Current

Topics.

Epidemics.* Studies in Conditions and Transmission. (Reprinted from the Statesman, Friday, 8th May, 1931.) Sir James Jeans tells us that man has been on the earth for 300,000 years but intelligent man has lived on it for a few thousand years at most. With the growth of his! intelligence and reasoning powers, probably no series of natural phenomena, apart from death itself, has affected man psychologically more than devastating epidemics of fatal diseases. They were the weapons chosen by Jehovah to wear down the hardened heart of Pharaoh. Many plagues are mentioned in the Old Testament. The "Justinian" plague and the " Black Death" are amongst the most vivid pictures we have of Europe of the 6th and 14th centuries. Cholera has circled the earth at various times and spread panic amongst the nations; and epidemics of syphilis, typhus, pneumonia, and influenza have appalled generations of men throughout the ages. The first glimmerings of man's reason were naturally directed to probing the of such disastrous visitacauses tions; they came insidiously, advanced like a conquering army, dealt havoc and death and gradually retreated. The first conceptions of religion must have been based on these mysterious happenings, the mind of primitive man saw in them the hand of retribution, revenge and supernatural power. The downfall of the Greek and Roman Empires has been attributed to epidemics of malaria and plague; and it is probable that a fatalistic outlook upon life among Eastern nations has not resulted from philosophic speculation but from the apparent hopelessness of generations to ward off or combat epidemics of cholera, plague, smallpox and malaria. Three main

factors.

How much more do we know of the

underlying

causes

and factors of epidemics than our superstitious primitive ancestors? Dr. Stallybrass in his Principles of Epidemiology has attempted to answer this question. He points out that there are three main factors concerned, firstly man himself, secondly, the causal agent (the cholera bacillus, the malarial parasite, the unknown cause of small-pox, etc., as the case may be), and thirdly, the means of transmission (close contact, water, food, biting insects, etc.). Each of these main factors may be affected by so many subsidiary causes and conditions, that to investigate, sum up and apportion properly the effect of each, and to arrive at a complete comprehension of the whys and wherefores of epidemic happenings is an exceedingly complex study, and usually Dr. Stallybrass has collected the results a baffling one. of past observation, experiment and opinion and brought them up to date. The result is a book of intense interest, a store-house of information, not the least valuable part of the book being Dr. Stallybrass'e original observations and opinions. The range of subjects is wide, and for the specialist intimate knowledge is required of each, but for the general reader certain broad outlines appear clearly. Hippocrates in 500 B.C. was the first to free medical thought from the deistic conception. "No disease is sent "by devils or demons, but is the result of purely natural causes; and each disease has its own and manifest cause." In the production of disease and _

* The Principles of Epidemiology and the Process of Injection. By C. O. Stallybrass, m.d. (State Medicine), & London: George Routledge Sons, 1931, pp. 696. d.p.h. Illustrated. Price, 30s. net.

468

THE INDIAN MEDICAL GAZETTE.

epidemics he laid great stress on the influence of atmospheric and telluric conditions. Many centuries later Sydenham, in the time of Charles I., propounded similar views, and coined the phrase Epidemic constitution" to define conditions of the weather and the land, and of the population, rendering the latter susceptible to attacks of epidemic disease. "

Mosquitoes and transmission. These " constitutions" recurred at cyclical intervals and were different for each disease. Pasteur's and Koch's discoveries of bacteria as the cause of infectious disease led to concentrated attention on microorganisms; variations in the virulence and activity of these bacteria seemed to offer an explanation of the periodicity of epidemic disease; but this explanation was soon found to break down in very many instances. Manson's discoveries of the transmission of filariasis by " of means focused attention on the ?a mosquito transmission " and showed that conditions favouring this had certainly to be taken into account. Susceptibility and immunity in animals and man also are essential pieces of the problem, and the investigation of these has brought some additional light. The study of immunity, however, is concerned with such intimate matters in the structure of protoplasm and protein and with such delicate and ever-changing activities of cell life and function, that the fundamental truths of the mechanism of-immunity still elude investigation. Experimental studies in animal herds initiated by Professor Toplev have given much suggestive information and are interestingly described in the book. It has been shown that in controlled herds of mice into which diseased mice are introduced, epidemics can only be kept up by the introduction from time to time of fresh susceptible mice. If no new individuals are introduced into the herd, tha epidemic dies out. Applying this practically to human communities, it means for instance that high birth rates and large wide movements of population in a country will encourage epidemic disease. These facts are very true in India and are one of the causes of the high epidemic prevalence in this country. A falling birth rate and a stabilization of population movement by the aggregation of labour in towns will tend to decrease epidemic disease. This has occurred and is still occurring in

