Some deductions from the Statistics on the Prevention of Pulmonary Tuberculosis.


D. H. C. Given, m.d., d.p.h.,

Surgeon Commander, R. N. The; author here compares the statistics of the four principal zymotic diseases (measles, scarlet fever, whooping-cough, diphtheria) with that of

tuberculosis and shows that all these diseases have declined together and that whatever the causes may be of. these diseases, the same causes are common to the whole group. Pulis only one of the tuberculosis monary air-borne group of diseases. The common cold is regarded author as the by the most important connecting links between all respiratory infection; it is the means of (1) disseminating air-borne disease, and (2) of preparing the soil for further invasions or for the condition of carrier. Consequently the author is convinced that the campaign against consumption must be directed against the air-borne diseases as a whole, and against the common cold in particular. The effects of other respiratory infections, including the common cold and zymotic diseases, in early life is to prepare the soil for the later invasions of the tubercle bacillus when otherwise resistance should be high. The remedy for all these diseases is a matter of improved housing and education in ventilation and general hygiene, yet at the same time much could be done meanwhile by the more thorough recognition and treatment of the common cold and its sequelae.?The British Medical Journal, "April 16, 1921.


Involvement of the Orbit in Disease of the Nasal Accessory Sinuses.

By Robkrt E. Wright, m.b., Major, i.m.s., Acting Superintendent, Government Ophthalmic



In this paper Major Wright gives notes of six cases. These notes show the importance of the accessory sinus affections in orbital cellulitis. In fact the disease is primarily clue to inflammation of the frontal and other

adjacent sinuses; when severe it causes necrosis and perforation of the sinus wall and the orbital plate, and an extension of the inflammation to the cellular tissues round the eye-ball and of the eyelids. The usual complaint is swelling of an eyelid, a persistent headache,

and a foul nasal discharge. These symptoms may be chronic or acute. In some there is a history of syphilis; more than 50 per cent, of cases occur in children. In such the nose should be carefully examined by inspection, transillumination, and a good X-ray phoThe syphilitic cases, tograph should also be obtained. of course, yield to anti-syphilitic treatment. In others the treatment consists in the removal of all dead and carious bone, together with the destruction of all fungating granulations in the nose, drainage of the frontal sinuses by the intra-nasal route and other accessory external route. The orbital or by both intra-nasal and cellulitis clears up remarkably, but it should be remembered, Major Wright points out, that a certain number



of cases comes back with optic neuritis.?The British Medical Journal, April 16, 1921.

Oil in the Treatment of Tuberculosis.


(Journal of Lab. and Clin. Med., Vol. VI, May, 1921, page 415.) The objects of this experiment (carried out by Culpepper and Ableson) are:? 1. To demonstrate the most active, soluble and least irritating fraction of chaulmoogra oil,

which has been used extensively in the treatment of leprosy and has been shown bv Walker and Sweenie to be destructive of acid fast bacilli in Aritro. / 2. To find out the most effective means of administration. 3. To find out the pathological effect, if any, produced by large doses. 4. To determine whether its use will inhibit or arrest the development of artificially induced tuberculosis in guinea pigs. The 1 per cent, solution of the soluble acid sodium salt of the fatty acids were found to be most active, most soluble, and least irritating when injected into the peritoneal cavity from which it was found to be absorbed within 24 hours even when given in large doses. Of two sets of 12 guinea-pigs infected with tuberculosis, the first set were treated with the sodium salts of the fatty acids and the other set were not treated. The untreated animals all died but one. The treated animals were killed one on each A day on which one of the untreated died. standard of pathological appearances was made and the treated scored 13.33 while the untreated scored 20; the maximum possible being 24. The untreated lost considerably more weight than the treated.

