were 549 cases treated in the leper asylums ;
130 lepers were transferred, 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, diarrhoea, 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 Eurasians die from it; but, on
the other hand, a great 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 parte, 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
increase 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
+o ee Ee ——— en —— — — —— — +e —— —
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 Ib. 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 diarrhea, 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 Officer, 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 cases, with 142 deaths.
Cholera appeared in the Lunatic Asylum, Taiping,
in October, and the last case 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
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 &t the District Hospital, Kuala
Lumpur; and of the 3 cases admitted in the hospital
at Seremban all proved fatal.
Chicken-pox.—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.
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
In
' 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 veritied Total
Perak 20,992 3,085 24,181 48,758
Selangor .. ww CEU 28 6,544 12,622 46,894
Negri Sembilan.. 6,636 1,005 177 7,818
Pehang .. 9,028 821 302 4,651
Total 58,884 .. 11,955 37,282 .. 108,121
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.
"d
jo^tc nO ‘or Contents see page v.]
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Erm bodying Selections from THE COLONIAL MEDICAL REPORTS.
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ALDO CASTELLANI, M.D.FLOR., AND C. M. WENYON, M.B., B.S., B.SC.
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In cases of Acute Neuralgia, treated with a view of determining the analgesic properties of Antikamnia, it has
been found to exceed any of its predecessors in rapidity and certainty of relief given. Neuralgia, Myaigia,
Hemicrania, and all forms of Headache, Menstrual Pain, &c., yield to its influence in a remarkably short time,
and in no instance has any evil after-effect developed. Strongly recommended in Rheumatism. The adult dose
is one or two tablets every one, two or three hours. To be repeated as indicated. All genuine tablets bear the AK monogram.
TO TREAT A COUGH. Antikamnia and Codeine Tablets are most useful. It matters not whether it be a deep-seated cough, tickling cough,
hacking cough, nervous cough, or whatever its character, it can be brought under prompt control by these tablets. To administer Antikamnia,
ge) and Codeine Tablets most satisfactorily, for coughs advise patient to allow one or two tablets to dissolve slowly upon the tongue and swallow the
saliva. For night coughs, take one on retiring.
THE ANTIKAMNIA CHEMICAL Co., 46, Holborn Viaduct, London.
"ue ks, 0 ie =
p a" E
| High- | | KE
Wa Gension NE
Profession.
A
A WX
EAN
QQ
\
,
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" È ec
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No
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-— —— —— — —
TEREST
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P tue
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PE oes
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GR ea AN
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T iulii mr——
? ' £ " -* p
~ Jhe BERGIUS IA
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THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.—ADVERTISEMENTS. iii.
—— ——
ALPHABETICAL LIST OF AOVERTISERS.
Allen & Hanburys Ltd, ....... desis caes — Colman; J, d d. TAGs. saisis te eezics VM Lewis, HE WES vchus ones task p PESE tot —
American Cockroach Co. ................ x Down Brom, LUL eias r2$1550205034 292 v Liebig's Extract of Meat Co., Ltd. ........ —
Angier Chemical Co., Ltd., The .......... — Droitwich Brine Baths Spa .............. = Manlove, Alliott & Co., Ltd... ............ —