England. Epidemiology in India. The important contributions by Lieutenant-Colonels Gill and Russell to the epidemiology of malaria, cholera and small-pox in India are adequately noticed. Gill, as the result of close study of malaria in the Punjab, concludes that favourable or unfavourable combination of variations in the transmitting agent (the mosquito), and in the susceptibility of the population at risk, are the causes of the rise and fall of epidemics generally. would appear to favour the concepStallybrass himself " tion of Peter's Epidemic Potential" which may be " balance between the infectivity of the defined as the causative organisms and the susceptibility of the population." In this it will be observed that the factor of transmission is disregarded as being a much more independent variable," than the other two." Alteration in the epidemic potential is a natural phenomenon occurring without or despite any alteration of the facility of transmission of any disease. An " alteration of epidemic potential" however occurring along with an increased facility of transmission will result in epidemics. The mathematical treatment of epidemics was initiated by Farr in 1840 when he" showed the similarity of the epidemic curve to the normal or Gaussian curve of probability." These conceptions have been extended by Pearson, Ross, Soper, Brownlee, Greenwood, McKendrick and others and a full description of these methods of the analysis of epidemic phenomena is given in the chapter on the " Epidemic Wave."

[Aug.,

1931.

Value of bacteriophage. for the decline of an epidemic are in some respects as puzzling as the reasons for the rise. Here again the author inclines to the view that variations in the " epidemic potential" as defined above determine the decline as well as the rise. Progressive decline in the pathogenic attributes of the parasite and the gradually lessening number of susceptibles have both been assigned values. Lately the dissemination of the bacteriophage by convalescents has been held by d'Herelle and his workers to be the main, if not the only of epidemic cause of the decline and disappearance cholera in India. The truth is there are so many factors that it is difficult, by reasoning alone, to sum up the effects of each and get a resultant. Of what benefit has the study of epidemiology been to man? Immense. It has discovered the particular problems in nearly every disease and pointed the way towards the measures of prevention; it forewarns health authorities of conditions likely to lead to outbreaks of disease; it is a study of intensely interesting aspects of nature and of life. Parasitism, which produces infectious disease, is a fundamental phenomenon pervading biological life; ^ is to be combated by close study and observation, knowledge and practice on the part of individuals and of collective communities. When man has freed himself from harmful parasites, he will have achieved ideals. Man will not be one of nature's biological satisfied with perfect health alone; but having attained it he will be freer and fitter to strive after other ideals in higher and more intellectual realms. The book is profusely illustrated by helpful diagrams; the printing and turn-out are excellent. We recommend it to the serious attention of every worker in public health; and at a time when preventive medicine is assuming such a dominant note in public life, there must be many workers in other fields, official or otherwise, who will find chapters of the book of great help both in their duties and in the study of everyday life. A. D. S. The

reasons

Epilepsy. By DAVID ORR, m.d. (Edin.). (Abstracted from the Prescriber, Vol. XXV, No. 4, April 1931, p. 127.) Epilepsy is not easily defined, nor can a simple clinical and pathological conception be given. The symptoms are far from uniform and not easily recog-

nized in many instances. There are numerous clinical varieties and combinations of phenomena. Some writers would exclude the Jacksonian type on account of the absence of disturbances of consciousness; others again tend to include too much. The important point to recognize is whether the essential fact irx epilepsy is a more or less profound disturbance consciousness, or merely a sensory-motor fact. Should convulsions without disturbance of conscious' ness, and amnesia, be excluded, or are we to include the " tics"? A wider conception of epilepsy would certainly include the latter in which the psychic characters of epilepsy are often very marked. Jacksonian epilepsy cannot be excluded, as frequently it is the precursor of classic epilepsy; that is to say* the beginning of a discharge which passing along the association paths leads to general convulsions. The pathological significance of the nervous discharge or explosion lies not in the partial or general convulsion, but in the functional disharmony and dissociation produced in the various cortical centres. Regarded " tics " appear of the same nature as in this light, the a convulsion?motor-cortical discharges, outside the control of subordination and association. It would do seem as if, in an epileptic, the anatomical structures not provide a ready means of communication between the various functional cortical groups, so that tension

