Current
Topics.
Medical Education in India. Report by SIR NORMAN WALKER. {British Med. J own., 20th Aug., 1927, p. 312.) During the early part of the present year Sir Norman Walker visited the medical colleges and associated hospitals of several Indian universities, and in a report to the Secretary of State for India, which is printed in the minutes of the Executive Committee of the General Medical Council, he summarizes his observations. Until quite recently medical education in India was directed and controlled by the Indian Medical Service. "That it is as good as it is," says Sir Norman Walker, " and in many respects it is excellent, is almost entirely due to the zeal, energy, and versatility of that Service." With the Indian Medical Service the various colleges grew up in close relationship, all the professors were presidency medical officers, and at first and for many years all of them were Europeans. So long as the Government was solely responsible for staffing the colleges almost all the candidates were holders of British qualifications, inasmuch as entrance to the Indian Medical Service, from which the staffs were drawn, could be gained only by passing an examination in London. But medical administration, including provision for medical education, has now become a provincial subject in India, and the change has been followed in the colleges everywhere by a great diminution in the number of European teachers. Methods of providing teachers other than through the Indian Medical Service have been called for, and the men whose teaching experience has been small and whose training as teachers has been brief have been appointed to professorships. Sir Norman Walker thinks it would be well if young men of promise, after a couple of years' service in a scientific department of an Indian university, were sent abroad to carry their studies further under different conditions before being appointed to chairs. With regard to examinations, he points out that there is no pre-registration examination in India; and also that all age limitations for the matriculation examination have been removed, so that not a few candidates pass at the age of fourteen, and after two years spent in studying for the. intermediate arts or science examination, find it possible to commence the study of medicine proper at 16, which is one year earlier than in Great Britain. The level of secondary education in India is admittedly lower than in Great Britain, and no British university accepts the matriculation examination of an Indian university as equivalent to its own. After pointing out that it is easier to work hard for nine months out of twelve in Great Britain than in India, Sir Norman Walker suggests, as to the medical curriculum proper, that it would be well if all
704
THE INDIAN MEDICAL GAZETTE.
the Indian universities followed the lead of Calcutta in establishing a curriculum of six years (eighteen terms) and continued in the curriculum the study of chemistry, physics, and biology as applied to medicine. At present the length of the medical curriculum varies in different universities from thirteen to eighteen terms. In anatomy, physiology, pathology, and materia medica
and pharmacology India shows to great advantage, and the laboratories are generally satisfactory in building and equipment. Hygiene is taught usually by the officers of the public health department in the respective provinces, and the teachers are well qualified and experienced. Forensic medicine?a very important subject in India? is taught by lecturers, usually the civil surgeon or his assistant, or by the police surgeon in addition to his ordinary work. The teaching in systematic medicine, surgery,, and midwifery is along lines similar to those followed by medical schools at Home, twenty years ago. In practical midwifery there has been an improvement during the last five years. Madras has an excellent and in Bombay the new Wadia maternity hospital, hospital will provide opportunities for teaching second to none. The teaching of midwifery and gynaecology in the Calcutta Medical College is at a high level, and in Lahore an excellent modern maternity hospital is well on the way to completion, but in Lucknow things are not so far advanced. So far as hospitals in> general are concerned, Sir Norman Walker says that some of the new ones are really excellent, and India is to be congratulated on its hospital architects. The ophthalmic department is nearly always a special feature of Indian hospitals. In Madras the ophthalmic hospital, thanks to the zeal and perseverance of Colonel R. H. Elliot and his successors, is one of the finest in the world. The special departments for diseases of children, ear and throat, skin, venereal diseases and tuberculosis, have a long way to go to catch up with ophthalmology. The arrangements for the teaching of mental diseases also leave much to be desired. There are many large asylums in India, but they are rarely in close proximity to the medical colleges. With regard, to research, Calcutta has one of \the foremost schools of tropical medicine in the world, and institutes at Kasauli, Bombay, and Madras are all doing admirable work, but it is greatly to be desired that research should be active in many centres, notably the universities. On the general subject of organization of medical education Sir Norman Walker states that what India lacks is a co-ordinating authority between the universities. That universities should be independent and should follow the lines which seem to them most fruitful is generally admitted by educationists, but when medicine is concerned the public interest is involved to a greater degree than with any of the other faculties. Here independence and autonomy must be combined with a minimum standard maintained for the public benefit. Some more satisfactory basis than periodic visitation and inspection through the direct agency of the General Medical Council should be found. The number of medical colleges has doubled since Sir Norman Walker's first visit of inspection to India in 1922, and the need for setting up some co-ordinating authority comparable to the General Medical Council, with which the Council could communicate, grows more urgent. The absence of any such directing authority in India is really the chief obstacle to a satisfactory solution of the problem. Pending the setting up of such a body, he suggests that a commissioner of medical qualifications and standards with a permanent office at Delhi should continue and extend the work already done by the Council's inspector, Colonel R. A. Needham, who has just completed the last of a series of visits and reports extending over a period of five years, and is now at Home on long leave. The General Medical Council would willingly accept the suggested commissioner as their visitor, until a central authority can be established, and his regular reports would be of much assistance in determining whether or not recognition should be accorded or continued.
[Dec.,
1927.
The Control of Malaria. By S. P. JAMES,
m.d.,
IJEUT.-COt,., I.M.S.
(British Med. Journ., 27th Aug., 1927,
p.
347.)
At the recent annual meeting of the British Medical Association held in Edinburgh, Lieut.-Col. S. P. James, i.M.S. (Retd.), read a paper before the section Jr>f Tropical Diseases on the conclusions of the Malaria Commission of the League of Nations regarding the problems of malaria prophylaxis. We think that the following summary of Col. James' paper may prove of interest to our readers. (1) One of the first and most important conclusions stated by the Commission is that at the present time, in the vast majority of the numerous regions where malaria prevails, antimalarial measures should be limited to an endeavour to reduce the severity and, so far as may be possible by the same measures, the incidence of the disease. They are of opinion that measures designed to accomplish" more than that (and particularly measures aiming at eradication ") are not a wise proposition, and can be justified only in very exceptional circumstances.
(2) A second conclusion of general interest is that it is not always necessary to deal with malaria by a method arising directly out of the knowledge that the disease is transmitted by mosquitoes. In this connection the Commission cites various regions and localities in which, in the past, malaria was robbed of its importance as a cause of sickness and death without any knowledge of the setiology of the disease, and without any reduction of anopheles having occurred, as well as various localities in which the same result is being brought about to-day. The Commission observes that, since the advent of the knowledge that malaria is transmitted by mosquitoes, there has been a tendency to forget that there are many methods of dealing with the disease, and that some of them are effective even without an attempt being made to reduce mosquitoes. Therefore they are of opinion that in certain circumstances it is very desirable for antimalarial workers to throw off the tyranny resulting from the general belief that because mosquitoes carry malaria their elimination should be the chief object of concern_and expenditure. (3) A result of the Commission's inquiries which is closely related to the conclusion just stated is the recognition that there is not yet any single method of malaria control which can be described as being superior to all others and therefore to be adopted in every country. There are, as has already been said, a number of methods of control, and some of them are constantly being improved. Each or any of them may, either wholly or in part, render valuable service in a country if it is a method well suited to the local conditions. This suitability or adaptability to local conditions is one of the most important matters to be considered in a choice of methods, and it is essential to the success of the method chosen. Malaria control is a local problem to a much greater degree than is the case with the control of other infectious diseases. Therefore in every country, and very largely in every area, there must be preliminary examination to ascertain the local conditions before deciding what method of malaria control is best adapted to them. (4) The question arises whether it is better to utilize several of the known antimalarial methods at the same
time, or to concentrate all available effort on one carefully selected method. This is a specific question which was put to the Commission by the public health authorities of several countries visited. The answer given was that, in the opinion of the Commission, it is better to limit the action taken to one or two selected methods, which can then be brought to a high degree of perfection. If, after a fair trial, these one or two measures are found to be insufficient to rob the disease of its practical. importance from the public health point of view, further methods can be systematically added until the desired end is attained.
CURRENT TOPICS.
Dec., 1927.]
(5) As regards the particular methods of malaria control to be adopted in any country or area, the Com-
mission considers that there should be considerable freedom of choice. It deprecates the adoption of measures in a country on the ground that they have been successful in another, whether, perhaps, circumstances and conditions are quite different. Each country, and to a more limited extent each locality, must work out its " own salvation in this matter, and the suggestion is made that countries and localities should do so in greater degree than has hitherto been the case. On this point the Commission states that in some of the countries which they visited there was evidence of an endeavour to follow too slavishly the antimalarial policy adopted in some other countries without ascertaining its suitability to the local circumstances and conditions, and in some instances without interpreting correctly its purpose and without giving full weight to the considerations which determined its adoption. As an example, they note that, in the world generally, there is a widespread misapprehension regarding Italian antimalarial methods, and that, in some countries, money, energy, and time have been misapplied in the false belief that the Italian example was being followed. (6) It is usual to classify antimalarial measures as direct and indirect. The Commission adopts that classification but defines the terms more strictly than is usual. In the Commission's view there are only two direct antimalarial measures?namely, killing the malaria parasite in man, and killing the malaria parasite in infected mosquitoes. In comparison with these two measures, anything else that can be done to control malaria is necessarily indirect. For example, no one who has made a particular study of antimalarial campaigns can doubt that general antilarval measures in the field, as usually carried out in practice, are an indirect method of trying to deal with human malaria?that this line of action is concerned with something which is remote from the particular knowledge of the etiology and epidemiology of malaria which we are fortunate enough _
to-day. (7) Adopting this restricted definition of direct and indirect means of controlling malaria, the Commission suggests that in every malarious locality certain direct methods, which they term primary measures and which to possess
"
"
concerned with malaria-infected individuals and the interior of the houses in which they live, are indispensable. As regards measures relating to malariainfected individuals, the Commission considers that, whatever else it may be possible to do in malarious localities, the first and most important thing to do is to In arrange for the treatment of cases of the disease. rural areas and localities under primitive conditions the State must make these arrangements, according to the means available, but at least an efficient arrangement for the gratuitous supply and effective distribution of quinine) is indispensable. The Commission considers that in organized communities satisfactory diagnosis as well as treatment should be arranged for, and suggests that, wherever possible, the services of private medical practitioners already established in the locality should be utilized and paid for by the State for this work. (8) The Commission recognizes that no useful purpose would be served by magnifying unduly the results that may be obtained by those arrangements for ensuring early discovery and effective treatment of cases and carriers. They have ascertained that, in the countries which they visited, nothing is more striking than the mild character of the manifestations of malaria in a locality where there are practising medical men who are fully equipped as to the diagnosis and treatment of the disease, as compared with the severe and often in a similar fatal manifestations locality which is without that expert medical aid; but they realize also that the good results are more apparent in the reduction of severity and mortality than in the reduction of incidence. This is not surprising of the in view knowledge that quinine is not an effective prophylactic for new infections or relapses, and in view of the are
705 "
of attaining the minimal effective standard " in the execution of the measures. Regular inspection of school children and of organized classes of the adult population must be part of the system, and must endeavour be made to follow up all an patients in their homes. The officer who is in charge of the measures will need assistants, especially for house-to-house inquiries. In some countries duly quali" health visitors" who have received the fied female necessary training may be usefully employed in this work. In small districts the office can be combined with kindred health duties, such as school nurse, tuberculosis visitor,
difficulty
etc.
