Abstracts from Reports THE ROCKEFELLER FOUNDATION, NEW YORK. ANNUAL REPORT FOR THE YEAR 1938 President's
review
The year in
brief
1938 The Rockefeller Foundation appropriated a total sum of over $15,000,000. Of this amount, speaking in terms of rough classifications, $3,800,000 was given to the medical sciences, $3,800,000 to the social sciences, $3,000,000 to the natural sciences, $2,500,000 to public health, $1,000,000 to the humanities, and $300,000 to rural reconstruction in China. The Foundation's income during 1938 amounted to In approximately $7,000,000. appropriating $15,000,000 it was necessary, therefore, not only to use up the balance carried over from earlier years, but to dip into the principal fund to the extent of $3,755,000. In carrying out its 1938 programme the Foundation operated in forty-two countries in all parts of the world. Eighteen of these countries were in Europe, five in Asia, two in Africa, five in South America, ten in North and Central America and the West Indies, and two were islands of the Pacific. During
Yellow fever Two years ago in this review it
was reported that jungle yellow fever, spread by some vector other than the Aedes cegypti mosquito, had been discovered in
wide areas of South America. In the last two years outbreaks of this disease have been observed from 7? 30' North Latitude to 27? South Latitude; from the eastern slope of the Andes to the mouth of the Amazon; at altitudes varying between sea level and 5,000 feet; in regions of dense jungle growth and in prairie districts where the infected forests cover not more than 5 per cent of the land area; in sparsely populated regions and in heavily populated agricultural districts; in the form of epidemic waves and under conditions suggesting permanent local endemicity. Jungle yellow fever has proven to be not only a constant source of virus for the reinfection of towns but also an important public health problem in its own
right.
In any must be
discussion of jungle yellow fever emphasis to the fact that this term is one of
given
epidemiological significance only. Clinically, pathologically, and immunologically, it has so far been
impossible to differentiate jungle yellow fever from the classical segypti-transmitted variety. Field observations have, during the past four years,failed to indicate
that
any
of
the
minor
segypti-
transmitted outbreaks during this period have been due to virus coming from a previous segypti-transmitted imection. Rather these observations have suggested
in each instance that the town had been invaded by a virus from near-by jungle districts. Were it the existence of the jungle infection, yellow fever have disappeared permanently from the Americas & 1934. Although the clinical picture of yellow fever is the same whether the infection develops in the town or in the jungle, the epidemiology of the two types is quite different. Aegypti-transmitted yell and it is of great importance to her overseas trad? that this suspicion should be dispelled as soon a? health in advance possible. Considerable port organization and in control of infectious disease has been made within the past few years. Another direction in which marked progress has been made is in the field of nutrition. The Indian Research Fund Association recognized the importance of sound nutrition of the people many years before the subjec was taken up by the League of Nations and by the Governments co-operating with that international bodyThe contributions made by Sir Robert McCarrison to this science are now seen to be much more general applicable than was originally realized. In more recent years, the practical aspects, of tj? nutrition problem have received greater attention. laboratory studies of the common foodstuffs and th actual diets consumed by the people, and by np' studies for ascertaining the nutritional state of th people, much information has been collected whic is invaluable for the betterment of national nutritionFurther, researches have demonstrated the advantag of adding milk, even skimmed milk, to the ordinary unsatisfactory diet of many people, while the deficiency of vitamin A in the diet can be correcte1 by taking red-palm oil which can be produced India. From the practical point of view the importan of these researches is immense, because the nutrition state of the people can be improved only by metho which are cheap. To better the nutritional state of the people it essential to correlate nutritional researches with t , activities of animal husbandry and agriculw , departments. For this purpose a liaison officer train in human nutritional work has been appointed, a it is his duty to keep in touch with all provinc and animal agricultural departmen husbandry Further, a National Nutrition Committee has be appointed which includes nutrition workers, represena , tives of agricultural and husbandry departments, expert educational and economic advisers. .
,
coiiini0^
.
?
The
population problem
Special committees in population problem and
provinces educate
to
study
the
public
e
recommended. ce While the birth rate has shown little change si ^ 1891, the death rate has been falling since 1921. A,gr uD average_ annual increase during 1921-30 was just two millions. During the succeeding seven J'e ,;c which were free from violent outbreaks of epide ^ disease, the average yearly increase of population British India is estimated at just short of three xn1"1 These facts support the inference that the pres 0f decade is likely to present an even larger rate increase than that recorded during 1921?31. During,^ period, 1921-31, the increase of population, in .-^3 was approximately 34 millions while the indicai *jj are that during 1931-41, the increase will m probability be 45 to 50 millions. pid The continuing low standard of living and Pe, jjjfl of numbers that characterized have expansion .
_
Dec., 1939]
ABSTRACTS FROM REPORTS
present and preceding decennia are facts which must Pe faced. Into this complex situation another important factor has been introduced in the form of a Preventive health campaign which, in spite of serious deficiencies, has already saved increasing numbers of human lives. No civilized government can turn back 011 an expanding programme of public health endeavour, so that it is all the more essential for thoughtful men and women to turn their attention to the study of the population problem. In the words of Sir John Megaw, ' What is required, of the whole community in life planning, ^iheeducation must be made to realize what they are up people against, and how they can control the forces of nature their own advantage. The best brains of India helped by the best brains of the outside world will be needed. Experts in agriculture, education, public health, economics and industry must co-operate in deciding what should be taught; then the subjectmatter must be prepared in a form which will be Palatable to the masses'. .
|?
Maternal deaths At least 200,000 women die every year in India from causes arising from child-bearing. In 1937, deaths of 'nfants under one year of age accounted for 24.8 per cent of the total mortality at all ages, of children Under five for 18.G per cent, and of those between five ten years of age for 5.4 per cent. Corresponding hgures for England and Wales in 1936 were 7.1 per cent, '?5 per cent and 1.2 per cent. Maternal mortality enquiries conducted in limited areas suggest that, for India as a whole, about 20 ^'ornen die among 1,000 undergoing pregnancy and
^nd
childbirth. Accumulating bearing takes a ln
evidence seems to indicate that childmuch higher toll of life in urban than areas and that the good effects of the better Urban facilities may be more than outweighed by the ill-effects of overcrowding, of lack of sunshine and fresh air and of ill-balanced diets. Few reliable figures for mortality are available for rural populations, Put the maternal mortality rate recorded in three health-unit' areas in South India was only 5.0 per l>000 total births. The increasing concern at this enormous loss of life ?ud the heightened sense of responsibility for the Uealth and safety of mothers and children were reflected in the decision of the Central Advisory Board Health in 1937 to appoint a special committee to ePort on the whole subject of maternity and childwelfare work in India. The committee completed its recently and its comprehensive report has now e?n approved by the board and has been issued. Hie report stressed the importance of appointing a Qualified and experienced woman medical offiperly mcer jn each province for the efficient administration maternity and child-welfare work. -The empioyment of women doctors in the manageand supervision of municipal and other local and child-welfare schemes is also urged. For le benefit of the mothers and children requiring advice ud assistance, a woman doctor's services are essential, ecause there are limitations to the employment of ?u-medical women in the welfare centres. Another recommendation refers to the desirability of j/r?viding a system of grants-in-aid from Government not only because these stimulate local bodies improve their services but because they give official health departments a suitable measure of control Ud supervision over the work undertaken by local ,
rural
paternal
^?rk
ment jUaternity
purees, ari'li
aufhorities. -further advance
has been made by the recent passing number of provincial Nurses', Midwives', and ,,?alth Visitors' Registration Acts, designed to secure K_g, registration and better training of midwives and alth visitors. ^ sound training in pre-natal and post-natal care essential both for medical students and midwives. 'this purpose, well-organized pre-natal and posttramin^? clinics should be provided in all hospitals students and niidwives, and attendance at these tr
?