Aug., 1931.]

n?t being discharged to others passes out through S oneeffector systems which are phylogenetically more

short period regained.

Pervious.

The psychic disturbance, always present except in epilepsy, is the epileptic character. This rri rnPjom.a^c be inherent or acquired. may -In the physiopathological sense the basis of epilepsy to be a_ hyperexcitability of the cerebral cortex, T?. differs in individuals, owing to some inherent ondition of the central nervous system. As yet we annot define what exactly this hyperexcitability is; and is interesting to note that it can be present in the sensory zones also. ihe psychic disturbance, which is more usually rigmal than acquired, often shows in childhood in the orm of obstinacy and bad temper. There is frequently ,s0 a history of nocturnal twitchings, distressing and somnambulism. These may disappear, but they persist may develop into an egotism difficult 0 In adolescence

a

criminal type of character

itself, along with lack of adaptation, preponderant individualistic instincts, cruelty, hate, agabondage, evil living, irascibility, and marked endency to impulse. Such individuals are difficult in

chool and may have to be sent away. a later age the epileptic character undergoes Modification. The individual becomes solitary, and voids company. He may be ostentatiously religious, and though his attitude may suggest diffidence and humility there is an underlying irascibility and a cruel Bature. The key-note of the epileptic temperament is the endency to anger and impulse; inhibitory power is developed, and the desires may be violent and 1 .

obstinate.

There are defects in association; thei sense of leriority as compared with others is much in evidence ; on the slightest provocation the epileptic is subject explosions of bad temper of a destructive and brutal ature. Vanity is prominent, and the entire psyche obile and explosive. Intelligence is subnormal, there s defective power of concentration; memory is weak, .ation variable, and along with those defects there exist ideas of grandeur, of persecution, and a high egree of selfishness. Epilepsy and inferiority are ynonymous terms. Epileptic excitement.?In addition to this epileptic ?

j

diverse forms of psychoses may arise. be classified as mania, stupor, sensory may l?s-e delirium, and paranoia. But in the majority of cases "ere is a direct relationship between the convulsion aud the attack of insanity, which may precede, follow, ?r take its place, the latter being termed an equivalent." Considered in relation to the convulsive attack, the psychic disorder may therefore be (1) pre-

Jjrnperament, ,

epileptic, or larval.

(2) post-epileptic,

.The

or

(3) equivalent epileptic

attack consists in an

exaggeration pre-epileptic epileptic character; the patient becomes more querulous, excitable, provocative, violent, impulsive, and threatening. There is great restlessness, ?^aci?us, ith loss of appetite, hostility, broken sleep, terrifying reams, and at times suicidal tendencies. In certain the

ases "een,

hallucinations

and delirium appear, visions

are

insults are hurled at them, voices from Heaven ?ndemn them, and various; commands with a religious ontent are experienced. Olfactory hallucinations, too, re

frequent;

and with all

I

this

psychic disturbance

psychomotor restlessness, impulse, rage, Malignancy, giving rise to false judgments. Erotic ^d??cies are very strong; and whatever may be the

aruf6 ^s.mucl1 ,

sychic

the convulsion follows. -f~ost-epileptic insanity.?After a seizure the patient akes up, and is confused; the gaze is wandering, and oyements are slow, torpid, and automatic. The R P uent seems to be in a dream. The speech is stamering and disconnected; headache is complained of. ?radually the mind clears, people and places are ognized, but there is complete amnesia for the period lrr>e just antecedent to the attack. There is a

rep611

disturbance,

of

irritability before

the

normal

is

In other cases a hallucinatory delirium may supervene accompanied by violence and destructive attacks, or by attempts at suicide. In equivalent or larval epilepsy, the mental disturbance is short and rapid, with profound confusion and