Anglo-American Pharmaceutical Co., Ltd. — | DODR Ee Vetera x ET 9 SAM A XN It EIN UR a (nón ul uin vii Martin H. Smith Company....7........... xi
Antikamnia Chemical Co. ................ ii Edgington & Co., Ltd., Jolin .............. vi Meister Lucius & Brüning, Ltd: .......... —
Army and Navy Co-operative Society, Ltd. — | Elder Dempster & Co., Ltd. .............. iv Melia sR Food; Ltd. (epos iad vic range --
Apenta Aperient Water .................. — . Fellows Company of New York............ i Merck, By aere snes devedsetdvses rhon nn . —
Bale, Sons & Danielsson, Ltd. .... vii, ix, x, xii Fletcher, Fletcher & Co., Ltd. ............ — Norris, G. ..... ee pap eer pns =
Bailliere, Tindall & Cox ................«» x Foot & Bom, d: RU. isctac device CIERRE GE -— Oppenheimer, Son & €o., Ltd. ............ vii
Bank of British West Africa, Ltd. ........ -— CES &/ Bone Up d, i lepores — ANUJ es Ce Peels Oe. eed d dies Kosi ias dT
Bergius Launch and Engine Co, .......... ii Griffiths. McAlister & Co. ................ — Sanatogen b won Cau RAO DA X a ER AE AA M a CR Ss —
Berkefeld Filter Co., Ltd., The............ — Hs WING ...cvkes dose bowie nrc on es — Sissons, Bros. & Co., Ltd. ..... aui AL -—
BORON Sas, M, Lise 32d orfo Satana na — Mana ior ore TEAMS e OPE ERES PEN qd — SWIIt-&:. Bon; Jamaa Zeta ste lestaal ea x
PO Salva e a As ek been vM S RE or IPTE -- Hearaon &.Qo., Lu, OBSS. euer iv, iii Tyrer & Co., Ltd., Th Cuyo wh sss EVANS —
Balivant- Me C0. TA. o ainen raioni ws iv Hewlett & Son, C. J., Ltd. .............. vi Union Castle Line ..................ueuue. iv
Burroughs Wellcome & Co................. — | Horlick's Malted Milk Co................. — Valentine's Meat Juice Company .......... xii
Barrow, We GB does circus reu ns Y cake Se Deos -- Howards & Bons, Lád. casey ches eee — Viel's Electric Colloids Co. .. ;............. =
Butterworth & Co. (India), Ltd. .......... vi | Humphrey Taylor & Co,, Ltd. ............ viii YIFOE andes vat Eu3 V voc PEE Wena dio d ix
Cadbury's Cocoa ..... 705 «pad esa Fed À n ea xb * dumperial Coulee: 10545932 t 23 44A — Whiffen & Sons, Ltd. ..........-.-eeeeeee xi
Cellular Clothing Co., Ltd. ................ iii Ingtàm & Boyle, LU. ...2. 2e ers ix Widenmann, broicher & Co., Ltd. ........ —
Christian Literature Society .............. — E T a MERT REAT EA TO EEE -— Wulüng & Co, ........... e ee ern —
Clayton Fire Extinguishing Co., Ltd. ...... ii Lambert Pharmacal Co. .................. xi Zimmermann, A, & Mi. ise esse tees —
The dash denotes that the advertisements does not appear in this issue but will appear in the next.
AERTEX CELLULAR.
‘Chis Label on All Garments. The Use of Red Garments
fession that the sun's rays in the Tropics act
in the Tropics.
very forcibly, but that it is the blue rays (known
scientifically as the actinic) which produce sunstroke, and that the red rays (known as the non-actinic rays) do not have any
harmful effect. Heat alone is not injurious, as is evidenced by the fact that persons can stand high temperatures in Turkish
baths, and stokers stay for days in boiler-rooms, without injurious effect, but heat together with strong sunshine often result in
disaster. We have therefore produced a specially-dyed red AERTEX fabric which is not a bluish-red, but is so carefully selected
as to colour, that only the red and orange rays are allowed to act on the body. The great comfort derived from the wearing of
AERTEX Garments in hot countries will, we believe, be still further increased by the substitution of AERTEX Garments madé
from red yarns which have been chemically tested and proved to be able to withstand the actinic rays. We are therefore confident
these garments will meet a great need, as they are admirably adapted for tropical use. i]
Suggestions from Medical men for fabric or garments specially suited for local requirements are respectfully invited.
I? has been definitely proved by the medical, pro-
NON-ACTINIC AERTEX CELLULAR.
Neck Sizes 14 to 17.