a
775
clinics should be included in the courses of instruction in midwifery for medical students. The organization of maternity and child-welfare work in India has, in the past, been largely due to voluntary effort. The stage seems to have been reached when transition from voluntary direction to official control must take place if further developments are to be made, and the problem during the next few years will be to preserve a proper balance between government and voluntary effort. Causes of death Fevers' alone accounted for over 3,000,000 deaths or 55 per cent of the total mortality, and respiratory diseases for 8 per cent in 1937. The large figure for ' fevers' almost certainly includes over a million due to malaria and large unknown numbers due to typhoid fever and tuberculosis. Existing agencies for the registration of vital statistics in rural areas make it impracticable to carry out classification of the causes of death except in a few large groups and, apart from such diseases as cholera, smallpox and plague with which the people are 'familiar, fevers other deaths are ordinarily recorded as ' ' respirator}'' diseases' and other causesSo true is this that nearly 93 per cent of the six million and odd deaths registered during 1937 were placed in these three groups. In comparison with these diseases deaths from cholera, smallpox and plague are of relatively minor importance, though in the popular imagination these three are the most dreaded epidemic diseases. In fact, during the period 1925-37, the combined mortality from these three diseases did not exceed, in any year, 10 per cent of the total recorded mortality. Malaria, tuberculosis and leprosy have, within recent received increasing attention from health years, authorities and voluntary organizations in the country. Provincial public health reports show a general recognition that malaria constitutes the major health problem in most provinces. The rural malaria death rate is approximately three times the urban rate and, as nearly 90 per cent of the population is rural, the problem is urgent. The general policy in the provinces is to provide an adequate supply of quinine or cinchona febrifuge, to popularize the use of these drugs as far as possible by means of propaganda and teaching in the schools, and to provide extra medical staff and travelling dispensaries to localities visited by regional epidemics. Regarding tuberculosis, the last decade has recorded considerable progress in organized effort. In 1929 a central organization came into being when various schemes were considered for the utilization of the King George V Thanksgiving Fund. It was decided that this fund should be devoted to a campaign against tuberculosis and the King George Thanksgiving Fund Anti-Tuberculosis Committee was constituted. With an annual income of onfy Rs. 53,000 the activities of the committee were necessarily restricted. The special appeal for funds for fighting tuberculosis which was issued in the name of the King-Emperor by Her Excellency the Marchioness of Linlithgow in December 1937, has met with an excellent response and has made it possible to organize the anti-tuberculosis campaign on a wider basis. The Tuberculosis Association of India was formed a few months ago, incorporating the King-Emperor's Anti-Tuberculosis Fund and King George Thanksgiving Anti-Tuberculosis Fund. The inauguration of the Indian Council of the British Empire Leprosy Relief Association in 1925 was a distinct advance in the campaign against leprosy. A capital fund of Rs. 20,25,000 was created by an appeal to the country and the annual income from this fund, amounting to nearly a lakh and a quarter, was made available for furthering anti-leprosy work in all directions. Later, a further donation of Rs. 3,13,000 was received from Their Majesties' Silver Jubilee Fund. The demonstration that early cases of leprosy were amenable to treatment also helped towards awakening public interest and towards the organization of effort to combat the disease. '
776
THE INDIAN MEDICAL GAZETTE
Research work has been carried on at the School of Tropical Medicine, Calcutta, in co-operation with the authorities of the School and the Indian Research Fund Association. This work has been carried out at a cost of Rs. 3,37,000 up to the end of 1938, and the results obtained have been published in the annual reports of the Association as well as in scientific journals in India and abroad. Food adulteration Adulteration of common articles of food is widely practised in India and the subject has not received the attention it deserves. Milk and milk products are everywhere adulterated. In one province," 73 per cent of the samples of ghee examined, 50 per cent of the samples of milk and 40 per cent of the samples of butter, were found to be adulterated. One of the of affairs is the causes of this unsatisfactory state apathy with which the public view the matter. _
Health in schools The importance of a well organized school medical service in a national health programme requires no special emphasis. 'Medical Science has proved_ with unmistakable clearness that disease and incapacity in adolescence and adult life find their source, all too often, in the seed time of childhood. It cannot be doubted that much of the excess of sickness and mortality under forty years of age must be attributed to this origin and some of the maternal mortality, some of the recruits rejected on physical grounds, some of the lost time in industry, some of the lack of resistance to infective disease may all derive from this same sourceThese words of the Chief Medical Officer to the Board of Education, England, and Wales, are equally applicable to India. Fairs and Within recent centres has
festivals
sanitary control of pilgrim increasing attention from provin-
cial health authorities. The measures taken for this have, in fact, reduced to a great extent the danger of explosive outbursts of cholera, although it must be remembered that, as in the extensive epidemic that followed the Hardwar Kumbh Mela in April 1938-,_ large festivals with their inter-provincial traffic in pilgrims, who have often to pass through endemic regions of cholera, always hold out a threat of outbreaks. However, the general effect of precautionary measures now being taken has been satisfactory, for during 1937, all fairs and pilgrimages in the provinces of British India passed off without any serious outbreak of infectious disease in epidemic form. The problem of health education in India is complicated by the fact that the majority of the population is illiterate. Moreover, there exist certain age-long customs and habits which cannot be easily changed. Instances are the_ indiscriminate pollution of village sites with nightsoil and the indifference of the people to contamination of their water supplies. It is difficult to convince the villager that, in respect of many diseases, man is his own_ worst enemy and that a radical change of habits is essential if sickness and mortality arising from avoidable diseases are to be purpose
_
_
prevented.
TION,
INDIAN 1938
The studies suggest that the offending factor is the seed of a plant, Argemone vicxicana, which appears to be widely distributed and to be often present as a weed in mustard plant field?. Its seeds are harvested with mustard seeds and argemone oil is also expressed with mustard oil without the manufacturers being aware of such adulteration. In some areas, such as the Punjab and the NorthWest Province, cholera appears only at intervals ot years, in certain parts of Bengal it starts almost regularly at the same season every year. An investigation into the causes is complicated by the fact that, apart from the true organism responsible for the disease, numerous other allied organisms exist in water supphesA differentiation of the characteristics of the true cholera vibrio from its allied organisms and the formulation of methods of separating the former when present with large numbers of the latter are therefore essential. Considerable success has of late been achieved tin these two directions in India, and the researches carried out have received warm appreciation from the International Public Health Office at Paris. In the light o the new knowledge, a field investigation is now being undertaken in Bengal, and it is hoped that the results of this enquiry will enable preventive measures to b taken with greater success. i Malaria investigations, both in the laboratory an^ the field, have proceeded under the Malaria Institut of India, which is financed by the Indian Researci Fund Association. In the Wynaad, Madras, and in? ? Terai in the United Provinces, research units haV been making field studies, and similar investigation are proposed for Orissa along the margin of ,tD Chilka Lake. In Delhi, also, anti-malarial operation were supervised by the Malaria Institute. In additio ' Heal1 advice is to the Public Provincial expert given Departments in respect of anti-malarial schemes. In the Haffkine Institute, Bombay, investigation were continued as to the best conditions under whic D anti-plague vaccine of high protective value could manufactured. An anti-plague serum has also bee produced for the treatment of patients. The seru has had a limited trial during an outbreak of in Bihar, and the results so far recorded suggest tn its use reduces mortality. Cyanogas fumigation for keeping down the rat Iation has been tried as an anti-plague measure in Cumbum Valley, Madras, and the conclusion that fumigation every quarter consistently fc>r a J years may reasonably be expected to eradicate disease. A statistical survey of leprosy has been carried ? in a group of 42 villages. While the gross inciden j of the disease was found to be 4.4 per cent in the to population, only 18 per cent among the patients ^t of the severe lepromatous type. Nearly 80 per c y of the cases gave a history of contact with ^ nnfipnf.s f.ho Kninnr pnm rr\ iim'na+orl in fL a a in patients, the infection being communicated ^ of cases by near relatives, in another third by *e(J relations, and in the remaining third either by or by unknown persons. The severe lepromatous i? of the disease transmitted infection more quickly the relatively milder nerve type. 0f A study has also been made of the influence skimmed milk as a supplement to the diet of patients, and it has been found that its administra^ seems to hasten the recovery of the lepromatous tyP Tuberculosis investigations covered a wide range included a detailed survey in a jute mill 23 miles 1 n Calcutta employing 5,000 labourers, a study of c in tuberculous homes and an enquiry into the incid of the infection among medical students and in Lahore. There is a general recognition that disease is spreading among urban and rural P?P tions owing to industrialization and rapidly increa transport facilities and the need is felt of defining extent of infection in different areas and of the social, economic^ industrial and other fa responsible for its incidence. The survey of tuberculous homes revealed tuberculosis was an important cause of morbidity >
P0^ reaCjLv _
leP^.r(j
unrefar0j
#
ABSTRACT FROM THE ANNUAL REPORT OF THE
1939
,
years the
received^
[Dec.,
RESEARCH
FUND
ASSOCIA-
The cause of_ epidemic dropsy has for long been the subject of intensive research in the School of Tropical Medicine, and the All-India Institute of Hygiene and# Public Health, Calcutta. Recent work at both institutions has tended to emphasize the association of mustard oil with the propagation of the disease, a theory which is not new but which had been replaced for a time by two others, namely, those of contact infection from patient to patient and of infection carried through rice damaged by unfavourable conditions of storage.
a^
nu^g .
de^er?1!,tors
^
ABSTRACTS FROM REPORTS
Dec. 1939]
mortality among infants and children, a fact not noticeable from public health returns. The enquiry at Lahore showed that of 434 medical students examined, 53 per cent had had t infection at some time or other and that fourth- and fifth-year students, the percentages were as
high
as 70 and 80 respectively. This does not of mean that they were active cases of tuberculoss the large majority the infection had been o by the natural resistance of the body. In f? 45 per cent showed physical signs of having ante from active tuberculosis. In the field of nutrition, simultaneously with basic research, the programme has been made more piac -
.
by relating laboratory investigations to the immediate necessity for improving the nutritional standa^
the people under present economic conditions, instances may be mentioned the discovery of a c i substitute in red palm oil for cod-liver oil to make the deficiencv of vitamin A in the diet, a fac or
p p
widely
deficient in India, and the demonstration tnat use of calcium lactate at a cost of half to one Per month per child improves its health, bp attention has been paid to diets largely composed
the
tapioca and it has been shown that the most lmporta defect in such diets is the deficiency of protein. .A study is being made of the effect of the use ot
,
highly
milled rice on nutrition. It is recognized tna the use of home-pounded rice is rapidly disappearing, a. solution of the problem of ensuring consumption o rice in its most nutritive form must be sought along other lines. as
.
ls
Comparison
of rice and maize has shown that
rice
richer than maize in nicotinic acid, which preven t Pellagra. This may explain why rice eaters rarely
develop
the disease. men from the and states hav e been trained to carry the provinces for better nutrition campaign *nto different parts of India and to educate the peop e in matters of nutrition.