Schistosomiasis, (I) Discussing the possibility of Schistosomiasis being introduced into India by troops returning from overseas, and of this disease being endemic in this country:?Major R. B. Seymour Sewell, i.M.S., gives the following as a summary of the parasitological results of his investigations:? 1. Attempt to infect examples of the more commolluscs of the Calcutta area with miracidia of Schistosoma hccmatobium have given negative results. 2. The peninsula of India has a very large indigenous Trematode population and is particularly rich in those forms whose cercaria: belong to the forked-tailed mon

group. A 3.

cercaria, apparently morphologically identical with that of Schistosoma japonicum has been discovered and appears to be widely distributed: -it is certainly indigenous, and all our evidence tends to show that it is connected with human activity. 4. Full descriptions of most other schistosome cercari?e arc still unavailable and are urgently required.? The Indian Journal of Medical Research, July, 1920. countries apparently are certain from schistosomiasis? exempt The most extensive of these apparently immune countries is the geographical entity known as India.

(II) Why

India embraces a very wide range of climate and is inhabited by many races of man. The climate in many



parts is favourable to the existence of schistosomes, and the mode of life and habits of vast numbers of the

population arc such as should favour the propagation of parasites with such a life-cycle as the schistosomes. In order that a digenetic trenjatode parasite may flourish in a given locality, six things would appear to be necessary:? (1) The introduction of the parasite. (2) A climate and general conditions suitable to the well-being of the parasite in all its stages of develop-


(3) A suitable intermediary host. (4) A suitable definitive host. (5) Conditions of existence of these hosts, enabling the parasite, as miracidium and as cercaria, to gain ready access to them. (6) The absence of any peculiar local conditions impeaching the development of the parasite in any of its stages. As to No. 1, it is known that two, at any rate, out of the three species of human schistosomes have been introduced into India on numberless occasions, and at the present moment there is a colony of returned Imperial Service troops at Bolarum, in the Hyderabad State, known to be carriers of S. hamatobium, with, probably, some carriers of S. mansoni also among them. (2) The climate of tropical and. semi-tropical India is well suited to the existence of schistosomes, as is evidenced by the existence in the country of several species of the parasites among the animals. (3) Whilst the genus Bullinus, the host of S. haematobium is said not to occur in India,1 the genus Planorbis, the carrier of S. mansoni, is common through? out the country. (4) and (5) The definitive host of the human schistosomes lives in India under ideal conditions for infection by the parasite. (6) By inference there should be some peculiar local cause preventing the development of the recognized species in the country. That neither S. mansoni nor S. japonicum does exist in India must be taken for eranted. The symptoms of the disease caused by the first are so striking that it is not possible that the disease could exist and fail to be identified. The symptoms due to S. mansoni and S. japonicum_ are much less obvious, but considering the number of highly qualified observers working in the country, it is impossible to believe that the disease, if present, could have escaped identification. Considering the immense area of the country and the great number of races of men living there, and taking into account that these various peoples live under all sorts of conditions, some possibly unfavourable to the propagation of the- parasite, but many more under peculiarly favourable conditions, it cannot be imagined that there is any generally acting cause inimical to the parasite either in the country itself or in its inhabitants. Even supposing there were something in the conditions of life in India inimical to the existence of the human schistosomes, why should these be absent also other extensive that from geographical unit, the Southern States of the North American Union? Here, whilst the conditions of life and the races of men are widely different from those present in India, and although the climate, etc., is favourable, the recognized species of the human parasite are equally unknown. Schistosome cercari.-e, fulfilling the conditions laid down by Leiper as necessary to the members of the bilharzia group of schistosomes, do exist in America, and have been identified as far north as 42 degrees, but none of the cercarije recognized are identical with either S. haematobium, mansoni, or japonicum, and are none of them recognized as being parasitic in man. In India also schistosome cercaria;, fulfilling the conditions of the bilharzia group, have been identified by both vSewell and Annandale, and the former has described a cercaria under the tentative name of C. indiccc XXX, which he declares to be exactly similar, if not identical, with the cercaria of S. japonicum. 1 Bullinus was officially declared not to exist in Palestine, and bilharziasis to be absent from that country ; but Searle has shown that this is erroneous.