Day Shirt Suet throughout) a T RIS 7/6 Tunic Shirt, i oan UU qo der 8/6
Tennis Shirt, with Collar and Pocket $a T. 8/- Day Shirt, Se Se eee Linen Cif 9/6
PB =a 3 — 5 x: E DE SAE E > .
| WHOLESALE ONLY— LONDON RETAIL AGENTS—
City: ROBERT SCOTT, Ltd., 8, Poultry, Cheapside, E.C.
THE CELLULAR CLOTHING CO., Ltd., | West End: OLIVER BROTHERS, Ltd., 417, Oxford Street, W. :
72 and 73, FORE STREET, Full Price List of Aertex Cellular Goods for Men, Women and Children sent
post free on application.
LONDON, E.C. Any Garments mentioned in price list may be obtained from the above-
named Agents, who keep a complete stock of AERTEX Cellular Garments
Cable Address : " CELLULAR," LONDON, Telephone : and Fabrics. i
A.B.C. Code used. £38, London Wall. All materials may be obtained at the above addresses by the yard, any
length cut. Very light fabrics specially manufactured for the Tropics,
Sie te a ee Special study is given to Outtits for India and the Colonies. Estimates
AERTEX Cellular is entirely of British Manufacture. for complete outfits furnished at short notice.
J Used in all the Bacteriological
Laboratories în the World, and
| H by all Medical Officers of Health.
= : <==
AWARDED
THE GRAND PRIX,
INTERNATIONAL CONGRESS OF MEDICINE, -
LONDON, 1913. | |
NEW CATALOGUE (1913) SENT ON APPLICATION.
Hearson's New
Combination Incubator.
Hearson's Patent
Bacteriological Incubator.
CHAS. HEARSON & CO., Ltd., Biological Incubator Manufacturers, 235, REGENT STREET, LONDON,
W.
iv. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE—ADVERTISEMENTS.
—— ——M——
BRAZIL, URUGUAY, ARGENTINA,
Via Spain, Portugal, Madeira, St. Vincent, Falkland Islands, &c.
Fortnightly from London to
WEST INDIES, PANAMA CANAL,
NEW YORK,
British Guiana, Colombia, Panama (for Pacific Ports), Cuba and
Bermuda.
Circular Cruises to Gibraltar, Morocco,
CANARY IS., MADEIRA, 23 DAYS, £18
THE ROYAL MAIL STEAM PACKET COMPANY ! LONDON: 18, Moorgate St., or 52, Cockspur St.
THE PACIFIC STEAM NAVIGATION COMPANY j LIVERPOOL: 31/33, James St.
WEST & SOUTH-WEST COASTS OF AFRICA, THE CANARY ISLANDS & MADEIRA.
THE STEAMERS OF
The African Steam Ship Company
(Incorporated 1852 by Royal Charter), AND
The British & African Steam Navigation Co., Ltd.,
CARRYING HIS MAJESTY'S MAILS,
SAIL: SAIL:
HIVEREOOU Ee WENT AFSICK Every WEDNESDAY, THURSDAY, HAMBURG to WEST AFRICA .. .. Five Times a Month
T P : T da St .. Fortnightly
LIVERPOOL to SOUTH-WEST AFRICA THURSDAY Four Weekl HAMBURG to LAGOS .
LONDON to WEST AFRICA .. THURSDAY Three Weekly ROTTERDAM to WEST AFRICA .. .. Five Times a Month
TAKING PASSENGERS AT LOW RATES.
ELDER DHMPSTER & CO. LIMITED,
Head Office: COLONIAL HOUSE, LIVERPOOL.
4, St. Mary Axe, LONDON, E.C., 30, Mosley Street, MANCHESTER.
CARDIFF. BIRMINGHAM. HAMBURG. GRAND CANARY. MADEIRA. TENERIFFE.
UNION-CASTLE LINE
BULLIVANT & Co., ROYAL MAIL SERVICE.
Inventors & Manufacturers of btd: | SAILINGS via THE WEST COAST,
FLEXIBLE STEEL | "tee ve THE SUEZ CANA
WIRE ROPES ; ere.
