? Tur ?

April, 1937]

-^ssstssL.

Original Articles tuberculosis

/

in infants and

CHILDREN %

f.nj. (Paris), (From the Tuberculosis Inquiry, I. R. F? A., All-India Institute of Hygiene and the Chest Department, Medical College Hospitals, Calcutta) .

A. c.

UKIL,

RENTED to

UKIL

INFANTS AND CHILDREN.

IN

TUBERCULOSIS

.

M.B., M.S.P.E.

Very little is known regarding tuberculous and disease in infancy and c u

infection

193

It is known that 15 per cent of the total deaths from tuberculosis in most European countries account for the initial peak of mortality from tuberculosis which has not yet been recorded in any municipal or non-municipal area in India. From the already increasingly high incidence and mortality rate from tuberculosis, especially in the urban and industrial areas, of this country and from the sanitary condition and hygienic habits of the people, one would expect a high mortality from tuberculosis in the earlier years. It has been previously noted by us that familial contagion is very frequent in India, a history

if?-

?>v\ '?

/ /

,

Fig. 1.?Mortality

curve

?--6

*? \ -

FEMALES

\\

MALES

x>O

?AGE

O

f?"Af?S'

of tuberculosis in Calcutta.

.

. ?

60

50

25

20

15

jo

5

I

M

5

10 |5

II

I

I

1

I

I

I

i5 35 45 55 65 7* 75 83

,9'2-^

\ 1912-w

1923

I

1

I

0

5

'0

II U

ZD

I Z5

I

I

I

I

I

I

3b 45 SS S5 75 %S

in England and Wales Wales Fig. 2.?Total tuberculosis death rates at age periods (1912-14 and 1923).

?^la-

nj2

Tuberculosis

is now

mos^ imPortant and mortality in oniv next to that of malaria

,r?orh"^S^ 1

?

already

major India,

recog-

cause

of

probably (Russell, 1935).

of contact having been obtained in 40.2 per cent of z-ray-diagnosed cases (Ukil, 1933). We do not yet know very well what fraction of the notoriously high infantile mortality in India-is

THE INDIAN MEDICAL GAZETTE

194 due to culous homes.

really In

tuberculosis, especially

in tuber-

sources

of

in

contagion

graphically

1937

[April, our

series

shown

are

below:?

to find out the position, idea from tuberculin surveys tuberculin sensitiveness in contact among infants and children among the average NON-CONTACT CASE S. Percent in tuberculous and non-tuberculous population, 100% from evidence and from homes, autopsy hospital Let us now see what evidence we can 90% cases. adduce from each. 80/. 702 contact cases Tuberculin survey among 1,656 apparently 6 or. non-contact cases normal children in rural, semi-rural and 50jt urban areas 4 OX we

investigation

an

can

get

an

&

3# Total number of Percentage of cases tested positive reaction

Age

20% 10* ~

0-5 years 5-10 ? 10-15 ?

..

236

..

813

..

507

11.4 30.1 33.3

These rates by the von Pirquet test are unlower than in highly industrialized and urbanized Western countries, but this probably represents the correct Indian position. The average tuberculin incidence at all ages obtained by us in an earlier investigation (Ukil, 1928) was found to be 45.9 per cent and the evidence obtained from the bodies of persons dying of accidents or murder autopsied at the Calcutta police morgue has been found to be 47.8 per cent. When we analyse the autopsy evidence among only 23 children between 0-15 years, the figures are found to be slightly higher, as will appear from the table below:?

doubtedly

Number of Evidence of

Age

cases

examined

i

tuberculosis, per cent

Tubercle bacilli demonstrated by culture, animal inoculation and

years

5-15

15

33.3

S

37.5

icf

~b

0

cent

20.0 37.5

incidence, however, changes quickly in presence of a source of infection in the home, those having an intimate and recent contact showing a higher incidence than those having distant and remote contact (Ukil, 1930). In one of our recent studies (unpublished)

3. 3.

HISTOGRAM ILLUSTRATING THE SOURCES OF

IN"CONTACT'\CHILDREN

INFECTION

5

15

Fig. 5. in general 111 this country, it is unthinkable that tuberculous disease, in its various forms, does not contribute substantially to the total mortality figures in infancy and childhood.

0/.

Years

>-*

Z

10

5

Fig. Fig.

6.6.