"
(9) The other primary measure" which the Commission recommends is the systematic killing of adult female anopheles mosquitoes which can be found in the interior of dwelling-houses. It would take too long to describe in this paper the epidemiological and experimental grounds on which the Commission has arrived at the conclusion that this measure, if it could be effectively carried out, would have very remarkable results. As to the manner in which it should be done, the Commission considers that, wherever it may be practicable to persuade householders themselves to undertake it, that arrangement is preferable to an organized arrangement by the authorities for killing mosquitoes in houses by periodic fumigation or other means. In the Commission's view the measure should be regarded as an important item in the sanitary education of the inhabitants of malarious areas. The Commission thinks that it should be a duty of the medical men and assistants who visit households to explain to the occupants how malaria is contracted and spread, and to demonstrate to them how to find and kill the adult anopheles mosquitoes which are present in the house. It should be explained also how to make the house inhospitable to anopheles by removing cobwebs and dirt, clearing out recesses and dark corners, whitewashing, arranging for more light and air, and other simple means suitable to the particular locality and type of dwelling. Female health visitors and health nurses, who have been properly instructed and trained, can do a great deal of good by instructing householders on these matters. The aim should be to teach the inhabitants to have the same dislike and objection to the presence of gorged and sluggish mosquitoes in their houses as cultured people already have to the presence of bed-bugs, lice, and other harmful and disgusting vermin. If this educational propaganda is successful, it may be hoped that in time the killing of anopheles mosquitoes in houses will become a routine part of the housewife's daily task, just as much as other more showy, but less useful, items of sweeping, brushing, and cleaning. The measure has the advantage of costing nothing. It is known, from the results of experimental laboratory work, that one infected mosquito can give malaria to as many as thirty persons; therefore it is difficult to praise too highly any person who succeeds in killing even one of these infected insects. (10) As regards these two primary or direct meais well aware that there is sures, the Commission nothing particularly new or original about the idea of endeavouring to combat malaria in the houses of the people themselves rather than in the general environment. They realize also that it is often a difficult matter to get into the houses of the people, to examine all the occupants, to treat those who are found to be infected, and to teach them to catch and kill the mosquitoes which may be hidden in inaccessible places. But no royal road or short cut to the prevention of malaria has yet been found. Therefore, in the opinion of the Commission, it is necessary for the present to continue to endeavour to combat the disease itself at its sources in the human and insect hosts. (11) The Commission has carefully considered in what circumstances any other measures than those dealt with should be recommended, and what those measures should be. On this subject reference is made in the first place to the problem of what should be done in regions where the conditions in which the people live and work
THE INDIAN MEDICAL GAZETTE.
706
primitive, and their economic position and social
[Dec.,
1927.
status and culture are so poor, that it is not possible in practice to apply direct antimalarial measures in a manner which enables them to be brought to the " minimal effective standard." Except the free distribution of quinine, no effective antimalarial measure can be applied in these regions until the land has been brought into such a condition that it is worth the while of the inhabitants to settle permanently upon it, and until those fair standard of permanent settlers have reached a housing and living. Nothing is more favourable to a
but, having regard to the financial aspect of its mandate, they are equally unwilling that countries should continue to believe that the kind of drainage which is necessary for agricultural reclamation of the soil is an important antimosquito measure. For it is now known, unquestionably, that the open ditches and canals by which swamps and marshy areas are drained for agricultural purposes are often more prolific breeding places of anopheles than were the original swamps themselves. The Italians are well aware of this. They do not regard the large bonifications as an antimosquito measure, and they know
movements of a
anopheles
are
so
high incidence and severity of malaria than frequent population hither and thither in search of a bare living, and very few things have a greater effect in reducing malaria than the stability of the population which comes when a place where the conditions of life are tolerable is found. Agricultural reclamation of the land, so that people may be settled permanently upon it with a fair prospect of gaining a livelihood, and perhaps a decent house and moderate comfort, is, therefore, a measure which tends indirectly to produce In general, the better the a great reduction of malaria. agricultural reclamation is carried out from the point of view of increasing its productiveness, the quicker will malaria seem to disappear as an important cause of sickthe ness and death?provided always, of course, that people themselves share in the improved prosperity by being able to adopt a higher standard of housing and living. It is hardly necessary to say that, when reclaimed land is worked by hired labourers who receive only a small daily or weekly wage and live a life of great hardship in temporary huts and hovels, there is no improvement of malaria among them. Indeed, in the tropics (and even in some parts of Europe) highly cul-
where these conditions obtain continue to the most malarious in the world. This indicates that the actual measures necessary for agricultural reclamation or improvement of the soil (drainage, etc.), are not the factor which causes the health of the people to improve, but that the good result is due to the better conditions of living and housing which the increased productiveness of the soil enables the people to obtain. In this connection the Commission notes that the changed conditions of life just referred to, and the subsequent reduction of malarial incidence and severity, have often been brought about in the absence of any of measures intentionally based on modern knowledge the etiology and epidemiology of malaria, and they illus" bonitrate this truth by describing a small scheme of " fication without antilarval or other antimosquito methods which was demonstrated to them during their tour in Sicily. The place is now an example of "anophelism without malaria." For these and other reasons the conclusion to which, the Commission has come is that, of all indirect methods of reducing malaria, most importance must be attached to general schemes which aim at improving the economic and social conditions of the people and their general well-being and standard of life. (12) The Commission has ascertained that almost in the countries which they visited terms everywhere " " like bonification," assainissement," etc., are misunderstood and misinterpreted except in the particular countries where the terms originated. They find also that in some countries the false belief still prevails that the actual measures which are necessary for making land more suitable for cultivation and more fertile are the means by which the reduction of malaria is brought about. In particular the drainage which is necessary for agricultural land reclamation is often credited with being the chief agent concerned. It is assumed that the drainage acts by reducing the breeding places of anopheles mosquitoes. In support of this belief it is often said that even the ancients knew that drainage reduces malaria, and that this antimalarial action of drainage was explained when the role of the mosquito was discovered. One result of the belief is that some countries have adopted drainage on a large scale as their first line of attack against malaria. The Commission does not desire to limit the output of public works of proved utility,
tivated be
areas
among
"
"
bonification may increase the abundance of in the area reclaimed. But they know also that in an area where bonification has been completed,
that such
a
and where, in consequence, the inhabitants settle permanently in better houses and in all the other circumstances of a moderately good standard of life, malaria tends more or less quickly to lose its importance as a cause of sickness and death. This good result more than compensates for an increase in the abundance of anopheles in the general environment. Thus it appears that the measures themselves are only a means to a definite end which is to be pursued despite the knowledge that some of the measures may be of a kind which actually favours the incidence and spread of malaria. (13) The Commission deals in separate chapters of the report with various other problems of malaria prophylaxis, particularly with the organization necessary for the work, and with different antimalarial and antimosquito methods?such as quinine treatment and prophylaxis, larvicides, the applicability of antilarval antimalarial measure, and measures, housing as an propaganda. (14) For various reasons which are given in the report, the Commission is unanimously of opinion that the scientific study of malaria must be continuously pursued in the laboratory and the field. They consider that the best prospect of discovering a method of dealing with malaria which can be applied in affected localities with the small amount of money and
means
that
can
usually be provided, lies in renewed activity in the study of the disease in all its aspects. Therefore they suggest that each Government which has not already done so should establish a small central permanent organization
of selected workers who would devote their whole time to malaria research. In this connection they suggest (a) the establishment in one or two malarious areas of "
"
each country of an observational station where certain routine epidemiological inquiries should be made at regular short intervals for several years; (b) the establishment in each country where malaria is used therapeutically of a laboratory for the cultivation of a pure strain of malaria in mosquitoes, to be used, under expert supervision, for the purposes of the treatment. The establishment of such a laboratory in a properly organized hospital automatically provides an opportunity of studying the clinical and parasitological features of malaria contracted in the natural way, as well as the circumstances governing the infection of anopheles and the persistence of the infective virus in those insects. It also enables a satisfactory study to be made of the action of quinine and other drugs which are used for the treatment of malaria. Examples of each of these institutions are described in the report, as well as an example of a station for "experimental malaria control."
League of Nations. Report of the Meetings of the Eighth Session of the Health Committee, held at Geneva in October, 1926. The Health Organisation of the League of Nations is doing very excellent work, but there is a feeling that much of this work is unknown even in educated circles, and a danger that this organisation may in time be regarded like every other health organisation; to be left alone and only taken notice cursorily say once a year. But the investigations and enquiries undertaken by the
Dec., 1927.]
CURRENT TOPICS.
Health Committee are no ordinary routine. They are carefully chosen because of their fundamental or urgent importance, and it is disappointing that the world at large is not better acquainted with this work. The composition of the Committee is a guarantee of the soundness and the authority of its opinions and conclusions. The work for 1926 includes medical, epidemiological, biochemical, and statistical problems of international concern, and the report is very interesting to every branch of the profession. The report of the Malaria Commission has been issued
separately and is reviewed elsewhere in our columns. Its further studies will consist of (a) malaria in deltas; (b) major sanitary measures in malaria; (c) laboratory problems; (d) relations between meteorological condi-
tions and malaria.
An important commission is investigating the standardisation of biochemical products, and various anti-sera f dysenteric, scarlet fever, tetanus, whooping cough), are being examined to determine their efficiency and if possible to fix uniform standards for these. A
special report has been submitted by ProfesCalmette regarding tuberculin, some standardisation of which seems very desirable. A similar examination of the various methods of preparation and standardising vaccine (small-pox) lymph are under examination and some uniformity in potency and purity is being aimed at. In some countries (Holland and Germany) cases of encephalitis have been noticed in conjunction with observers are of the vaccination and some Dutch opinion that the conjunction is real. The enquiry is sor
proceeding. With regard to the International List of Causes of Death, this was drawn up by the International Institute of Statistics who are apparently rather jealous that no outside agency should encroach on its preserves. A joint meeting of the two bodies is to be convened however to discuss the improvement of the list which is highly desirable. A special feature of the Committee's activities is the arrangement of interchanges of public health personnel of various countries. An interchange of sanitary engineers has already been held, and a party of port health officers visited the basins of the Baltic and the North Sea. This year a party of health officers is visiting India. There is also a proposal to institute international continuation courses in public health in various countries. It is suggested holding the first of these in Paris, the language used being French. A conference of health experts on Infant Welfare to resolutions. It was agreed submitted important study the various immunisation processes against infant and child diseases and a comprehensive enquiry into the various causes of infantile mortality in Europe was recommended. Unification of Infant Death Registration " dead birth" and adoption of a uniform definition of were also recommended.
An interesting discussion took place on a proposal to establish an Epidemiological Bureau for Africa in Algiers. Information regarding infectious disease on the East Coast of Africa is at present transmitted to the Singapore Bureau but such information for the rest of Africa is not furnished anywhere. Algiers seems suitable to collect such information from Western and Northern Africa. Such would be valuable not only to the States participating but to many Mediterranean Countries. It was agreed that work of an experimental nature might be carried out first before the Committee committed themselves to a definite proposal. The above indicates in some measure the activities of the Health Committee of the Health Organisation of the League of Nations, and it is necessary that every country should realise the importance of the work which is bound to extend year by year as the benefits arising from international co-operation and agreement in public health work are realised. A. D. S.