^

correct. ay show

469

CURRENT TOPICS.

amnesia without any antecedent convulsion. Here there has been simply a substitution for the convulsion. Frequently after an attack the patient may be found wandering in some other locality without any knowledge of how he arrived there. This is termed a "fugue." Frequently also automatic acts of an indecent nature are performed quite unconsciously; and occasionally the equivalent may show as an attack of tachycardia, or an obsessive act of violence. Protracted states of confusion are not infrequent (crepuscular). In these the confusion may last for many days or months, followed by convulsions. In such cases the confusion is very profound and judgment erroneous, while illusions and hallucinations develop slowly. Association is slow and false, the delusions are fleeting, or may become paranoid (fixed); there may be grandiose ideas, and delusions of persecution, while stupor and loquacity alternate. There is often a tendency to verbigeration and paraphrasia. Later, the memory for events spread over a prolonged period is much confused, and the return to normal very slow. Such an attack may pass straight on to dementia. Functional disturbances.?Spastic hemiplegia, diplegia, strabismus, homonymous hemianopsia, and alterations in sensation, are to be noted. Speech is usually slow, somewhat explosive, and the tone is heightened. The voice is monotonous. In the post-epileptic phase one often finds word-deafness, word-blindness, and echolalia. On the physical side of the disease one finds rapid and wide changes in the elimination of phosphoric acid, due to functional hyperactivity of tissue chemistry. JEtiology.?In regard to the fetiology of epilepsy very little is known. Heredity is undoubtedly a strong factor and next in importance comes alcohol. The toxic theory is not supported by sufficient evidence, and much the same can be said for any other theory hitherto advanced. It seems probable, however, that epilepsy is due to some alteration in the metabolism, which produces a deviation in normal evolution and irritates the nerve cells. The pathological anatomy is very obscure. Asymmetry of the brain has been observed along with a simplicity of convolution pattern and sulci. Some brains may show old destructive foci, and tumour growths may be present in a small percentage of cases. At post-mortem it is not unusual to find thickened meninges, sclerotic areas in the cortex, or rarely

porencephaly.

Diagnosis.?The diagnosis of the disease depends on (1) the rapid onset of the psychic disturbance; (2) the profound change in consciousness with psychomotor automatism; (3) the early remission of the phenomena with complete or incomplete amnesia of events during the attack; (4) marked somatic anomalies, such as obliquity of the cranium and other malformations of the head; (5) the presence of residua of old cerebral disease, for example, infantile spastic hemiplegia, or

strabismus.

Prognosis and treatment.?The prognosis should be to treatment one must still very reserved. In regard rely upon the bromides. The dose of these must be adjusted to each case as regards age and body-weight.

The best effects are obtained when all chlorides are omitted from the diet, and it is found that when this is done bromides act far better and less are required. is much lessened. Not only so, but tendency to bromism " The bromide can be used as a dry table salt," instead of sodium chloride, with meat, eggs, etc., and it is perhaps best to use sodium bromide. Medinal and luminal have in recent years been much used and deservedly so. The effects are quite good, and if luminal is used the drug will dissolve readily in water

470

THE INDIAN MEDICAL GAZETTE.

when a pinch of sodium bicarbonate is given along with it. The old-fashioned seton in the neck is worthy of a trial in some cases of an obstinate nature, and in all cases sources of reflex irritation should be sought for and if possible removed. Everything should be done to lighten the burden of this terrible affliction both to the sufferer and to his friends.