Early recognition

From the evidence adduced above, it will appear that the need for the early recognition of tuberculosis in infancy and childhood has

I*

,

April, 1937]

TUBERCULOSIS IN INFANTS AND CHILDREN: UKIL

from sufficient attention yet attracted health medical practitioners or from public workers. No doubt the infection and mortality in

not

than higher in home contacts' is particulaily n?n-contacts. The mortality much

are

much

'

in the first year of life and very as lower afterwards. This is easily understood, the infant lives strictly within the house and a lias therefore more chances of contact with who child older an source of infection than spends more time out of doors. The ultimate the do>e Prognosis of a case depends not only on and intimacy of contact, but also on the age ?f the child and the continuance or stoppage of contact. Asserson (1927) observed that 15 per cent of those infected under 12 months and 2.6 two per cent of those infected between one to disease. years of age died of tuberculous "ibadeau-Dumas (1925) gives the mortality after infection in the first three months as 92 Per cent, in the first year as 50 per cent and in he second year as 10 per cent.

high

a

\he three- to seven-year period represents Period of temporary calm, troubled only by occasional cases of meningitis or bone tubercuosis. This temporary calm is followed by the ' adult

candidates' for the of the ype of tuberculosis. The difficulties of a timely diagnosis are of ^creased by the fact that the symptoms

Preparation

As a correct interpretation of the Mantoux test and clinical findings is necessary for a correct and uniform diagnosis, we think it will not be out of place to give here a few points about them. The main points of difference between the childhood and adult type of tuberculosis may be summarized as follows:? Childhood type 1.

as a

The

rule, relatively manifestations with advanced

,llay be entirely absent in cases and active lesions. Tuberculous disease in mfancv and childhood occurs mostly in those raised in a tuberculous environment, i.e., where either a near relative or a nurse or an attendant tuberculosis, uis been or is a case of 1 open rowded living conditions, poverty and defective

Adxdt type

in occurs Usually children, much less frequently in adults.

It

is

the

result

1.

of

primary infection. May be localized in part of the lung.

2.

Associated tracheobronchial lymph nodes are

always

involved,

not but may demonstrable.

?3.

4.

be

Caseous lesions usually calcified or become encapsulated in fibrous tissue. Occasionally a lesion progresses to excavation. Infiltrated areas com-

2.

or

no

4.

Infiltrated areas may recede with the production of more or less fibrous tissue.

5.

Prognosis in children is

scars,

except for the foci which of caseation, usually become calci-

5.

fied. The prognosis is good.

apical.

Tracheo-bronchial lymph nodes not grossly involved by the reinfection except sometimes in the terminal stage. 3. Caseous lesions usually followed by excavation or fibrosis or both.

monly resolve, leaving trivial

Usually occurs in adults,

but may be found in children. Result of a continued infection or a reinfection. Localization is usually in the upper part of the lung. The first clinical manifestation is usually sub-

a

.

childhood tuberculosis are, ew in the average patient.

197

poor.

The first important point to note about a patient is whether there is a history of exposure. Next, we are to ask about the local and constitutional symptoms, which are less definite and less severe than in adults. In infants between 6 months to 2 years, the sanitary habits and customs increase the chances should be looked for :? India. following in disease exposure and 1 the in (1) Unexplained anorexia and loss of weight The problem of the open' adult case or suspension of growth. house is, therefore, of paramount importance Fever. A persistent fever even after half childhood of (2) case a only in diagnosing from an hour's rest in bed, when not explained by child the tuberculosis, but also in isolating which hypei- other verified causes, should lead one to suspect Repeated large dose infection to the tuberculosis. It should be remembered that sensitizes and makes him more vulnerable and athrepsia alone may be present without any education, disease process. The isolation, fever at all. treatment of the adult case are as much imin infection of (3) Fever and anaemia, often with enlarged portant as is the early detection and liver. In severe infections, the lung spleen mfancy and childhood. usually broncho-pneumonia, may be lesion, that Some have gone as far as to suggest associated with the above, along with the with tested child should not only be enlargement of superficial glands. Such cases tuberculin thrice before he reaches adolescence have to be differentiated from malaria, and may latent of llt also x-rayed for the detectionWe have saidkala-azar, syphilis and pseudo-leukaemia. Active tuberculous infiltrations. ' children (4) Cough and expectoration. Cough may be contact lat 8 or may be caused per cent of the by the prescen altogether absent 15 and pel on the bronchi. by us showed latent of sure glands Stethosenlarged showed active parenchymal lesions in the lungs, may be entirely absent or one may signs ot copic fraction what e are not in a position to say disease, bu hear unilateral, localized, crepitant or sub-crepilese will develop into adolescent circle ottant rales or rhonchi. As very few children some will do so if the vicious surely expectorate before the tenth year, the best way m eetion and resistance is not broken. '

f?t

f\ery f

e^arnined

THE INDIAN MEDICAL GAZETTE

198

to demonstrate the presence of tubercle bacilli is to examine for them either from a throat

swab,

or

from

fseces.

centrifugalized

stomach wash

or

Sero-fibrinous pleurisy, especially in the mammary region, is frequently present and should be looked for.