Medical
REPORT
OF THE HAFFKINE INSTITUTE, FOR THE YEAR 1938
BOMBAY,
In general the activities of the Institute remained as in previous years. The production ot la g Quantities of prophylactic vaccine, mainly Hankine P'ague vaccine, cholera vaccine, typhoid vaccine and antirabic vaccine, and the diagnostic work loi y?spitals largely monopolized its limited resources funds and personnel. An idea of the work invo ve m the production of vaccines alone can be gained lro the fact that 3,411,258 c.c. {i.e., 1,137,086 doses of plague Vaccine, 608,506 c.c. of cholera vaccine, 38,269 c.c. oi typhoid vaccine and 733,530 c.c. of 5 per cent antirabic Vaccine) were issued during the year. Dcspite *he same
Pressure
of routine duties most members of the st generous aid of the India ?Research Fund Association in funds and personnel t carry OUfc valuable researches. For plague and Pha?' ^logical researches the Association contributed a V;s- 50,000. Two voluntary workers and a Lady ia Memorial Scholar also contributed to the reseai ji activities of the Institute. During the year Government sanctioned a valuab e audition to the staff. Advantage was taken oi retirement of Rao Bahadur Chitre to engage an ^ntomologist in his place. The services of a noi ndian entomologist, Dr. M. Sharif, who is an aut y 11 fleas, were secured and a department of entom ?y ^'ganized. Since insects an important role in spread of disease in the play tropics this new departmo ?houlcl f the prove of great value to the health organiz province, if the staff could be strengthene Stable the Institute to undertake field mvestiga * f'e time of the present staff is fully occupied b> r i atory bench work and it, (ioes not permit the I > ie only medical research organization of the f o , 0 Play that role in health organization which it should bir conducting field and other studies on the urgent
Siere enabled by the
"
.
"
.
777^
health problems of the people, in close association with the Public Health Department. In the 1924 report the then director strongly stressed the value of such an association and advocated the organization of a mobile unit. The need of such a unit is greater than ever, and it is hoped the^ staff of the Institute will be strengthened to permit of such work being undertaken. How valuable such an association can be was demonstrated by the enquiry undertaken during the year by the Institute into the outbreak of typhoid fever in the city, in association with Municipal Health authorities. Antiplague serum.?A small outbreak of plague at Bettiah, Bihar, permitted a field trial of the antiplague serum prepared at the Institute to be carried out. A temporary hospital was erected at the place and other facilities provided by the Bettiah Raj and the Bihar Government for which our grateful thanks are due. The trial lasted from the middle of January to the end of April 1938. One hundred and twenty-four cases of plague were dealt with. Every alternate admission others were treated with was treated with serum; intravenous injections of iodine solution. No selection was made, but during the third week of the trial all patients admitted were treated with serum. Thus 69 patients were treated with serum, and of these 19 died of plague, giving a percentage mortality of 27 per cent. Of the 55 cases treated with iodine injections, 36 died, giving a percentage mortality of 65 per cent. If to these figures we add the figures of a previous trial conducted at Hyderabad with the same serum, we get 94 patients treated with serum, with 24 deaths, and percentage mortality of 25.5. From among 80 controls, there were 50 deaths giving a percentage mortality of 625. Clinically the administration of the serum produced very striking results; the general condition of the patients improved very rapidly with the disappearance of toxic symptoms. These results show that we have obtained a serum of a high curative value. The preparation of this serum was made possible by the exact biological methods worked this Institute. Animal in out experiments were designed which closely reproduced the conditions which severe cases of plague present, and serum was tested These experiments yielded a clear on such animals. idea as to the conditions under which the best serum could be obtained. The full significance of these results can be realized only when they are compared with the results obtained with other antiplague sera tried since the beginning of the present pandemic. None of these sera reduced the case mortality below 60 per cent.
Chemotherapy of plague.?Some of the sulphanilamide compounds which have proved to be so valuable in the treatment of streptococcal infection were tested for their curative value in plague infection. For this purpose animal experimental conditions were designed to produce disease approximating to the actual severe' The compounds tested, Prontosil and cases of plague. M. and B. 693, showed little or no curative power. Further work is proceeding. Plague vaccine.?No changes were introduced in the preparation of the plague vaccine during the year. Though the recent researches conducted at the Institute have thrown a flood of light on the problem of the preparation of a plague vaccine, there are still Exact determinasome obscure points to be solved. tions are being made to compare the protective powers of agar and broth vaccines to see which of the two methods gives the best chance of producing vaccines of uniformly high protective power. Experiments are also being conducted to increase the growth of organism in broth cultures, as the protective power of a broth vaccine incubated at a suitable temperature depends on the number of the organisms growing in the medium. Serology of plague.?A great deal of work has been conducted to elucidate the phenomena of agglutinin and precipitin reaction and their relation to active immunity in plague, but the results are still very divergent and more work will have to be carried out before any worthwhile conclusion can be drawn.
THE INDIAN MEDICAL GAZETTE
778
Enquiry
into the outbreak oj
typhoid fever
in the
City of Bombay
During the year there was a sudden increase in the incidence of typhoid fever in the city and the Institute was asked to investigate the sources and mode of this outbreak in collaboration with the Municipal Health authorities. The Institute assumed responsibility for (1) laboratory diagnosis of cases by sending out an officer to take samples of blood and other material on receipt of a call from any medical practitioner or hospital and (2) investigation into the source or sources of infection and the mode of spread of the disease. Cases.?From the 25th of June to the end of the year, the Institute examined 398 cases, out of which 234 proved to be cases of typhoid fever and 16 cases of paratyphoid A. The fact which requires to be stressed here is that this laboratory aid in the diagnosis of cases, given absolutely free of charge to medical practitioners, improved considerably the situation regarding the notification of this disease in the city. For the five-year period previous to the present enquiry 1,959 attacks and 1,349 deaths had been notified from typhoid. These figures give a very improbable case mortality of 69 per cent while the present enquiry yields among the definitely diagnosed case cases, the very likely figure of 9.3 per cent mortality, showing that in previous years roughly 1 attack out of every 6 occurring in the city was notified. It was obvious that the medical practitioners appreciated the help given to them; they were willing to make use of it, leading to a much higher percentage of notification. It is very gratifying to note that Government is devising a permanent scheme to make available to medical practitioners such laboratory aid in the diagnosis of their cases, free of charge. Sources and mode of spread.?Though the water supply of the city was not found to be up to the required standard of purity, it was not held responsible for the typhoid outbreak. Largest number of cases occurred in unsewered parts of the city where basket privies were in use. Some sewage from the areas was allowed to flow into the open drains. This, coupled with a great increase in the number of flies in the area, explained part of the trouble. Direct contact due to overcrowding in tenement houses and the refusal of patients to go to the infectious diseases hospital was another factor in the spread of the disease. No articles of food examined were incriminated, but the carrier problem could not be tackled for lack of co-operation on the part of the public. Studies on the synthetic anti-malarial drugs, plasmoquine and atebrin, were continued. The observation reported last year that the placenta filtered out plasmoquine and prevented large quantities of the drug from entering the foetal circulation, was further confirmed by the actual measurement of the concentration ?of plasmoquine in the maternal and foetal blood simultaneously after giving large doses of the drug to the mother. It was further shown that therapeutic doses of plasmoquine given to pregnant experimental animals did not in any way affect the litters given by the animals. These studies show that this drug can be safely used during pregnancy. The fate of plasmoquine and atebrin in the body has been studied. Plasmoquine is largely destroyed by the liver and atebrin was retained by reticuloendothelial cells. A very important observation regarding the formation of acetylcholine was made. It was found that chiefly nerve cells were responsible for its formation. Some studies had shown that the average haemoglobin content of blood of Indian normal subjects tallied exactly with similar averages worked out in America for white American subjects. These averages were 15.37 g. and 12.99 g. per 100 c.c. of blood for men and women respectively. This observation suggested the possible existence of a haemoglobin constant. Nineteen subjects have so far been examined and an attempt is being made to find if there is a definite ratio between haemoglobin content and some such unit as body surface.
[Dec.,
1939
The power of the kidney to eliminate urea from the blood stream is employed as a measure of renal function for clinical purpose. Moller, Macintosh and Van Slyke's blood urea clearance test worked out on American subjects is usually employed for the purpose. It was noticed in the course of clinical work that in the case of normal Indian subjects while the blood the same limits as that of urea content is within American subjects the urea content of urine of normal Indian subjects is about half of American subjects. This raises an interesting issue whether the formula on which the urea clearance test is based applies to Indian subjects. This subject is being studied. Four more antirabic treatment centres were opened during the year, making a total of 87 in the Province and in the neighbouring areas. The opening of these centres centres is a real boon to the public. These enable the public to get the antirabic treatment without having to make unnecessarily long journeys. Demand for the antirabic treatments showed a further rise during the year. 11,479 treatments were issued as compared with 9,715 treatments issued last year.