707
Tuberculosis and Venereal Diseases in
Pregnancy. (British Med. Journ., 13th Aug., 1927, p. 247.) The importance (a) of tuberculosis, and (b) of
venereal diseases in relation to pregnancy was discussed in the section of Obstetrics and Gynecology at the Annual Meeting of the British Medical Association held in Edinburgh in July of this year. (a) Pregnancy has an unfavourable effect on tuberculous patients, leading to aggravation of symptoms and the production of fresh lesions. The reason is not quite clear but it has been shewn that a comparatively high proportion of pregnant women lose the capacity of giving a positive skin reaction to tuberculin, recovering it only some time after confinement. The flaring up of the disease may be only temporary; it may be limited to the reappearance of some bacilli in the sputum, which had remained sterile for a long period before, to a transient loss of weight with abnormal temperatures. But it may also be, and it too often is, quite serious, characterized by the rapid extension of the existing lesions or by the appearance of severe lesions in the hitherto sound contralateral lung. Many a woman, who had the most favourable prospects for making a complete recovery has lost all her chances and has died because of an intervening pregnancy. Regarding the treatment of pregnant tuberculous patients, artificial pneumothorax, though far from ideal was considered to be preferable to the iduction of abortion. (b) Venereal Diseases: I. Syphilis.?The frequency of this disease in the average ante-natal clinic in Great Britain is at most 5 per cent. The diagnosis is made on the clinical and obstetric histories and on the results of the Wassermann reaction. The last mentioned is not absolutely infallible: a small proportion of patients whose blood serum is negative subsequently give birth to syphilitic children. Examination of the products of conception is considered to be of great value, but stress is laid on the fact that the placenta of a live syphilitic infant may appear to be perfectly healthy both to the naked eye and miscroscopically: the pale, greasy, bulky placenta typical of syphilis and caused by endarteritis obliterans of the fcetal capillaries in the chorionic villi is found only in the macerated foetus. The presence of round cell infiltration around the walls of the umbilical vein is important, and should be looked for by miscroscopic examination of a piece of cord taken from as near the foetal end as possible. In the fresh dead foetus or the dead infant the most typical changes are found in the liver, lungs, thyroid gland and pancreas.
Treatment. principles should be borne in
In treatment four main
mind.
(a) It should commence as early in pregnancy as possible, or, better still, a full curative course of treatment should be completed before pregnancy is allowed. (b) The patient should be treated by arsenical compounds in every pregnancy?no matter whether she seems cured
or
not.
(c) Treatment
may be continued with perfect safety up till the time of confinement. (d) Arsenic and mercury or bismuth should not be combined in treatment, on account of their tendency to damage the kidneys. In this respect bismuth and mer-
dangerous than arsenic; if there is no albuminuria, however, they may be given alternately.
cury are more
If there is albuminuria it may be necessary to stop all treatment, except by potassium iodide, so long as the, albuminuria lasts. In some rare cases the albuminuria may be due to syphilis, and then arsenical treatment,
carefully watched, may be tried. Method of Treatment.?The best results are obtained by the use of novarsenobenzol intravenously, starting with
a
small dose of 0.3
or
0.45 gram, and
increasing
carefully to 0.6 or 0.75 gram. The injections should be given once weekly, and continued until six or eight doses are given. A careful watch should be kept for
708
THE INDIAN MEDICAL GAZETTE.
albuminuria. After this there should be a month's interval, during which mercury in the form of 10 minims of grey oil (corresponding to 1 grain of metallic mercury), is administered intramuscularly into the buttock once weekly, the site of injection being massaged so as to aid absorption. Intramuscular bismuth?preferably one of the insoluble compounds such as bicreol? may be given as an alternative twice weekly. In the case of both bismuth and mercury treatment the most careful attention should be paid to the state of the teeth. These courses of arsenic and mercury or bismuth should be given alternately until the end of pregnancy. After delivery treatment should be continued; a course of treatment of eighteen months' duration, as outlined above, is the minimum, and it is well to continue treatment for a year after all tests are negative. In the case of husbands with old and probably cured syphilis it is well to advise a prophylactic course as a safety measure for some weeks preceding marriage. Finally, it must be emphasized that there is no proof of the cure of syphilis treatment except reinfection, and that antisyphilitic should be repeated in every pregnancy, no matter whether apparently cured or not. II. Gonorrhoea.?Gonorrhoea in pregnancy seldom gives rise to acute symptoms such as cystitis. Infection usually occurs primarily (a) in the ducts and glands of Bartholin; (b) in the urethra and periurethral gland, especially Skene's glands; (c) in the racemose glands of the cervix. IIow to Examine a Case of Suspected Gonorrhoea. Examination can only be properly carried out with the patient in the lithotomy position, and in a good light. In private practice this position can easily be obtained by a pair of lithotomy straps. The gland of Bartholin is first examined by picking up the labium majus at the junction of its posterior and middle thirds between the] finger and thumb. Normally the gland is not palpable. If any enlargement is felt it is almost invariably due to gonorrhoea. It may, if only slight enlargement and induration are present, be caused by very old-standing infection. Next the orifice of the duct should be examined; this is a pin-point opening at the junction of the hymen with the labium minus, near the posterior end of the latter. An area of rosy redness spreading on to the adjacent mucosa is suspicious, but it is not so strong evidence as enlargement of the gland. It may be possible to squeeze a little pus from the duct; if so, it should be spread on a glass slide and allowed to dry in air, being afterwards sent to a bacteriologist for examination. The urethra should next be examined, care being taken that the patient has not passed urine for three hours. The urethra should be milked from the neck of the bladder downwards to the external meatus, and if pus is obtained a smear, and possibly a culture, should be taken. The absence of Bartholinitis and urethritis, however, by no means excludes gonorrhoea. The cervix should then be examined, preferably using bivalve speculum, which gives the best exposure. In acute infection it usually appears purple and congested, and bleeds on touching. In more chronic cases there may be actual desquamation of epithelium, the well known erosion. Often it is bathed in mucopurulent secretion. A swab must be taken from the cervical canal, care being taken not to trespass above the internal os. Smear or culture is again made. The cervix, however, may look perfectly normal, and yet gonococci may be obtained from the canal. A swab merely from the vagina is generally of 110 value whatever in excluding gonorrhoea. What is the value of a negative smear? A negative smear is of little value in diagnosis and it should be repeated 011 at least three successive occasions. The gonococcus is most likely to be found just after a period, but this test is not available in pregnancy. We may, however, give a provocative injection of 200 million gonococcal vaccine and examine the discharge twenty-four, forty-eight, and seventy-two hours later. If in doubt regarding the diagnosis it is always better to treat the case as if it were gonorrhoea!. a
[Dec.,
1927.
Treatment. The multiplicity of remedies in gonorrhoea is evidence that none is very efficient. Almost the weakest antiseptic will kill the gonococcus if it can be brought into contact with it, but the organisms lie entrenched in the periurethral or cervical glands beyond the reach of most local
applications.
The patient should be in the same position as for diagnosis and the external genitals cleansed with a solution of lysol or mercury perchloride. With a bivalve speculum the cervix is exposed, and from it and the vagina all mucopus is wiped, either with a dry sterile swab or with sodium bicarbonate solution. The latter removes mucus better and leaves a clean surface. The portio and vagina should now be swabbed with a silver or other preparation, such as 10 per cent, protargol or neoprotosil, or 1 per cent, picric acid in spirit: as good results are obtained by swabbing with saline solution. In pregnancy the parts must be handled very carefully, and special care be taken in making application to the cervical canal, lest premature labour be induced. One may, however, very gently swab the canal, using a Playfair's probe dressed with cotton-wool dipped in the selected solution, and rotating the probe carefully. It is rare to find urethritis persisting at this stage, but if it is, it may be necessary to inject, with a glass syringe carrying an acorn nozzle, a silver or other preparation such as 1 per cent, picric acid or 1 in 1,000 acriflavine, or 1 per cent, silver protein; or, as an alternative, medicated urethral bougies may be used containing 10 per cent, neoprotosil or any similar preparation. Sometimes there is a chronic infection of Skene's ducts, and it is necessary to inject them by means of a blunt-pointed hypodermic needle, or they may be destroyed with a cautery. Finally, the cervix and vagina are dusted with an astringent dusting powder such as dermatol, which helps to keep the surface dry. Twice a week is generally sufficient for local treatment, and in most cases there is no need for rest in bed. Detoxicated vaccines are of considerable assistance in clearing up the discharge, starting with a dose of 5,000 million, repeating once weekly, and gradually increasing to 50,000 million, which may be continued till the end of pregnancy. With the treatment outlined above it is almost alway^ possible to get the discharge cleared up in a few weeks, and before delivery occurs. Very few of the cases cause trouble in the puerperium. Douching is dangerous, and less effective than the method above described, and should have no place in the treatment of gonorrhoea in pregnancy. Finally, it must be emphasized that the only absolute* test of cure of gonorrhoea is the absence of the power to reinfect the male, and that treatment must be continued after pregnancy is over until at least all clinical evidence of disease is eradicated.
Bismuth in the
Therapy
of
Syphilis.
By Dr. D. LEES, n.s.o., m.b., p.r.c.s. (Edin.). (British Med. Journ., 20th Aug., 1927, p. 298.) In a paper read before the Section of Venereal Diseases at the1 Annual Meeting of the British Medical Association at Edinburgh, Dr. Lees summarises the present position of bismuth in the therapy of syphilis. (1) Bismuth is an active antisyphilitic drug and is more rapid in its destructive action on the Spirochccta pallida in vivo than mercury; it is not so rapid as the salvarsan group of drugs in this respect. (2) Bismuth influences the surface lesions of syphilis as rapidly as the arsenobenzols, and more rapidly than mercury.
(3) Bismuth, with few exceptions, is less active than influencing the Wassermann test,
the arsenobenzols in
but is
more
active than mercury in this respect.
(4) The combined administration of bismuth and arsenic is more potent than either drug alone and is
CURRENT TOPICS.
Dec., 1927.]
free from clanger if given in therapeutic doses. The same holds good of arsenic and mercury. (5) The administration of metallic bismuth in isotonic glucose solution is remarkably free from pain and side-effect, and in this respect is better tolerated than either aj-senic or mercury. (6) Bismuth is a very valuable drug in cases of syphilis which are intolerant to treatment by arsenic or mercury. (7) Bismuth is a very valuable drug in the treatment of any patient who has advanced organic disease, whether the latter is due to, or is intercurrent with, the syphilis. (8) The intramuscular injection of an insoluble com-
pound of bismuth gives better therapeutic results with
effects than other methods of the intravenous administration of colloidal bismuth or the intramuscular injection of the salts of bismuth. (9) The addition of bismuth and its salts to the other available methods of treatment does not as yet justify anyone in lessening the length of time over which every case of syphilis should be treated and kept under observation. (10) Apart from cases of intolerance to other drugs, bismuth is only an adjuvant to the treatment of syphilis and should not be used alone, even in the very earliest cases of infection. less
risk
of
toxic
administering it, such
A
Study
of
as
709
the patient is under treatment, they are apt to recur when treatment is discontinued. One patient, a man aged 44, has been receiving treatment at intervals for more than fifteen years, and although he has not had a single clean negative Wassermann reaction he has not had any recurrence of interstitial keratitis. During this time he has had about seventy-five injections of arsphenamine, 150 of mercury, thirty-five of bismuth, and mixed treatments at intervals. Usually when treatment was begun in early infancy, the Wassermann reaction became negative after about four courses of arsphenamine and mercury and remained A relapse to a positive Wassermann reaction after so. the serum has once become negative was rare, having occurred in only four cases of the series. Although the symptoms of those suffering from neurosyphilis have either become less severe or have entirely disappeared under treatment, in no case has the cerebro-spinal fluid become negative. Meningitis has been fatal in all cases. Congenital syphilis of the kidney was diagnosed during life in fourteen cases, and in each instance was confirmed by autopsy. Not including the four patients who had a relapse to a positive Wassermann reaction, a negative result in 29 per cent, of the cases has been obtained. as
Bismuth in the Treatment of
Congenital
Syphilis.