(5)

and stridor are observed in of tracheo-bronchial adenopathy. They may be sometimes confused with diphtheria, asthma or enlarged thymus.

(6) Dyspnoea

many

cases

When

one or more

of the above symptoms

are

present, it is as well to do a Mantoux test, and, if positive, to have a careful examination under the rc-ray screen, including the lordosis position, and a skiagram of the chest. A definite involvement of the lung parenchyma or hilum or both, along with a positive tuberculin test, ought to justify a diagnosis of infantile tuberculosis, until otherwise proved. In the case of enlarged superficial glands, syphilis and Hodg-

kin's disease should be excluded.

children between 2 to 10 years, the should be clinched on a common-sense consideration of a multiplicity of minor symptoms and signs, local and constitutional. The history of exposure having been taken first, a weakly pale child with capricious appetite and failure to thrive, with perhaps some temperature or cough, ought to be looked on with great suspicion. A careful physical examination may show a flat chest or visible veins or enlarged supra-clavicular glands on inspection. The percussion signs, except perhaps the tracheophony of d'Espine's sign to some extent, if properly interpreted, are not of much value. Auscultatory signs indicate nothing else but the presence on trachea or pressure of enlarged glands or bronchi. The Mantoux test should always be done, and, when positive, it should be interpreted evidence of past infection. It indicates as active disease in very young children in cities or in older children in rural and semi-rural areas only when the clinical manifestation of impairment of health is present, along with corroboration by .r-ray evidence. It requires a good deal of experience and carefulness in interpreting rc-ray evidence of parenchymal infiltration or tracheo-bronchial adenopathy. The interpretation of z-ray pictures should go hand in hand with the history, constitutional symptoms and signs, tuberculin test and laboratory data. In the case of older children, however, it should be remembered that stethoscopic signs may sometimes be present long before radiological evidences are brought forth. In

diagnosis

The technique and interpretation of the intradermic tuberculin test (Mantoux) are given in an appendix at the end of this paper in the hope that they may prove useful to physicians and public health workers in investigation and diagnosis. The interpretations are based on

[April,

1937

Indian experience of quite a large number of cases in rural, semi-rural and urban areas.

Prognosis and treatment Barring meningeal complications or intercurrent acute infections, the prognosis in childhood tuberculosis is, generally speaking, favourable. If they are removed from the source of exposure, they respond well to good food, fresh air, sunlight and a hygienic environment. This response, of course, depends, to a great extent, on the patient's relative immunity to infection by the tubercle bacillus, the size and virulence

of the dose and the duration of exposure. The average child with tuberculosis need not be excluded from school but he should have more rest, fresh air and better diet than other children. Those with active diffuse parenchymatous lesions should be institutionalized in a climatic sanatorium until the signs of activity have completely disappeared. It should be remembered, however, that though the childhood lesion may be fibrosed or calcified, there is a danger of its breaking down into adult tuberculosis during adolescence. Every tuberculous child should, therefore, be under medical supervision until the period of adolescence is safely over. Such cases should always guard against over-exertion, both mental and physical, and should try to maintain a good standard of resistance. Conclusion It has been stated above that infantile and childhood tuberculosis occurs mostly in tuberculous homes. Do we really possess any idea about the sources of contagion in urban and rural areas in India to-day ? Tuberculosis has been declared an infectious disease, notifiable by medical practitioners (but the rule is very seldom enforced), only in municipal areas in three or four provinces. In two more (Bombay and the Central Provinces), the heads of families in municipal areas are required to notify on penalty for non-compliance. Nowhere is it notifiable in rural areas. The registration of deaths is so defective that the Public Health Commissioner in his report for 1932 (p. 87) made the following remarks:? ' The value of the recorded figures is greatly vitiated by the fact that correct diagnosis of the cause of death is rarely obtained and numerous deaths from tuberculosis are, without doubt, registered both in towns and villages as due to fevers and respiratory diseases. Indeed it may safely be assumed that the majority of deaths from tuberculosis is registered under one or other of these groups\ A large number of deaths reported to be due to fever, bronchitis, etc., has been found on investigation to be really due to tuberculosis. Rogers (1904) and Stewart and Proctor (1906-07) found that, in some rural areas in Bengal, 9 per cent of the deaths reported as due to fever were really