THE ON REPORT ADMINISTRATION THE YEAR 1937 The population of the the estimated mid-year
HEALTH THE PUBLIC OF THE PUNJAB FOR province
continues to increase,
population for 1937 being 26,000,000 as against 25,500,000 in 1936. As the director states, this annual increase raises questions with respect to standards of living and the economic development of the province which deserve consideration. Fevers.?The
number
of
deaths
in
the
province
during the year from all causes was 556,000, of which 376,000 were recorded as deaths from fever as comfever pared with 374,000 in 1936. The term '
includes a considerable group of diseases of which the predominant symptom is fever, e.g., malaria, enteric, tuberculosis and influenza, and as the director explains, reports as to the diseases which may have caused death in particular cases cannot be regarded as accurate. Inaccuracies are in fact to a large extent inevitable in the rural area where there are at present few doctors to diagnose the exact nature of a disease. Smallpox.?The province is never entirely free from smallpox. The disease does not as a rule assume serious epidemic form but it shows a tendency t? increase every few years; there was, for example, j* severe epidemic in 1932, and a further epidemic, though of lesser intensity, has to be recorded in 1937. In l93o there were 6,000 cases with 2,500 deaths, and at the same time three and a half million vaccinations and revaccinations were carried out. In 1937 there were 10,000 cases with 4,000 deaths, and five and a million vaccinations and revaccinations were carried ot out. During the two years therefore the number persons vaccinated was eight millions, which is nearly a third of the total population of the province but the disease showed a further increase in 1938 thougn exact figures for that year are not yet available. As regards the 10,000 cases which occurred in 1937, the number of villages infected was 1,350 as compared witn 1,000 in 1936. Of the 4,000 deaths in 1937, 1,500 were of infants below one year of age, and 1,800 of children between the ages of 1 and 10. The figures indicate that still greater effort is needed to ensure the vaccination of infants as soon as possible after birth. Under to the present act local bodies are only empowered make primary vaccination compulsory; the director has, however, submitted proposals for an amendmen of the law so as to enable any local body which m&X wish to do so to make revaccination compulsory, and these are being examined. , Cholera.?Cholera is a disease of which a number well3 cases occur every year, and when streams or are infected it sometimes spreads with great rapidityA? In 1936 there were 2,700 cases with 1,700 deaths. is, however, satisfactory to note that during 1937 ther As usual the were only 184 cases with 105 deaths. infection was in an appreciable number of case-
h&lj
imported from outside the
Hardwar. Plague.?Plague
is
a
province, particularly
disease from which the
Maternity and child welfare?It is probable
from
there is
province
The director states that the cannot be determined. known about the is incidence of tuberculosis except that it is believed to be considerable. The people as a rule are not inclined to take notice of the disease in the early stages when it may be curable, and death when it occurs may be recorded as from fever or one of the respiratory diseases. It is noted that during 1937, 5,000 deaths in the province were returned as on account of tuberculosis compared with 4,800 in 1936, but the true figure is probably higher. While what it has seemed Possible to do to deal with the tuberculosis question has been done in the past, no concerted attack has been instituted against the disease, partly on account of the magnitude of the question and the difficulty of knowing where to make a beginning. A concerted attack is however now about to be launched on an ah-India basis under the auspices of Her Excellency the Marchioness of Linlithgow's Tuberculosis Association of India with its affiliated provincial branches. Leprosy.?A leprosy survey has been proceeding for ?some 3'ears, and has now been completed in 18 out of the 29 districts. Two thousand cases have so far been observed, and the number of special clinics, which serve as both treatment and propaganda centres, is now 106. rhe five leper homes continued their excellent work, ministering to 646 inmates of whom however only a hundred are Punjabis. Two hundred and sixty-four doctors in the province have now received special Gaining in the diagnosis and treatment of leprosy. Hookworm.?A hookworm survey has also been in progress for some years, and has now been completed 20 districts. In some as many as 30 per cent of the persons examined were found to be infected, and treatment is now being administered partly at the local hospital or dispensary and partly by special treatment units. The disease would almost entirely disappear if latrines conforming to hygienic principles were to be generally adopted, or alternatively if all persons wore
The
.
shoes.
Sanitation.?The
standard of sanitation in towns low. In the larger municipalities which employ a whole-time health officer, arrangements are the whole as satisfactory as can lie expected, regard being to the insanitary habits of many of the People. In the smaller towns, however, which have not ?.he funds either for a health officer or for roadside uramage, conditions are usually deplorable, and, as the director states, the 3,000 cases of enteric with a thousand deaths reported from urban areas are almost Certainly an underestimate. Before public health conditions in a village can be '.egarded as satisfactory, the minimum that is necessary ]?"atthatthethe water supply should be safe from pollution, inhabited area should be properly drained, that there should be a system for the regular ^Qd enioval of refuse to a distance; out of the 35,000 vulages in the province only 1,960 attain this standard a'i present but improvement may be expected as spreads. Six thousand new hand-pumps are plication ePorted to have been installed in villages during the laid ^ear while 450,000 feet of masonry drains were also jtown compared with 260,000 feet in 1936. It is were ,ePorted that 600 village sanitary committees ormed during the year, and though the director^ notes oat few seem to have functioned it is encouraging to ee. that villagers themselves in different districts subyear for bribed over a lac of rupees during the labour and J^ntary works and in addition contributed
remains
Material.
urban
area
that in which there is not a
women
are
trained at
health
centres
of
which
School at Lahore at the rate of about 14 a year. The demand for lady health visitors exceeds the supply with the result that it has not been possible to open further centres for which funds existed. About 2,000 trained dais are known to be practising in the province, while another 2,000 are at present under training. Inspection of schools and school children .?The medical inspection of school children is still in the experimental stage, and here again the difficulty in arranging for defects noted, to be regularly treated, is for a number of reasons considerable. During 1937 the further experiment was started of supplying milk in certain schools to those children who being sickly or undernourished may be most in need of it.
outside.
_
no
during the year under report there were 89 with 128 sub-centres, the centres being under the charge of lady health visitors who are trained in the Punjab Health
factors which have caused this Tuberculosis.?Very little
_
now
sufficiency of trained dais, and municipal and small town committees are being encouraged to frame by-laws prohibiting practice by untrained women. In the rural area, however, there is still a shortage of trained dais.
has suffered much in the past. Wherever the disease has appeared mass inoculation has been undertaken; at the same time the public health department have for many years conducted a campaign against rats in areas in which the disease has constantly appeared. In 1936, only 153 deaths from plague were recorded, and in 1937 (for the first time after 40 years) no cases at all occurred in the province though 4 were
imported from
779
ABSTRACTS FROM REPORTS
Dec., 1939]
THE THIRD ANNUAL REPORT OF THE INDIAN FOR INSTITUTE MEDICAL RESEARCH,^ CALCUTTA, FOR 1937-38 The third Annual Report of the Indian Institute for Medical Research shows that this Institute is receiving a much greater measure of sympathy and recognition both at home and abroad. Although our financial difficulties still persist, there is "no lack of devotion and earnestness on the part of our workers who alone have made it possible for the Institute to carry on its work fruitfully and efficiently. In the department of bacteriology, the programme of researches included the work on the immunity problems connected with cholera and typhoid, which was continued throughout the year under review. The relation of streptococcus isolated from the throat with that isolated from puerperal fever was investigated and the result showed that the number of hemolytic streptococcus obtained from throat swab of the maternity cases suffering from puerperal fever was very small. In the department of protozoology, further studies on the problem of protozoal cultivation and protozoal immunity are being made with special reference to malaria, amcebiasis and leishmaniasis. The results so far achieved appear to be very encouraging. The department of biochemistry and nutrition put on the forefront of its programme of work during the year the problem of a nutritional survey of Indian food-stuffs and dietaries. What is most gratifying to note is that of late public interest has steadily awakened in researches into food-stuffs and dietaries undertaken at different laboratories in the country, including ours. The importance of nutrition as a paramount factor in the improvement of national health needs no emphasis and we feel that the institute's work in this direction has the support of the public of India. A large number of common food-stuffs and dietaries of Bengal have been investigated from various aspects at the institute. It has been known for some time that the type of food commonly consumed by urban populations in Bengal is not calculated to afford adequate nutrition especially during childhood and adolescence and also during pregnancy and lactation. Our biological investigations have revealed that the ordinary diet taken by an average family in Calcutta or in an average students' hostel is partially deficient in vitamins A and B-complex. The work at the institute reveals that the average diet is not only deficient in these vitamins, but also lacks to a_ considerable degree the very important body-building ?
minerals,
780
THE INDIAN MEDICAL GAZETTE
calcium and iron, and further that the diet is also deficient to some extent in protein of high nutritive value. A word should be said with regard to dietary requirements during pregnancy anil lactation, which is considered to be of great and urgent importance. From an analysis of the food-stuffs and dietaries we have found that during pregnancy, when extra amounts of vitamins and minerals are needed, there is a deplorable insufficiency of these essential dietary ingredients. It is not at all strange that owing to the relative lack of iron in the diet, the majority of pregnant women in Bengal should be so prone to ansemia. Much of the short stature and rickety constitution of Bengali children may also be traced to the insufficiency of calcium and necessary vitamins during the mother's gestation and lactation periods. It is well to emphasize that the harm due to malnutrition during pre- and post-natal periods cannot be adequately made good by dietary abundance in the later life of the individual. In the interest of both the mother and the baby, every expectant mother in Bengal should be given an extra ration of milk, if possible, a little iron in the form of iron-rich food-stuffs like polta or of ferric ammonium citrate, more of green vegetables and occasionally a little cod-liver oil and the gently cooked liver of fish
[Dec.,
1939
or mammals. This is an urgent matter, which in our view should receive immediate attention. In the department of chemistry, immuno-chemistry and chemotherapy the measurement of electrical charge of Leishmanial tropica under a variety of conditions received special attention, and the results indicate that in their cataphoretic behaviour in the presence of immune sera the protozoa closely resemble the bacteria. The work on the effect of electrolytes on the rate of flocculation of toxin-antitoxin mixtures of diphtheria and tetanus was also undertaken and the data so far obtained show that the balanced mixture flocculates most quickly compared with the other mixture. In addition to these activities, investigations of the occurrence of the Danysz phenomenon in diphtheria toxinantitoxin mixtures under various conditions was carried out. A very valuable branch of the institute is its diagnostic section. It has in effect subserved many purposes?humanitarian and scientific from the public point of view and from the institute's point of view it has been one of the main sources of income which sustains the institute. In deserving and indigent cases, it has given its services free or at concession rates. And, last, but by no means the least, it has served as a training ground for research students.