Congenital Syphilis.
By A. BENSON CANNON, m.d. (Journ. Amer. Med. Assoc., Vol. 89, No. 9, 27th Aug., 1927, p. 666.)
By CARRON S. WRIGHT. (Journ. Amer. Med. Assoc., Vol. 89, No. 6, 6th Aug., 1927, p. 424.)
In a recent number of the Journal of the American Medical Association. Cannon gives an account of his studies of two hundred and two cases of congenital
Dr. Wright, in an important and interesting paper, gives his experience of the treatment of fifty-four cases of congenital syphilis by means of bismuth. Potassium bismuth tartrate was administered intramuscularly into the buttocks in doses equivalent to 5 mg. kilogram of body weight. Each course consisted of sixteen weekly injections, with one month's rest between courses. Forty-seven of the cases whose ages ranged from two were to sixteen years examples of late congenital syphilis : all of them had had prolonged courses of various organic arsenic compounds but of the total only four showed a negative Wassermann reaction after this line of treatment. The remaining forty-three were put on bismuth treatment: of these twenty became negative, sixteen remaining so at the time of writing. The average number of injections necessary to produce this serological change is not stated. Interstitial keratftis responds very well to bismuth, and cutaneous lesions disappear with remarkable rapidity. Untoward effects are rare. The injections are painless if properly given: occasional eczematoid eruptions were seen during treatment, and blue lines on the gums may develop?this last is not a serious manifestation. Albuminuria and anjemia, recorded by some observers, were not prominent features in this series.
syphilis.
His conclusions may be summarised as follows:? (1) In a study of 202 cases of congenital syphilis
representing 181 mothers, it was found that the more recent the infection in the mother the more frequently
the children infection.
were
affected and the
severer
the type of
(2) Only 23 per cent, of the mothers had received treatment before or during pregnancy.
(3) The greater number of these cases represented the first pregnancy. (4) The average age at which symptoms developed was between the tenth and fifteenth years. (5) Ninety-one per cent, of the patients were normal mentally. (6) Interstitial keratitis was the most frequent symptom, occurring in 35 per cent, of the cases. (7) Dental defects were the most common physical sign. (8) The Wassermann reaction and organic luetin tests were strongly to moderately positive in all except two cases.
(9) Spinal fluid tests were positive in 10.S per cent. CIO) The plan of treatment was continuous. (11) There were fourteen cases of syphilitic nephritis. All were fatal and all were studied at autopsy. (12) There were four cases of meningitis, all of which were fatal. Three were examined at autopsy.
Conclusions. Generally speaking, the sooner after birth the child receives antisyphilitic treatment the fewer and less pronounced the late stigmas. If treatment is started during the first year of life, the child usually develops normally with little or no evidence of syphilis. As a rule, the older the child when treatment is begun, the more resistant the disease. It has been especially difficult to obtain a negative Wassermann reaction in those suffering from interstitial keratitis, even after prolonged treatment. Only six out of a total of seventy patients have become serologically negative, and these after from four to six years of almost continuous treatment with bismuth. While mercury, iodide and the symptoms usually clear up and remain clear as long
arspheivamine,
The Treatment of Amoebiasis. By P. MANSON-BAHR,
d.s.o.,
m.d., f.r.c.p.,
and E. G. SAYERS, m.b., ch.B., n.z., d.t.m. & h. (British Med. Journ., 17th Sept., 1927, p. 490.) RecKnt advances in the treatment of amoebic dysentery discussed by Dr. Manson-Bahr and others in the Section of Tropical Diseases at the Annual Meeting of the British Medical Association held in Edinburgh in July, 1927.- These may be' summarised as follows:? Emetine is the drug of choice in acute amoebiasis and hepatitis, but is apt to prove disappointing in chronic cases. Emetine-bismuth iodide and emetine periodide have given fairly good results, particularly the former. Yatren 105 is safe from toxicity and relatively satisfactory. In Manson-Bahr's opinion, however, the best were
THE INDIAN MEDICAL GAZETTE.
710
results are obtained by a combined treatment with emetine-bismuth iodide and yatren: the former is given orally in capsules, the latter is used as a rectal lavage. In administering emetine-bismuth iodide, there are certain precautions to be adopted?the patient should be absolutely at rest and no solid or liquid food should have been administered within 4 hours of taking the drug. The yatren lavage consists of 200 c.c. of 2\ per cent, solution; emetine-bismuth iodide is given every night and yatren lavages in the morning. Treatment is controlled by the sigmoidoscope.
Pain and
Radiology.
By M. J. HUB EN Y, m.d. Amcr. Med. Assoc., Vol. 89, No. 4, (Journ. July, 1927,
p.
271.)
Pain is a most important subjective symptom: its significance and the assistance in its interpretation which can frequently be given by roentgenography are stressed by Dr. Hubeny in a recent issue of the Journal of the
American Medical Association. With modern methods of diagnosis pain, which is a purely subjective phenomenon, can almost be classed as an objective symptom. Often, for example, pressure might elicit pain, or movement might produce it; regardless of the stimulation, the questions of the precise nature of the pain, where and at what times experienced, are important factors, and however subjective the pain might be from the standpoint of the patient, its interpretation always presents to the physician a
problem Pain
as
objective diagnosis. or outstanding symptom is pathologic conditions not always
in
the initial
common
to easy differentiate. The first consideration should be to determine whether the condition is medical and amenable to to
many
whether the pain indicates the surgical condition that may require operative relief. For instance, a number of non-surgical conditions may cause upper abdominal pain, such as simple gastric indigestion, food or ptomain poisoning, or the ingestion of poisonous drugs or substances; or conditions above the diaphragm, such as pleurisy, pneumonia, pulmonary abscess or infarct, thoracic aneurysm, mediastinal inflammation or neoplasms, may produce pain in the upper part of the abdomen. It is therefore quite obvious that a method which can tangibly account for the pain is a valuable adjunct. ?Diseases often present themselves in an atypical and bizarre manner: occasionally a pain syndrome is absent, or the pain is very severe or exaggerated from the standpoint of patient tolerance, or sometimes it is minimized by a hyposensitive individual. There are many diseases in which pain is absent; so many complications and combinations, particularly in adult life, may co-exist- that one must be on the alert to recognize them because of their influence on one another, affecting seriously the prognosis or occasionally prohibiting a serious surgical intervention. It is quite proper to mention just a few of these diseases, namely, pernicious anaemia, early sarcoma, and often carcinoma, in which pain is distinctly absent or mild and the termimedical treatment,
or
onset of some serious
nation fatal. The foregoing remarks will impress one with the vagaries of that most important indicator of disease,
pain.
The importance of referred pain is emphasised and a is quoted in which the real origin of a pain in the hip joint region was revealed only by .r-ray examination of the whole pelvis and femur when a metastatic carcinoma of the shaft of the latter bone was revealed: the patient had previously had a breast amputation for malignant disease. This case, together with others quoted, emphasises the necessity for examination not only of the actual seat of pain but also of structures in the neighbourhood. Fractures present an interesting phase because some serious cases frequently occur with little or no pain. case
[Dec.,
1927.
The author had two cases of what proved to be impacted fractures of the hip in which both patients walked into the office; one used a cane, the other had no assistance whatever, and both protested the needlessness of a roentgen-ray examination. Fractures of the smaller bones occur often with little or no pain and very little disability, and it is legally and therapeutically unsafe not to have a roentgenographic examination. It occasionally happens that a fracture of the lower end of the tibia, particularly a spiral fracture, is accompanied by a compensatory fracture of the upper end of the fibula. The latter is frequently overlooked because the major pain and apparent injury are at or near the ankle joint. It is unwise to examine the skull roentgenologically over the scalp wound area only, because of the well known contrecoup fractures which happen only too often; in spite of the presence or absence of tender points and visible contusions one should always use a four way examination, at least. A common experience of all roentgenologists is the frequent occurrence of pathologic dental conditions without any local pain; this, of course, is diametrically opposite to the experience of a dentist, because ordinarily a patient will consult a dentist for dental aches. Hence it is quite understandable why it has taken a long time to drive home to the dental profession the actuality of dental infections as direct or contributory causes of disease processes elsewhere. By way of an opposite illustration, a thorough roentgenographic examination of an acute fulminating osteomyelitis will be valueless, because a time interval is necessary to produce demonstrable bone changes; in the meantime, the surgeon will be obliged to make a clinical diagnosis and proceed with the necessary medical or surgical intervention, because waiting for roentgen-ray confirmation might be disastrous to the patient. Gastro intestinal .r-ray examinations offer a fruitful field explaining many abdominal aches. The paper is an interesting one and will repay further study.
Atypical
Malaria.
Assoc., Vol. VII, No. 8, August, 1927.) Vitug and Ignacio point out the baffling complexity of the picture presented by malaria in certain cases and quote instances from their own experience in which clinically the illness appeared to be (1) influenza; (2) typhoid; (3) cholecystitis; (4) acute multiple peripheral neuritis; (5) dysentery; (6) cerebrospinal The of encephalitis. presence meningitis; (7) malaria was only discovered after repeated blood examination: in one case the real cause was only dis(Journ. Philippine
Isi. Med.
covered at autopsy. The protean nature of malarial manifestations, like those of syphilis, should ever be borne in mind and should be excluded by repeated hematological examinations before diagnosing the symptom complex, no matter how atypical, as non-malarial.
Malaria Control in Italy. By Professor ARTURO CASTIGLIONI, m.d. (British Med. Joum., 13th Aug., 1927, p. 278.) In a recent number of the British Mcdical Journal Professor Arturo Castiglioni gives an interesting account of the measures adopted by the present Italian Government for the control of malaria in Italy. These may be stated shortly as follows: (1) State distribution of quinine. (2) Classification of the disease as an occupational complaint, and as such carrying a right to indemnity. (3) Gratuitous supplies of quinine and assistance towards sanitation purposes for all workers and settlers inhabiting malarial zones. (4) Foundation of malarial research institutes. (5) Draining of possible anopheles breeding places. The breeding of cattle in malarious regions is regarded as important since researches have shown that certain mosquitoes prefer
REVIEWS.
Dec., 1927.]
species other than the human. Studies in Italy have demonstrated that in places in which rice is grown the development of anopheles is much more marked?a finding- which, if subsequently confirmed, will be of considerable importance to us in India. A sum of nearly four million lire (about Rs. 3i lakhs) per annum is obtained from the State sale of quinine and is subsequently employed in subsidies for antimalarial purposes.
An Alcohol-Bath Thermometer Case. (China Med. Journ., Vol. XIJ, No. 7, July, 1927, p. 660.) The following simple piece of apparatus described and
illustrated in a recent number of The China Medical Journal may prove of interest to our readers. The thermometer case here illustrated is used, and recommended, by Dr. Daniels of Nanking. It is hard to distinguish in appearance from a fountain pen,? pocket-clip and all. It carries the thermometer in a bath of alcohol which does not spill when the case is either closed or opened.
RUBBER RING ROUNO THERMOMETER
The special feature in this device is that the case has inside sheath of metal which contains the thermometer. This is perforated near the bottom to give access to the spirit, but when it is drawn out, the holes lie within the rubber cuff which closes the mouth of the outer case, and are so sealed. Dr. Daniels adds that he finds the case apt to break when dropped on cement, though on one such occasion the thermometer within did not! an
711
Topics.