April, 1937j due to

TUBERCULOSIS IN INFANTS AND CHILDREN: UKIL

tuberculosis.

suburbs ducted

In

an

inquiry

(Cossipore-ChitpurJI

Acknowledgment

the

in

199

con-

of Calcutta per in 1907-11, it was found that cent of the deaths entered as due to respiratory a diseases were actually due to phthisis and as entered were 50 per cent of phthisis cases due to fever in public health returns. Lieu Col. (now Sir Cuthbert) Sprawson found that, o in the Lucknow municipality, 17.2 per cen Dr. all deaths were due to tuberculosis. Health m Sousa, an Assistant Director of Public oi the United Provinces, found that 19 per cent due were all deaths in Allahabad municipality sta e to tuberculosis. Major-General Graham in tuberculosis in 1927 that the mortality from certain of that some large cities exceeded crowded European cities. If this is so and if we know that a larg number of infants below one year, who_ have been in contact with tuberculosis cases m the succumb to this disease, is it possible that the infants and children of India escape age period death from tuberculosis in the early ' when the bacilli are implanted on virgin soil f The Public Health Commissioner's report lor 1932 states that 40 per cent of infantile mortality are from respiratory diseases, that debili y, Preformation and premature birth account for another 40 convulsions account per cent, that for 10 per cent and that remittent and undefined tevers account for 2.5 per cent of deaths. Do we know to-day what fraction of these is really due to tuberculosis ? Probably because we do B?t know anything about these, the Public tlealth returns for mortality do not refer deaths separately to the different categories of lr?m tuberculosis in infancy and childhood shut our miliary, etc.). Can we eyes any more to this state of affairs ? The workers of the public health department cannot get correct returns unless, in the absence the ?t a tuberculosis service in the country, general practitioners come forward with a proper outlook towards the problem. A proper knowedge on this subject has so long been lacking because we neither possessed special children s 1Qspitals nor tuberculosis dispensaries whereThe very introm data could be gathered. sufficient data which we have been able to ?

.

household,

_

(meningeal,

The writer acknowledges with grateful thanks the help that he has received from the authorities of the Medical College Hospitals, Calcutta, the Professor of Pathology, Calcutta Medical College, the Police Surgeon, the Health Visitors of the Tuberculosis Association of Bengal, Dr. P. K. Sen and from his staff at the Chest Department and at the All-India Institute of Hygiene and Public Health in working upon and in mobilizing the materials used in this paper. APPENDIX The

and

interpretation oj the dermic tuberculin test (Mantoux)

technique

intra-

The Mantoux test is more accurate than the cutaneous and other tests in that a known amount of tuberculin can be given and the dose increased, if desired. For this reason, a slightly larger number of reactions can be obtained than with the cutaneous test of von Pirquet. It has been shown that the Pirquet test may be considered to be equivalent to 0.1 c.cm. of a 1/1,000 dilution (= 0.1 mg.) of Old Tuberculin (O.T.) administered intradermally, so that when 1/10,000 dilution is employed the Pirquet test may be more sensitive when a reliable brand of undiluted O.T. is used for the latter. By the intracutaneous method, any two successive tests, done in graded doses, can be compared, which is not possible with the cutaneous test. The International Standard Tuberculin is recommended for general use.

Technique of

the test

Use International Standard Tuberculin or preferably the new Purified Protein Derivate (P.P.D.), the active principle of O.T. isolated in pure form. Use sterile, normal saline or 0.2 per cent carbolized saline for dilution in such a way that 0.1 c.cm. contains the desired dose. Dilutions should be kept in the ice chest and never employed when more than a fortnight old.