review
The year in
brief
1938 The Rockefeller Foundation appropriated a total sum of over $15,000,000. Of this amount, speaking in terms of rough classifications, $3,800,000 was given to the medical sciences, $3,800,000 to the social sciences, $3,000,000 to the natural sciences, $2,500,000 to public health, $1,000,000 to the humanities, and $300,000 to rural reconstruction in China. The Foundation's income during 1938 amounted to In approximately $7,000,000. appropriating $15,000,000 it was necessary, therefore, not only to use up the balance carried over from earlier years, but to dip into the principal fund to the extent of $3,755,000. In carrying out its 1938 programme the Foundation operated in forty-two countries in all parts of the world. Eighteen of these countries were in Europe, five in Asia, two in Africa, five in South America, ten in North and Central America and the West Indies, and two were islands of the Pacific. During
Yellow fever Two years ago in this review it
was reported that jungle yellow fever, spread by some vector other than the Aedes cegypti mosquito, had been discovered in
wide areas of South America. In the last two years outbreaks of this disease have been observed from 7? 30' North Latitude to 27? South Latitude; from the eastern slope of the Andes to the mouth of the Amazon; at altitudes varying between sea level and 5,000 feet; in regions of dense jungle growth and in prairie districts where the infected forests cover not more than 5 per cent of the land area; in sparsely populated regions and in heavily populated agricultural districts; in the form of epidemic waves and under conditions suggesting permanent local endemicity. Jungle yellow fever has proven to be not only a constant source of virus for the reinfection of towns but also an important public health problem in its own
right.
In any must be
discussion of jungle yellow fever emphasis to the fact that this term is one of
given
epidemiological significance only. Clinically, pathologically, and immunologically, it has so far been
impossible to differentiate jungle yellow fever from the classical segypti-transmitted variety. Field observations have, during the past four years,failed to indicate
that
any
of
the
minor
segypti-
transmitted outbreaks during this period have been due to virus coming from a previous segypti-transmitted imection. Rather these observations have suggested
in each instance that the town had been invaded by a virus from near-by jungle districts. Were it the existence of the jungle infection, yellow fever have disappeared permanently from the Americas & 1934. Although the clinical picture of yellow fever is the same whether the infection develops in the town or in the jungle, the epidemiology of the two types is quite different. Aegypti-transmitted yell and it is of great importance to her overseas trad? that this suspicion should be dispelled as soon a? health in advance possible. Considerable port organization and in control of infectious disease has been made within the past few years. Another direction in which marked progress has been made is in the field of nutrition. The Indian Research Fund Association recognized the importance of sound nutrition of the people many years before the subjec was taken up by the League of Nations and by the Governments co-operating with that international bodyThe contributions made by Sir Robert McCarrison to this science are now seen to be much more general applicable than was originally realized. In more recent years, the practical aspects, of tj? nutrition problem have received greater attention. laboratory studies of the common foodstuffs and th actual diets consumed by the people, and by np' studies for ascertaining the nutritional state of th people, much information has been collected whic is invaluable for the betterment of national nutritionFurther, researches have demonstrated the advantag of adding milk, even skimmed milk, to the ordinary unsatisfactory diet of many people, while the deficiency of vitamin A in the diet can be correcte1 by taking red-palm oil which can be produced India. From the practical point of view the importan of these researches is immense, because the nutrition state of the people can be improved only by metho which are cheap. To better the nutritional state of the people it essential to correlate nutritional researches with t , activities of animal husbandry and agriculw , departments. For this purpose a liaison officer train in human nutritional work has been appointed, a it is his duty to keep in touch with all provinc and animal agricultural departmen husbandry Further, a National Nutrition Committee has be appointed which includes nutrition workers, represena , tives of agricultural and husbandry departments, expert educational and economic advisers. .
,
coiiini0^
.
?
The
population problem
Special committees in population problem and
provinces educate
to
study
the
public
e
recommended. ce While the birth rate has shown little change si ^ 1891, the death rate has been falling since 1921. A,gr uD average_ annual increase during 1921-30 was just two millions. During the succeeding seven J'e ,;c which were free from violent outbreaks of epide ^ disease, the average yearly increase of population British India is estimated at just short of three xn1"1 These facts support the inference that the pres 0f decade is likely to present an even larger rate increase than that recorded during 1921?31. During,^ period, 1921-31, the increase of population, in .-^3 was approximately 34 millions while the indicai *jj are that during 1931-41, the increase will m probability be 45 to 50 millions. pid The continuing low standard of living and Pe, jjjfl of numbers that characterized have expansion .
_
Dec., 1939]
ABSTRACTS FROM REPORTS
present and preceding decennia are facts which must Pe faced. Into this complex situation another important factor has been introduced in the form of a Preventive health campaign which, in spite of serious deficiencies, has already saved increasing numbers of human lives. No civilized government can turn back 011 an expanding programme of public health endeavour, so that it is all the more essential for thoughtful men and women to turn their attention to the study of the population problem. In the words of Sir John Megaw, ' What is required, of the whole community in life planning, ^iheeducation must be made to realize what they are up people against, and how they can control the forces of nature their own advantage. The best brains of India helped by the best brains of the outside world will be needed. Experts in agriculture, education, public health, economics and industry must co-operate in deciding what should be taught; then the subjectmatter must be prepared in a form which will be Palatable to the masses'. .
|?
Maternal deaths At least 200,000 women die every year in India from causes arising from child-bearing. In 1937, deaths of 'nfants under one year of age accounted for 24.8 per cent of the total mortality at all ages, of children Under five for 18.G per cent, and of those between five ten years of age for 5.4 per cent. Corresponding hgures for England and Wales in 1936 were 7.1 per cent, '?5 per cent and 1.2 per cent. Maternal mortality enquiries conducted in limited areas suggest that, for India as a whole, about 20 ^'ornen die among 1,000 undergoing pregnancy and
^nd
childbirth. Accumulating bearing takes a ln
evidence seems to indicate that childmuch higher toll of life in urban than areas and that the good effects of the better Urban facilities may be more than outweighed by the ill-effects of overcrowding, of lack of sunshine and fresh air and of ill-balanced diets. Few reliable figures for mortality are available for rural populations, Put the maternal mortality rate recorded in three health-unit' areas in South India was only 5.0 per l>000 total births. The increasing concern at this enormous loss of life ?ud the heightened sense of responsibility for the Uealth and safety of mothers and children were reflected in the decision of the Central Advisory Board Health in 1937 to appoint a special committee to ePort on the whole subject of maternity and childwelfare work in India. The committee completed its recently and its comprehensive report has now e?n approved by the board and has been issued. Hie report stressed the importance of appointing a Qualified and experienced woman medical offiperly mcer jn each province for the efficient administration maternity and child-welfare work. -The empioyment of women doctors in the manageand supervision of municipal and other local and child-welfare schemes is also urged. For le benefit of the mothers and children requiring advice ud assistance, a woman doctor's services are essential, ecause there are limitations to the employment of ?u-medical women in the welfare centres. Another recommendation refers to the desirability of j/r?viding a system of grants-in-aid from Government not only because these stimulate local bodies improve their services but because they give official health departments a suitable measure of control Ud supervision over the work undertaken by local ,
rural
paternal
^?rk
ment jUaternity
purees, ari'li
aufhorities. -further advance
has been made by the recent passing number of provincial Nurses', Midwives', and ,,?alth Visitors' Registration Acts, designed to secure K_g, registration and better training of midwives and alth visitors. ^ sound training in pre-natal and post-natal care essential both for medical students and midwives. 'this purpose, well-organized pre-natal and posttramin^? clinics should be provided in all hospitals students and niidwives, and attendance at these tr
?