1921. J'


The only solution of the difficulty appears to me to lie in the theory of pre-occupation of these countries by sonic other, as yet unidentified, human schistosomes, the existence of which is inimical to the existence of the other recognized forms.?Frank Milton from the Journal of Tropical Medicine and Hygiene, Jan. 15, 1921.

A Study of Kala-Azar. Being an interim report of the kala-azar work from 1917 to 1919 at the King Edward VII Memorial Pasteur Institute, Shillong, by Major R. Knowles, i.m.s. :?The following Summary gives the chief features of interest and is quoted in extenso. 1. In the clinical diagnosis of kala-azar, and especially differentiating it from chronic malaria, the following points are of importance. In kala-azar the patient usually comes from an area known to he infected; there may be a history of consecutive deaths from low fever in the family or household; the patient is usually much emaciated. Other symptoms to be

looked for in


kala-azar case are, a


of attacks of

dysentery; pigmentation of the skin of the forehead and nose; a weak intermittent and rapid pulse; oedema of feet, ankles and face; the simultaneous presence of albumin and urobilin in the urine; epistaxis; ascites; enlargement of the liver as well as of the spleen; cancrum oris and other septic complications. 2. The blood picture of the disease is one of progressive and usually severe anaemia. The characteristic leucocyte picture is a total leucocyte count of less than 4,000 per with polymorph, percentage of less than 50 per cent, and a large hyaline mononuclear count of 20 per cent, or upwards. The simultaneous

presence of all three is evidence in favour of kala-azar rather than of malaria. Leucocytosis may occur in kala-azar in the presence of complications, .and a case with a. total leucocyte count of 74,500 per deserves to be recorded. 3. The treatment at Shillong is by intravenous injections of one per cent, solution of tartar emetic in normal saline, commencing with a dose of 4 to 5 c c. for an adult and rising to 10 to 12 c.c. After 100 cgms. have been given it is difficult to find parasites in the

spleen puncture films; at 200 cgms. the patient is cured, subsidiary treatment, tonics, and the clearing of any helminthic infections present are essential. Points of good prognosis in the course of treatment are subsidence of fever, gain in weight, and improvement of the blood picture. Points of bad prognosis are dysentery, nephritis, and especially the onset of marked cardiac irregularity and weakness. Cure is usually accompanied by a high total leucocyte count, a restoration of the polymorph, percentage to nearly normal, and an excessive production of C. G. eosinophils and large hyaline mononuclears. 4. Of 86 patients treated at Shillong in 2-i years, 46 were discharged cured; the test of cure being, whereever possible (31 cases), spleen puncture with negative findings in film and N. N. N. cultures. Twelve patients remain under treatment, 11 of them with good prognosis. Twenty-two deaths occurred, but of these six were from influenzal pneumonia, and included two cases where the primary condition of kala-azar seemed to have been cured.

forward for consideration is 5. The' point put whether treatment of patients, throughout the infected areas, on a large scale, in temporary hospitals, by men specially trained in the necessary technique, may not assist in the eradication of kala-azar in the Province. (B). A study of the peripheral blood in kala-azar:? 1. The Leishman Donovan body has been found in 45 per cent, of the Shillong cases in the peripheral blood. It is probable that it is present,?as a rule in very scanty numbers only,?die peripheral blood of all or of a majority of cases of kala-azar. 2. The presence of the L. D. body in the peripheral There blood, however, seems to be purely fortuitous.



is evidence that the parasite is more abundant in the blood at night; its appearance is not cyclical or remittent; and whilst the parasite is more frequently found at times of fever, dysentery and in the terminal phase of severe cases, such cases may still shew negative findings. 3. Any agency which leads to either leucocytosis or to increased activity of the suprarenal glands will also lead to an increase of the number of parasites in the peripheral circulation. Where myelocytes are present, and during the phase of bone marrow involvement in the disease, an occasional case may shew an overwhelming infection in the peripheral blood, c.

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