Medical Education in India. Report by SIR NORMAN WALKER. {British Med. J own., 20th Aug., 1927, p. 312.) During the early part of the present year Sir Norman Walker visited the medical colleges and associated hospitals of several Indian universities, and in a report to the Secretary of State for India, which is printed in the minutes of the Executive Committee of the General Medical Council, he summarizes his observations. Until quite recently medical education in India was directed and controlled by the Indian Medical Service. "That it is as good as it is," says Sir Norman Walker, " and in many respects it is excellent, is almost entirely due to the zeal, energy, and versatility of that Service." With the Indian Medical Service the various colleges grew up in close relationship, all the professors were presidency medical officers, and at first and for many years all of them were Europeans. So long as the Government was solely responsible for staffing the colleges almost all the candidates were holders of British qualifications, inasmuch as entrance to the Indian Medical Service, from which the staffs were drawn, could be gained only by passing an examination in London. But medical administration, including provision for medical education, has now become a provincial subject in India, and the change has been followed in the colleges everywhere by a great diminution in the number of European teachers. Methods of providing teachers other than through the Indian Medical Service have been called for, and the men whose teaching experience has been small and whose training as teachers has been brief have been appointed to professorships. Sir Norman Walker thinks it would be well if young men of promise, after a couple of years' service in a scientific department of an Indian university, were sent abroad to carry their studies further under different conditions before being appointed to chairs. With regard to examinations, he points out that there is no pre-registration examination in India; and also that all age limitations for the matriculation examination have been removed, so that not a few candidates pass at the age of fourteen, and after two years spent in studying for the. intermediate arts or science examination, find it possible to commence the study of medicine proper at 16, which is one year earlier than in Great Britain. The level of secondary education in India is admittedly lower than in Great Britain, and no British university accepts the matriculation examination of an Indian university as equivalent to its own. After pointing out that it is easier to work hard for nine months out of twelve in Great Britain than in India, Sir Norman Walker suggests, as to the medical curriculum proper, that it would be well if all
704
THE INDIAN MEDICAL GAZETTE.
the Indian universities followed the lead of Calcutta in establishing a curriculum of six years (eighteen terms) and continued in the curriculum the study of chemistry, physics, and biology as applied to medicine. At present the length of the medical curriculum varies in different universities from thirteen to eighteen terms. In anatomy, physiology, pathology, and materia medica
and pharmacology India shows to great advantage, and the laboratories are generally satisfactory in building and equipment. Hygiene is taught usually by the officers of the public health department in the respective provinces, and the teachers are well qualified and experienced. Forensic medicine?a very important subject in India? is taught by lecturers, usually the civil surgeon or his assistant, or by the police surgeon in addition to his ordinary work. The teaching in systematic medicine, surgery,, and midwifery is along lines similar to those followed by medical schools at Home, twenty years ago. In practical midwifery there has been an improvement during the last five years. Madras has an excellent and in Bombay the new Wadia maternity hospital, hospital will provide opportunities for teaching second to none. The teaching of midwifery and gynaecology in the Calcutta Medical College is at a high level, and in Lahore an excellent modern maternity hospital is well on the way to completion, but in Lucknow things are not so far advanced. So far as hospitals in> general are concerned, Sir Norman Walker says that some of the new ones are really excellent, and India is to be congratulated on its hospital architects. The ophthalmic department is nearly always a special feature of Indian hospitals. In Madras the ophthalmic hospital, thanks to the zeal and perseverance of Colonel R. H. Elliot and his successors, is one of the finest in the world. The special departments for diseases of children, ear and throat, skin, venereal diseases and tuberculosis, have a long way to go to catch up with ophthalmology. The arrangements for the teaching of mental diseases also leave much to be desired. There are many large asylums in India, but they are rarely in close proximity to the medical colleges. With regard, to research, Calcutta has one of \the foremost schools of tropical medicine in the world, and institutes at Kasauli, Bombay, and Madras are all doing admirable work, but it is greatly to be desired that research should be active in many centres, notably the universities. On the general subject of organization of medical education Sir Norman Walker states that what India lacks is a co-ordinating authority between the universities. That universities should be independent and should follow the lines which seem to them most fruitful is generally admitted by educationists, but when medicine is concerned the public interest is involved to a greater degree than with any of the other faculties. Here independence and autonomy must be combined with a minimum standard maintained for the public benefit. Some more satisfactory basis than periodic visitation and inspection through the direct agency of the General Medical Council should be found. The number of medical colleges has doubled since Sir Norman Walker's first visit of inspection to India in 1922, and the need for setting up some co-ordinating authority comparable to the General Medical Council, with which the Council could communicate, grows more urgent. The absence of any such directing authority in India is really the chief obstacle to a satisfactory solution of the problem. Pending the setting up of such a body, he suggests that a commissioner of medical qualifications and standards with a permanent office at Delhi should continue and extend the work already done by the Council's inspector, Colonel R. A. Needham, who has just completed the last of a series of visits and reports extending over a period of five years, and is now at Home on long leave. The General Medical Council would willingly accept the suggested commissioner as their visitor, until a central authority can be established, and his regular reports would be of much assistance in determining whether or not recognition should be accorded or continued.
[Dec.,
1927.
The Control of Malaria. By S. P. JAMES,
m.d.,
IJEUT.-COt,., I.M.S.
(British Med. Journ., 27th Aug., 1927,
p.
347.)
At the recent annual meeting of the British Medical Association held in Edinburgh, Lieut.-Col. S. P. James, i.M.S. (Retd.), read a paper before the section Jr>f Tropical Diseases on the conclusions of the Malaria Commission of the League of Nations regarding the problems of malaria prophylaxis. We think that the following summary of Col. James' paper may prove of interest to our readers. (1) One of the first and most important conclusions stated by the Commission is that at the present time, in the vast majority of the numerous regions where malaria prevails, antimalarial measures should be limited to an endeavour to reduce the severity and, so far as may be possible by the same measures, the incidence of the disease. They are of opinion that measures designed to accomplish" more than that (and particularly measures aiming at eradication ") are not a wise proposition, and can be justified only in very exceptional circumstances.
(2) A second conclusion of general interest is that it is not always necessary to deal with malaria by a method arising directly out of the knowledge that the disease is transmitted by mosquitoes. In this connection the Commission cites various regions and localities in which, in the past, malaria was robbed of its importance as a cause of sickness and death without any knowledge of the setiology of the disease, and without any reduction of anopheles having occurred, as well as various localities in which the same result is being brought about to-day. The Commission observes that, since the advent of the knowledge that malaria is transmitted by mosquitoes, there has been a tendency to forget that there are many methods of dealing with the disease, and that some of them are effective even without an attempt being made to reduce mosquitoes. Therefore they are of opinion that in certain circumstances it is very desirable for antimalarial workers to throw off the tyranny resulting from the general belief that because mosquitoes carry malaria their elimination should be the chief object of concern_and expenditure. (3) A result of the Commission's inquiries which is closely related to the conclusion just stated is the recognition that there is not yet any single method of malaria control which can be described as being superior to all others and therefore to be adopted in every country. There are, as has already been said, a number of methods of control, and some of them are constantly being improved. Each or any of them may, either wholly or in part, render valuable service in a country if it is a method well suited to the local conditions. This suitability or adaptability to local conditions is one of the most important matters to be considered in a choice of methods, and it is essential to the success of the method chosen. Malaria control is a local problem to a much greater degree than is the case with the control of other infectious diseases. Therefore in every country, and very largely in every area, there must be preliminary examination to ascertain the local conditions before deciding what method of malaria control is best adapted to them. (4) The question arises whether it is better to utilize several of the known antimalarial methods at the same
time, or to concentrate all available effort on one carefully selected method. This is a specific question which was put to the Commission by the public health authorities of several countries visited. The answer given was that, in the opinion of the Commission, it is better to limit the action taken to one or two selected methods, which can then be brought to a high degree of perfection. If, after a fair trial, these one or two measures are found to be insufficient to rob the disease of its practical. importance from the public health point of view, further methods can be systematically added until the desired end is attained.
CURRENT TOPICS.
Dec., 1927.]
(5) As regards the particular methods of malaria control to be adopted in any country or area, the Com-
mission considers that there should be considerable freedom of choice. It deprecates the adoption of measures in a country on the ground that they have been successful in another, whether, perhaps, circumstances and conditions are quite different. Each country, and to a more limited extent each locality, must work out its " own salvation in this matter, and the suggestion is made that countries and localities should do so in greater degree than has hitherto been the case. On this point the Commission states that in some of the countries which they visited there was evidence of an endeavour to follow too slavishly the antimalarial policy adopted in some other countries without ascertaining its suitability to the local circumstances and conditions, and in some instances without interpreting correctly its purpose and without giving full weight to the considerations which determined its adoption. As an example, they note that, in the world generally, there is a widespread misapprehension regarding Italian antimalarial methods, and that, in some countries, money, energy, and time have been misapplied in the false belief that the Italian example was being followed. (6) It is usual to classify antimalarial measures as direct and indirect. The Commission adopts that classification but defines the terms more strictly than is usual. In the Commission's view there are only two direct antimalarial measures?namely, killing the malaria parasite in man, and killing the malaria parasite in infected mosquitoes. In comparison with these two measures, anything else that can be done to control malaria is necessarily indirect. For example, no one who has made a particular study of antimalarial campaigns can doubt that general antilarval measures in the field, as usually carried out in practice, are an indirect method of trying to deal with human malaria?that this line of action is concerned with something which is remote from the particular knowledge of the etiology and epidemiology of malaria which we are fortunate enough _
to-day. (7) Adopting this restricted definition of direct and indirect means of controlling malaria, the Commission suggests that in every malarious locality certain direct methods, which they term primary measures and which to possess
"
"
concerned with malaria-infected individuals and the interior of the houses in which they live, are indispensable. As regards measures relating to malariainfected individuals, the Commission considers that, whatever else it may be possible to do in malarious localities, the first and most important thing to do is to In arrange for the treatment of cases of the disease. rural areas and localities under primitive conditions the State must make these arrangements, according to the means available, but at least an efficient arrangement for the gratuitous supply and effective distribution of quinine) is indispensable. The Commission considers that in organized communities satisfactory diagnosis as well as treatment should be arranged for, and suggests that, wherever possible, the services of private medical practitioners already established in the locality should be utilized and paid for by the State for this work. (8) The Commission recognizes that no useful purpose would be served by magnifying unduly the results that may be obtained by those arrangements for ensuring early discovery and effective treatment of cases and carriers. They have ascertained that, in the countries which they visited, nothing is more striking than the mild character of the manifestations of malaria in a locality where there are practising medical men who are fully equipped as to the diagnosis and treatment of the disease, as compared with the severe and often in a similar fatal manifestations locality which is without that expert medical aid; but they realize also that the good results are more apparent in the reduction of severity and mortality than in the reduction of incidence. This is not surprising of the in view knowledge that quinine is not an effective prophylactic for new infections or relapses, and in view of the are
705 "
of attaining the minimal effective standard " in the execution of the measures. Regular inspection of school children and of organized classes of the adult population must be part of the system, and must endeavour be made to follow up all an patients in their homes. The officer who is in charge of the measures will need assistants, especially for house-to-house inquiries. In some countries duly quali" health visitors" who have received the fied female necessary training may be usefully employed in this work. In small districts the office can be combined with kindred health duties, such as school nurse, tuberculosis visitor,
difficulty
etc.