Serum Treatment of Pneumonia.

obstacles in the way, chief of which is the fact that the pneumococcus has many types and these types show seasonal variations in virulence. The first sera prepared were so low in antibodies that very large amounts were necessary to be effective. Therefore the reactions were so frequent and sometimes so severe that most clinicians abandoned use of the sera. From time to time progress in the development of such a pneumonia treatment has been reported in these columns, and now it is interesting to note that recent contributions indicate substantial advance in the study. No name has been more consistently associated with this progress than that of Dr. Russell L. Cecil, whose reports we have now and then reviewed. His most recent conclusions formulated from a study made in association with Dr. Plummer, seem to justify the confidence in the possibilities of the serum treatment of pneumonia which we expressed two years ago. Huntoon made the first effort to overcome the lack of concentration objected to in the former sera when he produced a solution of antipneumococcal immune bodies obtained from types I, II and III. This solution was almost entirely free from horse serum. But after two years' use by Cecil and other clinicians it was found to be no more concentrated than the earlier sera. About this time Felton and Dougherty demonstrated the possibility of increasing or decreasing the virulence of pneumococci for mice by an in vitro method. From information elicited in these studies Felton endeavoured to isolate the substance so antagonistic to virulence, and as a result of his experiments it was determined that this protective substance was at least associated with, if not wholly in, the water-insoluble part of the serum, namely, the globulin. A protective power was then found in globulins prepared by the carbon dioxide method, but the yield, as was the case in Huntoon's experience, was never more than half as great as the original serum from which it had been precipitated. Then, while making these studies with carbon dioxide as a precipitant, Felton noticed that a very heavy precipitate was formed in antipneumococcus serum when simply diluted 1 : 10 in water, and that it was much greater than that precipitated by the carbon dioxide method. In this way he was able to isolate and concentrate a substance in larger quantity which phagocytized virulent pneumococci in vivo and in vitro. He was also successful in decreasing the virulence of pneumococci with solutions of this substance. In further tests to determine whether the substance was bactericidal in whole blood there was_ found a marked retardation in growth in all specimens, and bactericidal action in some. Cecil, one of the first to use this serum, has made a consistent study of it since his first report seven years ago. He has collected a series of 3,662 cases of pneumococcus pneumonia in adults and 271 cases in children. At the outset of the work Cecil tested the therapeutic value of Felton's serum on monkeys experimentally infected with pneumococcus type I pneumonia. Four monkeys were given lethal doses of pneumococcus type I intratracheally, and all four animals promptly

1931.

developed pneumonia and pneumococcus bacterisemia. Twenty-four hours after infection, three of the monkeys each received several intravenous injections (from 5 to 10 c.c.) of concentrated serum. These three monkeys showed almost immediate signs of improvement, and pneumococci disappeared from the blood stream. The fourth monkey did not receive any serum and died on the third day with a heavy pneumococcal septicemia. In his investigations with Felton's serum Cecil used the alternate

(Abstracted from the International Medical Digest, Vol. XVIII, February 1931, No. 2, p. 122.) One of the most interesting and most perplexing studies attracting the attention of investigators in recent years is the finding of an effective serum for the treatment of pneumonia. There have been many

[Aug.,

case

method:

Every patient diagnosed as having lobar pneumonia was given a number. The patients with even numbers received the serum; those with odd numbers served as controls. After a preliminary test for sensitiveness to horse serum, 5 c.c. of concentrated serum were slowly injected intravenously. From one to two hours later, between 10 and 20 c.c. were given intravenously, the dosage depending upon the potency of the lot and the severity of the case. In general, Cecil tried to administer from 100,000 to 200,000 units (from 40 to 100 c.c.) during the first 24 hours of treatment. It is his present conviction that in most cases serum treatment should be completed in 48 hours; that is, if results

to be obtained within that time. Cecil says there is no more striking clinical effect in the whole domain of specific therapy than that which frequently follows the early administration of Felton's serum in type I pneumonia. The temperature drops rapidly, very much as in a natural crisis, and all signs of toxtemia frequently disappear within 24 hours after the initiation of treatment. The effect of concentrated serum on pneumococcal septicaemia is quite as marked as that of unconcentrated serum. Unless the sepsis is extreme (several hundred colonies to 1 c.c. of blood), pneumococci disappear from the blood stream after one or two injections of serum. The effect of concentrated serum on the mortality rate of type I pneumonia is indicated by the following results: Altogether, 239 cases of type I pneumonia have been treated with Felton's concentrated serum, with a death rate of 20.1 per cent.; 234 alternate controls show a death rate of 31.2 per cent. It is noteworthy that in the 4-year period the death rate of the treated cases has varied from 17.7 to 22.9 per cent., and for the controls from 26.3 to 39.4 per cent. The favourable results obtained at the Bellevue Hospital with Felton's serum by Cecil and his associates have been fully corroborated by figures reported for the Harlem Hospital in New York by Parke, Bullowa and Rosenbluth. One hundred and nine cases of type I pneumonia treated with Felton's serum showed a death rate of 17 per cent., while 105 controls had a rate of are

31 per cent.