Natal,
Delagoa Bay,
For SHIPS HAWSERS, CRANES, Mombasa
LIFTS, HOISTS, DERRICKS, &c. À and other
| REN t Sut South & East
MAKERS OF pope eio
WINDING and HAULING ROPES, e
BLOCKS, PULLEYS, CRAB- TYPUM
WINCHES, and all Appliances "m AR] The Canaries.
for Working Wire Ropes. alb c. dn :
African Ports.
. Mediterranean
and Egypt.
Hegistered Offices :
12, Mark Lane, London, E.C.
Works: MILLWALL, LONDON, E.
Telegraphic Address: BULLIVANTS, LONDON. HEAD OFFICES OF THE COMPANY,
Codes: Al., A.B.C., NEW GENERAL & MINING. 3, FENCHURCH STREET, LONDON.
Tours round
Africa.
The Journal of Tropical Medicine and Wygiene.
CONTENTS.—DECEMBER 15ra, 1914.
PAGE PAGE
ORIGINAL COMMUNICATIONS. ANNOTATIONS.
l. The O i i
Mew EP YR iod Certain Stractures in me The French Medical Service (DELORME) ds .. 978
Erythrocytes of Guinea-pigs and their relation- Post-Tvphoid Cholelithiasis (Bar 378
ship to the so-called Parasite of Yellow Fever. V OIBBSIIAMIE tae cata gi Gi
By C. M. WENYON and Gxonax C. Low (with Practical Points in Abdominal Surgery (DALZIEL)... 378
plate). “Traumatic Malacia" following Fractures (Gaza)... 378
Description of Bodies in Normal Guinea-pigs—The Treatment of Tetanus (W. F. Law) ... tes ec S
Supposed Inoculation of Guinea-pigs with the Treatment of Enteric Fever (BROADBENT) ... 2. IS
so-called Yellow Fever Parasite—-Tne so-called
Parasite of Yellow Fever—-The Value of these Pathological -Afinitics: ‘of Beriberi: and Bprus
Bodies as a Diagnosis of Yellow Fever—What are Danes) he X. im i rs uy
the Bodies in Yellow Fever Cases ? — Conclusions 369 Malnutrition in Adults (Funcx) i ia m 379
Differential Skin Reaction in Yariola and Yaricella
2.. The Transmission of Trypanosomæe brucei of (TIÈCHE) "y ar E a id .. 880
Nigeri PE 9 i í
igeria by G ossina tachinoides, with some Notes Actinomycosis (DREssL) ... " ud u .. 880
on Trypanosoma nigeriense. By 3. H. GALLAGHER
Description of the Parasite— Animal Reactions— TT
Discussion as to the Identity of the Parasite— Con- '
clusions ... Te P - se ts ac BI | NOTES AND NEWS.
ES A Hardy Annual ... - T. ^ X .. 880
LEADER. Teff, a valuable Tropical and Sub-Tropical Half-
Fruits and their Action ... M T ya crx 3976 crop vas ii Y T sts oe .. 3980
4, DOWN BROS.’ Specialities,
. COMPLETE PORTABLE APPARATUS
for injecting Hypertonic Saline Solution
in Cholera Collapse and Infantile Diar-
rheea, also useful for Post-operative
Infusions, &c. Suggested by Lt.-Col.
Leonard Rogers, I.M.S.
Conveniently arranged in a neat
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instruments are fitted into nickel
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, Te
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Paris snes ee odio reba Aires 1910 DOWN BROS., LTD.,
SE Surgical 3netrument Makers,
21 & 23, ST. THOMAS’S STREET, LONDON, S.E.
(Opposite Guy’s Hospital)
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Gold Medal, Allahabad 1912. “ Down, LONDON.” L
vi. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE —ADVERTISEMENTS.
— ÍÜ o À——
BUTTERWORTH & Co. (india), LTD..
have pleasure in announcing that
—— they now hold
The largest stock of Medical and Surgical
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Should any book desired not
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it will be cabled for free of charge.
Butterworth & Co. (India), Ltd.
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BUTTERWORTH €& Co. (India), Ltd., 6, Hastings Street, Calcutta (Box 251).