"
(9) The other primary measure" which the Commission recommends is the systematic killing of adult female anopheles mosquitoes which can be found in the interior of dwelling-houses. It would take too long to describe in this paper the epidemiological and experimental grounds on which the Commission has arrived at the conclusion that this measure, if it could be effectively carried out, would have very remarkable results. As to the manner in which it should be done, the Commission considers that, wherever it may be practicable to persuade householders themselves to undertake it, that arrangement is preferable to an organized arrangement by the authorities for killing mosquitoes in houses by periodic fumigation or other means. In the Commission's view the measure should be regarded as an important item in the sanitary education of the inhabitants of malarious areas. The Commission thinks that it should be a duty of the medical men and assistants who visit households to explain to the occupants how malaria is contracted and spread, and to demonstrate to them how to find and kill the adult anopheles mosquitoes which are present in the house. It should be explained also how to make the house inhospitable to anopheles by removing cobwebs and dirt, clearing out recesses and dark corners, whitewashing, arranging for more light and air, and other simple means suitable to the particular locality and type of dwelling. Female health visitors and health nurses, who have been properly instructed and trained, can do a great deal of good by instructing householders on these matters. The aim should be to teach the inhabitants to have the same dislike and objection to the presence of gorged and sluggish mosquitoes in their houses as cultured people already have to the presence of bed-bugs, lice, and other harmful and disgusting vermin. If this educational propaganda is successful, it may be hoped that in time the killing of anopheles mosquitoes in houses will become a routine part of the housewife's daily task, just as much as other more showy, but less useful, items of sweeping, brushing, and cleaning. The measure has the advantage of costing nothing. It is known, from the results of experimental laboratory work, that one infected mosquito can give malaria to as many as thirty persons; therefore it is difficult to praise too highly any person who succeeds in killing even one of these infected insects. (10) As regards these two primary or direct meais well aware that there is sures, the Commission nothing particularly new or original about the idea of endeavouring to combat malaria in the houses of the people themselves rather than in the general environment. They realize also that it is often a difficult matter to get into the houses of the people, to examine all the occupants, to treat those who are found to be infected, and to teach them to catch and kill the mosquitoes which may be hidden in inaccessible places. But no royal road or short cut to the prevention of malaria has yet been found. Therefore, in the opinion of the Commission, it is necessary for the present to continue to endeavour to combat the disease itself at its sources in the human and insect hosts. (11) The Commission has carefully considered in what circumstances any other measures than those dealt with should be recommended, and what those measures should be. On this subject reference is made in the first place to the problem of what should be done in regions where the conditions in which the people live and work
THE INDIAN MEDICAL GAZETTE.
706
primitive, and their economic position and social
[Dec.,
1927.
status and culture are so poor, that it is not possible in practice to apply direct antimalarial measures in a manner which enables them to be brought to the " minimal effective standard." Except the free distribution of quinine, no effective antimalarial measure can be applied in these regions until the land has been brought into such a condition that it is worth the while of the inhabitants to settle permanently upon it, and until those fair standard of permanent settlers have reached a housing and living. Nothing is more favourable to a
but, having regard to the financial aspect of its mandate, they are equally unwilling that countries should continue to believe that the kind of drainage which is necessary for agricultural reclamation of the soil is an important antimosquito measure. For it is now known, unquestionably, that the open ditches and canals by which swamps and marshy areas are drained for agricultural purposes are often more prolific breeding places of anopheles than were the original swamps themselves. The Italians are well aware of this. They do not regard the large bonifications as an antimosquito measure, and they know
movements of a
anopheles
are
so
high incidence and severity of malaria than frequent population hither and thither in search of a bare living, and very few things have a greater effect in reducing malaria than the stability of the population which comes when a place where the conditions of life are tolerable is found. Agricultural reclamation of the land, so that people may be settled permanently upon it with a fair prospect of gaining a livelihood, and perhaps a decent house and moderate comfort, is, therefore, a measure which tends indirectly to produce In general, the better the a great reduction of malaria. agricultural reclamation is carried out from the point of view of increasing its productiveness, the quicker will malaria seem to disappear as an important cause of sickthe ness and death?provided always, of course, that people themselves share in the improved prosperity by being able to adopt a higher standard of housing and living. It is hardly necessary to say that, when reclaimed land is worked by hired labourers who receive only a small daily or weekly wage and live a life of great hardship in temporary huts and hovels, there is no improvement of malaria among them. Indeed, in the tropics (and even in some parts of Europe) highly cul-
where these conditions obtain continue to the most malarious in the world. This indicates that the actual measures necessary for agricultural reclamation or improvement of the soil (drainage, etc.), are not the factor which causes the health of the people to improve, but that the good result is due to the better conditions of living and housing which the increased productiveness of the soil enables the people to obtain. In this connection the Commission notes that the changed conditions of life just referred to, and the subsequent reduction of malarial incidence and severity, have often been brought about in the absence of any of measures intentionally based on modern knowledge the etiology and epidemiology of malaria, and they illus" bonitrate this truth by describing a small scheme of " fication without antilarval or other antimosquito methods which was demonstrated to them during their tour in Sicily. The place is now an example of "anophelism without malaria." For these and other reasons the conclusion to which, the Commission has come is that, of all indirect methods of reducing malaria, most importance must be attached to general schemes which aim at improving the economic and social conditions of the people and their general well-being and standard of life. (12) The Commission has ascertained that almost in the countries which they visited terms everywhere " " like bonification," assainissement," etc., are misunderstood and misinterpreted except in the particular countries where the terms originated. They find also that in some countries the false belief still prevails that the actual measures which are necessary for making land more suitable for cultivation and more fertile are the means by which the reduction of malaria is brought about. In particular the drainage which is necessary for agricultural land reclamation is often credited with being the chief agent concerned. It is assumed that the drainage acts by reducing the breeding places of anopheles mosquitoes. In support of this belief it is often said that even the ancients knew that drainage reduces malaria, and that this antimalarial action of drainage was explained when the role of the mosquito was discovered. One result of the belief is that some countries have adopted drainage on a large scale as their first line of attack against malaria. The Commission does not desire to limit the output of public works of proved utility,
tivated be
areas
among
"
"
bonification may increase the abundance of in the area reclaimed. But they know also that in an area where bonification has been completed,
that such
a
and where, in consequence, the inhabitants settle permanently in better houses and in all the other circumstances of a moderately good standard of life, malaria tends more or less quickly to lose its importance as a cause of sickness and death. This good result more than compensates for an increase in the abundance of anopheles in the general environment. Thus it appears that the measures themselves are only a means to a definite end which is to be pursued despite the knowledge that some of the measures may be of a kind which actually favours the incidence and spread of malaria. (13) The Commission deals in separate chapters of the report with various other problems of malaria prophylaxis, particularly with the organization necessary for the work, and with different antimalarial and antimosquito methods?such as quinine treatment and prophylaxis, larvicides, the applicability of antilarval antimalarial measure, and measures, housing as an propaganda. (14) For various reasons which are given in the report, the Commission is unanimously of opinion that the scientific study of malaria must be continuously pursued in the laboratory and the field. They consider that the best prospect of discovering a method of dealing with malaria which can be applied in affected localities with the small amount of money and
means
that
can
usually be provided, lies in renewed activity in the study of the disease in all its aspects. Therefore they suggest that each Government which has not already done so should establish a small central permanent organization
of selected workers who would devote their whole time to malaria research. In this connection they suggest (a) the establishment in one or two malarious areas of "
"
each country of an observational station where certain routine epidemiological inquiries should be made at regular short intervals for several years; (b) the establishment in each country where malaria is used therapeutically of a laboratory for the cultivation of a pure strain of malaria in mosquitoes, to be used, under expert supervision, for the purposes of the treatment. The establishment of such a laboratory in a properly organized hospital automatically provides an opportunity of studying the clinical and parasitological features of malaria contracted in the natural way, as well as the circumstances governing the infection of anopheles and the persistence of the infective virus in those insects. It also enables a satisfactory study to be made of the action of quinine and other drugs which are used for the treatment of malaria. Examples of each of these institutions are described in the report, as well as an example of a station for "experimental malaria control."
League of Nations. Report of the Meetings of the Eighth Session of the Health Committee, held at Geneva in October, 1926. The Health Organisation of the League of Nations is doing very excellent work, but there is a feeling that much of this work is unknown even in educated circles, and a danger that this organisation may in time be regarded like every other health organisation; to be left alone and only taken notice cursorily say once a year. But the investigations and enquiries undertaken by the
Dec., 1927.]
CURRENT TOPICS.
Health Committee are no ordinary routine. They are carefully chosen because of their fundamental or urgent importance, and it is disappointing that the world at large is not better acquainted with this work. The composition of the Committee is a guarantee of the soundness and the authority of its opinions and conclusions. The work for 1926 includes medical, epidemiological, biochemical, and statistical problems of international concern, and the report is very interesting to every branch of the profession. The report of the Malaria Commission has been issued
separately and is reviewed elsewhere in our columns. Its further studies will consist of (a) malaria in deltas; (b) major sanitary measures in malaria; (c) laboratory problems; (d) relations between meteorological condi-
tions and malaria.
An important commission is investigating the standardisation of biochemical products, and various anti-sera f dysenteric, scarlet fever, tetanus, whooping cough), are being examined to determine their efficiency and if possible to fix uniform standards for these. A
special report has been submitted by ProfesCalmette regarding tuberculin, some standardisation of which seems very desirable. A similar examination of the various methods of preparation and standardising vaccine (small-pox) lymph are under examination and some uniformity in potency and purity is being aimed at. In some countries (Holland and Germany) cases of encephalitis have been noticed in conjunction with observers are of the vaccination and some Dutch opinion that the conjunction is real. The enquiry is sor
proceeding. With regard to the International List of Causes of Death, this was drawn up by the International Institute of Statistics who are apparently rather jealous that no outside agency should encroach on its preserves. A joint meeting of the two bodies is to be convened however to discuss the improvement of the list which is highly desirable. A special feature of the Committee's activities is the arrangement of interchanges of public health personnel of various countries. An interchange of sanitary engineers has already been held, and a party of port health officers visited the basins of the Baltic and the North Sea. This year a party of health officers is visiting India. There is also a proposal to institute international continuation courses in public health in various countries. It is suggested holding the first of these in Paris, the language used being French. A conference of health experts on Infant Welfare to resolutions. It was agreed submitted important study the various immunisation processes against infant and child diseases and a comprehensive enquiry into the various causes of infantile mortality in Europe was recommended. Unification of Infant Death Registration " dead birth" and adoption of a uniform definition of were also recommended.
An interesting discussion took place on a proposal to establish an Epidemiological Bureau for Africa in Algiers. Information regarding infectious disease on the East Coast of Africa is at present transmitted to the Singapore Bureau but such information for the rest of Africa is not furnished anywhere. Algiers seems suitable to collect such information from Western and Northern Africa. Such would be valuable not only to the States participating but to many Mediterranean Countries. It was agreed that work of an experimental nature might be carried out first before the Committee committed themselves to a definite proposal. The above indicates in some measure the activities of the Health Committee of the Health Organisation of the League of Nations, and it is necessary that every country should realise the importance of the work which is bound to extend year by year as the benefits arising from international co-operation and agreement in public health work are realised. A. D. S.