It is interesting to note that to some extent these experiences have been supported by papers from Scotland which have appeared recently in the Lancet. Both of these papers indicate that the serum was given to every second case of lobar pneumonia admitted over a period of 10 weeks; the cases so treated were with the alternate controls, as Cecil has done. The Scotch physicians believe that their results show the serum to have a definitely remedial effect in both types I and II. Apart from the lower mortality, it was noticed

that half the serum cases had their crisis on or before the fifth day, and certain cases seemed to be more comfortable for their treatment although their illness One of these papers came from the was not shortened. Royal Infirmary in Glasgow and the other from the Royal Infirmary in Edinburgh. At Glasgow the serurn was given to 58 consecutive cases of lobar pneumonia immediately after admission and before they had been typed. These cases were compared with a control series from previous years who, but for serum, had been treated in just the same way; the age incidence in the two groups corresponded very closely. It was again found that the mortality in the serum-treated group was appreciably less in both male and female patients. In both the Edinburgh and Glasgow series there were anaphylactic reactions in several patients despite preliminary tests to detect supersensitiveness.

With the foregoing contributions we have further Progress in the search for an adequate serum treatment ?f pneumonia. Apparently enough evidence has been submitted to indicate that Felton's antibody solution ls a remedy decidedly effective in type I and type II Pneumococcus pneumonia. It still seems to be more effective in type I, but the more recent contributions appear to establish its value in type II more than even Cecil believed possible two years ago. It is Jnteresting to be able to compare figures from two such "widely separated sections of the world. We believe that the foregoing discussion indicates that there should be no relaxation in the effort to obtain sera which will be even more reliable than any

existing

to-day.

Bacillus coli Infections. By K. D. WILKINSON,

(Abstracted from Journal, October Every

Avell

471

CURRENT TOPICS.

Aug., 1931.]

mistaken diagnosis of appendicitis or abdominal tuberculosis. Indeed, there is scarcely any mistake which cannot be made in regard to these children. Many of the chronic cases show surprisingly little constitutional disturbance. The patients are perhaps restless, imperfectly nourished children, who tend to be nervous; but they are brought up for consultation on account of symptoms apparently wholly unconnected with the urinary tract, so that as a rule it is only during the search for the cause of their troubles that the infection is discovered. Fever may be absent or very slight in such children, and apart from the general lassitude and malaise, with anorexia and some pallor, there are The subacute cases generally no definite symptoms. occur among children who show periodic exacerbations of a latent infection, recurrent upsets which may appear with attacks of vomiting simulating cyclical vomiting, or periodic bouts of fever, the cause of which remains obscure until pus and B. coli are found in the urine.

m.d., f.r.c.p.

Treatment.

the

Canadian Medical Association 1930, Vol. XXIII, No. 4, p. 499.)

clinician who works with children must be

acquainted with Bacillus coli infections of the

Urinary tract because especially during the

the condition is a common one, earlier years; but as pyelitis can ?nlv be diagnosed with certainty by an examination of the urine it is difficult to form any estimate of the exact frequency of such infections. The symptoms are often misleading, so that the urine is not examined, and in less severe cases the diagnosis must be missed *nany times for each occasion on which it is correctly

Blade. The typical urine is pale and opalescent, the appearance being unaltered by the addition of acid or alkali; there is at least a trace of albumin present, and under

the microscope pus and B. coli are seen. But there ^ay be no such gross bacilluria as to produce and the quantity of pus may not be great, ?Palescence, 80 that to naked-eye examination the urine appears formal. In such cases a correct diagnosis can only be rnade by a careful microscopic examination. It is hardly necessary to add that a culture of a fresh specimen of urine is always advisable. Clinical aspect.