a
775
clinics should be included in the courses of instruction in midwifery for medical students. The organization of maternity and child-welfare work in India has, in the past, been largely due to voluntary effort. The stage seems to have been reached when transition from voluntary direction to official control must take place if further developments are to be made, and the problem during the next few years will be to preserve a proper balance between government and voluntary effort. Causes of death Fevers' alone accounted for over 3,000,000 deaths or 55 per cent of the total mortality, and respiratory diseases for 8 per cent in 1937. The large figure for ' fevers' almost certainly includes over a million due to malaria and large unknown numbers due to typhoid fever and tuberculosis. Existing agencies for the registration of vital statistics in rural areas make it impracticable to carry out classification of the causes of death except in a few large groups and, apart from such diseases as cholera, smallpox and plague with which the people are 'familiar, fevers other deaths are ordinarily recorded as ' ' respirator}'' diseases' and other causesSo true is this that nearly 93 per cent of the six million and odd deaths registered during 1937 were placed in these three groups. In comparison with these diseases deaths from cholera, smallpox and plague are of relatively minor importance, though in the popular imagination these three are the most dreaded epidemic diseases. In fact, during the period 1925-37, the combined mortality from these three diseases did not exceed, in any year, 10 per cent of the total recorded mortality. Malaria, tuberculosis and leprosy have, within recent received increasing attention from health years, authorities and voluntary organizations in the country. Provincial public health reports show a general recognition that malaria constitutes the major health problem in most provinces. The rural malaria death rate is approximately three times the urban rate and, as nearly 90 per cent of the population is rural, the problem is urgent. The general policy in the provinces is to provide an adequate supply of quinine or cinchona febrifuge, to popularize the use of these drugs as far as possible by means of propaganda and teaching in the schools, and to provide extra medical staff and travelling dispensaries to localities visited by regional epidemics. Regarding tuberculosis, the last decade has recorded considerable progress in organized effort. In 1929 a central organization came into being when various schemes were considered for the utilization of the King George V Thanksgiving Fund. It was decided that this fund should be devoted to a campaign against tuberculosis and the King George Thanksgiving Fund Anti-Tuberculosis Committee was constituted. With an annual income of onfy Rs. 53,000 the activities of the committee were necessarily restricted. The special appeal for funds for fighting tuberculosis which was issued in the name of the King-Emperor by Her Excellency the Marchioness of Linlithgow in December 1937, has met with an excellent response and has made it possible to organize the anti-tuberculosis campaign on a wider basis. The Tuberculosis Association of India was formed a few months ago, incorporating the King-Emperor's Anti-Tuberculosis Fund and King George Thanksgiving Anti-Tuberculosis Fund. The inauguration of the Indian Council of the British Empire Leprosy Relief Association in 1925 was a distinct advance in the campaign against leprosy. A capital fund of Rs. 20,25,000 was created by an appeal to the country and the annual income from this fund, amounting to nearly a lakh and a quarter, was made available for furthering anti-leprosy work in all directions. Later, a further donation of Rs. 3,13,000 was received from Their Majesties' Silver Jubilee Fund. The demonstration that early cases of leprosy were amenable to treatment also helped towards awakening public interest and towards the organization of effort to combat the disease. '
776
THE INDIAN MEDICAL GAZETTE
Research work has been carried on at the School of Tropical Medicine, Calcutta, in co-operation with the authorities of the School and the Indian Research Fund Association. This work has been carried out at a cost of Rs. 3,37,000 up to the end of 1938, and the results obtained have been published in the annual reports of the Association as well as in scientific journals in India and abroad. Food adulteration Adulteration of common articles of food is widely practised in India and the subject has not received the attention it deserves. Milk and milk products are everywhere adulterated. In one province," 73 per cent of the samples of ghee examined, 50 per cent of the samples of milk and 40 per cent of the samples of butter, were found to be adulterated. One of the of affairs is the causes of this unsatisfactory state apathy with which the public view the matter. _
Health in schools The importance of a well organized school medical service in a national health programme requires no special emphasis. 'Medical Science has proved_ with unmistakable clearness that disease and incapacity in adolescence and adult life find their source, all too often, in the seed time of childhood. It cannot be doubted that much of the excess of sickness and mortality under forty years of age must be attributed to this origin and some of the maternal mortality, some of the recruits rejected on physical grounds, some of the lost time in industry, some of the lack of resistance to infective disease may all derive from this same sourceThese words of the Chief Medical Officer to the Board of Education, England, and Wales, are equally applicable to India. Fairs and Within recent centres has
festivals
sanitary control of pilgrim increasing attention from provin-
cial health authorities. The measures taken for this have, in fact, reduced to a great extent the danger of explosive outbursts of cholera, although it must be remembered that, as in the extensive epidemic that followed the Hardwar Kumbh Mela in April 1938-,_ large festivals with their inter-provincial traffic in pilgrims, who have often to pass through endemic regions of cholera, always hold out a threat of outbreaks. However, the general effect of precautionary measures now being taken has been satisfactory, for during 1937, all fairs and pilgrimages in the provinces of British India passed off without any serious outbreak of infectious disease in epidemic form. The problem of health education in India is complicated by the fact that the majority of the population is illiterate. Moreover, there exist certain age-long customs and habits which cannot be easily changed. Instances are the_ indiscriminate pollution of village sites with nightsoil and the indifference of the people to contamination of their water supplies. It is difficult to convince the villager that, in respect of many diseases, man is his own_ worst enemy and that a radical change of habits is essential if sickness and mortality arising from avoidable diseases are to be purpose
_
_
prevented.
TION,
INDIAN 1938
The studies suggest that the offending factor is the seed of a plant, Argemone vicxicana, which appears to be widely distributed and to be often present as a weed in mustard plant field?. Its seeds are harvested with mustard seeds and argemone oil is also expressed with mustard oil without the manufacturers being aware of such adulteration. In some areas, such as the Punjab and the NorthWest Province, cholera appears only at intervals ot years, in certain parts of Bengal it starts almost regularly at the same season every year. An investigation into the causes is complicated by the fact that, apart from the true organism responsible for the disease, numerous other allied organisms exist in water supphesA differentiation of the characteristics of the true cholera vibrio from its allied organisms and the formulation of methods of separating the former when present with large numbers of the latter are therefore essential. Considerable success has of late been achieved tin these two directions in India, and the researches carried out have received warm appreciation from the International Public Health Office at Paris. In the light o the new knowledge, a field investigation is now being undertaken in Bengal, and it is hoped that the results of this enquiry will enable preventive measures to b taken with greater success. i Malaria investigations, both in the laboratory an^ the field, have proceeded under the Malaria Institut of India, which is financed by the Indian Researci Fund Association. In the Wynaad, Madras, and in? ? Terai in the United Provinces, research units haV been making field studies, and similar investigation are proposed for Orissa along the margin of ,tD Chilka Lake. In Delhi, also, anti-malarial operation were supervised by the Malaria Institute. In additio ' Heal1 advice is to the Public Provincial expert given Departments in respect of anti-malarial schemes. In the Haffkine Institute, Bombay, investigation were continued as to the best conditions under whic D anti-plague vaccine of high protective value could manufactured. An anti-plague serum has also bee produced for the treatment of patients. The seru has had a limited trial during an outbreak of in Bihar, and the results so far recorded suggest tn its use reduces mortality. Cyanogas fumigation for keeping down the rat Iation has been tried as an anti-plague measure in Cumbum Valley, Madras, and the conclusion that fumigation every quarter consistently fc>r a J years may reasonably be expected to eradicate disease. A statistical survey of leprosy has been carried ? in a group of 42 villages. While the gross inciden j of the disease was found to be 4.4 per cent in the to population, only 18 per cent among the patients ^t of the severe lepromatous type. Nearly 80 per c y of the cases gave a history of contact with ^ nnfipnf.s f.ho Kninnr pnm rr\ iim'na+orl in fL a a in patients, the infection being communicated ^ of cases by near relatives, in another third by *e(J relations, and in the remaining third either by or by unknown persons. The severe lepromatous i? of the disease transmitted infection more quickly the relatively milder nerve type. 0f A study has also been made of the influence skimmed milk as a supplement to the diet of patients, and it has been found that its administra^ seems to hasten the recovery of the lepromatous tyP Tuberculosis investigations covered a wide range included a detailed survey in a jute mill 23 miles 1 n Calcutta employing 5,000 labourers, a study of c in tuberculous homes and an enquiry into the incid of the infection among medical students and in Lahore. There is a general recognition that disease is spreading among urban and rural P?P tions owing to industrialization and rapidly increa transport facilities and the need is felt of defining extent of infection in different areas and of the social, economic^ industrial and other fa responsible for its incidence. The survey of tuberculous homes revealed tuberculosis was an important cause of morbidity >
P0^ reaCjLv _
leP^.r(j
unrefar0j
#
ABSTRACT FROM THE ANNUAL REPORT OF THE
1939
,
years the
received^
[Dec.,
RESEARCH
FUND
ASSOCIA-
The cause of_ epidemic dropsy has for long been the subject of intensive research in the School of Tropical Medicine, and the All-India Institute of Hygiene and# Public Health, Calcutta. Recent work at both institutions has tended to emphasize the association of mustard oil with the propagation of the disease, a theory which is not new but which had been replaced for a time by two others, namely, those of contact infection from patient to patient and of infection carried through rice damaged by unfavourable conditions of storage.
a^
nu^g .
de^er?1!,tors
^
ABSTRACTS FROM REPORTS
Dec. 1939]
mortality among infants and children, a fact not noticeable from public health returns. The enquiry at Lahore showed that of 434 medical students examined, 53 per cent had had t infection at some time or other and that fourth- and fifth-year students, the percentages were as
high
as 70 and 80 respectively. This does not of mean that they were active cases of tuberculoss the large majority the infection had been o by the natural resistance of the body. In f? 45 per cent showed physical signs of having ante from active tuberculosis. In the field of nutrition, simultaneously with basic research, the programme has been made more piac -
.
by relating laboratory investigations to the immediate necessity for improving the nutritional standa^
the people under present economic conditions, instances may be mentioned the discovery of a c i substitute in red palm oil for cod-liver oil to make the deficiencv of vitamin A in the diet, a fac or
p p
widely
deficient in India, and the demonstration tnat use of calcium lactate at a cost of half to one Per month per child improves its health, bp attention has been paid to diets largely composed
the
tapioca and it has been shown that the most lmporta defect in such diets is the deficiency of protein. .A study is being made of the effect of the use ot
,
highly
milled rice on nutrition. It is recognized tna the use of home-pounded rice is rapidly disappearing, a. solution of the problem of ensuring consumption o rice in its most nutritive form must be sought along other lines. as
.
ls
Comparison
of rice and maize has shown that
rice
richer than maize in nicotinic acid, which preven t Pellagra. This may explain why rice eaters rarely
develop
the disease. men from the and states hav e been trained to carry the provinces for better nutrition campaign *nto different parts of India and to educate the peop e in matters of nutrition.