707
Tuberculosis and Venereal Diseases in
Pregnancy. (British Med. Journ., 13th Aug., 1927, p. 247.) The importance (a) of tuberculosis, and (b) of
venereal diseases in relation to pregnancy was discussed in the section of Obstetrics and Gynecology at the Annual Meeting of the British Medical Association held in Edinburgh in July of this year. (a) Pregnancy has an unfavourable effect on tuberculous patients, leading to aggravation of symptoms and the production of fresh lesions. The reason is not quite clear but it has been shewn that a comparatively high proportion of pregnant women lose the capacity of giving a positive skin reaction to tuberculin, recovering it only some time after confinement. The flaring up of the disease may be only temporary; it may be limited to the reappearance of some bacilli in the sputum, which had remained sterile for a long period before, to a transient loss of weight with abnormal temperatures. But it may also be, and it too often is, quite serious, characterized by the rapid extension of the existing lesions or by the appearance of severe lesions in the hitherto sound contralateral lung. Many a woman, who had the most favourable prospects for making a complete recovery has lost all her chances and has died because of an intervening pregnancy. Regarding the treatment of pregnant tuberculous patients, artificial pneumothorax, though far from ideal was considered to be preferable to the iduction of abortion. (b) Venereal Diseases: I. Syphilis.?The frequency of this disease in the average ante-natal clinic in Great Britain is at most 5 per cent. The diagnosis is made on the clinical and obstetric histories and on the results of the Wassermann reaction. The last mentioned is not absolutely infallible: a small proportion of patients whose blood serum is negative subsequently give birth to syphilitic children. Examination of the products of conception is considered to be of great value, but stress is laid on the fact that the placenta of a live syphilitic infant may appear to be perfectly healthy both to the naked eye and miscroscopically: the pale, greasy, bulky placenta typical of syphilis and caused by endarteritis obliterans of the fcetal capillaries in the chorionic villi is found only in the macerated foetus. The presence of round cell infiltration around the walls of the umbilical vein is important, and should be looked for by miscroscopic examination of a piece of cord taken from as near the foetal end as possible. In the fresh dead foetus or the dead infant the most typical changes are found in the liver, lungs, thyroid gland and pancreas.
Treatment. principles should be borne in
In treatment four main
mind.
(a) It should commence as early in pregnancy as possible, or, better still, a full curative course of treatment should be completed before pregnancy is allowed. (b) The patient should be treated by arsenical compounds in every pregnancy?no matter whether she seems cured
or
not.
(c) Treatment
may be continued with perfect safety up till the time of confinement. (d) Arsenic and mercury or bismuth should not be combined in treatment, on account of their tendency to damage the kidneys. In this respect bismuth and mer-
dangerous than arsenic; if there is no albuminuria, however, they may be given alternately.
cury are more
If there is albuminuria it may be necessary to stop all treatment, except by potassium iodide, so long as the, albuminuria lasts. In some rare cases the albuminuria may be due to syphilis, and then arsenical treatment,
carefully watched, may be tried. Method of Treatment.?The best results are obtained by the use of novarsenobenzol intravenously, starting with
a
small dose of 0.3
or
0.45 gram, and
increasing
carefully to 0.6 or 0.75 gram. The injections should be given once weekly, and continued until six or eight doses are given. A careful watch should be kept for
708
THE INDIAN MEDICAL GAZETTE.
albuminuria. After this there should be a month's interval, during which mercury in the form of 10 minims of grey oil (corresponding to 1 grain of metallic mercury), is administered intramuscularly into the buttock once weekly, the site of injection being massaged so as to aid absorption. Intramuscular bismuth?preferably one of the insoluble compounds such as bicreol? may be given as an alternative twice weekly. In the case of both bismuth and mercury treatment the most careful attention should be paid to the state of the teeth. These courses of arsenic and mercury or bismuth should be given alternately until the end of pregnancy. After delivery treatment should be continued; a course of treatment of eighteen months' duration, as outlined above, is the minimum, and it is well to continue treatment for a year after all tests are negative. In the case of husbands with old and probably cured syphilis it is well to advise a prophylactic course as a safety measure for some weeks preceding marriage. Finally, it must be emphasized that there is no proof of the cure of syphilis treatment except reinfection, and that antisyphilitic should be repeated in every pregnancy, no matter whether apparently cured or not. II. Gonorrhoea.?Gonorrhoea in pregnancy seldom gives rise to acute symptoms such as cystitis. Infection usually occurs primarily (a) in the ducts and glands of Bartholin; (b) in the urethra and periurethral gland, especially Skene's glands; (c) in the racemose glands of the cervix. IIow to Examine a Case of Suspected Gonorrhoea. Examination can only be properly carried out with the patient in the lithotomy position, and in a good light. In private practice this position can easily be obtained by a pair of lithotomy straps. The gland of Bartholin is first examined by picking up the labium majus at the junction of its posterior and middle thirds between the] finger and thumb. Normally the gland is not palpable. If any enlargement is felt it is almost invariably due to gonorrhoea. It may, if only slight enlargement and induration are present, be caused by very old-standing infection. Next the orifice of the duct should be examined; this is a pin-point opening at the junction of the hymen with the labium minus, near the posterior end of the latter. An area of rosy redness spreading on to the adjacent mucosa is suspicious, but it is not so strong evidence as enlargement of the gland. It may be possible to squeeze a little pus from the duct; if so, it should be spread on a glass slide and allowed to dry in air, being afterwards sent to a bacteriologist for examination. The urethra should next be examined, care being taken that the patient has not passed urine for three hours. The urethra should be milked from the neck of the bladder downwards to the external meatus, and if pus is obtained a smear, and possibly a culture, should be taken. The absence of Bartholinitis and urethritis, however, by no means excludes gonorrhoea. The cervix should then be examined, preferably using bivalve speculum, which gives the best exposure. In acute infection it usually appears purple and congested, and bleeds on touching. In more chronic cases there may be actual desquamation of epithelium, the well known erosion. Often it is bathed in mucopurulent secretion. A swab must be taken from the cervical canal, care being taken not to trespass above the internal os. Smear or culture is again made. The cervix, however, may look perfectly normal, and yet gonococci may be obtained from the canal. A swab merely from the vagina is generally of 110 value whatever in excluding gonorrhoea. What is the value of a negative smear? A negative smear is of little value in diagnosis and it should be repeated 011 at least three successive occasions. The gonococcus is most likely to be found just after a period, but this test is not available in pregnancy. We may, however, give a provocative injection of 200 million gonococcal vaccine and examine the discharge twenty-four, forty-eight, and seventy-two hours later. If in doubt regarding the diagnosis it is always better to treat the case as if it were gonorrhoea!. a
[Dec.,
1927.
Treatment. The multiplicity of remedies in gonorrhoea is evidence that none is very efficient. Almost the weakest antiseptic will kill the gonococcus if it can be brought into contact with it, but the organisms lie entrenched in the periurethral or cervical glands beyond the reach of most local
applications.
The patient should be in the same position as for diagnosis and the external genitals cleansed with a solution of lysol or mercury perchloride. With a bivalve speculum the cervix is exposed, and from it and the vagina all mucopus is wiped, either with a dry sterile swab or with sodium bicarbonate solution. The latter removes mucus better and leaves a clean surface. The portio and vagina should now be swabbed with a silver or other preparation, such as 10 per cent, protargol or neoprotosil, or 1 per cent, picric acid in spirit: as good results are obtained by swabbing with saline solution. In pregnancy the parts must be handled very carefully, and special care be taken in making application to the cervical canal, lest premature labour be induced. One may, however, very gently swab the canal, using a Playfair's probe dressed with cotton-wool dipped in the selected solution, and rotating the probe carefully. It is rare to find urethritis persisting at this stage, but if it is, it may be necessary to inject, with a glass syringe carrying an acorn nozzle, a silver or other preparation such as 1 per cent, picric acid or 1 in 1,000 acriflavine, or 1 per cent, silver protein; or, as an alternative, medicated urethral bougies may be used containing 10 per cent, neoprotosil or any similar preparation. Sometimes there is a chronic infection of Skene's ducts, and it is necessary to inject them by means of a blunt-pointed hypodermic needle, or they may be destroyed with a cautery. Finally, the cervix and vagina are dusted with an astringent dusting powder such as dermatol, which helps to keep the surface dry. Twice a week is generally sufficient for local treatment, and in most cases there is no need for rest in bed. Detoxicated vaccines are of considerable assistance in clearing up the discharge, starting with a dose of 5,000 million, repeating once weekly, and gradually increasing to 50,000 million, which may be continued till the end of pregnancy. With the treatment outlined above it is almost alway^ possible to get the discharge cleared up in a few weeks, and before delivery occurs. Very few of the cases cause trouble in the puerperium. Douching is dangerous, and less effective than the method above described, and should have no place in the treatment of gonorrhoea in pregnancy. Finally, it must be emphasized that the only absolute* test of cure of gonorrhoea is the absence of the power to reinfect the male, and that treatment must be continued after pregnancy is over until at least all clinical evidence of disease is eradicated.
Bismuth in the
Therapy
of
Syphilis.
By Dr. D. LEES, n.s.o., m.b., p.r.c.s. (Edin.). (British Med. Journ., 20th Aug., 1927, p. 298.) In a paper read before the Section of Venereal Diseases at the1 Annual Meeting of the British Medical Association at Edinburgh, Dr. Lees summarises the present position of bismuth in the therapy of syphilis. (1) Bismuth is an active antisyphilitic drug and is more rapid in its destructive action on the Spirochccta pallida in vivo than mercury; it is not so rapid as the salvarsan group of drugs in this respect. (2) Bismuth influences the surface lesions of syphilis as rapidly as the arsenobenzols, and more rapidly than mercury.
(3) Bismuth, with few exceptions, is less active than influencing the Wassermann test,
the arsenobenzols in
but is
more
active than mercury in this respect.
(4) The combined administration of bismuth and arsenic is more potent than either drug alone and is
CURRENT TOPICS.
Dec., 1927.]
free from clanger if given in therapeutic doses. The same holds good of arsenic and mercury. (5) The administration of metallic bismuth in isotonic glucose solution is remarkably free from pain and side-effect, and in this respect is better tolerated than either aj-senic or mercury. (6) Bismuth is a very valuable drug in cases of syphilis which are intolerant to treatment by arsenic or mercury. (7) Bismuth is a very valuable drug in the treatment of any patient who has advanced organic disease, whether the latter is due to, or is intercurrent with, the syphilis. (8) The intramuscular injection of an insoluble com-
pound of bismuth gives better therapeutic results with
effects than other methods of the intravenous administration of colloidal bismuth or the intramuscular injection of the salts of bismuth. (9) The addition of bismuth and its salts to the other available methods of treatment does not as yet justify anyone in lessening the length of time over which every case of syphilis should be treated and kept under observation. (10) Apart from cases of intolerance to other drugs, bismuth is only an adjuvant to the treatment of syphilis and should not be used alone, even in the very earliest cases of infection. less
risk
of
toxic
administering it, such
A
Study
of
as
709
the patient is under treatment, they are apt to recur when treatment is discontinued. One patient, a man aged 44, has been receiving treatment at intervals for more than fifteen years, and although he has not had a single clean negative Wassermann reaction he has not had any recurrence of interstitial keratitis. During this time he has had about seventy-five injections of arsphenamine, 150 of mercury, thirty-five of bismuth, and mixed treatments at intervals. Usually when treatment was begun in early infancy, the Wassermann reaction became negative after about four courses of arsphenamine and mercury and remained A relapse to a positive Wassermann reaction after so. the serum has once become negative was rare, having occurred in only four cases of the series. Although the symptoms of those suffering from neurosyphilis have either become less severe or have entirely disappeared under treatment, in no case has the cerebro-spinal fluid become negative. Meningitis has been fatal in all cases. Congenital syphilis of the kidney was diagnosed during life in fourteen cases, and in each instance was confirmed by autopsy. Not including the four patients who had a relapse to a positive Wassermann reaction, a negative result in 29 per cent, of the cases has been obtained. as
Bismuth in the Treatment of
Congenital
Syphilis.