This infection may occur as early as the first week of hfe; indeed some cases have recently been labelled congenital. It becomes more common at a later date, and only begins to diminish in frequency after about the eighth year. Symptoms. Cases may be classified as acute, subacute, or chronic. The acute case often commences with a rigor, or convulsions, and high fever, and general disturbance which mav be so severe as to suggest meningitis or Pneumonia; the child is obviously ill. Sometimes omiting or gastro-intestinal disturbance is a marked ^'eature. In slightly less abrupt cases headache, backache, and general illness may suggest a typhoid or some similar infection. These acute symptoms are

relatively common in the younger children and make the diagnosis particularly difficult and uncertain until "the urine has been examined. In older children the symptoms of pyelitis tend to be puzzling, and constitutional disturbance is generally severe. An abrupt onset is still common, but in the majority of these cases there is some local symptom, such as tenderness in the loin, frequency of micturition, ?r some discomfort in passing urine to point to the correct, diagnosis. Still, many cases are obscure at the onset, and, where vomiting is a feature, the child may Present the picture of a profound acidosis when first seen. At times an increased respiration-rate may suggest pneumonia. Malnutrition and ansemia may ?et in rapidly, and occasionally jaundice complicates the diagnosis. Malaise, rather vague aches and pains, and moderate fever may suggest rheumatism, or abdominal discomfort and tenderness may lead to a

jess Jess

^

The general rule is that patients having acute symptoms do well at all ages under strict treatment, but a certain number of those affected either fail to respond at all or only respond moderately well and gradually fall into the subacute or chronic groups. In the less acute groups the cure is much more difficult, and treatment has to be more prolonged. In some instances the most painstaking treatment seems to be utterly unavailing, and nothing has the slightest effect upon the urine, for the bacilluria persists unchanged in spite of every form of therapy. Some cases show evidence of renal damage, such as the presence of casts in the urinary deposit, a raised blood urea, or a poor urea concentration test. In such cases the prognosis is not at all good, for sooner or later they develop signs of renal inadequacy or cardio-vascular damage. There seem to be three important requisites in the successful treatment of all cases. Needless to say the earlier the diagnosis is made, and correct treatment commenced, the better the outlook. The first requisite is rest in bed until the condition of the urine is normal. Children generally relapse if allowed to get up and run about before bacilli are completely abolished from the urine. They may relapse after the urine has become normal, but are certainly less likely to do so if kept at rest until the urine is free from bacteria. The second requisite is alkali; this should be given in plentiful doses as sodium bicarbonate or potassium citrate. These drugs are not palatable, and should be made at least tolerable by the addition of syrup and The bicarbonate may also be some flavouring agent. added to drinks, and the citrate given in moderate quantity in home-made lemonade is not objectionable. No degree of alkalinization can completely inhibit the growth of B. coli in the urine, since the organism will grow in a more alkaline urine than the kidney can excrete. Wright states that B. coli grow in urine of pH 9.0 and the most alkaline urine the kidney can excrete has a pH of 8.6. For some years I have been in the habit of maintaining a constantly varying pH of the urine by alternating alkaline and acid medication. The alkalies are given in as large doses as the child will tolerate until the urine is definitely alkaline; then a mixture containing hexamine and acid sodium phosphate is used until the urine becomes acid, at which point alkalies are again exhibited. This treatment has the advantage not only of discouraging the colon bacillus, but also of diminishing other urinary organisms. I do not place any great faith in hexamine, but prolonged usage has given it some reputation and it seldom does harm. The third point in treatment is the flushing of the kidney by a large fluid intake. Fortunately most of the small patients are eager to drink, and this readiness should be used to give as large a quantity of fluid as possible; even a small child should take fifty to sixty ounces of fluid a day, and Various urinary antimore can sometimes be given. _

septics

are

resorcinol

recommended; hexamine, salol, or hexylthose most commonly taken by the

are

472

THE INDIAN MEDICAL GAZETTE.

month, while the usual lengthy list of antiseptics may tried locally. Good results seldom follow such measures. Vaccines occasionally seem to be useful but far more often prove disappointing. be