THE ORIGINAL PREPARATIONS.
7
“MIST. DAMIANA 60." “MIST. HEPATICA CONG.”
HEWLETT’S.) (HEWLETT'S.)
This reliable preparation contains Damiana, | c9gMpOSITION.—Ext. Cascare, Rhei, Jala-
Nux Vomica, &c., combined with Medicinal 3 ; hl
Bitters aud Aromatics, and is perfectly miscible | Pin, Podophyllin, Cocaine Hydrochlor.
with water. It possesses all the special prop- (4. £r.), and Aromatics in each drachm.
erties of Damiana in the most convenient
form —its alterative effects on the alimentary
canal and tonie action upon the brain and
nervous system generally. In the numerous
forms of Neurasthenia it has been highly
successful, asit soothes the stomach, invigorates
the nervous system aud relieves the exhaustion.
Invaluable in Chronic Biliousness, Jaundice,
and all torpid conditions of the Liver. Useful
in Constipation, especially when accompanied
with depression and general malaise. Does
not cause griping or sickness.
: Dose: 10 to 60 minims.
Dose: One to two fluid drachms in water.
Price 11s. per lb. In 10, 22, 40 and
Price 11s. per lb. In 10, 22, 40 and odor, Bottles.
90-oz. Bottles.
INTRODUCED AND PREPARED ONLY BY
C. J. HEWLETT & SON, Ltd,
Uübolesale ano Erport Druggists,
35-42, Charlotte Street, and 83-85, Curtain Road, London, E.C.
Medical Practitioners are invited to ask for our Price Lists, sent Post Free on application.
The Journal of Tropical MANedicine and fIDyvgiene
Selections from COLONIAL MEDICAL REPORTS.
As a preventative of the spread of infectious
disease and as a general prophylactic “ Cofectant"
(Cook’s Disinfectant Fluid) is unequalled.
It is a non-toxic, non-corrosive disinfectant
forming a stable emulsion when mixed with
water.
It has been proved to have a higher co-
efficient than any other disinfectant on the
market (vide Lancet, Nov., 1909).
IMPORTANT BOOKS
For those interested in
FIRST-AID WORK.
Why and Wherefore in First-Aid.
by Question in Study & Treatment solved
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lémo. Limp Cloth. Price 6d. net. Post free 7d.
The Whole Art of Bandaging.
By THEKLA BOWSER, F.J.L, with Introduction
by JAMES CaNTLIE, M. A., M.B., F.R.C.S. With
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Instruction in Cutting Out
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THE ‘PULVERETTE’
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RESEMBLES A PILL ———
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vii. THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. —ADVERTISEMENTS.
COLMAN 9 25? MUSTARD
Nature’s unequalled appetiser and digestive for all Meats,
Game, &c.
Extremely useful as a tonic and recuperative in the Bath
—hot or cold.
ROBINSON'S “parent” BARLEY ww powner rom.
Invaluable for quickly making Barley Water, the most
refreshing and sustaining drink in Hot Countries.
IN COMPACT, RELIABLE TINS. EASY FOR PACKING & SAFE TRANSIT.
HAS NEARLY too YEARS’ REPUTATION,
nn M s
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Distillers to
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A delicate dry appetising wine contain-
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Junora strengthens the whole Nervous System and Perma-
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so frequently Impaired in Hot and Enervating Climates.
A splendid antidote to hot weather lassitude.
Lecithin-Ovo | 13 grs., 4/6 per 100. Lecithin-Ovo "ac quality from 10
Capsules | 3 grs. 8/6 per 100. - Powders | to $0 per cent. strength
Humphrey Taylor & Co., Ltd. 775
45, New Oxford Street, London, England.
The Natural Mineral Waters of
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CELESTINS
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———— —
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A Handbook of the Gnats or Mosquitoes,
including a Revision of the Anophelinz-.
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M.B.Lord., F.R.C.S. Cloth, gilt lettered. Price
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The Maintenance of Health in the Tropics.