Congenital Syphilis.
By A. BENSON CANNON, m.d. (Journ. Amer. Med. Assoc., Vol. 89, No. 9, 27th Aug., 1927, p. 666.)
By CARRON S. WRIGHT. (Journ. Amer. Med. Assoc., Vol. 89, No. 6, 6th Aug., 1927, p. 424.)
In a recent number of the Journal of the American Medical Association. Cannon gives an account of his studies of two hundred and two cases of congenital
Dr. Wright, in an important and interesting paper, gives his experience of the treatment of fifty-four cases of congenital syphilis by means of bismuth. Potassium bismuth tartrate was administered intramuscularly into the buttocks in doses equivalent to 5 mg. kilogram of body weight. Each course consisted of sixteen weekly injections, with one month's rest between courses. Forty-seven of the cases whose ages ranged from two were to sixteen years examples of late congenital syphilis : all of them had had prolonged courses of various organic arsenic compounds but of the total only four showed a negative Wassermann reaction after this line of treatment. The remaining forty-three were put on bismuth treatment: of these twenty became negative, sixteen remaining so at the time of writing. The average number of injections necessary to produce this serological change is not stated. Interstitial keratftis responds very well to bismuth, and cutaneous lesions disappear with remarkable rapidity. Untoward effects are rare. The injections are painless if properly given: occasional eczematoid eruptions were seen during treatment, and blue lines on the gums may develop?this last is not a serious manifestation. Albuminuria and anjemia, recorded by some observers, were not prominent features in this series.
syphilis.
His conclusions may be summarised as follows:? (1) In a study of 202 cases of congenital syphilis
representing 181 mothers, it was found that the more recent the infection in the mother the more frequently
the children infection.
were
affected and the
severer
the type of
(2) Only 23 per cent, of the mothers had received treatment before or during pregnancy.
(3) The greater number of these cases represented the first pregnancy. (4) The average age at which symptoms developed was between the tenth and fifteenth years. (5) Ninety-one per cent, of the patients were normal mentally. (6) Interstitial keratitis was the most frequent symptom, occurring in 35 per cent, of the cases. (7) Dental defects were the most common physical sign. (8) The Wassermann reaction and organic luetin tests were strongly to moderately positive in all except two cases.
(9) Spinal fluid tests were positive in 10.S per cent. CIO) The plan of treatment was continuous. (11) There were fourteen cases of syphilitic nephritis. All were fatal and all were studied at autopsy. (12) There were four cases of meningitis, all of which were fatal. Three were examined at autopsy.
Conclusions. Generally speaking, the sooner after birth the child receives antisyphilitic treatment the fewer and less pronounced the late stigmas. If treatment is started during the first year of life, the child usually develops normally with little or no evidence of syphilis. As a rule, the older the child when treatment is begun, the more resistant the disease. It has been especially difficult to obtain a negative Wassermann reaction in those suffering from interstitial keratitis, even after prolonged treatment. Only six out of a total of seventy patients have become serologically negative, and these after from four to six years of almost continuous treatment with bismuth. While mercury, iodide and the symptoms usually clear up and remain clear as long
arspheivamine,
The Treatment of Amoebiasis. By P. MANSON-BAHR,
d.s.o.,
m.d., f.r.c.p.,
and E. G. SAYERS, m.b., ch.B., n.z., d.t.m. & h. (British Med. Journ., 17th Sept., 1927, p. 490.) RecKnt advances in the treatment of amoebic dysentery discussed by Dr. Manson-Bahr and others in the Section of Tropical Diseases at the Annual Meeting of the British Medical Association held in Edinburgh in July, 1927.- These may be' summarised as follows:? Emetine is the drug of choice in acute amoebiasis and hepatitis, but is apt to prove disappointing in chronic cases. Emetine-bismuth iodide and emetine periodide have given fairly good results, particularly the former. Yatren 105 is safe from toxicity and relatively satisfactory. In Manson-Bahr's opinion, however, the best were
THE INDIAN MEDICAL GAZETTE.
710
results are obtained by a combined treatment with emetine-bismuth iodide and yatren: the former is given orally in capsules, the latter is used as a rectal lavage. In administering emetine-bismuth iodide, there are certain precautions to be adopted?the patient should be absolutely at rest and no solid or liquid food should have been administered within 4 hours of taking the drug. The yatren lavage consists of 200 c.c. of 2\ per cent, solution; emetine-bismuth iodide is given every night and yatren lavages in the morning. Treatment is controlled by the sigmoidoscope.
Pain and
Radiology.
By M. J. HUB EN Y, m.d. Amcr. Med. Assoc., Vol. 89, No. 4, (Journ. July, 1927,
p.
271.)
Pain is a most important subjective symptom: its significance and the assistance in its interpretation which can frequently be given by roentgenography are stressed by Dr. Hubeny in a recent issue of the Journal of the
American Medical Association. With modern methods of diagnosis pain, which is a purely subjective phenomenon, can almost be classed as an objective symptom. Often, for example, pressure might elicit pain, or movement might produce it; regardless of the stimulation, the questions of the precise nature of the pain, where and at what times experienced, are important factors, and however subjective the pain might be from the standpoint of the patient, its interpretation always presents to the physician a
problem Pain
as
objective diagnosis. or outstanding symptom is pathologic conditions not always
in
the initial
common
to easy differentiate. The first consideration should be to determine whether the condition is medical and amenable to to
many
whether the pain indicates the surgical condition that may require operative relief. For instance, a number of non-surgical conditions may cause upper abdominal pain, such as simple gastric indigestion, food or ptomain poisoning, or the ingestion of poisonous drugs or substances; or conditions above the diaphragm, such as pleurisy, pneumonia, pulmonary abscess or infarct, thoracic aneurysm, mediastinal inflammation or neoplasms, may produce pain in the upper part of the abdomen. It is therefore quite obvious that a method which can tangibly account for the pain is a valuable adjunct. ?Diseases often present themselves in an atypical and bizarre manner: occasionally a pain syndrome is absent, or the pain is very severe or exaggerated from the standpoint of patient tolerance, or sometimes it is minimized by a hyposensitive individual. There are many diseases in which pain is absent; so many complications and combinations, particularly in adult life, may co-exist- that one must be on the alert to recognize them because of their influence on one another, affecting seriously the prognosis or occasionally prohibiting a serious surgical intervention. It is quite proper to mention just a few of these diseases, namely, pernicious anaemia, early sarcoma, and often carcinoma, in which pain is distinctly absent or mild and the termimedical treatment,
or
onset of some serious
nation fatal. The foregoing remarks will impress one with the vagaries of that most important indicator of disease,
pain.
The importance of referred pain is emphasised and a is quoted in which the real origin of a pain in the hip joint region was revealed only by .r-ray examination of the whole pelvis and femur when a metastatic carcinoma of the shaft of the latter bone was revealed: the patient had previously had a breast amputation for malignant disease. This case, together with others quoted, emphasises the necessity for examination not only of the actual seat of pain but also of structures in the neighbourhood. Fractures present an interesting phase because some serious cases frequently occur with little or no pain. case
[Dec.,
1927.
The author had two cases of what proved to be impacted fractures of the hip in which both patients walked into the office; one used a cane, the other had no assistance whatever, and both protested the needlessness of a roentgen-ray examination. Fractures of the smaller bones occur often with little or no pain and very little disability, and it is legally and therapeutically unsafe not to have a roentgenographic examination. It occasionally happens that a fracture of the lower end of the tibia, particularly a spiral fracture, is accompanied by a compensatory fracture of the upper end of the fibula. The latter is frequently overlooked because the major pain and apparent injury are at or near the ankle joint. It is unwise to examine the skull roentgenologically over the scalp wound area only, because of the well known contrecoup fractures which happen only too often; in spite of the presence or absence of tender points and visible contusions one should always use a four way examination, at least. A common experience of all roentgenologists is the frequent occurrence of pathologic dental conditions without any local pain; this, of course, is diametrically opposite to the experience of a dentist, because ordinarily a patient will consult a dentist for dental aches. Hence it is quite understandable why it has taken a long time to drive home to the dental profession the actuality of dental infections as direct or contributory causes of disease processes elsewhere. By way of an opposite illustration, a thorough roentgenographic examination of an acute fulminating osteomyelitis will be valueless, because a time interval is necessary to produce demonstrable bone changes; in the meantime, the surgeon will be obliged to make a clinical diagnosis and proceed with the necessary medical or surgical intervention, because waiting for roentgen-ray confirmation might be disastrous to the patient. Gastro intestinal .r-ray examinations offer a fruitful field explaining many abdominal aches. The paper is an interesting one and will repay further study.
Atypical
Malaria.
Assoc., Vol. VII, No. 8, August, 1927.) Vitug and Ignacio point out the baffling complexity of the picture presented by malaria in certain cases and quote instances from their own experience in which clinically the illness appeared to be (1) influenza; (2) typhoid; (3) cholecystitis; (4) acute multiple peripheral neuritis; (5) dysentery; (6) cerebrospinal The of encephalitis. presence meningitis; (7) malaria was only discovered after repeated blood examination: in one case the real cause was only dis(Journ. Philippine
Isi. Med.
covered at autopsy. The protean nature of malarial manifestations, like those of syphilis, should ever be borne in mind and should be excluded by repeated hematological examinations before diagnosing the symptom complex, no matter how atypical, as non-malarial.
Malaria Control in Italy. By Professor ARTURO CASTIGLIONI, m.d. (British Med. Joum., 13th Aug., 1927, p. 278.) In a recent number of the British Mcdical Journal Professor Arturo Castiglioni gives an interesting account of the measures adopted by the present Italian Government for the control of malaria in Italy. These may be stated shortly as follows: (1) State distribution of quinine. (2) Classification of the disease as an occupational complaint, and as such carrying a right to indemnity. (3) Gratuitous supplies of quinine and assistance towards sanitation purposes for all workers and settlers inhabiting malarial zones. (4) Foundation of malarial research institutes. (5) Draining of possible anopheles breeding places. The breeding of cattle in malarious regions is regarded as important since researches have shown that certain mosquitoes prefer
REVIEWS.
Dec., 1927.]
species other than the human. Studies in Italy have demonstrated that in places in which rice is grown the development of anopheles is much more marked?a finding- which, if subsequently confirmed, will be of considerable importance to us in India. A sum of nearly four million lire (about Rs. 3i lakhs) per annum is obtained from the State sale of quinine and is subsequently employed in subsidies for antimalarial purposes.
An Alcohol-Bath Thermometer Case. (China Med. Journ., Vol. XIJ, No. 7, July, 1927, p. 660.) The following simple piece of apparatus described and
illustrated in a recent number of The China Medical Journal may prove of interest to our readers. The thermometer case here illustrated is used, and recommended, by Dr. Daniels of Nanking. It is hard to distinguish in appearance from a fountain pen,? pocket-clip and all. It carries the thermometer in a bath of alcohol which does not spill when the case is either closed or opened.
RUBBER RING ROUNO THERMOMETER
The special feature in this device is that the case has inside sheath of metal which contains the thermometer. This is perforated near the bottom to give access to the spirit, but when it is drawn out, the holes lie within the rubber cuff which closes the mouth of the outer case, and are so sealed. Dr. Daniels adds that he finds the case apt to break when dropped on cement, though on one such occasion the thermometer within did not! an
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