The following dilutions are generally employed :? 1/10,000, 1/1,000, 1/100, and 1/10. A wellProduce with a great deal of difficulty, we hope, fitting 1 c.cm. syringe graduated in 20ths with and child a will convince short, bevelled, intradermal needle is required. public health, maternity Welfare workers and practitioners in general of The syringe, once filled, holds fluid for 10 tests, he importance of detection, registration and the needle being merely wiped with cotton wool Prevention of infantile and childhood mortality soaked in absolute alcohol or flamed between r?m tuberculosis. The establishment of tuber- the injections. It is well to have a separate culosis clinics in different parts of the country syringe for each dilution. ls no doubt a move in the right direction, but Injection.?Clean the front of the forearm with rectiWhat can we expect from only 58 clinics in the fied spirit and allow to dry. Stretch the skin by

Whole of India at the

moment ?

An

holding the forearm taut from below, select a point away from superficial veins, insert the needle into the general practitioner can, the smallest possible with the bevel f^ore to prevent this unnecessary slaughter of dermis atand inject 0.1 angle c.cm. of the dilution. The lnfants and children. If this small paper helps upwards injection, if properly made, should raise a white bleb, ? our on the surface of which the hair follicles are easilv bring about this alertness, we shall deem visible. Subcutaneous injections should be avoided aa ?rts amply rewarded. a ert

present

therefore, do much

THE INDIAN MEDICAL

200 they

give rise

to general febrile reactions. No necessary up to 1/100 dilution. In case of dilution, it is better to keep a control with

may

controls

same

Reading oj

the reaction

Reactions should be read at the end of 48 hours. If negative, they should be re-examined at the end of 72 hours, and if still negative, at the end of 96 hours, when a final opinion might be put down. To read, hold the arm slightly flexed at the elbow and in good light and look across the arm rather than down on it. A test should be recorded as positive or negative to the given dilution. A positive reaction is indicated by oedema and redness around the site of inoculation. When in doubt, feel with the fingers and gently palpate between them. Its intensity is judged by the amount of cedema (its extent and thickness) and redness and by any elevation of temperature and malaise, if they occur. The area of redness is usually less important than the cedema. In measuring the area of erythematous infiltration of the skin (as judged by palpating between two fingers), reactions with the greatest diameter below 5 mm. are regarded as negative. Four categories or degrees of intensity of the reaction are considered, viz:

plus (+)

reaction

?=

slight but defined cedema raised about skin 1 mm. above surface and not more than 10 mm. in diameter.

1937

[April,

plus (-]?[-)

==

strength,

Dosage.?The initial dose may be 0.1 c.cm. of 1/1,000 dilution (which is sometimes called the 'standard dilution'), except for patients (a) suspected of having bone, joint, ocular and skin tuberculosis or in children with visible cervical nodes, ulcerations or discharging sinuses, (b) who have had a recent haemoptysis, (e) who are home-contacts of tuberculosis, (d) where their attendance for further tests can be guaranteed, and (e) who are very young infants, in which case it is advisable to employ the 1/10,000 or an even higher dilution. Whichever dilution is employed, read result at the end of 48 and 72 hours. If negative, employ the next stronger dilution at the last visit (i.e., at the end of 72 hours). The delay between two tests should not' be more than a week. In a large majority of cases, a dilution of 1/100 suffices, but if this gives a negative result a dilution of 1/10 may be employed as the practicable upper limit, as stronger solutions In to give non-specific reactions. are likely of doubtful reactions, employ the next case stronger dilution to settle the result. No test is complete without using the 1/100 dilution, especially for mass investigations.

One

Two

are

1/10 glycerinated veal peptone broth of the to avoid atypical non-specific reaction.

GAZETTE

well-defined oedema, raised somewhat than 1 mm. more above skin surface; between diameter 10-15 mm.

Three

plus ( + -{-+)

=

more ma

?

extensive oedediameter

with

15

exceeding

thickness ceeding 1.55

mm. ex-

and

mm.

above skin surface; wide area of redness beyond but no vesi-

culation

or

necrosis

of the skin. Four

plus (-]?f--|?[-) recharacterized by

ex-

tensive oedema, redvesiculation ness, and necrosis; may be associated with temperature and malaise.

Interpretation A positive tuberculin test always means the presence of tuberculous infection. The positive reaction has its chief value in infancy, when it is more likely to be associated with active tuberculous disease that may lead to a fatal issue. The younger the age, the worse the prognosis. .