Medical
REPORT
OF THE HAFFKINE INSTITUTE, FOR THE YEAR 1938
BOMBAY,
In general the activities of the Institute remained as in previous years. The production ot la g Quantities of prophylactic vaccine, mainly Hankine P'ague vaccine, cholera vaccine, typhoid vaccine and antirabic vaccine, and the diagnostic work loi y?spitals largely monopolized its limited resources funds and personnel. An idea of the work invo ve m the production of vaccines alone can be gained lro the fact that 3,411,258 c.c. {i.e., 1,137,086 doses of plague Vaccine, 608,506 c.c. of cholera vaccine, 38,269 c.c. oi typhoid vaccine and 733,530 c.c. of 5 per cent antirabic Vaccine) were issued during the year. Dcspite *he same
Pressure
of routine duties most members of the st generous aid of the India ?Research Fund Association in funds and personnel t carry OUfc valuable researches. For plague and Pha?' ^logical researches the Association contributed a V;s- 50,000. Two voluntary workers and a Lady ia Memorial Scholar also contributed to the reseai ji activities of the Institute. During the year Government sanctioned a valuab e audition to the staff. Advantage was taken oi retirement of Rao Bahadur Chitre to engage an ^ntomologist in his place. The services of a noi ndian entomologist, Dr. M. Sharif, who is an aut y 11 fleas, were secured and a department of entom ?y ^'ganized. Since insects an important role in spread of disease in the play tropics this new departmo ?houlcl f the prove of great value to the health organiz province, if the staff could be strengthene Stable the Institute to undertake field mvestiga * f'e time of the present staff is fully occupied b> r i atory bench work and it, (ioes not permit the I > ie only medical research organization of the f o , 0 Play that role in health organization which it should bir conducting field and other studies on the urgent
Siere enabled by the
"
.
"
.
777^
health problems of the people, in close association with the Public Health Department. In the 1924 report the then director strongly stressed the value of such an association and advocated the organization of a mobile unit. The need of such a unit is greater than ever, and it is hoped the^ staff of the Institute will be strengthened to permit of such work being undertaken. How valuable such an association can be was demonstrated by the enquiry undertaken during the year by the Institute into the outbreak of typhoid fever in the city, in association with Municipal Health authorities. Antiplague serum.?A small outbreak of plague at Bettiah, Bihar, permitted a field trial of the antiplague serum prepared at the Institute to be carried out. A temporary hospital was erected at the place and other facilities provided by the Bettiah Raj and the Bihar Government for which our grateful thanks are due. The trial lasted from the middle of January to the end of April 1938. One hundred and twenty-four cases of plague were dealt with. Every alternate admission others were treated with was treated with serum; intravenous injections of iodine solution. No selection was made, but during the third week of the trial all patients admitted were treated with serum. Thus 69 patients were treated with serum, and of these 19 died of plague, giving a percentage mortality of 27 per cent. Of the 55 cases treated with iodine injections, 36 died, giving a percentage mortality of 65 per cent. If to these figures we add the figures of a previous trial conducted at Hyderabad with the same serum, we get 94 patients treated with serum, with 24 deaths, and percentage mortality of 25.5. From among 80 controls, there were 50 deaths giving a percentage mortality of 625. Clinically the administration of the serum produced very striking results; the general condition of the patients improved very rapidly with the disappearance of toxic symptoms. These results show that we have obtained a serum of a high curative value. The preparation of this serum was made possible by the exact biological methods worked this Institute. Animal in out experiments were designed which closely reproduced the conditions which severe cases of plague present, and serum was tested These experiments yielded a clear on such animals. idea as to the conditions under which the best serum could be obtained. The full significance of these results can be realized only when they are compared with the results obtained with other antiplague sera tried since the beginning of the present pandemic. None of these sera reduced the case mortality below 60 per cent.
Chemotherapy of plague.?Some of the sulphanilamide compounds which have proved to be so valuable in the treatment of streptococcal infection were tested for their curative value in plague infection. For this purpose animal experimental conditions were designed to produce disease approximating to the actual severe' The compounds tested, Prontosil and cases of plague. M. and B. 693, showed little or no curative power. Further work is proceeding. Plague vaccine.?No changes were introduced in the preparation of the plague vaccine during the year. Though the recent researches conducted at the Institute have thrown a flood of light on the problem of the preparation of a plague vaccine, there are still Exact determinasome obscure points to be solved. tions are being made to compare the protective powers of agar and broth vaccines to see which of the two methods gives the best chance of producing vaccines of uniformly high protective power. Experiments are also being conducted to increase the growth of organism in broth cultures, as the protective power of a broth vaccine incubated at a suitable temperature depends on the number of the organisms growing in the medium. Serology of plague.?A great deal of work has been conducted to elucidate the phenomena of agglutinin and precipitin reaction and their relation to active immunity in plague, but the results are still very divergent and more work will have to be carried out before any worthwhile conclusion can be drawn.
THE INDIAN MEDICAL GAZETTE
778
Enquiry
into the outbreak oj
typhoid fever
in the
City of Bombay
During the year there was a sudden increase in the incidence of typhoid fever in the city and the Institute was asked to investigate the sources and mode of this outbreak in collaboration with the Municipal Health authorities. The Institute assumed responsibility for (1) laboratory diagnosis of cases by sending out an officer to take samples of blood and other material on receipt of a call from any medical practitioner or hospital and (2) investigation into the source or sources of infection and the mode of spread of the disease. Cases.?From the 25th of June to the end of the year, the Institute examined 398 cases, out of which 234 proved to be cases of typhoid fever and 16 cases of paratyphoid A. The fact which requires to be stressed here is that this laboratory aid in the diagnosis of cases, given absolutely free of charge to medical practitioners, improved considerably the situation regarding the notification of this disease in the city. For the five-year period previous to the present enquiry 1,959 attacks and 1,349 deaths had been notified from typhoid. These figures give a very improbable case mortality of 69 per cent while the present enquiry yields among the definitely diagnosed case cases, the very likely figure of 9.3 per cent mortality, showing that in previous years roughly 1 attack out of every 6 occurring in the city was notified. It was obvious that the medical practitioners appreciated the help given to them; they were willing to make use of it, leading to a much higher percentage of notification. It is very gratifying to note that Government is devising a permanent scheme to make available to medical practitioners such laboratory aid in the diagnosis of their cases, free of charge. Sources and mode of spread.?Though the water supply of the city was not found to be up to the required standard of purity, it was not held responsible for the typhoid outbreak. Largest number of cases occurred in unsewered parts of the city where basket privies were in use. Some sewage from the areas was allowed to flow into the open drains. This, coupled with a great increase in the number of flies in the area, explained part of the trouble. Direct contact due to overcrowding in tenement houses and the refusal of patients to go to the infectious diseases hospital was another factor in the spread of the disease. No articles of food examined were incriminated, but the carrier problem could not be tackled for lack of co-operation on the part of the public. Studies on the synthetic anti-malarial drugs, plasmoquine and atebrin, were continued. The observation reported last year that the placenta filtered out plasmoquine and prevented large quantities of the drug from entering the foetal circulation, was further confirmed by the actual measurement of the concentration ?of plasmoquine in the maternal and foetal blood simultaneously after giving large doses of the drug to the mother. It was further shown that therapeutic doses of plasmoquine given to pregnant experimental animals did not in any way affect the litters given by the animals. These studies show that this drug can be safely used during pregnancy. The fate of plasmoquine and atebrin in the body has been studied. Plasmoquine is largely destroyed by the liver and atebrin was retained by reticuloendothelial cells. A very important observation regarding the formation of acetylcholine was made. It was found that chiefly nerve cells were responsible for its formation. Some studies had shown that the average haemoglobin content of blood of Indian normal subjects tallied exactly with similar averages worked out in America for white American subjects. These averages were 15.37 g. and 12.99 g. per 100 c.c. of blood for men and women respectively. This observation suggested the possible existence of a haemoglobin constant. Nineteen subjects have so far been examined and an attempt is being made to find if there is a definite ratio between haemoglobin content and some such unit as body surface.
[Dec.,
1939
The power of the kidney to eliminate urea from the blood stream is employed as a measure of renal function for clinical purpose. Moller, Macintosh and Van Slyke's blood urea clearance test worked out on American subjects is usually employed for the purpose. It was noticed in the course of clinical work that in the case of normal Indian subjects while the blood the same limits as that of urea content is within American subjects the urea content of urine of normal Indian subjects is about half of American subjects. This raises an interesting issue whether the formula on which the urea clearance test is based applies to Indian subjects. This subject is being studied. Four more antirabic treatment centres were opened during the year, making a total of 87 in the Province and in the neighbouring areas. The opening of these centres centres is a real boon to the public. These enable the public to get the antirabic treatment without having to make unnecessarily long journeys. Demand for the antirabic treatments showed a further rise during the year. 11,479 treatments were issued as compared with 9,715 treatments issued last year.