The

chronic

case

and

the

recurrent

case

present

special difficulties in treatment, and it is still an open question how far one ought to go in attempting to

eradicate the infection. 20 per cent, of children with chronic pyuria show some abnormality of the urinary tract. The most common deviations from the normal are dilatation of the ureter or kidney pelvis, and kinking or doubling of the ureter on one or both sides. It is_ suggested that these abnormalities have a special relationship to urinary infection, such that the abnormality either predisposes the tract to infection, or that a fortuitous infection persists because of the abnormality. In 153 consecutive post-mortem examinations of children in which particular attention was paid to the urinary tract, no less than 13 per cent, of abnormalities were found. Curiously enough the commonest abnormality was ureteral narrowing or obstruction, which occurred in 11 cases. In this series of 20 cases only 4 patients died as a result of urinary tract infection, and as the eldest of these was only 6 weeks old congenital abnormalities can hardly be said to have played a large part in predisposing to urinary infection in this series. On the other hand, there is no definite evidence here for or against the suggestion that abnormalities favour the persistence of acquired infections. In the present state of our knowledge, then, it is essential that every effort should be made to discover any abnormality of the urinary tract in any case of chronic or subacute pyelitis, in order that it may be corrected if possible or the prognosis modified accordingly. A child with recurring attacks of pyuria who has a double dilated ureter and kidney pelvis can only be regarded as most seriously ill. On the other hand, a single hydronephrosis with a double ureter, provided that the sound kidney is functioning normally, can be treated surgically with reasonably good hope of a definite cure. It is therefore advisable to have a cystogram taken in all chronic cases, and to make a cystoscopic examination in such as are unsatisfactory or doubtful as well as in the definitely abnormal. Pyuria is often associated with bowel infections and occasionally with a chronically inflamed appendix. These conditions should receive appropriate treatment. Conclusions. As a clinician I am familiar with a B. coli infection of the urine, a condition which is frequent in children, acute, commoner in girls than in boys, appearing in chronic, and recurrent forms, but which is relatively called been pyelitis, seldom fatal. This condition has and although I am not in a position to prove that it it is that is always a pyelitis, I feel that I can prove not always part of a septicemia or evidence of a

nephritis. a

It seems that the pathologist has experience only of selected group of patients out of the many who have

B. coli infections of the urinary tract?the more severe cases which are septictemias, and in which the colon bacillus is seldom if ever the primary infecting organism. It is hardly likely that a severe septicaimic condition in children, with renal infection and possibly abscess formation, could have a mortality as low as 3 per cent, after the age of 2, and it is significant that the collection of 78 post-mortem records took no less than twelve years at two large children's hospitals, whereas clinically B. coli infections are common.

Nocturnal Incontinence in Children. Bv J. PEREIRA GRAY.

(Abstracted from the British Medical Journal, 29th November, 1930, p. 906.) is

The treatment of nocturnal incontinence in children eminently unsatisfactory. The distress of mind

[Aug.,

1931.

caused to parent and also to child as soon as it is old to realize its disability calls for the publication of any method of relief which has proved successful in several cases. The time-honoured method of getting the child to' empty its bladder on going to bed and of awakening it in an hour or two to pass water, of withholding all drinks after 5 or 6 p.m., and of fixing reels to the child's back to prevent it lying supine, have in my hands proved unsuccessful. I have administered tincture of belladonna up to 30 minims three times a day on the advice of textbooks I have consulted; I have removed tonsils and adenoids and given thyroid; I have tried strychnine and arsenic. With these methods I have had no success whatever. I have elicited the fact that children who wet the bed at night have also very irritable bladders by day. At home they are constantly running to the lavatory; at school they are constantly asking permission to leave the room. The obvious prophylaxis, then, is to bring the bladder under control. I have therefore insisted on parents training their children to empty their bladders at fixed hours. The child is not permitted, at first, to pass water for two' hours, then for three hours, then for four, and so on. When the child can hold its water for four or five hours, the nocturnal incontinence disappears. The bladder becomes trained, just as the rectum can be trained to function properly.

enough