By W. J. SIMPSON, M.D., F.R.C.P. Crown $vo,
119 pp., cloth limp. Price 2s. 6d. net, postage 3d.
Health Preservation in West Africa.
By J. CHAN. RYAN, L.R.C.P.I.
by Sir RoNALD Ross.
Price 58. net.
With Introduction
Crown Svo, cloth, lettered.
The Principles of Hygiene.
As applied to Tro Spica and Sub-Tropical Climates and
the Principles of gira Hygiene in them as applied
to Europeans. By W. R. SIMPSON, M.D.
F.R.C.P., D.P.H. Demy 8vo, about 400 pp. Price
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Hints to Rosani and Travellers in Persia.
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ANGUS & ROBERTSON.
THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE. —ADVEBIISBMENTS ix.
The use of Virol
in Fevers.
The latest Studies in the cytology
of the marrow confirm the long
accepted belief that the function
of this tissue is indissolubly
associated with the highest
protectiveand reparative processes
of the human constitution.
Increase of Opsonins.
It is definitely known that the
exhibition of bone marrow in the
form of Virol in all febrile
disorders has a potent influence
for good, increasing the opsonins
and thus strengthening the
defensive processes i of the body.
Virol has moreover a marked
effect upon the conservation of the
tissues, repairing the waste and
restoring the equilibrium of a
healthy metabolism,
Recent Investigations.
It was recently demonstrated in
an elaborate series of investi-
gations at the Frant Forest
Sanatorium thatthe Opsonic Index
of the patients against B. Tuber-
culosis rose in proportion to the
number of weeks the patient had
been fed on Virol.
Similar results were obtained
in experiments carried out at
the Monsall Fever Hospital.
Manchester, with the result that
“ Virol was generally adopted in
this Hospital of 450 beds in
Typhoid Fever, Scarlet Fever, and
Diphtheria with entirely satis-
factory results.”
VIROL IS EXTENSIVELY USED
IN MORE THAN 1,000
HOSPITALS IN GREAT BRITAIN.
VIROL, LiwiTED,
152/166, Old Street, London, E.C.
E THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE—ADVEBTISEMENTS.
JAMES SWIFT & SON,
Grands Prix, Diplomas of Hanour, “na rapid
Medals at London, Paris, Brussels, &c.
"PREMIER" MICROSCOPE
This stand is pre-eminent befor e all others
^
Prescriber's Formulary and Index of Pharmacy. By
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for perfection of design, finish and adjust-
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visual research and for photo-micrography
VATURE" (the leading scientific journal) says :
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AN ILLUSTRATED TEXT-BOOK FOR STUDENTS AND PRACTITIONERS.
Dy Prof, GEORG HIRSCHEL. Royal octavo, pp. 198. Price 8s. 6d. net, postage 6d,
Disturbances of the Visual Functions.
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THE JOURNAL OF TROPICAL MEDICINE AND HYGIENE.—A DVERTISEMENTS. xi.
EMETINE HYDROCHLORID
EMETINE HYDROBROMID
FOR eaoat ENT
THE NEW REMEDY IN AMCEBIC DISEASE
—vide BRITISH MEDICAL JOURNAL, Aug, 24th, 1912, pp. 405/408.
no have ag cir eeu Mes id Ptopsrenons dur ^s past 15 yam nee ^ 5 s For
tai i HIFFEN’S Brand, f i H
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ERGOAPIOL (Smith) is supplied only in M4
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SAMPLES and LITERATURE
dI
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IIMARTIN H. SMITH COMPANY, New York, N.Y.U.S.A. IBS
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It is quite generally accepted as the standard antiseptic preparation
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. There is no possibility of poisonous effect through the absorption of
Listerine.
A pamphlet descriptive of the antiseptic, and indicating its utility in medical, surgical and dental practice
may be had upon application to the manufacturers, Lambert Pharmacal Co.,
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British Agents, Messrs. S. Maw, Son £ Sons, T, Aldersgate Street, London
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