An infant under 2 years showing a positive reaction, but without symptoms, should be kept under observation for some years on account of the possible development of clinical tuberculosis. Meantime the prognosis should be optimistic, though guarded. If, however, obscure and persistent symptoms like unexplained pyrexia or loss of weight are present, the origin might probably be tuberculous and a more serious view should be taken until time shows this to be unwarranted. A positive reaction in a child aged 2 to 5 or

10 years with persistent symptoms should in suggest that these symptoms are tuberculous origin. A weightage towards positive significance in interpretation should be given in cases of children in rural and semi-rural areas. An immunized adult in a infected or

even

improperly

remote rural area in India may, however, behave like an urban child with regard to hvpersensitiveness. Where a patient over 5 years gives a positive reaction to a qualitative test, it must not be concluded that clinical tuberculosis is present. In such cases, the positive reaction has its principal diagnostic value when elicited by quantitative intracutaneous tests made with weak solutions of tuberculin {e.g., by 1/50,000 and 1/100,000 dilutions), especially in rural people or hill tribes and in dermatological conditions. tests are of doubtful value for

Quantitative estimating the prognosis

in clinical tuberculosis.

April, 1937]

MODERN SANATORIUM TREATMENT: FRIMODT-MOLLER

201

tests

The principal application of tuberculin diagnosis ln clinical practice is for a negative Failure or the exclusion of clinical tuberculosis. not always t? get a positive reaction does harbouring of exclude tuberculosis. In spite a negative the body, in bacilli tubercle living tuber.

test may be obtained where the dose of 01 culin has been too small to elicit a reaction antethe the reaction has been done during is where the immunity or allergic

period depressed or absent hke

in certain clinical conditions pregnancy, diseases, infectious tuberculosis a few day^

acute

cachexias and advanced before death, or in acute miliary or generalized tuberculosis. Tuberculin tests are of great value in c0^"

tact' cases, both for detecting infection in infants and for excluding tuberculosis in these and oldei tubeichildren. In testing contact children of on negative test culous families, make a routine the cases at six monthly intervals, to determine still Children nne when they are infected. a negative at 4 to 5 years may be given Prognosis. The prognosis should be guarded when infants under 2 years react positively and when obscure symptoms persist for some time. 2 to positive reaction in a young child aged 0 0r symptoms with even 10 years persistent should suggest that these symptoms are tuber(ulous. About this age, children who give a Positive reaction to 1/10,000 or weaker dilutions 1Quld be viewed with suspicion and should be ?t'-rayed. If impaired health and conspicuous underweight are noticed in these children, they and receive special care in diagnosis found 1 are reactors eatment. If several positive a among the children in a family, suspect carrier' in the house. is -fr?The International Standard Tuberculin available at the following places:?

g?oc|

_

^'ould

"fickenham (England)

..

tt

^mpstead (London) t)

..

.

paris Copenhagen

..

..

..

rankfort-on-Main

..

ReWellcome Physiological search Laboratory, National Institute for Medical Research. Institut Pasteur. Statens Serum Institut.

Staatliches

Institut

Experimented

fur

Therapie.

and Select Bibliography Amer. Rev. Tuberculosis. M. A. (1927). Asserson, 359. XVI, p. Brit. Med. , Dow, D. J and Uoyd, W. E. (1930). ?'ournV0i II p 188 Dow, D. J., and Lloyd, W. E. (1931). Ibid., Vol. II,

References

.

^

p

p

Dow,

D. J, and Lloyd, W. E. (1932).

Voj^Xin'

J., and Lloyd, W. E. (1932).

^ibadeau-Dumas,

v yoi. yj

'

p

Ibid., Vol. I,

233

L.

(1925). Rev.

Tuberclc,

Tuberculosis,

(Continued from previous column) Ukil, A. C. (1930). Ibid., Vol. XVII, p. 849. Ukil, A. C. (1930). Bull. Soc. Path. Exot., Vol. XXIII

p. 5.

Ukil, A. C. (1931). Tubercle, Vol. XII n 244 of the A. J H (1935). Annual Report p India, Ukil, A. C. (1931). Zeitschr. Hyq. Govt, oj the Vg u 'infektinnvbr with Wtiomkr., Health Commissioner Vol. CXII, p. 182. laO,l y0l yj A. C. Indian Eastern (1933). Far Jo'urn. Pediat. Vol I Ukil, ^'1, A. c'. (192sS Trans. 7th Congress, , p. 8. V?L n' V- 394' n e J A. C. Re*., (1933). Med. TTIM Tr0p- Med- 1927' Med. Coll. Man. Vol VII n 33 Ukil, A. c. (1930). Indian Journ. Ukil, A. C. (1933). Indian Journ. Med Kes0|Res XVII, p. 821. Vol. XX. p. 1209. (Continued at foot of next column)

Russell,

1