THE ON REPORT ADMINISTRATION THE YEAR 1937 The population of the the estimated mid-year
HEALTH THE PUBLIC OF THE PUNJAB FOR province
continues to increase,
population for 1937 being 26,000,000 as against 25,500,000 in 1936. As the director states, this annual increase raises questions with respect to standards of living and the economic development of the province which deserve consideration. Fevers.?The
number
of
deaths
in
the
province
during the year from all causes was 556,000, of which 376,000 were recorded as deaths from fever as comfever pared with 374,000 in 1936. The term '
includes a considerable group of diseases of which the predominant symptom is fever, e.g., malaria, enteric, tuberculosis and influenza, and as the director explains, reports as to the diseases which may have caused death in particular cases cannot be regarded as accurate. Inaccuracies are in fact to a large extent inevitable in the rural area where there are at present few doctors to diagnose the exact nature of a disease. Smallpox.?The province is never entirely free from smallpox. The disease does not as a rule assume serious epidemic form but it shows a tendency t? increase every few years; there was, for example, j* severe epidemic in 1932, and a further epidemic, though of lesser intensity, has to be recorded in 1937. In l93o there were 6,000 cases with 2,500 deaths, and at the same time three and a half million vaccinations and revaccinations were carried out. In 1937 there were 10,000 cases with 4,000 deaths, and five and a million vaccinations and revaccinations were carried ot out. During the two years therefore the number persons vaccinated was eight millions, which is nearly a third of the total population of the province but the disease showed a further increase in 1938 thougn exact figures for that year are not yet available. As regards the 10,000 cases which occurred in 1937, the number of villages infected was 1,350 as compared witn 1,000 in 1936. Of the 4,000 deaths in 1937, 1,500 were of infants below one year of age, and 1,800 of children between the ages of 1 and 10. The figures indicate that still greater effort is needed to ensure the vaccination of infants as soon as possible after birth. Under to the present act local bodies are only empowered make primary vaccination compulsory; the director has, however, submitted proposals for an amendmen of the law so as to enable any local body which m&X wish to do so to make revaccination compulsory, and these are being examined. , Cholera.?Cholera is a disease of which a number well3 cases occur every year, and when streams or are infected it sometimes spreads with great rapidityA? In 1936 there were 2,700 cases with 1,700 deaths. is, however, satisfactory to note that during 1937 ther As usual the were only 184 cases with 105 deaths. infection was in an appreciable number of case-
h&lj
imported from outside the
Hardwar. Plague.?Plague
is
a
province, particularly
disease from which the
Maternity and child welfare?It is probable
from
there is
province
The director states that the cannot be determined. known about the is incidence of tuberculosis except that it is believed to be considerable. The people as a rule are not inclined to take notice of the disease in the early stages when it may be curable, and death when it occurs may be recorded as from fever or one of the respiratory diseases. It is noted that during 1937, 5,000 deaths in the province were returned as on account of tuberculosis compared with 4,800 in 1936, but the true figure is probably higher. While what it has seemed Possible to do to deal with the tuberculosis question has been done in the past, no concerted attack has been instituted against the disease, partly on account of the magnitude of the question and the difficulty of knowing where to make a beginning. A concerted attack is however now about to be launched on an ah-India basis under the auspices of Her Excellency the Marchioness of Linlithgow's Tuberculosis Association of India with its affiliated provincial branches. Leprosy.?A leprosy survey has been proceeding for ?some 3'ears, and has now been completed in 18 out of the 29 districts. Two thousand cases have so far been observed, and the number of special clinics, which serve as both treatment and propaganda centres, is now 106. rhe five leper homes continued their excellent work, ministering to 646 inmates of whom however only a hundred are Punjabis. Two hundred and sixty-four doctors in the province have now received special Gaining in the diagnosis and treatment of leprosy. Hookworm.?A hookworm survey has also been in progress for some years, and has now been completed 20 districts. In some as many as 30 per cent of the persons examined were found to be infected, and treatment is now being administered partly at the local hospital or dispensary and partly by special treatment units. The disease would almost entirely disappear if latrines conforming to hygienic principles were to be generally adopted, or alternatively if all persons wore
The
.
shoes.
Sanitation.?The
standard of sanitation in towns low. In the larger municipalities which employ a whole-time health officer, arrangements are the whole as satisfactory as can lie expected, regard being to the insanitary habits of many of the People. In the smaller towns, however, which have not ?.he funds either for a health officer or for roadside uramage, conditions are usually deplorable, and, as the director states, the 3,000 cases of enteric with a thousand deaths reported from urban areas are almost Certainly an underestimate. Before public health conditions in a village can be '.egarded as satisfactory, the minimum that is necessary ]?"atthatthethe water supply should be safe from pollution, inhabited area should be properly drained, that there should be a system for the regular ^Qd enioval of refuse to a distance; out of the 35,000 vulages in the province only 1,960 attain this standard a'i present but improvement may be expected as spreads. Six thousand new hand-pumps are plication ePorted to have been installed in villages during the laid ^ear while 450,000 feet of masonry drains were also jtown compared with 260,000 feet in 1936. It is were ,ePorted that 600 village sanitary committees ormed during the year, and though the director^ notes oat few seem to have functioned it is encouraging to ee. that villagers themselves in different districts subyear for bribed over a lac of rupees during the labour and J^ntary works and in addition contributed
remains
Material.
urban
area
that in which there is not a
women
are
trained at
health
centres
of
which
School at Lahore at the rate of about 14 a year. The demand for lady health visitors exceeds the supply with the result that it has not been possible to open further centres for which funds existed. About 2,000 trained dais are known to be practising in the province, while another 2,000 are at present under training. Inspection of schools and school children .?The medical inspection of school children is still in the experimental stage, and here again the difficulty in arranging for defects noted, to be regularly treated, is for a number of reasons considerable. During 1937 the further experiment was started of supplying milk in certain schools to those children who being sickly or undernourished may be most in need of it.
outside.
_
no
during the year under report there were 89 with 128 sub-centres, the centres being under the charge of lady health visitors who are trained in the Punjab Health
factors which have caused this Tuberculosis.?Very little
_
now
sufficiency of trained dais, and municipal and small town committees are being encouraged to frame by-laws prohibiting practice by untrained women. In the rural area, however, there is still a shortage of trained dais.
has suffered much in the past. Wherever the disease has appeared mass inoculation has been undertaken; at the same time the public health department have for many years conducted a campaign against rats in areas in which the disease has constantly appeared. In 1936, only 153 deaths from plague were recorded, and in 1937 (for the first time after 40 years) no cases at all occurred in the province though 4 were
imported from
779
ABSTRACTS FROM REPORTS
Dec., 1939]
THE THIRD ANNUAL REPORT OF THE INDIAN FOR INSTITUTE MEDICAL RESEARCH,^ CALCUTTA, FOR 1937-38 The third Annual Report of the Indian Institute for Medical Research shows that this Institute is receiving a much greater measure of sympathy and recognition both at home and abroad. Although our financial difficulties still persist, there is "no lack of devotion and earnestness on the part of our workers who alone have made it possible for the Institute to carry on its work fruitfully and efficiently. In the department of bacteriology, the programme of researches included the work on the immunity problems connected with cholera and typhoid, which was continued throughout the year under review. The relation of streptococcus isolated from the throat with that isolated from puerperal fever was investigated and the result showed that the number of hemolytic streptococcus obtained from throat swab of the maternity cases suffering from puerperal fever was very small. In the department of protozoology, further studies on the problem of protozoal cultivation and protozoal immunity are being made with special reference to malaria, amcebiasis and leishmaniasis. The results so far achieved appear to be very encouraging. The department of biochemistry and nutrition put on the forefront of its programme of work during the year the problem of a nutritional survey of Indian food-stuffs and dietaries. What is most gratifying to note is that of late public interest has steadily awakened in researches into food-stuffs and dietaries undertaken at different laboratories in the country, including ours. The importance of nutrition as a paramount factor in the improvement of national health needs no emphasis and we feel that the institute's work in this direction has the support of the public of India. A large number of common food-stuffs and dietaries of Bengal have been investigated from various aspects at the institute. It has been known for some time that the type of food commonly consumed by urban populations in Bengal is not calculated to afford adequate nutrition especially during childhood and adolescence and also during pregnancy and lactation. Our biological investigations have revealed that the ordinary diet taken by an average family in Calcutta or in an average students' hostel is partially deficient in vitamins A and B-complex. The work at the institute reveals that the average diet is not only deficient in these vitamins, but also lacks to a_ considerable degree the very important body-building ?
minerals,
780
THE INDIAN MEDICAL GAZETTE
calcium and iron, and further that the diet is also deficient to some extent in protein of high nutritive value. A word should be said with regard to dietary requirements during pregnancy anil lactation, which is considered to be of great and urgent importance. From an analysis of the food-stuffs and dietaries we have found that during pregnancy, when extra amounts of vitamins and minerals are needed, there is a deplorable insufficiency of these essential dietary ingredients. It is not at all strange that owing to the relative lack of iron in the diet, the majority of pregnant women in Bengal should be so prone to ansemia. Much of the short stature and rickety constitution of Bengali children may also be traced to the insufficiency of calcium and necessary vitamins during the mother's gestation and lactation periods. It is well to emphasize that the harm due to malnutrition during pre- and post-natal periods cannot be adequately made good by dietary abundance in the later life of the individual. In the interest of both the mother and the baby, every expectant mother in Bengal should be given an extra ration of milk, if possible, a little iron in the form of iron-rich food-stuffs like polta or of ferric ammonium citrate, more of green vegetables and occasionally a little cod-liver oil and the gently cooked liver of fish
[Dec.,
1939
or mammals. This is an urgent matter, which in our view should receive immediate attention. In the department of chemistry, immuno-chemistry and chemotherapy the measurement of electrical charge of Leishmanial tropica under a variety of conditions received special attention, and the results indicate that in their cataphoretic behaviour in the presence of immune sera the protozoa closely resemble the bacteria. The work on the effect of electrolytes on the rate of flocculation of toxin-antitoxin mixtures of diphtheria and tetanus was also undertaken and the data so far obtained show that the balanced mixture flocculates most quickly compared with the other mixture. In addition to these activities, investigations of the occurrence of the Danysz phenomenon in diphtheria toxinantitoxin mixtures under various conditions was carried out. A very valuable branch of the institute is its diagnostic section. It has in effect subserved many purposes?humanitarian and scientific from the public point of view and from the institute's point of view it has been one of the main sources of income which sustains the institute. In deserving and indigent cases, it has given its services free or at concession rates. And, last, but by no means the least, it has served as a training ground for research students.
